State caps payment as three million fictitious patients removed from SHA
Health Cabinet Secretary Aden Duale.
Hospitals will no longer receive unlimited reimbursements from the Social Health Authority (SHA), with payments now capped at their licensed bed capacity in reforms aimed at ending fraud and patient crowding.
Health Cabinet Secretary, Aden Duale, announced the policy shift during a two-day National Assembly Health Committee retreat in Mombasa, saying the era of hospitals cramming people on one bed and claiming full reimbursement for the patients has come to an end.
“Up to four patients share a bed in many hospitals, yet the hospital charges SHA for the number of patients,” Mr Duale told healthcare stakeholders, including the Council of Governors and ministry officials, on Wednesday.
“The dignity of patients is important. That is why we will restore dignity in public hospitals.
Under the new system, hospitals that want to treat more patients must first procure additional beds and expand their infrastructure.
Sharing beds will be classified as insurance fraud, with hospitals facing consequences for doing that.
The minister painted a stark picture of the widespread abuse, describing scenarios of hospitals routinely over-admitting patients and creating conditions where strangers are made to share beds or sleep on the floor while the health institutions claim maximum reimbursements.
“Admit up to the bed capacity only. If you want to admit more patients, add more beds to your hospital,” Mr Duale stressed.
He said such practices would not continue as long as he is the head of the ministry.
Fictitious patients
The policy change comes as the government says at least three million fictitious patients have been eliminated from the country’s healthcare system, marking what Mr Duale described as “a milestone in the reforms under SHA and Taifa Care framework”.
The minister disclosed alarming levels of fraud across all hospitals – from private, faith-based to public.
“The fraud is alarming. Some outpatient cases are falsely upgraded to inpatient status,” he stated, adding that SHA investigations have uncovered claims where one patient is recorded in multiple hospitals on the same day.
“Some private hospitals claim to perform more surgeries than Kenyatta National. The data is shocking.”
SHA’s integrated digital platform has not only curbed fraud but also ushered in a paperless, biometric-based system that is revolutionising health services across the country, the Cabinet Secretary added.
He said the government has introduced biometric devices in hospitals, with a nationwide rollout expected by August 2, eliminating the need for patients to carry physical files.
So far, some 24.4 million Kenyans have registered for Taifa Care, with 5.8 million already undergoing evaluation to determine eligibility for subsidised care, he added.
Under the ongoing reforms, some 4.3 million people are accessing free primary healthcare, supported by a network of 9,655 hospitals, including 5,219 public and 496 faith-based institutions, Mr Duale told the retreat.
In a move aimed at maintaining standards, the government has downgraded or closed 497 health institutions found to be non-compliant, with the minister warning that more closures could follow in the coming days in an effort to end fraud.
“It is better to have 20 hospitals that meet the standards than 100 that defraud Kenyans,” Mr Duale said.
The new policy is a significant shift from the current fee-for-service model that has incentivised hospitals to maximise patient numbers regardless of available beds and other infrastructure.
“This will not happen under my watch as the Health Cabinet Secretary. People are taking money but do not want to pay for beds,” Mr Duale stated, indicating the hardline stance taken by the government against hospitals engaged in fraudulent billing.
On financing, the minister said the SHA – which is chaired by Dr Mercy Mwangangi – has committed to reimbursing genuine claims by the 14th of every month, providing certainty to healthcare providers operating within the new framework.
Seme MP James Nyikal, who chaired the retreat, emphasised the need to strengthen financing, human resources and quality assurance to ensure Universal Health Coverage (UHC) becomes a reality.
He acknowledged the challenges in transitioning UHC employees to devolved governments and called for urgent resolution, whilst urging faith-based, private and public health providers to align their operations with the new national standards.
Tharaka Nithi Governor Muthomi Njuki said 95 per cent of hospitals are managed by counties, with more than 100,000 community health promoters deployed countrywide.
These efforts have enabled visits to more than six million households and contributed to a decline in maternal and neonatal deaths, Governor Njuki told the meeting.
“UHC is about ensuring a woman receives maternity care without worrying about the cost. We are enhancing digital systems, onboarding counties into the Facility Improvement Fund and working to resolve staffing and supply delays,” the Council of Governors Health Committee Chairman said.
He added that under SHA, some 78 per cent of hospitals have been empanelled, and called for transparent processes and timely disbursement of money to sustain services.
The Ministry of Health said it is prioritising reforms at the Kenya Medical Supplies Authority to restore trust in the supply chain, whilst also monitoring the defunct National Health Insurance Fund pending bills, some of which are under litigation.
