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Table 1 Summary of reviewed studies

From: A systematic review on hospital inefficiency in the Eastern Mediterranean Region: sources and solutions

AuthorYearCountryHospital typeNumber of hospitalsMethod used to calculate efficiencyInput and outputsSource of inefficiency
Al-Shammari [19]1999JordanHospitals of MoH*15DEAInputs: Numbers of bed-days, physicians, health workforce
Outputs: Numbers of inpatient days, minor operations, major operations
Excess resources
Ramanathan [20]2005OmanRegional and Wilayat hospitals (MoH), Sultan Qaboos University Hospital, Hospital of the Royal Oman Police20DEA (Malmquist index)Inputs: Numbers of beds, physicians, and other medical workforces.
Outputs: Number of visits, in-patient services, surgical operations
Partial utilization of inputs, lack of full compliance with technological changes
Hajialiafzali [21]2007IranHospitals affiliated with the Social Security Organization53DEA (frontier-based methods)Inputs: Total numbers of FTE* medical doctors, of FTE nurses, of other FTE workforces, number of beds
Outputs: Numbers of outpatient visits and emergency visits, ratio of major surgeries to total surgeries, total numbers of medical interventions and surgical procedures
Partial utilization of inputs
Hatam [15]2008IranHospitals affiliated with the Social Security Organization18DEA (frontier-based methods)Inputs: Numbers of beds, FTE, total expense
Outputs: Patient-days, BOR*, BTR,* ALS*, ratio of available beds to constructed beds, hoteling expense, bed-day costs, workforce costs
Unused beds
Goshtasebi [22]2009IranMoH hospitals6Pabon LassoOutput: ALS, BOR, BTRUnderutilization of resources, high BOR
Jandaghi [23]2010IranPublic and private hospitals8DEA (frontier-based methods)Inputs: Numbers of physicians, nurses, medical workforce, official workforce, annual costs of hospital
Outputs: Numbers of clinical visits, emergency visits, and bed-days
Excess resources
Hatam [24]2010IranGeneral public hospitals21DEA (frontier-based methods)Inputs: Numbers of hospital beds, FTE physicians, nurses, and other workforces
Outputs: BOR, patient–day admissions, bed-days, ALS, BTR
Lack of motivation to select inputs to minimize expenses caused by the fact that hospitals are public and therefore do not seek profitability.
Shahhoseini [25]2011IranProvincial hospitals12DEA (frontier-based methods)Inputs: Numbers of active beds, nurses, physicians, and other professionals
Outputs: Number of surgeries, outpatients visits, BOR, ALS, inpatient days
Excess resources
Ketabi [26]2011IranHospitals in Isfahan23DEAInputs: Average numbers of active beds, medical equipment, workforce (such as doctors, nurses and technicians)
Outputs: BOR (%), ALS, total percentage of survival, performance ratio
Excess medical equipment, workforce and technology for teaching and private hospitals. Teaching hospitals are less efficient because of bureaucratic processes and private hospitals have lower BORs.
Bahadori [27]2011IranHospitals affiliated with Urmia University of Medical Sciences23Pabon LassoOutput: ALS, BOR, BTRPoor performance in BOR and/or BTR in 60.87% of hospitals.
