Regional patterns and improvement mechanisms of health resource allocation efficiency in China: evidence from SHAP-based variable selection and a game cross-efficiency model

The efficiency of health resource allocation is fundamental to improving health service accessibility and advancing health equity. This study aims to evaluate the efficiency of health resource allocation across Chinese provinces and examine regional disparities, associated factors, and potential improvement pathways. Using provincial panel data from 31 Chinese provinces over the period 2012–2024, this study employs a game cross-efficiency data envelopment analysis (DEA) model to measure health resource allocation efficiency. It further integrates the Dagum Gini coefficient, kernel density estimation, the XGBoost-SHAP method, and a two-way fixed effects model to examine regional disparities, influencing factors, and underlying mechanisms. The mean efficiency score declined from 0.4034 in 2012 to 0.3116 in 2020, before recovering to 0.3651 in 2024; it remained below the 2012 level. Spatially, efficiency exhibits a pattern of relatively high levels in the eastern and central regions and comparatively low levels in the western region, while interregional disparities account for the largest share of overall inequality. Both fiscal health expenditure and educational attainment are positively associated with health resource allocation efficiency. Specifically, exploratory analyses found associations between fiscal health expenditure and health security indicators, and between educational attainment and residents’ income and health expenditure. Substantial scope remains for improving the efficiency of health resource allocation in China, and regional imbalance continues to be a prominent challenge. Future policies should optimize the structure of fiscal health expenditure, improve health resource utilization efficiency, and attach greater importance to the role of education and residents’ health investment capacity in promoting equitable and accessible health services.