DSpace at VNU: Efficiency and productivity of hospitals in Vietnam

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Journal of Health Organization and Management Efficiency and productivity of hospitals in Vietnam Thuy Linh Pham Article information: Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) To cite this document: Thuy Linh Pham, (2011),"Efficiency and productivity of hospitals in Vietnam", Journal of Health Organization and Management, Vol 25 Iss pp 195 - 213 Permanent link to this document: http://dx.doi.org/10.1108/14777261111134428 Downloaded on: 09 February 2015, At: 19:41 (PT) References: this document contains references to 38 other documents To copy this document: permissions@emeraldinsight.com The fulltext of this document has been downloaded 1130 times since 2011* Users who downloaded this article also downloaded: Joseph Sarkis, Srinivas Talluri, (2002),"Efficiency measurement of hospitals: issues and extensions", International Journal of Operations & Production Management, Vol 22 Iss pp 306-313 http:// dx.doi.org/10.1108/01443570210417605 Minwir Al-Shammari, (1999),"A multi-criteria data envelopment analysis model for measuring the productive efficiency of hospitals", International Journal of Operations & Production Management, Vol 19 Iss pp 879-891 http://dx.doi.org/10.1108/01443579910280205 Ibrahim A Al-Darrab, (2000),"Relationships between productivity, efficiency, utilization, and quality", Work Study, Vol 49 Iss pp 97-104 http://dx.doi.org/10.1108/00438020010318073 Access to this document was granted through an Emerald subscription provided by 277661 [] For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all Please visit www.emeraldinsight.com/authors for more information About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services Emerald is both COUNTER and TRANSFER compliant The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation *Related content and download information correct at time of download The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-7266.htm Efficiency and productivity of hospitals in Vietnam Efficiency of hospitals in Vietnam Thuy Linh Pham University of Economics and Business, Vietnam National University, Hanoi, Vietnam Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) Abstract 195 Received May 2009 Revised 13 November 2009 Accepted 24 February 2010 Purpose – The purpose of this paper is to examine the relative efficiency and productivity of hospitals during the health reform process Design/methodology/approach – Data envelopment analyses method (DEA) with the input-oriented variable-returns-to-scale model was used to calculate efficiency scores Malmquist total factor productivity index approach was then employed to calculate productivity of hospitals Data of 101 hospitals was extracted from databases of the Ministry of Health, Vietnam from the years 1998 to 2006 Findings – There was evidence of improvement in overall technical efficiency from 65 per cent in 1998 to 76 per cent in 2006 Hospitals’ productivity progressed around 1.4 per cent per year, which was mainly due to the technical efficiency improvement Furthermore, provincial hospitals were more technically efficient than their central counterparts and hospitals located in different regions performed differently Originality/value – The paper provides an insight in the performance of Vietnamese public hospitals that has been rarely examined before and contributes to the existing literature of hospital performance in developing countries Keywords Process efficiency, Productivity rate, Hospitals, Data analysis, Indexing, Vietnam Paper type Case study Introduction Efficiency improvement in the provision of health care has been a major issue facing the health system in Vietnam The demand for health care is large and increasing over time due to a growing and an ageing population However, resources for health care provision are limited and the government has inadequate resources to finance the rising demand for increased and better quality services The constrained ability to adequately meet health care needs was exacerbated as the economy was transformed from a centrally planned one to a market-based one in the end of 1980s This has led to deficiencies and inefficiencies in the health system, especially within hospitals Therefore, since the 1990s a series of structural and institutional reforms has been being introduced, whose main objectives were to meet the increasing demand of health services and boost the efficiency and productivity of the health system in general, and hospitals in particular Despite the extensive body of literature dealing with the efficiency and productivity of service provision in health care, few empirical analysis in developing countries during the reform process exist A number of recent surveys of Hollingsworth et al (1999), Hollingsworth (2003), and Worthington (2004) have provided an overview of efficiency literature in hospitals Most of the studies identified in these review papers are on the efficiency and productivity of developed countries, for example, out of 188 studies reviewed in Hollingsworth (2003), only one study of Zere et al (2001) investigated the efficiency and productivity of hospitals in a developing country, South Journal of Health Organization and Management Vol 25 No 2, 2011 pp 195-213 q Emerald Group Publishing Limited 1477-7266 DOI 10.1108/14777261111134428 JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 196 Africa However, recently, there are also some more studies on hospital efficiency and productivity of developing countries such as Osei et al (2005) on Ghana’s hospitals, and Pilyavsky and Staat (2008) on Ukraine’s hospitals Inspired from an empirical literature, which has investigated the efficiency and productivity of hospitals under the structural change circumstances, it is important to analyse whether the Vietnamese hospital sector is able to keep up its productivity by adapting to these changes The study, therefore, aims to measure the relative efficiency and changes in productivity of hospitals during the health reform process from 1998 to 2006, and then highlight possible policy implications of the results for policy makers This paper is organised as follows Section gives a brief overview of the healthcare system in Vietnam Section reviews the existing literature on hospital efficiency and productivity Section presents the selection of the estimation techniques used and the data set Section details the analysis and the efficiency and productivity results, which are then summarised in the conclusions in section The system of healthcare in Vietnam Before the reform initiatives in the 1990s, the Vietnamese health system could be considered a universal health system, where the government was responsible for the provision of health services to all of the population and entirely financed health care programmes and the operations of health facilities (Bloom, 1997) All health facilities, especially hospitals, were state-owned, entirely funded by the government, and provided free medical services to the entire population These public hospitals also had to follow state-led targets, which focused on the volume of health services delivered Meanwhile, private health care facilities did not officially exist Accordingly, the health system was characterised by the shortage of health service provision, under-funding and inefficiency (Chen and Hiebert, 1994; Hoi et al., 2000) Since the 1990s, therefore, a series of structural and institutional reforms has been introduced across different sections of the healthcare system in order to meet the increasing demand for health services and to boost its efficiency and productivity Following these structural change programmes, the health system has basically changed from a state-led system providing free-of-charge health care into a mixed, fee-for-service based care system The health reform programmes have called for, for example, liberalisation of the pharmaceutical industry, legalisation of the private provision of health services, and the deregulation of the retail trade in drugs and medicines The most important change of the health care reform programmes has been the restructuring of the public hospital sector In particular, the restructuring programme in the hospital sector has emphasised financial and managerial regulatory changes via the introduction of user fees, the implementation of health insurance schemes, and the granting of autonomy for public hospitals (Sepehri et al., 2005; World Bank, 2005; Sepehri et al., 2003; Ladinsky et al., 2000) Health care services are now carried out by both private and public health providers in the Vietnamese healthcare system The public health providers include health care centres and public hospitals The private health providers consist of private clinics and private hospitals Among these public and private health care providers, hospitals play important roles in the health system, especially in the improvement of the overall health of the public There are 1,053 hospitals with 143,999 beds activate in the healthcare system, including 1,002 public hospitals and 51 private hospitals The Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) public hospitals are vertically divided into first three tiers of national administrative structure: central, provincial, district These hospitals are closely related to each other, with the central and provincial hospitals assisting the district ones in terms of providing professional medical operations and techniques The private hospitals mainly provide health services on demand of middle- and high-income people Vietnam has been spending a significant proportion of its wealth on health, approximately 5.1 per cent of gross domestic product (GDP) per year Currently, the health care finance comes from two sources, public and private ones The former source consists of revenue from direct and indirect taxes and the latter source consists of direct payments from patients and health insurance schemes Of these two sources, health care expenditure has been increasingly financed by the private sources During the period 1990-2005, the total private spending on health has increased 2.7 times in nominal terms, from US$ 0.76 billion to 2.06 billion This means that the private percentage of health expenditure has risen from 67.3 per cent of total health expenditure in 1998 to 77.4 per cent in 2005 Meanwhile, the role of the government in financing the health sector has gradually decreased, from 32.7 per cent of total health expenditure to 22.6 per cent, respectively Most of the public funds and a large part of the private funds are spent on public health facilities, in which public hospitals consume approximately 40 per cent of the total health expenditure The structure of financial sources for public hospitals, as presented in Figure 1, therefore, can partly illustrate both the public and private expenditure on health It can be observed in the figure that public hospitals have four financial sources: the state budget, reimbursement from health insurance; direct patient payments (user fees), and domestic or foreign aid The figure also shows that the government budget is still an important financial source for public hospitals during 1994-2006 However, the proportion provided by the government budget in terms of the total financial sources of public hospitals has considerably declined from 68.4 per cent in 1994 to 32 per cent in 2006 The most important financial source – although only by a small margin – is now direct patient payments The percentage of user fees in financing hospitals has increased over time, from 23.2 per cent of total revenues of public hospitals in 1994 to 33 per cent in 2006 The percentage of revenue coming from health insurance reimbursement has also gradually increased from 7.2 per cent to 28 per cent, respectively Among the health service providers in the Vietnamese health system, public hospitals play the most crucial role, and their performance has a significant effect on the well-being of the Vietnamese people Therefore, there is a need for empirical analysis measuring hospital efficiency and productivity under the ongoing structural change circumstance This is the focus of this paper Hospital efficiency: literature review There has been an extensive body of literature examining the performance of the health care sector Studies, which focus on efficiency and productivity using frontier techniques, have been undertaken in all areas of the health sector: from primary care to secondary care, tertiary care to nursing home care, as well as from the overall health system to health care providers, administration bodies, and subgroups in health care providers such as departments and professionals Of the empirical studies on efficiency in the health care sector, many have investigated the efficiency and productivity of Efficiency of hospitals in Vietnam 197 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) JHOM 25,2 198 Figure Financial sources in hospitals 1994-2006 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) hospitals under the health reform process These empirical studies focused on the efficiency and productivity of hospitals in Turkey, South Africa, Kenya, Ghana, Namibia, and Ukraine among others In Turkey, two studies were conducted to examine the technical efficiencies of hospitals: one analysed the acute general hospitals (Ersoy et al., 1997) and the other considered the Ministry of Health public hospitals (Sahin and Ozcan, 2000) Ersoy et al (1997) used the DEA method to examine technical efficiency and found that over 90 percent of Turkish acute general hospitals were inefficient They indicated that the inefficient hospitals used far more inputs and produced fewer outputs than their efficient counterparts To be specific, the inefficient hospitals, on average, utilised 32 per cent more specialists, 47 per cent more primary care physicians, and had 119 per cent more staffed bed capacity, whilst producing 13 per cent less outpatient visits, 16 per cent less inpatient hospitalisation, and 57 per cent less surgical operations than the efficient ones The findings of Sahin and Ozcan (2000) were found to be in agreement with the results obtained in Ersoy et al (1997) According to Sahin and Ozcan (2000), more than half of public hospitals (55 per cent) were inefficient The inefficient hospitals could save over 