Facilitators and barriers to sustainable regional health networks: governance lessons from a multi-case study in Germany

Demographic change, fiscal constraints, and persistent health workforce shortages are intensifying pressures on healthcare systems and exposing the limits of fragmented, sector-based governance. In response, policymakers increasingly promote regional healthcare networks as instruments of network governance to advance integrated care and care coordination, yet their development and sustainability remain highly uneven. This study examines which factors facilitate the development and long-term sustainability of regional healthcare networks, and which obstacles hinder their institutionalization within existing health system conditions. Drawing on a qualitative multi-case study of seven regional healthcare networks in Germany, the analysis integrates semi-structured expert interviews with network governance actors, document analysis, and systematic cross-case comparison. The results identify recurring enabling conditions, including sustained stakeholder commitment and leadership, a tangible perceived added value for participating actors, institutional support and external partnerships, and coordination capacity anchored in shared care pathways and enabling organizational and digital infrastructure. At the same time, network development is constrained by fragmented financing and legal frameworks, acceptance and collaboration barriers, and selective contracting arrangements that restrict coverage to specific insured groups. Interpreted through a phase-sensitive governance lens, the findings demonstrate that integrated care is not merely an implementation challenge but a political one: the sustainability of regional healthcare networks depends on institutional reforms that loosen financing silos, enable task redistribution across professions and sectors, and strengthen the legitimacy and inclusiveness of network-based governance under resource constraints.