jats:sec <jats:title content-type="abstract-subheading">Purpose</jats:title> jats:pThe purpose of this paper is to investigate how and why some service ecosystems are more resilient and, consequently, more sustainable than others during turbulent times, and how resilience can be cultivated to enable pathways to service ecosystem sustainability.</jats:p> </jats:sec> jats:sec <jats:title content-type="abstract-subheading">Design/methodology/approach</jats:title> jats:pThis work integrates disparate literature from multiple service and sustainability literature streams, iterating through constant comparison with findings from 44 semistructured interviews conducted in the context of primary health care clinic service ecosystems.</jats:p> </jats:sec> jats:sec <jats:title content-type="abstract-subheading">Findings</jats:title> jats:pThe authors offer a novel conceptual framework comprising pillars (shared worldview, individual actor well-being and multiactor interactions), changing practices to cultivate resilience through resilience levers (orchestrators, individual actor effort, actor inclusivity and digitaltech–humanness approach), and pathways to service ecosystem sustainability (volume vs value, volume to value, volume and value). The authors demonstrate that service ecosystems need to change practices, integrating resources differently in response to the turbulent environment, emphasizing the importance of a shared worldview across the ecosystem and assessing different pathways to sustainability.</jats:p> </jats:sec> jats:sec <jats:title content-type="abstract-subheading">Originality/value</jats:title> jats:pThis paper offers new insights into the important intersection of service marketing, sustainability and health care. The authors provide guidance to practitioners aiming to cultivate resilience in service ecosystems to achieve pathways to sustainability in primary health care clinics. Finally, implications for theory are discussed, and directions to guide future service research offered.</jats:p> </jats:sec>