Planning a Community Approach to Diabetes Care in Low- and Middle-Income Countries Using Optimization

Diabetes is a global health priority, especially in low- and-middle-income countries, where over 50% of premature deaths are attributed to high blood glucose. Several studies have demonstrated the feasibility of using Community Health Worker (CHW) programs to provide affordable and culturally tailored solutions for early detection and management of diabetes. Yet, scalable models to design and implement CHW programs while accounting for screening, management, and patient enrollment decisions have not been proposed. We introduce an optimization framework to determine personalized CHW visits that maximize glycemic control at a community-level. Our framework explicitly models the trade-off between screening new patients and providing management visits to individuals who are already enrolled in treatment. We account for patients' motivational states, which affect their decisions to enroll or drop out of treatment and, therefore, the effectiveness of the intervention. We incorporate these decisions by modeling patients as utility-maximizing agents within a bi-level provider problem that we solve using approximate dynamic programming. By estimating patients' health and motivational states, our model builds visit plans that account for patients' tradeoffs when deciding to enroll in treatment, leading to reduced dropout rates and improved resource allocation. We apply our approach to generate CHW visit plans using operational data from a social enterprise serving low-income neighborhoods in urban areas of India. Through extensive simulation experiments, we find that our framework requires up to 73.4% less capacity than the best naive policy to achieve the same performance in terms of glycemic control. Our experiments also show that our solution algorithm can improve upon naive policies by up to 124.5% using the same CHW capacity.