Objectives

1. To create an environment of good governance for diabetes care and prevention 
2. To improve access and quality of diabetes care
3. To improve diabetes care for children, pregnant women, children and people with TB
4. To strengthen health information system and medical records in diabetes health facilities

Approach
Initially the project will focus on the development and endorsement of a national diabetes strategy by all key stakeholders within diabetes and NCD care in Sudan, accompanied by an update and revision of clinical practice and guidelines for diabetes care (last updated in 2011), which will be distributed to all targeted health facilities.

Subsequently, the project will roll out a comprehensive model for improvement of access to diabetes care through special emphasis on primary care raising capacity in 200 primary health centres (PHCs) in basic diabetes screening and referral to NCD clinics. It will furthermore establish NCD clinics in 40 PHCs, building on previously established mini diabetes clinics (WDF12-726). NCD clinics will offer care for uncomplicated diabetes patients, conduct community outreach and train patients in self-management. 

Furthermore, Enhanced Diabetes Care Units (EDCUs) will be established at 30 PHCs / rural hospitals and linked to tertiary diabetes centres using telemedicine and offering care for diabetes patients with co-morbidities, poor glycaemic control, or other complications, including foot care. 11 PHCs will provide retina screenings. At 15 district hospitals referral and coordinating diabetes teams will be established and be responsible for education and referral of patients from EDCU, including through provision of mobile and virtual referral clinics, where selected patients from EDCU are virtually connected to diabetes teams at district hospital. 

The project will also include components focusing on care for children and adolescents (including through integration of project WDF19-1716 in the national framework and alignment with Novo Nordisk’s CDiC programme), and on diabetes in people with TB through adoption of the collaborative framework for TB and diabetes.

Finally, the project will improve the registration and sharing of patient data through standardisation of NCD indicators and establishment of simple electronic registries at EDCU and integrated NCD clinics.

Expected results

•  288 health facilities (270 primary, 15 secondary, 4 tertiary) strengthened, with provision of equipment and trainings 
• 25 master trainers, 50 family physicians, 75 diabetes educators and nurses trained in diabetes management incl. foot care and eye care
•  At least 200 health care assistants (CHWs) representing 200 PHCs mentored in diabetes screening and referral
• 50 HCPs (pre-natal care) representing 30 ECDUs and 15 district hospital trained in GDM management
• 50 paediatricians trained in childhood diabetes management
• 50 doctors trained in use of mobile outreach and telemedicine referral 
• 97 data clerks trained in improved registration of NCD data
•  At least 200,000 patients with diabetes treated at established clinics
• 6,000 pregnant women receive treatment for GDM
• 2,000 TB patients screened for diabetes
• 3,000 children with diabetes across ten states receive care