title: Novel models to improve access to medicines for chronic diseases in South Africa: an analysis of stakeholder perspectives on community-based distribution models.
abstract: BACKGROUND
  The 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.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  Models 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 largelyacceptableto patients andaccommodatingof their needs.Affordabilityof 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 specificlens in order to harmonise with current implementation efforts.
  
  
  CONCLUSIONS
  A 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.
authors.affiliation: School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535 South Africa.
authors.forename: Bvudzai Priscilla
authors.identifier: 0000-0002-4164-6233
authors.initials: BP
authors.lastname: Magadzire
authors.affiliation: School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535 South Africa ; Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Bruno
authors.initials: B
authors.lastname: Marchal
authors.affiliation: School of Pharmacy, University of the Western Cape, Bellville, South Africa.
authors.forename: Kim
authors.initials: K
authors.lastname: Ward
keywords: Access to medicines; Community-based distribution; Pharmaceutical policy; South Africa