As well as the intended improvement in the staff complement at rural hospitals, the transcripts documented how graduates benefitted personally,and how their families and communities benefitted.
Health science students
Their responses centred around two main themes, namely: (1) the poor quality of their education at school which would normally lead to poor prospects of being employed, (2) the UYDF intervention which would lead to a career that they could be proud of. Figure 1 illustrates the way in which the themes and subthemes were connected in a sequential pattern showing the life-changing consequences that the UYDF intervention would have for them. (see figure 1 below)
The poor quality of schooling in rural areas
Many rural schools lack facilities, such as computers, libraries and laboratories for those learners who want to pursue science subjects. The sub-themes of ‘Low Levels of Literacy’, ‘Poor Skills’ and ‘Unlikely to find employment’ were identified as the key consequences of poor schooling. Many of the students said they were ill-prepared for higher education as a consequence of poor facilities in rural schools. In most South African universities, the medium of instruction is English, and as first language isiZulu speakers this was said to affect their ability to express themselves and shook their confidence.
‘… I had never seen a computer, let alone used one and when I came here, I was told to type in assignments…., so it is difficult - you end up handing in assignments late’
‘I have never done experiments in my life…. but my lecturer expected me to be able to do the experiment and produce the report….
Several students pointed out that rural schools usually do not give guidance concerning the correct subject choice for their careers in the health sciences, and nor do students receive a grounding in core subjects.
“In my first year, I hadn’t done chemistry in eleven years [of schooling] ……I was struggling in this module and when I went to consult my chemistry lecturer, I was told if I didn’t understand the basic concepts of chemistry then I chose the wrong career…”
“… I am doing my second year I repeated my second year …. they gave me another chance although I had to explain why I failed…”
Move to the city
The students pointed out that people, especial young people, migrate to cities as a result of the under-development of rural areas. This migration comes with the culture shock of new experiences and learning new habits in order to make their way in the new environment. Most students said that they found the change difficult.
“…there are not even traffic lights in KwaNongoma and when you come here there are a thousand of them…., you just wonder how to cross this road.”
Going to a tertiary institution came with unexpected changes and challenges.
“During all my basic education I used one classroom, or if we had to move, we were escorted by a teacher…… when I got to university, I was now expected to move from one lecture hall to another….”
The rural students had more difficulty than most students in adjusting to university life, having lived in relatively closed communities. They were accustomed to being with friends in familiar places, and now they had to find their way about the university alone.
“In my first week at university I missed almost all the morning classes as I was expecting to hear the bell ring, but this was not the case here…”
The UYDF intervention
The students expressed gratitude to the UYDF for understanding their need for more than what a scholarship usually provides.
“…given such an opportunity all I can do is study and pass and become the best radiographer…. This is not just bursary, the programme offers more and we are like a family.”
As a mentor to UYDF students, the author has observed that lack of emotional and social support sometimes leads to failure to progress and even dropping out altogether. The UYDF has introduced mentorship for all their students which is designed to help them develop strategies to deal with the heavy workload associated with health science training. UYDF students are allocated mentors that they meet on a monthly basis. The mentoring begins from the first month at university up to the time when the students graduate. This is supplemented by biannual visits by a UYDF senior mentor, orientation, monthly telephone/SMS/email enquiries, quarterly reports by each student, holiday work (practical exposure to patients in June/July and December/January), quarterly peer support at university and the annual Imbizo – year-end meetings to discuss crucial issues with all UYDF funded students. The UYDF believes that providing compulsory mentorship will bridge the gap of poor schooling and equip them with the necessary skills to cope with the demands of Institutions of Higher Learning and health science training.13
Home Away from Home
The students develop a close relationship with the UYDF. Participants stated that they feel cared for, as all their needs were taken care of by the UYDF. The author encountered extreme cases: students who were orphans and others who came from broken families who had feelings of loneliness and hopelessness, and they benefited most from this support and encouragement. UYDF appointed a chief mentor to keep track of the students, and the students had to account to him when there were difficulties.
“…Umthombo [UYDF] is like home to me. Any time you can call if you have a problem with money, Dumsani [the chief mentor] is there to take you through and they always help you….”
Most of the participants have not previously been away from home and this requires adjustment, as they now have to adjust to seeing their families only during holidays. The majority are affected by homesickness especially in their first few months at IHLs, but with time they do adjust, although not without personal stress. The students’ social and academic adjustment has implications for the overall success of the student. Failure to do this is often delays graduation and some students drop out, thus UYDF is playing a pivotal role in making sure that students adjust to both social and academic life.
Post study placement anxiety
The students remarked on the fact that UYDF goes beyond providing a scholarship as it further facilitates placement of their graduates.
