Measuring the efficiency of the Greek rural primary health care using a restricted DEA model; the case of southern and western Greece

This is a study to measure the efficiency of the rural Health Centres (HCs) and their Regional Surgeries (RSs) of the 6th Health Prefecture (HP) of Greece, which covers Southern and Western Greece. Data Envelopment Analysis (DEA) was applied under Constant and Variable Returns to Scale, using a weight-restricted, output-oriented model, to calculate pure technical efficiency (PΤΕ), scale efficiency (SE) and total technical efficiency (TE). The selection of inputs, outputs and their relative weights in the model was based on two consecutive consensus panels of experts on Primary Health Care (PHC). Medical personnel, nursing personnel and technological equipment were chosen as inputs and were attributed appropriate weight restrictions. Acute, chronic and preventive consultations where chosen as outputs; each output was constructed by smaller subcategories of different relative importance. Data were collected through a questionnaire sent to all HCs of the covered area. From the 42 HCs which provided complete data, the study identified 9 as technical efficient, 5 as scale efficient and 2 as total efficient. The mean TE, PTE and SE scores of the HCs of the 6th Health Prefecture were 0.57, 0.67 and 0.87, respectively. The results demonstrate noteworthy variation in efficiency in the productive process of the HCs of Southern and Western Greece. The dominant form of inefficiency was technical inefficiency. The HCs of the 6th HP can theoretically produce 33 % more output on average, using their current production factors. These results indicated potential for considerable efficiency improvement in most rural health care units. Emphasis on prevention and chronic disease management, as well as wider structural and organisational reforms, are discussed from the viewpoint of how to increase efficiency.

[1]  Abraham Charnes,et al.  Measuring the efficiency of decision making units , 1978 .

[2]  C. Lionis,et al.  How Greek GPs manage hepatitis C infected patients: experiences gained from a primary health care district in rural Crete. , 1999, Australian family physician.

[3]  J. Kyriopoulos,et al.  Public and private imperatives of Greek health policies. , 1993, Health policy.

[5]  M. Farrell The Measurement of Productive Efficiency , 1957 .

[6]  Steffen Flessa,et al.  Efficiency of primary care in rural Burkina Faso. A two-stage DEA analysis , 2011, Health economics review.

[7]  Luis R. Murillo-Zamorano Economic Efficiency and Frontier Techniques , 2004 .

[8]  P. Groenewegen,et al.  A future for primary care for the Greek population. , 2013, Quality in primary care.

[9]  Roberta Shanman,et al.  Identifying, Categorizing, and Evaluating Health Care Efficiency Measures , 2008 .

[10]  D. Niakas,et al.  Balancing efficiency of health services and equity of access in remote areas in Greece. , 2006, Health policy.

[11]  B. Golany,et al.  Alternate methods of treating factor weights in DEA , 1993 .

[12]  William W. Cooper,et al.  Introduction to Data Envelopment Analysis and Its Uses: With Dea-Solver Software and References , 2005 .

[13]  Y. Tountas,et al.  The Greek economic crisis: a primary health-care perspective , 2011, The Lancet.

[14]  Y. Tountas,et al.  The "unexpected" growth of the private health sector in Greece. , 2005, Health policy.

[15]  E. Oikonomidou,et al.  Rural primary care in Greece: working under limited resources. , 2010, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[16]  C. Webb,et al.  The Delphi technique: a methodological discussion. , 1994, Journal of advanced nursing.

[17]  Allen Hutchinson,et al.  The european primary care monitor: structure, process and outcome indicators , 2010, BMC family practice.

[18]  Adamakidou Theodoula,et al.  New health policies on primary health care in greece , 2010 .

[19]  Emmanuel Thanassoulis,et al.  Weights restrictions and value judgements in Data Envelopment Analysis: Evolution, development and future directions , 1997, Ann. Oper. Res..

[20]  J. Kirigia,et al.  Technical efficiency of public clinics in Kwazulu-Natal Province of South Africa. , 2001, East African medical journal.

[21]  Francisco Pedraja-Chaparro,et al.  On the Role of Weight Restrictions in Data Envelopment Analysis , 1997 .

[22]  A. Worthington,et al.  Frontier Efficiency Measurement in Health Care: A Review of Empirical Techniques and Selected Applications , 2004, Medical care research and review : MCRR.

[23]  M. S. Sebastian,et al.  Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis , 2014, Global health action.

[24]  Y. Tountas,et al.  The need for measurement of efficiency in Greek primary healthcare , 2012, Applied Health Economics and Health Policy.

[25]  Claude Giorno,et al.  Improving the Performance of the Public Health Care System in Greece , 2009 .

[26]  R. Jacobs,et al.  Alternative Methods to Examine Hospital Efficiency: Data Envelopment Analysis and Stochastic Frontier Analysis , 2001, Health care management science.

[27]  Harold O. Fried,et al.  The measurement of productive efficiency : techniques and applications , 1993 .

[28]  William W. Cooper,et al.  Handbook on data envelopment analysis , 2011 .

