title: Technical and scale efficiency in the delivery of child health services in Zambia: results from data envelopment analysis.
abstract: Despite tremendous efforts to scale up key maternal and child health interventions in Zambia, progress has not been uniform across the country. This raises fundamental health system performance questions that require further investigation. Our study investigates technical and scale efficiency (SE) in the delivery of maternal and child health services in the country.
  
  
  
  The study focused on all 72 health districts of Zambia.
  
  
  
  We compiled a district-level database comprising health outcomes (measured by the probability of survival to 5 years of age), health outputs (measured by coverage of key health interventions) and a set of health system inputs, namely, financial resources and human resources for health, for the year 2010. We used data envelopment analysis to assess the performance of subnational units across Zambia with respect to technical and SE, controlling for environmental factors that are beyond the control of health system decision makers.
  
  
  
  Nationally, average technical efficiency with respect to improving child survival was 61.5% (95% CI 58.2% to 64.8%), which suggests that there is a huge inefficiency in resource use in the country and the potential to expand services without injecting additional resources into the system. Districts that were more urbanised and had a higher proportion of educated women were more technically efficient. Improved cooking methods and donor funding had no significant effect on efficiency.
  
  
  
  With the pressing need to accelerate progress in population health, decision makers must seek efficient ways to deliver services to achieve universal health coverage. Understanding the factors that drive performance and seeking ways to enhance efficiency offer a practical pathway through which low-income countries could improve population health without necessarily seeking additional resources.
authors.affiliation: Department of Global Health, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.|Centre for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, The Netherlands.
authors.forename: Tom
authors.initials: T
authors.lastname: Achoki
authors.affiliation: Centre for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, The Netherlands.
authors.forename: Anke
authors.initials: A
authors.lastname: Hovels
authors.affiliation: Department of Global Health, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.|Department of Economics, University of Zambia, Lusaka, Zambia.
authors.forename: Felix
authors.initials: F
authors.lastname: Masiye
authors.affiliation: University of Maryland School of Medicine, Baltimore, Maryland, USA.
authors.forename: Abaleng
authors.initials: A
authors.lastname: Lesego
authors.affiliation: Centre for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, The Netherlands.
authors.forename: Hubert
authors.initials: H
authors.lastname: Leufkens
authors.affiliation: Faculty of Health, University of Canberra, Canberra, Australia.
authors.forename: Yohannes
authors.initials: Y
authors.lastname: Kinfu
mesh_terms: D000293:Adolescent; D000328:Adult; D002662:Child Health Services / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data*; D046688:Child Mortality; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data*; D004522:Educational Status; D017598:Efficiency, Organizational; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015233:Models, Statistical; D010043:Outcome and Process Assessment, Health Care; D012424:Rural Population / Q000706:statistics & numerical data; D015996:Survival Rate; D014505:Urban Population / Q000706:statistics & numerical data; D055815:Young Adult; D015024:Zambia
keywords: Data Envelopment Analysis; Health Systems Performance;; Scale Efficiency; Technical Efficiency