India tops global TB list again: What gaps keep pushing us into this crisis?

India has long stood at the centre of the global tuberculosis (TB) burden. The latest Global Tuberculosis Report again places the country at the top of global incidence. 

India, Indonesia, the Philippines, China and Pakistan together accounted for 55 per cent of the world’s TB cases in 2024, and India alone contributed a staggering 25 per cent.

Even more troubling, India logged 32 per cent of all cases of multidrug-resistant TB (MDR-TB). MDR-TB refers to TB that no longer responds to rifampicin and isoniazid—the most effective first-line drugs—and must therefore be treated with costlier, harsher second-line medicines. Globally, MDR-TB numbers have been falling since 2015, but India’s remain worryingly high.

“The basic reason is that India has the highest number of tuberculosis cases in the world,” says public health expert Dr S. S. Lal. When case numbers are that large, even a slowly spreading disease becomes overwhelming unless the health system functions with great precision.

India adopted major TB control programs soon after antibiotics became available, yet the sheer volume of cases continues to strain the system.

“TB is completely curable—if diagnosed early. But many people here reach hospitals late,” says Dr Lal. “On the patient side, there is neglect; on the health-system side, there are gaps.”

Social behaviour plays a role

A lingering cough is often dismissed with a casual “take cough syrup,” delaying proper diagnosis. Despite TB being curable and medicines being free, many people begin treatment far too late.

Surveillance gaps deepen the challenge. While the government provides free, high-quality TB drugs under WHO guidelines, a large share of patients remains outside the government’s radar. One major reason is the huge number of people who seek care in the private sector.

Stigma compounds the problem. People avoid disclosure, and the long treatment duration—with notable side effects—makes adherence difficult.

Within the public system, treatment is tightly supervised. TB supervisors, lab staff and health workers conduct regular follow-ups to ensure patients do not abandon treatment. 

“I have worked with WHO teams across state—the system is commendable. But still, people choose private hospitals because of convenience, not quality,” says Dr Lal.

In the private sector, even when a patient sees a competent doctor, many cannot afford the full six-month course of medicines. Symptoms ease after a few weeks, and patients stop taking drugs. It is estimated that at least 30 per cent of people do not complete treatment without supervision. Missing even a couple of doses can lead to drug resistance. This pattern of interrupted treatment is seen as a major driver of India’s high MDR-TB numbers.

“Drug resistance can occur because of poor adherence, poor prescriptions, or because someone is infected with a resistant strain,” says Dr Lal. Second-line drugs exist, he adds, but they are more expensive, cause stronger side effects, and are harder to administer. He also points to widespread over-the-counter use of powerful antibiotics for coughs and fevers, which accelerates resistance. As a result, the very medicines needed later to treat MDR-TB become less effective.

Given India’s massive TB burden, the complexity of its health system, and persistent delays in diagnosis and treatment, experts argue for a stronger public-private mix, tighter regulation of antibiotic use, and more focused surveillance.

Nevertheless, India’s national TB control programme remains among the strongest in the world. If patients reach the system early and adhere fully to treatment, the country still has a real chance to break free from TB.