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Analyzing the Implementation of the Rural Allowance in Hospitals in North


West Province, South Africa

Article  in  Journal of Public Health Policy · June 2011


DOI: 10.1057/jphp.2011.28 · Source: PubMed

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Original Article

Analyzing the implementation of the rural


allowance in hospitals in North West Province,
South Africa

Prudence Ditlopo a, * , Duane Blaauw a , Posy Bidwell b ,


and Steve Thomas b
a
Centre for Health Policy & Medical Research Council Health Policy Research Group,
School of Public Health, University of the Witwatersrand, Johannesburg, Private Bag
X3, Wits, Johannesburg 2050, South Africa.
E-mail: prudence.ditlopo@wits.ac.za
b
Centre for Health Policy and Management, Trinity College, Dublin, Ireland.

*Corresponding author.

Abstract Using a policy analysis framework, we analyzed the implementation


and perceived effectiveness of a rural allowance policy and its influence on the
motivation and retention of health professionals in rural hospitals in the North
West province of South Africa. We conducted 40 in-depth interviews with policy-
makers, hospital managers, nurses, and doctors at five rural hospitals and found
weaknesses in policy design and implementation. These weaknesses included:
lack of evidence to guide policy formulation; restricting eligibility for the
allowance to doctors and professional nurses; lack of clarity on the definition of
rural areas; weak communication; and the absence of a monitoring and evaluation
framework. Although the rural allowance was partially effective in the recruitment
of health professionals, it has had unintended negative consequences of perceived
divisiveness and staff dissatisfaction. Government should take more account of
contextual and process factors in policy formulation and implementation so that
policies have the intended impact.
Journal of Public Health Policy (2011) 32, S80–S93. doi:10.1057/jphp.2011.28

Keywords: rural allowance; policy analysis; motivation; retention; health


professionals; South Africa

Introduction
Worldwide, there is a shortage of health professionals working in rural
areas1,2 and this is a major obstacle to achieving the health Millennium

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Analyzing the implementation of the rural allowance

Development Goals and improving health service access. South Africa


has more health professionals than neighboring African countries,
but it has a severe mal-distribution of personnel between the public
and private sectors and between rural and urban areas.3 In 2004,
46 per cent of the South African population lived in rural areas,
yet they were served by only 12 per cent of doctors and 19 per cent
of nurses.4
The South African government has made several attempts to redress
the imbalance of health professionals between rural and urban areas
(Table 1),3,5 but researchers or government have not evaluated
implementation of these policies systematically.4
We analyzed the implementation and perceived effectiveness of a
rural allowance policy and its influence on the motivation and retention
of health professionals in rural hospitals in the North West province
of South Africa. The results are part of a larger multi-country project
investigating health worker motivation and retention in South
Africa, Tanzania, and Malawi.6 Table 1 summarizes South Africa’s
relevant post-apartheid policy initiatives to provide context.

Methods
Conceptual framework
We used the Walt and Gilson policy analysis framework focusing on
four related factors critical to understanding public policy-making
(Figure 1):7 actors, policy content, contextual factors, and process.

Study design
We used a multiple descriptive case study design, with complementary
methods: document reviews, key informant interviews with policy-
makers, and in-depth interviews with hospital managers and with
health professionals.

Study setting
We conducted the study in the North West province, a predominantly
rural province with a population of 3.2 million (6.4 per cent of the total
South African population).8 We selected five hospitals out of a total

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Table 1: Policy initiatives to address mal-distribution between rural and urban settings in South
Africa

Year Policy initiative

1996 Government recruited first group of Cuban doctors and initiated training of medical
doctors in Cuba
1997 Government released White Paper for the transformation of the health system,
containing recommendations on equitable health professional distribution
1998 Government introduced community service for doctors and for allied health
professionals, making it mandatory for these health professionals to work in
under-served areas for a 1-year period
2004 Government introduced a:
K Rural allowance to attract and retain certain health professionals in rural
facilities
K Scarce skills allowance to attract and retain certain categories of health
professionals in the public health sector
Government released a policy on the recruitment and employment of foreign health
professionals restricting recruitment to persons with verified qualifications and
competencies to work in under-served areas
Government finalizes a bilateral agreement with Iran to allow Iranian doctors to
work in rural South African health facilities
2005 Government promulgated the National Health Act No. 61 of 2003 with a certificate
of need provision for health professionals wishing to establish a private practice
to decrease the concentration of health professionals in urban areas. This clause
has never been enacted
2005 Commonwealth Ministers of Health signed an agreement regarding the ethical
recruitment of health workers
2006 Government releases a National Human Resources for Health Framework to
address the critical shortage of health professionals
Activists developed a Draft Rural Health Strategy for South Africa to improve
health services in rural areas in the period 2006–2009
2007 Government signed an agreement to allow recruitment of Tunisian medical
practitioners for temporary employment in rural areas
2008 Government released a National Nursing Strategy for South Africa
Government introduced community service for nurses, making it mandatory
for nurses with 4-year diplomas or degrees to work in the public sector and
under-served areas for a 1-year period
2008–2010 Government introduced occupation specific dispensation, that is salary categories
specific to each occupational category in the health sector
2010 World Health Organization launched a set of recommendations on increasing access
to health workers in remote and rural areas through improved retention in
Johannesburg, South Africa

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Situational
Structural
CONTEXT Cultural
Exogenous

Stakeholders
(Individuals / groups)
Interests & concerns

Influence and power ACTORS


Stages
Strategies

Dealing with actors


CONTENT PROCESS
Objectives
Policy design
Specific mechanisms

Implementation plan

Figure 1: Framework for health policy analysis.


Source: Walt & Gilson, 1994.7

of 30: all three district hospitals participating in a national hospital


revitalization programme (the broader study focus), and two other
randomly selected hospitals.

Research instruments and study participants


The University of the Witwatersrand and the North West Department
of Health Research Ethics Committee approved the study, as did
hospital managers. All participants signed consent forms after receiving
an information sheet.
The study team reviewed relevant National Department of Health
policies, including the rural allowance policy to understand its
content, along with relevant media releases. We then selected policy-
makers purposively on the basis of their influence or knowledge
about the rural allowance policy process. We used a ‘snowballing’
sampling approach, asking each policy-maker to identify others to

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interview. The study team conducted face-to-face key informant


interviews with seven policy-makers from national and provincial
government and health professional bodies using a semi-structured
interview guide derived from the policy framework. We also con-
ducted in-depth interviews with five hospital managers, 22 nurses,
and six doctors in the study hospitals. We taped all in-depth
interviews and then transcribed them.

Analysis
We conducted a thematic content analysis9 using the ATLAS.ti software
program, using a common coding framework to ensure consistency.
Two researchers first independently read six transcripts from different
groups of participants and then discussed coding discrepancies until
they reached agreement.

Findings
Analyzing the rural allowance policy
Contextual factors
In 2004, near the time of the country’s second democratic elections,
the South African government introduced a rural allowance policy
to address geographical inequities in health personnel distribution
within the country. Although the timing suggests a political motive,
one respondent commented on the context of policy implementation:

It was a huge policy problem that we have enormous inequities


in the distribution of doctors in rural areas. The reason for the
rural allowance is that health workers tend to drift to cities, so
countries put in place incentives like rural allowances to try to
send most of the health workers to more remote areas. (Policy-
Maker 7, National Government)

Policy content
The intention of the rural allowance policy was to attract and retain
health professionals to work full-time in public health services in rural,
under-served, and other inhospitable areas identified by provincial
health departments. Government awarded the rural allowance, a

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Analyzing the implementation of the rural allowance

non-pensionable fixed percentage linked to the annual salary notch10


to most categories of health professionals including doctors, dentists,
dieticians, pharmacists, psychologists, radiographers, therapists, and
professional nurses with 4-year diploma or degree. The policy excluded
junior nurses (enrolled nurses with 2 years of training and nursing
assistants with 1-year training).
Government paid doctors allowances of 18–22 per cent of their
annual salaries, 8–12 per cent for professional nurses, and awarded
payments retrospectively to July 2003. We could not determine why
policy-makers excluded junior nurses, how they determined the salary
percentage additions, or what information they considered to set the
allowance scale. Policy-makers, when interviewed, were also unclear on
the evidence that guided the rural allowance decisions. One policy-
maker commented on the lack of evidence used to inform the develop-
ment of the rural allowance:

I think there wasn’t proper research done to say what is it that


other countries are paying [to] keep their doctors. (Policy-Maker 5,
Health Professions Council)

The rural policy called for an annual review of the allowance, notably
the percentage allowance and health professional eligibility.

When the rural allowance was introduced, the Department of


Health was required to conduct an analysis as part of the
agreement. I think it was supposed to be an annual or every
third year analysis, I can’t remember the specifics. That would
then determine if they needed to roll it out further or extend it.
(Policy-Maker 2, National Government)

The Department of Health has not conducted a review nor has it


evaluated the effectiveness of the rural allowance:

I can’t say whether rural allowance is effective or not, because we


haven’t done research y, I am not sure whether the allowance
brought more doctors and health professionals into those areas
and secondly if at all they were retained there. (Policy-Maker 2,
National Government)

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Media releases in 2004 quoted the Minister of Health claiming that the
rural allowance would benefit 33 000 full-time health professionals
working in designated areas; and that an entry-level medical doctor
working in a rural area with an annual salary of R150 000 (US$21 000;
$1 ¼ R7) would gain R15 000 (US$2100) per year.11
Government added R500 million (approximately US$71 million)
in 2004 and a further R750 million (US$107 million) in 2005 for the
implementation of the rural allowance.12 In the absence of evaluations
or annual reviews, we do not know how many health professionals
benefited from the allowance.

Policy implementation
The interviews with policy-makers and health managers indicated that
there were problems with the implementation of the rural allowance
policy. At least four policy-makers and all hospital managers reported
that the Department of Health failed to implement this policy
effectively, leaving information gaps, uncertainty, and room for
subjective policy interpretation. Provincial health departments desig-
nated ‘rural areas’ without national oversight for consistency within or
across provinces. For awarding rural allowances, the provincial
Department of Health relied on an outdated list of hospitals that
excluded a number of rural institutions:

I think rural allowance was most appropriate but it was not


necessarily implemented correctly because the declaration of what
is rural depended on the provinces. And the problem is that if you
leave any policy to individual interpretation, you’ll actually have a
problem. (Policy-Maker 1, National Government)

Communication among hospital managers and health professionals,


particularly those in excluded categories, was another weakness:

There was no clear communication to the nursing profession


resulting in confusion. And even managers within the health
services found it difficult to understand. As a result, when nurses
queried whether they are eligible or not, the responses they
got were often not helpful. (Policy-Maker 6, Health Professions
Council)

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Analyzing the implementation of the rural allowance

Actors and their roles


The key institutional actors included the Department of Health,
the National Treasury, the Department of Public Service and
Administration (DPSA), representatives from the Public Health and
Welfare Sectoral Bargaining Council, and the relevant trade unions.
One respondent defined the role of the DPSA:

We as the DPSA assist in dealing with all financial implications


and technical implementation. The reason for that is that our own
minister [of DPSA] is the person who can determine or approve
any allowance in the Department of Health. (Policy-Maker 2,
National Government)

Perceived effectiveness of the rural allowance


Figure 2 presents key themes about perceptions of all the respondents
on the effectiveness of the rural allowance and links between the policy
development and implementation processes.

Partial effectiveness of rural allowance in recruitment


Some hospital managers reported that the rural allowance had
been partially effective in attracting health professionals to their

Key policy Perceptions on Consequences for


development Implementation health professionals
features
Definition of rural at
provincial discretion • Rural allowance partially
& interpretation • Weak improved recruitment
communication • Rural allowance led to
• Perceived as unintended
Exclusion of lower consequences
nursing categories divisive
Rural allowance incentive • Junior nurses felt
developed as a
• Remoteness of undervalued &
targeted financial
area not dissatisfied
incentive
Not evidence based considered • Impact of financial
• Amount low incentives short-lived
relative to total • Financial incentives
salary insufficient if
No monitoring and
evaluation system implemented in isolation

Figure 2: Key themes on the perceived rural allowance effectiveness and linkages with the policy
development and implementation processes.

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facilities. One commented:

Since our hospital was considered rural and our nurses started
getting the rural allowance, we were able to attract more nurses.
(Hospital Manager 9, District Hospital)

Other managers argued that the rural allowance was only effective in
addressing short-term recruitment needs:

y you give people a rural allowance but salary excites you for the
first three to four months. And we know, the more you earn,
the more you want y and that’s basically the challenge, it doesn’t
make a sustainable impact. (Hospital Manager 1, District Hospital)

Rural allowance seen as divisive


Almost all policy-makers, hospital managers and health professionals
(doctors and nurses) consistently perceived the rural allowance to be
divisive because it excluded junior nurses. The excluded cadres felt
undervalued and dissatisfied, thus affecting team spirit.

The rural allowance is only paid to professional nurses. Enrolled


nurses and assistant nurses are not getting a rural allowance y
this causes a lot of conflict because sometimes if you work with a
registered nurse, and she wants you to assist her, you say to her:
“do your work; you are getting the rural allowance”. (Enrolled
Nurse, District Hospital)

Some nurses (professional and junior nurses) felt that equity was
compromised in the implementation of the rural allowance:

I feel that the rural allowance is unfair y It can be better if we were


all getting it because personally I feel bad because it looks like some
of us are better than others. (Professional Nurse, District Hospital)

All doctors and most of the professional nurses who received the
rural allowance indicated that it was low relative to their total salary
and felt unhappy that this amount would not be included in the
calculation of their retirement pensions.

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Remoteness of the area not considered


The implementation of the rural allowance was not linked to the
remoteness of rural areas. Health professionals working in deep rural
areas received no more than those in semi-rural areas. One hospital
manager commented:

The problem with the rural allowance is that what a person


gets here [deep rural area], is the same amount that a person gets
in Vryburg [rural town]. The semi-rural areas should have a lower
percentage than the extremely rural areas. (Hospital Manager 3,
District Hospital)

Financial incentives alone are insufficient


Most participants (nurses, doctors, health managers, and policy-
makers) indicated that financial incentives alone are insufficient to
motivate and retain staff.

