Sustainability 11 00954 PDF

sustainability
Article
Developing Sustainable Healthcare Systems in
Developing Countries: Examining the Role of
Barriers, Enablers and Drivers on Knowledge
Management Adoption
Jawad Karamat 1, *, Tong Shurong 1 , Naveed Ahmad 1 , Sana Afridi 2 , Shahbaz Khan 3
and Nidha Khan 4
1 School of Management, Northwestern Polytechnical University, Xi’an 710072, China;
stong@nwpu.edu.cn (T.S.); naveedahmad@mail.nwpu.edu.cn (N.A.)
2 Department of Pathology, School of Basic Medical Science, Xi’an Jiaotong University, Xianning West Road,
Xi’an 710049, China; sanaafridi1@sut.xjtu.edu.cn
3 School of Automation, Northwestern Polytechnical University, Xi’an 710072, China;
shahbaz@mail.nwpu.edu.cn
4 Department of Politics and International Relations, The University of Auckland,
Auckland 1010, New Zealand; nkha086@aucklanduni.ac.nz
* Correspondence: jawad@mail.nwpu.edu.cn

Received: 1 January 2019; Accepted: 11 February 2019; Published: 13 February 2019
Abstract: Knowledge management (KM) adoption is crucial to integrating sustainable development

within the healthcare sector. Different barriers, enablers, and drivers affect KM adoption. Identifying
these barriers, enablers, and drivers and their role in KM adoption is the core of successful KM
adoption. However, there is scarcity of studies applying quantitative models and combing barriers,
enablers and drivers to check their effect on KM adoption, especially form a developing country’s
perspective such as Pakistan. Therefore, this study explores the role of barriers, enablers and
drivers on KM adoption in Pakistan. Healthcare professionals participated in the data collection
process, and results were analyzed using structural equation modeling. The findings described that:
(1) organizational and strategic barriers have significant negative association with KM adoption;
(2) government related enablers have significant positive association with KM adoption; (3) healthcare
related drivers, and performance-based drivers have significant positive association with KM
adoption. This study concludes that government intervention to promote KM adoption is necessary
especially in developing countries. These findings will be helpful for the healthcare professionals
and policy makers to promote KM adoption in healthcare sector. Current study contributes to the
healthcare literature and body of knowledge by providing the empirical evidence of checking the
quantitative effect of barriers, enablers and drivers on KM adoption.
Keywords: knowledge management; healthcare; barriers; enablers; drivers; developing

countries; Pakistan
1. Introduction
Sustainability as an emerging issue and has been widely discussed in the healthcare sector.
Considerable literature focused on the need of the sustainable, efficient, and effective healthcare [1].
However, currently, the healthcare systems are facing multiple challenges to cope with the current
healthcare needs, and sustainability is considered to be a significant requirement to obtain strategic
a fit for the future [2,3]. The world business council for sustainable development (WBCSD) defined
Sustainability 2019, 11, 954; doi:10.3390/su11040954 www.mdpi.com/journal/sustainability

Sustainability 2019, 11, 954 2 of 31
sustainable development as “development that meets the needs of the present without compromising
the ability of future generations to meet their own needs” [4]. Based on the current issues and future
needs, sustainable development captured a great focus in the development of the healthcare system.
Developing a sustainable healthcare system can lead towards improved healthcare performance.
The healthcare sector needs to be able to utilize its current resources more effectively, to find new
resources, manage its finances, improve service, and response to emergency situations [5]. Currently
both the management and treatment of patients are suffering in the public and private sector
healthcare organizations.
Due to intense competition in healthcare, the healthcare industry, as the largest contributor to
the service industry, is facing enormous challenges and developing an effective sustainable healthcare
system has become a difficult task. Therefore, effective and sustainable healthcare systems are key
to providing quality healthcare at a low cost, with large population coverage and effective disease
management. However, cost efficiency and healthcare effectiveness cannot be achieved at the same time
and researchers indicated a trade-off between the increase in efficiency and effective healthcare system.
Healthcare effectiveness shows the potential of the healthcare system to achieve maximum healthcare
output [6]. It is only possible if an effective and sustainable healthcare system such as knowledge
management (KM) is implemented for the better management of extensive data [7]. As healthcare is
a knowledge intensive industry, healthcare professionals cannot possess plenty of new knowledge
because there are over 200,000 medical journals, with over 7,000 types of prescriptions, 800 tests,
1,000 image tests, 1,500 surgical procedures. Therefore, there is a need to utilize, assess, interpret
and share most relevant and appropriate knowledge in healthcare [8]. KM in healthcare focuses on
two aspects; improvement in the management of the hospital and improvement in the treatment
of the patient [5]. It is considered to be one of the most important tools in the healthcare industry
today due to lower utilization of resources, reduced costs, better patient care, and educating patients
with preventive measures [8]. However, the adoption of KM is facing several issues in developing
countries and KM does not get the deserved recognition in healthcare. There are many barriers,
enablers and drivers that influence KM adoption in the healthcare sector. In order to implement KM,
it is important to understand these barriers, enablers and drivers. Several studies have been conducted
on the analysis of barriers [9–11], enablers [12–14] and drivers [15,16]. These studies have multiple
limitations and results cannot be generalized to all the countries. KM adoption in Pakistan is at its
infancy stage, and many different studies suggest that KM adoption in developing countries is at
a slower pace [17–19]. Analyzing the barriers, enablers and drivers of KM adoption plays a crucial
role in understanding how to promote KM. However, research relating to the barriers, enablers and
drivers of KM adoption in developing countries such as Pakistan has been inadequate, as suggested
by different studies [20,21].
In developing countries such as Pakistan, public hospitals make up a significant portion of
healthcare. They are consuming a large amount of resources and have many shortcomings, as in
Pakistan, the bed to patient ratio is 1 bed/1,647 patients. The doctor to patient ratio is 1 to 1,099
and dentist to patient is 1 to 13,441. These indicators are not sufficient to provide quality healthcare.
The government of Pakistan (GoP) spent approximately PKRS 102 billion (2.6% of the budget) in fiscal
year (FY) 2013, which is 29% more as compared to PKRS 76.46 billion (0.57%) in FY 2007 (figures taken
from Economic Survey of Pakistan [22]). The GoP is claiming that by increasing its expenditure in
healthcare it will improve its performance. However, without implementing a sustainable healthcare
system such as KM, the scenario cannot be changed. Therefore, a scientific study is necessary to check
the issues involved in the successful adoption of KM.
Earlier studies employed the interpretive structural modeling (ISM) technique for analyzing
barriers, enablers and drivers to KM adoption. ISM is a technique that helps in defining the
relationships along with the hidden interrelationships that exist between the variables in complex
systems and represents them in a hierarchical form. However, there is a little knowledge about the
quantitative impact of different barriers, enablers and drivers on KM adoption in the healthcare
sector [20,21]. Researcher and policy makers are not only interested in exploring barriers, enablers
and drivers to KM adoption, but also which barriers hinder the KM adoption more and which
enablers and drivers promote KM adoption more. SEM can be used for multivariate data and is
suitable for identifying the relations between exogenous and endogenous latent variables in a single
model [23]. SEM has been acknowledged by many researchers and is used in several studies and
disciplines, social, engineering and management sciences [24]. This technique has also been used in
various studies related to healthcare. Avkiran and Kemal [25] used SEM to analyze the residential
aged care networks combining low-level and high-level care. Mitchell et. al. [26] conducted a study
to develop a predictive model for patients of urinary tract infection. Guo et. al. [27] developed a
predictive model for the intention of administrators in the healthcare of USA to use evidence based
management. Debata et. al. [28] analyzed the interrelationship between service quality and loyalty
for medical tourism. Jacobs et. at. [29] examined how innovation is implemented in healthcare and
its effectiveness. Considering the wide application of SEM in healthcare, this study is the primary
study exploring the quantitative effect of barriers, enablers and drivers to KM adoption in developing
countries especially in Pakistan.
This paper is divided into six sections; Section 2 consists of literature review, Section 3 gives
the research methodology, Section 4 the results are shown and discussed in Section 5 and finally in
Section 6 the conclusion is given.
2. Literature Review
2.1. Knowledge Management

Knowledge management is emerging as a source of sustainable competitive advantage [30].
It is being used by multiple business organizations dealing with all types of knowledge. KM deals
with creating, structuring, storing, disseminating and using knowledge to promote learning and
innovation [31]. KM in an organization can improve its performance by retaining and reusing
knowledge within the organization [32]. Knowledge is an important resource which is managed
with the help of KM, by selecting the appropriate knowledge, giving it structure, and storing it in the
appropriate place that will later help in problem solving.
KM carefully considers the type of customers the organization is targeting and the knowledge that
will be required. It identifies the knowledge, categorizes and summarizes the information for better
administration and quality of knowledge. A good KM infrastructure in the healthcare organizations
can considerably help with the creation and management of patient treatment knowledge; it will
improve the efficacy of healthcare, improve the patients’ loyalty and make healthcare more flexible
to changes [33]. Considering these reasons and the importance of knowledge, the experts consider it
important to invest in KM to improve performance of healthcare organizations [34].
2.2. The Need for KM in the Healthcare of Pakistan

Pakistan is situated in South Asia; it has a population of over 212 million and a growth rate of
2% [35], making it the 6th most populous country in the world. It has an annual budget of PKRS
5,246.2 billion and is growing by 5% annually. GoP spent PKRS 13,897 million on its healthcare in
2017–2018 fiscal year, which is about 0.75% of the budget, and the percentage amount has steadily
increased over the years [36]. The GoP is under the impression that by increasing the budget spending
on healthcare it can improve the service of healthcare, but despite this the healthcare service is
not improving.
The public sector hospitals in the healthcare sector take up most of the budget. The public sector
hospitals of developing countries use up a lot of resources, like money and trained personnel. It is
estimated to be 50–80% varying on the country [37]. The healthcare organizations have also become
rigid and are having trouble adjusting to the rapid changes in the healthcare sector globally, and they
are unable to provide quality healthcare to their customers as per their desires [38]. The healthcare of
Pakistan currently ranks 149 out of 188 among the United Nations (UN) member countries in terms of
healthcare goals [39]. The healthcare of Pakistan, despite growing, has always been under pressure due
to disease outbreaks, natural disasters, large amount of information available on internet, and alternate
healthcare delivery systems [40]. Pakistan is suffering from many diseases, the major diseases being
neonatal disorders 20.4%, cancer 7%, ischemic heart disease 6.4%, lower respiratory infections 4.94%,
stroke 3.42%, chronic kidney disease 1.45%, malaria 0.43%, etc. (figures according to [41]). Other than
diseases, there are people that suffer due to disasters (earthquake and floods) and terrorism. During
the earthquake of 8th October 2005 there was chaos; there were many patients pouring in and most
of them in critical condition [42]. All the patients had to go through many tests to get their details,
life prevalent conditions, blood type etc. This resulted in loss of time, increase in cost, and loss of life.
If there was an effective knowledge management system these problems could have been overcome.
The GoP has now realized that increasing the budget is not a solution to the problem, they need
to look for new methods. They are now considering the adoption of KM in their healthcare. It helps in
the effective utilization of resources, adoption of best practices, rapid response to change and creating
a competitive advantage [3]. KM helps with the storing and sharing of knowledge. If a new patient
comes to a doctor with an improper record of health, then there is a chance of improper treatment and
wastage of doctor’s time increasing the cost, as research by Hersch W. R. [43] shows that improper
documentation takes up 1/3 of the doctor’s time. KM also helps the healthcare professional keep
updated with the latest knowledge. Generally it is not possible for a doctor to keep up with new
knowledge because there are over 200,000 medical journals, with over 7000 types of prescriptions, 800
tests, 1000 image tests, 1500 surgical procedures [8].
2.3. Knowledge Management Barriers to Healthcare

There have been several studies regarding barriers to KM. Singh, et al. [11] addressed
unsupportive organizational culture, lack of leadership, improper strategic planning, lack of knowledge
resources, lack of financial resources, improper technological infrastructure, lack of innovation and
knowledge creation, integration of system, and inability to capture information as the main barriers
to KM. Karamitri, et al. [44] identified several barriers to KM, such as slow transfer of information,
sharing of useless information, inaccurate information, information overflow, and lack of time with a
physician to keep updated. Hojabri, et al. [18] mentioned eight barriers; improper process activities,
no training and education, absence of performance checks, ineffective knowledge management
strategies, insufficient technology, a non-supporting organizational culture, and lack of management
and leadership support. Kothari, et al. [45] stated the barriers under two categories; organizational
level and individual level. The organizational barriers are the goals of KM conflicting with those
of employees, the frequent turnover of employees, improper monetary reward system, no standard
definition of KM, the tasks are not clear, lack of balance between information technology (IT) and
people, the cost of implementing KM, the uncertainty of successful implementation, and unsupportive
structure and culture. The individual barriers are lack of motivation, resistance to change, insufficient
technological knowledge, unqualified authority, unwilling to share information, and employee
turnover. The barriers identified by Sharma and Singh [9] are lack of top management commitment,
unsupportive structure, high turnover, lack of knowledge about technology, no learning from past
mistakes, reluctance to use technology, difference between company and individual goals, lack of trust
among the employees, improper training, unavailability of time, restriction on the flow of knowledge,
improper reward system, unsupportive organizational culture, lack of integration of KM, and lack of
financial resources.
The knowledge management barriers to healthcare are given in Table 1.
Table 1. Knowledge management barriers to healthcare according to literature review.
Category Code Barrier Reference

