BackgroundFront-line health providers have a unique role as brokers (patient advocates) between the health system and patients in ensuring access to medicines (ATM). ATM is a fundamental component of health systems. This paper examines in a South African context supply- and demand- ATM barriers from the provider perspective using a five dimensional framework: availability (fit between existing resources and clients’ needs); accessibility (fit between physical location of healthcare and location of clients); accommodation (fit between the organisation of services and clients’ practical circumstances); acceptability (fit between clients’ and providers’ mutual expectations and appropriateness of care) and affordability (fit between cost of care and ability to pay).MethodsThis cross-sectional, qualitative study uses semi-structured interviews with nurses, pharmacy personnel and doctors. Thirty-six providers were purposively recruited from six public sector Community Health Centres in two districts in the Eastern Cape Province representing both rural and urban settings. Content analysis combined structured coding and grounded theory approaches. Finally, the five dimensional framework was applied to illustrate the interconnected facets of the issue.ResultsFactors perceived to affect ATM were identified. Availability of medicines was hampered by logistical bottlenecks in the medicines supply chain; poor public transport networks affected accessibility. Organization of disease programmes meshed poorly with the needs of patients with comorbidities and circular migrants who move between provinces searching for economic opportunities, proximity to services such as social grants and shopping centres influenced where patients obtain medicines. Acceptability was affected by, for example, HIV related stigma leading patients to seek distant services. Travel costs exacerbated by the interplay of several ATM barriers influenced affordability. Providers play a brokerage role by adopting flexible prescribing and dispensing for ‘stable’ patients and aligning clinic and social grant appointments to minimise clients’ routine costs. Occasionally they reported assisting patients with transport money.ConclusionAll five ATM barriers are important and they interact in complex ways. Context-sensitive responses which minimise treatment interruption are needed. While broad-based changes encompassing all disease programmes to improve ATM are needed, a beginning could be to assess the appropriateness, feasibility and sustainability of existing brokerage mechanisms.

BackgroundThe Chronic Dispensing Unit (CDU) is an out-sourced, public sector centralised dispensing service that has been operational in the Western Cape Province in South Africa since 2005. The CDU dispenses medicines for stable patients with chronic conditions. The aim is to reduce pharmacists’ workload, reduce patient waiting times and decongest healthcare facilities. Our objectives are to describe the intervention’s scope, illustrate its interface with the health system and describe its processes and outcomes. Secondly, to quantify the magnitude of missed appointments by enrolled patients and to describe the implications thereof in order to inform a subsequent in-depth empirical study on the underlying causes.MethodsWe adopted a case study design in order to elicit the programme theory underlying the CDU strategy. We consulted 15 senior and middle managers from the provincial Department of Health who were working closely with the intervention and the contractor using focus group discussions and key informant interviews. In addition, relevant literature, and policy and programme documents were reviewed and analysed.ResultsWe found that the CDU scope has significantly expanded over the last 10 years owing to technological advancements. As such, in early 2015, the CDU produced nearly 300,000 parcels monthly. Medicines supply, patient enrollment processes, healthcare professionals' compliance to legislation and policies, mechanisms for medicines distribution, management of non-collected medicines (emanating from patients’ missed appointments) and the array of actors involved are all central to the CDU’s functioning. Missed appointments by patients are a problem, affecting an estimated 8 %–12 % of patients each month. However, the causes have not been investigated thoroughly. Implications of missed appointments include a cost to government for services rendered by the contractor, potential losses due to expired medicines, additional workload for the contractor and healthcare facility staff and potential negative therapeutic outcomes for patients.ConclusionsThe CDU demonstrates innovation in a context of overwhelming demand for dispensing medicines for chronic conditions. However, it is not a panacea to address access-to-medicines related challenges. A multi-level assessment that is currently underway will provide more insights on how existing challenges can be addressed.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1164-x) contains supplementary material, which is available to authorized users.

