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Spotlight’s Top 9 Health Stories to Watch in 2026

On By ModernMedia
With several important developments on the horizon, 2026 is set to be another eventful year in healthcare. Photo by Sergey Mikheev on Unsplash

19th January 2026 | By Marcus Low

From the limited rollout of a new HIV prevention jab to developments with new weight loss medicines, to high-stakes court cases relating to National Health Insurance (NHI), 2026 is set to be another tumultuous year in healthcare. Here are nine stories that Spotlight will keep a close eye on.

 1. How will things go with the local rollout of a new HIV prevention jab? 

Given the high rates of HIV in South Africa, the biggest HIV story this year is likely to be the rollout of a new HIV prevention jab at around 360 (roughly 10%) of South Africa’s public sector clinics. The jab, which contains the antiretroviral medicine lenacapavir, provides six months of protection against HIV infection at a time. It could be a gamechanger for people who, for whatever reason, struggle to take daily prevention pills. We will be tracking how and to who the jab is made available and whether uptake meets expectations. 

As we reported last year, work is also underway on a new lenacapavir formulation that could provide 12 months of protection per shot. We’ll be scouring journals and conference programmes for new data on this formulation. 

2. Will we see better access to weight loss medicines? 

The class of diabetes and weight loss drugs called GLP1-RAs have taken the world by storm in recent years. Until recently, drugs like semaglutide (brand names Ozempic or Wegovy) and tirzepatide (brand names Zepbound or Mounjaro) were only available as injections. The GLP1-RA market is, however, set to be upended by the introduction of some of these medicines in pill form. The United States Food and Drug Administration (FDA) recently registered a semaglutide pill for use for weight loss. Another weight loss pill called orforglipron is also expected to be registered this year. One big question is when these pills will be registered and made available in South Africa and at what price. 

Another important GLP1-RA development this year will be the expiration of a key patent on semaglutide in India. This will open the door to generic manufacturers bringing their own versions of semaglutide to market – something that usually leads to substantial price reductions. We will be keeping a close eye on how this situation plays out and analysing what the implications are for people in South Africa. 

3. Might we see earlier than expected findings from pivotal TB vaccine trials? 

The one TB vaccine we have is over a hundred years old and only provides limited protection for kids. Several experimental vaccines are, however, currently being evaluated in late-stage clinical trials. Arguably, the most notable of these is the M72 vaccine, which is being assessed in a massive phase 3 study, partly conducted in South Africa. 

While timelines suggest most of the key TB vaccine studies will not yet have anything to report this year, it is possible that we might see a surprise or two. Findings are sometimes reported early if it becomes apparent ahead of schedule that a medicine or vaccine is clearly working, or clearly not working, as the case may be. Whether or not we see findings this year, it is important to start thinking about what a rollout might look like in our health system should results be as good as hoped. The M72 vaccine had around 50% efficacy in phase 2 trials, so there is reason for optimism. 

4. Will we see a concrete plan to address public sector healthcare worker shortages? 

Arguably, the most important dynamic in South Africa’s public healthcare system today is that provincial health departments are not employing enough healthcare workers across multiple categories. One reason for this is simply that budgets have generally shrunk over the last decade – obviously corruption and mismanagement in several provincial departments have made things even worse. There was a glimmer of hope in last year’s budget in which we saw a meaningful upturn in health funding for the first time in years, but that was at best a good first step toward recovery. As we enter 2026, our understanding is that all of the nine provinces are still facing severe healthcare worker shortages. 

More money for health in the next budget will certainly help, but there is a broader sense that government doesn’t really have a big picture vision for how to address the crisis. We do have a 2030 Human Resources for Health Strategy, but as with many such strategies, it seems to have so far gone largely unimplemented. 

5. Will enablers be held accountable for corruption such as that at Thembisa Hospital? 

One of last year’s big media moments was a Special Investigating Unit (SIU) press conference in which they described the extensive corruption said to have taken place at Thembisa Hospital. One snag, however, is that while the SIU can recoup funds and take matters to the Special Tribunal, the SIU does not conduct criminal prosecutions – though they can refer matters to the National Prosecuting Authority (NPA) for prosecution. Whether we will see successful NPA prosecutions relating to the Thembisa Hospital corruption is one of the year’s top questions. 

