Return-of-service schemes - which fund the education of health sciences students provided they return to work in their local communities for a period of time after qualifying - have been used to address healthcare worker shortages across South Africa.

But are they a good investment? A team of researchers from The George Institute and UNSW, Sydney, set out to try and answer this question by seeking the insights of key policymakers from the country’s provincial health departments. Their findings have now been published in PLOS Global Public Health.

According to lead author Sikhumbuzo Mabunda, Africa - especially sub-Saharan Africa - has the highest burden of disease in the world, the second largest population, and also the biggest shortage of health professionals.

“The country’s public health sector has only 33 medical practitioners per 100,000 people compared to the global average of 176 per 100,000 population and its primary care facilities are serviced by less than a third of the professional nurses and midwives that are actually needed,” he said.

“The main reasons driving this shortage are a limited capacity to train health professionals and the tendency for them to move to urban centres or to the private sector once qualified or even move overseas to work in more developed countries.”

But despite the adoption of several policies by governments in selected African countries in the south of the continent - like mandatory service in public sector for the duration of government-funded training - the inequitable distribution of resources persists.

To obtain on-the-ground insights into what is and isn’t working well, the George Institute research team conducted semi-structured, qualitative interviews with 16 key South African policymakers from eight of its nine provinces.

“They did feel that RoS schemes played an important role in increasing the pool of skilled health professionals and said they helped rural and disadvantaged South Africans secure academic qualifications and jobs in the health sector,” said Sikhumbuzo.

“But these benefits were undermined by lack of long-term planning, lack of transparency in the selection of some recipients, poor monitoring and coordination, and deliberate breaches of contract.”

Despite the high costs of the bursaries - reported to account for one quarter of the health worker training budget in Gauteng province, for example - no formal evaluations of the impact of RoS schemes were reported.

“We identified a number of areas where RoS schemes could be improved, such as better monitoring and enforcement of fines when contracts are broken, and policies to better support beneficiaries to fulfil their contracts,” said Sikhumbuzo.

“Given that these schemes represent a significant expenditure in an already resource constrained health system, ongoing monitoring and evaluation is important to ensure they are meeting population needs” he added.   

The George Institute continuing its journey in the mental health space is proud to announce another initiative supporting the psychosocial needs of the frontline workforce. The institute is leading the Psychosocial Support for Front Line health Workers (FLWs) component (in partnership with Engender Health) as a part of the USAID funded project titled - MOMENTUM Safe Surgery in Family Planning and Obstetrics and Gender-integrated Responses to COVID-19 Priorities in India, launched in Bengaluru, Karnataka on April 25, 2022.

The launch event was inaugurated and attended by Dr K Sudhakar, Hon’ble Minister for Health & Family Welfare & Medical Education, Government of Karnataka, Sri Achar Halappa Basappa, the honourable Minister for Women & Child Development & Empowerment of Differently Abled & Senior Citizens, Government of Karnataka, Dr Arundhanthi Chandrashekhar, Director, National Health Mission – Karnataka along with other senior government officials and relevant stakeholders.

The MOMENTUM project aims to prevent future and current pregnancy-related mortality and morbidity in India by promoting awareness of equitable access to high-quality care for voluntary and consented safe surgeries. It intends to provide a gender-integrated response to the emerging COVID-19 priorities in India, including for Gender-Based Violence (GBV) and psychosocial support for the FLWs.

The George Institute has been leading the mental health space for years through various flagship programmes. In this component, the team is leveraging extensive learnings and experiences from the India Health Accelerator Program and Digital health Innovations for psychosocial Support to FLWs – Accelerated response (DISHA) project. The DISHA project aims to co-create a basket of solutions (combination of online and offline) packaged as an intervention to be implemented in 25 districts across six states, namely: Assam, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, and Odisha. The identified interventions will respond to psychosocial issues faced by FLWs (including increasing reported incidents of stress, burnout, violence, and stigma) and build their knowledge, capacity, and resilience by promoting effective responsiveness in the future.

