Follow Us HCI Project on FacebookHCI Project on TwitterHCI Project on Vimeo
Why Register?     Register      Login

Retaining doctors in deep rural areas in South Africa through “marriage counsellors” who work to negotiate the relationships between management and doctors.

Improvement Report
Saul Kornik and Candice Clark

Topics: Behavior change and communication, Community involvement, Employee Engagement, Equipment/supplies, HIV/AIDS, Program design, Program management, Recruitment, Retention of health workers/reducing attrition, Scaling up, Service integration, Sustainability, Training

Region and Country: South Africa

Organization: Africa Health Placements
The Report

Retention of doctors in rural areas is a global issue most frequently linked to the professional and personal isolation that results in the majority of qualifying medical professionals to migrate to urban healthcare facilities leaving those in rural areas horribly understaffed. The situation in South Africa is no different, only to be made more dire by poor management at hospitals and within health districts. Unfortunately, isolation is not the only issue faced by the South African public health sector. Poor management at both facility and department level result in poorly equipped hospitals which are already struggling under the burden of HIV/Aids and TB. In addition to management difficulties, HR in these facilities are frequently ill-equipped and understaffed resulting in erratic salary payments causing further frustration for doctors. What often occurs is a breakdown between healthcare facility management and its clinical staff creating an additional obstacle to the resolution of such issues. Once this relationship breaks down, dissatisfaction escalates highlighting other issues related to rural placements such as professional isolation which them drives these professionals to seek alternative urban appointments.

Considering all the reasons explained above it is not surprising that South Africa’s rural public health sector is critically understaffed. According to the latest statistics 43% of the population is served by less than 8% of doctors, and doctor-to-patient ratios are five times less in rural areas than urban areas.

Africa Health Placements (AHP) is a non-profit organisation that sources, recruits and works to retain local and foreign-qualified healthcare workers to work in underserved public healthcare facilities, with a focus on rural areas.


Rural doctors often have to travel long distances to urban areas in search of continued professional development courses which often has little or no relevance to rural clinical practice. Recognising this challenge as well as the fact that rural areas were suffering from a breakdown in the relationship between management and doctors - AHP launched a pilot project in January 2011 called the "Rural Doctors' Support Programme". Piloted in three rural Eastern Cape districts: Chris Hani, OR Tambo and Joe Gqabi respectively, the primary aim of this project was to address the lack of support available to medical officers working in rural healthcare facilities. The backbone of this programme revolves around AHP's version of a "marriage counsellor" and a networker. A dedicated Practice Manager (PM) was appointed for each of the three rural districts. Critical to their success was going to be their integration into the South African Department of Health (DoH), while managing to maintain a level of independence that would allow them to move across all levels of the management hierarchy without anyone within that hierarchy feeling like the PMs were going "over their head" AHP has been closely working with a high level DoH official, a champion within the Eastern Cape who facilitated the relationship building. This individual has clinical skills and internal experience to guide the technical aspects of the programme in a way that is aligned with DoH priorities and plans.

Continuous Professional Development (CPD) sessions are held to reduce the feeling of professional isolation as well as to create a forum where doctors could network and interact. CPD sessions have covered a range of topics and interests relevant to rural practice. In one particular case school children were brought in talk to the doctors about medicine. Not only do such interventions inspire children to work hard and pursue careers in medical science, it allows for information sharing, and an increase in community support for the public health system.

The PM's work to troubleshoot problems in procurement, salaries, supplies and other administrative concerns. There have been instances where PM's have even had to deal with road and water infrastructural troubles. Resolving such issues aims to make doctors feel heard, allowing them to focus on their work. Part of this programme also aims to identify recurring issues and bring these to the attention of the DoH and civil society for long term solutions.


To date this innovative programme has proved to be incredibly successful, with PMs forging strong working relationships at both facility and district health levels. Going forward, AHP is developing an "improvement index". This measures key retention factors; ranging from procurement to accommodation, the index then rates improvement based on programme interventions. This index is also going to allow the DoH to gauge their own successes and will eventually become a tool for them to identify where and when problems occur and how to remedy them. This programme has proved to be cost-effective; essentially costs involved include the salary of one PM per health district and their travel expenses. The programme has had a positive impact on an estimated 3.2 million people in the Eastern Cape.


 There are many reasons for the shortage of doctors in rural areas and addressing the problem requires long-term and systemic interventions. This programme illustrates that a grassroots approach where doctors are supported through addressing day-to-day problems and improving relationships between management and doctors, can address the challenges faced by rural doctors.

As a result of the success of the programme, it has now been expanded to five more districts in South Africa as of January 2012. By the end of 2012, more than half the country will be benefiting from PMs.