INSURANCE DYNAMICS AND FINANCIAL SUSTAINABILITY OF PRIVATE HEALTH SERVICE PROVIDERS IN KAJIADO NORTH SUB-COUNTY
Abstract
Purpose of the study: The study examined the relationship between health insurance dynamics and the financial sustainability of private health service providers in Kajiado North Sub-County. It assessed enrolment rate, reimbursement days, claim approval rate, and out-of-pocket (OOP) burden, and examined the moderating effect of insurance scheme type.
Statement of the problem: Private health service providers help reduce patient overload and support universal health coverage in resource-constrained areas such as Kajiado North Sub-County. Their revenues depend partly on insured patients and the operational performance of insurance schemes. Reimbursement delays, claim rejections, and OOP payment burdens can undermine revenue stability. Understanding how these dynamics relate to provider sustainability across insurance scheme types is therefore necessary.
Research methodology: The study employed a cross-sectional research design. A sample of 102 providers was selected from a target population of 121 using simple random sampling. Key respondents were purposively selected within the sampled facilities, and data were extracted from audited reports. Descriptive statistics and hierarchical regression were used to analyse the data.
Findings: The mean enrolment rate was 64.43%, the mean reimbursement period was 74.01 days, the mean claim approval rate was 81.87%, the mean OOP burden was 25.71%, and the mean operating self-sufficiency ratio was 101.87%. The main effects regression model explained 63.1% of the variation in financial sustainability. Enrolment and claim approval were positively associated with sustainability, whereas reimbursement days and OOP burden were negatively associated. The interaction between claim approval rate and insurance scheme type was significant (β = 0.21, p < .001).
Conclusion: The study concludes that provider financial sustainability is associated with insurance scheme type and the efficiency of insurance processes. The positive relationship between claim approval rate and sustainability was stronger among facilities dominated by the Social Health Insurance Fund.
Recommendations: The Social Health Authority should shorten reimbursement periods and improve claim approval rates through digital claims automation and provider support. Private providers should strengthen claims processing capacity and diversify their payer mix. Policymakers should develop support measures that reflect differences between insurance schemes.
Keywords: Enrolment, reimbursement, claim approval, out-of-pocket burden, financial sustainability
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