Investing in nursing and midwifery enterprise ... - Nursing Outlook

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Nurs Outlook 64 (2016) 7e16

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Investing in nursing and midwifery enterprise to empower women and strengthen health services and systems: An emerging global body of work Marla E. Salmon, ScD, RN, FAANa,b,*, Akiko Maeda, PhDc a

School of Nursing, University of Washington, Seattle, WA b Global Health, University of Washington, Seattle, WA c Health, Population and Nutrition Global Practice, The World Bank, Washington, DC

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abstract

Article history: Received 9 July 2015 Revised 20 October 2015 Accepted 7 November 2015 Available online 22 November 2015

In September of 2014, the Institute of Medicine (IOM) convened a global Rockefeller Bellagio Center workshop focusing on the largely overlooked area of investment in nursing and midwifery enterprise as a means for both empowering women and strengthening health systems and services. The report of this meeting, Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary, was released in February, 2015. This report represents a pivotal point in a growing body of work begun in 2012, providing insights and perspectives of global experts that have resulted in subsequent global discussions and are paving the way for the future. This three-part article summarizes the initial exploration leading to the IOM workshop and report, followed by highlights and insights from the report and related meetings, and authors concluding discussion of implications for the future and next steps.

Keywords: Impact investment Women/women’s empowerment Gender equity Nursing and midwifery enterprise Social enterprise Social finance Health systems strengthening Health sector reform Universal health coverage Institute of Medicine

Cite this article: Salmon, M. E., & Maeda, A. (2016, FEBRUARY). Investing in nursing and midwifery enterprise to empower women and strengthen health services and systems: An emerging global body of work. Nursing Outlook, 64(1), 7-16. http://dx.doi.org/10.1016/j.outlook.2015.11.010.

A Personal Note of Introduction Ideas and their development often emerge from the convergence of experience, jarring realizations, and enabling opportunities. The work summarized in this article proceeded in just this way. For decades, I had observed the transformative power of nursing and midwifery for women working in these fields. In 2011,

I became vividly aware of the effects of investment in women’s commercial and agricultural enterprise on their empowerment and overall wellbeing. This led me to a realization that was both simple and troubling: in that this appeared to be a very large blind spot for both the health and international development sectors. In 2012, I had the opportunity to turn my attention to these nagging ideas, thanks to my year-long experience

* Corresponding author: Marla E. Salmon, Psychosocial and Community Health, University of Washington, Box 357263, Seattle, WA 98195-7263. E-mail address: [email protected] (M.E. Salmon). 0029-6554/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.11.010

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as Distinguished Nurse Scholar in Residence at the Institute of Medicine (IOM)/American Academy of Nursing/American Nurses Foundation/American Nurses Association Distinguished Scholar 2012e2013, which was “jump-started” by my month-long residency at the Rockefeller Foundation Bellagio Center. Later, support from the Robert Wood Johnson Foundation and the IOM enabled the work leading to the IOM’s global workshop, its resulting workshop report, Empowering Women and Strengthening Health Systems and Services through Investing in Nursing and Midwifery Enterprise: Lessons from LowerIncome Countries: Workshop Summary (IOM, 2015), and its global discussion meeting held in March of 2015. These efforts have provided an important foundation for work going forward.

This three-part article describes a global body of work elucidating the possibilities for, and impact of, investment in NMEs both to empower women and to strengthen health services and systems. Part I describes the initial inquiry that ultimately led to the IOM initiatives; Part II presents highlights and key perspectives from the IOM summary report and related discussions, followed by implications for the future; and Part III presents the authors’ concluding views.

