By Holly Joubert
Between 2023 and 2025, the South African (“SA”) healthcare system found itself balancing between two positions. On one end, the undeniable reality of rampant fraud, from syndicate procurement looting to fraudulent practitioners. On the other side, the medical care system is bound to the constitutional imperative for fairness, highlighted through the landmark Section 59 investigation into racial profiling by medical schemes, through the Council of Medical Schemes (“CMS”), the final report of which was released in July 2025. The developments in the past two years have fundamentally reshaped the legal and compliance landscape for fraud, waste, and abuse (“FWA”).
Public Sector Looting: The Tembisa Hospital Revelation
In September 2025, the Special Investigating Unit (“SIU”) released an interim report exposing the misappropriation of over R2 billion at Tembisa Hospital (Health-E-News). The investigation, which began in earnest in 2022, with the interim findings released in 2025, exposed 207 service providers involved in 4501 irregular purchase orders. The direct explanation is a classic failure of supply chain management where hospital officials colluded with different syndicates, such as the Maumela Syndicate, to approve payments for goods that were either inflated in price or never delivered (Health-E-News). Throughout the investigation, the SIU uncovered more than R122 million in direct payments made to corrupt officials and identified luxury assets valued at over R520 million connected to various syndicates. Such an investigation highlighted the vulnerability of public health funds within the country and the lack of a legitimate and robust internal verification process (Health-E-News).
The Section 59 Investigation: Algorithms and Factual Discrimination
Throughout the last two years, the private sector’s battle against FWA took a technological and constitutional turn. The section 59 inquiry, tasked with determining whether the FWA investigation system used by major medical schemes unfairly targeted Black healthcare providers (Investigation report). Following a hiatus in the investigation between 2021 and 2023, the findings handed to the Minister of Health, Dr Pakishe Aaron Motsoaledi, in July 2025, were statistically damning (Investigation report, 48).
Such an investigation found that between 2012 and 2019, Black providers were significantly more likely to be found guilty of FWA than their non-black counterparts (Investigation report, 309). Data analysed showed that Black anaesthetists flagged by Medscheme were 650% more likely to be found guilty of FWA than non-black anaesthetists; similarly, black psychiatrists dealing with Discovery were roughly 350% more likely to be flagged (Investigation report, 309). However, a crucial distinction was made, where a factual finding of discrimination based on these risk ratios, but a legal finding regarding unfair discrimination under the Constitution, was made to avoid prolonged litigation (Investigation report, 314).
The Section 59 Investigation also brought the use of AI under scrutiny, with the decision-making process being opaque, undermining procedural fairness (Business Day). In August 2025, it was argued that if training data reflects historical inequalities, the supposed “neutral” algorithms will inevitably produce biased outcomes. With AI being an inevitability in the future, the Panel recommended full algorithmic transparency to the CMS to ensure that automated FWA detection does not infringe on Constitutional rights (Business Day).
The Bogus Practitioner Crisis
Beyond the crisis of billing fraud, in the period between 2023 and 2025, South Africa (“SA”) experienced a surge in “bogus practitioners”, individuals practising medicine without registration. In the 2023/24 period alone, the HPCSA received over 300 complaints regarding unregistered practitioners (Central News). The HPCSA conducted over 3528 inspections throughout 2024 and 2025 to try to curb the rising trend, with fraudulent practitioners targeting low-income areas where private medical care is unaffordable. With a prominent example being Dr Matthew Lani being arrested in 2023 for posing as a doctor, and a deepfake of Dr Salim Abdool Karim, an epidemiologist, with the deepfake video claiming his house had been bombed by pharmaceutical companies, as well as featuring him selling a miracle cure for hypertension (Africa Check). Such an incident circulated in mid 2025, exposing the risks of AI in the medical field.
The medical fraud fight also shifted the burden of proof in the workplace, with a significant judgment in Woolworths (Pty) Ltd v CCMA being handed down through the Labour Appeal Court (“LAC”) (Daily Maverick).
This case involved an employee who was dismissed for submitting a medical certificate from a doctor suspected of selling fake sick notes. Despite the employer’s own investigation revealing the doctor’s practice was chaotic and unprofessional, the court ruled that general suspicion about a doctor is insufficient grounds for dismissal. The LAC ruled employers need to possess concrete proof that a specific sick note is fake and that the employee was aware (Daily Maverick).
The Road Ahead
After years of tension between medical schemes and healthcare providers, efforts have begun to create a better way of resolving disputes. In 2023, the CMS started working toward a dedicated tribunal that will deal specifically with FWA cases. By 2025, draft rules had been circulated, setting out a process that would allow both sides to have legal representation and to properly challenge evidence, including questioning witnesses.
As South Africa approaches the 2026/27 financial year, the following is clear. Whether the issue involves large-scale hospital scandals or a single practitioner being suspected of fraud, the system only works if it is transparent and evidence based. This current shift suggests a move away from opaque algorithmic systems and assumptions of wrongdoing, toward procedures that are open, balanced, and firmly rooted in constitutional fairness (Investigation report, 232).
Anti-Fraud & Corruption Law in Africa 