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Improving Medication Adherence for TB patients in Bangladesh

Updated: Jun 22, 2021

In Association With

Stop TB Partnership, icddr,b


Bangladesh is a high burden country for tuberculosis. Bangladesh has adopted the universal "Directly Observed Therapy" (DOT) strategy, a WHO recommended mode of adherence support. This strategy involves healthcare staff directly observing intake of medication by patients, either at the facility or the patient’s house. This requires the patient or the staff to travel for every dose. It reached 100% coverage by progressively expanding over all upazillas (sub-districts) by mid-1998 and all metropolitan cities throughout the country by 2007.


Time and monetary burden for patients and staff adopting DOT, as there is a need to travel everyday. It is also challenging for the program managers of conventional DOT facilities to detect and respond to patients who have missed doses. Moreover, there is minimal information available regarding treatment adherence, patient follow up and treatment success rates from the private sector. These lead to inconsistent or partial treatment, which in turn have resulted in increasing incidence of TB

The Solution

99DOTS, a Digital Adherence Technology pioneered by Everwell, was implemented in Bangladesh for monitoring and improving TB medication adherence. The antiTB blister packs were wrapped in custom envelopes, which included hidden phone numbers that are visible only when doses are dispensed. After taking daily medication, patients made a toll-free call to the popped up phone number which was hidden till then, yielding high confidence that the dose was “in-hand” and had been taken. The sequence of hidden numbers cannot be predicted by the patients, but is known only by the system for each blister pack prescribed. Hence one can be fairly confident that patients who responded correctly have indeed taken their medication.

Patients were sent reminder SMSs at the end of each day, in case they had not reported their adherence for that day

The field staff had access to the patient’s adherence behavior on the Everwell Hub using their login and password. This helped them detect any missed doses and they could follow up with the patient through a phone call or a home visit. All such follow-up actions could be updated on the Everwell Hub as support actions and patient notes.


675 persons infected with drug sensitive TB have been enrolled and supported through this technology for the six months of their treatment. TB treatment centers in six upazillas in the Dhaka district were part of the program,

98% adherence as recorded on an average across all the patients, which includes adherence reported directly by patients through 99DOTS, as well as doses reported by staff in cases where patients did not report.

110425 phone calls were made by patients cumulatively to report their adherence remotely. This is as many trips to health care facilities saved for the patients.

99DOTS during Covid-19

“Albeit the challenges due to the COVID-19 situation, the 99DOTS being a digital platform, has also enabled all of our project staff to work from home. We have ensured adequate medications to last them for a longer period, while engaging and supporting patients, even those living out of the city during the pandemic through the use of the platform.”


For Patient

Patient benefits such as reduced stigma, less travel costs and reduced work absenteeism were reported. A simple feature-phone allows them to conveniently report adherence at no cost and increase compliance to the TB treatment. Active Program management through SMS reminders, notifications help them feel cared for

For Staff

Healthcare workers can easily provide differentiated care by identifying patients requiring additional support through the adherence calendar and daily SMS. They need not physically attend to all the patients everyday which reduces their burden. Aggregate data allows providers to quickly determine treatment centers needing more support.

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