Programme National de Lutte contre les Maladies Métaboliques (PNLMM) — Document Plan Stratégique

Objectives

The 2008–2012 Strategic Plan of Côte d’Ivoire’s National Programme for the Control of Metabolic Diseases provides an integrated national framework for reducing morbidity, mortality and costs associated with diabetes, hypertension, obesity, dyslipidaemias, thyroid disorders and related metabolic conditions. It succeeds the National Diabetes Control Programme, aligns with the National Health Development Plan and responds to epidemiological transition, poverty, sedentary lifestyles and changing diets.[1][2][3][4]

• Reduce morbidity, mortality and the cost of metabolic diseases by at least 50% over 2008–2012.[5]
• Make the Programme Coordination Directorate operational by the end of 2008 through appointment of service heads, acquisition and equipment of premises, and validation of national policy and strategic-plan documents.[5][6]
• Prevent metabolic diseases in at least 50% of the intended population by 2012 through primary prevention, screening of people at risk and care intended to prevent complications.[7][8]
• Ensure management of metabolic diseases for at least 50% of people requiring care by 2012.[5][3]
• Coordinate at least 80% of diabetes organisations and develop operational research addressing at least 80% of metabolic diseases.[5][7]
• Strengthen institutional capacity, prevention, care, research, partnership, stakeholder coordination and resource mobilisation as the plan’s principal intervention areas.[6]

Prevention is prioritised because available curative and preventive services face serious resource constraints, while diabetes and obesity are linked in the plan’s context analysis to inequity, high treatment costs and limited access to specialised services beyond Abidjan.[2][9][10]The strategy combines population-wide health promotion with risk screening and longer-term clinical management, rather than treating diabetes in isolation.[2][7][8]

• Deliver primary prevention through information, education and communication campaigns using radio, television, posters, leaflets, conferences and community discussion sessions.[7][6][8]
• Conduct secondary prevention through organised screening campaigns for people at risk of metabolic diseases.[8][11]
• Provide tertiary prevention through organised care that limits progressive complications among people living with metabolic diseases.[8][11]
• Generate evidence through operational research, including work to determine the glycaemic index of locally consumed foods.[12][3]

Implementation

Implementation is led by the National Programme for the Control of Metabolic Diseases, created by Ministerial Order No. 173 MSHP/CAB of 21 June 2007 and based at the National Institute of Public Health.[13][14]Its Coordination Directorate administers the programme with scientific support from a Scientific Support Group, and implementation extends through regional and departmental or district health structures.[15][16][17]

• Assign leadership to a Co-ordinating Director appointed by ministerial order, with responsibility for strategic planning, annual operational plans, implementation coordination, identification of programme needs and periodic reporting.[15]
• Organise the Directorate through services for care, epidemiological surveillance, studies, evaluation and research, communication, and accounting.[15][16]
• Engage regional and departmental health directors to organise activities, communicate directives, coordinate local stakeholders and awareness events, supervise research, and submit reports to the Programme Coordinator.[17]
• Use a National Coordination Group of Stakeholders in the Fight against Metabolic Diseases as a permanent forum chaired by the Programme Coordinator.[5]
• Include diabetes associations, service clubs, non-governmental organisations, pharmaceutical laboratories and a representative of REPMASCI in national stakeholder coordination.[5]

The care model seeks to reduce the historic concentration of specialist diabetes services in Abidjan by identifying and equipping care centres, assessing staffing needs, training non-specialist providers, strengthening specialist capacity and creating an information network between centres.[9][18][11]It also prioritises improved insulin access, reflecting high prices, availability concerns, inadequate cold-chain storage and widespread affordability barriers affecting medicines, diagnostics and self-monitoring equipment.[10][18]

• Equip identified centres with blood glucose meters, test strips, height measures and weighing scales.[3]
• Establish centre follow-up and evaluation arrangements, including an information network and monitoring plan.[18][19]
• Improve insulin availability through procurement and establishment or support of an insulin bank.[3]
• Coordinate patient organisations and support awareness activities, including World Diabetes Day and the National Awareness Week on metabolic diseases.[5]
• Mobilise resources by identifying financing sources, conducting advocacy and securing required inputs for programme activities.[7][12]

Monitoring is embedded in a 2008–2012 activity matrix structured by intervention area, objective, activity, indicator, annual timetable and responsible institution.[6]The surveillance service is to establish data-collection tools, analyse information with relevant ministry services and maintain the programme database, while the studies, evaluation and research service develops evaluation tools and operational research.[16]Quarterly and annual activity reports provide formal reporting mechanisms.[15][16]

• Track prevention through counts of broadcast messages, communication materials, conferences, discussion sessions and people screened.[8]
• Track care through identified and equipped centres, personnel assessments and training, information-network establishment, insulin availability and reduced insulin cost.[18]
• Track institutional capacity through appointment orders, premises leases, available equipment and validation-workshop reports.[6]
• Verify research progress through identified topics, prepared protocols, evidence of ongoing studies and documented results.[12]

The plan assigns financial administration to the Coordination Directorate and Accounting Service, including budget preparation and participation in resource mobilisation.[15][16]Although activity tables distinguish acquired resources from resources still to be sought for equipment, insulin, an insulin bank and research, the supplied material does not specify a consolidated programme budget, currency-denominated financing commitments, expenditure allocations or funding gap.[3]

