Tuberculosis elimination in India: With days left for the national target, are we any close?

In 2023, India accounted for more than a quarter of global incidences of TB and 29 per cent TB deaths in the WHO African and South East Asia regions that jointly claimed 80 per cent of the global mortality from TB. 

Of the many contradictions that India has to offer, one that is glaring is the lingering high burden of tuberculosis (TB), an age-old disease both preventable and curable, in the face of India’s repute of being the fastest growing economy in the world. As the tenure of the National Strategic Plan (NSP) for Tuberculosis Elimination (2017-25) of the Government of India draws to a close, a review of the status of TB in the country becomes imperative. 

India accounted for the highest share (26 per cent) of global incident cases of TB in 2023, according to the Global TB Report (2024) published by the World Health Organization (WHO).

Additionally, India features in all three global High Burden Country lists of WHO attributed to TB, TB with HIV and Multi Drug Resistant (MDR) or Rifampicin-Resistant TB for 2012-25.

India has consistently recorded the highest annual incidence of TB for almost a decade now.

India, Indonesia, China, Philippines and Pakistan lead the list of 30 High TB burden countries identified by WHO, in global TB incidence from 2015 to 2023.

India maintains an all-time high share of more than a quarter in global annual TB incidence throughout the specified period.

Top five high TB burden countries

SDG 3, which is a consolidated health-related goal (ensure healthy lives and promote well-being for all at all ages) has 13 targets of which Target 3.3 mentions TB explicitly: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.”

In adherence to this, the End TB Strategy was launched by WHO with an overall goal to end the global TB epidemic. The government of India framed the NSP 2017-25 to hasten the decline in morbidity and mortality from TB while working towards TB elimination by 2025, five years ahead of the global targets of 2030. However, statistics on the current scenario of TB in the country indicate that TB elimination in India anytime soon might actually be an overambitious goal. 

Data on TB notifications from the NIKSHAY portal of the government of India reveals an increasing trend in the number of notified TB cases between 2017 and 2024, followed by a decline in 2025.

In between, the dip in notifications around 2020-21 was possibly a result of difficulties in healthcare access due to lockdowns following COVID. Notifications are seen to have picked up post pandemic.       

Notified TB cases in India (2017-2025)

Across the country, 222 of every 100,000 people were estimated to have medically treated tuberculosis, according to the National Family Health Survey (NFHS) Round 5 (2019-21). This was a dip from 305 per 100,000 population recorded in NFHS 4 (2015-16).

Among the states that accounted for higher than the national average of self-reported and medically treated TB cases were all the northeastern states, Bihar, Orissa and West Bengal in the East; Andhra Pradesh, Kerala and Telengana in the South. This indicates high clustering of TB prevalence around the eastern and northeastern regions of India.

Self-reported and medically treated TB rate in India (2019-21)

NFHS-5 further showed that more than 60 per cent of adult women (aged 15-49 years) and men (aged 15-54 years) who had heard of TB, had misconceptions about the route of transmission of TB. Misconceptions included TB spreading through sharing of utensils, touching a person with TB, through food, sexual contact, mosquito bites or any other means except through the air when coughing or sneezing.

Lack of awareness about the correct mode of transmission of TB leads to inadequate adoption of basic preventive measures like cough etiquette that help break the chain of transmission of infection, besides fuelling negative attitudes like secrecy and stigma around a contagious disease like pulmonary TB.

Among adult women, 15.6 per cent reported that they wanted to keep the diagnosis of TB in a family member, a secret from neighbours. Among adult men, the share was higher (22.9 per cent). The percentages hardly improved in comparison to the last round of the survey (in fact, worsened for men) where the corresponding shares of women and men were 15.9 per cent and 20 per cent respectively.

The tendency of maintaining secrecy around TB might lead to underreporting of diagnosed TB cases, leading to underestimation of TB incidence. 

According to NFHS-5 data, around a quarter of TB patients (25.65 per cent) sought treatment at private healthcare facilities only. Some 71.01 per cent sought treatment either at public facilities alone or in both private and public centres, which implies a visit to the public sector at least once in the treatment tenure.

Since the NFHS does not specify if those seeking treatment exclusively in the private sector come under the ambit of the PPP model of the National TB programme of the Government of India (TB notification by private practitioners was made mandatory since May 2012), data indicated that the safety net of the public TB programme that provides free diagnosis and treatment, failed to cover a substantial chunk of TB patients in India.

Studies also showed that private health facilities are the first point of contact for more than 50 per cent of TB patients in India. Besides, there is documented evidence of suboptimal care and exorbitant costs of TB treatment, a long-term ailment, in the private sector. This not only leads to adverse patient outcomes but also push patients into a ‘medical poverty trap’. 

Where TB patients sought treatment

So, what stands in the way of a “TB-Free India with zero deaths, disease and poverty due to TB” as the vision of NSP for TB elimination 2017-25 quotes? Despite a public TB control programme providing standard, free-of-cost diagnosis and treatment to TB patients, running for years now all over the country with revisions in structures and nomenclatures, incidence of TB in India remains appallingly high.

While TB deaths have slowly but steadily declined over time due to effective treatment intervention, TB prevention remains a challenge with a dearth of public health infrastructure and meagre overall share of health expenditure in India’s GDP.

There has been weak advocacy around TB with limited political commitment, unlike in the case of the communicable disease HIV / AIDS, and perpetual underinvestment by the government. Despite investments by the Union health ministry on campaigns like “TB Harega, Desh Jeetega”, involving popular celebrities like Amitabh Bachhan, awareness about TB is poor among the masses.

Unfortunately, there has been minimal concern and involvement of the media to generate large-scale public awareness about a deadly disease like TB that remains a public health priority for India even in the era of the newfound COVID-19 pandemic. 

Unequal and rather biased allocation of economic and political resources in favour of COVID-19 in the face of an already existing burden of TB lays bare the dilemma in public health management by the government.

It is high time TB receives the attention long due and backing of strong political will so that its eradication no longer remains a goal on paper but is actually realised.  

Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth.