Health Care Manag Sci (2014) 17:126–138
DOI 10.1007/s10729-013-9249-8
Efficiency determinants and capacity issues in Brazilian
for-profit hospitals
Cláudia Araújo & Carlos P. Barros & Peter Wanke
Received: 8 February 2013 / Accepted: 22 July 2013 / Published online: 4 August 2013
# Springer Science+Business Media New York 2013
Abstract This paper reports on the use of different approaches
for assessing efficiency of a sample of major Brazilian for-
profit hospitals. Starting out with the bootstrapping technique,
several DEA estimates were generated, allowing the use of
confidence intervals and bias correction in central estimates to
test for significant differences in efficiency levels and input-
decreasing/output-increasing potentials. The findings indicate
that efficiency is mixed in Brazilian for-profit hospitals. Op-
portunities for accommodating future demand appear to be
scarce and strongly dependent on particular conditions related
to the accreditation and specialization of a given hospital.
Keywords For-profit hospitals . DEA . Bootstrap . Brazil .
Efficiency
1 Introduction
In Brazil, the total per capita spending on healthcare grew
102.8 % between 1999 and 2009, reaching $ 900.00 in 2010,
while health spending accounted for only 8.4 % of GDP in
2010. In 2009, health plans bore 41.2 % of private expenditure
on health, while the Brazilian government health spending
C. Araújo
Center for Studies in Healthcare Services, COPPEAD Graduate
Business School, Federal University of Rio de Janeiro,
Rio de Janeiro, Brazil
e-mail: claraujo@coppead.ufrj.br
C. P. Barros (*)
Technical University of Lisbon, Lisbon, Portugal
e-mail: cbarros@iseg.utl.pt
P. Wanke
Center for Studies in Logistics, Infrastructure and Management,
COPPEAD Graduate Business School, Federal University of Rio de
Janeiro, Rio de Janeiro, Brazil
e-mail: peter@coppead.ufrj.br
stood at 45.7 %.1 Regardless of the rising costs, there is a
deterioration in the quality of services and a large mass of
underserved, since public services are not able to adequately
serve the country’s population totaling approximately 195
million people in 2011, 10 % of whom (19.5 million) were
over the age of 60 years then.2
The health care sector in Brazil is divided into the public
and private systems, and all Brazilians have free access to
health care through the Unified Health System (Sistema Único
de Saúde, or SUS). SUS offers free health services through
public institutions at the federal, state and municipal levels, as
well as private institutions, which provide services to SUS
through agreements with public agencies. In 2013, Brazil had
4,812 private hospitals, which corresponds to 70 % of the
6,875 Brazilian hospitals.3
The inefficiency of the Brazilian public hospitals has been
widely reported by previous research [1–3], but very few
studies have been devoted to the study of the efficiency of
Brazilian private hospitals. Therefore, this paper helps to close
this gap by presenting a benchmark and efficiency analysis of
20 major Brazilian private for-profit hospitals belonging to
largest health-care provider corporations in Brazil. A comple-
mentary approach is used for measuring the efficiency levels
of these hospitals and for characterizing their returns to scale
condition: Data Envelopment Analysis (DEA) in its envelop-
ment and multiplicative forms, respectively.
Despite the increased use of DEA to measure the efficiency of
hospitals over the last decade, there are still few studies that also
exploit bootstrapping methodology to account for measurement
errors in estimates within this particular sector, such as Proite and
Sousa [4], Staat [5], and Tiemann and Schreyögg [6, 7]. Initially
1
World Health Organization 2011: site http://apps.who.int/ghodata/?
theme=country#. Access in 09/12/2012.
2
World Health Organization 2011: site http://apps.who.int/ghodata/?
theme=country#. Access in 09/12/2012.
3
Ministry of Health, DATASUS 2013: site http://cnes.datasus.gov.br/.
Access in 05/08/2013.
Efficiency determinants and capacity issues in Brazilian
introduced by Simar and Wilson [8, 9], bootstrapping allows
sensitivity analyses on efficiency scores and slacks, as well as on
other scaling indicators, to be performed by repeatedly sampling
from the original data.
This paper uses the bootstrapping methodology to test,
among other things, for the presence of scale inefficiency–input
and output slacks–at different Brazilian for-profit hospitals. Its
contribution lies in an empirical application, inspired by the
current debate in the Brazilian healthcare sector, in which there
is a capacity shortfall: between 2005 and 2012, the number of
hospital beds in Brazil decreased 40,5 %, resulting in 505,906
beds in 2013 (2.4 beds/1000 inhabitants).4 Furthermore, the
capacity shortage resulted from a combination of factors, includ-
ing doctor and nurse shortage, population growth, and aging
population, as shown by the numbers above. Another contribu-
tion of this paper is to deepen the discussion about issues still
controversial in the literature, such as the effects of hospital
accreditation, age, and specialization on the efficiency levels.
2 Literature review
This section presents the background of DEA-based studies
on hospital efficiency measurement around the world. In each
one of its subsections, different efficiency determinants are
thus revisited: ownership and profit focus, size, accreditation,
and specialization.
2.1 Background
Since the 90’s there have been a growing number of studies to
benchmark hospital efficiency [10–12]. Initially, DEA was
applied mainly in studies conducted in the USA [10], but from
the following decade on, a significant number of studies
conducted in other countries have appeared, such as in Austria
[13], Greece [14, 15], Italy [16, 17], Germany [5, 6, 18, 19],
Spain [20, 21], Norway and Finland [22, 23], Portugal [24,
25], Turkey [26–28], China [29, 30], India [31, 32], Botswana
[33], Iran [34, 35], Korea [36], and so on.
In Brazil, the methodology started to be applied more
recently, in general investigating public and university hospi-
tals [1, 2, 37–39]. There is, however, a lack of studies focusing
on Brazilian private for-profit hospitals.
2.2 Ownership and profit focus
Comparing public and private hospitals, the evidence from
studies conducted by Hollingsworth [40, 41] indicate that pub-
lic hospitals have a higher mean efficiency score than private
NFP and private FP hospitals. Likewise, studies conducted in
4
Ministry of Health, DATASUS 2013: site http://cnes.datasus.gov.br/.
Access in 05/08/2013.
127
the USA and Germany suggests that private ownership
(i.e., private NFP and private FP) is not necessarily asso-
ciated with higher efficiency when compared to public
ownership [6]. Tiemann and Schreyögg [6, 7] researched
1046 German hospitals and identified that public hospitals
performed significantly better than private FP and NFP
hospitals. The results suggest that public hospitals focus
mainly on input efficiency because of their resource limi-
tations. In a previous study conducted in Germany, Helmig
and Lapsley [18] concluded that public hospitals are more
efficient because they use relatively fewer resources than
private hospitals do. By studying 1170 Brazilian hospitals,
852 private and 319 public, Proite and Souza [4] also
concluded that public hospitals tend to be more efficient
than private FP and NFP hospitals.
In this sense, Lee, Yang, and Choi [42] defend that NFP
hospitals behave similarly to FP, since the former have been
struggling with cost reduction efforts. Their research in hos-
pitals in Florida (USA) indicates that NFP hospitals were
more efficient than FP hospitals for all 4 years examined in
this study. According to these authors, this result can be
explained by the hospital size: a larger organization can pursue
a variety of managerial strategies to improve efficiency.
However, there is no consensus on the greater efficiency of
public hospitals in relation to private ones. Burgess and Wilson
[43] applied DEA in a study conducted in the USA to analyze
whether the ownership structures–NFP, FP, federal, state, and
local government hospitals–differ in terms of their technical
ability to convert inputs into outputs. The results of their
research indicate that FP are more efficient than NFP hospitals.
The authors argue that NFP hospitals tend to have managers
more committed to providing high-quality service than to
generating profit. Therefore, these managers might use more
inputs to produce the same outputs than FP hospitals. Besides,
they may be less concerned about waste in the production
process. Also, Hu et al. [44] affirm that due to more invest-
ments in medical technologies, FP hospitals are generally more
efficient than NFP hospitals. Equally, some studies conducted
in Taiwan indicate that public hospitals have lower operational
efficiency than private hospitals [45, 46]. According to Hu and
Huang [45], public ownership significantly worsens a hospi-
tal’s efficiency. Moreover, Grosskopf et al. [47] suggest that
private hospitals use fewer inputs to produce outputs, when
compared with public hospitals. This being the case, such a
fact makes private hospitals more efficient than public ones.
2.3 Size
Some studies suggest a positive association between hospital
size and efficiency [4, 6, 48, 49]. The results of the research
conducted by Hu and Huang [45] suggest that increasing the
number of beds improves hospital efficiency, but there should
be a balance between capacity and utilization. Likewise,
128
Rahman [47] argues that the greater the number of nurses per
bed in a hospital, the greater its efficiency.
2.4 Accreditation
Accreditation can be defined as a process that a health care
institution undergoes to demonstrate compliance with stan-
dards developed by an official agency. A professional associ-
ation or nongovernmental agency grants recognition to a
health care institution that meets the established standards.
Hospital accreditation in Brazil is voluntary.
Some studies indicate that accredited hospitals tend to be
more efficient than those that are not [48, 50]. Wei et al. [50]
argue that accredited hospitals tend to be more efficient than
those that are not, since the former usually make great invest-
ment in research and development. In turn, some authors ques-
tion whether or not accreditation actually has a positive impact
on efficiency [47, 51]. Alexander et al. [51] affirm that the
accreditation demands additional staff for bureaucratic activities
which would decrease the hospital efficiency. Grosskopf et al.
[47] argue that the higher investments in equipment and re-
sources required to treat the patients (inputs) can lead to ineffi-
ciency in accredited hospitals. Furthermore, the results of the
research conducted by Grosskopf et al. [47] to assess the per-
formance of US teaching hospitals suggest that if the hospital
has a mix of high complexity services (tertiary hospitals, for
example), this can lead to inefficiency. On the other hand, Lee,
Yang, and Choi [42] argue that the greater the number of
services delivered (i.e., higher service complexity) the greater
the economics-of-scale, which increases the hospital efficiency.
2.5 Specialization
Specialty hospitals provide a limited range of medical proce-
dures, such as cancer specialty hospitals, and specialty hospi-
tals focusing on cardiac, orthopedic, or neurological proce-
dures. Regarding specialization, Lee et al. [52] argue that
specialized hospitals are more likely to be efficient, since they
may gain advantage over their competitors in that specific
area. On the other hand, Proite and Sousa [4] affirm that the
excessive specialization of institutions may have negative
effects on efficiency, since these hospitals tend to lengthen
the patient’s stay. As a matter of fact, Proite and Sousa [4]
suggest that hospitals should seek an optimal combination
between specialization and generalization.
3 Methodology
3.1 The data
Secondary data regarding a sample of 20 Brazilian private for-
profit hospitals were obtained from the statistical database
C. Araújo et al.
provided by the largest private health-care provider corpora-
tion in Brazil, with a market share of approximately 10,1 % in
terms of number of enrollees, 6,3 million members, and total
net revenue from services of $ 5.2 billion5.
As regards the input/output variables used, readers should
recall that one of the aims of the paper is to assess the input
slacks in Brazilian private for-profit hospitals, as well as their
output-increasing potentials. The nine inputs originally col-
lected from each hospital are: (i) hospital area (m2), (ii) num-
ber of intensive care units beds (ICU beds), (iii) number of
emergency beds, (iv) total number of hospital beds, (v) total
number of staff, (vi) number of doctors, (vii) number of
nurses, (viii) number of doctor’s offices in the hospital, and
(ix) number of surgical rooms. According to Ozcan [12], these
variables reflect the some of the usual inputs for hospitals:
human resources and capital (beds). With respect to the out-
puts, five variables were collected: (i) number of ordinary
inpatients (per year), (ii) number of ICU inpatients (per year),
(iii) number of emergency inpatients (per year), (iv) total
number of outpatient treatments (per year), and (v) number
of surgeries (per year). Descriptive statistics for each input and
output are respectively presented in Table 1.
Contextual variables presented in Table 1 relate to the hospital
type: specialized (1) or non-specialized (0); accredited (1) or
non-accredited (0); complexity level of the medical procedures
performed (1 = low–primary health centers; 2 = medium;–
outpatient clinics; 3 = high–outpatient specialty and hospitals);
and hospital age. Besides the variables previously mentioned in
section 2, such as accreditation and specialization, Grosskopf
et al. [47] relate the complexity level of the medical procedures
performed with the hospital efficiency and affirm that the higher
the complexity level, the lower the efficiency. Rahman [48], in
turn, concluded that older hospitals tend to be less efficient
because of bureaucracy.
3.2 Data envelopment analysis
3.2.1 Background
DEA is a non-parametric model first introduced by Charnes
et al. [53]. It is based on linear programming (LP) and is used
to address the problem of calculating relative efficiency for a
group of DMUs by using multiple measures of inputs and
outputs. Given a set of DMUs, inputs, and outputs, DEA
determines for each DMU a measure of efficiency obtained
as a ratio of weighted outputs to weighted inputs.
Consider a set of n observations on the DMUs. Each
observation, DMUj (j=1, …, n) uses m inputs xij (i=1,
…, m) to produce s outputs yrj (r=1, …, s). DMUo
represents one of the n DMUs under evaluation, and xio
5
Amil Assistência Médica Internacional S.A. site: http://www.amil.com.
br/portal/institucional/empresa. Access in 05/08/2013.
Efficiency determinants and capacity issues in Brazilian 129

