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Help me continue my thesis by following my tutors comments comments of tutor Chapter 3 is a walkthrough of what you are doing and what you did so far.. you write it while you work on the chapters. it is the link between all chapters. (open up a bit of discussion on the literature) You are on time….you must see this as a holistic project no need to panic. Start working on the thesis – i.e. chapter 4 collecting data and once you put a deadline example mid June on the data collection you start putting the findings together and discussing it. this should take you through to July to close off chapters 1 to 4 – then chapter 5 can be done in a week end – salient point, conclusion, what is so important about your findings and for whom and why. limitations of the study, further studies on the area and overall conclusions. A SWOT-BASED APPROACH TO EVALUATING PROCUREMENT EFFICIENCY IN HOSPITALS _________________________________________________________________________________ KYLIE COLEIRO GRIMA 0441592M CHAPTER 1 Introduction: Context of the study Healthcare systems internationally are being increasingly pressured to provide affordable and high-quality treatment. One of the most crucial elements that impacts hospitals’ performance is procurement efficiency, or how healthcare organisations obtain services, equipment, drugs and medical supplies. Procurement extends beyond simple purchasing transactions to encompass strategic decision-making processes that directly influence patient outcomes through supply chain reliability, cost optimization, and quality assurance. Effective procurement ensures that healthcare facilities maintain consistent access to essential medical supplies while maximizing value for money through informed vendor selection, contract negotiation, and inventory management. The World health Organisation (WHO, 2022) has reported that ineffective or poorly planned hospital procurement practices led to unnecessary resource wastage, failures in the supply chain and augmented expenses especially in small or decentralized health systems like Malta. With increasing budgetary constraints and demands for accountability, reforming procurement systems has become a strategic imperative Increasing costs of health sector expenditure, budgetary constraints, increased accountability suggests that reform of procurement systems is vital. In this context, procurement is no longer a peripheral administrative task but a central strategic function that determines the efficiency, equity, and sustainability of health service delivery. This transformation is especially visible in the aftermath of the COVID-19 pandemic, which exposed systemic procurement vulnerabilities even in advanced healthcare systems. Thus, understanding and improving procurement efficiency has become a global priority, particularly for smaller health systems with limited bargaining power and resource flexibility. This research uses SWOT analytical framework analysis which is selected as the primary analytical framework because it provides a systematic approach to evaluating both internal capabilities and external environmental factors affecting procurement systems. Unlike other analytical methods, SWOT’s comprehensive structure allows for the identification of actionable improvement strategies while maintaining analytical rigor suitable for healthcare contexts (detailed methodology justification is provided in Chapter 3). Motivation for the study Evaluating procurement inefficiencies in hospitals is a problem that has consequential implications for quality of care, patient outcomes, and the overall sustainability of the healthcare system. The significance of this study has been established. Healthcare procurement has often provided a background hum of inertia, but essentially it is a core function supporting the delivery of healthcare services. The implications of procurement efficiency are perhaps most significant for hospitals, where access to the right medical supplies integrated with timely delivery will be paramount. Procurement inefficiencies in Malta, a small island nation with a limited capacity for local manufacture, can create lengthened lead times, stock-outs, and ultimately delays in the delivery of care. Therefore, it is evident that procurement inefficiency is an operational matter but at a higher level is a strategic national priority as it has implications for the quality of healthcare and for financial accountability. This motivation stems not only from local constraints but also from the pressing need to respond to international calls for health system strengthening, especially in resource-scarce or decentralised systems. As highlighted by the OECD (2018), fragmented procurement models in smaller states often result in duplicated efforts, reduced economies of scale, and inefficiencies that undermine care delivery. In a broader sense, the importance of this study transcends Malta’s borders as it can be considered a case study for other smaller, resource-stricken systems under the European Union (EU) footprint. There are other Small Island Developing States (SIDS) that might experience similar procurement issues, as do decentralised hospitals in other larger nations where budgets are limited, and sourcing is transnational. The global pandemic, COVID-19 has highlighted global systemically significant procurement challenges including vulnerabilities like supply chain failure, inflationary pressures, and geopolitical threats, many systems are — to varying degrees — faced with these issues. The analysis of Malta’s procurement challenges can serve to inform scalable, context aware policy formulation and for the purposes of international policy development, operational efficiencies and more effective use of funding. This is driven by the recognition that hospital procurement infrastructures tend to be disjointed and typically lack consistency of protocols, oversight or even training. According to initial reading and conversations with medical professionals there is evidence of some hospitals in Malta adhering to centrally managed models, while others have greater autonomy in their operational procedures, producing differential procurement outcomes. The combination of disjointed models results in overlaps, wasted economies of scale, and higher supplier risks (OECD, 2018). As a research practitioner I will remain open to any emergent hypotheses or conditions that were not anticipated at the outset of the study. The rationale for researching procurement efficiency in Maltese hospitals has both locally driven issues and global pressures, but associated with a specific gap with regard to existing literature shows us that the operational mismanagement of procurement across the diversity of procurement types in the Maltese healthcare system represent a broader theoretical and practical problem of healthcare procurement management, which calls for systematic research. Statement of the problem Despite growing interest in healthcare supply chain management, the concept of “procurement efficiency” in hospitals remains underexplored, with limited consensus on its definition and measurement. Moreover, there is a paucity of empirical studies comparing procurement practices across small healthcare systems, particularly in resource-constrained settings like Malta. This gap hinders the development of evidence-based strategies to optimize procurement in such contexts. Aim and Objectives This study aims to assess the effectiveness of hospital procurement systems using a SWOT-based analytical framework. A number of specific objectives shall be followed to achieve these main aims. First, the study will assess the specific procurement models of the selected hospitals to understand their structure and processes. Second, the study will identify and establish the key areas influencing procurement effectiveness in the healthcare domain. Third, the study will analyse the current hospital procurement practices in the centre of the local procurement community through an international perspective and related best practice literature. Fourth, the study will make grounded recommendations to improve hospital procurement organisation efficiency based on the SWOT analysis and feedback from the health procurement systems. Research Questions The study aims to address the following research questions, which will further guide the evaluation of hospital purchasing efficiency: What procurement methods are currently utilised in Maltese hospitals? What are the strengths and weaknesses of current hospital procurement practices in Malta? How well do these procurement systems perform compared to established best practices internationally? What internal and external influences affect how well hospital procurement systems perform? What does procurement efficiency mean when considered in the context of health care? 1.6 Propositions (Theoretical Framework) This study adopts a proposition-based case study approach, guided by Yin (Case Study Research Design and Methods (5th ed.), 2014); to structure the investigation around theoretically informed assumptions. The propositions are rooted in systems theory, which views hospital procurement as a dynamic network of interconnected processes, stakeholders, and resources (Von Bertalanffy, 1968; Checkland, 2018). Systems theory enables a holistic analysis of procurement efficiency, recognizing that changes in one subsystem case in point technology may ripple across other organisational structure. By integrating systems theory with SWOT analysis, this study examines both discrete procurement components and their interdependencies, offering a nuanced perspective on efficiency as an emergent property. Proposition 1: Centralised procurement strategies have a positive effect on efficiency in procurement because of the size and standardisation of processes (Thai, 2009); (Massimiliano Ferraresi, 2021). Proposition 2: Positive procurement outcomes are positively related to professional development training in procurement, supply chain management, and logistics ( (Thai, 2009); Basheka & Mugabira, 2018). Proposition 3: Hospitals that utilise digital procurement technology are more efficient than hospitals that use paper systems ( (Monczka, 2015); Ketikidis et al., 2020). These propositions draw on systems theory to frame procurement as a complex adaptive system and are supported by public procurement literature (Thai, 2009); Erridge, 2015). While Yin (2014) supports a structured, proposition-led case study design, Stake (1995) emphasizes a more interpretivist approach focusing on narrative depth and context. This study operationalizes a blended methodology by employing Yin’s (2014) structured case study design for data collection and initial analysis, while incorporating Stake’s (1995) interpretivist approach during the interpretive phase to capture contextual nuances specific to Malta’s healthcare environment. Specifically, Stake’s emphasis on narrative depth and stakeholder perspectives will be applied when analysing interview data and contextualizing quantitative findings within Malta’s unique small-state healthcare constraints. This methodological integration allows for systematic data gathering while preserving the rich contextual understanding essential for developing transferable insights to similar small-state healthcare systems. The operational framework for this blended approach is detailed in Chapter 3. 1.7 Limitations and Mitigation Strategies This study employs a Likert-scale filtering mechanism to ensure expert-level responses, enhancing the reliability of qualitative data. Participants self-report their expertise across five procurement domains on a 7-point Likert scale, with responses weighted using an expertise index adapted from Schmidt et al. (2019). Only participants scoring above 28 points (out of 35) on the composite expertise scale are classified as experts, ensuring that qualitative insights reflect specialized knowledge. This approach mitigates potential biases in snowball sampling by prioritizing respondents with verified procurement experience (Benner, 2018). Additionally, the study acknowledges the limitation of generalizability due to its focus on Malta, but mitigates this by benchmarking findings against international standards to enhance transferability. 1.8 Significance Study This study addresses documented empirical gaps in healthcare procurement research. According to systematic reviews by Kumar et al. (2020) and the WHO Global Health Observatory (2022), less than 15% of healthcare procurement research focuses on small-state systems, despite these systems serving over 65 million people globally. Furthermore, the OECD Health Statistics (2023) indicate that procurement inefficiencies in small healthcare systems result in 12-18% higher per-unit costs compared to larger systems, yet targeted analytical frameworks remain underdeveloped. This study bridges these theoretical and practical gaps by providing empirically-grounded insights for policy reform and academic advancement. Explicit Policy Relevance: The SWOT-based framework directly informs actionable policy interventions at both institutional and national levels. Findings will translate into specific recommendations for legislative frameworks governing procurement standardization, professional certification requirements for procurement specialists, and targeted investments in digital infrastructure. These policy implications have relevance for Malta’s current healthcare reform initiatives and can guide similar small-state healthcare systems in strategic procurement planning. Empirical Gap Framing: This research addresses a critical gap in healthcare procurement literature, which has predominantly focused on large healthcare systems with substantial resources. While previous studies like Eadie (2007) and Howard (2016) identified inefficiencies in procurement processes, they lacked a comprehensive analytical framework suitable for small-state healthcare contexts. This study’s SWOT-based methodology specifically tailored to resource-constrained environments represents a novel empirical contribution that bridges theoretical procurement models with practical implementation challenges faced by smaller healthcare systems. Theoretical Contribution: Beyond practical outcomes, this study advances public procurement theory by integrating systems thinking with strategic analysis frameworks. It extends Thai’s (2009) public procurement model by incorporating contextual factors specific to healthcare settings and small-state operations. This theoretical refinement has implications beyond Malta, contributing to a more nuanced understanding of how procurement theory must adapt to different scales and contexts within public sector operations. The relevance of this study goes beyond simply descriptive understandings and creates new possibilities for concrete policy making and theory building in several key areas: Clear Policy Relevance: The proposed SWOT-based framework is immediately applicable to policy making at both the institutions and at the level of the nation state. Outcomes can be used to produce recommendations to inform legislative standards for standardisation of procurement, professional certification for procurement professionals, and investment in digital infrastructure. The importance of these specific policy types is particularly relevant in the context of Malta’s current health reform programme but could also provide strategic guidance for smaller similarly funded health systems on procurement planning and resource allocation. Positioning the Empirical Gap: The area of healthcare procurement has a limited academic literature which has focused on large healthcare systems with much larger levels of funding. Prior studies (like Eadie, 2007; Howard, 2016) that noted waste or inefficiency in health procurement specifically did not provide a comprehensive analytical framework to address the problem from potential budget constraints faced by smaller health systems. Adopting this study’s SWOT approach to address waste in procurement represents a new empirical contribution to areas of procurement that bridged the gap between theoretical models of procurement and practical issues dealing with implementation in smaller healthcare systems. As a Theory Building Contribution: This study goes beyond simply producing practical outcomes to contribute to public procurement theory development. It integrates systems thinking with strategic analysis frameworks. This research extends Thai’s (2009) public procurement model by introducing situational factors related to how health sector operations take place, how health systems work at small-state levels and importantly for New Zealand and Australia – has theoretical development implications for our understanding of how procurement theory accommodates the scale and scope of public sector operations. In addition, this study helps bridge the gap between strategic frameworks like SWOT and operational procurement realities. By refining existing procurement models through a systems-informed lens, this research generates policy-relevant insights and a framework adaptable to other small-state health systems such as those in the Caribbean, Pacific Islands, and Southern Europe. 1.10 Structure of the Thesis This thesis follows a logical progression from contextual foundation through methodological application to findings and implications. The introductory chapter establishes the research context, problem statement, objectives, and theoretical propositions that guide the investigation. Chapter 2 builds upon this foundation by critically reviewing literature on procurement efficiency, SWOT analysis applications, and global comparative practices to identify key research gaps that this study addresses. The methodology chapter (Chapter 3) details the case study approach, including data collection procedures, sampling strategies, analytical frameworks, and ethical considerations, demonstrating how these methods align with the research objectives. Chapter 4 presents the comprehensive SWOT analysis results, comparing empirical findings with theoretical propositions and synthesizing cross-case themes to reveal patterns and insights. The concluding chapter synthesizes key findings, discusses both theoretical contributions and practical implications, offers evidence-based policy recommendations, acknowledges study limitations, and identifies promising directions for future research in healthcare procurement optimization. CHAPTER 2 2.1 Literature Review: Introduction This chapter critically synthesizes literature on hospital procurement efficiency, focusing on definitions, determinants, and analytical frameworks. It distinguishes between empirical and conceptual sources to highlight inconsistencies and gaps, particularly in small-scale healthcare systems. The review also evaluates the application of SWOT analysis in healthcare procurement and compares global procurement practices to contextualize the study. To ensure a balanced evaluation, the literature is classified into three main streams: (1) conceptual frameworks that define procurement strategies and theoretical models; (2) empirical studies that evaluate real-world practices; and (3) comparative research that situates procurement models across global health systems. This structure facilitates both critical integration and analytical depth, addressing the tutor’s recommendation for a more structured synthesis. This literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure comprehensive and transparent literature identification and evaluation. The systematic search strategy encompassed multiple databases (PubMed, Scopus, Web of Science, Cochrane Library) using predefined search terms related to healthcare procurement, efficiency measurement, and SWOT analysis applications. The review period covered 2010-2024, with additional hand-searching of reference lists and grey literature sources. Inclusion criteria prioritized peer-reviewed empirical studies, while grey literature was included only when providing unique policy insights or comparative data unavailable in academic sources. The literature reveals three interconnected themes that form a systems-based understanding of procurement efficiency. Education and training initiatives create the human capital foundation necessary for both centralized and decentralized procurement models to function effectively, while technological integration serves as an enabler that amplifies the benefits of well-trained staff and appropriate organizational structures. These themes operate synergistically: centralized procurement systems achieve greater efficiency gains when supported by standardized training programs and integrated digital platforms, while decentralized models require even more sophisticated technological support and higher staff competency levels to maintain efficiency. This systems perspective guides the analytical framework employed in this study. 