Is capital investment in Australian hospitals effectively funding patient access to efficient public hospital care?

Rhonda Kerr; Delia V. Hendrie

doi:10.1071/AH17231

RESEARCH ARTICLE (Open Access)

Previous Next Contents Vol 42(5)

Is capital investment in Australian hospitals effectively funding patient access to efficient public hospital care?

Rhonda Kerr ^A ^B and Delia V. Hendrie ^A

+ Author Affiliations

- Author Affiliations

^A Centre for Population Health Research, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. Email: D.V.Hendrie@curtin.edu.au

^B Corresponding author. Email: kerr005@bigpond.com

Australian Health Review 42(5) 501-513 https://doi.org/10.1071/AH17231
Submitted: 5 October 2017 Accepted: 7 May 2018 Published: 23 August 2018

Journal compilation © AHHA 2018 Open Access CC BY-NC-ND

Abstract

Objective This study asks ‘Is capital investment in Australian public hospitals effectively funding patient access to efficient hospital care?’

Methods The study drew information from semistructured interviews with senior health infrastructure officials, literature reviews and World Health Organization (WHO) reports. To identify which systems most effectively fund patient access to efficient hospitals, capital allocation systems for 17 Organisation for Economic Cooperation and Development (OECD) countries were assessed.

Results Australian government objectives (equitable access to clinically appropriate, efficient, sustainable, innovative, patient-based) for acute health services are not directly addressed within Australian capital allocation systems for hospitals. Instead, Australia retains a prioritised hospital investment system for institutionally based asset replacement and capital planning, aligned with budgetary and political priorities. Australian systems of capital allocation for public hospitals were found not to match health system objectives for allocative, productive and dynamic efficiency. Australia scored below average in funding patient access to efficient hospitals. The OECD countries most effectively funding patient access to efficient hospital care have transitioned to diagnosis-related group (DRG) aligned capital funding. Measures of effective capital allocation for hospitals, patient access and efficiency found mixed government–private–public partnerships performed poorly with inferior access to capital than DRG-aligned systems, with the worst performing systems based on private finance.

Conclusion Australian capital allocation systems for hospitals do not meet Australian government standards for the health system. Transition to a diagnosis-based system of capital allocation would align capital allocation with government standards and has been found to improve patient access to efficient hospital care.

What is known about the topic? Very little is known about the effectiveness of Australian capital allocation for public hospitals. In Australia, capital is rarely discussed in the context of efficiency, although poor built capital and inappropriate technologies are acknowledged as limitations to improving efficiency. Capital allocated for public hospitals by state and territory is no longer reported by Australian Institute of Health and Welfare due to problems with data reliability. International comparative reviews of capital funding for hospitals have not included Australia. Most comparative efficiency reviews for health avoid considering capital allocation. The national review of hospitals found capital allocation information makes it difficult to determine ’if we have it right’ in terms of investment for health services. Problems with capital allocation systems for public hospitals have been identified within state-based reviews of health service delivery. The Productivity Commission was unable to identify the cost of capital used in treating patients in Australian public hospitals. Instead, building and equipment depreciation plus the user cost of capital (or the cost of using the money invested in the asset) are used to estimate the cost of capital required for patient care, despite concerns about accuracy and comparability.

What does this paper add? This is the first study to review capital allocation systems for Australian public hospitals, to evaluate those systems against the contemporary objectives of the health systems and to assess whether prevailing Australian allocation systems deliver funds to facilitate patient access to efficient hospital care. This is the first study to evaluate Australian hospital capital allocation and efficiency. It compares the objectives of the Australian public hospitals system (for universal access to patient-centred, efficient and effective health care) against a range of capital funding mechanisms used in comparable health systems. It is also the first comparative review of international capital funding systems to include Australia.

What are the implications for practitioners? Clinical quality and operational efficiency in hospitals require access for all patients to technologically appropriate hospitals. Funding for appropriate public hospital facilities, medical equipment and information and communications technology is not connected to activity-based funding in Australia. This study examines how capital can most effectively be allocated to provide patient access to efficient hospital care for Australian public hospitals. Capital investment for hospitals that is patient based, rather than institutionally focused, aligns with higher efficiency.

Introduction

Commonwealth government funding requires hospitals to deliver improvements in quality of care at the efficient price with limited growth in activity-based funding.¹ Yet patient numbers increase, clinical practice evolves and technological advances and replacement costs for medical equipment increasingly challenge hospitals.

Resolving this dilemma involves the key concepts of appropriate, sustainable and effective healthcare and three significant efficiency instruments. In this study these terms are understood to be:

‘Appropriate’ acute health facilities are suitable or fitting for their purpose.² Appropriate care derives from government agreements and Australian evidence-based standards.³^–⁵ National standards affirm that all Australians are entitled to access safe, high-quality health care that is responsive to the needs of individuals.⁴^,⁶^–⁸ Appropriate health facilities provide access for individuals to contemporary standards of care.
‘Sustainable’ has two meanings in the health context: (1) financial sustainability for governments and health services; and (2) environmental sustainability. Financial sustainability within the health sector identifies the ‘desirable composition of the capital stock to bequeath to future generations.⁹ Manageable and predictable levels of expenditure are determined by maximising efficiency¹⁰^,¹¹
‘Effectiveness’ identifies whether the outputs of the service achieve the stated objectives of that service⁶ in terms of equity of access, appropriateness and quality.⁶
‘Efficiency’ has three elements, namely allocative, productive (or technical efficiency) and dynamic efficiency.¹² Efficiency in hospitals considers the quality of health services, access to care and cost.¹³
‘Allocative efficiency’ optimises the distribution of assets to achieve the greatest community well-being or outcomes at a point in time.¹² In health, allocative efficiency involves priority setting for the distribution of resources between elements of the health system.¹⁴ Allocative efficiency is the optimal choice of input proportions, given their respective prices, according to their cost-effectiveness.¹⁵ Productive efficiency and allocative efficiencies together provide the concept of economic efficiency.
‘Productive or technical efficiency’ maximises outputs for a given level of inputs so that achieving an additional output requires additional inputs.¹⁶ Productive efficiency can be measured as a ratio of outputs to inputs.⁶
‘Dynamic efficiency’ is the allocation of resources to achieve the greatest possible community well-being or outcomes over time.¹² Dynamic efficiency examines how effectively capital distribution systems respond to emerging risks for public hospitals, including sustainability, patient demand, technological change and increased acuity.¹⁷^–¹⁹

An effective system of capital allocation for public hospitals would provide equity of access for patients, be appropriate, efficient and would fund quality services.²⁰ So the aim of the present study was to ask the question, is the system of capital funding for Australian hospitals effectively funding patient access to efficient public hospital care?

Hospitals achieving productive efficiency have been found to require access to capital that is timely, flexible, affordable and fairly distributed.²¹^,²² Allocative efficiency of capital in public hospitals requires capital resources to be optimised for maximum social benefit, which, in the case of public hospitals, is described as patient access to appropriate treatment. In considering assessing which systems most effectively fund patient access to efficient public hospital care, comparative measures of the access of hospitals to capital, patient access to hospital services and productive efficiency have been identified in Fig. 1, which illustrates the relationship between the qualities sought for Australian hospitals and the measures used in this study to assess the ability of hospitals to fund patient access to efficient care.

**Fig. 1.** Funding patient access to efficient hospitals, qualities and measures.

Methods

To investigate whether the capital funding of Australian hospitals effectively funds patient access to efficient public hospital care, we addressed the following questions: (1) how is capital allocated for acute care to public hospitals in Australia; and (2) what is international best practice for allocating capital to hospital infrastructure for acute care? To understand Australian processes and priority setting for hospital capital funding, 10 senior health officials,²³ experienced in the process of capital allocations to hospitals, were interviewed about capital decision making across three domains: (1) the process of capital allocation for public hospitals; (2) decision making about funding levels; and (3) health system objectives, including clinical appropriateness, sustainability, approach to innovation and evidence-based change, patient-centred care, clinical pathways and evidence-based design. This study was granted ethics approval (SPH-86-2013) by Curtin University. Semistructured interviews were conducted over a 12-month period with the senior health officials sharing responsibility for capital funding systems covering 84% of Australian public hospitals.²³ Officials from two states and one territory declined invitations to participate in the study.

In addition to interviews, a literature review was conducted to identify publications addressing Australian and overseas capital allocation systems with the following objectives: (1) to determine the methods for allocating capital for public hospitals in Organisation for Economic Cooperation and Development (OECD) health systems; (2) to assess the ability of public hospitals to fund access to efficient care; and (3) to identify the attributes of an effective system of investment for public hospitals.

Inclusion criteria for the literature review were articles or reports published after 2000 in the English-language peer-reviewed literature on system-wide approaches to capital funding. Articles were identified using the search terms ‘capital allocat*’ with ‘hospital*’, ‘patient access’ and ‘public hospital investment process’ and variants thereof for OECD countries in the electronic databases Emerald, Informit and Medline. Items were reviewed based on title and abstract and excluded if only one hospital was discussed, references were for social or intellectual capital or the studies were focused on portfolio investment strategies. Well-known comparative health efficiency studies were excluded because they did not include capital.²⁴^–²⁸ Three relevant Australian references were identified¹²^,¹³^,²⁹ in addition to 58 reports and articles for the international comparisons.¹⁵^,²²^,³⁰^–⁸⁵

Searching Australian government and university websites using the same criteria as for the peer-reviewed literature identified 56 relevant documents⁵^,⁸⁶^–¹⁴⁰ that were used to verify the results of the Australian interviews. International grey literature information sources and websites included the World Health Organization (WHO), relevant European, US and UK official websites, the OECD, the Commonwealth Fund and university health economic sites (McMaster, University of York, Imperial College London, London School of Economics, London School of Hygiene and Tropical Medicine). The literature review provided sufficient data on national capital allocation systems for the 17 OECD countries. The WHO Health in Transition (HiT) studies³¹^–³⁸^,⁴⁰^–⁴⁶^,⁴⁸^–⁵⁰^,⁵³^,⁵⁸^,⁵⁹^,⁶⁷^,⁷³ for those nations provided a common source.⁵¹ National systems for capital allocation for public hospitals were identified from the HiT studies and categorised into five groups, namely diagnosis-related group (DRG)-type systems, government subsidy, government project grants, mixed government–private–public partnership (PPP) or private funding (Table 1).

**Table 1. Source of capital funds for hospitals in Australia and 17 Organisation for Economic Cooperation and Development countries**
Data from World Health Organization (WHO) Health Systems in Transition by nation and other peer-reviewed literature. PPP, private–public partnerships; DRG, diagnosis-related group

Health systems in Australia identify efficiency, sustainability, innovation and patient-centred care as system objectives.¹⁴¹^–¹⁴⁴ Three aspects of economic efficiency were examined: (1) productive efficiency, analysed from econometric reports on efficiency;¹⁰^,¹²^,¹³^,¹⁵^,²²^,⁵²^,¹⁴⁵ (2) allocative efficiency measures, which, in the present study, are based on systems for priority setting for public hospital capital allocation and patient access; and (3) dynamic efficiency, assessed by examining systems for environmental sustainability, responsiveness to innovation and patient-centred care.¹⁷

Productive efficiency was scored from three studies ranking WHO member countries for health service allocative and productive efficiency.¹⁵^,²²^,⁵² These three studies ranked 191 countries using frontier production function model and data envelope analysis, and were reviewed by an international scientific committee¹⁴⁶^–¹⁴⁸ and by the European Commission study of health system efficiency.¹⁴⁵ Each study had a different emphasis and measures providing different, but comparable, national rankings. Conversion of rankings to graduated scores within the range 0–3 was based on relative rankings between the 17 OECD countries and Australia such that the highest-ranking nation (of the designated group) for each study scored 3, the second scored 2.83 and the lowest-ranked countries scored 0.17 for each study. The scores for each nation across the three studies were then averaged to provide one national score for productive efficiency.

To compare the measures for capital from national and international sources, a common scoring scheme was developed across the measures to be tested: hospital access to capital and patient access to hospital to match the measure for productive efficiency. Together, these measures were used to assess which systems most effectively fund patient access to efficient hospital care (Fig. 1).

‘Patient access to hospital’ and ‘hospital access to capital’ were assessed by three scorers (RK, DVH, Rachel Moorin) using the 0–3 scoring system (with 3 the highest score, 2 indicating satisfactory, 1 indicating poor or inadequate and 0 indicating a very poor standard). Scores were based on extracts from Section 4.1 of each HiT study and other peer-reviewed studies.¹⁰^,¹²^,³¹^–⁵¹^,⁵³^–⁷⁴^,⁸¹^–⁸⁵^,¹⁴⁹^–¹⁵⁹

Using the same scoring system, scoring for ‘hospital access to capital’ per country was for each of the four domains (timely access to capital, flexibility of funding, affordable capital and fairness of distribution); these domain scores were averaged to provide a single score for ‘hospital access to capital’ within the 0–3 range for each country. ‘Patient access to hospital’ was scored directly for each country. Then, the scores for each country, as assessed by the three scorers, were averaged to provide a final score in the range 0–3 for ‘patient access to hospital’ and ‘hospital access to capital’.

Scoring was compared between scorers using weighted Cohen’s kappa analysis.¹⁶⁰ Scoring of these measures reflected fair to moderate agreement or better, with no levels of poor agreement.

Scores for hospital access to capital, patient access to hospital and efficiency were summed (Table 2) to assess how effectively hospitals fund patient access to efficient hospitals for each country. Finally, in Table 3, countries were grouped by their system of capital allocation (Table 1) for the qualities of hospital access to capital, patient access to hospital and efficiency (Table 2) to assess which funding system most effectively funds patient access to efficient care. Because the US scored considerably lower than most other countries, the funding categories were expanded to include DRGs without the US to aid comparison.

**Table 2. Mean scores for access to capital, patient access to hospital and efficiency in Australia and 17 Organisation for Economic Cooperation and Development nations**
Data from World Health Organization (WHO) Health in Transition reviews, other peer-reviewed literature and the scoring of Evans¹⁵, Murray²² and Tandon⁵²

**Table 3. Mean scores for access to capital, patient access to hospital and efficiency by capital allocation systems**
CaDRG, capital aligned to the diagnosis-related group

Results and discussion

Capital allocation systems in Australia

Interviews with senior officials identified that all Australian states have similar systems for annual capital allocations for public hospitals. Regional health authorities compile prioritised project investment lists that are amalgamated and prioritised centrally for funding. Decision making on capital for public hospitals was identified by 43% of senior officials to take place in the state departments of health, whereas 29% indicated that decision making was at ministerial level and 29% identified cabinet or treasury level. The amount allocated for public hospital facilities and medical equipment was recognised as part of a planned replacement process or a similar amount annually by 50% of officials, and was stated to be dependent on the state budget by 20% of officials.

Clinical alignment

In the process for capital allocation, clinical views were universally sought in the planning process at the beginning of the capital allocation process, but were half as likely to be included at each further step in the planning process. Only 50% of officials used evidence-based clinical standards or clinical guidelines. This result aligns with the findings of system-wide reviews and commentators.⁸⁶^–⁸⁸^,¹⁴¹^,¹⁶¹^–¹⁶⁵ Clinical pathways were always referenced in planning, but not used in the capital allocation process.

Clinical service planning at the beginning of the capital allocation process was found to be hospital and region based in 80% of cases, with only one state using patient-centred planning as the foundation of capital allocation.

Allocative efficiency

Allocative efficiency is promoted under activity-based funding because all patients treated within the same DRG are funded to have access to comparable recurrent resources.¹⁶⁶ Similarly, an effective system of capital allocation would promote allocative efficiency when capital for hospitals was sufficient to fund equitable patient access to appropriate quality care that is efficient.²⁰

However, all Australian jurisdictions use a similar system that compares and prioritises capital allocation options within the health system. Prioritisations draw from asset-replacement strategies based on lifespans for buildings of up to 50 years, and up to 20 years for some technologies.²⁹^,¹⁶⁷ Twenty per cent of officials saw capital as an asset with a 20- or 50-year lifespan, with another 20% of officials, from different states, identifying elections as significant in setting priorities for capital allocation. Fifty per cent of officials reported working from a defined plan for allocations or used asset-specific replacement as a determinant of capital allocations. Prioritised systems are also used for medical equipment investment, with new builds and redevelopments receiving the majority of funds for medical equipment, and the replacement and improvement of older medical equipment receiving a lower priority. Similarly, investment in information and communications technology (ICT) was recognised as associated with major hospital developments by 92% of officials.

Productive efficiency

Productive efficiency in public hospitals is dependent on optimal combinations of skilled labour and capital so desired outputs are achieved within resources.¹⁰^,¹⁶⁸ Australian public hospitals were found to be operating at an estimated 90% efficiency in the most detailed study of hospitals, but the value of capital cost per patient could only be estimated.⁶^,¹²

Dynamic efficiency

Innovations in clinical services are less clearly supported in the capital funding system, with no national or state-wide systems to support capital for evidence-based clinical innovation; commonly, funding to facilitate innovation was sought at the project or hospital level (60%).

Sustainability is a significant issue for acute health care, with high energy costs and carbon emission particularly in ward areas and surgical services.¹⁶⁹ Up to 60% of public sector energy costs in Victoria were estimated to have been generated by hospitals.¹⁷⁰ Several states have trialled projects to monitor the use of energy in existing hospitals, but officials could not reference a state-wide system of energy or carbon management. The prevailing approach to improving energy consumption was redevelopment of the hospital (60%) or was a matter for individual hospitals (40%).

Patient access to appropriate hospital care is a national measure of equity.¹⁷¹ Patient-centred care is an aspiration of most health systems, but only 20% of officials reported patient-centred, rather than hospital-based, clinical service planning within the capital allocation system.

Funding patient access to efficient hospital care: the international experience

Hospital investment systems of 17 countries were examined to assess which systems most effectively fund patient access to efficient public hospital care. Examining the system of capital funding (Table 1) found that although many countries have mixed systems, most countries reviewed have transitioned to capital aligned with the DRG-type payment (CaDRG). Fewer nations use traditional government project grants (Table 1). Centralised government funding was less common than funding closer to the clinical level (CaDRG, mixed government–PPP and private funding).

Table 2 provides results for the three elements of the research question: capital funding for hospitals, patient access to hospitals and economic efficiency.

Access to capital for hospitals identified the UK and the US to have the lowest scores (Table 2). Australia ranked eighth for access to capital, whereas the best-performing national systems were France, the Netherlands and Norway.¹²^,²⁷^,³⁰^,³³^,³⁴^,³⁷^,⁴⁶^,⁴⁷^,⁴⁹^,⁵⁰^,⁵⁹^,⁷⁰^,⁷³^,¹⁵¹^,¹⁵⁸^,¹⁷²^–¹⁷⁶

Considering patient access to hospitals, the US again scored lowest, with the best patient access in Germany, the Netherlands, Switzerland, France and Japan.²⁵^,³¹^,³⁵^–³⁸^,⁴⁵^,⁴⁸^,⁵⁰^,⁵⁷^,⁶⁴^,⁶⁷^,¹⁵¹^,¹⁵⁸^,¹⁷⁵^,¹⁷⁷^–¹⁸⁰

Evaluating the relative economic efficiency of health systems found that the US and Denmark ranked lower than the average efficiency figure for the 18 countries studied.¹⁵^,²²^,⁵²

Bringing the three measures of access to capital, patient access and economic efficiency together (Table 2), France and the Netherlands funded the best access to efficient hospital care for patients, followed by Switzerland, Austria, Germany and Norway. The international comparative studies echo Productivity Commission reports that Australia ranked below the 18-nation average for patient access to efficient care.¹⁰^,¹²^,⁷⁴^,¹⁸¹ The US scored lowest at funding patient access to efficient care, with a score equivalent to 33% of the top scoring nations.

Does the capital funding system influence how well nations fund patient access to efficient hospital services? Table 3 aggregates nations by capital funding system (from Table 1), for hospital access to capital, patient access and efficiency (Table 2). CaDRG systems gained the highest scores for (timely, flexible, affordable and fairly distributed) capital allocations for hospitals. Government subsidies were ranked as the next most appropriate capital funding method. Private funding scored below average. The least effective system for funding patient access to efficient hospital care was mixed government–PPP funding.

Patient access to public hospitals was best provided by CaDRG (when the US was excluded) and government subsidy systems, narrowly ahead of CaDRG capital allocation systems that included the US. Private and mixed government–PPP funding again scored below average (Table 3).

For efficiency, countries using DRG-type funding were 70% of the top 10 rated countries.¹⁵^,²²^,²⁵^,⁵² So when nations were aggregated by funding system for efficiency, DRG-based funding ranked highest regardless of inclusion of the US (Table 3).

Overall, DRG-based capital funding systems (with or without the US) scored highest for funding patient access to efficient hospital care. Government subsidies ranked above average. Market-based funding systems did not provide better access to capital for hospitals than government-funded systems. Predominantly private capital funding and mixed government–PPP systems provided one-third or less access to capital afforded by the CaDRG and government subsidy systems, scoring lowest for funding patient access to efficient care (Table 3).

Conclusions

Australian capital allocation systems are generally not patient centred or focused on clinical standards. Instead, Australia has a prioritised hospital investment system based on hospital asset replacement, institutionally based capital planning, budgetary and political priorities.

Because Australian systems for capital allocation for acute care were also found not to demonstrate allocative, productive or dynamic efficiency, the fundamental question was asked, which capital allocation method most effectively funds patient access to efficient hospitals?

The present study identified that the OECD countries most effectively funding acute care have transitioned to DRG alignment for capital funding for hospitals. Measures of effective capital allocation for hospitals, patient access and efficiency found DRG-based capital allocation superior to government subsidies, with the worst performing systems based on private finance. Of the 18 health systems assessed, France, the Netherlands and Norway provided the best access to effective capital funding for hospitals.

Numerous reviews of health service delivery across Australia have found that a prioritised capital allocation system does not comprehensively provide appropriate access to capital resources for all patients and clinicians.²⁹^,⁸⁶^–⁸⁸^,¹⁴¹^,¹⁶¹^–¹⁶³^,¹⁸²^,¹⁸³ Australian systems of capital allocation for public hospitals were not found to match health system objectives for promoting allocative, productive¹⁰ or dynamic efficiency within the national study or in comparison with 17 OECD nations.

The present study is the first to review capital allocation systems for Australian hospitals, to evaluate those systems against the contemporary objectives of the health systems, and to assess whether prevailing Australian allocation systems deliver funds to facilitate patient access to efficient hospitals. Commonly, hospital efficiency and access are considered by type of ownership or bed numbers rather than system of funding. The present study is the first to evaluate hospital capital allocation and efficiency. It is also the first to analyse the effectiveness of a range of capital funding systems to facilitate access for patients to efficient hospital care across a range of OECD countries. Similarly, it is the first time capital allocation for Australian hospitals has been included in an international review.

Although the measures used to quantify capital allocation, patient access and efficiency have been used with care, all measures have their limitations. Information has been drawn from various sources, themselves containing limitations. A wider search over 12 additional languages may have found further information on patient access, innovation, clinical standards and access to capital. Patient access to hospital services relies on a wide range of factors, including recurrent funding of hospitals, staffing and access to primary care. The efficiency measure is a generalised measure because comparative efficiency studies are challenged by method,¹⁴⁸ data and specificity,¹⁸⁴ defining outputs or outcomes¹⁸⁵ and because inputs rarely include measures of capital investment other than hospital beds.¹³^,²⁵ The studies scored for efficiency date from the turn of the century and do not include later changes made in health systems.

Allocative efficiency for capital in Australia, in an activity-based funding context, invites capital to be linked to patient care, clinical standards and efficiency, and to be equitably distributed between hospitals for patients in similar DRGs. The international evidence identified that an allocation system that provides hospitals with access to capital that is timely, flexible in use, affordable and fairly distributed improves efficiency. The evidence indicates that DRG-aligned capital allocation in Australia can provide the equitable, patient-centred distribution required for allocative, productive and dynamic efficiency in acute care.

Competing interests

The authors declare no conflicts of interest.

Acknowledgements

The contribution of Rachael Moorin in scoring international evidence on capital funding for patient access to efficient care is acknowledged. The authors acknowledge the contribution of Curtin University and an Australian Government Research Training Program Scholarship in supporting this research.

References

[1] Morrison S. Budget 2016–17. Budget paper no. 3. Federal financial relations 2016–17. Canberra: Commonwealth of Australia; 2016.

[2] Hanks P. Collins concise dictionary plus. Glasgow: William Collins Sons; 1989.

[3] Council of Australian Governments (COAG). National health reform agreement. Canberra: COAG; 2011.

[4] Australian Commission on Safety and Quality in Health Care. Australian charter of healthcare rights. 2009. Available at: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/17537-charter.pdf [verified 8 June 2018].

[5] Australasian Health Infrastructure Alliance. Australasian health facility guidelines (AusHFG). 2016. Available at: https://healthfacilityguidelines.com.au/full-guidelines [verified 8 June 2018].

[6] Steering Committee for the Review of Government Service Provision. Report on government services. 2018. Available at: https://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health/public-hospitals [verified 29 June 2018].

[7] Australian Commission on Safety and Quality in Health Care. Patient and consumer centred care. 2011. Available at: http://www.safetyandquality.gov.au/our-work/patient-and-consumer-centred-care/ [verified 8 June 2018].

[8] Australian Commission on Safety and Quality in Health Care. National safety and quality health service standards. 2012. Available at: https://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/ [verified 8 June 2018].

[9] Markulev A, Long A. On sustainability: an economic approach. Productivity Commission staff research note. 2013. Available at: http://www.pc.gov.au/research/supporting/sustainability/sustainability.pdf [verified 8 June 2018].

[10] Productivity Commission. Public and private hospitals: Productivity Commission research report. Melbourne: Productivity Commission; 2009.

[11] Productivity Commission. Shifting the dial: 5 year productivity review. 2017. Available at: https://www.pc.gov.au/inquiries/completed/productivity-review/report [verified 8 June 2018].

[12] Productivity Commission. Performance of public and private hospital systems: multivariate analysis. Supplement to research report. 2010. Canberra. Available at: http://www.pc.gov.au/inquiries/completed/hospitals/supplement [verified 8 June 2018].

[13] Productivity Commission. Efficiency in health. Productivity Commission research paper. Canberra: Productivity Commission; 2015. Available at: https://www.pc.gov.au/research/completed/efficiency-health/efficiency-health.pdf [verified 8 June 2018].

[14] Duckett SJ, Ward M. Developing ‘robust performance benchmarks’ for the next Australian health care agreement: the need for a new framework. Aust New Zealand Health Policy 2008; 5 1
| Developing ‘robust performance benchmarks’ for the next Australian health care agreement: the need for a new framework.Crossref | GoogleScholarGoogle Scholar |

[15] Evans DB, Tandon A, Murray CJL, Lauer J. The comparative efficiency of national health systems in producing health: an analysis of 191 countries. GPE discussion paper series: no. 29. 2000. Available at: http://www.who.int/healthinfo/paper29.pdf [verified 8 June 2018].

[16] Hurley E, McRae I, Bigg I, Stackhouse L, Boxall A-M, Broadhead P. The Australian health care system: the potential for efficiency gains a review of the literature. Background paper prepared for the National Health and Hospitals Reform Commission. 2009. Available at: http://webarchive.nla.gov.au/gov/20090926213718/http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/background-papers [verified 29 June 2018].

[17] Duckett SJ. The Australian health care system: reform, repair or replace? Aust Health Rev 2008; 32 322–9.
| The Australian health care system: reform, repair or replace?Crossref | GoogleScholarGoogle Scholar |

[18] Tremblay VJ, Tremblay CH. Chapter 17 Technological change, dynamic efficiency, and market structure. New perspectives on industrial organization. New York: Springer; 2012. pp. 485–519.

[19] Abel AB, Mankiw NG, Summers LH, Zeckhauser RJ. Assessing dynamic efficiency: theory and evidence. Rev Econ Stud 1989; 56 1–19.
| Assessing dynamic efficiency: theory and evidence.Crossref | GoogleScholarGoogle Scholar |

[20] Steering Committee for the Review of Government Service Provision. Chapter 12 Public hospitals. Report on Government Services 2017. Canberra. Productivity Commission; 2017. Available at: http://www.pc.gov.au/research/ongoing/report-on-government-services/2017/health/public-hospitals/rogs-2017-volumee-chapter12.pdf [verified 8 June 2018].

[21] Hellowell M, Vecchi V. An evaluation of the projected returns to investors on 10 PFI projects commissioned by the NHS. Financial Accountability & Management 2012; 28 77–100.
| An evaluation of the projected returns to investors on 10 PFI projects commissioned by the NHS.Crossref | GoogleScholarGoogle Scholar |

[22] Murray CJL, Lauer J, Tandon A, Frenk J. Overall health system achievement for 191 countries. 2001. Available at: http://www.who.int/healthinfo/paper28.pdf [verified 8 June 2018].

[23] Australasian Health Infrastructure Alliance. Australasian health infrastructure alliance. 2016. Available at: https://healthfacilityguidelines.com.au/australasian-health-infrastructure-alliance [verified 8 June 2018].

[24] Schneider ECS, Squires D, Shah D, Doty A. Mirror mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund; 2017 Available at: http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/assets/Schneider_mirror_mirror_2017.pdf [verified 8 June 2018].

[25] Davis K, Sternikis K, Squires D, Schoen C. Mirror mirror on the wall, 2014 update: how the U.S. health care system compares internationally. The Commonwealth Fund; 2014. Available at:http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror [verified 8 June 2018].

[26] Davis K, Stremikis K, Schoen C. Mirror mirror on the wall: how the performance of the U.S. Health care system compares internationally: 2010 update. The Commonwealth Fund; 2010. Available at: http://www.commonwealthfund.org/publications/fund-reports/2010/jun/mirror-mirror-update [verified 8 June 2018].

[27] National Research Council (US), Institute of Medicine (US). In: Woolf SH, Aron L, editors. US health in international perspective: shorter lives, poorer health. 2013. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24006554 [verified 19 June 2018].

[28] National Research Council (US), Institute of Medicine (US). Chapter 4 Public health and medical care systems. In: Woolf SH, Aron L, editors. Health in international perspective: shorter lives, poorer health. 2013. Available at: https://www.ncbi.nlm.nih.gov/books/NBK154484/#ch4.s3 [verified 8 June 2018].

[29] Deeble J. Capital investment in public hospitals. Aust Health Rev 2002; 25 45–60.
| Capital investment in public hospitals.Crossref | GoogleScholarGoogle Scholar |

[30] Mossialos E, Wenzl M, Osborn R, Anderson C, editors. 2015 International profiles of health care systems. The Commonwealth Fund; 2016. Available at: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf?la=en [verified 8 June 2018].

[31] Hofmarcher M, Quentin W. Austria: health system review. Health Syst Transit 2013; 15 1–291.

[32] European Observatory on Health Systems and Policies. HiT summary: Austria. 2006. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98825/E89021sum.pdf [verified 1 May 2015].

[33] Corens D. Belgium: health system review. Health Syst Transit 2007; 9 1–172.

[34] Marchildon GP. Canada: health system review. Health Syst Transit 2013; 15 1–179.

[35] Olejaz M, Nielsen AJ, Rudkjøbing A, Birk HO, Krasnik A, Hernández-Quevedo C. Denmark: health system review. Health Syst Transit 2012; 14 1–192.

[36] Strandberg-Larsen MB, Nielsen MB, Vallgårda S, Krasnik A, Vrangbæk K. Denmark: health system review. Health Syst Transit 2007; 9 1–164.

[37] Vuorenkoski L. Finland: health system review. Health Syst Transit 2008; 10 1–168.

[38] Chevreul K, Durand-Zaleski I, Bahrami S, Hernández-Quevedo C, Mladovsky P. France: health system review. Health Syst Transit 2010; 12 1–291.

[39] Chevreul K, Brigham KB, Mounier-Jack S. France. In: Figueras J, Thomson S, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M and Kluge H, editors. Economic crisis, health systems and health in Europe: Country experience. Maidenhead: Open University Press; 2014. pp. 379–84.

[40] Chevreul K, Brigham KB, Durand-Zaleski I, Hernández-Quevedo C. France: health system review. Health Syst Transit 2015; 17 1–218.

[41] Busse R, Blümel M. Germany: health system review. Health Syst Transit 2014; 16 1–296.

[42] Ferré F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, Ricciardi W, Maresso A. Italy: health system review. Health Syst Transit 2014; 16 1–168.

[43] Tatara K, Okamoto E. Japan: health system review. Health Syst Transit 2009; 11 1–164.

[44] Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. Netherlands: health system review. Health Syst Transit 2016; 18 1–239.

[45] Ringard A, Sagan A, Saunes IS, Lindahl AK. Norway: health systems review. Health Syst Transit 2013; 15 1–162.

[46] Barros PP, Machado SR, Simões JdA. Portugal: health system review. Health Syst Transit 2011; 13 1–156.

[47] Serrano CT, Ferrer MM, Toner AdR. The Alzira model: Hospital de la Ribera, Valencia, Spain. In: Rechel B, Erskine J, Dowdeswell B, Wright S, McKee M, editors. Capital investment for health: case studies from Europe. Copenhagen: World Health Organisation; 2009. pp. 11–26.

[48] Anell A, Glenngård AH, Merkur S. Sweden: health system review. Health Syst Transit 2012; 14 1–159.

[49] Boyle S. United Kingdom (England): health system review. Health Syst Transit 2011; 13 1–486.

[50] Rice T, Rosenau P, Unruh LY, Barnes AJ. United States of America: health system review. Health Syst Transit 2013; 15 1–486.

[51] Rechel B, Thomson S, van Ginneken E. Health systems in transition: template for authors. 2010. Available at: http://www.euro.who.int/__data/assets/pdf_file/0003/127497/E94479.pdf?ua=1 [verified 8 June 2018].

[52] Tandon A, Murray CJL, Lauer J, Evans DB. Measuring overall health system performance for 191 countries. 2002. Available at: http://www.who.int/healthinfo/paper30.pdf [verified 8 June 2018].

[53] De Pietro C, Camenzind P, Sturny I, Crivelli L, Edwards-Garavoglia S, Spranger A, Wittenbecher F, Quentin W. Switzerland: health system review. Health Syst Transit 2015; 17 1–288.

[54] Abrams MK, Nuzum R, Zezza MA, Ryan J, Kiszla J, Guterman S. The Affordable Care Act’s payment and delivery system reforms; a progress report at five years. The Commonwealth Fund; 2015. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2015/may/aca-payment-and-delivery-system-reforms-at-5-years [verified 8 June 2018].

[55] Cleemput I, Guillaume J, Van de Voorde C, Maresso A. The impact of the crisis on the health system and health in Belgium. In: Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M, Kluge H, editors. Maidenhead: Open University Press; 2014. pp. 3–46.

