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The B.E. Journal of Economic Analysis & Policy

Editor-in-Chief: Ludwig, Sandra / Schmitz, Hendrik

Ed. by Auriol, Emmanuelle / Barigozzi, Francesca / Brunner, Johann / Fleck, Robert / Mastrobuoni, Giovanni / Mendola, Mariapia / Requate, Till / de Vries, Frans / Wenzel, Tobias / Zulehner, Christine

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Volume 19 (2019)

Volume 6 (2006)

Volume 4 (2004)

Volume 2 (2002)

Volume 1 (2001)

The Impact of Secondary Environmental Variables on OECD Healthcare Efficiency: A Robust Conditional Approach

Richard Gearhart III
Published Online: 2019-01-11 | DOI: https://doi.org/10.1515/bejeap-2018-0063


In this paper, I estimate country-level efficiency using a newer order-m estimator where I condition efficiency estimates on secondary environmental variables. This allows me to identify which variables influence the effectiveness of a healthcare delivery system. I find that not controlling for secondary environmental variables leads to the average OECD country being 11% inefficient; after controlling for demographics and economic (social protection) environmental variables, inefficiency reduces to 7% (5%). This provides evidence that a substantial part of the inefficiencies of a healthcare system is related to demographics, socioeconomics, and the structure of the healthcare delivery system. Using the second-stage results, I find lower healthcare spending, both as a percent of GDP and total out-of-pocket, as well as more of the population covered by public health insurance, is related to better efficiency. Lower fertility rates, lower immigration rates, higher incomes, and lower pharmaceutical doses are also consistent with better healthcare efficiency. Lastly, a healthcare system that provides a basic benefits package but allows for purchase of private health insurance, with moderate gatekeeping and flexibility to increase the budget for healthcare through public and private financing, are the most efficient healthcare systems.

Keywords: healthcare efficiency; OECD; order-m; robust conditional estimation; healthcare institutions; non-parametric econometrics

JEL Classification: C14; I11; I12; I18


  • Afonso, A, and M St Aubyn. 2011. “Assessing Health Efficiency across Countries with a Two Step and Bootstrap Analysis.” Applied Economics Letters 18: 1427–30.CrossrefGoogle Scholar

  • Antecol, H, and K Bedard. 2006. “Unhealthy Assimilation: Why Do Immigrants Converge to American Health Status Levels?.” Demography 43 (2): 337–60.CrossrefGoogle Scholar

  • Bădin, L, C Daraio, and L Simar. 2010. “Optimal Bandwidth Selection for Conditional Efficiency Measures: A Data-Driven Approach.” European Journal of Operational Research 201: 633–40.CrossrefGoogle Scholar

  • Badin, L, C Daraio, and L Simar. 2012. “How to measure the impact of environmental factors in a nonparametric production model.” European Journal of Operational Research 223 (3): 818–33.CrossrefGoogle Scholar

  • Banks, J, M Marmot, Z Oldfield, and JP Smith. 2006. “Disease and Disadvantage in the U.S. and in England.” JAMA: the Journal of the American Medical Association 295 (17): 2037–45.CrossrefGoogle Scholar

  • Berk, M, and A Monheit. 2001. “The Concentration of Health Care Expenditures, Revisited.” Health Affairs 20 (2): 9–18.CrossrefGoogle Scholar

  • Cazals, C, J-P Florens, and L Simar. 2002. “Nonparametric Frontier Estimation: A Robust Approach.” Journal of Econometrics 106: 1–25.CrossrefGoogle Scholar

  • Danzon, P, and M Furukawa. 2008. “International Prices and Availability of Pharmaceuticals in 2005.” Health Affairs 27 (1): 221–33.CrossrefGoogle Scholar

  • Daraio, C, and L Simar. 2005. “Introducing Environmental Variables in Nonparametric Frontier Models: A Probabilistic Approach.” Journal of Productivity Analysis 24: 93–121.CrossrefGoogle Scholar

  • Daraio, C, and L Simar. 2007a. Advanced Robust and Nonparametric Methods in Efficiency Analysis. New York: Springer Science+Business Media, LLC.Google Scholar

  • Daraio, C, and L Simar. 2007b. “Conditional Nonparametric Frontier Models for Convex and Nonconvex Technologies: A Unifying Approach.” Journal of Productivity Analysis 28: 13–32.CrossrefGoogle Scholar

  • Daraio, C, L Simar, and PW Wilson. 2018. “Nonparametric Estimation of Efficiency in the Presence of Environmental Variables.” Econometrics Journal 21: 170–91.Google Scholar