You can give people a million [rands] but after a year they will
go. So the strategy should not only be about money. It is true,
money helps but if you have kids that go to school, you won’t come
here because there are no good schools. But there are other things
that the management can do; they can send people for training.
For example, people can be sent to a bigger hospital for six months
to enhance their speciality skills. (Doctor, District Hospital)

A doctor in a Regional Hospital commented:

I get a rural allowance; it’s about two thousand rands. For me


to get to town just to get a decent meal at a restaurant, I have to
travel for about 80 km. There are no recreational facilities here.
So you actually spend that money on transport anyway.

Discussion
This study illustrates that good policies with admirable intentions can
have reduced impact or even negative consequences because of process
and implementation weaknesses. The successful implementation of
future retention strategies will require more coordinated effort across

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Ditlopo et al

a range of governmental actors. Particular attention needs to be paid


to process issues, better communication, use of evidence to inform
policy and effective monitoring and evaluation.
Previous reviews of retention strategies found that financial
incentives can improve recruitment and retention in the short-term,
but long-term impact on retention is less certain.13–15 We found
unintended negative consequences from design and implementation
shortcomings. Our findings contrast with those of Reid5 who found
that between 28 and 35 per cent of his study population, mainly
professional nurses, remained in rural hospitals as a result of the
rural allowance. Reid collected data soon after the implementation
of the policy and near in time to the large back-dated payouts received
by health professionals. Both could have influenced responses. In the
absence of before and after studies, evidence on the effectiveness of
financial incentives remains inconclusive.14
Some studies found that financial incentives alone are insufficient
to motivate and retain health professionals.16,17 Some demonstrated
that non-financial incentives related to working and housing conditions
had greater potential to influence retention.18,19 Others recognized that
health professionals will always move, often for reasons beyond the
influence of any workforce retention programme, no matter how well
designed.14 Thus, no single measure is likely to improve motivation
and retention if other factors are not taken into consideration.
The provincial governments’ efforts to engage and consult with local
managers and providers during implementation of the policy were
weak, particularly in relation to the exclusion of junior categories
of nurses and the differential allowance increases. Central level policy-
makers were the key actors driving the overall policy process,
suggesting a top–down approach in the formulation of the rural
allowance policy.
Policy development should be guided by the best available evidence
and every attempt should be made to generate rigorous evidence if
novel or untested policies are adopted.20 Because respondents perceived
the rural allowance to have had limited effect on the motivation and
retention, policy-makers should obtain better data on the factors that
influence health workers’ location choices in order to develop more
appropriate human resource interventions in future.21
Although the rural allowance policy document called for annual
reviews, government did not develop a framework to monitor potential

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Analyzing the implementation of the rural allowance

implementation challenges nor evaluate policy impact. The rural


allowance is an expensive intervention to have been left without
proper evaluation.

Limitations
Our data are valuable as they represent views of those closely involved in
formulating the policy or responsible for its implementation, but we
recognize that such accounts are inevitably influenced by the respondents’
viewpoints at the time of the event and the interview. Another limitation
of the study is that it was only conducted in one province although some
aspects of the policy formulation relate to national processes.

Conclusion
The use of financial incentives to motivate and retain health professionals
is particularly challenging; limited resources make it difficult to provide
allowances to all categories of health professionals, their impact may be
short-lived, and they may be inadequate if implemented alone. Retention
strategies combining financial and non-financial incentives are likely to be
more effective than increased remuneration alone, but these would need
to be tailored to individual country contexts.

Acknowledgements
The study was funded by Irish Aid and administered through the
Health Research Board in Ireland. We would like to thank all study
participants.

About the Authors

Prudence Ditlopo, MA (Research Psychology), is a researcher at the


Centre for Health Policy (CHP), School of Public Health, University
of the Witwatersrand, Johannesburg. She conducts research on human
resources for health.

Duane Blaauw is a medical doctor and public health specialist with


additional qualifications in public management, medical science,

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Ditlopo et al

tropical medicine, and occupational health and is a senior researcher


at the CHP at the University of the Witwatersrand, Johannesburg.

Posy Bidwell has a Masters in Demography and Health and is a


researcher at the Centre for Health Policy and Management, Trinity
College Dublin. She conducts research on the needs, aspirations, and
career plans of non-European doctors in Ireland.

Steve Thomas, PhD, is a health economist and lecturer at the Centre


for Health Policy and Management, Trinity College Dublin. He has
18 years of research experience in health financing, systems, human
resources, and policy analysis.

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