600 million dollars over five years if they reduced the number of unused beds, the excessive number of specialist and other health labour, and the overspent revolving funds In South Africa, Zere et al (2001) measured the technical efficiency and productivity of 86 hospitals using the DEA model, and subsequently examined the impact of some hospital characteristics on hospital efficiency and productivity using the Tobit and OLS regression models The authors found that a large number of hospitals (87 per cent) were inefficient, in which the level of pure technical efficiency was the same whilst the degree of scale efficiency was different across size-groups of hospitals The decline of hospital productivity over the period studied was explained by technical regression Furthermore, it was shown that occupancy levels and the number of outpatient visits as a proportion of inpatient days were significantly positively significantly related to efficiency In Kenya, Kirigia et al (2002) used two basic DEA models, constant returns to scale and variable returns to scale, to examine the technical efficiency of 54 public district hospitals in the financial year 1998/1999 Due to a plenitude of information from the database of the Ministry of Health, 12 input and eight output measures were employed The results showed that 74 per cent of the total public hospitals were technically efficient and 70.5 per cent achieved scale efficiency The relative technical efficiency and scale efficiency of public hospitals and health centres in Ghana was evaluated by Osei et al (2005) In the study, the sample of 21 public hospitals and 17 health centres was chosen by the simple random sampling technique Of the total number of hospitals and health centres investigated, 47 per cent of hospitals and 70 per cent of health centres were found to be technically inefficient and the number of scale inefficient hospitals and health centres accounted for 59 per cent and 47 per cent, respectively The findings indicated that the hospitals could improve their efficiency by reducing their current number of medical officers/dentists, technical staff, subordinate staff and beds, or increasing numbers of maternal and child care visits, deliveries and discharges Health centres could become more efficient by increasing maternal and child health visits, deliveries, fully-immunised children, and outpatient curative visits Efficiency of hospitals in Vietnam 199 JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 200 In Namibia, Zere et al (2006) investigated the technical efficiency of Namibian hospitals based on a sample of 26 district hospitals during the period 1997-2001 The input-oriented DEA model was employed and the robustness of the DEA technical efficiency scores was tested The authors reported that more than half of the district hospitals were inefficient and the inefficiency was due to both pure technical inefficiency and scale inefficiency It was also indicated that the prevalent inefficiency was due to the increasing returns to scale It would be possible for the hospitals to become efficient by reducing their excess inputs used by 26-37 per cent or by merging some small hospitals after expanding the primary care units In Ukraine, Pilyavsky and Staat (2008) conducted a study to investigate technical efficiency and efficiency changes of hospitals and polyclinics The DEA and Malmquist productivity index methods were employed upon the data set for the five-year period 1997-2001 It was found that most hospitals analyzed were efficient; however, a large number of polyclinics were inefficient Furthermore, the findings revealed that productivity does not almost change over the period under consideration As mentioned in the introduction, although there are some studies on efficiency and productivity of hospitals under the reform process, there is no research regarding to productivity of hospital sector in Vietnam This paper, therefore, uses a complete time-series to examine the changes in efficiency and productivity of public hospitals Estimation techniques and data set Estimation techniques To measure efficiency of healthcare organisations, two different frontier methodologies, stochastic frontier analysis (SFA) and data envelopment analysis (DEA), are widely used These methods were developed based on the concepts of efficiency measurement introduced by Farrell (1957) Farrell (1957) indicated that the key to measuring efficiency is the estimation of the best practice production frontier (isoquant) against which each individual decision-making unit (DMU) is to be compared Accordingly, SFA methodology developed by Aigner et al (1997), and Meeusen and Van den Broeck (1977), and DEA methodology developed by Charnes et al (1978) use different techniques to envelope data, either statistical or mathematical programming, respectively To that end, they make different accommodations for the structure of production technology, for random noise and for the measurement of efficiency There is a longstanding debate on how to measure the technical efficiency of health facilities The cornerstone of the discussion is the problem of choosing the appropriate methodology, either DEA or SFA Some comparisons between frontier techniques in measuring hospital efficiency have been made (e.g Chirikos and Sear, 2000; Jacobs, 2001; among others) These studies showed that despite the intense research effort, there is still no consensus to the best method for measuring frontier efficiency in hospitals Therefore, this paper chooses the DEA approach[1] in order to measure the efficiency of the Vietnamese hospitals for the two following reasons First, as indicated by Osei et al (2005) in their study of efficiency in Ghana hospitals and Valdmanis et al (2004) in their study of efficiency in Thai hospitals, the application of DEA is likely to Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) be suitable in low-income countries where there is insufficient health sector information, and particularly the data on prices of hospital inputs and outputs Second, the preference for DEA is driven by considering its advantages and disadvantages as opposed to SFA The important advantage of the DEA method is that it requires no pre-specification of a functional form and distributional form for the inefficiency terms It can simultaneously accommodate multiple inputs and outputs, and enable a decomposition of the efficiency measurement into several components Furthermore, DEA is less “data-intensive” than econometric methods because it does not require a relatively large sample size, information on prices of inputs and outputs, nor transformation of input and output physical units into any other single unit measure However, it is sensitive to outliers and measurement errors In this paper, an input-oriented DEA framework is employed Alongside the fact that an input-based DEA orientation has been widely applied in the literature on hospital efficiency, the input-based approach is chosen over the alternative output-based approach for the following reasons First, there is a growing demand for health services in terms of both quantity and quality; however, demand for health services is difficult to estimate Second, the