CS Duale defends health fund over delayed payments, cites incomplete claims, systemic reforms

Health Cabinet Secretary Aden Duale has defended the Social Health Authority (SHA) against concerns raised over delayed settlement of hospital claims and high rejection rates.

While acknowledging the challenge, Duale said the government is taking decisive measures to streamline reimbursements and ensure predictable cash flows for health service providers.

Appearing before a National Assembly’s health committee Tuesday, Duale attributed the problem largely to incomplete and improperly filled claim documents.

“Some claims have missing signatures, incorrect patient details, or incomplete medical records, while others are delayed because providers take too long to resubmit missing documents,” Duale explained.

The delays in settling claims under the Social Health Insurance Fund (SHIF) and the Emergency, Chronic and Critical Illness Fund (ECCIF) had sparked frustration among health facilities.

According to the ministry, the current claims settlement rate stands at 59 percent across all categories, with faith-based facilities performing best at 64.56 percent, followed by national referral hospitals (61.71%), county government hospitals (59.62%), and private facilities (56.55%).

The CS stated that while the Social Health Insurance (SHIF) regulations, 2025 requires all verifiable claims to be settled within 90 days of submission, SHA has been making payments every 14th day of the month.

Verification and adjudication are mandatory before any payout, he added.

To address the backlog, Duale said SHA has embarked on a comprehensive arrears verification exercise in collaboration with service providers, and is holding regular sensitisation meetings to improve claim documentation and reduce rejections.

He further revealed that the authority is strengthening its Claims Management Office, which has faced recruitment delays due to court cases.

Recently, nine case management officers were hired, with plans to expand to 15 headquarters officers, 47 county claims managers, and 47 quality assurance officers to enhance efficiency.

SHA has also designated relationship managers at the county and national levels to track pending claims and support facilities facing reimbursement challenges.

On financial sustainability, Duale reported that Sh79.2 billion has been collected under SHIF so far, aided by the “Lipa Pole Pole” platform that allows informal sector contributors to pay in manageable installments.

He said the government is also forging strategic partnerships with major hospitals and pharmaceutical companies to expand specialised care and reduce treatment costs.

Key agreements include partnerships with Aga Khan University Hospital, Nairobi Hospital, Roche, Pfizer, and Johnson & Johnson to support kidney transplant care and subsidized breast cancer medication.

Addressing concerns about higher payments to private hospitals, Duale clarified that this was not due to favoritism, but differences in service scope, specialization, and documentation quality.

Private facilities often offer advanced diagnostic and surgical services, have better documentation systems, and face fewer drug shortages, leading to higher reimbursements,” he said.

Duale also assured MPs that SHA is working closely with the Council of Governors (CoG) to ensure all county hospitals submit their bank details for prompt reimbursements, adding that the government’s broader goal is to build a transparent, efficient, and equitable universal health coverage system for all Kenyans.