The Ministry of Health has suspended 40 health facilities nationwide for allegedly defrauding the Social Health Authority (SHA) through false claims.

Health Cabinet Secretary (CS) Aden Duale, addressing a press briefing at Afya House, Friday, said the crackdown seeks to protect public resources and restore confidence in Kenya’s reformed national health insurance scheme.

The suspensions, effective immediately, follow a month-long forensic audit and review of suspicious claims flagged by SHA’s digital health system.

“These activities undermine public trust in our health system and threaten the feasibility and sustainability of the Social Health Authority. We will not allow the theft that crippled the defunct NHIF, to infiltrate the new system,” CS Duale declared.

The facilities are accused of engaging in illegal practices that contravene the Social Health Insurance Act, 2023, and their contractual obligations with SHA.

Fraudulent schemes identified, include upcoding billing for costlier procedures than those performed. as illustrated, a Nairobi facility allegedly claimed Sh201,600 for a Transurethral Resection of Bladder Tumor (TURBT), when it had actually conducted an open prostatectomy worth Sh89,600, an overcharge exceeding Sh112,000.

In Bungoma, falsified records and altered patient information were reported, including claims for a patient who was admitted elsewhere at the same time.

Some hospitals in Nairobi and Homa Bay reportedly upgraded simple outpatient visits to inpatient admissions without patients’ knowledge thus inflating claims.

Additionally, four facilities in Mandera allegedly colluded to submit duplicate claims of the same patient, while others billed for “ghost patients” who never received services.

“These acts are not only unethical, but criminal, draining resources meant for all Kenyans and jeopardizing the scheme’s ability to settle genuine claims,” the CS stressed.

The list of suspended facilities appears in Kenya Gazette No. 168 of August 7, 2025, in line with SHA’s Transparency Policy.

During suspension, the facilities will not receive SHA payments and will be surcharged to recover funds already disbursed through fraudulent claims.

The Ministry will forward the names to the Directorate of Criminal Investigations (DCI) for prosecution.

SHA has also withdrawn system access for 12 healthcare professionals; eight doctors and four clinical officers linked to the fraud. They are based in facilities in Nairobi, Bungoma, Kilifi, and Homa Bay.

“We have notified the Kenya Medical Practitioners and Dentists Council and the Clinical Officers Council to initiate immediate disciplinary action, which may lead to cancellation of their licenses,” CS Duale stated.

SHA’s system requires a One-Time Password (OTP) from a registered healthcare professional to authorize procedures. CS Duale warned that providers whose credentials are used in fraud will be held personally liable.

He noted that OTP abuse, where patients share verification codes with providers, is a loophole exploited mainly in Level 2 and Level 3 facilities.

To counter this, SHA has introduced biometric verification in Level 4, 5, and 6 facilities and plans to extend it to lower-level facilities.

“Kenyans must protect their personal details; if your OTP is used to commit fraud, you will also be held liable,” the CS cautioned.

The Ministry is urging citizens to report suspected fraud via SHA’s toll free number 147.

CS Duale also warned public facilities against illegally charging patients for primary healthcare services.

Parliament has allocated Sh13 billion this Financial Year to cover outpatient care at Level 2, 3, and 4 hospitals through the Primary Healthcare Fund.

“The drugs, consultations, and lab tests at these facilities are fully paid for by the Government of Kenya; any co-payment is illegal,” he emphasized.

The crackdown is part of broader reforms under the Universal Health Coverage (UHC) agenda, aimed at ensuring affordable, quality healthcare for all Kenyans.

During Wednesday’s launch of the National Equipment Service Project, President William Ruto reiterated that SHA will not settle fraudulent claims and vowed to hold culpable facilities and professionals accountable.

CS Duale said the Ministry remains committed to settling genuine claims by the 14th of every month but stressed that clearing fraudulent ones first is critical for sustainability.

“We are building a solid, transparent, and accountable social health insurance scheme that will serve over 25 million registered Kenyans with dignity,” he said.

The CS warned that lobbying to reverse suspensions will be futile unless facilities fully comply with corrective actions issued by regulators.

“Those who benefited from NHIF loopholes should know that business as usual is over. Our systems and forensic auditors will catch you,” he added.

SHA’s digital monitoring system, integrating real-time data from facilities nationwide, has been credited with exposing the fraudulent activities. The current crackdown is the first phase, with more investigations underway.