Healthcare system efficiency and its drivers in pre- and COVID-19 pandemic settings
Abstract
Purpose – The aim of the study is to assess healthcare system efficiency in both regular circumstances and during the COVID-19 pandemic, with a focus on key factors influencing efficiency, and offer health authorities insights into healthcare system resilience.
Research methodology – The analysis was conducted in two stages. The initial stage involved the application of Data Envelopment Analysis output-oriented model with a constant-returnto-scale framework. The second stage employed Tobit regression method to identify factors that influenced countries’ efficiency.
Findings – We identified the healthcare system efficiency of 14 CIS and EU countries in Pre and pandemic settings and provided a methodology for results interpretation accounting for the complexity of healthcare systems and temporal variations in pandemic trends. The Tobit regression highlighted the role of the health workforce, emphasizing the caution for the reduction of physicians in the system.
Research limitations – The research focused on efficiency in just two regions of Eurasia and only considered medical factors as the primary drivers of efficiency. Additionally, the examination covered the initial year of the pandemic, reflecting only the earlier stages of countries’ performance during the pandemic.
Practical implications – This study contributes to the assessment of healthcare resilience on a global scale and provides information for policymakers, aiding in the selection of optimal practices during the pandemic and enhancing preparedness for future crises.
Originality/Value – Countries’ efficiency assessment in four models and two settings provides valuable insight into the healthcare systems’ resilience.
Keyword : healthcare efficiency, health system resilience, health workforce, pandemic preparedness, DEA
How to Cite
Vishniakov, D., Kasiev, N., & Abdrasulova, F. (2023). Healthcare system efficiency and its drivers in pre- and COVID-19 pandemic settings. Business, Management and Economics Engineering, 21(2), 293–310. https://doi.org/10.3846/bmee.2023.20409
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Adabavazeh, N., Nikbakht, M., & Tirkolaee, E. B. (2023). Identifying and prioritizing resilient health system units to tackle the COVID-19 pandemic. Socio-Economic Planning Sciences, 85, Article 101452. https://doi.org/10.1016/j.seps.2022.101452
Afonso, A., & St. Aubyn, M. (2006). Relative efficiency of health provision: A DEA approach with non-discretionary inputs. SSRN. https://doi.org/10.2139/ssrn.952629
Ahmed, S., Hasan, M. Z., MacLennan, M., Dorin, F., Ahmed, M. W., Hasan, M. M., Hasan, S. M., Islam, M. T., & Khan, J. A. M. (2019). Measuring the efficiency of health systems in Asia: A data envelopment analysis. BMJ Open, 9(3), Article e022155. https://doi.org/10.1136/bmjopen-2018-022155
Arhin, K., Oteng-Abayie, E. F., & Novignon, J. (2023). Assessing the efficiency of health systems in achieving the universal health coverage goal: Evidence from Sub-Saharan Africa. Health Economics Review, 13(1), Article 25. https://doi.org/10.1186/s13561-023-00433-y
Barpanda, S., & Sreekumar, N. (2020). Performance analysis of hospitals in Kerala using data envelopment analysis model. Journal of Health Management, 22(1), 25–40. https://doi.org/10.1177/0972063420908372
Behr, A., & Theune, K. (2017). Health system efficiency: A fragmented picture based on OECD data. PharmacoEconomics – Open, 1(3), 203–221. https://doi.org/10.1007/s41669-017-0010-y
Berchet, C., Bijlholt, K., & Ando, M. (2023). Socio-economic and ethnic health inequalities in COVID-19 outcomes across OECD countries. OECD Health Working Papers, 153. https://doi.org/10.1787/6c2a96c9-en
Boffardi, R. (2022). Causes and factors determining healthcare system inefficiency: The case of Italian regions. Rivista Economica Del Mezzogiorno, 3, 659–693.
Bollyky, T. J., Hulland, E. N., Barber, R. M., Collins, J. K., Kiernan, S., Moses, M., Pigott, D. M., Reiner Jr, R. C., Sorensen, R. J. D., Abbafati, C., Adolph, C., Allorant, A., Amlag, J. O., Aravkin, A. Y., Bang-Jensen, B., Carter, A., Castellano, R., Castro, E., Chakrabarti, S., … Dieleman, J. L. (2022). Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. The Lancet, 399(10334), 1489–1512. https://doi.org/10.1016/S0140-6736(22)00172-6
Breitenbach, M. C., Ngobeni, V., & Aye, G. C. (2021a). Efficiency of healthcare systems in the first wave of COVID-19 – A technical efficiency analysis. Economic Studies (Ikonomicheski Izsledvania), 30(6), 3–21.
