A situational analysis of type 2 diabetes prevention, diagnosis and treatment services in a typical district health system in Eastern Uganda: a qualitative study

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We conducted a situational analysis of type 2 diabetes services in two districts in Eastern Uganda to inform development of service improvement interventions. Methods: This was a formative qualitative assessment within a broader feasibility study in the Iganga-Mayuge Health and Demographic Surveillance Site. Managers of eight health facilities (two each from Health Centres II, III, IV and district hospitals) underwent in-depth interviews and completed a checklist adapted from the WHO Service Availability and Readiness Assessment (SARA) tool. Four District Health Team members were interviewed as key informants. We analysed the data using manifest content analysis organised around pre-determined themes. Results: There was no routine risk factor screening or preventive health checks related to type 2 diabetes. The disease was detected passively using classical symptoms and a single random blood sugar, typically after patients had been treated for other conditions. Care was concentrated at hospital and HCIV levels. Stockouts of medicines were frequent, and clinical algorithms to guide treatment decisions were absent. Insulin prescriptions faced storage and adherence challenges. Glucose monitoring was accessible only at diabetes clinics. Lifestyle education, where offered, was neither standardised nor individualised. No patient follow-up existed once patients left facilities. Patients followed tortuous pathways involving traditional healers and unqualified providers before reaching diagnosis. Conclusions: There are glaring gaps in type 2 diabetes services at the district level. Operationalising the national NCD strategy will require tiered, cost-effective improvements in care and prevention matched to the capabilities of different health facility levels, drawing lessons from successful chronic care programmes. Type 2 diabetes situational analysis health services primary health care district health system sub-Saharan Africa Uganda service readiness Figures Figure 1 Background Chronic non-communicable diseases (NCDs), including type 2 diabetes (T2D), have become a major global health challenge. Available evidence indicates that the future rise in NCDs will fall disproportionately on low- and middle-income countries (LMICs) compared to high-income countries (HICs) [ 1 ]. NCD deaths were projected to increase by over 20% in Africa and South-East Asia between 2010 and 2020, against a global average of 15% [ 1 ]. Between 2010 and 2030, a 69% increase in type 2 diabetes was anticipated in LMICs, compared to 20% in HICs [ 2 ]. More recent International Diabetes Federation estimates indicate that Africa will see a 129% increase in people with diabetes by 2045, the highest proportional increase of any world region [ 3 ]. This growing incidence of chronic diseases in sub-Saharan Africa places enormous strain on health systems that were not designed for it [ 4 ], and the response has largely been inadequate [ 5 ]. Acute conditions still account for the bulk of disease burden in the region [ 6 ], and primary health care systems remain oriented towards episodic, acute care delivery [ 7 ]. Even within this domain, major access, quality and efficiency challenges persist for conditions such as malaria, tuberculosis and pneumonia [ 8 , 9 ]. NCD control capacity is generally poor [ 5 , 10 ], and integration of care for communicable and non-communicable diseases remains limited, despite clear opportunities, particularly building on the HIV care infrastructure [ 11 ]. NCDs now account for at least 20% of the disease burden in sub-Saharan Africa [ 12 ] and can no longer reasonably be treated as peripheral to the infectious disease agenda [ 13 ]. What is needed is a major reorientation of health services towards chronic care and prevention [ 7 , 14 , 15 ]. The practical question, however, is how to build systems that handle both acute and chronic conditions effectively in settings where resources are severely constrained. Given that communicable and non-communicable disease burdens will likely co-exist in Africa for the foreseeable future [ 4 ], smarter interventions targeting low-resource health systems are required, supported by translational research evidence [ 16 ]. While epidemiological data on the NCD burden in sub-Saharan Africa have expanded considerably, there is a relative paucity of formative studies that characterise the actual gaps in service delivery at primary care level. Many countries in the region have begun updating their minimum health care packages and issuing NCD clinical guidelines [ 17 , 18 ]. Uganda, for example, established an NCD department within the Ministry of Health, expanded the NCD component of the minimum health care package [ 19 ], and issued the Uganda Clinical Guidelines incorporating NCD management in 2019 [ 20 ]. Yet, NCD programmes receive approximately 1% of the national health budget [ 21 ], which severely limits what can be achieved at the operational level. The policies exist on paper, but we lack a clear picture of what services are actually available and functional at primary care level, and what the real capacity is to deliver them. This kind of formative understanding is essential before meaningful improvement interventions can be designed. We set out to describe the current services and support systems for prevention, diagnosis and management of type 2 diabetes, used as a tracer condition for related NCDs, within a typical district health system in Eastern Uganda. Our aim was to identify priority gaps that need to be addressed to operationalise the national NCD strategy at district level. Methods Study setting The study was carried out in Iganga and Mayuge districts, Eastern Uganda, within the Iganga-Mayuge Health and Demographic Surveillance Site (HDSS). These districts served as implementation sites for a broader project exploring the feasibility of establishing a population cohort for long-term NCD risk factor research. Both districts lie about 120 km east of Kampala. Iganga has an estimated population of 466,200 and Mayuge 461,200, with roughly 93% of residents in rural areas. The predominant livelihood is small-scale farming, supplemented by petty trading in semi-urban centres. Study design and participants This was a qualitative assessment using key informant interviews (KIIs) and in-depth interviews (IDIs). Key informant interviews were conducted with members of the District Health Team (DHT) comprising of the District Health Officer, a District Nursing Officer, a District Health Visitor, and District Health Educators. These individuals were selected because their coordination responsibilities span the components of the minimum health care package most relevant to chronic care that includes clinical services, nursing, patient communication and health education, and community follow-up. In-depth interviews were held with managers of eight public health facilities: two HCIIs, two HCIIIs, two HCIVs, and two district hospitals. Two facilities were included at each level to allow triangulation. The eight facilities were selected randomly from the list of public health facilities in both districts. Uganda operates a tiered public health system [22]. The HCII (parish level) serves about 5,000 people, is nurse-led, and offers a minimum activity package with no inpatient services. The HCIII (sub-county level) serves about 25,000 people, is headed by a Clinical Officer, has a basic laboratory, and provides additional services including deliveries and TB treatment. The HCIV and district hospital serve about 100,000 people and have medical officers, emergency surgical capacity, and responsibility for technical support and planning across lower facilities in their zone. Data collection Data were collected using a key informant guide (for DHT members) and an in-depth interview guide combined with a facility assessment checklist (for facility managers). The guides were structured around four pre-determined themes adapted from the WHO Service Availability and Readiness Assessment (SARA) tool [23]: (i) type of care provided that is relevant to diabetes, (ii) status of the minimum package of diabetes services, (iii) availability of equipment and drugs, and (iv) support services for people with risk factors or with diabetes. All interviews were conducted in English by four research assistants with clinical or nursing backgrounds. They underwent two days of training on the tools, which were pre-tested through mock interviews at a HCIII in Kampala and refined accordingly. Data analysis Interview recordings were transcribed verbatim. We used manifest content analysis, reading and re-reading transcripts, then organising the findings under the pre-determined themes using thematic master sheets. This approach allowed us to identify service delivery gaps at each level of the health system. Findings from the facility checklists were summarised using simple frequency counts. Ethical approval The study was conducted in accordance with the Declaration of Helsinki and was approved by the Higher Degrees Research and Ethics Committee of Makerere University School of Public Health (ref. no. 426) and registered with the Uganda National Council of Science and Technology (ref no. HS 2118). Permission was obtained from the district health offices. All participants provided written informed consent, including consent for audio recording. Results Where diabetes care is provided Diabetes care was concentrated at hospitals and, to a lesser extent, HCIVs. Lower-level facilities played almost no role. Only one of eight HCIIIs provided oral medication refills for diabetes; the others limited their involvement to assessing and referring suspected cases. HCIIs had no role beyond referring very sick patients. Hospitals had the range of staff needed (10+ clinical staff /medical officers and 20+ senior nurses) to run dedicated diabetes services. HCIVs, by contrast, had only two to five clinical staff including one or two medical officers. All surveyed facilities were physically accessible, most being situated along main roads. Services at public facilities were nominally free, but widespread medicine shortages meant patients frequently incurred out-of-pocket costs. Only hospitals ran regular diabetes clinics (weekly, all-day). HCIVs saw diabetes patients on a walk-in basis with no dedicated clinic days. Patients tended to bypass HCIVs entirely, going straight to the hospital. As one district health officer explained: “Most diabetes patients come directly to the hospital. They know the lower centres cannot help them, so they don’t bother stopping there” (District Health Officer, Iganga). Details of these findings are detailed in Table 1. Minimum package for type 2 diabetes services There were no preventive services or risk factor screening programmes for diabetes at any level. Health workers did not see preventive care for diabetes as part of their expected duties. Wellness checks existed only for maternal and child health programmes (mainly blood pressure and weight were measured routinely for pregnant women during antenatal care) but in outpatient departments these measurements were reserved for patients presenting with symptoms suggestive of hypertension. One HCIII was an exception: it screened all clients aged 35 and over for high blood pressure and obesity, but this was not linked to any formal risk reduction programme. New diabetes cases were identified almost entirely through passive case detection at HCIVs or hospitals. Suspicion was triggered by classical symptoms, and confirmation typically relied on a single random blood sugar combined with the clinical picture. Among confirmed patients, glucose monitoring occurred only at monthly clinic visits using fasting plasma glucose. Fewer than 5% of patients owned a glucometer. HbA1c testing was unavailable everywhere. Medication initiation and changes happened only at hospital and HCIV levels, though some HCIIIs dispensed refills. Evidence-based clinical guidelines were conspicuously absent. Facilities avoided insulin even where indicated, citing home storage problems. Patients started on insulin received more frequent appointments, but many missed these visits due to transport costs, user fees at private not-for-profit facilities, or feeling better after initial treatment. Hypertension was treated from HCIII upward, but only with older-generation drugs like Nifedipine. The sole bio-analyser in the study districts was non-functional, leaving no facility able to perform renal function, liver function, or lipid profile tests. Some HCIVs stocked ACE inhibitors and ARBs; no facility had statins. Fundoscopy equipment existed at the district hospital eye clinic but was not routinely used for diabetes patients. Facilities did not set treatment targets. Staff cited low numbers, heavy workload, absent training, lack of IEC materials, misinformation from traditional healers, and patient non-attendance as key obstacles. These findings are presented in Table 2. Availability of equipment and drugs Glucometers were present at hospitals, HCIVs, and some HCIIIs, but roughly half were non-functional, mostly because of stockouts or supply of incompatible test strips. Weighing scales were widely available but poorly calibrated. Height meters existed at HCIII and above but were used