Seposo et al. BMC Health Services Research (2019) 19:415 https://doi.org/10.1186/s12913-019-4163-5 RESEARCH ARTICLE Open Access Assessing frontline HIV service provider efficiency using data envelopment analysis: a case study of Philippine social hygiene clinics (SHCs) Xerxes T. Seposo1,2,3* , Ichiro Okubo4 and Masahide Kondo5 Abstract Background: Globally, local and frontline HIV service delivery units have been deployed to halt the HIV epidemic. However, with the limited resources, there is a need to understand how these units can deliver their optimum outputs/outcomes efficiently given the inputs. This study aims to determine the efficiency of the social hygiene clinics (SHC) in the Philippines as well as to determine the association of the meta-predictor to the efficiencies. Methods: In determining efficiency, we used the variables from two data sources namely the 2012 Philippine HIV Costing study and 2011 Integrated HIV Behavioral and Serologic Surveillance, as inputs and outputs, respectively. Various data management protocols and initial assumptions in data matching, imputation and variable selection, were used to create the final dataset with 9 SHCs. We used data envelopment analysis (DEA) to analyse the efficiency, while variations in efficiencies were analysed using Tobit regression with area-specific meta-predictors. Results: There were potentially inefficient use of limited resources among sampled SHC in both aggregate and key populations. Tobit regression results indicated that income was positively associated with efficiency, while HIV prevalence was negatively associated with the efficiency variations among the SHCs. Conclusions: We were able to determine the inefficiently performing SHCs in the Philippines. Though currently inefficient, these SHCs may adjust their inputs and outputs to become efficient in the future. While there were indications of income and HIV prevalence to be associated with the efficiency variations, the results of this case study may only be limited in generalisability, thus further studies are warranted. Keywords: Data envelopment analysis, HIV, Social hygiene clinic, Philippines, Efficiency Background has succeeded in decreasing the number of People Living HIV/AIDS is one of the gravest public health issues in with HIV (PLHIV) steadily [2, 3]. the world. According to the 2014 Global Statistics [1], In recent years, country-led frontline service delivery 1.2 million people died of AIDS-related illnesses, with programs/interventions have been carried out to halt the about 36.9 million people infected with HIV, of which 2 epidemic across the globe [4–6]. These programs/inter- million accounts for the annual newly-infected cases. ventions, focusing on better access to basic prevention, The global response to date, through the prevention and care and treatment (PCT) services, have catered to both treatment services for sufferers and population at risk, the PLHIV population and key populations such as, male having sex with male (MSM), female sex workers (FSW) and people who inject drugs (PWID). Each country devised * Correspondence: [email protected] their own intervention as a response to the epidemic. In 1 Graduate School of Global Environmental Studies, Kyoto University, Kyoto Ghana, TB integration into the HIV services through “one-- City, Japan 2Environmental Health Division, Department of Environmental Engineering, stop shops” were found to have improved HIV screening Graduate School of Engineering, Kyoto University, Kyoto City, Japan [7]. While in Asia, Hong Kong and the Philippines have Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/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://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Seposo et al. BMC Health Services Research (2019) 19:415 Page 2 of 14 social hygiene clinics (SHC), which provide basic PCT frontline service providers, SHCs, among the aggregate services to key populations, particularly for FSW [8]. and key populations, as well as to identify its possible de- With the increasing number of HIV/AIDS-related terminants of efficiency, as a mean to improve the SHC’s frontline health service providers, there is a growing operational practice compared to the efficient ones in need to assess whether these providers have been effi- search for better management. ciently delivering the health services subject to the avail- able resources. In literature, effectiveness/outcomes and Methods costing studies of the frontline HIV/AIDS services have Philippine HIV situation been extensively studied independently [9–27]. However, As of July 2015, the Philippines has recorded a total of efficiency studies, which account for both effectiveness/ 27,138 HIV/AIDS cases, which has been increasing annu- outcomes and costs at the