Breitenbach, M. C., Ngobeni, V., & Aye, G. C. (2021b). Global healthcare resource efficiency in the management of COVID-19 death and infection prevalence rates. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.638481
Bruinen de Bruin, Y., Lequarre, A.-S., McCourt, J., Clevestig, P., Pigazzani, F., Zare Jeddi, M., Colosio, C., & Goulart, M. (2020). Initial impacts of global risk mitigation measures taken during the combatting of the COVID-19 pandemic. Safety Science, 128, Article 104773. https://doi.org/10.1016/j.ssci.2020.104773
Cylus, J., Papanicolas, I., & Smith, P. (2016). Health system efficiency. How to make measurement matter for policy and management. https://pubmed.ncbi.nlm.nih.gov/28783269/
Dessie, Z. G., & Zewotir, T. (2021). Mortality-related risk factors of COVID-19: A systematic review and meta-analysis of 42 studies and 423,117 patients. BMC Infectious Diseases, 21(1), Article 855. https://doi.org/10.1186/s12879-021-06536-3
Evans, D. B., & Etienne, C. (2010). The world health report – health system financing. The path to universal coverage. Bulletin of the World Health Organization, 88, Article 402. https://doi.org/10.2471/BLT.10.078741
Gavurova, B., Kocisova, K., & Sopko, J. (2021). Health system efficiency in OECD countries: Dynamic network DEA approach. Health Economics Review, 11(1), Article 40. https://doi.org/10.1186/s13561-021-00337-9
Herrera, S., & Pang, G. (2005). Efficiency of public spending in developing countries: An efficiency frontier approach 1, 2 & 3 (Policy research working papers). https://doi.org/10.1596/1813-9450-3645
Hollingsworth, B., & Peacock, S. (2008). Efficiency measurement in health and health care. Routledge. https://doi.org/10.4324/9780203486566
Hradsky, O., & Komarek, A. (2021). Demographic and public health characteristics explain large part of variability in COVID-19 mortality across countries. European Journal of Public Health, 31(1), 12–16. https://doi.org/10.1093/eurpub/ckaa226
Ibrahim, M. D. (2023). Efficiency and productivity analysis of maternal and infant healthcare services in Sub‐Saharan Africa. The International Journal of Health Planning and Management. https://doi.org/10.1002/hpm.3705
Iflaifel, M., Lim, R. H., Ryan, K., & Crowley, C. (2020). Resilient health care: A systematic review of conceptualisations, study methods and factors that develop resilience. BMC Health Services Research, 20(1), Article 324. https://doi.org/10.1186/s12913-020-05208-3
Kapitsinis, N. (2021). The underlying factors of excess mortality in 2020: A cross-country analysis of pre-pandemic healthcare conditions and strategies to cope with Covid-19. BMC Health Services Research, 21(1), Article 1197. https://doi.org/10.1186/s12913-021-07169-7
Keskin, Z. B., & Delice, E. K. (2023). Determining the effectiveness of countries in combating pandemics: COVID-19 case. RAIRO – Operations Research, 57(4), 2151–2176. https://doi.org/10.1051/ro/2023077
Khan, Y., Brown, A. D., Gagliardi, A. R., O’Sullivan, T., Lacarte, S., Henry, B., & Schwart, B. (2019). Are we prepared? The development of performance indicators for public health emergency preparedness using a modified Delphi approach. PLoS ONE, 14(12), Article e0226489. https://doi.org/10.1371/journal.pone.0226489
Klumpp, M., Loske, D., & Bicciato, S. (2022). COVID-19 health policy evaluation: Integrating health and economic perspectives with a data envelopment analysis approach. The European Journal of Health Economics, 23(8), 1263–1285. https://doi.org/10.1007/s10198-021-01425-7
Kujawska, J. (2018). Efficiency of healthcare systems in European countries – the DEA network approach. Metody Ilościowe w Badaniach Ekonomicznych, 19(1), 60–70. https://doi.org/10.22630/MIBE.2018.19.1.6
Kumbhakar, S. C. (2010). Efficiency and productivity of world health systems: Where does your country stand? Applied Economics, 42(13), 1641–1659. https://doi.org/10.1080/00036840701721588
Kuzior, A., Kashcha, M., Kuzmenko, O., Lyeonov, S., & Brożek, P. (2022). Public health system economic efficiency and COVID-19 resilience: Frontier DEA analysis. International Journal of Environmental Research and Public Health, 19(22), Article 14727. https://doi.org/10.3390/ijerph192214727
Lupu, D., & Tiganasu, R. (2022). COVID-19 and the efficiency of health systems in Europe. Health Economics Review, 12(1), Article 14. https://doi.org/10.1186/s13561-022-00358-y
Mbau, R., Musiega, A., Nyawira, L., Tsofa, B., Mulwa, A., Molyneux, S., Maina, I., Jemutai, J., Normand, C., Hanson, K., & Barasa, E. (2022). Analysing the efficiency of health systems: A systematic review of the literature. Applied Health Economics and Health Policy, 21(2), 205–224. https://doi.org/10.1007/s40258-022-00785-2
Medeiros, J., & Schwierz, C. (2015). Efficiency estimates of health care systems. https://doi.org/10.2765/49924
Mitropoulos, P. (2021). Production and quality performance of healthcare services in EU countries during the economic crisis. Operational Research, 21(2), 857–873. https://doi.org/10.1007/s12351-019-00483-3
Mok, V., Yeung, G., Z., H., & Li, Z. (2007). Leverage, technical efficiency and profitability: An application of DEA to foreign-invested toy manufacturing firms in China. Journal of Contemporary China, 16(51), 259–274. https://doi.org/10.1080/10670560701194509
Mourad, N., Habib, A. M., & Tharwat, A. (2021). Appraising healthcare systems’ efficiency in facing COVID-19 through data envelopment analysis. Decision Science Letters, 10(3), 301–310. https://doi.org/10.5267/j.dsl.2021.2.007
Ngami, A., & Ventelou, B. (2023). Respective healthcare system performances taking into account environmental quality: what are the re-rankings for OECD countries? Health Research Policy and Systems, 21(1), Article 57. https://doi.org/10.1186/s12961-023-01005-6
Nyawira, L., Mbau, R., Jemutai, J., Musiega, A., Hanson, K., Molyneux, S., Normand, C., Tsofa, B., Maina, I., Mulwa, A., & Barasa, E. (2021). Examining health sector stakeholder perceptions on the efficiency of county health systems in Kenya. PLOS Global Public Health, 1(12), Article e0000077. https://doi.org/10.1371/journal.pgph.0000077
OECD. (2023). Ready for the next crisis? Investing in Health system resilience. https://doi.org/10.1787/1e53cf80-en
Ordu, M., Kirli Akin, H., & Demir, E. (2021). Healthcare systems and Covid-19: Lessons to be learnt from efficient countries. The International Journal of Health Planning and Management, 36(5), 1476–1485. https://doi.org/10.1002/hpm.3187
Ozcan, Y. A., & Khushalani, J. (2017). Assessing efficiency of public health and medical care provision in OECD countries after a decade of reform. Central European Journal of Operations Research, 25(2), 325–343. https://doi.org/10.1007/s10100-016-0440-0
Pan American Health Organization. (2023). Core indicators dashboard. https://opendata.paho.org/en/core-indicators/core-indicators-dashboard
Panwar, A., Olfati, M., Pant, M., & Snasel, V. (2022). A review on the 40 years of existence of data envelopment analysis models: Historic development and current trends. Archives of Computational Methods in Engineering, 29(7), 5397–5426. https://doi.org/10.1007/s11831-022-09770-3
Pérez-Cárceles, M. C., Gómez-Gallego, J. C., & Gómez-Gallego, M. (2018). Environmental factors affecting European and Central Asian health-systems’ bias-corrected efficiency. Applied Economics, 50(32), 3432–3440. https://doi.org/10.1080/00036846.2017.1420901
Ratner, S. V., Shaposhnikov, A. M., & Lychev, A. V. (2023). Network DEA and its applications (2017–2022): A systematic literature review. Mathematics, 11(9), Article 2141. https://doi.org/10.3390/math11092141
Rostamzadeh, R., Akbarian, O., Banaitis, A., & Soltani, Z. (2021). Application of DEA in benchmarking: A systematic literature review from 2003–2020. Technological and Economic Development of Economy, 27(1), 175–222. https://doi.org/10.3846/tede.2021.13406
Singh, S., Charles, V., & Pandey, U. (2023). Examining operational efficiency with prudent risks of Covid-19: A contextual DEA analysis with an undesirable intermediate measure. Annals of Operations Research. https://doi.org/10.1007/s10479-023-05207-7
Skica, T., Leśniowska-Gontarz, M., & Miszczyńska, K. (2019). Measuring the efficiency of Polish municipalities – Data Envelopment analysis approach. South East European Journal of Economics and Business, 14(2), 54–66. https://doi.org/10.2478/jeb-2019-0013
Sommersguter-Reichmann, M. (2022). Health care quality in nonparametric efficiency studies: A review. Central European Journal of Operations Research, 30(1), 67–131. https://doi.org/10.1007/s10100-021-00774-1
Sorci, G., Faivre, B., & Morand, S. (2020). Explaining among-country variation in COVID-19 case fatality rate. Scientific Reports, 10(1), Article 18909. https://doi.org/10.1038/s41598-020-75848-2
Spinks, J., & Hollingsworth, B. (2009). Cross-country comparisons of technical efficiency of health production: A demonstration of pitfalls. Applied Economics, 41(4), 417–427. https://doi.org/10.1080/00036840701604354
Timofeyev, Y., Dremova, O., & Jakovljevic, M. (2023). The impact of transparency constraints on the efficiency of the Russian healthcare system: systematic literature review. Journal of Medical Economics, 26(1), 95–109. https://doi.org/10.1080/13696998.2022.2160608
Tobit, J. (1958). Estimation of relationship for limited dependent variables. Econometrica, 26(1), 24–36. https://doi.org/10.2307/1907382
Traore, T., Shanks, S., Haider, N., Ahmed, K., Jain, V., Rüegg, S. R., Razavi, A., Kock, R., Erondu, N., Rahman-Shepherd, A., Yavlinsky, A., Mboera, L., Asogun, D., McHugh, T. D., Elton, L., Oyebanji, O., Okunromade, O., Ansumana, R., Djingarey, M. H., … Dar, O. (2023). How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach. The Lancet, 401(10377), 673–687. https://doi.org/10.1016/S0140-6736(22)01589-6
Vörösmarty, G., & Dobos, I. (2023). Management applications and methodology developments in DEA – an overview of literature reviews. International Journal of Management and Decision Making, 22(4), 472–491. https://doi.org/10.1504/IJMDM.2023.134049
Walters, J. K., Sharma, A., Malica, E., & Harrison, R. (2022). Supporting efficiency improvement in public health systems: a rapid evidence synthesis. BMC Health Services Research, 22(1), Article 293. https://doi.org/10.1186/s12913-022-07694-z
Wang, H., Paulson, K. R., Pease, S. A., Watson, S., Comfort, H., Zheng, P., Aravkin, A. Y., Bisignano, C., Barber, R. M., Alam, T., Fuller, J. E., May, E. A., Jones, D. P., Frisch, M. E., Abbafati, C., Adolph, C., Allorant, A., Amlag, J. O., Bang-Jensen, B., … Murray, C. J. L. (2022). Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21. The Lancet, 399(10334), 1513–1536. https://doi.org/10.1016/S0140-6736(21)02796-3
Wiig, S., Aase, K., Billett, S., Canfield, C., Røise, O., Njå, O., Guise, V., Haraldseid-Driftland, C., Ree, E., Anderson, J. E., & Macrae, C. (2020). Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Services Research, 20(1), Article 330. https://doi.org/10.1186/s12913-020-05224-3
World Health Organization. (2020a). COVID-19 Emergency Committee highlights need for response efforts over long term. https://bit.ly/46U2bvh
World Health Organization. (2020b). Healthy life expectancy (HALE). Data by country. https://apps.who.int/gho/data/view.main.HALEXv
World Health Organization. (2020c). Hospital bed density Data by country. https://apps.who.int/gho/data/node.main.HS07?lang=en
World Health Organization. (2020d). Life tables by country. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-life-tables-by-country
