Evaluating the Productivity of Faith based Hospitals in Tanzania: Application of Malmquist Productivity Index (MPI) Approach

Transcription

1 Inernaional Journal of Financial Economics Vol. 3, No. 4, 204, Evaluaing he Produciviy of Faih based Hospials in Tanzania: Applicaion of Malmquis Produciviy Index (MPI) Approach Kembo M. Bwana Absrac In his sudy we esimae he produciviy of No For Profi (NFP) hospials in Tanzania over sampled period from 200/ /202, of which mos of hem belongs o faih based orgarnisaions. Faih based orgarnisaions in Tanzania are caegorized ino Voluneering Agency Hospials (VAHs) and Councils Designaed Hospials (CDHs) our focus in his paper premised on Voluneering Agency Hospials (VAHs). We employ a DEA based Malmquis Produciviy Index (MPI) in he daa se of 5 faih based hospials. Objecive of his sudy is o deermine he oal facor produciviy (TFP) and is componens over he period under he sudy as well as esablishing he sources of produciviy change. Conribuion of our sudy sems in he following ways: firsly, examine he produciviy change of he hospials under he sudy and hence be able o provide generalizaion abou he produciviy of faih based hospials in Tanzania (paricularly voluneering agency hospials), his will give hospials adminisraors, owners and policy makers a clear picure wih regards o produciviy performance. Secondly, he sudy will conribue o he exising lieraures on hospial produciviy (paricularly faih based hospials in developing counries such as Tanzania). The resuls of our sudy revealed ha he Voluneering Agency Hospials (VAH) in Tanzania experienced.6 per cen deerioraion rae per year during he period under he sudy (200/ /202). This deerioraion of.6 per cen per year is largely due o a decline (worsening) in echnical progress (2.6 per cen per year) which counerbalanced he improvemen in echnical efficiency change which is very small ( per cen per year). Keywords: Produciviy, Faih based Hospials, Malmquis Produciviy Index (MPI), Tanzania. Inroducion Toal facor produciviy (TFP) change is he measuremen of he changes in oupus conrolling for he inpus used, and i can be divided ino differen componens. By comparing he annual changes in he produciviy of individual hospials i is possible o idenify general rends in he produciviy of he hospials indusry as whole and helps in idenifying individual hospial exhibiing paern of changes in he produciviy ha differ from he res of he indusry. The focus of our sudy is o measure produciviy change in he hospials (paricularly faih based) secor in Tanzanian. Taking is componens ino consideraion ha is efficiency change (assessing wheher he hospials is becoming closer o he producion fronier or no) and echnological change (wheher here is a shif in producion fronier or no). We employ DEA-based Malmquis Produciviy Index (MPI) as he esimaing echnique. Several sudies have employed he use of MPI o measure he efficiency and echnological changes in hospials secor. The concep was originally advocaed by Sen Malmquis (Malmquis, 953) who used i in he analysis of consumer heory. I was laer advanced for he use in produciviy measures in he work of Caves e al (982) followed by is applicaion in many oher sudies. The major aribues of MPI in produciviy analysis Accouning School, Dongbei Universiy of Finance and Economics, No. 27, Jianshang Sree, Dalian, China, Lecurer, Deparmen of Accouning, College of Business Educaion, Tanzania 204 Research Academy of Social Sciences hp:// 207

2 K. M. Bwana is ha i can handle mul-oupus, mul-inpus se up even in he presence of only quaniy informaion (in oher words i doesn need he relaive price informaion or he resricive behavior assumpions in is formaion. Building on argumen of Fare e al (994) he MPI applicaion allows for he esimaion of changes in overall produciviy and hen for decomposiion ino efficiency changes (ECH) and echnological change (TCH) for each decision making uni (DMUs) over ime. In order o esimae he MPI and is componens we employ a non parameric esimaor known as DEA. Given is aribues (ie i doesn requires he neiher imposing funcional for echnology nor disribuional assumpions abou variables or error erms), DEA