Differences And Influencing Factors Of Health Expenditure Managerial Efficiency In Achieving Universal Health Coverage Across Middle-income Countries

Making progress towards Universal Health Coverage is one of the Sustainable Development Goals under the theme of Good Health and Wellbeing.For governments and decision-makers of middle-income countries especially,improving the efficiency of health expenditure in the course of pursuit is of uppermost priority.In this study we first measure and compare pure technical efficiency(managerial efficiency)scores of health expenditure across middle-income countries with available data of health expenditure and universal health coverage outcomes(including service coverage and financial protection)between the years of 2010 and 2019,then we identify health financing settings and social development characteristics that will influence the efficiency in managing health expenditure.Data from the World Bank and the World Health Organization have been collected and two-stage Data Envelope Analysis has been applied accordingly.In the first stage,a oneinput,two-output non-parametric model is built to perform both cross-sectional and crosstime comparison of pure technical efficiencies of health expenditure in realizing universal health coverage across 72 middle-income countries.In the second stage,Tobit regression model is chosen to investigate factors explaining variations of pure technical efficiencies across time and countries.Results of the alternative regression option suggested in previous literature(OLS regression)are also reported as references.Cross-sectional analysis of pure technical efficiencies shows that although only a few countries settled on the frontier for each observation year,generally speaking gaps of managerial efficiencies between countries had been narrowed in the 2010s(when influences from scale were set aside).The results also identify a bunch of relatively highly-efficient countries(i.e.Argentina,Cabo Verde,China,Kazakhstan,Romania,Thailand,Turkey and Vanuatu)in all four observation years.Panel analysis generating Malmquist indexes suggests that in general managerial efficiency only fluctuated slightly and did not contribute much to the change of total productivity in the 2010 s.However,still some countries(i.e.Bhutan,Bosnia and Herzegovina,Botswana,India,Indonesia,Iran,Islamic Rep.,Mauritius,Moldova,Nepal and Tunisia)had been constantly improving their efficiency in the management of health expenditure.In the second stage after performances of different countries across years were assessed together in the same pool,both Tobit and OLS regression results suggest that pure technical efficiency scores of middle-income countries are strongly influenced by compulsory financing arrangements(mainly including government financing arrangements and social or private compulsory health insurance)positively,followed by the percentage of population with access to electricity-a variable indicating infrastructure level.They are negatively influenced by the share of people living in urban areas-a variable indicating urbanization and population gathering.The two regression models do not agree on the potential role played by the share of domestic health expenditure in total health expenditure and gross domestic product per capita.It is believed that the results of this study are of great significance to improving the efficiency of health expenditure management in realizing Universal Health Coverage across middle-income countries and boosting the pursuit of this Sustainable Development Goal in middle-income countries.At the end of this study,the author puts forward some suggestions on carrying out targeted policy learning and communications across countries,as well as domestic health financing reforms,for the improvement of country-level managerial efficiency.Possibilities to further polish and deepen this research based on limitations are also discussed.