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Outcome Indicators
Health Systems Trust
2010-03-30
Tuberculosis
South Africa is at the centre of the concurrent human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics. The country has the largest number of people living with HIV infection in the world (about 5.5 million people) and in 2007 South Africa accounted for 17% of the global burden of HIV infection.1 The incidence of TB continues to rise and the 2007 incidence rate of 805 per 100 000 led to South Africa being ranked fifth in the list of 22 high burden TB countries in 2009.2 In 2007, 73% of those with TB were co-infected with HIV.2
4.2.1 Case Finding
The treatment of patients with TB continues to improve, although the improvement is slower than it should be (see the sub-sections on smear conversion and cure rates below). While new smear positive case finding increased slightly between 2007 and 2008 on a national level, new smear positive case finding has decreased in 21 of the 52 districts. During the same period, case finding in the 'all TB' category has decreased in 10 of the 52 districts, but has increased by 9% nationally. District TB management programmes should focus on improving TB case finding, especially new smear positive cases. Improved case finding, together with effective treatment, is required for the TB epidemic to be curbed.
The districts requiring greater focus on case finding activities are those where the incidence of new smear positive TB cases is high, e.g. Cacadu (EC), Dr Kenneth Kaunda (NW), Eden (WC), Ugu (KZN) and Nelson Mandela Bay Metro (EC), together with those districts where the TB caseloads are high, e.g. eThekwini (KZN), City of Cape Town (WC), City of Johannesburg (GP) and Amathole (EC), as shown in Figure 1: Number of TB cases reported (all TB) by district, 2008.
Figure 1: Number of TB cases reported (all TB) by district, 2008
4.2.2 Smear Conversion Rate
It is encouraging to note that the country is edging closer to the smear conversion rate (SCR) national target of 70%. In 2008 the average SCR for South Africa was 62.5%, compared to 60.5% in 2007 and 55.8% in 2006. Although the slow but steady increase over the last five years is positive, greater efforts are necessary to effectively treat this pool of infectious patients in order to curb the TB epidemic and curtail the number of patients who develop drug-resistant TB.
Four provinces have failed to increase their SCR over the last year (2007-2008): Eastern Cape, North West, Western Cape and Free State, although the latter two were above the national target. Of these, the North West Province is of greatest concern as the SCR in the province has not improved over the last five years and it is the only province with a SCR lower than 50%. Three provinces achieved SCRs higher than the national target: Gauteng, Free State and Western Cape. Gauteng had the highest SCR (77%) with five of its six districts above 70%.
Figure 2: Smear conversion rate (new Sm+) by district, 2008, shows that the smear conversion rate in 2008 varied markedly across districts, ranging from a high of 86.6% in Overberg (WC) to a low of 40.7% in Alfred Nzo (EC). A further four districts excelled, achieving SCRs of more than 80%: Metsweding (GP), Ekurhuleni (GP), City of Tshwane (GP) and Umzinyathi (KZN). Similarly, three of the country's 18 priority sub-districts achieved SCRs of more than 80%, namely Engcobo (EC), Kungwini (GP) and Bushbuckridge (MP).
Many of the districts and sub-districts that achieved SCRs of over 80% are in rural areas and are often hindered by constraints in human resources and infrastructure. These districts serve as an example to the rest of the country, indicating what can be achieved if issues are prioritised and there is effective leadership. The 15 districts that have achieved the national target of 70% must now strive toward achieving the World Health Organization (WHO) target of 85%.3
Figure 2, together with the accompanying DHB data file, helps to identify the lesser-performing districts, as illustrated by low SCR values, that require intensified support from the provincial TB co-ordinators. Different levels of focus include:
- Metros: eThekwini (KZN) and the Nelson Mandela Bay (EC) metros where the TB caseload is high but the SCR remains below 60%.
- Districts: A number of districts have shown minimal improvement over the year and in 17 of the districts the SCR has decreased - in Ngaka Modiri Molema by 10%. In addition to the latter, the following districts have decreased by over 5% - Xariep (FS), Mopani (LP), Vhembe (LP), Alfred Nzo (EC), West Rand (GP) and Gert Sibande (MP).
