Patient’s perceived quality of care in South Africa’s public health sector: gratitude for access or ideal care experience
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Abstract Background South Africa strives to close the quality divide between public and private healthcare services. However, it is unclear whether patients’ demands for access to care matches their desire for quality service. Therefore, we sought to determine if patients’ satisfaction with quality of care received in the public healthcare matches their overall care experience. Methods We conducted a mixed-methods cross-sectional survey from February to August 2021, enrolling 40 adult (>18 years) patients/clinics in waiting areas across a proportional sample (10%) of 45 public clinics in the Gauteng province (N=1800). Study participants completed a semi-structured questionnaire. High quality of care was defined as achieving a score>3.5 on a ten-item scale (Cronbach’s alpha= 0.67) measuring agreement with statements about care experiences, including staff communication, attitudes, and clinic amenities. Open-ended questions were analysed thematically and coded as complaints (yes/no). Results Overall, 1788/1800 (99.3%) completed the survey, and 70.2% (95% Confidence Interval (CI): 63.6-76.0) of participants reported high quality of service, equivalent between HIV/TB (73.5, 95%CI: 66.0, 79.9) and non-HIV/TB care seekers (67.8%, 95%CI: 61.0, 73.9). Still, 31.7% of participants reporting high service quality had complaints. Overall, 69.6% (62.3%, 76.0) of participants deeming services low-moderate quality reported complaints. Participants’ complaints included long waiting times, clinic appointment system inefficiencies, staff shortages, and poor staff time management. Additionally, participants reported disrespectful treatment from clinic staff and very poor communication. It appears that the improved access to care compensated for sub-standard experiences, as illustrated by statements like: “I like attending here at this facility as it's closer to my home. Overall experience is good except for long waiting hours and numbering system which is not followed.” “We all know the health care workers are always under pressure as they work with different kinds of people every day, but they need to be very much respectful to some of us who are seeking help politely”. Conclusions Patients’ perception of quality of care is partly driven by gratitude for the widespread access to free care. Still, quality measures must give equal weight to non-clinical experiences of care, such as waiting time and communication, which are essential determinants of improved care-seeking behaviours, particularly among patients in lifelong chronic care.
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However, it is unclear whether patients’ demands for access to care matches their desire for quality service. Therefore, we sought to determine if patients’ satisfaction with quality of care received in the public healthcare matches their overall care experience. Methods We conducted a mixed-methods cross-sectional survey from February to August 2021, enrolling 40 adult (>18 years) patients/clinics in waiting areas across a proportional sample (10%) of 45 public clinics in the Gauteng province (N=1800). Study participants completed a semi-structured questionnaire. High quality of care was defined as achieving a score>3.5 on a ten-item scale (Cronbach’s alpha= 0.67) measuring agreement with statements about care experiences, including staff communication, attitudes, and clinic amenities. Open-ended questions were analysed thematically and coded as complaints (yes/no). Results Overall, 1788/1800 (99.3%) completed the survey, and 70.2% (95% Confidence Interval (CI): 63.6-76.0) of participants reported high quality of service, equivalent between HIV/TB (73.5, 95%CI: 66.0, 79.9) and non-HIV/TB care seekers (67.8%, 95%CI: 61.0, 73.9). Still, 31.7% of participants reporting high service quality had complaints. Overall, 69.6% (62.3%, 76.0) of participants deeming services low-moderate quality reported complaints. Participants’ complaints included long waiting times, clinic appointment system inefficiencies, staff shortages, and poor staff time management. Additionally, participants reported disrespectful treatment from clinic staff and very poor communication. It appears that the improved access to care compensated for sub-standard experiences, as illustrated by statements like: “I like attending here at this facility as it's closer to my home. Overall experience is good except for long waiting hours and numbering system which is not followed.” “We all know the health care workers are always under pressure as they work with different kinds of people every day, but they need to be very much respectful to some of us who are seeking help politely”. Conclusions Patients’ perception of quality of care is partly driven by gratitude for the widespread access to free care. Still, quality measures must give equal weight to non-clinical experiences of care, such as waiting time and communication, which are essential determinants of improved care-seeking behaviours, particularly among patients in lifelong chronic care. Perceived quality of care Quality assurance Ideal clinic realization and maintenance Primary Healthcare South Africa Figures Figure 1 Figure 2 Figure 3 BACKGROUND In South Africa, primary healthcare (PHC) is the backbone of the healthcare delivery system and is necessary to achieve Universal Health Coverage (UHC) (1, 2). The South African government has made considerable strides in improving access to healthcare for all its citizens (1, 3). As a result, over 90% of the population has free access to primary healthcare at over 3500 PHC facilities within 5 kilometres of their homes or work, supported by a community-based network of outreach teams (2, 4). However, a multifaceted burden of infectious and non-communicable diseases, historical inequalities in healthcare delivery, and poor management and leadership place immense strain on the health system (1, 5, 6). Consequently, attaining universal access to efficient, high-quality, and appropriate healthcare is at risk. The Ideal Clinic Realization and Maintenance (ICRM) program was launched in July 2013 to improve the quality of care at the PHC level and ensure compliance with the national core standards for healthcare facilities (7, 8) in preparation for the implementation of the National Health Insurance (NHI) (9, 10). The program defines an Ideal Clinic as one with appropriate infrastructure, sufficient staff, necessary medicine and supplies, efficient administrative processes, and support from partners and stakeholders to deliver high-quality healthcare services to the community (11–13). The program involves annual assessments and grading of facilities using the ICRM manual and tools. Facilities are assigned certification status based on how they are scored on the tool during the assessment, ranging from platinum (the highest certification) to gold, silver, or not-achieved (N/A). Managers receive guidance for quality improvement actions based on the assessment results to enhance the functioning and quality of the facilities to ensure that they meet established standards and continuously improve their quality of care (12–14). It is uncertain whether ICRM certification improves patient experience or aligns with patients' expectations for quality care. Patient perception of quality of care refers to an individual's personal evaluation or assessment of the healthcare services they have received. It is based on the patient's own experiences, observations, and opinions about different aspects of their care. These aspects include the interactions with healthcare providers, how effective the treatments were, how timely the services were, how comfortable and convenient the facilities were, and overall satisfaction with their healthcare experience (15). Despite the ICRM program being prioritised to enhance service delivery and patient experience at the PHC level, reports of negative patient experiences persist (16, 17). These negative experiences include long waiting times, lack of privacy, communication barriers, poor staff attitude, and infrastructure challenges. Furthermore, there has been a lack of national assessments regarding the program's impact on the quality of health services at the PHC level. Therefore, our study aims to examine the consistency between patients' perception of the quality of care received at public PHC facilities and their overall care experience, investigate the ICRM program's influence on this relationship, and identify the factors associated with patient's perceived quality of care. METHODS Study design and population The current analysis was part of a larger mixed-methods cross-sectional study conducted in Gauteng to examine the implementation of the ICRM programme from health provider perspectives and patient experiences. The study sampled 10% (~45) of public-sector primary healthcare facilities (primary healthcare clinics (PHCs), Community Health Centers (CHCs), and Community Day Centers (CDCs)), stratified by district and the 2018 ICRM certification level (Supplementary file 1). We report on results from the review of the impact of the ICRM classifications on patients' experiences and perceived quality of care conducted among adults aged 18 years or older seeking care in sampled facilities from February to August 2021. We aimed to recruit 40 patients per facility across participating facilities (N=1800) in the general service-specific waiting areas across four broad service areas: HIV/TB, Non-communicable diseases, Sexual and reproductive services (including obstetric services), and casualty/emergency services (CHCs and day hospitals). Patients were eligible to be enrolled if they were at least 18 years old, were well enough to consent, and were present for a personal clinic visit. The study questionnaire included questions about their recent experience at the selected facility, and their assessment of the quality of the care received. Data collection Eligible patients who provided written consent completed a structured study questionnaire at study enrolment. The questionnaire assessed participants’ experiences with clinic services and their perception of the quality of care received. We also assessed patient and clinic factors that could affect patient experiences, including clinic size and location, conditions currently being treated at the clinic, and the main reason for the current clinic visit at study enrolment. The information sheet and questionnaire were available in English, Sesotho, and isiZulu, which are widely spoken and understood in Gauteng. All patients were recruited and interviewed by trained study interviewers. Outcome measures Patient perceived quality of care outcome The primary outcome of the study was the perceived quality of care assessed using a 10-item measure with a 5-point scale ranging from one (strongly disagree) to five (strongly agree) (Cronbach’s alpha = 0.67). The tool included statements relating to different aspects of the patient’s care experience at the facility, including provider attitude, privacy and confidentiality, provider-patient communication, provider competency, and clinic amenities. We computed mean scores for overall perceived quality of care, with higher scores reflecting higher perceived quality of care. The mean score was categorised as either high (>=3.5) or not high (<3.5), indicating, on average, item responses were in agreement or above ‘uncertain’. The tool has been validated in South Africa among HIV, TB, and diabetes patients in the primary healthcare setting (12-14). Analytic variables Sociodemographic factors assessed include age, sex, highest education completed, English literacy, marital status, living with a partner/spouse, employment status, social grant received in the household, type of settlement they live in, and duration of living in the current community. We also assessed factors related to healthcare access, including health conditions currently being treated at the clinic (HIV/TB, Diabetes /Hypertension, and mental health or other conditions) and the main reason for the current clinic visit at study enrolment (HIV/TB, Hypertension/Diabetes, pregnancy/ child health or family planning or other reasons). ICRM-related factors assessed include the clinic ICRM certification at study enrolment (2021) (platinum, gold, silver, or not achieved). We also created an ICRM status change variable by comparing each participating clinic’s latest (2021) ICRM certification status with the certification used for sampling (2018) and categorised it as improved, no change, or regressed. We also assessed whether the clinic implemented an appointment system (yes-time /timeslot appointments, yes-appointment day, or no-appointment system) based on facility assessments. Clinic-level characteristics assessed include the district the clinic is in (City of Johannesburg (COJ), Ekurhuleni, Sedibeng, Tshwane, and West Rand) and the type of clinic (PHC, CHC, or CDC). We defined an informal urban clinic area locality as an area that included a large section of informal (shacks) dwellings; formal urban areas were more built-up areas with formalised infrastructure, while rural areas had low population density and smaller population settlements outside a town. The clinic size was determined using the nurse-patient per day ratio calculated by dividing the average headcount per month by the number of rooms in the facility and days in a month. We dichotomised the final nurse-patient per day ratio to =30. Additionally, the number of patients on antiretroviral therapy (ART) currently managed at the site was sourced from each clinic’s Three Interlinked Electronic Registers (TIER.Net) data platform used to collect data for HIV patients. We