Is the quest for efficiency harmful to health equity? An examination of the health efficiency-equity nexus in OECD countries over the past two decades

Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades. We used a three-step methodology based on annual macro-level data from 36 OECD countri...

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Vydáno v:	Social science & medicine (1982) Ročník 383; s. 118379
Hlavní autoři:	Bousmah, Marwân-al-Qays, Abu-Zaineh, Mohammad, Combes, Simon, Ventelou, Bruno
Médium:	Journal Article
Jazyk:	angličtina
Vydáno:	England Elsevier Ltd 01.10.2025
Témata:	Efficiency, Organizational - standards Equity-efficiency tradeoff Granger causality Health Equity - standards Health Equity - statistics & numerical data Health Equity - trends Health system Humans Organisation for Economic Co-Operation and Development - organization & administration Organisation for Economic Co-Operation and Development - statistics & numerical data Reverse causality Socioeconomic Factors Stochastic frontier analysis Health system Reverse causality Equity-efficiency tradeoff Stochastic frontier analysis Granger causality
ISSN:	0277-9536, 1873-5347, 1873-5347
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Abstract	Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades. We used a three-step methodology based on annual macro-level data from 36 OECD countries for the period 2004–2021. First, we estimated the efficiency of health systems using a stochastic frontier analysis. We then assessed the equity of health systems using simple measures of income-related inequality in self-assessed health. Lastly, we estimated the dynamic relationship between health system efficiency and equity using a panel Granger causality analysis. We also stratified the analysis by type of health system: viz. publicly- vs. privately-dominated health service provision. We find evidence for a bidirectional causality between health system efficiency and equity. An increase in health system efficiency leads to an increase in socioeconomic inequalities in health; a result particularly salient in countries with predominantly private health service provision. Interestingly, decreases in socio-economic inequalities in health are likely to lead to higher health system efficiency, especially in countries where the health system relies predominantly on public provision. The pursuit of efficiency gains in OECD health systems has not been a precondition for socioeconomic equity in health. Adverse effects of efficiency-seeking interventions on health equity are particularly apparent in the private provision of healthcare. However, addressing health inequalities provides a plausible route to enhance efficiency. •There is a long-standing debate on the equity-efficiency nexus within health systems.•We analyse the bidirectional efficiency-equity relationship in OECD health systems.•Efficiency gains jeopardize equity, especially when health service provision is mainly private.•However, reducing health inequality may lead to higher health system efficiency.
AbstractList	Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades.BACKGROUNDHas the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades.We used a three-step methodology based on annual macro-level data from 36 OECD countries for the period 2004-2021. First, we estimated the efficiency of health systems using a stochastic frontier analysis. We then assessed the equity of health systems using simple measures of income-related inequality in self-assessed health. Lastly, we estimated the dynamic relationship between health system efficiency and equity using a panel Granger causality analysis. We also stratified the analysis by type of health system: viz. publicly- vs. privately-dominated health service provision.METHODSWe used a three-step methodology based on annual macro-level data from 36 OECD countries for the period 2004-2021. First, we estimated the efficiency of health systems using a stochastic frontier analysis. We then assessed the equity of health systems using simple measures of income-related inequality in self-assessed health. Lastly, we estimated the dynamic relationship between health system efficiency and equity using a panel Granger causality analysis. We also stratified the analysis by type of health system: viz. publicly- vs. privately-dominated health service provision.We find evidence for a bidirectional causality between health system efficiency and equity. An increase in health system efficiency leads to an increase in socioeconomic inequalities in health; a result particularly salient in countries with predominantly private health service provision. Interestingly, decreases in socio-economic inequalities in health are likely to lead to higher health system efficiency, especially in countries where the health system relies predominantly on public provision.FINDINGSWe find evidence for a bidirectional causality between health system efficiency and equity. An increase in health system efficiency leads to an increase in socioeconomic inequalities in health; a result particularly salient in countries with predominantly private health service provision. Interestingly, decreases in socio-economic inequalities in health are likely to lead to higher health system efficiency, especially in countries where the health system relies predominantly on public provision.The pursuit of efficiency gains in OECD health systems has not been a precondition for socioeconomic equity in health. Adverse effects of efficiency-seeking interventions on health equity are particularly apparent in the private provision of healthcare. However, addressing health inequalities provides a plausible route to enhance efficiency.INTERPRETATIONThe pursuit of efficiency gains in OECD health systems has not been a precondition for socioeconomic equity in health. Adverse effects of efficiency-seeking interventions on health equity are particularly apparent in the private provision of healthcare. However, addressing health inequalities provides a plausible route to enhance efficiency. Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades. We used a three-step methodology based on annual macro-level data from 36 OECD countries for the period 2004-2021. First, we estimated the efficiency of health systems using a stochastic frontier analysis. We then assessed the equity of health systems using simple measures of income-related inequality in self-assessed health. Lastly, we estimated the dynamic relationship between health system efficiency and equity using a panel Granger causality analysis. We also stratified the analysis by type of health system: viz. publicly- vs. privately-dominated health service provision. We find evidence for a bidirectional causality between health system efficiency and equity. An increase in health system efficiency leads to an increase in socioeconomic inequalities in health; a result particularly salient in countries with predominantly private health service provision. Interestingly, decreases in socio-economic inequalities in health are likely to lead to higher health system efficiency, especially in countries where the health system relies predominantly on public provision. The pursuit of efficiency gains in OECD health systems has not been a precondition for socioeconomic equity in health. Adverse effects of efficiency-seeking interventions on health equity are particularly apparent in the private provision of healthcare. However, addressing health inequalities provides a plausible route to enhance efficiency. Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades. We used a three-step methodology based on annual macro-level data from 36 OECD countries for the period 2004–2021. First, we estimated the efficiency of health systems using a stochastic frontier analysis. We then assessed the equity of health systems using simple measures of income-related inequality in self-assessed health. Lastly, we estimated the dynamic relationship between health system efficiency and equity using a panel Granger causality analysis. We also stratified the analysis by type of health system: viz. publicly- vs. privately-dominated health service provision. We find evidence for a bidirectional causality between health system efficiency and equity. An increase in health system efficiency leads to an increase in socioeconomic inequalities in health; a result particularly salient in countries with predominantly private health service provision. Interestingly, decreases in socio-economic inequalities in health are likely to lead to higher health system efficiency, especially in countries where the health system relies predominantly on public provision. The pursuit of efficiency gains in OECD health systems has not been a precondition for socioeconomic equity in health. Adverse effects of efficiency-seeking interventions on health equity are particularly apparent in the private provision of healthcare. However, addressing health inequalities provides a plausible route to enhance efficiency. •There is a long-standing debate on the equity-efficiency nexus within health systems.•We analyse the bidirectional efficiency-equity relationship in OECD health systems.•Efficiency gains jeopardize equity, especially when health service provision is mainly private.•However, reducing health inequality may lead to higher health system efficiency.
ArticleNumber	118379
Author	Ventelou, Bruno Bousmah, Marwân-al-Qays Combes, Simon Abu-Zaineh, Mohammad
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Cites_doi	10.1016/j.healthpol.2013.09.003 10.1093/qje/qjy020 10.1016/j.ahj.2007.10.043 10.1007/BF01205442 10.1186/s12961-023-01005-6 10.1016/0304-4076(88)90045-0 10.1016/S0277-9536(96)00073-1 10.1016/j.healthpol.2016.08.009 10.1377/hlthaff.28.5.1260 10.1177/1536867X231162034 10.1086/293210 10.1016/S0140-6736(16)00580-8 10.1007/s00181-020-01970-9 10.1111/1756-2171.12270 10.1016/S0140-6736(71)92410-X 10.1057/s41599-022-01271-9 10.2307/1912791 10.1093/fampra/cmae017 10.1111/maq.12555 10.1377/hlthaff.2014.1059 10.1016/S2468-2667(22)00133-5 10.1016/j.socscimed.2006.07.003 10.1016/j.socscimed.2019.04.028
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Keywords	Health system Reverse causality Equity-efficiency tradeoff Stochastic frontier analysis Granger causality
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Snippet	Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system...
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SubjectTerms	Efficiency, Organizational - standards Equity-efficiency tradeoff Granger causality Health Equity - standards Health Equity - statistics & numerical data Health Equity - trends Health system Humans Organisation for Economic Co-Operation and Development - organization & administration Organisation for Economic Co-Operation and Development - statistics & numerical data Reverse causality Socioeconomic Factors Stochastic frontier analysis
Title	Is the quest for efficiency harmful to health equity? An examination of the health efficiency-equity nexus in OECD countries over the past two decades
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