Delays in tuberculosis diagnosis and treatment in India: A patient journey analysis from Mumbai and Patna during the COVID-19 Pandemic

Tuberculosis (TB) care for people with TB in India are often fragmented, undermining timely diagnosis and treatment. Understanding patient journeys is critical to strengthening TB care delivery and advancing elimination goals. We conducted a cross-sectional study of 400 people with TB diagnosed between 2020–2022 in two Indian cities: Mumbai (n = 200) and Patna (n = 200). Using structured interviews, we assessed care-seeking behavior, delays to diagnosis and treatment, the number and type of healthcare encounters, and out-of-pocket costs. Participants predominantly initiated care in the private sector (Mumbai 91%; Patna 85%), often at pharmacies or private clinics. Care journeys were fragmented, with 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 contributed a median of ~19 days in both cities. Participants made a median of 3 pre-diagnosis healthcare visits, and 23% had ≥ 6 encounters. The financial burden was substantial particularly in Mumbai, where consultation and diagnostic costs were higher than in Patna. Longer delays and more encounters were associated with male sex, unemployment, larger household size, and care-seeking hesitancy during the study period. Patient journeys in urban India during the COVID-19 pandemic were prolonged and costly, with delays driven primarily by systemic fragmentation rather than patient hesitancy. The reliance on an under-regulated private sector led to multiple pre-diagnosis encounters (23% requiring more than 6) and significant out-of-pocket costs. Because no individual characteristic consistently predicted delay, these findings suggest that structural reforms including standardized diagnostic pathways and enhanced public-private integration are essential to build health system resilience and accelerate TB elimination.