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Background  The reform of county-level public hospitals is a breakthrough in the new era of healthcare reform in China and has attracted considerable attention since 2012. Continuous and efficient operations of hospital are primary concerns of this reform. To ensure the effectiveness of county-based intervention reform measures in Chongqing, it is significant to understand how hospital and county characteristics are associated with county-level public hospital efficiency due to significant development differences between counties. This study identifies the trajectory of hospital efficiency over time and determinants. It will also provide preliminary references for advancing reform.    Methods  This study employs data from the Chongqing Regional Health Information Platform, Chongqing Health and Family Planning Statistical Yearbook, and Chongqing Statistical Yearbook for 2012–2016. A three-level growth model is used to estimate the efficiency growth trajectories within the contexts of hospitals and counties.    Results  The intra-hospital level factors that affect the initial efficiency include government financial assistance, daily charge per bed, total assets turnover, number of hospital healthcare technicians, and medical costs per 100-yuan medical income. Inter-hospital variance is explained by hospital type. Inter-county level factors affecting the growth rate include the number of healthcare technicians per 1000 people and population density of the county. The interaction effect of the number of hospital healthcare technicians, hospital type, and number of healthcare technicians per 1000 people on hospital efficiency growth is significant.    Conclusions  This study identifies determinants that contribute to efficiency changes in public county-hospitals over time by using a three-level growth model. The differences in efficiency are associated with intra-hospital, inter-hospital, and inter-county characteristics in Chongqing, which provides useful insight into government decision-making and the progress of reform. The stability and reasonable increase in the number of healthcare technicians in a county are the key factors that improve the efficiency. Further reform should focus on maternal and child healthcare hospitals for increasing investment and implementing government compensation.

Determinants of efficiency growth of county-level public hospitals-evidence from Chongqing, China