1. Introduction
Financial actors across the private investment industry – such as asset managers, private equity firms, venture capitalists, portfolio firms, and institutional investors – are increasingly turning their attention to the healthcare sector. Attracted by the sector’s rising demand and relatively stable character, healthcare appears as a relatively safe and promising sector for investment across countries, particularly in Northern Americas, the UK, and West-European countries (August, Reference August2022; Bain & Company, 2025; Henry & Loomis, Reference Henry and Loomis2023; Singh et al., Reference Singh, Fuse Brown and Papanicolas2025a). Private investments and financial practices in contemporary healthcare systems are rising against the backdrop of growing concerns about a looming healthcare crisis across these countries, characterised by (although to varying extents and in different forms) workforce shortages, increasing demands for care, more complex care needs, austerity measures and a decreasing belief that public funding can pursue the ‘necessary transition’ (Aveline-Dubach, Reference Aveline-Dubach2022; Bos et al., Reference Bos, Kruse and Jeurissen2020; Dowling, Reference Dowling2021; Henry & Loomis, Reference Henry and Loomis2023; Hoppania et al., Reference Hoppania, Karsio, Näre, Vaittinen and Zechner2024; O’Neill & Mercille, Reference O’Neill and Mercille2025).
The involvement of financial actors is diverse and continually evolving, spanning private equity investments to the provision of technological and data infrastructures. In undertaking these activities, financial actors draw in a wide array of other actors – including auditors, consultants, lawyers, rating agencies, tech firms, and real-estate companies – thereby introducing new logics, expertises, and practices into healthcare systems from both inside and outside the financial domain. Illustrative examples include leveraged buyouts, buy-and-build strategies, and mergers and acquisitions (Bain & Company, 2025; Batt & Morgan, Reference Batt and Morgan2020). Such mechanisms, often aimed at expanding scale and international reach, actively cultivate a ‘culture of value extraction’ (Froud & Williams, Reference Froud and Williams2007), thereby rendering healthcare an increasingly attractive domain for investors (August, Reference August2022; Horton, Reference Horton2022; White, Reference White2024).
By invoking notions of efficiency, optimisation, and growth, financial actors promote their involvement as offering forward-thinking, innovative solutions to current system challenges (Froud et al., Reference Froud, Johal, Leaver and Williams2006; Froud & Williams, Reference Froud and Williams2007; Henry & Loomis, Reference Henry and Loomis2023; Horton, Reference Horton2021). Here, the ability to unlock hidden value, turnaround underperforming organisations, and introduce managerial and operational expertise is highlighted, particularly in contexts of perceived inefficiency and institutional inertia (Batt & Morgan, Reference Batt and Morgan2020). Hence, alongside the financial capital that is invested, promises of data-driven efficiencies, scalable solutions, and new delivery models make these actors attractive to both governments and healthcare institutions (Gardner, Reference Gardner2023; Gauld, Reference Gauld2021; Henry & Loomis, Reference Henry and Loomis2023; Kannan et al., Reference Kannan, Bruch and Song2023; Waring, Reference Waring2015).
The growing intervention of financial actors and private investments in healthcare is not without controversy, however. Several cases in which the involvement of financial actors resulted in malpractices or significant decline in healthcare quality and accessibility have attracted considerable public and political attention (August, Reference August2022; Lintern, Reference Lintern2025). Consequently, there are concerns about how the profit-driven orientation of financial actors may lead to tensions between financial objectives and the provision of qualitative, accessible, and affordable healthcare – a tension that has been examined in a growing body of research (Aveline-Dubach, Reference Aveline-Dubach2022; Batt & Morgan, Reference Batt and Morgan2020; Kruse et al., Reference Kruse, Auener and Jeurissen2022; Orewa et al., Reference Orewa, Karabukayeva, Pradhan, Jimoh and Weech-Maldonado2025; Singh et al., Reference Singh, Fuse Brown and Papanicolas2025b). These concerns trigger policy and political debates over whether and to what extend profit-making should play a role in healthcare.
The work of scholars in Science and Technology Studies (STS) and political economy help to engage with these debates by directing the attention to what financial actors do. These literatures show how financial actors make themselves present, the practices they enact and the infrastructures they draw on and develop (Birch & Muniesa, Reference Birch and Muniesa2020; Birch & Ward, Reference Birch and Ward2022; Çalışkan & Callon, Reference Çalışkan and Callon2010; Callon et al., Reference Callon, Caliskan and MacKenzie2025; White, Reference White2024). Building on this, we will argue that healthcare is increasingly being transformed into an investable asset class, governed by an investor logic centred on ownership, valuation, and profitability, and materialised through financial strategies, valuation frameworks and knowledge practices that entangle it with broader financial infrastructures. To explore how healthcare is being (re)articulated, valued, and shaped through this ‘investor logic’, in this paper we employ the concept of assetization – the active process through which different ‘things’, such as goods, services, and infrastructures, are transformed into asset forms, capable of producing return for investors (Birch & Muniesa, Reference Birch and Muniesa2020).
While we recognise that assetization is a flexible and fluid term with varying meanings across fields and disciplines, we adopt an STS-perspective that foregrounds how assets are actively produced and how diverse entities can be transformed into assets. This allows us to move beyond a technical, accounting-based understanding of assets and instead emphasise their processual and socially transformative dimensions. Through this lens, we examine how entities can be reconstituted as assets via legal, technical, and political mechanisms that align them with an investor logic (Birch & Muniesa, Reference Birch and Muniesa2020; Birch & Ward, Reference Birch and Ward2022; Golka, Reference Golka2021).
To investigate these dynamics, we employ a multiple case study design, examining how financial actors have gained access to healthcare systems in three countries: England, Canada, and the Netherlands. Rather than selecting and comparing cases based on a fixed logic, we deliberately explore the diverse contexts in which financial actors have found entry points – that is, in England as a ‘more efficient shadow’ infrastructure to the NHS, in Canada through the promise of data-driven healthcare, and in the Netherlands through digital labour platforms’ mediated self-employment. These three national cases reflect diverse ways assetization can materialise and evolve over time within different institutional landscapes and socio-political cultures. Although the cases might seem to unfold simultaneously, they are better understood as distinct positions, or moments in time, within a wider trajectory of assetization processes.
