South Africa has a complex disease burden, including a high prevalence of human immunodeficiency virus (HIV), with approximately 7.4 million people living with HIV and 5.5m on antiretroviral therapy (ART).¹ As countries strive towards achieving Joint United Nations Programme on HIV and AIDS (UNAIDS) 95-95-95 targets, there is an increased focus on models of Differentiated Service Delivery (DSD), which facilitate available and accessible health services.²

In the South African context, DSD refers to delivery of healthcare services that differ from standard models of care in terms of the type of service, location, which individuals receive the service, and when the service is provided.³ For example, DSD models for medication provision include E-lockers, home deliveries, adherence clubs and vending machines, among others.

When used to provide chronic medication, including ART, DSD models have been shown to increase access to medication, decongest healthcare facilities and reduce waiting times. These improvements contribute to reduced missed appointments, improved retention and improved viral load suppression.^4,5,6 A key value of DSD models is their flexibility and client-centredness, placing clients at the centre of the service design, empowering them to self-manage their health and, ideally, providing clients with a choice as to which service model to use.⁷

In South Africa, DSD is guided by the Adherence Guidelines for HIV, Tuberculosis and non-communicable diseases (NCDs), developed by the National Department of Health in 2016 and updated in 2020. These guidelines encourage and support the implementation of DSD models to make it easier for people with chronic illnesses to access treatment and stay in care.⁷ They include Standard Operating Procedures (SOPs) for specific DSD modalities for chronic medication provision. All Department of Health facilities are encouraged to adopt context-specific models to ensure clients have access to their medication. The DSD modalities described in the SOPs are facility pick-up points (medication ‘fast lanes’), adherence clubs and external pick-up points.⁷

With a supportive policy framework in place, DSD models have been widely implemented across South Africa. The Centralised Chronic Medicines Dispensing and Distribution (CCMDD) programme was established in 2014. Through the CCMDD programme, the National Department of Health contracts with private service providers to pre-pack, distribute, dispense and collect undispensed medication at designated pick-up points, including external pick-up points such as community-based outreach or adherence club locations, independent pharmacies and private medical practices. This public–private partnership has been essential for the expansion of chronic disease programmes and support for people living with HIV and other chronic conditions. The CCMDD programme has a robust recording, data and electronic management system, known as Synchronised National Communication in Health (SyNCH), which enables electronic prescriptions, automated reporting and promotes rational prescribing and compliance with the Standard Treatment Guidelines (STGs).⁸ The CCMDD programme has a set formulary that includes medications for HIV, non-communicable diseases (e.g. diabetes and hypertension) and other health needs (e.g. oral contraceptives). This integration of HIV services with NCD care helps optimise resources use and address comorbidities in tandem.⁸

Despite its reach, CCMDD is not available to all clients. Some may be excluded due to clinical eligibility criteria, a lack of identification documents required for SyNCH registration, and geographic availability (CCMDD is not available in Western Cape province). As an alternative to CCMDD, the Department of Health (DOH) runs chronic dispensing units (CDU). The Western Cape operates a CDU model similar to that of other provinces, implemented since 2005, but delivered as an outsourced, public sector centralised dispensing service.⁹

Beyond CCMDD and CDU, a variety of DSD modalities have been introduced or are in development. In 2023, the Western Cape province published an updated provincial framework for Differentiated Models of Care (DMOC) outlining 13 potential modalities for medication collection.³ This framework builds on existing models and is designed to be flexible and non-prescriptive.³

As the CCMDD and DMOC programmes have strengthened alternative distribution and access to medicine, other role-players, such as community-based organisations, civil society groups and private sector partners, including participating retailers, play a vital role in expanding medication access. These actors provide financial, infrastructural and logistical support. Non-profit organisations have been key partners to the DOH in implementing the HIV response, and have played an important role in innovating, testing and scaling up DSD services. For example, Right to Care has been instrumental in the developing E-lockers and ATM-style medication vending machines. The Anova Health Institute, a non-profit organisation, previously funded by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID), supported the Department of Health to implement and monitor HIV and tuberculosis (TB) programmes, including DSD models, across five South African districts. The Anova nurses, pharmacists and other staff worked alongside DOH in facilities to implement DSD and collected, analysed and reported programme data to stakeholders.

While several studies have described the current CCMDD model, there is limited evidence of how the broader complex array of DSD modalities has been implemented at facility level.^9,10,11 This study aims to describe how the DSD modalities contained in the National Adherence Guidelines and Western Cape Government DMOC Framework have been operationalised by the Department of Health, with support from the Anova Health Institute.

We describe DSD types for 601 health facilities across 5 districts. Eighteen healthcare managers from five districts participated in the mapping workshop and World Café session.

In describing the availability of various DSD models across five South African districts, we found that coverage of DSD services was broad and that, from the perspective of healthcare workers, it is feasible to implement a variety of DSD options within public sector services. These models provide both clients and providers with choice regarding care delivery. Our findings align with those from three recent studies in South Africa showing that a range of DSD modalities can be effectively operated in public-sector settings,¹⁴ and that offering clients the opportunity to choose a DSD model based on their needs is feasible.^15,16

In our study, the most common DSD modalities were facility pick-up points located within public healthcare facilities (377 facilities, 63% of facilities) and external pick-up points situated at private pharmacies, general practitioners’ offices and other community settings (344 facilities, 57% of facilities). Overall, out of 972 481 clients active on ART across the five districts, 55% (n = 577 415) received services in a facility that offered more than one DSD model, potentially enabling greater choice for stable clients.

