A network Data Envelopment Analysis to estimate nations' efficiency in the fight against SARS-CoV-2.

The ongoing outbreak of SARS-CoV-2 has been deeply impacting health systems worldwide. In this context, it is pivotal to measure the efficiency of different nations' response to the pandemic, whose insights can be used by governments and health authorities worldwide to improve their national COVID-19 strategies. Hence, we propose a network Data Envelopment Analysis (DEA) to estimate the efficiencies of fifty-five countries in the current crisis, including the thirty-seven Organisation for Economic Co-operation and Development (OECD) member countries, six OECD prospective members, four OECD key partners, and eight other countries. The network DEA model is designed as a general series structure with five single-division stages - population, contagion, triage, hospitalisation, and intensive care unit admission -, and considers an output maximisation orientation, denoting a social perspective, and an input minimisation orientation, denoting a financial perspective. It includes inputs related to health costs, desirable and undesirable intermediate products related to the use of personal protective equipment and infected population, respectively, and desirable and undesirable outputs regarding COVID-19 recoveries and deaths, respectively. To the best of the authors' knowledge, this is the first study proposing a cross-country efficiency measurement using a network DEA within the context of the COVID-19 crisis. The study concludes that Estonia, Iceland, Latvia, Luxembourg, the Netherlands, and New Zealand are the countries exhibiting higher mean system efficiencies. Their national COVID-19 strategies should be studied, adapted, and used by countries exhibiting worse performances. In addition, the observation of countries with large populations presenting worse mean efficiency scores is statistically significant.

Reforms in the Portuguese health care sector: Challenges and proposals.

Portugal has one of the most complete public systems worldwide. Since 1979, the Portuguese National Health Service (NHS) was developed based on the integration and complementarity between different levels of care (primary, secondary, continued, and palliative care). However, in 2009, the absence of economic growth and the increased foreign debt led the country to a severe economic slowdown, reducing the public funding and weakening the decentralized model of health care administration. During the austerity period, political attention has focused primarily on reducing health care costs and consolidating the efficiency and sustainability with no structural reform. After the postcrisis period (since 2016), the recovery of the public health system begun. Since then, some proposals have required a reform of the health sector's governance structure based on the promotion of access, quality, and efficiency. This study presents several key issues involved in the current postcrisis reform of the Portuguese NHS response structure to citizens' needs. The article also discusses the implications of this Portuguese experience based on current reforms with impact on the future of citizens' health.

Technical efficiency of Portuguese public hospitals: A comparative analysis across the five regions of Portugal.

The present study aims to analyse the efficiency scores of hospital units, with reference to the five Portuguese health administrative regions (North, Centre, Lisbon and Tagus Valley, Alentejo, and Algarve). This paper contextualizes the process of decentralization of health in Portugal (started 1993) as well as the hospitals' corporatization and merging reforms (started 2002). These reforms aimed to meet health care needs by optimizing costs, improving efficiency, and broadening both access and quality in health services. Data envelopment analysis was used to quantify and compare the efficiencies of 27 hospitals heterogeneously distributed by five administrative regions. The results show a large average performance across the country. However, there are regions with scores larger than the national average and others with inferior results. This interregional diversity points towards disparities that deserve special attention from the policymakers and hospital managers.

The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis.

The Portuguese health system concentrates most of its activity in a National Health Service, created in 1979 to promote universal and general access. The National Health Service should ensure equity, efficiency, and quality of all health care delivered services. This study assesses the impact of health care policies between 2002 and 2017, focusing on 3 timeframes: the adoption and adaptation of New Public Management principles to the health care sector (2002 to 2010), the economic and financial crisis period (2011-2015), and the postcrisis recovery period (2016-2017). The current study evaluates the main policy measures in the health sector, presenting their impacts in terms of access, efficiency, accountability, and costs over those 3 economic periods. It was verified that not all the measures implemented by the successive governments obtained the desired outcomes, generating even costs increase, apart from the austerity period in which health expenditure showed a significant reduction because of the financial constraints.

Should inpatients be adjusted by their complexity and severity for efficiency assessment? Evidence from Portugal.

Hospital efficiency analysis depends largely on the model specifications. This study discusses the importance of the case-mix index (CMI) to homogenize the sample of inpatient discharges. It proposes a new index where they are classified by service, since it is usual to have lack of data to compute the CMI and this can influence the credibility of results. Data from the Portuguese national diagnosis-related group (DRG) database was utilized. Three different approaches are developed in this paper, based on locally convex order-m method as well as on translog functions. The first one correlates the efficiency with different inpatients weighting schemes, by using the Nadaraya-Watson method. The second approach compares different frontiers that have been computed using the different weighting schemes. Finally, by using bootstrap, the paper investigates whether the inclusion of severity/ complexity-related variables in the model statistically modifies the results. It has been shown that, under the Portuguese healthcare framework, if the model is environment corrected (which should include epidemiological and main political/ structural health reforms variables), then the severity adjustment of inpatients is pointless. The employment of an inpatient-weighting scheme, such as the CMI, may introduce significant frontier shift, thus its absence is not recommended in productivity evolution analyzes. The CMI shifts the efficiency frontier, but not the relative position of units against it (the last scenario if exogenous variables are present).

