Four Times Over Target: India's TB Elimination Problem

This is more than four times the TB elimination target for 2025, under the National Strategic Plan for Tuberculosis, set in March 2017. TB elimination means cases should be reduced to 44 cases per 100,000 population and mortality from TB to 3 per 100,000 population, as IndiaSpend reported in March 2025.

The 2025 target set by the government was five years ahead of the global End TB targets and United Nations’ Sustainable Development Goals. The latest update on progress, released yesterday, reverts to the SDG target.

Overall, India’s TB notification has increased by 13% since pre-Covid levels, data show.

Higher notification is not necessarily the outcome of increased incidence. Lack of testing accounts for the highest number of patients lost in the TB care cascade, and stigma keeps many patients from accessing tests, as IndiaSpend reported in July 2025. The government under the National Tuberculosis Elimination Programme (NTEP) has been pushing to boost the notification of cases, we had reported.

Researchers model the TB care cascade to estimate the gaps, as we explained in May 2023. The number of patients with incident TB who did not access TB tests constitute gap 1, patients who did not get diagnosed constitute gap 2, those who did not register for treatment constitute gap 3, those who were not successfully cured comprise gap 4, and those who relapsed or died even after being treated constitute gap 5.

Gaps represent patient losses--essentially, patients who fell through the TB care net. In this context, India’s most significant gap was gap 1, according to a 2019 study published in PLOS Medicine, that concluded that half of all patient losses in India are individuals with incident TB who didn’t access a TB test.

On World TB Day, as India pushes the elimination target back by five years, IndiaSpend spoke to patients, clinicians and researchers to understand how the target could be met.

Testing troubles

India’s testing strategy under the TB-Mukt Bharat Abhiyan includes active casefinding—that is, screening communities with high risk of TB. When a patient reaches the health system with symptoms, or when vulnerable populations are screened through camps, the process begins with an X-ray to rule out active TB.

For all presumptive TB cases—that is, those with an abnormal X-ray or patients showing symptoms—the strategy requires 100% molecular testing using NAAT (rapid molecular tests that detect the genetic material of Mycobacterium tuberculosis). Sputum microscopy should only be used for follow-up tests, the document says.

Further, it also prescribes radiological tests, histopathology and other appropriate tests to detect extra-pulmonary TB.

For every positive result, this is followed-up with tests for drug resistance for first and second line drugs, and testing for anaemia, diabetes, hypertension & body-mass index assessment for detecting comorbidities.

But this experience is yet to become universal, researchers told us.

Take the case of Rajendra Nayak, a driver in Odisha’s Khordha district who showed classic TB symptoms in March 2024 —persistent cough, declining health and weight loss. He was given a sputum microscopy test thrice, all of which came back negative.

"Fifty percent of the people with TB will be missed if you do microscopy—then they again need to go for the subsequent test," said P.S. Rakesh, Deputy Director (Programmes) at the Paris-based International Union Against Tuberculosis and Lung Disease (The Union). "At each step there will be enormous leaks in the cascade of care.”

Given that Nayak also had a history of alcohol use, those around him attributed his condition to his drinking rather than disease. Believing the negative result meant he was healthy, he was ready to stop seeking care altogether.

Jogini, a community volunteer with experience in active case-finding, knew that a negative smear is not always the final word. She contacted Jyoti Choudhary Swain, a senior treatment supervisor at SAHAYOG, an Odisha-based NGO working on TB care and community health. This time the sample was sent to the district hospital in Khordha, where it was tested on a CBNAAT machine. The results confirmed TB.

In 2023, India conducted 19.3 million smear tests and 6.83 million molecular tests through Cartridge-Based Nucleic Acid Amplification Test (CBNAAT)/GeneXpert and Truenat, according to the India TB Report for 2024, the latest available. That means smear microscopy still accounted for about three in four tests.

And this is not just in India. Only 70% of pulmonary TB cases notified in 2024 were bacteriologically confirmed, according to the WHO TB Profile 2025.

"It practically means that if you do have resistance, it does not get detected in the first place," said Leena Meghnaney, an independent public health activist at the Health Justice Initiative. "And second, for some people, TB is not detected in sputum. PCR technology is more sensitive and can catch TB earlier."

