Using DEA to evaluate efficiency and formulate policy within a Greek national primary health care network. Data Envelopment Analysis

Primary Health Care: Our Experience From an Urban Primary Health Care Center in Greece

This observational study reported patient data derived from the emergency files of a primary health care (PHC) center in Greece, with the aim of providing potential solutions for a well-organized, well-structured, and effective social healthcare system. This series was conducted at a single urban PHC center in Greece between August 2017 and March 2020. A total of 83,592 patient visits were registered. The mean patient age was 42.5 years (range: three months to 93 years). Demographics, presenting complaints, and the need for patients who visited the healthcare center to be referred to tertiary hospitals were examined. Further perspectives and future strategies to strengthen the national PHC system were addressed. The most common reasons for visits were pathological (33.6%), followed by general surgery (21.2%) and orthopedics (18.1%). Pediatric conditions accounted for 12% of visits, cardiological conditions accounted for 8.6%, and dental problems accounted for 6.8%. The majority of the patients (n = 81,317, 97.3%) were managed within the health center, and only 2.7% of cases (n = 2275) needed to be referred to a secondary or tertiary healthcare structure. Reasons for patient referral included the severity or complexity of the patient's situation, lack of a specific medical specialty, and the unavailability of overnight laboratory tests. The PHC center remains the cornerstone of a high-quality healthcare system. A well-structured PHC unit can improve health outcomes and decongest secondary and tertiary health care.

Temporal-Spatial Evolution and Trend Prediction of the Supply Efficiency of Primary Medical Health Service-An Empirical Study Based on Central and Western Regions of China

China has established a comprehensive primary medical health service system, but the development of primary medical health services in the central and western regions is still unbalanced and insufficient. Based on data from 2010 to 2019, this paper constructs a super efficiency Slack-Based Measure model to calculate the supply efficiency of primary medical health services in 20 provinces and cities in central and western China. Using Kernel density estimation and Markov chain analysis, this paper further analyzes the spatial-temporal evolution of the supply efficiency of primary medical health services in central and western China, and also predicts the future development distribution through the limiting distribution of Markov chain to provide a theoretical basis for promoting the sinking of high-quality medical resources to the primary level. The results show that firstly, during the observation period, the center of the Kernel density curve moves to the left, and the main peak value decreases continuously. The main diagonal elements of the traditional Markov transition probability matrix are 0.7872, 0.5172, 0.8353, and 0.7368 respectively, which are significantly larger than other elements. Secondly, when adjacent to low state and high state, it will develop into convergence distributions of 0.7251 and 0.8243. The supply efficiency of primary medical health services in central and western China has the characteristics of high (Ningxia) and low (Shaanxi) aggregation respectively, but the aggregation trend is weakened. Thirdly, the supply efficiency of health services has the stability of keeping its own state unchanged, but the transition of state can still occur. The long-term development of the current trend cannot break the distribution characteristics of the high and low clusters, the efficiency will show a downward trend in the next 10-20 years, and still the problem of uneven long-term development emerges.

Approaches to Measure Efficiency in Primary Care: A Systematic Literature Review

BACKGROUND

Primary care in England is facing increasing pressure due to the increasing number and complexity of consultations and the declining number of doctors per head of population. The improvement of primary care efficiency and productivity should be a priority, to ensure that future investments in the medical workforce can cope with the increasingly large and complex demand for care.

OBJECTIVES

This paper presents a systematic literature review of studies that define or measure efficiency in primary care in high-income settings. The review of the existing definitions of primary care efficiency and their limitations will inform future research on the measurement of efficiency in primary care in England and its determinants.

METHODS

Literature searches were performed on Embase, Medline, and EconLit in January 2020. The records that passed the screening were reviewed in full text, and data on the study settings, the efficiency definition, and the efficiency analysis were extracted.

RESULTS

Of the 2590 non-duplicate records retrieved from the searches, 38 papers were included in the analysis. The volume of the literature on primary care efficiency has evolved significantly from the 1980s, with the majority of the published studies focussing on European health systems. The setting most often analysed was primary care centres. Output was usually expressed using measures of primary care utilisation, with or without quality adjustments. Reference to the health outcomes achieved was, however, limited. Inputs were more commonly expressed in labour terms, while the exogenous variables related either to the characteristics of the patient population or the organisation of primary care. While all studies included an analysis of technical efficiency, consideration of allocative or cost efficiency or the determinants of productivity (e.g. technological change, skill mix) was rare.

