Challenges and countermeasures of the “Xinjiang Model” in tuberculosis prevention and control: a qualitative study based on health specialists’ perspectives

Abstract

Background

Tuberculosis (TB) remains a significant public health threat, particularly in Xinjiang Uygur Autonomous Region of China, showing a high incidence. The “Xinjiang Model” is a TB service delivery system integrating universal chest X-ray screening, hospitalization for infectious patients, community-based follow-up for non-infectious cases, and nutritional support. Since 2018, Xinjiang has implemented the “Xinjiang model” for TB prevention and control to improve early screening and cure rates, but it continues to face challenges in long-term implementation.

Objective

This qualitative study aimed to explore the challenges encountered during the implementation of the “Xinjiang Model” and identify sustainability strategies to optimize and enhance TB prevention and control efforts.

Methods

Semi-structured interviews were conducted with 26 healthcare professionals from the Centers for Disease Control and Prevention across various Xinjiang prefectures, selected through purposive sampling. Data collection followed a tailored interview outline, and thematic analysis using Colaizzi’s method was applied.

Results

Six significant challenges were identified: workforce fragility and insufficient incentives for TB providers; physical and psychological vulnerabilities affecting patients’ treatment continuity; gaps in funding standards and policy alignment; limited public awareness and TB-related health literacy; capacity pressures affecting the quality and timeliness of universal health check-ups; and delays across referral pathways. Participants expressed confidence in the sustainability of the model and proposed strategies grouped into three domains: strengthening system inputs, including financial and policy support and provider compensation; improving patient-centered care, such as patient management, follow-up, and psychosocial or social support; and enhancing service delivery capacity by optimizing the TB workforce and improving the quality of universal health check-ups.

Conclusion

This study revealed key operational barriers to sustaining the “Xinjiang Model” and underscores the need for strengthened financing, workforce incentives, and patient-centered support within ongoing health system reforms. These findings are essential for maintaining TB control efforts in Xinjiang, serve as a reference for similar regions in China, and offer contextual insights for comparable low- and middle-income countries seeking to implement integrated TB control strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-28272-6.

Introduction

Tuberculosis (TB), as a chronic infectious disease that seriously threatens global public health, is still one of the main causes of adult infectious disease death so far [1, 2]. According to the World Health Organization Global Tuberculosis Report 2025, the estimated global TB incidence rate in 2024 was 131 per 100,000 population, and the TB mortality rate was approximately 13 per 100,000 population among HIV-negative individuals [3]. The global TB burden varies significantly across regions, particularly in marginalized and resource-poor areas, where TB incidence and mortality remain alarming [3].

Xinjiang Uygur Autonomous Region (Xinjiang), located in the northwest frontier region of China, has a TB incidence much higher than the national average [4, 5]. According to the China Health Statistics Yearbook 2024, the national pulmonary TB incidence rate in 2023 was 43.49 per 100,000 population, while the incidence rate in Xinjiang reached 92.12 per 100,000 population [6]. This substantial disparity not only poses a serious challenge to the health of local residents, but also draws considerable attention from local governments and public health departments [7].

Since 2018, the Xinjiang government has implemented the “Xinjiang Model” as a region-specific TB prevention and control strategy designed to reduce TB transmission and improve early detection and treatment completion. In this study, the “Xinjiang Model” refers to a multi-component service delivery and support system that includes [8]: population-wide active case-finding through the integration of chest X-ray screening into the national physical examination program; standardized referral, diagnosis, and treatment pathways, including hospitalization for infectious TB patients to control transmission; community-based management for non-infectious patients, featuring directly observed therapy alongside the “centralized medication + nutritional breakfast” support program; and a specific financing arrangement in which inpatient treatment costs are 90% reimbursed, with patients covering the remaining 10% out-of-pocket. These component strategies are designed to increase TB screening coverage, early detection, treatment initiation, adherence, and cure rates, thereby contributing to regional TB control.

Although the “Xinjiang Model” has achieved certain success in reducing the regional TB incidence rate [9], its long-term implementation faces complex challenges, particularly regarding financial sustainability, healthcare workforce capacity, and patient adherence within this structured framework. Therefore, systematic identification and analysis of the challenges faced in the implementation of the “Xinjiang Model” is of great practical significance for optimizing existing policies and formulating more targeted interventions.

