Health Policy and Technology 9 (2020) 335–347

Contents lists available at ScienceDirect

Health Policy and Technology

journal homepage: www.elsevier.com/locate/hlpt

Technical efficiency in health production: A comparison between Iran

and other upper middle-income countries
Efat Mohamadi a, Alireza Olyaee Manesh a,b,∗, Amirhossein Takian a,c,d,∗, Reza Majdzadeh b,e,f,
Farhad Hosseinzadeh Lotfi g, Hamid Sharafi g, Matthew Jowett h, Mohammad Mehdi Kiani a,c,
Leila Hosseini Qavam Abadi a,i, Ali akbar Fazaeli c, Zahra Goodarzi b, Haniye Sadat Sajadi j,
Somayeh Noori Hekmat k, Leila Freidoony c
a
Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran
b
National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
c
Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
d
Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
e
Community Based Participatory Research Centre, Tehran University of Medical Sciences
f
Knowledge Utilization Research Centre, Tehran University of Medical Sciences
g
Department of Mathematics, Science and Research Branch, Islamic Azad University, Tehran, Iran
h
Health Financing Unit, World Health Organization, Geneva, Switzerland
i
Department of Health Care Management, Sciences and Research Branch, Islamic Azad University, Semnan, Iran
j
Knowledge Utilization Research Center, University Research and Development Center, Tehran University of Medical Sciences, Tehran, Iran
k
Management and Leadership in Medical Education Research Center, Kerman University of Medical Sciences, Kerman, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To achieve sustainable health development, health systems need to constantly enhance their
Available online 6 July 2020 efficiency, through for instance reducing waste of resources. This study aimed to measure the efficiency
in producing health in Upper Middle-Income Countries (UMICs) with a focus on Iran.
Keywords:
Efficiency Method: A modified data envelopment analysis (DEA)-based Malmquist Productivity Index (MPI) was
Productivity used to assess the changes in health productivity. Panel data was extracted from databases of the World
Data Envelopment Analysis (DEA) Health Organization and the World Bank for the period of 2009–2015.
upper middle-income countries (UMICs)
Malmquist Productivity Index (MPI) Results: The efficiency score of 13% of countries was higher than 0.8, while the score of all countries was
above 0.5. The average score of Iran performance was 0.791 during the period. On average, performance
improved in 15 countries, while it declined in 20 countries during the study period.
Conclusion: Different countries have implemented various health reforms to improve efficiency. We en-
visage, policy makers in the UMICs locate their health system performance and plan to improve it in
line with the local specifications, along with the global pathway towards universal health coverage and
sustainable health development ultimately.
© 2020 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.

List of abbreviations GGHE General Governance Health Expenditure

CHE Current Health Expenditure HTP health transformation plan
CV Coefficient of Variation LE life expectancy at birth
DEA Data Envelopment Analysis MPI Malmquist Productivity Index
DMU Decision Making Units OECD Organization for Economic Co-operation and Develop-
FDH Free Disposal Hull ment
GDP Gross Domestic Production OOP Out of Pocket
SD standard deviation
SDH Social Determinants of Health
∗
Corresponding authors.
SFA Stochastic Frontier Analysis
E-mail addresses: arolyaee@gmail.com (A. Olyaee Manesh), takian@tums.ac.ir
(A. Takian), farhad@hosseinzadeh.ir (F. Hosseinzadeh Lotfi), jowettm@who.int (M.
U5 Under-five mortality rate
Jowett). UHC Universal Health Coverage

https://doi.org/10.1016/j.hlpt.2020.06.007
2211-8837/© 2020 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
336 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347
UMICs Upper Middle-Income Countries
WB World Bank
WHO World Health Organization
WHR World Health Report
Background
The need for a sustainable, efficient, and productive health sys-
tem is clear. This is a crucial and ongoing concern for govern-
ments [1] that has led to series of reforms towards improving per-
formance in many countries [2,3]. These include reforms targeted
at various functions of the health system functions, i.e. financing,
stewardship, service delivery, human resource, access to essential
medicines and health information system [4,5].
Many countries are struggling with ever-spiraling healthcare ex-
penditure [6,7]. While the contribution of private and public payer
differs across countries, on average, more than 55% of total health
care expenditure came from public sources during 2009 -2015 in
Upper Middle-Income Countries (UMICs) [1]. Hence, it is essen-
tial to provide a comparative policy learning platform for decision
makers to understand how health systems work around the globe,
and whether investment in the health system would make good
impact on citizens’ health status or there are opportunities to im-
prove cost- effectiveness. One of the practical studies for health
policy makers in these issues is “health system efficiency studies”.
Since Farrell’s major research [8], the number of studies that
used frontier methods for measuring efficiency and productivity
to identify the best-performance production has been increasing.
Frontier methods are classified into nonparametric ones such as
Data Envelopment Analysis (DEA) and Free Disposal Hull (FDH),
as well as parametric ones such as Stochastic Frontier Analysis
(SFA). The use of nonparametric and parametric efficiency meth-
ods in healthcare has been argued in detail [9]. Hollingsworth re-
viewed 317 papers and book chapters published up to mid-2006
and showed that most health efficiency studies used DEA method
to measure efficiency and the most of them focused on analyzing
the efficiency of hospitals and health care centers [10,11].
International evaluation and comparison of health systems’ effi-
ciency, e.g. through the use of World Health Organization (WHO)
and World Bank (WB) data, can provide macro-level efficiency
analyses and good evidence for policy decisions. The World Health
Report (WHR) introduced two types of efficiency: in producing
health and related to composite goal attainment [12]. The values
in producing the composite goal varied between close to 0% (Sierra
Leone) to over 99% (France), while 30 countries estimated to be
producing fewer than 40% of their potential observed level of in-
puts [13,14] (2).
It is of great importance for policymakers and health system re-
searchers in Iran to measure health system efficiency changes over
the past years considering the fact that the health care expendi-
ture has increased during this period [15]. Given the concept of
“efficiency” that is relative, we needed to select bench mark that
were similar in terms of income, health and socioeconomic indi-
cators. Therefore for measuring Iran health system efficiency com-
pare with other countries the best benchmarks were UMICs. To the
best of our knowledge, few studies have been conducted to analyze
the efficiency in producing health in the UMICs [16].
As a part of a bigger national research to measure health sys-
tem efficiency in Iran, this study reports the findings of measur-
ing Iran’s efficiency in producing health in comparison with other
UMICs for a 7-years period (2009-2015). Similar to many coun-
tries, Iran is moving towards Universal Health Coverage(UHC) and
sustainable health development through its comprehensive Health
Transformation Plan (HTP) [17]. Our evidence-based findings and
recommendations may help, we envisage, policy makers in Iran
and other UMICs locate their health system performance and plan
to improve it in line with the local specifications.
Methods
Setting: The Ministry of Health and Medical Education is man-
dated to fulfill the goal of healthy community through design-
ing and implementing a national-level health policy. The Min-
istry delegates its implementation to medical universities across
the 32 provinces in the country. They are in charge of public
health; health care and public health services are provided through
a nation-wide network. The public sector provides primary, sec-
ondary, and tertiary health services. The private sector mainly fo-
cuses on secondary and tertiary health care. Iran has had sev-
eral reforms in health system e.g. establishing health network for
providing Primary Health Care, expanding basic health insurance
across the country and most recently is HTP in the last decade.
Iran health system has made great efforts to improve health indi-
cators over the years [18]. Comparative statistics for Iran vs other
countries were provided in Appendix 2 to prove this.
Type of study: We conducted a quantitative and descriptive-
analytical study to measure the efficiency score, the Malmquist
Productivity Index (MPI) and provided the benchmark for each of
the indicators. The aim of this study was to measure efficiency of
Iran health system in producing health; for this, using homoge-
neous DMUs is one of the limitation of DEA therefore [19], we se-
lected UMICs as benchmarks because the UMICs (Table 1) were the
best match comparing with Iran. We designed our research within
four steps, as described below:
Determining input and output indicators
In this step, we conducted literature review and sought experts’
opinions to identify the input and output indicators. First, we iden-
tified a list of related indicators with respect to the objective of
the study [1,2,20,21]. Then, we examined the existence of data as-
sociated with each indicator and the reliability of the data sources,
which resulted in inclusion and exclusion of some indicators. Fi-
nally, the included indicators were reviewed and approved by an
expert panel, comprising of the research team plus selected key in-
formants in the field of heath management, policy and economics.
The panel participators discussed about definition of “producing
health” and the proxies. Then, participants scored indicators based
on importance and necessity of each indicator in line with the pur-
pose of the study and its importance for policy makers. We ana-
lyzed expert opinion with Excel software and finalized the indica-
tors to be included in the research (Appendix 1).
Data collection and cleaning
We began data collection in our two main identified resources
(WHO and WB). We designed an Excel sheet checklist based on
the indicators and the time of studies and entered the UMICs’
data there as Decision Making Units (DMU) (Appendix 1). We then
cleaned up the data considering the existence and accuracy of all
data for each indicator for each DMU during the study years. Ir-
regular data was compared with other sources, after ensuring the
integrity of the number, the correct number was replaced. Because
of the limited number of input and output indicators, if a DMU
did not have data for one of the indicators in one year (or years),
it was excluded from the study. In addition, countries with pop-
ulation below 1,0 0 0,0 0 0, were excluded. This phase lasted four
months.
 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347 337