Unfortunately, even when the SIU does sterling work and delivers cases to the NPA on a plate, there is no guarantee that the NPA will do its job. One depressing example is that of Buthelezi EMS. Last year, the Special Tribunal ordered Buthelezi EMS (and other companies with similar names) to pay over half-a-billion Rand back to the state. The SIU also referred a related matter to the NPA in 2024 for prosecution, but Spotlight understands that the NPA has rather mind-bogglingly decided to drop the matter. 

6. Which, if any, senior health leaders will lose their jobs this year? 

While we won’t have national or provincial elections this year, that is no guarantee that we won’t see any health leaders losing their jobs. Over the last two decades, there have after all been many examples of people being ousted between elections, be it for purely political reasons or due to corruption scandals. 

Possibly the political leader in the health sector at greatest risk is KwaZulu-Natal MEC for Health, Nomagugu Simelane. Should the currently governing coalition of political parties in the province crumble, as it seems it might do, chances are several new MECs will be deployed, including for the health portfolio. 

There is also an outside chance that the country’s top health official, Dr Sandile Buthelezi, Director-General for Health in the National Department of Health, might be forced to step down. As reported by AmaBhungane, Buthelezi played a central role in an “irregular” R836-million oxygen procurement process and is also “at the centre of a Hawks investigation into allegations that he solicited a R500 000 bribe”. Our understanding is that Buthelezi has not been charged and that in the absence of charges he will stay in the job. 

7. What will happen in the landmark NHI court cases? 

Despite a new call for dialogue from Finance Minister Enoch Godongwana, chances for a political settlement over National Health Insurance (NHI) remains very low. The bottom line remains that Health Minister Dr Aaron Motsoaledi refuses to yield an inch on the version of NHI described in the Act and President Cyril Ramaphosa is not willing to force the matter. 

Instead, it seems the battle over NHI will this year be fought mainly in the courts. At our count, there are at least eight cases challenging the NHI Act, parts of the Act, or the process resulting in the Act. A first development to look out for is whether or not some of the cases will be combined and heard together. In case you missed it, last year we published a two-part series in which we tried to pin down the issues on which these court cases are likely to turn (see part 1 and part 2). 

While we will cover the NHI court cases in some depth, we will also try to foster constructive discussions on health reforms on our opinion pages and in our analysis. In our view, it is dangerously limiting to reduce the debate over South Africa’s healthcare reforms to a simple binary of whether one is for or against NHI. 

8. What will be left of the FDA, NIH, and CDC by the end of 2026? 

It used to be the case that United States Food and Drug Administration (FDA) decisions and health advice from the United States Centres for Disease Control and Prevention (CDC) carried a lot of weight around the world. In recent months, however, there have been increasing signs of political interference at these institutions and a turn away from evidence-based policy making. It seems inevitable that we will see more of the same in 2026 and the credibility of both the CDC and probably also the FDA will be further diminished. 

Similarly, the US National Institutes for Health (NIH) has been the world’s leading funder of health research for many years. But as with the CDC, the work of the NIH has been overly politicised over the last year and its reputation for rigour and scientific excellence has already been severely degraded. As with the FDA and CDC, the outlook is bleak. 

9. How well will SA and other countries recover from last year’s US aid cuts? 

With the dust settling after last year’s severe and abrupt cuts to US healthcare aid and US funding for medical research, the longer-term impacts of those cuts in South Africa and neighbouring countries should become clearer this year. Among others, we will get the first reliable estimates of key HIV and TB indicators for 2025 (reliable figures for a specific year are typically only published in the subsequent year). New HIV estimates from the Thembisa mathematical model (Spotlight’s preferred source for HIV estimates) should be out around the middle of the year, while new World Health Organization (WHO) TB estimates are usually released in November. 

Last year Motsoaledi was widely criticised by activists for underplaying the seriousness of the cuts for South Africa’s HIV response and the scale of specialised services and capacity that was destroyed here. Eventually some extra funds were made available in response to the cuts, but it amounted to only a small fraction of what was lost. The harsh reality is that in some places the aftermath of the aid cuts will be felt for years to come. 

