Healthcare entrepreneurship: current trends and future directions

Purpose – Thegoalofthisarticleistoprovideanoverviewofhealthcareentrepreneurship,bothintermsofits current trends and future directions. Design/methodology/approach – The article engages in a systematic review of extant research on healthcare entrepreneurship using the scientific procedures and rationales for systematic literature reviews (SPAR-4-SLR) as the review protocol and bibliometrics or scientometrics analysis as the review method. Findings – Healthcare entrepreneurship research has fared reasonably well in terms of publication productivityandimpact,withdiversecontributionscomingfromauthors,institutionsandcountries,aswellasarangeofmonetaryandnon-monetarysupportfromfundersandjournals.The(eight)majorthemesof healthcareentrepreneurshipresearchrevolvearoundinnovationandleadership,disruptionandtechnology, entrepreneurship models, education and empowerment, systems and services, orientations and opportunities, choices and freedom and policy and impact.


Introduction
Healthcare is fundamental to enriching (i.e.improving health outcomes), safeguarding (i.e.preventing disease and illness) and supporting (i.e.monitoring and maintaining good health and wellbeing) public health.As a unifying lynchpin, healthcare entails both health (e.g.diagnostic and treatment) and care (e.g.palliative care, rehabilitation and recovery and social care) services.
The history of healthcare could be traced back to ancient Greece where (public) hospitals were first established by the Byzantine Empire in the 4th century (Riva and Cesana, 2013).The rise of modern-day healthcare could be located in the 19th century following the emergence of innovative entrepreneurs in healthcare such as Florence Nightingale who in 1,860 established the first nursing school in the world (Karimi and Alavi, 2015).Fast forward to the 21st century, healthcare has evolved into a truly diverse state, consisting of both local and international public and private practice that offers a wide range of health and care services in co-created and integrated ways across in-person and virtual modes involving the latest innovation and technologies as well as social practices (e.g.citizen science and telehealth) (Ciasullo et al., 2022a, b;Lim, 2016Lim, , 2021;;Lim and Ting, 2012;Mishra and Pandey, 2023;Sahoo et al., 2023;Yap et al., 2023).
The evolution and proliferation of healthcare would, inarguably, not have reach its present state without entrepreneurship, which is widely regarded as a catalyst of innovation (Maritz et al., 2020) and a magnifier of impact (Rastoka et al., 2022).At its core, entrepreneurship can be defined as the dynamic, innovative, strategic, resourceful and resilient process of starting, managing and growing a venture that generates profit.When these profits are channeled back into the venture to effectuate positive change and scale activities that benefit society, the venture evolves into social entrepreneurshipa form of entrepreneurship that typically blends financial goals with the desire to create positive societal outcomes.Nevertheless, it is important to note that while reinvesting profits for positive change is a distinguishing feature of many social entrepreneurial ventures, the crux lies in the purpose-driven intent and outcome of creating societal impact.Unlike traditional entrepreneurs who measure performance in terms of the return on investment (profit), social entrepreneurs prioritize the return on value (societal benefits), often employing a combination of both profit-oriented and non-profit strategies to achieve their objectives.Such delineations of entrepreneurship and social entrepreneurship align with recent scholarly investigations (e.g.Sharma et al., 2023;Snihur et al., 2022;Tan Luc et al., 2022;Vedula et al., 2022).Given that profit-making ventures that inherently serve a social purpose and generate social impact may be regarded as social entrepreneurship, we define healthcare entrepreneurship as a form of social entrepreneurship centered on advancing healthcare delivery, products, or services that inherently generate social good.
Several reviews on advances in healthcare have been conducted.For example, Ciasullo et al. (2022a) delivered an overview of citizen science in healthcare, whereas Ciasullo et al. (2022b) offered a retrospection of the patient as a prosumer of healthcare while Sahoo et al. (2023) presented the state of telehealth research.In the domain where healthcare and entrepreneurship intersect, existing reviews tend to engage in a narrow rather than a broad examination.For example, Suryvanshi et al. (2020) carried out a scoping review of In doing so, this article contributes by evaluating the performance, providing a directory of expertise and mapping extant knowledge of healthcare entrepreneurship research (Kraus et al., 2022;Mukherjee et al., 2022).
The rest of the article is organized as follows.The next sections disclose the review methodology, followed by the review findings, which is organized based on the bibliometrics or scientometrics analysis that is conducted (i.e.performance analysis and science mapping).The article concludes with key takeaways and promising pathways for future healthcare entrepreneurship research.