Studies have analyzed various factors affecting the implementation of the “Xinjiang Model” through quantitative investigation, such as public knowledge of TB, adverse drug reactions and treatment costs [10]. However, quantitative studies often fail to cover all unrecognized factors and are thus limited in providing a comprehensive understanding of implementation realities. In contrast, qualitative research has a unique advantage in exploring specific phenomena in depth and interpreting quantitative results, providing complementary perspectives and in-depth analysis [11, 12].

Accordingly, this study aimed to explore the implementation challenges and sustainability strategies related to the “Xinjiang Model” from the perspectives of health specialists using qualitative methods. We sought to identify not only the barriers encountered during implementation, but also their underlying system-level causes and potential strategies for strengthening long-term TB prevention and control.

Materials and methods

Study design

This was an exploratory qualitative interview study, in which semi-structured interviews were conducted with implementers of the “Xinjiang Model” policy to explore problems in the implementation of the policy and suggestions for its sustainability. In this study, sustainability refers to the capacity of the model to maintain its core TB control functions over time, including stable workforce availability, adequate and predictable financing, timely screening and referral, continuous patient management, and sufficient service delivery capacity. The study followed a descriptive phenomenological approach and was designed and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist to ensure transparency, rigor, and completeness in qualitative reporting. The completed COREQ checklist is provided as Supplementary Material (Supplementary File 1).

The study was approved by the Ethics Committee of Xinjiang Medical University (Ethics Review No. XJYKDXR20230303016), and all interview participants provided written informed consent prior to data collection.

Interview participants

Interview participants were selected using purposive sampling [13], taking into account age, educational background, workplace, and time spent working in TB prevention and control. In October 2023, staff from the TB department of disease prevention and control centers across various prefectures in Xinjiang were selected as interview participants, with the requirement that they had at least one year of experience in TB prevention and control. These participants held roles focused on the coordination, management, and daily execution of the “Xinjiang Model” at the local level. Their primary responsibilities included organizing population-wide TB screening programs, managing the referral system for persons with presumptive TB, supervising community-based treatment and follow-up (including the “centralized medication + nutritional breakfast” initiative), conducting public health education, and monitoring program data. They did not have direct clinical care duties (e.g., diagnosis or inpatient treatment) but were integral to the public health implementation process.

The sample size for interviews was determined based on the principle of information saturation [14], defined as the point at which repeated information is observed during interviews and no new themes emerge from data analysis. A total of 26 participants were included in the study, with identifiers assigned from A1 to A26 to protect their privacy. Participant demographics are summarized in Table 1. Overall, most participants were female and held a bachelor’s degree, with a broad range in age and years of work experience in TB prevention and control. Detailed individual characteristics are provided in Supplementary Table S1.

Table 1.

Demographic characteristics of interview participants (n = 26)

Characteristic	Value
Age, mean ± SD (years)	43.0 ± 8.1
Gender, n (%)
Male	8 (30.8)
Female	18 (69.2)
Highest Education, n (%)
Bachelor’s degree	21 (80.8)
Junior college	5 (19.2)
Work experience in TB, mean ± SD (years)	10.5 ± 8.8

Data collection

Data collection was conducted using personal semi-structured in-depth interviews from October 13 to October 20, 2023. Based on the literature review and expert discussions with TB experts, a preliminary outline for the interviews was developed, covering problems in the implementation of the “Xinjiang Model” and suggestions for its continuation. Pre-interviews were conducted with two individuals (who were not included in the final sample) to refine the interview format and content and to confirm the final version of the semi-structured interview guide. The final interview guide, including the questions asked of participants, is presented in Table 2. Before the interviews, the purpose and significance of the study were explained to the participants, along with the necessity of audio recording, ensuring that all content would remain anonymized. Participants were informed that the interviewers were academic researchers without administrative authority, and the interview process was independent from clinical or managerial evaluation. There was no prior personal or hierarchical relationship between the researchers and participants, which helped reduce the risk of response bias.

Table 2.

Interview guide

Dimension of question	Question
Problems	What do you think are the problems with active patient detection measures in local TB prevention and control efforts? What do you think are the problems with patient referral measures in local TB prevention and control efforts? What do you think are the problems with patient diagnosis measures in local TB prevention and control efforts? In your opinion, what are the problems in the local tuberculosis prevention and control work regarding patient treatment measures (inpatient isolation treatment)? What do you think are the problems with patient management measures (centralized medication + nutritious breakfast) in the local TB prevention and control work?
Recommendations	Do you think that active patient detection measures can be sustained in the local TB prevention and control efforts, and what are your suggestions? Do you think that patient treatment measures (hospitalization) can be sustained in the local TB prevention and control work, and what are your suggestions? Do you think patient management measures (centralized medication + nutritious breakfast) can be sustained in the local TB prevention and control work, and what are your suggestions? What are your suggestions for patient referral measures? What do you suggest for patient diagnostic measures?