is widely used o esimaes he MPI and echnical efficiency in an environmen wih muliples inpus and oupus (Emrouznejad, e al 2008; Gaoufi e al, 2004b; Gaoufi e al, 2004c; Seiford, 997) and in paricular in healh secor ( Grosskopf e al, 2004; Hollingsworh, 2003; Ozcan, 995; Wang e al, 999; Ferrier and Valdamanis, 2008) Objecives of he Sudy General objecive of his sudy is o examine he facor produciviy of voluneering Agency hospials (VAHs) in Tanzania. Specifically he assessmen includes: i. Deermine he oal facor produciviy change and is componens in voluneering Agency hospials (VAHs) hospials in Tanzania ii. To esablish he sources of oal facor produciviy change of voluneering Agency hospials (VAHs) in Tanzania Significance of he Sudy Managemen of any organizaion always considers he effeciveness, produciviy and efficiency as he sound performance indicaors which in mos cases indicae he realizaion of he managemen objecives and goal of he firm (Pharm, 200). In he same line of argumen performance of any secor/indusry depends upon he efficacy, efficiency and produciviy of individual unis/firms in he secor over a period of ime. The need for qualiy healh care in Tanzania (like in any oher counry) is large and increasing over ime while he governmen has inadequae resources o finance he rising demand herefore privae hospials (paricularly faih based) are playing a very imporan role o cover he gap. Alhough here are exisence of exensive lieraures on efficiency and produciviy in healh care provision, a few empirical analysis on produciviy of faih based privae (no for profi) hospials in developing counries paricularly in Tanzania have been conduced. This sudy herefore aims a measuring produciviy change of he privae hospials (no for profi) for he period of eleven years. One of novelies of our sudy is ha we use he daa se of 5 faih based (Privae No for Profi) hospials o analyze he produciviy change over he period of en years (200/ /202). By employing he DEA based Malmquis Produciviy Index (MPI). Mos of lieraures on hospials produciviy focus on he public hospials, and for shor period in which i is difficul o horoughly assess he change of produciviy and is componens. Differen sysemaic reviews of lieraures on hospials efficiency and produciviy have been conduced by Hollingsworh e al (999), Hollingsworh (2003) and Worhingon (2004). However, mos of he lieraures reviewed were emanaing from he hospials in developed counries. This sudy again is expeced o conribue on he few lieraures on he hospials produciviy in developing counries (paricularly Tanzania). The oucome of he sudy can help he decision makers, policy makers and hospials adminisraors o undersand wha acually derive he produciviy change of faih based hospials and helps in resources allocaion process. The policy makers may also use he informaion from his sudy o revisi policies on healhcare delivery o ensure improvemen in he healh secor. 208

3 Inernaional Journal of Financial Economics The res of his paper is as follows; Secion wo gives he review of exising lieraures on he curren sudy. Mehodology (ha is daa se descripions, esimaion echniques and model as well as variables selecion are presened in secion hree. Secion four provides he esimaion resuls, discussion of he findings and is implicaions. Secion five gives concluding remarks and recommendaions. 2. Lieraure Review There has been subsanial coverage of lieraures on evaluaing he performance hospials and healh care secor paricularly in developed counries. However, liearures on hospials produciviy is sill lagging behind in developing counries. Several sudies which have been conduced on hospials produciviy in boh developed and developing counries have employed he Malmquis Produciviy Index (MPI). The approach has been widely used in measuring he efficiency and echnological change, change in pure echnical efficiency and change in scale efficiency as well as oal produciviy change of hospials services. Lieraures record ha using an inpu based MPI, Pharm (200) sudied changes in produciviy of hospials in Vienam beween 998 and 2006 wih daa from 0 hospials; and he auhor found ha hospials produciviy