The comparative study of strategic purchasing of health services in selected countries: A Review Study

Abstract

Introduction: strategic purchasing is the constant search for achieving the best method through deciding on what to purchase, how to do it, and choosing service providers in a way that maximizes the health system performance to the desired level. In other words, strategic purchasing is defined as interventions that enhance system's accountability and causes financial balance. Methods: This study is explained as a comparative study with the purpose of strategic purchasing of health services in the world. In this study, 13 databases and search engines with relating key words have been searched in published papers of national and international journals from 2000 to 2016. CAPS tool is used to ensure the reliability of the paper. The obtained information was then extracted and exploited in the summarized form of data. Results: Findings of the study indicate that countries have considered several factors effective in strategic purchasing of health services. The quality and purchasing with the reasonable price were referred in 7 studies, motivating factors in 6 studies, interventions on the supply side in 7 studies (manufacturers), interventions on the demand side in 8 studies (recipients and purchasers), and transportation and resource allocation in 4 studies. Conclusion: According to the World Health Organization report in 2000 and the results of studies, countries will be required to use strategic purchasing of services for financing and optimal and equitable use of health services that using countries experiences will be very beneficial in this field. Therefore, studying in other areas is recommended.

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ORIGINAL ARTICLE
Bali Medical Journal (Bali Med J) 2018, Volume 7, Number 1: 1-6
P-ISSN.2089-1180, E-ISSN.2302-2914
1
Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj
CrossMark
Published by DiscoverSys
ABSTRACT
Introduction: strategic purchasing is the constant search for
achieving the best method through deciding on what to purchase,
how to do it, and choosing service providers in a way that maximizes
the health system performance to the desired level. In other words,
strategic purchasing is defined as interventions that enhance system’s
accountability and causes financial balance.
Methods: This study is explained as a comparative study with the
purpose of strategic purchasing of health services in the world. In
this study, 13 databases and search engines with relating keywords
have been searched in published papers of national and international
journals from 2000 to 2016. CAPS tool is used to ensure the reliability of
the paper. The obtained information was then extracted and exploited
in the summarized form of data.
Results: Findings of the study indicate that countries have considered
several factors effective in strategic purchasing of health services. The
quality and purchasing with the reasonable price were referred in
7 studies, motivating factors in 6 studies, interventions on the supply
side in 7 studies (manufacturers), interventions on the demand side in
8 studies (recipients and purchasers), and transportation and resource
allocation in 4 studies.
Conclusion: According to the World Health Organization report
in 2000 and the results of studies, countries will be required to
use strategic purchasing of services for financing and optimal and
equitable use of health services that using countries experiences will
be very beneficial in this field. Therefore, studying in other areas is
recommended.
Keyword: comparative Study, strategic purchasing, health services.
Cite This Article: Abedi, G., Shojaee, J., Bastani, P., Kabir, M.J., Yazdani, J. 2018. The comparative study of strategic purchasing of health services
in selected countries: A review study. Bali Medical Journal 7(1): 1-6. DOI:10.15562/bmj.v7i1.602
The comparative study of strategic purchasing of
health services in selected countries: A review study
Ghasem Abedi,1* Jalil Shojaee,2 Peivand Bastani,3 Mohammad Javad Kabir,4
Jamshid Yazdani1
INTRODUCTION
In 2000, the World Health Organization proposed
a new approach to look at the health system in
its annual report and enumerated this system
as a set of four main functions (custodianship,
creating resources, supplying nancial resources,
and service provision) and three main objectives
(health, equity in nancial cooperation and meet-
ing the non-medical expectations of people). In
this context, the role of the insurance system was
considered as one of the most important role-play-
ers in the system, and strategic purchasing of
health services was introduced with the purpose of
protecting people against the nancial risk resulting
from disease.1 Strategic purchasing is the constant
search for achieving the best method through
deciding on what to purchase, how to do it, and
choosing service providers in a way that maximizes
the health system performance to the desired level.2
On the other hand, strategic purchasing is one of
the main components of promoting health system
performance which ideally it can increase the e-
ciency, ecacy, and accountability. Moreover, it
has a signicant role in the health care system to
achieve public health goals and the broader goals
of social justice.3 In contrast, passive purchas-
ing means predetermined budgeting or settling
presented bills.4 In active purchasing method (stra-
tegic), drawing up a contract provides the most
basic interaction part of purchaser and provider.5
At the same time, the growth of medical technol-
ogy, population growth and the change of lifestyle
towards industrialization, an increase in physical
and nancial access, individual’s awareness level of
health services, and the emergence of new diseases
have accompanied the health services cost with an
increasing growth.6 On the other hand, evidence
suggests that the main weakness of nancing in
the current health system of countries is purchas-
ing services by governmental organizations from
the private sector at several times higher than the
approved rate which this can lead to an increase in
inequality.7
e results of Branson’s study indicate that
around 30 percent of Medicare expenditures, as
one of the biggest purchasers of health services
in America, has been unnecessary or is spent on
purchasing expensive services. However, with the
shi in approach from traditional purchasing to
1Associated professors, Health
Sciences Research Center, School of
Health, Mazandaran University of
Medical Sciences, Sari, Iran
2Ph.D. of student, Health Sciences
Research Center, School of Health,
Mazandaran University of Medical
Sciences, Sari, Iran
3Assistant Professor, School
of Management and Medical
Information Sciences, Shiraz
University of Medical Sciences,
Shiraz, Iran
4Assistant Professor, Health
Management and Social Research
Center, Gorgan University of
Medical Sciences, Gorgan, Iran
*Correspondence to: Ghasem Abedi,
Associated professors, Health
Sciences Research Center, S chool of
Health, Mazandaran University of
Medical Sciences, Sari, Iran
iq134589@yahoo.com
Received: 2017-04-23
Accepted: 2017-09-28
Published: 2017-09-30
Volume No.: 7
Issue: 1
First page No.: 1
P-ISSN.2089-1180
E-ISSN.2302-2914
Doi: http://dx.doi.org/10.15562/bmj.v7i1.602
ORIGINAL ARTICLE

