Diabetes Policy Review - Report of the Expert Panel

Stakeholder Input and Research

What follows is a summary of stakeholder input and the relevant research findings, based on the Panel's Terms of Reference.

1. Priorities

1.1 Progress in Achieving the Priorities Identified in the Canadian Diabetes Strategy Developed by Stakeholders between 1999 and 2005:

The renewed Canadian Diabetes Strategy was designed to be the federal government's response to the priorities identified in the National Diabetes Strategy consultations by all stakeholders. However, both program documentation review and consultations with diabetes stakeholders revealed that there are a number of areas where recommended actions identified through the National Diabetes Strategy consultations have not been implemented by the federal government. Stakeholders pointed to a lack of clear understanding as to who is responsible for implementing recommended actions. While the Public Health Agency of Canada and the federal government are not the only actor that is responsible for implementing these actions, a vast majority of stakeholders consulted were of the view that the federal government could do more in supporting and facilitating action by other partners, including provincial/territorial governments and non-governmental organizations.

The Panel also heard that:

• Formal partnership with non-governmental organizations was severed by the disbanding of the Diabetes Council of Canada and the Coordinating Committee for National Diabetes Strategy in 2005.
• While diabetes prevention and management is a multi-faceted issue requiring action in a wide range of areas, existing programs/policies tend to be narrowly focused.
• The renewed Strategy is considered a strategy for type 2 diabetes, failing to address the long-term goal of finding a cure for type 1 and type 2 diabetes, identified through the National Diabetes Strategy consultations.
• Mixed views exist in relation to the federal government's role in supporting the implementation of the recommended actions in some of the strategic areas. The constitutional issue over the responsibility for health care is considered a source of frustration in efforts to implement the recommended actions.

The following represents stakeholders' analysis of the renewed Canadian Diabetes Strategy's progress in achieving the recommended actions identified through the National Diabetes Strategy consultations, as well as relevant research findings.

Strategic Area #1: Support the development of healthy public policy:

Through the Pan-Canadian Healthy Living Strategy, which was approved in October 2005, the federal and provincial/territorial governments (except for Quebec) agreed to healthy living targets, seeking to obtain, by 2015, a 20% increase in the proportion of Canadians who are physically active, eat healthy and are at healthy body weights.

One of the three pillars of the Healthy Living and Chronic Disease initiative is "promoting health by addressing the conditions that lead to unhealthy eating, physical inactivity and unhealthy weight". The initiative aims to "mobilize action and engage partners across jurisdictions, the health system and other sectors". Its objectives are to: "work through the determinants of health; target common risk factors for multiple disease and injury; and consolidate promotion and prevention efforts where people work, live, learn and play".⁴⁴ Promotion and prevention activities that have been implemented under the initiative include federal/provincial/territorial collaboration to undertaken health promotion to children and youth in schools. The initiative and the renewed Canadian Diabetes Strategy have also encouraged collaboration among stakeholders in all sectors (health and non-health) and at all levels.

However, stakeholder consultations and program documentation review indicated that:

• Many recommended actions relating to healthy public policy have not been addressed and barriers to healthy living continue to exist.
• There has been little coordination and collaboration with non-health sectors, with the exception of education, in the development and implementation of healthy public policies, under the Healthy Living and Chronic Disease initiative.
• Several policies/programs concerning physical activity and healthy eating exist at the federal level, both within and outside the Health portfolio. However, the extent of coordination and collaboration among these programs seems rather insufficient.
• There is an urgent need for "consolidating promotion and prevention efforts where people work, live, learn and play", which is one of the objectives of the Healthy Living and Chronic Disease initiative.

Strategic Area #2: Provide community-based health promotion and prevention programs:

To date, the focus of the Community-Based Programming component of the renewed Strategy has been on funding promotion and prevention projects supporting high-risk groups and the prevention of complications among those living with diabetes. The component has also supported community-based projects that are tailored to the particular needs of communities (e.g., cultural and ethnic diversity, demographics and other existing high-risk conditions).

