Global Public Health, 2015 Vol. 10, No. 1, 15–27, http://dx.doi.org/10.1080/17441692.2014.964745

An economic framework for transitioning to capacity building Eric Baranicka, Aaron Bairdb* and Ajay Vinzec a

Regional Representative for Central America, American Red Cross, Ciudad de Panamá, Republica de Panamá; bInstitute of Health Administration, J. Mack Robinson College of Business, Georgia State University, Atlanta, GA, USA; cDepartment of Information Systems. W. P. Carey School of Business, Arizona State University, Tempe, AZ, USA (Received 20 November 2013; accepted 18 August 2014) Global Health Organizations (GHOs) often focus on resource provisioning strategies to assist communities in need, especially when disaster strikes. While such strategies are commendable, how should GHOs approach the challenge of developing sustainable strategic objectives after critical needs have been addressed? Leveraging the context of GHOs partnering with communities in need of support after disaster strikes, we propose an economic framework for use in strategic assessment and transition planning. We focus on a strategic process by which GHOs can systematically assess and manage the temporal shift from resource provisioning to capacity building strategies. The proposed framework is applied to pragmatic field experiences undertaken by the American Red Cross in the aftermath of the 2007 Peru earthquake. We specifically develop and propose: (1) An economic strategy assessment framework for GHOs seeking to provide support to communities characterised by high risk variances, incentive complexities and contingencies, and, (2) A practical strategic transition model for GHOs that emphasises proactively moving towards capacity building programme objectives through an emphasis on co-creation of value with community partners. Keywords: economic framework; strategy; resource provisioning; capacity building; Peru 2007 earthquake

Introduction We develop and propose an economic framework for Global Health Organizations (GHOs) to use when strategically assessing the transition from resource provisioning to capacity building in community partnerships. We define GHOs as any multi-lateral, bi-lateral or non-governmental organisation with strategic objectives focused on providing health needs assistance and/or disaster recovery assistance to communities residing in global contexts as part of its mission. Our conceptualization of resource provisioning strategies is based on the transfer of resources (money, medications, medical supplies, etc.) from GHOs to community partners with immediate and/or long-term public health needs. Our conceptualization of capacity building strategies is based on strategic efforts by which GHOs seek to enable community partners to fulfil their goals and objectives in a sustained manner (based on the definition provided by UNESCO, 2010). Successful capacity building efforts should result in community resilience where communities are empowered to sustain valuable actions for mitigating long-term impacts from crises as a result of more generally

*Corresponding author. Email: [email protected] © 2014 Taylor & Francis

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considered capacity building strategy (Bloom, 2011). We consider our proposed framework in the context of a GHO (The American Red Cross) responding to the aftermath of the 2007 earthquake in Pisco, Peru. We suggest two fundamental issues. First, capacity building is critical to community socio-economic development. Second, the lack of an economics-based, systematic approach to strategy assessment and transition in partnership arrangements contributes to the lack of proactive strategic approaches observed in practice. We acknowledge that public health management research has been conducted in the context of governance in international settings (Shakarishvili et al., 2010; Siddiqi et al., 2009), combinations of short-term and long-term development approaches (Newbrander, Waldman, & Shepherd‐ Banigan, 2011), and developing sustainable programmes (Shediac-Rizkallah & Bone, 1998; Yang, Farmer, & McGahan, 2010). However, we suggest that economically-based strategic assessment and transition approaches are missing from the global public health literature. In general, there is very limited work describing how GHOs should strategically assess the economic viability and sustainability of targeted, partnership-driven interventions. Overall, while the need for such sustainable strategic approaches to capacity building have been identified in the literature (Crisp, Swerissen, & Duckett, 2000; Garrett, 2003, 2007; Graham, 2010; Minkler, Wallerstein, & Wilson, 1997), an economically-oriented strategic framework is not currently available. We apply our economic framework to the context of transitioning from resourceprovisioning to capacity building. We suggest that as the emergency phase transitions to medium and longer-term recovery and reconstruction, capacity building strategies should be emphasised. While such short-term resource provisioning approaches are commendable, especially in a world where global health is a significantly growing concern (Gostin, 2007; Schieber, Gottret, Fleisher, & Leive, 2007), we question the long-term viability of a resource provisioning-only strategy. After the criticality of a crisis situation has receded and life-saving disaster response has been implemented, long-term resource provisioning strategies may result in significant waste and/or dependence rather than independence and sustainability, especially when providing assistance to less developed economies subject to high levels of risk and uncertainty (Garrett, 2007). Global public health resources provisioned in such contexts are often inefficiently allocated, under-utilised or subject to corruption (Garrett, 2003). As critical needs stabilise, we recommend a gradual, temporal shift towards capacity building strategies, using a teacher-apprentice approach, where the GHO acts as a ‘strategic bridge’ towards a desired, future state (Folke, Hahn, Olsson, & Norberg, 2005). To elaborate on the proposed strategic assessment and transition approach, we assess and apply experiences from the aftermath of the 2007 earthquake in Pisco, Peru. Following the 2007 earthquake in Pisco, Peru, the American Red Cross partnered with a number of communities affected by the earthquake and initially focused on disaster response and recovery. This partnership naturally transitioned to capacity building in disaster preparation and mitigation as well as community health and first aid. Recently, the Red Cross has sought to expand beyond traditional, often reactive, strategic goals into the area of capacity building with the goal of ‘community resilience’ as an ideal outcome (Preparedness Summit: American Red Cross Community Resilience Pilot Program, 2012). Community resilience is a new strategic effort focused on proactively identifying and jointly prioritising communities’ needs based on evaluation of socioeconomic statistics, public health needs and community characteristics. Throughout this paper, we provide examples of how the American Red Cross followed this strategy when responding to the short-term and longterm needs of the people of Peru after the 2007 earthquake.

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In particular, we focus on how the Red Cross worked with 28 neighbourhoods within the district of Chincha – Hoja Redonda, Condorillo Bajo, Tambo de Mora, Keiko Sofía and Pueblo Nuevo – to provide temporary shelter for 1900 families. This initial crisis response effort was followed by an 18 month capacity building programme focused on disaster risk reduction and sustainable community health. This capacity building process was primarily informed by a participatory assessment with community members through a joint mapping exercise, a review of historical trends and a community transect walk. In general, this approach applied a holistic vision of the community in an effort to address and identify the imminent hazards. Public health, disaster risk reduction, water and sanitation, livelihoods and shelter are the major components targeted. Additionally, this new strategic approach emphasises proactively building strong social networks within areas where development needs are high, but the Human Development Index is low (Bloom, 2011). By working closely with community leaders to self-identify hazards and vulnerabilities, a greater sense of awareness is manifested among community members. The ultimate goal is to develop a well-organised community capable of self-identifying and sustainably responding to their own underlying needs. The reasoning for proposing and applying a proactive capacity building approach is multiple. First, a proactive approach inherently involves the community and by extension ownership leading to greater levels of sustainability and impact. Second, by involving the community from the onset, GHOs can target their programmes and activities to specific gaps in knowledge or existing vulnerabilities. Third, early and proactive engagement with the community provides a background for identifying, building and maintaining strategic alliances with government entities charged with providing the services desired by the community. Based on this background motivation, we propose and illustrate: (1) a comprehensive economics-based strategy assessment framework for GHOs to leverage when seeking strategically viable partners in which capacity could be proactively enhanced (Figure 1), and (2) a conceptual, longitudinal process for strategically transitioning from reactive (i.e., crisis mitigation and resource-provisioning) to proactive (i.e., capacity building) programme strategies through an emphasis on co-creation of value, sustainability and ultimately community resilience (Figure 2).

Developed economy Formal societal structures

Institutions (rules of the game)

Infrastructure (the foundation)

Policies

Interconnected

Markets

Hierarchies

Proactive

Formal institutions (i.e., formal ‘ rules of the game’)

Interconnected economics, physical and social infrastructure.

Formal, market based exchange mechanisms

Organizations and governmental agencies

Mature, managed and often optimized health needs fulfillment capacity

Norms

Dispersed

Networks

Relationships

Reactive

Informal institutions (i.e., informal ‘ rules of the game’)

Dispersed economic, physical and social infrastructure.

Less formal, network-based exchange mechanisms

Social capital and person-to-person connections

Immature, ad-hoc, sometimes chaotic health needs fulfillment capacity

Transition (Developing) Economy Informal societal structures

Exchange mechanisms Operational structures (stocks) (day-to-day activities)

Undeveloped/ emerging economy

Figure 1.

Economic framework for strategic assessment.

Needs fulfillment (capacity)

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Economic framework Unique and diverse approaches to resource allocation and distribution, rather than standardised approaches, are often observed in undeveloped, developing and emerging economies. In extreme cases, each village or community may have its own informal method of allocating and distributing resources, subject to locally established social norms (Fuster & Kelly, 2010; Skinner, 2011). For instance, following the Peru earthquake, the American Red Cross worked in rural settings characterised by limited resources and weak infrastructure. Some communities did not have continuous access to potable water, while others did not have access to basic health care. Awareness of basic disaster prevention and mitigation actions was unheard of prior to the earthquake. Communication and coordination with government entities was limited and community members lacked basic knowledge about health care and disaster mitigation and prevention. Such variations contribute to the considerable challenges faced by GHOs when seeking to develop systematic, targeted and sustainable support strategies and programmes. Therefore, assessment of complex economic contexts (Ostrom, 2010), at both macro- and microlevels, is essential to long-term GHO strategic and operational success. In many cases, the macro level does not have the human or financial resources and the micro level lacks the requisite awareness. Therefore, it is incumbent on the GHO to identify the gaps and address needs in a comprehensive and sustainable manner. Following the Peru earthquake, the American Red Cross recognised that many of the response mechanisms had been decentralised to the local or mayoral level, but not in a comprehensive or locally sustainable manner. Once critical needs had been met, the American Red Cross worked directly with community leaders to strengthen relationships through a multistage design of assessment, preparation (training) and equipping of community committees who were networked with the government entity responsible for service. Based on lessons learned from this experience in combination with economically derived theoretical constructs, we propose an economic assessment framework as an essential component of GHO strategy formation (Figure 1). We specifically propose five, economic assessment constructs: institutional maturity (North, 1990, 1993), infrastructure (Eberts, 1990; Rives & Heaney, 1995), exchange mechanisms (London & Hart, 2004; Ostrom, 2010; Peng, Wang, & Jiang, 2008), operational structures (Hillman & Keim, 1995; North, 1990; Peng, 2003) and needs fulfilment capacity (Helfat et al., 2009; Stevens & Gillam, 1998; Wright, Williams, & Wilkinson, 1998). We suggest that assessment of the targeted community should initially be based on the degree of formality (or informality; North, 1990) present in each of these economic assessment constructs. The degree of formality within each economic assessment construct will depend on local priorities and development efforts. Such variation is vital for GHOs to consider when seeking local partnerships, as one community may function much differently from another, even within the same region. Additionally, the mere appearance of maturity and formality may not accurately reflect the reality of effectively allocating and distributing needed resources within the community in question (Wright, Filatotchev, Hoskisson, & Peng, 2005), further supporting the need for a comprehensive economic assessment as an essential component of strategic planning. We map these five economic assessment constructs to three, well-known types of economies: undeveloped/emerging economies (Hoskisson, Eden, Lau, & Wright, 2000), transition (developing) economies (Peng, 2001), and developed economies (Mike, Sunny, Brian, & Hao, 2009). We note that we use the term ‘economy’ rather than ‘country’ in order to support both macro- and micro-level analyses. These broad economic classifications can be

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applied to macro levels of analysis (to entire countries) or micro (community and stakeholder) levels of analysis where the local economy may be a unique subset of the broader national level economic structure. We propose that the maturity of the economy within (and surrounding) the community being targeted by the GHO must play a central role in strategic planning. Due to high potential risks (i.e., uncertainties associated with planning actions and unintended consequences), incentive misalignments (i.e., who wants what) and contingencies (e.g., local norms may dominate interactions and expectations), careful and systematic economic assessment is recommend prior to development of specific programme objectives and selection of community partners, especially when targeting less economically developed communities. Institutions Institutions are the ‘rules of the game’ within an economy that provide political, legal and social structures for ownership, production, distribution and exchange (North, 1971, 1990; Peng, 2002; Scott, 1995). In developed economies, institutions are often formal (e.g., codified policies and legal frameworks; Hoskisson et al., 2000; Peng, 2003), which typically results in more efficient allocation and distribution of resources. In less developed economies, institutions are often informal (e.g., absence of formally established policies) and rely more upon informal rules formed through social contracts and social norms (Hoskisson et al., 2000; London & Hart, 2004; North, 1990). Such institutional assessment, as well as community participation and leadership, is especially important at local levels in less developed economies as informal social contracts and norms may not be readily understood by foreign entrants, requiring careful attention to significant potential heterogeneity in political and economic stability, legal enforcement and property rights (Hillman & Keim, 1995; Meyer, Estrin, Bhaumik, & Peng, 2009; Wright et al., 2005). In the 2007 Peru earthquake scenario, formal policies existed at a national level, but had not been institutionalised at the community level. The American Red Cross worked to correct this gulf through local capacity building of community committees for sustainable (and eventually independent) disaster preparation and mitigation. The American Red Cross also advocated for strengthened linkages and networks with government entities by suggesting integrating national policies and practices related to disaster risk reduction and community health into institutional methodologies. Societal infrastructure Societal infrastructure is the foundation of community development and economic growth (Eberts, 1990). Societal infrastructure can include: physical infrastructure (e.g., roads, sanitation, buildings), human or social infrastructure (e.g., education, health, housing), economic infrastructure (e.g., capital investments in transportation and distribution) and may be further subdivided into public and private infrastructure (Bougheas, Demetriades, & Mamuneas, 2000; Eberts, 1990; Hirschman, 1958; Ostrom, 1996, 2010; Rives & Heaney, 1995). Developed economies tend to have more mature, interconnected infra‐ structures that provide the foundation for broad economic activities and community development (Ostrom, Schroeder, & Wynne, 1993; Porter, 2000). When infrastructure development is less mature and is developed at local levels rather than regional or national levels, we refer to it as ‘dispersed’. In such dispersed situations, targeted strategies focused on specific communities (even at the village or neighbourhood level) are more likely to be successful than broad, country-level approaches, as broad strategies may oversimplify or over-generalise micro-level infrastructure heterogeneity, resulting in operational failures. It is important to establish a link between the infrastructure support mechanism and the

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national coordination mechanism. In this regard, the American Red Cross worked with community leaders to repair or rebuild specific areas related to protecting communities from further calamities. For instance, a community house or building that serves a variety of purposes including as a temporary shelter following a crisis would need to be managed by a community emergency response team and would need to be linked very closely to the local water authority where by water and sanitation assistance is easily exchanged. Exchange mechanisms Exchange mechanisms are developed in societies to effectively and efficiently facilitate the flow of ‘stocks’ (capital stocks, labour stocks, resource stocks, etc.). If market-based exchanges are utilised, the GHO is likely entering a more developed economic region where transaction costs are likely to be lower if the market is utilised to obtain the capital, labour and/or resources needed to conduct business (London & Hart, 2004; Meyer et al., 2009; Ostrom, 2010; Peng et al., 2008). In contexts where market-based exchanges are not the norm, though, exchanges often occur through informally specified networks, which will likely require local knowledge to navigate. Such networks may be very limited in scope, perhaps only within a narrowly considered community, and may also be complex (i.e., many informal connections and social contracts in an n-to-n network; London & Hart, 2004; Ricart, Enright, Ghemawat, Hart, & Khanna, 2004). Partnering with individuals or entities that understand the network and operational norms will likely be necessary. In the 2007 Peru earthquake response, the American Red Cross partnered with a local entity to provide transitional shelters. This was an innovative partnership, because the American Red Cross was to mobilise a significant portion of the labour (community members) to implement the actual construction, which was a new concept for this particular for-profit entity that the Red Cross partnered with. The new methodology entailed provisioning the materials (wood, zinc, nails), the technical support (i.e., the training for the community members on how to assemble the temporary shelter), as well as monitoring the building process. The American Red Cross was responsible for identifying, organising and mobilising the targeted population for allocating and distributing the raw materials, for processing finished materials, for participating in trainings and for assisting those community members unable to contribute to the process but nonetheless in need (elderly, disabled). This relationship created a link between the American Red Cross and community members for longer-term community health and disaster risk reduction activities once the immediate shelter needs had been satisfied and contributed to long-term independence goals. Operational structures Operational structures provide the basis for the day-to-day economic activities of a society. They are carried out by public and private organisations seeking both incentives and societal order (North, 1990; Scott, 2007; Wright et al., 2005). If the community being considered for support has well developed operational structures, reliance on local organisations is often beneficial, as local partner knowledge and capabilities are likely to be significantly more effective and efficient than those of a foreign entrant. In such informal, socially driven contexts, it will be vital for the GHO to be very involved in operations (the day-to-day management of allocation and distribution, for instance), even if local partnerships are leveraged. In the Peru 2007 earthquake response, it was incumbent upon the GHOs to ensure that community structures and systems not only recouped, but

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also improved so that future disaster impacts could be sustainably mitigated. For example, the Red Cross worked with the community leaders to establish and train neighbourhood disaster response, water and sanitation and health committees. These neighbourhood committees were then linked with responsible government entities, such as Ministry of Health and Civil Defense. Furthermore, it is critical that the GHO involve and empower the community leaders from the onset of the health activity to not only create an aura of ownership, but also increase the possibility of sustaining long-term activities. We also suggest that evaluation of stakeholders is essential for GHOs seeking operational successes with community partners and needs fulfilment processes. Stakeholder assessments are typically used to determine the primary actors (individuals and entities) within a society who have interest, influence and involvement in societal and local development, operations and growth (Brugha & Varvasovszky, 2000; Varvasovszky & Brugha, 2000). The overall goal of stakeholder assessment is to drill-down into which stakeholders play pivotal roles in regional and local economic activity (especially economic activity related to population health) and how each stakeholder must be addressed when developing strategic approaches. If success is to be achieved, active engagement of all involved stakeholders, including the downstream recipients of the global health support, will be a necessary condition (Ostrom, 1996). The American Red Cross utilised a simple Venn diagram as one practical manner to identify the ‘level’ of influence as well as the strengths of the relationships of the primary actors in the Peruvian community. In this exercise, community members were able to visualise the influence various actors had on community growth and development and thereby focus efforts on the entities that had the highest influence and interest. Needs fulfilment capacity Needs fulfilment capacity can range from ‘firefighting’ modes of reacting to crises as they occur to more proactive approaches to actively managing risks and preparing for (or seeking to prevent) future crises (e.g., Menne & Bertollini, 2005). More developed economics tend to have more mature and proactive capacity for fulfilling health needs, while undeveloped and transitioning economies typically have to address crises as they occur in a more reactive and ad-hoc fashion. Additionally, as argued in the organisational strategy literature, capabilities evolve over time and are subject to life cycles as various dynamics impact resource utilisation strategies (Helfat et al., 2009; Helfat & Peteraf, 2003). Similar to organisational dynamics and strategies, communities also have limited resources for addressing current and potential future health needs, in all types of economies. Strategic planning of resource development, allocation and distribution are key functions of community leadership, but scarce resources often lead to ad-hoc needs fulfilment approaches. Determining which needs are adequately addressed (or planned for) and which needs require capacity building is essential for incoming GHOs. Therefore, an essential aspect of assessing GHO programme and funding targets is systematic health needs assessment. Health needs assessments, when conducted at a community level, seek to assess the scale of the population (how large or small) and the potential effectiveness of potential intervention(s) (Stevens & Gillam, 1998; Wright et al., 1998). More detailed assessments may include analyses of the problem (what is lacking?), the demand (what do patients want?), the supply (what assets and capabilities are available?), the feasibility and implications of potential interventions and potential outcomes (or outcome measures, such as clinical and cost effectiveness; Wright et al., 1998). Based on the initial participatory assessment conducted by the American Red Cross, a training plan was developed for the

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community with the support of the respective government agency. The assessment was a multiphase process whereby Peruvian Red Cross Volunteers and community members jointly conducted a transect walk through the community with the intention of identifying hazards. A second phase consisted of gathering a broad spectrum of community members to discuss and document the history of the major events in the community. Finally, a collaborative process was conducted to map the significant (important) structures such as churches, schools or community centres, as well as hazards. The information collected had a twofold intention: first it was designed to create community awareness and GHO recognition where capacity building was required, second it was critical in determining evacuation routes, potential shelter areas and disaster mitigation initiatives the community and Red Cross could jointly undertake. A concluding action was a simulation exercise during which community members’ knowledge was put to practical action and included the active participation of the responsible government entities (MOH and Civil Defense). Evaluations of the simulation exercise were critical whereby feedback was provided to the community in conjunction with the government entity for adjusting the response mechanisms accordingly.

Strategically transitioning to capacity building In the immediate aftermath of the Peru earthquake, the American Red Cross developed a localised, pragmatic capacity building strategy with two major components. The first component consisted of providing material goods (resource provisioning). A number of houses had been destroyed in the Chincha district and it was determined, after undertaking an assessment, that transitional shelters would provide the greatest benefit for families whose houses were declared inhabitable by the authorities. Not only was the material for the transitional shelter reusable, so that families could utilise the wood for permanent structures, but it permitted the families to stay in place to rebuild. The second and longer-term dimension of the programme focused on capacity building in disaster risk reduction and public health, whereby the American Red Cross acted as the aforementioned ‘strategic bridge’ towards self-sustainability. The future state sought community capabilities to operate independently (Garrett, 2007), with the ultimate goal of community resilience (Bloom, 2011). Pragmatically, this entailed a community focus whereby self-organising structures and systems emerged to meet the needs of the individuals within the community. The Red Cross supported the development of community structures via a participative empowerment process – forming committees consisting of community members focused on water and sanitation, disaster prevention and community health. Recognition from local authorities provided legitimacy for these committees to execute activities and manage resources. Each committee was trained and provided with basic supplies relative to their role in the community. For example, the health committee was given a first aid kit, while the disaster prevention committee was responsible for managing the community disaster early warning system. Generally speaking, to achieve such objectives, we recommend that the GHO initially seek community partner(s) that can provide not only operational support for resource allocation and distribution, but also be receptive to learning new capabilities that will increase independent value creation abilities. We also suggest that GHOs acknowledge the often limited nature of their support objectives, which often results in community exit or support reduction prior to full building sustainable community capacity, and specifically include community sustainability in programme strategy formation.

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Figure 2.

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Capacity building strategic transition model.

Figure 2 conceptually illustrates a prescriptive, longitudinal approach for such strategic transitions from market entrance (and initial partnership) to market exit, specifically for when a GHO has decided on a strategy that will eventually include capacity building (even if capacity building is not included in initial response or programme objectives). Partnerships and community capacity building have long been espoused in the health policy literature (Caines, 2004a, 2004b; Israel, Schulz, Parker, & Becker, 1998; Lasker, Weiss, & Miller, 2001; Minkler et al., 1997), but a systematic approach to longitudinally shifting strategic objectives in community partnership contexts has not yet been addressed. The American Red Cross initiated community health and disaster risk reduction programmes with a well-developed exit strategy in motion, providing a foundation for ensuring a transition of responsibility to local committees and government entities in due course. Throughout the capacity building phase it was the empowering of community leaders to recognise vulnerabilities and working with local government leaders to find solutions that led to success. Capacity building provided empowerment. In one community, the leaders so appreciated the work of the Red Cross that they were able to self-organise to continue providing similar levels support on their own. This provided for a targeted methodology whereby the American Red Cross would strategically reduce financial inputs and programmatic influence leading to a community in much greater control of the assets and empowered to respond to disasters. This is especially pertinent to partners subject to significant asymmetries, as often occurs when GHOs seek to partner with community entities characterised by significantly fewer resources and capabilities than the GHO. Overall, we propose a temporal approach to GHO strategic objectives transitions (Figure 2) that seeks to account for both resource and capacity flows over the generally considered lifecycle of the GHO-community partner relationship. Formal descriptions of market entry and transitioning towards community self-sustainability are discussed in the following paragraphs. At the beginning (timeentrance) of the GHO-community partner relationship(s), it is anticipated that the GHO will primarily provide resources, but will also seek opportunities for capacity building. Once initial assessments are conducted (as proposed earlier) and community partnership(s) are formalised, the GHO will likely be the dominant partner, due to the heavy asymmetry between GHO resources and capabilities and those of the local partner(s). While the GHO may be the dominant partner initially, the overall strategic goal of the GHO should be to gradually enhance the ability of community partner(s) to efficiently and effectively source, allocate, distribute, manage and maintain public health resources and infrastructure on their own.

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By the mid-point (timemid-point) of the relationship (or when the relationship is mature enough for the community partners to handle many of the operational activities on their own), the strategic goal(s) should be shifting towards the development of co-creation of value. Co-creation of value occurs when two or more entities work together to create value, above and beyond value that can be created when using markets (or networks) alone (Sarker, Sarker, Sahaym, & Bjørn-Andersen, 2012). As an example, business partners may work together by sharing information between each other to more effectively and efficiently deliver value to the end-customer (Rai, Pavlou, Im, & Du, 2012; Sarker et al., 2012). In a global health context, GHOs and their partners should seek ways in which all participating entities can contribute to value creation (e.g., improved community health). To facilitate this shift towards co-creation of value, the GHO should: (1) Begin to shift operational details to the community partner(s) as soon as possible, and (2) Begin teaching and developing absorptive capacities (ability to absorb and apply external knowledge, Cohen & Levinthal, 1990) and dynamic capabilities (ability to sense and response to changes, Teece, Pisano, & Shuen, 1997) within the partners. This can be a significant obstacle to overcome. In some cases, no such community partner exists and the GHO must establish a viable liaison as part of the capacity building process. In the case of the Red Cross, there is a natural partner and that would be the national Red Cross society of the country. However, creating a community partner is a multifarious and non-linear process involving community politics, personalities and cultural barriers. If successful, established local partner(s) have the potential to significantly impact sustainability. As time continues and as the GHO begins considering market exit (timeexit), the remaining strategic, tactical and operational management should be shifted to the community while resource provisioning is tapered off (or transferred to other entities). This may involve identification of alternative (or local) sources of support and resources as well as continued efforts to enhance sourcing, allocation, distribution, management and maintenance capabilities throughout the region. A ‘contagion’ approach (Angst, Agarwal, Sambamurthy, & Kelley, 2010), whereby the capabilities being established within the local partner(s) are spread to other local entities, is the ultimate goal.

Conclusion Seeking to improve the health of global populations, especially the sustainable health of communities with the most needs but the least resources, requires a systematic approach to strategy assessment and formation. Global health sustainability is conceptualised as a partnership approach where resource and capacity flows lead communities in need towards empowerment and ownership of public health resources and capabilities. Motivated by the new proactive strategic approach undertaken by the American Red Cross and exemplified in their handling of the aftermath of the 2007 earthquake in Peru, we developed and recommended an economics-based strategic framework for GHOs that can ultimately be used to support a transitional strategic approach beginning with resource provisioning (and assessment) and gradually working towards capacity building. Acknowledgements The opinions expressed in this paper are those of the authors and do not necessarily reflect the views of the American National Red Cross.

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