Al-Shayea [28]2011Saudi ArabiaKhalid University Hospital1 (9 departments)DEAInputs: doctors’ total salary, nurses’ total salary
Outputs: Numbers of in-patients, outpatients, bed and average turnover rate
High costs of inputs
Kiadaliri [29]2011IranGeneral hospitals affiliated with Ahvaz Jondishapour University of Medical Sciences19DEA (frontier-based methods)Inputs: beds, human resources
Outputs: inpatient days, outpatient days, number of surgeries, BOR
Inappropriate hospital sizes
Osmani [30]2012AfghanistanDistrict Hospitals68DEA and Tobit regression analysis modelInputs: Numbers of physicians, midwives, nurses, non-medical workforce, and beds
Outputs: Numbers of outpatient visits, inpatient admissions, and patient days, ALS, BOR, number of hospital beds (proxy for hospital size), bed-physician and outpatient physician ratio, number of physicians
Excess numbers of doctors, nurses, and beds
Farzianpour [31]2012IranTeaching hospitals of Tehran University of Medical Sciences16DEA (frontier-based methods)Inputs: Numbers of physicians, practicing nurses in health facilities, and active beds
Outputs: Numbers of inpatients, outpatients, ALS
Excess inputs or insufficient outputs
Chaabouni [32]2012TunisiaPublic hospitals10DEA and The Bootstrap ApproachInputs: Numbers of physicians, nurses, dentists and pharmacists, other workforces, and beds
Outputs: Numbers of outpatient visits, admissions, post-admission days
High hospital expenditures
Barati Marnani [33]2012IranAffiliated with Shahid Beheshti University of Medical Sciences23Pabon Lasso model and DEA (frontier-based methods)Pabon Lasso: ALS, BOR, BTR
DEA: Inputs: Numbers of physicians, nurses, other workforces, and active beds
Outputs: BOR, numbers of patients and surgeries
Excess resources
Sheikhzadeh [34]2012IranElected public and private hospitals of East Azerbaijani Province6DEA (frontier-based methods)Inputs: Numbers of specialist physicians, general physicians, nurses, residents, medical team workforce with a degree (Bachelor’s), medical team, nonmedical and support workforce, and active beds
Outputs: Numbers of emergency patients, outpatients, and inpatients, average daily inpatients residing in hospital
Excess and inefficient inputs: lack of medical services for the amount of resources used.
Yusefzadeh [35]2013IranPublic hospitals23DEAInputs: Numbers of active beds, doctors, and other workforces
Outputs: Number of outpatients’ admissions and day-beds
Excess inputs or insufficient outputs
Gholipour [36]2013IranObstetrics and gynaecology teaching hospitals2Pabon LassoOutput: ALS, BOR, BTRLow BOR
Arfa [37]2013TunisiaPublic hospitals101DEAFive fixed inputs: Numbers of physicians, dentists, mid-wives, nurses or equivalents, and beds. One variable input: budget
Outputs: Numbers of outpatient visits and admissions
Hospitals are not operating at full capacity
Ajlouni [38]2013JordanPublic hospitals15DEA and Pabon-LassoPabon Lasso: ALS, BOR, BTR
DEA: Inputs: Numbers of bed-days, physicians per year, and health workforce per year
Outputs: Patient days, numbers of minor operations and major operations
Poor management, treatment of diseases requiring long patient stays
Abou El-Seoud [39]2013Saudi ArabiaPublic hospitals that have been reformed to operate under private sector management through the full operating system in Saudi Arabia20DEAInputs: Numbers of specialists, nurses, allied workforce, and beds
Outputs: Numbers of visits, patient hospital admissions, laboratory tests, and beneficiaries of radiological imaging
Administrative weakness to overcome external environmental factors rather than inability to manage internal operations
Bastani [40]2013IranHospitals affiliated to the MoH139Four hospital performance indicatorsOutput: ALS, BOR, BTRInappropriate hospital sizes
Younsi [41]2014Tunisia30 public and 10 private hospitals40Pabon LassoOutput: ALS, BOR, BTRLow bed density which may not match population hospital needs. Hospital bed numbers should be increased or maintained.
Torabipour [42]2014IranTeaching and non-teaching hospitals of Ahvaz County12DEA (Malemquist index)Inputs: Numbers of nurses, beds, and physicians.
Outputs: Numbers of outpatients and inpatients, ALS, number of major operations
Lack of familiarity of managers with advanced hospital technologies, lack of equipment and inappropriate use of technology in diagnosis, care and treatment.
Syed Aziz Rasool [43]2014PakistanNon-profit private organization (branches of LRBT hospitals)16DEAInputs: Numbers of beds, specialists, nurses
Outputs: Numbers of outpatient visits, inpatient admissions, and total numbers of surgeries
Lack of government funds to hospitals run by non-profit organizations.
Pourmohammadi [44]2014IranAll hospitals affiliated with the Social Security Organization64The Cobb-Douglas modelInputs: Numbers of physicians, nurses, other workforces, and active beds
Outputs: Number of outpatients and inpatients
Excess workforce
Mehrtak [45]2014IranAll general hospitals located in Iranian Eastern Azerbijan Province18Pabon Lasso and DEAPabon Lasso: ALS, BOR, BTR
DEA: Inputs: Numbers of active beds, physicians, nurses, discharged patients
Outputs: Number of surgeries and discharged patients, BOR
Excess inputs: larger hospitals are more efficient than smaller hospitals.
