Background
Methods
Data collection processes and tools
Stakeholder group | Description and relevance to this study | Number of participants |
---|---|---|
Implementing organization (Implementation task team for our purposes): Provincial directors/managers, facility liaison officers and managers from the current and previous contracted service provider) | Responsible for organizing resources and coordinating implementation activities. The capability of this organization affects the quality of implementation. | 8 |
Implementers (actors): mid-level managers, i.e. sub-structure pharmacists, primary healthcare managers; frontline healthcare practitioners - clinicians and health promoters | Responsible for implementation at the frontline. | 32 |
Key informant interviews
Document analysis
The feedback sessions with participants
Ethics
Data analysis
Results
“The CDU is dependent upon a lot of interventions that collectively make the system, but if the building blocks [referring to the World Health Organization’s health system building blocks] are not in place, then it doesn’t matter how good the CDU package looks. [The]CDU is not a plaster that you stick on a wound. You’ve got to fix the building blocks, your [medical] depot has got to work, your staff and your facilities have to be present and working, your referral system has to work, the contract management for your medicines supply has to be done properly. It’s a complex system, but if the little bits are done, then cumulatively, the CDU works.”
Implementation successes and challenges
“If those 300,000 prescriptions [dispensed by the CDU monthly] needed to be done [manually], I can tell you, on a daily basis, the pharmacist can do only a 100 prescriptions. So, you can do the calculations. Even 200 prescriptions are a huge workload, even if we were able to pay salaries … and now we have an influx problem [with patients].” (Sub-structure pharmacist manager).
“When I worked in the facility in 2001 there was no CDU and you know we did six hundred scripts a day on our own, and when I returned to the system in 2008 there was this amazing system and it was just fantastic because it took that repetitive work away from the pharmacist - not doing the same scripts every month, you actually had a little bit more time to spend with the patients and actually answer their questions. It also reduces the pressure on the pharmacist. You know in the facilities there’s so much pressure on you that you eventually take your frustration out on the patient. So I think it has helped the pharmacists to reduce their workload and I hope that it makes us better pharmacists at the end of the day, able to focus more on the patient more than just focusing on getting that big pile of folders down.” (Provincial pharmacist manager)
Role of macro-level processes
Contracting of CDU service provider
Role of contracting procedures on medicines supply
Implementation at the frontline
Planned vs. actual activities and results
Dimension | Planned activities and expected results | Actual activities and results |
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Patient selection | Selection of stable patients | Selection of patients who are not clinically stable because strict guideline application proved difficult within a context of: (a) multi-morbidities (b) high prevalence of patients with sub-optimal outcomes (c) changing outcomes and (d) patients’ needs perceived to be beyond clinical care. In addition, non-medical factors such as service pressures, enrolment targets by management, intention to save on the facility’s financial budget for medicines by putting more patients on the CDU’s budget. |
Prescription quality | Clinicians issue prescriptions in accordance with legislation and policies | Overall rate of prescription rejection was an estimated 4–5% (of approximately 14,000 prescriptions each day). Errors were attributed to: (a) cumbersome administrative processes attached to the intervention (b) misunderstanding of processes between healthcare practitioners and the service provider. |
Pharmacists check all new prescriptions for compliance with legislation and policies | Pharmacists did not always check prescriptions before submitting them to the CDU because they felt it was time consuming. | |
Dispensing and dispatch of patient medicine parcels (PMP) | Prescription verification, dispensing and delivery to the facility three working days before the collection date | Except when a prescription had been rejected for reasons earlier stated, PMP were delivered on time. |
Medicines distribution | Pharmacist checks all parcels and fulfils the prescription requirements using pharmacy stock in case of stock-outs. Distribution of PMP follows at the facility or in the community. | Pharmacists did not check all parcels – the process was deemed to be time consuming and consequently to reduce the benefits of the intervention. Pharmacists recommended the use of transparent instead of opaque packaging and inclusion of prescriptions in the PMP to facilitate easier checking. That said, when there were stock-outs, the facility was provided with a list of outstanding prescriptions needs and these were fulfilled unless the facility was also stocked-out. |
Health system causes for non-collected medicines | Patients are given 5 working days should they miss their scheduled appointment. Thereafter, PMP are returned to the CDU within 10 working days from the date of collection or the medication is absorbed into the facility’s pharmacy. | Challenges resulted from: (a) clinicians who were resistant to changing their ways of working to adapt to CDU requirements (b) locum doctors who were not familiar with processes (c) patients who reported for acute care prior to their CDU appointment often led to establishment of new appointment systems. Clinicians recommended marking CDU patient files differently from other patient files for easier identification. |
Management of non-collected medicines | If a patient misses 2 appointments consecutively, the prescription is stopped and the patient must consult the clinician for counselling and assessment. Reports on non-collected PMP should be submitted to the CDU. | Some pharmacy staff returned non-collected PMP while others opened PMP that were not collected. The reasons given for the latter were: (a) shortage of space to keep the parcels until the patient comes or until the parcel is returned to the CDU (b) to discourage patients from missing appointments [coercion] Pharmacy staff who opened PMP believed that the same patients would come to the facility even if late so they could re-dispense medicines and save on their facility's financial budget for medicines. Unstable patients who missed appointments were not removed from the system as per protocol for similar reasons earlier mentioned (saving on facility budget and high prevalence of unstable patients). |
