Interventions to Improve Medication Adherence Among MDR-TB Patients in India: A Systematic Review (2015–2025)

India carries a high burden of drug-resistant tuberculosis (DR-TB), including multidrug-resistant tuberculosis (MDR-TB), and national program reports continue to document substantial numbers of MDR-TB diagnoses and treatment initiations each year.1 Treatment for MDR/RR-TB has historically been prolonged, toxic, and socially disruptive, creating a “perfect storm” for non-adherence: pill burden, adverse drug reactions, economic loss, travel costs, stigma, depression/anxiety, and variable access to patient-centred care.2,3 Global guidance emphasizes that adherence is not merely “patient behaviour” but a dynamic product of regimen complexity, patient experience, social context, and health-system responsiveness.4

Incidence of Four countries contributed over half of all global MDR/RR-TB incident cases in 2024, with India alone accounting for 32% of global MDR/RR-TB cases. Proportions among TB cases ~3.2% of all new TB cases globally were estimated to have MDR/RR-TB in 2023/2024. Among previously treated people with TB, ~16% had MDR/RR-TB. 5 India accounted for an estimated 32% of global MDR/RR-TB incident cases in 2024, making it the single largest contributor. In India, MDR-TB constituted approximately 2.5% of new TB cases and around 13% of previously treated TB cases, corresponding to an estimated incidence of about 8 per 100,000 population. 6

Prevention of multidrug-resistant and drug-resistant tuberculosis (MDR/DR-TB) and improvement of medication adherence require a comprehensive, patient-centred approach. Early diagnosis through universal drug susceptibility testing using rapid molecular methods ensures timely initiation of appropriate regimens and prevents amplification of resistance. The use of WHO-recommended, DST-guided, all-oral treatment regimens with correct dosing and duration is essential to avoid treatment failure. Directly observed treatment and flexible DOT models help ensure regular drug intake and completion of therapy. Patient-centric care, including individualized treatment plans, community-based services, and digital adherence technologies such as video-observed therapy and mobile reminders, further enhance compliance. 7

Recognizing these challenges, the World Health Organization (WHO) and national programmes increasingly recommend person-centred models that combine effective regimens with differentiated adherence support, including community-based care, psychosocial support, and the selective use of digital technologies. 8 In India, NTEP policy documents and DR-TB guidance underscore treatment support, adherence monitoring, counselling, and socioeconomic enablers as core elements of DR-TB care.9 Alongside decentralization and newer, shorter oral regimens (which may themselves improve adherence by reducing duration and burden), the programme has also piloted and scaled a range of adherence interventions.10

Digital adherence technologies (DATs) have become particularly prominent. WHO’s handbook on digital technologies for TB adherence describes three broad approaches—SMS/phone-based tools, medication event monitoring systems (MEMS) such as digital pillboxes, and video-supported treatment (VOT)—and stresses that implementation design determines whether technology improves care or simply creates new failure points.11 Therapeutic Drug Monitoring (TDM) and personalized (precision) medicine can be included as evidence-based, patient-centred strategies that improve “compliance” mainly by reducing toxicity, improving tolerability, and preventing treatment failure. Recent reviews emphasize that MDR/RR-TB drugs show high inter-patient pharmacokinetic variability, and TDM helps detect sub-therapeutic exposure (risk of failure/resistance) as well as excess exposure (risk of adverse events), allowing dose individualization to keep concentrations within a therapeutic window and thereby reduce treatment interruptions and loss-to-follow-up.12

However, the promise of DATs is tempered by real-world constraints. Qualitative evidence from India shows that acceptability may be high for health-care providers but variable among patients due to literacy, phone access, network coverage, stigma, technology fatigue, and suboptimal counselling during roll-out.13 Among MDR-TB patients using MERM, reminders and organization features can support adherence and family engagement, yet portability, durability, and fear of disclosure can limit use.14 Importantly, large program evaluations of DAT scale-up may show limited or no improvement in treatment outcomes, suggesting that technology must be embedded in a functioning care pathway that responds to adherence signals.15

Beyond technology, India has expanded socioeconomic support. The Nikshay Poshan Yojana (NPY) provides nutritional support through direct benefit transfer (DBT), aiming to reduce catastrophic costs and support treatment completion. Yet mixed-methods analyses highlight “last-mile” challenges—delays, administrative barriers, and incomplete coverage—that can blunt impact.16

Given the diversity of interventions and mixed findings, this systematic review synthesizes evidence on adherence-improving interventions relevant to MDR-TB patients in India from 2015–2025, focusing on what works, for whom, and under what implementation conditions.

Twelve studies were included: 5 qualitative/mixed-methods, 5 observational/quasi-experimental evaluations, and 2 programmatic outcome/impact studies.