Organizational barriers OB1 Lack of top management commitment [45–51]
OB2 Unsupportive organization structure [2,13,45,50–54]
OB3 Unsupportive organizational culture [2,13,45,50–54]
OB4 Learning from previous mistakes [44]
Table 1. Cont.
Category Code Barrier Reference

Strategic barriers SB1 Insufficient strategic planning [51,55,56]
SB2 No common definition of knowledge management [57,58]
SB3 Fear of inefective knowledge management implementaiton [45,59]
Technology barriers TB1 Implementation of complex knowledge managenent system [54,60–62]
Difficulty of integrating knowledge management with
TB2 [13,45,51,63]
existing system
Resource barriers RB1 Implementation cost of knowledge management [45,48,51,64–67]
RB2 Unavailability of resources [51,68,69]
RB3 Questionable information quality [44]
Individual barriers IB1 Conflict between employees [51,54,60,61]
IB2 Resistance to change [45,68]
IB3 Unwilling to work in a team [68,70,71]
IB4 Unmotivated employee [2,45,52,72–75]
IB5 Resistance to information sharing [51,76]
IB6 Fear of sharing incorrect information [51,77,78]
The literature shows that barriers make it difficult for the stakeholders to adopt KM in their
healthcare; the barriers have a negative influence. Due to this the current study considers the following
hypotheses regarding the barriers:
Hypothesis 1a (H1a). Organizational barriers have negative influence on the adoption of KM

in healthcare.
Hypothesis 1b (H1b). Strategic barriers have negative influence on the adoption of KM in healthcare.
Hypothesis 1c (H1c). Technological barriers have negative influence on the adoption of KM

in healthcare.
Hypothesis 1d (H1d). Resource barriers have negative influence on the adoption of KM in healthcare.
Hypothesis 1e (H1e). Individual barriers have negative influence on the adoption of KM in healthcare.
2.4. Knowledge Management Enablers of Healthcare

After a detailed literature review, several researches regarding the enablers of KM were studied.
Pee and Kankanhalli [79] identified KM technology, supportive organizational structure, senior
management championship, good social capital, high KM capability, and good organizational
effectiveness to be the most important enablers for KM implementation in healthcare. Yeh, et al. [13]
stated four main enablers to KM; effective information technology infrastructure, motivated employees,
good corporate culture and strategy, and leadership. Lee and Choi [14] mentioned supportive
organizational culture and structure, people, and technology. Karamitri, et al. [44] revealed
IT, leadership, quick knowledge sharing, proper workflow assignment, elimination of distrust,
open communication channels, motivation of employees, knowledge brokers and willingness of
employees to share information as critical enablers of knowledge management. Kothari, et al. [45]
identified training and education, a proper framework for knowledge management implementation,
ability to identify a knowledge broker, support from the management, organizational structure and
culture as the main enablers of KM.
The knowledge management enablers of healthcare are given in Table 2.
Table 2. Knowledge management enablers of healthcare according to literature review.
Category Code Enabler Reference

Management related enablers MRE1 Management support [44,79,80]
MRE2 Proper well defined transparent workflow [44,81,82]
MRE3 Creation of trust among employees [18,44,79,83]
MRE4 Identification of the knowledge champion [44,45,84]
MRE5 Creating a learning environment [18,68,85–87]
Alignment of organization and knowledge
MRE6 [18,19,88]
management goals
Government related enablers GRE1 Government policies [89–91]
GRE2 Strategic planning [18,19,92]
Information Technology Information Technology for
ITRE1 [44,79,81,87,93]
related enablers knowledge management
ITRE2 Avoiding information overflow [18,57]
ITRE3 Knowledge filtering [44,87,94,95]
ITRE4 E-data promotion [44,96]
Customer related enablers CRE1 Taking constant feedback from customers [85–87]
Establishing customer relationship
CRE2 [81,97]
management (CRM)
Employee related enablers ERE1 Motivated employee [44,79,80]
ERE2 Empowerment of employee [44]
Recruitment of skilled professionals with
ERE3 [79,85,98]
knowledge management experience
ERE4 Training and education [18,19,48,99]
The literature shows that enablers make it easy for the stakeholders to adopt KM in its healthcare;
the enablers have positive influence. Due to this the current study considers the following hypotheses
regarding the enablers:
Hypothesis 2a (H2a). Management related enablers have positive influence on the adoption of KM
in healthcare.
Hypothesis 2b (H2b). Government related enablers have positive influence on the adoption of KM
in healthcare.
Hypothesis 2c (H2c). Information Technological related enablers have positive influence on the
adoption of KM in healthcare.
Hypothesis 2d (H2d). Customer related enablers have positive influence on the adoption of KM
in healthcare.
Hypothesis 2e (H2e). Employee related enablers have positive influence on the adoption of KM
in healthcare.
2.5. Knowledge Management Drivers of Healthcare

There are several studies regarding drivers of KM. Davenport, et al. [100] identified several drivers
to KM; improved knowledge access, enhanced knowledge environment, management of knowledge as
an asset, improved economic performance, improved knowledge transfer, improved service, improved
decision making process, bringing innovation, creating job opportunities, and decentralized decision
making. Du Plessis [16] stated that improved quality of knowledge, knowledge hoarding, increase
in efficiency, organizational communication, efficient transfer of knowledge, improved IT, effective

decision making, creating competitive advantage, reduction in knowledge loss, and treatment of
knowledge as a commodity as the main drivers of KM. Darko, et al. [101] addressed the main drivers
of KM as setting a culture for best practice adoption, making a standard for other organizations to
follow, improved employee efficiency, job creation, improved well-being of customers, reduced costs,
and improved image of the organization. Lee, et al. [102] only addressed two drivers of KM; improved
knowledge quality and quick transfer of knowledge. Yu [103] identified the drivers of KM as reduced
administrative cost, reduced service cost, and quick decision making.
The knowledge management drivers of healthcare are given in Table 3.
Table 3. Knowledge management drivers of healthcare according to literature review.
Category Code Drivers References

Healthcare related drivers HCRD1 Attaining competitive advantage [16,104–106]
HCRD2 Setting a standard for other organizations [107]
HCRD3 Improved reputation of healthcare [101,108]
HCRD4 More job openings [100,101,109]
HCRD5 Rapid adjustment to change [110–112]
Performance-based drivers PBD1 Efficient decision making [16,100,103,113]
PBD2 Less resources used [101,109]
Improved administrative
PBD3 [16,100,101]
healthcare performance
Improved interdepartmental
Communication related drivers CRD1 [16,104,107]
communication
Communication with other
CRD2 [14,16,104,110,114]
healthcare organizations
CRD3 Improved knowledge quality [16,107,112]
Knowledge related drivers KRD1 Reduced knowledge loss [16,110,115]
KRD2 Elimination of distrust [14,101,107]
KRD3 Increased innovation [100,104,110,116]
KRD4 Creation of learning organization [14,100,107]
Recommended by Group
Patient related drivers PRD1 Reduced deaths due to error
of Experts
PRD2 Improvement in patient service [15,100,101,117]
PRD3 Reduction in administrative cost [100,101,103,118]
PRD4 Less costly service [100,103,118]
Drivers also make it easy for the stakeholders to adopt KM in its healthcare like enablers; drivers
have positive influence. Due to this the current study considers the following hypotheses regarding
the drivers:
Hypothesis 3a (H3a). Healthcare related drivers have positive influence on the adoption of KM
in healthcare.
Hypothesis 3b (H3b). Performance-based drivers have positive influence on the adoption of KM

in healthcare.
Hypothesis 3c (H3c). Communication related drivers have positive influence on the adoption ofKM
in healthcare.
Hypothesis 3d (H3d). Knowledge related drivers have positive influence on the adoption of KM
in healthcare.
Hypothesis 3e (H3e). Patient related drivers have positive influence on the adoption of KM
in healthcare.
3. Research Methodology
The aim of this study is to identify and analyze the barriers, enablers and drivers (variables)
of KM adoption in healthcare. This study has been divided into two-steps; first the variables were
identified by conducting a comprehensive literature review by reviewing several peer reviewed journals.
After identifying the variables, the fuzzy Delphi method (FDM) was utilized to narrow down to the most
Sustainability 2019, 11, x FOR PEER REVIEW 9 of 33
relevant variables. In the second step SEM is applied. The step-by-step methodology is given in Figure 1.
Figure 1. Step-by-step methadology.

Figure 1. Step-by-step methadology.
3.1. Fuzzy Delphi Method (FDM)
3.1. Fuzzy Delphi Method (FDM)
The Delphi method (DM) was initially used in the 1950s by the RAND corporation in their
studiesThe Delphi
[119], method
at that time it(DM) was initially
was considered as used in the
a reliable 1950s bysince
technique the it
RAND corporation
considered in their
the collective
studies of
opinion [119], at that
experts timeDespite
[120]. it was considered
the multiple as disadvantages
a reliable technique since
attached it considered
with the collective
DM e.g., expensive to
opinionexperts
execute, of experts [120].
would Despite
seldom agreethetomultiple disadvantages
an opinion, attachedhad
and the researcher with theDM e.g., to
facility expensive
adjust theto
execute,toexperts
opinion would DM
their benefit, seldom agree
is still to an opinion,
a widely and the
used method researcher
in KM studies.had To the facility the
overcome to adjust
flaws the
of
the DM, the fuzzy theory was implemented [121–123]. The DM was improved further by Hsu andof
opinion to their benefit, DM is still a widely used method in KM studies. To overcome the flaws
the DM,
Yang [124],the
by fuzzy theory
applying was implemented
the triangular [121–123].
fuzzy number The DMthe
to encompass wasopinion
improvedof thefurther
expert,by Hsu and
providing
Yang [124], by applying the triangular fuzzy number to encompass the opinion of the expert,
providing foundation to the FDM. In the triangular fuzzy numbers (TFNs) the maximum and
minimum values of the expert opinion are taken into consideration, based on them the geometric
mean is calculated to avoid statistical biasedness based on extreme values. This helps in the correct
selection of variables, it is a simple method and gives proper weightage to the expert’s opinion in the
foundation to the FDM. In the triangular fuzzy numbers (TFNs) the maximum and minimum values
of the expert opinion are taken into consideration, based on them the geometric mean is calculated to
avoid statistical biasedness based on extreme values. This helps in the correct selection of variables,
it is a simple method and gives proper weightage to the expert’s opinion in the selection process [119].
The FDM was composed of two different rounds. At the end of first round, a facilitator prepared
a summary which could help the experts for further screening (deletion or addition) the barriers,
enablers and drivers. The step-by-step approach to obtain results for FDM are as follows:
(1) Distribute the questionnaire and obtain response and preference for each barrier, enabler or driver
through TFNs.
(2) At the second step, fuzzy weights Wwk obtained through TFNs were transformed into one single
value Vk by utilizing the center of gravity technique:
( Min + GM + Max )
Vk = (1)
3
(Where Vk is the threshold criteria for rejection or selection of the appropriate item, Min represent
the minimum value of TFNs, GM shows the geometric mean, and Max represent the maximum
value of TFNs).
(3) After two rounds, facilitator adopted the questions according to the threshold criteria that were
the part of final questionnaires distributed in respondents.
3.2. Data Collection

