Patient adherence to prescribed tuberculosis regimens must be assured to prevent relapse, acquired resistance, and transmission. Directly observed therapy (DOT), an outpatient management strategy designed to ensure adherence, is not widely used because it is perceived to be inordinately expensive. The primary focus of this article is on using universal, as opposed to selective, DOT in the treatment of tuberculosis patients. Universal DOT is a policy where it is intended that observed therapy be used for all patients. Selective DOT is a policy where patients are observed taking medications only if certain selection criteria are satisfied. Topics addressed include cost, efficacy, nonadherence, and implementation guidelines.