Investing in health workers: a retrospective cost analysis of a cohort of return-of-service bursary recipients in Southern Africa.

Background: Return-of-service (RoS) schemes are investment strategies that governments use to increase the pool of health professionals through the issuing of bursaries and scholarships to health sciences students in return for service after graduation. Despite using these schemes for many years, Eswatini, South Africa, Botswana and Lesotho have not assessed the costs and return on investment of these schemes. This study aimed to assess the costs and relative rates of contract defaulting in these four Southern African countries.

Methods: A retrospective cohort study was carried out by reviewing databases of RoS beneficiaries for selected health sciences programmes who were funded between 2000 and 2010. Costs of the schemes were assessed by country, degree type and whether bursary holders completed their required service or defaulted on their public service obligations.

Results: Of the 5616 beneficiaries who studied between 1995 and 2019 in the four countries, 1225 (21.8%) beneficiaries from 2/9 South African provinces and Eswatini were presented in the final analysis. Only Eswatini had data on debt recovery or financial repayments. Beneficiaries were mostly medical students and slightly biased towards males. Medical students benefited from 56.7% and 81.3% of the disbursement in Eswatini (~US$2 million) and South Africa (~US$57 million), respectively. Each South African medical student studying in Cuba cost more than five times the rate of medical students who studied in South Africa. Of the total expenditure, 47.7% and 39.3% of the total disbursement is spent on individuals who default the RoS scheme in South Africa and Eswatini, respectively.

Conclusions: RoS schemes in these countries have loss of return on investment due to poor monitoring. The schemes are costly, ineffective and have never been evaluated. There are poor mechanisms for identifying beneficiaries who exit their contracts prematurely and inadequate debt recovery processes.