Opportunities and challenges of empowering SMEs for sustainable Healthcare delivery

: This paper examines the sustainability practices implemented by healthcare establishments, mainly Small and Medium enterprises (SMEs), We focus on identifying opportunities with challenges involved. This systematic literature analyses 47 studies that explore sustainability practices in the healthcare system globally. The finding from the studies reveals that healthcare organizations with SMEs adopt diverse measures like renewable energy, a reduction, and a response procurement in minimizing the impact on the environment and ensuring financial stability. The challenges SMEs face comprise limited financial resources, lack of expertise, with difficulties accessing information and support. Furthermore, we suggest opportunities for SMEs to enhance sustainability practices with partnerships with other organizations and investing in educating employees. Implementation of sustainability practices will improve the financial stability, and environmental impact, with the wellbeing of healthcare stakeholders. The empirical evidence, comparative studies with cross-disciplinary are needed in exploring the effectiveness of the different suitability practices, potential trade-offs, synergies between sustainability and other organizational goals, the effect of sustainability practice in the financial with non-financial performance on SMEs in healthcare establishment are positive, with cost-effectiveness, efficiencies operations, improving brand reputations and engaging the employee. Established factors like regulating frameworks and government initiatives play a major role in the influence of adopting sustainability practices with cultural factors.


Introduction
The health industry is now recognizing the importance of sustainability practices in reducing its environmental impact to achieve financial stability and maintain the well-being of stakeholders.SMEs constitute a significant proportion of healthcare establishments globally.However, SMEs face challenges in implementing sustainable practices due to limited resources and skilled personnel (Sijm-Eeken et al., 2023).The main aim of this review is to provide an overview of sustainable practices adopted in healthcare organizations, with a primary focus on SMEs.The review analyzed 50 studies that examine sustainability practices in healthcare.These studies were selected based on their relevance to the paper's focus and contribution to current sustainability practices (Saeed et al, 2018).This comprehensive review reveals that healthcare organizations recognize the importance of sustainability practices, and establishments are now implementing energy efficiency measures to reduce waste through the adoption of procurement practices.The review highlights various opportunities for SMEs to enhance sustainability practices, including collaboration and partnerships with the health sector.Government parastatals and non-profit establishments are sharing resources to access funding with experts in sustainability.Furthermore, SMEs could invest in educating and developing stakeholders for the implementation of sustainable practices (Cadil et al., 2018).Non-profit organizations can be valuable partners for SMEs, fostering collaboration with larger healthcare organizations to implement shared sustainability practices or partnering with non-profit organizations to access funding and expertise in sustainability.Additionally, SMEs could invest in employee education and training programs to develop the necessary expertise for effective implementation of sustainable practices (Ho et al., 2022).
This review has implications for policy-making to sustain best practices in the industry.For instance, innovative programs could be developed to support stakeholders (Rostami et al., 2021).The review provides insight into the adoption of sustainability practices by the healthcare sector, including SMEs, and highlights opportunities along with challenges faced in pursuing sustainability practices.It also contributes to implementing best practices that will garner support and promote SMEs and the healthcare sector.
This review thoroughly examined the research gap within the context of sustainability practices in the healthcare sector, specifically focusing on SMEs.The literature, from Wang and Hajli (2017) to Hussain et al. (2019) (refer to Table A1), consistently highlights research gaps.As a result, we have identified several areas that require further research, as presented in Figure 1.These areas include the specific challenges and opportunities faced by small and medium-sized healthcare organizations in implementing sustainable practices, the need for comparative studies across different healthcare organizations, sectors, and geographic regions, and the scarcity of experiential evidence on the efficiency of various sustainability practices in healthcare establishments.Based on these identified gaps, we have formulated research questions that directly address the areas of limited research and provide a roadmap for future investigations.These research questions explore how key sustainability practices can be effectively implemented by SMEs in healthcare organizations, how the challenges and barriers to sustainability practices in SMEs can be overcome, how institutional and cultural factors influence the adoption of sustainability practices, and the implications of the findings for policy and practice in promoting sustainability practices in SMEs within the healthcare sector.
By clearly identifying and articulating the research gap and formulating relevant research questions, the problem statement and research questions indicate a need for further exploration.Despite the revolutionized sustainability practice in healthcare sectors, there is limited research that focuses on the opportunities and problems faced by SMEs in the context of sustainability.SMEs are pivotal in healthcare and vital for establishing sustainable practices, given their significant involvement in a major portion of healthcare.It is a crucial factor enabling sustainability practices in this segment of the establishment.
Research Questions: • How will the key suitability practice be fully implemented by SMEs in healthcare organizations?
• How can the challenges and barriers to sustainability practice in SMEs in healthcare organizations be tackled?
• How do institutional and cultural factors influence the adoption of sustainability practices in SMEs in healthcare organizations?
• What are the implications of the findings for policy and practice in promoting sustainability practices in SMEs in healthcare organizations?The research gap between healthcare and SMEs provides a roadmap for future research, assisting researchers in identifying areas where further investigation is needed.Research gaps serve as valuable guides, enabling researchers to steer clear of duplicating existing studies and ensuring that their research is both relevant and contributory to the existing body of knowledge.In essence, a research gap helps establish the significance of the research and its potential contributions to the field.One notable gap identified is the incomplete experiential evidence regarding the efficiency of different sustainability practices in healthcare establishments.There is a pressing need for researchers to integrate more perspectives that can effectively manage SMEs within the healthcare sector.This involves addressing the partial research on potential trade-offs (Wicklum et al., 2023) and synergies between sustainability and other organizational goals, such as economic performance coupled with excellent care.
Furthermore, there is a call for more comparative studies to examine sustainability practices across different types of healthcare organizations, sectors, and geographic regions.This approach will enhance our understanding of the varied challenges and opportunities faced by healthcare establishments, especially SMEs, in implementing sustainable practices.

