Factors influencing the technical efficiency of diabetes care at primary care level in Mexico

Diabetes prevalence is rising globally, especially in low- and middle-income countries like Mexico, posing challenges for healthcare systems that require efficient primary care to manage the disease. However, healthcare efficiency is influenced by factors beyond decision-makers, including socioeconomic and political conditions. This study aims to evaluate the technical efficiency of primary healthcare for diabetes patients in Mexico over a 12-year period and explore the impact of contextual variables on efficiency. A longitudinal analysis was conducted using administrative and socio-demographic data from 242 health jurisdictions between 2009 and 2020. Data envelopment analysis with bootstrapping and output orientation was used to measure the technical efficiency; health resources in infrastructure and human resources were used as inputs. As outcome, the number of patients receiving treatment for diabetes and the number of patients with controlled diabetes were considered. Machine learning algorithms were employed to analyse multiple factors affecting the provision of diabetes health services and assess heterogeneity and trends in efficiency across different health jurisdictions. The average technical efficiency in primary healthcare for diabetes patients was 0.44 (CI: 0.41-0.46) in 2009, reaching a peak of 0.71 (CI: 0.69-0.72) in 2016, and moderately declining to 0.60 (CI: 0.57-0.62) in 2020; these differences were statistically significant. The random forest analysis identified the marginalization index, primary healthcare coverage, proportion of indigenous population and demand for health services as the most influential variables in predicting efficiency levels. This research underscores the crucial need for the formulation of targeted public policies aimed at extending the scope of primary healthcare services, with a particular focus on addressing the unique challenges faced by marginalized and indigenous populations. According to our results, it is necessary that medical care management adjust to the specific demands and needs of these populations to guarantee equitable care in Mexico.

Evaluating health systems' efficiency towards universal health coverage: A data envelopment analysis

To estimate the technical efficiency of health systems toward achieving universal health coverage (UHC) in 191 countries. We applied an output-oriented data envelopment analysis approach to estimate the technical efficiency of the health systems, including the UHC index (a summary measure that captures both service coverage and financial protection) as the output variable and per capita health expenditure, doctors, nurses, and hospital bed density as input variables. We used a Tobit simple-censored regression with bootstrap analysis to observe the socioeconomic and environmental factors associated with efficiency estimates. The global UHC index improved from the 2019 estimates, ranged from 48.4 (Somalia) to 94.8 (Canada), with a mean of 76.9 (std. dev.: ±12.0). Approximately 78.5% (150 of 191) of the studied countries were inefficient (ϕ < 1.0) with respect to using health system resources toward achieving UHC. By improving health system efficiency, low-income, lower-middle-income, upper-middle-income, and high-income countries can improve their UHC indices by 4.6%, 5.5%, 6.8%, and 4.1%, respectively, by using their current resource levels. The percentage of health expenditure spent on primary health care (PHC), governance quality, and the passage of UHC legislation significantly influenced efficiency estimates. Our findings suggests health systems inefficiency toward achieving UHC persists across countries, regardless of their income classifications and WHO regions, as well as indicating that using current level of resources, most countries could boost their progress toward UHC by improving their health system efficiency by increasing investments in PHC, improving health system governance, and where applicable, enacting/implementing UHC legislation.

Research on the Operational Efficiency of Basic Medical Insurance for Urban Employees in China-Based on Three-Stage DEA Model

Purpose

To conduct a three-stage data envelopment analysis (DEA) of the operational efficiency of urban employee basic medical insurance (UEBMI) across 31 provinces in China from 2012 to 2021.

Methods

Utilized a three-stage DEA model, this study measured and evaluated the operational efficiency of urban employee basic medical insurance within China's 31 provinces.

Results

The operational efficiency of urban employee basic medical insurance in China was notably low, displaying significant disparities across different regions and periods. Substantial room for improvement exists. Environmental factors, including urbanization level and unemployment rate, wielded a pronounced influence on the operational efficiency of China's employee medical insurance. Conversely, the fiscal revenue and expenditure ratio hindered the enhancement of employee medical insurance efficiency.

Conclusion

This study held valuable insights for enhancing the operational efficiency of China's urban employee basic medical insurance. To effectively improve insurance efficiency, the following recommendations are put forth: firstly, relevant departments should escalate resource investments and optimize resource utilization based on rational allocation; secondly, enhance legislation and regulations, fortify fund oversight, and ensure equitable and judicious utilization of the medical insurance fund; finally, leveraging modern high-tech advancements can comprehensively elevate the operational efficiency of the employee medical insurance fund. Ultimately, with the advent of cutting-edge technology, the operational efficiency of employee medical insurance fund can be comprehensively elevated.

Stochastic frontier approach to efficiency analysis of health facilities in providing services for non-communicable diseases in eight LMICs

BACKGROUND

The rising burden of non-communicable diseases presents an increasing public health challenge to many low- and middle-income countries. This problem may be compounded in health systems with lower levels of technical efficiency (TE).

METHODS

This study used recent Service Provision Assessments data to estimate the level of TEs of health facilities in eight countries. Initially, the general and disease-specific service readiness indexes are estimated. Finally, the production function is estimated using the exposures and the outcomes of the model.

RESULTS

Evidence shows that the general and disease-specific service readiness indexes are significantly associated with an increase in the number of outpatient visits. Outpatient visits may increase by 14% with an increase in health worker density. Similarly, outpatient visits may increase by 0.3% with a unit increase in the general and diabetes service readiness indexes. Furthermore, outpatient visits may increase by 0.4% and 0.8% with an increase in services readiness for cardiovascular and respiratory diseases. respectively. Overall, the level of TE score suggests the need for improvement.

CONCLUSIONS

Facility-level service readiness for chronic diseases is quite low. Therefore, improving health outcomes related to chronic diseases requires urgent investment in high-quality health systems in these countries.

Effect of surgeon experience on technical efficiency

Surgeon experience certainly improves their technical efficiency although it also causes physiological changes with aging. The authors hypothesized that surgeons' technical efficiency improves with increasing experience up to a point where it then decreases, which is a concave relationship. The authors collected data from all the surgical procedures performed at University Hospital from April through September in 2013-19. The dependent variable was defined as surgeons' technical efficiency scores that were calculated using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. Inputs were defined as (1) the number of assistants and (2) the duration of surgical operation. The output was defined as the surgical fee for each surgery. Surgeon experience was defined as the number of years since medical school graduation. Five control variables were selected: surgical volume, gender, academic rank, surgical specialty, and the year of surgery. Multiple regression analysis using pooled and random-effects Tobit models was performed for our panel data. Totally 20,375 surgical procedures performed by 264 surgeons in 42 months were analyzed. The coefficients of experience and the square of experience were not significantly different from zero. The other coefficients were also insignificant. Surgeons' technical efficiency does not have a concave relationship with experience.

Data envelopment analysis for ambulance services of different service providers in urban and rural areas in Ministry of Health Malaysia

Introduction

Ambulance services are pivotal in any country's healthcare system. An efficient ambulance service not only decreases patient mortality rate but also allows resource prioritization for better outputs. This study aims to measure the efficiency of ambulance services provided by health facilities in the Ministry of Health (MOH), Malaysia.

Methods

This cross-sectional study analyzed the efficiency of 76 Decision-Making Units (DMUs) or health facilities, consisting of 62 health clinics and 14 hospitals. Data Envelopment Analysis (DEA) was used for computing efficiency scores while adopting the Variable Return to Scale (VRS) approach. The analysis was based on input orientation. The input was the cost of ambulance services, while the output for this analysis was the distance coverage (in km), the number of patients transferred, and hours of usage (in hours). Subsequent analysis was conducted to test the Overall Technical Efficiency (OTE), the Pure Technical Efficiency (PTE), the Scale Efficiency (SE), and the Return to Scale with the type of health facilities and geographical areas using a Mann-Whitney U-test and a chi-square test.

Results

The mean scores of OTE, PTE, and SE were 0.508 (±0.207), 0.721 (±0.185), and 0.700 (±0.200), respectively. Approximately, 14.47% of the total health facilities were PTE. The results showed a significant difference in OTE and SE between ambulance services in hospitals and health clinics (p < 0.05), but no significant difference in PTE between hospitals and clinics (p>0.05). There was no significant difference in efficiency scores between urban and rural health facilities in terms of ambulance services except for OTE (p < 0.05).

Discussion

The ambulance services provided in healthcare facilities in the MOH Malaysia operate at 72.1% PTE. The difference in OTE between hospitals and health clinics' ambulance services was mainly due to the operating size rather than PTE. This study will be beneficial in providing a guide to the policymakers in improving ambulance services through the readjustment of health resources and improvement in the outputs.

Measuring Productivity and Relative Efficiency of Public Tertiary Traditional Chinese Medicine Hospitals in Hubei, China

Improving the productivity and relative efficiency of traditional Chinese medicine (TCM) hospitals is pivotal for hospital managers and policymakers to optimize the utilization of TCM resources in China. This study aimed to measure the productivity and relative efficiency of public tertiary TCM hospitals in Hubei Province. The input and output indicators data were extracted from the Health Commission of Hubei Province (HCHP) from 2019 to 2021. The Bootstrap-Malmquist-DEA model was employed to measure the productivity and relative efficiency of the hospitals. The statistical significance was set at P < .05. The numbers of total diagnostic patients and discharged patients declined by 23.44% and 28.34% from 2019 to 2020, and then increased by 25.76% and 20.44% respectively from 2020 to 2021. The average bias-corrected technical efficiency (TE) scores of the TCM hospitals from 2019 to 2021 were 0.8391, 0.8048, and 0.8559, indicating good efficiency. The average total factor productivity (TFP) in 2020 and 2021 decreased compared to that in 2019, with scores of 0.7479 and 0.8996, respectively. Between 2019 and 2020, the TFP changes among 19 out of 21 (90.48%) TCM hospitals and the technological changes (TC) among 20 out of 21 (95.24%) were less than 1.0000 (P < .05). The TFP changes of 17 out of 21 (80.95%) TCM hospitals and the TC of 20 out of 21 (95.24%) were less than 1.0000 (P < .05) between 2019 and 2021. COVID-19 might have constrained the provision of healthcare services by the public tertiary TCM hospitals in Hubei Province. Priority should be given to the utilization of healthcare resources, performance evaluation, information system strengthening, and internal hospital management to boost technical efficiency. TCM hospitals need to focus further on technology innovation to improve their technological progress.

How Does the Land Rental Market Participation Affect Household Efficiency? Evidence from Rural China

The active land rental market affects inter-household efficiency. Using nationally representative household panel data in China from 2017 to 2019, we estimate rural household efficiency with consideration of diversification, and analyze the effect of land rental market participation on household efficiency using a control function approach. Results show that: (1) the mean technical efficiency and allocative efficiency were 0.45 and 0.64 in 2017 and 0.44 and 0.66 in 2019, respectively, suggesting the existence of efficiency loss; (2) land rented-in activities improve rural households' technical efficiency but not allocative efficiency; (3) land rented out activities decrease household technical efficiency but increase allocative efficiency. Further analysis showed that farm size heterogeneity might be the main reason for the efficiency difference. Households with large farms and plot sizes on rented land have significant advantages in technical efficiency and insignificant impacts on allocative efficiency. The results explain why the land rental market promotes efficient land transfer, but households with a large farm size are still rare in rural areas. Finally, we provide suggestions on how to stimulate the land rental market under diversification circumstances.

Green fodder cultivation improves technical efficiency of dairy farmers in semi-arid tropics of central India: a micro-analysis

This study assessed the impact of improved green fodder production activities on technical efficiency (TE) of dairy farmers in climate vulnerable landscapes of central India. We estimated stochastic production frontiers, considering potential self-selection bias stemming from both observable and unobservable factors in adoption of fodder interventions at farm level. The empirical results show that TE for treated group ranges from 0.55 to 0.59 and that for control ranges from 0.41 to 0.48, depending on how biases are controlled. Additionally, the efficiency levels of both adopters and non-adopters would be underestimated if the selectivity bias is not appropriately accounted. As the average TE is consistently higher for adopter farmers than the control group, promoting improved fodder cultivation would increase input use efficiency, especially in resource-deprived small holder dairy farmers in the semi-arid tropics.

Analysis of the Operational Efficiency of Basic Medical Insurance for Urban and Rural Residents: Based on a Three-Stage DEA Model

Following the integration of the urban residents' medical insurance into the new rural cooperative medical insurance in 2016, China has now formed a basic medical insurance system with the urban workers' basic medical insurance system and the rural residents' basic medical insurance system as the main entities. With the development of basic medical insurance, the protection for residents is becoming more and more comprehensive, and its fund expenditure also increases, so it is necessary to research the efficiency of the medical insurance fund expenditure. This paper conducts a three-stage DEA analysis of the efficiency of basic health insurance for urban and rural residents in 31 provinces, based on a Chinese panel data from 2017 to 2020. It is found that China's health insurance operation is still in the development stage, with four regions in the efficiency frontier and Guizhou province having the lowest efficiency value nationwide. The GDP and fiscal investment on social security effectively reduce the input redundancy in the basic health insurance operation, which contributes to the efficiency of the health insurance operation. This study further proposes suggestions and countermeasures to improve the operational efficiency of China's basic health insurance, based on the empirical results: (1) develop the economy and broaden the financing sources; (2) improve the level of health care services and improve the efficiency driven by quality; and (3) improve the level of health insurance supervision through multiple measures.

Can a global budget improve health care efficiency? Experimental evidence from China

Health care in China suffers from substantial allocative inefficiency in the delivery system and technical inefficiency within hospitals. To ameliorate this problem in rural areas, the Analysis of Provider Payment Reforms on Advancing China's Health (APPROACH) project shifted the payment method of China's rural health insurance scheme for county hospitals from fee-for-service to a novel global budget. In particular, APPROACH global budget incentivized system-level allocative efficiency by reimbursing county hospitals at higher tariffs for gatekeeping and averting out-of-county (OOC) admissions among local patients they could treat. APPROACH conducted a large-scale randomized controlled trial of the global budget in 56 counties (22 million enrollees) of Guizhou province during 2016-2017. Applying randomization inference to claims data, we find a significant shift of inpatient utilization and expenditure from OOC hospitals to county hospitals. At county hospitals, average expenditure per admission and length of stay decreased, though not significantly. Effects on readmissions show no clear sign of compromised quality. We further find limited effect heterogeneity with respect to treatment and hospital characteristics. Overall, APPROACH global budget may offer a framework for improving health care efficiency without sacrificing quality.

Two-Step Estimation of the Impact of Contextual Variables on Technical Efficiency of Hospitals: The Case Study of Public Hospitals in Iran

Background: Measuring the efficiency and productivity of hospitals is a key tool to cost contamination and management that is very important for any healthcare system for having an efficient system. Objective: The purpose of this study is to examine the effects of contextual factors on hospital efficiency in Iranian public hospitals. Methods: This was a quantitative and descriptive-analytical study conducted in two steps. First, we measured the efficiency score of teaching and non-teaching hospitals by using the Data Envelopment Analysis (DEA) method. Second, the relationship between efficiency score and contextual factors was analyzed. We used median statistics (first and third quarters) to describe the concentration and distribution of each variable in teaching and non-teaching hospitals, then the Wilcoxon test was used to compare them. The Spearman test was used to evaluate the correlation between the efficiency of hospitals and contextual variables (province area, province population, population density, and the number of beds per hospital). Results: On average, the efficiency score in non-teaching hospitals in 31 provinces was 0.67 and for teaching hospitals was 0.54. Results showed that there is no significant relationship between the efficiency score and the number of hospitals in the provinces (p = 0.1 and 0.15, respectively). The relationship between the number of hospitals and the population of the province was significant and positive. Also, there was a positive relationship between the number of beds and the area of the province in both types of teaching and non-teaching hospitals. Conclusion: Multilateral factors influence the efficiency of hospitals and to address hospital inefficiency multi-intervention packages focusing on the hospital and its context should be developed. It is necessary to pay attention to contextual factors and organizational architecture to improve efficiency.