Patient Satisfaction with Healthcare Services and the Techniques Used for its Assessment: A Systematic Literature Review and a Bibliometric Analysis.

Patient satisfaction with healthcare provision services and the factors influencing it are be-coming the main focus of many scientific studies. Assuring the quality of the provided services is essential for the fulfillment of patients' expectations and needs. Thus, this systematic review seeks to find the determinants of patient satisfaction in a global setting. We perform an analysis to evaluate the collected literature and to fulfill the literature gap of bibliometric analysis within this theme. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach. We conducted our database search in Scopus, Web of Science, and PubMed in June 2022. Studies from 2000-2021 that followed the inclusion and exclusion criteria and that were written in English were included in the sample. We ended up with 157 articles to review. A co-citation and bibliographic coupling analysis were employed to find the most relevant sources, authors, and documents. We divided the factors influencing patient satisfaction into criteria and explanatory variables. Medical care, communication with the patient, and patient's age are among the most critical factors for researchers. The bibliometric analysis revealed the countries, institutions, documents, authors, and sources most productive and significant in patient satisfaction.

A Critical Analysis of Decentralizing the Portuguese Public Healthcare Provision Services.

The Portuguese health system has a universal, public, general National Health Service (NHS), tending towards free healthcare access. Created in 1979, this delivery model developed from the integration and complementarity between the different response levels (primary, hospital, continuing, and palliative care). However, over the last 40 years, the initially centralized system underwent a decentralization process with the creation of Regional Health Administrations in the five mainland administrative regions. Since then, the entire NHS has settled around this new organization. The most recent step started in 2018 with the decentralization of primary healthcare skills to 190 municipalities. This paper presents the various critical issues involved in the latest gradual decentralization process in health, intending to bring services closer to the citizens, and to be more focused on their needs. The article identifies and discusses the implications of this experience based on the steps foreseen in the already-published legal texts.

An Incentive-Based Framework for Analyzing the Alignment of Institutional Interventions in the Public Primary Healthcare Sector: The Portuguese Case.

Over the years, the Portuguese National Health Service has undergone several reforms to face the challenges posed by internal and external factors on the access to and quality of its health services. One of its most recent reforms addressed the primary healthcare sector, where understanding the incentives behind the actors of the inherent institutional interventions and how they are aligned with the governing health policies is paramount for reformative success. With the purpose of acknowledging the alignment of the primary healthcare sector's institutional interventions from an incentive-based perspective, we propose a framework resting on a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, which was built in cooperation with a panel of decision-making actors from the Portuguese Ministry of Health. In the end, we derive possible policy implications and strategies. This holistic approach highlighted the positive impact of the primary healthcare reform in the upgrade of physical resources and human capital but stressed the geosocial asymmetries and the lack of intra- and inter-sectorial coordination. The proposed framework serves also as a guideline for future primary healthcare reforms, both national- and internationally.

Investment in drinking water and sanitation infrastructure and its impact on waterborne diseases dissemination: The Brazilian case.

Investment in sanitation and drinking water infrastructure is essential for universal access to these services in developing countries. Universal coverage of water and sanitation services (WSS) can prevent the dissemination of waterborne diseases and mitigate their adverse effects. These diseases are responsible for many deaths worldwide, especially among the disadvantaged population and children. A causal effect can be established between WSS investment and hospital admissions due to waterborne diseases. Therefore, we considered an innovative network-DEA approach that models the link between serially connected subsystems (upstream investment and downstream hospitalizations). This approach allowed us: to measure the efficiency of both subsystems; estimate the amount of (efficient) investment necessary to universalize the access to proper WSS infrastructure; and mitigate hospital admissions due to waterborne diseases. We used the Brazil case study to test our model. On average, Brazilian states could increase the number of people not requiring hospitalizations due to waterborne diseases by 157 thousand per R$100 million invested in sanitation and 26 thousand per R$100 million invested in drinking water. Our results suggest that relatively small (efficient) investment in those two infrastructure types has a massive impact on hospitalizations. This impact would be more significant than the investment in WSS coverage. Therefore, if safely managed, WSS would cover all citizens, and Brazil would come closer to developed countries.

Waste services' performance assessment: The case of Tuscany, Italy.