Number of surgical

(1 = yes/0 = no)
and yro are the ith input and rth output for DMUo,
respectively. Table 2 presents the envelopment model for the

Accredited
hospital
VRS frontier type [54, 55]. Also presented is the DEA model in
rooms its multiplicative form.

14.0
6.5

3.0
2.7
0.4

1.0
An output maximization orientation is adopted here.

–
Under these circumstances, decision-makers should at-

Specialized hospital
(1 = yes/0 = no)
tempt to maximize production outputs for a given level
Number of doctor

of inputs, supposedly fixed in the short term. According

to Mogha et al. [56], the choice of model orientation,
offices

either input-oriented or output-oriented, depends on the

20.0

extent to which the health institution has control on its

7.6
7.0
0.9

1.0
–

–
inputs or outputs. Since the main objective of private
Complexity

hospitals is to maximize the operating income using the

Number of
nurses

level

existing inputs, the output oriented model is suitable for

Contextual variables
220.0
19.0
75.7
54.8

this analysis, and it is in line with previous studies [17,

2.0
0.7

3.0
44–46, 55].
Number of
doctors

(years)
Hospital

3.2.2 Data reduction

age
460.0
108.3
95.1

71.0
6.0
1.1

6.0

One of the frequent problems of DEA is a lack of differenti-

Total number

(per year)

ation between DMUs, which can be caused by an excessive

surgeries
Number of
of staff

19,108.0
11,467.0

number of input (output) variables with respect to the total

2,446.9
1,321.1

6,855.9
4,073.6
185.0

952.0

number of observed DMUs in the respective analysis [57].

