In a tribal health centre in rural Chhattisgarh, a spirometer sits on a shelf, its plastic tubing still wrapped in factory packaging. The device arrived two years ago as part of India's National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD). No one at the centre has been trained to use it. The staff nurse, who asked not to be named, says she was told it was for 'lung testing' but never shown how to perform a forced expiratory manoeuvre. So patients with chronic cough and breathlessness are diagnosed by clinical instinct alone. Across the district, eight of ten such centres report similar stories. Spirometers gather dust while asthma remains undiagnosed or misdiagnosed.

Why Spirometers Sit Unused in Tribal Clinics

The NP-NCD programme, launched in 2010 and expanded over the following decade, aimed to integrate screening for hypertension, diabetes, and common cancers into primary care. Asthma and chronic obstructive pulmonary disease (COPD) were added later, with spirometers procured for sub-centres and primary health centres. Between 2018 and 2023, the programme spent roughly ₹120 crore—about US$14 million—on these devices. But procurement did not come with a plan for implementation.

Staff at tribal health centres lack training to perform or interpret forced expiratory volume in one second (FEV1) measurements. A 2025 audit in Madhya Pradesh found that 62% of spirometers had not been used in the preceding 12 months. Common reasons: no calibrating equipment, no replacement mouthpieces, and no one confident enough to operate the software. Many devices are the cheapest models available through state tenders, often without the necessary accessories or user manuals in local languages.

The result is that clinicians rely on symptom checklists alone. The NP-NCD screening form includes four respiratory questions—cough, sputum, breathlessness, and wheeze—but none have been validated in Hindi, Gondi, or other tribal languages. Patients often describe breathlessness as 'chest heaviness' or 'feeling tired', which may be attributed to anaemia or age. Chronic cough is assumed to be from smoking or biomass smoke exposure, both common in tribal households. Objective lung function testing is seen as a luxury, not a necessity.

Public health officials sometimes cite a 'lack of demand' from patients for spirometry. But this is a circular argument: when diagnosis is absent, patients do not know to ask for a test. The few who are referred to district hospitals for spirometry often face travel costs and lost wages, so they do not go. The device on the shelf becomes a symbol of a system that buys equipment but forgets the human infrastructure needed to make it work.

Symptom-Based Diagnosis Misses Half of Asthma Cases

A 2024 cross-sectional study in Odisha, published in the Indian Journal of Chest Diseases, found that symptom-based screening—using the NP-NCD questionnaire—missed 48% of spirometry-confirmed asthma cases. The study enrolled 1,200 adults from tribal communities who reported respiratory symptoms. Spirometry was performed at a mobile camp. Nearly half of those with objective airflow obstruction had been labelled as having 'chronic bronchitis' or 'post-TB sequelae' and were not receiving inhaled corticosteroids.

The overlap of symptoms with tuberculosis, post-COVID fibrosis, and even heart failure makes clinical diagnosis unreliable. In tribal populations, where tuberculosis prevalence remains high—around 200 per 100,000 in some districts—a cough is often assumed to be infectious. Patients may receive multiple courses of antibiotics or even empirical anti-TB treatment before anyone considers asthma. Conversely, overdiagnosis of asthma wastes the limited supply of inhaled corticosteroids, which cost roughly ₹300–500 per month at public sector prices.

Underdiagnosis leads to preventable exacerbations. A 2022 survey in Bastar, Chhattisgarh, estimated that adults with uncontrolled asthma lost an average of 14 workdays per year due to breathlessness. Many were daily-wage labourers; a single exacerbation could push a family into debt. Asthma mortality in central India remains around 45 per 100,000—several times higher than in urban areas or wealthier states. Without objective diagnosis, the disease is invisible until it becomes an emergency.

Clinicians are aware of the problem. A doctor at a community health centre in Koriya district told me, 'I know I'm missing cases. But what can I do? I have 80 patients a day. I can't spend 20 minutes on a lung function test.' The time pressure is real. But the cost of not testing is also real, and it is borne by patients who deteriorate silently.

