Technical and scale efficiency in health service production in Kenya: subnational analysis of 47 county governments

BACKGROUND: Kenya adopted a decentralized health system to improve access to care and accelerate progress toward universal health coverage (UHC). County governments now manage most health service delivery; however, the extent to which resources are used efficiently remains unclear. METHODS: We compiled county-level data on health inputs, outputs, and contextual factors for 2022. Overall technical efficiency (OTE), pure technical efficiency (PTE), and scale efficiency (SE) were estimated using the single-step Simar and Wilson Data Envelopment Analysis (DEA) approach. Contextual determinants of efficiency were examined using truncated regression. RESULTS: Counties demonstrated moderate efficiency for child survival (OTE = 0.74; 95% CI: 0.70-0.78), indicating potential to improve outcomes by about 26% using existing resources. PTE averaged 0.85, suggesting that 15% of inefficiency stemmed from managerial factors, while SE averaged 0.87, reflecting a 13% loss attributable to suboptimal scale. For childhood immunization, the average OTE was 0.83 (95% CI: 0.81-0.87), implying that coverage could increase by 17% without additional inputs; uniformly high PTE points to strong managerial performance in immunization programs. Maternal survival showed the greatest inefficiency (OTE = 0.51; 95% CI: 0.48-0.55), with counties achieving only half of their potential. Efficiency for healthy life expectancy (HALE) was moderate (OTE = 0.83; 95% CI: 0.81-0.85), indicating scope for a 17% improvement without new resources. Substantial heterogeneity was observed across counties for all outputs. CONCLUSION: In 2022, maternal health services exhibited markedly lower efficiency than child health and immunization programs. The severe inefficiency in maternal service delivery, compared to child health and immunization programs, highlights an urgent need for targeted managerial strengthening in low-performing counties such as Kisii and Nyeri. Strengthening managerial capacity and optimizing scale of operations could yield major health gains without additional resources.