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South African Community Rights and Gender Assessment

South African Community Rights and Gender Assessment
Publication date: 
Jul 2020

EXECUTIVE SUMMARY

Introduction

International bodies and national TB programmes have scaled up their efforts to meet the aims outlined in the Global Plan to End TB (2016 – 2020), which include reaching at least 90% of all people with TB, reaching at least 90% of TB-key populations (defined as the most vulnerable, underserved, at risk populations), and achieving at least 90% treatment success for all people diagnosed. The Stop TB Partnership (http://www.stoptb.org) has engaged an array of countries to implement national Community, Rights and Gender (CRG) Assessment processes, which examine the ways in which gender, affiliation to certain selected TB-key populations, and the legal and policy environment impact on vulnerability to TB infection and disease, and access to care and treatment.

The South African assessment, led by TB HIV Care, had the following objectives:

  1. To determine gender-related barriers and facilitators to accessing TB services, and develop recommendations for overcoming barriers and scaling up any facilitators.
  2. To assess available baseline data on selected key populations likely to be missed by current services, to develop additional data on the barriers to access to care, and to develop recommendations on how to increase available data and facilitate access to care.
  3. To determine legal and human rights-related barriers and facilitators to accessing TB services, and develop recommendations for overcoming barriers and scaling up any facilitators.

Process

The assessment process followed the following steps:

  1. Inception planning
  2. Initial literature reviews: to provide baseline data for core group meeting
  3. Core group meeting: to nominate members for the workstream teams and the multi- stakeholder working group, approve the grant application and narrow down key populations to be proposed to multi-stakeholder working group
  4. Research protocol draft: for presentation at the first multi-stakeholder meeting
  5. Meeting of multi-stakeholder working group: to discuss and approve ethics protocols, tools, and to select key populations for further research through a prioritisation process
  6. Revision of literature reviews: to include areas and additional highlights in the multi- stakeholder meeting and to expand on reviews for the selected key populations
  7. Revision and submission of ethics protocols: to include refinements based on the multi- stakeholder meeting
  8. Development of scoping reviews: to provide insight into national guidelines and processes related to assessment areas9.
  9. Implementation of qualitative research processes: to gather new insights into the areas of the assessment
  10. Data analysis
  11. Drafting of findings
  12. Meeting of multi-stakeholder working group to validate findings
  13. Report compilation
  14. Report dissemination

Qualitative research methodology

The qualitative research asked the following key questions:

  1. How do gender identity, belonging to one or more of the selected key populations, and the current legal and policy environment impact on TB vulnerability, care access and treatment outcomes?
  2. What policy and programmatic changes could be made to improve the TB response to ensure service provision that is:
    • Inclusive of members of the selected TB-key populations
    • Gender sensitive and responsive
    • Grounded in a human-rights based approach

The research used a combination of key informant interviews, facility observations, focus group discussions with healthcare providers and people affected by TB, and facilitated research activities with people affected by TB. The research tools were designed to broadly capture the dynamics and experiences of TB infection, diagnosis, care access and quality and treatment completion from the perspectives of people affected by TB (patients and family members), healthcare providers and stakeholders (including civil society advocates and government representatives).

The qualitative research included the following populations:

  • Men, women and transgender people affected by TB. In this case, ‘people affected by TB’ refers to people who are ill with TB and their family members, dependents, communities and healthcare workers who may be involved in caregiving or are otherwise affected by the illness.
  • People who self-identified as belonging to the following three selected key populations, and have been affected by TB:Research was conducted in the Eastern Cape and Western Cape. These provinces were selected in the first multi-stakeholder meetings because they have high TB burdens, had representations of the key populations included in the research, and had partner organisations that could assist with accessing the selected key populations. Key informant interviews were either conducted at a place suitable to the interviewee, telephonically, or over skype. In the Western Cape, facility-based research was conducted at two facilities – one TB hospital, which provides in-patient treatment to people in Boland towns and surrounding farm areas, and another urban facility in Cape Town. In the Eastern Cape, research was done in one healthcare facility on the outskirts of Port Elizabeth, which provides services to urban and rural populations. Sites for key population focus groups were selected by partner organisations based on the location accessibility to the people in the key populations being engaged.
    • Farm dwellers. We focused on people working and living on farms as a subset of the rural population that faces particular difficulties in relation to care access.
    • Healthcare workers. Focus groups and facilitated activities focused on community healthcare workers (CHWs) as members of the community working as part of the healthcare system to provide frontline care and support for people with TB. We chose this focus is because we found less information available in the literature about their experiences than that of other healthcare workers. Our facility-based research and discussions key informant interviews included healthcare workers more generally, where healthcare workers is taken to mean all people working within healthcare settings, or directly for the provision of healthcare.
    • People who use substances. In this category, we have included both individuals who use alcohol in ways that might disrupt treatment and those who use unregulated drugs. This inclusion is premised on the fact that there are many overlapping concerns between these two groups of people who use these substances. We distinguish between people who use alcohol and people who use drugs only when the literature makes this distinction, or as far as it is important for the analysis.
    • Contacts of TB-index patients. We also included an exploration into accessing Contacts of TB-index patients, but this was done through incorporating questions about contacts and contact tracing into the other research areas.