A questionnaire is a systematic method of data collection, it is said to be effective and helps
in reaching the objective and is quantifiable. That is why questionnaires have been used in
this study to collect data regarding barriers, enablers, and drivers effecting KM adoption in the
healthcare of Pakistan. The population considered for the study consists of stakeholders that
possess knowledge about KM adoption in the healthcare industry of Pakistan. The stakeholders
included Federal and Provincial Ministry of Health employees, hospital administration, doctors,
nurses, dentists, and patients in major cities (Peshawar, Mardan, Abbotabad, and Islamabad). Due to
this, the nonprobability sampling technique has been adopted. When random sampling cannot be
done then the researcher can select the participant based on the participant’s willingness to take
part in the research. Hence a combination of two techniques was used, convenience sampling and
snowball sampling to increase the overall sample size. Convenience sampling gave the ease of
selecting respondents nearby, while snowball sampling helped in collecting data through references
and networking. These techniques have been used in some management studies [125].
The questionnaire was developed based on the literature review of previous studies, the barriers
mentioned in Table 1, enablers in Table 2 and drivers in Table 3. The questionnaire consists of five
sections. In the first section a brief detail about the research is given, the objectives of the research,
and the contact details of the researcher in case of quarries. In Section 2, the details of the respondent are
recorded such as age, gender, organization type, ownership of organization, profession, and experience.
In Sections 3–5, the respondents were asked to rate the barriers, enablers and drivers to KM adoption
in the healthcare of Pakistan in their respective sections. The respondents were asked to rate the
variables using the five-point Likert scale, in which 1 = Strongly disagree, 2 = Disagree, 3 = Neutral,
4 = Agree, and 5 = Strongly agree. The five-point Likert scale is used by many experts in research and
it gives unambiguous results [126]. The initial questionnaire that was prepared was in English, but
considering the national language of Pakistan, an Urdu version was also prepared. The translated
version was prepared by two language experts.
The data collected for this study were obtained through self-collection, the research team,
and short seminars. The team consisted of five individuals; two masters students and three masters
graduates. They were briefed about the current research, its objectives and aims, to give them a good
understanding about the study. These research team members were asked to collect data based on their
contacts. The short fifteen-minute seminars were held in the public and private hospitals, attended
by people willing to participate in the research. They were giving brief information about the current
study and KM. After the seminar, a brief question and answer session was held to remove any queries
and confusion, and after this, the participants were requested to fill out the questionnaire.
The sample size considered sufficient for SEM is 100 to 200 [127]. The response rate of healthcare
is very low, and the experts consider above 42% as acceptable [128,129]. About 500 questionnaires were
circulated among the stakeholders, out of which 255 were received. Of those, 18 of the questionnaires
were removed because they gave invalid answers, 13 were removed because they were incomplete,
resulting in 224 valid questionnaires making the response rate for the current study at 45%. The low
response rate shows that KM adoption in healthcare is at the very initial stages and needs considerable
attention of relevant authorities.
The demographic of the respondents is given in Table 4. The majority of respondents come in
the age bracket of 31–40 which is 36.2%, with 37% respondents below this age and 26.8% above it.
There were more male respondents (57.1%) as compared to females (42.9%). Of the respondents,
26.3% were working for the government in which 12.1 % were in government owned hospitals, while
14.3% were working in teaching hospitals. There were 38.8% of respondents working in privately
owned organizations out of which, 10.7% were working in hospitals, 13.8% were working in teaching
hospitals, 8% in medical centers, and 6.3% in the pharmaceutical companies. However, 34.8% of
the respondents were not considered for this category since they were government employees or
patients. The respondents had various different occupations 8.5% worked in the federal ministry of
health, 12.9% in the provincial ministry of health, 11.2% were doctors, 8.9% dentists, 12.9% nurses,
15.6% administration, 13.4% patients, and 16.5% were technicians. Most of the respondents came in
the experience bracket of 6–9 which is 32.6%, 29% of the respondents had less experience than this,
and 25% had more experience than this.
Table 4. Details of respondents.
Category Frequency Percentage

Age
<20 9 4%
21–30 74 33%
31–40 81 36.2%
41–50 55 24.6%
>50 5 2.2%
Gender
Male 128 57.1%
Female 96 42.9%
Organization
Government hospital 27 12.1%
Government teaching hospital 32 14.3%
Private hospital 24 10.7%
Private Teaching hospital 31 13.8%
Medical centers 18 8%
Pharmaceutical employees 14 6.3%
N/A1 78 34.8%
Ownership
Privately owned 87 38.8%
Government owned 59 26.3%
N/A1 78 34.8%
Occupation
Federal Ministry of Health employee 19 8.5%
Provincial Ministry of Health employee 29 12.9%
Doctor 25 11.2%
Dentist 20 8.9%
Nurse 29 12.9%
Administration 35 15.6%
Patient 30 13.4%
Technicians 37 16.5%
Table 4. Cont.
Category Frequency Percentage

Experience
<5 65 29%
6–9 73 32.6%
10-19 51 22.8%
>20 5 2.2%
N/A2 30 13.4%
Note: N/A1 is referring to the government employees and patients that are not employed by the hospital or
pharmaceutical company. N/A2 is referring to the patient’s experience that is not relevant to study.
3.3. Structural Equation Modeling (SEM)

SEM is a multivariate statistical tool that has been used several times for different types of research
such as social science, applied science, health science etc. [130,131]. The SEM considers two types
of variables; the observable, which can be easily measured, and latent, which are inferred from the
observable. It is a technique which gives the researcher the ability to check the relationship between
the observable variables and latent variables [132]. There are generally two approaches to using SEM.,
one is co-variance based (CB-SEM), and the other is partial least squares based (PLS-SEM). In this
study the PLS-SEM was used because it is preferred by management researches [133,134], and it
can be used with a small sample size [134]. In this study we have used a two-step method; first
the measurement model was checked and then the structural model was checked, as proposed by
Anderson and Gerbing [135]. In this study Statistical Package for Social Sciences (SPSS version 21) and
AMOS (version 21) were used for analysis.
First of all, the goodness-of-fit measures must be checked, and to check it, several tests were
performed. The chi-square (χ2 ) test was done to check the relationships between the measured
variables, and the degree of freedom (df) was also calculated referring to values that are free to vary in
the final calculation. As suggested by Jöreskog and Sörbom [136] we used χ2 /df as a measurement
test. Other tests used for goodness-of-fit suggested by Hu and Bentler [137] were, (1) standardized
root mean square (SRMR) used to calculate the difference between observed correlation and predicted
correlation, (2) goodness-of-fit index (GFI) to determine how well the model fits the observation,
(3) adjusted goodness-of-fit index (AGFI) was used to correct the GFI, to avoid being affected by latent
variables, (4) normed fit index (NFI) is an incremental measure used to measure the goodness-of-fit, to
insure the model was not affected by the number of variables, (5) comparative fit index (CFI) to check
if the tested model was better than the alternate model, (6) root mean square error of approximation
(RMSEA) to check the discrepancies in the hypothesized model, with parameters, and population
covariance matrix by avoiding the issues of sample size.
The measurement model was tested using the (1) confirmatory factor analysis (CFA); it helped
in testing the relationships between the variables, (2) Cronbach’s alpha was used for internal
consistency, (3) composite reliability (CR) was used to determine how much a latent variable effects
the measurement of a measured variable, and (4) average variance extracted AVE was used to measure
of the amount of variance that was captured by constructs in relation to the amount of variance due to
measurement error.
Finally, after the measurement model was validated, the structural model was checked using the
same goodness-of-fit measures. When the structural model is considered valid then the path coefficient,
t-value and p-value will be used to check the hypothesis.
4. Results
4.1. Barriers
4.1.1. Validation and Reliability of Measurement Model

The model consisted of five latent variables, and eighteen indicators. The measurement model
was tested using the confirmatory factor analysis (CFA) suggested by Hair, et al. [132]. After
testing with CFA barrier OB4, SB2 and IB6 were removed for having a value lower than 0.5. After
removing the barriers, the test was performed again, until a valid and reliable model was attained.
The goodness-of-fit of measurement model is shown in Table 5, and the results show that the
measurement model is valid. The χ2 (70) has been calculated as well as the degree of freedom
(32). Since χ2 has some discrepancies [138], the test suggested by Jöreskog and Sörbom [136] was used,
χ2 /df = 2.180 which is within the limit ≤3 [138]. Other goodness-of-fit tests suggested by Hu and
Bentler [137] were also calculated, and they all are given in Table 5.
Table 5. Checking the goodness-of-fit for measurement model of barriers.
Goodness-of-Fit Recommended Value * Result

The Chi Square (χ2 ) N/A 70
Degree of freedom (df) N/A 32
χ2 /df ≤3 2.180
Standardized root mean square (SRMR) ≤0.1 0.053
Goodness-of-fit index (GFI) ≥0.9 0.985
Adjusted goodness-of-fit index (AGFI) ≥0.85 0.950
Normed fit index (NFI) ≥0.9 0.980
Comparative fit index (CFI) ≥0.95 0.983
Root mean square error of approximation (RMSEA) ≤ 0.08 0.06
Note: * The recommended values have been taken from Schermelleh-Engel, et al. [138].
To check if the results of the latent variables are valid and reliable, the Cronbach’s alpha, composite
reliability and average variance extracted (AVE) were calculated. Since the values of Cronbach’s alpha
in Table 6 are between 0.856 and 0.715, which is more than 0.7, the data is reliable. Composite reliability
is within 0.856 and 0.736, indicating that there is internal consistency in the measurement model since
all values are greater than 0.6 [139]. The AVE values are between 0.605 and 0.527 which is more than 0.5.
This indicates that more than 50% of the latent variables explain the variance in measurement items.
Table 6. Checking the model fit for barriers.
Cronbach’s Composite
Category Code Factor Loading AVE
Alpha Realiability
Organizational barriers OB1 0.925 0.856 0.879 0.605
OB2 0.899
OB3 0.875
OB4 0.489
Strategic barriers SB1 0.917 0.839 0.871 0.583
SB2 0.465
SB3 0.872
Technology barrier TB1 0.973 0.733 0.761 0.529
TB2 0.686
Resource barrier RB1 0.673 0.762 0.785 0.540
RB2 0.505
RB3 0.618
Table 6. Cont.
Alpha Realiability
Individual barrier IB1 0.762 0.715 0.736 0.527
IB2 0.812
IB3 0.755
IB4 0.829
IB5 0.756
IB6 0.492
Table 7 shows the correlation of the latent variables and, since the values are less than the square
root of their AVE, proves their validity. Table 8 shows the factor loading of each indicator, and as the
values of the respective indicators are higher than others, the indicators have been correctly grouped.
The structural equation model of barriers and knowledge management (KM) adoption derived from
these calculations is given in Figure 2.
Table 7. Checking the validity of constructs for barriers.
Category OB SB TB RB IB
Organizational barriers (OB) 0.852
Strategic barriers (SB) 0.537 0.759
Technology barriers (TB) 0.482 0.479 0.739
Resource barriers (RB) 0.358 0.384 0.520 0.763
Individual barriers (IB) 0.438 0.258 0.347 0.428 0.628
Note: the bold values show the square root of average variance extracted of each construct, and the other values
show the correlation.
Table 8. Cross loadings of barrier model.
Code OB SB TB RB IB
OB1 0.925 0.475 0.394 0.398 0.413
OB2 0.899 0.463 0.248 0.285 0.311
OB3 0.875 0.418 0.267 0.375 0.479
OB4 0.489 0.049 0.038 0.395 0.021
SB1 0.278 0.917 0.236 0.349 0.408
SB2 0.053 0.465 0.025 0.059 0.06
SB3 0.234 0.872 0.346 0.429 0.016
TB1 0.473 0.394 0.973 0.246 0.279
TB2 0.213 0.386 0.686 0.379 0.197
RB1 0.364 0.349 0.175 0.673 0.264
RB2 0.326 0.149 0.196 0.505 0.151
RB3 0.418 0.285 0.259 0.618 0.230
IB1 0.427 0.349 0.200 0.186 0.762
IB2 0.253 0.259 0.349 0.267 0.812
IB3 0.053 0.281 0.255 0.112 0.755
IB4 0.212 0.351 0.351 0.058 0.829
IB5 0.369 0.247 0.188 0.192 0.756
IB6 0.031 0.035 0.089 0.039 0.492
Note: OB stands for organizational barriers, SB stands for strategic barriers, TB stands for technology barriers,
RB stands for resource barriers, and IB stands for individual barriers. The bold values show the highest values in
their category, implying that they have been correctly grouped.
Sustainability 2019,
Sustainability 11, 954
2019, 11, x FOR PEER REVIEW 14 16
of 31
of 33
Figure 2. Structural equation model of barriers and knowledge management (KM) adoption.
Figure 2. Structural equation model of barriers and knowledge management (KM) adoption.
4.1.2. The Structural Model Validation and Reliability
After checking the measurement model, the structural model was tested. The structural
After
model had checking
five the measurement
exogenous model, the structural
variables; organizational model was
barriers, strategic tested.technology
barriers, The structural model
barriers,
had five exogenous variables; organizational barriers, strategic barriers,
resource barriers and individual barriers, and one endogenous variable which was knowledge technology barriers,
resource barriers
management adoptionand individualThe
in healthcare. barriers, and further
exogenous one endogenous variable three,
had their indicators, whichtwo,
wastwo,
knowledge
three,
management adoption
and five respectively. in healthcare. The exogenous further had their indicators, three, two, two,
three,
The and five respectively.
structure model was validated using the same tests as the measurement model. The χ has 2
The structure
been calculated model
to be 76.51 andwas
thevalidated
degree ofusing the as
freedom same tests asχ2the
40, hence /dfmeasurement model.
= 1.913. The other testThe χ² has
results
been calculated to be
are also given in Table 9. 76.51 and the degree of freedom as 40, hence χ²/df = 1.913. The other test results
are also given in Table 9.
Table 9. Checking the goodness-of-fit for structural model of barriers.
Table 9. Checking the goodness-of-fit for structural model of barriers.
Goodness-of-fit
The Chi Square (χ2 )
Recommended
N/A
Value* 76.51
Result
The
degree of Chi Square
freedom (df) (χ²) N/A N/A 40 76.51
χ2 /dfof freedom (df)
degree ≤3 N/A 1.913 40
Standardized root mean χ²/df
square (SRMR) ≤0.1 ≤3 0.052 1.913
Standardized root mean square (SRMR) ≤ 0.1 0.052
Goodness-of-fit
Normed index (GFI)
fit index (NFI) ≥0.9 ≥ 0.9 0.981 0.975
Adjusted
Comparative fit index (CFI) index (AGFI)
goodness-of-fit ≥0.95 ≥ 0.85 0.99 0.955
Root mean square error of approximation
Normed (RMSEA)
fit index (NFI) ≤0.08 ≥ 0.9 0.058 0.981
Comparative
Note: * The recommendedfitvalues
index (CFI)
have ≥ 0.95
been taken from Schermelleh–Engel, et al. [138]. 0.99
Root mean square error of approximation (RMSEA) ≤ 0.08 0.058
To get theNote:
results displayed
* The in Table
recommended 10, the
values bootstrapping
have technique
been taken from was used. The
Schermelleh–Engel, path
et al. coefficient,
[138].
t-value and p-value were calculated. The path coefficient shows the influence of independent variables
To get the results displayed in Table 9, the bootstrapping technique was used. The path
on the dependent variables [23]. If the value of the path coefficient is between 0.1 and 0.3 the influence
coefficient, t-value and p-value were calculated. The path coefficient shows the influence of
is weak, between 0.3 and 0.5 the influence is moderate, between 0.5 and 1 the influence is strong. If the
independent variables on the dependent variables [23]. If the value of the path coefficient is between
t-values are less than 1.65, 1.96 or 2.58, respectively, they are insignificant.
0.1 and 0.3 the influence is weak, between 0.3 and 0.5 the influence is moderate, between 0.5 and 1
Table 10. Evaluating the structural model for barriers.
Hypothesis Path Coefficient t-Value p-Value Result