Interviews were conducted face-to-face in quiet, private environments such as conference rooms or offices to minimize disruptions and ensure confidentiality. Each interview was conducted collaboratively by two female researchers (YZ and JR), both public health doctoral candidates with formal qualitative training, with one asking questions based on the outline and the other responsible for audio recording and taking notes. Each interview lasted approximately 20–40 min. Repeat interviews were not conducted because single interviews were considered sufficient to reach data saturation and address the study objectives.

Data analysis

Within 24 h after each interview, the researchers transcribed and archived the recorded audio. Transcription was completed by YZ (PhD candidate) and XW (Master’s student). During transcription, the researchers first used speech-to-text software for initial text recognition, followed by thorough listening to the recordings for careful verification and revision of the content, ultimately saving the data as Word documents. Transcripts were not returned to participants for member checking, but to ensure accuracy, each transcript was verified by a researcher who did not conduct that specific interview. All transcripts were then imported into NVivo 11.0 software for data management and coding.

The qualitative data were analyzed using the Colaizzi seven-step method [15], which systematically organizes and synthesizes qualitative interview data to extract significant themes that assist the researchers in understanding the perspectives and experiences of the participants. Colaizzi was selected because it is widely used in descriptive phenomenological research and provides a rigorous, traceable analytical structure appropriate for exploratory implementation studies. As a qualitative phenomenological approach, Colaizzi analysis does not inherently generate quantitative measures or weighting of codes. Accordingly, the findings of this study were derived from thematic interpretation rather than numerical weighting.

The specific analysis process consists of seven steps, as illustrated in Fig. 1. Throughout this analysis process, two researchers independently conducted initial coding and theme development according to Colaizzi’s procedures. Coding results were then compared line-by-line to identify consistency and divergence in interpretation, with opposing or divergent views treated as valuable analytical material and synthesized in the same manner as other statements. To ensure depth and consistency of understanding, discrepancies were discussed with direct reference to the transcript text until consensus was reached. If agreement could not be achieved, the coding decision was reviewed and adjudicated by senior TB experts (SW or MC) to ensure credible alignment in interpretation.

Fig. 1.

The steps in the Colaizzi method

After the initial thematic analysis, the identified barriers and recommendations were further mapped onto the WHO health system building blocks framework [16], to support a structured systems-level interpretation of the findings. Based on this systems-based interpretation, a conceptual diagram was developed to illustrate how key system domains interact to influence the sustainability of the “Xinjiang Model”.

Results

Problems encountered during implementation

The problems in the implementation of the “Xinjiang Model” can be broadly categorized into six themes, as shown in Fig. 2.

Fig. 2.

Themes of problems encountered during implementation of the “Xinjiang model” (numbers in parentheses indicate the number of participants who mentioned each theme)

Structural workforce fragility undermining service delivery

Participants consistently described staffing-related challenges as a major factor influencing the delivery of the “Xinjiang Model” (Table 3). These challenges included gaps in professional knowledge and clinical experience, especially in the diagnosis of smear-negative cases. As one participant noted, “The diagnostic techniques still need to be improved… there are still instances of non-standard diagnoses or a lack of experience” (A6).

Table 3.

Sub-themes and illustrative quotes under structural workforce fragility undermining service delivery

Sub-theme, n (% of participants)	Quotes
Lack of professional knowledge, experience, and responsibility, 11 (42.3%)	“The diagnostic techniques still need to be improved, especially for patients with negative cultures. Supervision has revealed that there are still instances of non-standard diagnoses or a lack of experience” (A6). “The sense of responsibility among the medical staff at our treatment facility is still insufficient. They tend to prioritize their own workload over the feelings of the patients” (A12).
Insufficient staffing and high work pressure, 9 (34.6%)	“There are not enough medical personnel and grassroots epidemic prevention workers. In the office, there are just one or two dedicated epidemic prevention staff responsible for the entire communicable disease work, including HIV and TB” (A1).
Low compensation, 6 (23.1%); High staff turnover, 3 (11.5%)	“There is no performance-based compensation in the tuberculosis outpatient and infectious disease departments. Because designated hospitals receive 70% of salaries while 30% come from performance, their year-end bonuses are lower compared to other departments. Staff turnover is frequent, and the risk of TB transmission is high, which makes them unwilling to stay in this department” (A5).

