Access to essential medicines is considered a fundamental part of universal health coverage and a key element for the delivery of services and high-quality care [
1]. A 2012 assessment of the South African health system underscored the need to give a higher priority status to medicines supply chains as they affect various dimensions of access to medicines and health care utilisation in general [
2]. Although South Africa offers free primary health care (PHC) services in the public sector, subscribes to an essential medicines programme [
3] and provides free medicines at PHC level [
4], there are persistent challenges that hinder sustainable access to medicines. The increasing burden of disease [
5], coupled with a general shortage and maldistribution of health professionals (private-public, urban–rural) [
6], for example, threaten the ability of supply chain systems to function optimally. Shortages in all areas of pharmacy practice are common. Vacancy rates for pharmacists in the public sector of up to 76 %, were reported in one province and only 29 % of pharmacists were working in the public sector as of 2010 [
7]. Various reforms and interventions have been implemented to address shortages of pharmacists, such as the introduction of incentives, the impact of which is yet to be determined on pharmaceutical human resource trends [
8] and new models of centralised dispensing of medicines for chronic conditions [
9,
10]. In this article, we report on a centralised dispensing intervention in the Western Cape Province, in South Africa.
Western Cape Province’s response to strengthen access to medicines
Each of South Africa’s nine provinces has its own legislature, premier and executive council, and specific population and economical characteristics. The Western Cape is South Africa’s most cosmopolitan province, with a population of just under six million in 2011 [
2]. The 2010 mortality profile reported that about 65 % of deaths occurred in the metropolitan district of Cape Town [
11], which has the greatest proportion of patients and the greatest pressure on health services [
9]. HIV/AIDS and non-communicable diseases (NCDs), account for a large proportion of premature mortality [
12]. The healthcare system is two-tiered, consisting of a public and a private sector. However, the vast majority of the population (more than 75 %) is dependent on the public sector for, inter alia, supply of medicines [
13].
The Western Cape Department of Health (WCDoH) established an out-sourced, centralised dispensing intervention known as the Chronic Dispensing Unit (CDU). Introduced in December of 2005, the CDU dispenses medicines for stable, public- sector patients with the aim to: reduce pharmacists’ workload (by relieving pharmacy staff from repetitive and time consuming tasks that detract from patient-focussed elements), decongest health facilities (hereafter referred as facilities) and improve the patient experience by reducing waiting times [
9,
10]. The contractor, is responsible for specific supply chain functions which are elaborated on in later sections of this article.
The CDU was initially implemented as part of the province’s first strategic vision for health care (Health Care 2010), which acknowledged the necessity to substantially improve the quality of care of the health service, while recognising that “
One of the biggest challenges facing the Department is the need to ensure that its workforce meets the challenges of service delivery within a changing environment with a sizeable burden of disease.” [
14]. Since its establishment in 2005, the CDU has remained a significant part of the province’s plans. The current provincial strategy (Health Care 2030) states that “…
it is expected that the CDU will be well-established in future and will assist to address the increasing demand for efficient dispensing of chronic medicines, which are expected to form the bulk of the burden of disease in the next two decades” [
15]. In light of this, the CDU has been presented as part of the motivation for an increase in the health budget allocation [
16], and a huge financial investment towards this service has been made. The current five-year contract between the government and the contractor, which commenced in 2012, is valued at 500 million South African rands [
17], which was approximately 62,5 million United States dollars in 2012.
Despite the leadership’s commitment and efforts, several operational challenges exist. Among these challenges, the trend of missed appointments by patients is a concern to the WCDoH and our study was commissioned to investigate this issue. Within the context of this intervention, the term “non-collected medicines” is used to refer to pre-packed Patient Medicine Parcels (PMPs) that are not picked up by patients on or close to the scheduled date and are subsequently returned to the CDU. Monthly collection statistics are a key monitoring indicator of the intervention’s performance.
In this paper, we provide a comprehensive description of the operations of the CDU and seek to gain a better understanding of the current issue of concern—i.e. missed appointments. Earlier articles described the CDU in its initial stages of implementation focusing mostly on the dispensing processes [
9,
10]. We set out to elicit the programme theory (defined as processes planned to achieve certain outcomes), which according to Van Belle et al. [
18] is useful for understanding complex interventions. More specifically, this study aims to identify the actors’ interpretations of how the CDU’s activities are linked to the outcomes. Therefore, our objectives are: (1) to illustrate the CDU’s interface with the health system and describe its coverage, dispensing capacity and beneficiary profile; (2) to quantify the magnitude of missed appointments by patients and (3) to describe the implications thereof in order to inform a subsequent in-depth empirical study on the underlying causes.