CONCLUSIONS

The main limitations that future research on primary care efficiency should address relate to the definition of output. Current approaches to measure the impact on health and the multiple dimensions of output are not sufficient to represent the valued output of primary care. In light of the recent changes in the model of primary care delivery in England, future research should also investigate the impact of technological change on productivity and the scope for substitution across staff roles.

Measurement and Evaluation of the Operating Efficiency of China's Basic Pension Insurance: Based on Three-Stage DEA Model

Purpose

This paper aims to measure the operating efficiency of China’s basic pension insurance from 2014 to 2019 in 31 provinces.

Methods

The three-stage DEA model was used to evaluate the operating efficiency of basic pension insurance in 31 provinces.

Results

On the whole, the operating efficiency of China’s basic pension insurance was at a high level, but there was still room for improvement. GDP, urbanization level and scale of government public expenditure had a positive impact on the operating efficiency of regional basic pension insurance. In contrast, the old-age dependency ratio had a significant negative effect. There were noticeable regional differences in the operating efficiency of China’s basic pension insurance, which showed a pattern of Central (0.742) >Eastern (0.689) >Western (0.505) after removing the influence of environmental variables.

Conclusion

This study systematically analyzes the impact of external environmental regulations on China’s basic pension insurance’s operating efficiency and provides decision-making references for further improving the operating efficiency of China’s basic pension insurance. In order to further optimize the allocation of basic endowment insurance, this paper proposes the following countermeasures and suggestions: (1) broaden investment channels and improve the investment efficiency; (2) increase supervision of social security departments and strengthen information disclosure; (3) unify the management of social basic pension insurance.

Evaluation of Biomedical Laboratory Performance Optimisation using the DEA Method

Introduction

The Slovenian Resolution on the National Healthcare Plan notes that the country’s medical laboratory activities are fragmented, which may result in cost-inefficiency and a reduction in the quality of the services provided. Defining the efficiency of laboratory service providers can therefore help us to pursue the objectives of the Resolution, i.e. to consolidate and integrate laboratory activities.

Methods

Using the DEA method, we conducted an analysis of the efficiency of 20 biomedical laboratories in Slovenia, and made a comparison with a “virtual” laboratory, i.e. a merger of laboratories within a selected organisational unit. By testing different DEA models, we sought to determine whether the use of different input variables caused significant differences in the laboratories’ efficiency scores.

Results

The research results show that inefficiency resulting from the size of the units is 1.5 times greater than process inefficiency. Using a non-parametric Wilcoxon Signed Rank test, we determined, at a risk level of 0.05, that there was no difference between the efficiency results when using two different technical efficiency DEA models. When evaluating the virtually merged laboratory, we determined that, under all three models, the virtual laboratory achieved 100% VRS efficiency. However, when the CRS methodology was used, the laboratory showed a certain degree of scale inefficiency.

Conclusions

When evaluating merger of medical laboratories we note that the DEA method is methodologically suitable for evaluating the effects of health policy implementation, and is an appropriate tool for identifying where the field of laboratory medicine might be further developed and improved.

Improving Efficiency Assessment of Psychiatric Halfway Houses: A Context-Dependent Data Envelopment Analysis Approach

This study proposes the approach of context-dependent data envelopment analysis (DEA) to measure operating performance in halfway houses to enable suitable adjustments at the current economic scale. The proposed approach can be used to discriminate the performance of efficient halfway houses and provide more accurate DEA results related to the performance of all halfway houses in a region or a country. The relative attractiveness and progress were also evaluated, and individual halfway houses’ competitive advantage and potential competitors could be determined. A case study of 38 halfway houses in Taiwan was investigated by our proposed approach. Findings suggest that fifteen halfway houses belong to the medium level, which can be classified into a quadrant by examining both their attractiveness score and progress score. The results can be used to allocate community resources to improve the operational directions and develop incentives for halfway houses with attractive and progressive values, which can reduce the institutionalization and waste of medical resources caused by the long-term hospitalization of patients with mental illnesses. Our proposed approach can also provide references for operators and policy makers to improve the management, accreditation, and resource allocation of institutions.

ISO 9001-certified public healthcare center’s efficiency and re-certification

Purpose

The purpose of this paper is to measure the efficiency of ISO 9001-certified public healthcare center in Jakarta, Indonesia and examine the impact of “re-certification“ on the efficiency.

