Diabetes and tuberculosis (TB) are a burdensome comorbidity for the patients who experience both diseases and for health systems struggling to get them under control. In 2013, over 1 million people globally were diagnosed with both TB and diabetes, which means 15 percent of all TB patients also had diabetes. Individuals with diabetes are three times as likely to develop TB compared to those who do not have diabetes, almost four times as likely to experience a relapse of their TB after being cured, and nearly twice as likely to die during TB treatment. On the other hand, developing TB can result in poor glycemic control for diabetes patients.
A decade ago, in recognition of the challenges posed by this comorbidity, the World Health Organization (WHO) and The International Union Against Tuberculosis and Lung Disease developed the “Collaborative framework for care and control of tuberculosis and diabetes.” This framework recommends integrated prevention and care for the two conditions. The WHO defines integrated health services delivery as “an approach to strengthen people-centred health systems through the promotion of the comprehensive delivery of quality services across the life-course, designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care.” While integration sounds good in principle, the practical reality of how patients receive health services remains fragmented, with integration the exception rather than the rule.
At RTI, we are investigating country experiences in integrating noncommunicable disease (NCD) services with care for other diseases in low- and middle-income countries (LMICs). We are seeing where integration has succeeded, where it has failed, and where it hasn’t yet been tried so that we can help guide countries seeking to achieve more effective results from their health programs.
The Need for Integration
Consider the hypothetical case of Mary. Mary has been recently diagnosed with TB. Prior to her TB diagnosis, she had also been experiencing symptoms that were suggestive of diabetes. Her doctor at the TB clinic refers her to another doctor at the medical clinic for further investigations. She comes back on another day to attend the clinic and they confirm that she has diabetes. She then begins treatment for TB in the TB treatment center and treatment for diabetes in the medical outpatient clinic - clinics that are in the same hospital but not co-located. She finds herself shuttled from one clinic to another and during her treatment she must juggle the pills she needs to take for both TB and diabetes and manage numerous visits to the hospital to see several doctors. In addition, she must regularly update the different healthcare staff at each clinic about her treatment for her comorbidity as there is no shared care record for the staff to get a more comprehensive picture.
Many patients diagnosed with TB and diabetes in LMICs have a similar story. What if instead, when Mary was diagnosed with TB, she was also screened for diabetes as a routine practice, since her health providers should know that diabetes causes worse TB outcomes? What if she could be attended to by a team of doctors, who work together using a shared medical record and care plan to provide both her TB and diabetes care? Such changes could save Mary the time and money she spends attending the different clinics, could strengthen her understanding of the two diseases and how they interact, and could streamline the process for obtaining her medications, reducing the risk of non-adherence. Moreover, these changes could ensure that each clinic could take account of Mary’s comorbidity and use this to adjust their own treatment and care approach as needed, helping all parties to achieve better health outcomes for Mary. For the health system, it could help to identify a large population of otherwise undiagnosed patients, increase efficiency, and save human resources costs.
Building the Evidence for Effective Integration of TB and Diabetes Care
Our team at RTI set out to understand the extent of TB and diabetes integration in LMICs and how health systems in these countries might better integrate these services. We conducted a systematic review of the literature that identified examples of integrated care from 15 LMICs. Most of these examples came from research studies conducted in middle-income countries, with only two low-income countries represented. Reasons for this observation are complex and highlight that low-income countries are less able to provide NCD services due to resource and knowledge gaps.
We found that most programs primarily focused on integration of disease screening at the patient level, which is simple to perform and less costly than integrating treatment services. Integration of care beyond screening would require more comprehensive changes at the facility or health system level, such as setting up a robust health information system, providing additional training to staff on delivering integrated care, and establishing integrated financing, all of which require a longer-term commitment and more resources. As a result, patients might have been screened for both diseases, but those identified as having both TB and diabetes continued to receive care from the respective programs separately. In addition, it was unclear if these screening initiatives were institutionalized and routinely provided as part of the package of care or were just in place for the duration of the research studies as pilots.
One of the promising programs we identified as part of our review was described by Salifu & Hlongwan 2020, who shared health workers’ perspectives on barriers and facilitators to TB-diabetes integration in Ghana. Following the introduction of the Collaborative Framework for Care and Control of Tuberculosis and Diabetes, Ghana began conducting bidirectional screening for TB and diabetes. The Ghana National Tuberculosis Control Program (NTP) institutionalized the role of a TB task shifting officer who conducts training and coordinates screening for TB in all settings, including in diabetes clinics. The supportive policy adopted by the Ghana NTP was critical for making this change. In addition, the dissemination of integration guidance, and training for the health workers were important facilitators to support integration.
However, TB screening among diabetes patients is conducted more consistently than diabetes screening among TB patients. This difference may be because the funding from the NTP accommodates TB screening among diabetes patients, but similar funding is not available from the diabetes programs. Some of the additional challenges include the fear and stigma that may be associated with a TB diagnosis, and suboptimal collaboration between the TB and diabetes units that contributed to frequent stockouts of needed screening supplies and equipment. While the example of Ghana’s NTP shows that integration is feasible, it also underscores the fact that integration requires the necessary resources and planning to be effective.
Finally, as part of our research to identify effective strategies for integration and to understand the challenges integrated programs face, RTI hosted a webinar on April 29 entitled “Tuberculosis and Diabetes: Why Integrated Care Matters.” The webinar brought together speakers from clinical, country and global perspectives to share learnings from their experience and highlight challenges that need addressing.
During the discussion, John Paul Dongo, Country Director for the International Union Against Tuberculosis and Lung Disease Uganda Office, cited a program that has conducted diabetes screening for TB patients in 10 clinics in Kampala. To make this possible, the program worked with stakeholders to develop guidelines and standard operating procedures for screening and referral; established capacity building, mentorship, and supportive supervision for health workers; and provided participating sites with the supplies needed for testing.
Over two years, more than 4,000 TB patients were screened and 88 were diagnosed with diabetes and referred for further care. The program demonstrated the feasibility of routine screening for diabetes among TB patients in a low-resource setting, an important starting point for integration of services. Applying these findings to implement bi-directional screening as a standard procedure within services, as well as developing options to integrate the follow-on care for patients with a comorbidity, is a challenge that countries need guidance and support to undertake.
Integration is a Key Ingredient for Resilient Health Systems
COVID-19 has heightened the urgency for health systems to provide more integrated detection and care for infectious and noncommunicable diseases and underscores the need to build resilient health systems that will serve countries for years to come. Effectively scaling up integrated services will require increased commitment from countries, stronger policy guidance, and resources to support the development of integrated programs. All three pieces go hand in hand, as country commitment must be guided by evidence-based action and accompanied by financial support.
Promising examples of integration, as detailed above, should be expanded upon and used as potential models for other settings. Funders that have traditionally focused on infectious diseases, such as the Global Fund and others, should scale up access to more flexible models of funding to encourage and enable integrated care. The global movement for Universal Health Coverage (UHC) is further advancing these conversations about how we re-envision our health systems. Now, while we are still dealing with and learning from COVID-19, is the time to get serious about integrated health care that includes NCDs.