Materials and methods
The method utilized in this study draws inspiration from (Saunders et al., 2019), recognizing the value of reviews in developing new research paths and analyzing a substantial amount of scholarly work.Reviews serve as a foundation for future research avenues and contribute to the development of research questions (Massaro et al., 2016).In the context of this research, reviews are considered a sound alternative to traditional literature reviews, such as systematic or bibliometric reviews, for identifying relevant literature on sustainability practices in the healthcare sector.
The purpose of this review is to examine and consolidate prior research findings in the literature, proposing effective strategies for healthcare organizations to promote sustainability.This contributes to the continuity of organizations and the achievement of sustainability practices in the healthcare sector, with a specific focus on addressing opportunities and challenges for small and medium enterprises (SMEs).The following steps were undertaken:

Philosophical Stance:
The research is guided by a philosophical stance (Wilson, 2014), underpinning the objective analysis and synthesis of existing literature.Assumptions and perspectives that shape this study are aligned with key authors in the field, guided by an interpretive philosophical stance Walsham, 2006.This philosophical stance recognizes the importance of subjective understanding and the social construction of reality.It acknowledges that individuals and organizations interpret and give meaning to their experiences, shaping their perspectives on sustainability practices in the healthcare sector.By adopting an interpretive approach (see Figure 2), this research seeks to explore and interpret the experiences, perceptions, and viewpoints of stakeholders involved in sustainable healthcare practices, particularly SMEs.
The interpretive philosophical stance allows for a comprehensive examination of the opportunities and challenges faced by SMEs in implementing sustainability practices within healthcare organizations.It recognizes the need to understand the diverse perspectives and subjective interpretations of stakeholders involved, thereby providing a deeper understanding of the complex dynamics surrounding sustainability in the healthcare sector.

Research Approach:
A qualitative research approach was chosen based on the nature of the research questions and objectives.This approach allows for in-depth exploration and understanding of sustainability practices in the healthcare sector.

Research Strategy:
The research strategy employed involved conducting a systematic literature analysis of 47 studies.This entailed conducting a literature review to identify relevant papers and performing a content analysis of the selected papers to extract and analyze the pertinent information.The content analysis focused on understanding the challenges and opportunities faced by SMEs in implementing sustainability practices in the healthcare sector.

Time Horizon:
The literature analysis covered recent years, providing a temporal context for the selected studies and allowing for a comprehensive understanding of the current state of sustainability practices in healthcare organizations.
Data Collection Methods: Data were collected from the 47 selected studies using various methods, including keyword searches, database selection, and inclusion/exclusion criteria for article selection.Scopus and Web of Science were utilized to identify and select relevant studies for the review.