We observed substantial variability in the availability of DSD models, driven by both policy and geographic context. While South Africa’s national DSD policy outlines three broad categories of DSD model – adherence clubs, external pick-up points and facility pick-up points⁸ – the Western Cape’s policy document outlines 13 options.³ Both the policies are flexible and non-prescriptive, allowing for context to influence the selection and implementation of DSD models. The Western Cape, as the first province to implement DSD models, pioneered the adherence club model. However, because of policy restrictions on cooperation with private pharmacies, it was also the only province not implementing CCMDD.¹⁷ This has led to a different mix of models evolving in the Western Cape, including quick pick-up point trailers. While adherence clubs were largely replaced by CCMDD, external pick-up points or facility pick-up points in most parts of the country, they remain the most prevalent DSD models both in City of Cape Town and in Mopani district.

Geographic setting was another key factor driving variation. Rural districts in our study offered fewer options for external pick-up points than urban areas, largely because of the limited presence of private pharmacies or general practitioners that were capable of meeting the contractual requirements of CCMDD. To expand access in these settings, it is important to consider alternative distribution points such as farms, shops or traditional health practitioners. Additional support for private providers in rural districts – including donations of equipment such as computers and air conditioners – may also be necessary to meet contracting criteria.

Differentiated Service Delivery models are known to result in at least equivalent outcomes to standard clinic-based care, with additional benefits from the clients’ perspective such as reduced cost.¹⁸ In addition, there may be benefits for service providers. A study conducted in rural Nigeria showed a reduced workload for healthcare providers, decreased waiting times and lower transport costs for clients, as well as decongestion of facilities.¹⁹ Similarly, a multi-country study showed increased job satisfaction among facility staff.²⁰ However, participants in our study highlighted the significant administrative burden of DSD models, emphasising the need for careful planning and resource allocation to ensure their efficiency.

In our World Café discussion of benefits and limitations, no single model stood out as preferred by participants. Each DSD model presented distinct benefits and challenges for both clients and providers. Facility-based models, such as adherence clubs and facility pick-up points, were seen to decongest healthcare facilities, carry fewer operational barriers and allow more direct interaction between healthcare workers and clients. These findings are consistent with studies from the Cape Winelands, where most health workers reported that adherence clubs reduced their workload and eased congestion.²¹ However, facility-based services were often perceived as less anonymous, potentially exposing clients to stigma. This challenge, also reported in KwaZulu-Natal and Khayelitsha,^14,22 was compounded by waiting times linked to over-enrolment and rigid medication collection deadlines. Many healthcare workers recommended extending the 5-day grace period for medication pick ups in effect in the Western Cape at the time of the workshop, to improve client flexibility and reduce administrative burden.

External pick-up points were valued for reducing nurse workload, improving client waiting times, decongesting facilities and minimising stigma. Yet, they were also associated with lengthy registration processes and administrative demands. Delays in medicine parcel deliveries, reported in our study and others, created further barriers to effective service delivery.^23,24,25

E-lockers and trailers offered enhanced privacy and stigma reduction, while also supporting facility decongestion. A 2021 study from Johannesburg found E-lockers outperformed other modalities in client satisfaction and privacy.²⁵ Our participants similarly felt that E-lockers, external pick-up points and trailers helped manage stigma. However, unlike other settings where E-lockers reduced staff workload, our study found that enrolling clients in this service created an administrative burden for healthcare workers.¹⁹

Infrastructure challenges also affected DSD implementation. Trailers and E-lockers located on facility grounds were vulnerable to theft and damage. In rural areas, E-lockers were largely confined to facilities because of limited infrastructure and fewer private providers. As a cloud-based technology requiring mobile phones to access PIN codes, E-lockers were further constrained by unreliable electricity and network availability. These logistical and infrastructural limitations must be considered when planning DSD service expansion.

Our findings highlighted the tension between client-centred priorities (such as convenience and flexibility) and provider concerns around maintaining oversight of medication dispensing, ensuring appropriate clinical management and integrating adherence and psychosocial support within service delivery. There was a general concern that models allowing for clients to collect medication without entering a facility or seeing a counsellor could lead to poorer outcomes. In our study, participants also reported that clients themselves feared having less interaction with facility staff, echoing findings from a 2019 Ugandan study where clients reported concerns about detachment from the health system when using external or facility pick-up points.²⁶

Across modalities, our findings illustrate that no single DSD model offers a perfect solution. Each option presents trade-offs between convenience, clinical oversight, stigma management and administrative burden. This reinforces the need for a diverse mix of modalities and client choice, tailored to local context.

This study described the implementation of DSD models within a large-scale national programme, highlighting how health system and environmental contexts influenced the type and number of options available. Full implementation of national and provincial DSD policies has the potential to improve access to chronic medication, reduce healthcare facility congestion and expand client choice – critical steps towards strengthening the South African healthcare system. While external pick-up points are more readily accessible in urban areas, models such as E-lockers may be better suited to rural settings. Wherever possible, implementers should offer clients a mix of DSD options, tailored to their client-specific needs and circumstances.