Institutional Voids as a Playing Field: Financial Growth Strategies of Commercial Care Providers. A Patchwork Study in the Financialization of Health Care in the Netherlands.

Commercial healthcare providers and private equity have become increasingly prominent across Europe, from long-term care to specialised outpatient clinic-chains. In the Netherlands, decades of welfare-state reform and decentralization have produced a mixed economy in which commercial providers operate alongside non-profits. The growing importance of commercial actors unfolds within a regulatory context that aims to both facilitate competition (to enhance efficiency and curb costs) and defend the public good. Commercial expansion does not occur despite regulation but exploits and stabilizes it. This is especially visible where healthcare, real estate, and finance intersect as the care–property–finance chain is rarely governed as a whole. Commercial actors integrate healthcare provision with real estate and finance by pursuing financial growth strategies (e.g. buy-and-build, sale-and-leaseback), bundling these domains into one business case. Our RQ: How do commercial healthcare providers use financial growth strategies to work through and reshape institutional seams between healthcare regulation, real estate arrangements, and finance, and how does the state move with these strategies? A useful lens for analyzing such dynamics is the notion of institutional voids. Hajer (2003) defines these as situations where accepted rules and norms that guide political conduct are absent or no longer taken for granted, creating a mismatch between formal arrangements and actual policymaking and encouraging action across established orders. From a market-oriented view, Khanna and Palepu (2004) see institutional voids as weaknesses of market-supporting institutions (such as regulatory frameworks, intermediaries and information systems) that hinder transactions and create “gaps” in the institutional infrastructure. Methodologically, studying commercial actors in public sectors is difficult: limited transparency and access are part of their market strategy. To gain insight, we employed a patchwork ethnography (Günel & Watanabe, 2024) to “stitch” together fragments from public materials (annual reports, press releases, financial media), regulatory and parliamentary documents, marketing materials, ownership and transaction data (Orbis, PitchBook), and 15 interviews with managers, investors, merges and acquisitions (M&A) consultants and supervisory experts. We argue in the analyses that commercial providers do not merely exploit institutional voids, but actively create and stabilize them by deploying financial growth strategies that fall outside existing regulatory categories and oversight capacities, as these actors operate at the intersections of care, real estate, and finance. Our results show three linked corporate strategies. F irst, multinational companies create recognizable local brands and hybrid care propositions frontstage that align with public expectations and regulatory categories. Second, they maintain complex corporate structures backstage, including PropCo/OpCo and sale-and-leaseback deals, that translate care locations into standardized assets. Third, these arrangements enable value appreciation, refinancing, and resale, making M&A central to market positioning. Crucially, and adding to institutional void theory, the state is not simply an external counterforce: reforms and divisions of responsibility co-produce voids; ex-post governance and integrity requirements consolidate emerging configurations; and s ofter steering instruments can contribute to jointly shaping and stabilising new healthcare markets. These findings point to the growing importance of research on the market politics of commercializing healthcare systems, as corporate growth strategies and governance arrangements mutually shape and reinforce each other.