World Health Organization. (2020e). Healthy life expectancy (HALE) at age 60 (years) (Mortality and global health estimates). https://apps.who.int/gho/data/node.imr.WHOSIS_000007?lang=en
World Health Organization. (2022). Health system performance assessment. A framework for policy analysis. https://iris.who.int/bitstream/handle/10665/352686/9789240042476-eng.pdf?sequence=1
World Health Organization. (2023a). Current health expenditure (CHE) per capita in US$. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/current-health-expenditure-(che)-per-capita-in-us$
World Health Organization. (2023b). Global excess deaths associated with COVID-19 (modelled estimates). https://www.who.int/data/sets/global-excess-deaths-associated-with-covid-19-modelled-estimates
World Health Organization. (2023c). Medical doctors. https://apps.who.int/gho/data/node.main.HWFGRP_0020?lang=en
World Health Organization. (2023d). Nursing and midwifery personnel. https://apps.who.int/gho/data/node.main.HWFGRP_0040?lang=en
Yari, F., Agheli, L., & Sadeghi, H. (2023). Healthcare expenditure efficiency and its determinants in Iran: a data envelopment analysis and Tobit regression (2000-2019). International Journal of Data Envelopment Analysis, 11(1), 1–14. https://doi.org/10.30495/IJDEA.2023.72415.1192
Yetim, B., Sönmez, S., Konca, M., & İlgün, G. (2023). Benchmarking countries’ technical efficiency using AHP-based weighted slack-based measurement (W-SBM): A cross-national perspective. Health Policy and Technology, 12(3), Article 100782. https://doi.org/10.1016/j.hlpt.2023.100782
Zakowska, I., & Godycki-Cwirko, M. (2019). Data envelopment analysis applications in primary health care: A systematic review. Family Practice. https://doi.org/10.1093/fampra/cmz057
Afonso, A., & St. Aubyn, M. (2006). Relative efficiency of health provision: A DEA approach with non-discretionary inputs. SSRN. https://doi.org/10.2139/ssrn.952629
Ahmed, S., Hasan, M. Z., MacLennan, M., Dorin, F., Ahmed, M. W., Hasan, M. M., Hasan, S. M., Islam, M. T., & Khan, J. A. M. (2019). Measuring the efficiency of health systems in Asia: A data envelopment analysis. BMJ Open, 9(3), Article e022155. https://doi.org/10.1136/bmjopen-2018-022155
Arhin, K., Oteng-Abayie, E. F., & Novignon, J. (2023). Assessing the efficiency of health systems in achieving the universal health coverage goal: Evidence from Sub-Saharan Africa. Health Economics Review, 13(1), Article 25. https://doi.org/10.1186/s13561-023-00433-y
Barpanda, S., & Sreekumar, N. (2020). Performance analysis of hospitals in Kerala using data envelopment analysis model. Journal of Health Management, 22(1), 25–40. https://doi.org/10.1177/0972063420908372
Behr, A., & Theune, K. (2017). Health system efficiency: A fragmented picture based on OECD data. PharmacoEconomics – Open, 1(3), 203–221. https://doi.org/10.1007/s41669-017-0010-y
Berchet, C., Bijlholt, K., & Ando, M. (2023). Socio-economic and ethnic health inequalities in COVID-19 outcomes across OECD countries. OECD Health Working Papers, 153. https://doi.org/10.1787/6c2a96c9-en
Boffardi, R. (2022). Causes and factors determining healthcare system inefficiency: The case of Italian regions. Rivista Economica Del Mezzogiorno, 3, 659–693.
Bollyky, T. J., Hulland, E. N., Barber, R. M., Collins, J. K., Kiernan, S., Moses, M., Pigott, D. M., Reiner Jr, R. C., Sorensen, R. J. D., Abbafati, C., Adolph, C., Allorant, A., Amlag, J. O., Aravkin, A. Y., Bang-Jensen, B., Carter, A., Castellano, R., Castro, E., Chakrabarti, S., … Dieleman, J. L. (2022). Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. The Lancet, 399(10334), 1489–1512. https://doi.org/10.1016/S0140-6736(22)00172-6
Breitenbach, M. C., Ngobeni, V., & Aye, G. C. (2021a). Efficiency of healthcare systems in the first wave of COVID-19 – A technical efficiency analysis. Economic Studies (Ikonomicheski Izsledvania), 30(6), 3–21.
