Rural Recruitment and Retention: Why are we not winning?

Rural Recruitment and Retention: Why are we not winning?

While the Department of Health has started work on a new plan for HRH, what we have achieved in the past 5 years?

Sadly, the picture is bleak and progress is hampered by a combination of factors: ranging from lack of NDoH prioritisation and capacity; National Health Council resolutions on rural health education and task teams that are not followed through; provincial priority-setting out of tune with rural health needs; and the overall fiscal climate and austerity measures. In our Stocktake Report we report on our monitoring of Chapter 8 of the National Human Resources for Health Plan. Many of the goals have not been achieved. These must not get lost in the new five year plan. In addition, the next HRH plan needs to be more multi-disciplinary. The Nursing committees, rural health committee etc need to talk to each other.

Credit where credit is due: we welcome the pilot project in North West Province on operationalising RHAP’s guidelines on critical health posts, following our advocacy on this critical matter over the past 2 years

Here is a summary of the challenges and achievements:


  • Delayed formalisation and irregular and scarce meeting of the Rural HRH task team has resulted in slow progress on Strategic Objective 8 implementation
  • Provincial CSO allocations still do not uniformly favour rural placement
  • Clinical associates have not yet been adequately included in HR planning in the provinces, with lack of sufficient posts. This is despite the critical role they can play in expanding access to clinical care in rural areas in a cost-effective manner
  • Hiring moratoria and post freezing continue in 2016 , with dire consequences for rural health services in particular. NDoH has not yet released the guidelines for protecting critical posts developed by RHAP and finalised at a stakeholder meeting hosted by the NDoH on 1 April, with inputs from Health and Treasury
  • Fiscal climate and the austerity measures in Universities threaten funding for rural clinical training platforms
  • NDoH has yet to adopt formal definitions of rurality for purposes of HR planning and post protection, despite offers by RHAP to assist with this
  • Graduate tracking by universities is largely non-existent, undermining their accountability for producing the workforce required for the South African population.
  • As yet, minimal HR data are available for cadres other than medicine, although work is underway to address this.
  • While the WISN methodology selected by the NDoH for HR planning provides a systemic manner in which to estimate HR needs per facility, it has critical flaws, most notably its use of utilisation rates as proxy for need, which systematically disadvantages areas with non-existent services, and which does not take into account various access barriers people face in accessing services.

Key achievements to date:

  • Appointment of a Chief Director for HR at NDoH
  • A task team for rural HRH has met annually, and DG approved its formalisation as a sub-committee under the Technical Advisory Committee of the National Health Council. However an annual meeting is not enough, without  minutes at times and resolutions not honoured. The formalisation of the sub-committee never materialised.
  • Community Service Summit in April 2015 reaffirmed relevance of the community service program for extending services to rural and underserved communities. Rural partners played a prominent role in reviewing the policy and developing recommendations adopted
  • CSO applications and allocations have been transferred to a national online platform in 2016, for greater transparency to the users of the system. At the time of writing, the impact on rural allocations was not yet known and success of system depends on provinces offering sufficient rural CSO posts. We since issued a statement on the 2017 rural CSO placements fiasco.
  • CHEER work on pro-rural health professionals education (HPE) has helped with gaining traction on admission criteria at several universities, increasing opportunities for rural origin students
  • Rural clinical exposure is being expanded at some universities, and rural clinical training platforms have been established at Stellenbosch University, UCT (semi-rural) and Wits, with further work underway at UKZN
  • RHAP’s Voice advocacy training is gaining traction, with Stellenbosch university being the first to include this in their medical curriculum. The training is now CPD accredited and is being offered to rural healthcare workers across the country
  • Following the tightening fiscal climate and continuous staffing moratoria, RHAP has produced guidelines for critical post protection that take into account rural context. Engagement with treasury has been strengthened through this process, and Treasury did pronounce that critical posts must be protected, however insufficient detail is provided. Two rural recruitment and retention round table meetings have been convened by NDoH, with rural partners included, to unpack how to identify critical posts when there are more unfilled posts than that funds are available
  • 516 Clinical associates have been trained to date, with the majority now employed in the public sector
  • In the general dearth of HRH data for South Africa, the rural partners have produced several significant studies, notably the CSO exit survey (2002 – 2014). A proposal for graduate tracking by the HPCSA has been approved for ethics, but is currently stalled at HPCSA

Detailed discussion of challenges and progress in the full report: