“How to live with both of these?” A study of challenges and opportunities for health and health care in tuberculosis/diabetes co-morbidity in three districts of Karnataka, India
Like many other low- and middle-income countries, India is fighting a double burden of communicable and non-communicable diseases, creating special challenges for the already overburdened health system. A deep professional and institutional divide persist between communicable and non-communicable diseases in public health professions in spite of evidence of associations between disease groups. Recent years have gathered strong evidence for an association between tuberculosis (TB) and diabetes (DM), with DM tripling the risk of active TB. Furthermore, during co-morbid presentations of TB/DM people are more seriously ill and run a higher risk of relapse, treatment failure, and fatal disease outcomes. As the aetiologies and management approaches of the two diseases appear to go in opposite directions, patients and health care providers (HCP) may encounter increasingly complex barriers for health and health care.
The objective of this study is to explore the challenges and opportunities of living with and managing TB/DM from the perspective of patients and health care providers. The aim is to shed light on challenges that may be less visible to programme implementers and policy makers, but may be very real to the actual users and providers of health care.
An ethnographic field study was conducted between May and July 2012 in Karnataka, India. 7 women and 21 men living with TB/DM, as well as 2 female and 8 male HCP were interviewed, using semi-structured, open-ended interview guides. Moreover, participant observations were conducted in private and government health facilities, as well as in the homes of interviewees.
The study demonstrates that the double burden of TB/DM manifests itself as more than double for people affected, and for the health system as a whole. TB and DM give rise to contradictory treatment advice and possibilities for care; and fragmented service delivery act as a major challenge for people living with TB/DM, as well as HCP. The many health care options in India are not expressed in equal realised access to care – particularly evident for DM care, which largely depends on availability, affordability and acceptability of services. Practices such as non-adherence and frequent change of health care provider may strike as irrational and dangerous to patients’ health. However, this study illustrates how these practices are in fact rational if considered as individual strategies to manoeuvre in the uncertainties created by a resource-poor setting within which TB and DM produce contradictory treatment advice and unequal opportunities for health and health care.
Based on these challenges, the study identifies and discusses three interlinked priority areas for addressing the TB/DM co-morbidity: i) service integration, ii) awareness-raising, and iii) research. The study concludes that, optimally, primary care – after appropriate training and supervision – should function as a single point of entry for diagnosis, treatment, and monitoring of TB/DM and other chronic diseases, and serve the role of gatekeeper for specialised treatment for complications. However, service integration may not be acceptable to all patients and HCP, and the acceptability of such an intervention should be assessed before implementation.