Evidencing the contribution of social enterprise in health and social care sector

Since the late 1990s the concept of ‘social enterprise’ has achieved policy recognition in many countries as a possible means to reform health and social care systems, particularly amid growing societal needs and financial constraints (Teasdale, 2012). The growing attention on social enterprise has been mirrored in academia; scholars have researched the extent to which social enterprises: (1) develop sustainable solutions to social problems (Borzaga and Defourny, 2001; Tracey et al., 2011) (2) meet societal needs (Bornstein, 2007), (3) generate measurable social impact (Bagnoli and Megali, 2011; Nicholls, 2009) and (4) broaden the field of social innovation (Leadbeater and Wong, 2010; Nicholls and Murdock, 2012). One of the sectors in which social enterprises are heavily involved is health care. Social enterprise has been presented, for instance, as one of the key players in providing an innovative response to health inequalities (Donaldson et al., 2011; Fiorentini, 2006; Roy et al., 2013).

The first part of my PhD research has been based on a review of literature on health policy development, both in the UK and Italy, alongside a review of the development of social enterprise and non-profit organisations in the wider context of social policy. Thanks to a systematic analysis of policy and laws relating to the main periods of development of mixed economy of welfare on the base of three different dimensions (service provision, finance and regulation) it is possible to assume a form of path dependency towards the inclusion of new service providers after a period characterised as the ‘Golden Age’ of welfare within the UK and Italy. Following a model suggested by Gidron et al. (1992), the different periods for both countries were characterised by a third sector dominant model (1830-1945), a government dominant model (1945-1970) and a collaborative model (1970-present). However, today it is becoming more difficult to classify the welfare mix as a collaborative model because of the involvement of new players in the provision of services (e.g. social enterprises and private providers), the increasing number of new players in financing services (e.g. social impact investing) and the evolution among different players in terms of regulation (e.g. growing influence of the private sector). The clear lack of evidence on impact both in terms of equity and cost containment, combined with endogenous (e.g. economic crisis) and exogenous variables (e.g. austerity policies) impacting strongly on national economies has led to calls for a new model that should present better outcomes for improving services for citizens. In the economy of today countries all over the world, but particularly in Europe, are seeing the concept of social enterprise as a ‘panacea’ for solving the economic and social crises. The trouble is, however, that this is not based upon an evidence base demonstrating the effectiveness and efficiency of this new player, particularly in comparison to other models of delivery (Roy et al., 2014).

Consequently, we consider that the following overarching question is particularly important for researchers, practitioners and policy makers:

  • How can such organisations measure and demonstrate efficiency and effectiveness in comparison with other providers (such as for-profit organisations, the public sector and other non-profits)?

This leads to the three more specific questions to be explored in my PhD:

  • What does the literature tell us about the quality of the evidence base, particularly with respect to whether social enterprises or other third sector organisations provide improved outcomes in comparison with private for-profit and public providers in health and social care systems?
  • Can this evidence base be improved, perhaps through the use of quasi-experimental methods, such as a controlled comparative study of a community-based, health focused social enterprise initiative?
  • What mechanisms and environmental factors support (or impede) the production of positive outcomes from such social enterprise-led activity?

In order to begin to address the questions, a Systematic Review is being undertaken (registered at Prospero: see Calò et al., 2014) to address if social enterprises or third sector organisations provide improved outcomes in comparison with private for profit and public providers in health and social care systems. This Systematic Review involves a synthesis of quantitative and qualitative studies, identified from 11 health and social science databases. The results of this Systematic Review will act as the base for developing an integrative mixed method analysis to address the second and third questions. In addressing the second question, a quasi-experiment would be devised and piloted. For creating a counterfactual analysis there will be the need to explore issues such as: i) whether it is feasible to establish a control group; ii) number of potential study subjects; iii) availability of retrospective data; iv) and ability to collect some data prospectively. These issues may be resolved through a participatory approach evaluation involving the identified main stakeholders. Finally a third, qualitative, study would involve interviews with key stakeholders and in particular deviant and extreme cases from the quantitative analysis in order to identify causal inferences and the causal paths behind the more quantitative results. This will include investigation of the ‘eco-system’ within which the case studies operate. The possibility of undertaking the quasi-experiment is currently investigated with a major social enterprise initiative in the west of Scotland. Consideration also has to be given to the time and effort required to replicate the quasi-experiment and qualitative analysis (or parts thereof) in an Italian setting.

