School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown, Johannesburg, 2193, South Africa.
Centre for Health Policy & Department of Science and Innovation/National Research Foundation Research Chair, University of the Witwatersrand, 27 St Andrews Road, Johannesburg, 2193, South Africa.
Health Res Policy Syst. 2020 Jun 3;18(1):55. doi: 10.1186/s12961-020-00567-z.
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.
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.
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 decision-making, thus questioning the sustainability of the ICRM programme.
National health sector reforms should consider the context of policy implementation and potential impact on actors' motivation, cognition and power. All relevant policy actors should be involved in policy design and implementation. A clear communication strategy and ongoing monitoring and evaluation are prerequisites for implementation success.
全民健康覆盖是可持续发展目标的一个关键目标，而医疗质量是实现这一目标的基础。在南非，国家健康保险（NHI）制度是实现全民健康覆盖的一项重大医疗融资改革。理想诊所实现和维持（ICRM）计划旨在提高初级卫生保健水平的医疗质量，为 NHI 系统的实施做好准备。本研究借鉴了 Bressers 的情境互动理论，探讨了 ICRM 计划更广泛的、结构性的和具体的政策背景，以及这种背景对政策行为者的动机、认知和感知权力的影响。
这是一项嵌套的定性研究，在南非豪登省和姆普马兰加省的两个 NHI 试点区进行。在获得知情同意后，我们对参与 ICRM 计划的概念和实施的主要利益相关者进行了深入访谈。问题集中在 ICRM 政策背景、基本原理和理念、政府间关系、对实施中的角色和责任的看法、ICRM 计划资源、实施进展、挑战和制约因素。我们使用主题分析，根据 Bressers 的理论分析数据。
共对来自国家、省和地方政府的 36 名主要利益相关者进行了访谈。ICRM 计划实施的更广泛背景是提高初级医疗保健水平的医疗质量，为 NHI 做准备。然而，这种背景的特点是三个政府领域之间关于角色和责任的争议以及薄弱的政府间关系。尽管有一些地方领导力的例子，但两个国家医疗质量倡议之间的脱节以及资源限制影响了政策行为者对 ICRM 计划的经验和看法。他们对缺乏问责制或问责制分散表示不满，对自己没有参与决策表示不满，因此对 ICRM 计划的可持续性提出了质疑。
国家卫生部门改革应考虑政策实施的背景及其对行为者动机、认知和权力的潜在影响。所有相关的政策行为者都应该参与政策的制定和实施。明确的沟通策略以及持续的监测和评估是实施成功的前提。
