Could smart lockers help people stay on their meds?

Smart lockers such as Peleboxes have been rolled out across the country — but not in the Eastern Cape, which leaves people living in rural areas losing out

Asanda Kekana* places a parcel of medicine in her patterned tote bag on an open seat — a rare luxury in the crowded waiting area at Ngcobo Community Health Centre (CHC), a clinic in the rural town of Ngcobo in the Chris Hani district in the Eastern Cape, 80km away from Mthatha.

More than 70% of the population in Ngcobo live below the poverty line, putting a strain on public healthcare. In one month alone, at least 3,000 people visit the CHC.

“I’ve been here since nine o’clock this morning. I can’t afford the taxi fare from my village to Ngcobo, so I must wake up early to walk to the clinic,” the 45-year-old mother of three says, then checks the time on her cellphone. It’s 3pm.

“Whether the queues are long or short, I have to [come to get medication because I have to] take these ARVs [antiretrovirals] to treat my HIV infection for the rest of my life. There’s no point in complaining,” she shrugs. 

Kekana slips her bag over her shoulder, preparing for the long journey home.

More than 700km away, at about lunchtime on an autumn Monday morning, Neo Hutiri, 33, is helping a patient standing outside the Germiston Municipal Clinic in Ekurhuleni, east of Johannesburg. 

Hutiri, an engineer, is showing a woman how to punch in numbers on a touchscreen surrounded by 144 small turquoise boxes set in a scaffold made out of metal bars painted in bright orange enamel.  

Suddenly, a box pops open. Inside it is a brown cardboard package about the size of a brick with a barcode sticker stuck on one side. The woman laughs, surprised and happy at the same time. She takes out the parcel — a three-month supply of blood pressure pills — from the cubbyhole, waves goodbye and hurries off to work. All this took less than three minutes.

“It’s the convenience factor that really matters here — people are in and out,” Hutiri beams. “This is quality healthcare. This is access.”

Staying on meds

The compartment the woman collected her package from is one in a set of smart lockers, called Pelebox, which is made by Hutiri’s software development company Technovera. The lockers allow patients registered on the health department’s distribution system for chronic medicine, called Dablapmeds, to collect their pills without having to see a health worker each time. 

Patients simply type in their cellphone number and a one-time password sent via SMS on the system’s built-in touchscreen to unlock a cubbyhole in which their packet of prescription medication has been placed earlier. 

With this automated system, patients avoid having to wait in long queues to get their repeat medicine, like what Kekana had to endure at her clinic in Ncgobo. 

The rows of boxes have been popping up at public clinics across the country as part of the government’s chronic medication distribution programme, which was introduced in 2014 as a way to make collecting medicine for long-term conditions such as diabetes, high blood pressure or asthma easier and faster.

Instead of having to go to the clinic every month, whether to get a new prescription or a packet of pills, patients can get medicine for two or three months at a time from a fast-lane counter at the clinic or pick it up from an alternative collection point like a private pharmacy or a community centre close to where they live or work.  

Travelling long distances to a clinic and waiting in a slow queue discourages people from collecting their medication, research shows — with bad consequences for a patient’s health. 

For example, if someone with HIV doesn't stick to taking their ARVs, the virus can start replicating in their body again, which weakens their immune system, makes them prone to other infections and allows the virus to spread through unprotected sex. 

In contrast, if someone consistently takes their anti-HIV medication, the amount of virus in their body becomes so little that they can’t infect someone else through unprotected sex. This is called being virally suppressed, which is the third goal in a cascading series of targets set by the Joint UN Programme on HIV and Aids (UNAids) — commonly known as the 95-95-95 targets — to end Aids as a public health threat by 2030.   

In 2023 close to 1-million of the almost 5.9-million people on antiretroviral treatment in South Africa stopped taking their medicine. That same year, almost 150,000 people were newly infected with HIV in the country.

“Just because people are poor, it doesn’t mean that their time is less valuable,” says Hutiri. “We need solutions that focus on people’s humanity.”

Closer to home

Although the Dablapmeds system is a way to make medicine collection easier for patients and so get more people to stay on treatment, a fifth of the 25,000 medicine parcels in the Chris Hani district in the Eastern Cape went uncollected in March this year. 

In 2023 almost half of 1,387 people in the province said they’d like to collect their parcels closer to home in a survey by the community-based monitoring organisation Ritshidze. 

But according to the provincial health department, there are only 12 external pick-up points in the entire Chris Hani district, serving only 8,254 patients — a sixth of the active patients registered on Dablapmeds here.

Manighandan Sivaramakrishnan, project operations manager for the humanitarian aid organisation Doctors without Borders, explains: “The Eastern Cape has vast rural areas, bad roads and a lack of public transport. Unfortunately, external collection points like private pharmacy chains are more likely to be in urban areas, which may be challenging for some people to reach.”

Smart lockers sound like a fresh solution to an old problem. Peleboxes and Collect & Go e-boxes, a similar product supplied by Right ePharmacy, have been rolled out to 200 sites across the country — but not in the Eastern Cape, which leaves people like Kekana living in rural areas losing out.

One problem, different solutions

The province’s health department says it doesn’t have enough money to install and maintain smart lockers. Yet a lot of money goes to waste in the Eastern Cape. 

The annual report for the financial year 2022/23 shows that the provincial health department incurred roughly R243m in unauthorised, irregular and wasteful and fruitless expenses. 

Poor money management in the Eastern Cape has undermined health service delivery for years. A 2013 report by Section27 says that it may be difficult for the province to ask for a fair share of the health budget if it “continues to contribute to the inefficient, ineffective and unaccountable use of public resources for health”.  

Keeping people on their medicine is particularly necessary in the Eastern Cape. For example, only 79% of people with HIV in the province are virally suppressed, which is more than 10% lower than the national number of 91%.

Smart boxes could be one more solution to the problem. But there are also others — and public health experts say that combining these mechanisms to fit the needs of a specific community may prove to be the best solution.

For example, for people who don’t have transport or are too sick to travel, home delivery could be an option. This works in Komani — an hour’s drive from Ngcobo — where entrepreneur Siphelo Lose uses a rickety bike to deliver medicine parcels to people who work or live in remote areas at R7 a pop.

Another option is adherence clubs, which the Eastern Cape health department says it’s been encouraging people in rural areas to join — especially with sign-ups being very low at the moment, the Ritshidze report shows. At these clubs, groups of up to 30 people meet every two or three months at a clinic or another place close to where they live, with a community health worker handing out their medication and helping them with other health checks like routine blood tests and weigh-ins.

The approach has proven successful in keeping people on their ARVs since it was first introduced in 2007. For example, in a study from 2007 to 2011 in Khayelitsha, 502 of 2,829 HIV-positive people chose to join an adherence club, while the rest (2,327) preferred to rather go to a clinic to get their pills. Almost all (97%) of those in the support club kept coming back to fetch their pills and do their health checks over the roughly three-and-a-half years the study ran, compared with the 85% return rate of the 2,327 people who visited their usual clinic.

Club members were also more likely to stay virally suppressed. 

Says Hutiri: “South Africa is full of great ideas and if you just give them a chance, it can make a world of difference.”

If only Ngcobo could experience one more option too. 

* Not her real name

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.