The recent article by Wells et al, provides an excellent but troubling description of (a) the extensive distribution of tuberculosis (TB) drugs by the private sector which exceeds the distribution by the public sector is several in high burden countries, (b) the widespread use of multiple non approved regimens by the private sector, and (c) the minimal mechanisms in place to monitor and ensure patient adherence to a TB regimen. (1) These daunting problems have helped create a serious worldwide problem of multiple drug resistance tuberculosis (MDRTB) (2). Because of the size and appeal of the private sector for some patients it is not likely to go away. To help solve the problem WHO has advocated private public mix (ppm) programs but found that they require considerable public sector effort to gain private sector participation. (3) One additional potential solution, not mentioned in the paper, is the use of medication monitors to provide surveillance of patient adherence.
Medication monitors are devices, which determine when medication is removed from a container and keep a retrievable record of the patient’s adherence. Several groups have created a variety of relatively inexpensive portable medication monitors and related technology in various stages of development including functioning equipment. These are shown on the website www.medicationmonitors.ne.... The optimal device characteristics and settings where they could be used to improve TB treatment have been described. (4)(5)

One such setting is TB treatment in the private sector. Trained and subsidized pharmacies could dispense medication for private patients in medication monitors, retrieve the adherence record each time the device was refilled, and provide the data to the patient’s physician and public officials. The physician could continue the treat the patient with appropriate counseling if the adherence record was fair or good. If the adherence record was poor or bad, the public sector could take over the treatment and give directly observed therapy (DOT) when necessary.

The introduction of medication monitors into ppm programs and providing subsidies to pharmacies may be met with resistance. However, it has been shown that subsidized drugs are an important component for success in ppm programs. (6) Furthermore, the addition of medication monitors makes a stronger case for ppm programs. Some patients will be found to have poor adherence records that clearly need the intensive supervision, including DOT that public programs can provide. This evidence should help convince physicians, funders, and legislators that medication monitors are needed in ppm programs. When one considers the extent and cost of solving the MDRTB problem, this additional effort and expense to implement monitor-supervised treatment of private cases to prevent MDRTB seems eminently reasonable.


1) Wells WA, Ge CF, Patel N, Oh T. Gardiner E, et al. (2011) Size and Usage Patterns of Private TB Drug Markets in the High Burden Countries. PLoS ONE 6: e18964

2) Nathanson E, Nunn P, Uplekar M, Floyd K, Jaramillo E, et al. (2010) MDR tuberculosis–critical steps for prevention and control. N Engl J Med 363:1050–1058

3) Lönnroth K, Uplekar M, Arora VK, Juvekar S, Nguyen TN, et al. Public–private mix for DOTS implementation: what makes it work? (2004) Bull World Health Organ. 82: 580-586.

4) Moulding T. Adapting to new international tuberculosis treatment standards with medication monitors and DOT given selectively. (2007) Trop Med Int Health 12: 1302-1308.

5) Moulding T. A neglected approach to prevent acquired drug resistance when treating new tuberculosis patients. Int J Tuberc Lung Dis (in Press)

6) Lonnroth K, Uplekar M, Blanc L (2006) Hard gains through soft contracts: productive engagement of private providers in tuberculosis control. Bull World Health Organ 84: 876–883.