Breitenbach, M. C., Ngobeni, V., & Aye, G. C. (2021b). Global healthcare resource efficiency in the management of COVID-19 death and infection prevalence rates. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.638481
Bruinen de Bruin, Y., Lequarre, A.-S., McCourt, J., Clevestig, P., Pigazzani, F., Zare Jeddi, M., Colosio, C., & Goulart, M. (2020). Initial impacts of global risk mitigation measures taken during the combatting of the COVID-19 pandemic. Safety Science, 128, Article 104773. https://doi.org/10.1016/j.ssci.2020.104773
Cylus, J., Papanicolas, I., & Smith, P. (2016). Health system efficiency. How to make measurement matter for policy and management. https://pubmed.ncbi.nlm.nih.gov/28783269/
Dessie, Z. G., & Zewotir, T. (2021). Mortality-related risk factors of COVID-19: A systematic review and meta-analysis of 42 studies and 423,117 patients. BMC Infectious Diseases, 21(1), Article 855. https://doi.org/10.1186/s12879-021-06536-3
Evans, D. B., & Etienne, C. (2010). The world health report – health system financing. The path to universal coverage. Bulletin of the World Health Organization, 88, Article 402. https://doi.org/10.2471/BLT.10.078741
Gavurova, B., Kocisova, K., & Sopko, J. (2021). Health system efficiency in OECD countries: Dynamic network DEA approach. Health Economics Review, 11(1), Article 40. https://doi.org/10.1186/s13561-021-00337-9
Herrera, S., & Pang, G. (2005). Efficiency of public spending in developing countries: An efficiency frontier approach 1, 2 & 3 (Policy research working papers). https://doi.org/10.1596/1813-9450-3645
Hollingsworth, B., & Peacock, S. (2008). Efficiency measurement in health and health care. Routledge. https://doi.org/10.4324/9780203486566
Hradsky, O., & Komarek, A. (2021). Demographic and public health characteristics explain large part of variability in COVID-19 mortality across countries. European Journal of Public Health, 31(1), 12–16. https://doi.org/10.1093/eurpub/ckaa226
Ibrahim, M. D. (2023). Efficiency and productivity analysis of maternal and infant healthcare services in Sub‐Saharan Africa. The International Journal of Health Planning and Management. https://doi.org/10.1002/hpm.3705
Iflaifel, M., Lim, R. H., Ryan, K., & Crowley, C. (2020). Resilient health care: A systematic review of conceptualisations, study methods and factors that develop resilience. BMC Health Services Research, 20(1), Article 324. https://doi.org/10.1186/s12913-020-05208-3
Kapitsinis, N. (2021). The underlying factors of excess mortality in 2020: A cross-country analysis of pre-pandemic healthcare conditions and strategies to cope with Covid-19. BMC Health Services Research, 21(1), Article 1197. https://doi.org/10.1186/s12913-021-07169-7
Keskin, Z. B., & Delice, E. K. (2023). Determining the effectiveness of countries in combating pandemics: COVID-19 case. RAIRO – Operations Research, 57(4), 2151–2176. https://doi.org/10.1051/ro/2023077
Khan, Y., Brown, A. D., Gagliardi, A. R., O’Sullivan, T., Lacarte, S., Henry, B., & Schwart, B. (2019). Are we prepared? The development of performance indicators for public health emergency preparedness using a modified Delphi approach. PLoS ONE, 14(12), Article e0226489. https://doi.org/10.1371/journal.pone.0226489
Klumpp, M., Loske, D., & Bicciato, S. (2022). COVID-19 health policy evaluation: Integrating health and economic perspectives with a data envelopment analysis approach. The European Journal of Health Economics, 23(8), 1263–1285. https://doi.org/10.1007/s10198-021-01425-7
Kujawska, J. (2018). Efficiency of healthcare systems in European countries – the DEA network approach. Metody Ilościowe w Badaniach Ekonomicznych, 19(1), 60–70. https://doi.org/10.22630/MIBE.2018.19.1.6
Kumbhakar, S. C. (2010). Efficiency and productivity of world health systems: Where does your country stand? Applied Economics, 42(13), 1641–1659. https://doi.org/10.1080/00036840701721588
Kuzior, A., Kashcha, M., Kuzmenko, O., Lyeonov, S., & Brożek, P. (2022). Public health system economic efficiency and COVID-19 resilience: Frontier DEA analysis. International Journal of Environmental Research and Public Health, 19(22), Article 14727. https://doi.org/10.3390/ijerph192214727
Lupu, D., & Tiganasu, R. (2022). COVID-19 and the efficiency of health systems in Europe. Health Economics Review, 12(1), Article 14. https://doi.org/10.1186/s13561-022-00358-y
