There is a deficit of psychiatrists in South Africa, and to our knowledge, there is no situational analysis of training posts for psychiatrists in the country.
To compare the number of specialists and subspecialists in training and training posts available in 2008 and 2018.
South African medical schools with departments of psychiatry.
A situational analysis involving data collection through a survey completed by eight heads of academic psychiatric departments followed by a comparative analysis of the two aforementioned years.
Data shows an 11% increase in funded and unfunded posts combined and a 9.3% increase in funded posts. The occupancy of funded posts decreased (92% in 2008 to 82% in 2018). When considering both funded and unfunded posts, only three more psychiatrists were being trained in 2018. Supernumeraries appointed in unfunded posts can be expected to return to their countries of origin. As such, a decrease in filled funded posts likely reflects a decrease in training psychiatrists destined to work in South Africa. While child and adolescent psychiatry was the only sub-speciality with accredited training posts in 2008, all sub-specialities included on the questionnaire had accredited training posts in 2018, and the number of accredited training posts in child and adolescent psychiatry doubled. That said, many of the posts were unfunded and vacant.
While there was an increase in posts from 2008 to 2018, many posts remained unfilled. As such, not only are additional funded training posts required but also strategies to increase post-occupancy and successful completion of training.
This study is the first situational analysis of specialist and subspecialist training posts in Psychiatry in South Africa, at two time points over a 10 year period, that draws on academic heads of departments of psychiatry as respondents. The study highlights the nominal increase in funded training posts over this period, especially subspecialist training posts. The majority of Health Professions Council of South Africa (HPCSA) accredited subspecialities in Psychiatry have no funded training posts which is particularly concerning.
The South African Stress and Health (SASH) study, the only nationally representative study of its kind in South Africa to date, documented a 30.3% lifetime prevalence of common mental disorders in the country.
In South Africa, an undergraduate medical degree (generally requiring 6 years training) and completion of a 2-year internship and 1-year community service is a minimum requirement before one can apply for a specialist training post in psychiatry (an additional 4 years training).
While the main examination body for specialist and subspecialist psychiatric training is the Colleges of Medicine of South Africa (CMSA) through the College of Psychiatrists, the majority of training is conducted by the nine universities registered for specialist and subspecialist training across the country. These institutions also confer the MMed degree in Psychiatry upon completion of the research requirement of the FCPsych (SA) curriculum and submission of an examined dissertation or a published peer-reviewed article. These universities include Sefako Makgatho University (SMU), Stellenbosch University (SU), University of Cape Town (UCT), University of the Free State (UFS), University of Kwazulu-Natal (UKZN), University of Limpopo (UL), University of Pretoria (UP), the University of the Witwatersrand (WITS) and Walter Sisulu University (WSU). The provincial departments of health in the nine provinces that make up South Africa are generally the main employers of registrars who are specialising or sub-specialising through funded training posts (a training post entails full-time employment with overtime requirements; trainees in funded posts are fully renumerated for their hours of employment as contracted). However, there are also training posts with registered training numbers that are not funded by the provincial department of health (unfunded), and trainees are required to source funding independently for these posts (e.g. foreign nationals from other African states who may be funded by their own government or hospital). Substantial waiting lists for funded training posts have previously been described;
Considering the historical and present deficits in the number of psychiatrists in the country,
The heads of department (HODs) of the nine academic psychiatry departments in South Africa were asked to provide data by means of a questionnaire. Of the nine departments, eight responded including UL, UP, UFS, WITS, SU, UKZN, WSU and UCT.
Ethical approval was obtained from all research sites, including SU’s Health Research Ethics Committee (N18/06/063), UCT’s Faculty of Health Science Human Research Ethics Committee (155/2019), UFS (provided reciprocal review approval based on the strength of ethics clearance obtained at SU), Limpopo Department of Health and Social Science (PMREC03UL2019C), Faculty Health Sciences Research Ethics Committee, UP (537/2018), Biomedical Research Ethics Committee University of Kwazulu-Natal (RECIP401/19) and WSU Human Research Committee (072/2018). The participation of HODs was voluntary, and written informed consent was obtained from all participants. All data were stored on a password-protected device.
All data were summarised as absolute counts and percentages using Excel.
Specialist training posts.
