Ethiopia has achieved rapid expansion of TB microscopic centers for acid fast bacilli (AFB). However, external quality assurance (EQA) services were, until recently, limited to few regional and sub-regional laboratories. In this paper, we describe the decentralization experience and the result of EQA using random blinded rechecking. We decentralized sputum smear AFB EQA from 4 regional laboratories (RRLs) to 82 EQA centers and enrolled 956 health facilities (HFs) in EQA schemes. From 2012 to 2014 (Phase I), the false positivity rate declined from 0.6% to 0.2% and false negativity fell from as high as 7.6% to 1.6% in supported HFs. In HFs that joined in Phase II, FN rates ranged from 5.6% to 7.3%. The proportion of HFs without errors increased from 77.9% to 90.5% in Phase I HFs and from 82.9% to 86.9% in Phase II HFs. Overall sensitivity and specificity were 95.0% and 99.7%, respectively. Positive predictive and negative predictive values were 93.3% and 99.7%, respectively. Decentralizing blinded rechecking of sputum smear microscopy is feasible in low-income settings. While a comprehensive laboratory improvement strategy enhanced the quality of microscopy, laboratory professionals' capacity in slide reading and smear quality requires continued support.