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KENYA NATIONAL DIABETES STRATEGY 2010-2015

July 2010

FIRST EDITION

KENYA NATIONAL DIABETES STRATEGY 2010 – 2015

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Kenya National Diabetes Strategy 2010-2015

Funded by: Ministry of Public Health and Sanitation, World Diabetes Foundation and the International Diabetes Federation.

Any part of this document may be freely reviewed quoted, reproduced or translated in full or in part so long as the source is acknowledged. It is not for sale or for use in commercial purposes.

Enquiries regarding the Kenya National Diabetes Strategy should be addressed to:

National Diabetes Control Programme,Division of Non-communicable Diseases,Ministry of Public Health and Sanitation,P.O. Box 30016 – 00100Nairobi, Kenya

Telephone: +254 202717077/+254202722599Email: [email protected]: www.pubhealth.go.ke

Supported by :


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TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................ (iii)FOREWORD................................................................................................ (iv)INTRODUCTION ...................................................................................... (v)LIST OF CONTRIBUTORS ....................................................................... (vi)ABBREVIATIONS ...................................................................................... (vii)ACKNOWLEDGEMENTS ........................................................................ (viii)EXECUTIVE SUMMARY ......................................................................... (ix)

Introduction ................................................................................................. 1Situation analysis ......................................................................................... 3Prevention and Control .............................................................................. 4Purpose ......................................................................................................... 6Scope ............................................................................................................. 6Justification ................................................................................................... 6Guiding Principles ....................................................................................... 8The Strategy .................................................................................................. 9Objectives ..................................................................................................... 9Key Strategies ............................................................................................... 101. Advocacy .................................................................................................. 102. Empowerment ......................................................................................... 103. Resource Mobilization and Prioritization ............................................ 114. Capacity building .................................................................................... 125. Partnership and Coordination............................................................... 126. Diabetes Control Policies, Legislation and Regulations ..................... 136. Reaserch .................................................................................................... 148. Monitoring and evaluation .................................................................... 14National Diabetes Strategy Implementation Framework 2010 - 2015 . 15


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FOREWORD

The scourge of diabetes is ravaging our country affecting the lives of our people, mainly the economically active groups resulting in a decrease in the output put of the country’s labour force and consequently reducing the Gross Domestic Product (GDP). This has been compounded by a rapid increase in the prevalence of risk factors for diabetes and other chronic non-communicable diseases. If the disease is not tackled, it will hinder the attainment of the Millennium Development Goals (MDGs) and realization of the Vision 2030.

In order to achieve effective diabetes control a coordinated multi-sectoral approach must be adopted throughout the country. This National Diabetes Strategy (NDS) provides a framework of what needs to be done to reduce the burden of diabetes and its risk factors. This will eventually reduce the morbidity and mortality attributable to diabetes.

To pursue the vision of ensuring an efficient diabetes care system that is socially and culturally acceptable to all Kenyans, the NDS highlights the need for availability of skilled human resource, sustained adequate funding and partnership building. It also emphasizes the need for mobilizing communities and fighting poverty to accelerate social and economic growth.

The management of diabetes can sometimes seem straight forward but the burden of serious complications and their sequelae may represent a serious problem for people with diabetes their families, health care services and government.

It is our belief that collectively we can make a difference: Let us all join hands in the fight against diabetes and strive to achieve a diabetes free Kenya.

Hon. Beth W. Mugo, EGH, MPMinister for Public Health and Sanitation


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INTRODUCTION

Diabetes and other non-communicable disease are now a threat to national development as they often result in long standing complications that are usually very costly to treat. Similarly these diseases are long standing and if not managed well can be fatal. They progressively drain the strength and resources of an individual rendering them unproductive and poor. This burden is in most cases passed on to families and the community with untold retardation of economic progress and eventually exacerbating poverty.

In response to this crisis, the Ministries of Health in collaboration with Non-Governmental Organizations, Regional and International Diabetes Support Bodies spearheaded the Kenya National Diabetes Strategy 2010-2015 in order to accelerate mainstreaming of diabetes policies and programmes with a view to make them an integral part of the national public health response to disease prevention and care at all levels of health care. This strategy will articulate strategic priorities in diabetes to ensure that services are directed to those areas that are likely to yield high impact for people with diabetes and those at risk of the disease.

This strategic framework will guide the funding, planning, organization, provision and monitoring and evaluation of services for people with or at risk of diabetes. It will consolidate and improve the quality and coverage of diabetes care services in Kenya.The framework also identifies the roles of various key players in the development and implementation of diabetes prevention and control services. It defines the processes and inputs necessary for the timely realization of the national targets.

A technical Working Group was established under the auspices of the Division of Non-communicable Diseases (DNCD) to develop this strategy based on evidence based prevention and control strategies for diabetes mellitus. This Strategy is a synthesis of information drawn from an extensive review of local and international knowledge and experience.

The successful implementation and strict adoption of this strategy will require the partnership of the various stakeholders in diabetes control. The Ministry is committed to provide leadership and guidance in the process of implementation of this strategy.

Dr. S. K. Sharif, MBS, MB.ChB, M.Med, DLSTMH, MSc.Director of Public Health & Sanitation


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LIST OF CONTRIBUTORS

Dr. William K. Maina Ministry of Public Health and SanitationDr. Eva Njenga Diabetes Endocrinology CentreDr. Acharya Kirtida University of NairobiDr. Gaman Mohamed Comprehensive Diabetes CentreDr. Izaq Odongo Ministry of Medical ServicesScholastica Mwende Ministry of Public Health and SanitationZachary M. Ndegwa Ministry of Public Health and SanitationEva Muchemi Kenya Diabetes Management and Information

CentreDr. Lois N. Wagana Central Provincial General Hospital, NyeriDr. Thomas Ngwiri Eastern Provincial General Hospital, EmbuDr. Paul Laigong Gertrude Children’s Hospital, NairobiMrs. Rosemary Ngaruro Ministry of Medical Services Dr. Rachael Nyamai Ministry of Medical ServicesDr. Ayman M. Qureshi Ministry of Medical ServicesDr. Peter Munyua Ministry of Public Health and SanitationMs. Lilian Karugu Kenya Diabetes Management and Information

CentreMr. Edward Ndungu Ministry of Public Health and SanitationMr. Ibrahim Wako Ministry of Medical ServicesDr. Zeinabu Gura Ministry of Public Health and Sanitation

