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To cite: Kang J, Peng R, Feng J,
et al. Health systems efficiency
in China and ASEAN, 2015–
2020: a DEA-­Tobit and SFA
analysis application. BMJ Open
2023;13:e075030. doi:10.1136/
bmjopen-2023-075030
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1
Health and Policy Research
Center, Guangxi Medical
University, Nanning, China
2 the TFP of health systems. It is suggested that China
School of Information and
Management, Guangxi Medical
University, Nanning, China
3
School of Nursing, Guangxi
Medical University, Nanning,
China
4
School of Public Policy
and Management, Guangxi
University, Nanning, China
5
School of Global management,
Hongik University, Seoul, Korea
6
Department of Emergency
Management of Guangxi Zhuang
Autonomous Region, Nanning,
Guangxi, China
Correspondence to
Dr Qiming Feng;
​fengqm1963@​163.​com
Health systems efficiency in China and
ASEAN, 2015–2020: a DEA-­Tobit and
SFA analysis application
Jing Kang ‍ ‍,1,2,3 Rong Peng,4 Jun Feng,5 Junyuan Wei,1,6 Zhen Li,1,2 Fen Huang,1,2
Fu Yu,1,2 Xiaorong Su,1,2 Yujun Chen,1,2 Xianjing Qin,1,2 Qiming Feng1,2
ABSTRACT
Objective To evaluate the health systems efficiency in
China and Association of Southeast Asian Nations (ASEAN)
countries from 2015 to 2020.
Design Health efficiency analysis using data envelopment
analysis (DEA) and stochastic frontier approach analysis.
Setting Health systems in China and ASEAN countries.
Methods DEA-­Malmquist model and SFA model were
used to analyse the health system efficiency among China
and ASEAN countries, and the Tobit regression model was
employed to analyse the factors affecting the efficiency of
health system among these countries.
Results In 2020, the average technical efficiency, pure
technical efficiency and scale efficiency of China and 10
ASEAN countries’ health systems were 0.700, 1 and 0.701,
respectively. The average total factor productivity (TFP)
index of the health systems in 11 countries from 2015 to
2020 was 0.962, with a decrease of 1.4%, among which
the average technical efficiency index was 1.016, and the
average technical progress efficiency index was 0.947.
In the past 6 years, the TFP index of the health system in
Malaysia was higher than 1, while the TFP index of other
countries was lower than 1. The cost efficiency among
China and ASEAN countries was relatively high and stable.
The per capita gross domestic product (current US$)
and the urban population have significant effects on the
efficiency of health systems.
Conclusions Health systems inefficiency is existing in
China and the majority ASEAN countries. However, the
lower/middle-­income countries outperformed high-­income
countries. Technical efficiency is the key to improve
and ASEAN countries should enhance scale efficiency,
accelerate technological progress and strengthen regional
health cooperation according to their respective situations.
INTRODUCTION
Health system efficiency has long been the
focus of health policymakers and researchers
for its importance to health equity and
sustainability. The efficiency of the health
system can be defined as the degree to which
the health system achieves the outcomes
with the given input of health resources.1
An efficient health system makes full use of
the resources while an inefficient system is
wasteful of resources. In 2000, the WHO
Kang J, et al. BMJ Open 2023;13:e075030. doi:10.1136/bmjopen-2023-075030
Original research
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ Health systems efficiency in China and Association
of Southeast Asian Nations countries was specifical-
ly analysed by using data envelopment analysis and
stochastic frontier approach models.
⇒ More independent variables of Tobit regression
models were included.
⇒ Confined to the data unavailability, we only chose
the health outcome as the output indicators and
obtained the missing data from national statistical
yearbooks or interpolated.
conducted an overall efficiency measure-
ment in all member countries and reached
the conclusion that 20%–40% of total health
resources were wasted every year due to inef-
ficiency worldwide.2 Owing to the scarcity of
health resources, increasing health systems
efficiency is essential to ensure the availability
of health services and enhance the popula-
tion’s health. The improvement of health
system efficiency is also critical to the prog-
ress of universal health coverage (UHC).3
Furthermore, last couple of years have
witnessed remarkable changes in the health
sector due to the fast development of medical
technology, rapid ageing of populations,
and growing burdens of non-­communicable
and communicable diseases.4 It was also
found that health spending rose both in per
capita terms and in share of gross domestic
product (GDP) worldwide even under the
COVID-­19 pandemic in 2020.5 However, the
economic stagnation caused by the pandemic
combined with the continuing costs calls for
reducing unnecessary healthcare and better
use of resources,6 which highlights the impor-
tance of improving health system efficiency.
