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ANALYSIS OF DETERMINANTS OF PUBLIC HOSPITALS EFFICIENCY IN CAMEROON
Abstract
In Cameroon, the public health system is consisted of three sectors: public, private and traditional sectors. Quantitatively, the public sector is the dominant sector, in terms of its staff and equipment. The private sector is marginal. However, the national survey tracking public expenditures in the health sector shows that 65% of those surveyed prefer public hospitals and 34.7% prefer private hospitals. In the cities of Douala and Southwest, 55.6% and 56.6% of their population prefer private hospital services respectively. This result is paradoxical given that public hospitals usually have more structured technical support, higher budget allocations, increasing number of doctors and nurses and in addition practice relatively low charges. The objective of this study is to analyze the determinants of the efficiency of public hospitals in Cameroon. The methodology for measuring efficiency is the nonparametric approach (data envelopment analysis) and sources of inefficiency are analyzed using a censored Tobit model. We can retain that District health centres and integrated health centres, characterized mainly by low levels of available resources, are more efficient than district hospitals that have more resources. This result corroborates the fact that the fall in production of public hospitals in Cameroon is better explained by a lack of efficiency than by a lack of resources. Furthermore, the inefficiency of Cameroonian public hospitals is particularly explained by the occupation rate of hospital beds, corruption, the cost of health care and the degree of specialization.
... Just under half (40.85%) preferred the public hospitals, 136 (36.07%) the private sector while 87 (23.08%) used the mission hospital. These findings corroborate the study carried out by Shu (2010) on service quality and patient choice of hospitals in Cameroon where 115 (47.1%) participants preferred the public health and private health facilities (11). This could be due to the fact that the public sector have more structured technical support, higher budget allocations, increasing number of doctors and implement relative low charges, which are affordable health care services and medications. ...
Payment for dental services is one of the key determinants of treatment options, access to health care, and treatment decisions. The ability to pay for services directly affects the quality of life of an individual and also their accessibility to oral health services. The aim of the present study was to identify the different methods of payment used to obtain oral health care in Yaoundé, Cameroon. This was a cross-sectional descriptive study carried out in selected dental clinics in Yaoundé using convenient sampling between January 2021 and June 2021. Data was collected using a structured questionnaire. A total of 377 patients aged 8 to 83 years made up of 194 (51.46%) females and 183 (48.54%) males participated in the study. There is no government-assisted package for oral health care in Cameroon and more than two-thirds (66.84%) made direct payments or paid out of pocket without a refund from any insurance company. More than half 147 (58.33%) of the study population did not complete the planned dental care due to insufficient funds. Direct payments covered treatments such as scaling, restorations, root canal therapy, and dental extractions while prostheses (dentures, crowns, bridges, and implants) were only afforded by very few patients. The reasons for the inability to pay for dental services included financial difficulties 107 (72.97%) and lack of time 36 (24.49%). Only half 36 (50%) of the participants employed in the formal sector had access to health insurance and treatments like scaling, dental prosthesis, orthodontics, and dental implants were rarely provided by an insurance company. These procedures were considered to be very expensive with fluctuating prices and were viewed as being for aesthetic purposes. The majority 67 (93.06%) of payments through insurance reported being reimbursed aftercare.
Mycobacterium ulcerans, the causative agent of Buruli ulcer, was discovered by Australian scientists during the investigation of an unusual cluster of destructive skin ulcers affecting residents of the Bairnsdale region in the temperate Australian state of Victoria. The disease was also recognised from the 1950s in tropical far north Queensland where it is called Daintree ulcer or Mossman ulcer. There are other small pockets of transmission in coastal Queensland and the Northern Territory near Darwin but remarkably Buruli ulcer is almost entirely absent from New South Wales, the most populous Australian state. In Victoria, there has been a marked recent increase in cases of Buruli ulcer associated with the establishment of new endemic areas near Melbourne, almost 300 km west of the original endemic area near Bairnsdale. There is emerging evidence in Victoria that BU may be a zoonosis that first affects the local possum population and then spills over to humans living nearby. Biting insects, particularly mosquitoes, are likely mechanical vectors but there may be other pathways of transmission involved. Universal access to rapid diagnosis with PCR and availability of combination oral antibiotic therapy and surgery have improved outcomes for Australian patients with BU. However, some cases can still be severe and require complex and prolonged treatment.
A major objective of this open access book is to summarize the current status of Buruli Ulcer (BU) research for the first time. It will identify gaps in our knowledge, stimulate research and support control of the disease by providing insight into approaches for surveillance, diagnosis, and treatment of Buruli Ulcer. Book chapters will cover the history, epidemiology diagnosis, treatment and disease burden of BU and provide insight into the microbiology, genomics, transmission and virulence of Mycobacterium ulcerans.
