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This chapter provides a reflective synopsis of six cases focused on making healthcare sustainable. The nature and value of an ecosystem perspective is explored. The intent is to apply and generate organizational knowledge to understand and guide purposeful design and learning.

From five countries where healthcare is organized differently, these cases illuminate particular approaches to develop the capabilities for healthcare to deliver greater value to society. Each case is examined through the lens of an appropriate theoretical perspective. This chapter reports the themes that were common in the six case studies.

New approaches are changing the connections in the healthcare ecosystem, including the flows of: medical knowledge, clinical information, and resources. Common themes include: the importance of networks in the emerging healthcare ecosystem; the role of governance mechanisms and leadership to align the diverse ecosystem components; the engagement of dominant ecosystem actors; the need for adaptive change capabilities, and for multi-stakeholder research collaborations to generate actionable knowledge.

Taking an ecosystem perspective enables healthcare leaders to broaden their conceptualization of the changes that will be required to be sustainable in a changing society.

Almost every man, woman and child is affected by the healthcare system. Increasing the sustainability of healthcare is integral to increasing societal sustainability overall.

Viewing the ecosystem as the appropriate focus of purposeful change departs from a traditional approach that focuses on the effectiveness of each element.

Despite the abundance of research in open innovation, few contributions explore it at inter-organizational level, and particularly with a focus on healthcare ecosystem, characterized by a dense network of relationships among public and private organizations (hospitals, companies and universities) as well as other actors that can be labeled as “untraditional” player, i.e. doctors, nurses and patients. The purpose of this paper is to cover this gap and explore how knowledge is transferred and flows among all the healthcare ecosystems’ players in order to support open innovation processes.

The paper is conceptual in nature and adopts a narrative literature review approach. In particular, insights gathered from open innovation literature at the inter-organizational network level, with a particular attention to healthcare ecosystems, and from the knowledge transfer processes, are analyzed in order to propose an interpretative framework for the understanding of knowledge transfer in open innovation with a focus on healthcare ecosystem.

The paper proposes an original interpretative framework for knowledge transfer to support open innovation in healthcare ecosystems, composed of four main components: healthcare ecosystem’s players’ categories; knowledge flows among different categories of players along the exploration and exploitation stages of innovation development; players’ motivations for open innovation; and players’ positions in the innovation process. In addition, assuming the intermediary network as the suitable organizational model for healthcare ecosystem, four classification scenarios are identified on the basis of the main players’ influence degree and motivations for open innovation.

The paper offers interpretative lenses for managers and policy makers in understanding the most suitable organizational models able to encourage open innovation in healthcare ecosystems, taking into consideration the players’ motivation and the knowledge transfer processes on the basis of the innovation results.

The paper introduces a novel framework that fills a gap in the innovation management literature, by pointing out the key role of external not R&D players, like patients, involved in knowledge transfer for open innovation processes in healthcare ecosystems.

The chapter redefines the focus of the changes required to create sustainable healthcare away from fixing healthcare organizations and toward reconfiguring the constituent elements of the healthcare ecosystem and redefining how they interrelate to yield value more sustainably.

Based on a review of recent literature on healthcare reform, we argue that unlike other sectors, healthcare organizations cannot change themselves without changing their connections to the rest of the healthcare ecosystem, including other healthcare organizations, patients, governments, research institutions, vendors, and the citizenry at large. This is because these are not only stakeholders but also integral parts of healthcare processes.

Interventions intended to create more sustainable healthcare must bring together knowledge and perspectives from across the ecosystem, and must converge different sources of information and analysis to generate novel ways of connecting across the ecosystem. Change within a healthcare system cannot achieve the magnitude of transformation needed to become sustainable.

If the healthcare ecosystem evolves in the manner described in this chapter, the healthcare ecosystem will no longer center around particular institutions and doctors’ offices but rather be defined by flexible and variable interactions between co-acting elements of the ecosystem.

The chapter treats the context as the focus of change in order to change the healthcare system. It proposes three kinds of flows: knowledge, clinical, and resource that are already beginning to change and that will eventually result in fundamentally different approaches to healthcare.

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.

The purpose of this paper is to investigate the role of patient loyalty programs in healthcare environment, generally considered as a way to engage patients and potentially increase the perception of service quality of healthcare systems, but not systematically analyzed at the state of the art.

The Service Dominant logic and, in particular, the service ecosystem construct are adopted and integrated with relevant literature references and empirical studies on a sample of patients. Loyalty programs are interpreted as institutions coordinating actors of the healthcare service ecosystem.

A conceptual model linking loyalty programs to patients and healthcare providers’ co-creation practices, engagement, satisfaction, trust, and perception of service quality is build and explained based on literature and a case study, finding that loyalty programs can strengthen the adaptability and the well-being of a healthcare service ecosystem.

This contribution can have a significant impact on the design of new and the evolution of current healthcare service ecosystem, providing interesting insights to practitioners on the topic of loyalty programs, both for their development and their benefits.

The paper revised previous healthcare service ecosystems and highlights the role of the loyalty program institution at each level and between levels of the ecosystem.

The purpose of this paper is to propose a typology of institutions enabling or constraining customer centricity and value co-creation in service ecosystems; illustrate the various types of institutions with examples from healthcare; and provide case study evidence on how pharmaceutical companies react to and induce institutional change.

First, a typology of institutions enabling or constraining customer centricity and value co-creation is proposed and illustrated with examples from healthcare. Next, to clarify how companies deal with these institutions by reacting to or inducing institutional change, two case companies from the pharmaceutical industry are described.

The research identifies and illustrates nine types of institutions (culture, structure, processes, metrics, language, practices, IP, legislation and general beliefs) grouped by three levels of analysis (micro, meso and macro). Furthermore, the findings of the two case studies indicate that companies react to, but also proactively induce, institutional change.

The investigation is limited to two case studies.

Organizations need to understand the micro-, meso- and macro-level institutions of their service ecosystem; react to institutional changes imposed by other actors; and proactively change institutions by breaking, making or maintaining them.

Pharmaceutical companies can improve patient well-being by inducing institutional change.

This research develops a mid-range theory of service ecosystem institutions by developing a typology. This typology is empirically examined in a healthcare context.

The present article aims at rising stream of literature about intellectual capital in healthcare organizations, by exploring how knowledge-based activities are designed to promote innovation and create value. This process concerns not only buyers and sellers of industrial products/services but, more widely, larger networks of healthcare actors which include patients, payers and health institutions.

To answer the research question, we adopted a conceptual approach aimed at reaching overall comprehension of healthcare innovation mechanisms. We have tracked the pivotal extant studies for catching the roots and dynamics at the base of diffusion of healthcare innovation. This article demonstrates, based on previous literature and theoretical speculations, the contribution that innovative knowledge-based activities (e.g. market access approach) make to intellectual capital in healthcare organizations to promote innovation and create value.

The results show that three knowledge-based activities of the healthcare ecosystem shape the basis of the proposed conceptual framework. First, a value co-creation strategy to develop capabilities for each health stakeholder is intended as human capital. Second, the market access approach to promote innovation is reported to the relational capital. Third, a digital servitization strategy is referred to the structural capital.

This paper provides implications for the stream of literature about intellectual capital in healthcare organizations. It aims at exploring three knowledge-based activities as value co-creation, market access and digital servitization that respond to different intellectual capital levels components (human, relational, structural).

This article provides a conceptual framework based on the linkage of two fundamental streams of management studies, which correspond to innovation diffusion and intellectual capital management. This offers a more solid conceptualization for managing intellectual capital in healthcare organizations with respect to previous studies and creates value in the ecosystem.

Healthcare policy-makers are implementing practices based on the logic of cost-opportunity to rationalize investments and resource consumption. The successful implementation of these practices depends on policy-makers’ capacity to involve professionals dispersed in the ecosystem, and who are unaccustomed to cooperating. Our case study investigates the institutional work pursued by the Lombardy Region to stimulate a Health Technology Assessment (HTA) program.

This chapter is based on a longitudinal case study of institutional change linked with a HTA program in the Lombardy Region. The HTA program initiatives were implemented during the 2009–2012 period. The case study is based on triangulating data from archival data, contents of the assessment forms and interviews with regional staff and experts.

The Lombardy Region implemented two distinct strategies, with mixed results. A strategy that was based on the formalization of the HTA program in a legislative direct through educational efforts did not obtain the commitment of the key actors in the relevant ecosystem. Subsequently, the Region implemented an ‘institutional work’ design strategy that included a combination of political, cultural, technical and structural work. This strategy stimulated local HTA experiments that might be used in the future to legitimize the full diffusion of the new practice in the ecosystem.

This study highlights a viable strategy of change that policy-makers can use to manage processes of institutional change in a professional ecosystem. The ‘institutional work’ strategy can support the establishment of new practices that incorporate the logic of cost-opportunity, which might rationalize the use of resources and improve investment decisions.

The access to high quality, a reliable and affordable basic healthcare service is one of the key challenges facing the rural and semi‐urban population lying at base of the pyramid (BoP) in India. Realizing this as a social challenge and an economic opportunity (shared value), there has been an emergence of healthcare service providers who have bundled entrepreneurial attitude and passion with available scarce resources to design and implement cost‐effective, reliable and scalable market solutions for the BoP. The purpose of this research paper is to understand the underlying operating principles of these self‐sustainable business models aimed at providing healthcare services to the BoP segment in India.

The empirical context involves the use of case study research methodology, where the source of data is published case studies and the company websites of four healthcare organizations who have made a socio‐economic difference in the lives of the rural and semi‐urban population lying at the BoP in India.

The analysis and findings reflect the key operating principles for sustainable healthcare business ventures at the BoP. These include focus on 4A's (accessible, affordable, acceptable and awareness), local engagement, local skills building, learning by experiment, flexible organizational structure, dynamic leadership, technology integration and scalability.

This research study has focused mainly on the published case studies as source of data.

The intent is to understand and bring forth the learning and guiding principles, which act as a catalyst for the future researchers and business ventures engaged in BoP context.