TOSHIBA MEDICAL SYSTEMS

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TOSHIBA MEDICAL SYSTEMS

The cardiology market: in(s) or out(s)

Amsterdam, December 2004

M.C. Bouma Student number 1062247

International Business

Faculty of Management and Organization University of Groningen

The Netherlands

Mentors Toshiba: Mentors University:

Mr. Dick Blesing Mr. Drs. D.P. Tavenier

Mr. Kai Odhner Mr. Mr. W.W. Wijnbeek

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Toshiba Medical Systems The cardiology market: in(s) or out(s)

The author is responsible for the contents of this thesis, copyrights are with the author

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Preface

This thesis has been written in the scope of the final phase of my studies “International Business” at the Faculty Management and Organization, University of Groningen.

I had the opportunity to precede my research at Toshiba Medical Systems Europe. A big challenge for me since I had no knowledge of the medical market! Albert Einstein’s phrase:

“If I knew what I was doing it would not be called research” was definitely the ground line of the first few months.

Fortunately, after these months of struggling with all this new information I have managed to conduct the market research presented in front of you. This last period of my studies has been a great experience, which I really enjoyed.

I owe Toshiba and all the people I worked with a big thank you for this very nice time.

Special thanks go to Dick Blesing and Kai Odhner who guided me through the world of healthcare and its technology and Evie Herst who made me feel right at home. Finally I would like to thank my mentors from the University, Drs. D.P. Tavenier and Mr. W.W. Wijnbeek, for their input and guidance during this research.

Marike Bouma,

Amsterdam, 21 December 2004

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Abstract

Toshiba Medical Systems used to be one of the biggest players in the cardiology market; the market for medical systems within the clinical department cardiology. Over the last decade, their three main competitors; Philips, General Electric and Siemens, passed them by and left Toshiba with a very small market share. This was the primary input for the research objective of this research: To provide Toshiba Medical Systems with information about the cardiology market to help them gain a better insight in this market and to include recommendations for a possible improvement in their market position within the cardiology segment in Belgium and The Netherlands.

This objective has been achieved by answering the following research question: What does the cardiology market look like in Belgium and The Netherlands, what opportunities and threats arise from this market, what are Toshiba’s strengths and weaknesses in this market and what recommendations can be made for a possible improvement of their market position?

To provide an answer to the opportunities and threats of the market, an external analysis was conducted. This external analysis comprises a market analysis, a competitor analysis and a customer analysis. To be able to provide an answer to Toshiba’s strengths and weaknesses in the market, an internal analysis was conducted. The recommendations were finally subtracted from a SWOT analysis confronting the opportunities and threats with the strengths and weaknesses.

External analysis

Market analysis: Despite of all the cut backs and the withdrawing of subsidies in health care, both the Belgian as the Dutch cardiology market are expected to grow. Both populations are expected to grow, where the percentage of elderly is expected to rise. Most patients suffering from problems in the heart area are over the age of sixty. Furthermore, patients are becoming more interested and demanding in transparency of the medical systems. The introduction of the Diagnoses Related Groups (DRG) in Belgium, the Diagnoses Treatment Combinations (DBC) in The Netherlands and the amount of people that have access to the Internet provide and demand more insight in the treatments of the hospitals and clinics. Patients can compare the different ways hospitals and clinics treat their patients and the quality these hospitals and clinics provide. Finally, in the future a shortage in the amount of cardiologists is expected. To decrease the amount of cardiologists needed, an early diagnosis has to be made that a number of patients can be sent home. To be able to make a secure decision and therefore cut in the amount of patients that have to be treated by them, more systems are needed to be able to check all complaints with an echo.

Where the current size of the markets is estimated as the following:

The Netherlands Belgium

Amount of hospitals 97 150

Amount of cardiologists 648 797

Market size (in Euros/year) 2.980.894 5.175.500

Finally, the pressure on the profit margins is not very high, what makes the cardiology market quite attractive.

Customer analysis: The decision process in The Netherlands differs from Belgium. Where in a public hospital in The Netherlands the replacement time of a system takes approximately a year, in a public hospital in Belgium it will not over cede six months and in a private hospital in Belgium it will not even exceed a few months.