In what follows, we further conceptualise the notion of assetization and situate it within broader discussions on commodification, financialization and private investments. We then present the three empirical cases in which we discuss how assetization takes root in each country. Through this analysis, we seek to illuminate the evolving infrastructures through which healthcare is organised under the influence of investor logic.
2. Theoretical framework
Over the past decades, healthcare has increasingly been framed and valued through an economic lens, frequently discussed in relation to processes like marketisation, privatisation, and commodification (Engelen et al., Reference Engelen, Mosciaro and Kaika2023; Maarse et al., Reference Maarse, Jeurissen and Ruwaard2016; McGregor, Reference McGregor2001; Waring & Bishop, Reference Waring and Bishop2012). Within this broader transformation, the growing presence of private interests and financial actors in public financing has become a key topic of scholarly debate (Batt & Morgan, Reference Batt and Morgan2020; Christophers, Reference Christophers2023). These debates reflect a contemporary policy environment in which states increasingly look at the private sector to achieve sustainable funding for public services and ensure the economic viability of public services, like transport infrastructures (Buier, Reference Buier, Birch and Muniessa2023), healthcare (Horton, Reference Horton2021), housing (Beswick et al., Reference Beswick, Alexandri, Byrne, Vives-Miró, Fields, Hodkinson and Janoschka2016; White & Madden, Reference White and Madden2024; Wijburg et al., Reference Wijburg, Aalbers and Heeg2018) and education (Milyaeva & Neyland, Reference Milyaeva, Neyland, Birch and Muniessa2023).
Chiapello (Reference Chiapello2015, Reference Chiapello, Mader, Mertens and Van Der Zwan2020) observes that a central feature of this shift is the proliferation of quantification practices designed to assess efficiency, accountability, and economic value. These financialized practices have come to underpin investment-based thinking and practices across sectors outside of the financial markets (Chiapello, Reference Chiapello, Mader, Mertens and Van Der Zwan2020; Froud et al., Reference Froud, Johal, Leaver and Williams2006). Especially with the rise of private investors, corporations and ‘Big Tech’, such practices have become increasingly embedded within public domains and infrastructures across Europe and North America (Birch & Muniesa, Reference Birch and Muniesa2020), reshaping how value is defined, measured and distributed in fields like healthcare.
2.1. Assetization
Recent work in STS has renewed attention to how future value is constructed in the present through techno-economic processes, knowledge practices and investment-based thinking (Birch & Ward, Reference Birch and Ward2024; Chiapello, Reference Chiapello, Mader, Mertens and Van Der Zwan2020; Delvenne, Reference Delvenne2021; Doganova and Rabeharisoa, Reference Doganova and Rabeharisoa2024; Doganova, Reference Doganova, Kemp and Andersson2020; White, Reference White2024). Building on scholarship on promissory economies (see e.g., Petersen & Krisjansen, Reference Petersen and Krisjansen2015), STS scholars emphasise that expectations and valuations are not inherent but socially organised: they are authored, circulated, and stabilised by specific actors across diverse institutional and technological settings. In this sense, value is not a fixed thing out there to be discovered but actively produced through discursive and calculative practices that shape what counts as profitable, investable, or valuable in the present.
This notion of assetization differs from more conventional economic definitions, which tend to understand assets as financial instruments, components of investment portfolios associated with valuation, hedging, and arbitrage (Burton & Jermakowicz, Reference Burton and Jermakowicz2015), or which emphasise the institutional nature of assets (Birch & Muniesa, Reference Birch and Muniesa2020). Using an STS-informed understanding of assetization as a conceptual lens enables us to unpack the notion of the asset as both an objective resource (a factor of production) and a subjective value (an outcome of valuation practices) (Muniesa, Reference Muniesa2014). It is simultaneously a form and condition that structures contemporary economies and governance – and, as this paper explores, the organisation and functioning of healthcare.
In relation to broader economic shifts, such as the rise of platform capitalism, financialization, and digitalisation, Birch & Muniesa (Reference Birch and Muniesa2020) innovated the assetization literature to capture the active, situated practices through which entities are configured or reconfigured as assets. Although markets, speculation and commodities continue to play an important role in shaping contemporary economies, assetization allows for an exploration of how economic activity is increasingly structured around capital growth and rent extraction rather than production or exchange on markets (Birch & Ward, Reference Birch and Ward2022; Birch & Ward, Reference Birch and Ward2024). Assetization, in this understanding, offers a lens to look at the current moment not merely as an extension of markets but as a re-orientation and reconfiguration of value itself, and the complex circuits and entanglements of actors through which value is generated and captured.
Assets may be traded, but their primary value lies not in their immediate sale. Instead, their value derives from their capacity to generate revenue over time through enclosure (the restriction of access and control) and capitalisation (as the calculation of the present valuation of future income streams). Assetization highlights how the interplay between balance sheet asset formation and the market-making of financial risk and return structures modes of meaning-making, accumulation, governance, and infrastructural reconfigurations (Birch & Ward, Reference Birch and Ward2024). As such, the financial contours of the market are limited in explaining the complex networks through which value is generated and captured, nor does it capture the social and technical processes implicated in the making of an asset (Birch & Muniesa, Reference Birch and Muniesa2020).
Assetization is therefore not just about ownership but about also financial engineering, the process through which future revenue is anticipated, priced and pulled into present-day financial circulation. This introduces a speculative dimension in which the value of an asset is performative, where the value of an asset is performed into being – i.e., it (re)produces realities by enacting the very values it anticipates (Birch, Reference Birch2017; Muniesa, Reference Muniesa2017; Unal et al., Reference Unal, Polillo, Caliskan and MacKenzie2025). From this perspective, assets are not given but actively made. They are not static objects of exchange but performative entities, whose value and ownership are actively constituted in the present (Golka, Reference Golka2021).
Hence, in understanding assetization as relational and future-oriented process, the asset is not a neutral or fixed entity but a constructed form embedded with political, social, and economic assumptions about who can claim future revenue and on what terms (Birch & Ward, Reference Birch and Ward2022). This process involves the labour of a diverse range of experts such as economists, analysts, and policymakers, whose practices enact and legitimize the very assets they evaluate (Adkins et al., Reference Adkins, Cooper and Konings2022; Christophers, Reference Christophers2020, Reference Christophers2024). Using assetization as a lens, therefore, allows for a focus on how assets are actively constructed, emphasising the legal, technical, and institutional mechanisms involved in turning diverse entities into revenue-generating assets (Birch & Muniesa, Reference Birch and Muniesa2020; White, Reference White2024).
2.2. Investor logic
As Birch & Muniesa (Reference Birch and Muniesa2020) argue, assetization is not merely an economic mechanism or financial practice, but a process of narrative transformation. It reshapes how financial actors are represented and how they imagine their roles in value creation. The notion that financial actors ‘create value’ for their clients ties into liberal market rationalities, in which financial markets are seen as allocating resources efficiently and producing socially optimal outcomes (Chiapello, Reference Chiapello2015; Preda, Reference Preda2009). Through narratives of innovation, efficiency, and sustainability, financial actors sustain this worldview, presenting their interventions as forward-looking solutions (Froud & Williams, Reference Froud and Williams2007; Golka, Reference Golka2021; Willmott, Reference Willmott2010). These narratives sell the promise of future returns while legitimising the transformation of public domains into legitimate sites of investment. The logic of the investor informs how value, efficiency and responsibility are conceived and accordingly (re)configured.
In this sense, assetization depends on the normalisation of the investor’s logic as the standard for evaluating forms of value. Executives are urged to ‘think like investors’ rather than managers, equating value creation with return on investment rather than with innovation or public service (Ortiz, Reference Ortiz2014). This imperative extends beyond the corporate world to governance and policy, where decision-making adopts the rationalities of investment management and opportunity cost (Birch & Muniesa, Reference Birch and Muniesa2020; Ortiz, Reference Ortiz2013). The asset base of firms increasingly functions as the principal indicator of organisational performance, replacing traditional measures of productivity or competitiveness (Chiapello, Reference Chiapello, Mader, Mertens and Van Der Zwan2020; Christophers, Reference Christophers2024).
Understanding this investor logic as an extension of assetization highlights its political and institutional implications. Following this, the ongoing pursuit to enter healthcare systems and the extraction of value is not just a technical matter, but a power-laden process administered by particular actors with specific interests at specific times, including alliances between political and financial actors (Birch & Ward, Reference Birch and Ward2022; Ortiz, Reference Ortiz2013; White, Reference White2024). This includes alliances that capitalise on, and sometimes actively shape, regulatory gaps, policy shifts, and windows of political momentum (Birch & Ward, Reference Birch and Ward2022). For example, governments sanction and protect assets, transforming them into something that provides security over future income streams (Birch & Muniesa, Reference Birch and Muniesa2020; Pistor, Reference Pistor2020; Tellmann, Reference Tellmann2022). Moreover, the strategies and practices of investors and financial actors can also actively exploit political–economic crises, mapping onto long-standing structural inequalities and emerging fragilities in healthcare systems (Horton, Reference Horton2021).
This is not, however, to suggest that all investors are the same, and that the assetization of care is driven by singular investor logic. Instead, what we see is a varied consortium of interests, sometimes in collaboration, and sometimes in competition. These actors opt into different parts of healthcare systems depending on variables including their size, mandates, risk appetite, and the way in which they judge the realisation of value – for example asset value, earnings potential or market share. We also see how there is a variety of ‘routes to market’ through which an investor can get involved in healthcare – from direct real asset acquisition (e.g., purchasing a building) to fractional and indirect ownership of key services via investment funds, to holding equity stakes in healthcare platforms. Hence, to grasp how assetization takes place through diverse narratives, practices, and infrastructures, we must empirically study how financial actors gain access, introduce investor logic, and reshape infrastructures of healthcare. Accordingly, this paper examines how an emerging investor logic restructures the conditions under which financial actors are able to transform healthcare into an asset, and it explores this by analysing the mechanisms through which that logic is articulated and enacted.
3. Mapping assetization in England, Canada, and the Netherlands
In this paper, we turn to a series of empirical cases with specific socio-political and institutional contexts and examine how financial actors have gained access to healthcare. We show how they were introduced or ‘invited themselves’ in distinct ways, exemplifying financial practices and epistemic visions seeking for rent-generation. At the same time, we will show how these processes are shaped by certain governmental ambivalence in which they simultaneously welcomed financial actors for their promises of efficiency and investment, while exploring and learning to regulate and constrain their influence.
The three case studies in respectively England, Canada, and the Netherlands are cases in the sense that they illustrate distinct ways in which financial actors embed themselves in healthcare policy and practices – often through ambiguous and conflict-prone collaborations with public government agencies. As mentioned before, the three countries discussed do not serve as exclusive or representative cases, but rather as entry points for understanding and mapping how assetization can materialise within distinct institutional environments. While the cases may appear to unfold in parallel, they, in fact, represent different stages within the broader cycle of assetization.
3.1. Elective care modernisation and provision in England
In England, the dynamics of assetization can be traced back to the 1990s, taking root in the National Health Service (NHS) first in the financing of long-term community-based care, and later in diagnostic and pathology services, as well as in some areas of acute hospital provision. Historically, the NHS has offered healthcare services ‘free at the point of use’ funded through central taxation, which has become highly cherished as part of the English social and political culture (Klein, Reference Klein2013). Yet, for over three decades, in the context of constrained public finances, the NHS has faced a sustained problem of under-investment in hospital infrastructure, lack of modernisation in service organisation and delivery, and lack of strategic planning for workforce development (The Health Foundation and The King’s Fund, 2015). At the same time, the growing demand for acute hospital services, especially with an ageing population with complex care needs, further strained resources. This has resulted in long waits, variable experience of care quality, and declining public acceptance of the NHS.
These pressures provided the economic antecedents for multiple English governments to look for alternate sources of investment and funding for public NHS services, especially to innovate and modernise the infrastructures of care services – both in hospital and nursing home care. Added to these, are the ideological antecedents initially laid down by the Conversative governments of the 1980s and 1990s which saw, for example, a strong endorsement of neo-liberal market principles in the allocation of NHS resources and the marketisation of community and social care services. Subsequent Labour governments in the late 1990s and 2000s further deepened this trend, purportedly on the basis of pragmatism rather than ideological fervour.
Against this backdrop, we focus on the processes of assetization that centred on the use of Public–Private Partnerships (PPPs) in the financing and building of new hospital infrastructure. As indicated above, multiple governments in the 1990s and 2000s actively courted private sector investors to alleviate the demands of public resources whilst also to source new ideas, management practices and technologies to revolutionise public services, which reached beyond healthcare to include rail and postal services, for example. In many cases, these PPPs involved long-term financial relationships that involved the investment of private capital to finance the design and build on a new hospital infrastructure. This infrastructure would then be leased back to the NHS through long-term financial commitments in the form of rent to provide return on investment. This enabled a form of rent extraction from the NHS with relatively stable and lucrative contracts, effectively transforming hospital infrastructure into rent-bearing assets. The private sector thereby extracted rent from public healthcare budgets while assuming limited operational risks. This created a type of landlordism and dependency in the health sector, embedding financial actors, practices and logics within the fabric of NHS.
In these PPPs, it was also common for the private firm to either directly or indirectly assume responsibility for a range of ancillary services, such as cleaning, catering, parking, and portering. In this sense, the private investor was able to assume financial responsibility for the peripheral elements of the organisation, which would be again provided under contract to the NHS renter of the facility. In most cases, the organisation and delivery of core care remained with the established governance arrangements of the NHS, including NHS employed doctors, nurses and other healthcare professionals. Although less common, in some cases, the private investor would assume more direct responsibility of NHS-services, including the employment and management of staff and provision of services. In these situations, the private firm would bid for contracts to provide NHS services, often with relative secure or guaranteed margins. In these situations, NHS patients encountered new hospital facilities that were co-branded as both NHS and the private operator.
For example, the global brand ‘Virgin’ acquired a stake in ‘Assura Medical Services’ in the mid-2000s, a company that specialised in developing primary and community estates and facilities. By the late 2000s, Assura Medical Service was brought within the Virgin Group and started managing walk-in centres to expand the provision of urgent care. In 2011, Assura Medical was rebranded as Virgin Care and, since then, has grown to manage and provide over 200 community health and social care services across England under contractual arrangement with NHS commissioners (Hawkes, Reference Hawkes2010; O’Dowd, Reference O’Dowd2012). A number of other private firms have since acquired contracts to provide NHS services, often specialising in diagnostic and community services that might be regarded as working on the fringes or periphery of more acute and specialist services. This includes, for example, community health services, younger people’s service, sexual health services, urgent care services and prison health services.
The impact of such private investments in health services is complex and multifaceted. On the one hand, it has seen significant improvements in the NHS infrastructure through the funding for new hospitals and technologies (Waring & Bishop, Reference Waring and Bishop2012). In many cases, it has also resulted in the expansion of services, reduction in waiting times, operational efficiencies and improved outcomes. At the same time, there have been other less obvious implications for the organisation of health service work and the provision of care, including the ‘McDonaldization of care’ (Waring & Bishop, Reference Waring and Bishop2012), as not only the structure of healthcare but also the social meaning of care and care work is changing. In the privatised context, doctors and nurses are increasingly expected to confirm with hyper-standardised services models and standardised guidelines. Meanwhile, patients are expected to act as proactive, rational consumers of healthcare who must actively choose among a menu of service providers and who can access care in more convenient and time-limited interactions.
There are also noteworthy cases where the relationship with private firms resulted in financial risks for both partners, but often with more fundamental service delivery problems for public care provisioners. A prominent example was with the collapse of the Carillon Construction group in 2018, which halted construction of new hospital buildings in Liverpool and the West Midlands (National Audit Office, 2020). The private contractor responsible for the design and construction of these hospitals ran into financial difficulties due to financial mismanagement, cost overruns and audit failures. In Liverpool, for example, the construction of the 600+ bed state-of-the-art hospital scheduled to open in 2017 was delayed and a second contractor was brought in to complete the work needed to undertake significant remedial improvements, with the hospital eventually opening in 2022. Notwithstanding such situations, it remains commonplace for new NHS infrastructure to be constructed and management in partnership with a private contract, with opportunities to transform non-clinical aspects of service organisation into rent-bearing assets. Here, the so-called asset conditions become visible, where the political logic that determines what returns asset investors are entitled to expect and safeguarded, even though these expectations take precedence over other collective or public considerations.
Over the last two decades, the role of the private sector in the financing and provision of NHS care has waxed and waned. Since the 2010s and with the return of a Conservative government, the health services was re-imagined in the form of the ‘NHS marketplace’ and there has been renewed interests in encouraging private actors to contribute to the provision of NHS care – either in collaboration or competition with public providers. In this context, private providers again play a more direct role in providing health and care services often through direct competitive tendering with NHS care commissioners.
Major markets for care have become established in high demand areas with both NHS and direct out-of-pocket payments, especially in GP services, child and adolescent mental health services, and family health services. Coinciding with this in recent years, there has been a growth in private involvement in English healthcare services that has been indirect to customer (or workplace employer) private medical insurance which affords rapid access to private diagnostic and care services outside of the NHS, exemplifying the increasingly diverse set of assetized healthcare services and ‘products’ in the ‘national’ English health system. In recent years, there has been growing interest in transatlantic partnership around NHS modernisation, ‘health tech’ and pharmaceutical innovation, such as the Meridian Health Ventures. Such partnerships allow for US capital investors, pharmaceuticals and start-ups to more closely invest in and collaborate with NHS provider organisations. However, there often remain strong voices of concerns relating to this international intervention and dependencies in the NHS.
3.2 Data, technology vendors, and government interventions in Canadian health care
The Canadian healthcare system is characterised by a shared responsibility between federal and provincial/territorial governments. At a national level, the Canada Health Act (1985) dictates the conditions by which the federal government will transfer funds to provinces/territories. It is through the transfer of funds that the federal government is most able to exercise its influence over provinces/territories and to shape healthcare at a national level. These funds are directed towards medically necessary hospital and medical services, meaning that a substantive amount of health and preventive care remains outside the jurisdiction of the Canada Health Act (Denis et al., Reference Denis, Germain, Régis and Veronesi2022).
Having received a proportion of funds from the federal government, each province/territory is responsible for setting healthcare standards, establishing programmes, and determining eligibility for healthcare outside of what is considered medically necessary. Thus, provinces/territories have differential approaches to drug coverage, long-term care, community support services, home care, and rehabilitation services (Digital Health Canada, 2023). Notably, the Canada Health Act does not forbid inclusion of the private sector in the publicly funded aspects of healthcare, as long as providers do not charge for medically necessary services already insured by provinces/territories. As such, many aspects of health care, such as laboratory services, facility maintenance and additional services are carried out privately.
In recent years, and in response to austerity pressures, escalating costs, and a diminishing workforce, Canadian governments have directed policy attention to information technologies as a potential solution space with national impact. Under the banner of ‘data saves lives’ (Alberta Virtual Care, 2023), the data produced through clinical care becomes increasingly valuable to a range of stakeholders. These stakeholders include administrators and policy makers using this data to inform workforce planning (Vezyridis & Timmons, Reference Vezyridis and Timmons2021).
In response, for-profit technology developers and vendors leverage the current surge of ‘data appetites’ by making promises about what their technologies can do. The ongoing development and deployment of technologies such as telehealth (e.g., videoconferencing technologies), remote patient monitoring (e.g., in-home surveillance technologies, tele-homecare), and mobile health applications (e.g., wearable technologies, patient-focused decision aids) would reduce the pressure on physical infrastructures of health care, expanding the reach of clinical service without expanding the real estate footprint. In addition, these tools would open possibilities for task-shifting, potentially reducing pressure on beleaguered workforces as technology supported tasks are shifted between practitioners, patients, caregivers, and volunteers.
To fully leverage health care data as a public asset, the federal government recently proposed a $505 million investment to the Canadian Institute for Health Information, Canada Health Infoway, and federal data partners to work with provinces and territories to improve digital health tools, develop new health data indicators, and support the use of new data to improve safety and quality of care (Government of Canada, 2023). In addition, this plan promises additional funds to provinces to support health services, in turn requiring a commitment from provinces to improve how health information is collected, shared, used, and reported (Government of Canada, 2023). Thus, the federal government aims to use cash and tax transfers to incentivize increased provincial and territorial investment in digital futures.
For the federal government, the value of data is dependent on the technological and social practices and processes that allow the translation and transfer of data from one site to another, freely sharing and combining data. However, technology companies have no financial incentive to develop standards, practices or processes that would allow meaningful sharing of data across their boundaries. For developers and vendors of technology – or the organisations that have purchased these technologies – the value of data derives exactly through the creation and maintenance of data enclaves (Birch, Reference Birch2023). There is little financial incentive to address broader problems of interoperability that do not impact their day-to-day operations. Indeed, there are financial incentives to maintain data boundaries and associated assets (Birch & Adediji, Reference Birch and Adediji2023; Competition Bureau Canada, 2022). Data that is held in isolated databases, incompatible systems, and proprietary software is difficult to exchange, analyse, and interpret, raising issues of interoperability. With healthcare data becoming an increasingly attractive investment asset, the vested interests of private sector software vendors impede moves towards better data interoperability (Birch & Adediji, Reference Birch and Adediji2023; Competition Bureau Canada, 2022).
In response to these tensions that colour the promises of vendors, the federal government proposed a new Act. Called the Connected Care for Canadians Act (Bill C-72), the stated purpose of this Act was to facilitate access, use, and exchange of electronic health information and to prohibit data blocking by health information technology vendors. This Act specifically outlines the responsibility of health information technology vendors to ensure that users of these technologies will be able to access all available electronic health information, exchange health information with other health information technologies, and meet prescribed standards, specifications, and requirements that will be set in future regulation. This Act was presented as crucial to the broader aims of integrated care (Connected Care for Canadians Act, 2024).
However, attempts to regulate technological vendors or designing digital infrastructures without these vendors appears not without risk. Critics of this act worry about the exclusive focus on vendors in the absence of technology deployers, the fluidity of what counts as ‘health information’ and ‘health information technologies’, and the wide net being cast to define ‘health information technology vendor’ (Fekete et al., Reference Fekete, Kardash, Watts, Newell and Cartagena2024). These critics warn that the act may result in further boundaries between health service providers unwilling to share the technology services to which they have already made substantial investments. Moreover, attempts to intervene in the ways data is produced and shared shifts the value proposition for various investors. Too strong of a federal government intervention is seen by many to risk the exit of these vendors in Canadian’s business landscape (Fekete et al., Reference Fekete, Kardash, Watts, Newell and Cartagena2024).
With the call for a federal election in 2025, Bill C-72 has not passed through House of Commons and its future as an act is far from certain. At stake is how these distributions of value will be determined in these intersections between private and public interests. The fate of the proposed act highlights the difficulty of designing and implementing government interventions in light of election cycles. Moreover, increasing socio-political tensions between Canada and the United States raise new questions about the vulnerabilities implicated by Canada’s reliance on American software vendors and what the role of government should be in protecting the sovereignty of health data held by international companies (Geist & Wilson, Reference Geist and Wilson2025).
