Integration of tuberculosis and diabetes mellitus care in health systems: a cross-sectional analysis of healthcare facilities in Lagos, Nigeria.

BACKGROUND

Despite WHO recommendations for integrated care since 2011, implementation of tuberculosis (TB) and diabetes mellitus (DM) care integration remains poorly documented in sub-Saharan Africa. We assessed integration and identified implementation barriers across healthcare facilities in Lagos, Nigeria.

METHODS

Cross-sectional survey of 100 facilities providing TB or diabetes services in Lagos State, January to June 2019, drawn by stratified random sampling from a frame of 237 facilities. Structured questionnaires based on WHO guidelines assessed integration measures, and twelve focus group discussions explored barriers. We used chi-square tests and multivariable logistic regression.

RESULTS

Among 100 facilities (response rate 67%), 8 (8.0%, 95% CI 4.0 to 15.1) had surveillance systems for diabetes screening in TB patients and 4 (4.0%, 95% CI 1.5 to 9.9) for TB screening in diabetes patients; formal screening guidelines were present in 12 (12.0%) and 7 (7.0%). Diagnostic capacity was largely available but unused: chest X-ray was present in 78% of facilities but systematically used in 42%. Staff trained in both conditions was the strongest facilitator (adjusted OR 6.2, 95% CI 2.9 to 13.4) and resource constraints the strongest barrier (adjusted OR for integration 0.20, 95% CI 0.11 to 0.36). Integrating facilities detected 2.4 more diabetes cases and 1.9 more TB cases per month, with higher TB treatment success (89.2% versus 83.4%, p=0.014) and diabetes control (48.7% versus 41.3%, p=0.029). The incremental cost-effectiveness ratio was US$1121 per quality-adjusted life-year in 2025 dollars.

CONCLUSIONS

In this 2019 pre-pandemic survey, TB and diabetes integration in Lagos was critically inadequate, with fewer than 15% of facilities implementing formal screening protocols. Substantial diagnostic capacity was present but underused, and joint staff training showed the strongest positive association with integration. These findings provide a structural baseline for post-pandemic reassessment and suggest that training should be accompanied by joint registers, supervision indicators and sustainable financing.