Tuberculosis (TB) remains one of India's most pressing public health challenges. Despite decades of control efforts, India continues to bear the highest global burden of TB, accounting for over a quarter of the world's TB cases. The National Tuberculosis Elimination Program (NTEP), launched in 2020, is an evolution of previous initiatives aimed at tackling this epidemic. The program's objective is to eliminate TB in India by 2025, five years ahead of the global goal set by the World Health Organization (WHO).[^1,2] This review provides an in-depth look at the successes and gaps of NTEP in controlling TB in India, considering the latest updates and challenges.

Historical Context: From NTP to NTEP^[3,4]

India's fight against tuberculosis began in 1962 with the launch of the National Tuberculosis Program (NTP), a centralized system aimed at tackling the disease. At that time, TB diagnosis relied heavily on chest X-rays and limited bacteriological tests like sputum smear microscopy. The treatment mainly used drugs such as Streptomycin and Isoniazid. Although NTP made headway in establishing infrastructure, it faced severe operational challenges, including lack of treatment adherence, inadequate coverage, and poor diagnostic accuracy​.

By the late 20th century, TB was resurging in India, leading to the realization that a more robust program was required. This prompted the government to introduce the Revised National Tuberculosis Control Program (RNTCP) in 1997, which adopted the globally recommended Directly Observed Treatment Short-Course (DOTS) strategy. RNTCP decentralized TB management, allowing treatment and diagnostic services to be available at the community level through Designated Microscopy Centres (DMCs) and TB Units (TUs)​.

RNTCP’s efforts were instrumental in improving TB treatment success rates and providing structured patient management. However, it still faced challenges such as drug resistance, stigma, and inconsistent coverage in rural and tribal areas. In 2020, RNTCP was rebranded as the National Tuberculosis Elimination Program (NTEP). This renaming signified a shift from TB control to elimination, reflecting India’s intensified commitment to meet the WHO's End TB Strategy by 2025, five years ahead of the global deadline​.

Key Components of NTEP^[5-9]

Early Diagnosis and Prompt Treatment

A core strategy of NTEP is to ensure early diagnosis and timely initiation of treatment to reduce transmission and prevent the escalation of drug-resistant strains. NTEP places strong emphasis on the rapid detection of TB cases through advanced diagnostic tools. Molecular diagnostic technologies, particularly GeneXpert MTB/RIF, are at the heart of this effort. These tools provide highly accurate results within two hours, significantly reducing the waiting time for diagnosis and helping to initiate treatment faster, especially in cases of multi-drug-resistant TB (MDR-TB)​

The introduction of GeneXpert has also allowed the identification of rifampicin resistance at the point of diagnosis, thus ensuring that patients receive the appropriate drug regimens immediately. Additionally, decentralized access to diagnostic centers through District TB Centers (DTCs) and health facilities under the Ayushman Bharat Health and Wellness Centres (HWC) ensures that testing is available even in remote locations​.

By ensuring prompt treatment, NTEP has been able to reduce mortality and treatment default rates. Under the program, first-line anti-TB drugs such as isoniazid, rifampicin, ethambutol, and pyrazinamide are provided free of charge to all diagnosed patients, further removing economic barriers to care.

Active Case Finding and Vulnerable Populations

A standout feature of NTEP is its focus on active case finding (ACF). Instead of waiting for symptomatic individuals to seek care, health workers actively screen populations with a high risk of TB. Vulnerable groups targeted by this strategy include slum dwellers, migrants, tribal populations, and individuals with HIV/AIDS​.

Mobile diagnostic units, door-to-door screening campaigns, and contact tracing efforts are employed to identify TB cases early.

One of the most successful initiatives under NTEP’s ACF strategy is the Active Case Finding Campaign, which has mobilized thousands of community health workers to screen high-burden districts, especially in rural areas where TB reporting is historically lower. This campaign is particularly critical in detecting latent TB cases, which, if left untreated, can develop into active disease.

Moreover, vulnerable populations are more likely to suffer from co-morbid conditions like HIV, which complicates TB treatment. For these high-risk groups, NTEP has rolled out integrated TB-HIV services, ensuring that co-infection cases are managed with enhanced clinical attention​.

NTEP has recognized that medical interventions alone are insufficient to combat TB, as socio-economic factors like malnutrition, overcrowding, and poverty play a significant role in the disease's spread and severity. Hence, the program has emphasized a multisectoral response that includes social support initiatives such as the Nikshay Poshan Yojana, which provides nutritional support to TB patients​.

Proper nutrition is vital for TB patients, as malnutrition weakens their immune system and delays recovery.

The program also integrates with various ministries such as the Ministry of Housing and Urban Affairs, which addresses housing conditions that exacerbate TB transmission. Efforts like awareness campaigns aim to educate communities about airborne infection control and preventive measures​.

