Kenya health system productivity change between 2014 and 2022: progress towards universal health coverage

Introduction: The decentralization of health services is a central pillar of Kenya’s constitutionally mandated devolution, intended to promote equity, accountability, and more effective service delivery. In line with these reforms, significant investments have been made across the 47 county governments to strengthen healthcare provision. Methods: We assembled a panel dataset of health system inputs, outputs, and contextual factors for 2014 and 2022 to measure productivity change across Kenya’s 47 counties. Using the Malmquist Productivity Index (MPI), we estimated total factor productivity change (TFPCH), technology change (TECCH), technical efficiency change (TECH), and scale efficiency change (SECH). We further examined the impact of contextual factors on productivity shifts using linear regression analysis. Results: On average, TFPCH was 0.69 for under-5 survival, 0.74 for maternal survival, and 0.67 for healthy life expectancy (HALE). Similarly, TECCH scores were 0.70, 0.71, and 0.67 respectively. While TECH and SECH averaged around 1.0, indicating little net change, there was significant regional and county-level heterogeneity. Notably, counties classified as marginalized showed significantly greater productivity growth across all three outcome measures. Conclusion: Despite considerable investments in decentralization and service expansion, Kenya’s health system exhibited overall productivity declines between 2014 and 2022, largely due to suboptimal adoption and application of health technologies. Enhancing managerial capacity, process optimization, and leveraging proven cost-effective interventions may be more important than large-scale equipment investments alone.