Programa Nacional de Diabetes

Objectives

Cuba’s National Programme for Comprehensive Diabetes Care aims to reduce the population impact of diabetes mellitus through integrated prevention, early detection, high-quality treatment, rehabilitation, patient participation and coordinated action across the health system. Its overarching purpose is to reduce diabetes-related morbidity, premature mortality, complications, disability and societal costs, while improving quality of life for people with diabetes and those at risk.[1][2][3]The programme is permanent, operates nationwide across primary, secondary and tertiary care, and is intended to be updated every five years.[4][5]

• Prevent disease onset by promoting healthy weight, regular physical activity, appropriate diets, reduced salt and saturated-fat intake, and avoidance of tobacco and other recognised risk factors.[6][7][8]
• Detect diabetes and high-risk states early through active case finding, particularly among people with symptoms, obesity, hypertension, dyslipidaemia, previous gestational diabetes, family history, impaired fasting glucose and other risk factors.[9][10]
• Achieve near-normal metabolic control and support self-management through continuing education, nutrition, physical activity, glucose monitoring, medicines or insulin where required, and sustained clinician-patient relationships.[11][12][13]
• Prevent, identify and manage acute and chronic complications, including nephropathy, retinopathy, diabetic foot disease, cardiovascular and cerebrovascular disease, infections, ketoacidosis, hyperosmolar coma and lactic acidosis.[8][14][15]
• Integrate diabetes action with programmes addressing obesity, hypertension, ischaemic heart disease, chronic renal failure, nutrition, older people’s health and other non-communicable diseases.[3]
• Reduce diabetes mortality among people aged 15–64 years by 15% under the 2000 national objectives, and subsequently reduce age-specific diabetes mortality by 7.5% by 2010 relative to 2000.[2][16]
• Reduce medium-term mortality from ketoacidosis by 20%, nephropathy by 15% and diabetes-related sepsis by 15%; reduce visual loss by 15% and major amputations by 25%.[16]
• Improve pregnancy outcomes by bringing perinatal mortality among infants of diabetic mothers towards that of the non-diabetic population and reducing congenital malformations to below 2.5%.[16]

Implementation

The programme uses an integrated, decentralised care model centred on primary care and the family-doctor system, supported by structured referral and counter-referral arrangements with municipal, provincial and national specialist services.[3][4]The National Institute of Endocrinology coordinates the programme and chairs the National Multidisciplinary Diabetes Commission, while national, provincial, municipal and health-unit leaders direct implementation, standards, resource provision and quality control at their respective levels.[5][17]

• Deliver routine prevention, detection, follow-up, education and rehabilitation through family-doctor surgeries, polyclinics and emergency polyclinics, supported by hospitals, Diabetes Care Centres, provincial services and tertiary institutes.[4][18][19]
• Use multidisciplinary teams involving endocrinology, internal medicine, nursing, nutrition, podiatry, psychology, social work, ophthalmology, nephrology, cardiology, neurology, angiology, obstetrics and gynaecology, paediatrics and other relevant disciplines.[17][20][21]
• Provide comprehensive initial assessment, consultations at least every three months, annual reviews and periodic household visits that assess clinical status, treatment practices, psychosocial adaptation, family support, diet, activity, glucose monitoring, foot care, smoking and alcohol use.[12][13]
• Educate patients and families continuously, individually or in groups, on diabetes, hypo- and hyperglycaemia, diet, exercise, medicines, insulin, self-monitoring, complication prevention, sexual and reproductive health, and management during illness.[13]
• Refer children and adolescents, pregnant women, people seeking preconception care, patients with unstable disease, severe acute episodes or chronic complications, and those requiring intensive education or specialist review to appropriate secondary or tertiary services.[22][23][24]
• Coordinate prevention with agriculture, food services, education, sport, culture and mass media, recognising that healthier environments and intersectoral action are required alongside medical care.[3][6]
• Establish or strengthen provincial Diabetes Care Centres for day-hospital management, counselling, patient and family courses, professional training, multidisciplinary consultations and locally adapted service development.[25]
• Conduct annual provincial education and medical-care workshops, beginning with assessment of local conditions, followed by tailored actions, workforce training, municipal replication and review.[26][27]
• Secure medicines, insulin, needles, syringes, diagnostic reagents, glucose-testing supplies, equipment and specialist resources through relevant national pharmaceutical, industrial and health-service structures.[26][27][28]
• Monitor implementation through registration and follow-up of people with diabetes, assessment of metabolic control, morbidity, mortality, case fatality, complications, service coverage, quality, patient satisfaction, direct and indirect costs, and outcomes of specialised treatments.[21][28][29][30]
• Evaluate progress, quality, effectiveness and efficiency at municipal, provincial and national levels, using coordinated indicators supported by the National Diabetes Commission, National Institute of Endocrinology and National Endocrinology Group.[31][26]

Monitoring & Evaluation

The programme establishes a multi-level monitoring and evaluation system spanning clinical follow-up, service performance, population outcomes, costs and user satisfaction. It combines diabetes registration, epidemiological surveillance, structured clinical assessment, mortality and complication review, and systematic evaluation by municipal, provincial, national and tertiary institutions.[20][31][28][30]

• Monitor diabetes prevalence, incidence, morbidity, case fatality and mortality, including trends in diabetes-related deaths and causes such as ketoacidosis, nephropathy, cardiovascular disease, cerebrovascular disease, sepsis, acute complications and hypoglycaemia.[32][33][31]
• Track diabetes registration and the gap between known and undiagnosed cases; the programme reported 263,808 registered cases in 2000, or 23.6 per 1,000 inhabitants, and estimated a similar number of undiagnosed cases.[32]
• Measure progress against explicit outcome targets, including a 15% reduction in mortality among people aged 15–64 years and, by 2010, a 7.5% reduction in age-specific diabetes mortality compared with 2000.[2][16]
• Monitor medium-term reductions in mortality from ketoacidosis, nephropathy and diabetes-related sepsis, and reductions in visual loss, major amputations, congenital malformations and perinatal mortality among infants of diabetic mothers.[16]
• Assess metabolic control through fasting, post-prandial and nocturnal glucose, glycated haemoglobin, glucosuria, ketonuria, body mass index, blood pressure and lipid measures, with good, acceptable and poor control categories tailored where necessary for age, chronic illness and hypoglycaemia risk.[34][35]
• Undertake systematic clinical and laboratory follow-up, including quarterly consultations, annual comprehensive assessment, retinal examination, microalbuminuria testing, lipid assessment, renal-function tests, foot assessment and monitoring of self-recorded glucose or urine results.[36][12][14]
• Use household visits at least three times yearly to assess psychosocial adaptation, diet, exercise, self-monitoring, insulin handling, family knowledge, foot care, hygiene, smoking and alcohol use.[12][13]
• Record and analyse acute diabetes episodes statistically, including their case fatality, and improve death-certificate quality because diabetes mortality may be under-recorded or over-recorded.[33][20]
• Review diabetes-related deaths jointly across primary and secondary care, involving the relevant family doctor in hospital death reviews and escalating local concerns to the Municipal Health Council where warranted.[19][21]
• Evaluate programme progress, quality, effectiveness, efficiency, coverage, intermediate and final achievements, population satisfaction, and direct and indirect costs at medical-care and administrative levels.[21][28]
• Assess municipal performance through programme coverage, field-assessed quality in polyclinics and hospitals, metabolic control, hospital case fatality, education, morbidity, mortality and five indicator complications: ketoacidosis, amputations, nephropathy, retinopathy and adverse pregnancy outcomes.[30]
• Assess provincial and national performance through participating municipalities or provinces, implementation of education-care workshops and approved action and supplies plans, secular outcome trends, costs, satisfaction and healthy life-years lost.[26][30]
• Coordinate consistent indicators through the National Diabetes Commission, the National Institute of Endocrinology and the National Endocrinology Group, using research findings to support continuous programme improvement.[31][26]
• Assign accountability for implementation control to provincial and municipal health directors and health-unit directors, while the National Multidisciplinary Diabetes Commission participates in systematic programme evaluation.[5][17]

Costing & Financing

The programme recognises diabetes as imposing substantial societal costs, particularly through hospitalisation and complications, and incorporates cost and efficiency analysis into evaluation. However, the supplied material does not provide a quantified programme budget, monetary allocation, financing source, funding gap, unit cost, currency or total expenditure.[1][28][30]

• Recognise reducing the societal costs of diabetes as a complementary programme objective.[3][32]
• Analyse direct costs associated with diabetes admissions, consultations and medicines, alongside indirect costs associated with sickness certificates, assessments, early retirement and premature mortality.[28]
• Review hospital admission costs for diabetes at hospital level and analyse diabetes-admission, direct and indirect costs at municipal, provincial and national levels.[29][30]
• Include cost information with prevalence, mortality and complications in the health diagnosis of each service area, with reporting at the required frequency.[20]
• Manage programme resources through the Vice-Ministry of Economy and plan nationally for equipment, diagnostic supplies and medicines, while provincial and municipal authorities provide human and material resources.[5][17][26]
• Secure medicines, equipment, instruments and reagents through Ministry of Public Health industry and pharmaceutical structures, including domestic development or external procurement where necessary.[26]
• Apply the economic assumption that ensuring prevention-related inputs will produce important savings by reducing expenditure on diabetes complications.[26]
• Note that the programme received priority despite Cuba’s difficult Special Period economic conditions during the 1990s.[2]