Public health is political. We learnt that during the early days of the HIV epidemic, when civil society stood up to Aids denialism. As a result, South Africa today has the world’s biggest  antiretroviral therapy programme, with just more than six million of the country’s estimated 7.8 million people with HIV on treatment. New infections in children dropped by 84% in six years since 2009 and people with HIV now live almost as long as people without, provided they get on treatment early enough. 

If this could be done for one disease, why is tuberculosis (TB) – a preventable and curable disease – still the country’s biggest killer? Every day, 150 people in South Africa die from TB. This toll is so high that infections here make up about 3% of the world’s burden. 

Yet only four political parties so far – the EFF, African Transformation Movement (ATM), African Christian Democratic Party and Pan Africanist Congress – consider TB enough of a crisis to mention the disease in their manifestos for the 29 May elections.

We as civil society leaders will be scrutinising manifestos and election talk – and holding politicians accountable for mostly ignoring South Africa’s leading cause of death. 

Goodman Makanda, a TB survivor and advocacy officer at TB Proof, warns that people (read: voters) are struggling to get tested, treated or to access prevention services. “They’re saying, and I also know, that these services are not offered at their local clinic. What should I tell them?” 

Less money, less service

Ironically, South Africa’s TB numbers are high despite meaningful policy decisions, such as swapping sputum smears, for which results can take up to two days to be processed, for the rapid GeneXpert test to diagnose people with TB in 2011, which gives a diagnosis within two hours. Shorter, safer antibiotic treatment plans were introduced in 2018 and since 2023, anyone who’s had close contact with someone with TB can obtain preventive medicine. 

Many of the delays in implementing these TB policies, however, relate to ongoing cuts to the national and provincial health budgets. In 2023, R4.4-billion less was earmarked for health than in 2022. The 2024 health budget is R271.9-billion, which includes allocations to national and provincial health services. (As a reference, R382.2-billion is set aside for paying debt). 

According to the 2022/23 District Health Barometer, provincial budgets, from where the money comes for district health services, including for dealing with TB, dropped by 6.6%. This means less money was available for primary healthcare per patient. Moreover, because the money for district health pays for many different services, such as community health clinics, HIV and Aids, nutrition and district hospitals, the budget for TB spending is not ring-fenced. As a result it’s hard to track how money is spent and to see whether it’s in line with national targets to find, treat and prevent the disease.

But it’s not only because of local austerity measures that TB spends are hamstrung; globally, the disease also gets too little funding, says the World Health Organization, despite 1.3 million deaths and 7.5 million newly diagnosed people with TB worldwide in 2022. Of the $13-billion (about R260-billion) that delegates at the UN high-level meeting in 2018 agreed was needed each year until 2022 to diagnose, treat and prevent the disease in poorer countries (where 99% of cases occur), only about half was actually available. 

The Global Fund, the world’s largest TB donor, perpetuates this neglect: Only about a fifth of its total budget (of just more than $13-billion – about R260-billion) for 2023-25 is for TB, while malaria gets about a third and HIV half. This doesn’t reflect the burden of these diseases, but rather how much of a political priority each is. 

So, how can politicians make sure TB gets the attention – and resources – it deserves over the next five years? 

1. Talk about TB publicly 

Parties have to show voters that they realise how serious a health issue TB is – and that they understand the bigger picture around the disease. The disease should be mentioned repeatedly in their manifestos and be linked to community well-being through plans for better social security (eg social grants), housing and agriculture, for example. These measures can help to improve overcrowded living conditions (in which infections can easily spread) and give people the means to eat healthily, which can build up their immune system. Together, these can go a long way towards curbing the spread of the disease.  

But we’re not seeing much of this.

In its manifesto, the EFF says it will increase funding for TB and HIV research, build TB hospitals, do things to help people eat healthier and make it easier to get mental health services. The ATM commits to TB prevention through education and long-term treatment.

The ANC says it is committed to implementing national health insurance over the next five years, but it doesn’t mention any specific plans to address TB at all. The DA doesn’t mention TB or HIV in its election promises, although it does talk about improving food security. 

But we’re yet to see a political party make the links between the need for food security and TB. 

Helping people eat better can make a big difference in saving lives, research shows. 

In the Rations trial in India, more than half of the participants (of whom more than 80% were underweight) had picked up 5% body weight after two months of getting a food package that included rice, milk powder, chickpea powder, vegetable oil and a vitamin supplement – and their chances of dying from TB had dropped markedly. Moreover, for someone without the disease, the chance of getting sick if a household member had TB was almost halved when people regularly had healthy food in their homes. Food aid that costs less than R10 a day can help to save lives, the results showed, because fewer people get sick, patients respond better to their treatment and get cured, and fewer slip through the system without being followed up.

2. Put your money where your mouth is

Funds for dealing with TB should be kept specifically for that purpose, rather than being part of the general pot of health money, so that good care can get to people who need it the most. A study led by TB Proof shows that rolling out national policies in provinces needs funded implementation plans. 

Data from the National TB Prevalence Survey shows that more than half of people with TB in South Africa had none of the typical disease symptoms such as fever, weight loss, night sweats and coughing. New national policies recommend that people who might have a bigger chance of getting TB, such as those with HIV, close TB contacts (like living with or sharing transport with someone who is sick) and previous patients should get checked, regardless of their having symptoms. And if the tests come back negative, they should be able to get medicine to prevent them from falling ill at all (preventive therapy). 

New data and policies like these mean we have to rethink how we set aside money for testing and treatment services – and then spend that money wisely. 

3. Check that policies are actually rolled out 

Policies on paper don’t save lives – that only happens when they’re actually rolled out. Having a new screening method, medicine to prevent TB or food support available at a local clinic can mean the difference between life and death. Communities need to demand these services to ensure that what the policies promise actually get done.

The work of Ritshidze, which sends community workers out to clinics to check on services that are available, is a good example. Its recent audit of clinics in Gauteng found that of the 135 health facilities visited, 88 didn’t do even three of the seven easy things needed to stop TB from spreading, such as opening windows, not letting people sit too close to each other in the waiting room, reminding people to cover their mouths and noses when coughing or sneezing, and separating those who are coughing from others. In only 5% of the clinics all these steps were followed. 

We need community discussions where community leaders, politicians, civil society organisations, health workers and clinic committees can come up with workable ideas on how to overcome challenges. For example, last week, representatives from groups like these came together at an imbizo in Cape Town to draw up plans that will ensure that measures described in TB policies actually reach people at the facilities where they go for care.  

The question now is: Will political leaders use their power to implement plans that will make people’s lives better and stop TB deaths? DM

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Ingrid Schoeman is the director of advocacy and strategy at TB Proof. Anele Yawa is the general secretary at the Treatment Action Campaign. Harry Hausler is the CEO of TB HIV Care. Russell Rensburg is the director of the Rural Health Advocacy Project and project director for the TB Accountability Consortium SA.