The health sector is one of the most important service sectors and indicators of development [1]. Health systems today form one of the largest sectors of the world's economy [2]. It was found that when GDP increased, health expenditure in general increases [3]. The share of health expenditures in the budgets of low- and middle-income countries is increasing. Countries such as Brazil, Russia, India, China, and South Africa remain to be major drivers of such change since 1990s [4]. Getzen and Jakovljevic confirmed that shifts in GDP growth rates have already reflected heavily on world’s health expenditure landscape [5]. Purchase power parity in terms of health expenditure in low and middle-income countries’ has already grown in some indicators from almost 26.1% in 1995 to 39.7% in 2013, in only a span of 19 years [6]. Over the past few decades, national health spending has risen sharply around the world. It seems that the share of global medical spending by emerging economies is increasing and the share of rich countries is declining [7]. With the rapid growth in the costs of the health sector worldwide, economic experts, managers, and decision-makers are seeking to find new ways to limit costs and increase efficiency [8]. Despite the high volume of resources allocated to the health sector, there is a gap between the growth of the available resources and the resources needed by the health sector, which highlights the need for effective use of resources [9].
The World Health Organization (WHO) in its report emphasized on three goals for the health system [10] including improving health, meeting non-medical needs, and ensuring that financial burden is distributed equitably. In order to achieve this, the WHO has emphasized the performance of health systems [11]. Evaluating the effectiveness and efficiency of health systems is the measurement of the performance of system management. This comparison, when done in a large scale and in the health systems of the countries, shows the results of the selection of managers' policies and practices [10].
Poor management leads to the waste of resources, including money, manpower, buildings, and equipment. Such a loss means that a certain share of services (outputs) can be achieved with fewer resources. By preventing the loss of financial and human resources, they can be used to provide high-quality and cost-effective services [12]. Financial economic analysis provides a logical and specific framework for analyzing important issues in health care [13]. Deciding on the optimal provision of health care is a complex task and requires information about system performance for decision makers. The task of health economists is to analyze issues and report the results of economic assessments in a variety of ways to health policymakers [14]. In addition, with population aging, it is needed national strategies for sustainability of health systems. Countries whose populations are moving faster toward old age need to invest and spend more on health care for the elderly [15]. Non-communicable diseases will continue to be a challenge for low- and middle-income countries. High and out-of-pocket costs will impoverish 150 million people worldwide [16]. Despite significant global health gains, reports show that many low- and middle-income countries are not aligned with global health goals, and the gap between low-income and high-income countries seems unlikely to be narrowed. Current trends show that a significant increase in the resources of the health system requires coordinated action [17]. Poor countries are not able to provide enough funding to meet their health needs in the short to medium term. Governments in these countries have limited ability to collect taxes or health insurance benefits because people are poor and many people work in the informal sector, making it difficult to collect taxes [18].
This paper seeks to answer the question of which countries are more effective in allocating their health resources in Eastern Mediterranean Region, and does Iran, in relation to those countries, have an effective health system?
Literature
Productivity or efficiency is a criterion for measuring performance, and the value of the input (i.e., what is being used in production) is evaluated by the output (i.e., what is obtained) [19]. Efficiency is a very comprehensive concept, and it is discussed in various areas such as engineering, management, economics, and health. Therefore, different definitions of efficiency are provided in various sources. Farrell defines a firm's efficiency as "to produce an output to a sufficiently large extent than a given input value", and it specifies the technical allocation and economic performance of its types [20]. In many studies were used data envelopment analysis (DEA) method to investigate health systems efficiency [21,22,23,24].
It was reviewed 317 studies on health efficiency in a systematic review study, which were divided into two types of micro- and macro-level studies [25]. Micro-level studies evaluated the efficiency and function of health units such as hospitals and clinics [26]. Of course, some recent studies with a macro-level approach have also evaluated the performance of healthcare centers [27,28,29,30,31]. In most of these studies, the outcomes and impacts of the health system are measured in terms of life expectancy, and the main input in most studies is the per capita cost of health. In another study was used DEA method to investigate life expectancy and health expenditure evolution in eastern Europe [23].
It was found in a systematic review of 137 papers that most of reviewed studies employed data envelopment analysis for measuring efficiency in health systems [32]. In an another study was found that Lebanon, Qatar, and Morocco have the most efficient health systems in Middle east and North Africa (Mena) region [33]. Bousmah et al. n their paper analyzed health efficiency in 18 countries between 1995–2012 [34]. In a study about health efficiency in 18 countries between 1995–2012 was found that increasing health expenditure in the MENA region will not result health outcome improvement necessarily and full efficiency of health system [34].
Spinx and Halings [35] evaluated the effects of socioeconomic determinants on the outcome of health care. They used unemployment rate, the level of attribution, and GDP per capita as inputs. Ratzald Roberts et al. [36] provided a comprehensive model of inputs in which social environment, lifestyle, access to health services, and health costs were considered as inputs. Some studies also looked at hospital beds, the number of health care workers and health expenditure as inputs [30, 37]. In a study, two models with different inputs and the same output were studied. In the first model, the number of physicians and beds along with health expenditures were set as input, and in the second model, GDP per capita along with consumption of vegetables and fruits were specified as input. Outputs or outcomes in the health system were considered life expectancy and infant survival rate. By comparing these two models through the data envelopment analysis (DEA) method, the first model was found to be more appropriate [38].
