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South Africa (SA) is a unique country with large discrepancies between the public and private sector medical infrastructure. A 2015 health policy project reported that 84% of the population was served in the public sector compared with only 16% in the private sector. In stark contrast, the report highlighted that the SA private sector accounted for 49.8% of the total health expenditure.[1] SA’s healthcare systems have to manage a heavy burden of interpersonal violence and road traffic accidents. A 2007 report found that SA men had an 8.2 higher mortality rate than their global counterparts, secondary to interpersonal violence.[2] The frequency of unnatural death peaks in young individuals aged 20 24 years, accounting for 49.9% of cases. The overall rate of morbidity and mortality with external causes was 11.5%, as reported by Statistics SA in 2017.[3] In recent years, an increase in gang violence in Western Cape Province, which has subsequently led to an increase in interpersonal morbidity and mortality, has been well documented in the media.[4] In response to the increase in violence, the SA National Defence Force was deployed in July 2019 with the aim of stabilising various affected areas – subsequently reducing gang-related violence. Although the efficacy of this intervention remains to be established, it highlights the magnitude of the problem, directly on society and indirectly on healthcare facilities. A local study published in 2017 highlighted the orthopaedic burden of gunshot-related injuries at a tertiary centre and found that 111 patients needed orthopaedic procedures during a 1-year period in 2012.[5] The Western Cape population is growing disproportionally to the estimated country population growth of 1.43%. The province is second only to Gauteng in terms of in-migration, with an estimated net migration of 316 308 people between 2016 and 2021,[6] further compounding population growth and the demand for medical services. To manage this demand, in 2018, SA had 897 orthopaedic surgeons, of whom 81% were in private practice. The Western Cape had 229 orthopaedic surgeons; 177 of these were in private practice, with a surgeon-to-patient ratio of 11:100 000 compared with 0.9:100 000 in the public sector.[7] Orthopaedic registrars perform a large percentage of trauma surgery, which is always done with direct supervision or availability of senior surgeons for assistance and quality assurance. The health sector budget for the Western Cape increased by only 7.3% during 2018 2019,[8,9] with the annual increase being offset by the population growth and increased cost of care, which are directly related to implant and consumable costs. In 2016, the Western Cape Department of Health secured a 3-year tender contract, with predetermined prices for implants. The yearly increases vary from 3-year fixed prices to annual increases of 10.3%, with most companies annually increasing prices between 4.5% and 10%.[10] However, with a deterioration of 33% in the exchange rate from April 2017 to March 2020, and the current economic climate, further increases can be expected. This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Three months in a high-volume tertiary orthopaedic trauma unit: What is a registrar worth?