mainly for maternal and child health, except at Iganga Hospital. Blood pressure machines were adequate at HCIVs and hospitals but each HCIII had only one, stationed at the maternity. Both HCIIs assessed lacked functional height meters and BP machines. Tape measures were mainly used for paediatric nutritional assessment, not adult anthropometry. Fundoscopes existed only at hospitals and were not used routinely. Insulin (Soluble and Lente) was available at HCIVs and hospitals. Oral hypoglycaemics and antihypertensives were nominally available down to HCIII, but stockouts were common. Older-generation drugs predominated - Nifedipine rather than Amlodipine, Captopril rather than newer ACE inhibitors, and some facilities still stocked Methyldopa. Statins were absent entirely. IEC materials for diabetes were virtually non-existent. Table 3 provides the full details. Person-centred care and patient education At the two hospitals, health workers reported trying to tailor care to patients’ circumstances, but HCIVs and HCIIIs were too understaffed to do the same. No facility conducted any secondary data analysis to track patient outcomes. Staff described offering psychosocial support, but the available counsellors had been trained exclusively for HIV care and were not equipped for diabetes counselling. Patient consultations lasted about 15 minutes for return visits and 30 minutes for new patients, extending to an hour when tests were required. No training in patient-centred care had been provided. Staff reported consulting patients about treatment decisions that had resource implications. Longstanding patients were seen as knowledgeable and self-directing; newly diagnosed patients needed extensive support before adapting. Self-monitoring of blood glucose was rare and very few patients had glucometers. Urine dipsticks remained the default monitoring tool in many settings. Community-level diabetes awareness programmes were absent. There was considerable misinformation from traditional healers, market-based drug vendors, and drug shops. Where provided, lifestyle education was offered in group sessions at Iganga Hospital and individually at lower facilities, but without standardised IEC materials the quality of messages varied widely. No formal coaching on diet or physical activity existed. Hospital nutritionists focused on childhood malnutrition and were not involved in chronic disease programmes. Health workers suspected that patient adherence to lifestyle recommendations was poor, but had no way to measure it. Self-management support for people with risk factors and those with diabetes Newly diagnosed patients received education about what to expect with their condition. At Iganga Hospital, patients were asked to bring a treatment companion to their second visit for more in-depth lifestyle education. The hospital had a diabetes patient club that met on clinic days for blood sugar checks, peer education, and mutual encouragement. Club members sometimes raised money to purchase test strips during stockouts. Expert patients were trained by health workers and were closely linked to the clinical team. The picture was quite different elsewhere. No other facility had a diabetes patient group. Crucially, once patients left any facility, no follow-up existed. One facility manager captured the situation plainly: “When the patient walks out of this gate, we have no idea what happens to them until the next appointment, if they come back at all” (Facility Manager, Busesa HCIV). There were no home visits, no phone calls, and no community-based adherence support. Monitoring patients on insulin between visits was especially difficult. Table 4 provides these details. Patient pathway to diagnosis Because detection depended on classical symptoms, patients were typically diagnosed late, often with established complications. The preceding period typically involved episodic illness misdiagnosed and treated as malaria, infections, or other acute conditions. Patients described a meandering care-seeking journey through private clinics, drug shops, traditional healers, and herbalists, a journey accompanied by considerable misinformation. As one hospital clinician observed: “By the time they reach us, they have spent months or even years going from one herbalist to another. Some come with complications that we could have prevented if they had come earlier” (Clinician, Mayuge District Hospital). Contacts with accompanied by much misinformation. Contacts with lower-level health facilities often failed to identify diabetes. Patients eventually self-referred to the hospital when nothing else had worked, by which time the disease was usually advanced. Notably, even after receiving a definitive diagnosis, many patients continued to combine biomedical treatment with traditional remedies. Figure 1 maps this typical itinerary. Discussion This assessment reveals significant weaknesses in type 2 diabetes services across the health system hierarchy in two typical Ugandan districts. The gaps span prevention, detection, treatment, and ongoing patient support, and they broadly align with the challenges reported from other parts of sub-Saharan Africa. Five main findings merit discussion. Concentration of care at higher-level facilities Our finding that diabetes care is overwhelmingly concentrated at the hospital level, with lower facilities playing a marginal role, runs counter to the decentralisation model that underpins Uganda’s health system. This is not, however, a finding peculiar to our setting. A systematic review of diabetes care readiness across sub-Saharan Africa found that primary-level capacity for managing diabetes remains embryonic in most countries, despite policy commitments to decentralise chronic care [24]. A mixed-methods study of diabetes care quality in rural Eastern Uganda (conducted in a similar setting) likewise found that services were largely confined to hospitals, with lower-level health centres lacking even basic capacity [25]. The practical implication is that a deliberate decentralisation strategy is needed, one that equips HCIIIs with simplified protocols and the clinical supplies to manage uncomplicated diabetes. Task shifting of this kind is not without precedent in the region: the scale-up of HIV treatment relied heavily on shifting responsibilities to clinical officers and nurses at peripheral facilities [26]. The INTE-AFRICA trial, conducted across facilities in Uganda and Tanzania, recently demonstrated that managing HIV, diabetes and hypertension through the same primary care team is both feasible and safe [27], providing an evidence base for scaling integrated care. Incomplete minimum package for prevention and care The absence of any form of risk factor screening, the reliance on a single random blood sugar for diagnosis, the complete unavailability of HbA1c testing, and the lack of clinical protocols at the point of care constitute serious shortcomings. These are the building blocks of a functioning diabetes service, and they were missing across the board. Park and Pastakia have noted that the over-reliance on fasting blood glucose at clinic visits leaves clinicians with little real insight into how patients are doing between their monthly or less frequent appointments [28]. They note that where HbA1c testing was introduced in resource-limited settings, it emerged as the primary predictor of glycaemic control, suggesting that its absence actively contributes to poor outcomes. The lack of clinical guidelines at facility level is equally troubling but, again, not uncommon. A narrative review of diabetes care across the region found that few countries have managed to place contextualised, practical guidelines in the hands of the health workers who need them most [29]. What exists at the national level often does not filter down to where care is actually delivered. There is, therefore, a need to deploy adapted versions of the WHO Package of Essential NCD Interventions (WHO-PEN) to all facility levels, accompanied by practical job aids, and to explore the introduction of affordable point-of-care HbA1c testing. These are not luxurious additions but rather the minimum requirements for credible diabetes care. Chronic shortages of equipment and essential drugs Frequent stockouts of oral hypoglycaemics, antihypertensives and glucose test strips, compounded by the supply of strips incompatible with available glucometers, represent a systemic failure in procurement and supply chain management. The continued stocking of old-generation drugs (Nifedipine, Methyldopa, Captopril) when more effective and better-tolerated options exist, and the total absence of statins, reflect both budgetary limitations and inertia in essential medicines list updates. These patterns mirror what has been documented in the wider region. A review of health system readiness for diabetes in sub-Saharan Africa found medication stockouts and diagnostic shortfalls to be near-universal [24]. Park and Pastakia observed that even where countries have taken steps to decentralise diabetes care, the monitoring tools and consumables needed to make decentralisation meaningful have not followed [28]. Addressing this will require ringfenced funding for NCD commodities, given that current budget allocations to NCDs in Uganda are wholly inadequate [21]. Procurement practices need attention too: the mismatch between glucometers and test strips is an avoidable logistics failure, not a fundamental resource constraint. Essential medicines lists at the district level need updating to reflect current evidence on the comparative effectiveness of antihypertensive agents and the role of statins in cardiovascular risk reduction. Inadequate patient education and personalised care Health workers made genuine efforts to educate patients, but they were working without training, without standardised materials, and without the specialist support (dieticians, counsellors) that effective chronic disease education requires. The fact that available counsellors were ring-fenced for HIV care and had no involvement in diabetes services is a telling illustration of how vertical programming creates artificial boundaries that disadvantage newer health priorities. Studies from Ghana have described how inadequate patient education and long hospital waiting times push diabetes patients towards traditional healers who lack diagnostic capacity, contributing to late diagnosis and poor outcomes [30]. There is encouraging evidence, however, that these gaps can be bridged. The MOCCA cohort study in Tanzania and Uganda showed that when the counselling and adherence support approaches refined through HIV care were applied to diabetes and hypertension management, patient retention improved markedly [31]. A scoping review of HIV-NCD integration confirmed that tools, systems and implementation strategies from HIV care can potentially be transferred rapidly and efficiently to NCD programmes [32]. The implication for policy is that the artificial separation between HIV and NCD support cadres needs to end. Counsellors, community health workers and peer educators should be trained and deployed across chronic conditions, not siloed within single-disease programmes. Tortuous pathway to diagnosis The circuitous route that patients followed before reaching a correct diagnosis—cycling through drug shops, private clinics, traditional healers, and lower-level facilities where diabetes went unrecognised was perhaps the most troubling of our findings, as it means patients arrive at definitive care with complications that might have been avoided. A subsequent qualitative study at Iganga Hospital specifically examined these diagnostic delays and identified strong socio-cultural drivers, including deeply held beliefs about witchcraft and supernatural causation, that kept patients circulating through the traditional health sector long after symptoms appeared [33]. Research in Ghana similarly found that spiritual interpretations of illness led patients to exhaust traditional options before presenting to biomedical facilities, typically late and with complications [30]. Two responses seem warranted. First, community-based awareness campaigns must improve public understanding of diabetes symptoms and the importance of early care-seeking at formal health facilities. Rather than ignoring or opposing traditional healers, who are deeply embedded in the social fabric and will continue to be consulted regardless of official policy, public health programmes should also explore collaborative frameworks. A pilot project in Cameroon demonstrated that traditional healers could learn basic diabetes prevention messages relatively quickly, could refer patients for blood glucose testing, and were enthusiastic about collaborating with the formal health system [34]. Such models deserve further testing and scale-up. Recommendations Drawing on the five findings discussed above, we propose the following recommendations for strengthening diabetes services at the district level in Uganda and comparable settings. Diabetes care should be deliberately decentralised to HCIII level through simplified clinical protocols and task shifting to clinical officers and nurses, following the model that proved successful for HIV treatment scale-up. The INTE-AFRICA trial provides an evidence base for this approach [27]. The WHO Package of Essential NCD Interventions (WHO-PEN) should be adapted and deployed to all facility levels, accompanied by practical job aids. Affordable