Tuberculosis (TB) is a global public health concern and the epidemic in southern Africa has not stabilised. In South Africa, since 1994, there have been significant political reforms including transformation of the health system to provide equitable healthcare, which has resulted'in legislative changes and increased resource allocation for service delivery. Despite these endeavours, South Africa has one of the highest burdens of TB in the world. In this article we review the TB epidemic in KwaZulu-Natal, one of nine provinces in South Africa, and reflect on the factors which continue to drive this epidemic despite substantial public healthsectorreformsandinvestments.