Health and human development in Kenya

European Journal of Training and Development Healt h and human development in Kenya: A review of lit erat ure f rom high income, middle income, and low income count ries Caroline Sabina Wekullo, Elise Catherine Davis, Fredrick Muyia Nafukho, Bita A. Kash, Article information: Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) To cite this document: Caroline Sabina Wekullo, Elise Catherine Davis, Fredrick Muyia Nafukho, Bita A. Kash, (2018) "Health and human development in Kenya: A review of literature from high income, middle income, and low income countries", European Journal of Training and Development, Vol. 42 Issue: 1/2, pp.5-34, https://doi.org/10.1108/EJTD-06-2016-0040 Permanent link t o t his document : https://doi.org/10.1108/EJTD-06-2016-0040 Downloaded on: 11 July 2018, At : 08: 08 (PT) Ref erences: t his document cont ains ref erences t o 66 ot her document s. 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Kash Department of Health Policy and Management, Texas A&M Health Science Center School of Rural Public Health, College Station, Texas, USA Abstract Purpose – This paper aims to critically analyze the empirical literature on health and human development in high-, middle- and low-income countries to develop a sustainable model for investing in human health. The model is critical in building a comprehensive health-care system that fosters the stakeholders’ financial stability, economic growth and high-quality education for the local community. Design/methodology/approach – A comprehensive literature review was carried out on health, human development and sustainable health investment. After thoroughly examining theoretical frameworks underlying the strategies of successful human health systems, a summary of empirical articles is created. Summaries provided in this paper represent relevant health-care strategies for Kenya. Findings – Based on the empirical review of literature, a Nexus Health Care model focusing on human development, social and cultural development, economic development and environmental development in high-, middle- and low-income countries is proposed. The goal of this model is to enhance sustainable development where wealth creation is accompanied with environmental uplifting and protection of social and material well-being. Research limitations/implications – This paper is limited to a comprehensive literature review presenting empirical evidence of human development and sustainability. This paper forms part of a special section “Global health and human development in Africa”, guest edited by Fredrick Muyia Nafukho. European Journal of Training and Development Vol. 42 No. 1/2, 2018 pp. 5-34 © Emerald Publishing Limited 2046-9012 DOI 10.1108/EJTD-06-2016-0040 EJTD 42,1/2 6 Originality/value – Kenya like other developing nations aspires to contribute significantly in improving health through development of health products but the approaches used have been limiting. In most cases, the use of Western theories, lack of empowering the community and dependence on donor support have hindered the country from achieving comprehensive health and human development. This papers seeks to develop a model for health-care investment and provide strategies, operations and structure of successful health systems and human development for a developing country, such as Kenya. Keywords Kenya, Sustainable development, Human development, Social development, Human health development, Sustainable health, Human health improvement Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Paper type Literature review Introduction With a vision to establish a high-quality health-care capability in Kenya, the model in this paper is established with plans to invest in high-quality human resources and technology, which could help to build clinics and hospitals, and to manufacture medicines, medical devices and health supplies. Such large technological investments in health care have so far been unsuccessful in Kenya. One reason for this failure is that investments often disregard the interdependencies that exist between technology, human characteristics and the socioeconomic environment. The interdependencies that exist have a great impact on health-care delivery and health status of a population. With this realization, there is a need for a holistic health framework with the goal of promoting health and human development in Kenya. The holistic framework proposed is applicable to health organizations with a goal to promote health and human development. Background of the problem In contemporary African society, the meanings and views of the concepts of health and human development have been defined differently. To develop a functional health system that fosters development in low-income country such as Kenya, it is important to discuss the two concepts; health and development and how these are perceived across in the African context (Nafukho, 2013). To start with, Todaro (1992) defined development as a multidimensional process involving the reorganization and reorientation of entire economic and social systems. In the same spirit, Bryant and White (1982) described development as increasing the capacity of people to influence their future. On the basis of the above mentioned definitions, it is apparent that development has socioeconomic, cultural, environmental, human, political and psychological dimensions. The World Health Organization (WHO) has defined health as a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity (Huber et al., 2011). This definition has been criticized for underrating the role of human capacity to cope autonomously with life’s physical, emotional and social challenges, and to function with fulfillment. Huber et al. (2011) redefined the meaning of health by emphasizing the ability to adopt and to self-manage. In this new definition of health, emphasis is on the importance of stakeholders reflecting many cultures and future scientific and technological advances. Bircher and Kuruvilla (2014) looked at health as a state of well-being emergent from interactions between individuals’ potentials, life demands, social and environmental determinants. The two concepts, health and development, are intertwined. A nation’s development depends on the health of its population, similarly, the health of the people depends on the development level of a nation. Therefore, any investment in low- to middleincome countries must factor in the aspect of improving health. While development is sometimes inevitable, to be successful, nations and organizations should implement intentional development (Cowen and Shenton, 1996). Intentional development involves deliberate and planned interventions by individuals, institutions and developmental agencies that address important issues in their society. The United Nations Development Program (UNDP) defines intentional human development as: Health and human development Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) [. . .] a process of enlarging the range of people’s choice by increasing their opportunities for education, healthcare, income and employment and covering the full range of human choices from a sound physical environment to economic and political systems (United Nations, 1992, p. 2). Human development should aim to ensure access to quality health care, education facilities, opportunities to earn income and access to social welfare services (United Nations, 2003). The Human Development Report (HDR) (2011) further noted that development paradigm endeavors create an environment of self-respect, empowerment and a sense of belonging for a community (United Nations, 2011). This allows communities to participate in political, economic and social opportunities to develop their full potential to lead productive and creative lives in accordance with their needs, values and interest, which is critical for innovation companies to ensure that the people of Kenya, a low- to middle-income setting, are able to willingly choose to engage in the human development process. Without the voluntary participation of the people, human development will not be possible, or successful. Apart from the development of education and people, Kenya’s peoples, communities and cities face dire financial burdens. In the 1980s and 1990s, the World Bank and the International Monetary Fund prescribed structural adjustments programs (SAPs) as one of the ways to ensure economic recovery in Africa (World Bank, 1994). SAPs led to devaluation of currency, and reduced government spending in social service sectors, such as education and health (Mkandawire and Soludo, 2004). SAPs also led to liberalization and privatization of government enterprises. SAPs led to increased taxation and interest rates, the introduction