ObjectivesIn India, retail private pharmacists (RPPs) are often patients’ first point of contact for diseases, including tuberculosis (TB). We assessed the factors influencing RPPs’ referral of patients with chest symptoms to the National TB Elimination Programme (NTEP) and the way business is carried out with reference to TB drugs.DesignWe conducted semistructured interviews with a purposive sample of 41 RPPs in a South Indian district between May and October 2013. Data were collected from urban areas (21 RPPs) and rural areas (20 RPPs) employing the principle of data saturation. Data were analysed thematically using NVivo V.9.ResultsKnowledge and compliance of RPPs regarding TB symptoms and regulatory requirements were found to be poor. The RPPs routinely dispensed medicines over the counter and less than half of the respondents had pharmacy qualifications. None of them had received TB-related training, yet half of them knew about TB symptoms. Practice of self-referrals was common particularly among economically poorer populations who preferred purchasing medicines over the counter based on RPPs’ advice. Inability of patients with TB to purchase the full course of TB drugs was conspicuous. Rural RPPs were more likely to refer patients with TB symptoms to the NTEP compared with urban ones who mostly referred such clients to private practitioners (PPs). Reciprocal relationships between the RPPs, PPs, medical representatives and the prevalence of kickbacks influenced RPPs’ drug-stocking patterns. PPs wielded power in this nexus, especially in urban areas.ConclusionIndia hopes to end TB by 2025. Our study findings will help the NTEP to design policy and interventions to engage RPPs in public health initiatives by taking cognisance of symbiotic relationships and power differentials that exist between PPs, RPPs and medical representatives. Concurrently, there should be a strong enforcement mechanism for existing regulatory norms regarding over-the-counter sales and record keeping.