More decentralisation of health services in poor countries would strengthen the war on TB, say Norwegian researchers. This image is from Malawi. Photo: Stine Hellum Braathen/SINTEF

TB forgotten in fight against HIV

Tuberculosis seems to have fallen between the cracks in poverty-stricken Malawi’s sponsor-dependent health sector. The dominating focus on HIV may have left parts of Africa with a skewed health service, say researchers.

In Malawi in southern Africa, one of the poorest nations in the world, 50,000 new cases of tuberculosis are registered every year, compared to 5000 about 30 years ago. SINTEF scientist Lisbeth Grut has identified clear signs that information about TB is not reaching out to all strata of the population as well as campaigns about HIV do.

Grut has carried out a research study that interviewed disabled people in Malawi about the knowledge of epidemics. The informants turned out to be well informed about how to take precautions against HIV. However, they were confused when the questions turned to the causes and treatment of TB. Some of them did not even know that TB is an infectious disease, while many believed that it affected only people who already have HIV, and some did not know whether or not they had been tested for TB.

Grut’s findings have been published in the well-regarded scientific journal PLOS ONE:

Bilde av Malawis flagg som er rødt, sort og grønt.Lack of information a barrier

“This difference in an indication that the comprehensive efforts to prevent the spread of HIV in Malawi, supported as these efforts are by a number of international organisations, are taking place at the expense of information about tuberculosis. This is a serious matter, given that resistant strains of TB are rapidly becoming more widespread,” says Grut.


Gross national product (GNP) per inhabitant (corrected for purchasing power and expressed in PPP-dollars):

  • 660 PPP$ (The equivalent figure for Norway is 66,520 PPP$). (PPP stands for Purchasing Power Parity. When GNP is measured with the help of PPP, the calculation takes the level of prices and purchasing power in the individual country into account).
  • Malawi is one of the poorest countries in the world and is highly dependent on development aid.


  • 14,901,000
  • Most people live in villages.


  • 118,480 km2 (Norway: 385, 196 km2)

Source: Globalis/United Nations Association Norway

According to the SINTEF scientist, disabled persons’ experience of TB campaigns may be a good proxy measure of the quality and availability of health services in low-income countries. This is because disabled persons in these countries tend to have poorer access to information and health services than the rest of the population.

“Lack of information is a barrier that locks many people out of the struggle against TB. This studies on individuals perception of TB in Malawi is unique and its findings are so alarming that we hope that they will inspire strengthened efforts to eliminate TB in Malawi, says SINTEF’s experienced health services researcher.

Holistic thinking destroyed

“Do other low-income countries have the same problem?”

“What we know is that many development aid providers of development aid are disease-specific organisations. Some of them have focused on fighting AIDS, others on malaria. In Malawi, a country whose health services are completely reliant on aid, it looks as though the HIV campaign has made it difficult to establish a holistic way of thinking about healthcare. Something very similar is probably taking place in other poor countries. We can only hope that this will now be investigated, not least in order to document whether the fight to eliminate TB in other countries meets similar problems and a need to reorient efforts to improve health services.”

Clinics with poor logistics

A total of 89 persons were interviewed as part of SINTEF’s Malawi project. Of these, 47 were suffering from various types of disability, and 11 were family members of young people with disabilities. Health-care workers and local village leaders were also interviewed. The findings showed that the logistics that ought to support the diagnosis and treatment of TB are poorly adapted to the needs of persons with disabilities.

SINTEF’s Malawi project:

Topic/Title of project:

  • Access to tuberculosis services for individuals with disability in Rural Malawi, a qualitative study.

Project funded by:

  • LHL’s International Tuberculosis Foundation

Project partner:

  • Reach Trust, Malawi

“Some people who had attended the clinics were turned away because of a shortage of personnel, others because they had turned up on days when the clinic’s TB service was closed. It is more strenuous for people with disabilities to get to a clinic than it is for other people. If their first visit was unsuccessful, they were less likely to repeat the attempt, which is why people with disabilities tend to be worst affected by logistics problems of this sort,” says Grut.

Need for focus on general health

“What needs to be done to improve the spread of information and the inadequate logistics situation?”

“In many poor countries, the health services need to be restructured and their quality and capacity improved. In simple terms, this means that the number of competent health workers must be increased, and that these countries need to develop a decentralised health service that focuses on improving general health rather than on individual diseases,” says Lisbeth Grut.