"Differentiated care is not a matter of feasibility but a necessity"- service providers' perception on initiating a comprehensive tuberculosis care package (CCp-K) to reduce deaths in Kerala, India

Background Kerala reports one of the highest case fatality rates and high prevalence of comorbidities and risk factors among persons with tuberculosis (PwTB). We developed a comprehensive care model (CCp-K) focusing on triaging persons with tuberculosis for severe illness, uncontrolled diabetes, alcohol and nicotine dependence at diagnosis, and ensuring inpatient care and follow-up. In the pre-implementation phase, we explored the barriers, facilitators, and perceived suggestions in the design and implementation of CCp-K from various interest holders for sustainable implementation. Methods We conducted an interest holder mapping and using the Power-Interest matrix of Mendelow, we purposively selected key interest holders at the district and state level. In-depth interviews were conducted using an interview guide by trained interviewers until data saturation was achieved. The audio recordings were transcribed, translated, and analysed using a framework-guided thematic analysis approach. Results Twelve interest holders participated in the interview, which included nine men and three women. The interviews lasted for a mean duration of 74 min (SD = 22). A total of 33 codes were generated and categorized under five themes: (i) perception on TB deaths (ii) relevance of CCp-K differentiated TB care model, (iii) perceived feasibility and enablers of implementing CCp-K, (iv) perceived barriers, and (v) perceived suggestions for the model and its delivery. The interest holders perceived that while delayed diagnosis contributes to TB mortality, the CCp-K model can bridge critical gaps in post-diagnosis care, particularly through early triaging and comorbidity management to reduce TB deaths. The robust healthcare infrastructure of Kerala, local governments and community involvement, and cross-adaptation opportunities from previous successful models were perceived as facilitators. The lack of nodal treatment centres, stigma among healthcare workers, social vulnerability, and competing priorities were perceived as major barriers. Conclusions The interest holders perceived the CCp-K model to be relevant and feasible. However, Kerala should overcome the barriers of inadequate inpatient referral centers by establishing designated TB care facilities, leveraging existing collaboration with private partnerships, and strengthening the social support system.