Background: Diabetes care delivery in rural Africa is difficult. Problems include lack of dedicated personnel, monitoring systems, laboratory support and drugs. Few structured intervention projects have been undertaken, none with long-term follow-up. Aim: To determine the long-term (4 years) glycaemic outcome of a structured nurse-led intervention programme for type 2 diabetic patients in rural Africa. Design: Single-centre, observational cohort study. Methods: The programme was delivered in the scattered primary health clinics of Hlabisa District, in northern Kwazulu Natal, South Africa. Monthly diabetic clinics were held at which empowermentbased education was delivered and regularly reinforced. Oral hypoglycaemic agents (OHAs) were titrated according to a previously validated clinical algorithm. Outcome was measured by glycated haemoglobin (HbA1c), as well as body mass index (BMI). Data were collected at baseline, and then 6, 18, 24 and 48 month's post-intervention. Results: Eighty patients had data available at all time collection points. They were of mean±SD, age 56±11 years, 70% were female, BMI 31.5± 7.2 kg/m2 and HbA1c 10.8±4.2%. HbA1c fell significantly to 8.1±2.2% at 6 months and 7.5±2.0% at 18 months. By 24 months, it had risen (8.4±2.3%), and at 4 years post-intervention it was 9.7±4.0% (still significantly lower than baseline, P = 0.015). BMI rose significantly at 6 and 18 months, but by 48 months was not significantly different from baseline. Conclusions: We conclude that the intervention led to marked HbA1c improvements up to 18 months follow-up, but thereafter there was 'glycaemic slippage'. This may be not only due to educational 'wear-off', noted in other educationintervention programmes, but also to the expected glycaemic deterioration with time known to occur in type 2 diabetes. Nevertheless, 4-year HbA1c levels were still significantly lower than at baseline. The programme was also well received by staff and patients, and we believe is an appropriate and effective diabetes intervention system in rural Africa.