Calls grow for improved TB financing and district-level integration to close service gaps
By: Aphelele Buqwana
South Africa’s ability to better integrate TB services at district level to improve service delivery will need not only clinical and operational interventions, but also greater consideration of how socio-economic factors outside the health system drive the progression of the disease.
These issues, together with the need for stronger accountability, improved financing and community-led approaches, emerged as recurring themes during a satellite session hosted by TBAC in partnership with the AIDS Healthcare Foundation (AHF) South Africa at the 9th SA TB Conference.
The session, titled “How better co-ordination, financing and integration can improve TB implementation in districts”, focused on strengthening TB service delivery through improved coordination, financing and integration at district level.
During the session, speakers called for urgent reform of how health services are financed and delivered at district level, arguing that persistent gaps in coordination and resource allocation continue to undermine effective service delivery.
The panel discussion included Ramphelane Morewane, Chief Director of District Health Services at the National Department of Health, Russell Rensburg, Project Director at TBAC and Gladys Tshabalala, SANAC’s Civil Society Forum Gauteng TB representative.
Ramphelane Morewane, raised concerns about the deep social and economic drivers of TB, arguing that poverty continues to undermine clinical progress in treating and controlling the disease.
He said mobility and migration patterns illustrate the scale of the challenge, noting that high TB burden is often linked to vulnerable populations moving across borders in search of work and survival.
“We know that in each of those cars moving from one place to another, the likelihood is that some of the people are TB positive,” he said, referring to migrant communities moving between countries in the region.
Morewane stressed that even when patients are diagnosed, the ability to complete treatment is often shaped by poverty and competing survival needs, adding that financial hardship often forces people to prioritise immediate survival over long-term health.
He further warned that fragmented funding models and reliance on external donor funding continue to limit the effectiveness of the TB response.
“The enemy of all this is the donor funding,” he said, calling for more integrated and sustainable domestic approaches to TB financing and care.
Russell Rensburg focused on the constraints within the health system itself, particularly how current financing structures limit the ability to respond to real-time data and emerging service needs.
He said current health financing structures are limiting the health system’s ability to respond to real-time evidence generated through routine data systems.
“We know we need to respond to what the data is telling us, but because of the way we fund, that’s very difficult,” he noted.
He explained that while health dashboards and routine reporting systems generate valuable insights, budgets are often too rigid and “line-item bound” to allow programmes to adapt quickly to emerging needs.
Rensburg added that reform should begin with stronger use of data, improved coordination across the health system, and a shared understanding of what a basic package of services should look like at facility level.
Gladys Tshabalala spoke on behalf of communities affected by the disease during the session.
She supported Morewane’s concerns, emphasising that TB remains deeply rooted in broader social and economic conditions that extend beyond the health system.
“TB remains deeply linked to poverty, HIV, malnutrition, unemployment, overcrowding, gender inequality and other social determinants of health,” she said.
She stressed that responding to TB in a meaningful way requires more than clinical interventions, calling for stronger investment in community systems and leadership.
“Supporting TB-affected communities requires more than clinical services. It requires deliberate investment in community systems, community leadership and integrated delivery that responds to both medical and social realities,” she said.
She also pointed to the District Health Programme Grant as an important opportunity to strengthen community-based responses and improve integration across TB, HIV and non-communicable diseases.
“At community level, integration means delivering person-centred services that recognise that people often face multiple health challenges at the same time,” she said.
She added that this should be reflected in practical service delivery, including community outreach programmes led by community health workers and community-based organisations offering TB screening, HIV testing and counselling, as well as screening for conditions such as hypertension and diabetes.
Dr Nombuso Madonsela, Country Program Director at AHF, echoed concerns raised by panelists, saying lack of integration across government departments continues to undermine the TB response, particularly given the social and economic drivers of the disease.
Madonsela stated that this disconnect at national and provincial levels is ultimately felt most sharply at facility level, where clinic managers are expected to implement multiple programmes with limited resources and overlapping demands.
“These places an unrealistic burden on frontline healthcare workers, particularly those managing small clinics, who are required to integrate services within constrained budgets and competing programme priorities,” she said.
Madonsela also pointed to the way health financing is structured, noting that while conditional grants exist, funding is often unevenly distributed across programmes, with HIV receiving a larger share compared to TB and other services.
She called for a rethink of how resources are allocated, arguing for more systematic integration and flexible funding models that reflect the realities of district-level service delivery.
“We need to move away from one-size-fits-all policy approaches,” she said, warning that uniform implementation often ignores the capacity constraints of smaller facilities.
The session closed with a shared view that strengthening TB outcomes at district level will require more than incremental adjustments to existing systems. Speakers emphasised that sustainable progress depends on aligning financing, coordination and service delivery with the realities faced at community level, where the combined impact of poverty, mobility and unequal access to care continues to shape the country’s TB burden.