Correction: Mabunda et al. Development, Objectives and Operation of Return-of-Service Bursary Schemes as an Investment to Build Health Workforce Capacity in South Africa: A Multi-Methods Study. Healthcare 2023, 11, 2821.

In the original publication [...].

Development, Objectives and Operation of Return-of-Service Bursary Schemes as an Investment to Build Health Workforce Capacity in South Africa: A Multi-Methods Study.

BACKGROUND: South Africa uses government-funded return-of-service (RoS) schemes to train, recruit and retain skilled health professionals in underserved areas. These educate health professionals locally or internationally in return for a commitment to serve in a specified area for an agreed period. While such schemes are used widely and are funded by substantial public funds, their exact makeup differs across jurisdictions, and little is known about why these differences have emerged or how they influence their effectiveness or impact on the health system. We aimed to fill these gaps through an analysis of the origins, architecture, and evolution of RoS schemes in South Africa. METHODS: A multimethod research study including a policy review, a literature review, and semi-structured interviews of policymakers was undertaken between October 2020 and August 2022. The included policy documents and literature were analysed using the Walt and Gilson framework and narrative synthesis. Qualitative data were analysed using inductive, thematic analysis in NVIVO 12. RESULTS: RoS schemes are used as a recruitment and retention strategy and a mechanism to address equity in access to medical education. Whilst there is evidence of RoS schemes existing in 1950, no evidence of beneficiaries was found in databases until 1989. The impact of these schemes is likely being limited by sub-optimal institutional arrangements and poor transparency in their design and implementation. CONCLUSION: Despite rigorous research methods, the origins of RoS policies in South Africa could not be established due to poor preservation of institutional memory. Opportunities to monitor the value of public investment into RoS programs are being missed and often the underlying objective of the programs has not been well-specified. Policies were found to have been developed and operate in isolation from other health workforce planning activities and thus may not be maximising their impact as a retention and training tool.

Effectiveness of return-of-service schemes for human resources for health retention: a retrospective cohort study of four Southern African countries.

BACKGROUND: Governments use return-of-service (RoS) schemes to train, employ and retain health professionals in the public sector. We determined the effectiveness of RoS schemes in four Southern African countries. METHODS: This retrospective cohort study used databases of RoS beneficiaries from South Africa, Botswana, Eswatini and Lesotho. We ascertained the period of funding for beneficiaries between 2000 and 2010, study programme, selection criteria, study country and if they completed their studies. Records were sought to track beneficiaries' service and fulfilment of their RoS obligations. Data were sought at the provincial level in South Africa and nationally for the other three countries. Binomial logistics regression and Kaplan-Meier survival estimates were used to determine risk factors and predictors of defaulting. RESULTS: Most beneficiary enrolment (eg, decision on why they were funded, socioeconomic status, disability status, high school results) and service data (eg, health facilities where they worked, how long they worked at each health facility, movement between health facilities) were not available. A total of 5616 beneficiaries were drawn from the four countries' databases. Of those with full data available, 21.7% (229/1056) were retained/served beyond their obligatory period and 20.2% (213/1056) were still serving. A total of 24.3% (95% CI: 21.7% to 26.9%; n=257/1056) of beneficiaries in the final subanalysis of two South African provinces fulfilled their contractual obligations. Only 32.2% (277/861) of beneficiaries undertook internship within their funding provinces. Governments needed to fund six beneficiaries to have one beneficiary complete their contractual obligation if they undertook internship outside their province. CONCLUSION: Record keeping in all countries was poor, hampering the effectiveness of RoS schemes. Of the units with full data available, the retention rate was below 25%, and internship being undertaken outside the funding province was associated with higher defaulter rates, calling for a policy overhaul.

How Were Return-of-Service Schemes Developed and Implemented in Botswana, Eswatini and Lesotho?

Botswana, Eswatini and Lesotho are three Southern African countries that make use of return-of-service (RoS) schemes to increase human resources for health in their countries. These initiatives bind beneficiaries to a pre-defined period of service upon the completion of their studies based on the length of funding support received. We aimed to review the history of these policies to understand the conceptualisation, intent and implementation of these schemes. We used a multi-methods research design which consisted of a literature review, a policy review and semi-structured interviews with policymakers and implementors. All three governments have a combination of grant-loan schemes and full bursaries or scholarships. The policies have all been operating for over 20 years, with Eswatini's pre-service policy being the oldest since it was introduced in 1977, followed by Lesotho's 1978 policy and Botswana's 1995 pre-service policy. These policies have never been reviewed or updated. RoS schemes in these countries were introduced to address critical skills shortages, to improve employability prospects for citizens, to have competent public sector employees by global standards and to aid the career progress of government employees. Ministries of Health are passive role players. However, these schemes can only be efficient if there is clear cooperation and coordination between all stakeholders.

Utility of the Right to Health for Addressing Skilled Health Worker Shortages in Low- and Middle-Income Countries.

