Nairobi — Health Cabinet Secretary Aden Duale has revealed that the government lost at least Sh11 billion through fraudulent and irregular medical claims under the new Social Health Authority (SHA) system, blaming health facilities for attempting to carry over corrupt practices from the defunct NHIF scheme.
Speaking during the National Assembly leadership retreat in Naivasha, Duale said an audit conducted after he took over the ministry in April uncovered widespread manipulation of claims submitted between October and April, shortly after the rollout of SHA.
"That is why you saw today's headline about Sh11 billion being lost. We did an audit and found that some facilities were stealing because they were used to stealing from NHIF," Duale told MPs.
The CS said the amount represents rejected claims that failed basic medical and legal verification standards and has since been presented to Parliament's Health Committee for scrutiny.
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One of the red flags, Duale said, was the unusually high number of Caesarean section deliveries reported by some hospitals.
"Medically, only about 10 to 15 per cent of births should be C-sections. But we found facilities reporting 100 per cent of mothers delivering through surgery. In Tharaka Nithi, one private hospital claimed 500 mothers, all through C-section. That is against the law, and SHA will not pay," he said.
Duale also cited falsified documentation as a major source of rejected claims, particularly in maternity services.
Under the law, he explained, claim forms must be completed by three parties the patient, the attending health worker and the hospital administrator to confirm that treatment was actually provided.
"When SHA finds that the entire form is filled by one-person, same handwriting, same pen, that is automatic rejection. We will not pay that claim," he said.
Another key requirement, he added, is birth notification for all facility-based deliveries a document that confirms a child was born in a recognised health institution.
"If you submit a maternity claim without a birth notification, how do we know a child was delivered? That is fraud, and it is part of the Sh11 billion you are seeing," Duale said.
For surgical procedures, the CS said some facilities were claiming payments without submitting theatre notes official records confirming that an operation took place.
"If you don't provide theatre notes, how do you expect SHA to pay for surgery? That is another rejection," he said.
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Duale further revealed that the digital system used by SHA is now flagging suspicious patterns in outpatient services under the free primary healthcare programme.
He gave an example of one county where a single patient was recorded as visiting the same facility up to 10 times a day a pattern he said pointed to the creation of ghost patients to inflate capitation payments to counties.
"The system picks patterns. It is no longer people sitting and approving claims. We will engage the governor of that county because facilities are creating fake patients to get more money," he said.
The CS warned that similar checks were being applied to specialised treatments such as dialysis, where SHA covers a set number of sessions, but some facilities were submitting claims beyond approved limits.
Duale said the ministry will intensify audits and work with county governments to clean up the system, warning that facilities engaging in fraud risk deregistration and prosecution.
"We are determined to stop this culture of theft in healthcare. The money is for patients, not for cartels," he said.