Table 1
The UMICs and Iran, DMU classification.

DMU Country DMU Country DMU Country

DMU1 Albania DMU13 Dominican Republic DMU25 Namibia

DMU2 Algeria DMU14 Ecuador DMU26 Panama
DMU3 Argentina DMU15 Gabon DMU27 Paraguay
DMU4 Azerbaijan DMU16 Iran DMU28 Peru
DMU5 Belarus DMU17 Iraq DMU29 Romania
DMU6 Bosnia and Herzegovina DMU18 Jamaica DMU30 Russian Federation
DMU7 Botswana DMU19 Kazakhstan DMU31 Serbia
DMU8 Brazil DMU20 Lebanon DMU32 South Africa
DMU9 Bulgaria DMU21 Macedonia, FYR DMU33 Thailand
DMU10 China DMU22 Malaysia DMU34 Turkey
DMU11 Colombia DMU23 Mauritius DMU35 Turkmenistan
DMU12 Costa Rica DMU24 Mexico DMU36 Venezuela (Bolivarian Republic)

Table 2 this case, the difference in values is an undesirable output that was
Inputs and outputs.
applied in the model with the following modifications:
SYMBOL Output symbol Input
y˜1 j = 83.7 − y1 j
y1j LE x1j CHE
K1 = max{y˜1 j : j = 1, ..., n} + ε
y2j U.5
y3j General Government Health
Expenditure (GGHE) as CHE
New y1 j = −y˜1 j + K1
εis a small positive number.
For the second output which signifies the U5 mortality rate,
Data analysis the less value, to whatever extent, is the better, as an undesirable
output. Based on the best performance of countries as explained
We began with the panel of experts (including members and in the previous section, the value 2.8 was used as a standard in
advisors of the research team) to determine the standard and this index. The more the U5 mortality of countries was within the
weight for each indicator, by taking into account the relative im- proximity of this indicator, the better it was. For this purpose, the
portance of each indicator, so its influence on the efficiency score differences in values of the U5 mortality of countries were com-
could be measured [22]. puted with 2.8 as follows:
To determine the standard of Current Health Expenditure (CHE),
y˜2 j = y2 j − 2.8
countries with an Out of Pocket (OOP) payment of less than 20%
K2 = max{y˜2 j : j = 1, ..., n} + ε
in 2015 (target set for Universal Health Coverage (UHC) [23]) were
listed. Then, the median of the CHE indicator in those countries New y2 j = K2 − y˜2 j
was determined as standard, regarding the scattered data. The To define each of the input and output indicators, we con-
standard rates of other indicators, namely life expectancy at birth sidered the following constraints. Since the third output is ex-
(LE) and Under-five mortality rate (U5) were considered to be the pressed as a "percentage", its value should always be scalar, be-
best performance indicators [24] (Appendix 1). tween [0,100]. Therefore, the following constraint was added to
CCR Model:
Modeling

36 
2
0≤ λ j y3 j + γ j β3 j ≤ 100 (1)
We considered each country as a DMU in a set of UMICs (36 j=1 j=1
countries). The collection is intended as follows:
      To adjust the input, knowing that the minimum CHE was 1636
X1 X2 X36 US$, the following constraints was added to the model:
, , ...,
Y1 Y2 Y36

36
In the DMU column, No. 16 relates to Iran. This evaluation is λ j x1 j ≥ 1636 (2)
based on a seven-year data from 2009 to 2015 (Table 1). j=1
The inputs and outputs for each country have been rendered in
Table 2. For the three outputs considered for assessment in this study,
According to best practice as standard that we mentioned the experts’ opinions led us impose the following constraints on
above, the minimum of CHE by government in each country was the model for comparing these outputs:
1636 US$. For countries that the index was below the minimum
5.5
standard, a penalty was imposed as per the modeling below: u1 ≥ u2
 3.5
(3)
CHE , CHE ≥ 1636 3.5
Cost in the mode l = u2 ≥ u3
1636 + (1636 − CHE ) , CHE < 1636 1
We considered the amount of deficits from the minimum cost We selected indicators and set constraints as mentioned in the
as a penalty for each country. If the CHE of a country was less first stage. The constraint (3) signifies the fact that the magnitude
than 1636 US$, the CHE was considered as follows in the modeling of the first output relative to the second output is at least 1.57
process: times bigger. In the same manner, the second output relative to
The New CHE = 2x (1636) – the old CHE the third output is at least 3.5 times more important.
The LE Index has a standard value of 83.7 that is the maximum According to the aforementioned description, the CCR-
amount amongst countries, which was considered as an outlet. In envelopment input-oriented form to compute the relative effi-
338 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347

ciency of DMUp is given hereunder: The average of LE in UMICs was 72.7 years with a standard de-
viation (SD) of 5.6 and a range of 23.91, while LE in Iran was 74.7
Min θ
during the study period.

36
s.t. λ j x1 j ≤ θ x1 p , The U5 mortality indicator in Iran was also better than the av-
j=1 erage of other UMICs countries in 2015 (15.7 vs. 19.5). The range

36 
2 of GGHE as CHE is very variable in the studied countries with a
λ j yr j + γ j βr j ≥ yr p , r = 1, ..., 3, coefficient of variation (CV) of 0.26 (SD 14.6) in 2009. The rate of
j=1 j=1
this index in Iran (36.7 in 2009) was lower than the average of

36
λ j x1 j ≥ 1636, countries (55.3 in 2009). In 2015, this indicator was closer to the
j=1 (4) average of countries (Appendix 2).

