BMC Health Serv Res. 2025 Oct 8;25(1):1324. doi: 10.1186/s12913-025-13119-4.
ABSTRACT
BACKGROUND: Efficiency in healthcare delivery is crucial for maximizing resource utilization and achieving broader health system objectives, particularly in resource-constrained settings like hard-to-reach (HTR) areas in Bangladesh. Despite people facing barriers in these areas in accessing health services, health facilities have not undergone comparative efficiency evaluations with facilities in non-hard-to-reach (non-HTR) areas.
OBJECTIVES: This study aims to comparatively assess the technical efficiency of secondary-level hospitals, as well as identify the factors contributing to inefficiencies in both HTR and non-HTR regions.
METHODS: Data for 62 secondary level hospitals (30 located in HTR and 32 located in non-HTR areas) for the year 2022 were collected from the Local Health Bulletin of the Directorate General of Health Services in Bangladesh. Geographic locations with specific characteristics, such as wetland, coastal, river island, and hilly areas, were categorized as HTR areas, using the Water and Sanitation Program report published by the World Bank in 2012. Initially, data envelopment analysis was employed with output orientation to calculate the efficiency scores using inputs (e.g., number of physicians, nurses and hospital beds) and health service outputs (e.g., maternal care, outpatient visits and inpatient admission) under both constant and variable returns to scale assumptions. Then multiple Tobit regression models were conducted to determine the associations between hospital inefficiency and HTR area characteristics.
RESULTS: The findings revealed that, on average, secondary level hospitals were 73% and 80% efficient in terms of constant returns to scale (CRS) and variable returns to scale (VRS) assumptions, respectively. Hospitals located in HTR regions were relatively less technically efficient (efficiency score = 0.76) than those in non-HTR areas (efficiency score = 0.84), and the differences were statistically significant (p-value < 0.10) when the VRS assumption was used. Similar significant differences in efficiency scores (efficiency score was 0.68 in HTR and 0.77 in non-HTR areas) were observed between these two groups of hospitals when CRS assumption was used (p-value < 0.10). According to multiple Tobit regression, the positive coefficient (Coeff = 0.258, p-value < 0.05) of the association between inefficiency scores and HTR areas implies that hospitals in HTR regions had lower efficiency scores than hospitals in non-HTR regions. Comparable patterns were identified in two additional models using characteristics of geographical locations of the hospitals. Findings revealed that hospitals located in wetland (Coeff = 0.295; p < 0.05), river island (Coeff = 0.372; p < 0.05), and hilly areas (Coeff = 0.422; p < 0.05) exhibited lower technical efficiency compared to those in plain land areas under the CRS assumption. Furthermore, the negative coefficients under CRS (Coeff = -0.004) and VRS (Coeff = -0.003) reflecting a negative association between the bed occupancy ratio (BOR) and inefficiency scores across all models. This suggests that higher BOR levels were associated with greater efficiency (p < 0.01). Results from sensitivity analysis observed no substantial differences in coefficients with the relationship between HTR characteristics and efficiency scores of the hospitals.
CONCLUSION: Hospitals in HTR regions are found to be less technically efficient than non-HTR regions in Bangladesh. Policymakers should address the underlying causes of inefficiencies, implement targeted interventions such as improving healthcare access for vulnerable populations residing in HTR regions, optimize bed occupancy rates and reduce length of stays with proper referral systems and discharge planning in these particular areas. This indicates that further research on health systems in climate-vulnerable areas in Bangladesh should be prioritized to effectively address these challenges.
PMID:41063170 | DOI:10.1186/s12913-025-13119-4