Part I. Initial Exploration: Laying the Groundwork Approach

Background Investment in women’s enterprise aimed at empowerment is a long-standing international development practice (Duflo, 2012; International Center for Research on Women, 2015a, 2015b). Often, in the form of microfinance and philanthropy, investment has focused mostly on women’s commercial and agricultural ventures (Gates, 2014). In contrast, the health sector has generally aimed its empowerment investments on services to women, often focusing on family planning, maternal child, and family health. Empowerment of women working in the health sector appears largely incidental (recent signs of interest in embedding intentional empowerment strategies in health programs at the Gates Foundation may help to raise awareness in this regard; Gates, 2014). Growing health-related innovation in low- and middle-income countries (LMIC) is resulting in the emergence of enterprise that holds promise for empowerment of female health workers. Of particular note are those involving nursing and midwifery practices and associated education/training. A recent study of these enterprises (Krubiner, Salmon, Synowiec, & Lagomarsino, 2015) documented examples of both incidental and deliberate opportunities for women’s empowerment. These NMEs are most often associated with efforts to strengthen health systems and services, aligning with global health agendas (Faye, Bob, Fall, & Fall, 2012; Kra et al., 2012; Lawn et al., 2008; Maeda et al., 2014; World Health Organization, 1978). Increasing engagement of private and philanthropic investors and development of some innovative publiceprivate partnerships (International Partnership for Innovative Healthcare Delivery (IPIHD), 2013) have opened the doors for expansion of nurses and midwives in the delivery of services, leadership roles, and as owners and operators of their own practices. Although there is growing recognition of the value of these arrangements to health services and systems, their potential benefit to the women who make this work possible has been largely overlooked.

Much is known about the benefits of nursing and midwifery services to women’s health and well-being. However, there is little documentation of their contributions of these disciplines to empowerment of their female members. An initial global review of both conventional and gray literature (original and translated English) yielded no published studies, and few relevant reports. Subsequent investigation involved a broader range of approaches, including review of >700 articles and reports utilizing global search methodologies of literature, unpublished reports, and case studies. Our investigation broadened to include extensive meetings with experts whose knowledge and experience represented the key areas in which our search focused women’s empowerment, social finance and enterprise, health systems and services, and nursing and midwifery, yielding additional important additional resources, insights, and ideas. We ultimately honed in on the intersection among these as the conceptual location of NME that holds promise for empowering women and strengthening health systems and services. Figure 1 is the visual

Figure 1 e Focus of initial exploration.


representation of this conceptual terrain, with NMEs situated in the very small intersection at the center. Its size is scaled to approximately reflect the relative availability of information relevant to our inquiry. The components of this NME intersection are described in the following sections.

Women’s (Women) Empowerment Often a subcategory of gender equity, women’s empowerment (also referred to “women empowerment”), involves conditions or actions enabling women’s equitable participation in family, community, and society at large. Our work was guided by the United Nations Development Programme’s five key components of women’s empowerment: “.women’s sense of self-worth; their right to determine choices; their right to have access to opportunities and resources; their right to have power to control their own lives, both within and outside the home; and their ability to influence the direction of social change to create a more just social and economic order, nationally and internationally” (United Nations Development Programme, 2014).

Strong Health Systems and Services We sought to understand what the characteristics of strong health systems are, ultimately seeing them as those in which all people can “. access quality health services, safeguard them from public health risks, and protect all from impoverishment due to illness” (Maeda et al., 2014). Our work was also informed by the World Health Organization’s six key components of strong health systems: (a) leadership and governance, (b) health information systems, (c) sustainable and equitable health financing, (d) human resources for health, (e) essential medical products and technologies, and (f) health service delivery (World Health Organization, 2010). We also came to understand the importance public and private sectors have in aligning with public health goals to create strong health systems.

Nursing and Midwifery Enterprise We adopted the term NME in recognition of nursing and midwifery’s place in the rapidly growing landscape of health-related social enterprise opportunities. Our investigations utilized NMEs, and more common terms, such as nurse-managed health centers, nursing centers, midwifery centers, birthing centers, and nursing/ midwifery practices. We learned that although there are many different types of nursing and midwifery practice arrangements, very few were operated as sustainable businesses, with even fewer owned and operated by nurses and midwives. Ultimately, our work focused on NMEs that were businesses (both for-profit and nonprofit) involved in the delivery of services in which the work of nurses or midwives was a central focus.

Social Finance and Enterprise Social finance is a growing area of investment and support aimed at achieving both social and financial

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returns. Forms of finance vary and can include “debt, equity, grants, donor funding, and public funding” (IOM, 2015). Funding sources vary and may include conventional lenders, private investors, foundations and trusts, governments, cooperatives, crowdfunding, and lending circles. Social enterprise, a related concept, is made up of businesses aimed at benefitting society in financially sustainable ways. Good business practices are at the core of successful social enterprise, and their corporate status may be for-profit or not-for profit in nature. We see NMEs as a type of social enterprise, with potential for investment and support through social finance.

