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Table 3 Essential health system ‘software’ elements

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

Joint ownership: “When I went to various facilities to see what the problems were, the question that I kept asking myself was “who owns the CDU?”. In the facilities where the health workers were more collaborative … when that worked well, the CDU was implemented with less resistance. The problems were still there but they were resolved amicably. When it was only [regarded as] a pharmacy issue in the grand scheme of things … had nothing to do with the facility manager, the structure and the line function it didn’t work.” (Implementation Task Team member)
Trust: “… I always say have the name of the person first and always be consistent with that person and build a relationship with them because I know for me I just call [name of facility liaison officer]. [Name] knows what to do and by now you know how long it takes for [name] to get back to you because you have that trust.” (Pharmacist, facility 4)
Cooperation: “You find that in facilities, there is a disjuncture, with people working in silos, when you look at the CDU process, for example and how it’s supposed to work, it also requires team work in terms of the doctor, the nurse, the person in the pharmacy, the patient and often, you’ll find for example, you’ll end up having your chronic patient coming in for acute [care]getting another prescription when they are supposed to be coming in for another parcel but that’s because the people at work are not speaking to each other. I wonder how we can get these multi-disciplinary teams to work together for the system to work better than it is working at the moment because I think that some of the problems can be resolved in that way. Some of these non-collected parcels are not indicative of patients defaulting, it’s system issues.” (Senior manager, WCDoH)
Communication: “Yah you want to minimize the number of people involved (referring to involvement of locum doctors in the CDU process), because from the clinician’s perspective there is a lot of frustration because of that poor communication between different actors. I don’t know ‘Did the patient pick up their medication at the end of the month?’ the only way I know is if they have another appointment. So now what we have instructed them (locum doctors) is just to cross out the date for the next CDU appointment if we change the medication, so that’s one way to communicate to the pharmacist. That communicates to the pharmacy staff, don’t issue the parcel, the prescription has changed. Now, I don’t know if all pharmacy staff are aware of that.” (Physician and Advisor to WCDoH)
Willingness to change: Changing some traditional practices e.g. in prescription writing was influenced by perceived individual and organizational benefits. When tasks were considered to be time consuming, there was a lack of motivation to do them.
Leadership: “I have come to the conclusion that it’s the “captain of the ship” or the manager of the pharmacy who influences success. If he’s not performing well, then that pharmacy won’t function well”. (former Implementation Task Team member)