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Efficiency Measurement in Health Facilities: A Systematic Review in Low- and Middle-Income Countries

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Limited healthcare resources in low- and middle-income countries (LMICs) have led policy-makers to improve healthcare efficiency. Therefore, it is essential to understand how efficiency has been measured in the LMIC setting.


This paper reviews methodologies used for efficiency studies in health facilities in LMICs.


We searched MEDLINE, Embase, Global Health, EconLit and ProQuest Dissertations and Theses databases to Week 6 in 2018. We included all types of quantitative analysis studies relating to the measurement of the efficiency of services at health facilities in LMICs. We extracted data from eligible studies, and assessed the validity for each study. Because of the substantial heterogeneity of the studies, results were presented narratively.


A total of 137 papers were eligible for inclusion. These articles covered a wide range of health facility types, with more than half of the studies relating to hospitals. Our systematic review showed that there is an increasing trend in efficiency measurements in LMICs using various methods. Most studies employed data envelopment analysis as an efficiency measurement method. The studies typically included physical inputs and health services as outputs. Sixty-one percent of the studies analysed the contextual variables of the health facility efficiency.


This review highlights the potential for methodological improvement and policy impacts in efficiency measurements.

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Data Availability Statement

The search terms applied and list of formatted bibliography exported from EndNote database generated during this study are included in this published article as electronic supplementary material.


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The authors would like to acknowledge Prof. Simon Gilbody, Judy Wright, and Kirstine McDermid for their guidance, comments, and inputs for developing and running the search strategy during a systematic review course at the University of Leeds.

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All authors contributed to the manuscript content and approved its submission for publication. FH conceived and designed the study, acquired the articles, analysed and interpreted the results and drafted the article. ST and TE contributed to framing the research objectives, analysis and interpretation of data, and critically revising the article.

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Correspondence to Firdaus Hafidz.

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This work was supported by the Indonesia Endowment Fund for Education [S-1075/LPDP.3/2014].

Conflicts of Interest

Firdaus Hafidz, Tim Ensor, and Sandy Tubeuf declare they have no conflicts of interest.

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This review does not require ethical review.

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Hafidz, F., Ensor, T. & Tubeuf, S. Efficiency Measurement in Health Facilities: A Systematic Review in Low- and Middle-Income Countries. Appl Health Econ Health Policy 16, 465–480 (2018).

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