The backlog of newly qualified doctors seeking to specialise in South Africa is pushing some to take on unpaid posts in the public health system to gain experience and advance their training. They endure long hours and gruelling work with no pay, in the hope of attaining a registrar post down the line.
Medical practitioners seeking to specialise need to complete four years of training in a registrar programme at a state academic hospital, on top of their two-year internship and one-year community service requirements. However, the fierce competition for a limited number of registrar posts is serving as a barrier for young doctors looking to progress.
Daily Maverick spoke to young professionals working to qualify as anaesthetists about the challenges they were facing.
Kyle Kretzmer, who completed his community service in 2023, has been working in an unpaid, “supernumerary” medical officer post in the anaesthetics department at Chris Hani Baragwanath Hospital for the past three months. Medical officers are non-specialist doctors working in the public sector.
“The motivation is quite challenging… but I just see it as a future investment. It’s just tough at the moment,” he said.
“I think it’s unfair on multiple levels. You shouldn’t have to work and not be paid just because the posts aren’t there. It is very competitive and some people are more qualified than others… but the problem is, there’s more and more doctors graduating with fewer and fewer posts. The thing is, how long do you go with working for free?”
Time spent as a medical officer – paid or unpaid – does not count towards the registrar component of specialisation training, but it does allow young doctors to “beef up their CVs”, according to Dr Celeste Quan, consultant anaesthesiologist at Chris Hani Baragwanath and lecturer at Wits University.
A minimum requirement when applying for a registrar post in an anaesthetics department is passing the Fellowship of the College of Anaesthetists of South Africa 1 examination.
“Then [young doctors] try and beef up their CVs by getting diplomas… For example, for anaesthesia, the College of Anaesthetists runs a Diploma of Anesthesia (DA)… [To do] your DA, you’ve got to have six months of training in an accredited hospital. So, what these young doctors are doing is they’re working for free in an accredited hospital so that they can get the work experience to write the diplomas… to try and improve their chances of getting into a [registrar] training post,” explained Quan.
The College of Anaesthetists of South Africa is one of 29 constituent branches of the Colleges of Medicine of South Africa, representing all the disciplines of medicine and dentistry.
Unfair and exclusionary
Kretzmer told Daily Maverick he saved money during his internship and community service, knowing he might have to take an unpaid post. He and his wife, who is working, have also moved in with her parents to save money. However, he noted that for many newly qualified doctors, working for free was not financially viable.
“The majority of people I know… haven’t gotten medical officer posts. Most of them are just doing [work as] private casualty locums,” he said.
Quan said that those without financial support were usually unable to take on unpaid positions. “That’s where the inequality then comes in,” she said.
“Most doctors won’t practise without paying medical insurance with the Medical Protection Society or one of those, and it’s not a cheap exercise. So to me, it’s a travesty that you’ve got a young doctor who’s paying to work.”
*Fiona is a young doctor who started working in a paid medical officer post in an anaesthetics department in Gauteng in October this year. She completed her community service in anaesthetics in 2022 and was able to acquire her Diploma in Anaesthetics during this phase of her training.
She said that the challenges involved in getting medical officer or registrar positions in state hospitals was driving young doctors out of the public health system.
“It’s really, really dire. There’s quite a few of my friends who would love to be specialising and would love to be working in the government sector, who are stuck working in GP [general practitioner] practices… Then it’s so much harder to get back into the government sector,” she said.
For those young doctors who do elect to take an unpaid post, there is no guarantee they will receive a paid medical officer or registrar position on the other side, according to Fiona.
“From what I understand, they’ve not increased the number of registrars in any training programmes in the last 10, 15 years, but more and more people have been graduating med school, doing the internship and community service. So, there’s just this complete bottleneck of medical officers trying to get into registrar spots, and now there’s even a bottleneck to get the medical officer job,” she said.
Earlier this year, former Minister of Health Dr Joe Phaahla said that universities had increased the number of medical interns they trained by about 60% in less than a decade, according to a BusinessLive report. However, the budgets for provincial health departments have not increased at the same pace, meaning they are unable to employ the increasing number of graduates.
“I think the big problem now is the gap between community service and trying to get into a registrar training post… I chatted to a girl who’s 35 and still waiting to get into a registrar training post,” said Quan.
“I was a specialist by the time I was 29 years old. That doesn’t happen at all. And then with the female doctors, it becomes really hard because by this stage, you’re married, your body clock is ticking. A lot of them actually talk about harvesting and storing eggs, because by the time they’re finished, most of them are in their late thirties, forties, because they wait so long to get into training posts.”
Fiona was based in the Western Cape before relocating for work, and she says that unpaid, supernumerary posts are more common in that region.
“In the Western Cape, it’s everywhere… I have a lot of friends from the Western Cape and there are literally waiting lists to work for free,” said Kretzmer.
Daily Maverick asked the National Department of Health about the problems facing young doctors seeking to specialise, but it had not responded at the time of publishing.
Read more: Tertiary hospital professionals sound the public healthcare alarm after severe national budget cuts
Long-term strategy
The strain on resources in the public health system is not new. In a recent interview, head of the Western Cape Health Department Dr Keith Cloete told Daily Maverick there was a “significant shock” to public healthcare financing in the country during the 2023/24 financial year. A major factor behind this was a national government commitment to a higher-than-expected wage increase for public servants, which ended up being only 78% funded.
Over the past year, posts at hospitals across the country – including registrar posts – have been frozen or left vacant due to cost-cutting measures.
Professor Johan Fagan, head of the division of Otorhinolaryngology (Ear, Nose and Throat/ENT) at Groote Schuur Hospital, said that one of the biggest concerns around cost-cutting had been the need to cut salaries, as 70% of the hospital’s budget went to that expense.
“[In] the Western Cape, we were asked to cut our staff budget by about 9%... but the difficulty is, it’s been a random process because they can’t fire people. They can only freeze positions or discontinue positions as people leave,” he said.
“In ENT, they’ve discontinued one of our registrar posts, and that’s happened nationally. So, it does create problems in terms of training opportunities. And of course, then you’re going to pay a long-term price. That’s also part of the strategic thinking – what does the country need? Not today, but what did you need for the next 20 years? You might prioritise training positions because that’s what the country needs in the long term.”
According to Fagan, the haphazard process behind freezing positions has been a “missed opportunity”. He advocated for a more strategic approach that retained medical practitioners in key positions.
Reflecting on how to reduce the barrier to specialisation at the stage of registrar training, he said, “We need the posts, that’s number one. And the posts are linked to funding. We may find that the posts might be linked to the number of consultant [specialists] as well, because of the ratio the [Health Professions Council of South Africa] determines between the number of consultants and registrars for the programme to be accredited.”
Fagan noted that it was not the first time the public health system had faced a crisis in funding, adding that the most recent round of budget cuts could serve as an opportunity to refocus and pursue a strategy of frugal innovation.
“I think we’ve been living in a false economy for too long… We often forget that we are an upper middle-income country... and I think it’s an opportunity for us to focus our minds on what we can afford… and what services we offer… It’s an opportunity for us to introspect and to really define what our mission and our role is,” he said. DM
*Fiona is a pseudonym ascribed to a source who asked to remain anonymous for fear of victimisation.