All participants were required to be 18 years old and older (based on self-reports) and to provide informed consent for their data to be included in the research report. In addition, participants had to have been affected by TB in the past five years; and/or self-identify as belonging to one of the selected key population groups; and/or work with, or have an interest in one of the selected key populations and the TB response; and/or work with or have an interest in gender-related aspects of the TB response.

Data was collected by two trained social scientists between September and November 2018. Research processes were guided by data collection tools set out in the approved research protocol. Data was recorded through a combination of audio recordings, written notes and participant-drawn images. Audio recordings were transcribed and, where necessary, translated. Data was analysed thematically in NVivo.

Research was conducted with careful attention to the vulnerability of the included populations. All processes were approved by the Human Research Ethics Committee at the University of Cape Town, as well as by the Department of Health in the Western Cape and Eastern Cape.

Key limitations to the work include the focus on the perspective of TB affected individuals, rather than that of healthcare providers and policy makers; limited geographic coverage, which limits generalisability; the inclusion of only a few key populations; limited inclusion of gender minorities other than transgender women; and the selection bias resulting from accessing participants through service providing non-profit organisations. We were notably not able to access the perspectives of people actively avoiding any healthcare.

Findings

This section provides a summary of the findings in the report. It prioritises the findings of the qualitative research, but also draws on insights in the relevant available literature on TB in South Africa. It starts with the overarching findings that apply across the board to the genders and key populations included in this assessment. This is followed by the findings per researched population.

Overarching findings

  1. TB knowledge is limited in people affected by TB. All people have the right to access to information and the right to health, which includes health information. The National Strategic Plan (NSP) makes clear provision for information and social behaviour change communication around TB. However, it appears that messages are not reaching TB affected people and the people with whom they have close contact. This is possibly a resource and implementation issue rather than a legal and regulatory issue.
  2. TB-related stigma and discrimination is pervasive. Stigma impacts negatively on the psychosocial well-being of TB affected individuals, access to care and TB status disclosure. While law and policy protect all people’s right to equality and non-discrimination, this is not TB-specific. The NSP also provides for various measures to address TB-related stigma and discrimination, but this work is still in its infancy and needs further understanding, expanding and strengthening. Criminal laws that prohibit drug use and sex work have also been found to exacerbate stigma and discrimination against affected populations, increasing barriers to health care.
  3. TB counselling and support processes are concentrated at the beginning of the treatment period. These processes are also overly focused on adherence to treatment, without providing support for potential psychosocial or structural barriers to taking treatment. TB plans and guidelines do provide for counselling at various intervals during the treatment period, including for Contacts of TB-index patients. They also provide for training of healthcare workers, including counselling training for CHWs. However, the TB Management Guidelines do not provide for sufficient ongoing counselling and education processes. In addition, it appears that in practice facilities do often not have sufficient capacity and resources to implement holistic counselling and support.
  4. Gender impacts on vulnerability to infection, access to TB diagnosis and treatment, quality of care and treatment completion. Men are markedly more vulnerable to TB infection and disease and have higher mortality than women. Structural barriers to accessing TB services for men include cultural attitudes towards health-seeking and insufficiently tailored healthcare services. Women have lower morbidity and mortality rates and access care with greater ease than men, but suffer additional strains in their roles as care providers. Transgender people face extreme vulnerabilities and extensive stigma, which inhibits treatment access and care. Yet gender differences are not adequately reflected in health and TB policy and guidelines. As a result, healthcare providers are not educated on, or able to respond to gendered needs and gender diversity in TB management processes.
  5. Human rights contraventions are occurring frequently in TB care provision in the public healthcare sector, especially for members of key populations, and there is limited access to justice for violations. Violations include stigmatising attitudes and behaviour, inequitable care and exclusion from treatment, including to gender minorities and key populations. Law and policy provide for non-discriminatory access to healthcare, although not specifically on the grounds of TB. All persons also have the right to legal redress for rights violations. Furthermore, The NSP provides for intensified efforts to reduce healthcare related stigma and discrimination in the context of TB, including sensitisation training for Healthcare Workers (HCWs), strengthening monitoring and complaints mechanisms, and improved access to justice. It appears that these measures need strengthened implementation.

