Table 3. Direct participant quotes: Structure and delivery of post-TB care services.

Theme	Sub-theme	Quotes
Content of post-TB services	Need for holistic care	“TB has very catastrophic effects and these patients end up being affected not just physically but also mentally. It has also a way of disabling their whole quality of life in totality…so I believe it is something we cannot ignore and it is something that we need to ensure that if we are talking about improving the quality of life of this particular TB patient, then we need to look at them holistically and ensure that they are being followed up beyond their period of treatment” (MoH staff, Kenya) “The consequences of post-TB complications is quite strenuous to the patient…because financially, emotionally, the patient is affected and even the normal health being of the patient is really affected. Nutrition, all those are affected. So if the donors are to be involved or the policy-makers, they should include all these people, nutritional, psychological counsellors such people that can help the patient holistically”. (Healthcare Provider, Kenya)
	Importance of broader management of TB-comorbidities	“And again we know that not only does TB cause obviously lung damage and longer term problems, but we also know that there are many other health conditions that contribute to a greater risk of someone developing TB, and those are often not treated and continue to pose ongoing risks for people. Whether it be things like smoking…or COPD….you know drinking alcohol” (Multilateral Organisation–TB policy)
	Importance of psychosocial support, and re-integration	“We forget that psychosocial support is supposed to be like a long term. We focus on it when somebody is on TB medication but medication is not only tablets…it is ensuring that we have proper counsellors or proper professionals that can provide psychosocial support even after treatment to ensure that somebody is well transitioned to the community”. (TB Patient advocate, Kenya) “…then the counselling for me is very very important and even training community counsellors as we have done for HIV. It would go a long way in supporting the TB-survivors.” (TB Survivor, Malawi) “It is a community issue, it is a social issue whether someone has lost their jobs, it is a social issue. Then you see it is also affecting many other aspects of development in terms of housing, in terms of education, in terms of you know livelihoods….[there is a need] to support those people who have had TB in terms of reintegration into the communities because it is not always physical. The impact is not always physical.” (TB Patient advocate, Malawi)
	Need for economic support	“… when you are transitioning from treatment, not everyone might need money but just to ensure that you have something like IGA–income generating activity” (TB patient advocate, Kenya) “…in terms of work, because some people cannot really do the work they used to do after TB. Maybe making sure people are getting vocational skills or maybe starting smaller businesses.” (TB Community Advocate, Malawi) “So we need to empower them. Economically, we have heard of cash transfer. I think those should be for the beneficiaries so that they can restart their life afresh.” (Healthcare provider, Malawi)
Location of post-TB services	Need for decentralisation, with a hierarchy of healthcare services	“The care should also be then provided in an affordable and accessible way closest to the patient. So perhaps the person with a mild presentation, we should be able to attend to them at the primary and even secondary level of care. So that only the persons who have very very severe (inaudible) with this condition would end up in the national referral or tertiary care or hospitals. That is how I would imagine it.” (Multilateral Organisation–TB Policy) “The trend in Malawi, the flow of patients, they will start from the primary healthcare which is the health centre, then secondary health facility like the district hospitals. If they fail there, they will go to the tertiary which is for the TB… Let them follow the same route because for most of the people, going to the tertiary it is expensive.” (Healthcare provider, Malawi)
	Need for community based care	“They need support and that is where we need civil society, community based organisations or patient support groups who can be linked to those people who are exiting the system that they are able to be integrated and supported to be reintegrated into the community.” (TB Patient advocate, Malawi)
	Importance of learning from HIV-NCD services	“….so initially you would start with high level cadres and then you need to learn as much as possible and develop detailed training, manuals and guidelines that are easy to follow. The HIV programme should be a good resource for whoever is working on this to look at how these rather complicated tasks were successfully handed over to lower cadres and how the services got as close to the patient as possible…and I would say start conservatively but do not take too long to decentralise.” (In country Researcher, Malawi) “In HIV first of all they all used to come in the tertiary hospitals because nobody knew how to handle it [HIV/AIDS]. But over time we developed our HIV systems, we developed systems protocols even. Now a patient does not need to walk very far. They can go to their nearest health centre and the nurse there has got very clear algorithms and she can manage to some level… So I think we have experience, we can learn lessons from the HIV programme and do it for lung health” (Healthcare Provider, Kenya)
Timing of post-TB services	Proactive care, from TB treatment completion	“It should be integrated from the beginning. Let us not wait for them to finish and then come back. In fact, I think if we would start treating this patient with that in mind that there is likely to be complications, there is even a way that we can be able to mitigate those complications. …” (TB Patient advocate, Kenya) “I think we need to be proactive but we should be proactive when we know what we will offer to these individuals. So screening or looking for individuals with the condition is not ethical if you are not able to provide care for them.” (Multilateral Organisation—TB Policy)