Monitoring and Evaluation | Data on all activities | Mid-level managers found it difficult to comprehend routine data and in some cases doubted its accuracy. Statistics on collection of PMP were still under reported because healthcare practitioners considered reporting a time-consuming task and feared negative views. |
Health system ‘hardware’ and ‘software’ influencing implementation
Limited storage space was further exacerbated by missed appointments by patients. One informant estimated that at least 40% of patients did not collect PMP during the initial phases of CDU implementation which created a challenge for facilities to keep non-collected parcels and at the same time create space for new stock. Over the years, the WCDoH facilitated installation of additional shelving in facilities. Also, improved shelving and storage, and clear labelling of parcels by the service provider led to improved retrievability of PMP. Previously, facilities had no system in place to organize the PMP, therefore, boxes containing PMP piled up and it took a long time for pharmacy personnel to locate PMP for distribution. Consequently, they opted to re-dispense from facility stock, which frustrated both healthcare practitioners and patients as patient queues grew longer.“If you have a container of a 100 pills in your shelf it takes up a fairly small space on your shelf but when you take a 100 pills and divide that up into 20 you need space for 5 containers. The fridge items were also a huge problem because facilities had these little fridges for their own purposes. If you deliver a prescription which contains fridge items, you have to put the whole PMP into the fridge so the fridge becomes full. Facilities had to buy new fridges but didn’t have the budget.” (Former Implementation Task Team member)
Facility preparation improved over time and standard operating procedures were revised owing to the lessons learnt from implementation in urban facilities. At the time of this research, the Implementation Task Team was conducting two to three training sessions at each facility prior to enrolment and regular follow-up from facility liaison officers was provided. Also, implementation has shifted to a phased approach to allow for more investment towards supporting facilities prior to and during implementation. Healthcare practitioners identified the implementation support offered by facility liaison officers as a strength of the intervention. The quote below illustrates positive relationships between healthcare practitioners and facility liaison officers.“The CDU could deliver a perfect product, but if it’s received in chaos, that product will also be seen as chaotic... I always say: in the first six months, when the CDU was implemented (2005-6), it did so much more harm to the reputation of the CDU than it did good.” (Former member of the Implementation Task Team)
Finally, we identified the following set of essential elements for successful CDU implementation: ownership, trust, cooperation, communication, willingness to change and leadership. In Table 3, we provide some key informant voices and our own interpretations to illustrate the role of each of these elements.“Okay, what is working and needs to continue, it’s direct support from CDU like [name] and [name] they are playing a very excellent role actually, they are very important people and whoever is taking care of CDU parcels in the facilities has someone to phone, to talk to and then they've got those weekly schedules to visit facilities and check if everything is okay, providing training and support, this is very important to continue…” (Senior manager, pharmacy services)
Joint ownership: “When I went to various facilities to see what the problems were, the question that I kept asking myself was “who owns the CDU?”. In the facilities where the health workers were more collaborative … when that worked well, the CDU was implemented with less resistance. The problems were still there but they were resolved amicably. When it was only [regarded as] a pharmacy issue in the grand scheme of things … had nothing to do with the facility manager, the structure and the line function it didn’t work.” (Implementation Task Team member) |
Trust: “… I always say have the name of the person first and always be consistent with that person and build a relationship with them because I know for me I just call [name of facility liaison officer]. [Name] knows what to do and by now you know how long it takes for [name] to get back to you because you have that trust.” (Pharmacist, facility 4) |
Cooperation: “You find that in facilities, there is a disjuncture, with people working in silos, when you look at the CDU process, for example and how it’s supposed to work, it also requires team work in terms of the doctor, the nurse, the person in the pharmacy, the patient and often, you’ll find for example, you’ll end up having your chronic patient coming in for acute [care]getting another prescription when they are supposed to be coming in for another parcel but that’s because the people at work are not speaking to each other. I wonder how we can get these multi-disciplinary teams to work together for the system to work better than it is working at the moment because I think that some of the problems can be resolved in that way. Some of these non-collected parcels are not indicative of patients defaulting, it’s system issues.” (Senior manager, WCDoH) |
Communication: “Yah you want to minimize the number of people involved (referring to involvement of locum doctors in the CDU process), because from the clinician’s perspective there is a lot of frustration because of that poor communication between different actors. I don’t know ‘Did the patient pick up their medication at the end of the month?’ the only way I know is if they have another appointment. So now what we have instructed them (locum doctors) is just to cross out the date for the next CDU appointment if we change the medication, so that’s one way to communicate to the pharmacist. That communicates to the pharmacy staff, don’t issue the parcel, the prescription has changed. Now, I don’t know if all pharmacy staff are aware of that.” (Physician and Advisor to WCDoH) |
Willingness to change: Changing some traditional practices e.g. in prescription writing was influenced by perceived individual and organizational benefits. When tasks were considered to be time consuming, there was a lack of motivation to do them. |
Leadership: “I have come to the conclusion that it’s the “captain of the ship” or the manager of the pharmacy who influences success. If he’s not performing well, then that pharmacy won’t function well”. (former Implementation Task Team member) |