Health system requirements: Training of health care workers at peripheral levels of the health system is a critical requirement to ensure adequate implementation of decentralized approaches. Similarly, resources are needed at the peripheral level, especially initially to establish services. It is expected that as services are established and effectively implemented, the long-term impact will result in a decrease in TB incidence with an associated reduction in resource requirements. A phased approach may be applied if this is most appropriate in the country or area, depending on the local burden of TB, availability of domestic or donor funding and of technical and programmatic support.
Factors to consider in decentralizing child and adolescent TB services include: existing infrastructure (such as baseline health infrastructure, needs for expansion or upgrading), applicable regulatory framework, financing, choosing between an operational research setting or programmatic implementation, human resource issues (including staffing requirements and human resources development, such as capacity building/training and consultation skills), monitoring and evaluation, conducting qualitative research into community needs, perceptions (including views on stigma) and suggestions. Decentralization of services to the PHC level requires child and adolescent TB services to be integrated within general PHC services, resulting in possible significant overlap between decentralization and family-centred, integrated approaches.
Contact investigation: Active contact investigation at community and household level is a critical intervention for enhancing both case finding and provision of TPT among children and adolescents.
Task shifting: Decentralization should not only concern the levels of the health system but should ideally also take place within the same structure, by training all health care providers of all child and adolescent care services in the recognition and management of TB. This so-called task shifting was mentioned by the GDG as an important implementation factor.
Family-centred and integrated care: Although in child health, care evolves around the family, the concept of family-centred care has not been well defined. Family-centred care is related to the more common concept of patient-centred care. In the End TB Strategy (6): "Patient-centred care involves systematically assessing and addressing the needs and expectations of patients. The objective is to provide high-quality TB diagnosis and treatment to all patients - men, women and children - without their having to incur catastrophic costs. Depending on patients' needs, educational, emotional and economic support should be provided to enable them to complete the diagnostic process and the full course of prescribed treatment." Multiple descriptions exist that include components of support and education based on individual needs, building a patient-provider partnership and participatory decision-making. Family-centred care also includes interventions at the level of the household to identify members of the household requiring evaluation for TB disease, TPT, treatment support, etc. As the concept of family-centred, integrated care may be setting specific, one of the first steps in implementation includes clarifying which definition applies to the setting in which it is to be implemented. Similarly, the implementation strategy varies by setting and needs to be country- or region-specific, informed by social, cultural and societal values.
The package of TB services to be provided needs to be defined and developed by the NTP, in close coordination with other relevant programmes, such as through an existing child and adolescent TB technical working group. This package needs to be based on identifying and addressing capacity needs for national programmes interested in the uptake of proposed interventions, and ideally based on family and community perceptions on the ideal family-centred model of care. It could include community-based models for active contact investigation, identifying children with TB signs and symptoms or exposure as part of routine growth monitoring services, or an integrated model for IMCI integration, starting with the sick child and identifying signs and symptoms pointing to a high likelihood of TB.
Integration can start within the family, by equipping the family with the knowledge to recognize signs and symptoms to understand the importance of a history of contact, to know when to seek help at the health care facility and how to minimize stigma related to TB. High yield entry points provide a good starting point within the health system. For example, child and adolescent TB services can be integrated in malnutrition clinics, ANC, the expanded programme on immunization, inpatient sites, adult TB and chest clinics, HIV and general paediatric clinics. Ideally TB care should be integrated into general health services, rather than be limited to enhanced coordination between two programmes. However, defining an optimal patient flow between services and creating strong linkages between child health entry points and TB clinics remains essential, especially in facilities where services are physically separated. This is critical to enhance the quality of services, including the follow-up of persons with TB during the diagnostic evaluation, to also ensure accuracy of recording and reporting. In the early phase, pilot programmes could be considered, which should be evaluated and adjusted as needed and then scaled up.
Factors to consider in designing an integrated approach to child and adolescent TB care include existing infrastructure (such as baseline health infrastructure, needs for expansion or upgrading), the applicable regulatory framework, financing, choosing between an operational research setting or programmatic implementation, human resource issues (including staffing requirements and human resources development such as capacity building/training and consultation skills), monitoring and evaluation, conducting qualitative research into community needs, perceptions (including views on stigma) and suggestions.
Differentiated service delivery (DSD): DSD is a person-centred approach developed in the HIV programme that simplifies and adapts HIV services across the cascade of care in ways that both serve the needs of people living with and vulnerable to HIV and optimize the available resources in health systems. The principles of DSD can be applied to prevention, testing, linkage to care, ART initiation and follow-up, and integration of HIV care and coinfections and comorbidities (123). This approach embraces the idea that when families are given the choice to interact with the health system, it could provide a possible mechanism for integration of child and adolescent TB services within primary health or other programmes. Examples of implementing DSD for children and adolescents with or at risk of TB are provided in the operational handbook.