Social Indicators Research

, Volume 129, Issue 1, pp 113–132 | Cite as

Analysis of the Efficiency Determinants of Health Systems in OECD Countries by DEA and Panel Tobit

  • Pınar Kaya Samut
  • Reyhan Cafrı


In recent years, almost all countries around the world face budget cuts in health spending, which force public and private hospitals in these countries to use their resources effectively and to provide more efficient health care. In this context, the present study evaluates hospital efficiency across 29 OECD countries between 2000 and 2010 and investigates the determinants affecting hospitals’ activities. In the first stage of the two-stage performance analysis, efficiency scores of the hospitals were measured by data envelopment analysis (DEA) while, in the second stage, Panel Tobit Analysis was used to identify the environmental factors that affect the efficiency scores obtained in the first stage. The paper also explores the changes in the factor efficiency compared to the previous years by decomposition through the Malmquist Productivity Index. In the first stage, it was found that the efficiency scores achieved after 2000 began to decline in 2004 and reached their lowest levels between 2009 and 2010. The highest slack values were found in the figures regarding tomography, MR, and nurses, respectively. In the second stage, due to the censored nature of the dependent variable obtained by DEA, in order to achieve consistent and unbiased estimators, the use of Panel Tobit Analysis was proposed. Estimations showed that, among the environmental factors that secondarily affect hospital efficiency, income, education and number of private hospitals affect efficiency in a positive way, while the effects of public and private health expenses and the number of public hospitals on such efficiency was negative.


Health services sector Data envelopment analysis Malmquist Productivity Index Panel Tobit Model 


