Birmingham Business School, University of Birmingham, Birmingham, UK.
Health Services Management Centre, University of Birmingham, Birmingham, UK.
Int J Health Policy Manag. 2019 Jan 1;8(1):4-17. doi: 10.15171/ijhpm.2018.93.
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.
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.
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.
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.
在人们对医疗保健的可负担性严重关切的背景下，许多作者和国际政策机构建议，战略采购是改善卫生系统绩效的关键手段。此类建议通常以组织经济学（EOO）的理论为依据。本文认为，这些理论不足以全面理解医疗保健中的战略采购，因为它们侧重于防范绩效不佳，而忽略了提高绩效所需的协调和适应。我们认为需要其他互补理论的见解。
采用了现实主义审查方法，共分 3 个步骤：首先，借鉴组织经济学和组织间关系（IOR）视角中的互补理论，制定了一个理论解释框架来指导审查；其次，有针对性地在学术数据库中搜索解决医疗保健采购问题的相关文献；最后，对选定的文本进行定性分析，并对结果进行主题综合，重点关注从国际卫生政策文献中提取的 3 个关键政策目标的相关经验教训。只有提供相关经验数据并符合特定严谨性和稳健性标准的文本才会被纳入最终分析。
最终纳入了 58 篇分析文本。增强患者权能的经验教训包括：需要为患者明确界定权利和采购者的责任，并通过患者与采购者之间的定期互动来实施这些权利和责任。政府管理的经验教训包括：需要卫生战略包含具体目标，以激励采购者与国家政策目标保持一致，需要国家政府行为者与采购者建立密切、信任的关系，以便获取有关需求和优先事项的当地知识。提高提供者绩效的经验教训包括：提供者决策自主权可能推动创新和资源的有效利用，但也可能为机会主义创造空间，相互依存可能是激励协作以推动绩效提升的最佳权力结构。
使用互补理论为医疗保健中的战略采购提供了一系列一般性政策经验教训，但需要进一步的实证工作来探索这些经验教训在各种医疗保健系统、国家背景和采购过程阶段对政策的实际指导作用有多大。
