# Exploring potential barriers and facilitators to integrate tuberculosis, diabetes mellitus, and tobacco control programmes in India

## TL;DR

This study explores challenges and opportunities for combining tuberculosis, diabetes, and tobacco control programs in India to better manage these co-occurring health issues.

## Contribution

The study identifies specific barriers and facilitators to integrating TB, DM, and TC programs in India using qualitative insights from health workers and stakeholders.

## Key findings

- Inadequate implementation and insufficient resources are major barriers to program integration.
- Well-designed programs with strong guidelines and infrastructure support integration efforts.
- Digital platforms and improved referral systems could help overcome integration challenges.

## Abstract

Co-integrating tuberculosis (TB), diabetes mellitus (DM), and tobacco control (TC) programmes in India could help address the triple burden of these diseases. However, limited information exists regarding the feasibility and determining factors of such integration. We explored potential barriers and facilitators to integrating TB, DM, and TC programmes in Ambegaon Block of Pune District, Maharashtra, and Ballabgarh Block of Faridabad District, Haryana, in India.

We conducted a qualitative study based on in-depth interviews with health workers, programme managers, and stakeholders involved in TB, DM, and TC programme implementation whom we enrolled using purposive and snowball sampling. The interview guide was based on World Health Organization's Health System Strengthening framework. We collected the data between November 2022 and March 2023 and analysed it through the rapid analysis method.

We interviewed 32 participants. The major challenge for integration, according to the participants’ perspectives, relates to the level of service delivery, which is primarily attributed to inadequate implementation of all the programmes. Themes that emerged as facilitators were well-designed programmes with robust guidelines and ample space for infrastructure, while those seen as barriers included inadequate referral systems, insufficient infrastructure, limited resources, a shortage of trained staff, and a lack of essential drugs and equipment, all of which impeded the uptake and coverage of services.

Our findings highlight the critical importance of addressing barriers and facilitators to implementing programmes in India for tackling the triple burden of TB, DM, and TC. A multidimensional approach and targeted strategies are needed for overcoming these challenges. Sensitising the health system staff, implementing feedback and referral systems, and developing cross-programme digital platforms will offer a roadmap for policymakers and healthcare system managers.