“I felt weak,” she recalls, “and preferred to be alone.”
Battling extensively drug-resistant tuberculosis or XDR-TB, a form of the disease in which drugs rarely worked, Anushka’s only option was to be loaded each day with scores of tablets and injections. Those came with toxic side effects. For over four years, she moved between government and private hospitals, enduring cycles of failed treatment.
Relief came only when she was placed on a salvage regimen—the last option when all other interventions are exhausted—at a Médecins Sans Frontières (MSF) clinic in Govandi, Mumbai. The global humanitarian group offered Anushka a cocktail of bedaquiline, delamanid and imipenem injections, a set of very powerful meds often inaccessible to most Indians due to supply restrictions aimed at curbing drug resistance.
Anushka, who has now recovered, recounted her ordeal at MSF’s TB Day event in Mumbai on May 12, speaking before an audience of doctors, a quiet smile breaking through years of pain. Her journey to recovery is rare, and alien to millions in India, which reflects a public health system still failing its most vulnerable. India now accounts for more than a quarter of all TB cases reported worldwide. In 2023, the country had 26% of the global TB burden, according to the World Health Organization (WHO). Bending the curve remains difficult despite multiple national programmes.
How can India improve?
MISSING CASES
In 2018, when India pledged to eliminate TB by 2025, five years ahead of the set global target, the objective was clear. And progress has been made, too. Between 2015 and 2023, TB incidence (new and relapsed cases per 1 lakh population every year) fell by 18% and deaths by 24%, per WHO.It’s is a sign in the right direction, but the number of cases are still astounding, especially when it comes to drug-resistant variants. “India bears the highest burden of XDR-TB globally, with an estimated 110,000 new cases annually,” says Professor Anil Koul of the London School of Hygiene and Tropical Medicine. A key figure in TB drug research, Koul was part of a Johnson & Johnson team that developed bedaquiline, one of the most effective drugs against resistant TB strains.
He notes that Covid-19 deepened the crisis, and underfunded research has stalled progress. Of the 27 drugs in clinical trials, none have reached Phase III. Bedaquiline remains the mainstay.
A 100-day TB Elimination Challenge was launched by the government in December 2024 to amplify efforts to diagnose and treat TB at the village level, but experts aren’t satisfied.
“We are not on track,” says Dr Animesh Sinha, chronic care and infectious disease advisor, MSF. “To meet the 2025 milestones of WHO’s End TB strategy, India should achieve a 50% reduction in TB incidence rate and a 75% reduction in the total number of TB deaths compared with 2015.” Although numbers have fallen, the quantum has been woefully short of the target, as WHO numbers suggest.
A PIB release dated March 24, 2025, says India’s TB elimination targets for 2025 are an 80% reduction in incidence and a 90% reduction in deaths, compared with 2015.
A key problem is underreporting emanating from under-diagnosis. India’s notification rate (number of TB cases diagnosed and officially reported) has improved from 108 per 100,000 population in 2010 to 166 in 2023, yet many cases, especially in rural areas, go undetected.
“In order to address the TB crisis, we have to find the missing cases,” says Sinha. Nonetheless, the 2025 goal helped push TB up the political agenda. Ni-kshay, a digital platform for notification and treatment monitoring, is improving reporting. But without proportionate investment in diagnostics, staffing and drug access, the pace of progress will be inconsistent.
Intermittent drug shortages have been reported, and India spent just 2.1% of the National Tuberculosis Elimination Programme budget on diagnostics till 2023-24, an IndiaSpend RTI revealed.
“The 2025 target was always a stretch,” says Koul. “But it did galvanise government machinery, leading to faster approvals for newer regimens like bedaquiline, speedier rollout across TB centres and more budgetary support, including for nutritional aid.”
That said, TB continues to receive only a sliver of public health funding. But even so, he notes, there certainly is a positive trend in fighting back, considering the complexity of the disease and the socioeconomic factors shaping it.
However, in an ET Morning Brief podcast in January, Dr Urvashi Singh, deputy director-general (TB), Ministry of Health and Family Welfare, said, “The domestic budget for the national TB programme has increased over five times in the last 10 years.” India, she added, is the only high-burden country where 91% of the programme is backed by domestic funding.
NEW HOPE, OLD GAPS
Early detection is often the difference between quick recovery and years of suffering. Goa-based diagnostic device maker Molbio Diagnostics’ Truenat, a portable molecular-testing platform, introduced in 2017, expanded diagnostic access, particularly in low-access regions. “We supplied over 90 lakh testing kits last year and expect to provide 1.25 crore this year,” says Sriram Natarajan, CEO of Molbio, which is working with government and statelevel partners to rollout molecular testing.
A Truenat test costs just Rs 640, a fraction of what imported diagnostics demand, says Natarajan. In public health, he argues, the real measure isn’t price, but cost-effectiveness, especially when early detection can avert far greater expenses.
Some globally approved diagnostics protocols remain out of reach in India. The WHO-recommended urine TBLAM test, used to diagnose TB in HIVpositive patients, is still unavailable in the country, despite successful validation studies in Mumbai in 2022. Registration barriers and lack of supply from manufacturers have led to lack of access, says Leena Menghaney, a public health lawyer based in Delhi. Supplyrelated issues could be because trials in India have yet to conclude, according to industry sources.
Such delays cost precious lives. Late detection risks high transmission rates and complications for patients. Dr Jennifer Furin, infectious diseases clinician, Harvard Medical School, says while Truenat is helpful and the diagnostic pipeline is robust, the outdated and slow systems for approving novel tools in India have a detrimental impact. Furin points to a critical gap: the lack of household-level prevention. Studies, including a 2023 trial published in TheLancet, show that modest nutritional support for families of TB patients can sharply reduce transmission. Another model, published in TheLancet this year, estimates that improving household nutrition alone could prevent nearly 5% of TB deaths by 2035.
A CURE WITH ISSUES
Despite carrying the world’s highest TB burden, regulatory reforms have been slow in India. Some gains have been made, but systemic delays continue to blunt the impact of new treatments.
For patients with drug-resistant TB, a new wave of treatment offers hope, but conditions apply. Regimens like a six-month, all-oral combination termed BPaLM— bedaquiline, pretomanid, linezolid and moxifloxacin—have been game-changers, replacing the gruelling 24-month regimens of daily injections and pills. “These regimens are better tolerated and highly effective, with about 90% of people completing treatment successfully,” says Sinha.
While clinicians welcome the government’s push for shorter regimens, access remains limited—only 1,700 patients in India have received them, according to Dr Rupak Singla, head of the department of respiratory medicine, National Institute of Tuberculosis and Respiratory Diseases, Delhi, who spoke at the event in Mumbai. Adoption has lagged due to limited access to drug susceptibility testing for newer drugs, which is crucial for choosing an appropriate treatment strategy.
The BPaLM regimen can’t be given in cases where more than one organ system is involved or in patients with severe extrapulmonary disease, “both of which are common in India,” according to Dr Alpa Dalal, head of unit, Group of TB Hospitals, Sewri, Mumbai. BPaLM should not be prescribed for patients previously treated with bedaquiline, says Dalal, unless drug susceptibility to bedaquiline and linezolid is confirmed.
Dalal says even in extensive pulmonary TB, where studies have shown good outcomes with BPaLM, many clinicians are cautious. In longer regimens, patients with extensive lung involvement have had higher relapse rates, compared with patients with limited disease, she explains, and that concern carries over. A study published in OUP’s research platform, Oxford Academic, in March 2025 shows that bedaquiline resistance among previously treated patients can reduce the drug’s efficacy.
Researchers warn that such resistance could undercut its effectiveness in the long term if not addressed early. But Koul says, “Bedaquiline has galvanised TB R&D. It will remain a core component of future regimens, unless we see a dramatic rise in resistance in clinical practice.”
The economics of care create barriers too. Pricing is a big hurdle. Regimens with imipenem cost thousands of rupees per day. Anushka was treated free by MSF. Else each injection alone, she said, would cost Rs 2,499. Considering the socioeconomic realities of India, perhaps this is where the government could step in.
India’s approach to procurement is problematic too. The country selectively joins pooled procurement platforms like the Global Drug Facility, which could reduce costs. “India has in the past refused to participate in this, unless they had an emergency,” says Furin.
WHAT NEXT?
Beyond policy and procurement, TB is a profoundly social disease, shaped by stigma, poverty and undernutrition. Even the best drugs won’t work if care doesn’t reach those who need it most. Guidelines may improve and approvals may accelerate but until the system meets people where they are, too many will be left behind.
Anushka suffered for years before she got cured. Her strength wasn’t just in surviving; it was in refusing to give up. “Even in that condition, I completed my graduation and kept chasing my dreams,” she says. India’s TB response must now rise to match that grit, with urgency, equity and compassion.
