نزدیک سازی مدیریت واحدهای بیمارستانی به روش تحقیق در عملیات: مورد 32 واحد دولتی زنان و زایمان یونانی

Controlling healthcare costs is a multifaceted problem for governments all over the world, as they have the difficult task of ensuring that patients receive high quality care, and that this is delivered as efficiently as possible. Through the use of quantitative analysis, an attempt is made to determine the areas of activity of 32 Greek Public Obstetrical and Gynaecological Units which present problems with regard to their performance. Based on the results that emerge from the application of Data Envelopment Analysis in the 32 hospital units of the sample, information is provided to their managers, which refer to: (i) the degree of utilization of their production factors, (ii) the particular weight of each factor of production in the formation of the relative efficiency score, (iii) the utilization level of each factor of production, and (iv) those hospital units that utilize their factors of production in an optimal way and constitute models for the exercising of effective management. The derived information assists in the formulation of an appropriate policy mix per hospital unit which should be applied by their management teams along with a set of administrative measures that need to be undertaken in order to promote efficiency.

The Greek health care system is characterized by the coexistence of the National Health Service (NHS), a compulsory social insurance and a voluntary private health insurance system [1]. The NHS provides universal coverage to the population operating on the principles of equity, social cohesion and equal access to health services for all. Under this context, citizens are not directly dependent on a specific healthcare institution. On the other hand, they are free to choose amongst a variety of healthcare units depending on the type of treatment they wish to follow. It should be pointed out that the Greek Ministry of Health decides on the overall national health strategy and the relative health policy issues within Greek healthcare organizations. Its main responsibilities, amongst all, are the definition of priorities, the approval and extension of funding for proposed activities and the resource allocation at a national level. With the latest reforms, the main objectives were the decentralization of the system with the establishment of 17 Regional Health Authorities. Decentralization efforts devolved political and operational authority to Regional Health Authorities but were only partially fulfilled [2]. Decision making and all administrative procedures continued to depend on a very centralized and bureaucratic Ministry of Health [2]. The consequences of this fragmentation, combined with the lack of a monitoring system had an impact on the extent and quality of services provided to beneficiaries of different funds, leading to over-consumption of services and serious socioeconomic health inequalities [3]. Moreover, Greek public hospital units operate within a framework characterized by limited economic resources, a restricted number of beds and a geographically unequal distribution of both personnel and patients [2] and [4]. There are wide discrepancies between the number of hospitals and number of hospital beds allocated in different regions [2] and a wide variation between the distribution of resources in urban and rural areas [5]. For example, in the greater Athens area in 2000 there were 6.4 hospital beds per 1000 population while the corresponding ratio in Central Greece was 1.2 beds per 1000 population [2]. These characteristics are more vivid in the provision of health care services in obstetrical and gynaecological (O&G) cases than in others [6] and [7] and are attributable to demographic and national factors. The lack of gynaecologists/obstetricians together with the limited experience of the serving staff on obstetric issues in rural areas, pose difficulties in the routine follow-up of pregnant women [7] and [8]. As a consequence, women choose to seek health services and even follow-up examinations at tertiary hospitals in Athens [8]. Under this context, hospital O&G management staff is expected to perform an optimal utilization of resources in terms of quantity and quality of offered services. In other words, managers are expected to achieve efficiency despite the fact that reality imposes certain, well-known limitations. Under these circumstances, the use of quantitative methods can provide the management staff useful information concerning: (1) the evaluation of the efficiency score regarding the utilization of the available production factors; (2) the contribution of every productive factor used and of the health services provided (outputs) in the formation of the efficiency score; (3) the policy mixture, that is, the combination of inputs and outputs, which must be applied to improve the degree of utilization of the production factors; (4) the “prototype—models of best practice” hospital units which constitute “models to be emulated” in managing the other hospital units. This information, when complete, assures the improvement of efficiency and quality when combined with the managers’ ability to make analogous with reality, the needs of the receivers of health services and the producers of health services. The objective of the current study is two-fold. Primarily, to estimate the relative technical efficiency by using a sample from public hospital units that provide obstetrical and gynaecological services in Greece. Secondly, to emphasize the policy implications for health sector policy-makers. These implications can trigger the associated policy-makers in order to conduct a national efficiency study amongst all healthcare organizations in Greece. The present paper is organized as follows. Section 2 below describes the materials and methods used. This section includes a thorough discussion on the data sources, the Data Envelopment Analysis approach and the inputs and outputs of the study. In addition, the selection strategy for the appropriate sample is presented in conjunction with a discussion for the analysis plan of the study. Continuously, Section 3 provides an outline of the results obtained along with their interpretation. Section 4 is then presenting a discussion on the overall study and its outcomes whereas the last section, Section 5, provides a summary and conclusion remarks.

