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2.4.1 Jointly develop policies, guidelines and procedures for collaborative TB/DM activities.
To implement and scale up people-centred services for TB and diabetes, programmes should jointly develop policies, guidelines and tools for collaborative action and mainstream collaborative TB/DM activities within national guidelines and SOPs.
Job aids, tools and checklists can be developed for health workers on several aspects of collaborative services, such as screening, diagnosis and co-management of TB and diabetes, TB IPC, referral and counter-referral to specialist care, and linkage to counselling, peer support and social and nutritional care. Job aids can also be developed for the assessment and management of other common comorbidities and risk factors such as HIV, undernutrition, pulmonary disorders other than TB, mental health conditions, tobacco use and substance use disorders.
2.4.2 Mobilize a qualified multidisciplinary workforce, including private providers and non-health sectors, for collaborative action.
Adequately trained multidisciplinary teams should be mobilized and equipped to implement collaborative TB/DM activities. The workforce may include primary-care practitioners, community health workers or other health-care workers who may perform some of the tasks through taskshifting. It is important to also engage private and nongovernmental sector players and medical associations, as they can help to increase the coverage of collaborative activities while leveraging capacity and resources (62). WHO has developed guidance to facilitate the engagement of private sector providers in TB prevention and care (63).
Training should include the medical and public health aspects of TB and diabetes prevention and care as well as recording and reporting, including use of digital systems. Integrated delivery of collaborative TB/DM services should be incorporated into undergraduate and pre-registration training programmes for all relevant cadres and in continuous professional development to ensure that current workers update their skills and knowledge (64). Continued professional development of health-care workers through clinical mentoring, regular supportive supervision by trained mentors and supervisors and the availability of SOPs, job aids, reference materials and up-to-date national guidelines are important for improving service quality.
The use of digital apps can provide health-care workers with up-to-date information and support. For example, people with newly diagnosed diabetes in a TB clinic should undergo a cardiovascular risk assessment, or a decision should be made about a referral to a diabetes care provider. The WHOPEN Application is one such digital app that provides assistance in implementing essential NCD interventions in primary health care, offering guidelines and protocols that are adaptable to local settings and empower care providers. The use of mobile health digital platforms for capacity-building and mentoring by specialist diabetes services of staff in rural primary care services has been shown to increase access to diabetes care, and this might also be applicable to health-care workers who provide TB care (61).
2.4.3 Ensure access to essential medicines, vaccines, diagnostics and health technologies for TB and diabetes.
While TB programmes in low- and middle-income countries have usually received support for ensuring access to TB diagnostics and high-quality medicines from various international organizations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (65) and the Global Drug Facility (66), there has been significantly less access to diagnostics, equipment for self-monitoring of blood glucose and medicines for diabetes. This disparity creates considerable barriers to implementation of collaborative TB/DM activities and results in out-of-pocket costs for those in need (35). A first step towards ensuring access to TB and diabetes services is to advocate for related prevention measures, screening tools, diagnostic tests including point-of-care tests, medication and care for TB and diabetes within the national essential package of care under universal health coverage (67,68).
The WHO lists for essential medicines and for priority medical devices for management of cardiovascular diseases and diabetes include essential medicines for diabetes and for medical devices required for priority interventions to manage diabetes, aligned with WHO guidance, policies and evidence-based guidelines. These can be used to guide countries and programmes in determining their essential needs for the diagnosis and management of diabetes and to align their national lists accordingly (69–72). They can also be the basis for public-sector procurement and distribution and can influence practice in the private sector through education (69).
Quantification is critical for ensuring an uninterrupted supply of medicines and products. It comprises both forecasting and supply planning. Effective forecasting starts with the number of individuals currently being treated at a facility for a given condition, the current and anticipated burden of disease and existing stocks. Programmes should therefore collaborate in forecasting as this will need to be based on estimates of the number of people likely to attend health facilities that provide TB and diabetes care and estimates of the anticipated joint burden of TB and diabetes (69).
