Critical success factors in the maintenance strategies of public healthcare facilities

Building maintenance is essential for ensuring the safety, health, and longevity of a structure (Abisuga et al., 2017). Regular inspections and maintenance proactively address potential hazards like electrical malfunctions or leaks, preventing accidents and ensuring code compliance. Addressing minor issues early prevents costly repairs down the line, similar to how regular car maintenance extends a vehicle's life. Well-maintained buildings promote good indoor air quality, improving occupant health and productivity (Ezeudoye et al., 2022). Building maintenance offers financial benefits and opportunities for strategic investment. It safeguards occupants, protects the building's value, and promotes a positive environment. Public healthcare facilities (PHFs) represent an important building infrastructure, as the wellness of the patients is significantly dependent on the hospital building performance (Olanrewaju et al., 2018). The criticality of healthcare services underlines the importance of effective maintenance management functions in healthcare facilities (Ebekozien, 2021). Achieving universal health coverage is a top priority of the health reform agenda in many countries, while the physical condition of the health facility buildings is usually poor (Kapologwe et al., 2020).

Consequent upon the refegoing, the maintenance of PHFs is crucial to ensure they remain safe, functional, and equipped to provide quality care to the community. Regular upkeep and inspections prevent the deterioration of infrastructure and equipment, reducing the risk of malfunctions and potential harm to patients (Cai and Choi, 2020). Adequate maintenance reflects a commitment to public health, ensuring that healthcare services are accessible and reliable for everyone who needs them. Inadequate maintenance of PHFs can have severe consequences, including the deterioration of buildings over time due to intrinsic design flaws, construction errors, and the impact of climate (Waziri, 2016). Such deterioration can pose health risks to both employees and patients, hindering the delivery of quality healthcare services.

Reports from the Democratic Nursing Organization (Abisuga et al., 2017) and the Treatment Action Campaign (Oladejo et al., 2015) highlight the increasing deterioration of PHFs, despite their vital role in delivering quality healthcare services to the population. Notwithstanding government commitment to proper planning for PHF maintenance, challenges associated with PHFs continue to confront the maintenance sector. The PHFs face significant maintenance challenges, contributing to dilapidated buildings (Mukwevho, 2017). The increasing dilapidation of PHFs continues to pose health risks to both employees and patients (Abisuga et al., 2017). The state of disrepair of healthcare institutions hinders the delivery of quality healthcare (Oladejo et al., 2015; Nevhutalu, 2016). In the 2021/22 fiscal year, the Department of Health (DoH) received an allocation of R760 million for infrastructure programs, including COVID-19-related initiatives. The primary focus was on hospital revitalization, clinic construction, upgrades, and building and equipment improvements (Abisuga et al., 2017). Despite an annual maintenance budget allocation for PHFs within the DoH in Limpopo Province, financial constraints often lead to deferred maintenance. Numerous factors prevent the effective maintenance of PHFs (Jandali and Sweis, 2019).

Barriers to effective implementation of maintenance strategies include a top-down senior management style, inconsistent plans, competing agendas, an inefficient senior management team, weak vertical communication, and poor teamwork across roles (Construction Industry Development Board, 2017). Several studies, including Zulkarnain et al. (2011), Hopland and Kvamsdal (2019), and Lee et al. (2022), have identified critical success factors (CSFs) for building maintenance strategies for PHFs in different regions and countries. While there is some agreement on certain CSFs reported in these studies, discrepancies exist regarding CSFs for PHFs. The lack of consensus on maintenance factors affecting PHFs across regions and countries necessitates the continual development of strategies to improve the maintenance of PHFs (Jandali and Sweis, 2019). This is especially important on a regional and national basis. Considering the dearth of CSF research for PHFs in South Africa, this study reports on the CSFs for improving the implementation of maintenance strategies in PHFs in South Africa, with a specific focus on Limpopo Province. The interventions proposed in this study can be adopted by PHF managers to enhance their maintenance operations.

Hospital buildings are unique concerning purpose, complexity, and size (Olanrewaju et al., 2018). Evaluating and adopting an appropriate maintenance strategy tailored to the specific operational context is critical for healthcare facility management (De Vries and Visser, 2021). Recognizing that not every maintenance strategy is universally applicable, Abd Rani et al. (2015) underscore the need for healthcare facilities to modernize traditional approaches. Aligning strategies with contemporary practices enhances both facility and environmental efficiency. Given their unique demands, hospitals necessitate heightened maintenance attention to extend their operational lifespan (Ezeudoye et al., 2022). Healthcare facility management plays a pivotal role in crafting a strategic maintenance plan that aligns with the objectives of the Health Department. While Abd Rani et al. (2015) emphasize modernizing traditional maintenance approaches, other researchers argue for a balanced approach that combines both traditional and innovative maintenance strategies. According to Kapologwe et al. (2020), integrating modern technologies and practices with established maintenance methods can lead to more effective and sustainable outcomes in healthcare facilities. This perspective suggests that combining traditional and contemporary strategies offers a holistic and adaptable approach to maintenance.

The significance of an effective maintenance strategy is highlighted by its potential to significantly reduce the likelihood of major infrastructure failures (Abd Rani et al., 2015). Addressing the issue of inadequate implementation of maintenance strategies in PHFs, both globally and within South Africa, requires immediate attention. A crucial step in this endeavor understands the CSFs associated with successful maintenance strategy implementation in healthcare facilities (Putri et al., 2022). Such understanding is indispensable for achieving effective maintenance operations within these critical institutions. CSFs, acting as guiding principles, provide insight into achieving specific objectives within realistic timelines, considering end-user feedback and the specific procedures or systems in place (Olanrewaju et al., 2018). These factors serve as indicators for attaining specific goals with rational and attainable targets, closely tied to organizational objectives and priorities (Lee et al., 2022). In the context of PHFs, the influence of these CSFs on implementing maintenance strategies is profound. Research efforts, highlighted by Abd Rani et al. (2015), focus on enhancing maintenance cost-effectiveness, optimizing resource allocation, measuring performance, and refining strategic planning to address diverse constraints.

In healthcare, prioritizing and scheduling maintenance activities necessitate a comprehensive framework that considers the criticality of services, the age of facilities, and fluctuating service demand (Yousefli et al., 2020). On the other hand, some scholars argue for a more human-centered approach, emphasizing employee training and professional development to enhance the efficacy of maintenance strategies. According to Ogunbayo et al. (2022), CSFs in maintenance work extend beyond technical aspects to include service excellence, process efficiency, teamwork, coordination, and effective human resource management. This perspective highlights the importance of investing in the skills and capabilities of maintenance staff to ensure the effective and sustainable implementation of maintenance strategies in healthcare facilities.

The Municipal Finance Management Act (MFMA) and the Local Government Asset Management Guideline contribute to identifying CSFs for successfully coordinating and implementing maintenance strategies within municipalities (Ebekozien, 2021). This includes having a change champion to drive sustained implementation and organizational commitment to change, requiring endorsement and commitment from stakeholders such as the mayor, councilors, municipal manager, senior management, and support staff (Olanrewaju et al., 2018). Integrating these diverse perspectives and CSFs into healthcare facility management practices can substantially enhance the efficacy of maintenance strategies, ensuring the sustained operational health of critical facilities (Ogunbayo et al., 2022). This multifaceted approach to maintenance strategy development and implementation acknowledges the complex and dynamic nature of healthcare facility management and highlights the importance of adopting a flexible and adaptive approach (Amos et al., 2020).

The CSFs involved in a maintenance process represent the diverse activities that makeup maintenance processes and activities, supporting decision-making at each step of the delivery of maintenance services. These CSFs are essential for making both strategic and tactical decisions (Olanrewaju et al., 2018). Existing studies have documented various CSFs, providing different perspectives explored in this section of the article. Investment in training is a leading CSF that promotes the seamless implementation of a maintenance strategy (Ebekozien, 2021). A study by Fatoni and Nurcahyo (2018) in Indonesian hospitals found that a training program focusing on preventive maintenance practices significantly reduced equipment downtime and improved overall maintenance performance. Similarly, a study by Ackley-Holbrook et al. (2016) in the United States highlighted the positive impact of employee recognition programs on commitment and overall organizational outcomes in hospital maintenance departments. This emphasizes the need for a two-pronged approach: fostering a culture of continuous learning for the maintenance team and fostering employee engagement through recognition programs.

Effective communication is also paramount. A study by Then et al. (2004) in South Africa explored various communication methods adopted by public facilities, including meetings, email, a help desk, and online platforms. The study found that a multi-channel approach facilitating communication between top management, maintenance teams, and end-users is crucial for identifying maintenance needs and ensuring timely interventions. Policy formulation plays a vital role in PHF maintenance. For instance, the South African government's Construction Industry Development Board (CIDB, 2017) emphasizes the importance of a national framework for maintenance planning, budgeting, and asset registers for PHFs. This is corroborated by a case study by Abd Rani et al. (2015) in Malaysia, which highlights the successful implementation of a maintenance management plan that included a detailed asset register and a structured inspection regime. The case study demonstrates the significant role of clear policies and well-defined plans in guiding effective maintenance practices.

Budget allocation is equally important. The CIDB (2017) emphasizes the responsibility of government departments to allocate adequate budgets for PHF maintenance. However, a contrasting viewpoint was reported in a study by Olanrewaju et al. (2018) in Nigeria. This study suggests that outsourcing maintenance to readily available private companies can be a more effective strategy, particularly in resource-constrained settings. This highlights the need for a context-specific approach, where budget limitations may necessitate exploring alternative solutions like outsourcing. The Maintenance Competency Framework for Immovable Assets (MCFIA, 2017) outlines five key maintenance management factors: planning, operations, monitoring, records, and knowledge management. A study by Zulkarnain et al. (2011) in Malaysia emphasizes that focusing on these CSFs can significantly improve the overall state and standard of the maintenance system.

The type of maintenance strategy chosen is also crucial. Abd Rani et al. (2015) categorize strategies as preventive, condition-based, time-based, and corrective. A study by Fouladgar et al. (2012) in the United Kingdom provides deeper perspectives, differentiating preventive maintenance into time-based, risk-based, and predictive approaches. The study suggests that hospitals can benefit from a combination of these strategies, with a focus on predictive maintenance using technologies like sensor-based monitoring to identify potential equipment failures before they occur. Effective PHF maintenance hinges on a multifaceted approach. Investing in training and development programs for the maintenance team, along with employee recognition initiatives, fosters a culture of continuous learning and commitment (Lee et al., 2022). This needs to be complemented by a multi-channel communication strategy that bridges the gap between management, maintenance teams, and end-users (Ebekozien, 2021).

Policymakers have a crucial role to play. Advocating for clear government policies and frameworks that prioritize PHF maintenance planning, budgeting, and asset management is essential. However, budget limitations are a reality. Practitioners should conduct cost-benefit analyses to determine if insourcing or outsourcing maintenance offers the best value (Ogunbayo et al., 2022). Ultimately, the success of any strategy lies in its execution. Developing a comprehensive maintenance management plan that incorporates preventive, condition-based, and predictive maintenance strategies is key (Falorca, 2019). Utilizing performance management tools allows for continuous monitoring and ensures the effectiveness of the chosen approach. Healthcare facility managers can consider these guidelines to create and implement effective maintenance strategies that guarantee the optimal functionality and safety of their facilities, ultimately ensuring the delivery of quality healthcare.

One key takeaway is the importance of tailoring maintenance strategies to the specific context of each facility. A one-size-fits-all approach is demonstrably ineffective (De Vries and Visser, 2021). Hospitals, with their complex equipment and unique demands, require a more heightened focus on maintenance compared to other healthcare facilities (Ezeudoye et al., 2022). Modernizing traditional approaches and aligning them with contemporary best practices can significantly improve efficiency (Abd Rani et al., 2015). Healthcare facility managers play a crucial role in crafting strategic maintenance plans that align with the overall objectives of the Health Department. Another critical CSF is investing in the training and development of the healthcare facility's maintenance workforce. Studies have shown that training programs focusing on preventive maintenance practices can significantly reduce equipment downtime and improve overall maintenance performance (Fatoni and Nurcahyo, 2018). Fostering a culture of continuous learning equips staff with the latest skills and knowledge necessary to adapt to emerging technologies and best practices in the field. Complementing these efforts with employee recognition programs can further enhance staff morale and commitment, leading to a more productive and engaged maintenance team (Ackley-Holbrook et al., 2016).

Effective communication is another practical implication of focusing on CSFs. A multi-channel communication approach that utilizes meetings, email, a dedicated help desk, and online platforms for service requests facilitates the smooth flow of information (Then et al., 2004). This ensures that maintenance needs are identified and addressed promptly, preventing minor issues from escalating into major problems. Effective communication also fosters collaboration between maintenance teams, end-users (such as medical staff and patients), and facility management, ensuring that maintenance activities are conducted with minimal disruption to daily operations. Clear and well-defined government policies are essential for creating a supportive framework for effective healthcare facility maintenance. National frameworks for maintenance planning, budgeting, and asset registers provide a roadmap for resource allocation and ensure the systematic upkeep of PHF infrastructure (Then et al., 2004). However, budgetary constraints are a common challenge faced by many healthcare facilities (Olanrewaju et al., 2018). In such cases, exploring alternative solutions like outsourcing maintenance to qualified private companies can be a viable option. A cost-benefit analysis is crucial to ensure the most effective use of available resources.

