Capitalizing on healthcare: Institutional voids and financial growth strategies in Europe

• In Event: Environmental Sociology Section Roundtables
  In Refereed Roundtable (60 minute): Table 7: Law, Institutions, and Governance Systems

Abstract

This paper examines how commercial healthcare providers in Europe pursue financial growth by operating in and actively shaping “institutional voids” and “institutional ignorance” in healthcare governance. It asks how buy-and-build expansion, real-estate finance, and legal strategies interact with regulation, and how the state becomes entangled in these financial projects. Although private equity and commercial ownership are increasingly visible in European healthcare, the paper argues that the links between market formation, financial engineering, and regulatory blind spots remain underexplored.
Methodologically, the study uses a qualitative multi-case design and “patchwork ethnography”. Instead of relying on a single, comprehensive access point, the researchers assemble evidence from multiple partial sources. They analyze public corporate and investor materials, regulatory and policy documents, financial data, and social media, and conduct interviews with managers, investors, and regulatory experts. Empirically, the analysis centers on the Netherlands, with close attention to state regulators and for-profit providers.
Findings show that institutional voids are not merely background conditions but resources that providers deliberately mobilize. Firms exploit regulatory ambiguity and institutional ignorance, often through litigation, to contest administrative decisions and generate case law that expands the permissible space for profit in care. In merger control, fragmented mandates and threshold-based triggers create systemic blind spots: many small deals can accumulate into major consolidation without effective scrutiny. Providers also use complex ownership arrangements (including layered “Ltd. Christmas trees”) to obscure control and growth trajectories, deepening opacity. Finally, regulators are often constrained in what information they can request, particularly about broader market movements, ownership chains, and the cumulative effects of acquisitions, which produces structured ignorance.
Overall, the paper shows that financial growth strategies in European healthcare do not simply fit within regulation; they leverage and reshape institutional gaps, reinforcing state-enabled financialization through fragmented oversight and limited knowledge infrastructures.

Authors

• Laura Rita M De Brabandere, Erasmus Universiteit Rotterdam

• jitse jonne schuurmans, University of Amsterdam

• Fenna Nijboer, Erasmus University Rotterdam

• Oemar van der Woerd, Erasmus University Rotterdam

• Roland Bal, Erasmus University Rotterdam

• Iris Wallenburg, Erasmus University Rotterdam