36 
2
λ j y3 j + γ j β3 j ≤ 100, Efficiency scores
j=1 j=1


36 
2
λ j y3 j + γ j β3 j ≥ 0, According to the findings, 4 (11.11%) of 36 UMICs were found
j=1 j=1 to be efficient (E>0.9) in producing health. The efficiency of 13%
λ j ≥ 0, j = 1, ..., 36, of countries was higher than 0.8 and 100% of countries had effi-
γ j ≥ 0, j = 1, 2. ciency score above 0.5 (Table 3). The highest performance (score
1) in the studied years was for Costa Rica. The lowest performance
Where (λ∗ , γ ∗ , θ ∗ ) is the optimal response to model (4), in which score belongs to Gabon (0.578) (Table 4). Iran performance score in
the coordinates of DMUp target point were obtained from the fol- these years (average of 0.791) was higher than the average of the
lowing: UMICs’ efficiency (0.7) (Fig. 1). Among the 36 countries compared,

36 Iran ranked 12th in the performance score (Table 4).
x̄1P = λ∗ j x1 j .out put benchmark#1DMU p (5)
j=1 MPI -total factor efficiency change


36 
2 Tables 5 and 6 show MPI for UMIC countries between 2009 and
ȳ1P = λ∗ j yr j + γ ∗ j βr j + 83.7 − K1 , 2015. MI indicates the changes in efficiency over the years studied.
j=1 j=1 On average, 33.3% of countries had an improvement in efficiency
out put benchmark #1DMU p (6) score, 1.4% did not change, and 56.9% had a regression (Table 5).
Accordingly, the highest progress in the performance score was
for Azerbaijan from 2014 to 2015 (1.092) and the lowest rate was

36 
2
for Lebanon between 2011 and 2012 (0.823). Iran performance
ȳ2P = −( λ∗ j yr j + γ ∗ j βr j ) + K2 + 2.8, score also improved from 2013 to 2014 (1.056) (Table 6).
j=1 j=1

out put benchmark#2DMU p (7) Benchmark of efficiency in producing health

.36
 
2
ȳ3P = λ∗ j yr j + γ ∗ j βr j ,
j=1 j=1
r = 1, ..., s. out put benchmark #3 DMU p
In order to calculate the progressive and regressive aspects of
each country on the basis of efficiency or performance, the MPI
was computed. “The MPI calculates the relative performance of a
DMU at different periods of time using the technology of a base
period” [25]. The MPI is a bilateral index that can be used to com-
pare the production technology of DMUs. It is named after Profes-
sor Sten Malmquist, on whose ideas it is based. It is also called the
Malmquist Productivity Index. The MI is based on the concept of
the Production function. This is a function of maximum possible
production, with respect to a set of inputs and outputs [26].
This index is derived from the comparison of efficiency changes
(Catch-up) to Frontier-shift [27]. The value 1 indicates that there
has been no change in the efficiency score. Values higher than 1
represent progress in efficiency and values lower than 1 represent
a decrease in the efficiency score.
Data were analyzed using GAMS software 24.3.
Results
Input and output indicators
Our results showed that the CHE per capita in Iran in 2009
(1088) was higher than the average of UMICs (745). In all stud-
ied years, the value of this indicator in Iran was higher than the
average of all countries.
Table 7 shows benchmarks for achieving the highest efficiency
scores. These benchmarks were based on the performance of coun-
tries with the highest scores. It suggests that how much change
needs to be made for each indicator to improve the efficiency level.
(8) Considering to determine “Standards” for each indicators, for some
of these the same values are suggested (see the Modeling section).
Based on these finding, to achieve a performance score of 1 in
2015, Iran should have increased the per capita CHE to 1636 US$,
the LE to 75.73, and GGHE as CHE ratio to 66.857 (Table 7), while
decreasing the U5 mortality rate to 15.7.
Discussion
The aim of this study was to measure and compare the perfor-
mance of the Iranian health system with the UMICs in terms of
efficient use of resources during the period of seven years (2009-
2015).
Our findings showed that the range of CHE in the UMICs was
926 US$. In 2009, the highest and lowest CHE were observed in
Serbia (1171.5 US$) and China (380.5 US$), respectively. Serbia had
one of the highest CHE over the study years. The average of LE is
72 in the UMICs, showing a 10.2 years difference with Japan, the
leading country with the highest average of life expectancy in the
world. The LE measure in Iran is higher than its average in the
UMICs (LE=74.7).
The relationship between income and life expectancy has been
demonstrated by a number of statistical studies. Studies indicate
that individuals born in wealthier countries, on average, can expect
to live longer than those born in poor countries [28]. The compar-
ison of U5 mortality in the studied countries (Mean: 21.8 deaths
 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347 339

Table 3
Overall results of efficiency.

Years

Summary statistics 2009 2010 2011 2012 2013 2014 2015 Average of period

N 36 36 36 36 36 36 36 36
Max 1 1 1 1 1 1 1 1
Min 0.576 0.564 0.564 0.569 0.577 0.578 0.586 0.578
Average 0.745 0.729 0.715 0.723 0.729 0.743 0.750 0.733
SD 0.110 0.111 0.106 0.101 0.109 0.113 0.110 0.105
Range 0.424 0.436 0.436 0.431 0.423 0.422 0.414 0.422
CV 0.147 0.152 0.149 0.140 0.150 0.152 0.147 0.143
Range of efficiency score (%) 0.1<E<0.2 0 0 0 0 0 0 0 0
0.2<E<0.3 0 0 0 0 0 0 0 0
0.3<E<0.4 0 0 0 0 0 0 0 0
0.4<E<0.5 0 0 0 0 0 0 0 0
0.5<E<0.6 3 4 3 2 3 3 3 2
0.6<E<0.7 11 12 18 17 14 12 9 14
0.7<E<0.8 10 7 5 5 7 9 12 7
0.8<E<0.9 9 10 8 10 9 8 8 9
0.9<E<0.99 1 1 0 1 2 2 2 3
E=1 2 2 2 1 1 1 2 1

Table 4
Technical efficiency score of countries (2009–2015).

Years

Countries 2009 2010 2011 2012 2013 2014 2015 Average of period

Albania 0.731 0.704 0.698 0.733 0.731 0.751 0.708 0.722

Algeria 0.779 0.741 0.72 0.753 0.724 0.755 0.752 0.746
Argentina 0.942 0.933 0.887 0.858 0.887 0.894 0.92 0.903
Azerbaijan 0.663 0.654 0.65 0.673 0.699 0.72 0.786 0.692
Belarus 0.695 0.715 0.655 0.694 0.725 0.719 0.748 0.707
Bosnia and Herzegovina 0.853 0.828 0.809 0.815 0.809 0.821 0.794 0.818
Botswana 0.666 0.658 0.677 0.697 0.679 0.687 0.711 0.682
Brazil 0.831 0.8 0.778 0.799 0.819 0.858 0.87 0.822
Bulgaria 0.775 0.781 0.771 0.8 0.831 0.911 0.919 0.827
China 0.674 0.649 0.632 0.646 0.634 0.632 0.652 0.646
Colombia 0.751 0.721 0.697 0.697 0.678 0.685 0.676 0.701
Costa Rica 1 1 1 1 1 1 1 1.000
Dominican Republic 0.619 0.614 0.622 0.633 0.643 0.662 0.682 0.639
Ecuador 0.712 0.696 0.69 0.732 0.725 0.722 0.714 0.713
Gabon 0.589 0.564 0.571 0.569 0.587 0.579 0.586 0.578
Iran 0.814 0.803 0.788 0.788 0.731 0.798 0.814 0.791
Iraq 0.614 0.57 0.564 0.57 0.577 0.578 0.586 0.580
Jamaica 0.672 0.646 0.615 0.612 0.601 0.584 0.593 0.618
Kazakhstan 0.651 0.659 0.641 0.672 0.673 0.687 0.691 0.668
Lebanon 1 1 1 0.883 0.975 0.944 0.884 0.955
Macedonia, FYR 0.758 0.729 0.682 0.676 0.659 0.67 0.677 0.693
Malaysia 0.728 0.685 0.675 0.68 0.714 0.777 0.792 0.722
Mauritius 0.661 0.647 0.64 0.648 0.673 0.726 0.753 0.678
Mexico 0.853 0.834 0.798 0.806 0.786 0.773 0.758 0.801
Namibia 0.623 0.658 0.675 0.672 0.669 0.669 0.702 0.667
Panama 0.89 0.865 0.835 0.903 0.951 0.998 1 0.920
Paraguay 0.585 0.579 0.591 0.605 0.611 0.632 0.642 0.606
Peru 0.733 0.713 0.662 0.668 0.664 0.67 0.653 0.680
Romania 0.782 0.777 0.717 0.718 0.737 0.735 0.75 0.745
Russian Federation 0.778 0.75 0.775 0.817 0.814 0.847 0.881 0.809
Serbia 0.779 0.797 0.809 0.828 0.856 0.854 0.84 0.823
South Africa 0.757 0.726 0.704 0.729 0.714 0.729 0.749 0.730
Thailand 0.681 0.647 0.623 0.612 0.596 0.608 0.616 0.626
Turkey 0.876 0.852 0.819 0.809 0.798 0.798 0.769 0.817
Turkmenistan 0.576 0.587 0.601 0.611 0.637 0.67 0.721 0.629
Venezuela (Bolivarian Republic of) 0.737 0.657 0.668 0.629 0.622 0.622 0.608 0.649

