7 Discussion

The aim of the study was to investigate the most common challenges health technology start-
ups face in customer acquisition within the Swedish healthcare sector. With the aim, a
research question that was to be answered was what are the main challenges in B2B customer
acquisition faced by Swedish health technology start-ups? Bearing the research question in
mind, the qualitative research highlighted five common areas of challenges that are faced
when having the healthcare sector as a customer. The following paragraphs will discuss the
identified themes in relation to the aim and research question and outline how each theme
relates to prior research and discuss what the results may imply.

7.1 Stakeholders

The most common and biggest challenge that was mentioned by the interviewees was the
numerous stakeholders required in the sales process. This was exemplified by the results
revolving around major challenges with identifying the key individuals who to talk to.
Similarly, the interviewees described finding the necessary contact information difficult in
addition to gaining the attention of the individuals in question and getting sales meetings
booked. Interestingly, one interviewee had faced the opposite and had no challenge in
identifying, contacting or getting the attention of customers. Furthermore, due to having
multiple different stakeholders, there are individuals with differing aims, complicating the
sales process further.

Having multiple stakeholders is a significant issue. The more individuals are part of the
process the more complex it gets for the selling party, the start-ups. The start-ups have to
manage the stakeholders involved and understand the needs of each one, in order to be able to
cater to the key stakeholders as has already been identified in prior literature (45). For
example, there are positions of blockers and enablers, both of which have to support the
decision as enablers are ones who are to drive the successful customer acquisition while

20
blockers can single-handedly prevent the sale from happening (59). Consequently, accurate
identification of the position each stakeholder possesses is necessary (60). With regards to
finding the right stakeholders to converse with, specialist positions such as champions
emerged. A champion could be a healthcare professional, such as a nurse, who guides the
selling party through the organisation in question, aiding in identifying key stakeholders (60).
The implications of the use of champions may be significant as they appear to provide great
benefits regarding a major challenge experienced by the interviewees.

Furthermore, the involvement of multiple stakeholders was seen to cause divergence of aims
from the stakeholders deciding on the purchases. The results showed that customer
expectations were a challenge as it was noted that hospital management have unreasonable
expectations of the solution. The finding was in line with past research by Geiger et al. who
identified increased customer expectations as sales academics’ views on influential
challenges (48).

The results of the study also agree with challenges of prospecting and getting a response from
the prospects as highlighted by HubSpot research (50). Despite the research by HubSpot
being on a global scale and non-industry specific (50), especially prospecting and finding the
right person to talk to, in addition to getting in touch with them was repeatedly mentioned as
a major challenge by the interviewees. Similarly, Trailer identified that increasing levels of
decision makers and increased times prospecting are major issues sales managers face (49).
This would suggest that some of the common challenges are not specific to just Swedish
health technology start-ups but rather a global challenge induced by country specific factors.

It is interesting to note that there were discrepancies between the interviewees’ views of
challenges in identifying and contacting the key stakeholders. One interviewee noted that
there were no challenges in either finding the right person to talk to or getting in contact with
them. Bearing in mind the complexity of the healthcare providers that was discussed by all
the interviewees, the result could possibly indicate that some segments of the organisations
are easier to contact than others. Perhaps a specific group of nurses and physicians are more
receptive towards the introduction of new solutions. For example, from a related industry, the
pharmaceutical industry, it has been identified that nurses are a desirable target for sales
efforts (61). It could also be suggested that the precise identification of the right stakeholder
to contact ensured that it is easier to contact and book meetings due to well defined sales
pitches aimed at that specific person.

Nevertheless, the multiple stakeholders required to contact suggests that it is possible that the
use of CRM could be used to partly counter the challenges currently faced. As stated by
Nour, CRM can be used as a strategic tool to understand and respond to customers and
improving customer satisfaction (34). Consequently, with the multiple different stakeholders
to manage, the use of CRM solutions to manage and build relationships with each stakeholder
may be beneficial.

7.2 Complex organisations

A second main challenge that the study identified was understanding the structure of the
organizations they were selling to. This was illustrated by the complexity of the specific
organizations within the healthcare sector and differences in understanding how the decision-
making process is organized within the specific clinic in question. In addition, interviewees

21
highlighted that differences in decision making within regions and the procurement processes
between regions vary.

The results are consistent with prior theory in complexity in decision making processes. The
WWM described in the early 1980s highlights the complexity of organisational buying
behaviour (14) and was supplemented by Laczniak with the buying centre containing
physicians, hospital administration employees, nurses and the purchasing department (13).
The entire buying centre was, correspondingly, identified as a challenge for sales by the
interviewees. The structure of the buying centres within the healthcare providers presented
difficulties as the organisational structures can be so complex that individuals within the
clinics sometimes do not know, in detail, all the participants involved. For example, one
interviewee demonstrated the issue by pointing out that sometimes it is unknown who is the
one to sign the contract.

Regarding the Swedish healthcare sector in general, it may have not been the size of the
buying centres that were the biggest issue but rather the inconsistency. Interviewees
mentioned that there were differences in decision making between regions while the
procurement process changed too. This implies that start-ups could be provided with clearer
instructions and paths within each region to aid in the selling party to understand the decision
making of the organisations in question.

Furthermore, the size of the organisation in question is an interesting factor to consider. The
results suggested that organisational complexity and difficulty with a variety of stakeholders
appeared to increase with increasing size of organisation, in line with current knowledge (62).
Interviewees also noted that becoming a well-known name was important in sales
discussions. Consequently, getting the first sales is of importance to start-ups. The results
imply that targeting smaller, less complex clinics first would be of benefit for start-ups as the
sales process may provide less challenges.

7.3 Pace

Thirdly, the slow pace of the healthcare providers was identified as a challenge by several
interviewees. One interviewee described that the sales pitches and contracts were being
pushed aside and others emphasized the reluctance to change from pilot projects into
purchasing the solution. Similarly, attempting to change current practices within the clinics
was seen as a challenge that hindered sales towards the healthcare sector. It should be noted
that differences were prevalent between private and public healthcare providers of different
sizes and smaller clinics were pointed out to have faster processes.

The motivation of nurses and physicians and getting them to change practices was mentioned
by some interviewees as an impediment to the pace of the sales process. As identified by
Konttila et al., motivation of healthcare professionals to accept new digital solutions is
imperative in application of new solution (63). However, the interviewees in the current study
highlighted that nurses and physicians sometimes lacking motivation to change current
practices are a hindrance to sales. This is contradictory to Koivunen et al., who identified that
up to 89% of nurse managers and 85% of registered nurses showed strong motivation to use
new information and communication technologies (64). Similarly, other studies have noted
that negative attitudes towards new technologies is decreasing (65). The variance in these
results imply that some groups of healthcare professionals may still be less receptive towards
new solutions than others.

22
Some of the results regarding pace were against current literature. Despite Geiger et al.
describing market turbulence as a challenge (48), none of the interviewees described the field
of healthcare and the market involved as moving too fast. The consensus of the interviewees
was that the field rather moves too slow for the adoption of new products. There was more an
issue of internal pressure from the companies themselves to have faster deals and shorter lead
times.

7.4 Budgets and finance

The interviewees also described challenges with projects getting stuck in the piloting phase.
The reason for being stuck in the piloting phase was identified by the interviewees to be due
to reluctance or slowness to getting a conversion of a pilot project to an integrated solution.
The slowness for decision making may be due to the lack of clear hospital budgets for new
solutions which can imply a structural challenge for Swedish health technology start-ups. As
pilot projects can be more readily funded, there is a discrepancy of where and how the
products in question get funded and lack of clear solutions hinders the sales process.
Similarly, prior research by Anderson has also found funding to be a challenge with high
initial costs and lack of budgets hindering adoption of IT solutions (46). The result implies
that budgets provided for the healthcare providers could benefit from linking pilots to fully
implemented solutions.

7.5 Regulation and legislation

Lastly, the regulation and legislation related to hospitals acquiring new technological
products was a challenge described by some of the interviewees. The regions were described
not to be ready to assess the new technology and getting regulatory approval for new
products was determined to be a challenge. Due to the interviewees noting the challenge of
hesitance to fully adopt the solutions and closing the deal, the risk-taking willingness of the
stakeholders in the decision-making bodies could be of fault. The risk-taking willingness of
management has been previously recognised to be a factor in organisational buying (62). The
lack of risk-taking for healthcare organisations may be connected to the regulation and
legislation regarding new products as the involvement of lawyers and judgement of old
legislation makes decision making more difficult for the stakeholders. Similarities can be
seen in the United States where privacy concerns and legal barriers are an obstacle for
adoption of technologies in healthcare (46).

7.6 Summary of main implications

Finally, the data provided by the interviewees suggests that it is difficult for Swedish health
technology start-ups to establish a single sales process as the purchasing decision making of
clinics are so different depending on size, between regions, and whether the customer is
private or public. The challenges faced are limiting the potential of current innovation as
solutions are less readily available for use. The results indicate that much of the challenges
regarding structural issues such as organisational differences and budgeting are out of control
for the start-ups. Consequently, if Sweden is to maintain its goals with e-hälsa 2025 (11), the
identified challenges faced by health technology start-ups should be addressed.

23
7.7 Strengths and limitations

The study performed was an exploratory study and consequently, the method of choice was
one of the main strengths because of the gap in knowledge was such that it involved
investigating previously unknown challenges. The use of semi-structured interviews in
qualitative research enabled the collection of rich data not confined by predetermined
concepts (55). Furthermore, as the interview guide developed was used to direct the
interviews, it was ensured that the whole sales process was covered in the interview while
allowing for exploring previously unidentified challenges. Furthermore, using thematic
analysis as a data analysis method followed the same strengths as it allowed for flexibility
with identification of themes within the challenges faced by Swedish health technology start-
ups (55).

