Abstract
BACKGROUND: In China, most primary health care institutes (PHCIs) support ground-level medical services which are essential to residents' health levels. The Chinese government implemented a health reform in 2009 to strengthen PHCIs through increased fiscal inputs. However, how efficiently these inputs were converted into PHCIs' services remains unclear. We aimed to examine the efficiency of PHCIs' medical services and investigate if any changes occurred following the implementation of the health reform. METHODS: We aggregated data from PHCIs from Hainan's 18 districts (2011-21), treating those from the same district as one decision-making unit (DMU). We used three-stage data envelopment analysis (DEA) to assess the efficiencies of these PHCIs, adjusting the approach for environmental factors, managerial ineffectiveness, and statistical errors potentially arising from the background variability of measured data that deviates from the input and output values, allowing all DMUs to be compared in a homogeneous environment. We used the adjusted efficiency scores to evaluate the efficiency of PHCIs in Hainan each year and the Malmquist Productivity Index (MPI) to explore the productivity change of PHCIs over time. RESULTS: After adjusting for environmental factors between 2011-21, technical efficiency (TE) decreased from 0.825 to 0.745, pure technical efficiency (PTE) increased from 0.936 to 0.954, and scale efficiency (SE) decreased from 0.883 to 0.783. Seven districts had full PTE (1.0) and two districts had full TE (1.0) after adjustment. The mean MPI from 2011 to 2021 was 0.9430, indicating a 5.7% decrease in PHCIs' efficiency. After excluding the low productivity index possibly influenced by COVID-19 (2019 to 2021), PHCIs' efficiency decreased by 0.49%, with a mean MPI of 0.9951. CONCLUSIONS: The efficiency of PHCIs in Hainan has declined slightly since the health reform. Low level of scale efficiency posed a significant impact on the overall efficiency of the medical services in PHCIs. Among potential inefficient technological performances, future policy formulation might focus more on the imbalanced allocation of resources in less-developed regions and PHCIs' lack of attractiveness to local patients.