1. Lack of access to diagnostic test
1.1. Challenges in health system: Approved TB tests are not accessible or feasible to implement
1.1.1. Marginalized populations & subpopulation
1.1.1.1. Increasing availability of TB services in geographic areas that are unconnected to health facilities using health extension worker
1.1.1.2. Engaging private sector, including traditional healers, certified non-allopaths and chemists
1.1.1.3. Active screening at camps
1.1.2. Distance or other barriers
1.1.2.1. Improving access to health facility for diagnostic tests
1.1.3. Unavailability of diagnostic facilities particularly for EP-TB in rural areas
1.1.3.1. Ensuring availability of diagnostic facilities particularly for EP-TB in rural areas
1.1.4. Insufficient referral mechanism at community based facilities
1.1.4.1. Insufficient incentives, enablers, and systems in place
1.1.4.1.1. Ensuring referral mechanism at community based facilities
2. Services are available but people may not seek care with diagnostic facility
2.1. Lack of awareness
2.1.1. Addressing knowledge gap of patients through community awareness
2.1.2. Multifaceted and innovative interventions to improve ACF
2.2. Patients may not have a care-seeking behaviour
2.2.1. Modification of care-seeking behavior by public education strategies
2.3. Patients may be asymptomatic
2.3.1. Identify assymptomatic individuals by using sensitive diagnostic tests such as chest X-ray or biomarker-based screening
2.4. Challenges in navigating between health facilities
3. Patients do not get complete diagnosis of TB, despite reaching health facilities getting evaluated and tested
3.1. Low TB testing rates
3.1.1. Supporting HCPs through public-private collaborations or provision of incentives
3.1.1.1. Supporting HCPs through public-private collaborations
3.1.1.2. Provision of incentives
3.2. Use of suboptimal diagnostic tests (Sputum microscopy)
3.2.1. Using more sensitive new TB diagnostic tests such as LED microscopy or automated nucleic acid molecular diagnostics
3.2.2. Upfront Xpert MTB/RIF assay
3.2.3. Facilitating identification of DR-TB via rapid susceptibility testing
3.3. Poor quality of diagnosis
3.3.1. Laboratory do not have capacity for quality tuberculosis diagnosis
3.3.1.1. Improving public health-care system, including use of rapid, accurate diagnostics and algorithms
3.3.2. Private health facilities were not subject to the same policies requiring screening, referral, or sample collection
3.4. Poor adherance to algorithms
3.4.1. Wide variability in implementation of Xpert MTB/RIF
3.4.1.1. Use of appropriate diagnostic algorithms
3.5. Lack of specialist services in health facilities to suspect EP-TB
3.6. Attitude and behaviour of the HCPs
3.6.1. HCPs often delay or defer bacteriological TB testing over empirical treatment
3.6.1.1. Increasing TB testing rates
3.7. Knowledge and skills of HCPs
3.7.1. Incompetency of the doctor in suspecting and diagnosing TB
3.7.1.1. Capacity and skill building of HCPs
3.7.1.2. Provision of support through public-private initiatives
3.7.2. HCPs often use inaccurate diagnostic tests, or omit testing altogether
3.7.2.1. Increasing capacity and skill building of HCP and provision of support through public-private initiatives
4. Individuals with higher risk of missed diagnosis
4.1. PLHIV, immunosuppressed for other reasons children
4.1.1. Systematic screening in high-risk populations
4.2. People previously infected with TB
4.2.1. Longitudinal follow-up of old TB patients
4.3. Contacts of TB patients
4.3.1. Screening contacts of TB patients