This study describes the path to national scale for South Africa’s Central Chronic Medication Distribution and Dispensation (CCMDD) program during Project Last Mile’s support. CCMDD is a differentiated service delivery model designed to improve access to medications and retention in care for patients with stable, chronic disease while decongesting public health facilities. From March 2016 through October 2019 (3 years, 7 months), there were significant increases in the number of districts participating in the program (reaching full saturation in 8 of South Africa’s 9 provinces in January 2018), the number of health facilities enrolled; the number of external pick-up points registered; and the number of patients engaged. By the end of March 2019 [per District Health Barometer 2018/2019] , there were 2,850,325 adults on ART from participating districts who were virally suppressed, of which 1,068,938 or ~ 37.5% were actively enrolled in CCMDD.
As the CCMDD program’s administrative processes and operational systems strengthened, more detailed insights into specific areas of growth were gained. The proportion of active patients who received medication for chronic diseases other than HIV (either alone or in combination with ART) increased during the last year of the reported period, with one out of four collecting medications for non-communicable diseases only. This trend highlights the potential of the program in offering integrated NCD and HIV treatment [24–26], a global priority. In particular, these data demonstrate the success of the program in engaging patients who are not living with HIV, which bodes well for the potential of the program to address the rising burden of NCDs in South Africa  and serves to help overcome any stigma associated with differentiated service delivery models being labeled as HIV-only program .
Patients’ choice of pick-up points evolved over time, and there were increasing numbers and proportions of patients opting to collect their medications at external pick-up points, particularly as more of these pick-up points became available. This is particularly encouraging because this option serves to most fully unburden public facilities, affording patients access to medications in convenient locations close to home or work, and is aligned with Project Last Mile’s strategic and technical inputs (geomapping to inform placement of external PuPs, engagement of retailers across the country, and innovation in new external PuP models in areas that lack brick and mortar solutions, eg. SmartLockers). We also observed growth in the number of patients choosing to collect their medications at outreach and adherence clubs, as well as clinic-based fast lanes, demonstrating the continued value of these options.
At the end of the observation period, nearly 70% of patients ever registered with CCMDD were considered active. This proportion signals relatively high levels of retention within the program, but also highlights the need for future research to understand the experiences of the remaining 30% of registered patients who were no longer active in the program.
Our findings should be interpreted in light of their limitations. First, the trends described herein are based on analysis of routine aggregate administrative data. The systems for tracking this data became more robust over time (as evidenced by increasingly granular data in later periods). New contracts were awarded to two Service Providers who dispense medications in April 2018 and a transition period ensued until September 2018, introducing data errors. However, we report on trends over weekly reporting intervals from 43 months of data collection, increasing the confidence in the overall observations. Second, this study evaluates expansion of the program from the national level, does not explore district- or provincial-level variation in uptake of the CCMDD program or urban/rural distinctions. Further analysis to understand this variation could be useful to those seeking to accelerate progress toward national scale in other settings. Third, sociodemographic data were not available for review to understand the demographics of patients participating in the CCMDD program (sex, age, ethnicity) which would assist to understand program reach and retention. Fourth, program metrics associated with clinic decongestion including staffing, patient volume at clinics, and health care worker satisfaction were not assessed to understand the impact of scale up of CCMDD at facility-level, and should be evaluated in the future. Fifth, the patient-experienced benefits associated with CCMDD, including satisfaction with care and clinical outcomes were not quantified.
It should also be noted that the observation period for this data is not inclusive of the Dolutegravir (DTG) rollout (launched December 2019) or changes in CCMDD eligibility criteria to engage patients on ART with viral suppression at six months instead of 12-months (revised March 2020), both of which may have potential impact on CCMDD uptake and retention . Despite these limitations, these data inform future implementation of differentiated service delivery and will be useful for other countries considering how to expand or establish chronic medication dispensing models, particularly in resource-constrained settings with high patient volume and clinical staff shortages. Notably, decentralizing routine medication collection, particularly for those living with chronic disease who may be vulnerable to infectious diseases, has become of increasing importance as health systems adapt to the global threat of the COVID-19 pandemic [30–34].