Stakeholders noted that:

• Supporting community-based programs is instrumental to the promotion of healthy living and the prevention of type 2 diabetes at the grassroots level.
• Few linkages have been built among community-based programs that address diabetes and related health problems.
• There is a lack of accessible information about programs funded under the renewed Strategy and the Healthy Living and Chronic Disease initiative.
• Single-year funding that starts well into the fiscal year without the ability to be carried over into the next fiscal year presents a challenge to the continuity and long-term value of projects.
• There has been little progress in raising awareness of the connection between healthy living (physical activity and healthy eating) and chronic disease prevention.

Strategic Area #3: Provide accessible health services for the prevention of diabetes in high-risk individuals and optimal diabetes detection and management:

The Community-Based Programming component of the renewed Strategy funds community-based prevention and promotion projects. "Communities" can mean not only the public health and health care communities, but also communities of practitioners, researchers, planners or policy-makers.

The Knowledge Development and Exchange component is currently undertaking pilots of pre-diabetes and diabetes screening. To date, most of the work under the Knowledge Development and Exchange component has been on information gathering to support prevention in high-risk groups as well as early detection. It has funded or conducted: risk assessment studies to support prevention in high-risk groups and early detection; intervention studies to assess the effectiveness and/or feasibility of programs/policies for prevention, early detection and management; and more limited economic analysis (e.g., screening).

In addition, the Public Health Agency of Canada, through the Healthy Living and Chronic Disease initiative, is currently funding and supporting the re-establishment of the Canadian Task Force for Preventive Health Care (originally established in 1976 and discontinued in 2001), which, if re-established, is expected to develop evidence-based guidelines for preventive health care, including those related to diabetes.

Some of the recommended actions under this strategic area have not been fully addressed to date. These recommended actions include:

• Education of high-risk people in primary health care settings;
• Screening of high-risk people in primary health care settings;
• Maintaining clinical information systems and access to guidelines for their application in practices; and
• Innovative delivery models for remote and under-serviced areas.

Stakeholders noted that:

• There continues to be a lack of accessible health services both for prevention in high-risk individuals and for diabetes detection and management. The current health system works only for those with diabetes who can afford to pay to receive care.
• The accessibility of health services and medication/supplies for treating diabetes varies significantly between provinces/territories and between urban and rural areas.
• The constitutional/jurisdictional issue over the responsibility for health care is considered a major barrier to concerted efforts in providing accessible health services.
• There is strong support for a team-based approach to diabetes care/management. A recent report of the Health Council of Canada called for team-based treatment and prevention strategies for diabetes. Why Health Care Renewal Matters: Lessons from Diabetes (March 2007) maintains that a lack of access to interprofessional health care teams and of widespread use of electronic patient health records or electronic systems is "particularly troubling" for people with multiple health conditions, such as those with diabetes, "who need a wide range of service, from prevention to treatment to education to support for healthy living, if they are to prevent or delay avoidable complications".⁴⁵
• Providing comprehensive support to the self-management of diabetes is considered key in light of the growing pressures on the health care system.
• The lack of a federal agency/authority responsible for promoting the quality and efficiency of care has resulted in little research on alternative health care delivery models/approaches to help improve quality of life for people with diabetes.

Strategic Area #4: Develop human resource capacity and enhance the education of those who provide diabetes prevention and management programs and services:

A number of recommended actions identified in this strategic area through the National Diabetes Strategy consultations remain unfulfilled to date. These recommended actions may necessitate federal/provincial involvement:

• Provide relevant training opportunities for health, recreation and policy professionals in colleges and universities for work in collaborative prevention and care models;
• Provide a variety of continuing education opportunities;
• Educate primary care providers on diabetes prevention and screening;
• Provide incentives for service providers to work in under-serviced areas; and
• Educate policy makers on the resources required to enhance the current human resources capacity for diabetes.

Research, conducted across the country in 2007 under the Knowledge Development and Exchange component, revealed certain key gaps in physicians' awareness and knowledge about proven interventions, as well as about the relative effectiveness of different blood tests used for diabetes screening. Further work is expected in order to provide a complete assessment of current practice and knowledge of diabetes prevention in high-risk groups (e.g., pre-diabetes) and early detection of diabetes and pre-diabetes.

