Lessons and updates from India's National Tuberculosis Elimination Program – bold decisions and innovative ways of fast-tracking progress toward ending tuberculosis

Highlights

• •India bears the highest tuberculosis burden.
• •Strong political commitment cascaded from the Prime Minister to local stakeholders.
• •Innovations in diagnosis, treatment, vaccines, and digital health were prioritized.
• •Socio-economic impact was mitigated by direct benefit transfer schemes.
• •Decentralized initiatives of tuberculosis-free villages/districts empowered local stakeholders.

Abstract

India has the highest burden of tuberculosis (TB) globally. Strong political commitment, bold targets, and innovations have been the hallmark of the TB response. Lessons learned in India, such as understanding the diversity of TB epidemiology, approaches beyond conventional response strategies, bold decisions, and innovations, are invaluable for the global TB response. The India TB response is supported by strong political commitment cascading from the Prime Minister to local stakeholders. An initial key step was the sub-national assessment of the diverse TB burden and recognition of the public and private health care landscape. India effectively demonstrated innovative models to meaningfully engage all stakeholders, leveraging technology to bridge gaps. Community participation and social engineering movements were used to reduce stigma and address the nutritional needs of TB patients. Patient-support systems through an innovative adoption program, crowdsourced solutions, and direct benefit cash transfers were implemented to mitigate the socio-economic impact of TB. Decentralized initiatives such as the TB-Free Panchayat, district, and city schemes empowered local stakeholders and encouraged healthy sub-national competition. Advances in research and development of screening tools, rapid molecular diagnostics, real-time integrated digital surveillance systems such as Ni-kshay, and innovations such as telemedicine, call centers, direct benefit transfers, and artificial intelligence (AI)-based tools are accelerating the TB response in India.

Introduction

The context of tuberculosis in India

Tuberculosis (TB) remains a significant public health challenge in India [1]. The disease poses multiple challenges—biological, medical, social, and economic. The burden of TB in the country is quite heterogeneous, with prevalence rates varying from as high as 747 (510-984) per 100,000 population in Delhi state to as low as 149 (60-237) in Kerala state [2]. TB affects the most vulnerable populations, including socially vulnerable groups, clinically high-risk individuals, tribal communities, and people living in poverty, urban slums, and remote rural areas, where access to health care is limited [3,4]. TB continues to impact the economic productivity of the affected individuals, families, and communities. It fuels and propagates the vicious cycle of poverty–malnutrition–TB [5]. Despite having a national TB program in place for more than 6 decades, disease transmission continues and is complicated by asymptomatic/subclinical TB, emerging drug resistance to anti-TB drugs with unfavorable health outcomes, including higher fatality. Socio-cultural, economic, and health care system-related factors contribute to the persistence of TB in India. Delayed diagnosis, stigma associated with the disease, lack of awareness, poor health-seeking behavior of the population, and the financial burden of treatment often hinder progress in the decrease of the TB burden. India's high population density and rapid urbanization exacerbate the risk of transmission. Despite these challenges, India has demonstrated a commitment to combating TB through several initiatives reflecting bold policies and innovation. Understanding the context of TB in India is crucial to addressing this pervasive health crisis, which affects not only individual lives but also the socio-economic fabric of the nation.

TB burden in India compared to global: India contributes to one-fourth of the global TB burden while its population is less than 18% of the global population. Although India ranks 40^th in per capita TB-incidence rate, its absolute number of incident TB cases is the highest in the world [6]. India's TB-incidence rate has decreased by 18% in 2023 as compared to 2015 and the number of deaths decreased by 24% during the same period [6]. During the same period, the global incidence rate decreased by only 8.3% and deaths decreased by 23% (Table 1). Based on the modeling done by Ding et al. [7], the pool of prevalence of TB-infected population in 2019 globally was 1.8 billion, in the Southeast Asia region over half a billion, and in India was over one-third of a billion. The average annual rate of change in this between 1990 and 2019 is similar at all three levels at around −0.9%.

Table 1.

Tuberculosis burden in India compared to Global and SEAR in 2023 as per WHO's Global TB Report 2024 database.