The research aim of this paper was to primarily estimate the relative technical efficiency by using a sample from public hospital units that provide obstetrical and gynaecological services in Greece and secondly, to emphasize the policy implications for health sector policy-makers. In order to effectively address the above goals, a comparative analysis of 32 Greek Public Hospital Units with obstetrical and gynaecological services was conducted. The research was based on data collected from official public sources [3], [5], [9], [10], [11], [12] and [13]. From an analysis of the evaluation of the utilization of the production factors of these 32 Greek Public Hospital Units of the Central and Outlying regions, using the DEA method, the following emerged: (i) The areas were noted which must be reorganized in order to increase the efficiency of the functioning of the hospital units. (ii) Estimates were made of the breadth of the interventions which must be made by the administrations of the hospitals. (iii) It was ascertained that both the problems and their breadth differ between the hospital units of the central region and those of the outlying regions and as a consequence, the administrative measures to be taken also differ. (iv) The “model” hospital units that should be emulated as well as the production factors which contribute to the creation of these models were identified. These results give an overall picture of the benefits. Inevitably to implement changes it is necessary for policy and decision makers to know exactly which units need changes and the magnitude of these changes. With respect to this DEA is a powerful tool as it provides information about the efficiency of individual units taking into consideration multiple-inputs and multiple-outputs. It can thus enable decision makers to know exactly which inputs (beds or staff), need to be increased or decreased in an individual unit to maximise efficiency and cost savings. Inevitably, the reliability and validity of the DEA results are vital if decisions are to be made based on these, and further work may be required to establish their accuracy. However, even if the predictions from DEA are not completely accurate, DEA will still almost certainly indicate which areas could be targeted to improve use of resources and to maximise efficiency. Consequently, the following benefits should be achieved to a large extent by implementing changes: • Prevention of unnecessary journeys by female patients. • Better geographical distribution of O&G cases. • More efficient use of resources in rural areas. • Increased provision of services in rural areas. • Information indicating which resources should be targeted to improve efficiency maximise resources and provide more equitable care. DEA results can help administrators by providing new insights on the distribution of health resources to individual hospital units. The present study provides valuable information regarding deployment of medical staff and beds, the utilization of financial resources and the deployment of medical supplies and equipment. Resource planning and the identification of the needs of O&G units are greatly aided by the availability of up-to-date DEA results. Briefly, all of the above are believed to constitute useful information for the managers of the hospital units, which will assist them in making decision that will lead to the more effective operation of the units. Over and above these measures, which fall into the competencies and responsibilities of the managers of the hospital units, the possibility for comparison between these units facilitates monitoring by those in charge while at the same time it contributes to the creation of a spirit of rivalry and competition with each other. Finally, the differences in the evaluations between the hospitals of the central region and of those of the outlying regions underline the necessity for the geographic redistribution of the cases. Underline, also, the necessity to investigate the reasons that patients prefer the central Attica hospitals, considering that are reputed to be better. Marketing campaigns and regulation to create barriers to movement of non-local patients into the centrally located hospitals are issues for further research. Social marketing is an approach to changing behaviour and thus improving public health. It could help to facilitate this critical review, the object of which would be to isolate those approaches that really do enable individuals and communities to gain greater control over their health and the quality of their lives [37]. Nevertheless, the redistribution is assumed to be achieved through the implementation of Information and Communication Technologies (ICT). This can be used not only to store and transfer patient information but also to improve decision making, to improve institutional efficiency, to promote better health behaviour, and to enhance more rational management of resources [38], [39], [40] and [41]. The essence of telemedicine lies in transferring expertise and not the patient [39]. This enables the needs and demands of healthcare to be met across large distances and is an important means for achieving geographical redistribution of resources and thus this would facilitate the taking of more effective measures at the management level of the units. Telemedicine allows local services to be provided to patients wherever and whenever it is possible, eliminating unnecessary journeys for patients. The feasibility of the introduction of such a national system of telemedicine and its impact on the efficiency of hospital units of the central and outlying regions is an issue which requires further research.