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Service organizations operate in an increasingly complex and uncertain context that makes decision-making challenging. Despite well-recognized changes in the operational context of government as service organization, service literature has given surprisingly limited attention to what these changes imply for organizational decision-making. This study aims to face with the lack of fit of decision-making theorizing with the reality, within which most service practitioners operate, in order to foster the relevance of decision-making in service research and properly approach the false assumptions and misguided instructions for action.

To rectify the situation, the purpose of this paper is to advance a more holistic understanding of decision-making in government as service organization. The authors do so by reviewing the sparse, though insightful, prior literature on decision-making in service research and identifying four foundational assumptions of decision-making in the service context, that radically differ from the traditional assumptions of decision-making within the wider management literature.

The authors contribute to service research by further advancing the emerging dynamic understanding of decision-making by developing eight systems thinking-informed research propositions and a connected research agenda. In doing so, the paper offers the essential ground work that can revitalize the field of service management and equip it for facing the challenges that government as service organization is encountering in the 21st century.

The formulated eight research propositions demonstrate that decision-making in a government as service organization occurs within complex adaptive systems composed of multiple subsystems and is characterized by a high degree of unpredictability. It is a process influenced by multiple actors part of the system and subsystems, through multiple feedback loops, where the implications of prior decisions inform the future decisions.

Research has examined how new ventures strengthen local economic outcomes; however, limited research examines health-oriented ventures and their impact on social outcomes, including health outcomes. Increased VC investment in healthcare service start-ups signals more activity toward this end, and the need for further academic inquiry. We examine the relationship between these start-ups and county-level health outcomes, health factors, and hospital utilization.

Data on start-ups funded via institutional venture capital from PitchBook were merged with US county-level outcomes from the County Health Rankings and Area Health Resources Files for 2010 to 2019. We investigated how the number of VC-funded healthcare service start-ups, as well as a subset defined as innovative, were associated with county-level health measures. We used panel models with two-way fixed effects and Propensity Score Matched (PSM), controlling for demographics and socioeconomic factors.

Each additional VC-funded healthcare service start-up was related to a significant 0.01 percentage point decrease in diabetes prevalence (p < 0.01), a decrease of 1.54 HIV cases per 100,000 population (p < 0.1), a 0.02 percentage point decrease in obesity rates (p < 0.01), and a 0.03 percentage point decrease in binge drinking (p < 0.01). VC-funded healthcare service start-ups were not related to hospital utilization.

This work expands our understanding of how industry-specific start-ups, in this case healthcare start-ups, relate to positive social outcomes. The results underscore the importance of evidence-based evaluation, the need for expanded outcome measures for VC investment, and the possibilities for integration of healthcare services and entrepreneurship ecosystems.