Citation: Mabunda, S.A.; Durbach, A.; Chitha, W.W.; Moaletsane, O.; Angell, B.; Joshi, R. How Were Return-of-Service Schemes Developed and Implemented in Botswana, Eswatini and Lesotho? Healthcare 2023, 11, 1512. https://doi.org/10.3390/ healthcare11101512 Academic Editor: Pedram Sendi Received: 23 April 2023 Revised: 18 May 2023 Accepted: 19 May 2023 Published: 22 May 2023 Copyright: © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). healthcare Review How Were Return-of-Service Schemes Developed and Implemented in Botswana, Eswatini and Lesotho? Sikhumbuzo A. Mabunda 1,2, * , Andrea Durbach 3 , Wezile W. Chitha 4 , Oduetse Moaletsane 5 , Blake Angell 2,† and Rohina Joshi 1,2,6,† 1 School of Population Health, University of New South Wales, Sydney, NSW 2052, Australia 2 The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042, Australia 3 Australian Human Rights Institute, University of New South Wales, Sydney, NSW 2052, Australia 4 Health Systems Enablement and Innovation Unit, University of the Witwatersrand, Johannesburg 2000, South Africa 5 Pharmacovigilance and Clinical Trials, Botswana Medicines Regulatory Authority, Gaborone P.O. Box 505155, Botswana 6 The George Institute for Global Health India, New Delhi 110025, India * Correspondence: drskhumba@gmail.com or s.mabunda@unsw.edu.au † Joint senior authors. Abstract: Botswana, Eswatini and Lesotho are three Southern African countries that make use of return-of-service (RoS) schemes to increase human resources for health in their countries. These initiatives bind beneficiaries to a pre-defined period of service upon the completion of their studies based on the length of funding support received. We aimed to review the history of these policies to understand the conceptualisation, intent and implementation of these schemes. We used a multi- methods research design which consisted of a literature review, a policy review and semi-structured interviews with policymakers and implementors. All three governments have a combination of grant-loan schemes and full bursaries or scholarships. The policies have all been operating for over 20 years, with Eswatini’s pre-service policy being the oldest since it was introduced in 1977, followed by Lesotho’s 1978 policy and Botswana’s 1995 pre-service policy. These policies have never been reviewed or updated. RoS schemes in these countries were introduced to address critical skills shortages, to improve employability prospects for citizens, to have competent public sector employees by global standards and to aid the career progress of government employees. Ministries of Health are passive role players. However, these schemes can only be efficient if there is clear cooperation and coordination between all stakeholders. Keywords: health system; health workforce; human resources; health policy; bursary 1. Introduction With high burdens of morbidity and premature mortality, many Southern African countries are failing to meet their health targets [1]. Contributing to this are the marked human resources for health (HRH) shortages and maldistribution [1,2]. Botswana, Eswatini (formerly Swaziland) and Lesotho are three landlocked middle-income Southern African countries (Table 1), which are mostly rural and have pronounced health worker shortages, especially in rural areas [3–9]. With Lesotho completely surrounded by South Africa, all three countries share borders with South Africa [7–9]. In 2019, these three countries had the highest reproductive-age (15–49 years) HIV prevalence in the world, with Eswatini ranking first and Botswana ranking third [10]. Lesotho has the highest tuberculosis (TB) incidence in the world, which stood at 650/100,000 people in 2020 [11]. All three countries have a doctor-to-population ratio of below 5 per 10,000 population and a nurse and midwife population ratio of below 42 per 10,000 population [12]. The ratio of doctors, nurses and Healthcare 2023, 11, 1512. https://doi.org/10.3390/healthcare11101512 https://www.mdpi.com/journal/healthcare