Launched in 2013, the ideal clinic programme has been one of the Department of Health's cornerstone interventions aimed at improving the quality of care provided at public healthcare facilities in South Africa. The programme (its full name is the Ideal Clinic Realisation and Management programme - ICRM) sets out to ensure that clinics have good infrastructure, adequate staff, adequate medicine and supplies, and good administrative processes, among others.
Now, four new studies together suggest that, while some progress has been made in recent years, the programme has had only a limited impact on the actual and perceived quality of care patients receive in Gauteng. In some cases, staff see ideal clinic certification as merely a box-ticking exercise. Three of the four studies were part of a larger rapid review study of the implementation of the ICRM programme in 45 clinics in Gauteng from 2015.
The studies were presented last week at the 17th annual conference of the Public Health Association of South Africa (PHASA) held in Durban. The theme of the conference was 'Building Back Better: Public Health Resilience and Recovery'.
Impact on quality of care
One study asked clinic staff about their views on the ICRM programme and its impact on quality of care.
When assessed for ICRM compliance, a clinic can be classified as either: not achieved, silver, gold, or platinum. As quality improves, the idea is that clinics should progress from lower to higher classifications.
"We assessed the impact of the programme and identified factors that promote or hinder the implementation of the ICRM progression and maintenance of the ICRM certification," said Idah Mokhele, one of the study authors. The researchers interviewed 335 healthcare workers from 45 clinics in Gauteng from February to August 2021.
The study identified several gaps in ICRM compliance. Only 20% of the ICRM clinics were using date and timeslot appointments, and some were experiencing stockouts of medicines. 80% of the clinic staff interviewed had a general understanding of the ICRM programme, but there was no real difference in knowledge levels about the programme across the different ICRM certifications.
Participants were also asked about their confidence levels in being able to implement the ICRM programme. Confidence was highest among silver and platinum-certified clinics and lowest among non-achieved clinics.
Those with low confidence were asked for reasons why they had low confidence in implementing the programme. Reasons cited included staffing capacity - not having enough staff or training and support to implement the programme as well as poor clinic conditions like inadequate infrastructure.
One participant was quoted as saying, "The ICRM is just on paper, not perceived as instructions for operation. It's seen by staff as a nuisance done for inspection purposes only."
Mohkele said, "More needs to be done in terms of not just investing in the programme itself but investing in our healthcare workers... that are supposed to serve people to be able to actually have the impact that is supposed to have."
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Issues with going platinum
A smaller study, located within the bigger rapid review study on the ICRM in Gauteng looked at how many clinics in Gauteng had progressed to platinum status since the programme's implementation in 2015 and explored the perceptions of healthcare workers on platinum certification.
According to Nelly Jinga, who presented the findings only 3 clinics of the 44 clinics assessed for ICRM status in 2015 achieved platinum status. By 2020, 27 facilities had achieved platinum status. The average time it took for clinics, starting from their initial certification to transition to platinum status was two years.
138 staff members from the 27 platinum-certified clinics were interviewed. Of these, just over one in three (35.8%) said the ICRM programme was not a success, citing poor clinic conditions in general, shortage of staff, shortage of equipment, and poor infrastructure. Those who saw the programme as a success, according to Jinga, attributed it to implementation planning and preparedness and having clearly defined roles, as well as motivation to address structural and resource challenges at the clinics.
The finding that poor clinic conditions persist at some clinics despite those clinics having achieved platinum status, raised the question of whether ideal clinic status actually leads to improved operations or whether it is simply about ticking boxes. "I think it's important to let the healthcare workers know that this is not about ticking boxes. It's about the day-to-day quality that you provide to patients. So, it's like a culture, not just that you get the highest certification," Jinga said.
Impact on waiting times
One of the things that the ICRM was meant to address was long patient waiting times at clinics. Refiloe Cele, from the University of Witwatersrand, presented a sub-set study, part of the larger rapid review, that sought to assess how much time patients were spending in clinics. The study suggests that ICRM certification does indeed reduce patient waiting times, although there are some interesting nuances.
441 patients at 45 clinics (around 10 patients per clinic) in Gauteng participated in a so-called time-in motion study. They were observed from the time they entered the clinic until the time they left, with time stamps being recorded by research staff at each service station the patient visited.
The patients' waiting times were calculated as the time difference between service stations. The total time spent at the clinic was also calculated and was separated into being over or under three hours, as the ICRM stipulates that patients should spend no more than three hours at a clinic and that no more than ten minutes should be spent waiting for their patient files to be collected.
The results showed that the majority of patients were spending three hours or less at clinics. While the aggregate waiting time, according to Cele, did not vary significantly by ICRM status, clinics classified as non-achieving had the longest waiting times.
The aggregate median waiting time for services in platinum status clinics was 63 minutes, for gold 71 minutes, for silver 63 minutes, and for not-achieved 112 minutes.
The average total time spent in platinum clinics was 90 minutes, in silver 68 minutes, in gold 102 minutes, and in non-achieved it was 115 minutes. The average time spent waiting for a file was 13 minutes for platinum, 14 minutes for gold, 10 minutes for silver and 36 minutes for non-achieved clinics.
Two factors were associated with the total time spent at the clinic. The first is arrival time at the clinic. The second was whether or not the clinic had a time-slot appointment system in place - not surprisingly, having a time-slot appointment system rather than a day-slot system resulted in people spending less time at the clinic.
To assess how the clinic waiting times compared to the private sector clinic standard (which according to Cele is one hour or less), waiting times were also divided into waiting times of more or less than one hour. This was done because the aim of the ICRM programme, according to Cele, is to get public sector clinics ready for the implementation of National Health Insurance. Here the results were significantly different as the majority of patients spent more than an hour waiting at clinics.
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The researchers concluded that having ICRM accreditation does seem to reduce patient waiting times and total time spent in the facility and that clinics could benefit from having a time-slot appointment system instead of a day appointment system. "Our main policy message here is that government or the national Department of Health needs to actually strengthen and monitor the implementation of time slots appointment systems, not day appointment systems," Cele said.
Contradictory patient perceptions?
Mokhele also presented a study (which also formed part of the bigger rapid review) that explored whether the perceived quality of care reported by patients matches their experiences in clinics. The researchers interviewed 1 788 patients from February to August 2021.
70.2% of patients indicated a high perceived quality of care. As expected, patients at clinics with ICRM status were more likely to say that they were receiving quality care.
However, despite the high percentage of patients saying they had high perceived quality of care, in qualitative open-ended interviews, many patients had complaints about their experiences at the clinic. 31.7% of patients who reported high service quality had complaints. While 69.6% of patients who reported receiving low to moderate quality care had complaints.
Complaints included long waiting times at clinics and inadequate facility infrastructure like not having any outdoor shelter or enough seating in waiting rooms. Some wanted staff to be more professional and communicate better and also want to have more privacy when disclosing health information.
This, according to Mokhele, highlighted that there is a disconnect between the actual patient experience and their reported/perceived quality of care. This may be partly driven by patient gratitude for having free access to services and that expectations of services are actually quite low. "Meaning that they may overrate their quality of services if their expectations are low," she says.
