Market strategies used by private hospital providers to consolidate and increase power; a systematic scoping review and evaluative synthesis

Abstract

Background

Hospitals controlled by private firms, like many private sectors, will employ market strategies to safeguard their investments and increase the profitability of the services they provide. These market strategies not only determine their financial success but also influences broader outcomes, including health system performance and population health indicators. Yet, strategies that enhance market influence and profitability may at times diverge from those aimed at improving health outcomes. This raises issues around market power imbalances and concerns that hospitals could prioritise profits over health if forced to choose. This systematic scoping review sought to identify and synthesise scholarly evidence on the market strategies employed by private hospitals to expand and consolidate market power.

Methods

Titles and abstracts of 1,642 English-language articles sourced from seven databases were screened, with 371 articles assessed for eligibility based on whether they identified the use of market strategies within a hospital setting. Data from 133 relevant studies were extracted and analysed thematically using Porter’s ‘Five Forces’ framework.

Results

We identified 22 distinct market strategies used by private hospitals, falling under six interconnected strategic objectives: 1) reduce rivalry among existing competitors; 2) raise barriers to market entry by new competitors; 3) counter the threat of market disruptors and drive patient health service usage towards hospital care provided by the hospital; 4) increase hospital buyer power by exerting leverage over upstream actors; 5) Increase hospital seller power by exerting leverage over downstream organisational actors; and 6) increase hospital seller power by exerting leverage over downstream individual actors. Although international in scope, the United States accounted for over two-thirds of the studies included. This partly reflects the dominance of U.S. scholarship in these areas.

Conclusion

The resulting typological framework offers a structured means of analysing hospital market strategies internationally, within and across jurisdictions. Additionally, it can aid the identification of pertinent public policies, such as those addressing merger control, unfair trading practices, and public procurement. This works to bolster policy-analytic functions that can be influential in rectifying market-power imbalances.

Introduction

Privatisation and commercialisation of healthcare systems globally has had a transformative impact. Scholars have identified that this expansion has reshaped access, costs, and accountability structures [1, 2]. The growing influence of capital markets, private finance, and private sector control has further embedded commercial logics within the delivery of healthcare services. Acquisitions and consolidations have accelerated trends toward the financialisaton of health, greater ownership concentration in healthcare provision and further enabled corporations to build new ways to extract profit from patients and governments [3, 4]. Market failure, displayed typically through higher costs for patients, lower quality of care, and resource inefficiencies, has been identified as a key risk associated with increased market concentration [5, 6]. When the services or products affected constitute a human right, as healthcare is widely recognised to be [7], these failures can be detrimental for patients, their families [8], and the human rights paradigm [9]. Proponents of competition in health generally expect that increased competition between providers will improve quality, patient choice, innovation, efficiency and reduce costs, whilst opponents fear competition will lead to negative outcomes such as reduced quality and access to healthcare, as well as inequities based on patients’ ability to pay rather than medical need [10]. While elements of healthcare privatisation can support innovation [11] and patient access [12, 13], a growing body of work has identified increased privatisation in healthcare services as having a harmful impact, with a trend in recent studies highlighting the problematic consequences of expanding private control [3, 14–17].

Private health providers are playing an increasingly influential role internationally in both the delivery and financing of healthcare services. In low- and middle-income countries there has been a steep rise in the provision of private healthcare [1], with the World Health Organisation (WHO) arguing that the private sector has become essential in the supply of health products and services, including for lower incomes groups [18]. Equally, in high-income countries, the expansion of private ownership models, like private equity, has become a significant feature in the provision of healthcare, raising concerns around quality and the need for increased reporting and regulation [19].

To remain viable, companies and financing entities must navigate a complex landscape marked by economic ambiguity, regulatory pressures and heightened competition. Within this context, how is ‘success’ defined? In private healthcare settings influenced by market logic, success is often measured by financial sustainability and profitability. As (Perry and Bernasek [20], p.4) observe, private sector goals in healthcare management are frequently “driven by a quest for profits” with revenue generation through patient treatment being a key indicator of performance. Yet private healthcare is complex and will not always fit into the confines of a simple market commodity. Unlike other private sectors, success must also be measured by the degree to which care is effective, safe, and people-centred, criteria central to the WHO’s definition of quality care [21]. According to Wieland [22], this includes eliminating health disparities so that the provision of care is just and fair. Governments that incorporate market-oriented healthcare models often uphold a dual policy objective: to incentivise profit generation while also aiming to improve population health outcomes with some degree of efficiency. These goals can coexist with commercial objectives in theory, but when considered independently, they can also lead to conflicting approaches. This tension is powerfully captured by (Freudenberg [23], p.151), who warns:

By giving corporations a powerful voice in setting science and medical policy, the nation sacrificed a rational evidence-based approach for a casino mentality, where the promise of profit decides which medical avenues are pursued and which ignored!

The potential health harms arising from the privatisation and financialisaton of essential goods and services (e.g. healthcare, education, water, and housing) are increasingly recognised in the commercial determinants of health (CDoH) scholarship, which examines the pathways through which businesses and their allies shape health and equity [24, 25]. Yet as Wood et al. [26, 27] notes, limited attention has been paid to the market strategies used by powerful businesses. A small but growing body of work has begun to explore these dynamics in specific sectors such as the food and drink industry [28, 29]. However, analyses of healthcare provision remain largely absent. This represents a critical gap given the concerns raised about the ways for-profit healthcare can generate harms and deepen inequities.

While concerns have long been raised that marketisation and privatisation can distort the quality of public services [30, 31] this study focuses on the issue of market power. In the context of health outcomes and governance, private-sector hospital consolidation has been linked to negative patient experiences and compromised standards of care [32], reduced health services [33], as well as the undermining of universal health objectives [2]. Sector concentration also has the potential for companies to use their increased influence to shape regulation to favour their own interests [34]. These concerns about the risks to healthcare quality and equity posed by market concentration and power are implicitly supported by scholars such as Van de Ven et al. [35] and Henriquez et al. [36], who highlight the conditions under which the private sector can deliver efficient and affordable care – foremost being robust competition regulation.

This review aims to catalogue and analyse the market strategies used by private hospitals to build and consolidate their influence, addressing patient health outcome gaps identified in the academic literature [14, 37, 38]. Our analysis is informed by two, complementary approaches to understanding power inequities and health: first, political economy of health, which argues that ill health and health inequities are not so much the consequence of individual behaviour as the result of structural inequities in the social and economic organisation of society [39, 40]. And second, a commercial determinants of health (CDoH) approach, which argues that greater attention be paid to the role of business actors in shaping health outcomes [24]. Combining these approaches helps us interrogate the strategies through which specific business actors seek to influence the markets in which they operate and how, in turn, this can influence health and equity.

Background

To date, no study has systematically consolidated the international scholarly literature on the market strategies used by private hospitals and their financier partners to increase power and influence. While some reviews have explored the private sector’s role in healthcare systems, highlighting the challenges it presents [41–43], others have examined economic and market dynamics [44] such as hospital pricing [45], market failures of private health services during COVID-19 [46], and offered initial reflections on the impact of healthcare privatisation [47], research into private hospital strategies remains an emerging area. Ghiasi et al. [38] analysed environmental factors and business strategy in the United States (U.S.) urban general acute care hospitals between 2006 and 2016. They explicitly identified key gaps in the literature regarding the application of Porter’s theories to healthcare and underscored the need for international research into hospital strategies.

To address these gaps, this paper draws on key themes from the CDoH literature, particularly the observation that different industries often employ similar strategies to shape markets and their operating environment. Sectors such as tobacco, food, alcohol, gambling, pharmaceuticals, and automobiles have been shown to contribute substantially to non-communicable diseases and broader social harms [48–51]. Increased global corporate control and market fundamentalism has created what Gilmore et al. [24], p.5) describes as a “pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so.” To better understand the private hospital sector, it is therefore useful to compare parallels with other industries.

This paper does so by drawing on the approach developed by Wood et al. [26], which analysed market strategies in the processed food industry. We recognise that healthcare and food are fundamentally different sectors of the economy, with different companies, market dynamics, regulatory forces and pathways through which they impact health. Indeed, Wood makes the argument that the market power possessed by processed food companies is a risk to public health as it increases the accessibility of ultra-processed foods (linked to non-communicable diseases) and that companies can leverage their market power to undermine public health policies they perceive as risks to their business. Market power in healthcare presents different risks. Unlike ultra-processed foods, access to healthcare is essential and a human right. Far from being considered a health-harming industry, hospitals offer services and interventions which aim to improve the health and quality of people’s lives. However, the overuse of medical services can negatively impact public budgets and population health [52]. Market power in healthcare (and private hospitals in particular) raises different risks for health and equity. This can lead to compromised hospital quality, reduced access and affordability, short-term goals prioritised over long-term investment, weakened governance and accountability, and system vulnerabilities where corporate hospitals become ‘to-big-to-fail.’

For-profit vs not-for-profit

This research is focused on the private hospital sector. For this reason, public hospitals (i.e. those defined as being largely owned and managed publicly) are excluded from the analysis, although cases of public sector sub-contracting of hospital operations as well as private divisions of public hospitals may be considered.

We focus on private hospitals which we define as not being owned or managed by governments, including both for-profit and not-for-profit hospitals. For-profit hospitals are those owned and managed by private companies or investors whose goal is typically that of profit maximation and company value. Not-for-profit hospitals are predominantly those owned by charities, religious organisations, or community groups. Typically, not-for-profits provide healthcare services to the community, with a view to sustainability as opposed to profitability.

Critical perspectives on not-for-profit hospitals, particularly in U.S. markets, argue that these institutions are highly profitable in all but name. For example, Shay and White [53] found multiple examples of not-for-profit hospitals paying increasingly higher salaries and bonuses than their for-profit counterparts, whereas Moon and Shugan [54] went as far as asserting strategies implemented by not-for-profits achieved higher yields and profits than for-profit hospitals. Adding to this, literature around New Public Management contends reforms of the 1980s and 1990s have compelled public-sector organisations to operate according to the logic of the free market [55, 56]. In the context of this study, it is theorised that private hospital ownership status (not-for-profit or for-profit) does not materially change the behaviour.

Strategic management

This article is informed by strategic management literature, defining ‘market strategies’ as deliberate collaborative actions undertaken within a market environment to enhance corporate performance [26, 57]. According to Baron [57] and Porter [58], private sector firms are known to use a variety of strategies to safeguard their business models from unfavourable regulation, while simultaneously increasing their market dominance and profitability. Wood’s analysis of market strategies draws on Porter’s ‘Five Competitive Forces’ framework from the strategic management literature. In applying this framework to the hospital sector, we respond to calls from scholars who have argued that Porter’s theories could be productively applied to healthcare [38]. Generally regarded as the father of the modern strategy field, Michael Porter’s ideas are widely cited as a foundational pillar in the field of competitive strategy. According to Porter [59], a sustainable competitive advantage refers to a firm’s ability to maintain above-average performance within its industry or market. In this context, strategy is defined as the distinct set of activities used to influence market position, achieved through the application of different approaches [60]. The effectiveness of a competitive strategy, Porter [61], argued, depends on two factors: how attractive the market is, and how strong the firm’s position is within that market.

As Wood et al. [26] and Barney et al. [62] suggest, firms’ influence on markets can pose a risk to fair competition within a sector, emphasising the need for governments to both monitor these practices and intervene where appropriate. This is especially relevant in healthcare, an industry prone to market failure, where patients are not typical consumers: they cannot access full information on health services, and ill-health makes them particularly vulnerable [63, 64]. Hospitals controlled by private firms, like other private sectors, employ market strategies to safeguard their investments and increase profitability. For example, a firm might take a cost leadership approach (e.g. offer the lowest prices) to gain market share and achieve economies of scale with the aim of gaining a competitive market advantage as the lowest-cost producer [58]. Market strategies not only determine financial success but can also influence broader outcomes, including health system performance and health indicators. For instance, vertical integration, such as when a hospital acquires a general practice, may strengthen care coordination and service continuity. By contrast, negative outcomes may arise when a hospital acquires a rival provider in the same geographic area, leading to reduced services and increased prices.

Baron [57], distinguishes between market and non-market components of the business environment, noting that effective strategies integrate both. Market strategies operate within conventional economic exchanges, while non-market strategies seek to influence policy, regulation, and social contexts. In practice, these domains often overlap. Corporate social responsibility (CSR) initiatives, including community programs, voluntary adherence to public health guidelines, and environmental projects, illustrate this integration. Such actions can enhance brand reputation and consumer trust (market goals) while reducing regulatory scrutiny and fostering government goodwill (non-market goals), increasing a company’s financial performance [65]. For instance, a private hospital’s voluntary compliance with public health measures serves both objectives. However, CSR’s voluntary nature can also act as a barrier to stronger statutory regulation, potentially weakening public health protections [66]. While this review focuses on market strategies, non-market strategies are often interlinked through corporate activity.

Materials and methods

A scoping review is useful for mapping the breadth of research in a field and to identify knowledge gaps [67]. This approach is particularly salient given the limited analyses, to date, of market strategies used in the private hospital sector. Using the Joanna Briggs Institute’s eight steps for reviewing evidence [68, 69] the review protocol was informed using a scoping review framework and checklist [67, 70]. A systematic approach was adopted to comprehensively map existing literature and, where sufficient data were available, evaluate the effectiveness of identified hospital market strategies. Population, Concept, Context (PCC) elements [71] were used to shape the research question: What types of strategies are associated with increased market power amongst private hospitals?

Inclusion criteria and search strategy

The review focused on identifying articles that describe or discuss the use of market strategies and tactics undertaken in private hospital markets. Peer-review status was reported as a study characteristic to limit potential risk of bias, with grey literature excluded. We also restricted inclusion to English-language articles due to the scope of the project and the fact that English remains the dominant lingua franca in public health research. For example, 29 English-language articles focused on India and China were excluded as they did not meet the inclusion criteria. We recognize, however, that the exclusion of non-English literature is a limitation, which we discuss at the end of the article. Table 1 outlines the full inclusion criteria and Table 2 provides the complete search string.

Table 1.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Study characteristics
• Published in English.	• Not published in English, or no English full text available.
• Published between January 1st 1995 to February 24th 2025	• Published outside of January 1st 1995 to February 24th 2025
• Conducted original/primary scholarly research which is peer reviewed. • Relevant commentary and opinions can be included (if they conduct original/primary scholarly research which is peer reviewed) but must be appropriately cited with 12+ citations.	• Commentary and opinions which did not include detailed refencing and scholarly research (identified as being under 12 references and not conducting primary research), editorial, policy submission, book reports, annual reports, political party platform or news articles, letters, conference abstracts, and book chapters. • Reviews and/or systematic reviews were excluded as they are secondary sources. • However, where relevant, the references included in their analyses were screened against our selection criteria. • Models with no empirical data were excluded as well as studies which refer to other studies without conducting original research.
Population
• Focuses on private hospitals. This includes publicly listed, privately owned, and not-for-profit hospitals.	• Public hospitals or public healthcare systems, including those owned or operated by government entities. • Non-hospital healthcare settings, such as outpatient clinics, rehabilitation centres, or long-term care facilities. • Non-healthcare sectors or organisations that do not have an ownership stake in private hospitals. • Private hospitals are not discussed in detail. For example, private hospitals are mentioned but only spoken about for one or two sentences before the focus is changed.
Concept
• The evidence focuses on market strategies which impact corporate power or influence. We define market strategies as deliberate collaborative actions undertaken within a market environment to enhance corporate performance.	• The research focused on just political strategies (lobbying, government pressure, revolving door practices etc) but not market strategies. • The evidence examined concepts and influence of corporatisation, privatisation, and corporate power without analysing specific market strategies. Market strategies are discussed but not explicitly linked with a change in market power/influence. • Investigates patient-level decisions or outcomes, unless these are directly influenced by the decision-making of the private hospital owners or administrators.
Context
• The scope was worldwide including any country that has private hospital services. • Studies based solely on private hospital services modelling, rather than real-world contexts, were also eligible for inclusion.	• Countries which do not have any form of private hospital service provision.

Table 2.

Search string

Concept	Search Terms
Strategy	(strategy OR strategies OR strategic OR tactic OR tactics OR approach OR analysis) AND
Business/Market actor	(business OR corpora* OR “commercial own*” OR company OR companies OR “private sector” OR “private equity” OR “private owne*” OR “for-profit” OR “for profit” OR market OR markets OR charity OR religious) AND
Setting	(hospital OR hospitals OR “health facilit*” OR “healthcare facilit*” OR “health care facilit*” OR “health service” OR “health services”) AND
Marker power/influence	(“market power” OR “corporate power” OR “bargaining power” OR “purchas* power” OR “monopoly power” OR “monopsony power” OR “sell* power” OR “buy* power” OR monopol* OR oligopol* OR cartel OR collusion OR “market control” OR “corporate control” OR “private control” OR “market failure” OR “market driven” OR “market concentration” OR “market dominance” OR “market expansion” OR “market disruption” OR “market decline” OR “market consolidation” OR private?ation OR corporati?ation OR neoliberali* OR marketi?ation)

The lead author (TS) conducted an initial search of Web of Science, PubMed and Google Scholar using key terms to identify relevant articles on the topic and inform an initial list of the search terms and inclusion criteria. In consultation with public health and business school research librarians, a comprehensive search strategy was developed, focusing on four key concepts: market strategies, the private/corporate sector, hospitals, and influence/power.

The updated search was undertaken in March 2024 across seven databases (Medline (Ovid), ABI Inform Complete, Web of Science, Business Source Complete, EconLit, Academic Search Complete, and SocIndex) searching for articles published between 1996 to 2024 using the search string outlined in Table 2 below. TS undertook a full text search across Web of Science and Medline and conducted, title, abstract and key word searches across Business Source Complete, EconLit, Academic Search Complete, and SocIndex. This included a search ‘everywhere apart from full text’ in the ABI Inform Complete database. The search was repeated in February 2025 to update recent articles as well as including articles published from January 1995. Finally, the reference section of identified articles was examined for additional sources using backwards sampling. During the screening process any additional relevant articles outside of the database search were included.

Study selection

The search results from each database were uploaded into the review software Covidence for de-duplication, screening, and data extraction. A total of 1,642 titles and abstracts were screened, of which 371 articles were assessed for eligibility through full-text review. Ultimately, 133 articles were extracted and included in the review. Figure 1 documents this process.

Fig. 1.

PRISMA diagram

The reliability and relevance of each article was obtained through double screening. Titles and abstracts were screened against the inclusion criteria in Covidence by two reviewers (TS and PK). The full text of selected studies was assessed in detail against the inclusion criteria. Any discrepancies were resolved through discussion where the final decision was agreed on by both reviewers. Full text analysis combined methods of key word searches with targeted analysis of the abstract, introduction and conclusion to determine relevance. If required, the entire text was read in full.

Given the descriptive focus of this review, no standardised effect measures were used. Results are presented narratively, summarising the frequency and nature of reported outcomes

Adapted typology of private hospital market strategies

Our analysis drew on Wood et al.’s [26] typology, which differentiates between strategic objectives and associated market strategies within the food industry. Their framework is based on Porter’s Five Competitive Forces, a leading strategic management model [58]. Although occasionally criticised for oversimplifying modern markets [72], it remains a valuable tool for analysing and categorising market strategies. The framework offers a structural lens for understanding how companies, including private hospitals, identify and exploit power asymmetries within the market environment to inform strategic decision-making [26, 62]. Porter’s Five Competitive Forces are:

1. Industry rivalry – the intensity of competition among existing firms.

2. Threat of new entrants – the extent to which new competitors can enter and be blocked from the market.

3. Threat of substitutes – the risk of buyers switching to alternative products or services.

4. Bargaining power over suppliers – increasing purchaser power (hospitals in this study) by consolidating power over suppliers (e.g. medical equipment manufacturers and general practices).

