Tuberculosis (TB) and Sustainable Community Health Development in South Africa

Vanessa Carter
ePatient Date: 21 June 2017
Time: 20:30 SAST | 14:30 EST 
Hashtag: #hcsmSA
How to participate
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Start your answers with T1, T2, T3, T4 or CT for transcript purposes after the moderator prompts.

T1: How can community health help to improve the management of diseases like TB?
T2: Which stakeholders can be useful to improve community health and how?
T3: What can be done to improve patient and community empowerment?
T4: What are some of the barriers in the healthcare delivery system for TB?

CT: Closing Thoughts – What do you think is important to healthcare innovation for TB?

The TB epidemic in South Africa
Growing up on the Witwatersrand in Johannesburg, I’ve been familiar with the sand dumps and waste from the gold mines since I was a young child. The discovery of gold on the Witwatersrand in 1886 was a turning point in South African history. Far more than diamonds, this changed South Africa from an agricultural society to become the largest gold producer in the world. What I never knew about gold mining was the serious impact it was having on our public health, mineworkers and their communities. According to a World Bank article, there are an estimated 500,000 mineworkers working in South Africa. Statistics indicate that there are 2,500–3,000 diagnosed TB cases per 100,000 mineworkers in South Africa’s gold mines. This is 10 times the World Health Organization’s threshold for an emergency (250/100,000 people). In addition, an estimated 70% of occupational TB cases go undetected. Stigma, lack of information about TB and poverty are a few issues which disempower those who are most affected. In 2015, 87% of new TB cases occurred in the 30 high TB burden countries. Six countries accounted for 60% of the new TB cases: India, Indonesia, China, Nigeria, Pakistan, and South Africa. Global progress depends on advances in TB prevention and care in these countries.

TB and Community Health
Advancing community health is central to achieving sustainable development and universal primary healthcare as is ending the TB epidemic as explained by the WHO. The Health Systems Trust website describes a Community Health Worker (CHW) as any health worker delivering health care services and who is trained in the context of the intervention but has no formal professional, certificated or degreed tertiary education. Community Health Worker’s is an umbrella term used for a heterogeneous group of health workers, their scope of practice ranging from implementing biomedical interventions to acting as community agents for social change. There are numerous benefits which include improving access to treatment, support as well as community and patient education. Early diagnosis, treatment adherence, and effective disease prevention are also required for mitigating the spread of tuberculosis. TB is a treatable and curable disease. Active, drug-susceptible TB disease is treated with a standard 6-month course of 4 antimicrobial drugs that are provided with information, supervision and support to the patient by a health worker or trained volunteer. Without such support, treatment adherence can be difficult and the disease can spread. The vast majority of TB cases can be cured when medicines are provided and taken properly.

We recently used a Medicins Sans Frontieres video as an example for a previous chat to explain what community health programs are being utilised in the AIDS community. Below is a repetition of that video for reference.



Designing health innovation for TB in South Africa
A recent abstract suggests that mobile phones present an enormous promise for healthcare. In areas where infrastructure and resources are often lacking, m-health initiatives are beginning to provide a wide range of services, including real-time case notification, interactive health messaging, and performance-based incentives for health workers. The Digital Divide is not the problem in itself but it is low income, under-development of the socio-economic conditions and the lack of literacy that also divides the rich from the poor. The promise of the electronic health record (EHR) system in South Africa is also set to improve the management of diseases. What other technologies could be utilised to improve the management of TB and how can we ensure they are meaningful? Many health innovation programs globally utilise a design thinking methodology. They use a multidisciplinary approach to working with patients, caregivers and health care workers to understand the gaps from diverse perspectives using empathy. As we move towards a more connected world in future, it might be an important method to consider now. Tim Brown is CEO and president of IDEO. He frequently speaks about the value of design thinking and innovation to businesspeople and designers around the world. He participates in the World Economic Forum in Davos, Switzerland, and his talks “Serious Play” and Change By Design appears on This article explains more about design thinking and global health innovation.

During this hour of the #hcsmSA Twitter chat, we will discuss these issues pertaining to TB in South Africa and ideas to improve them with our attendees and special experts.panel-experts

Stuart Grande



Dr Stuart Grande
Dartmouth College, USA



Stuart has recently completed research working with Wits University in South Africa
titled Mining for Solutions: a Preliminary Report on Research Designed to Engage
Southern African Miners, Ex-miners, Managers and Policymakers, Clinicians,
and Communities on Tuberculosis to Improve Health Care Delivery –
Read the Report here: Mining_For_Solutions_Prelim_Report_06302015_Final

Stuart has continued to foster a deep interest in the behavioural factors that contribute to differences in health utilisation that define and shape communities. He completed a post-doctoral fellowship in Shared Decision Making (SDM) under the mentorship of Glyn Elwyn where he developed patient-reported measures of SDM and explored the scope of patient engagement methodologies. Stuart has brought his research interests in health disparities and patient engagement to medical and public health education. Recently, Stuart managed a multidisciplinary team of clinicians and social scientists in an applied ethnography with ex-miners and their families to characterise the experiences of ex-miners with TB and to identify barriers to health care. Their research found unnecessary suffering due to limited health education, a lack of trust in their healthcare providers, and a care system that does not prioritise lived experience and fails to address the full range of health conditions. In addition, they found clinicians felt devalued and unable to provide optimal care due to system constraints. Overall, the narratives they collected showed feelings of invisibility and abandonment in communities living with and disproportionately dying from, TB and related diseases.

To date, Stuart and a committed cadre of researchers and educators have been exploring questions on innovation and methods of patient/student engagement. Their collaboration has yielded novel tools and curriculum that applies dynamic instructional design (ID) principles to address social and behavioural determinants and their relationship to health communication. While Stuart’s current research considers collaborative benefits of new technologies on patient-provider communication, he remains focused on exploring how principles of community-based participatory research overlap with SDM in novel ways to improve the ways people from all walks of life engage with health care. Stuart’s work has been profiled in Patient, Education and Counseling, The Journal of General Internal Medicine, PLoS One, The American Journal of Men’s Health, Journal of Medical Internet Research, and The American Journal of Bioethics.


Dr Shakira Choonara
International Sustainable e-Health Policy Expert & Youth Leader in South Africa


Dr Shakira Choonara is considered to be a young leader, researcher and activist at the forefront of public health and development both in South Africa (SA) and globally.  Dr Choonara is currently employed as a regional advocacy officer at the Southern African AIDS Trust where she is responsible for driving innovative youth activism programmes in sexual and reproductive health throughout five African countries. She recently completed her PhD in Public Health focusing on financial management in the health sector and also hold an Honours (Cum Laude) and a Masters in Demography from the University of the Witwatersrand, SA. She has also contributed substantially to multi-country research through the Resilient and Responsive Health System (RESYST) project which aims to improve healthcare across various African and Asian countries.

Dr Choonara’s writings and involvement in other research such as Universal Health Coverage (UHC- Health for All), fostering leadership in the health system and malaria prevention has been widely published, engaged with internationally and feeds into improving the health system in SA and other low-and-middle income settings. Additionally, she has been the recipient of several prestigious research and leadership awards throughout her career. She was recently named 2017 Woman of the Year in Healthcare by the Woman of Stature network, SA.  Internationally, she was selected as the European Union (EU) Development Days Young Leader for Health in 2015 and an Emerging Voice for Global Health in 2014.  Dr Choonara has made a marked impact on social justice, particularly fighting corruption in Africa, advocating for the rights of persons with disabilities and non-racism.