By Peter John
Proprietors and directors of at least 30 health facilities could soon face prosecution over fraud-related offences, pending approval from the Office of the Director of Public Prosecutions (ODPP).
According to a report by the Directorate of Criminal Investigations (DCI) dated April 2, investigations into fraudulent claims submitted to the Social Health Authority (SHA) have established that the facilities have a case to answer.
The report outlines the status of 260 fraud complaints lodged by SHA. Out of these, 30 case files have already been forwarded to the ODPP for review and possible prosecution.
Already, 68 suspects and facilities have been charged and are facing ongoing court proceedings.
Additionally, charges against 19 other suspects have been approved, while some individuals have obtained conservatory orders or opted for alternative dispute resolution mechanisms, including refunding irregular payments made by SHA.
Among those currently facing charges are former National Hospital Insurance Fund (NHIF) Chief Executive Officer Elijah Wachira and former acting SHA CEO Robert Ingasira. The two are accused of fraudulent claims linked to the authority.
They were charged alongside two directors of Archprime Medical Clinic over allegations of falsifying medical records and handling proceeds of crime amounting to KSh17.5 million.
In a separate case, an ICT officer at the Kenya Medical Practitioners and Dentists Council (KMPDC), Harun Liluma, has also been charged.
He is accused of facilitating the fraudulent registration of eight medical facilities and receiving unlawful payments from SHA.
According to investigators, Liluma worked with 15 directors of the eight facilities to fraudulently obtain KSh30.7 million from the authority.
The facilities include Danaba Care Hospital, Kamsihawa Medical Centre, Kaafi Nursing Home, Mama Nerbeel Nursing Home, Alati Nursing Home, Julun Nursing Home, Adfaal Kids Care Medical Centre, and Dimtu Nursing Home Limited, all based in Mandera County.
These are among 19 facilities whose prosecution has already been approved by the ODPP.
The DCI report identifies Mandera as one of the counties most affected by fraudulent claims, with 51 facilities flagged and subsequently suspended.
Investigations revealed multiple fraudulent schemes, including falsification of medical records, conversion of outpatient claims into inpatient claims to inflate payments, use of forged documents to demand additional funds, and submission of claims by non-existent facilities.
Some facilities were also found to have received payments despite lacking signed contracts with SHA or operating using fraudulently acquired licenses.
Despite the scale of the fraud, Health Cabinet Secretary Aden Duale maintained that no public funds have been lost under the SHA system. He noted that the authority has successfully rejected over KSh12.7 billion in fraudulent claims.
Duale attributed the reduction in fraud to the implementation of a robust digital system that tracks patients, healthcare providers, and facilities across the country.
He said the system has reduced fraudulent claims from 36 percent to about 6 percent since he assumed office.
The Cabinet Secretary warned healthcare providers, workers, and patients against engaging in fraudulent activities, stating that the government will take firm action to safeguard public funds and ensure the success of Universal Health Coverage.
