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Government subsidies are the backbone of the large-scale Coal to Clean Heating Policy launched in China in 2017. We analyze data from 27 pilot cities from 2017 to 2019. We use a slacks-based measure model with undesirable outputs to evaluate the optimal design of central and local government subsidies under the policy. While the overall efficiency is high, provincial capitals and cities with lower economic development levels show less efficiency. Our findings suggest that distributing central government subsidies based solely on administrative levels is not the best way to achieve perfect efficiency. Additionally, perfect efficiency at the city level may take years to achieve. A sweeping phase-out of government subsidies could lead to undesirable policy outcomes. Content analysis of normative documents from the six best-performing cities and six least efficient cities indicates that better-formulated legal and policy documents may contribute to higher efficiency. As lessons for designing and evaluating large-scale energy policies, we recommend considering 17 factors that could impact subsidy efficiency. We also suggest implementing a progressive phase-out schedule as a measure of policy efficiency and identifying factors that could ensure the long-term success of nationally implemented government subsidies., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Aim: This study aimed to evaluate the operational efficiency of traditional Chinese medicine (TCM) hospitals in China., Methods: Pearson's analysis was used to test the correlation between the input and output variables. Data envelopment analysis (DEA) was utilized to analyze the input and output variables of 16 TCM hospitals, and each hospital efficiency score was computed by Deap 2.1, assuming variable return to scale (VRS), which is an input-oriented model. t tests were conducted to confirm the significant difference of efficiency scores at the hospital level and by hospital type, and ANOVA was used to test for significant differences in efficiency scores according to hospitals' size., Results: The correlation coefficient of the input and output indicators was between 0.613 and 0.956 ( p  < 0.05). The difference in number of doctors (ND) and numbers of pharmacists (NP) were statistically significant ( p  < 0.05) at the hospital level. The mean efficiency scores for technical efficiency (TE), pure technical efficiency (PTE), and scale efficiency (SE) in secondary TCM hospitals were 0.766, 0.919, and 0.838, respectively. Additionally, the lowest TE, PTE, and SE were 0.380, 0.426, and 0.380, respectively. Eight TCM hospitals in this study were DEA efficient, with an efficiency score of 1. There were no statistically significant differences in TE, PTE, and SE among hospital levels, hospital types or hospital sizes groups ( p  > 0.05)., Conclusion: This study revealed that tertiary TCM hospitals had a greater level of efficiency than secondary TCM hospitals. In our study, 50% of TCM hospitals had inefficient management. Therefore, to activate the new development power of TCM hospitals, it is necessary to reform and improve the management system and mechanism of TCM hospitals, optimize the development environment of TCM hospitals and formulate development plans and measures based on local conditions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Wang, Lv, Jiang and Ren.)

This study examines the effectiveness of the countries' health systems in the Horn of Africa region. It also investigates the perspectives of actors who have played an active role in health affairs in Somalia carried out by Türkiye. Using the Data Envelopment Analysis and Malmquist Total Factor Efficiency Analysis, we investigated the effectiveness of the health systems and improvements made throughout the years. In the countries of interest, efficiency levels and average total factor productivity showed positive and/or negative trends between 2000 and 2020. Kenya showed a marked performance in achieving improved average total factor productivity thanks to the effective use of current technology in health, success in integrating new technologies into the health system, and a high potential to produce more output despite insufficient existing inputs. The remaining countries lagged behind in improving their production factors. Since 2014, Türkiye has provided health services in Somalia through health diplomacy and conducted medical examinations for numerous patients in a well-equipped hospital., Competing Interests: The Authors declared no conflict of interest, (African Journal of Reproductive Health © 2024.)

Background: Primary healthcare management efficiency conditions the functioning of specialized care and has a direct impact on the outcomes of the health system and its sustainability. The objective of this research is to develop models to evaluate the efficiency, including health outcomes, of the primary healthcare centres (PHC) of the Clínico - La Malvarrosa Health District in Valencia., Methods: To evaluate efficiency, Data Envelopment Analysis (DEA) was used with output orientation and variable returns to scale, with panel data from the years 2015 to 2019. In rates per 10,000 inhabitants, the inputs are: medical and nursing staff and pharmacy cost. The outputs are: number of consultations, hospital emergencies, referrals, avoidable hospitalisations, avoidable mortality and pharmaceutical prescription efficiency. As exogenous variables: the percentage of population over 65 years old, over 80 and case-mix. Three models were developed, all of them with the same inputs and different combinations of outputs related to: healthcare activity, outcomes, and both, in order to study the influence of the different approaches on efficiency. Each model is analysed both without exogenous variables and with each of them., Results: The efficiency results vary depending on the model used, although certain PHCs are always on, or very close to, the efficient frontier, while others are always inefficient. When healthcare activity outputs are considered, efficiency scores improve and the number of efficient PHCs increases. However, in general, the PHC score decreases throughout the evaluated period. This decrease is more pronounced when only activity outputs are included., Conclusions: DEA allows the inefficiencies of PHCs to be analysed and the efficient ones are clearly distinguished from the inefficient, although different efficiency scores are obtained depending on the model used. Evaluation can be according to healthcare activity, health outcomes or both, making it necessary to identify the expected objectives of the PHCs, as the perspective of the analysis influences the results., (© 2024. The Author(s).)

Background: Medical diagnostic laboratories are an essential work environment that plays an important role in diagnosing, treating, and being sensitive to diseases. One way to evaluate laboratories' performance is to calculate their efficiency. This study investigates the efficiency of laboratories that are related to health centers in the south of Iran., Methods: This study was conducted in 2021. The input numbers include: the number of technical personnel and the number of cell counters, and the output data includes: the scores obtained from the level 2 health laboratory evaluation list. And efficiency was calculated with DEAP software. The analysis is accomplished by the assumption of input-oriented., Findings: The efficiency of laboratories of Orzueeyeh and Ravar Cities had the highest efficiency with the assumption of variable returns to scale efficiency 1, and the model of all laboratories is the laboratory of Ravar City. The laboratories of Kuhbanan and Rabor cities had the lowest efficiency with the assumption of variable returns to scale efficiency of 0.859 and 0.899, respectively. The average scale efficiency, Variable returns to scale, and constant returns to scale for laboratories in the cities of Kerman province are 0.842, 0.943, and 0.895, respectively., Conclusions: To increase the efficiency of laboratories, significant resources and funds should be used, as well as few studies have been done on the efficiency of laboratories, which requires more attention., (© 2024. The Author(s).)

Background: Health Complex Model was implemented to provide primary health care services in urban, especially in slum areas. As a pilot at a provincial level, Chamran Health Complex offers healthcare for more than 57,000 residents of Tabriz. Despite the necessity of cost information in healthcare decision-making, there was limited knowledge about the unit cost of services. This study aims to analyze the cost and efficiency of health centers., Methods: Activity-Based Costing method with direct and step-down allocation methods was adopted. We estimated unit costs in a hypothetical scenario according to national standards to quantify the gap between current and standard practice. Input-oriented Data Envelopment Analysis was administered to measure the efficiency of health centers., Results: The total cost of the complex was $2,841,897, of which 67% ($1910373) and 33% ($931523) were accounted for direct and indirect costs, respectively. The vaccination center had the lowest ($9), and the occupational health center had the highest average unit cost ($76). The average technical efficiency of the health centers was 0.519, where the HC1 and HC3 showed the best performance., Conclusion: There is remarkable variability in service costs across health centers, which must be addressed in performance management and contracting practices. Although we found a gap between current and standard practice in terms of staff and facilities according to national standards, Chamran Health Complex has an untouched capacity that can be utilized with better planning and without incurring additional costs. It raises the need for revising national standards by the Iran Ministry of Health., (© 2024. The Author(s).)

One of the paramount challenges in natural resource management revolves around the delicate equilibrium between the demand for and the supply of diverse Ecosystem Services (ESs) within a cultural landscape. Recognizing the centrality of cultural landscapes to human well-being, the sustainability of these landscapes hinges upon the health and stability of ecosystems that can effectively provide the required ESs. Over the long term, the sustainable supply of ESs is constrained by the potential supply of ESs. Understanding the potential supply of ESs is crucial for averting compromises to the ecosystems within a landscape. This article introduces a novel perspective on evaluating the ESs of a landscape by means of efficiency analysis. Instead of presenting the potential supply of ESs in absolute terms, we offer a comparative analysis of ESs' relative supply to associated management costs. In principle, the efficiency of Landscape Units (LUs) is defined as the ratio of the potential supply of multiple ESs to the costs associated with land use and land cover management. The resultant efficiency maps serve as hot and cold spot maps, revealing efficient ecosystem compositions that yield multiple ESs. This composition reflects management efforts, incorporating various management costs. Forests emerge as pivotal ecosystems in landscapes, delivering the most ESs at the lowest costs. These efficiency maps offer valuable insights for regional planners, enabling them to enhance the supply of ES in inefficient LUs by studying the ecosystem structure and associated costs of the most efficient LUs., (© 2024. The Author(s).)

Countries have become increasingly concerned about the impact of their activities and their alignment with sustainable development goals. Consequently, it is necessary to examine their performance efficiency in a unified manner, accounting for economic, environmental, and social variables. A country's performance efficiency is defined as the ratio of observed output to frontier output, given the country's productive resources. In this paper, we use the frontier technique of Data envelopment analysis (DEA) to estimate the frontier output. The objective of this study is to assess the performance efficiency of 111 worldwide countries and to examine whether gender inequality, the share of renewable energy consumption, the government control of corruption and government expenditure on education could explain differences in performance. We employed the non-parametric DEA model using three inputs (capital, labor, and primary energy consumption) and one output (GDP). We also considered an additional output (CO 2 emissions); however, the results were identical to the one output model because CO 2 emissions and primary energy consumption are highly correlated (0.96). We find that there is a negative impact of gender inequality, a positive impact of the share of renewable energy consumption and government control of corruption on performance efficiency. Our results also indicate that reducing CO 2 emissions required transitioning towards renewable energy and using the energy efficiently. However, we did not find a positive relationship between government expenditures on education and country efficiency., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Policymakers, who are constantly discussing growing health expenditures, should know whether the health system is efficient. We can provide them with such information through international health system efficiency evaluations. The main objectives of this study are: (a) to evaluate the efficiency of health systems in 28 developed countries by multiple-criteria decision analysis (MCDA) and data envelopment analysis (DEA) and (b) to identify reasonable benchmark countries for the Czech Republic, for which we collect information on the relative importance of health system inputs and outputs., Methods: We used MCDA and DEA to evaluate the efficiency of the health systems of 28 developed countries. The models included four health system inputs (health expenditure as a relative share of GDP, the number of physicians, nurses, and hospital beds) and three health system outputs (life expectancy at birth, healthy life expectancy, and infant mortality rate). The sample covers 27 OECD countries and Russia, which is also included in the OECD database. To determine the input and output weights, we used a questionnaire sent to health policy experts in the Czech Republic., Results: We obtained subjective information on the relative importance of the health system inputs and outputs from 27 Czech health policy experts. We evaluated health system efficiency using four MCDA and two DEA models. According to the MCDA models, Turkey, Poland, and Israel were found to have efficient health systems. The Czech Republic ranked 16th, 19th, 15th, and 17th. The benchmark countries for the Czech Republic's health system were Israel, Estonia, Luxembourg, Italy, the UK, Spain, Slovenia, and Canada. The DEA model with the constant returns to scale identified four technically efficient health systems: Turkey, the UK, Canada, and Sweden. The Czech Republic was found to be one of the worst-performing health systems. The DEA model with the variable returns to scale identified 15 technically efficient health systems. We found that efficiency results are quite robust. With two exceptions, the Spearman rank correlations between each pair of models were statistically significant at the 0.05 level., Conclusions: During the model formulation, we investigated the pitfalls of efficiency measurement in health care and used several practical solutions. We consider MCDA and DEA, above all, as exploratory methods, not methods providing definitive answers., (© 2024. The Author(s).)

How to accurately assess logistics industry efficiency to identify production issues and provide support for optimizing logistics efficiency has become a current research challenge. Range adjust measure (RAM) is a method for efficiency assessment in data envelopment analysis. Currently, the RAM model only applies under the variable returns to scale condition and not to other conditions. This paper aims to establish a modified RAM (MRAM) model by revising the ranges for inputs and outputs of the RAM model. Under the constant returns to scale (CRS) condition, we first develop the RAM-CRS model. Then, by introducing radial models to define the lower bounds of inputs and the upper bounds of outputs, the MRAM is proposed. The logistics data from 18 provinces are collected to validate the practicality of the MRAM model. We compare the results of the MRAM with those of the RAM-CRS and conclude that the range bounds under RAM-CRS are too tight, which results in efficiency values at a relatively low level. The MRAM with modified bounds appropriately alleviates this restriction. We also compare the MRAM and the additive model. The results show that the efficiency of the MRAM is more accurate., (© 2024. The Author(s).)

Maternal, neonatal, and child health play crucial roles in achieving the objectives of Sustainable Development Goal (SDG) 2030, particularly in promoting health and wellbeing. However, maternal, neonatal, and child services in Moroccan public hospitals face challenges, particularly concerning mortality rates and inefficient resource allocation, which hinder optimal outcomes. This study aimed to evaluate the operational effectiveness of 76 neonatal and child health services networks (MNCSN) within Moroccan public hospitals. Using Data Envelopment Analysis (DEA), we assessed technical efficiency (TE) employing both Variable Returns to Scale for inputs (VRS-I) and outputs (VRS-O) orientation. Additionally, the Tobit method (TM) was utilized to explore factors influencing inefficiency, with hospital, doctor, and paramedical staff considered as inputs, and admissions, cesarean interventions, functional capacity, and hospitalization days as outputs. Our findings revealed that VRS-I exhibited a higher average TE score of 0.76 compared to VRS-O (0.23). Notably, the Casablanca-Anfa MNCSN received the highest referrals (30) under VRS-I, followed by the Khemisset MNCSN (24). In contrast, under VRS-O, Ben Msick, Rabat, and Mediouna MNCSN each had three peers, with 71, 22, and 17 references, respectively. Moreover, the average Malmquist Index under VRS-I indicated a 7.7% increase in productivity over the 9-year study period, while under VRS-O, the average Malmquist Index decreased by 8.7%. Furthermore, doctors and functional bed capacity received the highest Tobit model score of 0.01, followed by hospitalization days and cesarean sections. This study underscores the imperative for policymakers to strategically prioritize input factors to enhance efficiency and ensure optimal maternal, neonatal, and child healthcare outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study investigates the potential economies of scope in the Norwegian public hospital sector after a major structural and organizational reform. Economies of scope refers to potential cost savings occurring from the scope of production rather than the scale. We use a data driven approach to distinguish between relatively specialized and differentiated hospitals. Using registry data spanning the period 2013-2019, we use non-parametric data envelopment analysis with bootstrapping procedures to investigate the potential presence of economies of scope. This is done separately for three different dimensions of which hospital production can be either specialized or differentiated. The findings suggest that economies of scope are present in the Norwegian hospital sector, meaning that there are cost savings related to the optimal differentiation of the activity. It is difficult to conclude on how these findings relate to the reform., (© 2024. The Author(s).)

Background: With Primary Health Care (PHC) being a cornerstone of accessible, affordable, and effective healthcare worldwide, its efficiency, especially in developing countries like China, is crucial for achieving Universal Health Coverage (UHC). This study evaluates the efficiency of PHC systems in a southwest China municipality post-healthcare reform, identifying factors influencing efficiency and proposing strategies for improvement., Methods: Utilising a 10-year provincial panel dataset, this study employs an enhanced Data Envelopment Analysis (DEA) model integrating Slack-Based Measure (SBM) and Directional Distance Function (DDF) with the Global Malmquist-Luenberger (GML) index for efficiency evaluation. Tobit regression analysis identifies efficiency determinants within the context of China's healthcare reforms, focusing on horizontal integration, fiscal spending, urbanisation rates, and workforce optimisation., Results: The study reveals a slight decline in PHC system efficiency across the municipality from 2009 to 2018. However, the highest-performing county achieved a 2.36% increase in Total Factor Productivity (TFP), demonstrating the potential of horizontal integration reforms and strategic fiscal investments in enhancing PHC efficiency. However, an increase in nurse density per 1,000 population negatively correlated with efficiency, indicating the need for a balanced approach to workforce expansion., Conclusions: Horizontal integration reforms, along with targeted fiscal inputs and urbanisation, are key to improving PHC efficiency in underdeveloped regions. The study underscores the importance of optimising workforce allocation and skillsets over mere expansion, providing valuable insights for policymakers aiming to strengthen PHC systems toward achieving UHC in China and similar contexts., (© 2024. The Author(s).)

An unreasonable overtaking attempt on two-lane highways could cause drivers to suffer in terms of driving safety, comfort, and efficiency. Several external factors related to the traffic environment (e.g., speed and car type of surrounding vehicles), were found to be the significant factors in drivers' overtaking performance in the previous studies. However, the microscopic decision-making (e.g., the moments of the occupation of the opposite lane) mechanisms during overtaking, by means of which drivers react to changes in the external traffic environment and adjust their overtaking trajectories, are still need to be explored. Hence, this study had three goals: (i) To explore the spatial characteristics of micro-decisions (MDs) (such as the start and end point) in overtaking trajectories; (ii) To measure three types of performance indicators (i.e., safety, comfort, and efficiency) for the execution of overtaking maneuvers; (iii) To quantitatively explain the microscopic decision-making mechanism in overtaking. Data for overtaking trajectories were collected from driving a simulation experiment where 52 Chinese student drivers completed a series of overtaking maneuvers on a typical two-lane highway under different traffic conditions. Two analyses were conducted: firstly, the distributions of the relative distance between the ego and surrounding vehicles at four key points (i.e., the start, entry, back, and end) in the overtaking trajectory were investigated and clustered to uncover the spatial characteristics of the MDs. Secondly, the safety, comfort, and efficiency of the overtaking were measured by the aggregations of multi-targets collision risks, triaxial acceleration variances, and spatial consumptions respectively based on the Data Envelopment Analysis (DEA), which were further applied in a two-stage SEM model to reveal the quantitative interrelationships among the external factors, microscope decisions and performances in overtaking. We confirmed that the MDs could be considered as the mediating variables between the external factors and overtaking performances. In the presence of the more hazardous traffic environment (e.g., faster traffic flow and impeded by a truck), the safety, comfort and efficiency of overtaking would be deteriorated inevitably. But drivers would execute the overtaking under the longer passing sight distance, migrate their trajectories forward, and shorten the spatial duration to significantly improve the overtaking performances. Based on this mechanism, a overtaking trajectory optimization strategy for the advanced or automatic driving system, was confirmed and concluded that 1) the passing gap should be firstly planned according to the sight distance acceptance of different drivers, which directly determine the upper limit of the safety performance in the overtaking; 2) the trajectory forward migration and shortening the whole duration in overtaking could be effective to enhance the overtaking performances of the overtaking on the two-lane highway; 3) the guidance of the stable control of the steering wheel and gas/brake pedals is essential in the overtaking., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

The Water-Energy-Food (WEF) nexus approach is increasingly being used for supporting a transition to sustainable development, with initiatives involving the concept of circular economy (CE). In the agricultural sector in particular, assessing this nexus is crucial to ensure food security, control the consumption of key resources such as water and energy, as well as measure atmospheric emissions linked to climate change. This manuscript aims to propose a novel approach by coupling the WEF nexus with a circularity indicator, seeking to capture in a single index (the WEF+CEi) both performances in a sample of companies. The novel approach is applied to 30 dairy farms located in Galicia (NW Spain) to benchmark them in a holistic manner. To do this, the WEF nexus of each farm was represented through the following indicators: carbon footprint, water footprint, energy footprint, and food productivity. In addition, the percentage of circularity for each farm, and for the agro-industrial cooperative was measured thanks to the application of a circularity tool in percentage terms. Finally, the WEF+CEi indicator was obtained using the multicriteria mathematical tool of Data Envelopment Analysis (DEA). The results show that without considering the agro-industrial cooperative, the system is 51 % circular. On the other hand, considering the farms and the cooperative, the system goes up to 80 % of circularity. Finally, the proposed approach can support decision-making and provide insights for producers and stakeholders in the area., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This study aims to evaluate the technical efficiency levels of healthcare systems in underdeveloped countries and to reveal the impact of COVID-19 along with some other factors on the efficiency levels via a two-stage data envelopment analysis. The study covers panel data from 2013 to 2020. The results show that technical efficiency scores decreased during the pandemic period. It is also understood from the results that immunization and the ratio of population ages 65 and above have significant and negative effects on inefficiency scores while carbon dioxide emissions have significant and positive effects. It is thought that the results of this study can guide decision-makers regarding efficiency gains in healthcare systems., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024. Published by Elsevier Ltd.)

The extensive waste emissions and energy consumption in the construction industry has spurred calls for sustainable development reform. Identifying valuable development paradigms through evaluating the spatial-temporal environmental efficiency (EE) of the construction sector offers an effective avenue for practice guidance. However, a comprehensive and detailed global analysis of the construction sector's EE remains lacking. This study applies the super-slack-based measure (Super-SBM) model to assess EE of the construction sector across 112 countries from 2006 to 2016. The results reveal relatively low overall EE performance of global construction sector, with notable disparities among countries and improvements were observed in certain years. Singapore, Malta, and Paraguay emerge as top performers, while Moldova, Swaziland, and Iceland rank at the bottom. The findings highlight significantly better EE in European and coastal Asian countries compared to inland Asian and African nations. Using the Tobit model, we identify that industrial structure, trade dependency, international cooperation, energy intensity, and geographic factors significantly influence EE, with varying impacts across countries of different income levels. These findings provide a comprehensive overview of the global construction sector's environmental efficiency, emphasizing the urgent need for increased awareness and the adoption of sustainable practices. The study offers practical policy implications, advocating for targeted strategies to balance economic development with environmental protection., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The fishing sector constitutes an important source of economic revenue in northern Spain. In this context, various research studies have focused on the application of the five-step Life Cycle Assessment (LCA) and Data Envelopment Analysis (DEA) methodology to quantify environmental impacts of fishing systems. However, some of them have used environmental indicators that focus on individual environmental issues, hindering the goal of achieving integrated resource management. Therefore, in this study, the Water-Energy-Food (WEF) Nexus is employed as an integrative perspective that considers the synergies and trade-offs between carbon footprint, energy requirements, and water demand. The main objective of this study is to evaluate the operational efficiency and environmental impacts of Cantabrian fishing fleets. To this end, the combined use of LCA and DEA, along with the WEF Nexus, was applied to the Cantabrian purse seine fleet. DEA matrices were generated using the LCA-derived WEF nexus values as inputs to calculate efficiency scores for each vessel. Subsequently, based on the efficiency projections provided by the DEA model, a new impact assessment was performed to understand the eco-efficiency and potential environmental benefits of operating at higher levels of efficiency within this fleet. The average efficiency of the fleet was above 60 %. Inefficient units demonstrated a greater potential to reduce their environmental impacts (up to 65 %) by operating according to efficiency projections. Furthermore, the results revealed a strong dependence of environmental impacts on one of the operational inputs, i.e., fuel consumption. These findings highlight the significance of embracing holistic approaches that combine technical, economic, and social factors to achieve a sustainable balance in fisheries systems. In this regard, the five-step LCA + DEA method applied in conjunction with the WEF Nexus emerged as a suitable tool for measuring operational and environmental objectives., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The improvement of energy-related efficiency has promoted energy-sustainable development in China; however, it may be inhibited by energy poverty. This paper constructs an index system to measure China's energy poverty. Subsequently, we evaluate energy-related efficiency towards SDG7 comprised of energy production efficiency and energy sustainable utilization efficiency using a dynamic two-stage data envelopment analysis model. Furthermore, we adopt fixed effect models to quantify the impact of energy poverty on improving energy-related efficiency and the underlying mechanism. The findings indicate that: (1) China's energy poverty situation gradually improves from 2011 to 2020. The energy-related system's performance is medium due to the poor performance in its energy production stage in 30 provinces during 2011-2020. Energy-related efficiency is greater in areas with a higher response to SDG7. (2) The impact of energy poverty on improving energy-related efficiency is significantly negative. Addressing energy poverty significantly improves energy-related efficiency in regions characterized by a high energy poverty index and low energy-related efficiency. However, it bears no impact in regions with a low energy poverty index and high energy-related efficiency. (3) The moderating effect of technological innovation effectively improves energy-related efficiency, whereas the marketization level has an inverse effect. Consequently, this paper suggests several policy implications., Competing Interests: Declaration of competing interest No conflict of interest exists in the submission of this manuscript, and the manuscript is approved by all authors for publication. We would like to declare on behalf of the co-authors that the work described was original research that has not been published previously, and not under consideration for publication elsewhere, in whole or in part. All the authors listed have approved the manuscript that is enclosed., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The slowdown in economic development caused by traffic accidents in Spain, together with the disparity in the risk of death or injury due to traffic accidents in its provinces, makes it necessary to evaluate their road safety performance. Therefore, the objectives of the present research are, on the one hand, to find out the level of road safety efficiency of Spanish provinces in the period 2014-2018. On the other hand, it is also aimed to determine to what extent the annual efficiency change is originated by pure changes in efficiency or by technological changes. To achieve both objectives, the nonparametric technique of Data Envelopment Analysis and the Malmquist Index have been used based on the consideration of the Safety Performance Indicators (SPI) as the inputs of the process. The research findings show changes in the level of road safety efficiency in each of the years of the study period. Thus, it is possible to identify a geographical delimitation of the causes that generate changes in efficiency in recent years. A contraction in efficiency and technological progress is identified in part of the Spanish provinces in the north, northeast, and south of Spain., Competing Interests: Declaration of Conflicting InterestsThe author(s) declare(s) that there is no conflict of interest with respect to the research, authorship, and/or publication of this article.

The rational allocation of carbon emission quotas is crucial for improving the orderly operation of carbon markets. As a major energy-consuming province in China, Jiangsu's cities must allocate allowable carbon emissions effectively to meet China's 2030 peaking target. This study aims to achieve an optimal allocation of carbon emission quotas by considering principles such as responsibility, efficiency, and equity. To accomplish this goal, we developed a three-stage progressive optimization allocation process. This process incorporates the entropy weight TOPSIS allocation model, zero-sum game-DEA model, and Gini coefficient. The initial allocation scheme revealed that cities in southern Jiangsu, which have higher economic development levels, also received higher carbon emission quotas, compromising efficiency and equity. In response, the second stage involves adjusting the allocation to optimize efficiency for each city, aligning the quotas more closely with historical levels. Finally, the third stage uses the Gini coefficient to further refine the allocation scheme, achieving a more balanced distribution that aligns responsibility, efficiency, and fairness. This research highlights the importance of a structured approach to carbon quota allocation, ensuring a balance that supports both environmental goals and equitable development., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Using data envelopment analysis, we examine the efficiency of Canada's universal health care system by considering a set of labour (physicians) and capital (beds) inputs, which produce a level of care (measured in terms of health quality and quantity) in a given region. Data from 2013-2015 were collected from the Canadian Institute for Health Information regarding inputs and from the Canadian Community Health Survey and Statistics Canada regarding our output variables, health utility (quality) and life expectancy (quantity). We posit that variation in efficiency scores across Canada is the result of regional heterogeneity regarding socioeconomic and demographic disparities. Regressing efficiency scores on such covariates suggests that regional unemployment and an older population are quite impactful and associated with less efficient health care production. Moreover, regional variation indicates the Atlantic provinces (Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick) are quite inefficient, have poorer economic prospects, and tend to have an older population than the rest of Canada. Oaxaca-Blinder decompositions suggest that the latter two factors explain about one-third of this efficiency gap. Based on our two-stage semi-parametric analysis, we recommend Canada adjust their transfer payments to reflect these disparities, thereby potentially reducing inequality in regional efficiency.

Objective: The immunisation programme in Zambia remains one of the most effective public health programmes. Its financial sustainability is, however, uncertain. Using administrative data on immunisation coverage rate, vaccine utilisation, the number of health facilities and human resources, expenditure on health promotion, and the provision of outreach services from 24 districts, we used Data Envelopment Analysis to determine the level of technical efficiency in the provision of immunisation services. Based on our calculated levels of technical efficiency, we determined the available fiscal space for immunisation., Results: Out of the 24 districts in our sample, 9 (38%) were technically inefficient in the provision of immunisation services. The average efficiency score, however, was quite high, at 0.92 (CRS technology) and 0.95 (VRS technology). Based on the calculated level of technical efficiency, we estimated that an improvement in technical efficiency can save enough vaccine doses to supply between 5 and 14 additional districts. The challenge, however, lies in identifying and correcting for the sources of technical inefficiency., (© 2024. The Author(s).)

This study investigates the relationship between financial technology (fintech) and environmental efficiency across G20 countries, emphasizing the moderating effect of foreign direct investment (FDI) from 2010 to 2022. Employing Data Envelopment Analysis (DEA) through both Slack-Based Measure (SBM) and Epsilon-Based Measure (EBM), alongside Tobit regression and the Generalized Method of Moments (GMM) for analytical rigor, the research reveals that fintech exerts a positive influence on environmental efficiency within these countries. Furthermore, it demonstrates that FDI contributes to enhancing environmental efficiency. However, when FDI is combined with fintech investments, it yields a negative impact. This detrimental effect stems from FDI's emphasis on short-term gains, rapid expansion, and a globally oriented supply chain that favors cost efficiency at the expense of sustainability. The study highlights the necessity for investments in fintech that comply with environmental standards and offers policy recommendations to improve environmental efficiency. It urges policymakers to promote environmentally sustainable investment practices within the fintech sector to aid in achieving sustainable development goals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Air pollution has been one of the biggest environmental challenges for cities in their pursuit of sustainability. The removal of air pollutants usually entails a cost that can negatively impact economic activities. Assessing urban environmental performance can offer valuable insights for cities to balance their economic production and environmental protection. This paper develops a novel approach to measuring environmental performance by using the Euclidean distance function. An appealing feature of this approach is its ability in endogenously allocating the optimization pathway to each emitter, thereby avoiding arbitrary estimation results and distorted managerial implications. We apply this approach to study the environmental performance of Chinese key environmental protection cities. We find the heterogeneity in performance estimates and endogenous optimization pathways. Prioritizing the reduction of a specific type of emissions while simultaneously increasing industrial output value seems to be the most appropriate objective for the majority of cities. Our study can serve as a basis for urban governments to pinpoint the underlying factors contributing to low urban environmental performance and establish diverse objectives for enhancing environmental performance., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: The Ethiopian government has introduced several healthcare financing reforms intending to improve efficiency. Piloting implementation of performance-based financing is one of these actions. The purpose of this research is to assess the efficiency of healthcare facilities that have implemented performance-based financing compared to those that have not., Methods: Efficiency was measured using a nonparametric data envelopment analysis and the Malmquist Productivity Index technique. Total factor productivity change, technical change, and technological change are compared across eight sampled healthcare facilities that are implementing performance-based financing and eight that are not in Ethiopia., Results: Health facilities implementing performance-based financing have a mean technical efficiency score of 64%, allowing for a potential 36% reduction in inputs without affecting outputs. Their scale efficiency is 88%, indicating a potential 12% increase in total outputs without expanding facilities. In contrast, facilities not implementing performance-based financing have a mean technical efficiency score of 62%, with a potential for 38% input reduction without affecting outputs. Their scale efficiency is 87%, suggesting a potential 13% increase in total outputs without scaling up facilities. Among the 16 healthcare facilities observed, seven experienced a decline in the mean total productivity, while one remained stagnant. The remaining eight facilities witnessed an increase in productivity. The healthcare facilities implementing performance-based financing showed a 1.3% decrease in mean total productivity during the observed period. Among them, five showed an increase and three showed a decrease in the total factor of productivity. The mean total factor of productivity of all healthcare facilities not implementing performance-based financing remained stagnant over the three-year period (2019-2021), with four showing an increase and four showing a decrease in total productivity., Conclusions: The study concludes that implementing performance-based financing did not improve productivity levels among healthcare facilities over three years. In fact, productivity decreased among the facilities implementing performance-based financing, while those not implementing it remained stagnant. This shows health facilities that implement performance-based financing tend to utilize more resources for similar outputs, contradicting the anticipated efficiency improvement., (© 2024. The Author(s).)

In the context of increasing global resource and environmental problems, it is of great practical significance to accurately test the impact of various factors on energy use efficiency for maintaining national energy security and formulating relevant policies. This paper measures firms' total factor energy efficiency (TFEE) using the two-stage stochastic frontier method within the data envelopment analysis (DEA) framework, leveraging data from listed firms in China spanning 2010 to 2022. Employing the establishment of free trade zones (FTZs) as a quasi-natural experiment, we apply the staggered differences-in-differences (DID) and stacked DID methods and analyze the impact of FTZs on firms' TFEE. The results show that the establishment of FTZs significantly promotes the improvement of firms' TFEE, and it has a greater promotion effect on heavily polluting, non-manufacturing, state-owned, private, and small-scale firms. The results of the mechanistic analysis showed that the promotion effect of FTZs on firms' TFEE is mainly realized through three channels: increasing government subsidies, reducing the financing constraint effect, and encouraging the technology innovation effect. Furthermore, industry-level decomposition results indicate that the surge in industry energy efficiency primarily results from improvements within firms rather than inter-industry variations. This paper's results propose that countries can enhance energy efficiency by progressively endorsing the implementation of FTZs., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In the face of various agro-climatic shocks when agricultural income becomes highly volatile, farmers often undertake multiple jobholding and engage in non-farm activities for income smoothing. The earnings from these activities are often used to purchase productivity enhancing agricultural inputs. In this context, the impact of non-farm income on intensification of agricultural inputs and the consequent impact on over-all farm efficiency is well documented in the literature. However, with a rapid rise in usage of agricultural inputs with environmentally detrimental impact, very little is known about whether non-farm income has any impact on farmers' environmental efficiency-ability to reduce the amount of polluting inputs to the largest extent possible without reducing the amount of agricultural production. Our study fills the gap in the literature by analysing the impact of non-farm income on environmental efficiency of the farmers. We first estimate the environmental efficiency scores adopting the non-parametric data envelopment analysis (DEA) method and using a household level panel data from Village Dynamics of South Asia project on Indian states for a span of five years (2010-2014). We then estimate the impact of non-farm income on environmental efficiency using Instrumental Variable Tobit Model. Our results show that average environmental efficiency of the Indian farmers was 46 % during the study period indicating the fact that a reduction in polluting agricultural inputs by 54 % was possible without compromising the level of farm production. We also find that for 1 % increase in non-farm income, environmental efficiency of farmers rises by around 4 %. This reflects the environment friendly behaviour of farmers as a channel through which non-farm activities affect usage of environmentally linked inputs. These results provide vital policy insights in terms of how non-farm activities could be integrated with policies related to farming, in order to ensure sustainable agricultural practices., Competing Interests: None of these authors have any conflicting interest with any individual or organization that can prevent publishing the research output of this paper., (© 2024 The Authors.)

Countries around the world have set aggressive carbon emission reduction targets using various carbon reduction technologies to overcome the worsening global climate crisis. However, amid concerns among experts that such aggressive targets are difficult to achieve with existing carbon reduction technology, CCUS technology has gained recognition as an innovative technology, showing great promise in directly removing carbon dioxide and achieving carbon neutrality. This study employed a two-stage network DEA to analyze efficiency at knowledge diffusion and application stages of CCUS technology in relation to country-specific R&D environments. Based on the analysis, the following conclusions were derived. First, countries with higher standards of innovation in science and technology were more focused on quantitative R&D outcomes, making them less efficient in the diffusion and application stages. Second, countries with heavier dependence on manufacturing were less efficient in the diffusion of research outcomes due to difficulties in enforcing strong environmental-friendly policies. Lastly, countries with heavier dependence on fossil fuels were actively promoting CCUS development as a solution to carbon dioxide emissions, and such efforts were a driving factor in the diffusion and application of R&D outcomes. The significance of this study lies in analyzing the efficiency of CCUS technology in terms of knowledge diffusion and application, which are clearly distinct from a quantitative R&D efficiency analysis, thereby serving as a valuable reference in the establishment of country-specific R&D strategies for greenhouse gas reduction., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

To promote sustainable intensification and provide guidance for decisionmakers, we must understand the potential for mitigating greenhouse gas emissions in greenhouse cultivation. Therefore, this study aimed to evaluate the greenhouse gas emission mitigation potential of agricultural plastic greenhouses in China using a combination of life cycle assessment, data envelopment analysis, and scenario analysis. We found that: (1) In China, the mean mitigation potential for greenhouse gas emission intensity related to the crop production inputs of agricultural plastic greenhouses is 1.67 kt CO 2 -eq/km 2 , demonstrating a remarkable mitigation rate of 47 %. This mitigation potential, driven mostly by fertilizer use, exhibited a spatial pattern characterized by high mitigation rates in the southern regions compared to those in the northern regions; (2) in scenarios S1 and S2, the greenhouse gas emission intensity mitigation potential of greenhouse construction materials was 0.645 kt CO 2 -eq/km 2 and 0.968 kt CO 2 -eq/km 2 , respectively, with steel being the primary contributor to mitigation; (3) under scenarios S1 and S2, the greenhouse gas emission mitigation rates for China's agricultural plastic greenhouses were 42 % and 48 %, respectively. This study highlights the greenhouse gas emission mitigation potential of China's agricultural plastic greenhouses. To ensure sustainability in plastic greenhouses, emphasis should be placed on optimizing fertilizers and extending the lifespan of construction materials., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

This study constructs a composite indicator system covering the core dimensions of medical equipment input and output. Based on this system, an innovative cone-constrained data envelopment analysis (DEA) model is designed. The model integrates the advantages of the analytic hierarchy process (AHP) with an improved criterion importance through intercriteria correlation (CRITIC) method to determine subjective and objective weights and employs game theory to obtain the final combined weights, which are further incorporated as constraints to form the cone-constrained DEA model. Finally, a bidirectional long short-term memory (Bi-LSTM) model with an attention mechanism is introduced for integration, aiming to provide a novel and practical model for evaluating the effectiveness of medical equipment. The proposed model has essential reference value for optimizing medical equipment management decision-making and investment strategies., (© 2024. The Author(s).)

Background: Besides the scarcity of resources, inefficient utilization of available health service resources has been the bottleneck to deliver quality health services in Ethiopia. However, Information regarding the efficiency of health service providers is limited in the country. Health service managers and policy makers must be well informed about the efficiency of health service providers and ways of using limited resources efficiently to make evidence-based decisions. This study aimed to assess the level of technical efficiency and associated factors among health centers in East Gojjam Zone, Northwest Ethiopia., Methods: A facility-based cross-sectional study was conducted among 27 randomly selected health centers in East Gojjam zone, Northwest Ethiopia, from October 30, 2022, to April 30, 2023. Using an interviewer-administered questionnaire and document review checklist, health centers' data was collected and entered to Epi-Data version 4.6. The data was exported to Microsoft office excel and Stata version 14 for analysis. A two-stage output-oriented data envelopment analysis with a variable return to scale assumption was employed to determine the level of technical efficiencies. Finally, the tobit regression model was applied to identify the associated factors at 5% level of significance., Results: In this study, 59.3% of the health centers were technically efficient. The mean technical efficiency score of the health centers was 0.899 ± 0.156. Inefficient health centers could provide more 22, 433 outpatient visits, 1,351 family planning visits, 155 referral services, 206 skilled deliveries and 385 fully vaccinations of children if they were technically efficient as their peer health centers for the same year. From the tobit regression, the catchment population and number of administrative staffs were statistically significant determinants of the technical efficiency of health centers., Conclusions: The mean technical efficiency of the health centers in East Gojjam zone, Northwest Ethiopia was high. However, nearly half of the health centers were technically inefficient, which indicates the exitance of a space for further improvements in the productivity of these health centers. Employing excess number administrative staffs (above the optimal level) should be discouraged and selecting appropriate sites where the health centers to be constructed (to have large catchment population coverage) could improve the productivity of health centers., (© 2024. The Author(s).)

Efficiency is generally defined as the capacity to deliver desirable results with little effort or input. A bank cannot afford to allocate limited resources at random in a competitive market. Only once the efficiency factors have been identified can resources be allocated in a conscious and effective manner. The study investigates the determinants of technical efficiency of banks in the SADC region. The study is significant in the SADC region as the block is trying to create a robust and stable banking system. This is driven by the desire to stay away from the current global financial system volatility and the region is working to develop an integrated banking system. The results show that the banks are relatively inefficient with the level of inefficiency around 40 percent. The efficiency of the banks is determined by the level of capitalisation, size of the bank, research costs and automation of the banks. The results of the study imply that that there is great scope for the banks in the SADC region to increase their efficiency. Improved efficiency will ensure banks provide services at a lower cost to clients. The study recommends adequately capitalizing banks, increasing the asset base of the banks, investing in research and the automation of the banking systems., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objectives: The aim of the study was to answer whether the central government has been more efficient than the regional governments or vice versa. Likewise, through the analysis of the data, the aim was to shed light on whether decentralisation has had a positive impact on the efficiency of the hospital sector or not., Design: In this paper, we have used data envelopment analysis to analyse the evolution of efficiency in the last 10 Autonomous Regions to receive healthcare competences at the end of 2001., Participants: For this study, we have taken into account the number of beds and full-time workers as inputs and the calculation of basic care units as outputs to measure the efficiency of the Spanish public sector, private sector and jointly in the years 2002, 2007, 2012 and 2017 for the last Autonomous Regions receiving healthcare competences., Results: Of the Autonomous Regions that received the transfers at the end of 2001, the following stand out for their higher efficiency growth: the Balearic Islands (81.44% improvement), the Madrid Autonomous Region, which practically reached absolute efficiency levels (having increased by 63.77%), and La Rioja which, together with the Balearic Islands which started from very low values, improved notably (46.13%)., Conclusion: In general, it can be observed that the transfer of responsibilities in the health sector has improved efficiency in the National Health Service., Jel Classification: C14; I18; H21., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Diabetes prevalence is rising globally, especially in low- and middle-income countries like Mexico, posing challenges for healthcare systems that require efficient primary care to manage the disease. However, healthcare efficiency is influenced by factors beyond decision-makers, including socioeconomic and political conditions. This study aims to evaluate the technical efficiency of primary healthcare for diabetes patients in Mexico over a 12-year period and explore the impact of contextual variables on efficiency. A longitudinal analysis was conducted using administrative and socio-demographic data from 242 health jurisdictions between 2009 and 2020. Data envelopment analysis with bootstrapping and output orientation was used to measure the technical efficiency; health resources in infrastructure and human resources were used as inputs. As outcome, the number of patients receiving treatment for diabetes and the number of patients with controlled diabetes were considered. Machine learning algorithms were employed to analyse multiple factors affecting the provision of diabetes health services and assess heterogeneity and trends in efficiency across different health jurisdictions. The average technical efficiency in primary healthcare for diabetes patients was 0.44 (CI: 0.41-0.46) in 2009, reaching a peak of 0.71 (CI: 0.69-0.72) in 2016, and moderately declining to 0.60 (CI: 0.57-0.62) in 2020; these differences were statistically significant. The random forest analysis identified the marginalization index, primary healthcare coverage, proportion of indigenous population and demand for health services as the most influential variables in predicting efficiency levels. This research underscores the crucial need for the formulation of targeted public policies aimed at extending the scope of primary healthcare services, with a particular focus on addressing the unique challenges faced by marginalized and indigenous populations. According to our results, it is necessary that medical care management adjust to the specific demands and needs of these populations to guarantee equitable care in Mexico., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

In the context of healthcare systems, the performance evaluation of hospitals plays a crucial role in assessing the quality of healthcare systems and facilitating informed decision-making processes. However, the presence of data uncertainty poses significant challenges to accurate performance measurement. This paper presents a novel uncertain common-weights data envelopment analysis (UCWDEA) approach for evaluating the performance of hospitals under uncertain environments. The proposed UCWDEA approach addresses the limitations of traditional data envelopment analysis (DEA) models by incorporating the uncertainty theory (UT) to model the inherent uncertainty in input and output data. Also, by utilizing a common set of weights (CSW) technique, the UCWDEA method provides a more robust and reliable assessment of hospital performance. The main advantages of the proposed UCWDEA approach can be succinctly summarized as follows. Firstly, it allows for the comparison of all hospitals on a consistent basis to calculate a realistic efficiency score, rather than an overly optimistic efficiency score. Secondly, the uncertain common-weights DEA approach exhibits linearity, enhancing its applicability. Thirdly, it possesses the capability to extend its utility under various other prevalent uncertainty distributions. Moreover, it enhances the discriminatory power of results, facilitates the ranking of hospitals in the presence of data uncertainty, and aids in identifying the sensitivity and stability levels of hospitals towards data uncertainty. Notably, in order to showcase the pragmatic application and efficacy of the uncertain common-weights DEA model, a genuine dataset has been utilized to evaluate the efficiency of 20 public hospitals in Tehran, all of which are affiliated with the Iran University of Medical Sciences. The results of the experiment demonstrate the efficacy of the UCWDEA approach in assessing and ranking hospitals amidst uncertain conditions. In summary, the research outcomes can offer policymakers valuable insights regarding hospital performance amidst data uncertainty. Additionally, it can provide practical recommendations on optimizing resource allocation, benchmarking performance, and formulating effective policies to augment the overall efficiency and effectiveness of healthcare services.

Accountable care organizations (ACOs) were created to promote health care value by improving health outcomes while curbing health care expenditures. Although a decade has passed, the value of care delivered by ACOs is yet to be fully understood. We proposed a novel measure of health care value using data envelopment analysis and examined its association with ACO organizational characteristics and social determinants of health (SDOH). We observed that the value of care delivered by ACOs stagnated in recent years, which may be partially attributed to challenges in care continuity and coordination across providers. ACOs that were solely led by physicians and included more participating entities exhibited lower value, highlighting the role of coordination across ACO networks. Furthermore, SDOH factors, such as economic well-being, healthy food consumption, and access to health resources, were significant predictors of ACO value. Our findings suggest a "skinny in scale, broad in scope" approach for ACOs to improve the value of care. Health care policy should also incentivize ACOs to work with local communities and enhance care coordination of vulnerable patient populations across siloed and disparate care delivery systems., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Achieving a Circular Economy requires effective waste management. Monitoring the transformation path taken by the European Union (EU) and its Member States is crucial for assessing the impact and effectiveness of current European waste legislation. Even though numerous studies have shown positive performance and convergence in waste treatment, regional efficiency evaluation studies are still lacking. This research aims to benchmark the performance of municipal solid waste management in 167 regions - at level 2 of the Nomenclature of Territorial Units for Statistics - across European Member States during the period from 2008 to 2013. It looks to assess whether there is any positive convergence among these regions. The efficiency assessment employs four different Data Envelopment Analysis models. One of these models, the Benefit-of-Doubt, is a non-parametric approach and represents a special case within the Data Envelopment Analysis framework. Our findings indicate a yearly reduction in the coefficient of variation of 3.6%. Despite this progressive convergence, substantial differences in municipal solid waste management performance exist between EU-20 regions, even within the same country. Particularly, the analysis demonstrates that the best performers are registered in the Central and Northern EU regions, while the Eastern and Southern EU regions performed worse., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

In the wake of hospital reforms introduced in 2011 in Turkey, public hospitals were grouped into associations with joint management and some shared operational and administrative functions, similar in some ways to hospital trusts in the English National Health Service. Reorganization of public hospitals effect hospital and market area characteristics and existence of hospitals. The objective of this study is to examine the effect of closure on competitive hospital performances. Using administrative data from Turkish Public Hospital Statistical Yearbooks for the years 2005 to 2007 and 2014 to 2017, we conducted a three-step efficiency analysis by incorporating data envelopment analysis (DEA) and propensity score matching techniques, followed by a difference-in-differences (DiD) regression. First, we used bootstrapped DEA to calculate the efficiency scores of hospitals that were located near hospitals that had been closed. Second, we used nearest neighbour propensity score matching to form control groups and ensure that any differences between these and the intervention groups could be attributed to being near a hospital that had closed rather than differences in hospital and market area characteristics. Lastly, we employed DiD regression analysis to explore whether being near a closed hospital had an impact on the efficiency of the surviving hospitals while considering the effect of the 2011 hospital reform policies. To shed light on a potential time lag between hospital closure and changes in efficiency, we used various periods for comparison. Our results suggest that the efficiency of public hospitals in Turkey increased in hospitals that were located near hospitals that closed in Turkey from 2011. Hospital closure improves the efficiency of competitive hospitals under hospital market reforms. Future studies may wish to examine the efficiency effects of government and private sector collaboration on competition in the hospital market., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The production efficiency factor is widely used to measure the zootechnical performance of a batch of broilers. The unit cost of production brings new elements to improve efficiency evaluation and financial sustainability for this activity in agriculture. This research aims to evaluate the production efficiency level of the crop to maximize the return on investment. This study uses Data Envelopment Analysis (DEA) with the computational processing of the SIAD software (Integrated Decision Support System). The variables selected were poultry housing, age at slaughter, feed consumed, mortality, and unit cost. The chosen output variable was the total available weight. The analysis spans 31 decision-making units (DMUs) composed of integrated producers, unveiling a frontier of efficiency delineated by the most exemplary DMUs. Notably, only two DMUs, specifically DMU 4 and DMU 23, approached the threshold of maximum relative efficiency. This research illuminates the critical role of unit cost in enhancing the assessment of production efficiency and financial sustainability within the agriculture environment. By setting benchmarks for efficient management and operational protocols, our findings serve as a cornerstone for improving practices among less efficient DMUs, contributing significantly to the literature on agricultural efficiency and offering actionable insights for the poultry farming sector., Competing Interests: The authors declare no conflicts of interest.

Hazardous waste rotary kiln incineration, as the most effective and comprehensive technology to reduce and detoxify waste, generally faces problems such as low load rate and short continuous operating periods. However, there are few studies on the actual operation of such facilities and evaluation of their technical efficiency. Based on the 77-week time-series data of the case company, this study introduces in-depth key operating parameters and evaluates long-term technical efficiency through the data envelopment analysis (DEA) method. The results show that the continuous operating period of the rotary kiln incineration facility can reach more than half a year, with an average load rate of 91.7%. In the analysis of 9 input indicators, the amount of injected activated carbon could not be effectively evaluated due to the lack of relevant standards and online real-time monitoring of dioxins, which might become a weak link in the control of flue gas pollution. The average comprehensive technical efficiency of rotary kiln incineration facilities was 0.939, of which the average pure technical efficiency was 0.949 while the average scale efficiency was 0.989. With 33 of the 77 decision-making units being invalid, there is scope for improvement. The amount of incineration could be increased by 5.34%, and among the input variables, dosage of urea, calcium hydroxide and lye with a relatively high improvement ratio. Based on the results, targeted suggestions were proposed to advance the scientific and precise compatibility of hazardous waste, strengthen the control of dioxin emissions, and promote the intelligent control of the entire process., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

This study developed a novel framework that combined data envelopment analysis and multi-regional input-output database to investigate the economic and environmental productivity change in the global supply chains associated with 18 manufacturing sectors in 43 countries from 2000 to 2014. Two models are developed; manufacturer model is used to evaluate performance of direct production activity of a sector in countries and supplier model is used to evaluate performance of indirect production activity of upstream suppliers of the sector. The proposed framework enables us to separately analyze the performance of supply chains into direct production activity and indirect production activity of suppliers. The empirical results show that the environmental productivity of direct production activity of 18 manufacturing sectors was improved by 12.9 percent, while the environmental productivity of the upstream suppliers was improved by only 4.7 percent during 2000-2014 on average. Different patterns of economic and environmental productivity growth were observed between the direct production activity and upstream suppliers in all sectors. The finding suggests that the performance of an entire supply chain should be separately analyzed to consider industry-specific policies. The proposed framework is used to identify countries that succeed/fail to improve economic and environmental performance. Based on the results, this study discusses policies regarding production and supply chain management toward CO 2 mitigation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author.)