This paper assesses the performance of waste services in the region of Tuscany in Italy. It adopts non-parametric techniques for this purpose. Furthermore, it investigates the influence of the operational environment on the estimated performance by using the robust order-m technique. Meaningful levels of inefficiency were found in the Italian waste services. A specification of the ownership of the operator entrusted with waste management by municipalities and the formal adoption of the zero-waste strategy are included as environmental variables. The study concludes that the influence of the operational environment is a determinant of performance. The income per capita is negatively associated with efficiency, while population density is positively associated. Furthermore, efficiency levels are lower for municipalities with higher mixed waste per capita produced. Improving good pro-environmental behaviours is likely to improve efficiency and, thus, tariffs. The empirical results support the idea that it is necessary to make relevant organizational decisions that imply higher costs to increase the refuse collection rate. An increase in the separate collection rate beyond 50% is associated with the reduction of the efficiency level reached. Efficiency analysis does not consider the additional costs and the opportunities for municipalities to get revenues by selling them as secondary raw materials. Besides, the adoption of a zero-waste strategy is related to higher efficiency in MSW service provision. Finally, results about the ownership issue support the idea that privatization is not necessarily associated with the performance improvement of the waste services.

The Portuguese generic medicines market: What's next?

Brand-name medicines have dominated the Portuguese market for several decades with unquestionable exclusivity. This resulted particularly from the absence of a requirement of prescriptions by international non-proprietary name. To promote the enhancement of both efficiency and sustainability in the health system, the Portuguese government introduced the generics in Portugal by the 90 s. However, only in the first decade of the 21st century were some policies implemented to increase their market share. Although some expectations were created, the use of generics has increased moderately during that period, in which policies to promote them were consolidated by imposing the austerity principles in the midst of the economic and social crisis. This study analyses the main policy measures already implemented as well as the incentives created for the replacement of brand-name medicines with generics. In addition, the present study also makes some recommendations to promote a broader and better use of generics in Portugal.

Transnational resource generativity: Efficiency analysis and target setting of water, energy, land, and food nexus for OECD countries.

Depletion of natural resources needs quantification and efficiency analysis of the use of resources to improve sustainability. This paper evaluates the efficiency of Organization for Economic Co-Operation and Development (OECD) countries in terms of Water-Energy-Land-Food (WELF-Nexus) to ensure sustainability and environmental viability for both present and future generations. An input-output index system is built at a transnational level. Composite and intrinsic indicators are introduced to incorporate the interconnections and tradeoffs between sectors of the nexus and outcomes of the nexus. The nonparametric benchmarking order-α model, resulting from Data Envelopment Analysis (DEA) is used to estimate WELF-Nexus efficiency of each country, and to alleviate the intricacies of using composite and intrinsic indicators. To ensure resource generativity, an output target setting model that accommodates predefined input is proposed. Results show variation in performance among OECD members, with an annual average efficiency score of 68%, 69% and 78% in 2007, 2012, and 2016. Sensitivity analysis was performed to measure the effect of drought on WELF efficiency, a decrease of about 13% on average WELF efficiency was observed. Outputs improvement was recommended for each country: Lithuania (14%), Mexico (10%) and 11% for Hungary, Latvia, and Turkey due to their high inefficiency. The study provides a robust framework for policy making and shows that a win-win strategy for the nexus must be implemented to achieve WELF-Nexus efficiency, given the trade-offs within its sectors. Furthermore, it highlights that innovative-driven policies will enhance WELF-Nexus efficiency and sustainability.

Doctors, nurses, and the optimal scale size in the Portuguese public hospitals.

This study analyses the scale efficiency, optimal scale for hospital clinical staff, and the exogenous dimensions that can be associated with them. They offer useful insights for health policy design, particularly when human resources need to be reallocated across the country due to uneven distributions. Initial data considered a sample of 27 Portuguese general/acute-care public hospitals belonging to the National Health Service, observed between 2013 and 2016. This resulted into a sample of 108 hospitals-year. Data Envelopment Analysis was employed to assess scale efficiency and optimal scale associated with the workforce and at the overall hospital level. Quality and access to health care services adjusted the measures of scale efficiency and optimal size. A multiple regression analysis was carried out to associate optimal scale and scale efficiency to demographics. Optimal scale centred on 274 full-time equivalent (FTE) doctors and 475 FTE nurses. Overall, there is an excess of FTE doctors and FTE nurses, even after potential reallocations. There is an uneven distribution of health workforce, with excess of staff located in urban areas. Hospitals productivity would increase if they reduced their operational scale. Drivers of potential change include population size, childhood mortality rate, birth rate, and purchasing power parity. Health policies are required, not to hire more staff, but rather to promote the reallocation of employees to deprived regions.

