South Africa's battle to tackle one of the world's oldest, curable and preventable diseases came into the spotlight again at the recent SA TB Conference.
Over four days, scientists, researchers, advocates and government officials discussed some of the key challenges in our response to one of the leading causes of death in the country. These include the diagnostic gap, the persistent challenges of adherence, the impact of socioeconomic factors and the need for bolder action and political will.
On the other hand, there is genuine reason for optimism.
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New diagnostic technologies are becoming available. These include testing for TB through a digital stethoscope and a near point-of-care test that may become even cheaper. Advances in treatment continue to improve patient outcomes. The availability of publicly accessible data is helping South Africa structure our plan and our advocacy. And the prospect of an effective TB vaccine is no longer a distant dream but a real possibility.
But there is another reality we must confront.
Strained budgets
The fiscal environment in which these innovations will be introduced is becoming increasingly constrained.
Following the cuts in development assistance earlier this year, the National Treasury called on health departments to tighten their belts.
Government budgets are under pressure. Provinces are struggling to maintain existing services. And the longstanding model of disease-specific programmes operating alongside one another is becoming harder to justify in a country facing multiple, overlapping health challenges.
The question is no longer simply whether we have the tools to end TB. The question is whether our health system is organised and financed in a way that allows those tools to reach the people who need them most.
For years, South Africa has approached HIV, TB and non-communicable diseases (NCDs) through largely separate funding streams, reporting systems and programme structures. While this approach helped drive progress against individual diseases, it has also created fragmentation. Patients move between clinics and services. Health workers are expected to navigate multiple reporting requirements. Communities often experience healthcare as a collection of disconnected interventions rather than a coordinated system designed around their needs.
Yet the people most affected by these conditions do not experience them separately.
A person living with HIV may also have TB. Someone receiving treatment for diabetes may require screening for TB. A grandmother managing hypertension may be caring for a family member with HIV. The realities of people's lives demand integrated services. Our financing systems should reflect that reality.
Integrating budgets and services
The District Health Programme Grant, which is the current mechanism that funds HIV, TB and other communicable diseases, presents an opportunity to move in that direction - if it can be strengthened to ensure better management. Properly utilised, it can become a mechanism for strengthening integrated service delivery at the district level, supporting multidisciplinary teams, strengthening service delivery at the clinic level, and investing in shared information systems that improve patient care rather than duplicating administrative processes.
This matters because districts are where health policy becomes reality.
It is at district level where a patient either receives a diagnosis or is missed. It is where a clinic either has the staff it needs or operates with vacancies. It is where medicines are available, or stock-outs occur. It is where communities either trust the health system or disengage from it.
The district health system is not simply another layer of administration. It is the frontline of healthcare delivery. If we want to strengthen South Africa's response to TB, HIV and the growing burden of NCDs, we must start by strengthening districts, because this is where most people first experience the healthcare system.
The challenge is not simply finding more money.
Beyond budgets
Of course, additional resources would help. But equally important is ensuring that existing resources are used more efficiently. In an environment of constrained budgets, value for money becomes essential. Every rand spent should contribute to stronger systems, better patient outcomes and more equitable access to care.
Integration offers one pathway to achieving this. When services are planned together, delivered together and monitored together, the health system becomes more efficient. Patients make fewer visits. Health workers spend less time navigating administrative barriers. Resources can be directed to where they have the greatest impact.
Integration, however, requires accountability.
District managers must have the tools and authority to coordinate services effectively. Provincial departments must be transparent about how funds are allocated and spent. Communities must have access to information that enables them to monitor performance and demand improvements. Civil society organisations must continue to play their role in ensuring that health financing decisions translate into better services on the ground.
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The experience of the TB Accountability Consortium has repeatedly shown that public accountability drives better outcomes. When communities have access to data, they can identify gaps. When policymakers are held accountable for results, programmes improve. When patients' experiences inform decision-making, services become more responsive.
As South Africa prepares for a future in which domestic resources will play a larger role in financing health services, we must seize the opportunity presented by the District Health Programme Grant. We must use it to build a health system that is integrated rather than fragmented, preventative rather than reactive, and centred on people rather than programmes.
The goal is bigger than ending TB. It is about building a health system capable of responding to the realities of South Africa today and resilient enough to meet the challenges of tomorrow.
Russell Rensburg is the executive director of the Rural Health Advocacy Project and the project director of the TB Accountability Consortium.
The views and opinions expressed in this opinion piece are those of the author, who is not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.