Design/methodology/approach

The sample of the research is 30 ISO 9001-certified district public healthcare centers in Jakarta. The data envelopment analysis (DEA) and the Man–Whitney U test were applied.

Findings

The research result showed that there is a variation in efficiency values of ISO 9001-certified public healthcare centers that this research studied. There are only 23 percent of the public healthcare centers that can be categorized as the technically efficient public healthcare center. Furthermore, this research also found that there are no significant efficiency value differences among the groups of public healthcare center based on the number of “re-certification” the center experienced.

Research limitations/implications

This research only involved ISO 9001-certified public healthcare center from Jakarta, Indonesia.

Practical implications

Registering ISO 9001 for the public healthcare center does not guarantee that the public healthcare center will have better efficiency. The government and the public healthcare center management should ensure that the ISO 9001 implementation method used by the public healthcare center is appropriate for improving the efficiency of the public healthcare center.

Originality/value

There is a lack of research that studied the efficiency of ISO 9001-certified public healthcare center. Furthermore, there is no research that investigates the effect of “re-certification“ on efficiency. This research fulfills the literature gaps.

Fatores associados à eficiência na Atenção Básica em saúde, nos municípios brasileiros

RESUMO Este artigo tem por objetivo identificar os fatores que influenciam a eficiência na aplicação dos recursos destinados à Atenção Básica nos municípios brasileiros. Para isso, utilizou-se o modelo de regressão beta inflacionado, uma vez que a variável dependente apresenta valores no intervalo (0,1]. De acordo com os resultados, o índice Firjan de desenvolvimento municipal na saúde e serviços de saneamento básico são fatores que influenciam positivamente a eficiência média na Atenção Básica de um município. Por outro lado, o gasto per capita de um município, em Atenção Básica, exerce efeito negativo na eficiência média.

Estimating efficiency of Directive 2011/24/EU cross-border healthcare in member states

Aim: Directive 2011/24/EU on patients' rights in cross-border healthcare facilitates EU citizens' access to and reimbursement for healthcare provided or prescribed in a member state other than the member state of affiliation. Materials & methods: The efficiency of cross-border healthcare policy is evaluated using data envelopment analysis of relevant items in Eurobarometer Survey on Safety and Quality of Care and Patients' Rights in the EU. Results: Our study shows policy inefficiency in 52% of the 25 EU member states included in the analysis. Addressing difficulties patients encounter while seeking reimbursement from their national health service or health insurer and reducing the number of adverse events patients experience when receiving healthcare improves policy efficiency. Conclusion: Our findings confirm that there is country-level variation in cross-border healthcare policy efficiency.

Efficiency and productivity assessment of public hospitals in Greece during the crisis period 2009-2012

Background

This study is an initial effort to examine the dynamics of efficiency and productivity in Greek public hospitals during the first phase of the crisis 2009–2012. Data were collected by the Ministry of Health after several quality controls ensuring comparability and validity of hospital inputs and outputs. Productivity is estimated using the Malmquist Indicator, decomposing the estimated values into efficiency and technological change.

Methods

Hospital efficiency and productivity growth are calculated by bootstrapping the non-parametric Malmquist analysis. The advantage of this method is the estimation efficiency and productivity through the corresponding confidence intervals. Additionally, a Random-effects Tobit model is explored to investigate the impact of contextual factors on the magnitude of efficiency.

Results

Findings reveal substantial variations in hospital productivity over the period from 2009 to 2012. The economic crisis of 2009 had a negative impact in productivity. The average Malmquist Productivity Indicator (MPI) score is 0.72 with unity signifying stable production. Approximately 91% of the hospitals score lower than unity. Substantial increase is observed between 2010 and 2011, as indicated by the average MPI score which fluctuates to 1.52. Moreover, technology change scored more than unity in more than 75% of hospitals. The last period (2011–2012) has shown stabilization in the expansionary process of productivity. The main factors contributing to overall productivity gains are increases in occupancy rates, type and size of the hospital.

Conclusions

This paper attempts to offer insights in efficiency and productivity growth for public hospitals in Greece. The results suggest that the average hospital experienced substantial productivity growth between 2009 and 2012 as indicated by variations in MPI. Almost all of the productivity increase was due to technology change which could be explained by the concurrent managerial and financing healthcare reforms. Hospitals operating under decreasing returns to scale could achieve higher efficiency rates by reducing their capacity. However, certain social objectives should also be considered. Emphasis perhaps should be placed in utilizing and advancing managerial and organizational reforms, so that the benefits of technological improvements will have a continuing positive impact in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s12962-017-0068-5) contains supplementary material, which is available to authorized users.

Efficiency of Ontario primary care physicians across payment models: a stochastic frontier analysis

OBJECTIVE

The study examines the relationship between the primary care model that a physician belongs to and the efficiency of the primary care physician in Ontario, Canada.

METHODS

Survey data were collected from 183 self-selected physicians and linked to administrative databases to capture the provision of services to the patients served for the 12 month period ending June 30, 2013, and the characteristics of the patients at the beginning of the study period. Two stochastic frontier regression models were used to estimate efficiency scores and parameters for two separate outputs: the number of distinct patients seen and the number of visits.

RESULTS

Because of missing data, only 165 physicians were included in the analyses. The average efficiency was 0.72 for both outputs with scores varying from 4 % to 93 % for the visits and 5 % to 94 % for the number of patients seen. We observed that there were both very low and very high efficiency scores within each model. These variations were larger than variations in average scores across models.

Measuring the efficiency of the Greek rural primary health care using a restricted DEA model; the case of southern and western Greece

This is a study to measure the efficiency of the rural Health Centres (HCs) and their Regional Surgeries (RSs) of the 6th Health Prefecture (HP) of Greece, which covers Southern and Western Greece. Data Envelopment Analysis (DEA) was applied under Constant and Variable Returns to Scale, using a weight-restricted, output-oriented model, to calculate pure technical efficiency (PΤΕ), scale efficiency (SE) and total technical efficiency (TE). The selection of inputs, outputs and their relative weights in the model was based on two consecutive consensus panels of experts on Primary Health Care (PHC). Medical personnel, nursing personnel and technological equipment were chosen as inputs and were attributed appropriate weight restrictions. Acute, chronic and preventive consultations where chosen as outputs; each output was constructed by smaller subcategories of different relative importance. Data were collected through a questionnaire sent to all HCs of the covered area. From the 42 HCs which provided complete data, the study identified 9 as technical efficient, 5 as scale efficient and 2 as total efficient. The mean TE, PTE and SE scores of the HCs of the 6th Health Prefecture were 0.57, 0.67 and 0.87, respectively. The results demonstrate noteworthy variation in efficiency in the productive process of the HCs of Southern and Western Greece. The dominant form of inefficiency was technical inefficiency. The HCs of the 6th HP can theoretically produce 33 % more output on average, using their current production factors. These results indicated potential for considerable efficiency improvement in most rural health care units. Emphasis on prevention and chronic disease management, as well as wider structural and organisational reforms, are discussed from the viewpoint of how to increase efficiency.

Primary care efficiency measurement using data envelopment analysis: a systematic review

There is a gap between the demand and supply of efficiency analyses within primary care (PC), despite the threatening financial sustainability of health care systems. This paper provides a systematic literature review on PC efficiency analysis using Data Envelopment Analysis (DEA). We reviewed 39 DEA applications in PC, to understand how methodological frameworks impact results and influence the information provided to decision makers. Studies were combined using qualitative narrative synthesis. This paper reports data for each efficiency analysis on the: 1) evaluation context; 2) model specifications; 3) application of methods to test the robustness of findings; 4) presentation of results. Even though a consistent number of analyses aim to support policymakers and practice managers in improving the efficiency of their PC organizations, the results indicate that DEA--at least when applied to PC--is a methodology still in progress; it needs to be further advanced to meet the complexity that characterizes the production of PC outcomes. Future studies are needed to fill some gaps in this particular domain of research, such as on the standardization of methodologies and the improvement of outcome research in PC. Most importantly, further studies should include extensive uncertainty analyses and be based on good evidence-based rationales. We suggest a number of considerations to academics and researchers to foster the utility of efficiency measurement for the decision making purposes in PC.