Stakeholders noted:

• The inadequate capacity of the health care system has been a key challenge to the implementation of standards of practice for diabetes management.
• Seeing a specialist requires a referral by a general practitioner; people with diabetes struggle to access their services.
• There is a lack of information about diabetes services and programs across the country.
• There is a lack of consistency in information and care provided to people with diabetes across the country.

Strategic Area #5: Conduct research and evaluation, and support knowledge exchange:

The Knowledge Development and Exchange is a new component added to the renewed Strategy in response to the need for greater knowledge development and exchange as identified through the National Diabetes Strategy consultations. It is designed to help identify, generate, collect, evaluate, translate and share the evidence about "what works" for diabetes to the Canadian public health system, and add economic evidence about cost-effectiveness to inform policy and program decision-making.

As noted earlier, the focus of the work under the Knowledge Development and Exchange component to date has been on research to support prevention in high-risk groups and early detection. It has also undertaken or funded a limited number of projects aimed at developing the capacity for information exchange in the area of diabetes. In addition, several integrated platforms for knowledge dissemination are currently being developed under the Healthy Living and Chronic Disease initiative.

However, work to support knowledge exchange in the area of diabetes has been very limited to date. Many of the recommended actions identified through the National Diabetes Strategy consultations have not been fully addressed. These include:

• Support the use of research results in policy, and clinical and community settings;
• Create a clearinghouse of effective policies, programs and resources; and
• Maintain a database of all diabetes-relevant research.

Stakeholders consulted stressed that:

• Knowledge dissemination and transfer is a major gap. A lack of coordination and information sharing at the national level has resulted in the duplication of work and lost opportunities for knowledge transfer and research collaboration.
• In addition to a knowledge dissemination mechanism, there is a need for the creation of a central body that coordinates/oversees diabetes-related research activities nationally.
• The federal commitment to diabetes research is inadequate. Little research has been undertaken beyond basic science studies.
• Evaluation is an area of weakness, despite the growing recognition of its importance to the transfer of best practices.

Strategic Area #6: Enhance surveillance:

The National Diabetes Surveillance System is considered to be the most effective component of the original Strategy. It is viewed as a successful model of federal/provincial/territorial cooperation. The use of a Memorandum of Understanding between the federal government and individual provincial/territorial governments has enabled data sharing across jurisdictions. The Public Health Agency of Canada, through the Healthy Living and Chronic Disease initiative, is currently working toward the creation of an integrated chronic disease surveillance system.

Stakeholders noted that:

• This National Diabetes Surveillance System has formed the foundation of chronic disease surveillance in Canada.
• Data collected through the National Diabetes Surveillance System is useful to inform provincial/territorial or community-level diabetes programs/services.
• The dissemination of data collected through the System at the national level is a major challenge. The full report on the National Diabetes Surveillance System including data up to fiscal year 2004-05, prepared in 2005, is still unavailable to the public.
• A vast amount of data is currently collected without being used.

Stakeholders also identified a number of limitations with the current National Diabetes Surveillance System, including but not limited to its inability to:

• Differentiate between type 1 and type 2 diabetes; and
• Collect data on ethnicity due to restrictions under human rights/privacy legislation.

Expansion and enhancement to the National Diabetes Surveillance System were expected under the renewed Strategy, including:

• The inclusion of regional data;
• The development of indicators and additional sources for community and population data;
• The development of a methodology for, and implementation of, linkages between the National Diabetes Surveillance System's information and other key data sources such as drug and laboratory data; and
• Helping to differentiate between types 1, 2 and gestational diabetes, impaired glucose tolerance and elevated fasting blood glucose⁴⁶.

Many of these expected activities, however, have not been implemented.

1.2 Value and Appropriateness of the Funding Invested in the Canadian Diabetes Strategy since 2005:

The Panel was constrained in its assessment by a lack of supporting information as well as the complexity of the structure of the Healthy Living and Chronic Disease initiative.