of cost-sharing schemes, user fees, cost-recovery measures and wage restraints (Kayizzi-Mugerwa et al., 1998). The implementation of SAPs in Africa did not result in economic recovery. There have been a number of suggested paths, including Nyerere’s Ujamaa and self-reliance model to Africa’s recovery. More recently, we have the New Partnerships for Africa’s Development. While these approaches have been formulated and implemented, the African continent remains economically underdeveloped. In most African countries, development policies and programs have been largely informed by the modernization theory (Arat, 1988). The modernization theory is supported by the import substitution policies and reliance on foreign aid. However, because of unimpressive performance of these development strategies, neoliberal trade theory seeks to bring about human development in sub-Saharan Africa through trade, deregulation of capital markets and less state involvement in socioeconomic affairs (Lemke, 2001). This differs from the past, when many countries in Africa relied on aid from foreign countries (Moyo, 2009). Trade liberalization is a process of systematically reducing and eliminating tariff and non-tariff barriers between countries as trading partners. The liberalization policies aim at creating a level playing field on which Kenyan and other African economies and organizations can fairly compete. Its main foundation is the economic theory of the invisible hand of the free market enterprise and the notion that unrestrained markets will lead to efficiency in the production and distribution of goods and services between African countries and the rest of the world (Nafukho, 2013). Trade liberalization is based on the neoliberal idea that successful development can only be achieved by adopting the policy of openness to global capital and competitive forces, and closer integration with the global economy (Moyo, 2009). While this sounds quite plausible in theory, in practice it has also been proved elusive. Trade liberalization advocates for the opening up of national economies to global market forces and limited government intervention in the management of the local 7 EJTD 42,1/2 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) 8 economies. This is successful when there is fairness in international trade between developing and developed countries. In the absence of fair trade, Africa remains disadvantaged. The United Nations (1992) Human Development Programme report questioned why world markets have only benefited the wealthier countries. One reason for this phenomenon is that: [. . .] world trade is completely free and open as in financial markets; it generally works to the benefit of the strongest. Developing countries enter the market as unequal partners and leave with unequal rewards (United Nations, 1992, p. 1). In addition, some countries experience economic disadvantage when market rules are changed to prevent free and open competition, for example, those African countries functioning with competitive advantage, such as in labor-intensive manufacturing or trading in precious minerals. Regarding development, the neoliberal trade theory rests on the idea that immanent development of capitalism can positively change the destiny of communities in low-income countries. The trade theory advocates for the distribution of welfare through the market, as well as advocating for the distribution of wages and enterprise management for profit accumulation (Nafukho, 2013). Capitalism was the dominant view of development in the 1980s, and could be considered the desired form of modernization for many communities. The reality, however, requires some form of intentional development, which includes proactive initiatives aimed at providing public facilities and investments, especially in education and health. Intentional development is guided and works to address the imperfections of free market economy by ensuring equal distribution of resources, and by making essential infrastructure freely available. At the macro level, there is a need for intentional development to help reduce poverty. When discussing the strategies to promote development in Kenya, there is a dichotomy between outside-driven initiatives and internally driven solutions. This paper is focused on the idea that investing in education and health is what will bring true and successful human development to Africa. Statement of the problem With increasing globalization coupled with increasing health and epidemiological transitions, international communities and multilateralism have become vibrant and well-coordinated. The effectiveness of these initiatives depends on the effectiveness of regional and international collaborative efforts on health and development issues. There are, however, knowledge gaps on models international and local investors in health care can use to attain a sustainable health care and development. Most research on health innovation organizations is focused on verifying the existing theories. The existing global macroeconomic theory is grounded on data from Western nations (Davidson, 2011) , which does not fit globalization of local conditions in developing countries. Moreover, several theories on investment in health care have been discussed, but no theory adequately explains the workings of transnational organization for human development in the frontier market. Researchers in international development have eked out small gains of knowledge from existing grand theories of human development, rather than exploring new areas grounded in indigenous knowledge systems. Furthermore, research has shown that the absence of relevant theory has caused more than seven decades of work by organizations such the World Bank, the International Finance Corporation, the UNDPs and country-based development agencies to produce little results in terms of human development in frontier market countries (Grenier, 1998) . Since the niche to invest in developing countries has continued to rise, and a lot of data on health and development exist, there is a need for a comprehensive model to guide the process. Razmi et al. (2012) investigated the effect of government spending on health and suggested a future study to review and analyze the relationship between health and human development in developing countries, such as Kenya. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) This paper reviews health and human development literature in high-, middle- and low-income countries to develop a model that can be applied to developing nations, in particular, Kenya. The next sections present the research design, followed by the review of related literature. The review of literature discusses the concept of health and development, states strategies to achieve a comprehensive human health development, models used in health and development, and presents the proposed model for investment in health care. Next, we present the discussions and implications of the study. Method An integrative literature review was conducted to present the current state of knowledge on health and development, theories used in health development and strategies for achieving a successful health and human development. A computerized search was done in the following databases: PubMed, EBSCO, Business Source Complete, academic search complete, SCOPUS and Google Scholar. The initial search was restricted to the following primary keywords “human health development” and “human health improvement.” Then a number of peer-reviewed journal articles on the topic were identified and reviewed. Further refined searches were performed on the basis of the following secondary keywords as descriptors: “health sustainable development,” “social development,” “biodiversity,” “eHealth strategies,” “sustainable health,” “environment health care,” “global health,” “health-care reform,” “human development theories,” “population health improvement,” “health technology,” “health-care capacity,” “health financing,” “ecohealth,” “health investment model,” “global health,” “health-care improvement” and “health governance.” Given the multitude of articles written on the topic of human development, it was not only necessary to review the relevant literature on this topic but to also make a decision on inclusion criteria. Our inclusion criteria considered empirical studies on human development and issues related to sustainable health investment. The selected articles represented original scholarship and documents published in the past eight years (2009-2017). It is assumed that the articles published within this period provide the current trend on the theories used in health care and development. Other relevant literature, such as books and book chapters, were also included. The summary of empirical articles included herein is representative of strategies for human health development relevant to developing countries. Review of related literature Health and human development Health and human development are intertwined and these interact to produce a sustainable human development in any given context (Razmi et al., 2012).The relationship between health and human development is not linear but cyclical without any specific starting point (Alin and Marieta, 2011). The assumption behind this relationship is that healthy people contribute to building good human capital, which then contributes to economic development. On the one hand, an economically improved nation empowers its people by increasing their access to affordable fundamental needs, such as food, health-care services and education. On the other hand, economic inability tends to affect health and other fundamental needs, as low income may constrain people’s ability to access health care and health-promoting opportunities (Freire and Kajiura, 2011). Advancing on the same idea, Alin and Marieta (2011) tested the bond between the effect of the health system and the effort and the value of human development using correlation analysis and found a strong relationship between health systems and the level of human development. However, the authors found no relationship between the health systems efficiency and human Health and human development 9 EJTD 42,1/2 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) 10 development. The findings have significant implications for investors in health who focus on effect rather than effort in providing health services. The main concern for both developed and developing countries has been to improve health and human development (Razmi et al., 2012). However, Gudes et al. (2010) examined frameworks for organizing information in a collaborative health planning and noted that this process faces significant challenges resulting from narrow information and absence of framework to guide decision-making. A part from the stated challenges, Kumar (2013) in analysis of health development found that the set development agenda for the twenty-first century is not comprehensive enough to cater for all health issues of poor people and poor nations. Kumar concluded that there is a need to accelerate efforts to succeed in all areas of health. Both Gudes et al. (2010) and Kumar (2013) emphasized the need for nations to deal with the fundamental issues of health. Razmi et al. (2012) and Freire and Kajiura (2011) advancing on this idea stated the need for countries to prioritize health issues. The author pointed out that investing in health increases human capital through capital health accumulation, which has a direct effect on development. Overall, the reviewed articles provide a compelling evidence of the existing bilateral relationship between health and human development. Specifically, health improves human development and human development itself increases health. Researchers in this field have further pointed out the need for collaborative approach between several agencies and institutions if nations want to achieve health equality for all people across the world (United Nations, 2012). Others have maintained that there is no one-fit-all solution for health problems. The past studies suggest that each country must prioritize to tackle its own health issues. Strategies to achieve a comprehensive health and human development The result of the selected empirical studies suggested several strategies for health investment in developing countries. The findings suggest that there are multiple strategies and can be categorized in various ways, but for this study, the strategies are categorized into four groups. Strategies on human development, economic development, social development and environmental development. Aday (2005) noted that when investing in health for a healthy nation, policymakers must take into account the fundamental determinants of health and they must reduce health disparities. Fundamental determinants of health include natural resources (environmental resources), human capital (education), material capital (occupation, employment and income) and social and cultural capital (social support and community empowerment). Aday (2005) further pointed out that increasing investments in health care is not an efficient way of improving population health and saw the need to focus on main policy domains that determine health, which include human development, economic development, socioeconomic development, environmental development, community development and sustainable development. Provided below is a discussion on each of the five policy domains. Human development. Human development refers to investing in the skills and capabilities of individuals, which enable them to act in ways that enhance their contributions to society. UNDP observed that human development goes beyond broadening individuals’ choices to ensure that the choices made by individuals do not compromise or restrict future generations. Choices made by humans should ideally lead toward long and healthy lives, allow opportunities for education and allow individuals to live a high quality of life (United Nations, 2015). In the 2015 HDR for Africa, the sub-Sahara region is ranked third best in the human development index (HDI) growth of 1.08 per cent. Even with this improvement, challenges emanating from poverty, inequalities and environmental effects persist. Consequently, the 2015 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) HDR has placed emphasis on developing strategies and policies, which create job opportunities, ensure workers well-being and develop targeted actions (United Nations, 2015). If we consider human development by and for the people, then we can confirm that people both rich and poor, as individuals or groups are the real wealth of nations (Von Wagner et al., 2009). The studies reviewed in this section emphasize the need to empower people to proactively help themselves, either as individuals or groups. For instance, Kobayashi et al. (2014), Von Wagner et al. (2009) and Ramírez-Luzuriaga et al. (2016) pointed out the need for increasing interpersonal interaction with health professionals. Other scholars maintained that the concept of human development is dynamic and its components are interconnected between economic, social environmental and political dimensions, thus, the analysis and strategies to advance human development should take a holistic view (Poverty, 2010). In a holistic view, the argument is that the HDI does not capture the rich content of our human development concept. The focus on economic growth is necessary for enhancing different aspects of human well-being, but is not sufficient as a means to human development. To include all the dynamics of human development, the index measure should be extented to reflect inequalities, human security, empowerment, increased attainment of education, access to health information technology (HIT), improved health and safeguard the environment (United Nations, 2014). Table I shows the strategies taken from the literature which will improve human development. Each strategy outlines the most important aspects of the literature, and what key findings will allow for successful and healthy human development. Economic development. Economic Development is mainly concerned with enhancing the efficiency of a national, regional, state or local economy by investing in and introducing businesses to an area. The actions yield multiplier effects by creating new jobs and increasing the wealth and income of target residents (Aday, 2005; Muiya and Kamau, 2013; Mwaura and Pongpanich, 2012). Kim et al. (2013) in their analysis of the global health care reached the same conclusion with the above authors. Ki Kana et al. stated that economic development is synergistic with the development of health systems and fundamental to the improvement of value in health-care delivery. Advancing on the ideas further, Aday (2005) summarized the prerequisites a health-care investment that would effectively improve population health and reduce disparities should have. These include:  creating delivery system that directly catalyzes economic development through the mechanisms of ensuring a healthier and more productive population;  creating employment opportunities that contribute to the formation of a middle class of individuals;  improving skills and thus incomes;  increasing local purchasing power for goods, services and equipment, including certain food supplies, support services, maintenance, construction services and other health system inputs; and  purposeful development of health-care delivery systems in low-income communities that leads to improved infrastructure – i.e. cellular phone towers, internet access, electrification, clean water access and local transportation systems. Table II outlines the selected empirical studies on strategies for economic development. Just as Table I successfully outlined the most important aspects of the literature for each strategy, Table II emphasizes the aspects vital for economic development in the developing world. Social development. The review of literature has shown that social development can be accomplished by addressing income and gender inequality (Chen et al., 2015), addressing the Health and human development 11 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Summary Relevancy Strategy 1. Use health education programs to create awareness Von Wagner et al. Health literacy has a direct effect Patient–provider interactions (2009) on health outcomes Effectiveness of education Understand the process in which tailored to community health literacy affects health Kobayashi et al. (2014) Limited health literacy is a barrier to participating in national publicly available cancer screening program Bostock and Steptoe (2012) Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services Strategy 2. Improve community health and nutrition Ramírez-Luzuriaga Poor feeding practices, poor et al. (2016) hygiene, and prevalence of communicable diseases are leading causes of chronic malnutrition (micronutrient deficiencies) in children under 5 Many nutrition intervention programs fail because of inadequate implementation Need for: Interventions in designing of information materials Provision of alternative support Increase interpersonal interaction with health professionals Need for appropriate design and delivery of health related services for older adults Use of locally available resources to prevent impact of chronic malnutrition and its irreversible consequences Follow-up services for identified cases Regular evaluation programs Need to engage all stakeholders Adequate resources EJTD 42,1/2 12 Table I. Selected empirical studies for strategies on human development Author Theory Key findings/outcomes Health literacy framework and Social cognitive model Health literacy improves population health and reduces health disparities Reduces risk behavior Improvement in knowledge of diseases Reduces health costs and premature deaths Adequate health literacy is linked to greater accuracy of screening, independent of other predictors of screening such as age and coming from higher wealth quintile Multivariableadjusted logistic regression Longitudinal cohort study Older adults have difficulties reading and understanding basic health related information Lower literacy is related to high mortality Behavior changes communication approach To improve dietary quality in children, food baskets that include fortified complementary foods may be more effective than cash transfers 19% of screened children were underweight and malnourished Community participation (510 volunteers were trained to support the program) (continued) Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Author Summary Strategy 3. Attract and retain qualified health professionals Bertone and Witter Human resources for progress (2015) toward universal health coverage Underperformance of health workers Salary of health workers is unclear Kenya has a shortage of approximately 18,000 physicians, with 51% immigration rate Strategy 4. Continuous professional development Aluttis et al. (2014) Capacity building is linked to improved performance in health Core domains for public health capacity: resources, organizational structures, workforce, partnerships, leadership and governance, knowledge development and country-specific context Relevancy Theory Key findings/outcomes Devise effective incentive packages for health workers Understand factors underlying health workers remuneration Consider both financial and non-financial motivations Human resources for health Remuneration is a critical in recruiting, retaining, and motivating workers Remuneration also affects performance of health systems and the progress toward universal health care Need for capacity mapping Acknowledge pre-existing capacities Country-level framework Capacity building ensures sustainable health improvement, independent of external events A broader health development governance framework Policymakers can establish sources of weak health governance and develop appropriate interventions Strategy 5. Build a strong leadership for effective internal and external management Kirigia and Kirigia Weak governance and leadership Use data in estimating health (2011) in health development explain why development governance the majority of African countries index are far from Millennium Training programs reflect Development Goals development in health systems Health leaders and managers at performance various levels of national health Education programs for systems are not trained properly medical and public health WHO health governance domain practitioners should include excludes effective keys to health leadership and governance governance (continued) 13 Health and human development Table I. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) EJTD 42,1/2 14 Table I. Author Summary Relevancy Theory Key findings/outcomes Mikkelsen-Lopez et al. (2011) Vital elements of system governance are strategic vision, participation of all relevant stakeholders, transparency, accountability A comprehensive assessment develops governance interventions to strengthen system performance and improve health as a basic human right Helps understand how health systems work to govern appropriately Develops indicators to assess governance across the health sector Health systems framework and systems thinking Increased investment by donors Improved understanding of management in developing counties Weaknesses in governance are addressed by targeted interventions and policy Normalization process theory HIT initiatives that have a good fit with existing organizational goals, staff skill sets and a positive impact on patient– professional interactions Relationships between professional groups are likely to normalize Improves quality through communication Increased efficiency through reduced duplication of investigations Improved outcome and efficiency HIT payment form has a strong influence in health care If interoperable and compatible HIT is adopted, it allows aggregation and integration of data across regions and diseases, medical knowledge is likely to expand Strategy 6. Use of information communication and technologies in provision of health care Murray et al. (2011) Information and communication Knowledge of barriers and technologies in health care are facilitators to successful essential for high quality and implementation of e-health affordable health care initiatives Setting HIT initiatives in line with organization goals Christensen and Remler (2009) Increase in financial support for HIT in health care to lower costs and improve health outcomes High replacement costs and the need for technical compatibility (health-care services, health insurance and labor markets) are barriers to HIT Setting technical standards for HIT is critical to include all relevant stakeholders, including patient groups Ensure the process of adopting HIT is slow and flexible to allow for as much diversity as possible Standard-setting approach (continued) Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Author Summary Relevancy Theory Key findings/outcomes Wickramasinghe and Schaffer (2010) Health-care reform is a global priority. The USA has identified design, development and implementation of technology solutions as a critical success factor Need for HIT preparedness for e-health solutions (HIT infrastructure; standardization in policy, protocols and procedures; user access and accessibility; and governance regulations) Patient centric ehealth Scott and Mars (2013) eHealth is a viable solution for developing countries eHealth strategy is essential in achieving the complex goal of aligning health system, health needs of the entity (institution, subnational, region and state) and culture involved by providing evidence-based guidance Absent, inadequate or vague eHealth strategy is a significant barrier to efficient investment in, implementation of sustainable eHealth solutions Need for a wise investment in eHealth to address the growing expectations, changing demographics and disease patterns, and resource limitations Embrace principles of eHealth development: simplify complex content, use pragmatic approach and spread costs through networking eHealth strategy Development Framework Efficiency, decrease costs Enhance quality of care Evidence-based information and clinical data Empowerment of consumers and patients – increases satisfactory patient choice Education keeps abreast with the quality of health care and use of latest medical treatments and preventive protocols Ethical operations Equitable health care Greater efficiency, reduces adverse drug reactions, has positive socioeconomic returns 15 Health and human development Table I. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Summary Relevant/Applicable Strategy 1. Empower stakeholders/communities to actively participate in economic growth OECD (2012) Women’s economic empowerment is a Need to integrate all gender-specific prerequisite for sustainable perspectives at the design and development, pro-poor growth and the programming stage achievement of all the MDGs Need to reach and enhance Women’s economic empowerment is opportunities for the poorest women in “smart economics” remote communities More equitable access to assets and Ensure equitable access to assets and services – land, water, technology, services innovation and credit, banking and financial services – promotes economic growth Strategy 2. Develop a sustainable health financing mechanisms Muiya and Kenya’s health-care financing system Need for collaborations in resource Kamau (2013) faces several major challenges resulting design and implementation to ensure from poverty, and reduced donor financing mechanism is synchronized funding with economic growth for higher social returns on investments Community-based health insurance is an option toward generating additional Ensure financing mechanism is resources for universal health care efficient and equitable both in revenue generation and service delivery Raise awareness of the value of insurance Theory/ Framework EJTD 42,1/2 16 Table II. Selected empirical studies for strategies on economic development Author Key findings/outcomes Holistic approach Women perform 66% of the world’s work, and produce 50% of the food, yet earn only 10% of the income and own 1% of the property Higher female earning and bargaining power translate into greater investment in children’s education, health and nutrition, which leads to economic growth Cooperative structure improves both economic and social standing in the household Leadership training Increase prepayment from the informal sector and mobilize resources for health care Community-based financing provides social inclusion and financial protection Health financing cannot be dealt separately as it has to do with good governance, economic growth and education (continued) Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Theory/ Framework Key findings/outcomes Author Summary Relevant/Applicable Musango et al. (2012) Majority of African population have no access to health services or health insurance The expectation is that universal access to health care is human development and will lead to economic development A focus on financing reforms and actions can improve coverage of health services Country and donor have turned to informal sector insurance mechanisms: community-based health insurance schemes as a way to improve financial protection, mobilize revenues and improve the efficiency of out-of-pocket spending Need to explore innovative domestic revenue collection mechanisms to increase expenditure on health Need for donor countries and development partners to invest in health in low-income countries Efficient use of existing resources, greater equity in financing and accessing quality health care Evidence-based approach Clear health financing strategy leads to a success of universal health coverage in an efficient, sustainable and publicly accountable manner Need for increased awareness on the benefits of community-based insurance schemes Data collection Community-based health insurance schemes improve equity and access of the poor to essential health care: through low weekly premiums More women are insured (62%) than men (38%) Individuals from lower-income quartile are more likely to enroll in the community- based insurance schemes Pooling of risk reduces financial barriers to health care Mwaura and Pongpanich (2012) (continued) 17 Health and human development Table II. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Summary Relevant/Applicable Strategy 3. Establish cooperative societies for sustainable development Wanyama In an era of privatization and reduction Need to recognize the role of (2014) of public health services, membercooperatives in achieving sustainable owned, not-for-profit health development cooperatives constitute an alternative Establish education and training to private insurers programs geared toward empowering Cooperatives contribute to both cooperative members and the economic, social and environmental community sustainability Cooperatives provide financial services, including affordable micro-health and life insurance to individuals living in rural areas Theory/ Framework Sustainable business model EJTD 42,1/2 18 Table II. Author Key findings/outcomes Cooperatives contribute to economic growth by creating employment (Kenya – 250,000 jobs) and income Stimulate performance and competitiveness, as members are also the beneficiaries Cooperatives ensure healthy lives by providing infrastructure for health-care services, financing health care and providing home-based health-care services in rural areas otherwise not available Pharmacy cooperatives give members access to genuine and affordable medicines Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) issue of inconsistent migration patterns and inadequate protection of human rights (Burns et al., 2002), which have great impact on people’s health (United Nations, 2012). In the same vein, Musango et al. (2012) pointed out the need to reinforce social health protection through establishing sustainable health financing mechanisms. In sum, the reviewed literature offers evidence that social aspect of development plays a vital role in overall health and human development. In particular, it reduces the overreliance on direct pocket payments. Community development. The reviewed studies have provided evidence for the community development because of its focus on change and empowering individuals and groups through activities (Aday, 2005; Franke and Guidero, 2012). Although community development does not solve specific problems faced by the community (Franke and Guidero, 2012; Meijboom et al., 2010), it builds confidence in community members to address problems at large. For community development initiatives to become self-sustainable, the formation process should seek resources from all possible avenues (grants, contracts and loans) and ensure that there are reliable means of maintaining funding to realize the desired objectives. The community development initiatives should ensure that proper human resource organization is available, and that these actively engage members in pragmatic activities. In addition, initiatives should have strong and extensive networks and political capacities, in addition to being flexible and resilient (United Nations, 2014). Table III outlines empirical studies from the literature that explain the aspects of social development. Environmental development. Environmental factors have a substantial influence on human health, life expectancy and socioeconomic development. The issues in environmental health are constantly changing. The WHO 2015 Report estimates that between 2030 and 2050, climate change will cause approximately 250,000 deaths per year; these deaths would be as a result of malnutrition, malaria, diarrhea and heat stress. The costs of health are estimated to range from US$2 to US$4bn per year by 2030. A concern is that most developing nations with weak health infrastructure will not be able to cope without assistance from developed nations (Kumar et al., 2013). Asakura et al. (2015) in their analysis of the relationship between health systems and human development found that although global risks related to environment and climate change are intensifying, little is known about the health consequences of environmental dilapidation, especially in developing countries. The authors suggested the need for increased awareness of the effects of environmental threats on health and human development. The authors maintained that reducing disease burden caused by environmental factors could result in improved health. An ecohealth approach is proposed – a concept of health that takes into account the contents of the wider eco-system. The approach aims at attaining sustainable health so that communities experience decent livelihoods, and pursue their lives with purpose (Asakura et al., 2015). Ecohealth involves collaborative research by engaging community residents to explore the practical solutions for the specific problems they face. These suggestions by Asakura et al. are similar to