Responsibility for medicine and supply procurement, distribution and storage must be clearly assigned during joint planning and for funding proposals to avoid duplication or gaps in the supply chain. Facilities may have to be adapted to increase their storage capacity, and health care staff will have to be trained in supply chain management for the additional stock. Further guidance on strengthening access to essential medicines and products for NCDs can be found in the HEARTS Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology (69).
2.4.4 Engage civil society and communities affected by TB and diabetes in refining and delivering people-centred services.
Representatives of people affected by TB and diabetes or people living with diabetes who are exposed to TB, their families, communities and civil society should be actively engaged in decision-making, defining needs, prioritizing actions, designing and implementing interventions to address TB and diabetes, as well as in monitoring, evaluating and reviewing the impact of the interventions. They are also important partners in generating demand for integrated services, for addressing stigmatization, discrimination and other forms of social exclusion and in delivering health education, advocacy and peer support and self-care for affected people. Advocacy to influence policy and sustain political commitment, programme implementation and resource mobilization is also important to ensure that resources are available for implementation of collaborative TB/DM activities. Civil society organizations, including nongovernmental and community-based organizations, should advocate, promote and follow national TB and diabetes guidelines, including monitoring and evaluating TB/ DM activities. NTPs and NCD programmes should collaborate with communities and civil society in deciding on the indicators to be used in national surveillance, and communities should play an active role in identifying gaps, solving problems and advocating for change and improvement. Further guidance on engagement of civil society and communities can be found in WHO’s Guidance on engagement of communities and civil society to end tuberculosis and in the WHO framework for meaningful engagement of people living with noncommunicable diseases, and mental health and neurological conditions (41,73).
Trained community health workers can provide a range of integrated services, including for TB, NCDs and HIV (74–78). Integrated community care services are cost-effective (79,80), and community health workers should be remunerated according to their engagement, in line with local employment rules and regulations (81).
2.4.5 Facilitate access to social protection to prevent financial hardship due to TB and diabetes.
Although TB services are generally free of charge after a diagnosis has been established, services for diabetes are usually not free. In addition, there may be high costs related to accessing services for TB and diabetes, such as transport costs and income loss, particularly if services are not delivered at the same time and place (82,83). Access to social protection may help prevent financial hardship along the cascade of care for TB and diabetes and may also contribute to reducing the impact of social determinants on the TB and diabetes epidemics. Access to existing national social protection services should be optimized and people should be linked to those services where appropriate. WHO has published guidance to support countries in ensuring social protection for people with and affected by TB (46).
2.4.6 Facilitate uptake of digital technologies to deliver health and social protection services across programmes.
Digital technologies can be used to scale up collaborative TB/DM activities. The technologies may include telemedicine and video-supported treatment, computer-aided detection of TB-related abnormalities on chest radiography and digital data collection tools (84). Telemedicine may be used to support the co-management of diabetes for people in TB care in settings with limited human resources and coverage of care for NCDs (61,85,86). National programmes can collect data on the barriers to and performance of digital technologies to continuously improve interventions, ensure the people centredness of service delivery and to improve data capture.
2.4.7 Scale up people-centred services for TB and diabetes.
Informed by continuous monitoring, review and prioritization and evidence-based recommendations and national policies, services for TB and diabetes can be scaled up incrementally towards universal coverage. Services could initially be scaled up in selected geographical regions (or selected facilities within a region), with phased nationwide decentralization to community level. To gather “low-hanging fruit” and establish momentum for scaling-up, it may be useful to focus initially on settings with TB and diabetes services that are close together or on selected components of the cascade of TB/DM detection and care (e.g. screening people with TB for diabetes), which would require the least additional resources or changes to established practice. Furthermore, it is important to learn from and build on existing models of integrated care for addressing multimorbidity, such as in services for HIV-associated TB or in primary care facilities, by introducing services for several comorbidities and health-related risk factors, such as diabetes, smoking and alcohol use, mental health conditions, HIV and malnutrition. As part of scaling-up, monitoring and review should be ongoing to identify and address health system barriers and bottlenecks and to improve coverage and quality.