Methodology
This article adopts a SLR approach to provide an overview of healthcare entrepreneurship, both in terms of its current trends and future directions.In essence a SLR engages in a systematic process to review the literature and thus is deemed to be transparent and replicable, unlike traditional literature reviews that do not engage in a systematic process in its review (e.g.critical reviews) (Kraus et al., 2022;Lim et al., 2022).To engage in a systematic process of reviewing the literature, we adopt the SPAR-4-SLR protocol, which consists of three stages (and six sub-stages): assembling (identification and acquisition), arranging (organization and purification) and assessing (evaluation and reporting) (Paul et al., 2021).To analyze the literature derived from this systematic process, a bibliometrics or scientometrics analysis is performed (Donthu et al., 2021) as it can handle a large corpus of articles and enables the reviewing of that corpus in an objective manner due to its reliance on quantitative techniques and statistical information (Mukherjee et al., 2022).The review methodology is depicted in Figure 1 and disclosed in greater depth in the next sections.

Assembling
To assemble the literature on healthcare entrepreneurship, we engage in the activities of identification and acquisition.
In terms of identification, we focus on the domain of healthcare entrepreneurship and ask the following research questions (RQs): RQ1.How is the performance of healthcare entrepreneurship research?RQ2.Who are the contributors of healthcare entrepreneurship research?
RQ3.What are the major themes and topics in healthcare entrepreneurship research?RQ4.Where can healthcare entrepreneurship research be pursued in the future?
Besides that, the identification of healthcare entrepreneurship research also necessitates the selection of source type and source quality.Here, the source type selected is journals, as they signify the highest level of peer-review scrutiny (Lim, 2022), whereas the source quality selected is Scopus, which not only indexes sources that satisfy a stringent set of quality criteria but also serve a dual role as a search mechanism for the acquisition of articles (Paul et al., 2021).
In terms of acquisition, we use Scopus as the search mechanism and tool for material acquisition in line with the recommendation of Donthu et al. (2021) and Paul et al. (2021).The search period was limited up to 2022, which is the latest full year at the time of review, enabling a more accurate evaluation of yearly performance, which is in line with recent review practice (Singh et al., 2023).The search keywords were brainstormed among four professors (two in Asia and two in Europe) who have published on healthcare in the business discipline.These keywords were also cross-checked in two ways, first, against a random selection of 10 articles on healthcare entrepreneurship, and second, with five healthcare entrepreneurs via LinkedIn.These keywords were paired with operators (OR, AND, *) to IJEBR form the search string "('entrepreneur*' OR 'start*up' OR 'scale*up') AND ('health*care')" that is used for the search within the article title, abstract and keywords in Scopus.This practice is in line with the 3 Es (experience, expertise, exposure) recommendation of Kraus et al. (2022).In total, 723 documents were returned form the search results in the assembling stage of the review.

Arranging
To arrange the literature on healthcare entrepreneurship returned from the assembling stage, we engage in the activities of organization and purification.We leverage the Scopus Healthcare entrepreneurship categorization of documents, namely document type, publication stage and language, to organize and purify the documents.Specifically, we chose articles (i.e.document type) that were finalized (i.e.publication stage) and published in English (i.e.language) on the basis that articles (1) represent the development of new knowledge that have been peer reviewed (e.g.unlike editorials and notes), (2) could be replicated in search and review when finalized and (3) could be understood and reviewed given that English is lingua franca of scientific research.The rationales behind these review decisions are in line with the recommendations of Kraus et al. (2022).As a result, a total of 572 articles that fulfilled these criteria were included and 151 articles that did not were excluded in the review.

Assessing
To assess the literature on healthcare entrepreneurship returned from the arranging stage, we engage in the activities of evaluation and reporting.
In terms of evaluation, we engage in bibliometrics or scientometrics analysis.In particular, a performance analysis is conducted to ascertain the performance of healthcare entrepreneurship research (RQ1) and identify the contributors of healthcare entrepreneurship research (RQ2), whereas a science mapping using a keyword cooccurrence analysis is performed to unpack the major themes and topics in healthcare entrepreneurship research (RQ3) and locate promising pathways that healthcare entrepreneurship research can pursue in the future (RQ4).These analyses were conducted using the analytics functions in Scopus and VOSviewer (Van Eck and Waltman, 2010).More importantly, the scope of bibliometrics or scientometrics analysis herein is in line with the recommendations of Donthu et al. (2021).
In terms of reporting, we use the conventions of reporting our findings primarily in words with the supplementary support of relevant visuals such as figures depicting network diagrams and tables presenting key statistics.We also disclose that we have no conflict of interests that may influence the findings of the review and that we have not received any funding for this review.
In total, 572 articles were assessed in the present review of healthcare entrepreneurship research and the findings are reported in the next sections.