Efficiency of HIV/AIDS health centers and effect of community-based health insurance and performance-based financing on HIV/AIDS service delivery in Rwanda

This study evaluates the efficiency of rural health centers in Rwanda in delivering the three key human immunodeficiency virus/acquired immunodeficiency syndrome services: antiretroviral treatment, prevention of mother-to-child transmission, and voluntary counseling and testing using data envelopment analysis, and assesses the impact of community-based health insurance (CBHI) and performance-based financing on improving the delivery of the three services. Results show that health centers average efficiency of 78%, and despite the observed variation, the performance increased by 15.6% from 2006 through 2007. When the services are examined separately, each 1% growth of CBHI use was associated with 3.7% more prevention of mother-to-child transmission and 2.5% more voluntary counseling and testing services. Although more health centers would have been needed to evaluate performance-based financing, we found that high use of CBHI in Rwanda was an important contributor to improving human immunodeficiency virus/acquired immunodeficiency syndrome services in rural health centers in Rwanda.

The measurement of relative efficiency of general practice and the implications for policy makers

PURPOSE

This study aimed to compare technical efficiency of general practice (GP) delivered by the twenty Regions of Italy's decentralized healthcare system and to determine if it was affected by contextual factors.

METHODS

First, we calculated the Regional efficiency scores by means of Data Envelopment Analysis. Then we carried out a regression analysis to investigate the influence of contextual factors on the efficiency in the provision of GP services.

RESULTS

Six Northern Regions were identified as efficient using the best combinations of general practitioners to deliver a given level of GP outcomes. Compared with peer benchmarks, inefficient Regions used more (on-call and regular) general practitioners with important underproductions of outputs (e.g. avoidable hospitalizations). The regression analysis showed a negative relationship between efficiency and the Regional total health care expenditures as percentage of its Gross Domestic Product.

DISCUSSION

Improving efficiency of GP services delivery is likely to result in reduced health expenditures. Since there is a general tendency in Europe to decentralize governmental systems of countries and Italy can be seen as an extreme example of this trend, we consider our findings of high relevance for international comparative studies on performance of primary care systems.

Technical Efficiency and Scale Efficiency of District Hospitals

The Government of Tamil Nadu state in India has been implementing various health sector reforms (for example, expansion and upgradation of public health facilities, provision of round the clock services in selected primary health centres and continuous availability of quality medicines decentralisation) in a bid to improve efficiency in health care. However, few attempts have been made to make an estimate of the efficiency of hospitals in Tamil Nadu as well as in India till date. The objectives of this study are: (i) to estimate the relative technical efficiency (TE) and scale efficiency (SE) of a sample of public hospitals in Tamil Nadu; and (ii) to demonstrate policy implications for health sector policy makers. The Data Envelopment Analysis (DEA) approach, a well-known operations research (OR) technique for evaluating the relative efficiency of a set of similar decision making units (DMU), was used to estimate the efficiency of these hospitals. To do so we made use of the data collected from the Directorate of Medical and Rural Health Services (DMRHS) for 29 districts of Tamil Nadu in 2004–05. The output data included are outpatient visits, number of inpatients, number of surgeries undertaken, number of deliveries and number of emergency cases. The numbers of staff members and bed strength were used as input. Of the 29 hospitals, it was found that 52 per cent were technically efficient as they had relative efficiency score 1.00 and lie on the efficiency frontier, while the remaining 48 per cent were technically inefficient and can use some of the efficient hospitals as their peers to improve their efficiency. Further, the average scale efficiency among the inefficient hospitals was 81 per cent, which implies that the scale inefficient hospitals could reduce their size by 19 per cent without reducing their current output levels.

Separating managerial inefficiency from influences of the operating environment: an application in dialysis

In any production unit, the ability to achieve technical efficiency is influenced by characteristics of the external operating environment. This study uses the Greek dialysis sector to employ a previously reported frontier procedure to obtain a measure of managerial inefficiency that controls for exogenous features. The sample consisted of 124 dialysis facilities. Two inputs -nursing staff and dialysis machines- and one output -dialysis sessions--were used in an input-oriented, variable-returns-to-scale DEA model. Input slacks were regressed against environmental characteristics such as ownership, location, operating years and facility size, and parameter estimates were used to adjust primary input data. New efficiency scores were generated to measure managerial inefficiency. Older, public, regional facilities were operating under unfavorable circumstances, whereas newer, private, Athens-based facilities under favorable conditions. This respectively generated lower and higher efficiency scores than would have been attained on a level "playing field". After adjustment, scores reflected only management inefficiency and could be compared fairly. This study emphasizes the importance of efficiency comparisons, which take into account external conditions beyond the influence ofmanagement, as these have been shown to under- or overstate true management inefficiency.