Participants also described the effects of high workload and limited personnel, reporting that TB services were often provided by very small teams. One provider explained that “there are just one or two dedicated epidemic prevention staff responsible for the entire communicable disease work, including HIV and TB” (A1).

In addition, low compensation and perceived salary inequity contributed to frequent staff turnover, adding to the instability of TB service capacity. A participant shared, “staff turnover is frequent… which makes them unwilling to stay in this department” (A5). Overall, these findings suggest that workforce-related barriers were primarily implementation capacity constraints at the facility and local public health system levels, rather than inherent problems in the design of the “Xinjiang Model”.

Patient vulnerability shaping engagement and treatment continuity

Participants described patients’ physical and psychological vulnerabilities as major barriers to continuous TB care (Table 4). Providers reported that some individuals, particularly older patients or those with comorbidities, faced mobility challenges that made clinic-based treatment difficult. One participant explained that certain patients “are physically unable to adhere… requiring village doctors to deliver medication,” illustrating how health status influenced treatment feasibility (A1).

Table 4.

Sub-themes and illustrative quotes under patient vulnerability shaping engagement and treatment continuity

Sub-theme, n (% of participants)	Quotes
Health status, 10 (38.5%)	“Older patients with severe conditions may have complications; some patients are physically unable to adhere to treatment or manage medication, requiring village doctors to deliver medication, which is a significant workload” (A1).
Low treatment adherence and cooperation, 8 (30.8%)	“The treatment duration is too long, and patients are uncooperative. Some patients are unwilling to go to the village’s medication point due to laziness” (A22).
High psychological pressure, 8 (30.8%)	“The lengthy hospitalization can be psychologically difficult for patients. They feel that after undergoing tests and treatment, they just want to go home” (A9).

Psychological factors were also commonly noted. Participants described how long treatment courses and prolonged hospitalization could reduce patient motivation and cooperation. As one participant shared, “after undergoing tests and treatment, they just want to go home” (A9). Others observed that low treatment adherence was sometimes linked to limited engagement in follow-up or medication collection. For example, one provider noted that some patients were “unwilling to go to the village’s medication point” (A22).

Misaligned financial and policy structures weakening program sustainability

Participants described financial and policy-related challenges as key obstacles to program implementation (Table 5). Several highlighted insufficient funding standards for nutritional breakfast support, noting that rising food costs had exceeded the original allocation. Nutritional support is a core component of the “Xinjiang Model”; however, participants emphasized that the problem lay in the adequacy of implementation funding rather than in the inclusion of nutritional support itself. One interviewee commented that “public health funding of three yuan and fifty cents can’t meet the current cost of eggs, milk and bread” (A20).

Table 5.

Sub-themes and illustrative quotes under misaligned financial and policy structures weakening program sustainability

Sub-theme, n(% of participants)	Quotes
Low funding standards for nutritional breakfasts, 7 (26.9%)	“Due to rising prices, public health funding of three yuan and fifty cents, can’t meet the current cost of eggs, milk and bread” (A20).
Lack of support for inpatient lunch and dinner funding, 5 (19.2%)	“Hospitalization for two months during the dinner problem, the local government does not solve the problem, but also the hospital to bear, the hospital is under great pressure” (A5).
High economic burden of hospitalization for patients, 5 (19.2%)	“Patients are hospitalized for a minimum of two months, and if the medical cost is fifteen thousand, then the patient pays 10% out of pocket for at least fifteen thousand. If treated at home, they wouldn’t incur such costs” (A16).
Reimbursement issues for suspected case screenings, 3 (11.5%)	“There is currently no policy stating that screenings for suspected patients and close contacts are free. Each screening can cost at least four hundred yuan, which is unaffordable for a poor family.” (A3)
Lack of policy support for inpatient treatment, 6 (23.1%)	“There is no policy support for inpatient treatment. The Infectious Disease Prevention Law does not outline this, and we lack tangible measures, such as mandates for unwilling patients to seek isolation and treatment” (A26).

