Objective To establish which of the many possible linkages between tuberculosis (TB), direct observation of treatment (DOTS), and the social reality of migrant workers in Kathmandu are the most relevant to the health outcomes and economic and social well-being of these populations, and which are amenable to possible interventions and high-yield policy changes. Methods Fourteen semi-structured in-depth interviews were conducted through an interpreter with male migrant TB patients aged 18-50 years recruited from three DOTS clinics in the Kathmandu valley in May 2005. The interviews were coded using constant comparison and analysed using a grounded theory method. Results The economic burden of TB treatment is far greater than the financial reserve of migrants. Consequently remittances sent to families are reduced and migrants remain in debt long after treatment completion, tied to the treatment location paying off high interest loans. Forced to attend clinics far away from their home, and isolated by the stigma associated with TB, migrants are vulnerable without social support networks. Migrants find that daily clinic visits are incompatible with working schedules and important cultural festivals, which forces them into defaulting. Conclusion The needs of migrant workers with TB living in Kathmandu are not being adequately met. Current service provision needs to be reviewed to build in greater flexibility and support for migrant men. © 2009 Blackwell Publishing Ltd.