CORRESPONDENCE

Supernumerary registrars: The unsung heroes facing unprecedented predicaments

To the Editor: Supernumerary registrars in South Africa (SA) face many obstacles in the workplace. They encounter not only the same perplexities as local registrars,^[1] but also many other difficulties unique to them. SA's healthcare system is significantly overburdened and depends to an appreciable extent on the extra, expense-free healthcare provided by these doctors.^[2,3] In return, supernumeraries receive training from SA's best institutions, with studies showing that the majority of registrars deem the experience academically worthwhile despite the many personal sacrifices and challenges they face.^[4] The COVID-19 pandemic, however, has exposed the vulnerability of their health and financial wellbeing.

According to the Health Professions Act No. 56 of 1974, foreign doctors may engage in postgraduate studies and/or research in medicine or dentistry in SA in a temporary and supernumerary capacity.^[5] It is important to note that doctors registered as supernumeraries with the Health Professions Council of South Africa (HPCSA) may not fill registrar posts reserved for South Africans.^[5] However, where budgetary constraints result in frozen registrar posts, supernumerary registrars often offer relief to the constrained health system because they are either in unpaid posts or posts sponsored by their home country.^[3] Furthermore, supernumeraries are prohibited from registering as specialists in SA, despite receiving equivalent training.^[5] This is in line with the original auspices under which the supernumerary programme was created - to give doctors from other African countries the opportunity to train in specialties they may not have access to in their home country and to return to their home country thereafter.^[3

A study on the experience of supernumerary registrars in SA highlighted that many of them experienced xenophobia from patients (~24%) and colleagues (~48%).^[4] The way in which the broader community perceives supernumerary doctors has also been concerning and was amplified after ambiguous statements made by the media in 2017. These statements alluded to Libyan supernumeraries being favoured over local doctors as 'cheap labour'.^[6-However, the KwaZulu-Natal Department of Health released a statement to reassure the public that supernumeraries are not taking any jobs away from South Africans.^[7]

In addition to xenophobia, a study also showed that many supernumeraries experience great financial hardship. Insufficient funding was reported by 61% of registrars, and a third of supernumeraries deemed their experience not financially worthwhile. Despite all the social and financial challenges, more than 80% still considered the experience academically worthwhile.^[4]

Apart from the financial and social strain supernumeraries are faced with, the COVID-19 pandemic has brought new challenges to this community of doctors. The pandemic requires an extraordinary public health response with as many healthcare workers as possible. As of 6 May 2020, more than 500 healthcare workers in SA have been infected with COVID-19, with positive cases and deaths on the rise.^[8-The occupational risk is therefore considerable.

Although supernumeraries are at equal risk to SA registrars, depending on their place of work, they are not employees of the state^[4 and therefore do not enjoy the same occupational compensation and protection as their SA counterparts.^[9] Owing to financial constraints, many supernumeraries are also forced to choose more affordable health insurance that offers minimal benefits. Their health insurance schemes therefore often do not cover ICU care, which is of great concern in the light of the possible severity of COVID-19.

There has been a great deal of discourse surrounding the duty of supernumeraries to serve during the pandemic. Supernumeraries are more than students - they are medical doctors registered with the HPCSA.^[5] The oath they took when they started practising medicine extends beyond the borders of their country of origin. However, in light of the occupational cover and health insurance issues, supernumeraries will be taking on considerable personal risk without the guarantee of being provided with the same benefits of care that SA doctors receive.

There has not been a universal government approach to this issue. Universities have therefore responded heterogeneously. Some universities allowed supernumeraries to return to their home country before the lockdown, while others made this provision but could not guarantee supernumeraries an academic place upon their return, leaving these foreign doctors in a difficult position with regard to their academic future and the investment they have already made into their specialisation in SA.

Although the state has no legal obligations regarding the health insurance and financial wellbeing of supernumerary registrars, we question whether the government and universities are ethically fulfilling their duty towards those who are currently working on the frontline of the pandemic in SA. Utilitarian and virtue ethics would support putting measures in place to support these registrars financially and medically during this extraordinary time, as their safety and wellbeing will aid the SA healthcare system.

Supernumerary doctors have been the unsung heroes in the under-capacitated SA healthcare system for almost 25 years. Although supernumerary programmes are in place to provide training to these doctors, the SA healthcare system benefits substantially from their services. The vast amount of money spent on Cuban doctors recruited to aid SA during the pandemic - in contrast to the lack of health insurance and financial support provided to the supernumerary registrars - raises a contentious point. In light of this neglect, their duty to SA during the pandemic remains an ethical quandary.

A J Arendse, J F Coelho, S H Gebers

Fifth-year medical students, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa 19984480@sun.ac.za

References

1. Balie GM, Branch SJ, du Toit Lombard HA. Burnout among obstetrics and gynaecology registrars in teaching hospitals of the University of the Witwatersrand Medical School. S Afr J Obstet Gynecol 2019;25(3):75-78. https://doi.org/10.7196/SAJOG.1490        [ Links ]

2. Majola N. The ophthalmology postgraduate training programme in South Africa: The registrars' perspective. Afr Vis Eye Health 2019;78(1):a493. https://doi.org/10.4102/aveh.v78i1.493        [ Links ]

3. Naidoo R, Singh B. Supernumerary registrars: Are we helping them or are they helping us; S Afr J Surg 2017;55(2):38-39. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000200011&lng=en (accessed 30 May 2020).         [ Links ]

4. Peer S, Burrows SA, Mankahla N, Fagan JJ. Supernumerary registrar experience at the University of Cape Town, South Africa. S Afr Med J 2017;107(1):76-79. https://doi.org/10.7196/SAMJ.2017.v107i1.11345 (accessed 30 May 2020).         [ Links ]

5. Health Professions Council of South Africa. Professional boards HPCSA. https://isystems.hpcsa.co.za/PBMedicalDental/Education (accessed 25 May 2020).         [ Links ]

6. Medical Brief. Libyan doctors being used as 'cheap labour' in KZN. 3 May 2017. https://www.medicalbrie£co.za/archives/kzn-doctors-voice-concern-training-libyan-specialists/ (accessed 28 May 2020).         [ Links ]

7. Department of Health, Province of KwaZulu-Natal. It is a fallacy that the Department is discriminating against its own doctors in favour of Libyans for specialist training; says Health MEC. http://www.kznhealth.gov.za/mediarelease/2017/Fallacy-that-Department-is-discriminating-against-own-doctors-02052017.htm (accessed 28 May 2020).         [ Links ]

8. EyeWitness News. Over 500 health workers tested positive for COVID-19 - Mkhize. https://ewn.co.za/2020/05/06/more-than-500-health-workers-tested-positive-for-covid-19-mkhize (accessed 30 May 2020).         [ Links ]

9. South Africa. Compensation for Occupational Injuries and Diseases Act, 130 of 1993. Notice on compensation for occupationally-acquired novel corona virus disease (COVID-19) under Compensation for Occupational Injuries and Diseases Act, 130 of 1993 as amended. Government Gazette No. 43126, 23 March 2020. (Published under Government Notice 193 of 2020.) https://www.gov.za/documents/compensation-occupational-injuries-and-diseases-act-compensation-occupationally-acquired-0 (accessed 28 May 2020).         [ Links ]