Keywords

Introduction

Entrepreneurship policy assumes that venture creation is important due to its contribution to the economy through innovations, employment and investments (Gilbert et al. 2004). Such a policy shapes the institutional environment in which entrepreneurs take their decisions and start their ventures (Hart 2003). However, the question of if and how entrepreneurship policy influences entrepreneurial activity positively is far from being answered (Minniti 2008). This question becomes more relevant when entrepreneurship policy is evaluated from the perspective of specific industries and countries. Entrepreneurship policy works when governments understand that one-size efforts do not fit all when they take on the important role of fostering environments conducive to entrepreneurship (Audretsch et al. 2007; Minniti 2008).

Since the late 1990s, the Government of Rwanda has been working to identify entrepreneurship potential in different sectors in the country. It recently specifically identified investment opportunities for the health sector including in health facilities, pharmaceutical plants, distribution networks for pharmaceutical products, training of health professionals and health training schools. The underlying assumption behind these efforts is that the health sector needs to increase the involvement of the private sector to improve efficiency and sustainability in the provision of healthcare services. The policymakers’ role is to ensure that strong and adequate regulatory frameworks are in place to control and avoid fraudulent activities, especially given the very sensitive social but also private good that the health sector domain represents for people and for any country. These regulatory frameworks are then translated into entrepreneurship policies which provide guidance, rules and regulations on investments in different sectors through tax regulations, trading regulations and regulating entry.

This chapter conducts a content analysis of entrepreneurship policies for the health sector in Rwanda. It specifically looks at the discourses linked to an entrepreneur and business-enabling environment and analyzes how they contribute in promoting entrepreneurship in the health sector in Rwanda from a contextual perspective (Welter 2011). The focus of the chapter is on entrepreneurship in the health sector for three main reasons: (1) As in any other country, the health sector is a major concern in Rwanda and the need to improve its functioning is a key objective. This is why there is so much hope in entrepreneurship being a force of renewal of the sector. (2) Rwanda has a demography which has more young citizens than what is considered normal and much hope is assigned to educating and training young citizens for a more entrepreneurial mentality and then directing this spirit towards entrepreneurial opportunities in the health sector (among other key sectors). (3) The need for improving and greater availability of good quality healthcare is of course a concern for all Rwandans, but given Rwanda’s recent history (the genocide in 1994), this concern is accentuated in relation to the big share of young Rwandan citizens as it is important to provide hope and an improved life situation to encourage youngsters to stay in the country.

The rest of the chapter is organized as follows. The next section provides a short overview of major themes in literature on the decontextualized public entrepreneurship policy. We want to emphasize ‘short’ and ‘decontextualized’ here: Given our methodology (conventional content analysis), we follow its inductive logic that states that with “a conventional approach to content analysis, relevant theories or other research findings are addressed in the discussion section of the study […] The discussion would include a summary of how the findings from her study contribute to knowledge in the area of interest” (Hsieh and Shannon 2005: 1279). Section “Research Methodology” describes this research methodology in detail and section “Findings” gives the findings. Section “Discussion” provides a reflexive discussion based on the analysis and interpretations. Finally, section “Conclusion” gives the conclusions of the study.

Decontextualized Entrepreneurship Policy and Its Implications

The role of policy has been central in the development of entrepreneurship research (Oborn et al. 2011). Entrepreneurship policy has emerged as an important element in the new industrial policy which is featured by a shift in emphasis from declining industries to policy measures focusing on research and development, regions and regulatory frameworks (Hölzl 2010; Gilbert et al. 2004). National and regional governments have implemented new programs and regulatory frameworks for fostering business growth (Hölzl 2010). In Europe, there is an emphasis on promoting competitiveness and innovation in the economic policy discourse which has led to an industrial policy that favors adjusting industries to competitive challenges. Indonesia is an example of a single-case country where government interventions have focused on supporting venture capital, entrepreneurship education, entrepreneurship culture, entrepreneurship infrastructure and training of trainers (Mirzanti et al. 2015).