What’s more, previous studies also found that
even with the increasing health spending,
many countries were still underspending on
health.7 Therefore, the efficiency of health-
care systems is an intriguing topic which
deserves further research.
1
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ASEAN, officially the Association of Southeast Asian
Nations consists of 10 countries in Southeast Asia—
Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar,
the Philippines, Singapore, Thailand and Vietnam. It is
a region of wide diversity in politics, economy and social
culture. In light of this, health systems among the 10
ASEAN member states are of great differences.8 Over the
years, Countries in the region have been making major
strides to strengthen health systems and have achieved
substantial health gains in improving life expectancy
and reducing the maternal, neonatal and child health
mortality.8–10 Besides all the progress, ASEAN countries
are still facing great challenges in the healthcare sector
including health disparities among and within coun-
tries, the shortage and inadequate distribution of health
human resources, the rise of chronic non-­communicable
diseases as well as the new and re-­emerging infectious
diseases.10–13 China has implemented a profound health-
care reform since 2009. Since the healthcare reform,
Chinese government has put momentous financial invest-
ment on the healthcare sector and made impressive prog-
ress in enhancing people’s health.14 From 2009 to 2019,
the total health expenditure in China increased year by
year with an average annual growth rate of 14.17%.15
However, the rapid increasing health spending may pose
threat to the long-­term financial sustainability of social
health insurance programmes.16 Besides, considering the
persistent limited access of health and impoverishment
by illness as well as the huge population density, a study
on the health systems efficiency is essential to the fulfil-
ment of China’s health reform.
Connected by the land border and sea, China and
ASEAN countries are close neighbours. Both sides share
deep historical links, sociocultural connections and polit-
ical economic dynamics since ancient times. China and
ASEAN established cooperation in the health sector
after the 2003 SARS pandemic.17 Recent years have seen
vigorous cooperation between China and ASEAN coun-
tries in fields like public health, traditional medicine, the
health industry, health human resources and hospital
management.18 The COVID-­ 19 pandemic stresses the
magnitude of regional and global health collaboration,
and the Chinese government proposed to work with
ASEAN countries to jointly build a ‘health shield’ for
the region.19 As a region which contains almost 30% of
the world’s population and one of the fastest-­growing
and dynamic regions in the world, it is important for
China and ASEAN countries to use the health resources
efficiently.
Many studies have analysed the efficiency in the health
sectors from the macro healthcare system level and the
micro healthcare institution level. For health systems
efficiency, in 2001, based on the findings of the World
Health Report 2000 Evans et al further estimated the
relation between the health outputs (population health)
and inputs, and revealed that besides increasing health
resources input, most countries could achieve important
gains by using the actual resources more efficiently.20
2 Kang J, et al. BMJ Open 2023;13:e075030. doi:10.1136/bmjopen-2023-075030
BMJ Open: first published as 10.1136/bmjopen-2023-075030 on 6 September 2023. Downloaded from http://bmjopen.bmj.com/ on September 7, 2023 by guest. Protected by copyright.
Following, many scholars explored the efficiency of
the health systems in Asian countries,21 Organisation
for Economic Cooperation and Development coun-
tries,22 23 European Union state,24 Eastern Mediterranean
Region,25 Middle East and North Africa26 and ASEAN
countries,27 etc, and the findings suggested that differ-
ences of the health systems efficiency existing among
regions and countries and many of the countries still
need to make efforts to improve the health systems effi-
ciency. Besides the cross-­national researches, there are
also a number of studies examining the health systems
efficiency from a single country’s perspective. 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 Studies about the health system effi-
ciency in China and some provinces in China also exhib-
ited the need to increase the usage efficiency of health
resources.31–33 The previous studies laid the foundation
for health systems efficiency analysis. Meanwhile, they
also suggested that there are still a short of researches
specific to China and ASEAN countries.
