Background
Type 2 Diabetes (DM2) is increasing everywhere and foot ulcers and amputations are a major cause of morbidity and disability. The International Diabetes Federation estimates there are 1.33 million people with DM2 in Ethiopia and 2.66 million with prediabetes. Studies in urban Ethiopia report a prevalence of 6-6.5%. The Diabetes Center at Tikur Anbessa, the largest university hospital in Ethiopia, sees 800 to 1000 patients with diabetes a week. There are no trained podiatrists or wound care specialists in Ethiopia. The Toronto Addis Ababa Academic Collaboration (TAAAC) was created in 2008 as a unique multi-disciplinary educational initiative, partnering University of Toronto (UofT), Canada with Addis Ababa University (AAU).

Aims
To test whether a model for developing a diabetic foot care program used in Guyana, South America (1) would work in Addis Ababa. 

Methods
The steps are: assessing system barriers to implementation of best practices, training local key opinion leaders (KOLs) and establishing a center of excellence as a focus for local education and system change.
1.	Needs Assessment: An Endocrinologist visiting Addis Ababa through TAAAC found conditions similar to those existing prior to the implementation of the Guyanese diabetic foot care program: health professionals working in silos, no comprehensive assessment process for people with diabetic foot ulcers, inappropriate use of antibiotics/dressings, patients presenting late for treatment, no systematic screening for high risk feet and poor footwear. Foot ulcers with or without gangrene was the leading cause of admission to Tikur Anbessa, accounting for 39% of DM2 patients admitted in 2010-2013 (2). Patients admitted with diabetic foot problems have unacceptably high rates of amputation (47.2%) and in-hospital mortality (21%) (3). An audit of people with diabetes seen at the Diabetes Center showed only 4.5% had had a foot exam in the last 5 years, 15.5% had previous ulcer, and 35.5% had at least one risk factor for ulceration. 
2.	Key opinion leaders: Local leaders in Endocrinology and Orthopedics within the Department of Medicine, College of Health Sciences and AAU were eager to improve diabetic foot care. Medical and nursing staff was willing to be trained as KOLs to spearhead change.
3.	Space was available to establish a center of excellence in the Diabetes Center and there was a well-established training program for rehabilitation specialists. 


Results
Prevention: Screening was started in the diabetes clinic using the Simplified 60 second tool.
Interprofessional education initiatives and KOL team: Two endocrinologists and one nurse have been trained in wound care through the International Interprofessional Wound Care Course (IIWCC). Another endocrinology fellow and nurse started this year. In October 2016, a team from UofT consisting of an endocrinologist, wound care specialist and chiropodist visited the clinic for a week of teaching and practical training. During this week, there were 4 education sessions and 2 foot clinics attended by  orthopedic staff and residents, medical residents, nurses and orthopedic nurses - close to 120 attendees. 
Infrastructure: Three rooms in the Diabetes Center were renovated to function as a foot care clinic through funding from the Banting and Best Diabetes Centre (UofT), which also donated offloading supplies and OR equipment.
System Change: Access to rehabilitation services on site remains a challenge.

Discussion
While it is still early, changes have been made and enthusiasm is high. Future plans include further visits by Canadian and US foot care experts for hands-on training, and visits by KOLs to overseas centers of excellence to improve practical skills. We would also like to obtain funding to train community health workers to establish centers of excellence outside the capital.

References
1.	Lowe J, Sibbald RG, Taha NY, Lebovic G, Martin C, Bhoj I, et al. (2015) The Guyana Diabetes and Foot Care Project: A Complex Quality Improvement Intervention to Decrease Diabetes-Related Major Lower Extremity Amputations and Improve Diabetes Care in a Lower-Middle-Income Country. PLoS Med, 12(4): e1001814. 
2.	Gizaw, M., Harries, A. D., Ade, S., Tayler-Smith, K., Ali, E., Firdu, N., & Yifter, H. (2015). Diabetes mellitus in Addis Ababa, Ethiopia: admissions, complications and outcomes in a large referral hospital. Public Health Action, 5(1), 74–78. 
3.	Wondwossen A, Reja A, Amare A. (2011) Diabetic foot disease in Ethiopian patients: A hospital based study. Ethiop J Health Dev, 25(1):17-21.

International collaboration to develop an interprofessional diabetic foot center at Black Lion Hospital, Ethiopia