(FELTP)Mrs. Rose Kuria Ministry of Medical ServicesMrs. Monica G. Mukiira Ministry of Medical ServicesMr. Francis K. Muma Ministry of Medical ServicesMrs. Eunice Ndungu Ministry of Medical ServicesMs. Mary Karimi Ministry of Public Health and SanitationDr. Anil Kapur World Diabetes Foundation


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ABBREVIATIONS

AIDS - Acquired Immunodeficiency SyndromeCDF – Constituency Development FundsCVA – Cerebrovascular AccidentsCVD – Cardiovascular DiseasesDCPP – Disease Control Priorities ProjectDHMT – District Health Management TeamsDMI – Diabetes Management and Information CentreDNCD – Division of Non-communicable DiseasesGDM – Gestational Diabetes MellitusGDP – Gross Domestic ProductHCP – Health care ProviderHIV – Human Immunodeficiency SyndromeHMIS – Health Management and Information SystemICC – Inter-agency Coordinating CommitteeIDF – International Diabetes FederationIEC – Information Communication and Education JPWF – Joint Programme for Work and FundingKDA – Kenya Diabetes AssociationMDG – Millennium Development GoalsMOMS – Ministry of Medical ServicesMOPHS – Ministry of Public Health and SanitationNCD – Non-communicable DiseasesNDS – National Diabetes StrategyNDSC - National Diabetes Steering CommitteeNGO – Non-governmental OrganizationPHC – Primary Health CareWDF – World Diabetes FoundationWHO – World Health Organization


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ACKNOWLEDGEMENTS

The Kenya National Diabetes Strategy was prepared with the active participation of several diabetes experts from several organizations in Kenya. The participation of the following individuals and organization is gratefully appreciated.

The Strategy was based on the Diabetes Strategy for Sub Sahara developed by the International Diabetes Federation (IDF) Africa whom we owe thanks for allowing us to use the materials.

Funding for the process of development of these Guidelines was provided by the World Diabetes Foundation (WDF) through the National Diabetes Comprehensive Care Project. The process received a lot of technical support from the Kenya Diabetes Management and Information Centre (DMI), Diabetes Kenya Association, the University of Nairobi and Kenyatta National Hospital. Dr. Joyce N. Nato of the World Health Organization, Kenya Country Office provided technical advice to the drafting team. We thank all our regional diabetes coordinators (Dr. L.N. Wagana-Central, Dr. C.Muyodi – Coast, Dr. H. Sultani – Western, Dr. Otepo – Nyanza, Dr. Sule – Nairobi, Dr. Njoroge – N. Eastern, Dr. Muli – Eastern, Mr. Kimonjino – R/Valley for their active participation in the process of developing the draft.

The development of this Strategy was carried out under the auspices of the Division of Non-communicable Diseases. In this regard, the support extended by Dr. William K. Maina, Head of the Division and the staff of the division, particularly Zachary Ndegwa and Mrs. Scholastica Mwende is gratefully acknowledged.


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EXECUTIVE SUMMARY

Kenya recognizes that diseases, disability and ill health are major impediments to national development and poverty reduction. Consequently, the government is committed to the promotion quality of health for all its citizenry. Kenya, like other developing countries, is experiencing this emerging diabetes epidemic. It is estimated that the prevalence of diabetes in the country is about 3.3%. This figure is projected to rise to 4.5% by 2025 if this trend is not checked.

The complications of undetected and untreated diabetes are serious and cause huge human suffering and disability, and have huge socio – economic costs resulting from premature morbidity and mortality. Diabetes is one of the leading causes of blindness, renal failure and lower limb amputation. It also triggers cardiovascular disease which is the leading cause of deaths in diabetes patients.

The key risk factors for diabetes—obesity, physical inactivity, and unhealthy diets—require interventions to change unhealthy lifestyles. These changes are most likely to occur with implementation of a coordinated range of interventions to encourage individuals to maintain a healthy weight, participate in daily physical activity, and consume a healthy diet. Education is central to implementing such changes. It is more effective when provided through multiple methods and sites, such as schools, workplaces, mass media, and health centers. Educational messages are also more effective if they are reinforced by action. Schools, for example, should provide not only curricula on good nutrition but also healthy meals; worksites should not only inform workers about the role of physical activity but facilitate the use of non-motorized transportation such as walking and cycling.

The National Diabetes Strategy (NDS) proposes a framework and implementation options based on the overall goal of preventing or delaying the development of diabetes in the Kenyan population, improvement of the quality of life through reduction of complications and premature mortality in people with diabetes.


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This strategy has eight key strategic interventions; 1. Advocacy - to make diabetes everybody’s business and combine

the notion of individual, community, social, corporate and government responsibility.

2. Empowerment - to encourage full engagement of all levels and facets of society in taking responsibility for health as a fundamental common asset. Empowering individuals, families and communities helps to prevent and manage diabetes optimally.

3. Resource Mobilization and Prioritization – this entails having clear priorities and evidence of effectiveness to provide a sound platform for arguing for resources to be directed to diabetes. Clear and rational priorities will help to reduce waste and duplication and can highlight ways in which existing resources can be allocated more effectively.

4. Capacity building- this is about making what you have, work better by improving the human resource capacity, making health systems more responsive to diabetes through improved infrastructure, adequate medical supplies, improved diagnostic services and provision of necessary protocols and standards.

5. Partnership And Coordination – This is aimed at promoting efficient implementation of diabetes control interventions through improved coordination and collaboration of partners in the country. The implementation of National Diabetes Strategy will be coordinated by National Diabetes Steering Committee with the guidance of the Diabetes Inter Agency Coordinating Committee (ICC)

6. Diabetes policies, legislation and regulations - policies and legislation are pertinent in the implementation of interventions that support diabetes prevention and control. These are important in control of exposure of the population to risk factors for diabetes and other chronic non-communicable diseases.

7. Research - Combating the rapidly growing burden of diabetes requires strategic effort across the entire spectrum of research - epidemiology, behavioral, health system, biomedical and clinical. There is need to support research on diabetes and timely disseminate the findings to the decision makers.


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8. Monitoring and evaluation - Continuous measurement of the progress and impact of the implementation of NDS are essential to achieving planned interventions. The National Diabetes Strategy recognizes that establishing effective systems for Monitoring and evaluation (M&E) are a vital management tool.

This National Strategy for Diabetes (NDS) recognizes the humanitarian, social and economic burden of diabetes and consequently provides a platform for the development of affordable cost-effective public-health strategies for the prevention of diabetes. It also places more emphasis on the need for more research towards better treatment, prevention and control methods for diabetes. It calls for the country to invest in diabetes as the effects of that investment also yields substantial returns in reducing heart diseases, stroke, kidney diseases, hypertension, and cancers. All stakeholders are called upon to embrace this NDS and join hands in confronting this new and explosive epidemic of diabetes mellitus in Kenya.


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KENYA NATIONAL DIABETES STRATEGY

Introduction

Diabetes Mellitus is a chronic metabolic disorder that occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This results in elevated blood sugar (hyperglycaemia) which over time leads to multiple organ damage. The commonest complications of diabetes include – eye complications, heart and blood vessels, kidneys, nervous system and foot complications leading to amputations. However, acute complications do occur such as Diabetes ketoacidosis, and diabetes non-ketotic coma (hyperosmolar).

Predisposing Factors � Advancing age. � Family history � Excessive body weight � Excessive alcohol consumption � Physical inactivity. � Stress. � Unhealthy diet. � Gestational Diabetes Mellitus � Chronic use of steroids

Diabetes SymptomsDiabetes Mellitus often goes undiagnosed because many of its symptoms though serious are often missed or are treated as common ailments. Recent studies indicate that the early detection of diabetes symptoms and treatment can decrease the chance of developing the complications of diabetes.

Common symptoms of diabetes include: � Frequent urination � Excessive thirst � Extreme hunger � Unexplained weight loss � Increased fatigue � Irritability � Blurry vision � Impotence � Numbness or tingling sensation of the feet


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Types of diabetes

1. Type 1 – Previously referred to Insulin Dependent Diabetes or Autoimmune Diabetes or Juvenile diabetes or early onset diabetes mellitus. Type 1 diabetes is as a result of failure of the pancreas to produce insulin. This type comprises about 10-15% of total diabetes burden.

2. Type 2 – Previously referred to as Non-insulin Dependent or Maturity onset diabetes- This type results from failure of the pancreas to produce adequate insulin or failure of body cell to utilize insulin or both. It accounts for about 85- 90% of total diabetes burden.

3. Gestation diabetes Mellitus (GDM) – Pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects about 4% of all pregnant women. Gestational diabetes starts when the body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood and be changed to energy.

4. Other specific types: � Diabetes as part of other Endocrine syndromes � Drug Induced diabetes � Pancreatic disease � Monogenic diabetes; previously referred to as Maturity Onset

Diabetes of the Young (MODY)

Epidemiology

Diabetes is one of the commonest non-communicable diseases of the 21st century. In 2007 the global burden of diabetes was estimated to be 246 million people. The international diabetes federation (IDF) estimates that this figure is likely to rise to 380 million by the year 2025 (IDF Atlas, 2007). In its 2009 Diabetes Atlas publication, the International Diabetes Federation, the global burden of diabetes in 2010 is estimated at 285 million and projected to increase to 438 million by the year 2030, if no interventions are put in place (IDF Atlas, 2009).This rise in diabetes is associated with demographic and social changes such as globalization, urbanization, aging population and adoption of unhealthy lifestyles such as consumption of unhealthy diets and physical inactivity.

The World Health Report 2002 estimated that globally, 7.1 million deaths could


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be attributed to high blood pressure, 4.4 million deaths to high cholesterol, and 2.6 million deaths to excessive body weight. Excessive body weight is a growing problem in almost every country, even the poorest. It is increasing so rapidly that in middle-income countries the disease burden associated with having a body mass index greater than 25 is now equal to or greater than the disease burden resulting from under-nutrition (WHO, 2002). Excessive body weight is known to be an independent risk factor for development of type 2 diabetes mellitus.

Despite the higher prevalence of diabetes in high-income countries, the majority of the disease burden from diabetes, more than 70 percent, is in the developing regions because of their larger populations.

In Kenya, the prevalence of diabetes is estimated to be 3.3%. This figure is based on regional projections and is likely to be an underestimation as over 60% of people diagnosed to have diabetes in Kenya usually present to the health care facility with seemingly unrelated complaints. Therefore two thirds of people with diabetes do not know they have the disease (IDF 2007).

Several modifiable risk factors come to fore as driving forces of the rising prevalence of type 2 diabetes in Kenya. These factors associated with urbanization include:

� Consumption of refined carbohydrate � Consumption of high-fat diets, � Lack of physical activity due to sedentary lifestyles, lack of exercise

or Circumstantial reduction of physical exercises occasioned by the availability of motorized transport, watching television and computer games for long hours

These common urban events and lifestyles are now reaching rural Kenya.

Situation analysisThere is a high proportion of undiagnosed cases of diabetes that end up with irreversible complications imposing a huge economic burden to the individual, family, community and in the health care system. The country has severe shortage/limited resources to take care of the extra burden of diabetes. In areas where resources such health workers exist, they are not adequately trained and equipped to effectively manage diabetes and its complications. In addition, many of the existing health facilities in the country lack the capacity for early detection of diabetes as routine screening for high blood sugar is not often done.


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To confound all these there is very low public awareness of most chronic diseases particularly diabetes. This is basically due to lack of Primary Health Care (PHC) systems that are geared towards tackling chronic diseases.

There is lack of population based data on the burden and trends of diabetes and no comprehensive research exists that can inform policy on the best practices for the control of diabetes. Little attention is therefore given to the prevention and control of non-communicable diseases. Much of the emphasis, during medical training and in human and financial resources allocation is focused on infectious diseases.

Non-communicable diseases such as diabetes, cardiovascular diseases and cancers, and their related risk factors such as high blood pressure, high cholesterol, and excessive bodyweight are increasing in Kenya. Once considered diseases of industrialized countries or of the affluent in developing countries, they are now recognized as a common problem even among the poor in developing countries.

The healthcare environment in Kenya is affected by several significant factors, including a double burden of both communicable and non-communicable diseases. The system needs redesigning in order to align itself with the emerging challenge of a double burden of disease. Prevention, care and treatment, and research are all activities that are facilitated by the presence of a strong and functioning health care system.

Prevention and ControlThe key risk factors for diabetes—obesity, physical inactivity, and unhealthy diets—require interventions to change unhealthy lifestyles. These changes are most likely to occur with implementation of a coordinated range of interventions to encourage individuals to maintain a healthy weight, participate in daily physical activity, and consume a healthy diet. Education is central to implementing such changes and it is more effective when provided through multiple methods and sites, such as community groups, schools, workplaces, mass media, religious organizations and health centers. Educational messages are also more effective if they are reinforced by action. Schools, for example, should provide not only curricula on good nutrition but also serve healthy school meals; worksites should not only inform workers about the role of physical activity in health but also encourage and facilitate its implementation.


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Urban design and transportation policy are other key elements of lifestyle interventions. People can be encouraged to increase their physical activity by using public and non-motorized transport, especially walking and bicycling. Although not normally considered an instrument for improving health, national transportation policies can strongly influence automobile use and dependency.

Food policy is another important area for encouraging lifestyle change. Policy requirements to include how food is processed by fortifying foods with micronutrients, limiting salt contents, limiting advertising for unhealthy foods and correct labeling of food products. One of the most effective ways to improve diets is to regulate or provide incentives for food manufacturers to replace unhealthy ingredients or products with healthier ones. Changes in types of fats, for example, can be almost imperceptible to consumers and relatively inexpensive. Agricultural policies should be geared towards the production of traditional/indigenous food varieties while price policies need to make such food more affordable to the population.

Many European manufacturers have greatly reduced foods’ trans-fatty acid content by changing production methods. In this way, the Netherlands reduced the trans-fat content of the food supply from about 6 percent of the energy content to approximately 1 percent in a single decade. In Mauritius, government policies replaced commonly used palm oils for cooking with soybean oil, which reduced the intake of saturated fatty acids and lowered serum cholesterol levels. Other easily targeted changes in food processing include reducing salt and fortifying foods with micronutrients such as vitamin A, vitamin B12, iodine, iron, and folic acid (DCPP, 2006).

The above measures are some of the important primary prevention interventions of diabetes. When lifestyle changes are insufficient and the disease sets in there are variety of medical interventions, many of which are expensive. The essential treatment for type 1 diabetes is insulin injections to maintain normal blood glucose levels. For type 2 diabetes, treatment requires good dietary practice, physical activity and oral glucose-lowering agents and/or insulin. Maintaining normal blood glucose in diabetic patients is essential to delay and prevent complications. In comprehensive care of diabetes blood pressure, lipids and weight abnormalities should also be managed. Other important and effective interventions for prevention and control of diabetes and its complications include health education, early screening and detection followed by prophylaxis and treatment for diabetes complications.


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Complications of diabetes are difficult and expensive to treat thus maintaining adequate glyceamic control is the more cost effective option

PurposeThe purpose of the NDS is to accelerate mainstreaming of diabetes policies and programmes with a view to make them an integral part of the national public health response to disease prevention and care at all levels of health care. This strategy will articulate strategic priorities in diabetes to ensure that services are directed to those areas that are likely to yield high impact for people with diabetes and those at risk of the disease.

This strategic framework will guide the funding, planning, organization, provision and monitoring and evaluation of services for people with or at risk of diabetes. It will consolidate and improve the quality and coverage of diabetes care services in Kenya.

The framework also identifies the roles of various key players in the development and implementation of diabetes prevention and control services. It defines the processes and inputs necessary for the timely realization of the national targets.

ScopeThe NDS focuses on the prevention and control of diabetes in Kenya. The vision, recommendations and key strategies in the NDS span the continuum of care from pre-diabetes through diagnosis, routine monitoring and care to the onset of complications and palliation.

The NDS will target policy makers, government departments, health institutions, non-governmental organizations, civil society groups, communities, development partners and funding agencies with the aim of reducing the burden of diabetes.

JustificationAddressing diabetes and other non-communicable diseases is not something that Kenya can leave to the future. These conditions already account for a substantial share of the disease burden in the country and are likely to increase further as the country makes progress in controlling infectious diseases and reducing the high rates of mortality and morbidity associated with childbearing and infancy. A similar effort should be put in place to address non-communicable diseases.Diabetes and other related non-communicable diseases are not inevitable


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consequences of modern life. Prevention can be achieved with moderate changes in lifestyles that are fully compatible with life in the 21st century. Nevertheless, the requisite changes in smoking and alcohol habits, physical activity, and diet may not be easy and will require support and encouragement through investments in education, changes in food policies, and sometimes even changes in urban infrastructure. Whereas the required behavioral changes are the same everywhere, the ways to achieve them will necessarily vary across the country, with different approaches corresponding to cultural, social, and economic features.

The toll that diabetes takes on individuals, societies and economies especially in the developing and less developed world cannot be overstated. For many patients in Kenya maintenance treatment for diabetes is expensive and poses an economic challenge to their families. As a result some of these patients do not comply with treatment therefore placing them at a higher risk of developing end organ damage. Those who need more advanced, more expensive care for diabetes related complications are often the very people who cannot afford such care, taking into consideration that approximately 46% of the Kenyan population lives on less than a dollar a day (Kenya household economic survey). When burdened with debilitating or life threatening complications requiring expensive advanced care, many of them are forced to sell their meager assets in order to pay for treatment thus becoming impoverished at the individual, family and community level. Diabetes also affects the most productive age group in the society

Effective prevention strategies for diabetes are not costly and may actually bring down costs related to other related NCDs. However, both in health and economic terms, neglecting chronic diseases such as diabetes is very expensive. The costs of treatment and loss of productivity undermine and stunt economic growth and negatively impact on realization of the Millennium Development Goals (MDGs) (WDF, 2007), vision 2030 and other national development targets.

If Kenya can successfully strengthen its health systems to improve the coverage of interventions that reduce infectious disease and maternal and childhood conditions, it equally can build further capacity to address the rising burden of diabetes and other non-communicable diseases.

The National Diabetes Strategy proposes a framework and implementation guidelines based on the overall goal of preventing or delaying the development of diabetes and its associated complications in the Kenyan population, improvement of the quality of life and premature mortality in people with diabetes.


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NOTE:Many chronic diseases including diabetes do not cause sudden death. Rather, they cause progressive illness and debilitation. In this way, they reduce productivity of the individual, draining away their resources. This aggravates poverty .

Guiding Principles

The following are the guiding principles for the implementation of NDS 2010 – 2015.

1. Equity and accessibility of diabetes services: The NDS is aimed at ensuring that every person irrespective of their social or economic status, race or creed access diabetes care services without discrimi-nation.

2. Gender responsiveness: The NDS recognizes the particular vulner-able position of women and children in the society and supports interventions geared towards these groups.

3. Partnerships, Team Building and coordination: With the involve-ment of all partners at various levels (government , private sector, civil society and community) in the development, planning and implementation of interventions; such coordination should be based on a clear definition and understanding of roles, responsibilities and mandates

4. Innovation, creativity and accountability, with the involvement of individuals, people with diabetes and their families, civil society and community at all stages of decision making, planning, implementa-tion and evaluation

5. Privacy and confidentiality: Every diabetes patient has a right to privacy and confidentiality regarding their health.