per 10 0 0 livebirths per year) with the global under-5 mortality
rate in 2015 (40.9 deaths per 10 0 0 livebirths) [29], indicates that
the average of this indicator is better than mean of under-5 deaths
worldwide (21.8 vs. 20). Low rate of U5 mortality has a high effect
on technical efficiency. As results showed, Belarus is a country that
has low U5 mortality and from 2009 to 2015 the score of efficiency
is acceptable. The average ratio of GGHE as CHE in the UMICs was
56.2% over the study period. There was a huge difference between
UMICs in terms of GGHE and Iran’s ratio was less than the total
average. The GGHE as CHE ratio is generally associated with the
overall health policies of countries and their economic infrastruc-
ture, which means that the type of market and the degree of gov-
ernment control (private or public) determine the amount of in-
vestment in the health sector [30].
Iran’s efficiency score was higher than the average score of the
UMICs (0.791 vs. 0.733) during the study period. Among the 36
compared countries, Iran ranked 12th in terms of the efficiency
score. In this group of countries, Lebanon, Panama, Costa Rica, and
340 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347

Fig. 1. Comparison of Iran’s efficiency with the average of UMICs.

Table 5
Overall results of MPI.

Years

Summary statistics 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15

Max 1.056 1.033 1.06 1.064 1.08 1.092

Min 0.914 0.911 0.823 0.908 0.94 0.949
Average 0.988 0.984 0.987 0.997 1.004 1.013
SD 0.029 0.028 0.044 0.034 0.035 0.030
Range 0.142 0.122 0.237 0.156 0.140 0.143
CV 0.029 0.028 0.045 0.034 0.034 0.030
Range of MI MI>1 (N) 12 9 13 16 14 26
MI>1 (%) 33.3 25.0 36.1 44.4 38.9 72.2
MI=1 (N) 0 0 0 0 3 0
MI=1 (%) 0 0 0 0 8.3 0
MI<1 (N) 24 27 23 20 19 10
MI<1 (%) 66.7 75.0 63.9 55.6 52.8 27.8

Table 6
MI of countries (2009–2015).

Years

Countries 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15

Albania 0.978 0.993 0.967 0.973 0.998 0.957

Algeria 0.965 0.988 1.026 0.956 1.017 1.009
Argentina 1.003 0.954 0.93 1.027 0.981 1.042
Azerbaijan 0.985 0.995 1.034 1.039 1.03 1.092
Belarus 1.041 0.911 1.06 1.045 0.99 1.041
Bosnia and Herzegovina 0.985 0.992 0.987 0.991 0.99 0.98
Botswana 0.987 1.03 1.029 0.975 1.011 1.035
Brazil 0.979 0.967 0.984 0.991 1.035 1.014
Bulgaria 1.015 0.99 1.003 1.005 1.077 1.008
China 0.976 0.978 0.97 0.961 0.97 1.015
Colombia 0.974 0.982 0.984 0.975 0.988 0.981
Costa Rica 1.008 1.01 0.97 0.989 0.973 1.004
Dominican Republic 0.992 1.005 1.009 1.015 1.029 1.031
Ecuador 1.003 0.994 0.992 0.968 0.971 0.981
Gabon 0.958 1.012 0.997 1.031 0.986 1.013
Iran 1.016 0.959 0.948 0.908 1.056 1.019
Iraq 0.931 0.987 1.011 1.013 1 1.015
Jamaica 0.968 0.956 0.942 0.96 0.946 1.01
Kazakhstan 1.013 0.973 1.049 1.001 1.021 1.005
Lebanon 1.03 0.996 0.823 1.064 0.94 0.949
Macedonia, FYR 0.969 0.941 0.94 0.954 0.981 1.012
Malaysia 0.951 0.993 0.974 1.028 1.058 1.031
Mauritius 0.991 0.97 0.993 1.028 1.08 1.036
Mexico 0.986 0.966 0.979 0.965 0.953 0.986
Namibia 1.056 1.026 0.997 0.995 1 1.049
Panama 0.993 0.967 1.005 1.028 1.019 1.019
Paraguay 0.98 1.015 1.023 1.01 1.035 1.016
Peru 0.987 0.945 0.992 0.995 0.985 0.987
Romania 1.009 0.937 0.98 1.029 0.973 1.021
Russian Federation 0.963 1.033 1.055 0.996 1.041 1.04
Serbia 1.023 1.015 1.024 1.033 0.998 0.984
South Africa 0.98 0.974 0.976 0.952 1 1.026
Thailand 0.965 0.979 0.966 0.969 0.995 1.013
Turkey 0.988 0.977 0.97 0.989 0.977 0.975
Turkmenistan 1.02 1.023 1.017 1.043 1.051 1.077
Venezuela (Bolivarian Republic of) 0.914 0.999 0.911 0.978 0.999 0.977
 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347 341

Table 7
Total input and output changes required to make countries efficient.

Indicators Countries CHE LE U5 GGHE AS CHE

Albania 1769.87 78.17 14 54.789

Algeria 1685.609 75.86 24 70.58
Argentina 1731.353 76.41 11.6 71.42
Azerbaijan 1636 71.9 32 88.036
Belarus 1636 73.62 4 77.81
Bosnia and Herzegovina 1723.299 76.73 6.1 68.68
Botswana 1636 65.84 42.1 121.392
Brazil 1636 75.28 15.7 69.332
Bulgaria 1636 74.61 8.2 72.813
China 1636 76.09 10.7 64.773
Colombia 1636 74.2 15.8 75.274
Costa Rica 1985.537 79.63 9.1 75.97
Dominican Republic 1636 73.67 31.5 78.299
Ecuador 1636 76.1 21.5 64.882
Gabon 1636 65.68 50.6 122.286
Iran 1636 75.73 15.7 66.857
Iraq 1636 69.65 32.2 100.411
Jamaica 1636 75.83 15.8 66.309
Kazakhstan 1636 72 12.6 87.317
Lebanon 1905.606 79.4 8.4 58.991
Macedonia, FYR 1636 75.54 12 67.833
Malaysia 1769.124 75.14 8.2 81.6
Mauritius 1636 74.35 14.3 74.425
Mexico 1714.534 76.93 15 67.15
Namibia 1636 63.78 48 132.732
Panama 1729.204 77.8 16.9 53.53
Paraguay 1636 73.02 20.6 81.815
Peru 1698.043 74.74 16 77.76
Romania 1636 75.01 9.2 70.66
Russian Federation 1636 71.16 8 91.778
Serbia 1636 61.98 13.7 142.45
South Africa 1636 75.3 17.2 69.242
Thailand 1636 75.1 12.6 70.267
Turkey 1749.62 75.49 13.6 78.13
Turkmenistan 1636 67.7 52.6 111.179
Venezuela (Bolivarian Republic of) 1636 74.36 16.6 74.404