Population	Global	SEAR	India	India: World	India: SEAR
	8.06 billion	2.1 billion	1.44 billion	17.8%	68.5%
Estimated TB incidence (per 100,000)	134 (98-178)	234 (193-280)	195 (164-228)	–	–
Estimated TB incidence (numbers million)	10.8 (7.9-14,3)	4.9 (4.1-5.9)	2.8 (2.4-3.3)	26% (23-30%)	57% (56-58%)
Estimated percentage of TB HIV out of all TB	6.1% (5.2-6.8%)	2.0% (1.6-2.4%)	1.5% (1.5-2.9%)	–	–
Estimated TB with HIV incidence (per 100,000)	8.2 (5.1-12.1)	4.7 (3.1-6.7)	2.9 (2.5-3.5)	–	–
Estimated TB with HIV incidence (number in 000)	662.5 (412.1-975.4)	97.8 (65.9-140.1)	42 (36-50)	6% (5-9%)	43% (36-55%)
Estimated TB mortality excluding HIV (per 100,000)	13.2 (9.3-18.1)	26.5 (19.8-35.3)	22 (16-30)	–	–
Estimated TB mortality excluding HIV (number in 000)	1061 (748-1459)	557 (415-741)	315 (233-428)	30%	57%
Estimated TB mortality with HIV per 100,000 population	1.98 (1.12-3.18)	1.05 (0.78-1.37)	0.57 (0.41-0.76)	–	–
Estimated TB mortality with HIV (number in 000)	160 (90-256)	22 (164-29)	8.2 (5.9-11)	5%	37%
Estimated total TB mortality (per 100,000)	15 (11-21)	28 (20-36)	22 (16-30)	–	–
Estimated total TB mortality (number in 000)	1219 (856-1662)	578 (428-757)	323 (233-428)	27%	56%
Case fatality ratio	11% (11-12%)	12% (11-13%)	12% (8-16%)	–	–
TB notification of incident cases (per 100,000)	101	183	166	–	–
TB case detection rate	75%	78%	85%	–	–
Estimated rif-resistant TB (number in 000)	444 (241-562)	169 (120-209)	110 (82-130)	25%	65%
Estimated rif-resistant TB among laboratory-confirmed pulmonary TB (number in 000)	175 (154-199)	68 (62-74)	46 (43-49)	26%	67%

SEAR, South-East Asia Region; TB, tuberculosis.

Evolution of national TB response

Since the introduction of the directly observed treatment short-course (DOTS) strategy in 1997, India's TB program has been evolving. After achieving complete coverage of the DOTS strategy in March 2006, India adopted the Stop TB Strategy in 2006 and focused on consolidating its implementation with continuous improvement in coverage and quality of the program. In 2015 the End TB Strategy was adopted and adapted in India in its real sense [8]. A pivotal step in this evolution was the integration of the TB program into the general health system and the National Health Mission (NHM). State- and district-level TB control societies were merged into the respective health societies of the NHM, aligning planning, implementation, and monitoring activities with broader health service delivery systems. This integration allowed a substantial portion of human resources to be mainstreamed into the general health system, freeing program resources to focus on newer priorities. These included the scale-up of programmatic management of drug-resistant TB (PMDT), laboratory diagnostics, addressing TB and comorbidities, and expanding TB preventive treatment (TPT). People-centered approaches were introduced in the care and support. The diagnostic algorithm was upgraded with the introduction of chest x-rays as a screening tool to improve the sensitivity of the algorithm. Newer diagnostic tools, such as rapid molecular testing infrastructure, were introduced and scaled up with over 8,295 machines to provide decentralized quality diagnostics with reduced turnaround time. An annual capacity of more than 14 million tests has been established in the country [9]. This was helpful for considerably reducing the diagnostic delays of drug-sensitive TB and rapid expansion of drug susceptibility testing (DST) for all TB patients [10]. Digital adherence tools, such as 99-DOTS and Video DOT, were established in addition to a multi-lingual national call center called Ni-Kshay Sampark for patient counseling.[11,12]^, A real-time information system called “Nikshay” was developed and introduced [13].