Year | University | SA funded posts |
Unfunded posts (supernumerary registrars) |
||||
---|---|---|---|---|---|---|---|
Vacant | Filled | Total | Vacant | Filled | Total | ||
2008 | UL | 0 | 8 | 8 | 0 | 0 | 0 |
UP | - | - | - | - | - | - | |
SMU | - | - | - | - | - | - | |
UFS | 0 | 12 | 12 | 0 | 0 | 0 | |
WITS | 0 | 46 | 46 | 0 | 0 | 0 | |
SU | 0 | 21 | 21 | 2 | 0 | 2 | |
UKZN | 12 | 24 | 36 | 0 | 2 | 2 | |
WSU | - | - | - | - | - | - | |
UCT | 0 | 27 | 27 | 3 | 1 | 4 | |
Total | 12 | 138 |
150 |
5 | 3 | 8 | |
2018 | UL | 4 | 4 | 8 | 0 | 0 | 0 |
UP | 10 | 20 | 30 | 0 | 2 | 2 | |
SMU | - | - | - | - | - | - | |
UFS | 0 | 16 | 16 | 0 | 0 | 0 | |
WITS | 6 | 48 | 54 | 0 | 1 | 1 | |
SU | 0 | 21 | 21 | 2 | 2 | 4 | |
UKZN | 18 | 18 | 36 | 0 | 3 | 3 | |
WSU | 5 | 16 | 21 | 1 | 0 | 1 | |
UCT | 0 | 29 | 29 | 2 | 2 | 4 | |
Total | 43 (28 |
172 (136 |
215 (164 |
5 (4 |
10 (8 |
15 (12 |
University of Limpopo, UL; UP, University of Pretoria; SMU, MEDUNSA; UFS, University of the Free State; WITS, University of the Witwatersrand; SU, Stellenbosch University; UKZN, University of Kwazulu-Natal; WSU, Walter Sisulu University; UCT, University of Cape Town; UP, University of Pretoria.
, excluding UP and WSU.
The number of available registrar posts for 2018 was 176 (164 funded and 12 unfunded), representing 18 (14 funded and 4 unfunded) additional posts and an increase of 11% from 2008 to 2018. These posts were added to the following universities, UFS (four funded), WITS (eight funded and one unfunded), UCT (two funded), SU (two unfunded) and UKZN (one unfunded). University of Pretoria (32 total, 30 funded, 2 unfunded) and WSU (22 total, 21 funded, 1 unfunded) were excluded from the aforementioned calculation as 2008 information for these institutions was not available.
An increase in vacant posts was observed when comparing 2008 and 2018. Excluding UP and WSU, in 2008: total 17 (10.8% of total available posts), 12 funded (8% of funded posts) and 5 unfunded (62% of unfunded posts) and in 2018: total 32 (18.2% of total available posts), 28 funded (17% of funded posts) and 4 unfunded (26% of unfunded posts).
The number of vacant funded posts increased at the following institutions: UL (0 in 2008, 4 in 2018), WITS (0 in 2008, 6 in 2018) and UKZN (12 in 2008, 18 in 2018), while UFS, SU and UCT had no vacant funded posts in both 2008 and 2018.
There was a small increase in the number of filled posts from 141 to 144 (138 funded and 3 unfunded in 2008 and 136 funded and 8 unfunded in 2018 (representing a 2% increase in filled posts 2008–2018 when UP and WSU were excluded from the 2018 statistics). A decrease in the number of filled funded posts was observed from 138: 2008 to 136: 2018 (representing a 1% decrease in filled funded posts from 2008 to 2018 excluding UP and WSU from the 2018 stats). As such, at the six of nine South African universities that we have data for only three more psychiatrists were trained in 2018 compared with 2008. These additional trainees were in unfunded posts, which are frequently filled by supernumeraries who are not South African and frequently return to their country of origin upon completion of training.
Sub-specialist training posts.
