Working in South Africa
Authors: Katie Connor, Ella Teasdale, Kenneth Boffard
Publication date: 29 Apr 2014
Katie Connor, Ella Teasdale, and Kenneth Boffard give some practical guidance for doctors planning to do postgraduate work in South Africa
Growing numbers of British trainees are opting to do a period of postgraduate work abroad,    and the benefits of this are increasingly being recognised for individuals and for the NHS.  The introduction of Modernising Medical Careers in 2005 aimed to rationalise career progression, but many UK trainees believe they need broader clinical experience before committing to a future training programme or subspecialisation. Furthermore, many trainees in specialties such as surgery believe that the breadth of their training opportunities are constrained by working time restrictions.    Working in South Africa can therefore be an attractive prospect for those looking to gain diverse clinical and personal experiences.
South African healthcare system
Doctors in South Africa work within a cultural, social, and political landscape shaped by the country’s remarkable history. There is an abundance of trauma, but doctors also see many pathologies and a diverse array of clinical presentations, which are often advanced, in part because of the high prevalence of HIV infection. There are 11 official languages in South Africa, but in practical terms English is the language of medicine. In our experience, a visiting postgraduate doctor has the prospect of securing a salary equivalent to that earned in the UK (table 1 ).
The South African health system has four tiers. The well resourced private sector is similar to well developed Western healthcare systems. The public sector ranges from delivering the most basic of care to highly specialised services in large tertiary hospitals, but many centres remain underfunded and under-resourced. There is also further subdivision into a rural system and an urban system. Small, private, well resourced hospitals exist, but do not have the quality of care that might be expected given their resources because they are insulated by distance from both knowledge resources, and the need to audit their results. The reality is that rural hospitals, both public and private, often lack the ability to teach, supervise, or provide the same quality of care as those in urban areas.
There is a shortage of doctors willing to fill remote and rural placements, and it is often for these rural jobs that the healthcare system tries hardest to recruit foreign doctors. Paid employment within the major tertiary hospitals is competitive and challenging for both foreign and South African doctors.
Rural health placements, which are a clinical requirement in the South African medical training programme, demand and develop a very broad clinical skill set. The community service year is the third postgraduate year and is equivalent in level to core training year 1 in the UK (table 1 ). Many posts require doctors to administer anaesthetics, run resuscitations, carry out various emergency surgical and obstetric procedures, and prepare sick patients for transfer to other centres, often within a resource constrained and relatively unsupervised environment.
The skill set these posts require is nurtured as part of the South African internship programme. This includes generic hands-on rotations in surgery, obstetrics and gynaecology, paediatrics, internal medicine, family medicine, psychiatry, anaesthesia, and the emergency department. These specialties may not necessarily be covered by the UK’s equivalent foundation programme. Such exposure represents a steep, yet valuable, learning curve for many visiting trainees. Furthermore the average working week usually exceeds the restrictions of the European Working Time Directive, with “full overtime” approximating at least 20 hours of overtime in addition to a 40 hour week recommended as the limit by the Health Professions Council of South Africa (HPCSA, the equivalent of the General Medical Council (GMC) in the UK).
Typically, foreign doctors are offered a medical officer (MO) post. Theoretically a grade 1 MO is equivalent in seniority (but often not in experience) to that of the early post-foundation training doctor. However, South African doctors will have undergone a further year of training in community service after internship before they secure an MO grade 1 post. This grading system is most relevant for pay scales and is a separate entity from that for training grades.
Securing a job in South Africa
Early planning is key when considering an application, and it can take over a year. The applicant can either apply directly to the prospective hospital and registering bodies or alternatively via the non-profit organisation African Health Placements (AHP), which is a charitable organisation whose priority is to place applicants within predominantly rural, underserved hospitals. As such, the organisation does not seek to fill jobs within the Western Cape or Johannesburg, which do not have difficulty recruiting. Furthermore, AHP will support you only if you are planning to work in South Africa for a minimum of one year. If you wish to work in hospitals outside the AHP mandate, you must find a post directly, although AHP may still assist you with employment endorsements and registration.
There are several laborious administrative steps that must be completed to obtain employment in South Africa. Ultimately, the goal is to acquire registration with the HPCSA. An overview of the preceding administrative steps is outlined in table 2 . There may be some variation in the application steps depending on previous experience in relation to the position applied for and whether the HPCSA requires you to take their board examinations. The HPCSA will not consider you for registration if you have not completed two years of training post-qualification by the time you come to take up your post in South Africa.
The first priority, and the longest step in the application process, is the Educational Commission for Foreign Medical Graduates (ECFMG). This is only required if you are planning to work within South Africa for longer than six months. This application requires copies of your undergraduate and postgraduate qualifications, medical transcript, medical registration, and passport, and these copies must have been “notarised” (by a notary public, see further information box). The ECFMG then independently validates these qualifications by writing to the granting bodies (your university, foundation school, and the General Medical Council). This may take up to six months to process and without it you cannot proceed with your HPCSA application. However, it is worthwhile completing the HPCSA application (“Form 12”) at the same stage to avoid multiple notary fees. Completion of Form 12 requires the presence of two other medical practitioners, to sign the form at the same notary appointment.
The next priority is Foreign Workforce Management (FWM) endorsement, which is free and can be completed while awaiting ECFMG accreditation. The FWM is a sub-directorate of the National Department of Health in South Africa. Its aim is to recruit suitably qualified foreign doctors to underserved areas within South Africa. Without FWM approval, you cannot gain HPCSA registration. While awaiting initial endorsement from the FWM to seek work in South Africa, you can make inquiries about potential posts. You can only apply for specific posts when FWM initial endorsement has been granted (with a z83 form, see further information).