2Published by DiscoverSys | Bali Med J 2018; 7(1): 1-6 | doi: 10.15562/bmj.v7i1.602
ORIGINAL ARTICLE
strategic purchasing models, Medicare and other
purchaser institutions will be able to increase access
to high-quality services by using competitive tools
and cause the improvement of quality and patients’
satisfaction.8 e experiences obtained from
purchasing and its successful use in developing
countries were considered as a tool for developing
and promoting performance. Due to the constant
limitation of resources in the area of health and
still, the needs are unlimited on the other hand, the
necessity of prioritization to cover more important,
eective and vital services of health area in the
category of services sponsored by the government
is considered as an important necessity.9 One of the
ways to deal with this challenge is adopting a strat-
egy that not only can control costs but also guaran-
tees services purchasing with a desirable quality.10
According to what is stated about the advantages
and the importance of strategic purchasing, it seems
that a thorough and comprehensive study of strate-
gic purchasing of health services in other countries
and applying their experiences should be addressed
before anything done in this eld so that the most
suitable and eective health service be purchased
using this method and better allocation of resources.
Although there are dierent evidence on increasing
eectiveness and equality promotion, access, and
satisfaction with the establishment of strategic
purchasing in the health section,2,11,12,13 there will be
practically no achievement in its implementation
without the knowledge about the experiences and
factors aecting the strategic purchasing of health
services in other countries.erefore, the present
study is carried out with the aim of familiarity with
the experiences of other countries in this eld and
identifying the most important inuencing factors.
METHODE
e current study is a comparative study with the
purpose of strategic purchasing of health services.
In this study, in order to nd published studies
electronically from 2000 to 2016, published papers
in national and international journals indexed
in Google’s databases, Google Scholar, PubMed,
Proquest, EBSCO, Science Direct, Scopus, Web
of Science and Persian keywords through Persian
databases such as Magiran, scientic database of
information and scientic documents center in
Iran, conferences in Iran, and iranmedex are entered
into studies. Also, studies which were performed
in the eld of purchasing and strategic purchasing
of services in non-health area were excluded from
the study because of incompatibility with the aim
of the research was used. In order to achieve the
full text of related papers or their abstracts, Persian
and English keywords by incorporating keywords,
original and sensitive have been used such as:
Resource allocation and purchasing OR Resource
allocating and purchasing strategic Purchasing
OR strategic purchase OR Strategic Purchases
Healthcare OR Healthcare system OR Healthcare
industry OR Medical service OR Medical care OR
hospital.
e reference list of studies was also examined
for increasing the sensitivity and choosing a greater
number of studies that the researchers couldn’t
get through the database. Search evaluation was
performed by one of the researchers randomly, and
it was determined that not a study was removed.
e instrument used in this study was data
extraction forms from previous studies (data collec-
tion form). ese forms were used to preserve the
integrity, reduce biases and increase the reliability
and validity of the comprehensive review.11 For this
purpose, rst the original list of keywords appropri-
ate to the purpose of this study was selected in both
English and Persian, and then they were searched
in the above databases. Finally, data collection form
was lled out based on retrieved data sources.
Aer a search by using mentioned keywords,
840papers were obtained from databases and search
engines. ese topics were rst classied, and then
unrelated topics were excluded so that at this stage
525 relevant topic were identied and 315 topics
were excluded as irrelevant. In the next step, the
abstracts of relevant papers to 525 mentioned papers
were reread to identify the most relevant papers’
abstract on study’s goal. At the nal stage, the full
text of 53 selected papers was investigated so that
papers’ goals were rst examined. If they meet the
present comprehensive review study, papers’ quality
will be studied with CASP tool. Finally, 19 papers
were conrmed following this method and their
information was recorded on the data forms.
Aer collecting the considered data from
obtained papers, the ndings were integrated based
on the data extraction forms, and according to it
the most important points inuencing strategic
purchasing of health services were determined and
classied.
RESULT
e results of the current study from reviewing the
literature indicate that numerous factors have been
eective in the infrastructure of strategic purchasing
of countries’ health services that can be classied in
6major and minor infrastructures. Among the major
infrastructures are the following: 1. Purchasers and
consumers (demand side), 2. Manufacturer (supply
side), 3. Interventions in purchasing, 4. Incentives,
5. Price interventions, and 6. Structure. Minor infra-
structures include the following items:

3
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ORIGINAL ARTICLE
Table 1 Conducted researchers
Research
Locations The Results of the Research
Type of
Research
Research
Time Researcher
America Identifying strategic purchasing of services include: the nature of the
services purchased services, reducing uncertainty and purchasing
risk mechanisms services to choose the best supplier and service
provider
Mixed
(quantitative and
qualitative)
2004 Yae z
Northern
European
countries
Health service providers, drawing up contracts, payment
mechanisms, hierarchical structure, the supply of nancial resources,
ownership rules and regulations, the allocation of resources as the
most important component of the strategic purchasing
review 2005 Figores
America e most important strategic purchasing variables of primary
and secondary cases suppliers (doctors, hospitals, pharmacies)
distributors (wholesalers and retailers), service purchasers (public
and private insurance) and incentives for change the behavior of
suppliers
Qualitative, case
study
2007 Ford and Hagaz
e World Bank 9 eective components of strategic purchasing of health services
were introduced: the allocation of resources, organizational
structure, users of purchasing services, service providers, the price
of paying mechanism, priority, purchasing policy and organizational
environment
Data collection
form
2007 Perker
Canada Identifying the supply side interventions, interventions by the
demand, the price of strategic thinking, and nally a high-quality
and cost-eectiveness of the appropriate services for the elderly as
the most important component of purchasing home care services
2008 Williams
Germany e introduction of 4 components as the important components of
the strategic purchasing of health services: health service providers
(with the characteristics of the competition, independence, and
accountability). Appropriate purchasing organizations (correct
purchaser and multiple purchases), appropriate contracts (cost
eective, evidence based and volumetric) and the Mechanism of
payment
A review and
descriptive study
2008 Bos
England e emphasis on the supply side interventions, price performance,
organizational capabilities and nancial motives as the most
important component of the strategic and value-based purchasing
equipment
2008 Robinson
Spain e introduction of the most important component of the strategic
purchasing of health services eective on the two general categories
of expansion of suppliers and the purchasing performance (includes
variables below cost, quality, transportation, and satisfaction)
2009 Sanchez
France e common goal of all pharmaceutical reforms, moderating costs
spent for medicines and ensuring the existence of a universal cover of
services package, meanwhile strategic purchasing medication as the
perfect lever for the eectiveness of this reforms
2010 Sarmant
Germany Identifying four major area, strategic purchasing barriers, the remote
care: technology, institutional, economic and human.
qualitative 2011 Riog
Iran e eect of 12 under the theme of eective variables in the
eld of price interventions as one of the requirements for the
implementation of the strategic purchasing of medicines
2016 Bastani
 Introducing 6 groups of inuencing factors in the strategic
purchasing of health service include: target group and users of
services (demand side); purchased interventions, providers supplier
interventions (supply side); the methods and motives (payment
methods); the price and the organization structure of all strategic
purchasing of all health intervention.
review 2017 Bastani

