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What South Africa, Ethiopia, Mexico, and South Korea can teach us about community-based pharmacy

By Paul Trigonoplos

April 6, 2022

    A colleague recently forwarded me a new study published in Nature that analyzes health care service interruptions that ten countries faced in the first year of the pandemic. The 10 countries in question represented a range of income levels—low-income such as Haiti, middle-income such as Mexico or Nepal, and high-income such as Chile.

    The paper had a few front-and-center conclusions but buried deeper in the analysis was one point that I think has the biggest lesson for health systems of all stripes, regardless of policy landscape or income level. The authors found that one service—HIV therapy, and more specifically, antiretroviral therapy or ART—was not disrupted whatsoever in Mexico, South Korea, South Africa, or Ethiopia.

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    Further, those countries all had something in common: they used a differentiated service delivery, or DSD, model to deliver ART. The DSD approach effectively made ART one of the most resilient services to the shocks brought on by Covid-19, and there is growing evidence that a DSD approach can be used for other non-communicable diseases such as diabetes or hypertension.

    I firmly believe that jurisdictions around the world should be looking to these countries to learn about and adopt their DSD approaches to improve outcomes and care for other chronic conditions.

    What is differentiated service delivery?

    DSD is a blanket term describing models of care that move away from the status quo of frequent, health facility-based visits to models that vary the location (e.g., community spaces), reduce the frequency, and expand the roles of pharmacists, nurses, lay healthcare workers, and patients themselves in service delivery.

    To date, DSD has been used almost exclusively in the public health space for HIV medication delivery, after the WHO endorsed it in 2015. Some examples of DSD use in HIV treatment are:

    • Group refills for ART medication, which can be managed by a health care professional or by a community leader.
    • Separating ART refills from clinical consultations.
    • Moving consultations to a door-to-door or community-hub model and away from hospitals or outpatient departments.

    In recent years, countries have also expanded the use of DSD models to the prevention and testing phase of HIV treatment. Other countries have also begun using DSD to target HIV prevention and treatment efforts to hard-to-reach target populations in the community.

    DSD care models represent the direction most national health systems are already heading

    There is growing evidence that HIV is only the beginning for how impactful DSD can be. In 2014, South Africa launched its Central Chronic Medicines Dispensing and Distribution program to provide patients with access to medicines from contracted, community-based pick-up points where they live and work. The model serves patients who may have HIV, asthma, hypertension, diabetes, and other chronic diseases. And one study on their program found that expanding DSD models to include other chronic diseases can both improve patient activation and decrease costs.

    Match this proof-of-concept with the demographic and policy landscape that we are seeing all over the world. We know national populations are ageing and growing sicker. We also know governments are increasingly investing in community-based sites that disrupt the status quo of 'all roads lead to the hospital.' Notable examples here are Italy or Denmark, two countries whose governments announced in 2021 a heavy investment in polyclinics located within communities aimed to manage chronic illness and relieve hospitals from non-acute care. And in Singapore, one suburb is slated to become the country's first 'health district,' where citizens can use technology to easily access community health screenings and care.

    DSD care models have an array of benefits to patients, payers, and providers: they push prevention closer to the patient, they save money by avoiding utilization in costly care settings, relinquish health systems from unnecessary visits, they promote top-of-license practice, the list goes on. Countries like Italy or Singapore can match their community infrastructure investment with DSD principles, and in doing so can go even further in not only keeping more care in the community, but also engendering a culture of clinical engagement across the patient populations they serve.

    Global insights on shifting the site of care


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