Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application

Ade Renner 2 Joses M Kirigia 1 Eyob A Zere 0 Saidou P Barry 1 Doris G Kirigia 5 Clifford Kamara 4 Lenity HK Muthuri 3 0 World Health Organization , Country Office, Windhoek , Namibia 1 World Health Organization, Regional Office for Africa , B.P. 06, Brazzaville , Congo 2 World Health Organization , Country Office, Freetown , Sierra Leone 3 School of Public Health, Department of Health Sciences, Kenyatta University , Nairobi , Kenya 4 Department of Planning and Information, Ministry of Health and Sanitation , Freetown , Sierra Leone 5 University of New South Wales, School of Public Health and community medicine , Australia Background: The Data Envelopment Analysis (DEA) method has been fruitfully used in many countries in Asia, Europe and North America to shed light on the efficiency of health facilities and programmes. There is, however, a dearth of such studies in countries in sub-Saharan Africa. Since hospitals and health centres are important instruments in the efforts to scale up pro-poor costeffective interventions aimed at achieving the United Nations Millennium Development Goals, decision-makers need to ensure that these health facilities provide efficient services. The objective of this study was to measure the technical efficiency (TE) and scale efficiency (SE) of a sample of public peripheral health units (PHUs) in Sierra Leone. Methods: This study applied the Data Envelopment Analysis approach to investigate the TE and SE among a sample of 37 PHUs in Sierra Leone. Results: Twenty-two (59%) of the 37 health units analysed were found to be technically inefficient, with an average score of 63% (standard deviation = 18%). On the other hand, 24 (65%) health units were found to be scale inefficient, with an average scale efficiency score of 72% (standard deviation = 17%). Conclusion: It is concluded that with the existing high levels of pure technical and scale inefficiency, scaling up of interventions to achieve both global and regional targets such as the MDG and Abuja health targets becomes far-fetched. In a country with per capita expenditure on health of about US$7, and with only 30% of its population having access to health services, it is demonstrated that efficiency savings can significantly augment the government's initiatives to cater for the unmet health care needs of the population. Therefore, we strongly recommend that Sierra Leone and all other countries in the Region should institutionalise health facility efficiency monitoring at the Ministry of Health headquarter (MoH/HQ) and at each health district headquarter. - Government PHUs Government Hospitals Private hospitals/clinics Source: WHO Regional Office for Africa [10] Background "Public health is the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort." [1] Located in West Africa, Sierra Leone has a population of 4.6 million and a total fertility rate of 6.5. Its health indicators are poor. For example, life expectancy at birth is 34.2 years; the probability of dying (per 1000 live births) before the age of 5 years is 313 and between 15 and 59 years is 619 [2]. The number of maternal deaths per 100000 live births is 2000 [3]. These dismal health indicators are a reflection of poor governance [4], poor macroeconomic performance [5] and poor national health system performance [6]. The total expenditure on health as a percentage of the gross domestic product (GDP) increased from 2.6% in 1996 to 4.3% in 2000 [2]. General government expenditure on health constituted 60% of the total expenditure on health; the remaining 40% came from private households and out-of-pocket spending. The fact that health indicators had continued to decline [7] in spite of health expenditure increases could be partly due to an inefficient public health system. Peripheral health units (PHUs) are a vital part of Sierra Leone's public health system. Given their strategic location in the midst of communities, they constitute an invaluable vehicle for 'organizing community effort for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene and the organization of medical and nursing services for the early diagnosis and preventive treatment of disease' [1]. PHUs are instrumental in efforts to scale up pro-poor package of cost-effective interventions aimed at achieving the U.N. Millennium Development Goals [8,9]. We concur with the father of public health, C.E.A. Winslow [1], that a part of the mandate of the public health discipline ought to be promotion of efficiency, i.e. to maximize the benefit of health interventions (promotion, prevention and preventive treatment) to communities at large from available resources. Therefore, decision-makers need to ensure that PHUs (and all other branches of the public health system) provide services efficiently. In Sierra Leone no studies of the efficiency of health facilities have been conducted using Data Envelopment Analysis (DEA). This study will therefore be significant in assessing efficiency using more robust techniques and generate information that will be useful for policy, planning and operational management. The objectives of this study were: (i) to measure the technical and scale efficiency among a sample of public PHUs in Sierra Leone employing the DEA method; and (ii) to demonstrate how its results could be used in the pursuit of the public health objective of promoting efficiency in health facilities. Methods Overview of Sierra Leone health care delivery system The Ministry of Health and Sanitation (MOHS) provides about 50% of health care services. The remainder is provided by the private sector (private-for-profit institutions and traditional healers) and national (e.g. Christian Health Association of Sierra Leone) and international (e.g. German Leprosy Rehabilitation Association and Medecins Sans Frontieres) NGOs [10]. Categories of Human Resources Number employed by Government Number employed by NGOs & Private sector Total number of human Population per health resources worker Source: WHO Regional Office for Africa [10] The country has 13 health districts, each with a District Health Management Team responsible for the implementation, supervision and monitoring of health programmes in the district. Sierra Leone has a total of 31 government hospitals, 22 mission hospitals/clinics, 78 private hospitals/clinics and a network of 788 PHUs. As indicated in Table 1, there are geographical inequities in the distribution of health facilities in the country [10]. Table 2 provides estimates of the number and ratio of human resources for health in 2002. Approximately 63% of the health workers were employed by the government and the remaining by NGOs and private-for-profit institutions. Data Input and output data were analysed for the year 2000. Due to research resource constraints, the planning and information department at th (...truncated)