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Objectives: To investigate the pattern of tuberculosis (TB) care initiation and risk factors for TB diagnostic delay in The Gambia. Methods: In this cross-sectional study, adult patients diagnosed with pulmonary TB (pTB) in public facilities in the Greater Banjul Area of The Gambia were consecutively recruited from October 2016 to March 2017. Diagnostic delay was defined as >21 days from the onset of at least one symptom suggestive of pTB to diagnosis. Logistic regression analyses were used to investigate risk factors for diagnostic delay. Results: Overall, 216 pTB patients were included in the study; the median (Interquartile Range (IQR)) age was 30 (23–39) years and 167 (77%) were male patients. Of the 216 patients, 110 (50.9%) of them initiated care-seeking in the formal and informal private sector and 181/216 (83.8%) had TB diagnostic delay. The median (IQR) duration from the onset of symptoms to TB diagnosis was 34 (28–56) days. Age groups 18–29 years (aOR 3.2; 95% CI 1.2–8.8 [p = 0.02]) and 30–49 years (aOR 5.1; 95% CI 1.6–16.2 [p = 0.006]) and being employed (aOR 4.2; 95% CI 1.7–10.5 [p = 0.002]) were independent risk factors for TB diagnostic delay. Conclusion: There is considerable TB diagnostic delay in The Gambia, and this is likely to be worsened by the COVID-19 pandemic.