The Vhembe district has a hundred and thirty public health facilities, which are rendering central chronic medicine dispensing and distribution. The study was conducted in three of these primary health care facilities, which are located in Makhado Local Municipality, Vhembe District, Limpopo Province, South Africa. The first primary health care facility had eight (08) professional nurses who facilitated CCMDD activities to three hundred and twenty (320) patients since 2014. The second primary health care facility also had eight (08) professional nurses who facilitated CCMDD activities to two hundred and seventy (270) patients, and lastly, the third primary health care facility also had eight (08) professional nurses who facilitated CCMDD activities to one hundred and seventy (170) patients. All three of the selected primary health care facilities received their CCMDD medicines from Dischem pharmacy at Louis Trichardt Table 1.

The study population consisted of 24 professional nurses working at three (03) purposively selected primary health care facilities in Vhembe District Limpopo province. According to Grove, Gray, and Burns, the researchers select specific participants, events, or situations that they believe will provide them with the rich data needed to gain insight and discover new meaning in their study [14]. Therefore, non-probability purposive sampling was used to select the professional nurses who facilitate the CCMDD in the three selected primary health care facilities. The sample size was guided by data saturation, which was reached at participant number 15.

Data were collected by the principal researcher from September to November (2017) through semi-structured one-on-one interviews. The recruitment of the participants was done through the assistance of the operational managers in the identified primary health care facilities. The purpose of the study, the category of participants to be interviewed, and how the interviews were to be conducted, was outlined. Thereafter the operational managers introduced the researcher to the professional nurses who were facilitating the CCMDD and explained the aim of the study, as well as the voluntary nature of participation and the freedom to withdraw at any time. Individual appointments were established at a time convenient to them. A well-ventilated consulting room, free from noise, was identified as suitable to conduct the interview sessions. The semi-structured in-depth interviews with an interview guide were conducted to facilitate free-flowing communication. One central opening question was asked: “Can you kindly describe your experience regarding the implementation of the central chronic medicine dispensing and distribution program”. After the first response, clarity seeking questions were asked, which assisted the researcher in eliciting more information about the lived experiences of professional nurses, concerning the implementation of CCMDD [15]. The participants’ permission was sought to record the interviews while assuring them of anonymity. To build rapport with the participants, each interview session lasted for approximately 30 to 45 minutes. A voice recorder was used to capture all the interview sessions and field notes were written. The interview sessions were conducted until data saturation was reached with participant number 15.

Tesch's inductive, a descriptive open coding technique, as described by Creswell was used [16]. The researcher got an idea of the entire study by reading all the verbatim transcripts carefully and writing down all thoughts came to mind. The researcher analysed the information by coding the concepts based on the frequency of issues noted during the verbatim transcriptions. All topics were indexed as they emerged at some point in the scaling down. The same topics were grouped, and those that did not have any association were clustered one by one. These codes were written in the margins of the paper, indicating the data they represented. The researcher used advanced themes and sub-themes from the coded data and decreased the entire listing with the aid of grouping themes and sub-themes based on their similarity. The final issues and sub-subject matters were written in a table showing the relationship between the themes and their sub-themes.

Trustworthiness was ensured by adhering to four criteria of Guba's model that is credibility, dependability, confirmability, and transferability. Credibility was ensured by recording all the interview sessions conducted and capturing the field notes as proof that data was collected from the participants. Transferability was ensured by a thorough description of the research methodology. Dependability was ensured by keeping safe all the voice recordings and field notes. To ensure confirmability, the researchers submitted the verbatim transcripts to the independent coder, and a meeting was set to discuss the themes and sub-themes which were reached independently [17].

The permission to conduct the study was obtained from the University of Limpopo ethics committee (TREC/ 340/2017: PG). Permission to conduct the study was also obtained from the Department of Health, Limpopo Province, and the operational managers in the three selected clinics. The aim and objectives of the study were outlined and the participants were also told that participation was voluntary and they can withdraw from the study at any time without fear of victimisation. Thereafter a written informed consent form was provided for participants to sign as a means of an agreement between the researcher and participants. The anonymity of participants was protected by making it impossible to link the information to a specific individual through using numbers instead of names. Furthermore, the identity of the three selected primary health care facilities was also protected; they were identified by clinic 1, 2, and 3. To maintain confidentiality, data was kept under lock and key and the soft copy was password locked.