The Policy Gap: Equipment Procurement Without Implementation

India's NP-NCD programme has been praised for expanding non-communicable disease screening to over 150,000 health facilities. But the asthma component reveals a pattern: devices are procured centrally, distributed to states, and then abandoned. No central training module exists for spirometry in primary care. The 2025 Madhya Pradesh audit found that only 12% of health workers at centres with spirometers had received any formal instruction, and most of that was a single half-day session without hands-on practice.

State tenders often buy the cheapest devices, sometimes without software or disposable mouthpieces. A spirometer that costs ₹15,000 may require ₹5,000 worth of accessories that are not included. Replacement parts are difficult to source, especially in remote areas. The Medical Devices Rules classify spirometers as 'Class B' devices, requiring physician oversight for use. This regulatory barrier discourages task-shifting to nurses or community health workers, even though the World Health Organization endorsed task-shifting spirometry to non-physician providers in its 2023 guideline on chronic respiratory diseases.

The circular argument of 'lack of demand' reappears in policy documents. A 2024 review by the Public Health Foundation of India noted that state-level NP-NCD performance indicators do not include spirometry utilisation rates. Without a metric, there is no accountability. The programme tracks the number of people screened for hypertension and diabetes but not the number who receive lung function testing. What is not measured is not managed.

Some states have tried to innovate. In Tamil Nadu, a pilot programme trained nurses to perform spirometry at primary health centres, with remote interpretation by pulmonologists. But the model was not scaled nationally. In Chhattisgarh, a 2023 proposal to train ASHA workers in peak expiratory flow (PEF) measurement was approved by the state health department but never funded. The gap between evidence and implementation remains wide.

A Low-Cost Fix That Remains Unscaled

Handheld micro-spirometers, costing US$50–100 per unit, offer a potential solution. These devices measure FEV1 and peak expiratory flow with reasonable accuracy and require only 10–15 minutes of training. They run on AA batteries, making them suitable for centres with unreliable electricity. In Jharkhand, the BreatheWell initiative trained 120 community health workers (ASHAs) to perform screening spirometry in Ranchi district during 2025. The results were striking: referral rates for suspected asthma rose threefold, and confirmatory testing at district hospitals increased correspondingly.

The BreatheWell model used a simple algorithm: any adult with respiratory symptoms and an FEV1 below 80% of predicted was referred. ASHAs used a mobile app to record results and send data to a central dashboard. The total cost per screening was about ₹50 (US$0.60), including the device amortisation and training. Despite these results, the initiative has not been incorporated into any national or state programme. The devices were donated by a non-profit; the health system has not committed to procuring them.

Critics point out that micro-spirometers are less accurate than full-sized devices and cannot measure forced vital capacity (FVC) or FEV1/FVC ratio. But in a setting where the alternative is no objective measurement at all, a screening tool with moderate sensitivity may still improve outcomes. The trade-off is between perfect diagnosis and practical diagnosis. For primary care in tribal areas, a simple PEF measurement—which takes under two minutes—could identify the majority of patients who need further evaluation.

The World Health Organization's 2023 guideline on chronic respiratory diseases explicitly endorses task-shifting spirometry to non-physician providers, including community health workers. India's own task force on non-communicable diseases recommended PEF screening by ASHAs in 2021. That recommendation has not been implemented. The regulatory classification of spirometers as Class B devices remains a barrier, though the Indian Council of Medical Research (ICMR) recommended in 2024 that basic spirometers be reclassified as Class A for primary care use. That recommendation has not been acted upon.

What Community Health Workers Could Do — If Allowed

India's ASHA workers—over one million across the country—already measure blood pressure and blood glucose under the NP-NCD programme. Adding a peak expiratory flow measurement would take less time than a blood glucose test. A 2023 study in The Lancet Global Health found that community health workers in Bangladesh and Nepal could perform PEF screening with high accuracy after a two-day training. The cost per test was less than US$0.10, not including the device.

In India, the regulatory barrier is not insurmountable. The Drugs and Cosmetics Act and the Medical Devices Rules could be amended to exempt basic spirometers from physician-only use, as the ICMR has suggested. But the health ministry has not prioritised this. Meanwhile, professional bodies such as the Indian Chest Society have expressed concern about quality assurance. They worry that misclassification could lead to over-treatment with corticosteroids or under-detection of restrictive lung disease. These are legitimate concerns, but they should be addressed through training and supervision, not by maintaining a prohibition that leaves millions without any testing.

