Guidelines for the Management of Diabetes Mellitus in Primary and Secondary Care Facilities in Ghana

Objectives

Strengthen diabetes prevention, early detection, diagnosis, patient-centred treatment and complication control across Ghana’s primary and secondary health-care system, in alignment with the national non-communicable disease policy and strategic plan.[1]The guideline aims to reduce diabetes burden, improve quality of life and support timely referral for people requiring more specialised care.[1][2]

• Prevent type 2 diabetes through healthy diets, physical activity, tobacco cessation, moderation of alcohol use, weight management and broader health promotion.[1][3]
• Detect diabetes early through risk assessment and screening, recognising that type 2 diabetes may be asymptomatic for a prolonged period and is often preventable.[2][4]
• Achieve individualised glycaemic control, eliminate symptoms where possible, prevent or slow complications and maintain quality of life through lifestyle measures, medicines and self-management support.[5]
• Address clinical risks including obesity, hypertension, dyslipidaemia, cardiovascular disease, kidney disease, diabetic eye disease, foot problems, hypoglycaemia and hyperglycaemia.[3][6][7]
• Support people with type 1 diabetes, type 2 diabetes and diabetes in pregnancy, while recognising priorities concerning childhood and adolescent diabetes, gestational diabetes, multimorbidity and socio-cultural barriers to self-care.[4][8]
• Promote sustained self-care by involving people living with diabetes, families, social-support systems, health workers and other stakeholders.[1][9]

Implementation

Implement the guideline as an operational reference for integrated diabetes care in primary and secondary facilities, combining prevention, screening, non-pharmacological care, pharmacological treatment, routine clinical review and referral.[10][1]Care is designed to be evidence-based, quality-assured, culturally sensitive and tailored to clinical circumstances, treatment preferences, risks and affordability.[4][5]

• Deliver community and primary care through Community-based Health Planning and Services zones and compounds, health centres, polyclinics and relevant hospitals, with referral and back-referral across community, sub-district, district, regional and tertiary levels.[11]
• Use Community Health Teams, comprising health workers and community volunteers, with community health committees providing local oversight and support.[11]
• Equip community health officers, nurse prescribers, physician assistants, medical officers, family physicians, specialists and paediatricians to use the guidance, while enabling other health workers to contribute.[11]
• Involve the Ghana Health Service, Ministry of Health, Non-Communicable Disease Control Programme, technical working group, professional contributors, clients, families and relevant public, quasi-governmental, private and faith-based providers.[2][11]
• Integrate nutrition counselling, meal planning, physical activity, mental-health support, smoking cessation, alcohol-use counselling, medication adherence, foot care and psychosocial support into routine diabetes services.[10][3][12]
• Provide structured diabetes self-management education and support in every diabetes care service, including education on blood-glucose control, danger signs, complications and healthy lifestyles.[4][9]
• Assess dietary history and promote balanced, locally appropriate meals, portion control, meal timing and carbohydrate awareness rather than unnecessary elimination of food groups.[3][13]
• Administer the diabetes risk-assessment tool at all health-system levels, offer blood-glucose testing in accordance with applicable national guidance and use urine dipstick testing as an additional method or where alternatives are unavailable and suspicion is high.[3]
• Apply laboratory diagnostic criteria including fasting blood glucose of at least 7.0 mmol/L, two-hour postprandial glucose of at least 11.0 mmol/L during an oral glucose tolerance test, random plasma glucose of at least 11.1 mmol/L, or glycated haemoglobin of at least 6.5%.[14]
• Initiate lifestyle and pharmacological treatment for people meeting diagnostic criteria, individualise medicine selection according to glycaemia, cardiovascular and renal risk, complications, adverse effects, cost and preferences, and intensify therapy when targets are not met.[4][5]
• Use metformin with diet and physical activity as initial treatment for type 2 diabetes unless it is contraindicated or not tolerated, and use insulin as the treatment of choice for type 1 diabetes.[15]
• Prioritise glucagon-like peptide-1 receptor agonists or sodium-glucose co-transporter 2 inhibitors for clinically appropriate people with cardio-renal complications, stroke or heart failure, while recognising that medicine access and cost may constrain choices.[16]
• Refer promptly when clinical needs exceed facility capacity, including for specialist review, insulin treatment, persistent hyperglycaemia, kidney-function testing, paediatric cases and unavailable glycated haemoglobin testing.[1][5][17][18]
• Monitor blood glucose, glycated haemoglobin, urine dipstick findings, kidney function, blood pressure, lipids, body weight, waist measures, medication side effects, complications and follow-up adherence through regular clinical review.[10][17][6][7]
• Undertake annual kidney-function and eye assessments, with more frequent review for people at higher risk, and screen for depression particularly at diagnosis or when complications emerge.[12][6][7]