Health conditions in China and ASEAN countries have
been greatly improved through the Millennium Devel-
opment Goals (MDGs) from 2000 to 2015.34 35 While
China and ASEAN countries still face similar health
problems from the double burden of non-­communicable
and communicable diseases and inadequate of health
resources especially under the impact of the COVID-­19
pandemic. Accordingly, the objectives of this study are
to examine the technical efficiency of the health systems
among China and ASEAN countries from 2015 to 2020
and to understand the variables that influence the health
systems technical efficiency, so as to help both sides better
understand each other’s health conditions, find out the
deficiencies in the usage of health resources, improve the
health capacities and to explore the key areas of future
health cooperation.
METHODS
Data envelopment analysis
Data envelopment analysis (DEA) has been a dominant
performance measurement tool in measuring health
efficiency since its invention in the late 1970s.36 37 It is a
non-­parametric linear programming method to measure
the technical efficiency of different decision-­making units
(DMUs) by constructing and determining an efficient
frontier.38 The value of technical efficiency is considered
to vary between 0 and 1, where 1 means the best efficiency
value of the DMUs while 0 refers to the worst, and the
efficiency is positively correlated with the value.37 39 There

are mainly two kinds of DEA models, namely radial and
non-­radial, and the radial models contain CCR (Charnes-­
Cooper-­Rhodes) and BCC (Banker-­Charnes-­Cooper)
models.40 According to the return to scale assumption,
the CCR models assume that the production has constant
returns to scale while the BCC models assume variable
returns to scale.37 Besides, based on the correlation
between the input and output, DEA models are catego-
rised into input-­oriented and output-­oriented. According
to the previous studies,40–42 the out-­oriented BCC model
is chosen to assess China and ASEAN countries health
system efficiency.
Malmquist index model
Malmquist index measures the changes in productivity
of DMUs during a certain period by analysing the total
factor productivity (TFP) which consists of the technical
change and technological change. Although DEA models
can assess several inputs and outputs simultaneously,40
it can only compare the efficiency of different DMUs in
the same period and cannot explain the changing trend
of the efficiency in different periods. Malmquist index
model can cover this shortage of DEA by evaluating the
efficiency of DMUs dynamically during a certain period.43
Stochastic frontier approach
Stochastic frontier approach (SFA) is a parametric
method which is often used to measure the technical
efficiency and cost efficiency based on production fron-
tier theory.44–47 The main merit of SFA models is that
it considers the random effects to the variation in effi-
ciency.48 Combined with DEA, SFA is employed to inves-
tigate the cost efficiency of health systems among China
and ASEAN countries, so as to analyse the characteristics
of the cost of healthcare. The value of cost efficiency is
considered to vary from 0 to 1, and the larger the value,
the higher the efficiency.
Tobit regression model
Tobit regression model is frequently used to explore the
influencing factors of the technique efficiency by model-
ling the censored variables. One restriction of the Tobit
regression model is that only the dependent variables or
‘censored’ data can be observed.49 The relative technique
efficiency and cost efficiency measured by DEA model
and SFA method range from 0 to 1 which depends on the
mustard of dependent or ‘censored’. Therefore, in this
study, the technique and cost efficiency of health system
was used as dependent variable and estimated by Tobit
regression analysis.
Data sources
China and 10 ASEAN countries were considered as the
DMUs in this analysis. The period of the analysis is from
2015 to 2020. Data of the health system in the eleven
countries were obtained from WHO Global Health
Observatory, Global Health Expenditure Database, World
Bank Database. The missing data were first supplemented
Kang J, et al. BMJ Open 2023;13:e075030. doi:10.1136/bmjopen-2023-075030
Open access
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by searching the national statistical yearbooks and then
interpolated.
Input and output variables for DEA and Malmquist models
Health inputs consist of the human and material
resources serving the health service delivery. Guided
by previous studies25 36 42 and the availability of data, we
took the proxies for financial and physical factor which
affect the output of health systems as input variables.
These input variables are medical doctors (per 1000
population), current health expenditure (CHE) per
capita and hospital beds (per 1000 population). For the
health output variables, two commonly reported health-
care outcomes indicators reported in the previous studies
were chosen for DEA and Malmquist models, namely life
expectancy at birth and neonatal mortality rate (per 1000
live births). Considering the positivity of DEA and Malm-
quist models, the neonatal mortality rate was replaced by
the neonatal survival rate (the calculation is: neonatal
survival rate=1−neonatal mortality rate/1000). Different
from DEA model which can deal with multiple output
variables, SFA model is normally used for single output
variable. Hence, for SFA model, only life expectancy at
birth was taken as the output variable.
