Introduction
Healthcare organizations encounter difficulties in several critical domains, despite employing diverse advanced methodologies and tools. Data envelopment analysis (DEA) is a non-parametric method in the field of operational research (OR), mainly utilized for evaluating the relative efficiency and productivity of decision-making units (DMUs) across various sectors, with a notable application in healthcare systems. Nunamaker, in 1983, employed the DEA for the first time to assess the technical efficiency of 16 hospitals in Wisconsin, USA. Within the healthcare context, DEA serves as a valuable tool for evaluating the performance of hospitals, clinics, and other healthcare providers, pinpointing inefficiencies, and identifying opportunities for improvement that can enhance the quality and efficiency of healthcare services. While DEA holds significant promise for transformation and offers robust analytical capabilities, it has its own limitations and challenges that should be addressed to fully realize its benefits. Therefore, this study aims to review the challenges and benefits of DEA in evaluating the performance of healthcare systems.

Methods
In this narrative review study, a search for related articles in English or Persian published from 2010 to 2024 was conducted in Medline, Google Scholar, PubMed, Science Direct, Scopus, and Scientific Information Database (SID) databases using the keywords DEA, Efficiency, Opportunities, and Healthcare system. Initially, 76 articles were found. Then, according to the review criteria, 31 articles with available full texts were selected and reviewed completely.

Results

Challenges of applying DEA

Complexity of health care services
DEA results are significantly influenced by the selected inputs and outputs, and omitting critical variables may lead to inaccurate results. This challenge is particularly evident in the healthcare sector, where it is often difficult to quantify all relevant dimensions. Factors such as the variety of services provided by centers, the types of available treatments, and the patient’s medical condition contribute to this complexity and may overshadow the actual performance of health care centers and complicate the interpretation of DEA findings.

Data quality and availability
Inadequate data quality can lead to poor healthcare services, which in turn increases costs and reduces productivity. Sometimes data may be incomplete, heterogeneous, or inaccessible. The effectiveness of DEA depends on the availability and quality of data, which is a major challenge in the healthcare sector.

Dynamic and diverse nature of health care
In the medical field, diversity pertains to healthcare professionals, trainees, educators, researchers, and patients who come from different backgrounds, including race, ethnicity, gender, social class, socioeconomic status, primary language, and geographic location. Furthermore, the constant changes in laws, treatment protocols, and technological advances that characterize the healthcare sector further complicate the standardization of services across different healthcare units. 

Resistance to change
Change, especially in the healthcare field, represents a complex and challenging phenomenon, and an organization’s ability to adapt is of paramount importance to its survival. Implementing the DEA and subsequent actions based on its results may even encounter resistance from health care managers and professionals. Some may perceive that the DEA acts primarily as a mechanism to punish misperformance rather than to improve the efficiency of the system. To effectively address this resistance, it is essential to demonstrate the benefits of DEA in improving health care delivery by establishing clear communications and providing the necessary educational resources.

Benefits of DEA

Benchmarking 
DEA plays a vital role in identifying health and medical units with optimal performance that demonstrate superior efficiency. By identifying benchmarks based on these exemplary units, DEA offers valuable targets for decision-makers and policymakers. This information is particularly beneficial for those overseeing healthcare systems, as it highlights areas that need improvement and helps them perform optimally by directing available resources toward underperforming centers. 

Resource allocation and optimization
Healthcare sectors consist of a set of input and output variables, such as the size of hospitals, the number and type of specialists, the rate of patient admission and discharge, and the level of patient satisfaction with treatment, that help to clarify the complex interactions between available resources and overall system performance. DEA helps health care managers understand how resources are utilized across different units. By identifying inefficient units, managers can optimize resource allocation and ensure that each unit is operating at its maximum capacity.

Performance improvement
Effective performance management is essential for improving the quality of healthcare systems through optimizing effectiveness and efficiency. In general, performance management encompasses a wide range of activities including defining, planning, measuring, monitoring, and ultimately improving the performance of a system. 

Policy formulation
Efficiency is one of the most potent measures of health system performance. Insights gained from efficiency evaluations can guide targeted interventions to improve performance. DEA can also identify specific areas where efficiency gains are possible. It can help policymakers develop strategies to increase efficiency and improve healthcare, thereby ensuring equitable access to quality care for patients. DEA can provide evidence-based knowledge that can guide the development of future health system policies.

Patient-centred care
In the digital era landscape, the integration of technology into public services is clearly evident as a fundamental element for enhancing productivity and service delivery in various sectors, such as healthcare systems. By focusing on outcomes such as patient satisfaction and treatment outcomes, DEA encourages a shift towards patient-entered care. Health care providers with the accurate knowledge gained through DEA and observing its positive results in patient treatment, can be able align with the overall goals of healthcare systems. 

Conclusion 
The DEA offers significant opportunities for enhancing healthcare management through efficiency assessment and benchmarking; however, there are some challenges for its implementation. Overcoming these challenges requires a committed approach to improving data collection practices, building an organizational culture to create sustainable progress, and adapting DEA techniques to the specific conditions in different health sectors. When successfully implemented, DEA can lead to substantial improvements in resource allocation, patient-centered care, and overall health system performance. The DEA models can be used to monitor the performance of healthcare systems over time, thereby assisting health policymakers in identifying areas for improvement and implementing strategies to achieve better outcomes.

Ethical Considerations

Compliance with ethical guidelines
This is a review study and did not involve any human or animal experiments. Therefore, it did not require an ethical code.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflicts of interest
The authors declared no conflict of interest.




 

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