Initial Insights Our exploration helped set the stage for the subsequent work discussed below in Part II. The insights that we gained from our initial exploration are discussed in the following sections.

Forces at Work We noted that important forces are shaping NMEs. Among these is the growth of women’s enterprise more broadly, which can help to inform and provide rationale for NME development. Increasing social finance, which is fueling the growth of these enterprises, is rapidly moving into the health sector focusing on enterprises that address unmet need and demand for health services, while also yielding financial returns for investors. NMEs with compelling health, social, and business cases could hold appeal for these types of investment. Another important force is growing global concern about the impact of poverty and powerlessness on the health and well-being of people and societies around the world (United Nations Development Programme, 2015). Ensuring universal access to affordable, quality health services will be an important contribution to ending extreme poverty and boosting shared prosperity in LMICs, where most of the world’s poor live (Maeda et al., 2014). Efforts to improve access are resulting in shifts from institutional settings toward innovative community-based approaches, often owned and/or operated by individuals or groups outside governments (World Bank, 2008). Many of these enterprises rely on nurses and midwives; some afford opportunities for them to own, or to own and operate these NMEs (IPIHD, 2013), and improving the lives of other women with whom they work. We also noted that the growing private sector has made significant strides in gaining expanded practice scopes and payment for the services of nurses and midwives. The power of the private sector to effect change is not easily achieved through traditional health sector channels and is an important consideration for the future of NMEs. Another factor shaping NMEs is the relationship between the expanding private sector and the public sector. Private sector growth creates challenges for

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governments to find ways to ensure alignment with public interests. Development of constructive models for publiceprivate engagement is important to all involved. Regardless of their roles, nurses and midwives will be affected by the extent to which the public and private sectors work well together. NMEs may be well advised to develop ways in which their work directly advances public good agendas.

NMEs and the Work of Nurses and Midwives We learned very early in our exploration that nurses and midwives at all levels of education and training can provide services delivered through NMEs. We identified types of community-based services in which this was the case. For nurses, these included services focusing on chronic disease and illness care management, psychiatric/mental health, home health and long-term care, post-hospital transitional care, hospice care, school health, primary care, women’s health, elder care, public health, long-term care, health coaching, occupational health, and specialized services such as foot care, wound care, and simple surgical procedures such as circumcisions for HIV prevention. In some areas, there was overlap with the work of midwives, whose services focus on meeting the general health needs of women, girls, and new families to those more specialized, such as caesarian sections and post-abortion care (The Lancet, 2014). Nurses and midwives also play crucial roles in the provision of emergency and humanitarian relief services to those affected by war, epidemics, political or social unrest, or forced migration. Often working as volunteers, they may themselves be victims whose service may go on for months or even years (Maternal Health Task Force, 2010; Time, 2014; von Roenne et al., 2010). Developing NMEs in these situations or mobilizing those able to extend their reach to affected areas may enable enhanced service delivery, service continuity, and infrastructure development.

midwives also interface with physicians and other health practitioners. Technology is an important enabler of collaborations, making possible delivery of more complex and better quality services. Nurses and midwives also work with one another, often through professional organizations, cooperatives, and other groups that enable development and longer term success. These organizations appear to play central roles in the development of many NMEs. We identified examples of organizations providing financing, peer support, business and professional training, and quality assurance activities. Some organizations also worked to advance women’s enterprise more broadly, engaging members in related political, social, and community service activities (PRINMAT Tanzania, 2015; White et al., 2013). The work of the International Council of Nurses in partnership with national nursing organizations to improve the well-being of girl children is another example of collective action (International Council of Nurses, 2009).

Timing and NMEs Many forces appear to be converging that set the stage for NMEs. Growing unmet health needs and demand and increasing investment in the health sector are resulting in innovative approaches to service delivery. Timing appears to be particularly opportune for nurses and midwives to engage in creation of enterprises that align well in this changing health sector landscape.

Limitations Lack of relevant literature and research limited our ability to draw concrete, evidence-based conclusions. The exploration discussed previously provides the groundwork for future efforts, including those described in Part II of this article.

Connections with Other Health Workers

Part II: The IOM Workshop, Report, and Related Deliberations

Nurses and midwives often work closely with others; many of whom are women working as outreach/community health workers, assistants, volunteers, and family care providers. For example, the Grande Aide Program augments the reach of the traditional health workforce in several countries with auxiliary health workers trained, supported, and supervised by the nurses with whom they work (Garson Jr., Green, Rodriguez, Beech, & Nye, 2012). These types of arrangements can also be seen in the delivery of mental health services and other community-based services in which trained professionals are scarce (Usher et al., 2014). Midwives also partner with community-level health workers, including midwifery assistants and trained birth attendants. The importance of outreach and ongoing connection with vulnerable women is a key feature of midwifery practice and benefits from these collaborations (Sibley, Sipe, & Koblinsky, 2004a; Sibley, Sipe, & Koblinsky, 2004b). Nurses and

In September of 2014, the IOM convened “a workshop on empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise” at the Rockefeller Center in Bellagio, Italy (IOM, 2015). Experts in women’s empowerment, development, health systems’ capacity building, social enterprise and finance, and nursing and midwifery came together to consider lessons of nursing and midwifery service enterprise models holding promise for strengthening health services, empowering women, and informing innovation in the United States and beyond. IOM released the report of this meeting, Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries (IOM, 2015), at a global discussion meeting in Washington, D.C. on March 10, 2015. Subsequent related discussions, including those at


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the annual forum of IPIHD, and the World Bank Human Resources Seminar, also took place in March, 2015. Important highlights emerging from the workshop, report, and related discussions are summarized in the following sections.

Utility of NMEs A fundamental question underlying all discussion related to the utility of NMEs in advancing the aims of empowering women and strengthening of health systems and services. Their possible relevance to reducing poverty also emerged as an important area of interest. The discussion below focuses on these topics.

Figure 2 e Focus of nursing and midwifery enterprises (Krubiner et al., 2015).

Contributions to Women’s Empowerment IOM workshop deliberations initially focused only on empowering female nurses and midwives. Discussions broadened to include other female health workers, such as community health workers, assistive and administrative staff, and voluntary and informal care providers. Participants recognized the crucial roles (often unrecognized and uncompensated) that women play in the health sector and the NMEs’ potential to improve their lives (IOM, 2015). Nursing and midwifery education and training emerged as ways to empower women and girls through improving educational levels and affording employment opportunities. “Prestige is given to educational qualifications, which can improve the status of nursing and women (IOM, 2015).” Career progression or “laddering” from lower level training and work to more advanced levels were seen as an important empowerment tool. Both vocational and leadership training surfaced as crucial components of educational empowerment. Discussions also identified the potential value of NMEs in affording economic opportunity through employment and ownership. Income, decent jobs for entry-level health workers, opportunities for career development, and the possibility to own and control assets are important ways in which NMEs could empower women. NMEs may also provide a platform for having a voice in society through collective, organized political and social engagement. The idea that NMEs could serve as a community focus or “hub” for empowering women surfaced in discussions. The work of caring is largely performed by womendmost of whom intersect in some way with nurses and midwives. In addition, much of the work of NMEs focuses on women’s well-being, often providing safe motherhood and reproductive health service (Figure 2). This strong connection with women can provide a platform for building other empowerment approaches.

Contributions to Health Systems and Services NMEs vary widely in their organization and financing. In their IOM workshop presentation, Carleigh Krubiner and Gina Lagomarsino described initial findings of

