South Africa

Differentiated Service Delivery Implementation in South Africa

South Africa joined the CQUIN learning network in 2017 as a thought leader in differentiated service delivery (DSD) design. The country has cultivated a wide diversity of models—from appointment spacing to fast track to facility-based clubs to community-based antiretroviral (ART) groups, services for adolescents and key populations, and more. In 2015, South Africa’s National Department of Health (NDOH) introduced national adherence guidelines for chronic diseases, folding DSD into the guidelines with the overarching aim to improve the effectiveness of all health services.

South Africa’s less-intensive DSD models are put into action through models that allow patients to collect medication both in and out of health facilities.  These models include:

• Spaced and Fast Lane Appointments: whereby recipients of care receive a six-month prescription for medication available for pick-up every two months in their nearest health facility.  These patients do not need to wait in queues in the facility, but are fast tracked and are able to simply collect medication and leave the facility.
• Adherence Clubs: clubs comprised of approximately 30 people, meeting on a bi-monthly basis to facilitate ART pickup and adherence support. Participants are also required to attend health clinics annually for check-ups.
• External Pick-up Points: recipients can collect medication at community based, easy to access pick-up points such as private pharmacies, approved churches, post offices, and other collection points on a monthly basis. Recipients are still required to attend clinic visits at least once a year for clinical assessment and laboratory tests.

In addition to medication being distributed through the standard health system and facility mechanisms, South Africa has introduced the Central Chronic Medicine Dispensing and Distribution system.  Through this mechanism, medication is pre-packed by an external service provider and delivered to pick-up points across the country. This reduces pressure on the South African medicine distribution system as the service providers become responsible for end to end distribution and only refer clients back into health facilities if they have issues that need to be addressed by a health care worker.

South Africa’s more-intensive DSD models include the Advanced Clinical Care models, which were shared with CQUIN colleagues from Malawi and Zimbabwe during a November 2018 CQUIN-supported south-to-south visit. The standardized package of care for patients at high risk includes daily and weekly home visits, spot pill counts, enhanced adherence counseling, clinical monitoring with viral load monitoring every two months, and decentralized pharmacovigilance. In addition to this more-intensive model, NDOH recognizes the importance of enhancing its community-based models to address the needs of patients at high risk of disease progression and is continually looking to strengthen and diversify models.

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