The study had two main broad but related objectives. The first objective was to determine the actual causes of under detection of pulmonary TB cases in the Northern Region of Ghana. Data was collected through administering a structured questionnaire; and collection of sputum samples from the respondents. The second objective was to determine the actual causes of low smear positive rates by assessing the capacity to effectively perform sputum smear microscopy for Acid Fast Bacilli (AFBs) in the district hospitals where the study was conducted. Collection of data here involved the use of a structured checklist for the laboratory and the staff who performed Tb microscopy. In all, 26 laboratory staff who performed Tb microscopy in the study district hospital laboratories were involved. The study lasted for a period of three months. The study revealed that, 41.2% of the study participants did not go to hospital when they fell sick. Out of this figure, 20.4% (21) attributed their inability to do so to poverty, 4.9% (5) to lack of access, 35.9% (37) to stigma, 28.2% (29) to cultural beliefs and 10.6%(11) attributed it to other reasons.