The delay in Parliamentary approval of the 2005-06 program budget forced the Public Health Agency of Canada to operate on a month-by-month cash management basis. Funding was available only through the Healthy Living and Chronic Disease initiative. The Agency was unable to provide the actual expenditure associated with diabetes-related activities in 2005-06; however, it was estimated to be significantly smaller than the annual allocation of $18 million to the renewed Strategy. As a result of the uncertainty of a minority government situation and the Government-wide operational constraints, many of the expected activities did not take place in this first year of the renewed Strategy's existence. A number of diabetes positions within the Agency were vacated without being re-staffed. Without new project funding, multi-year contribution agreements were terminated.

Furthermore, the fall of the government in November 2005 and the election process that followed delayed the 2006-07 funding cycle. While the renewed Strategy came into full-operation in fiscal year 2007-08, many of the diabetes-related positions that have been vacated were not staffed immediately and are being staffed now. The lack of human resource capacity has greatly constrained the level of activities undertaken under the renewed Strategy during the first three years of its implementation.

The planned allocations to the six components of the renewed Strategy for fiscal year 2007-08 were as follows:

• Leadership, Coordination and Strategic Policy Development: $1,210,692
• Community-Based Programming: $6,434,435
• Public Information: $284,298.
• Knowledge Development and Exchange: $3,585,653
• National Diabetes Surveillance System: $4,440,474
• Monitoring and Evaluation: $812,285.

Stakeholders noted that:

• The appropriateness of the investment in the renewed Strategy has to be assessed taking into account the investments under the Healthy Living and Chronic Disease initiative, other relevant federal programs and those by key partners, such as national non-governmental organizations.
• It is very difficult to estimate how much of the investment in primary prevention activities contributed toward the prevention of type 2 diabetes, given the integrated nature of this program under the Healthy Living and Chronic Disease initiative.

Stakeholders also noted that:

• The amount of money allocated to the Community-Based Programming and Public Information components is insufficient.
• More investment is needed for facilitating knowledge exchange under the renewed Strategy.
• Greater federal funding is needed for research beyond basic biomedical studies, to support clinical research, research related to health services and health systems as well as population health.
• There is a lack of a clear definition of "research" under the renewed Strategy, which has resulted in confusion between the role of the Strategy and those of other federal funding organizations in the area of diabetes research.

1.3 Priorities Necessary for an Effective Canadian Diabetes Strategy:

Stakeholders identified a number of areas where greater efforts are required through the renewed Strategy, including the following:

• Prevention of type 2 diabetes and early detection of pre-diabetes and diabetes:
  • The prevention of type 2 diabetes is an area where the Public Health Agency of Canada should focus its efforts, especially as provinces/territories have done little in this area.
  • The prevention of type 2 diabetes should be integrated with the prevention of other chronic diseases, particularly cardio-vascular disease.
  • There is a need to rethink the approach to primary prevention. General awareness of the connection between healthy living and chronic disease prevention remains low.
  • There is a real need to find more effective ways of communicating the importance of healthy living and societal conditions to support healthy living. These conditions would include:
    • Food and income security;
    • Healthy-built environments;
    • Early childhood learning and care;
    • Access to quality education and healthy school environments;
    • Healthy workplaces; and
    • Access to effective health care services.
  • The prevention of type 2 diabetes and the early detection of diabetes and pre-diabetes have been made a priority in a number of foreign jurisdictions. For example, Finland's Development Programme for the Prevention and Care of Diabetes 2000-2010 combines population based and high-risk prevention approaches including screening for undiagnosed diabetes and early treatment for the prevention of chronic complications especially cardiovascular disease.⁴⁷
  • There is a need for an economic analysis of the long-term costs and benefits of screening for diabetes and pre-diabetes using the oral glucose tolerance test.
  • There has been a delay in the implementation of the oral glucose tolerance test as a screening method for type 2 diabetes and pre-diabetes in Canada, primarily due to a lack of awareness, and the cost and time associated with the use of this method.
• Support to self-management:
  • Supporting self-management of diabetes is a key to diabetes management.
  • Self-management is a way of utilizing community resources.
  • A number of roles that the federal government can, and should, play in supporting self-management are:
    • Providing greater and more accessible information and educational resources;
    • Providing affordable drugs and medical supplies/devices (e.g., through national catastrophic drug coverage); and
    • Supporting better utilization of available non-health-professional resources (e.g., volunteers).
  • Supporting self-management of diabetes has also been made a priority in a number of foreign jurisdictions, including Finland, New Zealand, Sweden, the United Kingdom and the United States.
  • Establishing a central system/platform for information sharing on existing diabetes services/activities is critical to leveraging limited resources.
  • There is a need to nationally standardize the information used to support self-management.
• Research, evaluation and knowledge exchange:
  • There is a need for a national system/platform for knowledge dissemination and exchange.
  • There is a lack of access to information about existing diabetes initiatives, including health services, research projects and community-based programs. This has resulted in the duplication of work and lost opportunities for collaboration and learning from the experiences of the existing initiatives.
  • A number of other countries have established a web-based central database of diabetes research and related activities, which may provide a good model for the platform - for example, the United States National Diabetes Information Clearinghouse (http://diabetes.niddk.nih.gov/) is a web-based inventory supported by the National Institute of Diabetes and Digestive and Kidney Disease, the United States National Institute of Health.
  • Creating an ongoing forum to bring together diabetes researchers from across the country is critical to supporting knowledge transfer. Having a central system/inventory is not sufficient to ensure that the data reaches the hands of those who should use it, thereby facilitating knowledge transfer.
  • There is a need to strengthen evaluation capacity. Researchers and practitioners supported the creation of a centralized mechanism/system to facilitate the transfer of best practices.
  • The renewed Strategy should enter into partnership with other federal research funding agencies to support clinical research and research related to health services and health systems.
  • Federal support to diabetes research is inadequate, especially compared to other countries such as the United States and the United Kingdom.
• Enhancement of the surveillance:
  • There is a need to further enhance the National Diabetes Surveillance System to capture data that is useful in planning and coordinating diabetes programs/services.
  • Data currently collected through the National Diabetes Surveillance System is at a "minimum".
  • A number of additional data or indicators/variables to be added to the National Diabetes Surveillance System include:
    • Different types of diabetes (types 1, 2 and gestational);
    • Data on the complications and associated conditions of diabetes;
    • Ethnicity of people diagnosed with diabetes;
    • Behavioural data, such as healthy eating practices or physical activity estimates; and
    • A measure of diabetes-specific quality of life (e.g., similar to data collected through the US National Centre for Chronic Disease Prevention and Health Promotion's Behavioural Risk Factor Surveillance System)⁴⁸.
  • Supporting greater use of National Diabetes Surveillance System data is critical - "measuring" and "managing" are not the same thing.

1.4 Government Instruments that Could Be Used to Achieve the Outcomes Identified in the Canadian Diabetes Strategy:

Based on the findings from the document and literature review, international scan and stakeholder consultations, there are a number of instruments that can be considered to better support the achievement of the outcomes identified in the Canadian Diabetes Strategy:

• A framework with clearly defined and measurable short-, medium-, and long-term targets/goals:

  Stakeholder consultations and document review indicate that:

  • There is a lack of measurable targets or goals.
  • Outcome monitoring and evaluation under the renewed Strategy focuses primarily on the early progress made on the Strategy's short-term outcomes.
  • The logic model for the renewed Strategy (April 2007) identifies the ultimate results to which the Strategy is expected to contribute, which include:
    • Decreased risk factors and conditions among at-risk groups;
    • Earlier detection of chronic disease;
    • Better management of chronic disease;
    • Decreased proportion of Canadians who develop chronic disease;
    • Maintained and enhanced quality of life, fewer complications and premature deaths; and
    • Decreased personal, social, and economic burden of chronic disease for individuals and society.
  • No mechanism has been designed or developed for monitoring and reporting on the ultimate results of the renewed Strategy.
  • There are currently no national short-, medium-, or long-term targets for diabetes prevalence, incidence, risk factors, morbidity and mortality rates under the renewed Strategy.
  • Several countries have set clear, measurable targets as part of their diabetes strategies.
    • For example, the United Kingdom established two targets for the first three years of its plan, including a numerical goal.⁴⁹
    • Finland's diabetes programme also sets outcome goals for 2010 for each of the three strategies, including numerical targets.⁵⁰
• Greater partnership in implementing the Canadian Diabetes Strategy:

  Stakeholder consultations and document review indicate that:

  • There is currently little involvement of stakeholders, in particular non-governmental organizations.
  • Other public and private partners also have not been involved under the renewed Strategy.
  • There is a need for greater partnership with non-governmental organizations and private sector partners in delivering the renewed Strategy. For example:
    • Non-governmental organizations should play a greater role in delivering public information/education programs for the prevention of type 2 diabetes and healthy living promotion.
    • It is necessary to seek partnerships with, and/or funding from, partners in the private sector who have a "stake" in diabetes, such as pharmaceutical companies, insurance companies and the food industry.
    • There is a need for a framework for broad public-private partnership to help ensure accountability, rather than pursuing involvement of individual partners.
  • A number of countries, such as the United States and Finland, are increasingly seeking partnership with both non-governmental organizations and private sector partners in delivering their diabetes programs.
  • ParticipACTION is a good example of health-related organization that has succeeded in establishing public and private partnership in delivering its programs.
• Multi-departmental healthy living policy:

  Stakeholder consultations and document review indicate that:

  • At the federal level, there is only limited inter-departmental/agency collaboration and cooperation beyond the health portfolio in efforts to promote healthy living to reduce the burden of preventable chronic diseases.
  • There are a number of broad barriers to diabetes and other chronic disease prevention and management, including: the lack of access to affordable healthy food and an environment friendly to physical activity; and poverty.
  • At the provincial level, British Columbia and Quebec have recently introduced the population health approach, referred to as "whole-of-government approach", which involves all government sectors in a coherent effort.
  • Financial incentives, such as tax credits, may be used to promote healthy living. However, people without the financial resources require refundable tax credits in order to benefit from the government financial incentives.

2. Processes

2.1 Governance of the Program (i.e., What Structures and Processes are in Place to Ensure Transparency and Accountability) and Recommendations for Improvement:

Stakeholders noted that:

• Greater accountability and transparency is needed in relation to how the money is being spent under the renewed Strategy. There is little information about the renewed Strategy available to the public.
• Formal involvement of stakeholders has been minimal and ad-hoc under the renewed Strategy.
• The comprehensiveness and integration, so much a part of the original Strategy, is lacking in the renewed Strategy.
  • The coordinating committee provided for stakeholder involvement for a national diabetes policy no longer exists.
• The Public Health Agency of Canada's Website does not include updated information on the renewed Strategy.
• There is a very low level of awareness of and familiarity with the renewed Strategy and its activities except for the National Diabetes Surveillance System.
• There is a need to make the information about the activities undertaken under the renewed Strategy available to the public in order to show the achievements that have been made with the money invested.

One of the governance instruments was the Public Health Network, which was designed to address the issues around infectious and chronic diseases. The Public Health Agency of Canada hoped that it would increase the ability of the federal government to leverage greater engagement of the provinces/territories in working in partnership in a number of areas including diabetes. This federal/provincial/territorial process established the Chronic Disease and Injury Prevention Control Expert Group, mandated to provide strategic advice on diabetes, other chronic disease and injury prevention to the Public Health Network Council. Non-governmental organizations were excluded from this Expert Group.

However, government stakeholders identified a number of challenges with the new structure, including:

• Government staff mandated to attend the Chronic Disease and Injury Prevention Control Expert Group were often not departments/units dealing with diabetes.
• There is a disconnect with non-governmental organizations.
• There are communications disconnect and a lack of coordination within the provincial/territorial governments. Through the Public Health Network and the Expert Group, provincial/territorial governments were expected to bring their integrated input on chronic diseases, including diabetes, to the federal/provincial/territorial table as well as bring information back to their respective provinces/territories. However, this model has not worked well.
• There is a lack of a forum for discussion of diabetes issues. In general, agendas for the Expert Group are seen as covering only high-level issues in relation to diabetes. The Expert Group is not viewed as providing a direct link to the federal/provincial/territorial process on issues related to diabetes.

