American Journal of Public Health Research
ISSN (Print): 2327-669X ISSN (Online): 2327-6703 Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
American Journal of Public Health Research. 2021, 9(4), 120-129
DOI: 10.12691/ajphr-9-4-1
Open AccessArticle

Comparative Study of Affiliated and Non-Affiliated Hospitals: DEA Based Analysis in Turkey

Dursun BALKAN1,

1Industrial Engineering Department, University of Turkish Aeronautical Association, Ankara, Turkey

Pub. Date: May 10, 2021

Cite this paper:
Dursun BALKAN. Comparative Study of Affiliated and Non-Affiliated Hospitals: DEA Based Analysis in Turkey. American Journal of Public Health Research. 2021; 9(4):120-129. doi: 10.12691/ajphr-9-4-1


Measuring and comparing efficiency of healthcare organizations is critical for improved and uninterrupted service quality. The main objective of the study is to compare technical efficiency between affiliated and non-affiliated hospitals of Turkey. Totally, 25 affiliated hospitals and 53 non-affiliated hospitals were analyzed using input-oriented Data Envelopment Analysis (DEA) model under variable return to scale assumptions. There are six output variables and four input variables to evaluate hospitals efficiencies using with Ministry of Health (MoH) data from 2013 to 2017. The study results that, affiliated hospitals efficiency scores are higher than non-affiliated training and research hospitals. These results showed us the application of the affiliation system is successful in Turkey. Furthermore, this is the first study which has been performing whole affiliated and non-affiliated hospital efficiency measures together in Turkey and it offers an original contribution to literature with this direction.

