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      Analyzing implementation dynamics using theory-driven evaluation principles: lessons learnt from a South African centralized chronic dispensing model

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          Centralized dispensing of essential medicines is one of South Africa’s strategies to address the shortage of pharmacists, reduce patients’ waiting times and reduce over-crowding at public sector healthcare facilities. This article reports findings of an evaluation of the Chronic Dispensing Unit (CDU) in one province. The objectives of this process evaluation were to: (1) compare what was planned versus the actual implementation and (2) establish the causal elements and contextual factors influencing implementation.


          This qualitative study employed key informant interviews with the intervention’s implementers (clinicians, managers and the service provider) [ N = 40], and a review of policy and program documents. Data were thematically analyzed by identifying the main influences shaping the implementation process. Theory-driven evaluation principles were applied as a theoretical framework to explain implementation dynamics.


          The overall participants’ response about the CDU was positive and the majority of informants concurred that the establishment of the CDU to dispense large volumes of medicines is a beneficial strategy to address healthcare barriers because mechanical functions are automated and distribution of medicines much quicker. However, implementation was influenced by the context and discrepancies between planned activities and actual implementation were noted. Procurement inefficiencies at central level caused medicine stock-outs and affected CDU activities. At the frontline, actors were aware of the CDU’s implementation guidelines regarding patient selection, prescription validity and management of non-collected medicines but these were adapted to accommodate practical realities and to meet performance targets attached to the intervention. Implementation success was a result of a combination of ‘hardware’ (e.g. training, policies, implementation support and appropriate infrastructure) and ‘software’ (e.g. ownership, cooperation between healthcare practitioners and trust) factors.


          This study shows that health system interventions have unpredictable paths of implementation. Discrepancies between planned and actual implementation reinforce findings in existing literature suggesting that while tools and defined operating procedures are necessary for any intervention, their successful application depends crucially on the context and environment in which implementation occurs. We anticipate that this evaluation will stimulate wider thinking about the implementation of similar models in low- and middle-income countries.

          Electronic supplementary material

          The online version of this article (10.1186/s12913-017-2640-2) contains supplementary material, which is available to authorized users.

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          Most cited references 19

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          Case study research: design and methods

           R. YIN,  R. Yin,  RK YIN (2003)
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            What drives change? Barriers to and incentives for achieving evidence-based practice.

            To bridge the gap between scientific evidence and patient care we need an in-depth understanding of the barriers and incentives to achieving change in practice. Various theories and models for change point to a multitude of factors that may affect the successful implementation of evidence. However, the evidence for their value in the field is still limited. When planning complex changes in practice, potential barriers at various levels need to be addressed. Planning needs to take into account the nature of the innovation; characteristics of the professionals and patients involved; and the social, organisational, economic and political context.
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              Access to medicines from a health system perspective

              Most health system strengthening interventions ignore interconnections between systems components. In particular, complex relationships between medicines and health financing, human resources, health information and service delivery are not given sufficient consideration. As a consequence, populations' access to medicines (ATM) is addressed mainly through fragmented, often vertical approaches usually focusing on supply, unrelated to the wider issue of access to health services and interventions. The objective of this article is to embed ATM in a health system perspective. For this purpose, we perform a structured literature review: we examine existing ATM frameworks, review determinants of ATM and define at which level of the health system they are likely to occur; we analyse to which extent existing ATM frameworks take into account access constraints at different levels of the health system. Our findings suggest that ATM barriers are complex and interconnected as they occur at multiple levels of the health system. Existing ATM frameworks only partially address the full range of ATM barriers. We propose three essential paradigm shifts that take into account complex and dynamic relationships between medicines and other components of the health system. A holistic view of demand-side constraints in tandem with consideration of multiple and dynamic relationships between medicines and other health system resources should be applied; it should be recognized that determinants of ATM are rooted in national, regional and international contexts. These are schematized in a new framework proposing a health system perspective on ATM.

                Author and article information

                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                4 December 2017
                4 December 2017
                : 17
                Issue : Suppl 2 Issue sponsor : Publication of this supplement was funded by the International Development Research Center (Grant Number 107508-001) and the John D. and Catherine T. MacArthur Foundation (Grant Number 14-107495-000-INP). The articles have undergone the journal's standard peer review process for supplements. Chimaraoke Izugbara is employed by the African Population and Health Research Center (APHRC), which co-manages the African Doctoral Dissertation Research Fellowship Program. Caroline Kabiru was employed by APHRC at the time the supplement articles were prepared. No other competing interests were declared.
                [1 ]ISNI 0000 0001 2156 8226, GRID grid.8974.2, School of Public Health, University of the Western Cape, ; Bellville, South Africa
                [2 ]ISNI 0000 0001 2153 5088, GRID grid.11505.30, Department of Public Health, Institute of Tropical Medicine, ; Antwerp, Belgium
                [3 ]ISNI 0000 0004 0635 5945, GRID grid.467135.2, Western Cape Department of Health, ; Cape Town, South Africa
                [4 ]ISNI 0000 0004 1936 7558, GRID grid.189504.1, School of Public Health, Department of Global Health, , Boston University, ; Boston, MA USA
                [5 ]ISNI 0000 0001 2156 8226, GRID grid.8974.2, School of Pharmacy, University of the Western Cape, ; Bellville, South Africa
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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