progressed around.4 percen per year which was mainly due o he echnical efficiency improvemen. Furhermore, he auhor found ha provincial hospials were more echnical efficien han heir couner hospials, and hospials locaed in differen regions performed differenly. Using Malmquis Produciviy Index (MPI) Zere (2008) sudied he hospial efficiency and produciviy in Souh Africa using daa which covers 992/ /998, he auhor found ha over he sample period oal facor produciviy dropped by 2. percen, his was largely due o decline in he echnical progress over he years 992/ /998. Technical efficiency dropped by he average of 2. percen as opposed o a 6.5 decrease in echnological growh. The efficiency change and echnological change were observed o move in opposie direcion. Sahin e al (2009) found ha echnological progress was he main driver of he improvemen in produciviy in 2007 due o minisry of healh (MoH) invesmens in general hospials in Turkey, bu raher here was a decline in echnological progress in he subsequen years which lef overall produciviy unchanged. In he sudy conduced by Maniadakis e al (999) he auhor found ha produciviy changes are dominaed by echnological changes wih a lile change in hospial efficiency. Fare e al (994a) invesigaed 7 Swedish hospials and found a wide variaion in performance during he period of They found ha long erm average annual produciviy growh was negaive for abou 3 ou of 7 hospials. Auhors concluded ha 3 ou of 7 hospials were experiencing echnological regress and only five ou of 7 experience average annual gains in efficiency. Ozcan and Ozgen (2008) conduced similar sudy and found ha here was improvemen in echnical efficiency along wih regress in echnologies causing major source of negaive movemens in produciviy. Therefore, from he lieraures we noed ha produciviy changes can occur by eiher change in efficiency or echnological changes or change in boh. 3. Mehodology DEA-based Malmquis oal facors produciviy (TFP) index approach (Fare e al, 994) is used o measure he produciviy changes of DMUs a differen poins in ime idenifying he source of produciviy changes and decompose oal produciviy changes ino echnical efficiency change (he cach up effec) and echnological change (he fronier shif effec). The TFP change index beween periods () and (+) is given by: M x, y, x, y D D x, y x, y D D x x, y, y D D x, y x, y / 2 ECH TCH 209

4 K. M. Bwana Where he noion D denoes he inpu based disance funcion and M is he produc of echnical efficiency change (EFC) and echnological change (TCH). The efficiency change erm (ECH) is equivalen o he raio of Farrell echnical efficiency in period + divided by Farrell echnical efficiency in period. The echnological change (TCH) erm is he geomeric mean of he shif in echnology as observed a, x y (he firs raio inside he bracke) and shif in echnology observed a x, y (he second raio inside bracke), i signifies wheher he producion fronier has shifed beween he wo periods () and (+) (Pharm, 200). The ECH componen may be greaer han, equal o, or less han uniy depending on wheher efficiency of he evaluaed DMUs (hospial in our sudy) improves (caching he fronier effec), sagnaes, or declines. This will depend on he case. However, he TCH may also ake a value greaer han, equal o or less han uniy in order o make he echnological change be posiive, zero, or negaive respecively. A Malmquis Index greaer han one indicae growh in produciviy, where as he value less han one indicae a decline. MPI is widely used and more suiable in measuring he produciviy in public secor since i doesn requires he prior behavioral assumpions abou producion echnology nor inpus or oupus prices. Malmquis Produciviy Index (MPI) was proposed by Caves e al (982), he esimaion echnique ha measure Toal Facor Produciviy (TFP) change beween he wo daa poins in erms of raios of disance funcions (Zere, 2000) i should be noed ha oal facor produciviy measures he average producs of all inpus (he opposie, parial facor produciviy measure he average produc of a single inpus. Daa Sources and Descripions Daa used in his sudy are relaing o hospials inpus and oupus from 5 faih based (privae no for profi) hospials