Optimal use of physical resources, human forces, and technologies is one of the main motivations for evaluating the performance of organizations. Determining the efficiency of organizations and service providers is one of these tools [23]. Thus, the present study was conducted to evaluate the efficiency of the PHC system in the Iranian districts. The results of this study can help to make better use of resources in the health systems of districts and contribute to the expansion and development of health services to the populations covered.
According to the results, the performance of the DPHCS in Kerman and Kuhbanan during 2018 was more favorable than other districts. For instance, the results indicated that with 57.4% of the available inputs, the health managers of Orzooieh district had the potential of increasing the provision of health services to the community. In other words, the DPHCS of Orzooieh was using only 42.6% of its capacity. Thus, the health managers of Orzooieh district could use proper planning to provide more services to the covered population. Otherwise, they had to reduce and adjust the inputs to improve efficiency. The same analysis can be used for other districts.
The results showed that the efficiency of the DPHCS of Ravar and Rabor districts fluctuated more in different scenarios. It means that according to the classification carried out, they were considered as efficient districts in some scenarios and inefficient in others. For example, the district of Rabor was quite efficient in three scenarios, but achieved the efficiency score of < 0.4 in the others. An examination of the inputs and outputs used in the scenarios shows that human forces and service recipients were respectively the common inputs and outputs in three scenarios in which the district of Rabor was quite efficient. But in the four scenarios in which the district achieved low efficiency, human forces was not an input. Therefore, the available human forces in this district had been probably used well, but the other two inputs had not. Another reason might be the nature of primary care services that is work- intensive (not capital- intensive), so the human forces are not expected to be ignored. This result indicates that some scenarios do not reflect performance well. This is why designing appropriate scenarios for thematic performance evaluation is of great importance. The results also highlighted the limitations of one-dimensional (one-scenario) performance studies and showed that performance appraisal based on a single scenario was not an accurate basis for managerial decisions. Therefore, it is recommended to first pay special attention to the selection of inputs and outputs, and then evaluate and analyze the efficiency of firms in different scenarios.
Thus, it is necessary for districts health managers to consider the limitations and work in accordance with their conditions in order to improve their efficiency levels. Health managers can improve their efficiency by modifying the inputs, but the importance of access (to) and utilization (from) health services should not be overlooked because one of the main goals of the health system is public access to health services, equity and strengthening it. Yazdi et al. Also pointed out the importance of paying attention to equity and access along with improving efficiency and effectiveness [24]. Therefore, it is more appropriate for health managers to prioritize the improvement and expansion of service delivery in their area of responsibility over the modification of the inputs. To increase the outputs, not only service providers (Supply side) should be encouraged to provide quality and effective services, but the covered population and service recipients (Demand side) should also be encouraged to use health services in PHC centers. A study by Marschall et al. also showed that improving access to primary care facilities had a significant impact on their efficiency. Hence, managers and policymakers must remove the barriers to the demand for access to PHC [25]. By conducting cultural, promotional, and educational activities, health managers can encourage people to use primary care services and expand the provision of the services to all people covered [26].
Using the obtained results, the health managers of inefficient districts can carry out further investigations to identify the factors affecting efficiency and take actions to remove the obstacles in order to provide the conditions for improving efficiency and providing quality services. Many primary care professionals have divided the determinants of health center performance into two categories: external factors such as population size, access to the health centers, and access to the nearest hospital, and internal factors such as staff skills and behavior or managerial competence. They believe that the first category (external factors) has greater importance and affects efficiency to a higher degree [27]. In general, inefficiency can be affected by various factors such as environmental, structural, and organizational ones [28].
In the study by Oikonomou et al. in Greece, two factors including population coverage and distance to the nearest health center in the city were identified as structural factors affecting efficiency. In their study, efficient centers had a relatively large population and were located near large districts [27]. In other countries, the role of structural factors in determining the efficiency of primary care units has been emphasized [25, 29]. In this regard, the lack of appropriate mechanisms to evaluate the performance of primary care units is considered as the cause of clinical and administrative deficiencies in primary care services [27, 30]. Therefore, conducting further research and evaluations in highly inefficient units can help identify the weaknesses and failures and guide efforts to eliminate the barriers to proper performance. On the other hand, investigating relatively efficient units can facilitate the identification and dissemination of appropriate operational procedures as well as the monitoring of progress towards objectives. This process may lead to increased productivity in both inefficient and inefficient units [27]. The results of a study by Cordero et al. indicated that environmental factors had a significant and negative effect on the performance, quality, and efficiency of primary health care providers [31].
