Forgone care as a systemic failure: health literacy and the breakdown of co-creation in public service ecosystems

In the face of mounting demographic pressures and structural asymmetries, the sustainability of healthcare systems increasingly depends on their ability to function as service ecosystems, relatio-nally structured environments where public value is co-created through the integration of diverse resources. This paper investiga-tes the interplay between health literacy and the phenomenon of forgone care within the Italian National Health Service (SSN), conceptualizing both as expressions of ecosystem alignment or failure. Drawing on a cross-sectional survey of 502 Italian citizens, we ana-lyse how limited health literacy - defined as the capacity to access, understand, and apply health-related information - constrains individuals’ ability to engage with health services and participate in value co-creation. The results show a significant association between lower health literacy and higher probability of reporting forgone ca-re, with implications for equity, system resilience, and the reproduction of social vulnerabilities. Interpreted through the lens of Service-Dominant Logic, these findings highlight how individual capabilities and structural enablers must co-evolve to sustain inclusive participation and optimize societal well-being. We argue that health literacy should be reframed as a systemic resource and that collective action is needed to reduce access barriers and enhance navigational support, especially for disadvantaged groups. The study contributes to the debate on collaborative networks by emphasizing the interdependence between personal empowerment, institutional design, and the sustainable governance of public service ecosystems.