MDG 6 has as a target detecting at least 70% of new sputum smear-positive TB cases and cure at least 85% of these cases plus to reduce TB prevalence and death rates by 50% relative to 1990 levels.

The authors of the SAHR review chapter on HIV/AIDS and TB pointed out that mortality due to TB and treatment interruption remained high in South Africa.

They attributed this to the high HIV infection rates and weak ‘€œhealth care service delivery mechanisms’€.

Before the emergence of HIV, the Western Cape reported the highest rates of TB. However, in 2006 KwaZulu-Natal, with an antenatal HIV prevalence of 39.1%, exceeded the national HIV incidence rate, reporting a TB prevalence rate of 1 066 per 100 000 population. The province also had among the worst National TB Programme performance indicators.

The SAHR confirms that the challenges faced are substantial and include increasing caseloads in the face of over-burdened health infrastructure, extremely poor cure rates in some provinces, high mortality, high treatment interruption rates, high levels of TB-HIV co-infection, increased levels of multi-drug resistant TB (MDR-TB) and the emergence of extensively drug resistant (XDR) TB.

Of the high burden TB countries, South Africa has among the highest estimated costs for TB. This is due mainly to two reasons: the enormous cost of maintaining about 8 000 TB beds and the cost of diagnosing and treating drug resistant TB.

Other challenges facing South Africa’€™s ability to meet the MDGs are high treatment interruption rates, late presentation of patients to health facilities, insufficient community engagement, the HIV epidemic and poverty.

The SAHR revealed that of the 2 472 and 2 572 cases of MDR-TB diagnosed in KwaZulu-Natal laboratories in 2005 and 2006 respectively, only 56% in 2005 and 28% in 2006 were treated in hospital. The remaining patients died while awaiting admission, were lost to follow-up or remained infectious in the community.

‘€œThis situation highlights the discordance between the number of central beds available for management of drug resistant TB and the actual caseload,’€ the authors said.

The former health department Director General Thami Mseleku defended the institutional model for years despite the fact that it was not reaching the majority of those with drug resistant TB.

Under health minister Dr Aaron Motsoaledi there has been a definite move towards decentralising the management of MDR-TB.

Under the new policy the centralised MDR-TB units (one in each province) will be responsible for initiating and monitoring treatment of MDR-TB and XDR-TB cases, in addition to providing support to the decentralised satellite MDR-TB units within that province.

Decentralised MDR-TB units will initiate and monitor treatment of only MDR-TB cases.

Mobile MDR-TB clinics and community supporters will provide treatment and support to MDR-TB patients after they have been discharged from both the decentralized and satellite units.

Despite these challenges, TB control in South Africa has improved somewhat in the last 10 years, but not enough. South Africa has failed to achieve the targets set by the World Health Assembly and this has led to a realisation that the programme needs to be overhauled.