In South Africa, tuberculosis is mainly diagnosed and treated in the public healthcare system. On paper, the private sector should also be able to deal with it, but in reality, TB care in this sector is often fragmented and confusing. Spotlight's Elri Voigt asks local experts why things work like this and what can be done about it.
TB remains one of the leading causes of death in the country, claiming around 50 000 lives a year. Caused by the tenacious bug called Mycobacterium tuberculosis, it has plagued mankind for centuries.
In response, South Africa’s public healthcare system has devoted a lot of resources to TB, and many public sector doctors, nurses, pharmacists, and community healthcare workers have years of experience with the illness.
The country was ahead of the rest of the world in rolling out new molecular TB tests in the early 2010s, and in the past decade, has introduced new treatments for drug-resistant forms of TB, before most other countries did.
Much important TB research has also been conducted at clinical sites countrywide, like the recent BEAT-TB study published in the New England Journal of Medicine.
But what about the private healthcare sector? Indications are that it has not become similarly expert at combatting the age-old bug, even though people who use mainly private sector healthcare services also get TB.
Spotlight recently reported on a PhD student who became ill with TB and was diagnosed in the private sector but received treatment in the public sector. That was not an isolated case. Up to 29% of TB patients across 13 high TB burden countries, including South Africa, engaged with the private healthcare system when their symptoms first started, found a 2017 study.
In the country’s first TB prevalence survey, of the 1 726 participants surveyed who had TB symptoms and sought care, 139 (8.1%) first approached the private sector.
However, finding information on TB care in the private sector has proven to be a challenge, and what Spotlight was able to find was sometimes contradictory and confusing.
Most cases could be treated privately
Let’s start with the basics. Does the private sector diagnose and treat TB at all?
Here a distinction between types of TB is important. More than 90% of people who develop TB in South Africa have “normal” drug-susceptible TB: TB that can be successfully treated with the standard antibiotics.
A much smaller group, fewer than one in 10, have drug-resistant forms of TB. Drug-susceptible TB can be treated in the private sector, while drug-resistant TB appears to be exclusively treated in the public sector.
“There is a common misconception that TB can only be treated in the public healthcare sector,” said Dr Noluthando Nematswerani, chief clinical officer at Discovery Health.
She told Spotlight many healthcare providers can diagnose and treat TB in the private sector, since TB is part of the standard training medical doctors receive in South Africa.
“Discovery Health does not maintain a dedicated network of healthcare professionals who exclusively treat TB, as TB care falls within the scope of practice of suitably trained medical practitioners across multiple disciplines.”
Treating TB is covered under the prescribed minimum benefits. According to the Council for Medical Schemes (CMS), treatment can be made available to medical aid scheme members through public sector clinics, but they should be given the option of accessing treatment through the private sector.
Medical aid schemes are prohibited by the Medical Schemes Act from saying that “they do not cover the costs of diagnosing, treating and/or the care of TB and that you can only get this cover in the public sector”.
A member of a medical scheme may only be referred to a public sector facility if that scheme has a designated service providers arrangement with that facility. And a medical aid scheme cannot refuse to cover TB treatment.
“In line with these regulations, members across all Discovery Health Medical Scheme plans have access to comprehensive evidence-based TB care, which includes consultations with the relevant healthcare professionals, diagnostic and follow-up laboratory and radiology investigations, and clinically appropriate medications for the effective management and care of TB,” said Nematswerani.
However, while the option is there for private doctors to diagnose and treat drug-susceptible TB, most cases are tested for and treated in the public healthcare sector, said Dr Francesca Conradie, a leading TB researcher.
At the moment, drug susceptible TB in adults is treated with a six-month treatment course – consisting of four drugs for two months and then two drugs for the remaining four months.
Drug-resistant TB probably only treated in the public sector
The picture for drug-resistant TB looks quite different. Conradie said some of the medications are only available in the public sector – so patients with drug-resistant TB must be referred to a state facility for treatment.
While there does not appear to be any outright legal or regulatory prohibition on private sector pharmacies supplying these drugs (in fact, they have listed single exit prices), by all appearances the medicines are not available in the private sector.
The CMS does not plainly say that drug-resistant TB (sometimes subdivided into MDR-TB, pre-XDR-TB, or XDR-TB) cannot be treated in the private sector at all. It does however state: “Complex cases such as MDR-TB are often referred to specialised public TB hospitals or clinics, as the required drugs and monitoring may be unavailable or too expensive in private settings.”
“Discovery Health Medical Scheme members have cover for MDR-TB, including consultations, diagnostics and hospitalisations. However, there are limits … as they are only available in the public sector…but they would be funded as per the Scheme’s policy if they were made available in the private sector,” said Nematswerani.