6. Systematic and integrated approach to step by step implementation of priority interventions as part of a national diabetes action plan

7. Supportive leadership and management:


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The StrategyThis strategy represents the views and opinions of diabetes experts, health care providers and other stake holders in Kenya. The priority of this strategy is prevention, early detection and control of diabetes. It recognizes that to achieve this, there is need to address the health care system to support delivery of prevention and care services.

The implementation of this strategy will eventually alleviate the suffering and unnecessary early deaths of people with diabetes, find and treat those with diabetes, and to prevent new cases.

It recognizes that to achieve this, there is need to address the health care system to support delivery of prevention and care services for diabetes.

Vision A diabetes care system that is efficient, responsive and acceptable to all Kenyans.

MissionTo promote the provision of high quality, accessible, affordable and evidence-based diabetes prevention and care services to all people living in Kenya.

Overall Goals1. To prevent or delay the development of diabetes in the Kenyan

population.2. To improve the quality of life and reduce complications and prema-

ture mortality in people with diabetes.

Objectives 1. To improve the capacity of the health systems to deliver, manage,

monitor and evaluate services for the prevention of diabetes and the care of people with diabetes.

2. To reduce the number of new cases of Type 2 diabetes through life style modification

3. To improve early detection for diabetes and its complications through screening

4. To increase the knowledge and understanding of diabetes to the population

5. To improve maternal and child outcomes for gestational diabetes, and for pregnant women with pre-existing diabetes.


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6. To network and integrate diabetes care with other national programs e.g. HIV/AIDS, TB and malaria.

7. To promote research in diabetes in order to advance knowledge about the prevention and care.

Key Strategies

1. AdvocacyThis is about making diabetes everybody’s business and combines the notion of individual, community, social, corporate and government responsibility. This is because diabetes affects everybody in some way and so should be the responsibility of everyone to address the determinants of diabetes and related chronic diseases and conditions.

Activities: � Develop a broad-based advocacy platform that integrates diabetes

and related chronic diseases to have a stronger voice. � Identify and network with Non-Governmental Organization

(NGOs), key opinion leaders, health professionals and academia in diabetes and related chronic diseases.

� Develop appropriate information materials for diabetes and as-sociated risk factors, such as obesity, physical inactivity, tobacco use, alcohol abuse and inappropriate nutrition, and their primary prevention

� Liaise with media services to promote diabetes awareness and avail-able services.

� Lobby government Ministries and departments to invest in health and healthy environments.

� Lobby corporate groups to contribute to diabetes related pro-grams and to provide diabetes prevention and care to their workers through their corporate social responsibility programmes.

� Sensitize Communities on diabetes prevention and control � Commemorate the World Diabetes Day every year

2. EmpowermentThe concept of empowerment is encouraging full engagement of all levels and facets of society in taking responsibility for health as a fundamental common asset. Empowering individuals, families and communities helps to prevent and manage diabetes optimally. To achieve this, diabetes prevention and care must be


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integrated into the primary health care programme at all levels.

Activities: � Conduct education sessions for people with diabetes to empower

them with self management skills � Develop clear consistent diabetes information education and

communication materials targeting people with diabetes. � Encourage people with diabetes to pass on health messages and

practice healthy lifestyle choices within their families. � Support Individuals and heads of households to promote and adopt

healthy lifestyles within their families � Support school health programmes to create awareness of diabetes

and other non-communicable diseases � Encourage diabetes awareness and healthy lifestyles at work places � Conduct community education campaigns � Set up and train diabetes support groups

3. Resource Mobilization and Prioritization

Resource MobilizationHaving clear priorities and evidence of effectiveness will provide a sound platform for arguing for resources to be directed to diabetes. Clear and rational priorities can also help to reduce waste and duplication and can highlight ways in which existing resources can be allocated more effectively.

Activities � Conduct needs assessment and identify available resources for dia-

betes � Lobby government, development partners and funding agencies to

allocate adequate resources for diabetes and other non-communica-ble diseases.

� Integrate diabetes prevention and control into the national and district health plans

� Advocate for allocation of resources for diabetes from devolved development funds such as constitution and local authority develop-ment funds.


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PrioritizationThis involves making the best use of scarce resources to achieve highest impact, engage all stakeholders in assessing the needs versus available resources, and in setting national and local priorities for what needs to be done, in what order, and to what extent.

Activities � Set national and local diabetes priorities and identify actors in the

priority areas � Assess available resources and existing opportunities for funding � Define common diabetes agenda and develop a joint program for

work and funding (JPWF) with partners

4. Capacity buildingCapacity building is about making what you have work better by improving the human resource capacity, making health systems more responsive to diabetes through improved infrastructure, adequate medical supplies, improved diagnostic services and provision of necessary protocols and standards.

Activities � Conduct Training of health care providers on the required compe-

tencies and deploy them appropriately for diabetes care. � Develop and provide the health care providers (HCP) with clinical

guidelines and treatment protocols � Develop norms and standards for diabetes care at all levels. � Provide clinical and diagnostic equipments, medical supplies and

infrastructure for diabetes care according to the national standards � Develop appropriate information systems and appropriately train

providers on how to use it. � Develop and maintain efficient systems for evaluation and quality

improvement.

5. Partnership and CoordinationThe purpose of this strategy is to promote efficient implementation of diabetes control interventions through improved coordination and collaboration of partners in the country. The implementation of National Diabetes Strategy will be coordinated by National Diabetes Steering Committee with the guidance of the Inter Agency Coordinating Committee


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Activities � Setting up and strengthening of the following coordinating units � National Diabetes Steering Committee (NDSC) � Inter- Agency Coordinating Committee (ICC) � National diabetes stake holders forum (NDSF) � Health Facility/District Diabetes Management Committee � Community diabetes support groups � Develop and strengthen Collaboration and linkages with other

health programs (HIV/AID, ophthalmic, TB, Malaria etc) in order to address Diabetes concerns.

� Support districts to integrate Diabetes control issues into the district health plans

� Support districts to integrate Diabetes control issues into the district stake holders forum

� Support District and Health Facility Diabetes management commit-tee

� Support Community diabetes support groups � Mobilize resources for implementation of National Diabetes Strat-

egy.

6. Diabetes Control Policies, Legislation and Regulations

To ensure that policies and legislation that support diabetes are enacted and implemented. The government will take up issues of policy, regulations and legislation.