“…. I would say the UYDF made a good plan by signing the MOU [memorandum of understanding] with Department of Health, because as UYDF graduates we have no problem of finding jobs, unlike many graduates in South Africa”
“…. People who graduate are not guaranteed jobs in South Africa. UYDF graduates are kind of lucky because of the MOU with the Department of Health that tries to place the UYDF graduates back in their rural hospitals without any interviews….”
In summary, most students indicated that UYDF had broken the cycle of poverty by introducing career guidance, informing them of work opportunities in the health care field, and making it possible for them to complete the necessary courses. The scholarship scheme did more than just provide financial support but also helped to develop the individual’s coping skills through the mentorship programme that prepared them for life at university and away from home, and to cope during difficult times.
The three FGD groups gave similar responses to the main topics introduced by the facilitator, namely (1) the impact of the UYDF intervention on the personal lives of the graduates, (2) the impact at community level’; and (3) the difficult workplace environment. (see figure 2 below)
The graduates talked extensively about the way in which the scholarships changed their lives. They had been removed from a poverty-stricken situation.
‘… I come from a poor family and I never thought my family could afford tertiary education for me…. Without UYDF, I would not have made it this far….’
They said that the UYDF programme provided them with funds for studying as well as basic requirements for students. This freedom from pressing financial need continued after graduation because they now earn salaries. Most are now breadwinners for their families and can afford the basic needs of life.
‘…as a student I would budget my money and sometimes buy a few things for my siblings but now that I am working life has changed and whatever my family needs, I make sure I provide it. That’s how good UYDF has been for me...’
“…. I love my community that much; I want to see it prosper and the only person to bring that change is me…’
Most of the graduates spoke of the pride they take pride in their contributions to others.
‘… We arewilling to start a fund where we can put as little as R100 in future it will help other students who are in the same situation as we were…. Even if it goes towards their studies in other professions ……’
The graduates realised that although they are making a difference in the health sector, other professions such as teachers, engineers, architects are still needed in the rural communities in order to stimulate development in rural areas.
The Impact of UYDF at Community level
Most of the participants mentioned the impact of the scholarship scheme at community level since it was introduced in 1999. Patients can now access health services without needing interpreters to convey the message to the health care practitioners.
‘…there are some things that my rural home people cannot explain clearly to a white doctor or nurse because they do not know how to say it in their language….it is now easy to talk to us because they are able to say it in isiZulu’
The increase in qualified health care workers in rural hospitals assists the patients who used to have to go to a regional or tertiary hospital for a small procedure. Previously some community patients could not travel to a distant facility because of the cost.
‘…it is no longer necessary for people in the rural areas to have appointments scheduled in the peri-urban / urban parts of the region because now you also find an optometrist and audiologist at a rural hospital which was usually not the case before…’,
Some participants noted that they had become role models for rural youth. They said that young people do not value education and drop out of school because they do not see the value of continuing.These local graduates can act as a point of reference for other youth facing similar challenges.
‘…Umthombo (UYDF) has afforded me an opportunity which my family was not able to because I come from a very poor background…, now children in my community will see the importance of education.’
‘… I have built my mother a house and I now drive…., most people in my community also wish to do the same for their families as well as for themselves’.
Some graduates believed the current marketing strategy of that UYDF is insufficient and this needs to be strengthened to reach more learners at school as early as possible.
‘… Umthombo (UYDF) should go out there into schools and make the staff and students know the services they provide, what programmes they sponsor, all that information is not readily available…’
Difficult Workplace Environment
Despite the gains in health care provision afforded by the scheme, several difficulties remained which made it difficult for the rural hospitals to retain staff. The graduates said that even though they were from area, the reality of the poor infrastructure in rural communities may affect what the UYDF’s programme is trying to change. There were several examples of poor infrastructure.
‘…as much we want to stay long in our rural hospitals but we sometimes feel that we are not appreciated if you look at the type of accommodation that is available within the hospital’…… it is difficult to work in a place where you are not appreciated’.
The availability of a sufficient number of posts in rural hospital and good equipment is essential for the smooth running of the system and the job-satisfaction and well-being of the staff. If there are insufficient posts or if the existing posts are not filled, over-worked staff may eventually leave. These limitations also affect the variety of services that are required. Generally, there is a lack of equipment in public hospitals which affects the delivery of quality health services to the community.
‘…. the rural community also deserves better and quality health care, as this is stipulated by the constitution of South Africa’…. sometimes there are essential posts that are not available at district hospital….’
‘In my first year at work I had to work the whole year without proper equipment… this affected the provision of quality services as I had to compromise a lot’
Graduates pointed out that long distances between the location of the health care facilities still exists in most rural communities. For health service providers the poor transport and inadequate roads affects their mobility between clinics and hospitals and risks the lives of their patients.
‘The accessibility of health care facilities in rural areas still remains (a problem), there is not much of choice in relation to health care facilities and if they are there, they are isolated….’
