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.

     

Accounting for quality in the measurement of hospital performance: evidence from Costa Rica

This paper provides insights into how Costa Rican public hospitals responded to the pressure for increased efficiency and quality introduced by the reforms carried out over the period 1997-2001. To that purpose we compute a generalized output distance function by means of non-parametric mathematical programming to construct a productivity index, which accounts for productivity changes while controlling for quality of care. Our results show an improvement in hospital performance mainly driven by quality increases. The adoption of management contracts seems to have contributed to such enhancement, more notably for small hospitals. Further, productivity growth is primarily due to technical and scale efficiency change rather than technological change. A number of policy implications are drawn from these results.     

Productivity growth,case mix and optimal size of hospitals. A 16-year study of the Norwegian hospital sector

Background and objectives

This paper analyses productivity growth in the Norwegian hospital sector over a period of 16 years, 1999–2014. This period was characterized by a large ownership reform with subsequent hospital reorganizations and mergers. We describe how technological change, technical productivity, scale efficiency and the estimated optimal size of hospitals have evolved during this period.

Productivity and efficiency changes in primary care: a Malmquist index approach

The reforms of the National Health System in the UK introduced in 1990 led to substantial changes in the organisation of primary health care. In this paper we analyse the efficiency of primary care provision in the English Family Health Service Authorities (FHSAs) over the period 1990/91–1994/95. We use Data Envelopment Analysis to measure Malmquist indices of productivity changes, which are then decomposed into indices of pure technical efficiency change, scale efficiency change and technological change. The analysis indicates a small improvement in the productivity over the period considered. The increase is attributed to pure technical efficiency improvement and positive change in scale efficiency, while the technology does not show significant change. The analysis suggests that there is very limited scope for productivity gains in this sector.     

基于Malmquist指数的北京三级医院全要素生产率分析

目的测量综合三级医院全要素生产率的变化状况,为提高医院运营效率提供决策依据和参考。方法收集北京市12所三甲医院2007～2009年3年面板数据（4项投入指标,5项产出指标）,应用数据包络分析（DEA）的Malmquist模型进行分析。结果3年间样本医院全要素生产率的年平均增长率为33．7％,进一步分解发现：技术进步年均增长率为达到33．4％,技术效率、纯技术效率增长率分别为0．2％,而规模效率没有变化。结论北京地区三级综合医院全要素生产率增长较为显著,其增长贡献主要来源于技术进步,并且不存在技术衰退;为最大限度提高医院生产率,应加强医院内部管理,激发技术效率和规模效率;在医院生产率测量和效率评价研究中,宜吸收患者和公共利益维度的评价指标。     

Exploring the influence of context and policy on health district productivity in Cambodia

Background

Cambodia has been reconstructing its economy and health sector since the end of conflict in the 1990s. There have been gains in life expectancy and increased health expenditure, but Cambodia still lags behind neighbours One factor which may contribute is the efficiency of public health services. This article aims to understand variations in efficiency and the extent to which changes in efficiency are associated with key health policies that have been introduced to strengthen access to health services over the past decade.

Methods

The analysis makes use of data envelopment analysis (DEA) to measure relative efficiency and changes in productivity and regression analysis to assess the association with the implementation of health policies. Data on 28 operational districts were obtained for 2008–11, focussing on the five provinces selected to represent a range of conditions in Cambodia. DEA was used to calculate efficiency scores assuming constant and variable returns to scale and Malmquist indices to measure productivity changes over time. This analysis was combined with qualitative findings from 17 key informant interviews and 19 in-depth interviews with managers and staff in the same provinces.

Results

The DEA results suggest great variation in the efficiency scores and trends of scores of public health services in the five provinces. Starting points were significantly different, but three of the five provinces have improved efficiency considerably over the period. Higher efficiency is associated with more densely populated areas. Areas with health equity funds in Special Operating Agency (SOA) and non-SOA areas are associated with higher efficiency. The same effect is not found in areas only operating voucher schemes. We find that the efficiency score increased by 0.12 the year any of the policies was introduced.

Conclusions

This is the first study published on health district productivity in Cambodia. It is one of the few studies in the region to consider the impact of health policy changes on health sector efficiency. The results suggest that the recent health financing reforms have been effective, singly and in combination. This analysis could be extended nationwide and used for targeting of new initiatives. The finding of an association between recent policy interventions and improved productivity of public health services is relevant for other countries planning similar health sector reforms.

     

Hierarchical Generalised Linear Models with Time-Dependent Clustering: Assessing the Effect of Health Sector Reform on Patient Outcomes in New Zealand

New Zealand has one of the most reformed health systems in the world. This paper is primarily concerned with modelling the impact on hospital outcomes of the reforms of the early 1990s, when as part of a major, health sector wide reform process, the administration of public hospitals passed from elected Area Health Boards (AHBs) to Crown Health Enterprises (CHEs) operating under a competitive model of health care provision dominated by the funder/purchaser/provider split. The impact of reform processes on public hospitals is of particular interest since they consume 40%–50% of public expenditure on health, and have been repeatedly restructured in an attempt to contain the ever-expanding cost of health care. There is concern among both health professionals and the general public that these restructurings are reducing the quality of hospital services, and therefore negatively effecting patient outcomes. Using data from a study of 34 New Zealand public hospitals, we discuss the application of Bayesian hierarchical generalised linear models to the analysis of trends in patient outcomes over the period 1988–2001. The time-varying nature of the grouping of hospitals within larger health authorities complicates the application of HGLMs because the cluster structure of the data changes over the study period. An approach to dealing with such time-dependent clustering by introducing period-specific authority level effects is developed. The analysis does not support the proposition that higher level authorities had an effect on outcome trends, or that the administrative changeover from AHBs to CHEs impacted on 60-day post-admission mortality.     

Efficiency. Measured response

An analysis of the activity of 75 acute hospitals over the period 1991-96 using data envelopment analysis shows that, while overall productivity increased, the efficiency of individual hospitals did not. A small decrease in the efficiency of individual hospitals was found in the last four years studied. An analysis of quality of care over the same period suggests that gains in volume of services may have been at the expense of quality of care. The results suggest that incentives for increasing hospital efficiency have a one-off impact rather than a sustained effect.     

Does restructuring hospitals result in greater efficiency?--An empirical test using diachronic data.

Hospitals are being restructured more frequently. Increased cost efficiency is the usual justification given for such changes. All 20 major teaching hospitals in Australia's two most populous states were investigated by classifying each over a 5-6 year period in terms of their cost efficiency (average cost per case weighted by Australian diagnosis-related group [AN-DRG] data and adjusted for inflation) and structure, categorized as traditional-professional (TP), clinical-divisional (CD), or clinical-institute (CI). In all, 12 hospitals changed structure during the study period. There was slight evidence that CD structures were more efficient than TP structures but this was not supported by other evidence. There were no significant differences in efficiency in the first or second years following changes from either TP to CD or TP to CI structures. All four hospitals changing from CD to CI structure became significantly less efficient. This may be due to frequency rather than type of change as they were the only hospitals that implemented two structural changes. Hospitals that changed or did not change structure were similar in efficiency at the beginning and at the end of the study period, in overall efficiency during the period, and in trends toward efficiency over time. The findings challenge those who advocate restructuring hospitals on the grounds of improving cost efficiency.     

福建省县级综合性公立医院运行效率变化分析

目的:研究福建省40家县级综合性公立医院的综合效率、技术效率和规模效率变化情况,以及全要素生产率随着时间变化的情况,为提高县级综合性公立医院运营效率提供决策依据和参考。方法:收集2009—2014年福建省40家县级综合性公立医院运营相关数据,运用数据包络分析法(DEA)的CCR、BCC和Malmquist模型进行分析。结果:40家县级综合性公立医院中绝大多数处于规模递减状态,2009—2014年的全要素生产率为1.019,21家(52.5%)医院生产率有所提高,其中3家医院生产率提高是由于技术进步,3家是由于效率提高,15家是由于技术进步和效率提高共同作用。结论:福建省县级综合性公立医院效率总体不足,且不同地区医院运行效率有差异,山区医院效率有所提高,沿海地区医院效率出现下降。因此,政府在加大对县级综合性公立医院投入时,应采取差别化政策,注意合理控制医院规模,同时应加强内涵建设,重视医疗技术的提升。