EXPOSED: SHA Officials Approve Higher Payments for Family, Friends as Poor Patients Pay Out of Pocket

NAIROBI, Kenya – A disturbing pattern of preferential treatment has emerged at the Social Health Authority, with well-connected Kenyans receiving significantly higher medical package approvals than ordinary citizens suffering from identical conditions, an investigation has established.

The shocking revelations expose how a single phone call from influential figures can transform healthcare outcomes, with senior SHA officials routinely overriding gazetted benefit packages to favour family members and friends while leaving thousands of patients to pay out of pocket for services the authority should cover.

At the heart of the scandal are two breast cancer patients, Elizabeth Kerubo and Jecinter Awino (not their real names), who pay the same Sh6,000 premium and were diagnosed with the same disease at the same hospital. Yet their experiences could not have been more different.

When Kerubo underwent diagnostic tests, SHA approved and paid for all three required procedures. Confident in the system, she encouraged her friend Awino to visit the same facility.

What she did not disclose was that a relative holding a senior position at SHA had made a call to ensure the approval went through.

Awino, lacking such connections, received approval for only one test. Frustrated and desperate, she was forced to dip into her savings to cover the costs of the other two tests out of her own pocket.

“I do not understand. We pay the same premium of Sh6,000. We were diagnosed with the same disease. We were scheduled for the same tests. But I have to pay extra, from my pocket, because I do not know anyone. This is impunity,” Awino told The Star.

System Designed to Fail

Dr Ahmed Kalebi, a consultant pathologist, revealed the devastating financial implications of these inconsistencies. Immunohistochemistry costs Sh3,500 per marker, flow cytometry costs Sh2,500 per marker, and PCR analysis for gene detection in cancer costs Sh8,000 per marker.

According to Dr Kalebi, SHA often approves payment for only one marker for patients who require multiple markers for accurate cancer diagnosis. The system for review and approval, he said, is not working as designed.

“Breast cancer requires three or four immunohistochemistry markers, but SHA approves only one. A patient with leukaemia may require 10 flow cytometry markers, but SHA approves only one. Similarly, a patient with lung cancer requiring four molecular test markers gets only one approved,” Dr Kalebi explained.

“This means the patients do not benefit fully from the gazetted SHA benefits package, and they have no recourse for appeal,” he added.

While Dr Kalebi acknowledged that SHA is working better than the defunct National Health Insurance Fund in terms of specialized laboratory testing, he noted that the lack of clarity and consistency in authorization remains the biggest concern.

“Many patients fail to benefit because of deficiencies at the SHA review and approval stage, forcing them to top up out of pocket,” he said.

Maternity Care Disparities

The inconsistencies extend far beyond cancer treatment. A gynaecologist who requested anonymity revealed shocking disparities in maternity care payments.

“We have normal delivery and caesarean section patients receiving different packages, even when treated in the same hospital, by the same doctor, using the same equipment,” the gynaecologist said.

“One patient who had undergone a caesarean section received Sh30,000, yet another received Sh80,000, same hospital, same doctor, yet completely different experiences.”

According to gazetted tariffs, normal delivery and essential newborn care is capped at Sh10,000, while caesarean section is capped at Sh30,000. For oncology services, facilities from Level 3 to Level 6 with National Cancer Institute certification have a limit of Sh400,000 per annum.

Human Interference Blamed

Dr Brian Lishenga, chairperson of the Rural and Urban Private Hospitals Association, identified human interference as the root cause of SHA’s allocation problems.

“There is a disconnect between what is written in the guidelines and how it is executed,” Dr Lishenga said.

He added that many SHA packages are priced below market value, making it difficult for healthcare providers to offer them without incurring losses.

“If hospitals cannot afford to treat patients under these packages, they often will not accept them at all. This leads to a scenario where only patients with connections to senior officials receive the care they need,” he said.

When the association raised the issue of human interference with senior SHA officials, they were assured it would stop. The so-called “engine rule,” a system where all approvals are processed automatically, was meant to ensure allocations are handled equitably.

“But it seems the ‘engine’ only works for those who do not have powerful people to call. Even with that system in place, many Kenyans are not getting the services they need. They have to beg to be treated,” Dr Lishenga said.

He further stated that the interference has led to increased out-of-pocket payments, contradicting the very purpose of universal health coverage.

“In a world where healthcare should be a right, not a privilege, these inconsistencies in SHA serve as a painful reminder of the work that lies ahead. We need to speak up and have this stopped,” he said.

SHA Leadership Silent

When The Star reached out to SHA Chief Executive Officer Dr Mercy Mwangangi on her known telephone number, she neither answered nor returned calls. WhatsApp messages also went unanswered.

Ms Golda Larissa, SHA’s director of benefits and claims management, said she was not authorized to speak to the media and referred inquiries to the corporate communications department.

SHA Deputy Corporate Communication Officer Jacob Mutinda requested questions in writing, mentioning that the authority was developing a structured process for the CEO to address media inquiries comprehensively. However, no response was received by the time of publication.

Wider SHA Scandal

These revelations come amid a wider corruption scandal that has engulfed SHA since its launch in October 2024 to replace the troubled NHIF.

The Sh104 billion health insurance system has been rocked by multiple fraud cases involving ghost hospitals, fake patients, inflated bills, and payments to non-existent facilities. Over 85 health facilities have been suspended, and investigations have revealed that Sh10.6 billion in fraudulent claims were rejected out of Sh82.7 billion submitted.

In March 2025, Auditor General Nancy Gathungu exposed irregularities in the procurement of the technology used to manage the SHA system, highlighting unbudgeted and non-competitive procurement processes.

The controversy has sparked widespread public anger, with calls for the resignation of Health Cabinet Secretary Aden Duale and SHA CEO Dr Mwangangi over what critics have termed a “well-calculated scandal.”

Former Chief Justice David Maraga has called on the Ethics and Anti-Corruption Commission to investigate SHA over allegations of losses running into billions through fraudulent payments, demanding that all money lost must be recovered and those responsible prosecuted.

President William Ruto, in a public address in August 2025, stated that SHA looters will face the full wrath of the law. However, no convictions have been made on individuals charged in the scandal.

As the crisis deepens, ordinary Kenyans continue to bear the brunt, with many unable to access essential healthcare services despite paying their monthly premiums religiously. The dream of universal health coverage appears increasingly distant as corruption, favouritism, and mismanagement threaten to collapse yet another public health insurance system.

For Elizabeth Kerubo, Jecinter Awino, and millions of Kenyans like them, the question remains: When will healthcare truly become a right, not a privilege reserved for those with connections?

Additional reporting by Daily Nation