[29]  Yasar A. Ozcan,et al.  Health Care Benchmarking and Performance Evaluation: An Assessment Using Data Envelopment Analysis (DEA) , 2007 .

[30]  Y. Tountas,et al.  Insufficient primary care services to the rural population of Greece. , 2011, Rural and remote health.

[31]  C P McLaughlin,et al.  Relative efficiency in rural primary health care: an application of data envelopment analysis. , 1989, Health services research.

[32]  Y. Tountas,et al.  Reforming the reform: the Greek National Health System in transition. , 2002, Health policy.

[33]  Miika Linna,et al.  Technical and cost efficiency of oral health care provision in Finnish health centres. , 2003, Social science & medicine.

[34]  I. Okkes,et al.  Developing an Appropriate EPR System for the Greek Primary Care Setting , 2003, Journal of Medical Systems.

[35]  A. Mariolis,et al.  Three trends that undermine the Greek health system: Is there a way out? , 2009, The European journal of general practice.

[36]  Russell G. Thompson,et al.  The role of multiplier bounds in efficiency analysis with application to Kansas farming , 1990 .

[37]  Michael F Furukawa,et al.  Electronic medical records and efficiency and productivity during office visits. , 2011, The American journal of managed care.

[38]  N. Antonakis,et al.  Assessment of vaccine coverage of schoolchildren in three primary health care areas in rural Crete, Greece. , 1998, Family practice.

[39]  Maria Papadakaki,et al.  Policy Special series : Integrated primary health care Integrated primary health care in Greece , a missing issue in the current health policy agenda : a systematic review , 2009 .

[40]  Robert G. Dyson,et al.  On comparing the performance of primary care providers , 2008, Eur. J. Oper. Res..

[41]  Vikram Patel,et al.  Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care , 2008, The Lancet.

[42]  C. Lionis,et al.  Is there room for general practice in penitentiary institutions: screening and vaccinating high-risk groups against hepatitis. , 1999, Family practice.

[43]  Niccie L McKay,et al.  Factors affecting productive efficiency in primary care clinics , 2008, Health services management research.

[44]  Barbara Starfield,et al.  Primary Care: Balancing Health Needs, Services, and Technology , 1998 .

[45]  C. Lionis,et al.  Creating an Integrated Health Care System in Greece: A Primary Care Perspective , 2004, Journal of Medical Systems.

[46]  A. Mariolis,et al.  How is Greece conforming to Alma-Ata's principles in the middle of its biggest financial crisis? , 2010, The British journal of general practice : the journal of the Royal College of General Practitioners.

[47]  Nick Kontodimopoulos,et al.  The effect of environmental factors on technical and scale efficiency of primary health care providers in Greece , 2007, Cost effectiveness and resource allocation : C/E.

[48]  Elias Mossialos,et al.  Analysing the Greek health system: a tale of fragmentation and inertia. , 2005, Health economics.

[49]  A. Charnes,et al.  Some Models for Estimating Technical and Scale Inefficiencies in Data Envelopment Analysis , 1984 .

[50]  Y. Ozcan Health Care Benchmarking and Performance Evaluation , 2008 .

[51]  John E. Beasley,et al.  Restricting Weight Flexibility in Data Envelopment Analysis , 1990 .

[52]  C. Lionis,et al.  Exploring health care reform in a changing Europe: Lessons from Greece , 2013, The European journal of general practice.

[53]  Cristiano Codagnone,et al.  Using Data Envelopment Analysis to Analyse the Efficiency of Primary Care Units , 2014, Journal of Medical Systems.

[54]  C. Lionis,et al.  Dementia and depression: two frequent disorders of the aged in primary health care in Greece. , 2001, Family practice.

[55]  S. Santos,et al.  Challenges for performance assessment and improvement in primary health care: the case of the Portuguese health centres. , 2009, Health policy.

[56]  B. Hollingsworth The measurement of efficiency and productivity of health care delivery. , 2008, Health economics.

[57]  Georgios Tsakos,et al.  Using DEA to Evaluate Efficiency and Formulate Policy Within a Greek National Primary Health Care Network , 2002, Journal of Medical Systems.

[58]  Yasar A. Ozcan,et al.  Electronic medical record use and efficiency: A DEA and windows analysis of hospitals , 2009 .

[59]  N. Antonakis,et al.  Are primary care physicians able to assess dementia? An estimation of their capacity after a short-term training program in rural Crete. , 2001, The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry.

[60]  C. Dimitrakaki,et al.  Sociodemographic and socioeconomic determinants of health services utilization in Greece: the Hellas Health I study , 2011, Health services management research.

[61]  Molla S. Donaldson,et al.  Defining Primary Care: An Interim Report , 1994 .

[62]  R. Dyson,et al.  Reducing Weight Flexibility in Data Envelopment Analysis , 1988 .

[63]  Y. Ozcan Performance Measurement Using Data Envelopment Analysis (DEA) , 2014 .

[64]  José Manuel Cordero-Ferrera,et al.  Efficiency assessment of primary care providers: A conditional nonparametric approach , 2015, Eur. J. Oper. Res..