Given the increasing growth in health care costs and the problems associated with financing the expenditures, policymakers have accepted that health care is not a mere social issue and should be addressed economically as well [1, 2]. According to the World Bank statistics and the World Health Organization reports, different countries spend an average of about 10% of their GDP on healthcare . According to the latest reports, it is more than 8% in Iran [4,5,6]. In fact, the main threat for the health sector in most developing countries is the non-optimal utilization of resources and the inefficient role of resource management in solving problems [7, 8].
The primary health care (PHC) system are most important parts of every health system around the world . Health centers and rural health houses are among the most important providers of primary health care. There has been a rapid growth in the number of health centers since the release of the Alma-Ata Declaration that had a key role in ensuring access to health for all people . Iran government has made many efforts to establish a broad network of primary health care facilities, especially in rural areas, through rural health centers and health houses, aimed at reducing the gap between rural and urban services [11, 12].
According to most critics and stakeholders of the health sector in the county, the delivery of primary health care in Iran by Behvarz (local health worker), as a forefront of health especially in deprived and rural areas, has been one of the most important activities and achievements of the Iranian health system in the field of health. Health House is the most peripheral unit of service delivery in the health network system of the country that is located in rural areas and mainly based on Behvarz. Each health house may cover one or more villages depending on geographical conditions, especially transportation routes and population. The most important feature of health houses is the selection of Behvarzs according to the social conditions of the community [12, 13].
Mortality reduction, population control and family planning, vaccination for children, and maternal education can be attributed to the endless and admirable efforts of Behvarzs in rural areas [12, 13]. At the present, 29% of the country’s population lives in rural areas, so Behvarzs have a crucial role in the health system [12, 13].
Increasing demands for primary health services put primary health sector mangers in a situation to allocate resource more rational to reach better health outcomes within constraint budget. One of the way to deal with this challenge is identify level efficiency and focus to improve it within health houses in processes and outcomes dimensions [14, 15].
Unfortunately, in developing countries, including Iran, there is limited information on the effectiveness of primary health care centers, especially rural health houses. Various studies around the world as well as some of studies in Iran have examined the efficiency of primary health care centers [16,17,18]. However, it suffered from a crucial methodological flaw. They used some surrogate outcomes, while selecting a final outcome as a performance would be more reasonable to show level of efficiency in health houses. considering the nature of these centers, their diverse functional areas of activity, and their inputs and outputs, it can be stated that data envelopment analysis (DEA) is the best model for a comprehensive and clear evaluation of the centers .
The utilization of DEA not only helps to determine the relative efficiency and identify weaknesses of the organization, but also defines the organization's policy and approach towards promoting efficiency and productivity through presenting the desirability of performance indicators. It also defines efficient patterns, i.e. units that, as compared with other units, have more outputs while using a similar level of inputs or produce the same output using fewer inputs [19, 20].
Depending on the geographical location and demographic features of the target population, health houses may undertake different volumes of activity. Therefore, their performance is affected by the availability of various demographic and geographic resources and their performance should be evaluated.
Previous studies have examined various factors affecting efficiency, such as the following: distance from health centers, number of family members, religion, ethnidistrict, domestic livestock, durable household goods , access to safe drinking water, employee motivation , information and communication technology , socioeconomic variables, quality of care proxies, geographic location, site of centers, and the type of ownership on efficiency .
In fact, the measurement of the efficiency of rural primary health care centers can serve as a source of feedback for the managers. Due to the no study has been conducted to measure the efficiency of rural primary health care centers based on the performance of Behvarz and key health indicators in Iran and also the effective factors on the efficiency of these centers have not been identified. The aim of this study was estimate the technical efficiency of rural primary health care centers and determinant factors in Hamadan providence in Iran.