India has made substantial and tangible progress in Tuberculosis (TB) care, adopting new strategies to detect, treat and prevent TB. Some key areas of progress include the expansion of molecular testing for rapid detection of TB and drug-resistance; the introduction of the shorter, all-oral BPaLM regimen (a combination of four drugs Bedaquiline (B), Pretomanid (Pa), Linezolid (L), and Moxifloxacin (M)); doubling of the entitlement under the Ni-kshay Poshan Yojana (NPY) for nutrition support to ₹1,000 a month; roll-out of TB preventive therapy; and an expanded role for communities through the involvement of TB survivors and Champions. The impact of the roll-out of these strategies can be seen in the 17.7% decline in TB incidence in India, from 237 per 1,00,000 population in 2015 to 195 per 1,00,000 population in 2023, in tandem with a 21.4% reduction in TB-related deaths.
Since Independence, India’s public health system has delivered disease control services through primarily vertical health programmes, such as the National Tuberculosis Elimination Programme (NTEP). While this vertical nature has allowed for concentrated focus and brought benefits in many ways, it has also been limiting. Integration of TB services within the broader public health system is key to India’s pursuit of equitable, universal health coverage (UHC) for all.
Decentralising TB care for all
The ambitious Ayushman Bharat National Health Protection Scheme was launched in India in 2018 to provide UHC for the Indian population. Today, TB has been integrated within both key components of Ayushman Bharat: the Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), considered the world’s largest insurance scheme, and the Ayushman Arogya Mandirs (AAMs, formerly known as Health and Wellness Centres), which provide a comprehensive basket of primary health-care services in rural and urban India.
From the perspective of a person with TB symptoms, the best experience would be accessing consistently high-quality services at the first point of contact. The integration of TB services at the AAM primary care level is designed to meet this need, bringing together diagnostic, treatment and preventive care under one umbrella. AAMs serve as sputum collection centres, where people with TB symptoms can give samples for testing. The NTEP has also been optimising sample collection and transportation methods through a diagnostics network optimisation exercise. A person diagnosed with TB at a secondary or tertiary care facility can undergo treatment at the health centre closest to their residence, again minimising time and costs. In the first two months when people with TB are weak and drop outs as well as mortality is highest, community health officers positioned at the AAMs and their teams must be trained to identify and refer such patients for admission.
While TB services have been free within the public health system, over 50% of all people with TB symptoms continue to seek care in the private sector. Uneven standards of care across the vastly heterogeneous private health sector has led to delays in diagnosis and contributed to poor outcomes as well as significant out-of-pocket expenditure (OOPE) for families. It is imperative to strengthen referrals from the private to the public health system, particularly for those who cannot afford to incur substantial expenditure on health and who may not be aware that TB services are freely available in the public health system. It is equally essential to ensure that the AB-PMJAY provides full insurance coverage for those who seek care for TB in the private or public sector, particularly those who are severely ill.
Equitable and decentralised care for all
What does the road to equitable TB care look like? There are five key steps we can take to accelerate our progress towards TB elimination and universal health coverage (UHC).
First, while we work to achieve decentralisation, we must strengthen person-centred care approaches, and deliver them at scale. There have been model interventions in several States that have assessed people with TB for social and clinical vulnerabilities and linked them to care. In Tamil Nadu, the Tamil Nadu Kasanoi Erappila Thittam (TN-KET), or “TB death-free project”, has been successful in achieving reduced TB mortality through a robust system of identifying those most vulnerable or sick, and referring them for a brief period of admission. Similarly, there have been other interventions focusing on tribal communities, migrants, and homeless populations. One clear pathway to achieving UHC and increased utilisation of the public health system is by strengthening investment in the traditional ‘inputs’ for health and streamlining their functioning — human resources, supplies and infrastructure.
Second, we must develop mechanisms to recognise intersectionalities. Multiple factors such as gender, age, caste, disability, socio-economic status, and occupation determine health seeking intent and access to health and TB services. The intersection of these aspects of identity can both positively and adversely impact TB outcomes. The NTEP has adopted the national framework for a gender-responsive approach to TB, recognising that women, men, and LGBTQIA persons experience TB differently. Improving understanding of gender will take time, and inevitably challenge personal behaviours and norms, but is essential to equitable care. Similarly, there has been some early work to better understand TB and disability, which must be built upon.
Third, integrated care remains a challenge for India’s health system, as we continue to build our primary care services. How do we ensure that someone who comes with TB symptoms is tested for Chronic obstructive pulmonary disease (COPD) or asthma? How can a person with TB be screened for depression or hypertension and linked to appropriate services and counselling? We must adopt models of integrated general health screening in community settings, for example, test for TB and COPD through validated Artificial Intelligence (AI)-enabled chest x-rays and upfront molecular testing, along with screening of common non-communicable diseases through blood pressure, blood glucose, and body mass index (BMI) monitoring.
Fourth, UHC approaches are centred around minimising OOPE, thereby eliminating health-related debt. Schemes such as the NPY have helped alleviate the financial burden on families, by providing monetary support for access to nutritious food. Case-finding approaches, such as the ongoing ‘100 Days’ campaign, can help reduce OOPE prior to diagnosis. However, there are still several significant indirect costs that remain. Expanding social protection by extending nutrition support to the family, piloting wage-loss schemes to offset a loss of income during TB treatment and introducing livelihood programmes for TB survivors are potential future actions.
Lessons from COVID-19, communication
Finally, equity in terms of access to information and knowledge is critical. TB remains severely misunderstood. Recall how swiftly we were able to ensure public understanding of COVID-19, through a flood of science-based information using a multitude of platforms. We need similar approaches for TB, to encourage people to seek care and adopt simple measures to reduce transmission within homes and communities. Promoting knowledge about drug-resistant TB, in the context of growing anti-microbial resistance (AMR) is vital. Decimating TB stigma is critical to ensuring early detection and successful treatment outcomes for people with TB.
An equitable TB programme is one where every individual receives the highest quality of person-centred care that takes into account individual needs. Equity is a cornerstone of health care, and is essential to achieving TB elimination and universal health coverage. India’s TB response is well poised to define global standards and benchmarks. Applying the equity lens will only accelerate our progress.
Dr. Soumya Swaminathan is Chairperson, M.S. Swaminathan Research Foundation (MSSRF)
Published – March 24, 2025 12:16 am IST
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