in Tanzania for he period from 200 o 202. These daa were exraced from annual repors of he hospials under sudy. Choice of he sudy period ( ) was decided based on he availabiliy and compleeness of daa required. Before 2002 mos of he daa/ annual repors from which he daa could be exraced were missing in many hospials under he sudy. Furhermore, he daa se employed in he sudy was panel daa; his also signifies he use of DEA based MPI approach since he echnique is much suiable for panel daa. To have represenaion of all VAHs, selecion of hospials was according o he Chrisian Social Service Commission (CSSC) zones which classifies faih based hospials in Tanzania ino five zones (i.e Lake zone, Norhern zone, Wesern zone, Easern zone and Souhern zone) he aim was o have aleas represenaive of each zone in our sudy. The hospials considered under he sudy was Voluneering Agency Hospials (VAH) Variables and Model Selecion DEA and DEA-based Malmquis Produciviy Index (MPI) as he echniques for esimaing fronier requires ha uni of measuremen of oupus o be homogeneous, uni dimensional and he oupu is measured cardinally (Coelli e al, However due o he heerogeneiy and join producion naure of he hospials service secor he mos commonly used measure of he hospials oupu is he number of inpaien days produced, since i is considered uni-dimensional and medically homogenous (Chowdhury e al, 20). Following he hospials efficiency sudies by Hu and Huang (2004); chang e al (2004); Pharm, (20) hospials oupus used in his sudy are proxied by oupaien visis, inapien days and surgical operaion performed. The oupaien visis including scheduled visis o physicians and unscheduled visis o he emergency room of hospials (Pharm, 20). We follow Granneman e al (986) wih argumen ha inpaien days are homogeneous uni han he inpaien facor. On he oher hand inpus used o assess hospials efficiency and produciviy ofen classified ino: recurren resources (which is represened by labour and capial resources (represened by hospials beds). herefore we follow previous hospials sudies by Pharm (20); Chen (2006); Ferrari (2006) where such inpus were used in measuring hospials performance. 20

5 4. Analysis of Findings and Discussion Inernaional Journal of Financial Economics Building on Zere (2000) we employed he DEAP 2. program developed by Coelli (996b) o run and esimaes DEA based Malmquis Produciviy Indices. Inpu oriened and variables reurn o scale models is used in his sudy o compue a DEA- based Malmquis produciviy index. An inpu oriened model is preferred in his sudy because unlike he oupus hospials managers have more conrol over he hospial inpus (Zere, 2000; Ozcan, 2008). Pharm (200) added ha inpu oriened DEA framework has been widely applied in he lieraure on hospials efficiency. Variable reurn o scale (VRS) were used because hospials differ in sizes (Ozcan, 998)-paricularly number of beds. Descripive saisics for he oupu (oupaien s visis, inpaien days and surgical operaion performed) and inpus (which is represened by labour and capial resources) is represened in able below.. Table : Descripive Saisics for he Hospials Inpus and Oupus Variable Obs Mean Sd. Dev. Min Max oalinpa~s oaloupa~ oalsurgi~n numberofbeds fullimes~s The MPI summary for he annual means is presened in Table 2. Over he years 200/ /202 The maximum and minimum oal facor produciviy index were.036 and respecively. Decomposiion of which gives he Efficiency change (EFFCH), Technological (TECHCH), in pure echnical efficiency (PECH) and change in Scale efficiency (SECH) where heir maximum and minimum indices are.40;.088;.06;.089 and 0.948; 0.84; 0.983; respecively. The resul of he Malmquis produciviy indices and all is componens (presened in able 2) shows he geomeric mean of all indices during enire period of 200/200-20/202. The resuls indicaes ha he echnical efficiency progressed (in he iniial years) he firs four years (200/ /2005) signifying he increase of 2 percen, percen, 7.4 percen and 4 percen respecively. The rend reversed in he subsequen pairs of years (2005/2006 and 2006/2007) as well as in he year 2008/2009, 200/20 and 20/202. Due o improvemen in he echnical efficiency