Buruli ulcer (BU) is a neglected, debilitating skin disease caused by infection with Mycobacterium ulcerans. After the first definite description in 1948, M. ulcerans infections have been reported from 34 countries, mainly with tropical and subtropical climates. Following a peak of 5954 reported BU cases globally in 2004 the number of new recorded cases has been decreasing over the past years. In 2016, a total of 1952 BU cases were reported to the World Health Organization (WHO) from twelve different countries. Underreporting is considered likely, as BU mostly affects populations in remote areas with limited access to the formal health sector. Although transmission pathways of M. ulcerans are still unclear, infection foci are closely associated with wetlands. Considering that M. ulcerans has evolved from the fish pathogen M. marinum, involvement of an environmental niche is strongly suggestive. The key event for the emergence of M. ulcerans as a species highly pathogenic for humans appears to be the acquisition of a plasmid, bearing genes encoding polyketide synthases and polyketide-modifying enzymes involved in the biosynthesis of a unique macrolide toxin, named mycolactone. The cytotoxic and immunosuppressive properties of mycolactone account for much of the pathology of BU, which is characterized by the formation of chronic, necrotizing, ulcerative skin lesions. In the further course of its reductive evolution, M. ulcerans has diverged into at least two principal niche-adapted lineages connected with different patterns of BU case distribution. Strains of the classical lineage are responsible for BU foci in Africa and Australia that are typically characterized by high local prevalence. In contrast, scattered, sporadic BU cases recorded in Asia and the Americas are caused by strains of the ancestral lineage, which also comprises globally distributed fish and frog pathogens. Adaptation of these divergent mycolactone-producing mycobacterial lineages to different ecological habitats seems likely. Limited knowledge on definite reservoirs and potential vectors as well as the lack of a vaccine hamper the control of BU. Therefore, early identification and adequate treatment of patients are currently the most important measures to prevent the debilitating consequences of the disease.
Buruli ulcer (BU) represents a unique human mycobacteriosis. Caused by Mycobacterium ulcerans, the disease spectrum is dominated by the activity of mycolactone, a dermanecrotic toxin that has shown the ability to interfere with the immune response. This poses an additional difficulty to the understanding of the immunological determinants for the outcome of infection, a fundamental step to develop better preventive or curative strategies. In this chapter, the immune response against M. ulcerans is reviewed, both with a series of clinical observations and experimental infection models and going through several other lines of evidence, including epidemiological and genetic studies. This holistic approach is expected to shed further light on the intriguing pathophysiology of this disease and help guide future research efforts.
MacCallum and coworkers described Buruli ulcer (BU) as an infectious disease caused by Mycobacterium ulcerans in Victoria, Australia. They first considered the skin lesions in their patients to be caused by tuberculosis or leprosy, when they observed numerous acid-fast bacilli in the biopsy specimens [1]. The typical duration of illness was between 1 and 2 years; treatment was essentially surgical. With the advent of chemotherapy for tuberculosis [2–4], and later for leprosy, doctors made individual attempts to treat the lesions with anti-tuberculosis and anti-leprosy drugs. The anecdotal evidence suggested poor or no response to chemotherapy with rifampicin monotherapy [5], despite the fact that in vitro susceptibility of 33 strains of M. ulcerans was as good as for M. tuberculosis [6]. A randomized clinical trial by the British Medical Research Council in Buruli county (now called Nakasongola; Uganda) failed to show any benefit from clofazimine, a drug then first marketed for leprosy [7]. A small-sized trial with cotrimoxazole (18 participants; 12 evaluable) was inconclusive [8]. A small-sized randomized study in Côte d’Ivoire compared a combination of dapsone and rifampicin with placebo; the follow-up was limited; the ulcer size decreased slightly faster in the intervention group but the baseline characteristics of both groups differed, and the study did not allow to draw any firm conclusions about the effectiveness of these drugs [9]. By the turn of the millennium, the discrepancy between in vitro efficacy of rifampicin [6] or clarithromycin [10] and lack of clinical response prompted to stressing the need for well-designed and well-powered drug trials, but in the meantime, to also improve early detection and surgical treatment [11].
Health social science (HSS) research has contributed in significant ways to our understanding of how rural communities in West Africa perceive and respond to Buruli ulcer (BU), and the challenges facing those involved with BU health service delivery. These challenges range from the need to mount more effective community outreach education programs leading to earlier BU detection to the need to identify and then address predisposing, enabling, and service delivery related factors that result in treatment delay, drop out, and non-adherence. In this chapter, we briefly highlight HSS research that has broadened our knowledge of community response to BU and then consider HSS-inspired BU interventions. Most of the sources we draw upon involve research carried out in Benin, Cameroon, and Ghana. To date, few HSS studies have been conducted in other endemic countries such as Cote d’Ivoire, The Democratic Republic of the Congo, Nigeria and Uganda. We include in our overview a selection of studies conducted by both social scientists and medical researchers investigating social and cultural factors that influence health care decision-making.
