Plan d’Action Opérationnel de Lutte contre le Diabète 2018-2020

Objectives

Togo’s 2018–2020 Diabetes Action Plan operationalises the Multisectoral Policy and Strategic Plan for Non-Communicable Diseases 2018–2022, aligned with national development and health plans and the World Health Organization global framework on non-communicable diseases. Its overall objective is to help reduce diabetes-related morbidity, mortality and disability.[1][2]The plan responds to diabetes as an expanding condition associated with lifestyle change, against a 2010 national prevalence estimate of 2.6%, while also addressing overweight, obesity and behavioural risk factors.[3][4]

• Strengthen leadership, governance, multisectoral action and partnerships for diabetes control.[2][5]
• Reduce exposure to modifiable risk factors and underlying social determinants by creating health-supportive environments and delivering integrated interventions for diabetes and other non-communicable diseases.[2][6][5]
• Promote healthy diets through food-vendor training and awareness campaigns in schools and universities, and promote physical activity through public education, sports-club awareness and screening sessions, and safe, equitable spaces for regular activity.[7]
• Strengthen diabetes prevention, diagnosis and management within primary healthcare, including integration of diabetes medicines and devices into the minimum package of activities and expansion of care capacity.[2][6][8]
• Improve access to diabetes education and clinical support, including diabetic-foot care, monitoring of women with known or gestational diabetes, and early detection of diabetic retinopathy.[8][9]
• Promote and support research by identifying national priorities, incorporating diabetes and non-communicable disease indicators into population surveys, supporting studies, strengthening research capacity and encouraging use of evidence in public policy.[9][10]
• Strengthen surveillance, monitoring and evaluation of diabetes and risk factors at every level through integrated surveillance, a diabetes register and annual diabetes mapping.[2][10]
• Contribute to 2025 national non-communicable disease targets, including a 25% relative reduction in mortality from cardiovascular disease, cancer, diabetes and chronic respiratory disease, a 10% reduction in insufficient physical activity, and a 30% reduction in average salt or sodium intake.[2]

Implementation

Implementation uses a decentralised, multisectoral health-system model led by the National Diabetes Control Programme within the Division of Non-Communicable Diseases.[11][12]The plan operates through Togo’s three-level health pyramid, in which health districts are the operational level, regional authorities provide support and oversight, and the central level defines and monitors national policy directions.[13][14][12]It seeks to address major service constraints, including limited specialist availability, inadequate equipment and infrastructure, weak training capacity, and low readiness of health facilities for diabetes care.[11]

• Coordinate implementation through the National Diabetes Control Programme with other non-communicable disease programmes, regional health authorities, districts, local authorities, communities, civil society, private-sector actors and technical and financial partners.[10][12]
• Integrate planned interventions into district annual workplans in collaboration with local authorities, while regional authorities disseminate and coordinate activities, facilitate multisectoral dialogue and develop partnerships.[12]
• Engage diabetes associations, non-governmental organisations, civil society, private partners and other programme partners through advocacy, implementation support, prevention activities outside the health sector and resource mobilisation.[6][15][12]
• Link diabetes-care integration with universal health coverage mechanisms, including health mutuals, health-insurance arrangements and targeted free care.[6]State support for indigent patients is delivered through public health establishments, while health mutuals use member prepayment contributions but remain underdeveloped nationally.[3]
• Develop and disseminate regulatory, educational and communication materials through radio, television, newspapers, posters and an integrated communication plan; raise awareness among political leaders, decision-makers and the public; and participate in integrated awareness and screening campaigns and World Diabetes Day activities.[6][15]
• Build workforce and community capacity by training communication actors, civil-society and community educators, healthcare providers, community health workers, community leaders, teachers, doctors and paramedical staff.[15][8]The plan also provides specialised training for diabetic-foot care, pregnancy-related diabetes follow-up and retinopathy detection.[8][9]
• Develop or update management protocols for non-communicable diseases and risk factors through a multi-programme process, followed by training of trainers and frontline personnel.[8]Traditional medicine is also recognised as culturally important and accessible, with the Ministry’s Division of Traditional Medicine and Pharmacopoeia identified as a basis for better integration into non-communicable disease care.[2]
• Track implementation through activity and output indicators with 2017 baselines and annual targets for 2018–2020, covering advocacy, communication, training, screening, associations supported, protocols, research, surveillance and mapping.[6][15][9][10]
• Institutionalise semi-annual monitoring of non-communicable disease data, routine supervision, annual sector reviews and an end-2020 evaluation of the action plan.[12][5]Supervision follows a cascade from the central level to regional teams, districts, health facilities and community health workers, using programme tools and written reports.[12][5]
• Mobilise financing jointly with health-development sectors, local authorities, communities, civil society, private-sector actors and technical and financial partners.[12]The plan does not specify a dedicated budget, costed allocations, quantified financing gap or resource-mobilisation target.[11][2][12]

