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Managing complexity within care ecosystems is an increasing universal challenge. In health, this is emphasised by recent calls for greater care integration to achieve service improvement as levels of comorbidity and frailty grow within populations. This research takes a service-dominant logic (SDL) stance in examining the sources, types and nature of complexity within a care ecosystem in the UK.

This illustrative case research focuses on a community care ecosystem. A multi-method approach is used combining semi-structured interviews, descriptive statistics and secondary data. The results were independently assessed and validated by participants through a second interview phase.

The findings from this research provide empirical support for the six complexities discussed in the supply chain literature. Identifying these complexities proffers the opportunity of applying manufacturing-derived complexity management strategies in care ecosystems. The conceptual model for institutional complexity, derived from the illustrative case study, showed that care professionals face additional complexity challenges in operating care ecosystems.

The management of complexity in care ecosystems requires professionals to be considerate of institutional arrangements when addressing the consequences of increasing levels of complexity. This necessitates the development of a balanced approach between reducing complexity while absorbing institutional arrangements which minimise risk.

Drawing on the supply chain complexity literature, the paper has developed a framework which guides care professionals facing increasing levels of complexity within the context of their institutional arrangements. As such, this research furthers our understanding of supply chain complexity effects in care ecosystems and provides a platform for future research.

The purpose of this paper is to understand value cocreation in service ecosystems from a multilevel perspective, uncovering value cocreation factors and outcomes at the micro, meso, and macro levels.

A Grounded Theory approach based on semi-structured interviews is adopted. The sample design was defined to enable the ecosystem analysis at its different levels. At the macro level was the Portuguese Health Information ecosystem. Embedded meso level units of analysis comprised eight health care organizations. A total of 48 interviews with citizens and health care practitioners were conducted at the micro level.

Study results enable a detailed understanding of the nature and dynamics of value cocreation in service ecosystems from a multilevel perspective. First, value cocreation factors are identified (resource access, resource sharing, resource recombination, resource monitoring, and governance/institutions generation). These factors enable actors to integrate resources in multiple dynamic interactions to cocreate value outcomes, which involve both population well-being and ecosystem viability. Study results show that these value cocreation factors and outcomes differ across levels, but they are also embedded and interdependent.

The findings have important implications for organizations that are ecosystem actors (like the Portuguese Ministry of Health) for understanding synergies among value cocreation factors and outcomes at the different levels. This provides orientations to better integrate different actor roles, technology, and information while facilitating ecosystem coordination and co-evolution.

This study responds to the need for a multilevel understanding of value cocreation in service ecosystems. It also illuminates how keystone players in the ecosystem should manage their value propositions to promote resource integration for each actor, fostering resource density and ecosystem viability. It also bridges the high-level conceptual perspective of Service-Dominant logic with specific empirical findings in the very important context of health care.

People with complex health conditions must often navigate landscapes of uncoordinated public, private and voluntary health-care providers to obtain the care they need. Complex health conditions frequently transcend the scope of typical health-care service systems. The purpose of this paper is to explore and characterize such unique assemblages of actors and services as “user-defined ecosystems”.

Building on literature on customer ecosystems, this paper introduces the concept of the user-defined ecosystem (UDE). Using an abductive approach, the authors apply the concept in an interpretive, qualitative study of ten families with special needs children.

This study uncovers complex UDEs, where families actively combine a broad range of services. These ecosystems are unique for each family and extend beyond the scope of designed service ecosystems. Thus, the families are forced to assume an active, coordinating role.

This paper shows how to identify ecosystems from the user’s point of view, based on the selected user unit (such as a family) and the focal value-creating function of the ecosystem for the user.

This paper highlights how service providers can support and adapt to UDEs and, thus, contribute to user value and well-being. This can be used to understand users’ perspectives on service and systems in health and social care.

This study develops the concept of the UDE, which represents a customer-focused perspective on actor ecosystems and contrasts it with a provider-focused and a distributed perspective on ecosystems. This study demonstrates the practical usefulness of the conceptualization and provides a foundation for further research on the user’s perspective on ecosystems.

Service ecosystems are gaining credence among management scholars. However, there is still little agreement about the distinguishing attributes of service ecosystems in both the public and the private sectors. The purpose of this paper is to focus on the health care service system, suggesting a “recipe” for the implementation of a sustainable and innovative health care service ecosystem.