3.3. Digital labour platforms as a site of assetization in Dutch healthcare
In the Netherlands, the prevalence of self-employed care workers has risen substantially, with their numbers increasing by 77 percent between 2014 and 2024 (CBS). Although temporary work and agency-based employment have long existed in healthcare (Carey & Hazelbaker, Reference Carey and Hazelbaker1986; Tailby, Reference Tailby2005), the recent growth of self-employment marks a broader structural shift. Since the 1990s, the number of self-employed professionals expanded steadily (Westerveld, Reference Westerveld2016), driven by neo-liberal reforms and mounting pressures on public budgets (Jabko, Reference Jabko, Dyson and Marcussen2009; Zuidhof, Reference Zuidhof2019). Policies such as tax incentives, start-up support, and initiatives promoting self-reliance and entrepreneurship have further facilitated this trend, positioning self-employed care workers largely outside the formal welfare state (Slagboom, Reference Slagboom2025; Sociaal Economische Raad, 1998).
Against this backdrop, digital platforms represent a new phase in the mediation and valuation of such work. In the Netherlands as elsewhere, private and for-profit digital labour platforms are entering public sectors and enabling new forms of self-employment. These platforms attract care workers into self-employment through narratives about autonomy, flexibility, and self-fulfilment, foregrounding the individual healthcare worker’s identity (Dingelstad et al., Reference Dingelstad, Grommé and Wallenburg2025). Such narratives resonate strongly in a context in which healthcare workers face high workloads and poor working conditions as a result of persistent workforce shortages (Dingelstad et al., Reference Dingelstad, Grommé and Wallenburg2025). At the same time, care work continues to be devalued through gendered framing that portray it as routine or emotionally driven, rather than as skilled, knowledgeable and complex labour. These framings cast healthcare workers as altruistic and self-sacrificing instead of as autonomous professionals or career-makers (Duijs et al., Reference Duijs, Haremaker, Bourik, Abma and Verdonk2021, Reference Duijs, Abma, Plak, Jhingoeri, Abena-Jaspers, Senoussi, Mazurel, Bourik and Verdonk2022; ten Hoeve et al., Reference ten Hoeve, Jansen and Roodbol2014). Digital labour platforms, therefore, offer healthcare workers a way to assert control over both the value of their labour and their professional identities.
In healthcare specifically, financial and technological actors behind these platforms promote them as an innovative solution to staff shortages and rising care demands. These actors position digital labour platforms as alternative infrastructures for organising work, aligning with broader trends of labour-market flexibilization and the rise of self-employment (Duijs et al., Reference Duijs, Abma, Plak, Jhingoeri, Abena-Jaspers, Senoussi, Mazurel, Bourik and Verdonk2022; de Vaujan et al., Reference De Vaujany, Leclercq-Vandelannoitte, Munro, Nama and Holt2021). Similar to gig economy models like Uber, these platforms structure labour through temporary, on-demand assignments facilitated by digital technologies (Chan, Reference Chan2019; Rosenblat & Stark, Reference Rosenblat and Stark2016). Self-employed care workers typically pay a service fee (often a percentage between 4.5–10% per hour) to the platform mediating their shifts. This arrangement reflects new forms of rent extraction from labour and fluid ownership: while workers earn income from their services, platforms simultaneously capture value from labour.
The valuation of healthcare work is also reshaped through the digital infrastructures on which these platforms rely. Rather than deriving primarily from activities performed on the work floor, the value of labour becomes tied to workers’ integration into data-driven infrastructures where their profiles constitute revenue-generating asset. On the digital platform, healthcare workers must create profiles, signal credibility and attractiveness as a professional, and compete for visibility in algorithmic systems. The valuation of labour thus becomes increasingly tied to a worker’s capacity to navigate algorithmic systems and perform professionalism within platform interfaces to ‘find’ and ‘get’ shifts (i.e., to earn income).
Comparable to Canada’s digital health technologies, the digital infrastructures that underpin these platforms generate extensive data on workers’ activities and behaviours. This data can be used to optimise logistical processes and enhance algorithmic decision-making. Unlike ‘traditional’ labour, the value of data is not fixed at the point of production. Instead, it is speculative and elastic, growing as it scales and becomes integrated into analytic systems. Platforms may sell or share datasets with third parties, like IT providers or operational service providers who participate in facilitating a broader value ecosystem around this new way of working. The data the platforms accumulate can be leveraged to gain competitive advantages by reducing costs, creating cross-sector innovations, and making analyses about the ‘future’.
At the same time, critics argue that the proliferation of self-employment undermines the continuity of care, inflates costs, and destabilises collaborative work environments (Bax, Reference Bax2023; Slagboom, Reference Slagboom2025; Slikker, Reference Slikker2024; Van Kommer, Reference Van Kommer2023). Blurring boundaries between employee and contractor and consumer and provider further complicate regulatory oversight. Despite that the majority of the self-employed workers in healthcare operate through intermediaries such as digital labour platforms (Bloemendal, Reference Bloemendal2024), these platforms remain notably absent from public and political debates about self-employment in the sector. Their marginal visibility contrasts sharply with the central role they play in structuring how healthcare work is organised, mediated and valued.
This disconnect becomes evident in the implementation in the Deregulation of Assessment of Employment Relationships Act (Wet DBA), introduced in 2016 and enforced as of January 2025, which aimed to clarify employment classifications and combat bogus self-employment. While the Act places regulatory pressure on self-employed workers and healthcare organisations, platforms themselves often manage to evade direct scrutiny. As digital labour platforms are often embedded in cycles of investment and exit, they can respond swiftly to such regulatory conditions. To explain, platforms are rarely standalone actors but are often subsidiaries of large (inter)national firms or tech conglomerates backed by private investments. A telling example is a Dutch healthcare platform formerly backed by private equity, which sold its shares to a staffing firm in response to intensified DBA enforcement. For the acquiring firm, it is attractive to offer temporary and secondment contracts to the self-employed workers who previously worked through the digital platform. Such contracts mitigate the risks of bogus self-employment while still being able to attract users to the platform through values of autonomy, flexibility and control embedded in the digital platform’s appearance, feel, branding and use.
