A study of social enterprise in health policy: Comparative approaches where resource and policy context differ

National and international policy actors use social enterprises in health system reform, but their meaning is contested. This inter-disciplinary research examines the logics of social enterprise. It contributes to health policy development in England and Tanzania by developing knowledge and theory of how and why they are used in health system reform. Institutional logic provides the inductive research framework using comparative, cross sectional case study design. Data collection methods included interviews with policy actors, literature, websites and other media using content, context, time series and narrative analysis. Three core characteristics of social enterprise were common to England and Tanzania: a social purpose, furthered with use of profits and social entrepreneurial outlook of actors in response to a market. The social determinants of health could be aligned with organisations’ social purpose. Three groups of organisations emerged: Holistic, Health care and Lifestyle. Social enterprises’ organisational strategies and their business models in each of these groups both respond to and are contingent on the state and market design of the health system. Socio-cultural and resource contexts constrained or enabled social entrepreneurs’ ability to achieve social innovation. The contribution of social enterprises to achieving health equity goals are not translated into the logic of state funded health care services or the market in either country. This is despite advocacy by policy actors and social enterprise policies in England. In Tanzania policy makers do not recognise the potential of social enterprises to achieve health equity goals. In both countries policy implementers and influencers were able to demonstrate how they contribute to health equity through their organisational strategies. Some social entrepreneurs acted collectively as institutional entrepreneurs to advocate for health system change. A framework and a diagnostic tool have been developed which contain the contingent variables required to introduce this logic into a health system.