Mbau, R., Musiega, A., Nyawira, L., Tsofa, B., Mulwa, A., Molyneux, S., Maina, I., Jemutai, J., Normand, C., Hanson, K., & Barasa, E. (2022). Analysing the efficiency of health systems: A systematic review of the literature. Applied Health Economics and Health Policy, 21(2), 205–224. https://doi.org/10.1007/s40258-022-00785-2
Medeiros, J., & Schwierz, C. (2015). Efficiency estimates of health care systems. https://doi.org/10.2765/49924
Mitropoulos, P. (2021). Production and quality performance of healthcare services in EU countries during the economic crisis. Operational Research, 21(2), 857–873. https://doi.org/10.1007/s12351-019-00483-3
Mok, V., Yeung, G., Z., H., & Li, Z. (2007). Leverage, technical efficiency and profitability: An application of DEA to foreign-invested toy manufacturing firms in China. Journal of Contemporary China, 16(51), 259–274. https://doi.org/10.1080/10670560701194509
Mourad, N., Habib, A. M., & Tharwat, A. (2021). Appraising healthcare systems’ efficiency in facing COVID-19 through data envelopment analysis. Decision Science Letters, 10(3), 301–310. https://doi.org/10.5267/j.dsl.2021.2.007
Ngami, A., & Ventelou, B. (2023). Respective healthcare system performances taking into account environmental quality: what are the re-rankings for OECD countries? Health Research Policy and Systems, 21(1), Article 57. https://doi.org/10.1186/s12961-023-01005-6
Nyawira, L., Mbau, R., Jemutai, J., Musiega, A., Hanson, K., Molyneux, S., Normand, C., Tsofa, B., Maina, I., Mulwa, A., & Barasa, E. (2021). Examining health sector stakeholder perceptions on the efficiency of county health systems in Kenya. PLOS Global Public Health, 1(12), Article e0000077. https://doi.org/10.1371/journal.pgph.0000077
OECD. (2023). Ready for the next crisis? Investing in Health system resilience. https://doi.org/10.1787/1e53cf80-en
Ordu, M., Kirli Akin, H., & Demir, E. (2021). Healthcare systems and Covid-19: Lessons to be learnt from efficient countries. The International Journal of Health Planning and Management, 36(5), 1476–1485. https://doi.org/10.1002/hpm.3187
Ozcan, Y. A., & Khushalani, J. (2017). Assessing efficiency of public health and medical care provision in OECD countries after a decade of reform. Central European Journal of Operations Research, 25(2), 325–343. https://doi.org/10.1007/s10100-016-0440-0
Pan American Health Organization. (2023). Core indicators dashboard. https://opendata.paho.org/en/core-indicators/core-indicators-dashboard
Panwar, A., Olfati, M., Pant, M., & Snasel, V. (2022). A review on the 40 years of existence of data envelopment analysis models: Historic development and current trends. Archives of Computational Methods in Engineering, 29(7), 5397–5426. https://doi.org/10.1007/s11831-022-09770-3
Pérez-Cárceles, M. C., Gómez-Gallego, J. C., & Gómez-Gallego, M. (2018). Environmental factors affecting European and Central Asian health-systems’ bias-corrected efficiency. Applied Economics, 50(32), 3432–3440. https://doi.org/10.1080/00036846.2017.1420901
Ratner, S. V., Shaposhnikov, A. M., & Lychev, A. V. (2023). Network DEA and its applications (2017–2022): A systematic literature review. Mathematics, 11(9), Article 2141. https://doi.org/10.3390/math11092141
Rostamzadeh, R., Akbarian, O., Banaitis, A., & Soltani, Z. (2021). Application of DEA in benchmarking: A systematic literature review from 2003–2020. Technological and Economic Development of Economy, 27(1), 175–222. https://doi.org/10.3846/tede.2021.13406
Singh, S., Charles, V., & Pandey, U. (2023). Examining operational efficiency with prudent risks of Covid-19: A contextual DEA analysis with an undesirable intermediate measure. Annals of Operations Research. https://doi.org/10.1007/s10479-023-05207-7
Skica, T., Leśniowska-Gontarz, M., & Miszczyńska, K. (2019). Measuring the efficiency of Polish municipalities – Data Envelopment analysis approach. South East European Journal of Economics and Business, 14(2), 54–66. https://doi.org/10.2478/jeb-2019-0013
Sommersguter-Reichmann, M. (2022). Health care quality in nonparametric efficiency studies: A review. Central European Journal of Operations Research, 30(1), 67–131. https://doi.org/10.1007/s10100-021-00774-1
Sorci, G., Faivre, B., & Morand, S. (2020). Explaining among-country variation in COVID-19 case fatality rate. Scientific Reports, 10(1), Article 18909. https://doi.org/10.1038/s41598-020-75848-2
