Efficiency of Primary Health Services in the Greek Public Sector: Evidence from Bootstrapped DEA/FDH Estimators

Abstract

Strengthening primary healthcare (PHC) is vital for enhancing efficiency and improving access, clinical outcomes, and population well-being. The World Health Organization emphasizes the role of effective PHC in reducing healthcare costs and boosting productivity. With growing healthcare demands and limited resources, efficient management is critical. Background/Objectives: Building on this point, this study aimed to evaluate the efficiency of PHC units across Greece, focusing on Health Centers (HCs) and Local Health Units (ToMYs). The objective was to assess their efficiency levels and identify factors contributing to observed inefficiencies. This study explores a novel research area by being the first to assess the efficiency of restructured primary healthcare facilities in Greece, utilizing 2019 data—the first year operational data became available for the newly established ToMY facilities following recent healthcare reforms. Methods: We applied a comprehensive suite of non-parametric methods, including Data Envelopment Analysis (DEA) under variable, constant, increasing, and decreasing returns to scale (VRS, CRS, IRS/NDRS, DRS/NIRS) assumptions, along with the Free Disposal Hull (FDH) model, all oriented toward output maximization. Efficiency scores were refined using bootstrapping to calculate 95% confidence intervals, and efficient units were ranked via the super-efficiency model. Outliers were identified and removed through the data cloud algorithm. For the first time at this scale, the final sample included the vast majority of PHC facilities in Greece—234 Health Centers and 94 Local Health Units—with inputs categorized into three human resource types: medical, nursing/paramedical, and administrative/other staff. Outputs encompassed scheduled visits, emergency visits, and pharmaceutical prescription visits. This diverse and comprehensive application of DEA methods represents a novel approach to evaluating PHC efficiency in Greece, with potential relevance to broader healthcare contexts. Results: The analysis revealed significant inefficiencies and differences in technical efficiency between HCs and ToMYs. HCs could nearly double their outputs (VRS score: 1.92), while ToMYs could increase theirs by 58% (VRS score: 1.58). Scale efficiency scores were closer, with HCs slightly more aligned with their optimal scale (1.17 vs. 1.20 for ToMYs). Conclusions: There is significant potential to improve efficiency in PHC, with variations depending on unit characteristics and regional differences. This evaluation provides a foundation for policymakers to identify areas for improvement and enhance the overall performance of healthcare services in Greece.