Delays in tuberculosis diagnosis and treatment in India: A patient journey analysis from Mumbai and Patna

BackgroundTuberculosis (TB) patient services in India are often fragmented, undermining timely access to timely diagnosis and treatment. Understanding patient journeys is critical to strengthening TB care delivery and achieving elimination goals. MethodsWe conducted a cross-sectional study of 400 TB patients diagnosed between 2020- 2022 in two major Indian cities: Mumbai (n=200) and Patna (n=200). Using structured interviews, we examined health-seeking behavior, delays to diagnosis and treatment, the number and type of healthcare encounters, and out-of-pocket costs. ResultsPatients predominantly initiated care in the private sector (91% in Mumbai; 85% in Patna), often with pharmacies or private clinics. Care pathways were fragmented, requiring multiple provider visits before diagnosis. The median total delay from symptom onset to treatment initiation was 35 days (IQR: 13-81) in Patna and 26 days (IQR: 12-59) in Mumbai. Provider delays accounted for nearly 19 days in both settings. Patients made a median of 3 healthcare visits pre-diagnosis, with 23% experiencing [≥]6 encounters. The financial burden of TB care was substantial, particularly in Mumbai, where consultation and diagnostic costs were markedly higher than in Patna. Longer delays and higher numbers of encounters were associated with being male, unemployed, having larger household size, and hesitation to seek care during the study period. ConclusionTB patient pathways in urban India pandemic were prolonged, costly, and fragmented -- especially within the private sector during the COVID-19. Strengthening public-private integration, improving early diagnosis strategies, and protecting patients from financial hardship are essential priorities to accelerate TB elimination and strengthen health system resilience against future disruptions.