Innovation in health care has aroused interest in many different fields. The role of innovation presented in this paper is dual 1) Innovation is a tool for necessary changes in the health care systems to adapt to demographical and epidemiological conditions. 2) Innovation is the way to develop new treatments and cure illness. Public financed health care is an activity in the innovation system on local as well as national and international level. It is also an arena for entrepreneurship where entrepreneurs and academic researchers in medical technology, medicine etc. share the workload to transfer knowledge into clinical practice and routine care in the health care facilities. This is an important and demanding task, as health care organizations are typically considered resistant to innovation. All activities health care related or not are dependent on policy issues, hence innovation policy must be designed to facilitate and accelerate innovation processes not only in firms and academia but also inside public organizations.
Innovation is a hot topic, and the term is circulated in several contexts in society. In the political debate, on a national as well as an international level, innovation is considered a condition for welfare and growth (Zahra et al, 1994; in Baregheh, 2009). Historically, Swedish industry, both medical technology and pharmaceutical industries, has been successful in this regard. Fostering products such as Losec, Xylocain (drugs), the implantable pacemaker and the Lexell gamma knife, Sweden, as an innovative nation, is considered globally to be high standing. (Action Medtech report, 2007) The development of medical technology as well as pharmaceuticals and health care services is dependent upon the possibility to perform clinical trials and to test concepts together with patients and health care professionals. Highly advanced technologies available in health care today save lives, and as long as mankind is at risk of incurable diseases innovation for development of functional diagnostics and therapies will be required. In order to meet the challenges we face, with demographical changes and high pressure on the health care system, there is a need for technology, which facilitates the organization and the activities of health care in the future. (Ilinca et al, 2012; Thakur et al, 2012) There is also an interest for 'frugal innovation' with more cost-efficient products. This is expected to open up for new markets in developing countries and to decrease the costs for the industrialized countries.
In Sweden, the amount of clinical trials is decreasing (Pettersson, 2013) and big companies such as St Jude Medical and AstraZeneca move their R&D facilities abroad, as of June 18, 2014, the last 200 researchers at St. Jude medical have been given notice and all R&D activities are to be moved from Uppsala. The relationship between industry and health care providers are today regulated due to ethical concerns, procurement regulations and business reasons (LIF, Swedish labtech, Swedish medtech, SKL, 2013).
Since health care is a civic function, predominantly financed by the public, the assignments on hospitals and other health care facilities are politically governed. The space for clinicians to participate in research activities and external collaborations beside the daily workload taking care of patients (and administration) has been diminishing. Subsequently, the space for individual clinicians to take part in innovation processes at work is limited. Nonetheless, worth mentioning is that university hospitals perform research and there are still positions combining the roles as professor at the medical faculty and chief physician in the hospital.
The ability and willingness to adopt innovations is dependent on a mixture of factors and these phenomena can be analyzed on individual as well as organizational level (Rogers, 2003; Greenhalgh et al 2004). The hierarchical organization between and among the professional categories working in health care is one aspect, both considering the capacity to adopt innovations and the conditions for the individual to be innovative. Regarding innovation in general, it is estimated that one third is based on research and the other two thirds originate from other sources (M??ller H, 2014).
In order to facilitate innovation in Swedish health care, hospital management and county councils organize innovation departments e.g. 'Innovationsplatsen at Karolinska University hospital' or 'SLL innovation', where the first coordinates collaboration and innovation with companies and the latter helps health care professionals innovate themselves, i.e. clinicians who come up with ideas that could be developed into products or services.
As described above, health care has been an arena for innovation, through research findings and high tech products such as drugs, pacemakers and radiation therapy. Health care is also mentioned as a context 'where innovation happens' in the Oxford Handbook of Innovation (Fagerberg et al, 2006). This is somewhat puzzling since the organization providing health care can be regarded quite resistant to innovation. (Nilsen et al, 2010). In addition, the entrepreneurial mindset is not the most commonly mentioned trait among health care professionals.
Aim of the study
The objective of this study is to elaborate on the discussion of the role of innovation in health care based on theoretical underpinnings found in the course literature on innovation and entrepreneurship. An interdisciplinary perspective on innovation presented by Baregheh et al. (2009) is reflected on, as a compliment to the original Schumpeterian definition, since the 'production' in health care constitutes of services. To frame the discussion, the scope of this paper will focus on the following questions: What is the role of innovation in healthcare? And what is the role of the healthcare system in the national innovation system? Is it reasonable to expect health care to contribute to national growth?
