Evaluation of a diabetes decentralization program in rural Madagascar using the RE-AIM framework

Diabetes is a significant cause of disabilities and deaths in Africa. In Madagascar, diabetes causes an estimated 5,000 deaths yearly. There are many barriers to diabetes care in Madagascar, and a key barrier is health systems readiness to provide care, especially in rural areas. To mitigate this, the non-governmental organization (NGO) Pivot and the Ministry of Public Health (MoPH) jointly implemented a diabetes decentralization program in Ifanadiana, a rural district of Madagascar. This program included advocacy; mass screening; training of healthcare workers (HCWs); procurement of equipment, medications and consumables; establishment of a dedicated diabetes care day at primary health centers (PHCs); and support groups for patients. This study evaluated the implementation of this multifaceted diabetes program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Using a mixed methods study design, we evaluated program implementation at PHCs at 3, 6, and 18 months of implementation. Overall, 2.1% of people tested during mass screenings were positive for diabetes and 59.3% of people diagnosed with diabetes during mass screenings entered into care at a PHC. There was a fasting blood glucose check at 93.2% of visits, and an average 1.35 days of medication stock out per month. 48.0% patients had their diabetes controlled, ranging from 33.3% at the PHCs with 3 months of implementation to 57.8% at 18 months of implementation. Qualitative data revealed that HCWs adopted various aspects of the program, with suggestions for improvement on the training received. A dedicated day for diabetes management weekly was widely accepted by patients and HCWs. The most difficult aspect of diabetes management for patients was dietary recommendations. This study demonstrated that NGO support enables accessibility of diabetes services even in the most remote areas, and a multi-layered approach to implementation of diabetes diagnosis and treatment is needed for effective care.