9 June 2026
Sinikka Kitö - THL

Small states in Europe, like Malta, provide an important opportunity to advance equity-focused surveillance, as smaller populations, centralised systems, and shorter distances make it easier to gain a comprehensive picture of population health. This data offers important signals for policymaking. As part of JACARDI’s Equity Lens series, this article explores what larger countries can learn from smaller ones, and how population-level surveys on non-communicable diseases could be developed to be more equity-driven, thereby helping to improve health systems so they are suitable for all.

Non-communicable diseases (NCDs) account for over 70% of deaths worldwide. Yet current health monitoring systems do not adequately capture who is affected and why.

Most surveillance relies on mortality data, hospital records, and self-reported surveys. While valuable, these sources primarily reflect late stages of disease and clinical outcomes. As a result, health systems often measure what is easiest, rather than what matters most for health equity. Prof. Sarah Cuschieri, a leading voice in chronic disease epidemiology and a Senior Lecturer at the University of Malta, shared learnings in JACARDI Masterclass titled “Small States, Shared Equity Challenges: Reframing NCD Surveillance for Equity-Driven Health Systems”.

The missing middle of the disease pathway

According to Prof. Cuschieri, a major weakness of current surveillance is that it overlooks large parts of the disease pathway. Undiagnosed conditions, differences in awareness and access, patterns of risk clustering, and variations in treatment adherence and disease control often go unmeasured.

These are not minor gaps, they represent the earliest and most preventable stages of disease. When they remain invisible, disadvantage accumulates over time. This creates a “cascade of inequity,” where people with fewer resources face higher risks, delayed diagnoses, poorer treatment, and ultimately worse outcomes. By the time inequalities appear in morbidity statistics, they are already deeply entrenched and much harder to address.

Making inequities visible through Health Examination Surveys

Health Examination Surveys (HES) offer a more equitable approach to surveillance. Unlike routine data systems, HES are population-based, standardised, and biomarker-integrated. This allows them to identify both diagnosed and undiagnosed disease.

They also reveal how health varies across income, education, sex, age, and other demographic factors. When conducted regularly, HES should be seen not as one-off research projects, but as essential health system infrastructure.

Critically, they help identify who is being left behind, those unaware of their condition, inadequately treated, or unable to achieve disease control. In doing so, they make inequities visible and actionable signals for policy.

Small states as living laboratories for equity-oriented policy

Small states offer an ideal setting for building surveillance systems that support health equity. Their smaller populations and centralized structures allow near‑complete population coverage instead of fragmented data. This makes it easier to move from data to decisions quickly and to clearly see differences between population groups.

They also act as “living laboratories,” where policies can be tested and their effects seen sooner. The fast cycle from data to action means we can learn quickly what works, for whom, and under what conditions. As a result, small states can detect emerging trends early and provide valuable lessons for larger countries.

Towards fairer surveillance and policies

The lessons derived from small states are highly transferable and point toward a necessary reframing of surveillance in larger systems:

  • Surveillance must capture the full disease pathway, not just mortality
  • Indicators should be systematically disaggregated by socioeconomic factors
  • Data sources should be linked to track how inequities develop over the life course
  • Surveillance is inherently a political choice, measuring inequity creates accountability
  • Designing more effective systems requires sustained political commitment.

Read our interview with Sarah Cuschieri, a member of JACARDI’s advisory board here:

Sarah Cuschieri: Transforming small-state initiatives into the strength of Europe

Further readings: