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(3). Service integration, collaboration, benchmarking, locally-tailored solutions and knowledge sharing were clear themes in successful approaches to supporting efficiency improvement(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(74). The historical design of health systems based around siloes and episodes of care also presents a barrier to be overcome(75). Despite the interlinked nature of financial performance and health services outcomes, these outcomes are not always addressed concurrently(60). Capability, enthusiasm and centrally-led support for efficiency-focused initiatives across public health systems is not always sufficient to enable sustained improvements(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(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(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(16,61). Effective Organization-wide stakeholder engagement and consultation is linked with successful change at the public health system level(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(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(4,1). The Program Management Office model is an evidence-based approach to providing this support across public health systems(59).