Bridging clinical and social gaps in tuberculosis management: A review of India’s differentiated TB care framework
Year: 2026
Type: article
Abstract: INTRODUCTION Tuberculosis (TB) is a formidable public health concern in India, accounting for 27% of the global burden and over 315,000 deaths in 2023.[1] The Government of India has made a bold commitment to end TB by 2025. Much progress has been made towards this goal; however, there exist significant gaps due to undetected cases and the associated social determinants associated with the disease, which affect clinical severity and treatment outcomes, especially among high-risk individuals. To address this, the National TB Elimination Program (NTEP) had developed technical guidance in 2021.[2] The challenges identified during the interim are proposed to be overcome in the newly published National Guidance on Differentiated TB Care (2025).[3] This Differentiated TB Care (DTC) framework proposes a patient-centred, tiered approach to TB care with an emphasis on identifying high-risk populations, addressing social determinants of health, multi-level health institutions, community involvement and integrating technological tools in preference to the current routine passive care [Table 1].Table 1: Comparison of routine passive TB care and differentiated TB careWe review the framework in relation to regular clinical care, focusing on feasibility, strengths, and challenges in implementation within the Indian public healthcare system. STRENGTHS OF THE FRAMEWORK 1. Risk Stratification and Early Intervention Best practices in routine clinical care include detailed clinical assessment of all cases that include both past history and current clinical presentation, relevant clinical examination, laboratory and ancillary testing to arrive at a diagnosis and the severity of any disease and comorbidities. Differentiated TB care is designed to supplement, not undermine these clinical practices. It builds on clinical care foundations but recognises that a strictly standardised model does not meet the diverse needs of all TB patients, especially those with complicating factors or social vulnerabilities. The DTC includes sociodemographic and anthropometric angles to identify high-risk groups that contribute disproportionately to TB mortality.[1] It highlights the need for comprehensive risk stratification based on clinical and sociodemographic indicators such as HIV, diabetes, and severe undernutrition.[4-6] This aligns with best practices in clinical care, which prioritise early detection and prevention of complications, particularly in these high-risk groups. DTC brings additional support and flexibility without diminishing the clinical role of doctors in TB management. 2. Structured Tiered Care Approach The existing referral hierarchy in India’s public health system is a multi-level care model—from community health centres (PHCs/CHCs) to tertiary hospitals. Currently, these function in isolation, have human resource and other source deficits leading to disproportionate workloads especially on tertiary care institutions. The stratification of risk groups will facilitate appropriate case management based on severity, helping prevent both under- and over-utilisation of services.[7,8] Such a distribution of cases will relieve undue workload on the already overutilised services at the tertiary and secondary care facilities, eventually improving the quality of care at each level. 3. Integration of Social Determinants of Health With the growing interest in holistic care for chronic diseases, recognising that TB is as much a social disease as a clinical one, the inclusion of nutritional support, counselling, and TB Social Autopsy (TBSA) mechanisms reflects a sound approach to care.[9-12] This is particularly relevant in India, where undernutrition, poverty and climate change significantly influence TB outcomes. 4. Empowering Community Health Workers Nonclinical staff and community workers play essential roles in DTC by providing support that goes beyond medical treatment, helping to ensure medication adherence, address social and psychological needs, and connect patients to needed resources. Frontline workers such as ASHAs, CHVs and other healthcare personnel have a central role in ensuring community linkage. Clinical care models often neglect this very important link in care delivery. By working in multidisciplinary teams that combine medical and nonmedical skills, these community workers improve coordination, address gaps in social support, and increase treatment completion rates. DTC relies on the collaboration between nonclinical and clinical staff making health services more accessible, holistic and responsive to individual needs.[13] 5. Use of Digital Platforms and AI Tools India is leading in digital technology, the incorporation of Nikshay and AI-driven risk prediction models demonstrates an effort to modernise TB care delivery through data-driven decision-making.[14] These tools are beneficial in monitoring patient outcomes, predicting adverse events, and enhancing continuity of care in clinical settings. IMPLEMENTATION CHALLENGES AND SYSTEMIC CONSTRAINTS Differentiated care for TB, while promising, faces several limitations that can impact its effectiveness on a broad scale: 1. Operational and Logistical Challenges The DTC requires complex triaging, referral coordination, and digital reporting, which may be impractical in understaffed and resource-constrained PHCs. Clinicians may lack the time and training to implement structured stratification protocols effectively.