This study is an initial effort to examine the dynamics of efficiency and productivity in Greek public hospitals during the first phase of the crisis 2009–2012. Data were collected by the Ministry of Health after several quality controls ensuring comparability and validity of hospital inputs and outputs. Productivity is estimated using the Malmquist Indicator, decomposing the estimated values into efficiency and technological change. Hospital efficiency and productivity growth are calculated by bootstrapping the non-parametric Malmquist analysis. The advantage of this method is the estimation efficiency and productivity through the corresponding confidence intervals. Additionally, a Random-effects Tobit model is explored to investigate the impact of contextual factors on the magnitude of efficiency. Findings reveal substantial variations in hospital productivity over the period from 2009 to 2012. The economic crisis of 2009 had a negative impact in productivity. The average Malmquist Productivity Indicator (MPI) score is 0.72 with unity signifying stable production. Approximately 91% of the hospitals score lower than unity. Substantial increase is observed between 2010 and 2011, as indicated by the average MPI score which fluctuates to 1.52. Moreover, technology change scored more than unity in more than 75% of hospitals. The last period (2011–2012) has shown stabilization in the expansionary process of productivity. The main factors contributing to overall productivity gains are increases in occupancy rates, type and size of the hospital. This paper attempts to offer insights in efficiency and productivity growth for public hospitals in Greece. The results suggest that the average hospital experienced substantial productivity growth between 2009 and 2012 as indicated by variations in MPI. Almost all of the productivity increase was due to technology change which could be explained by the concurrent managerial and financing healthcare reforms. Hospitals operating under decreasing returns to scale could achieve higher efficiency rates by reducing their capacity. However, certain social objectives should also be considered. Emphasis perhaps should be placed in utilizing and advancing managerial and organizational reforms, so that the benefits of technological improvements will have a continuing positive impact in the future.

Background: The European Union health policy agenda stresses the importance of environmental and qualitative factors in structural hospital reforms. In response to the economic crisis, both cost containment and performance improvements of the Greek hospital sector, have become a pertinent issue for overall reforms.Objective: The study examines the efficiency of 112 Greek public hospitals, by applying bootstrapping techniques and investigating the effect of contextual factors on hospital efficiency. Furthermore, the effect of qualitative evidence, on hospital efficiency is explored by focusing on a subset of 28 large hospitals.Methods: The quality aspects of the Greek hospitals are investigated by applying two models of Data Envelopment Analysis (DEA), augmented by bootstrapping techniques, in order to assess the importance of quality dimensions on the efficiency of hospital scores. In addition, two Tobit regression models are estimated assessing the contribution of contextual factors, in the efficiency and bias-corrected efficiency scores.Results: Efficiency analysis indicated that only 23.2% of the hospitals are fully efficient (0.96-1.00), 37.5% are efficient (0.71-0.95) while 39.3% are inefficient (0.30-0.70). The Kolmogorov-Smirnov test, between the original and the bootstrap-corrected efficiency, indicates that their distributions are significantly different (p-value < .001). The environmental factors, influencing efficiency, are Occupancy Rate and the ratio between Outpatient Visits and Inpatient Days. Results indicate that the inclusion of Risk-Adjustment Mortality Rate significantly influences (p-value < .05) the efficiency of the hospitals.Conclusions: In the era of economic crisis, the inclusion of quality variables and the use of bootstrapping techniques provide a vital framework in assessing the efficiency of the hospital sector.

The objective of this study was to explore the dynamics of efficiency and productivity of Greek public hospitals during the crisis, as well as to review the effect of implemented policies on hospital efficiency before and the implementation of the claw-back for hospital pharmaceutical expenditure. We implemented Data Envelopment Analysis and decomposed the Malmquist productivity index (MPI) to investigate the fluctuations of the Greek public hospital productivity frontier and therefore their technical efficiency between 2009 and 2019. The MPI components allowed us to capture the frontier shift, as well as pure efficiency changes and scale efficiency changes. Through the period 2009-2019 hospital inputs were reduced drastically. Doctors were reduced by 54% while beds were reduced by 15%. Hospital expenditure was decreasing between 2009 and 2015 but increased by 23% since due to fixed hospital budgets and the “claw-back”. Moreover, output seems to have increased. Patient discharges increased by 14% while diagnostic procedures were reduced by 10% between 2009 and 2016 but have been continuously rising since. Nonetheless, under variable returns to scale (VRS) average hospital efficiency was stable (~75%) for most of the period under study while declining since 2016. Policymakers in Greece have always chosen to implement cost- or input-oriented policies, instead of opting to improve outputs and quality of services. Our analysis indicated that fixed-budget-oriented reforms have impacted hospital efficiency negatively by creating a counterincentive to adopting best practices and improving hospital efficiency. Highlights Technical Efficiency under CRS was stable in Greece (0.70) over the period 2012-2016, and declined to 0.51 in 2019. Hospital Fixed Budget reforms had a negative impact on hospital efficiency. During the economic crisis 2009-2019 hospital inputs were reduced drastically Memorandum Policies introduced by Troika focused exclusively in reducing cost and not improving efficiency.