Providers also reported financial pressures related to inpatient care. Some facilities were responsible for meal expenses during hospitalization, resulting in cost burdens for both institutions and patients. One participant noted that this created “great pressure” on hospitals (A5). Furthermore, participants explained that hospitalization costs required patients to pay 10% out-of-pocket, which could be substantial. As one respondent stated, “If medical cost is fifteen thousand, the patient pays 10%… which is a burden” (A16).

In addition, participants described reimbursement gaps for screening persons with presumptive TB and close contacts, explaining that the absence of clear policy guidance made regular screening difficult to sustain. Participants also noted that current policies did not include specific measures to support or enforce inpatient treatment.

Limited public knowledge shaping engagement and care-seeking behaviors

Inadequate popularization of TB knowledge is reflected in the public’s lack of understanding of health check-ups, low awareness of TB, and the tendency to seek care at higher-level hospitals due to unfamiliarity with the advantages of local TB-designated facilities.

“Although we carry out a lot of publicity and education, there are still some problems with the public’s knowledge of TB and they do not actively cooperate with the screening work” (A17).

“Our county now has too many patients who go out for consultation and go directly to higher level medical institutions, which puts some burden on our work” (A25).

System capacity constraints diminishing screening accuracy and follow-through

Due to the scale of universal screening, participants reported that screening tasks were required to be completed within specific administrative deadlines (“time nodes”) set by higher-level health authorities. Facilities that failed to meet these deadlines would receive supervisory notifications requesting explanation or corrective action. These time pressures constrained operational capacity and often prioritized speed over accuracy, leading to compromised examination quality.

“The work pressure is relatively high, the medical examination should be completed in accordance with the time node, otherwise it will be notified. Leaders pursue speed, everyone’s capacity is limited, when the overload exceeded two times three times, then the quality of work is certainly reduced” (A12).

Referral complexity obstructing timely diagnosis and treatment initiation

Delays in referrals could be attributed to several factors: persons with presumptive TB may postpone confirmatory diagnosis at designated TB hospitals due to family responsibilities or transportation difficulties; some patients show no obvious symptoms in the early stages, leading to reluctance to accept referral; and poor cooperation in sputum collection makes laboratory confirmation difficult.

“Patients or persons with presumptive TB found during universal health check-ups are asked to be referred, but some are reluctant, thinking that they are not sick and have no symptoms” (A22).

“The biggest difficulty is sputum collection, many of the persons with presumptive TB found have no sputum and cannot be sputum collected, also the standardization of sputum collection may not be enough, the quality of the specimen is not good, and the results of the experiments are not good, so the persons with presumptive TB may drag on for one or two months” (A12).

Recommendations for sustained implementation

All 26 participants agreed that the strategies and measures associated with the “Xinjiang Model” could be sustained in their region. Suggestions for the implementation of the policy, including active detection, referral, inpatient treatment, and “centralized medication + nutritious breakfast”, can be broadly grouped into seven themes: (1) strengthening financial and policy support, (2) improving the welfare and compensation of TB healthcare providers, (3) improving patient management, (4) improving social support, (5) optimizing TB healthcare providers, (6) enhancing the overall capacity of TB healthcare providers, and (7) improving the quality of universal health check-ups. The themes and their corresponding sub-themes are shown in Fig. 3.

Fig. 3.

Themes and sub-themes of recommendations for the sustained implementation of the “Xinjiang model” (numbers in parentheses indicate the number of participants who mentioned each theme)

To further organize these findings from a systems perspective, we mapped the six implementation barriers and corresponding recommendations onto system domains informed by the WHO health system building blocks framework. These domains included health workforce, financing, service delivery, patient-centered support, and governance. This mapping suggested that the most critical constraints were concentrated in workforce capacity, financing mechanisms, and service delivery processes, because these domains directly influenced screening quality, referral timeliness, patient management, and treatment continuity. The systems-based diagnosis is summarized in Table 6.

Table 6.