Performance of healthcare entrepreneurship research (RQ1)
The publication trend of healthcare entrepreneurship research is depicted in Figure 2. The figure shows that healthcare entrepreneurship research began in 1988, which examines an entrepreneur's venture into women's healthcare (Meadows, 1988).The field's research was sluggish in its initial years, recording publications of only a single digit each year, and it is not until five years into the new millennium that the field begun to publish research in double digits, with exponential growth witnessed in the last five years (2018-2022) and 2022 setting the record for the highest number of publications, which may be attributed to increasing emphasis on innovation (Sharma et al., 2022a) and interest in entrepreneurship education (Martina and G€ oksen, 2022), as well as the rise of entrepreneurial opportunities and threats emerging from COVID-19 (Sharma et al., 2022b), new-age technologies (Shepherd and Majchrzak, 2022) and sustainability challenges (Ketprapakorn and Kantabutra, 2022).
The impact of publications on healthcare entrepreneurship research is presented in Table 1.The table shows that the most impactful article is by Camarillo et al. (2004), who emphasize the importance of a shared understanding among surgeons, engineers, entrepreneurs and healthcare administrators to build on past success and fully leverage the potential of surgical robotics in the future.This is followed by Meterko et al. (2004), who IJEBR highlight the importance of entrepreneurial cultures and mindsets in healthcare teams to satisfy patients and Kuratko et al. (2001), who showcase the power of entrepreneurial actions in improving firm performance.The rest in the list of the top 10 most impact articles on healthcare entrepreneurship relate to digitalization (Angst et al., 2017;Dimitrov, 2019 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018  Healthcare entrepreneurship Srivastava and Shainesh, 2015), public policy (Acs et al., 2016), strategic management (Monsen and Wayne Boss, 2009), as well as lessons and implications that extrapolate to new fields of research (Ateljevic, 2020;Gupta et al., 2020).
The distribution of journals where these impactful articles on healthcare entrepreneurship are published provides an intriguing insight into the multifaceted nature of the subject.Notably, only one article, by Monsen and Wayne Boss (2009), appeared in a dedicated entrepreneurship journal, Entrepreneurship Theory and Practice.This pattern suggests that healthcare entrepreneurship merges a plethora of disciplines, ranging from medicine (Camarillo et al., 2004;Meterko et al., 2004) to economics (Acs et al., 2016), management (Kuratko et al., 2001), information systems (Angst et al., 2017;Srivastava and Shainesh, 2015), information technology (Dimitrov, 2019) and tourism (Ateljevic, 2020).Several motivations could be driving this publishing trend.Firstly, healthcare entrepreneurship often entails the application of entrepreneurial principles in specific clinical or medical contexts, making journals like American Journal of Surgery (Camarillo et al., 2004) or Medical Care (Meterko et al., 2004) inclined to publish such research.Secondly, the implications of technological trends for healthcare entrepreneurship in the digital era, such as the emphasis on digitalization (Srivastava and Shainesh, 2015) and cybersecurity (Angst et al., 2017;Dimitrov, 2019), might resonate with an information technology (IT)-focused audience, explaining the prominence of articles in journals such as IEEE Access and Healthcare Informatics Research.However, as the domain matures, there is potential for entrepreneurship journals like Entrepreneurship Theory and Practice and the International Journal of Entrepreneurial Behavior and Research to take on a more substantial role in shaping the interdisciplinary discourse on healthcare entrepreneurship from the perspective of entrepreneurship.Initiatives such as journal sub-sections and special issues can offer valuable platforms for this purpose.

Contributors to healthcare entrepreneurship research (RQ2)
The major contributors to healthcare entrepreneurship research are listed in Table 2 according to journals (Panel A), authors (Panel B), institutions (Panel C), countries (Panel D) and funders (Panel E).
In terms of journals, Modern Healthcare emerges as the most prolific journal with 20 articles, followed by Journal of Health Organization and Management and Technological Forecasting and Social Change with 10 articles each, Emerald Emerging Markets Case Studies with eight articles, Social Science and Medicine with 7 articles and BMJ Open and Healthcare Informatics with 6 articles each (Panel A).Other notable journals that have published healthcare entrepreneurship research include International Entrepreneurship and Management Journal with 4 articles and Entrepreneurship Education and Pedagogy, International Journal of Entrepreneurship and Small Business, Small Business Economics and Technovation with 3 articles each.This shows that healthcare entrepreneurship research is accepted across a myriad of domains including but not limited to business, entrepreneurship, healthcare, information technology and innovation.
In terms of authors, P. Lehous emerges as the most prolific author with 5 articles, followed by M. Friebe, B. Kirchheimer, F.A. Miller and V. Riddle with 4 articles each, 8 other authors with 3 articles each and 56 other authors with two articles each (Panel B).This shows that many scholars are interested in healthcare entrepreneurship research, but not many, to date, have developed a strong track record in this field of research (e.g.absence of double-digit publications), signaling a specialty niche where emerging scholars may wish to pursue and stake a claim.
