Seme MP James Nyikal has raised concerns over structural weaknesses in the Social Health Authority (SHA) system, pointing to poor communication with hospitals as one of the factors aggravating operational challenges and instances of fraud.

Speaking during a media interview with a local media station on September 3, 2025, Nyikal, who is part of a parliamentary team investigating fraud at SHA, said preliminary findings have revealed confusion in facility management, debt backlogs, and a lack of clarity in how payments are processed.

“The system now does not give a lot of communication between the facilities and the SHA system itself,” he stated.

Payment confusion

He cited a case where two facilities bearing the same name but under different management, one in Nairobi and another in Wajir, had raised questions about accountability.

“With the same name, different management, would there be confusion? We are looking at the facts into that,” he said.

Nyikal noted that many health facilities are struggling to reconcile what they have been paid against what is owed to them, since SHA often releases bulk payments without detailed breakdowns.

“If you ask them what they have been paid for and what is pending, it is difficult for them to split out. That information has to come from SHA itself,” he observed.

The legislator further said private hospitals seemed more conversant with SHA’s system than public hospitals, but both faced hurdles when trying to resolve disputes.

“The private facilities know quite a bit, in fair amount, what the system is and what the problems are and how claims should be made and issues, how they need to follow up,” Nyikal observed.

Outpatient coverage issues

He further highlighted that many public hospitals lack coverage for outpatient services, despite provisions under primary health care, forcing patients to pay out-of-pocket or forgo treatment altogether.

“In public hospitals now, they are actually paying, they told us they are waiving, but my suspicion is that those people are being sent away without getting treatment, or they are paying when they are in outpatient,” he explained.

Nyikal mentioned that the ongoing fact-finding mission would include facilities in Homa Bay, Western, and Central Kenya, with plans to present a report to the Health Cabinet Secretary later this month.

“By the end of this month, we may have more information to say on what about these frauds, what about the systems, what about the services that are being offered to the people. We will definitely sit down with the Minister and say what is the best way forward to make this system better,” he said.