Recognizing the presence of a vibrant private health care sector and people's preference for seeking health care in the private sector, the TB program made TB notification mandatory in 2012. To facilitate this financial incentive scheme for private health facilities was introduced. Tools like Ni-kshay with mobile applications were developed for hassle-free notification. Call center support was extended for TB notification and patient support for both the public and private sectors. Free rapid molecular diagnostics testing was extended to patients in the private sector. Post-treatment follow-up was introduced to address post-TB sequala and reduce post-treatment mortality.

Research and evidence-based policymaking

To improve the efficiency and effectiveness of program implementation structures were developed and activated to promote implementation research. Medical colleges were engaged with mechanisms of state, zonal, and national-level research committees. More than 100 operational and implementation research studies were undertaken and published in the last decade. Evidence-based decision-making was followed by regular review of learnings from these research studies based on which the policies were updated, for example, decisions on testing during the mid-continuation phase of treatment, front loading with single sample testing on rapid molecular diagnostics, introduction of digital chest x-ray as screening tools. Several mechanisms, such as the patient-provider support agency, clinical sample collection and transportation, and the use of AI tools, were introduced.

In 2020, the name of the TB program was changed from the Revised National TB Control Program to the National TB-Elimination Program (NTEP).

Progress update

The progress in India's TB response is evident in the significant reduction in disease burden over the years. TB incidence per 100,000 population decreased from 322 (110-644) in 2000 to 195 (164-228) in 2023. Similarly, TB-related mortality dropped from 87 (67-109) per 100,000 population in 2000 to 22 (16-30) in 2023 (Figure 1). In absolute terms, annual TB-related deaths have been reduced by two-thirds, from approximately 1 million deaths to one-third of that figure.

Figure 1.

Trend of TB burden (incidence and mortality per 100,000) in India between 2000 to 2023.

TB, tuberculosis.

However, variations in TB incidence persist across states. Higher TB-incidence rates are observed in states like Delhi, with 499 (546-595) cases per 100,000 population, and Bihar, with 294 (349-458) cases per 100,000 population. In contrast, states like Kerala, with 76 (88-99) cases per 100,000, and the Union Territory of Lakshadweep, with 23 (12-45) cases per 100,000, exhibit much lower incidence rates [2].

Efforts to increase case detection are visible, especially in the last 10 years, with the presumptive examination rate increasing from less than 650 per 100,000 population before 2014 to over 1820 in 2024. TB Case notification rate has increased from 1.5 million in 2014 to 2.6 million in 2024 [14] (Figure 2). The TB treatment success rate has increased from less than 80% in 2015 to 89% in 2023. Treatment success rates have improved to as high as 87% among multi-drug-resistant (DR)-TB, 72% among pre-extensively DR-TB, and 68% among extensively DR-TB which is considerable progress. Preventive treatment has been scaled up to 31% of the eligible household contacts in 2023. Almost 6 million additional TB patients have been notified in the last 10 years under the TB program from private health care providers, with increasing quality in terms of bacteriological confirmation of more than 40% of the cases and treatment success rates of over 88% which is comparable to public sector treatment outcomes. Five districts, including Union Territory of Lakshadweep, Anantnag, Budgam & Pulwama of Jammu and Kashmir, and The Nilgiris, have achieved End TB targets as per sub-national certification methods of India, and a dozen more are close to achieving such status; though it is a long journey for most of the others.

Figure 2.

Presumptive TB examination rate and TB notification rate per 100,000 population – India between 2011-2024. TB, tuberculosis.

Challenges in achieving tuberculosis elimination

Despite considerable progress, India faces unique challenges in ending TB. First and foremost is the scale of interventions needed in India. Secondly, the diversity of states and districts not just in terms of epidemiology but also the demography, socio-cultural context, infrastructure, development, health-seeking behavior, and presence and role played by the private sector. In such situations, India has prioritized a group of districts and villages with lower health and socio-economic indicators, called “aspirational districts/villages” for special focus, additional support, and monitoring to facilitate progress in these aspirational geographies so that they can be brought forth at par with the rest of the country in the process of development and thereby helping accelerate progress toward ending TB all across the country [15].