Activities � Develop policies that ensure access to insulin and other diabetes

commodities in terms of quality, availability and affordability � Regulation of food labeling � Standardization and availability of testing kits for diabetics � Establishment of a national diabetes registry � Regulate and Define the role of herbal medicine, food supplements

and alternative medicine in diabetes care � Formulate National Standards for diabetes prevention and care. � Support the development and implementation of Legislation and

policies that favour diabetes prevention and control.


14

7. ResearchCombating the rapidly growing burden of diabetes requires strategic effort across the entire spectrum of research - epidemiology, behavioral, health system, biomedical and clinical. There is need to support research on diabetes and timely disseminate the findings to the decision makers.

Activities � Identify priority research issues on diabetes � Support epidemiological and operational research on priority diabe-

tes issues at all levels � Undertake formative research to guide the development of advocacy

tools � Improve dissemination of research finding on diabetes to stakehold-

ers � Document, publish and share existing research findings on diabetes.

8. Monitoring and evaluationContinuous measurement of the progress and impact of the implementation of NDS are essential to achieving planned interventions.NDS recognizes that establishing effective systems for M&E are a vital management tool. Indicators to monitor inputs, process, outputs, outcomes and impact will be used to assess collective efforts.Activities

� Develop M&E indicators and tools for diabetes � Review and harmonize M&E indicators and tools for diabetes � Strengthen collection, reporting, analysis and utilization of diabetes

data � Establish data base for diabetes at all levels of health care � Develop software for diabetes data capture and integrate it within

the health management information systems (HMIS) � Regular review of the NDS implementation


15

NAT

ION

AL

DIA

BETE

S ST

RAT

EGY

IMPL

EMEN

TATI

ON

FR

AM

EWO

RK

201

0 - 2

015

Stra

tegy

Out

puts

Act

iviti

esM

onito

ring

In

dica

tors

Tim

e Fr

ame

Lead

A

genc

yK

ey

Part

ners

Advo

cacy

Incr

ease

d aw

aren

ess o

f di

abet

es at

all

leve

ls

Dev

elop

a b

road

-bas

ed

advo

cacy

pla

tform

that

in

tegr

ates

dia

bete

s and

re

late

d ch

roni

c dise

ases

to

have

a st

rong

er v

oice

.

No.

of p

artn

ers

activ

ely

invo

lved

in

diab

etes

adv

ocac

y

Y1Y2

Y3Y4

Y5M

oPH

S/D

NC

D

MO

MS

WD

F D

MI

KD

A

WH

O

Esta

blish

stro

ng n

etw

orks

w

ith N

GO

s, ke

y op

inio

n le

ader

s, he

alth

pro

fess

iona

ls an

d ac

adem

ia in

dia

bete

s and

re

late

d ch

roni

c dise

ases

.

No.

of f

orum

s hel

dX

XX

XX

MoP

HS/

DN

CD

MO

MS

WD

F D

MI

KD

A W

HO

U

nive

rsiti

es

Dev

elop

appr

opria

te

info

rmat

ion

mat

eria

ls fo

r di

abet

es a

nd a

ssoc

iate

d ris

k fa

ctor

s.

No.

of I

EC m

ater

ials

deve

lope

d an

d di

ssem

inat

ed

XX

XX

XM

oPH

S/D

NC

D

MO

MS

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F D

MI

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A W

HO

Liai

se w

ith m

edia

serv

ices

to

prom

ote

diab

etes

awar

enes

sN

umbe

r of m

edia

pr

ovid

ers i

nvol

ved

in p

rom

otio

n of

di

abet

es aw

aren

ess

XX

XX

XM

oPH

S/D

NC

D

MO

MS

WD

F D

MI

KD

A W

HO

Lobb

y go

vern

men

t M

inist

ries a

nd d

epar

tmen

ts

to in

vest

in h

ealth

and

he

alth

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nmen

ts

No.

of G

over

nmen

t M

inist

ries a

nd

depa

rtm

ents

su

ppor

ting

diab

etes

pr

even

tion

and

cont

rol

XX

XX

XM

oPH

S/D

NC

D

MO

MS

WD

F D

MI

KD

A W

HO


16

Lobb

y co

rpor

ate

grou

ps

to su

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t dia

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s rel

ated

pr

ogra

ms

No.

of c

orpo

rate

gr

oups

supp

ortin

g di

abet

es re

late

d pr

ogra

ms

XX

XX

XM

oPH

S/D

NC

D

MO

MS

DM

IK

DA

Lobb

y co

rpor

ate

grou

ps to

su

ppor

t dia

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s car

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d pr

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to th

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orke

rs

No.

of c

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rate

gr

oups

supp

ortin

g di

abet

es c

are

to

thei

r wor

kers

XX

XX

XM

oPH

S/D

NC

D

MO

MS

DM

I K

DA

Sens

itize

Com

mun

ities

on

dia

bete

s con

trol

and

pr

even

tion

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of c

omm

unity

m

embe

rs re

ache

dX

XX

XX

MoP

HS/

DN

CD

M

OM

S

DM

I K

DA

Com

mem

orat

e W

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iabe

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ay a

nnua

llyRe

port

of e

vent

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ldX

XX

XX

MoP

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DN

CD

M

OM

S

DM

I K

DA

Empo

wer

men

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pow

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of th

e co

mm

unity

to

eng

age

in

prev

entio

n an

d ca

re o

f dia

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s

Con

duct

edu

catio

n se

ssio

ns

for p

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e w

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ith se

lf m

anag

emen

t ski

lls

No.

of p

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e re

ache

dX

XX

XX

MoP

HS/

DN

CD

M

OM

S

WD

FD

MI

KD

AW

HO

Dev

elop

dia

bete

s in

form

atio

n, e

duca

tion

and

com

mun

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mat

eria

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rget

ing

com

mun

ity

mem

bers

No.

of I

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ater

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lope

dM

oPH

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NC

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IK

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Supp

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d he

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f hou

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of h

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XX

XX

XM

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NC

D

Stra

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Out

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Act

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ame

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Part

ners


17

Supp

ort I

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ls an

d he

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of h

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hold

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ted

XX

XX

XM

oPH

S/D

NC

D

MO

MS

Supp

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choo

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lth

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ram

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to cr

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aw

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f dia

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able

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es

No.

of s

choo

ls w

ith

heal

thy

lifes

tyle

pr

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mm

es

XX

XX

XM

oPH

S/D

NC

D

MO

MS

Enco

urag

e di

abet

es

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enes

s and

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lthy

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s at w

ork

plac

es

No.

of w

ork

plac

es

with

hea

lthy

lifes

tyle

pr

ogra

mm

es

XX

XX

XM

oPH

S/D

NC

D

MO

MS

Con

duct

com

mun

ity

educ

atio

n ca

mpa

igns

No.

of c

ampa

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co

nduc

ted

XX

XX

XM

oPH

S/D

NC

D

MO

MS

Empo

wer

men

t of

peo

ple

with

dia

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s to

eng

age

in

prev

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n an

d ca

re o

f dia

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s

Con

duct

edu

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n se

ssio

ns

for p

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e w

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er th

em w

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anag

emen

t ski

lls

No.

of n

umbe

r of

peop

le w

ith d

iabe

tes

reac

hed

XX

XX

XM

oPH

S/D

NC

D

MO

MS

WD

F D

MI

KD

AW

HO

Dev

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dia

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s in

form

atio

n , e

duca

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and

com

mun

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mat

eria

ls ta

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of d

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mat

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rget

ing

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le w

ith d

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tes

deve

lope

d an

d di

ssem

inat

ed

XM

oPH

S/D

NC

DM

OM

S

WD

F D

MI

KD

AW

HO

Set u

p an

d tr

ain

diab

etes

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t gro

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No.

of d

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supp

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ng aw

aren

ess

activ

ities

XX

XX

XX

MoP

HS/

DN

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MS

Stra

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Out

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Act

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onito

ring

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18

Reso

urce

M

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d Pr

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izat

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Incr

ease

d su

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t for

di

abet

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activ

ities

and

ot

her r

elat

ed

NC

Ds

Lobb

y go

vern

men

t, de

velo

pmen

t par

tner

s and

fu

ndin

g ag

enci

es to

allo

cate

ad

equa

te re

sour

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or

diab

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and

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on-

com

mun

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es.

No.

of g

over

nmen

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part

men

ts a

nd

orga

niza

tions

al

loca

ting

reso

urce

s fo

r dia

bete

s

XX

XX

XM

oPH

S/D

NC

DM

OM

S

WD

F D

MI

KD

AW

HO

Inte

grat

e di

abet

es p

reve

ntio

n an

d co

ntro

l int

o th

e na

tiona

l an

d di

stric

t hea

lth p

lans

No.

of d

istric

ts

with

dia

bete

s in

corp

orat

ed in

to

thei

r ann

ual w

ork

plan

s

XX

XX

XM

oPH

S/D

NC

DM

OM

S

WD

F D

MI

KD

AW

HO

Adv

ocat

e fo

r allo

catio

n of

re

sour

ces f

or d

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tes f

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de

volv

ed d

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su

ch a

s con

stitu

tion

and

loca

l au

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ity d

evel

opm

ent f

unds

No.

of

cons

titue

ncie

s and

lo

cal a

utho

ritie

s su

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ting

diab

etes

ac

tiviti

es

XX

MoP

HS/

DN

CD

MO

MS

WD

F D

MI

KD

AW

HO

Con

duct

nee

ds a

sses

smen

t an

d id

entif

y av

aila

ble

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urce

s for

dia

bete

s

Repo

rts o

n ne

eds

asse

ssm

ent a

nd

avai

labl

e re

sour

ces

XX

XX

MoP

HS/

DN

CD

WD

FD

MI

KD

AW

HO

Reso

urce

s ap

prop

riate

ly

allo

cate

d to

pr

iorit

y ar

eas

Set n

atio

nal a

nd lo

cal

diab

etes

prio

ritie

s and

id

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y ac

tors

in th

e pr

iorit

y ar

eas

Repo

rt o

n na

tiona

l pr

iorit

ies a

nd a

ctor

s in

eac

h pr

iorit

y ar

ea

XX

MoP

HS/

DN

CD

MO

MS

WD

FD

MI

KD

AW

HO

Defi

ne co

mm

on d

iabe

tes

agen

da a

nd d

evel

op a

jo

int p

rogr

am fo

r wor

k an

d fu

ndin

g (J

PWF)

with

pa

rtne

rs

Join

t wor

k pl

anX

XM

oPH

S/D

NC

DM

OM

S

WD

FD

MI

KD

AW

HO

Stra

tegy

Out

puts

Act

iviti

esM

onito

ring

In

dica

tors

Tim

e Fr

ame

Lead

A

genc

yK

ey

Part

ners


19

Capa

city

build

ing

Incr

ease

d hu

man

reso

urce

ca

paci

ty fo

r pr

even

tion

and

cont

rol o

f di

abet

es

Con

duct

Tra

inin

g of

hea

lth

care

pro

vide

rs o

n th

e re

quire

d co

mpe

tenc

ies a

nd

depl

oy th

em fo

r dia

bete

s ca

re.

No.

of h

ealth

car

e pr

ovid

ers t

rain

ed

Prop

ortio

n of

HC

P w

orki

ng in

dia

bete

s cl

inic

s

XX

XX

XM

oPH

S/D

NC

DM

OM

S

WD

FD

MI

KD

AW

HO

Dev

elop

and

pro

vide

the

heal

th c

are

prov

ider

s (H

CP)

w

ith cl

inic

al g

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lines

and

tr

eatm

ent p

roto

cols

No.

of g

uide

lines

an

d tr

eatm

ent

prot

ocol

s ava

ilabl

e

XX

MoP

HS/

DN

CD

MO

MS

WD

FD

MI

KD

AW

HO

Impr

oved

in

fras

truc

ture

fo

r man

agem

ent

of d

iabe

tes

Dev

elop

nor

ms a

nd

stan

dard

s for

dia

bete

s car

e at

al

l lev

els.

Dia

bete

s car

e no

rms

and

stan

dard

s m

anua

l in

plac

e

XX

MoP

HS/

DN

CD

MO

MS

WD

FD

MI

KD

AW

HO

Prov

ide

clin

ical

and

di

agno

stic

equ

ipm

ent,

med

ical

supp

lies a

nd

infr

astr

uctu

re fo

r dia

bete

s ca

re a

ccor

ding

to th

e na

tiona

l sta

ndar

ds

No.

of e

quip

men

t pr

ovid

ed a

s per

the

natio

nal s

tand

ards

No.

of d

iabe

tes

clin

ics r

epor

ting

regu

lar s

uppl

ies

XX

XX

XM

oPH

S/D

NC

DM

OM

S

WD

FD

MI

KD

AW

HO

Dev

elop

appr

opria

te

info

rmat

ion

syst

em a

nd

appr

opria

tely

trai

n pr

ovid

ers

on h

ow u

se it

.