categorised this as =2500 based on the median among the sampled clinics. Data analysis Quantitative data analysis We describe participant and clinic characteristics using proportions, frequencies, means with standard deviation, and medians with interquartile ranges (IQR) as appropriate. We assessed factors associated with high perceived quality of care using Modified Poisson regression models, and we report crude Relative Risk Ratio (RRR) and 95% confidence intervals (95% CI) due to the small sample size (effective sample=45). All analyses were completed using STATA version 16/17 (Stata Corporation, College Station, Texas, USA). STATA survey commands were used to adjust for sampling probability weights. Qualitative data analysis Qualitative data from open-ended questions were analysed thematically using an Excel-based tool. The analysis involved reading respondents' open-ended comments by the study team to identify emerging themes. The process was repeated until no new themes emerged. After that, themes were assigned codes accordingly. RESULTS Survey respondents’ sociodemographic characteristics Table 1 presents descriptive statistics for patients surveyed and participating clinics, stratified by district. Although clinic enrolment into the study was proportional to the district size (~10% of clinics in each district), 40 patients/selected facilities were enrolled, with a total of 1788 of the total 1800 target sample. Although participants were randomly selected in the clinic's general waiting area, 80.1% were female participants with a median age of 33 years, IQR (27.0-41.0). Overall, 55.7% were employed, with 53.0% living in a household that received social grants. Most (89.0%) of the study participants lived in townships or informal settlements; 50.4% lived in their current community for over five years. Overall, 40.9% surveyed patients were receiving ongoing HIV/TB care at the facility, and around 78.5% of these accessed HIV/TB services on the survey day. A third of patients were visiting the clinic to seek HIV/TB services, and a similar proportion sought family planning services during study enrolment. Characteristics of facilities surveyed Overall, 45% of clinics surveyed were in urban informal areas and 51.7% in urban formal areas, while two clinics were in rural settings. The majority (84.0%) were PHC facilities, 10.7% were CHC and 5.3% CDCs. Over 50% of study participants were from clinics with a platinum 2021 ICRM status, while 22.4% were from clinics with a Gold certification. Overall, most facilities improved their ICRM classification between 2018 and 2021. However, over 20% regressed, and most facilities classified as “Not Achieved” (NA) retained this status. Moreover, 16% of patients surveyed were from facilities that regressed their certification status, while the majority (54.2%) were from facilities that improved. Table 1. Sociodemographic characteristics of study participants (n=1788) Johannesburg Ekurhuleni Sedibeng Tshwane West Rand Total No. (95%CI) No. (95%CI) No. (95%CI) No. (95%CI) No. (95%CI) No. (95%CI) Sex Female 395 (74.1-79.6) 334 (72.8-80.0) 142 (81.3-93.5) 302 (78.1-88.1) 264 (80.4-83.9) 1,437 (77.9-82.2) Age, Med (IQR) 33 (27-40) 32 (26-39) 33 (25-41) 34 (28-42) 33 (27-43) 33 (27-41) 18-29.99 181 (28.0-41.2) 176 (34.3-46.5) 60 (29.4-47.1) 117 (28.0-39.9) 107 (27.7-37.5) 641 (32.7-39.1) 30-39.99 195 (34.7-42.5) 152 (30.4-40.5) 47 (22.1-37.1) 126 (31.2-38.3) 116 (27.6-50.3) 636 (33.2-38.8) 40+ 139 (22.4-32.6) 109 (19.8-29.8) 53 (27.0-39.9) 113 (27.0-36.6) 97 (22.1-37.7) 511 (25.6-31.1) Marital status Married 124 (18.5-31.0) 68 (12.0-18.7) 26 (11.7-22.0) 89 (18.4-31.1) 57 (8.6-20.5) 364 (16.7-22.9) In a relationship 235 (38.9-50.5) 243 (48.0-62.8) 84 (43.6-62.5) 165 (40.9-55.1) 162 (40.1-64.3) 889 (46.1-53.8) Not in a relationship 156 (25.2-38.0) 122 (23.1-36.7) 49 (25.7-36.0) 100 (21.9-34.8) 100 (26.2-43.3) 527 (27.3-33.8) Lives with spouse/partner? No 109 (17.2-24.9) 121 (22.3-32.5) 39 (21.1-28.6) 66 (14.3-25.9) 73 (17.8-29.1) 408 (20.5-25.4) Yes, husband or wife 126 (19.3-30.9) 76 (13.9-21.4) 25 (10.3-22.7) 91 (18.4-34.1) 52 (7.0-18.4) 370 (17.2-23.6) Yes, regular partner 121 (17.1-30.4) 114 (21.5-31.4) 46 (23.0-36.4) 95 (23.6-30.7) 93 (24.7-38.7) 469 (23.5-29.4) Not in a relationship 156 (25.4-38.2) 122 (23.1-36.7) 49 (25.7-36.0) 100 (22.0-35.0) 100 (26.2-43.3) 527 (27.4-33.9) English literacy I can read well 456 (84.2-93.1) 350 (71.5-86.4) 135 (79.5-88.8) 319 (88.1-93.8) 260 (71.0-86.2) 1,520 (82.1-88.4) I can read somewhat 54 (6.2-15.2) 81 (12.9-26.1) 20 (8.8-18.2) 25 (5.7-10.2) 38 (7.6-15.6) 218 (9.7-15.1) I cannot read 4 (0.2-2.7) 6 (0.5-4.1) 4 (0.7-8.7) 3 (0.4-2.5) 21 (5.9-14.7) 38 (1.3-4.1) Highest level of education High school or less 243 (40.5-52.7) 223 (44.2-57.6) 94 (52.6-64.5) 193 (46.6-60.5) 175 (39.5-67.6) 928 (47.5-55.0) Completed Matric 181 (32.1-40.8) 149 (27.7-42.7) 43 (22.5-31.4) 97 (221.-36.3) 100 (22.1-44.8) 570 (29.6-36.4) Tertiary 90 (13.2-21.9) 64 (10.0-19.9) 23 (9.0-22.8) 65 (11.8-25.7) 44 (6.0-28.3) 286 (13.1-18.8) Employment status Employed 265 (45.6-58.7) 177 (37.0-45.1) 56 (30.1-40.7) 169 (36.6-57.7) 122 (26.2-45.6) 789 (40.2-48.4) Unemployed 248 (41.3-54.4) 257 (54.9-63.0) 103 (59.3-69.9) 186 (42.3-63.4) 198 (54.4-73.8) 992 (51.6-59.8) Type of settlement they live in Town/Suburb 98 (9.9-43.8) 39 (3.7-17.1) 12 (2.3-23.6) 80 (7.0-48.4) 77 (2.2-24.0) 306 (8.9-24.2) Township/Location 358 (49.1-85.5) 336 (65.9-91.6) 134 (67.1-95.0) 184 (33.0-74.4) 214 (72.1-93.1) 1,226 (64.0-82.0) Informal settlement 32 (3.6-12.9) 52 (4.5-19.8) 9 (2.4-13.5) 81 (10.9-46.2) 16 (2.8-15.4) 190 (7.0-16.8) Duration living in current community 5 years 180 (24.1-42.4) 271 (55.0-69.6) 121 (75.2-80.7) 176 (40.0-60.8) 146 (31.7-63.8) 894 (43.7-57.1) Reason for clinic visit HIV/TB 162 (26.8-40.9) 174 (33.0-46.2) 47 (22.6-36.6) 104 (23.2-37.3) 100 (22.4-41.7) 587 (30.0-37.2) Diabetes/Hypertension 37 (4.2-9.9) 22 (2.3-7.1) 21 (7.2-21.8) 26 (4.5-10.6) 34 (6.0-13.6) 140 (5.5-8.9) Pregnancy/child health 136 (19.6-35.0) 103 (20.1-29.9) 40 (15.4-39.3) 118 (26.4-38.4) 66 (14.2-27.0) 463 (22.8-29.8) Fam pl/other 175 (28.0-39.1) 131 (26.0-38.2) 52 (25.9-40.1) 107 (22.7-40.9) 119 (33.1-46.9) 584 (30.1-36.7) Being treated for HIV/TB No 322 (54.0-68.5) 230 (49.6-57.4) 87 (48.2-60.9) 226 (53.6-70.8) 201 (50.6-73.2) 1,066 (55.4-62.7) Yes 193 (31.5-46.0) 207 (42.6-50.4) 73 (39.1-51.8) 130 (29.2-46.4) 119 (26.8-49.4) 722 (37.3-44.6) Being treated for Hypertension/ Diabetes No 454 (85.1-91.5) 389 (86.5-93.0) 124 (69.5-84.4) 322 (86.1-94.1) 264 (81.0-87.4) 1,553 (85.5-89.8) Yes 61 (8.5-14.9) 48 (7.0-13.5) 36 (15.6-30.5) 34 (5.9-13.9) 56 (12.6-19.0) 235 (10.2-14.5) Being treated for other chronic conditions No 247 (39.5-57.5) 309 (64.2-74.5) 114 (56.1-82.0) 158 (37.7-52.9 176 (42.5-62.6) 1,004 (50.9-61.2) Yes 268 (42.5-60.5) 128 (25.5-35.8) 46 (18.0-43.9) 198 (47.1-62.3) 144 (37.4-57.5) 784 (38.8-49.1) ICRM status (2021) Not achieved 117 (8.8-59.7) 41 (1.4-50.9) - 40 (1.7-57.4) 81 (5.1-74.8) 279 (8.2-34.2) Silver - - 40 (2.8-75.8) - 81 (9.5-80.8) 121 (2.4-22.4) Gold 79 (4.1-50.7) 80 (2.4-37.5) 80 (12.1-89.0) 80 (6.5-65.4) 79 (4.9-73.5) 398 (11.7-38.4) Platinum 319 (26.9-80.6) 316 (45.9-93.9) 40 (3.2-78.4) 236 (25.8-86.6) 79 (0.8-19.2) 990 (36.3-67.6) ICRM status change (2018-2021) No change 160 (6.7-57.2) 41 (0.7-33.4) 40 (3.2-78.5) 120 (10.3-69.3) 159 (5.6-67.3) 520 (11.2-37.1) Regressed 37 (1.2-47.3) 81 (3.5-50.9) 40 (2.8-75.9) 40 (1.7-57.4) 82 (12.5-84.4) 280 (8.8-35.3) Improved 278 (34.9-88.4) 315 (45.8-93.8) 80 (12.1-89.0) 196 (21.5-82.1) 79 (4.9-73.6) 948 (43.4-74.5) Type of Facility CDC - - 80 (12.1-89.0) - - 80 (1.3-19.7) CHC 40 (1.2-46.7) 41 (1.4-50.9) - 77 (6.2-64.2) - 158 (3.9-26.0) PHC 475 (53.3-98.8) 396 (49.1-98.6) 80 (11.0-87.9) 279 (35.8-93.8) 320 (-) 1,550 (68.0-92.8) Clinic area locality Urban Informal 237 (14.8-66.8) 201 (20.6-76.7) 80 (11.0-87.9) 200 (22.5-82.9) 79 (9.1-80.0) 797 (29.6-60.8) Urban Formal 278 (33.2-85.2) 236 (23.3-79.4) 80 (12.1-89.0) 116 (9.8-67.9) 200 (9.3-78.3) 910 (33.9-65.3) Rural - - - 40 (1.7-57.4) 41 (3.1-74.6) 81 (1.4-21.2) Total on ART =2500 435 (47.3-95.5) 239 (24.0-80.0) 80 (12.1-89.0) 196 (26.0-85.6) 79 (3.7-73.0) 1,029 (42.7-73.5) Nurse, patient per day ratio =30 356 (41.7-91.1) 356 (42.5-94.8) 120 (21.6-96.8) 120 (10.3-69.3) 40 (0.6-34.0) 992 (41.5-72.6) Clinic appointment system No appointment system 39 (1.1-45.5) 40 (0.7-32.9) - 40 (1.7-57.4) - 119 (2.0-20.2) Yes - appointment days 317 (38.0-90.2) 356 (49.1-96.5) 160 (-) 157 (11.2-67.3) 320 (-) 1,310 (9.5-35.9) Yes - appointment times/time slots 119 (5.4-54.5) 41 (1.4-51.0) - 159 (21.8-82.0) - 319 (9.5-35.9) Med, median; IQR, interquartile range; HIV, human immunodeficiency virus; TB, tuberculosis; ICRM, ideal clinic realisation and maintenance; CDC, community day centre; CHC, community health centre; PHC, primary health clinic, ART, antiretroviral treatment Patients’ perceived quality of care Overall, 70.2% (95% CI: 63.6-76.0) of participating clinic patients perceived the quality of primary healthcare services as high (Figure 1). Patient-perceived quality of health care was similarly high across the 2021 ICRM status certification. Yet, a clinic that did not achieve accreditation in 2021 had a lower percentage of patients who perceived the quality of care as high. Figure 1. Patient perceived quality of care by Ideal Clinic status Patient level determinants of high perceived quality of care Patient factors associated with high perceived quality of care are described in Figure 2. Older patients were more likely to report high quality of care compared to younger patients (RRR 1.3 for 30-39 years old vs 18-30 years, 95% CI: 1.0-1.7, RR 1.7 for being ≥40 years vs 18-30 years, 95% CI: 1.3-2.1). Similarly, those currently treated for HIV/TB at the clinic compared to those who received other care (RRR 1.3, 95% CI: 1.0-1.7). Compared to married patients, those in a relationship were less likely to report high-quality of care (RRR 0.7, 95% CI: 0.5-0.9). Overall, patients who had lived in their current communities for five years or longer were also likely to report lower quality of care (RRR 0.5 vs living in the area for <5 years, 95% CI: 0.4-0.7). Similarly, those that came for pregnancy or child health-related service on the day of study enrolment (RRR 0.7 vs HIV/TB, 95% CI: 0.5-0.9). Facility level determinants of high perceived quality of care Patient perception of quality of care did not differ significantly by facility-level characteristics except by district (Figure 3). Patients attending clinics based in Ekurhuleni were less likely to report their quality of care as high than facilities in the City of Johannesburg (RRR 0.25, 95% CI: 0.13-0.48). Patients’ perception of quality of care did not differ significantly by the current facility ICRM status (RRR 1.3 for Gold vs Platinum, 95% CI: 0.6-2.7; RRR 1.0 for Silver vs Platinum, 95% CI: 0.4-2.5; RRR 0.8 for Silver vs Platinum, 95% CI: 0.3-1.8), nor by a change in ICRM status between 2018-2021 (RRR 1.6 for No change vs Improved, 95% CI: 0.8-3.3; RRR 0.7 for Regressed vs Improved, 95% CI: 0.3-1.2). Figure 2. Patient level determinants of perceived quality of care Figure 3. Facility level determinants of perceived quality of care Study participants highlighted the clinic’s proximity to their homes or place of work as the primary reason for attending the chosen clinic. Although most (70%) patients reported the service as acceptable or good, they had complaints regarding their overall experience at the clinic. The feedback themes, including participant sex, age, and current services or diseases being treated at the clinic, are summarized in Table 2. Although patients reported coming to the clinic very early, they found very long queues. For the most part, clinics did not have outside shelter or enough seating in the waiting areas, considering the long wait they had to endure. These interviews were conducted during COVID-19 restrictions, and queuing was only allowed outside facilities for social distancing. While patients acknowledged that staff shortages challenged clinics, they also attributed the long waiting times to inefficiencies in clinics’ appointment systems and patient record management. They also highlighted poor time management among staff who are seen as purposefully slow, going on breaks at the same time with no consideration for the patients. Patients also bemoaned disrespectful treatment from clinic staff, with reports of being scolded. Finally, they wanted clinic staff to be more professional and communicate better with them, including better communication about the processes for ensuring that queues moved and reasons for undue delays. Patients also highlighted the lack of privacy, with nurses sometimes sharing consulting rooms. Patients highlighted that the clinics were too small and no longer matched the size of the population seeking service. Table 2. Illustrative quotes from patient-reported experiences at the facility Theme Illustrative quote Facility infrastructure and cleanliness “The service of our clinic is average; we wait outside in the cold weather even before COVID due to space issues in the clinic.” – Female, 43 years old, Other chronic disease services “The service is okay. Patients see the improvement of the clinic because last time 2018 it was a small room but at same time wish the government can build the clinic for patients and the population is growing.” – Male, 33 years old, Acute/ preventative services “They facility/government have to look population is increasing around this area in terms of extending the clinic. The service it not bad at all.” – Male, 39 years old, Acute/ preventative services Patient waiting times “We stay long in the queues before we can receive a file. Waiting long at the pharmacy as well, no time management.” – Female, 33 years old, Acute/ preventative services “There