Advancing universal health coverage in the COVID-19 era: an assessment of public health services technical efficiency and applied cost allocation in Cambodia

Abstract

Background Achieving universal health coverage (UHC) is a global priority and a keystone element of the 2030 Sustainable Development Goals. However, COVID-19 is causing serious impacts on tax revenue and many countries are facing constraints to new investment in health. To advance UHC progress, countries can also focus on improving health system technical efficiency to maximize the service outputs given the current health financing levels. Methods This study assesses Cambodia’s public health services technical efficiency, unit costs, and utilization rates to quantify the extent to which current health financing can accommodate the expansion of social health protection coverage. This study employs Data Envelopment Analysis (DEA), truncated regression, and pioneers the application of DEA Aumann-Shapley applied cost allocation to the health sector, enabling unit cost estimation for the major social health insurance payment categories. Results Overall, for the public health system to be fully efficient output would need to increase by 34 and 73% for hospitals and health centers, respectively. We find public sector service quality, private sector providers, and non-discretionary financing to be statistically significant factors affecting technical efficiency. We estimate there is potential supply-side ‘service space’ to expand population coverage to an additional 4.69 million social health insurance beneficiaries with existing financing if the public health system were fully efficient. Conclusions Public health service efficiency in Cambodia can be improved by increasing utilization of cost-effective services. This can be achieved by enrolling more beneficiaries into the social health insurance schemes with current supply-side financing levels. Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary health financing, and incentivizing a referral system.

Health systems efficiency in China and ASEAN, 2015–2020: a DEA-Tobit and SFA analysis application

“…Therefore, it is important for China and ASEAN countries to better health inputs usage and allocate the health resources, especially the public health funds appropriately and effectively so as to ensure the accountability and transparency of public health expenditure. Besides, all countries need to improve health technology, and take full account of health quality,56 population development, economic development and demand for medical services and other factors according to their actual conditions 29…”

“…A study targeted the healthcare system efficiency in Lebanon showed that health system efficiency has improved after the health system reform 28. Robert Kolesar et al assessed the technical efficiency of Cambodia’s public health services in the COVID-19 era and made suggestions to increase the efficiency 29. The overall efficiency of the health system in Malaysia during COVID-19 proved to be high from its response and one of the essential success factors is to allocate the health resources according to the population density 30.…”

“… 28 Robert Kolesar et al assessed the technical efficiency of Cambodia’s public health services in the COVID-19 era and made suggestions to increase the efficiency. 29 The overall efficiency of the health system in Malaysia during COVID-19 proved to be high from its response and one of the essential success factors is to allocate the health resources according to the population density. 30 Studies about the health system efficiency in China and some provinces in China also exhibited the need to increase the usage efficiency of health resources.…”

Progress towards health equity in Vietnam: evidence from nationwide official health statistics, 2010-2020

“…As the Deputy Director of the Ministry of Health’s Department of Planning and Finance noted, ‘Vietnam has strongly emphasized the importance of equity in health with a series of pro-poor health policies, seeking to achieve small gaps in health outcomes between the poor and better off’ 11. Vietnam’s pro-poor policies and measures have played an important role in reducing the economic burden on patients and reduced catastrophic health expenditures 12 13. One of the most commendable policies targeting the poor is Vietnam’s social health insurance (SHI) programme.…”

Cambodia

“…Efficiency issues. On technical efficiency (cost effectiveness), it has been estimated that Cambodia's public hospitals and health centers can achieve higher service output (e.g., outpatient/inpatient case, major/minor surgery, and maternity care) by 34 and 73 percent respectively with current level of resources (Kolesar et al, 2022). On allocative efficiency, resources are concentrated in urban areas, while rural areas with higher maternal mortality rates remain underfunded (Masaki et al, 2021).…”