Handle with Care: Transformative Learning as Pedagogy in an Under-Resourced Health Care Context.

Issue: A significant component of health professions education is focussed on students' exposure to the social determinants of health and the challenges that patients within the health care system face. An appropriate way to provide such exposure is through distributed clinical training. This usually entails students training in smaller groups along the continuum of care, away from tertiary academic hospitals. This also means students are away from their existing academic and social support systems. It is evident that knowledge and clinical skills alone are not sufficient to prepare students, they also need to be taught to critically reflect on how their own values and attitudes traverse their knowledge and skills to influence their practice as healthcare professionals. This process of critical reflection should aim to provide a transformative learning experience for students and requires active facilitation. In under-resourced health care contexts where clinicians responsible for student training are facing high patient load, lack of resources, inequitable health care services and high levels of burn-out, the facilitation of student learning may be compromised. Evidence: Clinical learning opportunities that are considered transformative, frequently challenge students' sense of self and sense of belonging. This experience can have detrimental effects if the processes of transformative learning pedagogy are not adequately facilitated. The provision of support staff, lecturers and clinical facilitators on the distributed training platform is challenged by the remote nature of some of the sites and the cost of recruiting and capacitating additional on-site staff. The potential for what has been termed "transformative trauma" and the subsequent halted transformative learning experience, has ethical implications in terms of student wellness and the educational responsibility institutions carry. Implications: The authors suggest considerations in facilitating an ethical transformative learning process. These include making the transformative learning pedagogy explicit to students and clinical facilitators and using the 'brave spaces' framework to help students with individuation and provide them with the tools to understand how emotion influences behavior. Strategies to improve relationship development and communities of support, as well as ideas for faculty development are offered.

COVID-19 preparedness and response in rural and remote areas: A scoping review.

This scoping review used the Arksey and O'Malley approach to explore COVID-19 preparedness and response in rural and remote areas to identify lessons to inform future health preparedness and response planning. A search of scientific and grey literature for rural COVID-19 preparedness and responses identified 5 668 articles published between 2019 and early 2022. A total of 293 articles were included, of which 160 (54.5%) were from high income countries and 106 (36.2%) from middle income countries. Studies focused mostly on the Maintenance of Essential Health Services (63; 21.5%), Surveillance, epidemiological investigation, contact tracing and adjustment of public health and social measures (60; 20.5%), Coordination and Planning (32; 10.9%); Case Management (30; 10.2%), Social Determinants of Health (29; 10%) and Risk Communication (22; 7.5%). Rural health systems were less prepared and national COVID-19 responses were often not adequately tailored to rural areas. Promising COVID-19 responses involved local leaders and communities, were collaborative and multisectoral, and engaged local cultures. Non-pharmaceutical interventions were applied less, support for access to water and sanitation at scale was weak, and more targeted approaches to the isolation of cases and quarantine of contacts were preferable to blanket lockdowns. Rural pharmacists, community health workers and agricultural extension workers assisted in overcoming shortages of health professionals. Vaccination coverage was hindered by weaker rural health systems. Digital technology enabled better coordination, communication, and access to health services, yet for some was inaccessible. Rural livelihoods and food security were affected through disruptions to local labour markets, farm produce markets and input supply chains. Important lessons include the need for rural proofing national health preparedness and response and optimizing synergies between top-down planning with localised planning and coordination. Equity-oriented rural health systems strengthening and action on rural social determinants is essential to better prepare for and respond to future outbreaks.

Exploring the ideas of young healthcare professionals from selected countries regarding rural proofing.

