The National Department of Health (NDoH) supported the implementation of GREAT and saw that it was aligned with policy goals. They would like to see GREAT incorporated into the model of care for NCDs in each province, but recognised that provinces had autonomy over their own budgets and could not be forced to implement GREAT.

Provincial level managers in Northern Cape and KwaZulu-Natal espoused support for adopting GREAT, but this was not translated into sustained implementation. This may have been due to changing leadership, competing priorities and discouragement with the initial levels of implementation. In some cases, it appeared that managers had attempted to implement beyond the agreed remit. For example, in Johannesburg, we received feedback that the district had attempted to train many more facilitators without support from the GREAT team and had copied materials themselves. In Tshwane, implementation was conducted in collaboration with another university-based project that was trying to improve initiation of insulin. The GREAT team had assumed that such a collaboration would enhance implementation. In reality, the project lacked capacity to support implementation and actually hindered the facilities by retaining many of the educational resources within the university. Gauteng province indicated that they did not want to continue implementing GREAT.

In KwaZulu-Natal, we were told that managers attempted to implement in another district with the existing materials and untrained facilitators. This suggested that managers wanted to implement faster than the GREAT team was able to support, but then became discouraged when these initiatives were not sustained.

In the Metro Health Services of the Western Cape, two substructures adopted GREAT and incorporated implementation into their annual operational plans. This meant that implementation was monitored and reported on, throughout the year, and taken seriously by managers. Implementation at a single health centre in neighbouring Southern and Western Substructure (SWSS) initially struggled for support from the facility manager, as GREAT was not a priority in that substructure plan. They saw it as an individual project of the medical officer involved. High-level adoption of GREAT, formal inclusion in district goals and implementing at a feasible speed were key to successful implementation.

All five provinces indicated that they had a very high prevalence of people with diabetes in their facilities and that GREAT was a solution to their problem, specifically in addressing patients with diabetes who were uncontrolled, to reduce the number of complications and premature deaths.

In general the availability of funds for NCDs has been less than funds for infectious diseases, such as HIV and TB. Respondents recognised that the allocation of funds for resources, space and training to implement GREAT was minimal, when compared to the cost of frequent visits, medication, and complications of diabetes. Increasing austerity measures and health budget cuts made allocation of funds to support new initiatives difficult.

Nevertheless, NTSS committed finances to print the resource materials and signed a memorandum of understanding (MOU) with the university. This was a key factor in enabling implementation. Despite commitments from other provinces to do the same, the MOU was never signed, thus preventing further training and scale-up. Reasons for these included changes in provincial leadership and complex bureaucracy.

In some facilities, the issue of space was not an issue, as they had designated suitable areas for the GREAT sessions to take place. Facilities that could not accommodate the groups used public libraries or halls in close proximity to the facility. In the more rural areas, facilities had little to no space, and they made use of kitchens, parking lots, offices and even ablution facilities. In cases where space was an issue, one-on-one sessions were held, until they found a solution. Different services might compete for space and priority. For example, in one facility, GREAT was stopped because the SASSA (South African Social Security Agency) needed to deal with a backlog of applications and took over the space.

Staff in the facilities were overstretched to take care of the needs of the patients. Most facilities sent 2–3 people to train as facilitators, although not always appropriate people (see subsection on facilitators). The impression was that small rural facilities might struggle to accommodate GREAT when they had a very small workforce.

The facilities in all the provinces had enough resource materials to conduct the GREAT sessions and were therefore equipped to implement. Resource materials were provided to all the staff who attended the GREAT training (10 facilities per province). Further scale-up, however, depended on the Department of Health signing an MOU to print additional resources. Only the NTSS in the Western Cape was able to do this.

According to the NDoH, the health information system for NCDs is not functioning well. It does not give the department the basic information they need to monitor strategic goals, and therefore to include GREAT was not seen as feasible at present. Districts were asked to capture data on number of groups and patients reached. However, only KESS and NTSS appeared to have collected such data. In NTSS, an indicator was officially added to the substructure dashboard. In some facilities, the clinicians informally monitored and reported on changes in HbA1c (glycosylated haemoglobin) and blood pressure. Negotiating for inclusion of a formal indicator at district level, which would be monitored by the Director, should be included in the preparation of implementation.

Prior to the implementation of GREAT for diabetes, many managers and staff were sceptical on how this would impact their already busy workloads and whether the staff would have capacity to implement the programme. In NTSS, the management was motivated by their neighbouring substructure, who had already implemented and gave feedback on the positive benefits.

In some facilities and provinces, the management and staff supported the trained facilitators in their implementation, and staff had a renewed sense of energy, motivation and excitement. They saw GREAT as an opportunity to reduce their workload in the long term, as patients with improved diabetic control did not need to attend so often. In other provinces, where there was less management support and buy-in, facilitators were not motivated enough to implement GREAT and felt like it was adding to their workload.

