{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T19:15:43Z","timestamp":1792782943085,"version":"4.5.0"},"reference-count":19,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Murdoch University","id":[{"id":"https:\/\/ror.org\/00r4sry34","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur J Health Econ"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>This study examines how digital finance, digital transformation, and governance quality jointly influence healthcare efficiency across emerging and high-income health systems. We assess whether digital innovations contribute to productivity improvements and whether institutional capacity conditions these effects.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study design<\/jats:title>\n                    <jats:p>We analyse a balanced panel of 13 countries over 2000\u20132023 using a multi-method empirical strategy. Baseline OLS and fixed- and random-effects models establish structural patterns, while the two-step system GMM corrects for endogeneity, persistence, and unobserved heterogeneity. Random Forest Trees (RFT) provide complementary predictive validation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data sources<\/jats:title>\n                    <jats:p>Healthcare efficiency, digital readiness, governance indices, and macroeconomic indicators were sourced from the World Bank, WHO, Global Findex, and national statistics, yielding 325 country-year observations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Principal findings<\/jats:title>\n                    <jats:p>Healthcare efficiency exhibits strong persistence over time. Digital finance and digital transformation significantly improve efficiency across all model specifications. Critically, governance quality amplifies these digital effects: interaction terms (GOV\u2009\u00d7\u2009DF, GOV\u2009\u00d7\u2009DT) remain robust in GMM and rank among the most influential predictors in the RFT model. Cross-country disparities in efficiency largely reflect differences in digital and institutional maturity rather than economic or demographic scale.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Digital tools can enhance healthcare efficiency, but their effectiveness depends on the institutional environment in which they are deployed. Strengthening governance capacity alongside digital investment is therefore essential for improving system-wide performance and advancing SDG 3. The combined econometric\u2013machine-learning approach provides robust causal and predictive evidence for policy design.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s10198-026-01994-5","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T14:18:33Z","timestamp":1790777913000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Digital transformation, governance multipliers, and healthcare efficiency: evidence from emerging and high-income health systems"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9848-6234","authenticated-orcid":false,"given":"Manoj","family":"Kumar M V","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4539-662X","authenticated-orcid":false,"given":"Prashanth B.","family":"S","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8369-6653","authenticated-orcid":false,"given":"Ariful","family":"Hoque","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9220-8604","authenticated-orcid":false,"given":"Nasser","family":"Al Muraqab","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4027-3508","authenticated-orcid":false,"given":"Immanuel Azaad","family":"Moonesar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6877-8466","authenticated-orcid":false,"given":"Udo Christian","family":"Braendle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8110-5423","authenticated-orcid":false,"given":"Ananth","family":"Rao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"1994_CR1","doi-asserted-by":"publisher","first-page":"1023","DOI":"10.1007\/s10198-024-01753-4","volume":"26","author":"J Arenas-Gait\u00e1n","year":"2025","unstructured":"Arenas-Gait\u00e1n, J., P. E. Ram\u00edrez-Correa, and L. J. Callarisa Fiol. 2025. Medical teleconsultation from the patient\u2019s perspective: Demographic segmentation. European Journal of Health Economics 26:1023\u20131039. https:\/\/doi.org\/10.1007\/s10198-024-01753-4.","journal-title":"European Journal of Health Economics"},{"key":"1994_CR2","doi-asserted-by":"publisher","unstructured":"Brunello, G., et al. (2020). Reducing the cost of remoteness: Community-based telemedicine and remoteness cost. Journal of Health Economics, 72\u201373. https:\/\/doi.org\/10.1016\/j.jhealeco.2019.102345","DOI":"10.1016\/j.jhealeco.2019.102345"},{"key":"1994_CR3","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2022.102581","volume":"82","author":"JH Cantor","year":"2022","unstructured":"Cantor, J. H., R. K. McBain, M. F. Pera, D. M. Bravata, and C. M. Whaley. 2022. The impact of the COVID-19 pandemic and policy response on health care utilization: Evidence from county-level medical claims and cellphone data. Journal of Health Economics 82 : 102581. https:\/\/doi.org\/10.1016\/j.jhealeco.2022.102581.","journal-title":"Journal of Health Economics"},{"key":"1994_CR4","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2022.787135","volume":"10","author":"A Gentili","year":"2022","unstructured":"Gentili, A. 2022. The cost-effectiveness of digital health interventions. Frontiers in Public Health 10 : 787135. https:\/\/doi.org\/10.3389\/fpubh.2022.787135.","journal-title":"Frontiers in Public Health"},{"key":"1994_CR5","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1186\/s12911-023-02194-4","volume":"23","author":"M Haimi","year":"2023","unstructured":"Haimi, M., et al. 2023. The paradoxical effect of telemedicine on healthcare disparities: A narrative review. BMC Medical Informatics and Decision Making 23:95. https:\/\/doi.org\/10.1186\/s12911-023-02194-4.","journal-title":"BMC Medical Informatics and Decision Making"},{"key":"1994_CR6","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2020.102365","volume":"73","author":"C Herrera-Almanza","year":"2020","unstructured":"Herrera-Almanza, C., and M. F. Rosales-Rueda. 2020. Reducing the cost of remoteness: Community-based health interventions and fertility choices. Journal of Health Economics 73 : 102365. https:\/\/doi.org\/10.1016\/j.jhealeco.2020.102365.","journal-title":"Journal of Health Economics"},{"issue":"7","key":"1994_CR7","doi-asserted-by":"publisher","first-page":"1079","DOI":"10.1007\/s10198-022-01503-4","volume":"23","author":"P Kanavos","year":"2022","unstructured":"Kanavos, P., M. Vogelsang, M. Haig, and V. Kolovou. 2022. Challenges for health systems seeking to embrace virtual health care for population health. European Journal of Health Economics 23 (7): 1079\u20131083. https:\/\/doi.org\/10.1007\/s10198-022-01503-4.","journal-title":"European Journal of Health Economics"},{"key":"1994_CR8","doi-asserted-by":"publisher","DOI":"10.1007\/s10198-025-01788-1","author":"J Kwon","year":"2025","unstructured":"Kwon, J., J. Mensah, R. Milne, J. Petrie, and B. Guthrie. 2025. Health economic outcomes and national economic impacts associated with Long COVID in England and Scotland. European Journal of Health Economics. https:\/\/doi.org\/10.1007\/s10198-025-01788-1.","journal-title":"European Journal of Health Economics"},{"key":"1994_CR9","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2022.102665","volume":"85","author":"N Edward Okeke","year":"2022","unstructured":"Okeke, N Edward. 2022. Playing defense? Health care in the era of Covid. Journal of Health Economics 85 : 102665. https:\/\/doi.org\/10.1016\/j.jhealeco.2022.102665.","journal-title":"Journal of Health Economics"},{"key":"1994_CR10","doi-asserted-by":"publisher","DOI":"10.2174\/0117450179279732231211110248","volume":"21","author":"DR Petretto","year":"2024","unstructured":"Petretto, D. R., et al. 2024. Telemedicine, e-health, and digital health equity: A scoping review. International Journal of Environmental Research and Public Health 21 : e17450179279732. https:\/\/doi.org\/10.2174\/0117450179279732231211110248.","journal-title":"International Journal of Environmental Research and Public Health"},{"key":"1994_CR11","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2021.102529","volume":"80","author":"L S\u00e1","year":"2021","unstructured":"S\u00e1, L., and O. R. Straume. 2021. Quality provision in hospital markets with demand inertia: The role of patient expectations. Journal of Health Economics 80 : 102529. https:\/\/doi.org\/10.1016\/j.jhealeco.2021.102529.","journal-title":"Journal of Health Economics"},{"issue":"10","key":"1994_CR12","doi-asserted-by":"publisher","DOI":"10.2196\/17298","volume":"22","author":"CL Snoswell","year":"2020","unstructured":"Snoswell, C. L., et al. 2020. Determining if telehealth can reduce health system costs: A systematic review. Journal of Medical Internet Research 22 (10) : e17298. https:\/\/doi.org\/10.2196\/17298.","journal-title":"Journal of Medical Internet Research"},{"key":"1994_CR13","doi-asserted-by":"publisher","DOI":"10.1016\/j.heliyon.2022.e09766","volume":"8","author":"Lee-Ying Tay","year":"2022","unstructured":"Tay, Lee-Ying., Hen-Toong. Tai, and Gek-Siang. Tan. 2022. Digital financial inclusion: A gateway to sustainable development. Heliyon 8 : e09766. https:\/\/doi.org\/10.1016\/j.heliyon.2022.e09766.","journal-title":"Heliyon"},{"key":"1994_CR14","doi-asserted-by":"publisher","first-page":"993","DOI":"10.1007\/s10198-017-0947-x","volume":"19","author":"LI van Lier","year":"2018","unstructured":"van Lier, L. I., J. E. Bosmans, H. P. J. van Hout, M. J. J. Mangen, M. J. Postma, and G. A. de Wit. 2018. Consensus-based cross-European recommendations for the identification, measurement, and valuation of costs in economic evaluations: A European Delphi study. European Journal of Health Economics 19:993\u20131008. https:\/\/doi.org\/10.1007\/s10198-017-0947-x.","journal-title":"European Journal of Health Economics"},{"key":"1994_CR15","volume-title":"Global strategy on digital health 2020\u20132025","author":"World Health Organization","year":"2021","unstructured":"World Health Organization. 2021. Global strategy on digital health 2020\u20132025. Geneva: WHO."},{"key":"1994_CR16","doi-asserted-by":"publisher","DOI":"10.2196\/53500","volume":"26","author":"N Zakiyah","year":"2024","unstructured":"Zakiyah, N., et al. 2024. Economic evaluations of digital health interventions for chronic disease management: A systematic review. Journal of Medical Internet Research 26 : e53500. https:\/\/doi.org\/10.2196\/53500.","journal-title":"Journal of Medical Internet Research"},{"key":"1994_CR17","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2023.102780","volume":"90","author":"D Zeltzer","year":"2023","unstructured":"Zeltzer, D., L. Einav, J. Rashba, Y. Waisman, M. Haimi, and R. D. Balicer. 2023. Adoption and utilization of device-assisted telemedicine. Journal of Health Economics 90 : 102780. https:\/\/doi.org\/10.1016\/j.jhealeco.2023.102780.","journal-title":"Journal of Health Economics"},{"key":"1994_CR18","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2024.1397560","volume":"12","author":"Y Zhang","year":"2024","unstructured":"Zhang, Y., K. Li, Y. Pang, and P. C. Coyte. 2024. The role of digital financial inclusion in China on urban\u2014rural disparities in healthcare expenditures. Frontiers in Public Health 12 : 1397560.","journal-title":"Frontiers in Public Health"},{"key":"1994_CR19","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-024-57788-3","volume":"14","author":"X Zhao","year":"2024","unstructured":"Zhao, X., S. Wu, B. Yan, et al. 2024. New evidence on the real role of digital economy in influencing public health efficiency. Scientific Reports 14 : 7190. https:\/\/doi.org\/10.1038\/s41598-024-57788-3.","journal-title":"Scientific Reports"}],"container-title":["The European Journal of Health Economics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10198-026-01994-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s10198-026-01994-5","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10198-026-01994-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T14:18:34Z","timestamp":1790777914000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s10198-026-01994-5"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":19,"alternative-id":["1994"],"URL":"https:\/\/doi.org\/10.1007\/s10198-026-01994-5","relation":{},"ISSN":["1618-7598","1618-7601"],"issn-type":[{"value":"1618-7598","type":"print"},{"value":"1618-7601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]},"assertion":[{"value":"17 December 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"2 September 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 September 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This study used\u00a0publicly available, fully anonymized secondary data, which contains no identifiable personal information. As such, this study was deemed\u00a0exempt from institutional ethics review, and no informed consent was required.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable. No individual-level clinical images or identifiable data are included in this manuscript.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare that they have\u00a0no known competing financial interests or personal relationships\u00a0that could have appeared to influence the work reported in this paper.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}]}}