Bulgaria were some years efficient over the study period, each of
them received score 1 at least for one year over the study years.
In addition, Turkmenistan, Gabon, and Iraq had the lowest effi-
ciency score. According to the MPI findings for the UMICs, Azer-
baijan has had the most progress in efficiency score from 2014 to
2015 (1.092). Iran has showed the regression in 2010 to 2013; it
seems that the economic sanctions affected to GGHE as CHE indi-
cators and it lead to decrease in efficiency while there is a progress
in efficiency score since 2013, which might be associated with the
recent health transformation plan (HTP) since 2014 in the country
[17]. In 2015, Iran still ranked 12th in terms of the efficiency score
among 36 UMICs. To be among the efficient countries, Iran should
have increased the CHE to 1636 US$, which was 1262 US$ in 2015,
showing a 374 US$ per capita deficit.
The findings of the study which conducted to estimates the effi-
ciency of the health care systems of 170 countries by DEA method,
show that countries in the high-income group have a relatively
high average efficiency and Asian countries performed more effi-
ciently among other regions in each group. The average efficiency
of UMICs was 0.773 that was almost in line with the findings of
our study [16].
WHO conducted a comparison of 191 countries in terms of
health system efficiency in producing health and ranked Iran 58
among 191 countries with a score of 0.805. They used health ex-
penditure per capita, U5 mortality rate, infant mortality rate, and
LE as the input criteria, and the average income and average years
of education as control variables. The study showed that Malawi,
Botswana, Namibia, Zamia, and Zimbabwe had the lowest effi-
ciency scores (ranked 187 to 191) Iran’s performance score in this
study was between 0.789 and 0.848, which ranked 58th out of
191(2).
Another that study conducted in 20 countries in the WHO East-
ern Mediterranean Region, used the DEA method, as well as MPI,
similar input indicators to our study, while their outputs were in-
fant mortality rate and LE. The highest technical efficiency scores
were for Syria, Qatar, Tunisia and Bahrain, and the lowest score
was for Djibouti (0.767) over the study period. The technical effi-
ciency score of Iran was 0.960(20) while the average of Technical
efficiency in Iran compare with UMICs was 0.789 in our study.
A study was done in African countries to measure the health-
care system efficiency of 36 African countries. In this study, DEA
was used; the input variables include: the proportion of total
health expenditures in the gross domestic product; the number
of physicians, nurses and hospital beds per 10 0 0 people and the
unemployment rate. The study’s output variables were life ex-
pectancy at birth and infant mortality rate. According to findings,
21 (58.33%) of 36 African healthcare systems were found to be ef-
ficient [31].
Our study utilized DEA method as the common technique to ef-
ficiency measurement. According a systematic review on efficiency
of health system, the studies that used SFA and DEA were stronger
than other studies. Also, the frequency of using DEA method was
higher than all other methods used for measuring efficiency. Al-
most all studies used life expectancy as the most important indica-
tor to measure the efficiency of health production. The study con-
cluded that the methodological problems of existing cross-country
comparisons for the efficiency of health systems make it difficult to
provide meaningful guidance for policymakers [1]. Our study faces
the same limitation. In addition, another limitation of this method
342 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347
is that the importance of some output variables, which may be a
higher priority for the health system, is not considered in measur-
ing efficiency; but as explained in the Method, we tried to consider
this limitation by weighing the out puts variables.
It should be noted that the proposed benchmarks in this re-
search were based on the initial data of the compared countries,
especially the countries with the highest efficiency. In order to
conduct the reforms or plans to meet the target indicators, pol-
icy makers need to consider the feasibility of change, the time
period to assess the impact of changes, a set of contextual fac-
tors affecting an indicator, the importance of an indicator, and the
funds needed to affect the intended reforms. Through improving
health system efficiency, the studied high-income, upper middle-
income, low-income and lower middle-income countries can im-
prove health system outcomes by 6.6%, 8.6% and 8.7%, respectively,
using the existing level of resources [32].
Added value of this study
– Realizing the shortcomings of conventional DEA method, we
modified the method to improve the DEA with weighting the
input and output indicators and set the standards for them by
taking into account an expert assessment of the relative value
of each indicator.
– Despite most studies measuring efficiency in a cross-sectional
design, the strength of this study was its duration over a 7
years period (2009-2015).
– It is the unique study that focus on measuring efficiency in pro-
ducing health in UMICs.
– In addition, our study took advantage of the GGHE to CHE ratio
to take into account the fair financial contribution in the health
system as output indicator; according our assumption, this in-
dicator is a proxy for fair financing contribution which is one
of the final objective of health system [21].
Limitations
– The main limitation of this study was data accessibility. Vari-
ous major output indicators are required to show a clear view
of the quantitative and qualitative level of health production in
any setting. However, since we measured and compared effi-
ciency across different countries, we used indicators that were
certainly accessible and internationally comparable in all of
those countries and used in other studies.
– Methodological limitation of DEA on using homogeneous DMUs
was another limitation of this study for restrict the benchmark.
Policy implications
– Most health policy discussions focus on reducing or increasing
health care budgets, while ignoring ways to turn these funds
into an effective health care system. Improving the efficiency
of health systems to mitigate against rapid healthcare expendi-
ture growth is a key challenge for many countries (especially
UMICs). Hence, improving the efficiency of health care system
is critical for rapidly growing health care needs.
– Targeted interventions to improve fair financial protection
against health costs: It is recommended that these interven-
tions be designed and implemented at both the health system
and the public level. The major cause of catastrophic and im-
poverishment due to health care costs are related to the wide
range of health services covered by public resources and the
model of service delivery in the country.
– Complementary and Supportive Interventions to Maintain
GGHE as CHE: The CHE as GDP has increased significantly since
the implementation of the HTP, but remains a challenge about
unstable public resources for health policy makers. Therefore
the strengthening health financing resource is inevitable in our
country.
– According to our findings and other similar studies, the im-
provement of the "life expectancy" indicator had the greatest
impact on the health system efficiency in producing health.
Considering that the promotion of life expectancy requires
intersectoral collaboration, more government investment is
needed to improve this health output indicator.
– The benchmarks were presented based on the initial data of the
countries and in particular the country with the highest effi-
ciency. Policy makers need to make decisions about the mod-
ified indicators, according to available infrastructures and the
possibility of change.
Conclusion
Our study created a platform to compare the efficiency scores
of selected UMICs countries with Iran, which provides a clear pic-
ture for policy makers to compare and reform the health system
accordingly. In addition to countries’ efforts to optimize health-
care budgets and sustain fiscal space to reach UHC, more impor-
tant is finding appropriate ways to use these funds more efficiently.
Different countries have undergone various health reforms to im-
prove efficiency, however, the approach of "single solution" to re-
form is not recommended. While countries are moving towards
sustainable health development, it is essential that each country
develop and implement tailored multiple solutions to improve the
efficiency of its health care system through exploring the underly-
ing causes of in house inefficiency. Measuring efficiency with DEA
is highly sensitive to selecting indicators to calculate performance
scores. The factors contributing to the performance in this method,
are only identifiable by the selected variables. Therefore, further
qualitative analyzes are recommended to identify the roots of in-
efficiency along with the quantitative results obtained from data
envelopment analysis.
Availability of data and material
All of them are available.
Acknowledgements
The authors would like to thank the Ministry of Health and
Medical Education of Iran, for their help to provide national data.
Author Statements
Funding
Tehran University of Medical Sciences was our research funder.
Competing interests
None declared.
Ethical approval
This study received the ethical code from Tehran University of
Medical science: IR.TUMS.VCR.REC.1396.4018.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.hlpt.2020.06.007.
 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347 343

Appendix 1. Definition of input-output indicators

Types of Source and

indicators method of data Standard of Weights of
Indicators Definition (Input/ Output) collection Years of study indicators indicators