point-of-care HbA1c testing should be explored to improve glucose monitoring beyond the current reliance on single fasting blood glucose readings. Procurement and supply chain systems for NCD commodities need dedicated funding. At a minimum, this means ensuring compatible test strips for available glucometers, updating essential medicines lists to include newer-generation antihypertensives and statins, and ringfencing NCD commodity budgets within the district health budget. Patient education and self-management support should be structured and extended beyond the health facility. Counsellors and community health workers currently confined to HIV programmes should be cross-trained for NCD care. Standardised IEC materials for diabetes need to be developed and distributed. Hospital nutritionists should be reoriented to include adult chronic disease counselling alongside their current focus on childhood malnutrition. Community-based awareness campaigns are needed to reduce diagnostic delay. Public health programmes should explore collaborative frameworks with traditional healers, training them as diabetes educators and referral agents rather than treating them as adversaries. The Cameroon pilot project [34] offers a tested model for such collaboration. Strengths and limitations This study’s main strength lies in its systematic coverage of all four levels of Uganda’s district health system, using a structured tool derived from the WHO SARA framework, combined with purposive interviews that captured both the technical and the experiential dimensions of diabetes care. Including two facilities at each level allowed us to check the consistency of findings. There are, however, important limitations. The qualitative design and the small number of districts mean the findings cannot be statistically generalised, though the contextual similarity of Iganga-Mayuge to many rural Ugandan districts (and to rural districts elsewhere in the region) suggests they are broadly transferable. We did not include patient perspectives, which would have enriched our understanding of demand-side barriers. And the study provides a snapshot at a single point in time, while service availability, particularly for drugs and supplies, can fluctuate considerably. Conclusions This situational analysis exposes significant gaps in type 2 diabetes services at the district level in Eastern Uganda. Care is concentrated at hospitals, the minimum service package is incomplete, essential drugs and equipment are chronically short, patient education is unstructured and unstandardised, and patients navigate a long and often harmful path before arriving at a correct diagnosis. These findings are not unique to our study districts; they reflect the wider reality of diabetes care across much of sub-Saharan Africa. What the HIV experience in the region demonstrates, however, is that transforming chronic care at the primary level is achievable with the right combination of task shifting, simplified protocols, community engagement, and supply chain commitment. The challenge now is to translate that experience into practical, tiered interventions for diabetes and other NCDs, matched to the real capabilities and resource realities at each level of the health system, backed by adequate and sustained financing. Declarations Ethics approval and consent to participate The study was approved by the Higher Degrees Research and Ethics Committee of Makerere University School of Public Health (ref no. 426) and registered with the Uganda National Council of Science and Technology (ref no. HS 2118). All participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials The qualitative datasets generated and analysed during this study are not publicly available due to confidentiality concerns inherent to the small number of respondents and their identifiable roles, but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Swedish International Development Cooperation Agency (SIDA) through the Makerere University-Karolinska Institutet capacity building partnership, and by the Rockefeller Foundation through the ResilientAfrica Network at Makerere University School of Public Health. The funders had no role in study design, data collection, analysis, interpretation, or manuscript preparation. Authors’ contributions RWM conceived the study, led the design and data collection, performed the analysis and drafted the manuscript. PK contributed to study design and reviewed the manuscript. AN contributed to data analysis and manuscript review. WA was involved in the research from end to end, participating in the design, data collection, analysis and completed the manuscript. AS participated in data collection and reviewed the manuscript. BK contributed to data analysis and critical review. All authors read and approved the final manuscript. Acknowledgements We thank the district health teams of Iganga and Mayuge districts and the health facility managers who participated in this study. We also acknowledge the research assistants who collected the data. References World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:4-14. International Diabetes Federation. IDF Diabetes Atlas. 10th ed. Brussels: IDF; 2021. Dalal S, Beunza JJ, Volmink J, et al. Non-communicable diseases in sub-Saharan Africa: what we know now. Int J Epidemiol. 2011;40:885-901. Alwan A, Maclean DR, Riley LM, et al. Monitoring and surveillance of chronic non-communicable diseases. Lancet. 2010;376:1861-8. WHO-AFRO. Health situation in the African Region: Atlas of Health Statistics 2011. Brazzaville: WHO-AFRO; 2011. 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Integrating care for diabetes and hypertension with HIV care in sub-Saharan Africa: a scoping review. Int J Integr Care. 2022;22:6. Mayega RW, Kiwanuka SN, Engel N, et al. Understanding the diagnostic delays and pathways for diabetes in Eastern Uganda. PLoS One. 2021;16:e0250421. Mbeh GN, Edwards R, Ngufor G, Assah F, Fezeu L, Mbanya JC. Traditional healers and diabetes: results from a pilot project in Cameroon. Glob Health Promot. 2010;17(2 Suppl):17-26. Tables Table 1: Type of care provided that is relevant to type 2 diabetes care and prevention Topic Hospitals HC IV HC III HC II Type of care provided relevant for T2D or its associated risk factors They are the main level where T2D is managed; However, no routine preventive services targeting diabetes risk factors. The hospital is the only level with a regular diabetes clinic They conduct diagnosis and treatment of T2D and hypertension No routine prevention services They take history and examine after which they refer suspected cases Hypertension is identified coincidentally but treatment is only given when drugs are available No formal preventive services Have no role in diabetes management except for referral Usual number and type of staff who provide diabetes care or prevention services They have over 50 health workers. This allows them to allocate a small team specifically for diabetes care including 1 Medical Officer, 2 nurses, 2 Clinical Officers & 1 doctor Busesa: 2 Medical Officers & 2 Clinical officers, 1 Senior Nursing Officer, 3 Nursing Officers and 3 lab staff Busowobi: 1 Clinical Officer, 1 Nursing Officer, 3 Nurses, 4 Midwives, 2 Nursing Assistants, 1 Records Assistant, 1 Lab Assistant Busembatya: 1 CO, 1 NO, 2 Nurses, 2 Midwives, 1 Lab technician and 1 lab assistant Nawanzu: 1 Enrolled Nurse; 1 Midwife Nawansinge: 3 ENs & 2 registered nurses Geographical access to health facilities Some hospitals are accessible but others have a hard-to-reach catchment population Accessible as most are near the highway Fairly accessible though some are hard to reach Not applicable Who pays for diabetes treatment related services? All public health facilities offer free direct services while patients meet the indirect costs e.g. transport. However, stockouts lead to frequent out-of-pocket expenditures Free services but with frequent stockouts Some HCIII offer free drugs refills for diabetes and hypertension but with frequent stockouts Not applicable Accommodation aspects Opening time, waiting time, and clinic opening days generally okay Sporadic walk-ins. They have no formal clinic days Sporadic walk-ins for drugs refills Not applicable Evidence-based guidelines for care and prevention Apart from Buluba hospital which had a capacity building program, there is a general lack of guidelines and job-aids None None None Are the referral levels functional? Referral lines non-functional for diabetes as patients predominantly prefer the hospital Table 2: Status of the minimum package of diabetes services in assessed health facilities Category IDF package component Currently offered? Level where provided Where it could be provided Risk factor screening for preventive action Passive wellness checks Very rarely done (2/8 facilities) A HCIV and III as a special program All levels; community Opportunistic screening for selected risk factors For hypertension , among people with symptoms but not for obesity At HCIII, HCIV, Hospital All levels; Community Preventive services for people with risk factors Not routinely provided All levels; Community Detection of diabetes Passive case detection Yes HC IV & Hospital HCIII OGTT Not done anywhere HC III Random Blood Sugar Most commonly used test HCIV & Hospital HC III Glucose monitoring for people with diabetes HbA1c Not done anywhere HC IV/V Random Blood Sugar Yes HCIV & Hospital HC III FPG Yes HCIV & Hospital HCIII Self-monitoring of blood sugar Mainly through the diabetes club; very few have personal glucometers Hospital Community Oral anti-diabetics Initiation & change Yes HCIV & Hospital HC III Providing & explaining Yes HCIV & Hospital HC III Refills Yes; HC V, IV, III HCIII, IV & Hospital Compliance monitoring Yes; HCV and V HCIV & Hospital All levels; community Insulin therapy Initiation and change Yes HC IV & Hospital Adaptation to dose Yes Hospital Follow up support for patients Yes Hospital; Some HCIV All levels; community BP control Checking of BP Yes HCIII, IV & Hospital All; community Treatment for hypertension Yes HCIII, IV & Hospital HC III Adaptation to dose Yes; HCIII, IV & Hospital HC III Changing of drugs Yes; HCIII, IV & Hospital HC III Blood lipids Lipid profile Intermittent Hospital HC IV Statins No HC IV Eye screening Visual acuity Yes Hospital; some HCIV HC IV Fundoscopy No Kidneys Renal function tests Intermittent Hospital All HCV Provision of ACE inhibitors Yes Hospital; some HCIV HC IV Foot care Advice on foot care Yes Hospital All; community Nerve care Annual monofilament No HC V Assessing nerve problems Yes Hospital All HC III Life-style education On diet Yes; only PWDs Hospital; some HCIV All; community On physical activity Yes; only PWDs Hospital; some HCIV All; community On self-care & adherence Yes; only PWDs Hospital; some HCIV All; community Psycho-social Counselling to patients Yes Hospital All; community Managing Complications Glycaemia de-regulation Yes Hospital HC III Vascular complications Yes; only partly Hospital HC IV Table 3: Availability of equipment and drugs for diabetes and associated risk factors Equipment/drugs Present Level Comments Equipment Glucometer Yes HCIV & Hospital; some HC III Some not functional Test strips for glucometer Yes HCIV & Hospital; some HC III Frequent stockouts; supply of brands that do not match available glucometer HBA1c meters No There is no HBA1c testing provided Glucose urine sticks Yes HCIV & Hospital; some HC III Weighing scales Yes All facilities Not regularly calibrated; some facilities have one scale, usually at the maternity or OPD Height meters Yes Hospitals, Some HCIII & IV Some are drown by hand on the walls Blood Pressure machine Yes HCIII, IV and Hospitals Some are not functional Tape Measures Yes HCIV& Hospital; some HCIII Mostly used for nutritional assessment of children not adults Fundoscope Yes Only Hospitals Not used routinely in diabetes care Diabetes drugs Insulin (Soluble) Yes HCIV & Hospital Insulin (Long-acting) Yes HCIV & Hospital Metformin Yes HCIV & Hospital; some HC III Stockouts frequent; Some HCIII provide pill refills Risk factor drugs Tolbutamide/ Glibenclamide Yes HCIV & Hospital; some HC III Stockouts frequent; Some HCIII provide pill refills Calcium Channel Blocker Yes HCIV & Hospital Tend to stock older generation drugs (e.g. Nifedipine instead of Amlodipine) ACE Inhibitor or ARB Yes HCIV & Hospital Tend to stock older generation drugs (e.g. Captopril); Losartan also available Beta Blocker Yes Hospital only Mainly Atenolol; older drugs like propranolol still used Statins No Not in stock anywhere IEC Materials IEC materials on diet & physical activity Partly HCIV & Hospital, but fragmented and unstandardized IEC materials widely lacking, not comprehensive and not standardized Table 4: Support services for people with risk factors and with diabetes Topics Details from different perspectives Support provided to people with risk factors but no diabetes None of the health facilities has a formal program for people with obesity. People with hypertension receive treatment from HC III upwards. Hypertension is usually discovered passively when patients present with other complaints but there is no structured program for routine assessment of hypertension among risk groups. Support services for risk factor reduction are non-existent. HCII do not currently handle any risk factor assessment. Home-based support to people with diabetes None of the health facilities have any follow-up program for home-based support of people with diabetes. Unlike HIV, there are virtually no support programs for people with chronic conditions when they go back to their homes. How are families involved in supporting diabetes patients? At Iganga hospital each patient is requested to come with a ‘treatment companion’ who will support them with treatment. Most of them come with their spouses while others come with a family member. In Buluba, involvement of other family members is minimal. Lower facilities (HCIII and IV) report no support of this type at all. Some health centers however were involved in a one off program called ‘family health day’ that involved risk factor screening Referral pathways from communities to health facilities Communities have VHTs who support treatment and referrals for other common conditions (e.g. Malaria and TB) but no such programs exist for diabetes. Before patients reach a definitive diagnosis of diabetes, they will have visited traditional healers, private clinics and lower health centers (See figure 1) Patient groups Iganga district hospital has a functional patient group with a chairperson and group activities. Other health centers (III and IV) do not have any diabetes patient groups. HC IVs have chronic illness groups for HIV. HIV groups provide a broader range of support activities compared to the diabetes group including adherence support, psychosocial support and income generation activities. They move home to home supporting each other, and searching for clients who are lost to follow-up. Diabetes groups are not providing such support. Describe: Types, roles, linkage of patient groups to health system and support received from system In Iganga hospital, the diabetes patient group is closely linked to the health facility. The facility provides them with an area where they conduct their meetings every week on the clinic day. Some management tasks like lifestyle education and blood glucose measurement are delegated to the patient group. None of the other facilities have diabetes patient groups. HIV groups on the other hand have trained peer counsellors and expert patients who are closely linked to the health facilities. Facility led community programs Health facilities from time to time implement community programs related to reproductive health, malaria prevention and sanitation, through VHTs. All health facilities conduct integrated outreaches focusing on MCH. None of these programs involved NCD prevention activities Health education sessions on diabetes None of the health facilities conducts routine preventive health education for diabetes. Occasional education is given to people with hypertension but it is not structured. Quote: “We feel it is not a priority; we have other pressing needs” (Nurse in at Busesa HCIV) Health education for people with diabetes In general, patients receive specific health education about their illness. This is especially in their first two visits to the clinic. At the initial diagnosis, patients receive individualized health education about the disease. If managed as outpatients, they are requested to come with a care-companion at the second visit where they both receive more in-depth education. How are the health education sessions conducted? In Iganga Hospital, diabetes health education is conducted as a group session. In other facilities, patients are educated on a one-on-one basis since there are no formal clinics. Facilities lack the involvement of dieticians Challenges in providing health education to people with diabetes Shortage of personnel, lack relevant training in lifestyle diseases, lack of IEC materials, high turn-over of personnel, competition from herbalists, patients not coming as a group at lower health facilities, and lack of space are cited as some of the challenges Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 09 May, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers invited by journal 22 Apr, 2026 Editor invited by journal 02 Apr, 2026 Editor assigned by journal 01 Apr, 2026 Submission checks completed at journal 01 Apr, 2026 First submitted to journal 26 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9234072","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":632052853,"identity":"04902463-f794-4384-9545-14d7b69e0fb6","order_by":0,"name":"Roy William Mayega","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBADORDBTJIWY9K1JDYQrcV82uFnEh9+2aWvnZH+7HEBg508g0T6BbxaZG6nmUnO7EvO3XYjx9x4BkOyYYNETgFeLRLSCWbSvD3MIC1s0jwMzAkMEjkJBLSkf5P+21OfbnYj/RlQSz0xWnLMpBl+HE4wuwG0jofhMFBL+gFCWootexuOG24788bcmMfguGEbzxu8OkAO23jjx59qebPjwBDjqaiW52dPf4BfDwMDiwRjG5jBxsBgACJ5DAhpYf7A8AemBQzYCdoyCkbBKBgFIwsAAJdkQK37VolzAAAAAElFTkSuQmCC","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Roy","middleName":"William","lastName":"Mayega","suffix":""},{"id":632052854,"identity":"ae0cc360-368e-49a1-8efa-074da384ad98","order_by":1,"name":"Paul Kyambadde","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Kyambadde","suffix":""},{"id":632052856,"identity":"4fe44d1b-b929-402a-8629-178a7ab450eb","order_by":2,"name":"Wilson Abigaba","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Wilson","middleName":"","lastName":"Abigaba","suffix":""},{"id":632052859,"identity":"b47dbf30-6baa-4d11-a964-d86bd726ca4e","order_by":3,"name":"Agnes Nyabigambo","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Agnes","middleName":"","lastName":"Nyabigambo","suffix":""},{"id":632052863,"identity":"dd18f8ff-7736-4b7a-8046-ca12a0638936","order_by":4,"name":"Anthony Sebagereka","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"","lastName":"Sebagereka","suffix":""},{"id":632052869,"identity":"5619f933-4257-4e32-aa14-dfca85808945","order_by":5,"name":"Barbara Kirunda","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Barbara","middleName":"","lastName":"Kirunda","suffix":""}],"badges":[],"createdAt":"2026-03-26 12:24:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9234072/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9234072/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108406110,"identity":"ee757207-dfcd-408f-a1ab-ccd1b726b52c","added_by":"auto","created_at":"2026-05-04 09:41:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":264519,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTracing the diabetes patient’s itinerary before and after diagnosis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9234072/v1/efef045e3d77eda0afa06906.png"},{"id":108492708,"identity":"89c89ce5-e90d-4c37-a8be-c94cd048669c","added_by":"auto","created_at":"2026-05-05 09:58:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":680629,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9234072/v1/d5be1687-03a7-4dc2-a296-e8ab9c73e217.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A situational analysis of type 2 diabetes prevention, diagnosis and treatment services in a typical district health system in Eastern Uganda: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic non-communicable diseases (NCDs), including type 2 diabetes (T2D), have become a major global health challenge. Available evidence indicates that the future rise in NCDs will fall disproportionately on low- and middle-income countries (LMICs) compared to high-income countries (HICs) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. NCD deaths were projected to increase by over 20% in Africa and South-East Asia between 2010 and 2020, against a global average of 15% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Between 2010 and 2030, a 69% increase in type 2 diabetes was anticipated in LMICs, compared to 20% in HICs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. More recent International Diabetes Federation estimates indicate that Africa will see a 129% increase in people with diabetes by 2045, the highest proportional increase of any world region [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis growing incidence of chronic diseases in sub-Saharan Africa places enormous strain on health systems that were not designed for it [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and the response has largely been inadequate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Acute conditions still account for the bulk of disease burden in the region [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and primary health care systems remain oriented towards episodic, acute care delivery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Even within this domain, major access, quality and efficiency challenges persist for conditions such as malaria, tuberculosis and pneumonia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. NCD control capacity is generally poor [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and integration of care for communicable and non-communicable diseases remains limited, despite clear opportunities, particularly building on the HIV care infrastructure [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNCDs now account for at least 20% of the disease burden in sub-Saharan Africa [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and can no longer reasonably be treated as peripheral to the infectious disease agenda [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. What is needed is a major reorientation of health services towards chronic care and prevention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The practical question, however, is how to build systems that handle both acute and chronic conditions effectively in settings where resources are severely constrained. Given that communicable and non-communicable disease burdens will likely co-exist in Africa for the foreseeable future [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], smarter interventions targeting low-resource health systems are required, supported by translational research evidence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile epidemiological data on the NCD burden in sub-Saharan Africa have expanded considerably, there is a relative paucity of formative studies that characterise the actual gaps in service delivery at primary care level. Many countries in the region have begun updating their minimum health care packages and issuing NCD clinical guidelines [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Uganda, for example, established an NCD department within the Ministry of Health, expanded the NCD component of the minimum health care package [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and issued the Uganda Clinical Guidelines incorporating NCD management in 2019 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Yet, NCD programmes receive approximately 1% of the national health budget [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which severely limits what can be achieved at the operational level. The policies exist on paper, but we lack a clear picture of what services are actually available and functional at primary care level, and what the real capacity is to deliver them. This kind of formative understanding is essential before meaningful improvement interventions can be designed.\u003c/p\u003e \u003cp\u003eWe set out to describe the current services and support systems for prevention, diagnosis and management of type 2 diabetes, used as a tracer condition for related NCDs, within a typical district health system in Eastern Uganda. Our aim was to identify priority gaps that need to be addressed to operationalise the national NCD strategy at district level.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy setting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was carried out in Iganga and Mayuge districts, Eastern Uganda, within the Iganga-Mayuge Health and Demographic Surveillance Site (HDSS). These districts served as implementation sites for a broader project exploring the feasibility of establishing a population cohort for long-term NCD risk factor research. Both districts lie about 120 km east of Kampala. Iganga has an estimated population of 466,200 and Mayuge 461,200, with roughly 93% of residents in rural areas. The predominant livelihood is small-scale farming, supplemented by petty trading in semi-urban centres.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design and participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a qualitative assessment using key informant interviews (KIIs) and in-depth interviews (IDIs). Key informant interviews were conducted with members of the District Health Team (DHT) comprising of the District Health Officer, a District Nursing Officer, a District Health Visitor, and District Health Educators. These individuals were selected because their coordination responsibilities span the components of the minimum health care package most relevant to chronic care that includes clinical services, nursing, patient communication and health education, and community follow-up.\u003c/p\u003e\n\u003cp\u003eIn-depth interviews were held with managers of eight public health facilities: two HCIIs, two HCIIIs, two HCIVs, and two district hospitals. Two facilities were included at each level to allow triangulation. The eight facilities were selected randomly from the list of public health facilities in both districts.