Lotfi [46]2014IranAll hospitals of Ahvaz (8 hospitals affiliated with Jundishapur University of Medical Sciences and 8 non-affiliated hospitals)16Pabon Lasso and DEAPabon Lasso: ALS, BOR, BTR
DEA: Inputs: Numbers of physicians, nurses, other workforces, and active beds
Outputs: BOR, numbers of patients and surgeries
Underuse of resources, excess hospital inputs
Kalhor [47]2014IranHospitals affiliated with Qazvin University6Pabon LassoOutput: ALS, BOR, BTRPoor managerial decisions
Goudarzi [48]2014IranTeaching hospitals affiliated with Tehran University of Medical Sciences12DEA (frontier-based methods)Inputs: Numbers of medical doctors, nurses, and other workforces, active beds, and outpatient admissions
Outputs: Number of inpatient admissions
Excess numbers of nurses and active beds
Askari [49]2014IranHospitals affiliated with Yazd University of Medical Sciences13DEAInputs: Numbers of active beds, nurses, physicians, and non-clinical workforce
Outputs: hospitalization admissions, BOR (%), and number of surgeries
High excess inputs, particularly the excess number of nurses.
Adham [50]2014IranTeaching and non-teaching hospitals14Pabon LassoOutput: ALS, BOR, BTRLow BOR
Imamgholi [51]2014IranHospitals affiliated to Busheher University of Medical Sciences7Pabon LassoOutput: ALS, BOR, BTRNon-optimal hospital sizes
Shetabi [52]2015IranHospitals affiliated to Kermanshah University of Medical Sciences7DEAInputs: Numbers of active beds, doctors, nurses, and other workforces
Outputs: Numbers of accepted inpatients, outpatients and BOR (%)
Excess inputs
Masoompourb [53]2015IranTeaching Hospital1Pabon LassoALS, BOR, BTRDecrease in ALS
Chaabouni [54]2016TunisiaPublic Hospitals10DEA (frontier-based methods)Inputs: Numbers of physicians, nurses, dentists, pharmacists, and beds, total cost
Outputs: Numbers of outpatient visits, admissions, and post-admission days, price of labor
large hospital sizes
Safdar [55]2016PakistanA large public hospital1DEAInputs: Waiting time at the pharmacy, length of waiting line
Outputs: Consultation time at the pharmacy
High waiting times: low efficiency levels (less than 50% efficiency) are associated with high waiting times.
Mohammadi [56]2016IranPublic hospitals67Cobb-Douglas production functionInputs: Human resources (including net working hours of specialized workforce) and bed numbers (including the number of active beds)Insufficient inputs: Inpatient service production levels were lower than expected in 40% of hospitals. A 10% increase in net working hours of specialized human resources would generate a 8.8% increase in average inpatient service production levels. A 10% increase in the number of active beds would generate a 1.1% increase in average inpatient service production levels.
Mahate [57]2016United Arab EmiratesPrivate and public hospitals in the UAE96DEAInputs: Numbers of beds, doctors, dentists, nurses, pharmacists and allied health workforce, and administrative workforce
Outputs: Numbers of treated inpatients, outpatients, ALS
Waste of 41 to 52% of inputs during service delivery.
Kalhor [58]2016IranTehran city general hospitals54DEAInputs: Total numbers of FTE medical doctors, and nurses, numbers of supporting medical workforce including ancillary service workforce, and beds
Outputs: Numbers of patient days, outpatient visits, patients receiving surgery, ALS
Ownership type (lower efficiency of university hospitals because of more expenditures)
Kakemam [59]2016IranHospitals of public, private, or social security ownership types in Tehran54DEAInputs: Numbers of active beds, physicians, nurses, and other medical workforces
Outputs: Numbers of outpatient visits, surgeries, and hospitalized days, ALS
Lack of resource optimization. Poor adaptation of the sizes, types of practices, and ownerships of hospitals, affecting their technical efficiency. Approximately 70% of the hospitals were inefficient.