Finally, the type of maintenance strategy chosen has a significant impact on its effectiveness. Research suggests that a combination of preventive, condition-based, and time-based approaches, with a focus on predictive maintenance using sensor technology, can be particularly beneficial (Abd Rani et al., 2015). Predictive maintenance allows for the identification of potential equipment failures before they occur, enabling proactive interventions and minimizing downtime. By implementing a comprehensive maintenance management plan that incorporates these diverse approaches, healthcare facilities can ensure a data-driven and proactive approach to facility upkeep.

The research adopted an interpretivism research philosophy to explore different perspectives among the PHF maintenance team, aligning with the research objectives. This research followed an inductive approach, characterized by its qualitative nature (Pellegrino and Glaser, 2021). Inductive research begins with the observation of specific problems or situations, aiming to develop and test theories based on these observations (O'Kane et al., 2021). It is typically associated with qualitative research and is often referred to as a bottom-up or data-driven research method (Proudfoot, 2023). A purposive sampling technique was employed to select participants actively involved in hospital and clinic maintenance within Limpopo Province, South Africa. This technique is particularly suited for this research as it allows us to recruit participants who meet pre-defined criteria essential for the study (Adebowale et al., 2022). In this case, our criteria focused on individuals with firsthand knowledge and experience in PHF maintenance practices within the specific provincial context.

This research aimed to gain a good understanding of CSFs for PHF maintenance in Limpopo Province. By purposively selecting participants actively involved in these practices, we ensured the inclusion of individuals with the most relevant and up-to-date knowledge and experiences. While purposive sampling does not guarantee a statistically representative sample, we took steps to ensure a degree of diversity within the participant pool. This included selecting participants from various types of healthcare facilities and geographic locations within Limpopo Province. Additionally, we sought participants with diverse roles within the maintenance hierarchy to capture a range of perspectives on PHF maintenance practices.

Data collection involved qualitative interviews, specifically semi-structured interviews, to gather insights from the participants. To ensure credibility, the study aimed for a minimum of five and a maximum of twenty interviews (Saunders et al., 2019a, b). This range was selected based on the principle of data saturation, aiming to capture a comprehensive understanding of the phenomenon under study (Guest et al., 2006). The range allows for initial insights with a minimum of five interviews and ensures in-depth exploration and validation of emerging themes with up to twenty interviews (Fusch and Ness, 2015). Nineteen participants from PHFs in Limpopo province were interviewed, including maintenance managers, supervisors, artisans, and tradesman aids. Due to COVID-19 restrictions, some interviews were conducted on-site (inside PHFs), while others were carried out telephonically. The interview guide was first developed from the factors and subsequently validated by two senior maintenance managers who provided feedback on the relevance, appropriateness, and clarity of the interview questions.

For on-site data collection, the interview questions were read to the participants, and they provided answers based on their perceptions. A similar process was maintained with telephonic interviews, except that the interviewee was not in the same location as the interviewer. Both on-site and telephonic interviews were audio-recorded for subsequent transcription. Data collection was conducted within healthcare facilities after obtaining approval through the Head of Department's office, complying with COVID-19 protocols. Before obtaining permission to collect data at the healthcare facilities, ethics clearance was obtained from the Research Ethics Committee (REC) at the Tshwane University of Technology and the DoH in Limpopo. This was followed by ethical approval through the National Health-Research Database (NHRD) application for permission to conduct research at the provincial district level, and approval by the Chief Executive Officer and Head of Department of the healthcare facility where the interview was conducted.

The combination of on-site and telephone interviews was chosen to maximize the diversity of participant perspectives while accommodating logistical constraints. On-site interviews can provide richer contextual insights and non-verbal cues, enhancing the depth and quality of data collected (Denzin, 2001). In contrast, telephone interviews offer flexibility and can facilitate participation from a geographically dispersed sample, ensuring a broader representation of perspectives (Novick, 2008). By utilizing both methods, we aimed to capture a comprehensive understanding of maintenance strategies and challenges in PHFs. However, it is acknowledged that the mode of interview may influence participant responses and data quality. To mitigate potential differences, interview protocols were standardized, and the lead researcher who conducted the interviews ensured to maintain consistency in questioning and probing techniques across both methods. To ensure the reliability and validity of the study, before data collection, we implemented regular discussions and consultations with peers and PHF maintenance managers to validate the research process. Preliminary findings were shared with participants through member checking to enhance the validity of the study. Lastly, the researchers maintained a reflexive journal throughout the research process to critically reflect on their biases and assumptions, ensuring a balanced and unbiased interpretation of the data.

