It feels like every doctor I know wants to move to Cape Town. Almost none of them has thought about what that wanting does to the job they’re moving there to do.
Let’s discuss what doesn’t make it into the marketing brochure. The reason Cape Town is a hard place to work as a doctor is the same reason it’s a good place to live. Everyone wants to be there. And when everyone wants to be somewhere, the people already there hold the cards.
If you want to know what that looks like in practice, there’s a case. A gynaecologist applied for admitting privileges at a Cape Town hospital and was refused - the board’s position, as reported, being that there was no medical or financial necessity for another gynaecologist. It went to court. The Western Cape High Court found that granting privileges is a contractual decision rather than administrative action, which means it isn’t reviewable. The Supreme Court of Appeal dismissed the appeal last month.
So a hospital board in Cape Town can decide the market already has enough of you, and there is no forum in which you get to argue otherwise.
I get the rationale. The Western Cape has roughly a quarter of the country’s specialist surgical workforce serving about twelve percent of its population, and it’s the only province above the international minimum for surgical density. The register data behind that is a few years old now, but the direction hasn’t reversed - the largest inter-provincial movement of family physicians is still toward the Western Cape.
Now hold that against the market they’re all serving. Medical scheme coverage in South Africa has sat at roughly fifteen percent of the population for two decades. Not falling, just not moving. Beneficiary numbers grew under half a percent in 2024. So the number of doctors chasing private work keeps climbing in one province while the pool of people who can pay for it stays frozen.
The schemes have noticed and responded the way you’d expect. Tariff cost assumptions were capped at 3.3% for 2026 while practice costs run at two or three times that. General practitioners now receive about four percent of what schemes pay out, down from over nine percent in 2007. And increasingly you aren’t chosen by a patient at all - Discovery’s Flexicare allocates a patient to whichever practice they first claim from, and pays a fixed monthly amount per head.
The public side you already know about. There are no posts, and there haven’t been for a while.
I should voice the other side of this, because there is nuance. The Health Market Inquiry looked directly at whether new practitioners could get into the private market and concluded in 2019 that the barriers were surmountable - around a thousand did get in over five years, during which scheme membership didn’t move at all. Netcare granted a net 117 specialists admission rights last year. Life is planning about 140 this year. And Cape Town has the highest medical aid penetration of any metro in the country, at twenty-eight percent, and rising.
So it isn’t that the door is shut. It’s that nobody is counting who doesn’t get through. There’s no published figure for how many practices fail in Cape Town, how long a new one takes to become viable, or what a doctor earns in their first three years there against what they’d have earned in Johannesburg. The arithmetic is against you and the outcome is unmeasured, which is a bad combination to walk into on the strength of a view.
The mountain and the sea are the product. You pay for them out of your income, whether or not anyone calls it that.