We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines when conducting this scoping review. The search and selection strategies were implemented by three researchers who replicated and audited each other’s work. Cases of conflicting study selections were discussed by the research team, and the outcome was determined through joint consensus.

A standardised template was designed in Microsoft Excel and used to capture the searches, collect the relevant extracted data and compare study characteristics. We used a narrative approach to integrate and synthesise the findings according to Penchansky and Thomas’s access framework, after which knowledge gaps were identified.

We systematically searched five databases (Google Scholar, PubMed, SocIndex, Cumulative Index to Nursing and Allied Health Literature [CINAHL] and Academic Search) to identify studies from 2020 to 2022 using the following search strings: (1) ‘tuberculosis’ AND ‘access’ AND ‘COVID-19’ AND ‘South Africa’; (2) ‘tuberculosis’ AND ‘servic*’ AND ‘access’ AND ‘COVID-19’ AND ‘South Africa’ as indicated in Box 1. The literature search was conducted from 21 September 2022 to 05 October 2022.

The search rule was implemented to search for articles within the databases that met the inclusion criteria of this review. The articles were sorted by relevance and limited to 10 per page. The search process continued until the last three articles were irrelevant (after 13 pages, in this case). This search was completed on 05 October 2022, and all duplicate articles were removed by 06 March 2023.

The inclusion criteria were specified as original research published in peer-reviewed journals that contained findings directly linked to our objectives (i.e. it explained demand-side and supply-side issues related to access to TB care during the COVID-19 pandemic). Only studies written in English and that had full text available were selected.

The exclusion parameters related to the study type included thoughts, critiques, editorials, comments and opinions. Reviews (i.e. scoping, systematic, narrative and literature reviews) were also excluded from our final sample. However, we retained reviews (i.e. scoping, systematic, narrative and literature reviews) in the initial rounds of the searches until the penultimate step in the search and selection process. These reviews were then scanned for additional original research that was not found in the first rounds of searches using the search strings. Once this step was completed, the reviews were excluded, and the additional original research sources were selected and added to the screening round. Online Appendix 1 shows the exclusion process of all the articles by original reviews.

All selected studies were screened by their titles and abstracts and balanced with inclusion and exclusion criteria. Studies that made it through this round of screening were downloaded, and the full texts were further read by the researchers. Thereafter, the researchers reached consensus on which studies would be included in the final sample for review.

Data were extracted into a standardised Microsoft Excel template according to the following fields:

Data for extraction points (1) to (5) are presented in Table 1, while data for extraction points (1) to (3) and (6) to (10) are presented in Table 2.

Table 1 provides an overview of the methodological characteristics of the three included articles conducted in South Africa, arranged by the first author’s name. Two of the three articles were published in 2021, and one article was published in 2022. Two of the articles employed a qualitative approach design, and one article used a quantitative approach.

The first article reported on the emotional and psychological challenges of TB patients throughout their treatment journey and also the challenges patients and their families faced across the BRICS nations. The second article analysed the effects as well as the constraints of COVID-19 on health services in South Africa from 2019 to 2020 through data collected from the District Health Information System (DHIS). The last article aimed to understand the role of trust in the workplace of community health workers (CHWs). Together these articles highlighted the various challenges TB patients faced during treatment, how COVID-19 strained the delivery of healthcare services, and the challenges CHWs faced in providing treatment during the pandemic.

Table 2 summarises the demand-side and supply-side issues with access to TB care before and during the COVID-19 pandemic, as well as the study limitations of the three included studies. On the demand side, TB patients had been discouraged from seeking treatment not only by lockdowns and fear of infection but also by the social stigma of COVID-19, including blame, social exclusion and being labelled contagious, which made them avoid clinics. These factors delayed diagnosis and worsened treatment outcomes. Before the pandemic, marginalised groups were disproportionately affected by problems like poverty, stigma and long wait times.^9,11

On the supply side, inadequate funding and overcrowded facilities were two instances of structural issues that hindered CHWs’ ability to deliver quality care. They also struggled because of a lack of resources, poverty and difficulty identifying migrants. Drug shortages and COVID-19-related disruptions raised concerns about treatment interruptions and multidrug-resistant TB. Between 2019 and 2020, GeneXpert TB tests decreased by 26%, and during the pandemic, fewer TB diagnoses were made because of staff shortages and reduced routine services. Poor infrastructure, long queues, drug shortages and reliance on private healthcare further restricted access to TB medications. Among the limitations noted by the authors of the three studies were the use of non-random samples, secondary data and a lack of attention to certain subjects such as trust.