affiliated hospitals data envelopment analysis health services efficiency Turkey

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Küçük, A. Kapitalizm, Devlet, Sağlık ve Türkiye. Ankara: Akademisyen Kitabevi; 2018.
[2]  Sulku SN. The impacts of healthcare reforms on the efficiency of the Turkish public hospitals: Provincial Markets. MPRAPaper. 2011; 34-43.
[3]  OECD (Organisation for Economic Co-operation and Development). OECD Reviews of Health Systems: Turkey. Paris: OECD and IBRD/The World Bank; 2008.
[4]  WHO (World Health Organization). Turkey health system performance assessment 2011. Geneva: Regional Office for Europe; 2012.
[5]  Ministry of Health Turkey. Health Transformation Program. Ankara: Ministry of Health; 2003.
[6]  Pardes H, Pincus AH. Models of academic-clinical partnerships: goods, better, best. Acad Med. 2010; 85: 1264-5.
[7]  Samastı M. A history of affiliation in health. Journal of Health Thought and Medical Culture. 2018; 47: 46-49.
[8]  Ülger N, Baldemir E, Battaloğlu İB. Employee Satisfaction in Hospitals with Affiliation; Sample of Training and Research Hospital of Muğla University. Journal of Clinical and Analytical Medicine. 2015: 1-5.
[9]  Uğurluoğlu Ö. Evaluation of Organizational Structures Applied in University Hospitals. Journal of Business Science. 2015; 3(1): 52-63.
[10]  Coyne JS. Hospital performance in multihospital systems: a comparative study of system and independent hospitals. Health Serv. Res. 1982; 17 (4): 303-329.
[11]  Menke TJ. The effect of chain membership on hospital costs. Health Serv. Res.1997; 32 (2): 177-196.
[12]  Carey K. Hospital cost efficiency and system membership. Inquiry. 2003; 40(1): 25-38.
[13]  Burns LR, McCoulgh JS, Wholey DR, et al. Is the system really the solution? Operating costs in hospital systems. Med. Care Res. Rev. 2015; 72(3): 1-26.
[14]  Gaynor M, Town R. The Impact of Hospital Consolidation e Update. The Robert Wood Johnson Foundation Synthesis Project; June 2012.
[15]  Cutler DM, Morton FS. Hospitals, market share, and consolidation. Journal of the Medical Association. 2013; 310(18): 1964-1970.
[16]  Dafny L. Hospital industry consolidation e still more to come? N. Engl. J. Med. 2014; 370(3): 198-199.
[17]  Daly R. Hospital consolidation trend to continue. Healthc. Financ. Manag. 2014; 68(7): 11.
[18]  Ciliberto F, Dranove D. The effect of physician hospital affiliations on hospital prices in California. Journal of Health Economics. 2006; 25(1): 29-38.
[19]  Kirchhoff SM. Physician Practices: Background, Organization, And Market Consolidation. Congressional Research Service Report for Congress, 2013.
[20]  Zepeda ED. Toward an Effective Design of Behavioral Health Care Delivery: An Empirical Analysis of Care for Depression. Production and Operations Management. 2016; 25(5): 952-967.
[21]  Rafiei S, Pourreza A. The moderating role of power distance on the relationship between employee participation and outcome variabless. International Journal of Health Policy and Management. 2013; 1: 79-83.
[22]  Ebrahimipour H, Vafaee-Najar A, Khanijahani A, et al. Customers’ complaints and its determinants: the case of a training educational hospital in Iran. International Journal of Health Policy and Management. 2013; 1: 273-277.
[23]  Mahdavi M, Parsaeian M, Jaafaripooyan E, Ghaffari S. Recent Iranian health system reform: an operational perspective to improve health services quality. Int J Health Policy Manag. 2018; 7(1): 70-74.
[24]  Farzianpour F, Aghababa S, Delgoshaei B, Haghgoo M. Performance Evaluation a Teaching Hospital Affiliated to Tehran University of Medical Sciences Based on Baldrige Excellence Model. American Journal of Economics and Business Administration. 2011; 3(2): 277-281.
[25]  Goudarzi R, Pourreza A, Shokoohi M, Askari R, Mahdavi M, Moghri J. Technical efficiency of teaching hospitals in Iran: the use of Stochastic Frontier Analysis 1999-2011. Int J Health Policy Manag. 2014; 3: 91-97.
[26]  Farzianpour F, Hosseini S, Amali T, Hosseini S, Hosseini SS. The Evaluation of Relative Efficiency of Teaching Hospitals. American Journal of Applied Sciences. 2012; 9(3): 392-398.
[27]  İlgün G, Konca M. Assessment of Efficiency Levels of the Training and Research Hospitals and the Factors Affecting Their Efficiencies. Health Policy and Technology. 2019.
[28]  Kucuk A, Ozsoy VS, Balkan D. Assessment of technical efficiency of public hospitals in Turkey. European Journal of Public Health. 2019.
[29]  Ersoy K, Kavuncubasi S, Ozcan YA, Harris JM. Technical Efficiencies of Turkish Hospitals: DEA Approach, Journal of Medical Systems. 1997; 21(2): 67-74.
[30]  Junoy JP. Partitioning input cost efficiency into its allocative and technical components: an empirical DEA application to hospitals. Socio-Economic Planning Sciences. 2000; 34(3):199-218.
[31]  Athanassopoulos A, Gounaris C. Assessing the technical and allocative efficiency of hospital operations in Greece and its resource allocation implications. European Journal of Operational Research. 2001; 133(2): 416-431.
[32]  Giokas DI. Greek hospitals: how well their resources are used. Omega. 2001; 29: 73-83.
[33]  Chang H, Cheng MA, Das S. Hospital ownership and operating efficiency: evidence from Taiwan. European Journal of Operational Research. 2004; 159(2): 513-527.
[34]  Watcharasriroj B, Tang JCS. The Effects of Size and Information Technology on Hospital Efficiency. J High Technology Management Research. 2004; 15(1): 1.
[35]  Linna M, Hakkinen U, Magnussen J. Comparing hospital cost efficiency between Norway and Finland. Health Policy. 2006; 77: 268-78.
[36]  Aletras V, Kontodimopoulos N, Zagouldoudis A, Niaka, D. The short term effect on technical and scale efficiency of establishing regional health systems and general management in Greek NHS hospitals. Health Policy. 2007; 83(2): 236-245.
[37]  Vitikainen K, Street A, Linna M. Estimation of hospital efficiency—Do different definitions and casemix measures for hospital output affect the results?. Health Policy. 2009; 89(2): 149-159.
[38]  Berta P, Callea G, Martini G, Vittadini G. The effects of upcoding, cream skimming and readmissions on the Italian hospitals efficiency: A population-based investigation. Economic Modelling. 2010; 27(4): 812-821.
[39]  Caballer-Tarazona M, Moya-Clemente I, Vivas-Consuelo D, and Barrachina-Martínez I. A model to measure the efficiency of hospital performance. Mathematical and computer modelling. 2010; 52(7-8): 1095-1102.
[40]  Chang SJ, Hsiao HC, Huang LH, Chang H. Taiwan quality indicator project and hospital productivity growth. Omega. 2011; 39(1): 14-22.
[41]  Ying Chu NG. The productive efficiency of Chinese hospitals. China Economic Review. 2011; 22(3): 428-439.
[42]  Hu H, Qi Q, Yang CH. Analysis of hospital technical efficiency in China: Effect of health insurance reform. China Economic Review. 2012; 23: 865-877.
[43]  Kirigia JM, Asbu EZ. Technical and Scale Efficiency of Public Community Hospitals in Eritrea: An Exploratory Study. Health Economics Review, 2013; 3: 1-16.
[44]  De Nicola A, Gitto S, Mancuso P. Evaluating Italian public hospital efficiency using bootstrap DEA and CART. Int.J.Appl.Decision Sci. 2013; 6(3): 281-292.
[45]  Mitropoulos, P, Mitropoulos, I, and Giannikos, I. Combining DEA with location analysis for the effective consolidation of services in the health sector. Computers & Operations Research. 2013; 40(9): 2241-2250.
[46]  Gok MS, Sezen B. Analyzing the ambiguous relationship between efficiency, quality and patient satisfaction in healthcare services: the case of public hospitals in Turkey. Health Policy. 2013; 111(3): 290-300.
[47]  Kaçak H, Ozcan YA, Kavuncubasi SA. New Examination of Hospital Performance after Health Care Reform in Turkey: Sensitivity and Quality Comparisons. International Journal of Public Policy. 2014; 10 (4/5):178-194.
[48]  Yang J, Zeng W. The trade-offs between efficiency and quality in the hospital production: Some evidence from Shenzhen, China. China Economic Review. 2014; 31:166-184.
[49]  Chowdhury T, Kowalski S, Arabi Y, Dash HH. Pre-hospital and initial management of head injury patients: An update. Saudi journal of anaesthesia. 2014; 8(1): 114.
[50]  Harrison JP, Meyer S. Measuring efficiency among US federal hospitals. The Health Care Manager. 2014; 33(2): 117-127.
[51]  Leleu H, Moises J, Valdmanis VG. How do payer mix and technical inefficiency affect hospital profit? A weighted DEA approach. Operations Research for Health Care. 2014; 3(4): 231-237.
[52]  Mitropoulos P, Talias ΜA, Mitropoulos I. Combining stochastic DEA with Bayesian analysis to obtain statistical properties of the efficiency scores: An application to Greek public hospitals. European Journal of Operational Research. 2015; 243(1): 302-311.
[53]  Matranga D, Sapienza F. Congestion analysis to evaluate the efficiency and appropriateness of hospitals in Sicily. Health Policy. 2015; 119(3): 324-332.
[54]  Alonso F, Salinas-Perez JA, Gutierrez-Colosia MR, et al. Use of an integrated atlas of mental health care for evidence informed policy in Catalonia (Spain). Epidemiology and psychiatric sciences. 2015; 24(6): 512-524.
[55]  Jola-Sanchez AF, Pedraza-Martinez AJ, Bretthauer KM, Britto RA. Effect of armed conflicts on humanitarian operations: Total factor productivity and efficiency of rural hospitals. Journal of Operations Management. 2016; 45:73-85.
[56]  Erus B, Hatipoglu O. Physician payment schemes and physician productivity: Analysis of Turkish healthcare reforms. Health Policy. 2017; 121(5): 553-557.
[57]  Campanella P, Azzolini E, Izzi A, et al. Hospital efficiency: how to spend less maintaining quality? Annali dell'Istituto Superiore Di Sanita. 2017; 53(1): 46-53.
[58]  Flokou A, Alestras V. Niakas D. A window-DEA based efficiency evaluation of the public hospital sector in Greece during the 5-year economic crisis. Plos One. 2017; 12 (5).
[59]  Gimenez V, Diego P, Tortosa-Ausina E. Evaluation of efficiency in Colombian hospitals: An analysis for the post-reform period. Socio-Economic Planning Sciences. 2018.
[60]  Charnes A, Cooper WW, Rhodes E. Measuring the efficiency of decision making units. European journal of operational research. 1978; 2(6): 429-444.
[61]  Banker RD, Charnes A, Cooper WW. Some models for estimating technical and scale inefficiencies in data envelopment analysis. Management science. 1984; 30(9): 1078-1092.
[62]  Aigner D, Lovell CK, Schmidt P. Formulation and estimation of stochastic frontier production function models. Journal of econometrics. 1977; 6(1): 21-37.
[63]  Färe R, Grosskopf S, Norris M, Zhang Z. Productivity growth, technical progress, and efficiency change in industrialized countries. The American economic review. 1994: 66-83.
[64]  Hashjin, A. A., Kringos, D. S., Manoochehri, J., Aryankhesal, A., Klazinga, N. S. Development and impact of the Iranian hospital performance measurement program. BMC health services research, 2014; 14(1): 448.
[65]  Linde, S. The formation of physician patient sharing networks in medicare: Exploring the effect of hospital affiliation. Health economics, 2019; 28(12): 1435-1448.
[66]  Kutney-Lee, A., Melendez-Torres, G. J., McHugh, M. D., & Wall, B. M. Distinct enough? A national examination of Catholic hospital affiliation and patient perceptions of care. Health care management review. 2014; 39(2): 134-144.
[67]  Chowkwanyun M. Rethinking Private-Public Partnership in the Health Care Sector: The Case of Municipal Hospital affiliation. Bulletin of the history of medicine. 2019; 93(4): 483-517.
[68]  Casalino L, Robinson JC. Alternative models of hospital-physician affiliation as the United States moves away from tight managed care. Milbank Q. 2003; 81(2): 331-174.