Published in PLOS One on 2026-02-11, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. HealthSignal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Michael Strauss, Muhammad Osman, Sue-Ann Meehan, Florian M. Marx, Anneke C. Hesseling, Andrew Boulle, Pren Naidoo, Gavin George
Source: PLOS One • DOI 10.1371/journal.pone.0342708
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Tuberculosis (TB) patients who are diagnosed but not registered and initiated on TB treatment are categorised as initial loss to follow-up (ILTFU). ILTFU is a key driver of morbidity and mortality associated with TB and is a contributing factor to high TB transmission rates. LINKEDin was a quasi-experimental study which evaluated two specific interventions for reducing ILTFU in three high-TB burden provinces in South Africa, conducted from October 2018 to December 2020. As part of LINKEDin, we undertook a micro-costing from the healthcare provider perspective using an activity-based costing approach. Cost estimates included the cost of the operation of an integrated provincial health data centre in the Western Cape, apportioned to the TB activities it supported in the province. Cost estimates were linked to intervention outcomes to understand the incremental cost of the intervention per additional patient linked to care compared to rates of ILTFU in the absence of the interventions. Sensitivity analyses were conducted to account for uncertainty in the intervention outcomes, and for periods where the implementation of the intervention was interrupted due to COVID-19 related disruptions. Costing data were collected between August 2020 and March 2021. The total cost of implementing the LINKEDin intervention in the WC and KZN was $7 534.42 per month. The cost of implementing LINKEDin in the Western Cape accounted for 56% the total cost of the intervention – 8% from the operations of the PHDC and 48% from the cost of running the intervention – while only 44% of the total cost was accounted for by the intervention run in KwaZulu-Natal. The primary cost driver of the interventions were staff salaries, with the cost of data extraction and in-hospital activities low relative to primary healthcare (PHC)-based follow-up activities. In terms of cost effectiveness, the LINKEDin interventions in KZN was cost $377.28 per additional person linked to care, and $243.62 in the WC, per additional person linked to care. In the Western Cape, systematically tracking persons with TB using an automated system proved highly cost efficient compared to the more labour intense approach adopted in KwaZulu-Natal. Optimising the curation and management of data and increasing the effectiveness of tracing systems and processes can result in cost-savings.
Introduction
South Africa has a high burden of tuberculosis (TB), with an estimated 270 000 people developing TB in 2023, with only 78% (211 810) registered and initiated on TB treatment [1]. Individuals who are lost from care between TB diagnosis and treatment initiation and registration are categorised as initial loss to follow-up (ILTFU) [2]. Previous South African studies have estimated ILTFU to be between 12% and 25% [3–5] with an estimated mortality of 17% among ILTFU patients [6]. Addressing the gap between TB diagnosis and treatment initiation and registration is vital to prevent ongoing transmission of TB [7] and decrease morbidity and mortality [8].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider research & evidence desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Michael Strauss, Muhammad Osman, Sue-Ann Meehan, Florian M. Marx, Anneke C. Hesseling, Andrew Boulle, Pren Naidoo, Gavin George. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by HealthSignal. The researchers are the authors of the source study, not members of HealthSignal’s staff.
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