Variables for Tobit regression model
Health systems efficiency can be explained by social,
economic and political factors.42 Hence, population
density, GDP per capita (current US$), urban popula-
tion, population ages 65 and above (% of total popula-
tion), literacy rate, adult total (% of people ages 15 and
above) and CHE as percentage of GDP were expected
as the independent variables. Thanks to the huge gap
between the variables’ values, we used natural logarithm
of four variables, namely population density, GDP per
capita (current US$), urban population and literacy rate.
Descriptive statistics are presented in table 1.
Patient and public involvement
No patient involved.
RESULTS
Results of the variables
As can be seen in the descriptive statistics of the input,
output and independent variables in table 1, there are
great diversities in the health sectors among China and
the ASEAN member states. The number of medical
doctors per 10 000 population ranges from a minimum
of 1.53 in Cambodia to maximum 26.1 in Singapore. The
per capita CHE is from a minimum of US$52.15 in Laos
to a maximum of US$3537 in Singapore with a mean and
SD of 468.4 and 754.18, respectively. The hospital beds
per 10 000 population is also differentiated from the
scope of a minimum of 8 in Cambodia to the maximum
of 50.5 in China. Meanwhile, the average life expectancy
at birth is 73.57 with a range from a minimum of 65.81
in Myanmar to a maximum of 83.74. The minimum of
3
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Table 1 Descriptive statistics of variables
Variables
Input variables
 Medical doctors (per 10 000 population)
 Current health expenditure per capita
 Hospital beds (per 10 000 population)
Output variables
 Life expectancy at birth (year)
 Neonatal mortality rate (per 1000 live births)
Independent variables
 Population density (people per sq. km of land area)
 Gross domestic product (GDP) per capita (current US$)
 Urban population (% of total population)
 Population ages 65 and above (% of total population)
 Literacy rate, adult total (% of people ages 15 and above)
 Current health expenditure as percentage of GDP (%)
neonatal mortality rate per 1000 live births is 0.81 while
the maximum is 25.04 with a mean of 10.81.
Among the influencing indicators selected in this
study, the average population density is 851.69 with the
minimum of 29.41 in Laos and the maximum of 7965.88
in Singapore. The lowest GDP per capita is US$1161.86
in Malaysia and the highest is US$66 859.34 in Singa-
pore with the average and SD of US$11 966.07 and
US$17 498.97. The urban population ranges from the
minimum of 22.19 in Cambodia to the maximum of 100
in Singapore. The percentage of population ages 65 and
above is from 4.9% in Brunei to 13.85 in Thailand. The
average literacy rate of the total population is 92.50. The
average CHE as percentage of GDP (%) is 4.16.
Results of the DEA model
The average technical efficiency score of health systems
in China and 10 ASEAN countries was 0.700, over half
of the countries had the technical efficiency above the
average. The mean pure technical efficiency was 1.000,
and the average scale efficiency was 0.701, suggesting
that the technical efficiency was mainly determined by
scale efficiency. Different from the conclusions of other
studies that high-­ income countries outperformed the
lower-­middle countries in health systems efficiency, the
best performers in China and ASEAN countries are
Cambodia, Laos, Myanmar and the Philippines. These
four countries reached the optimal level of technical
efficiency of 1.000, indicating that the health systems of
these four countries were in the best state of efficiency
and scale. From the perspective of pure technical effi-
ciency, the pure technical efficiency scores of all coun-
tries were 1.000 except Brunei, whose pure technical
efficiency reaches 0.998 which was close to 1, revealing
that the health technology and management level of all
countries were relatively high, and the output maximisa-
tion was achieved under the condition of existing health
4 Kang J, et al. BMJ Open 2023;13:e075030. doi:10.1136/bmjopen-2023-075030
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Min Max
1.53 26.10
52.15 3537
8.00 50.50
65.81 83.74
0.81 25.04
29.41 7965.88
1161.86 66 859.34
22.19 100.00
4.09 13.85
71.04 98.18
2.19 7.51
input. In Brunei, Indonesia, Malaysia, Singapore, Thai-
land, Vietnam and China, the technical efficiency scores
were in the state of inefficiency due to insufficient scale
efficiency, and returns to scale were all in a decreasing
mode, suggesting that health resource input in those
countries were not in the best state, and the proportions
of health system output were smaller than the proportion
of health input increase (see table 2).
Results of the Malmquist index model
As shown in table 3, according to the result of the Malm-
quist index model, the TFP index of the health system in
China and ASEAN countries from 2015 to 2020 showed a
downward trend, with an average value of 0.962. It shows
that the efficiency of the overall health system in China
and ASEAN countries as a whole decreased by 1.4%
during the 6 years. From the decomposition point of view,
the average value of the technical efficiency index was
1.016, which decreased by 0.1 from 2015 to 2020, and the
average value of the technical progress efficiency index
was 0.947, which increased by 0.045 in 6 years, indicating
that the service efficiency of health systems in China and
ASEAN countries did not change significantly from 2015
to 2020. The change of TFP was still mainly influenced by
technological regression.
To analyse the Malmquist index from the single country
perspective, the results showed that only the TFP index
of the health system in Malaysia was greater than 1, while
other countries were less than 1. But there was little
difference in the Malmquist indexes among countries.
All countries, including Malaysia, had experienced the
technological regression. Except Malaysia and Vietnam,
all the other countries witnessed the reduction of TFP
mainly caused by technological regression, while Vietnam
had both technological inefficiency and technological
regression (see table 3).
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Table 2 Technical and scale efficiency scores of the health systems in China and Association of Southeast Asian Nations
countries, 2020
Country name CRS technical efficiency VRS technical efficiency Scale efficiency Returns to scale
Brunei 0.315 0.998 0.316 decrease
Cambodia 1 1 1 –
Indonesia 0.976 1 0.976 decrease
Laos 1 1 1 –
Malaysia 0.759 1 0.759 decrease
Myanmar 1 1 1 –
Philippines 1 1 1 –
Singapore 0.427 1 0.427 decrease
Thailand 0.521 1 0.521 decrease
Viet Nam 0.458 1 0.458 decrease
China 0.250 1 0.250 decrease
Mean 0.700 1 0.701 –
CRS, constant returns to scale; VRS, variable returns to scale.

Results of the SFA model
As shown in figure 1, the cost efficiency scores in China
and ASEAN countries were relatively high and stable from
2015 to 2020. Singapore ranked first with the mean cost
efficiency of 0.999 during the 6 years, followed by Thai-
land and China with an average cost efficiency of 0.949
and 0.935, respectively. Cambodia, Laos and Myanmar
were the least three countries with the lowest cost effi-
ciency. While the gap among countries were not obvious
and there were little changes within countries. Mean-
while, compared with technical efficiency, cost efficiency
is generally higher and stable than technical efficiency.

Table 3 The Malmquist index and its decomposition of the health systems in China and Association of Southeast Asian
Nations (ASEAN) countries, 2015–2020
The Malmquist index and its decomposition of the health systems in China and ASEAN countries as a whole, 2015–2020
Year Effch Techch Pech Sech Tfpch
2015–2016 1.083 0.902 1.001 1.082 0.976
2016–2017 1.041 0.914 1 1.041 0.952
2017–2018 0.981 0.98 1 0.981 0.961
2018–2019 1.006 0.955 1 1.006 0.961
2019–2020 0.975 0.986 1 0.975 0.961
Mean 1.016 0.947 1 1.016 0.962
The Malmquist index and its decomposition of the health systems across China and ASEAN countries, 2015–2020
Country name Effch Techch Pech Sech Tfpch
Brunei 0.999 0.941 1 0.999 0.939
Cambodia 1 0.918 1 1 0.918
Indonesia 1.030 0.929 1 1.030 0.956
Laos 1 0.976 1 1 0.976
Malaysia 1.050 0.954 1 1.050 1.002
Myanmar 1.004 0.973 1.001 1.003 0.977
Philippines 1.040 0.950 1.001 1.039 0.988
Singapore 1.012 0.954 1 1.012 0.966
Thailand 1.060 0.916 1 1.060 0.972
Viet Nam 0.975 0.970 1 0.975 0.946
China 1.014 0.933 1 1.013 0.945
Mean 1.016 0.947 1 1.016 0.962

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Figure 1 Cost efficiency scores of the health systems in China and Association of Southeast Asian Nations countries, 2015–
2020.

Results of the Tobit regression model
Tobit regression model was employed to analyse the tech-
nical and cost efficiency scores of health systems in China
and ASEAN countries with six independent variables.