Stakeholders also noted:

• The complexity of the structure of the Healthy Living and Chronic Disease initiative has impeded the implementation and coordination of different components under the renewed Strategy.
• Coordination among different program components under the Healthy Living and Chronic Disease initiative and the renewed Strategy is complex and challenging.
• The structure of the Healthy Living and Chronic Disease initiative is confusing and convoluted.

In relation to the solicitation and approval processes for grants and contributions programs under the renewed Strategy, stakeholders noted:

• Inadequate communications around solicitations for proposals from the Public Health Agency of Canada.
• It is necessary to simplify and streamline the Public Health Agency of Canada's current funding process for diabetes-related programs.
• There is a need for greater openness and transparency in the approval process.
• Multi-year funding is required for supporting both the sustainability of programs and the efficient use of available resources.
• The lack of a clear understanding of activities under the renewed Strategy and the Healthy Living and Chronic Disease initiative has challenged their respective work.
• The dissemination of information on funded programs is necessary both to help the coordination of activities at the provincial/territorial level and to enable learnings from their outcomes.
• The current funding process for diabetes-related programs is a lengthy process with much duplication, which requires extensive work and coordination on the part of fund recipients.
• There are a number of challenges with the current funding process, in addition to the lack of communications, including:
  • Long wait times for a decision on funding.
  • A large number of funding programs/streams, each with different reporting and administrative requirements.
  • Disease specific funding within a chronic disease management framework.
  • The inability to carry the remaining money over into the next fiscal year.
  • The need for multi-year funding.
  • The importance of funding community-based projects with a goal of building their capacity for self-sustainability over time.

2.2 Model for Managing the Canadian Diabetes Strategy:

Stakeholders noted:

• The need for a formal governance/coordination body that allows all diabetes stakeholders to come together.
• There is support for creating a national body to provide a single point of contact for all diabetes stakeholders which could include federal/provincial/territorial governments, non-governmental organizations academics and researchers, and the private sector.
• There needs to be national coordination to maximize opportunities for collaboration and knowledge transfer.
• The new body should be an addition to, rather than replacing, the Public Health Network.

3. Performance

3.1 Identification of the Expected Outcomes:

Stakeholders noted:

• The logic model from the Healthy Living and Chronic Disease initiative was created in 2007 and applied retroactively to the logic model for the renewed Canadian Diabetes Strategy.
• No specific outcomes or results were identified. Only the process outcomes are being monitored and evaluated.

3.2 Progress Made on Achieving Outcomes:

Stakeholders noted:

• It is impossible to determine whether there have been any long-term positive or negative impacts on people living with or at the risk of diabetes to date.

3.3 Recommendations for Improving Program Outcomes:

Stakeholders identified ways of improving program outcomes, including:

• Reporting on the achievement of outcomes for greater transparency and accountability annually.
• Establishing a mechanism for regular stakeholder communications.
• Simplifying and streamlining the funding process for diabetes-related programs and provide multi-year funding.
• Supporting knowledge transfer from community-based programs through information dissemination and supporting the linkages among funded programs.

3.4 Recommendations to Maximize the Federal Government Investments for Improving Health Outcomes for Canadians Living with Diabetes

Stakeholders also recommended broader changes to the federal government's approach to the prevention and management of diabetes in Canada, including:

• Addressing primary prevention of type 2 diabetes and the management of diabetes and pre-diabetes separately.
• Supporting a separate strategy for diabetes management with a focus specific to the disease outside the Healthy Living and Chronic Disease initiative, while at the same creating synergy with other chronic disease management strategies.
• Supporting electronic health information systems to better address diabetes prevention and management.
• Coordinating clinical research, and increasing investments in health services and systems research.