'We are watching closely,' Duale warns hospitals over SHA fraud

Health Cabinet Secretary Aden Duale. [File, Standard]

Health Cabinet Secretary Aden Duale has warned hospitals and doctors against fraudulent claims under the Social Health Authority (SHA), saying offenders will be forced to refund money and face prosecution.

Duale, who was addressing a press conference in Nairobi on Monday, August 25, noted that contractual agreements under the SHA Act are signed with individual facilities, not associations.

“Hospitals like Nairobi Hospital, Aga Khan, Kenyatta National Hospital and Kenyatta University Hospital all hold individual contracts with SHA, not through associations,” Duale explained.

He warned that any facility, doctor or patient found in fraudulent dealings will face the full force of the law. “We are watching closely. Anyone involved in fraud will be held liable,” Duale stated.

The Cabinet secretary observed that the ministry has already begun recovering misused funds and will work with law enforcement agencies to prosecute perpetrators. He urged Kenyans to report suspicious activities through SHA’s toll-free number 147.

“Your participation is vital in protecting our social health insurer and securing a healthier future for our nation,” Duale added.

Duale’s statement comes days after the Ministry of Health suspended 40 health facilities, eight doctors and four clinicians from accessing SHA services for allegedly engaging in fraudulent activities.

In a statement issued in Nairobi on Thursday, the Ministry said the suspensions, effective immediately, followed a comprehensive digital audit and forensic review of suspicious claims lodged over the past two months.

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“These facilities and professionals have engaged in corruption and theft of public resources. We will surcharge them to recover any money already paid based on these fraudulent claims,” the statement read.

The list of suspended facilities, published in the Kenya Gazette, includes hospitals in Nairobi, Homa Bay, Bungoma, Mandera, Kakamega, Busia, Kilifi, Wajir, Kajiado and Kirinyaga counties.

The audit exposed multiple fraudulent schemes, including upcoding, falsifying medical records, exaggerating outpatient visits into extended stays, and colluding to lodge duplicate claims for the same patient. In one case, a Nairobi hospital billed Sh201,600 for a bladder tumour surgery but only performed a procedure costing Sh89,600.

Eight doctors linked to facilities in Nairobi, Bungoma and Kilifi and four clinicians from Nairobi and Homa Bay were found directly involved. Their SHA and Digital Health Authority access has been revoked, and the Kenya Medical Practitioners and Dentists Council and Clinical Officers Council have been notified of possible disciplinary action.

The Directorate of Criminal Investigations (DCI) will also receive the full list of implicated facilities and professionals for possible prosecution.

On pending claims inherited from the defunct National Hospital Insurance Fund, Duale explained that the government will pay verified claims of up to Sh10 million through a supplementary budget in October. Larger claims, he noted, must undergo strict verification.

“We have a constitutional and moral duty to pay only for services legitimately rendered in line with public finance laws,” he observed.

He noted that SHA has disbursed Sh9 billion for primary healthcare and assured hospitals serving public servants that delayed payments will be cleared by the end of this week.

Duale further said SHA is working with private medical insurers to form a joint anti-fraud initiative.

“Our work has just begun. We will not rest until every Kenyan has access to quality, affordable and dignified healthcare free from fraud,” he noted.