Systems-based mapping of implementation barriers and recommendations for sustaining the “Xinjiang Model”

System domain	Main barriers identified	Operational implications	Actionable recommendations
Health workforce	Workforce fragility, limited professional capacity, high workload, staff turnover	Reduced quality and continuity of screening, follow-up, referral coordination, and patient management	Establish minimum staffing arrangements for TB prevention and control teams; provide workload-based compensation; strengthen continuous professional training
Health financing	Gaps in nutrition support, screening reimbursement, and residual out-of-pocket costs	Financial pressure on patients and institutions; weakened treatment adherence and service uptake	Adjust nutrition subsidy standards; reimburse screening for persons with presumptive TB and close contacts; reduce residual out-of-pocket costs
Service delivery	Pressure on universal health check-ups; referral delays; difficulties in sputum collection and follow-through	Reduced screening quality, delayed diagnosis, delayed treatment initiation, and interrupted continuity of care	Standardize referral timelines; strengthen feedback between screening sites and designated TB hospitals; improve sputum collection guidance; optimize screening workflows
Patient-centered support	Physical and psychological vulnerability	Interrupted treatment and poor continuity of care	Integrate psychosocial support, family involvement, and practical assistance into community-based follow-up
Governance	Policy misalignment and lack of detailed operational guidance for some components of the model	Inconsistent implementation across settings and difficulty sustaining some program components	Develop clearer operational protocols, accountability mechanisms, and routine monitoring requirements

Based on this systems-based mapping, we further developed a conceptual diagram to illustrate how health workforce, financing, service delivery, governance, and patient-centered support interact to influence screening quality, referral timeliness, patient management, and treatment continuity, which together shape the sustainability of the “Xinjiang Model” (Fig. 4).

Fig. 4.

Systems diagram of the key factors influencing the sustainability of the “Xinjiang model”

Discussion

This qualitative study explored frontline implementers’ perspectives on the challenges and sustainability of the “Xinjiang Model” for TB control. We identified six interconnected systemic barriers: structural workforce fragility, patient vulnerability, financing and policy misalignment, limited public knowledge, system capacity pressures associated with population-wide screening, and delays across referral pathways. By interpreting these findings through system domains informed by the WHO health system building blocks framework, this analysis moves beyond a descriptive list of barriers toward a structured systems diagnosis. The findings suggest that the sustainability of the model depends not only on its technical design, but also on the alignment of workforce capacity, financing mechanisms, service delivery processes, governance arrangements, and patient-centered support. This study adds to existing evidence by explaining implementation bottlenecks from the perspective of frontline health specialists, thereby providing practical guidance for maintaining TB control gains and advancing TB elimination efforts in Xinjiang.

The structural workforce fragility identified in our study, encompassing knowledge gaps, heavy workload, and low compensation, resonates with human resource challenges documented in TB programs globally. From a systems perspective, this barrier reflects a mismatch between expanding TB control responsibilities and insufficient dedicated staffing, compensation, and professional incentives at the local level. Governance and workforce constraints have been described as barriers to TB program performance in Nigeria [17], while qualitative evidence from eastern China highlighted demotivation and limited perceived power among TB staff within integrated, hospital-based TB care [18]. However, our findings further illustrate how role overload, staff instability, and perceived salary inequity interact in practice to undermine service continuity at the local level, echoing patterns reported in other high-burden settings where workforce constraints disrupt program delivery. Evidence from China and other settings suggests that targeted capacity-building approaches, including continuing education and e-learning, may help strengthen TB service delivery when combined with broader workforce stabilization measures [19–21].

Patients’ engagement with TB care was shaped not only by service availability, but also by individual vulnerabilities, including physical limitations, comorbidities, and psychological distress. This finding is consistent with evidence from other high-burden settings. A systematic review of global evidence shows that practical challenges including limited mobility, transport difficulties, and competing household responsibilities can delay diagnosis and treatment initiation [22]. Psychological distress, stigma, and treatment fatigue may also reduce cooperation and self-management during care, as reported in qualitative studies from multiple low- and middle-income countries (LMICs) [23, 24]. Importantly, our data suggest that the existing community-based support components of the “Xinjiang Model” may not fully mitigate these layered vulnerabilities. Evidence from intervention research further indicates that structured psychosocial or educational support can improve adherence within routine TB programs [25], while family involvement has been associated with stronger participation in long-term treatment [26]. Taken together, these findings support our interpretation that biomedical management alone may be insufficient, and that reinforcing psychosocial and practical support could enhance the sustainability of the “Xinjiang Model”.