No.

of t

ools

deve

lope

d an

d in

us

e

XX

MoP

HS/

DN

CD

MO

MS

WD

FD

MI

KD

AW

HO

Dev

elop

and

mai

ntai

n effi

cien

t sys

tem

s for

ev

alua

tion

and

qual

ity

impr

ovem

ent

Qua

lity

assu

ranc

e sy

stem

in p

lace

XX

MoP

HS/

DN

CD

MO

MS

WD

FD

MI

KD

AW

HO

Stra

tegy

Out

puts

Act

iviti

esM

onito

ring

In

dica

tors

Tim

e Fr

ame

Lead

A

genc

yK

ey

Part

ners


20

Part

ners

hip

and

Coor

dina

tion

Coo

rdin

atin

g un

its se

t up

and

stre

ngth

ened

Set u

p an

dst

reng

then

coor

dina

ting

units

No.

of c

oord

inat

ing

units

set

XX

MoP

HS/

DN

CD

WD

FD

MI

KD

AW

HO

No.

of m

eetin

gs

held

by

coor

dina

ting

units

XX

XX

XM

oPH

S/D

NC

DD

MI

KD

A

Col

labo

ratio

n an

d lin

kage

s w

ith o

ther

he

alth

pro

gram

s de

velo

ped

and

stre

ngth

ened

.

Dev

elop

and

stre

ngth

en

Col

labo

ratio

n an

d lin

kage

s w

ith o

ther

hea

lth p

rogr

ams.

No.

of o

ther

he

alth

pro

gram

s co

llabo

ratin

g w

ith

diab

etes

pro

gram

XX

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

O

Dia

bete

s co

ntro

l iss

ues

inte

grat

ed in

to

the

dist

rict

heal

th p

lans

Supp

ort d

istric

ts to

inte

grat

e D

iabe

tes c

ontr

ol is

sues

into

th

e di

stric

t hea

lth p

lans

No.

of d

istric

ts

inte

grat

ing

diab

etes

iss

ues i

nto

thei

r D

HP

XX

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

O

Dia

bete

s co

ntro

l iss

ues

inte

grat

ed in

to

the

dist

rict

stak

e ho

lder

s fo

rum

Supp

ort d

istric

ts to

inte

grat

e D

iabe

tes c

ontr

ol is

sues

into

th

e di

stric

t sta

ke h

olde

rs

foru

m

No.

of D

istric

ts

stak

e ho

lder

s fo

rum

s foc

usin

g on

di

abet

es is

sues

XX

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

O

Dist

rict a

nd

Hea

lth F

acili

ty

Dia

bete

s m

anag

emen

t co

mm

ittee

es

tabl

ished

Esta

blish

Dist

rict a

nd

Hea

lth F

acili

ty D

iabe

tes

man

agem

ent

com

mitt

ees

No.

of d

istric

ts w

ith

func

tiona

l dia

bete

s co

mm

ittee

s

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

O

Stra

tegy

Out

puts

Act

iviti

esM

onito

ring

In

dica

tors

Tim

e Fr

ame

Lead

A

genc

yK

ey

Part

ners


21

No.

of h

ealth

fa

cilit

ies w

ith

func

tiona

l Dia

bete

s co

mm

ittee

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

OC

omm

unity

di

abet

es

supp

ort g

roup

s su

ppor

ted

Supp

ort C

omm

unity

di

abet

es su

ppor

t gro

ups

No.

of d

iabe

tes

supp

ort g

roup

s fo

rmed

XX

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

ON

o. o

f fun

ctio

nal

diab

etes

supp

ort

grou

ps

XX

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

ORe

sour

ces f

or

impl

emen

tatio

n of

Nat

iona

l D

iabe

tes

Stra

tegy

m

obili

zed

Mob

ilize

reso

urce

s for

im

plem

enta

tion

of N

atio

nal

Dia

bete

s Str

ateg

y.

Prop

ortio

n of

re

sour

ces m

obili

zed

for p

lann

ed

activ

ities

XX

XX

XM

oPH

S/D

NC

DW

DF

DM

IK

DA

WH

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Dia

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licie

s, le

gisla

tion

and

regu

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ns

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Dev

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pol

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t ens

ure

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mm

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te

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f qua

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labi

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and

affor

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pla

ceX

XX

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XM

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NC

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IK

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gula

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the

role

of

her

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ts a

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tes c

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of c

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idel

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velo

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dica

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22

No.

of c

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ssem

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XX

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atio

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.

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d ca

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lace

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XX

XX

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of p

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lope

dM

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NC

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chPr

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ch is

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on

dia

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all

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tify

prio

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23

Form

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e re

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ches

un

dert

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cum

ente

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DN

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arch

shar

ing

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ms h

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&E

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of M

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cato

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nd to

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lope

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XX

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XX

XX

XM

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NC

DW

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all

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blish

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a ba

se fo

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abet

es at

all

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port

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with

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ase

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lace

XX

XM

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24

Col

lect

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iliza

tion

of

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etes

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a st

reng

then

ed

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ngth

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llect

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XX

XM

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lope

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tion

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DS

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25

Bibliography

1. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta- analysis IDF, 2006. Diabetes Education Training Manual for Sub Saharan Africa.

2. World Health Organisation, Definition, Diagnosis and Classification of ’Diabetes Mellitus and its Complications. Report of a WHO Con-sultation. Pail 1: Diagnosis and Classification of Diabetes Mellitus. Geneva: WHO Department of Noncomnranicable Disease Surveil-lance, 1999; 1-59.

3. World Health Organization. Screening for Type 2 Diabetes. Report of a World Health Organization and International Diabetes Federa-tion meeting. WHO/NMH/MNC/03.1 Geneva: WHO Department of Non-communicable Disease Management, 2003

4. IDF, 2006. Diabetes Education Training Manual for Sub Saharan Africa. International Diabetes Federation Africa Region.

5. IDF, 2006. Diabetes Strategy for Sub Saharan Africa. International Diabetes Federation Africa Region.

6. IDF 2007. Diabetes Atlas 3rd Edition. International Diabetes Federa-tion.

7. DCPP, 2006. Disease Control and Prevention Project8. WDF 2007. The First African Diabetes Summit Report. World Dia-

betes Foundation, Copenhagen, Denmark.9. IDF Atlas, 2009. Diabetes Atlas 4th Edition. International Diabetes

Federation.10. WHO 2002. The World Health Report 2002: Reducing Risks, pro-

moting healthy life. World Health organization, Geneva.


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