input-based orientation seems to be more consistent with the regulated context of the public hospitals, in which managers have more control over inputs (resources) than they over outputs (service production) Finally, this method also reflects the primary goal offered by policy makers that public hospitals are obliged to meet all people’s demands of health care services and that hospitals should reduce costs or limit input use In general, any analysis using DEA method provides only a “snap-shot” of hospital performance in a given point of time (i.e static performance) However, an extension to the standard DEA model such as Malmquist productivity index approach developed by Faăre et al (1994) can take into account the hospital performance in a time-series setting Therefore, the Malmquist productivity index[2] is also analysed in this paper, to measure performance over time (i.e productivity change) and decompose any change into the efficiency and frontier shift effects Data set Data for this study were obtained from the database on the hospitals of Vietnamese Ministry of Health and cover a period of nine years from 1998-2006 The sample hospitals used in this study, was the 101 general public hospitals over a total of 116 hospitals belonging to the hospitals under consideration Central general hospitals and provincial general hospitals, operating as either the tertiary or main secondary centres, were chosen because they consume the largest part of the health resources in the health care system and their performance will have a significant influence on the health services provided and the health status of the overall population The general district hospitals were taken out of the sample because they are of a small size and less complicated, and provide fewer kinds of health services at a lower quality than the sampled hospitals The specialty central and provincial hospitals have distinct missions, unique production processes, and serve distinct patients, which would have resulted in a heterogeneous sample In addition, due to the elimination of some inaccurate and missing values, 15 provincial hospitals were excluded As a result, the sample had 101 hospitals, including nine central hospitals and 98 provincial hospitals Efficiency of hospitals in Vietnam 201 JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 202 The selected model for the empirical analysis of this paper is presented in Table I and the descriptive statistics of input and output variables are displayed in Appendices and Regarding the output variables, following the hospital efficiency studies by Hu and Huang (2004), Chang et al (2004); hospital outputs in this study are proxied by outpatient visits (Y1), inpatient days (Y2) and surgical operations (Y3) performed First, outpatient visits (Y1) are chosen as an output, which include both the scheduled visits to physicians and the unscheduled visits to the emergency room of hospitals Second, health services for inpatients have different features and consume more resources than outpatient services, therefore, inpatient health services is another output of hospitals This study follows the argument of Granneman et al (1986) that the inpatient day factor is more medically homogeneous unit than the inpatient factor; therefore the use of inpatient days (Y2) can provide a more favourable hospital output Finally, the surgical operation output (Y3) is used because it requires different combinations of inputs than medical care, such as specialised equipment and personnel All of these output measures are aggregate, and measuring hospital outputs by such aggregate variables does not capture case-mix variation and quality of services provided Even though the use of case-mix index such as diagnosis-related-groups (DRGs) applied in many health systems may handle the problem, the absence of data makes its use limited in Vietnam as well as in most developing countries (Zere et al., 2006; Pilyavsky et al., 2006; Pilyavsky and Staat, 2008) Regarding the input variables, inputs used in assessment of hospital efficiency often fall into two categories: recurrent resources and capital resources The numbers of personnel and hospital beds are considered as proxies for recurrent and capital resources used in hospitals, respectively; and therefore they are widely used in the studies of hospital efficiency (e.g Ferrari, 2006; Chen, 2006) Accordingly, the number of actual hospital beds used to provide health services and surgical operations are employed as an overall indicator of the capital input (X1) However, due to unavailability of disaggregate data on personnel, only the total number of hospital’s personnel (X2), including physicians and non-physicians working in the hospitals, is used as a proxy of recurrent capital The use of these inputs can be explained by the fact that the hospital production process, as mentioned above, is largely administrative, delivers the health care services, and extensively uses the qualified labour and beds to produce health outputs Variables Inputs Beds (X1) Personnel (X2) Table I Selected variables for DEA and Malmquist TFP models Outputs Outpatient visits (Y1) Inpatient days (Y2) Surgical operations (Y3) Definitions The total number of beds actually used by the hospital within a year The total number of full-time physicians and non-physicians employed by the hospital in a year Total number of outpatient visits to the hospitals within a year Total number of days that inpatients stayed in hospital beds and received inpatient services within a year Total inpatient and ambulatory surgical operations within a year Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) Results Efficiency results The resulting efficiency scores of 101 general hospitals in Vietnam are presented in Table II It is worth noting that the efficiencies reported are only relative, i.e efficiencies relative to the best performing hospitals The results reveal that the average overall technical efficiency increased from 65.2 per cent in 1998 to 76.7 per cent in 2006, and the pure technical efficiency increased from 71 per cent to 80.1 per cent, respectively It can be seen that both overall and pure technical efficiency had a slight decrease initially (1998-1999) and rose sharply for the last two years Overall, Vietnamese hospitals have experienced an upward trend in technical efficiency during the sample period 1998-2006 This implies that the levels of hospital efficiency scores are getting better over time An explanation for this could lie in the fact that structural changes in public hospitals in terms of financing mechanism and management were undertaken during the period of study The scale efficiency of the hospitals is quite high and, in general, increased over the period studied It has increased from 91.9 per cent in 1998 to 96 per cent in 2006, resulting in average scale efficiency for the entire sample period of 92.4 per cent It can be observed that the average scale efficiency was more than 93 per cent in the last three years of the sample period This suggests that the sample hospitals move closer to the most productive scale and that there is a little room for the inefficient hospitals to improve their performance by