Men

  1. Men’s TB risks largely exist outside the home. This includes risks in public transport and social spaces and, notably, in male-dominated work environments such as construction and agriculture. Broadly speaking, South African labour law provides all employees with the right to be protected from occupational injury and disease and the right to compensation. In practice, however, participants in this research seemed unaware of their rights to a safe working environment, to compensation for occupational injury and disease and to access to justice for rights violations.
  2. Men affected by TB tend to experience challenges accessing healthcare due to cultural norms that discourage healthcare access unless illness is severe. Men reported that accessing traditional healers was more acceptable than accessing the public healthcare system.
  3. Clinics are not seen or experienced to be male-friendly spaces. This is because the majority of patients are women and services are focused on mothers and children.
  4. Healthcare workers may prefer and encourage fewer men in clinics. This is because groups of men can feel threatening and security is limited.

Women

  1. Women generally frame their TB risk as existing within the home, often from men who are infected and not on treatment.
  2. Women access healthcare with speed and ease, but they suffer additional difficulties when ill due to their role as care providers. This is because while self-care, including ensuring health, is seen as an expression and requirement of good womanhood and motherhood, conversely, these social requirements place additional pressures on women to be care providers, even when they are in need of care themselves.

Transgender women

  1. There is extremely limited data available on TB in transgender persons in South Africa, including a dearth of incidence and prevalence data.
  2. Transgender women face numerous and layered vulnerabilities to TB infection and disease. Social marginalisation results in homelessness, joblessness, sex work and drug use. These, in turn, increase risk of HIV infection and rates of incarceration, which further exacerbate vulnerability to TB infection and disease.
  3. As an extremely marginalised population, transgender women suffer daily stigma and discrimination in the general community and in the healthcare system. This discrimination serves as a critical barrier to access to care and treatment and continues, despite the fact that South African law and policy protects all persons, including transgender persons, from discrimination.
  4. HCWs are not sensitised to the difficulties faced by transgender women or equipped to understand and respond to the needs of transgender women accessing TB services. While the NSP provides for the needs of transgender people, including for stigma and discrimination reduction, this is largely in relation to HIV, for which transgender persons are a key population.

Farm dwellers

  1. Farm dwellers face numerous vulnerabilities to TB infection and disease. These include crowded living conditions; a substantial migrant population; lung conditions consequent of exposure to silica dust and pesticides; exposure to other people who are not on treatment; and poor knowledge about TB infection and spread. Farm workers have the right to safe working conditions under general labour laws. However, unlike in the case of mines, there are no specific agriculture- related policies or guidelines relating to safe working conditions, access to care and compensation for occupationally acquired TB.
  2. Access to TB treatment and care depends on the attitude of the farm owner or manager. Despite protective labour laws, power imbalances between farm workers and employers limit the ability of farm workers to access care and legal redress. They fear losing their jobs based on a positive TB diagnosis. Where farm owners are sensitive to the needs of TB care and engaged in supporting workers, it facilitates care, but may compromise confidentiality.
  3. Farm dwellers face substantial barriers to appropriate care access, despite the fact that all persons have the right to accessible and appropriate health care services. Barriers include long distances from local clinics; difficulty getting time off work, especially for contract workers; difficulty finding transport to local healthcare facilities; local clinic resourcing not always matching the size of the population served; and small local clinics that lack the capacity to deal with complex cases.
  4. Healthcare providers are not always sufficiently accommodating of the barriers to care access faced by farm dwellers and workers. Practices that serve to exclude farm dwellers and workers from care include refusal of care to those who arrive at the healthcare facility late in the day due to difficulties with transport or getting time off work, and insisting on daily facility attendance in the early treatment period, despite the impossibility of regular facility access for some people. Conversely, some health workers are adapting treatment protocols to be more flexible based on patient health and needs.