‘Transport – the availability of transport is a major challenge in our area, the roads are terrible and sometimes not usable….’
Because some of the graduates have decided to get married or engaged to local people, this works in favour of stabilising the hospital workforce and is an unintended consequence of the UYDF policy of requiring graduates to return to their area of origin. Others are marrying fellow UYDF graduates and this results in them staying longer than the contract period. The graduatesthought that if the UYDF had a bigger workforce the graduates would have an opportunity to involve the UYDF on issues affecting the hospitals where they are placed. Due to the difficulties faced in these workplaces some graduates would like to work in the private sector, but because they are indebted to UYDF they feel obliged to stay.
The health managers dealt with two main topics, their problems with finding and retaining staff, and the changes which have taken place in their hospitals as a result of the UYDF programme. (see figure 3 below)
Awareness of UYDF Services: The UYDF had signed a memorandum of understanding (MoU) with the provincial Departments of Health but some of the hospital managers were not aware of this agreement and what it means to them and their facilities.
“We were told by UYDF staff that there is a MoU between the department and them (UYDF), but no one has ever explained these agreements to us as the hospitals, and we always get graduates allocated to our hospital by the province….”.
“If the province can give details on the graduates they are allocating to us, if we knew they were from UYDF, that will help us allocate their duties, and let the UYDF Graduates do more of the outreach programmes because of their local knowledge of the area and community”.
However, most managers knew about the UYDF graduates and that they had played a part in different areas of hospital functioning, and this had been welcomed by both the hospital community and the community at large. The managers reported that the UYDF graduates were enthusiastic in their support of community development, which helped with the prevention of diseases.
Addressing shortage changes due to the UYDF programme: The respondents said that not only was there a general scarcity of health care professionals in the country, but few qualified personnel chose to work in rural areas. Most said that the difficulty of attracting health care professionals to rural hospitals was ongoing and the rural hospitals where this study was conducted were severely affected. There had been vacant posts in some hospitals for 20 years and district hospitals reported being unsuccessful in recruiting and retaining a staff for the posts
“When I started here there was only one doctor and one clinical associate with 6 wards to be covered (Male, Female, Peadiatrics, Maternity, OPD and Casualty). Patients used to go back home untreated, and sometimes the ward rounds would only be done once a week in order to cover all wards and that increased the death rate at our hospital,”
“… Our facilities have struggled in the past to train and attract professionals especially health care professionals, due to the lack of funding and the geographical location …”
The UYDF has produced over 300 graduates covering seventeen different health science disciplines over a period of 19 years and this has helped to staff sixteen different hospitals. The Managers reported that the UYDF graduates had brought some stability in terms of reliable staff, although there are still not enough of them. Some said that the posts in their institutions werefilled only when the UYDF scholarships started to produce graduates who returned to work back their commitments in their local hospitals. This was not always the case because some staff get married and want a better education for their children, so they leave the rural hospitals prematurely. Also, the workload may become too heavy and these factors leaving more likely.
“… Majority of the healthcare professionals at our institution are there through UYDF. They are long-term staff that bring stability”.
“… UYDF assists with our staff retention strategy as the students work in their rural communities after completion of their studies, and the majority of them stay longer than their contracts….”.
However, some graduates do not choose to work in rural areas because of the lack of equipment and the poor accommodation for doctors.
“…. Even those who came to our facilities, we are unable to retain them, they are overworked with no recreational facilities around our hospitals…”
The medical manager in one of the hospitals said that the services have improved in their hospitals, because of the medical practitioners from UYDF. Even though the staffing is not at an optimal level it is better than it was, and they will continue to receive staff through the UYDF.The hospitals that had been working with UYDF for a longer period had received a larger number of healthcare stuff than those with fewer years.
The respondents mentioned a variety of advantages to employing local health care practitioners:
Better range of services and cutting costs:
“…it is no longer necessary for people in the rural areas to have appointments scheduled in the regional or tertiary hospitals…. because patients get a variety of services at the local hospital, such as psychological services, eye care and all rehabilitation services are on site now, which was not the case before…”,
This variety of services has helped rural hospitals to cut the cost of transporting the patients to referral hospitals.
Improved communication, saving lives: The medical officers pointed out that patients can communicate in isiZulu with the UYDF graduates, who, in turn, understand the community needs and are willing to go the extra mile to provide quality health care. This not only helps to produce a stable workforce but makes it possible for the hospitals to have outreach services to prevent the spread of diseases in the community.
“They are generally local and know the language and situation of the patients”.
“Majority of the UYDF graduates had a strong sense of commitment to the rural communities where they work, and they showed responsibility in giving back to their communities of origin….”
“No one wants to see anyone die, and an idea that fights mortality is always a good idea which needs to be supported. This is exactly what the UYDF is doing for our institution – it prevents deaths of many people”.