Promoting and Prioritizing an Integrated Lung Health Approach: A Narrative Review of the WHO Resolution, Global Disease Burden, Evidence for Integration, and Implementation Pathways for Low-, Middle-, and High-Income Countries, 2021–2026

 Promoting and Prioritizing an Integrated Lung Health Approach: A Narrative Review of the WHO Resolution, Global Disease Burden, Evidence for Integration, and Implementation Pathways for Low-, Middle-, and High-Income Countries, 2021–2026

Authors: Dr. Shekhar,  and Team, Doctor's Forum For All 🏥⚖️

Disclaimer

This article is strictly for educational purposes only. It does not constitute medical advice or a substitute for professional clinical judgment. Readers should consult qualified healthcare providers for specific recommendations. The authors and Doctor's Forum For All 🏥⚖️ disclaim any liability for actions taken based on this content. All data cited are from publicly available sources as of the date of publication. The views expressed are those of the authors alone.

Abstract

Background: In 2021, communicable and noncommunicable lung diseases, including COVID-19, tuberculosis, pneumonia, asthma, chronic obstructive pulmonary disease (COPD), and lung cancer, caused more than 18 million deaths globally. These conditions share risk factors and frequently coexist, yet health systems have historically addressed them through vertical, disease-specific programmes that produce inefficiency, delayed diagnosis, and fragmented care. In May 2025, the Seventy-eighth World Health Assembly adopted a landmark resolution on promoting and prioritizing an integrated lung health approach.

Methods: We conducted a narrative synthesis of the WHO resolution WHA78.5 and its accompanying Executive Board documentation, WHO and GBD surveillance data on respiratory disease burden, systematic reviews and meta-analyses on integrated care models for chronic respiratory diseases, and documented implementation case studies from India, Nepal, Sri Lanka, and Malawi.

Results: The resolution formally recognizes that pulmonary diseases share common risk factors requiring a horizontal preventive approach, calls on Member States to develop integrated national policies for lung health encompassing both communicable and noncommunicable diseases, and emphasizes strengthening primary healthcare as the platform for integrated service delivery. Evidence from a 2026 narrative review suggests that horizontal integration of evidence-based interventions can improve clinical outcomes in chronic respiratory diseases, including reductions in unscheduled care episodes. Integrated COPD care reduced emergency department visits from 35.2% to 25.1% (p = 0.011) and hospitalizations from 28.6% to 22.5% at district hospitals. India, Nepal, Sri Lanka, and Malawi have piloted integration models that embed spirometry-based diagnosis, protocol-driven management, and community health worker screening into existing primary care platforms with promising feasibility results. Approximately 45% of tobacco-related deaths are due to lung diseases, totalling 3.3 million deaths in 2021.

Conclusion: The integrated lung health approach is a pragmatic, evidence-supported pathway to improve respiratory outcomes, optimize healthcare resources, and accelerate progress toward universal health coverage. The WHO resolution provides the policy framework. The clinical evidence supports integration. The implementation models exist. What is needed now is political commitment, sustained financing, and health system readiness to translate policy into practice. Lung health can no longer be managed in silos.

Keywords: integrated lung health, WHO resolution, tuberculosis, COPD, asthma, primary healthcare, universal health coverage, horizontal integration, pulmonary rehabilitation

Introduction

Lung diseases kill more people than most health systems are designed to handle. In 2021, communicable and noncommunicable lung diseases, including COVID-19, tuberculosis, pneumonia, influenza, chronic obstructive pulmonary disease, pulmonary fibrosis, asthma, and lung cancer, caused more than 18 million deaths globally. That is a number larger than the population of many countries. It represents a failure of system design, not of medicine.

The tools to prevent, diagnose, and treat most lung diseases exist. Smoking cessation works. Vaccines prevent pneumonia and influenza. Inhalers control asthma and COPD. Tuberculosis is curable. Pulmonary rehabilitation improves function and quality of life. Lung cancer screening reduces mortality in high-risk populations. Yet the delivery of these interventions remains fragmented. A patient with tuberculosis is managed in one programme. If that same patient develops COPD, they enter a different vertical silo. If they develop post-tuberculosis lung disease, they may fall through the gap entirely.

This fragmentation is not accidental. It reflects decades of disease-specific programme design, where tuberculosis, HIV, immunization, and noncommunicable diseases each built their own systems, their own supply chains, their own reporting mechanisms, and their own cadre of health workers. Vertical programmes delivered results for specific diseases. They also created inefficiencies that are now impossible to ignore.