Additionally, these platforms can make use of the vulnerability for self-employed healthcare workers arising from uncertainty and anxiety about the enforcement of the DBA Act. Formally bearing the risks and responsibilities of their entrepreneurship, therefore, labour regulations are therefore mainly focused on the self-employed healthcare workers and the work that is happening ‘offline’ in local geographies. Digital platforms respond to these perceived risks and responsibility by, for example, providing extensive resources on legislation, practical tips, and step-by-step guides aimed both at self-employed healthcare workers seeking to maintain their independent status and healthcare organisations wanting to preserve a flexible workforce.
By promoting a ‘new way of working’, framed in terms of technological innovation and labour-market sustainability, platforms position themselves as contributing to a more resilient healthcare system, and by extension, as attractive investment opportunities. These narratives of social impact are deliberately constructed through strategic branding practices, often in collaboration with communication and PR experts. This positioning appeals to private equity and venture capital firms, including those investing on behalf of institutional investors such as pension funds and insurers seeking socially or sustainably oriented returns. The networked organisation of work, the consolidated user base, the accumulation of data and the carefully constructed brand narrative remains to constitute a rent-generating asset attractive to investors, despite public and political concerns.
4. Discussion and Conclusion
By examining how financial actors gain access, introduce investor logic, and reshape national healthcare systems in England, Canada, and the Netherlands, this paper sought to understand what these actors do to and within healthcare systems through the lens of assetization. To answer our research question, we draw on a cross-case comparison that allows us to analyse how an emerging investor logic restructures the conditions under which financial actors seek to transform healthcare into an asset and to trace the mechanisms through which this logic is articulated and enacted. Across the cases, we observed how financial actors did not simply occupy existing roles or reactively took over specific forms of care. Rather, they were manifested in healthcare systems in two mutually reinforcing ways.
On the one hand, they were welcomed as actors capable of solving persistent public issues – such as the long waiting times in England – that governments themselves struggled to solve. On the other hand, they strategically navigated regulatory environments to identify and create ‘openings’ through which they could embed themselves in healthcare systems, capitalising on existing systemic tensions – particularly noticeable in Canada and the Netherlands. We have demonstrated how in all three country cases the activities of financial actors were shaped in interaction with local institutional responses, political cultures and regimes, and shifting policy landscapes. At the same time, across the cases we found that financial actors actively leveraged these contexts by positioning their narratives, promises, and expertise within policy logics that legitimize their presence. Building on this, we argue that assetization appears as a relational, contingent, and strategic process: it unfolds differently across time and space, depending on dynamic configurations of actors, crises, institutional and political contexts, and regulatory environments.
That financial actors are welcomed as a solution for persistent issues is particularly evident in the English case. Long waiting lists and declining care quality appeared as problems the NHS was unable to resolve internally. The public–private partnerships offer a source of investments and funding, manifesting financial actors as essential to deal with the increasing pressures on the NHS. A similar dynamic was visible in the Canadian case, where health information technology vendors are increasingly cast and welcomed as indispensable for developing digital and technological infrastructures needed to support and maintain service delivery. These examples illustrate how investor logic became embraced as legitimate pathway for addressing public challenges within national healthcare systems. In this context, investor logic emerges as an extension, or next step, of earlier reforms centred on introducing market mechanisms and advancing the marketisation of healthcare. The innovative potential and expertise attributed to financial actors – and bound up with an investor logic – are increasingly viewed as crucial for a future-proof healthcare system, as well as for maintaining a competitive business landscape.
This paper has furthermore shown that financial actors often expand their involvement and activities into new domains, continually identifying opportunities and creating new financial-legal entities for their own investment portfolios. The Dutch case illustrates this clearly: digital labour platforms not only respond to labour-market shortages but offer a new service that mediates self-employment and facilitates planning. In doing so, the platform owners and investors found a new mechanism through which they could extract rents from both self-employed healthcare workers and healthcare facilities. This extended and deepened the reach of investor logic within the national healthcare system.
Following this, it becomes evident across the cases that assetization does not manifest and materialises in a uniform way in creating new spaces for value creation. In the English case, public–private partnerships embodied the expectations of an NHS ‘marketplace’ to enable more patient-driven and efficient healthcare. This established the role of financial actors as structural and fostering components of the healthcare system. The Canadian case showed that the manifestions of assetization also includes friction. Here, financial actors identified opportunities in the tensions around data fragmentation, interoperability, and waiting times. However, their investor logic – with its emphasis on data enclosure and value extraction – clashed with the public value placed on accessible and shared data infrastructures. Regardless of this tension, private equity-backed technology vendors were able to strategically position themselves as an ‘obligatory passage point,’ controlling both the data generated and the conditions under which that data is interoperable, exchangeable, or remains enclosed.
Rather than a uniform or fixed process, our analysis showed that assetization manifests through the fluid and adaptive ways in which financial actors respond to regulatory and changing socio-political environments. Whereas traditional healthcare systems actors are often relatively robust, stable, and institutionally embedded, financial actors are more fluid and strategically agile in their operations. This enables them to reposition themselves as conditions shift, continually adjusting their forms of involvement and modes of value extraction. Moreover, this adaptive movement is not confined to national contexts as it unfolds across sectors, across countries, and through interconnected financial markets. This manifestation of assetization as a contingent, relational and strategic process poses significant challenges for regulation.