Table 4 shows that the per capita GDP (current US$) and
the urban population had statistical significance on the
technical efficiency of health system in China 10 ASEAN
countries (p<0.05), where the per capita GDP (current
US$) was positively correlated with technical efficiency,
and the urban population was negatively associated with
technical efficiency. Population density was the main
influencing indicators to the cost efficiency with a posi-
tive association.
DISCUSSION
Performance of health systems based on efficiency
The main findings of this study suggested that China and
over half of the ASEAN countries are still confronting tech-
nical inefficiency in using the health systems resources.
Meanwhile, although the overall trend of cost efficiency
in China and ASEAN countries were higher and more

Table 4 Regression results of the Tobit regression model

Variables Coefficient (95% CI) P value
Main DEA model regression results
 Population density (people per sq. km of land area) 0.0449317 (−0.1083365 to 0.018473) 0.165
 Gross domestic product (GDP) per capita (current US$) 0.0672207 (0.0085992 to 0.1258422) 0.025**
 Urban population (% of total population) 0.4827829 (−0.8157207 to −0.1498452) 0.004***
 Population ages 65 and above (% of total population) 0.0113915 (−0.0151828 to 0.0379659) 0.401
 Literacy rate, adult total (% of people ages 15 and above) 0.4643171 (−0.4930024 to 1.421637) 0.342
 Current health expenditure (CHE) as percentage of GDP (%) 0.0093055 (−0.0523179 to 0.0709289) 0.767
Main SFA model regression results
 Population density (people per sq. km of land area) 0.0188001 (0.0046622 to 0.0329381) 0.009***
 GDP per capita (current US$) 0.0021588 (−0.0138504 to 0.0095328) 0.717
 Urban population (% of total population) 0340433 (−0.0089688 to 0.0770553) 0.121
 Population ages 65 and above (% of total population) 0.0003696 (−0.0020561 to 0.0013168) 0.667
 Literacy rate, adult total (% of people ages 15 and above) 0.006653 (−0.0238764 to 0.0238764) 0.669
 CHE as percentage of GDP (%) 0.0010322 (−0.0018335 to 0.0038979) 0.480
*p<0.1, **p<0.05, ***p<0.01.43
DEA, data envelopment analysis; SFA, stochastic frontier approach.

6 Kang J, et al. BMJ Open 2023;13:e075030. doi:10.1136/bmjopen-2023-075030


stable than technical efficiency, there were still space for
improving. The inefficiency in technique and cost may
be attributed to the unfinished agenda of achieving the
primary healthcare (PHC) system. The strengthening
of PHC is essential to improve the efficiency of health
system.50 Both China and ASEAN countries have made
great efforts in achieving PHC and universal health cover-
age(UHC), however, many countries are still fall short of
the expectation or facing new challenges including the
financial burden and modernisation of life styles which
might in turn exhibited as health inefficiency.16 51–55
Among all the studying countries, only Cambodia, Laos,
Myanmar and the Philippines reached technical effi-
ciency, indicating that the health input of these four
countries have achieved effective output. One possible
reason is that these countries have placed neonatal
mortality reduction high on the agenda of health systems
in achieving the MDGs and the Sustainable Develop-
ment Goals (SDGs), thereby positively influencing their
health outcomes indicators selected in this study.21
Among China and the six other ASEAN countries whose
technical efficiency scores were less than 1, the scale effi-
ciency is the key to improve the health system efficiency.
According to the results of Malmquist index analysis of all
countries from 2015 to 2020, combined with the results of
decreasing returns to scale, it can be known that although
the scale of the health system in China and these ASEAN
countries continues to expand, the usage efficiency of
health resources is not high, resulting in the growth rate
of output lower than that of health input. It suggests that
there might be some disadvantages such as unreason-
able distribution of health resources, insufficient usage,
redundant health input and insufficient health output.
The stable trend of the cost efficiency together with the
fact that health spending was increasing year by year
among all countries except Brunei indicated that the
allocation of health input should be further optimised.
Therefore, it is important for China and ASEAN coun-
tries to better health inputs usage and allocate the health
resources, especially the public health funds appropri-
ately 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
Technological progress is key to improve TFP
It was also found that technological progress is the deci-
sive factor limiting the improvement of TFP in the health
system of China and ASEAN countries. In recent years,
in the process of advancing the SDGs and UHC, both
China and ASEAN countries pay increasing attention to
the development and investment in the field of health.