Healthcare workers

  1. HCWs are at high risk of contracting TB in their work contexts. High levels of risk are largely because healthcare workers are inadequately educated about their own vulnerability; in-facility infection control is inconsistently implemented and poorly measured; and accountability for safe working conditions remains a challenge. This despite their right to be protected from occupationally acquired pulmonary TB infection being recognised in South African labour law, as well as in policy, including the Occupational Health and Safety Act (OHSA), NSP, the DR-TB Treatment Guidelines and infection control policies.
  2. CHWs face significant difficulties protecting themselves when working in the homes of patients. This is due to poor community knowledge of TB and infection control; difficulties in using an N-95 respirator with patients in a home-based context prior to TB diagnosis; and lack of information about whether TB-affected people being recalled have drug-sensitive (DS) or drug-resistant (DR) TB. Furthermore, N-95 respirators may not always be regularly supplied to HCWs or correctly fitted, especially when they are provided by non-governmental organisations (NGOs). Despite these vulnerabilities, CHWs are not protected by current labour regulations, although the recent Policy Framework and Strategy for ward-based primary healthcare outreach teams (WBPHCOT) seeks to improve provision for their occupational health and safety.
  3. Systems of support and compensation for occupationally acquired TB for healthcare workers are currently not uniform, exclude extra-pulmonary TB, and only apply to healthcare workers who are employees. Healthcare workers who contract occupationally acquired TB are not always supported to apply for compensation, as responses are dependent on facility management, despite the fact that in South African law pulmonary tuberculosis (PTB) is recognised as an occupational disease in the healthcare setting.
  4. HCWs affected by TB experience TB-related stigma and discrimination in the community and in their places of work. This is despite the fact that all persons, including employees, have the right to equality and non-discrimination and fair labour practices. This undermines accessing TB testing and care at work. The availability of treatment at work facilitates access, but undermines confidentiality, which is particularly problematic where stigma levels are high.

People who use substances

  1. Various laws and policies serve to exclude or discourage people who use substances, particularly the most marginalised, from TB care access and treatment. These include laws criminalising drug use, procedures for admission and referral for medically complex TB cases (e.g. requirements for an ID document and fixed address) and policies that serve to limit the availability of opioid substitution therapy for people who use heroin and require inpatient TB care.
  2. Stigma and discrimination to people who use substances within the healthcare setting undermines treatment quality and access. People who use substances are routinely subject to shaming, scolding, confidentiality breaches and conditional access to care.
  3. HCWs are not equipped to effectively manage people who use substances. HCWs are generally ill-informed as to if and when there may be interactions between alcohol, unregulated drugs and TB medication. They are consequently often providing incorrect information to people who use substances, for example, propagating the myth that complete abstinence is a requirement for TB cure. This contributes towards poor treatment outcomes.
  4. People who use drugs avoid the healthcare system because of past experiences of discrimination and withdrawal while waiting for assistance.
  5. A harm reduction approach to drug use and dependence is a key approach in the forthcoming National Drug Master Plan (NDMP) but is presently not integrated into the TB management system.

Contacts of TB-index patients

  1. Effective tracing and linkage to care for contacts of TB-index patients, especially children, is inadequate due to healthcare facilities lacking the training, capacity and resources. Although linkage to care for contacts of TB-index patients is provided for in TB policy and treatment guidelines, there is some confusion between various health guidance documents as to who should be regarded as a contact patient and whether or not these are necessarily household members.
  2. Tracing of the contact of TB-index patients is undermined by pervasive TB-related stigma and discrimination, and poor levels of knowledge about TB. All persons have the right to protection from unfair discrimination in South African law. However, poor knowledge feeds into pervasive stigma and discrimination and shame in TB-affected people, which undermines TB status disclosure and the willingness of contact patients to be linked to care. Poor understanding and knowledge about the availability of preventive therapy - currently isoniazid preventive therapy (IPT) - further undermines effective prevention.
  3. Clear guidelines and standardised processes for systematic reporting and monitoring of contacts identified, screened and linked to care are not in place. The exclusion of TB-index patient contact tracing data from key performance indicators undermines the emphasis on this aspect of work in TB-care facilities. There is a need for standardised reporting and monitoring and evaluation of contact management and preventive therapy delivery.