For one, the difficulty for regulation is reflected within the attempts to regulate these fluid and adaptive financial actors. That is to say, the search for regulation itself provided a fertile ground for the (continued) manifestion of assetization, as visible in the Dutch case. Here, we saw clearly how the investor logic introduced by digital labour platforms shaped the ways in which self-employed healthcare professionals can work and how their labour is valued. Platforms – and their parent companies and investors – thus define the conditions under which labour becomes an investable asset and occupy a position that is often fluid and difficult for policymakers to grasp or address. This makes it difficult for regulators to respond to these platforms. The enforcement of the DBA-law mainly focused on individual self-employed healthcare workers and healthcare institutions rather than digital labour platforms. In turn, this produced insecurities and anxiety among self-employed professionals and among organisations that depend on a flexible workforce. Platforms responded by presenting themselves as actors that can provide clarity and stability, highlighting their value as mediators for self-employment. In doing so, they also move strategically with regulatory developments, such as the DBA-law enforcement, by identifying new opportunities for value creation.
Second, we have shown that regulating financial actors is difficult due to an incremental dependency on the expertise, networks, and most notably the capital of financial actors. The regulatory difficulties and entanglement with political processes are particularly visible in the English case. Here, financial actors introduced an investor logic into the social, technical, legal, and organisational infrastructures of the NHS. Through gradual entanglement, investor logic became an integral part of the system in England. This integration helped to explain the enduring reliance on private actors because assetization generates value not through the actual provision of services or productive activity, but through contracting, enclosure, and ownership based on projected or imagined futures that align with the ideological conditions of a specific political era. The influence of these actors is thus not only technical, but also political and infrastructural, highlighting how investor logic becomes integral to inform decision-making processes and governance rationales.
The dependency on financial actors was also noticeable in the Canadian case. The faltering and hesitant regulatory response, visible in new, but possibly already failing legislative attempts to curb the power of tech vendors, makes clear that there is a limited institutional support for a robust regulatory regime due to a fear that these vendors are leaving the Canadian business landscape. This reflects how investor logic percolates into healthcare systems and their governance, as the innovative potential and expertise attributed to these actors is seen as crucial for a future-proof healthcare system. In that sense, we have shown that investor logic informs the repertoire for responding to solving pressing issues and for moving towards possible solutions. The collapse of public–private partnerships, the withdrawal of technology vendors, or the banning of digital labour platforms and their data analytics would create risks for the continuity of efficient, sustainable healthcare systems and labour markets, as well as for the investment and business climate for commercial actors and capital.
Third, this research has shown that it is difficult to fully apprehend and regulate financial actors because they operate through transnational flows of capital that transcend national jurisdictions and contexts. The flexibility of financial actors was clearly reflected in the Dutch case. Digital platforms are often part of a larger, international ecosystem of subsidiaries and investment chains, which makes them much more flexible than (for example) traditional ICT operators. Being part of global financial infrastructures, they can be easily bought and sold, with organisational forms, ownership structures, and contractual arrangements embedded in their digital infrastructures changing, while core logics of rent extraction remain intact. The potential for revenue extraction thus persists even when ownership strategies shift. These vendors furthermore operate across national borders, drawing on capital, expertise, and networks built up elsewhere (for example, in the United States). This created a strong bargaining position vis-à-vis national governments, as we saw in the Canadian case in which the government struggled with the threats of the Trump administrated that is closely related to Big Tech.
Taken together, the cases have shown that assetization is not merely about capitalising on pre-existing entities, but about transforming the conditions under which assets can emerge at all as entities that generate economic rent. By segmenting, valuing, and projecting future income streams, entities such as physical healthcare infrastructures, data generated by self-employed healthcare professionals, and patient information are rendered legible and investable as assets. In doing so, these actors contribute to the reconfiguration of social and material life into a revenue-generating asset, reshaping definitions of productive activity and ownership.
Therefore, as we aimed to show throughout this paper, when financial actors shift their core activities towards the pursuit of economic rents and the generation of returns on investment, the object of regulation must also shift. It may no longer be sufficient to focus on labour, services, or products in isolation. Instead, the active formation of the asset, assetization, itself must come into view. This requires attention to the temporality and spatiality through which assetization unfolds: the changing meanings, relationships, and valuations of healthcare that emerge as financial actors and investor logic interact with socio-political landscapes. By foregrounding these dynamics, this paper contributes to existing scholarship by demonstrating how assetization is actively produced and continually reshaed, rather than merely applied to pre-existing entities. It also necessitates attention to the narrative work through which financial actors justify and expand their role in healthcare. Moreover, this makes it important to examine the situated processes through which their narratives take shape across borders, and how these are strategically adapted to different contexts in order to manifest and materialise assetization. When financial actors position themselves as contributors to a more sustainable healthcare sector within a particular national setting, they simultaneously cultivate an identity designed to attract investors seeking scalable and socially legitimate assets. This dynamic underscores that investor logic is not necessarily oriented toward improving healthcare systems but towards the generation of value for investors.
To think critically about how healthcare is financed, valued, and governed, we must develop insight into the mechanisms through which investor logic shapes healthcare infrastructures, and into the ethical and political questions this raises about the future of health systems. If we are to understand – and where necessary, question the growing influence of financial actors in healthcare – research must not only trace visible flows of capital, but also the often more invisible, sociotechnical and institutional work through which assets are created. Assetization offers a valuable perspective for analysing this transformation and for developing and opening a research agenda attuned to the evolving role of financial actors in health systems worldwide. By following these processes, we can better assess which futures of care are being made possible, and which are being foreclosed.
Acknowledgements
This research was conducted as a contribution to the Special Issue on Cross-National Evidence on the Role of the Private Sector in Healthcare. The authors are deeply grateful to the members of the European Health Policy Group for their valuable feedback, and for hosting the Europe-Americas meeting in New York City on May 8–9, 2025, together with the Columbia Mailman School of Public Health. A special thanks to Yashawini Singh and the anonymous reviewers for their valuable feedback that helped us to improve the paper.
Competing interests
The authors declare none.
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