Are return-of-service bursaries an effective investment to build health workforce capacity? A qualitative study of key South African policymakers.

Return-of-service schemes (RoS) or bursaries are used in South Africa and other nations to publicly fund the training of skilled health professionals in return for the beneficiary agreeing to return to serve in their local provinces on a year-for-year basis. This study aimed to understand insights of key policymakers in South African provinces to identify barriers and solutions to implementation of RoS schemes used to recruit and retain skilled health professionals. This research draws on the insights of 16 key South African policymakers from eight of its nine provinces through semi-structured, qualitative interviews. The respondents were interviewed through Microsoft Teams virtual platform, either in pairs (ten) or as individuals (six). Data were analysed using inductive, thematic analysis in NVIVO. The study was reported according to the consolidated criteria for reporting qualitative research. Respondents reported that the schemes had resulted in an increase in the number of skilled health professionals and had provided opportunities for study and employment for previously marginalised groups. Formal evaluations of the impact of the schemes were not reported, however, a number of shortcomings with current schemes were identified that were likely limiting their effectiveness. Respondents reported a lack of foresight in the scheme implementation including a bias in the selection of beneficiaries towards medical professionals at the expense of other health workers. Furthermore, failure to plan for practice location when beneficiaries finished training limited the capacity of the schemes to meet the needs of local populations. Monitoring of recipients was limited by loopholes in contract design, decision-making and poor coordination between departments. Between 1 and 30% of beneficiaries were reported to default their contracts with some not completing their studies, some not returning after completing their internship and others terminating their services before concluding their contracts. Return-of-service schemes have helped in overcoming health professional shortages. However, they haven't been formally evaluated. Several planning and implementation shortcomings were identified which can be improved to enhance access to healthcare in South Africa.