ONYIMBI: To counter evolving health claims fraud, transparency must be a priority

As Kenya advances towards universal health coverage (UHC), the emergence of a Sh19.8 billion funding gap for primary health care (PHC), following last week’s reported loss of Sh11 billion through fraudulent claims at the Social Health Authority (SHA), presents a contrasting picture of what the ordinary taxpayer expects when they duly pay taxes and what they actually get.

Reported losses have become increasingly frequent, pointing to a deep structural issue. From a health policy and public health financing perspective, closing this gap relies more on sealing structural loopholes that enable leakages than on finding new money to finance the programmes. The Ministry of Health currently faces an uphill task in restoring trust in health financing institutions.

Foremost, the government, through the Ministry of Health at the national level, must urgently reform the system that processes and pays claims under SHA. Fraud thrives where provider payment systems reward weak verification systems that cannot demonstrate the quality of treatment given to the patient.

Policies should support and implement a transition from open-ended fee-for-service claims to capped, regularly revised, risk-adjusted payment mechanisms such as case-based payments for inpatient care and capitation for PHC.

These mechanisms will reduce incentives for overbilling and ghost patients. Regular revision offers the promise of more efficient funding to sustain frontline health services such as maternal health.

There is a need to move digital claims management from passive automation to active fraud detection. As a digital country, Kenya already has advanced digital infrastructure; thus, the policy failure lies in governance and enforcement.

SHA should have the legal authority to deploy real-time analytics, including fraud detection, to flag unusual billing patterns before payment. Additionally, the integration of biometric patient verification, interoperable electronic medical records, strong audit mechanisms and facility-level service logs would sharply reduce identity fraud that leads to inflated claims.

However, technology alone is insufficient: clear accountability frameworks must specify who is responsible when controls fail, with administrative and criminal sanctions enforced consistently.

To counter the evolving system of health claims fraud, transparency must be a priority. The relevant authorities must act swiftly to hold culprits to account, while linking the amounts lost to fraud with any recovered sums or legal consequences to deter further misconduct.

Stealing money meant for health is the outright theft of life, since it diminishes the quality and availability of medication, personnel, services or legal provisions. Accredited institutions must also face thorough scrutiny, alongside their administrative holders.

Kenya does not face a shortage of health financing, but fraud and corruption have reversed health gains over the years and enabled fiscal indiscipline. Only by sealing loopholes that enable fraud and redirecting recovered resources to health targets can the country protect pregnant women and newborns while placing UHC on a fiscally sustainable path, as enshrined in Article 43 of the constitution.

Health policy advocate at Naya Kenya