Strengthening accountability for TB policy implementation in South Africa: perspectives from policymakers, civil society and communities

Abstract Background Translating health policy into effective implementation is a core priority for responding effectively to the TB crisis. The national TB Recovery Plan was developed in response to the negative impact that the COVID-19 pandemic had on TB care in South Africa. We aimed to explore the implementation of the TB Recovery Plan and develop recommendations for strengthening accountability for policy implementation for this and future TB policies. Methods We interviewed 24 participants working on or impacted by TB policy implementation in South Africa. This included perspectives from national, provincial, and local health department representatives, civil society, and community representatives. In-depth interviews were conducted in English and isiXhosa and we drew on reflexive thematic methods for analysis. Results Implementation of the TB Recovery Plan predominantly used a top-down approach to implementation (cascading from national policy to local implementers) but experienced bottlenecks at provincial level. Civil society organisations were concerned about the lack of provincial implementation data which impeded advocacy for better accountability. There was strong interest in community-led monitoring for local TB policy implementation from community representatives. Participants recommended broader multi-stakeholder engagement regarding TB as a public health priority and on new policies in the development and implementation phases. Conclusion Communities affected by TB, with the support of civil society organisations, could play a bigger role in monitoring policy implementation at local level and need to be capacitated to do this. This bottom-up approach could complement existing top-down strategies and contribute to greater accountability for TB policy implementation.