Monitoring & Evaluation

The 2008–2012 plan establishes a structured monitoring and evaluation function within the National Programme for the Control of Metabolic Diseases, combining epidemiological surveillance, activity monitoring, operational research, periodic reporting and verification of planned outputs. The Coordination Directorate, its Epidemiological Surveillance Service, and its Studies, Evaluation and Research Service have defined responsibilities for collecting, analysing, managing and using programme information.[15][16]

• Establish surveillance and data-collection tools for target metabolic diseases; analyse information with relevant Ministry services and maintain the programme database.[16]
• Develop evaluation materials and operational research, with a target of research coverage for at least 80% of metabolic diseases by 2012.[16][5]
• Track implementation through a 2008–2012 activity matrix specifying intervention areas, objectives, activities, indicators, annual schedules and responsible institutions.[6]
• Measure institutional strengthening through appointment of service heads, acquisition and equipment of headquarters premises, and validation-workshop reports for policy and strategic-plan documents.[6][20]
• Monitor prevention through counts of radio and television messages, posters and leaflets produced, conferences and discussion sessions held, and people screened during campaigns.[8]
• Assess care delivery through the number of centres identified and equipped, personnel assessed and trained, specialist capacity strengthened, information networks established, follow-up and evaluation plans in place, and insulin continuously available through the Public Health Pharmacy at lower cost.[18]
• Monitor stakeholder coordination through the number of diabetes organisations identified and the establishment of a framework to coordinate their activities.[18]
• Use activity reports, programme archives, workshop reports, activity reviews, personnel lists, training reports and meeting minutes as verification sources.[20][11][19]

Outcome targets include making the Coordination Directorate operational by 2012, preventing metabolic diseases in at least 50% of the intended scope, providing management or care to at least 50% of those requiring it, coordinating at least 80% of diabetes organisations, and conducting operational research across at least 80% of metabolic diseases.[7][6]

Reporting is assigned at several levels: the Co-ordinating Director is responsible for reporting implementation progress; the Programme is to prepare quarterly and annual activity reports; and regional and departmental health directors must transmit reports on promotional meetings and activities to the Programme Coordinator.[15][16][17]Regional and departmental directors also supervise research and coordinate implementation with non-governmental organisations and other stakeholders.[17]

Baseline evidence includes surveys and studies of hypertension, obesity, tobacco use, diabetes, dyslipidaemia, goitre and metabolic syndrome. A 2005 National STEPS survey in 13 districts of the Lagunes health region and a 2006 level-two Stepwise survey supplied risk-factor evidence, although the latter did not include blood sampling.[21][22]The plan also identifies information gaps, including an inability to establish current national hypertension prevalence, while evidence on dyslipidaemia and thyroid disorders was fragmented or mainly hospital-based.[22][9]

The supplied material does not define a comprehensive evaluation design, standard reporting templates, a detailed surveillance schedule, sanctions, or wider formal accountability procedures beyond assigned responsibilities, activity reporting, indicators and verification sources.[17][12][20]

Costing & Financing

The plan identifies resource mobilisation as a strategic intervention area and assigns financial administration to the Coordination Directorate and Accounting Service. It envisages identifying funding sources, conducting advocacy and acquiring resources for programme activities, but does not provide a complete costed budget, expenditure allocation, confirmed financing commitments, quantified funding gap or economic assumptions.[15][16][7][6]

• Prepare and administer the programme budget through the Accounting Service under the direction of the Co-ordinating Director.[16]
• Mobilise resources by identifying financing sources, undertaking advocacy and securing resources required for planned activities.[12]
• Distinguish, in activity tables, between resources already acquired and resources still to be sought; identify the insulin bank as a financing source for insulin-access activities.[3]
• Finance equipment procurement, insulin purchasing, insulin-bank activity and research on the glycaemic index of locally consumed foods within the 2008–2012 activity period.[3]

The overarching objective includes reducing the cost associated with metabolic diseases by at least 50% during 2008–2012.[5]The plan does not explain the cost baseline, methodology or financing mechanism for achieving this reduction.[5]

Affordability is a major implementation constraint. Food, medicines, diagnostic tests and self-monitoring equipment are described as costly for many patients, who are frequently indigent and lack social protection.[9][23]Insulin prices in Côte d’Ivoire were reported at approximately 16,000 to 17,000 CFA francs per vial, compared with indicative prices of 1,000 CFA francs in Senegal and 3,000 CFA francs in Mali.[10]The source links high insulin prices partly to the absence of a government subsidy in Côte d’Ivoire, notes price increases after the 1994 CFA franc devaluation, and records a 2007 price reduction for an insulin pen product without quantifying that reduction.[10]

An insulin-bank initiative was intended to contribute 200 million CFA francs over five years to improve access to insulin treatment.[24]Other external support included insulin assistance from the Lions Club, diabetes education sponsored by Sanofi-Aventis and training support from Servier, but no values are provided for these contributions.[23]The National Diabetes Control Programme was reported not to have received development-partner support, particularly from the World Health Organization, because advocacy had not been undertaken.[25]

Several activity-table figures are presented without a stated currency or unit of account: 15 for blood glucose meters and test strips, 10 for height measures and weighing scales, 37.5 for insulin purchases, 100 for the insulin bank, and 20 for determining the glycaemic index of local foods.[3]These figures should therefore not be interpreted as monetary amounts in a specified currency.[3]