CS or sleuth? Duale hands SHA fraud files to DCI amid uproar

Despite the Ministry of Health admitting to fraud at the newly established Social Health Authority (SHA), senior officials implicated in the scandal appear shielded, with no action taken against them.

The sluggish response is testing President William Ruto’s vow to ensure swift arrests and recover the stolen billions.

In a dramatic turn yesterday, Health Cabinet Secretary Aden Duale handed the matter to the Directorate of Criminal Investigations (DCI), distancing himself from the scandal.

Addressing journalists at Afya House, Duale declined to give details, arguing it would jeopardise investigations. He instead directed the media and public to seek answers from the DCI.

“This press conference is unique because the Inspector General, his deputy, and the DCI are here. I have handed the files to them. They no longer belong to the Ministry of Health or SHA, but to the leadership of the National Police Service. If anybody has questions, kindly direct them to the DCI on Kiambu Road. I promised to hand over the files, and I have,” he said yesterday.

Health experts

Duale’s move has, however, drawn criticism from health experts and providers, who argue that he sidestepped responsibility by failing to outline the scope of the fraud, despite repeatedly declaring a fight against graft in the sector.

They note that while the CS insists taxpayers’ money has been stolen, he has yet to quantify the losses.

The SHA replaced the scandal-ridden National Health Insurance Fund (NHIF) in October last year, with a promise of efficiency and transparency.

Last week, the Health ministry revealed that insurance claims worth Sh10.6 billion had been revoked, with an additional Sh13.3 billion still under scrutiny — meaning taxpayers could lose up to Sh24 billion in a scheme created to cure corruption witnessed at the defunct NHIF.

“Now that Duale has said he is fighting fraud at SHA, he should tell us how much we have lost as a country. He should also tell us what specifics he is addressing and mention specific hospitals and individuals behind the fraud,” said Rural and Urban Private Hospitals Association of Kenya (Rupha) chairperson Brian Lishenga.

He added: “What exactly is Duale fighting, how much have we lost, is it not public relations gymnastics.”

During the press conference, Duale said SHA and the Kenya Medical Practitioners and Dentists Council (KMPDC) submitted a total of 1,188 files and supporting evidence to the DCI.

According to Duale, submission of the files is a major step in the fight against healthcare fraud. Additionally, SHA has suspended 85 health facilities for fraudulent activities to allow for investigations.

The rigorous forensic audits and digital system have uncovered deeply troubling patterns of fraud that directly harm the public and deplete the monies meant for patients.

The fraudulent practises according to the CS include upcoding, where some hospitals bill for more expensive procedures than what was actually performed.

Other fraudulent practises were falsification of records conversion of outpatient to inpatient, and hospitals billing for non-existent patients.

Some 24 hospitals have had their cases concluded, 61 facilities cases are ongoing whereas 105 facilities have been closed by KMPDC and had contracts with SHA.

Duale said the submissions are a critical step in a multi-agency collaboration that allow the DCl investigate and prosecute those responsible.

But he did not give finer details on the hospitals involved, and individuals implicated in the graft.

In a quick rejoinder, Lishenga said handing over investigations is meant to mute Kenyans questioning the efficiency of the new health scheme expected to provide quality care.

Fraud at SHA was unearthed by Kenyans, with criticism going viral on social media.

Some ghost hospitals were identified despite receiving millions of money, whereas some were in deplorable state yet they received pay from SHA.

“The CS is the complainant here, so it is important for him to let the public know, what is the nature of the dispute. He doesn’t have to go into the finer details of each individual case, but at least he should have been able, because this is a matter of public interest,” said Lishenga.

Being an oversight body, SHA chairperson, according to Lishenga should make pronouncements and not Duale.

Yesterday’s pronouncements by Duale did not touch on officials from SHA and KMPDC, this is despite the SHA system, including Sh104 billion digital superhighway manned by SHA.

“Even as they forward files to DCI, we call upon the same DCI to open investigations into KMPDC conduct, and also into DCI conduct,” said Lishenga.

He added: “SHA employees especially those who approved contracts of ghost facilities should be investigated, and KMPDC employees also who licensed and registered those facilities should be investigated.” 

The Kenya Healthcare Federation (KHF) has also objected to move, saying it is a not a solution to graft at SHA, unless the Authority’s system is worked on.

Gone back

SHA structures, according to KHF Chief Executive Officer Tim Theuri has a dispute resolution mechanism to fight graft, unlike NHIF that acted as a judge and jury in execution of payments.

“It seems we have gone back where there is no recourse. When SHA wrongs us, do we take them to DCI?,” posed Dr Theuri.

With DCI, he regretted that individuals entangled in fraud will easily go to court to stop arrests and investigations, resulting into continuous stealing of taxpayers’ money.

“The CS needs to be methodical in what he is doing. Individuals involved in fraud might rush to court, and money will continue to be stolen,” said Theuri adding that action should also be taken against SHA officials and KMPDC as corruption is not a one way street.

Duale noted that in accordance with Section 48(5)of the Social Health Insurance Act,2023, penalties for health facilities who knowingly or fraudulently alter information to defraud the Authority include a fine of up to Sh2 million, suspension, and removal from the register of empanelled providers.

On his part Lishenga questioned on whether audit was done internally by the SHA, and reports shared to concerned hospitals. 

But Duale did not make it clear on whether an internal audit was done

mkahenda@standardmedia.co.ke.

Rupha maintained that it welcomes the fight against medical fraud and against ghost hospitals, but said transparency around the 1,188 files handed over to DCI must prevail.

Last week, Cotu Secretary General Francis Atwoli claimed SHA board has been reduced to an observer, poking it of not playing its oversight role.

“In other words, we need to know how much he is seeking to recover, we also need to know if due process is being followed. Have internal mechanism at SHA and KMPDC been fully exhausted, if they have been exhausted, have those reports been made available to the affected facilities,” posed Lishenga.

He noted that when a matter is not of a criminal in nature, rushing the issue to DCI is not a way to handle challenges facing healthcare.

If the matter is to do with professional conduct, those matters should be within KMPDC and SHA, whereas if it is a matter to do with contract, the minister should allow the SHA Board.

Being an oversight body, SHA chairperson, according to Lishenga should make pronouncement and not Duale.

Yesterday’s pronouncements by Duale did not touch on officials from any of the entities, this is despite the SHA system, including Sh104 billion digital superhighway manned by SHA.

Rupha took issue with failure to have individuals at SHA, KMPDC and ministry take responsibility for the graft.

“Even as they forward files to DCI, we call upon the same DCI to open investigations into KMPDC conduct, and also into DCI conduct,” said Lishenga.

He added: “SHA employees especially those who approved contracts of ghost facilities should be investigated, and KMPDC employees also who licensed and registered those facilities should be investigated.” 

About a year later after its establishment, SHA is yet to activate its dispute tribunal, that is supposed to handle complaints and fraud.