A multiple stage approach for performance improvement of primary healthcare practice

Chilean primary healthcare practice is analyzed using a Data Envelopment Analysis (DEA) multiple stage approach. We estimate the efficiency level of 259 municipalities nationwide. Since the efficiency score by itself is of limited value for decision making, we use a multivariate tool to help explain the effect of relevant factors. First, we use a cluster analysis to homogenize the units under study. Second, we use DEA to estimate the efficiency levels, which varies from 61% to 71% for urban municipalities, and from 51% to 56% in rural ones. Third, we use bootstrap to estimate confidence intervals for the efficiency scores, and a Biplot method to identify adequate variables to include in the Tobit Model, which is our last stage. We identify six factors associated with rural municipalities' operational efficiency, and two with urban ones. Knowing the efficiency level of municipalities can help determine ways to improve their efficiency.

Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review

BACKGROUND

Over the past years, Greece has undergone several endeavors aimed at modernizing and improving national health care services with a focus on PHC. However, the extent to which integrated primary health care has been achieved is still questioned.

PURPOSE

This paper explores the extent to which integrated primary health care (PHC) is an issue in the current agenda of policy makers in Greece, reporting constraints and opportunities and highlighting the need for a policy perspective in developing integrated PHC in this Southern European country.

METHODS

A systematic review in PubMed/Medline and SCOPUS, along with a hand search in selected Greek biomedical journals was undertaken to identify key papers, reports, editorials or opinion letters relevant to integrated health care.

RESULTS

Our systematic review identified 198 papers and 161 out of them were derived from electronic search. Fifty-three papers in total served the scope of this review and are shortly reported. A key finding is that the long-standing dominance of medical perspectives in Greek health policy has been paving the way towards vertical integration, pushing aside any discussions about horizontal or comprehensive integration of care.

CONCLUSION

Establishment of integrated PHC in Greece is still at its infancy, requiring major restructuring of the current national health system, as well as organizational culture changes. Moving towards a new policy-based model would bring this missing issue on the discussion table, facilitating further development.

Factors affecting productive efficiency in primary care clinics

This study examines factors affecting the productive efficiency of primary care clinics. The empirical analysis uses a single-stage stochastic frontier regression model, in which factors affecting productive efficiency are specified as part of the inefficiency error component and estimated simultaneously with the production function. The study population includes primary care clinics in the US Military Health System from 1999 through 2003; the analytical data set is an unbalanced panel of 442 observations. The study's main results were that primary care clinics not associated with medical centres had significantly higher levels of productive efficiency than those associated with medical centres and that having proportionately more civilian staff (and thus less turnover) had a positive impact on productive efficiency. Due to their nature, these findings would be expected to also be applicable to the production of primary care in other settings. A key implication of the results is that improvements in productive efficiency should be a top priority, given the possibility for providing more primary care visits without increases in cost.

The effect of environmental factors on technical and scale efficiency of primary health care providers in Greece

BACKGROUND

The purpose of this study was to compare technical and scale efficiency of primary care centers from the two largest Greek providers, the National Health System (NHS) and the Social Security Foundation (IKA) and to determine if, and how, efficiency is affected by various exogenous factors such as catchment population and location.

METHODS

The sample comprised of 194 units (103 NHS and 91 IKA). Efficiency was measured with Data Envelopment Analysis (DEA) using three inputs, -medical staff, nursing/paramedical staff, administrative/other staff- and two outputs, which were the aggregated numbers of scheduled/emergency patient visits and imaging/laboratory diagnostic tests. Facilities were categorized as small, medium and large (<15,000, 15,000-30,000 and >30,000 respectively) to reflect catchment population and as urban/semi-urban or remote/island to reflect location. In a second stage analysis, technical and scale efficiency scores were regressed against facility type (NHS or IKA), size and location using multivariate Tobit regression.

