Health Cabinet Secretary Aden Duale has mounted a spirited defense of the Social Health Authority (SHA), revealing that enhanced monitoring systems have intercepted fraudulent health insurance claims worth Sh11.6 billion.
Speaking during a Wednesday interview with a local station, Duale argued that the new authority’s effectiveness is being overshadowed by sensational media coverage that focuses on teething problems rather than concrete achievements in protecting public funds.
“Screaming headlines sell; if you say SHA is working, it will not sell, but screaming headlines will get out of the shell,” the CS said, adding that the detection and rejection of billions in questionable claims demonstrates the system is functioning as designed.
According to Duale, the bulk of the rejected claims emerged during the critical transition phase from the National Hospital Insurance Fund (NHIF) to SHA—a period that demanded heightened vigilance and robust verification mechanisms.
The CS disclosed that most flagged claims originated from health facilities and were subjected to rigorous multi-stage scrutiny before being declined.
“Facilities made claims amounting to about Sh11 billion. Most of these were fraudulent claims. The system picked them up, went through different validation and clinical reviews, and we are not paying,” Duale explained.
He emphasized that each claim undergoes automated validation, clinical reviews, and additional system checks to ensure compliance with established standards before any payment is authorized.
The Health CS issued a stern warning to facilities attempting to exploit the health insurance system, stressing that every shilling contributed by Kenyans is now under strict surveillance.
“Every coin that a Kenyan has paid for health care insurance, if it is stolen, the system will detect it, flag it, and the government will prosecute,” Duale stated firmly.
On Sunday, the CS had outlined the rigorous due diligence processes now mandatory for all claims, including forensic audits and clinical reviews to verify that billed services were actually delivered to patients.
“We will only pay after we do due diligence. SHA will conduct forensic audits and clinical reviews to make sure that the services offered are appropriate and that the Kenyan patient has actually received them,” he said.
While Duale celebrates the fraud detection success, some hospitals have raised concerns about delayed payments, arguing that the enhanced scrutiny is affecting their cash flow and operations.
The CS, however, maintained that facilities complaining loudest are primarily those whose claims remain under verification due to red flags raised during the review process.
He insisted the government is operating within legal parameters and that the thorough vetting is essential to safeguarding the integrity of Kenya’s health insurance system and protecting contributors’ funds from exploitation.
Duale’s remarks signal the government’s determination to ensure SHA operates with greater accountability than its predecessor, even as stakeholders navigate the challenges of implementing sweeping health sector reforms.