change in he firs four years (200/ /2005) as well as improvemen in he years 2007/2008 and 2009/200 he hospials under he sudy have experienced an overall ne efficiency progress wih he value of.00, implying an increase of.0 per cen in echnical efficiency per year. Furhermore, he resuls records ha improvemen in echnical efficiency change is he deermined by he simulaneous increase of 0.3 per cen in pure echnical efficiency and 0.6 per cen in scale efficiency per year. Meanwhile, he sudy revealed ha echnological change are regarded as mixed, ha is regressing in he firs four years (200/ /2005) before experiencing progression in he subsequen four years (2005/ /2009) signifying he increase of 0.8 per cen, 0.08 per cen, 0.2 per cen and 0.4 per cen respecively. However, he observed increase (2005/ /2009) was followed by a negaive increased of 3.5 per cen in he year 2009/200 before experiencing anoher posiive increase of 0.7 per cen and 0.6 per cen in he year 200/20 and 20/202 respecively. The combined resuls give a ne negaive of 2.6 per cen per year in echnological change. 2

6 year Technical Efficiency (EFFCH) K. M. Bwana Table 2: Malmquis Index Summary of Annual Means in in Technological Pure-Technical Scale- Efficiency Efficiency (TECHCH) (PECH) (SECH) Toal-Facor Produciviy (TFPCH) 200/ / / / / / / / / / / mean Effch<=05 Effch==00 Effch>=06 TechEff<=05 TechEff==00 TechEff>=06 PeffCh<=07 PeffCh==00 PeffCh>=04 SeffCh<=04 SeffCh==00 SeffCh>=07 TfPCh<=06 TfPCh==00 TfPCh>=05 Toal facor produciviy (TFP) which is he produc of echnical efficiency change and echnological change also provides he mixed resuls during he period under he sudy. Overall produciviy progressed in he firs wo years (200/2002 and 2002/2003) before experiencing a reverse in he rend in he nex subsequen hree years (2003/ /2006) as well as he year 2008/2009, 2009/200 and 200/20. The progression in oal facor produciviy was again experienced in he year 2006/2007, 2007/2008 and 20/202 where here was posiive increase of 3.6 per cen, 2.6 per cen and 0.6 per cen respecively. Overall, he Voluneering Agency Hospials (VAH) in Tanzania experienced a.6 per cen deerioraion rae per year during he period under he sudy (200/ /202). This deerioraion of.6 per cen per year is largely due o a decline (worsening) in echnical progress ( 2.6 per cen per year) which counerbalanced he improvemen in echnical efficiency change which was very marginal ( per cen per year). General observaion suggess ha alhough he Voluneering Agency Hospials (VAH) in Tanzania faced decline in overall produciviy which is largely caused by worsening in echnological progress, here is a sligh improvemen in echnical efficiency change implying ha he hospials are geing closer o he producion fronier (experiencing improvemen in efficiency). However, worsening in he echnological change has offse he improvemen in efficiency change and lead o he deerioraion of he oal facor produciviy. Generally, values of Malmquis index or is componens greaer han one indicae progress or improvemen in performance, while indices less han one shows he regress or deerioraion of performance of he firm (Pharm, 200) - in our case, Malmquis produciviy index greaer han or less han one implies progress or deerioraion of hospials performance respecively. The indices equals o one indicae ha here is no change in performance. Fig indicae he movemen of oal facor produciviy and is componens during he period under he sudy. 22

7 Inernaional Journal of Financial Economics Fig.: Produciviy, 200/ / EFFCH TECHCH PECH SECH TFPCH The resuls found in our sudy o some exen are similar o hose found in sudy of hospials produciviy in Vienam conduced by Pharm (200), in boh sudies here were echnical efficiency improvemen and worsening of he echnological change. I was also observed ha echnological worsening was he main driver of he oal facor produciviy change. However, he wo sudies differ in he aspecs of movemen of oal facor produciviy change (TFP) where in Vienam he overall produciviy was improving (.4 per cen per year) in Tanzania i was deerioraing (negaive improvemen.6 per cen per year). Resuls of he wo sudies conform o anoher sudy conduced in Souh Africa by Zere (2000). In he sudy conduced in Souh Africa i was observed ha decline in echnological progress was he main driver of he change in he oal facor produciviy. However, as i was in he case of Tanzania deerioraion (.6 per cen per year) of oal facor produciviy, in Souh Africa he oal facor produciviy dropped by 2. per cen per year. Observaion in oher sudies conduced by he Sahin e al (2009) in Turkey and Maniadakis e al (999) revealed ha echnological progress was he main driver of he improvemen in oal facor produciviy. Sahin e al poined ha invesmen by Turkish Minisry of Healh in 2007 in general hospials caused a sligh improvemen, bu raher han here was a decline in echnological progress in he subsequen years which lef overall produciviy unchanged. In he sudy conduced by Maniadakis e al (999) he auhor found ha produciviy changes are dominaed by echnological changes wih a lile change in hospial efficiency. 5. Conclusion and Recommendaions This sudy evaluaed he oal facor produciviy (TFP) and is componens of 5 Voluneering Agency Hospials (VAHs) in Tanzania using MPI. The findings lend suppor o he already exising lieraures on hospials produciviy in developing counries. The resuls from our sudy hrow lighs on empirical evidence on he performance (produciviy measuremens) of Voluneering Agency Hospials (VAH) in Tanzania. Lieraures documen ha in some sudies echnological change was found o be he dominan facor while in oher i was he change in echnical efficiency ha played he influencing role o he change in overall produciviy change. Our sudy records ha overall produciviy change was largely dominaed by improvemen in echnical efficiency change and posiive change in echnical efficiency seems o ouweigh he impac on overall produciviy (which seems o deeriorae) due o echnological regress. The decline in overall produciviy of 23

8 K. M. Bwana Voluneering agency hospial in Tanzania is an issue o boh he governmen and faih based organizaions whose hospials are regarded as unis of sudy in his paper. To he governmen i is he se back o he governmen s effors o improving delivery of healh care in Tanzania. As he regulaor, supervisor and policy maker, in he pas wo decades he governmen hrough he Minisry of Healh and Social Welfare (MoHSW) has been underaking several measures including healh policy reforms and subsidizing he privae hospials paricularly privae no for profi hospials wih he aim of improving among oher hings he efficiency and produciviy of hospials. Generally, his sudy suggess ha he governmen should increase is invesmen and suppor o hese hospials in order o realize he echnological progress as well as he overall produciviy. As i was observed in he sudy by Sahin e al (2009) improvemen in echnological progress and overall produciviy was he resuls of increase in invesmen by Turkish governmen in public healh. However, faih based organizaion are urged o adop new sraegies ha would enhance produciviy performance of hese hospials. Our sudy suggess ha fuure sudies and naural exension of his work would be o deermine he causes of decline in he echnological change which led o he deerioraion of he overall produciviy of he voluneering agency hospials in Tanzania. References Biorn, E., Hagen, TP., Iversen,T and Magnussen, J (2003) The effec of Aciviy based financing on Hospial efficiency: A panel Daa analysis of DEA efficiency scores , Healhcare Managemen Science, 6 pp Burgess, JF and Wilson, PW (995) Decomposing hospials produciviy changes : A non Parameric Malmquis Approach. The journal of produciviy analysis, 6 pp Caves D,W., Crisensen, L R and Diewer, WE (982) The economic heory of index numbers and he measuremen of inpus, oupus and produciviy, Economerica, 50; pp Chowdhury, H., Zelenyuk, V., Wodchis, W and Lapore, A (20) Efficiency and Technological in Healh Care Services in Onario. An applicaion of he Malmquis Produciviy Index wih boosrapping, Inernaional Journal of Produciviy and Performance Managemen, Vol 60, No 7, pp Coelli, TJ., Prasada, RD., O donnel, CJ and Baese, GE (2005) An inroducion o efficiency and Produciviy analysis 2 nd ed, Springer, Berlin Emrouznejad