Section 59 Investigation

Five Years, Millions Spent — and Still No Action: When Practitioners Are Ill-Treated, Patients Pay the Price

By Dr Sipho KabaneSDK Health Leadership

In July 2025, the long-awaited Section 59 Inquiry Report into allegations of racial bias and procedural unfairness in fraud, waste and abuse (FWA) investigations by medical schemes was finally released.

It took five years to complete.It consumed considerable public and private resources.It involved extensive data analysis, stakeholder engagement, expert input and political oversight.

And yet, months later, the uncomfortable truth remains: very little has changed.

A report acknowledged, debated — and then effectively parked

The Section 59 Report did not emerge lightly. It was commissioned following sustained complaints from Black healthcare practitioners who alleged that they were being disproportionately targeted, subjected to opaque audit processes, financially strangled through delayed payments, and left without fair or independent recourse when accused of wrongdoing.

The inquiry found:

• Disproportionate adverse outcomes for Black healthcare providers in FWA investigations;

• Opaque risk-rating tools and algorithms, shielded from scrutiny;

• Procedural unfairness, including delayed notifications, prolonged investigations and weak appeal mechanisms;

• Power asymmetries between large medical schemes and individual practitioners that left providers economically and psychologically exposed.

The report stopped short of making formal legal findings of racial discrimination — but it did not need to. Its findings were systemic, structural, and deeply troubling.

And yet, despite this:

• Medical schemes largely rejected the findings;

• Industry bodies defended the status quo;

• The Council for Medical Schemes (CMS) has sought legal advice and held engagements — but has not published a clear, time-bound implementation roadmap;

• The National Department of Health (NDoH) has acknowledged the report — but has not driven visible regulatory or legislative reform.

This is not reform.This is drift.

Five critical years lost — and counting

One must ask the obvious, uncomfortable questions:

• Why commission a five-year inquiry if its recommendations are not going to be implemented?

• What signal does this send to healthcare practitioners who testified, submitted evidence and trusted the process?

• How many more years of “consultation” are required before basic fairness is enforced?

• Who benefits from delay — and who pays the price?

The answer to the last question is clear.

When practitioners are ill-treated, patients are ill-treated

Healthcare systems do not function in silos. They are human systems, and pressure applied at one point inevitably travels downstream.

When practitioners are:

• Treated as guilty before proven innocent;

• Subjected to endless audits with no timelines;

• Financially destabilised through payment suspensions;

• Psychologically worn down through intimidation and uncertainty;

They do not simply absorb this harm in isolation.

It manifests as:

• Shortened consultations;

• Defensive medicine;

• Burnout and withdrawal from high-need communities;

• Reduced willingness to treat complex or high-risk patients;

• Erosion of trust — not only in medical schemes, but in the system as a whole.

A practitioner who is ill-treated will, in turn, struggle to deliver compassionate, patient-centred care.This is not a moral judgement — it is a systems reality.

This matters even more in the context of NHI

South Africa is in the midst of attempting the most ambitious health reform since 1994: National Health Insurance.

Yet the Section 59 impasse raises a fundamental question:

If we cannot enforce fairness, transparency and procedural justice in a regulated private medical schemes environment — how will we do so under NHI, at vastly greater scale and complexity?

Unchecked algorithmic decision-making, weak appeals mechanisms and institutional inertia are not side issues. They are governance fault lines that could fracture NHI before it fully takes root.

What must happen now — urgently

The time for defensiveness and delay has passed.

At minimum, the CMS and the National Department of Health must jointly:

1. Publish a monitorable implementation roadmap, with:

   • Clear actions;

   • Responsible parties;

   • Timelines;

   • Public reporting milestones.

2. Clarify which recommendations will be implemented through:

   • Regulation;

   • CMS rules;

   • Legislative amendment to the Medical Schemes Act.

3. Establish or mandate an independent FWA appeal mechanism, credible to practitioners and enforceable against schemes.

4. Address algorithmic opacity head-on, balancing commercial interests with constitutional and administrative justice.

5. Communicate transparently with practitioners, especially those who have borne the brunt of these practices.

Anything less risks rendering the Section 59 Inquiry a symbolic exercise, rather than a catalyst for reform.

A final word

South Africa cannot afford governance theatre.

Five years of inquiry must not be followed by five years of silence.

If we allow this report to fade into obscurity, we send a chilling message: that even when evidence is gathered, voices are heard, and wrongdoing is identified — nothing need change.

That is a message our healthcare workers cannot afford to hear.And it is a message our patients will ultimately pay for.

The time to act is now.

Dr Sipho KabaneSDK Health Leadership