The shortage of registrar and sub-specialist posts may save Health Departments millions in the short term, but experts warn it costs billions long-term in litigation and worsens patient outcomes, writes Chris Bateman for MedicalBrief.
South Africa’s already dire specialist-to-patient ratios are falling further behind global norms, leading to preventable deaths and prolonged illness.
Many registrars wait years for a funded post, some working without pay to complete their training, and others stuck as senior medical officers. The result is clogged referral chains, with tertiary specialists unable to assist at district level.
Across provinces, shortages range from crisis to barely manageable. Specialists spend excessive time triaging patients to prevent deaths while awaiting scans or lab results.
Defensive policies, such as requiring all placentas to be examined by anatomical pathologists, further delay urgent tests like cancer diagnostics.
In 2019, South Africa had 16.5 specialists per 100 000 people – just seven per 100 000 in the public sector versus 69 in private care. That’s one specialist for every 14 285 public patients. Since then, austerity has worsened the gap. No sub-specialist posts are currently funded, despite more than 40 recognised sub-specialties.
“Registrars are being paid medical officer salaries while awaiting openings, some waiting up to two years,” said Professor Eric Buch, CEO of the Colleges of Medicine of SA.
The 2019 budget foresaw only 4.8% annual staff-cost growth to 2030, barely matching inflation. Around 35% of public sector specialists do remunerative work outside the public service, with anaesthetists, physicians, obstetricians/gynaecologists, and surgeons leading the list.
Dr Laetitia Rispel, a professor of public health at the University of the Witwatersrand who interrogates health policy, management and health services, said poor workforce data crippled planning: “We recommended they set up a central intelligence unit. It hasn’t happened. No one knows what the numbers are. Remember, the shortages in one specialty impact all others.” Rispel helped craft the 2019-2030 Human Resources for Health strategy document.
SA Medical Association (SAMA) chair Dr Mvuyisi Mzukwa calls unpaid registrar work “unacceptable and exploitative,” warning that talented doctors are completing training overseas. “Under-resourced facilities and frozen posts lead to worse outcomes, which fuel medical-legal claims – short-sighted and ultimately more expensive,” he said.
Sub-specialists often graduate in their mid-forties; delays cut into already short career spans. Freezing posts worsens burnout, lengthens waiting times, and deepens inequities. Policies vary wildly by province – some ring-fence registrar funding, others freeze it entirely.
SAMA’s demands include a national ring-fenced budget for registrar posts, needs-based workforce planning, an end to unpaid posts and transparent recruitment.
Provincial disparities are stark: the Western Cape has 25.81 specialists per 100 000 people, the North-West just 3.66. One registrar warned: “One obstetrics case gone wrong can cost R18m. Compare that to R2m saved by freezing a post. People are dying.”
Charlotte Maxeke Hospital’s internal medicine head, Dr Adam Mohammed, said Gauteng regularly delayed sub-specialist appointments to save money: “Doctors do the cardiology job without being paid for it.” His cardiology department is 40% understaffed; gastroenterology, 30% short for 30 months; endocrinology and rheumatology, 25% short.
Lab delays are also critical.
In Gauteng, mandatory placenta histology reviews slow cancer diagnoses by weeks. Pathologists are leaving the public sector despite competitive salaries due to overwhelming workloads.
Some provinces, like the Western Cape, have shielded registrar training from cuts. Private hospital groups and Discovery Health fund specialist posts and fellowships, recognising they will also face staffing crises without intervention.
“Any break in the training conveyor belt means long-term devastation,” said Professor Mark Sonderup, a former SARA chairperson, ex-vice-chair of SAMA and a senior Groote Schuur Hospital/UCT hepatologist.
“By the time you exit as a sub-specialist, you’re 40, with 20 productive years left. No other profession tells you to wait unpaid for a post,” he added.
Buch warns the shortage will “seriously damage NHI aspirations and deny universal healthcare.”
The NDoH said it recognised both fiscal and service constraints. Health Minister Aaron Motsoaledi has appointed an advisory committee to review doctors’ conditions of service, including overtime, RWOPS, and rural allowances. Deputy DG Dr Percy Mahlati is in talks with medical deans and Treasury and leading a mid-term review of the Human Resources for Health Strategy.