Children have long been the invisible victims of tuberculosis. They rarely produce the classic symptoms seen in adults, they often struggle to provide sputum samples, and they commonly fall through the cracks of health systems designed for grown-ups. In many countries, paediatric TB services remain concentrated in referral hospitals, far from where most children live. This reality is at the heart of a recent editorial authored by Prof. Stephen Graham of the University of Melbourne, and colleagues, on quality of care that calls for a fundamental rethink of how tuberculosis services for children are delivered. The editorial argues that decentralisation is not simply a logistical adjustment but a moral and clinical imperative. By shifting services closer to families, health systems can detect and treat disease earlier, prevent progression through timely preventive therapy, and reduce the unacceptable toll of missed or delayed diagnoses.

Graham, a leading researcher in child and adolescent tuberculosis who also works with the International Union Against Tuberculosis and Lung Disease and is a chief investigator of the Australian TB Centre of Research Excellence, has been a consistent voice in this conversation. His work has repeatedly highlighted how children suffer when care is centralised and fragmented, and how quality must be defined not just by clinical guidelines but by whether services actually reach those who need them. The editorial emphasises that quality of care for children with TB cannot be separated from accessibility. A perfectly written guideline is meaningless if a caregiver must choose between a day’s wages and a clinic visit. Decentralised care, by contrast, recognises the realities of family life and seeks to fit services around children rather than forcing children to fit services.

The logic of decentralisation is simple. Tuberculosis is a household disease. Transmission happens in shared rooms, on crowded beds, and during everyday routines. Yet traditional models require families to travel to facilities, often long distances and multiple times, for screening, diagnosis, and follow-up. Each step creates an opportunity for delay or dropout. When care is decentralised, health workers go to homes, schools, and local clinics. They screen contacts systematically, follow children over time, and build trust through repeated interactions. This approach is particularly powerful for prevention. Identifying exposed children early and offering preventive treatment can stop tuberculosis before it starts, but only if those children are actually found. Furthermore, a household-based approach allows integration of care and treatment support to household members of all ages whether being treated for disease or for prevention.

Randomised trial evidence now supports what many practitioners have long suspected. A landmark cluster randomised trial published in The Lancet Global Health in 2023 evaluated a community-based, decentralised approach to tuberculosis contact management in high-burden settings. The study compared standard facility-based care with a model that relied on trained community health workers to identify, screen, and support household contacts, including children. The results were striking. Decentralised care substantially increased the number of children screened, improved uptake of preventive therapy, and did so without compromising safety. In fact, outcomes were better precisely because services were delivered where families lived.

This trial matters because it moves the debate beyond theory. Decentralisation is sometimes dismissed as idealistic or risky, especially for children who are perceived as clinically complex. The trial demonstrated that with appropriate training and support, community health workers can safely deliver high-quality care. It also showed that decentralisation can reduce inequities. Children in poorer or more remote households, who are least likely to reach health facilities, benefited the most. This aligns closely with the editorial’s argument that quality of care must be judged by equity as much as by technical competence.

Observational evidence from Uganda reinforces these findings and adds important context. Over the past decade, Uganda has experimented with decentralising child tuberculosis services, particularly through community-based screening and preventive therapy initiatives. Studies from Uganda show that when child TB services are integrated into primary care and delivered by community health workers, case detection rises and preventive treatment uptake improves. Families are more willing to engage when services are familiar and nearby. Follow-up becomes feasible, and children who might otherwise remain invisible are identified earlier. While observational by nature, this evidence reflects real-world conditions and highlights the sustainability of decentralised approaches beyond the confines of a clinical trial. Furthermore, although not an intended focus, strengthening services for child TB at primary care was also associated with an increase in TB detection and treatment in adults in those facilities.

The Ugandan experience also illustrates a critical point. Decentralisation is not about lowering standards or shifting responsibility without support. It requires investment in training, supervision, and referral pathways. Community health workers need clear protocols, access to diagnostic tools, and strong links to higher levels of care with support and mentorship. When these elements are in place, decentralised models can outperform centralised ones precisely because they are embedded in communities rather than isolated from them.

