Bursaries build health sector skills, but need monitoring

The return-of-service or bursary schemes that provincial health authorities in South Africa use to assist students from disadvantaged backgrounds to obtain educational qualifications in the health sector could be improved by basing them on current and forecast health needs, a group of researchers has found.

The group noted, too, that there should be sufficient allocation of resources for future salary needs and efficient monitoring mechanisms to ensure compliance and the integrity of beneficiaries in underserved areas, adding that, “these schemes have been socially responsive in helping people from disadvantaged backgrounds who would not have been able to obtain an educational qualification in the health sector without the bursaries.”

Bursaries, as return-of-service schemes are known in South Africa, are used to fund the study of beneficiaries on the understanding that they will serve health facilities which find it difficult to recruit health professionals for at least the same number of years as the candidate was funded during their studies.

The study, ‘Are return-of-service bursaries an effective investment to build health workforce capacity? A qualitative study of key South African policymakers’, published in PLOS Global Public Health on 9 May 2022 said: “While most beneficiaries are funded for the duration of their studies [an average of six years for studying medicine in South Africa, nine years in Cuba and four years for most other qualifications], some beneficiaries can be funded for less than that – for example, one year, if only offered the sponsorship in their final year of study.”

Bursaries ‘poorly managed’

Noting that these bursaries have helped in overcoming health professional shortages, the researchers, however, said that they “are often poorly planned, coordinated and monitored and have not been formally evaluated”.

The researchers said that some NGO return-of-service schemes, such as the Umthombo Youth Development Foundation and the Friends of the Mosvold Hospital Scholarship Scheme have previously been reported on in more detail and found the schemes to have a good return on investment.

However, to date, there is little literature scrutinising the challenges, implementation processes and sustainability of the government-sponsored schemes.

The study’s work was, therefore, intended to fill this gap through an examination of insights from key policymakers in South African provincial health departments on how they have designed and implemented health professional training policies, and to identify barriers and solutions to implementation.

In addition, the researchers wanted to understand the insights of key policymakers in South African provinces to identify barriers and solutions to implementation of return-of-service schemes used to recruit and retain skilled health professionals.

The study drew the insights of 16 key South African policymakers from eight of the country’s nine provinces through semi-structured, qualitative interviews.

Training needs

The study found that South Africa’s public health sector has 0.64 anaesthetists per 100,000 population, compared to 9.69 in the private health sector, whereas the country needs only five per 100,000 population.

In addition, the country’s public health sector has only 33 per 100,000 medical practitioners compared to a global average of 176 per 100,000 population.

According to the researchers, the public sector’s primary care facilities are serviced by only 29.1% of the required professional nurses and midwives, adding that, to address this “shortfall requires substantial and strategic investments in the health workforce, as well as improvements in health workforce-related planning, education, deployment, retention, management and remuneration”.

The research was conducted in eight out of nine South African provinces because the country has a devolved system of governance, whereby provinces are responsible for the provision of healthcare through their respective provincial departments of health as mandated by the constitution.

Researchers said they used the qualitative critical theory methodology, and designed the study to enable an assessment and critique of the current situation that is attempting to overcome shortages of health professionals in underserved communities.

They aimed at interviewing the entire initially identified population of policymakers from nine provinces. Through snowball sampling they identified a key policymaker from one provincial department, and participants were individuals who were directly involved with the development and implementation of health-related return-of-service schemes in government departments of all nine South African provinces.

The researchers said that, at times, the policy had been implemented with opportunity costs of not employing other deserving citizens and at times employing incompetent beneficiaries, thus rendering them non-sustainable.

“To have a lasting impact, health workforce planning strategies need to be non-sporadic, long-term and continuous in nature, with ongoing monitoring and evaluation to ensure they are contributing to these objectives and guard against unintended consequences,” they said.