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The decision-making unit (DMU) in The Netherlands also differs quite from the DMU in Belgium. In a public hospital in The Netherlands, a special committee is appointed which decides on the purchase together with the cardiologists and the financial department if not with more stakeholders. In Belgium in a public hospital, the cardiologists decide on a purchase themselves and in a public hospital the medical board and the board of directors have to approve on the purchase where the supplier is officially to be found through the Law Gazette.

Influencing factors in the decision making process can be: past experience, specialist journals, seminars, relationships with suppliers, friends/colleagues, personality and the knowledge of the salesperson. The product characteristics that are mentioned as being important are in The Netherlands: 1 & 2. inurement and the quality of the images, 3. versatility, 4. a fast technique and 5. price. In Belgium the order of the product characteristics is a little different: 1. price, 2.

quality, 3. brand/inurement, 4. mobility, 5. user friendliness.

Customer relationship management (CRM) is becoming more important in the cardiology market. CRM creates loyalty. The advantages of loyalty are that loyal customers handle the organization and her means with more efficiency, which lower the transaction costs. Also, loyal (satisfied) customers share their experiences with others, which could lead to new customers without spending (much) acquisition costs.

Competitor analysis: Siemens, Philips and General Electric were identified as Toshiba’s main competitors by an internal research on their market shares as by the cardiologists themselves.

The different strengths and weaknesses of the competitors result in opportunities and threats, which are summarized in the table below.

Opportunities Threats

1. Netherlands: introduction DBC 1. Cut down expenses Government 2. Belgium: quality health care 2. Increasing health consciousness 3. Devaluating Yen 3. Financial problems customers 4. Growing population 4. Switching brands unlikely

5. Obsolescence 5. Decline ultrasound

6. Social development 6. Increasing R&D (GE, Philips) 7. Expected deficit of cardiologists 7. Environmental focus (Siemens) 8. Package deals

9. Build stronger relationships

10. Contact by seminars / specialist journals 11. Increase MRI

12. Focus on The Netherlands and Belgium 13. Cardiac specifications

Internal analysis

Toshiba has no unique market position in the cardiology market anymore, where they used to be market leader. Whereas customers are eventually the ones deciding on the market shares of the different competitors, they were interviewed for reasoning the transfer of market shares over a period of ten years. They demonstrated the following:

• Toshiba’s introduction time was too late; other competitors already introduced their new cardiology systems two years before Toshiba.

• The amount of competition grew enormously the last decade. Competitors merged or took over another companies that were able to provide medical systems in this market.

• Toshiba misses out on connection with the market, their sales policy is much too technical for the cardiology market

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Furthermore Toshiba’s internal analysis resulted in different strengths and weaknesses, which are summarized in the following table:

Strengths Weaknesses Technical support and after sales Absence of package offering

Customer magazine Visions Too technical attitude

Japanese accuracy Absence of MRI

Acknowledging weaknesses Limited marketing No unique position SWOT

In the SWOT analysis the opportunities and threats confront the strengths and weaknesses, which results in different strategic issues. These issues can be translated into qualifiers, which represent aspects of a product or service that are not distinguishing a product but are essential to guarantee its continuity, and differentiators that could establish a competitive advantage and indicate strategic direction. The different qualifiers were identified as the following:

• Belgium: Toshiba has to keep up its reputation of a high quality technical support and after-sales supplier.

• Netherlands: Toshiba should pursue a less technical attitude towards the cardiologists.

• Netherlands and Belgium: Toshiba should update and increase its interaction of customers magazine Visions with cardiac specifications and local issues.

• Netherlands and Belgium: Toshiba should build (stronger) relationships with customers.

The differentiators were identified as the following:

• Market penetration: Improvement of sales with current products on the current market.

• Market development: Marketing the same products but to new target groups. In The Netherlands these new target groups could be clinics and private hospitals. In Belgium on the other hand, no new exceptional growing target groups are expected, at least not on short term.

• Product development: To serve the same market but to introduce the MRI would be the third strategic option.

• Diversification: To introduce a new system to a new target group. This new product could be a mini-ultrasound for family doctors.

These four strategic directions were evaluated where market development enjoyed preference in The Netherlands and diversification in Belgium. In The Netherlands the clinics and private hospitals are expected to grow. Focussing on this new target group could result in a better market position. In Belgium a shortage in cardiologists is expected as well as an increase in the amount of cardiology patients. Introducing a mini-ultrasound in Belgium to family doctors could result in a soon, high quality, high negative rule-out, where the right patients can be send home and the right patients send through to the cardiologist. This development could imply perfect fit with the market and create an improvement in market position as a consequence.

Finally the following aspects deserve discussion and are eligible for further research:

• Financial research, where financial limitations enable further evaluation of strategic options.

• The communication between Japan and headquarters Europe, where they can be of great influence on the strategy Toshiba follows in The Netherlands and Belgium.

• The differences in technical specifications of systems of the different suppliers, where this could also reason the customers’ choice.

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Table of Contents

PREFACE ... 2

ABSTRACT ... 3

INTRODUCTION ... 9

PART I GENERAL INFORMATION ... 10

1 INTRODUCTION INTO TOSHIBA ... 11

1.1 THE HISTORY... 11

1.2 PROFILE... 11

1.3 TOSHIBA MEDICAL SYSTEMS... 12

1.4 PRODUCTS... 12

1.5 CARDIOLOGY MODALITIES... 12

1.5.1 X-ray (conventional radiology) ... 13

1.5.2 Computed Tomography (CT) ... 13

1.5.3 Magnetic Resonance Imaging (MRI) ... 14

1.5.4 Ultrasound... 15

1.5.5 Nuclear Medicine ... 15

1.6 FOCUS... 16

2 RESEARCH DESIGN ... 17

2.1 PROBLEM STATEMENT... 17

2.1.1 Inducement of the research ... 17

2.1.2 Research objective... 17

2.1.3 Research question ... 18

2.1.4 Sub questions... 18

2.1.5 Conceptual model... 19

2.1.6 Limiting conditions... 21

2.1.7 Research process... 22

2.2 PROBLEM HAVER ANALYSIS... 22

2.3 RESEARCH TYPE... 22

2.4 RESEARCH METHOD... 23

2.5 DATA COLLECTION METHOD... 23

2.5.1 Desk research ... 23

2.5.2 Field research ... 24

2.5.3 Interviews and sub questions... 25

2.6 THEORETIC FRAMEWORK... 26

2.6.1 Business-to-Business ... 26

2.6.2 External analysis ... 27

2.6.3 Internal analysis ... 29

2.6.4 SWOT ... 30

2.6.5 Recommendations... 31

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PART II EXTERNAL ANALYSIS ... 33

3 MARKET ANALYSIS... 34

3.1 THE GENERAL ENVIRONMENT FACTORS... 34

3.1.1 Governmental factors ... 34

3.1.2 Economical factors... 37

3.1.3 Demographic factors... 38

3.1.4 Socio-cultural factors ... 39

3.1.5 Technological variables ... 40

3.2 AGGREGATED MARKET FACTORS... 41

3.2.1 The (potential) size of the market... 41

3.2.2 (Expected) Growth of the market ... 45

3.3 PORTERS’ FIVE FORCES MODEL... 47

3.3.1 Threat of substitutes ... 47

3.3.2 Bargaining power of the customers ... 48

3.3.3 Threat of new entrants... 48

3.3.4 Bargaining power of the suppliers ... 48

3.3.5 Internal competition ... 49

3.3.6 Intensity of the competition ... 49

3.4 OPPORTUNITIES AND THREATS... 50

4 CUSTOMER ANALYSIS... 51

4.1 IDENTIFYING THE CUSTOMERS... 51

4.2 THE BUYING PROCESS... 51

4.2.1 DMU in The Netherlands ... 52

4.2.2 DMU in Belgium ... 53

4.2.3 The influencing factors of the buying process... 54

4.3 IMPORTANCE OF THE PRODUCT CHARACTERISTICS... 55

4.3.1 Product characteristics in The Netherlands... 56

4.3.2 Product characteristics in Belgium... 57

4.3.3 The product characteristic quality ... 57

4.4 CUSTOMER RELATIONSHIP MANAGEMENT... 58

5 COMPETITOR ANALYSIS ... 60

5.1 THEORETIC INTRODUCTION... 60

5.2 IDENTIFYING THE COMPETITORS... 61

5.2.1 General Electric Medical Systems ... 62

5.2.2 Philips Medical Systems... 63

5.2.3 Siemens Medical Solutions... 65

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PART III INTERNAL ANALYSIS... 69

6 INTERNAL ANALYSIS... 70

6.1 EVALUATION OF PREVIOUS PERIOD... 70

6.2 LIMITATIONS AND RESTRAINTS... 71

6.3 CUSTOMER RELATIONSHIP MANAGEMENT... 72

6.4 STRENGTHS AND WEAKNESSES... 72

6.4.1 Strengths... 72

6.4.2 Weaknesses... 73

PART IV SWOT ANALYSIS... 75

7 SWOT ANALYSIS... 76

7.1 CONFRONTATION MATRIX... 76

7.2 STRATEGIC ISSUES... 78

7.3 QUALIFIERS... 79

7.3.1 Discussing the qualifiers ... 80

7.4 STRATEGIC OPTIONS... 81

7.5 STRATEGIC EVALUATION... 83

8 CONCLUSION AND RECOMMENDATIONS ... 87

8.1 WHAT DOES THE CARDIOLOGY MARKET LOOK LIKE IN BELGIUM AND THE NETHERLANDS? ... 87

8.2 WHAT OPPORTUNITIES AND THREATS ARISE FROM THIS MARKET? ... 88

8.3 WHAT ARE TOSHIBA’S STRENGTHS AND WEAKNESSES IN THIS MARKET? ... 88

8.4 DISCUSSION... 90

LITERATURE ... 92

APPENDIX A INTERVIEWS ... ERROR! BOOKMARK NOT DEFINED.

APPENDIX B ORGANIZATION CHART ...ERROR! BOOKMARK NOT DEFINED.

APPENDIX C HOSPITAL CLASSIFYING EXAMPLE ERROR! BOOKMARK NOT DEFINED.

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Introduction

The research is carried out in the company Toshiba Medical Systems. An international company based in Zoetermeer, The Netherlands. Toshiba used to be a very big player in the cardiology market; the market for medical systems within the clinical department cardiology.

Nowadays they have to satisfy with a small market share behind their three main competitors Philips, General Electric and Siemens. In short this research will comprise an analysis of the cardiology market and the opportunities Toshiba has in this market. The research objective that has been determined for this research is:

To provide Toshiba Medical Systems with information about the cardiology market to help them gain a better insight in this market and to include recommendations for a possible improvement in their market position within the cardiology segment in Belgium and The Netherlands.

The main research question is: What does the cardiology market look like in Belgium and The Netherlands, what opportunities and threats arise from this market, what are Toshiba’s strengths and weaknesses in this market and what recommendations can be made for a possible improvement of their market position?

The thesis has been divided into four main parts. The first part, consisting of chapter one and two, provides general information about the research. The first chapter discusses Toshiba as a company, where the second chapter provides the research design. This research design will outline the background of the research, from where the research objective and the main research question will be formulated. Furthermore chapter two provides the different sub questions to enable this research to find an answer to the research question and to reach the research goal. The methodology for this research will also be discussed in this chapter. The chapter concludes with a research model, which illustrates the steps that will be made conducting this research.

The second part of the research provides the external analysis, which consists of chapter three to five. Chapter three comprises the market analysis. In this chapter the attractiveness of the market will be discussed as well as opportunities and threats that arise from the market. A market becomes less attractive when the intensity of the competition is high. Strong competition leads to higher marketing activity and therefore raises the costs, which will lower the profitability of the organization. Chapter four analyses the customers. The analysis will obtain insight in the customers themselves, what the buying process looks like, what product characteristics they rate as important and how they value relationships with suppliers. Finally, in chapter five the competitors will be analysed. The chapter identifies the competitors and subsequently discusses the different competitors separately. The strengths and weaknesses of all competitors will be discussed and the chapter will be concluded with the opportunities and threats arisen due to these.

The third part of the research comprises chapter six, the internal analysis. In the internal analysis, Toshiba will be the main topic. The goal of this chapter is to obtain insight in the strengths and weaknesses of the company. Furthermore, in this analysis, the limitations and restraints will be explored, with the eye on realizing a future image for the organization. Also, the amount of customer relationship management already executed will be discussed.

