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\begin{document}

\title{Supporting Efficiency Improvement in Public Health Systems: a Rapid
Systematic Review of Current Evidence}



\author[1]{James Walters}%
\author[2]{Reema Harrison}%
\author[2]{Anurag Sharma}%
\author[1]{Emma Malica}%
\affil[1]{NSW Health}%
\affil[2]{University of New South Wales}%


\vspace{-1em}



  
  \date{June 13, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Rationale, aims and objectives Public health systems are under pressure
to meet increasing demand for health care in environments of increasing
financial resource constraint. There is therefore a need to maximise
health outcomes given limited public healthcare expenditure. This paper
aims to establish the extent of literature and approaches to efficiency
improvement in public health systems of developed countries. Methods The
Rapid Evidence Assessment model was used to address the review question.
Two database searches returned a result of 3,526 unique titles, which
were individually screened for potential relevance. 144 titles were
selected for full review to determine relevance. 73 papers were included
in the final review. Results Data on country, study design, key findings
and links to efficiency improvement were extracted and synthesized.
Synthesis of findings revealed that the literature on this topic is
disparate and non-cohesive. A range of isolated approaches were
described, and no evidence or consensus on a single best-practice
approach to efficiency improvement was identified. Conclusions Combining
the factors identified in this review has the potential to inform a
framework for supporting efficiency improvement in public health
systems. By considering these factors central health system management
bodies can support efficiency improvement to deliver both financial and
health services benefits.%
\end{abstract}%



\sloppy


\textbf{Title}

Supporting Efficiency Improvement in Public Health Systems: a Rapid
Systematic Review of Current Evidence

\textbf{Running title}

Efficiency Improvement in Public Health Systems

\textbf{Author detailsAuthor 1}James Walters FCHSM CHIA, A/Director,
Patient Experience and System Performance Division, NSW Health, 100
Christie St, St Leonards Australia Ph: (+61) 02 9461 7532\textbf{Author
2}Associate Professor Reema Harrison PhD, Director UNSW Health
Management, School of Public Health and Community Medicine, University
of New South Wales, UNSW, High St, Kensington 2052 Australia Ph: (+61)
02 9385 3324\textbf{Author 3}Dr Anurag Sharma PhD, Co-Director Public
Health Programs, School of Public Health and Community Medicine,
University of New South Wales, UNSW, High St, Kensington 2052 Australia
Ph: (+61) 02 9385 2372\textbf{Author 4}Emma Malica FCHSM, General
Manager, Program Management Office, NSW Health, 100 Christie St, St
Leonards Australia Ph: (+61) 02 9391 9000

Corresponding author name: James Walters

Corresponding author email: james.walters@health.nsw.gov.au

Corresponding author postal address: 158 Woodcourt Rd, Berowra Heights
NSW 2082 Australia

Corresponding author phone: (+61) 02 9461 7532

\begin{enumerate}
\tightlist
\item
  \textbf{Author's institutional affiliations}New South Wales Health,
  100 Christie St, St Leonards NSW 2065 Australia
\item
  \textbf{Abstract and Keywords}
\end{enumerate}

\emph{Rationale, aims and objectives}

Public health systems are under pressure to meet increasing demand for
health care in environments of increasing financial resource constraint.
There is therefore a need to maximise health outcomes given limited
public healthcare expenditure. This paper aims to establish the extent
of literature and approaches to efficiency improvement in public health
systems of developed countries.

\emph{Methods}

The Rapid Evidence Assessment model was used to address the review
question. Two database searches returned a result of 3,526 unique
titles, which were individually screened for potential relevance. 144
titles were selected for full review to determine relevance. 73 papers
were included in the final review.

\emph{Results}

Data on country, study design, key findings and links to efficiency
improvement were extracted and synthesized. Synthesis of findings
revealed that the literature on this topic is disparate and
non-cohesive. A range of isolated approaches were described, and no
evidence or consensus on a single best-practice approach to efficiency
improvement was identified.

