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Nail all the culprits in new SHA fraud

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By  Editorial

The Social Health Insurance Fund (SHIF), which was reportedly devised as an answer to the fraud and glaring shortcomings that had characterised its predecessor, the National Health Insurance Fund (NHIF), is still stuck in the same rut.

This Sh104 billion healthcare system under the Social Health Authority (SHA) has failed to get out of the mess left behind by the NHIF, which for six decades was a cash cow for crooked officials and their associates. The ghosts that had bedevilled the NHIF have refused to go away.

Just months after the government launched the SHA, promising an efficient digital system, some 31 hospitals across the country stand accused of defrauding it. Health Cabinet Secretary Aden Duale has conceded that this is a huge blow to the government’s credibility. It raises fundamental questions about the country’s expensive healthcare reform.

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Some health facilities in 13 counties have been suspended as evidence emerges of a coordinated exploitation of the new system’s weaknesses. The scam involves double billing, fraudulent outpatient claims, and forced admissions. There is also an abuse of the pre-authorisation code, ghost patient admissions, and illegal sharing of patient codes by hospitals.

In one shocking case, hospitals billed SHA for five-day admissions when the patients had merely donated blood, which takes less than three hours. Before the SHA, the NHIF had lost Sh21 billion through a fraudulent process known as “Incurred But Not Reported”. Another Sh368 million was stolen through overpayments blamed on “typing errors”. These are some of the loopholes the SHA had been expected to seal.

It is, however, encouraging that the Kenya Medical Practitioners and Dentists Council has already suspended the licences of all the implicated facilities pending investigations.

CS Duale has vowed to initiate criminal prosecutions and recover the looted funds. The minister should not just talk about this. Kenyans, who struggle to access quality and affordable healthcare, which is a constitutional right, continue to suffer as the fraudsters thrive. They deserve a fraud-proof system.