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Post Reply: Auditor General Faces Ongoing Barriers in Accessing NHIF Claims System

<blockquote><div class="quotetitle">Quote from <a class="profile-link highlight-moderator" href="https://lawguide.co.ke/understanding-law/legal-forum/profile/lawyer/">Lawyer</a> on July 17, 2025, 12:23 pm</div><div id="pl-7012"  class="panel-layout" ><div id="pg-7012-0"  class="panel-grid panel-no-style" ><div id="pgc-7012-0-0"  class="panel-grid-cell"  data-weight="1" ><div id="panel-7012-0-0-0" class="so-panel widget widget_sow-editor panel-first-child panel-last-child" data-index="0" data-style="{&quot;background_image_attachment&quot;:false,&quot;background_display&quot;:&quot;tile&quot;,&quot;background_image_size&quot;:&quot;full&quot;,&quot;background_image_opacity&quot;:&quot;100&quot;,&quot;border_thickness&quot;:&quot;1px&quot;}" ><div
			
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	<p dir="ltr" data-pm-slice="0 0 []">For four years, Kenya’s Auditor General, Nancy Gathungu, has been unable to access the National Health Insurance Fund’s (NHIF) e-claims system, raising serious concerns about transparency and accountability in the management of public health funds. The persistent lockout has hindered efforts to audit the state insurer’s financial operations, leaving billions of shillings in payments unverified and fueling suspicions of mismanagement within the NHIF.</p>
<p dir="ltr">Gathungu’s latest audit report, covering the 2023-2024 financial year, highlights a staggering discrepancy of 22.5 billion Kenyan shillings in NHIF payments. The report reveals that the e-claims system, critical for processing and tracking hospital claims, remains inaccessible to the Office of the Auditor General. This lack of access has prevented Gathungu’s team from verifying the accuracy and legitimacy of claims paid out by the NHIF, a cornerstone of Kenya’s healthcare system that serves millions of citizens.</p>
<p dir="ltr">The NHIF’s e-claims system, which was outsourced to a private entity, has been a point of contention in previous audits. Gathungu has repeatedly flagged irregularities, including overpayments and duplicate claims, that suggest systemic issues in the fund’s operations. For instance, earlier audits uncovered 368 million shillings in excess payments attributed to “typing errors” by hospital clerks, with no evidence of recovery or reconciliation efforts. The current report builds on these findings, noting that the inability to access the e-claims system has made it impossible to confirm whether payments align with billed amounts or if public funds are being used appropriately.</p>
<p dir="ltr">The implications of this lockout are far-reaching. Without access to the e-claims system, the Auditor General cannot fully assess the NHIF’s financial health or ensure that taxpayer money is being spent efficiently. This raises questions about the governance of the NHIF, especially as it transitions to the Social Health Authority (SHA), a new framework intended to replace the NHIF and improve healthcare delivery. Critics argue that the lack of transparency in the NHIF’s operations could undermine confidence in the SHA before it even begins.</p>
<p dir="ltr">Gathungu has called for urgent action to address these issues, emphasizing that her office’s role is to audit and report, while corrective measures fall to Parliament and other oversight bodies. She has advocated for amendments to the Public Finance Management Act to introduce penalties for accounting officers who fail to act on audit recommendations. Such reforms, she argues, would promote fiscal discipline and prevent the continued misuse of public resources.</p>
<p dir="ltr">The NHIF’s challenges are not new. Previous audits have exposed a range of problems, from unsupported payments to stalled projects and potential fraud. For example, the EduAfya scheme, designed to provide medical cover for secondary school students, was found to have overpaid 2.2 billion shillings due to ineligible beneficiaries and inflated premiums. Similarly, the Linda Mama program, which offers free maternal healthcare, reported duplicate payments and unexplained variances totaling millions of shillings. These findings underscore the need for robust oversight and access to critical systems like the e-claims platform.</p>
<p dir="ltr">Public reaction to the audit findings has been one of frustration and concern. Many Kenyans rely on the NHIF for affordable healthcare, and reports of financial discrepancies have sparked calls for greater accountability. Social media discussions have highlighted the need for systemic reforms to ensure that public health funds are managed transparently and that services reach those who need them most.</p>
<p dir="ltr">As the NHIF transitions to the SHA, questions remain about how these longstanding issues will be addressed. The Auditor General’s inability to access the e-claims system is a glaring obstacle to ensuring value for money in Kenya’s healthcare sector. Without immediate steps to grant full access and implement stricter oversight, the risk of financial mismanagement could continue to erode public trust in the system.</p>
<p dir="ltr">Gathungu’s tenure as Auditor General, which began in July 2020, has been marked by her commitment to uncovering financial irregularities across government institutions. Her reports have consistently highlighted the need for stronger accountability mechanisms, from county governments to national programs like the NHIF. As she continues her non-renewable eight-year term, her efforts to shine a light on public finance mismanagement remain a critical part of Kenya’s push for better governance.</p>
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