Establishment of DR-TB centers of excellence under India's National TB Elimination Program: Early programmatic experiences.

BACKGROUND: Drug-resistant tuberculosis (DR-TB) remains a major challenge to global tuberculosis elimination efforts. Despite substantial expansion of diagnostic and treatment services under India's National TB Elimination Program (NTEP), variability in advanced clinical expertise and management of difficult-to-treat DR-TB cases continued to affect quality of care. To address these gaps, selected high-performing Nodal DR-TB Centers were strengthened and operationalized as DR-TB Centers of Excellence (CoEs). OBJECTIVES: To describe the framework, implementation process, and early programmatic experiences from establishment of DR-TB Centers of Excellence under NTEP, India. METHODS: A descriptive programmatic study using mixed-methods program assessment data was conducted under NTEP between 2022 and 2024. A structured institutional strengthening framework and hub-and-spoke model linking CoEs with nodal and district DR-TB centers were operationalized through a five-phase implementation process involving institutional assessment, gap filling, designation, mentoring, and implementation of advanced DR-TB services. Program implementation experiences were documented through contextual enquiries, review of institutional records and meeting minutes, and analysis of quarterly performance reports. RESULTS: Eight institutions were assessed for potential designation as CoEs, of which five were formally designated in October 2022. The CoEs were linked with 9-17 spoke institutions each and provided advanced clinical consultations, tele-mentoring, technical guidance, and capacity-building support for management of difficult-to-treat DR-TB cases. Key programmatic innovations included establishment of pulmonary rehabilitation services, palliative care models, and thoracic surgery training programs. The CoEs also supported implementation of newer DR-TB regimens, including BPaLM-based treatment approaches. Important operational learnings included the need for strong administrative commitment, dedicated human resources, robust governance systems, and improved access to program-level performance data for supportive supervision. CONCLUSION: The DR-TB CoE initiative under NTEP operationalized a structured institutional strengthening model integrating advanced clinical expertise, mentorship, innovation, and decentralized dissemination of best practices. The framework provides a scalable approach for strengthening DR-TB care and institutional capacity in high-burden settings.