Year Sub-specialty | University | Funded vacant | Unfunded |
||||
---|---|---|---|---|---|---|---|
Filled | Total | Vacant | Filled | Total | |||
2008 | UL | 0 | 0 | 0 | 0 | 0 | 0 |
Child Psychiatry | UP | - | - | - | - | - | - |
UFS | 0 | 0 | 0 | 0 | 0 | 0 | |
WITS | 0 | 4 | 4 | 0 | 0 | 0 | |
SU | 0 | 1 | 1 | 1 | 0 | 1 | |
UKZN | 0 | 0 | 0 | 0 | 0 | 0 | |
WSU | 0 | 0 | 0 | 0 | 0 | 0 | |
UCT | 1 | 1 | 2 | 0 | 1 | 1 | |
Total | 1 | 6 | 7 | 1 | 1 | 2 | |
2018 | UL | 0 | 0 | 0 | 0 | 0 | 0 |
Child Psychiatry | UP | 1 | 0 | 1 | 0 | 0 | 0 |
UFS | 1 | 0 | 1 | 0 | 0 | 0 | |
WITS | 4 | 2 | 6 | 0 | 0 | 0 | |
SU | 0 | 1 | 1 | 3 | 0 | 3 | |
UKZN | 0 | 0 | 0 | 0 | 0 | 0 | |
WSU | 0 | 0 | 0 | 0 | 0 | 0 | |
UCT | 1 | 0 | 1 | 5 | 0 | 5 | |
Total | 7 | 3 | 10 | 8 | 0 | 8 | |
Forensic Psychiatry | UL | 0 | 0 | 0 | 0 | 0 | 0 |
UP | 6 | 0 | 6 | 0 | 0 | 0 | |
UFS | 0 | 0 | 0 | 0 | 0 | 0 | |
WITS | 5 | 3 | 8 | 0 | 0 | 0 | |
SU | 0 | 0 | 0 | 0 | 0 | 0 | |
UKZN | 0 | 0 | 0 | 0 | 0 | 0 | |
WSU | 0 | 0 | 0 | 0 | 2 | 2 | |
UCT | 0 | 0 | 0 | 1 | 1 | 2 | |
Total | 11 | 3 | 14 | 1 | 3 | 4 | |
Geriatric Psychiatry | UL | 0 | 0 | 0 | 0 | 0 | 0 |
UP | 0 | 0 | 0 | 0 | 0 | 0 | |
UFS | 0 | 0 | 0 | 0 | 0 | 0 | |
WITS | 0 | 0 | 0 | 0 | 0 | 0 | |
SU | 0 | 0 | 0 | 1 | 1 | 2 | |
UKZN | 0 | 0 | 0 | 0 | 0 | 0 | |
WSU | 0 | 0 | 0 | 0 | 0 | 0 | |
UCT | 0 | 0 | 0 | 0 | 0 | 0 | |
Total | 0 | 0 | 0 | 1 | 1 | 2 | |
Neuropsychiatry | UL | 0 | 0 | 0 | 0 | 0 | 0 |
UP | 0 | 0 | 0 | 0 | 0 | 0 | |
UFS | 0 | 0 | 0 | 0 | 0 | 0 | |
WITS | 4 | 1 | 5 | 0 | 0 | 0 | |
SU | 0 | 0 | 0 | 2 | 0 | 2 | |
UKZN | 0 | 0 | 0 | 0 | 0 | 0 | |
WSU | 0 | 0 | 0 | 0 | 0 | 0 | |
UCT | 0 | 1 | 1 | 0 | 1 | 1 | |
Total | 4 | 2 | 6 | 2 | 1 | 3 |
Note: Geriatric Psychiatry, Neuropsychiatry and Forensic Psychiatry had not been approved as of yet in 2008 and as such there were no funded posts at any institution. Child Psychiatry was the only accredited subspecialty
UL; University of Limpopo; UP, University of Pretoria; UFS, University of the Free State; WITS, University of the Witwatersrand; SU, Stellenbosch University; UKZN, University of Kwazulu-Natal; WSU, Walter Sisulu University; UCT, University of Cape Town.
The only subspeciality in psychiatry that had training posts in 2008 was Child and Adolescent Psychiatry with nine training posts (seven funded and two unfunded; no 2008 data were available for UP). Child and Adolescent Psychiatry had only two vacant posts in 2008 (22% of total available posts) (one funded and one unfunded). By 2018, the number of Child and Adolescent Psychiatry training posts had doubled to 18 training posts in total (10 funded and 8 unfunded). Of these, 15 posts were vacant (83% of total available posts) (seven funded and eight unfunded). Despite the increase in posts in Child and Adolescent Psychiatry, fewer child and adolescent psychiatrists were being trained in 2018 compared with 2008 (seven in 2008 and three in 2018).
