Efficiency and productivity of community rehabilitation centres during service expansion in Shanghai, China: a longitudinal data envelopment analysis

In the crowded landscape of modern healthcare, a quiet but critical challenge is growing: how to deliver rehabilitation services to the millions of people recovering from stroke, injury, or chronic illness without wasting the resources meant to help them. As populations age and the need for long-term care rises, health systems face a constant tension between building more capacity and ensuring that every new hospital bed, piece of equipment, and hired therapist actually translates into better patient outcomes. This is not merely a question of having enough supplies; it is about the intricate mechanics of how those supplies are used. When a community adds more staff or expands its treatment rooms, does the quality of care improve proportionally, or does the system become cluttered and less effective? To answer this, researchers look at the relationship between what goes into a service—money, space, and people—and what comes out, such as the number of patients treated and their recovery rates. The goal is to find the sweet spot where resources are converted into care with maximum effectiveness, a balance that becomes increasingly difficult to maintain as systems expand rapidly.

In Shanghai, China, where the demand for community-based rehabilitation has surged, a team of researchers set out to examine exactly what happens when a network of local health centers grows. Between 2020 and 2024, the city invested heavily in its community rehabilitation infrastructure, adding new equipment, expanding treatment areas, and hiring more staff. The researchers wanted to know if this expansion made the centers more efficient or if the rapid growth created bottlenecks that slowed them down. They tracked 48 community centers over these five years, looking at the raw data of their daily operations: the value of their medical machinery, the square footage of their treatment floors, the number of full-time workers, and the volume of patients they served. By comparing these inputs against the outputs—such as the number of visits, the success of treatments, and patient satisfaction scores—the team could measure how well each center was performing relative to the best possible performance observed during that time.

The results revealed a story of significant growth that did not immediately translate into better efficiency. Over the five-year period, the centers saw their equipment value rise by more than 80 percent, their treatment space expand by nearly 66 percent, and their workforce grow by almost 88 percent. Despite this massive injection of resources, the overall efficiency of the system actually declined. In 2020, the average center was operating at a certain level of effectiveness, but by 2024, that average had dropped significantly. The data showed that while the centers were bigger and busier, they were not converting their new resources into care as effectively as they had before. A major part of this decline was due to the centers becoming too large for their current management capabilities; more than 70 percent of the centers were operating at a size where adding more resources actually yielded diminishing returns. It was as if the centers had outgrown their ability to coordinate their own activities, leading to a situation where having more staff or more machines did not result in a proportional increase in successful patient recoveries.

The study also looked at whether connecting these community centers with larger hospitals through formal partnerships and referral systems helped improve performance. The idea was that if a local center could easily send a patient to a specialist hospital and get them back, or if they shared staff and knowledge, the local center would become more efficient. The data showed that participation in these medical alliances and the use of two-way referrals did increase substantially during the study period. However, the researchers found no clear evidence that simply joining these networks or having a referral pathway in place made a specific center more efficient. The act of being connected did not automatically fix the internal inefficiencies. In fact, the centers that adopted these integration measures did not show a measurable improvement in their ability to turn resources into care compared to those that did not. This suggests that the structural labels of "being part of a network" are less important than the actual day-to-day work of transferring skills, managing patient flow, and ensuring that referrals are completed successfully.

Perhaps the most telling finding was about the nature of the productivity loss. The researchers broke down the decline into two parts: one related to how well the centers managed their existing operations, and another related to the movement of the "frontier" of best practice. They found that the biggest drop in productivity came from a shift in what was considered the best possible performance across the entire system, rather than just individual centers getting worse at their jobs. This implies that the rapid expansion and the disruptions of the pandemic period may have shifted the baseline of what is achievable, or that the high-performing centers struggled to maintain their lead during a time of rapid change. While the centers recovered in terms of patient numbers after 2022, the efficiency gains did not keep pace with the resource growth. The study concludes that simply building more facilities or signing up for network memberships is not enough. Instead, health leaders need to focus on the specific internal processes of each center, ensuring that staff are trained to handle the new scale of operations and that referral pathways are not just administrative checkboxes but functional, closed loops that actually move patients through the system. The path forward requires moving away from broad construction targets and toward a more nuanced approach that diagnoses the unique constraints of each center and measures success by the actual completion of care pathways, not just the size of the building.