The shared risk factors are well documented. Tobacco smoking, biomass fuel exposure, ambient air pollution, occupational hazards, poverty, malnutrition, and overcrowding amplify the burden of respiratory illness. Over 45% of tobacco-related deaths are due to lung diseases, totalling 3.3 million deaths in 2021. Poor and crowded living conditions, poor ventilation, and indoor and outdoor air pollution are all leading risk factors, especially in developing countries that are disproportionately impacted. These are not separate problems requiring separate solutions. They are the same problems manifesting in different clinical forms.

In May 2025, the Seventy-eighth World Health Assembly took a decisive step. It adopted resolution WHA78.5, “Promoting and prioritizing an integrated lung health approach.” The resolution recognizes the critical importance of addressing both communicable and noncommunicable diseases that affect the lungs and the need to strengthen primary healthcare in the context of an integrated approach towards attainment of universal health coverage. It acknowledges that pulmonary diseases and other noncommunicable diseases often share the same risk factors, requiring a horizontal preventive approach.

This is a milestone. It is also a starting point. Resolutions do not treat patients. Systems do.

This article examines the integrated lung health approach through four questions. First, why did the World Health Assembly act, and what does the resolution actually say? Second, what is the clinical and epidemiological case for integration? Third, what does the evidence show about integrated care models? Fourth, how are countries implementing integration in practice, and what can others learn?

The article is written for health professionals, public health practitioners, policymakers, and informed readers. It argues that the integrated lung health approach is not an abstract aspiration. It is a practical pathway supported by clinical evidence, implementation experience, and now global policy consensus. The question is no longer whether to integrate. The question is how fast and how well.

Methods and Materials

Study Design: This article is a narrative synthesis of publicly available policy documents, surveillance data, peer-reviewed literature, and documented implementation case studies. It is not a systematic review.

Setting and Population: The scope is global, with emphasis on low- and middle-income countries where the burden of respiratory disease is concentrated. Data sources reflect populations of adults and children affected by communicable and noncommunicable lung diseases.

Data Sources: The primary data sources were the Seventy-eighth World Health Assembly resolution WHA78.5 and its accompanying Executive Board documentation (EB156(19)); WHO and Global Burden of Disease (GBD) study estimates for respiratory conditions; a 2026 narrative review on integrated care for chronic respiratory disease published in the European Respiratory Review; a 2026 narrative review on integrating tuberculosis and lung health services in India; a 2026 WHO report on strengthening asthma and COPD care through primary health care in Nepal and Sri Lanka; a 2025 feasibility study on integrating spirometry and protocol-driven CRD care in rural Tamil Nadu, India; and the Practical Approach to Lung Health (PAL) strategy documentation and implementation research from Malawi.

Variables and Measurements: Disease burden was measured using WHO and GBD estimates for mortality, prevalence, and disability-adjusted life years. Policy content was assessed through direct review of resolution text and Executive Board documentation. Intervention effectiveness was assessed through reported effect sizes from systematic reviews, including changes in emergency department visits, hospitalization rates, and clinical outcomes such as FEV₁ and CAT scores. Implementation feasibility was assessed through documented case studies reporting coverage rates, diagnostic yield, and health worker training outcomes.

Statistical Analysis: No primary statistical analysis was conducted. Published figures are reported as cited.

Ethical Considerations: This article uses only publicly available policy documents, de-identified aggregate data, and published literature. No primary data collection involving human subjects was conducted. Institutional review board approval was not required.

Results

The Global Burden of Lung Disease

Respiratory diseases remain among the leading causes of death and disability worldwide. COPD affects approximately 200 million people globally and causes 3.2 million deaths each year, making it the third-leading cause of death worldwide. Asthma affects 262 million people and causes more than 461,000 deaths annually. Tuberculosis continues to claim over a million lives each year, with India contributing nearly one-quarter of the global burden and an estimated 2.8 million cases in 2024.

In the WHO South-East Asia Region alone, chronic respiratory diseases account for an estimated 12% of all deaths, with more than 104 million people living with these conditions and around 1.56 million deaths in 2021. India contributes disproportionately to the global respiratory disease burden, accounting for nearly 32% of global respiratory disease-related DALYs despite comprising only 18% of the world population.

The economic and social costs extend far beyond mortality. Stigma associated with lung cancer, tuberculosis, and COPD affects access to early detection and treatment. Workplace exposures contribute substantially to both infectious and chronic respiratory diseases. Indoor and outdoor air pollution, whose root cause is predominantly socioeconomic in nature, disproportionately affects developing countries.

What the WHO Resolution Says

Resolution WHA78.5, adopted on 27 May 2025, is the first global policy instrument to formally recognize lung health as an integrated priority spanning communicable and noncommunicable diseases. The resolution notes with deep concern that in 2021, communicable and noncommunicable lung diseases caused more than 18 million deaths globally.

