Equity and efficiency of medical service systems at the provincial level of China's mainland: a comparative study from 2009 to 2014

Background: The astonishing economic achievements of China in the past few decades have remarkably increased not only the quantity and quality of medical services but also the inequalities in health resources allocation across regions and inefficiency of the medical service delivery. Methods: A descriptive analysis was used to compare the inequities in inputs and outputs of the provincial medical service systems, a non-radial super-efficiency data envelopment analysis model was then used to estimate the efficiency, and a regression analysis of the panel data was used to explore the determinants. Results: The inputs and outputs of most provincial medical service systems increased gradually from 2009 to 2014. Overall, the eastern region allocated more human and capital resources than the other two regions, and produced more than 50% of the total outpatient and emergency room visits, whereas the western region produced more inpatient services (about 30% of the total volume of inpatient services) according to the distribution of the population. The average efficiency scores of the provincial medical systems in China's mainland were 0.895, 0.927, 0.929, 0.963, 0.977 and 0.968 from 2009 to 2014, with a slight average improvement of 1.60%. The efficiency score of each provincial medical service system varied greatly from one another: Tibet (1.475 +/- 0.057) performed extremely well, whereas several others including Heilongjiang (0.579 +/- 0.001) performed poorly. Furthermore, the proportion of high-class medical facilities was negatively associated with efficiency, whereas the proportion of the vulnerable population, the per capita Gross Domestic Product, the proportion of the illiterate population and the improvement of primary health care had positive effects on efficiency. Conclusion: Inequity in health resources allocation and service provision existed across the regions, but not all the gaps have begun to narrow since 2009. The difference of efficiency was great among provincial medical service systems but minor across regions, and the score changed very little over time. More importantly, the central region held the lowest average efficiency score in the past 6 years, while the western region held the largest average efficiency score at the first 5 years, which should receive enough attention of the government and decision-makers. In practice, efficiency was related to many complicated factors, indicating that the improvement of efficiency is a complex and iterative process that requires the strong cooperation of many sectors.