In terms of institutions, Harvard University emerges as the most prolific institution with 17 articles, followed by University of Montreal with 13 articles, University of Toronto with 10

Major themes and topics in healthcare entrepreneurship research (RQ3)
A co-occurrence analysis of author keywords was conducted to unpack the major themes and topics in healthcare entrepreneurship research.The keywords that authors specify in their published articles typically reflect the essence of such articles (Kumar et al., 2022), and thus, the keywords of articles are often treated as the topics studied in the field (Varma et al., 2022).Through a keyword co-occurrence analysis, keywords (topics) that often appear together form a common cluster that represents a major theme in the field (Donthu et al., 2021).In total, the co-occurrence analysis of keywords with a minimum of five occurrences (i.e. the default setting in VOSviewer) revealed a total of 42 keywords (topics) that are segmented across 8 clusters (themes).The nomological network of major themes and topics in healthcare entrepreneurship research is illustrated in Figure 3 and the details are discussed in the next sections by means of sensemaking (Lim and Kumar, 2024) and summarized in Table 3.
Innovation and leadership.Cluster 1 comprises 7 keywordsi.e."innovation", "medical education", "leadership", "qualitative research", "healthcare innovation", "design thinking" and "technology transfer"that reflect healthcare entrepreneurship research pertaining to innovation and leadership.Studies in cluster emphasize the importance of developing entrepreneurial skills and innovation (Panther et al., 2019;Sharma et al., 2022a), which could be done through design thinking (Niccum et al., 2017).They also highlight the returns of entrepreneurial leadership in fostering innovation behavior among medical personnel such as nurses (Bagheri and Akbari, 2018), as well as the that relating to innovation spin-offs such as technology transfer (Helm et al., 2010).
Disruption and technology.Cluster 2 consists of 7 keywordsi.e."covid-19", "startup", "digital health", "technology", "blockchain", "pandemic" and "healthcare entrepreneurship"that reflects healthcare entrepreneurship research relating to disruption and technology.Studies in this cluster shed light on the unprecedented disruption caused by COVID-19 and the ways in which technology is harnessed for digital health in the fight against the pandemic as well as the related infodemic (Lemaire et al., 2022).Other studies devoted attention to newage technologies such as blockchain and the Internet of things, showing how such Healthcare entrepreneurship technologies could facilitate safe and secure data sharing of personal health records in emergency conditions (Rajput et al., 2021) in addition to identifying business opportunities and enhancing value creation (Tuan et al., 2019).
Entrepreneurship models.Cluster 3 contains 6 keywordsi.e."artificial intelligence", "social enterprise", "mHealth", "institutional entrepreneurship", "business models" and "global health"that reflect healthcare entrepreneurship research pertaining to entrepreneurship models.Scholars in this cluster explain that new-age technologies such as artificial intelligence can present opportunities and threats that need to be considered in healthcare entrepreneurship (Shepherd and Majchrzak, 2022).Their studies also looked into the current landscape of lean healthcare startups, showing how venturing into mHealth can foster good customer engagement (Eppley et al., 2021), as well as various models of healthcare entrepreneurship involving the bottom of the pyramid (Angeli et al., 2018), institutional entrepreneurship (Heinze and Weber, 2016), telemedicine (Sundin et al., 2016) and the telepresence of robots (Wang et al., 2021).
Education and empowerment.Cluster 4 covers 6 keywordsi.e."education", "nurses", "nursing", "empowerment", "entrepreneurs" and "intrapreneurship"that reflect healthcare entrepreneurship research relating to education and empowerment.Scholars in this cluster reaffirmed the importance of creating a culture of innovation in healthcare (e.g.nursing), Healthcare entrepreneurship which could be fostered through shared vision, leadership, interdisciplinary partnerships and positive deviance (Melnyk and Davidson, 2009).They also highlighted the impact of startup programs (e.g.entrepreneurial attitude, entrepreneurial intention, entrepreneurial empowerment, entrepreneurial self-efficacy and entrepreneurship), which may be rolled out through entrepreneurship camps (Neerg ard et al., 2022) or management strategy simulations (Lim et al., 2021), as well as the role of intrapreneurship as drivers of innovation in healthcare (e.g.among nurses) (Ferraz et al., 2021).
Systems and services.Cluster 5 encapsulates 6 keywordsi.e."India", "startups", "public health", "medical tourism", "health system" and "health services"that reflect healthcare entrepreneurship research pertaining to systems and services.Scholars in this cluster explore the startup ecosystem, which has been driven in recent years by the digital revolution with Industry 4.0, including in healthcare (Bhatt et al., 2022).They have also explored specific segments of health system and services such as medical tourism, revealing the importance and value of the enterprising self in expanding the boundaries of healthcare (Muth and Suryanarayan, 2020) and showed how the service divide in healthcare could be bridged through digitally-enabled service innovations (Srivastava and Shainesh, 2015) and how health technology assessments (HTAs) could ensure the smooth confluence of technology, innovation and policy in realizing the positive impacts of health innovation emerging from healthcare entrepreneurship (Mukherjee, 2021).
Orientations and opportunities.Cluster 6 entails 4 keywordsi.e."entrepreneurial orientation", "emerging markets", "corporate entrepreneurship" and "healthcare industry"that reflect healthcare entrepreneurship research relating to orientations and opportunities.Scholars in this cluster highlight the role of achievement motivation and locus of control as factors of entrepreneurial orientation (Kne zevi c et al., 2021).They also reveal the stimuli of entrepreneurial activities like the autonomy of involved actors, collaborative and entrepreneurial mindset of healthcare leaders, policymakers and employees, technological and social development and the market environment, which, in turn, can contribute to improving the quality and efficiency of healthcare (Brandt and Znotka, 2021), including mitigating the potential of burnout among healthcare professionals (Kearney et al., 2020) and strengthening sustainable corporate entrepreneurship in terms of increased internal corporate venturing, strategic entrepreneurship and competitive capability (Urban and Maboko, 2020).
Choices and freedom.Cluster 7 includes 3 keywordsi.e."entrepreneurship", "selfemployment" and "health care"that reflect healthcare entrepreneurship research pertaining to choices and freedom.Studies in this cluster highlighting the importance of enabling environments to promote healthcare entrepreneurship.For example, Kuo and Lin (2020) observe a natural experiment where a universal health insurance program that extended health insurance coverage to all citizens increased the likelihood of being an entrepreneur.This extends the work of Salvino et al. (2014), who find that federal healthcare subsidies have disproportionately benefitted larger firms and thus contributing to the decline in the rate of self-employment.Other scholars such as Zandberg (2021) show that better access to reproductive healthcare increases the likelihood for women to engage in entrepreneurship.
Policy and impact.Cluster 8 is made up for 3 keywordsi.e."healthcare", "social entrepreneurship" and "health policy"that reflect healthcare entrepreneurship research relating to policy and impact.Studies in this cluster highlights a myriad of policies that could influence healthcare entrepreneurship such as gender policies seeking to transform the landscape of healthcare entrepreneurship through gender mainstreaming (Kuhlmann and Annandale, 2012), performance-based financing policies for healthcare entrepreneurs (Sieleunou et al., 2017) and innovation policies that seek to stimulate venture capital investments in healthcare enterprises (Lehoux et al., 2016).They also show the impact of healthcare entrepreneurship, particularly through the lens of social entrepreneurship, in IJEBR rising to the challenge of healthcare reforms through entrepreneurial and intrapreneurial initiatives (Wilson et al., 2012).Scholars such as Farmer and Kilpatrick (2009) further reaffirm that healthcare entrepreneurship is a form of social entrepreneurship, with evidence from rural health professionals whose many community activities resulted in social outcomes relating to health, while scholars such as Ketprapakorn and Kantabutra (2022) introduce a sustainable social healthcare enterprise development model with core components involving wellbeing, social vision, values and norms, knowledge and local and international impact.
3.3.1 Theoretical implications.The realm of healthcare entrepreneurship, much like the broader scope of the healthcare sector, exists at the confluence of empirical reality and evolving theoretical paradigms.As we delve into the nuances of the major themes and topics underpinning this field, the ripple effects on theoretical understandings become increasingly evident.Each cluster and corresponding study not only fills gaps in our present knowledge but reshapes the contours of existing theories and occasionally births new ones.The theoretical implications arising from this vast body of research signal both a consolidation of what we know and an invitation to further inquiry.It is a testament to the dynamism of healthcare entrepreneurship as a field of study.The subsequent sections aim to unearth and elaborate on these theoretical insights, offering scholars a fresh lens through which to approach and contribute to the ongoing discourse.
Integrative framework for healthcare entrepreneurship.The delineation of eight distinct clusters/themes suggests that the development of an integrative framework for healthcare entrepreneurship is necessary.Such a framework should encapsulate the interplay of various elements like innovation, technology, education, policy and diverse entrepreneurship models.By studying healthcare entrepreneurship through this integrative lens, researchers can address the complexities of healthcare entrepreneurship more holistically.This calls for a scientific movement that encourages interdisciplinary collaboration, ensuring that all facets of healthcare entrepreneurship, from technological innovations to policy implications, are adequately addressed.
Evolutionary role of technology and innovation in healthcare entrepreneurship.The emphasis on innovation, leadership, technology and disruption, especially in the first and second cluster, signals a theoretical shift in how healthcare entrepreneurship should be perceived.Healthcare entrepreneurship cannot and must not be limited to the confines of traditional enterprises.Instead, it is evolving into a platform of continuous, dynamic innovation.As the world grapples with unprecedented challenges, such as public health crises, global supply chain disruptions and technological revolutions, the theorization of phenomena surrounding healthcare entrepreneurship need to evolve, highlighting the imperative for agile and adaptive entrepreneurial models that can swiftly respond to disruptions.
