Chest x-ray (CXR) plays an important role in childhood tuberculosis (TB) diagnosis, but access to quality CXR remains a major challenge in resource-limited settings. Digital CXR (d-CXR) can solve some image quality issues and facilitate their transfer for quality control. We assess the implementation of introducing d-CXR in 12 district hospitals (DHs) in 2021-2022 across Cambodia, Cameroon, Ivory Coast, Mozambique, Sierra Leone and Uganda as part of the TB-speed decentralisation study on childhood TB diagnosis. For digitisation of CXR, digital radiography (DR) plates were setup on existing analogue radiography devices. d-CXR were transferred to an international server at Bordeaux University and downloaded by sites' clinicians for interpretation. We assessed the uptake and performance of CXR services and health care workers' (HCW) perceptions of d-CXR implementation. We used a convergent mixed method approach utilising process data, individual interviews with 113 HCWs involved in performing or interpreting d-CXRs and site support supervision reports. Of 3104 children with presumptive TB, 1642 (52.9%) had at least one d-CXR, including 1505, 136 and 1 children with one, two and three d-CXRs, respectively, resulting in a total of 1780 d-CXR. Of them, 1773 (99.6%) were of good quality and 1772/1773 (99.9%) were interpreted by sites' clinicians. One hundred and sixty-four children had no d-CXR performed despite attending the radiography department: 126, 37 and 1 with one, two and three attempts, respectively. d-CXRs were not performed in 21.6% (44/203) due to connectivity problem between the DR plate captor and the computer. HCW reported good perceptions of d-CXR and of the DR plates provided. The main challenge was the upload to and download from the server of d-CXRs due to limited internet access. d-CXR using DR plates was feasible at DH level and provided good quality images but required overcoming operational challenges.< Réduire