Current options to control Buruli ulcer (BU) are limited, as no effective vaccine is available and knowledge on transmission mechanisms of the causative agent, Mycobacterium ulcerans, is incomplete. Early case detection and rapid initiation of treatment are key elements to prevent the development of large, disfiguring ulcers often associated with permanent physical disability and stigma. BU has been reported from 34 countries, with the greatest disease burden in West Africa and steadily increasing case numbers in south-eastern Australia. The disease can present in a variety of clinical manifestations, including relatively unspecific, painless nodules, plaques, and edema, which may eventually progress to chronic, ulcerative lesions. The clinical diagnosis of BU is therefore complicated by a broad differential diagnosis, particularly in tropical areas, where the prevalence of other skin conditions with a similar appearance is high. With the introduction of combination antibiotic therapy, replacing excision surgery as the standard treatment for BU, pre-treatment confirmation of the clinical diagnosis has further gained in importance to avoid the redundant use of anti-mycobacterial drugs. At present, available confirmatory diagnostic tests either lack sufficient sensitivity/specificity or are centralized and thus often not accessible to patients living in remote, rural areas of Africa. In recognition of this disparity, WHO and other stakeholders have called for new diagnostic tools for BU that can be applied at district hospitals or primary healthcare facilities. This chapter highlights challenges, advances and future prospects for the necessary decentralization of the diagnosis of BU.
The temperature sensitivity of M. ulcerans has long been recognized. Meyers et al. in the 1970ies successfully treated patients with local heat application. Based on this success, WHO guidelines listed the application of heat as a treatment option for BU in 2000. However, the heat application devices initially employed were impractical. The phase change material (PCM) sodium acetate trihydrate, offers an ideal technical solution. Both, a proof-of-principle and a phase II trial showed that thermotherapy with rechargeable heat packs filled with sodium acetate is well tolerated and effective. Heat packs can be applied in early, undifferentiated stages of disease without causing harm and with the benefit of preventing advancement into severe complicated disease. Thermotherapy is highly effective, easy to apply, cheap, well tolerated, free of relevant adverse effects and has nonspecific positive effects on wound healing.
Africa bears the major brunt of the global Buruli ulcer (BU) burden. In the past decade, more than 95% of all cases have been reported from Africa, with Côte d’Ivoire, Ghana, Benin, and Cameroon being the four most endemic countries. As the disease affects mainly populations in remote, rural areas, where access to formal healthcare structures is limited, the true prevalence of BU is difficult to gauge. The continued preference of BU patients in many of these endemic areas to first consult traditional healers before seeking biomedical treatment, results in a high proportion of patients with advanced stages of the disease, which often cause permanent disabilities. Reasons for a marked reduction of new infections reported from Africa in the past few years are poorly understood and include—apart from an actual reduction in BU incidence—the decline in international support for BU control programs and consequently decreased BU case-finding activities. Major efforts are required in the coming years to mobilize resources to maintain established healthcare infrastructure, surveillance systems, and expertise among health staff. Continued research is needed to solve serious challenges in the diagnosis and treatment of patients at primary healthcare facilities and district hospitals and to fill knowledge gaps on environmental reservoirs, potential vectors, and transmission mechanisms of Mycobacterium ulcerans, a crucial prerequisite for more targeted BU control strategies.
In 2007, the UBS Optimus Foundation identified Buruli ulcer as a disease where a relatively small investment had the potential to make a big difference. With the goal to catalyse a transdisciplinary consortium bundling Buruli ulcer research into a consorted effort, the UBS Optimus Foundation engaged researchers from different disciplines and countries, with a prominent role of endemic countries and good links to national Buruli ulcer control programs. This chapter takes a critical look back at the whys, hows and major results of the Stop Buruli Initiative initiated by the UBS Optimus Foundation and partially co-funded by the Medicor Foundation. It discusses the long-term and comprehensive approach of the UBS Optimus Foundation in research and control of Buruli ulcer, and the lessons learned for achieving the aspiration of innovation and impact.
Shortage of human resource for health poses a major challenge to achieving the millennium development goals. Uganda is among the 57 countries with human resource shortage reaching critical level and the situation is worst at lower levels of the health system. The private-not-for-profit (PNFP) health sub-sector in Uganda complements government efforts to achieve the MDG, the second health sector strategic plan (HSSP II) and the health-related objectives of the poverty eradication plan (PEAP). The Uganda Catholic Medical Bureau coordinates the Roman Catholic health facilities network, one of the three PNFP networks in Uganda. This paper, presented at a conference organized by the Faculty of Health Sciences of Uganda Martyrs University in March 2007, looks at the HRH crisis as experienced by the UCMB network giving the trend, examining the reasons, the destinations of attritional cases and what the network is trying to do to improve human resource stability. The information is based on quarterly reports received by the bureau from its affiliated health facilities.