She added that those diagnosed with drug-resistant TB will be referred by their private sector doctor to a designated public healthcare facility offering the treatment under the National Department of Health’s MDR-TB programme.
“When designated facilities submit claims for MDR-TB services, Discovery Health assesses and Discovery Health Medical Scheme funds eligible claims in line with applicable Prescribed Minimum Benefit (PMB) requirements,” she said.
Drug-resistant TB is treated with anything from three to seven drugs and treatment can last anything from six to 24 months. Two of the drugs, bedaquiline and pretomanid, which form the backbone of the treatment regimen, are monitored closely and can only be accessed through the National Department of Health in public sector facilities.
This is according to Professor Keertan Dheda, Head of Pulmonology at Groote Schuur Hospital and the University of Cape Town. The reason, Dheda said, is to “ensure antibiotic stewardship and so that we do not get acceleration of antimicrobial resistance to specific drugs through inappropriate prescription of such drugs used for DR-TB”.
“It’s because they [the drugs in the current DR-TB regimen] are pearls of great price,” said Conradie, adding that the restriction is to try to safeguard some of them, particularly bedaquiline, against the development of resistance for as long as possible. Another reason is that drug-resistant TB patients need to be monitored closely for potential side effects, something for which he public sector is well-equipped, said Conradie.
Finding confirmation on the degree to which the private sector can or cannot access bedaquiline and pretomanid directly has proven challenging.
National Department of Health spokesperson Foster Mohale said the department does not have information on these issues and that our questions could be better handled or addressed by the pharmaceutical industry and the private sector.
Spotlight contacted all pharmaceutical companies that were listed on SAHPRA’s website as having registered the DR-TB drugs bedaquiline, pretomanid, and delamanid.
“Viatris in South Africa is the Marketing Authorisation Holder (MAH) for pretomanid and delamanid, both registered for drug-resistant TB, available to the public sector through the national tender and to the private sector upon request,” said a spokesperson for pharmaceutical company Viatris.
“Drug-resistant TB treatment is predominantly co-ordinated through the public health system, where patient follow-up, pharmacovigilance and reporting mechanisms are established.”
Bedaquiline, from Johnson & Johnson, is available in South Africa, including through the private healthcare sector, a spokesperson said.
Two other companies said they are not directly involved in supplying the drugs and were only involved in the registration process.
Private sector prices for bedaquiline and pretomanid are listed in South Africa’s single Exit Price database, something that usually indicates at least some intent from the manufacturers to supply it to the private sector.
UKZN pharmaceutical sciences expert Dr Andy Gray said there is no legal reason for not making these medicines available in the private sector, but access is often constrained.
“That the manufacturers have taken the trouble to submit a launch Single Exit Price to the National Department of Health Pharmaceutical Economic Evaluations unit is important, and indicates a willingness to supply a private market, even if availability is limited because demand is almost non-existent,” he added.
TB knowledge gaps in private sector
The complexities of drug-resistant TB aside, the option for testing and treatment of drug-susceptible TB in the private sector clearly exists on paper. Yet it is not clear how widely such care is actually available, and when it is, whether it is always up to scratch. Our impression is it’s a bit of a lottery as to whether or not your private GP has knowledge of TB.
“There are many gaps in knowledge among general practitioners, not only for TB,” said Dheda. “Unlike other countries where regular licensing exams are undertaken, we have decided to use a different approach in South Africa and updating one’s knowledge in a particular field is achieved through their own reading and conference attendance, and through the CPD system, where they need to accrue a certain number of points showing they have attended continuing medical education meetings.”
From the limited information available, it appears the private sector’s approach to testing for and treating TB is under-developed.
A likely reason is because most TB cases are treated in the public sector, so there is little opportunity or need to develop these skills. A few recent studies on TB care in the private sector have shown significant gaps among GPs.
“South Africa’s leading role in prioritising TB in policy and practice possibly contributes to its strong public sector performance,” notes a commentary in the South African Medical Journal. “However, it is unclear to what degree recent advancements in screening and care recommendations have permeated the private sector.”
One 2022 study looked at the quality of TB and HIV care in the private sector. The researchers used specially trained staff who would go to a GP with one of three sets of symptoms and histories – all indicating possible or confirmed TB.
Case one had typical TB symptoms and was HIV-positive; case two had a TB-specified laboratory report and was HIV-negative; and the third case had a history of incomplete TB treatment and was HIV-positive.
Among the 511 interactions the trained staff had with 212 general practitioners in KwaZulu-Natal and the Western Cape, TB was more likely to be ideally managed as per the study framework – meaning the patient was referred to the public sector or given the relevant tests – if the patient had a diagnosis of TB already or a history of TB. The researchers also found that the private sector GPs in their study did not perform as well as public sector doctors in South Africa.
Some of the public health experts we interviewed were sceptical about the private sector’s ability to provide TB care.
