Article Text

Download PDFPDF

Tuberculosis: treatment failure, or failure to treat? Lessons from India and South Africa
  1. Nesri Padayatchi1,2,
  2. Amrita Daftary3,
  3. Naressa Naidu1,2,
  4. Kogieleum Naidoo1,2,
  5. Madhukar Pai3
  1. 1 Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
  2. 2 Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
  3. 3 McGill International TB Centre, McGill University, Montreal, Quebec, Canada
  1. Correspondence to Dr Nesri Padayatchi; nesri.padayatchi{at}


Tuberculosis (TB) remains an enormous public health concern globally. India and South Africa rank among the top 10 high TB burden countries with the highest absolute burden of TB, and the second highest rate of TB incidence, respectively. Although the primary drivers of TB transmission vary considerably between these two countries, they do indeed share common themes. In 2017, only 64% of the global estimated incident cases of TB were reported, the remaining 36% of ‘missing’ cases were either undiagnosed, untreated or unreported. These ‘missing TB cases’ have generated much hype for the challenges they present in achieving the End TB Strategy. Although India and South Africa have indeed made significant strides in TB control, analysis of the patient cascade of care clearly suggests that these ‘missed’ patients are not really missing—most are actively engaging the health system—the system, however, is failing to appropriately manage them. In short, quality of TB care is suboptimal and must urgently be addressed, merely focusing on coverage of TB services is no longer sufficient. While the world awaits revolutionary vaccines, drugs and diagnostics, programmatic data indicate that much can be done to accelerate the decline of TB. In this perspective, we compare and contrast these two national epidemics, and explore barriers, with a particular focus on the role of health systems in finding the missing millions.

  • tuberculosis control
  • South Africa
  • India
  • missing millions

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Handling editor Alberto L Garcia-Basteiro

  • Contributors All authors contributed equally to the writing of this manuscript.

  • Funding This work was supported by the South African Medical Research Council. NP, NN and KN are supported by the Centre for the AIDS Programme of Research in South Africa (CAPRISA). AD is supported by a salary award from Fonds de recherche du Québec–Santé (FRQS). MP is supported by a Canada Research Chair award.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.