For years, hospitals have relied on the unpaid, unprotected labour of trainee-specialists to fill their rosters, but these doctors are reaching a breaking point, writes Joan van Dyk for Spotlight.
Across South Africa's public sector hospitals, a growing number of aspiring specialists are choosing to work for nothing – sometimes for years at a time – in pursuit of the coveted title.
Nearly every step of the 12 to 15 years of training required to specialise or sub-specialise can only happen in the public sector, but provincial Health Departments, bruised by more than a decade of austerity and graft, have few paid posts to offer.
Consequently, hundreds of local doctors and hopeful specialists are stuck in a nightmarish competition to be the most impressive candidate. There are waiting lists for both paid and unpaid positions.
Once the paid positions are filled, doctors from poorer backgrounds who did not get placed are at a dead end, perpetuating historical injustices and undercutting transformation targets. “A new apartheid,” several doctors call it.
The volunteer specialists Spotlight interviewed knew they were lucky to have the option to specialise, but their stories suggest it’s a dubious privilege.
They endure the financial and emotional stress of specialising without pay for a number of reasons, passion, to take over the family practise, or, most commonly, to secure a ticket out of the public healthcare sector.
But to reach the predictable hours and high income of specialist private practise, they must first navigate a clinical wasteland left behind by years of budget cuts and mismanagement by provincial health departments.
The gruelling unpaid route to specialisation they describe crosses a financial abyss with toll gates guarded by sometimes powerful bullies and dotted with legal and professional traps that could cast a long shadow over the futures they’re working to build.
How to spot a clinical spectre
South Africa’s phantom doctors have many names; they’re called fellows, volunteers or supernumeraries, depending on the facility.
The role was originally created as part of a regional programme allowing foreign doctors to train in South African hospitals. Their salaries are covered by their home governments and they’re not guaranteed a work visa through the Department of Home Affairs or accreditation from the Health Professions Council of South Africa (HPCSA) once they are qualified.
Only 3% of the 5 772 doctors added to the government’s payroll between January and May were not South African citizens.
In recent years, so many South African doctors have accepted such unpaid positions that some provincial Health Departments advertise these “opportunities” and plan their budgets accordingly.
Spotlight was unable to quantify South Africa’s unpaid trainee specialist workforce. Only two of the eight medical schools surveyed between April and July provided trainee data, and requests for the HPCSA’s list of active training codes for specialists and sub-specialists went unanswered.
A training code is a non-negotiable prerequisite for sitting specialist exit exams, regardless of funding source or employment status of the trainee. When cross-referenced with provincial payroll data, these lists could help estimate the extent to which the health system relies on unpaid expertise.
Anecdotal evidence suggests, however, that the trend started around 2020 in the Western Cape, where many interviewees say they wouldn’t mind working for the state. These days, Gauteng and KwaZulu-Natal’s cohorts of unpaid citizen specialists appear to be increasing too.
Interviews with numerous local supernumeraries suggest they often endure toxic hierarchies, bullying and administrative neglect, but they prefer to suffer in silence, terrified that seniors will fail them in expensive tests.
Specialist exams are officially set by the Colleges of Medicine (CMSA), but there are usually only a few qualified specialist examiners for each academic circuit. So, in reality, trainees are often being examined by their own department heads or a close colleague.
Pride, debt and resentment
The cut-throat race to build a standout CV starts as soon as medical students graduate. It’s no longer enough to gain experience as a medical officer and then to apply for a job as a registrar a couple of years later: there simply aren’t enough paid positions for either.
Any job posting can draw hundreds of applications from equally qualified candidates. The resulting competition is harsh, and requirements ever shifting and often unstated.
Naeema Govender*, an aspiring anaesthesiologist in Gauteng, says it took her a couple of failed interviews to figure out how to decode a government job ad.
Experience in intensive care and internal medicine, she says, are now de facto requirements for anyone applying for a job as an anaesthesia registrar (or trainee-specialist) whether the advert says so or not, and “anaesthesia experience” really means a minimum of two years’ experience.
In highly competitive fields like urology, registrar candidates are now expected to have completed two out of three major specialist exams (usually written during training) before they even apply.
Pulling shifts – free – ends up being a good way to get an edge over others.
After a string of unsuccessful interviews for paid jobs, Meera Patel*, another anaesthesiologist-in-training, says she accepted a supernumerary post at Steve Biko Academic Hospital in Tshwane out of sheer desperation.
“I used to tell anyone who would listen that I would never subject myself to it,” she says. The extra experience did help her to get a paid registrar job in the Western Cape, but it left her deeply resentful about having to compromise her principles and work without pay to crack the system.
In Johannesburg, Govender says she also reluctantly took an unpaid position to beef up her CV. She’s still conflicted about the exploitation she felt forced into.
“I don’t know if I should be proud or ashamed,” she said.
Paranormal planning
The unpaid trainee specialist workforce does little to eventually increase the number of qualified specialists available to the public at government hospitals, so private healthcare appears to be the overall winner.
Once doctors are qualified specialists, they often flee to the private sector or emigrate. This is perhaps illustrated by the fact that 30% of the 22 405 doctors employed by the state are under 35.
The trend has ultimately turned the public sector clinical platform into a subsidised training ground for private healthcare, says Bernhard Gaede, an associate professor and HoD of Family Medicine at the University of KwaZulu-Natal.
