Background Adherence to tuberculosis (TB) treatment is essential to control the disease. Directly Observed Treatment (DOT) is considered the universal ‘standard care’ and has proven to be an effective method of ensuring compliance with the treatment. Resource constraints and technology improvements are generating increased efforts in local TB control programs to develop efficient strategies to ensure patient adherence to appropriate treatments. One example is video-observed treatment (VOT) in which the observation is performed through a live video connexion. Purpose To develop a TB VOT implementation plan in a health area. Materials and methods We analysed the current situation of DOT in our health area. We reviewed other experiences with VOT. We designed the new system by estimating the relevant requirements: patient enrolment criteria, staffing, technology and costs incurred (time of observation, medicines, equipment and communication systems) from the perspective of the national health service. Results In the last two years 35 DOTs involving 206 cases of TB (17%) were performed in our health area (458,000 inhabitants). The plan contains a pilot with 10 TB patients meeting certain inclusion criteria (at least: understanding of the medicines and the disease, risk of poor adherence, no multi drug-resistant TB). If the pilot scheme goes ahead, patients will be provided with a computer with a secure internet connexion including a user-friendly videoconferencing system. Time per connexion will be set at 10 min. A medicines dispensing, monitoring and control system will be set up by the Pharmacy Service. Initial investment will be about 3,100 € including the purchase of the computer equipment for the pilot. The cost per patient of monitoring including drug treatment will be 66 €. An implementation schedule and indicators to measure results have also been developed. Conclusions VOT design requires little initial investment and would enable more effective and efficient TB control. No conflict of interest.