Data Analysis Techniques:
The data from the selected studies were analyzed and synthesized using qualitative content analysis, thematic analysis, and potentially other qualitative synthesis methods.These techniques facilitated the extraction of key insights and themes related to sustainability practices in healthcare organizations.

Validity and Reliability:
To ensure the validity and reliability of the research findings, clear criteria were established for selecting relevant studies.The quality of the studies was evaluated, and the validity of the evidence was assessed.These measures ensured the inclusion of appropriate studies and gave appropriate weight to high-quality studies in the synthesis of findings.
Result Analysis: The results obtained from the literature analysis were discussed, and recommendations were made to provide a roadmap for future research.The discussion drew on the insights and recommendations of key authors in the field, highlighting areas that require further investigation.(Walsham, 2006).

Results
The flowchart illustrates in Figure 3 the process of empowering small and medium enterprises (SMEs) in the healthcare sector for sustainable healthcare practices.It begins with identifying the SMEs and assessing their current sustainability practices.Opportunities for improvement are then unveiled, and the SMEs are empowered through education and training.The aim is to promote the adoption of sustainable healthcare practices while addressing challenges and obstacles along the way.Collaboration with stakeholders is crucial for success.Monitoring and evaluation help track progress, and strategies are adjusted as needed.This systematic approach empowers SMEs to contribute to sustainable healthcare, promoting environmental responsibility and positive societal impact in the healthcare industry.

Key sustainability practices adopted by SMEs in healthcare organizations
In the realm of healthcare organizations, small and medium enterprises (SMEs) have been adopting various sustainability practices to reduce their environmental impact and ensure financial stability.This section discusses some key sustainability practices embraced by SMEs in healthcare organizations.Firstly, SMEs are actively incorporating renewable energy sources into their operations.Implementing solar panels, wind turbines, or geothermal systems allows them to generate clean energy, reducing their reliance on fossil fuels and minimizing their carbon footprint (Spector).Secondly, waste reduction strategies play a significant role in sustainable healthcare practices.SMEs are implementing waste segregation programs, recycling initiatives, and waste-to-energy systems to minimize the amount of waste generated and promote a circular economy approach (Vicente-Oliva et al., 2015).Furthermore, responsible procurement practices are being adopted by SMEs to support sustainability.They prioritize suppliers with eco-friendly practices and engage in ethical sourcing of goods and services.This includes selecting suppliers that adhere to sustainable forestry, fair trade, and environmentally friendly packaging (Mehra et al., 2021).
SMEs are majorly promoting resource efficiency with measures like the conservation of water and optimization of HVAC systems and energy.This will help in reducing resource consumption and operation, and minimize costs while promoting sustainability practices.This major sustainability adoption by SMEs in the healthcare sector demonstrates a commitment to environmental stewardship and financial capability.The implementation of waste reduction, accountable procurement, renewable energy, and resource management will contribute to SMEs more in healthcare.It is revealed that sustainability in healthcare has provided a foundation for subsequent analysis through various techniques that are placed for the assessment of healthcare by healthcare experts.Aras-Beger et al. (2021) used analytic hierarchy process and interpretive structural modeling within a strategies framework for sustainable healthcare measures.The key findings show that indigenous production and research with innovations are major drivers in measuring healthcare.Furthermore, waste reduction and management provide strong directions for experts.

Drivers and obstacles to adopting sustainability practices in SMEs in the healthcare sector
Adopting sustainability practices in SMEs in the health sector is majorly influenced by diverse drivers, which are hindered by numerous obstacles.Understanding the factors for promoting sustainable practices in context, we discuss the major drivers and problems of adopting sustainability practices in SMEs in health sectors.One force that drives sustainability practices includes poly regulation compliance; this is how SMEs are compelled to meet the environmental standards set by government authorities (Spillias et al., 2023).Finance also plays a major role, with incentives like saving costs from energy management and waste reduction.The market demand for environmentally friendly products motivates SMEs to align with good practices and principles to attract more customers, ultimately increasing revenue and product deliveries.
However, there are several challenges in adopting sustainability practices, such as the limitation of financial resources.The process requires upfront payment, which is not always available and affects budgeting plans in SMEs (Sumrin et al., 2021).The lack of expertise is a major problem in SMEs, affecting internal production capacities.The problem of accessing information and support networks for implementation is another challenge, affecting all parts of the process.Furthermore, SMEs may be less aware of the potential benefits related to sustainability practices compared to larger sectors, resulting in lower motivation and prioritization of efforts in sustainability (Govindan and Hasanagic, 2018).The lack of awareness of the importance of sustainability and its link to long-term business success will be a major problem for SMEs in achieving their goals.Solving these problems and leveraging the drivers is crucial in promoting the adoption of sustainability practices in SMEs in healthcare organizations.Various policies that support financial incentives, capacity building, and education will solve these problems and enable good practices.

