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Background: TB is a disease of poverty affecting disenfranchised populations. A major impediment to treatment access is the need to complete a diagnostic process that requires multiple visits to health services. An estimated one third of the cases occurring globally each year are never diagnosed. Addressing access barriers for TB diagnosis therefore is critical to increase access to treatment. Aims: The study aimed to identify economic, social and cultural barriers hindering patients with symptoms of TB from completing the diagnostic process and, by extension, accessing treatment, with a view to assessing the gains to be made through the implementation of a screening process that could complete smear microscopy on the first day of consultation. Methodology: Two large cross sectional studies were conducted among adults at first attendance for diagnosis. The first survey was conducted in Nigeria, Nepal, Ethiopia and Yemen and quantified the cost of attending diagnostic services, describing expenditure for the first and second day of attendance. Patients with expenditure ranking above the 75th centile were compared with patients with lower expenditure to identify risk factors for high expenditure. A screening score was developed by performing logistic regressions of these risk factors to identify patients with high expenditure. A second survey in Yemen and Ethiopia described adults' knowledge of services and the disease, service satisfaction and risk factors for defaulting. Further qualitative studies were then conducted in Yemen and Ethiopia comprising in depth interviews and focus group discussions with individuals who completed/did not complete the diagnostic process or who had registered/did not register for treatment. Results: The most significant expenses incurred by patients for diagnosis were for clinic fees and transport. Many factors were associated with high expenditure. The main contributors for high cost across all study settings were attending the services with company and rural residency. Costs for first and second day attendance were comparable. The score to identify patients at risk of high expenditure achieved 54% and 69% sensitivity and specificity and its performance varied across settings. Most participants (particularly women) attended the services with companions considerably increasing the cost of diagnosis. Many patients were unprepared for the duration of the diagnostic process. Women were perceived to face particular difficulties to access health services. Patients' reasons for defaulting diagnosis included the cost of the process, receiving negative smear results (especially in Yemen) or having a clear chest X-rayon the first day and receiving misleading or misinterpreting the information given by staff. In some settings patients had to pay additional unofficial fees and were often referred to private services. Patients found non-TB medication and additional tests in the private sector prohibitive. Many patients highlighted , opportunity costs for diagnosis and treatment. In Ethiopia, the lure of attending private sector services and poor staff attitude featured strongly. Conclusion: Patients in resource poor contexts face multiple barriers to attending and completing TB diagnosis. These barriers disproportionally affect women and are mediated by sociocultural norms. Although structural and health systems reform is needed to address many of these barriers, some could be resolved at local level with education, approaches that are patient-centred and respectful, free provision or clear charging policies and more flexible opening hours that minimise opportunity costs. A same day smear microscopy process could assist patients by reducing direct and opportunity costs if diagnostic services could complete the diagnostic process the same day of consultation.