However, the concern in Western-world-dominated literature on entrepreneurship policy is that Western policies do not provide solutions to market issues but instead encourage those who are already intent on becoming entrepreneurs and mostly generate one-employee businesses with low-growth intentions and a lack of interest in innovating (Henrekson and Stenkula 2009; Acs et al. 2016). Further, little or contradictory evidence can be found that policy actually leads to successful firms (Norrman and Bager-Sjögren 2010). This opens up the area for more contextual approaches to studies on entrepreneurship policy (see, e.g. Pierre 2013; Pollitt 2013a, 2013b) and also explains why we position our study therein. Entrepreneurship meets dramatic situations and a lack of resources to create opportunities in developing countries (Bruton et al. 2013). In general, entrepreneurship is linked to out-of-the-box thinking for creating opportunities in situations where there are scarce resources and the circumstances are challenging (Welter and Smallbone 2011). Studying these generic processes in developing countries is of great importance (Ramírez Pasillas et al. 2017; Umuhire 2016) as this enables us to explore the multiplicity of contexts and their impact on entrepreneurship (Zahra et al. 2014; Welter 2011; Zahra 2007), which will advance our understanding of entrepreneurship.

The institutional context is central to contextualizing entrepreneurship research (Welter 2011) and is shaped by formal and informal institutions (North 1990). In relation to entrepreneurship, Welter (2011) specifies that formal institutions have rules which generate or hinder business opportunities for entrepreneurship, for example, laws and regulations for market entry and exit such as export and import regulations. Further, informal institutions form a society’s norms, values and attitudes and influence access to scarce resources and opportunity formation and exploitation.

Developing countries are often characterized by high institutional uncertainties due to poverty, rapid growth in populations, lack of access to education and medical health programs, government corruption, natural catastrophes and civil conflicts (Bruton et al. 2010).

In places influenced by such factors whether to a larger or a smaller degree, entrepreneurship materializes by means of activities, practices and processes that differ from those in other countries where there is institutional certainty. Entrepreneurship studies need to take these fundamental contextual differences into account (Ramírez Pasillas et al. 2017) and this chapter takes on this challenge.

Research Methodology

We perform a conventional content analysis (Hsieh and Shannon 2005), a method used within the context in question (health research), that in summary includes the following steps:

  1. (1)

    Deriving codes by highlighting the exact words and formulations that capture key thoughts or concepts from the text that is the subject of analysis.

  2. (2)

    The codes are then sorted into categories based on how different codes are related and linked.

  3. (3)

    These emergent categories are used to organize and group codes into meaningful clusters.

  4. (4)

    Examples for each code and category are identified from the data to prepare for reporting the findings.

Conventional content analysis is a suitable method for studying policy documents mainly because of the far-from-perfect practical impact of policy documents on lived realities. Policy documents are directive, normative and aspirational in nature and it is important to choose methods that neither overstate nor understate their importance. Policy documents exist for a reason and have a role in the fabric of social and economic development. They are limited in practice as the method we have matched it with: “The conventional approach to content analysis is limited in both theory development and description of the lived experience, because both sampling and analysis procedures make the theoretical relationship between concepts difficult to infer from findings. At most, the result of a conventional content analysis is concept development or model building” (Hsieh and Shannon 2005: 1281).

Since the focus of this chapter is on concept development, we repeatedly read the policy documents to understand them better and to build a sense of the whole. We identified codes that captured key thoughts or concepts. We sorted the codes in categories and then organized them into clusters of meaning informed by entrepreneurship theory.

Our findings show whether Rwanda’s policymaking is strong/weak, focused/fragmented and which topics are in focus/out of focus. Seven public policy documents constitute our data sample (see Table 13.1).

Table 13.1 Data for the study: seven policy documents
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Findings

This section describes the extraordinary contexts that the health sector in Rwanda constitutes after the genocide in 1994. This is followed by an analysis of the policy documents in thematic tables. Technical comments on each table on how the codes were worked out from the categories and how we arrived at clusters of meaning are also discussed.

Contextualizing the Health Sector in Rwanda

After the genocide in 1994, the country faced a multitude of enormous problems that were and are health-related as captured by Umuhire (2016). A large number of healthcare providers (i.e. nurses, psychiatrists and surgeons) were killed, many health facilities were destroyed and most supply chains for drugs and consumables collapsed. These and many other devastating consequences of the genocide extensively limited Rwanda’s capacity to provide the right treatment and care to the people in need. To numerically illustrate the scale and scope of the problems: About 250,000 women were raped in the genocide, leading to a considerate increase of HIV. During five years after the genocide, Rwanda’s child mortality rate was the highest in the world. Cholera and malaria, for example, were common causes of mortality among the population and less than one out of four children were fully vaccinated against polio and measles.

Since these, the darkest days, Rwanda has achieved significant results in providing better services and access to health. For instance, the immunization coverage for measles and rubella has reached 97% and acute malnourishment has decreased from 5% to 3% contributing to a reduction in child and mother mortality (National Institute of Statistics of Rwanda 2010). The increase in the number of HIV clinics between 2004 and 2014 combined with HIV prevention initiatives has contributed to maintaining HIV prevalence at 3%. The prevalence of malaria among children decreased from 2.6% in 2008 to 1.4% in 2010. Among pregnant women, it decreased from 1.4% in 2008 to 0.7% in 2010 (Ministry of Health 2012). There was also an increase in health facilities from 816 in 2013 to 1161 (including private health facilities) by the end of 2014 (Ministry of Health 2014). This was possible because of a high level of external funding, community health initiatives such as health insurance and reliance on community health workers for community healthcare. However, health development in the country is still far from ensuring universal health coverage and equity in healthcare provision.

The health sector has several challenges such as shortage and turnover of qualified healthcare providers, lack of staff with knowledge about maintenance, lack of medical equipment, limited availability of drugs and consumables and high service costs (Ministry of Health 2015b). These challenges call for the health sector to revise the way in which health services are provided (Ministry of Health 2012). The main ways of providing health services are through promoting entrepreneurship, promoting public-private partnerships for the provision of health services and above all involving the private sector considerably more in the health sector. Overall, the ‘Rwanda Vision 2020’ aims at increasing private sector investments in the health sector from 10% to 70% during 2000–20 (Ministry of Finance and Economic Planning 2000). If this happens, it will mean development from very low levels. The current private health sector in Rwanda is at an embryonic stage and is also not well structured. It includes private facilities, hospitals, polyclinics, clinics, dispensaries, health posts, pharmacies, pharmaceutical wholesalers, private health insurance companies, private professional associations and private medical training institutions (Ministry of Health 2015b). Some other actors such as development partners (DPs), faith-based organizations (FBOs), non-governmental organizations (NGOs), professional associations and regulatory bodies too impact Rwandan people’s health either directly or indirectly. The Rwandan health system is developed in a pyramidal structure made of five levels, from the umudugudu (village) level up to the national level (see Table 13.2).

Table 13.2 Governance structure in the health sector
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Entrepreneurship Policy as Outlined in the Seven Policy Documents

We group our main findings under five major areas and outline various details within each area. Overall we identified that entrepreneurship policy in the health sector in Rwanda fosters entrepreneurship by (1) pushing entrepreneurship in a strategic manner in the health sector, (2) creating inclusiveness through entrepreneurship in the health sector, (3) enabling an environment for entrepreneurship in the health sector, (4) stimulating and simultaneously matching supply and demand in the health sector and (5) institutionalizing social inclusion through entrepreneurship and management education.

Pushing Entrepreneurship in a Strategic Manner in the Health Sector

The Government of Rwanda portrays entrepreneurship in a strategic manner as a business opportunity for various stakeholders (Category 1.1 in Table 13.3) and focuses its efforts on key areas of the health sector (Category 1.2 in Table 13.3).

Table 13.3 Excerpts on pushing entrepreneurship in a strategic manner in the health sector
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Category 1.1: The Government of Rwanda recognizes that economic growth depends on business development across sectors, including the health sector. It also believes that the economic and social conditions in the country are favorable enough to strategically promote investments in new and existing businesses even if the conditions still need to be improved. This is an important position as communicating that crucial macroeconomic variables are robust enough for investors to consider investing while still admitting that things are not yet perfect is a delicate matter. For instance, the National Pharmacy Policy (2016: 5) states, “In Rwanda Health commodities and technologies are financed through […] [the] private sector.” The policy documents seek to strengthen the role of entrepreneurship and the private sector in the health sector (the Republic of Rwanda Policy on Science, Technology and Innovation 2006). For example, the Health Financing Sustainability Policy (2015a: 13) says that the Government of Rwanda engages “with the private sector in order to increase investment in health.” Such an investment is perceived as an “opportunity to leverage the private sector in ways that improve risk pooling, access and increase the financing and quality of health care goods and services” (Health Financing Sustainability Policy 2015a: 6). The private sector is not the only one included though as various policy documents acknowledge that business opportunities are available to a broad range of stakeholders including the government, the private sector, international investors and civil society.

Category 1.2: The Government of Rwanda focuses on key areas of the health sector. Entrepreneurial activities are supported in specific types of health businesses, health offerings and the overall health sector. For example, the Health Sector Policy (2015a: iii) states “…the health sector has to support the increasing role of … the private sector that need to be enhanced in a manner that ensures increased accessibility and quality of health services.” In addition, government efforts target local providers of health services, commodities and technologies and also the creation of businesses that can improve, upgrade and position the Rwandan health sector domestically and internationally. For instance, the National Pharmacy Policy (2016: 12) seeks to, “Attract global pharmaceutical companies to establish pharmaceutical manufacturing facilities in Rwanda or invest in joint ventures with local investors.” The policy documents go so far as to define the specific interventions that are needed. For example, the Health Sector Policy (2015a: 11) states, “the investment in preventive interventions will be strengthened, especially for some costly health services like HIV/AIDS, Malaria and communicable diseases. It will be a priority of public financing as well as private investment” (Table 13.3 gives additional excerpts on pushing entrepreneurship in a strategic manner).

Creating Inclusiveness Through Entrepreneurship in the Health Sector

The Government of Rwanda emphasizes that creating inclusiveness in the health sector can be achieved by economic inclusion (Category 2.1 in Table 13.4) and that economic progress of individuals and organizations is related with SME development, development of the private sector and the development of home-based industries. The view adopted here is entrepreneurship as a mean towards these ends (Category 2.2 in Table 13.4).

Table 13.4 Excerpts on creating inclusiveness through entrepreneurship in the health sector
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Category 2.1: The Government of Rwanda’s emphasis on social inclusion through economic inclusion corresponds to the inclusion of indigenous persons, youth and women in start-ups which stimulates social inclusion. Social inclusion corresponds to the process of improving the conditions in which individuals and groups take part in society (or not). Agendas of social inclusion aim at improving the abilities, opportunities and dignity of people, disadvantaged on the basis of their identity, to take part in society (The World Bank 2013a: xiv, 2013b). The Rwandan policy documents analyzed in this chapter include the inclusion of indigenous people, youth and women (SMEs Development Policy 2010b: 36) as well as civil society as entrepreneurs and/or employees of enterprises and community-based organizations (Health Sector Policy 2015a: 7). These forms of socializing and attempts to discursively signalize social inclusion via economic inclusion are founded on crucial values such as equality, fairness, unity and reconciliation.

The policy documents have one thing in common—they emphasize the central role that SMEs play not only in improving an economy’s trajectory but also in promoting social inclusion. For example, the Republic of Rwanda Policy on Science, Technology and Innovation (2006: 9) states, “Micro, small and medium scale enterprises are of particular interest for employment creation to develop indigenous entrepreneurs and advance inter-sectorial linkages. Private sector entities undertaking activities in these areas shall be supported by scientific, teaching and research institutes.” Social inclusion also relates to the availability of health services in varied geographical areas. For instance, the National Pharmacy Policy (2016: 11) states that the government will “Encourage the equitable distribution of pharmacy services both in rural and urban services.” However, the policy documents lack a discussion on which specific approaches to follow while working with identified individuals and targeted groups.

Category 2.2: The Government of Rwanda advocates entrepreneurship as a mean towards an end (economic progress of individuals and organizations as ways of increasing social inclusion) rather than the dominant Western view on entrepreneurship as self-actualization, ‘follow-your-dreams,’ ‘bringer of glorious things’ and strict economic phenomena only. Emphasizing an integrated view on entrepreneurship as intimately related to social, economic and societal inclusion is in line with the Rwandan context. It is refreshing that the Government of Rwanda refrains from importing some of the more bombastic self-actualization discourses on entrepreneurship from Western discourses. We only found one exception to this: The Republic of Rwanda Policy on Science, Technology and Innovation Policy (2006: 10) that has imported Western flaws when it states that private sector business enterprises’ primary focus is to “maximise value for shareholders, understand consumer needs, compete in the market place to increase customer base.” When entrepreneurship is narrowly linked to economic progress, there is a lack of connection to societal development and social inclusion.

The policy documents agree that the involvement of the private sector is central for reducing foreign support and instead mobilizing domestic resources and encouraging investments and involvement of the private sector. For instance, the Republic of Rwanda Policy on Science, Technology and Innovation Policy (2006: 9) states, “Small and medium enterprises shall be advanced to the extent possible, including the encouragement of traditional and home grown technologies.” The Health Sector Policy (2015a) states, “The private sector, which is identified as a growing source of investment for health, has not been sufficiently involved until now” (p. 10) (Table 13.4 gives additional excerpts from policy documents linked to creating inclusiveness through entrepreneurship in the health sector).

Enabling an Environment for Entrepreneurship in the Health Sector

The Government of Rwanda focuses on enabling an environment for entrepreneurship in the health sector by developing institutions favoring entrepreneurship (Category 3.1 in Table 13.5), on building an integrated view on entrepreneurship as a social, societal and economic phenomenon (Category 3.2 in Table 13.5) and on overcoming the challenges of scale and size by means of collaborations and clusters (Category 3.3 in Table 13.5).

Table 13.5 Creating an enabling environment for entrepreneurship in the health sector
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Category 3.1: Enabling an environment for entrepreneurship in the health sector by developing institutions favoring entrepreneurship means that the Government of Rwanda’s aim is to create and change regulations, procedures, processes and systems to foster local and international investments in the industry in general and in the health sector in particular. The Government of Rwanda recognizes that the existing regulatory environment favors large companies and disfavors the growth of SMEs (SMEs Development Policy 2010b) and overall lacks arenas for dialogue and inclusion of the corporate world no matter the size of the company. For instance, the Health Sector Policy (2015a: 8) says, “The conditions for the desired increase in private sector involvement in decision making and provision of health services need to be put in place (participation in establishment of regulations governing the health sector, conducive environment to provision of quality private health services)” in order to “strengthen policies, resources and mechanism of health service delivery systems” (p. 23). Other enabling activities focus on affordability and attitudes. For example, the National Pharmacy Policy (2016: 11) states that the government will, “Establish mechanisms to ensure that the health commodities and technologies are affordably.” Such focused efforts include the development of an “entrepreneurial mindset” (SMEs Development Policy 2010b: 19).

Category 3.2: Enabling an environment for entrepreneurship in the health sector by building an integrated view means that the government creates awareness about various needs and actively works to meet such needs in an integrated manner. For instance, the SMEs Development Policy (2010b: 11) states, “It is clear that a focused coherent policy and integrated approach is necessary to create an enabling environment for SMEs. This will require a concerted effort to develop human capacity at the national and local level.” The policy documents identify the relevant stakeholders for building an integrated view. For instance, the Rwanda Competition and Consumer Protection Policy (2010a: 5) states, “The vision of this Competition Policy is to: incorporate the interests of consumers, emerging entrepreneurs, and existing firms, through the promotion of free and active competition in Rwandan markets.” However, sometimes these policy documents lack the incorporation of the interests and needs of particular sectors. For example, the Health Sector Policy (2015a: 14) is very sweeping and general in this respect: “All sectors of the Rwandan population are actively involved (in integrated services), including the private sector and civil society.” The Health Sector Policy (2015a: 17) is also very normative when it says, “…private sector and other non-health sectors must be strengthened for integrated interventions (in service delivery)” without saying anything specific about how this will be done.

Category 3.3: Enabling an environment for entrepreneurship in the health sector by overcoming the challenges of scale and size through collaborations and clusters refers to the government’s approach to building public-private-community partnerships between public offices, businesses and the local community. In particular, the Health Sector Policy (2015a) specifies that cross-sector collaborations are required. Specifically, this policy document highlights that such collaborations will “tackle multi-factorial determinants affecting the health of the population (poverty reduction, nutrition and food security, water and sanitation, human rights, education and social protection, empowerment of youth and vulnerable populations” (p. 8). With this, the Government of Rwanda is aiming for a positive reception of the private sector in creating medical services for promoting medical tourism, increasing existing services, creating multidisciplinary private medical centers and private healthcare providers for planning and organizing training supervision activities. Such an approach is in line with the aspirations of the SMEs Development Policy (2010b) and the National Industrial Policy (2011) which aim to develop clusters with a specific focus (Table 13.5 gives additional excerpts from policy documents on enabling an environment for entrepreneurship in the health sector).

Stimulating and Simultaneously Matching Demand and Supply in the Health Sector

The Government of Rwanda’s aim is a delicate balancing act when stimulating demand for health services and activating the supply side of the health sector (more entrepreneurs and higher involvement of the private sector, Category 4.1 in Table 13.6). It also simultaneously aims at matching supply and demand (Category 4.2 in Table 13.6). This is an ambitious and complex task.

Table 13.6 Stimulating and simultaneously matching demand and supply in the health sector
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Category 4.1: Creating and responding to demand for health services implies that the Government of Rwanda intends to take care of basic health problems by providing health services and access to services in an equitable, effective and efficient manner. According to the Health Sector Policy (2015a: 14), “The first principle is that the health system ensures universal demand and access to affordable quality services.” To improve demand, access and quality of service packages, the government has created specific programs for “maternal, neonatal and child health; family planning and reproductive health; nutrition services; communicable diseases, infectious diseases surveillance and research and disaster preparedness and response; non-communicable diseases; health promotion” (Health Sector Policy 2015a: 15). While the Government of Rwanda aims at advances in this regard, there is still a key health challenge—the increasing demand for services for addressing non-communicable diseases that are associated with high costs of care (Health Financing Sustainability Policy 2015a). This also underscores that there is an emerging demand for health services from neighboring countries: “In addition, there is a demand from other countries for Rwanda to share its success and achievement in health. However, there is not a legal framework or formal systems in place to foster this new market niche” (Health Financing Sustainability Policy 2015a: 6–7).

Category 4.2: Matching supply and demand in the health sector implies that the Government of Rwanda’s aim is to promote start-ups wherever they are needed in the health sector. Creating supply through entrepreneurship is important for developing the industry in general and the health sector in particular. The Republic of Rwanda Policy on Science, Technology and Innovation (2006: 10) highlights this: “In order to provide incentive schemes for the promotion of innovative, entrepreneurial activities, with special emphasis on the rural areas, a national competition shall be set up to link rural entrepreneurs with counterparts in the Diaspora.” Such entrepreneurial endeavors are intended to guarantee supply. For example, the National Industrial Policy (2011: 20) states, “For a sector to be profitable domestically and competitive internationally, the supply of affordable raw materials and inputs must be ensured.” These efforts are also made for developing science and knowledge in the country. For example, the Republic of Rwanda Policy on Science, Technology and Innovation (2006: 10) underscores the importance and need to, “recognize and reinforce these complementary strengths and ensure a link to bridge the gap between the public research institution and private enterprise.” In the health sector in particular, matching supply and demand includes the increased importance of the businesses that complement government efforts. The Health Sector Policy (2015a: 22) states: “The private sector will be encouraged to be involved in both supply of health services (including development hospital, clinics, diagnostic centers, education institutions, medical tourism etc.) and demand for health services, essentially through the health insurance system.” Such efforts raise awareness about the types of businesses that are needed along the supply chain: “Ensure that the private sector is part of national supply chain system to provide health product of assured quality” (National Pharmacy Policy 2016: 20). To complement government efforts, specific initiatives will be launched for creating social markets for health products, promoting cost-saving plans for health products and fostering semi-private hospitals (Health Sector Policy (2015a: 12) (Table 13.6 gives additional excerpts from policy documents on entrepreneurship linked to stimulating and simultaneously matching demand and supply in the health sector).

Institutionalizing Social Inclusion by Means of Entrepreneurship and Management Education

The Government of Rwanda’s aim is to institutionalize social inclusion with entrepreneurship as a means towards this end via capacity building in entrepreneurship education (Category 5.1 in Table 13.7) and in management training (Category 5.2 in Table 13.7).

Table 13.7 Institutionalizing social inclusion by means of entrepreneurship and management education
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Category 5.1: Building capacity through entrepreneurship education corresponds to the perception that entrepreneurship courses are a tool for developing entrepreneurial skills and matching students with future job opportunities or helping them create their own ventures. For example, the SMEs Development Policy (2010b: 21) states that the objective is to, “Introduce a component of entrepreneurship training into school and TVET curriculums (Technical and Vocational Education and Training), both focusing on risk and innovation and also business skills such as financial management and marketing.” This policy document further indicates that there is a need to add the practical component of starting a company: “By offering practical opportunities for young people interested in business to engage in entrepreneurship, they are more likely to engage in entrepreneurial activities” (p. 20). The government hopes to build an entrepreneurial mindset with this approach.

Category 5.2: Building capacity through management training refers to identifying management skills to effective administration, increasing service quality and improving efficiency in the management of scarce resources. The National Industrial Policy (2011: 16) indicates this when it emphasizes, “In addition, there is a need to strengthen the overall management skills of businesses and entrepreneurs in Rwanda”. Besides creating general awareness about the need for improving management skills, the National Industrial Policy also highlights creating awareness about improving skills according to the needs of specific industries: “For new industrial sectors to develop in Rwanda human capital must be developed beyond the current scope of skills available” (p. 16).The Health Sector Policy (2015a: 19) further states, “The capacity of teaching institutions (TI) is being strengthened to augment human resources for health (HRH) production and identify specialized training needs which cannot be offered locally to be considered abroad.” This implies that there is an aspiration to improve competencies in the health sector through education. Collaboration is important for achieving this: “Strengthen collaboration with training institutions in the training of sufficient competent professionals” (National Pharmacy Policy 2016: 13) (Table 13.7 gives additional excerpts from policy documents on institutionalizing the link between economic and social inclusion with entrepreneurship as a means towards this end).

Discussion

Our analysis of entrepreneurship policy in the health sector in Rwanda yields several outcomes when looked at from the perspective of contextualizing entrepreneurship (Welter 2011; Zahra 2007). Welter (2011) argues that entrepreneurship as a process of social change relies on the recursive links between context and entrepreneurship. Entrepreneurship is embedded in temporal and spatial places (Johannisson et al. 2002). Hence, theorizing about the context of an entrepreneurship policy is about identifying theories in context (Whetten 2009). The importance of the institutional context in entrepreneurship policy cannot be ignored (Welter 2011; Welter and Smallbone 2011).

Figure 13.1 gives our model for constructing the institutional context for entrepreneurship policy in the health sector in Rwanda. We organize our five clusters (a–e) in three top-down processes: (1) raising awareness about the need for entrepreneurship (cluster a), (2) shaping the institutional context (clusters b–d) and (3) generating aspirations with the proposed institutional context (cluster e). The three processes are topically oriented in relation to the five clusters that they address while temporally oriented in relation to each other (in practice, 1 normally happens before 2 which is followed by 3, while in the world of policy these can be developed simultaneously).

Fig. 13.1
figure 1

Development of an institutional context for entrepreneurship and social inclusion. Source: Authors’ creation

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Literature on entrepreneurship agrees that the role of policy within an entrepreneurial economy is promoting ease of starting and growing a business, rewarding for productive entrepreneurial activities, establishing disincentives for unproductive activities and providing incentives for sustaining long-term productive entrepreneurship (Henrekson and Stenkula 2009; Gilbert et al. 2004). When we relate our five clusters to the three top-down processes for generating an institutional context that favors entrepreneurship in the health sector in Rwanda, we observe that each cluster has a specific role in discursive policymaking.

By pushing entrepreneurship in a strategic manner (a), the Government of Rwanda aspires to raise awareness about entrepreneurship as a business opportunity in strategic areas relevant for the health sector and thus relevant for the country as a whole. By enabling an environment for entrepreneurship in the health sector (b), stimulating and simultaneously matching demand and supply in the health sector (c) and institutionalizing social inclusion through entrepreneurship and management education (d), the Government of Rwanda aspires not only to shape opportunities, interactions and collaborations in the health sector but also to undertake the difficult task of matching these macro-variables reasonably well in relation to each other. By creating inclusiveness by means of entrepreneurship (e), the Government of Rwanda aims to generate and influence stakeholders’ aspirations in the health sector. Various policies aspire to create social inclusion and are themselves a quest for social inclusion which makes social inclusion both a means to an end and also an end as such.

In sum, the institutional context of the health sector in Rwanda is influenced by the government’s prioritizing the delivery of quality health services because of a sense of urgency and the need for social inclusion at a societal level. Such an institutional context is also affected by the dominant perception of a non-entrepreneurial mindset in all the involved stakeholders, pervading high costs of starting and running a venture, the prevailing low tolerance to business failure (SME Development Policy 2010b), the burden of compliance with new regulations and resource scarcity (Health Sector Policy 2015a).

Conclusion

This chapter aims to conduct a content analysis of the entrepreneurship policy for the health sector in Rwanda from a contextualizing perspective (Zahra et al. 2014; Welter 2011; Zahra 2007). Our research highlights that we can understand the role of policy in stimulating entrepreneurship better by focusing our analytical efforts on generating and shaping an institutional context (in our case the health sector in Rwanda). While previous literature indicates the importance of context in public management research (Pierre 2013; Pollitt 2013a, 2013b), our analysis shows how policy discourses are concretely put to use within any given context. In our case this is via pushing entrepreneurship in a strategic manner, enabling an environment for entrepreneurship, stimulating and simultaneously matching demand and supply, institutionalizing social inclusion by means of entrepreneurship and management education and creating economic and social inclusiveness by means of entrepreneurship. These policy discourses are expected to enable an institutional context that will lead to positive behavior and aspirations among the involved stakeholders.

Welter (2011) called for research that identifies top-down processes influencing the entrepreneurship context. Accordingly, we proposed three top-down processes—raising awareness about the need for entrepreneurship, shaping the institutional context and generating aspirations within the proposed institutional context. These top-down processes support the population’s economic and social inclusion. Our study contributes theoretically to research on contextualizing entrepreneurship and research on entrepreneurship policy in two ways: First, by undertaking an empirical study on entrepreneurship policy in a developing country rather than applying Western policymaking to developing countries. Second, by focusing on a case where the entrepreneurship policy aims at the bettering of society and social relations “by raising awareness of alternative entrepreneurship (that is, for society)” (Ramírez Pasillas et al. 2017: 9).