Clear adoption by district or substructure management was important as well as practical support from the facility manager. Facilities varied in the perceived levels of support from district managers. In one province, although district level managers agreed to implement GREAT, this commitment did not percolate down to the facilities. Facility managers needed to understand the GREAT programme and be orientated towards it in order to offer support. They should have their own workshop or orientation session and attending some of the training could also help them to understand the programme.

Managers needed to monitor implementation on a regular basis and to identify gaps or challenges to implementation with a problem-solving approach. Several facilities temporarily stopped implementation over challenges, such as the space being used by another organisation or loss of trained facilitators. These roadblocks required a proactive problem-solving approach in the context of seeing GREAT as a priority. Otherwise, significant, but surmountable, roadblocks could quickly lead to abandonment of the initiative.

Implementation needed to be owned by the whole clinical team and not regarded as one person’s initiative or project. The initiative needed to become institutionalised and not regarded as just another pilot project. Managers needed to keep GREAT visible by discussing implementation regularly. Giving feedback on the benefits was also motivational, particularly when substantial improvements in HbA1c were documented. A combination of mechanisms, on the one hand, to hold people accountable for implementing plans while, on the other hand, giving feedback on the benefits worked well. Accountability was enhanced by including one’s role in implementing GREAT in individual performance agreements. Many respondents had already had this done. Sometimes performance was only indirectly appraised, for example, when the focus was on outcomes (e.g. improving glycaemic control or adherence) rather than actual activities (e.g. number of sessions facilitated).

In NTSS, they covered all 15 PHC facilities by running three training workshops with three people from each of the facilities. Training was provided in house by the Department of Health – three trainers were dieticians, and one was a diabetes educator from the tertiary hospital. All were released from their usual duties to assist with training. Substructures were reluctant to release staff to assist other substructures. There was a clear need to develop training capacity for the whole district through formal structures such as the People Development Centre (PDC). It was also clear that training of facilitators would be an ongoing need to sustain the initiative. The PDC, however, had their own priorities and preferred virtual online training courses. In some provinces, further training required commitment to print the resource materials and sign an MOU to enable this. This became a stumbling block to further training in these provinces as the university had no further funds to provide additional resource materials.

The style of the training programme alongside support from staff at the facility made the facilitators feel empowered, motivated and more knowledgeable to implement GREAT in their facilities. Nearly all the management, staff and facilitators across the facilities felt that they had good knowledge of diabetes, and the GREAT training had equipped staff with the necessary information. Where they felt they needed more expertise, they would learn from each other, or the clinicians would support them.

Implementation required different roles and contributions, from receptionists to draw the folders, facilitators (who could be health promotion officers, nurses, dieticians, etc.), enrolled nurses in the preparation areas, clinicians (nurse practitioners or medical officers) to identify patients and consult patients, and pharmacy staff (to fast-track medication). The team was empowered by the family physician and facility management. Sometimes it was useful to identify a clear champion. Ownership by the whole team was therefore vital to success. Most of the facilities felt that the staff had a positive attitude and belief towards patient education and counselling in general.

Respondents agreed that the programme should focus on people with diabetes who were uncontrolled or newly diagnosed. In some cases, patients with poor diabetic control were defined quite loosely as those ‘struggling’ or ‘not doing well’, while in other places they were defined by their HbA1c. In these instances, it was the very uncontrolled who were recruited, with HbA1c > 10% or even > 12%. Patients were selected by the clinicians and referred to the facilitator for a date to attend the first session. In one facility, the facilitator then had a pre-GREAT discussion with the patient. In one setting, they also included those with pre-diabetes. In one or two facilities, they also intended to allow staff to attend sessions. Not only could they personally benefit, but also they could share their new knowledge with patients.

The key principle was not to penalise people for attending GREAT by making their visit longer than others or longer than the ideal clinic norms and standards. Ideally, they should be rewarded or prioritised in some way. At the same time, the process should not adversely impact on other patients. One facility that ran sessions on the same day as usual attendance described their approach in detail in Figure 2. If this was an additional visit, then the consultation with the clinician would be omitted. One facility combined the visit to the clinician with the actual session itself.

Training of facilitators in NTSS appeared to go well with 2–3 people appropriately selected and trained from each facility. In other locations, although multiple people were trained from each facility, the number actually available to implement often dwindled quickly. For example, trained facilitators might leave the facility, be rotated to other duties (e.g. nurse practitioners), go on leave, not really be available due to their role (e.g. medical officers who must consult patients or dieticians who have several facilities to visit), have a limited focus of expertise (e.g. pharmacy assistant) or not be capable of facilitating well (e.g. retains very directive communication style). Some facilitators might also lack motivation or agency to implement.

