Understanding competition between healthcare providers: Introducing an intermediary inter-organizational perspective

Daan Westra*, Federica Angeli, Martin Carree, Dirk Ruwaard

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Pro-competitive policy reforms have been introduced in several countries, attempting to contain increasing healthcare costs. Yet, research proves ambiguous when it comes to the effect of competition in healthcare, with a number of studies highlighting unintended and unwanted effects. We argue that current empirical work overlooks the role of inter-organizational relations as well as the interplay between policy at macro level, inter-organizational networks at meso level, and outcomes at micro level. To bridge this gap and stimulate a more detailed understanding of the effect of competition in health care, this article introduces a cross-level conceptual framework which emphasizes the intermediary role of cooperative inter-organizational relations at meso level. We discuss how patient transfers, specialist affiliations, and interlocking directorates constitute three forms of inter-organizational relations in health care which can be used within this framework. The paper concludes by deriving several propositions from the framework which can guide future research.

Original languageEnglish
Pages (from-to)149-157
Number of pages9
JournalHealth Policy
Issue number2
Publication statusPublished - 1 Feb 2017


  • Health outcomes
  • Inter-organizational cooperation
  • Inter-organizational networks
  • Managed competition
  • Market structure
  • Pro-competitive reform

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