Drug-Resistant TB Management

Managing drug-resistant TB (DR-TB), including MDR-TB and extensively drug-resistant TB (XDR-TB), remains one of NTEP’s most challenging tasks. As a response, NTEP has introduced newer drug regimens, including the BPaLM combination (Bedaquiline, Pretomanid, Linezolid, Moxifloxacin) for the treatment of MDR-TB​.

This regimen has shortened the treatment duration for drug-resistant cases from 18–24 months to just six months, reducing patient burden and improving adherence.

The use of Bedaquiline, a game-changing oral medication, has shown promise in treating patients who do not respond to conventional anti-TB drugs. Initially introduced in 2016, the use of Bedaquiline was scaled up under NTEP, and it is now available at Drug-Resistant TB Centers across the country​.

However, managing DR-TB is not limited to drug availability. Monitoring adherence through tools like the Nikshay platform and directly observed treatment (DOTS) ensures that patients stick to their medication regimens. Still, challenges such as drug toxicity and patient dropout continue to hinder outcomes for DR-TB patients.

Private Sector Engagement

Given the fact that more than 50% of India’s population initially seeks medical care in the private sector, engaging private healthcare providers in TB control efforts has been a priority for NTEP. Under this program, private doctors are incentivized to notify TB cases, ensuring that every diagnosed individual is registered and monitored in the Nikshay system​.

NTEP also facilitates the supply of free anti-TB drugs to patients receiving care in the private sector, reducing the risk of patients being prescribed improper treatment or substandard drugs. This integration has enhanced TB reporting and ensured that cases in the private sector are not overlooked​.

Despite progress, private sector engagement still faces challenges like inconsistent notification rates and the reluctance of some practitioners to follow standardized treatment protocols. Ongoing efforts aim to address these gaps through training, awareness programs, and stronger partnerships between the public and private sectors.

Digital Monitoring Systems

The Nikshay platform, launched under RNTCP and expanded under NTEP, has become a cornerstone of TB management in India. This web-based digital system tracks the entire journey of a TB patient, from notification to treatment completion​. 

Nikshay allows for real-time monitoring of patient outcomes, enabling healthcare providers to identify and address gaps in care.

The system also supports the Direct Benefit Transfer (DBT) scheme, ensuring that financial assistance, such as the Nikshay Poshan Yojana, reaches patients in need. By reducing human error and increasing transparency, Nikshay enhances the accountability of health systems​.

Moreover, the platform provides a means of identifying patients who are at risk of dropping out of treatment. Automated reminders, patient counseling, and follow-up visits are arranged based on the data captured in the system, improving overall treatment adherence.

Successes of NTEP^[10-13]

1. Incidence and Mortality Reduction

The NTEP has made significant strides in reducing TB incidence and mortality in India. According to WHO's Global TB Report, TB incidence in India dropped from 217 per lakh population in 2015 to 188 per lakh population in 2020. This remarkable reduction reflects the program's effectiveness in enhancing early diagnosis and treatment, especially in regions with historically high burdens. The introduction of advanced diagnostics, including molecular testing like GeneXpert, has played a crucial role in detecting TB cases early, thus reducing transmission rates. Furthermore, TB-related mortality has decreased, which can be attributed to improved treatment protocols, free drug distribution, and focused public health campaigns.

The success of the NTEP in reducing mortality and morbidity is also tied to its community-based active case finding (ACF) strategy. This involves regular screening campaigns in high-risk areas, such as urban slums and tribal regions, ensuring early detection in populations that might otherwise go undiagnosed. For example, the large-scale implementation of the “Active Case Finding” initiative has screened millions of people, significantly increasing TB case detection. As a result, India is on the right trajectory toward achieving its ambitious goal of eliminating TB by 2025.

2. Improved Diagnostics and Treatment Outcomes

One of the most critical successes of NTEP is its ability to modernize and expand diagnostic services across the country. The widespread availability of GeneXpert MTB/RIF machines has revolutionized TB diagnosis, particularly for drug-resistant strains. By reducing the diagnostic window from weeks to just a few hours, GeneXpert ensures that patients, especially those with MDR-TB, are quickly diagnosed and started on appropriate treatment regimens. This rapid diagnosis not only improves individual outcomes but also reduces the time that patients may unknowingly spread the infection to others.

In addition to improved diagnostics, the introduction of shorter, more effective treatment regimens like BPaLM (Bedaquiline, Pretomanid, Linezolid, Moxifloxacin) for MDR-TB has been a game changer. Previously, MDR-TB patients faced treatment durations of 18-24 months, with high toxicity and low adherence rates. The new BPaLM regimen reduces this to just six months, with fewer side effects, leading to better patient compliance and higher cure rates. Early results from pilot programs show that this treatment has great potential to be scaled up nationwide, drastically reducing the burden of drug-resistant TB in India.

