TB Mukt Bharat: Challenges, Opportunities, and the Road Ahead

Tuberculosis (TB) remains one of the world’s deadliest infectious diseases, with 10.7 million cases and 1.23 million deaths globally in 2024. India is making significant strides toward tuberculosis elimination, achieving a 28% to 21% reduction in mortality and incidence, respectively and a reduction in missing cases from 15 lakhs to less than 1 (from 2015 to 2024), the most notable declines among high-burden countries. Although the original goal of TB Mukt Bharat was to eliminate tuberculosis by 2025, efforts continue vigorously under the National TB Elimination Programme (NTEP), aligned with the WHO’s End TB Strategy aiming for an 80% reduction in incidence and 90% reduction in mortality by 2030. Despite remarkable progress, challenges persist, including social determinants, drug resistance, and health system gaps. Sustaining momentum requires in-depth analysis using strategic tools such as Strengths-Weaknesses-Opportunities-Threats (SWOT) Analysis, Stakeholder Matrix, Threats-Opportunities-Weaknesses-Strengths (TOWS) Analysis, BCG Matrix, Log frame to define goal and Evaluation Framework to comprehensively track program performance to re-look again using Problem Tree & Objective Tree.

Tuberculosis (TB) is a preventable and usually curable disease. However, it remains one of the world’s deadliest infectious diseases, with over 10 million people falling ill and more than 1 million deaths annually worldwide, making it the leading cause of death from a single infectious agent and among the top 10 causes of death globally. Without treatment, the death rate from TB disease is high, with untreated smear-positive cases having a 10-year fatality rate averaging around 70%.^[1] With WHO-recommended treatment regimens, typically 4–6 months of anti-TB drugs, about 90% of people with TB can be cured.

Global scenario:

Globally, TB incidence was estimated at 131 cases per 100,000 population in 2024. Among the 30 high TB burden countries, most have improved service coverage between 2000 and 2019, with the largest absolute gains seen in China, India, Myanmar, Thailand, and Vietnam. In India, TB incidence declined from 237 per lakh to 187 per lakh population, while mortality decreased from 28 to 21 per lakh from 2015 to 2024. All WHO and UN Member States have committed to ending the global TB epidemic through the End TB Strategy and Sustainable Development Goals (SDGs). The 2030 targets of the End TB Strategy aim for a 90% reduction in TB deaths and an 80% reduction in TB incidence compared to 2015 levels, with interim 2025 milestones of 75% and 50% reductions, respectively. Despite significant progress, TB remains a major global public health challenge, with many regions falling short of these targets. The COVID-19 pandemic caused setbacks, but recent data show most indicators are improving, with notable regional and country successes.

Key updates under TB Mukt Bharat Abhiyaan:

India is making significant strides toward tuberculosis elimination, in terms of reduction in mortality (21 per lakh) and incidence (187 per lakh) by 28% to 21%, respectively. India diagnosed 2.61 million of the estimated 2.7 million TB cases in 2024, significantly closing the notification gap and missing cases (from 15 lakhs to < 1 lakh) from baseline to 2024. Further and faster reductions in TB burden as per the set target of achieving mortality 3 per lakh and incidence 47 per lakh require enhanced coverage of diagnostic, treatment, and preventive services; addressing social determinants that fuel new infections and disease progression; and breakthroughs such as new TB vaccines.^[2] State-Level Performance: Achievers: States like Kerala excel for significant drops in TB incidence (83 per lakh) and mortality (14 per lakh) due to a combination of decentralised governance, aggressive technology adoption, active private-sector alignment, leveraging strong private sector engagement, nutrition support, and digital monitoring. Their success is driven by treating TB elimination as a social movement rather than just a medical campaign.

State-Level Strugglers:

While some states have made tremendous progress, however, several states like Uttar Pradesh, Bihar, Madhya Pradesh, Jharkhand, and Rajasthan- are struggling with the TB burden. According to national data, Uttar Pradesh alone accounts for approximately 20% of India’s drug-sensitive TB cases.^[3] These states face challenges including human resource shortages, persistent stigma, and weak integration with other health programs, hindering progress.