Monitoring & Evaluation

The plan establishes a monitoring and evaluation approach based on routine data collection, supervision, reviews and evaluation, supplemented by service-readiness, risk-factor and activity-output indicators. It seeks to strengthen diabetes and risk-factor surveillance at every level of the health system.[2][10][12]

• Monitor implementation through level-specific monitoring plans integrated with the wider 2018–2022 non-communicable disease strategic plan.[12]
• Institutionalise semi-annual monitoring meetings for non-communicable disease data, including diabetes data, led by the central level and involving regional and operational actors.[12]
• Conduct supervision through a cascade from central authorities to regional focal points and hospitals, from regional teams to district focal points and hospitals, and from districts and facility managers to health workers and community health workers.[12][5]
• Use programme-provided supervision tools and require a report to be produced and submitted at each level.[5]
• Undertake annual sector reviews in the first quarter, organised by the central level, to assess implementation effectiveness.[5]
• Evaluate the diabetes action plan at the end of 2020, alongside participation in the mid-term evaluation of the 2018–2022 non-communicable disease strategic plan, to reinforce or redirect strategic orientations where needed.[12][5]

Performance monitoring uses 2017 baselines and annual targets for 2018, 2019 and 2020. Indicators encompass medicines and devices integrated into the minimum activity package, partners reached through advocacy, stakeholders participating in delivery, dissemination of regulatory texts, communication materials, awareness events, people reached, training, campaigns, support to associations, prevention initiatives and World Diabetes Day events.[6][15]

• Track healthy-eating vendor training, school and university campaigns, communities and cities reached, public spaces promoting physical activity, and diabetes and obesity awareness and screening sessions for sports clubs.[7]
• Measure protocols developed or updated and the numbers of trainers, providers, community health workers, community leaders and teachers trained in non-communicable disease management.[8]
• Monitor diabetes education and clinical-capacity training, including targets for trained community actors, doctors, paramedical staff, diabetic-foot practitioners, midwives supporting women with known or gestational diabetes, and ophthalmology technicians conducting fundus examinations.[8][9]
• Track research priorities, strengthened institutions, supported studies, use of evidence for policy, and the availability of advocacy, research, surveillance and mapping documents.[9][10]
• Establish an integrated surveillance system, assess the timeliness and completeness of monthly reports, create a diabetes register by 2019, and produce diabetes mapping annually from 2018.[10]

Existing evidence highlights substantial gaps in diabetes-service readiness. In the 2012 Service Availability and Readiness Assessment, 1% of facilities possessed all tracer elements required for diabetes care and the average readiness score was 51%; guidelines were available in 39% of facilities, trained personnel in 27%, proteinuria strips in 62%, blood-glucose testing in 41%, metformin in 27% and insulin in 11%.[11]The source does not provide detailed indicator definitions, a reporting timetable beyond monthly and semi-annual arrangements, or explicit sanctions and other accountability procedures.[11][12][5]

Costing & Financing

No dedicated 2018–2020 diabetes action-plan budget, activity costing, quantified funding gap, financing allocation or economic assumption is specified in the supplied material.[11][2][9][10][12]Financing and resource mobilisation are nevertheless presented as shared responsibilities of health-development sectors, local authorities, communities, civil society, private-sector actors and technical and financial partners.[12]

• Increase health-sector resources, reduce regional allocation disparities and improve spending efficiency and effectiveness.[14]
• Mobilise financing through public funding, household and other private expenditure, international technical and financial partners, insurance arrangements, mutual health organisations and targeted support for indigent people.[14][16][3]
• Consider innovative financing sources, including levies related to air tickets, remittances, mining resources, alcohol and telecommunications; tobacco-tax advocacy was underway to support non-communicable disease control.[14][16]
• Support public servants and military personnel through the National Health Insurance Institute, private-sector employees through the National Social Security Fund, and indigent people through state subsidies to public health facilities.[16]

Health financing was characterised by a low public health-budget share and substantial reliance on private spending. The health budget represented 5.97% in 2014 and 6.13% in 2016, below the 15% Abuja Declaration benchmark.[14]Private sources financed 60.3% of health expenditure, including 50.5% paid by households; the state financed 22.4% and international technical and financial partners financed 17.3%.[14]Health mutuals operated through member prepayment contributions but remained underdeveloped nationally.[16][3]

The wider fiscal context may constrain resource availability: Togo recorded a fiscal deficit of 4.9% of gross domestic product in 2014, while public debt rose from 48.6% of gross domestic product in 2011 to 75.4% in 2015, exceeding the 70% West African Economic and Monetary Union ceiling.[17]External technical and financial partners made an important contribution to financing the 2012–2015 National Health Development Plan, while insufficient state resource allocation was identified as a general implementation barrier.[17][18]