Onoya Dorina, Mokhele Idah, Cele Refiloe, Musakwa Nozipho, Kgowedi Sharon, Shumba Khumbo, Nattey Cornelius, Jinga Nelly, Kono Alice, Miot Jacqui
Health Economics and Epidemiology Research Office, University of the Witwatersrand Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
Health Economics and Epidemiology Research Office, University of the Witwatersrand Johannesburg Faculty of Health Sciences, Johannesburg, South Africa.
BMJ Open Qual. 2025 May 15;14(2):e003212. doi: 10.1136/bmjoq-2024-003212.
The ideal clinic realisation and maintenance (ICRM) programme in South Africa aims to elevate primary healthcare clinic (PHC) service quality in preparation for the National Health Insurance rollout. This study investigated ICRM implementation from clinic workers' and patients' experiences in the Gauteng province.
A mixed-methods cross-sectional survey was conducted across 45 Gauteng PHCs. Anonymous semistructured interviews with 335 clinic staff explored their knowledge and experiences with the ICRM programme. Facility assessments captured structural factors impacting ICRM implementation. Log-binomial regression was used to assess factors related to confidence in ICRM implementation and improvements in ICRM certification, and thematic analysis examined patient and staff experiences.
While 86.9% of clinical/management staff (95% CI 75.1 to 93.6) reported understanding ICRM, only 41.9% (95% CI 32.6 to 53.0) could cite specific guidelines. Enablers included guideline training (reported by 47.9% of staff, 95% CI 39.6 to 56.3) and support from district teams (44.6%, 95% CI 36.6 to 52.8). Barriers included facility size (32.9%, 95% CI 25.7 to 40.9) and infrastructure challenges (28.4%, 95% CI 21.6 to 36.2). Staff confidence in ICRM implementation was moderate (63.1%, 95% CI 56.1 to 69.6), higher when ICRM champions were present (relative risk ratio (RRR) 2.3 vs not present, 95% CI 1.0 to 5.2), guidelines were clear to staff (RRR 2.3, 95% CI 1.1 to 5.0) and sufficient training was perceived (RRR 2.7, 95% CI 1.4 to 5.3). From 2018 to 2021, 60.3% of facilities (95% CI 43.8 to 74.8) improved in ICRM classification. Compared with facilities with no status change, staff from clinics with downgraded stats were less likely to report clear guidelines (RRR 0.5, 95% CI 0.2 to 1.0) to identify an ICRM champion (RRR 0.3, 95% CI 0.1 to 0.7) or have a knowledgeable manager (RRR 0.01, 95% CI 0.01 to 0.3).
Challenges in ICRM implementation persist. Staff knowledge, training and district support play significant roles, while clear guidelines, sufficient resources and effective leadership are essential for sustaining and enhancing ICRM performance.
南非的理想诊所实现与维护（ICRM）计划旨在提升初级医疗保健诊所（PHC）的服务质量，为国家健康保险的推出做准备。本研究从豪登省诊所工作人员和患者的经历出发，对ICRM的实施情况进行了调查。
在豪登省的45家初级医疗保健诊所开展了一项混合方法的横断面调查。对335名诊所工作人员进行了匿名半结构化访谈，以探究他们对ICRM计划的了解和经历。设施评估记录了影响ICRM实施的结构因素。采用对数二项回归评估与ICRM实施信心及ICRM认证改进相关的因素，并通过主题分析考察患者和工作人员的经历。
虽然86.9%的临床/管理人员（95%置信区间为75.1%至93.6%）表示了解ICRM，但只有41.9%（95%置信区间为32.6%至53.0%）能够列举具体指南。促成因素包括指南培训（47.9%的工作人员报告接受过培训，95%置信区间为39.6%至56.3%）以及地区团队的支持（44.6%，95%置信区间为36.6%至52.8%）。阻碍因素包括设施规模（32.9%，95%置信区间为25.7%至40.9%）和基础设施方面的挑战（28.4%，95%置信区间为21.6%至36.2%）。工作人员对ICRM实施的信心处于中等水平（63.1%，95%置信区间为56.1%至69.6%），当有ICRM倡导者在场时信心更高（相对风险比（RRR）为2.3，无倡导者时为1.0至5.2），工作人员对指南清晰明了时信心更高（RRR为2.3，95%置信区间为1.1至5.0），且认为有足够培训时信心更高（RRR为2.7，95%置信区间为1.4至5.3）。从2018年到2021年，60.3%的设施（95%置信区间为43.8%至74.8%）在ICRM分类方面有所改进。与状态未改变的设施相比，统计数据下调的诊所工作人员报告指南清晰明了的可能性更低（RRR为0.5，95%置信区间为0.2至1.0），识别ICRM倡导者的可能性更低（RRR为0.3，95%置信区间为0.1至0.7），拥有知识渊博的管理人员的可能性更低（RRR为0.01，95%置信区间为0.01至0.3）。
ICRM实施过程中的挑战依然存在。工作人员的知识、培训和地区支持发挥着重要作用，而清晰的指南、充足的资源和有效的领导对于维持和提升ICRM绩效至关重要。