\emph{Conclusions}

Combining the factors identified in this review has the potential to
inform a framework for supporting efficiency improvement in public
health systems. By considering these factors central health system
management bodies can support efficiency improvement to deliver both
financial and health services benefits.

Keywords: Public Health, Efficiency

\textbf{Main Text}

\textbf{Introduction}

Public health systems are under intense pressure to meet increasing
demand for health care in environments of considerable and increasing
financial resource constraint\textsuperscript{(1)}. In order to continue
to meet the current and future health services needs of the public there
is a need to maximise health outcomes given limited public healthcare
expenditure, a requirement which may also be described as efficiency
improvement. Many policy suggestions to improve efficiency are based on
expenditure-reducing ``cost containment'' initiatives, seemingly without
much consideration for impacts on care quality in terms of patient
outcomes and health service delivery\textsuperscript{(2,3)}. We argue
that such short-term, silo-based efficiency improvement approaches might
not always result in improvements in patient outcomes or service
delivery regardless of financial impact. We further argue that there is
a need to focus on approaches that can potentially improve both
efficiency and health outcomes concurrently. This paper identifies and
discusses approaches to improving efficiency in public health systems
which are identified as having evidence of success in enhancing both
financial and health service outcomes.

Public health system efficiency and quality is challenged by factors
including tightening budgets, growing demand, professional shortages,
increasing disease burdens, increasing pressure on infrastructure,
technological implications, changing service models and changing service
accessibility\textsuperscript{(4)}. An ongoing state of inefficiency
amidst an environment of seemingly-constant reform is characteristic of
the public health systems of many well-developed countries around the
world\textsuperscript{(5,6)}. Compounding this state is a common trend
in rates of growth in health services demand in excess of funding growth
rates, creating further pressure on already-burdened public health
systems\textsuperscript{(7)}. Continuing with business-as-usual
approaches is likely to result in further compounding of risks to health
system sustainability. The ability of public health systems to continue
to meet these increasing pressures may not be sustainable without
changes with a combined focus on efficient use of resources and service
delivery optimization.

The links between care quality, care outcomes and the investments
required to achieve them are well-embedded in models of health care
efficiency\textsuperscript{(8)}. Despite this longstanding focus, the
literature on approaches to supporting efficiency and quality
improvement in public health systems is disparate and non-cohesive, with
a range of isolated approaches described rather than a consensus on a
single best-practice approach. We suggest that there is an urgent need
to consolidate understanding around efficiency improvement approaches
that have been effective internationally in order to support efforts to
improve health services quality and efficiency using evidence-based,
best-practice approaches.

This study was undertaken in order to identify and explore what is
currently known and what approaches are currently in place for
supporting efficiency improvement in public health systems. There is an
identified gap in the literature on this topic towards which this
synthesis adds new knowledge. This paper aims to provide a consolidated
view of the existing evidence to inform public health decision-making on
evidence-based approaches to supporting efficiency and quality
improvement. We suggest that applying the findings of this study as a
framework for policy-setting and decision-making can support efficiency
improvement approaches across public health systems.

\textbf{Purpose}

This paper aims to explore the efficiency improvement environment and
approaches in public health systems using OECD countries as a frame of
reference. To accomplish this aim, this paper addresses the following
review question: What current evidence exists regarding approaches to
supporting efficiency improvement in public health systems in developed
countries? The Rapid Evidence Assessment model was used to address the
review question. This model follows the same approaches and principles
as a systematic review, making allowances for limited timeframes and
lower strength of evidence while addressing key issues related to the
topic\textsuperscript{(9)}. This method is also well-equipped to enable
the synthesis of disparate evidence in addition to existing synthesised
literature\textsuperscript{(10,11)}. A review protocol was developed to
guide this study and its processes.