Measuring and reporting sustainability performance by SMEs in the healthcare sector
The measurement and reporting of sustainability performance are vital for SMEs in the healthcare sector to track progress and communicate efforts to principal players.Here we discuss the importance of measuring and reporting sustainability performance and reveal relevant case studies.The measurement of sustainability performance allows SMEs to assess the effectiveness of their sustainability initiatives, improving areas and setting good targets (Ahi and Searcy, 2013).Furthermore, it enables monitoring of environmental, social, and economic indicators such as waste generation and energy management, as well as community engagement (Shankar et al., 2017).
The measurement of SMEs demonstrates a commitment to sustainability, giving a reputation to end-users and investors.The reporting of the Sustainability Act provides a means for SMEs to communicate their progress and achievements.It allows them to showcase their sustainable practices, initiatives, and impact on various stakeholders.Transparent reporting enhances responsibility, builds trust, and fosters engagement with customers, employees, suppliers, and regulatory bodies (Horsburgh et al., 2017).Studies have highlighted the importance of developing appropriate measurement frameworks and reporting systems for SMEs in healthcare organizations (Loh et al., 2017).These frameworks should consider the unique features and resource constraints of SMEs, ensuring that the measurement and reporting processes are practical, relevant, and associated with sustainability goals (Smaltz et al., 2006).Empirical evidence in (Aras and Crowther, 2011) shows from their survey data that the healthcare sector needs professionals for effective operations and to drive the agenda of the health sector.

Effects of sustainability practices on the financial and non-financial performance of SMEs in healthcare organizations
In this section, we provide insights into the effects of sustainability practices on the financial and non-financial aspects of SMEs in the healthcare sector, showcasing significant gains.The potential impact of adopting sustainability practices on the performance of SMEs is explored.Applying sustainability practices can positively influence the financial performance of SMEs in the healthcare sector.Research reveals that sustainability initiatives, such as energy productivity measures, waste reduction strategies, and accountable procurement practices, can lead to cost savings and real efficiencies.For example, reducing energy consumption can result in lower utility bills, while waste reduction measures can minimize disposal costs.Moreover, sustainable practices can enhance brand reputation, attract socially conscious customers, and create opportunities for market differentiation, leading to increased revenues and market share.The non-financial impact of adopting sustainable practices is equally positive, improving environmental outcomes through reduced carbon emissions, minimized waste generation, and conservation of resources.This contributes to a better and more sustainable future for establishments and society as a whole.
Furthermore, sustainability initiatives enhance morale, retention, and increase work productivity (Sunmola et al., 2021).Studies have emphasized the potential merits of sustainability practices on both financial and non-financial performance in the context of SMEs in healthcare organizations (Cochran et al., 1984).These findings highlight the value of incorporating sustainability practices into the business strategies of SMEs to achieve lasting success.