operating at the optimal scale Furthermore, technical efficiency is investigated in terms of hospital types and location The results are presented in Table III and Table IV, respectively Table III shows that the central hospitals have experienced an increase in overall and pure technical efficiency from 2002, after a slight reduction in 1999 The average overall technical efficiency of central hospitals increased from 58 per cent in 1998 to 79 per cent in 2006 and average pure technical efficiency increased from 66.1 per cent to 81.8 per cent, respectively Meanwhile, the efficiency of provincial hospitals increased by 10.7 per cent for overall technical efficiency and 8.4 per cent for pure technical efficiency increased over the sample period This suggests that central hospitals’ performance may differ from that of provincial hospitals Non-parametric Mann-Whitney test is used to compare the distribution of the efficiency measures of provincial and central hospitals The result of the test is at the 95 per cent level of 1998 1999 2000 2001 2002 2003 2004 2005 2006 Average CRSTE VRSTE SCALE Number of CRSTE ¼ 0.652 0.599 0.620 0.619 0.635 0.661 0.674 0.748 0.767 0.664 0.710 0.672 0.677 0.685 0.704 0.731 0.722 0.781 0.801 0.720 0.919 0.898 0.920 0.906 0.907 0.909 0.934 0.958 0.960 0.924 5 6 6 Efficiency of hospitals in Vietnam 203 Table II Annual average efficiency scores JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 204 Table III Annual average technical efficiency scores by hospital types Central hospitals Provincial hospitals All hospitals Overall technical efficiency 1998 1999 2000 2001 2002 2003 2004 2005 2006 Mean 0.584 0.555 0.568 0.562 0.566 0.608 0.665 0.778 0.791 0.631 0.659 0.603 0.625 0.624 0.641 0.666 0.675 0.745 0.765 0.667 0.652 0.599 0.620 0.619 0.635 0.661 0.674 0.748 0.767 0.664 Pure technical efficiency 1998 1999 2000 2001 2002 2003 2004 2005 2006 Mean 0.661 0.650 0.671 0.672 0.694 0.721 0.743 0.809 0.818 0.715 0.715 0.674 0.677 0.686 0.705 0.732 0.720 0.779 0.799 0.721 0.710 0.672 0.677 0.685 0.704 0.731 0.722 0.781 0.801 0.720 confidence, therefore, the null hypothesis that the efficiency distributions are the same for two types of hospitals are rejected It means that the provincial hospitals, in general, have performed better than their central counterparts during the period under consideration Table IV shows that the overall technical efficiency scores of hospitals located in North East, South East and Mekong River Delta regions are 68 per cent, 70 per cent, and 67 per cent, respectively; and the pure technical efficiency are 74 per cent, 74.1 per cent and 73.2 per cent These scores are slightly higher than those of hospitals located in other regions These results suggest that hospitals located in the different regions may have performed differently The non-parametric Kruskal-Wallis test is employed to examine the null hypothesis that there is no median difference in overall and pure technical efficiency across regions The result shows that the null hypothesis is rejected at the 99 per cent of level of confidence, implying that at least one pair of the efficiency medians is not equal, and that the technical efficiency in the sample hospitals changed across regions As noted earlier in section 4, the DEA efficiency results are sensitive to outliers and measurement errors Therefore, this stage analyses the robustness of the efficiency scores using the jackknife technique (Magnussen, 1996; Zere et al., 2006) The efficient hospitals are removed one at a time from the analysis and the efficiency measures are recalculated The similarity of the efficiency ranking between the model – prior to deleting any efficient hospitals and new models – omitting each of the efficient hospitals, is then tested by using the Spearman rank correlation coefficients If the efficient hospitals are influential, the results should be varied and not correlated 0.636 0.569 0.662 0.651 0.664 0.682 0.699 0.775 0.806 0.683 0.695 0.648 0.728 0.719 0.737 0.747 0.740 0.806 0.840 0.740 Pure technical efficiency 1998 0.704 1999 0.651 2000 0.619 2001 0.655 2002 0.694 2003 0.696 2004 0.691 2005 0.762 2006 0.794 Mean 0.696 North East Overall technical efficiency 1998 0.660 1999 0.604 2000 0.580 2001 0.594 2002 0.627 2003 0.635 2004 0.655 2005 0.720 2006 0.755 Mean 0.648 Red River Delta 0.666 0.700 0.680 0.595 0.622 0.677 0.634 0.749 0.890 0.690 0.503 0.492 0.492 0.452 0.483 0.549 0.535 0.714 0.869 0.565 North West 0.756 0.656 0.634 0.667 0.669 0.652 0.664 0.753 0.778 0.692 0.663 0.557 0.544 0.568 0.567 0.570 0.603 0.699 0.747 0.613 North Central Coast 0.684 0.638 0.615 0.658 0.701 0.725 0.688 0.803 0.804 0.702 0.637 0.591 0.587 0.616 0.661 0.672 0.661 0.783 0.782 0.666 South Central Coast 0.668 0.602 0.612 0.609 0.624 0.712 0.726 0.825 0.824 0.689 0.587 0.510 0.531 0.497 0.503 0.588 0.632 0.755 0.772 0.597 Central Highland Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 0.707 0.694 0.729 0.707 0.722 0.752 0.757 0.809 0.793 0.741 0.665 0.628 0.687 0.662 0.675 0.701 0.722 0.790 0.767 0.700 South East 0.744 0.716 0.679 0.708 0.711 0.767 0.746 0.749 0.767 0.732 0.691 0.646 0.630 0.642 0.641 0.687 0.682 0.713 0.725 0.673 Mekong River Delta Efficiency of hospitals in Vietnam 205 Table IV Annual average technical efficiency scores by regions JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 206 Subsequently, the value of implies that there is no correlation between the rankings The value of (or 1) indicates that there is no influence of outliers on hospital efficiency Jack-knifing analysis has been done on a year-by-year basis for the above pure technical efficiency and overall technical efficiency The results yield the value ranges of Spearman rank order correlation coefficient from 0.801 to 0.951 for pure technical efficiency and from 0.851 to 0.997 for technical efficiency, which are significantly different from zero at per cent level of significance This suggests that no efficient hospital influences the efficiency of other hospitals and the efficiencies obtained from the sample are reasonably robust, at least on an ordinal scale of ranking of the hospitals As compared with the findings of the previous study on the performance of developing countries reviewed above, the efficiency findings of the Vietnamese hospitals, to some extent, are similar to the hospital efficiency in those studies First, the study on hospital efficiency during the period 1997-2001 in Ukraine (Pilyavsky et al., 2006), that used to be a member of the communist block before 1990s and has undertaken economic reform at the same time as Vietnam, shows that the Ukraine’s hospitals could increase from 26 per cent to 32 per cent of their outputs, if they could operate on the production frontier The findings of this study show that Vietnamese hospitals can save from 28 per cent to 36 per cent of their resources if they can operate on the efficiency frontier Furthermore, the comparison of these findings indicates that the efficiency level of both Ukraine’s and Vietnamese hospitals can be improved by a reduction in number of beds and number of employees used However, between two different kinds of labour – nurses and physicians – in Ukraine hospitals, nurses were