Meanwhile, the DHN in Iran, especially in rural areas, has developed based on population. Therefore, factors such as migration and changes in the population pyramid affect the number of services provided and the number of people in need of services, because migration of young people from rural to urban areas or from small towns to large cities provides the basis for changing the age pyramid of such areas towards adulthood and aging, and decreases the population at reproductive ages. This will reduce the demand for major services provided by health centers, including vaccinations, maternity and postpartum services, etc. In their study, Ali Mohammadi Ardakani et al. also acknowledged that the number of people in need of health services depended on the covered population and its age composition, and these characteristics would directly affect the number of services provided and would thus affect efficiency [26]. According to Zare Ahmadabadi et al., non-referral and the covered population structure were the reasons for the fluctuation of the efficiency of health centers. They suggested that in order to increase the efficiency of efficient centers, health officials and managers needed to change the geographical areas covered, to float the working hours of the specialized personnel in health centers, and to apply zoning [32]. Rahimi et al. also considered migration and demographic transition as two social trends affecting the performance of the Iranian health system in the coming years [33].
Thus, in order to have an efficient system, it is necessary to provide health services based on the macro and current policies of the country, the age composition of the society and their health needs. For example, due to the policy of reducing childbearing in Iran, contraceptive services were once widely provided in health centers. However, in response to the rapid trend of declining fertility in Iran, pregnancy incentive policies have been on the agenda since 2014, limiting the provision of contraceptive services in health units and increasing the importance of pregnancy care. Even now, due to the change in the age pyramid and the movement towards increasing the elderly population [33], it is necessary for the health system to develop and provide appropriate services for this population group. Another factor that can affect efficiency is the population density and dispersion of villages around some districts and their type of settlement (permanent or nomadic). For instance, 78% of the population in Orzooieh district, which had the lowest efficiency, was rural population, part of which consisted of the nomads who migrated to the neighboring province (Hormozgan) in cold seasons. To eliminate the effect of residence (urban or rural), Ali Mohammadi Ardakani et al. suggested that the calculation of efficiency in terms of urban or rural health units would be more accurate and helpful [26].
However, dealing with inefficiency is not possible only by taking actions at operational and executive levels, because inefficiency is mainly associated with the weaknesses of the PHC system in management and policy-making areas such as budgeting and service purchasing, human resource planning and development, targeting, performance management, quality improvement, coordination, evaluation, monitoring, and control. Therefore, a new culture must be built through the implementation of structural, governance, service, and financial reforms in the health system, and the centers must be allowed to operate autonomously, effectively, and productively. In this regard, the most important measures to improve efficiency are the ones that improve accountability, information exchange, and responsibility [27]. In general, it can be acknowledged that in order to improve the efficiency of the PHC system at districts level, an integrated and more comprehensive health care system must first be develop through the expansion of family medicine (not family physician), better management of limited resources, and updating organizational policies and goals. Meanwhile, building the culture of using first-level preventive services should be promoted and strengthened at the community.
It is worth noting that investigating and analyzing the efficiency of health centers (unlike hospitals) and identifying the factors affecting it has been somewhat neglected or done limitedly in Iran. Therefore, it is necessary for health officials and researchers to focus on this issue and identify the factors affecting inefficiency in primary health centers in order to eliminate them. Of course, this is not the case only in Iran, but around the world, and the majority of health efficiency studies are focused on hospitals. One reason for this can be the clear boundaries of hospitals and their processes from admission to discharge. But the primary care system is an open, community-based system with no clear boundaries, which makes it more complex to do economic analyses [34].
Unlike previous studies that evaluated the efficiency of healthcare units in a single mode, the present study evaluated the efficiency of the DPHCS in different scenarios. In other words, the use of different scenarios as an analysis scenario led to carrying out the sensitivity analysis of change in the inputs and outputs in the performance of the healthcare units, which is not usually seen in performance evaluation studies. This can enable health managers to identify their weaknesses and improvable qualities more effectively and take measures to address them. Furthermore, this study was the first research that evaluated the efficiency of the PHC system at the level of the districts in Iran. The limitation of the present study was the limited number of the variables, which is one limitation of the DEA method. The smaller the number of firms studied, the more limited variables we had to use. However, this was somewhat resolved by using different scenarios.