research (a summary of this study appears in elsewhere in this issue; Krubiner et al., 2015; June) on investment NME in lower income countries (Krubiner et al., 2015). These were largely community based, with maternal and child health, primary care, and family planning reproductive services most commonly reported as primary areas of work (Figure 2). The following four key attributes emerged as common among these NMEs: (a) meeting unmet need, (b) filling care gaps, (c) responding with creativity and flexibility, and (d) working in community-based and engaged ways. These attributes position NMEs as important resources to meeting the challenges facing health systems today. Discussions recognized the important contributions that NMEs can make to delivering cost-effective community-based services to underserved and vulnerable populations as contributions. During both IOM and World Bank meetings, Julie Fairman cited U.S.-based examples of these contributions, highlighting both NurseeFamily Partnerships and the Developing Families Center in Washington, D.C. (IOM, 2015). Fairman also spoke to the challenges facing NMEs, many shared in the larger global context. Restrictive payment systems, regulatory limitations, oppressive professional and institutional hierarchies, and lack of business supports were all seen as potential stumbling blocks for NMEs. Discussions also identified growing unmet health needs and demand and private-sector engagement as possible countervailing forces enabling NME development. The increasing reliance of nurses and midwives to provide cost-effective, accessible services also emerged as an important driver in lowering NME barriers, while also expanding provider roles and responsibilities. Discussions identified emerging areas of need and opportunity for NME services. Primary care and preventive services were identified as areas of particular opportunity, along with others in which significant unfilled service gaps exist (IOM, 2015). Specific examples included mental health and chronic disease care. It was noted that there are important, often overlooked

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opportunities relating to lack of health care choice for underserved populations (IOM, 2015). Additional areas of need and opportunity for NMEs related to epidemics, disasters, and humanitarian relief.

Contributions to Poverty Reduction Although reducing poverty was not an initial focus for IOM deliberations, it emerged as a potential benefit of NMEs. Employment, asset ownership, and career opportunities identified previously provide important economic opportunities for individuals working in NMEs, with downstream impact on families and communities. NMEs can also provide access to affordable and effective health services, a crucial component to lessening the economic impact of injury and illness on individuals and families. In many countries, a single illness or injury episode can leave families destitute with little hope of recovery (World Health Organization, 2015). Early services within financial reach can not only reduce the direct economic illness and injury but also mitigate the longer term, multigenerational effects of poverty (Maeda et al., 2014).

Feasibility of NMEs The discussions of NME utility noted their apparent alignment with the direction of health sector change, and their potential contributions to growing international development efforts aimed at improving the lives of women (United Nations Global Compact, 2015) and reducing poverty. However, the question of NME feasibility is far more complex, with answers that are largely situational, given health systems transformation underway around the world. Launching, scaling, and sustaining health-related enterprise is challenging, particularly in a landscape in which virtually every factor shaping health markets and service delivery models is changing. Although there were no simple answers to the question of NME feasibility, important approaches did emerge and were seen as enabling the development of NMEs to advance the aims of women’s empowerment and health systems strengthening.

the importance of developing evidence-based strategies and monitoring their progress and impact through use of gender specific measures. Such measures would both help structure the empowerment work of NMEs, while providing a platform for attracting financial and other types of support. “When you think about planning for empowerment you also have to think about resources that have to be devoted solely for that purpose and incorporating them into an otherwise complex situation of changing the delivery system.” Diep Vuong, Pacific Links Foundation (IOM, 2015; p. 9).

Stakeholder Engagement and Partnerships Meaningful engagement of all stakeholders is crucial to the success of all health ventures. Discussants identified patients, families, and communities as key, necessary partners in the development and sustainability of NMEs. They highlighted partnerships between the public and private sectors as crucial to the longer term success of all health-related social enterprise. Successful integration of public, private, and voluntary sector providers into a country’s health system is crucial to meeting the goals of universal health coverage. This cannot take place without constructive relationships among all actors. “Health is not just the business of government, but also of the private sector, communities, professionals, and most importantly the families (particularly the women in those families).” (IOM, 2015, p. 89) Partnership development also extends to the need to deliver care through collaborative teams that make full use of the capacities of all involved. Professional self-protectionism and regulatory restrictions surfaced as important challenges that will need to be overcome. The collaboration of nurses, midwives, and community health workers surfaces as a particularly opportune area for NME collaboration.