BackgroundMissed appointments serve as a key indicator for adherence to therapy and as such, identifying patient reasons for this inconsistency could assist in developing programmes to improve health outcomes. In this article, we explore the reasons for missed appointments linked to a centralised dispensing system in South Africa. This system dispenses pre-packed, patient-specific medication parcels for clinically stable patients to health facilities. However, at least 8%–12% of about 300,000 parcels are not collected each month. This article aims to establish whether missed appointments for collection of medicine parcels are indicative of loss-to-follow-up and also to characterise the patient and health system factors linked to missed appointments.MethodsWe applied an exploratory mixed-methods design in two overlapping research phases. This involved in-depth interviews to yield healthcare practitioners’ and patients’ experiences and medical record reviews. Data collection was conducted during the period 2014–2015. Qualitative data were analysed through a hybrid process of inductive and deductive thematic analysis which integrated data-driven and theory-driven codes. Data from medical records (N = 89) were analysed in MS excel using both descriptive statistics and textual descriptions.ResultsReview of medical records suggests that the majority of patients (67%) who missed original appointments later presented voluntarily to obtain medicines. This could indicate a temporal effect of some barriers. The remaining 33% revealed a range of CDU implementation issues resulting from, among others, erroneous classification of patients as defaulters. Interviews with patients revealed the following reasons for missed appointments: temporary migration, forgetting appointments, work commitments and temporary switch to private care. Most healthcare practitioners confirmed these barriers to collection but perceived that some were beyond the scope of health services. In addition, healthcare practitioners also identified a lack of patient responsibility, under-utilisation of medicines and use of plural healthcare sources (e.g. traditional healers) as contributing to missed appointments.ConclusionWe suggest developing a patient care model reflecting the  local context, attention to improving CDU’s implementation processes and strengthening information systems in order to improve patient monitoring. This model presents lessons for other low-and-middle income countries with increasing need for dispensing of medicines for chronic illnesses.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-017-0655-8) contains supplementary material, which is available to authorized users.

ObjectiveImmunisations are highly impactful, cost-effective public health interventions. However, substantial gaps in complete vaccination coverage persist. We aimed to describe caregivers’ immunisation experiences and identify determinants of vaccine dropout.DesignWe used a community-based participatory research approach employing Photovoice, SMS (short messaging service) exchanges and in-depth interviews. A team-based approach was used for thematic analysis. The Increasing Vaccination Model guided the analysis and identification of vaccination facilitators and barriers.SettingThis study was conducted in Zambézia province, Mozambique, in Namarroi and Gilé districts, where roughly 19% of children under 2 start but do not complete the recommended vaccination schedule.ParticipantsParticipants were identified through health facility vaccination records and included caregivers of children aged 25–34 months who were fully vaccinated (n=10) and partially vaccinated (n=22). We also collected data from 12 health workers responsible for delivering immunisations at the selected health facilities.ResultsFour main patterns of barriers leading to dropout emerged: (1) social norms and limited family support place the immunisation burden on mothers; (2) perceived poor quality of health services reduces caregivers’ trust in vaccination services; (3) concern about side effects causes vaccine hesitancy; and (4) caregivers hesitate to seek and advocate for vaccination due to power imbalances with health workers. COVID-19 created additional barriers related to social distancing, mask requirements, supply chain challenges and disrupted outreach services. For most caregivers, dropout becomes increasingly likely with compounding barriers. Caregivers of fully-vaccinated children noted facilitators, including accompaniment to health facilities or assistance caring for other children, which enabled them to complete vaccination.ConclusionsOvercoming immunisation barriers requires strengthening health systems, including improving logistics to avert vaccine stockouts and building health worker capacity, including empathic communication with caregivers. Consistent and reliable immunisation outreach services could address access challenges and improve immunisation uptake, particularly in distant communities.

Background. South Africa (SA) has experienced several stock-outs of life-saving medicines for the treatment of major chronic infectious and non-communicable diseases in the public sector. Objective. To identify the causes of stock-outs and to illustrate how they undermine access to medicines (ATM) in the Western Cape Province, SA. Methods. This qualitative study was conducted with a sample of over 70 key informants (frontline health workers, sub-structure and provincial health service managers). We employed the critical incident technique to identify significant occurrences in our context, the consequences of which impacted on access to medicines during a defined period. Stock-outs were identified as one such incident, and we explored when, where and why they occurred, in order to inform policy and practice. Results. Medicines procurement is a centralised function in SA. Health service managers unanimously agreed that stock-outs resulted from the following inefficiencies at the central level: (i) delays in awarding of pharmaceutical tenders; (ii) absence of contracts for certain medicines appearing on provincial code lists; and (iii) suppliers' inability to satisfy contractual agreements. The recurrence of stock-outs had implications at multiple levels: (i) health facility operations; (ii) the Chronic Dispensing Unit (CDU), which prepacks medicines for over 300 000 public sector patients; and (iii) community-based medicines distribution systems, which deliver the CDU's prepacked medicines to non-health facilities nearer to patient homes. For instance, stock-outs resulted in omission of certain medicines from CDU parcels that were delivered to health facilities. This increased workload and caused frustration for frontline health workers who were expected to dispense omitted medicines manually. According to frontline health workers, this translated into longer waiting times for patients and associated dissatisfaction. In some instances, patients were asked to return for undispensed medication at a later date, which could potentially affect adherence to treatment and therapeutic outcomes. Stock-outs therefore undermined the intended benefits of ATM strategies. Conclusion. Addressing the procurement challenges, most notably timeous tender awards and supplier performance management, is critical for successful implementation of ATM strategies.