Eficiência na assistência hospitalar em Portugal: um estudo comparativo / Secondary health care efficiency in Portugal: a comparative study

Objetivo: Os hospitais públicos em Portugal melhoraram desde 2002 seus resultados em termos de eficiência, porém, nem sempre na mesma proporção nas diferentes regiões do país. O presente estudo tem como objetivo analisar os escores de eficiência em unidades hospitalares nas cinco regiões administrativas portuguesas. Métodos: A técnica da Análise Envoltória de Dados para quantificar e comparar a eficiência na atenção hospitalar em 27 unidades hospitalares das cinco regiões. Na aplicação dos modelos usaram-se quatro tipos de variáveis: insumos (custos totais), serviços prestados medidos pelo número de doentes atendidos ajustados por case-mix, qualidade do serviço prestado e acesso ao mesmo, bem como o ambiente externo (demografia e epidemiologia) usado para homogeneizar as condições em que os hospitais operam. Resultados: O nível de ineficiência médio, apenas para hospitais ineficientes, é aproximadamente 6%, um valor próximo do encontrado na literatura. Este valor corresponde a cerca de 370 milhões de Euros desperdiçados. Conclusões: Os hospitais públicos portugueses exibem um desempenho médio considerável. No entanto, existem regiões com pontuações maiores que a média nacional e outras com resultados mais pobres. A diversidade encontrada aponta para disparidades que merecem atenção especial de formuladores de políticas e gestores.

Objective: This study analysis the efficiency levels of public hospitals in Portugal. The paper explains the health care decentralization process in Portugal (started 1993) and the reforms of corporatization and merging. These ones intended to optimize costs with health care, improving efficiency, and augmenting the access and quality to the health services. Methods: Data Envelopment Analysis was used to estimate and compare the efficiency of 27 hospital units distributed across five administrative regions. In the application of the models four types of variables were used: inputs (total costs), services provided measured by the number of patients attended by case-mix, quality of service provided and access to it, as well as the external environment (demography and epidemiolog) used to homogenize the conditions in which the hospitals operate. Results: The average level of inefficiency, only for inefficient hospitals, is approximately 6%, a value close to that found in the literature. This amount corresponds to about 370 million Euros wasted. Conclusions: Portuguese public hospitals exhibit a considerable average performance. Nevertheless, there are regions with scores larger than the national average and others with poorer outcomes. The diversity found points towards disparities deserving special attention from policy makers and managers.

Utilização de fronteiras não-paramétricas para avaliação da eficiência técnica: o caso dos hospitais públicos portugueses / Using nonparametric frontiers for technical efficiency evaluation: the case of Portuguese public hospitals

Objetivo: Os hospitais públicos em Portugal apresentaram nos últimos anos uma melhoria dos seus resultados em termos de assistência. Porém, poucas têm sido as avaliações realizadas no âmbito do seu desempenho. Este estudo procura determinar a eficiência dos hospitais públicos em Portugal. Métodos: Este estudo considerou duas alternativas de modelos não paramétricos bidireccionais, baseados em Análise Envoltória de Dados e em Ordem-a. A utilização de ambos os modelos visa a validação da robustez dos resultados. Usaram-se quatro tipos de variáveis: custos totais, número de doentes atendidos ajustados ao risco, qualidade do serviço prestado, e o ambiente externo (demografia e epidemiologia). Com referência ao ano 2016, consideraram-se 27 hospitais e centros hospitalares públicos portugueses. Resultados: O nível de ineficiência médio, apenas para hospitais ineficientes, é aproximadamente 10%, correspondendo a cerca de €617 milhões desperdiçados. Conclusões: Os níveis de ineficiência variam conforme os modelos apresentados. A avaliação do desempenho deve considerar fatores como a presença de outliers, o número de variáveis, as condições externas desfavoráveis, bem como as características das fronteiras de eficiência. Um aspeto importante corresponde à convexidade da fronteira. Conclui-se que a melhor solução para avaliar o desempenho hospitalar é a abordagem por Ordem-a.

Objective: Portuguese public hospitals have exhibited an improvement of resources management in the past few years. However, only few analyses over their performance have been done. This study aims at find technical efficiency levels of Portuguese public hospitals using robust methods. Methods: This study has considered two different nonparametric alternatives for efficiency assessment. These methods are based on the Data Envelopment Analysis and on the Order-a frameworks. Four main variable categories were used: total expenses, risk-adjusted treated patients, delivered healthcare services' quality, and the epidemiologic and demographic conditions in which hospitals operate. A sample of 27 Portuguese public hospitals and hospital centres was used. Data regards the year of 2016. Results: Inefficient hospitals exhibit average technical inefficiency levels of about 10%, which corresponds to the waste of nearly €617 million. Conclusions: Inefficiency levels have a strong dependence on model features. Hence, performance evaluation should account for the existence of potential outliers, the number of variables, the existence of external factor affecting the hospitals' production process, as well as the characteristics of the achieved frontiers. An important aspect is the assumption of convexity of the frontier. A better solution for hospital performance assessment is, then, the Order-a method.