TB and Migration: Is South Africa’s Health System Ready

Opening: Snapshot & Case Study

In 2023, South Africa recorded roughly 270,000 new tuberculosis (TB) cases and an estimated 56,000 deaths. (tbac.org.za) Although the country reduced TB incidence by 51% since 2015, the burden remains high.

South Africa also hosts a large migrant population. The 2022 Census indicates that Lesotho and Malawi rank among the top sending countries. Lesotho nationals make up about 10.9% of foreign-born residents; Malawians represent 9.5%. (statssa.gov.za)

Consider the anonymized case of Mpho, a 34-year-old woman from Lesotho working in Johannesburg’s informal economy. She delayed seeking care due to fears over documentation. When she finally visited a clinic, her pulmonary TB had advanced. She required inpatient treatment, which disrupted her employer’s workflow and stressed the clinic’s resources.

This example illustrates the combined pressures of high TB burden, migrant influx, and structural vulnerabilities. It raises a pressing question: Can South Africa sustain healthcare for Lesotho and Malawian migrants during TB outbreaks? The answer requires targeted interventions.

Policy Context & Gaps

Legal Framework & Rights

South Africa’s Constitution (Section 27) guarantees healthcare access for everyone, regardless of citizenship. (wits.ac.za) The Refugees Act 1998 also grants refugees and asylum-seekers basic healthcare on the same basis as citizens.

SADC nationals, including Lesotho and Malawi migrants, generally can access basic health services even if undocumented. However, implementation gaps exist. Many face hurdles for higher-tier care due to fees or identification requirements.

Policy Tools for TB

The National Department of Health (NDoH) launched the “TB Recovery Plan 4.0” covering 2025–2026. The 2023–2028 National Strategic Plan (NSP) for HIV, TB & STIs emphasizes case-finding, treatment completion, preventive therapy, and data transparency. (health.gov.za)

For instance, a real-time TB dashboard launched in October 2025 tracks testing and diagnosis across provinces. (nicd.ac.za)

Key Policy Gaps

Limited migrant data: Health facilities rarely disaggregate service use by nationality or documentation status. (businessday.co.za)
Service denial & xenophobia: Migrants often report delays or refusals of care due to lack of South African IDs. Basotho migrants in Gauteng reported over 60 such cases. (groundup.org.za)
Cross-border flows ignored: Policy largely overlooks migrant movement between Lesotho, Malawi, and South Africa.
System strain: TB treatment success remains below 80% in 2021 versus the 85% target. (health.gov.za)
Social determinants: Housing overcrowding, informal work, language barriers, and undocumented status heighten TB risk but are under-addressed.

Empirical Evidence: TB, Migration & System Stress

Migration & TB Spread

An NHLS study found 16% of TB patients used clinics in more than one municipality, often traveling a median of 304 km. Migration correlated with higher future TB incidence in receiving areas. (pmc.ncbi.nlm.nih.gov)

Urban Vulnerabilities & Migrant Profiles

In Johannesburg, migrants in informal settlements faced high TB risk due to overcrowding, poverty, HIV co-infection, and limited access to care. (mdpi.com) Many Malawian and Lesotho migrants work informal jobs and live in shared housing, which complicates treatment adherence.

Access Barriers & Xenophobia

The Migrant Workers Association of Lesotho reports Basotho migrants are sometimes denied care even with valid permits. Women are disproportionately affected. Some have paid bribes to access treatment. (thereporter.co.ls)

System Capacity

South Africa reported 226,689 TB cases in 2023, an increase from 187,735 in 2021. (gov.za) Testing increased 14% year-on-year. (nhls.ac.za) Yet treatment success remains below optimal levels.

Can the Health System Sustain an Influx?

Capacity

Public clinics already face long waits and staff shortages. If a surge occurs, especially in Gauteng, KwaZulu-Natal, and Limpopo, resources could be overwhelmed.

Continuity of Care

Migrants often face interrupted treatment due to mobility, undocumented status, and language barriers. Cross-border TB patients from Lesotho and Malawi risk incomplete therapy, which can trigger outbreaks.

Equity & Resilience

Migrants face systemic inequities. Denials and delays affect women, informal workers, and undocumented migrants disproportionately. A resilient system must absorb shocks while protecting the most vulnerable—currently, it is not fully prepared.

Intersectional Considerations

Gender: Women in domestic work face higher barriers.
Age: Younger adults (20–39) dominate the migrant population.
Nationality & documentation: Legal status affects access.
Housing & work: Overcrowding and informal employment elevate TB risk.

Anonymized Real-Life Examples

Amina, a Malawian in Johannesburg, delayed TB treatment due to fear of workplace discrimination. Job mobility interrupted her care.
Thabo, a Basotho construction worker commuting weekly from Lesotho, lost access to treatment when his job moved across provinces.

These cases highlight risks to treatment continuity and outbreak control.

Innovative Solutions & Successes

WHO and NDoH’s “Health and Migration Agenda” integrates migrant health into policy. (afro.who.int)
The 2025 TB dashboard provides near-real-time data by province, age, and gender. (nicd.ac.za)
IOM’s cross-border screening of miners detected TB early, a model adaptable for Lesotho and Malawi migrants. (blogs.worldbank.org)

Recommendations & Timelines

National Government:

Q1–Q2 2026: Collect migrant-disaggregated data at all primary health facilities.
Q3–Q4 2026: Create bilateral health agreements for TB care continuity.
2026–2028: Implement universal TB screening among high-mobility migrant workers.

Provincial/Metro Departments:

By end 2026: Establish migrant-friendly clinics with culturally competent staff and no ID requirement.
2027–2028: Offer mobile clinics, SMS reminders, and community health worker support for treatment adherence.

NGOs & Community Organizations:

2026: Launch peer-support networks for Lesotho/Malawi migrants.
2026–2029: Co-design flexible clinic schedules and mobile screening initiatives.

Employers/Private Sector:

2026: Provide TB screening, referral pathways, and protect employees undergoing treatment.

Limitations & Research Gaps

Disaggregated migrant TB data is scarce.
Cross-border TB flow studies are limited.
Housing, labour, and TB dynamics require more research.
Economic modelling of migrant TB burden is lacking.
Xenophobia’s effect on outbreak control needs further exploration.

Conclusion & Calls to Action

South Africa can manage TB among Lesotho and Malawian migrants, but only with targeted, inclusive strategies. Without reform, the system risks overload, treatment disruption, and inequitable access.

Policymakers must fund migrant-specific data systems and establish cross-border care agreements. Public health practitioners should implement migrant-sensitive TB strategies. NGOs must empower migrants to access services. Employers need to protect workers during TB treatment.

Proactive action will protect both migrants and host communities while strengthening the country’s TB response.

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