Recognition of entrepreneurial diversity in healthcare entrepreneurship.The findings from the third cluster underline the variety of models within healthcare entrepreneurship, signaling the theoretical acknowledgment that healthcare entrepreneurship is not monolithic.The existence of a myriad of models, ranging from ventures driven by artificial intelligence to initiatives focusing on global health, implies that theoretical frameworks and underpinnings of healthcare entrepreneurship need to be adaptive and flexible.They should recognize and accommodate the wide spectrum of approaches in healthcare entrepreneurship, emphasizing the absence of a singular, universal model.
Shaping the next generation of healthcare entrepreneurs through entrepreneurship education.The spotlight on education and empowerment through the fourth cluster points toward an often-underestimated aspect of healthcare entrepreneurshipthe cultivation of an entrepreneurial mindset among healthcare professionals.From a theoretical standpoint, it accentuates the notion that healthcare entrepreneurship's roots lie in education and empowerment.Theoretical frameworks need to elucidate the pathways through which educational initiatives can spark innovation in healthcare, shaping a generation of Healthcare entrepreneurship professionals who are not just skilled in their specialties but are also entrepreneurial in their endeavors.
Entrepreneurial synthesis of healthcare systems and services.The emphasis on systems and services in the fifth cluster posits a theoretical challenge: how do we integrate entrepreneurial ventures seamlessly into established health systems?Theories must delve into the intricate relationship between budding startups and established healthcare entities, exploring collaboration, integration and potential competition.
Recognition of intrinsic and extrinsic entrepreneurial orientations in healthcare.The significance of entrepreneurial orientations, as illustrated in the sixth cluster, brings to the fore a dual theoretical challenge.On one hand, there is a need for theoretical models that encapsulate intrinsic factors like motivation and mindset.On the other, these models must also account for extrinsic factors, such as market conditions and the broader policy landscape.The theoretical exploration of healthcare entrepreneurship should, therefore, be both introspective and extrospective, capturing the multifaceted nature of the field.
Positioning healthcare entrepreneurship within the policy landscape.The revelations from the seventh and eighth cluster underscore a pivotal observation: healthcare entrepreneurship operates within the context of broader health and economic policies.This suggests that theories of healthcare entrepreneurship cannot be isolated from the dynamic interplay of policy landscapes.Future theoretical frameworks should articulate this relationship, capturing how policies can both enable and constrain healthcare entrepreneurial ventures.
Towards dual-motivation healthcare entrepreneurial models.One of the most striking theoretical implications is the positioning of healthcare entrepreneurship within the broader realm of social entrepreneurship.The findings suggest that motivations in healthcare entrepreneurship often transcend mere profit, extending into social outcomes.Therefore, any theoretical advancement in the field must recognize this dual motivation, ensuring that models are framed with both profit (return on investment) and social impact (return on value) at their core.
The theoretical landscape of healthcare entrepreneurship stands at a pivotal juncture.The profound insights from the analysis provide a compass for future academic endeavors, ensuring that emerging theories are not only reflective but also predictive of the complex, multifaceted realities of healthcare entrepreneurship.
3.3.2Practical implications.The evolution of healthcare is perpetually intertwined with the innovations and disruptions ushered in by entrepreneurship.As our understanding of healthcare entrepreneurship deepens, it is evident that its implications extend beyond theoretical contours and have tangible, actionable ramifications for a myriad of stakeholders.From the corridors of hospitals to the boardrooms of venture capitalists, from the classrooms of medical schools to the chambers of policymakers, the findings from the major themes and topics in healthcare entrepreneurship research chart a roadmap.This roadmap, laden with opportunities and challenges, requires strategic navigation.The onus is on key stakeholders, whether they are healthcare managers, investors, educators, or policymakers, to interpret these findings and translate them into pragmatic actions.The following sections delineate tailored recommendations, offering a comprehensive guide to harnessing the promise of healthcare entrepreneurship effectively and efficiently.
Be entrepreneurial in embracing technological integration of healthcare systems.With the emergence of themes emphasizing technological disruptions and innovations, notably from the first and second clusters, there is an urgent call for healthcare system administrators and hospital managers to be at the forefront of integrating technological advancements into their operations.This extends beyond merely adopting the latest technologies.Healthcare managers should actively seek collaborations with tech startups, particularly those highlighted under the disruption and technology cluster, such as digital health platforms and blockchain solutions.By doing so, healthcare systems can enhance their service IJEBR delivery, streamline patient data management and potentially revolutionize patient care paradigms.
Diversify entrepreneurial avenues in healthcare.The variety of entrepreneurial models showcased in the third cluster necessitates healthcare investors and venture capitalists to broaden their horizons.Rather than concentrating their investments in traditional healthcare models, they should explore and financially back ventures dabbling in artificial intelligence (AI)-driven solutions, global health and telemedicine.This diversified approach will not only mitigate investment risks but will also cater to emerging healthcare needs of the 21st century.