are papers written 120 minutes waiting time and sometimes we wait for more than that but there is nothing like 120 minutes in this clinic and we don't know what does it mean but because we have to get the services we want, we should wait.” – Male, 61 years old, Other chronic disease services “I like attending here at this facility as it's closer to my home. Overall experience is good except for long waiting hours and numbering system which is not followed.” – Male, 27 years old, Acute/ preventative services Privacy and confidentiality “There is no privacy here at the clinic. People come in and out of the consultation and staff don't reprimand them.” “I need privacy in consultation room. I don't feel comfortable to see a sister with another colleague in the same consultation room.” – Male, 46 years old, HIV/TB services Staff communication “The service is poor, no communication, staff admin, they don't attend patient in reception end up not knowing where to go.” – Male, 33 years old, Acute/ preventative services “Not sure what causes this, but I think patients sometimes wait for help for too long and there is never a communication to say what's the reason” – Female, 42 years old, HIV/TB services Staff shortages “The only thing I don't really like here is that they are always short staffed and we tend to wait for long.” – Female, 42 years old, Acute/preventative services “The staff is not enough and we can blame them for staying long in the facility and there is too much people” – Female, 23 years old, Acute/preventative services “They should add more staff. They are always complaining that they don't have staff but don't make any changes about it.” – Male, 46 years old, HIV/TB services Staff attitude “We all know the health care workers are always under pressure as they work with different kinds of people every day, but they need to be very much respectful to some of us who are seeking help politely” – Female, 25 years old, Acute/preventative services “I like attending at this facility they give us medication whenever we are not feeling well however they tend to have attitudes by asking us why we don't go and buy medication at the pharmacy.” – Female, 23 years old, Acute/preventative services “I was judged for asking help during my first pregnancy, instead of them accommodating me. They told me I was too young to be here, I was even afraid to ask for another alternative I could during that course. That thing made me to feel scared when attending the health facilities, I don't wish for that to happen again. It's was so unprofessional on their side.” – Female, 23 years old, Other DISCUSSION The perspectives of patients regarding the quality of care are gaining increasing importance in evaluating and reforming healthcare services. To our knowledge, this is one of the first studies to explore the ICRM programme's effect on patient-perceived quality of care. Among our study participants, 70.2% reported perceiving their care quality as high. Notably, patient perception of care quality did not differ based on ICRM certification status or changes in certification status over time. However, it did differ by district, where patients receiving care at facilities in Ekurhuleni district were less likely to perceive their quality of care as high which is surprising, considering that the district achieved the highest percentage of Ideal Clinics in Gauteng in 2021 (18, 19). A patient experience survey conducted in 2017 across a random sample of 168 primary healthcare facilities in South Africa demonstrated a moderately positive correlation between ideal clinics and patient satisfaction, with an overall satisfaction rate of 76.5% and 82.2% among clinics with high ICRM scores (15). In our survey of Gauteng clinics, a majority of patients reported high-quality care and positive experiences. However, higher ICRM accreditation status did not lead to improved patient perception of care quality (16). Older patients and those receiving HIV/TB services at the clinic were more likely to report receiving high quality of care, possibly due to improved access to healthcare by the South African government (1, 20). The longer experience of older patients with the healthcare system may have led to expectations more in line with the system's standards, despite its limitations (21). Additionally, the recent increase in investment in HIV/TB care at the primary healthcare level may have significantly improved the care experience of patients by addressing previous issues related to treatment access (22-24). Patients seeking pregnancy or child health services reported low quality of care, with persisting issues in health provider attitudes and behaviours which have been shown to affect patient satisfaction and may lead to reluctance to seek care (25). Patients in long-term relationships and those who have lived in their community for five years or more are less likely to report receiving high-quality care. As communities grow, access to care and quality may decline, as the infrastructure and staffing struggle to keep up with increased demands (26). Additionally, social support among patients in relationships can raise expectations for the quality of healthcare they receive (27, 28). It is evident that current measures of patient satisfaction do not accurately reflect the true sentiments patients have towards their lived care experiences, when compared against the standards of the healthcare system. Notably, nearly one-third of patients who reported high perceived care quality also expressed concerns about their clinic experiences. A study conducted in Mpumalanga province among clinic patients in public health services showed that although 87.8% of patients reported satisfaction with nursing care, only 64.8% would recommend the clinic to others in the community (17). Enhancing patients' expression of care quality can be achieved by addressing the challenges prevalent in clinics while ensuring high access to care (16, 18). Patients acknowledged the difficulties faced by clinics, but their complaints mainly revolved around inefficiencies in workflow, such as poor staff time management, inadequate communication about queues and waiting times, and overall disrespectful communication. The perceived quality of care may not always align with objective measures or clinical outcomes. Factors such as communication, empathy, and patient-centeredness heavily influence how patients perceive the quality of their care (29). It's important to empower patients to expect higher quality care and include their complete experiences in satisfaction surveys. Surveys should cover factors like time spent in clinics, staff communication, and navigation through different section (30). By actively seeking and addressing patient feedback, healthcare systems can work towards providing care that meets patients' expectations, preferences, and values, ultimately leading to improved patient satisfaction, engagement, and better health outcomes (16, 29, 30). The provision of quality care depends on health systems and providers involving patients in decision-making (30). Recognizing that healthcare providers have their own professional, physical, and emotional needs is essential to providing quality care. A positive work environment, ongoing training, effective leadership, collaborative teamwork, and adequate resources have been identified as facilitators for healthcare providers to deliver patient-centred care (30). Moreover, healthcare providers associate care quality with inadequate infrastructure and insufficient accountability and support from district and provincial authorities more than national quality standards (19). LIMITATIONS: The facility sample consisted of about 10% of primary healthcare clinics in Gauteng stratified by districts and ICRM accreditation status in 2018 because of data availability. The distribution of ICRM accreditation status in Gauteng is skewed toward the Platinum classification limiting our ability to appropriately compare facilities that had not achieved (NA) certification and Silver facilities to Gold and Platinum clinics in some districts. Nevertheless, the sample included as many NA and Silver clinics as possible at during sampling. The list of HIV interventions explored in this study is not exhaustive and consists of programmes that we purposely selected for review in this phase of the survey. Further research is needed to review other areas of synergies between HIV and other chronic conditions and ICRM health system improvement guidelines. CONCLUSIONS Patients’ perception of quality of care may be partly driven by gratitude for the widespread access to free care. When assessing patient experiences with care quality measures must give equal weighting to non-clinical experiences of care such as waiting-time, communication which are essential determinants of improved care-seeking behaviours, particularly among patients in lifelong chronic care. Abbreviations PHC Primary Healthcare UHC Universal Health Coverage ICRM Ideal Clinic Realisation and Maintenance NHI National Health Insurance Not Achieved NA CHC Community Health Centre CDC Community Day Centres HIV Human immunodeficiency virus TB Tuberculosis COJ City of Johannesburg TIER.Net Three Interlinked Registers IQR Interquartile Range RRR Relative Risk Ration CI Confidence Interval COVID-19 Coronavirus disease of 2019 Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Human Ethics Research Committee (Medical) of the University of the Witwatersrand (protocol M201081). All participants provided written informed consent before all data collection procedures. Confidentiality and anonymity were safeguarded by removing all participant identifiers from the data. Consent for publication Not applicable Availability of data and material Qualitative data extracts are presented in the article to support the findings. The original transcripts are not available to the public as they may contain information that could compromise the confidentiality of study participants. All relevant data is included in the paper. Competing interests The authors declare that they have no competing interests Funding This study has been made possible by the generous support of the American People and the President's Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of Cooperative Agreement 72067419CA00004 to the Wits Health Consortium. The contents are the responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government. Author Contributions DO conceptualised the study and paper. contributed to the study design and interpretation of the results. IM conducted the primary data analysis. IM managed the study implementation and contributed to the result interpretation. RC, CN, SK, AK and NM managed district-level study implementation and contributed to the result interpretation. NJ and JM critically provided feedback on the manuscript. All authors reviewed and approved the manuscript. Acknowledgements We extend our gratitude to the data collection team (Annah Morifi, Alice Kono, Nonhlanhla Tshabalala, Portia Ngwenya, Hazel Tau, Melda Musina, Michael Motapo, and Sinethemba Madlala.) for their diligent support during the study implementation. Additionally, our sincere thanks go to the Gauteng Province, the National Department of Health of South Africa and the staff of participating clinics for accommodating the study. Our thanks also go to the patients attending participating clinics for sharing their valuable information that made this study possible. References Mayosi BM, Benatar SR. Health and health care in South Africa—20 years after Mandela. New England Journal of Medicine. 2014;371(14):1344-53. World Health Organization (WHO). Primary health care on the road to universal health coverage: 2019 global monitoring report. 2021. South African National Department of Health. Annual report 2020/2021. Pretoria, Health Do. Report No.: RP264/2021. Naledi T, Barron P, Schneider H. Primary health care in SA since 1994 and implications of the new vision for PHC re-engineering. South African health review. 2011;2011(1):17-28. Bradshaw D, Nannan N, Pillay-van Wyk V, Laubscher R, Groenewald P, Dorrington R. Burden of disease in South Africa: Protracted transitions driven by social pathologies. South African Medical Journal. 2019;109(11b):69-76. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. The lancet. 2009;374(9693):934-47. South African National Department of Health. National core standards for health establishments in South Africa: ‘Towards quality care for patients’. In: Health Do, editor. Tshwane, South Africa2011. Whittaker S, Linegar A, Shaw C, Spieker N. Quality standards for healthcare establishments in South Africa. South African health review. 2011;2011(1):59-67. South African National Department of Health. Milestones in the Implementation of the National Health Insurance. Pretoria: Government Printer; 2015. South African National Department of Health. National health insurance for South Africa: towards universal health coverage. Government Gazette. 2015;1230:1-97. Hunter JR, Chandran TM, Asmall S, Tucker J-M, Ravhengani NM, Mokgalagadi Y. The Ideal Clinic in South Africa: progress and challenges in implementation. South African health review. 2017;2017(1):111-23. South African National Department of Health. Ideal clinic components and definitions. National Department of Health Pretoria; 2015. South African National Department of Health. Ideal Clinic Facility Monitoring System. Pretoria: South African National Department of Health,; 2018. South African National Department of Health. Office of Health Standards Compliance, Annual Inspection Report 2021/22. Pretoria, South Africa: Office of Health Standards Compliance; 2022. Mosadeghrad AM. A conceptual framework for quality of care. Materia socio-medica. 