Finally, the fourth part of the research comprises the SWOT, chapter seven and eight. Chapter seven will analyse the SWOT and will formulate strategic issues. These strategic issues will result in qualifiers, which represent aspects of a product or service that are not distinguishing a product but are essential to guarantee its continuity and differentiators that could establish a competitive advantage and indicate strategic direction. Finally, chapter eight will comprise the conclusion where the research question will be answered.

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Part I General Information

In the first part of the research, general information of the research will be provided. The first chapter will comprise information of the company, the source of the research. The second chapter will discuss the design and the format of the research and will provide a theoretical framework.

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1 Introduction into Toshiba

In this chapter the company Toshiba will be introduced to provide an insight in the situation of the research. The first paragraph will contain the history of Toshiba, its arising, followed by a profile sketch in the second paragraph. As a result of this paragraph a liaison can be drawn to Toshiba Medical Systems, which will be described in paragraph three. Furthermore an overview will be given of their products. At the end of this chapter the focus of the research will be stated. The information used is mostly derived from the company itself, for example from their website.¹

1.1 The history

Toshiba’s early history has two strands. 1875 saw the establishment of Tanaka Seizo-sho (Tanaka Engineering Works), Japan’s first manufacturer of telegraphic equipment. Its founder, Hisashige Tanaka (1799-1881), was well known from his youth for inventions that included medical dolls and a perpetual clock. Under the name Shibaura Seisaku-sho (Shibaura Engineering Works), his company became one of Japan’s largest manufacturers of heavy electrical apparatus. In 1890, Hakunetsu-sha & Co., Ltd. was established as Japan’s first plant for electric incandescent lamps. Subsequent diversification saw the company evolve as a manufacturer of consumer products. In 1899, the company was renamed Tokyo Denki (Tokyo Electric Co.).²

In 1939, these two companies, leaders in their respective fields, merged to form an integrated electric equipment manufacturer, Tokyo Shibaura Denki (Tokyo Shibaura Electric Co. Ltd.).

The company was soon well known as ‘Toshiba’, which became its official name in 1978. ³

1.2 Profile

Toshiba has a proud tradition of achievement. In 125 years of operation, Toshiba has recorded numerous firsts and many valuable contributions to technology and society. The company is today the world’s 7^th largest integrated manufacturer of electric and electronic equipment, has over 190.000 employees worldwide, and reports annual sales of over US$54 billion on a consolidated basis.⁴

Toshiba, a world leader in high technology, is an integrated manufacturer of electrical and electronic products spanning:

• Information & communication equipment and systems; PC and other computer systems, storage devices, telecommunications equipment, social automatic systems, medical electronics equipment, space related products, etc.

• Electronic components and material; semiconductors, electron tubes, optoelectronic devices, liquid crystal display, batteries, printed circuit boards, etc.

• Power systems & industrial equipment; industrial apparatus, power generating plants, transportation equipment, elevators & escalators etc.

• Consumer products; video and digital home products, home appliances, etc.

1 www.toshiba.com

2 Source: Toshiba in Brief; facts and background 2000/2001

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As can be derived from above, one part of the information and communication equipment and systems is medical electronics equipment: Toshiba Medical Systems.⁵

1.3 Toshiba Medical Systems

Since the development of the X-ray tube in 1914, Toshiba Medical Systems has grown into one of the world’s leading diagnostic imaging manufacturers, contributing to the advancement of medicine. Their operations include, research and development, design, production, sales, service and support of diagnostic imaging equipment and systems.

Overseas operations started in 1974 with the founding of Toshiba Medical do Brasil Ltda.

(TMB) for sales and service. This was followed in 1976 by the founding of Toshiba America Medical Systems, Inc. (TAMS) to coordinate sales and service for previously established business operations in the USA. The year 1979 saw the founding of Toshiba Medical Engineering Centre (TMEC) for R&D, design, production, training and sales support activities. To further stimulate sales activity in Europe, Toshiba Medical Systems Europe B.V. (TMSE) was established in 1981 to coordinate sales and service operations in the European region, which had started already in 1970. In yet another step in 1995, Toshiba Medical Systems Asia Pte. Ltd. (TMA) was established to handle sales in the Southeast Asia region. The expanding Toshiba Medical Systems Group is now based in more than 120 countries.⁶