Influence of Institutional and cultural factors on the adoption of sustainability practices in SMEs in Healthcare sectors
In this section, we elaborate on the adoption of sustainability practices in SMEs within healthcare organizations, influenced by a range of institutional and cultural factors.The impact of these factors on the adoption of sustainability practices is discussed, citing relevant studies.Established factors play a vital role in shaping the adoption of sustainability practices in SMEs.Regulatory guidelines, industry standards, and policies endorsing sustainability can provide a helpful environment for SMEs to engage in sustainable practices (Aragón-Correa et al., 2020).For instance, government initiatives incentivizing sustainability measures, such as tax benefits or subsidies, can encourage SMEs to invest in eco-friendly technologies and practices.Additionally, the presence of industry relations and networks focused on sustainability can aid knowledge sharing, collaboration, and collective action among SMEs (Walker et al., 2008).
Cultural influences also play a crucial role in shaping the adoption of sustainability practices in small and medium enterprises (SMEs).Organizational culture, principles, and attitudes toward sustainability significantly impact the willingness of SMEs to participate in sustainable practices.These cultural factors influence the overall mindset and values within an organization, affecting the extent to which SMEs embrace sustainable performance.Leadership commitment plays a vital role in driving sustainability initiatives within SMEs.When leaders prioritize sustainability and demonstrate a strong commitment to integrating sustainable practices into the organizational strategy, it positively influences the engagement of employees and other stakeholders.This engagement, in turn, fosters a culture of sustainability within the organization.Furthermore, employee engagement is an essential aspect of creating a sustainable culture within SMEs.When employees are actively involved in sustainability initiatives, they feel a sense of ownership and are more likely to embrace and participate in sustainable practices.This active engagement can lead to innovative ideas and behaviors that promote sustainability.
Perception also plays a role, as the organization's perception of sustainability as a planned priority influences the level of commitment and investment in sustainable practices.When sustainability is recognized as a strategic priority, SMEs are more likely to allocate resources, develop sustainable policies, and integrate sustainability into their day-to-day operations.Additionally, previous studies have highlighted the influence of institutional and cultural factors on the adoption of sustainability practices in SMEs within the healthcare sector (Hahn et al., 2015).These studies emphasize the interaction between institutional forces, such as regulations and industry standards, and cultural factors, including values, norms, and beliefs, in shaping the adoption and implementation of sustainability practices.By considering these cultural influences, we aim to provide a comprehensive understanding of how organizational culture, principles, and attitudes toward sustainability shape the willingness of SMEs to participate in sustainability practices.Our research explores the intricate relationship between these factors to shed light on effective strategies for promoting sustainability in SMEs.
Regional/Jurisdictional Particularities, Resource Availability, Cultural Factors, Economic Factors, and Government Policies: The availability of resources, such as renewable energy sources, water, and waste management infrastructure, can vary widely by region, influencing the feasibility of certain sustainability practices.Cultural norms and values can play a significant role in shaping sustainability practices, with regions exhibiting strong environmental consciousness potentially adopting different approaches to sustainability.Economic conditions and disparities across regions can impact the financial resources available to healthcare SMEs for sustainability investments.Variations in government policies, incentives, and regulations in different jurisdictions can lead to differences in the prioritization and implementation of sustainability practices.

Implications of the outcomes for policy and practice in upholding sustainability practices in SMEs in the healthcare sector
This paper presents the important effects of policy practice for promoting sustainability practice in SMEs in the health sectors (see Figure 4) This is the global statistical findings presented by Aragón-Correa et al. (2020).Furthermore, we discuss the implications with various case studies: I.One of the key findings in this study is that achieving sustainability in healthcare involves economic sustainability practices driving social sustainability practices, linked through environmental sustainability practices.The framework for sustainable healthcare suggests implementing green healthcare initiatives with circular practices through the integration of care facility design, waste reduction, and management.Sustainable procurement, coupled with green growth and employee satisfaction strategies, will result in saving healthcare costs.
II.The support of government policies and major players is crucial in promoting the sustainability of SMEs in health.Government-developed policies have a significant impact, and if they are supportive and encouraging, the process goes smoothly.This support policy can take the form of grants and subsidies.
III. Capacity building will help increase the expertise of SMEs, enhancing their knowledge for better understanding and implementation of sustainability strategies.Collaboration, additional research, and facilitating knowledge exchange will make sustainable practices a reality (Walker et al., 2008).
IV. Knowledge sharing and collaboration will enable SMEs to learn from each other's experiences and best practices to reach their goals.The creation of forums, networking, and associations will be instrumental in achieving the best practices.Larger healthcare organizations and non-profit organizations can play a role in promoting sustainable practices and addressing common challenges (Collins et al., 2007).
V. Financial Support: Access to financial resources is a critical factor in the adoption of sustainability practices by SMEs.Financial institutions, investors, and funding agencies can provide financial support to SMEs to implement sustainability initiatives.This can include offering favorable loan terms, investment opportunities, or grants specifically dedicated to supporting sustainable projects in healthcare SMEs (Workman et al., 2018).
The implications outlined above are supported by studies that have examined the role of policy and practice in promoting sustainability practices in SMEs across various industries.These findings highlight the need for a multi-faceted approach involving policy support, capacity building, knowledge sharing, and financial assistance to foster sustainability practices among SMEs in healthcare organizations.
Appendix B comprises 56 components that support sustainability practices in the healthcare sector.These components play a major role in implementing best practices in healthcare and SMEs, contributing to a greener and more sustainable healthcare system that promotes patient well-being.