5. Bargaining power over buyers – increasing seller power (e.g. hospitals) by consolidating power over buyers (e.g. patients, government).

An initial classification template was developed, adapting the Wood Typology to correspond more closely with the healthcare sector. In applying the typology to the private hospital sector, we interpreted ‘substitutes’ as competing hospital service providers, ‘suppliers’ being upstream distributional firms involving either provision of resources (medical equipment, hospital facilities) or patient referrals (medical practices), and ‘buyers’ to be both downstream firms e.g. insurers, governments and patients. The primary product sold by firms in the private hospital sector is health services. For this reason, this review uses ‘services’ rather than ‘product’, which more accurately reflects the hospital market context. Finally, we divided the strategic objective ‘increase seller power’ into two distinct categories, recognising an important distinction, particularly from a public health perspective, between the strategies employed by private hospitals in relation to governments and insurers, versus those directed towards patients (resulting in six overarching objectives).

More than 100 market strategies were initially identified and grouped under six strategic objectives. Through an iterative grouping process, informed by the market strategies identified in Wood’s Typology, this was reduced to 22. Initial classifications were reviewed by all authors, and any inconsistencies were resolved through consultation. In our final typology, we provide illustrative examples of each market strategy.

Finally, to help us consider the mediating role of health systems, we classified countries according to their national health financing systems. Using Gabani et al.‘s [73] cluster analysis of 2017 country-year observations, we classify and compare national health financing systems, sorting them into three groups: first, government-financed (i.e. those providing programmed, universal coverage based on residency, without requiring individual contributions); second, social health insurance (SHI) (also prepaid but requiring mandatory contributions to access coverage); and third, out-of-pocket (paying directly for services when needed, with little or no prepayment or risk pooling). We analysed which strategies were common across these systems.

Results

Data extraction, synthesis, and analysis

We included 133 studies in the analysis. Close to half of the included studies were published in the last 10 years, compared to the previous two decades. Most studies centred on or included the U.S. context (>70%). The other studies covered a range of regional contexts including Europe, North and South America, Asia, Africa, Oceania and the Middle East. Notably, all studies were from upper or upper-middle income contexts. Four studies analysed two regions, both countries are accounted for individually in Table 3.

Table 3.

Included studies by region and year

The strategies were drawn from a broad interdisciplinary body of literature that spans public health, business and strategic management, social sciences, competition law and policy, and the humanities. The data informing this article comes from a wide demographic including international hospital markets spanning across three decades, 20+ countries, and 77 peer-review journals. We identified 22 market strategies corresponding to 6 interconnected strategic objectives and 72 illustrative practices specific to private hospital service provision. Table 4 provides a complete typological framework of this evaluative synthesis.

Table 4.

A typological framework of the strategic objectives and associated market strategies and related practices used by private hospitals to increase and consolidate market power

Strategic Objective	Strategy	Illustrative practices	Countries
Reduce rivalry among existing competitors (n = 132) Competitive Rivalry: This refers to the intensity of competition among existing firms, shaped by the number and size of competitors, and the extent to which they compete on price, quality, or other factors. High rivalry in hospital markets will often pressures firms to innovate, cut costs, or differentiate their services.	Horizontal integration (n = 36)	Acquisition of a rival hospital within the same service and geographic market.	Germany (n = 1): [74] Japan (n = 1): [75] Greece (n = 1): [76] The UK (n = 1): [77] The US (n = 31): [77–83, 83–103] Western Europe (n = 1): [104]
		Acquisition (in the US) of non-tertiary care hospitals (providing general medical and surgical services, along with some specialised care), within the same service and geographic market, thereby expanding tertiary hospital market dominance.	The US (n = 2): [105, 106]
	Direct transnational expansion (n = 9)	Direct investment in foreign markets through acquisition of overseas firms.	Australia (n = 1): [107] India (n = 2): [108, 109] Türkiye (n = 2): [110, 111] Western Europe (n = 1): [104]
		Expanding internationally to penetrate new markets and share costs e.g. establishing diagnosis centres abroad, contracting independent intermediaries overseas to recruit new patients, sharing advertisement and marketing expense across multiple hospitals, opening new hospitals or selling healthcare expertise abroad.	China (n = 1): [112] Türkiye (n = 1): [111] The UK (n = 1): [112] The US (n = 1) [84]
	Horizontal collaboration (n = 13)	Strategic network formation and cooperative arrangements, such as U.S. hospitals collaborating to enhance bargaining power and negotiate better terms with insurers and downstream actors. For example, in the U.S., accountable care organisations (ACOs) can lead to shared savings for participating providers, coordinated new services, and shared profits.	The US (n = 6): [113–118]
		Hospital affiliation and ‘affiliating programs’ used to enhance reputation, whereby dominant firms lend their brand and clinical expertise to other hospitals. In the U.S., this included non-tertiary hospitals affiliating with well-respected tertiary care hospitals, sometimes for a hefty fee.	The US (n = 4): [78, 80, 105, 119]
		Not-for-profit hospitals match for-profits in market behaviour but collaborate and reduce rivalry among similar non-profits.	The US (n = 1): [120]
		Risk-spreading arrangements with rivals to strengthen market dominance, e.g., U.S. hospitals joining chains and then unilaterally reducing nurse-to-patient ratios, or private hospitals sharing costly equipment.	The US (n = 2): [113, 121]
	Anti-competitive and leveraged based pricing strategies (n = 24)	Exploiting dominant market position to raise prices and profit margins, e.g., hospitals with a geographical monopoly increasing service prices or merging to do so without improving inpatient care or community services. Not-for-profit hospitals may also increase capital investment as market power grows (enabled by charitable status) rather than directing surplus resources to care.	Greece (n = 1): [76] The US (n = 7): [54, 86, 87, 102, 122–124]
		Exploiting market dominance in one area to raise prices across all regions, e.g., hospitals compelling insurers to accept higher prices under threat of exclusion from controlled areas, thereby weakening insurer power (an “all-or-none” policy).	The US (n = 3): [86, 115, 125]
		Reducing labour costs through increasing firm leverage over staff e.g. hiring overseas doctors at lower salaries or merging hospitals to expand market power and slow wage growth.	Türkiye (n = 1): [126] The US (n = 1): [92]
		Hospitals engaging in vertical cream skimming practices; selecting or ‘cherry picking’ profitable patients or saddling more expensive patients on the public sector.	Australia (n = 1): [127] Modelling (n = 1): [128]
		Firms pursuing profit-maximising strategies that harm population health, e.g., reducing service access or quality, increasing staff-to-patient ratios, cutting healthcare spending, or worsening work conditions. Tactics include asset stripping, debt loading, accepting penalties for poor service up to marginal cost limits, and targeting affluent or elderly areas for hospital conversion to private ownership.	Australia (n = 1): [107] Georgia (n = 1): [129] Türkiye (n = 1): [110] Nordic countries (n = 1): [130] The UK (n = 1): [130] The US (n = 4): [95, 131–133] Modelling (n = 1): [134]
	Create, maintain, poach and increase consumer demand (n = 28)	Incentivising referrals through monetary commissions, kickbacks, or institutional partnerships; offering higher salaries to doctors who generate more revenue; and fostering staff accountability for financial performance.	Australia (n = 1): [135] Georgia (n = 1): [129] India (n = 1): [136] Malaysia (n = 1): [137] The US (n = 2): [138, 139]
		Investing in promotional practices to build and maintain consumer demand, e.g., employing ‘star doctors’ to boost brand and recruitment, offering limited-time service deals, recruiting international patients, and influencing patient choice through advertising rather than clinical outcomes.	India (n = 1): [140] Georgia (n = 1): [129] Malaysia (n = 1): [137] Türkiye (n = 1): [111] The US (n = 3): [54, 84, 141]
		Improve hospital facilities and workforce to give a competitive edge e.g. invest in service, technologies, amenities, and administrational staffing.	The US (n = 3): [54, 142, 143]
		Segment consumer markets through pricing strategies e.g. firms integrating luxury hospitality elements into their care model, targeting affluent patients, offering lower-cash-price services to target out of pocket consumers, offering different service options.	Brazil (n = 1): [144] Germany (n = 1): [145] India (n = 1): [146] Mexico (n = 1): [145] The US (n = 2): [54, 147]
		Using high debt-to-asset ratios in public or not-for-profit hospitals to facilitate conversion into for-profit entities via acquisition	The US (n = 1): [133]
		Acquiring and shifting business away from other firm, e.g. hospitals acquiring patients from other hospitals, targeting an area because rivals have a strong presence there, vertically integrates to foreclose a competing hospital, reducing firm access to patients and insurers, using recruitment practices.	Georgia (n = 1): [129] Malaysia (n = 1): [137] The US (n = 4): [54, 80, 138, 148]
		For-profit hospital expansion in less competitive regions and more lucrative market niches.	The US (n = 1): [89]
	Health provision cost reduction strategies (n = 22)	Adapting hospital processes to give strategic competitive cost advantage e.g. automation of billing practices lowering operational costs, selective admitting privileges (limiting doctors ability to admit lower-reimbursing Medicaid patients, streamlining administrative tasks to maximise physician productivity.	Germany (n = 1): [149] The US (n = 2): [150, 151]
		Competing on lower cost and lower quality of service.	Australia (n = 1): [107] Georgia (n = 1): [129] The US (n = 2): [38, 152]
		Reduction in healthcare resources and facilities to cut costs and improve efficiency (often through mergers).	Australia (n = 1): [107] Georgia (n = 1): [129] The US (n = 2): [88, 141]
		Reducing spending on clinical staffing (especially nursing). This is achieved through reducing staffing numbers, increasing staff/patient ratios, increasing expectations for workers to see more patients for shorter time periods, cutting higher paid senior staff reducing experience.	Australia (n = 1): [135] Germany (n = 1): [153] India (n = 1): [108] Spain (n = 1): [154] The US (n = 3): [16, 121, 155]
		Reducing back-office staff (e.g. technical support, accounting, human resources, administrative, etc).	Germany (n = 1): [153] The US (n = 3): [88, 123, 156]
Raise barriers to market entry by new competitors (n = 37) Threat of New Entrants: This measures how easily new firms can enter the market, shaped by barriers to entry such as high capital requirements or strong brand loyalty. Low barriers increase the risk of disruption from new competitors in hospital markets.	Develop, acquire and protect value, and market position of brands and other intangible assets (n = 10)	Investing heavily in advertising to build and protect brand equity and loyalty.	India (n = 2): [108, 140] Malaysia (n = 1): [137] Sweden (n = 1): [157] Türkiye (n = 1): [111] The US (n = 3): [54, 158, 159]
		Build brand power and loyalty by differentiating services based on different qualities and characteristics, marketing brands to different consumer bases.	Moldova (n = 1): [160] Türkiye (n = 1): [110]
	Exploit economies of scale (service provision, marketing and financial) (n = 13)	Cutting costs to increase efficiency typically through mergers e.g. sharing resources, reducing duplication, improving service coordination.	Australia (n = 1): [161] India (n = 1): [108] The US (n = 5): [117, 142, 156, 162, 163] Western Europe (n = 1): [104]
		Exploiting economies of scale to make large capital investments, implement cost-cutting financial strategies (e.g. transfer pricing) and gain competitive advantage in cost, reach, and provision.	Australia (n = 1): [161] The US (n = 1): [16]
		Exploit marketing economies of scale by spreading large budgets across multiple advertising channels.	The US (n = 1): [84]
		Leveraging scale and investment capacity to differentiate and pre-empt market competition e.g. using company size and economies of scale to offer unique or high-value services that differentiate from competitors, raise barriers to entry, occupy key market spaces, and deters new entrants.	The US (n = 2): [38, 162]
	Supply chain and market control (n = 11)	Controlling market access by combining legal, institutional, and infrastructural advantages such as ownership networks, regulatory influence, privileged co-location with public hospitals, and retention of key personnel through supplementary income.	Australia (n = 1): [161] India (n = 1): [108] Malaysia (n = 1): [164] The US (n = 3): [120, 165, 166]
		Blurring public–private boundaries to expand market influence e.g. not-for-profit hospitals using existing infrastructure to expand into for-profit markets, making it harder for new standalone clinics to compete. Increasing ‘contracting out’ of public sector services to the private sector. And the creation of for-profit subsidiary clinics by public hospitals to compete in the private sector e.g. hospital owned private rehab services.	Australia (n = 1): [161] Canada (n = 1): [167] China (n = 1): [112] The UK (n = 1): [112]
		Establish distribution networks in hard-to-access areas or leveraging dominate market position in industries with high ‘sunk’ costs.	Greece (n = 1): [76] The US (n = 1): [113]
	Policy and regulatory capture (n = 3)	Influencing government policy to favour hospital economic interests e.g. using economic modelling to shape merger review outcomes, securing preferential treatment during COVID-19, and reducing taxation on treating medical tourists.	Greece (n = 1): [168] India (n = 1): [109] The US (n = 1): [82]
Counter the threat of market disruptors and drive patient health service usage towards the hospital (n = 38) Threat of Substitute Services: This measure reflects the likelihood that patients (or customers) will switch to alternative services that meet the same needs, influenced by the availability of substitutes and the ease of switching. Greater accessibility of substitutes increases competitive pressure on existing hospital providers.	Sector diversification (increase economies of scope) (n = 16)	Investing heavily in expanding current services in response to consumer trends and developing new healthcare offerings in line with consumer trends and strategic market positioning.	Australia (n = 1): [107] Malaysia (n = 1): [164] Germany (n = 1): [169] The US (n = 2): [162, 167]
		Expanding into related markets via strategic partnerships, joint ventures, and financing arrangements e.g. private equity and partnership arrangements.	Australia (n = 2): [161, 170] Malaysia (n = 1): [137] Türkiye (n = 1): [110] The US (n = 6): [163, 171–175] Western Europe (n = 1): [104]
	Control market disruptors (n = 7)	Invest in advanced capabilities (such as high-tech services, superior quality care, and proprietary leadership or knowledge systems) that are difficult for alternative providers e.g. telehealth platforms, public rehab services or outpatient centres) to replicate or substitutes the public sector.	The US (n = 3): [38, 54, 176]
		Maintaining a competitive edge through co-opting potential competitors or cultivating stronger relationships with physicians and offering tailored services that aligned with patient preferences (e.g., convenience, shorter wait times, advanced technologies).	The US (n = 2): [162, 177]
		Preserving mission-based ownership (rather than for-profit acquisition) to maintain distinctive service offerings e.g., no-abortion services, charity care.	Canada (n = 1) [178]: The US (n = 1): [120]
	Achieving ‘cost efficiency’ via lower delivery, service, and performance costs (n = 12)	Shifting costs to insurers and consumers e.g. hospitals making up for decreased Medicare reimbursement and uninsured patients through increasing service prices, and deferring costs to future periods.	Australia (n = 1): [107] The US (n = 2): [179, 180] Modelling (n = 1): [128]
		Leveraging charitable (tax-exempt) status as a competitive advantage e.g. tax-exempt status is a structural advantage that shapes how aggressively not-for-profit hospitals can compete, increasing the rivalry pressure on for-profits and, at times, enables lighter regulatory scrutiny.	The US (n = 3): [165, 181, 182]
		Reducing access or outsourcing services to shift cost and risk e.g. to decreasing medical staff, limiting specialist services, reducing less profitable services, and post-merger closures to eliminate duplication.	Australia (n = 1): [107] France (n = 1): [33] The US (n = 3): [16, 167, 183]
		Strategically increase throughput and demand to escalate the overall cost of care.	Australia (n = 1): [107]
	Drive healthcare services displacement to maximise profit potential (n = 3)	Pull the time of senior medical staff away from public hospitals into the private sector through higher paying salaries causing a ‘brain drain’ in the public system.	Egypt (n = 1): [17]
		Limit and control patient access to general practices and clinical services e.g. acquiring and closing clinics, thereby increase cost for competitors.	Moldova (n = 1): [160] The US (n = 1): [96]
Increase firm buyer power by exercising power over upstream actors (e.g. staff, suppliers) (n = 29) Upstream—Bargaining Power of Suppliers This analyses the power that suppliers (e.g., staff, medical suppliers, landlords, general practitioners (GPs), staff suppliers, health service contractors) have over private hospitals. These actors provide key inputs and services. High supplier power can reduce private hospital profitability by increasing input costs or limiting flexibility.	Backwards vertical integration (n = 3)	Acquisition of upstream firms and related assets e.g. medical equipment, GPs and GP practices (facilitating kickback practices), staffing agencies, laboratory services, pharmaceutical firms etc.	India (n = 1): [108] Japan (n = 1): [75] Western Europe (n = 1): [104]
	Backwards control (n = 22)	Controlling access to inputs (e.g. land, staff provider, equipment), using workforce flexibility to cut costs, and acquiring primary care practices to close them or raise competitors’ costs and limit their patient access.	Australia (n = 1): [135] The US (n = 1): [96]
		Increasing referrals through ownership of general practices or smaller/community hospitals which raise rivals’ costs and streamlines patient flow to owned facilities.	The US (n = 4): [105, 106, 119, 156]
		Pressuring doctors to increase output and generate higher profits (achieved via leverage over employment contract) through increased performance targets or encouraging over-proscribing.	India (n = 1): [108, 140]
		Exerting control over practitioner staffing e.g. limiting professionals’ ability to work elsewhere, dictating fees for service (or eroding professionals’ income), weakening and marginalising professional autonomy (through ‘toxic’ leadership), incentivising doctors to join the hospital (reducing independents), inflexibility with working hours, performance targets which prioritise profitable practices, using bonuses as a strategy to achieve higher profits.	Australia (n = 1): [135] Egypt (n = 1): [17] India (n = 2): [140, 184] Georgia (n = 1): [129] Türkiye (n = 1): [126] The US (n = 3): [119, 155, 185]
		Using debt as a leveraging bargaining tool. When a hospital takes on debt it commits to paying creditors (lenders) part of the profits or “surplus” generated by the firm. This reduces the amount of money available for suppliers (like suppliers, employees etc.) can bargain for. In other words, creditors get their share first, leaving less for other stakeholders to negotiate over.	The US (n = 1): [186]
		Reducing expenditure by negotiating lower prices for medical devices, leveraging regional dominance and strong procurement teams.	The US (n = 3): [162, 187, 188]
		Accessing global capital (e.g., private-equity models) to reduce reliance on local finance.	Türkiye (n = 1): [110]
	Backwards vertical coordination (n = 4)	Coordinating through risk-spreading arrangements and resource sharing (e.g., strategic alliances and joint ventures) with suppliers (e.g. general practices).	The US (n = 2): [163, 172]
		Integrating with physicians (often in concentrated hospital or insurance markets) to increase power over insurance companies.	The US (n = 2): [171, 173]
Increase firm seller power by exerting leverage over downstream organisational actors (e.g. insurance, government) (n = 59) Downstream—Bargaining Power of Buyers This analyses the power that buyers (e.g. insurers and government payers) have over private hospitals.	Forwards vertical integration (n = 3)	Acquiring downstream firms and assets e.g. insurance providers to reduce competitors’ options and increase market leverage.	The US (n = 3): [119, 138, 189]
	Forwards vertical control (n = 49)	Undermining payer control through selective targeting and cost manipulation e.g. vertical cream skimming (avoiding high-risk patients), cherry-picking profitable cases, cost shifting, outsourcing and reallocating overheads to increase institutional reimbursements.	Australia (n = 2): [127, 161] Canada (n = 1): [167] Malaysia (n = 1): [137] The US (n = 1): [152] Modelling (n = 1): [128]
		Using mergers, monopolies or duopolies in a specific geographic area to increase bargaining power and negotiate higher prices with service buyers, such as health insurers.	The US (n = 22): [79, 81, 83, 85, 89–91, 93, 94, 97–99, 101, 103, 113, 115, 131, 171, 180, 190–192]
		Controlling distribution channels and patient flow through contracting agreements guaranteeing rent extraction, exclusive government agreements that limit alternatives for high-end care, and selective payer contracting.	Australia (n = 1): [107] Malaysia (n = 1): [164] The US (n = 5): [88, 190, 193–195]
		Leveraging specialised services and geographical coverage to strengthen bargaining power e.g. hospital having ‘must have’ treatments which payers need to include.	The US (n = 5): [82, 113, 115, 196, 197]
		Switching between for-profit and not-for-profit status to align with financial goals or regulatory advantages. E.g. not-for-profit hospitals converting to for-profit status to access private capital and expand profitable services, while underperforming for-profit hospitals may convert to not-for-profit status to reduce tax burdens and tap into public or charitable funding, especially in markets with high indigent populations.	Germany (n = 1): [153] The US (n = 3): [133, 141, 198]
		Using debt as a leveraging bargaining tool. When a hospital takes on debt it commits to paying creditors (lenders) part of the profits or “surplus” generated by the firm. This reduces the amount of money available for suppliers (e.g. insurers) can bargain for. In other words, creditors get their share first, leaving less for other stakeholders to negotiate over.	The US (n = 4): [186]
		Leveraging data asymmetries, complex ownership/partnership structures, and internal expertise to secure favourable insurer/government terms. This limits external visibility into cost, quality and regulatory oversight.	Canada (n = 1) [178] Germany (n = 1): [74] The US (n = 3): [86, 117, 123]
	Forwards vertical coordination (n = 7)	Coordinating downstream processes through risk-spreading arrangements e.g. parenting with medical travel facilitators to attract more patients, sharing resources with health funds, or offering better insurer terms where hospital bargaining power is weak.	Australia (n = 1): [170] Malaysia (n = 1): [137] The US (n = 1): [175]
		Perusing “wholesale’’ strategies (e.g. offering services tailored to managed care plans that contract for large enrolee populations).	The US (n = 1): [177]
		Securing favourable government market conditions e.g. co-locate with a public hospital, blending and blurring of public and private perceptions for the patient, offering community benefits which support tax exemptions, and reducing regulatory scrutiny.	Australia (n = 1): [161] The US (n = 2): [174, 181]
Increase firm seller power by exerting leverage over patients (n = 19) Downstream—Bargaining Power of Buyers (patient specific) This analyses the power that buyers (e.g., patients) have over private hospitals.	Limit patient ability to access healthcare through controlling demand (n = 7)	Restricting patient access to services to generate profit e.g. blocking access to private hospitals during national emergencies or excluding specific insurance providers.	Germany (n = 1): [145] Greece (n = 1): [168] Mexico (n = 1): [145] The US (n = 5): [88, 190, 193–195]
	Exploit information opportunities and asymmetries (n = 12)	Exploiting information and resource asymmetries over patients e.g. patients’ inability to judge cost and quality of services, leveraging firms’ ability to afford delays/denials to claims while the patient cannot, or advertising to drive referrals rather than demonstrable clinical outcomes.	Canada (n = 1) [178] The US (n = 3): [121, 150, 159]
		Raising patient costs via over-treatment, hidden fees, or upselling non-essential interventions (e.g., add-ons beyond “package” care), and by increasing patient cost-sharing (e.g., deductibles, co-payments).	India (n = 2): [109, 140] The US (n = 2): [138, 199]
		Limiting sharing information externally as a way of minimising costs, which can reduce clinical knowledge exchange and harm patient outcomes.	The US (n = 1): [200]
		Upcoding the severity of illness or treatment to increase hospital profits.	Georgia (n = 1): [129] The US (n = 2): [93, 199]

To date, most of the research related to the strategic objective of reducing rivalry among existing competitors as it was by far the most cited of the six (n = 132 articles). The second most cited strategic objective was to increase firm seller power by exerting leverage over downstream organisational actors (n = 59), and the third was to counter the threat of market disruptors and drive patient health service usage towards the hospital (n = 38). Of the 22 identified market strategies, forward vertical control (n = 49 articles) was the most discussed in the literature. This was followed by horizontal integration (n = 36), create, maintain, poach and increase consumer demand (n = 28), and anti-competitive and leveraged based pricing strategies (n = 24).

Figure 2 depicts these strategic objectives as six distinct forces operating within private hospital markets, illustrating their interconnected impact on competition. At the centre is rivalry among existing competitors, representing the most immediate manifestation of competitive pressure and mirroring the structure of Porter’s original Five Forces framework [58].

Fig. 2.

Private hospital forces flowchart and strategic objectives

Regional differences

Through further synthesis of the results, patterns can be identified across different regions and contexts. Of the regions represented in this study, eight were government-financed (Australia, Brazil, Canada, Malaysia, Spain, Sweden, United Kingdom (U.K.), and the Nordic countries), four were out-of-pocket (Georgia, Egypt, Mexico and India), and 8 were SHI (France, Germany, Japan, Moldova, China, Türkiye, the U.S. and Western Europe) [73]. Greece was excluded from Gabani et al.’s. [73], analysis due to missing data. Given that out-of-pocket spending accounted for 34.8% of total health expenditure in 2017 [201], we have chosen to classify Greece in this group. We classified the Nordic countries as government-financed and Western Europe as SHI because a clear majority of countries within each region fell into those categories.

Market strategies identified in SHI health systems were most prevalent in our dataset, largely driven by the predominance of U.S.-focused studies. Apart from Strategy 2: Raise barriers to market entry by new competitors (where SHI accounted for 58%), SHI economies accounted for 70% or more of the strategic objective data (Table 5). This means the findings are most applicable to economies like the U.S. which have market-led rather than social health systems. When U.S.-focused studies are excluded, SHI becomes the least represented system type and the distribution across system categories becomes more balanced (approximately one-third each).

Table 5.

Distribution of strategic objectives across health financing systems

Strategic Objectives	Government-financed	Out-of-pocket	Social health insurance (SHI)	Not applicable (non-country study)
Reduce rivalry among existing competitors	16	15	105	2
Raise barriers to market entry by new competitors	9	7	22	0
Counter the threat of market disruptors and drive patient health service usage towards the hospital	9	1	28	1
Increase firm buyer power by exercising power over upstream actors (e.g. staff, suppliers)	2	6	20	0
Increase firm seller power by exerting leverage over downstream organisational actors (e.g. insurance, government)	10	0	52	1
Increase firm seller power by exerting leverage over patients	1	5	14	0

Strategy 1: reduce rivalry among existing competitors

Horizontal integration

One prominent approach identified throughout the literature analysis was horizontal integration, where a company acquires another operating in the same market [74–83, 83–104]. This strategy allows firms to expand market share while reducing the number of direct competitors, thereby consolidating their position in the industry. In the context of hospital markets, horizontal acquisitions offer several competitive advantages, including the expansion of brand portfolios, the realisation of economies of scale and scope [104], and the acquisition of managerial systems, processes, and technology [54, 142, 143].

Huppertz et al. [84], p.1604) highlights that horizontal integration can lead to greater marketing efficiency by allowing hospitals to spread “advertising costs across more hospitals and a market-wide geographic footprint,” increasing market leverage.

As horizontal integration increases, firms may edge closer to monopolistic control over specific service areas. For example, (Scheffler et al. [96], p.1415) argues that “if a hospital system controls the market for orthopedists, it can raise prices for orthopedic surgery,” illustrating how market dominance can directly influence pricing power.

Horizontal collaboration

Hospital firms have also used less formal risk-spreading arrangements with rivals as a means of increasing their collective position. This was shown to occur in the U.S. through hospitals joining together, that is partnering but not merging, to reduce labour costs and through the sharing of expensive equipment [113, 121]. By collaborating, hospitals gained a strategic advantage through reducing rivalry which lowered their costs. Horizontal collaboration between hospitals through strategic network formation and cooperative arrangement was also identified as an effective approach to renegotiate better deals with health insurance through increasing collective power [113–118]. For example, (Berenson et al. [115], p.702) noted that University of California hospitals began “negotiating as a system rather than as individual entities,” having only recently recognised that the collective power of group bargaining could overcome “bureaucratic inertia”. By aligning their negotiating strategies, hospitals can effectively leverage collective market power to exert pressure on payers. Finally, hospital affiliation whereby dominant providers lend their brand and clinical expertise to other hospitals to increase their reputation, in some instances for a hefty fee, was identified as another strategic form of collaboration in U.S. markets [78, 80, 105, 115–117, 119]. This strategy was identified only in a SHI financing system, the U.S.

Direct transnational expansion

The acquisition of hospitals overseas was also shown to be a prominent means by which firms enter new markets [104, 107–111]. International expansion was shown to support firms diversifying, leverage management experience and benefit through knowledge cross fertilisation [104]. Expansion has also occurred through firms investing in diagnostic centres abroad to penetrate emerging markets, as this strategy boosted referrals and marketing capabilities while undercutting domestic markets [111].

Anti-competitive pricing strategies

It was identified that hospitals can exploit a dominant market position to increase their prices and profit margins. This typically occurs following hospital mergers where prices are raised without any corresponding improvements in the quality of inpatient care or the provision of community-based services [54, 76, 86, 87, 102, 122–124]. U.S. examples showed that when a hospital chain achieved dominance in a specific geographical market, it could leverage that position to impose higher prices on insurers across all its hospitals, using the threat of exclusion from the controlled market as part of an ‘all-or-none’ contracting strategy [115]. Failure to comply in the U.S. could lead to exclusion and a gap in cover for insurance companies geographically, which could significantly weaken the insurer’s business model particularly for attracting business or customers who work nationwide [86, 115, 125].

Evidence shows that hospitals operating in markets without competition use anti-competitive pricing strategies through engaging in profit maximising behaviour which can impact negatively on population health outcomes [95, 131, 132, 134]. This was shown through either reducing access to services, the number or type of services provided, the number of employees engaged to perform the work, workers conditions, or the quality of work performed [107, 110, 129].

Create, maintain, poach and increase consumer demand

Private hospitals would employ aggressive marketing to stimulate demand in both new and established markets. Strategies include promoting “star doctors” to enhance corporate branding and attract patients, as well as offering limited‑time deals on healthcare services to drive uptake [54, 84, 111, 129, 137, 140, 141]. Other strategies included taking business away from competing firms. This might occur through hospitals acquiring patients from competitors, targeting areas with a strong rival presence. Or vertically integrating to control referrals with the aim of foreclosing the rival hospital to reduce expenses, though this could also reduce access for patients [80, 129, 138, 148].

The literature further indicated that hospitals could increase patient numbers through using promotional practices, such as commissions and kickbacks for referrals. This could be achieved either through recruiting patients [129, 137] or doctors as intermediaries to increased demand [136, 138, 139], as well as institutional commercial practices that lead to increased referrals [135].

Health provision cost reduction strategies

The reduction of costs can strengthen a private hospitals position through improving profit margins. Many private hospitals displayed a preference for cost-cutting strategies over improving services in the U.S., but also across Australia, Germany and Georgia [38, 107, 123, 129, 152, 153, 156]. This was evidenced in three ways. First, mergers or reductions in resources and facilities to reduce costs and improve efficiency [88, 107, 129, 141]. In Türkiye , globalisation enabled hospitals to “employ migrant and refugee doctors from Syria and other countries based on lower pay scales” ([126] p.7). Second, a reduction in clinical staffing numbers to cut costs – for example, by lowering staff-to-patient ratios, pressuring healthcare professionals to see more patients in less time, and reducing senior positions that are more costly but provide greater experience [16, 108, 121, 135, 154, 155]. Third, a reduction in administrative staffing positions, often through mergers where employees serve multiple hospitals, increasing workload but improving spending efficiency [88, 123, 153, 156].

Strategy 2: raise barriers to market entry by new competitors

Develop, acquire and protect value of brands and other intangible assets

Hospitals, particularly hospital chains, make substantial investments in marketing practices to increase and protect branding and to help foster brand loyalty [108, 111, 137, 140, 157–159]. This is achieved through building brand power by differentiating services based on different qualities and characteristics and marketing brands to different consumer bases [110, 160]. As Eren Vural [110 p.29] notes, larger chains will develop multiple brands “each owned by the same chain but serving patients with different purchasing power and health care coverage.” In this way, hospitals segment patients by offering different brands, service levels, and access.

Exploit economies of scale (service provision, marketing and financial)

A key barrier to market entry in many private hospital sectors is the economies of scale achieved by dominant firms through acquisitions, co-location of facilities, and investment in advanced technologies that increase efficiency, reduce duplication, and lower costs [104, 108, 117, 156, 161, 162]. In contrast, some evidence shows that while hospitals identified potential efficiencies from mergers, these were not always realised. Studies have found that hospitals within groups may charge higher prices than stand-alone facilities, with limited evidence that chains achieve greater efficiencies or deliver anticipated savings from staffing reductions [142, 163].

Supply chain and market control

Private hospitals’ control over medical provision and their ability to direct paying patients to their services (‘supply chain control’), is another barrier to market entry. Evidence indicates that hospitals established distribution networks in hard‑to‑access areas or leveraged dominant market positions in industries with high sunk costs to maximise patient referrals [76, 113]. Co-location with public or charity hospitals was identified in Australia and India as being advantageous, enabling privileged access to prestigious locations and infrastructure that were difficult for new entrants to replicate [108, 161]. This facilitates capturing more business from the public sector, as well as the blurring of public–private boundaries to expand market influence, as shown across multiple government-financed health systems [112, 161, 167].

Policy and regulatory capture

Regulatory power and the ability to adapt and shape regulation can be used as an effective means of limiting competition. Although this comes close to being a non-market component, it is influential to market access and lowering corporate barriers. This is revealed in the literature through examples of firms influencing government policy, which favours their market position including economic modelling to shape merger review outcomes [82, 109, 168]. Kondilis and Benos [168], p.47) illustrate this in Greece, showing how private hospitals “kept an average of 97.8% of their bed capacity COVID-19-free” and were able to select profitable patients and exclude nonprofitable patients during a national health emergency. This was achieved without regulatory pushback, highlighting the hospitals strategic influence on regulation and policy:

“The five largest health care corporate groups in the country sustained their revenues in 2020 despite the steep recession that the Greek economy faced at that time, and they managed to fully recover at the peak of the pandemic in 2021, recording historically high revenue and profit growth rates”. [168], p.475.

Looking at medical tourism in India, (Murray et al. [109], p.13) further emphasises how private hospitals can achieve favourable policy through lobbying governments for preferential market benefits such as “lower import duties and enhanced rate of depreciation for life-saving medical equipment.” Importantly, this is one of the few instances in which the strategy is dominated by countries that rely predominantly on out-of-pocket financing.

Strategy 3: counter the threat of market disruptors and drive patient health service usage towards the hospital

Sector diversification (increase economies of scope)

Hospitals often invest in expanding services to diversify revenue streams, either in response to consumer trends or to strengthen market positioning [107, 164, 167, 169]. Diversification and economies of scope enable integrated care offerings that reduce patient migration to alternative providers. Public hospitals remain a major substitute and potential market disruptor, prompting private hospitals to support health system designs that increase reliance on private services and capture a greater share of government healthcare funding. Beyond competing with the public sector, diversification and cost‑efficiency strategies were also effective in consolidating control of private hospital markets. This was identified in the literature in both government-financed and SHI financed systems.

Control market disruptors

Control over private hospital markets in the U.S. and Canada was shown to be achieved through firms exercising market dominance by investing in advanced, hard-to-replicate capabilities [38, 176], building strategic alliances with physicians, tailoring services [162, 177], and preserving nonprofit status to avoid the regulatory scrutiny faced by competitors [120, 178].

Achieving ‘cost efficiency’ via lower delivery, service, and performance costs

Utilising pricing efficiency through the reduction of delivery, service, and performance costs enables firms to offer higher-value services, thereby reducing the risk of customers switching to substitute health providers. This was observed in Australia’s government-financed system and in France and the U.S.’s SHI systems, but not in out-of-pocket financing systems. One example of this is shifting of costs onto health insurance companies, allowing for increased hospital revenue. This is often seen when hospitals try to make up for decreased Medicare reimbursement and uninsured patients. This is achieved through increasing service prices which are passed on to insurance providers [107, 128, 179, 180]. Another way identified in the literature was by reducing patient access. Methods used to achieve this included reducing services in rural areas, decreasing medical staff, limiting specialist services, cutting or reducing less profitable services, or merging and then closing a hospital to reduce duplicate services, while this reduces costs it can also negatively impact health outcomes [16, 33, 107, 167, 183]. Finally, some hospitals achieved cost efficiencies by leveraging charitable status to gain competitive market advantages. Tax exemptions for not-for-profits provided structural benefits, granting hospitals greater control over earnings and increasing competitive pressure on for-profit hospitals that paid taxes. Not-for-profit hospitals also used their status to bypass certain competition regulations, lowering compliance costs, while continuing to exercise market power [165, 181, 182].

Drive health provision displacement to maximise profit potential

Controlling access to care was acknowledged as a strategy for increasing hospital profits, with practices such as acquiring clinical services to close them, limiting competition, or significantly raising referral prices for rivals as tactics, which increase hospital profits identified [96, 160]. Higher salaries in the private sector were also noted as contributing to a ‘brain drain’ in the public hospital system [17]. Collectively, these practices were described as contributing to the displacement of health service provision; the implications for equitable access are explored further in the discussion.

Strategy 4: increase firm buyer power by exercising leverage over upstream actors

Backwards vertical integration

Private hospitals vertically integrate ‘backwards’ by acquiring upstream suppliers, including general or primary care practices, staff or medical suppliers, property, service contracts for general practitioners, financers and health provision contractors [75, 81, 96, 104, 108, 119, 139, 156, 162, 166, 171, 180, 185, 199, 202]. The most common form of integration was between hospitals and general or primary care practitioners, motivated by the hospital buyer’s desire to expand patient volumes, boost physician productivity, increase leverage over payers and suppliers, and grow market share [162, 185].

Backwards vertical control

Backwards vertical control (hospital power over suppliers) was exercised through integration, which restricts access to key inputs such as land, staff and equipment, thereby increasing market power. Examples include reducing staff during low‑demand periods [135] and acquiring primary care practices to shut them down or limit competitors’ patient referrals [96]. In U.S. markets, ownership of general practices or smaller community hospitals allowed hospitals to raise rivals’ costs, and direct patients in-house [105, 106, 119, 156]. Vertical control through integration also enabled hospitals to assert greater influence over their staff through restricting physicians’ opportunities to practice elsewhere, imposing service fees, undermining professional autonomy via autocratic leadership, converting independent practitioners into employees, enforcing rigid working hours, implementing performance targets, and incentivising high-revenue-generating procedures [17, 119, 126, 129, 135, 140, 155, 184, 185]. In Indian markets, hospitals pressured doctors to increase their workload, tied performance to contract renewals, and encourage overprescription of medications [108, 140]. Finally in U.S. markets, hospitals leveraged regional dominance over upstream suppliers to negotiate lower prices for medical devices [162, 187, 188].

Backwards vertical coordination

Vertical coordination was observed in U.S. markets through strategic alliances and joint ventures with upstream firms such as general practices, enabling risk‑sharing and resource pooling [163, 172]. Such partnerships combine complementary resources to create joint capabilities that were “valuable to the buyer” [172], p.337). Coordination with physicians was also identified as a way of enhancing hospitals’ bargaining power over insurers [171, 173].

Strategy 5: increase firm seller power by exerting leverage over downstream organisational actors (insurance, government)

Forward vertical integration

Forward vertical integration in U.S. markets was highlighted through hospital acquisition of downstream firms and related assets, typically insurance providers [119, 138, 189]. This reduced competitors’ options for insurers, increasing the hospital market leverage and increasing referrals through integrated networks.

Forward vertical control

Forward vertical control was observed throughout the literature in government-financed and SHI systems but not out-of-pocket financing systems. This included private hospitals undermining payer control through selective patient targeting and cost manipulation, such as vertical cream skimming (avoiding high-risk patients) or cherry-picking profitable cases [128], and reallocating overhead costs to increase hospital reimbursements [152]. Private hospitals in Australia, for example, conduct the majority of high-throughput (and profitable) elective procedures, whereas public hospitals provided more in-patient bed-days to chronically ill patients [127]. Private hospitals would use strategic contracting by selectively choosing insurers favouring those with higher remuneration, as well as terminating contracts with insurers (gatekeeping) to secure higher payment rates. This aims to leverage short-term disruption for long-term gain, often relying on insurers needing their services [88, 190, 193, 194].

Hospitals strategically converting between not-for-profit and for-profit ownership was shown to be beneficial as it could improve financial goals, market conditions, and regulatory advantages [133, 153, 198]. Not-for-profit hospitals may convert to for-profit status to access private capital and expand profitable services, while underperforming for-profit hospitals may convert to not-for-profit or government status to reduce tax burdens and tap into public or charitable funding. As Sloan et al. [133], p.53) discusses, conversions from for-profit status often followed declining profitability, and these hospitals were less profitable than those converting to for-profit status, with for-profit organisations tending “to be more nimble.” This strategic approach shows how private hospitals can enhance their market position and bargaining power by adapting their ownership structures to align with financial goals and market conditions.

Many U.S. studies identified that hospitals would merge or use a dominant market position to increase bargaining power and raise service prices. This was seen in cases where hospitals formed a monopoly or duopoly within a market, raising prices for buyers, typically insurance companies, without increasing their spend or the quality of care [79, 81, 83, 85, 89–91, 93, 94, 97–99, 101, 103, 113, 115, 131, 171, 180, 190–192]. Private hospitals often leverage specialised services to strengthen their bargaining power. For instance, having ‘must have’ treatment which insurers needed to include, otherwise they would have ‘holes’ in their coverage, meaning customers would be less inclined to choose their plan [82, 113, 115, 196].

Finally, the U.S. literature shows vertical control in private hospitals through enhanced information pooling and strengthened negotiating capacity [86, 117, 123]. As (Lewis and Pflum [86], p.602) note, hospital bargaining power might increase “after joining a system if the system shares the costs of creating a larger and more skilled team of contract negotiators or if it pools information from previous contract negotiations, giving the member hospital more information to use in the bargaining process”. This illustrates how larger firms can develop more robust resources, thereby increasing their bargaining power when negotiating with insurers and other payers.

Forward vertical coordination

Hospitals coordinating vertically through risk-spreading agreements was identified as another means for increasing seller power over downstream actors. For example, intermediaries who sell medical care to patients teaming up with hospitals to increase patient numbers [137], or hospitals coordinating with health funds “enabling organisations to tap into each other’s complementary resources and capabilities share resources to gain mutual benefits” ([170], p.1995).

Private hospitals would coordinate to secure better government market conditions. For example, co-location with a public hospital in Australia blurred perceptions on what constituted public or private care [161], while in the U.S., offering community benefits enabled tax exemptions and minimised regulatory scrutiny [166, 174]. This strategy was identified in government-financed and SHI systems but not out-of-pocket financing systems.

Strategy 6: increase firm seller power by exerting leverage over patients

Limit patient ability to access healthcare through controlling demand

In many cases, private hospitals restricted buyer access to services as a means of generating higher profits (e.g. avoiding patients who are less lucrative). Examples included blocking patient access to private hospitals during a national emergency and restricting patient access through excluding certain insurance providers [88, 145, 168, 190, 193–195].

Exploit information opportunities and asymmetries

The review identified several ways in which for-profit hospitals leverage information asymmetries over patients, insurers, and governments. Examples include practices that encourage over-treatment and impose “hidden costs” beyond the originally purchased “package deal” ([109], p.6,18). Around cost sharing as a form of control [199], p.17) identified that larger co-payment and deductibles forced patients to have more skin in the game but led many to “forgo or delay necessary care, resulting in worse outcomes”. Other practices included hospitals promoting medical interventions that were unnecessary or not cost effective, but motivated primarily by the pursuit of higher profits [138, 140]. Lastly, hospital upcoding – assigning a more severe or complex diagnosis than the treatment provided – leveraged information asymmetries between patients and insurers, resulting in inappropriately high payments [93, 129, 199]. Limited information means that patients are not positioned to understand or challenge inappropriate coding of (a) their risk profile, which affects payment levels, or (b) the interventions received.

Firms would also weaponise information complexity to increase their position over buyers [121, 150, 178]. For instance, (Douven et al. [138], p.35) argued that as hospitals acquire better information, they are motivated to distort incentives by reducing “investments in unprofitable products (the ‘bleeders’) while increasing investments in profitable ones (the ‘feeders’)”. Adding to this, Rudden [150] highlights the case of Advent Orlando Health, which billed the Bennett family over $550,000 after an insurance change during their son’s hospital stay led both insurers to reject payment and the hospital charged the family. While such billing systems are deemed “efficient” by large businesses, the burden falls on patients, who are often left to navigate an unresponsive system. This is just one example but “for the Bennetts, it took a national publication’s outreach to penetrate the impersonal shield erected by their hospital and insurer” ([150] p.296).

Discussion

This article identified a range of market strategies used by private hospitals to consolidate and enhance their influence and profitability. This included six interconnected strategic objectives which illustrated how market strategies can be deployed to leverage power asymmetries within the market, typically over patients, insurers, governments, general practices, and hospital suppliers. Notable differences from Wood’s Typology included the absence of collusion strategies, which were instead categorised under coordination. Strategies were also adapted to reflect the hospital context, as well as additional strategies being identified that were not present in Wood’s Typology, relating to policy capture, health provision costs, and cost efficiency.

Although this review had an international scope, many articles included (over 70%) focused on U.S. healthcare markets. One reason for this is that the U.S. has allowed far greater private sector ownership and reliance than most other countries [203]. Additionally, the U.S. market size and potential research bias towards the U.S. health system may have also led to our search terms collecting more studies from this context. With the increasing global influence of private equity and expanding private involvement in hospital provision, this may change in the coming years [19]. While the U.S. operates under a set of market conditions specific to its context, its healthcare landscape offers valuable insights for other countries moving toward greater private sector participation in hospital care.

A noteworthy pattern across U.S. focused studies was an implicit assumption that readers would recognise the U.S. as the default context. Authors rarely noted the setting in their introductions, nor would they provide comparative market analysis with other countries. While the scope of some journals is U.S.-focused, this contrasts to studies on markets outside of the U.S., which clearly clarified the geographic context being discussed.

Given the predominance of U.S. studies, a second key theme was the historical trajectory of for-profit versus not-for-profit hospitals. During the 1990s, a period of significant hospital mergers and expansion, U.S. courts and policymakers treated not-for-profit hospitals differently from their for-profit counterparts. Not-for-profits were viewed as being guided by altruistic principles in management and care delivery. As a result, antitrust laws were not enforced to the same degree in not-for-profit hospitals, under the assumption that their increased market power would not be exercised in the same competitive as for-profits. This was highlighted in 1996, where a U.S. court approved the merger of the two largest hospitals in Grand Rapids (regardless of their combined 73% market share) on the grounds that not-for-profit hospitals were unlikely to exploit monopoly power [124]. The judge relied heavily on a 1995 study by William Lynk, which argued that not-for-profit hospitals typically did not raise prices after mergers, as their boards were community-focused and unlikely to harm local interests. Since then, multiple studies have shown that not-for-profit hospitals will act in markets similar to for-profit hospitals, driven by strategic interests to perform well [102, 120, 141, 167]. The findings of this study support the view that both for-profit and not-for-profit hospitals adopt comparable strategic behaviours to enhance market performance.

We identified three interconnected public health concerns arising from market-based power imbalances within the private hospital sector. First, prioritisation of profit over patient care, where hospital clinical decisions and operations become overly influenced by financial returns rather than patient well-being. Second, exploiting systemic vulnerabilities (internal weaknesses), including reduced funding for public and preventative care, reducing staffing capacity, and weakening accountability structures, to achieve cost savings and competitive advantage, often at the expense of care quality and public oversight. Finally, anti-competitive profit generation (external distortion), enabling private hospitals to consolidate market power and support tactics that can undermine equitable and effective public health delivery. Unlike capitalising on the system from within, these tactics exploit and distort broader structures and the allocation of care. These concerns raise the question of how to strike the right balance between financial incentives and the logic of marketisation that underpins how for-profit hospitals operate and deliver quality healthcare to all patients.

From a public health and government policy perspective, private hospital care should prioritise patient wellbeing above profit maximisation [14, 204, 205]. We argue that when profits are generated at the expense of patient or population health outcomes, hospitals profiting from the delivery of care should be considered inappropriate. Perry and Bernasek’s [20] analysis of 21st-century capitalism and cancer treatment outlined how the effects of profit maximisation and monopoly power in the hospital sector were associated with higher mortality rates. The market strategies employed by private hospitals to increase profits can have harmful effects on population health, regardless of any wealth generation through these practices.

This review highlighted several examples, including cost-cutting measures such as reducing nurse-to-patient ratios [121, 153] and increasing clinical workloads [108, 135]. Indeed, many studies highlighted the strategic use of power over staff and medical practitioners to maximise profitability, often reflecting a preference for cost‑cutting over service improvement. This aligns with the concept of ‘short‑termism’ where short‑term profit goals undermine long‑term investment [206, 207]. For example, a private hospital’s reliance on cost‑cutting rather than sustained service investment reflects a strategic choice. As (Clark et al. [206], p.339) argue, short-termism may erode incentives for companies to commit to sustainable long-term investments. This perspective frames the broader implications of such strategies for public health outcomes in globalised healthcare markets, health system regulation, and competition policy, where the imperative to deliver quick profits can undermine longer-term investment. In this respect, the short-termism of private hospital market strategy can cause harm Accordingly, where market-based power imbalances allow private hospitals to generate profits which negatively impact health service access and quality, it is likely to negatively affect hospital care and patient health outcomes.

Second, beyond measurable impacts on patients, market power in hospital care can have significant system-level public health implications. These arise when hospitals pursue cost-saving or competitive strategies that compromise care quality and, in turn, adversely affect population health outcomes. Practices such as asset stripping and debt loading, while generating short-term investor profits, impose long-term debt on hospitals [110], reducing quality through ‘rent-seeking’ behaviour which extracts wealth without adding new value. Furthermore, private hospitals may exploit dominant market positions to boost margins by decreasing spending on services, leading to quality erosion and aggravated healthcare outcomes [95, 131, 134]. As identified by Kondilis and Benos [168], in a time of an acute public health crisis, private hospitals in Greece were able to circumvent the constraints placed on their public counterparts by withholding services until they secured inflated reimbursement fees, using their power to prioritising profits over patients care. Similar patterns were observed during the COVID-19 pandemic, with private health providers in multiple countries across Asia, the Middle East, Africa, and South America refusing to treat patients or charging inflated prices for health services [46].

Gilmore et al. [24] identify corporations exploiting system weakness to avoid tax and regulation as a commercially driven harm to public health. Competitive strategies such as conversions between for-profit and non-profit status to avoid regulation, a practice often seen in the US, enable firms to leverage public funding and tax exemptions [133, 141, 153, 198], thereby undermining regulatory frameworks and having a detrimental impact on public health. Additionally, the recruitment of senior medical staff from the public sector into private hospitals leads to a significant “brain drain”, consequently weakening the overall public health system [17, 164].

Thirdly, private hospitals’ ability to exert market power over competitors facilitates corporate practices that can erode public health efforts and restrict equitable access to healthcare. Building brand power and loyalty through differentiating services, or advertising brands to different consumer bases have been shown to protect value and market position for hospitals [110, 160]. The impact of these approaches on public health outcomes is hard to gauge as firms could mislead the public to select something not in their best interest [208]. Examples include promoting consumer demand through targeted communication and advertising, exploiting patients’ limited information and resources, and upcoding illness severity to inflate hospital profits. However, in a competitive market this could be a way for hospitals to distinguish themselves without causing harm [209, 210]. The literature also identified examples of substantial investments in expanding current and developing new healthcare services in response to consumer trends or strategic market positioning [162, 164, 167, 169]. While this could help increase the hospital services available, prioritising profit generation might also substitute a patient focus for a profit focus. Lastly, examples of private sector influence in healthcare expanding through blurred public–private boundaries highlight a potential challenge for health outcomes. We found that not-for-profit hospitals, for example, often leverage existing infrastructure to enter for-profit markets, limiting opportunities for new standalone clinics. Similarly, public hospitals increasingly contract out services to private providers or establish for-profit subsidiaries, such as private rehabilitation clinics or overseas satellite hospitals, to generate revenue and compete in commercial health spaces. While this might increase health services for those who can afford care, private expansion through public and nonprofit funding can take away financial resources, staff time, and focus, undermining equitable and effective public health delivery.

How private hospital providers use strategic tools to expand their market influence, and what this means for health systems are often overlooked issues in global health. This manuscript’s foremost contribution is a typological framework of the market strategies private hospitals use to increase market power (Table 4). Through the adaption of Porter’s Five Forces and integrating CDoH and political economy perspectives, we conceptualise private hospital market behaviour as more than a list of business strategies. Rather, the typology situates these approaches within wider processes of marketisation, neoliberal reform, and shifting provider power. Through this theoretical framing we add to the literature a conceptual bridge between business strategies and global health, highlighting some of the concerns this might bring to hospital care including internal weaknesses, external distortions, and the potential for prioritising profit over patient health outcomes.

Limitations

While this paper benefits from systematically including a 30-year timeframe of study, a wide geography of markets and a broad discipline of literature, there are several important limitations. First, the search parameters limited analyses to peer-reviewed articles, the purpose of this was to focus the analysis on academic perspectives. However, leaving out grey literature and market perspectives outside of peer-reviewed journals means some elements of market strategy might have been missed. Second, interpreting power relations is often subjective, and while the systematic process of multiple reviewers helps limit bias, the framing of different strategies in the review could be interpreted differently. Additionally, conceptual ambiguity surrounding the definition of “market power” may have contributed to the inadvertent omission of relevant studies. Third, limiting inclusion to English-language publications may have introduced publication bias and regional imbalance, potentially excluding alternative geographical perspectives. Some studies may have been missed because local terms for private hospital power and influence were not captured by English-language search strategies. Forth, as identified previously, the articles included mostly focus on U.S. markets. While the analytical framework used in this study can be applied to any private hospital market system, it is important to note that individual countries are subject to their own unique market conditions. Furthermore, the authors recognise that elements of the review may reflect bias towards the U.S. context, as data from these markets were more prominent Finally, while Porter’s Five Forces model provided an excellent starting point, this was not created as a tool for studying hospital markets. This means that some elements, such as the hospital sector serving a ‘public good’ function, are not always considered. The six strategic objectives identified in this review therefore offer an updated application of Porter’s Five Forces to a unique sector. However, across the review there are clear crossovers and examples of hospital behaviours which fit into multiple strategies.

Future directions

Future research on the CDoH could apply this framework to other sectors, such as pharmaceuticals, private health insurance, housing, aged care, and pathology, to develop similar tailored typologies within different contexts. Doing so would enrich the existing literature and deepen public health understanding of how market-power used by the private sector shapes health outcomes across a range of industries.

Conclusion

This paper has captured academic literature from the past 30 years, condensing analysis on the use of market strategies within the private hospital sector. Novel findings are presented through a typological framework of market strategy used by private hospitals to consolidate and increase their market power. Both for-profit and not-for-profit hospitals are identified as operating with similar market position and profit maximising behaviour. The typology and results were informed by Porter’s Five Forces framework, identifying 72 illustrative practices, across 22 identified strategies, relating to 6 strategic objectives. The application of this analysis is well placed to inform the examination and understanding around corporate power within hospital care. Additionally, private sector influence within the provision of healthcare services can be better scrutinised, particularly if practices are identified as health harming or undermining for public health outcomes. Competition policies, particularly those addressing unfair trading practices, corporate expansion and market power abuse, hold significant potential to improve healthcare systems and the delivery of health services.

Although the empirical examples in this study are predominantly U.S. based, the implications extend beyond this context. Governments seeking to improve public service delivery in healthcare can use these insights to better understand and counteract negative corporate influence. In economies where universal health coverage is a priority, anticipating and responding to private hospital tactics may enable more effective policy design. Regulators and policy makers are encouraged to view hospital business strategies through a CDoH and market forces lens and be aware of the strategic objective and Illustrative practices corporations use to gain market control. Private hospitals have been shown to use market strategies to their advantage. We therefore argue that in a health system that seeks to prioritise health outcomes, it is fundamental that the strategies hospitals employ are designed to benefit public health, and that competition authorities monitor this. With the increasing private ownership of hospitals and shifting short-term responsibility of care to the private sector, social and ecological dimensions that affect societal wellbeing can be overlooked or under examined by regulators. To address this gap, health policy and the public health community should actively engage in shaping competition in ways that prioritise patient welfare and serve a public good function.

Abbreviations

CDoH

Commercial Determinants of Health

CSR

Corporate Social Responsibility

GP

General Practitioner

PCC

Population, Concept, Context

SHI

Social health insurance

U.K.

United Kingdom

U.S.

United States

WHO

World Health Organisation

Author contributions

T.S., S.L., A.E, and J.L.N. contributed to the conception or design of the work. T.S. contributed to the data collection. T.S. and P.K. contributed to the data analysis and interpretation. T.S. wrote the main manuscript text and prepared all tables and figures. T.S., S.L., A.E, and J.L.N. contributed to critical revision of the article. All authors reviewed the manuscript.

Funding

The lead author has received funding through a University of Melbourne PhD scholarship.

Data availability

Our study did not generate any new datasets. All data analysed in this review were extracted from published articles that are cited in the reference list.

Declarations

Ethics approval and consent publication

Not applicable

Consent for publication

Not applicable

Competing interests

Tom Shore is supported by a University of Melbourne graduate research scholarship. Shaun Larkin worked as a consultant for Healthscope Operations Pty Ltd [2019-2024], participated on advisory boards Perx Health [2018 – present] and Eucalyptus [2023-2024]. In the last 36 months SL has also worked in other board/groups leadership roles including Eucalyptus [2024 – present], Prudence Rehab [2022 – present], Humanetix [2019 – 2024], Pharmaceutical Benefits Remuneration Tribunal [2018 – 2024], Like Family [2019 – 2023], and Prospection [2019 – 2023]. Adam G Elshaug has received grants from NHMRC, MRFF, NIH, ACT Health Directorate, Safer Care Victoria, NSW State Insurance Regulatory Authority, and the Australian Dept of Health and Aged Care. In the last 36 months AE has been contracted as a consultant for Cancer Australia and has attended meetings for the Australian Commonwealth Department of Health and Aged Care. Preet Kalkat is supported by a University of Melbourne graduate research scholarship. Jenn Lacy Nicholas is the recipient of a fellowship from the Victorian Health Promotion Foundation (2022-2025); JLN was contracted by the George Institute of Global Health to draft a report commissioned by WHO on commercial determinants of health (2021-2022). JLN is a member of the Public Health Association of Australia, Transparency International Australia and Healthy Food Systems Australia. She was a member of the expert advisory group on commercial determinants of health for WHO (2022-24).