Duale: SHA blocked Sh11bn in suspected fraudulent claims during NHIF transition

                                                                                          Health CS Aden Duale speaking at a past event / HANDOUT 

Health Cabinet Secretary Aden Duale has defended the effectiveness of the Social Health Authority (SHA), saying public criticism often overlooks progress made in strengthening oversight within the health insurance system.

Speaking on the reforms, Duale said the government has rejected fraudulent health insurance claims amounting to Sh11.6 billion, citing this as evidence that tighter controls are beginning to yield results.

He noted that the government has enhanced monitoring mechanisms within the health insurance framework and warned that any attempt to misuse public funds would be detected and addressed in accordance with the law.

“Screaming headlines sell; if you say SHA is working, it will not sell, but screaming headlines will get out of the shell,” Duale said during an interview with Citizen TV.

“As of this evening [Wednesday], we have rejected Sh11.6 billion in fraudulent claims. Every coin that a Kenyan has paid for health care insurance—if it is stolen—the system will detect it, flag it, and the government will prosecute,” he added.

According to the CS, the rejected claims were identified largely during the transition from the National Hospital Insurance Fund (NHIF) to the SHA, a period he said required heightened scrutiny.

He stated that most of the questionable claims originated from health facilities and were subjected to multiple verification processes before being declined.

Duale said the claims underwent automated validation, clinical reviews, and other system checks to ensure compliance before a decision was made.

“Facilities made claims amounting to about Sh11 billion. Most of these were fraudulent claims. The system picked them up, went through different validation and clinical reviews, and we are not paying,” he said.

He maintained that the detection of irregular claims demonstrates improved accountability under the new system and reflects the government’s commitment to safeguarding contributors’ funds.

The CS reiterated that the protection of health insurance contributions remains a priority, emphasising that SHA will not process fictitious claims for services not rendered to patients.

On Sunday, Duale said all claims must undergo due diligence before payment, including forensic audits and clinical reviews, to confirm that services billed were actually provided.

“We will only pay after we do due diligence. SHA will conduct forensic audits and clinical reviews to make sure that the services offered are appropriate and that the Kenyan patient has actually received them,” he said.

Addressing concerns from some hospitals over delayed payments, Duale said facilities raising complaints were mainly those whose claims were still undergoing verification.

He insisted that the government was acting within the law and that the review process was necessary to ensure integrity and accountability in the health insurance system.