Ni-kshay: India’s Integrated Digital System for Supporting Tuberculosis Prevention and Care

INTRODUCTION

Ni-kshay, meaning “end (Ni) tuberculosis (kshay),”¹ symbolizes India’s ambitious drive to defeat tuberculosis (TB) by 2025. With more than 50 million people—including diagnosed, presumptive cases of TB and those receiving TB preventive treatment—registered since its inception, Ni-kshay stands out for its scale and integration.² It has revolutionized TB care management, introducing a shift from a paper-based system fraught with data loss and duplication to a comprehensive digital suite. This suite not only captures the continuum of care from initial screening to post-treatment follow-up, it also integrates real-time case reporting and support mechanisms, providing a nuanced view of India’s TB burden. The Ni-kshay system, under the National TB Elimination Programme, manages a vast network of beneficiaries that, as of December 2023, includes over 1.5 million individuals on treatment for TB or receiving preventive treatment through the program.³

Before Ni-kshay, India tracked people with TB who sought care through a paper-based system that resulted in missing data, duplicate records, and inefficiencies due to multiple registers (paper booklets where data are recorded). It also largely excluded data for people seeking care in the private sector, resulting in significant data gaps. These data gaps hindered service delivery and the ability of managers and providers to follow the TB care cascade, make data-informed decisions, and deliver comprehensive care.^2,4 Furthermore, the paper-based system’s inefficiency and inability to scale compromised the country’s goal to eliminate TB by 2025, spurring demand for a digital TB case management platform.⁵

When Ni-kshay was first launched in June 2012, it was the first web-enabled, case-based TB tracking system in the country. The system now spans public and private sectors and reaches nearly the entire population of people living with TB or in need of TB preventive treatment in India. Developed by the Central TB Division of the government of India, Ni-kshay has transformed India’s legacy paper-based system into an efficient information hub for people seeking care, health care providers, and health system managers. Ni-kshay’s development offers valuable lessons for how to successfully scale and integrate digital tools into service delivery.

WHAT DOES NI-KSHAY DO?

Ni-kshay is a comprehensive tool that brings stakeholders across India’s TB program under one digital umbrella. It creates a digital case file and records the continuum of care—including presumptive TB case screening, identification, TB case notification, drug prescription, direct benefit payments, treatment adherence support, outcome monitoring, and post-treatment follow-up.^2,6 Collectively, these data—rich in consistency and depth—provide a more accurate and holistic view of the burden of reported TB cases in India.

Ni-kshay is easily accessible via desktop computers, tablets, and mobile phones, and it centers around a user-friendly, all-inclusive design that enables providers, people seeking care, and managers in the public and private sectors to view critical TB indicators and support a patient’s ongoing treatment using the same unique ID.

The platform is nimble, easy to scale, and highly responsive due to its microservice-based, open-source architecture designed to be modular and interoperable. Ni-kshay is interoperable with other systems within India, including state dashboards and the Direct Benefit Transfer portal, which enables government incentives to be sent straight to the beneficiary. This allows government programs and other systems to expand their reach by leveraging the technical infrastructure that Ni-kshay developed. Ni-kshay is also integrated with the Ayushman Bharat Health Account (ABHA), the national digital health ID system created under the country’s digital health construct known as the Ayushman Bharat Digital Mission (ABDM). One of ABDM’s central objectives is to generate a unique digital health ID for every citizen; this unique identifier enables individual health record integration across multiple systems.⁷

WHO IS NI-KSHAY DESIGNED FOR?

At its core, Ni-kshay is a digital TB registry, but its integration with external systems means it can be used by a range of users. It can be accessed via a mobile application and separate web interfaces for health system managers, patients, and providers, enabling different features for each. For example, people seeking care for TB can view their treatment plans, treatment adherence, and receive government incentives; providers can manage cases and end-to-end patient care; and health system managers can better oversee the country’s overall progress toward TB elimination.²

Importantly, Ni-kshay was constructed with a “user first” mindset. The Central TB Division worked with both developers and end users, including clinical health workers and people seeking care. User feedback identified pain points, informed product decisions, and inspired its overall road map, ensuring that the final tool was easy to navigate and met user needs.