Current Health This indicator calculates the Input WHO, WB 2009-2015 1636 of high
Expenditure average expenditure on health check list importance
(CHE) per per person in comparable
Capita in Int$ currency including the
(Purchasing purchasing power of national
Power Parity) currencies against USD. It
contributes to understand the
health expenditure relative to
the population size facilitating
international comparison.
Life expectancy The average number of years Out put 83.7 of extreme
at birth, total that a newborn could expect important
years (LE) to live, if he or she were to
pass through life exposed to
the sex- and age-specific death
rates prevailing at the time of
his or her birth, for a specific
year, in a given country,
territory, or geographic area.
Under-five Probability (expressed as a Out put 2.8 of high
mortality rate rate per 1000 live births) of a importance
(per 1000 live child born in a specific year or
births)(U5 period dying before reaching
mortality) the age of five years, if subject
to age-specific mortality rates
of that period. Numerator:
Deaths at age 0–5 years.
Denominator: Number of
surviving children at
beginning of specified age
range during the 10 years
prior to survey.
General This indicator calculates the Out put - relatively
Government average domestic general important
Health government health
Expenditure expenditures per person in
(GGHE) as % comparable currency including
Current Health the purchasing power of
Expenditure national currencies against
(CHE) (GGHE USD. It contributes to
as CHE) understand the general
government health
expenditure relative to the
population size and
purchasing power of each
country facilitating
international comparison.
344 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347

Appendix 2. Input-output indicators

- Summary statistics of indicators

output/input indicators Summary statistics 2009 2010 2011 2012 2013 2014 2015

CHE Max 1171 1238 1279 1297 1360 1477 1543

Min 380 372 370 398 439 440 481
Average 745 778 809 851 893 948 998
SD 245 262 263 264 264 278 284
Range 791 866 908 898 921 1037 1062
CV 0.33 0.34 0.33 0.31 0.30 0.29 0.28
Iran 1088.4 1201.0 1196.0 1135.1 1034.5 1222.6 1261.7
LE Max 78.61 78.75 78.91 79.07 79.25 79.44 79.63
Min 54.7 55.8 57.2 58.54 59.83 60.99 61.98
Average 71.7 72.0 72.4 72.7 73.2 73.4 73.7
SD 5.6 5.4 5.1 4.7 4.6 4.3 4.2
Range 23.91 22.95 21.7 20.5 19.4 18.5 17.7
CV 0.08 0.07 0.07 0.06 0.06 0.06 0.06
Iran 73.48 73.93 74.37 74.78 75.15 75.46 75.73
U5 Max 66.3 63.7 61 58.2 56.3 54.5 52.6
Min 6 5.5 5.1 4.8 4.5 4.2 4
Average 24.3 23.3 22.5 21.7 20.9 20.2 19.5
SD 17.5 16.7 16.1 15.6 14.9 14.3 13.8
Range 60.3 58.2 55.9 53.4 51.8 50.3 48.6
CV 0.72 0.72 0.72 0.72 0.71 0.71 0.71
Iran 20.3 19.3 18.4 17.6 16.9 16.3 15.7
GGHE /CHE Max 80.5 80.5 79.1 79.2 79.1 78.8 78.1
Min 24.3 23.4 25.7 25.8 25.5 23.2 20.2
Average 55.3 56.0 56.8 56.0 56.5 56.8 55.9
SD 14.6 14.6 13.6 13.4 13.2 13.0 14.2
Range 56.2 57.0 53.4 53.4 53.6 55.6 57.9
CV 0.26 0.26 0.24 0.24 0.23 0.23 0.25
Iran 36.7 32.4 33.4 34.3 38.5 50.4 53.4

- Current Health Expenditure (CHE) per Capita in Int$ (Purchasing Power Parity)

Country 2009 2010 2011 2012 2013 2014 2015

Albania 591.1 688.9 770.8 881.0 942.0 994.4 980.2

Algeria 656.1 645.3 684.3 804.4 828.0 929.1 1031.2
Argentina 1088.4 1201.0 1196.0 1135.1 1034.5 1222.6 1261.7
Azerbaijan 805.6 768.7 756.9 839.8 930.7 998.8 1191.3
Belarus 1162.7 1238.0 1244.5 1225.5 1287.7 1268.3 1389.8
Bosnia and Herzegovina 804.1 863.7 908.6 964.4 981.9 1029.3 1086.4
Botswana 444.9 481.1 570.9 612.8 665.7 779.3 773.7
Brazil 1112.4 1135.9 1170.5 1203.5 1275.6 1365.3 1391.5
Bulgaria 774.4 809.7 774.0 915.4 1017.0 995.2 1084.6
China 933.7 1059.5 1116.6 1226.9 1303.1 1477.1 1491.9
Colombia 816.1 784.3 856.5 923.7 864.2 890.4 970.0
Costa Rica 814.6 842.5 908.8 966.4 1026.6 1072.0 1101.8
Dominican Republic 392.3 444.7 505.0 567.4 593.4 682.9 724.3
Ecuador 929.2 1002.7 1020.6 1132.2 1301.0 1432.5 1542.8
Gabon 447.1 463.6 479.4 529.3 572.6 621.8 671.0
Iran 441.6 448.0 483.0 518.4 528.1 579.7 616.7
Iraq 430.8 486.7 549.0 595.1 705.5 830.2 1003.8
Jamaica 857.9 882.4 921.7 924.2 983.5 1005.6 996.0
Kazakhstan 414.0 421.3 444.0 429.6 483.8 469.2 511.4
Lebanon 512.4 608.4 642.1 689.2 728.5 799.9 873.1
Macedonia, FYR 380.5 407.0 468.4 535.0 592.5 658.0 762.2
Malaysia 875.8 978.4 839.5 891.6 1027.3 1045.0 1090.4
Mauritius 1171.5 1219.2 1250.0 1296.6 1360.2 1355.8 1323.7
Mexico 448.6 402.5 370.2 400.7 438.9 440.0 481.0
Namibia 1169.8 1089.5 1159.9 1269.8 1261.1 1339.9 1414.0
Panama 758.4 790.0 719.9 839.0 842.0 891.0 903.3
Paraguay 957.5 1031.2 1131.0 1149.5 1204.6 1237.5 1286.5
Peru 655.9 656.2 683.1 735.9 765.4 856.0 852.8
Romania 493.4 372.5 406.5 398.4 485.2 445.0 480.9
Russian Federation 1068.4 1200.2 1278.6 1237.9 1172.1 1140.4 1117.3
Serbia 670.7 670.7 740.2 817.6 859.1 962.7 1039.4
South Africa 755.1 785.9 762.9 745.5 782.1 828.5 857.1
Thailand 868.7 887.8 915.0 973.2 1001.3 986.1 1008.7
Turkey 627.9 716.6 714.2 746.0 840.0 1020.0 1098.6
Turkmenistan 644.7 784.8 847.3 839.2 827.6 827.9 942.5
Venezuela (Bolivarian Republic of) 845.8 733.8 821.8 669.4 641.6 640.1 579.4
 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347 345

- Life expectancy at birth, total years (LE)

