The promise of Universal Health Coverage (UHC) in Kenya, underpinned by the ambitious KSh 100 billion digital superhighway launched under the Social Health Authority (SHA), was a beacon of hope for millions. This monumental investment in digital infrastructure was envisioned to streamline operations, enhance transparency, and eliminate the systemic inefficiencies that have long plagued the nation's health sector. Yet, barely past its inception, this grand vision is now clouded by alarming reports of widespread fraud and fierce criticisms from key industry stakeholders, casting serious doubt on its effectiveness and integrity.
The alarm was first sounded by Health Cabinet Secretary Aden Duale, who revealed on Monday from Afya House that at least 31 hospitals have been implicated in a deep-seated web of fraudulent activities. These facilities stand accused of brazen schemes designed to exploit the digital system: double billing for services, forcefully admitting patients for unnecessary procedures, falsifying claims, engaging in the illegal sharing of patient codes, admitting outright 'ghost patients', deliberately bypassing crucial pre-authorization procedures, and a general abuse of patient codes to siphon off public funds. These illicit practices not only drain vital resources meant for genuine patient care but also severely erode public trust in the new health scheme. The implicated hospitals span a wide geographic area, including Kisumu, Kakamega, Busia, Homabay, Vihiga, Nakuru, Kajiado, Bungoma, Kiambu, Kilifi, Mandera, and Wajir, indicating a systemic challenge rather than isolated incidents.
However, the CS's revelation, while impactful, immediately drew sharp rebukes for its lack of specific names of hospitals or individuals involved, sparking a fresh wave of demands for transparency and accountability.
The backlash against SHA has been swift and severe. Dr. Brian Lishenga, Chairman of the Rural and Urban Private Hospitals Association of Kenya, did not mince words, directly faulting SHA and demanding full responsibility. Dr. Lishenga pointedly questioned the role of SHA's own quality assurance officers and reviewers, posing a damning query: “We can only think of officers at SHA colluding with rogue providers for fraud to happen. Or rather, what role do reviewers and quality assurance officers do? Are they incompetent?”
His critique went further, expressing dismay that fraud permeates both public and private hospitals, but crucially, he alleged that the problem extends within SHA itself. “Fraud is a complex thing, it is not, as CS puts it. There is fraud within SHA itself. It is worrying at SHA, you get paid depending on whom you know, how do we then fight fraud?” Dr. Lishenga claimed that payments at SHA, contrary to promises of an AI-digitalized system designed to eliminate human error, are influenced by connections rather than merit. He highlighted the stark contrast in setup costs – KSh 100 billion for SHA versus KSh 700 million for the defunct NHIF – arguing that the massive investment in SHA should have eradicated all previous errors. “What we are seeing, is the facilities that get paid are those with some level of connection with SHA,” he asserted, concluding that "there is collusion between rogue SHA employees and facilities.” He directly challenged Duale's ministry to take decisive action against corrupt quality assurance officers and reviewers.
Echoing these grave concerns, Dr. Dennis Miskellah, Deputy Secretary General of the Kenya Medical Practitioners and Dentist Union (KMPDU), claimed that the SHA digital superhighway system has been fundamentally compromised. Dr. Miskellah alleged that some doctors are securing pre-authorization for services they have not even rendered. His powerful statement, “No laws and systems can fix people who compromise the system,” underscores a deeper crisis of integrity within the system. He warned that SHA is struggling with financial obligations, theft, and mismanagement by healthcare workers, predicting that these issues "will fail our healthcare needs." He also lamented that some public hospitals are "cheating" to claim Facility Insurance Financing (FIF), fostering a "capitalist" mindset that is "very unfair and frustrating." While supporting the CS's call to shut down fraudulent hospitals, Miskellah demanded that it "not be a roadside declaration," urging arrests and adherence to due process.
Adding another layer of complexity, private hospitals are now raising concerns over the sudden and seemingly arbitrary downgrading of their facilities from health centers (Level 3) to dispensaries (Level 2). These hospitals claim they received no formal communication regarding this critical decision, leaving them in a quandary. As a result, affected facilities are unable to offer essential services like maternity care and minor surgical procedures under the Social Health Insurance Fund (SHIF). With licensing fees already paid to the KMPDC based on their previous classification, many are left demanding refunds and accusing the KMPDC of "alleged double standards." This administrative confusion is leading to a "disruption of care" for patients who now have to change their health plans mid-treatment.
The KMPDC's crackdown has indeed seen over 700 hospitals closed or downgraded across five counties (Nairobi, Mandera, Wajir, Kisii, and Nyamira) for failing to meet basic standards, with CS Duale confirming the operation will extend to "all counties, and all constituencies and all wards."