3. Integration with Other Health Programs

A critical factor in NTEP’s success is its integration with India’s Ayushman Bharat Health and Wellness Centres (HWC). This integration has brought TB screening and treatment closer to the community level, ensuring easier access for remote and underserved populations. By decentralizing TB services, patients no longer have to travel long distances for diagnosis or treatment, which was previously a significant barrier to care. HWCs serve as nodal points where patients can access TB diagnostic facilities, counseling, and free treatment. This strategy also leverages community health workers to conduct follow-ups, ensure treatment adherence, and provide nutritional support.

Additionally, through the Nikshay Poshan Yojana, the NTEP ensures that TB patients receive financial assistance for nutrition, recognizing the crucial role that diet plays in immune system recovery. This integration with broader social welfare initiatives reflects a holistic approach to TB management, addressing both medical and socioeconomic factors that contribute to the disease burden.

4. Public-Private Partnership

Engaging the private healthcare sector has been one of the most transformative aspects of NTEP’s strategy. Given that more than 50% of patients in India seek care from private practitioners before entering the public health system, integrating private providers has been essential to ensuring comprehensive TB control. NTEP has incentivized private doctors to notify TB cases, participate in standardized treatment regimens, and enter patient data into the Nikshay system. These incentives, along with government-supplied free drugs for TB treatment in the private sector, have helped increase case detection and improve treatment continuity.

Despite these successes, challenges remain in ensuring full participation from private practitioners, especially in rural areas. Nevertheless, public-private partnerships have already improved notification rates and are crucial for achieving the last mile in TB elimination efforts.

Challenges and Gaps^[14-18]

1. COVID-19 Pandemic Impact

The COVID-19 pandemic had a devastating impact on global health systems, and TB services in India were no exception. In 2020, TB case notifications dropped significantly as healthcare resources were diverted to manage the pandemic, and lockdowns made it difficult for patients to access services. The result was a backlog of undiagnosed and untreated TB cases, which allowed for continued transmission within communities. Additionally, COVID-19 symptoms such as cough and fever often overlapped with TB, leading to diagnostic confusion and further delays in TB detection.

Efforts to recover from this setback include intensified TB screening campaigns and the integration of TB screening into COVID-19 testing centers. However, the pandemic's long-term impact on India's TB elimination goals remains to be fully understood, and a concerted effort will be required to regain lost ground.

2. MDR-TB and XDR-TB

While NTEP has introduced innovative treatments for MDR-TB, drug-resistant TB continues to pose a significant challenge. MDR-TB and extensively drug-resistant TB (XDR-TB) are harder to diagnose and treat, requiring longer, more expensive, and more toxic drug regimens. While the BPaLM regimen offers hope, scaling this treatment across all TB treatment centers and ensuring patient adherence remain formidable challenges.

Adherence issues are especially prevalent in marginalized communities, where socioeconomic factors and limited healthcare access complicate long-term treatment. Innovative approaches like telemedicine follow-ups and directly observed treatment (DOTS) using digital tools could help improve adherence and outcomes in these high-risk populations.

3. Stigma and Health-Seeking Behavior

TB-related stigma remains a profound barrier to care, particularly among women and marginalized groups. In many parts of India, TB is seen not only as a medical condition but as a social affliction, leading to isolation, rejection, and even loss of livelihood. This stigma often delays care-seeking behavior, especially in communities where health literacy is low.

To address this, NTEP has implemented IEC (Information, Education, and Communication) campaigns, but these efforts need to be scaled up to reach more communities, particularly in rural areas. Collaborating with community leaders, religious figures, and local influencers to reduce stigma and encourage health-seeking behavior is essential to overcoming this barrier.

4. Underreporting in Private Sector

Despite the progress made in involving the private sector in TB control, underreporting of TB cases remains a persistent issue. Many private practitioners, particularly in rural areas, do not notify cases to NTEP, leading to significant gaps in surveillance and treatment. This issue is compounded by the lack of standardized treatment protocols in some private facilities, which may lead to inappropriate treatment regimens and drug resistance.

The NTEP’s efforts to engage private practitioners must include stronger regulatory oversight and continuous training to ensure adherence to national TB guidelines. Expanding the reach of the Nikshay system and incentivizing timely case reporting are critical next steps to closing these gaps.

5. Nutritional Support and Socioeconomic Barriers

Although the Nikshay Poshan Yojana has provided essential financial aid for nutritional support, many TB patients still face severe socioeconomic barriers that impact their ability to complete treatment. Poverty, malnutrition, and limited access to healthcare remain major obstacles, particularly in rural and tribal areas.

A more comprehensive approach is needed, involving multi-sectoral collaborations that address housing, education, and employment to mitigate the underlying socioeconomic drivers of TB. Strengthening partnerships between health services and social welfare programs could ensure that TB patients receive the holistic support they need to recover fully.