Specific features available to different users are described below.

Health care providers

Health care providers can use Ni-kshay to register and support people seeking care across public and private providers throughout every district. The system allows health workers to engage with people seeking care during their entire care journey—from presumptive cases to post-treatment to recurrence—using the same unique ID.

The case management tool includes unified modules for drug-susceptible TB, drug-resistant TB, and vaccination to support the entire continuum of care. As a case support platform, Ni-kshay supports patient and episodic management, diagnostic integration, drug dispensing management, adherence management, and patient data access. Clinical staff use it to manage and support people seeking care through patient notifications, adherence technologies (which enable digital records of medication intake), direct benefit payments, and task lists.

Health system managers

The system provides health system managers with the data needed to effectively allocate resources, strategize efforts, and plan follow-up action. Ni-kshay has data visualization and analytics capabilities to help health system managers observe and evaluate the delivery of care, as well as follow TB case surges through dashboards, reports, automated emails, and integrated dashboards with other programs. Health system managers can access data dumps and visualizations within Ni-kshay. Ni-kshay Analytics—a modern, open-source data exploration and visualization platform that enables self-serve analytics without compromising individual identifiers—has also been established to democratize data and further empower decision makers. Decision makers can also leverage low-code data science platforms through Gramener and Gramex for advanced data visualization and dashboarding. These platforms enable individuals to run analytics and create visualizations without writing code in R or other scripting languages.

People seeking care

People seeking care for TB and other individuals can use Ni-kshay via a mobile application called TB Aarogya Sathi. To promote ease of use, the application can be accessed without logging in. Users can find information on TB (e.g., symptoms, treatment side effects), resources (e.g., health facility search), and tools (e.g., body mass index assessment).⁸ All users receive the same content, but after logging in, they can view information on their specific case and follow it throughout their entire course of TB treatment. The Ni-kshay mobile application integrates three digital adherence technologies, allowing people to use different methods to digitally record their daily dose, check their daily detailed adherence information, and inform the treatment coordinator of any unreported doses.

More recently, use of digital signature certificates by health system managers and staff has helped simplify and fast-track the payment process. The payment gets credited to the beneficiary within hours of approval in the Public Financial Management System, which considerably reduces the turnaround time of payments.

ENABLING ENVIRONMENT

Ni-kshay’s development benefited from a committed national leadership, strong national strategy, and India’s digital-ready environment.

A World Health Assembly resolution and governments’ recognition of TB as a major global public health problem strengthened the government of India’s efforts and other global efforts to identify, support, and treat TB. At the same time, strong political commitment and a coinciding mandate to achieve universal health coverage gave momentum to the effort to digitize national health care and contributed to much of Ni-kshay’s growth.⁹

Ni-kshay was able to leverage India’s preexisting digital infrastructure, along with growing connectivity. In January 2021, nearly 80% of the population had access to mobile phones, 54% being smartphone users, and more than half of the population could access the internet.¹⁰ However, that growth is uneven across groups, with the digital divide driven by gender and geography. It is estimated that while 57% of men use the internet, just 33% of women use it. This gap persists across urban and rural populations, with roughly 73% of urban men and 52% of urban women having ever used the internet, compared with less than half of rural men and just a quarter of rural women.¹¹

Legislation and policy have also enabled India’s digital ecosystem to grow. In response to this growth, India implemented a framework of data security and privacy laws that protect patients’ medical data. These enforce security, confidentiality, patient privacy, and are codified in laws that are part of India’s general data protection framework. These laws and regulations include the Information Technology Act of 2000, the Information Technology Rules of 2011, and the Information Technology Intermediary Guidelines of 2011.

