Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders’ insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail. Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer.