Measuring the Capacity Utilization of Public District Hospitals in Tunisia: Using Dual Data Envelopment Analysis Approach

Document Type : Original Article


1 Iational Institute of Labour and Social Studies (INTES), University of Carthage, Tunisia, Tunis

2 LEM-CNRS, IÉSEG School of Management, Lille, France

3 LEFA-IHEC, University of Carthage, Tunisia, Tunis

4 Health Economist Expert (free lance)


Public district hospitals (PDHs) in Tunisia are not operating at full plant capacity and underutilize their operating budget.
Individual PDHs capacity utilization (CU) is measured for 2000 and 2010 using dual data envelopment analysis (DEA) approach with shadow prices input and output restrictions. The CU is estimated for 101 of 105 PDH in 2000 and 94 of 105 PDH in 2010.
In average, unused capacity is estimated at 18% in 2010 vs. 13% in 2000. Of PDHs 26% underutilize their operating budget in 2010 vs. 21% in 2000.
Inadequate supply, health quality and the lack of operating budget should be tackled to reduce unmet user’s needs and the bypassing of the PDHs and, thus to increase their CU. Social health insurance should be turned into a direct purchaser of curative and preventive care for the PDHs.




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  1. Arfa C, Achouri H. Tunisia: “Good Practice” in Expanding Health Care Coverage: Lessons from Reforms in a Country in Transition. In: Pablo G, George JS, Hugh RW, eds. Good Practices in Health Financing Lessons from Reforms in Low- and Middle-Income Countries. Washington: The World Bank; 2008:335-438.
  2. Ministry of Health (MoH). Annual Statistical Book of Hospital's indicators. Tunisia: Department of Publics' Hospital; 2011.
  3. Ministry of Health (MoH). Health Map 2011. Tunisie: Direction of Studies and Planning; 2013.
  4. Arfa C, Souiden A, Achour N. National Health Accounts in Tunisia: Results for Years 2004 and 2005. Published 2007.
  5. Abdelmoumene M, Achour N, Chaoui F, et al. Les systèmes de santé en Algérie, Maroc et Tunisie : Défis nationaux et enjeux partagés. Paris: Institut de Perspective Economique du Monde Méditerranéen; 2012.
  6. Gaynor M, Anderson F. Uncertain demand, the structure of hospital costs and the cost of empty hospital bed. J Health Econ. 1995;14:291-317. doi:10.1016/0167-6296(95)00004-2
  7. Johansen L. Production Functions and the Concept of Capacity. Namur:  Recherches recentes sur la fonction de production; 1968.
  8. Grosskopf S, Valdmanis V. Measuring hospital performance. A non-parametric approach. J Health Econ. 1987;6(2):89-107.
  9. Charnes A, Cooper WW, Rhodes EL. Measuring the efficiency of decision making units. Eur J Oper Res. 1978;2:429-444. doi:10.1016/0377-2217(78)90138-8
  10. Cooper WW, Seiford LM, Tone K. Data Envelopment Analysis: A Comprehensive Text with Models, Applications, References and DEA-Solver Software. Boston: Kluwer Academic Publishers; 2000.
  11. Färe R, Grosskopf SC. Measuring plant capacity, utilization and technical change: a nonparametric approach. International Economic Review 1989;30(3):655-666. doi:10.2307/2526781
  12. Färe R, Grosskopf S, Lovell KCA. Production Frontiers. New York: Cambridge University Press; 1994.
  13. Färe R, Grosskopf S, Valdmanis V. Capacity, competition and efficiency in hospitals: a nonparametric approach. Journal of Productivity Analysis. 1989;1(2):123-128. doi:10.1007/bf00157792
  14. Morrison CJ. Primal and dual capacity utilization: an application to productivity measurement in the U.S. automobile industry.  Journal of Business & Economic Statistics, American Statistical Association. 1985;3(4):312-324.
  15. Valdmanis V, Kumanarayake L, Lertiendumrong J. Capacity in Thai public hospitals and the production of care for poor and nonpoor patients. Health Serv Res. 2004;39(6 Pt 2):2117-2134. doi:10.1111/j.1475-6773.2004.00335.x
