An investigation reveals how fraudulent claims, unnecessary surgeries, and ghost patients led to the loss of Ksh. 11 billion from Kenya’s new health fund in just six months.
The promise of the Social Health Authority (SHA) was to provide accessible and efficient healthcare for all Kenyans, moving away from the troubled National Hospital Insurance Fund (NHIF). However, recent revelations have exposed a deep rot within the system, with billions of shillings meant for the sick being siphoned off through a web of fraud and collusion .
In a startling admission before the National Assembly, Health Cabinet Secretary Aden Duale revealed that the country lost a staggering Ksh. 11 billion in just six months (October 2024 to April 2025) due to fraudulent and irregular claims . The loss was uncovered in an audit that exposed how some health facilities, accustomed to exploiting the old NHIF system, simply shifted their corrupt practices to SHA .
The Anatomy of a Heist
The methods used to fleece the system were brazen and varied, painting a picture of a scheme designed to exploit every loophole.
- Forced and Fake Surgeries: Perhaps the most disturbing trend was the dramatic increase in Caesarean section deliveries. Medically, only about 10-15% of births require a C-section. However, auditors found facilities claiming that 100% of their deliveries were through surgery—a clear attempt to pocket the extra Ksh. 20,000 paid for the procedure . In one extreme case, a facility in Tharaka Nithi that didn’t even have a functioning theatre still managed to submit 35 claims for C-sections .
- Patients Who Didn’t Exist: The creativity of the fraudsters seemed boundless. CS Duale presented the jaw-dropping case of a single patient in Kwale County who was fraudulently listed as having 381 dependent children . This was just one example of how ghost patients and phantom dependents were created to milk the system.
- Falsified Documentation: The audit uncovered a trail of forged paperwork. Claims were submitted with forms completely filled out by one person—same handwriting, same pen—which is an automatic red flag . Maternity claims were filed without birth notifications, and surgical procedures were billed without providing any theatre notes . All of these missing documents pointed to one thing: the services were never provided.
- The “Frequent Flyer” Patients: In the outpatient program, the new digital system flagged suspicious patterns where a single patient was recorded as visiting the same facility up to 10 times in a single day, a clear sign that facilities were creating fake patient visits to inflate the capitation payments they receive from the government .
A Crackdown Begins
In response to these alarming findings, the Ministry of Health has begun a crackdown on the perpetrators. So far, 22 doctors and 36 clinical officers have been deregistered from the SHA platform, stripping them of the authorization to treat patients under the scheme. Additionally, a staggering 1,118 health facilities have been shut down for their involvement in the fraud . Over 1,000 files have been handed over to the Directorate of Criminal Investigations (DCI) for further action .
CS Duale has vowed to continue the fight, stating, “We are determined to stop this culture of theft in healthcare. The money is for patients, not for cartels” . The scandal has left many Kenyans wondering just how deep the rot goes and whether the promised “waterproof” system was ever truly secure.