Endorsement by FWM is on a case by case basis and depends on how your clinical experience matches that of the South African internship and the clinical requirements of the post for which you are applying. Most posts will require a phone interview, although some locations will accept applications on the basis of a CV. Many hospitals will consider foreign applicants only after the period for all potential South African applicants has passed, leaving you with the choice of any leftover unfilled positions. When you have secured a job offer, you can apply for full FWM endorsement, which lasts for three years and allows you to apply for a work permit.
The penultimate and most arduous of all of the application steps is your application to HPCSA. A successful HPCSA application requires all of the preceding administrative steps to have been completed, including FWM endorsement and ECFMG accreditation. This application takes about eight weeks to complete from submission. The HPCSA receives a large number of fraudulent applications and it is completely inflexible about the nature of applications, which must be “right first time.” Any alterations, smudges, or other discrepancies can result in rejection.
As with FWM endorsement, HPCSA registration is decided on a case by case basis with the aim of matching a person’s qualifications and experience to those required for the post being applied for. The HPCSA requires detailed clinical experience criteria, with authorisation by the training hospital. These are intended to be equivalent to the final skill set obtained at the end of the South African internship programme, and some of the application steps would be challenging to organise from outside the country in which you did your “internship.”
The stipulations for placement within a rural hospital can be daunting for a graduate of the UK foundation programme. Those with less than three years’ post-internship experience can be registered as medical officers, but they may be required to do a period of unpaid supervised experience to gain the further skills needed before being allowed to work unsupervised within a rural hospital.
The HPCSA divides applicants into two groups. The first includes graduates from “approved” universities, including many European universities and most British ones, and these applicants do not have to sit written examinations. The second group includes those who have completed programmes with reduced training times or who have not been assessed as having a standard similar to the South African universities, and these applicants are placed in the “exam track.” These applicants have to take the HPCSA medical board exam, similar to the GMC’s Professional and Linguistic Assessments Board exam in the UK, and at a level similar to the UK MBChB. These exams are both theoretical and clinical and are set just twice a year in South Africa. Applicants who have not graduated from universities in English speaking countries also have to show proficiency in English through the ECFMG International Credentials Services (EICS).
If you decide to stay in South Africa and embark on a full training programme (usually registrar training is four to five years, equivalent to the second year of core training to the sixth year of specialty training in the UK) or subspecialist fellowship (equivalent to the seventh and eighth years of specialty training) you will need to jump through two further hoops. The first is obtaining permanent residency. This is usually not too much of a problem as the application is made on the basis of possessing “scarce skills,” but it may take a while for this to be approved. The second is that you will have to pass a South African university final MB examination, which you apply for through the HPCSA (box).
Other pre-departure considerations
We recommend several additional essential pre-departure arrangements. Safety is a pertinent consideration, given the rate and nature of crime within South Africa. You should obtain local advice, avoid travelling alone at night, and secure insurance for personal belongings. It is worth a visit to the local travel clinic for guidance on post-exposure prophylaxis in the event of inadvertent exposure to HIV positive blood products and for up to date information on relevant vaccinations. Be aware of certain respiratory infections, such as tuberculosis, and the importance of appropriate personal protective equipment, such as masks, goggles, and double gloving.
You should make arrangements for indemnity insurance and personal medical insurance, and you should notify the NHS superannuation scheme, the student loans company, and secure UK tax clearance. Those planning on moving on a more permanent basis ought to make arrangements for medical aid cover to access medical treatment.
When you have obtained HPCSA registration, FWM endorsement, and a job offer, you may apply for a work permit or visa. Visas for overseas doctors are granted for three years and thereafter you must apply for a permanent work permit. The more time consuming parts of this application are the statutory declaration of good health by a medical practitioner (including a chest x ray), official recent employment history, and a criminal records check. In total the cost of the application process for the non-exam candidate is between £500 and £700 (table 2 ). At this point you can begin to plan your flights, accommodation, and car rental.
Finally, you may be deterred by anxieties about the effect on career progression of taking time out of UK medical training. This is a personal decision and there are sometimes ways to make your training experience in South Africa count towards your overall career progression. It is important that you explore these options with your relevant programme well before departure. Although much of the training may be fully recognised if you return to the UK, you may be asked to do additional training time.
Working as a doctor in South Africa is not for the fainthearted, but it is immensely rewarding and enjoyable. The clinical challenges you will encounter will nurture a diverse skill set and a great deal of perspective, which will be assets for the rest of your career.
Useful contacts for the UK applicant
Notary Public— [Link]
African Health Placements— [Link]
Health Professions Council of South Africa (HSPCA)— [Link]
Form Z83 is available for download at [Link]
Foreign Workforce Management of South Africa— [Link]
Educational Commission for Foreign Medical Graduates— [Link]
Competing interests: KC and ET have recently secured work in South Africa in part by engaging with the services provided by AHP. KC and ET have developed an unfunded supporting website to support this work. KB is a member of the Medical Board of the Health Professions Council of South Africa (HPCSA).
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Katie Connor medical officer grade 1
Department of Clinical Surgery, Frere Hospital, Private Bag X9047, East London, Eastern Cape 5200, South Africa
Ella Teasdale False Bay Hospital, Fish Hoek, Cape Town, South Africa
Kenneth Boffard Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of Witwatersrand, Johannesburg, South Africa