The remainder of the paper is structured as follows; the first section summarizes the concept of innovation and entrepreneurship from the course literature. The theoretical part then moves on to innovation systems and the aspects of innovation and growth highlighted by Edquist and colleges. Internationalization and globalization of innovation will be shortly mentioned in relation to 'frugal innovation' i.e. medical technology devices that are 'ultra-low cost, durable, easy to use, draw sparingly on raw materials and minimize environmental impact, they are often well suited to any health sector under growing pressure to achieve better outcomes at significantly lower costs.' (Dandonoli, 2013 p.2). From Edquist's contributions on innovation systems I will touch on the role of growth, which pushes the discussion to the works of Delmar (2011) on entrepreneurship and growth. Here, knowledge spillovers from clinical research fostering entrepreneurs are mentioned. The last topic for discussion is the knowledge translation from academia to clinicians might take place thanks to the system with double roles for professors in academia who also have part-time engagements as clinicians in the hospitals. In the end, the discussion is summarized and conclusions are drawn.
This part of the paper will present and utilize commonly used concepts and definitions in entrepreneurship and innovation research in order to analyze and discuss the role of health care in the innovation system.
Already the ancient Greeks have referred to the phenomenon of entrepreneurship. Although entrepreneurial activities have taken place ever since, the research field is quite young. Some of the great economists that have had strong influence on the research field and the approach to entrepreneurship are Schumpeter, Kirzner, Knight and Gartner. (Davidsson 2004; Landstr??m 2010; Landstr??m 2012)
According to the first, Schumpeter (1912), the entrepreneur creates imperfections in the market by introducing new arrangements of existing resources, resulting in innovation. Kirzner (1973), in contrast, presents an entrepreneur aiming to remove imbalances by means of entrepreneurial alertness. From Kirzner's perspective there is a clear distinction between innovation and entrepreneurship, while in the Schumpeterian view, they two are intertwined. Hence, Schumpeter's entrepreneur forms something new, but not Kirzner's, at least not primarily; The perspectives are complementary as the first 'generates uncertainty at the market' and the second 'recognizes and act on it'. In behavior science, entrepreneurship has been explored with a strong focus on the entrepreneur as an individual and definitions related to personal traits. Already Cantillon (1755) described the entrepreneur as a 'rational decision maker who assumed risk and provided management for the firm' (in Landstr??m, p. ). This connects well to Knights reasoning on risk, uncertainty and true uncertainty as prerequisites for entrepreneurship. (Landstr??m 2010, Landstr??m 2012)
The individual-focused approach was criticized by William Gartner who contributed to change the way of thinking in entrepreneurship research in his book 'Who is the entrepreneur is the wrong question' (1988). Gartners addition to the discussion is his argumentation on entrepreneurship and the development process of a new organization. Venkataraman and Shane (1997, 2002) 'focus on the emergence of opportunities, before/ ahead of the emergence of organizations' (in Landstr??m ). From their vantage point, entrepreneurship research should be concerned with why, when and how 1) opportunities for creation of services/goods occur, 2) some people manage to discover and exploit these opportunities, and 3) diverse approaches are applied to exploit and take advantage of opportunities. (Landstr??m, 2010)
The concept of innovation was first introduced by Schumpeter (1912, 1934), presented as a driving force for economic development. The term is defined as 'new combinations of existing resources' (Fagerberg et al., 2006, p.6). Examples of innovations are new products, new methods of production, new sources of supply, exploitation of new markets and new ways to organize businesses. Schumpeter worked on 'the role of innovation in economic and social change'. He categorized innovations as incremental (marginal), radical (introduction of new types of technology/organization etc.) or technological revolutions (i.e. clusters of innovations that have higher impact when put together than they would have separately). Schumpeter emphasizes the tendency of innovations clustering in certain areas or businesses. (Fagerberg et al., 2006; Fagerberg et al., 2012)
The field of innovation studies emerged as a research field in the 1960s. The 'black box' (see Fig 1) containing the innovation process has aroused great interest in social science and a more cross-disciplinary approach. While the distribution of resources for innovation and the economic effects of innovation have been of research interest among economists. Traditionally, the main focus among economists has been on new products and production methods. The social and economic impact of product and process innovation can differ. Introduction of new products on the market may have implications in terms of income and employment while the consequences of process innovation are more uncertain, since process innovation aims to optimize and save resources. Organizational innovation may include the rearrangement of positions, actors and individuals and can ultimately result in restructuring and reorganization of industries, which in this paper is considered to include health care organizations.
Fig. 1 From resources spent on R&D to the economic effects of innovation
To distinguish between invention and innovation, invention is regarded as 'the first occurrence of an idea' and innovation is the first attempt to put it into practice. There is usually a time delay between these intertwined phenomena reflecting the necessities to work through the ideas and put them into practice, i.e. implementing them. The capacity, of an individual or an organization, to turn invention into innovation is a combination of factors, such as different types of knowledge, skills, resources and capabilities. The roles of the inventor and the innovator may differ. The innovator, whom Schumpeter called the entrepreneur, is the individual or organization responsible for combining the requisite factors. From the Schumpeterian perspective, innovation and entrepreneurship are very much intertwined. (Fagerberg et al., 2006; Landstr??m 2010)
According to Kline and Rosenberg (1986) invention and innovation is a continuous process; high impact innovations undertake far-reaching modifications during their lifespan. (Fagerberg et al., 2006) A limiting factor for the development of the field of innovation studies is the occurrence of disciplinary voids between different research fields and traditions considering definitions of innovation (Baregheh, 2009; Fagerberg 2010). Baregheh and colleges (2009) suggest an interdisciplinary perspective on organizational innovation based on a literature review and content analysis:
'Innovation is the multi-stage process whereby organizations transform ideas into new/improved products, service or processes, in order to advance, compete and differentiate themselves successfully in their marketplace'
(Baregheh et al., 2009, p. 1334)
Although Baregheh and Fagerberg focus mainly on innovation in business organizations, their perspectives can be applicable for innovation in health care since the production in health care constitutes of services. However, the 'marketplace', i.e. the context where the 'inventions' are to be implemented and thereby converted to innovations, is regarded a bit different. Baregheh's definition emphasizes innovation being a process.
Inertia to innovation is mention already by Schumpeter, and is further explored in the literature on diffusion of innovations mainly by Everett Rogers (Fagerberg et al, 2006; Fagerberg et al, 2010). Implementation science is an emerging subfield for the study of how innovation is implemented in health care. (Nilsen et al., 2010)
The System of Innovation (SI) approach
The system of innovation approach (SI) is a framework to handle the determinants of the innovation process, using the Schumpeterian definition of innovation. Focus is on the components of the innovation system rather than the consequences of innovation. SI, presented by Lundvall (1992, in Edquist 2011) can be considered at different levels e.g. regional, national or international where an innovation system consists of organizations and institutions. The innovating organizations are the actors who perform innovation. The institutions are the rules of the game, i.e. product safety regulations, tax laws etc. The objectives of SIs are to enable development and diffusion of innovations, that is, to make innovation happen. A common definition of an SI is a framework containing 'all important economic, social, political, organizational, institutional and other factors that influence the development, diffusion and use of innovations' (Edquist, 2011, p.4). Since it is not yet recognized which factors that are not of importance for innovation processes, it is hard to exclude any of them.
Systems of innovation can be studied based on the activities going on (Edquist et al., 2006). Those activities in the innovation system determine development, diffusion and deployment of innovations. E.g. R&D activities should provide knowledge of economic relevance, which might be the basis for innovation. Through financing, knowledge can later on be transferred into innovation and thereby commercialized. (Edquist, 2011)
'Non-firm public organizations do not normally influence the innovation process directly but influence (change, reinforce, improve) the context in which the innovating firms operate.' (Edquist, 2011 p. 3)
The context wherein innovating organizations, most often firms, perform their work is made up of all the determinants influencing the innovation process. The context is therefore dependent on innovation policy, which is defined as 'actions by public organizations that have influence on innovation processes' (Edquist, 2011, p. 4). However, the policy tool must be handled with care, bad policy is worse than no policy. The selection of policy instruments must be made to address the problems of the innovation system, the types of instruments can roughly be categorized as regulatory instruments, economic/financial instruments and 'soft instruments' i.e. voluntary agreements or code of conducts. (Borr??s et al., 2013) Today, firms meet a changing market with a great level of uncertainty. Consequently, public action must focus on the adaptability of the innovation systems, whether local, regional or national, to support firms to adapt to and efficiently exploit new opportunities.
