Children and Adolescents

Generally, integration of TB care and treatment into DSD models requires adaptations at multiple levels of the health system, including national, facility and community levels (177). This includes enhancement of leadership and coordination, adaptation of guidelines, capacity-building, adjustments in logistics management, alignment of existing recording and reporting tools, and community engagement. Other factors to consider include the local burden of HIV and TB disease, existing infrastructure and
human resources.

The concept of DSD (previously referred to as differentiated care) is increasingly being applied during the provision of comprehensive HIV services (78). In the context of HIV, DSD is a people-centred approach that simplifies and adapts HIV services to better serve the needs of people living with HIV and to optimize the available resources in health systems. DSD is premised on the fact that delivery of services is not a one-size-fits-all model but rather recognizes the diversity of people who seek the services.

A wide range of private health care providers exist in different settings, and the services they provide vary. It is important for NTPs to map the different private health care providers in their settings and implement flexible models of engagement guided by the scope of services they provide.

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.

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.