As Ni-kshay was built and deployed, it leveraged the Ayushman Bharat Digital Mission (ABDM), overseen by the National Health Authority and Ministry of Health and Family Welfare. Launched in 2021, the ABDM aims to develop the backbone necessary to support the integrated digital health infrastructure of the country. The ABDM connects stakeholders across the health care ecosystem to create and house longitudinal electronic health records for India’s entire population. The system establishes national health IDs, a registry for facilities and providers, and national digital health records to improve patient care and outcomes. It has assigned unique health IDs, through the Ayushman Bharat Health Account (ABHA), for more than 500 million citizens and more than 230,000 health facilities, as of December 2023.¹² While Ni-kshay experienced healthy growth in its early years, the launch of ABDM allowed it to reach much greater scale because it provides Ni-kshay with a high volume of clean, organized data. It also standardizes the national ID system, which can eliminate duplicate and conflicting patient records.¹³

IMPLEMENTATION TIMELINES

In 2012, the National Informatics Centre of the government of India developed Ni-kshay 1.0, the country’s first national TB digital tracking system focused on public sector care. The initial version was a forerunner to today’s version of Ni-kshay, serving as a springboard from which new features were added to increase efficiency and expand reach. The goals for enhanced use included integration of drug-susceptible TB and drug-resistant TB modules and, more notably, the inclusion of people seeking care who were being treated in the private sector.

At the time that Ni-kshay 1.0 was initially developed, about 74% of people seeking care for TB accessed services in private clinics.¹⁴ Compared with the public sector, some private providers exhibited inconsistent prescribing practices. There was limited information pertaining to drug dosing, prescription and treatment practices, and concerns about increasing drug-resistant TB.¹⁵ Information on cases was not regularly reported to the public health department,¹⁶ resulting in lower overall TB notifications.¹⁷ In July 2013, with the support of development partners, the Central TB Division focused on developing patient-centered digital adherence tools. They adapted the underlying software built to support 99DOTS (directly observed treatment, short-course). 99DOTS was originally designed as a low-cost, mobile phone-based, TB medication adherence technology that enabled people seeking care to digitally register when they take their medication.¹⁸ The system initially supported adherence among people coinfected with TB–HIV across the country and then later, for deployment of 99DOTS for TB patients seeking care across five states in India.

Two other early attempts - UATBC and e-Nikshay - to develop a web-based system for case-based TB management including private providers were built by third-party developers in June 2014 and March 2017, respectively. They were eventually retired because the architecture of these platforms and technological constraints made it difficult to scale. They were also unable to integrate with external systems that would have allowed for key features such as direct benefit payments. Learnings from the pilots of these earlier tools were important to understand the user experience and were used to refine the existing Ni-kshay platform accordingly.

In September 2018, the Central TB Division, with the support of partners, developed the current version of Ni-kshay (Ni-kshay 2.0), building on innovations of the original version and these other tools. Technical support was provided by Everwell Health Solutions, with primary funding support from the Bill & Melinda Gates Foundation and catalytic support from US Agency for International Development. The revamped architecture—open, inclusive, and interoperable—was critical to the improved system’s ability to scale, and easily accommodated new service requests. It was modernized as an end-to-end, case-based system that follows a patient’s journey from the time they first receive care until two years after the treatment ends.

Through joint partnerships between the Central TB Division and the World Health Organization, the new system includes improved user experiences and response times, an interface that unifies public and private care providers, integration with the Public Financial Management System for direct benefit transfers, and real-time access to patient data. In subsequent iterations, new additions included a mobile application, patient-specific application, dashboards, and automated, downloadable reports.

The following timeline illustrates Ni-kshay’s evolution:

IMPACT

Ni-kshay coverage

No formal impact evaluation of Ni-kshay has been conducted, as of December 2023. In the absence of an evaluation, platform-use metrics were used as a proxy for assessment. As of December 2023, 1.5 million beneficiaries were on treatment for TB or were receiving preventive treatment and were fully managed by Ni-kshay.³ Over the course of three years (2021–2023), cumulative TB notifications have increased with a compounded annual growth rate of 70%. By the end of 2023, Ni-kshay had also registered 325,000 private health facilities and 186,000 public health facilities.³

Notification of TB Diagnosis

Furthermore, Ni-kshay’s impact can be measured through its contribution to the impressive gains in the number of people who were notified of their TB diagnosis by the National TB Elimination Programme.