Cultivate an entrepreneurial culture in educational institutions to shape and safeguard the future of healthcare entrepreneurship.The fourth cluster's emphasis on the power of education and empowerment in healthcare entrepreneurship is a clear signal for educational institutions, especially medical and nursing schools.Deans and educational leaders should revisit their curricula, infusing them with entrepreneurial training modules.This might mean collaborating with business schools to design hybrid courses or even introducing entrepreneurial bootcamps specifically tailored for healthcare students.Such initiatives can prepare the next generation of healthcare professionals to be not just caregivers but also innovators.
Bridge the gap between healthcare startups and established systems.For healthcare policymakers and regulators, insights from the fifth cluster present an interesting challenge and opportunity.While the rise of healthcare startups, particularly in regions undergoing digital revolutions, is promising, there is a need to ensure they align with and complement existing healthcare systems.Policymakers should design frameworks encouraging partnerships between startups and established healthcare providers.Such alliances can expedite the integration of innovative solutions into mainstream healthcare, ensuring a wider reach and quicker adoption.
Design entrepreneurial work environments to support healthcare entrepreneurship.In light of the findings from the sixth cluster, human resource managers in healthcare facilities, both large and small, should be proactive in fostering a conducive environment for entrepreneurial orientations.This might involve creating in-house innovation hubs, organizing regular ideation sessions, or even facilitating external workshops that equip healthcare professionals with entrepreneurial tools and mindsets.Such initiatives can inspire and empower professionals to be intrapreneurs, innovating from within the organization.
Engage in constructive policy dialogs for healthcare entrepreneurship.The entwined relationship between healthcare entrepreneurship and policies, especially evident from the seventh and eighth clusters, presents a unique recommendation for both entrepreneurs and policymakers.Healthcare entrepreneurs should not remain passive observers of the policy landscape.They should form coalitions, engage in constructive dialogs with policymakers and play a part in shaping regulations that impact their ventures.On the flip side, policymakers should actively seek feedback from entrepreneurs, ensuring that policies are not stifling innovations but rather fostering a thriving entrepreneurial ecosystem.
Merge profit with purpose for social impact via healthcare entrepreneurship.For healthcare entrepreneurs and their investors, the recurring theme of social outcomes across clusters should serve as a guiding principle.In the race to profitability, the core mission of healthcare-to provide care and improve well-being-should not be overshadowed.Entrepreneurs should design business models that merge profitability with purpose.Investors, while seeking returns, should also measure the social impact of their investments, ensuring that the ventures they back are contributing positively to societal health.
Incorporating these managerial recommendations, tailored for distinct stakeholders, can holistically elevate healthcare entrepreneurship.By ensuring that each stakeholder-from investors to educators, from policymakers to entrepreneurs-plays their part effectively, we can foster an environment where innovations thrive, policies support and healthcare outcomes flourish.

Healthcare entrepreneurship
3.4 Future directions for healthcare entrepreneurship research (RQ4) The average publication year of topics on healthcare entrepreneurship is indicated in Table 3 and the trajectory of research in the field is illustrated using an overlay visualization in Figure 4. Temporal retrospection and futures prospecting are engaged to curate the future directions for healthcare entrepreneurship research, which will be presented in the next sections.
3.4.2How can the field be further developed?.Given the observed trajectory of healthcare entrepreneurship research alongside the discussion of major themes and topics in the field, several noteworthy reflections and promising pathways are available to inform future endeavors intending to advance the body of knowledge on healthcare entrepreneurship (Table 4).

IJEBR
Firstly, healthcare entrepreneurship can be viewed internally and externally.The internal viewpoint implies that future research efforts can be channeled to examine how entrepreneurship in healthcare can be nurtured and supported, whereas the external viewpoint suggests that future research efforts can be invested to investigate how healthcare can support the proliferation and success of entrepreneurship.
Secondly, healthcare entrepreneurship is not immune to disruptions.There is also a noticeable lack of taxonomies or toolboxes that healthcare entrepreneurs can rely on to not only survive and stay resilient but also safeguard transient and sustainable competitive advantages to continue to grow and prosper in a disruptive, volatile, uncertain, complex and ambiguous (DVUCA) environment.Therefore, future research efforts can be directed to develop a taxonomy or toolbox of strategies, tactics and tools that can be used to foster a competitive, innovative and resilient culture in healthcare enterprises, including the dynamic capabilities (Kraus et al., 2023), intellectual capitals (Schiavone et al., 2022a) and enabling environments (Soni et al., 2022;Ciasullo et al., 2023) that will be required.
