Technical Efficiency and Spatial Interdependence in Health Service Production in Kenya: Subnational Analysis for 47 County Governments

Introduction: Low- and middle-income countries like Kenya are making efforts to improve population health by expanding universal health coverage.  Improving access to health services through decentralization is one of the key considerations requiring additional resources to meet urgent and emerging population health needs. However, there are fundamental questions about whether the available resources are optimally utilized.  Methods: We assembled a dataset comprising health sector inputs, outputs, and contextual factors to measure the efficiency of Kenya’s health system across all its 47 counties. We estimated overall technical, pure technical and scale efficiencies employing Simar and Wilson’s single-step data envelopment analysis approach. We assessed the impact of spatial interdependence and contextual factors on efficiency levels by applying a truncated regression model. Finally, we cross-checked our results using stochastic frontier analyses. Results: We found an overall technical efficiency score of 32.2%, pure technical efficiency of 76.0% and scale efficiency of 43.0%. There was wide spatial heterogeneity in all measures across the 47 counties in Kenya. County-specific socio-economic development levels had a positive impact on overall technical efficiency. We found significant adverse spatial interdependence in over 75% of the counties. Conclusion: Health systems in low- and middle-income countries need to carefully examine the factors that optimize the available resources to improve population health. Ongoing decentralization efforts must pay attention to spatial interdependence and adopt mitigation measures to address unintended consequences within the health system. Funding: None to declare. Declaration of Interest: The authors declare no competing interests Ethical Approval: Ethical approval was not sought as the data used for the study were sourced from various publically available secondary sources and pertained to aggregate population and health system indicators.