A mixed methodology was used. First, a critical literature review was conducted to lay the conceptual foundations of this study. Then a theory about the institutional, organizational and managerial requisites for the implementation of a health care service ecosystem was developed.

The health care sector is appropriate for the core tenets of the service ecosystem perspective. Tailored interventions aimed at improving the functioning of the health care service ecosystem should be implemented at the micro, meso, macro and mega levels. Patient empowerment, patient-centered care and integrated care are the fundamental ingredients of the recipe for effective health care service ecosystems.

The ecosystem approach provides health policy makers with interesting insights to help shape the health care service system of the future. The paper also contributes to the innovation of managerial practices emphasizing the role of patient involvement in the design and delivery of health care.

This is one of the first attempts to systematize scientific knowledge about service ecosystems in the health care sector. An agenda for further research is suggested, in order to further advance the establishment of an effective and innovative health care service ecosystem.

The purpose of this paper is to investigate how and why some service ecosystems are more resilient and, consequently, more sustainable than others during turbulent times, and how resilience can be cultivated to enable pathways to service ecosystem sustainability.

This work integrates disparate literature from multiple service and sustainability literature streams, iterating through constant comparison with findings from 44 semistructured interviews conducted in the context of primary health care clinic service ecosystems.

The authors offer a novel conceptual framework comprising pillars (shared worldview, individual actor well-being and multiactor interactions), changing practices to cultivate resilience through resilience levers (orchestrators, individual actor effort, actor inclusivity and digitaltech–humanness approach), and pathways to service ecosystem sustainability (volume vs value, volume to value, volume and value). The authors demonstrate that service ecosystems need to change practices, integrating resources differently in response to the turbulent environment, emphasizing the importance of a shared worldview across the ecosystem and assessing different pathways to sustainability.

This paper offers new insights into the important intersection of service marketing, sustainability and health care. The authors provide guidance to practitioners aiming to cultivate resilience in service ecosystems to achieve pathways to sustainability in primary health care clinics. Finally, implications for theory are discussed, and directions to guide future service research offered.

The purpose of this paper is to address a critical problem for health-care organizations: patient referral leakage. This paper explores the nature of patient referrals by examining how health-care providers’ breadth and depth of connectivity within a hospital network and identification with each other influence the likelihood of future patient referrals.

The data was collected by using a multi-sourced data set from the health-care industry. The proposed model was tested by using logistic regression to determine the likelihood of a primary care physician’s (PCP) referral to a specialist within a hospital network.

A model linking provider connectivity to examine co-creation practices in the form of patient referrals is tested. Results indicate that patient referrals are multidimensional. A PCP’s likelihood to refer to a specialist within the hospital network is influenced by the breadth and depth of connectivity of each provider.

This investigation extends service ecosystems to patients, health-care providers and hospital organizations, making it the first to explore how different degrees of connectivity (breadth of referral partners and depth of exchange) between and among health-care providers influence the likelihood of future patient referrals. Findings complement extant literature on service ecosystems by empirically showing that provider relationships are interdependent and rely on the mutual coordination of benefits within the entire health-care organization and network.

Managers and health-care professionals can use the framework to build and strengthen relational ties/alliances within a service organization. An ecosystems perspective reduces patient referral leakage through enhanced organizational performance, competitive advantage and continuity of care.

The authors offer a novel view of referral relationships using hard-to-access proprietary data. Moreover, this study responds to the need for transformative service research by offering service researchers and policymakers a means to enhance consumer well-being. The main contribution of this study is a framework to gain a better understanding of patient referral relationships between employees (i.e., health-care providers) in an organization, thereby affording an opportunity to bolster operational efficiencies, improve clinical outcomes and strengthen referral pathways. By viewing health-care networks through a service ecosystems perspective, contextual boundaries and the relative power of relationships are also identified. The novel use of rarely available hospital data in this setting helps explain how patient leakage compromises the health of the ecosystem and its members.

The COVID-19 pandemic has created a crisis for healthcare systems worldwide. There have been significant challenges to managing public and private health care and related services systems’ capacity to cope with testing, treatment and containment of the virus. Drawing on the foundational research by Frow et al. (2019), the paper explores how adopting a service ecosystem perspective provides insight into the complexity of healthcare systems during times of extreme stress and uncertainty.

A healthcare framework based on a review of the service ecosystem literature is developed, and the COVID-19 crisis in Australia provides an illustrative case.