Key challenges:

Despite this, there is a long way to go to achieve a significant reduction in high incidence and prevalence of TB in India. Factors like lack of awareness and resources, poor infrastructure, increasing drug-resistant cases, poor notification and overall negligence are the major challenges. If we eradicate poverty and undernourishment, educate the masses and eliminate the stigma attached to TB, we can hope for a disease-free future.^[4] The social conditions and co-morbidities that fuel the TB epidemic have been very poorly addressed in India. An estimated 300 million Indians still live in extreme poverty. India has been called the ‘epicentre of global malnutrition and the high prevalence of malnutrition is well documented.^[5] Diabetes is another important risk factor for TB.^[6] Furthermore, tobacco smoking is strongly associated with a higher risk of TB mortality; according to one estimate, smokers accounted for 66% of males who died from TB in India.^[7]

Analytical Tools: 

SWOT Analysis: A comprehensive SWOT analysis can navigate the complexities of tuberculosis control in India.^[8] By leveraging strong political will, advanced diagnostics, and digital tools, the program shall address critical challenges such as private sector engagement gaps, workforce limitations, and social stigma. Coupled with opportunities from global partnerships and health initiatives like Ayushman Bharat, NTEP strategically confronts threats including drug-resistant TB and resource constraints, ensuring a focused and adaptive approach to eliminating tuberculosis nationwide. (Table 1) 

TOWS:

The TOWS Matrix is a strategic planning framework that builds on the SWOT analysis by matching internal strengths and weaknesses with external opportunities and threats, used to transition situational assessments (like SWOT) into actionable strategies. It matches internal strengths and weaknesses against external opportunities and threats to optimise TB eradication efforts.^[9] (Table 2)

Logical Framework Analysis (LFA):

Under the NTEP is a strategic planning and management tool. It provides a systematic, structured matrix to define project goals, activities, and expected results. This approach maps out how program inputs will achieve objectives and sets standards for Monitoring and Evaluation (M&E). Log Framework is a foundational system for recording and monitoring TB program activities, ensuring accurate data collection and timely reporting to evaluate performance and guide strategic decisions. This framework integrates diverse data sources (Ni-kshay, Lab registers, HMIS, TB Report) and focuses on indicators (Detect, Treat, Prevent, Build) supported by continuous monitoring and independent audits to ensure accountability and guide improvements.^[10] (Table 3)

Stakeholder Matrix:

Map influence and interest. The Stakeholder Matrix maps key actors in NTEP by their level of influence and interest, clarifying their roles and contributions. This tool aids in prioritising engagement strategies to ensure effective collaboration and resource allocation for tuberculosis control.^[11] (Table 4) 

The BCG Matrix:

A strategic management tool developed by the Boston Consulting Group in the 1970s to help organisations analyse their portfolio of products or programs based on market growth and market share.^[12] The BCG Matrix categorises interventions into Stars, Cash Cows, Question Marks, and Dogs, guiding resource allocation based on performance and growth potential to enable evidence-based prioritisation. For NTEP, this matrix serves as a strategic lens for decision-making within the National Strategic Framework, helping policymakers and program managers allocate resources based on performance and potential growth.^[13] (Figure 1) TOWS and BCG Matrix are helpful to guide resource allocation.

Problem Tree & Objective Tree:

These tools are vital visual tools in NTEP that help systematically identify and frame core problems, then translate them into clear, actionable goals.^[14] By mapping root causes and their effects, the Problem Tree highlights key challenges, while the Objective Tree converts these into strategic objectives, guiding focused planning and effective implementation toward tuberculosis elimination. (Figure 2)

Evaluation Framework:

This framework integrates diverse data sources to comprehensively track program performance. It tracks the four national pillars (Detect, Treat, Prevent, Build) across four stages: Input, Process, Output, and Outcome. This ensures targets like early diagnosis and high cure rates are met.^[15] (Table 5)