In South Africa, the control of TB and HIV co-infection remains a major challenge despite the
availability of international and national guidelines for integration of TB and HIV services. This study
was undertaken in KwaZulu-Natal, one of the provinces most affected by both TB and HIV, to identify
and understand managers’ and community care workers’ (CCWs) perceptions of health systems barriers
related to the implementation of collaborative TB⁄ HIV activities, including prevention of mother to
child transmission of HIV (PMTCT). We conducted 29 in-depth interviews with health managers at
provincial, district and facility level and with managers of NGOs involved in TB and HIV care, as well as
six focus group discussions with CCWs. Thematic analysis of transcripts revealed a convergence of
perspectives on the process and the level of the implementation of policy directives on collaborative TB
and HIV activities across all categories of respondents (i.e. province-, district-, facility- and communitybased
organizations). The majority of participants felt that the implementation of the policy was
insufficiently consultative and that leadership and political will were lacking. The predominant themes
related to health systems barriers include challenges related to structure and organisational culture;
management, planning and power issues; unequal financing; and human resource capacity and
regulatory problems notably relating to scope of practice of nurses and CCWs. Accelerated
implementation of collaborative TB⁄ HIV activities including PMTCT will require political will and
leadership to address these health systems barriers.