RESULTS

Regarding technical efficiency, IKA performed better than the NHS (84.9% vs. 70.1%, Mann-Whitney P < 0.001), smaller units better than medium-sized and larger ones (84.2% vs. 72.4% vs. 74.3%, Kruskal-Wallis P < 0.01) and remote/island units better than urban centers (81.1% vs. 75.7%, Mann-Whitney P = 0.103). As for scale efficiency, IKA again outperformed the NHS (89.7% vs. 85.9%, Mann-Whitney P = 0.080), but results were reversed in respect to facility size and location. Specifically, larger units performed better (96.3% vs. 90.9% vs. 75.9%, Kruskal-Wallis P < 0.001), and urban units showed higher scale efficiency than remote ones (91.9% vs. 75.3%, Mann-Whitney P < 0.001). Interestingly 75% of facilities appeared to be functioning under increasing returns to scale. Within-group comparisons revealed significant efficiency differences between the two primary care providers. Tobit regression models showed that facility type, size and location were significant explanatory variables of technical and scale efficiency.

CONCLUSION

Variations appeared to exist in the productive performance of the NHS and IKA as the two main primary care providers in Greece. These variations reflect differences in primary care organization, economical incentives, financial constraints, sociodemographic and local peculiarities. In all technical efficiency comparisons, IKA facilities appeared to outperform NHS ones irrespective of facility size or location. In respect to scale efficiency, the results were to some extent inconclusive and observed differences were mostly insignificant, although again IKA appeared to perform better.

The short-term effect on technical and scale efficiency of establishing regional health systems and general management in Greek NHS hospitals

OBJECTIVES

The Greek National Health System has been subjected to a reform initiative in 2001. The new legislation required hospitals to operate as administrative and economic decentralized units, under the control of newly established Regional Health Systems. In addition, Professional Managers have been appointed and signed "efficiency contracts", which supposedly committed them to run the hospitals effectively and efficiently. The present study aims at estimating the efficiency impact of this reform.

METHODS

Data Envelopment Analysis was employed with included inputs being the number of medical staff employees, other hospital employees and staffed beds, whereas outputs were the case-mix adjusted inpatient cases, outpatient visits and surgical operations performed. The technical and scale efficiencies of a sample of 51 general acute National Health System hospitals have been comparatively examined before and after the reform.

RESULTS

The analysis surprisingly indicates that technical and scale efficiency has been reduced following the policy changes.

CONCLUSIONS

It appears that the expected benefits from the reform have not in general been achieved, at least in the short-run. This result is examined in light of coexisting administrative and organizational factors, which are impeding the reform process.

Balancing efficiency of health services and equity of access in remote areas in Greece

Data envelopment analysis (DEA) was used to investigate the efficiency of a set of small-scaled Greek hospitals known as hospital-health centers (HHCs). These facilities naturally provide primary and secondary care but are also expected to function as health centers addressing mostly preventive medicine, hygiene and other public health issues. They are located in remote rural areas and serve the relatively small local populations. This study aimed to obtain insight on their productive efficiency in light of their particular role. The sample consisted of 17 from the 18 units existing in the Greek NHS. Variables chosen to characterize production were numbers of doctors, nurses and beds as inputs, and admissions, outpatient visits and preventive medical services as outputs. The DEA model was input oriented, allowed for constant returns to scale and units were ranked according to a benchmarking approach. Analyses were performed with and without the preventive medicine variable and the results demonstrated technical inefficiencies 26.77 and 25.13%, respectively. Location appeared to affect performance, with remote units, e.g. on small islands, more inefficient. This raises the question if correcting reduced efficiency compromises equity of service access for highly dependent populations. Moreover, we observed superior performance of units additionally offering preventive medical services. This generates another question as to the role these facilities should play in our currently changing health care system.

Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application

BACKGROUND

The Data Envelopment Analysis (DEA) method has been fruitfully used in many countries in Asia, Europe and North America to shed light on the efficiency of health facilities and programmes. There is, however, a dearth of such studies in countries in sub-Saharan Africa. Since hospitals and health centres are important instruments in the efforts to scale up pro-poor cost-effective interventions aimed at achieving the United Nations Millennium Development Goals, decision-makers need to ensure that these health facilities provide efficient services. The objective of this study was to measure the technical efficiency (TE) and scale efficiency (SE) of a sample of public peripheral health units (PHUs) in Sierra Leone.

METHODS

This study applied the Data Envelopment Analysis approach to investigate the TE and SE among a sample of 37 PHUs in Sierra Leone.

RESULTS

Twenty-two (59%) of the 37 health units analysed were found to be technically inefficient, with an average score of 63% (standard deviation = 18%). On the other hand, 24 (65%) health units were found to be scale inefficient, with an average scale efficiency score of 72% (standard deviation = 17%).