Association between efficiency and quality of care of public healthcare facilities: Evidence from Pakistan

BACKGROUND

Maternal and child health is an important component of the Sustainable Development Goals. Pakistan has one of the worst maternal and neonatal health outcomes in the world. This is despite significant health system investments across the country.

AIMS

The objectives of this study are twofold. First, the study estimates the technical efficiency of the public healthcare facilities in Pakistan, defined as the number of obstetric deliveries compared to the number of medical specialists, nurses, and other health and non-health staff members. Second, the study evaluates the relationship between efficiency and quality of care; the latter is measured in terms of maternal and neonatal mortality.

MATERIALS & METHODS

The data were taken from the Pakistan Health Facility Assessment Survey. Efficiency score was calculated for 843 public healthcare facilities, using Stochastic Frontier Analysis. We then used two-stage residual inclusion approach with bootstrapping to evaluate the relationship between efficiency and quality.

RESULTS AND DISCUSSION

The average efficiency score was 0.48 (range: 0-1) and none of the public healthcare facilities were on the frontier, implying that efficiency gains can be made across the board. The relationship between efficiency and quality is found to be positive and statistically significant, that is, more efficient healthcare facilities also had lower rates of maternal and neonatal mortality.

CONCLUSION

We conclude that more efficient public healthcare facilities also had lower mortality rates, probably due to better infrastructure and health system financing.

Efficiency Measurement and Heterogeneity Analysis of Chinese Cultural and Creative Industries: Based on Three-Stage Data Envelopment Analysis Modified by Stochastic Frontier Analysis

Industry sustainability plays a vital role in shaping the environment for cultural and creative business development. However, considering the influence of the external environment and random factors on the technical efficiency (T.E.) of cultural and creative industries with the inherent defects of the traditional data envelopment analysis (DEA) model; this manuscript analyzed the operating efficiency of 56 cultural and creative enterprises using the three-stage DEA model from 2012 to 2018. An analysis of the results shows that differences in efficiency exist between stage one and stage three DEA. Furthermore, the environmental elements and statistical noise measured by the stochastic frontier analysis (SFA) in stage two reveal positive and negative influences on the creative cultural enterprises at different stages. As a result, the overall efficiency of the listed cultural and creative industries was revealed to be low in China. Finally, this study suggested effective countermeasures and recommendations for better-operating efficiency systems for cultural and creative enterprises.

The productive efficiency of community health service stations in China: Taking Shandong province as a case

The present study evaluated the efficiencies of community health service (CHS) stations based on a survey of 1246 CHS stations, covering nine subcategories in 16 cities in Shandong province. Data envelopment analysis (DEA) was applied to investigate the overall efficiency, the technical and the scale efficiency of community health care resources. The results are, the overall efficiency was 9.47%, and the overall efficiency was generally higher in the central-west region than in the east. There were 23.27% of CHS stations showing technically efficient. The technical efficiency was higher in the east (31.11%) relative to the central-west (19.72%), and 72.71% of CHS stations had a technical efficiency higher than the regional average efficiency. The scale efficiency was 9.31% for CHS stations in Shandong province, being the decisive factor for overall efficiency, and 68.96% of CHS stations showed a scale efficiency above the regional average. Stations held by enterprises and universities, and extended by tertiary hospitals had lower efficiencies than other types of CHS stations. In conclusion, the CHS stations had low efficiencies in general, and scale inefficiencies were the main cause. Related suggestions to improve the efficiency are provided accordingly.

Evaluating R&D efficiency of China’s listed lithium battery enterprises

Promoting the growth of the lithium battery sector has been a critical aspect of China’s energy policy in terms of achieving carbon neutrality. However, despite significant support on research and development (R&D) investments that have resulted in increasing size, the sector seems to be falling behind in technological areas. To guide future policies and understand proper ways of promoting R&D efficiency, we looked into the lithium battery industry of China. Specifically, data envelopment analysis (DEA) was used as the primary approach based on evidence from 22 listed lithium battery enterprises. The performance of the five leading players was compared with that of the industry as a whole. Results revealed little indication of a meaningful improvement in R&D efficiency throughout our sample from 2010 to 2019. However, during this period, a significant increase in R&D expenditure was witnessed. This finding was supported, as the results showed that the average technical efficiency of the 22 enterprises was 0.442, whereas the average pure technical efficiency was at 0.503, thus suggesting that they were suffering from decreasing returns to scale (DRS). In contrast, the performance of the five leading players seemed superior because their average efficiency scores were higher than the industry’s average. Moreover, they were experiencing increasing scale efficiency (IRS). We draw on these findings to suggest to policymakers that supporting technologically intensive sectors should be more than simply increasing investment scale; rather, it should also encompass assisting businesses in developing efficient managerial processes for R&D.

Efficiency and Productivity of Public Hospitals in Serbia Using DEA-Malmquist Model and Tobit Regression Model, 2015-2019

Improving productivity within health systems using limited resources is a matter of great concern. The objectives of the paper were to evaluate the productivity, efficiency, and impact of environmental factors on efficiency in Serbian hospitals from 2015-2019. Data envelopment analysis, Malmquist index and Tobit regression were applied to hospital data from this period, and public hospitals in Serbia exhibited a great variation regarding their capacity and performance. Between five and eight hospitals ran efficiently from 2015 to 2019, and the productivity of public hospitals increased whereas technical efficiency decreased in the same period. Tobit regression indicated that the proportion of elderly patients and small hospital size (below 200 beds) had a negative correlation with technical efficiency, while large hospital size (between 400 and 600 beds), the ratio of outpatient episodes to inpatient days, bed turnover rate and the bed occupation rate had a positive correlation with technical efficiency. Serbian public hospitals have considerable space for technical efficiency improvement and public action must be taken to improve resource utilization.

Efficiency Evaluation of China's Public Sports Services: A Three-Stage DEA Model

Improving the level of public sports services enhances citizens’ physical fitness by implementing the national fitness program. A systematic and scientific efficiency evaluation is a prerequisite for optimizing and improving the level of public sports services in China. Based on data of the Chinese Statistic Yearbook, this study adopted the three-stage data envelopment analysis (DEA) model to measure and analyze the efficiency of public sports services in 31 provinces in China in 2016. To analyze the efficiency of public sports services, technical efficiency was decomposed into pure technical efficiency and scale efficiency. Simultaneously, environmental variables were added to improve accuracy. The results showed that scale efficiency was overestimated, and external technical efficiency was underestimated, before the elimination of external factors and environmental variables. Environmental factors significantly impacted the efficiency of public sports services. Regional gross domestic product (GDP) had a potentially positive impact, while population size partially restricted public sports service efficiency. After eliminating the impact of environmental and random factors, the comprehensive efficiency, pure technical efficiency, and scale efficiency of public sports services all showed improvement in varying degrees. The results provide beneficial insights for the formulation of rational improvement policies for public sports services.

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.

Economic evaluation and health systems strengthening: a review of the literature

Health systems strengthening (HSS) is firmly on the global health and development agenda. While a growing evidence base seeks to understand the effectiveness of HSS, there is limited evidence regarding cost and cost-effectiveness. Without such evidence, it is hard to argue that HSS represents value for money and the level of investment needed cannot be quantified. This paper seeks to review the literature regarding the economic evaluation of HSS from low- and middle-income country (LMIC) settings, and to contribute towards the development of methods for the economic evaluation of HSS. A systematic search for literature was conducted in PubMed, Scopus and the Health Systems Evidence database. MeSH terms related to economic evaluation were combined with key words related to the concept of HSS. Of the 204 records retrieved, 52 were retained for full text review and 33 were included. Of these, 67% were published between January 2015 and June 2019. While many HSS interventions have system wide impacts, most studies (71%) investigated these impacts using a disease-specific lens (e.g. the impact of quality of care improvements on uptake of facility deliveries). HSS investments were categorized, with the majority being investments in platform efficiency (e.g. quality of care), followed by simultaneous investment in platform efficiency and platform capacity (e.g. quality of care and task shifting). This review identified a growing body of work seeking to undertake and/or conceptualize the economic evaluation of HSS in low- and middle-income countries. The majority assess HSS interventions using a disease-specific or programmatic lens, treating HSS in a similar manner to the economic evaluation of medicines and diagnostics. While this approach misses potential economies of scope from HSS investments, it allows for a preliminary understanding of relative value for money. Future research is needed to complement the emerging evidence base.

Global Healthcare Resource Efficiency in the Management of COVID-19 Death and Infection Prevalence Rates

The scale of impact of the COVID-19 pandemic on society and the economy globally provides a strong incentive to thoroughly analyze the efficiency of healthcare systems in dealing with the current pandemic and to obtain lessons to prepare healthcare systems to be better prepared for future pandemics. In the absence of a proven vaccine or cure, non-pharmaceutical interventions including social distancing, testing and contact tracing, isolation, and wearing of masks are essential in the fight against the worldwide COVID-19 pandemic. We use data envelopment analysis and data compiled from Worldometers and The World Bank to analyze how efficient the use of resources were to stabilize the rate of infections and minimize death rates in the top 36 countries that represented 90% of global infections and deaths out of 220 countries as of November 11, 2020. This is the first paper to model the technical efficiency of countries in managing the COVID-19 pandemic by modeling death rates and infection rates as undesirable outputs using the approach developed by You and Yan. We find that the average efficiency of global healthcare systems in managing the pandemic is very low, with only six efficient systems out of a total of 36 under the variable returns to scale assumption. This finding suggests that, holding constant the size of their healthcare systems (because countries cannot alter the size of a healthcare system in the short run), most of the sample countries showed low levels of efficiency during this time of managing the pandemic; instead it is suspected that most countries literally "threw" resources at fighting the pandemic, thereby probably raising inefficiency through wasted resource use.

A Survey of Broiler Farmers' Perceptions of Animal Welfare and their Technical Efficiency: A Case Study in Northeast China

This study was conducted to assess the current status of famers' perceptions of animal welfare and technical efficiency in broiler farms using a stochastic frontier analysis (SFA). In this study, 355 farms registered in Heilongjiang Province, China were surveyed, with 240 of them responding. The results showed that 75% of farmers recognize the importance of animal welfare, and 56.3% of them expressed their willingness to implement animal welfare on their farms without conditions or having a negative attitude. The technical efficiency of the farmers' ranged from 55% to 99%. All the variables assessed in this study had a statistical influence on production. Education, experience, and gender of farmers were significant variables and increased efficiency, while age and distance of a farm to the main road increased inefficiency. Based on our survey, we suggest that the implementation of animal welfare measures will require government subsidy or incentive, which could encourage 35% of farmers to implement animal welfare measures. To increase production efficiently, farmer needs to control the mortality rate, but the contribution of vaccine during production is below 1% (0.09%).

Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

How Do Pharmaceutical Companies Overcome a Corporate Productivity Crisis? Business Diversification into Medical Devices for Growth Potential

The purpose of this study was to analyze the performance of pharmaceutical companies’ business diversification into medical devices in terms of their technical efficiency (TE) as compared to that of traditional pharmaceutical companies. For a total of 174 externally audited pharmaceutical companies engaged in the drug product business between 2008 and 2019, pharmaceutical companies were classified into two groups according to medical device business diversification. The TE of pharmaceutical companies that diversify the medical device business was lower than that of traditional pharmaceutical companies. However, in terms of the meta-technology ratio (MTR) calculated using meta-frontier analysis, pharmaceutical companies diversified into medical devices showed higher MTR than the traditional pharmaceutical company group. The results imply that the corporate performance growth potential of traditional pharmaceutical companies is lower than that of pharmaceutical companies that have diversified into the medical device business.

Technical Efficiency of Maternal Health Services Provision in Public Hospitals of Northwest Ethiopia: A Two-Stage Data Envelopment Analysis

Introduction

Ethiopian health expenditure as a share of total government expenditure increased from 7.6% in 2013/14 to 8.1% in 2016/17. But it remained low even for the low-income country average expected share of 8.7%. It signifies the efficient use of scarce resources in the health sector is still critical to achieving sustainable development goals. But little evidence is available about public hospitals' technical efficiency in providing maternal health services. Therefore, the aim of this study was to assess the technical efficiency of maternal health services provision of public hospitals in Northwest Ethiopia.

Methods

Facility-based cross-sectional study was conducted among twelve randomly selected public hospitals. Input data (salary expenditure, non-salary expenditure, and the number of beds) and maternal health services output data (antenatal care, skilled delivery, and postnatal care) for a 2011 Ethiopian fiscal year (July 2018 to June 2019) were collected and entered into Epi-Data 3.1. We used both primary and secondary data collection procedures to determine independent variables and the dependent variable, respectively. We also used a two-stage input-oriented data envelopment analysis with variable returns to scale assumption.

Results

The study showed that hospitals included in this study wasted US$ 6833.50 for salary and US$ 3886.8 for non-salary expenditures. The study also revealed that the mean pure technical efficiency of public hospitals for maternal health service provision was 0.92±0.142, and their scale efficiency was 0.795±0.24. The hospital manager's experience year, the educational level of the manager, and the hospital service year associated positively with the technical efficiency. However, the catchment population and distance of another health facility associated negatively with technical efficiency.

Conclusion

The public hospitals' pure technical efficiency in the provision of maternal health services in Northwest Ethiopia was high. More than half of the public hospitals were technically efficient. The wasted amount of expenditures could be used for satisfying the unmet health services need of the population. Therefore, it is better to monitor the health facilities for the wise use of the existing resources for their best performance.

Evaluation of the Efficiency of Basic Sanitation Integrated Management in Brazilian Municipalities

This study aims to evaluate the level of technical efficiency of companies that perform the integrated management of basic sanitation in Brazilian municipalities. A Multiple Data Envelopment Analysis (M-DEA) model was applied to estimate the performance of water supply and sewage services in 1628 municipalities covering more than 56% of the Brazilian population, identifying the factors that most influence the efficiency of the sector in the years 2008 and 2016. The M-DEA methodology is an extension of Data Envelopment Analysis (DEA) with multiple DEA executions considering all combinations of inputs and outputs to calculate efficiency scores. The methodology reduces possible biases in the selection of resources and products of the model, ability to support decision-making in favor of improvements in the sector's efficiency based on national regulatory framework. The analyses show that the companies analyzed can increase their operating results and attendance coverage by more than 60%, given the current levels of infrastructure, human and financial resources in the sector. Based on the simulation of potential efficiency gains in Brazilian basic sanitation companies, the estimates show that the coverage of the population with access to sanitary sewage would go from the current 59.9% to 76.5%. The evidence found provides indications to subsidize sanitation management in the country at the micro-analytical level, enabling a better competitive position in the sector for the integrated management of basic sanitation and its universalization in Brazil.