\u003c/p\u003e\n\u003cp\u003eUganda operates a tiered public health system [22]. The HCII (parish level) serves about 5,000 people, is nurse-led, and offers a minimum activity package with no inpatient services. The HCIII (sub-county level) serves about 25,000 people, is headed by a Clinical Officer, has a basic laboratory, and provides additional services including deliveries and TB treatment. The HCIV and district hospital serve about 100,000 people and have medical officers, emergency surgical capacity, and responsibility for technical support and planning across lower facilities in their zone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a key informant guide (for DHT members) and an in-depth interview guide combined with a facility assessment checklist (for facility managers). The guides were structured around four pre-determined themes adapted from the WHO Service Availability and Readiness Assessment (SARA) tool [23]: (i) type of care provided that is relevant to diabetes, (ii) status of the minimum package of diabetes services, (iii) availability of equipment and drugs, and (iv) support services for people with risk factors or with diabetes.\u003c/p\u003e\n\u003cp\u003eAll interviews were conducted in English by four research assistants with clinical or nursing backgrounds. They underwent two days of training on the tools, which were pre-tested through mock interviews at a HCIII in Kampala and refined accordingly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterview recordings were transcribed verbatim. We used manifest content analysis, reading and re-reading transcripts, then organising the findings under the pre-determined themes using thematic master sheets. This approach allowed us to identify service delivery gaps at each level of the health system. Findings from the facility checklists were summarised using simple frequency counts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and was approved by the Higher Degrees Research and Ethics Committee of Makerere University School of Public Health (ref. no. 426) and registered with the Uganda National Council of Science and Technology (ref no. HS 2118). Permission was obtained from the district health offices. All participants provided written informed consent, including consent for audio recording.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWhere diabetes care is provided\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiabetes care was concentrated at hospitals and, to a lesser extent, HCIVs. Lower-level facilities played almost no role. Only one of eight HCIIIs provided oral medication refills for diabetes; the others limited their involvement to assessing and referring suspected cases. HCIIs had no role beyond referring very sick patients. Hospitals had the range of staff needed (10+ clinical staff /medical officers and 20+ senior nurses) to run dedicated diabetes services. HCIVs, by contrast, had only two to five clinical staff including one or two medical officers.\u003c/p\u003e\n\u003cp\u003eAll surveyed facilities were physically accessible, most being situated along main roads. Services at public facilities were nominally free, but widespread medicine shortages meant patients frequently incurred out-of-pocket costs. Only hospitals ran regular diabetes clinics (weekly, all-day). HCIVs saw diabetes patients on a walk-in basis with no dedicated clinic days. Patients tended to bypass HCIVs entirely, going straight to the hospital. As one district health officer explained: \u0026ldquo;Most diabetes patients come directly to the hospital. They know the lower centres cannot help them, so they don\u0026rsquo;t bother stopping there\u0026rdquo; (District Health Officer, Iganga). Details of these findings are detailed in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMinimum package for type 2 diabetes services\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no preventive services or risk factor screening programmes for diabetes at any level. Health workers did not see preventive care for diabetes as part of their expected duties. Wellness checks existed only for maternal and child health programmes (mainly blood pressure and weight were measured routinely for pregnant women during antenatal care) but in outpatient departments these measurements were reserved for patients presenting with symptoms suggestive of hypertension. One HCIII was an exception: it screened all clients aged 35 and over for high blood pressure and obesity, but this was not linked to any formal risk reduction programme.\u003c/p\u003e\n\u003cp\u003eNew diabetes cases were identified almost entirely through passive case detection at HCIVs or hospitals. Suspicion was triggered by classical symptoms, and confirmation typically relied on a single random blood sugar combined with the clinical picture. Among confirmed patients, glucose monitoring occurred only at monthly clinic visits using fasting plasma glucose. Fewer than 5% of patients owned a glucometer. HbA1c testing was unavailable everywhere. Medication initiation and changes happened only at hospital and HCIV levels, though some HCIIIs dispensed refills.\u003c/p\u003e\n\u003cp\u003eEvidence-based clinical guidelines were conspicuously absent. Facilities avoided insulin even where indicated, citing home storage problems. Patients started on insulin received more frequent appointments, but many missed these visits due to transport costs, user fees at private not-for-profit facilities, or feeling better after initial treatment. Hypertension was treated from HCIII upward, but only with older-generation drugs like Nifedipine. The sole bio-analyser in the study districts was non-functional, leaving no facility able to perform renal function, liver function, or lipid profile tests. Some HCIVs stocked ACE inhibitors and ARBs; no facility had statins. Fundoscopy equipment existed at the district hospital eye clinic but was not routinely used for diabetes patients. Facilities did not set treatment targets. Staff cited low numbers, heavy workload, absent training, lack of IEC materials, misinformation from traditional healers, and patient non-attendance as key obstacles. These findings are presented in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of equipment and drugs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGlucometers were present at hospitals, HCIVs, and some HCIIIs, but roughly half were non-functional, mostly because of stockouts or supply of incompatible test strips. Weighing scales were widely available but poorly calibrated. Height meters existed at HCIII and above but were used mainly for maternal and child health, except at Iganga Hospital. Blood pressure machines were adequate at HCIVs and hospitals but each HCIII had only one, stationed at the maternity. Both HCIIs assessed lacked functional height meters and BP machines.\u003c/p\u003e\n\u003cp\u003eTape measures were mainly used for paediatric nutritional assessment, not adult anthropometry. Fundoscopes existed only at hospitals and were not used routinely. Insulin (Soluble and Lente) was available at HCIVs and hospitals. Oral hypoglycaemics and antihypertensives were nominally available down to HCIII, but stockouts were common. Older-generation drugs predominated - Nifedipine rather than Amlodipine, Captopril rather than newer ACE inhibitors, and some facilities still stocked Methyldopa. Statins were absent entirely. IEC materials for diabetes were virtually non-existent. Table 3 provides the full details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerson-centred care and patient education\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the two hospitals, health workers reported trying to tailor care to patients\u0026rsquo; circumstances, but HCIVs and HCIIIs were too understaffed to do the same. No facility conducted any secondary data analysis to track patient outcomes. Staff described offering psychosocial support, but the available counsellors had been trained exclusively for HIV care and were not equipped for diabetes counselling.\u003c/p\u003e\n\u003cp\u003ePatient consultations lasted about 15 minutes for return visits and 30 minutes for new patients, extending to an hour when tests were required. No training in patient-centred care had been provided. Staff reported consulting patients about treatment decisions that had resource implications. Longstanding patients were seen as knowledgeable and self-directing; newly diagnosed patients needed extensive support before adapting.\u003c/p\u003e\n\u003cp\u003eSelf-monitoring of blood glucose was rare and very few patients had glucometers. Urine dipsticks remained the default monitoring tool in many settings. Community-level diabetes awareness programmes were absent. There was considerable misinformation from traditional healers, market-based drug vendors, and drug shops. Where provided, lifestyle education was offered in group sessions at Iganga Hospital and individually at lower facilities, but without standardised IEC materials the quality of messages varied widely. No formal coaching on diet or physical activity existed. Hospital nutritionists focused on childhood malnutrition and were not involved in chronic disease programmes. Health workers suspected that patient adherence to lifestyle recommendations was poor, but had no way to measure it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSelf-management support for people with risk factors and those with diabetes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNewly diagnosed patients received education about what to expect with their condition. At Iganga Hospital, patients were asked to bring a treatment companion to their second visit for more in-depth lifestyle education. The hospital had a diabetes patient club that met on clinic days for blood sugar checks, peer education, and mutual encouragement. Club members sometimes raised money to purchase test strips during stockouts. Expert patients were trained by health workers and were closely linked to the clinical team.\u003c/p\u003e\n\u003cp\u003eThe picture was quite different elsewhere. No other facility had a diabetes patient group. Crucially, once patients left any facility, no follow-up existed. One facility manager captured the situation plainly: \u0026ldquo;When the patient walks out of this gate, we have no idea what happens to them until the next appointment, if they come back at all\u0026rdquo; (Facility Manager, Busesa HCIV). There were no home visits, no phone calls, and no community-based adherence support. Monitoring patients on insulin between visits was especially difficult. Table 4 provides these details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient pathway to diagnosis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause detection depended on classical symptoms, patients were typically diagnosed late, often with established complications. The preceding period typically involved episodic illness misdiagnosed and treated as malaria, infections, or other acute conditions. Patients described a meandering care-seeking journey through private clinics, drug shops, traditional healers, and herbalists, a journey accompanied by considerable misinformation. As one hospital clinician observed: \u0026ldquo;By the time they reach us, they have spent months or even years going from one herbalist to another. Some come with complications that we could have prevented if they had come earlier\u0026rdquo; (Clinician, Mayuge District Hospital). Contacts with accompanied by much misinformation. Contacts with lower-level health facilities often failed to identify diabetes. Patients eventually self-referred to the hospital when nothing else had worked, by which time the disease was usually advanced. Notably, even after receiving a definitive diagnosis, many patients continued to combine biomedical treatment with traditional remedies. Figure 1 maps this typical itinerary.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis assessment reveals significant weaknesses in type 2 diabetes services across the health system hierarchy in two typical Ugandan districts. The gaps span prevention, detection, treatment, and ongoing patient support, and they broadly align with the challenges reported from other parts of sub-Saharan Africa. Five main findings merit discussion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConcentration of care at higher-level facilities\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur finding that diabetes care is overwhelmingly concentrated at the hospital level, with lower facilities playing a marginal role, runs counter to the decentralisation model that underpins Uganda\u0026rsquo;s health system. This is not, however, a finding peculiar to our setting. A systematic review of diabetes care readiness across sub-Saharan Africa found that primary-level capacity for managing diabetes remains embryonic in most countries, despite policy commitments to decentralise chronic care [24]. A mixed-methods study of diabetes care quality in rural Eastern Uganda (conducted in a similar setting) likewise found that services were largely confined to hospitals, with lower-level health centres lacking even basic capacity [25].