Annual TB notifications increased 21% between 2013 and 2018, after the rollout of Ni-kshay version 1 in June 2012. Similarly, 13.4 million TB episodes were notified between 2018 and 2023, after the availability of Ni-kshay version 2 in September 2018, with 28% of those having sought care from the private sector.³

Treatment completion

Between 2018 and 2022, an additional 10 million TB patients were initiated on treatment through Ni-kshay and 87% completed their treatment³. Since 2018, 490 thousand TB patients have used digital adherence tools in Ni-kshay to support their care. Other metrics that highlight the platform’s scale include TB program clinical cascade measures, such as the number of test results captured (47 million since 2017)⁴.

Direct benefit transfers

Ni-kshay is also integrated with the government’s Public Financial Management System which allows it to facilitate direct benefit transfers, a government incentive that is sent straight to the beneficiary. These are used to incentivize actions and behaviors, such as providers notifying public health authorities of TB diagnosis and patients adhering to treatment. For people seeking care, direct benefit transfers also provide financial payments for food to support nutrition throughout the continuum of care.¹⁹ People in care can also review their digital payments received via the mobile application. As of December 31, 2023, Ni-kshay has distributed over 30 billion Indian rupees (approximately US$380 million)³ in government incentives to TB-affected people and health care providers.³ Those numbers continue to grow daily as disbursements are made to all newly diagnosed TB patients seeking care and their health care providers.

Finally, the mobile application consistently receives high ratings from users on the Google Play Store. Developers monitored and fast-tracked features in response to user feedback, fulfilling requests that included translations and the ability to geotag facilities.

PATH TO SCALE AND SUSTAINABILITY

The government of India welcomed the technical expertise, financial support, and deployment assistance from external partners to scale Ni-kshay and focus efforts to institutionalize the digital tool within the government. Partners established clearly defined roles and a process to ensure continuous alignment, which minimized redundancies and competition, and provided a level of stability that has been critical.

What were the key drivers of scale?

Ni-kshay’s success at scale can be attributed to multiple drivers, including the following:

• Groundwork—contextual environment: The government’s political and technical support and ongoing involvement in Ni-kshay has been highlighted since its inception. In public remarks, the prime minister and president of India both promoted the platform’s significance to the country’s campaign to eliminate TB.²⁰ Full public support from the Central TB Division as the platform owner also gave Ni-kshay the momentum required to get it off the ground, create a professional product, and encourage use.

  In addition, a new policy that required private practitioners, chemists, and public health staff to notify people seeking care for TB of a positive diagnosis through Ni-kshay accompanied the tool’s implementation in 2018.^21,22 This policy led to an increased adoption of Ni-kshay among private providers and the need to switch to case-based, patient-level reporting. As a result, Ni-kshay became an all-inclusive TB case registry that combined previously siloed data from the public and private sectors and allowed the government to support all people seeking care for TB, regardless of where they received it.

• Groundwork—parameters of scale: The decision to shift to a digital records system, combined with a commitment to include the private sector from the beginning, promoted the scale and adoption of Ni-kshay. Additionally, in-country teams developed and refined Ni-kshay while working closely with its end users—health workers and people seeking care—to incorporate their feedback into product decisions, resulting in a user-centered design that could be interoperable with other digital health tools. Continuous improvement of the Ni-kshay tool led to a more comprehensive and inclusive final product that incorporated, for example, improvements to data collection processes, the addition of private sector health care providers, direct benefit payments, TB medication adherence integration, dashboards, downloadable reports, a patient application (TB Aarogya Saathi), and a Ni-kshay Sahyogi chat bot.
• Partnerships—partnership sustainability: Government ownership and the intentional thought given to long-term sustainability throughout Ni-kshay’s evolution was critical to its adoption and growth. With many organizations involved throughout Ni-kshay’s evolution, clear guidance from the Central TB Division helped define each partner’s respective role and focus area. Plans were in place from the beginning around the development of training materials and sessions, cloud hosting, required licenses, system maintenance, and budget allocation to support ongoing system maintenance.
• Financial health—financial management and sustainability: The Central TB Division financed the earliest version of Ni-kshay and subsequently partnered with the Bill & Melinda Gates Foundation to offer the project financial stability through its iterative development process.
• Technology and architecture—interoperability and integration: Ni-kshay can connect to and operate in coordination with other government digital health tools (e.g., ABHA digital ID system, state dashboards, Direct Benefit Transfer portal), allowing it to easily evolve according to changing needs and to promote wider adoption. The platform used India’s digital payments infrastructure and integrated with the Public Financial Management System, enabling direct benefit transfers to people seeking care, providers, and treatment supporters, who help ensure that patients complete their drug regimen. It is also integrated with the Unified Mobile Application for New-age Governance, a platform that enables all Indian citizens to access government services.

