تعليق
2.1.1 Strengthen political commitment, coordination and accountability for collaborative action on TB and diabetes.
TB programmes and NCD programmes, their counterparts in other line ministries, the private sector, communities and TB and diabetes civil society organizations should work together to provide access to integrated services, for the prevention, diagnosis, treatment and care of TB and diabetes. Coordination should be established at regional, district and local levels and be sensitive to countryspecific factors in order to ensure strong, effective collaboration between TB programmes and NCD programmes and to offer a platform for synergy among stakeholders within and beyond the health sector.
Few countries have established formal coordination between programmes for the prevention and care of diabetes and TB, although integration of clinical care for the two conditions may be in place at service delivery level. Evidence from the TB/HIV response shows that coordinating bodies are feasible and can help foster political commitment and ownership of collaborative activities at country level (36,37). Establishment of a coordinating body to address TB and comorbidities more broadly, including diabetes, can strengthen collaboration among existing programmes. Coordination may be achieved with existing resources, depending on the local situation, and may be a part of coordination mechanisms for TB and other relevant comorbidities, such as HIV. If such a coordinating body already exists, coordination of activities for the two diseases could be incorporated into its terms of reference. In countries where a national multisectoral mechanism for TB has already been established (e.g. as part of the Multisectoral accountability framework for TB (38)), the coordinating platform should have clear linkages with this mechanism to optimize synergies, particularly in crosscutting areas such as financing and social protection.
Stakeholder mapping is useful for identifying individuals or parties who are affected by, can influence or may have an interest in the programme activities. It should be conducted at all stages of strategic planning and implementation (39). Stakeholders to be considered as members of the coordination body beyond the programmes responsible for TB and NCDs may include those in the ministry of health responsible for primary health care, mental health, smoking and substance use disorders and social support services. Full participation in the coordinating body of people at risk of or with lived experience of TB and diabetes will provide insights into the pathway of care and understanding of barriers in health systems and solutions.
A national coordinating body for collaborative TB/DM activities should have clear, consensus-based terms of reference, including the roles and responsibilities of the national TB and NCD programmes and of other health programmes and relevant sectors in implementing, scaling up, monitoring and evaluating collaborative TB/DM activities at all levels. Important areas of responsibility are:
- coordinating collaborative TB/DM activities throughout the programme management cycle, from assessment, planning and resource mobilization to scaling up, monitoring and evaluation;
- liaison with and reporting to the multisectoral coordination mechanism for TB and equivalent coordinating platform for NCDs and any coordinating mechanism(s) that may exist on human rights, social protection and gender, among others;
- supporting the development of legal and policy documents, guidelines and protocols for comanagement of TB and diabetes;
- facilitating the involvement of representatives of communities and people affected by TB and diabetes, civil society and nongovernmental organizations in planning, implementing, monitoring, evaluating and conducting research on collaborative TB/DM activities; and
- ensuring alignment of advocacy and communication on TB and diabetes and other comorbidities.
2.1.2 Support financing and legislation to promote people-centred care.
Programmes should work together to support and advocate for financing and legislation for the delivery of integrated TB and diabetes care. This might include:
- scaling up financing models that incentivize the provision of comprehensive services as part of national health financing strategies;
- advocating for changes in legislation and financing to allow task-shifting and the engagement of peer supporters to deliver human rights-based people-centred care; and
- building capacity in civil society organizations to monitor and strengthen implementation of laws to address stigmatization and discrimination and other forms of social exclusion.
As legislation and financing are often outside the purview of TB and NCD programmes, it is essential to develop strong partnerships with stakeholders from outside the health system, including funding agencies, to advocate for and assist in addressing these areas. Further guidance and examples of legislation and financing for integrated care can be found in the WHO implementation guide Integrating the prevention and control of noncommunicable diseases in HIV/AIDS, tuberculosis, and sexual and reproductive health programmes (40).
2.1.3 Ensure meaningful engagement of civil society and affected communities at all stages of planning, implementation, monitoring and evaluation.
The involvement of civil society and affected communities is imperative in planning and developing new or improved services for people with TB and diabetes. Their involvement will also strengthen advocacy, ongoing evaluation and implementation of programmes and services. Engagement and support for civil society and affected communities are therefore critical.
In practice, such engagement requires financing for sustainable engagement, a supportive legal and policy environment for civil society to be involved in the response, and a national network (or coordinating platform, or equivalent) of affected communities and civil society engaged in ending TB or addressing diabetes (41). Members of the network may include people at risk of, or affected by, TB and diabetes, as well as community leaders (e.g. opinion and religious leaders), community-led and community-based organizations. While their scope of engagement may vary from advocacy and treatment literacy to community mobilization and demand creation for people-centred services, they should also be systematically engaged in planning, decision-making, monitoring and evaluation. In settings where there is limited civil society engagement on issues related to TB or diabetes, engagement and active participation of civil society and communities should be encouraged by strengthening or establishing mechanisms for engagement (e.g. a network or a coordinating body). Programmes and stakeholders should work together to empower affected people, communities and civil society to ensure that they are a continuum of the health system and can be actively, formally, regularly engaged in shaping the agenda on TB and diabetes. This includes governance, decisionmaking, planning, monitoring and evaluation, as well as advocacy for scaling up non-discriminatory, high-quality care for TB and diabetes and other comorbidities and for resources from domestic and external sources.