1.9

0.6

According to Cooper et al. [58], the number of DMUs is a

relevant issue when using DEA as the cornerstone methodol-
Total number of

Total number of
hospital beds

outpatients

ogy. More precisely, following Barros et al. [59], the combi-

(per year)

nation of the measured indicators should not only ensure

13,238.4

64,169.0
20,412.6
303.0
128.7

adherence to the literature survey, but also to the DEA con-

39.0
80.2
0.6

1.5

vention that the minimum number of DMU observations

–

should be greater than three times the number of inputs plus

inpatients (per year)
Number of emergency

Number of emergency

outputs.
However, a systematic statistical method for deciding
which of the original correlated variables can be omitted with
102,378.8

254,600.0
73,585.9

the least loss of information, and which should be retained, is

8,118.0
beds

deemed necessary [60]. This issue is of utmost importance

30.0
13.0
8.4
0.6

2.0

0.7

because, traditionally, highly correlated variables have been

omitted on an ad hoc basis producing unpredictable impacts
Number of ICU

Number of ICU

on DEA efficiency estimates [60, 61].

(per year)
inpatients

Adler and Berechman [57] developed a methodology

2,085.7
2,034.8

7,452.0
beds

based on Principal Component Analysis (PCA) to reduce the

19.6

70.0
29.2

0.7

1.0

number of input (output) variables used in DEA into factors.

–

PCA explains the variance structure of a matrix of data

Table 1 Summary statistics for the sample

Number of ordinary

through linear combinations of variables, which generally

describe 70–90 % of the variance in the data. If most of the
Hospital area

(per year)
inpatients

population variance can be attributed to the first few factors,

(sq. m)

16,103.1
27,000.0

15,061.6

70,897.0
10,483.3

Outputs
7,845.0

2,028.0

then they can replace the original variables without much loss
Inputs

10.1
0.7

1.1

of information.
When comparing PCA and variable reduction based on
Standard deviation

Standard deviation

partial covariance using a simulation based approach, Adler

Coefficient of

Coefficient of

and Yazhemsky [62] found that PCA provides a more power-

Descriptives

Descriptives
variation

variation
Maximum

Maximum
Minimum

Minimum

ful discrimination tool than variable reduction with consistent-

ly more accurate results when the curse of dimensionality
Mean

Mean

exists. One disadvantage, however, is related to the fact that

130
Table 2 DEA output-oriented
envelopment and multiplicative Frontier type
models
Constant Returns to Scale
(CRS), also known as CCR
Varying Returns to Scale (VRS),
also known as BCC
the targets and the efficient peers obtained might reflect a
substantial change in the current mix of input–output levels
of the inefficient DMU’s [63]. Since problems related to
discrimination often arise, there is a need to trade-off between
using complete DEA information and improving discrimina-
tion [64, 65].
In this study, PCA was used to determine the most relevant
inputs and outputs by means of factor extraction. In other
words, PCA allowed the identification of the most represen-
tative inputs and outputs within each factor by looking at their
factor loads. According to Tabachnick and Fidel [66], only
factor loads greater than 0.50 deserve to be interpreted, and in
these cases the variable is said to represent a good factor
measure.
3.2.3 Bootstrapping
Nonparametric efficiency estimators such as Data Envel-
opment Analysis (DEA) typically rely on linear program-
ming techniques for computation of estimates, and are
often characterized as deterministic, as if to suggest that
the methods lack any statistical underpinnings [9]. Ap-
plied studies that have used these methods have typically
presented point estimates of inefficiency, with no measure
or even discussion of uncertainty surrounding these esti-
mates [67].
The method used in this research departs from that
presented by Simar and Wilson [9], who adapted the bootstrap
methodology to the case of DEA efficiency estimators and
uses a Gaussian kernel density function for random data
generation. All the computations were carried out with Maple
codes developed by the authors; 1,000 bootstrap replications
were performed on models (1) and (2), following the discus-
sion presented by Simar and Wilson [8, 9] and Curi et al. [68]
on deriving statistical properties for each hospital vis-à-vis
bias estimation, central tendency correction, and confidence
intervals (CIs).
C. Araújo et al.
Envelopment Multiplicative
m
maxf
s:t: min ∑ vi xio þ vo
i¼1
n
s:t:
∑ λ j xij ≤xio ; ∀i ð1Þ m s
j¼1
n ∑ vi xij − ∑ ur yrj þ vo ≥0 ð2Þ
∑ λ j yrj ≥fyro ; ∀r i¼1 r¼1
j¼1
s
λj ≥ 0 ; ∀ j ∑ ur yro ¼ 1
r¼1
ur ; vi ≥0; vo ¼ 0
n
vo free in sign
Add ∑ λ j ¼ 1
j¼1
3.3 Bootstrapped truncated regression
The approaches to the statistical treatment of the variations in
the efficiency estimates produced using DEA–CCR, BCC, or
SE–have evolved over the course of the years; see, for exam-
ple, Banker [69] and Simar and Wilson [70, 71]. As a depic-
tion of this evolution, Cooper et al. [72] point to the growing
number of studies that combine DEA scores obtained in a first
stage with those of multivariate data analysis (such as regres-
sion analysis) in a second stage, when the scores are incorpo-
rated in the form of the dependent variable.
Simar and Wilson [70] argue that truncated regression
combined with bootstrapping as a re-sampling technique best
overcomes the unknown serial correlation complicating the
two-stage analysis. The adequacy of the functional form to the
data is a prevalent problem and a common critique on the
stochastic frontier models, as seen in Khumbakar and Lovell
[73]. In this research, the Simar and Wilson [70] approach is
employed and the following regression specification is as-
sumed and tested:
E j ¼ a þ Z j δ þ ε j ; j ¼ 1; …:; n; ð1Þ
which can be understood as the first-order approximation of
the unknown true relationship. In Eq. (1), a is the constant
term, εj is statistical noise, and Zj is a row (vector) of
observation-specific variables for DMU j that is expected to
be related to the DMU’s efficiency score, Ej, which may
represent, as will be seen later on, BCC, CCR, or even scale
efficiency (SE) scores.
Specifically, noting that the distribution of εj is restricted by
the condition εj ≥1−a−Zjδ (since both sides of (1) are bounded
by unit), Simar and Wilson [70] is followed here and it is
assumed that this distribution is truncated normal with zero
mean (before truncation), unknown variance, and (left) trunca-
tion point determined by this very condition.
Efficiency determinants and capacity issues in Brazilian
Furthermore, replacing the true but unobserved regressand
in (1), Ej, by its DEA estimate, E j , the econometric model
formally becomes:
E j ≈ a þ Z j δ þ ε j ; j ¼ 1; …:; n; ð2Þ
where

some inputs and outputs presented in Table 1. These zero
ε j ∼ N 0; σ2ε ; such that ε j ≥ 1−a−Z j δ; j ¼ 1; …; n; ð3Þ
which is estimated by maximizing the correspondent likeli-
hood function, with respect to (δ,σε2), given the data collected.
Parametric bootstrap for regression can be employed to con-
struct the bootstrap confidence intervals for the estimates of
parameters (δ,σε2), which incorporates information on the
parametric structure and distributional assumption. For the
sake of brevity, readers should refer to Simar and Wilson
[70] for the details of the estimation algorithm, the respective
computations of which were carried out with R codes devel-
oped by the authors.
4 Results and discussion
4.1 Principal component analysis
An extraction of factors from the transformation of the nine
input variables was conducted by means of PCA with Varimax
standardized rotation for data collected from 20 hospitals.
Results are presented in Table 3 only for eigenvalues greater
than 1.
Two main factors represent the hospital inputs, interpreted
next. The inputs hospital area, number of ICU beds, number of
emergency beds, total number of hospital beds, total number
of staff, number of nurses, and number of surgical rooms
make up factor 1, interpreted as the Hospital
Infrastructure and Supporting Staff Index. Within this
factor, the input hospital area presented the largest factor
load and was chosen to be the most representative variable. In
turn, the variables number of doctors and number of doctor’s
offices make up factor 2, simply named Hospital Doctor and
Office Index, and its interpretation is similar. Similarly, within
this factor, the most representative variable was found to be
the number of doctor’s offices.
With respect to the outputs, five production related vari-
ables were reduced into two factors: Longer-Term
Medical Procedures Index and Shorter-Term
Medical Procedures Index. The two most representative
outputs for these two factors are, respectively, the number
of ICU inpatients and the total number of outpatient
treatments. It should be also noted, however, that for each
one of the four factors analyzed, the most representative
131
variable could be considered as a proxy for the behavior of
the remainder variables within each factor, since these vari-
ables tend to be strongly correlated with each other.
4.2 DEA original and bootstrapped estimates
Before proceeding, it is noteworthy to comment about the
methodological treatment on the zero values that appear in
values were substituted by 0.01. According to Barr [74], this
is a common feature offered by different DEA softwares that
is used in order to proceed with the derivation of the efficiency
scores. Additional analysis conducted to assess the methodo-
logical bias introduced by this procedure seems to be minimal:
these results still hold when 0.001 is used instead of 0.01.
Initial efficiency estimates and their bootstrapped correc-
tion are presented in Table 4, as well as the respective peers,
lambda values, and dual values. As one would expect, the
CCR model yields lower average efficiency estimates than the
BCC model, with respective average values of 0.46 and 0.62,
and where an index value of 1.00 equates to maximum effi-
ciency. In other words, the CCR model identifies more inef-
ficient hospitals (15 vs. 14) than the BCC model does. This
result is not surprising, as the CCR model fits a linear produc-
tion technology, whereas the BCC model features variables
returns to scale, which are more flexible and reflect manage-
rial efficiency apart from purely technical limits. As a matter
of fact, the CCR and BCC scores will only be equal if there is
no scale inefficiency.
In a broad sense, it is possible to affirm that the group of
DMUs that were found to be both BCC and CCR-efficient,
that is, the group DMUs that are scale efficient, encompasses
both high/low complexity, accredited/non-accredited, and
specialized/non-specialized hospitals. This results preliminary
suggest that there may be different paths, with respect to
contextual variables, for achieving the most productive scale
size.
As regards the comparison of initial and bootstrapped
estimates on efficiency measurements, it is important to ac-
knowledge that initial DEA estimates tend to be upward
biased. According to Bogetoft and Otto [75], if there are no
measurement errors then all of the observations in the sample
are from the technology frontier. As expected, bootstrap bias
correction led to lower estimates in BCC and CCR frontiers,
with the exception of Hospital Samaritano, a hospital located
in Rio de Janeiro that is no accredited so far. According to
Wanke [76], results like these suggest that the DEA convexity
assumption may not hold on the entire efficient frontier.
In addition to providing efficiency measures, DEA also
provides other information relevant for the inefficient DMUs.
Particularly, DEA identifies the efficient facet being used for
comparison, the combination of inputs that are being used
inefficiently, and the deviation of specific outputs from the
132 C. Araújo et al.

Table 3 Factor extraction

Inputs Factors Outputs Factors

Hospital infrastructure Hospital doctor and Longer-term medical Shorter-term medical

and supporting staff offices index procedures index procedures index
index

Hospital area (sq. m) 0.88 0.24 Number of ordinary 0.85 (0.12)

inpatients (per year)
Number of ICU beds 0.80 0.22 Number of ICU 0.86 (0.03)
inpatients (per year)
Number of emergency beds 0.59 (0.27) Number of emergency (0.04) 0.90
inpatients (per year)
Total number of hospital beds 0.79 0.40 Total number of 0.09 0.92
outpatients (per year)
Total number of staff 0.73 (0.35) Number of surgeries 0.72 0.32
(per year)
Number of doctors 0.22 0.63
Number of nurses 0.82 0.32
Number of doctor offices 0.01 0.80
Number of surgical rooms 0.86 0.36
Kaiser-Meyer-Olkin measure of sampling adequacy 0.70 Kaiser-Meyer-Olkin measure of sampling 0.56
adequacy
Bartlett’s test of sphericity Approx. Chi-square 104.58 Bartlett’s test of sphericity Approx. Chi-square 23.82
df 36.00 df 10.00
Sig. 0.00 Sig. 0.01
Percent of variance explained by the factors 67.80 % Percent of variance explained by the factors 75.10 %

Bold values indicate load factors greater than 0.50

efficient level. It should be noted that efficient DMUs tend not
to present any slack and this information is reported solely for
the inefficient DMUs.
The BCC model results for the inefficient DMUs, as well as
the facet terminal numbers and associated lambdas (in
brackets) are presented in Table 4. All lambdas add up to
one as a result of the convexity constraint, and, therefore, they
may be interpreted as relative weights. Higher lambda values
indicate which efficient terminal was more important in de-
termining the inefficiency of a particular DMU. For instance,
for Hospital ABC (DMU #12), Hospital Mario Lioni presents
the highest weight in the facet (0.60), followed in sequence by
CS Santa Lucia (0.27), and Hospital Vitoria (0.13). It is
interesting to note that Hospital Mario Lione, which is
accredited but not specialized and presents a low complexity
level, is appears the greatest number of times (13 out of 20) as
the efficient peer with highest weight. On the other hand, well-
known referenced hospitals in terms of handling complex
procedures and specialization, such as CS Santa Lucia, Pró-
Cardíaco, and TotalCor, appear only a small number of times
(3 out of 20) as the efficient peer with highest weight, always
referencing themselves.
According to Thanassoulis [77], the virtual input and out-
put levels reflect the extent to which the efficiency rating of a
Pareto-efficient DMU is underscored by each one of its inputs
and output levels. On average, the hospitals in the sample
relies for its efficiency rating mostly on the hospital area
(62.3 %), as regards the virtual inputs, and on the ICU inpa-
tients (57.3 %), as regards the virtual outputs. Results suggest
that high complexity, specialized units tend to rely mostly on
these virtual input and output. On the contrary, low complex-
ity and non-specialized units derive its efficiency levels from
doctor’s offices, as regards the virtual inputs, and total number
of outpatient treatments, as regards the virtual outputs. It is
very important to note, however, that the existence of multiple
optimal solutions to the model does not necessarily mean that
the specific DMU cannot have a high virtual level on that
input or output in some other optimal solution to the model.
Results for the bias-corrected input and output slacks for
the major Brazilian for-profit hospitals are presented in detail
in Table 5. Available input-decreasing and output-increasing
potentials were also calculated in percent terms, dividing each
corrected slack by the respective input/output index.
One can easily appreciate that, in many cases, the avail-
able hospital area and doctor’s offices to meet future de-
mand growth are negligible, although the former are not as
so severely restricted as the later. More precisely, some
hospitals in Rio de Janeiro and São Paulo, such as Pró-
Cardíaco, Pasteur, Samaritano, TotalCor, Santa Lúcia, and
Alvorada, present virtually no input slacks in terms of the
number of doctor’s offices, taken current demand levels as
a basis for comparison.
Table 4 Initial and bootstrapped efficiency estimates

DMU Initial estimates Lambdas (BCC frontier) Peers Bootstrap corrected Virtual inputs/outputs
estimates (BCC frontier)

BCC CCR SE L2 L3 L4 L6 L8 L11 Sum # 1 #2 #3 BCC CCR SE u1 u2 Sum v1 v2 Sum

HC Padre Miguel 0.39 0.38 0.96 0.54 0 .08 – – 0.38 – 1.00 HC Mário Lioni H TotalCor H Vitória 0.32 0.29 0.92 0.41 0.59 1.00 – 1.00 1.00
HC Mário Lioni 1.00 1.00 1.00 1.00 – – – – – 1.00 HC Mário Lioni – – 0.68 0.58 0.86 1.00 0.00 1.00 1.00 – 1.00
Efficiency determinants and capacity issues in Brazilian

H TotalCor 1.00 0.22 0.22 – 1 .00 – – – – 1.00 H TotalCor – – 0.98 0.33 0.34 0.99 0.01 1.00 1.00 – 1.00
H Pró-Cardíaco 1.00 1.00 1.00 – – 1 .00 – – – 1.00 H Pró-Cardíaco – – 0.98 0.74 0.75 1.00 0.00 1.00 1.00 – 1.00
H Santa Paula 0.21 0.15 0.72 1.00 – – – – – 1.00 HC Mário Lioni – – 0.18 0.15 0.82 0.50 0.50 1.00 1.00 – 1.00
CS Santa Lúcia 1.00 1.00 1.00 – – – 1.00 – – 1.00 CS Santa Lúcia – – 0.91 0.83 0.91 0.10 0.90 1.00 1.00 – 1.00
H Pasteur 0.18 0.06 0.33 – – – 1.00 – – 1.00 CS Santa Lúcia – – 0.24 0.13 0.53 0.00 1.00 1.00 – 1.00 1.00
H Vitória 1.00 1.00 1.00 – – – – 1.00 – 1.00 H Vitória – – 0.98 0.95 0.96 0.99 0.01 1.00 1.00 – 1.00
H Nove de Julho 0.82 0.38 0.46 0.40 – – – – 0.60 1.00 HC Mário Lioni HM Ipiranga 0.46 0.28 0.60 0.50 0.50 1.00 0.21 0.79 1.00
H Alvorada - SP 0.67 0.17 0.26 – – – 1.00 – – 1.00 CS Santa Lúcia – – 0.57 0.27 0.48 0.00 1.00 1.00 – 1.00 1.00
HM Ipiranga 1.00 1.00 1.00 0.00 – – – – 1.00 1.00 HC Mário Lioni HM Ipiranga 0.55 0.44 0.80 1.00 0.00 1.00 – 1.00 1.00
(Mogi das Cruzes)
H ABC Materno Infantil 0.01 0.01 1.00 0.13 – – 0.27 0.60 – 1.00 HC Mário Lioni CS Santa Lúcia H Vitória 0.01 0.01 1.00 0.97 0.03 1.00 1.00 – 1.00
H Metropolitano Butantã 0.69 0.42 0.61 1.00 – – – – – 1.00 HC Mário Lioni – – 0.40 0.28 0.70 0.50 0.50 1.00 1.00 – 1.00
HC Caieiras 0.79 0.64 0.81 0.03 – – – 0.53 0.44 1.00 HC Mário Lioni H Vitória HM Ipiranga 0.41 0.34 0.81 1.00 0.00 1.00 0.05 0.95 1.00
HM Metropolitano 0.97 0.90 0.93 0.21 – – – – 0.79 1.00 HC Mário Lioni HM Ipiranga – 0.54 0.42 0.78 0.50 0.50 1.00 0.14 0.86 1.00
H ABC 0.13 0.11 0.85 0.59 – – – 0.41 – 1.00 HC Mário Lioni H Vitória – 0.14 0.13 0.93 1.00 0.00 1.00 1.00 – 1.00
H Paulistano 0.63 0.21 0.34 1.00 – – – – – 1.00 HC Mário Lioni – – 0.34 0.20 0.58 0.50 0.50 1.00 1.00 – 1.00
H Samaritano 0.12 0.04 0.36 – – – 1.00 – – 1.00 CS Santa Lúcia – – 0.17 0.10 0.56 0.00 1.00 1.00 – 1.00 1.00
H Alvorada–DF 0.48 0.35 0.72 0.04 – – – 0.50 0.46 1.00 HC Mário Lioni H Vitória HM Ipiranga 0.29 0.23 0.78 1.00 0.00 1.00 0.05 0.95 1.00
HC Niterói 0.26 0.11 0.41 1.00 – – – – – 1.00 HC Mário Lioni – – 0.19 0.15 0.75 0.50 0.50 1.00 1.00 – 1.00
133
 134

Table 5 Slack analysis

Hospital Hospital area (sq. m) Number of doctor offices Number of ICU inpatients (per year) Total number of outpatients (per year)

Corrected Available hospital area to Corrected Available doctor offices to Corrected Increasing potential for ICU Corrected Increasing potential for
slack meet future demand growth slack meet future demand growth slack inpatients if current resources slack outpatients if current resources
given current efficiency levels given current efficiency levels were efficiently used were efficiently used
(corrected, in %) (corrected, in %) (corrected, in %) (corrected, in %)

HC Padre Miguel 247.43 5.15 % 0.14 3.54 % – 0.00 % 1,058.64 13.23 %

HC Mário Lioni 866.83 10.20 % 0.34 5.72 % – 0.00 % 2,121.53 5.93 %
H TotalCor – 0.00 % – 0.00 % – 0.00 % – 0.00 %
H Pró-Cardíaco – 0.00 % – 0.00 % – 0.00 % – 0.00 %
H Santa Paula 5,296.66 36.53 % 0.45 7.47 % – 0.00 % 1,934.27 35.51 %
CS Santa Lúcia 547.80 9.77 % – 0.00 % – 0.00 % – 0.00 %
H Pasteur 9,024.49 53.09 % – 0.00 % – 0.00 % – 0.00 %
H Vitória – 0.00 % – 0.00 % – 0.00 % – 0.00 %
H Nove de Julho 13,785.00 51.06 % 6.43 32.17 % – 0.00 % 2,230.04 5.14 %
H Alvorada–SP 12,958.02 59.23 % – 0.00 % – 0.00 % – 0.00 %
HM Ipiranga (Mogi das 1,497.54 12.60 % 3.71 20.64 % 169.46 22.65 % – 0.00 %
Cruzes)
H ABC Materno Infantil – 0.00 % – 0.00 % – 0.00 % – 0.00 %
H Metropolitano Butantã 1,567.74 17.26 % 4.04 40.40 % – 0.00 % – 0.00 %
HC Caieiras 157.21 2.86 % 5.48 36.53 % – 0.00 % – 0.00 %
HM Metropolitano 1,733.28 14.65 % 3.84 22.56 % – 0.00 % – 0.00 %
H ABC 200.78 3.97 % 0.91 15.18 % – 0.00 % 1,879.82 76.92 %
H Paulistano 9,838.41 48.15 % 2.84 31.55 % – 0.00 % 3,908.70 190.02 %
H Samaritano 7,940.09 50.93 % – 0.00 % – 0.00 % – 0.00 %
H Alvorada–DF 194.81 3.33 % 9.69 48.46 % – 0.00 % – 0.00 %
HC Niterói 9,815.85 48.64 % 1.62 20.25 % – 0.00 % 1,013.63 20.84 %
C. Araújo et al.
Efficiency determinants and capacity issues in Brazilian 135

On the other hand, when the bias-corrected estimates for hospital production outputs and, therefore, efficiency, giv-
the output-increasing potentials are put into perspective, the en a certain level of inputs. Hospitals could benefit, for
opportunities for accommodating future demand growth are instance, from receiving additional outpatients from SUS,
severely restricted in the great majority of hospitals, especially the public Brazilian health-care system. Of course, the
with respect to ICU inpatients. Among the hospitals in Rio de complexity and specialization of the medical procedure
Janeiro and São Paulo, none of them could comfortably han- would be of paramount importance in attracting such ad-
dle a significant increase in additional longer-term procedures. ditional patients.
It is also noteworthy that, although the relative potential for
increasing outputs appears to be greater as regards outpatient 4.3 Efficiency determinants
treatments rather ICU inpatients, healthcare planners should
take a closer look based on the characteristics of demand for As far as this dataset is concerned, following Simar and
such services. The full picture emerges when, at last, the Wilson [70], the bootstrapped truncated regression was
complexity and specialization of such procedures are ana- used for testing significant differences in efficiency esti-
lyzed. It appears to be severely restricted in high-complexity, mates (cf. Table 6). Specialization presented a significant,
specialized for-profit hospitals, when compared to other low- negative impact on pure (CCR) efficiency levels, probably
complexity, non-specialized units, such as those of general due to the higher commitment of resources required by
purposes (e.g. Paulistano, Padre Miguel, and Metropolitano, medical procedures of such nature. These results are in
to name a few). line with previous research carried out by Proite and Sousa
The inference of future strategic actions based on the [4]. Surprising, however, is the fact that hospital age con-
conclusions of a slack analysis should, however, be conducted tributed significantly to increasing efficiency levels, unlike
with care, and its embedded within the choice of the model what was founded by Rahman [48]. Accreditation also
orientation. Essentially, one should select the DEA model showed a significant impact on pure efficiency levels, in
orientation according to which quantities (inputs or outputs) line with previous studies [48, 50]. Complexity, however,
the decision-makers have most control over, as discussed in despite its negative sign, did not impact significantly on
Coelli [78]. efficiency levels, different from Grosskopf et al. [47]
More precisely, according to Wanke et al. [79], the basic findings.
idea behind the selection of an input oriented model is that the Therefore, expansion priorities should be given to general
output increasing potential should be interpreted with more purpose hospitals. More precisely, they should have an in-
care, unless there is demand for it. So, when selecting an creased focus on receiving outpatients from SUS in order to
input-orientation, decision-makers are focusing on “stressing” augment their output levels. These procedures, however,
production inputs for a given level of output that may not should be low-specialized ones, helping to increase the pure
necessarily be maximal, as it is discussed in Odeck and Alkadi efficiency levels (CCR scores) of a given DMU. On the other
[80]. However, on the other hand, some hospital inputs tend to hand, priority in hospitals should be avoiding further special-
be fixed, as they may reflect long-term investments and ca- ization in order to prevent from diminishing current efficiency
pacitated staff, which are difficult to demobilize in the levels. An additional focus on increasing outpatients from
medium/short-terms, as it is elaborated in Cullinane et al. SUS, similarly as general purpose hospitals, should also be
[81]. Thus, in such cases, similarly as to this research, given, as long as accompanied by an expansion in the number
decision-makers should focus on maximizing outputs for a of doctor’s offices.
given level of production inputs (an output orientation is
preferable).
Table 6 Truncated bootstrapped two-stage regression
Therefore, this overall picture calls for an urgent capacity
expansion, as the current level of inputs (the scale variables in Models for corrected estimates
an output-oriented model according to Thanassoulis [77])
Independent variables BCC CCR SE
does not seem to accommodate future demand growth in
several DMUs. Firstly in terms of doctor’s offices–and subse- Constant 0.734 0.858 1.421***
quently in terms of hospital area–in order to accommodate Contextual Age 0.005 0.006* 0.003
future demand levels. The chronological sequence by which Complexity −0.049 −0.125 −0.206
this capacity expansion should occur is discussed next, based Specialized −0.121 −0.259* −0.119
on the results of the impact of contextual variables, also Accredited 0.303* 0.218* −0.005
providing some guidelines on what type of production output Variance of the model 0.038 *** 0.036 *** 0.033***
should be focused on first. Total number of observations 1000 1000 1000
Besides capacity expansion there are, however, short/
middle term actions that could be taken in order to increase ***,**,*, statistical significance at 1 %, 5 %, and 10 % respectively
136
5 Conclusions
The findings presented herein corroborate anecdotal evidence
with respect to a capacity shortfall in the Brazilian health-care
sector, now under the private sector perspective. Their output
increasing-potentials are also severely constrained, particular-
ly in terms of ICU inpatients.
Our findings can serve as a resource for Brazilian
health-care planners to administer the efficient future
growth of inpatients and outpatients when making use
of currently available resources for capacity expansion.
More precisely, it can aid in decision-making with re-
spect to funding hospital improvement projects and set-
ting priorities in terms of infrastructure or human re-
sources, by means of establishing different policies for
each hospital cluster. The central idea is to identify
short term (increase in efficiency levels) and long term
actions (input expansion) to accommodate future de-
mand growths.
Another contribution of the paper lies in its demonstration
of bootstrapping to unambiguously evaluate returns to scale
and slacks for each hospital via confidence intervals and bias-
corrected central estimates. Benchmarks for improving oper-
ations of for-profit hospitals that perform poorly have also
been provided, discussing the role of contextual variables–
such as accreditation, complexity, and specialization–on in-
creased efficiency levels.
References
1. Ozcan YA, Lins ME, Lobo ME, Silva AC, Fiszman R, Pereira BB
(2010) Evaluating the performance of Brazilian university hospitals.
Ann Oper Res 178:247–261
2. Guerra M, Souza A, Moreira D (2012) Performance analysis: a study
using data envelopment analysis in 26 Brazilian hospitals. J Health
Care Finance 38(4):19–35
3. Varela P, Pacheco R (2012) Federalism and health expenditures:
competition and cooperation in the metropolitan region of São Paulo.
Rev Contabilidade Finanças 23(59):116–127
4. Proite A, Sousa M (2004) Eficiência técnica, economias de escala,
estrutura da propriedade e tipo de gestão no sistema hospitalar brasileiro.
In: Proceedings of the 32th Encontro Nacional de Economia, João
Pessoa, Brazil
5. Staat M (2006) Efficiency of hospitals in Germany: a DEA-bootstrap
approach. Appl Econ 38:2255–2263
6. Tiemann O, Schreyögg J (2009) Effects of ownership on hospital
efficiency in Germany. BuR Bus Res 2(2):115–145
7. Tiemann O, Schreyögg J (2012) Changes in hospital efficiency after
privatization. Health Care Manag Sci 15(4):310–326
8. Simar L, Wilson PW (1998) Sensitivity analysis of efficiency scores:
how to bootstrap in nonparametric frontier models. Manag Sci 44(1):49–
61
9. Simar L, Wilson PW (2004) Performance of the bootstrap for DEA
estimators and iterating the principle. In: Cooper WW, Seiford LM,
Zhu J (eds) Handbook on data envelopment analysis. Kluwer Aca-
demic Publishers, Boston, pp 265–298
C. Araújo et al.
10. Hollingsworth B, Dawson PJ, Maniadakis N (1999) Efficiency mea-
surement of health care: a review of non-parametric methods and
applications. Health Care Manag Sci 2(3):161–172
11. O’Neill L, Rauner M, Heidenberger K, Kraus M (2008) A cross-
national comparison and taxonomy of DEA-based hospital efficiency
studies. Socio Econ Plan Sci 42:158–189
12. Ozcan YA (2008) Health care benchmarking and performance eval-
uation: an assessment using data envelopment analysis (DEA).
Springer, Newton
13. Hofmarcher MM, Paterson I, Riedel M (2002) Measuring hospital
efficiency in Austria: a DEA approach. Health Care Manag Sci
5(1):7–14
14. Athanassopoulos A, Gounaris C (2001) Assessing the technical and
allocative efficiency of hospital operations in Greece and its resource
allocation implications. Eur J Oper Res 133:416–431
15. Kontodimopoulos N, Nanos P, Niakas D (2006) Balancing efficiency
of health services and equity of access in remote areas in Greece.
Health Policy 76:49–57
16. Falavigna G, Ippoliti R, Manello A (2012) Hospital organization and
performance: a directional distance function approach. Health Care
Manag Sci. doi:10.1007/s10729-012-9217-8
17. Ancarani A, Di Mauro C, Giammanco MD (2009) The impact of
managerial and organizational aspects on hospital wards’ efficiency:
evidence from a case study. Eur J Oper Res 194:280–293
18. Helmig B, Lapsley I (2001) On the efficiency of public, welfare and
private hospitals in Germany over time: a sectoral data envelopment
analysis study. Heal Serv Manag Res 14(4):263–274
19. Tiemann O, Schreyögg J, Busse R (2012) Hospital ownership and
efficiency: a review of studies with particular focus on Germany.
Health Policy 104:163–171
20. Caballer-Tarazona M, Moya-Clemente I, Vivas-Consuelo D, Barrachina-
Martínez I (2010) A model to measure the efficiency of hospital perfor-