There is a significant gap of knowledge on understanding the impact and the contribution of social enterprises in health and social care sector (Roy et al., 2014). The policy measures regarding social enterprises developed in the last decades could be said, thus, to be driven by ideology rather than any ‘rational’ evaluation of the evidence. It is hoped that my PhD will lead to a greater understanding on impact evaluation of social enterprises, and provide a useful evidence base for developing policies, and improving impact assessment methodologies.


Bagnoli, L., Megali, C., 2011. Measuring Performance in Social Enterprises. Nonprofit Volunt. Sect. Q. 40, 149–165. doi:10.1177/0899764009351111

Bornstein, D., 2007. How to Change the World: Social Entrepreneurs and the Power of New Ideas. Oxford University Press, New York.

Borzaga, C., Defourny, J. (Eds.), 2001. The Emergence of Social Enterprise. Routledge, London.

Calò, F., Donaldson, C., Baglioni, S., Teasdale, S., 2014. Social Enterprise: A Growing Myth or an Impactful Reality? Do Social Enterprises Provide Improved Outcomes in Comparison with Private for Profit and Public Providers in Health and Social Care Systems? Prospero – Int. Prospect. Regist. Syst. Rev.

Donaldson, C., Baker, R., Cheater, F., Gillespie, M., McHugh, N., Sinclair, S., 2011. Social business, health and well-being. Soc. Bus. 1, 17–35. doi:10.1362/204440811X570545

Fiorentini, G., 2006. Impresa sociale e sussidiarietà. Dalle fondazioni alle spa; management e casi. Franco Angeli.

Gidron, B., Kramer, R.M., Salamón, L.M., 1992. Government and the third sector: emerging relationships in welfare states. Jossey-Bass.

Leadbeater, C., Wong, A., 2010. Learning from the Extremes. Cisco, San Jose, CA.

Nicholls, A., 2009. Capturing the Performance of the Socially Entrepreneurial Organization: An Organizational Legitimacy Approach, in: Robinson, J., Mair, J., Hockerts, K. (Eds.), International Perspectives on Social Entrepreneurship. Palgrave Macmillan, Basingstoke, Hants.

Nicholls, A., Murdock, A., 2012. Introduction: The Nature of Social Innovation, in: Nicholls, A., Murdock, A. (Eds.), Social Innovation: Blurring Boundaries to Reconfigure Markets. Palgrave Macmillan, Houndmills, Basingstoke, Hampshire, pp. 1–32.

Roy, M.J., Donaldson, C., Baker, R., Kay, A., 2013. Social enterprise: new pathways to health and well-being? J. Public Health Policy 34, 55–68. doi:10.1057/jphp.2012.61

Roy, M.J., Donaldson, C., Baker, R., Kerr, S., 2014. The potential of social enterprise to enhance health and well-being: A model and systematic review. Soc. Sci. Med. In Press. doi:10.1016/j.socscimed.2014.07.031

Teasdale, S., 2012. What’s in a Name? Making Sense of Social Enterprise Discourses. Public Policy Adm. 27, 99–119. doi:10.1177/0952076711401466

Tracey, P., Phillips, N., Jarvis, O., 2011. Bridging Institutional Entrepreneurship and the Creation of New Organizational Forms: A Multilevel Model. Organ. Sci. 22, 60–80.

ImmagineFrancesca Calò is in the second year of her PhD at the Yunus Centre for Social Business and Health at Glasgow Caledonian University, Glasgow, UK under the supervision of Professor Cam Donaldson, Dr. Simone Baglioni and Professor Simon Teasdale. Prior to joining the Yunus Centre, Francesca received her Double MSc (International Management) from Fudan University, Shanghai and Bocconi University Milan.  She worked as a research fellow in CERGAS- Bocconi University (non profit area) for three years and as a practitioner in a social enterprise (Impact Hub Milan) for one year. E-mail: Francesca.Calo@gcu.ac.uk


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