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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.

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.

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 dynamics of the physician knowledge system in the Southern California Region of Kaiser Permanente are explored. The framing and analysis use concepts from the knowledge management literature and network theory. The criticality of this issue to the establishment of sustainable healthcare relates to the lynchpin nature of embedding evidence-based knowledge in healthcare practice and the simultaneous challenge of combining this with clinical knowledge that derives from practice.

The case study is compiled from longitudinal interviews with over 40 physicians and other stakeholders and an examination of archival information including published articles generated by the learning system.

The socio-technical approach to building this learning system was critical given the expectations of physicians for autonomy in making clinical decisions with respect to their patients. This robust learning system builds on rich professional and organizational networks, is led by physicians, and builds on and extends the foundation of evidence relating to quality and value. The goals of the physician practice and a robust measurement and feedback system provide focus for the learning system.

Accelerating the incorporation of evidence-based practice and increasing the scope and reach of the learning system entails building physician networks, having a robust system for critically examining and extending evidence, and a clear linkage to valued outcomes.

This detailed examination of the dynamics of knowledge absorption extends understanding of the capacity of medical care systems to absorb evidence-based knowledge.

This chapter examines why managed clinical networks are an appropriate approach to sustainable healthcare, and discusses the conditions for the effectiveness of these multi-stakeholder, clinician-led modes of organizing. It describes the development of a national clinical network to achieve system-wide improvement in the provision of publicly funded cardiac surgery services in New Zealand, and the subsequent evolution of a broader network encompassing the whole cardiac care patient pathway.

The case study of the two cardiac clinical networks focuses on the emergence and evolution of the networks over a four-year period from 2009. Data were collected from interviews with key stakeholders of both networks and from internal and published documentary evidence. Analysis of the case study is informed by network theory and prior studies of managed clinical networks.

Progress made towards the achievement of the goals of the initial cardiac surgery network encouraged a broadening of focus to the entire cardiac care pathway and the establishment of the national cardiac network. An important benefit has been the learning and increase in understanding among the different stakeholders involved. Both clinical networks have demonstrated the value of clinician engagement and leadership in improving the delivery of health services, and serve as a best practice model for the development of further clinical networks for health services that require a national population base.

The case study analysis of the two cardiac clinical networks identifies five mutually reinforcing themes that underpin network effectiveness: network structure, management and governance, and internal and external legitimation. These themes encompass a number of factors suggestive of successful managed clinical networks, and offer insights into the use of such networks in organizing for sustainable healthcare.

Digitization is the process of transforming analog systems into digital ones, and it has become a crucial factor in the sustainable development of emerging economies. Although implementing digitization may be challenging due to limited budgets, missing strategies, pushback from employees, and the existing organizational structure, it can bring multifaceted benefits to the economy, such as improved employment and income, enhanced access to knowledge and education, and reduced costs for companies and countries. Moreover, digitization can significantly impact economic growth, as it can create new job opportunities, foster innovation, and improve infrastructure, among other benefits. The United Nations Sustainable Development Goals (SDGs) provide a global agenda for creating a more sustainable, equitable, and prosperous future by 2030, and digital technologies have become increasingly important in addressing the challenges of achieving these goals, particularly for emerging economies. However, achieving these ambitious goals presents significant challenges, particularly for emerging economies. Hence, this literature review aims to discuss the potential impact of digital technologies on the implementation of the SDGs in emerging economies, supported by scholarly research and opinions. In conclusion, digital technologies have significant potential to contribute to the achievement of the SDGs by promoting economic growth and innovation while also promoting sustainability, creating a more prosperous and equitable world for all.

This conceptual chapter aims to understand the role of artificial intelligence (AI) in value co-creation phenomena in a healthcare service ecosystem, through a literature review and the definition of a conceptual framework. AI, as an operant resource, can stimulate a completely patient-centered, adaptive and resilient healthcare system, and governance models in healthcare based on data-driven decision-making (DDDM), ensuring faster choices, more timely diagnosis and more personalized treatment paths. However, the full implementation of AI in healthcare is inhibited by some frictions, mainly related to the risk that the AI black box may generate an inadequate automatic decision, also due to the quality of data used, often partial and unstructured given the reluctance to share them by patients concerned by privacy threats. The co-design (multi-part and multi-level) of a predictive decision model based on the functional transparency of the AI algorithm would allow for augmented decision as result of an effective human–machine interaction. Healthcare actors could thus make decisions using the information detected by the software (based on clear cause-and-effect correlations and modifiable variables in case of mistakes), integrated with their professional knowledge. This would also help to strengthen the patient’s perception of the decision’s reliability and accuracy and the safety of the tool (factors that can affect his/her trust). AI may be considered as a driver for value co-creation in healthcare, thanks to transparency. It would allow the promotion of collaborative behaviors involving actors by generating new institutions and new resource integration practices among them.

Healthcare innovations for bottom-of-pyramid populations face considerable risks and few economic incentives. Can entrepreneurial innovators provide new solutions for global health? This chapter examines how a technology enterprise built a collaborative network and supportive ecosystem making it possible to steer an innovation for TB patients through discovery, development, and delivery. Ecosystem resources were mobilized and upstream and downstream co-innovation risks were mitigated to commercialize a new diagnostic test. Detailed evidence on this innovation for TB care uses ecosystem analysis to clarify core issues in the context of joint value creation. The case study shows how resources from private and public partners can be leveraged and combined by the focal firm to build joint value and to lower execution, co-innovation, and adoption risks in healthcare ecosystems combating diseases of poverty.