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).