Identifying the strengths, weaknesses, opportunities and threats (SWOT) of return-of-service bursary schemes for health workforce capacity: a qualitative study of Botswana, Lesotho and Eswatini.

Background: Investing in training citizens in return for service is a strategy used by Botswana, Eswatini and Lesotho to strengthen their health workforce. These strategies, known as return-of service (RoS) schemes, offer bursaries in exchange for future service. We aimed to ascertain the strengths, weaknesses, opportunities and threats (SWOT) of RoS schemes in these three Southern African countries to inform ongoing policy debates on the value of the schemes. Methods: Qualitative semistructured interviews were undertaken via Microsoft Teams to elicit the perspectives of policy-makers who administer RoS schemes in each of these countries. The interview guide was developed from a detailed literature review, and discussions with policy-makers and other researchers. Interviews were conducted over a 17-month period between November 2020 and April 2022. We used deductive and inductive approaches to thematic analysis. Furthermore, we conducted internal and external analysis of the emergent themes using SWOT framework. Results: We interviewed 9 policy-makers who had work experience that ranged from 5 to 22 years implementing the schemes. The organisational structure of the schemes was a strength compared with seventeen weaknesses, four opportunities and three threats. Prominent weaknesses are the outdated policy documents with some irrelevant and discriminatory conditions, rigid policies, failure to renew bilateral agreements, contextually different training from country of origin, high defaulter rates, poor coordination of schemes, poor monitoring and lack of evaluation of the schemes. Sustainability of the schemes in retaining health professionals is threatened by lack of funds. These schemes present opportunities to invest in effective information systems. Conclusions: While the intention of the RoS schemes were to educate the citizens, develop the economy through increased employability of the citizenry and build the health workforce, the schemes were poorly planned and coordinated and have never been evaluated. Weak information systems and failure to employ some RoS beneficiaries render the scheme unsustainable.