[56] Czypionka T, Hofmarcher M. Austria. In: Maresso A, Mladovsky P, Thomson S, Sagan, A, Karanikolos M, Richardson E, Cylus J, Evetovits T, Jowett M, Figueras J, Kluge H, editors. Economic crisis, health systems and health in Europe. Maidenhead: Open University Press; 2014. pp. 329–32.

[57] Dickman SL, Himmelstein DU, Woolhandler S. Inequality and the health-care system in the USA. Lancet 2017; 389 1431–41.
| Inequality and the health-care system in the USA.Crossref | GoogleScholarGoogle Scholar |

[58] García-Armesto S, Abadía-Taira MB, Durán A, Hernández-Quevedo C, Bernal-Delgado E. Spain: health system review. Health Syst Transit 2010; 12 1–295.

[59] Gerkens S, Merkur S. Belgium: health system review. Health Syst Transit 2010; 12 1–266.

[60] Guerrero I, Mosse PR, Rogers V. Hospital investment policy in France: pathways to efficiency and the efficiency of the pathways. Health Policy 2009; 93 35–40.
| Hospital investment policy in France: pathways to efficiency and the efficiency of the pathways.Crossref | GoogleScholarGoogle Scholar |

[61] Henke K-D, Quentin W. Germany. In: Maresso A, Mladovsky P, Thomson S, Sagan, A, Karanikolos M, Richardson E, Cylus J, Evetovits T, Jowett M, Figueras J, Kluge H, editors. Economic crisis, health systems and health in Europe. Maidenhead: Open University Press; 2014. pp. 387–89.

[62] Jacobs P, Moffatt J, Ohinmaa A, Jonsson E. Everybody’s business: economic surveillance of public health services in Alberta, Canada. Eur J Public Health 2013; 23 79–82.
| Everybody’s business: economic surveillance of public health services in Alberta, Canada.Crossref | GoogleScholarGoogle Scholar |

[63] Klein DJ, Brown AD, Huynh TM, Bevan G, Markel F, Ottaway SD, Pink G, Zyblok M. Capital spending in healthcare: a missed opportunity for improvement? Canadian Foundation for Healthcare Improvement; 2013. Available at: http://www.cfhi-fcass.ca/Libraries/Reports/Capital-Spending-Brown-E.sflb.ashx [verified 8 June 2018].

[64] Martinussen PE, Magnussen J. Healthcare reform – the Nordic experience. In: Magnussen J, Vrangbæk K, Saltman RB, editors. Nordic healthcare systems: recent reforms and current policy challenges. Maidenhead: Open University Press; 2009. pp. 21–52

[65] NHS Trust Development Authority. Capital regime and investment business case approvals guidance for NHS Trusts. 2014. Available at: http://www.ntda.nhs.uk/wp-content/uploads/2014/07/TDA-Cap-Regime-and-IBC-Approvals-Guidance-NHS-Trusts.pdf [verified 16 February 2015].

[66] Rudkjøbing A, Vrangbæk K. Denmark. In: Maresso A, Mladovsky P, Thomson S, Sagan, A, Karanikolos M, Richardson E, Cylus J, Evetovits T, Jowett M, Figueras J, Kluge H, editors. Economic crisis, health systems and health in Europe. Maidenhead: Open University Press; 2014. pp. 366–70.

[67] Schäfer W, Kroneman M, Boerma W, van den Berg M, Westert G, Devillé W, van Ginneken E. The Netherlands: health system review. Health Syst Transit 2010; 12 1–229.

[68] Schoenstein M, Kumar A. Managing hospital volumes: Germany and experiences from OECD countries. 2013. Available at: http://www.oecd.org/els/health-systems/ManagingHospitalVolumes_GermanyandExperiencesfromOECDCountries.pdf [verified 8 June 2018].

[69] US Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics. Health United States, 2014: with special feature on adults aged 55–64. 2015. Available at: http://www.cdc.gov/nchs/data/hus/hus14.pdf#1022014 [verified 8 June 2018].

[70] Shaoul J, Stafford A, Stapleton P. NHS capital investment and PFI: from central responsibility to local affordability. Financ Account Manag 2011; 27 1–17.
| NHS capital investment and PFI: from central responsibility to local affordability.Crossref | GoogleScholarGoogle Scholar |

[71] The Henry J Kaiser Family Foundation. Hospital beds per 1,000 population by ownership type, 2015. 2015. Available at: https://www.kff.org/other/state-indicator/beds-by-ownership/?currentTimeframe=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D [verified 17 March 2017].

[72] Thompson CR, McKee M. An analysis of hospital capital planning and financing in three European countries: using the principal–agent approach to identify the potential for economic problems. Health Policy 2011; 99 158–66.
| An analysis of hospital capital planning and financing in three European countries: using the principal–agent approach to identify the potential for economic problems.Crossref | GoogleScholarGoogle Scholar |

[73] Durán A, Lara JL, van Waveren M. Spain: health system review. Health Syst Transit 2006; 8 1–208.

[74] Healy J, Sharman E, Lokuge B. Australia: Health system review. Health Syst Transit 2006; 8 1–158.

[75] de Belvis AG, Ferrè F, Specchia ML, Valerio L, Fattore G, Ricciardi W. The financial crisis in Italy: Implications for the healthcare sector. Health Policy 2012; 106 10–6.
| The financial crisis in Italy: Implications for the healthcare sector.Crossref | GoogleScholarGoogle Scholar |

[76] Maresso A, Mladovsky P, Thomson S, Sagan A, Karanikolos M, Richardson E, Cylus J, Evetovits T, Jowett M, Figueras J, Kluge H, eds. Economic crisis, health systems and health in Europe. Maidenhead: Open University Press; 2015.

[77] Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, Cylus J, Karanikolos M, Kluge H. Economic crisis, health systems and health in Europe: impact and implications for policy. Policy Summary 12. Maidenhead: Open University Press; 2015. Available at: http://www.euro.who.int/__data/assets/pdf_file/0008/257579/Economic-crisis-health-systems-Europe-impact-implications-policy.pdf?ua=1 [verified 10 July 2018]

[78] World Health Organization (WHO) Health Systems Equity. Geneva: WHO; 2018. Available at: http://www.who.int/healthsystems/topics/equity/en/ [verified 10 July 2018]

[79] World Health Organization (WHO) Regional Office for Europe Greening Health Systems. Copenhagen: WHO; 2013. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/236548/Greening-health-systems.pdf [verified 10 July 2018]

[80] Rice T, Unruh LY, Rosenau P, Barnes A, Saltman RB, van Ginneken E. Challenges facing the United States of America in implementing universal coverage. Bull World Health Organ 2014; 92 894–902.
| Challenges facing the United States of America in implementing universal coverage.Crossref | GoogleScholarGoogle Scholar |

[81] Mossialos E, Wenzl M, Osborn R, Anderson C, editors. International profiles of health care systems, 2014. The Commonwealth Fund; 2015 Available at: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2015_jan_1802_mossialos_intl_profiles_2014_v7.pdf [verified 8 June 2018].

[82] Martin D, Miller A, Quesnel-Vallée A, Caron N, Vissandjée B, Marchildon G. Canada’s universal health-care system: achieving its potential. Lancet 2018; 391 1718–35.
| Canada’s universal health-care system: achieving its potential.Crossref | GoogleScholarGoogle Scholar |

[83] O’Reilly J, Busse R, Häkkinen U, Or Z, Street A, Wiley M. Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Econ Policy Law 2012; 7 73–101.
| Paying for hospital care: the experience with implementing activity-based funding in five European countries.Crossref | GoogleScholarGoogle Scholar |

[84] Vogl M. Hospital financing: Calculating inpatient capital costs in Germany with a comparative view on operating costs and the English costing scheme. Health Policy 2014; 115 141–51.
| Hospital financing: Calculating inpatient capital costs in Germany with a comparative view on operating costs and the English costing scheme.Crossref | GoogleScholarGoogle Scholar |

[85] Darzi A. Better health and care for all. A 10-point plan for the 2020s. The Lord Darzi review of health and care. Final Report. London: Institute for Public Policy Research; 2018. Available at: http://apo.org.au/system/files/181346/apo-nid181346-951981.pdf [verified 3 August 2018]

[86] Travis D. The Travis Review. Final report. Increasing the capacity of the Victorian public hospital system for better patient outcomes. Melbourne: Department of Health; 2015.

[87] Garling P. Final report of the Special Commission of Inquiry. Acute care services in NSW public hospitals. Sydney: NSW Government; 2008.

[88] Bansemer A. Commission on Delivery of Health Services in Tasmania. Report to the Australian Government and the Tasmanian Government health ministers; 2014. Available at: https://stors.tas.gov.au/store/exlibris3/storage/2014/05/09/file_3/1240287.pdf [verified 19 June 2018].