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ORIGINAL ARTICLE
Minor infrastructures of purchasers and
consumers (paying attention to users of health
services, paying attention to the interventions of
the demand side, paying attention to the number
of random interventions for purchaser, creating
monetary mechanism following the patient),
minor infrastructures of manufacturers or the
supply side (interventions on the supply side,
paying attention to wholesalers and retailers,
paying a special attention to purchasers and
insurances, accountability of service providers,
paying attention to the number of providers),
minor infrastructures of purchasing interventions
(payment system to provider, suitable contracts,
payment system to insurance, rules and regula-
tions, determining priority, and determining cost
of ecacy), minor infrastructures of methods
and incentives (incentives of suppliers’ change
of behavior, payments based on performance,
payments based on time, nancial protection, risk
coverage of providers), minor infrastructures of
price interventions (the price being actual, services
being payable, endowing the bargaining power,
and determining payment system), minor infra-
structures of structure and organization (think-
ing and decision-making of strategic purchasing,
environment and organization’s capabilities, the
hierarchical structure of the organization, identi-
fying rules and regulations, and paying attention
to nancial structure). 11 papers were referred to
the supply side interventions.14,15,16,17,18,19,20,21,22,23,24
6 studies paid attention to the demand side inter-
ventions.18,25,26,27,28,29 2 papers were referred to
methods and incentives.15,22 7 papers mentioned
price interventions.16,20,24,30,31,32,33 5 studies were
commonly referred to the quality of provided
services by manufacturers and providers and
the other 7 studies were commonly referred to
economical aspect of purchased goods price and
eective purchasing system.16,20,24,30,31,32,33 4 studies
attended to payment based on performance which
was from the minor infrastructures of methods
and incentives.15,16,17,19 3 studies referred to goods
transportation and provided services from manu-
facturers.15,24,32 5 studies referred to the structure
and organization.11,16,26,31,34
e results of the studies show that infrastruc-
tures in dierent countries were not similar and
there are some dierences in this eld based on
policies and being developed or developing coun-
tries, in other words, being rich or poor.
DISCUSSION
e results of the current study indicate that other
6 major infrastructures and minor infrastructures
have been eective in strategic purchasing.
Among the major infrastructures are the follow-
ing: 1. Purchasers and consumers (demand side),
2. Manufacturer (supply side), 3. Interventions in
purchasing, 4. Incentives, 5. Price interventions,
and 6. Structure.
In the study by Nasiripour about eective factors
on strategic purchasing in the indirect health
section of Iran’s social security organization, the
importance of nine factors are referred to including
organization, price, resource allocation, payment
mechanism, priorities, contract, providers, bene-
ciaries, purchasing model in the strategic purchas-
ing process which is consistent with the present
st u dy.35
In the study conducted by Preker strategic
purchasing components are referred to including
resources allocation, accumulation of risk, gath-
ering resources and nancial revenues, exploiters
of health services, and providers) public, private,
competitive (price), and subsidies (payment mech-
anism) which conrm the identied components of
the present study.11
In the study conducted by Baeza and Torz,
providers’ components of contract and payment
mechanisms are referred to as inuencing compo-
nents in strategic purchasing which conrm the
accuracy of the present study components namely
providers and contract and payment mechanism.36
In the report by World Health Organization,
strategic purchasing components of medical
services are referred by topics such as exploiters,
priorities, resources allocation, accountability,
payment mechanism and organizing purchasers
that conrm the results of present study in deter-
mining similar components.2
Katzin and kanhal in Estonia believed that
strategic purchasing components are payment
mechanism, contractual framework, medical care
providers, selective and bulk contracts, price,
providers’ structure and nancial ownership which
are consistent with the results of the present study.27
Figors et al. in their study in Australia intro-
duced strategic purchasing components as medical
services providers, contracts, purchasing mecha-
nism, hierarchical structure, supplying nancial
resources, rules and regulations, ownership, and
resource allocation which conrm the current
st u dy.37 Nasiripour et al. in their study that was
planned with the aim of identifying inuencing
variables in price for strategic purchasing of health
services by social security organization as the
largest institution of purchasing health services
and drugs in Iran in 2011 showed that agreeable,
payable, and real price and also competitive market,
and bargaining power by purchasing institutions

5
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ORIGINAL ARTICLE
or insurance organizations are among the most
important factors inuencing price interventions
for implementing strategic purchasing in the coun-
try’s health section which is consistent with the
present study.28
e results of study by Cheraqali (2013) indi-
cated that political sanctions against Iran impacted
pharmaceutical sector greatly such as banking and
transportation sanctions resulted in the reduction
timely access to vital drugs in Iran’s markets and
pharmaceutical industries problems related to
drugs import or their raw materials which were not
referred to in the present study.28
Bastani’s study in the eld of eective compo-
nents in implementing strategic purchasing of
health services indicates that the presented main
models for strategic purchasing of health services
namely World Health Organization Model29 and
World Bank Model38 in all the investigated studies
in the present study are somehow subset of World
Health Organization’s political levers (what to
buy, for whom to buy, from whom to buy, how to
pay, and at what price), in the mentioned study it
is preferred that the 6th component of this study
(structure and organization), is not included in
the proposed strategic purchasing model based on
the World Bank’s experts. In other words, other
organizational structures are a framework that
purchasing and resources allocation take place in
them and therefore it is not mentioned directly in
the proposed framework of the World Bank which
is consistent with the present study.
CONCLUSION
We nd out that eective infrastructures in strategic
purchasing of health services are dierent in dier-
ent countries in the world and applying these coun-
tries’ experiences can be very helpful in establishing
our country’s strategic purchasing. erefore, the
future studies in the eld of establishing strategic
purchasing of dierent health services are recom-
mended including incurable diseases and dierent
kinds of contagious and non-contagious diseases.
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