- Sub-districts: 5 of the 18 priority sub-districts have SCRs of less than 50%. These are Moratele (NW), Maphumulo (KZN), Umhlabuyalingana (KZN), Umzimvubu (EC) and Qaukeni (EC).
Figure 2: Smear conversion rate (new Sm+) by district, 2008
Figure 3: Smear conversion rate (new Sm+) by metro district, 2008
Figure 4: Smear conversion rate (new Sm+) by priority sub-districts, 2008
Figure 5: Annual trends: Smear conversion rate (new Sm+), 2008
4.2.3 Cure Rate
The WHO cure rate target is 85%3. South Africa set a more achievable interim target of a 10% increase per year, but this has not yet been attained. Over the last four years the cure rate has risen by only 13.2%, from 50.8% in 2004 to 64.0% in 2007. Although too slow, this steady improvement is promising and staff working in the TB control programme must be encouraged to intensify their efforts.
Cure rates vary across the provinces. Three provinces (Western Cape, Gauteng and Free State) have cure rates of over 70% and two provinces have cure rates of under 60% - KZN (55.4%) and North West (54.1%). Over the last four years cure rates in all provinces, except Limpopo and the North West, have improved. Although the cure rate in the Northern Cape declined over the last year, it is possible that the 19% improvement recorded in 2006 was not accurate and the 62.8% cure rate for 2007 is more reliable.
A large variation in cure rates across districts is evident from Figure 6: TB cure rate (new Sm+) by district, 2007, with values ranging from a high of 85.4% in Overberg (WC) to a low of 39.1% in Umkhanyakude (KZN). Twenty districts achieved the national target of 70% and, in addition to Overberg which achieved the WHO target, Umzinyathi (KZN) and Eden (WC) excelled with cure rates of 80%. In contrast, a number of districts have failed to improve their cure rates over the past year (2006 - 2007). Five of the 10 districts with the lowest cure rates in the country are in KwaZulu-Natal. Six districts had cure rates of less than 50%: Uthukela (49.9%), eThekwini (49.2%) and Umkhanyakude (39.1%) in KwaZulu-Natal Ngaka Modiri Molema (48.4%) and Bojanala Platinum (48%) in the North West and Nkangala (45%) in Mpumalanga. Cure rates in the metros showed a similar pattern to the SCRs with Nelson Mandela Bay and eThekwini metros performing the worst.
An analysis of the cure rates in the 18 priority sub-districts reveals further discrepancies in the performance of the TB programme. Senqu (EC) and Umhlabuyalingana (KZN) had cure rates of less than 40%, while Umzimvubu (EC) had a cure rate of 11.3%. An analysis of the reasons for the poor cure rates and an investigation into the relationship between cure rate and defaulter rate should be addressed as a matter of urgency, especially in these weaker districts and sub-districts.
Figure 6: TB cure rate (new Sm+) by district, 2007
Figure 7: TB cure rate (new Sm+) by metro district, 2007
Figure 8: TB cure rate (new Sm+) by priority sub-district, 2007
Figure 9: Annual trends: TB cure rate (new Sm+), 2007
Resources:
The indicators in these sections are calculated from the Basic Accounting System (BAS) data obtained from National Treasury, North West Province's financial data, National Treasury data on Local Government expenditure, the current DHIS mid-2008 population estimates and the 3-year rolling average of medical aid coverage calculated using the General Household survey data 2005-2007.
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REFERENCES
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS epidemic update 2008. Regional Summary Sub-Saharan Africa. Geneva: UNAIDS 2008.
2. WHO. Global Tuberculosis Control: Epidemiology, strategy, financing. WHO Report 2009. (WHO/HTM/TB/2009.411). Geneva: World Health Organisation 2009.
3. WHO. Global Tuberculosis Control: Surveillance, planning, financing. WHO report 2007. (WHO/HTM/TB.2007.376). Geneva: World Health Organisation 2007.
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