تعليق
2.2.1 Assess the joint burden of TB and diabetes.
Current WHO guidance recommends surveillance of diabetes in people with TB in all settings and surveillance of TB among people living with diabetes in countries with a medium-to-high TB burden (21,42). Periodic surveys may be considered to identify TB disease among people with diabetes in countries with a lower burden of TB as part of TB elimination activities.
The two key methods for TB surveillance among people living with diabetes and for diabetes surveillance in people with TB are periodic (special) cross-sectional surveys among representative groups of people living with diabetes or with TB and data from routine TB or diabetes screening among people living with diabetes and TB, respectively.
Screening should be done according to national guidelines, although special surveys or operational research may involve use of other tools or technologies. Guidance on TB screening among people with diabetes is covered in chapter 3, while chapter 4 provides the guidance on diabetes screening among people with TB.
To assess the prevalence of diabetes and of risk factors for diabetes such as smoking, countries can conduct a national STEPwise approach to NCD risk factor surveillance (STEPS) surveys (43). Questions from STEPS surveys can also be included in TB prevalence surveys to assess the joint burden of TB and diabetes.
If national joint surveillance of TB and diabetes is not yet in place, WHO estimates of the number of TB episodes attributable to diabetes may be used, which are available in country profiles in the WHO Global Tuberculosis Report (1, https://worldhealthorg.shinyapps.io/tb_profiles/). A review of published studies in similar settings could also be used to estimate the burden of diabetes among people with TB.
Further guidance on the inclusion of diabetes and other comorbidities in TB surveillance and in prevalence surveys can be found in Consolidated guidance on tuberculosis data generation and use. Module 1: tuberculosis surveillance (42) and Module 3: national tuberculosis prevalence surveys (44).
2.2.2 Determine access to services and the financial burden for people with TB and diabetes.
To deliver human rights-based, people-centred services, it is crucial to understand the factors that affect access to services, including barriers experienced by subpopulations such as vulnerable populations and those at greatest risk or people residing in certain geographical locations. The following approaches may be considered:
- patient pathway analyses or other operational research to determine access to services for TB and diabetes;
- consultation with affected communities on the accessibility and user-friendliness of services;
- national TB patient cost surveys (45), national demographic and health surveys and health expenditure and utilization surveys; and
- assessment of the existence of and access to social protection schemes that cover some or all of the needs of people affected by TB and diabetes (46).
2.2.3 Map health service delivery for TB and diabetes.
Health services may be mapped to identify opportunities for increasing access to coordinated or integrated care for TB and diabetes delivered at the same time and place wherever feasible to reduce out-of-pocket expenses for individuals in need. Mapping should include the following elements:
- placement, performance, quality and safety of collaborative services for TB and diabetes at primary, secondary and tertiary care facilities, as well as in the private sector and in facilities supported by nongovernmental stakeholders;
- the availability, deployment, qualification, supervision, mentoring and training of the health workforce, including affiliated cadres such as community health workers, peer support workers and social workers;
- access to equipment, consumables and tools for TB and diabetes. If point-of-care diagnostics for TB or diabetes are not available, connection to the required laboratory or health facility and sample transportation networks should be considered, taking into account factors such as frequency of sample collection and speed of turnaround of results; and
- feasibility and acceptability of collaborative services for TB and diabetes for health-care workers and affected communities.
Data on the current capacity, performance and distribution of health and social protection services for people with TB and diabetes and other comorbidities may be collected from sources including TB programme reviews, health system reviews or readiness assessment mapping, such as the Harmonized Health Facility Assessment or the Interagency Social Protection Assessment Core Diagnostic Instrument for mapping and rapid assessment of existing social protection programmes (47–49). An audit or rapid situation analysis may also be conducted through document review, key informant interviews and focus group discussions to assess the feasibility, quality, performance and accessibility of services (50,51).
2.2.4 Identify gaps in services and conduct root cause analysis.
Data collected on epidemiology, access to services from the end-user perspective, the health system and service delivery, as described above, should be analysed to identify gaps and opportunities to improve access to services for TB and diabetes. Root cause analysis can help to understand the reasons for gaps in services and barriers to access and can identify enabling factors for observed successes and achievements (52). Further guidance on identifying gaps in services and conducting root cause analyses can be found in WHO’s Guidance for national strategic planning for tuberculosis (39).
