TB and Diabetes Alliance – An Effort to Break It Through Integrated Care.

Tuberculosis (TB) and diabetes mellitus (DM) might seem like opposites - one infectious and the other a metabolic disorder - but together they form a deadly and an often overlooked alliance. People living with diabetes are up to three times more likely to develop active TB; conversely, TB roughly doubles the risk of subsequent diabetes. When these two conditions co-occur, treatment outcomes worsen dramatically, amplifying the  burden on individuals, families and the healthcare system. In Pakistan—ranked fifth highest in the world for TB incidence—the parallel rise in diabetes is particularly alarming. Although WHO recommends bidirectional screening and integrated care, in practice our health services still treat TB and diabetes in isolation, missing a crucial opportunity for early intervention. It was this gap in care that inspired our integrated-care approach.

Providing Optimised Tuberculosis and diabetes Integrated care in LMIC (POTENTIAL) study

POTENTIAL is a three phase, mixed-methods study that weaves diabetes prevention and management into standard TB treatment. 

In Phase I, we held co-design workshops with district health managers, clinicians, and community representatives to craft strategies that fit local realities—leveraging existing staff, infrastructure, and cultural norms. Phase II tested feasibility and acceptability across six pilot districts in Khyber Pakhtunkhwa and Punjab, training health workers, refining counseling manuals, and establishing clear referral pathways and screening protocols. Phase III rolled out the optimized package across 15 different TB care facilities in Pakistan.

Voices from the field

Fieldwork revealed surprisingly limited awareness of TB–diabetes co-morbidity and its broader health implications. For many community members, our program constituted their first exposure to the concept of integrated management—underscoring a critical knowledge gap and catalyzing informed discussion. In response, several facilities initiated pilot bidirectional screening during the feasibility phase. Both patients and providers responded positively and contributed valuable insights:

"Good initiative of integrated TB diabetes care package, we want to implement this program in all the districts of our country. It should be implemented in all the BMUs of the districts'' - (TB facility staff - Health care professional) 

"Yes it is very good now compared to other hospitals and we are having free tests, and doctors give us free consultation. Both tests are free here. Nobody charges us here, doctors give us their best advice, with their treatment now I am feeling better and my overall health is getting better day by day." - (Person living with TB and diabetes)

Our initiative demonstrated that healthcare workers not only support integration but are prepared to operationalize it. Engaging stakeholders and frontline personnel throughout the process has proven instrumental in fostering ownership and bolstering prospects for sustained integration.

Advocating for Integrated Care Model

Our pilot implementation across multiple districts demonstrates that embedding diabetes prevention and management into routine TB services enhances early identification and control of diabetes. A pivotal milestone for POTENTIAL was the guidelines-development workshop convened with the National and Provincial TB Control Programs—securing crucial policy alignment. Our long-term vision, in accordance with WHO recommendations, is to institutionalize TB–diabetes co-management within primary care across Pakistan’s high-burden regions, thereby strengthening the resilience and responsiveness of the national health system.