  • De Cos, PH, and E Moral-Benito. 2014. “Determinants of Health-System Efficiency: Evidence from OECD Countries.” International Journal of Healthcare Finance and Economics 14: 69–93.CrossrefGoogle Scholar

  • De Witte, K, and M Kortelainen. 2013. “What Explains the Performance of Students in a Heterogeneous Environment? Conditional Efficiency Estimation with Continuous and Discrete Variables.” Applied Economics 45 (17): 2401–12.CrossrefGoogle Scholar

  • Dor, A, and W Encinosa. 2004. “Does Cost Sharing Affect Compliance? The Case of Prescription Drugs”. NBER Working Paper 10738.Google Scholar

  • Dubard, CA, and MW Massing. 2007. “Trends in Emergency Medicaid Expenditures for Recent and Undocumented Immigrants.” JAMA: the Journal of the American Medical Association 297 (10): 1085–92.CrossrefGoogle Scholar

  • Fisher, E, D Wennberg, T Stukel, D Gottlieb, FL Lucas, and E Pinder. 2003a. “The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care.” Annals of Internal Medicine 138 (4): 273–87.CrossrefGoogle Scholar

  • Fisher, E, D Wennberg, T Stukel, D Gottlieb, FL Lucas, and E Pinder. 2003b. “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care.”.” Annals of Internal Medicine 138 (4): 288–98.CrossrefGoogle Scholar

  • Fried, H, CAK Lovell, and S Schmidt. 2008. The Measurement of Productive Efficiency and Productivity Growth. Oxford University Press: New York.Google Scholar

  • Garber, A, and J Skinner. 2008. “Is American Health Care Uniquely Inefficient.” Journal of Economic Perspectives 22 (4): 27–50.CrossrefGoogle Scholar

  • Gaynor, M, J Li, and W Vogt. 2006. “Is Drug Coverage a Free Lunch? Cross-Price Elasticities and the Design of Prescription Drug Benefits”. NBER Working Paper 12758.Google Scholar

  • Gearhart, R. 2016a. “The Robustness of Cross-Country Healthcare Rankings among Homogeneous OECD Countries.” Journal of Applied Economics 19 (1): 113–43.CrossrefGoogle Scholar

  • Gearhart, R. 2016b. “No Theory: An Explanation of the Lack of Consistency in Cross-Country Health Care Comparisons Using Non-Parametric Estimators.” Health Economics Review 6: 40.CrossrefGoogle Scholar

  • Giuntella, O, and F Mazzonna. 2014. “Do Immigrants Bring Good Health” IZA Discussion Paper No. 8073. Online at http://ftp.iza.org/dp8073.pdf.

  • Greene, W. 2004. “Distinguishing between Heterogeneity and Inefficiency: Stochastic Frontier Analysis of the World Health Organization’s Panel on National Health Care Systems.” Health Economics 13: 959–80.CrossrefGoogle Scholar

  • Hadad, S, Y Hadad, and T Simon-Tuval. 2013. “Determinants of Healthcare System’s Efficiency in OECD Countries.” The European Journal of Health Economics 14 (2): 253–65.CrossrefGoogle Scholar

  • Hall, RE, and CI Jones. 2007. “The Value of Life and the Rise in Health Spending.” The Quarterly Journal of Economics 122 (1): 39–72.CrossrefGoogle Scholar

  • Hollingsworth, B. 2008. “The Measurement of Efficiency and Productivity of Health Care Delivery.” Health Economics 17: 1107–28.CrossrefGoogle Scholar

  • Hurley, RE, DA Freund, and DE Taylor. 1989. “Emergency Room Use and Primary Care Case Management: Evidence from Four Medicaid Demonstration Programs.” American Journal of Public Health 79 (7): 843–46.CrossrefGoogle Scholar

  • Journard, I, C Andre, and C Nicq. 2010. “Health Care Systems: Efficiency and Institutions”. OECD Economics Working Paper 769.Google Scholar

  • Kneip, A, B Park, and L Simar. 1998. “A Note on the Convergence of Non-Parametric DEA Efficiency Measures.” Econometric Theory 14: 783–93.Google Scholar

  • Kneip, A, L Simar, and P Wilson. 2015. “When bias kills the variance: central limit theorems for DEA and FDH efficiency scores.” Econometric Theory 31 (2): 394–422.CrossrefGoogle Scholar

  • Kumbhakar, S. 2010. “Efficiency and Productivity of World Health Systems: Where Does Your Country Stand?.” Applied Economics 42: 1641–59.CrossrefGoogle Scholar

