Evaluating the Efficiency and Determinants of Efficiency of Rural Health Centers Situated in Punjab, Pakistan

This study calculates the efficiency of Rural Health Centers (RHCs) and in-vestigates the impact of other variables affecting the efficiency of RHCs. The study considers 29 RHCs, 13 of District Faisalabad, 9 of Toba and 7 of Jhang; a survey was conducted to collect data from each RHC for the year 2016. Data Envelopment Analysis (DEA) model was utilized to get the scores for efficiency. Thereafter, after getting the results from DEA Tobit regression was used in the second stage. Out of the 29 Rural Health Centers, only 11 (38%) are working efficiently as compare to others. Distance from the tehsil headquarter, Distance from the road with “0” probability, Distance from private hospital with “0” probability, Behavior of the staff with “0.0064” probability and laboratory equipment’s with “0” probability, have an impact on the efficiency scores. Distance from other health facilitators, Staff’s behavior, list of medicine and equipment’s used at RHCs should be improved to increase the efficiency of RHC’s.


Introduction
There is a consensus on the importance of health care all over the globe because the healthy population plays a very important role in growing and in the development of an economy [1]. To earn a long lasting return as a prosperity investment in the health sector is very important as a healthy labor force will increase gram. The total expenditures on health during (July-March) 2014-2015 is estimated Rs. 145.97 billion, which is 0.9 percent more than last year [6].

Data Source
Primary data is used in this study. Due to the shortage of time, this study chooses the nearest districts to collect the data for estimating the efficiency of Rural Health Centers. The sample consists of 3 districts and the data about Medical staff, paramedical staff at the RHC's, Medicine stocks, lab equipment's, number of beds, outdoor patient visits, number of family planning visits, number antenatal care visits, no child immunized and no of normal deliveries at RHC is collected for 29 rural health centers, from their concerning Executive District Office of Health (EDO Health) for the year 2014. Therefore, the sampling technique is a convenience sampling technique. In addition, these districts are: 1) Faisalabad; 2) Jhang; 3) Toba Tek Sing.
And the data is collected for 29 rural health centers from their respective Executive District Officer Health's Office (Table 1).
As the study used primary data so a questionnaire was developed to collect the data before conducting the survey for this study. I got permission from respec- Quarters in kilometers, and how many kilometers RHC is away from the road were asked, timing of the Rural Health Center, distance from any private hospital in kilometers and address was asked to know the facts. In second section questions related to infrastructure were asked like total area of the RHC in canals, covered area in canals, no of Rooms, water availability, availability of sui gas facility, telephone generator facility and related to ambulance facility were asked, are these facilities available there "0" for no and "1" for yes.
In third section questions related to services provided at RHC. Like indoor patient facility, outdoor patient facility, no of wards, no of available beds, is dental room available there, ophthalmology facility available there, is operation theater available, and operation theater is fully equipped or partially equipped, basic laboratory and separate laboratory room is available or not were asked and dummies were created for them like "0" for no and "1" for yes. Do all the staff including senior medical officer, women's medical officer, dental surgeon and medical officer deal with outdoor patients or not, in which patients with malaria, fever due to other causes, vaccine preventable diseases, skin diseases, hypertension, depression, dental caries, injuries, road accidents, fractures, burns, dog bite, and snake bites, indoor and emergency cases also treated there.
Questions about the availability of equipments like X-ray machine, ultrasound machine, and basic laboratory test equipment's are available "0" for no "1" for yes and the condition of those equipments was observed in the fourth section.
The fifth section was about the stock of medicine and drugs are in surplus or in shortage at RHC "0" for shortage if they have medicine stock for less than 3 Health months and surplus if they have medicine stock for more than 6 months, and how the bulk of medicine a Rural Health Center purchased and used. Last but not the least, questions about environment of the RHC were asked and observed like rooms are kept clean or not so "0" for satisfactory and "1" for excellent condition was used, as through survey it is noticed that no RHC was with bad condition and where the waste of the RHC was thrown. It is also noticed that how is the condition of the buildings, is it satisfactory and well maintained, do people have easy access to RHC's, are RHC's are near to the main road in the area (Table 3).

Methods
The concept of measuring efficiency has been analyzed since Adam Smith's era and before. There are different methods available to measure the efficiency.

Estimation of Factors Affecting Efficiency
To estimate the factors, which affect the efficiency of Rural Health Centers, this study applies the Tobit regression and the description about variables is given in (Table 4).

Results and Discussions
The descriptive statistics of output and input variables which are the products or output of Rural Health Centers by using a set of outputs and these outputs are used in calculating efficiency by using Data Envelopment Analysis. As the (Table 5) (Table 7). There is only one Rural Health Center, which has an efficiency score of 90%, which is close the to 100% efficiency score.
Five are working well above the average efficiency score, with efficiency score to 70% to 80% and they are in Tehsil Jhumra, Jaranwala and Tandlianwala. 23% of the Rural Health Centers are those which are working inefficiently as their efficiency score is quite below the average efficiency score but above 50% as they have an efficiency score between 50% and 60% there is 40% capacity available to increase their productivity. Rural Health Center situated at Chak No. 134 GB showed 20% efficiency score which is very disappointed as that is working totally inefficiently and there is 80% capacity available to increase its productivity to production possibility frontier. According to variable return to scale out of 20  Centers is from Tehsil Head Quarter, the variable is positively significant at 1% level, the coefficient tells that as the distance between THQ and RHC increases the efficiency of RHC will increase by 0.015 and the p-value is "0" which means it is statistically significant. As the distance between THQ and RHC increases people will go to RHC's rather going to THQ's.
Coefficient of Distance from Roads negatively significant at 1% level o as shown in Table 9. This distance is between the main road and Rural Health Centers. In addition, the coefficient indicates that Rural Health Centers, which are located on the main road the efficiency of those Rural Health Centers, are higher than the RHC's far away from the main road. There is a negative relation between Distance from Road and Efficiency as the distance increases the efficiency decreases by 0.19 units and the p-value is "0" which is less than alpha which means it is statistically significant.
There are some private hospitals near the RHC's and the variable Distance from the private hospital show positive and significant effect on efficiency at 1% level of significance. As the distance between private hospitals and Rural Health Centers increases the efficiency of the RHC's will also increase by 0.046 units because people will go to Rural Health Centers than going to private hospitals its p-value is also "0" it means it is statistically significant.
Maintenance and cleanliness of the rooms also affect the efficiency of Rural Health Centers. Cleanliness is positively significant at 1% level of significance and the coefficient of Cleanliness shows that efficiency of Rural Health Centers with excellent condition will 0.233 units higher than the RHC's with satisfactory condition.
The behavior of the staff also has a positive impact on efficiency. Coefficient of the behavior of the staff is positively significant at 1% level and shows that efficiency is 0.086 units higher of those Rural Health Centers where staff has friendly behavior with their patients than the Rural Health Centers where staff has rude behavior with their patients and the p-value is "0" which means it is statistically significant.
Availability of the Staff is a variable which tells that the presence of the staff affects the efficiency of Rural Health Centers or not. The above table shows that it is positively significant at 10% level and the coefficient shows that the effi- there is no effect on the efficiency of this variable as it has an insignificant impact on efficiency score.