Measuring the Efficiency of Fiscal Policies for Environmental Pollution Control and the Spatial Effect of Fiscal Decentralization in China

This paper uses both fiscal expenditure policy and fiscal revenue policy as input indicators and selects environmental pollution control results reflecting different forms and sources of pollution as output indicators. The efficiency of fiscal policies for environmental pollution control (EFPE) of 30 provincial-level administrative divisions in China from 2007 to 2017 is measured by adopting the data envelopment analysis (DEA) method. Then, the spatial effect of fiscal decentralization on EFPE is empirically analyzed by using the spatial lag model (SLM). The results show that EFPE values in China have been greatly improved overall since 2014. The change in technical efficiency (TE) is caused mainly by the change in pure technical efficiency (PTE). EFPE values have regional heterogeneity and convergence. The eastern region has clearly higher EFPE values than other regions. The growth rate of the low efficient region is greater than that of the high efficient region. Fiscal expenditure decentralization has a direct negative effect and spatial spillover effect on EFPE values, while fiscal revenue decentralization has a non-significant effect. Based on these results, this paper proposes the following policy implications: increasing the level of fiscal expenditure of environmental pollution control and improving the central transfer payment system for environmental protection; reforming the government performance assessment system and innovating the conditions of government expenditure on environmental pollution control; and promoting horizontal fiscal cooperation in cross-regional environmental governance.

Somatic cell counts, reproduction indicators, and technical efficiency in milk production: A stochastic frontier analysis for Spanish dairy farms

Health and reproductive conditions affect milk yields in dairy cows and may lead to differences in technical efficiency across farms. To investigate this, we created a novel panel data set of 197 dairy farms in northern Spain observed over the period 2006-2014 by combining information from 2 different sources and including data on production variables, somatic cell count, and reproduction indicators, as well as a genetic index. We used these data to estimate a stochastic production frontier where the somatic cell count, age at first calving, and calving interval are included as determinants of technical efficiency. Higher somatic cell count, greater age at first calving, and longer calving intervals were found to decrease technical efficiency, translating into significant losses in profits which we quantify through a simulation exercise. We also quantified the effect of genetic selection on profits, taking into account not only its direct effect on productivity but also its indirect effect through reduced technical efficiency due to the effect of genetic selection on the health and reproduction variables.

Technical Efficiency of Public and Private Hospitals in Beijing, China: A Comparative Study

Objective: With the participation of private hospitals in the health system, improving hospital efficiency becomes more important. This study aimed to evaluate the technical efficiency of public and private hospitals in Beijing, China, and analyze the influencing factors of hospitals’ technical efficiency, and thus provide policy implications to improve the efficiency of public and private hospitals. Method: This study used a data set of 154–232 hospitals from “Beijing’s Health and Family Planning Statistical Yearbooks” in 2012–2017. The data envelopment analysis (DEA) model was employed to measure technical efficiency. The propensity score matching (PSM) method was used for matching “post-randomization” to directly compare the efficiency of public and private hospitals, and the Tobit regression was conducted to analyze the influencing factors of technical efficiency in public and private hospitals. Results: The technical efficiency, pure technical efficiency and scale efficiency of public hospitals were higher than those of private hospitals during 2012–2017. After matching propensity scores, although the scale efficiency of public hospitals remained higher than that of their private counterparts, the pure technical efficiency of public hospitals was lower than that of private hospitals. Panel Tobit regression indicated that many hospital characteristics such as service type, level, and governance body affected public hospitals’ efficiency, while only the geographical location had an impact on private hospitals’ efficiency. For public hospitals in Beijing, those with lower average outpatient and inpatient costs per capita had better performance in technical efficiency, and bed occupancy rate, annual visits per doctor, and the ratio of doctors to nurses also showed a positive sign with technical efficiency. For private hospitals, the average length of stay was negatively associated with technical efficiency, but the bed occupancy rate, annual visits per doctor, and average outpatient cost were positively associated with technical efficiency. Conclusions: To improve technical efficiency, public hospitals should focus on improving the management standards, including the rational structure of doctors and nurses as well as appropriate reduction of hospitalization expenses. Private hospitals should expand their scale with proper restructuring, mergers, and acquisitions, and pay special attention to shortening the average length of stay and increasing the bed occupancy rate.

Technical and scale efficiency of provincial health systems in China: a bootstrapping data envelopment analysis

OBJECTIVE

With escalating health expenditures and increasing health needs, improving health system performance has become imperative in China and internationally. The objective of this study is to examine the efficiency of China's health system and to understand the underlying causes of the variation in efficiency across provinces.

SETTING

A system-wide perspective is adopted, focusing on performance in maternal health, child health and non-communicable diseases (NCDs) in the 31 provinces of mainland China during 2015.

METHODS

Analyses were performed using bootstrapping data envelopment technique. Health outcomes were measured by infant survival rates, maternal survival rates and healthy life years calculated only considering NCDs. Health inputs were measured using health expenditure, and density of medical personnel and hospital beds. The model also examined the impact of environmental factors on health system efficiency.

RESULTS

Due to wide-spread scale inefficiency in the country, the average bias-corrected overall technical efficiency (OTE) was 0.8022 (95% CI values ranging from 0.7251 to 0.8492). Socioeconomic status, hospitalisation rate and share of out-of-pocket expenditures were significant determinants of OTE. Nearly 60% of the provinces operated at a decreasing return to scale, meaning that a gain in efficiency could be achieved only through downsizing the scale of operation.

CONCLUSIONS

Given the pervasive nature of diminishing returns across provinces, health policy makers must explore the optimum operational scale which is people-centred and focused on prevention, rather than on treatment, of diseases. Moreover, due consideration should be afforded to social determinants of health and health financing arrangements to complement health-sector based reforms and meet the ambitious goals of the Healthy China 2030 Plan.

The influence of constraints on the efficient allocation of resources for HIV prevention

OBJECTIVE

To investigate how 'real-world' constraints on the allocative and technical efficiency of HIV prevention programmes affect resource allocation and the number of infections averted.

DESIGN

Epidemiological modelling and economic analyses in Benin, South Africa and Tanzania.

METHODS

We simulated different HIV prevention programmes, and first determined the most efficient allocation of resources, in which the HIV prevention budget is shared among specific interventions, risk-groups and provinces to maximize the number of infections averted. We then identified the efficient allocation of resources and achievable impact given the following constraints to allocative efficiency: earmarking [provinces with budgets fund pre-exposure prophylaxis (PrEP) for low-risk women first], meeting targets [provinces with budgets fund universal test-and-treat (UTT) first] and minimizing changes in the geographical distribution of funds. We modelled technical inefficiencies as a reduction in the coverage of PrEP or UTT, which were factored into the resource allocation process or took effect following the allocation. Each scenario was investigated over a range of budgets, such that the impact reaches its maximum.

RESULTS

The 'earmarking', 'meeting targets' and 'minimizing change' constraints reduce the potential impact of HIV prevention programmes, but at the higher budgets these constraints have little to no effect (approximately 35 billion US$ in Tanzania). Over-estimating technical efficiency can result in a loss of impact compared to what would be possible if technical efficiencies were known accurately.

CONCLUSION

Failing to account for constraints on allocative and technical efficiency can result in the overestimation of the health gains possible, and for technical inefficiencies the allocation of an inefficient strategy.

Technical Efficiency of Maternal and Reproductive Health Services in Public Hospitals of Oromia Regional State, Ethiopia

As the Ethiopian health system faced critical resource constraints, wise use of the available health resources is a priority agenda. Therefore, our study aimed to assess technical efficiency of maternal and reproductive health services in public hospitals of Oromia regional state, Ethiopia. Two-stage data envelopment analysis was performed among 14 hospitals with input orientation and variable returns to scale assumptions. Technical efficiency scores were computed at the first stage, and predictors were determined using Tobit regression at the second stage. The assessment revealed that 12 (85.7%) hospitals were pure technical efficient and 9 (64.29%) hospitals were scale efficient. Level (primary/general) (β = 1.17, 95% confidence interval [CI] = 0.16-2.18), service years (β = 0.02, 95% CI = 0.003-0.03), and size of catchment population (β = 5.58E–07, 95% CI = 2.95E–08 to 1.09E–06) were positively associated with technical efficiency of maternal and reproductive health service, whereas average waiting time for maternal health service (β = –0.03, 95% CI = –0.05 to −0.01) was negatively associated with efficiency. In conclusion, most of the hospitals were technically efficient and around two-thirds were operating scale efficient. Allocation of more resources to older secondary hospitals with larger catchment population could result in more efficient use of resources for maternal and reproductive health service delivery.

