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Assessing the efficiency of countries in making progress towards universal health coverage: a data envelopment analysis of 172 countries
  1. Emma Jordi1,
  2. Caitlin Pley2,
  3. Matthew Jowett3,
  4. Gerard Joseph Abou Jaoude1,
  5. Hassan Haghparast-Bidgoli1
  1. 1Institute for Global Health, University College London, London, UK
  2. 2School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
  3. 3Health Financing and Governance, World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Hassan Haghparast-Bidgoli; h.haghparast-bidgoli{at}


Introduction Maximising efficiency of resources is critical to progressing towards universal health coverage (UHC) and the sustainable development goal (SDG) for health. This study estimates the technical efficiency of national health spending in progressing towards UHC, and the environmental factors associated with efficient UHC service provision.

Methods A two-stage efficiency analysis using Simar and Wilson’s double bootstrap data envelopment analysis investigates how efficiently countries convert health spending into UHC outputs (measured by service coverage and financial risk protection) for 172 countries. We use World Bank and WHO data from 2015. Thereafter, the environmental factors associated with efficient progress towards UHC goals are identified.

Results The mean bias-corrected technical efficiency score across 172 countries is 85.7% (68.9% for low-income and 95.5% for high-income countries). High-achieving middle-income and low-income countries such as El Salvador, Colombia, Rwanda and Malawi demonstrate that peer-relative efficiency can be attained at all incomes. Governance capacity, income and education are significantly associated with efficiency. Sensitivity analysis suggests that results are robust to changes.

Conclusion We provide a 2015 baseline for cross-country UHC technical efficiency scores. If countries wish to improve their UHC outputs within existing budgets, they should identify their current efficiency and try to emulate more efficient peers. Policy-makers should focus on strengthening institutions and implementing known best practices to replicate efficient systems. Using resources more efficiently is likely to positively impact UHC coverage goals and health outcomes, and without addressing gaps in efficiency progress towards achieving the SDGs will be impeded.

  • health economics
  • health systems
  • health systems evaluation
  • other study design

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  • Handling editor Lei Si

  • Contributors HH-B and EJ conceptualised the study. EJ collected and collated the data, carried out the analysis and wrote the first draft of the paper. HH-B, CP, MJ and GJAJ contributed to the interpretation of the results and contributed to the final written version of the paper. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are publicly available from the WHO Global Health Observatory database, and may be shared directly upon request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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