Decentralized care means care that is provided in smaller, ambulatory, non-specialized health-care centres closer to where a patient lives, often by community health workers or nurses, non-specialized doctors, community volunteers or TB treatment supporters. Care could occur at local centres (e.g. community centres), or at the patient’s home or workplace. Having treatment and care provided in decentralized health-care centres is a good way to improve access to treatment and increase the number of patients who receive regular, community-based treatment and support. Decentralized care is often less disruptive to patients’ lives, allowing them to access treatment, care and counselling more easily and with less cost. It may also allow them to continue to work (therefore lessening the financial burden of TB disease) and to remain with their families. Decentralized care can be used for patients with either DS-TB or DR-TB. According to the WHO guidelines, all oral regimens are preferred for TB treatment (61 –63); however, if the patient must receive injectable medication, it should be investigated whether the injectable can be given at a decentralized location (60–62)
Decentralized care may not be best for all patients. Of particular concern would be patients with severe TB disease or severe comorbidities or very infectious forms of TB. However, studies have shown higher rates of treatment success and fewer patients lost to follow-up when patients were treated with decentralized care versus hospital-based care (64). There were no higher risks of death or treatment failure among patients who were treated with decentralized care. Before a patient begins decentralized care, the health-care provider needs to make sure that all required safety monitoring (e.g. laboratory tests, ECG) can still be done in the decentralized system or that, when needed, a patient can travel to a clinic or hospital with a higher level of care that can do this monitoring. There should always be a plan to get patients to a hospital if they need inpatient treatment. This may be necessary in certain patient groups at particular risk, such as children with severe forms of TB or people who also have advanced HIV. These patients may need close monitoring in a hospital for a certain period of time.
The backbone of community-based TB care is often a community TB treatment supporter, who may belong to the neighbourhood where the patient lives (53). Community TB treatment supporters, like all health-care workers, must respect and preserve patient confidentiality at all times. They can also play an important role in educating the community about TB and can help reduce stigma around the disease. Community-based TB providers need to be properly trained and supervised by qualified health-care workers (65). In some settings, and where there are no other alternatives, a communitybased TB treatment supporter can even be a family member who has undergone proper training and is supervised by a health-care worker or qualified community member. However, family relationships can be complex, and so the nature of family relations should be evaluated beforehand to ensure that the patient receives fully supportive care.
Decentralized care requires staff at the clinics to receive extra training and for the clinics to be able to support TB patients. This is likely to require additional help from the NTP. Clinic staff must be aware of the early detection and management of adverse drug reactions and should be familiar with social support services. When patients are on good medical treatment, the bacterial load rapidly falls and the risk of transmission of TB drops. Nevertheless, infection control measures need to be put in place at the clinic. The patients also need to be educated on infection control measures they can do at home, particularly if they live with someone who is at a particular risk from TB infection, such as a young child or someone living with HIV. These infection control measures will decrease the risk of transmission in households, the community and clinics. In the case of a patient with DR-TB, it may be illegal in some countries to treat DR-TB patients in a decentralized setting, especially when the treatment involves injections. Such legal concerns need to be considered when making plans for decentralized versus hospital-based care (see Box 3).
This decentralized model of care may require the patient to travel from home and receive medicines under person-centred treatment support at the clinic. Long daily travel times or cost of travel could lead to loss to follow-up. Patients may need financial support to help with their travel costs.