Analysing the Efficiency of National and Sub-national health systems - A Systematic Review of Literature

Abstract Introduction Health system efficiency is a priority concern for policy makers globally as countries aim to achieve universal health coverage. Efficiency analysis in the health sector has typically focused on the efficiency of healthcare facilities (hospitals, primary healthcare facilities), with few studies focusing on system level (national or sub-national) efficiency. We carried out a thematic review of literature that assessed the efficiency of health systems at the national and sub-national level. Methods We conducted a systematic search of PubMed, Google, and Google scholar between 2000 and 2021 and a manual search of relevant papers’ reference lists. A total of 131 papers were identified. We analysed and synthesized data from the selected papers using a thematic approach. Findings There were more publications from high and upper middle-income countries (62%) than from low income and lower-middle income countries. There were also more publications focusing on national level (60%) compared to sub-national health systems efficiency. Only 5% of studies used either qualitative methods or mixed methods while 95% used quantitative approaches. Data envelopment analysis was the most common methodological approach used, followed by stochastic frontier analysis. A range of regression methods were used to identify the determinants of health system efficiency. While studies used a range of inputs, these generally considered the building blocks of health systems, health risk factors, and social determinants of health. Outputs used in efficiency analysis could be classified as either intermediate health outputs, single health outcomes or composite measures of health outcomes. Factors that were found to affect health system technical efficiency include demographic and socio-economic characteristics of the population, macro-economic characteristics of the national and sub-national regions, population health and wellbeing, the governance and political characteristics of these regions, and health system characteristics. Conclusion This review highlights the limited evidence on health system efficiency in low- and middle-income countries. It also reveals the dearth of efficiency studies that use mixed methods approaches by incorporating qualitative inquiry. The review offers insights on the drivers of the technical efficiency of national and sub-national health systems, highlights potential targets for reforms to improve health system efficiency.