Xiaodong Liu, Qingjun Jia, Cai Hu
Abstract Tuberculosis (TB) remains a global public health challenge, particularly in resource-limited settings, where centralized diagnostic systems may be constrained by logistical delays, infrastructure gaps, and limited workforce capacity. In recent years, decentralized diagnostic approaches have emerged as promising alternatives to improve access, timeliness, and patient-centered care. This narrative review examines the evolving landscape of decentralized TB diagnostics in primary laboratories, especially in the post-COVID-19 era, where pandemic-related investments in health infrastructure and digital systems have created new opportunities for diagnostic reform. We identify and synthesize five persistent implementation challenges — quality assurance, human resource limitations, infrastructural deficits, financial sustainability, and community engagement — as well as several key enablers, including portable molecular technologies, digital health platforms, and policy-linked diagnostic networks. This review highlights the importance of embedding decentralized models into national TB programs, supported by regulatory frameworks, sustainable financing, and cross-sector collaboration. Accelerating the institutionalization of decentralized diagnostics is essential to achieving diagnostic equity and advancing TB elimination goals in high-burden countries.