Revitalizing state tuberculosis training and demonstration centres in India: A health system strengthening and implementation research case study, 2021-2025.

BACKGROUND: State Tuberculosis (TB) Training and Demonstration Centres (STDCs) were established to serve as the technical backbone of India's TB programme in each state. However, many STDCs were underutilized, with gaps in staffing, financing, access to programme data, and functions beyond classroom-based training. The 2017-2025 National TB Elimination Plan (NTEP) mandated STDC revitalization but provided limited guidance on implementation pathways. Evidence on how such subnational technical institutions can be operationally strengthened and integrated into decentralized programme management remains limited. METHODS: We conducted a retrospective descriptive case study of STDC revitalization between April 2021 and March 2025. Programme documents, policy records, training and monitoring records, and project reports were reviewed to document changes in STDC functioning. Interventions and changes were organized using the six WHO health system building blocks, while implementation strategies and responses to operational barriers were documented using an iterative problem-solving approach. RESULTS: Changes were documented across all six WHO health system building blocks. Key changes included revised STDC guidelines endorsed in 2023; access to NIKSHAY data for all 26 STDCs; strengthened digital learning and monitoring systems, including training records and certification; strengthened infrastructure for digital training; integration of STDC activities with other health programmes; development of cadre-specific training and skills; and submission of state budget requests for STDC activities. Five STDCs were designated as Centres of Learning. Best practices were documented and available for cross-learning of other STDCs. STDC roles were expanded to include monitoring of cascade training, support to State TB Cells in programme monitoring, routine data review with District TB Officers, and supportive supervision. CONCLUSION: The experience demonstrates that policy revision, data access, workforce development and financing mechanisms can be combined with iterative implementation support to strengthen subnational technical institutions. Longer-term evaluation is needed to determine whether these system-level changes translate into improved programme performance and epidemiological outcomes.