mance. Math Comput Model 52:1095–1102
21. Navarro-Espigares JL, Torres EH (2011) Efficiency and quality in
health services: a crucial link. Serv Ind J 31(3):385–403
22. Biorn E, Hagen TP, Iversen T, Magnussen J (2003) The effect of
activity-based financing on hospital efficiency: a panel data analysis of
DEA efficiency scores 1992–2000. Health Care Manag Sci 6(4):271–
283
23. Linna M, Häkkinen U, Magnussen J (2006) Comparing hospital
cost efficiency between Norway and Finland. Health Policy 77:
268–278
24. Barros CP, Menezes AG, Peypoch NP, Solonandrasana B, Vieira JC
(2008) An analysis of hospital efficiency and productivity growth
using the Luenberger indicator. Health Care Manag Sci 11:373–381
25. Barros CP, Menezes AG, Vieira JC (2013) Measurement of hospital
efficiency using a latent class stochastic frontier model. Appl Econ
45(1):47–54
26. Ersoy K, Kavuncubasi S, Ozcan YA, Harris JM (1997) Technical effi-
ciencies of Turkish hospitals: DEA approach. J Med Syst 21(2):67–74
27. Sahin I, Ozcan YA (2000) Public sector hospital efficiency for
provincial markets in Turkey. J Med Syst 24(6):307–320
28. Sahin I, Ozcan YA, Ozgen H (2011) Assessment of hospital efficiency
under health transformation program in Turkey. CEJOR 9(1):19–37
29. Wang S, Ma Q, Guan Z (2007) Measuring hospital efficiency in
China using grey relational analysis and data envelopment analysis.
Grey Systems and Intelligent Services, 2007. GSIS 2007. IEEE
International Conference on: 135–139. 18–20 Nov. 2007. doi::10.
1109/GSIS.2007.4443252
30. Ng YC (2011) The productive efficiency of Chinese hospitals. China
Econ Rev 22(3):428–439, Elsevier
31. Agarwal S, Yadav SP, Singh SP (2006) Assessment of relative
efficiency of private sector hospitals in India. J Math Syst Sci
2(1):1–22
32. Srinivasan R (2009) Healthcare in India vision 2025, issue and
prospects. Planning Commission, Government of India
Efficiency determinants and capacity issues in Brazilian
33. Ramanathan TV, Chandra KS, Thupeng WM (2003) A comparison
of the technical efficiencies of health districts and hospitals in
Botswana. Development Southern Africa 20(2):307–320
34. Jandaghi G, Matin HZ, Doremami M, Aghaziyarati M (2010) Effi-
ciency evaluation of Qom public and private hospitals using data
envelopment analysis. Eur J Econ Finance Adm Sci 22:83–92
35. Shahhoseini R, Tofighi S, Jaafaripooyan E, Safiaryan R (2011)
Efficiency measurement in developing countries: application of data
envelopment analysis for Iranian hospitals. Heal Serv Manag Res
24:75–80
36. Su S, Lai M, Huang H (2009) Healthcare industry value creation and
productivity measurement in an emerging economy. Serv Ind J
29(7):963–975
37. Gonçalves AC, Noronha CP, Lins M, Almeida R (2007) Análise
envoltória de dados na avaliação de hospitais públicos nas capitais
brasileiras. Rev Saúde Pública 41(3):427–435
38. Lobo MSC, Ozcan YA, Silva ACM, Lins MPE, Fiszman R (2009)
Financing reform and productivity change in Brazilian teaching
hospitals: Malmquist approach. Cent Eur J Oper Res. doi:10.1007/
s10100-009-0097-z
39. Varela P, Martins G (2011) Efficiency of primary health care spend-
ing by municipalities in the metropolitan region of São Paulo: a
comparative analysis of DEA models. Rev Bus 32(1):17–34
40. Hollingsworth B (2003) Non-parametric and parametric applications
measuring efficiency in health care. Health Care Manag Sci 6:203–
218
41. Hollingsworth B (2008) The measurement of efficiency and produc-
tivity of health care delivery. Heal Econ 17:1107–1128
42. Lee K-H, Yang S-B, Choi M (2009) The association between hospital
ownership and technical efficiency in a managed care environment. J
Med Syst 33:307–315
43. Burgess JF, Wilson PW (1996) Hospital ownership and technical
inefficiency. Manag Sci 42(1):110–123
44. Hu H-H, Qi Q, Yang C-H (2012) Analysis of hospital technical
efficiency in China: effect of health insurance reform. China Econ
Rev. doi:10.1016/j.chieco.2012.04.008
45. Hu J-L, Huang Y-F (2004) Technical efficiencies in large hospitals: a
managerial perspective. Int J Manag 21(4):506–513
46. Chang H, Cheng M-A, Das S (2004) Hospital ownership and
operating efficiency: evidence from Taiwan. Eur J Oper Res 159:
513–527
47. Grosskopf S, Margaritis D, Valdmanis V (2004) Competitive effects
on teaching hospitals. Eur J Oper Res 154:515–525
48. Rahman M (2006) Measuring and explaining the managerial effi-
ciency of private medical clinics in Bangladesh: an exploratory study.
Thesis. Brandeis University
49. Groff J, Lien D, Su J (2007) Measuring efficiency gains from hospital
mergers. Res Healthc Financ Manag 11(1):77–90
50. Wei C-K, Chen L, Li R, Tsai C, Huang H (2012) A study of optimal
weights of data envelopment analysis: development of a context-
dependent DEA-R model. Expert Syst Appl 39:4599–4608
51. Alexander J, Wheeler J, Nhara T, Lemak C (1998) Managed care and
technical efficiency in outpatient substance abuse treatment units. J
Behav Heal Serv Res 25(4):377–396
52. Lee K-H, Chun K, Lee J (2008) Reforming the hospital service
structure to improve efficiency: urban hospital specialization. Health
Policy 87:41–49
53. Charnes A, Cooper WW, Rhodes E (1978) Measuring efficiency of
decision making units. Eur J Oper Res 2(6):429–444
54. Bazargan M, Vasigh B (2003) Size versus efficiency: a case study of
US commercial airports. J Air Transp Manag 9(3):187–193
55. Zhu J (2003) Quantitative models for performance evaluation and
benchmarking: data envelopment analysis with spreadsheets and
DEA excel solver. Springer, New York
137
56. Mogha SK, Yadav SP, Singh SP (2012) Performance evaluation of
Indian private hospitals using DEA approach with sensitivity analy-
sis. Int J Adv Manag Econ 1(2):1–12
57. Adler N, Berechman J (2001) Measuring airport quality from the
airlines’ viewpoint: an application of data envelopment analysis.
Transp Policy 8(3):171–181
58. Cooper WW, Li S, Seiford LM, Thrall RM, Zhu J (2001) Sensitivity
and stability analysis in DEA: some recent developments. J Product
Anal 15(3):217–246
59. Barros CP, Gonçalves O, Peypoch N (2012) French regional public
airports technical efficiency. Int J Transp Econ 39(2):255–274
60. Jenkins L, Anderson L (2003) A multivariate statistical approach to
reducing the number of variables in data envelopment analysis. Eur J
Oper Res 147(1):51–61
61. Nadimi R, Jolai F (2008) Joint use of Factor Analysis (FA) and Data
Envelopment Analysis (DEA) for ranking of data envelopment anal-
ysis. Int J Math Phys Eng Sci 2(4):218–222
62. Adler N, Yazhemsky E (2005) Improving discrimination in data
envelopment analysis: PCA-DEA versus variable reduction. Which
method at what cost? http://pluto.huji.ac.il/~msnic/1W.pdf. Accessed
09 December 2012
63. Allen R, Athanassopoulos A, Dyson RG, Thanassoulis E (1997)
Weights restrictions and value judgements in data envelopment analysis:
evolution, development and future directions. Ann Oper Res 73:13–34
64. Adler N, Golany B (2007) PCA-DEA. In: Zhu J, Cook W (eds)
Modeling data irregularities and structural complexities in data en-
velopment analysis. Springer, New York, pp 139–153
65. Kordrostamia S, Amirteimoori A, Masoumzadeh A (2011) Evaluat-
ing the efficiency of DMUs with PCA and an application in real data
set of Iranian banks. Int J Ind Math 3(4):251–258
66. Tabachnick BG,Fidell LS (2001). Using multivariate statistics. Allyn
and Bacon, Boston
67. Cesaro L, Marongiu S, Arfini F, Donati M, Capelli MG (2009)
Methodology for analyzing competitiveness, efficiency and economy
of scale. Use and applications of DEA. FACEPA Deliverable D5.1.3
(April). http://www.ekon.slu.se/facepa. Accessed 09 December 2012
68. Curi C, Gitto G, Mancuso P (2011) New evidence on the efficiency of
Italian airports: a bootstrapped DEA analysis. Socio Econ Plan Sci
45(2):84–93
69. Banker RD (1993) Maximum likelihood, consistency and DEA: a
statistical foundation. Manag Sci 39(10):1265–1273
70. Simar L, Wilson PW (2007) Estimation and inference in two-stage,
semi-parametric models of production processes. J Econ 136(1):31–
64
71. Simar L, Wilson PW (2008) Statistical inference on nonparametric
frontier models: recent developments and perspectives. In: Fried HO,
Lovell CAK, Schmidt SS (eds) The measurement of productive
efficiency and productivity growth. Oxford University Press, New
York, pp 421–521
72. Cooper WW, Seiford LM, Tone K (2007) Data envelopment analysis:
a comprehensive text with models, applications, references and
DEA-solver software. Springer, New York
73. Kumbhakar SC, Lovell CA (2003) Stochastic frontier analysis. Cam-
bridge University Press, Cambridge
74. Barr R (2004) DEA software tools and technology—a state-of-the-art
survey. In: Cooper WW, Seiford L, Zhu J (eds) Handbook on data
envelopment analysis. Kluwer Academic Publishers, Boston
75. Bogetoft P, Otto L (2010) Benchmarking with DEA, SFA, and R.
Springer, New York
76. Wanke PF (2012) Efficiency of Brazil’s airports: evidences from
bootstrapped DEA and FDH estimates. J Air Transp Manag 23:
47–53
77. Thanassoulis E (2001) Introduction to the theory and application of
data envelopment analysis. Springer, New York
138
78. Coelli T (1996) A guide to DEAP version 2.1: a data envelopment
analysis (computer) program. Accessed at http://www.une.edu.au/
econometrics/cepa.htm
79. Wanke PF, Barbastefano RG, Hijjar MF (2011) Determinants of
efficiency at major Brazilian port terminals. Transp Rev 31(5):653–
677
C. Araújo et al.
80. Odeck J, Alkadi A (2001) Evaluating efficiency of the Norwegian bus
industry using data envelopment analysis. Transportation 28:211–232
81. Cullinane K, Wang T, Song D, Ji P (2006) The technical
efficiency of container ports: comparing data envelopment
analysis and stochastic frontier analysis. Transp Res A 40:
354–374
Copyright of Health Care Management Science is the property of Springer Science &
Business Media B.V. and its content may not be copied or emailed to multiple sites or posted
to a listserv without the copyright holder's express written permission. However, users may
print, download, or email articles for individual use.