The Colleges of Medicine of South Africa (CMSA) on February 16, issued a stark statement: the country’s ability to train medical specialists is under severe strain.
Funded registrar posts (specialists in training) remain frozen. Young doctors who have completed their community service and passed primary exams are waiting – some for years – for training positions that do not exist.
The warning is not new. But the tone is becoming more urgent. South Africa faces a well-documented shortage of specialists.
The landmark Global Surgery 2030 report by the Lancet Commission – one of the leading global medical journals – established that countries need a minimum specialist surgical workforce density of 20 surgeons, anaesthesiologists and obstetricians per 100 000 population to ensure timely, safe and affordable essential surgical care – a standard aligned with achieving universal health care; in other words what the National Health Insurance (NHI) hopes to achieve.
In South Africa it was estimated in 2019 that our specialist surgical density was 10.5 per 100 000 population (this included both public and private sector-based specialists) and striking inter-provincial disparities ranging from as low as 1.8 per 100 000 in Limpopo to 22.8 per 100 000 in the Western Cape.
So, both an absolute shortage and geographic maldistribution, with the rural provinces paying the price.
Yet, here is the uncomfortable truth: the problem is not a lack of specialists training posts in the country. It is a lack of funded training posts in the public sector and an unwillingness to rethink where and how we train.
Specialist training in South Africa follows an apprenticeship model. Registrars learn by doing time on task, supervised clinical exposure, and ultimately a national exit examination set by the CMSA.
That examining structure is unusual in higher education. The CMSA is a centralised, independent examining body – not owned by any one university. It defines in painstaking detail the educational outcomes required before a candidate may sit the final fellowship examination.
This is a unique advantage. In other words, we already have a nationally standardised, competency-based assessment system.
The quality gate exists. The blueprint exists. What does not exist – in sufficient numbers – are registrar posts funded by provincial departments under austerity constraints. So, the pipeline narrows.
Young doctors emigrate. Others leave medicine. Some wait in limbo. We are not short of talent. We are short of training posts.
With minimal effort we could solve this crisis almost overnight. Most specialists in the country practise in the private sector. Many of the most advanced technologies – robotic surgery, interventional radiology suites, and specialized oncology platforms—are located in private hospitals.
It has become common practice for registrars to rotate through these facilities for exposure to cutting-edge technology and procedures. Yet, we persist in treating specialist training as if it is structurally confined to the public sector. This is illogical.
Specialists training is about supervised exposure to defined competencies. None of those competencies are intrinsically “public sector only”. A coronary bypass, a complicated psychiatric assessment, or a hip replacement does not change its educational value depending on who pays the hospital bill.
If anything, the breadth of pathology in the public sector combined with the technological sophistication of the private sector makes a blended training model academically stronger.
In 2018, the Academy of Science of South Africa (Assaf) recommended precisely this. That specialist training capacity should be expanded into the private sector. It was a carefully considered consensus view from the country’s most prestigious academic body. A recommendation that has been ignored – we are again heading to a “you were warned” scenario.
It should be noted the Assaf recommendation is not radical. Leveraging the private sector to increase the production pipeline is already well established in several high-income countries with centralised examining bodies such as the UK and Australia.
So, why the resistance to do something about a well-documented problem?
A historical objection has been that if doctors train in the private sector, they will never return to the public sector.
But this assumes that sector boundaries will remain static. South Africa is moving towards a National Health Insurance framework, in which providers – public and privat—are contracted into a unified purchasing system.
The future health economy is not a binary public/private divide.
It is a network of contracted providers delivering defined packages of care. Training models should anticipate that reality, not cling to yesterday’s architecture.
The other is the fiscal problem – government austerity limits registrar posts. But there are considerable incentives for the private sector to create registrar positions at no costs to the fiscus.
Even historical regulatory obstacles seem more amenable to such a model. Untilrecently,y the Health Professions CouncilEthicall Rule– effectively prohibited private hospitals from directly employing doctors.
Recent amendments and policy clarifications, indicate a relaxation of this restrictive position.
While employment remains subject to council approval and ethical safeguards, the regulatory stance appears to create to potential space for more structured employment and training models within private facilities.
I cannot conjecture any defensible justification for South Africa not embracing a model of accredited private training sites, registrar posts funded by the private sector, CMSA-defined competency requirements, transparent logbook documentation and qualification through the CMSA. Even if every public sector registrar post was funded tomorrow it will not erase the backlog that has developed overyears.
The government would have to radically increase the number of registrars posts to meet the projected minimum number of specialists, we need to provide universal health care.
Resistance to change is the real shortage – the biggest obstacle is not regulation or money it is institutional inertia. Health systems are like load-bearing walls.
Once constructed, they are rarely moved, even when demographic and economic pressures demand redesign. But when the foundation shifts – as it has with fiscal austerity, migration, and NHI policy – the wall becomes a constraint rather than support.
We are currently wasting a generation of doctors because we have failed to adjust the scaffolding of training to the realities of our mixed health economy.
The CMSA statement is not merely about posts. It is about pipeline failure. And pipeline failure in healthcare inevitably leads to longer waiting times for surgery, unfilled rural posts, overworked consultants, and avoidable deaths.
Those who believe private healthcare insulates them from public system failure should reflect carefully. Specialists trained today are the ones who will operate, anesthetize, diagnose, and manage tomorrow, in both sectors. A constrained training pipeline eventually constrains everyone.
• Dr Wolvaardt is the managing director of the Foundation for Professional Development, a
private higher education institution driving social change through education, research, and strengthening of health systems.