H1a: OB→KMAHC −0.573 −3.016 0.009 ** Supported
H1b: SB→ KMAHC −0.546 −2.817 0.087 * Supported
H1c: TB→ KMAHC −0.023 −0.216 0.903 Not Supported
H1d: RB→ KMAHC −0.087 −0.621 0.627 Not Supported
H1e: IB→ KMAHC −0.290 −1.672 0.146 Not Supported
Note: OB stands for organizational barriers, SB stands for Strategic barriers, TB stands for technology barriers, RB
stands for resource barriers, IB stands for individual barriers, and KMAHC stands for knowledge management
adoption in healthcare. *** shows that the path coefficient is significant at p < 0.01, ** shows that the path coefficient
is significant at p < 0.05, and * shows that the path coefficient is significant at p < 0.10.
The results indicate that organizational barriers and strategic barriers both had a path coefficient
of more than 0.5 and t-value more than 2.58, organizational barriers are statistically significant at 1%
and strategic barriers at 10% respectively. Due to this, hypothesis H1a and H1b were both supported.
The other hypothesis H1c, H1d, and H1e were not supported because the path coefficient and t-values
were less than 1.65, 1.96 or 2.58, so they are insignificant. The results indicate that technology barriers,
resource barriers and individual barriers have a relatively lesser impact on KM adoption in healthcare.
The SEM is given in Figure 2. The R2 , also called the coefficient of determination, was calculated to be
0.386, indicating the accuracy of the model.
4.2. Enablers
4.2.1. Validation and Reliability of the Measurement Model

The CFA test was run on the enabler indicators of KM adoption, and the results showed that the
factor loading of MRE4 and ITRE4 were less than 0.5, hence they were removed. After the removal of
these indicators, the test was rerun until a valid model was developed. The χ2 = 75 and the df was 38,
making χ2 /df = 1.974 which is less than 3, hence the model was considered reliable. Several other tests
have also been applied and they are given in Table 11.
Table 11. Checking the goodness-of-fit for measurement model of enablers.

degree of freedom (df) N/A 38
χ2 /df ≤3 1.974
Root mean square error of approximation (RMSEA) ≤0.08 0.059
Note: * The recommended values have been taken from Schermelleh–Engel, et al. [138].
The Cronbach’s alpha, composite reliability and average variance extracted (AVE) were calculated.
The Cronbach’s alpha value was greater than 0.7, between 0.803 and 0.752, indicating that the data
was reliable. The composite reliability shows that there is internal consistency in the measurement
model when all values are greater than 0.6 [139], and since the values of our result were between 0.880
and 0.729, it indicates that there is internal consistency. The AVE values were between 0.713 and 0.516
which is higher than the recommended 0.50, indicating that half of the variances have been explained
by the indicators. This showed that the data was strong, reliable and valid. The details of the values
are given in Table 12, validity of constructs for enablers have been checked in Table 13 and their cross
loadings are given in Table 14. From these values the structural equation model of enablers and KM
adoption is given in Figure 3.
Table 12. Checking the model fit for enablers.
Alpha Realiability
Management related
MRE1 0.835 0.752 0.758 0.627
enablers (MRE)
MRE2 0.639
MRE3 0.679
MRE4 0.499
MRE5 0.637
MRE6 0.826
Government related
GRE1 0.930 0.803 0.880 0.713
enablers (GRE)
GRE2 0.921
Information Technology
ITRE1 0.839 0.718 0.729 0.697
related enablers (ITRE)
ITRE2 0.518
ITRE3 0.713
ITRE4 0.439
Customer related
CRE1 0.813 0.805 0.815 0.559
enabler (CRE)
CRE2 0.589
ERE1 0.651 0.755 0.763 0.516
Employee related
ERE2 0.695
enablers (ERE)
ERE3 0.756
ERE4 0.718
Table 13. Checking the validity of constructs for enablers.
Category MRE GRE ITRE CRE ERE

Management related enablers (MRE) 0.765
Government related enablers (GRE) 0.475 0.863
Information Technology related enablers (ITRE) 0.084 0.388 0.715
Customer related enabler (CRE) 0.395 0.265 0.285 0.706
Employee related enablers (ERE) 0.092 0.397 0.056 0.349 0.649
Table 14. Cross loadings of enablers model.
Code MRE GRE ITRE CRE ERE

MRE1 0.835 0.214 0.288 0.022 0.012
MRE2 0.639 0.168 0.358 0.061 0.084
MRE3 0.679 0.311 0.447 0.059 0.361
MRE4 0.499 0.298 0.065 0.083 0.006
MRE5 0.637 0.335 0.197 0.007 0.199
MRE6 0.826 0.182 0.418 0.018 0.164
GRE1 0.486 0.930 0.265 0.191 0.179
GRE2 0.438 0.921 0.319 0.252 0.298
ITRE1 0.283 0.053 0.839 0.189 0.249
ITRE2 0.255 0.372 0.518 0.259 0.294
ITRE3 0.187 0.290 0.713 0.184 0.130
ITRE4 0.269 0.189 0.439 0.125 0.035
MRE5 0.637 0.335 0.197 0.007 0.199
MRE6 0.826 0.182 0.418 0.018 0.164
GRE1 0.486 0.930 0.265 0.191 0.179
GRE2 0.438 0.921 0.319 0.252 0.298
ITRE1
Sustainability 2019, 11, 954 0.283 0.053 0.839 0.189 0.249 17 of 31
ITRE2 0.255 0.372 0.518 0.259 0.294
ITRE3 0.187 0.290 0.713 0.184 0.130
ITRE4 0.269 Table
0.189 14. Cont.
0.439 0.125 0.035
CRE1
Code 0.121
MRE 0.354
GRE ITRE0.189 CRE 0.813 ERE 0.085
CRE2 0.043 0.097 0.165 0.589 0.058
CRE1 0.121 0.354 0.189 0.813 0.085
ERE1
CRE2 0.553
0.043 0.079
0.097 0.056
0.165 0.5890.354 0.0580.651
ERE2
ERE1 0.450
0.553 0.297
0.079 0.268
0.056 0.3540.299 0.6510.695
ERE3
ERE2 0.433
0.450 0.198
0.297 0.199
0.268 0.2990.219 0.6950.756
ERE3
ERE4 0.433
0.005 0.198
0.354 0.199
0.319 0.2190.149 0.7560.718
ERE4 0.005 0.354 0.319 0.149 0.718
Note: MRE stands for management related enablers, GRE stands for government related enablers,
Note: MRE stands for management related enablers, GRE stands for government related enablers, ITRE stands
ITRE stands for information technology related enablers, CRE stands for customer related enablers,
for information technology related enablers, CRE stands for customer related enablers, and ERE stands for
and ERErelated
employee stands for employee
enablers. relatedshow
The bold values enablers. Thevalues
the highest bold in
values show the
their category, highest
implying thatvalues in their
they have been
correctly
category,grouped.
implying that they have been correctly grouped.
Figure 3. Structural equation model of enablers and KM adoption.

Figure 3. Structural equation model of enablers and KM adoption.
4.2.2. The structural Model Validation and Reliability
4.2.2. The structural Model Validation and Reliability
The structural model was tested after the measurement model. The structural model had five
The structural
exogenous variables,model was tested
management afterenablers
related the measurement model. The
with five indicators, structuralrelated
government model enablers
had five
exogenous variables, management related enablers with five indicators, government related
with two indicators, information technology related enablers with three indicators, customer related
enablerswith
enabler withone
two indicators,
indicator, information
employee related technology related
enablers with enablers with
four indicators, threeendogenous
and one indicators,
variable knowledge management adoption in healthcare.
Same tests were made on structural model validation as on the measurement model. The χ2 has
been calculated to be 79 and the degree of freedom as 43, hence χ2 /df = 1.837. The other test results
are given in Table 15.
To get the results displayed in Table 16 the bootstrapping technique was used. The path coefficient,
t-value and p-value were calculated. The path coefficient showed the influence of independent
variables on the dependent variables [23]. If the value of the path coefficient is between 0.1 and 0.3 the
influence is weak, between 0.3 and 0.5 the influence is moderate, and between 0.5 and 1 the influence
is strong. If the t-values are less than 1.65, 1.96 or 2.58, respectively, they are insignificant.
Table 15. Checking the goodness-of-fit for structural model of enablers.
Goodness-of-fit Recommended Value* Result

χ2 /df ≤3 1.837
Table 16. Evaluating the structural model for enablers.

H2a: MRE→KMAHC 0.388 1.613 0.148 Not Supported
H2b: GRE→ KMAHC 0.699 4.100 0.000 ** Supported
H2c: ITRE→ KMAHC 0.002 0.010 0.887 Not Supported
H2d: CRE→ KMAHC 0.350 1.618 0.221 Not Supported
H2e: ERE→ KMAHC 0.265 1.086 0.460 Not Supported
Note: MRE stands for management related enablers, GRE stands for government related enablers, ITRE stands
for information technology related enablers, CRE stands for customer related enablers, ERE stands for employee
related enablers, and KMAHC stands for knowledge management adoption in healthcare. *** shows that the path
coefficient is significant at p < 0.01, ** shows that the path coefficient is significant at p < 0.05, and * shows that the
path coefficient is significant at p < 0.10.
Since the government related enablers had a path coefficient of more than 0.5, a t-value of more
than 2.58, and was statistically significant at 1%, the hypothesis H2b has been supported. The other
hypothesis H2a, H2c, H2d, and H2e were not supported because the path coefficient and t-values were
less. The results indicate that management related enablers, information technology related enablers,
customer related enabler, and employee related enablers have a relatively less impact on KM adoption
in healthcare. The SEM is given in Figure 3. The R2 , also called the coefficient of determination,
was calculated to be 0.526, indicating the accuracy of the model.
4.3. Drivers
4.3.1. Validation and Reliability of the Measurement Model

After doing the CFA test, HCRD4 and PRD1 were removed because their factor loading was
less than 0.50. The test was continuously redone untill a valid model was achieved. The results of
goodness-of-fit tests are given in Table 17. The Cronbach’s alpha, composite reliability, and average
variance extracted (AVE) were all within approved limits given in Table 18. The validity of constructs
for drivers have been checked in Table 19 and their cross loadings are given in Table 20. From these
values the structural equation model of drivers and KM adoption is given in Figure 4.
Table 17. Checking the goodness-of-fit for measurement model of drivers.

The Chi Square (χ2 ) N/A 132.83
χ2 /df ≤3 1.820
Table 17. Cont.

Table 18. Checking the model fit for drivers.
Alpha Realiability
Healthcare related drivers HCRD1 0.934 0.825 0.869 0.596
HCRD2 0.910
HCRD3 0.859
HCRD4 0.436
HCRD5 0.693
Performance-based drivers PBD1 0.846 0.779 0.806 0.654
PBD2 0.685
PBD3 0.829
Communication related
CRD1 0.759 0.756 0.813 0.643
drivers
CRD2 0.723
CRD3 0.668
Knowledge related drivers KRD1 0.651 0.758 0.856 0.513
KRD2 0.706
KRD3 0.678
KRD4 0.618
Patient related drivers PRD1 0.498
PRD2 0.659 0.635 0.746 0.649
PRD3 0.643
PRD4 0.621
Table 19. Checking the validity of constructs for drivers.
Category HCRD PBD CRD KRD PRD

Healthcare related drivers (HCRD) 0.754
Performance-based drivers (PBD) 0.617 0.775
Communication related drivers (CRD) 0.513 0.562 0.616
Knowledge related drivers (KRD) 0.492 0.486 0.466 0.603
Patient related drivers (PRD) 0.335 0.354 0.361 0.442 0.698
Table 20. Cross loadings of driver’s model.
Code HCRD PBD CRD KRD PRD

HCRD1 0.934 0.280 0.215 0.335 0.160
HCRD2 0.910 0.523 0.384 0.253 0.218
HCRD3 0.859 0.416 0.522 0.366 0.021
HCRD4 0.436 0.021 0.153 0.067 0.089
HCRD5 0.693 0.610 0.277 0.150 0.516
PBD1 0.434 0.846 0.223 0.336 0.513
PBD2 0.553 0.685 0.254 0.234 0.463
PBD3 0.489 0.829 0.166 0.315 0.246
HCRD3 0.859 0.416 0.522 0.366 0.021
HCRD4 0.436 0.021 0.153 0.067 0.089
HCRD5 0.693 0.610 0.277 0.150 0.516
PBD1 0.434 0.846 0.223 0.336 0.513
Sustainability 2019, 11, 954
PBD2 0.553 0.685 0.254 0.234 0.463 20 of 31
PBD3 0.489 0.829 0.166 0.315 0.246
CRD1 0.432 0.298 0.759 0.299 0.326
Table 20. Cont.
CRD2 0.398 0.317 0.723 0.352 0.142
CRD3
Code HCRD 0.580 PBD0.456 CRD 0.668 KRD0.250 0.156
PRD
KRD1
CRD1 0.4320.386 0.2980.533 0.286
0.759 0.651
0.299 0.166
0.326
KRD2
CRD2 0.3980.366 0.3170.357 0.723 0.646 0.706
0.352 0.059
0.142
CRD3
KRD3 0.5800.339 0.4560.168 0.668 0.246 0.250
0.678 0.156
0.441
KRD1
KRD4 0.3860.311 0.5330.258 0.286 0.054 0.651
0.618 0.166
0.493
KRD2 0.366 0.357 0.646 0.706 0.059
KRD3
PRD1 0.339
0.049 0.168
0.028 0.246 0.166 0.206
0.678
0.498
0.441
KRD4PRD2 0.3110.274 0.2580.156 0.054 0.462 0.395
0.618 0.659
0.493
PRD1PRD3 0.0490.190 0.0280.502 0.166 0.180 0.373
0.206 0.643
0.498
PRD2PRD4 0.2740.200 0.1560.611 0.462 0.513 0.395
0.486 0.659
0.621
PRD3 0.190 0.502 0.180 0.373 0.643
Note: HCRD stands for healthcare related drivers, PBD stands for performance-based drivers, CRD
PRD4 0.200 0.611 0.513 0.486 0.621
stands for communication related drivers, KRD stands for knowledge related drivers, and PRD
Note: HCRD stands for healthcare related drivers, PBD stands for performance-based drivers, CRD stands for
stands for patient related drivers. The bold values show the highest values in their category,
communication related drivers, KRD stands for knowledge related drivers, and PRD stands for patient related
implying
drivers. Thethat
boldthey have
values been
show correctly
the highest grouped.
values in their category, implying that they have been correctly grouped.
Figure 4. Structural equation model of drivers and KM adoption.

Figure 4. Structural equation model of drivers and KM adoption.
The structural model had five exogenous variables, healthcare related drivers with four indicators,
performance-based drivers with three indicators, communication related drivers with three indicators,
knowledge related drivers with four indicators, patient related drivers with four indicators, and one
endogenous variable knowledge management adoption in healthcare. The results of the goodness-of-fit
are given in Table 21.
The bootstrapping technique was used to get the results given in Table 22. The path coefficient,
t-value and p-value were calculated. The results indicated that healthcare related drivers and
performance-based drivers both have a path coefficient of more than 0.5 and t-value more than
2.58, that healthcare related drivers are statistically significant at 1%, and performance-based drivers
at 5% respectively. Due to this, hypothesis H3a and H3b were both supported. The other hypothesis
H3c, H3d, and H3e were not supported because the path coefficient and t-values were less. The results
indicate that communication related drivers, knowledge related drivers, and patient related drivers
have less impact on KM adoption in healthcare. The SEM is given in Figure 4. The R2 , also called the
coefficient of determination, was calculated to be 0.485, indicating the accuracy of the model.
Table 21. Checking the goodness-of-fit for structural model of drivers.

The Chi Square (χ2 ) N/A 139.7
χ2 /df ≤3 1.768
Table 22. Evaluating the structural model for drivers.

H3a: HCRD→KMAHC 0.571 3.048 0.004 ** Supported
H3b: PBD→ KMAHC 0.559 2.990 0.031 * Supported
H3c: CRD→ KMAHC 0.032 0.098 0.928 Not Supported
H3d: KRD→ KMAHC 0.089 0.550 0.625 Not Supported
H3e: PRD→ KMAHC 0.212 1.514 0.169 Not Supported
Note: HCRD stands for healthcare related drivers, PBD stands for performance-based drivers, CRD stands for
communication related drivers, KRD stands for knowledge related drivers, PRD stands for patient related drivers,
and KMAHC stands for knowledge management adoption in healthcare. *** shows that the path coefficient is
significant at p < 0.01, ** shows that the path coefficient is significant at p < 0.05, and * shows that the path coefficient
is significant at p < 0.10
5. Discussion
5.1. Barriers
Barriers are variables that negatively influence the adoption of KM in the healthcare. Among
the selected barriers, organizational barriers and strategic barriers hinder the adoption of KM
the most. In an organization, the top management plays a vital role. If top management of the
healthcare does not support the implementation of KM in healthcare, then it is one of the most critical
barriers [45–51]. The top management of healthcare must give a clear vision and create an atmosphere
where knowledge sharing is encouraged in order to ensure effective KM adoption in healthcare.
Other than the top management, the structure and culture of healthcare must be considered as well.
Organizational structure helps in task allocation, coordination, and supervision. It also controls the flow
of information [140]. If the structure of the organization does not allow the flow of information then
it will prove to be a barrier [2,13,45,50–54]. Ichijo, et al. [12] pointed out that healthcare firms should
maintain consistency between their structures to put their knowledge to use. Organization culture
can be a critical problem when it comes to successful KM implementation [2,13,45,50–54]. Culture is
very important for the transferring of knowledge between employees [141]. A culture that encourages
knowledge sharing is critical for KM success. Such a culture requires the healthcare employee to get
together and exchange ideas; culture helps in collaboration and motivates the healthcare employees to
work productively. Whenever a new plan is to be launched in an organization, its culture is considered
carefully because the employees are involved. If KM is to be introduced in healthcare, the structure
and culture must be taken into consideration. The infrastructure of Pakistan healthcare is very large.
It is headed by the Ministry of Health (MoH); they should appoint heads of departments that possess
the ability to make decisions on their own, rather than following the bureaucratic procedures. The top
management of each department must create a structure that encourages the flow of information and
create a learning environment. This would make KM adoption easier.
Strategic planning is also very important for the execution of KM. Ineffective strategic planning
will prove to be a barrier [51,55,56]. Without effective strategic planning, it will be impossible to
achieve KM [142] in healthcare. To implement KM in healthcare a clear strategy has to be made,
one that everyone understands, and its goals, purpose, and objectives must be clear. Strategic planning
is crucial for KM implementation in healthcare for sustainable competitive advantage and survival in
the international market. Uncertainty about the effectiveness of KM may also prove to be a barrier.
It is, however, not considered to be very critical, but it cannot be ignored [45,59]. To implement KM
takes a long time, and it takes even longer to see the positive changes it gives. Due to this, the concept
of KM according to the employees is not worth the effort/resources. The Government of Pakistan
(GoP) has tried its best to improve healthcare by developing several strategies [143], but are currently
not successful. The National Health Vision (NHV) [144] was approved in 2016 and is trying their level
best to achieve it. The GoP is looking for new methods and is considering KM as an option.
Technology barriers, resource barriers and individual barriers also hinder the implementation of
KM but it is not considered as significant in the case of Pakistan. The system of KM might be complex
and difficult to implement or there might be difficulty in integrating it with the existing system.
Resource barriers refer to cost of implementation and other resources needed for KM implementation.
The individual barriers refer to conflicts, lack of motivation and resistance to change. Pakistan has
recently invested heavily in getting new technology to improve administration and new machines for
healthcare to improve patient service and has spent $3.04 billion [145]. It has increased its budget over
the years to overcome other issues such as employee motivation and strikes [36].
5.2. Enablers
Enablers are variables that positively influence the adoption of KM in the healthcare. The results
suggest that the government related enablers support the implementation the most. The government
policies highly affect all organizations [89–91] in the public sector, and since the Pakistan healthcare
sector has a large infrastructure it is highly influenced by policies [146]. The GoP provides basic
healthcare through 5334 Basic Health Units (BHUs) and 560 Rural Health Centers (RHCs), secondary
care through 919 Tehsil Headquarter Hospitals (THQs), District Headquarter Hospitals (DHQs) and it
is estimated that there are about 96,430 private health establishments [146]. In Pakistan, the national
polices and strategies are developed by the Federal MoH, which sets the goals and objectives. Whereas
according to the constitution of Pakistan the provincial MoH is responsible for its deliverance and
execution, except in the federally administrated areas. Favorable healthcare sector policies support
the implementation of KM in healthcare. In the healthcare sector, clear long term strategic planning
for implementation of knowledge management is also most critical for success [18,19,92]. Perera
and Peiró [147] have stated that strategic planning is very important for all healthcare organizations,
the short, medium, and long term vision and mission must be clear.
The GoP vision is “health for all”. Pakistan, to improve its healthcare, has developed several
policies over the years such as the National Health Policy (2001) [146], the Health Sector Vision
(2005–2010) [146], and NHV (2016) [144]. The NHV was developed in 2010, it took a long time to
be approved by both federal and provincial MoH. This document states the vision, mission, values
and targets for 2025 of the healthcare very clearly so that Pakistan can improve its health standards.
Pakistan has also signed international treaties such as the Millennium Development Goals (2000)
setting targets for 2015 [148], and Sustainable Development Goals for healthcare setting targets for
2030 made by the United Nations (UN) [149]. The GoP has increased the budget of healthcare over the
years to make sure it is not the shortage of money that is hindering its healthcare service [36]. Pakistan,
realizing its weakness in the healthcare sector, is desperately trying to improve it and is now looking
for new methods and is willing to adopt KM.
There are other enablers to healthcare as well such as management related enablers, information
technology related enablers, customer related enablers, and employee related enablers, but they
are considered as less supportive. If the management is supportive, there is a learning environment,
and the employees trust each other, it will be easy to implement KM. The role of information technology
cannot be avoided since it helps in storage and quick transferring of information. The customers help
the process by giving constant feedback. If the employees are motivated, well trained and empowered
they will perform better and help with implementation of KM in healthcare.
5.3. Drivers
Drivers are variables that positively influence the adoption of KM in the healthcare. The drivers
that most significantly affect the adoption of KM are healthcare related drivers and performance-based
drivers. Almost all the organizations have realized the importance of knowledge as an asset or
commodity and are adopting KM to gain sustainable competitive advantage [16]. Globalization
has increased the sense of competition among organizations, and healthcare is no exception. These
days medical tourism has increased, patients are looking for places where they can get the best
treatment [150]. This is why healthcare should be able to rapidly adjust to changes in the environment.
If the healthcare sector is able to do this, it will certainly be setting the standard for other sectors by
focusing on the best practices and utilizing the minimum of resources [151]. Over time other sectors
will adopt the practices of healthcare [152]. However, the change in the health sector will not come
overnight; it will take its time.
Pakistan progress in the healthcare has always been hindered by diseases and outbreaks [153].
Pakistan also suffers due to its large population, growth rate [35], and limited resources [143].
Nevertheless, Pakistan realizes the problems in its healthcare, and it has developed several polices
and signed international treaties to improve performance. Pakistan is now considering KM because
it understands the advantages that KM has to offer in the healthcare of Pakistan. It wants to bring a
competitive advantage in its healthcare so that it can improve its reputation and get a share of the
international market.
The performance is a critical factor of healthcare, and if there is effective decision making it will
considerably improve the administration of healthcare. Decisions have to be made at many levels;
top, middle and lower levels. The decisions made at the patient level are the most critical, as they
have to be effective to reduce medical errors [154]. Pakistan healthcare generally has a centralized
decision-making process. It will have to adopt a certain level of decentralization to ensure the quick
flow of knowledge, and quick and effective decision making. This will also result in reduced utilization
of resources by quickly dealing with the patients.
The other drivers, communication related drivers, knowledge related drivers and patient related
drivers also support KM adoption but they are not as supportive. Communication is an important
part of knowledge sharing. If there is communication between departments and other organizations,
the knowledge will flow freely. Similarly, if there is a learning environment in the organization, the loss
of knowledge will be less, and will create trust among the employees. This will create improvement in
patient service resulting in less cost.
6. Conclusions
KM adoption has always been considered a source of sustainable competitive advantage. There are
many barriers, enablers, and drivers that will influence its adoption. There have been very few studies
in the area of KM in healthcare of developing countries [20,21]. This study was undertaken to check the
quantitative influence of the variables on the adoption of KM in the healthcare of Pakistan. This study
employs the SEM technique for the analysis of the variables. The data was collected via questionnaires,
by five research representatives with knowledge of KM and several short seminars. The result of the
study shows that organizational barriers and strategic barriers have a negative influence (barriers),
whereas government related enablers (enablers), healthcare related drivers, and performance-based
drivers (drivers) have a positive influence on KM adoption.
The reason of this study is to give a clear idea of KM adoption in the healthcare of Pakistan.
The findings of this research will help the relevant authorities of Pakistan (government, hospitals,
unions, staff, and etc.) get a better understanding of the barriers, enablers and drivers. The results
show that the barriers can be overcome by the enablers and drivers. The organizational and strategic
barriers are the main barriers. They need to be addressed in a way that reduces their influence. It can be
done by developing suitable government policies (enabler) that encourage the flow of knowledge and
make it easier to implement KM. Similarly, the adoption of KM will give the healthcare organizations
a sustainable competitive advantage and improve their performance by effective decision making.
This in return makes the healthcare sector a benchmark for other sectors and developing countries.
In this study there are a few limitations; the sample size and coverage were sufficient for the
current study to apply SEM but they can be increased in future. The study, however, gives a good
idea of how barriers, enablers and drivers influence KM adoption in healthcare. This study can be
considered for other developing countries but it is more relevant to the situation of Pakistan.
In the future this study can be conducted again because barriers, enablers and drivers change
with the passage of time depending on the phase of implementation. These studies might give further
insight into the situation of KM in the healthcare of Pakistan. The same style of study can be used by
researchers to determine the barriers, enablers and drivers in their respective developing countries.
Author Contributions: Conceptualization, J.K. and N.A.; Data curation, J.K., N.A., S.A., S.K. and N.K.; Formal
analysis, J.K. and N.A.; Investigation, N.K.; Methodology, J.K.; Project administration, T.S.; Resources, S.A. and
N.K.; Supervision, T.S.; Validation, J.K. and T.S.; Visualization, N.A.; Writing—original draft, J.K. and S.A.;
Writing—review & editing, J.K., N.A. and S.K.
Funding: This research received no external funding.
Acknowledgments: The authors are very grateful to everyone that participated in the research. The experts that
helped by participating in the fuzzy Delphi method, the hospitals administration that were kind enough to allow
us to hold short seminars, and the staff and patients that attended it. The authors would also like to thank the
respondents that filed and submitted a valid questionnaire. Finally, the authors would like to thank the five
research assistants that helped in the collection of questionnaires.
Conflicts of Interest: The authors declare no conflict of interest.
References
1. Varabyova, Y.; Müller, J.-M. The efficiency of health care production in OECD countries: A systematic review
and meta-analysis of cross-country comparisons. Health Policy 2016, 120, 252–263. [CrossRef] [PubMed]
2. Edwards, J.S.; Hall, M.; Shaw, D. Proposing a Systems Vision of Knowledge Management in Emergency
Care. In Operational Research for Emergency Planning in Healthcare: Volume 2; Springer: Berlin, Germany, 2016;
pp. 203–228.
3. El Morr, C.; Subercaze, J. Knowledge management in healthcare. In Handbook of Research on Developments in
e-Health and Telemedicine: Technological and Social Perspectives; IGI Global: Hershey, PA, USA, 2010; pp. 490–510.
4. WBCSD (World Business Council on Sustainable Development). 2014. Available online: http://www.wbcsd.
org/ (accessed on 23 December 2017).
5. Guptill, J. Knowledge management in health care. J. Health Care Financ. 2005, 31, 10–14.
6. lo Storto, C.; Goncharuk, A.G. Efficiency vs effectiveness: A benchmarking study on European healthcare
systems. Econ. Sociol. 2017, 10, 102–115. [CrossRef] [PubMed]
7. Sackett, D.L.; Rosenberg, W.M.; Gray, J.M.; Haynes, R.B.; Richardson, W.S. Evidence Based Medicine: What It Is
and What It Isn’t; British Medical Journal Publishing Group: London, UK, 1996; Volume 312, pp. 71–72.
8. Sharma, S.K.; Wickramasinghe, N.; Gupta, J.N. Knowledge management in healthcare. In Creating Knowledge-Based
Healthcare Organizations; IGI Global: Hershey, PA, USA, 2005; pp. 1–13.
9. Sharma, B.; Singh, M. Modeling the knowledge sharing barriers: An ISM approach. Int. J. Knowl.-Based
Organ. (IJKBO) 2015, 5, 16–33. [CrossRef]
10. Martini, A.; Pellegrini, L. Barriers and levers towards knowledge management configurations: A case
study-based approach. J. Manuf. Technol. Manag. 2005, 16, 670–681. [CrossRef]
11. Singh, M.; Shankar, R.; Narain, R.; Agarwal, A. An interpretive structural modeling of knowledge
management in engineering industries. J. Adv. Manag. Res. 2003, 1, 28–40. [CrossRef]
12. Ichijo, K.; von Krogh, G.; Nonaka, I. Knowledge enablers. In Knowing in Firms: Understanding, Managing and
Measuring Knowledge; SAGE Publications Ltd.: Thousand Oaks, CA, USA, 1998; pp. 173–203.
13. Yeh, Y.-J.; Lai, S.-Q.; Ho, C.-T. Knowledge management enablers: A case study. Ind. Manag. Data Syst. 2006,
106, 793–810. [CrossRef]
14. Lee, H.; Choi, B. Knowledge management enablers, processes, and organizational performance: An integrative
view and empirical examination. J. Manag. Inf. Syst. 2003, 20, 179–228.
15. Shabbir, S.; Kaufmann, H.R.; Shehzad, M. Service quality, word of mouth and trust: Drivers to achieve
patient satisfaction. Sci. Res. Essays 2010, 5, 2457–2462.
16. Du Plessis, M. Drivers of knowledge management in the corporate environment. Int. J. Inf. Manag. 2005, 25, 193–202.
[CrossRef]
17. Jafari, M.; Akhavan, P.; Fesharaki, M.N.; Fathian, M. Iran aerospace industries’ KM approach based on a
comparative study: A benchmarking on successful practices. Aircr. Eng. Aerosp. Technol. 2007, 79, 69–78.
[CrossRef]
18. Hojabri, R.; Eftekhar, F.; Sharifi, M.; Hatamian, A. Knowledge Management in an Iranian Health organization:
Investigation of Critical Success Factors. J. Ind. Distrib. Bus. Vol. 2014, 5, 31–42. [CrossRef]
19. Borousan, E.; Sharifian, N.; Hajiabolhassani, A.; Hazrati, S. Evaluating effect of knowledge management in
sales forecasting: Evidence from Iran’s food retail industry. Int. J. Bus. Manag. 2011, 6, 213. [CrossRef]
20. Karamat, J.; Shurong, T.; Ahmad, N.; Waheed, A.; Khan, S. Barriers to Knowledge Management in the Health
Sector of Pakistan. Sustainability 2018, 10, 4155. [CrossRef]
21. Karamat, J.; Shurong, T.; Ahmad, N.; Afridi, S.; Khan, S.; Mahmood, K. Enablers Supporting the Implementation of
Knowledge Management in the Healthcare of Pakistan. Int. J. Environ. Res. Public Health 2018, 15, 2816. [CrossRef]
[PubMed]
22. Khan, A. Pakistan Economic Survey 2013–14, Health & Nutrition. 2013. Available online: http://www.
finance.gov.pk/survey/chapters_14/11_Health_and_Nutrition.pdf (accessed on 1 December 2018).
23. Aibinu, A.A.; Al-Lawati, A.M. Using PLS-SEM technique to model construction organizations’ willingness
to participate in e-bidding. Autom. Constr. 2010, 19, 714–724. [CrossRef]
24. Byrne, B.M. Structural Equation Modeling with AMOS: Basic Concepts, Applications, and Programming; Routledge:
Abingdon-on-Thames, UK, 2016.
25. Avkiran, N.K. An in-depth discussion and illustration of partial least squares structural equation modeling
in health care. Health Care Manag. Sci. 2018, 21, 401–408. [CrossRef] [PubMed]
26. Mitchell, B.; Anderson, M.; Ferguson, J. A predictive model of days from infection to discharge in patients
with healthcare-associated urinary tract infections: A structural equation modelling approach. J. Hosp. Infect.
2017, 97, 282–287. [CrossRef] [PubMed]
27. Guo, R.; Berkshire, S.D.; Fulton, L.V.; Hermanson, P.M. Predicting intention to use evidence-based
management among US healthcare administrators: Application of the theory of planned behavior and
structural equation modeling. Int. J. Healthc. Manag. 2019, 12, 25–32. [CrossRef]
28. Debata, B.R.; Patnaik, B.; Mahapatra, S.S.; Sree, K. Interrelations of service quality and service loyalty
dimensions in medical tourism: A structural equation modelling approach. Benchmarking 2015, 22, 18–55.
[CrossRef]
29. Jacobs, S.R.; Weiner, B.J.; Reeve, B.B.; Hofmann, D.A.; Christian, M.; Weinberger, M. Determining
the predictors of innovation implementation in healthcare: A quantitative analysis of implementation
effectiveness. BMC Health Serv. Res. 2015, 15, 6. [CrossRef] [PubMed]
30. Desouza, K.C. Managing Knowledge with Artificial Intelligence: An Introduction with Guidelines for Nonspecialists;
Greenwood Publishing Group: Santa Barbara, CA, USA, 2002.
31. Popadiuk, S.; Choo, C.W. Innovation and knowledge creation: How are these concepts related? Int. J. Inf. Manag.
2006, 26, 302–312. [CrossRef]
32. Nonaka, I. A dynamic theory of organizational knowledge creation. Organ. Sci. 1994, 5, 14–37. [CrossRef]
33. Beveridge, R. Creating value-focused healthcare delivery systems: Part three—Core competencies. J. Oncol. Manag.
1997, 6, 16–23. [PubMed]
34. Anderson, J.G.; Aydin, C.E. Evaluating the impact of health care information systems. Int. J. Technol. Assess.
Health Care 1997, 13, 380–393. [CrossRef] [PubMed]
35. Pakistan Bureau of Statistics. 6th Population and Housing Census. 2017. Available online: www.pbscensus.gov.pk
(accessed on 1 November 2018).
36. Government of Pakistan, Ministry of Finance. Budget in Brief. Available online: http://www.finance.gov.
pk/budget/Budget_in_Brief_2018_19.pdf (accessed on 20 November 2018).
37. Amin Tabish, S. Towards development of professional management in Indian hospitals. J. Manag. Med. 1998,
12, 109–119. [CrossRef]
38. Eiriz, V.; António Figueiredo, J. Quality evaluation in health care services based on customer-provider
relationships. Int. J. Health Care Qual. Assur. 2005, 18, 404–412. [CrossRef]
39. Ilyas, F. Pakistan ranked 149th in UN health goals. Dawn, 23 September 2016.
40. Saad Andaleeb, S. Determinants of customer satisfaction with hospitals: A managerial model. Int. J. Health
Care Qual. Assur. 1998, 11, 181–187. [CrossRef]
41. Institute for Health Metrics and Evaluation. Pakistan Diseases. 2017. Available online: https://vizhub.
healthdata.org/gbd-compare/ (accessed on 4 November 2018).
42. Khan, S. The Kashmir Earthquake of October 8, 2005: Impacts in Pakistan. 28 Feburary 2006. Available online:
https://reliefweb.int/report/pakistan/kashmir-earthquake-october-8-2005-impacts-pakistan (accessed on
29 November 2018 ).
43. Hersch, W.R.; Lunin, L.F. Perspectives on medical informatics: Information technology in health care.
Introduction and overview. J. Am. Soc. Infrastruct. Sci. 1995, 44, 726–727.
44. Karamitri, I.; Talias, M.A.; Bellali, T. Knowledge management practices in healthcare settings: A systematic
review. Int. J. Health Plan. Manag. 2017, 32, 4–18. [CrossRef]
45. Kothari, A.; Hovanec, N.; Hastie, R.; Sibbald, S. Lessons from the business sector for successful knowledge
management in health care: A systematic review. BMC Health Serv. Res. 2011, 11, 173. [CrossRef] [PubMed]
46. Nicolini, D.; Powell, J.; Conville, P.; Martinez-Solano, L. Managing knowledge in the healthcare sector. A review.
Int. J. Manag. Rev. 2008, 10, 245–263. [CrossRef]
47. Hung, Y.-C.; Huang, S.-M.; Lin, Q.-P.; Tsai, M.-L. Critical factors in adopting a knowledge management
system for the pharmaceutical industry. Ind. Manag. Data Syst. 2005, 105, 164–183. [CrossRef]
48. Akhavan, P.; Jafari, M.; Fathian, M. Critical success factors of knowledge management systems: A multi-case
analysis. Eur. Bus. Rev. 2006, 18, 97–113. [CrossRef]
49. Chua, A.Y. The rise and fall of a community of practice: A descriptive case study. Knowl. Process Manag.
2006, 13, 120–128. [CrossRef]
50. Robinson, H.; Carrillo, P.; Anumba, C.; Al-Ghassani, A. Developing a business case for knowledge
management: The IMPaKT approach. Constr. Manag. Econ. 2004, 22, 733–743. [CrossRef]
51. Patil, S.K.; Kant, R. A fuzzy AHP-TOPSIS framework for ranking the solutions of Knowledge Management
adoption in Supply Chain to overcome its barriers. Expert Syst. Appl. 2014, 41, 679–693. [CrossRef]
52. Seidler-de Alwis, R.; Hartmann, E. The use of tacit knowledge within innovative companies: Knowledge
management in innovative enterprises. J. Knowl. Manag. 2008, 12, 133–147. [CrossRef]
53. Cervigon, V.G.; Romero, N. A Knowledge Management experience in the energy sector. In Proceedings of
the Engineering Management Conference (IEMC Europe 2008), Estoril, Portugal, 28–30 June 2008; pp. 1–4.
54. Hsiao, J.-L.; Chen, R.-F. Critical factors influencing physicians’ intention to use computerized clinical practice
guidelines: An integrative model of activity theory and the technology acceptance model. BMC Med. Inform.
Decis. Mak. 2015, 16, 3. [CrossRef]
55. Blumenberg, S.; Wagner, H.-T.; Beimborn, D. Knowledge transfer processes in IT outsourcing relationships
and their impact on shared knowledge and outsourcing performance. Int. J. Inf. Manag. 2009, 29, 342–352.
[CrossRef]
56. Raisinghani, M.S.; Meade, L.L. Strategic decisions in supply-chain intelligence using knowledge management:
An analytic-network-process framework. Supply Chain Manag. 2005, 10, 114–121. [CrossRef]
57. Alavi, M.; Leidner, D.E. Knowledge management and knowledge management systems: Conceptual
foundations and research issues. MIS Q. 2001, 107–136. [CrossRef]
58. Wilson, T.D. The nonsense of knowledge management. Inf. Res. 2002, 8, 1–33.
59. Lien, B.Y.H.; Hung, R.Y.; McLean, G.N. Organizational learning as an organization development intervention
in six high-technology firms in Taiwan: An exploratory case study. Hum. Resour. Dev. Q. 2007, 18, 211–228.
[CrossRef]
60. Flottorp, S.A.; Oxman, A.D.; Krause, J.; Musila, N.R.; Wensing, M.; Godycki-Cwirko, M.; Baker, R.; Eccles, M.P.
A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and
taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement. Sci.
2013, 8, 35. [CrossRef] [PubMed]
61. Kortteisto, T.; Kaila, M.; Komulainen, J.; Mäntyranta, T.; Rissanen, P. Healthcare professionals’ intentions
to use clinical guidelines: A survey using the theory of planned behaviour. Implement. Sci. 2010, 5, 51.
[CrossRef] [PubMed]
62. Castillo, V.H.; Martínez-García, A.I.; Pulido, J. A knowledge-based taxonomy of critical factors for adopting
electronic health record systems by physicians: A systematic literature review. BMC Med. Inf. Decis. Mak.
2010, 10, 60. [CrossRef]
63. Hahn, T.; Schmiedinger, B.; Stephan, E. Supporting Research and Development Processes Using Knowledge
Management Methods. In Knowledge Management: Concepts, Methodologies, Tools, and Applications; IGI Global:
Hershey, PA, USA, 2008; pp. 490–508.
64. Bartczak, S.E.; England, E.C. Challenges in Developing a Knowledge Management Strategy for the Air Force
Materiel Command. In Knowledge Management and Business Strategies: Theoretical Frameworks and Empirical
Research; IGI Global: Hershey, PA, USA, 2008; pp. 314–340.
65. Larsen, M.H.; Pedersen, M.K. Distributed knowledge management in health care administration.
In Proceedings of the 34th Annual Hawaii International Conference on System Sciences, Maui, HI, USA,
3–6 January 2001; p. 10.
66. Rich, E.; Duchessi, P. Keeping the Flame Alive: Sustaining a Successful Knowledge Management Program.
In Knowledge Management: Concepts, Methodologies, Tools, and Applications; IGI Global: Hershey, PA, USA,
2008; pp. 112–122.
67. del-Rey-Chamorro, F.M.; Roy, R.; van Wegen, B.; Steele, A. A framework to create key performance indicators
for knowledge management solutions. J. Knowl. Manag. 2003, 7, 46–62. [CrossRef]
68. Hamaideh, S.H. Sources of Knowledge and Barriers of Implementing Evidence-Based Practice Among
Mental Health Nurses in Saudi Arabia. Perspect. Psychiatr. Care 2017, 53, 190–198. [CrossRef] [PubMed]
69. Aziz, N.; Sparrow, J. Patterns of gaining and sharing of knowledge about customers: A study of an Express
Parcel Delivery Company. Knowl. Manag. Res. Pract. 2011, 9, 29–47. [CrossRef]
70. Lowe, A.; McIntosh, A. Knowledge management in a New Zealand tree farming company: Ambiguity and
resistance to the “technology solution”. J. Organ. Chang. Manag. 2007, 20, 539–558. [CrossRef]
71. Samuel, K.E.; Goury, M.-L.; Gunasekaran, A.; Spalanzani, A. Knowledge management in supply chain:
An empirical study from France. J. Strateg. Inf. Syst. 2011, 20, 283–306. [CrossRef]
72. Burley, D.L.; Pandit, G. Lesson learned: Organizational realities influence KMS implementation. Vine 2008,
38, 476–489. [CrossRef]
73. Franco, M.; Mariano, S. Information technology repositories and knowledge management processes: A
qualitative analysis. Vine 2007, 37, 440–451. [CrossRef]
74. Davenport, E. Mundane knowledge management and microlevel organizational learning: An ethological
approach. J. Assoc. Inf. Sci. Technol. 2002, 53, 1038–1046. [CrossRef]
75. Downing, J.R. “It’s Easier to Ask Someone I Know” Call Center Technicians’ Adoption of Knowledge
Management Tools. J. Bus. Commun. (1973) 2004, 41, 166–191. [CrossRef]
76. Cheng, J.-H.; Yeh, C.-H.; Tu, C.-W. Trust and knowledge sharing in green supply chains. Supply Chain Manag.
2008, 13, 283–295. [CrossRef]
77. Pillai, K.G.; Min, S. A firm’s capability to calibrate supply chain knowledge—Antecedents and consequences.
Ind. Mark. Manag. 2010, 39, 1365–1375. [CrossRef]
78. Willem, A.; Buelens, M. Knowledge sharing in public sector organizations: The effect of organizational
characteristics on interdepartmental knowledge sharing. J. Public Adm. Res. Theory 2007, 17, 581–606.
[CrossRef]
79. Pee, L.G.; Kankanhalli, A. Interactions among factors influencing knowledge management in public-sector
organizations: A resource-based view. Gov. Inf. Q. 2016, 33, 188–199. [CrossRef]
80. Sánchez-Polo, M.T.; Cegarra-Navarro, J.G. Implementing knowledge management practices in

hospital-in-the-home units. J. Nurs. Care Q. 2008, 23, 18–22. [CrossRef] [PubMed]
81. Chang, Y.-Y.; Hsu, P.-F.; Li, M.-H.; Chang, C.-C. Performance evaluation of knowledge management among
hospital employees. Int. J. Health Care Q. Assur. 2011, 24, 348–365. [CrossRef] [PubMed]
82. Ash, J.S.; Sittig, D.F.; Guappone, K.P.; Dykstra, R.H.; Richardson, J.; Wright, A.; Carpenter, J.; McMullen, C.;
Shapiro, M.; Bunce, A. Recommended practices for computerized clinical decision support and knowledge
management in community settings: A qualitative study. BMC Med. Inform. Decis. Mak. 2012, 12, 6.
[CrossRef] [PubMed]
83. Kümpers, S.; Mur, I.; Hardy, B.; Maarse, H.; Raak, A.V. The importance of knowledge transfer between
specialist and generic services in improving health care: A cross-national study of dementia care in England
and The Netherlands. Int. J. Health Plan. Manag. 2006, 21, 151–167. [CrossRef]
84. Armstrong, R.; Waters, E.; Crockett, B.; Keleher, H. The nature of evidence resources and knowledge
translation for health promotion practitioners. Health Promot. Int. 2007, 22, 254–260. [CrossRef] [PubMed]
85. Kulkarni, U.R.; Ravindran, S.; Freeze, R. A knowledge management success model: Theoretical development
and empirical validation. J. Manag. Inf. Syst. 2006, 23, 309–347. [CrossRef]
86. Quaddus, M.; Xu, J. Adoption and diffusion of knowledge management systems: Field studies of factors
and variables. Knowl.-Based Syst. 2005, 18, 107–115. [CrossRef]
87. Chang, S.-F.; Hsieh, P.-J.; Chen, H.-F. Key success factors for clinical knowledge management systems:
Comparing physician and hospital manager viewpoints. Technol. Health Care 2016, 24, S297–S306. [CrossRef]
[PubMed]
88. Sunassee, N.N.; Sewry, D.A. A theoretical framework for knowledge management implementation.
In Proceedings of the 2002 Annual Research Conference of the South African Institute of Computer
Scientists and Information Technologists on Enablement through Technology, Port Elizabeth, South Africa,
16–18 September 2002; pp. 235–245.
89. Ein-Dor, P.; Myers, M.D.; Raman, K. Information technology in three small developed countries. J. Manag.
Inf. Syst. 1997, 13, 61–89. [CrossRef]
90. Gibbs, J.; Kraemer, K.L.; Dedrick, J. Environment and policy factors shaping global e-commerce diffusion:
A cross-country comparison. Inf. Soc. 2003, 19, 5–18. [CrossRef]
91. Zhu, K.; Kraemer, K.L.; Dedrick, J. Information technology payoff in e-business environments: An international
perspective on value creation of e-business in the financial services industry. J. Manag. Inf. Syst. 2004, 21, 17–54.
[CrossRef]
92. Liebowitz, J.; Wright, K. Does measuring knowledge make “cents”? Expert Syst. Appl. 1999, 17, 99–103.
[CrossRef]
93. Holtshouse, D.K. Information Technology for Knowledge Management; Springer Science & Business Media:
New York, NY, USA, 2013.
94. Van de Walle, S.; Van Dooren, W. How is information used to improve performance in the public sector?
Exploring the dynamics of performance information. In Connecting Knowledge and Performance in Public
Services: From Knowing to Doing; Cambridge University Press: Cambridge, UK, 2010; pp. 33–45.
95. Godbout, A.J.; Godbout, G.M. Filtering knowledge: Changing information into knowledge assets. J. Syst.
Knowl. Manag. 1999, 1, 1–5.
96. Dobbins, M.; DeCorby, K.; Twiddy, T. A knowledge transfer strategy for public health decision makers.
Worldviews Evid.-Based Nurs. 2004, 1, 120–128. [CrossRef]
97. Lee, M.-C. Customer Relationship management and knowledge Management enhancing on innovation
Competence: Case Study. Int. J. Inf. Technol. Manag. 2014, 10, 1784–1800.
98. Kankanhalli, A.; Tan, B.C.; Wei, K.-K. Contributing knowledge to electronic knowledge repositories: An empirical
investigation. MIS Q. 2005, 29, 113–143. [CrossRef]
99. Chourides, P.; Longbottom, D.; Murphy, W. Excellence in knowledge management: An empirical study to
identify critical factors and performance measures. Meas. Bus. Excell. 2003, 7, 29–45. [CrossRef]
100. Davenport, T.H.; De Long, D.W.; Beers, M.C. Successful knowledge management projects. Sloan Manag. Rev.
1998, 39, 43–57.
101. Darko, A.; Chan, A.P.C.; Yang, Y.; Shan, M.; He, B.-J.; Gou, Z. Influences of barriers, drivers, and promotion
strategies on green building technologies adoption in developing countries: The Ghanaian case. J. Clean. Prod.
2018, 200, 687–703. [CrossRef]
102. Lee, J.-H.; Kim, Y.-G.; Kim, M.-Y. Effects of managerial drivers and climate maturity on
knowledge-management performance: Empirical validation. Inf. Resour. Manag. J. (IRMJ) 2006, 19, 48–60.
[CrossRef]
103. Yu, D. Building the Knowledge Advantage. 1999. Available online: http://www.pwcglobal.com/extweb/
newcolth.nsf/DocID/D68D5EE66EDBFE828525679F0050D362 (accessed on 20 November 2018).
104. Du Plessis, M. The role of knowledge management in innovation. J. Knowl. Manag. 2007, 11, 20–29. [CrossRef]
105. Parlby, D.; Taylor, R. The Power of Knowledge: A Business Guide to Knowledge Management. 2000.
Available online: http://www.kpmgconsulting.com/index.html (accessed on 28 November 2018).
106. Bontis, N. There’s a price on your head: Managing intellectual capital strategically. Bus. Q. 1996, 60, 40–78.
107. Yu, S.-H.; Kim, Y.-G.; Kim, M.-Y. Linking organizational knowledge management drivers to knowledge
management performance: An exploratory study. In Proceedings of the 37th Annual Hawaii International
Conference on System Sciences, Big Island, HI, USA, 5–8 January 2004; p. 10.
108. Luxford, K.; Safran, D.G.; Delbanco, T. Promoting patient-centered care: A qualitative study of facilitators
and barriers in healthcare organizations with a reputation for improving the patient experience. Int. J. Qual.
Health Care 2011, 23, 510–515. [CrossRef]
109. Bjørnson, F.O.; Dingsøyr, T. Knowledge management in software engineering: A systematic review of
studied concepts, findings and research methods used. Inf. Softw. Technol. 2008, 50, 1055–1068. [CrossRef]
110. Du Plessis, M. The strategic drivers and objectives of communities of practice as vehicles for knowledge
management in small and medium enterprises. Int. J. Inf. Manag. 2008, 28, 61–67. [CrossRef]
111. Zack, M.H. Managing codified knowledge. Sloan Manag. Rev. 1999, 40, 45–58.
112. Martiny, M. Knowledge management at HP consulting. Organ. Dyn. 1998, 27, 71–78. [CrossRef]
113. Ernst, Y. A Blueprint for Success: How to Put Knowledge to Work in Your Organization. 1999. Available online:
http://www.ey.com (accessed on 21 November 2018).
114. Mudge, A. Knowledge Management: Do we know that we know? Commun. World 1999, 16, 24–27.
115. Caldwell, F. Knowledge Management Risk Analysis Framework. 1999. Available online: http://gartner4.
gartnerweb.com:80/gg/purchase/0/00/853/52/doc/00085352/ (accessed on 19 November 2018).
116. Hargadon, A.; Sutton, R.I. Building an innovation factory. Harv. Bus. Rev. 2000, 78, 157–166, 217.
117. Andaleeb, S.S. Service quality perceptions and patient satisfaction: A study of hospitals in a developing
country. Soc. Sci. Med. 2001, 52, 1359–1370. [CrossRef]
118. Greco, J. Knowledge Is Power. Available online: http://web7.infotrac.london.galegroup.com/itw/infomark/
482/356/72858976w3/purl=rcl_GBI-M_0_A54293713&dyn=30!xrn_10_0_A54293713?sw_aep=up_itw
119. Okoli, C.; Pawlowski, S.D. The Delphi method as a research tool: An example, design considerations and
applications. Inf. Manag. 2004, 42, 15–29. [CrossRef]
120. Dalkey, N.; Helmer, O. An experimental application of the Delphi method to the use of experts. Manag. Sci.
1963, 9, 458–467. [CrossRef]
121. Murray, T.J.; Pipino, L.L.; van Gigch, J.P. A pilot study of fuzzy set modification of Delphi. Hum. Syst. Manag.
1985, 5, 76–80.
122. Ahmad, N.; Zhu, Y.; Gebreslase, M.; Han, Q. Establishing standard definition and guidelines for brownfields
in Pakistan; a stakeholder perspective. In Proceedings of the International Conference on Management
Sciences and Engineering, Kanazawa, Japan, 28–31 July 2017.
123. Ahmad, N.; Zhu, Y.; Ibrahim, M.; Waqas, M.; Waheed, A. Development of a standard brownfield definition,
guidelines, and evaluation index system for brownfield redevelopment in developing countries: The case of
Pakistan. Sustainability 2018, 10, 4347. [CrossRef]
124. Hsu, T.; Yang, T. Application of fuzzy analytic hierarchy process in the selection of advertising media.
J. Manag. Syst. 2000, 7, 19–39.
125. Mao, C.; Shen, Q.; Pan, W.; Ye, K. Major barriers to off-site construction: The developer’s perspective in
China. J. Manag. Eng. 2013, 31, 04014043. [CrossRef]
126. Ekanayake, L.L.; Ofori, G. Building waste assessment score: Design-based tool. Build. Environ. 2004, 39, 851–861.
[CrossRef]
127. Wolf, E.J.; Harrington, K.M.; Clark, S.L.; Miller, M.W. Sample size requirements for structural equation
models: An evaluation of power, bias, and solution propriety. Educ. Psychol. Meas. 2013, 73, 913–934.
[CrossRef]
128. Wu, J.-H.; Wang, S.-C.; Lin, L.-M. Mobile computing acceptance factors in the healthcare industry: A structural
equation model. Int. J. Med. Inform. 2007, 76, 66–77. [CrossRef]
129. Mercer, S.W.; Neumann, M.; Wirtz, M.; Fitzpatrick, B.; Vojt, G. General practitioner empathy, patient enablement,
and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland—A pilot
prospective study using structural equation modeling. Patient Educ. Couns. 2008, 73, 240–245. [CrossRef]
130. Bagozzi, R.P.; Yi, Y. Specification, evaluation, and interpretation of structural equation models. J. Acad. Mark.
Sci. 2012, 40, 8–34. [CrossRef]
131. Ahmad, N.; Zhu, Y.; Shafait, Z.; Sahibzada, U.F.; Waheed, A. Critical barriers to brownfield redevelopment
in developing countries: The case of Pakistan. J. Clean. Prod. 2019, 212, 1193–1209. [CrossRef]
132. Hair, J.F.; Ringle, C.M.; Sarstedt, M. PLS-SEM: Indeed a silver bullet. J. Mark. Theory Pract. 2011, 19, 139–152.
[CrossRef]
133. Hair, J.F.; Sarstedt, M.; Ringle, C.M.; Mena, J.A. An assessment of the use of partial least squares structural
equation modeling in marketing research. J. Acad. Mark. Sci. 2012, 40, 414–433. [CrossRef]
134. Hair, J.F.; Sarstedt, M.; Hopkins, L.; Kuppelwieser, V.G. Partial least squares structural equation modeling
(PLS-SEM) An emerging tool in business research. Eur. Bus. Rev. 2014, 26, 106–121. [CrossRef]
135. Anderson, J.C.; Gerbing, D.W. Structural equation modeling in practice: A review and recommended
two-step approach. Psychol. Bull. 1988, 103, 411. [CrossRef]
136. Jöreskog, K.G.; Sörbom, D. LISREL 8: Structural Equation Modeling with the SIMPLIS Command Language;
Scientific Software International: Skokie, IL, USA, 1993.
137. Hu, L.-T.; Bentler, P.M. Fit indices in covariance structure modeling: Sensitivity to underparameterized
model misspecification. Psychol. Methods 1998, 3, 424. [CrossRef]
138. Schermelleh-Engel, K.; Moosbrugger, H.; Müller, H. Evaluating the fit of structural equation models: Tests of
significance and descriptive goodness-of-fit measures. Methods Psychol. Res. Online 2003, 8, 23–74.
139. Bagozzi, R.P.; Yi, Y. On the evaluation of structural equation models. J. Acad. Mark. Sci. 1988, 16, 74–94.
[CrossRef]
140. Lim, M.; Griffiths, G.; Sambrook, S. Orgarnizational Structure for the 21st Century. In Annual Meeting
of the Institute for Operations Research and Management Sciences; The Institute of Operations Research and
Mananagemen: Austin, TX, USA, 2010.
141. Ashkanasy, N.M.; Broadfoot, L.E.; Falkus, S.A. Questionnaire Measures of Organizational Culture; Sage
Publications, Inc.: Thousand Oaks, CA, USA, 2000.
142. Borousan, E.; Hajiabolhasani, A.; Hojabri, R. Evaluating factors that cause problem in implementation of
knowledge management in Irans oil and gas industry. Afr. J. Bus. Manag. 2012, 6, 9589–9596. [CrossRef]
143. Akram, M.; Khan, F.J. Health Care Services and Government Spending in Pakistan. 2007. Available online:
www.pide.org.pk/pdf/Working%20Paper/WorkingPaper-32.pdf (accessed on 1 September 2018).
144. Government of Pakistan. National Health Vision 2016–2025. 2016. Available online: http:
//www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/pakistan/national_health_
vision_2016-25_30-08-2016.pdf (accessed on 25 September 2018).
145. export.gov. Pakistan—Healthcare and Medical Equipment. Available online: https://www.export.gov/
article?id=Pakistan-Healthcare-and-Medical-Equipment (accessed on 1 November 2018).
146. Organization, W.H. Health Systems Profile—Pakistan. 2017. Available online: http://www.emro.who.int/
human-resources-observatory/countries/country-profile.html (accessed on 15 September 2018).
147. Rodríguez Perera Fde, P.; Peiró, M. Strategic planning in healthcare organizations. Rev. Esp. Cardiol. 2012, 65, 749–754.
148. Islam, A. Health-related millennium development goals: Policy challenges for Pakistan. JPMA J. Pak. Med. Assoc.
2004, 54, 175–181.
149. Ali, S. Pakistan: Achieving the SDGs. Daily Times, 17 April 2018.
150. Ranjan Debata, B.; Sree, K.; Patnaik, B.; Sankar Mahapatra, S. Evaluating medical tourism enablers with
interpretive structural modeling. Benchmarking 2013, 20, 716–743. [CrossRef]
151. Layne-Farrar, A. Business Models and the Standard Setting Process. 2010. Available online:
http://www.konkurrensverket.se/globalassets/english/publications-and-decisions/the-pros-and-
cons-of-standard-setting.pdf (accessed on 30 November 2018).
152. Egan, M. Setting standards: Strategic advantages in international trade. Bus. Strategy Rev. 2002, 13, 51–64.
[CrossRef]
153. WHO. Country Cooperation Strategy at a Glance, Pakistan. 2017. Available online: http://apps.who.int/
iris/bitstream/handle/10665/136607/ccsbrief_pak_en.pdf?sequence=1 (accessed on 25 August 2018).
154. Blake, W. Hospitals Are Learning from Industry How to Cut Medical Errors. Available online: https://www.
economist.com/international/2018/06/28/hospitals-are-learning-from-industry-how-to-cut-medical-errors
© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

Sustainability 11 00954 PDF

Uploaded by

Copyright:

Available Formats

You might also like

Sustainability 11 00954 PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Sustainability 11 00954 PDF

Uploaded by

Copyright:

Available Formats

sustainability

Abstract: Knowledge management (KM) adoption is crucial to integrating sustainable development

Keywords: knowledge management; healthcare; barriers; enablers; drivers; developing

Sustainability 2019, 11, 954; doi:10.3390/su11040954 www.mdpi.com/journal/sustainability

2.1. Knowledge Management

2.2. The Need for KM in the Healthcare of Pakistan

2.3. Knowledge Management Barriers to Healthcare

Table 1. Knowledge management barriers to healthcare according to literature review.

Category Code Barrier Reference

Category Code Barrier Reference

Hypothesis 1a (H1a). Organizational barriers have negative influence on the adoption of KM

Hypothesis 1c (H1c). Technological barriers have negative influence on the adoption of KM

2.4. Knowledge Management Enablers of Healthcare

Table 2. Knowledge management enablers of healthcare according to literature review.

Category Code Enabler Reference

2.5. Knowledge Management Drivers of Healthcare

in efficiency, organizational communication, efficient transfer of knowledge, improved IT, effective

Table 3. Knowledge management drivers of healthcare according to literature review.

Category Code Drivers References

Hypothesis 3b (H3b). Performance-based drivers have positive influence on the adoption of KM

Figure 1. Step-by-step methadology.

3.2. Data Collection

Table 4. Details of respondents.

Category Frequency Percentage

Category Frequency Percentage

3.3. Structural Equation Modeling (SEM)

4.1.1. Validation and Reliability of Measurement Model

Table 5. Checking the goodness-of-fit for measurement model of barriers.

Goodness-of-Fit Recommended Value * Result

Table 6. Checking the model fit for barriers.

Table 7. Checking the validity of constructs for barriers.

Table 8. Cross loadings of barrier model.

Table 10. Evaluating the structural model for barriers.

Hypothesis Path Coefficient t-Value p-Value Result

4.2.1. Validation and Reliability of the Measurement Model

Table 11. Checking the goodness-of-fit for measurement model of enablers.

Goodness-of-Fit Recommended Value * Result

Table 12. Checking the model fit for enablers.

Table 13. Checking the validity of constructs for enablers.

Category MRE GRE ITRE CRE ERE

Table 14. Cross loadings of enablers model.

Code MRE GRE ITRE CRE ERE

Figure 3. Structural equation model of enablers and KM adoption.

Table 15. Checking the goodness-of-fit for structural model of enablers.

Goodness-of-fit Recommended Value* Result

Table 16. Evaluating the structural model for enablers.

Hypothesis Path Coefficient t-Value p-Value Result

4.3.1. Validation and Reliability of the Measurement Model

Table 17. Checking the goodness-of-fit for measurement model of drivers.

Goodness-of-Fit Recommended Value * Result

Table 17. Cont.

Goodness-of-Fit Recommended Value * Result

Table 18. Checking the model fit for drivers.

Table 19. Checking the validity of constructs for drivers.

Category HCRD PBD CRD KRD PRD

Table 20. Cross loadings of driver’s model.

Code HCRD PBD CRD KRD PRD

Figure 4. Structural equation model of drivers and KM adoption.