Abstract
Background: In the context of serious concerns over the affordability of healthcare, various authors and international
policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is
typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are
insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against
poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights
from other, complementary theories are needed.
Methods: A realist review method was adopted involving 3 steps: first, drawing upon complementary theories from the
EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed
to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare
purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons
relevant to 3 key policy objectives taken from the international health policy literature. Texts were included if they
provided relevant empirical data and met specified standards of rigour and robustness.
Results: A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for
clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patientpurchaser
interaction. Lessons for government stewardship included: the need for health strategy to contain specific
targets to incentivise purchasers to align with national policy objectives, and for national government actors to build
close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for
provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may
also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration
needed to drive performance improvement.
Conclusion: Using complementary theories suggests a range of general policy lessons for strategic purchasing in
healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy
in a variety of healthcare systems, country settings and purchasing process phases.