The European market has specific characteristics that must be addressed with a diversified strategy and therefore Toshiba Medical Systems Europe (TMSE) has been established. The Netherlands headquarters provides guidelines for European marketing, logistics and personnel training in order to supply continued support to all the European TMS offices. TMSE provides the tools for interpreting the needs that are specific to this market and to satisfying them.⁷

1.4 Products

A full line-up of X-ray equipment, CT scanners, magnetic resonance imaging systems, ultrasound equipment and nuclear medicine equipment (modalities) has made the company one of the world’s leading suppliers of medical equipment. From this established base, the company has developed total health management solutions, including comprehensive hospital information systems (HIS) and imaging information systems (PACS).⁸

Toshiba provides modalities for different clinical departments. Various examples are radiology, cardiology and gynaecology.

1.5 Cardiology modalities

The products for cardiology that Toshiba provides can be divided into different modalities.

These modalities are: Computed Tomography, X-ray, Ultrasound, Magnetic Resonance Imaging and Nuclear Medicine. These different modalities are described below. Even though Toshiba Medical Systems temporarily does not market MRI and Nuclear Medicine in

6 Source: Internal documentation by president of Toshiba Medical Systems, Mr. Katsurada, 2002-2003

7 Source: Internal documentation by president of Toshiba Medical Systems, Mr. Katsurada, 2002-2003

8 Source: www.Toshiba.nl

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Belgium and The Netherlands, paragraphs on these modalities are included, to make a full diagnosis possible.

1.5.1 X-ray (conventional radiology)

X-rays are a form of electromagnetic radiation, just like visible light. A machine emits X-rays as individual "particles" that pass through the body and then get detected by a sensitive detector.

How the test is performed

A very small tube (catheter) is inserted into a blood vessel in your groin or arm. The tip of the tube is positioned either in the heart or at the beginning of the arteries supplying the heart, and a special fluid (called a contrast medium or dye) is injected. This fluid is visible by X-ray, and the pictures (angiograms) make it possible to examine the blood vessels or chambers of the heart.⁹

Why the test is performed?

An angiogram is often used to determine the size and shape of the heart and position and the shape of the large arteries. The angiogram can detect congestions in the arteries (stenosis), so the flow through of the blood.¹⁰

1.5.2 Computed Tomography (CT)

Computed Tomography is a method of body imaging in which a thin x-ray beam rotates around the patient. Small detectors measure the amount of x-rays that pass through the patient or particular area of interest.

A computer analyses the data to construct a cross-sectional image. These images can be stored, viewed on a monitor, or printed on film. In addition, stacking the individual images, or

“slices” can create three-dimensional models of organs.¹¹ How the test is performed

The patient will be asked to lie on a narrow table, which slides into the centre of the scanner.

If contrast media (dye) is to be administered, an IV will be placed in a small vein of a hand or arm. As the exam takes place, the table moves in incremental motion through the gantry.

Modern "helical" scanners can perform the examination in one continuous motion of the table through the gantry opening.¹²

9 Source: www.cardiology.nl

10 Source: www.scai.org

11 Source: http://www.nlm.nih.gov/medlineplus/ency/article/003330.htm

12 Source: http://www.nvvn.org/voorlichting/COM_ctscan.html

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Why the test is performed

CT provides rapid, detailed cross-sectional imaging of the patient, which can then be reconstructed into three-dimensional models, as needed. Intravenous contrast enhanced scans allow for evaluation of vascular structures and further evaluation of masses and tumours.¹³ CT is often utilized when there is a need for examination of the structures inside the chest;

when a tumour or mass (clump of cells) is suspected and to determine the size, shape, and position of the heart and to look for bleeding or fluid collections.Most modern CT is capable of visualizing structures of less than 0,5mm, but most common scans are performed to visualize pathology of at least a few millimetres in size.¹⁴

1.5.3 Magnetic Resonance Imaging (MRI)

MRI imaging is based on the magnetic properties of atoms. A powerful magnet generates a magnetic field roughly 10,000 times stronger than the natural background magnetism from the earth. A very large percentage of hydrogen atoms within a human body will align with this field.

