Functional readiness as the linchpin of integrated tuberculosis and comorbidity care in Pakistan: a health-system and ethical imperative
Main Article Content
Abstract
In Pakistan, for the effective management of tuberculosis and its comorbidities, functional readiness at the point of service delivery, including the preparedness of health facilities in terms of infrastructure, human resources, screening and diagnostics, coordination mechanisms, and culturally sensitive service delivery, is of utmost importance. Despite having a nascent TB services infrastructure, Pakistan’s health system faces persistent challenges, such as inadequate diagnostic capacity at basic health units, logistical obstacles in patient referrals, workforce shortages, and sociocultural barriers that impede timely and effective TB comorbidity management. These challenges are exacerbated across all care levels, from primary to tertiary hospitals, and thus restrict the extent and effectiveness of integrated interventions. In this viewpoint, we discuss these barriers in detail and propose that comprehensive health system strengthening to enhance functional readiness and ultimately improve clinical outcomes for patients with TB with comorbid conditions.
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Funding data
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Higher Education Commision, Pakistan
Grant numbers 20-GCF-770/RGM/R&ID/HEC/2021
References
1. World Health Organization. Global Tuberculosis Report (2025). [Accessed on: April 10, 2026. Available from URL: https://www.who.int/teams/global-programme-on-tuberculosis-and-lung-health/tb-reports/global-tuberculosis-report-2025
2. Khalid N, Ahmad F, Qureshi FM. Association amid the comorbidity of diabetes mellitus in patients of active tuberculosis in Pakistan: a matched case control study. Pak J Med Sci 2021;37(3):816-20. https://doi.org/10.12669/pjms.37.3.3274
3. Naz F, Ahmad N, Wahid A, Ahmad I, Khan A, Abubakar M, et al. High rate of successful treatment outcomes among childhood rifampicin/multidrug-resistant tuberculosis in Pakistan: a multicentre retrospective observational analysis. BMC Infect Dis 2021;21(1):1209. https://doi.org/10.1186/s12879-021-06935-6
4. Afaq S, Zala Z, Aleem S, Qazi FK, Jamal SF, Khan Z, et al. Implementation strategies for providing optimised tuberculosis and diabetes integrated care in LMICs (POTENTIAL): protocol for a multiphase sequential and concurrent mixed-methods study. BMJ Open. 2024;14(11):e093747. https://doi.org/10.1136/bmjopen-2024-093747
5. Khanum S, Basit A. Comparison of prevalence and severity of anxiety and depression among patients with bronchial asthma, chronic obstructive pulmonary disease, and tuberculosis. Pak J Chest Med 2025;31(1):3-9.
6. Husain MO, Dearman SP, Chaudhry IB, Rizvi N, Waheed W. The relationship between anxiety, depression and illness perception in tuberculosis patients in Pakistan. Clin Pract Epidemiol Ment Health 2008;4:4. https://doi.org/10.1186/1745-0179-4-4
7. Sulehri MA, Dogar IA, Sohail H, Mehdi Z, Azam M, Niaz O, et al. Prevalence of depression among tuberculosis patients. Ann Punjab Med Coll 2010;4(2):133-7. https://doi.org/10.29054/apmc/2010.546
8. Kakisingi CN, Mwelwa GC, Matanda SK, et al. Service availability and readiness of tuberculosis units’ clinics to manage diabetes mellitus in Lubumbashi, Democratic Republic of the Congo. BMC Health Serv Res 2025;25:233. https://doi.org/10.1186/s12913-025-12368-7
9. World Health Organization. Collaborative framework for care and control of tuberculosis and diabetes. World Health Organization; 2011. [Accessed on: April 10, 2026]. Available from URL: https://www.who.int/publications/i/item/9789241502252
10. Nyirenda, J.L.Z, Wagner, D, Ngwira, B. et al. Bidirectional screening and treatment outcomes of diabetes mellitus (DM) and Tuberculosis (TB) patients in hospitals with measures to integrate care of DM and TB and those without integration measures in Malawi. BMC Infect Dis 2002;22:28. https://doi.org/10.1186/s12879-021-07017-3
11. Nyirenda JLZ, Bockey A, Wagner D, Lange B. Effect of Tuberculosis (TB) and Diabetes mellitus (DM) integrated healthcare on bidirectional screening and treatment outcomes among TB patients and people living with DM in developing countries: a systematic review. Pathog Glob Health 2023;117(1):36-51. https://doi.org/10.1080/20477724.2022.2046967
12. Aleem S, Afaq S, Gill S, Ahmad B, Michael Z, Zarkaish R, et al. Implementation determinants of integrated tuberculosis and diabetes care in South Asian Association for Regional Cooperation (SAARC) countries: a systematic review. Int J Integr Care 2026;26(2):211-7. https://doi.org/10.5334/ijic.9882
13. Moxon SG, Guenther T, Gabrysch S, Enweronu-Laryea C, Ram PK, Niermeyer S, et al. Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now? J Glob Health 2018;8(1):010702. https://doi.org/10.7189/jogh.08.010702
14. Afaq S, Ayub A, Faisal MR, Nisar Z, Zala, Rehman AU, et al. Depression care integration in tuberculosis services: a feasibility assessment in Pakistan. Health Expect 2024;27(1):e13985. https://doi.org/10.1111/hex.13985
15. World Health Organization. Framework on integrated, people-centred health services. Geneva: WHO; 2016. [Accessed on: June 25, 2026]. Available from URL: https://apps.who.int/gb/ebwha/pdf_files/wha69/a69_39-en.pdf
