Tuberculosis (TB) remains one of the top 10 causes of death worldwide, despite being preventable and curable. According to the World Health Organization (WHO), in 2022, around 10.6 million people fell ill with TB, and 1.3 million people died from it. India alone accounted for over 28% of global TB deaths, making it the country with the highest TB burden. To combat this, experts and public health advocates are now proposing the adoption of a death audit model similar to that used in tracking maternal mortality. This approach could significantly improve the effectiveness of India’s TB elimination strategy.

What is a Death Audit and Why It Matters

A death audit is a systematic review of individual cases of death to understand the causes, missed opportunities, systemic failures, and social determinants that contributed to the fatal outcome. In maternal health, this model has helped reduce maternal mortality by identifying root causes of death and translating findings into actionable policy changes.

India introduced maternal death surveillance and response (MDSR) in 2017, which mandates the reporting and investigation of every maternal death. This process allows health officials to identify patterns, improve service delivery, and raise accountability. A similar model applied to TB could uncover important gaps in diagnosis, treatment adherence, access to care, or co-morbidities that escalate risk.

The Problem with TB Deaths in India

Despite having the National Tuberculosis Elimination Programme (NTEP), India continues to report high mortality rates. Experts argue that without a comprehensive review of TB deaths, the country cannot understand the real causes behind them. TB deaths are often underreported, especially in the private sector or in rural and tribal regions.

A 2021 Lancet study highlighted that many TB patients in India died due to delayed diagnosis, poor follow-up, inadequate nutrition, and lack of treatment for co-existing diseases like HIV or diabetes. Moreover, social stigma and lack of community support contribute to late care-seeking behavior.

Learning from Maternal Mortality Reviews

The maternal death review system involves community-based reporting, verbal autopsies, facility audits, and structured analysis. The collected data is used to recommend facility-level and systemic interventions. In states like Kerala and Tamil Nadu, MDSR has significantly improved maternal care outcomes.

Applying this to TB, death audits can help identify whether the deceased had timely access to TB diagnosis and drugs, whether drug-resistant TB was tested, whether treatment adherence was monitored, and if socioeconomic vulnerabilities were addressed. For example, if a patient died of TB because they had to discontinue medication due to loss of income, this insight would signal the need for social protection interventions.

Steps Toward TB Death Auditing

In 2023, India’s Ministry of Health and Family Welfare acknowledged the potential of TB death audits. Pilot projects have been conducted in a few districts of Uttar Pradesh, Maharashtra, and Gujarat, where officials documented TB deaths using verbal autopsies and community interviews. The initial findings showed that nearly 30% of TB deaths were preventable.

The Central TB Division (CTD) is now exploring the possibility of integrating TB death audits into the existing NIKSHAY system — India’s digital TB case-tracking platform. Health experts recommend starting with sentinel surveillance in high-burden districts, training health workers to conduct interviews, and forming district TB audit committees.

Challenges and the Way Forward

Implementing TB death audits across India comes with challenges. These include lack of trained personnel, resistance from private providers, poor data infrastructure in rural areas, and delays in reporting. However, if linked with existing health systems like Ayushman Bharat Health and Wellness Centres and supported by community health workers (ASHAs), the implementation can be streamlined.

Public-private partnerships are also essential. Around half of TB patients in India seek treatment in the private sector. Collaboration with private hospitals, NGOs, and local governance bodies can improve the quality of data and widen the reach of audit efforts.

Global Examples and WHO Guidelines

Globally, South Africa has implemented TB death audits in certain provinces with promising results. WHO also supports TB mortality reviews as part of the End TB Strategy. These include recommendations for confidential, non-punitive reviews of deaths, community involvement, and multidisciplinary analysis.

According to WHO, countries that have adopted TB death audits have seen better surveillance, increased funding for neglected areas, and higher political commitment. India can leverage its experience with maternal health audits to build a similar framework for TB.

Conclusion

To eliminate TB by 2025, as envisioned by India’s National Strategic Plan, a shift in approach is essential. Death audits, modeled on the successful maternal mortality review system, offer a powerful tool to uncover hidden failures and systemic weaknesses. They transform deaths into data, and data into direction.

As India stands at a critical juncture in its fight against TB, adopting a structured, transparent, and community-rooted audit process could be the game-changer the country needs. Every TB death matters — and every one should be studied, not just counted.

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