“The issue is not detecting TB in the first place,” says Rakesh. “If a person with TB undergoes microscopy and the sensitivity is 50%, then 50% is missed at that point—they may include drug-resistant cases—the primary failure is not finding TB at that point at all.”

Shibu Vijayan, chief medical officer at QureAI, a diagnostics technology organisation, said the problem lies partly in how the testing pathway works in practice.

"The intention has been articulated in policy, but if you are not actually well-resourced, it will not happen," Vijayan said. That pathway, he said, creates drop-offs. A patient may first go to a primary health centre, then be referred elsewhere to submit sputum, then return later for results, and if smear-negative, be referred again for an X-ray or molecular test.

"You are actually convoluting the patient's pathway to hit the health system multiple times," Vijayan said. "So it is designed for leakages."

The asymptomatic cases

“Approximately 40-50% of all microbiologically confirmed, culture-positive pulmonary TB cases will not have typical TB symptoms,” said Rakesh. "These people can transmit the disease,” he said, adding that “Transmission will continue in the community even as we focus on symptomatic screening.”

"That is why community-based screening with both symptoms as well as chest X-ray for asymptomatic is of paramount importance," says Kiran Rade, international technical consultant with Stop TB Partnership.

In 2025, under the new protocol of the TB-Mukt Bharat Abhuyan, 2.73 million TB cases were reported last year of which 35% were asymptomatic, according to the document released yesterday.

Rade said that the government has gradually expanded the use of community screening and chest X-rays.

The campaign document shows that the programme now looks for a 10-symptom complex that also includes chest pain, shortness of breath, loss of appetite, fatigue, lymph node swelling and extrapulmonary signs.

“Every attempt is made for microbiological confirmation, and that is happening," Rade said. "Even if the patient is initially diagnosed based on smear microscopy, the patient immediately undergoes a NAAT test for rifampicin testing."

Active-casefinding efforts

The TB Mukt campaign has identified 158,000 high-risk villages and wards using an AI-based Vulnerability Mapping for TB tool that assesses more than 30 indicators—including TB incidence, population density, child malnutrition, tobacco use, occupation and cooking fuel—to pinpoint where screening should be concentrated, as per the TB Mukt campaign document of 2026.

However, experts say that things are different on the ground. A lack of access to kits, machine maintenance, uneven spread of technicians and health workers across the country are a significant challenge.

“India now has almost 10,000 Nucleic Acid Amplification Test (NAAT) machines, and the expansion of both microscopy centres and molecular testing sites has improved access over time,” says Rade of Stop TB Partnership.

"Microscopy centres increased from 11,000 to more than 25,000 today. The proportion of cases diagnosed on molecular testing is also increasing rapidly." he said.

Rade argued that the current network is already sufficient to confirm cases at scale, and that more technologies are likely to be rolled out. He pointed to RT-PCR machines installed during the Covid-19 pandemic that could also be used for TB testing.

"In terms of numbers, it is a good number. But the challenge is not the machines—the challenge is the support system around them," said Rakesh. "like specimen collection, transportation systems and supply chain management."

Operational inefficiency compounds the problem. "These machines can work for 24 hours. We need to make them operationally efficient, to run 24 hours, wherever possible, through good management practices," Rakesh said.

Meghnaney says that given the availability of PCR tests, upfront screening can now detect both TB and drug resistance from a single sample. But “access remains the real challenge,” she explains. “Home-based sample collection is still a major gap, and diagnostics must reach the patient’s doorstep.”

Tuberculosis is a ‘social’ disease in that the malnourished, living in areas with poor hygiene, are more vulnerable to the disease, as IndiaSpend reported in June 2024. The lack of nutrition and the risk of contracting TB are interrelated, research found, as IndiaSpend reported in October 2022.

The government has increased the transfers under Nikshay Poshan Yojana to Rs 1,000 per month, aimed at enabling patients to consume nutritious meals during treatment. Moreover, all TB patients with BMI below 18.5 receive Energy-Dense Nutritional Supplementation for the first two months of treatment, targeting the most critical window, as per the campaign document.

IndiaSpend reached out to Shobini Rajan, deputy director general (TB) for the RNTCP programme and Urvashi B. Singh, deputy director general at economic (TB) advisor’s office for comment. We will update this story when we receive a response.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.