Availability refers to the presence and adequacy of health services and resources, such as sufficient health facilities and infrastructure, adequate staffing, diagnostic tools and medication to meet patient needs. Before the COVID-19 pandemic, South Africa’s TB care system faced ongoing issues with drug shortages and inconsistent supply chains, particularly in rural areas^9,11 These issues prevented patients from receiving treatment, raising the risk of drug-resistant tuberculosis. Despite efforts to integrate tuberculosis services into general healthcare, resources remained insufficient.¹²

The pandemic further amplified these issues by reallocating resources to COVID-19 response operations. GeneXpert TB tests, which are vital for early TB identification, declined by 26% between 2019 and 2020.¹⁰ This reduction is noteworthy since early detection is critical for reducing TB transmission.¹³ The reallocation of healthcare resources not only slowed TB diagnosis but also reduced patient monitoring and interrupted follow-up care, raising the risk of further transmission.^9,10

The findings from South Africa are consistent with global trends reported by the WHO, which found a 15% decline in enrolment in drug-resistant tuberculosis therapy worldwide in 2020, with only minimal recovery by 2021.¹⁴ Furthermore, WHO predicted that pandemic-related disruptions would result in 4.7 million new TB cases and 1 million TB fatalities by 2025,¹⁵ further highlighting the far-reaching consequences of the pandemic’s restricted availability of TB treatment.

Healthcare professionals reported that their workloads had increased and that they had limited access to personal protective equipment, which added to the strain on service delivery.¹⁰ The increasing workload, along with inadequate personal protective equipment, raised the risk of infection among healthcare professionals, restricting their ability to offer care and further highlighting the critical requirement for robust health systems that can provide normal tuberculosis care amid public health emergencies.

Accessibility focuses on the geographical location of healthcare services and whether they are within reasonable proximity to patients with regard to time and distance for patients to access these services. South Africa faced severe accessibility issues even before the pandemic, particularly for patients who resided in rural and underdeveloped areas of the country and frequently had to travel long distances to reach medical facilities. Long waiting times and poor transportation infrastructure exacerbated these issues.⁹

The COVID-19 pandemic exacerbated these issues by imposing strict lockdown measures and movement restrictions, which significantly limited patients’ ability to access care. Restrictions on movement, the curtailment of public transportation and fear of exposure to COVID-19 in healthcare settings further discouraged many patients from visiting medical facilities. A national survey found that 57% of individuals were apprehensive about visiting clinics or hospitals during the lockdown, primarily because of concerns about being exposed to COVID-19.¹¹ As a result, many patients missed crucial medical appointments, delayed treatments and experienced interruptions in their care.^9,10

Additionally, health facilities experienced a decline in the number of TB and HIV patients collecting their medication on schedule, further highlighting the impact of accessibility barriers during the lockdown.^10,11 In one province alone, over 1000 TB patients and nearly 11 000 HIV patients did not collect their medications on time.¹⁶ Additionally, long waiting times and limited services in public healthcare systems, already problematic before the pandemic, were worsened by resource redirection toward the COVID-19 response, which further diminished patients’ ability to access necessary care during the pandemic.⁹

Accommodation refers to how healthcare facilities are organised to meet patients’ needs, including their operating hours, how appointments are scheduled and whether they can handle patients’ time constraints and preferences. Even before the pandemic, South Africa’s healthcare system was already struggling with long waiting times, limited facilities and work overload, which made it difficult for TB patients to get the care they needed on time.⁹ These challenges caused delays in starting treatment, disrupted patient monitoring and led to poor follow-up, which likely worsened the spread of TB and patient outcomes.

