Let’s set the scene with the basics. There is an obscene shortage of medical officer and registrar posts - probably consultant posts too. And any system where there is a shortage of something people want lends itself to exploitation.
It’s particularly interesting with doctors, because there’s a perception of affluence whenever people think about someone who studied medicine. They’re going to be a doctor, so they’ll figure out the finances. I’m not saying it’s rational, but it is something people assume. A group of people studying medicine is still a slice of a larger population, though, which means some have a lot of money, some have very little, and most are in between.
The problem that’s been simmering is work without remuneration.
Doctors who have finished community service and can’t get a post are working in hospital departments for free. Doing calls. Treating patients. Not being paid. In Johannesburg one of them told a reporter he’d been in an unpaid post in the anaesthetics department at Baragwanath for three months. Asked about the Western Cape, he said there are literally waiting lists to work for free.
That time counts towards nothing. A consultant anaesthetist at Bara put it plainly: time spent as a medical officer, paid or unpaid, does not count towards the registrar component of specialist training. The regulations agree - specialist training only accrues in a board-approved registrar post. So this isn’t a shadow route into specialising. It’s unpaid labour that buys you a slightly better CV and slightly better odds in next year’s application round.
The people doing it are not the problem. I want to say that explicitly. Someone who decides they want to specialise in South Africa, cost be damned, is a motivated person and they may be willing to sacrifice a great deal. But some people are able to sacrifice more than others, because giving up pay when you have a financial support system behind you is doable, and giving up pay when you have no buffer is just starving.
The same consultant said this: those without financial support usually couldn’t take the unpaid posts at all. That’s where the inequality comes in.
So what we end up with is a system in which the ability to work for free becomes a qualification. And that qualification is only available to a small slice of people.
Now here is the more vexing part of this situation (even though it isn’t surprising).
In December, the Minister of Health was asked in Parliament how many supernumerary registrars there are, and whether any of them are South African. His answer was no. Not “we don’t track it” - a definite “no”. According to departmental records, everyone in a supernumerary post came through the foreign workforce programme and none of them are South African citizens.
Yet, a month earlier, the University of KwaZulu-Natal had advertised a self-funded supernumerary trainee post, on provincial recruitment forms, explicitly open to South African or foreign qualified applicants. Their own registrar handbook describes self-funded supernumerary registrars who do the same duties, including after-hours, as everyone else. UCT’s radiation oncology department refers to supernumerary registrars from South Africa and the rest of the continent. And there’s a named South African doctor in a national newspaper describing his unpaid post at Bara.
I don’t think this is a lie so much as a blind spot, and the blind spot is the whole problem. The department can only count the people who came through the foreign workforce endorsement process, because that’s the process that generates a record. A South African who funds themselves, or simply works unpaid, never touches that system. There is no form. There is no category.
“Supernumerary” officially means a foreign doctor, sponsored by their home government, who is not allowed to be paid here. We are using the same word for South Africans working for nothing, because the vocabulary has no other slot for them.
You cannot fix what you don’t measure, and you don’t have to answer for a group that officially doesn’t exist. Nobody has to explain the wealth filter, because there is no filter - there are no such doctors.
What South Africa has now is not a healthy specialisation pathway. It’s a pay-to-win model, where those with the resources to carry themselves without pay are more likely to unlock a chance to specialise. Nobody should be maligned for using every resource they have to chase what they want. But we should lament a system that has devolved into this, and we should be uneasy that the official record says it isn’t happening.