Thematic analysis was utilized to identify relevant themes and sub-themes related to PHF maintenance. Thematic analysis was chosen as it is a flexible and widely used method for analyzing qualitative data, enabling the identification, interpretation, and reporting of patterns or themes within the data (Braun and Clarke, 2006). The analysis process involved several stages: familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report (Braun and Clarke, 2006). To ensure the reliability and validity of the thematic analysis, a systematic and iterative approach was adopted. Initially, two of the researchers independently coded a subset of the data to identify initial themes, which were then compared and discussed to resolve discrepancies and refine the coding framework. This iterative process continued until consensus was reached on the final set of themes, enhancing the credibility and trustworthiness of the analysis (Nowell et al., 2017). The interpretation of themes involved linking them to the research objectives and existing literature, providing a coherent and comprehensive understanding of the maintenance strategies and challenges in PHFs.

Table 1 presents the sociodemographic characteristics of the respondents. Among the total respondents, two participants (10.53%) hold a National Diploma qualification, eight respondents (42.11%) possess a National Diploma, and two (10.53%) have a National Certificate. Seven respondents (36.84%) hold certificates. Among the participants, one has an architecture qualification, two have qualifications with building maintenance skills, six possess building qualifications, five hold electrical qualifications, and five have mechanical qualifications. One respondent is professionally registered with the South African Council for Architectural Profession, while the remaining eighteen are not professionally registered.

The respondents represent various employment levels within the maintenance domain. Five of them (26.32%) hold the position of Chief Artisans, also known as maintenance managers. Two respondents (10.53%) serve as supervisors with building maintenance skills. Seven respondents (36.84%) are artisans and five (26.32%) work as tradesman-aids. All participants are involved in general building works for healthcare facility maintenance, including tasks such as small building renovations, mechanical work for air conditioning, standby generators, boilers, calorifiers, theater machines, and electrical work for lights, theater equipment, and transformers. Respondents were also asked to indicate their years of work experience in maintaining PHFs. One respondent reported having 0–10 years of experience, fifteen respondents had 11–20 years of experience, and three respondents possessed over 20 years of experience in maintaining PHFs. The years of experience among respondents in delivering maintenance services contribute to their depth of knowledge in PHF maintenance and their ability to provide reliable information related to the research inquiry.

Table 2 presents maintenance critical success factors. Effective implementation of maintenance guidelines is crucial to prevent defects in hospital buildings. This section highlights the essential CSFs for successful maintenance strategy implementation. Participants 8 and 13 emphasized proper planning as a critical CSF for maintenance strategy implementation, stating that planning involves compiling a weekly schedule and determining the duration of work. This finding aligns with the emphasis by Abisuga et al. (2017) on the importance of adequate planning for qualitative maintenance and risk mitigation. However, contrasting this with the findings of Jesumoroti et al. (2022), who highlighted inadequate budgetary allocation as a leading issue affecting building maintenance, and Breesam and Jawad (2021), who noted that many government organizations face budget shortages leading to substandard maintenance work, it becomes evident that while planning is essential, budgetary allocation remains a significant challenge affecting the successful implementation of maintenance strategies. Participants 1, 7, and 9 emphasized the importance of allocating an adequate budget by the Limpopo DoH for maintaining PHFs to ensure the successful implementation of maintenance strategies. Participant 11 also stressed the significance of budget allocation for successful maintenance strategy implementation. This finding reinforces the critical role of budgetary allocation in the effective implementation of maintenance strategies and highlights the need for policymakers to prioritize adequate budget allocation to support maintenance activities in PHFs. However, this perspective is contradicted by Lee et al. (2022), who argued that proper planning and efficient utilization of existing resources are more crucial than budget allocation for successful maintenance strategy implementation. Similarly, Ezeudoye et al. (2022) suggested that the focus should be on optimizing the maintenance process rather than solely relying on budget allocation, questioning the emphasis on budgetary allocation as a CSF for maintenance strategy implementation.

Adequate manpower is one of the factors that can contribute to the success of maintenance initiatives. Participants mentioned that maintenance would largely be successful if “we can get enough manpower” (P6, P19) and emphasized “staff availability” (P16). For instance, one participant highlighted the need for diverse skills, stating, “For example, we have one painter, we don’t have a bricklayer, no welder, no carpenter, and no grounds men.” – P9. This finding aligns with the emphasis by Lok et al. (2018) on the association between the methodologies and processes utilized to deliver facilities maintenance services and the availability of adequate manpower for maintenance operations. However, this perspective is contradicted by Oleribe et al. (2019), who argued that while adequate manpower is essential, the quality of the workforce and their skills and competencies are more crucial for successful maintenance strategy implementation. One of the participants noted that problem-solving abilities are critical in the maintenance industry and can be developed through weekly and monthly meetings with the personnel. The participant emphasized, “Arrange weekly and monthly meetings with the staff so that they can report about the problems they are experiencing in their work situation” - (P1). This finding is supported by Sogaxa et al. (2021), who stress the significance of meeting attendance and suggest that adopting site meetings and formalizing their effective implementation will improve the flow of maintenance operations. Olanrewaju et al. (2018) argue that the focus should be on enhancing the problem-solving capabilities of the maintenance team through training and development programs rather than solely relying on regular meetings.

