Carrying more than a quarter of the world's tuberculosis burden, India's trajectory toward elimination reveals a collision of structural, microbial, and logistical forces that together illuminate why infectious disease targets routinely outlast the political calendars set for them. The lessons here extend well beyond South Asia — they expose the fragility of any nation's infectious disease infrastructure when simultaneously stress-tested by pandemic disruption and antimicrobial resistance.
This structured review, drawing on PubMed, Scopus, WHO reports, and Indian government data, maps the compounding obstacles facing India's National Tuberculosis Elimination Programme, which had set a 2025 elimination target. COVID-19 emerges as a critical inflection point: case notification rates declined markedly during the pandemic period, suggesting a growing reservoir of undiagnosed and untreated TB. Multidrug-resistant and rifampicin-resistant TB (MDR/RR-TB) added a further layer of complexity, as these strains demand costlier, longer treatment regimens with lower success rates. Fragmentation between public and private healthcare sectors compounded underreporting, leaving surveillance platforms like Nikshay — India's digital TB tracking system — operating on incomplete data. Molecular diagnostics, including GeneXpert-based rapid resistance detection, represent genuine advances, but geographic and economic disparities in access continue to limit their population-level impact.
This review is confirmatory in nature rather than paradigm-shifting — the challenges it catalogs have been documented in TB literature for over a decade. Its value lies in synthesizing the cumulative post-COVID picture into a single analytical frame. From a global health standpoint, the findings reinforce a critical principle: digital surveillance tools and advanced diagnostics only translate into outcomes when healthcare access is equitably distributed. For health-conscious populations in high-income settings, the relevance is indirect but real — MDR-TB strains originating in high-burden countries create reservoir conditions that can affect global transmission dynamics. The 2025 elimination target appears unachievable, making the strategic recalibration described here both timely and operationally necessary.