CONCLUSION

It is concluded that with the existing high levels of pure technical and scale inefficiency, scaling up of interventions to achieve both global and regional targets such as the MDG and Abuja health targets becomes far-fetched. In a country with per capita expenditure on health of about USD 7, and with only 30% of its population having access to health services, it is demonstrated that efficiency savings can significantly augment the government's initiatives to cater for the unmet health care needs of the population. Therefore, we strongly recommend that Sierra Leone and all other countries in the Region should institutionalize health facility efficiency monitoring at the Ministry of Health headquarter (MoH/HQ) and at each health district headquarter.

Technical efficiency of public district hospitals and health centres in Ghana: a pilot study

Background

The Government of Ghana has been implementing various health sector reforms (e.g. user fees in public health facilities, decentralization, sector-wide approaches to donor coordination) in a bid to improve efficiency in health care. However, to date, except for the pilot study reported in this paper, no attempt has been made to make an estimate of the efficiency of hospitals and/or health centres in Ghana. The objectives of this study, based on data collected in 2000, were: (i) to estimate the relative technical efficiency (TE) and scale efficiency (SE) of a sample of public hospitals and health centres in Ghana; and (ii) to demonstrate policy implications for health sector policy-makers.

Methods

The Data Envelopment Analysis (DEA) approach was used to estimate the efficiency of 17 district hospitals and 17 health centres. This was an exploratory study.

Results

Eight (47%) hospitals were technically inefficient, with an average TE score of 61% and a standard deviation (STD) of 12%. Ten (59%) hospitals were scale inefficient, manifesting an average SE of 81% (STD = 25%). Out of the 17 health centres, 3 (18%) were technically inefficient, with a mean TE score of 49% (STD = 27%). Eight health centres (47%) were scale inefficient, with an average SE score of 84% (STD = 16%).

Conclusion

This pilot study demonstrated to policy-makers the versatility of DEA in measuring inefficiencies among individual facilities and inputs. There is a need for the Planning and Budgeting Unit of the Ghana Health Services to continually monitor the productivity growth, allocative efficiency and technical efficiency of all its health facilities (hospitals and health centres) in the course of the implementation of health sector reforms.

Analysing the Greek health system: a tale of fragmentation and inertia

The Greek health system does not yet offer universal coverage and has fragmented funding and delivery. Funding is regressive, with a reliance on informal payments, and there are inequities in access, supply and quality of services. Inefficiencies arise from an over reliance on relatively expensive inputs, as evidenced by the oversupply of specialists and under-supply of nurses. Resource allocation mechanisms are historical and political with no relation to performance or output, therefore providers have little incentive to improve productivity. Some options for future health system reform include focusing on coordinating funding by developing a monopsony purchaser with the aim of improving quality of services and efficiency in the health system and changing provider incentives to improve productivity.

Efficiency measurement of hemodialysis units in Greece with data envelopment analysis

This paper reports on a study of the suitability of data envelopment analysis for measuring efficiency of hemodialysis units in Greece. The sample consists of 118 such units operating in the public and private sector. Production characteristics were designated in terms of two input measures--nursing staff and dialysis machines--and one output measure, namely the number of patients treated per month. The DEA model selected was input oriented, allowed for variable returns to scale and the units were ranked according to a benchmarking approach. The results yielded mean efficiency scores of 65.04% and 82.21% for the public sector and private sector units, respectively. Independent sample t-tests showed statistically significant differences between these scores. The units were also classified, according to location, as either being in Athens, Thessalonica or another region and the procedure was repeated. The results yielded mean efficiency scores of 58.89%, 61.48% and 67.51%, respectively. Comparison, in this case, indicated significant differences between the public sector units located Athens from those located in Thessalonica or elsewhere. The overall findings are encouraging for the potential of DEA in this setting and generate the need for further research in order to validate any conclusions.

Non-parametric and parametric applications measuring efficiency in health care

This paper reviews 188 published papers on frontier efficiency measurement. The techniques used are mainly based on non-parametric data envelopment analysis, but there is increasing use of parametric techniques, such as stochastic frontier analysis. Applications both to hospitals and wider health care areas are reviewed and summarised, and some meta-type analysis undertaken. Results appear to confirm earlier findings that public provision demonstrates less variability than private. The paper is meant as a resource in itself, but also points to the future in terms of possible directions for research in efficiency measurement in health care and health.