	Reactive care, responding to patient need	“The onus is on the patient that you feel a certain type of symptoms or whatever, and you will, the expectation is that you will have a health seeking behaviour to go to the hospital and say look I had TB and now I have noticed.” (Policy-maker, Malawi)
Delivery of post-TB services	Integration of services, for delivery	“We need to integrate with other services. The HIV services, the TB services, the Covid-19 services that are there…I would love if those activities can be integrated with other services that are already existing in that treatment level and prevention level and at community level. That could not make the work difficult to implement.” (MoH staff, Malawi) “TB programmes in most countries are not a vertical programme. Maybe [at the] national level, [or for] provincial level teams supervising the programmes and so on. But the service delivery level is integrated. I think that is what we need to promote…. I do not think we need to go for post-TB as another vertical approach. It should be integrated. It would make sense because we are talking about TB affecting other different organs and it is beyond TB now—it is post-TB. And that is where it makes sense to think about integration because the same person will have other problems. It could be HIV as well, and now we have COVID and post-COVID.” (Multilateral Organisation–TB Policy) “But I think there has to be a lot more emphasis about …the rest of the system to play its role. I think you will find that Ministries of Health loathe to verticalise things so much. So the thinking as I understand it is to allow the general health system to be able to deal with a wide swathe of problems rather than have specialised units or entities.” (Multilateral Organisation–TB policy)
Ownership / leadership of post-TB services	Leadership by the NTP, with support from others	“Who is responsible for it in Malawi, it would obviously be the Malawian health authorities, the NTP programme as far as I can see.” (Multilateral Organisation–TB policy) “I think more than ever, TB is slowly emerging to be a cross-cutting issue…so it is not something or an area that you would want to leave to TB program to solely address but they would obviously take lead…we need other players to come and support this…”(Non-governmental Organisation, Kenya)
	Challenges of NTP ownership	“I personally do not think TB programmes should be responsible for what happens after. We are a stakeholder but we are not the ones best equipped to deal with you if you are having difficulties breathing. That is not us. The people best equipped to do that would be clinical services and everything under clinical services.” (Policy-maker, Malawi) “Remember it is a National TB control programme so their priority is to control TB but not necessarily to rehabilitate. So it has to be carefully crafted to make sure that it does not look like an add-on to the TB programme but should be part of the TB programme.” (Multilateral Organisation–Funder) “The highlight on post-TB health I think is not new per se, but the emphasis is something that is new to a TB programme. So from a TB programme perspective it is simply designed to deal with the episode of the disease not what happens after” (Policy-maker, Malawi) “….they (NTLP) remain very lean and it will only be restricted to TB and leprosy as it is. So how do they even start to discuss that agenda of post-TB? Are they the right people to discuss that agenda or should they now move this discussion to the non-communicable disease side? So for me, to avoid a lot of back and forth, the easiest way is a lung health programme” (Healthcare Provider, Kenya) “It would be great if [ownership] was the TB programme. I cannot see that it would be responsible…there are so many different post-TB health issues that you could have… how does that work from an implementation standpoint?” (Multilateral Organisation–TB Policy)
	Challenges of situating within the health system	“For me it is outside the medical approach. So if we bring in another aspect that is outside the medical approach into the medical system then it will not be sustainable, it will not run. ….we need a structure that can be sustainable, that can make sure that they are carrying oversight and making sure that things are being done in the right order.” (TB Patient advocate, Malawi)
Framing of post-TB care, in discussion with patients	Need for careful communication	“…we are saying that TB is curable…So now if you say that after your medication there are complications that you can face, people now will be put off, to say what is going on? So I think it is a matter of in a way having clever programmatic and strategic programming because otherwise you might defeat the purpose …People still get cured of TB, but also we want to make sure that we are being realistic enough to say yes the medication might have side effects after but there is help…I think in a way it is a bit overwhelming because it feels like you are going to be a patient for the rest of your life.” (TB Patient advocate, Malawi)
	Presentation as part of the TB care cascade	“I think if it were to be like a continuation, people would take it more serious rather than when you are told now you have finished this treatment there is another phase because most people would be like why do I need it yet I feel I am okay. I think if it were to be one joint thing, it would work better” (TB Patient advocate, Kenya)
	Presentation as an optional service	“It should not be mandatory—‘Well you have finished TB we have got this package for you’…some others do not want to feel victimised and feel like they are victims of a certain thing.”(TB Patient advocate, Malawi)