Health Cabinet Secretary Aden Duale has said the government’s position on safeguarding public resources has been consistent, clear, and unwavering.
The CS, who had called for a press conference to provide a comprehensive update on the relentless fight against fraud and to address recent discussions including those on social media from various professional associations, said that the concerns being raised are not new, and that they have been an integral part of public discourse and enforcement actions from the beginning.
“We are committed to transparency. That’s why we continuously publish the list of all health facilities paid by the Social Health Authority (SHA), even though we aren’t legally required to,” he told the media, adding that this was also meant to ensure the public can hold the government and healthcare providers accountable.
Duale warned healthcare providers who will be caught in fraudulent activities, saying they will be held liable and face the full force of the law.
“We have already initiated the process to recover paid monies and this will involve law enforcement to prosecute the perpetrators. I call upon all Kenyans to continue with this spirit of social accountability and vigilance and report any concerns or information regarding fraudulent activities to SHA through the toll-free number 147,” he said.
Since April this year, the CS noted, they have intensified the fight and a comprehensive digital system specifically designed to detect and eliminate the very vulnerabilities that plagued the defunct National Health Insurance Fund (NHIF) is now in place.
“The primary function of our digital system is to detect fraud,” he said adding, We have seen that facilities are looking for innovative ways to cheat the system, but our digital architecture is designed to detect and flag anomalies at every stage of the claims process.
The CS further said fraud can be detected and stopped at any point including at the payment stage, because of the AI module that has become more effective with the availability of more data.
The more data we collect, the easier the detection of fraud becomes, added Duale.
This intensified fight against fraud, the CS noted, resulted in the closure of 728 non-compliant facilities and the downgrading of an additional 301 facilities by the regulator KMPDC.
“The government strategy is to build a robust, corruption-proof system and together with medical insurance companies, we have agreed to establish a Joint Anti-Fraud Action to crack down on malpractice and strengthen collaboration.
I want to be clear: our work has just begun. We will not rest until every Kenyan has access to quality, affordable, and dignified healthcare, free from the burden of fraud,” Duale said.
Giving the current status of claims processing since the Taifa Care rollout on 1st October, 2024, the CS said that a total of Sh9 billion in claims have been submitted to SHA, with Sh7.7 billion in total claims paid to health facilities, while the remaining balance will be paid in the next payment cycle.
On the claims status for SHIF, Duale said that health facilities have submitted claims to SHA totaling Sh82.7 billion and SHA has paid Sh53 billion for claims submitted by health facilities.
He added that claims totaling Sh6.4 billion have been approved and are pending payment, and the claims are for a portion of July, and will be paid in the next cycle.
The CS noted that the claims worth Sh10.6 billion have been rejected due to fraudulent activities or non-compliance, an action taken under the authority of Section 48(5) of the Social Health Insurance Act, 2023, which outlines penalties for providers, who knowingly or fraudulently alter information to defraud the Authority.
By Wangari Ndirangu
