Scaling up Maternal and Child Healthcare Delivery among Mission Hospitals in Southeast Nigeria: An Empirical Application of Data Envelopment Analysis for Setting Benchmarks and Targets

Henry E. Aloh, Obinna E. Onwujekwe, Hyacinth E. Ichoku, Augustine C. Osigwe


The health system in many parts of Nigeria has been dysfunctional in several domains including financing, human resources, infrastructure, health management information system and hospital services. In an attempt to scale up Maternal and Child Health (MCH) services and ensure efficiency, Ebonyi State Government in Southeast Nigeria provided funding to mission hospitals
across the State as a grant. This study used nonparametric method to assess the effect of this public financing on the efficiency of the mission hospitals. Operational cost and number of hospital beds were used as the input variables, while antenatal registrations, number of immunization doses and hospital deliveries were the output variables. The hospitals were disaggregated into 15 hospital-years. The mean overall technical efficiency of the mission hospitals was 84.05 22.45%. The mean pure technical efficiency was 95.56±6.9% and the scale efficiency was 88.05±22.20%. About 46.67% of all the hospital-years were
technically and scale efficient. Although, 55.33% were generally inefficient, only 33.33% of hospital-years exhibited pure technical inefficiency. Low immunization coverage was the major cause of inefficiency. The study showed increased maternal health service output as result of public funding or intervention; however, the mission hospitals could have saved 16% of input resources if they had performed efficiently. It also shows that data envelopment analysis can be used in setting targets/benchmarks for relatively inefficient health facilities, and in monitoring impact of interventions on efficiency of hospitals over-time. (Afr J Reprod Health 2019; 23[3]: 57-67).

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National Population Commission (NPC) [Nigeria] and

ICF International. 2014 Nigeria Demographic and

Health Survey 2013, Abuja Nigeria, and Rockville,

Maryland, USA: NPC and ICF International.

Ichoku HE, Fonta WM, Onwujekwe OE and Kirigia JM.

Evaluating the Technical Effeciency of Hospitals in

South Eastern Nigeria. European Journal of

Business and Management. ISSN 2222-1905(paper)

ISSN-2839 (online).

UNFPA. Final Report on Ebonyi State Mother and Child

care Initiative UNFPA Ebonyi State, Nigeria

Documentation, October 2010.

Bryan L, Conway M, Keesmaat T, Mc Kenna S and

Richardson B. Strengthening Sub-Saharah African‘s

health systems: A practical approach. Insight and

publications, June 2010.

Russell S and Gilson L. User Fees Policies to promote

Health Services Access for the poor: A wolf in

sheep‘s clothing? International Journal of Health

Services; 1997 Vol. 27 (2), Pages 359-379

Ebonyi State Ministry of Health; Department of

Planning, Research and Statistics (DPRS), 2014.

Bang A and Chatter J. High level expert group report on

universal health coverage for India. New Delhi:

Planning Commission of India, 2011.

Jeffrey DS. Achieving universal health coverage in lowincome

settings. Lancet 2012; 380: 944-947.

Igwe A and Chukwu B. An appraisal of open system

business policy model in the management of

mission Hospitals in the South East Nigeria.

European Journal of Business and management Vol.

, No. 14, 2012.

Masiye F. Investigating health system performance: An

application of data envelopment analysis to Zambia

hospitals. BMC Health Services Research 2007,


Porcelli F. Measurement of Technical Efficiency. A brief

survey on parametric and non-parametric

techniques. 2009, Jan; Source:

Xing Z, Kaoru T and Yingzhe L. Impact of the Local

Public Hospital Reform on the Efficiency of

Medium sized Hospitals in Japan: An Improved

Slacks based Measure Data Envelopment Analysis

Approach. Health Services Research, Vol 53: No.

, April 2015.

Uka F. Ebonyi gives N 100 million to mission hospitals.

Daily Independent, newspaper, 2013, December


Akpa N. Ebonyi disburses N 100 million for rural

healthcare. Nigeria Health News online, 2012,

February 10th.

Opwora A, Kabere M, Molyneux S and Goodman C.

Direct facility funding as a response to user fee

reduction: Implementation and perceived impact

among Kenyan health centres and dispensaries.

Health Policy and Planning, 2010, 25:406-418.

Frederique P, Michael Van H, Rony Z, Seco G, Mit P

and Guillaume J. Abolishing user fees for children

and present woman trebled uptake of malariarelated

intervention in Kangaba, Mali. Health Policy

and planning 2011; 26:ii 72-ii83.

Bruno M, Gilson L and Abdelmajid T. User fee removal

in low-income countries: sharing knowledge to

support managed implementation. Health Policy

and Planning 2011; ii 1-ii 14.

