Professional nurse Nomsa Dlamini* has been picking up extra shifts in Gauteng’s private health sector for years, without the required approval from her public sector managers.
The health department has no record of this work, a breach of the rules meant to regulate “moonlighting” among state employees.
She says the benefits of keeping her extra shifts off-book far outweigh the risks of getting caught.
Over the course of her 20-year career, Dlamini says she has watched retaliation against her complying colleagues, often in the form of a punishing shift schedule that makes rest unlikely and private sector shifts impossible.
Losing the extra income would be the worst-case scenario, she says.
Dlamini is not the only one bending the rules to avoid backlash.
A survey of 1,397 health workers in Gauteng and Mpumalanga found that among public sector employees who were moonlighting, just 20% of professional nurses said they had permission, compared with 85% of doctors and 13% of rehabilitation therapists. The results were published in the South African Medical Journal in 2025.
The policy that allows moonlighting — usually called remunerative work outside of the public service — started in the 1990s as a retention strategy with few official rules. Dlamini says she and her colleagues understand why the government needs to make the rules, but they feel the health system no longer has the legitimacy to enforce them.
They suggest that years of corruption have gutted the system by draining resources, stripping services, and eroding trust. At Tembisa Hospital, for instance, the Special Investigating Unit found that medical supply spending dropped by nearly three quarters in the year after massive graft was uncovered there.
Sometimes, patients aren’t being monitored because their nurse is selling cosmetics for a multi-level marketing scheme in the tea room, Dlamini says. Or a nurse has called in sick when they’re really working in the private sector while still being paid by the government.
There’s also a gruelling cycle that begins after a nurse spends their day at a private facility and then reports for night duty at a public hospital. At some point in the night, they might disappear to get some sleep, leaving an even smaller team to make sure dozens of patients are clean, comfortable and medicated by morning.
Gauteng shop stewards for the Democratic Nursing Organisation of SA, Jacky James and Isaac Rabotapi, say they know of many night shift tragedies. The pair regularly represent nurses during disciplinary hearings.
In one instance, they say a six-month-old baby needed a drip. The ward was short staffed, and the nurses in attendance were exhausted. Nobody was monitoring the infant once the drip was in. By the time somebody checked up several hours later, the infusion had leaked into the surrounding tissue, causing irreversible damage. Surgeons had to amputate the infant’s hand.
The two shop stewards say this is one of many instances they believe are linked to exhaustion and compromised judgment of nurses who work nonstop. In one nationally representative study from 2015, just over half of surveyed nurses said that they are too tired to work while they’re on duty. This study, however, found no statistically significant link between moonlighting and medico-legal claims.
Dlamini, James and Rabotapi are all professional nurses. Among them, they have about 85 years of experience in SA’s public hospitals.
James and Rabotapi say they also used to love nursing but switched to union work in an effort to help patients by improving the system in which they’re treated.
SA is also battling a critical shortage of nurse educators.
The health department’s staffing strategy until 2030 admits that SA needs to view nursing as an investment rather than an expense. It describes the many benefits of investing in nursing care, which include economic growth and improved health services.
The document, drawn up in 2020, included measurable goals to address workforce issues by 2025, including a plan to meet a shortage of nurse educators and to train and employ up to 34,000 professional nurses and midwives.
The government hasn’t yet tracked progress against these targets, says health department spokesperson Foster Mohale.
However, a review by the department of planning, monitoring and evaluation is in the pipeline to guide the strategy’s remaining period.
Mohale did not respond to detailed questions about moonlighting by public sector staff.
Research published in the journal PLOS One in 2025 suggests that professional nurses would give up moonlighting in exchange for a minimum 20% pay increase.
- Dlamini is not her real name.
