Exploring the Implementation Potential of Integrating Diabetes Care Into Tuberculosis Services in Pakistan: A Qualitative Case Study

BACKGROUND: The co-occurrence of diabetes and tuberculosis (TB) worsens outcomes for both conditions, increasing mortality risk and treatment failure. Despite the need for integrated care for the two conditions, evidence on feasible and context-specific implementation strategies remains limited. This study explored the implementation potential of contextually designed implementation strategies to integrate diabetes within TB care in Pakistan, using the Optimised TB and Diabetes (Opt-TBD) package. METHODS: This qualitative case study was conducted from October 2023 to June 2024, across four TB facilities representing primary, secondary and tertiary levels of care in Pakistan. Using a qualitative design, we conducted in-depth interviews with TB patients with comorbid diabetes (n = 12) at 3 and 6 months after implementation, while healthcare providers (n = 6) were interviewed towards the end of the implementation period. We applied the Consolidated Framework for Implementation Research (CFIR) alongside Proctor's implementation outcomes framework to explore implementation processes and six implementation outcomes: acceptability, appropriateness, feasibility, adoption, penetration and sustainability. RESULTS: Several contextually tailored implementation strategies, including structured staff training, standardised screening protocols and strengthened referral mechanisms, were employed to integrate diabetes care within routine TB services. Overall, the intervention aligned well with existing TB workflows, provided that adequate resources, clearly defined referral pathways and ongoing staff training were ensured. Despite logistical challenges-such as delays in obtaining HbA1c test results and patient privacy concerns-healthcare providers reported adopting diabetes screening and counselling practices beyond the initial study participants. Strong leadership engagement and consistent programmatic support facilitated early implementation; however, sustaining these efforts long-term will require securing dedicated financial resources and formal integration into policy frameworks. CONCLUSION: This qualitative study indicates promising implementation potential for integrating the Opt-TBD care package within routine TB services in Pakistan. Participants generally perceived the package as acceptable and workable within routine TB services, while laboratory delays, referral challenges and dependence on external financing remained important barriers to wider implementation. These findings informed refinement of the Opt-TBD package and the subsequent broader RE-AIM evaluation. LIVED EXPERIENCE OR PUBLIC CONTRIBUTION: To develop a more inclusive and contextually relevant integrated TB-diabetes care pathway, we gathered input from both service providers and service users, including patients with TB-diabetes multimorbidity. The Opt-TBD care package was co-designed with relevant stakeholders, and this qualitative study was undertaken to capture the experiences and insights of patients and healthcare providers during implementation. Participation was sought across different genders, age groups, provinces and levels of care to ensure a broad range of perspectives. This approach helped ensure that the views of those directly affected by and involved in service delivery informed the refinement of the care package and its implementation strategies.