BackgroundThe rising demand for chronic disease treatment and the barriers to accessing these medicines have led to the development of novel models for distributing medicines in South Africa’s public sector, including distribution away from health centres, known as community-based distribution (CBD). In this article, we provide a typology of CBD models and outline perceived facilitators and barriers to their implementation using an adapted health systems framework with a view to analysing how future policy decisions on CBD could impact existing models and the health system as a whole.MethodsA qualitative exploratory study comprising in-depth interviews and non-participant observations was conducted between 2012 and 2014 in one province. Study participants consisted of frontline healthcare providers (HCPs) in the public sector and a few policy, supply chain and public health experts. Observations of processes occurred at two CBD sites. We conducted deductive analysis guided by the adapted framework.ResultsModels varied in typology ranging from formal (approved by the Department of Health) to informal (demand-driven) and with or without user-fees. Processes and structures also differed, as did HCPs’ perceptions of what is appropriate. HCPs perceived that CBD models were largely acceptable to patients and accommodating of their needs. Affordability of services linked to charging of user-fees was a contested issue, requiring further exploration. CBD models operated in the absence of formal policy to guide implementation, and this, coupled with the involvement of non-health professionals, issues regarding medicines handling and storage; and limited patient counselling raised concerns about the quality of pharmaceutical services being delivered. Policy decisions on each of the health system elements will likely affect other elements and ultimately influence the structure and operational modalities of models. In anticipation of a future CBD policy, stakeholders cited the need for a context specific lens in order to harmonise with current implementation efforts.ConclusionA formal policy on CBD is required in an effort to standardise services for quality assurance purposes. Frontline HCPs should be involved in the development of such policy to ensure that existing arrangements already working well are not undermined. Further research will seek to contribute towards evidence-based development of policy and service delivery guidelines for CBD activities in South Africa.

A missed opportunity for vaccination (MOV) refers to any contact Background with health services by an individual who is eligible for vaccination, which does not result in the person receiving the vaccine doses for which he or she is eligible. A consortium of partners, including VillageReach, the Ministry of Health in Mozambique and the World Health Organization, will implement a strategy to reduce MOV in Mozambique. The strategy involves demonstrating the magnitude of missed opportunities and their causes, and exploring tailored health system interventions to reduce them, with the aim of increasing vaccination coverage and timeliness of vaccinations.: A mixed-methods approach will incorporate both quantitative and Methods qualitative tools. The assessment will target caregivers of children between the ages of 0-23 months who attend a health facility in the selected districts on the day of the assessment. Caregivers who are at least 18 years old will be eligible for inclusion. Another component of the assessment will target all health workers in the selected health facilities on the day of the assessment. A sample of 30 health facilities in different regions of the country will be assessed, with a target sample size of 600 caregiver exit interviews, 300 health worker interviews and focus group discussions with both caregivers and health workers. Data collection will commence late 2017, and the data will be electronically captured, managed and analyzed. Thematic analysis of data from the qualitative aspects of the assessment will be conducted, presenting the scope of interviews, representative verbatim quotes and key conclusions.: A concerted effort to reduce or eliminate MOV could increase Conclusions vaccine coverage by up to 30% and may contribute to wider improvements in efficiencies of service delivery beyond the immunization program. In addition, the findings could contribute to a better understanding of MOV in similar settings.

Background: Microneedle patch (MNP) technology is designed to simplify the process of vaccine administration; however, depending on its characteristics, MNP technology may provide additional benefits beyond the point-of-use, particularly for vaccine supply chains. Methods: Using the HERMES modeling software, we examined replacing four routine vaccines – Measles-containing vaccine (MCV), Tetanus toxoid (TT), Rotavirus (Rota) and Pentavalent (Penta) – with MNP versions in the routine vaccine supply chains of Benin, Bihar (India), and Mozambique. Results: Replacing MCV with an MNP (5 cm3-per-dose, 2-month thermostability, current single-dose price-per-dose) improved MCV availability by 13%, 1% and 6% in Benin, Bihar and Mozambique, respectively, and total vaccine availability by 1% in Benin and Mozambique, while increasing the total cost per dose administered by $0.07 in Benin, $0.56 in Bihar and $0.11 in Mozambique. Replacing TT with an MNP improved TT and total vaccine availability (3% and <1%) in Mozambique only, when the patch was 5 cm3 and 2-months thermostable but increased total cost per dose administered by $0.14. Replacing Rota with an MNP (at 5–15 cm3-per-dose, 1–2 month thermostable) improved Rota and total vaccine availability, but only improved Rota vaccine availability in Bihar (at 5 cm3,1–2 months thermostable), while decreasing total vaccine availability by 1%. Finally, replacing Penta with an MNP (at 5 cm3, 2-months thermostable) improved Penta vaccine availability by 1–8% and total availability by <1–9%. Conclusions: An MNP for MCV, TT, Rota, or Penta would need to have a smaller or equal volume-per-dose than existing vaccine formulations and be able to be stored outside the cold chain for a continuous period of at least two months to provide additional benefits to all three supply chains under modeled conditions.