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  • The use of state sponsored educational initiatives for Sustainable Health Workforce Solutions: Alignment of Policies and Practices in Selected Southern African Countries
    (2024) Mabunda, Sikhumbuzo
    Thesis
    Introduction Return-of-service (RoS) initiatives are government-funded strategies used to educate health professionals by contracting beneficiaries to undertake government work following their qualifications. It is envisaged that once they have served their contracts, they will be attracted to serve in the same area or government institution beyond the duration of their obligatory period. Little is known about the processes that have led to the development and implementation of RoS policies. This research aimed to evaluate RoS initiatives, explore their effectiveness and sustainability across four Southern African countries to determine their value as a sustainable solution and propose areas for improvement. Methods and Analysis This study was conducted in South Africa, Eswatini, Lesotho and Botswana in a phased approach through a multi-methods approach of policy reviews, literature reviews, and quantitative and qualitative research. Data were sourced from multiple provincial or national information systems and/or databases. The fourth and final phase included data analyses and triangulation of the findings, enabling recommendations on restructuring and enhancing, maintaining or even eliminating RoS schemes as a viable mechanism for expanding healthcare coverage. Findings The precise origins of South African RoS schemes could not be established. The origins of RoS schemes in Botswana, Eswatini and Lesotho could be established. RoS schemes aim to address critical skills shortages, contribute to citizens’ education, comply with legislation and boost the economy. The schemes are poorly planned, poorly implemented and poorly monitored, and they have not been evaluated. This study also revealed that the schemes lack effectiveness, incur significant costs, experience high defaulter rates and suffer from inadequate information management. Conclusion RoS schemes do not currently offer sustainable health workforce solutions in the four countries studied and will not unless governance, planning and implementation (including coordination and monitoring) are improved. Better monitoring and placement of beneficiaries in suitable health facilities could lead to quick improvements. Over the longer term, improved identification of the service need and appropriate incentivisation of needed skills could lead to a worthwhile investment through improved beneficiary retention.