In the six-month period between October 2024 and April 2025, Sh11 billion was stolen from the Social Health Authority (SHA). This has been exposed by an audit that was conducted by the Ministry of Health. According to the audit, most of these funds were stolen through schemes that mainly involved private hospitals.
For instance, the audit found out that there was deliberate conversion of outpatient services into inpatient services in order to claim bigger but fake amounts. Patients would visit a hospital with mild illness, but instead of being treated and released, they would be deliberately admitted. This would then allow the hospital to claim higher reimbursements.
At the same time, there were hospitals that were found to have sent bills to SHA for medical procedures that had never been performed. The hospitals would also claim reimbursements for treatments they billed at higher costs than what they actually cost on the ground.
“There are health facilities where healthcare workers registered themselves as patients and logged false claims into the system,” the Cabinet Secretary for Health Aden Duale told a local daily newspaper.
The schemes to defraud SHA extended to childbirths. For instance, the audit report found that some hospitals had alleged that all their deliveries were caesarean and then gone on to file for payment from SHA.
In addition, there were hospitals that wanted to be paid for surgical claims even though their claims lacked theatre notes and complete surgical records. According to the audit, these missing details created doubts on whether the surgical procedures being claimed for had actually taken place or not.
It is under SHA that the government has been running the Social Health Insurance Fund (SHIF) which replaced the National Health Insurance Fund (NHIF). The replacement of NHIF by SHIF brought on board a new format in salary deductions, with the SHIF deductions being larger in comparison to the old NHIF deductions.
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In the financial year to June, SHA had a total of 27 million registered members. Out of these, formal workers comprised of 5.4 million, with only 4.3 million of them making contributions that amounted to a total of Sh47 billion.
The informal sector which forms the bulk of SHA members only had contributions from 860,000 people. Their contributions amounted to a total of Sh23 billion. 20.7 million people in the informal sector did not contribute anything to the SHA kitty.