Evidence directly evaluating MDR-TB adherence interventions was limited; the most MDR-TB-specific primary study focused on MERM acceptability in public-sector MDR-TB care, while additional India evidence came from programmatic DAT studies and socioeconomic support evaluations that shape MDR-TB adherence pathways in practice. (PMC)

Indian interventions largely combine monitoring (DATs) with reduced patient burden (fewer visits, flexible DOT timing) and/or supportive enablers (counselling, DBT). MDR-TB-specific usability issues (stigma, portability, device durability) strongly influence whether monitoring translates into better adherence. (PMC)

Most evidence focuses on how adherence interventions are implemented, with clear insights into barriers and facilitators, but limited data on their exact impact on MDR-TB outcomes in India.

Table 1. Characteristics of included studies (India, 2015–2025)[RM1] 

Table 2. Intervention categories and core components

Table 3. Risk of bias / quality appraisal (narrative grading)

Table 5. Barriers and facilitators influencing adherence intervention success

MDR-TB adherence interventions succeed when they reduce burden, protect confidentiality, and are coupled to rapid, supportive clinical action (not punitive monitoring). The most persistent barriers were stigma, and weak implementation support/training. (PMC)

Table 6. Practical recommendations for MDR-TB adherence programs in India

A high-functioning MDR-TB adherence strategy in India is multi-component, with DATs as one tool inside a supportive ecosystem: counselling, patient choice, socioeconomic enablers, and responsive clinical follow-up.

This Systematic review found that adherence interventions in India relevant to MDR-TB fall into a converging model: patient-centred monitoring + supportive follow-up + reduced burden of care + socioeconomic enablers. Evidence most directly focused on MDR-TB came from the MERM pilot implementation study, where patients and providers reported that audible/visual reminders, medication organization, and remote monitoring could support adherence and reduce clinic visit burden.^2 Yet the same study demonstrated why technology alone is insufficient: stigma-related fears, device practicality (size/portability), and implementation issues (counselling quality, signal reliability, supply constraints) can prevent sustained use.^2

Findings from 99DOTS in India echo theme. Qualitative evidence shows that while providers often value dashboards and alerts, patient acceptability is variable and shaped by phone access, literacy, stigma, and technology fatigue, alongside concerns that reduced face-to-face contact can weaken supportive relationships.^8 Importantly, a large-scale pre-post evaluation of statewide 99DOTS implementation found no statistically significant improvement in treatment outcomes.^9 This aligns with global digital health experience: uptake and “fidelity” of implementation determine impact, and incomplete engagement can dilute any potential benefit at population level.

Beyond DATs, counselling and mHealth “support packages” reported improved adherence in program settings, suggesting that structured communication and education remain central—especially for MDR-TB, where adverse events and psychological distress are common triggers for interruption.^12,13 Recent India-based qualitative work on MDR-TB adherence emphasizes biomedical, psychosocial, and structural determinants and explicitly calls for patient-centred strategies and strengthened financial support mechanisms.^13 In parallel, policy and mixed-methods analyses of Nikshay Poshan Yojana (DBT) highlight the logic of socioeconomic support but show that administrative delays and incomplete receipt are persistent last-mile obstacles.^11,14 When MDR-TB patients face months of lost wages and high indirect costs, delayed support may arrive too late to prevent treatment interruption.

Service delivery design also matters. Flexible DOT timing (e.g., evening DOTS) addresses a practical barrier for working patients—rigid clinic hours—which can be amplified in MDR-TB due to frequent follow-ups and longer treatment duration.^15 DR-TB linkage models (e.g., DOST) may not measure adherence directly, but by increasing timely treatment initiation and integrating patients into program support structures, they strengthen the foundation on which adherence interventions operate.^16

Correlating with previous studies and guidelines, our synthesis supports WHO recommendations that adherence support must be individualized and embedded in a broader care model, with digital tools used selectively and ethically, not as surveillance substitutes for care.^5,7 India’s DR-TB guidance similarly stresses treatment support and monitoring within programmatic care pathways.^6 Overall, the strongest “signal” across studies is not a single magic intervention, but the fit between intervention and context: technology that reduces burden and enhances support can help, but only when stigma is addressed, counselling is strong, and health systems reliably respond to adherence data.

In India, interventions to improve medication adherence relevant to MDR-TB include digital pillboxes (MERM), phone-based DATs (99DOTS), mHealth counselling packages, differentiated DOT delivery, DR-TB linkage models, and socioeconomic support via DBT/NPY. Evidence indicates that DATs can be acceptable and helpful for many patients but are constrained by stigma, practical usability, and implementation fidelity; large-scale outcome gains are not assured. Improving MDR-TB adherence in India will likely need a combined, patient-friendly approach that includes good counselling, quick follow-up for missed doses, fewer clinic visits, and timely financial support within NTEP care pathways.

