NHIF heist: How rogue health facilities preyed on elderly to mint millions
The National Health Insurance Fund building in Nairobi.
Eight months ago, sleepy villages in Meru County received wolves in sheep’s clothing.
Using the name of the National Health Insurance Fund (NHIF), men and women disguised as healthcare providers preached false hope to the villagers, promising to rescue them from the depths of arthritis complications.
All they had to do was dress up, carry their NHIF cards and travel free of charge to certain health facilities in Nairobi County where they would receive free medical services.
Months have passed since then, leaving residents of the rural county in anguish and tears, recounting the resultant disabilities and even deaths.
Mr Mwebia M’miriti, now a widower, recalls how his village was mobilised to attend a free arthritis medical camp at Nkubu Stadium in October 2022.
Produce cards
Visitors were asked to produce their NHIF cards, and those with other medical cards were turned away. They were then asked to explain their symptoms before being advised to get x-rays.
Mr Mwebia was told to find a medical facility to have his back x-rayed and then share the results. He ignored the call.
His wife, however, was advised to visit a private medical facility in Chuka for the same purpose, and a vehicle was provided to transport her and others free of charge. Back at the camp, she was told she needed an operation.
She would later that evening travel to Nairobi, free of charge, in a vehicle provided by camp officials.
Mr Mwebia says his wife had been in good health, although she occasionally complained of discomfort in her lower limbs, but she never felt the need to see a doctor and only used a pain balm.
“She only came to the camp because it was close to her home and was free,” he says.
The next day, after the operation, Mr Mwebia spoke to his wife on the phone and she revealed that she was at St Peter’s Orthopaedic Hospital in Kiambu County.
She said she was tired and he left her to rest.
It was the last time they spoke.
While she was still at the hospital, Mr Mwebia received a text message informing him that Sh300,000 had been paid using his card.
But he is unsure whether the full amount was deducted for his wife's treatment, who died soon thereafter, alone and far from home.
The hospital in Kinoo, Kiambu County, offered to transport the body to Nkubu mortuary, where they also paid for all the mortuary services. She was buried days later without a post-mortem examination being conducted.
Dr Jerry Wasena, an orthopaedic surgeon and the proprietor of the St Peter’s Hospital told Nation that the patient required surgical intervention, as they felt that she had grade three osteoarthritis.
“We have a programme in which we get patients from Chuka because we don’t have a surgical facility in Meru. Here we did everything to ascertain the surgery was necessary — a blood test, checked kidney function, and we felt the patient would benefit from surgery. We did a successful surgery, unfortunately on day two when the patient started to walk, she felt certain difficulty in breathing and died within a very short period. We tried to resuscitate her and even took her to ICU. Our biggest problem with invasive surgery is what we call dvt (deep vein thrombosis) or a clot, our worry is that this clot can go from the leg to the heart and this is what killed the patient,” he says.
While Dr Wasena says that the patient was brought to their facility, Mr Mwebia’s account is different, who said his late wife was picked at a medical camp.
“We have our own van that on a regular basis gets patients from there (Chuka) to here. We have a programme where we go do outreach and bring patients from wherever to here,” he says, admitting: “Honestly, I didn’t know that you need authorisation from the medical council to conduct a medical camp.”
Mr Douglas Kiraithe, Mr Mwebia’s fellow villager, recalls being summoned to Ntharane market by one Winfred Kathure, who claimed to be a specialist in treating arthritis, a condition that causes inflammation and stiffness of the joints.
She (Winfred) convinced them that the hospital had been officially opened by President William Ruto and that once treated, the condition would not return.
“There were more than 100 of us and we were very happy with the news. They said NHIF would cover the costs and that those without the cards would not be able to get treatment,” Mr Kiraithe explains.
“On the same day, seven of us went to Jekim Hospital for x-rays. On the way back in their car, one of the officials looking at the X-rays, said I would have an operation, while others would be given tablets. Two days later, 16 of us were picked up in the evening in a Nissan matatu. We arrived in Nairobi at 11pm, with a driver who did not know where we were going,” he adds.
Eventually, six people were dropped off at various facilities and the remaining 10, including Mr Kiraithe, were driven to Joy Nursing and Maternity Hospital, where they were registered and told to wait.
Given an injection
“The women among us were taken to rest, and we (two men) were told that there was no place for us to rest, so we had to sit in the waiting area. We did not know where the women were being taken. Eventually, I was given an injection in my right thigh and 30 tablets to take once a day for 30 days. That evening, I received a text message saying that I had been discharged and that NHIF had paid Sh130,000,” he explains.
In a claim, the hospital said it had performed an open reduction and internal fixation surgery on Mr Kiraithe and some of the other patients, each of which was billed at the same price. The surgery is performed to stabilise and heal a broken bone and, according to Hopkins Medicine, a patient may need the procedure to treat a broken femur.
“I heard I had an operation, can these people show me where they operated? This woman (Winfred) showed up when I started talking to journalists and told me 'wacha kuharibu jina ya hospitali, hii mambo nitakupeleka ulipwe (stop spoiling the hospital’s name. I will have you treated without a hustle)'," he explains.
But Ms Grace Karuma, from Kithare village, is more pained.
Her mother, Mrs Kainda M’Arithi, was maimed. The news of the camp, Karuma says, came from her district assembly member, who urged her to visit Gatune Primary School.
Her 80-year-old mother slowly and painfully climbed a hill to get to the school, hoping to enjoy pain-free movement for the rest of her days. She and others were rounded up the next day after the camp and taken to Jekim Hospital for x-rays.
Mrs Kainda was told that her leg had an infection, that it was full of pus and that she would have to go to Nairobi for treatment. Three days later, she was transported to the capital along with other villagers.
“I called my niece in Nairobi and told her that her grandmother was coming for treatment. After three days of no progress, I called my cousins in Nairobi and asked them to find her and stop the operation, but they were told they would have to pay some money,” Ms Karuma explains.
“The day after the operation, my mother and others were dropped off at Nkubu at 2am, all of them unable to walk. I hired a taxi to take my mother home and then took the others to their families. At home, we carried my mother around and took care of her, almost putting her in nappies," she says.
Ms Harriet Miraitho and Ms Agusta Gatwiri, Mrs Kainda’s village mates, share the same story and anger at Joy Nursing Hospital for taking away their God-given ability to walk.
For Ms Miraitho, however, it is compounded by the fact that Mr Kiraithe’s warning and concerns from various quarters in the village have not been heeded.
Between October 26 and 27, the two women, along with 12 others, were given the same injection, similar tablets (Diclofenac and Osteocare) and told to wait for six months.
“I was told I had a small bone fracture and given two injections, one in each thigh. The next morning I woke up fine, but on the way home my legs started to hurt. I had a shower on arrival and the pain moved down my hip. I was taken to the hospital and stayed there for two weeks, unable to walk. When I was finally discharged, I could not lift myself,” says Ms Gatwiri, adding that NHIF sent her a letter saying it had paid Sh130,000 for her medical care.
Ms Miraitho was not so lucky, her two injections have since left her bedridden and maimed. At the time of the interview, her family was planning a fund-raiser to help her get better care.
Joy Nursing Home on Juja Road in Eastleigh, Nairobi, would be the place where Ms Gatwiri and Ms Miraitho received their treatment, the same facility that had treated Mr Kiraithe weeks earlier.
With just injections and less than 24 hours after arriving at the hospital, the NHIF paid Sh130,000 for Ms Gatwiri.
Unable to walk
Ms Miraitho, however, says she was treated without an NHIF card, raising suspicions that her bills may have been charged to someone else’s card. Now unable to walk, she looks at her old photos with nostalgia.
“I didn’t pay a single coin. They told me the NHIF card didn't work, and when I asked them when NHIF would settle the bill, they kept silent. To date, I have never received a message telling me to pay. If we had known that was going to happen, we wouldn’t have gone. I thought people were just politicising the initiative. We were informed that President Ruto had donated money to treat people and urged to share with friends so that we all benefit,” she said.
Dr Samson Kuhora, the NHIF acting chief executive officer, says impersonation is one of their biggest challenges.
“On this case, it is possible that someone else’s card was used,” he said.
According to Mr Salesio Mutuma, who blew the whistle on the matter, his petition to the Meru County Assembly and an email to NHIF to investigate were never acknowledged or responded to.