At an international level, we are also not convinced that a clear roadmap has been set out for building back better after US withdrawal, though we’d be happy to be proven wrong. What is clear though is that entities like the WHO and UNAIDS are facing unprecedented financial and political pressures – it seems possible that UNAIDS will no longer exist a year from now. Much reform has already been undertaken at the WHO. By the end of the year, we should have some sense of whether things have stabilised and whether a coalition of willing nations is truly committed to keeping the WHO and multilateralism in health alive. 

We have outlined only nine health issues in the above, but there are of course many more questions that we could have added to this list. Some of those include: 

  • Whether we will see meaningful improvement in the South African government’s response to non-communicable diseases such as diabetes, cancers, and mental health conditions. 
  • How well implementation of South Africa’s latest TB recovery plan is going, and in particular how we are doing against the target of testing five million people in 12 months. 
  • How climate change will impact people’s health and whether the South African government is prepared for it. 
  • Whether South Africa will see real progress in addressing antimicrobial resistance. After adopting a good policy a few years ago, it appears momentum has been lost. 
  • Whether the state will start taking xenophobia in the healthcare system and around clinics and hospitals more seriously, as a recent court judgment requires it to do. 
  • Whether a serious effort will be made to better regulate private healthcare and to bring down the cost of private healthcare services and medical scheme membership – that after a half-baked effort to create a new tariff-determination framework was launched and then canned last year. 
  • Whether we will see legislation introduced amending the Patents Act in line with a policy adopted by government in 2018 and whether we’ll see progress on the much-delayed State Liability Bill, which should have relevance for the state’s vulnerability to medico-legal claims. 
  • Whether we will see concrete steps forward with the new electronic health records and data systems government is developing. 
  • What progress we might see with the local production of vaccines and pharmaceuticals – one of the areas in which we are quite optimistic, despite the lack of coherent and enabling government policy. 
  • What impact AI will, or will not, have in our healthcare system this year. 

Are there issues not mentioned here that you think Spotlight should cover in 2026? Let us know by commenting below this article or by tagging us on BlueSky. 

*Low is the editor of Spotlight. 

Republished from Spotlight under a Creative Commons licence.

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Categories : Ethics and Law Medical IndustryTags :

The Impact of Fraud, Waste, and Abuse on Medical Scheme Members and Strategies for Industry Reform

On By ModernMedia
Photo by Jp Valery on Unsplash

South Africa’s medical schemes industry is taking a strong, zero-tolerance stance against fraud, waste, and abuse – practices that are undermining the healthcare system. Fraudulent claims, unnecessary procedures, and mismanagement of resources are costing billions of rand, inflating healthcare costs, and putting additional financial strain on members. Instead of supporting essential treatments and care, these resources are being misused and misallocated, writes Dr Katlego Mothudi, Managing Director at the Board of Healthcare Funders (BHF).

At the recent BHF Healthcare Collab Hub, industry leaders highlighted the need for immediate reforms to curb these harmful practices and safeguard the future of medical schemes. As healthcare costs continue to rise, tackling fraud (deliberate deception), waste (inefficient use of resources), and abuse (excessive or improper use of services) is essential for ensuring that medical schemes remain affordable and sustainable. Without swift action, members may face higher premiums, with fewer resources available for the critical care they depend on.

Fraud, waste, and abuse (FWA) in the healthcare sector is not just a regulatory issue or an administrative headache, but a direct assault on the wellbeing of medical scheme members. Every fraudulent claim, and every misuse of resources, drains the pool of funds that are meant to ensure that individuals have access to necessary healthcare services. For millions of members, the repercussions of unchecked FWA include increased premiums, reduced benefits, and the potential for schemes to become financially unsustainable. It is a burden borne by all members, regardless of whether they have directly engaged with healthcare services or not.

The healthcare industry, specifically medical schemes and their administrators, has a significant responsibility to address this problem head-on. Their duty extends beyond managing funds – they are custodians of a system designed to protect individuals’ access to essential healthcare services. 