  1. Afonso, A., & Aubyn, M. (2005). Non-parametric approaches to education and health efficiency in OECD countries. Journal of Applied Economics, 8(2), 227–246.Google Scholar
  2. Afonso, A., & Aubyn, M. (2011). Assessing health efficiency across countries with a two-step and bootstrap analysis. Applied Economics Letters, 18, 1427–1430.CrossRefGoogle Scholar
  3. Alexander, C. A., Busch, G., & Stringer, K. (2003). Implementing and interpreting a data envelopment analysis model to assess the efficiency of health systems in developing countries. IMA Journal of Management Mathematics, 14, 49–63.CrossRefGoogle Scholar
  4. Ancarani, A., Di Maurob, C., & Giammancob, M. D. (2009). The impact of managerial and organizational aspects on hospital wards’ efficiency: Evidence from a case study. European Journal of Operational Research, 194, 280–293.CrossRefGoogle Scholar
  5. Atkinson, S. E., & Wilson, P. W. (1995). Comparing mean efficiency and productivity scores from small samples: A bootstrap methodology. The Journal of Productivity Analysis, 6, 137–152.CrossRefGoogle Scholar
  6. Baltagi, B. (2008). Econometric analysis of panel data (4th ed.). Hoboken: Wiley.Google Scholar
  7. Banker, R. D., Charnes, A., & Cooper, W. W. (1984). Some models for estimating technical and scale inefficiencies in data envelopment analysis. Management Science, 30(9), 1078–1092.CrossRefGoogle Scholar
  8. Berger, M. C., & Messer, J. (2002). Public financing of health expenditures, insurance, and health outcomes. Applied Economics, 34(17), 2105–2113.CrossRefGoogle Scholar
  9. Bhat, V. N. (2005). Institutional arrangements and efficiency of health care delivery systems. European Journal of Health Economics, 50, 215–222.CrossRefGoogle Scholar
  10. Biorn, E., Hagen, T. P., Iversen, T., & Magnussen, J. (2003). The effect of activity-based financing on hospital efficiency: A panel data analysis of DEA efficiency scores 1992–2000. Health Care Management Science, 6, 271–283.CrossRefGoogle Scholar
  11. Caves, D. W., Christensen, L. R., & Diewert, W. E. (1982). The economic theory of index numbers and the measurement of input, output, and productivity. Econometrica, 50(6), 1393–1414.CrossRefGoogle Scholar
  12. Charnes, A., Cooper, W. W., & Rhodes, E. (1978). Measuring the efficiency of decision making units. European Journal of Operational Research, 2, 429–444.CrossRefGoogle Scholar
  13. Chen, A., Hwang, Y., & Shao, B. (2005). Measurement and sources of overall and input inefficiencies: Evidences and implications in hospital services. European Journal of Operational Research, 161, 447–468.CrossRefGoogle Scholar
  14. Chilingerian, J. A. (1995). Evaluating physician efficiency in hospitals: A multivariate analysis of best practices. European Journal of Operational Research, 80, 548–574.CrossRefGoogle Scholar
  15. Chowdhury, H., Zelenyuk, V., Laporte, A., & Wodchis, W. P. (2014). Analysis of productivity, efficiency and technological changes in hospital services in Ontario: How does case-mix matter? International Journal of Production Economics, 150, 74–82.CrossRefGoogle Scholar
  16. Chu, N. G. Y. (2011). The productive efficiency of Chinese hospitals. China Economic Review, 22, 428–439.CrossRefGoogle Scholar
  17. Coelli, T.J. (1996). A guide to DEAP version 2.0: A data envelopment analysis (computer) program. Center for Efficiency and Productive Analysis (CEPA) Department of Econometrics University of New England, Armidale, Australia.Google Scholar
  18. Cooper, W. W., Seiford, L. M., & Zhu, J. (2003). Handbook on data envelopment analysis. International series in operations research and management science (2nd ed., Vol. 164). Norwell: Springer.Google Scholar
  19. Davidson, R., & MacKinnon, J. (2003). Econometric theory and methods. Oxford: Oxford University Press.Google Scholar
  20. Erdoğan, A. H., & Samut, P. K. (2013). Analysis of the efficiency determinants of Turkey’s agriculture sector by two-stage data envelopment analysis (DEA). Ege Academic Review, 13(1), 21–28.Google Scholar
  21. Eurostat, European Commission. (2014). Accessed March 10, 2014.
  22. Evans, D., Tandon, T., Murray, C. & Lauer, J. (2000). The comparative efficiency of national health systems in producing health: An analysis of 191 countries. GPE Discussion Paper No. 29, Geneva: WHO.Google Scholar
  23. Färe, R., & Grosskopf, S. (1992). Malmquist productivity indexes and fisher ideal indexes. Economic Journal, 102(410), 158–160.CrossRefGoogle Scholar
  24. Färe, R., Grosskopf, S., Lindgren, B., & Roos, P. (1994). Productivity developments in Swedish hospitals: A malmquist output index approach. In A. Charnes, W. Cooper, A. Lewin, & L. Seiford (Eds.), data envelopment analysis: Theory, methodology and applications. Boston: Kluwer.Google Scholar
  25. Farrell, M. J. (1957). The measurement of productive efficiency. Journal of the Royal Statistical Society, 120(3), 253–290.CrossRefGoogle Scholar
  26. Fernandez-Val, I., Weidner, M. (2013). Individual and time effects in nonlinear panel models with large N, T. Accessed April 24, 2014.
  27. Gok, M. S., & Sezen, B. (2013). Analyzing the ambiguous relationship between efficiency, quality and patient satisfaction in healthcare services: The case of public hospitals in Turkey. Health Policy, 111, 290–300.CrossRefGoogle Scholar
  28. Greene, W. (2003). Econometric analysis (5th ed.). New Jersey: Prentice Hall.Google Scholar
  29. Greene, W. (2004a). Distinguishing between heterogeneity and inefficiency: Stochastic frontier analysis of the World Health Organization’s panel data on national health care systems. Health Economics, 13, 959–980.CrossRefGoogle Scholar
  30. Greene, W. (2004b). Fixed effects and bias due to the incidental parameters problem in the tobit model. Econometric Reviews, 23(2), 125–147.CrossRefGoogle Scholar
  31. Grosskopf, S., Self, S., & Zaim, O. (2006). Estimating the efficiency of the system of healthcare financing in achieving better health. Applied Economics, 38, 1477–1488.CrossRefGoogle Scholar
  32. Hollingsworth, B., & Wildman, J. (2003). The efficiency of health production: Re-estimating the WHO panel data using parametric and non-parametric approaches to provide additional information. Health Economics, 12, 493–504.CrossRefGoogle Scholar
  33. Hu, H. H., Qi, Q., & Yang, C. H. (2012). Analysis of hospital technical efficiency in China: Effect of health insurance reform. China Economic Review, 23, 865–877.CrossRefGoogle Scholar
  34. Jamil, N. (2013). A comparison of iterative methods for the solution of non-linear systems of equations. International Journal, 3(2), 119–130.Google Scholar
  35. Kittelsen, S. A. C., Magnussen, J., Anthun, K. S., Häkkinen, U., Linna, M., Medin, E., Olsen, K. R., & Rehnberg, C. (2008). Hospital productivity and the Norwegian ownership reformA Nordic comparative study (Vol. 10, pp. 1–25). HERO Working Paper, University of Oslo, Health Economics Research Programme.Google Scholar
  36. Kjekshus, L., & Hagen, L. (2007). Do hospital mergers increase hospital efficiency? Evidence from a National Health Service country. Journal of Health Services Research and Policy, 12(4), 230–235.CrossRefGoogle Scholar
  37. Lovell, K. C. A. (2003). The decomposition of Malmquist productivity indexes. Journal of Productivity Analysis, 20, 437–458.CrossRefGoogle Scholar
  38. Malmquist, S. (1953). Index numbers and indifference surfaces. Trabajos de Estadistica, 4, 209–242.CrossRefGoogle Scholar
  39. Medin, E., Anthun, K. S., Hakkinen, U., Kittelsen, S. A. C., Linna, M., Magnussen, J., et al. (2011). Cost efficiency of university hospitals in the Nordic countries: A cross-country analysis. The European Journal of Health Economics, 12, 509–519.CrossRefGoogle Scholar
  40. Mitropoulos, P., Mitropoulos, I., & Sissouras, A. (2013). Managing for efficiency in health care: The case of Greek public hospitals. The European Journal of Health Economics, 14, 929–938.CrossRefGoogle Scholar
  41. Mobley, L. R., & Magnussen, J. (1998). An international comparison of hospital efficiency: Does institutional environment matter? Applied Economics, 30, 1089–1100.CrossRefGoogle Scholar
  42. Moran, V., & Jacobs, R. (2013). An international comparison of efficiency of inpatient mental health care systems. Health Policy, 112, 88–99.CrossRefGoogle Scholar
  43. National Health System of Spain. (2014). Accessed March 10, 2014.
  44. Nedelea, I. C., & Fanin, J. M. (2013). Analyzing cost efficiency of critical access hospitals. Journal of Policy Modeling, 35, 183–195.CrossRefGoogle Scholar
  45. OECD. (2012). Health at a glance: Europe 2012. Paris: OECD Publishing. doi: 10.1787/9789264183896-en.Google Scholar
  46. OECD. (2013). Health at a glance 2013: OECD indicators. Paris: OECD Publishing. doi: 10.1787/health_glance-2013-en.Google Scholar
  47. OECD. (2014). Stat Extracts. Accessed March 7, 2014.
  48. Pelone, F., Kringos, D. S., Valerio, L., Romaniello, A., Lazzari, A., Ricciardi, W., & Giulio de Belvis, A. (2012). The measurement of the relative efficiency of general practice and the implications for policy makers. Health Policy, 107, 258–268.CrossRefGoogle Scholar
  49. Pritchett, L., & Summers, L. H. (1996). Wealthier is healthier. Journal of Human Resources, University of Wisconsin Press, 31(4), 841–868.Google Scholar
  50. Puig-Junoy, J. (1998). Measuring health production performance in the OECD. Applied Economics Letters, 5, 255–259.CrossRefGoogle Scholar
  51. Puig-Junoy, J. (2000). Partitioning input cost efficiency into its allocative and technical components: An empirical DEA application to hospitals. Socio-Economic Planning Sciences, 34, 199–218.CrossRefGoogle Scholar
  52. Ray, S. C. (2004). Data envelopment analysis: Theory and techniques for economics and operations research. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  53. Retzlaff-Roberts, D., Chang, C. F., & Rubin, R. M. (2004). Technical efficiency in the use of health care resources: A comparison of OECD countries. Health Policy, 69, 55–72.CrossRefGoogle Scholar
  54. Sahin, I., Ozcan, Y. A., & Ozgen, H. (2011). Assessment of hospital efficiency under health transformation program in Turkey. Central European Journal of Operations Research (CEJOR), 19, 19–37.CrossRefGoogle Scholar
  55. Self, S., & Grabowki, R. (2003). How effective is public health expenditure in improving overall health? A cross-country analysis. Applied Economics, 35(7), 835–845.CrossRefGoogle Scholar
  56. Sherman, H. D. (1984). Hospital efficiency measurement and evaluation: Empirical test of a new technique. Medical Care, 22(10), 922–938.CrossRefGoogle Scholar
  57. Spinks, J., & Hollingsworth, B. (2009). Cross-country comparisons of technical efficiency of health production: A demonstration of pitfalls. Applied Economics, 41, 417–427.CrossRefGoogle Scholar
  58. Steinmann, L., Dittrich, G., Karmann, A., & Zweifel, P. (2004). Measuring and comparing the (in) efficiency of German and Swiss hospitals. The European Journal of Health Economics, 5, 216–226.CrossRefGoogle Scholar
  59. The World Bank. (2014). Accessed March 10, 2014.
  60. Thomas, A. (2007). Applied panel data econometrics Accessed April 11, 2014.
  61. Varabyova, Y., & Schreyögg, J. (2013). International comparisons of the technical of the hospital sector: Panel data analysis of OECD countries using parametric and non-parametric approaches. Health Policy, 112, 70–79.CrossRefGoogle Scholar
  62. Weng, S.-J., Wu, T., Blackhurst, J., & Mackulak, G. (2009). An extended DEA model for hospital performance evaluation and improvement. Health Service Outcomes Research Method, 9, 39–53.CrossRefGoogle Scholar
  63. Witte, K. D., & Marques, R. C. (2010). Designing performance incentives, an international benchmark study in the water sector. Central European Journal of Operations Research (CEJOR), 18, 189–220.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  1. 1.Department of Management, Faculty of ManagementAtilim UniversityIncek Golbasi, AnkaraTurkey
  2. 2.Department of EconomicsCankiri Karatekin UniversityCankiriTurkey

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