16. Aleem S, Khan Z, Khan BA, Zala, Afaq S. Readiness assessment as a strategy, not an afterthought: leveraging implementation science to integrate tuberculosis comorbidity care in Pakistan's health system. Front Tuberc 2026;4:1809118. https://doi.org/10.3389/ftubr.2026.1809118
17. McQuaid CF, Vassall A, Cohen T, Fiekert K, White RG. The impact of COVID-19 on TB: a review of the data. Int J Tuberc Lung Dis. 2021;25(6):436-46. https://doi.org/10.5588/ijtld.21.0148
18. Kirubi B, Eman KU, Lodhi UR, Fatima RK, Kazi GN, Tahmeena T, et al. Enhancing tuberculosis case notifications through mapping sales of medicine in the private sector: a quasi-experimental study in Punjab province, Pakistan. BMC Health Serv Res 2025;25:53. https://doi.org/10.1186/s12913-024-12202-6
19. van den Boom M, Bennani K, Sismanidis C, Gunneberg C, Khawaja L, Safdar MA, et al. Pakistan Joint TB Program Review Mission. 2022 TB programme review in Pakistan: strengthening governance, with better patient diagnosis and treatment. Int J Tuberc Lung Dis Open 2024;1(3):136-43. https://doi.org/10.5588/ijtldopen.23.0587
20. Aleem S, Khan Z, Afaq S. Implementation determinants of integrated diabetes care in the Pakistan tuberculosis control program: a pragmatic mixed method study protocol. Discover Public Health 2026;23(1):128. https://doi.org/10.1186/s12982-026-01444-w
21. Nadeem M. Factors Influencing Access to Tuberculosis Diagnostic Services in Pakistan–An Analysis. 2023. [Accessed on: October 17, 2025]. Available from URL: https://bibalex.org/baifa/Attachment/Documents/i9FTUpxE1O_20231123114730482.pdf
22. Aleem S, Afaq S, Ahmad B, Zala, Latif Khan H, Khan Z. From silos to synergy: assessing tuberculosis basic management units readiness for integrated diabetes mellitus care across different districts of Pakistan. Prim Health Care Res Dev 2026;27:e47. https://doi.org/10.1017/S146342362610111X
23. Ahmed SM, Krishnan A, Karim O, Shafique K, Naher N, Srishti SA, et al. Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared? Lancet Glob Health 2024;12(10):e1706-e1719. https://doi.org/10.1016/S2214-109X(24)00118-9
24. Zaidi SMA, Creswell J, Khowaja S, Khan A, Copas A, Esmail H. Detection of pulmonary tuberculosis through mobile X-ray based active case-finding in Pakistan: a retrospective analysis from programmatic screening of1 214 289 individuals from 2017 to 2021. BMJ Glob Health 2025;10(7):e019133. https://doi.org/10.1136/bmjgh-2025-019133
25. Government of Pakistan. Ministry of Finance. Health and Nutrition. In: Pakistan Economic Survey 2025–26. [Accessed on: June 26, 2026]. Available from URL: https://www.finance.gov.pk/survey/chapter_26/11_Health_and_Nutrition.pdf
26. Dam TA, Forse RJ, Tran PMT, Vo LNQ, Codlin AJ, Nguyen LP, et al. What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications. Hum Resour Health 2022;20(1):25. https://doi.org/10.1186/s12960-022-00708-1
27. Salomon A, Law S, Johnson C, Baddeley A, Rangaraj A, Singh S, et al. Interventions to improve linkage along the HIV-tuberculosis care cascades in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2022;17(5):e0267511. https://doi.org/10.1371/journal.pone.0267511
28. Rahman M, Islam MJ, Adam IF, Duc NH, Sarkar P, Haque MN, et al. Assessing the readiness of health facilities to provide family planning services in low-resource settings: Insights from nationally representative service provision assessment surveys in 10 countries. PloS One 2023;18(11):e0290094. https://doi.org/10.1371/journal.pone.0290094
29. Nyirenda JL, Mbemba E, Chirwa M, Mbakaya B, Ngwira B, Wagner D, et al. Acceptability and feasibility of tuberculosis and diabetes mellitus bidirectional screening and joint treatment services in Malawi: a cross-sectional study and a policy document review. BMJ Open 2023;13(1):e062009. https://doi.org/10.1136/bmjopen-2022-062009
30. Aleem S, Khan S, Khan Z, Kibria Z, Sheikh S, Moult A, et al. Amplifying every echo; public partnerships in ongoing CONTROL (COgNitive Therapy for depRessiOn in tubercuLosis treatment) research study. Res Involv Engagem 2025;11(1):112. https://doi.org/10.1186/s40900-025-00787-z
31. Yang J, Xu J, Benn C, Yu X, Chen Y, Zhou S, et al. Evaluation of integration in WHO’s tuberculosis, HIV, and antimicrobial resistance policies through the social-ecological lens. Glob Health 2025;21(1):53. https://doi.org/10.1186/s12992-025-01150-3
32. Oh AL, Makmor-Bakry M, Islahudin F, Wong IC. Prevalence and predictive factors of tuberculosis treatment interruption in the Asia region: a systematic review and meta-analysis. BMJ Glob Health 2023;8(1):e010592. https://doi.org/10.1136/bmjgh-2022-010592
33. Habib SS, Jamal WZ, Zaidi SMA, Siddiqui JU, Khan HM, Creswell J, et al. Barriers to Access of Healthcare Services for Rural Women-Applying Gender Lens on TB in a Rural District of Sindh, Pakistan. Int J Environ Res Public Health 2021;18(19):10102. https://doi.org/10.3390/ijerph181910102
34. Fonseka N, Khan Z, Lewis M, Kibria Z, Ahmad F, Khan MF, et al. Cognitive therapy for depression in tuberculosis treatment: protocol for multicentre pragmatic parallel arm randomised control trial with an internal pilot. BMJ Open 2024;14(6):e083483. https://doi.org/10.1136/bmjopen-2023-083483