However, limited by technological progress, the health
resources were not fully used, resulting in low efficiency of
health system. Therefore, while increasing health invest-
ment and expanding the scale and facilities of health and
Kang J, et al. BMJ Open 2023;13:e075030. doi:10.1136/bmjopen-2023-075030
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medical service institutions, China and ASEAN countries
should improve the technology of health usage. On the
one hand, the promotion and application of new tech-
nologies and new methods within the region should be
promoted through the exchange of experience within the
region, so as to improve the overall health technology; on
the other hand, the training of health manpower should
be accelerated to improve the ability of health-­related
workers to use health resources.
Economic development and health resources allocation
matters
Per capita GDP (current US$) and the urban population
(% of the total population) are the leading influencing
factors affecting the efficiency of the health system in
China and ASEAN countries. The per capita GDP has a
positive impact on both the technical and cost efficiency,
indicating that the higher the per capita GDP, the higher
the efficiency of the health system. This might be explained
by the economic theory that the higher per capita GDP
people have, the more willing for them to invest in
health, and thus the healthier they are. Furthermore, per
capita GDP can help to reduce the infant mortality rate.56
The urban population (% of the total population) has a
negative impact on the technical efficiency of the health
system in China and ASEAN countries, one possible
reason might be that there were increasing urban popula-
tion combined with floating population who were seeking
healthcare in cities seized for the certain health resources,
and then caused health inefficiency.57 This also indicates
the uneven allocation of the health resource. Therefore,
to speed up the economic development and improve
peoples’ health service consumption capability is vital to
China and ASEAN countries. Besides, the associations of
the urban population (% of the total population) with
the health systems efficiency disclosed the importance
of the allocation of health resources. China and ASEAN
countries need to optimise the distribution of health
input according to the density of urban population.
CONCLUSION
This study has enriched the cross-­country studies on the
efficiency of health systems and provided reference for
the health cooperation between China and ASEAN. It
is suggested that China and many of the ASEAN coun-
tries confronted technical and cost inefficiency in health
systems while the lower/middle-­ income countries had
better performance in the region. Therefore, to allocate
the health resources scientifically and to improve the
technical management of using the limited resources is
important. The per capita GDP (current US$) and the
urban population are the key indicators influencing
the health systems efficiency. Considering the uneven
health systems efficiencies and robust health cooperation
among China and ASEAN countries, it is a future trend
to strengthen regional health cooperation, share health
technology experience and enhance the overall resilience
7
 Open access
and capacity of the regional health system. Under the
current mechanism of health cooperation between
China and ASEAN, cooperation can build on lower/
middle-­income countries and focus on exchanges and
communication in the fields of health system reform and
construction, health personnel training, vaccine research
and development, and universal health coverage, so as to
promote the in-­depth development of health coopera-
tion between China and ASEAN countries.58 59
Limitations
This study depicts a general picture of the healthcare
system efficiency performance of China and ASEAN coun-
tries by combining the parametric and non-­parametric
methods. However, there are some limitations lied in the
choice of indicators due to the availability of data. Future
studies can take the healthcare delivery indicators such
as the inpatient and outpatient amount and the health
behaviours, economic and environment factors as inde-
pendent variables. What is more, the study showed that
lower/middle-­income countries had higher health effi-
ciency in resource allocation and usage based on the
technical and cost efficiency ranking, there should be
deeper and further analysis for the future studies.
Contributors XQ and QF contributed equally to this paper and are joint last
authors, QF is also the guarantor. JK, RP, JF and QF conceived and designed the
study. JK, RP and JF collected and analysed the data, and drafted the manuscript.
JW, ZL, FH, FY, XS, YC contributed to literature research and reviewing the
manuscript. XQ and QF contributed to the interpretation of the results and critically
revised the draft. All authors provided advice at different stages. All authors
approved the final version of the manuscript. The corresponding author attests that
all listed authors meet authorship criteria and that no others meeting the criteria
have been omitted.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data used in this study were obtained from WHO
Global Health Observatory (https://www.who.int/data/gho/data/indicators), WHO
Global Health Expenditure Database (https://apps.who.int/nha/database) and World
Bank Database (https://data.worldbank.org/) as well as the national statistical
yearbooks.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
Jing Kang http://orcid.org/0009-0003-3624-0604
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