INTRODUCTION: Globally, most countries struggle to meet the health needs of rural communities. This has resulted in rural areas performing poorly when compared to urban areas in terms of a range of health indicators. There have been few coherent or systematic strategies that target rural communities and address their needs within the rural context. Rural proofing, defined as the systematic application of a rural lens across policies and guidelines to ensure that they speak to these health needs, seeks to address this gap. The healthcare professionals (HCPs) who will be called upon to advocate for and lead the implementation of rural proofing efforts are those currently in training or early career stages. We thus sought to understand the perspectives of young HCPs regarding the concept of rural proofing. METHODS: The study adopted an interpretivist paradigm. Data were collected using semi-structured individual interviews and focus group discussions (FGDs). Selected HCPs who are in leadership in Rural Seeds, a movement for young HCPs, participated in the study. FGDs in the form of Rural Cafés were led by some Rural Seeds leaders who participated in the interviews and who showed interest in organising the discussions. Eleven exploratory interviews and six FGDs were conducted using Zoom. HCPs were from Australia, Europe, Africa, North America, South America, and Asia. Interviews and FGDs were conducted in English, recorded, and transcribed verbatim. Thematic analysis was then undertaken. RESULTS: Participants perceived the state of rural healthcare globally to be problematic. Access to care was seen as the most significant issue in rural health care, associated with the challenges of lack of equity in access, and limited funding and support for healthcare professionals and their career pathways. Despite varying understanding of the concept, rural proofing was seen to be of great value in improving rural health care. A number of ideas for applying rural proofing, with examples, were proposed from their perspectives as frontline healthcare providers. They particularly recognised the importance of addressing the local needs of rural communities and the needs of present and future HCPs. Implementation of rural proofing was seen to require the involvement of key stakeholders from a range of sectors at multiple levels. CONCLUSION: Given the state of rural health, young rural HCPs suggest that rural proofing strategies are needed as they have the potential to bring about equity in the delivery of health care in rural and remote communities. These strategies will assist in creating a more positive future for rural health care worldwide and motivate young HCPs to become involved in rural health care, as well as to increase their motivation to take an interest in health policy development. These strategies need to be applied at multiple levels, from national government to local contexts. It is also seen to be critically important to involve multiple levels of stakeholders, from politicians to healthcare providers and community members, in the process of rural proofing.

Preparing Graduates for Interprofessional Practice in South Africa: The Dissonance Between Learning and Practice.

With South Africa's tumultuous history and resulting burden of disease and disability persisting post-democracy in 1994, a proposed decentralization of heath care with an urgent focus on disease prevention strategies ensued in 2010. Subsequently a nationwide call by students to adapt teaching and learning to an African context spoke to the need for responsive health professions training. Institutions of higher education are therefore encouraged to commit to person-centered comprehensive primary health care (PHC) education which equates to distributed training along the continuum of care. To cope with the complexity of patient care and health care systems, interprofessional education and collaborative practice has been recommended in undergraduate clinical training. Stellenbosch University, South Africa, introduced interprofessional home visits as part of the students' contextual PHC exposure in a rural community in 2012. This interprofessional approach to patient assessment and management in an under-resourced setting challenges students to collaboratively find local solutions to the complex problems identified. This paper reports on an explorative pilot study investigating students' and graduates' perceived value of their interprofessional home visit exposure in preparing them for working in South Africa. Qualitative semi-structured individual and focus group interviews with students and graduates from five different health sciences programmes were conducted. Primary and secondary data sources were analyzed using an inductive approach. Thematic analysis was conducted independently by two researchers and revealed insights into effective patient management requiring an interprofessional team approach. Understanding social determinants of health, other professions' roles, as well as scope and limitations of practice in a resource constrained environment can act as a precursor for collaborative patient care. The continuity of an interprofessional approach to patient care after graduation was perceived to be largely dependent on relationships and professional hierarchy in the workplace. Issues of hierarchy, which are often systemic, affect a sense of professional value, efficacy in patient management and job satisfaction. Limitations to using secondary data for analysis are discussed, noting the need for a larger more comprehensive study. Recommendations for rural training pathways include interprofessional teamwork and health care worker advocacy to facilitate collaborative care in practice.

A self-assessment study of procedural skills of doctors in peri-urban district hospitals of Gauteng, South Africa.

BACKGROUND: Several studies have been carried out on procedural skills of doctors in district hospitals in rural South Africa. However, there is insufficient information about skills of doctors in peri-urban district hospitals. This paper attempts to supplement this vital information. AIM: The aim of the study was to determine self-reported levels of competence in procedural skills of doctors in peri-urban district hospitals and to assess factors influencing this. SETTING: The study was undertaken in three district hospitals in two health districts of Gauteng Province. METHODS: A cross-sectional descriptive study using a self-administered questionnaire was undertaken in three district hospitals in two health districts of Gauteng Province. The questionnaire assessed procedural skills based on district health service delivery requirements for doctors in district hospitals using a modified skill set developed for family medicine training in South Africa. RESULTS: There was a wide range of self-reported competence and experience among doctors for various skill sets. Doctors were generally more competent for procedures in general surgery, medicine, orthopaedics, obstetrics and gynaecology and paediatrics than anaesthesia, ear, nose and throat and ophthalmology. There were statistically significant associations between age and overall anaesthetic competence (p = 0.03); gender and overall competence in surgery (p = 0.03), orthopaedics (p = 0.02) and urology (p = 0.005); years of experience and overall competence in dermatology skills; current hospital and overall competence in anaesthesia (p = 0.01), obstetrics and gynaecology (p = 0.015) and dermatology skills (p = 0.01). CONCLUSION: This was one of the first studies to look at self-reported procedural competence of doctors in a peri-urban setting in South Africa. The results highlight the need for regular skills audits, standardised training and updating of skills of doctors in district hospitals.

The value of interprofessional education in identifying unaddressed primary health-care challenges in a community: a case study from South Africa.

Many countries rely on community health workers (CHWs) at a primary health care (PHC) level to connect individuals with needs to health professionals at health-care facilities, especially in resource-limited environments. The majority of health professionals are centrally based in facilities with little to no interaction with communities or CHWs. Stellenbosch University (South Africa), included interprofessional home visits in collaboration with CHWs as part of students' contextual PHC exposure in a rural community to identify factors impacting on the health of patients and their families. The aim of this study was to determine the impact of this interprofessional student service-learning initiative on identifying and addressing health-care challenges of households known to CHWs. Active physical, social and attitudinal factors were identified and recorded using a standardized paper case report form. Data were anonymized, captured and categorized for analysis. The frequency and proportion of each type of active problem and referral were calculated. The collaborative team identified many unaddressed health and social issues during their visits. Their exposure to communities at a PHC level offered benefits of experiential learning and provided insight into community needs, as well as offering services to enhance the current health-care system.

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda.

BACKGROUND: Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

The value of the WIRHE Scholarship Programme in training health professionals for rural areas: Views of participants.

INTRODUCTION: Rural hospitals in South Africa, as elsewhere, face enduring shortages of, and challenges in attracting and retaining, suitably qualified staff. The Wits Initiative for Rural Health Education (WIRHE), based at the University of the Witwatersrand but covering three universities, is a rural scholarship programme established to find local solutions to these challenges in the North West and Mpumalanga provinces. The purpose of this evaluation was to ascertain whether the WIRHE project was achieving its objectives. METHODS: This article draws from an evaluation commissioned by the Swiss-South African Cooperative Initiative, a major funder of the programme when WIRHE was launched in 2003. Qualitative interviews were conducted either as face-to-face meetings or telephonically with 21 WIRHE students and graduates. Content analysis was undertaken to identify common themes. RESULTS: There was a consistency in the findings as the students and graduates reported similar experiences. Many of the participants were overwhelmed by their initial challenges of having to adapt to a different language, an institutional culture and resources that they previously did not have access to. The participants acknowledged the role of WIRHE staff in facilitating the transition from home to university and, in particular, the value of the financial and academic support. The geographic distance to Wits presented a challenge for the Pretoria- and Sefako Makgatho-based students. The holiday work affirmed clinical advantages for WIRHE students and heightened students' interest in becoming healthcare workers. CONCLUSION: WIRHE's key success factors are the financial, academic and emotional support offered to students. WIRHE achieved its objectives based on a principled strategic approach and an understanding that students from rural backgrounds are more likely to return to rural areas. The study supports the value of structured support programmes for students of rural origin as they pursue their studies.

Declaração de Gramado pela Saúde Rural nos países em desenvolvimento / Gramado Statement for Rural Health in developing countries / Declaración de Gramado para la Salud Rural en los países en desarrollo

Nós, aqui reunidos na XII Conferência Mundial de Saúde Rural da Wonca / IV Congresso Sulbrasileiro de Medicina de Família e Comunidade, declaramos como reflexão e recomendação para a saúde das populações rurais, em particular para os países em desenvolvimento, o que segue. Sistemas de saúde para uma melhor saúde rural A saúde rural não pode ser pensada separadamente do desenvolvimento do sistema de saúde. Pessoas de países em desenvolvimento merecem um uso racional e eficiente dos recursos disponíveis para gastos de saúde a fim de se otimizarem os resultados e a satisfação com os serviços. O aprimoramento da saúde rural deve estar associado a uma forte orientação do sistema de saúde para atenção primária à saúde1 e orientação para as reais necessidades das comunidades. Cobertura de saúde universal com equidade nos sistemas de saúde deve ser uma prioridade global2,3 Longitudinalidade e atenção integral devem ser constantemente alvo das políticas de saúde. Cuidado centrado na comunidade com competência cultural deve ser o princípio de todas as políticas de sistema de saúde. Hospitais e unidades de saúde rurais devem estar adequadamente vinculados a uma rede de saúde constantemente avaliada, e esta rede vinculada aos serviços mais especializados por meio de fluxos estabelecidos de comunicação, regulação e transporte. Envolvimento com a comunidade em todos os níveis das decisões deve ser encorajado para todos os sistemas de saúde. "Rural Proofing" implica "pensar no rural", consultar as comunidades rurais com a revisão de evidências rurais, desenvolver soluções rurais que são postas em prática, assim como monitorar, reavaliando continuamente e agindo em resposta a um ambiente em mudança.4 "Rural Proofing" deve ser centrado na pessoa e derivado por meio da lente do conhecimento contextualizado rural. É declaração do Wonca Working Party on Rural Practice (WWPRP) que Rural Proofing deve ser um aspecto rotineiro da aprovação e implementação das políticas. O WWPRP vai procurar desenvolver uma abordagem para ferramentas de Rural Proofing que abranja os princípios de melhoria da saúde para todas as pessoas rurais com uma apresentação do progresso dos resultados em 2015, na 13a Conferência Mundial de Saúde Rural da WONCA. Estratégias para o desenvolvimento profissional contínuo devem envolver tecnologias de suporte remoto e formação. As iniciativas de sucesso de treinamento em serviços de medicina de família já existentes devem ser exploradas. Competências desejáveis para a prática rural devem ser definidas e adicionadas de forma adaptada às diferentes realidades locais e necessidades. Devem-se qualificar e corresponsabilizar os gestores de saúde para a adoção de políticas orientadas pelo uso culturalmente apropriado das melhores evidências disponíveis. A necessidade de discussão das particularidades da saúde rural e da prática profissional é essencial. No entanto, a busca excessiva de definições muito estritas pode não ser útil para a implementação de políticas que realmente impactem a saúde dessas populações.5 Categorias intermediárias geradas pelo conceito de rururbano6,7 são fundamentais para estimular o intercâmbio de conhecimentos de medicina rural diante da enorme complexidade das situações sociais contemporâneas. Entende-se aqui rururbano como "um processo de desenvolvimento socioeconômico que combina, em termos de forma e conteúdo, uma única vivência regional e nacional. Ela representa uma rejeição à absoluta urbanização e, ao mesmo tempo, à idealização de camponeses vivendo arcaicamente em espaço rurais."6 O conceito também é utilizado para discutir a complexidade da definição de rural/urbano na legislação brasileira por outros autores, ao constatar-se que quase 15% da população nacional não se encaixam claramente em nenhuma das categorias isoladamente.7 O estabelecimento de um sistema de saúde, o que especificamente inclui a preocupação com a saúde das populações rurais, implica estabelecer redes de cooperação eficazes entre comunidades, educação e instituições de pesquisa, serviços de saúde e de gestão. Reconhecemos o trabalho realizado anteriormente nos fóruns rurais de Cartagena, Santa Fé e Montevidéu como importantes para o desenvolvimento da saúde rural na América Latina. Recursos humanos para a Saúde Rural A má distribuição e escassez de recursos humanos são muitas vezes maiores e mais graves nos países em desenvolvimento, e as soluções para este problema devem ser idealmente trabalhadas de forma conjunta por políticas de retenção e de qualidade, respeitando-se as recomendações internacionais8 e acordos para a migração internacional ética.9,10 O melhor perfil a ser alcançado por meio de políticas de alta prioridade para otimizar a saúde rural é o de pós-graduado em medicina de família. Em países em desenvolvimento, muitas vezes serão exigidos tempo e recursos para estimular a formação deste perfil, mas no médio e longo prazo, isto é custo-efetivo.1 Programas de residência devem ser a estratégia de padrão-ouro para este objetivo. Condições devem ser criadas para aumentar o número de vagas, sua descentralização e a garantia de uma quantidade adequada de bolsas de estudos para que os profissionais de saúde não sejam desviados para outras áreas nem entrem diretamente no mercado de trabalho. Outras maneiras de alcançar mais rapidamente o número necessário de profissionais devem preservar as diferenças entre esses modelos e valorar diferentemente profissionais com uma formação mais completa. Um escopo mais amplo de habilidades e conhecimentos deve ser incluído em uma formação estendida para esses profissionais. Em locais onde já há programas de medicina de família, períodos adicionais com conteúdo rural devem ser criados, ou seja, com conteúdos especiais ligados à realidade local, podendo incluir cirurgia, habilidades e conhecimentos de obstetrícia, atendimento de emergência, pediatria, etc. Políticas de migração, serviços obrigatórios, recrutamentos temporários sem estratégias de retenção devem ser estratégias excepcionais e não devem ser as principais políticas de nenhum país. Descentralização rural da formação, políticas para estimular os alunos advindos de áreas rurais, melhoramentos na qualidade do trabalho, de vida e de pagamento, incluindo programas de carreira profissional devem ser parte de políticas multifatoriais para retenção. Migração de profissionais internacionais deve sempre respeitar as legislações nacionais e as recomendações internacionais. Trabalhadores de saúde rural que vivem e trabalham em zonas rurais devem ser valorizados e sua situação sempre deve ser comparada com as novas políticas para evitar prejuízo destes. A exposição dos alunos de todas profissões da área da saúde deve incluir todos os possíveis cenários de prática profissional, incluindo rural e rururbanas, e deve ser planejada longitudinalmente sempre que possível. A formação necessariamente deve ser direcionada para as necessidades locais. As competências (conhecimentos, habilidades e atitudes) de medicina de família rural devem ser parte da formação de graduação. Unidades de cuidados de ensino nas áreas rurais são o cenário adequado para a formação de saúde rural e capacitação.

Early implementation of WHO recommendations for the retention of health workers in remote and rural areas.

The maldistribution of health workers between urban and rural areas is a policy concern in virtually all countries. It prevents equitable access to health services, can contribute to increased health-care costs and underutilization of health professional skills in urban areas, and is a barrier to universal health coverage. To address this long-standing concern, the World Health Organization (WHO) has issued global recommendations to improve the rural recruitment and retention of the health workforce. This paper presents experiences with local and regional adaptation and adoption of WHO recommendations. It highlights challenges and lessons learnt in implementation in two countries - the Lao People's Democratic Republic and South Africa - and provides a broader perspective in two regions - Asia and Europe. At country level, the use of the recommendations facilitated a more structured and focused policy dialogue, which resulted in the development and adoption of more relevant and evidence-based policies. At regional level, the recommendations sparked a more sustained effort for cross-country policy assessment and joint learning. There is a need for impact assessment and evaluation that focus on the links between the rural availability of health workers and universal health coverage. The effects of any health-financing reforms on incentive structures for health workers will also have to be assessed if the central role of more equitably distributed health workers in achieving universal health coverage is to be supported.

La mauvaise répartition des travailleurs de la santé entre les zones urbaines et rurales demeure une préoccupation politique dans pratiquement tous les pays. Elle empêche l'accès équitable aux services de santé, elle peut contribuer à une augmentation du coût des soins de santé et de sous-utilisation des compétences des professionnels de la santé dans les zones urbaines, et elle représente un obstacle à la mise en place d'une couverture maladie universelle. Pour répondre à cette préoccupation qui existe depuis longtemps, l'Organisation mondiale de la Santé (OMS) a émis des recommandations visant à améliorer le recrutement et la rétention des travailleurs du secteur de la santé en milieu rural. Ce document présente différentes expériences locales et régionales concernant l'adaptation et l'adoption des recommandations de l'OMS. Il souligne les défis et les leçons tirées de mises en œuvre dans deux pays - en République démocratique populaire lao et en Afrique du Sud - et il offre une perspective plus vaste dans deux régions - en Asie et en Europe. Au niveau des pays, l'application des recommandations a permis un dialogue plus structuré et plus ciblé sur les règlementations, qui a abouti à l'élaboration et à l'adoption de politiques plus pertinentes basées sur les faits. Au niveau régional, les recommandations ont suscité un effort plus soutenu en ce qui concerne l'évaluation des politiques entre les pays et leur apprentissage commun. Il faut évaluer l'impact des liens qui existent entre la disponibilité des travailleurs de la santé dans les zones rurales et la couverture maladie universelle. Les effets de toutes les réformes financières sur les structures d'incitation des travailleurs de la santé devront également être évalués si le but principal est de répartir plus équitablement les travailleurs de la santé et d'atteindre une couverture maladie universelle.

La distribución ineficaz del personal sanitario entre las zonas urbanas y rurales constituye una preocupación política en casi todos los países, pues impide el acceso equitativo a los servicios sanitarios, puede contribuir al aumento de los costes de atención sanitaria y la infrautilización de las capacidades profesionales sanitarias en las zonas urbanas, y obstaculiza la cobertura sanitaria universal. Para solucionar este problema de larga data, la Organización Mundial de la Salud (OMS) ha publicado una serie de recomendaciones generales para mejorar la contratación a nivel rural y la conservación del personal sanitario. Este informe presenta las experiencias en relación con la adaptación local y regional, y la adopción de las recomendaciones de la OMS. Además, subraya los desafíos y las lecciones aprendidas de la aplicación en dos países, la República Democrática Popular Lao y Sudáfrica, y proporciona una perspectiva más amplia en dos regiones, en concreto, Asia y Europa. A nivel nacional, el uso de las recomendaciones facilitó un diálogo político más organizado y específico, lo que permitió el desarrollo y la adopción de políticas más relevantes con base empírica. A nivel regional, las recomendaciones motivaron un esfuerzo más firme para evaluar las políticas entre los países y el aprendizaje conjunto. Es necesario realizar una evaluación y una valoración del impacto que se centren en la relación entre la disponibilidad de personal sanitario en zonas rurales y la cobertura sanitaria universal. Asimismo, deben evaluarse los efectos de las reformas financieras en asistencia sanitaria sobre las estructuras de incentivos para el personal sanitario con miras a promover el papel central del mismo, distribuido de forma más equitativa, en la consecución de la cobertura sanitaria universal.