Iron ore tailings (IOTs) need to be properly managed to mitigate the environmental, social, and economic impacts of mining activities. To cope with this issue, we use data envelopment analysis (DEA) to evaluate alternatives for using IOT in the construction sector. The classical and weight restriction output-oriented DEA models were used in this analysis. The results show that the ranking of alternatives depends on the aspect being evaluated. Concrete block is the most environmentally friendly alternative when analysing both models. For both social and economic aspects, ceramics produced better results in the classical model, whereas Portland cement showed better outcomes in the weight restriction model. In this sense, the results suggest great potential for the use of IOT in the construction sector, enabling the reduction of risks and social and environmental impacts of tailings dams., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Safety is one of the critical and persistent challenges in the construction industry. Measuring safety performance could allow decision-makers to check safety production processes and enhance the health and safety environment., Method: This study developed a total-factor framework based on the global Data Envelopment Analysis (DEA) method to measure safety performance. The performance trend and influencing factors of pure technical efficiency and scale efficiency were separately investigated. The safety performance of construction employees in Australia was measured as a case study., Results: The results demonstrate that the safety performance in the Australian construction industry has been evidently enhanced, which is mainly promoted by the progress of pure technical elements. The scale factors did not play a positive and important role in driving the performance., Conclusions: The increasing regional differences in safety performance could be reduced by learning the practices from the benchmark construction industry, such as a young worker program, small business safety program, workplace mental health program, and advanced construction technologies., Practical Applications: The method can be utilized to measure safety performance and investigate the pathways to enhance performance without influencing production inputs and outcomes. The model and experiences of how to promote safety performance on the policymakers and employers were recognized., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Efficiency remains pivotal to the banking sector, serving as a linchpin for resource allocation and competitive prowess. This study delves into the intricate dynamics between corporate governance and banking efficiency in Ghana, with an analytical lens on cost efficiency (CE) and total efficiency (TE). Utilizing Data Envelopment Analysis (DEA), our investigation spans over a decade (2008-2019) and encompasses a data set of 23 Ghanaian banks. The study findings unveils that rigorous corporate governance mechanisms, as quantified by the Corporate Governance Index (CGI), exert a salutary influence on both cost and total efficiencies. Moreover, a well-defined Risk Management Index (RMI) positively correlates with cost efficiency, albeit without a substantial impact on total efficiency. Conversely, the study identifies a counterintuitive effect: the current make-up of supervisory boards, as gauged by the Supervisory Board Index (SBI), inversely impacts both efficiency metrics, signaling sub-optimal governance structures. Significantly, the research also highlights a pressing concern: the average total efficiency of Ghanaian banks lags behind the global benchmarks prescribed by the World Bank. This discrepancy underscores an exigency for efficiency optimization within the sector. The study thereby offers invaluable insights for multiple stakeholders-including regulatory bodies, investment communities, and policymakers-by delineating the governance variables that can enhance or impede banking efficiency. It also identifies actionable avenues for improvement, specifically in the realms of risk management and board composition, with the potential to catalyze a transformation in Ghana's banking landscape., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

To estimate the technical efficiency of health systems toward achieving universal health coverage (UHC) in 191 countries. We applied an output-oriented data envelopment analysis approach to estimate the technical efficiency of the health systems, including the UHC index (a summary measure that captures both service coverage and financial protection) as the output variable and per capita health expenditure, doctors, nurses, and hospital bed density as input variables. We used a Tobit simple-censored regression with bootstrap analysis to observe the socioeconomic and environmental factors associated with efficiency estimates. The global UHC index improved from the 2019 estimates, ranged from 48.4 (Somalia) to 94.8 (Canada), with a mean of 76.9 (std. dev.: ±12.0). Approximately 78.5% (150 of 191) of the studied countries were inefficient (ϕ < 1.0) with respect to using health system resources toward achieving UHC. By improving health system efficiency, low-income, lower-middle-income, upper-middle-income, and high-income countries can improve their UHC indices by 4.6%, 5.5%, 6.8%, and 4.1%, respectively, by using their current resource levels. The percentage of health expenditure spent on primary health care (PHC), governance quality, and the passage of UHC legislation significantly influenced efficiency estimates. Our findings suggests health systems inefficiency toward achieving UHC persists across countries, regardless of their income classifications and WHO regions, as well as indicating that using current level of resources, most countries could boost their progress toward UHC by improving their health system efficiency by increasing investments in PHC, improving health system governance, and where applicable, enacting/implementing UHC legislation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The intensive care unit (ICU) holds significant importance in hospitals. Primarily concerned with monitoring and providing care to critically ill patients, the ICU has proven effective in reducing mortality rates and minimizing complications of diseases, thanks to the highly complex and specific measures taken within this department. Considering the unique contributions made by the staff in this unit, its performance assessment can help improve patient care and satisfaction. This study presents a framework that utilizes ergonomic and work-motivational factors (WMFs) to assess the performance of various ICUs. Upon the identification of these indicators, a standard questionnaire is developed to collect the required data. The mean efficiency score of the units is then determined using the data envelopment analysis (DEA). The model is validated using the principal component analysis (PCA). Ultimately, the SWOT (strengths, weaknesses, opportunities, and threats) matrix is employed to formulate an appropriate strategy and offer improvement measures to the managerial team to enhance their ICU performance. The proposed framework can be applied to evaluate the performance of other healthcare departments. Among the studied ICU centers, including general ICU, isolation ICU catering to individuals with infectious diseases, cardiac care unit (CCU), and neonatal ICU (NICU). NICU and general ICU have the best and worst performance in terms of macro- and micro-ergonomic and motivational indicators, which are on average 0.826% more elevated and 0.659% lower, respectively. According to the performed sensitivity analysis, the ICUs in question demonstrate the most appropriate and inappropriate performance about the indicators of "knowledge, situation assessment, and situation analysis" and "work stress", respectively., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance., Methods: We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics., Results: Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider., Conclusions: Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking., (© 2023. The Author(s).)

The measurement of performance within the water industry holds significant importance for policymakers, as it can help guide decision-making for future development and management initiatives. In this study, we apply data envelopment analysis (DEA) cross-efficiency techniques to evaluate the productivity change of the Chilean water industry during the years 2010-2018. Water leakage and unplanned interruptions are included in the analysis as quality of service variables. Moreover, we use cluster analysis and regression techniques to better understand what drives productivity change of water companies. The results indicate that the Chilean water industry is characterized by considerable high levels of inefficiency and low levels of productivity change. This is due to the existence of technical regress whereas gains in efficiency were small. Concessionary water companies were found to be more productive than full private and public water companies. Best and worst performers need to make efforts to reduce production costs and improve service quality. Other factors such as customer density and ownership type statistically affect productivity., (© 2023. The Author(s).)

Evaluating the eco-efficiency of wastewater treatment plants (WWTPs) is crucial for enhancing environmental and economic performance in the water utility sector. Previous studies in this area estimated WWTP eco-efficiency through self-evaluation, which might have led to overestimation and biased policy recommendations. To address these issues, this study applies a cross-evaluation strategy, combining self-evaluation and peer-evaluation, to assess the eco-efficiency of WWTPs. The empirical application focuses on a sample of Spanish WWTPs, yielding the following key findings. Average eco-efficiency scores were 0.353 and 0.230, for self-evaluation and global peer-evaluation approaches, respectively, confirming the overestimation of eco-efficiency scores based on self-evaluation. If WWTPs were eco-efficient, they could potentially reduce greenhouse gas (GHG) emissions by up to 0.39 kg CO 2eq /year. The application of reliable methods, such as peer-evaluation, for eco-efficiency assessment of WWTPs provides water regulators with a comprehensive understanding of the environmental and economic performance of WWTPs. This knowledge guides decision-making, policy development, and resource allocation, facilitating sustainable and efficient wastewater management practices., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)