Opportunities for more progress

While the challenges are identified, there are opportunities for favorable situations to End TB in India. These include the highest level of political commitment from the Prime Minister and his office. Ever-increasing capacity for innovation with mechanisms to promote research and development, advances in biomedical sciences, artificial intelligence, and economic progress are supportive of accelerating progress to end TB in India.

Key lessons

Political commitment and financing

India's TB-elimination efforts have demonstrated that the highest level of political commitment can significantly accelerate progress. In 2018, Prime Minister Narendra Modi issued an ambitious call-to-action to eliminate TB in India by 2025, articulating a vision for a TB-free India [16]. This leadership was complemented by regular review at the highest level and dramatic increases in budgetary provision which increased from US $106 million in 2015 to over US $500 million by 2020, a 5-fold increase, which was very crucial for launching newer initiatives. The national response emphasized addressing the needs of the poor and vulnerable, investing in new diagnostics, adopting AI tools, introducing shorter drug regimens, and implementing people-centered support systems. These actions have fundamentally reshaped India's TB response.

Ending TB became a priority for health leadership, with Health Ministers personally overseeing program details. Regular reviews and a commitment to reaching underserved populations characterized the past decade. Notable initiatives, such as the “TB Harega Desh Jitega” campaign (“TB will be defeated, and the Nation will win”), highlighted the resolve to eliminate TB. The National Strategic Plan (NSP), drafted in 2017, laid out comprehensive strategies to implement the End TB Strategy, demonstrating how even a vast and diverse country like India can adapt and achieve the global vision.

Decentralized leadership and local ownership: The highest political commitment was wafted to the states and districts. Decentralized political leadership with Chief Ministers (CM) and Members of Parliaments (MPs) and Health Ministers in states furthered the agenda. Several States initiated additional innovative patient-support schemes including financial protection in addition to implementation and utilization of central government support. The importance of local ownership of responsibility to end TB was visible with panchayat-level grassroots leadership. Local planning, implementation, and monitoring with supportive resource allocation is reflected in the expansion of the TB-Free panchayat initiative [17].

These efforts were harmonized at all levels creating an ‘all-of-the-government’ approach and a social movement against TB which facilitated the implementation of a TB program. It was based on the principle that India can end TB only if all the states do, and states will be able to end TB only if the districts can, and the districts can end TB only if all panchayats (local democratically elected bodies at villages) and villages can do so.

To ensure accountability at all levels, it is equally important to measure progress toward ending TB. While it is practically challenging to estimate the burden at the sub-national level, India developed an innovative method to measure TB incidence at the sub-national level (states and districts) using multiple sources of data from the sale of anti-TB drugs, state and district-level rapid surveys, and measurements of under-notification. These efforts were linked with awards and recognition for subnational level progress by dividing the End TB targets to reduce incidence into milestones of reduction of more than 20%, 40%, 60%, and 80% [18].

TB program financing increased from the Central Govt budget, complemented by additional financing from State Governments, other Ministries, the corporate/business sector, and crowdfunding. NTEP leadership never experienced a shortage of funds in the last 10 years. Funding figures and examples of additional funds. (Figure 3).

Figure 3.

Indian National Program Budget, approvals, and total expenditure in million US $ (2012-2022).

Indigenous India research and innovative approaches

The Indian Council of Medical Research (ICMR) established the India TB Research Consortium (ITRC) to foster research and innovation providing the mechanism and platform for academic institutions, research institutes, and the private sector to propose and conduct TB research. Commissioned research with proper funding and monitoring mechanisms were established. Four streams of research were created for research in diagnostics, drugs, vaccines, and implementation and operational research. To date, more than 50 studies have been funded under this mechanism.

The National Disease Modelling Consortium has been set up at the Indian Institute of Technology (IIT), Bombay, with several partnering institutes for estimating the TB burden and measuring progress toward ending TB.

