While South Africa has made notable strides in tackling TB, the proportion of estimated cases successfully placed on treatment has declined from 79% to 74% over the past year, raising fresh concerns about gaps in the national response.
On World TB Day, the TB Accountability Consortium warned that the country is failing to reach those most affected by the disease, particularly men.
The consortium’s fifth annual report, Deep diving into the TB Dashboard: How data can drive advocacy and accountability, highlights a stark disconnect between testing and infection rates.
Drawing on the first 10 months of data from South Africa’s public TB dashboard, launched in October last year, the report shows that while women account for nearly 61% of those tested, men make up more than 60% of TB diagnoses.
In simple terms: men are less likely to be tested, but far more likely to have TB when they are.
This gap is now emerging as one of the most significant blind spots in the country’s TB response.
We have recognised that it’s mostly men who don’t test, and we want to make a call for them to visit their nearest clinics to be screened and tested for TB.
Addressing community members, health workers and civil society organisations in the Western Cape on Tuesday, Deputy President Paul Mashatile acknowledged the challenge.
“We have recognised that it’s mostly men who don’t test, and we want to make a call for them to visit their nearest clinics to be screened and tested for TB,” he said.
Mashatile stressed the need for greater awareness, expanded testing and stronger community-led responses, adding that access to diagnostics, medicines and social support must be prioritised.
Experts say the problem runs deeper than behaviour, pointing to systemic weaknesses in how TB is detected.
Prof Jan Verschoor from the University of Pretoria said current diagnostic tools are simply not effective at identifying TB early enough.
Most tests rely on detecting the TB bacteria in sputum or other invasive samples, which are difficult to obtain, particularly from children, immunocompromised patients and healthcare workers who require frequent screening.
“Even chest X-rays are not adequate to detect the early onset of active TB,” he said, warning that delayed diagnosis reduces the chances of cure and allows transmission to continue.
According to Dr Christopher Ealand from the University of the Witwatersrand, South Africa is not on track to meet its 2030 TB targets.
The country aims to reduce TB incidence by 80% and deaths by 90% compared with 2015 levels, but current trends suggest those goals are slipping out of reach.
Ealand said a major concern is the large number of “missing” TB patients, particularly those with asymptomatic or early-stage disease who are not picked up through routine clinic screening.
“We currently work with a gross underestimate of the actual number of people who have the disease,” he said.
This failure to detect cases early has a ripple effect, delaying contact tracing, limiting preventive therapy and allowing transmission to continue unchecked.
Efforts to roll out TB preventive therapy to high-risk groups, including close contacts and people living with HIV, are also falling short.
Ealand attributes this to weak active case finding and decentralised care, which make it difficult to identify and treat patients before they become seriously ill or infect others.
There are also concerns about drug-resistant TB, with experts warning that failure to break transmission cycles could lead to more complex and costly cases.
Despite these challenges, the government insists progress is being made.
Mashatile said South Africa has achieved a 61% reduction in TB incidence since 2015, while treatment success rates for drug-resistant TB have improved to 79%, with fewer patients lost to follow-up.
He added that more than 3.5-million TB tests have been conducted under the national End TB campaign, the highest number recorded in a single year.
But experts caution that testing more people is not enough if the right people are not being reached.
South Africa’s TB strategy is not failing because of a lack of plans or effort, it is faltering at the point of execution.
Until the country can find the missing patients, detect TB earlier, and close the gap between testing and those most at risk, the epidemic will continue to outpace the response.
And for now, the data is clear: the people most likely to have TB are still the least likely to be tested.
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