South Africa: MSF Calls for Decentralisation of Life-Saving DR-TB Services in Rural Setting

Tadeu Andre/MSF
Phenduka Mtshali, a patient with Drug Resistant Tuberculosis (DR-TB), is seen at her home in Mbongolwanea, a rural area of South Africa’s KwaZulu-Natal province at the epicentre of South Africa’s HIV & TB epidemic, speaking with MSF fieldworker, Jabulile.
22 March 2024
Medecins Sans Frontieres (Geneva)

An evaluation report released today by Doctors Without Borders (MSF) charts progress towards decentralizing services for patients with drug-resistant tuberculosis (DR-TB) in South Africa's KwaZulu-Natal's King Cetshwayo District (KCD), in line with the country's 2011 DR-TB decentralization policy.

The report finds that the KwaZulu-Natal Department of Health (KZNDoH) has established some level of DR-TB services in six district hospitals, three district clinics, and one district community health centre but that progress towards the full implementation of the DR-TB decentralization policy is slow.

For example, the report highlights an absence of services for children with DR-TB and patients with extensively drug-resistant TB (XDR-TB) and pre-XDR TB. MSF, which supported the decentralization of DR-TB services in KCD from 2015 – 2023, calls for the decentralization of these services as a priority.

"The Department of Health has made enormous strides in implementing the decentralization policy, yet the most vulnerable DR-TB patients in the district are still having to travel several hours to the province's central TB hospital in Durban to get treatment and care, at a cost that is often catastrophic," said Dr. Liesbet Ohler, the long-standing medical coordinator of MSF's HIV/TB project in KCD, which closed in 2023.

According to the report, issues preventing or slowing the decentralization of DR-TB services in KCD include

  • A lack of medical resources such as Electrocardiogram (ECG) and vital-sign monitors, and a lack of funding for equipment maintenance and repair
  • A lack of human resources in facilities
  • Absence of knowledge regarding DR-TB and its management principles, and no government training

MSF provided considerable support, including structures, equipment, and staff, for implementing the decentralisation policy in KCD.

"In order to fully decentralize DR-TB services in the District, this support will need to be replaced, perhaps with strategic partnerships with non-governmental actors," said Ohler. He added that MSF's intention in producing the evaluation report "is not to criticize or apportion blame, but to highlight where the work of decentralization is incomplete so that it can be taken up with renewed energy."

South Africa's DR-TB decentralization policy was largely based on a successful decentralization model of care piloted by MSF and the Western Cape Department of Health in Khayelitsha between 2007 and 2011. Although the MSF project in KCD has closed, MSF is currently applying many of the lessons it learned in the district in terms of making treatment and care easier for patients to access in a newly opened non-communicable diseases project in the Eastern Cape.

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