Costs and cost-effectiveness of digital adherence technologies for tuberculosis in low- and middle-income countries: a systematic review

Digital adherence technologies (DATs) are increasingly used to improve tuberculosis (TB) treatment adherence and outcomes, yet evidence on their economic value in low- and middle-income countries (LMICs) remains limited. This systematic review assessed published reports of the costs and cost-effectiveness of DATs compared with standard of care (SOC) in LMICs settings. The review (PROSPERO-CRD420251148126) included full and partial economic evaluations using randomized, quasi-experimental, observational, and modelling approaches that reported costs or cost-effectiveness of DATs designed to improve TB treatment adherence or treatment outcomes compared with SOC in LMICs. Searches were conducted in PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, and Web of Science from inception through January 30, 2026. We assessed the quality of included studies using the Joanna Briggs Institute economic evaluation tool. Data extracted included study characteristics, population, intervention, comparator, analytical perspective, time horizon, costs, and cost-effectiveness. Findings were synthesized narratively by DAT type. Fourteen economic evaluations from 14 countries were included in the review. Study quality ranged from moderate to high, and the papers reported three types of DATs: electronic medication monitors (EMMs) (8 studies), video-observed therapy (VOT) (5 studies), and phone-based DATs (5 studies). EMMs increased health system costs, ranging from 3% to 38% versus SOC, but many were cost-effective and some were cost-saving. VOT for multidrug-resistant TB increased short-term health system costs by 5% to 10%, but long-term costs were heterogeneous, ranging from cost-saving to twofold increases depending on the smartphone and platform types used. VOT consistently reduced patient-incurred costs by up to 90%. Phone-based DATs, including 99DOTS and SMS, had the lowest implementation costs and reduced health system costs, but their cost-effectiveness evidence remains limited. Evidence on the costs and cost-effectiveness of DATs for TB treatment compared to SOC in LMICs is limited; however, existing studies suggest that EMMs can be cost-effective, and a few can even be cost-saving, depending on the device type and setting. The economic viability and scalability of DATs depend on digital infrastructure, local labour costs, and integration within existing digital ecosystems in national TB programs.