Project Type 2 Diabetes Care
A full-year program to improve type 2 diabetes (T2D) management for patients in Ecuador.
Impact at a Glance: Project Type 2 Diabetes Care
32 percentage point increase
in patients with T2D whose blood glucose was “in control” from a baseline of 20 percent in control (351 patients in total)
All five
core care processes improved during the program, without any additional resources
~95 percent
participation by 88 QI team members in bimonthly learning sessions
IHI's role:
- Teaching teams Quality Improvement (QI) methods and providing tools to measure and improve care for T2D through bimonthly video calls.
- Providing QI coaching to individual teams through bimonthly one-hour video meetings.
- Coordinating with the national Ministry of Health and local health authorities.
Dr. Maria Luisa Villa
Family physician, Lizarzaburu Health Center
Family physician, Lizarzaburu Health Center
The improvement methods and tools empowered us to see with our own eyes how our patients got better day by day.
Mrs. Blanca Quimi
Diabetic patient
Diabetic patient
We, as patients, feel an enormous difference when motivated to participate in our own treatment. This project has profoundly changed our roles and our lives.
Summary
Type 2 diabetes is the second-leading cause of mortality among adults in Ecuador, excluding accidents and violence. To address this, IHI’s team in Ecuador collaborated with FIGESS (a local NGO) and the Ministry of Health (MOH) to implement a year-long intervention to improve T2D management in the province of Chimborazo — a region in Ecuador’s highlands where approximately 32,500 adults have diabetes. The Improvement Science in Action (ISIA) design from IHI was adapted for this project, which was supported by a grant from the Ecuador office of the Inter-American Development Bank, IADB.
Background
In Ecuador’s province of Chimborazo — a region in the highlands that includes half a million inhabitants – 32,500 adults (~5 percent of the population) are expected to have diabetes. Insufficient care contributes to a high prevalence of diabetes complications, with up to half of diabetic patients in Latin America developing a complication. These can include chronic kidney disease, retinopathy (damage to the retina), and serious foot conditions such as ulcers or infections. These complications place a substantial financial burden on the public health system.
Ecuador, like many other Latin American countries, is in a phase of epidemiological transition, shifting from predominantly acute diseases in childhood, to chronic conditions in adulthood. Common chronic conditions include cardiovascular disease, diabetes, cancer, and others. Health systems, especially public ones, are often unable to modify their care models to accommodate this shift. The traditional model of care for acute diseases involves diagnosis, pharmacological or surgical treatment, and resolution. However, chronic diseases require a care model that includes continuous and prolonged patient follow-up, comprehensive treatment including lifestyle interventions, and active participation of the family and the community.
Despite the prevalence of diabetes in Ecuador, health care prevention and treatment are far from optimal.
Approach
To improve diabetes care and outcomes and address health system burden, IHI’s team in Ecuador collaborated with FIGESS (a local NGO) and the Ministry of Health (MOH) to implement a year-long intervention in the province of Chimborazo. The Improvement Science in Action (ISIA) design from IHI was adapted for this project, which was supported by a grant from the Ecuador office of the Inter-American Development Bank, IADB.
The quality improvement project had two aims, to be achieved from January to November 2025:
- Increase the percentage of all adults consulting for any reason screened for risk of T2D from 3 percent to 70 percent
- Increase the percentage of patients with T2D whose disease is “under control” – measured either with fasting blood glucose or glycated hemoglobin (HbA1C) – from 12 percent to 50 percent
Content Theory
Together with the local MOH officials and FIGESS professionals, a theory of change was developed based on understanding the shortcomings and difficulties of the current health care system in the province. The primary drivers identified included:
- improved screening for T2D risk and diagnosis processes for all adults consulting at the participating facilities;
- developing treatment plans, pharmacological and non-pharmacological, adapted to the individual needs of each patient with T2D;
- ensuring each T2D patient is given a follow-up appointment at each consultation;
- checking on and supporting attendance with reminder calls and home visits in case of absence;
- supporting patient, family, and community involvement in management of T2D.
The following figure represents the theory of change through a driver's diagram:
Execution Theory
Eleven QI teams from hospitals and ambulatory health centers were formed. The teams started by assessing quality of the main care processes for T2D: screening for risk factors in all adult patients; diagnosis through laboratory tests; establishing a treatment plan including pharmaceutical and non-pharmaceutical interventions; following up with patients and integrating families and communities into caring for patients. The baseline assessment showed very low levels of quality of care throughout all of these processes.
IHI’s role included teaching QI teams methods and providing tools to measure and improve care for T2D through bimonthly video calls. These calls had an impressive participation rate of approximately 95 percent of all team members throughout 2025. IHI also provided QI coaching to individual teams through bimonthly one-hour team video meetings. In some of these calls, clinical aspects of T2D management were also discussed. Each month, QI teams measured one outcome indicator, the percentage of T2D patients who achieved their blood glucose at control levels, as well as process indicators as percentages of patients who received improved care, following the main drivers.
Throughout 2025, QI teams tested change ideas aimed at improving the five primary drivers. Teams began testing change ideas on how best to increase screening all adult patients for risk of T2D and added change ideas for a new primary driver approximately every three months. At each bimonthly call, one or two QI teams presented to the rest of the teams their experience testing change ideas and run charts showing improvements achieved in process and outcome indicators. This practice fostered collective learning, enthusiasm and enrichment of change ideas.
Results
All five care processes improved throughout 2025, including percentage of patients with moderate or high risk of T2D undergoing lab tests, having a treatment plan, and most importantly, with glucose levels under control, as shown in the figures below.
Before this project, adult patients were not regularly screened for diabetes. The following figure shows the increase in the percentage of patients who through a screening, were found to have moderate or high risk of diabetes and then underwent a laboratory test for blood glucose.
The following figure shows the increase in the percentage of patients diagnosed with type 2 diabetes who were given an individualized treatment plan, with specific aims, both pharmacological and non/pharmacological.
The following graph depicts the increase in the percentage of patients being treated for type 2 diabetes, who were examined at a consultation in any month to detect possible signs of a complication.
The following graph shows the percentage of type 2 diabetes who, at a consultation in any month, were given a written follow-up appointment, specifying the date and time the patient should return. Previously, the patient was only advised verbally by the doctor to return for follow-up after a certain period of time, leaving the responsibility to obtain an appointment from the hospital totally on the patient. Obtaining an appointment in a public hospital may not be easy. With the change, these appointments were guaranteed for the diabetic patient, and programmed for a specific date and time.
These improved care processes impacted on achieving better clinical status of patients, as shown in the following run chart which shows, by the end of 2025, a 160 percent increase in the percentage of patients from a cohort comprised of all the newly diagnosed patients in the baseline period (October through December 2024) whose blood glucose was “in control,” measured through levels of fasting blood glucose or glycated hemoglobin in blood (HbA1c):
Furthermore, we conducted a correlation analysis between the levels of improvement in the main processes of care, and the improvement in the percentage of T2D patients whose blood glucose reached control levels. The following graph shows Pearson correlation coefficients indicating a clear positive correlation.
One important feature of this experience is that these achievements were attained without any additional resources. No additional personnel, equipment, or supplies were added to the regular operations of the participating facilities. The only addition throughout 2025 was training and coaching support to implement quality improvement methods.
Jorge Hermida C., M.D, is a Project Director at IHI.