  • Li, Q, and J Racine. 2007. Nonparametric Econometrics, Princeton University Press.Google Scholar

  • Orrenius, PM, and M Zavodny. 2009. “Do Immigrants Work in Riskier Jobs.” Demography 46 (3): 535–51.CrossrefGoogle Scholar

  • Paris, V, M Devaux, and L Wei. 2010. “Health Systems Institutional Characteristics: A Survey of 29 OECD Countries”. OECD health working papers no. 50, OECD, Paris.Google Scholar

  • Perez-Carceles, MC, JC Gomez-Gallego, and M Gomez-Gallego. 2017. “Environmental Factors Affecting European and Central Asian Health-Systems’ Bias-Corrected Efficiency.” Applied Economics 50 (32): 1–29.Google Scholar

  • Pritchett, L, and L Summers. 1996. “Wealthier Is Healthier.” The Journal of Human Resources 31 (4): 841–68.CrossrefGoogle Scholar

  • Puig-Junoy, J. 1998. “Measuring Health Production Performance in the OECD.” Applied Economics Letters 5: 255–59.CrossrefGoogle Scholar

  • Simar, L, and PW Wilson. 1999. “Estimating and Bootstrapping Mamlquist Indices.” European Journal of Operational Research 115: 459–71.CrossrefGoogle Scholar

  • Simar, L, and PW Wilson. 2007. “Estimation and Inference in Two-Stage, Semi-Parametric Models of Production Processes.” Journal of Econometrics 136: 31–64.CrossrefGoogle Scholar

  • Simar, L, and PW Wilson. 2008. “Statistical Inference in Non-Parametric Frontier Models: Recent Developments and Perspectives.” In The Measurement of Productive Efficiency and Productivity Growth, edited by H.O. Fried, C.A.K. Lovell, and S.S. Schmidt, 421–521. Oxford University Press: Oxford.Google Scholar

  • Simar, L, and PW Wilson. 2011. “Two-Stage DEA: Caveat Emptor.” Journal of Productivity Analysis 36: 205–18.CrossrefGoogle Scholar

  • Skinner, J, E Fisher, and J Wennberg. 2005. “The Efficiency of Medicare.” In Analyses in the Economics of Aging, edited by D. Wise, 129–57.University of Chicago Press and NBER: Chicago.Google Scholar

  • Spinks, J, and B Hollingsworth. 2009. “Cross-Country Comparisons of Technical Efficiency of Health Production: A Demonstration of Pitfalls.” Applied Economics 41: 417–27.CrossrefGoogle Scholar

  • Starfield, B, L Shi, and J Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” The Milbank Quarterly 83 (3): 457–502.CrossrefGoogle Scholar

  • Varabyova, Y, and JM Muller. 2016. “The Efficiency of Health Care Production in OECD Countries: A Systematic Review and Meta-Analysis of Cross-Country Comparisons.” Health Policy 120: 252–63.CrossrefGoogle Scholar

  • Wheelock, D, and PW Wilson. 1999. “Technical Progress, Inefficiency, and Productivity Changes in US Banking, 1984-93.” Journal of Money, Credit, and Banking 31: 212–34.Google Scholar

  • Wheelock, D, and PW Wilson. 2008. “Non-Parametric, Unconditional Quantile Estimation for Efficiency Analysis with an Application to Federal Reserve Check Processing Operations.” Journal of Econometrics 145: 209–25.CrossrefGoogle Scholar

  • Wheelock, D, and PW Wilson. 2009. “Robust Non-Parametric Quantile Estimation of Efficiency and Productivity Changes in U.S. Commercial Banking, 1985-2004.” Journal of Business and Economic Statistics 27: 354–68.CrossrefGoogle Scholar

  • Wilson, PW. 2011. “Asymptotic Properties of Some Non-Parametric Hyperbolic Efficiency Estimators.” In Exploring Research Frontiers in Contemporary Statistics and Econometrics, edited by I. Van Keilegom, and P.W. Wilson, 115–50. Berling: Springer-Vestag.Google Scholar

  • Wranik, D. 2012. “Healthcare Policy Tools as Determinants of Health-System Efficiency: Evidence from the OECD.” Health Economics, Policy, and Law 7: 197–226.CrossrefGoogle Scholar

About the article

Published Online: 2019-01-11

Citation Information: The B.E. Journal of Economic Analysis & Policy, 20180063, ISSN (Online) 1935-1682, DOI: https://doi.org/10.1515/bejeap-2018-0063.

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