If these schemes fail to adequately combat FWA, the entire medical scheme ecosystem becomes compromised, undermining trust in healthcare funding and leaving members exposed to higher costs and decreased quality of care.

The ripple effect of FWA

The scale of FWA in the medical schemes sector is staggering. According to industry reports, billions of rands are lost annually to fraudulent activities. Whether through inflated billing, unnecessary procedures, or outright false claims, these actions take funds directly from the pockets of members. Medical schemes are forced to increase premiums to cover these losses, meaning that honest, hardworking individuals are paying more for their healthcare – not because of rising medical costs, but because of the unethical behaviour of a few.

Moreover, the administrative costs associated with managing and investigating FWA claims are significant. These costs divert funds that could otherwise be used to enhance member benefits or improve healthcare services. 

The long-term impact is even more worrying. If left unchecked, FWA can destabilise the entire medical scheme system. Ultimately, it is the members who suffer the most, facing financial uncertainty and diminished healthcare support when they need it most.

What the industry can do: Curbing FWA

The healthcare industry has both the tools and the responsibility to take decisive action against FWA. Key stakeholders, including medical schemes, administrators, and regulatory bodies, must collaborate to develop comprehensive strategies that can curtail the losses associated with these unethical practices. Here are some key strategies:

1. Enhanced use of technology and data analytics

The industry is already moving towards the use of automated systems and data analytics to detect unusual patterns and potential fraud. However, the systems need continuous improvement to keep up with the evolving tactics of fraudsters. Schemes should invest in advanced algorithms and artificial intelligence (AI) tools that can analyse claims in real-time, flagging high-risk transactions before they are paid. Machine learning models, for instance, could identify patterns that suggest fraudulent behaviour, such as repeated claims for the same procedure or suspiciously high billing from certain providers.

This not only helps in early detection but also ensures that members who follow the rules aren’t unfairly penalised. It is essential, however, that these systems remain transparent to avoid unintended biases or discriminatory practices.

2. Collaboration across the healthcare ecosystem

The fight against FWA cannot be won by medical schemes alone. There needs to be greater collaboration between schemes, healthcare providers, and regulatory bodies. Sharing data across schemes and industries can help to identify serial offenders who hop between schemes, committing fraud on a wide scale.

Additionally, healthcare providers themselves play a critical role. They should be incentivised to report fraudulent activities or billing irregularities they observe within their network. Schemes can establish anonymous reporting systems and offer rewards for whistleblowers who help to uncover fraud. By creating a network of accountability, the industry can make it more difficult for fraudsters to operate with impunity.

3. Member education and engagement

Members are the first line of defence against fraud. If they are empowered with the right information, they can help to identify fraudulent or abusive practices. Medical schemes should launch educational campaigns that inform members about how to scrutinise their healthcare bills and understand their benefits better.

Simple actions such as checking that all billed procedures were performed or verifying service dates can catch many fraudulent claims early. Members who understand the importance of vigilance are less likely to be unwittingly complicit in fraud and can help schemes prevent abuse of the system.

4. Improved consequent management 

Strong consequent management is one sure way of deterring this fraudulent behaviour. The Health Professions Council should impose appropriate penalties on healthcare professionals found guilty. Schemes should not hesitate to take legal action against individuals or providers who commit fraud. 

Stronger penalties, including prison sentences and significant fines, can serve as a deterrent.

Moreover, schemes must ensure that once a provider or member has been found guilty of fraud, they are blacklisted across all schemes. Allowing repeat offenders to continue exploiting the system is a failure that impacts all members.

At the heart of any medical scheme is the promise to its members that they will be provided with financial protection when they need healthcare. Fraud, waste, and abuse erode this promise, making it harder for schemes to deliver on their commitments. To safeguard the integrity of the system and ensure that members receive the care they deserve, the healthcare industry must step up its efforts to curb these damaging practices.

By embracing technology, fostering collaboration, educating members, and enforcing strict penalties, the industry can make significant strides in reducing FWA. In doing so, they will not only protect their financial stability but also uphold the trust and confidence that members place in them. This, above all, is the most important goal.

