{ "background": "District hospitals are critical nodes in Rwanda's healthcare system, yet systematic evaluations of their operational efficiency remain limited. Existing analyses often fail to account for the hierarchical structure of health service data, potentially leading to biased estimates of performance drivers.", "purpose and objectives": "This review critically evaluates the application of multilevel regression modelling for assessing efficiency in Rwandan district hospitals. It aims to synthesise methodological approaches, identify key determinants of efficiency, and propose a robust analytical framework for future health systems research.", "methodology": "A systematic search identified peer-reviewed studies employing regression techniques to analyse hospital efficiency. Methodological rigour was appraised, with a focus on model specification to handle clustered data. The proposed core model is a three-level random intercepts model: $Efficiency{ijk} = \\beta0 + \\beta X{ijk} + u{k} + v{jk} + e{ijk}$, where $u{k}$ and $v{jk}$ are random effects for province and hospital, respectively, and robust standard errors are recommended for inference.", "findings": "The synthesis indicates that studies incorporating multilevel structures consistently identify significant variation in efficiency attributable to hospital-level factors, with bed occupancy rate being a positively correlated driver in most models. A key theme is that failing to account for data hierarchy underestimates the standard errors of catchment-area characteristics, such as poverty prevalence, by up to 30%.", "conclusion": "Multilevel regression provides a statistically sound framework for evaluating district hospital efficiency, offering insights obscured by single-level analyses. Its adoption is crucial for generating reliable evidence to inform resource allocation.", "recommendations": "Future research should routinely employ multilevel models with random effects. Policymakers should support the collection of standardised, hierarchical data on hospital inputs, outputs, and contextual factors to enable these advanced analyses.", "key words": "health systems research, efficiency analysis, hierarchical linear models, random effects, health policy, sub-Saharan Africa", "contribution statement":