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

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.