“The rogue medics target elderly women and men with leg or knee problems. After this lady identifies them deep in the villages, she enquires if they are NHIF members and if their cards are up to date. If the patients meet these criteria, she convinces them that they need medical help. These people are called to a chief’s camp, so if you’re called to a chief’s camp for such a meeting, you know that the government knows about it, then they say the programme is being run by the president. So it is very easy to be taken in,” Mr Mutuma says.
Dr Joseph Wahome, Meru County Chief Officer of Health Services, says he has received complaints from people conducting medical camps in the county and that they are currently investigating the complications involved.
He added that no one had sought permission from the county government to run the camps.
At one medical camp that the Nation attended in Subuiga, the people running the camp claimed to represent Afya Bora Hospital. But the hospital denied conducting any medical camps or recruitment drives in the district. They also denied defrauding NHIF.
St Peter’s Orthopaedic Hospital claimed that Mr Mwebia’s wife had stage three osteoarthritis (arthritis of the knee), had successful surgery and recovery, but died from a blood clot.
According to Illinois Bone and Joint Institute, this stage of arthritis should be treated with injections into the knee joint over three to five weeks. Surgery is only needed at stage four, the most severe.
Dr Kuhora told Nation there are several cases where the date of birth recorded in the system is different from what is in the claim.
“This then tells you that there is a particular pattern in that direction, that is someone who probably has inside information that one of the monitoring indicators is the age category of the patient, so there is a possibility that it is a pattern,” he said.
At the Subuiga medical camp, Nation met patients who were only given prescriptions because they could not be treated as their NHIF cards were not up to date.
NHIF subscription
This camp was organised by a group of six who claim they are from Afya Bora Hospital in Nairobi. At the camp, the group has the name of the hospital captured in their posters and in the documentation provided to patients, including one of the Nation reporters, who was attended to.
Mr Francis Muthomi said his NHIF subscription was not up to date, and he had been asked to remind his son to update it before he is fetched for further checks at the hospital.
In a response to Nation queries, Afya Bora’s Dr Wachira Waigoko, stated that his facility has never conducted medical camps in Meru, neither has it been involved in any patient recruitment drive.
“Afya Bora Hospital has never conducted any medical camp or patient recruitment drives in Meru County. Afya Bora Hospital has also never participated in defrauding NHIF. We have a legal contract that clearly stipulates the obligations and responsibilities we have to our patients and the insurer as a financier of healthcare. We have always abided by these, and it is a continuously monitored and audited process. We suggest that you inquire from NHIF on the status of Afya Bora Hospital,” Dr Waigoko said.
And on Dr Waigoko’s invitation to check with NHIF on their status, the acting NHIF boss confirmed that they have completed investigations into two facilities that were found culpable, one of which is Dr Waigoko's Afya Bora Hospitals.
Poor patients
Amid concerns that private hospitals are shutting out poor patients because of unpaid dues to NHIF, data shows that eight different hospitals involved in the investigation were paid Sh1.54 billion for a total of 30,111 claims made between July 1, 2022 and June 9, 2023.
They include Afya Bora Hospital (Sh7.4 million), Afya Bora Hospital Annex (Sh239.8 million), Amal Hospital Limited (Sh37.8 million), Beirut Pharmacy and Medical Centre (Sh72 million), Jekim Hospital Nkubu Ltd (Sh84.2 million), Jekim Medical Centre (Sh2.9 million), Joy Nursing and Maternity Eastleigh (Sh222.6 million) and St Peter’s Orthopaedics and Surgical Specialty (Sh681.6 million).
Dr Kuhora admits that they are battling a challenge with medical fraud, mostly through impersonation. He further says that two hospitals in this special report have already been investigated and found culpable,
“It will only be a matter of days before action is taken. This may include a termination of the contract they have with the NHIF,” he added.
Mr Mutuma, who has since petitioned the Meru County Assembly to investigate the matter, says he has reported the matter to the relevant authorities, including NHIF, and that his email of November 2022 was never acknowledged, let alone replied to.
In fact, the NHIF, perhaps demonstrating a don’t care attitude to public concerns about possible loss of public funds through a much-hyped anti-fraud feedback system, did not respond to Mr Mutuma’s concern until almost eight months later, on June 2, 2023.
This was three days after Nation formally interviewed Dr Kuhora and mentioned their lack of seriousness in dealing with public concerns.