the source of inefficiency whilst physicians resulted in efficiency improvement Accordingly, hospitals’ managers in Ukraine needed to replace some nurses by a number of physicians to increase their efficiency In contrast, because data on labour was limited in this paper, the findings could only show that hospital’ managers need to reduce number of staff employed to improve their overall technical efficiency The findings in this study did not identify what kinds of hospital personnel – nurses, physicians or non-health personnel – need to be reduced or replaced Second, when compared to another study – on Namibian hospitals (Zere et al., 2006) – the efficiency level of hospitals found in this study is also similar to that of Namibian hospitals In particular, the overall technical efficiency of Namibian hospitals was found to range from 62.7 per cent to 74.3 per cent during the period 1997-2001, whilst it ranged from 59.9 per cent to 76.7 per cent during the period 1998-2006 for Vietnamese hospitals However, whilst the overall technical inefficiency in Namibian hospital was equally attributed to pure technical inefficiency and scale inefficiency, the overall technical inefficiency in Vietnamese hospitals was mainly attributed to pure technical inefficiency Additionally, the main source of the efficiency improvement of the Namibian hospitals was the reduction in number of hospital beds whilst it was the reduction in number of hospital personnel employed in hospitals in Vietnam Malmquist total factor productivity results The results of the Malmquist indices and all of its components are presented in Table V It includes the geometric means of all the indices as well as the cumulative indices for Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) Year 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 Mean 1998-2006a Technical efficiency change (EFFCH) 0.922 1.033 0.995 1.028 1.040 1.019 1.119 1.029 1.022 1.189 Technological Change in pure change technical efficiency (TECHCH) (PECH) 1.045 0.953 1.023 1.008 0.949 0.963 0.961 1.040 0.992 0.938 0.946 1.005 1.012 1.028 1.038 0.988 1.089 1.026 1.016 1.133 Change in scale efficiency (SECH) Total factor productivity change (TFPCH) 0.975 1.028 0.983 1.000 1.003 1.032 1.028 1.002 1.006 1.050 0.964 0.984 1.018 1.037 0.987 0.981 1.075 1.069 1.014 1.114 Note: a Cumulative indices for period 1998-2006 the entire period 1998-2006 It is worth noting that all of these indices are measured by geometric means, which are used to preserve the multiplicative decompositions of the Malmquist productivity indices (Faăre et al., 1994) Furthermore, values of the Malmquist index or its components greater than denote progress or improvement in performance, whilst indices less than represent the regress or the deterioration of performance The indices equal to reflect no change in performance The results in Table V show that the technical efficiency regressed in the initial years (1998-1999 and 2000-2001) and then the trend reversed, with progression in the subsequent pairs of years Due to improvement in technical efficiency change in 1999-2000 and from 2001 to the end of the period under consideration, the hospitals have experienced an overall net efficiency progress with the value of 1.022, representing an increase of 2.2 per cent in technical efficiency per year It can be also observed that the improvement in technical efficiency change is due to the simultaneous increases of 1.6 per cent in pure technical efficiency and 0.6 per cent in scale efficiency per year Meanwhile, the results of technological change index, are reported to be mixed The production frontier progressed in the initial years of the sample period (1998-2002) before regressing in the period 2003-2005 In the final year of the sample period, the hospitals have again experienced progress in technological change, with an improvement of per cent However, the combined results of these changes produce a net negative of 0.8 per cent per year in technological change As shown in the table, it appears that there is an upward trend in the total factor productivity index (TFPCH), a product of technical efficiency change and technological change, during the entire period under consideration; although it experiences some downward movements in particular pair of years In particular, after an initial regression in the first two periods (1998-1999 and 1999-2000), productivity progressed in the two subsequent periods (2000-2001 and 2001-2002) Afterwards, it regressed and then progressed evenly for the next four consecutive periods Overall, the Vietnamese public hospitals experienced a 1.4 per cent productivity growth rate per year during Efficiency of hospitals in Vietnam 207 Table V Malmquist productivity indices and its components JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 208 1998-2006 This increase of 1.4 per cent per year of Malmquist productivity change index can be found to be due to the improvement in technical efficiency changes of 2.2 per cent per year, and is counterbalanced by the worsening in technological change of 0.8 per cent per year This suggests that on average the hospitals are getting closer (experiencing efficiency improvement) to the frontier However, the hospitals have on average experienced negative technological change during the sample period, thus offsetting somewhat the technical efficiency progress As compared with the findings of a study on the productivity of South African hospitals (Zere et al., 2001), the only study on hospital productivity currently undertaken in developing countries, the efficiency scores of Vietnamese hospitals are found to be lower However, whilst productivity growth and technical efficiency change was revealed to have regressed in South African hospitals, they are progressed in Vietnamese general hospitals Conclusions This study is an attempt to provide an empirical picture of the efficiency and productivity of Vietnamese hospitals during the period of reform process The findings showed that there are a considerable room for the efficiency improvement in the Vietnamese public hospitals as the average overall and pure technical efficiencies were 66.4 per cent and 72 per cent, respectively These results, to some extent, are similar to those found in some studies on hospital efficiency in other developing countries such as the Ukraine and Namibia These results could be attributed for the impact of the structural changes in the public hospital sector since the 1990s It also showed that the efficiency of hospitals have improved over the sample period The provincial hospitals were found to outperform their central counterparts and hospitals located in different regions were also found to perform differently Furthermore, the results of the Malmquist productivity indices showed that the total factor productivity progressed over the sampled period of 1.4 per cent per annual This progress of average productivity was mainly due to the technical efficiency improvement of 2.2 per cent per year and the worsening of technological change of 0.8 per cent per year The most striking results of this study of the efficiency and productivity in Vietnamese public hospitals suggest that the structural