The study demonstrates how the service ecosystem perspective provides new insight into the dynamics and multilayered nature of a healthcare system during a pandemic. Three propositions are developed that offer directions for future research and managerial applications.

The research provides an understanding of the relevance of managerial flexibility, innovation, learning and knowledge sharing, which offers opportunities leading to greater resilience in the healthcare system. In particular, the research addresses how service providers in the service ecosystem learn from this pandemic to inform future practices.

The service ecosystem perspective for health care offers fresh thinking and an understanding of how a shared worldview, institutional practices and supportive and disruptive factors influence the systems’ overall well-being during a crisis such as COVID-19.

Health care ecosystems instantiate different innovation trajectories, driven either by science-/techno-push or user-centric rationales. This article focuses on organization intermediaries (OIs), respectively, active in health care ecosystems driven by science- and techno-push versus user-centric innovation processes; it aims at characterizing their operation and intervention modes. The analysis elaborates on network and content brokerage. Innovation also needs to consider various challenges associated with physical vicinity. The authors check whether territorial anchoring plays a role in brokerage, depending on the innovation model.

The article offers an investigation of eight French organizations matching the definition of OIs and active in different areas of health care-related innovation. It follows a qualitative and abductive research protocol adhering to the precepts of grounded theory.

First, the authors show that content and network brokerage specialize in specific activities in each innovation model. On network brokerage, the authors show that OIs foster the development of communities of practice in the science-/techno-push model, while they nurture communities of innovation in the user-centric model. Services materializing content brokerage are typical consequences of activities performed in each model. The second contribution deals with physical vicinity. In the science-/techno-push model, OIs install a physical space (the “internal” dimension) to support the development of communities of practice, while the “external” dimension copes with agglomeration effects. In the user-centric model, OIs deliver services thanks to the “internal” space; communities of innovation create a leverage effect on the physical space to operate their activities that are supported by “external” network effects.

The originality of the article lies in the description of the alternative roles plaid by organization intermediaries in the science-/techno-push versus user-centric approaches of innovation. In these two approaches, (contents and network) brokerage and physical vicinity play different roles.

The purpose of this paper is to examine the role of proto-institutions that are new institutional subsystems that subsequently affect the current institutional arrangements in the evolution of service ecosystems.

To shed light on the mode of action of proto-institutions, the authors investigate the changes of three service ecosystems in Italy: the health care ecosystem, the food-supply ecosystem and the urban mobility ecosystem.

First, the paper elucidates how changes of service ecosystems are triggered by megatrends that are external to specific service ecosystems. Second, the study empirically shows how service ecosystems and their institutional settings change through the establishment of proto-institutions.

Responding to recent calls to investigate in more detail how actors challenge dominant social patterns and to conduct research to better understand how changes at the level of individual actors may lead to shifts within overall service ecosystems, this paper is one of the first to empirically study the relationships between phenomena that are external to service ecosystems, the emergence of proto-institutions and the resulting changes of institutional arrangements.

This paper aims to conceptualize and characterize service ecosystems, addressing calls for research on this important and under-researched topic.

The authors draw on four meta-theoretical foundations of S-D logic – resource integration, resource density, practices and institutions – providing a new integrated conceptual framework of ecosystem well-being. They then apply this conceptualization in the context of a complex healthcare setting, exploring the characteristics of ecosystem well-being at the meso level.

This study provides an integrated conceptual framework to explicate the nature and structure of well-being in a complex service ecosystem; identifies six key characteristics of ecosystem well-being; illustrates service ecosystem well-being in a specific healthcare context, zooming in on the meso level of the ecosystem and noting the importance of embedding a shared worldview; provides practical guidance for managers and policy makers about how to manage complex service ecosystems in their quest for improving service outcomes; and offers an insightful research agenda.

This research focuses on service ecosystems with an illustration in one healthcare context, suggesting additional studies that explore other industry contexts.

Practically, the study indicates the imperative for managing across mutually adapting levels of the ecosystem, identifying specific new practices that can improve service outcomes.

Examining well-being in the context of a complex service ecosystem is critical for policymakers charged with difficult decisions about balancing the demands of different levels and actors in a systemic world.

The study is the first to conceptualize and characterize well-being in a service ecosystem, providing unique insights and identifying six specific characteristics of well-being.