2012;24(4):251. Ritshidze. PEOPLE’S COP20 – COMMUNITY PRIORITIES – SOUTH AFRICA. Ritshidze; 2020. Ritshidze. Gauteng State of Health. Ritshidze; 2021. Padarath A, Moeti TL. South African Health Review 2022: health systems recovery after COVID-19. South African Health Review. 2023;25. City of Ekurhuleni. Ekurhuleni Health Facilities In The Lead In Gauteng. 2021 [Available from: https://www.ekurhuleni.gov.za/press-releases/health/ekurhuleni-health-facilities-in-the-lead-in-gauteng/. Sulla V, Zikhali P. Overcoming poverty and inequality in South Africa: An assessment of drivers, constraints and opportunities. The World Bank; 2018. Jaipaul CK, Rosenthal GE. Are older patients more satisfied with hospital care than younger patients? Journal of general internal medicine. 2003;18:23-30. World Health Organization (WHO). Consolidated guidelines for the use antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach - 2nd ed. Geneva: WHO; 2016. South African National Department of Health. Guidelines for Expanding Combination Prevention and Treatment Options for Sex Workers: Oral Pre-Exposure Prophylaxis (PrEP) and Test and Treat (T&T). Pretoria, South Africa 2016. Joint United Nations Programme on HIV/AIDS (UNAIDS). Understanding Fast-Track Targets: accelerating action to end the AIDS epidemic by 2030. Geneva2015. Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Globalization and health. 2015;11:1-17. Abrahams G, Thani X, Kahn S. South African public primary healthcare services and challenges: considerations during the Covid-19 pandemic. Administratio Publica. 2022;30(2):63-85. McDowell I. Social Networks, Social Support, and Health. In: McDowell I, editor. Understanding Health Determinants: Explanatory Theories for Social Epidemiology. Cham: Springer International Publishing; 2023. p. 365-400. Leahy-Warren P. Social support theory. Theories guiding nursing research and practice: Making nursing knowledge development explicit. New York, NY, US: Springer Publishing Company; 2014. p. 85-101. Bellio E, Buccoliero L. Main factors affecting perceived quality in healthcare: a patient perspective approach. The TQM Journal. 2021;33(7):176-92. Ellis S. The patient-centred care model: holistic/multiprofessional/reflective. British Journal of Nursing. 1999;8(5):296-301. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Nov, 2024 Editor assigned by journal 07 Nov, 2024 Submission checks completed at journal 07 Nov, 2024 First submitted to journal 05 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5396262","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":375698265,"identity":"7b604e44-5d17-4a8f-9a57-506a9fcf826d","order_by":0,"name":"Idah 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1","display":"","copyAsset":false,"role":"figure","size":37172,"visible":true,"origin":"","legend":"\u003cp\u003ePatient perceived quality of care by Ideal Clinic status\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5396262/v1/688e3b9e316cf2aea36fec3c.png"},{"id":71003409,"identity":"ac407cb3-8b85-4c5d-89e3-13ba792779cb","added_by":"auto","created_at":"2024-12-10 06:02:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":389197,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePatient level determinants of perceived quality of care\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5396262/v1/ec130db7ae92649cb604ca6f.png"},{"id":71003399,"identity":"345874a9-98b6-4ff2-93d7-524fc2d953db","added_by":"auto","created_at":"2024-12-10 06:02:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":338872,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFacility level determinants of perceived quality of care\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5396262/v1/b754709471ed69027b516d2e.png"},{"id":71004712,"identity":"e382656c-0c78-4eee-a0a6-eef92121c8e7","added_by":"auto","created_at":"2024-12-10 06:10:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1767972,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5396262/v1/f26fb85d-21e4-47ff-b8c7-ce2e8a92238e.pdf"},{"id":71003397,"identity":"eaa98a1e-c28b-4e51-8eaf-09f7bf071191","added_by":"auto","created_at":"2024-12-10 06:02:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13994,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5396262/v1/517079451497f9d709d48883.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient’s perceived quality of care in South Africa’s public health sector: gratitude for access or ideal care experience","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eIn South Africa, primary healthcare (PHC) is the backbone of the healthcare delivery system and is necessary to achieve Universal Health Coverage (UHC) (1, 2). The South African government has made considerable strides in improving access to healthcare for all its citizens (1, 3). As a result, over 90% of the population has free access to primary healthcare at over 3500 PHC facilities within 5 kilometres of their homes or work, supported by a community-based network of outreach teams (2, 4). However, a multifaceted burden of infectious and non-communicable diseases, historical inequalities in healthcare delivery, and poor management and leadership place immense strain on the health system (1, 5, 6). Consequently, attaining universal access to efficient, high-quality, and appropriate healthcare is at risk.\u003c/p\u003e \u003cp\u003eThe Ideal Clinic Realization and Maintenance (ICRM) program was launched in July 2013 to improve the quality of care at the PHC level and ensure compliance with the national core standards for healthcare facilities (7, 8) in preparation for the implementation of the National Health Insurance (NHI) (9, 10). The program defines an Ideal Clinic as one with appropriate infrastructure, sufficient staff, necessary medicine and supplies, efficient administrative processes, and support from partners and stakeholders to deliver high-quality healthcare services to the community (11\u0026ndash;13). The program involves annual assessments and grading of facilities using the ICRM manual and tools. Facilities are assigned certification status based on how they are scored on the tool during the assessment, ranging from platinum (the highest certification) to gold, silver, or not-achieved (N/A). Managers receive guidance for quality improvement actions based on the assessment results to enhance the functioning and quality of the facilities to ensure that they meet established standards and continuously improve their quality of care (12\u0026ndash;14).\u003c/p\u003e \u003cp\u003eIt is uncertain whether ICRM certification improves patient experience or aligns with patients' expectations for quality care. Patient perception of quality of care refers to an individual's personal evaluation or assessment of the healthcare services they have received. It is based on the patient's own experiences, observations, and opinions about different aspects of their care. These aspects include the interactions with healthcare providers, how effective the treatments were, how timely the services were, how comfortable and convenient the facilities were, and overall satisfaction with their healthcare experience (15).\u003c/p\u003e \u003cp\u003eDespite the ICRM program being prioritised to enhance service delivery and patient experience at the PHC level, reports of negative patient experiences persist (16, 17). These negative experiences include long waiting times, lack of privacy, communication barriers, poor staff attitude, and infrastructure challenges. Furthermore, there has been a lack of national assessments regarding the program's impact on the quality of health services at the PHC level. Therefore, our study aims to examine the consistency between patients' perception of the quality of care received at public PHC facilities and their overall care experience, investigate the ICRM program's influence on this relationship, and identify the factors associated with patient's perceived quality of care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch3\u003eStudy design and population\u003c/h3\u003e\n\u003cp\u003eThe current analysis was part of a larger mixed-methods cross-sectional study conducted in Gauteng to examine the implementation of the ICRM programme from health provider perspectives and patient experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study sampled 10% (~45) of public-sector primary healthcare facilities (primary healthcare clinics (PHCs), Community Health Centers (CHCs), and Community Day Centers (CDCs)), stratified by district and the 2018 ICRM certification level (Supplementary file 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe report on results from the review of the impact of the ICRM classifications on patients\u0026apos; experiences and perceived quality of care conducted among adults aged 18 years or older seeking care in sampled facilities from February to August 2021. We aimed to recruit 40 patients per facility across participating facilities\u0026nbsp;(N=1800) in the general service-specific waiting areas across four broad service areas: HIV/TB, Non-communicable diseases, Sexual and reproductive services (including obstetric services), and casualty/emergency services (CHCs and day hospitals). Patients were eligible to be enrolled if they were at least 18 years old, were well enough to consent, and were present for a personal clinic visit. The study questionnaire included questions about their recent experience at the selected facility, and their assessment of the quality of the care received.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eEligible patients who provided written consent completed a structured study questionnaire at study enrolment. The questionnaire assessed participants\u0026rsquo; experiences with clinic services and their perception of the quality of care received. We also assessed patient and clinic factors that could affect patient experiences, including clinic size and location, conditions currently being treated at the clinic, and the main reason for the current clinic visit at study enrolment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe information sheet and questionnaire were available in English, Sesotho, and isiZulu, which are widely spoken and understood in Gauteng. All patients were recruited and interviewed by trained study interviewers.\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003ch4\u003e\u003cem\u003ePatient perceived quality of care outcome\u0026nbsp;\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eThe primary outcome of the study was the perceived quality of care assessed using a 10-item measure with a 5-point scale ranging from one (strongly disagree) to five (strongly agree) (Cronbach\u0026rsquo;s alpha = 0.67). The tool included statements relating to different aspects of the patient\u0026rsquo;s care experience at the facility, including provider attitude, privacy and confidentiality, provider-patient communication, provider competency, and clinic amenities. We computed mean scores for overall perceived quality of care, with higher scores reflecting higher perceived quality of care. The mean score was categorised as either high (\u0026gt;=3.5) or not high (\u0026lt;3.5), indicating, on average, item responses were in agreement or above \u0026lsquo;uncertain\u0026rsquo;. The tool has been validated in South Africa among HIV, TB, and diabetes patients in the primary healthcare setting (12-14).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAnalytic variables\u003c/h3\u003e\n\u003cp\u003eSociodemographic factors assessed include age, sex, highest education completed, English literacy, marital status, living with a partner/spouse, employment status, social grant received in the household, type of settlement they live in, and duration of living in the current community. We also assessed factors related to healthcare access, including health conditions currently being treated at the clinic (HIV/TB, Diabetes /Hypertension, and mental health or other conditions) and the main reason for the current clinic visit at study enrolment (HIV/TB, Hypertension/Diabetes, pregnancy/ child health or family planning or other reasons). ICRM-related factors assessed include the clinic ICRM certification at study enrolment (2021) (platinum, gold, silver, or not achieved). We also created an ICRM status change variable by comparing each participating clinic\u0026rsquo;s latest (2021) ICRM certification status with the certification used for sampling (2018) and categorised it as improved, no change, or regressed. We also assessed whether the clinic implemented an appointment system (yes-time /timeslot appointments, yes-appointment day, or no-appointment system) based on facility assessments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinic-level characteristics assessed include the district the clinic is in (City of Johannesburg (COJ), Ekurhuleni, Sedibeng, Tshwane, and West Rand) and the type of clinic (PHC, CHC, or CDC). We defined an informal urban clinic area locality as an area that included a large section of informal (shacks) dwellings; formal urban areas were more built-up areas with formalised infrastructure, while rural areas had low population density and smaller population settlements outside a town. The clinic size was determined using the nurse-patient per day ratio calculated by dividing the average headcount per month by the number of rooms in the facility and days in a month. We dichotomised the final nurse-patient per day ratio to \u0026lt;30 and \u0026gt;=30. Additionally, the number of patients on antiretroviral therapy (ART) currently managed at the site was sourced from each clinic\u0026rsquo;s Three Interlinked Electronic Registers (TIER.Net) data platform used to collect data for HIV patients. We categorised this as \u0026lt;2500 or \u0026gt;=2500 based on the median among the sampled clinics.