Productivity growth in Norwegian psychiatric outpatient clinics for children and youths.

BACKGROUND Norwegian government policy is to increase the supply of psychiatric services to children and young persons, both by increasing the number of personnel, and by increasing productivity in the psychiatric outpatient clinics. Increased accessibility is observed for the last years, measured as the number of children receiving services each year. AIMS OF THE STUDY The paper aims to estimate change in productivity among outpatient clinics, and whether any change is related to personnel mix, budget growth or financial incentives. METHODS We use a non-parametric method called Data Envelopment Analysis (DEA) to estimate a best-practice production frontier. A Malmquist output-based technical productivity index is calculated and decomposed in technical efficiency change, scale efficiency change and frontier shifts. Bootstrapping methods are used to estimate standard errors and confidence intervals for the technical productivity index and its decomposition. In a second stage, the technical productivity index is regressed on variables that may potentially be statistically associated with productivity growth. The paper analyses panel data for the period of 1996-2001. RESULTS The results indicate increased overall technical productivity by about 4.5 per cent a year in the period, mostly due to frontier shift, but with important contribution from increased technical efficiency. Scale efficiency does not change. Personnel growth has a negative influence on productivity growth, whilst a growth in the portion of university educated personnel improves productivity. The financial reform of 1997 that gave greater weight to interventions per patient led to lower productivity growth in the subsequent period for those that had an initial budgetary gain from the reform. DISCUSSION Technical productivity has increased substantially during the period of study, implying a degree of success in the government plan for increasing psychiatric health care. While the decomposition of technical productivity change is less robust to outliers than the Malmquist productivity index itself, the results indicate that both clinics that were previously efficient, and those that were inefficient, have increased their productivity, the latter somewhat more than the former. The size of the clinic is not related to its technical productivity growth. A growth in the budget affects technical productivity negatively. While the clinics seem to respond to "mild coercion'' by increasing productivity, this growth is slowed down by a policy that at the same time increases the availability of resources. IMPLICATIONS FOR HEALTH POLICY The instruments used in the government psychiatric plan have been adequate in stimulating the productivity and availability of psychiatric services. On the other hand it may be difficult to maintain the pressure for increasing the service level without stronger financial incentives, especially since the service suppliers are receiving strong activity based financial incentives for somatic care. IMPLICATIONS FOR FURTHER RESEARCH Further research should focus on the effects of various organisational models of outpatient-clinics on both the level of, and change in, productivity. In this context the positive effect of increasing the portion of university educated personnel could provide a fertile starting point. It is also of interest to study whether productivity growth is accompanied by increased availability or increased treatment intensity.