Hassanain [60]2016Saudi ArabiaHospitals affiliated to the MoH12LeanOn-time start, room turnover times, percent of overrun cases, average weekly procedure volume and OR utilizationPpoor hospital infrastructure, old technology, suboptimal management of human resources, the absence of employee engagement, frequent scheduling changes, inefficient process flow
Hamidi [61]2016Palestine22 government hospitals22DEA (frontier-based methods)Inputs: Numbers of beds, doctors, nurses, and non-medical workforce
Outputs: Numbers of admitted patients, hospital days, operations, outpatient visits, ALS
Mismanagement of available resources, shortage of the numbers of doctors and nurses and excess number of non-medical staff
Nabilou [62]2016IranHospitals affiliated to Tehran University of Medical Sciences17DEA (Malmquist index)Inputs: Active beds, nurses, doctors and other workforces
Outputs: outpatient admissions, bed-days, number of surgical operations
Due to hospitals’ technological changes, a lack of knowledge of hospital workforce on proper applications of technology for patient treatment became the main cause of low hospital productivity and inefficiency.
Rezaei [63]2016IranKurdistan teaching hospitals12DEA (frontier-based methods)Inputs: Numbers of active beds, nurses, physicians, and other workforce members
Outputs: Inpatient admissions
Waste of inputs during service delivery
Farzianpour [64]2017IranTraining and non-training hospitals of Tabriz city19DEAInputs: Numbers of physicians, total workforce, and active beds
Outputs: Number of outpatients and BOR
Poor management of human and financial resources.
Arfa [65]2017TunisiaPublic district hospitals105DEAInputs: Numbers of physicians, surgical dentists, midwives, nurses and equivalents, and beds, operating budget
Outputs: Outpatient visits in stomatology wards, outpatient visits in emergency wards, outpatient visits in external wards, numbers of admissions, and admissions in maternity wards
Inadequate number of workforce, equipment, beds, and medical supply, health quality and lack of fitting operating budgets: tackling these sources of inefficiency would reduce net user needs and the bypassing of the public district hospitals, to increase their capacity utilization. Social health insurance should be turned into a direct purchaser of curative and preventive care for the public hospitals.
Aly Helal [66]2017Saudi ArabiaPublic hospitals270DEAInputs: Numbers of beds, doctors, nurses, and allied medical workforce
Outputs: Numbers of individuals visiting admitted patients, radiography service beneficiaries, laboratory testing beneficiaries, and inpatients
Excess inputs
Mousa [67]2017Saudi ArabiaPublic hospitals270DEAInputs: Numbers of physicians, nurses, pharmacists, allied health professionals, beds
Outputs: Numbers of outpatient visits, inpatients, laboratory investigations, X-rays patients, X-rays films, total number of surgical operations
Inadequate resources: some resources should be switched between regions to improve efficiency.
Moradi [68]2017IranPublic hospitals11Pabon LassoALS, BOR, BTRLow number of hospital beds, and need for hospital expansion
Sultan [69]2017JordanGeneral public hospitals27DEAInputs: Numbers of beds, physicians, healthcare workforce, administrative workforce
Outputs: Inpatient days, outpatient visits, emergency departments, and ambulances
Diseconomies of scale affect the operational efficiency, poor management, poor productivity in outpatient services and low numbers of physicians.
Kassam [70]2017IraqHospitals in Baghdad3DEA and Luenberger Productivity Indicator (LPI)Inputs: Numbers of doctors, nurses, and other health workforces
Outputs: Numbers of outpatients, laboratory tests, radiology tests, sonar tests, emergency visits
The cause of the inefficiencies is undetermined.
Rezaee [71]2018IranHospitals affiliated with Kermanshah University of Medical Sciences15Pabon LassoOutput: ALS, BOR, BTRExcess inputs
Yazan Khalid Abed-Allah Migdadi [72]2018JordanPublic hospitals15DEAInputs: Numbers of physicians, nurses, and beds
Outputs: ALS, number of Surgeries, BOR
Low BOR
Sajadi [73]2018IranAll hospitals in Isfahan City54Cross-sectional descriptive study comparing performance indicatorsOutputs: BOR, BTR, bed-days, inpatients visits, number of surgeries in all types of hospitals, outpatient visits in all non-private hospitals, emergency visits in public and social security hospitals, and natural deliveries in public and semi-public hospitalsInefficient use of limited resources
  1. *BOR bed occupancy rate, BTR bed turnover rate, ALS average length of stay, FTE Full Time Employee, MoH Ministry of Health