same time, were relatively ally [45]. The country responded to the worsening HIV/ limited [10, 28–34]. Efficiency studies provide informa- AIDS epidemic, by enabling grassroots level primary tion about the efficient/inefficient use of finite resources, health care service providers, such as the Rural Health which could be subsequently utilised as potential sugges- Units (RHU) and City Health Office (CHO), to function tions in the improvement of both management and pol- as SHCs in providing frontline STI PCT services [46]. In icy. As a tool to analyse efficiency, data envelopment the 1980s, there were roughly at total of 170 SHCs, how- analysis (DEA) has been used most often, since it is ever, the number went down to 70 SHCs due to the de- non-parametric, which imposes no restrictive hypothesis crease in the accreditation of the RHU/CHO [47]. on the data generating process and requires minimal as- sumptions about the technology [35, 36]. Although DEA Data envelopment analysis has been widely used in different disciplines [37–42], its In this study, DEA was used to evaluate the efficiency of utilisation in HIV/AIDS research is limited [28–30]. the SHCs. DEA benchmarks the performance of decision- HIV/AIDS research using DEA has been instrumental to making units (DMU) such as healthcare facilities, like the various areas across the globe as a means for resource SHC, taking into consideration the inputs and outputs at allocation and service delivery optimisation efforts. Health thesametime[43, 48]. A set of efficient DMUs were iden- centers in Rwanda were performing at an average effi- tified to form the best-practice frontier, and efficiency mea- ciency at 78%, which suggests that there are still room for sures were estimated relative to the remaining DMUs. improvement in service delivery [28]. Inclusion of effi- After constructing an efficient frontier line, DMUs which ciency determination in national HIV/AIDS programmes lie on the line were considered to be efficient, while those in resources-needs estimation, using macro-level data, can not on the line were inefficient [49]. By benchmarking to narrow the spending gap in the HIV/AIDS response [29]. the best performers, this will help the inefficient DMUs to Lepine, et al. [35] has observed that Avahan NGOs in improve their functional organisation based on the best India could have reduced their inputs by 43% given the performing DMUs in the frontier line [50]. DEA imposes outputs they reached. In a more comprehensive analysis less assumptions on the functional shape of the relation- by Zanakis, et al. [43], countries with lower population ship of the outputs and the inputs [51, 52], and can handle density that manage to provide better health system per- multiple inputs and outputs at the same time. Efficiency formance and per capita support with lower GNP and bet- in DEA was modeled as the maximum ratio of weighted ter media information, tend to have lower HIV/AIDS outputs (yrk)toweightedinputs(xik)subjecttothe indicators. In Kenya, Omondi Aduda, et al. [44] has similar ratios for every DMU be less than or equal to observed that significant improvement in the technical unity. This can be summarised in a mathematical for- efficiency among the outreach facilities were attributable mulation found below [36, 53–55](Eq.1)[56]: to the voluntary medical male circumcision using DEA. P Most of the HIV-related DEA studies have focused on S u y Max θ ¼ Pr¼1 r rk the efficiency of the delivery of health services to the gen- k m v x i¼1 i ik eral population, with little or no focus on the key popula- P tions. Key populations such as the MSM, FSW and PWID S u y Subject to Pr¼1 r rk ≤ ; also access the same basic health services but are at higher m v x 1 i¼1 i ik risk of acquiring sexually transmitted diseases. Their ac- cess to these health services may vary from the general ur ≥ε; vi ≥ε∀r; i population, hence, determining the efficiency of service ð1Þ delivery for these populations would provide insightful suggestions to current service provider. where, To the best of our knowledge, this is the first Philippine k ≡ SHCs; case study which aims to determine the less efficient θ ≡ efficiency coefficient; Seposo et al. BMC Health Services Research (2019) 19:415 Page 3 of 14 vi,i=1,2,…, m, are the weights assigned to the i-th regression in determining which meta-predictors can inputs; explain the variations among the efficiencies. ur,r=1,2,…, m, are the weights assigned to the r-th outputs Inputs and outputs DEA was used to facilitate the input-output modeling The inputs and outputs used in this study were from in determining the efficiency frontier, returns to scale secondary data sources, which are highlighted in the and inefficient-to-efficient movement in the first stage Additional file 1.