The resolution recognizes the critical importance of addressing both communicable and noncommunicable diseases that affect the lungs, including tuberculosis, pneumonia, influenza, COVID-19, chronic obstructive pulmonary disease, pulmonary fibrosis, asthma, and lung cancer. It emphasizes the need to strengthen primary healthcare in the context of an integrated approach towards attainment of universal health coverage.

Critically, the resolution acknowledges that pulmonary diseases and other noncommunicable diseases often share the same risk factors, requiring a horizontal preventive approach. It calls on Member States to develop integrated national policies for an integrated approach to lung health, encompassing both communicable and noncommunicable lung diseases.

The resolution also addresses specific risk factors and determinants. It stresses comprehensive infection prevention and control measures to reduce transmission of tuberculosis, COVID-19, pneumonia, and other airborne infectious diseases, particularly in high-burden, low-income settings. It acknowledges indoor and outdoor air pollution as one of the leading risk factors for lung diseases, especially in developing countries. It recognizes radon exposure as one of the leading causes of lung cancer after smoking in countries with known data. It emphasizes that over 45% of tobacco-related deaths are due to lung diseases, totalling 3.3 million deaths in 2021, and underscores the importance of primary care services for prevention of tobacco smoking, particularly tobacco and vaping control.

The European Respiratory Society and European Lung Foundation, which advocated for the resolution, commended its emphasis on strengthening primary care systems to deliver integrated services, addressing social and environmental determinants, enhancing prevention through tobacco and vaping control, and reducing stigma.

The Clinical and Epidemiological Case for Integration

The case for integration rests on three pillars: shared risk factors, overlapping clinical presentations, and compounding outcomes when diseases coexist.

Shared risk factors link tuberculosis with COPD, asthma, post-tuberculosis lung disease (PTLD), and other lung diseases. A 2026 narrative review on integrating TB and lung health services in India identified shared risk factors including tobacco smoking, biomass fuel exposure, ambient air pollution, occupational hazards, poverty, malnutrition, and overcrowding. These factors amplify the burden of respiratory illness across both communicable and noncommunicable categories.

Overlapping clinical presentations complicate diagnosis. In developing countries like Malawi, further investigation is rare after patients with chronic cough test negative for tuberculosis. Chronic airways disease often goes unrecognized due to a lack of diagnostic services. The World Health Organization developed the Practical Approach to Lung Health (PAL) strategy precisely because integrated guidelines for tuberculosis and chronic airways disease are needed.

Compounding outcomes occur when diseases coexist. COPD and tuberculosis frequently co-occur, worsening lung function and outcomes. A 2025 review found that COPD and TB often coexist, potentially amplifying disease severity through shared inflammatory and immune dysregulation mechanisms. Prior pulmonary TB is a robust, smoking-independent determinant of COPD. Increasing recognition of post-TB lung disease has intensified calls for an integrated lung health strategy.

Evidence for Integrated Care Models

A 2026 narrative review on integrated care for chronic respiratory disease examined the evidence supporting both horizontal and vertical integration models. Horizontal integration refers to better coordination of evidence-based interventions across services at the same level of care. Vertical integration refers to coordination between different organizational units in healthcare systems.

The review found that better coordination of the provision of evidence-based interventions through horizontal integration can improve clinical outcomes in chronic respiratory diseases, including reducing episodes of unscheduled care. Vertical integration provided by different organizational units can enhance delivery of evidence-based interventions, but impact on longer-term outcomes is less clear. The available evidence supports integration but does not conclusively support a specific model of care or organizational structure.

Specific clinical evidence is encouraging. Integrated COPD care reduced emergency department visits from 35.2% to 25.1% (p = 0.011) and hospitalizations from 28.6% to 22.5% at district hospitals, with patients with GOLD 3 and GOLD 4 grades showing significantly greater reductions. A WeChat-based integrated care model for pulmonary rehabilitation in COPD demonstrated significantly better outcomes in FEV₁ (53.2 ± 17.8 vs. 47.4 ± 19.8%), CAT scores, and 6-minute walk test distance.

Despite the availability of highly clinically and cost-effective interventions, including smoking cessation, pulmonary rehabilitation, vaccination, and pharmacotherapy, a significant proportion of patients still do not receive optimal basic care. Integration is not about adding complexity. It is about ensuring that interventions we already know work actually reach the patients who need them.

Implementation in Practice: Country Experiences

The evidence base is not limited to systematic reviews. Countries are implementing integrated lung health approaches and documenting results.

