Strategic Purchasing Theory in Weak Governance Contexts: Evidence from Pakistan's Sehat Sahulat Program

Abstract Strategic purchasing theory, often centered in high-capacity institutions, is built on three main assumptions- purchaser autonomy, professional management, and stable governance. These assumptions are frequently unmet in low- and middle-income health systems, leading to questions about the theory's applicability in settings with limited institutional capacity, contested authority, and devolved health governance. This study evaluates strategic purchasing and its theoretical bases within Pakistan's Sehat Sahulat Program, a national health insurance initiative serving over 100 million beneficiaries. A qualitative comparative case study utilized 22 interviews across five stakeholder groups, policy document reviews, and a four-rounded modified Delphi method with ten experts. Interviews were coded through hybrid deductive-inductive thematic analysis around Cashin and Gatome-Munyua's six purchasing functions, achieving Cohen's kappa 0.83. The analysis revealed persistent deficits in six purchasing functions. benefit packages designed through political negotiation rather than health technology assessment; passive open empanelment with no provider deselection; flat-rate payments generating unchecked upcoding; performance monitoring capturing financial flows with zero clinical outcomes; a beneficiary registry last updated in 2011 excluding 30-40% of the urban poor; and nominal regulatory oversight without enforcement. Four institutional capacity constraints were identified including lack of statutory authority, human resource shortages, information system inadequacies, and coordination issues post-2010 devolution. These findings represent precondition failure rather than implementation failure, a distinction with fundamental implications for how international evaluations attribute accountability and design remediation. A four-stage Strategic Purchasing Capacity Stages (SPCS) model is proposed, positioning Pakistan's programme at Stage 1 (Administrative Purchasing) and demonstrating that prescriptions calibrated to Stage 4 capacity generate structurally determined failure regardless of financing. Strategic purchasing theory requires explicit specification of governance capacity thresholds below which its prescriptions become infeasible Key Messages Strategic purchasing is mis-aligned with most low- and middle-income countries' health care delivery systems due to four institutional capacity weaknesses which are lack of purchasing authority, lack of specialized personnel, lack of data processing capacity, and failure to coordinate- an example being Pakistan's Sehat Sahulat program. This study gives out specific details of a model called the Strategic Purchasing Capacity Stages (SPCS) Model that categorizes systems into Stage 1 through Stage 4 and identifies where Pakistan stands on this scale at Stage 1. Therefore, international agencies should always assess the system's institutional capacity before recommending strategic purchasing reforms so that recommendations can be made to fit the system's stage.