# Estimation of Association between Healthcare System Efficiency and Policy Factors for Public Health
## 1 Introduction  
The world's healthcare system is changing. The United States initiated the 2010 Affordable Care Act (so-called Obama Care), which was formally launched in 2014. Germany also passed legislation on healthcare reform in 2010 to improve the profitability of health insurance and address high healthcare expenditure. In addition, countries like Brazil, Russia, India, China, and South Africa (BRICS) have recently made efforts to achieve universal health coverage [1]. As such, health care reform to improve people's standard of living is a major issue in many countries. However, there is still a lot of debate about how to change healthcare policy on issues of 'centralization versus decentralization' [2]. Furthermore, for example, whether to give patients a choice of healthcare provider or not is controversial among European countries even now [3, 4]. Moreover, universal health coverage (UHC), which is nowadays a 'universal agreement', still has room for 'how' to achieve UHC considering the distinct context of each country [5]. For example, there is a case when a detailed plan for UHC is so unrealistic that it cannot address the financing need of a certain group [6]. It is therefore important to analyze which healthcare system is better and what policies have a positive impact on public health.  
According to [PERSON] and [PERSON] [7], healthcare system performance is defined as what the system has achieved as an output relative to its potential for a given level of input. Meanwhile, [PERSON] [8] originally defined technical efficiency as the capability of yielding maximum output possible from a given set of inputs. Considering this logical equality between health system performance and technical efficiency, this paper used the term 'efficiency' as a synonym for the health system performance of a country. The quantified efficiency scores were obtained by data envelopment analysis (DEA), which is described in detail in the next section. This framework is referred to in [9].  
Few studies have conducted an efficiency analysis of the healthcare system, particularly using frontier efficiency methodologies. According to [PERSON] [10], who reviewed 317 studies on the productivity and efficiency of healthcare services, most studies (52%) have focused on hospitals and only 4% of those studies were cross-country analyses dealing with the efficiency of the healthcare system. Even among those cross-country studies, some studies did not address what contributes to efficiency [11; 12; 13; 14]. Only a few studies have paid attention to policy-related factors (e.g., institutional arrangement) as determinants of the efficiency of the healthcare system [15; 16; 17]. However, these studies used data before 2000 [15], applied a binary classification of healthcare systems [16], or the policy factors used were mostly expressed as dummy variables even though there were some variations in between [17].  
Therefore, this study analyzed the efficiency of healthcare systems using the DEA technique and examined the relevance of efficiency with the type of healthcare system or health policy indicators. The goal of the study was to find out which healthcare system was more efficient and to analyze which policy factor contributed to the efficiency of the healthcare system based on these results.