In 2018, Forensic Psychiatry had 18 training posts (14 funded and 4 unfunded), with 12 vacant (66.7% of total available posts) (11 funded and 1 unfunded). Geriatric Psychiatry had two training posts (two unfunded) in 2018, one filled and one vacant. Neuropsychiatry had nine training posts (six funded, three unfunded), six were vacant (66.7% of total available posts) (four funded, two unfunded).
Number and ratio of consultants and registrars at institutions.
University | Facility | Number of registrars | Number of consultants | Consultant: Registrar ratio |
---|---|---|---|---|
UL | Thabamoopo | 4 | 3 | 1:1.33 |
Mankweng | 2 | 2 | 1:1 | |
Total | 6 | 5 | 1:1.2 | |
UP | Weskoppies | 16 | 16 | 1:1 |
Steve Biko | 4 | 3 | 1:1.33 | |
Witbank | 0 | 0 | - | |
Tembisa | 0 | 1 | - | |
Total | 20 | 20 | 1:1 | |
UFS | Pelonomi | 2 | 2 | 1:1 |
FSPC | 14 | 7 | 1:2 | |
Total | 16 | 9 | 1:1.78 | |
WITS | CMJAH | 6 | 7 | 1:0.86 |
HJH | 4 | 3 | 1:1.33 | |
CHBAH | 14 | 14 | 1:1 | |
SBAH | 12 | 19 | 1:0.63 | |
Tara hospital | 9 | 9 | 1:1 | |
Community | 12 | 7 | 1:1.71 | |
RMMCH | 1 | 1 | 1:1 | |
Total | 58 | 60 | 1:0.97 | |
SU | TBH | 8 | 6 | 1:0.75 |
SLH | 9 | 9 | 1:1 | |
LGH | 4 | 4 | 1:1 | |
District | 0 | 1 | 1:0 | |
Total | 21 | 20 | 1:1.05 | |
UKZN | King Edward | 3 | 3 | 1:1 |
Addington | 4 | 3 | 1:1.33 | |
King DiniZulu | 6 | 4 | 1:1.5 | |
Town Hill | 6 | 6 | 1:1 | |
Fort Napier | 1 | 3 | 1:0.33 | |
Ngwelezana | 1 | 3 | 1:0.33 | |
Total | 21 | 22 | 1:0.95 | |
WSU | Nelson Mandela CH | 4 | 5 | 1:0.8 |
Dora Nginza Hospital | 7 | 2 | 1:3.5 | |
Komani Hospital | 0 | 1 | - | |
Elizabeth Donkin Hospital | 3 | 2 | 1:1.5 | |
Fort England Hospital | 4 | 5 | 1:0.8 | |
Total | 18 | 15 | 1:1.2 | |
UCT | VBH | 11 | 11 | 1:1 |
LGH | 6 | 6 | 1:1 | |
RXH | 3 | 3 | 1:1 | |
GSH | 9 | 6 | 1:1.5 | |
Alexandra Hospital | 1 | 1 | 1:1 | |
SLH | 1 | 1 | 1:1 | |
Community | - | 3 | - | |
Total | 31 | 31 | 1:1 |
UL, University of Limpopo; UP University of Pretoria; UFS, University of the Free state; SU, Stellenbosch University; UKZN, University of Kwazulu-Natal; WSU, Walter Sisulu University; UCT, University of Cape Town; WITS, University of the Witwatersrand; FSPC, Free State Psychiatric Complex; CMJAH, Charlotte Maxeke Johannesburg Academic Hospital; HJH, Helen Joseph Hospital; CHBAH, The Chris Hani Baragwanath Hospital; SBAH, Steve Biko Academic Hospital; RMMCH, Rahima Moosa Mother and Child Hospital; TBH, Tygerberg Hospital; SLH, Stikland Hospital; LGH, Lentegeur Hospital; VBH, Valkenburg Hospital; RXH, Red Cross War Memorial Children’s Hospital; GSH, Groote Schuur Hospital.
In the final section of the survey, HODs were asked if they believed the number of training posts at their respective institutions was adequate to meet population needs. All commented that there were shortages, particularly highlighting the lack of funded sub-specialist training posts.
