Audit uncovers huge fraud in universal health scheme

Kenya’s Social Health Authority (SHA) has lost Sh11bn ($85m) to fraud between October 2024 and April 2025, with private hospitals submitting the bulk of fake claims, reports the Daily Nation. This figure was uncovered during a Ministry of Health audit. Health Cabinet Secretary Aden Duale said the six-month period marked the height of theft within Kenya's flagship universal health coverage scheme. ‘This is when the real theft took place. The biggest fraud is in private facilities, though not all are culpable. It extends to referral hospitals as well, which have had claims rejected. Faith-based facilities have the lowest rejection rates. Hospital owners made a lot of money through the National Health Insurance Fund, and we will not allow that here.’ Duale admitted that when he took over the Health Ministry, he questioned why it was being called 'Mafia House'. After two weeks, he reached the same conclusion. ‘What I found here was shocking. The situation is different now. Much of the fraud identified by the system involves the deliberate conversion of outpatient services into inpatient claims,’ Duale said. Last year, Duale presented 118 files to the Directorate of Criminal Investigations. Investigations into 24 files have been completed, and another 15 were forwarded last week to the DPP. ‘Investigations are ongoing, and some cases have gone to court, including those involving senior SHA staff. More than 18 doctors and 22 clinicians have been denied access to the SHA portal,’ Duale said. Last October, the DPP, Renson Ingonga, approved charges against 10 suspects, including four directors of health facilities, in connection with alleged SHA fraud.

Full Daily Nation report