Nairobi, 5th January 2024
The Government recently enacted the Social Health Insurance (SHI) Act 2023 on 19th October 2023 which repealed the National Health Insurance Fund (NHIF) Act, rendering NHIF redundant and establishing the Social Health Authority (SHA). Upon commencement of the new Act, all funds, assets and other properties, movable and immovable, which immediately before that date were held for and on behalf of the Fund in the name of NHIF, vested in the authority. The Authority was mandated to This authoritative body is mandated to address and rectify systemic issues perpetuating fraudulent activities within our health facilities, ensuring the realization of Universal Health Coverage (UHC).
Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Kes 171 million. Extrapolating this to the total population of 8,886 hospitals, it is estimated that approximately 3,440 might have been engaged in fraudulent activities, potentially exceeding Kes 20 billion in losses from about 40% fraudulent hospitals. Luckily 60% carry out clean business.
The identified facilities have been suspended, and recovery of fraudulent claims is proceeding.
The widespread nature of these fraudulent cases is deeply concerning. The list of implicated facilities includes instances of induced demand, particularly targeting vulnerable citizens, notably older individuals, residing in regions such as Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos. Patients have been enticed into unnecessary medical procedures, exploiting their vulnerabilities.
Moreover, instances of induced sickness have been uncovered, wherein facilities deceitfully activate dormant accounts of members, financing medically unwarranted treatments. Fictitious records, manufactured claims, and deceptive practices, such as falsely indicating members undergoing major surgeries while actively at work, have all contributed to defrauding the Fund. Disturbingly, some hospitals have targeted groups of security guards from licensed security firms, financially inducing them to provide biometrics for fraudulent purposes.
Anomalies have also been identified, including facilities conducting an exceptionally high number of eye surgeries in a day, ranging from 10 to 22, in facilities with capacity of only 2 per day while lacking the adequate theatre capacity. Such discrepancies raise significant doubts about the legitimacy of claims and the resources available at these facilities.
Under the EduAfya cover, healthcare facilities have been enticing healthy students, providing food incentives for their biometrics that result in high financial losses. Additionally, cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed, significantly exploiting the scheme.
The Authority is envisioned to reduce and eliminate fraud by automating services to minimize human interface. The ICT systems are intended to have strong business intelligence modules to be able to flag outliers and double payments in time.
As we collectively tackle this crisis, we reaffirm our commitment to fortifying and safeguarding the integrity of our healthcare system. The government, in collaboration with relevant stakeholders, is resolute in ensuring that those responsible for these reprehensible actions are brought to justice, and our healthcare system is purged of this blight.
SUMMARY OF HOSPITAL RECOVERIES
No Name of Hospital Recovery Recovered Balance
1 Jekim Hospital -Nkubu Ltd – Meru 66669682 5,704,220.00 5,704,220.00
2 Jekim Medical Centre 6666460 295,224.00 295,224.00
3 Joy Nursing & Maternity – Eastleigh 73,964,470.00 73,964,470.00
4 Amal Hospital Ltd. 7,653,000.00 7,653,000.00
5 Beirut Pharmacy and Medical Centre 15,490,000.00 15,490,000.00
6 St. Peter’s Orthopedic and Surgical Specialty – Kangemi 14,089,500.00 14,089,500.00
7 Afya Bora Hospital Annex Ltd in Mwea 13,382,000.00 13,382,000.00
8 Afya Bora Hospital Ltd- Mwea 22246069 14,334,000.00 14,334,000.00
9 Charity Medical Centre 548,000.00 532,519.00 15,481.00
10 Queens and Kings Hospital 118,000.00 118,000.00 –
11 Chest & Skin Clinic 1,248,000.00 1,248,000.00
12 Kiritiri Medical Healthcare 3,326,000.00 3,325,923.00 77.00
13 Meswo (Tunza) Medical Services 788,295.00 788,295.00 –
14 Familia Bora Medical 195,000.00 195,000.00 –
15 Naivasha Quality Healthcare 447,600.00 447,600.00 –
16 Bingwa Family Clinic 218,000.00 218,000.00 –
17 Elburgon Nursing Home 362,000.00 86,950.00 275,050.00
18 Nyamira Jamii Medical 490,000.00 490,000.00 –
19 St. Joseph Shelter of Hope 159,500.00 159,500.00 –
20 Lenmek Hospital 369,000.00 369,000.00 –
21 Equity Afia Buruburu 7,191,000.00 7,173,052.00 17,948.00
22 Muranga High School Dispensary 4,256,000.00 276,000.00 3,980,000.00
23 Mathingira Medical Centre 4,053,500.00 1,704,500.00 2,349,000.00
24 Ruai Medical Centre 286,000.00 286,000.00 –
25 Thuti Medical Clinic 2,065,500.00 1,534,500.00 531,000.00
Sum Totals 171,033,809.00 17,704,839.00 153,328,970.00
NAKHUMICHA S. WAFULA, EGH
CABINET SECRETARY
