Political commitment, a robust primary health care network and civil society engagement were highlighted as critical enablers for patient-centred, integrated care for TB, non-communicable diseases (NCDs) and mental health, at The WHO Global Meeting to Accelerate Progress on SDG target 3.4 on NCDs and Mental Health in Oman, 9-12 December. During the session on Synergising Action to Address the Burden of Tuberculosis and NCDs in Vulnerable Populations, moderated by Annabel Baddeley of the Global TB Programme of WHO, representatives from Mexico, Oman, the Russian Federation and the United Republic of Tanzania described the challenges and practical examples, and enablers for ensuring integrated care for TB, NCDs and mental health.
Dr Seif Al Abri outlined the “One Health” approach taken in Oman where health services, including those for TB and conditions such as diabetes, high blood pressure and malnutrition are screened for, as part of a comprehensive package of care for both Omanis and migrants. Dr Al Abri stated that change in legislation had been a key factor to enhancing health seeking behaviour and reducing TB incidence in Oman. “Tuberculosis services are provided for free and anyone who has TB has the right to stay in the country – anyone in the country who has TB is investigated and treated for free of charge, regardless of who they are.”
Dr Vasilieva, stressed that almost 60% of TB patients in the Russian Federation have other comorbidities, so the services are delivered by multi-disciplinary teams of specialists to ensure that a person with TB and comorbidities receives the treatment they need. To ensure early detection, people who are most at risk, such as people with diabetes or COPDs and people with alcohol use disorder are screened regularly for TB. For patients with TB and substance use disorders, for whom treatment continuation can be challenging, outreach support to encourage adherence is being piloted in a number of regions. Dr Vasilyeva added that government action on decreasing alcohol and tobacco use has also had an impact on TB incidence. WHO estimates that 32% and 18% of TB cases are attributed to alcohol use disorder and tobacco use, respectively.
Session participants heard from Dr Ubaguyu how services have been developed to address the health needs of people who use drugs in the United Republic of Tanzania. According to studies much higher rates of HIV, of TB and multi-drug resistant TB were found in this population than among the general population. Through an evolved strategy combining community outreach workers, peer supporters as well as TB services provided within the methadone centre, there has been a considerable reduction in TB prevalence among clients. Challenges included the limited resources and infrastructure to meet the demand, as well as issues of sustainability, as the activity relies entirely on external funding.
Dr Ruiz Lopez highlighted how the growing trend of diabetes over recent years poses a major challenge to TB control in Mexico and that 30% of TB patients had been found to have diabetes. Dr Lopez outlined plans for stronger federal commitment to enable patient-centred care at PHC level and reduced out of pocket payments. He explained how Mexico has piloted the integration of diabetes services through community TB supporters, and how plans to recentralise the procurement of commodities for diabetes will ensure treatment for diabetes can be provided for free alongside free TB treatment. To ensure continuity of treatment in migrants, the government of Mexico has put in place strategies including the engagement of NGOs and civil society working on migration and mental health and patient records given to the migrants.
Conditions such as diabetes, malnutrition, tobacco use, and harmful use of drugs and alcohol are key drivers for tuberculosis incidence. Around 40% of TB patients suffer from mental illness. These comorbidities have bidirectional impact on one another – leading to poor treatment outcomes, development of multi-drug resistant TB and death. For these reasons TB, NCDs and mental illness cannot be addressed in silos. Whilst there may be competition for resources, it is critical that programmes work together to strengthen integration and multi-sectoral engagement and build a case for investment from respective Ministries of Finance to reduce the common determinants of the diseases and to build the necessary primary healthcare platform for quality assured, patient-centred service delivery.