\u003c/p\u003e\n\u003cp\u003eThe practical implication is that a deliberate decentralisation strategy is needed, one that equips HCIIIs with simplified protocols and the clinical supplies to manage uncomplicated diabetes. Task shifting of this kind is not without precedent in the region: the scale-up of HIV treatment relied heavily on shifting responsibilities to clinical officers and nurses at peripheral facilities [26]. The INTE-AFRICA trial, conducted across facilities in Uganda and Tanzania, recently demonstrated that managing HIV, diabetes and hypertension through the same primary care team is both feasible and safe [27], providing an evidence base for scaling integrated care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIncomplete minimum package for prevention and care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe absence of any form of risk factor screening, the reliance on a single random blood sugar for diagnosis, the complete unavailability of HbA1c testing, and the lack of clinical protocols at the point of care constitute serious shortcomings. These are the building blocks of a functioning diabetes service, and they were missing across the board. Park and Pastakia have noted that the over-reliance on fasting blood glucose at clinic visits leaves clinicians with little real insight into how patients are doing between their monthly or less frequent appointments [28]. They note that where HbA1c testing was introduced in resource-limited settings, it emerged as the primary predictor of glycaemic control, suggesting that its absence actively contributes to poor outcomes.\u003c/p\u003e\n\u003cp\u003eThe lack of clinical guidelines at facility level is equally troubling but, again, not uncommon. A narrative review of diabetes care across the region found that few countries have managed to place contextualised, practical guidelines in the hands of the health workers who need them most [29]. What exists at the national level often does not filter down to where care is actually delivered.\u003c/p\u003e\n\u003cp\u003eThere is, therefore, a need to deploy adapted versions of the WHO Package of Essential NCD Interventions (WHO-PEN) to all facility levels, accompanied by practical job aids, and to explore the introduction of affordable point-of-care HbA1c testing. These are not luxurious additions but rather the minimum requirements for credible diabetes care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChronic shortages of equipment and essential drugs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrequent stockouts of oral hypoglycaemics, antihypertensives and glucose test strips, compounded by the supply of strips incompatible with available glucometers, represent a systemic failure in procurement and supply chain management. The continued stocking of old-generation drugs (Nifedipine, Methyldopa, Captopril) when more effective and better-tolerated options exist, and the total absence of statins, reflect both budgetary limitations and inertia in essential medicines list updates. These patterns mirror what has been documented in the wider region. A review of health system readiness for diabetes in sub-Saharan Africa found medication stockouts and diagnostic shortfalls to be near-universal [24]. Park and Pastakia observed that even where countries have taken steps to decentralise diabetes care, the monitoring tools and consumables needed to make decentralisation meaningful have not followed [28].\u003c/p\u003e\n\u003cp\u003eAddressing this will require ringfenced funding for NCD commodities, given that current budget allocations to NCDs in Uganda are wholly inadequate [21]. Procurement practices need attention too: the mismatch between glucometers and test strips is an avoidable logistics failure, not a fundamental resource constraint. Essential medicines lists at the district level need updating to reflect current evidence on the comparative effectiveness of antihypertensive agents and the role of statins in cardiovascular risk reduction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInadequate patient education and personalised care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers made genuine efforts to educate patients, but they were working without training, without standardised materials, and without the specialist support (dieticians, counsellors) that effective chronic disease education requires. The fact that available counsellors were ring-fenced for HIV care and had no involvement in diabetes services is a telling illustration of how vertical programming creates artificial boundaries that disadvantage newer health priorities. Studies from Ghana have described how inadequate patient education and long hospital waiting times push diabetes patients towards traditional healers who lack diagnostic capacity, contributing to late diagnosis and poor outcomes [30].\u003c/p\u003e\n\u003cp\u003eThere is encouraging evidence, however, that these gaps can be bridged. The MOCCA cohort study in Tanzania and Uganda showed that when the counselling and adherence support approaches refined through HIV care were applied to diabetes and hypertension management, patient retention improved markedly [31]. A scoping review of HIV-NCD integration confirmed that tools, systems and implementation strategies from HIV care can potentially be transferred rapidly and efficiently to NCD programmes [32]. The implication for policy is that the artificial separation between HIV and NCD support cadres needs to end. Counsellors, community health workers and peer educators should be trained and deployed across chronic conditions, not siloed within single-disease programmes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTortuous pathway to diagnosis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe circuitous route that patients followed before reaching a correct diagnosis\u0026mdash;cycling through drug shops, private clinics, traditional healers, and lower-level facilities where diabetes went unrecognised was perhaps the most troubling of our findings, as it means patients arrive at definitive care with complications that might have been avoided. A subsequent qualitative study at Iganga Hospital specifically examined these diagnostic delays and identified strong socio-cultural drivers, including deeply held beliefs about witchcraft and supernatural causation, that kept patients circulating through the traditional health sector long after symptoms appeared [33]. Research in Ghana similarly found that spiritual interpretations of illness led patients to exhaust traditional options before presenting to biomedical facilities, typically late and with complications [30].\u003c/p\u003e\n\u003cp\u003eTwo responses seem warranted. First, community-based awareness campaigns must improve public understanding of diabetes symptoms and the importance of early care-seeking at formal health facilities. Rather than ignoring or opposing traditional healers, who are deeply embedded in the social fabric and will continue to be consulted regardless of official policy, public health programmes should \u0026nbsp;also explore collaborative frameworks. A pilot project in Cameroon demonstrated that traditional healers could learn basic diabetes prevention messages relatively quickly, could refer patients for blood glucose testing, and were enthusiastic about collaborating with the formal health system [34]. Such models deserve further testing and scale-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecommendations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDrawing on the five findings discussed above, we propose the following recommendations for strengthening diabetes services at the district level in Uganda and comparable settings.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDiabetes care should be deliberately decentralised to HCIII level through simplified clinical protocols and task shifting to clinical officers and nurses, following the model that proved successful for HIV treatment scale-up. The INTE-AFRICA trial provides an evidence base for this approach [27].\u003c/li\u003e\n \u003cli\u003eThe WHO Package of Essential NCD Interventions (WHO-PEN) should be adapted and deployed to all facility levels, accompanied by practical job aids. Affordable point-of-care HbA1c testing should be explored to improve glucose monitoring beyond the current reliance on single fasting blood glucose readings.\u003c/li\u003e\n \u003cli\u003eProcurement and supply chain systems for NCD commodities need dedicated funding. At a minimum, this means ensuring compatible test strips for available glucometers, updating essential medicines lists to include newer-generation antihypertensives and statins, and ringfencing NCD commodity budgets within the district health budget.\u003c/li\u003e\n \u003cli\u003ePatient education and self-management support should be structured and extended beyond the health facility. Counsellors and community health workers currently confined to HIV programmes should be cross-trained for NCD care. Standardised IEC materials for diabetes need to be developed and distributed. Hospital nutritionists should be reoriented to include adult chronic disease counselling alongside their current focus on childhood malnutrition.\u003c/li\u003e\n \u003cli\u003eCommunity-based awareness campaigns are needed to reduce diagnostic delay. Public health programmes should explore collaborative frameworks with traditional healers, training them as diabetes educators and referral agents rather than treating them as adversaries. The Cameroon pilot project [34] offers a tested model for such collaboration.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrengths and limitations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s main strength lies in its systematic coverage of all four levels of Uganda\u0026rsquo;s district health system, using a structured tool derived from the WHO SARA framework, combined with purposive interviews that captured both the technical and the experiential dimensions of diabetes care. Including two facilities at each level allowed us to check the consistency of findings.\u003c/p\u003e\n\u003cp\u003eThere are, however, important limitations. The qualitative design and the small number of districts mean the findings cannot be statistically generalised, though the contextual similarity of Iganga-Mayuge to many rural Ugandan districts (and to rural districts elsewhere in the region) suggests they are broadly transferable. We did not include patient perspectives, which would have enriched our understanding of demand-side barriers. And the study provides a snapshot at a single point in time, while service availability, particularly for drugs and supplies, can fluctuate considerably.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis situational analysis exposes significant gaps in type 2 diabetes services at the district level in Eastern Uganda. Care is concentrated at hospitals, the minimum service package is incomplete, essential drugs and equipment are chronically short, patient education is unstructured and unstandardised, and patients navigate a long and often harmful path before arriving at a correct diagnosis. These findings are not unique to our study districts; they reflect the wider reality of diabetes care across much of sub-Saharan Africa.\u003c/p\u003e\n\u003cp\u003eWhat the HIV experience in the region demonstrates, however, is that transforming chronic care at the primary level is achievable with the right combination of task shifting, simplified protocols, community engagement, and supply chain commitment. The challenge now is to translate that experience into practical, tiered interventions for diabetes and other NCDs, matched to the real capabilities and resource realities at each level of the health system, backed by adequate and sustained financing.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Higher Degrees Research and Ethics Committee of Makerere University School of Public Health (ref no. \u0026nbsp; 426) and registered with the Uganda National Council of Science and Technology (ref no. HS 2118). All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative datasets generated and analysed during this study are not publicly available due to confidentiality concerns inherent to the small number of respondents and their identifiable roles, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Swedish International Development Cooperation Agency (SIDA) through the Makerere University-Karolinska Institutet capacity building partnership, and by the Rockefeller Foundation through the ResilientAfrica Network at Makerere University School of Public Health. The funders had no role in study design, data collection, analysis, interpretation, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRWM conceived the study, led the design and data collection, performed the analysis and drafted the manuscript. PK contributed to study design and reviewed the manuscript. AN contributed to data analysis and manuscript review. WA was involved in the research from end to end, participating \u0026nbsp;in the design, data collection, analysis and completed the manuscript. AS participated in data collection and reviewed the manuscript. BK contributed to data analysis and critical review. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the district health teams of Iganga and Mayuge districts and the health facility managers who participated in this study. We also acknowledge the research assistants who collected the data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.\u003c/li\u003e\n \u003cli\u003eShaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:4-14.\u003c/li\u003e\n \u003cli\u003eInternational Diabetes Federation. IDF Diabetes Atlas. 10th ed. Brussels: IDF; 2021.\u003c/li\u003e\n \u003cli\u003eDalal S, Beunza JJ, Volmink J, et al. Non-communicable diseases in sub-Saharan Africa: what we know now. 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Hum Resour Health. 2010;8:8.\u003c/li\u003e\n \u003cli\u003eKivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, et al. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA). Lancet. 2023;402:1241-50.\u003c/li\u003e\n \u003cli\u003ePark PH, Pastakia SD. Access to hemoglobin A1c in rural Africa: a difficult reality with severe consequences. J Diabetes Res. 2018;2018:6093595.\u003c/li\u003e\n \u003cli\u003ePastakia SD, Pekny CR, Manyara SM, Fischer L. Diabetes in sub-Saharan Africa: from policy to practice to progress. Diabetes Metab Syndr Obes. 2017;10:247-63.\u003c/li\u003e\n \u003cli\u003eAhorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. Community beliefs and practices about diabetes and their implications in Southeast Ghana. BMC Public Health. 2024;24:3073.\u003c/li\u003e\n \u003cli\u003eBirungi J, Kivuyo S, Garrib A, Shabbar J, Namakoola I, Okebe J, et al. Integrating health services for HIV infection, diabetes and hypertension in sub-Saharan Africa: a cohort study. BMJ Open. 2021;11:e053412.\u003c/li\u003e\n \u003cli\u003eMcCombe G, Lim J, Van Hout MC, et al. Integrating care for diabetes and hypertension with HIV care in sub-Saharan Africa: a scoping review. Int J Integr Care. 2022;22:6.\u003c/li\u003e\n \u003cli\u003eMayega RW, Kiwanuka SN, Engel N, et al. Understanding the diagnostic delays and pathways for diabetes in Eastern Uganda. PLoS One. 2021;16:e0250421.\u003c/li\u003e\n \u003cli\u003eMbeh GN, Edwards R, Ngufor G, Assah F, Fezeu L, Mbanya JC. Traditional healers and diabetes: results from a pilot project in Cameroon. Glob Health Promot. 2010;17(2 Suppl):17-26.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Type of care provided that is relevant to type 2 diabetes care and prevention\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"945\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTopic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitals\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHC IV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHC III\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHC II\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eType of care provided relevant for T2D or its associated risk factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eThey are the main level where T2D is managed; However, no routine preventive services targeting diabetes risk factors. The hospital is the only level with a regular diabetes clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eThey conduct diagnosis and treatment of T2D and hypertension\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo routine prevention services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eThey take history and examine after which they \u0026nbsp;refer suspected cases\u003c/p\u003e\n \u003cp\u003eHypertension is identified coincidentally but treatment is only given when drugs are available\u003c/p\u003e\n \u003cp\u003eNo formal preventive services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHave no role in diabetes management except for referral\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eUsual number and type of staff who provide diabetes care or prevention services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eThey have over 50 health workers. This allows them to allocate a small team specifically for diabetes care including 1 Medical Officer, 2 nurses, 2 Clinical Officers \u0026amp; 1 doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eBusesa: 2 Medical Officers \u0026amp; 2 Clinical officers, 1 Senior Nursing Officer, 3 Nursing Officers and 3 lab staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eBusowobi: 1 Clinical Officer, 1 Nursing Officer, 3 Nurses, 4 Midwives, 2 Nursing Assistants, 1 Records Assistant, 1 Lab Assistant\u003c/p\u003e\n \u003cp\u003eBusembatya: 1 CO, 1 NO, 2 Nurses, 2 Midwives, 1 Lab technician and 1 lab assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNawanzu: 1 Enrolled Nurse; 1 Midwife\u003c/p\u003e\n \u003cp\u003eNawansinge: 3 ENs \u0026amp; 2 registered nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eGeographical access to health facilities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eSome hospitals are accessible but others have a hard-to-reach catchment population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAccessible as most are near the highway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eFairly accessible though some are hard to reach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eWho pays for diabetes treatment related services?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eAll public health facilities offer free direct services while patients meet the indirect costs e.g. transport. However, stockouts lead to frequent out-of-pocket expenditures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eFree services but with frequent stockouts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSome HCIII offer free drugs refills for diabetes and hypertension but with frequent stockouts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eAccommodation aspects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eOpening time, waiting time, and clinic opening days generally okay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSporadic walk-ins. They have no formal clinic days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSporadic walk-ins for drugs refills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eEvidence-based guidelines for care and prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eApart from Buluba hospital which had a capacity building program, there is a general lack of guidelines and job-aids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eAre the referral levels functional?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eReferral lines non-functional for diabetes as patients predominantly prefer the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Status of the minimum package of diabetes services in assessed health facilities\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDF package component \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrently offered?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel where provided\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhere it could be provided\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRisk factor screening for preventive action\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003ePassive wellness checks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eVery rarely done (2/8 facilities)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eA HCIV and III as a special program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll levels; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOpportunistic screening for selected risk factors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eFor hypertension , among people with symptoms but not for obesity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eAt HCIII, HCIV, Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll levels; Community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003ePreventive services for people with risk factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot routinely provided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll levels; Community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eDetection of diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003ePassive case detection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHC IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHCIII\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOGTT\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot done anywhere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eRandom Blood Sugar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMost commonly used test\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eGlucose monitoring for people with diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eHbA1c\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot done anywhere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC IV/V\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eRandom Blood Sugar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFPG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHCIII\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSelf-monitoring of blood sugar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMainly through the diabetes club; very \u0026nbsp;few have personal glucometers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eOral anti-diabetics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eInitiation \u0026amp; change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eProviding \u0026amp; explaining\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eRefills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes; HC V, IV, III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIII, IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCompliance monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes; HCV and V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll levels; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eInsulin therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eInitiation and change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHC IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAdaptation to dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFollow up support for patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital; Some HCIV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll levels; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eBP control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eChecking of BP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIII, IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eTreatment for hypertension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIII, IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAdaptation to dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIII, IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eChanging of drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHCIII, IV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eBlood lipids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eLipid profile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eIntermittent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC IV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eStatins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC IV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eEye screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eVisual acuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital; some HCIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC IV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFundoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eKidneys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eRenal function tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eIntermittent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll HCV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eProvision of ACE inhibitors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital; some HCIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC IV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eFoot care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAdvice on foot care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eNerve care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAnnual monofilament\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC V\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAssessing nerve problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll HC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLife-style education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOn diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes; only PWDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital; some HCIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOn physical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes; only PWDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital; some HCIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOn self-care \u0026amp; adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes; only PWDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital; some HCIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePsycho-social\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCounselling to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAll; community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eManaging Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eGlycaemia de-regulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eVascular complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYes; only partly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHC IV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Availability of equipment and drugs for diabetes and associated risk factors\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"619\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEquipment/drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComments\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eEquipment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eGlucometer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003eHCIV \u0026amp; Hospital; some HC