Evaluation of diabetes care services, data quality, and availability of resources in Ethiopia: Difference-in-differences analysis of the NORAD-WHO NCDs' midterm project evaluation

Abstract

Background: The Ethiopian government, supported by NORAD, the WHO, and other partners, is decentralizing diabetes care to primary health units via a task-shifting approach. Despite substantial investment, there is still a lack of up-to-date information on diabetes screening, diagnosis, treatment, and medication availability in the country.

Objective: This study assessed the effects of the NORAD-WHO intervention on diabetes care services, data quality, and the availability of infrastructure and medical supplies in Ethiopia.

Methods: A quasiexperimental study was conducted across 31 NORAD-WHO project facilities and 62 control facilities in six regions of Ethiopia and Addis Ababa. We used descriptive statistics to assess diabetes screening, diagnosis, treatment services, medication availability, and data quality over 54 months from January 2019 to June 2023. Additionally, we performed a difference-in-differences (DID) regression analysis comparing data from two periods: before the intervention (January to December 2019) and after the intervention (July 2022 to June 2023).

Results: This study revealed a notable increase in diabetes services, with over 82% of facilities offering screening, early diagnosis, and treatment. Written treatment guidelines are present in three quarters of the facilities. The proportion of trained staff increased from 58% in 2019 to 100% in 2023 across all the evaluated facilities. Intervention facilities had significantly more functional glucometers than did control facilities, averaging four (95% CI: 3.4, 4.6) per month in 2023 compared with 2.5 (95% CI: 2.1, 2.9) in 2019. However, hemoglobin A1C testing remains uncommon. Despite improvements in diabetes service data, issues with missing records, overreporting, and timeliness persist, with an average reporting rate of 99.2% and on-time reporting rate of 51.5%. The NORAD-WHO intervention notably increased the average number of fasting blood sugar tests by 17 per month (95% CI: 12.2-21.8, p = 0.014).

Conclusions: This midterm evaluation revealed a significant increase in the availability of fasting blood sugar tests in the intervention facilities. Additionally, the availability of medical equipment, laboratory services, and medications has improved over the years. Intervention facilities, with more trained healthcare professionals and better resources, outperform control facilities in screening, diagnosing, treating, and managing high blood sugar levels. Notably, intervention facilities screened more clients for diabetes and showed that patients receiving follow-up care achieved better glycemic control than did those at control facilities. While there has been progress in diabetes service data availability, addressing issues such as missing data, overreporting, and reporting timeliness is essential for further improving the quality of diabetes services.

Clinical trial number: Not applicable.

Keywords: Availability of medical supplies for diabetes care; Diabetes screening; Diagnosis and treatment services; Difference-in-differences analysis; NORA-WHO NCDs midterm project evaluation.

Fig. 1

Graphical diagnostic for the parallel trends and average number of patients having a given diabetes service per month for newly diagnosed diabetes patients (A), diabetes patients on treatment for diabetes (B), diabetes patients with controlled blood sugar (C), FBS tests available (D) for 93 health facilities in Ethiopia, 2023