regulatory changes in the public hospital sector during the health reform process may have affected the technical efficiency and productivity of the public hospitals However, the findings also implied that these regulatory changes might not have created any improvement in technology This may be due to some constraints such as the lack of financial resources for new technologies, the limited ability of staff in acknowledging and applying new medical techniques, and the insufficient attention of hospital managers to technological development in public hospitals In order to improve the performance of public hospitals, the regulators in the health sector may need to provide policies to solve these constraints Overall, this paper provides an insight of the performance of public hospitals during the reform process, which can then assist policy makers in choosing the best regulatory framework for the ongoing health sector reform process This analysis also shows that not only reform programmes but also hospital operating characteristics such as location and hospital types can affect the performance of hospitals Notes The detail of DEA approach is presented in Appendix Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) The Malquist productivity index approach is detailed in Appendix References Aigner, D.J., Lovell, C.A.K and Schmidt, P (1977), “Formulation and estimation of stochastic frontier production function models”, Journal of Econometrics, Vol No 1, pp 21-37 Banker, R.D., Charnes, A and Cooper, W.W (1984), “Some models for estimating technical and scale inefficiencies in data envelopment analysis”, Management Science, Vol 30, pp 1078-92 Bloom, G (1997), “Primary health care meets the market: lessons from China and Vietnam”, Working Paper 53, IDS, Brighton Chang, H., Chang, W., Das, S and Li, S (2004), “Health care regulation and the operating efficiency of hospitals: evidence from Taiwan”, Journal of Accounting and Public Policy, Vol 23 No 6, pp 483-510 Charnes, A., Cooper, W.W and Rhodes, E (1978), “Measuring the efficiency of decision making units”, European Journal of Operational Research, Vol 2, pp 429-44 Chen, L.C and Hiebert, L.G (1994) “From socialism to private markets: Vietnam’s health in rapid transition”, working paper, Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA Chen, S.N (2006), “Productivity changes in Taiwanese hospitals and the national health insurance”, The Service Industries Journal, Vol 26 No 4, pp 459-77 Chirikos, T.N and Sear, A.M (2000), “Measuring hospital efficiency: a comparison of two approaches”, Health Services Research, Vol 34 No 6, pp 1389-408 Ersoy, K., Kavuncubasi, S., Ozcan, Y.A and Harris, J.M II (1997), “Technical efficiencies of Turkish hospitals: DEA approach”, Journal of Medical Systems, Vol 21 No 2, pp 67-74 Faăre, R., Grosskopf, S., Lindgren, B and Roos, P (1994), “Productivity developments in Swedish hospitals: a Malmquist output index approach”, in Charnes, A., Cooper, W.W., Lewin, A.Y and Seiford, L.M (Eds), Data Envelopment Analysis: Theory, Methodology and Applications, Kluwer Academic, Boston, MA, pp 253-72 Farrell, M.J (1957), “The measurement of productive efficiency”, Journal of the Royal Statistical Society (A, General), Vol 120, pp 253-81 Ferrari, A (2006), “Market oriented reforms of health services: a non-parametric analysis”, The Service Industries Journal, Vol 26 No 1, pp 1-13 Grannemann, T.W., Brown, R.S and Pauly, M.V (1986), “Estimating hospital costs: a multiple-output analysis”, Journal of Health Economics, Vol No 2, pp 107-27 Hoi, N.D., Kiet, T.D., Ninh, L.H., Hung, T.P., Nguyen, N.D., Loan, N.B., Dung, D.V and Lich, B.D (2000), “Health development during the reform process”, Efficient, Equity-oriented Strategies for Health: International Perspectives – Focus on Vietnam, The Centre for International Mental Health, Melbourne Hollingsworth, B (2003), “Non-parametric and parametric applications measuring efficiency in health care”, Health Care Management Science, Vol No 4, pp 203-18 Hollingsworth, B., Dawson, P.J and Maniadakis, N (1999), “Efficiency measurement of health care: a review of non-parametric methods and applications”, Health Care Management Science, Vol No 3, pp 161-72 Hu, J.-L and Huang, Y.-F (2004), “Technical efficiencies in large hospitals: a managerial perspective”, International Journal of Management, Vol 21 No 4, pp 506-13 Efficiency of hospitals in Vietnam 209 JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 210 Jacobs, R (2001), “Alternative methods to examine hospital efficiency: data envelopment analysis and stochastic frontier analysis”, Health Care Management Science, Vol No 2, pp 103-15 Kirigia, J.M., Emrouznejad, A and Sambo, L.G (2002), “Measurement of technical efficiency of public hospitals in Kenya: using data envelopment analysis”, Journal of Medical Systems, Vol 26 No 1, pp 39-45 Ladinsky, J., Nguyen, H.T and Volk, N.D (2000), “Changes in the health care system of Vietnam in response to the emerging market economy”, Public Health Policy, Vol 21 No 1, pp 82-98 Magnussen, J (1996), “Efficiency measurement and the operationalization of hospital production”, Health Services Research, Vol 31 No Meeusen, W and Van den Broeck, J (1977), “Efficiency estimation from Cobb-Douglas production functions with composed errors”, International Economic Review, Vol 18 No 2, pp 435-44 Osei, D., d’Almeida, S., George, M.O., Kirigia, J.M., Mensah, A.O and Kainyu, L.H (2005), “Technical efficiency of public district hospitals and health centres in Ghana: a pilot study”, Cost Effectiveness and Resource Allocation, Vol No Pilyavsky, A.I and Staat, M (2008), “Efficiency and productivity change in Ukrainian health care”, Journal of Productivity Analysis, Vol 29, pp 143-54 Pilyavsky, A.I., Aaronson, W.E., Bernet, P.M., Rosko, M.D., Valdmanis, V and Golubchikov, M.V (2006), “East-west: does it make a difference to hospital efficiencies in Ukraine?”, Health Economics, Vol 15 No 11, pp 1173-86 Sahin, I and Ozcan, Y.A (2000), “Public sector hospital efficiency for provincial markets in Turkey”, Journal of medical Systems, Vol 24 No 6, pp 307-20 Sepehri, A., Chernomas, R and Akram-Lodhi, H (2003), “If they get sick, they are in trouble: health care restructuring, user charges, and equity in Vietnam”, International Journal of Health Service, Vol 33 No 1, pp 137-61 Sepehri, A., Chernomas, R and Akram-Lodhi, H (2005), “Penalizing patients and rewarding providers: user charges and health care utilization in Vietnam”, Health Policy, Vol 20 No 2, pp 90-9 Valdmanis, V., Kumanarayake, L and Lertiendumrong, J (2004), “Capacity in Thai public hospitals and the production of care for poor and non-poor patients”, Health Services Research, Vol 39 No 6p2, pp 2117-34 World Bank (2005), Vietnam: Managing Public Expenditure for Poverty Reduction and Growth: Public Expenditure Review and Integrated Fiduciary Assessment, World Bank, Washington, DC Worthington, A.C (2004), “Frontier efficiency measurement in health care: a review of empirical techniques and selected applications”, Medical Care Research and Review, Vol 61 No 2, pp 135-70 Zere, E., Mbeeli, T., Shangula, K., Mandlhate, C., Mutirua, K., Tjivambi, B and Kapenambili, W (2006), “Technical efficiency