Kenya's Health Cabinet Secretary, Aden Duale, has issued a stringent warning against fraudulent activities targeting the Social Health Authority (SHA) and its TaifaCare program, vowing to prosecute offenders, recover misused funds, and ensure strict adherence to public finance laws. Speaking from Nairobi, Duale reiterated the government's unwavering commitment to safeguarding public resources and ensuring that every shilling contributed to the Social Health Insurance Fund (SHIF) is used for legitimate healthcare services.

The Ministry of Health's intensified anti-fraud campaign has led to significant actions against errant facilities and professionals. Since the TaifaCare rollout on October 1, 2024, the SHA has rejected over Sh10.6 billion in claims due to suspected fraud and non-compliance. This comes after a rigorous digital audit system flagged numerous irregularities within the Sh82.7 billion worth of claims submitted, of which Sh53 billion had been paid out. Furthermore, 728 non-compliant facilities have been closed, an initial 40 hospitals were suspended, and an additional 45 are currently being degazetted pending further investigation.

Duale detailed various fraudulent schemes uncovered, including upcoding (billing for more expensive procedures than performed), falsifying medical records, exaggerating outpatient visits into extended inpatient stays, phantom billing (claims for non-existent patients), and colluding to lodge duplicate claims for the same patient across multiple locations. Specific examples highlighted included Nabuala Hospital in Bungoma, cited for allegedly falsifying claims for multiple Caesarean sections on the same patient within days, and Kotiende Medical Centre in Homa Bay, flagged for a single person supposedly signing off on both day and night shifts consecutively. A group of facilities in Mandera allegedly colluded to submit 312 fraudulent claims for patients admitted simultaneously across various locations.

The consequences for those involved in fraud are severe: offenders will be forced to refund money and face prosecution. The Ministry has already begun recovering misused funds and is collaborating with law enforcement agencies, including the Directorate of Criminal Investigations (DCI). Additionally, professional bodies like the Kenya Medical Practitioners and Dentists Council and the Clinical Officers Council have been notified for possible disciplinary action against implicated doctors and clinicians whose SHA and Digital Health Authority access has been revoked. Hospitals like Nairobi Hospital, Aga Khan, Kenyatta National Hospital, and Kenyatta University Hospital, among others, hold individual contracts with SHA, and Duale stressed that facilities, doctors, or patients found in fraudulent dealings will face the full force of the law.

Addressing the legacy debt from the defunct National Hospital Insurance Fund (NHIF), Duale assured that verified claims up to Sh10 million will be paid through a supplementary budget in October, while larger claims will undergo strict verification. SHA has already disbursed Sh9 billion for primary healthcare, and delayed payments to hospitals serving public servants are expected to be cleared promptly. The Ministry is also forming a