A comparison of pediatric tuberculosis care cascades in public- and private-sector facilities in Mymensingh Division, Bangladesh

Despite the crucial role of private healthcare facilities globally, little research compares pediatric tuberculosis (TB) services across public and private sectors. Public facilities generally adhere to national TB guidelines, while private clinicians may tailor care more flexibly, resulting in variable service quality. Cascade analysis is well-suited to comparing care delivery across providers and sectors but has not been used to compare pediatric TB care between public and private facilities. We applied cascade analysis to evaluate and compare pediatric TB services – including screening, diagnosis, and treatment – across facilities in Mymensingh Division, Bangladesh. Between 2018 and 2021, an intensified pediatric TB screening initiative was conducted in Mymensingh Division, Bangladesh. In this retrospective cohort analysis, we compared completion of the care cascade, consisting of screening, evaluation, diagnosis, treatment initiation, and treatment success, across public and private facilities, and by facility level (primary vs. tertiary). Of 842,203 children screened, 670,833 were in 79 public facilities and 171,370 in 47 private facilities. Private facilities had higher percentages of children screening positive (3.4% vs. 2.4%; p < 0.001), completing evaluations (77.1% vs. 71.0%; p < 0.001), and being diagnosed (17.3% vs. 12.2%; p < 0.001). Both sectors achieved 100% treatment initiation and > 98% treatment success. In primary facilities, private facilities outperformed public facilities across all steps. In tertiary facilities, evaluation was higher in the private sector (91.6% vs. 72.9%; p < 0.001). Cascade analysis identified areas where pediatric TB care succeeded and fell short across sectors. Whereas both sectors reliably initiated and completed treatment, evaluation and diagnosis were completed more consistently in private facilities, even as public facilities reached the majority of children. Applied across sectors, cascade analysis identified complementary strengths and weaknesses that may guide integrated public-private strategies and track progress towards pediatric TB targets.