Implementing alternative distribution points to rural communities in the Langeberg Sub-district | South Africa



The Langeberg area is a rural area consisting of five small towns servicing a vast farming community and is situated within the greater Cape Winelands District of the Western Cape of South Africa. The biggest town is Robertson, it is also from this centralised point that all drugs and medicines for the area are packaged and distributed to the two main hospitals and seven community health clinics. These clinics need to provide primary health care services as well as acute emergency care on a daily basis to all non-insured patients.

These facilities are also burdened with the task of distributing and managing the patients visiting the clinic to collect their chronic disease medications. Currently the area has 9000 patients living with chronic disease on medication and 1200 on Anti-retroviral Drugs.
The problem identified was that chronic care patients who merely visited the clinic once a month to collect their drugs, and were subjected to long waiting times as they simply had to wait in the first come first served basis that facilities use. This also contributed to unnecessarily full clinics, another factor that was identified is that the stable patient on chronic medication was essentially well and that sitting in the facility among potentially ill patients posed a health risk.
Methods to improve adherence, shorten waiting times and relieve the pressure on the facilities were investigated, tabled and implemented. It was thus that the alternative distribution sites were born.

The Pharmacy services under the leadership of Mr Salomon (Sampie) van Staden, Senior Pharmacist for the Langeberg sub-district developed a program of central dispensing of burden of disease medicines.

This meant that patients, who visited the clinic monthly simply to collect pills, are now able to visit a community centre close to their homes and collect their drugs from there. To “qualify” for the alternative distribution point, patients need to be adherent and their health in a stable condition. The system works on an appointment system which enable the service to inform patients by means of verbal interaction and a pamphlet which points are open on specific dates. All medication is pre-packed and labeled at the central pharmacy according to the appointments made.
Upon arrival at the venue the patient’s observations, (Blood Pressure and Glucose Levels) are measured by one of the trained Community Based Carers affiliated to a NGO in the area. After which they are requested to queue for their medication. Although there is a pharmacist overseeing the process, the dispensing table is managed by the Post Basic Pharmacist Assistants and Post Basic pharmacist Learners students currently training in the area.
In this manner the trainees develop skills other than those that they would by working in a facility bound pharmacy. Once the patient has collected their medication and received their next appointment they may leave and go home. The average total time for a visit is under an hour from time of arrival to leaving with medication.
Should a patient’s observations be unsatisfactory, the patient is referred to the Nurse on duty, who refers him/her back to the clinic closest to them for further counseling, testing or a doctor’s visit.
Stable patients receiving medication for any of the following chronic diseases may collect medication from these sites: Hypertension, Diabetes, Epilepsy, Cardiovascular Illness, Mental Health, and Asthma (COPD). Other conditions that are suitable for this service are chronic skin diseases, various illnesses related to the Thyroid and general aging and Lupus.
The introduction of a burden of disease management register allows us to keep track of our clients and adherence counseling is intensified in cases of non-adherence. Unused medicine is handed to the pharmacy outreach team at the outreach sites and is then destroyed as per good pharmacy practice specifications.
One of the advantages that was quickly identified and is being used extensively is the opportunity to disseminate health education to a very specific target group. This has resulted in visits from other professionals such as the occupational therapists to discuss the effects of strokes and how to exercise affected parts, the dieticians often talk about ways to live and eat in a healthier way and of course the pharmacist always talks about adherence and compliance.
The intervention is currently unable to deliver ARV¡¦s and TB medication due to several factors that are in the process of being addressed and will hopefully be resolved by the end of 2012. These factors include:
-       The legislation and policies around the dispensing of TB and HIV medication
-       The stigma and attitudes attached to these illnesses.
-       The issues around non-adherence in TB patients and how that will be addressed
-       The complications and side-effects that arise from the ARVs and how these will be referred for immediate attention

“What a wonderful Service.” “I am so happy to come and collect my pills.” Are some of the quotes from patients collecting medication. The results are twofold.

On the qualitative side it is wonderful to see the patient’s improvement of attitude toward these visits, on the quantitative there has been an increase of 25% in Burden of Disease Management in other words of chronically ill patients not only visiting the clinic when ill, but actually collecting and using their medication. Non-adherence has declined from an initial 30% to 25% in a 12 month period.
Another factor to consider is that patients enjoy visiting the sites, these halls are used for celebratory events and no-one is visibly ill or obviously suffering from pain during their visits, as opposed to a facility where many patients enter with acute illness, even if related to a chronic illness. This translates into a feeling of wellness among patients and the occasion is normally quite cheerful, if a tad noisy.
The intervention has had the unintentional effect of throwing together quite diverse people, all suffering from the same kind of illnesses; this too has led to greater empathy and respect for one another in the community.

The programme was rolled out in the area after a 2 year planning and costing phase.

Planning is the most important part of this kind of intervention. The service needs to run smoothly from the start, otherwise one risks losing the faith of one’s support which include, superiors, patients, facility based staff, and the NGO’s that form part of the programmes.
The intervention also addressed the overall vision of the Western Cape Government Health: “Better Together.” To further access support chronic disease management is one of the key focus areas for the department and its staff.


Report Author(s): 
Mr. Salomon van Staden | Ms. Jo-Anne Otto
Western Cape Government Health | Cape Winelands District Pharmaceutical Services
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