India's tuberculosis burden is as much a governance and urbanisation challenge as it is a medical one. Examine the structural determinants of TB persistence in urban India and suggest measures to make disease control programmes more inclusive and effective.

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Introduction

India accounts for the highest global TB burden, with urban areas acting as transmission hotspots. TB persistence reflects deeper governance deficits and unplanned urbanisation, beyond purely biomedical causes.

Structural Determinants of TB in Urban India

Unplanned Urbanisation: Expansion of informal settlements with overcrowding, poor ventilation, and inadequate sanitation fuels transmission.
Socio-economic Inequality: Poverty, malnutrition, and insecure livelihoods increase vulnerability and hinder treatment adherence.
Migrant and Mobile Populations: Lack of portability in healthcare disrupts diagnosis and continuity of care.
Fragmented Health Systems: Dominance of unregulated private sector leads to delayed diagnosis, irrational treatment, and underreporting.
Governance Deficits: Weak urban local bodies, poor inter-agency coordination, and inadequate surveillance systems.
Comorbidities and Risk Factors: High burden of diabetes, HIV, tobacco use, and air pollution aggravates TB incidence.
Stigma and Social Exclusion: Marginalised groups (urban poor, homeless) face barriers in accessing care.

Measures for Inclusive and Effective TB Control

Strengthening Urban Health Governance: Empower ULBs, integrate TB control with urban planning, housing, and sanitation policies.
Universal and Accessible Care: Expand free, decentralised diagnostics and treatment under National TB Elimination Programme (NTEP).
Private Sector Regulation: Enforce mandatory notification, standardise treatment, and incentivise compliance.
Targeted Support for Vulnerable Groups: Nutritional support, cash transfers, and social protection for migrants and informal workers.
Technology and Data Systems: Real-time tracking via Nikshay, digital adherence tools, and GIS-based hotspot mapping.
Community Engagement: Involve NGOs, ASHA workers, and peer networks to reduce stigma and improve outreach.
Addressing Social Determinants: Improve housing, reduce air pollution, and strengthen food security.

Conclusion

A shift from a disease-centric to a systems-based approach—integrating governance, urban development, and social policy—is essential to eliminate TB and ensure no vulnerable group is left behind.

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