Efficiency and productivity of Mongolian subnational public hospital systems, 2014-2023: annual DEA, global Malmquist and double-bootstrap analysis.
5 affiliations
- 1Graduate School, University of Finance and Economics, Ulaanbaatar, Mongolia.
- 2National Center for Pathology, Ministry of Health of Mongolia, Ulaanbaatar, Mongolia.
- 3Mongolian National Academy of Governance, Ulaanbaatar, Mongolia.
- 4Graduate School of Medical Science, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia.
- 5Graduate School of Medical Science, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia. [email protected].
Abstract
Background
Mongolia must organise public hospital capacity across regions that differ greatly in population and geography. We reanalysed subnational hospital efficiency after methodological review, using an auditable production set and inferential procedures tailored to estimated frontier measures.Methods
This retrospective longitudinal study included 22 aggregated regional public hospital systems from 2014 to 2023 (220 region-years). Inputs were beds, physicians and mid-level personnel; desirable outputs were inpatient admissions, operations and outpatient visits. Annual input-oriented constant- and variable-returns DEA described contemporaneous efficiency, with pooled DEA and a desirable-output-only slack-based measure as supplementary benchmarks. Productivity was estimated using an output-oriented global constant-returns Malmquist index. A 400-replicate smoothed trajectory frontier bootstrap generated pseudo outputs and re-estimated annual and global frontiers in every replicate. For contextual assessment, Simar-Wilson Algorithm 2 was applied to one decade-average observation per region (22 independent decision-making units), using standardised log population and log geographic area.Results
Mean annual variable-returns technical efficiency was 0.931 (annual range 0.909-0.950); mean pooled variable-returns efficiency was 0.845. Bias-corrected global productivity declined in 2014-2015 (0.933, 95% bootstrap CI 0.911-0.955), 2015-2016 (0.957, 0.927-0.985), 2016-2017 (0.955, 0.940-0.970) and 2019-2020 (0.940, 0.922-0.956), increased in 2020-2021 (1.105, 1.070-1.145), and increased again in 2022-2023 (1.038, 1.018-1.060). In the independent-region double-bootstrap model, neither log population (coefficient -0.007, 95% CI -0.107 to 0.094) nor log area (0.120, -0.093 to 0.201) had a clearly non-zero association with inefficiency.Conclusions
Mongolian regional public hospital systems showed high contemporaneous technical efficiency but several statistically supported periods of productivity decline, including 2019-2020, followed by recovery in 2020-2021. The revised independent-region analysis does not support a robust regression claim that geographic area predicts inefficiency. DEA results are relative production benchmarks, not cost-effectiveness estimates or incremental cost-effectiveness ratios, and should inform monitoring and further investigation rather than punitive rankings.
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BibTeX
@article{batsukh2026efficiency,
title = {{Efficiency and productivity of Mongolian subnational public hospital systems, 2014-2023: annual DEA, global Malmquist and double-bootstrap analysis.}},
author = {Buyantogtokh Batsukh and Ganzorig Batbaatar and Amarzaya Batchimed and Tumurbat Byamba and Gantsetseg Baljirsuren and Byambakhorloo Sukhbaatar and Byambatseren Boldbaatar and Dariimaa Ganbat},
journal = {Cost effectiveness and resource allocation : C/E},
year = {2026},
month = jul,
doi = {10.1186/s12962-026-00808-y},
url = {https://europepmc.org/article/MED/42902273},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Efficiency and productivity of Mongolian subnational public hospital systems, 2014-2023: annual DEA, global Malmquist and double-bootstrap analysis.
AU - Buyantogtokh Batsukh
AU - Ganzorig Batbaatar
AU - Amarzaya Batchimed
AU - Tumurbat Byamba
AU - Gantsetseg Baljirsuren
AU - Byambakhorloo Sukhbaatar
AU - Byambatseren Boldbaatar
AU - Dariimaa Ganbat
PY - 2026
DA - 2026/07/01
JO - Cost effectiveness and resource allocation : C/E
DO - 10.1186/s12962-026-00808-y
UR - https://europepmc.org/article/MED/42902273
AB - Background Mongolia must organise public hospital capacity across regions that differ greatly in population and geography. We reanalysed subnational hospital efficiency after methodological review, using an auditable production set and inferential procedures tailored to estimated frontier measures.Methods This retrospective longitudinal study included 22 aggregated regional public hospital systems from 2014 to 2023 (220 region-years). Inputs were beds, physicians and mid-level personnel; desirable outputs were inpatient admissions, operations and outpatient visits. Annual input-oriented constant- and variable-returns DEA described contemporaneous efficiency, with pooled DEA and a desirable-output-only slack-based measure as supplementary benchmarks. Productivity was estimated using an output-oriented global constant-returns Malmquist index. A 400-replicate smoothed trajectory frontier bootstrap generated pseudo outputs and re-estimated annual and global frontiers in every replicate. For contextual assessment, Simar-Wilson Algorithm 2 was applied to one decade-average observation per region (22 independent decision-making units), using standardised log population and log geographic area.Results Mean annual variable-returns technical efficiency was 0.931 (annual range 0.909-0.950); mean pooled variable-returns efficiency was 0.845. Bias-corrected global productivity declined in 2014-2015 (0.933, 95% bootstrap CI 0.911-0.955), 2015-2016 (0.957, 0.927-0.985), 2016-2017 (0.955, 0.940-0.970) and 2019-2020 (0.940, 0.922-0.956), increased in 2020-2021 (1.105, 1.070-1.145), and increased again in 2022-2023 (1.038, 1.018-1.060). In the independent-region double-bootstrap model, neither log population (coefficient -0.007, 95% CI -0.107 to 0.094) nor log area (0.120, -0.093 to 0.201) had a clearly non-zero association with inefficiency.Conclusions Mongolian regional public hospital systems showed high contemporaneous technical efficiency but several statistically supported periods of productivity decline, including 2019-2020, followed by recovery in 2020-2021. The revised independent-region analysis does not support a robust regression claim that geographic area predicts inefficiency. DEA results are relative production benchmarks, not cost-effectiveness estimates or incremental cost-effectiveness ratios, and should inform monitoring and further investigation rather than punitive rankings.
SN - 1478-7547
ER -