158 Chapter 7 To promote access to quality health services by patients at risk of DM–TB comorbidity, the World Health Organisation (WHO) advocates bidirectional screening and treatment for both conditions [27]. Through this approach, patients who present for either condition will receive screening for the other condition and treatment. To strengthen this, WHO has also provided guidelines for integrating NCD services in infectious disease programs (TB, HIV and STI) [28]. Integrating different services will limit parallel services in primary care settings, multiple clinic visits, long waiting times, and timely diagnosis and management of clinical conditions. While our study mainly assessed the level of integration of DM care at health facilities providing TB services, we note the operational status of health facilities may hinder the provision of DM-TB services in the same consultation room but allow for bidirectional screening and referral for treatment. This can be the case in a tertiary health facility with dedicated DM and TB clinics with separate staffing, unlike primary care clinics where one nursing staff provides care for all the patients. Existing health system gaps offer the opportunity to improve DM-TB care. Impact of COVID-19 on TB services Healthcare workers who were the first respondents during the COVID-19 pandemic were frequently infected and had to isolate, creating staff shortages with specific services either suspended or provided at half capacity to limit contacts while prioritizing patients with signs and symptoms of COVID-19 [29,30]. Restriction in movement and economic activities similarly impacted supplies of essential health commodities, including DM and TB drugs, test kits and reagents. Stringent measures adopted to limit the spread of the virus limited access to health services and worsened health outcomes across all patient groups. Admittedly, besides fewer patients accessing TB services, HIV, Malaria, noncommunicable diseases, and other specialized services also observed a drastic decline in the number of patients served [30]. Despite these limitations, healthcare workers adopted different approaches to ensure continued service delivery to meet patient’s needs. Not only peculiar to Sub-Saharan Africa, the COVID-19 pandemic disrupted healthcare services globally. To mitigate this, less-used innovations pre-pandemic, such as telemedicine, teleconsultation and virtual monitoring, became a standard for accessing health care [31]. In contrast, these technology-enabled services are not readily available in SubSaharan Africa. Contextualized approaches, including health outreaches, communitybased service points and home visits by healthcare workers, were used for HIV testing, screening for diabetes and hypertension, and medication refills.
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