Journal of Public Health Policy

, Volume 32, Supplement 1, pp S80–S93 | Cite as

Analyzing the implementation of the rural allowance in hospitals in North West Province, South Africa

  • Prudence DitlopoEmail author
  • Duane Blaauw
  • Posy Bidwell
  • Steve Thomas
Original Article


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.


rural allowance policy analysis motivation retention health professionals South Africa 



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


  1. Grobler, L., Marais, B.J., Mabunda, S.A., Marindi, P.N., Reuter, H. and Volmink, J. (2009) Interventions for increasing the proportion of health professionals practising in rural and other underserved areas (Review). Cochrane Database of Systematic Reviews CD 0053 14 (1): 1–25.Google Scholar
  2. Hamilton, K. and Yau, J. (2004) The Global Tug-of-War for Health Care Workers. Migration Policy Institute,, accessed October 2010.Google Scholar
  3. Department of Health (DOH). (2006) National Human Resource Plan. Pretoria, South Africa: DOH.Google Scholar
  4. George, G., Quinlan, T. and Reardon, C. (2009) Human Resources for Health: A Needs and Gaps Analysis of HRH in South Africa. Durban, South Africa: Health Economics and HIV & AIDS Research Division (HEARD), University of KwaZulu-Natal.Google Scholar
  5. Reid, S.J. (2004) Monitoring the Effect of the New Rural Allowance for Health Professionals. Durban, South Africa: Health Systems Trust.Google Scholar
  6. Ditlopo, P. and Blaauw, D. (2010) The impact of human resource interventions on the motivation and retention of health professionals in South Africa. Johannesburg: Centre for Health Policy, School of Public Health, University of Witwatersrand, Johannesburg.Google Scholar
  7. Walt, G. and Gilson, L. (1994) Reforming the health sector in developing countries: The central role of policy analysis. Health Policy and Planning 9: 353–370.CrossRefGoogle Scholar
  8. Statistics South Africa. (2010) Mid-year Population Estimates Pretoria: Statistics South Africa. Report No. P0302.Google Scholar
  9. Green, J. and Thorogood, N. (2004) Qualitative Methods for Health Research. London: Sage.Google Scholar
  10. Department of Health. (2004) PHWSBC Resolution No. 2 of 2004: Revised non-pensionable recruitment allowance, referred to as ‘rural allowance’,
  11. Venter, B. (2004) More cash for health workers in rural areas. The Star 29 January.Google Scholar
  12. Kahn, T. (2006) Salary review for health workers. Health Systems Trust News 20 June.Google Scholar
  13. Bärnighausen, T. and Bloom, D. (2009) Financial incentives for return of service in underserved areas: A systematic review. BMC Health Services Research 9: article 86.Google Scholar
  14. Buykx, P., Humphreys, J., Wakerman, J. and Pashen, D. (2010) Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence-based policy. Australian Journal of Rural Health 18: 102–109.CrossRefGoogle Scholar
  15. Sempowski, I.P. (2004) Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: Systematic review of the literature. Canadian Journal of Rural Medicine 9 (2): 82–88.Google Scholar
  16. Largade, M. and Blaauw, D. (2009) A review of the application and contribution of discrete choice experiments to inform human resources policy interventions. Human Resources for Health 7 (62).Google Scholar
  17. Willis-Shattuck, M., Bidwell, P., Thomas, S., Wyness, L., Blaauw, D. and Ditlopo, P. (2008) Motivation and retention of health workers in developing countries: A systematic review. BMC Health Services Research 8: article 247.Google Scholar
  18. Wilkinson, D., Symon, B., Newbury, J. and Marley, J.E. (2001) Positive impact of rural academic family practices on rural medical recruitment and retention in South Australia. Australian Journal of Rural Health 9: 29–33.CrossRefGoogle Scholar
  19. Wilks, C.M., Oakley Browne, M. and Jenner, B.L. (2008) Attracting psychiatrists to a rural area – 10 years on. Rural and Remote Health 8 (1): 824.Google Scholar
  20. Hewison, A. (2008) Evidence-based policy: Implications for nursing and policy involvement. Policy, Politics and Nursing Practice 9 (4): 288–298.CrossRefGoogle Scholar
  21. Dolea, C., Stormont, L. and Braichet, J. (2010) Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bulletin of the World Health Organization 88: 379–385.CrossRefGoogle Scholar

Copyright information

© Palgrave Macmillan, a division of Macmillan Publishers Ltd 2011

Authors and Affiliations

  • Prudence Ditlopo
    • 1
    Email author
  • Duane Blaauw
    • 1
  • Posy Bidwell
    • 2
  • Steve Thomas
    • 2
  1. 1.Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, University of the WitwatersrandWitsSouth Africa
  2. 2.Centre for Health Policy and Management, Trinity CollegeDublinIreland

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