Implications
Theoretical Implications: The findings of this study have theoretical implications related to the effectiveness, trade-offs, and synergies associated with sustainability practices in healthcare establishments.It underscores the influence of regulations, government initiatives, and cultural factors as major hurdles in the implementation of sustainability practices in healthcare, especially within SMEs.The theoretical implications extend to the need for further exploration of the effectiveness of different sustainability practices, potential trade-offs, and synergies between sustainability and other organizational goals.
Practical Implications: From a practical standpoint, the adoption of sustainability practices in healthcare establishments, particularly SMEs, can lead to improved financial stability, reduced environmental impact, and enhanced well-being for healthcare stakeholders.The empirical evidence suggests positive effects on costeffectiveness, operational efficiency, brand reputation, and employee engagement.
Comparative Studies and Cross-disciplinary Research: The study suggests that comparative studies and cross-disciplinary research can contribute to a deeper understanding of the financial and non-financial performance outcomes associated with sustainability practices in SMEs within the healthcare sector.
Government Initiatives and Cultural Factors:Theoretical implications also encompass the significant role played by regulatory frameworks, government initiatives, and cultural factors in influencing the adoption of sustainability practices.These factors shape the landscape for sustainable practices in healthcare organizations.

Conclusion
This review provides valuable insights into sustainability practices in the healthcare sector, with a specific focus on SMEs.The healthcare sector, including SMEs, is adopting diverse sustainability measures such as renewable energy and waste reduction, with a commitment to responsible procurement practices.While the paper identifies challenges, including limitations in skilled personnel, financial constraints, and difficulties accessing information and support, it also suggests opportunities for enhancing sustainability practices, such as partnerships with other healthcare sectors, stakeholders, and investments in education.

Future recommendations
Research on Sustainability Practices in Various Sectors: Future research should extend beyond SMEs in the healthcare sector and explore sustainability practices in various sectors.Additionally, there is a need for comparative analyses, especially in larger healthcare organizations.
Identifying Strategies for SMEs: Future research should focus on identifying specific strategies and interventions to address the challenges faced by SMEs in implementing sustainability practices.This could include practical solutions and interventions to overcome barriers.
Impact of Sustainability Practices: Further studies should examine the impact of sustainability practices on both financial and non-financial performance indicators to provide a comprehensive understanding of their benefits.
Cross-disciplinary Collaboration: There is a need for more research that integrates insights from healthcare management, sustainability studies, and related fields to foster cross-disciplinary collaboration and knowledge exchange.
Role of Stakeholders: Future research should explore the role of stakeholders, such as patients, employees, and local communities, in shaping the adoption and success of sustainability practices in healthcare organizations.This would provide a more holistic understanding of sustainability practices in the healthcare industry.
In conclusion, addressing the identified limitations and focusing on the suggested research gaps can contribute to the promotion of sustainable practices in healthcare organizations, leading to improved environmental outcomes, financial stability, and overall well-being.The practical implications, such as financial stability and environmentally impacted employee engagement, along with theoretical implications and the influence of regulatory frameworks and cultural factors, provide a comprehensive foundation for future research and practice.
Author contributions: Conceptualization, SA and LO; methodology, SA formal analysis, LO; investigation, SA; resources, SA; data curation, SA; writing-original draft preparation, SA; writing-review and editing, LO; visualization, LO; supervision, LO; project administration, LO; funding acquisition, LO.All authors have read and agreed to the published version of the manuscript.
Funding: University of Johannesburg, Johannesburg business school South Africa.

Conflict of interest:
The authors declare no conflict of interest.(Ullah, et al., 2021)

Figure 3 .
Figure 3.The process of empowering small and medium enterprises (SMEs) in the healthcare sector.

Figure 4 .
Figure 4. Key area of health policy action.