{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:55:51Z","timestamp":1790618151638,"version":"4.1.0"},"reference-count":58,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T00:00:00Z","timestamp":1790467200000},"content-version":"unspecified","delay-in-days":26,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["099818\/Z\/12\/Z"],"award-info":[{"award-number":["099818\/Z\/12\/Z"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["105825\/A\/14\/Z"],"award-info":[{"award-number":["105825\/A\/14\/Z"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["MR\/N015924\/1"],"award-info":[{"award-number":["MR\/N015924\/1"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MR\/N015924\/1"],"award-info":[{"award-number":["MR\/N015924\/1"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,9,7]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>In response to growing numbers of people with drug-resistant tuberculosis (DR-TB), South Africa was, in 2011, among the first countries to launch a national policy on the decentralisation of DR-TB management, preceding normative guidance from the World Health Organization. The objective was to understand the process of formulation of the South African policy on DR-TB service decentralisation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Qualitative policy analysis. We reviewed policy-related documents to create a timeline, then conducted in-depth interviews with key individuals who had influence over or insights into the policy formulation process. We used Kingdon\u2019s policy analysis framework to examine the convergence of problem, policy and politics streams in agenda-setting to create the window of opportunity for policy adoption.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>South Africa.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Policy makers, implementers and researchers in three South African provinces and at national level, and international DR-TB experts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>International publicity concerning the extensively drug-resistant TB outbreak in Tugela Ferry positioned DR-TB as a public health crisis. The health system lacked capacity to match hospital bed supply in specialised hospitals to the high number of people with DR-TB. Reports of detention against will, victimisation and stigmatisation, and failure to uphold person-centred approaches, sparked a human rights outcry. Tensions between actors favouring \u2018control-based\u2019 approaches with emphasis on centralisation and control of patient treatment and resources, and those favouring \u2018access-based\u2019 approaches that emphasised decentralised care led to a tipping point in the policy process. Centralised, specialised DR-TB approaches were perceived to protect quality of care, but these compromised person-centred care and human rights, and restricted access to DR-TB treatment. Policy actors used lessons from pilot studies of DR-TB decentralisation and HIV programmes to overcome policy stagnation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Policy makers should monitor demand and supply of specialised services and support evidence-informed policy change before health system pressures make reform unavoidable.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-115476","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:00:22Z","timestamp":1790614822000},"page":"e115476","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["\u201cWe were caught sleeping\u201d: formulation of national policy to decentralise management of drug-resistant tuberculosis in South Africa \u2013 a qualitative policy analysis study"],"prefix":"10.1136","volume":"16","author":[{"given":"Mosa","family":"Moshabela","sequence":"first","affiliation":[{"name":"Africa Health Research Institute, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa"},{"name":"School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lindy","family":"Dickson","sequence":"additional","affiliation":[{"name":"Department of Pathology, Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa"},{"name":"School of Biomedical Sciences, University of Western Australia, Perth, Australia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4279-3056","authenticated-orcid":false,"given":"Waasila","family":"Jassat","sequence":"additional","affiliation":[{"name":"School of Public Health, University of the Western Cape, Bellville, South Africa"},{"name":"School of Public Health, University of the Witwatersrand, Johannesburg, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6538-7192","authenticated-orcid":false,"given":"Helen","family":"Cox","sequence":"additional","affiliation":[{"name":"Institute of Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa"},{"name":"Burnet Institute, Melbourne, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karina","family":"Kielmann","sequence":"additional","affiliation":[{"name":"Institute of Global Health and Development, Queen Margaret University, Edinburgh, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9205-9314","authenticated-orcid":false,"given":"Marian","family":"Loveday","sequence":"additional","affiliation":[{"name":"HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa"},{"name":"Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Black","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, Livingstone Hospital, Port Elizabeth, South Africa"},{"name":"Division of Infectious Diseases, University of Cape Town, Cape Town, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Koleka","family":"Mlisana","sequence":"additional","affiliation":[{"name":"School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa"},{"name":"National Health Laboratory Service, Johannesburg, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1366-4805","authenticated-orcid":false,"given":"Mark P.","family":"Nicol","sequence":"additional","affiliation":[{"name":"Department of Pathology, Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa"},{"name":"Marshall Centre, School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2437-5195","authenticated-orcid":false,"given":"Alison D.","family":"Grant","sequence":"additional","affiliation":[{"name":"Africa Health Research Institute, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, 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