148 Chapter 6 Due to the pandemic, more people globally have become poorer. 9 TB already being a disease associated with poverty means more TB patients are disadvantaged. In addition to the increased poverty level, measures aimed at controlling the pandemic hindered patients from accessing care and basic support including food and psychosocial services; and transport to health facilities by both patients and healthcare workers.18,25 Patients in Eswatini also encountered these different challenges and healthcare workers adopted different measures to continue providing services. While these measures – home-based care, patient support services and patient education may not be completely new, their adaptation within limited resources ensured patients remained in care. This is different compared with some high-income countries where patients could easily access healthcare through telemedicine consultations, virtual consultation and monitoring.31 4.2 Strength and Limitations Our qualitative study presents healthcare workers' perspectives on how COVID-19 impacted TB service delivery at the peak of the pandemic and the different steps they took to ensure continued service delivery in Eswatini. This will provide insight into the reduced performance in key TB outcomes in Eswatini and other LMICs and guide TB program implementers on measures that can increase access to TB services. Our study participants were drawn from health facilities across Eswatini so our findings are representative of how COVID-19 impacted TB services. As a limitation, our study does not present data to quantify the impact of the pandemic on key TB indicators. This would have provided a more objective view of the problem. Secondly, we interviewed only doctors and nurses. We did not include other healthcare workers such as community TB officers responsible for active TB case finding, TB treatment supporters, and laboratory and pharmacy technicians. These healthcare workers could have presented a more complete perspective of how the pandemic affected TB service delivery and patients. Finally, we did not interview TB program staff. They would have offered an additional explanation for observations by our participants. Conclusion The COVID-19 pandemic affected health systems globally, even in advanced economies. The different approaches that sustained services must be standardized so patients can continue receiving care. In the future, tailored and hybrid approaches to care should be developed where patients can access care either at the health facility or remotely with the freedom to visit a health facility if necessary. Due to limited infrastructure, approaches such as telemedicine for consultation may not be feasible immediately in most LMICs but telephone calls, SMS and home-based services can be used for medication dispensing, testing, follow up and psychosocial support. Finally, bidirectional screening and integration of care for different comorbidities can increase access to care.
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