Future Directions and Recommendations^[7-14]

1. Strengthening Diagnostic Infrastructure

To reach the ambitious goal of TB elimination by 2025, India must expand access to molecular diagnostics, ensuring that all district and sub-district health centers are equipped with GeneXpert machines. Additionally, the government should explore point-of-care diagnostics, which can be deployed in community settings for faster results. This expansion would reduce diagnostic delays, particularly in remote areas, and ensure that treatment begins promptly.

2. Enhancing Community-Based Care

NTEP’s integration with Ayushman Bharat is a critical step toward decentralizing TB care, but more must be done to ensure that these services reach the most vulnerable populations. Strengthening the role of community health workers (ASHAs), training them to conduct TB screenings and follow-ups, and leveraging telemedicine could help bridge the gap in care access. Providing ASHAs with digital tools like smartphones equipped with Nikshay apps could further enhance community-based care delivery.

3. Addressing Social Determinants

TB elimination will require addressing the social determinants of health, including malnutrition, overcrowded housing, and poor sanitation. A multi-sectoral approach involving ministries responsible for housing, sanitation, and education can create healthier environments and reduce TB transmission. For example, programs that improve housing conditions in urban slums can mitigate the risk of overcrowded households, a known contributor to TB spread.

4. Combatting Stigma

TB-related stigma is one of the most deeply entrenched barriers to effective care. Individuals diagnosed with TB, particularly in rural and socially conservative areas, often face social ostracism, loss of employment, and isolation. This stigma is particularly severe among women, where a diagnosis can result in abandonment or exclusion from familial and community activities. Although IEC (Information, Education, and Communication) campaigns have been launched to address stigma, these efforts must be expanded to make a meaningful impact.

Strategies to combat stigma should involve community-based interventions, where trusted local leaders, influencers, and healthcare workers engage with communities to dispel myths about TB. Religious and community leaders can play a crucial role in changing public perceptions, framing TB as a treatable disease rather than a social affliction. Additionally, peer support groups for TB patients, where individuals share their experiences and support one another, can help reduce feelings of isolation and empower individuals to seek treatment earlier.

Education campaigns in schools and workplaces can also be highly effective in reducing stigma, especially if they focus on both prevention and treatment. By normalizing conversations about TB and addressing misconceptions, these efforts can reduce the fear and discrimination associated with the disease.

5. Scaling Up MDR-TB Treatments

While the new BPaLM regimen shows significant promise in treating MDR-TB with shorter durations and fewer side effects, the challenge lies in scaling this treatment model nationwide. The complexity and cost of administering the BPaLM regimen in every healthcare setting—especially in rural and under-resourced areas—remain hurdles. To overcome these barriers, it is essential to ensure the availability of diagnostic facilities that can promptly detect drug-resistant TB and guide appropriate treatment regimens.

Furthermore, ensuring treatment adherence among MDR-TB patients is critical to preventing relapse and the development of extensively drug-resistant TB (XDR-TB). The NTEP could invest more in telemedicine and mobile health interventions, which have proven effective in improving patient monitoring and adherence. For example, smartphone-based reminder systems and tele-consultations can help keep patients on track with their medications, reducing the risk of treatment interruption.

Training healthcare providers, particularly in rural areas, to manage MDR-TB patients is also vital. Continuous professional development and support for healthcare workers in Drug-Resistant TB Centers (DR-TB centers) will ensure that they are equipped with the latest knowledge and tools to manage these complex cases effectively.

The National Tuberculosis Elimination Program (NTEP) represents a significant and transformative effort in India's ongoing battle against tuberculosis. Through its integration of modern diagnostics, such as GeneXpert, innovative drug regimens like BPaLM, and an emphasis on early case detection and community-based care, NTEP has made considerable progress in reducing TB incidence and mortality. The program's alignment with broader healthcare initiatives, such as Ayushman Bharat, has brought TB services closer to vulnerable populations, ensuring better access to diagnostic tools and treatment. Despite these successes, several challenges remain, including the persistent threat of drug-resistant TB, the socioeconomic barriers many patients face, and the deep-rooted stigma associated with the disease. The COVID-19 pandemic further compounded these issues by disrupting TB services nationwide, highlighting the need for resilient healthcare strategies. Going forward, scaling up diagnostic infrastructure, enhancing private sector engagement, addressing social determinants of health, and expanding efforts to combat stigma will be critical to achieving the ambitious goal of eliminating TB in India by 2025. By continuing to adapt and innovate, NTEP has the potential to make TB a disease of the past in India, but sustained efforts and multisectoral collaborations will be key to closing the remaining gaps in care and treatment.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College, Shimla, Himachal Pradesh.

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