Categories : Expert Opinion Medical IndustryTags :

From Bottlenecks to Breakthroughs: BHF Report Charts the Course for Southern Africa’s Healthcare Future

On By ModernMedia
Photo by Hush Naidoo on Unsplash

By adopting bold, transformative strategies, the healthcare industry can overcome critical challenges and foster innovative collaborations to create a more equitable and sustainable healthcare future for southern Africa, writes Dr Katlego Mothudi, Managing Director at the Board of Healthcare Funders (BHF).

Committed to promoting collaboration and creating actionable insights within southern Africa’s healthcare ecosystem, BHF’s recently published report highlights significant trends, obstacles and breakthrough solutions from key figures in the healthcare sector, and charts the course for a robust, inclusive healthcare future. 

By interviewing industry leaders – including funders, hospitals, clinicians, and the pharmaceutical sector – the report presents a strategic path forward that promises to revolutionise the region’s healthcare landscape. As southern Africa grapples with rising healthcare costs, a growing burden of non-communicable diseases (NCDs), and economic instability, this report charts the course for a robust, inclusive healthcare future.

The evolving landscape of southern African healthcare

Healthcare organisations in southern Africa are navigating a complex landscape filled with escalating challenges and promising opportunities. The rapid increase in the burden of non-communicable diseases (NCDs) and economic volatility is driving a critical shift toward more sustainable healthcare models while increasing healthcare costs and reducing affordability. 

Concurrently, there is a renewed commitment to achieving health equity, with concerted efforts to ensure healthcare is universally accessible. Universal Health Coverage (UHC) is in various stages of rollout across the region, reflecting varying national priorities and capabilities. In South Africa, the proposed National Health Insurance (NHI), despite its controversies, is being closely watched for its potential impact on other countries if implemented pragmatically.

In the private sector, the health insurance market shows notable growth. This is in contrast to stagnation relating to traditional medical schemes. These schemes face slow or no membership growth and rising utilisation rates, pushing a gradual shift towards value-based care with strategies to strengthen contracting arrangements, control expenditure and improve health outcomes. 

High levels of fraud, waste and abuse persist, particularly in southern Africa, where economic conditions have severely limited the growth of private health insurance or medical scheme coverage, highlighting the critical need for innovative healthcare financing solutions.

Additionally, the post-COVID acceleration of digital healthcare is gradually reshaping service delivery. Significant investments in artificial intelligence and predictive analytics are set to strengthen health risk management, boost patient care and enhance operational efficiency. 

This era of digital transformation is marked by collaborations with local and global tech innovators and a strategic internal focus on tech integration to overhaul legacy systems and traditional practices. This complex tapestry of trends indicates a critical juncture for the region’s healthcare, laden with challenges, yet rich with opportunities for pioneering change.

Bottlenecks and barriers

Southern Africa’s healthcare systems face significant barriers to sustainability, including inefficient and politicised regulatory environments, inadequate workforce training, economic instability and the growing corporatisation of healthcare, all of which hinder innovation, affordability and access while threatening both public trust and the quality of care.

Reactive responses to emerging challenges

In response to the bottlenecks and challenges facing the sector, healthcare organisations across southern Africa are collaborating with government and business coalitions, such as Business for South Africa, to address fiscal risks and policy uncertainties, and promote private sector participation, regulatory harmonisation and advanced technologies. 

They are prioritising integrated healthcare models focused on primary care and value-based approaches, investing in digital innovations such as telemedicine, electronic health records and AI to improve efficiency and outcomes. Efforts to optimise resource allocation and care quality through digitalisation and process reengineering are also underway. 

While these actions address immediate challenges, longer-term systemic solutions are necessary to achieve UHC and future-proof their markets.

Proactive systemic responses

To create a sustainable and equitable healthcare environment in southern Africa, long-term strategic solutions are essential, and aimed at broadening healthcare access, enhancing system efficiency and ensuring financial sustainability. 

To achieve UHC, access through a multi-payer system that guarantees quality, affordable healthcare for all is instrumental. Implementing UHC principles will promote preventative care, care coordination, and effective management of chronic diseases. Additionally, advancing public-private partnerships (PPPs) can significantly enhance access and care quality, with proactive private sector engagement helping to overcome existing barriers and drive progress.

To improve policy and regulation, it is crucial to enhance the oversight and effectiveness of regulatory institutions while fostering regional inclusivity across the Southern African Development Community (SADC) for better knowledge sharing. 

In South Africa, aligning the NHI with a multi-funder framework will integrate private funders and recognise employers’ roles in system sustainability. Updating benefits to reflect current health needs and economic conditions will make healthcare more affordable and less hospital-centric. Introducing Low-Cost Benefit Options (LCBOs) within medical schemes will broaden access, while strengthening competition and optimising private sector performance, will enhance care quality. Additionally, establishing a risk equalisation fund and mandating medical scheme membership is key to stabilising the insurance market and lowering costs.

To advance healthcare, investments in infrastructure and technology are essential, especially in underserved areas, to ensure equitable access. Strengthening healthcare training and updating practice guidelines will improve care quality and expand capabilities, while better workforce planning and collaboration between academia and healthcare providers will align training with industry needs. Additionally, leveraging digital health initiatives, such as telemedicine and electronic health records, will enhance service reach and efficiency.

Furthermore, incorporating Environmental, Social, and Governance (ESG) principles is crucial for promoting resilience and establishing southern African healthcare systems as leaders in sustainable practices. Adopting ESG standards will enhance the sustainability and governance of these healthcare systems.

These strategies are designed not only to address immediate healthcare challenges, but also to establish a robust foundation for a future where high quality healthcare is universally accessible in southern Africa. By implementing these solutions, the region can bridge the current gaps and pave the way for a resilient healthcare system.

Through collaborative efforts, strategic reforms, and innovative solutions, southern Africa’s healthcare sector is not only meeting current needs but also preparing for future demands that are defined by innovation, equity and sustainability. 

Categories : COVID Ethics and LawTags :

COVID PPE Supplier Must Face the Music, Court Rules

On By ModernMedia

Pro Secure fails in bid to stop Special Investigating Unit going after it to recover millions of rands

Photo by J Castellon on Unsplash

A company accused of unlawfully benefiting from a multi-million rand contract to supply personal protective equipment (PPE) during the Covid pandemic, has failed in a bid to quash a summons issued against it by the Special Investigating Unit to recover the money.

Pro Secure raised several objections to the formulation of the case against it in the papers. But Special Tribunal Judge Kate Pillay has dismissed the company’s objections and ordered the company to pay the costs.

The SIU investigation uncovered irregularities in the Limpopo Department of Health’s appointment of service providers including Pro Secure, Clinipro and Ndia Business Trading, which resulted in about R182-million irregular and wasteful expenditure. The SIU initiated action against Pro Secure, alleging the company had made “secret profits”, and also instituted civil proceedings against the former head of health in the province, Dr Thokozani Florence Mhlongo.

In October 2022, the SIU secured an order from the Special Tribunal, effectively freezing Mhlongo’s pension fund until the outcome of the civil action against her. Mhlongo resigned in June that year while facing disciplinary charges.

In its application to the Tribunal, Pro Secure challenged the SIU’s legal standing, the fact that the Limpopo health department was not a party to the SIU action. Pro Secure also claimed that there was no allegation that its bid for the contract was not lawful.

Judge Pillay found there was no substance to any of the company’s arguments.

She said the particulars of claim in the civil action set out how Pro Secure had received a payment “significantly exceeding their initial bid”.

She said that according to the SIU, the request for quotation sent by the department was for 5000 automated hand sanitisers. Pro Secure had submitted a quote for 5000 white electronic hand disinfectant dispensers and for 5000 liquid sanitisers, the total amount being just over R7-million. Ultimately, the company had delivered 30 000 dispenser holders at R420 per unit and 900 000 litres of hand sanitiser at R170 a litre and had been paid almost R162-million.

In a statement, SIU spokesperson Kaizer Kganyago said: “This ruling supports the SIU’s stance on the irregular procurement of PPE by the Limpopo Department of Health during the pandemic.”

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Collaboration Needed to Reduce Billions Lost Annually in Healthcare Fraud, Waste and Abuse

On By ModernMedia
Photo by Jp Valery on Unsplash

In an age where healthcare integrity is of the utmost importance, a coalition of industry pioneers and technological trailblazers must lead the charge in driving transformation to combat fraud, waste and abuse (FWA) in the healthcare sector.

As a focal point of discussion on day two of the 2024 BHF Annual Conference, Vusi Makanda, HFMU Deputy Chairperson, and Manager of Fraud Management at Bonitas, set the stage for an interactive discussion on these healthcare issues. 

“Collaboration is paramount in addressing the challenges of healthcare FWA, evidenced by the erosion of trust and substantial financial losses highlighting the call for collective action,” says Makanda.  

Dr Hleli Nhlapo, MD of the medical schemes division at Dental Information Systems (DENIS), echoed Makanda’s sentiments. To this end, Nhlapo set the scene on the current state of FWA in the healthcare industry, suggesting that it exerts unnecessary pressure on resources while undermining trust between stakeholders. 

“Perpetrators are employing increasingly sophisticated tactics, leveraging technology and syndicates to orchestrate large-scale schemes, while regulatory delays and prosecutorial challenges hinder effective resolution,” says Nhlapo. “Despite this, collaboration among healthcare funders has emerged as a crucial solution, with recent initiatives indicating a promising shift towards industry-wide cooperation in addressing these complex challenges.”

Following Nhlapo’s address, Roxane Ferreira, Head of Department at the Association of Certified Fraud Examiners (ACFE), alluded to several global trends in FWA that are plaguing the global industry.

The impact of these is extensive and has led to concerning financial situations for healthcare systems around the world. So much so that Ferreira’s insights suggest that in the United States, it is estimated that as much as $68 billion is lost every year on the back of FWA. 

“In South Africa, the problem is not much better, with between R8 billion and R13 billion being lost annually to this. With between 15-35% of all claims submitted regarded as being fraudulent or abusive, the plight is adding approximately R22 billion to the cost of private healthcare,” adds Ferreira.  

Healthcare fraud is perpetrated by a variety of actors within the system, ranging from medical scheme staff to service providers and even syndicates. These perpetrators exploit vulnerabilities at different points in the healthcare process, whether through falsifying claims, overbilling or engaging in other deceptive practices.

Moreover, medical scheme members themselves, as well as patients, may also be complicit in fraudulent activities, while brokers and manufacturers can also play a role in facilitating these plans. 

Ferreira highlighted the multifaceted approach employed in identifying healthcare fraud, citing that 70% of cases stem from tip-offs or received information, while the remaining 30% are uncovered through data mining, audits and investigations.

“Healthcare fraud encompasses various deceptive practices,” suggests Ferreira. “ Some of the most common ones include merchandising, where pharmacies sell non-healthcare merchandise, but claim for a healthcare service; false claims by claiming for services rendered; ATM scams where doctors submit false claims and provide cash to patients; card farming where members lend their membership cards to non-members; code gaming that involves doctors manipulating billing rules to increase revenue; and lastly, the hospital cash plan fraud that entails doctors and members colluding to arrange unnecessary hospital admissions.”

In response to the escalating challenges of healthcare fraud, Ferreira adds that the sector is increasingly turning to innovative solutions, with the integration of Artificial Intelligence (AI) emerging as a pivotal strategy.

“AI technology offers the capability to analyse large volumes of data rapidly and accurately, enabling the identification of suspicious patterns and behaviours,” she says. “By leveraging AI algorithms, healthcare providers can proactively identify questionable activities, thereby safeguarding resources and maintaining the integrity of healthcare systems”

Using these advanced algorithms, AI can swiftly identify irregularities, such as sudden spikes in billed procedures and visit rates. Furthermore, it can compare billing practices, verify purchases, compare the geographical location of a patient against the practice, and treatments billed for the same or similar treatment by other practices.

In the fight against healthcare FWA, collaboration and technological innovation are emerging as critical pillars. By harnessing advancements such as AI, healthcare systems can effectively detect and prevent fraudulent activities, thus safeguarding resources, upholding the integrity of patient care and rebuilding trust.