Madhukar Pai

The world is far from achieving universal access to rapid tuberculosis (TB) diagnostics that align with the World Health Organization (WHO) TB diagnostic standard. Although WHO-recommended molecular rapid diagnostics (mWRDs), including low-complexity automated nucleic acid amplification tests (LCaNAAT), have significantly improved TB detection, high capital, maintenance, and consumable costs have constrained scale-up. Recently, lower-cost, near-point-of-care nucleic acid amplification tests (NPOCs) have emerged offering the potential to expand access to rapid TB diagnosis while reducing the financial burden. To better understand the budget impact of using newer NPOCs as the initial TB diagnostic compared with established mWRDs, we developed a flexible cost calculator. Developed in Microsoft Excel, key parameters were organized in a structured input sheet using standardized labels. Separate worksheets defined diagnostic scenarios and performed calculations, with results summarized in an overview covering various costs. After validation, the model was converted into R (version 2025.09.1 + 401). The app (app.R), developed with Shiny, is available here for free global access. Using two hypothetical countries, we compared current LCaNAAT- based testing strategies with scenarios in which NPOCs were implemented as the initial diagnostic test. In hypothetical Country A, there were cost savings of 56.4% in Scenario 1 (based on current testing trends) and 60.5% in Scenario 2 (based on ambitious testing goals). In hypothetical Country B, the corresponding cost differences were 44.2% in Scenario 1 and 59% in Scenario 2. The analysis showed that countries can reach ambitious TB testing targets over 3 years using NPOCs at roughly the same total cost as implementing one year of current LCaNAAT testing. This highlights the potential of cheaper molecular diagnostics to significantly improve access to mWRDs. By reducing capital and maintenance costs, NPOC platforms let TB programs test and detect more cases within existing budgets, accelerating progress toward universal rapid TB diagnosis.

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.

Introduction: Antimicrobial stewardship efforts in low- and middle-income countries (LMICs) largely focus on qualified practitioners, yet informal healthcare providers (IPs) deliver much of the primary care. Although these providers frequently dispense antibiotics, their practices remain poorly documented and are not captured in existing surveillance systems. Methods: Using the Joanna Briggs Institute methodology, this scoping review synthesised evidence on antibiotic dispensing and its determinants among IPs in LMICs. Nine databases (MEDLINE, EMBASE, SCOPUS, Global Health, CINAHL, Web of Science, LILACS, African Journals Online via Africa-Wide Information and Index Medicus for the South-East Asia Region) were searched, yielding 12 095 records, of which 37 studies met the inclusion criteria. Results: Across 31 studies reporting dispensing practices, antibiotic use by IPs varied widely: 18%–74% in studies using standardised methods, 5%–96% in provider-reported studies and 2%–86% in consumer-reported studies. Eight qualitative studies identified key behavioural and contextual determinants shaping dispensing, including limited knowledge, experience-based learning, patient expectations, peer and pharmaceutical influence, perceived consequences of withholding antibiotics and economic incentives. Conclusion: Antibiotic dispensing by IPs is widespread and represents a large but unmeasured component of antibiotic use in LMICs. These findings highlight a critical gap in antimicrobial resistance surveillance and highlight the need for stewardship strategies that effectively engage this provider group.

Persistent gaps in access to quality diagnostic tests undermine progress toward improved health outcomes and resilience to disease outbreaks in Africa. Furthermore, resources for strengthening laboratory systems have faced growing constraints owing to recent reductions in official direct financial assistance, highlighting an urgent need to identify investments that are high impact and minimally donor reliant. In this Perspective, we present a set of priority systems strengthening interventions based on expected impact and feasibility. These include the need for efficient and integrated testing networks, the establishment and implementation of national essential diagnostic lists, modernized procurement and supply chain practices, improved digital health standards and targeted strengthening of testing infrastructure for epidemic-prone diseases. These initiatives should be customized to local contexts and supported by reliable financing, enhanced national leadership and management capacity and updated policies. We propose that collective action focused on these priorities will improve health outcomes and be cost-saving—and will be superior to existing, more fragmented efforts to close gaps in testing. This also provides a pathway to self-reliance in health security and universal healthcare in the Africa region.

Background: Tuberculosis (TB) diagnosis typically relies on individuals producing sputum samples for microbiological testing. The inability to self-expectorate sputum, sputum scarcity, is a well-known concern. This systematic review and meta-analysis investigated sputum scarcity among adults with presumptive TB. Methods: We searched databases with no language restrictions from January 2010 to October 2023 using terms for TB and sputum. We excluded studies with participants aged <15 years, enrolling participants only after sputum collection, or not reporting information on sputum collection. Published summary data was extracted, and the risk of bias was assessed. Summary estimates and pooled proportion of sputum scarcity were calculated by random effects meta-analysis overall and by pre-specified sub-groups. The review protocol was registered on PROSPERO (CRD42023473882). Findings: Our search identified 9895 records, of which 114 studies were included which enrolled 93,158 participants and 81 studies were rated as a low risk of bias. The median proportion of sputum scarcity across all 114 studies was 6·0% (95% CI: 2·9-9·1%, IQR: 0-19·9%). In subgroup meta-analyses limited to studies collecting one or two self-expectorated spot sputum samples, the pooled estimate of sputum scarcity was 23% (95%CI: 14-33%, n=27). Sputum scarcity was higher in people living with (PLHIV); pooled estimate in studies enrolling only PLHIV was 24% (95% CI: 15-33%, n=9) and 32% (95% CI: 22-41%, n=5) in advanced HIV for one or two self-expectorated spot sputum samples. People without HIV had the lowest pooled estimate of scarcity for self-expectorated sputum, with 12% (95% CI: 3-21%, n=5) unable to provide samples. Studies using sputum induction to collect one or two spot samples had a pooled scarcity of 10% (95% CI: 0-21%, n=12). Interpretation: Sputum scarcity is common for individuals being evaluated for TB and compromises bacteriological TB diagnosis. These findings support the recent WHO endorsement of tongue-swab based molecular TB tests.

New tools and policies herald a major advance in tuberculosis diagnosis