Some patients think they’ll get better TB care in the private sector but in reality, it’s been shown that quality of care is actually far poorer, compared with the public sector, Professor Renier Coetzee told Spotlight. Coetzee is an associate professor at the School of Public Health at the University of the Western Cape.
Conradie has a similar view. Because of personal experience with relatives not getting timely TB diagnosis or appropriate treatment, and anecdotes from other doctors and researchers stating similar scenarios, she told Spotlight she is not convinced TB should be treated in the private sector at all.
Dheda disagrees with the idea that drug-susceptible TB shouldn’t be treated in the private sector. “Both the public and the private sectors prioritises patient care and well-being and improving outcomes in patients no matter what the disease. The same should apply for TB,” he said.
Strengthening TB care in the private sector
Strengthening these gaps in TB testing and treatment in the private sector is possible in theory, but according to Conradie will require significant investment by medical aid schemes to better equip general practitioners and private sector clinics.
She recommends strengthening referral pathways for the private sector to get TB patients linked to care in the public system, and strengthening education on TB for the private sector by improving awareness of how it presents and should be diagnosed.
One way to potentially strengthen the TB response in the private sector is through stronger partnerships with the public sector, particularly around testing for TB.
A 2025 pilot study conducted in KwaZulu-Natal linked 158 GPs to free public sector TB testing using an existing medical referral application (Vula). A toal of 61 of the doctors (38.6%) submitted at least one sputum sample collected at their practice to be tested for TB.
As a result, 107 people who had TB were identified and almost all were linked to care in the public sector. This showed, according to the researchers, a workable public-private mix model for TB management in a high TB burden setting, but more research is needed in this area.
There are some references to including the private sector in the National TB response: the current National Strategy Plan for HIV, TB and STI’s does list the need to engage with all stakeholders, including the private sector, on the policies and guidelines on TB prevention and management.
It also vaguely references a multisectoral collaboration that will be guided by the 2017 Moscow Declaration on multisectoral accountability framework for TB.
But how this is playing out in reality is not clear.
The role of pharmacists
A reoccurring theme in our research for this article is the notion that TB treatment in general could be improved by leveraging pharmacies – both private and public – to make it easier for people to get their medicines.
“More pharmacies in each locality should be designated to carry TB treatment,” said Dheda. “From my experience, often TB treatment is only available at certain designated private pharmacies, and it is not easy to find.”
This experience is echoed by private sector pharmacists interviewed for a recently completed master’s thesis. The thesis has not yet been published, but the author, Brenda Knipe, a pharmacist and master’s student at the University of the Western Cape’s School of Pharmacy, shared some general findings with Spotlight.
Her observations are based on interviews with 14 pharmacists from seven provinces (KwaZulu-Natal and the Northern Cape were not included), working in private hospitals or community pharmacies. She said how often pharmacists reported TB patients varied. Some saw many TB patients who come to them to get their treatment, while others never or rarely did.
For those pharmacists interviewed by Knipe who needed to refer patients to the public sector for treatment, some relied on informal networks based on contacts they’ve made in the public sector. This was due to a reported lack of clear guidelines on how or where to refer patients.
Knipe said these networks were essentially based on “who you know”. The pharmacists who didn’t have these contacts or informal networks expressed uncertainty about what to do to help their patients.
The pharmacists, according to Knipe, were eager for more consistent training and continuing professional development on TB so they can assist patients better.
The pharmacists in the study who had to provide TB patients with treatment, said Knipe, reported sometimes having difficulties in finding stock of drug-susceptible TB treatment. Most community pharmacies don’t normally keep a supply of TB drugs. If a patient does come to the pharmacy with a doctor’s script for TB medicines, the drugs have to be ordered from suppliers.
If the drugs are in stock, the pharmacists would then order the full course for that patient, dispense one month’s supply and keep the rest at the pharmacy specifically for that person.
However, not all suppliers keep a lot of stock of the drugs on hand, probably due to low demand in the private sector, resulting in some pharmacists in the study reporting that at times they had to phone several suppliers to find stock. The pharmacists interviewed who were working in private hospitals also had some difficulties sourcing stock of TB medicines, Knipe said.
Nematswerani said Discovery has had similar challenges.
“Discovery Health continues to see a decline in the availability of TB medicines within the private sector, mainly because of the relatively small number of cases managed privately,” she says.
“South Africa has a well-established public-sector treatment and monitoring programme, and many private healthcare practitioners refer patients to them for ongoing treatment and follow-up. As a result, demand for TB medicines in the private sector has progressively decreased, contributing to their limited availability.”
See more from MedicalBrief archives:
Crucial advance in MDR-TB treatment from South African team – NEJM
Tackling the threat of asymptomatic TB in South Africa
Two TB researchers on getting the disease themselves