Participant 3 stressed the necessity of an effective manager to lead the maintenance team, expressing dissatisfaction with the current situation: “ … We don't have a proper manager … as long as we have got an acting position. Now, things are not going well because that man is not holding all powers, for example, we have got an acting CEO” (P3). Participant 4 echoed this sentiment, emphasizing the importance of good leadership: “Good leadership” (P4). Naeem and Azam (2017) underscore the significance of competent leaders in the maintenance sector, highlighting the need for flexibility in leadership philosophies to enhance the success of maintenance work. They argue that the leader-follower dynamic strongly influences the outcome of maintenance activities. Sogaxa et al. (2021) emphasize the importance of functional human resources capable of recruiting a diverse set of skills for construction operations, a sentiment echoed by participants who identified a competent workforce as a CSF for maintenance strategies in Limpopo healthcare facilities. Participant 3 stated that “in maintenance, you cannot just put anyone; experienced expertise is needed to run with the maintenance of facilities.” Participant 19 also emphasized that “the best way to achieve the goal is to have a team of people who are qualified to execute their work.” This perspective aligns with Hopland and Kvamsdal (2019), who suggest that skilled site employees, along with effective communication and coordination, play a crucial role in project success. However, Kapologwe et al. (2020) argue that while competent leadership is essential, a well-defined organizational structure and clear communication channels are crucial for successful maintenance strategy implementation. Amos et al. (2020) advocate for enhancing the problem-solving capabilities of the maintenance team through training and development programs in addition to leadership.

Participants identified training as a CSF to enhance productivity. They expressed the need for workshops and training sessions tailored to their responsibilities to acquire knowledge and new skills. For instance, Participant 7 stressed the necessity for extensive training, while Participant 9 emphasized the importance of workshops and training sessions tailored to the maintenance team's needs. This finding is consistent with Chibu's (2018) emphasis on the role of training and development programs in enhancing employees' knowledge and abilities. Career development opportunities focused on future roles can be integrated into performance management systems to motivate employees and attract and retain top talent. However, Lee et al. (2022) argue that while training is essential, hands-on experience and practical skills development are more crucial for successful maintenance strategy implementation. Additionally, transportation is a crucial aspect for successful maintenance operations, as highlighted by participants. Participant 15 emphasized “transport availability,” while Participants 11, 12, and 18 pointed out challenges due to the scattered nature of PHFs. This dispersal complicates transportation logistics for maintenance teams working across hospitals and clinics in designated districts. Magdy (2020) supports this, emphasizing the importance of an efficient transportation network for distributing materials to maintenance sites. However, Abd Rani et al. (2015) suggest that the focus should be on optimizing the maintenance process rather than solely relying on transportation efficiency, questioning the emphasis on transportation as a CSF for maintenance strategy implementation.

Participant 4 emphasized the importance of regular inspections and site walks for maintenance operations, stressing the need for “regular inspection, walking around the hospital” (P4). This underscores the significance of proactive measures like routine maintenance and inspections. Ntakiyimana and Ineza (2021) support this perspective, highlighting that routine maintenance and inspections are crucial for early problem identification and prolonging a structure's lifespan. Such proactive approaches can prevent costly repairs, preserving the building's value (Hassanain et al., 2019; Zeni and Kikwasi, 2023). However, Ogunbayo et al. (2022) argue that while regular inspections are valuable, a data-driven and predictive maintenance approach might be more effective in identifying potential issues before they escalate, thereby reducing the need for frequent inspections and reactive maintenance.

The importance of implementing maintenance policies was stressed by participants in Limpopo's healthcare facilities. Participant 3 underscored the need for policies to support service delivery, while Participant 7 emphasized their significance. Participant 17 noted that policies encompass various aspects, including staff appointments and responsibilities. This recognition aligns with Putri et al.'s (2022) findings, highlighting the importance of having a maintenance policy (MP). A maintenance policy serves as a tool for formulating effective maintenance strategies, encompassing critical components like selecting a maintenance strategy, defining standards, and allocating resources. A well-defined maintenance policy ensures proper planning and execution of maintenance activities. Promoting teamwork is another CSF for maintenance strategies, as emphasized by participants P1, P4, and P14. P1 stressed the need for teamwork among staff to address problems, while P14 highlighted its importance in decision-making. De Vries and Visser (2021) support this, stating that effective teamwork is integral to high-performing teams. However, Olanrewaju et al. (2018) argue that while teamwork is essential, individual accountability and specialized roles are more crucial for successful maintenance strategy implementation, questioning the emphasis on teamwork as a CSF.

