Why do some inter-organisational collaborations in healthcare work when others do not? A realist review: A realist review

Justin Aunger, Ross Millar, Joanne Greenhalgh, Russell Mannion, Anne Marie Rafferty, Hugh McLeod

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BACKGROUND: Inter-organisational collaboration is increasingly prominent within contemporary healthcare systems. A range of collaboration types such as alliances, networks, and mergers have been proposed as a means to turnaround organisations, by reducing duplication of effort, enabling resource sharing, and promoting innovations. However, in practice, due to the complexity of the process, such efforts are often rife with difficulty. Notable contributions have sought to make sense of this area; however, further understanding is needed in order to gain a better understanding of why some inter-organisational collaborations work when others do not, to be able to more effectively implement collaborations in the future.

METHODS: Realist review methodology was used with the intention of formulating context-mechanism-outcome configurations (CMOCs) to explain how inter-organisational collaborations work and why, combining systematic and purposive literature search techniques. The systematic review encompassed searches for reviews, commentaries, opinion pieces, and case studies on HMIC, MEDLINE, PsycINFO, and Social Policy and Practice databases, and further searches were conducted using Google Scholar. Data were extracted from included studies according to relevance to the realist review.

RESULTS: Fifty-three papers were included, informing the development of programme theories of how, why, and when inter-organisational collaborations in healthcare work. Formulation of our programme theories incorporated the concepts of partnership synergy and collaborative inertia and found that it was essential to consider mechanisms underlying partnership functioning, such as building trust and faith in the collaboration to maximise synergy and thus collaborative performance. More integrative or mandated collaboration may lean more heavily on contract to drive collaborative behaviour.

CONCLUSION: As the first realist review of inter-organisational collaborations in healthcare as an intervention for improvement, this review provides actionable evidence for policymakers and implementers, enhancing understanding of mechanisms underlying the functioning and performing of inter-organisational collaborations, as well as how to configure the context to aid success. Next steps in this research will test the results against further case studies and primary data to produce a further refined theory.


Original languageEnglish
Article number82
JournalBMC Systematic Reviews
Issue number1
Early online date22 Mar 2021
Publication statusPublished - Dec 2021

Bibliographical note

Funding Information:
This research was supported by a grant from the National Institute for Health Research HS&DR fund under grant number NIHR127430. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR programme.

Publisher Copyright:
© 2021, The Author(s).


  • collaboration
  • partnership working
  • integration
  • healthcare
  • improvement
  • realist review
  • realist synthesis
  • context
  • programme theory
  • implementation


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