Spinks, J., & Hollingsworth, B. (2009). Cross-country comparisons of technical efficiency of health production: A demonstration of pitfalls. Applied Economics, 41(4), 417–427. https://doi.org/10.1080/00036840701604354
Timofeyev, Y., Dremova, O., & Jakovljevic, M. (2023). The impact of transparency constraints on the efficiency of the Russian healthcare system: systematic literature review. Journal of Medical Economics, 26(1), 95–109. https://doi.org/10.1080/13696998.2022.2160608
Tobit, J. (1958). Estimation of relationship for limited dependent variables. Econometrica, 26(1), 24–36. https://doi.org/10.2307/1907382
Traore, T., Shanks, S., Haider, N., Ahmed, K., Jain, V., Rüegg, S. R., Razavi, A., Kock, R., Erondu, N., Rahman-Shepherd, A., Yavlinsky, A., Mboera, L., Asogun, D., McHugh, T. D., Elton, L., Oyebanji, O., Okunromade, O., Ansumana, R., Djingarey, M. H., … Dar, O. (2023). How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach. The Lancet, 401(10377), 673–687. https://doi.org/10.1016/S0140-6736(22)01589-6
Vörösmarty, G., & Dobos, I. (2023). Management applications and methodology developments in DEA – an overview of literature reviews. International Journal of Management and Decision Making, 22(4), 472–491. https://doi.org/10.1504/IJMDM.2023.134049
Walters, J. K., Sharma, A., Malica, E., & Harrison, R. (2022). Supporting efficiency improvement in public health systems: a rapid evidence synthesis. BMC Health Services Research, 22(1), Article 293. https://doi.org/10.1186/s12913-022-07694-z
Wang, H., Paulson, K. R., Pease, S. A., Watson, S., Comfort, H., Zheng, P., Aravkin, A. Y., Bisignano, C., Barber, R. M., Alam, T., Fuller, J. E., May, E. A., Jones, D. P., Frisch, M. E., Abbafati, C., Adolph, C., Allorant, A., Amlag, J. O., Bang-Jensen, B., … Murray, C. J. L. (2022). Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21. The Lancet, 399(10334), 1513–1536. https://doi.org/10.1016/S0140-6736(21)02796-3
Wiig, S., Aase, K., Billett, S., Canfield, C., Røise, O., Njå, O., Guise, V., Haraldseid-Driftland, C., Ree, E., Anderson, J. E., & Macrae, C. (2020). Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Services Research, 20(1), Article 330. https://doi.org/10.1186/s12913-020-05224-3
World Health Organization. (2020a). COVID-19 Emergency Committee highlights need for response efforts over long term. https://bit.ly/46U2bvh
World Health Organization. (2020b). Healthy life expectancy (HALE). Data by country. https://apps.who.int/gho/data/view.main.HALEXv
World Health Organization. (2020c). Hospital bed density Data by country. https://apps.who.int/gho/data/node.main.HS07?lang=en
World Health Organization. (2020d). Life tables by country. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-life-tables-by-country
World Health Organization. (2020e). Healthy life expectancy (HALE) at age 60 (years) (Mortality and global health estimates). https://apps.who.int/gho/data/node.imr.WHOSIS_000007?lang=en
World Health Organization. (2022). Health system performance assessment. A framework for policy analysis. https://iris.who.int/bitstream/handle/10665/352686/9789240042476-eng.pdf?sequence=1
World Health Organization. (2023a). Current health expenditure (CHE) per capita in US$. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/current-health-expenditure-(che)-per-capita-in-us$
World Health Organization. (2023b). Global excess deaths associated with COVID-19 (modelled estimates). https://www.who.int/data/sets/global-excess-deaths-associated-with-covid-19-modelled-estimates
World Health Organization. (2023c). Medical doctors. https://apps.who.int/gho/data/node.main.HWFGRP_0020?lang=en
World Health Organization. (2023d). Nursing and midwifery personnel. https://apps.who.int/gho/data/node.main.HWFGRP_0040?lang=en
Yari, F., Agheli, L., & Sadeghi, H. (2023). Healthcare expenditure efficiency and its determinants in Iran: a data envelopment analysis and Tobit regression (2000-2019). International Journal of Data Envelopment Analysis, 11(1), 1–14. https://doi.org/10.30495/IJDEA.2023.72415.1192
Yetim, B., Sönmez, S., Konca, M., & İlgün, G. (2023). Benchmarking countries’ technical efficiency using AHP-based weighted slack-based measurement (W-SBM): A cross-national perspective. Health Policy and Technology, 12(3), Article 100782. https://doi.org/10.1016/j.hlpt.2023.100782
Zakowska, I., & Godycki-Cwirko, M. (2019). Data envelopment analysis applications in primary health care: A systematic review. Family Practice. https://doi.org/10.1093/fampra/cmz057