The Social Health Authority (SHA) has recovered nearly Sh300 million linked to fraudulent claims and taken 15 cases to court as the health insurer processes billions of shillings in claims amid a rapid expansion of enrolment and healthcare financing across the country.
SHA chief executive officer Dr Mercy Mwangangi said the authority had recovered Sh200 million from healthcare providers, while cases involving Sh28 million had been referred to the Director of Public Prosecutions as investigations into fraudulent claims continue.
“We have Sh 300 million recovered from fraud, and we are still recovering,” Dr Mwangangi said on Tuesday during a media town hall in Nairobi.
She said the authority was pursuing cases through internal investigations, administrative action and the courts, with the process expected to continue as SHA expands its operations.
The recovery comes as the Social Health Insurance Fund handles an increasing volume of money and claims following the transition from the National Health Insurance Fund to the new health financing system.
Mwangangi said SHA had collected Sh203.7 billion across its four funds and paid out Sh178.4 billion.
Separately, SHIF disbursed Sh65.42 billion between July 2025 and April 2026 across 4,718 facility payment records covering all 47 counties. SHA also disbursed Sh21.36 billion to counties in the 2025/2026 financial year, up from Sh12.7 billion the previous year, representing an increase of nearly 70 per cent.
The increase in payments has come alongside a rise in enrolment, with the number of Kenyans registered under the scheme increasing to 30.1 million from 18 million, according to figures presented by the Council of Governors. The expansion has placed greater attention on the systems used to process claims, pay healthcare providers and detect fraudulent activity, particularly as more facilities and patients come into the system.
Mwangangi said fraud remained a challenge not only for Kenya but also for health insurance systems globally, with fraudulent claims involving healthcare providers, officials and members of the public.
She cited a case reported by a private healthcare facility involving a civil servant who allegedly used her SHA card to have her sister admitted for treatment.
“We have one private facility telling me that a lady who is a civil servant brought her sister and admitted her using her card, and the sister had to run at night,” she said.
The authority has increasingly turned to digitisation as part of its efforts to manage claims and strengthen controls. Mwangangi said SHA had moved to a fully digital claims system and no longer relied on manual claims documents.
“Right now all our claims are digital. We do not have manual documents, and that is an improvement,” she said.
The digital system is expected to provide SHA with electronic records of claims and transactions that can be analysed to identify unusual activity and patterns associated with fraudulent claims.
Mwangangi said Kenya could learn from countries such as the United States, where specialised units investigate medical insurance fraud.
“We need to go and look at the FBI special unit for medical fraud, just like America,” she said.
The fraud cases come as SHA finances an expanding range of medical services. Between July 2025 and April 2026, SHIF financed 1,080,052 safe deliveries, 949,608 inpatient admissions and 220,097 surgical procedures.
The payments included 19,444 critical care admissions and 7,000 mental health admissions. The Fund is also financing treatment for 43,661 cancer patients, while about 14,800 patients have accessed dialysis services.
Government has increased oncology cover from Sh550,000 to Sh800,000, while an overseas treatment benefit capped at Sh500,000 per eligible patient has also been reintroduced.
Private healthcare facilities accounted for 49 per cent of SHIF payments during the period, compared with 31 per cent for government facilities and 20 per cent for faith-based providers.
Mwangangi also acknowledged that county healthcare providers were owed about Sh4 billion, although she said some of the claims classified as outstanding were rejected or returned submissions rather than genuine arrears.
The issue of payments to providers formed part of the wider questions raised during the media town hall, where officials from the Ministry of Health, SHA, the Council of Governors and other health agencies responded to questions from journalists.
The town hall, themed Ask your government anything on healthcare, was held ahead of the inaugural Kenya Health Summit scheduled for August 18 and 19 at the Kenyatta International Convention Centre in Nairobi.
It brought together Health Cabinet Secretary Aden Duale, principal secretaries, heads of state health agencies, county government representatives and journalists and editors from across the country.
Principal Secretary for Medical Services Dr Ouma Oluga described the engagement as a checkpoint for universal health coverage and urged journalists to compare government figures with the situation experienced by patients and health workers in health facilities.
Duale said the national government had allocated Sh138.1 billion to health in the 2026/27 financial year, an 8.7 per cent increase from the previous allocation.
Counties have allocated another Sh154.6 billion, bringing combined national and county allocations to nearly Sh293 billion.
The government also reported the recruitment of more than 17,800 community health promoters and the establishment of 277 primary healthcare networks.
The National Ambulance Dispatch Centre and toll-free 922 emergency line were launched on August 5 as part of efforts to strengthen emergency response.
The figures form part of a wider expansion of Kenya’s health system since devolution.
Council of Governors chief executive officer Mary Mwiti said the health workforce had grown from about 90,000 before devolution to nearly 200,000, while the number of health facilities had increased from about 9,000 to more than 15,000.
She also addressed ongoing health worker disputes, saying a collective bargaining agreement had been signed for clinical officers, with a return-to-work formula awaiting concurrence from the Salaries and Remuneration Commission.
The government also reported progress in specialised healthcare equipment.
Dr Oluga defended the National Equipment Service Programme, saying counties had gained access to CT scanners, MRI machines, dialysis units and modern theatres through a fee-for-service arrangement.
The programme is intended to allow patients to access specialised treatment closer to their homes rather than travelling to major referral hospitals.
Questions about the availability of medicines were also raised during the town hall. Kenya Medical Supplies Authority chief executive officer Dr Waqo Dulacha Ejersa said KEMSA had reduced its stock-keeping units from 3,800 to 485 essential items and achieved fill rates of more than 90 per cent.
He said KEMSA operates a pull system under which counties place orders according to their needs, adding that shortages reported at individual facilities should be distinguished from the availability of medicines within KEMSA.
Disease preparedness was another issue discussed during the meeting. Director General for Health Dr Patrick Amoth said 183 Ebola alerts had been investigated and tested negative as Kenya continues to monitor the outbreak in the Democratic Republic of Congo.
For the Ministry of Health, however, communication with the public and media remains another challenge. Duale promised to establish a media communication centre at the ministry to improve journalists’ access to health data and officials following concerns raised during the town hall about difficulties accessing information.