Edquist (2005, 2011) presents ten key activities in systems of innovation divided into four main areas: 1) provision of knowledge inputs to the innovation process, 2) demand-side activities, 3) provision of constituents for SIs and 4) support services for innovating firms. The purpose might be formulated as different intensities for different categories of innovation to maintain balance between different directions of the innovation process. Those categories can be: diffusion or absorption of 'new to the firm' or 'new to the hospital' innovations vs. development of innovations (that are actually 'new to the world'), radical or incremental innovations, low-tech products or high-tech products, product innovations or process innovations, innovations related to specific sectors of production, innovations related to certain vs. general objectives of innovation policy: economic, social, environmental, military, etc.
Performance of SI and Innovation policy
Innovation policy is preferably, following Edquists analysis presented above formulated in two steps, based on measuring innovation and measuring consequences. The consequences of innovation are significant once the objectives are formulated and achieved. However, certain kinds of innovation may have impact on wider phenomena that are under influence of other factors than those generally measured by policy. Therefore, the function of the innovation system should not be measured as economic growth. The consequences of innovation (note that these differ from the determinants of innovation) are commonly discussed in terms of environmental sustainability, growth or military power. However there is no guarantee that innovation is always good and that more innovation is better. Thus, innovation policy should be designed based on measurements of innovation intensity, and different innovation policies should be evaluated by comparing different SIs. This in order to boost and emphasize policies that actually works for accelerated innovation. (Edquist 2011, Borr??s et al., 2013)
As earlier discussed by Edquist and colleagues, most national policies are not based on relative performance and measuring unmeasurable improvements is a hard task. Policies must solve the problems behind low performance of an innovation system, i.e. low innovation intensity. Therefore, innovation policy ought to provide a division of labor between public organizations and firms to ensure optimal outcome in terms of innovation capacity. Activities for provision of knowledge inputs to the innovation process, demand-side activities, provision of constituents for SIs, support services for innovating firms, need to be performed by different actors. E.g. academia provides fresh knowledge, the demand side (in this paper represented by the health care system, clinicians and patients) defines their challenges, technology transfer offices are available to capture potential innovations and support the process, etc. One example of the usage of policy instruments is the implementation of innovation friendly procurement and public procurement of innovation in Swedish county councils. (Edquist 2011, Borr??s et al 2013)
Innovation in health care ' health care innovation
In the literature on health care innovation, it is agreed that due to the epidemic of chronic diseases and multi-morbidity today's European healthcare systems are unsustainable, innovation is predicted to be crucial for their future sustainability. How these challenges facing healthcare organizations can be met, need to be high prioritized among health care managers and practitioners. A key competence to take up the challenge is the ability to learn and the survival of the own organization. However, that are not the only driving forces for innovation in health care and inefficiency still exists, albeit there have been significant improvements. (Ilinca, 2012; Thakur, 2012) Medical research and development of health technologies aims to improve health overall in the human population and to reduce the burden of illness in the society, so, who are the actors driving or hindering innovation? The laggards, the champions and the gate-keepers? There are cases where rapid technological change can lead to undesirable outcomes (Thakur et al., 2012) and in the era of evidence-based care; There is a paradox situation where evidence must be shown before implementation, but testing is needed before a 'new to the world' solution get a chance to show significant clinical effects, hence, clinical evidence (Nilsen et al., 2010). Health innovation 'consists of complex bundles of new medical technologies and clinical services emerging from a highly distributed competence base' (Consoli et al., 2009, p. 297). Health care professionals in managerial roles can facilitate implementation of innovations and avoid friction between management/policy and professionals; nurses, doctors, paramedics etc. especially in those cases when it is about 'not invented here' innovation. Strong professional groups' inertia and propensity to hinder dissemination of knowledge coming from externally oriented sources is a known phenomenon. Hence, knowledge, technology and methods from external sources, such as other professional groups outside the sphere of medicine, are unlikely to disseminate across these barriers. On the other hand a new trend, documented in the US, is to involve the health care business to take a more active part in educating people about how health care works. (Thakur et al, 2012)
The present paper discusses the following issues based on the innovation system approach: What is the role of innovation in health care? And what is the role of the health care system in the national innovation system? Is it reasonable to expect health care to contribute to national growth?
