Health and TB systems resilience and pandemic preparedness: Insights from a cross-country analysis of data from policymakers in India, Indonesia, and Nigeria

Introduction The COVID-19 pandemic was an unprecedented challenge to health systems worldwide and had a severe impact on tuberculosis (TB) case notifications and service delivery. India, Indonesia, and Nigeria are high TB-burden countries where the majority of initial care-seeking happens in the private health sector. The objectives of this study were to ([1][1]) explore policymakers’ perspectives on the impact of the COVID-19 pandemic on private sector TB service delivery in India, Indonesia, and Nigeria; and ([2][2]) identify cross-cutting lessons learned for pandemic preparedness with respect to TB service delivery. Methods From May – November 2021, thirty-three interviews were conducted with key policymakers involved in health service administration, TB service delivery, and/or the COVID-19 response in India, Indonesia, and Nigeria (n = 11 in each country). Interviews focused on the impact of COVID-19 on TB services and lessons learned for pandemic preparedness with respect to TB. Data were analyzed thematically using a hybrid inductive-deductive approach, informed by Haldane et al.’s (2021) Determinants of Health Systems Resilience Framework. Results Policymakers highlighted the crucial role of intersectoral collaboration, effective governance, innovative financing strategies, health workforce reallocation, and technological advancements such as virtual consultations and mHealth in strengthening TB service delivery amid the COVID-19 pandemic. India relied on patient-provider support agencies to implement a joint strategy for TB care across sectors and states. Indonesia engaged networks of private provider professional associations to facilitate coordination of the COVID-19 response. Nigeria implemented a pandemic policy for public-private referral for the continuity of TB care. Conclusion Countries implemented varied measures to support TB service delivery during the COVID-19 pandemic. This study presents lessons learned from three countries (India, Indonesia, and Nigeria) that together offer a ‘menu’ of possibilities for supporting pandemic preparedness with respect to TB care vis-à-vis strengthening health systems resilience. ### Competing Interest Statement MP serves as an advisor to WHO, Stop TB Partnership, Bill & Melinda Gates Foundation, and Foundation for Innovative New Diagnostics. He is supported by a Tier 1 Canada Research Chair in Epidemiology and Global Health and has no financial or industry conflicts. ### Funding Statement This study was funded by the Bill and Melinda Gates Foundation (Grant #: INV-022420). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was obtained from McGill University (Certificate #: COVID BMGF/ 2021-7197), Georgetown University (STUDY00003422), Universitas Padjadjaran (No.166/ UN6.KEP/EC/2021), HREC Lagos State University Teaching Hospital (LREC/06/10/1517), and HREC Kano State MoH (MOH/Off797/T.I/2168). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript. [1]: #ref-1 [2]: #ref-2