the WHO 2015 tactics on climate change and health: to create partnerships that would ensure health is represented in the environmental agenda, to increase awareness of the threats of environmental pollution and climate change, to develop a research agenda that focuses on the environmental impact on health and to help countries build capacity to respond to environmental impacts that reduce susceptibility to health. Health-care waste also presents a serious hazard to the environment. Biomedical wastes comprise unsafe microbes, which can affect hospital patients, health workers, waste handlers and the general public (Hossain et al., 2011). Also, improper management of waste leads to contamination of air, water and soil, and in turn depletion of natural and financial resources (Hossain et al., 2011; Kumar et al., 2013). It is estimated that low-income Health and human development 19 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Summary Relevant/Applicable Strategy 1.Collaborating with health-care professionals and manufacturers Burns et al. (2002) The fragmented health industry Health-care professionals and results in free hospital systems manufacturers need to work composed of autonomous units together to form beneficial Health-care products are ordered strategic alliances by workers on the front line of Management and coordination of health-care delivery chain from raw material suppliers Technological investments are in to end consumers patient care rather than Able to establishing a portfolio information systems and approach for providers and infrastructure customers with proper Procurement is based on outdated infrastructure to support the legacy systems, with little direct relationship connectivity with manufacturers Strategy 2. Align health delivery with the local context; cultural sensitive Chen et al. (2015) A culturally sensitive, personalized Improve population health and intervention sustains patients’ reduce racial and ethnic disparities involvement in their own health Engage patients in their treatment and health care Recognizes the relevance of community culture in health Strategy 3. Ensure accessible and affordable quality health-care services Greater Cincinnati Many low- and middle-income Invest in capacity building for Foundation (2013) countries’ health is a challenge organizations working to improve especially in households with health-care delivery limited resources Advance policies related to health The high cost of medical bills for and wellness uninsured allow many families to go without doctor’s care or prescription medication because of other essential needs; food, clothing and shelter Theory/ Framework EJTD 42,1/2 20 Table III. Selected empirical studies for strategies on social development Author Key findings/outcomes Health-care value chain Optimizing firm’s overall activities to increase performance Benefit for highly competitive chains developed for all firms Patient-centered, multilevel activation and empowerment framework Help build patient-provider partnership through shared decision-making Theory of change Increased access to the medical home Healthier lifestyle, and improved social and emotional well-being (continued) Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Author Summary Relevant/Applicable Chuma et al. (2012) Universal health coverage in Kenya is still an important policy question Kenyan health sector is inequitable as benefits are not distributed by need Structuring health system to be accessible, affordable, available and acceptable Strategy 4.Build constructive engagement with community stakeholders Franke and Organizations struggle to engage Empower stakeholders through Guidero (2012) stakeholders training and workshops to better Constructive engagement with identify and prioritize their needs stakeholders brings the best and to develop strategies insight to the challenges in the Center stakeholder engagement on subject/project to address network building, trust, and Community buy-in concept fostering shared values depends on how familiar the Engage all stakeholders implementing agency is with local context, the potential obstacles and the challenge of project planning and implementation Network for Organizations are responsible for Need for community investment Business social and environmental impacts and involvement Sustainability Expectations are met through Community integration in joint (2012) stakeholder engagement learning and management of projects Theory/ Framework Key findings/outcomes Household survey Health benefits were distributed by ability to pay and not on need for care The private not-for-profit sector was propoor, public sector equally served both poor and rich, whereas the private-for-profit sector remained pro-rich Primary health-care services were pro-poor IRES Reduces redundancy in project efficiency in the use of time and skills, and fosters a positive work environment Sustainable relationships Improves organization’s decision-making, legitimacy and competitiveness Transformation of the community (continued) 21 Health and human development Table III. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Summary Relevant/Applicable Strategy 5.Collaborating with local hospitals, national and international health organizations Meijboom et al. Multidisciplinary collaboration in Care coordination between partner (2010) health care is complicated but organizations indispensable Importance of policy in Appropriate information coordinated services technology should support continuous communication within partner organizations Need for planning to realize full Syed et al. (2012) Combined developing country potential of international learning processes have potential cooperation to generate effective solutions for Blending global knowledge with global health systems on-the-ground innovations from developing countries for the future international cooperation and benefits accrued therefrom EJTD 42,1/2 22 Table III. Author Theory/ Framework Key findings/outcomes Supply chain management Improves information gathering and processing Partnership-based approach Improved service delivery with a mechanism to reduce cultural, social, financial and gender-related barriers Better information sharing Personal and professional development (in health technology and medication safety) Improved patient-provider relationships Greater awareness of the factors impacting health Increase health financing (continued) Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Author Summary Relevant/Applicable Strategy 6.Continuous health improvement through monitoring and evaluation Collaborative evaluation of the Adindu (2010) Participatory monitoring and project evaluation underpin achievement of health-care goals and objectives Building capacities and promoting partnership among beneficiaries, implementers and sponsors. Enhances accuracy and reliability of results, and promotes sustainability of health intervention Ensures relevance, progress, efficiency, effectiveness and sustainability after the exit of external stakeholders Subramanian The current emphasis on achieving Use means other than funding to et al. (2011) health services targets provides improve health little insight into the actions needed for further growth or sustainability Theory/ Framework Key findings/outcomes Participatory approach Empowers communities and health workers to make informed decisions on interventions and performance, and to promote collaboration, transparency, accountability and sustainability Enhances acceptability and support for the intervention and evaluation process Theories of change Learning by acting in ways that engage key stakeholders Use data to address constraints Incorporate results from pilot projects (continued) 23 Health and human development Table III. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) EJTD 42,1/2 24 Table III. Theory/ Framework Key findings/outcomes Author Summary Relevant/Applicable National Learning Consortium (2013) Continuous quality improvement has proved successful as a means to achieve the triple aims of health care: improving the experience of patient care, improving population health and reducing per capita cost of health care Ideal for large, complex health-care organizations and practice networks that want to standardize operations across multiple units or practice sites Ideal for achieving small, quick wins and applies lessons learned to new cycles Have the right data, use the data well, and have enough resources to finish the task Ensure all staff members understand the metrics for success Involve patients, families, providers and care team members in QI activities Continuous quality improvement (CQI) Meaningful use of CQI moves health practice from its current state to a more desirable future state of improved patient care, improved population health and reduced cost Integrating health systems with economic development to enhance value for resources Integration of prevention and care is needed for related diseases Integrating components of shared delivery infrastructure for economies of scale Global health-care delivery Increased productivity because of a healthier population Care delivery promotes equitable economic development The purposeful health-care delivery systems in poor communities are a catalyst for improving infrastructure Strategy 7. Improve value of health-care delivery Kim et al. (2013) Health-care delivery systems are powerful resources for equitable and sustained economic development Effective care delivery helps break the cycle of poverty and disease Health-care delivery systems to improve the value of delivered care to patients, measured regarding patient outcomes achieved Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) countries generate less health-care waste (0.2 kg) than the developed countries (0.5 kg). However, lack of separating hazardous and nonhazardous wastes in low-income countries makes the magnitude of hazardous waste much higher than reported (Hossain et al., 2011). WHO 2011 states that every year approximately 16 billion injections are administered worldwide, but not all syringes are appropriately disposed of. Furthermore, WHO reports that unsterilized syringes cause 8-16 million cases of hepatitis B, 2.3-4.7 million cases of hepatitis C and 80,000-160,000 cases of HIV every year. This is as a result of lacking awareness about the hazards related to health-care biomedical waste, inadequate training in proper waste management, absent waste management and disposal system, insufficient financial and human resources and failure to adhere with WHO biosafety regulations (Kumar et al., 2013; Hossain et al., 2011). Incinerating of health wastes (a common practice in most developing countries) produces dioxins, furans and other toxic air pollutants that are harmful to human life and the environment. In disposing of clinical waste, using alternative treatment technologies (advanced steam sterilization, microwave treatment, dry heat sterilization, alkaline hydrolysis, biological treatment and plasma gasification) can reduce human exposure to infectious waste, decrease labor and yield proper compliance with WHO regulations (Hossain et al., 2011). Table IV discusses the strategies that will allow for successful environmental development in the developing world. Sustainable development. Sustainability is crucial to achieve secure long-term human and environmental well-being. According to the 2014 UNDP report, the concept of sustainable development aims at meeting the current development needs without compromising the ability of future generations to respond to their needs. In so doing, it inculcates techniques of reducing implementation costs, dependency and poverty eradication to achieve lasting sustainable benefits. Sustainable development is achieved when economic growth, social development, environmental protection and cultural diversity are emphasized, with the health of the people as the main focus (Aday, 2005; Bircher and Kuruvilla, 2014). On the same note, Buse and Hawkes (2015) suggested that sustainable development can be accomplished, but there is a need for a paradigm shift in the way we address global health. The change should reflect leadership for intersectional coherence and coordination on the structural drivers of health, including social, economic, political and legal considerations. Moreover, the focus should shift from treatment to prevention through locally led, politically smart approaches to a broad agenda, and by identifying the effective means to tackle the economic determinants of ill-health and integrating rights-based approaches. Bircher and Kuruvilla (2014) observed that health goals have not been accomplished because of insufficient coordination across related health, socioeconomic and environmental sectors. Indeed, lack of integration across sectors of strategies, policies and implementation has long been perceived as one of the main pitfalls of previous approaches to sustainable development. Insufficient limited understanding and accounting of trade-offs and synergies across sectors have resulted in incoherent policies and strategies, adverse impacts of unintended development policies and ultimately in diverging outcomes and trends across broad objectives for sustainable development. As a solution, Bircher and Kuruvilla, Le Blanc and Shakarishvili et al. suggested an integrated approach to sustainable development (Bircher and Kuruvilla, 2014; Le Blanc, 2015; Shakarishvili et al., 2011). Models used in health and development It is clear from the literature that there is no standard model for framing the relationship between health and human development (Kim et al., 2013; Swanson et al., 2012). A wide Health and human development 25 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) Summary Relevancy Strategy 1. Incorporate safety into the health-care operation and services Hossain et al. (2011) Improper management of health-care Emphasis segregation of wastes at point of generation with wastes from hospitals, clinics and appropriate collection materials other health facilities poses public and pre-treat infectious waste health risks to patients, health before disposing of workers, waste handlers and Train health-care workers and communities as well as waste handlers contamination of air, water and soil, Increase awareness and effective in turn, affecting all forms of life control of health-care waste Outsourcing health-care wastes to the private partners or other stakeholders Kumar et al. (2013) Negligence of biomedical waste Need to create awareness among management contributes to all other stakeholders about the environmental pollution, affects importance of biomedical waste human health and depletes natural management and related and financial resources regulations Good knowledge, positive attitude Need for regular training of and safe practices of medical staff is hospital staff to improve vital in managing infectious waste knowledge, attitude, and to comply Lack of separating into hazardous or with health-care standards non-hazardous wastes in low-income countries EJTD 42,1/2 26 Table IV. Selected empirical studies for strategies on environmental development Author Theory Key findings/Outcomes Review Emphasize segregation of wastes at the point of generation with appropriate collection materials and pre-treat infectious waste before disposing of Train health-care workers and waste handlers Increase awareness and effective control of health-care waste Outsourcing health-care wastes to the private partners or other stakeholders Most hospitals did not practice health-care waste management (HCWM) – segregation, handling, storage, transportation and disposal of waste were below WHO and bio-safety rules Doctors and nurses have better knowledge, positive attitude and good practices for infectious waste management compared to paramedics and sanitary staff IHWM training model improved knowledge and attitudes in regulated medical waste management Intensive healthcare waste management (IHWM) training model Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) range of models has been proposed, such as health systems approach and systems thinking (Mikkelsen-Lopez et al., 2011), social cognitive model (Von Wagner et al., 2009), country-level framework (Aluttis et al., 2014), holistic approach (Kirigia and Kirigia, 2011), standardsetting approach (Christensen and Remler, 2009) and Patient-centered, multilevel activation and empowerment framework (Chen et al., 2015). However, none has received widespread acceptance. This is partly because of the complexity of the issue under discussion and partly because the proposed model/framework lacks fundamental components to guide the investment and improvement of a complex health system. Although it is impossible for a single model to contain all development and health aspects, there is need for new model to address the current challenges. Health and human development 27 A proposed model for investment in health care: ingredients for health development in developing countries On the basis of the relevant literature reviewed, we propose a Nexus model for investment in health in developing countries. The model consists of human development, social development, economic development and environmental development. We argue that every investment in health care in Kenya should focus on the following four aspects: economic development, which leads to prosperity; environmental development aimed at transforming the entire country regardless of physical and natural barriers; and social and human development designed for transforming people and communities where they live and work in. For each aspect, we propose various strategies, as well as why and how these strategies should be addressed. Figure 1 demonstrates the various processes that have been involved with the analysis of health conditions in developing nations. Figure 1. A Nexus model for investment in life science and health care EJTD 42,1/2 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) 28 Strategies to achieve a comprehensive human health development Human development  Use health education programs to create awareness.  