NAIROBI, Kenya — The Ministry of Health and the Social Health Authority (SHA) have vowed tough legal action against individuals implicated in fraudulent schemes following a recent impersonation incident at Mbagathi Hospital.
Health Cabinet Secretary Aden Duale says the government has activated both legal and digital safeguards to prevent public funds from being siphoned through fraudulent claims.
Beneficiaries Face Prosecution
The Ministry warned that any SHA beneficiary found colluding in fraud will face severe legal consequences under the Social Health Insurance Act, 2023.
Under Section 48(1)(c) of the Act, fraudulently altering or providing false information is a criminal offence. Individuals involved are immediately handed over to the Directorate of Criminal Investigations (DCI) for prosecution.
Charges may include conspiracy to defraud under the Penal Code and, where applicable, asset recovery proceedings under the Proceeds of Crime and Anti-Money Laundering Act (POCAMLA).
“We are ensuring that the full force of the law is applied to both healthcare providers and beneficiaries facilitating these crimes,” Duale said.
Dear Ode Francis, @citizentvkenyaThank you for reaching out and for Citizen TV’s continued role in keeping the public informed. The Ministry of Health and the Social Health Authority (SHA) take matters of fraud with the utmost seriousness. Regarding the recent impersonation
Sh11 Billion in Suspicious Claims Flagged
While the impersonation case raised concern, the Ministry pointed to what it described as a major success in fraud prevention.
According to Duale, the new digital health system recently flagged and rejected suspicious claims worth approximately Sh11 billion before any funds were disbursed.
“This demonstrates that our digital infrastructure is working exactly as intended to protect public health resources,” the CS said.
New Measures to Seal Loopholes
The Ministry acknowledged that the Mbagathi case exposed weaknesses in older verification systems, particularly the One-Time Password (OTP) method.
To address this, several reforms have been rolled out:
Biometric Health Identification (BHI):
Fingerprint authentication has replaced the OTP system at Level 4, 5, and 6 facilities to ensure that only registered beneficiaries access services. The rollout to Level 2 and 3 facilities is ongoing.
Practice360 App:
Healthcare professionals must now use a geo-fenced application for pre-authorizations, preventing off-site approvals and unauthorized code-sharing.
AI-Driven Fraud Detection:
SHA has deployed an artificial intelligence system capable of detecting anomalous billing patterns — such as upcoding or irregular admissions — in real time. Suspicious claims are automatically blocked for forensic review.
Facility Suspensions and Sanctions:
Dozens of non-compliant facilities have already been suspended, and implicated medical personnel have had their SHA access rights withdrawn. Their files have been forwarded to the DCI.
Protecting Public Health Funds
Duale reiterated that safeguarding public health resources remains a top priority, especially under the new social health insurance framework.
“The Ministry remains committed to protecting public health funds and ensuring that every shilling serves its intended purpose of providing quality healthcare to Kenyans,” he said.
The crackdown signals heightened scrutiny of both providers and beneficiaries as the government moves to tighten oversight within the country’s reformed health insurance system.