Background
The Government of Ghana has been implementing various health sector reforms (e.g. user fees in public health facilities, decentralization, sector-wide approaches to donor coordination) in a bid to improve efficiency in health care. However, to date, except for the pilot study reported in this paper, no attempt has been made to make an estimate of the efficiency of hospitals and/or health centres in Ghana. The objectives of this study, based on data collected in 2000, were: (i) to estimate the relative technical efficiency (TE) and scale efficiency (SE) of a sample of public hospitals and health centres in Ghana; and (ii) to demonstrate policy implications for health sector policy-makers.
Methods
The Data Envelopment Analysis (DEA) approach was used to estimate the efficiency of 17 district hospitals and 17 health centres. This was an exploratory study.
Results
Eight (47%) hospitals were technically inefficient, with an average TE score of 61% and a standard deviation (STD) of 12%. Ten (59%) hospitals were scale inefficient, manifesting an average SE of 81% (STD = 25%). Out of the 17 health centres, 3 (18%) were technically inefficient, with a mean TE score of 49% (STD = 27%). Eight health centres (47%) were scale inefficient, with an average SE score of 84% (STD = 16%).
Conclusion
This pilot study demonstrated to policy-makers the versatility of DEA in measuring inefficiencies among individual facilities and inputs. There is a need for the Planning and Budgeting Unit of the Ghana Health Services to continually monitor the productivity growth, allocative efficiency and technical efficiency of all its health facilities (hospitals and health centres) in the course of the implementation of health sector reforms.
Over 60% of the recurrent budget of the Ministry of Health (MoH) in Angola is spent on the operations of the fixed health care facilities (health centres plus hospitals). However, to date, no study has been attempted to investigate how efficiently those resources are used to produce health services. Therefore the objectives of this study were to assess the technical efficiency of public municipal hospitals in Angola; assess changes in productivity over time with a view to analyzing changes in efficiency and technology; and demonstrate how the results can be used in the pursuit of the public health objective of promoting efficiency in the use of health resources. The analysis was based on a 3-year panel data from all the 28 public municipal hospitals in Angola Data Envelopment Analysis (DEA), a non-parametric linear programming approach, was employed to assess the technical and scale efficiency and productivity change over time using Malmquist index. The results show that on average, productivity of municipal hospitals in Angola increased by 4.5% over the period 2000-2002; that growth was due to improvements in efficiency rather than innovation.
Classification JEL : I19, R22, R41
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There has been increasing interest in measuring the productive performance of health care services, since the mid-1980s. This paper reviews this literature and, in particular, the concept and measurement of efficiency and productivity. Concerning measurement, we focus on the use of Data Envelopment Analysis (DEA), a technique particularly appropriate when multiple outputs are produced from multiple inputs. Applications to hospitals and to the wider context of general health care are reviewed and the empirical evidence from both the USA and Europe (EU) is that public rather than private provision is more efficient.
In Sub-Saharan Africa (SSA), there is a huge knowledge gap of health facilities performance. The objective of this study is to measure relative technical efficiencies of 54 public hospitals in Kenya using Data Envelopment Analysis (DEA) technique. 14 (26%) of the public hospitals were found to be technically inefficient. The study singled out the inefficient hospitals and provided the magnitudes of specific input reductions or output increases needed to attain technical efficiency.
Health care institutions worldwide are increasingly the subject of analyses aimed at defining, measuring, and improving organizational efficiency. However, despite the importance of efficiency measurement in health care services, it is only relatively recently that the more advanced econometric and mathematical programming frontier techniques have been applied to hospitals, nursing homes, health management organizations, and physician practices, among others. This article provides a synoptic survey of the comparatively few empirical analyses of frontier efficiency measurement in health care services. Both the measurement of efficiency in a range of health care services and the posited determinants of health care efficiency are examined.
Data Envelopment Analysis has been widely used to analyze the efficiency of health sector in developed countries, since 1978, while in Africa, only a few studies have attempted to apply DEA in the health organizations. In this paper we measure technical efficiency of public health centers in Kenya. Our finding suggests that 44% of public health centers are inefficient. Therefore, the objectives of this study are: to determine the degree of technical efficiency of individual primary health care facilities in Kenya; to recommend the performance targets for inefficient facilities; to estimate the magnitudes of excess inputs; and to recommend what should be done with those excess inputs. The authors believe that this kind of studies should be undertaken in the other countries in the World Health Organization (WHO) African Region with a view to empowering Ministries of Health to play their stewardship role more effectively.
In most countries of the sub-Saharan Africa, health care needs have been increasing due to emerging and re-emerging health problems. However, the supply of health care resources to address the problems has been continuously declining, thus jeopardizing the progress towards achieving the health-related Millennium Development Goals. Namibia is no exception to this. It is therefore necessary to quantify the level of technical inefficiency in the countries so as to alert policy makers of the potential resource gains to the health system if the hospitals that absorb a lion's share of the available resources are technically efficient.
All public sector hospitals (N = 30) were included in the study. Hospital capacity utilization ratios and the data envelopment analysis (DEA) technique were used to assess technical efficiency. The DEA model used three inputs and two outputs. Data for four financial years (1997/98 to 2000/2001) was used for the analysis. To test for the robustness of the DEA technical efficiency scores the Jackknife analysis was used.
The findings suggest the presence of substantial degree of pure technical and scale inefficiency. The average technical efficiency level during the given period was less than 75%. Less than half of the hospitals included in the study were located on the technically efficient frontier. Increasing returns to scale is observed to be the predominant form of scale inefficiency.
It is concluded that the existing level of pure technical and scale inefficiency of the district hospitals is considerably high and may negatively affect the government's initiatives to improve access to quality health care and scaling up of interventions that are necessary to achieve the health-related Millennium Development Goals. It is recommended that the inefficient hospitals learn from their efficient peers identified by the DEA model so as to improve the overall performance of the health system.
Zambia has recently articulated an ambitious national health program designed to meeting health-related MDGs. Public expectations are high and Zambia continues to receive significant resources from global and bilateral donors to support its health agenda. Although the lack of adequate resources presents the most important constraint, the efficiency with which available resources are being utilised is another challenge that cannot be overlooked. Inefficiency in producing health care undermines the service coverage potential of the health system. This paper estimates the technical efficiency of a sample of hospitals in Zambia.
Efficiency is measured using a DEA model. Vectors of hospital inputs and outputs, representing hospital expended resources and output profiles respectively, were specified and measured. The data were gathered from a sample of 30 hospitals throughout Zambia. The model estimates an efficiency score for each hospital. A decomposition of technical efficiency into scale and congestion is also provided.
Results show that overall Zambian hospitals are operating at 67% level of efficiency, implying that significant resources are being wasted. Only 40% of hospitals were efficient in relative terms. The study further reveals that the size of hospitals is a major source of inefficiency. Input congestion is also found to be a source of hospital inefficiency.
This study has demonstrated that inefficiency of resource use in hospitals is significant. Policy attention is drawn to unsuitable hospital scale of operation and low productivity of some inputs as factors that reinforce each other to make Zambian hospitals technically inefficient at producing and delivering services. It is argued that such evidence of substantial inefficiency would undermine Zambia's prospects of achieving its health goals.
Generally, policy-makers and researchers in South Africa acknowledge that hospitals absorb a disproportionate share of health sector resources. The latter, to a certain extent, have failed to provide evidence needed to guide the former's decisions. Albeit in an ad hoc manner, the post-apartheid policy-makers have been reducing hospital budgets to avail the resources needed to strengthen the hitherto neglected primary health care system. Since political will exists to reduce (if not eliminate) wastage of resources within the hospitals, micro-efficiency analyses (like the one reported here) are needed to guide the policy-makers. This study employs Data Envelopment Analysis (DEA) methodology to identify and measure individual hospital's inefficiencies. The key results are as follows. Forty percent of the hospitals had some degree of technical inefficiency. Fifty eight percent were scale-inefficient. In total, the following inputs are currently wasted and not utilized in the production of hospital outputs in Kwazulu-Natal public hospitals: 117.4 doctors (8.0%); 2709 nurses (11.9%); 61 paramedics (11.5% ); 58 Technician (13.1%); 295 Administrative staff (11.1%); 835 General staff (11.3%); 1,193 Labour provisioning staff (14.3%); 38 Other staff (10.7 %); and 1,752 Beds (7.1%). Those are the specific input reductions required to make inefficient hospitals become technically efficient. In conclusion, the DEA results constitute a strong guide to health care decision making, especially with regard to practical always of increasing efficiency and rational use of health care resources.
Les vastes réformes entreprises en Chine dans le cadre de ce qu’il est convenu d’appeler le " socialisme de marché " ont eu d’importantes répercussions sur le fonctionnement du système de santé. Cette communication se propose d’en analyser certains effets sur l’activité et la performance d’un échantillon d’hôpitaux municipaux situés dans une zone rurale de la province de Shandong. Les données de base ont été recueillies lors d’une enquête en 2002 et complétées par des informations émanant des différents départements de l’administration concernés. Les déterminants de l’activité des hôpitaux ont été analysés à partir d’une analyse de panel sur la période 1986-2000. L’étude de leur performance a été faite en utilisant une analyse non paramétrique (DEA et indice de Malmquist). Les résultats obtenus suggèrent notamment que la contrainte de revenu de la population est un frein à l’augmentation de la fréquentation des hôpitaux municipaux et que les mécanismes d’assurance ne paraissent pas jouer en l’état de rôle significatif. L’activité s’avère influencée par des facteurs représentatifs de l’attractivité des hôpitaux. L’introduction d’un système de " gestion intégrée " a permis d’améliorer la qualité des soins des structures de santé de village placés sous la tutelle des hôpitaux municipaux tout en améliorant dans l’ensemble la situation financière de ces derniers. Dans l’ensemble, les hôpitaux municipaux de notre échantillon ont am&e
I modify the uniform-price auction rules in allowing the seller to ration bidders. This allows me to provide a strategic foundation for underpricing when the seller has an interest in ownership dispersion. Moreover, many of the so-called "collusive-seeming" equilibria disappear.
The concept of efficiency as it applies to Decision Making Units (DMUs), solutions, alternatives plays an important role both in Data Envelopment Analysis (DEA) and Multiple Objective Linear Programming (MOLP). Despite this and other apparent similarities, DEA and MOLP research has developed separately. We show that structurally the DEA formulation to identify efficient units is quite similar to the MOLP model based on the reference point or the reference direction approach to generate efficient solutions. DEA and MOLP should not be seen as substitutes, but rather as complements. We show that they cross-fertilize each other. MOLP provides interesting extensions to DEA and DEA provides new areas of application to MOLP. Keywords: Data Envelopment Analysis, Multiple Objective Linear Programming, Efficiency, Performance Measurement 1 1. Introduction Data Envelopment Analysis (DEA) was originally proposed by Charnes, Cooper and Rhodes [1978] as a method for evaluating the relative effici...
Comparaison des différentes mesures d'efficacité technique : une application aux centres hospitaliers français
par Hervé Leleu et Benoît Dervaux
L'engouement pour les techniques non paramétriques d'estimation de frontières de production dans le domaine hospitalier tient à leur capacité à prendre en compte les spécificités de ce secteur. Ces travaux recourent pratiquement tous à la méthodologie Data Envelopment Analysis (DEA) sous diverses hypothèses de rendements à l'échelle. Dans cet article, après avoir étudié les propriétés théoriques des différentes mesures d'efficacité, nous procédons à l'évaluation de l'efficacité productive de 137 hôpitaux publics français. Nous analysons l'impact du choix de la mesure d'efficacité sur la distribution des scores et sur les résultats des modèles explicatifs de la performance des hôpitaux. Nous constatons que le choix de la mesure modifie la distribution des scores d'efficacité mais affecte peu le classement des établissements au regard de leur performance relative.
New Zealand's public hospitals provide ‘free’ secondary health care to the public through taxation funding. Since these hospitals vary by both size and range of services provided, the possibility of more porductive resource use is of explicit interest. A translog variable cost function is estimated for New Zealand public hospitals using 1987 cross-section data. An analysis of sthe function reveals the marginal costs, short-run and long-run economies of scale and input factor substitution possibilities. Results suggest that a transfer of both patients with less severe conditions and staff from teachin hospitals to say, country hospitals will result in a short-run decareased total cost to the system. The long run economies of scale estimates suggest that efficiency gains could result from downsizing large hospitals, merging smaller hospitals and increasing patient turnover. Partial elasticites of demand indicate the asymmetric nature of factor substitution and the effect of specific inputs, such as nurses, on hospital costs.
This study examined the impact of managed care and other environmental factors on hospital inefficiency in 1631 US hospitals during the period 1990–1996. A panel, stochastic frontier regression model was used to estimate inefficiency parameters and inefficiency scores.
The results suggest that mean estimated inefficiency decreased by about 28% during the study period. Inefficiency was negatively associated with health maintenance organization (HMO) penetration and industry concentration. It was positively related with Medicare share and for-profit ownership status. Copyright
This paper presents an extended data envelopment analysis (DEA) model which includes a new benchmark filtering measure to
identify the decision making units (DMUs) which consistently have the best performance. Additionally, window analysis is utilized
over multiple time periods in order to consider the time dependent nature of hospital data. The proposed approach, termed
Panel-based Benchmarking, is applied to the data from previous research to demonstrate its effectiveness and benefits. Next,
the proposed approach is applied to a real-world data set spanning a five year period supplied by the Iowa Hospital Association.
Finally, the Malmquist method is used to compliment the proposed approach to verify temporal productivity performance of DMUs.
The results indicate that the proposed model can generate benchmarks which consistently perform well over multiple time periods.
The relation between the most productive scale size (mpss) for paparticular input and output mixes and returns to scale for multiple-inputs multiple-outputs situations is explicitly developed. This relation is then employed to extend the applications of Data Envelopment Analysis (DEA) introduced by Charnes, Cooper and Rhodes (CCR) to the estimation of most productive scale sizes for convex production possibility sets. It is then shown that in addition to productive inefficiencies at the actual scale size, the CCR efficiency measure also reflects any inefficiencies due to divergence from the most productive scale size. Two illustrations of the practical applications of these results to the estimation of most productive scale sizes and returns to scale for hospitals and stem-electric generation plants are also provided emphasize the advantage of this method in examining specific segments of the efficient production surface.
A nonlinear (nonconvex) programming model provides a new definition of efficiency for use in evaluating activities of not-for-profit entities participating in public programs. A scalar measure of the efficiency of each participating unit is thereby provided, along with methods for objectively determining weights by reference to the observational data for the multiple outputs and multiple inputs that characterize such programs. Equivalences are established to ordinary linear programming models for effecting computations. The duals to these linear programming models provide a new way for estimating extremal relations from observational data. Connections between engineering and economic approaches to efficiency are delineated along with new interpretations and ways of using them in evaluating and controlling managerial behavior in public programs.
The second edition of An Introduction to Efficiency and Productivity Analysis is designed to be a general introduction for those who wish to study efficiency and productivity analysis. The book provides an accessible, well-written introduction to the four principal methods involved: econometric estimation of average response models; index numbers, data envelopment analysis (DEA); and stochastic frontier analysis (SFA). For each method, a detailed introduction to the basic concepts is presented, numerical examples are provided, and some of the more important extensions to the basic methods are discussed. Of special interest is the systematic use of detailed empirical applications using real-world data throughout the book. In recent years, there have been a number of excellent advance-level books published on performance measurement. This book, however, is the first systematic survey of performance measurement with the express purpose of introducing the field to a wide audience of students, researchers, and practitioners. Indeed, the 2nd Edition maintains its uniqueness: (1) It is a well-written introduction to the field. (2) It outlines, discusses and compares the four principal methods for efficiency and productivity analysis in a well-motivated presentation. (3) It provides detailed advice on computer programs that can be used to implement these performance measurement methods. The book contains computer instructions and output listings for the SHAZAM, LIMDEP, TFPIP, DEAP and FRONTIER computer programs. More extensive listings of data and computer instruction files are available on the book's website: (www.uq.edu.au/economics/cepa/crob2005).
This paper shows how one can infer the nature of local returns to scale at the input- or output-oriented efficient projection of a technically inefficient input-output bundle, when the input- and output-oriented measures of efficiency differ.
The efficiency of hospitals is of interest to health insurers, government authorities and hospital management itself. However, econometric methods for determining (in)efficiency have severe drawbacks since hospitals are multiproduct firms and because the duality between production and cost functions cannot be assumed. In this work, non-parametric, deterministic data envelopment analysis (DEA) is used to measure the relative inefficiency of 89 Swiss hospitals covering the years 1993-1996 (310 observations). Special attention is given to the role of patient days in the production of health. The findings depend on whether patient days are viewed as an input of patient time or as an output, as in previous studies. While the probability of a unit being inefficient cannot be explained using the available data, the degree of overall inefficiency is shown to significantly depend on the financial incentives faced by management, in particular due to subsidization. Private hospitals do not seem to be less inefficient than public ones; however, this may be caused by their 'overusing' inputs that in fact are valued as amenities by patients. This consideration points to an important limitation in applying the purely quantitative criteria of DEA to hospitals.
For scientific use, stochastic frontier estimates of hospital efficiency must be robust to plausible departures from the assumptions made by the investigator. Comparisons of alternative study designs, each well within the 'accepted' range according to current practice, generate similar mean inefficiencies but substantially different hospital rankings. The three alternative study contrasts feature (1) pooling vs partitioned estimates, (2) a cost function dual to a homothetic production process vs the translog, and (3) two conceptually valid but empirically different cost-of-capital measures. The results suggest caution regarding the use of frontier methods to rank individual hospitals, a use that seems to be required for reimbursement incentives, but they are robust when generating comparisons of hospital group mean inefficiencies, such as testing models that compare non-profits and for-profits by economic inefficiency. Demonstrations find little or no efficiency differences between these paired groups: non-profit vs for-profit; teaching vs non-teaching; urban vs rural; high percent of Medicare reliant vs low percent; and chain vs independent hospitals. Copyright © 2001 John Wiley & Sons, Ltd.
We investigate the impact of implementing capitated-based Universal Health Coverage (UC) in Thailand on technical efficiency in larger public hospitals during the policy transition period. We measure efficiency before and during the transition period of UC using a two-stage analysis with Data Envelopment Analysis, bootstrap DEA, and truncated regressions. Our analysis indicates that during the transition period efficiency in larger public hospitals across the country increased. The findings differed by region, and hospitals in provinces with more wealth not only started with greater efficiency, but improved their relative position during the transitional phases of the UC system.
Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people.
This paper investigated the development of hospital cost efficiency and productivity in Finland in 1988-1994 using a comparative application of parametric and non-parametric panel models. Stochastic cost frontier models with a time-varying inefficiency component were used as parametric methods. As non-parametric methods various DEA models were employed to calculate efficiency scores and the Malmquist productivity index. The results revealed a 3-5% annual average increase in productivity, half of which was due to improvement in cost efficiency and half due to technological change. The results by parametric and non-parametric methods compared well with respect to individual efficiency scores, time-varying efficiency and technological change. The state subsidy reform of 1993 did not seem to have any observable effects on the hospital efficiency.
This paper uses a stochastic frontier multiproduct cost function to derive hospital-specific measures of inefficiency. The cost function includes direct measures of illness severity, output quality, and patient outcomes to reduce the likelihood that the inefficiency estimates are capturing unmeasured differences in hospital outputs. Models are estimated using data from the AHA Annual Survey, Medicare Hospital Cost Reports, and MEDPAR. We explicitly test the assumption of output endogeneity and reject it in this application. We conclude that inefficiency accounts for 13.6 percent of total hospital costs. This estimate is robust with respect to model specification and approaches to pooling data across distinct groups of hospitals.
This paper explores the relationship between cost and quality of hospital care. A total operating cost function is estimated for 137 US Department of Veterans Affairs hospitals for 1988-1993 using three rate-based measures of quality as regressors. The high likelihood of the existence of measurement error in quality in the cross section leads to the application of novel instrumental variable techniques. Results suggest that mortality and readmission indices are adjusted inadequately for illness severity. The measure on the failure to follow up inpatient discharges with outpatient care, however, appears to increase cost. The results of this paper underscore a number of practical difficulties and challenges facing government or other systems in evaluating the relative performance of their hospitals.
To assess the capacity of Thai public hospitals to proportionately expand services to both the poor and the nonpoor. This is accomplished by measuring the production of services provided to poor, relative to nonpoor, patients and the plant capacity of individual public hospitals to care for the patient load.
Thai public hospitals operating in 1999, following the economic crisis when public hospitals were required to treat all patients irrespective of ability to pay. STUDY DESIGN and
Input and output data for 68 hospitals were collected using databases and questionnaire surveys. A distinction was made between inpatient and outpatient services to both poor and nonpoor patients and the data were assessed statistically.
Congestion and capacity indices to measure poor/nonpoor service trade-offs and capacity utilization were estimated. The analysis was undertaken by data envelopment analysis (DEA), a nonparametric linear programming approach used to derive efficiency and productivity estimates. Principal Findings. Increases in the amount of services provided to poor patients did not reduce the amount of services to nonpoor patients. Overall, hospitals are producing services relatively close to their capacity given fixed inputs. Possible increases in capacity utilization amounted to 5 percent of capacity.
Results suggest that some increased public hospital care can be accomplished by reallocation of resources to less highly utilized hospitals, given the budgetary constraints. However, further expansion and increase in access to health services will require plant investments. The study illustrates how DEA methodologies can be used in planning health services in data constrained settings.
Standard real business cycle models must rely on total factor productivity (TFP) shocks to explain the observed comovement of consumption, investment, and hours worked. This paper shows that a neoclassical model consistent with observed heterogeneity in labor supply and consumption can generate comovement in the absence of TFP shocks. Intertemporal substitution of goods and leisure induces comovement over the business cycle through heterogeneity in the consumption behavior of employed and unemployed workers. This result owes to two model features introduced to capture important characteristics of U.S. labor market data. First, individual consumption is affected by the number of hours worked: Employed agents consume more on average than the unemployed do. Second, changes in the employment rate, a central factor explaining variation in total hours, affect aggregate consumption. Demand shocks--such as shifts in the marginal efficiency of investment, as well as government spending shocks and news shocks--are shown to generate economic fluctuations consistent with observed business cycles.
A guide to DEAP, version 2.1: A data envelopment analysis (computer) program », CEPA Working Paper
- T J Coelli
Coelli ,T.J (1996), « A guide to DEAP, version 2.1: A data envelopment analysis (computer) program », CEPA Working Paper, N° 96/08, PP.49
Impact of mission and operating environment on hospital X-inefficiency: A frontier approach
- M Rosko
Rosko, M. (1998), Impact of mission and operating environment on hospital X-inefficiency: A frontier approach. Paper presented at the Third International Conference on Strategic Issues in Health Care Management. St. Andrews, Scotland. April 2.
Mesure de l'efficience hospitalière à l'aide de Data Envelopment Analysis
- A L Guisset
- W Hoore
Guisset ,A.L. et D'hoore ,W. (1998), « Mesure de l'efficience hospitalière à l'aide de Data Envelopment Analysis », Health and System Science, Vol.2, N°12,PP. 127-162.