- Develop tools for prevention and care of diabetes in 2 rural districts of Lesotho.
- Provide diabetes care for 1,500 current and 3,000 new T2DM patients.
- Evaluate T2DM care at all levels and establish a national DM technical group.
- Establish social enterprises to improve the economic independence of CHWs.
The project will seek to strengthen clinical and programmatic support and generate evidence for task-shifted replicable models of integrating diabetes screening, care and treatment, follow up at facility level, incl. mobilization of CHW.
This will be carried out through the development of training material, protocols and refinement of eHealth application based on the WHO HEARTS package as well as the PIH Guide to Chronic Care through multi-stakeholder TWGs.
Primary level health facilities and district hospital will be strengthened through training of nurses in routine examination of diabetes patients, including screening for foot complications and referral for regular eye screening at district hospitals. Nurses will be linked to CHWs who will be trained in diabetes education and support with a view to perform regular screenings and monitoring of diabetes patients at community level.
An eHealth application already in use by HCPs for follow up of HIV/AIDS and TB patients will be extended for NCDs and primary level through CHWs in the communities. CHWs will also be trained in social enterprise concepts with a view to ensure economic independence and sustainability of the initiative beyond project completion.
Diabetes care will be strengthened through the roll out of a model for task-shifting at primary level, where CHWs screen for diabetes in communities and provide ongoing education and monitoring of patients. Newly diagnosed patients will be referred to health centres for comprehensive screening and all patients will further be referred to district hospitals for annual eye screening and treatment of complications.
In addition to this a multi-functional eHealth application will be used by CHWs and HCPs for registration of data to ensure improvement in monitoring and follow up of patients. System will be part of MoH integration of all NCDs into existing EMR system for HIV/TB as part of national NCD programme.
- 60 nurses trained in diabetes care and prevention
- 23 health facilities in two districts (3 district hospitals, 20 PHCs) strengthened.
- 100 CHWs from 100 communities trained in diabetes care and prevention.
- 32,000 people screened for diabetes.
- 3,000 people expected diagnosed with diabetes and referred for treatment.
- 1,500 known diabetes patients to receive improved diabetes care.
- 70% of patients within agreed target for glucose control by month 36.