ASHA workers themselves are often eager to take on the role. In Ranchi, the BreatheWell programme reported high satisfaction among trained ASHAs. 'Now I can tell a patient whether it is asthma or not,' one worker said. 'Before, I had to send everyone to the doctor, and many would not go.' The ability to provide a concrete measurement also improves patient adherence. When a patient sees their PEF reading improve after using an inhaler, they are more likely to continue treatment.

The potential impact is substantial. Asthma affects an estimated 38 million Indians, with tribal populations at higher risk due to indoor air pollution from biomass cooking stoves. A 2024 study in Environmental Health Perspectives found that women in tribal households who cooked with wood or dung had a 60% higher odds of asthma symptoms compared to those using clean fuel. Without screening, these women are often diagnosed late, after repeated emergency visits.

The Cost of Inaction in Rupees and Breath

Each avoidable hospitalisation for acute asthma costs a tribal family roughly ₹8,000–15,000—often a catastrophic expense. A 2022 survey in Bastar found that 40% of families with an asthmatic member had taken a loan or sold assets to cover treatment costs. The indirect costs of lost workdays and travel are additional. For a daily-wage labourer earning ₹300–400 per day, 14 lost days per year amounts to a significant income loss.

Spirometry screening for every adult with respiratory symptoms would cost about ₹50 per test in a programme setting—less than the cost of a single outpatient visit. Even if 10 million adults were screened annually, the total cost would be roughly ₹50 crore (US$6 million), a fraction of the ₹120 crore already spent on unused spirometers. The return on investment would come from reduced hospitalisations, appropriate use of inhaled corticosteroids, and improved productivity.

Without objective diagnosis, inhaled corticosteroids are misallocated. A 2023 analysis of NP-NCD drug procurement data found that nearly 30% of inhalers distributed in tribal districts were prescribed to patients without confirmed asthma. Meanwhile, many patients who would benefit from inhaled corticosteroids go without, leading to preventable exacerbations. The mortality rate from asthma in central India—around 45 per 100,000—is a stark indicator of failure. In high-income countries, asthma mortality is below 5 per 100,000.

The human cost is measured in breathlessness, missed school days, and early death. A 10-year-old girl in a tribal village who cannot run and play because of undiagnosed asthma is not counted in any statistic. Her family may attribute her fatigue to 'weakness' or 'anaemia' and never seek care until she has a severe attack. The spirometer on the shelf could have changed her trajectory, but it remains unused.

Three Steps to Unstick the Policy Logjam

First, reclassify basic spirometers as 'Class A' devices for primary care, as the ICMR recommended in 2024. This would allow nurses and community health workers to use them without direct physician supervision. The change requires an amendment to the Medical Devices Rules, 2017, which could be done through a notification by the Ministry of Health. The Indian Chest Society and other professional bodies should be consulted, but the evidence from pilot programmes supports the move.

Second, integrate peak expiratory flow measurement into the ASHA toolkit and link it to the NP-NCD reporting app. ASHAs already use a mobile app to record blood pressure and blood glucose. Adding a PEF field would be straightforward. Training could be delivered through existing NP-NCD training modules, which are already scheduled annually. The cost of adding PEF measurement to the toolkit is minimal—roughly ₹50 per device per year, including batteries.

Third, fund a national training programme for 50,000 primary care nurses and community health workers over three years. This would cost an estimated ₹30 crore (US$3.5 million), based on the BreatheWell model. The training should include hands-on practice, quality assurance, and periodic refreshers. State-level NP-NCD performance indicators should be revised to include spirometry utilisation rates. Start in three high-burden states—Chhattisgarh, Odisha, and Jharkhand—and scale based on evidence.

These steps are not expensive or technically difficult. They require political will and a shift in mindset from equipment procurement to implementation. The alternative is to continue buying spirometers that gather dust while patients suffer preventable morbidity and mortality. The choice is clear, but the system has not yet made it.

This article is for informational purposes only and does not constitute medical advice. Readers should consult a qualified healthcare professional for diagnosis and treatment of respiratory conditions.