Figure 1.
![Six-Domain Challenges in Decentralized TB Diagnostic ImplementationNote: The implementation of decentralized tuberculosis (TB) diagnostic testing is hindered by interconnected challenges spanning six critical domains (A–F): A. Quality Assurance: Requires regular proficiency testing, external quality assurance, and instrument/equipment calibration to ensure diagnostic accuracy [13,25,35]; B. Human Resources: Includes shortages of trained personnel, limited career development opportunities, and difficulties in retaining staff [14,24]; C. Infrastructure and Logistics: Encompasses inadequate infrastructure, sample transportation difficulties, and operational logistics challenges [1,7]; D. Financial Sustainability: Entails high initial setup costs, gaps in ongoing operational funding, and long-term sustainability concerns [19,23]; E. Community Engagement: Involves trust-building barriers, insufficient community advocacy, and concerns regarding test accuracy [16,18]; F. Socio-Cultural Barriers: Encompasses social stigma, low health literacy, and cultural misconceptions that limit service uptake [18,24,29]](https://sciendo-parsed.s3.eu-central-1.amazonaws.com/679e8276082aa65dea3df950/j_ahem-2025-0017_fig_001.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=ASIA6AP2G7AKL2Y7WIZC%2F20260306%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Date=20260306T015933Z&X-Amz-Expires=3600&X-Amz-Security-Token=IQoJb3JpZ2luX2VjEA4aDGV1LWNlbnRyYWwtMSJIMEYCIQCvkutjJqAI%2BOtw%2FVa7CPrK2sgqSovc7QTqwFBXJ5VjlwIhAJcpa0Gf%2B9CJ7fm1UmJI%2FR7PIp1pjxGx4E7NuGCLwUO5KsYFCNf%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEQAhoMOTYzMTM0Mjg5OTQwIgyy3tRNoypwe8WkTQoqmgV1yJ8eHHP4VzrhebJ9hYS2Eid%2BY0TfKLydMNNFx4eM2k9ABC7YfxGDjDY3aPYLflIGrci6Ltu24CNc1CjDn99c2Mpx5QpFUoUbZ2eiq1TaihBPTjY0K%2FP04XI9XR8AYZFXkXfb%2BQI3Q%2BFmHyAsoEjxk2OmA0IvrkQDYxXleGrecM4t2GgjPQyu7AlffpLAOhMdiWJa59nZT7rLDYDbedvSFDNQsXAm9UIyn%2ByAwVwupg2vGo0D6tETkE8sCYmbn5sAKg5MJUnVD59%2FmgGrcbwDQk4xBvwGeU94ssoMZHMMBwYzre7lCDS65GrTXdJKMev6j1OeA5u4SVSKKzfIwVnISCxnqLHiq211H3Oe4jE%2FbO615VWuSVcHLMCckjS8qIviJ2e966IJ%2BaGGp8%2BVVDIXGNkcWDu6jmO3yxtBvCv0G5vTXNE%2BOcjYPnXXluCTCylmk5sChNJ43k%2BSwZjGRa2y%2BFGBy2VjSqWwuGCCdrnJ7dv%2FyEuR0iU5Hkp7cZqur1o9xJ2Dk5RPP9mOaF0v4vByuP8eNUGsg%2F%2BKCQuZsi145n8D2srQo0j%2BGQ6VCLKV35r3sjvCuqLYowJ4he9fisObDFCKLYuAqc%2FKK5Gye6DywQAbHq6QAtEk%2BaTnkemGBKfXA%2BizLqdpW9DeVYYosVdqwDY0J0Gru97MT3iWIf7PeEXE1pVBYuSb9qh8LK35iOUM84DYhGfYDNufvNo6lc4jjrivd6TSv24hdrjzUp%2FZH4pGBt%2Bd4dCI6Fe3UyT1EtBtd0%2BRz4dE7uwPH%2Fzt3Cihg%2FxjIA9BdLVMVgziH4yB4XsvQUyIyOI%2B122NyLVul8lsNHvylytrlrnkWY%2FplwlDZ26S2nrc20OxX3G4m02GjMPY7kdjAnxp5w0w1fWnzQY6sAFnVzZpAPfXiLGX2nc%2FW17F800C2zoPEAmUhnZsVZ%2BMiFokhis75RPmIoScfPjHfas9YCqKZ0vW6SXatMdvWNbCX6w9x36rsq86tmOUSZMwDP3s%2B1NW9wvht95zVk3fQ%2FPtK%2F8QnIL2jW1dW79W2EfGnn6Idiw%2B%2FqKEpcPFlD2Ytmd3bDFbln1UcNodNNjSiLOQfKPoIELVteGNz7VeKquRJds05MHc3GhcnvGyxrjn1Q%3D%3D&X-Amz-Signature=00bc4dcfcdcd4cf3985abdea9a22b1019111915e849e337ed29e0c5339d084f6&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject)
Figure 2.
Policy and Action Matrix for Decentralized TB Diagnostic Implementation
| Future Direction | Policy Focus | Implementation Level |
|---|---|---|
| Institutionalization in NTPs | Health Policy | National |
| Regulatory & Quality Frameworks | Regulation & Standards | National |
| Sustainable Financing | Health Economics | National/International |
| Capacity Building for Workforce | Human Resources | Regional/National |
| Integration of Digital & AI Tools | Digital Health | National/Facility |
| Community-Centered Models | Public Engagement | Local/Community |
| Global Collaboration | Global Health | Regional/Global |
| Evidence quality and research | Promote high-quality RCTs, prospective studies | National/International |
| Patient-centered design | Incorporate patient feedback and satisfaction measures | Local/Community |
| Regional adaptation | Tailor strategies to local context | National/Regional |
Comparative Features of Centralized vs_ Decentralized Tuberculosis (TB) Diagnostic Models
| Dimension | Centralized Testing | Decentralized Testing |
|---|---|---|
| Test Location | National or regional central laboratories | Primary care settings or point-of-care (POC) sites |
| Turnaround Time | Days to weeks | Minutes to hours |
| Infrastructure | High-complexity set-up with biosafety and cold chain | Low-resource adaptable, portable platforms |
| Sample Logistics | Requires long-distance transport, cold chain | On-site testing, minimal logistics |
| Human Resources | Requires highly-trained laboratory specialists | Operable by general health workers with minimal training |
| Diagnostic Access | Limited in rural and remote areas | High accessibility across decentralized regions |
| Operational Cost | High fixed and variable costs | Lower marginal cost after implementation |
| Scalability | Limited by central lab capacity | Highly scalable across diverse health system levels |
| Patient Perspective | Indirect; limited engagement | Higher satisfaction, reduced travel costs, better adherence |
| Socio-cultural adaptability | Low (standardized protocols, limited cultural tailoring) | High (adaptable to local context, community involvement) |