Cross, Andrew, Nakull Gupta, Brandon Liu, et al. 2019. “99DOTS: A Low-Cost Approach to Monitoring and Improving Medication Adherence.” Proceedings of the Tenth International Conference on Information and Communication Technologies and Development (New York, NY, USA), ICTD ’19, January 4, 1–12. https://doi.org/10.1145/3287098.3287102.

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"However, the treatment course is demanding, requiring patients to consume daily (or alternate-day) medications for at least six months. Failure to adhere to treatment or sustain treatment for the recommended duration has been strongly associated with recurrent TB, furthering TB transmission in communities. Non-adherence can also contribute to drug-resistant TB (DR-TB), which is much more difficult to treat." (Page 2)

"This caused us to redesign our envelopes from scratch, with over 25 graphic design iterations, more than a dozen focus groups and field observations of over 100 patients. The result was a major simplification of the envelopes (and supporting algorithms) that allowed patients to dispense pills in any order." (Page 5)

"One advantage of working in tuberculosis is that there are standard form factors of medication that are used by most governments around the world. Each blister contains 28 pills. However, one inconvenient aspect of this medication is that dosing depends on weight: patients consume between 2 and 5 pills per day. In order to enable each category of patient to reveal exactly one hidden number per day, we originally designed and manufactured four different versions of the envelopes (one for each weight band). However, at scale we found that some centers would run out of stock of a given envelope, inhibiting treatment of those patients. Supplying sufficient surplus stock in each weight category was costly, especially in centers with unpredictable patient counts. Finally, maintaining four different envelope designs was unsustainably complex, as each required separate estimation, maintenance and fulfillment of inventory across a pipeline of manufacturers, distributors, and centers." (Page 5)

"While correct usage of 99DOTS may give strong evidence of dispensing pills, it does not prove that pills are swallowed. However, data from other contexts suggests that pills monitored to the point of disbursal are almost always taken [32, 59]. Moreover, patients who are intent on skipping their medications have little incentive to call 99DOTS. Patients’ foremost incentive to call is to retain custody of medications they are taking: a basic human dignity that we take for granted in almost every medical situation, but yet is far from standard in the treatment of tuberculosis. Patients who do not report high adherence via 99DOTS may be transitioned to more frequent DOT or other forms of adherence monitoring. Patients are also told that calling 99DOTS keeps their caregivers informed about their treatment, which helps to ensure a full recovery." (Page 6)

"While toll-free numbers might seem like an easy way to offer free calls to patients, we discovered that additional counseling was needed to ensure successful use of toll-free numbers. The concept of toll-free was not always familiar to patients, and thus required explanation and/or demonstration at the time of enrollment. Patients with prepaid accounts often received an SMS notifying them that Rs. 0.00 had been spent on a toll-free call; some patients (especially low-literate ones) associated such messages with charges to their account." (Page 9)

"We discovered that some patients had negative balance, which prohibited making any calls, even to toll-free numbers. Postpaid users with overdue payments can also be blocked from using toll-free numbers. We eventually distilled these lessons (and others) into a two-page worksheet that proved essential for counselors to easily troubleshoot any issues that patients faced in placing phone calls." (Page 9)

"The implication for present-day India is that 99DOTS is only applicable to a subset of patients; managing all patients will require a “cafeteria” of alternate approaches [57], which may include 99DOTS, DOT and potentially other means of technology or peer support." (Page 11)

"99DOTS aims to preserve the benefits of prior approaches while reducing cost and implementation complexity. Its philosophy is to replace a fully automated solution (such as an electronic pillbox) with one that contains a manual human step (placing a phone call). In other words, by “undoing” automation, it might be possible to offer transformative affordability without sacrificing user acceptance." (Page 11)