Dependent autonomy: developing and refining a theoretical construct of managerial autonomy in healthcare

Abstract Background Value-based healthcare (VBHC) frameworks, including the High-Value Health System (HVHS) model, emphasise structural components such as digital infrastructures, outcome measurement, and integrated care pathways. However, empirical evidence suggests that these components do not consistently translate into improved performance. This study addresses this gap by examining how system components are enacted in practice. Methods A theory-building design was employed, combining conceptual synthesis with empirical grounding in previously published studies of decentralised healthcare governance and hybrid management. An abductive analytical approach was used to integrate insights from decision space theory, organisational theory, and VBHC frameworks. Results The analysis resulted in a conceptual framework identifying dependent autonomy as the central mechanism linking system design to practice. HVHS components were found to operate indirectly through organisational systems, which function as dual mechanisms that both enable and constrain managerial action. Dependent autonomy, defined as the extent to which managerial autonomy is contingent upon organisational systems, determines the effective enactment of coordination and patient flows. Variation in VBHC outcomes is thus explained by differences in how organisational systems shape decision space. Conclusions This study reframes healthcare transformation as a problem of organisational enactment rather than system design. By introducing dependent autonomy, it extends decision space theory and integrates it with organisational and VBHC perspectives. The findings highlight that the effectiveness of healthcare reforms depends on the organisational conditions that make system components actionable, offering a theoretically grounded explanation for variability in implementation outcomes.