Leadership and Management Expertise Intentionality Empowerment of women working in the health sector will not happen unless it is intentionally incorporated into all aspects of enterprise development. There are significant challenges to intentionally improving the lives of women working in the health sector; many of whom are unpaid or underpaid and working in challenging and unsafe conditions (Langer et al., 2015). Barriers to empowerment efforts are deeply embedded in culture, professional hierarchies, regulatory systems, and cost-containment practices. The need for addressing gender inequity in the health sector was emphasized repeatedly throughout deliberations. However, progress will require explicit, intentional action to move beyond the status quo (Gates, 2014). IOM workshop discussions highlighted

Ownership of NMEs by nurses and midwives is uncommon. Possible explanations emerged during workshop discussions, including barriers associated with gender-related social, religious, or legal restrictions; access to finance; competing priorities between family and work responsibilities; and self-confidence, self-efficacy, or aspiration. Discussants also identified lack of relevant knowledge and skills as significant barriers that need to be addressed if NMEs are to be successful. Participants noted that the formal education and training of nurses and midwives prepare them to deliver care in the health sector, with little attention given to teaching the knowledge, skills, or attitudes necessary for successful enterprise development. Discussions identified business and leadership training as essential. Development of entrepreneurship was also


highlighted. Its importance was underscored in Oscar Picazo’s IOM workshop background paper on nursing/ midwifery enterprises in the Philippines, in which he concluded “These innovations were invariably started by individuals with an entrepreneurial streak .” (Picazo et al., 2014). Discussions emphasized the importance of early exposure of nursing and midwifery students to these content areas, highlighting their relevance to making a difference in the health of the people they serve. Key partners identified to advance this work included academic institutions (IOM, 2015) and professional and service delivery organizations. “Younger nurses are more business- and leadershiporiented; if given the proper support, they could be transformational in the health system.” Barbara Parfitt, Founding Principal, Grameen Caledonian College of Nursing, (IOM, 2015, p. 35).

Good Business Practices In his IOM workshop presentation, Krishna Udayakumar identified “secrets of success” for health enterprises. He emphasized a strong focus on patients beyond their needs and demands, involving paying close attention to “consumer patterns and behavior” (IOM, 2015). A.M. emphasized the value of behavioral economics in this regard, explaining their crucial importance to health systems transformation (IOM, 2015). Information and communications technology (ICT) emerged as a particularly powerful tool for successful clinical and administrative operations and support of health workers. In their IOM workshop presentation, Krubiner and Lagomarsino discussed the value of ICT to NMEs, highlighting their use in “telemedicine, communication outside the clinical setting, decision support and applications, data collection and management systems, and financial transactions.” They cited a number of areas in which ICT helps providers and other health workers access and provide mentoring, peer support, training, and consultation. They also cited ways in which ICTs contribute to women’s empowerment, including their “self-esteem, autonomy, greater social and professional connection, access to capital, and better practice through use of up-to-date knowledge” (IOM, 2015, p. 61, 64). Other discussion relating to enabling health workers focused on the importance of making full use of their capacities. Delivery of affordable high-quality services depends on closely aligning both individual and team competencies and supports with service gaps. Longterm success requires moving beyond conventional wisdom about who should provide what services. Responding to gaps was also seen as important in addressing the interests of purchasers and investors. In her workshop discussion of global investment in social enterprise, Beth Bafford emphasized opportunities relating to increasing willingness and ability of

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the middle class to pay for services, including those not currently provided or available (IOM, 2015). Enterprises that strategically position themselves to respond to such gaps are more likely to gain the support of payers and investors. Appealing to payers and investors requires creating and maintaining value in all aspects of the enterprise. High-quality, accessible, and affordable services were seen as crucial components of value closely aligned with the work of NMEs. The workshop presentation by Petra ten Hoope-Bender noted the value of midwifery services in producing an estimated 16% return on investment through lives saved and cesarean sections prevented, while having capacity to provide 87% of essential interventions for women and newborns (IOM, 2015; The Lancet, 2014). She also cited Jacaranda Health, a women’s health and social venture in Kenya, as an example an enterprise featuring the value added through midwifery and nursing (Kearns et al., 2014). The importance of quality to value was at the heart of many discussions. In her workshop presentations and discussions, Monique Dolfing-Vogelenzang discussed approaches to achieving and maintaining enterprise quality, citing the roles that investors can play in enabling and leveraging quality and access (IOM, 2015). She cited the work of the Medical Credit Fund and SafeCare as examples, focusing on the use of performance-based financing, risk reduction, technical support, and quality assessment (IOM, 2015). It was noted that partnering with social investors engaged in these practices can be very important to enterprise value and sustainability.

