This paper aims to propose the contribution of adopting a systemic perspective to researching sustainability in terms of inclusivity and holistic view, going beyond the limitations of a reductionist approach. Among the different systemic approaches, the methodological lens proposed herein is the one of the Viable Systems Approach, according to which sustainability, which can be seen as a process that is dynamic and changing over time, is linked to the notion of systemic viability and connected to some of the most relevant key concepts of Viable Systems Approach.\ud Through the proposition of the conceptual model of ‘The Viable Systems Cycle’, the authors intend to propose a different approach to the analysis and interpretation of sustainability that concerns the relationship among efficiency, effectiveness and sustainability itself and the way they orient and influence sustainable business behaviors

he main purpose of this paper is to highlight the new opportunities that the Viable Systems Approach (VSA) can provide for observing complex service systems and explaining social phenomena through general schemes of interpretation. At the same time, it explores methodological links with the Service Science (SS) approach in order to propose (VSA)'s contribution to moulding a unified vision of complex objects of analysis, and to evidence the many converging elements that emerge from the two perspectives as well as the benefits that derive from different interpretation schemes.In particular, in our paper we analyze healthcare service complexity in a relational perspective, using a VSA-SS conceptual framework to interpret the emergent systems instability in the Italian Health Service. The application of principles and concepts proper to the (VSA) and the SS approaches to articulated service structures, such as healthcare, identifies critical features and interesting new "therapeutic" prospects for healthcare service systems in order to guarantee their viability.The paper proposes an innovative methodological basis for evaluating the level of appropriateness of the healthcare service and, at the same time, evidences the need for achieving a balanced triple target of efficiency, effectiveness and sustainability (EES) in healthcare service systems governance. As a result, a new area of cross fertilization for collaborative research emerges.

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Purpose 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. Design/methodology/approach 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. Findings 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. Practical implications 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. Originality/value 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.

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