[89] Audit Office of NSW. Medical equipment management in NSW public hospitals. Sydney: NSW Health; 2017. Available at: https://www.audit.nsw.gov.au/publications/latest-reports/medical-equipment-management [verified 17 July 2018].

[90] Baird MNT. Infrastructure statement 2012–13: budget paper No. 4. Sydney: NSW Government Treasury; 2012. p. 3–22.

[91] Berejiklian G. Infrastructure statement 2015–16: budget paper No.2. Sydney: NSW Government Treasury; 2015. Available at: https://www.treasury.nsw.gov.au/sites/default/files/pdf/2015-2016_Budget_Papers_BP2_Infrastructure_Statement.pdf [verified 17 July 2018].

[92] Berejiklian G. Infrastructure statement 2016–17: budget paper No.2. Sydney: NSW Government Treasury; 2016. Available at: https://www.treasury.nsw.gov.au/sites/default/files/pdf/2016-2017_Budget_Papers_BP2_Infrastructure_Statement.pdf [verified 17 July 2018].

[93] Eagar K, Garrett P, Lin V. Health planning: Australian perspectives. Crows Nest NSW: Allen & Unwin; 2001.

[94] Haas M. Continuing reform in NSW. Health Policy Monitor, [Internet]. 2010 10 June 2014; April 2010.

[95] Koff E. Annual report 2016–17: NSW Health. Sydney: NSW Government Department of Health; 2017. Available at: http://www.health.nsw.gov.au/annualreport/Pages/default.aspx [verified 17 July 2018].

[96] NSW Agency for Clinical Innovation. Clinical Guidelines. Sydney: NSW Government Agency for Clinical Innovation; 2017. Available at: https://www.aci.health.nsw.gov.au/resources/clinical-guidelines [verified 17 July 2018].

[97] NSW Auditor General. NSW Auditor General’s Report. Report on Health 2017. pp. 17–8.Sydney: Audit Office of NSW; 2017. Available at: https://www.audit.nsw.gov.au/publications/latest-reports/health-2017 [verified 17 July 2018].

[98] NSW Health. NSW State Health Plan: Towards 2021. Sydney: NSW Government; 2014. Available at: http://www.health.nsw.gov.au/statehealthplan/Publications/NSW-State-Health-Plan-Towards-2021.pdf [verified 17 July 2018].

[99] NSW Health. NSW Health Guide to the Role Delineation of Clinical Services. Sydney: Health System Planning and Investment Branch in conjunction with the Guide to the Role Delineation of Clinical Services Reference Group; 2016. Available at: http://www.health.nsw.gov.au/services/Publications/role-delineation-of-clinical-services.PDF [verified 17 July 2018].

[100] NSW Health. eHealth Strategy for NSW Health 2016–2026. Sydney: NSW Government Department of Health; 2016. Available at: http://www.health.nsw.gov.au/eHealth/Documents/eHealth-Strategy-for-NSW-Health-2016-2026.pdf [verified 17 July 2018].

[101] Perrottet D. Infrastructure statement 2017–18: budget paper No.2. Sydney: NSW Government Treasury; 2017. Available at: https://www.treasury.nsw.gov.au/sites/default/files/2017-09/2017-18%20Budget%20Paper%20No.%202%20-%20Infrastructure%20Statement_0.pdf [verified 26 July 2018].

[102] Victorian Auditor-General. ICT Strategic Planning in the Health Sector. Melbourne: Victorian Government Printer; 2017. Available at: https://www.audit.vic.gov.au/sites/default/files/20170524-Health-ICT-Planning.pdf [verified 26 July 2018].

[103] Department of Health and Human Services Victoria. Energy consumption and carbon emissions of hospitals. Melbourne: Victorian Government Department of Health; 2011. Available at: https://www2.health.vic.gov.au/getfile/?sc_itemid=%7bFBEDE0BF-A920-4E09- BAEE-0DF016A8E877%7d&title=Energy%20consumption%20and%20 carbon%20emissions%20of%20hospitals [verified 17 July 2018].

[104] Capital Projects and Service Planning. Capital Development Guidelines In: Victoria DoH, editor. Melbourne 2010.

[105] Department of Health and Human Services Victoria. Capital Investment Process. Melbourne: Victorian Government Department of Health; 2016. Available at: http://www.capital.health.vic.gov.au/Planning_and_evaluation/Capital_investment_process/ [verified 17 July 2018].

[106] Department of Health and Human Services Victoria. Hospital Capital Planning Module. Melbourne: Victorian Government Department of Health; 2016. Available at: http://www.capital.health.vic.gov.au/Project_proposals/Benchmarking/Hospital_capital_planning_module/ [verified 17 July 2018].

[107] Duckett S, Cuddihy M, Newnham H. A review of hospital safety and quality assurance in Victoria: discussion paper. Melbourne: Victorian Government Department of Health and Human Services; 2016. Available at: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/review-of-hospital-safety-and-quality-assurance-in-victoria-discussion-paper [verified 17 July 2018].

[108] Victorian Auditor-General. Public hospitals 2014–15 audit snapshot. Melbourne: Victorian Government Printer; 2015. Available at: https://www.audit.vic.gov.au/sites/default/files/20151112-Hospitals-PSA.pdf [verified 17 July 2018].

[109] Pallas T. State Capital Program 2015–16.Victorian Government Budget Paper No 4. Melbourne: Victorian Government Treasury; 2015. Available at: https://www.dtf.vic.gov.au/previous-budgets/2015-16-state-budget [verified 17 July 2018].

[110] Pallas T. State Capital Program 2016–17.Victorian Government Budget Paper No 4. Melbourne: Victorian Government Treasury; 2015. Available at: https://www.dtf.vic.gov.au/previous-budgets/2016-17-state-budget [verified 17 July 2018].

[111] Pallas T. State Capital Program 2017–18.Victorian Government Budget Paper No 4. Melbourne: Victorian Government Treasury; 2015. pp. 55–8. Available at: https://www.dtf.vic.gov.au/previous-budgets/2017-18-state-budget [verified 17 July 2018].

[112] Peake K. Annual report 2016–17 Victorian Department of Health and Human Services. Melbourne: Victorian Government Department of Health and Human Services; 2017. Available at: https://dhhs.vic.gov.au/sites/default/files/documents/201710/DHHS-annual-report-2016-17_20171016.pdf [verified 17 July 2018].

[113] Department of Health and Human Services Victoria. Sustainability in healthcare. Melbourne: Victorian Government Department of Health and Human Services; 2018. Available at: https://www2.health.vic.gov.au/hospitals-and-health-services/planning-infrastructure/sustainability [verified 17 July 2018].

[114] Victorian Auditor-General. Efficiency and Effectiveness of Hospital Services: High-value Equipment. Melbourne: Victorian Government Printer; 2015. Available athttps://www.audit.vic.gov.au/sites/default/files/20150225-Hospital-Equipment.pdf [verified 17 July 2018].

[115] Victorian Department of Health. Victorian Health Priorities Framework 2012–2022. Metropolitan Health Plan. Melbourne: Victorian Government Department of Health; 2011. Available at https://www2.health.vic.gov.au/about/publications/policiesandguidelines/vhpf-2012- 22-metro [verified 17 July 2018].

[116] Department of Health and Human Services Victoria. Benchmarking: Service Planning Data Input. Melbourne: Victorian Government Department of Health; 2016. Available at: http://www.capital.health.vic.gov.au/Project_proposals/Benchmarking/Service_Planning_data_input/ [verified 17 July 2018].

[117] Department of Health and Human Services Victoria. Statewide Health ICT Strategic Framework. Melbourne: Victorian Government Department of Health; 2015. Available at: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/Statewide%20Health %20ICT%20Strategic%20Framework [verified 17 July 2018].

[118] Queensland Government. State Budget 2012–13. Capital Statement Budget Paper No. 3. Brisbane: Queensland Treasury; 2012. pp. 14–5. Available at: https://s3.treasury.qld.gov.au/files/bp3-2012-13.pdf [verified 17 July 2018].

[119] Queensland Audit Office. Hospital Infrastructure Projects (Report 2: 2014–15). Brisbane: Queensland Audit Office; 2014. Available at: https://www.qao.qld.gov.au/reports-parliament/hospital-infrastructure-projects [verified 17 July 2018].

[120] Queensland Government. Queensland Budget 2015–16. Capital Statement Budget Paper No. 3. Brisbane: Queensland Treasury; 2015. Available at: https://s3.treasury.qld.gov.au/files/state-budget-2015-16-bp3.pdf [verified 17 July 2018].

[121] Queensland Government. Queensland Budget 2016–17 Capital Statement Budget Paper No.3. Brisbane: Queensland Treasury; 2016. Available at: https://s3.treasury.qld.gov.au/files/bp3-2016-17.pdf [verified 17 July 2018].

