The Social Health Insurance Fund is consistently strengthening its system for protecting mandatory social health insurance funds and transitioning to a new financial control model based on digital traceability, risk-based management, and the prevention of unjustified payments before they are transferred to medical organizations.

This work is a key area of ​​implementation for the Fund's Development Strategy until 2030 and Kazakhstan's transition to a new model of public management of healthcare financing.

Strengthening Oversight and the Principle of Inevitability of Accountability

The incidents currently being investigated by law enforcement agencies primarily relate to previous periods of the system's operation (2024-2025). A significant portion of the materials were uncovered by the Fund itself during audit activities and transferred to law enforcement agencies for procedural decisions.

The violations relate to the reporting of medical care not actually provided, falsification of service volumes, fictitious enrollment of individuals, the illegal use of patient personal data, and other schemes for the illegal acquisition of compulsory health insurance funds.

In the first half of 2026, the Fund submitted 72 reports of violations totaling 4.5 billion tenge to law enforcement agencies. Following their review, 27 criminal cases were registered, with the estimated damage amounting to 3.7 billion tenge.

By comparison, for the entire year of 2025, 73 reports were submitted totaling 630 million tenge, resulting in 8 criminal cases.

Moreover, the increase in the number of identified violations does not indicate an increase in abuses, but rather a qualitative strengthening of the Fund's oversight function, the refinement of analytical tools, and the consistent legal assessment of each established fact.

The Fund's position remains fundamental and unchanged: every confirmed instance of illegal use of compulsory health insurance funds must receive an objective legal assessment, the perpetrators must be held accountable in accordance with the law, and the damage caused to the state must be compensated.

From Detecting Violations to Preventing Them

Along with strengthening cooperation with law enforcement agencies, the Fund is changing its approach to financial oversight.

While previously focused on identifying violations after funds were transferred, the new model aims to prevent them even before payments are made to a medical organization.

As part of the Fund's Development Strategy, a unified digital financial oversight ecosystem is being implemented, including the Qalqan IT platform, an automated anti-fraud system, and risk-based data analysis algorithms.

New digital tools will enable real-time detection of abnormal volumes of medical care, mass padding, signs of fraudulent provider activity, artificially inflated volumes of services rendered, and other risk scenarios.

The patient becomes a full participant in the oversight process.

An important element of the new model will be the development of public oversight mechanisms. Every citizen will be able to promptly verify medical services registered in their name and report instances where such care was not actually provided.

Such requests will be used as an additional source of risk indicators and taken into account during control activities.

A New Model for Protecting Compulsory Medical Insurance Fund Funds

Gulmira Sabdenbek, Chairperson of the Board of the Social Health Insurance Fund, emphasized that strengthening controls is not a one-time campaign, but a systemic reform of financial management in healthcare.

"The Fund is changing its very approach to control: from identifying violations after the fact to preventing them. Our goal is to make unjustified payments impossible even before funds are transferred to medical organizations. This will ensure the targeted use of every tenge and strengthen citizens' trust in the Compulsory Medical Insurance system," noted Gulmira Sabdenbek.

Currently, contributions and deductions for the Compulsory Medical Insurance Fund are paid for more than 5.5 million working Kazakhstanis. The new control system is designed to ensure that each of them has confidence that Compulsory Medical Insurance funds are allocated exclusively for actual medical care and are used strictly for their intended purpose.

Source : https://www.gov.kz/memleket/entities/abay-kurchatov/press/news/details/1269178?lang=ru