Trends in Tuberculosis Incidence and Mortality in South Africa and Bulgaria (2000–2023): The Impact of Income, Poverty, Unemployment, and Universal Health Coverage

Background: Tuberculosis (TB) remains a major global health threat, with burdens distributed unevenly across regions. South Africa continues to record some of the world’s highest TB incidence and mortality rates, while Bulgaria—although a low-burden country has shown stagnant or rising mortality among vulnerable groups. Comparing these contrasting settings offers insight into how epidemiological, socio-economic, and health system factors shape TB outcomes. Objective: This study compares TB incidence and mortality trends in South Africa and Bulgaria from 2000 to 2023 and examines how HIV prevalence, migration, poverty, ageing, incarceration, health system performance, and underreporting influence TB dynamics. Methods: A narrative comparative analysis drawing on WHO Global TB Reports, peer-reviewed literature, and demographic and system indicators was conducted across four policy-aligned periods (2000–2009, 2010–2015, 2016–2020, 2021–2023). Results: South Africa experienced a sharp rise in TB incidence in the early 2000s, largely driven by the HIV epidemic and system bottlenecks. Incidence fell substantially after 2010 following ART expansion, GeneXpert implementation, and increased programmatic investment. In Bulgaria, TB incidence steadily declined, yet mortality remains disproportionately high due to underdiagnosis, population ageing, socioeconomic vulnerability, and surveillance gaps. Conclusion: Despite differing epidemiological profiles, both countries show how TB persists at the nexus of social inequity and system performance. Strengthened, equity-focused strategies are needed to improve early diagnosis, treatment outcomes, and progress toward TB elimination.