A powerful and recent example of decentralised care comes from Mongolia, where a prospective implementation study evaluated community-based screening and management of household contacts of people with multidrug-resistant tuberculosis. In this study, trained community health workers conducted home visits, screened household members, and supported follow-up over an entire year. Nearly all identified contacts were successfully screened, and coverage remained above 98 percent through follow-up. Importantly, most of the tuberculosis cases detected were among children and adolescents, demonstrating the value of repeated, household-level engagement.

The Mongolian study is particularly instructive because it shows decentralisation working in a challenging context. Multidrug-resistant tuberculosis is often viewed as too complex for community-based care. Yet with appropriate training and oversight, community health workers were able to identify cases, support treatment, and even deliver preventive therapy safely. All children who started preventive treatment completed it, an outcome that many facility-based programmes struggle to achieve. Quality here was not defined by sophisticated technology but by consistency, trust, and follow-through.

What unites these diverse settings is a shift in perspective. Decentralised models start from the assumption that families are partners, not passive recipients of care. When health workers enter homes, they see the social and environmental realities that shape risk. They understand sleeping arrangements, crowding, and caregiving patterns. This contextual knowledge improves clinical judgement, especially for children whose symptoms may be subtle. It also builds relationships that make long-term follow-up possible, which is essential for both treatment and prevention.

Decentralisation also addresses stigma, often overlooked as a barrier to care. Facility-based tuberculosis services can be highly stigmatising, particularly for children. Being seen at a TB clinic may expose families to gossip or discrimination. Community-based care, when performed sensitively, can reduce this burden by normalising screening as part of routine household health visits. In Mongolia, community health workers were already trusted figures involved in vaccination and other public health activities. Their role in TB care felt like a natural extension rather than a mark of shame.

Critics of decentralisation often raise concerns about diagnostic accuracy, especially in children. These concerns are valid and are acknowledged in both the editorial and the Mongolian study. Diagnosing TB in children is inherently difficult, and decentralised models must be supported by training, mentorship, and access to diagnostics. Yet centralised systems have not solved this problem either. Children are still missed, still diagnosed late, and still die. Decentralisation does not eliminate diagnostic challenges, but it increases opportunities to recognise illness earlier and to act before disease becomes severe.

Another important benefit of decentralised care is resilience. The COVID-19 pandemic disrupted health services worldwide, and centralised systems were particularly vulnerable. In Mongolia, decentralised follow-up continued even during lockdowns, with community health workers maintaining contact through home visits and phone calls. Screening coverage remained high despite unprecedented constraints. This experience underscores a broader lesson. Health systems that rely solely on facilities are brittle. Those that invest in community-based networks are better able to adapt in times of crisis.

The editorial on quality of care argues that decentralisation should be seen as a cornerstone of child-centred tuberculosis services rather than a peripheral strategy. This view is echoed across the evidence. The randomised trial demonstrates effectiveness, the Ugandan experience shows feasibility, and the Mongolian study provides proof of sustained implementation at scale. Together, they make a compelling case that decentralised models are not experimental but essential.

Prof. Steve Graham’s contributions help tie these threads together. Across his research and advocacy, he has emphasised that children deserve the same urgency and attention as adults with TB. Decentralisation, in his framing, is not about lowering the bar but about meeting it more consistently. When services are designed around children’s needs, delivered close to home, and supported by strong systems, quality improves in the most meaningful sense. More children are found, more are protected, and fewer suffer preventable harm.

Looking ahead, the challenge is no longer whether decentralised models work but how to scale them responsibly. Policymakers must invest in community health workers, integrate TB services into primary care, and ensure clear referral pathways for complex cases. Community-wide active case-finding strategies should also support contact investigation and prevention among the households of people detected with TB. Data systems must support follow-up across settings, and quality assurance must focus on outcomes that matter to families. Decentralisation is not a shortcut. It is a reorientation of care around people rather than places.

In the end, tuberculosis control will succeed or fail in households, not hospitals. Children will continue to be exposed where they live, and prevention will only be effective if it reaches them there. The evidence from trials, observational studies, and implementation research points in the same direction. Decentralised models of care improve access, equity, and outcomes, especially for children. They bring services closer to those who need them most and redefine quality as something lived and experienced, not merely prescribed.

As the global community renews its commitment to ending tuberculosis, the lesson is clear. Centralised systems alone are not enough. By embracing decentralised, child-centred models of care, health systems can finally begin to close the gap between policy and practice. In doing so, they honour the principle that no child should be invisible, unreachable, or left behind simply because of where they live.