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData analysis\u003c/h3\u003e\n\u003ch4\u003e\u003cem\u003eQuantitative data analysis\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eWe describe participant and clinic characteristics\u0026nbsp;using proportions, frequencies, means with standard deviation, and medians with interquartile ranges (IQR) as appropriate. We assessed factors associated with high perceived quality of care using Modified Poisson regression models, and we report crude Relative Risk Ratio (RRR) and 95% confidence intervals (95% CI) due to the small sample size (effective sample=45). All analyses were completed using STATA version 16/17 (Stata Corporation, College Station, Texas, USA). STATA survey commands were used to adjust for sampling probability weights.\u003c/p\u003e\n\u003ch4\u003e\u003cem\u003eQualitative data analysis\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eQualitative data from open-ended questions were analysed thematically using an Excel-based tool. The analysis involved reading respondents\u0026apos; open-ended comments by the study team to identify emerging themes. The process was repeated until no new themes emerged. After that, themes were assigned codes accordingly.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003ch3\u003eSurvey respondents\u0026rsquo; sociodemographic characteristics\u003c/h3\u003e\n\u003cp\u003eTable 1 presents descriptive statistics for patients surveyed and participating clinics, stratified by district. Although clinic enrolment into the study was proportional to the district size (~10% of clinics in each district), 40 patients/selected facilities were enrolled, with a total of 1788 of the total 1800 target sample.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough participants were randomly selected in the clinic\u0026apos;s general waiting area, 80.1% were female participants with a median age of 33 years, IQR (27.0-41.0). Overall, 55.7% were employed, with 53.0% living in a household that received social grants. Most (89.0%) of the study participants lived in townships or informal settlements; 50.4% lived in their current community for over five years. Overall, 40.9% surveyed patients were receiving ongoing HIV/TB care at the facility, and around 78.5% of these accessed HIV/TB services on the survey day. A third of patients were visiting the clinic to seek HIV/TB services, and a similar proportion sought family planning services during study enrolment.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCharacteristics of facilities surveyed\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eOverall, 45% of clinics surveyed were in urban informal areas and 51.7% in urban formal areas, while two clinics were in rural settings. The majority (84.0%) were PHC facilities, 10.7% were CHC and 5.3% CDCs. Over 50% of study participants were from clinics with a platinum 2021 ICRM status, while 22.4% were from clinics with a Gold certification. Overall, most facilities improved their ICRM classification between 2018 and 2021. However, over 20% regressed, and most facilities classified as \u0026ldquo;Not Achieved\u0026rdquo; (NA) retained this status. Moreover, 16% of patients surveyed were from facilities that regressed their certification status, while the majority (54.2%) were from facilities that improved.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eSociodemographic characteristics of study participants (n=1788)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"689\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJohannesburg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEkurhuleni\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSedibeng\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTshwane\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWest Rand\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003eNo. (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003eNo. (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003eNo. (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003eNo. (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003eNo. (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003eNo. (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e395 (74.1-79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e334 (72.8-80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e142 (81.3-93.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e302 (78.1-88.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e264 (80.4-83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,437 (77.9-82.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, Med (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e33 (27-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e32 (26-39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e33 (25-41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e34 (28-42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e33 (27-43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e33 (27-41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e18-29.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e181 (28.0-41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e176 (34.3-46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e60 (29.4-47.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e117 (28.0-39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e107 (27.7-37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e641 (32.7-39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e30-39.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e195 (34.7-42.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e152 (30.4-40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e47 (22.1-37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e126 (31.2-38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e116 (27.6-50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e636 (33.2-38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e40+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e139 (22.4-32.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e109 (19.8-29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e53 (27.0-39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e113 (27.0-36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e97 (22.1-37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e511 (25.6-31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e124 (18.5-31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e68 (12.0-18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e26 (11.7-22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e89 (18.4-31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e57 (8.6-20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e364 (16.7-22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eIn a relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e235 (38.9-50.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e243 (48.0-62.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e84 (43.6-62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e165 (40.9-55.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e162 (40.1-64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e889 (46.1-53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNot in a relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e156 (25.2-38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e122 (23.1-36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e49 (25.7-36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e100 (21.9-34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e100 (26.2-43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e527 (27.3-33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLives with spouse/partner?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e109 (17.2-24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e121 (22.3-32.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e39 (21.1-28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e66 (14.3-25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e73 (17.8-29.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e408 (20.5-25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes, husband or wife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e126 (19.3-30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e76 (13.9-21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e25 (10.3-22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e91 (18.4-34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e52 (7.0-18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e370 (17.2-23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes, regular partner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e121 (17.1-30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e114 (21.5-31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e46 (23.0-36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e95 (23.6-30.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e93 (24.7-38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e469 (23.5-29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNot in a relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e156 (25.4-38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e122 (23.1-36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e49 (25.7-36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e100 (22.0-35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e100 (26.2-43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e527 (27.4-33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnglish literacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eI can read well\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e456 (84.2-93.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e350 (71.5-86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e135 (79.5-88.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e319 (88.1-93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e260 (71.0-86.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,520 (82.1-88.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eI can read somewhat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e54 (6.2-15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e81 (12.9-26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e20 (8.8-18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e25 (5.7-10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e38 (7.6-15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e218 (9.7-15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eI cannot read\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e4 (0.2-2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e6 (0.5-4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e4 (0.7-8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e3 (0.4-2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e21 (5.9-14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e38 (1.3-4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eHigh school or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e243 (40.5-52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e223 (44.2-57.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e94 (52.6-64.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e193 (46.6-60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e175 (39.5-67.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e928 (47.5-55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eCompleted Matric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e181 (32.1-40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e149 (27.7-42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e43 (22.5-31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e97 (221.-36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e100 (22.1-44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e570 (29.6-36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e90 (13.2-21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e64 (10.0-19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e23 (9.0-22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e65 (11.8-25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e44 (6.0-28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e286 (13.1-18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e265 (45.6-58.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e177 (37.0-45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e56 (30.1-40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e169 (36.6-57.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e122 (26.2-45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e789 (40.2-48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e248 (41.3-54.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e257 (54.9-63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e103 (59.3-69.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e186 (42.3-63.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e198 (54.4-73.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e992 (51.6-59.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of settlement they live in\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eTown/Suburb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e98 (9.9-43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e39 (3.7-17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e12 (2.3-23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e80 (7.0-48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e77 (2.2-24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e306 (8.9-24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eTownship/Location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e358 (49.1-85.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e336 (65.9-91.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e134 (67.1-95.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e184 (33.0-74.