The Social Health Authority building in Nairobi.
The country may have lost Sh2.3 billion in the government-sponsored student health insurance scheme, EduAfya, after Auditor-General Nancy Gathungu flagged weaknesses in the disbursement and utilisation of premium amounts.
In a special audit presented before the National Assembly, Ms Gathungu identified cases of ineligible students benefiting from the scheme, as well as overpayment of premiums by the government to the now-defunct National Health Insurance Fund (NHIF), which was the insurer at the time.
The audit on capitation and infrastructure grants in public schools, covering the period between 2020 and 2024, points to the possibility of inflated premiums, non-existent beneficiaries and systemic failures.
These issues place the Ministry of Education and NHIF under scrutiny over the prudent use of public funds.
For instance, premiums payable during the review period stood at Sh14.2 billion compared to an actual remittance of Sh16.5 billion.
“The excess remittance between the premium payable and the remitted amount for the period under review was neither reconciled nor explained,” the special audit states.
The EduAfya scheme was established following a contract between the Ministry of Education and NHIF on March 1, 2018, to provide comprehensive medical cover for three million learners in public secondary schools.
The initial premium cost the government Sh3.39 billion for the period from March 1, 2018, to December 31, 2018, with an annual renewable premium set at Sh4 billion.
The cover included inpatient and outpatient services, an accidental death benefit of Sh500,000, and a last expense benefit of Sh100,000 per beneficiary, as stipulated in the contract.
Contract documents available to auditors indicate that the Ministry of Education had negotiated an annual premium of Sh1,350 per student.
The audit reveals that of the 9,312 secondary schools whose capitation was retained and remitted to the EduAfya program, only 8,846 had beneficiaries who accessed medical services.
Accessing medical services
Worse still, the government disbursed Sh16.4 billion to the underwriter even though the actual cost of healthcare services rendered to students was Sh5.3 billion—meaning the NHIF insurer retained Sh11.1 billion during the audit period.
According to the Auditor-General, the government did not receive value for the Sh16.4 billion it spent on premiums.
“The value for money on the amount disbursed to NHIF for the health services rendered could not be confirmed,” the audit notes.
Additionally, 465 secondary schools, which had a combined capitation of Sh273 million remitted to EduAfya, showed no evidence of students accessing medical services.
The report also highlights that the National Educational Management Information System (Nemis) recorded facility visits up to February 28, 2024, two months after the EduAfya scheme had officially ended on December 31, 2023.
During this period, 65 visits were recorded with services amounting to Sh35,550, raising questions over how and why services were offered post-scheme.
The audit also flagged ineligible users who accessed medical services despite the law limiting benefits to secondary school students.
Roughly 4,100 primary and junior secondary schools benefited from the scheme despite not appearing in the Nemis capitation data indicating the system was vulnerable to abuse.
A total of 15,468 ineligible beneficiaries accessed services costing the government Sh40.2 million.
The EduAfya scheme was launched as part of the National Education Sector Strategic Plan (2018–2022) under Policy Priority 2, aimed at reducing disparities in secondary education.
The contract between the Ministry of Education and NHIF defined an eligible student as “a secondary school student enrolled in a public secondary school within the country and whose name is stated in a list provided to NHIF by the Ministry of Education
