SHA Warns of Growing Fraud Risks as Kenya Moves to Fully Digital Health Insurance System
Fraud is emerging as one of the key challenges facing Kenya’s health insurance system, with Social Health Authority (SHA) Chief Executive Officer Mercy Mwangangi warning that fraudulent claims can originate from health facilities, officials and members of the public.
Speaking during a media town hall in Nairobi on Tuesday, Mwangangi said health insurance fraud is a global problem and Kenya needs stronger mechanisms to detect and prevent it.
She pointed to the United States as an example, suggesting that Kenya could adopt specialised approaches similar to those used by American agencies to investigate medical fraud.
“We need to go and look at the FBI special unit for medical fraud, just like America,” she said.
Mwangangi stressed that fraudulent activity is not solely an issue involving healthcare providers or government officials, saying members of the public can also abuse the system.
She cited a case reported by a private health facility in which a civil servant allegedly used her SHA card to have her sister admitted for treatment.
“We have one private facility telling me that a lady who is a civil servant brought her sister, admitted her using her card, and the sister had to run at night. This is fraud by Kenyans,” she said.
“All of us are accomplices of fraud,” Mwangangi added.
According to the SHA chief, the ongoing digitisation of health insurance services is expected to strengthen the authority’s ability to identify suspicious claims and tackle fraudulent practices.
“We struggle with this, but our digitisation has come to support us,” she said.
Mwangangi, however, identified the transition to a fully digital health insurance system as another major challenge, saying effective change management will be critical to the success of the reforms.
She explained that stakeholders must understand the changes being introduced and be equipped to support their implementation.
“One of the things that when you introduce a reform or project you must deal with is if stakeholders understand the reform and that they are able to push forward,” she said.
Mwangangi said SHA has already shifted to a fully digital claims process, eliminating the use of manual claims documents.
“Right now all our claims are digital. We do not have manual documents and that is an improvement. It means we team ourselves in a highly digital work,” she said.
She added that continued public education and engagement will be necessary to help Kenyans understand how the digital system operates and ensure the transition is implemented effectively.
