SHA suspends 45 health facilities in fraud crackdown

The Social Health Authority (SHA) has suspended 45 health facilities across 17 counties in a move aimed at curbing fraudulent billing in the health sector.

The affected facilities will not access any benefits under the Social Health Insurance Act, 2023, during the period of suspension.

In a gazette notice dated August 26, 2025, SHA Chief Executive Officer Mercy Mwangangi said the action was taken in exercise of powers under Section 48 (6) of the Act.

“In exercise of the powers conferred by section 48 (6) of the Social Health Insurance Act, 2023, the Social Health Authority hereby gives notice to the public of the suspension of the health facilities set out in the schedule below. In accordance with the provisions of the Social Health Insurance Act, the health facilities set out in the schedule shall not be entitled to any benefit from the Social Health Authority during the period of their suspension,” Mwangangi said.

Mandera leads with nine facilities on the suspension list, followed by Homa Bay with five and Kisii with four. Other counties affected include Kisumu, Kakamega, Garissa, Bungoma, Meru, Kirinyaga, Narok, Turkana, Busia, Nandi, Kajiado, Migori, Uasin Gishu and Nairobi.

Among those named are Aasif Medical and Health Service Limited in Mandera, Abakore Nursing Home in Wajir, Abala Healthcare in Kisumu, Akemo Valley Maternity and Nursing Home in Narok, and Alasland Hospital in Turkana.

Also listed are Al-Baitul Tiiba Hospital in Garissa, Artan Medical Centre in Wajir, Aspro Medecol Solutions in Kakamega, Ayale Medicare and Nursing Home in Mandera, and Chala Health Services in Homa Bay.

Other facilities include Chemwaa Health Centre in Bungoma, Dawafront Pharmacy and Clinic in Kisumu, Desertview Healthcare Services in Mandera, Equity Afia branches in Homa Bay and Mandera, and Filyne Chima Hospital in Kisii.

Garissa Doctors Clinic, Gopima Medical Centre in Kisii, Grassroot Community Healthcare in Bungoma and Guardian Hospital in Meru also feature in the list.

The crackdown follows forensic audits that exposed elaborate schemes in hospitals.

Health Cabinet Secretary Aden Duale said investigations revealed unsupported maternity claims, fabricated clinical records, suspicious admissions of hospital staff as patients, and cases where individuals were simultaneously listed as being treated in different hospitals.

He said malpractice has also been detected in upcoding, falsifying records, converting outpatient visits into inpatient claims, and billing for non-existent patients.

“These actions contravene Section 48(5) of the Social Health Insurance Act, 2023, which prescribes penalties for providers who knowingly alter or falsify information to defraud the Authority,” Duale said.

The minister explained that the crackdown is supported by a new digital system designed to flag fraud attempts at every stage of the claims process.

“The primary function of our digital system is to detect fraud. We have seen that facilities are looking for innovative ways to cheat the system, but our digital architecture is designed to detect and flag anomalies at every stage of the claims process. Hence, you will find that fraud can be detected and stopped at any point, including at the payment stage,” he said.

Duale disclosed that claims worth Sh5.1 billion submitted to SHA are under review and surveillance.

Since the rollout of TaifaCare last October, SHA has received claims amounting to Sh91.7 billion under the Primary Health Care (PHC) and Social Health Insurance Fund (SHIF) schemes. Out of this, Sh60.7 billion has been disbursed, while Sh6.4 billion is awaiting release.

However, not all claims passed scrutiny.

“Claims worth Sh3 billion are being re-evaluated due to missing documents, while an additional Sh2.1 billion is under surveillance for further investigation,” he said.

He added that his ministry had outrightly rejected claims worth Sh10.6 billion over fraudulent practices, including upcoding, falsified medical records, conversion of outpatient visits into inpatient cases, and phantom billing.

SHA records show that out of Sh9 billion submitted in PHC claims, Sh7.7 billion has been paid. Hospitals also filed Sh82.7 billion under SHIF, with Sh53 billion released and Sh7.6 billion for August still under review.

The suspensions, according to the gazette notice, took effect on August 26, 2025, and will remain in force for the period provided by law.