Policy analysis of the implementation of the Ideal Clinic Realisation and Maintenance programme in Gauteng and Mpumalanga Provinces

Muthathi, Immaculate Sabelile
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Background: The Ideal Clinic Realisation and Maintenance (ICRM) programme is a major health policy reform in South Africa, designed to address the deficiencies in the quality of primary health care (PHC) services, and to lay a strong foundation for the implementation of the National Health Insurance (NHI) system. Aim: The aim of this PhD study was to analyse the implementation of ICRM programme. The specific objectives of the study were to: 1. Explore the policy context of the ICRM programme implementation. 2. Examine the roles and responsibilities of national, provincial and local government health departments. 3. Examine the network cohesion of inter-governmental relationships. 4. Determine the involvement of PHC facility managers in conceptualisation and their participation and decision space in the implementation of the ICRM programme. Methodology: During 2017, a mixed methods study was conducted in the NHI pilot district of Gauteng (GP) and Mpumalanga (MP) provinces. Drawing on policy implementation, network and decision space theories, the PhD study consisted of three components: in-depth interviews with 37 key informants at national, provincial and local government; a survey among 123 PHC facility managers; and a social network analysis (SNA) of 22 and 26 health policy actors in Gauteng and Mpumalanga respectively. STATA® 15 and UCINET were used for quantitative data analysis, while thematic analysis was used to analyse the qualitative data. Results: The context of the ICRM programme implementation was characterised by complexity, insufficient recognition of the roles and responsibilities of different government spheres, weak inter-governmental relationships, and unclear or diffuse accountability. The SNA revealed non-cohesive relationships between the different spheres of government. In both GP and (MP) there was poor consultation in the ICRM programme implementation, illustrated by the low densities of seeking advice (GP=15.6%; MP=23.4%) and providing advice (GP=14.1%; MP=25.1%). The most cohesive relationships existed within the National Department of Health (NDoH) with a density (d) = 66.7%, suggesting that national policy actors sought advice from one another on the ICRM programme, rather than from the two provincial health departments. A density of 2.1 % in GP, and 12.5% in MP illustrated the latter. The interactions regarding the ICRM programme implementation revolved around a few individuals (centralised networks), illustrated by the centralisation values of 0.5-0.8 in Gauteng Province and of 0.5-0.7 in Mpumalanga Province. Only 48% of PHC facility managers were part of the very first meetings to discuss the ICRM programme. They reported narrow to moderate decision space on the critical areas of the availability of medicines and resuscitation equipment with mean scores of 17% and 21% respectively. Conclusion: This PhD study has generated new knowledge on the context of ICRM implementation, inter-governmental relationships, and the interaction, response to or influence of health policy actors on this reform. The findings underscore the importance of context when planning nationwide health sector reforms, and the involvement of frontline managers in the design and planning to ensure long-term sustainability
A thesis submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy, 2020