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Technical Efficiency of Public District Hospitals in Bangladesh

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Ahmed et al. Cost Ef Resour Alloc (2019) 17:15 https://doi.org/10.1186/s12962-019-0183-6 Cost Effectiveness and Resource Allocation RESEARCH Open Access Technical efciency of public district hospitals in Bangladesh: a data envelopment analysis Sayem Ahmed1,2,3* , Md. Zahid Hasan1, Samia Laokri4, Zerin Jannat5, Mohammad Wahid Ahmed1, Farzana Dorin1, Veronica Vargas6,8 and Jahangir A. M. Khan2,7 Abstract Background: District hospitals (DHs) provide secondary level of healthcare to a wide range of population in Bangla- desh. Efcient utilization of resources in these secondary hospitals is essential for delivering health services at a lower cost. Therefore, we aimed to estimate the technical efciency of the DHs in Bangladesh. Methods: We used input-oriented data envelopment analysis method to estimate the variable returns to scale (VRS) and constant returns to scale (CRS) technical efciency of the DHs using data from Local Health Bulletin, 2015. In this model, we considered workforce as well as number of inpatient beds as input variables and number of inpatient, outpatient, and maternal services provided by the DHs as output variables. A Tobit regression model was applied for assessing the association of institutional and environmental characteristics with the technical efciency scores. Results: The average scale, VRS, and CRS technical efciency of the DHs were estimated to 85%, 92%, and 79% respectively. Population size, poverty headcount, bed occupancy ratio, administrative divisions were signifcantly associated with the technical efciency of the DHs. The mean VRS and CRS technical efciency demonstrated that the DHs, on an average, could reduce their input mix by 8% and 21% respectively while maintaining the same level of output. Conclusion: Since the average technical efciency of the DHs was 79%, there is little scope for overall improve- ments in these facilities by adjusting inputs. Therefore, we recommend to invest further in the DHs for improvement of services. The Ministry of Health and Family Welfare (MoHFW) should improve the efciency in resource allocation by setting an input-mix formula for DHs considering health and socio-economic indicators (e.g., population density, poverty, bed occupancy ratio). The formula can be designed by learning from the input mix in the more efcient DHs. The MoHFW should conduct this kind of benchmarking study regularly to assess the efciency level of health facilities which may contribute to reduce the wastage of resources and consequently to provide more afordable and acces- sible public hospital care. Keywords: Technical efciency, Secondary hospitals, District hospitals, Data envelopment analysis, Bangladesh *Correspondence: [email protected] 1 Health Systems and Population Studies Division, icddr,b, Dhaka 1212, Bangladesh Full list of author information is available at the end of the article © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ahmed et al. Cost Ef Resour Alloc (2019) 17:15 Page 2 of 10 Background In diferent countries (e.g. Angola, India, and Ghana) Sustainable development goals (SDG), developed by several studies were carried out in assessing the ef- the United Nations General Assembly, includes health ciency of healthcare facilities by using data envelopment as a major component to ensure healthy lives and pro- analysis (DEA) [7–10]. Over the decades, DHs are play- mote well-being for all ages by 2030 [1]. In South Asia, ing a key role in health systems of Bangladesh as second- Bangladesh is one of the poorest and densely populated ary hospitals. However, little has been known about the countries. Te country had a population of 161 million in efciency of these DHs in this context. In 1999, a study 2015. By 2030, this population size is expected to increase was conducted to assess the efciency by comparing bed to around 218 million [2]. occupancy rate and bed turnover rate of subdistrict level Constitutionally, Bangladesh government is obliged healthcare facilities in Bangladesh using Lasso’s graphi- to provide basic healthcare to every citizen. To ensure cal model [11]. Te fnding suggested that large sub- healthcare for the citizens, the country has built a district hospitals with more beds and staf were efcient structured health system covering diferent healthcare and optimal. Vargas et al. 2016 assessed the efciency of services, health education, health promotion, and reha- DHs using a similar approach. Tey found only 12 out