Table 1 Emerging themes on the context of the ICRM programme and interplay with the characteristics of actors
Context | Â | Actor characteristics (Cognition/Motivation/power) as influenced by the context | ||
|---|---|---|---|---|
| Â | Themes | Cognition | Motivation/demotivation | Power/capacity or lack of power |
Wider context | Improving quality in preparation for NHI implementation | NDoH recognised the need to improve quality in preparation for NHI | NDoH motivated to improve quality at PHC level | NDoH used legal powers to drive the ICRM programme |
Structural context | Contestations about roles and responsibilities | Conflicting views on roles and responsibilities | Frustrations about lack of reporting structure and lack of accountability | Unfulfilled responsibilities by all government spheres disempowered the implementers at facility level |
Weak intergovernmental relationships | Provincial, district and local government reported ineffective communication, lack of co-operation and top-down approach of the NDoH | Lack of ownership, insufficient buy in, leading to demotivation | – | |
Local leadership enables implementation | District and local government perceived their leadership knowledge and skills as facilitating the implementation | Knowledge and experience motivated the sub-district managers to implement ICRM | Managers negotiated for additional resources | |
Insufficient resourcing of ICRM | Ambivalence about ICRM programme sustainability | District managers expressed urgency and advocated for spending | District and local authority staff reported lack of authority or control over NHI grant or provincial cash flow | |
Specific context | Gaps in existing policy | District and local government reported insufficient communication on the NCS and lack of enforcement | NDoH motivated to design ICRM programme to assist with compliance with NCS | Insufficient communication disempowered district actors |
Insufficient policy coherence or disjuncture | District and local government staff recognised the need to align tools | District and sub-district staff experienced frustration, confusion and exhaustion, which were demotivating | Experienced lack of power to influence the alignment of tools | |
Geographical variations Infrastructural variations | Ambivalence about ICRM programme | District and local government reported sense of despair that some facilities will never be ideal | Perceived lack of capacity to implement ICRM in facilities with infrastructure challenges | |