During the COVID-19 pandemic, the situation worsened as healthcare facilities prioritised COVID-19 cases, significantly reducing their capacity to accommodate TB patients. Non-COVID-related admissions, including those for TB treatment, could no longer be accommodated in healthcare institutions because of the overwhelming number of COVID-19 cases at the time. Hospital admissions were limited because non-COVID cases were deprioritised.^9,10

The poor implementation of TB infection control procedures in primary health care institutions made it even more difficult for healthcare providers to accommodate TB patients. Contradicting standards, such as the National Core Standards and the Ideal Clinic Policy, perplexed healthcare personnel, particularly regarding whether TB patients should be separated from other patients.¹⁷ Facility administrators stated that the inconsistent requirements made it impossible to maintain consistent infection control methods, resulting in service disruptions. They also stated that, despite being required to train their employees on TB infection management, they did not feel prepared to do so.¹⁷

The lack of clear direction and sufficient support hampered healthcare facilities’ capacity to address patients’ requirements. Healthcare professionals also faced additional obstacles, such as a lack of frequent health examinations and insufficient occupational health support.⁹ These gaps left many people feeling hopeless and unmotivated and unfavourable attitudes increased as long-standing issues, such as resource constraints and inadequate district-level support, went unsolved. Together, these challenges made it impossible for healthcare facilities to provide regular and timely tuberculosis treatment.

Community health workers (CHWs), who played a vital role in helping TB patients, faced additional challenges during the pandemic. Poor infrastructure, a shortage of necessary supplies and a lack of personal protective equipment made it difficult for CHWs to continue providing care.^9,10 There were also persistent operational difficulties at healthcare institutions, with CHWs having to work in unfavourable environments with weak infrastructure.¹¹

Affordability looks at whether patients can afford the associated expenditures of healthcare services without experiencing financial hardship. In this scoping review, only one article reported on affordability issues. This article mentioned that even though most healthcare systems supplied free TB medications to patients during the COVID-19 pandemic, they still faced financial difficulty as a result of lost wages and the increase in medical and travel expenses. Many patients reported being unable to afford transportation to healthcare facilities or private healthcare services when public facilities were inaccessible.⁹ Particularly in private healthcare, several patients struggled to pay for further tests or prescriptions out-of-pocket.¹⁶ Before the pandemic, affordability was already a barrier for many TB patients, particularly for those from low-income households who struggled with transport and supplementary costs. Many families were already living in poverty, and the financial hardships brought on by COVID-19 regulations further deepened their struggles, limiting their ability to access healthcare.⁹ The WHO established a task force in 2015 to create a generic protocol for TB patient cost surveys, which was published in 2017. The first national patient cost study conducted in South Africa during the COVID-19 pandemic found that family and patient earnings were already poor before TB diagnosis and considerably worsened following the diagnosis.¹⁴ Household income declined by 15.6% and individual income fell by 44.9%, emphasising the necessity of securing these revenues to avoid increased economic strain.¹⁸

These difficulties were worsened by the government’s limited social aid.¹⁹ For example, an interview with a young pregnant woman who had tuberculosis during the pandemic in Cape Town, South Africa, showed how systematic flaws in the government’s social support system prevented her from receiving necessary assistance.¹⁹ Despite her being qualified for multiple support mechanisms, she received only 2 months’ worth of food aid because of stock-outs and delays. Her application for a Social Relief of Distress Grant (SRDG) was rejected because she received a child support grant (CSG) for her eldest child, which was sent to a caregiver in another province. Furthermore, she was not notified of or granted a disability grant despite her dire circumstances, being pregnant and weighing less than 50 kg. This instance demonstrates how social assistance programmes and healthcare providers did not collaborate, leaving her vulnerable and without sufficient financial aid.

Acceptability refers to the extent to which healthcare services conform to patients’ cultural values, beliefs and standards. It also includes how the attitudes and traits of healthcare practitioners influence patients’ willingness to seek care. The stigma associated with TB significantly affected the acceptability of healthcare services in South Africa before the outbreak. This was especially noticeable in impoverished communities where poverty has been linked to sickness. Patients were frequently subjected to prejudice and social exclusion, which discouraged them from getting treatment quickly.^2,7 TB-associated stigma was amplified during the COVID-19 pandemic, which further discouraged people from seeking medical attention. Furthermore, healthcare staff faced humiliation and mistrust from their communities because of their role in resolving COVID-19.⁷