The availability of materials and tools was also highlighted by multiple participants (P2, P7, P11, P15, P16, and P19) as crucial for maintenance success. They emphasized the importance of “availability of resources” for implementing maintenance strategies and improving hospital services. Jafarnejad et al. (2014) support this view, noting that a good maintenance management system ensures resource and equipment availability. Participant 11 specifically emphasized the need for improved procurement processes as a key factor for successfully implementing maintenance strategies, stating, “Procurement processes which need to be improved” (P11). Ebekozien (2021) reinforces this viewpoint by highlighting the benefits of efficient procurement, including cost savings, shorter lead times, user department satisfaction, and regulatory compliance. Figure 1 outlines the CSF for implementing maintenance strategies in Limpopo DoH.

To refine the CSF for a more focused analysis, the CSFs are further classified into relevant themes representing the CSFs. The two primary CSFs that have emerged are adequate maintenance planning and effective leadership. Other CSFs are categorized under these two overarching themes.

Maintenance planning is a crucial factor for PHFs. Effective planning is pivotal for strategy development and ensuring timely maintenance. Adequate planning, led by management, ensures the availability of parts, equipment, and materials. Abisuga et al. (2017) and Brankovic and Milovanovic (2019) stress the importance of effective planning in enhancing quality and reducing risks. Early project assessment allows for informed planning and previous maintenance operations aid in developing optimal maintenance plans and future strategies. Planning also involves budget, manpower, and transportation considerations (Sanchez-Barroso and Sanz-Calcedo, 2019). However, Amos et al. (2020) argue that while planning is essential, an overemphasis on planning can sometimes lead to delays in actual maintenance activities. They suggest a more flexible and adaptive approach to maintenance planning to address unexpected maintenance needs promptly.

Participants highlighted the critical need for sufficient budget allocation by the Limpopo Department of Health (DoH) for maintaining PHFs. They emphasized that adequate and accessible budgets are essential for effective maintenance strategy implementation and task execution. Proper budgeting reduces backlog and aligns financial resources with maintenance requirements (Jesumoroti et al., 2022). Lee et al. (2022) opined that increased budget allocations do not necessarily translate to improved maintenance outcomes, emphasizing the need for efficient budget utilization. Budget shortages in government organizations, including healthcare facilities, lead to compromised maintenance quality (Breesam and Jawad, 2021). In healthcare, skilled maintenance workers are crucial for handling tasks efficiently and participating in strategic decisions, resulting in cost savings and improved service quality (Lok et al., 2018; Hassanain et al., 2019). A well-managed workforce enhances maintenance operations' success by providing in-house expertise and superior service quality. It is crucial to have a qualified workforce strategically placed in departments where their experience can be effectively utilized. Technical staff responsible for building maintenance should possess expertise in specific components of structures and attachments. Comprehensive training in various trades is necessary for maintenance tasks in specific areas (Alves Tenorio de Morais and Casado Lordsleem Júnior, 2019).

Skilled staff in healthcare facilities not only ensure daily upkeep but also foster a conducive working environment. Transportation challenges were noted in maintaining PHFs due to their dispersed locations. The Government Motor Vehicle procedure allows vehicle requests for service delivery. However, sharing vehicles with medical personnel can hinder maintenance staff's effectiveness. Maintenance staff face various daily maintenance needs, some of which require after-hours responses when suppliers may be unavailable. Magdy (2020) highlights the distribution of materials from producers to sites through a network of spatial nodes interconnected by transportation, emphasizing the need for improvement. This limitation can impact maintenance task execution due to challenges in procuring materials and tools. It is the maintenance manager's responsibility to plan transportation, especially for unscheduled maintenance, to reduce the risk of incidents like burst pipes in hospitals. An effective maintenance management system ensures an efficient transportation system for staff, materials, and tools, preventing significant time and cost losses (Falorca, 2019; Jafarnejad et al., 2014).