Implementation and scale-up challenges

Ni-kshay has become the digital foundation supporting the government’s goal to end the TB epidemic within India by 2025, but it faces emerging and outstanding issues.

• Technology and architecture—technology maintenance: Ni-kshay’s core technology will benefit from upgrades over time as newer versions are released and the system continues to scale. Doing so could reduce security vulnerabilities, the risk that some services could become unavailable, and general system instability. In addition, new system demands, such as new TB standards rolled out by the World Health Organization and the government of India, will likely arise as India’s TB program evolves. Developers should also continue to monitor and be responsive to user feature requests to maintain engagement.
• Operations—training and support: Despite Ni-kshay’s transformation of TB care in India, reliance on paper-based records persists in some settings. This results in decreased efficiency, with backlogs and conflicting data existing in the two systems. In addition to the operational complexity from parallel systems, the training of users on the Ni-kshay platform is more complex due to the expansive number of features on the system and multiple platforms for different users, sometimes resulting in limited use of certain features.
• Financial health—budget and resource support: Over the last decade, the government of India has nearly doubled its budget allocation to the National TB Elimination Programme. Ongoing financial commitments could continue to support cloud hosting and toll-free lines, procurement of end-to-end technical resources, and increased training for users across the system.

Way forward

Ni-kshay has become an all-inclusive platform that enables people seeking care for TB to engage meaningfully with their care, while providing the government of India and managers with the data necessary to accelerate the elimination of TB from the country. Ni-kshay accounts for nearly all people seeking care who have been diagnosed with TB—and it has been recognized as the best public health TB digital system in the world.²

Looking ahead, Ni-kshay is poised for continued evolution. The platform, now a cornerstone of TB care in India, is set to broaden its capabilities through the integration of new modules to enhance user experience and reach. These developments align with India’s Ayushman Bharat Digital Mission and reinforce Ni-kshay’s role within an interconnected digital health landscape. Its success is a testament to India’s digital maturity, unwavering political will, and commitment to iterative improvement. As Ni-kshay embarks on this next phase, it remains a beacon in the global health community, demonstrating the power of digital solutions to address public health challenges.

CONCLUSION

Ni-kshay has accelerated India’s push to end the TB epidemic by providing stakeholders—health care managers, public and private providers, and people seeking care—with vital information to effectively oversee the state of TB at national, community, and individual levels. Crucial factors contributing to Ni-kshay’s widespread adoption include India’s digital-ready environment, strong political commitment, and willingness to continuously improve the original platform to maximize efficiency and reach. The platform now notifies more than 2.5 million people every year, in part due to successful cooperation among partners and enhancements made since the platform first launched in 2012. Such enhancements include Ni-kshay’s modernized technical architecture, its ability to deploy government incentives, and a user-friendly design.

METHODOLOGY

Initial research scoping included a desk review of publicly available literature as well as reports and presentations provided by Ni-kshay’s strategic partners. To further understand Ni-kshay’s development and implementation, we conducted in-depth interviews with key representatives from the Central TB Division under the Ministry of Health and Family Welfare, the World Health Organization, Everwell Health Solutions, and the Bill & Melinda Gates Foundation.

Ni-kshay’s performance was assessed according to the mHealth Assessment and Planning for Scale (MAPS) framework²³ to highlight strengths and challenges. All interviews were conducted in English and transcribed and coded for analysis.