  16. Nelson RA. On the Measurement of Capacity Utilization. J Ind Econ. 1989;37(3):273-286. doi:10.2307/2098615
  17. Karagiannis R. Analyzing the Capacity Utilization and Optimal Input Usage of Public Hospitals in Greece. Paper presented at: Proceedings of International Conference on Applied Economics; Athens; 2010.
  18. Shephard RW. Theory of Cost and Production Functions. Princeton: Princeton University Press; 1970.
  19. Koopmans TC. Analysis of Production as an Efficient Combination of Activities Activity Analysis of Production and Allocation. New Haven: Yale University Press; 1951:33-97.
  20. Farrell MJ. The measurement of production efficiency.  Journal of Royal Statistical Society. 1957;120:253-290.
  21. Arrow KJ, Debreu G. Existence of an equilibrium for a competitive economy. Econometrica. 1954;22(3):265-290. doi:10.2307/1907353
  22. Färe R GS. Theory and Application of Directional Distance Functions.  Journal of Productivity Analysis. 2000;13(2):93-103.
  23. Gary F, Leleu H, Valdmanis V. Hospital capacity in large urban areas: is there enough in times of need?  Journal of Productivity Analysis. 2009;32(2):103-117. doi:10.1007/s11123-008-0099-1
  24. Färe R, Primont D. Multi-Output Production and Duality: Theory and Applications Netherlands: Kluwer Academic Publishers; 1995.
  25. Hollingsworth B. Non-parametric and parametric applications measuring efficiency in health care. Health Care Management Science. 2003;6:203-218. doi:10.1023/a:1026255523228
  26. Hollingsworth B. The Measurement of Efficiency and Productivity of Health Care Delivery. Health Econ. 2008;17:1107-1128. doi:10.1002/hec.1391
  27. Ministry of Health (MoH). Survey of Public District Hospitals: Resources and Activities Tunis: Direction of Basic Healthcare; 2000.
  28. Worthington A. Frontier efficiency measurement in healthcare: a review of empirical techniques and selected applications.  Med Care Res Rev. 2004;61(2 ):1-36. doi:10.1177/1077558704263796
  29. Chilingerian JA, Sherman D. Health Care Applications - From Hospitals to Physicians; From Productive Efficiency to Quality Frontiers. In: Cooper WW, Seiford LM, Zhu J, eds. Handbook on Data Envelopment Analysis. Boston: Kluwer Academic Publishers; 2004.
  30. Farsi M, Filippini M. An empirical analysis of cost efficiency in non-profit and public nursing homes. Annals of Public and Cooperative Economics. 2004;75(3):339-365. doi:10.1111/j.1467-8292.2004.00255.x
  31. Nayar P, Ozcan Y. Data envelopment analysis comparison of hospital efficiency and quality. J Med Syst. 2008;32:193-199. doi:10.1007/s10916-007-9122-8
  32. Simar L, Wilson PW. Statistical inference in nonparametric frontier models: the state of the art. Journal of Productivity Analysis. 2000;13:49-78.
  33. Simar L, Wilson PW. Estimation and inference in two-stage, semi-parametric models of production processes. J Econ. 2007;136:31-64. doi:10.1016/j.jeconom.2005.07.009
  34. Zere E, Mbeeli T, Shangula K, et al. Technical efficiency of District Hospitals: Evidence from Namibia using data envelopment analysis. Cost Eff Resour Alloc. 2006;4:5. doi:10.1186/1478-7547-4-5
  35. Ferrier GD, Leleu H, Vivian G. VG. Hospital capacity in large urban areas: is there enough in times of need? Journal of Productivity Analysis. 2009;3
  36. Karagiannis R. Analysing the capacity utilization and optimal input usage of public hospitals in Greece. International conference on applied economics – ICOAE; 2010.
  37. Valdmanis V, Kumanarayake L, Lertiendumrong J. Capacity in    Thai Public Hospitals and the Production of Care for Poor and Nonpoor Patients.” Health Serv Res. 2004;39(6 Pt 2):2117-2134.