Country 2009 2010 2011 2012 2013 2014 2015

Albania 74.85 75.04 75.24 75.44 75.66 75.87 76.1

Algeria 74.37 74.67 74.96 75.18 75.41 75.64 75.86
Argentina 73.48 73.93 74.37 74.78 75.15 75.46 75.73
Azerbaijan 70.64 70.98 71.26 71.47 71.65 71.8 71.9
Belarus 75.43 75.59 75.65 75.18 76.06 76.25 76.41
Bosnia and Herzegovina 54.7 55.8 57.2 58.54 59.83 60.99 61.98
Botswana 76.28 76.65 77.03 77.38 77.7 77.96 78.17
Brazil 73.48 73.83 74.17 74.48 74.77 75.04 75.28
Bulgaria 70.4 70.4 70.55 71.96 72.47 72.97 73.62
China 73.41 73.51 74.16 74.31 74.86 74.46 74.61
Colombia 58.45 59.86 61.17 62.42 63.63 64.78 65.84
Costa Rica 75.75 75.9 76.06 76.22 76.39 76.56 76.73
Dominican Republic 72.08 72.28 72.47 72.63 72.78 72.91 73.02
Ecuador 76.64 76.82 77.02 77.21 77.41 77.61 77.8
Gabon 73.47 73.69 73.88 74.08 74.29 74.51 74.74
Iran 73.6 73.92 74.19 74.44 74.67 74.89 75.1
Iraq 66.35 66.65 66.92 67.16 67.37 67.55 67.7
Jamaica 73.85 74.15 74.43 74.71 74.97 75.23 75.49
Kazakhstan 74.61 74.88 75.12 75.33 75.52 75.68 75.83
Lebanon 72.49 72.7 72.9 73.09 73.29 73.48 73.67
Macedonia, FYR 75.03 75.23 75.42 75.6 75.76 75.93 76.09
Malaysia 73.31 73.45 74.41 74.41 75.06 74.96 75.01
Mauritius 73.98 74.33 74.53 74.83 75.18 75.33 75.28
Mexico 68.28 68.46 68.7 68.96 69.21 69.45 69.65
Namibia 68.68 68.84 69.68 70.07 70.57 70.74 71.16
Panama 68.42 68.29 68.98 69.61 70.45 71.62 72
Paraguay 78.61 78.75 78.91 79.07 79.25 79.44 79.63
Peru 73.14 73.32 73.5 73.67 73.84 74.02 74.2
Romania 62.24 62.89 63.51 64.11 64.68 65.21 65.68
Russian Federation 78.17 78.43 78.65 75.86 79.05 79.23 79.4
Serbia 74.02 74.21 74.4 74.6 74.7 74.97 75.14
South Africa 74.45 74.63 74.82 75.01 75.2 75.38 75.54
Thailand 75.94 76.09 76.25 76.41 76.57 76.75 76.93
Turkey 72.88 72.96 73.26 73.86 74.01 74.19 74.35
Turkmenistan 56.88 58.18 59.52 60.81 61.98 62.98 63.78
Venezuela (Bolivarian Republic of) 73.51 73.62 73.74 73.88 74.03 74.19 74.36

- Under-five mortality rate (per 10 0 0 live births)(U5 mortality)

Country 2009 2010 2011 2012 2013 2014 2015

Albania 26 25.1 24.4 23.7 22.9 22.2 21.5

Algeria 24 25 25 25 25 25 24
Argentina 20.3 19.3 18.4 17.6 16.9 16.3 15.7
Azerbaijan 41.2 39.2 37.4 35.9 34.5 33.2 32
Belarus 15 14.5 13.9 13.3 12.7 12.1 11.6
Bosnia and Herzegovina 65.7 62.9 60.3 57.7 55.1 52.7 50.3
Botswana 17.2 16.6 16 15.4 14.9 14.4 14
Brazil 20.8 19.8 18.9 18 17.2 16.4 15.7
Bulgaria 6 5.5 5.1 4.8 4.5 4.2 4
China 11.1 10.8 10.4 9.9 9.3 8.8 8.2
Colombia 56.6 52.5 51.7 49.4 46.3 44.6 42.1
Costa Rica 7.2 6.9 6.6 6.4 6.2 6.1 6.1
Dominican Republic 25 24.1 23.3 22.6 21.9 21.2 20.6
Ecuador 20.3 19.7 19.1 18.5 17.9 17.4 16.9
Gabon 21.4 20.3 19.2 18.2 17.4 16.6 16
Iran 15.4 14.9 14.4 13.9 13.4 13 12.6
Iraq 64.1 62 60 58 56.3 54.5 52.6
Jamaica 20.5 19.1 17.8 16.6 15.5 14.5 13.6
Kazakhstan 18.6 18.1 17.7 17.2 16.8 16.3 15.8
Lebanon 34.8 34.4 33.9 33.4 32.8 32.2 31.5
Macedonia, FYR 17 15.7 14.6 13.5 12.5 11.5 10.7
Malaysia 12.1 11.5 11 10.5 10 9.5 9.2
Mauritius 7.8 7.6 7.4 7.1 6.9 6.6 6.2
Mexico 37.8 36.9 36 35.1 34.1 33.2 32.2
Namibia 10.6 10 9.5 9 8.6 8.3 8
Panama 23.6 21.5 19.3 17.4 15.6 14 12.6
Paraguay 10.3 10.2 10.1 10 9.8 9.4 9.1
Peru 19.2 18.6 18 17.4 16.8 16.3 15.8
Romania 66.3 63.7 61 58.2 55.3 53 50.6
Russian Federation 10.8 10.3 9.8 9.4 9 8.7 8.4
Serbia 7.9 7.9 7.9 8 8 8.1 8.2
South Africa 10.9 10.4 10.2 10.3 10.8 11.5 12
Thailand 17.8 17.3 16.8 16.3 15.9 15.4 15
Turkey 15.4 15 14.9 14.8 14.8 14.7 14.3
Turkmenistan 58.6 56 54 53.4 50.6 48.4 48
Venezuela (Bolivarian Republic of) 17.1 17.1 17.1 17.1 17 16.8 16.6
346 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347

- General Government Health Expenditure (GGHE) as % Current Health Expenditure (CHE) (GGHE as CHE)
Country 2009 2010 2011 2012 2013 2014 2015

Albania 39.9 42.5 48.0 49.9 51.4 52.3 49.7

Algeria 70.9 69.5 70.6 72.9 71.0 72.0 70.6
Argentina 36.7 32.4 33.4 34.3 38.5 50.4 53.4
Azerbaijan 24.5 23.4 25.7 25.8 25.5 23.2 20.2
Belarus 52.3 54.9 57.2 63.7 66.6 70.4 71.4
Bosnia and Herzegovina 50.5 52.8 54.4 55.0 54.5 53.7 53.6
Botswana 54.1 49.9 50.2 45.1 43.6 43.6 42.3
Brazil 44.0 44.9 44.3 42.9 44.5 44.0 42.8
Bulgaria 65.6 75.9 68.5 66.8 64.0 64.1 62.4
China 54.3 55.4 54.3 51.0 51.6 53.0 51.1
Colombia 66.5 58.6 63.2 56.6 53.0 54.2 55.1
Costa Rica 68.1 68.2 68.5 68.7 69.4 69.7 68.7
Dominican Republic 47.9 46.4 49.1 53.6 50.4 54.2 53.5
Ecuador 64.4 63.3 61.6 57.0 61.3 61.1 61.6
Gabon 50.9 52.2 52.5 53.9 57.7 61.5 61.7
Iran 75.5 76.2 78.9 78.2 78.2 77.5 75.8
Iraq 24.3 24.1 26.0 26.7 28.5 27.0 23.9
Jamaica 80.5 80.5 79.1 79.2 78.4 77.6 78.1
Kazakhstan 55.3 55.3 53.9 53.4 55.4 52.5 58.6
Lebanon 45.8 45.1 48.1 47.0 47.4 42.2 40.3
Macedonia, FYR 50.8 52.9 55.6 56.3 56.6 57.6 59.8
Malaysia 78.7 79.9 75.1 76.7 79.1 78.8 77.8
Mauritius 61.6 61.0 61.1 62.1 59.9 58.3 57.7
Mexico 77.6 73.9 74.8 37.5 40.8 37.2 23.2
Namibia 62.1 61.4 62.7 63.7 62.4 61.8 61.1
Panama 63.6 66.0 67.8 65.7 63.8 61.9 60.2
Paraguay 71.9 73.3 73.9 75.0 76.3 74.0 76.0
Peru 71.2 71.4 73.1 73.2 73.3 71.0 66.8
Romania 44.8 63.6 62.0 61.3 64.2 59.9 58.9
Russian Federation 39.2 40.3 43.8 50.2 49.4 51.7 50.5
Serbia 55.7 53.0 53.0 53.8 53.9 54.8 52.9
South Africa 65.3 62.8 63.3 61.5 63.0 62.8 64.1
Thailand 46.7 48.6 51.3 51.6 52.8 51.8 52.2
Turkey 37.2 43.0 40.3 43.8 42.5 46.8 45.8
Turkmenistan 54.0 54.0 54.0 54.0 59.4 64.0 63.0
Venezuela (Bolivarian Republic of) 39.4 39.6 46.4 46.6 46.9 49.0 47.7

CRediT authorship contribution statement
Efat Mohamadi: Data curation, Investigation, Methodology,
Project administration, Writing - original draft, Writing - review
& editing. Alireza Olyaee Manesh: Conceptualization, Funding ac-
quisition, Investigation, Supervision, Writing - review & editing.
Amirhossein Takian: Conceptualization, Funding acquisition, In-
vestigation, Supervision, Writing - review & editing. Reza Ma-
jdzadeh: Conceptualization, Investigation, Methodology, Supervi-
sion, Writing - review & editing. Farhad Hosseinzadeh Lotfi: For-
mal analysis, Investigation, Methodology, Software, Writing - re-
view & editing. Hamid Sharafi: Formal analysis, Investigation, Soft-
ware, Writing - review & editing. Matthew Jowett: Investigation,
Validation, Writing - review & editing. Mohammad Mehdi Kiani:
Investigation, Writing - review & editing. Leila Hosseini Qavam
Abadi: Investigation, Writing - review & editing. Ali akbar Faza-
eli: Investigation, Software, Writing - review & editing. Zahra
Goodarzi: Data curation, Investigation, Writing - review & editing.
Haniye Sadat Sajadi: Conceptualization, Investigation, Writing - re-
view & editing. Somayeh Noori Hekmat: Investigation, Writing -
review & editing. Leila Freidoony: Investigation, Writing - review
& editing.
References
[1] Varabyova Y, Müller J-M. The efficiency of health care production in OECD
countries: a systematic review and meta-analysis of cross-country compar-
isons. Health Policy 2016;120(3):252–63.
[2] Evans DB, Tandon A, Murray CJ, Lauer JA. The comparative efficiency of na-
tional health systems in producing health: an analysis of 191 countries. World
Health Organ 20 0 0;29(29):1–36.
[3] Collins C, Green A, Hunter D. Health sector reform and the interpretation of
policy context. Health Policy 1999;47(1):69–83.
[4] Feldman R. The ability of managed care to control health care costs: how much
is enough? J Health Care Finance 20 0 0;26(3):15–25.
[5] Soderlund N. An essential hospital package for South Africa selection criteria,
costs and affordability. S Afr Med J 1999;89(7).
[6] Yousefinezhadi T, Mohamadi E, Palangi HS, Sari AA. The effect of ISO 9001 and
the EFQM model on improving hospital performance: a systematic review. Iran
Red Crescent Med J 2015;17(12).
[7] Mohamadi E, Tabatabaei SM, Olyaeemanesh A, Sagha SF, Zanganeh M,
Davari M, et al. Coverage decision-making for orthopedics interventions in the
health transformation program in Iran: a multiple criteria decision analysis
(MCDA). Shiraz E-Med J 2016;17(12).
[8] Farrell M. PEARsoN E. Series A (General). J R Stat Soc Ser A (General)
1957;120(3):229–53.
[9] Coelli TJ, Rao DSP, O’Donnell CJ, Battese GE. An introduction to efficiency and
productivity analysis. Springer Science & Business Media; 2005.
[10] Kohl S, Schoenfelder J, Fügener A, Brunner JO. The use of Data Envelopment
Analysis (DEA) in healthcare with a focus on hospitals. Health Care Manag Sci
2019;22(2):245–86.
[11] Hollingsworth B. The measurement of efficiency and productivity of health
care delivery. Health Econ 2008;17(10):1107–28.
[12] Moore M. Organization WH. Public sector reform: downsizing, restructuring,
improving performance. Geneva: World Health Organization; 1996.
[13] Jowett M, Brunal MP, Flores G, Cylus J. Spending targets for health: no magic
number. World Health Organization; 2016.
[14] Khalid F, Petro Brunal M, Sattar A, Laokri S, Jowett M, Raza W, et al. Assess-
ing the efficiency of sub-national units in making progress towards Universal
Health Coverage: evidence from Pakistan. Health Syst Reform 2019 (just-ac-
cepted).
[15] Mehrdad R. Health system in Iran. JMAJ 2009;52(1):69–73.
[16] Kim Y, Kang M. The measurement of health care system efficiency: cross-
country comparison by geographical region. 2014.
[17] Piroozi B, Rashidian A, Takian A, Amerzadeh M, Sakha MA, Faraji O, et al. The
impact of health transformation plan on hospitalization rates in Iran: an inter-
rupted time series. Int J Health Plann Manage 2019.
[18] Danaei G, Farzadfar F, Kelishadi R, Rashidian A, Rouhani OM, Ahmadnia S,
et al. Iran in transition. Lancet 2019.
 E. Mohamadi, A. Olyaee Manesh and A. Takian et al. / Health Policy and Technology 9 (2020) 335–347 347

[19] Cook WD, Tone K, Zhu J. Data envelopment analysis: prior to choosing a model. [27] Du J, Chen Y, Huang Y. A modified Malmquist-luenberger productivity index:
Omega 2014;44:1–4. assessing environmental productivity performance in China. Eur J Oper Res
[20] Pourreza A, Alipour V, Arabloo J, Bayati M, Ahadinezhad B. Health production 2018;269(1):171–87.
and determinants of health systems performance in WHO Eastern Mediter- [28] Biciunaite A. Economic growth and life expectancy–
ranean Region. East Mediterr Health J 2017;23(5). do wealthier countries live longer. Euromonitor Interna-
[21] Masri MD, Asbu EZ. Productivity change of national health systems in the tional Available online at http://blogeuromonitor.com/2014/03/
WHO Eastern Mediterranean region: application of DEA-based Malmquist pro- economic- growth- and- life- expectancy- do- wealthiercountries- live- longer- html.
ductivity index. Glob Health Res Policy 2018;3(1):22. 2014.
[22] Jahanshahloo GR, Memariani A, Lotfi FH, Rezai HZ. A note on some of DEA [29] You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, et al. Global, re-
models and finding efficiency and complete ranking using common set of gional, and national levels and trends in under-5 mortality between 1990
weights. Appl Math Comput 2005;166(2):265–81. and 2015, with scenario-based projections to 2030: a systematic analy-
[23] Xu K, Saksena P, Jowett M, Indikadahena C, Kutzin J, Evans DB. Exploring the sis by the UN Inter-agency Group for Child Mortality Estimation. Lancet
thresholds of health expenditure for protection against financial risk. World 2015;386(10010):2275–86.
Health Rep 2010(19). [30] Phua KLMeasuring, rformance. : a critique, with proposals for improving on
[24] Organization WH. World health statistics 2016: monitoring health for the SDGs the WHO “building blocks framework”. Open Public Health J 2014;7(1).
sustainable development goals. World Health Organization; 2016. [31] Top M, Konca M, Sapaz B. Technical efficiency of healthcare systems in African
[25] Wang Y-M, Lan Y-X. Measuring Malmquist productivity index: A new approach countries: an application based on data envelopment analysis. Health Policy
based on double frontiers data envelopment analysis. Math Comput Modell Technol 2019.
2011;54(11–12):2760–71. [32] Ahmed S, Hasan MZ, MacLennan M, Dorin F, Ahmed MW, Hasan MM,
[26] Tone K. Malmquist productivity index: efficiency change over time. Handbook et al. Measuring the efficiency of health systems in Asia: a data envelopment
on Data Envelopment Analysis. Cooper WW, Seiford LM, Zhu J, editors, New analysis. BMJ Open 2019;9(3):e022155.
York: Kluwer Academic Publishers; 2004. 2004.