III\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eSome not functional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTest strips for glucometer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003eHCIV \u0026amp; Hospital; some HC III\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eFrequent stockouts; supply of brands that do not match available glucometer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eHBA1c meters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eThere is no HBA1c testing provided\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eGlucose urine sticks\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003eHCIV \u0026amp; Hospital; some HC III\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eWeighing scales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAll facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eNot regularly calibrated; some facilities have one scale, usually at the maternity or OPD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eHeight meters\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHospitals, Some HCIII \u0026amp; IV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eSome are drown by hand on the walls\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBlood Pressure machine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIII, IV and Hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eSome are not functional\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTape Measures\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV\u0026amp; Hospital; some HCIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eMostly used for nutritional assessment of children not adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eFundoscope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eOnly Hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eNot used routinely in diabetes care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eInsulin (Soluble)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eInsulin (Long-acting)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eMetformin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital; some HC III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eStockouts frequent; Some HCIII provide pill refills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk factor drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTolbutamide/ Glibenclamide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital; some HC III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eStockouts frequent; Some HCIII provide pill refills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eCalcium Channel Blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eTend to stock older generation drugs (e.g. Nifedipine instead of Amlodipine)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eACE Inhibitor or ARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eTend to stock older generation drugs (e.g. Captopril); Losartan also available\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBeta Blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHospital only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eMainly Atenolol; older drugs like propranolol still used\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eStatins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eNot in stock anywhere\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIEC Materials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eIEC materials on diet \u0026amp; physical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePartly\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHCIV \u0026amp; Hospital, but fragmented and unstandardized\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eIEC materials widely lacking, not comprehensive and not standardized\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 4: Support services for people with risk factors and with diabetes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTopics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDetails from different perspectives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSupport provided to people with risk factors but no diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eNone of the health facilities has a formal program for people with obesity. People with hypertension receive treatment from HC III upwards. Hypertension is usually discovered passively when patients present with other complaints but there is no structured program for routine assessment of hypertension among risk groups. Support services for risk factor reduction are non-existent. HCII do not currently handle any risk factor assessment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHome-based support to people with diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eNone of the health facilities have any follow-up program for home-based support of people with diabetes. Unlike HIV, there are virtually no support programs for people with chronic conditions when they go back to their homes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHow are families involved in supporting diabetes patients?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eAt Iganga hospital each patient is requested to come with a \u0026lsquo;treatment companion\u0026rsquo; who will support them with treatment. Most of them come with their spouses while others come with a family member. In Buluba, involvement of other family members is minimal. Lower facilities (HCIII and IV) report no support of this type at all. Some health centers however were involved in a one off program called \u0026lsquo;family health day\u0026rsquo; that involved risk factor screening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eReferral pathways from communities to health facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eCommunities have VHTs who support treatment and referrals for other common conditions (e.g. Malaria and TB) but no such programs exist for diabetes. Before patients reach a definitive diagnosis of diabetes, they will have visited traditional healers, private clinics and lower health centers (See figure 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePatient groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eIganga district hospital has a functional patient group with a chairperson and group activities. Other health centers (III and IV) do not have any diabetes patient groups. HC IVs have chronic illness groups for HIV. HIV groups provide a broader range of support activities compared to the diabetes group including adherence support, psychosocial support and income generation activities. \u0026nbsp;They move home to home supporting each other, and searching for clients who are lost to follow-up. Diabetes groups are not providing such support.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDescribe: Types, roles, linkage of patient groups to health system and support received from system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eIn Iganga hospital, the diabetes patient group is closely linked to the health facility. The facility provides them with an area where they conduct their meetings every week on the clinic day. Some management tasks like lifestyle education and blood glucose measurement are delegated to the patient group. None of the other facilities have diabetes patient groups. HIV groups on the other hand have trained peer counsellors and expert patients who are closely linked to the health facilities.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eFacility led community programs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eHealth facilities from time to time implement community programs related to reproductive health, malaria prevention and sanitation, through VHTs. All health facilities conduct integrated outreaches focusing on MCH. None of these programs involved NCD prevention activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHealth education sessions on diabetes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eNone of the health facilities conducts routine preventive health education for diabetes. Occasional education is given to people with hypertension but it is not structured. Quote: \u003cem\u003e\u0026ldquo;We feel it is not a priority; we have other pressing needs\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Nurse in at Busesa HCIV)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHealth education for people with diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eIn general, patients receive specific health education about their illness. This is especially in their first two visits to the clinic. At the initial diagnosis, patients receive individualized health education about the disease. If managed as outpatients, they are requested to come with a care-companion at the second visit where they both receive more in-depth education.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHow are the health education sessions conducted?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eIn Iganga Hospital, diabetes health education is conducted as a group session. In other facilities, patients are educated on a one-on-one basis since there are no formal clinics. Facilities lack the involvement of dieticians\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eChallenges in providing health education to people with diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003eShortage of personnel, lack relevant training in lifestyle diseases, lack of IEC materials, high turn-over of personnel, competition from herbalists, patients not coming as a group at lower health facilities, and lack of space are cited as some of the challenges\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 2 diabetes, situational analysis, health services, primary health care, district health system, sub-Saharan Africa, Uganda, service readiness","lastPublishedDoi":"10.21203/rs.3.rs-9234072/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9234072/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eImproving type 2 diabetes (T2D) services in low-income countries requires identification of specific service gaps. We conducted a situational analysis of type 2 diabetes services in two districts in Eastern Uganda to inform development of service improvement interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis was a formative qualitative assessment within a broader feasibility study in the Iganga-Mayuge Health and Demographic Surveillance Site. Managers of eight health facilities (two each from Health Centres II, III, IV and district hospitals) underwent in-depth interviews and completed a checklist adapted from the WHO Service Availability and Readiness Assessment (SARA) tool. Four District Health Team members were interviewed as key informants. We analysed the data using manifest content analysis organised around pre-determined themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThere was no routine risk factor screening or preventive health checks related to type 2 diabetes. The disease was detected passively using classical symptoms and a single random blood sugar, typically after patients had been treated for other conditions. Care was concentrated at hospital and HCIV levels. Stockouts of medicines were frequent, and clinical algorithms to guide treatment decisions were absent. Insulin prescriptions faced storage and adherence challenges. Glucose monitoring was accessible only at diabetes clinics. Lifestyle education, where offered, was neither standardised nor individualised. No patient follow-up existed once patients left facilities. Patients followed tortuous pathways involving traditional healers and unqualified providers before reaching diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThere are glaring gaps in type 2 diabetes services at the district level. Operationalising the national NCD strategy will require tiered, cost-effective improvements in care and prevention matched to the capabilities of different health facility levels, drawing lessons from successful chronic care programmes.\u003c/p\u003e","manuscriptTitle":"A situational analysis of type 2 diabetes prevention, diagnosis and treatment services in a typical district health system in Eastern Uganda: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 09:41:15","doi":"10.21203/rs.3.rs-9234072/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-09T13:19:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31897028971622012832960587056500798834","date":"2026-04-27T05:52:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127172464845399962903136990674216906645","date":"2026-04-24T11:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-22T10:03:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-02T08:04:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-01T15:22:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-01T15:21:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-03-26T12:08:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f51f8fd0-9586-45db-bf00-375379c8756e","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-09T13:19:01+00:00","index":63,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T09:41:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 09:41:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9234072","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9234072","identity":"rs-9234072","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}