India’s TB gains face execution test as gaps persist, says stakeholder report

India has expanded tuberculosis diagnosis, treatment and digital surveillance over the past decade under its national programme, but weak private-sector integration and persistent inequities now threaten progress towards TB elimination, indicated a new stakeholder report.

The report, India’s Progress in Addressing the Challenge of Tuberculosis, issued by the Union health ministry, noted that India continues to account for about 27% of the global TB burden, with an estimated 2.5 million new cases and nearly 300,000 deaths annually, despite nationwide access to free diagnosis and treatment under the National Tuberculosis Elimination Programme (NTEP). While incidence and mortality have declined, progress remains uneven across states and population groups.

A central fault line lies in India’s dependence on private healthcare at the point of first contact. “Nearly 60% of individuals with TB symptoms in India initially seek care from private providers,” the report stated, making public-private coordination unavoidable for TB elimination. While private providers often reduce delays in diagnosis, the report flagged persistent gaps in notification, treatment adherence and affordability. “Patients frequently incur out-of-pocket expenses for services that are otherwise free in the public sector,” it noted.

India has attempted to address this through public-private interface agencies and intermediary models such as JEET and the Patient Provider Support Agency (PPSA). While these initiatives have improved notification and access to diagnostics in some states, the report cautioned that sustainability remains uncertain. Delayed reimbursements, dependence on third-party agencies and uneven oversight of treatment quality continue to limit scale. “Without systematic integration of private providers into national TB systems, progress will remain partial,” the report said.

Technology, often positioned as the backbone of India’s TB response, presents a similar mix of capability and constraint. The report highlighted the deployment of more than 8,400 molecular diagnostic tools nationwide and the expansion of platforms such as Nikshay for surveillance, adherence tracking and benefit transfers. AI-assisted X-ray screening, next-generation sequencing and digital adherence technologies have strengthened detection and monitoring.

Yet the report cautioned that “technology alone is not enough.” Adoption and impact remain uneven, particularly outside large urban centres. Indigenous digital and AI firms face “prolonged regulatory approvals, limited validation facilities and challenges in integrating with national platforms,” while poor interoperability and last-mile execution weaken outcomes in rural, tribal and northeastern regions. Stigma and limited community participation further constrain the effectiveness of digital tools, the report added.

These systemic gaps have a disproportionate impact on vulnerable populations. TB outcomes remain worse for women, adolescents, migrants, tribal populations and the urban poor, despite national programmes. Adolescents account for around 10% of TB cases nationally and up to 24% in some regions, yet face barriers related to stigma, school disruption and treatment side effects. “Gender- and age-specific barriers continue to affect diagnosis and treatment adherence,” the report noted.

Urban settings pose a different challenge. In cities such as Delhi, nearly two-thirds of newly diagnosed TB patients first seek care from informal providers or pharmacies, increasing the risk of delayed diagnosis and incomplete treatment. Among homeless populations, TB death rates can reach 10%, reflecting the intersection of disease, poverty and limited access to social protection.

Mortality trends underline the need for course correction. The report estimated that around 70% of TB deaths occur outside the treatment cascade, either before diagnosis or after patients fall out of care. While India has expanded free diagnosis, scaled up molecular testing and embedded digital surveillance, “implementation gaps are now the binding constraint,” the report said.

Rather than new policy announcements, the report called for mid-course correction focused on real-time mortality audits, structured post-treatment follow-up and differentiated care for high-risk patients, including those with severe undernutrition, alcohol dependence and co-morbidities. TB elimination, it concluded, will depend on interventions that are “clinically sound, socially responsive and operationally feasible across diverse settings.”