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e214 (72.1-93.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,226 (64.0-82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026nbsp;Informal settlement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e32 (3.6-12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e52 (4.5-19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e9 (2.4-13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e81 (10.9-46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e16 (2.8-15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e190 (7.0-16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration living in current community\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026lt;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e331 (57.6-75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e159 (30.4-45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e34 (19.3-24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e173 (39.2-60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e173 (36.2-68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e870 (42.9-56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026gt;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e180 (24.1-42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e271 (55.0-69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e121 (75.2-80.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e176 (40.0-60.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e146 (31.7-63.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e894 (43.7-57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReason for clinic visit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eHIV/TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e162 (26.8-40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e174 (33.0-46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e47 (22.6-36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e104 (23.2-37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e100 (22.4-41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e587 (30.0-37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eDiabetes/Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e37 (4.2-9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e22 (2.3-7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e21 (7.2-21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e26 (4.5-10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e34 (6.0-13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e140 (5.5-8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003ePregnancy/child health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e136 (19.6-35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e103 (20.1-29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e40 (15.4-39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e118 (26.4-38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e66 (14.2-27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e463 (22.8-29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eFam pl/other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e175 (28.0-39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e131 (26.0-38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e52 (25.9-40.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e107 (22.7-40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e119 (33.1-46.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e584 (30.1-36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeing treated for HIV/TB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e322 (54.0-68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e230 (49.6-57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e87 (48.2-60.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e226 (53.6-70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e201 (50.6-73.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,066 (55.4-62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e193 (31.5-46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e207 (42.6-50.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e73 (39.1-51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e130 (29.2-46.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e119 (26.8-49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e722 (37.3-44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeing treated for Hypertension/ Diabetes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e454 (85.1-91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e389 (86.5-93.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e124 (69.5-84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e322 (86.1-94.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e264 (81.0-87.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,553 (85.5-89.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e61 (8.5-14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e48 (7.0-13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e36 (15.6-30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e34 (5.9-13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e56 (12.6-19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e235 (10.2-14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeing treated for other chronic conditions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e247 (39.5-57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e309 (64.2-74.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e114 (56.1-82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e158 (37.7-52.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e176 (42.5-62.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,004 (50.9-61.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e268 (42.5-60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e128 (25.5-35.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e46 (18.0-43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e198 (47.1-62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e144 (37.4-57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e784 (38.8-49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICRM status (2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNot achieved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e117 (8.8-59.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e41 (1.4-50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e40 (1.7-57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e81 (5.1-74.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e279 (8.2-34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eSilver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e40 (2.8-75.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e81 (9.5-80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e121 (2.4-22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eGold\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e79 (4.1-50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e80 (2.4-37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (12.1-89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e80 (6.5-65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e79 (4.9-73.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e398 (11.7-38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003ePlatinum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e319 (26.9-80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e316 (45.9-93.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e40 (3.2-78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e236 (25.8-86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e79 (0.8-19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e990 (36.3-67.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICRM status change (2018-2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e160 (6.7-57.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e41 (0.7-33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e40 (3.2-78.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e120 (10.3-69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e159 (5.6-67.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e520 (11.2-37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eRegressed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e37 (1.2-47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e81 (3.5-50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e40 (2.8-75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e40 (1.7-57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e82 (12.5-84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e280 (8.8-35.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e278 (34.9-88.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e315 (45.8-93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (12.1-89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e196 (21.5-82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e79 (4.9-73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e948 (43.4-74.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eCDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (12.1-89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e80 (1.3-19.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eCHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e40 (1.2-46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e41 (1.4-50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e77 (6.2-64.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e158 (3.9-26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003ePHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e475 (53.3-98.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e396 (49.1-98.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (11.0-87.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e279 (35.8-93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e320 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,550 (68.0-92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinic area locality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eUrban Informal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e237 (14.8-66.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e201 (20.6-76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (11.0-87.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e200 (22.5-82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e79 (9.1-80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e797 (29.6-60.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eUrban Formal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e278 (33.2-85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e236 (23.3-79.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (12.1-89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e116 (9.8-67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e200 (9.3-78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e910 (33.9-65.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e40 (1.7-57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e41 (3.1-74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e81 (1.4-21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal on ART\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026lt;2500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e80 (4.5-52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e198 (20.0-76.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (11.0-87.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e160 (14.4-74.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e241 (27.0-96.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e759 (26.5-57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026gt;=2500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e435 (47.3-95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e239 (24.0-80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e80 (12.1-89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e196 (26.0-85.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e79 (3.7-73.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,029 (42.7-73.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNurse, patient per day ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026lt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e159 (8.9-58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e81 (5.2-57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e40 (3.2-78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e236 (30.7-89.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e280 (66.0-99.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e796 (27.4-58.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003e\u0026gt;=30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e356 (41.7-91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e356 (42.5-94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e120 (21.6-96.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e120 (10.3-69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e40 (0.6-34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e992 (41.5-72.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31.4949%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinic appointment system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eNo appointment system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e39 (1.1-45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e40 (0.7-32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e40 (1.7-57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e119 (2.0-20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes - appointment days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e317 (38.0-90.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e356 (49.1-96.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e160 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e157 (11.2-67.