Improve community health and nutrition.  Attract and retain qualified health professionals.  Continuous professional development.  Build strong leadership for effective internal and external management.  Use of communication and technologies in health-care provision. Social development  Collaborate with health-care professionals and manufacturers.  Align health delivery with the local context; remain culturally sensitive.  Ensure access to affordable and quality health-care services.  Build constructive engagement with community stakeholders.  Collaborate with local hospitals and international health organizations.  Continuous health improvement through monitoring and evaluation.  Improve value of health-care delivery. Economic development  Empower stakeholders and communities to actively participate in economic growth.  Develop sustainable health financing mechanisms.  Establish cooperative societies for sustainable development.  Create a culture of health through retail clinics and health centers for economic development. Environmental development  Incorporate safety standards into the health-care operation and services.  Comply with global health-care and treatment standards. Sustainability In the model, quality health care emerges from interactions between individuals’ potentials, economic demands and social and environmental determinants. To achieve sustainable innovations in health-care practice, various strategies suggest that human development, economic, social-economic and environmental development will interact both at individual and organizational level as shown in Figure 2. Discussion and implications To realize the vision of becoming a nation with high health-quality services and access to care for all of their citizens, Kenya should notice the need for interdependencies between Health and human development Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) 29 Figure 2. A network of strategies for sustainable health care technology, human characteristics, socioeconomic and environmental aspects. From a review of the literature, we identified the best strategies and operation practices that have been proved effective in strengthening health systems that Kenya may consider. These strategies are along the four dimensions of development (human, social, economic and environmental). These strategies further interact both at individual and organization level to realize sustainable investment in health care. The review of the literature has shown that the concept of human health development is more complex than it seems. For a nation to provide a comprehensive care to its citizen, it requires a long-term investment in system that can continuously provide high-quality health products, information and services that cover a wide range of diseases. The study also has significant implications for developing nations that donors and other funding agencies are shifting from mere support to a more collaborative investment. As a result, African countries are challenged to increase their commitment to health and create a conducive environment to both local and international investors, and develop a more sustainable human health and development system. More importantly, the African community should be certain to only invest in health systems that are sensitive and appropriate for its citizens. Finally, a wide range of models and framework has been proposed to model the relationship between health and human development; however, none has received widespread acceptance. The models/frameworks are not comprehensive enough to guide the investment and improvement of health, thus affecting development. This study proposes the nexus relationship between technology, human characteristics, socioeconomic and EJTD 42,1/2 Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) 30 environmental aspects as being critical in achieving a sustainable health-care delivery and economic development. We recognize that though there is no one single model that fits all the developing countries, but any innovative initiative related to health and development should contain the components suggested in the nexus model. We further recommend a future study to examine the practicability of the proposed model to determine the effect of the components in the model affecting health as well as human development. The study has significant implications for human resource practitioners in improving the overall health outcomes and health-care services, which further have effects on human development. In particular, the finding is that health system efficiency has no relationship with human development. Those in management should shift their focus from effective practices to effort practices by increasing the amount of investment made in health systems. Also, because health and human development are delivered by and for people, a strong understanding of human resource management issues is vital for the success of any health and human development relationship. Like other studies, this study has limitations; the approach used to review the literature is a limitation of this study as we may have missed a discussion surrounding an important concept or theory related to health, human development and sustainable health. Conclusion The review of the literature has revealed that issues of health and human development is complex when examined both at global and national levels. Several models have been proposed but none has received a global acceptance. 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(2006), “The EUHPID health development model for the classification of public health indicators”, Health Promotion International, Vol. 21 No. 2, pp. 153-159. Muiya, H.M. and Kacirek, K. (2009), “An empirical study of a leadership development training program and its impact on emotional intelligence quotient (EQ) scores”, Advances in Developing Human Resources, Vol. 11 No. 6, pp. 703-718. Nafukho, F., Muyia, M.A.H. and Irby, B.J. (2014), Governance and Transformations of Universities in Africa, Information Age Publishing, Charlotte, NC. Downloaded by Texas A&M University At 08:08 11 July 2018 (PT) About the authors Caroline Sabina Wekullo is a Doctoral Student in the Higher Education Administration program within the Department of Educational Administration and Human Resource Development at Texas A&M University in College Station, Texas. Elise Catherine Davis is a Graduate Assistant Researcher for the NSF Center for Health Organization Transformation within the Texas A&M University School of Public Health. She holds a bachelor’s degree in neuroscience and Africana studies (Augustana College), and will receive her master’s degree in Public Health from the Texas A&M University, School of Public Health. Her research interests include epidemiology, international health and international development. Elise Catherine Davis is the corresponding author and can be contacted at: edavis1@tamhsc.edu Dr Fredrick Muyia Nafukho is a Professor and Associate Dean for Faculty Affairs, College of Education and Human Development, Texas A&M University. Dr Nafukho serves as Editorial Board Member for numerous scholarly journals in the field of human resource development. He teaches educational statistics, evaluation and foundations of human resource development courses. Dr Bita A. Kash, PhD, MBA, FACHE, is the Director of the NSF Center for Health Organization Transformation at the Texas A&M University School of Public Health. She is the Editor-in-Chief of the Journal of Healthcare Management, an Associate Professor at the Department of Health Policy and Management in the School of Public Health, a Joint Associate Professor at the College of Medicine and a Faculty Fellow at the Center for Health Systems and Design, College of Architecture. Dr Kash is also a Fellow of the American College of Healthcare Executives and an active member of AcademyHealth, the Gerontological Society of America and Academy of Management. For instructions on how to order reprints of this article, please visit our website: www.emeraldgrouppublishing.com/licensing/reprints.htm Or contact us for further details: permissions@emeraldinsight.com