Kirigia JM, Emrouznejad A, Cassoma B, Asbu EZ and

Barry S. A Performance Assessment Methods for

Hospitals: The case of Municipal Hospitals in

Angola. Journal of Medical System, 2008, 32(6):


Joj RJ and Miguel SS. Technical efficiency of public

district hospitals in Madhya Pradesh, India: a data

envelopment analysis. Global Health Action; 2013,


Charnes A, Cooper WW and Rhodes. Measuring the

efficiency of decision making units. European

Journals of Operational Research 2(1978) 429 –

Kruk ME and Freedman LP. Assessing Health System

Performance in developing countries: A review of

the literature. Health Policy; 2008 March, Vol. 85

Issue 3, pages 263-276.

Jill J. Data envelopment analysis and its application to the

measurement of efficiency in higher education.

Economics of Education Review 25 (2006) page

– 280.

Rowena J, Peter CS and Andrew S. Measuring

Efficiency in health care: Analytic Techniques and

Health Policy. Cambridge University Press, 2006,

page 1

Tlotlego N, Nonvignon J, Sambo LG, Asbu EZ, Kirigia

JM. Assessment of productivity of hospitals in

Botswana: A DEA application.Intl Archives of

Medicine 2010, 3(1)27.

Kirigia JM, Emrouznejad A, Sambo LG, Munguti N and

Liambila W: Using Data Envelopment Analysis to

measure the technical efficiency of public health

centres in Kenya. Journal of Medical Systems; 2004

April, 26(2):155 -166.

Marshall P and Flessa S. Efficiency of primary care in

rural Burtina Faso. Atwo-stage DEA Analysis.

Health Economics Review, Springer Open Journal

, 1:5.

Zere E, Mbeeli T, Shangula K, Mand L, Mutrirua K,

Tjivambi B and Kapenambili S. Technical

efficiency of district hospitals: Evidence from

Mamibia using Data Envelopment Analysis. Cost

Effectiveness and Resource Allocation 2006,

March, 27, 4:5

Alison R, Hernandez and Miguel SS. Assessing the

technical efficiency of health posts in rural

Guatemala: a data envelopment analysis. Global

Health Action. Published online, 2014 Jan 20.doi:


Jehu-Appiah C, Sekidde S, Adjuik M, Akazili J, Almeida

AD, Nyonator F, Baltussen R, Asbu EZ and Kirigia

JM. Ownership and technical efficiency of

hospitals: Evidence from Ghana. Using data

envelopment analysis. Cost Effectiveness and

Resource Allocation 2014. http://www.resource.

Kirigia JM and Asbu EZ. Technical and Scale Efficiency

of public community hospitals in Eritrea: an

exploratory study. Health Economics Review, a

Springer Journal, 2013, 3:6.

Chen Y, Cook WD and Zhu J. Deriving the DEA

Frontier for Two-Stage Processes, European Journal

of Operational Research; 2010, Vol. 202, 138-142.

Osei D, George M, d‘ Almeida S, kirigia JM, Mensah

AO and Kainyu LH. Technical efficiency of public

district hospitals and health centres in Ghana: a pilot

study. Cost Effectiveness and Resource Allocation

, 3:9.

Kirigia JM, Mensah AO, Mwikisa CN, Absu EZ,

Emrouznejad A, Makoudode P and Hounnankan A.

Technical efficiency of zone hospitals in Benin. The

African health Monitor 2010, 12:30-39.

Kirigia JM, Emrouznejad A and Sambo LG.

Measurement of technical efficiency of public

hospitals in Kenya: Using Data Envelopment

Analysis. Journal of Medical System 2002,


Zere E, Mbeeli T, Shangula K, Mandhate C, Mutirua K,

Tjivambi B and Kapenambili W. Technical

efficiency of district hospitals: Evidence from

Namibia using Data Envelopment Analysis. Cost

Effectiveness and Resource Allocation 2006, 4:5.

Yawe BL and Kavuma SN: Technical efficiency in the

presence of desirable and undesirable outputs: A

case study of selected district referral hospitals in

Uganda. Health Policy and Development, 2008,


WHO: Primary health care: now ever than ever Geneva;

Abiodun AJ: Quantitative Analysis of Efficiency of

Public Health care Facilities in Nigeria: A study of

Ogun and Lagos States. Covenant University Ph. D

thesis and dissertations, School of Business, Dept of

Business Management 2011, 03.

WHO 2013. WORLD Health Report 2013: Research for

Universal coverage. Geneva: World Health


Novignon J and Nonvignon J. Improving primary health

care facility Performance in Ghana: efficiency

analysis and fiscal space implications. MC Health

Services Research (2017) 17:399 DOI



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