Ration or compassion? Stakeholder perspectives on the introduction of bedaquiline in South Africa

Antimicrobial resistance (AMR) is a global health emergency that poses a significant challenge to disease control efforts that rely on antibiotics. Drug-resistant tuberculosis (DR-TB) is a major contributor to global AMR, but its management has historically often remained confined to TB-specific discussions. The emergence of bedaquiline (BDQ), the first novel TB drug in decades, is a moment of potential confluence between AMR and DR-TB. By examining the period between 2012 and 2018, when BDQ was made available for DR-TB in South Africa, this study explores how the introduction of this novel drug foregrounded tensions between antimicrobial access and stewardship in resource-constrained settings. Through qualitative interviews with doctors, policymakers, patients, and activists in the context of DR-TB policy, programming, and care delivery, we explore how these stakeholders balanced the imperative to expand access to this critical new antibiotic and the imperative to ensure its longevity. South Africa, we show, adopted a liberal approach to access to BDQ, grounded in a compassionate care approach that represented a significant shift from the country's traditional drug rationing aimed at mitigating the spread of DR-TB. We document the numerous obstacles that were faced in enabling compassionate use, as well as the broader implications of South Africa's liberal BDQ policy both for TB management in South Africa and for global AMR strategies. The BDQ experience suggests that integrating compassionate care into stewardship models can yield positive public health outcomes, challenging some of the foundational assumptions underlying stewardship. In the process, it suggests that a third, balanced strategy is available that explicitly integrates equitable access with robust stewardship to fulfil both immediate and long-term public health goals.