SHA's Sh100b digital highway fails to curb fraudulent claims

Rural and Urban Private Hospitals Association Chairman Brian Lishenga during an interview at The Standard Group Offices, on February 25, 2025. [File, Standard]

Stakeholders in the health sector have raised concerns over the effectiveness of the Sh100 billion digital superhighway, under the Social Health Authority (SHA), following reports of fraudulent claims.

This comes after Health Cabinet Secretary Aden Duale revealed that at least 31 hospitals have been implicated in fraud.

The facilities are accused of engaging in double billing, forceful admissions, falsifying claims, illegal sharing of patient codes, admitting ghost patients, bypassing pre-authorisation procedures, and abuse of patient codes.

Addressing the media at Afya House, Nairobi, on Monday, Duale said the hospitals operate in Kisumu, Kakamega, Busia, Homabay, Vihiga, Nakuru, Kajiado, Bungoma, Kiambu, Kilifi, Mandea and Wajir.

However, he did not mention the hospitals and doctors involved in the fraud.

Rural and Urban Private Hospitals Association of Kenya Chairman Brian Lishenga faulted SHA, saying it should take full responsibility and action taken against those involved.

Dr Lishenga said SHA has quality assurance officers and reviewers who should flag fraud before being reported.

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“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 officer do. Are they incompetent?” He posed.

Lishenga regretted that fraud is happening in public and private hospitals.

“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?” He posed.

He claimed that payment at SHA is not as promised-Artificial Intelligence (AI) digitalised system that avoids human error.

Unlike National Health Insurance Fund (NHIF) that required Sh700 million to set up the digital system, SHA demanded Sh100 billion, an allocation Lishenga says should have cleared all errors witnessed in the defunct system.

“Digital platform at SHA should determine who gets paid and what services are offered and have been offered. What we are seeing, is the facilities that get paid are those with some level of connection with SHA,” he said.

“Fraud within SHA is multi sectoral, there is no one-sided fraud, there is no fraud limited to only facilities. There is collusion between rogue SHA employees and facilities,” he added.

“Duale’s ministry is responsible for fraud because they are the ones who should employ quality assurance officers and review them. If quality assurance officers, accounting officers and reviewers are colluding with rogue facilities, shouldn’t he be cracking the whip?”

Lishenga urged the dispute tribunal within SHA and Kenya Medical Practitioners and Dentists Council to pick up the issue and get quick solutions to win Kenyans trust.

“We cannot fight corruption by making political statements. If people are found culpable of fraud, why have they not been arrested and taken to court?” He posed.

Kenya Medical Practitioners and Dentist Union (KMPDU) Deputy Secretary General Dennis Miskellah claimed that the digital superhighway SHA system has been compromised

Dr Miskellah alleged that some doctors are getting pre-authorisation of services they have not offered.

“No laws and systems can fix people who compromise the system. SHA is struggling with financial obligations, theft and mismanagement of hospitals by healthcare workers, this will fail our healthcare needs,” he said.

Miskellah said some hospitals admit outpatient cases just to make claims.

“Public hospitals are cheating, because they want to enjoy Facility Insurance Financing (FIF). People have become capitalists. It is very unfair and frustrating,” he said.

“The 2.75 per cent is too much for Kenyans. When you twist figures and manipulate the system, you might think you are clever, but SHA will collapse,” he added.

KMPDU wants the system fixed to end fraud.

“We support the CS to shut the hospitals. Let it not be a roadside declaration. CS should arrest and shut the facilities,” said Miskellah.

However, he maintained that due process should be followed to address fraud at the health scheme and action taken.

“Let the individuals be held culpable, even any healthcare workers. KMPDU will not defend any doctors. There is nothing like free healthcare, we have to support any initiative that will root out fraud,” said the union official.

Digitalisation of SHA was meant to ease pre-authorisation of service, handle claims, monitor doctors operation, code claims, and reduce human errors as witnessed under defunct NHIF.

NHIF reported duplication of claims, an issue that caused financial strain on patients in need of healthcare.

To enable the country to actualise Universal Health Coverage (UHC) NHIF was repealed by SHA in November 2023.

“We are disappointed. Unless the system is not functional or was misleading. We want to know what is beating the system. How long will the system be fixed, as a public, we demand money to be protected. We need action,” said Miskellah.

Meanwhile, private hospitals have raised concerns over the recent downgrading of their facilities from health centers (Level 3) to dispensaries (Level 2).

The hospitals claim that they have not received any formal communication regarding the decision.

As a result, the affected facilities are unable to offer certain services under the Social Health Insurance Fund (SHIF), including maternity care and minor surgical procedures.

The hospitals, which had already paid licensing fees to the KMPDC based on their previous classification, are now in a dilemma over whether they are entitled to refunds for the fees paid.

They accused KMPDC of alleged double standards in the assessment of hospitals.

KMPDC has closed some 700 hospitals in five counties for failing to meet basic standards, with a number downgraded from Level 3 to Level 2.

The affected facilities according to Duale were found to be unregistered, unlicensed or operating below the required standards.

The CS warned that the crackdown is ongoing.

Counties where the inspection has taken place include Nairobi, Mandera, Wajir, Kisii and Nyamira.

Of the 1, 017 inspected hospitals in Nairobi, 394 were closed down and 23 downgraded.

In Kisii, some 291 were inspected, among them 120 closed, and 63 downgraded.

The KMPDC officers inspected 269 health facilities in Mandera and closed 58, and 60, whereas in Wajir, at least 239 were inspected, of which 77 were closed down with 114 being downgraded.

Elsewhere in Nyamira, 167 hospitals were inspected, of them 79 closed with 41 downgraded.

“We shall go to all counties, and all constituencies and all wards.

“I want to ask Kenyans to report two things- if they see a facility that doesn’t qualify to be called a health facility, report those fake facilities, report those quack doctors and health workers who are treating our patients and who are risking our lives,” said Duale.

But Lishenga said the procedure for downgrading hospitals was ignored.

“We noticed during inspection, some facilities were downgraded and declassified from Level 3 to 2. This means some of the facilities cannot enjoy services that they used to offer under SHIF fund. Level 2 facilities do not offer SHIF services.

Once your facility is downgraded from level 3 to 2, for instance maternity cases for CS are things that cannot be conducted, whether or not you have a theatre,” said Lishenga.

Further more, following the downgrading of facilities by KMPDC, there are a number that do not have access to SHA portal

Lishenga said KMPDC is reluctant to shed light on the matter, maintaining the move was based on KMPDC gazette notice of 2021.

Facilities are also concerned about loss of revenue, for example some clustered as Level 3, will be paid claims offered, under SHIF.

“We now have disruption of care. We have patients who were coming for services in the hospitals, and cannot access care, for example if you had started your Antenatal Clinic (ANC), hoping to deliver, they must change their health plan,” said Lishenga.

Hospitals that were downgraded are demanding to know if they will be refunded, having paid the registration fee to KMPDC.