Building consensus on key priorities for rural health care in South Africa using the Delphi technique.

BACKGROUND: South Africa is currently undergoing major health system restructuring in an attempt to improve health outcomes and reduce inequities in access. Such inequities exist between private and public health care and within the public health system itself. Experience shows that rural health care can be disadvantaged in policy formulation despite good intentions. The objective of this study was to identify the major challenges and priority interventions for rural health care provision in South Africa thereby contributing to pro-rural health policy dialogue. METHODS: The Delphi technique was used to develop consensus on a list of statements that was generated through interviews and literature review. A panel of rural health practitioners and other stakeholders was asked to indicate their level of agreement with these statements and to rank the top challenges in and interventions required for rural health care. RESULTS: Response rates ranged from 83% in the first round (n=44) to 64% in the final round (n=34). The top five priorities were aligned to three of the WHO health system building blocks: human resources for health (HRH), governance, and finance. Specifically, the panel identified a need to focus on recruitment and support of rural health professionals, the employment of managers with sufficient and appropriate skills, a rural-friendly national HRH plan, and equitable funding formulae. CONCLUSION: Specific policies and strategies are required to address the greatest rural health care challenges and to ensure improved access to quality health care in rural South Africa. In addition, a change in organisational climate and a concerted effort to make a career in rural health appealing to health care workers and adequate funding for rural health care provision are essential.

What interventions do South African qualified doctors think will retain them in rural hospitals of the Limpopo province of South Africa?

INTRODUCTION: In South Africa, the health system faces a variety of problems, such as an overall shortage of and misdistribution of healthcare workers. The Department of Health in South Africa has attempted to address the shortage of rural doctors by introducing various interventions, including an increase in salaries, introduction of scarce skills and rural allowances, the deployment of foreign doctors, and upgrading of clinics and hospitals. Despite these, the maldistribution of doctors working in South Africa has not improved significantly. This attests to the multifactorial nature of this problem and to the fact that intensive and sustained efforts are needed to rectify it. Few South African studies have been undertaken to establish the needs of rural doctors in South Africa and to seek possible solutions to their problems. While a number of studies have identified some of the major problems, much still needs to be done. Innovative ways to address this crisis are urgently needed. The main objectives of this study were to identify interventions as proposed by doctors in the rural Limpopo province of South Africa and to develop recommendations based on these. METHODS: This study utilised a descriptive qualitative design using a semi-structured questionnaire. Ten doctors from rural hospitals within all six districts of the Limpopo province were randomly selected and interviewed. RESULTS: Themes recommended included: increasing salaries and rural allowances; improving rural hospital accommodation; ensuring career progression; providing continuing medical education; increasing support by specialist consultants; improving the physical hospital infrastructure and rural referral systems; ensuring the availability of essential medical equipment and medicines; strengthening rural hospital management and increasing the role of doctors in management; improving the working conditions; establishing private-public collaborations with private general practitioners; increasing rural doctors' leave allocations; ensuring adequate senior support for junior doctors; improving rural hospital environments and providing recreational facilities; assisting rural doctors' families, and providing recognition and appreciation for the work rural doctors do. CONCLUSION: The resolution of one isolated factor without improving the host of push factors currently present in the health system is unlikely to lead to significant improvements in the retention of rural doctors. The results of this study can be used to assist the Limpopo Department of Health to identify the most pressing needs of rural doctors in the province. A number of interventions are suggested by rural doctors that they feel would retain them in their current rural practices. The recommendations include various interventions involving different levels of the healthcare system. It also recommends an incentive package for doctors willing to serve longer term in rural hospitals.