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e320 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e1,310 (9.5-35.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.8679%;\"\u003e\n \u003cp\u003eYes - appointment times/time slots\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.627%;\"\u003e\n \u003cp\u003e119 (5.4-54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e41 (1.4-51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0624%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e159 (21.8-82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.4978%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.9492%;\"\u003e\n \u003cp\u003e319 (9.5-35.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eMed, median; IQR, interquartile range; HIV, human immunodeficiency virus; TB, tuberculosis; ICRM, ideal clinic realisation and maintenance; CDC, community day centre; CHC, community health centre; PHC, primary health clinic, ART, antiretroviral treatment\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003ePatients\u0026rsquo; perceived quality of care\u003c/h3\u003e\n\u003cp\u003eOverall, 70.2% (95% CI: 63.6-76.0) of participating clinic patients perceived the quality of primary healthcare services as high (Figure 1). Patient-perceived quality of health care was similarly high across the 2021 ICRM status certification. Yet, a clinic that did not achieve accreditation in 2021 had a lower percentage of patients who perceived the quality of care as high.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003e Patient perceived quality of care by Ideal Clinic status\u003c/p\u003e\n\u003ch3\u003ePatient level determinants of high perceived quality of care\u003c/h3\u003e\n\u003cp\u003ePatient factors associated with high perceived quality of care are described in Figure 2. \u0026nbsp; \u0026nbsp; \u0026nbsp;Older patients were more likely to report high quality of care compared to younger patients (RRR 1.3 for 30-39 years old vs 18-30 years, 95% CI: 1.0-1.7, RR 1.7 for being \u0026ge;40 years vs 18-30 years, 95% CI: 1.3-2.1). Similarly, those currently treated for HIV/TB at the clinic compared to those who received other care (RRR 1.3, 95% CI: 1.0-1.7). Compared to married patients, those in a relationship were less likely to report high-quality of care (RRR 0.7, 95% CI: 0.5-0.9). Overall, patients who had lived in their current communities for five years or longer were also likely to report lower quality of care (RRR 0.5 vs living in the area for \u0026lt;5 years, 95% CI: 0.4-0.7). Similarly, those that came for pregnancy or child health-related service on the day of study enrolment (RRR 0.7 vs HIV/TB, 95% CI: 0.5-0.9).\u003c/p\u003e\n\u003ch3\u003eFacility level determinants of high perceived quality of care\u003c/h3\u003e\n\u003cp\u003ePatient perception of quality of care did not differ significantly by facility-level characteristics except by district (Figure 3). Patients attending clinics based in Ekurhuleni were less likely to report their quality of care as high than facilities in the City of Johannesburg (RRR 0.25, 95% CI: 0.13-0.48). Patients\u0026rsquo; perception of quality of care did not differ significantly by the current facility ICRM status (RRR 1.3 for Gold vs Platinum, 95% CI: 0.6-2.7; RRR 1.0 for Silver vs Platinum, 95% CI: 0.4-2.5; RRR 0.8 for Silver vs Platinum, 95% CI: 0.3-1.8), nor by a change in ICRM status between 2018-2021 (RRR 1.6 for No change vs Improved, 95% CI: 0.8-3.3; RRR 0.7 for Regressed vs Improved, 95% CI: 0.3-1.2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2. Patient level determinants of perceived quality of care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3. Facility level determinants of perceived quality of care\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy participants highlighted the clinic\u0026rsquo;s proximity to their homes or place of work as the primary reason for attending the chosen clinic. Although most (70%) patients reported the service as acceptable or good, they had complaints regarding their overall experience at the clinic. The feedback themes, including participant sex, age, and current services or diseases being treated at the clinic, are summarized in Table 2.\u003c/p\u003e\n\u003cp\u003eAlthough patients reported coming to the clinic very early, they found very long queues. For the most part, clinics did not have outside shelter or enough seating in the waiting areas, considering the long wait they had to endure. These interviews were conducted during COVID-19 restrictions, and queuing was only allowed outside facilities for social distancing. While patients acknowledged that staff shortages challenged clinics, they also attributed the long waiting times to inefficiencies in clinics\u0026rsquo; appointment systems and patient record management. They also highlighted poor time management among staff who are seen as purposefully slow, going on breaks at the same time with no consideration for the patients. Patients also bemoaned disrespectful treatment from clinic staff, with reports of being scolded. Finally, they wanted clinic staff to be more professional and communicate better with them, including better communication about the processes for ensuring that queues moved and reasons for undue delays.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients also highlighted the lack of privacy, with nurses sometimes sharing consulting rooms. Patients highlighted that the clinics were too small and no longer matched the size of the population seeking service.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Illustrative quotes from patient-reported experiences at the facility\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative quote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003eFacility infrastructure and cleanliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The service of our clinic is average; we wait outside in the cold weather even before COVID due to space issues in the clinic.\u0026rdquo; \u0026ndash; Female, 43 years old, Other chronic disease services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The service is okay. Patients see the improvement of the clinic because last time 2018 it was a small room but at same time wish the government can build the clinic for patients and the population is growing.\u0026rdquo; \u0026ndash; Male, 33 years old, Acute/ preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They facility/government have to look population is increasing around this area in terms of extending the clinic. The service it not bad at all.\u0026rdquo; \u0026ndash; Male, 39 years old, Acute/ preventative services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003ePatient waiting times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We stay long in the queues before we can receive a file. Waiting long at the pharmacy as well, no time management.\u0026rdquo; \u0026ndash; Female, 33 years old, Acute/ preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There are papers written 120 minutes waiting time and sometimes we wait for more than that but there is nothing like 120 minutes in this clinic and we don\u0026apos;t know what does it mean but because we have to get the services we want, we should wait.\u0026rdquo; \u0026ndash; Male, 61 years old, Other chronic disease services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I like attending here at this facility as it\u0026apos;s closer to my home. Overall experience is good except for long waiting hours and numbering system which is not followed.\u0026rdquo; \u0026ndash; Male, 27 years old, Acute/ preventative services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003ePrivacy and confidentiality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There is no privacy here at the clinic. People come in and out of the consultation and staff don\u0026apos;t reprimand them.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I need privacy in consultation room. I don\u0026apos;t feel comfortable to see a sister with another colleague in the same consultation room.\u0026rdquo; \u0026ndash; Male, 46 years old, HIV/TB services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003eStaff communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The service is poor, no communication, staff admin, they don\u0026apos;t attend patient in reception end up not knowing where to go.\u0026rdquo; \u0026ndash; Male, 33 years old, Acute/ preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Not sure what causes this, but I think patients sometimes wait for help for too long and there is never a communication to say what\u0026apos;s the reason\u0026rdquo; \u0026ndash; Female, 42 years old, HIV/TB services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003eStaff shortages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The only thing I don\u0026apos;t really like here is that they are always short staffed and we tend to wait for long.\u0026rdquo; \u0026ndash; Female, 42 years old, Acute/preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The staff is not enough and we can blame them for staying long in the facility and there is too much people\u0026rdquo; \u0026ndash; Female, 23 years old, Acute/preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They should add more staff. They are always complaining that they don\u0026apos;t have staff but don\u0026apos;t make any changes about it.\u0026rdquo; \u0026nbsp;\u0026ndash; Male, 46 years old, HIV/TB services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.9677%;\"\u003e\n \u003cp\u003eStaff attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79.0323%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We all know the health care workers are always under pressure as they work with different kinds of people every day, but they need to be very much respectful to some of us who are seeking help politely\u0026rdquo; \u0026ndash; Female, 25 years old, Acute/preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I like attending at this facility they give us medication whenever we are not feeling well however they tend to have attitudes by asking us why we don\u0026apos;t go and buy medication at the pharmacy.\u0026rdquo; \u0026ndash; Female, 23 years old, Acute/preventative services\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was judged for asking help during my first pregnancy, instead of them accommodating me. They told me I was too young to be here, I was even afraid to ask for another alternative I could during that course. That thing made me to feel scared when attending the health facilities, I don\u0026apos;t wish for that to happen again. It\u0026apos;s was so unprofessional on their side.\u0026rdquo; \u0026ndash; Female, 23 years old, Other\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe perspectives of patients regarding the quality of care are gaining increasing importance in evaluating and reforming healthcare services. To our knowledge, this is one of the first studies to explore the ICRM programme\u0026apos;s effect on patient-perceived quality of care. Among our study participants, 70.2% reported perceiving their care quality as high. Notably, patient perception of care quality did not differ based on ICRM certification status or changes in certification status over time. However, it did differ by district, where patients receiving care at facilities in Ekurhuleni district were less likely to perceive their quality of care as high\u0026nbsp;which\u0026nbsp;is surprising, considering that the district achieved the highest percentage of Ideal Clinics in Gauteng in 2021\u0026nbsp;(18, 19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA patient experience survey conducted in 2017 across a random sample of 168 primary healthcare facilities in South Africa demonstrated a moderately positive correlation between ideal clinics and patient satisfaction, with an overall satisfaction rate of 76.5% and 82.2% among clinics with high ICRM scores (15). In our survey of Gauteng clinics, a majority of patients reported high-quality care and positive experiences. However, higher ICRM accreditation status did not lead to improved patient perception of care quality (16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOlder patients and those receiving HIV/TB services at the clinic were more likely to report receiving high quality of care, possibly due to improved access to healthcare by the South African government\u0026nbsp;(1, 20). The longer experience of older patients with the healthcare system may have led to expectations more in line with the system\u0026apos;s standards, despite its limitations\u0026nbsp;(21). Additionally, the recent increase in investment in HIV/TB care at the primary healthcare level may have significantly improved the care experience of patients by addressing previous issues related to treatment access\u0026nbsp;(22-24).\u0026nbsp;Patients seeking pregnancy or child health services reported low quality of care, with persisting issues in health provider attitudes and behaviours which have been shown to affect patient satisfaction and may lead to reluctance to seek care\u0026nbsp;(25). Patients in long-term relationships and those who have lived in their community for five years or more are less likely to report receiving high-quality care. As communities grow, access to care and quality may decline, as the infrastructure and staffing struggle to keep up with increased demands\u0026nbsp;(26). Additionally, social support among patients in relationships can raise expectations for the quality of healthcare they receive\u0026nbsp;(27, 28).