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Essays on Managing Healthcare Ecosystems



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Betcheva, Lidia 


From medical services, community and social care, organ transplantation and blood supply chains, to pharmaceutical innovation, research and development, and manufacturing and distribution, the healthcare ecosystem is wide ranging in both its functions and stakeholders. This dissertation aims to better understand, evaluate, and address major challenges and inefficiencies in this complex system. Through the utilization of operations management concepts, strategies, and methodologies, the dissertation derives and offers insights for key decision–makers and practitioners.

The first half of the dissertation lays the groundwork by characterizing healthcare supply chain management and provides a framework that adapts and applies supply chain thinking to the healthcare domain. In the second half of the dissertation, the research focuses in on the pharmaceutical industry and, particularly, to examining recent and major trends in clinical development: the changing nature of clinical research outsourcing, and the decentralization of trials. These trends are assessed by considering the key stakeholders in the ecosystem and the intricacies of their interactions. The main chapters are summarized below.

Healthcare supply chains are categorized into four main categories with the primary strategies, challenges, and risks as well as the existing research for each category discussed. For each supply chain, Chapter 2 details at least one efficient and effective strategy that has been used in practice and includes a short discussion on future research.

With a focus on healthcare delivery, Chapter 3 offers a primer on supply chain thinking in healthcare, by following a framework that is customer focused, systems based, and strategically orientated and that simultaneously considers clinical, operational, and financial dimensions. The goal is to offer an understanding of how concepts and strategies in supply chain management can be applied and tailored to healthcare by considering the sector’s unique challenges and opportunities.

Pharmaceutical (pharma) companies face substantial financial consequences from clinical trial overruns. To offer an analytical perspective on how pharma managers’ choice of outsourcing relationship type with contract research organizations (CROs) can affect clinical development timelines, Chapter 4 explores strategic partnerships (characterized by a pharma company's commitment of future business to CROs) and transactional arrangements (one–off but potentially repeated engagements). The problem is formulated as a three–stage game between a pharma company and CRO. The when and how of strategic partnerships are investigated through the characterization of the conditions under which a pharma company should pursue a strategic partnership with a CRO rather than engage in a transactional arrangement, and in detailing the way that these relationships unfold.

The COVID–19 pandemic exposed the vulnerabilities of a conventional site centric clinical trial design and spurred the adoption of decentralized clinical trials (DCTs), trials wherein recruitment and data collection are not restricted to one centralized location. There has been a growing interest in understanding how DCTs can mitigate existing challenges in clinical development, particularly regarding sponsor, site, and participant burdens. Chapter 5 provides an overview on DCTs, emphasizing how they fit into and alter the current clinical development landscape. The chapter puts forward a conceptual framework that employs systems thinking to evaluate the impact of trial decentralization on the ecosystem through a reiterative assessment of stakeholder pain points.





Erhun, Feryal




Doctor of Philosophy (PhD)

Awarding Institution

University of Cambridge