In Xinjiang, gaps in nutrition support and screening reimbursement, together with residual out-of-pocket costs, posed financial and policy challenges to the implementation of the model. From a financing and governance perspective, these barriers suggest that policy-level reimbursement arrangements may not fully account for the real costs borne by patients, health facilities, and local public health workers during implementation. Undernutrition has been widely recognized as both a cause and consequence of TB, with adverse implications for treatment outcomes [27]. In China, qualitative research from Yunnan similarly documented how financial strain and coping strategies shaped access to TB care [28]. These findings clarify that nominally high reimbursement rates do not necessarily translate into financial protection in practice, as indirect expenses and copayments continue to deter uptake among vulnerable groups. Similar patterns in other LMICs highlight a shared implementation gap between policy design and lived financial reality, reinforcing calls to align TB control with broader social protection and health-system strengthening measures [29, 30].

Limited public knowledge about TB and the purpose of routine screening emerged as a key barrier to implementation. Participants described misunderstandings about TB transmission, screening procedures, and the function of designated facilities, which reduced willingness to participate in examinations and delayed engagement with services. Similar knowledge-related barriers have been documented in South India, where gaps in TB awareness affected care-seeking behavior [31], and in Inner Mongolia, China, where lower levels of TB knowledge were associated with reduced utilization of basic TB services [32, 33] .

Taken together, these findings suggest several practical implications for sustaining the “Xinjiang Model” within ongoing health system reforms. First, stabilizing the TB workforce through improved compensation, protected staffing arrangements, and continuous training may reduce turnover and enhance service quality. Second, integrating psychosocial and patient-centered support into routine TB care could improve adherence and continuity, consistent with evidence linking mental health and social support to treatment outcomes [24–26]. Third, strengthening financial protection, including adequate nutrition support, reimbursement for screening persons with presumptive TB, and reduction of residual out-of-pocket costs, may increase uptake and completion of TB care [28, 34]. Finally, sustained community engagement and targeted health education are essential to improve screening participation and appropriate care-seeking, as demonstrated in both Chinese and international contexts.

This study provides an in-depth qualitative analysis of the challenges faced in executing the “Xinjiang Model”, highlighting the factors influencing its effectiveness and offering vital insights for future improvements. However, this study had several limitations. First, the perspectives were limited to health system implementers; future research should include patients and community members for a more holistic view. Second, as a qualitative study conducted in one region, the findings were context-specific, yet the consistency of core themes with similar high-burden areas suggests potential transferability to other regions in China and comparable LMIC settings. Third, the study identified barriers but did not quantify their relative impact, which could be explored in future mixed-methods research.

Conclusions

This study identified workforce fragility, patient vulnerability, financing and policy gaps, limited public awareness, system capacity pressures, and referral delays as key challenges to sustaining the “Xinjiang Model” for TB control. Within Xinjiang, strengthening workforce support, patient-centered management, and financial protection is essential to maintain implementation quality. Nationally, these findings offer reference value for aligning similar strategies with China’s ongoing health system reforms, with practical implications for integrating stable funding, staffing protection, and patient support mechanisms into routine service delivery. For other LMICs, the results highlight that comprehensive TB models must be backed by system-level investment rather than by technical measures alone. Overall, sustaining the “Xinjiang Model” will require reinforcing human resources, financing mechanisms, and community engagement, with future mixed-methods research needed to inform policy prioritization.

Authors’ contributions

Yan Zhang contributed to the study design, performed the statistical analyses, interpreted the data and drafted the manuscript. Rurui Wei interpreted data and drafted the manuscript. Senlu Wang, Xiaomin Wang, Jaina Razbek, Baofeng Wen and Junan Wang collected data, interpreted data, and critically revised the manuscript. Mingqin Cao designed and supervised the study, interpreted the data, and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

This research was supported by the National Natural Science Foundation of China (grant number 82460699), Scientific Research Fund of Zhejiang Provincial Education Department (grant number Y202557672), Research Project of Zhejiang Chinese Medical University (grant number 2024RCZXSK02), 14-th Five-Year Plan Distinctive Program of Public Health and Preventive Medicine in Higher Education Institutions of Xinjiang Uygur Autonomous Region, open Project of State Key Laboratory of Causes and Prevention of High Incidence in Central Asia Co-constructed by Province and Ministry (grant number SKL-HIDCA-2023-16), and Xinjiang Uygur Autonomous Region Key Research and Development Special Project (grant number 2021B03003-1).

Data availability

The datasets used and analyzed during the current study are not publicly available, but they are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Xinjiang Medical University (XJYKDXR20230303016) and was conducted in accordance with the guiding principles of the Declaration of Helsinki. Informed consent was obtained from participants and all personal data were kept confidential.

Competing interests

The authors declare no competing interests.