For basic research in TB mechanisms, the Biotechnology Industry Research Assistance Council (BIRAC) introduced several rounds of TB research funding [19]. Several products were developed out of these efforts in the areas of diagnostics. One notable such product was indigenous TrueNAT—a rapid molecular platform technology. Private-sector incubator mechanisms, such as the India Health Fund, have been helpful in further developing such products from prototype to industry production and introduction into programmatic settings, assisting commercial production even for the private sector and other countries. Qure.ai's computer-aided detection tools for digital chest x-ray screening with automated reading is one such tool [20]. These mechanisms complement each other by overlapping funding different stages of product development till its effective use in public health.

For scaling up TB Preventive Treatment ICMR-validated Cy-TB, a new-generation accurate skin test which is now commercially available and endorsed by the World Health Organization (WHO). The Stop TB Partnership took these Indian-made new tools, TrueNAT, Qure.ai, and Cy-TB, to other countries, and now all countries can procure these tests from the Stop TB Partnership's Global Drug Facility.

Phase 3 clinical trials for two TB vaccine candidates, VPM1002 and Immuvac (MIP) have been completed and are under communication [21]. Additionally, under the NTEP, an adult BCG vaccination program study is currently underway with over 10 million vulnerable patients.

Several digital health tools have been developed, piloted, and scaled up, including Ni-Akshay for digital surveillance and patient management, Ni-Akshay Aushadhi for digital drugs and logistics management, Ni-Akshay Sampark, a multilingual contact center for patient counseling, and TB Arogya-Sathi, a patient-facing mobile application for digital access to own health records under NTEP. Swasthya e-Gurukul is an online training platform developed as an end-to-end digital solution for large-scale training of staff, including community-level workers such as Accredited Social Health Activist (ASHA) workers, ANMs, and CHOs at the community level, for the last mile connectivity in facilitated sessions with pre-and post-test and training certification.

Innovative approaches to private-sector TB care have been demonstrated to facilitate effective engagement of the private sector in TB care and support. Patient-provider interface agencies social stock exchange is the latest initiative that has the potential to streamline outsourcing of bundled interventions to for-profit and not-for-profit organizations with Zero Coupon Zero Principle (ZCZP) mechanisms (social business bonds), online system for registration and bidding, risk funding mechanism, and third party social audit by academic and research agencies [22]. Success has been demonstrated in nutritional interventions for TB patients through this mechanism.

Population-level interventions in the community

Community-based prevalence survey in Gujarat (2011-2012) and National TB Prevalence Survey (2019-2021) suggested that two-thirds of symptomatic patients do not seek care and half of the patients diagnosed with TB were asymptomatic. This is a major reason for missing people with TB. Despite improving the quality of the Indian health care system, there are still barriers to access, including personal priorities and the health-seeking behavior of the population. Recognizing this, the NTEP expanded the focus from clinics to the community and extended community-based outreach services.

Active Case Finding: Guidelines for active case finding were developed in 2016 for community-based systematic screening for TB. Annual campaigns for active case finding in the community are being regularly organized with increasing contributions of cases being identified through such campaigns. More than case finding such campaigns are important for creating awareness regarding TB in the community.

Integration with other health programs: Recently, a 100-day intensified campaign to eliminate TB under the TB Mukt Bharat Abhiyaan with the spirit of Jan Bhagidaari exemplifies a united approach to TB elimination, leveraging the strengths of diverse stakeholders [23].

Convergence has been established by the TB program with other community-based screening and awareness activities. The whole population above the age of 30 years has been prioritized for screening on an annual basis for non-communicable diseases, TB, and leprosy. A community-based assessment checklist (CBAC) has been developed for systematic screening by the ASHA [24]. Through this initiative, a total of 621 million population have been enrolled and screened to date [25].

Engaging TB survivors and affected communities: A guidance document for engaging TB survivors and TB-affected communities in NTEP was released in 2021 [26]. More than 30,000 TB champions have been trained and are engaged in peer support, including community-based TB screening. Several development partners, including Piramal Swasthya, The Union, REACH, and the William J. Clinton Foundation, have been implementing active case finding in the country. Resources from several corporates, such as the Indian Oil Corporation (IOC), FujiFilm, and Medanta, have been mobilized for community-based active case finding using mobile units with digital chest x-rays and AI tools for automated reading of x-rays. These large-scale interventions have shown ‘how the community response can be mounted with effective engagement in planning, screening, monitoring, and how the community can be empowered.’

Mass screening in vulnerable areas: India has demonstrated that large-scale contact tracing and expansion of TPT is possible and effective despite several challenges. The recent introduction of the Cy-TB skin test is expected to further improve the selection of contacts for TPT.

The feasibility of large-scale, whole-population mass screening has been demonstrated in an initiative in Mizoram state. Vulnerability assessment was undertaken, followed by the deployment of ultraportable digital x-ray machines with AI tools for automated reading, the use of cough sound-based AI tools in community settings, and the use of rapid molecular testing and linking with care and support for diagnosed TB patients.

The NTEP has effectively demonstrated both approaches for nutrition initiatives: direct benefit transfer of cash in bank accounts to support nutrition and crowdsourcing for the adoption of TB patients and provision of nutritional support kits on a monthly basis in kind to TB patients [27]. The benefits have, of late, been enhanced to double the amount for Direct Benefit Transfer, Energy Dense Nutrition Support for patients with BMI<18.5, and extending support through the provision of nutritional support kits for household contacts of TB patients through crowdsourcing.

Focus on prevention, early detection, and the drivers of tuberculosis

It is evident that despite the implementation of strong diagnosis and treatment programs there was a relatively slow decrease in the pool of the TB-infected population. To address this, India focused on prevention with a component of ‘early’ diagnosis. Strategy was developed to first identify different vulnerabilities (social and clinical). Then actual mapping and opportunities to identify vulnerable populations were systematically expanded, followed by periodic screening of these vulnerable populations in appropriate settings including communities and households. More appropriate tools were needed for this. Convenient and highly sensitive screening tests and accurate rapid molecular diagnostics testing infrastructure. The latter was established with the decentralized availability of rapid molecular diagnostics. For the screening tests, India is rolling out ultraportable hand-held x-rays which can be taken door to door to offer screening to all vulnerable populations, especially in difficult-to-reach geographies. Research for newer screening tools is ongoing, such as a blood-based, lateral flow test currently under validation, which is expected to facilitate large-scale screening.

Mass screening and testing strategy was complemented with another biomedical intervention of testing (those at higher risk) for TB infection and TPT thereby containing the pool of TB infection. Programmatic Management of TB Preventive Treatment was scaled up covering one-third of the eligible contacts in 2023 (Global TB Report 2024).

Nutritional interventions were designed and implemented because nutrition is one of the best tools for TB prevention. The direct benefit transfer amount for nutritional support was doubled in November 2024. Learnings from a cluster randomized trial in India also suggested that with extension of nutritional support to contacts of index TB patients can help reduce TB mortality by half and TB incidence can be reduced by 40% [28].

All preventive interventions were systematically extended to private-sector TB care and support through the expansion of public health actions.

Lessons from Community-Level TB interventions: India's efforts demonstrate that comprehensive, community-focused interventions, supported by technology, partnerships, and survivor engagement, can significantly improve TB detection, treatment, and prevention. These interventions not only reduce the TB burden but also empower communities to actively participate in the fight against TB.

Stigma and key vulnerable populations

To reduce stigma related to TB, the affected individuals, communities, and volunteers were identified. Training packages were developed and more than 30,000 TB champions were encouraged and empowered with knowledge and mechanisms like TB forums at different levels. More than 1010,000 Ni-kshay mitras have been identified who adopt TB patients and provide psychosocial and nutritional support to TB patients. Such societal cohesion and its systematic expansion are a sustainable way to reduce stigma. Linking TB patients to social welfare schemes under social empowerment schemes//insurance packages/monetary support schemes for tribal patients, co-morbidity management, and compensation packages for patients with silicosis have helped address vulnerable populations.

Digital tools

Several interventions and their effective planning, implementation, and monitoring could not have been effective without digital surveillance tools like Ni-Kshay. A comprehensive integrated digital surveillance system is crucial for success. Its components like direct benefit transfer and digital adherence tools (99-DOTS, V-DOT) have helped ensure financial inclusion and enhance patient-support systems. The telemedicine initiative of e-Sanjivani has helped arrange teleconsultation of the individual in peripheral health centers, and management of difficult-to-treat TB patients [29]. The online platform developed for Pradhan Mantri TB Mukta Bharat Abhiyan (Prime Minister's TB-Free India initiative) has helped mobilize more than 230,000 volunteers, a successful crowdsourcing [30].