There also seems to be an element of privatisation-by stealth unfolding. Trainees are increasingly being supported by foundations or private hospital groups to fill a growing niche for sub-specialists, says Marthinus Dicks, a member of the South African Medical Association’s (SAMA) subcommittee for registrars.
At the Groote Schuur Hospital unit where Dicks is training to be a clinical haematologist, he’s one of only two who are paid a government salary. He also logged unpaid hours before being offered a paid post.
He worries that the private money is taking pressure off the government to fulfil its training role. At the same time, he knows his already high workload would be much heavier without his three fellowship-supported colleagues. “It’s just not a life I want to imagine,” he says.
Between the free labour, private funding and foreign trainees, there’s little incentive for cash-strapped provincial Health Departments to create permanent posts, according to a SAMA submission to the ministerial advisory committee.
The unpaid trainee specialist workforce isn’t mentioned in the health department’s health staffing reform plan, which lapses in 2030.
The document does outline a five-year plan to improve clinical supervision, boost specialist retention and to develop a broader network of clinical support for trainees by 2025.
A progress report was submitted to Health Minister Dr Aaron Motsoaledi in March but critics say the plan is unlikely to have made a difference because the government lacks the high-quality data on public and private sector personnel that would be needed for implementation.
South Africa needs a Workforce Intelligence Authority that collates and cleans workforce data to be used for planning, suggests governance expert Professor Alex van den Heever. In July, he presented a draft policy brief to SAMA, which also proposes ring-fencing training funds to protect salaries from provincial mismanagement and extending training subsidies and accreditation to private health facilities.
Without structural changes to address waste and mismanagement, he says, simply giving provinces more money to counteract austerity will make no difference.
Meanwhile, the government now deliberately budgets for clinical gaps to be filled by volunteers, says Sharon Twum-Boafo, head of SAMA’s registrar subcommittee.
“It’s ludicrous,” she says, “without the volunteers, many hospitals would simply not have enough doctors to cover 24-hour rosters.”
A legal void
Unpaid trainee specialists carry a heavy workload with few administrative and legal protections.
Since they lack a payroll number, they’re locked out of the blanket indemnity for healthcare workers employed by the state. Instead, government compels them to buy expensive private malpractice cover just to log free hours in public hospitals.
There, Spotlight is told, it is possible they might be pressured to perform unsupervised, high-risk procedures far beyond their insured scope.
Several of these phantom physicians described to Spotlight their fear of being held personally liable for costs in potential lawsuits. Some are privately insured for millions of rands, which means they would make for more lucrative targets than the government, where mediation often leads to lower payouts.
Ruan Vlok, head of SAMA's employment law unit, agrees that unpaid specialists might become litigation lightning rods.
“It could become an easy making money machine for attorneys,” he says.
There are long term risks too.
Private insurance premiums are tied to clinical outcomes, so a pattern of bad events could drive up a doctor’s insurance premiums, or even render them uninsurable, the ultimate career-ending risk for a specialist.
Unfinished business
Some unpaid trainees face another tough reality. They are often summoned to fill critical service gaps left by paid, full-time consultants who have vanished to moonlight in the private sector.
Dual practise is allowed within certain parameters, but enforcement of the rules is patchy across provinces and facilities. Money is one of the factors driving moonlighting among the state’s contracted specialists, whose salaries have not kept pace with inflation. A SAMA report estimates that in 2022, doctors were earning about as much as they were in 2013.
To save money, provincial health departments have limited the number of paid overtime hours that consultants can log. In this case, says Vlok, doctors are fully within their rights to refuse to work free.
Ironically, this is when those who choose to work for nothing become extra useful in hospitals.
Yet should the phantom doctors themselves attempt to pull a paid shift to survive, they could be threatened with disciplinary action, heavy fines, or the immediate deactivation of their training numbers.
Under HPCSA and university rules, trainee registrars are legally barred from doing private paid work. Worse still, when a crisis occurs, these supernumeraries find themselves locked in dual contracts with universities and hospitals, with little protection from either.
An uneasy peace
The rights of the health system’s unpaid workforce have never been challenged in court, Vlok says, partly because doctors fear any litigation would lead to them being targeted or failed in their exit exams.
Because supernumeraries aren’t officially employees, they’re also excluded from recourse through the Commission for Conciliation, Mediation and Arbitration and the Bargaining Council, leaving them with no mechanism for redress.
Local supernumeraries technically sign away their rights by agreeing to work without pay, but Vlok argues the state is taking advantage of a vulnerable group because the public sector is the only route to specialisation.
The regulations allowing foreign trainees to work in South Africa do not cater to or even make provision for South Africans, Vlok says. He feels the Labour Relations Act and the Basic Conditions of Employment Act should take legal precedence, under which he believes unpaid trainees clearly meet the criteria of an employee.
“I don’t use this word lightly,” he says, “this is abuse.”
It’s unclear how much longer the strained peace will hold.
One exhausted trainee specialist told Spotlight: “We have to fix the medical system, it’s broken. Who is going to look after us when we’re old?”
*Spotlight granted the doctors quoted in this article anonymity because of the risk of reprisals from provincial health departments and the hospitals where they are working.
See more from MedicalBrief archives:
Public sector moonlighting headed towards a major crisis
Gauteng 'crisis' warning as specialists resign from hospitals
DoH’s ‘reckless’ failure to place junior doctors aggravates medical emigration
Moonlighting drains specialist care at state hospitals