The number of diabetes patients is increasing rapidly. There are currently 350 million diabetes patients in the world, and according to the World Health Organization (WHO), the number will double in the next 20 years. In 2012, it was estimated that diabetes directly caused 1.5 million deaths globally. To face this global health problem, in 2016, the WHO set the theme of the year’s World Health Day as “Beat Diabetes” to promote preventing or delaying diabetes with healthy lifestyles, especially in terms of maintaining a healthy weight, regular exercise, and a healthy diet. Those with diabetes need early diagnoses, appropriate control, effective management, and regular follow-ups to prevent complications and death. The Health Promotion Administration calculated the diabetes death rates in Taiwan’s counties and cities and designed a control score card for doctors, patients, and the public health system to help combat diabetes. 

Diabetes is the number five leading cause of death in Taiwan. On average, one person dies of diabetes every hour. 
According to the Health Promotion Administration, diabetes is the number five leading cause of death in Taiwan in 2014, claiming 9,845 lives, averaging 1.1 deaths every hour. Also, according to the Nutrition and Health Survey in Taiwan from 2013 to 2015, the rate of diabetes for people aged 18 or older was 11.8% (13.1% for males and 10.5% for females). There are around 2,275,267 diabetes patients in Taiwan, and an estimated 25,000 is being added to the number every year. Diabetes is a complex metabolic disease, which, without proper control, causes irreversible degeneration in blood vessels and nerves, leading to strokes, heart disease, kidney disease, retinal degeneration, foot gangrene, and other complications. Complications caused by diabetes have significantly affected people’s health and burdened the health care system. Health Promotion Administration Director Chiu, Shu-ti stated that Taiwan has implemented the Diabetes Shared Care Program to train and certify specialized medical teams that include doctors of different disciplines, nurses, nutritionists, and pharmacists to provide patients with comprehensive services to effectively control the disease. With the intervention of professional teams, patients can better manage their everyday lives. Meanwhile, 229 outstanding Diabetes Health Promotion Organizations have been selected and certified. The National Health Insurance Administration has also established the Diabetes Quality Payment Program (National Health Insurance Medical Care Quality Information Website). People are advised to choose medical facilities listed in these sources to receive better care including health education and case management. 

Implementing the Diabetes Shared Care Program for Better Diabetes Care 
The fight against diabetes cannot be carried out alone and requires multidisciplinary involvement. In 1996, the Department of Health conducted a trial run of the Diabetes Shared Care Program in Yilan County. This was Taiwan’s first implementation of a shared care program. With reviews showing effectiveness in improving disease control, the program expanded into regional diabetes shared care networks in 22 counties and cities. In 2003, the Health Promotion Administration implemented certification requirements for shared care medical personnel. In 2006, a number of diabetes Health Promotion Organizations was selected for diabetes patients to receive specialized care. Based on the Diabetes Shared Care Program, with payment incentives, the National Health Insurance Administration implemented the Diabetes Quality Payment Service Program, requiring doctors, nurses, nutritionists, and other medical professionals to pass the Diabetes Shared Care certification of local county or city authorities and offered payment for cases and follow-ups. When diabetes patients go to these medical facilities, the certified medical teams will take their cases, which will enter the Diabetes Quality Payment Service Program. Regular tests will be performed on glycated hemoglobin (HbA1c), fasting lipid profile, urine microalbumin, and eyegrounds. These tests will help monitor patients’ conditions and early complications to prevent, mitigate, and treat complications. After years of implementation, patients in the Diabetes Quality Payment Service Program have received better care than those outside the program. 

Analyzing the Distribution of Medical Resources and Minimizing Regional Gaps 
Although 22 counties and cities have implemented the Diabetes Shared Care Program, differences exist among the resources and the rates at which patients seek medical care in individual regions. The Health Promotion Administration has analyzed data from counties and cities and identified their difficulties to help minimize regional gaps. Based on data in 2014 from the National Health Insurance Administration Medical Care Quality Information Website, scores were given based on the examination rate of diabetes patients who received testing for HbA1c, fasting lipid profile, eyeground or fundus color photography, and urine microalbumin, as well as the rate of diabetes patients treated at medical facilities. The top five regions in diabetes care quality were, starting from the top, Changhua County, Chiayi City, Lienchiang County, Nantou County, and Chiayi County. The lowest-rated regions were Penghu County, Kinmen County, and Hsinchu City. In 2014, the regional case-receiving rates of diabetes patients at medical facilities showed a 54.3% gap between the highest and lowest regions - the highest being Yilan County (71.3%). Based on the Diabetes Shared Care Program and through medical facility evaluation, Yilan County is enhancing the analysis on the operations of all facilities and holding regular implementation committee meetings to provide resolutions and improvement strategies for practical difficulties, comprehensively enhancing the quality of care. The highest-rated Changhua County is using funding from the local Public Health Bureau to hire nutritionists to tour primary care clinics, providing professional health education to mitigate the lack of specialized personnel in remote areas. The Health Promotion Administration stated that counties and cities can learn from each other’s experiences, and it will continue to implement benchmark learning between counties and cities, using a two-pronged approach involving the medical and public health sectors to enhance the quality of care and provide better comprehensive service to all patients. 

The Golden Triangle for Diabetes Patients 
The government has been actively establishing and reinforcing the quality of the diabetes care system, while the Health Promotion Administration has implemented the quality payment service program to encourage patients to choose certified medical facilities for treatment of their diabetes. Medical facilities are also encouraged to be certified and apply for the quality payment service program to provide the best care to more patients. Director Chiu has stressed that the elements of the golden triangle - doctors, patients, and public health - must all be in place. 

1. Doctors: Choosing certified facilities and doctors 
There are currently 229 Diabetes Health Promotion Organizations certified by the Health Promotion Administration. More stringent standards are being placed on these facilities in terms of equipment, personnel distribution, quality of care, high-risk population health promotion, and support group operations. Patients can go to a Diabetes Health Promotion Organization to choose doctors certified in the Diabetes Shared Care Program to receive specialized care, support, and instructions from medical teams. (For lists of Diabetes Health Promotion Organizations and doctors, visit http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicBulletin.aspx?No=201311110001&parentid=200712250014) 

2. Patients: Smart lifestyles 
Keeping a healthy diet, regular exercise, and correct use of medication are the fundamental principles of self-care for patients. In addition, patients must monitor the three highs - blood pressure, blood sugar, and blood lipids. 

3. Public Health 
Formulating diabetes quality indicators based on empirical evidence, conducting certification, and continuing to monitor the effectiveness of diabetes control, the Health Promotion Organization has guided 22 counties and cities in the comprehensive implementation of the Diabetes Shared Cared Program. By coordinating public health agencies, clinical medical teams, and specialized organizations, we are continuing to improve diabetes prevention and treatment at the regional level.