Comparative efficiency of public health systems in Asia: evidence from bootstrap DEA in the context of the sustainable development goals (SDGs)

Abstract

Governments across Asia have increased health spending over the past decade, but child mortality rates – particularly under-five and neonatal deaths – remain high in many countries. The real question is: are countries spending their health budgets efficiently? This study aims to look at how efficiently 42 Asian countries used public health resources between 2010 and 2019 to reduce child mortality, and what factors may explain differences in efficiency. Using a bootstrap data envelopment analysis (DEA), the authors assessed how effectively each country converted health spending into lower child mortality rates. The authors also used bootstrap truncated regression to explore what might drive differences in efficiency – like female labor force participation, access to electricity and out-of-pocket spending by households. Most countries (36 out of 42) showed decreasing returns to scale, meaning more spending did not necessarily lead to better outcomes – just marginal improvements. Only five countries showed increasing returns to scale, where spending was both effective and efficient. The average efficiency improved over the decade, with China and Thailand standing out among emerging economies. In contrast, India had the lowest efficiency score. The analysis also found that social and infrastructure factors, like women’s participation in the workforce and electricity access, played a key role in shaping how efficiently health resources were used. This study has few limitations: first, the choice of the time period selected in the study is restricted to pre-Covid-19 period due to data unavailability. Second, because the countries selected in the analysis had to be mapped based on the availability of data, the authors could select only 42 countries. Finally, although, several factors are mentioned in the literature that may improve the efficiency of health expenditures, only a few were included in this analysis to maintain a sizable sample size. This study has practical implications, as higher health expenditure may not necessarily translate to better child health outcomes automatically. Rather, what really matters is how well that resources are allocated and used. Governments need to focus on getting better results from the spending they already do. Moreover, such an analysis can provide an understanding of a comparative performance of peers and provide valuable insights into effective policy design, resource management and service delivery. This study uniquely links health spending efficiency to health outcomes for a decade across 42 Asian countries using bootstrap DEA.