South Africa


TB programmes are all very well, but better governance will make them effective

There are clear gaps in the cycle of governance around South Africa’s TB response. The country has a well-considered policy framework in place and is often at the forefront of new technical solutions, but this does not consistently translate into effective implementation.

With more than 400 hospitals and 3,800 clinics across the country, the assumption is that accessing healthcare in South Africa’s public health system should be easy.

But for many people living in South Africa, this doesn’t translate into easy access to the healthcare system.

This is particularly true for people who need to be treated for tuberculosis (TB). And there are several reasons for this: either they don’t have money for transport to the healthcare facility, or they can’t afford to take time off work.

When they do manage to get a day off or find the money for transport to their local clinic, inefficiencies in the healthcare system can mean that they are not even seen by a healthcare practitioner, requiring them to return the following day.

A variety of studies have backed up these claims. One coordinated by the Human Sciences Research Council found that more than two-thirds of people in South Africa with TB do not seek treatment. Some said they were still planning to do so; some said their symptoms were not serious and some said they had no money for transport.

The challenge with people not testing is the nature of the disease and how it has been spread. Mostly affecting South Africa’s poorest citizens, TB is airborne and spreads in overcrowded, poorly ventilated areas.

Tech steps in

The National Department of Health’s solution has been to turn to technology – but in such a way that South Africa’s poorest residents can still benefit.

The TB Health Check app allows users to check their symptoms without having to go to a clinic to be tested. All they need is a mobile phone. They don’t even need data. The service is free and users access it via USSD codes or WhatsApp, making it the most cost-effective way of establishing whether you might need a TB test.

This is part of the government’s national TB response effort and is in line with the TB recovery plan set up in 2021 to help the country regain the momentum lost during the pandemic. At the centre of this plan is targeted universal testing for TB, which encourages anyone who is at risk to be tested.

The app creates an ideal opportunity to capitalise on this objective. But there is a problem.

While this system has been launched at national level, there are questions about how it is being rolled out at provincial level. What awareness is being created about the app in communities which are at the highest risk of TB?

Provincial hurdles

The biggest challenge lies at the provincial level, which manages the bulk of the country’s TB services. This can be seen most significantly in KwaZulu-Natal and the Western Cape, where TB prevalence sits well above the national rate of 615 cases for every 100,000 people. 

Since it has been launched, how many people have used the service? And how has this improved TB testing? And where can one find out the results of this service?

The challenges around the app point to governance failures within the national TB response. Lack of coordination at provincial level means that people who most need information about the TB Health Check app are not receiving it.

Community-led programmes

For the app to be successful, it requires the involvement of communities that could engage in community-led governance programmes.

Community champions, with the support of hospital boards and clinic committees, would spread the messages about the TB Health Check app and get residents to check their statuses in the comfort and privacy of their own homes.

These champions could also report on challenges and glitches within the system – and they could come back to the national Department of Health and hold them accountable by asking how many people who used the app actually went on to be tested and treated.

The newly established TB Accountability Consortium is working towards developing stronger accountability networks in the TB landscape. It is helping to speed up the recovery plan by asking hard-hitting questions about the implementation of the programme.

Good policy, poor implementation

The reality is that there are clear gaps in the cycle of governance around the TB response in South Africa. Although response to the disease is guided by a well-considered policy framework – which often means the country is at the forefront of new technical solutions – this does not consistently translate into effective implementation of these policies. 

While the trickle-down effect is problematic for the TB response, this initiative also shows the lack of consistent community involvement in the TB response. Yet this is where the success of the app lies.

Collectively, all these issues compromise the management of the TB response. The end result is that the policy framework is not met with effective implementation, adequate support and strong oversight so that proper accountability is ensured. DM

Sihle Mahonga Ndawonde is the project officer for the newly established TB Accountability Consortium, an initiative of the Rural Health Advocacy Project. The consortium aims to strengthen TB care in SA by consolidating the implementation of policies, technical solutions and advocacy efforts on a national and provincial level.


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