Drones and digital adherence monitoring for community-based tuberculosis control in remote Madagascar: A cost-effectiveness analysis

PLoS One. 2020 Jul 7;15(7):e0235572. doi: 10.1371/journal.pone.0235572. eCollection 2020.


Background: Continuing tuberculosis control with current approaches is unlikely to reach the World Health Organization's objective to eliminate TB by 2035. Innovative interventions such as unmanned aerial vehicles (or drones) and digital adherence monitoring technologies have the potential to enhance patient-centric quality tuberculosis care and help challenged National Tuberculosis Programs leapfrog over the impediments of conventional Directly Observed Therapy (DOTS) implementation. A bundle of innovative interventions referred to for its delivery technology as the Drone Observed Therapy System (DrOTS) was implemented in remote Madagascar. Given the potentially increased cost these interventions represent for health systems, a cost-effectiveness analysis was indicated.

Methods: A decision analysis model was created to calculate the incremental cost-effectiveness of the DrOTS strategy compared to DOTS, the standard of care, in a study population of 200,000 inhabitants in rural Madagascar with tuberculosis disease prevalence of 250/100,000. A mixed top-down and bottom-up costing approach was used to identify costs associated with both models, and net costs were calculated accounting for resulting TB treatment costs. Net cost per disability-adjusted life years averted was calculated. Sensitivity analyses were performed for key input variables to identify main drivers of health and cost outcomes, and cost-effectiveness.

Findings: Net cost per TB patient identified within DOTS and DrOTS were, respectively, $282 and $1,172. The incremental cost per additional TB patient diagnosed in DrOTS was $2,631 and the incremental cost-effectiveness ratio of DrOTS compared to DOTS was $177 per DALY averted. Analyses suggest that integrating drones with interventions ensuring highly sensitive laboratory testing and high treatment adherence optimizes cost-effectiveness.

Conclusion: Innovative technology packages including drones, digital adherence monitoring technologies, and molecular diagnostics for TB case finding and retention within the cascade of care can be cost effective. Their integration with other interventions within health systems may further lower costs and support access to universal health coverage.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aircraft
  • Antitubercular Agents / therapeutic use
  • Cost-Benefit Analysis*
  • Directly Observed Therapy
  • Humans
  • Madagascar / epidemiology
  • Medication Adherence*
  • Prevalence
  • Program Evaluation
  • Quality-Adjusted Life Years
  • Robotics
  • Tuberculosis / drug therapy
  • Tuberculosis / epidemiology
  • Tuberculosis / prevention & control*


  • Antitubercular Agents

Grant support

This work was supported by the Stop TB Partnership’s TB REACH wave 5 award to NR and PMS (http://www.stoptb.org/global/awards/tbreach/wave5.asp). The Stop TB Partnership is funded by the Government of Canada and the Bill and Melinda Gates Foundation. AMK is supported by the Rudolf Geigy Foundation, Swiss Tropical and Public Health Institute, Basel, Switzerland. SGL is supported by the Canadian Association for Microbiology and Infectious Diseases. The funder did not provide salary support for principal investigators but did provide salary support for research staff including a co-author on this manuscript (AA). The specific roles of the authors are articulated in the ‘author contributions’ section.” No funders or sponsors played any role in study design, data collection and analysis, decision to publish or preparation of the manuscript.