Thirdly, healthcare entrepreneurship remains underexplored in developing and less developed countries, especially in the Global South.In this regard, there is a need to engage in context-specific investigations, including that which is cross cultural (Schiavone et al., 2021) or that which targets market segments such as older adults (Schiavone et al., 2022b), in order to unpack the peculiarities that can shape our understanding of the varied nuances of healthcare entrepreneurship and how we will need to respond to support the growth and scale the impact of healthcare by means of entrepreneurship.
Fourthly, healthcare entrepreneurship is reliant on entrepreneurship education as much as with entrepreneurs themselves.While existing studies on entrepreneurship education programs have documented such as entrepreneurship camps (Neerg ard et al., 2022) and management strategy simulations (Lim et al., 2021), the evidence and scope of impact will Healthcare entrepreneurship need to expand.Given that entrepreneurship could occur internal (i.e.corporate entrepreneurship or intrapreneurship) and external (i.e.entrepreneurship or social entrepreneurship) to the organization, as well as in formal (i.e.startup and scaleup ventures) and informal (i.e.entrepreneurial attitude and mindset in work) ways, future research efforts can develop innovative entrepreneurship programs and map the impact outcomes to the various manifestations of entrepreneurship.
Finally, healthcare entrepreneurship, like other business or entrepreneurial ventures in any industry, in is the midst of transitioning from a digital revolution to a transformative revolution (Lim, 2023).In this regard, future research efforts will need to account and respond to recent trends such as the proliferation of generative artificial intelligence such as ChatGPT (Lim et al., 2023) and the rise of the metaverse (Kraus et al., 2023) in a timely and relevant manner so that entrepreneurship continues to drive innovative that enables healthcare to transition and even leapfrogged, into advances that will greatly benefit public health and the society.

Conclusion
To this end, this article has accomplished its goal to deliver an overview of healthcare entrepreneurship, both in terms of its current trends and future directions.Noteworthily, the article finds that healthcare entrepreneurship research has fared reasonably well in terms of publication productivity and impact.The article also shows diverse contributions coming from authors, institutions and countries, as well as a range of monetary and non-monetary support from funders and journals in relation to healthcare entrepreneurship research.The article also reveals eight major themes of healthcare entrepreneurship researchnamely, innovation and leadership, disruption and technology, entrepreneurship models, education and empowerment, systems and services, orientations and opportunities, choices and freedom and policy and impact.The article concludes with a collection of noteworthy reflections accompanied by a set of promising pathways that can be used to guide the future research efforts.
Nevertheless, this article remains limited to the accuracy and completeness of the database that was used (i.e.Scopus), as well as to the limitations of bibliometrics or scientometrics analysis (i.e.overview).Though legitimate and justified, future reviews may wish to engage in alternative databases (e.g.Web of Science) and review methods (e.g.content analysis using frameworks and meta-analysis) to supplement the insights herein this review (Kraus et al., 2022;Lim et al., 2022).Similarly, the scopeand by extension, the search keywordsof this article was limited to healthcare entrepreneurship in line with the theme of the special issue.Therefore, future reviews are encouraged to explore closely-related forms of entrepreneurship, for example, medical entrepreneurship, which is more specialized, predominantly revolving around innovations in medical practice (e.g.medical tourism) and supplies (e.g.pharmaceuticals).While there is an inherent overlap with healthcare, medical entrepreneurship is narrower, more clinician-centric and often more focused on tangible products or specific medical services.
Figure 1.The methodology for reviewing healthcare entrepreneurship research

Figure 4 .
Figure 4. Topical evolution of healthcare entrepreneurship research ;

Table 2 .
IJEBRarticles, King's College London with 6 articles and 5 other institutions with 5 articles each (Panel C).Other noteworthy institutions include IILM Graduate School of Management and University of the Witwatersrand Johannesburg with 4 articles each and Children's Hospital Boston, Massachusetts General Hospital and VA Boston Healthcare System with 3 articles each.This shows that most healthcare entrepreneurship research are conducted by academic institutions while non-academic institutions remain underrepresented, especially in the Global South, which is virtually non-existent.In terms of countries, the United States of America emerges as the most prolific country with 170 articles, followed by the United Kingdom with 63 articles, India with 46 articles, Canada with 34 articles and Germany with 29 articles (Panel D).Other developed countries such as Australia has 19 articles, Japan has 6 articles and Greece has 4 articles while developing countries such as China has 13 articles, South Africa has 12 articles and Malaysia has 7 articles.This shows that most healthcare entrepreneurship research are concentrated in countries located in the Global North while countries situated in the Global South are represented but remains underexplored.In terms of funders, the Economic and Social Research Council emerges as the most prolific funder with 9 articles, followed by the Canadian Institute of Health Research with 8 articles, the National Institutes of Health with 4 articles, 10 other funders with three articles each and 19 other funders with 2 articles each (Panel E), showing that funding is available for healthcare entrepreneurship research, which, with greater awareness, should motivate further research.