Drug-resistant tuberculosis (DR-TB) in Eshowe, KZN, South Africa.
South Africa

MSF calls for decentralisation of life-saving DR-TB services in rural setting

An evaluation report released on 20 March 2024 by Doctors Without Borders (MSF) charts progress towards the decentralisation of 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 decentralisation 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 finds that progress towards the full implementation of the decentralisation policy in slow.


Everybody Breathes: Part 1

Tuberculosis is a curable disease and commonly affects the lungs of patients. Despite being curable TB remains the number one killer of people living with HIV. And one of the top 10 causes of death worldwide. In 2018 alone, 1.5 million people died from TB.
Tadeu Andre/MSF

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 decentralisation of DR-TB services in KCD from 2015 – 2023, is calling for the decentralisation of these services as a matter of priority. 

“The department of health has made enormous strides in implementing the decentralisation 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.

MSF staff in South Africa, KwaZulu-Natal speaking with a Drug Resistant Tuberculosis (DR-TB)patient
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.  
Tadeu Andre/MSF

According to the report, issues preventing or slowing the decentralisation 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’s support for the implementation of the decentralisation policy in KCD was considerable, and it included the provision of structures, equipment, and staff.

Access the report below: 

World TB Day - Decentralisation Report pdf — 4.35 MB

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

South Africa’s DR-TB decentralisation policy was largely based on a successful decentralisation model of care piloted by MSF and the Western Cape Department of Health in Khayelitsha between 2007-2011. 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.