Background
Efficient use of resources has become the fundamental strategy of policy makers within most country’s health systems in the world. Such explosion of interest in measuring efficiency in health systems is attributed to intensified concerns with the costs of health care, increased demands for public accountability, and improved capabilities for measuring performances [
1].
Three main categories of efficiency measurements are known in health care. Namely, allocative efficiency, technical efficiency, and overall economic efficiency [
2]. Allocative efficiency (AE) is used to scrutinize whether limited resources are directed towards producing the correct mix of outputs or the entity under examination uses an optimal mix of inputs to produce its chosen outputs. Technical efficiency (TE) indicates the extent to which a given decision making unit (DMU) is minimizing the use of inputs in producing its chosen outputs or maximizing its outputs given its chosen level of inputs. If a DMU uses its resources in technical and allocative efficient way, then it can be said to have achieved its total economic efficiency [
3]. Since technical efficient is the primary footstep to attain the level of allocative efficiency and even the overall economic efficiency for a given DMU, we assessed the TE of health centers by considering the health center as a single DMU.
Health centers are health facilities which provides promotive, preventive, curative and rehabilitative outpatient care including basic laboratory and pharmacy services with the capacity of 10 beds for emergency and delivery services in the primary health care system of Ethiopia [
4].
The Ethiopian primary health care system ends at the primary hospitals at the top which provides primary curative, preventive and rehabilitative services with referral from health centers or directly. Next to the primary hospitals are health centers. These units are supposed to provide service for an average population of 25,000. Basic curative, preventive and rehabilitative services are delivered in the health centers. The nearest service point to the community are the health posts. Health posts provide mostly preventive and promotive services as well as some basic curative care home to home, outreach and at facility. There is a referral and administrative linkage between these three entities. Health center is a referral point for health posts. Similarly, primary hospitals are referral centers for health centers [
5].
The health sector of Ethiopia is facing with scarcity of resources. It is one of the underfinanced sectors in the country; the share of government health expenditure accounted 1.4% of the country’s GDP in 2016/17, which is lower than 1.9% in low-income countries for the same year, and well below the global average of 5.3% [
6]. Together with this constraint, inefficient use of available resources can be taken as a double burden for the country to deliver quality health services for its citizens.
There are studies on the assessment of health facilities’ efficiency globally [
7‐
11] and in different countries of Africa [
12‐
14]. However, such evidence is limited in Ethiopia. Few articles [
15‐
20] are documented on the technical efficiency of health facilities in some areas of the country. Getachew [
20] observed the technical efficiency of selected hospitals in Ethiopia. Ali, et al. [
15] assessed the technical efficiency of selected hospitals in eastern Ethiopia. The study conducted in Tigray region [
16] assessed the performance of health posts. The technical efficiency of 12 public hospitals was assessed by the study conducted in Northwest Ethiopia [
18]. The other study conducted in Southwest Ethiopia [
19] assessed the technical efficiency of health posts and health centers. Each of these studies were based on an input-oriented data envelopment analysis, which is mainly focus on an input minimization for a given set of outputs in a production process [
1]. However, there is an evenly resource allocation for similar health facilities in Ethiopia [
21] and the input side could not merely evaluate their efficiency levels, rather the quantity of outputs they produce from their services can be used to estimate their performances. Besides this, studies on the lower-level health facilities in the Northwest region of Ethiopia, where quality of health care could be compromised due to the scarcity and/or inefficient use of resources, are too minimal. To this end, we were interested to evaluate the technical efficiency of health centers in East Gojjam zone, Northwest Ethiopia using the output-oriented data envelopment analysis. We have also observed the effect of organizational and environmental related factors of health facilities, which are discussed on literatures, on the technical efficiency of health centers.
Discussion
Performance measurement seeks to monitor, evaluate, and communicate the extent to which various aspects of the health system meet their key objectives. Its role is to improve the quality of decisions made by all actors within the health system. Generally, the common health performance measures include; population health, individual health outcomes, quality and appropriateness of care, responsiveness of health system, equity, and productivity/efficiency [
36]. This study assessed the technical efficiency of health centers which is one of the performance measures in the health care delivery system. Technical efficiency was computed using health centers inputs (number of administrative staffs, number of clinical staffs, number of beds and expense for recurrent materials including pharmaceuticals) and outputs (number of outpatient visits, number of family planning visits, number of skilled deliveries, number of referrals and number of fully vaccinated children).
Overall, the mean technical efficiency of the health centers was 0.899 with a standard deviation of 0.156. This finding is consistent with the study conducted on public hospitals in Northwest Ethiopia [
18] with the mean technical efficiency score of 0.92. However, it is lower than the study on public hospitals in Eritrea [
34] with mean technical efficiency score of 0.97, and higher than studies on health centers in Southwest Ethiopia [
19] and health posts in Tigray region [
16] with the mean technical efficiency score of 0.76 and 0.57 respectively. it is also higher than studies conducted on health centers in Gambia [
37], hospitals in China [
38], hospitals before the implementation of the health sector evolution plan in Iran [
39] with the mean technical efficiency scores of 0.65, 0.79, and 0.86 respectively. This might be due to the use of a lower number of DMUs in our study, resulting in higher efficiency scores of health centers relative to the earlier studies [
40]. This difference might be also due to the variation in the level of health facilities and the health care systems across areas.
Fourteen (52%) health centers were scale inefficient and among the scale inefficient health centers, 8 (57%) were in increasing return to scale. This implies that these eight health centers were below the optimal scale of operation, and they need to scale up to become efficient as their peer efficient health centers.
In this study, the average number of outpatient visits, family planning visits, referrals, skilled deliveries, and fully vaccinated children required to make the relative technical inefficient health centers to be efficient were 22,433, 1,351, 155, 206 and 385, respectively. This indicates that these inefficient health centers could produce more 22, 433 outpatient visits, 1,351 family planning visits, 155 referrals, 206 skilled deliveries and 385 fully vaccinations of children.
From the tobit regression analysis, a 10,000 increase in catchment population increases the technical efficiency of health centers by 0.397. This finding is consistent with the study on health centers in Southwest Ethiopia [
19] where a 10,000 increase in catchment population increases the technical efficiency of health centers by 0.2. However, it is contrary to the study on public hospitals in Northwest Ethiopia [
18] in which a 100,000 increase in catchment population decreases the TE of hospitals by 0.0524. This may be due to higher number of health service users from the broad catchment population which results in more service outputs, and this perhaps increase the technical efficiency of health centers in our study. A unit increase in the number of administrative staffs decreases the technical efficiency of health centers by 0.13. This may be due to the hiring of too many admirative employees and underuse of these staffs which can result in lower efficiency of health centers.
This study has some limitations. First the DEA is a deterministic approach in which the efficiency of a DMU is assumed to be estimated by the ratio of its outputs and inputs. However, there are indeterministic factors which may influence the technical efficiency of health centers like civil war or natural disasters including epidemics. Besides this, we used the 2022 data for the efficiency analysis and the result cannot be applied for the current decision making though it shows the performances of the health centers for the 2022 year. We also used the self-reported data of health centers which may bias the estimation of the efficiency scores. Despite these limitations, this study can be used as a baseline for further studies in the area.
Conclusions
The mean technical efficiency of health centers in East Gojjam zone, Northwest Ethiopia was very high. However, nearly half of the health centers were technically inefficient, which indicates the exitance of a space for further improvements in the productivity of these health centers. Inefficient health centers could provide more 22, 433 outpatient visits, 1,351 family planning visits, 155 referrals, 206 skilled deliveries and 385 fully vaccinations of children if they were efficient as their peer efficient health centers. It is better to employ optimal number of administrative staffs and constructing health centers on appropriate sites to have high catchment population coverage to improve the productivity of the health centers. Here, sites where health centers be constructed should give due attention by the responsible bodies so that the standard requirement of population coverage for health centers [
41] (i.e. 25,000 in rural and 40,000 in urban) need to be fulfilled. In doing this, we can eliminate wastage of resources on the one hand and unmet need of health services on the other hand if health facilities provide health services according to their expectations.
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