Recommendations

  1. Implement a national TB education campaign as provided for by the NSP. A national education campaign that focuses on ensuring that the general population has a better understanding of what TB is, how it is spread, as well as how it can be prevented should be implemented. This should include comprehensive education about prevention strategies, information about children’s vulnerability to TB infection, information about the gendered dynamics of TB infection, and information on health rights.
  2. Develop a comprehensive and coordinated national stigma and discrimination reduction plan. This should include further efforts to understand TB-related stigma at a community and facility level and to coordinate and fully implement, monitor and evaluate the scale up and expansion of existing strategy and policy commitments and programmatic responses.
  3. Improve counselling and support processes for TB-affected people in policy and in practice. Building on the provisions in the NSP, review TB Treatment Guidelines to provide for continuous counselling and support processes through the illness period for people affected by TB that, amongst other things, fully integrate rights-based issues.
  4. Build recognition in policy makers and healthcare providers that gender impacts on vulnerability to TB infection and on care access, to review and improve gender-sensitive and transformative policies, plans and programmes.
    1. Support the use of the gender-disaggregated data gathered by healthcare facilities to review and strengthen gender transformative TB policies, planning and programming. 
    2. Ensure implementation of gender transformative policies and programmes, through provision of training and resources.
  5. Ensure that all measures to prevent and address TB-related stigma and discrimination, especially for vulnerable and key populations, as outlined in the NSP, are implemented.
    1. Ensure that healthcare workers receive sound, continuous training on a human rights-based approach to service provision.5.2. Strengthen awareness of and access to complaints and accountability mechanisms to facilitate reporting of violations and to ensure that the consequences for healthcare providers who contravene human rights in the process of care provision.

Men

  1. Recognise men’s particular risks of TB infection in TB policy and programming.
    1. Consider law and policy review to encourage all risky work environments to develop TB- specific prevention and care protocols and processes. These can build on the example provided by the mining industry.
  2. Review policy and guidelines and develop programmes to recognise and work with notions of masculinity and cultural norms that discourage treatment seeking in TB programming and planning.
    1. Seek to actively include traditional healers and cultural leaders in the TB response.
  3. Implement a drive to create male-friendly TB diagnosis and treatment facilities, times and locations. Experience and insights gathered from services for men who have sex with men could be used to create safe spaces for men in general.
  4. Ensure that healthcare providers are sensitised to the difficulties men face accessing care and trained on their responsibility to provide equitable care to all people.
    1. Ensure that staffing and security provisions in clinics are adequate, and that facility staff are trained in managing gender dynamics and de-escalating potential conflicts, while still upholding the right to treatment access.

Women

  1. Review policy and guidelines and develop programmes that seek to fulfil the right of access to information, including health information, to minimise women’s risks at home and as care providers to men.
    1. Provide additional counselling and support to women to enable them to disclose to healthcare workers when they have a partner or cohabitating person who is potentially putting them at risk of TB infection.
    2. Provide TB education and support processes that target couples, families and cohabitating units. This should include training on communication about managing TB in intimate relationships.
  2. Ensure that there is adequate psychosocial support for women affected by TB who are care providers.

Transgender women

  1. Ensure that transgender women, and transgender people more broadly, are included in the Integrated Bio-Behavioural Surveillance (IBBS) and population size estimation activities for key and vulnerable populations, as provided for by the NSP.
  2. Ensure that there is adequate policy and programmatic focus on TB prevention for transgender people in addition to the law reform recommendations for decriminalisation of sex work made by the NSP.
  3. Integrate the needs of transgender people into a comprehensive plan to tackle TB-related stigma and discrimination.
    1. Implement further efforts to understand transgender-related stigma at a community and facility level.
    2. Coordinate and fully implement the scale up and expansion of existing policy commitments and programmatic responses, including “know your rights” campaigns, peer navigation systems and various measures to strengthen access to justice.
  4. Scale up human rights and gender sensitivity training and education processes for all healthcare workers.
    1. Ensure the involvement of gender minorities in design and implementation of gender- transformative programming as provided for by the NSP.

Farm dwellers

  1. Consider law and policy review to encourage TB-specific prevention and care protocols and processes for farm workers and dwellers. This should include reasonable accommodation within the working environment to access healthcare.
  2. Engage with farm owners and managers to educate them about TB, to improve cooperation with healthcare services and ethical, rights-based care access and provision. Engage further with farm workers to educate them about their rights and access to legal redress.
  3. Improve the capacity of rural service provision:
    1. Extend the reach of mobile clinic facilities to rural areas where possible.
    2. Ensure that all facilities are matched to the size of the population they serve.
  4. Improve healthcare workers’ ability to provide effective, human rights focused care:
    1. Sensitise healthcare workers to the difficulties faced by farm dwellers in terms of accessing care to ensure that those who arrive at the clinics late in the day are still provided with assistance.
    2. Allow for sufficient flexibility in treatment protocols so that they can be adapted to the capacities and needs of individual patients.
    3. Empower healthcare workers to make patient-centred decisions about how and when treatment should be provided.