\u003c/p\u003e\n\u003cp\u003eIt is evident that current measures of patient satisfaction do not accurately reflect the true sentiments patients have towards their lived care experiences, when compared against the standards of the healthcare system. Notably, nearly one-third of patients who reported high perceived care quality also expressed concerns about their clinic experiences. A study conducted in Mpumalanga province among clinic patients in public health services showed that although 87.8% of patients reported satisfaction with nursing care, only 64.8% would recommend the clinic to others in the community (17). Enhancing patients\u0026apos; expression of care quality can be achieved by addressing the challenges prevalent in clinics while ensuring high access to care (16, 18).\u0026nbsp;Patients acknowledged the difficulties faced by clinics, but their complaints mainly revolved around inefficiencies in workflow, such as poor staff time management, inadequate communication about queues and waiting times, and overall disrespectful communication. The perceived quality of care may not always align with objective measures or clinical outcomes. Factors such as communication, empathy, and patient-centeredness heavily influence how patients perceive the quality of their care\u0026nbsp;(29). It\u0026apos;s important to empower patients to expect higher quality care and include their complete experiences in satisfaction surveys. Surveys should cover factors like time spent in clinics, staff communication, and navigation through different section\u0026nbsp;(30). By actively seeking and addressing patient feedback, healthcare systems can work towards providing care that meets patients\u0026apos; expectations, preferences, and values, ultimately leading to improved patient satisfaction, engagement, and better health outcomes\u0026nbsp;(16, 29, 30).\u003c/p\u003e\n\u003cp\u003eThe provision of quality care depends on health systems and providers involving patients in decision-making (30). Recognizing that healthcare providers have their own professional, physical, and emotional needs is essential to providing quality care. A positive work environment, ongoing training, effective leadership, collaborative teamwork, and adequate resources have been identified as facilitators for healthcare providers to deliver patient-centred care (30). Moreover, healthcare providers associate care quality with inadequate infrastructure and insufficient accountability and support from district and provincial authorities more than national quality standards (19).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eLIMITATIONS:\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe facility sample consisted of about 10% of primary healthcare clinics in Gauteng stratified by districts and ICRM accreditation status in 2018 because of data availability. The distribution of ICRM accreditation status in Gauteng is skewed toward the Platinum classification limiting our ability to appropriately compare facilities that had not achieved (NA) certification and Silver facilities to Gold and Platinum clinics in some districts. Nevertheless, the sample included as many NA and Silver clinics as possible at during sampling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The list of HIV interventions explored in this study is not exhaustive and consists of programmes that we purposely selected for review in this phase of the survey. Further research is needed to review other areas of synergies between HIV and other chronic conditions and ICRM health system improvement guidelines.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003ePatients\u0026rsquo; perception of quality of care may be partly driven by gratitude for the widespread access to free care. When assessing patient experiences with care quality measures must give equal weighting to non-clinical experiences of care such as waiting-time, communication which are essential determinants of improved care-seeking behaviours, particularly among patients in lifelong chronic care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePHC Primary Healthcare\u003c/p\u003e\n\u003cp\u003eUHC Universal Health Coverage\u003c/p\u003e\n\u003cp\u003eICRM Ideal Clinic Realisation and Maintenance\u003c/p\u003e\n\u003cp\u003eNHI National Health Insurance\u003c/p\u003e\n\u003cp\u003eNot Achieved NA\u003c/p\u003e\n\u003cp\u003eCHC Community Health Centre\u003c/p\u003e\n\u003cp\u003eCDC Community Day Centres\u003c/p\u003e\n\u003cp\u003eHIV Human immunodeficiency virus \u003c/p\u003e\n\u003cp\u003eTB Tuberculosis\u003c/p\u003e\n\u003cp\u003eCOJ City of Johannesburg\u003c/p\u003e\n\u003cp\u003eTIER.Net Three Interlinked Registers\u003c/p\u003e\n\u003cp\u003eIQR Interquartile Range\u003c/p\u003e\n\u003cp\u003eRRR Relative Risk Ration\u003c/p\u003e\n\u003cp\u003eCI Confidence Interval\u003c/p\u003e\n\u003cp\u003eCOVID-19 Coronavirus disease of 2019\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Human Ethics Research Committee (Medical)\u0026nbsp;of the\u0026nbsp;University of the Witwatersrand (protocol M201081). All participants provided written informed consent before all data collection procedures. Confidentiality and anonymity were safeguarded by removing all participant identifiers from the data.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and material\u003c/h3\u003e\n\u003cp\u003eQualitative data extracts are presented in the article to support the findings. The original transcripts are not available to the public as they may contain information that could compromise the confidentiality of study participants. All relevant data is included in the paper.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch3\u003eFunding\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThis study has been made possible by the generous support of the American People and the President\u0026apos;s Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of Cooperative Agreement 72067419CA00004 to the Wits Health Consortium. The contents are the responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAuthor Contributions\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDO conceptualised the study and paper. contributed to the study design and interpretation of the results. IM conducted the primary data analysis. IM managed the study implementation and contributed to the result interpretation. RC, CN, SK, AK and NM managed district-level study implementation and contributed to the result interpretation. NJ and JM critically provided feedback on the manuscript. All authors reviewed and approved the manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWe extend our gratitude to the data collection team (Annah Morifi, Alice Kono, Nonhlanhla Tshabalala, Portia Ngwenya, Hazel Tau, Melda Musina, Michael Motapo, and Sinethemba Madlala.) for their diligent support during the study implementation. Additionally, our sincere thanks go to the Gauteng Province, the National Department of Health of South Africa and the staff of participating clinics for accommodating the study. Our thanks also go to the patients attending participating clinics for sharing their valuable information that made this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMayosi BM, Benatar SR. 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PEOPLE\u0026rsquo;S COP20 \u0026ndash; COMMUNITY PRIORITIES \u0026ndash; SOUTH AFRICA. Ritshidze; 2020.\u003c/li\u003e\n\u003cli\u003eRitshidze. Gauteng State of Health. Ritshidze; 2021.\u003c/li\u003e\n\u003cli\u003ePadarath A, Moeti TL. South African Health Review 2022: health systems recovery after COVID-19. South African Health Review. 2023;25.\u003c/li\u003e\n\u003cli\u003eCity of Ekurhuleni. Ekurhuleni Health Facilities In The Lead In Gauteng. 2021 [Available from: https://www.ekurhuleni.gov.za/press-releases/health/ekurhuleni-health-facilities-in-the-lead-in-gauteng/.\u003c/li\u003e\n\u003cli\u003eSulla V, Zikhali P. Overcoming poverty and inequality in South Africa: An assessment of drivers, constraints and opportunities. The World Bank; 2018.\u003c/li\u003e\n\u003cli\u003eJaipaul CK, Rosenthal GE. Are older patients more satisfied with hospital care than younger patients? Journal of general internal medicine. 2003;18:23-30.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Consolidated guidelines for the use antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach - 2nd ed. Geneva: WHO; 2016.\u003c/li\u003e\n\u003cli\u003eSouth African National Department of Health. Guidelines for Expanding Combination Prevention and Treatment Options for Sex Workers: Oral Pre-Exposure Prophylaxis (PrEP) and Test and Treat (T\u0026amp;T). Pretoria, South Africa 2016.\u003c/li\u003e\n\u003cli\u003eJoint United Nations Programme on HIV/AIDS (UNAIDS). Understanding Fast-Track Targets: accelerating action to end the AIDS epidemic by 2030. Geneva2015.\u003c/li\u003e\n\u003cli\u003eMannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Globalization and health. 2015;11:1-17.\u003c/li\u003e\n\u003cli\u003eAbrahams G, Thani X, Kahn S. South African public primary healthcare services and challenges: considerations during the Covid-19 pandemic. Administratio Publica. 2022;30(2):63-85.\u003c/li\u003e\n\u003cli\u003eMcDowell I. Social Networks, Social Support, and Health. In: McDowell I, editor. Understanding Health Determinants: Explanatory Theories for Social Epidemiology. Cham: Springer International Publishing; 2023. p. 365-400.\u003c/li\u003e\n\u003cli\u003eLeahy-Warren P. Social support theory. Theories guiding nursing research and practice: Making nursing knowledge development explicit. New York, NY, US: Springer Publishing Company; 2014. p. 85-101.\u003c/li\u003e\n\u003cli\u003eBellio E, Buccoliero L. Main factors affecting perceived quality in healthcare: a patient perspective approach. The TQM Journal. 2021;33(7):176-92.\u003c/li\u003e\n\u003cli\u003eEllis S. The patient-centred care model: holistic/multiprofessional/reflective. British Journal of Nursing. 1999;8(5):296-301.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Perceived quality of care, Quality assurance, Ideal clinic realization and maintenance, Primary Healthcare, South Africa","lastPublishedDoi":"10.21203/rs.3.rs-5396262/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5396262/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSouth Africa strives to close the quality divide between public and private healthcare services. However, it is unclear whether patients’ demands for access to care matches their desire for quality service. Therefore, we sought to determine if patients’ satisfaction with quality of care received in the public healthcare matches their overall care experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a mixed-methods cross-sectional survey from February to August 2021, enrolling 40 adult (\u0026gt;18 years) patients/clinics in waiting areas across a proportional sample (10%) of 45 public clinics in the Gauteng province (N=1800). Study participants completed a semi-structured questionnaire. High quality of care was defined as achieving a score\u0026gt;3.5 on a ten-item scale (Cronbach’s alpha= 0.67) measuring agreement with statements about care experiences, including staff communication, attitudes, and clinic amenities. Open-ended questions were analysed thematically and coded as complaints (yes/no).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 1788/1800 (99.3%) completed the survey, and 70.2% (95% Confidence Interval (CI): 63.6-76.0) of participants reported high quality of service, equivalent between HIV/TB (73.5, 95%CI: 66.0, 79.9) and non-HIV/TB care seekers (67.8%, 95%CI: 61.0, 73.9). Still, 31.7% of participants reporting high service quality had complaints. Overall, 69.6% (62.3%, 76.0) of participants deeming services low-moderate quality reported complaints. Participants’ complaints included long waiting times, clinic appointment system inefficiencies, staff shortages, and poor staff time management. Additionally, participants reported disrespectful treatment from clinic staff and very poor communication. It appears that the improved access to care compensated for sub-standard experiences, as illustrated by statements like:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I like attending here at this facility as it's closer to my home. Overall experience is good except for long waiting hours and numbering system which is not followed.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We all know the health care workers are always under pressure as they work with different kinds of people every day, but they need to be very much respectful to some of us who are seeking help politely”.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients’ perception of quality of care is partly driven by gratitude for the widespread access to free care. Still, quality measures must give equal weight to non-clinical experiences of care, such as waiting time and communication, which are essential determinants of improved care-seeking behaviours, particularly among patients in lifelong chronic care.\u003c/p\u003e","manuscriptTitle":"Patient’s perceived quality of care in South Africa’s public health sector: gratitude for access or ideal care experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-10 06:02:06","doi":"10.21203/rs.3.rs-5396262/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-08T10:17:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-07T07:03:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-07T07:03:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-11-05T14:25:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"975f0b44-5071-4269-853d-c2717160e6c2","owner":[],"postedDate":"December 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-12-10T06:02:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-10 06:02:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5396262","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5396262","identity":"rs-5396262","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}
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