Tuberculosis (TB) remains one of South Africa’s most persistent public health crises. Despite decades of reform, improved diagnostics, and expanded treatment programmes, the country continues to rank among the highest TB-burden nations globally. In the Western Cape, incidence remains particularly high, with some Cape Town sub-districts reporting rates exceeding 500 cases per 100,000. Drug-resistant TB (DR-TB), including rifampicin-resistant TB (RR-TB), further complicates treatment and contributes to ongoing mortality.
TB is not simply a clinical or economic problem, but a knowledge problem. Few issues align as closely with UWC’s commitments to social justice, community engagement, and health equity. Yet research has not adequately interrogated where care breaks down. Historically, TB research has focused on primary healthcare clinics, while hospitals, which manage the sickest patients and often serve as the first point of diagnosis, remain under-researched. Hospitals expose the limits of South Africa’s TB response: delayed diagnosis, policy-practice gaps, and fragile continuity of care. They are epistemic sites where we can learn what we don’t yet understand.
South Africa’s policy architecture for TB control is robust. The National TB Recovery Plan 4.0 (2025–26) commits to testing 5 million people, scaling up digital chest X-rays (dCXR), and implementing shorter regimens such as BPaL-L for DR-TB. The End TB Campaign outlines intensified case-finding and universal testing, while the National Strategic Plan for HIV, TB and STIs (2023–28) integrates TB and HIV services.
These frameworks are ambitious but largely oriented toward primary healthcare. Hospitals are often treated as referral nodes rather than complex ecosystems requiring tailored implementation science. The question is not whether policy exists, but how effectively it functions in hospital environments where critical diagnostic and treatment decisions are made.
Foundational Blind Spot: The Diagnostic ‘Know-Do’ Gap
Despite massive investment in diagnostics, we still lack knowledge about why TB is detected too late, especially in hospitalised patients. A 2024 audit in eThekwini showed strong specimen management and TB/HIV integration (>90%), but moderate overall performance (76.5%) due to slow GeneXpert turnaround times and weak contact tracing. Similar systematic audits are scarce in Western Cape hospitals. Emergency departments often manage patients with advanced HIV, extrapulmonary TB, and severe respiratory disease, where empiric treatment decisions are made under uncertainty.
Key unanswered questions include:
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What are time-to-diagnosis metrics for hospital inpatients?
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How long between laboratory confirmation and treatment initiation?
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How effective are dCXR triage tools in tertiary hospitals?
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What is the diagnostic yield of universal inpatient screening?
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How well are patients linked to primary care after hospital diagnosis?
Without hospital-based evaluation, scaling up dCXR risks technological optimism without accountability.
Hospitals as Sites of Transmission: The Ethical Gap
Infection prevention and control (IPC) remain among the least studied aspects of hospital TB management. Healthcare workers report persistent “fear of exposure” to TB and MDR-TB, linked to inadequate isolation facilities and inconsistent PPE use. Yet actual nosocomial transmission risks remain unquantified. Are hospitals amplifying TB transmission or simply reflecting community burden? Without genomic cluster analysis, ventilation assessments, and occupational TB surveillance, the answer is unclear.
Failure of Knowledge Translation: The ‘Discharge’ Gap
Perhaps the most striking hospital-level challenge is the “discharge gap.” Nearly half of patients diagnosed with TB in tertiary hospitals are lost during the transition to primary care. Referral letters may be incomplete, electronic systems poorly integrated, and socio-economic realities — transport costs, stigma, unstable housing — disrupt continuity.
Delays in treatment initiation after discharge increase mortality and transmission. Yet few prospective studies have tested interventions such as patient navigators, integrated digital referrals, transport support, or community health worker linkage programmes. This persistent loss suggests TB research has prioritised discovery over delivery, producing evidence that rarely survives the shift from ward to community.
Pharmacotherapeutic Innovation: Knowledge Asymmetry
The introduction of the six-month BPaL-L regimen represents a major shift in DR-TB treatment. Hospitals are primary sites for initiation, but systems research has not kept pace. We know how drugs perform in trials, but little about their function across fragmented health systems. Practical questions remain:
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Are hospital pharmacies equipped for pharmacovigilance?
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How are adverse events tracked post-discharge?
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Are hospital records integrated with district TB data systems?
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What are real-world completion rates for BPaL-L?
In the Western Cape, with its substantial DR-TB burden, these questions are urgent. Patients carry the burden of research gaps, becoming the sites where incomplete evidence is tested in real time.
The Private-Public Gap
Many patients move between private and public sectors before hospital admission. Diagnostic delays in private care may contribute to advanced disease presentations in tertiary hospitals. Yet hospital research seldom examines these pre-admission pathways, perpetuating fragmented evidence and care. Understanding this continuum is essential for a complete picture of TB.
Addressing these gaps requires research that is:
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Translational – linking national policy frameworks to measurable hospital outcomes.
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Interdisciplinary – integrating epidemiology, clinical medicine, pharmacy, behavioural science, and health systems research.
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Provincially grounded – generating Western Cape-specific evidence to inform strategies.
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Implementation-focused – testing practical interventions that improve diagnosis, treatment continuity, and infection control.
The body of hospital-based research needed to ensure advances translate into reduced mortality and sustained treatment success is underdeveloped. For UWC, this presents a clear opportunity to generate rigorous, context-specific research on TB, particularly within hospital systems, to contribute directly to patient outcomes and national TB control.
TB remains one of South Africa’s most pressing public health challenges. If research universities are to play a meaningful role in ending TB, they must confront not only where care is delivered, but where knowledge fails. Hospitals expose the blind spots that undermine diagnosis, treatment, and continuity of care. For UWC, prioritising hospital-based TB research is not only strategic but essential to its mission of social justice, health equity, and transformation.
By Renier Coetzee and Carmen Christian
