Beyond biomedical care: A focused ethnography of health system readiness for tuberculosis–depression comorbidity in Pakistan

Pakistan faces a substantial burden of tuberculosis (TB) and comorbid depression. Although the TB control programme has made progress, it lacks personalised care for patients with both conditions. Therefore, we aim to explore the health system's readiness and challenges in effectively addressing TB-depression comorbidity. We conducted a multi-site focused ethnography in TB centres in Peshawar and Haripur, Khyber Pakhtunkhwa, Pakistan, involving observations and semi-structured interviews (SSIs). We purposively selected 15 TB centres for observation. For 29 SSIs, we recruited seven TB healthcare providers, 12 patients, and 10 caregivers. An inductive-deductive thematic analysis was performed using the framework method. We identified factors within Pakistan's TB care framework that influence the system's capacity to address TB-depression comorbidity. We organised findings into four themes: the first focusing on accessibility, location, and infrastructure of TB centres; the second highlighting patients' fears, psychological distress, and their past and current experiences; the third examining the working environment of healthcare providers, their behaviour, and interactions with patients; and the final theme emphasising opportunities to address TB-depression comorbidity within the system. Integrating mental health services into Pakistan's TB care is crucial. Training providers, fostering patient engagement, and involving stakeholders can enhance support systems and help address TB-depression comorbidity.