bilitation. Te health systems have a tire structure that of 62 DHs (19.4%) with greater inefciency and around includes primary, secondary, and tertiary level of health- one-third of the hospital with greater efciency and the care facilities in communities, sub-districts, districts, and remaining hospitals had average efciency. However, this divisions of the country. study only considered two indicators (e.g. bed occupancy Te primary level health facilities include Upazila rate and bed turnover rate) for efciency analysis [12]. Health Complexes at the sub-districts, Union Health and Terefore, efciency analysis of DHs is required consid- Family Welfare Centers at the Unions (collection of few ering multiple input and output variables to compare villages), and Community Clinics at the villages. District their level of efciency. Efcient DHs can contribute con- Hospitals or general hospitals (DHs) works as referral siderably toward achieving the health-related targets in centers of these primary level facilities and delivers the SDG. Tus, we aimed to estimate the technical efciency secondary level of healthcare including treatment for of the DHs in Bangladesh using DEA. non-communicable diseases and a number of other spe- cialized cares (e.g. Cardiac, Neuroscience, and Orthopae- Methods dic hospitals). Te tertiary hospitals (e.g. Medical college We used secondary data to conduct this cross-sectional hospitals, specialized hospitals) of various kinds provide study. Te efciency scores of DHs were estimated using supports to the primary and secondary level health facili- an input-oriented DEA [13]. Te association of institu- ties along with specialized health services [3]. tional and environmental characteristics with the tech- Tere are 62 DHs across the country and each of the nical efciency of the DHs was measured using a Tobit districts has at least one such hospital except Rajshahi regression model. and Dhaka. In some districts, the hospitals are called ‘general hospital’ or ‘250-bed hospital’ [3]. Te DHs pro- Sources of data vide primary and secondary care through the outdoor, In this study, we used data from the Local Health Bulle- indoor (outpatient and inpatient services), and emer- tin-2015. Te bulletin consists of annual hospital service gency departments [4]. About 6% of the total outpatient and monitoring statistics which is published annually by visits and 40% of the total inpatient admissions in public the Directorate General of Health Services (DGHS), Min- facilities were served by DHs, and more than 22% of the istry of Health and Family Welfare (MoHFW), Bangla- total government health expenditure was spent through desh [3]. Population data was collected from Bangladesh these facilities in 2015 [3, 5]. Bureau of Statistics (BBS) and district wise poverty head- Globally, it was estimated that about USD 300 billion counts from Te World Bank report [14, 15]. We selected were being lost annually due to hospital-related inef- these data sources for extracting input, output and ciency [6]. Efciency studies are important for informed explanatory variables for the efciency analysis (Table 1). decision making to improve the performance of hospitals and reduce wastage. It is important to reduce the con- Selection of input and output variables sumption of excessive resources in producing healthcare Te selection of variables was guided by a literature services for all healthcare system. Efciency in produc- review on the efciency analysis and considering the tion invariably results in better allocation of resources availability of the relevant data [3, 7–10]. Inputs in hos- and increase the opportunity to serve more benefciar- pital production are classifed as labour, capital and sup- ies. Tis in turn raises important sustainability and equity plies. Te labour input can be disaggregated into the implications. various professional groups such as physician, nurse, and Ahmed et al. Cost Ef Resour Alloc (2019) 17:15 Page 3 of 10 Table 1 Selected variables and sources of information Variables Measuring units (in year 2015) Source Input variables Beds Total number of beds available Local health bulletin 2015 [3] Doctors Total number of doctors (specialists and primary care physicians) available Local health bulletin 2015 [3] Nurses Total number of nurses available Local health bulletin 2015 [3] Output variables At least 4 ANC recipients Total number of women received 4 ANC services Local health bulletin 2015 [3] Normal deliveries Total number of normal deliveries Local health bulletin 2015 [3] Caesarean-section
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