Measuring the efficiency of health systems in Asia: a data envelopment analysis

OBJECTIVE

This study aims to estimate the technical efficiency of health systems in Asia.

SETTINGS

The study was conducted in Asian countries.

METHODS

We applied an output-oriented data envelopment analysis (DEA) approach to estimate the technical efficiency of the health systems in Asian countries. The DEA model used per-capita health expenditure (all healthcare resources as a proxy) as input variable and cross-country comparable health outcome indicators (eg, healthy life expectancy at birth and infant mortality per 1000 live births) as output variables. Censored Tobit regression and smoothed bootstrap models were used to observe the associated factors with the efficiency scores. A sensitivity analysis was performed to assess the consistency of these efficiency scores.

RESULTS

The main findings of this paper demonstrate that about 91.3% (42 of 46 countries) of the studied Asian countries were inefficient with respect to using healthcare system resources. Most of the efficient countries belonged to the high-income group (Cyprus, Japan, and Singapore) and only one country belonged to the lower middle-income group (Bangladesh). Through improving health system efficiency, the studied high-income, upper middle-income, low-income and lower middle-income countries can improve health system outcomes by 6.6%, 8.6% and 8.7%, respectively, using the existing level of resources. Population density, bed density, and primary education completion rate significantly influenced the efficiency score.

CONCLUSION

The results of this analysis showed inefficiency of the health systems in most of the Asian countries and imply that many countries may improve their health system efficiency using the current level of resources. The identified inefficient countries could pay attention to benchmarking their health systems within their income group or other within similar types of health systems.

Protocol for Investigating the Technical Efficiency of District Hospitals in the Public Health Sector of KwaZulu-Natal, South Africa

BACKGROUND

The central objective of policy makers and health managers is efficiency in the delivery of health care. With frequent reports of global economic crises, there is a need to continuously measure the performance of various sectors of the health care system. This can inform the decision-making process toward allocating scarce resources with the aim of maximizing output.

OBJECTIVE

The aim of this study is to determine the technical efficiency (TE) of public sector district hospitals in the province of KwaZulu-Natal, South Africa to provide information that will assist in policy formulation that may further assist in more efficient resource allocation decisions.

METHODS

This is a health system research based on a quantitative research approach. All 38 public district hospitals in the 11 municipalities of the province will be included in this study. The data for the study will include inputs from hospitals' operations that contribute toward subsequent outputs. The input data will include information such as the number of health professionals (doctors, nurses, and other personnel) and number of hospital beds, whereas the output data will include information such as outpatient visits and number of admissions or discharge. Other data categories to be included will be determined by data availability and will be uniform for all facilities. Data for each facility for a 3-year period from 2014 to 2017 will be obtained from databases of the district health information, basic accounting, and personnel salary systems. On the basis of the data obtained, a model will be developed that can be used to assess how TE of public districts hospitals may be improved. TE will be determined using Data Envelopment Analysis, and factors influencing efficiency will be computed using StataCorp statistical package.

RESULTS

As of February 2019, the study is at the data collection, data input, and analysis stages. The results are expected to be available from the second quarter of 2019.

CONCLUSIONS

Findings from this study can add to tools available to policy makers, health planners, and managers in making decisions about resource allocation in health care systems. Moreover, these findings will be disseminated electronically and in print.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12037.

A Tensionable Method for Subscapularis Repair after Shoulder Arthroplasty

Background

This study compared the biomechanical properties of a new lesser tuberosity (LTO) repair with a tensionable construct with suture tape and preplaced racking hitches vs. a traditional LTO repair using 4 high-strength sutures. The hypothesis was that there would be no difference between the 2 constructs.

Methods

LTO repairs were performed on 6 matched, paired cadaveric shoulders after placement of an uncemented humeral stem. The LTO in group 1 was repaired with 4 high-strength #2 sutures, each passed individually through the subscapularis tendon. The LTO in group 2 was repaired with 2 suture tape loops with a preplaced racking hitch knot and 2 passes through the subscapularis tendon. All sutures were passed around the humeral stem before passing through the subscapularis tendon. The specimens then underwent cyclic displacement and load-to-failure testing.

Results

Load to failure was 209.6 ± 71.2 N in group 1 compared with 502.8 ± 168.6 N in group 2 (P = .018). There was no difference in displacement between the 2 groups. All failures in group 1 occurred by knot slippage. The mode of failure in group 2 was tendon tearing in 5 of 6 cases.

Conclusion

A simplified LTO repair with suture tape and compression bridge and a preplaced half racking knot achieves favorable biomechanical properties in a technically efficient manner that may be useful clinically.

Analysis of the technical efficiency of the forms of hospital management based on public-private collaboration of the Madrid Health Service, as compared with traditional management

FUNDAMENTALS

The study aims to carry out a comparative analysis of the technical efficiency of hospital management based on public-private collaboration, as compared with traditional management. Specifically, we compare traditionally managed public hospitals, public hospitals managed by a private finance initiative (PFI), public hospitals managed through a public-private partnership (PPP), and hospitals managed through other forms of management, during the period 2009 to 2014, in the hospitals dependent on the Madrid Health Service (SERMAS).

METHODS

The study covers all publicly owned general hospitals under SERMAS, consisting of seven PFI hospitals, three PPP hospitals, 11 traditionally managed public hospitals (with the category of general hospital), and four hospitals managed through other forms of hospital management. The technical efficiency indices of the hospitals were calculated using the data envelopment analysis technique. Subsequently, a sensitivity analysis was performed by bootstrapping and variation of model variables to verify their impact on efficiency. Finally, an analysis of the evolution of efficiency in the analyzed period was carried out using the Malmquist Index.

RESULTS

In all the analysis models carried out in the analyzed period, the hospitals managed based on public-private collaboration were more efficient than the hospitals under traditional management.

CONCLUSIONS

The greater efficiency of hospitals managed based on public-private collaboration, as compared with traditional management, could be attributed to greater organizational and management flexibility.

Can Low- and Middle-Income Countries Increase Domestic Fiscal Space for Health: A Mixed-Methods Approach to Assess Possible Sources of Expansion

There has not been a systematic effort to synthesize findings of domestic fiscal space for health (DFSH) assessments, despite the existence of a commonly applied conceptual framework. To fill this gap and provide support to policy makers designing health financing policies toward universal health coverage (UHC), this study uses both qualitative and quantitative methods to assess the scope of possible sources of DFSH in low- and middle-income countries (LMICs). First, the findings of 28 studies assessing DFSH in LMICs were reviewed. A quantitative assessment was then conducted to assess potential expansion from increased tax revenues, a greater prioritization of health in the overall budget, and improved technical efficiency of health spending in a sample of 64 LMICs. The analysis found that macroeconomic conditions and budget prioritization are the key sources of DFSH expansion in 90% of the reviewed studies. Improved efficiency was referenced as having high potential for DFSH expansion in 60% of the studies. The quantitative analysis converged with these findings and further confirmed that an increase in tax revenues is, on average, the largest source of potential DFSH expansion (95% confidence interval [CI], 60%, 96%) in the studied countries. However, even without injecting new revenues, reprioritization of budget and technical efficiency improvements could significantly expand DFSH (95% CI, 77%, 102%). While highlighting the critical role played by fiscal conditions and tax policies, the study provides strong rationale for explicitly incorporating efficiency as a core source of DFSH in a more systematic manner in future assessments.

