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Focus on key populations: TB in Farms intervention

Focus on key populations: TB in Farms intervention
Publication date: 
May 2019

Key populations in rural South Africa

The Global Plan to End Tuberculosis (TB) (2016–2020) has set targets that include reaching 90% of the most vulnerable, underserved and at-risk populations across the globe with relevant TB services. These groups of people are referred to as key populations, comprising, among others, healthcare workers, prisoners, miners, children, pregnant women, informal communities and migrants.

The WHO estimated that 322,000 people would develop TB in South Africa in 2017 but the country only reported 227,224 cases of TB2, indicating over 94,776 missing TB cases. While key populations such as clinic attendees and people living with HIV constitute the majority of contributors to the TB epidemic; migrant workers, including farm workers, also significantly contribute to the TB burden. A USAID Tuberculosis South Africa Project Initiative Seasonal farm workers in the Eastern Cape Province of South Africa.

In 2018, the agriculture industry accounted for 5.2 percent of the total employment rate in South Africa. Increasingly the sector offers temporary employment opportunities, hiring farm workers on a seasonal basis during peak harvest periods; a common situation across different farms, districts, and at times provinces. As a result many farm workers migrate to wealthier provinces such as Gauteng and Western Cape, in search of employment and better lives. Recent research indicates that migrant workers in the agricultural sector increasingly include entire families and also mothers with young children, often migrating without childcare support networks.

Among this highly mobile population are TB patients who have started treatment already but may still have a few months left before completion. However migrating TB patients often fail to communicate their movements to their healthcare provider. This affects their ability to continue with TB treatment at their next area of employment. Once their TB treatment is interrupted the TB bacteria become infectious once more, increasing the risk of the TB disease spreading.

There are multiple reasons for TB treatment interruption and although migration and socio-economic and cultural issues do play a major role, stigma associated with TB, especially in rural and mobile communities can negatively impact treatment-seeking behaviour. Often farm workers do not disclose their TB or HIV status to their employers or to the communities in which they live for fear of losing their jobs or being discriminated against. Insufficient communication between patients and healthcare workers, and associated low treatment literacy also poses challenges since the importance of TB treatment adherence is at times not adequately explained to patients.

TB risk among farm workers in Sarah Baartman District

Sarah Baartman District in the Eastern Cape Province, ranks third in terms of agricultural production in South Africa. The district produces many agricultural outputs, including goats for mohair, ostrich, honey bush tea and citrus fruits. More than 2,500 commercial farms are active in the district. Seventeen percent (17%) of the district’s population of 450,516 live on farms, and many more in informal settlements around the farms.

In 2018, the district reported a total of 4,748 TB cases, translating to 1,054 cases per 100,0008. The situation is compounded by the district reporting a loss to follow-up rate of 16.7 percent, a 6.3 percent death rate and 9.7 percent not evaluated, all higher than the targeted 5 percent.

Furthermore, studies in South Africa suggest that farm workers have one of the highest HIV prevalence rates among any employment sector in South Africa. The often unhygienic living conditions and the high risk of HIV infection and exposure to other communicable diseases also increase the risk of TB infection.

TB in Farms initiative

In response to the challenges mentioned, the USAID Tuberculosis South Africa Project launched the TB in Farms initiative in collaboration with the Eastern Cape Provincial Department of Health.

The initiative aims to find missing TB patients in farming communities, and to ensure that people diagnosed with TB are provided with appropriate health services. Before the initiative was launched, the project conducted a baseline assessment, which included community dialogues, to determine what TB services are available on farms in the district, the level of understanding that farm owners have about TB and HIV, as well as challenges farm workers face that could make TB care and treatment difficult. The assessment showed a significant lack of knowledge around TB and HIV, high rates of alcohol abuse and incidences of stigma and discrimination, as well as the absence of reliable health services.

TB in Farms intervention package

To address some of the challenges highlighted during community dialogues, the TB in Farms initiative offers a comprehensive package of services aimed at:

  • increasing TB awareness among farm workers and local communities,
  • building capacities of local health workers and stakeholders on basic TB management, and
  • improving farm workers’ access to health services. 

To ensure sustainability and to leverage on available local resources, the TB in Farms initiative was launched as a public-private partnership project between stakeholders in Sarah Baartman, including the Sundays River Valley Citrus Producer Forum, Sundays River Valley Municipality, National Health Laboratory Services (NHLS), District Department of Health and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through district support partners Kheth’Impilo and Beyond Zero.

Launch of the TB in Farms initiative 

The TB in Farms initiative was officially launched in the Kirkwood,  Addo and Gamtoos farming communities in Kouga Sub-District of Sarah Baartman District in May 2017. Sipho Richard Ludidi (shown on the left), a farm worker at Sun Orange Farm, is a TB survivor who had the opportunity to share his story and views during the event. He explained: 

“The fact remains, TB kills and people need to take treatment and complete it in the prescribed time. I am living testimony of this and how it is possible to beat the disease. From my experience, support has proven to be very important as part of the journey and I thank my employers and all the partners involved for providing this platform”.

The launch kicked off with the provision of health screening services that offered comprehensive health services to farm workers and their families living in the surrounding farming communities, as well as to farm owners and farm dwellers. A health screening campaign was conducted in 13 farms and reached 1,500 farm workers in the Kouga Sub-District.  A range of services were provided, including TB screening, testing and treatment, as well as HIV testing services and comprehensive health education on HIV and TB. 

Pledging her support for the initiative, Ms Nombulelo Hawu, Mayor of Sundays River Valley Municipality in Sarah Baartman District said, “TB has found a resting place in our people and we cannot accept or allow this to continue. We have to address this as a matter of urgency, not forgetting the socio-economic challenges our communities face on a day-to-day basis”. 

Since the launch, the project lead the facilitation process of the signing of a Memorandum of Understanding (MOU) between the Eastern Cape Department of Health and San Miguel - The Global Citrus Experts, in November 2018.   

Addressing TB among the rural key population will greatly contribute to efforts toward ending TB in South Africa. To this end, the USAID TB South Africa Project will continue to support farming communities by improving and expanding the initiative to other areas.