\textbf{Data sources}

In order to limit the review to current and highly relevant material
inclusion criteria were established. Only full papers available in
English relating to public health systems in developed countries were
included, with OECD countries used to benchmark this criterion. A
timeframe for inclusion of papers published in or after 2011 was
established, as this aligns with significant national health reform
within the country of residence of the research team (Australia). Papers
not available in English were excluded from the study, as were title
matches for which full papers were not available. Papers based in
developing countries were excluded in order to align with the focus of
this work on OECD countries. Papers reviewed in full which held no clear
content relating to efficiency improvement in public health systems were
also excluded. A range of text words, synonyms and subject headings were
developed for the major concepts of health system, efficiency and
improvement. These search terms were used to undertake searches of two
electronic databases (PUBMED, MEDLINE) in February 2019. Search results
were merged with duplicates removed, and screening was managed using
Covidence.

\textbf{Data extraction}

All titles were screened by one reviewer (JW) and potentially-relevant
titles were retained. Two reviewers (JW, RH) independently screened
shortlisted abstracts, with any conflicts resolved by team discussion.
Full texts were obtained for these titles, and a final decision on
inclusion or exclusion was made for each of these titles following full
text review against the eligibility criteria. Data extracted from
studies selected for inclusion were first author, publication year,
country, study objective, sample, methods, key study findings and links
to efficiency improvement.

\textbf{Results of data synthesis}

A thematic analysis of each included study was undertaken to identify
key concepts related to the research question in order to inform the
description of these findings through a narrative
synthesis\textsuperscript{(12)}. Extracted data was themed twice;
firstly for major themes, and then for specific concepts relating to
health services efficiency within each major theme. Regular discussions
amongst the review team (JW, RH) regarding the structure, presentation
and content were scheduled to guide the synthesis of extracted data. The
systematic rigour and co-reviewed nature of this process grants a high
degree of validity to the depth and completeness of the evidence
synthesised in this review. A detailed data extraction summary table was
used to document extracted data.

The two database searches returned a result of 3,526 unique titles,
which were individually screened for potential relevance. 144 titles
were selected for full review to determine relevance, for which full
papers were obtained and reviewed. Following full-text review of these
144 papers, 73 papers were found to contain relevant material at a
whole-of-system level and were included in the final review. Three major
themes were identified:

\begin{enumerate}
\tightlist
\item
  Definitions and concepts relating to efficiency improvement
\item
  Central support and leadership for system-wide efficiency improvement
\item
  Concurrently managing efficiency, service delivery and service quality
  outcomes;
\item
  Stakeholder engagement
\end{enumerate}

No evidence-based comprehensive frameworks for managing efficiency
improvement in public health systems were identified.

\textbf{Review findings}

Financial sustainability concerns regarding public health systems in
developed countries were widely acknowledged, along with the associated
need for efficiency improvement to meet these concerns. Papers selected
for inclusion in this review described various approaches to address
these issues, however no single, best-practice or evidence-based
comprehensive framework for managing these issues at the system level
was identified. The findings discussed in the subsequent section of this
paper outline the efficiency context, factors, considerations and
approaches relevant to the review question in order to inform a
framework for managing efficiency improvement that offers a range of
strategies and supporting evidence. Given the fragmented and disparate
nature of the evidence identified, there were no clear and consistent
themes or factors which were consistently identified across all
countries or health systems. Rather, the synthesis of these factors
provides a collective view of factors which may be applicable to public
health systems in developed countries. The thematic analysis of factors
outlined below is the result of the synthesis of related but
separately-identified issues with each issue being identified in only
one or a few papers evaluated, rather than a wide consensus of repeated
key themes identified across all papers reviewed.

\emph{Definitions and concepts relating to efficiency improvement}

The concept of efficiency in the context of health services is
well-explored in the literature, with clear links to expenditure, health
system and health service outcomes. Productive efficiency involves
making the most of available resources while maximizing
outputs\textsuperscript{(1)}. Multiple factors contribute to the
efficiency landscape. Efficiency is comprised of technical and
allocative factors within the context of existing resources, operating
requirements, regulatory environments and health service
outputs\textsuperscript{(13,4)}. In healthcare these elements extend to
the delivery of services with comprehensiveness, coordination,
accessibility, quality and continuity all seen as determinants of health
services efficiency\textsuperscript{(15)}. In this context Pelone et
al.\textsuperscript{(15)} further provided that quality involves health
service effectiveness, safety and appropriateness along with
patient-centeredness and patient experience. When considering processes
and outcomes, the concept of technical efficiency involves achieving
specified outputs using the minimum amount of
resources\textsuperscript{(16)}. The concept of value is also associated
with efficiency in terms of weighing outcomes against the costs required
to achieve them\textsuperscript{(17)}.

\emph{Central support and leadership for system-wide efficiency
improvement}

The current public health services environment in developed countries is
consistently described in the literature in terms of increasing resource
pressure and system demand, creating an increasing focus on
sustainability across public health systems\textsuperscript{(18)}.
Specific and clear support for efficiency improvement initiatives from
the system management entities of public health systems is critical to
efficiency improvement success\textsuperscript{(19)}. Despite this
requirement, policy guidelines for enhancing public health service
efficiency are not readily evident despite widespread focus on measuring
efficiency\textsuperscript{(1)}. Across the literature, examples of
facility-level efficiency improvement projects are common however
studies focusing on efficiency improvement at the system-level are
rare\textsuperscript{(1)}. Variable levels of efficiency appear to be
evident within any given public health system between the different
services and facilities of that system\textsuperscript{(20)}.

The decentralized, department-based nature of healthcare facilities
within public health systems has been identified as a source of
inefficiency\textsuperscript{(21)}. This issue may be scalable to entire
public health systems with devolved governance structures. It is noted
than while reform can drive short term efficiency change, long-term
sustainability requires ongoing focus and
monitoring\textsuperscript{(22)}. Limiting the empowerment of individual
facilities to determine unique management and operating models in favour
of central control is not effective in improving efficiency, which
suggests that efficiency improvement can be supported through empowering
facilities to tailor operating models which best fit their unique local
needs while providing specific guidance on required
outcomes\textsuperscript{(3,23)}. This process requires consideration of
public health priorities, training, policy frameworks and business
models\textsuperscript{(24)}. Devolution of governance from central
bodies to health services can be managed through service agreements and
performance measures or indicators\textsuperscript{(25,26)}. Successful
performance against these metrics can be supported at the system level
by embedding a central focus on resource allocation in tandem with a
focus on optimizing care outcomes and resource utilization, with such an
approach also having the potential to avoid ethical dilemmas associated
with return on investment in the context of promoting health
outcomes\textsuperscript{(27)}.

In systems with fixed budgets, cost savings can be absorbed in other
areas of the system and therefore be masked in terms of overall
financial performance. This is further complicated by initiatives which
take several years to produce favorable impacts in systems with annual
financial cycles\textsuperscript{(28,29)}. Realistic timeframes for
efficiency improvement must be considered when weighing initial
investment and planned returns\textsuperscript{(28)}. Establishing
prompts, targets, guidelines, triggers and mandatory requirements for
resource allocation consideration has been linked with successfully
embedding efficiency improvement and disinvestment in routine systems
and processes\textsuperscript{(30)}. This can also be supported through
gaining an understanding of the points where efficiencies are
redistributed throughout the system\textsuperscript{(31)}. It has also
been suggested that focusing on productivity, savings, waste reduction
and resource maximization together when managing health services can
promote efficiency and quality outcomes
concurrently\textsuperscript{(32,33)}. Of these measures it has been
suggested that productivity is less frequently used than other
performance and operational efficiency measures, making productivity an
area where additional insight may be generated\textsuperscript{(34)}.

Elements of transparency in target-setting and performance reporting are
linked with more-efficient health organizations\textsuperscript{(35)}.
The setting of system-wide financial rules has been associated with a
modest reduction in public health expenditure, however this may not
occur until 1-2 years following implementation\textsuperscript{(36)}.
Local networking and benchmarking can promote collaboration identify
both high-performing and low-performing sites and is associated with
higher-performing health services\textsuperscript{(35,37)}. This
suggests that setting realistic timeframes for improvements to be
delivered and benefits realized while benchmarking to track performance
are evidence-based success factors in efficiency improvement performance
evaluation.

Peer benchmarking and comparison can also provide insight into new
potential opportunities for efficiency improvement by identifying
approaches which are achieving positive outcomes\textsuperscript{(38)}.
Successful initiatives can then potentially be scaled and shared to
similar settings elsewhere\textsuperscript{(39,40)}. This sharing of
successful initiatives promotes sustainability through increasing buy-in
and by building evidence of success\textsuperscript{(41)}. The ability
to adapt an initiative to suit local needs is a key long-term initiative
success factor and a factor which also includes the ability to modify
approaches over time\textsuperscript{(41)}.

Identifying high-performing sites and organizations provides
opportunities to identify and share factors associated with high
performance\textsuperscript{(42)}. Monitoring activity against set
targets and requirements can enable success to be championed and support
to be targeted as needed\textsuperscript{(43)}. Allin, Grignon \&
Wang\textsuperscript{(1)} suggest that peer benchmarking provides
opportunities to better allocate resources and take specific actions to
improve performance, as does identifying high-performing sites and
organizations in order to identify and share factors associated with
high performance.

Despite a focus on changes which improve efficiency the longevity of
these changes appears variable, with one study suggesting that only 60\%
of improvement projects in health are able to maintain at least one key
project element on an ongoing basis\textsuperscript{(44)}. This calls
for a system-wide focus on embedding key elements of successful programs
upon project completion. Less-successful programs can also contribute to
efficiency improvement practices, as examining reasons for failed
programs can assist with supporting those at risk\textsuperscript{(45)}.
It is therefore recommended to identify the causes of efficiency
improvement failure and take action to ensure these causes are not
repeated in future efficiency improvement initiatives.

Sharing risks, goals, responsibilities and feedback across public health
systems can promote a sustainable win-win outcome for patients and
public health systems\textsuperscript{(46)}. Health systems can utilize
performance and activity data to detect opportunities for disinvestment,
track progress towards targets and evaluate the impact of
initiatives\textsuperscript{(47,48)}. Disinvestment and investment
should be considered in parallel rather than
separately\textsuperscript{(49)}. Transparent, accountable systems and
processes are required to coordinate these
factors\textsuperscript{(49)}. Improvements to services and processes
must align with and embed into existing structures in order to
last\textsuperscript{(41)}.

It is important for public health systems to identify and overcome
barriers to successfully promoting efficiency improvement. Performance
measurement processes are important, however delays in reporting back
from central bodies to local facilities it seen as a barrier to
improvement\textsuperscript{(41)}. A lack of business plans in proposed
efficiency improvement processes poses a risk to achieving desired
outcomes\textsuperscript{(50)}. Over-restructuring, focusing on
short-term goals, focusing on advances rather than results and a culture
of complacency were also identified as barriers to efficiency
improvement\textsuperscript{(51)}. Avoiding these pitfalls should be a
constant consideration at the system level.

Public health system management bodies can take a lead role in
identifying low-value and high-risk procedures then removing less
efficient choices, removing funding, producing policy
guidelines/regulatory frameworks for cost-effective alternatives and
raising the profile of correct/incorrect
interventions\textsuperscript{(52,43)}. The identification and
scaling-up of high-value initiatives is an area of opportunity in this
space\textsuperscript{(53)}. Evidence for cost savings in similar
initiatives in other health jurisdictions can be used to justify
investment decisions and develop business cases for efficiency
improvement initiatives\textsuperscript{(54)}. Centralizing and
consolidating services can enhance performance, as can centrally-set,
system-wide annual efficiency targets\textsuperscript{(55)}. Evidence is
mixed for extending this approach to public-private partnerships, which
have been described as complex, difficult to implement and dependant up
a range of pre-existing conditions to succeed\textsuperscript{(56,57)}.
Pay-for-quality schemes and mergers between public hospitals intended to
improve performance are similarly fraught with limited evidence for
efficiency and quality improvement\textsuperscript{(2,58)}.

Centralized efficiency improvement units such as Program Management
Offices can have an impact on improving efficiency across public health
systems by providing support and reducing pressure on health service
managers\textsuperscript{(59)}. The extent to which the support offered
by such units is adopted can be significantly dependent upon the
engagement and enthusiasm of senior leadership across their public
health system\textsuperscript{(4)}. The decision-making level of the
efficiency improvement unit has significant bearing on the efficiency
improvement focus and activities of the unit\textsuperscript{(1)}.
Program Management Offices in health care promote efficiency as they can
help solve operations issues, reduce spending, share expertise,
standardize practices/processes, build capability, provide regular
progress reporting, promote effective communication, assist various
stakeholder groups to deliver results, optimize processes, evaluate
impacts and align management approaches to client
satisfaction\textsuperscript{(59)}.

In order to realize the potential benefits offered by centralized
efficiency improvement units, challenges were identified which require
consideration. These include task prioritization, managing expectations
and managing multiple concurrent projects\textsuperscript{(59)}. The
manner in which the capabilities and system knowledge of these teams is
perceived by stakeholders impacted by efficiency improvement-related
change is a determinant of the degree to which improvement initiatives
are adopted across public health systems\textsuperscript{(4)}. This
suggests that appointing team members recognized for their experience,
credibility and familiarity with the public health system involved will
facilitate the team's ability to deliver efficiency improvement support.
Establishing and managing realistic expectations as to the service
offerings of such teams across their stakeholders has also been
associated with the effectiveness of efficiency improvement
support\textsuperscript{(59)}.

\emph{Concurrently managing efficiency, service delivery and service
quality outcomes}

An emerging focus on concurrently improving both quality and efficiency
is replacing the previous focus on purely financial efficiency, with
evidence suggesting that focusing solely on financial efficiency does
not result in health service efficiency
improvements\textsuperscript{(3)}. At a system level the factors
contributing to efficiency improvement include focusing on efficiency at
all facilities and organizational levels, addressing unwarranted
variation, considered use of funding levers, and monitoring appropriate
performance indicators\textsuperscript{(16)}. Public health systems have
a role in shaping policy to encourage services which promote both
efficiency and better stakeholder outcomes\textsuperscript{(60)}.
Underpinning any efficiency improvement initiative are concurrent
requirements to improve patient satisfaction, service quality and staff
engagement in addition to managing cost\textsuperscript{(60)}.
Gerald\textsuperscript{(61)} suggests that this can be successfully
approached through setting policy levers which prioritize affordability,
access to care and innovation rather than targeting price or
utilization-based metrics as priority outcomes.

Efficiency improvement can be addressed in alignment with patient
outcomes and service quality, although inefficiency cannot be rectified
simply through additional resourcing\textsuperscript{(5)}. Efficiency
gains can be realized in combination between quality and patient
outcomes, with quality, cost and productivity regarded as interlinked
rather than isolated\textsuperscript{(39,62)}. Addressing health
services overuse and low-value activities is also linked to both
effectiveness and efficiency\textsuperscript{(63)}. While technological
solutions can potentially enhance efficiency across a broad range of
areas their potential is frequently overrated, with developing and
implementing such solutions being a driver of
cost\textsuperscript{(64,65)}. Importantly, health services cannot be
expected to operate at near-maximum efficiency levels as consideration
to reduced efficiency is a trade-off for workforce training capacity,
research and innovation\textsuperscript{(66)}. This calls for the
setting of realistic and balanced efficiency improvement targets and
timeframes. It has also been suggested that effective training in the
actions required to deliver efficiency improvement, consistent
leadership and continued post-implementation monitoring are required in
order for improvements in efficiency to be
maintained\textsuperscript{(4)}.

\emph{Stakeholder engagement}

Underpinning any efficiency improvement initiative are concurrent
requirements to improve patient satisfaction, service quality and staff
engagement in addition to managing cost\textsuperscript{(60)}. Despite
the clear need to enhance efficiency, overcoming the challenges of staff
resistance and staff expectations can prove difficult. Common
misconceptions amongst staff and patients that ''more is better'' and
''newer is better'' are a significant barrier\textsuperscript{(63)}.
There is a risk for resource investment to be considered a waste if no
value is added to patient outcomes\textsuperscript{(46)}. To mitigate
this risk, the involvement of stakeholders in target-setting has been
associated with improved acceptance and compliance towards established
targets\textsuperscript{(67)}. Clear target definition and stakeholder
collaboration during improvement initiative development are factors for
improvement initiative success\textsuperscript{(68,69)}. Collaboration,
knowledge sharing, performance monitoring and continuous training in
performance improvement are associated with project sustainability and
impact\textsuperscript{(4)}. It was clear throughout the studies
reviewed that effective, ongoing consultation and collaboration is a
core element in efficiency improvement.

To counter stakeholder engagement challenges, public health systems can
focus on enhancing collaboration and engagement to promote efficiency
improvement\textsuperscript{(46)}. Stakeholders are unlikely to be
motivated to engage in efficiency improvement solely because of
cost-effectiveness\textsuperscript{(70)}. Local management priorities
can be aligned across the system by linking unit manager goals, measures
and incentives to those of the Organization, thereby promoting
efficiencies at a system level and moving away from isolated pockets of
improvement\textsuperscript{(71)}. Central bodies can sponsor
collaborative networks to share successful practice and performance
information, with links to improved patient outcomes and costs while
also linking researchers with implementers and
beneficiaries\textsuperscript{(72)}. Consideration towards the issues of
data security and systems interoperability is required when planning
technological solutions to support collaboration, information sharing
and performance management\textsuperscript{(73)}. Although change
management approaches were not the focus of this review, the evidence
identified in this study consistently indicated that effective change
management is required in any efficiency improvement initiative.

\textbf{Discussion}

This review has identified that the current body of research is not
cohesive and does not provide evidence of single, comprehensive
approaches to supporting efficiency improvement in public health
systems. Many individual aspects and factors were identified from across
the sources reviewed in this paper which relate to improving health
services efficiency, and together these factors may inform the design of
a comprehensive support framework. The critical need to allow
flexibility to align any improvement initiatives with existing local
processes and individual service needs may also be supported by such an
approach\textsuperscript{(3)}. Service integration, collaboration,
benchmarking, locally-tailored solutions and knowledge sharing were
clear themes in successful approaches to supporting efficiency
improvement\textsuperscript{(35,38,41)}.

A range of challenges to achieving efficiency improvement across public
health systems were identified. This review identified a lack of clarity
in the literature around an evidence-based best-practice approach to
managing efficiency improvement at a whole-of-system level. Continuous
restructuring, delays in performance reporting, the setting of
short-term reactive goals and the prioritization of cost reduction over
service enhancement are barriers to efficiency
improvement\textsuperscript{(74)}. The historical design of health
systems based around siloes and episodes of care also presents a barrier
to be overcome\textsuperscript{(75)}. Despite the interlinked nature of
financial performance and health services outcomes, these outcomes are
not always addressed concurrently\textsuperscript{(60)}. Capability,
enthusiasm and centrally-led support for efficiency-focused initiatives
across public health systems is not always sufficient to enable
sustained improvements\textsuperscript{(4)}. Health services should be
aware of the impact of measures which may appear to represent efficiency
on paper but which do not represent genuine efficiency such as efforts
to increase coding acuity, coding creep and selective picking of more
highly-valued activity\textsuperscript{(76,77)}. Caution should also be
applied to delaying essential activity and expenditure to represent
short-term financial improvements as this can be detrimental to service
quality, accessibility and stability\textsuperscript{(78)}.

The impact of policy in establishing conditions for health services to
manage efficiency was evident. Transparent target setting and progress
reporting processes for efficiency improvement were supported, while
pairing financial improvement initiatives with efficiency improvement
and strategic directions was a key policy consideration which can
support efficiency improvement\textsuperscript{(16,61)}. Effective
Organization-wide stakeholder engagement and consultation is linked with
successful change at the public health system
level\textsuperscript{(69)}. There is clear scope for support for
efficiency improvement to be provided across healthcare facilities and
districts by the managing bodies of public health systems, such as
Ministries and Departments of Health\textsuperscript{(27)}. Dedicated
efficiency improvement offices or teams at appropriate decision-making
levels within these system management bodies can enable knowledge
sharing, enhance engagement with efficiency improvement and coordinate
system-wide efficiency improvement programs\textsuperscript{(4,1)}. The
Program Management Office model is an evidence-based approach to
providing this support across public health
systems\textsuperscript{(59)}.

\textbf{Implications and application}

The current public health system climate is one of increasing demand and
tightening resourcing, yet the vast majority of project-level
sustainability approaches in healthcare do not include a cost-related
definition of sustainability\textsuperscript{(44)}. System-level
responses to the challenge presented by the increasing need for
efficiency are often reactive, involving short-term actions such as
reducing funding rates, setting short-term targets, reducing services
and delaying non-essential activities\textsuperscript{(74)}. Such
approaches are unlikely to result in sustainable improvements and are
also likely to impact capacity for investment, capability development
and innovation aimed at improving both quality and
efficiency\textsuperscript{(79)}. Continuing with such approaches is
unlikely to meet current and future sustainability
pressures\textsuperscript{(7)}.

This study presents a synthesized view of current evidence relevant to
efficiency improvement in public health systems. While studies aimed at
improving efficiency were widespread, no single comprehensive frameworks
were identified in this review. This paper addresses the gap in the
literature in this space by outlining the range of current
evidence-based factors and strategies associated with supporting
efficiency improvement in public health systems. Evidence is also
presented which supports tandem improvements in financial efficiency and
health service outcomes. Public health systems in developed countries
may find guidance in this study on which efficiency improvement
approaches are linked with success. The findings of this study may also
be used to guide reflection on current practice in order to identify
approaches in place as well as potentially-successful approaches not
currently in place for the purpose of validating and augmenting
efficiency improvement practices.

\textbf{Limitations}

By searching only two databases in this study, the possibility that
published work relevant to the review question may have been overlooked
cannot be excluded. Similarly, by focusing only on published
peer-reviewed works, relevant perspectives in other works may also have
been excluded. While the search terms selected were broad and relevant,
given the diverse and far-reaching nature of the topic it is possible
that relevant material may have been missed where this material was
described using different key terms than those selected for this study.

\textbf{Conclusion}

The requirement for efficiency in the delivery of public health services
continues to increase. This narrative synthesis presents a combined view
of factors identified in the literature related to efficiency
improvement in public health systems. We argue that addressing the
challenges and enabling actions identified in this study represents an
evidence-based approach to supporting efficiency improvement. Combining
these factors can inform a framework for supporting efficiency
improvement in public health systems. By addressing each of these
factors as appropriate to specific local needs and by providing
system-wide support for efficiency improvement, central health system
management bodies can promote efficiency improvement in parallel with
patient, staff and service quality outcomes.

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\textbf{Acknowledgements}

This research did not receive any specific funding

\textbf{Conflict of interest}

The authors declare no conflicts of interest

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