Under colonial administrations, tuberculosis control strategies frequently reflected broader systems of social stratification, with the establishment of sanatoriums and isolation policies that prioritized the health and safety of colonial settlers, often at the expense of equitable care for indigenous populations. In South Africa, facilities like the Nelsproot Farm Sanatorium and Durban Sanatorium exemplify this model, often placing black patients in under-resourced wards ([26]). Colonial-era tuberculosis control was shaped by racialized public health ideologies that portrayed indigenous peoples as inherently vulnerable to the disease. This perception led to dismissive and controlling health interventions that excluded indigenous perspectives and contributed to long-standing distrust and systemic disparities in TB care ([28]; [44]).

The modern structure of TB programs in many LMICs mirrors these colonial patterns. Reliance on vertical programming, centralized authority, and externally imposed protocols often limits local agency. Historical and genetic evidence indicates that European colonization played a role in the introduction and spread of tuberculosis in various regions, often through trade, military activity, and migration. The Euro-American strain of Mycobacterium tuberculosis (Lineage 4) expanded into Africa, Asia, and the Americas alongside European movements ([10]; [27]; [40]). Understanding this historical context helps explain current disparities in TB burden and highlights the importance of more inclusive and equitable health strategies.

Decolonial approaches in global health critique the dominance of Western knowledge systems and advocate for the inclusion of diverse epistemologies rooted in local and Indigenous contexts. Recent studies emphasize the need for epistemic justice by challenging the historical marginalization of non-Western ways of knowing and promoting more pluralistic, relational frameworks for understanding health and knowledge production ([3]; [11]; [12]; [21]).

In global health, this involves questioning who sets the agenda, whose knowledge counts, and how systems of care are structured. For TB, this could mean integrating traditional healing into diagnostics and care, involving communities in policy design, and re-centering health sovereignty.

A decolonial TB response embraces pluralism, equity, and participatory governance. It requires recognizing the limitations of one-size-fits-all biomedical models and building partnerships with communities to co-create solutions that reflect their lived realities ([12]; [33]; [52]; [17]).

Global TB governance is dominated by institutions based in the Global North, such as the WHO, Global Fund, and donor governments ([50]). These actors often set priorities and funding conditions without full alignment with community contexts. This creates power asymmetries that marginalize national programs and local knowledge ([1]; [49]). These asymmetries have led to recurrent failures within TB programs—such as community resistance, low adherence, or unsustainable interventions—particularly when vertical, donor-driven approaches are implemented without adequate local input. In countries like Kenya, Mozambique, and Nigeria, standardized protocols have often clashed with local beliefs or lacked adaptability to rural health systems, undermining both effectiveness and long-term trust in TB services ([20]; [25]; [39]; [38]; [37]; [9]; [36]; [35]). Empowering local stakeholders through participatory mechanisms, transparent funding models, and localized metrics of success is essential to balance these asymmetries and improve TB outcomes.

Across many cultures, TB is not only a biomedical disease but a condition imbued with social and spiritual meaning. In parts of Mozambique and South Africa, TB is interpreted as a curse or result of ancestral displeasure. Traditional treatments include herbal medicine, cleansing rituals, and sacrifices ([15]; [29]; [24]; [14]).

In East Africa, TB may be seen as the result of social transgressions or inherited from the ancestors ([19]; [32]; [2]). Herbalists use local plants for respiratory symptoms, and spiritual healers perform rituals. Similar beliefs exist among India’s tribal communities, where TB is linked to sexual experience or punishment and treated by village healers ([41]; [6]). These interpretations may either delay or strengthen engagement with biomedical care depending on how health systems respond. Understanding and integrating these worldviews is crucial for culturally responsive TB care.

Community participation can improve TB outcomes by fostering trust and ensuring relevance. In Meghalaya, India, health teams used boats and mobile X-rays to reach remote villages, working with traditional healers and community leaders to identify cases ([48]; [47]; [16]). In Delhi, the “TB-Free Slums” initiative mobilized communities to screen and treat residents ([45]; [18]).

When TB control includes traditional authorities and community-based workers, interventions are more accepted and adhered to. For instance in Uganda, Tanzania and other African countries, traditional healers and community members were trained to refer TB cases and provide DOTS, leading to reduced defaults ([13]; [5]; [42]; [22]; [4]). This improved understanding and reduced stigma.

These examples show that community ownership and co-production are key to sustainable TB control. Respectful integration, not assimilation, of indigenous systems can create effective, community-rooted TB strategies. To balance potential conflicts between biomedical protocols and indigenous practices, structured collaborations—such as dual-referral systems and co-designed care models—can enable respectful integration while maintaining scientific integrity and treatment outcomes. Health sovereignty means giving communities the power to define their own health priorities. In this context, health sovereignty refers both to national-level policy autonomy and to the grassroots capacity of communities to define, lead, and govern their own health responses—two interlinked scales necessary for genuine decolonization.

A decolonial TB strategy demands structural transformation grounded in health sovereignty, where communities do not merely participate but take the lead in shaping interventions that affect their lives. Central to this approach is epistemic pluralism—the recognition that indigenous and biomedical knowledge systems can and should coexist within models of care. Furthermore, it calls for ethical collaboration that prioritizes reciprocity over extraction, ensuring that partnerships are rooted in mutual respect, transparency, and shared benefit. This means moving away from models where external actors (including foreign donors, non-governmental organizations, research institutions, and even central government authorities operating without local input) collect data, impose solutions, or extract knowledge without giving back; and instead fostering long-term, equitable relationships in which communities are recognized as co-creators of knowledge and co-owners of outcomes. Such collaborations must be attentive to power imbalances and designed to build capacity, redistribute resources, and affirm the dignity and agency of local actors. This vision disrupts the prevailing technocratic status quo, instead placing justice, cultural respect, and community agency at the core of effective and equitable TB control.

To translate a decolonial TB strategy into practice, several concrete actions must be undertaken by national TB programs, donors, researchers, and implementing partners. First, community leadership must be ensured in program design and governance by establishing formal advisory boards with decision-making authority, allocating budgets for community-led planning and monitoring, and training TB survivors and local leaders to co-lead projects. Indigenous knowledge should be meaningfully integrated into care pathways through respectful dialogue with traditional healers, community-based documentation of local health practices, and the creation of culturally grounded health education materials using local languages and metaphors. Partnerships must be redesigned around equity and reciprocity by mandating local co-leads in externally funded projects, shared authorship in publications, and transparent benefit-sharing agreements.

Decision-making and funding mechanisms should be decentralized, shifting resources directly to community organizations and local governments, using flexible grant procedures and locally defined success indicators. Investment in transformative research is also key—this includes funding participatory action research, training local actors in data collection and analysis, and adopting monitoring systems that capture power dynamics and qualitative outcomes. This could involve the use of participatory tools such as community-led audits, critical incident narratives, and reflective storytelling, which complement conventional indicators by highlighting the lived experience of power relations within TB care.

Finally, ethical accountability must be institutionalized through the development of decolonial ethics frameworks, cultural humility training for all partners, and community-led oversight mechanisms. These steps will help shift the TB response from one of top-down technocratic control to a model rooted in justice, dignity, and community agency. To address potential concerns about financial accountability, such decentralization must be paired with capacity strengthening, participatory budgeting processes, and community-led oversight structures, ensuring transparency without undermining local agency.