Understanding TB and PMB entitlements as a medical scheme member
What is Tuberculosis?
Tuberculosis (TB) is a contagious disease caused by infection with a germ called Mycobacterium tuberculosis. It spreads through the air when a person with lung TB coughs, sneezes, talks, or sings. A person needs to inhale only a few of these germs to become infected. This often leads to the TB bacterium settling in the lungs, causing lung TB, known as pulmonary tuberculosis.
Pulmonary tuberculosis is the infectious and most common form of TB disease, occurring in over 80% of cases. When TB remains untreated, TB can spread to other areas of the body, causing what is called extra-pulmonary tuberculosis. Organs mostly affected would be commonly pleura (the thin lining of the lungs), lymph nodes, spine, joints, the genito-urinary tract, nervous system or abdomen. Extra-pulmonary TB cases are rarely infectious, unless they have pulmonary tuberculosis as well. Laryngeal tuberculosis, although uncommon, is also very infectious.
Tuberculosis is curable and preventable
Why Does TB Matter?
TB is one of the top 10 causes of death in the world, ranking above HIV and Malaria, with South Africa being amongst the top 30 countries with a high TB burden globally. The TB burden in South Africa contributes 87% to the global numbers.
According to the World Health Organization (WHO) global report on TB, approximately 280,000 people develop TB annually in South Africa, with approximately 56,000 dying from this, despite the country having robust TB control programs. Every year, about 50–60% of people living with uncontrolled HIV develop TB because of the close relationship between TB and HIV. Around 11,000 people annually reported to be infected with TB have drug-resistant TB (National Department of Health [NDoH], 2022).
The TB Prevalence Survey, in South Africa, 2018, identified a higher TB burden in males than in females and high prevalence of TB among individuals aged 35-44 years and the elderly 65 years and older. Tuberculosis and HIV/ AIDS being the drivers of morbidity and mortality in the country, efforts must be put into strategies that help us to:
• Reduce transmission of infection in the communities,
• diagnose both drug sensitive TB (DS-TB) and drug resistant TB (DR-TB)
• initiate treatment in all patients diagnosed with TB early,
• retain patients in treatment and care until completion of treatment and,
• prevent TB in people living with HIV by initiating all eligible HIV positive people on ART and Isoniazid preventive therapy.
TB is a notifiable disease, meaning that by law, anyone diagnosing TB must report the case to government health authorities. The largest prevalence-to-notification gap has been identified in the youth aged 15-24 years and in those 65 years and older (SA TB Prevalence Survey, 2028).
How is TB diagnosed?
TB diagnosis in South Africa follows the National TB Management Guidelines and includes the following key methods:
• GeneXpert MTB/RIF Ultra: A rapid molecular test that detects Mycobacterium tuberculosis and rifampicin resistance within 2 hours. It is the first-line test for suspected pulmonary TB.
• Sputum Microscopy: Still used in some settings, particularly where molecular testing is unavailable.
• Chest X-rays: Employed as an adjunct diagnostic tool, especially for smear-negative or extrapulmonary TB.
• Culture and Drug Susceptibility Testing (DST): Gold standard for TB confirmation and detailed drug resistance profiling, though turnaround times are longer.
• Lipoarabinomannan (LAM) tests: Used in selected HIV-positive patients with low CD4 counts for rapid TB diagnosis (WHO, 2020).
What is covered under PMB level of care?
According to the Prescribed Minimum Benefits (PMBs) framework of South Africa’s Medical Schemes Act (131 of 1998), tuberculosis is a prescribed minimum benefit condition under diagnosis treatment code 11S. Medical Schemes must therefore provide cover for the investigation(s) to diagnose TB (radiology and pathology), acute medical management thereof, and successful transfer to maintenance therapy in accordance with the guidelines of the Department of Health, as well as care costs of the condition. Even though the National TB Programme (NTP) provides free TB medications through public health facilities, medical scheme members diagnosed with TB should be given a choice to receive care within the private healthcare sector as a first-line option.
Private practitioners may participate in public–private mix (PPM) initiatives, allowing them to collaborate with the public sector to offer free TB treatment while providing private consultations. Schemes should have treatment protocols that are not in contravention with the National TB treatment program guidelines. Individuals with drug resistant TB (DR-TB) may require second line drugs. Schemes have an obligation to investigate, diagnose and treat TB fully. Complex cases such as MDR-TB are often referred to specialised public TB hospitals or clinics, as the required drugs and monitoring may be unavailable or too expensive in private settings. Schemes have responsibility to facilitate channelling of the member to the appropriate public treatment centre to ensure smooth access to treatment.
Members who are HIV-positive have additional PMB entitlements for screening and preventative therapy, and treatment of TB, regardless of the outcomes of the tests. Hospitalisation for acute TB, TB meningitis and cases where surgery is required is included in the PMBs for the disease.
Challenges in Private Sector TB Care
The current problem experienced by the TB program is fragmentation, failure to notify and underreporting, as well as non-adherence to standard treatment protocols in the private sector.
Conclusion
TB remains a pressing health concern in South Africa, with high burdens of both drug-sensitive and drug-resistant forms, compounded by HIV co-infection. The country’s diagnostic infrastructure and mandatory medical aid coverage under PMBs ensure that medical scheme members can access essential TB services. Strengthening these systems and ensuring adherence to guidelines are key to reducing TB incidence and improving patient outcomes.
