Introduction

Tuberculosis (TB) continues to be one of India’s most pressing public health challenges. Despite major strides in detection, treatment, and prevention, India accounts for 27% of the global TB burden, making it a leading contributor to TB-related deaths and illnesses worldwide. The disease disproportionately affects marginalized communities, with socio-economic and gender-based disparities further exacerbating health inequities.

Recognizing the urgency of tackling TB, India has set an ambitious target to eliminate TB by 2025, five years ahead of the global Sustainable Development Goal (SDG) target of 2030. To accomplish this, the government has implemented several innovative strategies, including expanding molecular testing, introducing shorter treatment regimens, strengthening social support systems, and integrating TB services into universal health coverage (UHC).

While these efforts have led to a decline in TB incidence and mortality, there remain critical challenges related to accessibility, affordability, stigma, and healthcare infrastructure. This article provides a detailed analysis of India’s TB burden, key government initiatives, recent advancements, and existing challenges that must be addressed to achieve TB elimination.

India’s TB Burden and Trends

India continues to bear a significant portion of the world’s TB cases, but recent data indicates positive progress in reducing TB incidence and mortality.

Current TB Statistics

• TB Incidence (2023): 195 cases per 100,000 population, reflecting a 17.7% decline from 237 cases per 100,000 population in 2015.
• TB Mortality (2022): 331,000 deaths, representing 23 deaths per 100,000 population.
• Global Contribution: India accounts for 27% of global TB cases.
• Drug-Resistant TB (DR-TB):
• 2.5% of new TB cases are drug-resistant.
• 13% of previously treated cases develop drug resistance.
• TB-HIV Co-infection: 2% of TB patients in India are HIV-positive.

The India TB Report 2023 emphasizes that prevention remains a key pillar of the country's TB elimination strategy. Given the persistent burden of TB, targeted interventions, social support mechanisms, and stronger public health infrastructure are necessary to sustain progress.

Key Government Interventions and Strategies

To combat TB effectively, the Indian government has introduced comprehensive policies and programs focusing on early detection, treatment, financial assistance, and community involvement.

1. National TB Elimination Programme (NTEP)

• Launched in 2020, replacing the Revised National Tuberculosis Control Programme (RNTCP).
• Focuses on early detection, effective treatment, prevention, and community engagement to eliminate TB by 2025.

2. Expansion of Molecular Testing and New Drug Regimens

• Advanced molecular testing ensures rapid TB and drug-resistance detection, improving diagnosis and treatment efficiency.
• Introduction of BPaLM Regimen, a shorter, all-oral treatment for drug-resistant TB, consisting of:
• Bedaquiline (B), Pretomanid (Pa), Linezolid (L), and Moxifloxacin (M).

3. Financial and Nutritional Support Initiatives

• Ni-kshay Poshan Yojana (NPY):
• ₹1,000 per month provided as direct benefit transfer (DBT) to TB patients throughout their treatment.
• The entitlement was recently doubled to improve adherence and treatment success.
• Pradhan Mantri TB Mukt Bharat Abhiyan:
• Community-driven initiative offering additional nutritional support through contributions from individuals and organizations.

4. Integration of TB Services with Universal Health Coverage (UHC)

• Under Ayushman Bharat:
• TB services have been integrated with:
• Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) – The world’s largest health insurance scheme, covering TB treatment.
• Ayushman Arogya Mandirs (AAMs) – Health and Wellness Centres (HWCs) functioning as sputum collection and TB care facilities.

5. Strengthening Community Engagement

• Involvement of TB Survivors and Champions to create awareness and support early diagnosis.
• Targeted Interventions for Vulnerable Groups:
• Tamil Nadu Kasanoi Erappila Thittam (TN-KET): A TB mortality reduction program ensuring early identification and referral of high-risk patients.
• Programs for Tribal Communities, Migrants, and the Homeless: Focused case detection and tailored intervention models.

6. Addressing Private Sector Challenges

• Over 50% of TB patients seek treatment in private healthcare settings.
• Challenges:
• Uneven quality of care, leading to delays in diagnosis and poor treatment adherence.
• High out-of-pocket expenditure (OOPE) for TB treatment in private hospitals.
• Solutions:
• Strengthen referrals from private to public healthcare facilities.
• Ensure AB-PMJAY covers TB treatment costs for both public and private hospitals.

Challenges in Achieving TB Elimination by 2025

1. Social and Economic Barriers

• Stigma and Discrimination:
• Many TB patients delay seeking care due to social stigma and fear of isolation.
• Women in high-stress corporate jobs (e.g., MNCs) are at higher risk due to poor nutrition and workplace stress.
• Gender and Socio-Economic Inequities:
• Lower healthcare access for marginalized communities affects TB diagnosis and treatment outcomes.

2. Gaps in Integrated Healthcare

• Co-Morbidity Screening Deficiencies:
• TB patients should also be screened for Chronic Obstructive Pulmonary Disease (COPD), asthma, hypertension, and depression.
• Technological Gaps:
• AI-enabled chest X-rays can improve early TB detection but need wider implementation.

3. Financial Barriers and Out-of-Pocket Expenditure (OOPE)

• Current financial aid (₹1,000 per month under NPY) is insufficient to cover all indirect costs.
• Potential Solutions:
• Expand nutrition support to family members of TB patients.
• Pilot wage-loss compensation schemes to prevent economic hardship during treatment.

Lessons from COVID-19: The Need for Enhanced Public Awareness

• Lack of Mass Awareness Campaigns:
• Unlike COVID-19, TB has not received consistent, science-based public awareness efforts.
• Recommended Actions:
• Utilize social media, television, and community networks for mass awareness.
• Promote drug-resistant TB (DR-TB) education to prevent antimicrobial resistance (AMR).

Future Directions: Five Key Steps for TB Elimination

1.   Scaling Up Decentralized TB Care: Strengthen Health and Wellness Centres (AAMs) to provide holistic TB management.

2.   Implementing a Gender-Responsive TB Framework: Address gender-based disparities in TB treatment.

3.   Enhancing Integrated Healthcare Models: Integrate TB screening with non-communicable disease (NCD) check-ups.

4.   Reducing Out-of-Pocket Expenditure (OOPE): Expand wage-loss compensation and financial protection for TB patients.

5.   Strengthening Public Awareness Campaigns: Use multi-platform campaigns to combat TB stigma and misinformation.

Conclusion

India has made substantial progress in TB elimination, yet persistent challenges remain. While advanced diagnostics, shorter treatment regimens, financial aid, and community engagement have improved outcomes, issues related to stigma, financial hardship, and healthcare access must be addressed.

A multi-sectoral, equity-focused approach integrating technology, financial support, private sector engagement, and mass awareness efforts will be essential in achieving TB elimination by 2025 and ensuring universal health coverage (UHC) for all.