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The overall objective of this research was to elucidate the ecosystem of women’s health social enterprises (WHSEs) based in the United States. The Aim I was to conduct a secondary data analysis of a random national sample of non-profit WHSEs based in the United States regarding their characteristics and areas of intervention. Aim II was to conduct a qualitative assessment of a sample of WHSEs based in the United States regarding their perspectives on the ecosystem of WHSEs. Aim I utilized the GuideStar database and assessed enterprise size, geographic location, financial distress, health intervention area, and health activity category using descriptive statistics, statistical tests, and multivariable regression analysis via SPSS. Aim II utilized in-depth interviewing and grounded theory analysis via MAXQDA 2018 to identify novel themes and core categories while using an established framework for mapping social enterprise ecosystems as a scaffold.

Aim I findings suggest that WHSE activity is more predominant in the south region of the United States but not geographically concentrated around cities previously identified as social enterprise hubs. WHSEs take a comprehensive approach to women’s health, often simultaneously focusing on multiple areas of health interventions. Although most WHSEs demonstrate a risk for financial distress, very few exhibited severe risk. Risk for financial distress was not significantly associated with any of the measured enterprise characteristics. Aim II generated four core categories of findings that describe the ecosystem of WHSE: (1) comprehensive, community-based, and culturally adaptive care; (2) interdependent innovation in systems, finances, and communication; (3) interdisciplinary, cross-enterprise collaboration; and (4) women’s health as the foundation for family and population health. These findings are consistent with the three-failures theory for non-profit organizations, particularly that WHSEs address government failure by focusing on the unmet women’s health needs of the underserved populations (in contrast to the supply of services supported by the median voter) and address the market failure of over exclusion through strategies such as cross-subsidization and price discrimination. While WHSEs operate with levels of financial risk and are subject to the voluntary sector failure of philanthropic insufficiency, the data also show that they act to remediate other threats of voluntary failure.

Aim I findings highlight the importance of understanding financial performance of WHSEs. Also, lack of significant associations between our assessed enterprise characteristics and their financial risk suggests need for additional research to identify factors that influence financial performance of WHSE. Aim II findings show that WHSEs are currently engaged in complex care coordination and comprehensive biopsychosocial care for women and their families, suggesting that these enterprises may serve as a model for improving women’s health and health care. The community-oriented and interdisciplinary nature of WHSE as highlighted by our study may also serve as a unique approach for research and education purposes. Additional research on the ecosystem of WHSE is needed in order to better inform generalizability of our findings and to elucidate how WHSE interventions may be integrated into policies and practices to improve women’s health.

The chapter redefines the focus of the changes required to create sustainable healthcare away from fixing healthcare organizations and toward reconfiguring the constituent elements of the healthcare ecosystem and redefining how they interrelate to yield value more sustainably.

Based on a review of recent literature on healthcare reform, we argue that unlike other sectors, healthcare organizations cannot change themselves without changing their connections to the rest of the healthcare ecosystem, including other healthcare organizations, patients, governments, research institutions, vendors, and the citizenry at large. This is because these are not only stakeholders but also integral parts of healthcare processes.

Interventions intended to create more sustainable healthcare must bring together knowledge and perspectives from across the ecosystem, and must converge different sources of information and analysis to generate novel ways of connecting across the ecosystem. Change within a healthcare system cannot achieve the magnitude of transformation needed to become sustainable.

If the healthcare ecosystem evolves in the manner described in this chapter, the healthcare ecosystem will no longer center around particular institutions and doctors’ offices but rather be defined by flexible and variable interactions between co-acting elements of the ecosystem.

The chapter treats the context as the focus of change in order to change the healthcare system. It proposes three kinds of flows: knowledge, clinical, and resource that are already beginning to change and that will eventually result in fundamentally different approaches to healthcare.

Purpose – This chapter frames the topic of organizing for sustainable health care in terms of the environmental trends that have rendered current health care approaches unsustainable, the embeddedness of health care in society's triple bottom line, and the need to build adaptive capability within the complex health care ecosystem.

Design/methodology/approach – We synthesize documented trends and empirical findings regarding the viability of current approaches to health care, and provide a theoretically framed treatment of the adaptation process in the complex health care system that can lead to the emergence of sustainable approaches.

Findings – There is a misfit between current approaches to delivering health care and the requirements and trends in contemporary society. Fundamental transformation is required that entails a broadening of purpose, a future orientation, and a rethinking of how health care adds value and how it is embedded in society.

Originality/value – By reconceptualizing health care reform as intricately related to societal sustainability and the triple bottom line, we open the possibility of transcending a narrow focus on reengineering to create more efficient organizations and work processes that consume fewer resources and deliver greater value. We invite health care practitioners and scholars to rethink all the connections in the health care ecosystem, and the need to build in self-organizing capabilities and adaptive capacity. The cases in this book provide knowledge from systems engaged in fundamental transformation, analyzed through the lenses of theoretical frameworks that help us better understand essential dynamics involved in creating sustainable health care systems.

This chapter provides a reflective synopsis of six cases focused on making healthcare sustainable. The nature and value of an ecosystem perspective is explored. The intent is to apply and generate organizational knowledge to understand and guide purposeful design and learning.

From five countries where healthcare is organized differently, these cases illuminate particular approaches to develop the capabilities for healthcare to deliver greater value to society. Each case is examined through the lens of an appropriate theoretical perspective. This chapter reports the themes that were common in the six case studies.

New approaches are changing the connections in the healthcare ecosystem, including the flows of: medical knowledge, clinical information, and resources. Common themes include: the importance of networks in the emerging healthcare ecosystem; the role of governance mechanisms and leadership to align the diverse ecosystem components; the engagement of dominant ecosystem actors; the need for adaptive change capabilities, and for multi-stakeholder research collaborations to generate actionable knowledge.

Taking an ecosystem perspective enables healthcare leaders to broaden their conceptualization of the changes that will be required to be sustainable in a changing society.

Almost every man, woman and child is affected by the healthcare system. Increasing the sustainability of healthcare is integral to increasing societal sustainability overall.

Viewing the ecosystem as the appropriate focus of purposeful change departs from a traditional approach that focuses on the effectiveness of each element.

This chapter argues that organizations are not sustainable if they operate in unsustainable societal and ecological contexts, and that operating in a way that contributes to the health of the larger system requires organizations to develop new capabilities. It demonstrates the role that rich internal and external networks play in developing sustainability capability particularly in providing pathways to generate, import, apply, and disseminate knowledge about how to operate more sustainably.

The case study of the sustainability transition of Cleveland Clinic is based on four years of interviews and archival data collection examining the system’s transformational change that began in 2007. The case focuses on the building of sustainability capability, including an internal infrastructure to focus the organization on this outcome, and building of rich networks for learning and action. The case is framed with capability and network theory.

Guided and catalyzed by a small central group called the Office for a Healthy Environment, Cleveland Clinic has achieved measurable progress in key strategic focuses including waste diversion, energy efficiency, and increasing integration of local foods into its supply chain. To do so, it has developed strong internal networks to disseminate knowledge and accelerate innovation and adoption of sustainable practices. Strong, dynamic external networks have enabled Cleveland Clinic to import knowledge about sustainable practice from its environment, and have enabled it to help build the sustainability capability of its vendors, the community upon which it depends, and the health-care industry.

Starting with the perspective that the sustainability of an organization depends on the sustainability of the ecosystems in which it exists, this chapter focuses not on the design of specific sustainability initiatives, but on the dynamic networks that underpin the capability to simultaneously improve the health of the organization and of the larger ecosystem. This perspective provides insight into new organizing principles.

Purpose – This chapter provides a reflective synopsis of the chapters in the volume and highlights the learning from the cases about the development of new orientations, design configurations, and learning mechanisms. It charts directions for further research and possible managerial actions.

