Children and Adolescents

In most low- and middle-income countries, private providers are an important source of health care for the whole population. Typically, less poor people make more use of formal, qualified providers, while poor people often turn first to informal, unqualified providers. Private providers often account for 50–70% of care, especially outpatient primary care (175).

In many high TB burden countries, the majority of missing people with TB, including children, seek treatment from private providers or other care providers not linked to the public sector at least once (174). The private sector is also a common point of care for children presenting with common illnesses, such as cough, fever and diarrhoea, especially in countries with a large private sector (175).

TB commonly affects people of lower socioeconomic status and exacerbates poverty and social deprivation through catastrophic costs²⁵ and reduced household income. Most children with TB develop TB after contact with an adult family member with infectious PTB. A high number of TB notifications in children indicates an ongoing adult epidemic (170). TB in the family unit does not only result in transmission to children: it also poses a threat to household income and financial security.

Opportunities for integration of TB services at the health facility level exist in outpatient departments; nutrition, HIV, maternal and child health clinics (e.g. prevention of mother-to-child transmission, antenatal care, immunization clinics), general paediatric, adult TB and chest clinics; and inpatient departments. If resources are available, implementation of provider-initiated TB screening in relevant child health entry points and linkages to diagnosis or treatment may be considered by the NTP.

Health system costs are likely to increase in initial phases of decentralizing services, but they are then expected to reduce over time. Initial investment costs may include costs related to infrastructure enhancement and capacity-building of health care providers and community engagement (See web annex 4). Recurring costs may include salaries, incentives, administrative costs, expanded information systems costs, and supervision and mentoring costs.

Health care facilities that offer TB services should have access to supplies for sample collection such as nasogastric tubes, spatulas and specimen containers, and access to child-friendly formulations of TB medicines. Sample referral systems need to be established if access to mWRDs is not available on site (76).

Decentralization of health services requires decentralization of health information systems including capacity-building among staff responsible for data collection and analysis. The use of NTP recording tools (such as contact investigation, TPT and treatment registers) may need to be evaluated and enhanced, including through operational research.

Implementation of the recommendations related to treatment support should enable the provision of people-centred TB services. Treatment adherence interventions that may be offered for people on TB treatment may include material support (e.g. food, financial incentives, transport fees), psychological support, tracers such as home visits or digital health communication (e.g. SMS, telephone) and medicine monitoring (107). Interventions should be selected based on assessment of the individual’s needs and preferences as well as available resources.