Table 4. Direct participant quotes: Barriers to implementation of post-TB care.

Theme	Sub-theme	Quotes
Lack of data	Local data on burden of disease	“That is the first thing we need to know—what is the magnitude of this, before we make a big deal of this. And I do not want to sound careless. I want you to understand this from priorities upon priorities for the system. Someone always gets left behind because you cannot fund everything. So you need to know first, how big a problem is this?” (Policy-maker, Malawi)
	Data on risk factors for morbidity	“But again, we need to understand the disease better and how it manifests itself. Is it the same here as in India, as in China or is it different depending whether you are a man or a woman, HIV positive or negative, on ART or not on ART, viral load suppressed or viral load not suppressed. Does it depend on your age? What does it depend on? Does it depend on the type of TB you had? If you had Xpert positive TB compared to perhaps clinically diagnosed TB or pleural effusion. I do not know if we have the answers to those questions so we cannot design the interventions until we know what we need to improve.” (Multilateral Organisation–TB Policy)
Funding constraints	Need for funding sources from outside the TB programme	“If you are saying well now countries should include longer term post-TB care in their national TB response … it will just probably receive a lot of pushback to say we already stretched enough…The win would need to be having this idea, this concept, bringing in other areas of funding to support it. I think that would make it much more palatable” (Multilateral Organisation–TB Policy)
	Need for donor funding	’Even drugs, drugs are being procured by the Global Fund, PEPFAR and World Bank and GDF of course which means if there is any support which is post-TB care… in my perspective it will definitely be donor driven and donor funded.” (TB Patient advocate, Malawi)
	Domestic funding options	“They need probably long term or lifelong support and you cannot expect that from a project or a grant with a shorter period of time. That is why a sustainable financing system should be in place and that is why this group should be prioritised as part of the overall health system and part of the domestic funding.” (Multilateral Organisation–Funder) “One is that if we make it (post-TB care) nationwide and we have an NHIF cover, then we can say that with NHIF you can go to the nearest facility that is near you. So people have the freedom… you can access that service in Nairobi so long as you have a code which is computerised. So with that code you are known that you are a regular recipient of this service so you can go to any facility near you to get that service.” (TB Patient advocate, Kenya)
	Need for mandate for care at the National/Global level, in order to secure funding	“So there should be a guidance from you know from WHO and international organizations and countries should also include this [post-TB] group in their national strategic pan and then they can still include some of the support to come from Global Fund.” (Multilateral Organisation—Funder) ’I think if it is in line with the WHO guidance I think it is something that we can always look positively but above all I think it has to be a national priority. If the NTP does not look at it as a priority I think it is unlikely that we are going to fund it. For example, the Global Fund this year allowed countries to develop their funding requests based on the National Strategic Plan (NSP). So if it is not in the NSP it is hard to fund it.” (Multilateral Organisation–TB policy)
Staffing constraints	Lack of trained staff	“The TB programme at the district level or facility level is not run by medically trained people. It is run by environmental health staff …while post-TB care would require doctors, nurses, clinical officers to do the work and there is not much interest especially from clinical officers and doctors to do TB work at facility level…” (Multilateral Organisation–Funder) “In so many of the countries that we work in there is huge lack of clinicians of trained [staff], whether it be very specialised services like radiologists or other clinical staff, even coming down to nurses. There is a huge gap in human resource capacity especially as we move out of the cities.” (Multilateral Organisation–Funder)
	Need for staff training	“What needs to be done is to train staff and let them know that these patients can have lung complications. I used to see for example some years back and this happens a lot at lower level health facilities when patients with TB who have completed treatment come back with symptoms. Often they have chest pains, they have fever, and they are put back on treatment again. Then they are treated fully again for another 6 months, 8 months, some even up to one year because their symptoms are not resolving. And this is simply because people have not done tests to find out what else could it be if this is not TB…” (Healthcare provider, Kenya)
Clinical guidelines	Need to define key clinical interventions which should be used	“Are there other health services, are there medicines, are there procedures that can be offered to them that would make their life better and respiratory function better? So would it be physiotherapy, some sort of pulmonary rehabilitation, education about these airway clearance exercises, regular immunizations against respiratory pathogens, definitely it will include smoking…” (Multilateral Organisation–Funder)
	Need to define key patient outcomes for monitoring & evaluation	“But having something around longer term health outcomes for people, there would have to be something that is achievable, measurable, something that could be impacted to I think to get funding and donors move around that cause.” (Multilateral Organisation–Funder)
Models of care	Lack of existing models of care	“Probably the second reason is that we have not seen really much happening in other countries either so if somebody can bring up a model that has worked elsewhere, I guess we should have an open mind to have a look at it and see how we can adapt that to our setup.” (Multilateral Organisation—Funder)
Potential impact of COVID-19	Greater need for integrated care	“It makes sense to think about integration because the same person will have other problems. It could be HIV as well. Now we have COVID and post-COVID and all those.” (Multilateral Organisation–Funder)
	Limited capacity for change	“I think our world is now going through these pandemic times and how exactly we will come out of this also financially and economically will determine at least in short and medium term how the world and how all of us can take up new issues or newer issues. Because you know every organisation, every human being has some sort of saturation point I think.”(Multilateral Organisation–TB Policy)