From national policy to clinical practice: regional differences in the implementation of the national clinical protocol for type 2 diabetes mellitus in primary health care in the Republic of Tajikistan

Objective: To assess the degree of implementation of the national clinical protocol “Early diagnosis and management of patients with type 2 diabetes mellitus (T2DM) for family physicians”.

Material and methods: An observational multicenter cross-sectional study was conducted to assess the practical use of the national clinical protocol in primary health care facilities. The analysis was based on depersonalized medical records of patients with type 2 diabetes mellitus, a structured survey of primary health care workers, and aggregated data from the DHIS2 digital monitoring system. The study was conducted in 16 administrative districts across four regions of Tajikistan and covered a population of 3,436,952. Thirty diagnostic, therapeutic, and organizational indicators were used to assess protocol adherence. For clinical indicators, the primary unit of analysis was the outpatient medical record of a patient with T2DM; for organizational indicators, the unit of analysis was the primary health care (PHC) facility or district with subsequent regional summary. A separate medical record audit included 574 outpatient records of patients with T2DM: 102 from Sughd Region, 154 from Khatlon Region, 265 from the Districts of Republican Subordination, and 53 from GBAO.

Results are presented mainly as absolute numbers and percentages, considering differences in the volume of data across regions. Results: During the monitoring period, the registered number of patients with type 2 diabetes mellitus increased from 75,781 to 89,729, while registered prevalence increased from 735.7 to 879.8 per 100,000 population. This trend may reflect strengthened detection and registration at the primary health care level; however, the cross-sectional design does not allow causal inference regarding the effect of protocol implementation. Marked regional differences in adherence to protocol recommendations were identified. The highest level of compliance was observed in the Sughd Region (93.14%), a moderate level in the Khatlon Region (74.03%), whereas substantially lower rates were recorded in the Districts of Republican Subordination (18.49%) and the Gorno-Badakhshan Autonomous Region. In all regions, there is a low level of coverage of HbA1c testing, as well as insufficient anthropometric measurements and monitoring of complications.

Conclusion: Despite the formal adoption of the national clinical protocol for type 2 diabetes mellitus, its practical implementation in the primary health care system of Tajikistan remains heterogeneous and largely depends on regional organizational and resource-related factors. Improving the effectiveness of guideline implementation requires expanding access to essential diagnostic tests, strengthening systematic training of medical personnel, enhancing digital monitoring of health care quality, and addressing regional disparities in resource provision.

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