Barriers to effective management of drug-resistant tuberculosis in India, insights into patient & health system challenges: An exploratory review

The emergence of drug-resistant tuberculosis (DR-TB), especially multi drug resistant tuberculosis (MDR-TB), is increasingly threatening the effectiveness of India's National TB Elimination Program (NTEP). This review seeks to analyse the patient and health system challenges concerning the management of DR-TB and seeks to find appropriate solutions to maximize the programmatic impact. A systematic literature search was carried out on PubMed, Embase, Scopus and Google Scholar for articles published between 2015 and 2024 focusing on the treatment challenges in India's MDR or extensive drug resistant (XDR) TB. Factors regarding care access, adherence to treatment, and systemic barriers were prioritised. We accepted qualitative, retrospective, and cross-sectional designs; clinical trials and non-English publications were excluded. We included 15 eligible studies thematically. The socioeconomic factors, barriers to access to care were paired with a stigma, low disease awareness and care responsibility at home. This was alongside a high pill burden and adverse drug effects. Alcoholism and psychosocial depression comorbidities with poorly supportive social environments further worsened adherence. Gaps in the health system included insufficient drug resistance testing, delay in diagnostics, a lack of healthcare personnel, inadequate referral chains, and inconsistent treatment regimens. Lack of streamlined referral pathways and non-standardised treatment regimens posed problematic operational challenges. Weak involvement from the private sector and lack of training and supervision of frontline workers also contributed to operational gaps. Policy gaps included limited program scope, inadequate funding, or lack of universal health coverage. While urban areas faced coordination issues with the private sector, rural areas contended with further delays in diagnostics. A comprehensive strategy is essential when dealing with patients with DR-TB in India. Aligning psychosocial support, enhanced funding, and multisector coordination with infrastructure and better access to conflicting diagnostics can improve local contexts and targets NTEP's TB elimination goals.