This highlighted a number of lessons. Firstly, it was important to send the right people to the training course and, secondly, ongoing training of additional staff members will always be needed. Health promotion officers and nurse practitioners appeared to be well suited to facilitate the sessions. In one facility, the facilitator attempted to informally equip others to assist with facilitation. Patients appreciated continuity with the same facilitators when attending sessions. Where there were multiple facilitators and other staff members involved in implementation, it was important to meet regularly and plan when, where and who would be involved and to foster open communication.

Although the training recommended holding the sessions on the day of the usual appointment, many facilities required patients to make additional visits for the sessions. Extra visits placed an increased burden on patients in terms of travel costs and this could impact on attendance. Inclement weather and concerns about safety could also impact on attendance on any given day. Despite this, NTSS reported 80% – 90% attendance rates.

Group empowerment and training sessions were held during office hours and were not convenient for people working. Many of the employed patients were on a ‘no work no pay’ basis and without the benefit of sick leave. Nevertheless, facilities could issue employed people with a sick certificate for the day of attendance, which might help. Greater flexibility and innovation in terms of access for employed patients was needed.

One facility reported that they had to motivate patients to attend the first session, but after that they were self-motivated to attend. Some facilities tried to combine sessions into two visits to improve attendance, but others felt that this placed too much of a burden on patients to cope with the increased content. Numbers attending the groups could vary from 5 up to 25 people, but initial group size was typically around 15 people.

A number of stakeholders were important to the sustainability of implementation. Many facilities recognised the value of support from family medicine at Stellenbosch University and the people who trained the facilitators. Support included checking up on progress and helping to troubleshoot around any roadblocks. One facility saw that medical students could also assist with implementation during their rotations, for example, following up with patients. In KESS, they were successful at obtaining a grant from the Discovery Foundation to support the provision of resources, training and implementation. Some facilities saw the importance of informing the clinic health committees about the initiative as they could be supportive and might receive feedback from patients.

Some respondents saw the potential of engaging with other stakeholders. For example, community health workers could benefit from attending GREAT. This might benefit them personally if they had diabetes or risk factors, but could also empower them to reinforce GREAT in the community or share the key messages with those at risk of diabetes. This informal dissemination and reinforcement could occur in households, support groups or even wellness centres. One facility reflected on whether traditional healers might benefit from attending GREAT. In KESS, there was also collaboration with a project that was providing retinal screening.

Some facilities were already performing regular audit and feedback of the quality of care for diabetes. The effect of GREAT on quality of care outcomes (i.e. glycaemic and blood pressure control, body mass index) could easily be included in such audits. In other facilities, the clinicians were monitoring glycaemic and blood pressure control before and several months after attending GREAT and giving feedback to the team.

Only NTSS had managed to share clear data on reach for all facilities. This may be because more effort was put into selecting and monitoring an indicator with the substructure management team. In NTSS, 11 out of 15 facilities had implemented by the end of 2023 and had reached 41 groups with 252 patients. In KESS, which had implemented the previous year, feedback from three health centres suggested that they were running two groups per month with approximately 15 patients per group. They should therefore reach 300 patients per year per facility. Facilities initially implemented slowly to ensure the first groups worked, with the intention of increasing reach later. It appeared that in the Northern Cape, implementation was not successful. In Gauteng and KwaZulu-Natal, only a handful of facilities had managed to sustain implementation. No data on reach was available.

All respondents reported positive benefits to their patients. Group empowerment and training increased people’s knowledge and understanding of their condition and gave them insight into why their glucose went up or down. For many, this was new information despite having diabetes for more than a decade. Beyond knowledge, however, GREAT also had motivational and psychological benefits. Some patients were able to accept their diagnosis and shift their locus of control from a sense of fatalism or externalising responsibility to healthcare workers, to a sense of self-control and agency. Having greater health literacy with regard to their diabetes also enhanced the quality of interactions with clinicians.

Being part of a group was important for many. Group members were able to share relevant and context-appropriate solutions and lifestyle changes. Support continued outside the sessions, with interactions in the community or via WhatsApp groups. One patient recounted how her group helped her to cope via WhatsApp when she had hypoglycaemia in a taxi to the Eastern Cape.

Patients felt more satisfied with healthcare and more positive about their relationships with their healthcare workers. Healthcare workers felt more approachable and likely to be helpful. Clients were more motivated to utilise all the services available.

Patients also disseminated their knowledge and behaviour changes to family members and friends, and some made a special effort with those who were working and could not attend sessions. Some also spread the word that people with diabetes should attend the GREAT sessions.

Many respondents reported significant improvements in HbA1c, blood pressure and loss of weight. One facility documented substantial improvements in HbA1c among group members.

Respondents agreed that GREAT should be sustained as it was working for patients. A number of suggestions were made for future development: