Clinical advances in the 2025 WHO tuberculosis guideline update module 4 and their implications for health equity in sub-Saharan Africa

Tuberculosis (TB) remains a leading cause of morbidity and mortality globally, with sub-Saharan Africa (SSA) disproportionately affected due to high transmission rates, HIV co-infection, and an increasing burden of drug-resistant tuberculosis (DR-TB). The 2024/25 World Health Organization (WHO) Tuberculosis Guideline Update (Module 4) introduces clinical advancements to improve DR-TB management. This critical perspective discussed published studies and WHO guidelines, examining how these clinical advances are likely to translate into improved TB care and treatment equity in SSA, an analytical question that has not been addressed in prior commentary on WHO TB guideline (Module 4). The guideline emphasizes shorter, all-oral treatment regimens; novel drug combinations, such as bedaquiline, pretomanid, and linezolid-based therapies (BPaL/BPaLM); and decentralized, patient-centered care models. These have the potential to reduce treatment duration, improve adherence, minimize toxicity, and enhance accessibility, particularly for underserved populations, although evidence of SSA-specific outcomes supporting these benefits remains sparse. By aligning with Universal Health Coverage (UHC) and the End TB Strategy, Module 4 provides a framework for equitable TB service delivery. However, translating these clinical gains into real-world equity outcomes is hindered by persistent structural barriers in SSA, a heterogeneous region rather than a uniform setting. Weak health systems, limited diagnostic capacity, fragmented supply chains, financial constraints, and sociocultural factors such as stigma continue to impede equitable access to TB care, and the extent of these barriers varies substantially according to country-level health-system capacity. To bridge this gap, coordinated strategies are required, including health system strengthening, sustainable financing, local drug manufacturing, community engagement, and digital health integration, implemented through tiered, phased approaches appropriate to varying levels of health system readiness. Ultimately, while the WHO Module 4 update represents a clinically important shift in DR-TB management, achieving meaningful equity gains in SSA will depend on context-sensitive implementation, strong governance, and sustained investment in health systems.