Artificial intelligence tools, such as computer-aided detection with automated reading of x-rays and elicited cough sound-based TB screening, have been helpful in the rapid scale-up of mass screening by complementing human efforts.

Way forward

• 1.
  Development of the New National Strategic Plan: India is in the process of developing a new NSP. Key highlights of this NSP are:

  • •
    Consolidation of the achievements from existing and ongoing interventions.
  • •
    Alignment with the Vision documents of the National Institute for Transforming India (NITI) Ayog (New India @75 NITI Ayog), National Health Policy, Ayushman Bharat and NHM, Pradhan Mantri Jan AaRogya Abhiyan (PMJAY) a social health insurance scheme, Pradhan Mantri Ayushman Bharath Health Infrastructure Mission (PMABHIM), National Digital Health Mission (NDHM), Indian Public Health Standards (IPHS), Social and Financial Inclusion, Digital India.
  • •
    Population-level interventions to address vulnerabilities such as indoor air pollution, undernutrition, smoking, and alcoholism.
  • •
    Bharat Health Credit Score Bank to promote and incentivize health promotion. Multi-disease mass screening of population with digital data management and service linkages. Development and deployment of highly sensitive screening tools (finger prick tests, cough AI tools), and rapid molecular diagnostics. Shramdan scheme to appeal to volunteers to devote time and resources for mass screening.
  • •
    Differentiated TB care, post-treatment follow-up, rehabilitation, and regular death audits.
  • •
    Rapid scale-up of TB Preventive testing and treatment, adolescent, and adult vaccination against TB.
  • •
    TB-Free workplace and workforce, TB-Free Panchayat, towns, and cities initiative with local resource mobilization and engagement of local bodies.
  • •
    Multi-sectoral and interministerial TB response, linking with social welfare and empowerment schemes.
  • •
    Innovative patient adoption models to reduce stigma by engaging Ni-Kshay Mitras for patient-support systems (an online crowdsourcing mechanism where volunteers can register themselves and are linked to facilitate patient support offered by them).
  • •
    Enhancing R&D for Newer Molecules, vaccines, and biomarkers against TB.
  • •
    Enhancing digital surveillance tools, including various components of Ni-kshay with AI capabilities, blockchain technology, and integrated telemedicine networks, to improve surveillance, service delivery, program management, and overall efficiency of the system.
  • •
    Making TB response more sensitive to prevent climate change impact.
• 2.Vaccination strategy: A nationwide programmatic study for adult BCG vaccination is already underway; the decision to scale up is likely to be taken if the public health impact is found worth it. WHO guidance suggests that a vaccine with lesser vaccine efficacy (<50%) against confirmed TB in adolescents and adults, if widely used in areas of high TB endemicity, may still prove valuable and contribute to reducing the spread of Mycobacterium TB in a cost-effective way [31]. BCG vaccination is safe, time-tested, and available for use. At the same time, efforts for research and development will be ongoing for newer potential vaccine candidates MTBVAC, M-72. The decision to use the vaccine will be based on several factors, including vaccine effectiveness, public health impact, cost-effectiveness, ease of administration, frequency, indications, and contraindications. India's current experience will be helpful in strategic planning for the introduction of vaccines. For example, the selection of target groups in adults and adolescents is currently based on the learnings of the National TB Prevalence Survey findings. Six target groups, including individuals with a history of TB, contacts of TB patients, undernourished individuals, patients with diabetes, smokers, and those aged 60 years and above, constitute less than one-fourth of the population but contribute to almost three-fourths of all TB cases.[32,33]. Learnings from the current adult BCG vaccination initiative will be helpful in country-wide vaccination; however, local quantitative and qualitative vaccine hesitancy studies will have to be undertaken to improve vaccination coverage in adults and adolescents.
• 3.High coverage and quality treatment: With the unique epidemiology of TB, it is evident that no single strategy alone can be sufficient for ending TB. Early case finding, with the highest possible treatment coverage and best possible treatment outcomes, is important for ensuring that infectious cases are found and converted into non-infectious cases. This is important for both 1) reducing TB incidence by cutting the chain of transmission and 2) reducing TB mortality, as in the absence of chemotherapy, TB can be as fatal as 70-80%. Continuous efforts toward research in diagnostics, treatment, and other intervention strategies should continue to be a hallmark of the TB response.
• 4.Research in screening tools and diagnostics: NTEP has clear plans to further research on the state-of-the-art screening tests for TB, with collaboration with research networks within and outside the country. Simple, potentially self-administered tests, such as finger prick lateral flow blood-based or urine-based tests, can revolutionize the TB screening program. Alternatively, elicited cough sound-based AI tools are being developed by NTEP. Voice and cough sounds are being established as biomarkers for respiratory health [34]. Higher sensitivity and simple deployment of such tools can be really helpful for mass screening.[35,36]. Further development and deployment of such AI tools have the potential to further extend similar benefits or even replace the current role of digital chest x-ray in TB screening. Such screening tools can prove to be a game changer in the future and will be crucial in accelerating the progress to end TB.
• 5.Strengthening diagnostic and treatment capacity: With the continued expansion of a decentralized network of rapid molecular diagnostic testing offering drug resistance testing to additional drugs across the country, the country program is in the process of providing augmented DST to all drugs through targeted next-generation sequencing to all multi-DR/DR-TB patients to tailor the best treatment regimen offered, thereby addressing the drug resistance issue upfront without delay. The TB program has introduced newer shorter regimens, such as BPaLM, to further improve the outcomes of drug-resistant TB. DST capacity for newer molecules has been developed, and a laboratory network has been established for bedaquiline, pretomanid, linezolid, and moxifloxacin phenotypic DST necessary for ensuring the effectiveness and appropriateness of newer regimens in the public health context. At the same time, further research is planned with investment in trials for novel regimens and molecules in the future.
• 6.Expanding the TB prevention ecosystem: For the desired public health impact, more work is required to scale up a comprehensive approach, including integrated TPT, airborne infection control, and vaccination, to rapidly reduce the pool of TB infection and disease progress into active TB to dent the incidence and mortality in a relatively shorter time. Progress toward ending TB will be accelerated by investing in all these strategies in the years ahead. Coordinated efforts across various sectors, including health, social welfare, and economic inclusion, are needed to make significant progress toward TB elimination. These efforts will work together to reduce both incidence and mortality in the coming years.