Impact of Medicare Advantage penetration and hospital competition on technical efficiency of nursing care in US intensive care units

This study aimed to evaluate technical efficiency of US intensive care units and determine the effects of environmental factors on technical efficiency in providing quality of nursing care. Data were obtained from the 2014 National Database of Nursing Quality Indicators and the Centers for Medicare and Medicaid Services. Data envelopment analysis was used to estimate technical efficiency for each intensive care unit. Multilevel modeling was used to determine the effects of environmental factors on technical efficiency. Overall, Medicare Advantage penetration and hospital competition in a market did not create pressure for intensive care units to become more efficient by reducing their inputs. However, these 2 environmental factors showed positive influences on technical efficiency in intensive care units with certain levels of technical efficiency. The implications of the study results for management strategies and health policy may vary according to the levels of technical efficiency in intensive care units. Further studies are needed to examine why and how intensive care units with particular levels of technical efficiency are differently affected by certain environmental factors.

Bootstrapping data envelopment analysis of efficiency and productivity of county public hospitals in Eastern, Central, and Western China after the public hospital reform

China implemented the public hospital reform in 2012. This study utilized bootstrapping data envelopment analysis (DEA) to evaluate the technical efficiency (TE) and productivity of county public hospitals in Eastern, Central, and Western China after the 2012 public hospital reform. Data from 127 county public hospitals (39, 45, and 43 in Eastern, Central, and Western China, respectively) were collected during 2012-2015. Changes of TE and productivity over time were estimated by bootstrapping DEA and bootstrapping Malmquist. The disparities in TE and productivity among public hospitals in the three regions of China were compared by Kruskal-Wallis H test and Mann-Whitney U test. The average bias-corrected TE values for the four-year period were 0.6442, 0.5785, 0.6099, and 0.6094 in Eastern, Central, and Western China, and the entire country respectively, with average non-technical efficiency, low pure technical efficiency (PTE), and high scale efficiency found. Productivity increased by 8.12%, 0.25%, 12.11%, and 11.58% in China and its three regions during 2012-2015, and such increase in productivity resulted from progressive technological changes by 16.42%, 6.32%, 21.08%, and 21.42%, respectively. The TE and PTE of the county hospitals significantly differed among the three regions of China. Eastern and Western China showed significantly higher TE and PTE than Central China. More than 60% of county public hospitals in China and its three areas operated at decreasing return scales. There was a considerable space for TE improvement in county hospitals in China and its three regions. During 2012-2015, the hospitals experienced progressive productivity; however, the PTE changed adversely. Moreover, Central China continuously achieved a significantly lower efficiency score than Eastern and Western China. Decision makers and administrators in China should identify the causes of the observed inefficiencies and take appropriate measures to increase the efficiency of county public hospitals in the three areas of China, especially in Central China.

Evaluating Technical Efficiency of Nursing Care Using Data Envelopment Analysis and Multilevel Modeling

Data envelopment analysis (DEA) is an advantageous non-parametric technique for evaluating relative efficiency of performance. This article describes use of DEA to estimate technical efficiency of nursing care and demonstrates the benefits of using multilevel modeling to identify characteristics of efficient facilities in the second stage of analysis. Data were drawn from LTCFocUS.org , a secondary database including nursing home data from the Online Survey Certification and Reporting System and Minimum Data Set. In this example, 2,267 non-hospital-based nursing homes were evaluated. Use of DEA with nurse staffing levels as inputs and quality of care as outputs allowed estimation of the relative technical efficiency of nursing care in these facilities. In the second stage, multilevel modeling was applied to identify organizational factors contributing to technical efficiency. Use of multilevel modeling avoided biased estimation of findings for nested data and provided comprehensive information on differences in technical efficiency among counties and states.

Measuring the Efficiency of a Hospital based on the Econometric Stochastic Frontier Analysis (SFA) Method

Introduction

Hospitals are the most expensive health services provider in the world. Therefore, the evaluation of their performance can be used to reduce costs. The aim of this study was to determine the efficiency of the hospitals at the Kurdistan University of Medical Sciences using stochastic frontier analysis (SFA).

Methods

This was a cross-sectional and retrospective study that assessed the performance of Kurdistan teaching hospitals (n = 12) between 2007 and 2013. The Stochastic Frontier Analysis method was used to achieve this aim. The numbers of active beds, nurses, physicians, and other staff members were considered as input variables, while the inpatient admission was considered as the output. The data were analyzed using Frontier 4.1 software.

Results

The mean technical efficiency of the hospitals we studied was 0.67. The results of the Cobb-Douglas production function showed that the maximum elasticity was related to the active beds and the elasticity of nurses was negative. Also, the return to scale was increasing.

Conclusion

The results of this study indicated that the performances of the hospitals were not appropriate in terms of technical efficiency. In addition, there was a capacity enhancement of the output of the hospitals, compared with the most efficient hospitals studied, of about33%. It is suggested that the effect of various factors, such as the quality of health care and the patients’ satisfaction, be considered in the future studies to assess hospitals’ performances.

The Technical Efficiency of Earthquake Medical Rapid Response Teams Following Disasters: The Case of the 2010 Yushu Earthquake in China

Purpose: Performance assessments of earthquake medical rapid response teams (EMRRTs), particularly the first responders deployed to the hardest hit areas following major earthquakes, should consider efficient and effective use of resources. This study assesses the daily technical efficiency of EMRRTs in the emergency period immediately following the 2010 Yushu earthquake in China. Methods: Data on EMRRTs were obtained from official daily reports of the general headquarters for Yushu earthquake relief, the emergency office of the National Ministry of Health, and the Health Department of Qinghai Province, for a sample of data on 15 EMRRTs over 62 days. Data envelopment analysis was used to examine the technical efficiency in a constant returns to scale model, a variable returns to scale model, and the scale efficiency of EMRRTs. Tobit regression was applied to analyze the effects of corresponding influencing factors. Results: The average technical efficiency scores under constant returns to scale, variable returns to scale, and the scale efficiency scores of the 62 units of analysis were 77.95%, 89.00%, and 87.47%, respectively. The staff-to-bed ratio was significantly related to global technical efficiency. The date of rescue was significantly related to pure technical efficiency. The type of institution to which an EMRRT belonged and the staff-to-bed ratio were significantly related to scale efficiency. Conclusions: This study provides evidence that supports improvements to EMRRT efficiency and serves as a reference for earthquake emergency medical rapid assistance leaders and teams.

Measuring and Benchmarking Technical Efficiency of Public Hospitals in Tianjin, China: A Bootstrap-Data Envelopment Analysis Approach

China has long been stuck in applying traditional data envelopment analysis (DEA) models to measure technical efficiency of public hospitals without bias correction of efficiency scores. In this article, we have introduced the Bootstrap-DEA approach from the international literature to analyze the technical efficiency of public hospitals in Tianjin (China) and tried to improve the application of this method for benchmarking and inter-organizational learning. It is found that the bias corrected efficiency scores of Bootstrap-DEA differ significantly from those of the traditional Banker, Charnes, and Cooper (BCC) model, which means that Chinese researchers need to update their DEA models for more scientific calculation of hospital efficiency scores. Our research has helped shorten the gap between China and the international world in relative efficiency measurement and improvement of hospitals. It is suggested that Bootstrap-DEA be widely applied into afterward research to measure relative efficiency and productivity of Chinese hospitals so as to better serve for efficiency improvement and related decision making.