The role of innovation in health care
The demand for innovation in health care is dual; First it is necessary for a sustainable society to be able to maintain the health care system despite demographic changes and conditions. Second there is a claim for knowledge and new treatments. Hence, the market for health care innovation is global. Recently, the interest in frugal innovation for health care applications has increased, which indicates interest from industry to work on low-cost solutions to exploit new markets in the developing countries, but also to provide cheap products for the western countries. As Castelli (2013) discuss, internationalization of innovation has earlier been an issue of moving R&D departments between neighboring countries, mainly in the triad of Japan, Europe and the US. There have been international processes leading to geographical spread of economic activity. (Castelli et al., 2013) Now, globalization of innovation challenge and reshape the innovation system. What happens when we are not talking about advanced countries with advanced technological capabilities? (Lundvall et al., 2009) What are the most important functions of the innovation system? Companies that open an R&D department in a certain country signal that they are willing to invest, but also that they want to influence standards in that country in an early stage (Chaminade, 2014). In areas where the need for frugal innovation is greatest, the structures for innovation management i.e. the innovation system is hardly developed. However, there can be global innovation networks (GINs) available. Such a network is defined by Barnard and Chaminade as a 'globally organized web of complex interactions between firms and non-firm organizations engaged in knowledge production related to and resulting in innovation' (Barnard et al., 2011, in Chaminade et al., 2014, p.3 ).
Turning back to the political debate on health care in the developed countries, innovation is frequently mentioned as a prerequisite for the ability to provide high quality care in the future. The issue is to distribute the responsibility for performing the activities in the innovation system, on the local as well as on the national level. Which tasks can be performed by the operational health care organization, what might be done by public authorities and what should private industry do? This is in accordance with Edquist and colleagues' reasoning on the aim and role of innovation policy. Edquist states that 'Non-firm public organizations do not normally influence the innovation process directly but influence (change, reinforce, improve) the context in which the innovating firms operate.' (Edquist, 2011, p.3) From a health care system perspective, the 'non-firm public organizations' are the county councils and policymakers, and the health care professionals would represent the 'innovating firms'. Although, in most countries there is also an intermediate level between the county council and the individual clinician, namely the hospital or care center etc. whom the clinicians work for. However, public health care is not exactly a firm, with the commitment and responsibility to deliver care according to need, not what.
The consequences of product- process- or organizational innovation in health care may be the capacity to treat more patients due to a more efficient organization or therapies, to provide new treatments or to treat conditions that we have not been able to treat before. In the specific case of infectious medicine and antibiotics we are forced to innovate under the threat to evolve backwards standing without cures for bacterial infections. If more patients are cured, they will potentially be chronics with an increasing need of care step by step. The benefit of innovation might than be esteemed in quality adjusted life years (QALY), but not easily in monetary terms. Economic growth as an expected consequence of innovation in health care is therefore a delicate issue and an inappropriate measure. Innovation can create value in different dimensions, but it is not to be taken for granted that should be economic growth.
The role of healthcare in the innovation system
In Sweden, health care is provided on assignment of the state, according to policy and regulations. The commitment of the health care organizations, public or private owned working on contract with the county council is to deliver care, efficiently.
State-owned (health care) organizations are obliged to make their purchases due to the law of public procurement. Here, an important issue is how the procurements are managed, whether the price is the only key factor, how quality requests can be fulfilled and evaluated and how innovation friendly procurements can be used to obtain the most suitable products and services. One example that is considered a policy problem today is the reimbursement models that differ from one county council to another, in Sweden. Hence the economic incitements for health care organizations and individual health care professionals to put their ideas to reality, to develop their own business and their working environment, differ more than necessary. This might have influence on innovation capacity, intrapreneurship and entrepreneurship among health care professionals. The main interest of people who choose to follow education and training in health care is often to work with people. They are usually not trained to be entrepreneurs and innovators in a context where the golden rule is, to quote Hippocrates, 'To cure sometimes, to relieve often, to comfort always' (Stolt, 2000).
However, the existence of private care givers indicates that health care professionals also manage their own firms i.e. they are entrepreneurs offering services at the market. The market for health care services is strictly regulated and firms (clinicians) on contract with a county council follow the same reimbursement models as the public counterparts. There are extensive discussions at the policy level as well as ethical discussions on whether private health care services should be reimbursed or not.
This is in-line with the metaphor (described on page 8) regarding hospitals and county councils as the policy level and the physicians as the innovating firms. All entrepreneurs in health care do not necessarily work on innovations but they are all part of the puzzle, and to 'harvest' growth from healthcare is multi-dimensioned. Besides private health care facilities, there are also employment agencies specialized in health care professionals. At last, there is a range of companies selling products and services to all levels of the health care system, some with their own R&D departments outside Sweden, as Castelli (2013) and colleges have presented.