India. India bears one of the highest global burdens of tuberculosis and chronic respiratory diseases. A 2026 review examined the rationale, evidence, opportunities, and challenges for integrating TB and lung disease services in India. It found that integrated lung health services can improve continuity and efficiency of care, and that primary healthcare platforms can support syndromic respiratory management. Digital diagnostics and pulmonary rehabilitation were identified as key integration opportunities.

In rural Tamil Nadu, researchers assessed the feasibility of embedding spirometry-based diagnosis and protocol-driven CRD management into government primary care services. They trained community health workers in symptom screening and referral, therapists in performing spirometry, and primary care physicians in spirometry interpretation and evidence-based management. The intervention resulted in 170 people being screened, 71 diagnosed with CRD, and inhaler with spacer therapy started in CRD-diagnosed patients for the first time in primary care. The authors concluded that integrating spirometry and protocol-driven CRD care in existing government primary care is feasible through capacity building, health personnel training, and community engagement.

A separate implementation model, SHVASAN, is being tested in Pune district. It proposes screening by Accredited Social Health Activists (ASHAs) and diagnosis by Community Health Officers at primary health centres. The model is designed as a novel, low-cost adaptation for peripheral workers with limited specialist access.

India has also integrated tele-spirometry into eSanjeevani, the National Telemedicine Platform. The validation study showed strong correlation between traditional spirometry and portable tele-spirometry. Following integration, consultations were provided to 51,987 patients with respiratory illness from March 2021 to July 2024, with patient satisfaction exceeding 98%.

Nepal and Sri Lanka. WHO is supporting the integration of asthma and COPD services into primary health care in both countries. The approach integrates asthma and COPD services into existing NCD and PHC structures through short training modules, job aids, locally adapted materials, supportive supervision, and community engagement. In Nepal, implementation is underway in Kavre District. In Sri Lanka, implementation is being taken forward in Kandy and Kalutara districts through a primary care-focused model emphasizing systematic screening, improved diagnosis, health worker training, patient education, and stronger follow-up. Dr. Sarah Rylance, lead for chronic respiratory diseases at WHO headquarters, noted that these projects closely align with the integrated lung health approach endorsed by the Seventy-eighth World Health Assembly.

Malawi. A cluster randomized controlled trial is underway to determine the effect of using the Practical Approach to Lung Health strategy and training of informal health providers to improve case detection and treatment of patients with tuberculosis and chronic airways disease at primary care level. The trial addresses the reality that in developing countries, referral systems at primary care level are weak and patients turn to unskilled informal health providers to seek care.

Discussion

Key Findings

Three findings stand out.

First, the World Health Assembly resolution is a genuine milestone. For the first time, global policy formally recognizes that lung health must be addressed across the communicable-noncommunicable divide. The resolution is not aspirational language. It calls on Member States to develop integrated national policies, strengthen primary healthcare, address social and environmental determinants, and tackle stigma. This is a mandate for system redesign.

Second, the clinical evidence supports integration. Horizontal integration of evidence-based interventions can reduce unscheduled care episodes and improve clinical outcomes in chronic respiratory diseases. Integrated COPD care reduced emergency department visits by 10 percentage points and hospitalizations by 6 percentage points at district hospitals. The evidence does not yet identify a single best model, but it consistently supports the direction of travel.

Third, implementation is feasible. India, Nepal, Sri Lanka, and Malawi have demonstrated that integration can work in practice. Rural Tamil Nadu showed that spirometry-based diagnosis and protocol-driven management can be embedded into government primary care. India’s eSanjeevani tele-spirometry platform reached nearly 52,000 patients with respiratory illness. Nepal and Sri Lanka are integrating asthma and COPD services into existing NCD platforms through practical, low-cost approaches.

Comparison with Prior Literature

These findings align with and extend previous analyses. The 2026 European Respiratory Review found that despite ample evidence that many chronic respiratory conditions are preventable and responsive to timely, evidence-based interventions, delays in diagnosis and fragmented delivery of care remain persistent challenges, with the burden magnified in underserved populations. The 2026 India review identified that the epidemiological convergence of communicable and non-communicable respiratory diseases has exposed major limitations in India’s traditionally fragmented healthcare approach, where TB services are relatively well-developed through the National Tuberculosis Elimination Programme but CRD care remains poorly integrated into primary healthcare systems.

The WHO resolution builds on the Practical Approach to Lung Health (PAL) strategy, which was developed precisely to address the need for integrated guidelines for tuberculosis and chronic airways disease and has been shown to improve management of both conditions. It also aligns with the WHO Package of Essential NCD interventions for primary health care (WHO PEN), which includes peak flow meters and bronchodilator and steroid inhalers as core medicines and technologies for primary care facilities.