Supportive Organizational Arrangements NMEs have many different types of organizations, some appearing more able to support launching, scaling, and sustaining these enterprises. During workshop discussions, Krubiner and Lagomarso identified types of organizational approaches that appeared most promising for NME success. Among these were collective membership organizations, cooperatives, networks, and professional associations. Their potential benefits to members include “bargaining, negotiating, social support and peer mentoring participatory governance and union activities” (IOM, 2015). These organizations may also provide access to capital through pooling resources and risk, as well as political voice and influence. Another important organizational model is social franchises, which enable ownership and operation under an established brand often within a framework of certain process and quality standards. These organizations may also provide clinical and business supports and have central direction that can “embed systemic practices such as back-office systems and accounting” (Institute of Medicine, 2015). Social franchises can also help with start-up and scaling NMEs, including financing, business expertise and acumen, and other technical and strategic supports. They may also provide

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some of the other benefits associated with networks, cooperatives, and associations. Discussions of organizational structure emphasized the value of having a strong brand. The example of SafeCare, mentioned previously, was discussed in terms of the positive impact of its brand on trust and the status of those involved within their communities (Institute of Medicine, 2015). Affiliating with a strong brand located in multiple locations can have important advantages for both marketing and value. “Not everyone is suited for entrepreneurship, so what kind of model could support people at different levels of business?” (Institute of Medicine, 2015, p. 89)

Financing NMEs The topic of financing is interwoven throughout the above discussions. Adequate financial support is crucial to incubating, launching, scaling, and sustaining any enterprise. Start-up financing is particularly challenging, especially for NMEs, which may not be commonly understood by investors and other potential funders. As a result, most sources of early NME financing appear to be philanthropy, government, or group lending. In the longer term, however, sustainability depends on revenues associated with payments for services or other products. Payment sources can include contracts with governments, employers, and other types of organizations, third-party payers such as insurers and philanthropy, or directly from individuals and families. Regardless of sources, the flow and management of revenue are crucial to enterprise growth and sustainability. In her workshop presentation discussing lessons from the Global Health Investment Landscaping Project, Beth Bafford described a promising picture in which opportunities are increasing for support of enterprise development in the health sector, accompanied by increasing interest on the part of social impact investors. Bafford also identified factors important for future of investment in health enterprise: (a) communication among all actors, particularly the public and private sector, noting the need to enhance private-sector delivery and service coordination, and (b) the importance of government and philanthropy, focusing on providing proper support for social enterprise to thrive (IOM, 2015). These are important considerations as NMEs position for success.

Transferability Unprecedented, highly disruptive change is underway in health systems, rapidly transforming service delivery and creating significant challenges and opportunities. The search for promising delivery models has moved beyond national borders and is resulting in growing interest in finding ways to help translate models and lessons from other countries. It is in this context that the IOM workshop discussions of transferability took place. Discussions of transferability of NMEs focused on the potential value of models and lessons and learned from LMICs for the United States and more broadly (Pittman & Salmon, 2015). It did not appear that direct importation of any single NME model was likely to succeed, given variation across countries. However, discussions surfaced important areas for consideration in assessing the transferability of lessons and models. These echo the elements of enterprise feasibility described previously and include access to capital, ongoing financing of services, market considerations, patient mix, restrictive regulation, professional barriers, lack of trust (including brand trust), quality standards and support, and business expertise (IOM, 2015).

Intentionality and NMEs NMEs hold significant promise for empowering women, given the largely female composition of the health workforce and interconnectedness of nurses and midwives. Despite this, very few NMEs report explicit intention of empowering their female workers (Krubiner et al., 2015). This apparent absence of empowerment intent necessarily raises complex questions relating to both will and capacity. Assuming that this intentionality can be successfully embedded in NMEs from an enterprise development perspective, the question then focuses on the will of nurses and midwives themselves. Can nurses and midwives develop and operate NMEs that are explicitly designed to help empower the women with whom they work? This is not an easy question to answer, given health care’s long history of professional hierarchy and patriarchal relationships in which nurses and midwives themselves continue to reach to break down barriers to advance the profession and their own well-being. However, it is one with continuing importance for the future impact of NMEs on women’s empowerment.

Implications for the Future

Work Going Forward

The IOM workshop brought into focus important ways in which NMEs may help to empower women and strengthen health systems and services, along with possible approaches to their development and sustainability. Discussions raised important questions for the future, focusing on the potential transferability of NMEs, intentionality and NME empowerment efforts, and the way forward.

The body of work described previously is serving as an important platform for continuing progress. The global discussions hosted by the IOM, the World Bank, and International Partners in Innovation in Healthcare Delivery (IPIHD) have paved the way for future initiatives. For example, work has begun to advance research on empowerment of women working in the health sector, focusing on advancing landscaping methodologies, translation of innovation, and social investment impact


measurement. These can all help to inform development and financing NMEs, as well as other health sector enterprise. Others are focusing on actual NME and other health sector enterprise development, working to intentionally incorporate women’s empowerment, and/ or poverty reduction aims. Their efforts necessarily involve larger organizational, policy, economic, professional, and structural considerations in both the United States and beyond. Within the United States, discussions are focusing on how to help NMEs fill current and emerging care gaps, capitalize on emerging opportunities, extend their reach and impact, and become sustainable. It is hoped that the many unanswered questions emerging from the body of work described here will point the way for research and innovation needed to move NMEs forward in to improve women’s lives, strengthen health systems and services, and help address injury and illness-related poverty.

Part III: Closing Thoughts This article discusses work that is driven by significant causes of human suffering around the world: the growing unmet health needs around the world; the alarming plight of female health workers on whom all of us depend (women health workers contribute nearly $3 Trillion and 5% global GDP annually, with nearly half attributable to those receiving no payment; Langer et al., 2015); and the devastating effects of poverty caused by a lack of access to appropriate health services. The insights and guidance reported here are important because they help to raise awareness of these key issues and the potential of NMEs to help address these. The IOM workshop and report lay a strong foundation and outline a path going forward; subsequent discussions and emerging efforts are moving progress forward. Through this work, we have come to understand that the convergence of challenges and opportunity makes this a particularly important moment for advancing these efforts. We have also come to see the significant potential of NMEs to contribute to better futures for women in the health sector and for the people they serve. It is our hope that this article will inform and inspire others to build on the compelling platform presented here.

Author’s Acknowledgments (M.E.S.) The body of work described here has been made possible by the contributions of countless individuals, groups, and organizations. I am deeply indebted to the Rockefeller Foundation (the Bellagio Center Residency and the Bellagio Center Conference Grant); the Robert Wood Johnson Foundation (grant entitled Studying Global Lessons in Nursing and Midwifery to Inform U.S. Innovations to Empower Women and Strengthen Community Health Services); the Institute of Medicine (IOM);

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American Academy of Nursing; the American Nurses Foundation; the American Nurses Association and their support of the IOM Distinguished Nurse Scholar opportunity which became the incubator for this work; and the University of Washington for your financial and material support and guidance. Thanks also to my colleagues at the Center for Health Market Innovation (CHMI), the World Bank, the International Council of Nurses, and International Partners in Innovation in Healthcare Delivery (IPIHD), for the wealth of expertise, advice, and collaboration that you so generously shared. I also want to acknowledge individuals whose names do not appear in the various reports and articles relating to the work described here. My deepest thanks to Deborah Bae, my program officer at the Robert Wood Johnson Foundation, and to Stephanie Schuler, Janet Schnall, Leigh Anderson, Chantel Gibson, John Compton, Deborah Carnes, Deborah Fischler, Catherine Olcott, and students from the Evans School of Public Policy and Governance, all at the University of Washington. Thanks also to Katherine Blakeslee, Megan Perez, and Ellen Kimmel at the Institute of Medicine; Pilar Palacia and Elena Ongania at the Rockefeller Bellagio Center; and my insightful and inspirational coauthor, Akiko Maeda. You have each given more than was required and at times when help was most needed. And, to Jerrydno amount of acknowledgement can thank you enough for all that you give and do.

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