There are examples of small and medium sized enterprises (SME) commercializing product and service innovation based on knowledge from research discoveries with a positive turnover, hiring people and selling their product. There are also a few dealing with product development based on clinical needs e.g. Side Marker CT/MRI a system to mark left and right side to avoid side mix-ups (Innovator nurse Ylva Ryngebo, Medical Innovation Design AB). Hence, growth is a possible consequence of innovation and the desirable effect of entrepreneurship. However, the critical step is the entrepreneurial part.
Knowledge spillovers from medical/clinical research can possibly favor entrepreneurship and give rise to the development of small businesses, typically working on solutions based on advanced research, i.e. there is an ongoing transition of knowledge from university hospitals/academia to industry. When society invests in human capital, education, research etc. there are 'spills over' of knowledge that can be used by other actors, than in this case healthcare professionals and researchers. Such as economic actors transforming new knowledge into economic growth by means of entrepreneurship, creating new firms or using the competitive advantage of adopting certain kinds of knowledge. (Delmar et al, 2011) Moreover, during the last years it has been emphasized that there are several needs and ideas originating from non-researchers, from health care professionals such as nurses, physiotherapists etc. with clinical experience, as well as from the patients and their next-of-kin.
The last matter for discussion is the knowledge translation from academia to clinicians, which might take place thanks to the system with double roles for professors in academia who also have part-time engagements as clinicians in the hospitals. The act of performing evidence-based care i.e. to cure and nurse patients is one form of applying knowledge. However, a key issue in providing evidence-based medicine is the diffusion of academic knowledge from research to routine care by keeping clinicians working outside research facilities updated. The interactions between the academic community and wider society probably differ between different fields and the dual role of being researcher and clinician in university hospitals is one solution. One further dimension of diffusion of academic knowledge is counseling of patients e.g. the Swedish phone counseling 'Health care hotline' or the general health recommendations presented in public information channels, which must be based on clinical evidence.
The communication of knowledge might be reflected on in the light of how academics handle commercialization and public dissemination of their results. Wigren-Kristoferson (2011) and colleges published a study on 'the incentives for academics to work with industry and engage with the public, especially those funded to work on fundamental/basic excellent research' (Wigren-Kristoferson et al, 2011, p. 488). They found the driving forces for researchers to engage in activities for public dissemination and commercialization of results to be 1) the option to further their own research technologically and financially 2) from a 'sense of duty' and 3) they liked to do it. They also found an interrelationship between research excellence and effective diffusion where the first was a prerequisite for the latter. (Wigren-Kristoferson et al, 2011) In the context of research concerning medicine and health care, it might be expected that the diffusion of knowledge and the implementation of new methods and technologies in routine care is high priority and an imperative for clinicians.
Academic researchers, independent of field, who participate in university academia networks, work in university hospitals or take active part in 'introduction to the market processes' e.g. as consultants in spin-off companies working on research based innovations, all have high impact on commercialization of publicly funded scientific research (Jacobsson et al 2013).
This brings us back to the dilemma whether it is reasonable to expect health care to contribute to national growth? There are, following arguments presented in this paper, health care professionals able to combine their clinical assignment with being innovators and entrepreneurs, and innovation seems critical for sustainable health care systems. But, the main task for health care professionals must remain to deliver care according to need, not what.
However, health care in general can be regarded an investment, since maintaining health in the population contributes to society in overall. If innovation and business development within the system are performed in synergy, that would be particularly favorable. If we wish to have access to the best available technologies and services in health care, the health care organizations and the individual clinicians working there must have resources, motivation and capabilities to develop, evaluate and adopt innovations. Health care professionals must be prepared and willing to test new solutions and to take active part in the innovation process, for this purpose there must be some organizational slack to provide room for creativity and to give all health care professionals possibilities to take active part in innovation processes. Maybe, such a change in attitude can help to reverse the trend and increase the amount of clinical trials and also facilitate how new services and technologies are implemented and how health care is organized.
Innovation in health care is a complex phenomenon. The (expected) 'innovating firm' is represented by strong professional groups trained to be skeptical, working in a public high risk organization with personal responsibilities for the treatment of their patients and with politically appointed decision makers at several levels. Healthcare organizations are also under influence of regulations on procurements governing how products and services are available to buy and use in the core business. They are also obliged to follow strict regulations on how health care must be performed. Despite these conditions, there are both innovators and entrepreneurs creating their own businesses among health care professionals. Innovation intensity is considered a prerequisite for a sustainable health care. And health care is an activity in the innovation system. Growth is not a measure of innovation, but it may be a consequence of innovation in health care.
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