[122] Queensland Audit Office. Efficient and effective use of high value medical equipment (Report 10: 2016–17). Brisbane: Queensland Audit Office; 2017. Available at:https://www.qao.qld.gov.au/sites/all/libraries/pdf.js/web/viewer.html?file=https%3A%2F%2Fwww.qao.qld.gov.au%2Fsites%2Fqao%2Ffiles%2Freports%2Fefficient_and_effective_use_of_high_value_medical_equipment_report_10_2016-17_0.pdf [verified 17 July 2018].

[123] Queensland Department of Health. Guide to health service planning. Brisbane: Queensland Health; 2010. Available at: http://www.capital.dhs.vic.gov.au/Assets/Files/Q%20Guide%20to%20HSP_WEB%20vers_19Feb2010.pdf [verified 17 July 2018].

[124] Queensland Department of Health. Department of Health Strategic Plan 2014–18. Brisbane: Queensland Health; 2014. Available at: https://publications.qld.gov.au/dataset/strategic-plans-department-of-health/resource/73476e83-4092-4cf4-911d-b03da2eb538d [verified 17 July 2018].

[125] Queensland Department of Health. Guide to health service planning (version 3). Brisbane: Queensland Health; 2015. Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0025/443572/guideline-health-service-planning.pdf [verified 17 July 2018].

[126] Queensland Department of Health. eHealth Investment Strategy. Brisbane: Queensland Health; 2015. Available at: https://publications.qld.gov.au/dataset/ehealth-investment-strategy [verified 17 July 2018].

[127] Queensland Health. Sustainable Future Securing the future of great healthcare with efficient, effective, affordable and sustainable services. Brisbane: Queensland Health; 2017. Available at: https://www.health.qld.gov.au/cq/destination-2030/our-objectives/sustainable-future [verified 17 July 2018].

[128] Health Department of SA. South Australia’s Health Care Plan 2007–2016. Adelaide: Government of South Australia; 2007. Available at: http://www.sahealth.sa.gov.au/wps/wcm/connect/893b1180428de54db565b7e7eece1070/sahcp-sahealth-20072016.pdf?MOD=AJPERES&CACHEID=893b1180428de54db565b7e7eece1070 [verified 17 July 2018].

[129] Koutsantonis T. South Australia 2015–16. Budget Paper 4: Agency Statements. Adelaide: Government of South Australia; 2015. Available at: http://www.treasury.sa.gov.au/budget/current-budget/previous-budgets/budget-2015-16 [verified 17 July 2018].

[130] Health Department of SA. Delivering Transforming Health– Summary. Adelaide: Government of South Australia; 2014. Available at: http://www.sahealth.sa.gov.au/wps/wcm/connect/7ca5dd8043749205b338bff2cadc00ab/Delivering-Transforming-Health-Summary.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-7ca5dd8043749205b338bff2cadc00ab-m0LzZSq [verified 17 July 2018].

[131] Porter CWT. 2012–13 Budget. Budget Statements. Perth: WA Treasury, Government of Western Australia; 2012. p. 125.

[132] Wyatt B. 2017–18 Budget Paper No. 2. Budget Statements, Volume 1. Perth: WA Treasury, Government of Western Australia; 2017. pp. 129–30.

[133] WA Department of Treasury. 2015–16 Budget Paper No. 2. Budget Statements, Volume 1. Perth: WA Treasury, Government of Western Australia; 2015. Available at: https://www.ourstatebudget.wa.gov.au/2015-16/budget-papers/bp2/2015-16-wa-state-budget_bp2_vol1.pdf [verified 17 July 2018].

[134] WA Auditor General. Management of Medical Equipment. Perth: Office of the Auditor General of Western Australia; 2017. Available at: https://audit.wa.gov.au/wp-content/uploads/2017/05/report2017_08-MedicalEquipment.pdf [verified 17 July 2018].

[135] Reid M. A healthy future for Western Australians. Report of the Health Reform Committee. Perth: Health Department of WA; 2004.

[136] Department of Health WA. WA Health Clinical Services Framework 2014–2024. Perth: WA Department of Health; 2013. Available at: http://ww2.health.wa.gov.au/~/media/Files/Corporate/Reports%20and%20publications/Clinical%20Services%20Framework/Clinical_Framework_2014-2024.ashx [verified 17 July 2018].

[137] Auditor-General Tasmania. Report of the Auditor General No. 2 of 2015–16. Capital works programming and management. Hobart: Office of the Auditor General Tasmania; 2015. Available at: https://www.audit.tas.gov.au/wp-content/uploads/Capital-works-programming-and-management.pdf [verified 17 July 2018].

[138] Health and Human Services Tasmania. Supplement No. 1. Sustainability and the Tasmanian Health System. Hobart: Department of Health and Human Services Tasmania; 2016. https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0007/179053/OHS-OP01-Sustainability_vF_141208.pdf [verified 17 July 2018].

[139] Barr AAT. Australian Capital Territory Budget 2016–17. Budget Statements A. Canberra: ACT Treasury; 2016. Table 33, p. 24. Available at: https://apps.treasury.act.gov.au/__data/assets/pdf_file/0009/869976/A-Executive-Budget-Statements.pdf [verified 17 July 2018].

[140] Barr AAT. Australian Capital Territory Budget 2017–18. Budget Statements C. Canberra: ACT Treasury; 2017. Available at: https://apps.treasury.act.gov.au/__data/assets/pdf_file/0007/1069369/C-Budget-Statements.pdf [verified 17 July 2018].

[141] Victorian Department of Health. Victorian health priorities framework 2012–2022. Metropolitan health plan. 2011. Available at: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/vhpf-2012-22-metro [verified 19 June 2018].

[142] NSW Health. NSW State health plan. Towards 2021. Sydney: NSW Government; 2014. Available at: http://www.health.nsw.gov.au/statehealthplan/Publications/NSW-State-Health-Plan-Towards-2021.pdf [verified 8 June 2018].

[143] Queensland Health. Department of Health strategic plan 2014–18. Brisbane: Queensland Government; 2014. Available at: http://www.health.qld.gov.au/system-governance/strategic-direction/plans/doh-plan/ [verified 8 June 2018].

[144] Government of Western Australia. Department of Health. Annual report 2012–13. Perth: Government of WA; 2013. Available at: https://ww2.health.wa.gov.au/~/media/Files/Corporate/Reports%20and%20publications/Annual%20reports/annual_reports_2013_DOH.pdf [verified 19 June 2018].

[145] Medeiros J, Schwierz C. Efficiency estimates of health care systems. 2015. Available at: http://ec.europa.eu/economy_finance/publications/economic_paper/2015/pdf/ecp549_en.pdf [verified 8 June 2018].

[146] Anand S, Ammar W, Evans T, Hasegawa T, Kissimova-Skarbek K, Langer A, Lucas AO, Makubalo L, Marandi A, Meyer G, Podger A, Smith P, Wilbulpolprasert S. Report of the Scientific Peer Review Group on health systems performance assessment. In: Murray CJL, Evans DB, editors. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization; 2003. pp. 839–916.

[147] Greene W. Distinguishing between heterogeneity and inefficiency: stochastic frontier analysis of the World Health Organization’s panel data on national health care systems. Health Econ 2004; 13 959–80.
| Distinguishing between heterogeneity and inefficiency: stochastic frontier analysis of the World Health Organization’s panel data on national health care systems.Crossref | GoogleScholarGoogle Scholar |

[148] Hollingsworth B, Wildman J. The efficiency of health production: re-estimating the WHO panel data using parametric and non-parametric approaches to providing additional information. Health Econ 2003; 12 493–504.
| The efficiency of health production: re-estimating the WHO panel data using parametric and non-parametric approaches to providing additional information.Crossref | GoogleScholarGoogle Scholar |

[149] World Health Organization. Health impact assessment (HIA) glossary. 2013 Available at: http://www.who.int/hia/about/glos/en/index1.html [verified 8 June 2018].

[150] Álvarez A, Duran A. Spain’s hospital autonomy: muddling through the economic crisis. Eurohealth Observer 2013; 19 8–11.

[151] Barlow J, Roehrich JK, Wright S. De facto privatization or a renewed role for the EU? Paying for Europe’s healthcare infrastructure in a recession. J R Soc Med 2010; 103 51–5.
| De facto privatization or a renewed role for the EU? Paying for Europe’s healthcare infrastructure in a recession.Crossref | GoogleScholarGoogle Scholar |

[152] Bevan G, Karanikolos M, Exley J, Nolte E, Connolly S, Mays N. The four health systems of the United Kingdom: how do they compare? 2014. Available at: https://www.nuffieldtrust.org.uk/files/2017-01/4-countries-report-web-final.pdf [verified 8 June 2018].

[153] Blumenthal D. Wiring the health system – origins and provisions of a new federal program. N Engl J Med 2011; 365 2323–9.
| Wiring the health system – origins and provisions of a new federal program.Crossref | GoogleScholarGoogle Scholar |

[154] Gerkens S, Farfan MI, Stordeur S. Health systems in transition (HiT) profile of Belgium. Physical and human resources. 2016. Available at: http://www.hspm.org/countries/belgium25062012/livinghit.aspx?Section=4.1%20Physical%20resources&Type=Section#footnote18 [verified 8 June 2018].

