Africa’s ‘Unsung Hero’ Surgeons: Landmark Study Reveals Hidden Gaps in South Africa’s 30-Year Training Experiment

For nearly three decades, South Africa’s university hospitals have quietly run one of the most unusual medical training experiments in the world: hosting foreign surgeons-in-training who pay their own way, work alongside local registrars, and are expected to carry their skills back to some of the continent’s most underserved health systems. Now, for the first time, researchers at the University of Cape Town (UCT) have put that program under the microscope, and the results reveal both a quiet success story and a persistent surgical gap that no one had formally measured before.

The study, published in Global Surgical Education, the journal of the Association for Surgical Education, examined supernumerary registrars (SNRs) in orthopaedic surgery at UCT. SNRs are non-South African medical practitioners who undertake postgraduate training, research, and clinical work at South African universities. The program was first piloted in 1996 at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal and has since been adopted by universities across the country. It was designed specifically for doctors from countries, particularly in Africa, where postgraduate specialist training programs are limited or entirely absent.

The premise is simple but ambitious: SNRs enroll in the same Master of Medicine (MMed) degree as their South African counterparts, sit the same examinations set by the Colleges of Medicine of South Africa, and are expected to function at the same academic and clinical capacity. They manage orthopaedic emergencies and elective conditions in outpatient clinics, operating theatres, and after-hours emergency settings. Crucially, however, they occupy positions outside the standard registrar quotas, making them an additional resource rather than a replacement. They are not paid by the South African government; instead, they are sponsored by their home governments, non-governmental organizations, or themselves, covering living expenses, MMed fees, and annual tuition. This arrangement has led some to describe SNRs as the ‘unsung heroes’ of the South African healthcare system, contributing to an under-resourced environment for more than 25 years at no cost to the state.

Despite this long history, no formal evaluation of the program’s impact had ever been conducted. The UCT team, led by Nqaba Mancotywa, Nicholas Kruger, and Sithombo Maqungo, set out to change that. Their cross-sectional study surveyed current registrars and registrar alumni attached to UCT’s Division of Orthopaedic Surgery, collecting data on demographics, research output, academic progression, operating theatre involvement, and career paths after graduation. Ethical approval was obtained from the UCT Human Research Ethics Committee, and data were drawn from participant surveys alongside a prospectively maintained departmental database logging every surgical procedure and the role of each surgeon involved.

The response was striking. Of 45 invited participants, 40 responded, an 89 percent response rate, comprising eight current SNRs, 13 South African registrars (SARs), 11 supernumerary alumni, and eight South African registrar alumni. All current SNRs came from Sub-Saharan African countries, and most had completed their undergraduate training there. Among alumni, six were from Sub-Saharan countries and five from North Africa. The researchers then compared the two groups across three domains: academic performance, clinical exposure, and post-graduation trajectory.

Academically, the picture was one of parity. SNRs and SARs showed similar publication productivity, with SARs slightly ahead overall, though SARs tended to publish more in local journals while SNRs leaned toward international outlets. Both groups entered the program with prior research experience, and the majority completed their MMed research projects within their training time. Most registrars in both groups passed the Fellowship of the College of Orthopaedic Surgeons of South Africa (FCOrth(SA)) primary and intermediate examinations on their first attempt, despite markedly different undergraduate backgrounds. The authors describe this as encouraging evidence that academic support is being delivered equitably across the two groups.

The clinical picture was far less balanced. As primary surgeons, SNRs averaged 232 theatre appearances compared with 482 for SARs, meaning local registrars logged nearly 50 percent more operative exposure. Only one SNR in the sample exceeded the average SAR’s theatre count, while 94 percent of SARs surpassed the average SNR. The gap persisted across assistant roles: as first assistants, SNRs averaged 123 appearances against 194 for SARs, and as second assistants, 21 against 60. Although the gap narrowed as training years progressed, it never closed to equivalence. Even the least experienced Year 2 South African registrar had nearly twice the theatre experience of the least experienced Year 2 supernumerary.

The researchers trace this discrepancy to the structure of entry pathways rather than to ability alone. South African registrars must pass FCS(SA) primary and intermediate examinations before applying, then rotate through a structured Medical Officer program in Cape Town’s level 2 hospitals, where they are mentored, upskilled, and assessed by orthopaedic consultants before joining the Groote Schuur Hospital trauma service. SNRs, by contrast, are selected mainly on the basis of health professional registration and curriculum vitae, with no standardized way to validate skills acquired in distant, variable training systems. On occasion, arriving SNRs were found to have limited basic surgical skills despite their enthusiasm, placing them at a disadvantage from day one. The department responds with personalized mentorship, pairing new SNRs with senior trauma registrars, and sometimes stationing them in the Trauma and Emergency Unit to assess their skills before full integration, measures that can delay academic progression and strain four-year sponsorship windows. Previous studies have also reported that some supernumeraries felt unprioritized in rotation scheduling and cited experiences of xenophobia and unequal academic support.

Where graduates end up may be the program’s most important metric, and here UCT performs well. Most supernumerary alumni returned to their countries of origin, with only a quarter relocating to high-income countries abroad and two remaining in South Africa. This contrasts with earlier findings at the KwaZulu-Natal program, where many SNRs expressed no intention of returning home, though it aligns with earlier UCT research showing high retention of Sub-Saharan surgical trainees within Africa. More than half of the supernumerary alumni now practice in the public or state sector, compared with only a quarter of South African alumni, and two hold leadership roles as heads of department or clinical units. The Botswana model offers a glimpse of the program’s evolution: trainees complete part of their training as supernumeraries in South Africa, then return home to finish under the University of Botswana, receiving CMSA specialist certification while being registered with the Botswana Health Professionals Council, a hybrid structure that structurally guarantees return.

The authors conclude that the program largely achieves its founding purpose, producing academically and clinically capable specialists equipped for service in their home countries, but they caution that changes may be needed to bridge the early-training gap between SNRs and SARs, and that the program remains vulnerable to misuse. Research output declined equally in both groups after graduation, likely reflecting a shift from training toward income generation in systems where academic positions are scarce. The team calls for further studies across UCT’s broader Faculty of Health Sciences and a qualitative follow-up examining registrars’ lived experiences and the oversight of the program. In a world where international medical graduates are typically expected to migrate permanently and finance their own training in host countries, South Africa’s return-home model stands alone, and this first formal audit suggests that, with targeted reforms to early operative exposure, it could become a template for surgical capacity building across the African continent.

Subject of Research: Evaluation of the clinical and academic impact of supernumerary orthopaedic registrar training at the University of Cape Town compared with South African registrars

Article Title: Supernumerary registrars in orthopaedics at the University of Cape Town: a review of their training locally and in their countries of origin, compared to South African registrars

Article References: Mancotywa, N., Kruger, N., & Maqungo, S. (2026). Supernumerary registrars in orthopaedics at the University of Cape Town: a review of their training locally and in their countries of origin, compared to South African registrars. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 161. https://doi.org/10.1007/s44186-026-00561-z

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00561-z

Keywords: supernumerary registrars, orthopaedic surgery, University of Cape Town, surgical training, South Africa, medical education, Sub-Saharan Africa, MMed degree, theatre exposure, registrar alumni, surgical capacity building, CMSA examinations