Does animal welfare influence dairy farm efficiency? A two-stage approach

This article investigated how process-based animal welfare indicators (PAI) affected the technical efficiency of German dairy farms. A sample of 115 North-Rhine Westphalian dairy farms was used to estimate their technical efficiency with data envelopment analysis. A censored regression model was then applied to quantify the effects of PAI on technical efficiency. The results indicated that in particular a higher percentage of cow losses, a higher replacement rate, and a longer calving interval had, at their respective mean, a negative marginal effect on the technical efficiency of the sample farms. In contrast, a lower age of first calving, a higher in-milk performance, and a higher somatic cell count were positively correlated with technical efficiency. Some of the PAI followed a polynomial trend (i.e., their influence on technical efficiency did not have a constant sign, and levels for minimum/maximum technical efficiency were present). The minimum efficiency score at constant returns to scale was obtained when farmers had cow losses of 0.4%, a calving interval of 430d, and a cell count of 146,000 per milliliter. However, maximum technical efficiency was obtained at a milk yield of 9,796 kg per cow and year. The corresponding amounts in case of technical efficiency under variable returns to scale were at a similar level, except that milk yield showed a positive linear influence on technical efficiency. Moreover, technical efficiency under variable returns to scale was positively correlated with the fat content of milk. The lowest level of technical efficiency was reached at a fat content of 4.1%. Subsequently, we found that efficient dairy farms did not always correspond with recommended values concerning animal welfare criteria. Finally, the results showed that the assumption of a monotone effect direction of PAI on farm efficiency was inappropriate, and that this issue would need to be addressed in future research.

Assessing cost and technical efficiency of HIV prevention interventions in sub-Saharan Africa: the ORPHEA study design and methods

BACKGROUND

Scaling up services to achieve HIV targets will require that countries optimize the use of available funding. Robust unit cost estimates are essential for the better use of resources, and information on the heterogeneity in the unit cost of delivering HIV services across facilities - both within and across countries - is critical to identifying and addressing inefficiencies. There is limited information on the unit cost of HIV prevention services in sub-Saharan Africa and information on the heterogeneity within and across countries and determinants of this variation is even more scarce. The "Optimizing the Response in Prevention: HIV Efficiency in Africa" (ORPHEA) study aims to add to the empirical body of knowledge on the cost and technical efficiency of HIV prevention services that decision makers can use to inform policy and planning.

METHODS/DESIGN

ORPHEA is a cross-sectional observational study conducted in 304 service delivery sites in Kenya, Rwanda, South Africa, and Zambia to assess the cost, cost structure, cost variability, and the determinants of efficiency for four HIV interventions: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), and HIV prevention for sex workers. ORPHEA collected information at three levels (district, facility, and individual) on inputs to HIV prevention service production and their prices, outputs produced along the cascade of services, facility-level characteristics and contextual factors, district-level factors likely to influence the performance of facilities as well as the demand for HIV prevention services, and information on process quality for HTC, PMTCT, and VMMC services.

DISCUSSION

ORPHEA is one of the most comprehensive studies on the cost and technical efficiency of HIV prevention interventions to date. The study applied a robust methodological design to collect comparable information to estimate the cost of HTC, PMTCT, VMMC, and sex worker prevention services in Kenya, Rwanda, South Africa, and Zambia, the level of efficiency in the current delivery of these services, and the key determinants of efficiency. The results of the study will be important to decision makers in the study countries as well as those in countries facing similar circumstances and contexts.

Biomechanical effects of a 2 suture-pass medial inter-implant mattress on transosseous-equivalent rotator cuff repair and considerations for a "technical efficiency ratio"

BACKGROUND

Rotator cuff repair involving fewer tendon suture passes without compromising biomechanical performance would represent a technical advancement. An inter-implant "medial pulley-mattress" transosseous-equivalent (MP-TOE) repair requiring fewer tendon suture-passes was hypothesized to provide equivalent biomechanical characteristics compared to the control.

METHODS

In 6 human cadaveric shoulders, a transosseous-equivalent (TOE) repair (control) was performed utilizing 2 separate medial mattresses resulting in 4 tendon-bridging sutures. In 6 matched-pairs, 2 single-loaded anchors were used to create a medial inter-implant mattress construct (all sutures shuttled in 1 tendon pass per anchor)-after knot-tying, the same tendon-bridging pattern as the control was created. A materials testing machine cyclically loaded each repair from 10-180 N for 30 cycles; each repair subsequently underwent failure testing. Gap and strain were measured with a video digitizing system. A "technical efficiency ratio" (TER) was defined as: (#knots + #suture passes + #suture limbs)/#fixation points.

RESULTS

Cyclic and failure testing demonstrated no significant differences between constructs. Gap formation at cycle 30 was 5.3 ± 0.8 mm (TOE) and 5.0 ± 0.3 mm (MP-TOE) (P = .62). Cycle 30 anterior strain values were -16.0 ± 7.3% (TOE) and -15.8 ± 6.6% (MP-TOE) (P = .99). Yield loads were 208.7 ± 2.7 N (TOE) and 204.0 ± 1.3 N (MP-TOE) (P = .17). Mode of failure demonstrated less tendon cut-out with the MP-TOE repair. The MP-TOE repair has a TER of 2.0 vs 2.5 for the control.

CONCLUSION

The MP-TOE repair requiring fewer tendon suture passes, yet creating an additional inter-implant mattress configuration, is biomechanically equivalent to the original TOE technique, and may limit failure with improved medial load-sharing capacity. A TER may help quantify technical ease and help standardize comparisons between repair techniques.

Technical and scale efficiency of public community hospitals in Eritrea: an exploratory study

BACKGROUND

Eritrean gross national income of Int$610 per capita is lower than the average for Africa (Int$1620) and considerably lower than the global average (Int$6977). It is therefore imperative that the country's resources, including those specifically allocated to the health sector, are put to optimal use. The objectives of this study were (a) to estimate the relative technical and scale efficiency of public secondary level community hospitals in Eritrea, based on data generated in 2007, (b) to estimate the magnitudes of output increases and/or input reductions that would have been required to make relatively inefficient hospitals more efficient, and (c) to estimate using Tobit regression analysis the impact of institutional and contextual/environmental variables on hospital inefficiencies.

METHODS

A two-stage Data Envelopment Analysis (DEA) method is used to estimate efficiency of hospitals and to explain the inefficiencies. In the first stage, the efficient frontier and the hospital-level efficiency scores are first estimated using DEA. In the second stage, the estimated DEA efficiency scores are regressed on some institutional and contextual/environmental variables using a Tobit model. In 2007 there were a total of 20 secondary public community hospitals in Eritrea, nineteen of which generated data that could be included in the study. The input and output data were obtained from the Ministry of Health (MOH) annual health service activity report of 2007. Since our study employs data that are five years old, the results are not meant to uncritically inform current decision-making processes, but rather to illustrate the potential value of such efficiency analyses.

RESULTS

The key findings were as follows: (i) the average constant returns to scale technical efficiency score was 90.3%; (ii) the average variable returns to scale technical efficiency score was 96.9%; and (iii) the average scale efficiency score was 93.3%. In 2007, the inefficient hospitals could have become more efficient by either increasing their outputs by 20,611 outpatient visits and 1,806 hospital discharges, or by transferring the excess 2.478 doctors (2.85%), 9.914 nurses and midwives (0.98%), 9.774 laboratory technicians (9.68%), and 195 beds (10.42%) to primary care facilities such as health centres, health stations, and maternal and child health clinics. In the Tobit regression analysis, the coefficient for OPDIPD (outpatient visits as a proportion of inpatient days) had a negative sign, and was statistically significant; and the coefficient for ALOS (average length of stay) had a positive sign, and was statistically significant at 5% level of significance.

CONCLUSIONS

The findings from the first-stage analysis imply that 68% hospitals were variable returns to scale technically efficient; and only 42% hospitals achieved scale efficiency. On average, inefficient hospitals could have increased their outpatient visits by 5.05% and hospital discharges by 3.42% using the same resources. Our second-stage analysis shows that the ratio of outpatient visits to inpatient days and average length of inpatient stay are significantly correlated with hospital inefficiencies. This study shows that routinely collected hospital data in Eritrea can be used to identify relatively inefficient hospitals as well as the sources of their inefficiencies.