Insurer–provider contractual relationships and perceived healthcare service quality in Kenya

Abstract

The private health insurance sector in Kenya plays a growing role in enhancing access to healthcare, yet its effectiveness depends largely on the quality of relationships between insurers and healthcare providers. Despite constitutional guarantees of the right to health, insured clients frequently encounter service delays, contractual disputes, and weak communication mechanisms that compromise service quality. This study investigated the impact of insurer-provider contractual relationships on clients’ perceptions of healthcare service quality in private health facilities across selected urban and peri-urban counties in Kenya. Anchored on the Gaps Model of Service Quality and the Donabedian Model of Healthcare Quality, the study will examine three sets of variables: terms and enforcement of insurer-provider contracts, the efficiency of communication and coordination mechanisms, and the timeliness of claims reimbursement and dispute resolution. Using a cross-sectional correlational design, data were collected from insured clients, private medical insurers, and facility administrators through structured questionnaires and key informant interviews. SPSS version 31 was used to compute descriptive and inferential statistics, while qualitative data were analyzed thematically. The findings revealed that insurer-provider contractual relationships have a positive and statistically significant influence on perceived healthcare service quality. Communication and coordination mechanisms had the strongest positive influence on healthcare quality (β = .578, p < 0.01), followed by insurer-provider contractual arrangements (β = .472, p < 0.01), and timeliness of claims reimbursement and dispute resolution (β = .157, p < 0.05). The three predictor variables jointly explained 57.7% of the variation in healthcare quality. The study further established that efficient digital communication systems, effective contractual enforcement, and timely reimbursement processes improve service responsiveness, reliability, and patient satisfaction, while reimbursement delays and contractual inefficiencies negatively affect continuity of care and operational efficiency within healthcare facilities. The study concludes that insurer-provider contractual relationships significantly influence healthcare service quality in Kenya, whereby communication and coordination mechanisms has the strongest effect, followed by contractual arrangements and reimbursement and dispute resolution processes. Based on the findings, the study recommends strengthening contractual enforcement frameworks, enhancing adoption of integrated digital communication and claims management systems, improving transparency in reimbursement processes, and institutionalizing efficient dispute resolution mechanisms in order to improve healthcare service quality and patient satisfaction within Kenya’s private healthcare sector.