South Africa

South Africa is situated at the southern tip of the continent of Africa, and is divided into nine provinces. In 2005, gross domestic product per capita was estimated to be US$12,000, but 50 percent of the population lives below the poverty line and the unemployment rate is 26.6 percent.

South Africa is plagued by one of the most serious TB and HIV epidemics worldwide, causing the trends of TB to rise in the past 15 years. Between the 9 provinces TB rates show significant differences, the highest rate being found in the Western Cape (approx. 1,500/100,000 notification). As a middle income country SA has introduced the 6 month regimen using single dose formulations, already since the middle eighties, in the absence of a well functioning TB control program, as demonstrated by consistent low treatment success rates (67% in 2004 cohort of new ss+ patients) and high default rates (over 12%). This has resulted in the emergence of MDR-TB and XDR-TB.

South Africa has the second highest TB burden in Africa and is ranked fifth among the 22 high-burden countries. As of 2004, the estimated burden of TB was 316,260 (670/100,000 population) for all cases and 138,789 (294/100,000) for new smear-positive cases. TB/HIV co-infection is estimated at 60 percent. MDR-TB is 1.8 percent among new TB patients and 6.7 percent among previously treated patients.

TBCTA Project 1 (2000-2006)

• Objectives

• Strengthen the NTP through assistance to implement and monitor the National Medium-term Development Plan and development, implementation and monitoring of the provincial strategic plans.
• Improve technical and financial capacity to conduct research activities of the University of Stellenbosch and Chris Hani Baragwanath Hospital.
  

Major TBCTA Accomplishments

• The case detection rate for new smear-positive cases under DOTS increased from 65 percent in 2000 to 92 percent in 2003, then dropped to 83 percent in 2004, although it still exceeds the global target of 70 percent.
• TBCTA assisted with the development of the National Medium-term Development Plan in 2001. Provincial advocacy visits and a national workshop with major partners of the NTCP resulted in a draft plan and a second workshop with key stakeholders to finalize the plan, launched in January 2002. Workshops were implemented in nine provinces, leading to the development of provincial medium-term plans.
• Implementation of an electronic TB register has strengthened both management and data recording and reporting, resulting in improved capacity for monitoring and evaluation of DOTS strategy implementation.
• The NTCP ’ s HRD focal point took part n the Task Force on Training workshops, which resulted in an HRD plan focusing primarily on improving the structure and organization of training activities. Based on intensified technical assistance, the plan was adjusted to also include training of trainers and distribution of equitable training based on need and demand. In addition, two NTCP staff members participated in a study visit to Indonesia. The goal was to learn how the Indonesian NTP organizes its human resource development and the challenges it faces with DOTS expansion.
• National Training of Trainers workshops were implemented targeting provincial and district staff working in TB, HIV/AIDS and communicable diseases. The NTCP also adapted the new WHO Modules for Health Care Workers and each province identified five or six trainers to cascade implementation of the new modules. Furthermore, the provinces have been tasked to develop training implementation plans which will detail training needs, organization of training activities including follow-up mechanisms. Eleven HRD workshops were conducted at provincial level.      
• The HIV/AIDS Department participated actively in the development of the Medium-term Strategic Plan, although collaboration and coordination between the two programs has been slow. A limited number of HIV-positive TB patients have begun antiretroviral treatment. The only province in which significant numbers of TB patients are receiving treatment for HIV is the Western Cape.
• With technical and financial assistance, two universities conducted a total of four research projects. The University of Stellenbosch found that introducing a TB sputum register in all 13 clinics and two hospitals of the Stellenbosch district assisted in identifying gaps in the diagnostic process, and showed that 18 percent of people with two positive sputa are initial defaulters. The study also found that successful use of a TB sputum register requires a time commitment by clinic staff and supervisors. A second study in Cape Town on defaulting found that 14 percent of patients were initial defaulters, and that reasons for initial default included death, problems regarding addresses and patient perceptions. In the meantime, a sputum register has been introduced in the whole country.
• The University of Witwatersrand conducted research projects on the development of the TB Care Centre at Chris Hani Baragwanath Hospital and knowledge about TB and management practices at health centers and clinics. These projects demonstrated that guiding all TB patients through the TB Care Centre before discharge could improve referral to local clinics by a factor of 50 to 90 percent, thereby improving treatment adherence. This excellent example has led to the introduction of TB focal points in all hospitals in Gauteng province, and plans for countrywide implementation. A second study at the same hospital identified the misuse of cultures, gaps in registration and informing patients of culture results, under-registration of TB patients and deaths, and problems with laboratory turn-around time. Recommendations for improvement are being followed up. Members of the research teams presented results of the Stellenbosch and Witwatersrand studies during The Union ’ s World Lung Conference in Paris in 2004, 2005 and 2006. The first Witwatersrand study was published in the International Journal of Tuberculosis and Lung Disease.

TB CAP Project Period (2005-2010)

Expected output(s)

• TB CAP project efficiently implemented
• XDR- prevention and surveillance strengthened
• All provinces and national level have new TB strategic plan for period 2006-2011 in line with Stop-TB Strategy and Global Plan to Stop-TB
• PPP management capacity strengthened
• Financial planning capacity strengthened
• HRD management capacity strengthened
• Advocacy and social mobilization in Northern Cape strengthened
  

Current status

The NTCP has received support for the past 4 years through TBCTA for various activities including the development of a Medium-Term Development Plan at the national and provincial levels (2002-2006), human resource development and follow-up and monitoring visits. A new workplan will be prepared by TB CAP to continue support to the NTCP.