While long waiting lists for specialist psychiatric training posts were previously mentioned,
Fellowship of the College of Anaesthetists of South Africa (FCA[SA]) 58%
Fellowship of the College of Neurosurgeons of South Africa (FC Neurosurg [SA]) 52%
Fellowship of the College of Obstetricians and Gynaecologists of South Africa (FCOG[SA]) 65%
Fellowship of the College of Orthopaedic Surgeons of South Africa (FC Orth [SA]) 64.5%
Fellowship of the College of Paediatricians of South Africa (FC Paed [SA]) 65%
Fellowship of the College of Physicians of South Africa (FCP([SA]) 50.7%
Fellowship of the College of Surgeons of South Africa (FCS[SA]) 67%.
The pass rates over this period are concerning considering: (1) the need to increase the psychiatrist-to-population ratio in the context of a growing population (1.3% per year)
If it is assumed that the South African population in 2019 was 58 558 270
While there were no subspecialist training posts except for Child and Adolescent Psychiatry in 2008, all the subspecialities that were included in the questionnaire had HPCSA-accredited training posts in 2018, with the number of training posts in Child and Adolescent Psychiatry doubling over a 10-year period. Despite this increase, there were fewer Child and Adolescent psychiatrists being trained in 2018 compared with 2008. Sadly, many of the training posts are unfunded – geriatrics, for example, has no funded training posts yet with an ageing South African population,
There are a variety of factors that may be contributing to general medical practitioners and specialist psychiatrists not pursuing specialist and subspecialist training. Some that have been mentioned in the past include HPCSA’s decisions on which academic units should be allocated specialist and subspecialist training posts and which subspecialities get accredited, as well as limiting the total number of subspecialist training posts per institution to two per subspecialist (for each subspecialist employed by an academic department the possible number of subspecialist training posts for that particular subspeciality that the academic department can apply for is capped at two) and the National Department of Health and the Department of Higher Education and Training being the only bodies that can authorise training of specialists and sub-specialists with training only possible through the public healthcare sector as a 4-year (specialist) and 2-year full-time or 4-year part-time course (sub-specialist).
Differences across institutions in the numbers of filled and vacant posts in 2008 and 2018 are difficult to explain considering that the data presented here reflect two time points rather than longitudinal year-on-year estimates. Drawing comparisons and providing reasons for the discrepancies and the potential impact would, therefore, be purely speculative. Filling of registrar posts is a dynamic annual process with different institutions in the country filling registrar posts at different times in the calendar year. That said, the increase in training post numbers nationally (which in the absence of an increase in provincially funded registrar posts across the country, over time) represents a strategic effort on the part of university departments of psychiatry to increase capacity on the service training platform in light of the increase in mental health service demands.
Shortcomings of the study include that not all nine universities that provide specialist and sub-specialist psychiatry training in South Africa responded to the survey of this study and of the universities that did respond some did not have comparable data for both 2008 and 2018. As such, the actual increase in the number of specialist and sub-specialist training posts from 2008 to 2018 was difficult to determine. In addition, SMU prior to 2015 was known as MEDUNSA campus and was part of the Limpopo University. In 2015, MEDUNSA campus split from the Limpopo University and became SMU. Thus, any posts added in 2018 through the establishment of SMU in 2015 must be viewed with this background in mind. That said, the eight universities that did respond to the questionnaire represent the largest universities in the country that offer registrar training in Psychiatry. The data represent a cross-sectional analysis covering two calendar years approximately 10 years apart and may not be representative of sustained trends between 2008 and 2018, and lastly, HODs may have also completed the questionnaire without consulting their human resource department or personnel records, resulting in inaccurate data.
While long waiting lists for specialist psychiatry training posts were previously described, this situation analysis shows multiple vacant specialist posts at training institutions in the country. Despite an increase in the number of specialist psychiatry training posts from 2008 to 2018, South Africa is unlikely to reach the recommended number of three psychiatrists per 100 000 population with the current funded post allocations in the next two decades if retirement, migration and population growth are considered, even if all vacant posts were filled, and all trainees have successfully completed their training within the stipulated time frame. Not only are additional funded training posts required but also strategies to increase post occupancy, retention and successful (and timeous) completion of training.
The authors would like to acknowledge the College of Psychiatrists and Colleges of Medicine of South Africa as well as Professor Bernard Janse van Rensburg (posthumously) for his contributions to the conceptualisation of the study.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
All authors contributed equally to this work.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data supporting this study’s findings are available from the corresponding author N.B., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.