Limitations

This synthesis has limitations. It is not a systematic review. The literature selection was purposive and may have omitted relevant studies. The evidence on integrated care models does not conclusively support a specific model of care or organizational structure, and study duration and choice of outcomes remain key challenges for evaluating clinical and cost-effectiveness. Implementation case studies are subject to publication bias; unsuccessful integration efforts are less likely to be documented. The WHO resolution is recent, and its impact on national policy and health outcomes cannot yet be measured. The evidence base for integration in low-resource settings remains limited, and scaling successful pilots to national programmes presents substantial operational, financial, and political challenges.

Public Health Implications

The implications for policy and practice are substantial.

First, national governments should develop integrated lung health policies. The WHO resolution calls on Member States to do exactly this. An integrated policy should encompass prevention, diagnosis, treatment, and rehabilitation for both communicable and noncommunicable lung diseases, with primary healthcare as the delivery platform.

Second, health systems should invest in primary care capacity. The evidence from Tamil Nadu, Nepal, and Sri Lanka demonstrates that integration requires training, equipment, and supportive supervision. Community health workers can be trained in symptom screening and referral. Primary care physicians can be trained in spirometry interpretation and protocol-driven management. Inhalers and spacers must be available at primary care facilities. These are practical, achievable investments.

Third, digital health can accelerate integration. India’s tele-spirometry model shows that portable diagnostic devices integrated into national telemedicine platforms can extend specialist-level assessment to primary care and community settings. This approach reduces costs, lessens the burden on tertiary care centres, and improves access for patients with asthma, COPD, and other respiratory conditions.

Fourth, prevention must be integrated with treatment. Tobacco control, air quality improvement, occupational health, and infection prevention and control are all components of an integrated lung health approach. Over 45% of tobacco-related deaths are due to lung diseases. Indoor and outdoor air pollution disproportionately affects developing countries. These risk factors require multisectoral engagement, not just health sector action.

Fifth, stigma must be addressed. The WHO resolution explicitly acknowledges the impact of stigma associated with lung cancer, tuberculosis, and COPD on access to early detection and treatment. Stigma is a barrier to care. Integrated services that treat lung health as a unified clinical domain rather than a collection of stigmatized diseases can help reduce it.

Sixth, pulmonary rehabilitation should be part of the package. Community-based pulmonary rehabilitation led by peer volunteers and supported by professionals has proven feasible in low-resource settings and is associated with improved exercise tolerance and other outcomes. Integrating pulmonary rehabilitation into primary care expands access to a high-value, low-cost intervention.

Conclusion

The integrated lung health approach represents a fundamental shift in how the world addresses respiratory disease. For too long, tuberculosis, COPD, asthma, pneumonia, and lung cancer have been managed in separate silos, each with its own programme, its own funding, and its own reporting lines. That fragmentation has cost lives. It has delayed diagnosis, interrupted care, and wasted resources.

In May 2025, the Seventy-eighth World Health Assembly adopted a resolution that formally recognizes this problem and calls for a solution. The resolution acknowledges that more than 18 million deaths from lung diseases occurred in 2021. It recognizes that communicable and noncommunicable lung diseases share risk factors and often coexist. It calls on Member States to develop integrated national policies, strengthen primary healthcare, and address the social and environmental determinants of lung health.

The clinical evidence supports this direction. Horizontal integration of evidence-based interventions improves outcomes and reduces unscheduled care. Integrated COPD care reduces emergency department visits and hospitalizations. Pulmonary rehabilitation improves function and quality of life. These are not theoretical benefits. They are measured results.

Implementation is feasible. Rural Tamil Nadu showed that spirometry and protocol-driven CRD care can be embedded into government primary care. India’s eSanjeevani platform reached nearly 52,000 patients with tele-spirometry. Nepal and Sri Lanka are integrating asthma and COPD services into existing NCD platforms. Malawi is testing the Practical Approach to Lung Health with informal health providers. These are real programmes with real results.

The path forward is clear. National governments should develop integrated lung health policies. Health systems should invest in primary care capacity, including training, equipment, and essential medicines. Digital health should be leveraged to extend diagnostic reach. Prevention must be integrated with treatment. Stigma must be addressed. Pulmonary rehabilitation should be part of the standard package of care.

Lung health can no longer be managed in silos. The WHO resolution provides the framework. The evidence provides the rationale. The implementation models provide the proof of concept. What is needed now is the political will, the financing, and the health system readiness to translate policy into practice.

The lungs do not distinguish between communicable and noncommunicable diseases. Neither should we.

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