Institutionalizing reflexivity for sustainability: Two cases in health care

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Unsustainability in health care comprises diminishing returns and misalignment between the health care regime and the needs of the population. To deal with complex sustainability problems, niche solutions can be collaboratively designed and implemented through reflexive methods. For second-order sustainability, however, the institutionalization of the reflexive element itself is also needed. This paper aims to provide insight into the possibilities of embedding reflexivity into institutions to support second-order sustainability by reporting on two consecutive participatory research programs that sought to address unsustainability in terms of misalignment and diminishing returns. The first case study reflexively monitored the system’s innovation toward an integrated perinatal care system. Reflection within the project and implementation was supported successfully, but for stronger embedding and institutionalization, greater alignment of the reflexive practices with regime standards was needed. Building on these lessons, the second case study, which was part of the IMI-PARADIGM consortium, collaboratively built a structured tool to monitor and evaluate “the return on engagement” in medicine development. To institutionalize reflexivity, the creation of “reflexive standards” together with regime actors appears to be most promising. Broader and deeper institutionalization of reflexive standards can be attained by building enforcement structures for reflexive standards in the collaborative process as part of the reflexive methodologies for addressing complex sustainability problems.

Original languageEnglish
Article number11712
Pages (from-to)1-19
Number of pages19
Issue number21
Early online date23 Oct 2021
Publication statusPublished - 1 Nov 2021

Bibliographical note

Special Issue: Sustainability Perspectives on Health Care: Exploring the Contours of a Novel Field.

Funding Information:
Funding: The perinatal projects were funded by The Netherlands Organisation for Health Research and Development (ZonMW) grant numbers 154031996 and 209010002. PARADIGM has received funding from the Innovative Medicines Initiative 2 joint undertaking under Grant Agreement 777450.

Publisher Copyright:
© 2021 by the authors. Licensee MDPI, Basel, Switzerland.


  • Institutionalization
  • Interprofessional collaboration
  • Medicines development
  • Patient engagement
  • Perinatal care
  • Reflexivity
  • Second-order sustainability


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