This study highlights the crucial role of effective leadership in improving PHF maintenance. Leaders in healthcare maintenance must possess both maintenance expertise and strong leadership skills. A skilled maintenance manager can provide strategic direction for realistic maintenance planning aligned with both planned and unplanned strategies. Naeem and Azam (2017) stress the need for flexible leadership approaches to enhance project success, emphasizing the influence of the leader-follower dynamic. Sogaxa et al. (2021) highlight the importance of deploying skilled personnel who can transition between maintenance sites. Adaptable leadership tailored to maintenance sector challenges is crucial (Nhlapo, 2020).

Thompson and Brezicha (2022) argue that while strong leadership is essential, an overly rigid leadership style can stifle innovation and adaptability in maintenance teams. They suggest a more collaborative and inclusive leadership approach to encourage team members to contribute their ideas and insights. Training, maintenance policy, and teamwork are vital elements of effective leadership in maintenance management. Regular training for the technical maintenance team enhances productivity and goal achievement. Encouraging employees to submit personal development plans yearly allows funds allocation for training. Well-trained employees show greater dedication, excel in tasks, and acquire new skills, reducing the need for outsourcing (Chibu, 2018). Career development focuses on identifying skills for future roles, integrated into performance management to motivate employees and retain top talent. Adequate training is vital for education and skill enhancement in maintenance operations, elevating productivity.

Implementation of maintenance policies is crucial for maintenance managers and policymakers. According to the Asset Management Framework for National and Provincial Departments (2021), departments must develop and enact accounting policies addressing assets, including recognition, maintenance procedures, and safety protocols. Aligning with SANS 55000 standards, organizational-level asset management policies are essential, outlining goals and providing a framework for asset management strategies. In healthcare settings, adherence to maintenance policies under the Government Immovable Asset Management Act (GIAMA) is crucial. Workshops and policy reviews ensure teams' familiarity for effective asset maintenance. Standard operating procedures (SOPs) based on maintenance policies guide teams during activities. A well-defined maintenance policy, as emphasized by Putri et al. (2022), is vital, enabling effective maintenance strategies through elements like strategy selection and resource allocation, facilitating proper planning and execution.

Jesumoroti et al. (2022) argue that while policies are necessary, an over-reliance on rigid policy frameworks can sometimes hinder adaptability and responsiveness to unique maintenance challenges. They suggest a more flexible policy framework that allows for adjustments based on specific maintenance needs and conditions. Effective teamwork is crucial for implementing maintenance strategies. Maintenance managers should prioritize team-building sessions to foster a culture of collaboration and communication among team members, working towards common objectives. De Vries and Visser (2021) highlight effective teamwork as essential for high-performing teams. Organizations known for consistent performance prioritize teamwork in their organizational culture.

This study explores the CSF in maintaining PHFs to enhance healthcare service delivery. These CSFs play a pivotal role in reinforcing the structural integrity and overall performance of healthcare facilities. Effective planning is a cornerstone CSF, providing a robust foundation for developing maintenance strategies. It not only ensures the attainment of maintenance objectives but also addresses potential hurdles to effective maintenance. Maintenance budget, manpower, and transportation are identified as key areas that maintenance managers and policymakers should prioritize. Adequate financial resources are deemed indispensable for executing maintenance plans successfully, underscoring the importance of accessible budgets to prevent financial constraints from impeding effective implementation. The study highlights the crucial role of a competent and sufficient workforce, emphasizing that strategically placed, skilled maintenance personnel within healthcare institutions can significantly enhance maintenance operations.

Effective leadership stands out as the second major CSF in maintaining PHFs. To enhance effective leadership in maintenance operations, the study identifies training, maintenance policy, and teamwork as three crucial areas that maintenance managers should focus on. The study not only stresses the need for training but also underscores the importance of training tailored to performance improvement. Regular training for technical maintenance staff is highlighted as a means to boost productivity and align with intended objectives, reducing the dependency on outsourcing. Given the complexities involved in maintaining healthcare facilities, leadership from individuals with extensive engineering and built environment experience is essential. Competent leadership provides strategic direction and realism in maintenance planning, ensuring alignment with both planned and unplanned maintenance strategies.

The research holds implications for both theory and practice. The identified CSFs offer valuable insights for effective maintenance management of PHFs, aligning with the United Nations Sustainable Development Goal 3, which emphasizes ensuring healthy lives and promoting well-being for all ages. The study guides healthcare administrators, facility managers, and policymakers to make informed decisions regarding maintenance strategies. However, it is essential to acknowledge that this research was conducted in Limpopo with a limited sample size, which may limit the generalizability of the findings. Nonetheless, the identified CSFs may be applicable in other developing countries, particularly in African countries where similar practices are prevalent. The study advocates for further research in PHFs across other South African provinces and private healthcare facilities to compare and validate the research findings.