title: Addressing the double-burden of diabetes and tuberculosis: lessons from Kyrgyzstan.
abstract: The incidence of diabetes and tuberculosis co-morbidity is rising, yet little work has been done to understand potential implications for health systems, healthcare providers and individuals. Kyrgyzstan is a priority country for tuberculosis control and has a 5% prevalence of diabetes in adults, with many health system challenges for both conditions.
  
  
  
  Patient exit interviews collected data on demographic and socio-economic characteristics, health spending and care seeking for people with diabetes, tuberculosis and both diabetes and tuberculosis. Qualitative data were collected through semi-structured interviews with healthcare workers involved in diabetes and tuberculosis care, to understand delivery of care and how providers view effectiveness of care.
  
  
  
  The experience of co-affected individuals within the health system is different than those just with tuberculosis or diabetes. Co-affected patients do not receive more care and also have different care for their tuberculosis than people with only tuberculosis. Very high levels of catastrophic spending are found among all groups despite these two conditions being included in the Kyrgyz state benefit package especially for medicines.
  
  
  
  This study highlights that different patterns of service provision by disease group are found. Although Kyrgyzstan has often been cited as an example in terms of health reforms and developing Primary Health Care, this study highlights the challenge of managing conditions that are viewed as "too complicated" for non-specialists and the impact this has on costs and management of individuals.
authors.affiliation: UCL Institute for Global Health, London, UK. j.skordis-worrall@ucl.ac.uk.
authors.forename: Jolene
authors.identifier: 0000-0002-8633-0208
authors.initials: J
authors.lastname: Skordis-Worrall
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Jeff
authors.initials: J
authors.lastname: Round
authors.affiliation: Munich Center of Health Sciences, LMU München, Munich, Germany.|Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Oberschleißheim, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Arnold
authors.affiliation: Health Policy Analysis Centre, Bishkek, Kyrgyzstan.
authors.forename: Aida
authors.initials: A
authors.lastname: Abdraimova
authors.affiliation: Health Policy Analysis Centre, Bishkek, Kyrgyzstan.
authors.forename: Baktygul
authors.initials: B
authors.lastname: Akkazieva
authors.affiliation: Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Beran
mesh_terms: D015897:Comorbidity; D017281:Cost of Illness; D003920:Diabetes Mellitus / Q000191:economics / Q000453:epidemiology* / Q000628:therapy; D019538:Health Care Surveys; D005102:Health Expenditures / Q000706:statistics & numerical data; D006282:Health Personnel; D006801:Humans; D007707:Kyrgyzstan / Q000453:epidemiology; D015995:Prevalence; D014376:Tuberculosis / Q000191:economics / Q000453:epidemiology* / Q000628:therapy
keywords: Catastrophic spending; Co-morbidity; Diabetes; Health systems; Tuberculosis