China is one of the countries with the fastest growing prevalence of diabetes in the world, and also has the largest number of people with diabetes. The "Health China 2030" plan clearly proposes to further prevent and control major diseases, implement diabetes prevention and control, and guide patients with diabetes to strengthen health management and delay or prevent the development of diabetes. In the past 20 years, value co-creation theory has been well developed in the field of health services, and different countries (regions) have explored programs to prevent and control diabetes at low cost and high effectiveness, but it is currently lacking in the field of chronic disease management in China. Based on the perspective of value co-creation, this paper further summarizes the domestic and international experience of chronic disease management taking community as the research and analysis point, proposes the prospect from four aspects of active health, organizational guidance, digital technology, and incentive assessment, which provides references for optimizing and improving the service system of diabetes management at primary health care, establishing a model of collaborative participation of multiple subjects in community chronic disease management based on value co-creation, and realizing co-creation, co-management and sharing of chronic disease management.

中国是全球糖尿病患病率增长较快的国家之一，也是糖尿病患者最多的国家。《"健康中国2030"规划纲要》明确提出，要进一步防控重大疾病，实施糖尿病防治行动，指导糖尿病患者加强健康管理，延迟或预防糖尿病发生、发展。近20年来，价值共创理论在健康服务领域应用发展较好，不同国家（地区）探索低成本、高效果的方案以预防和控制糖尿病发生，但目前在国内慢性病管理领域较为缺乏。本文基于价值共创视角，以基层社区为研究分析点，进一步总结国内外慢性病管理经验，从主动健康、组织引导、数字技术、激励考核4个方面提出展望，为优化完善基层糖尿病管理的服务体系，建立基于价值共创的多元主体协同参与社区慢性病管理模式，实现慢性病管理的共创、共治、共享提供参考。