BACKGROUND: As a fundamental human right, the right to health (RTH) can influence state actors' behaviour towards health inequities. Human rights advocates have invoked the RTH in a collective demand for improved access to essential medicines in low- and middle-income countries (LMICs). Similarly, scholars have used the RTH as a framework for analysing health problems. However, its utility for addressing skilled health worker (SHW) shortages in LMICs has been understudied. Realising that SHW shortages occur due to existing push-and-pull factors within and between LMICs and high-income countries (HICs), we sought to answer the question: "how, why, and under what circumstance does the RTH offer utility for addressing SHW shortages in LMICs?" METHODS: We conducted a realist synthesis of evidence identified through a systematic search of peer-reviewed articles in Embase, Global Health, Medline (Ovid), ProQuest - Health & Medical databases, Scopus (Elsevier), Web of Science (Clarivate), CINAHL (EBSCO), APAIS-Health, Health Systems Evidence and PDQ-EVIDENCE; as well as grey literature from Google Scholar. RESULTS: We found that the RTH offers utility for addressing SHW shortages in LMICs through HIC state actors' concerns for their countries' reputational risk, recognition of their obligation to support health workforce strengthening in LMICs, and concerns for the cost implication. State actors in LMICs will respond to adopt programs inspired by the RTH when they are convinced that it offers tangible national benefits and are not overly burdened with ensuring its success. The socio-economic and institutional factors that constrain state actors' response include financial cost and sustainability of rights'-based options. CONCLUSION: State and non-state actors can use the RTH as a resource for promoting collective action towards addressing SHW shortages in LMICs. It can also inform negotiations between state actors in LMICs and their HIC counterparts.

Governance systems for skilled health worker migration, their public value and competing priorities: an interpretive scoping review.

BACKGROUND: Governments worldwide participate in skilled health worker (SHW) migration agreements to protect access to health services in their countries. Previous studies have described the value offered by these agreements in separate source and destination country perspectives. OBJECTIVE: We sought to identify and summarise existing literature on shared value creation for both source and destination countries. METHOD: We conducted a systematic scoping review of health databases and grey literature. Using Mark Moore and Colin Talbot frameworks, we summarised the public value propositions in migration agreements and how state actors addressed competing priorities. RESULTS: Most articles (34/63, 53.9%) reported transnational SHW mobility as the public value proposition for source and destination countries. Fewer articles, 14 (22.2%) and 9 (14.3%) articles, respectively, referred to achieving health workforce sustainability and building capacity for SHW migration governance as shared public values. The most identified competing public value (CPV) was an overriding focus on addressing SHW shortages in destination countries (20/63, 37.7%). Efforts to address this CPV include mitigation of the adverse effects of migration (43/63, 68.3%) and promoting health workforce development in source countries (15, 23.8%). At the same time, state actors retained regulatory discretion for protecting their country's public health interest (34, 54%). Most articles reported the lack of funds (15/63, 23.8%) and implementation mechanisms (19/63, 30.2%) as constraints on the authorising environment and the operational capacity of SHW migration governance systems. CONCLUSION: Regarding SHW migration governance, the literature reports shared public value propositions for source and destination countries. It also shows how the value-creating process in the management of SHW migration favours destination countries. Future studies will need to explore shared value creation models that ensure equity in the governance of SHW migration.

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.

Charting the Rights of Community Health Workers in India: The Next Frontier of Universal Health Coverage.

Community health workers (CHWs) have the capacity to bring essential health services to under-resourced communities. Globally, CHWs have made significant contributions to poverty alleviation, increased food security, and reductions in health inequalities. India's one million accredited social health activists (ASHAs), the largest cohort of CHWs in the world, have been credited with increasing the rate of institutional deliveries and the uptake of vaccinations. ASHAs operate at the margins of health systems and the formal health workforce, often due to misperceptions of their skills and discrimination based on gender, socioeconomic status, education, and rurality. The "voluntary" nature of their work can entrench their precarious status, which is characterized by a lack of access to employment rights, adequate remuneration, and institutional support. This article argues that the prioritization of the labor rights of CHWs in the design and implementation of the World Health Organization's 2018 Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes can serve to ensure safe working conditions and freedom from discrimination, coercion, and violence. It further argues that the resultant enhancement and protection of CHWs' rights and long-term security provides an essential pathway for harnessing their potential to transform universal health coverage.

Reformulation and strengthening of return-of-service (ROS) schemes could change the narrative on global health workforce distribution and shortages in sub-Saharan Africa.

Despite policies for addressing shortages and maldistribution of health professionals, sub-Saharan Africa continues to experience shortages and maldistribution of skilled health professionals. Policies such as return-of-service schemes or state-funded educational initiatives do not seem to be achieving their intended objectives, potentially due to poor design, implementation; and lack of monitoring and evaluation of the strategies. A focus by global health experts on strengthening and reformulating educational initiatives offers potential for producing, retaining and recruiting health professionals.