of district hospitals: evidence from Namibia using data envelopment analysis”, Cost Effectiveness and Resource Allocation, Vol No Zere, E., Mcintyre, D and Addison, T (2001), “Technical efficiency and productivity of public sector hospitals in three South African provinces”, The South African Journal of Economics, Vol 69 No 2, pp 336-58 Further reading Coelli, T.J., Rao, D.S and Battese, G.E (2005), An Introduction to Efficiency and Productivity Analysis, Kluwer Academic Publishers, London Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) Faăre, R., Grosskopf, S., Norris, M and Zhang, Z (1994), “Productivity growth, technical progress, and efficiency change in industrialized countries”, The American Economic Review, Vol 84 No 1, pp 66-83 McCallion, G., Glass, J.C., Jackson, R., Kerr, C.A and McKillop, D.G (2000), “Investigating productivity change and hospital size: a nonparametric frontier approach”, Applied Economics, Vol 32 No 2, pp 161-74 Maniadakis, N., Hollingsworth, B and Thanassoulis, E (1999), “The impact of the internal market on hospital efficiency, productivity and service quality”, Health Care Management Science, Vol No 2, pp 75-85 Ramanathan, R (2005), “Operations assessment of hospitals in the Sultanate of Oman”, International Journal of Operations & Production Management, Vol 25, pp 39-54 Appendix Methodology DEA methodology Data envelopment analysis method (DEA) constructs production frontiers and measures efficiency of a decision-making unit (DMU) relative to these constructed frontiers using mathematical programming technique This method was first developed by Charnes et al (1978) (CCR model) based on the work of Farrell (1957) on efficiency measurement The CCR model assumes a production technology with constant returns to scale, implying that any proportional change in inputs usage result in the same proportional change in outputs It was then extended by Banker et al (1984) (BCC model) The BCC model relaxes the assumption of constant returns to scale to allow for variable returns to scale The paper, in the first stage, employs the BCC model to measure the relative efficiency of hospitals The input-oriented BCC model is formulated as follows: MinE o ¼ uo subjectto n X lk X ik # uo X io ;i k¼1 n X lk Y rk $ Y ro ;r k¼1 n X lk ¼ k¼1 lk $ 0;k; r; i where: uo represents the efficiency score of DMU0, which is within a range from zero to one and a higher score implies a higher efficiency; lk is non-negative values related to the k th DMU Malmquist total factor productivity index The DEA-based Malmquist total factor productivity (TFP) index approach (Faăre et al., 1994) is to measure the productivity changes of DMUs at different points in time, identify the sources of productivity changes, and decompose total productivity change into technical efficiency change (the catch-up effect) and technological change (the frontier shift effect) The TFP change index between period tị and period t ỵ 1ị is given by: Efficiency of hospitals in Vietnam 211 JHOM 25,2 Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) 212 M I Y tỵ1 ;X tỵ1 " #1=2 tỵ1 Dtỵ1 ; X tỵ1 ị DtI Y tỵ1 ; X tỵ1 ị DtI Y t ; X t ị I Y ;Y ;X ị ẳ tỵ1 ; X tỵ1 ị Dtỵ1 Y t ; X t ị DtI Y t ; X t ị Dtỵ1 I Y I t t where the notion DI denotes the input-based distance function, and M I is the product of technical efficiency change and technological change The part outside the square brackets of the equation represents the technical efficiency change between period tị and period t ỵ 1ị, which denotes the ratio of Farrell technical efficiency in period t ỵ 1ị over the technical efficiency in period ðtÞ Technical efficiency change indicates whether a unit comes closer to (or further away from) its production frontier when moving from period ðtÞ to period t ỵ 1ị The remaining part inside the square brackets is a measure of technological change It is the geometric mean of the shift in the production frontier observed at Y t and the shift in the production frontier observed at Y tỵ1 Technological change indicates whether the production frontier has shifted between two periods ðtÞ and ðt þ 1Þ evaluated Appendix Inputs Table AI Descriptive statistics for input variables Mean Standard deviation Minimum value Maximum value Total number of beds 1998 363.41 1999 370.81 2000 400.58 2001 404.59 2002 410.16 2003 439.12 2004 449.10 2005 482.51 2006 500.50 195.17 196.73 221.74 220.67 224.84 237.17 236.60 259.32 266.72 60 63 63 70 74 78 80 87 103 1,090 1,090 1,340 1,340 1,360 1,400 1,407 1,550 1,567 Total number of personnel 1998 367.83 1999 381.55 2000 404.58 2001 424.35 2002 449.75 2003 463.06 2004 520.62 2005 537.16 2006 554.99 214.93 224.62 239.59 256.37 284.27 318.75 359.77 369.86 380.23 35 40 42 47 56 64 72 79 85 1,409 1,409 1,409 1,567 1,768 2,206 2,552 2,709 2,830 Appendix Downloaded by Universite Libre de Bruxelles At 19:41 09 February 2015 (PT) Outputs Mean Standard deviation Total number of outpatient visits 1998 7,970.31 1999 8,554.87 2000 8,517.53 2001 8,717.71 2002 9,532.60 2003 9,660.62 2004 10,455.10 2005 11,143.30 2006 10,920.31 Total number of inpatient days 1998 141,804.14 1999 136,987.77 2000 146,012.08 2001 155,007.44 2002 163,661.26 2003 170,394.30 2004 179,362.98 2005 199,156.47 2006 219,271.34 Total number of surgical operations 1998 3,944.56 1999 4,178.88 2000 4,577.05 2001 4,845.57 2002 5,235.38 2003 5,526.48 2004 5,985.72 2005 6,862.79 2006 7,634.77 Minimum value Maximum value 21,767.92 22,130.04 22,069.02 22,284.63 24,485.12 25,621.91 28,136.63 28,228.80 25,563.87 80 95 120 118 132 125 162 152 155 175,813 171,215 170,361 167,983 189,281 197,960 207,337 191,450 221,221 80,906.52 78,882.07 85,517.79 92,597.37 98,309.30 105,552.09 116,893.76 124,421.97 133,915.14 15,195 15,823 17,684 19,802 23,451 23,940 27,560 33,017 33,475 473,370 510,700 564,550 599,319 589,425 657,439 749,510 788,145 850,183 4,315.87 4,655.62 5,050.74 5,209.60 5,837.68 5,964.11 6,232.03 6,967.27 7,239.97 86 145 160 176 186 198 210 176 220 30,224 31,708 32,373 33,256 35,612 37,583 37,057 35,839 36,590 About the author Thuy Linh Pham is a Lecturer in Human Resource Management and Operations Management Her research interests include influence of public policy on performance of public and private organizations, human resource management and operations management in small and medium enterprises Thuy Linh Pham can be contacted at: phamlinh2010@yahoo.com To purchase reprints of this article please e-mail: reprints@emeraldinsight.com Or visit our web site for further details: www.emeraldinsight.com/reprints Efficiency of hospitals in Vietnam 213 Table AII Descriptive statistics for output variables ... issue and full text archive of this journal is available at www.emeraldinsight.com/1477-7266.htm Efficiency and productivity of hospitals in Vietnam Efficiency of hospitals in Vietnam Thuy Linh... inaccurate and missing values, 15 provincial hospitals were excluded As a result, the sample had 101 hospitals, including nine central hospitals and 98 provincial hospitals Efficiency of hospitals in. .. the increasing demand of health services and boost the efficiency and productivity of the health system in general, and hospitals in particular Despite the extensive body of literature dealing