[155] Organisation for Economic Cooperation and Development (OECD). OECD reviews of healthcare quality: Denmark. Executive summary, assessment and recommendations. 2013. Available at: https://www.oecd.org/els/health-systems/ReviewofHealthCareQualityDENMARK_ExecutiveSummary.pdf [verified 8 June 2018].

[156] Organisation for Economic Cooperation and Development (OECD). OECD economic surveys: Japan 2015. 2015. Available at: http://www.keepeek.com/Digital-Asset-Management/oecd/economics/oecd-economic-surveys-japan-2015_eco_surveys-jpn-2015-en#page3 [verified 8 June 2018].

[157] Organisation for Economic Cooperation and Development (OECD). OECD reviews of health care quality: Portugal 2015: raising standards. 2015. Available at: http://www.oecd.org/health/health-systems/Review-of-Health-Care-Quality-Portugal-Executive-Summary.pdf [verified 8 June 2018].

[158] Scheller-Kreinsen D, Quentin W, Busse R. DRG-based hospital payment systems and technological innovation in 12 European countries. Value Health 2011; 14 1166–72.
| DRG-based hospital payment systems and technological innovation in 12 European countries.Crossref | GoogleScholarGoogle Scholar |

[159] Ferré F, Ricciardi W. Italy. In: Maresso A, P Mladovsky, Thomson S, Sagan A, Karanikolos M, Richardson E, J Cylus, Evetovits T, Jowett M, Figueras J, Kluge H, editors. Economic crisis, health systems and health in Europe. Country experience. Maidenhead: Open University Press; 2014. pp. 414–18.

[160] Cohen J. Weighted kappa: nominal scale agreement provision for scaled disagreement or partial credit. Psychol Bull 1968; 70 213–20.
| Weighted kappa: nominal scale agreement provision for scaled disagreement or partial credit.Crossref | GoogleScholarGoogle Scholar |

[161] Richardson J. The Tasmanian hospital system: reforms for the 21st century. Report of the Expert Advisory Group review into key issues for public and private hospital systems in Tasmania. 2004. Available at: http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0004/8563/2004-06-Richardson-Report-v2.pdf [verified 8 June 2018].

[162] Forster P. Asset management and capital works planning to support service delivery. In Queensland Health systems review: final report. Brisbane: Queensland Health; 2005. pp. 269–89.

[163] Menadue J. Better choices, better health. Final report of the South Australian Generational Health Review. 2003. Available at: http://www.sahealth.sa.gov.au/wps/wcm/connect/f2f26480428ddf2ab41fb6e7eece1070/generationalhealthreviewreport-ce-0304.pdf?MOD=AJPERES&CACHEID=f2f26480428ddf2ab41fb6e7eece1070 [verified 8 June 2018].

[164] Leggat SG. Hospital planning: the risks of basing the future on past data. Health Inf Manag 2008; 37 6–14.
| Hospital planning: the risks of basing the future on past data.Crossref | GoogleScholarGoogle Scholar |

[165] Eyles J. From equalisation to rationalisation: public health care provision in New South Wales. Aust Geogr Stud 1985; 23 243–68.
| From equalisation to rationalisation: public health care provision in New South Wales.Crossref | GoogleScholarGoogle Scholar |

[166] Independent Hospital Pricing Authority. Annual report 2013–14. 2014. Available at: https://www.ihpa.gov.au/sites/g/files/net636/f/publications/ihpa_annual_report_2013-14.pdf [verified 8 June 2018].

[167] Australian Taxation Office (ATO). TR 2016/1 – Income tax: effective life of depreciating assets (applicable from 1 July 2016). ATO; 2016. Available at: https://www.ato.gov.au/law/view/document?docid=TXR/TR20161/NAT/ATO/00001&PiT=20160907000001 [verified 29 June 2018].

[168] Rumbold BE, Smith JA, Hurst J, Charlesworth A, Clarke A. Improving productive efficiency in hospitals: findings from a review of the international evidence. Health Econ Policy Law 2015; 10 21–43.
| Improving productive efficiency in hospitals: findings from a review of the international evidence.Crossref | GoogleScholarGoogle Scholar |

[169] Australasian Healthcare Infrastructure Alliance. Energy consumption and carbon emissions of hospitals. 2011. Available at: https://www2.health.vic.gov.au/getfile/?sc_itemid=%7bFBEDE0BF-A920-4E09-BAEE-0DF016A8E877%7d&title=Energy%20consumption%20and%20carbon%20emissions%20of%20hospitals [verified 8 June 2018].

[170] Burger B, Newman P. Hospitals and sustainability. Bentley: Curtin University of Technology, Curtin University Sustainability Policy Institute; 2010.

[171] Steering Committee for the Review of Government Service Provision. Report on Government Services 2016, Vol. E: Health. Canberra: Productivity Commission; 2016. Available at: http://www.pc.gov.au/research/ongoing/report-on-government-services/2016/health/rogs-2016-volumee-health.pdf [verified 8 June 2018].

[172] Mayston S, editor. Capital charges – the UK experience. Capital charging in the health sector-asset or liability? Sydney: Australian Department of Human Services and Health; 1995.

[173] Naylor C, Gregory S. Independent sector treatment centres. The Kings Fund; 2009. Available at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/briefing-independent-sector-treatment-centres-istc-chris-naylor-sarah-gregory-kings-fund-october-2009.pdf [verified 8 June 2018].

[174] Pollock AM, Dunnigan MG, Gaffney D, Price D, Shaoul J. Planning the ‘new’ NHS: downsizing for the 21st century. BMJ 1999; 319 179–84.
| Planning the ‘new’ NHS: downsizing for the 21st century.Crossref | GoogleScholarGoogle Scholar |

[175] World Bank. Fixing the public hospital system in China: China health policy notes. 2010. Available at: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1285186535266/FixingthePublicHospitalSystem.pdf [verified 8 June 2018].

[176] Rodríguez-Alvarez A, Knox Lovell CA. Excess capacity and expense preference behaviour in national health systems: an application to the Spanish public hospitals. Health Econ 2004; 13 157–69.
| Excess capacity and expense preference behaviour in national health systems: an application to the Spanish public hospitals.Crossref | GoogleScholarGoogle Scholar |

[177] World Health Organization (WHO). China–WHO country cooperation strategy 2013–2015. Bridging the past towards a new era of collaboration. 2013. Available at: http://www.who.int/countryfocus/cooperation_strategy/ccs_chn_en.pdf [verified 8 June 2018].

[178] Smith M, Saunders R, Stuckhardt L, McGinnis JM. Best care at lower cost: the path to continuously learning health care in America. 2012. Available at: https://www.nap.edu/catalog/13444/best-care-at-lower-cost-the-path-to-continuously-learning [verified 29 June 2018].

[179] Coye MJ, Kell J. How hospitals confront new technology. Health Aff (Millwood) 2006; 25 163–73.
| How hospitals confront new technology.Crossref | GoogleScholarGoogle Scholar |

[180] Or Z, Bellanger M. France: implementing homogeneous patient groups in a mixed market. In: Busse R, Geissler A, Quentin W, Wiley M, editors. Diagnosis-related groups in Europe. Moving towards transparency, efficiency and quality in hospitals. New York: McGraw-Hill; 2011. pp. 221–41.

[181] Duckett S, Breadon P. Controlling costly care: a billion-dollar hospital opportunity. Melbourne: Grattan Institute; 2014. Available at: https://grattan.edu.au/report/controlling-costly-care-a-billion-dollar-hospital-opportunity/ [verified 8 June 2018].

[182] Frost P. Public hospitals 2014–15 Audit snapshot. Auditor General Victoria. 2015. Available at: https://www.audit.vic.gov.au/report/public-hospitals-2014-15-audit-snapshot [verified 19 June 2018].

[183] Kerr R, Hendrie DV, Moorin R. Investing in acute health services: is it time to change the paradigm? Aust Health Rev 2014; 38 533–40.
| Investing in acute health services: is it time to change the paradigm?Crossref | GoogleScholarGoogle Scholar |

[184] Varabyova Y, Schreyogg J. International comparisons of the technical efficiency of the hospital sector: panel data analysis of OECD countries using parametric and non-parametric approaches. Health Policy 2013; 112 70–9.
| International comparisons of the technical efficiency of the hospital sector: panel data analysis of OECD countries using parametric and non-parametric approaches.Crossref | GoogleScholarGoogle Scholar |

[185] Joumard I, Andre C, Nicq C. Health care systems: efficiency and institutions. OECD Economics Department Working Paper No. 769. 2010. Available at: https://ssrn.com/abstract=1616546 [verified 8 June 2018].