[4,15] 2. Systemic and Social Barriers Stigma, delayed access to care, and socioeconomic factors—such as poverty and poor health literacy—continue to undermine differentiated care efforts. Resistance from traditional health systems, inadequate infrastructure, and poor monitoring of comorbidities, all present challenges to the widespread adoption and efficacy of differentiated care. Rural–Urban ambiguity In rural areas, TB services are anchored in primary health centres, with community health workers supporting case detection and treatment adherence. Barriers often include limited diagnostic access, transportation constraints, and stigma. In contrast, urban settings are characterised by a dense but fragmented private health sector, greater availability of molecular diagnostics, and variable notification practices. Delays commonly arise from multiple consultations, empirical treatment, and incomplete reporting. Yet the rural–urban divide is increasingly blurred in the settings of the urban slums. Additionally, migrant populations move between rural and urban spaces, disrupting continuity of treatment. Consequently, TB risk and outcomes are shaped less by geography and more by social vulnerability, mobility, and health system fragmentation. 3. Lack of Specific Clinical Protocols The DTC guidelines do not provide detailed clinical guidelines for managing moderate or high-risk patients at each care level. This may create ambiguity in practice, especially in rural or remote areas where physician availability is limited.[7,15] Baseline screening investigations such as haematocrit, assessing blood sugar levels, HIV testing, basic imaging, and advanced diagnostics for liver and renal disorders need to be performed to initiate specialised care for patients flagged during risk stratification. Additional tests may be required to assess adverse drug reactions, non or slow responders to treatment and functional assessments for physical and mental status to plan for rehabilitative services as needed. 4. Fragmentation Risk Without Integration While tiered care is conceptually strong, coordination between primary, secondary, and tertiary levels remains weak in many states. Without robust referral feedback systems, patients may fall through the cracks despite being enrolled in differentiated care.[7,14] 5. Workforce Capacity and Training Needs Community health workers (CHWs) may lack comprehensive skills to manage complex cases or comorbidities, such as HIV or diabetes, which are common among TB patients at high risk. Suboptimal support and mentoring from clinical professionals further reduce the impact of differentiated care models. Frontline workers are already burdened with multiple programmes (e.g., maternal health, immunisation, NCD screening etc). Adding responsibilities for DTC without adequate training, remuneration, and institutional support could dilute quality of care.[8,16] 6. Technological and Digital Inequities Despite the promise of digital tools, disparities in digital access and literacy among health workers and patients, especially in rural settings, will pose a risk to consistent implementation.[7] Over-reliance on AI tools without clinician oversight could also result in errors in care decisions. CLINICAL INTEGRATION AND SPECIALIST ROLES Role of the pulmonologist Within the framework of the National TB Elimination Programme (NTEP), differentiated TB care requires risk stratification and coordinated multidisciplinary management. The pulmonologist plays a central role in ensuring clinical precision within this model. They are integral to individualised treatment planning, especially for patients with comorbidities such as diabetes, chronic lung disease, or HIV infection. In drug-resistant TB, pulmonologists guide regimen selection, monitor adverse drug reactions, and determine the need for hospitalisation versus ambulatory care. They enhance quality assurance and clinical governance by mentoring primary and private sector providers; also address post-TB lung disease and long-term sequelae, incorporating pulmonary rehabilitation and functional assessment into follow-up care and thus function as a clinical anchor linking programmatic priorities with individualised, patient-centred care. TB social autopsy (TSA) TSA has important clinical implications for the pulmonologist within the framework of the NTEP. By identifying social, behavioural, and health system factors contributing to TB-related deaths—such as delayed care-seeking, stigma, malnutrition, financial barriers, comorbidities, or inappropriate empirical treatment—it prompts earlier recognition of vulnerability as a clinical risk modifier. Thus, TB social autopsy reframes mortality from an isolated clinical failure to a preventable systems event, strengthening patient-centred, risk-informed decision-making for the pulmonologist. RELEVANCE TO REGULAR CLINICAL CARE IN INDIA In routine clinical settings in India, TB care often suffers from delays in diagnosis, weak follow-up systems, poor adherence, and treatment default. The DTC proposes several corrective measures such as shift from passive to active case finding; structured patient-centric follow-up protocols, nutritional and psychosocial support and community-level support mechanism and most importantly a tiered clinical assessment and management paradigm. However, unless implementation is backed by investment in training, digital infrastructure, and inter-sectoral coordination, the guidance risks becoming policy on paper rather than practice on the ground. CONCLUSION The Differentiated TB Care guidance represents a comprehensive, patient-focused evolution in TB control strategy. It incorporates modern tools and emphasises personalisation and equity—principles essential to high-quality clinical care. Yet, operational challenges, especially in India’s fragmented healthcare infrastructure, must be addressed for the model to succeed. Effective implementation will require: clear clinical guidelines, capacity-building, community integration, robust digital infrastructure and finally most important a sustained political and financial commitment. If these conditions are met, the DTC framework could become a blueprint not just for TB, but for managing other chronic and complex diseases in resource-limited settings. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Lung India
Author: Yatin Dholakia
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7165804327