The professional nurses shared their experiences and challenges regarding the implementation of this program, which emerged from the following sub-themes:

In South Africa, the National Department of Health implemented the CCMDD program in February 2014 in ten National Health Insurance districts in eight provinces. In SA, the CCMDD program is described as 'a vehicle towards universal access to antiretroviral and other chronic medications [11]. The purpose of this study was to determine the experiences of professional nurses regarding the implementation of central chronic medicine dispensing and distribution programs at three primary health care facilities in Vhembe District, Limpopo Province, South Africa.

The study findings revealed that though the CCMDD program was introduced to assist with reducing overcrowding at primary health care facilities and to improve access to chronic medication, its implementation still has some challenges as outlined by the professional nurses who are facilitating the program. The current research findings revealed that a change of contact details by patients is one of the challenges experienced with the implementation of the program. Consequently, the patients who change their contact details are unable to receive the collection messages in time from the supplier. It also becomes difficult for the professional nurses to follow-up on those patients who change their contact numbers. Smith and Nico outlined that other than the primary health care facilities, the patients can also access treatment from private pharmacies, which offer long trading hours, including weekends. They also indicated that with the CCMDD program, the patients could also access chronic treatment from their place of employment [18]. However, the current study was conducted in a rural setting of the Vhembe district, where there are no other pick up points. It is only those working closer to the town who can access private pharmacies. The participants indicated that the only access points available are at public primary health care facilities.

Medications are being delivered late after the patients have received the messages for collection. There is also a lack of tracking of the patients’ parcels when the medication is lost. Lack of trained staff and understaffing contribute to this problem, which is aggravated by the fact that the professional nurses who are dispensing CCMDD medication are not trained in the program. Magadzire, Marchal and Ward’s study revealed that due to the lack of enough staff, many patients end up defaulting from the CCMDD program and miss appointments consecutively [8].

Poor infrastructure in the primary health care facilities is one of the challenges identified in hindering the effective implementation of the CCMDD program. There is limited space for storage of the medication and there are no shelves on which to pack the received medicine. The retrieving of medication thus becomes difficult and time-consuming as they have to rely on boxes for storage. Hunter, Asmal, Ravhengani, et al., study also outlines the challenges of inadequate and inappropriate facility infrastructure in SA primary health care facilities. They recommended that the public health care system develop a universal plan for the construction of all new proposed facilities, as well as for existing facilities needing major refurbishment. Furthermore, maintenance hubs must be developed in each district to ensure that a practical maintenance plan is carried out promptly [19].

The findings of this study revealed that the delivery of incorrect medication is one of the challenges faced by the patients and the staff in the clinics as some of the patients end up receiving the wrong medication. In support of this study, Zeeman’s study also identified parcel delivery abnormalities such as wrong deliveries, late deliveries, or non-deliveries as some of the challenges [12].

During the launch of the program in Limpopo Province, the Member of the Executive Council (MEC) of health mentioned that the CCMDD program was aimed at relieving the burden of the congested primary health system in both the department of health and the community of Limpopo. She further outlined that patients will be able to access their medication at places that are convenient to them such as Clicks, some private pharmacies, and private doctors’ rooms. Additionally, the prescription will be valid for six months and there will be no need for patients to visit the health care facilities regularly [20]. However, in the current study, the professional nurses who are facilitating the program in the selected primary health facilities were concerned that the program was supposed to benefit both the facilities and the patients. They have outlined that if the program was implemented efficiently they were expecting the following benefits: reduction of workload for staff members, reduction of waiting time for the patients, and reduction of overcrowding in the clinics. The results of this study concur with the results of a study done by Steel on the implementation of central chronic medicine dispensing and distribution, one of the positive initiatives on the implementation of the program was to reduce workload for overburdened staff in the clinics [13]. Furthermore, Van Staden also outlined that the program is aimed at promoting universal access to all including the reduction of traveling cost, and more importantly, there is increased privacy because medications are being sealed [21].