1.      Central TB Division, Ministry of Health & Family Welfare, India. India TB Report 2024. 2024. (Central Tuberculosis Division)

2.      Thomas BE, Kumar JV, Periyasamy M, et al. Acceptability of the Medication Event Reminder Monitor for promoting adherence to multidrug-resistant tuberculosis therapy in two Indian cities: qualitative study. J Med Internet Res. 2021;23(6):e23294. (PMC)

3.      Ladha N, et al. Factors affecting treatment adherence among persons with MDR-TB in western India: qualitative exploration. Cureus. 2025. (PMC)

4.      World Health Organization. WHO consolidated guidelines on drug-resistant tuberculosis treatment. 2019. (World Health Organization)

5.      World Health Organization. WHO operational handbook on tuberculosis. Module 4: treatment – drug-resistant TB treatment, 2022 update. 2022. (World Health Organization)

6.      Central TB Division, MoHFW, India. Guidelines for PMDT / DR-TB in India. 2023. (Central Tuberculosis Division)

7.      World Health Organization. Handbook for the use of digital technologies to support tuberculosis medication adherence. 2017/2018. (Iris)

8.      Thomas BE, et al. Explaining differences in acceptability of 99DOTS in India: qualitative study of patients and providers. JMIR Mhealth Uhealth. 2020;8:e16634. (PMC)

9.      Chen AZ, et al. Impact of the 99DOTS digital adherence technology on TB treatment outcomes in North India: pre-post study. BMC Infect Dis. 2023. (PubMed)

10.   Government of India / NTEP. Nikshay Poshan Yojana (DBT for TB patients) programme information. 2018 onward. (PMC)

11.   Shah H. Challenges and strategic solutions to guarantee last-mile reach for an Indian TB patient’s Nikshay Poshan Yojana: a conditional cash transfer scheme. Int J Health Policy Manag. 2023;12:7668. (PMC)

12.   Santra S, et al. Effect of a mHealth intervention on anti-tuberculosis medication adherence in Delhi: quasi-experimental study. Indian J Public Health. 2021;65:34–38. (Lippincott Journals)

13.   Dhumal G, et al. Improving treatment adherence in youths with multidrug-resistant tuberculosis: psychosocial intervention needs. Brain Behav. 2025. (Wiley Online Library)

14.   Jeyashree K, et al. Ni-kshay Poshan Yojana: receipt and utilization of DBT among persons with TB in India (mixed-methods). Glob Health Action. 2024. (Taylor & Francis Online)

15.   National Medical Journal of India. Improving treatment adherence through evening DOTS in Chennai, India. 2024. (The National Medical Journal of India)

16.   Vatsyayan V, et al. “DOST” model to link and support drug-resistant TB patients from private sector to NTEP (New Delhi). Front Public Health. 2022;10:835055. (Frontiers)

17.   Patel BH, et al. Cash transfer scheme for people with tuberculosis treated in public sector: mixed-methods evaluation (India). BMJ Open. 2019;9:e033158. (BMJ Open)

18.   Saha S, et al. Tuberculosis Monitoring Encouragement Adherence Drive (TMEAD) in Nashik, Maharashtra: adherence and cost-effectiveness. Front Public Health. 2022;10:1021427. (Frontiers)

19.   Prabhu A, et al. 99DOTS “techno-supervision” for TB treatment: mixed-methods evaluation in Delhi. Indian J Tuberc. 2020. (ScienceDirect)

20.   Kerschberger B, et al. Introduction of video-enabled DOT and adherence support in DR-TB care: implementation considerations. BMC Health Serv Res. 2024. (Springer)

21.   Jose NK, et al. Acceptability of adherence support via mobile phones for TB treatment in South India. JMIR Form Res. 2022;6(5):e37124. (JMIR Formative Research)

22.   Mirzayev F, et al. WHO recommendations on treatment of drug-resistant TB: evidence and policy implications. Eur Respir J. 2021;57(6):2003300. (ERS Publications)

23.   Jain NK. WHO consolidated guidelines on tuberculosis 2020: implications for DR-TB (review). Lung India. 2021. (Lippincott Journals)

24.   Dickson L, et al. Organisation of care for people receiving MDR/RR-TB treatment: transitions to community-based care (policy/implementation). BMJ Open. 2023;13(11):e067121. (BMJ Open)

Nath R. National Guidelines for Management of DR-TB (India). 2025. (Central Tuberculosis Division)