2.2 Procurement in Hospitals: Definitions and Importance Hospital procurement encompasses the acquisition of goods and services—such as drugs, medical equipment, and supplies—essential for healthcare delivery. Effective procurement ensures timely access to quality products, directly impacting patient care and operational costs (WHO, 2022). Inefficient procurement, however, leads to resource wastage, supply chain disruptions, and increased costs, particularly in resource-constrained settings like Malta. Conceptually, procurement in hospitals is now viewed as a strategic lever for improving healthcare outcomes, especially when embedded in governance systems and professionalised management structures (Thai, 2001; Callender & Matthews, 2002). Yet, empirical studies often lag behind in capturing how procurement inefficiencies manifest at smaller, decentralised facilities—an issue that this study aims to explore through its case-based methodology. Empirical research by Chen et al. (2021) demonstrates that procurement inefficiencies account for 8-15% of total hospital operating costs, with smaller facilities experiencing disproportionately higher impacts. Similarly, Kumar and Patel’s (2020) longitudinal study of 150 hospitals found that procurement-related supply disruptions directly correlated with increased patient wait times and reduced care quality indicators 2.3 Deeper Analytical treatment of global comparisons 2.3.1 Education and Training Empirical evidence underscores the role of professional training in enhancing procurement outcomes. (Thai, 2009)) argues that staff development in procurement and supply chain management improves decision-making and contract negotiation, leading to better organizational performance. However, Basheka and Mugabira (2018) note that training programs often lack standardization, limiting their impact in resource-constrained settings. This inconsistency highlights the need for context-specific training frameworks. Further evidence from the UNDP (2019) suggests that procurement professionals in low-resource environments are often underqualified or lack continuous education, resulting in compliance issues and poor value-for-money outcomes. Conceptually, this aligns with capacity-building theories which emphasise skill development as a precondition for institutional performance (Grindle, 1997). 2.3.2 Centralized vs. Decentralized Procurement Systems The debate over centralized versus decentralized procurement reveals context-dependent trade-offs. Ferraresi (Massimiliano Ferraresi, 2021) demonstrates that centralized procurement in Italy achieved cost savings through economies of scale. Conversely, Lundberg (2018) found that excessive centralization in Swedish rural hospitals caused supply delays, suggesting that geographic and organizational factors mediate outcomes. Similarly, Walker et al. (2020) report that decentralized procurement in British community hospitals enhanced local responsiveness but increased administrative costs. These contradictory findings indicate that no single model universally optimizes efficiency, necessitating tailored approaches based on system size, market conditions, and supply chain complexity. For example, New Zealand’s mixed procurement model struggles to balance economies of scale with local responsiveness, mirroring challenges in Malta (Wilson & McGuire, 2021). Comparative literature also reflects how procurement models are shaped by governance capacity and market maturity. For instance, Singapore’s Group Purchasing Organisations (Tan et al., 2020) offer a hybrid centralised system with local autonomy, reducing costs while maintaining responsiveness. In Denmark, regional procurement agencies provide semi-autonomous governance, allowing local hospitals to participate in national contracts while adapting to regional needs (Jensen & Nielsen, 2019). The COVID-19 pandemic further reshaped procurement dynamics. Handfield et al. (2023) document how health systems adopted dynamic sourcing and collaborative networks to mitigate disruptions, while Matopoulos and Michopoulou (2022) highlight blockchain’s role in enhancing supply chain transparency in European hospitals. These innovations underscore the need for adaptive procurement strategies in crisis contexts. This has shifted procurement thinking from static processes to dynamic systems requiring real-time risk assessment, redundancy planning, and predictive analytics. The shift aligns with Systems Theory, which emphasises adaptability, feedback loops, and learning within complex systems (Checkland, 2018). 2.3.3 Technological Integration Digital procurement technologies significantly enhance efficiency by automating processes and improving data accuracy. (Monczka, 2015)found that hospitals using e-procurement systems reduced order-processing times and administrative costs. Ketikidis et al. (2020) further note that digital tools improve supplier relationships but require significant upfront investment, posing challenges for smaller systems. Post-COVID advancements, such as AI-driven procurement forecasting (Sharma et al., 2024), highlight the evolving role of technology in addressing supply chain volatility. Empirical studies from the WHO Africa Regional Office (2022) also point to a growing digital divide in procurement maturity. While large hospitals in urban areas adopt integrated platforms, rural and smaller facilities often rely on manual systems, leading to fragmentation and inefficiencies. Conceptually, digital maturity models (KPMG, 2019) suggest that procurement efficiency gains are nonlinear and require parallel investments in staff training, systems interoperability, and regulatory alignment. 2.4 SWOT Analysis in Healthcare Procurement SWOT analysis provides a structured approach to evaluating procurement systems, but its limitations must be acknowledged. Helms and Nixon (Helms, 2010) critique SWOT for oversimplifying complex healthcare environments, as its quadrant-based structure may obscure interdependencies. Panagiotou (2018) adds that SWOT often lacks quantitative rigor, potentially skewing strategic priorities. This study mitigates these limitations by integrating systems theory and weighted scoring mechanisms, ensuring a more nuanced analysis of procurement dynamics. Additional critiques by Hill & Westbrook (1997) argue that SWOT often fails to differentiate between internal and external variables clearly, leading to misclassification of factors and poor strategic recommendations. By combining SWOT with systems-based mapping, this study moves beyond static categorisation, viewing procurement as an evolving system with complex causal relationships. 2.5 Global Comparisons in Hospital Procurement Efficiency Across the world, hospitals also face similar procurement issues such as budgetary constraints, supply chain interruption, and necessity for technological advancement. Comparative studies show that hospitals whose procurement systems and technologies are integrated are more cost-effective and service delivery oriented. For instance, a study in Italy showed that centralization of procurement activities led to substantial cost reduction and improved procurement efficiency (Massimiliano Ferraresi, 2021)Similarly, United States hospitals adopting new procurement technologies experienced better operational efficiency and reduced procurement cycle time (Monczka, 2015). In addition to Italy and the US, procurement models utilized in other geographical contexts also provide informative lessons. Singapore’s centralized procurement model’s group purchasing structure has resulted in considerable improvements in cost savings (Tan et al., 2020). Denmark’s regional procurement model balances the cost-savings aspects of centralization while allowing localized choices and access to procurement (Jensen & Nielsen, 2019). New Zealand’s mixed approach to procurement reflects challenges to balancing aggregated economies of scale and achieving responsive local supply chains in geographical isolation, similar to Malta (Wilson & McGuire, 2021). Australia’s National Product Catalogue approach provides a federal coordination model potentially applicable to Malta’s multi-hospital context. However, Australia’s success relies on scale advantages unavailable to Malta—with over 1,300 hospitals participating versus Malta’s handful of facilities. The critical insight for Malta lies not in replicating Australia’s scale-based savings, but in adapting their standardization methodologies and supplier evaluation frameworks to achieve comparable efficiency gains within Malta’s constrained market environment. Rwanda’s e-Procurement System (Umucyo) offers particularly relevant insights for Malta’s context, as both represent small-state systems with limited local manufacturing capacity. However, critical differences emerge in implementation approaches: while Rwanda prioritized transparency and corruption reduction through digital systems, Malta’s procurement challenges focus more on coordination between autonomous hospital units and EU regulatory compliance. Rwanda’s success in achieving 23% cost reductions (Ngoboka et al., 2020) stemmed from strong central government mandate and donor support—conditions that may not be replicable in Malta’s decentralized healthcare governance structure and established supplier relationships. 2.6 Gaps in the Literature The literature on hospital procurement efficiency remains limited, particularly in small-scale and resource-constrained settings like SIDS. Empirical studies often focus on large healthcare systems, overlooking the unique challenges of smaller systems (Eadie, 2007; Howard, 2016). Moreover, there is a lack of research on the impact of standardized training programs and the integration of emerging technologies in diverse healthcare contexts. This study addresses these gaps by applying a SWOT-based framework to Malta’s procurement systems, offering a replicable model for other small-state systems. Notably, no existing study has systematically integrated SWOT analysis with systems theory to assess procurement in a small-state health context. This methodological innovation provides a structured yet adaptive framework capable of capturing both static and dynamic factors. CHAPTER 3 3.1 RESEARCH METHODOLOGY This chapter outlines the methodological approach employed to assess hospital procurement efficiency in Malta using a SWOT-based analytical framework. The methodology combines systematic literature review techniques, case study analysis, and survey research to provide both breadth and depth in understanding procurement systems. This mixed-methods approach enables triangulation of findings while addressing the complex, multi-faceted nature of healthcare procurement efficiency.

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