{
  "abstract": "Background: Cross-country league tables of health system efficiency rank countries and are used to argue that one institutional form outperforms another. A country’s score depends on the comparator set. We ask how much of a ranking that choice produces, and what survives when it is made explicit and second-stage inference uses methods suited to bounded DEA scores.\n\nMethods: Input-oriented data envelopment analysis (DEA) was applied to a 2019 cross-section of 70 countries with complete data on four health inputs and one output (life expectancy at birth). Countries were scored against a pooled frontier, an income-group frontier, and a DEA meta-frontier with a technology gap ratio. Bias-corrected scores and confidence intervals came from a non-parametric bootstrap that resampled the decision-making units (B = 1000 replications). Leave-one-out and order-m estimates tested whether the pooled frontier was anchored by one or two observations. Second-stage inference used the Papke-Wooldridge fractional response model and a parametric truncated regression in the Simar-Wilson framework (B = 1000) on three dependent variables (pooled VRS, within-group CRS, meta-frontier TGR), n = 58.\n\nResults: Two of 70 countries defined the pooled CRS frontier (Gambia, Papua New Guinea). China scored 0.158 against pooled CRS (34th of 70) and 0.997 against pooled VRS (25th of 70; 23 of 70 countries sit on the VRS frontier with score = 1.000, so China is close to the VRS frontier). Within its upper-middle-income group it scored 0.491 (14th of 17), with a technology gap ratio of 0.322. Removing both frontier countries together moved China’s CRS score to 0.169 (rank 33 of 68) while leaving the country ordering nearly intact (Spearman rho = 0.993). The out-of-pocket share was not associated with efficiency on any of the three primary dependent variables (all p > 0.30). System-type coefficients did not reverse sign under VRS, and their 95% confidence intervals included zero on the TGR dependent variable; marginal VRS associations in one control set did not survive the other control set. The United States market-based coefficient was negative in direction but imprecise in the bounded-outcome model. Common support was poor (mean GDP per capita US$4813 vs. US$58842 across fragmented and national-health-service groups).\n\nConclusions: Comparison-set sensitivity is the main result. The out-of-pocket association and system-type effects reported in earlier pooled-CRS work do not survive methodologically appropriate re-estimation; they reflect that a pooled CRS frontier spanning all income groups is defined by the lowest-spending countries. China’s financing projections are exploratory.",
  "abstract_shown": true,
  "affiliations": [],
  "article_type": null,
  "arxiv": null,
  "author_total": 1,
  "authors": [
    {
      "name": "Hongwei Ma",
      "orcid": "0009-0006-5217-6878"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/acvda21a6c4ak.bib",
  "cited_by": 0,
  "doi": "10.1186/s12889-026-30061-0",
  "fulltext_url": null,
  "id": "acvda21a6c4ak",
  "issns": [
    "1471-2458"
  ],
  "landing_url": "https://link.springer.com/article/10.1186/s12889-026-30061-0",
  "language": null,
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "1803|Efficiency Analysis Using DEA"
    ]
  ],
  "openalex": "W7224114531",
  "pdf_url": null,
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-28",
  "publisher": "Springer Science and Business Media LLC",
  "ris": "https://research.draconitic.com/paper/acvda21a6c4ak.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:19:54Z",
      "native_id": "10.1186/s12889-026-30061-0",
      "source": "crossref",
      "url": "https://link.springer.com/article/10.1186/s12889-026-30061-0"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "issn:1471-2458",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "When the frontier is drawn by the poorest countries: comparison-set sensitivity in health system efficiency rankings",
  "title_text": "When the frontier is drawn by the poorest countries: comparison-set sensitivity in health system efficiency rankings",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:19:54Z",
  "url": "https://research.draconitic.com/paper/acvda21a6c4ak",
  "venue": "BMC Public Health",
  "versions": []
}