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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) explore policy-makers’ perspectives on the impact of the COVID-19 pandemic on private sector TB service delivery in India, Indonesia and Nigeria and (2) identify cross-cutting insights for pandemic preparedness with respect to TB service delivery.Methods From May to November 2021, 33 interviews were conducted with key policy-makers 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 learnt for pandemic preparedness with respect to TB in each study context. Data were analysed thematically using a hybrid inductive-deductive approach, informed by Haldane et al’s Determinants of Health Systems Resilience Framework.Results Policy-makers 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.Conclusions Countries implemented varied measures to support TB service delivery during the COVID-19 pandemic. This study presents insights 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.

Only a third of tuberculosis (TB) cases in Nigeria in 2020 were diagnosed and notified, in part due to low detection and under-reporting from the private health sector. Using a standardised patient (SP) survey approach, we assessed how management of presumptive TB in the private sector aligns with national guidelines and whether this differed from a study conducted before the start of the COVID-19 pandemic. 13 SPs presented a presumptive TB case to 511 private providers in urban areas of Lagos and Kano states in May and June 2021. Private provider case management was compared with national guidelines divided into three main steps: SP questioned about cough duration; sputum collection attempted for TB testing; and non-prescription of anti-TB medications, antibiotics and steroids. SP visits conducted in May–June 2021 were directly compared to SP visits conducted in the same areas in June–July 2019. Overall, 28% of interactions (145 of 511, 95% CI 24.5% to 32.5%) were correctly managed according to Nigerian guidelines, as few providers completed all three necessary steps. Providers in 71% of visits asked about cough duration (362 of 511, 95% CI 66.7% to 74.7%), 35% tested or recommended a sputum test (181 of 511, 95% CI 31.3% to 39.8%) and 79% avoided prescribing or dispensing unnecessary medications (406 of 511, 95% CI 75.6% to 82.8%). COVID-19 related questions were asked in only 2.4% (12 of 511, 95% CI 1.3% to 4.2%) of visits. During the COVID-19 pandemic, few providers completed all steps of the national guidelines. Providers performed better on individual steps, particularly asking about symptoms and avoiding prescription of harmful medications. Comparing visits conducted before and during the COVID-19 pandemic showed that COVID-19 did not significantly change the quality of TB care.

Background Pre-COVID-19, individuals with tuberculosis (TB) in Nigeria were often underdiagnosed and untreated. TB services were mostly in the public sector with only 15% of new cases in 2019 reported from the private sector. Reports highlighted challenges in accessing care in the private sector, which accounted for 67% of all initial care-seeking. Our study examined patients’ health seeking pathways for TB in Nigeria’s private sector and explored any changes to care pathways during COVID-19.Methods We conducted 180 cross-sectional surveys and 20 in-depth interviews with individuals having chest symptoms attending 18 high-volume private clinics and hospitals in Kano and Lagos States. Questions focused on sociodemographic characteristics, health-seeking behaviour, and pathways to care during the COVID-19 pandemic. All surveys and interviews were conducted in May 2021.Results Most participants were male (111/180), with an average age of 37. Half (96/180) sought healthcare within a week of symptoms, while few (20/180) waited over 2 months. Individuals testing positive for TB had more health-seeking delays, and those testing negative for TB had more provider delays. On average, participants visited two providers in Kano and 1.69 in Lagos, with 61 of 180 in Kano and 48 of 180 in Lagos visiting other providers before the recruitment facility. Private providers were the initial encounters for most participants (60/180 in Kano, 83/180 in Lagos). Most respondents (164/180) experienced short-lived pandemic-related restrictions, affecting access to transportation, and closed facilities.Conclusions This study showed a few challenges in accessing TB care, necessitating continued investment in healthcare infrastructure and resources, particularly in the private sector. Understanding the different care pathways and delays in care provides opportunities for targeted interventions to improve deployment of services closer to where patients first seek care.