131 5 Diabetes – Tuberculosis Care in Eswatini the different limitations they encountered may impact patient outcomes and hinder Eswatini from achieving the goal of ending the TB epidemic. Some opportunities and recommendations for improvement by the participants include the provision of a uniform guideline and documentation card for the management of TB patients with NCDs, patient support to address adherence and economic burden, additional human resources, training, and capacity building of healthcare workers on the management of TB patients with NCDs, increased access to and availability of TB and DM diagnostics, and improved supply chain management processes to limit the stock out of essential drugs and commodities. The participants also indicated some best practices they adopted to ensure efficient services. A 2021 study assessing the implementation of recommendations from WHO’s Collaborative Framework for Care and Control of Tuberculosis and Diabetes [14] indicates evidence is available from only 35 countries (out of 194 countries registered with WHO). The authors observed bidirectional screening for the two conditions is possible but that there was limited integration with a parallel care system for the two conditions, absence, and limited knowledge of guidelines for healthcare workers, limited knowledge of DM – TB care amongst healthcare workers, and more emphasis on screening than management. These findings are similar to our research findings, except that, in Eswatini, the services are integrated though the implementation is varied. An Ethiopian study to explore health system challenges and opportunities for integration of DM – TB care indicates healthcare workers had the motivation to provide integrated DM – TB services but encountered challenges with the continuity of care for DM – TB patients, limited knowledge, and skills in providing care, recurrent stock-outs of supplies for DM care, limited attention to DM, poor data management, and the inability of patients to pay for services [31]. Another study from India to explore stakeholder perspectives on challenges and opportunities for integrated DM – TB care indicates that integrated DM – TB care requires improvement in laboratory and diagnostics, drug management, human resources and training of healthcare workers, data infrastructure, and higherlevel coordination [32]. Findings from our study highlighted the need to also address these gaps. Patient factors reported in Ethiopia were also reported in studies conducted in Zimbabwe and Pakistan, where transportation costs or long distances to the health facility to access a test and the cost of the test hindered patients from visiting a health facility for a repeat test [33,34]. This is particularly important as TB is more prevalent in people of low socioeconomic status (SES) which has been shown to negatively impact
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