Fifteen out of nineteen (78.9%) policymakers from eight provinces were interviewed for this research. Females accounted for 7/15 (46.7%) of respondents. Respondents’ experience of managing RoS schemes at provincial level ranged from 5 to 23 years. Fourteen respondents were from the PDoH and one was from the Provincial Department of Education.
What are return-of-service schemes?
Bursaries, as RoS 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. As one respondent described:
…will pay for them for the amount of years that they need to go study, for example, if it's four years or six years in medicine (sic)… and at the end of the qualification they can work for the Department of Health….. they don't pay us back any money, they come back and work for the department and they will still get their full salary. ...…we need their services in our hospitals.
RoS Schemes are managed in each province by the bursary office through the human resource development office. In five of the provinces (Eastern Cape, Gauteng, KwaZulu-Natal, Limpopo and Western Cape), the policy is entirely managed directly by the Department of Health. Funding for study within the country has been shifted to the Office of the Premier in the North West province and to the Department of Education (DoE) in Mpumalanga and Northern Cape provinces. In addition to local universities, all provinces, with the exception of the Western Cape (WC), send students to Cuba for medical studies. The PDoH is responsible for funding and recruitment of students studying in Cuba. Mpumalanga province (MP) also sends students to Russia for medical studies, who are funded by the DoE. Clinical professions trained can include but are not limited to medicine, physiotherapy, nursing, radiography, medical specialty, nursing specialty, etc. Box 1 summarises the themes that emerged from the interviews.
Effectiveness and value for money of RoS schemes.
All provinces reported a positive impact of RoS schemes on training health professionals to deal with the shortages and maldistribution of the health workforce in South Africa. Some also highlighted the social effect of the bursaries for people who otherwise would not have been able to obtain a qualification.
…to support… disadvantaged children from… disadvantaged families. ......Especially those who pass very well in matric.
While all the provinces contact the students while they are being supported by the bursary, none of the schemes have been systematically evaluated. Respondents also noted the substantial cost of the schemes and specific instances of waste.
… nobody comes back at the end of the year and say: ‘Ok, we have generated so many bursaries, how much did it reduce your vacancy rate? What was the impact of this’?
The respondents suggested that it was important to review the strategy for workforce planning and deployment, and utilisation of resources:
…it's time that we… approached our implementation… of plans and utilisation of resources using scientific approaches because many at times we have caught ourselves…, finding that we have been implementing wrong decisions. All of a sudden maybe there is oversupply, or interestingly enough…… we find that the reason why we do not have medical practitioners in our facilities is not (sic) that we do not train them, but it's because we are unable to retain them.
All provinces experienced defaulters or individuals who breached their contracts, and this was estimated to range from 5-30% of funded individuals. One province also estimated that about 20% of the defaulters would not have served at all, and only half of the defaulters will settle their debt. Even if money is to be repaid, it’s not an easy exercise to quantify and/or replace their loss as suggested by a participant from a rural province:
But we lost a whole doctor!!! Two of them. Because it takes us another six years to produce… Seven…six…seven…eight years to produce a doctor!!!
Even though the two urban provinces (Gauteng and Western Cape) also reported defaulters, this did not seem to impact them as negatively, hence they could be able to say that: “We are still fine, we are working fine for few years now (sic), luckily”.
What factors impact effectiveness of the policy?
Respondents noted that, while South Africa has shortages of many groups of health workers, bursaries were often skewed towards medical doctors without any assessment of the skills-mix needed in a provincial health system based on assumptions.
Even the… international arrangements that I have mentioned, the Health Sciences students that we send there is medical practitioners and nothing else. So that on its own will tell you that it looks like the bias is on medical practitioners.
Most of the health professional beneficiaries complete their studies because they are “…a group of serious cadres who really go out and pass”. However, poor academic progression by a minority, impacts effectiveness of the schemes as not everyone who is funded is able to complete their studies. While the contract mandates the student to pay back the funding if they fail to complete the course, the participants felt that it was challenging to enforce the contractual clause.
According to the contract, the person must pay back the money. Though it’s very difficult to say to somebody… who is coming from a poor background to say: ‘pay the money’. While the person is failing even… to finish his studies. Where is he going to get the money? That is a challenge which is not easy to practice.
Despite the absence of an opt-out clause in at-least one provincial contract, some beneficiaries choose to opt-out. The opt-out clause gives beneficiaries the option to re-imburse government a pro-rata amount upon early termination of their contracts.
In some provinces, the bursaries are distributed by the Department of Education or Office of the Premier and the jobs are provided by the Department of Health, consequently, the data between the two departments is not integrated. Complexities introduced through splitting responsibility across departments include administrative bungles where the bursary holder is not known due to incomplete records at the funding department, in provinces where the Department of Health is not in control of the entire process. This poor communication and coordination leads to poor effectiveness of the schemes.
…they also give bursaries for things (qualifications) which doesn't (sic) exist and then the person comes back, and the person say (sic): ‘…I must be employed, I am a bursary holder’. … But the person is nowhere registered and no Council (health professionals’ regulatory council). It's not a health profession but it's a nutritionist. He needs to study another three years whilst we employ him. So, now it's our problem.
Another challenge “…is to get people to work where you actually need them”, thus needing to strike a balance between the preferences of the individual and the needs of the health system. Urban, peri-urban, and rural health facilities that are in a provincial boundary with urban centres are the most popular choices among beneficiaries.
…it’s a very small hospital… It’s close enough to Pretoria for you… to do your private practice in Pretoria. …they are rural hospitals. …you get a rural allowance… and then they don't pitch up to the hospitals, and they have their private … surgeries (practices) in town.
In some instances, there are different interpretations of contractual terms as the contract was ambiguous and beneficiaries did not know where they would be placed to serve the contractual period. The bursary contract also doesn’t specify the community that the beneficiary will be linked to on completion of their studies, despite this being the stated purpose of having RoS schemes.
I remember with the Cuba one, for example, the initial batch, signed the contract, which was designed by national and at that time the contract was blindly saying: ‘You are expected to come back and serve in the country’.
In other instances, the contracts may be open to different interpretations which can lead to possibilities for abuse:
We consulted some… learned lawyers and they told us: ‘No, there is no way you will win this one in court’.
Other challenges included using paper-based records and non-sophisticated excel spreadsheets to track beneficiaries some of which have been inaccurate in the past. In addition, some departments were reported to have lost some records and have a poor monitoring system. Even though the database of all the provinces is electronic now, the contracts are still paper based which makes monitoring the system cumbersome. Other systemic challenges such as corruption and maladministration have created barriers in the implementation of the program. For example, there have been instances where students from rich families who were not eligible for the RoS scheme have benefitted from the educational initiatives.
You know friends will be just walking to the office: ‘I want a bursary’ and it's given. When you look at the list of bursars compared to the ones… approved, it was a different number.
Sometimes, beneficiaries of the educational bursaries have not been able to fulfil their contractual agreements due to changing personal circumstances and ambitions.
‘I might come from a poor village, but I'm not destined to be poor, or I'm not destined to live in a poor village’. … you already are acclimatised to urban life. If you have already started a family, your children are attending some, well, fancy…, well-developed schools there, and you know that ‘if I go back to my province, there's a huge likelihood that they will put me in a rural facility’ and then all of a sudden you lose all the privileges of being in an urban area. So, you will find that the bursary holders will always try to find a way of not coming back…
However, the policy implementors believe that beneficiaries should fulfil their obligations regardless of the changing circumstances as highlighted by a respondent:
‘I have now got children and my husband is here or my wife is here. I can't go there anymore because I have all these responsibilities’. …but those responsibilities are secondary because your first responsibility was your bursary.
Notwithstanding, there are structural constraints of the departments including lack of expertise for health workforce planning.
we are not having qualified HR (Human Resource) practitioners…
4. Unintended consequences
Government bursaries come with the advantage of guaranteeing a government job for beneficiaries. However, at times this is to the disadvantage of non-bursary beneficiaries, some of whom would have studied using bank loans. As one respondent said:
…in these years, three years now, we do not take the non-bursary holders at all because we don't have budget (sic).
Some defaulting RoS beneficiaries have tried to return to the public health sector after being dismissed for misconduct in the private sector:
Then you've got the other side of the coin; the person leaves, she gets fired outside and then she wants to return, which we are not allowing. We don't allow you to return once you've gone because you make trouble outside. Then you want to come to our patients which can't choose a doctor
Another challenge is that the obligatory period of service could delay specialisation and professional development for those who have such intentions. For some beneficiaries, this obligatory period could be as long as eight or more years for medical students who studied in Cuba.
Poor economic conditions have led to conflict between a prior government undertaking to employ beneficiaries post-completion of their studies and the need to finance these posts. This in turn has led to a lack of funded posts for RoS graduates in some situations.
…it was sustainable but now …with this sudden change… with… issue of funding…we are not even sure whether this section is going to (laughs)… to be here for a long time. Because now…like even Cuba, we stopped sending the students to Cubans (sic)…. We sent ten in 2015 and then we stopped from there.
We actually cannot even afford to appoint them because we still have a lot sitting at home unemployed.
There has also been a recent change in policy to support the education of economically disadvantaged students throughout the country. All students who are assessed as being poor, now qualify for free tertiary education through support from the National Students Financial Aid Scheme (NSFAS), in a way rendering the RoS schemes redundant for poor students.
…the budget which was used for bursaries, were taken from the department… and… were given to the tertiary institutions to strengthen up the NSFAS (National Students Financial Aid Scheme). So, the minister of finance, view it: ‘If you are health, let us deal with health issues…let Minister of Higher Education deal with development of skills’…
However, NSFAS funding also has a quota of students that it can fund in a year. This inevitably leads to the exclusion of other needy students who have academic potential. Hence one respondent could confidently say of government bursaries:
…I don't see this programme discontinuing anytime soon.