The hon’ble minister - Dr Sudhakar, highlighted the need for psychosocial support through digital technologies and the potential to integrate Tele-Manas programme like initiatives into the response intervention. Other partners and senior officials present at the launch event acknowledged the urgency to respond to the psychosocial needs of the FLWs and highlighted the positive impact this component holds. Collective action towards designing effective strategies can influence and strengthen the overall outcomes of the MOMENTUM project. Dr Ajay Khera, India Country Representative, Engender Health, appreciated the value of association with The George Institute and other partners to address this primary component of the project.

Following the launch event, the team undertook a preliminary field visit to the Tumkur district in Karnataka to implement the activities planned under the project. They met the District Mental Health Programme (DMHP) and visited Nagavalli Primary Health Centre (PHC) and Kuripalaya Urban PHC. They interacted with the PHC staff, Auxiliary Nurse Midwives (ANMs), Accredited Social Health Activists (ASHAs), Medical officers and DMHP team members to understand the psychosocial needs of FLWs, current coping strategies for dealing with work-related stress and interventions aimed at improving the scenario of mental health and its services provided by the DMHP team.

Moving forward, The George Institute will conduct a series of co-creation workshops in six districts to assess the FLWs’ psychosocial needs in detail and incorporate the learnings to design a final package of intervention to pilot in these six districts and then roll out in the remaining 25 Districts over next 18 months.

UNSW held its inaugural Cardiovascular Symposium on 5 April 2022 to launch the newly established Cardiac, Vascular and Metabolic Medicine (CVMM) Research Theme. Several researchers from The George Institute presented at the Symposium, with PhD Candidate Jeffrey Ha receiving a runner-up award for his presentation on medications to prevent stroke in adults with atrial fibrillation and reduced kidney function.

Dr Jeffrey Ha is a clinician-researcher and the focus of his research at The George Institute has been investigating the role of blood thinning medications to address the high burden of cardiovascular disease in patients with poor kidney function.

“Patients with moderate to advanced kidney disease are at a much higher risk for heart disease and stroke and have been largely excluded from clinical trials with limited treatment options. Through a large international cohort study, we are providing more evidence to support effective and safe treatment options to prevent stroke in this high-risk population with atrial fibrillation and chronic kidney disease.”

Professor Alta Schutte, Professorial Fellow at The George Institute, leads the CVMM Theme at UNSW. At the Symposium, she introduced the Theme and talked about why it was a critically important focus for the nation’s health.

“Heart disease, stroke and diabetes remain the leading causes of death in Australia and account for the greatest healthcare costs. The Theme covers the spectrum of discovery research to implementation science, covering also primary health care, population health, intensive and critical care, big data in health and clinical trials.”

Prof Schutte, who has served as the President of the International Society of Hypertension, is a leading global researcher in hypertension and cardiovascular health. She has been the Chief Investigator of several multidisciplinary studies and is involved in numerous international consortia, such as the Global Burden of Disease study, the NCD Risk Factor Collaboration, the May Measurement Month initiative of the International Society of Hypertension, World Health Organization Blood Pressure Device working groups and the Lancet Commission on Hypertension.

In her latest publications, she has joined leading experts in Australia in calling for urgent action to tackle high blood pressure in Australia to achieve better cardiovascular, and related health outcomes.

“Globally, raised blood pressure is the leading risk factor for major adverse outcomes such as coronary heart disease, stroke and dementia. Given these conditions are the top three killers of Australians, raised blood pressure should be front and centre of the national health agenda.”

Under her guidance, the CVMM Theme and Steering Committee brings together expertise across Schools, affiliated Medical Research Institutes, allied Hospitals and Local Health Districts. It positions the faculty and researchers across the Institute as innovative leaders in this domain, both nationally and internationally. The George Institute has made significant contributions to this program of work through its ground-breaking research in blood pressure lowering therapies and novel treatments for diabetes. Other researchers from the Institute who presented their work at the Symposium include Assoc Prof Clare Arnott, Assoc Prof Sunil Badve, Prof Clara Chow, Prof Bruce Neal, Dr Cheryl Carcel and Dr Brendon Neuen.

This year discussions covered basic to clinical science, with talks ranging from genetics and imaging in new cardiometabolic therapies, to a polypill blood pressure control trial to congenital heart disease.

An annual event that will feature prominently on the UNSW calendar, the Symposium will showcase new networking opportunities and research covering a cross-section of fields under the overall Theme in response to broad interest from across the research network.