Design – The chapters in this second volume of the book series “Organizing for Sustainable Effectiveness” capture a rich set of cases in which organizing for sustainable health care was the central focus. Each chapter illuminated the development of a distinct health care system in a unique cultural and national context, and had a special focus on reporting theoretically informed and rigorously explored knowledge to guide purposeful design and learning approaches. Collectively the chapters highlighted the processes, organization and design, system regulation, and continuous learning approaches in complex organizational and multi-organizational health care systems that enable focus on and advancement of economic, social, and ecological outcomes.

Findings – Several critical themes have emerged from the cases, and from the broader literature on health care transformation: the importance of purpose; the need to overcome fragmentation; the need for alternative business models; technology as an investment in sustainable health care; the centrality of knowledge management; the importance of partnership and collaboration; the role of self-organization and leadership; and the criticality of building change capabilities.

Although healthcare and healthy living are integral to the Sustainable Development Goals (SDGs) for 2030, the coronavirus epidemic has dealt a devastating blow to these efforts. As governments and policymakers were compelled to shift their focus to lockdowns, sustenance, procurement, and distribution of vaccines, the momentum for health initiatives slowed, and the already fragile health systems of emerging markets were subjected to additional shocks. However, in many underserved regions of the globe, the introduction of technology has greatly facilitated the distribution and adoption of healthcare services.

This chapter highlights mini-cases from four emerging nations: Bangladesh, Nigeria, Vietnam, and the Philippines. Although the countries are emerging, each one of them are in a distinct stage of development and face a unique set of healthcare-related challenges. The chapter showcases how four different organizations based in these countries leveraged the use of technology to take healthcare services to underserved populations. In doing so, they addressed the key challenges of imparting healthcare: geographic accessibility, availability, financial accessibility, and acceptability.

This chapter concludes with a discussion of the implications of expanding healthcare industries leading to increased healthcare waste. To prevent mass population exposure to hazardous substances, the emergence of intelligent healthcare waste collection and disposal systems will be an absolute necessity. Hence, with the development of healthcare services, governments and policymakers need to mechanize smart waste management systems to safeguard humans, animals, and the environment.

Healthcare innovations for bottom-of-pyramid populations face considerable risks and few economic incentives. Can entrepreneurial innovators provide new solutions for global health? This chapter examines how a technology enterprise built a collaborative network and supportive ecosystem making it possible to steer an innovation for TB patients through discovery, development, and delivery. Ecosystem resources were mobilized and upstream and downstream co-innovation risks were mitigated to commercialize a new diagnostic test. Detailed evidence on this innovation for TB care uses ecosystem analysis to clarify core issues in the context of joint value creation. The case study shows how resources from private and public partners can be leveraged and combined by the focal firm to build joint value and to lower execution, co-innovation, and adoption risks in healthcare ecosystems combating diseases of poverty.

Purpose – This chapter argues that health care is best conceptualized as a complex adaptive system. Sustainable health care depends on harnessing the complexity of the system by building aligned purpose, flexible pathways to connect people, knowledge and resources, and the capacity for self-organization.

Design/methodology/approach – The case study of the Southern California Region of Kaiser Permanente is based on three years of interviews and archival data collection examining the system's transformational change that began in 2004 and has been aimed at building a sustainable health care system with the guiding principles of value and prevention. The case focuses primarily on the medical care delivery system designed by the Southern California Permanente Medical Group, the capabilities that have been built into the system to continually improve the quality of care and the outcomes of the system, and the results that have been achieved.

Findings – During the period from 2004 to 2011, the region improved significantly in slowing cost acceleration by significantly improving medical care. The implementation of an electronic medical records system and its integration with other clinical information technology systems have enabled: (1) truly integrated, well defined, and easily navigated care delivery systems that are based on evidence; (2) upstream focus on prevention, disease control, patient education, and population health; and (3) management accountability and organizational improvement systems based on transparency of data and feedback. Physician leadership and partnering with the region's administrative and hospital leadership have been critical change enablers.

Originality/value – Embracing the complexity of the system has led to the crafting of pathways and linkages that enable patients to move through the system to flexibly and efficiently connect to the knowledge and resources required to optimize their health. This requires continual self-organization based on well-defined roles and connections. Previous health care improvement approaches have stressed initiatives and organizational changes that may further fragment the health care system.