Policy context, coherence and disjuncture in the implementation of the Ideal Clinic Realisation and Maintenance programme in the Gauteng and Mpumalanga provinces of South Africa

Abstract

Background: Universal health coverage is a key target of the Sustainable Development Goals and quality of care is fundamental to its attainment. In South Africa, the National Health Insurance (NHI) system is a major health financing reform towards universal health coverage. The Ideal Clinic Realisation and Maintenance (ICRM) programme aims to improve the quality of care at primary healthcare level in preparation for NHI system implementation. This study draws on Bressers' Contextual Interaction Theory to explore the wider, structural and specific policy context of the ICRM programme and the influence of this context on policy actors' motivation, cognition and perceived power. Methods: This was a nested qualitative study, conducted in two NHI pilot districts in the Gauteng and Mpumalanga Provinces of South Africa. Following informed consent, we conducted in-depth interviews with key informants involved in the conceptualisation and implementation of the ICRM programme. The questions focused on ICRM policy context, rationale and philosophy, intergovernmental relationships, perceptions of roles and responsibilities in implementation, ICRM programme resourcing, and implementation progress, challenges and constraints. We used thematic analysis, informed by Bressers' theory, to analyse the data. Results: A total of 36 interviews were conducted with key informants from national, provincial and local government. The wider context of the ICRM programme implementation was the drive to improve the quality of care at primary healthcare level in preparation for NHI. However, the context was characterised by contestations about the roles and responsibilities of the three government spheres and weak intergovernmental relationships. Notwithstanding examples of strong local leadership, the disjuncture between two national quality of care initiatives and resource constraints influenced policy actors' experiences and perceptions of the ICRM programme. They expressed frustrations about the lack of or diffuse accountability and their lack of involvement in decisionmaking, thus questioning the sustainability of the ICRM programme.

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“…As of 2018/2019 (the most recent data available), 55.4% of primary care facilities had achieved IDEAL certification [93]. Two recent studies attribute the slow implementation, in part, to limited governance and leadership that has contributed to poor communication, resource constraints, limited input from frontline managers and staff, and limited accountability [94,95].…”

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“…The reach of these facilities is significant, but the quality of care provided is vastly variable, and noted to be poor in many parts of the country. 6 and treatment of common conditions, provision of ongoing management of patients with chronic illness, and the provision of support to community health workers, in line with trends in many other countries. 8 Ideally, PC nurses should function within an effective PC team, 9 but challenges in alignment between the PHC strategy and human resources for health lead to a very uneven realisation of that goal across the country.…”

“…10,11 Furthermore, a disjuncture between the South African 'Ideal Clinic' and the Office of Health Standards Compliance's criteria, two separate national quality care initiatives, puts strain on the resources of the provinces and the frontline staff because of diffused accountability and their lack of involvement in decision-making. 6 Of relevance to the current context, PC nurses play a key role in the response to and management of infectious diseases, being the first point of entry into the healthcare system. 12 This has resulted in PC nurses being increasingly expected to work long hours, with suboptimal nurse-patient ratios, and to upskill on very short notice to manage new types of diseases.…”

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“…Interview schedule. The earlier sections focused on the context of the ICRM programme implementation, and the roles and responsibilities of government health departments in the ICRM programme, as this study was part of a larger doctoral research project [40]. The final section of the key informant interview schedule focused on IGR.…”