Healthcare workers

  1. Improve infection control implementation, accountability and support for TB infected HCWs in all healthcare facilities.
    1. Implement a process of tracking occupational TB and providing infection control support to facilities with high rates of HCW infection.
    2. Implement an assessment of latent TB in HCWs and develop a policy on the provision of preventive therapy for HCWs with latent TB.
  2. Improve CHWs’ capacity to protect themselves.
    1. Provide education on HCW vulnerability to TB infection, training on what a respirator is and how it should be worn.
    2. Improve training and support for CHWs to ensure they are equipped to manage home-based situations where potentially infectious people are reluctant to take preventive measures.
  3. Finalise the Draft Policy on Occupational Health for Healthcare workers in respect of HIV and Tuberculosis to strengthen protection for occupationally acquired TB.
    1. Ensure adequate budget allocations for strengthening occupational health services at a facility level.
  4. Ensure that healthcare workers are educated on the policies that protect them and know how to act on policy recommendations.
    1. Ensure that the government amends the Compensation for Occupational Injuries and Diseases Act 130 of 1993 to include criteria on extra-pulmonary TB for HCWs.

People who use substances

  1. Actively seek to minimise and remove the barriers to care that are entrenched in current policies and treatment guidelines experienced by people who use substances.
    1. Support calls to decriminalise the use of drugs.
    2. Amend procedures to provide for referrals and hospital admission for people who do not have a fixed address or identity document.
    3. Amend policy to provide for the routine availability of opioid substitution therapy (OST) during and after inpatient TB care.
  2. Strengthen the implementation of human rights-based training and sensitisation for healthcare providers, as provided for by the NSP, to provide non-judgmental, non-stigmatising and inclusive services to people who use substances.
    1. Include people who use substances in designing and implementing training.
    2. Set up peer navigation systems and harm reduction champions in healthcare facilities.
  3. Seek to create a more inclusive response for people who use substances.
    1. Integrate TB prevention, diagnosis and treatment into programmes that provide services for people who use substances, to reduce waiting times and overcome reluctance to access the healthcare system.
    2. Implement peer navigation processes, in which trained and knowledgeable peers provide support to people who use substances accessing healthcare services.
  4. Ensure that healthcare workers are educated on how to respond supportively to people who use drugs.
    1. Ensure health care providers are equipped to provide evidence-based messaging about TB and substance use to TB-affected people and their contacts in order to facilitate treatment completion.
    2. Ensure healthcare providers are equipped to manage and support people who are intoxicated or withdrawing.
  5. Align TB programming with harm reduction principles as outlined in the forthcoming NDMP.

Contacts of TB-index patients

    1. Implement an assessment of the capacity, education and resource requirements of effective TB- index patient contact tracing to ensure that any policies and processes are possible and adequately supported.
      1. Develop and implement a comprehensive plan and guidelines that clearly define and guide TB index-patient contact tracing implementation, as provided for in the NSP.
    2. Implement a national TB education campaign as provided for by the NSP. Inter alia this should include information on the risks faced by Contacts of TB-index patients, why linkage to screening and testing is important, and how preventive therapy functions. This should include a focus on children’s vulnerability and engaging with parents/caregivers.
      1. Improve counselling and support processes for people diagnosed with TB, including support processes for addressing stigma and discrimination including self-stigma, diagnosis and linkage to care for TB-index patients’ contacts.
      2. Strengthen efforts to understand and address the impact of stigma and discrimination on TB- index patient contact tracing, within the comprehensive national stigma and discrimination reduction plan.
    3. Include contact tracing indicators and targets in Department of Health monitoring and evaluation processes
      1. Work towards integrating existing electronic data sources to minimize administrative burden on staff and enable efficient clinical management of identified contacts.

Conclusion

South Africa has, or for the most part, a progressive legal and policy framework that protects the equality and health rights of all persons. The NSP makes substantial provisions for the implementation of a human rights-based approach to TB that leaves no one behind. Health policies and guidelines have, to a large extent, echoed these provisions. There is, however, room for improvement in terms of strengthening protection of the rights of key populations and gender minorities. This includes decriminalisation of sex work and drug use and updating health and labour guidelines and protocols to fully reflect rights-based commitments to TB. There is also the need to strengthen implementation of strategic plans and commitments – including stigma and discrimination reduction initiatives as well as monitoring and evaluation processes and accountability frameworks. Furthermore, there is scope for an improved focus on a gender- transformative approach to TB vulnerability, care and treatment in strategic plans, policies and guidelines.