Managerial autonomy and hospital performance: evidence from the Spanish National Health System

PURPOSE: This study examines whether hospitals with and without managerial autonomy operate under distinct production technologies and achieve different efficiency outcomes. It also analyses whether they face differing structural or technological constraints within a universally accessible, publicly funded health system. DESIGN/METHODOLOGY/APPROACH: A dynamic metafrontier data envelopment analysis framework is applied to a panel of 213 general hospitals within the Spanish National Health System over seven years. FINDINGS: The results indicate that hospitals with managerial autonomy exhibit higher technical efficiency, operate closer to the system-wide potential frontier and function under distinct production technologies compared with traditional hospitals governed by public administration. These patterns remain largely stable over the period analysed. PRACTICAL IMPLICATIONS: Organisational and governance arrangements are strongly associated with differences in hospital performance. Greater managerial flexibility is related to fewer structural constraints on efficiency, even within a common regulatory and financing framework. These findings are relevant for health system managers and policymakers concerned with hospital governance and organisational design. ORIGINALITY/VALUE: This study contributes to the literature by analysing managerial autonomy as a source of technological heterogeneity in hospitals within a universally accessible, publicly funded health system. Applying a dynamic metafrontier data envelopment analysis framework provides new empirical evidence on the relationship between organisational and governance arrangements and efficiency, as well as on the structural conditions in which efficiency is observed, offering insights into the ongoing debate on hospital autonomy and governance.