In addition, the transferability of findings is accepted to be good as the sample is considered

to be representative due to being within the minimum sample size for homogenous samples
as outlined by Saunders et al. (55). However, the data cannot be used for statistical
generalisation (55). Moreover, the validity and credibility were strengthened by establishing
the interviewees level of knowledge about the topic through in depth research in sales models
such as the seven steps of selling (18, 55)

A limitation of the study was the use of online and mobile interviewing methods. It was
preferred to use face-to-face interviews at it facilitates building of rapport and increases the
likeliness of discussing delicate information about challenges their organisation is facing.
However, due to issues with distance between participants and limitations on the opportunity
to meet interviewees face-to-face, some interviews were held over online conferencing
platforms and over the phone, possibly lowering the quality of the data received. The
limitation was mitigated by performing as many interviews as possible face-to-face and by
expending time and effort to build rapport over online methods.

While the use of thematic analysis was a great strength of the study, it was also a limitation as
it leaves the research open for biases affecting reliability. The biases were avoided as much
as possible by performing numerous iterations of theme identification and re-checking
whether the themes fit the raw data. Furthermore, the language of interviews may have been a
limitation. Although, through sampling for people with sufficient grasp of the English
language, the effects of using the interviewees’ non-native language may have impacted the
quality of the data as it was expressed by some that they could not fully verbalise what they
wanted to. The limitation of language was attempted to be mitigated by having sufficient time
for the interviews and extending pauses during the interviews to promote explanations of
difficult terms.

7.8 Connection to bioentrepreneurship

Bioentrepreneurship stems from the two words bio- and entrepreneurship. While the word bio
may be self-explanatory, in relating to the field of life science, entrepreneurship is more
nuanced and deserves thought. It can be tempting to define entrepreneurship directly but in
doing so one must stay aware of the implications it has. Academics have attempted to define
entrepreneurship but in doing so, the definition has been guided by the beliefs the academics
have had and directed by assumptions made in the process (66). Consequently, there may not
be one correct definition of entrepreneurship, but the theory development behind
entrepreneurship matures with the community of scholars that partake in it (66).

24
As this study identifies as part of the field of bioentrepreneurship, an attempt at providing a
perspective of what bioentrepreneurship means is in place. According to Meyers,
bioentrepreneurship is the process of creating value from life science innovation (67). In line
with this, Bygrave et al. noted that “the entrepreneurial process involves all the functions,
activities and actions associated with perceiving the opportunities and the creation of
organisations to pursue them” (68). Moreover, with innovation, value is brought on by more
than just developing the firm, such as the benefits brought to other individuals, companies
and organisations. Consequently, outbound diffusion of the innovative solution through sales
or other means becomes an integral part of the entrepreneurial process (69). As a result of
these factors, bioentrepreneurship can be seen as the process of innovating, creating value
and bringing benefits of the innovation to others within the life science field.

This study contributes to research in the field of bioentrepreneurship by shedding light on the
challenges faced by start-ups and organisations in the entrepreneurial process. It has provided
insights into aspects of outbound diffusion with a focus on the sales process. The results of
the study can provide a foundation for more detailed research. They can also serve to bring
focus on the challenges faced by Swedish start-ups as it is not up to just the start ups to
realise the benefits of innovation, but also stakeholders in the healthcare sector and local and
regional decision makers.

7.9 Future research

The study identified some of the challenges faced by health technology start-ups faced in
Sweden but lacked in providing a holistic view of the entire process. Sales can be seen as a
relationship between the selling and the buying party. Consequently, future research should
be directed towards further understanding the interaction between the start-ups and the
healthcare sector and to why the challenges that were identified occur.

In addition, the current study provided a snapshot of the challenges that are currently faced.
However, in order to get the entrepreneurial innovation diffused into the healthcare sector,
more research needs to be done on how to counter the challenges identified. There is a
mismatch between what is being said with what is needed in the healthcare sector by the
introduction of programs such as e-hälsa 2025 and how it is perceived to sell to the healthcare
sector. Future research should be directed to explore how the healthcare sector is structured to
adapt to reaching the vision of increased adoption of heath technologies.

8 Conclusion
In conclusion, the study sought to investigate common challenges health technology start-ups
face in customer acquisition within the Swedish healthcare. The process of customer
acquisition was approached through the sales process. The research question was answered,
and several challenges were identified. The main challenges that Swedish start-ups face with
customer acquisition revolve around having a high number of various stakeholders involved
in the process, difficulty understanding the organisational structure of the healthcare
providers, the budgeting structure that the healthcare providers must adhere to, the slow pace
of the process and high prevalence of rules and regulations concerning purchases of digital
solutions.

25
While the results identified are not an exhaustive account of challenges faced by health
technology start-ups, they do highlight information that may be implicative of structural
issues that stem from within the healthcare sector. The results can be of interest to both start-
ups engaging in customer acquisition and the healthcare providers and regional decision
makers. Especially, if Sweden is to reach its goals with e-hälsa 2025, concrete efforts should
be made in addressing the identified challenges by implementing efforts to aid in identifying
decision makers and DMUs, providing programmes for easy access for start-ups to direct
sales efforts, and providing budgets linking pilots to fully implemented products.

26
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