A case in which one person attempted to register 375 children under a single health cover has laid bare the scale of fraud targeting the Social Health Authority, with Health Cabinet Secretary Aden Duale telling the Senate that the government is confronting organised abuse of the system.
Duale said the anomalies uncovered by the digital platform show coordinated schemes involving individuals, clinicians and private hospitals seeking to manipulate claims.
He maintained, however, that the system has proven effective in identifying and stopping irregular submissions before any money is paid out.
He clarified that reports claiming Sh12.7 billion had been lost are misleading, explaining that the figure refers to claims that were flagged as suspicious and rejected.
According to the CS, counties including Mandera, Kisii, Migori, Homa Bay and Wajir have recorded the highest number of questionable claims.
He linked the trend to private facilities allegedly working with individuals to push false claims through the system.
Among the extreme cases presented was that of a man who declared 375 children as dependants, while another individual listed more than 50 spouses under one cover.
Authorities are investigating both cases as part of wider probes into abuse of the scheme.
“I want to confirm that the majority of those taken to court are from Wajir and Mandera. Those who have opted for out-of-court settlements and refunded SHA are also largely from the same region, alongside other Kenyans,” Duale said on Wednesday.
He warned that the government will not allow fraud networks that thrived under the former National Hospital Insurance Fund to take root again under the new system.
“We do not want crooks and cartels who were used to eating from NHIF to continue with the same business. SHA is driven by technology and will seal those loopholes,” he said.
The CS also highlighted cases pointing to clear misuse of services, including a patient who sought treatment five times in one day for different conditions, moving from one complaint to another within hours.
He said such patterns indicate possible collusion between patients and health providers.
To address the issue, 22 doctors have already been denied access to the system, while over 40 clinicians have faced disciplinary measures.
In Bungoma, a facility came under scrutiny after reporting more than 400 deliveries in a single month, raising doubts about the legitimacy of the claims.
Investigations remain active, with the Directorate of Criminal Investigations handling more than 81 cases linked to suspected fraud.
At least 24 files have already been submitted to the Office of the Director of Public Prosecutions for further review.
Duale cautioned politicians against interfering with enforcement, stressing that action will be taken against any facility found culpable, regardless of ownership.
“When I close a hospital, don’t call me. Political affiliations will not protect anyone. Even if a facility is owned by a sitting Member of Parliament, it will be shut down if found culpable,” he said.
He attributed criticism directed at the new system to individuals and groups whose illegal activities have been disrupted, describing them as cartels resisting reforms.
The CS also addressed pending payments under the EduAfya Medical Scheme, stating that outstanding claims stand at Sh735.8 million.
This includes Sh116 million for group life and last expense, Sh320.5 million for inpatient services and Sh299 million for outpatient claims.
He said the Sh116 million has already been settled, with payments expected within two weeks, while the remaining Sh619.8 million will be paid once funds are available.
“These claims will be settled progressively alongside broader NHIF legacy debts. The National Treasury has already allocated Sh4 billion in a supplementary budget to clear debts owed to facilities with claims below Sh10 million,” he said.
The matter was raised by Nairobi Senator Edwin Sifuna, who sought clarity on timelines for clearing the outstanding EduAfya payments.