Monitoring & Evaluation

Monitoring centres on routine clinical assessment, screening, treatment response and complication prevention rather than a defined programme-level monitoring and evaluation system. Screening is emphasised because type 2 diabetes may remain undiagnosed during a prolonged pre-symptomatic phase.[4]Diabetes risk assessment tools should be administered at all levels of care, with random blood sugar testing and follow-up testing undertaken as indicated.[3]

• Monitor blood glucose, urine dipstick results, kidney function, medication side effects, hypoglycaemia, hyperglycaemia, cardiovascular risk factors and eye health in primary care.[10]
• Assess glycaemic control, body weight, waist circumference, blood pressure and lipid targets during regular follow-up.[4]
• Measure and document blood pressure at every clinic visit; assess lipid profiles annually, or more often for people receiving lipid-lowering treatment; and assess body mass index, waist-to-hip ratio and abdominal circumference.[6][19]
• Perform glycated haemoglobin testing at least twice yearly to assess long-term glucose control, referring patients where the test is unavailable.[17]
• Assess kidney function at least annually, with more frequent assessment for higher-risk patients, and use urine testing to identify possible kidney disease, poor glucose control, urinary tract infection and ketosis.[6]
• Conduct a urine dipstick test at every clinic visit to support identification of diabetic kidney disease, glucose-control concerns, possible adherence problems and urinary tract infection.[17]
• Monitor fasting blood glucose at scheduled reviews and assess two-hour post-prandial blood glucose where home monitoring is available.[17]
• Use glycated haemoglobin results to guide treatment intensification and assess whether treatment targets are achieved or maintained after two to three months of combination therapy.[16]
• Monitor fasting and self-monitored blood glucose when titrating insulin, investigate hypoglycaemia causes, and adjust treatment where clinically required.[20]
• Recheck blood glucose after hypoglycaemia treatment, repeat treatment or refer if hypoglycaemia persists, and reassess moderate episodes promptly.[19]
• Provide annual ophthalmology examinations, with more frequent eye monitoring for people at higher risk of diabetic eye disease.[7]
• Screen routinely for depression, particularly at diagnosis and after new complications, and manage or refer identified cases.[12][9]
• Review patients at intervals determined by treatment pathway and clinical response, ranging in the cited protocols from several days to three months.[18]
• Quality-assure structured diabetes self-management education and use patient-centred approaches to target-setting and care decisions.[4]

No detailed indicator framework, reporting schedule, surveillance architecture, evaluation methodology, named evaluation responsibilities or formal accountability mechanism is specified beyond clinical screening, routine follow-up and quality assurance.[2][4][16][20]

Costing & Financing

Cost is recognised as an influence on treatment selection and access, but the available material provides no quantified implementation budget, allocation, funding gap, resource-mobilisation plan or economic model for diabetes services.[5][16][20]

• Recognise that diabetes management is costly and that expenditure increases when complications develop.[2]
• Consider medicine cost alongside efficacy, hypoglycaemia risk, weight effects, adverse effects, cardiovascular and renal effects, route of administration, dosing requirements and patient preferences.[5][21][17]
• Use a second-generation sulphonylurea, preferably gliclazide, as an addition to metformin where affordability constrains treatment options.[16]
• Use human insulin where the cost of analogue insulin limits access, while recognising that acceptability, storage and other barriers may also restrict insulin availability.[16][21]
• Recognise that the medicine tables use qualitative low-cost and high-cost classifications without providing monetary values or currencies.[21][17]
• Consider self-care interventions as feasible and cost-saving in low- and middle-income countries.[9]
• Note that production of the guideline received financial support from Novo Nordisk and the Danish Embassy.[2]
• Recognise potential service-resource constraints where specialised microalbuminuria dipsticks or kidney-function testing are unavailable, requiring referral to higher-level facilities.[6]

The source does not specify the amount, currency, period or terms of external financial support, nor does it identify recurrent funding sources for screening, medicines, laboratory testing, referral, self-management education or complication care.[2][6]