Ali.,Parker Barne, R and Tevares Gabriel (2008) Evaluaion of research in efficiency and produciviy. A survey and analysis of he firs 30 years of scholarly lieraures in DEA, Socio Economics planning science 42 pp 5-57 Färe, RS. Grosskopf and Lovel (994) Producion Fronier, Cambridge, Cambridge Universiy Press. Fare, RS., Grosskopf, S.,Morris, M and Zhang, Z(994) Produciviy growh, echnical progress and efficiency change in indusrialized counries. American economic review 84, pp Färe,R.S., Grosskopf,S., Lindgren B, Roos, P(994a) Produciviy developmen in Swedish hospials: a Malmquis oupu index approach, in Charnes,A., Cooper,W.W., Lewin,A.Y and Seiford,M.L(eds)Daa Envelopemen Analysis: Theory, Mehodology and Applicaions, Boson, Kluwer Academic Publishers; Ferrier, G and Vivian, V (2008) efficiency and produciviy changes in larger urban hospials : Ownership, Marke and he Uninsured, In: Advanced in healh economics and healh services research Vol.8: Evaluaing hospials policy and performance; conribuion from he hospials policy and produciviy research Edied by Blank, Jos LT nd Valdamanis, Vivian, G. Gaoufi Said, Oral Muhiin, Reisman Arnold (2004b) A axonomy for daa envelopmen analysis, Socio Economic planning Sciences 38;

9 Inernaional Journal of Financial Economics Gaoufi Said, Oral Muhiin, Reisman Arnold (2004c) Daa Envelopmen Analysis lieraure: a bibliography updaes (95 200) Socio Economic planning Sciences 38; pp Gonzalez, LB and Barber, PP (996) s in he efficiency of spain public hospials afer he inroducion of programs-conrac. Invesigaions Economic as, 20 pp Grosskopf, S., M argaries, D and Valdamanis, V(2004) Compeiive effecs on eaching hospials. European Journal of operaional research 54, pp55 27 Hollingsworh, B (2003) Non Parameric and Parameric Applicaions Measuring Efficiency in Healh care, Healhcare managemen Science, Vol 6, No 4, pp203 8 Linna, M (998) Measuring he hospials cos efficiency wih panel daa models, Healh Economics pp Lobo, MS., Ozcan, YA., Silva, AC., Lins, MP and Fizman, R (200) Financing reforms and Produciviy change in Brazilian Teaching Hospials: Malmquis Approach, Cenral European, Journal of operaion research 8 (2) pp4-52 Luoma, K and Jarvio Maija-Liisa (2000) Produciviy change in finish healh ceners in , A Malmquis Index approach, VATT- Discussion paper Malmquis, S (953) Index numbers and indeffences surfaces, Trabajos de Esaisics 4, pp Ozcan, YA and Luke, R (200) Healh care Delivery Resrucuring and produciviy changes: Assessing he veerans inergraed services nework (VISNs) Using he Malmquis Approach, Medical Care Research and Review 20 (0) pp-6 Ozgen, H and Ozcan, YA (2004) Longiudinal Analysis of Efficiency in Muliple Oupus Dialysis markes, Healhcare managemen science 7, pp Pharm, L.T(200) Efficiency and produciviy of hospials in Vienam, Journal of healh organizaion and managemen, Vol 25 No 2, pp95-23 Sahin I., Ozcan, YA and Ozgen, H (2009) Assessmen of hospials efficiency under he healh ransformaion program in Turkey. Cenral European journal of operaional research, December Seiford Lawrence M (997) A bibliography for Daa Envelopemen analysis ( ) Analysis of operaional research, 73 pp Thrall, RM(2000) measures in DEA wih an applicaion o he Malmquis Index, Journal of Produciviy analysis 3, pp25-37 Wang, B., Ozcan YA.,Wan, TT and Harrison J (999). Trend in Hospials efficiency among Meropolian markes, Journal of medical sysems 23(2): Zere, E., Addison,T and Mc Inyre,D (2000) Hospial Efficiency In Sub Saharan African. Evidence from Souh Africa. Souh Africa Journal of Economics 69 (2);

10 Hospials K. M. Bwana Appendix : Malmquis Index Summary of Hospials Means Technical in Technological Efficiency Pure-Technical Efficiency (TECHCH) (EFFCH) (PECH) in Scale- Efficiency (SECH) Toal Facor Produciviy (TFPCH) Bukumbi Hosp Iambi Hosp Igongwe Hosp Ilembula Hosp Lugalawa Hosp Luembo Hosp Marangu Hosp Mbesa Mission Mbozi Mission Mkula Hosp Ndolage Hosp Nkinga Hosp Nkoaranga Hosp ST.Bernedic Uhai Bapis mean EffCH<=07 EffCH==02 EffCH>=06 TeffCH<=4 TeffCH==00 TeffCH<=0 PeffCH<=03 PeffCH==06 PeffCH>=06 SeffCH<=06 SeffCH==02 SeffCH>=07 TfpCH<= TfpCH==0 TfpCH>=03 26