Conclusion

India's efforts to combat TB over the past decade have shown significant progress, driven by political commitment, care delivery via public and private care providers, research, innovation, and a people-centric approach. The shift from a centralized model to a decentralized, multi-sectoral response has facilitated greater accessibility and inclusivity in TB care. Initiatives like the NSP, digital health tools, and innovative diagnostics have played a crucial role in improving detection and treatment efficiency.

The key to India's success lies in high-level political commitment, increased funding, and targeted interventions for vulnerable populations. The integration of AI and advancements in diagnostics and treatments has made TB management more efficient at all levels. Furthermore, community-based interventions and efforts to reduce stigma have significantly improved engagement and adherence.

However, challenges remain, including stigma, rural access to care, and the need for broader implementation of TPT and vaccination programs. Research and innovation, particularly in new vaccines and diagnostic tools, offer promising solutions for accelerating TB control efforts and advancing toward the goal of a TB-free India by 2025.

The new NSP offers an opportunity to build on past achievements while aligning with broader health frameworks. Targeting vulnerable populations, expanding access to diagnostics, and leveraging digital health innovations will be key to further progress. With continued investment in research, new treatment regimens, and cross-sector collaboration, India is poised to make significant strides in ending TB and improving health outcomes nationwide. India's fight against TB demonstrates the impact of political will, innovation, and collaboration. By continuing comprehensive and inclusive strategies, India can achieve the goal of a TB-free India.

Declarations of competing interest

The authors have no competing interests to declare.