When focused radio wave pulses are broadcast towards the aligned hydrogen atoms in tissues of interest, they will return a signal. The subtle differences in that signal from various body tissues enable MRI to differentiate organs, and potentially contrast benign and malignant tissue. The most positive factor of using Magnetic Resonance Imaging is that it produces pictures of the heart without exposure to ionising radiation. The negative factor is that it is very expensive.¹⁵

The patient will be asked to lie on a narrow table, which slides into a large tunnel-like tube within the scanner. To administer contrast, an IV will be placed, usually in a small vein of the hand or forearm.¹⁶

MRI provides detailed pictures of the heart and blood vessels and can distinguish tissues from moving blood. It can differentiate between heart muscle and surrounding tissues and can clarify findings from previous X-rays or CT scans. MRI excels at showing the heart from multiple imaging planes. MRI is useful in the diagnosis of congenital abnormalities, abnormal growths, and tumours.¹⁷

14 Source: www.hartstichting.nl

15 Source: http://www.nvvn.org

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1.5.4 Ultrasound

The ultrasound machine emits high-frequency sound waves, which reflect off body structures.

A computer receives these reflected waves and uses them to create a moving picture of the heart (echocardiogram).¹⁸

You will be lying down for the procedure. A clear, water-based conducting gel is applied to the skin to help with the transmission of the sound waves. An instrument that transmits high- frequency sound waves called a transducer is placed on dedicated places on the chest and directed towards the heart. The transducer picks up the echoes of the sound waves and transmits them as electrical impulses. The ultrasound machine converts these impulses in a way that the heart will be shown in 2-dimensional view, or nowadays even 3D or 4D is possible.¹⁹

This test is performed to evaluate the condition of the heart in a non-invasive manner. The echocardiogram allows doctors to evaluate for example the heart muscle (in case of chest pain, myocardial infarction, etc), the valves (in case of heart murmurs) and the blood flow. It is a very good screening test for a lot of patients in order to check if they suffer a heart disease.

1.5.5 Nuclear Medicine

Nuclear Medicine uses isotopes (compounds containing radioactive forms of atoms) for research. These isotopes are attached to special carriers, which go towards the heart or remain in the blood. Because of the radiation an image can be admitted.²⁰

First a movie of the heart is made. The patient will receive an infuse in his arm or hand and is asked to run or cycle. The moment of maximum exertion, isotopes are released through the infuse into the vein. Only healthy muscles absorb the isotopes well during exertion and therefore extend more radiation. When the (heart) muscle extends less radiation, it is damaged.²¹

18 Source: http://www.nlm.nih.gov/medlineplus

19 Source: http://www.nlm.nih.gov/medlineplus

20 Source: www.cardiology.com

21 Source: www.nlm.nih.gov/medlineplus/ency

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After the exertion the patient has to lie down on the research table. A large camera will circle around the patient and makes some sort of a map of the heart by means of the radiation.

Which part shows no, little or lots of radiation activity. After this series of exertion recording, a series of recording is made when the patient is ‘in rest’.

Also, there can be calculated how much blood the heart pumps out of the left chamber. This is called ejection fraction. Blood will be taken from the patient. The blood will be mixed with isotopes. After somewhat an hour the blood will be re-injected into the patient. When the isotope is mixed well through the entire blood circulation, the patient will be asked to lie under the camera again. The more radiation is shown, the more blood is in the left heart chamber.²²

By comparing the upper two recordings, there can be seen if the patient suffered from heart attacks, and/or if a part of the heart muscle did not receive enough oxygen during exertion.²³

1.6 Focus

This research will focus on Toshiba Medical Systems in The Netherlands and Belgium.

Furthermore, the research mainly focuses on the clinical department Cardiology and will comprise the modalities as mentioned in the previous paragraph (1.5). In the following chapter the research design will be further discussed.

22 Source: www.nlm.nih.gov/medlineplus/ency

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2 Research Design

In this chapter I will outline the design and the construction of this thesis. Based on the previous chapter, the problem statement will be developed, which will indicate the purpose of the research. Furthermore, this chapter will discuss the research methodology. Finally, the chapter concludes with the theoretic framework.

2.1 Problem statement

The problem statement consists of a research objective, a research question with its sub questions and limiting conditions.²⁴ Splitting the problem statement enhances the diligence of the research, according to De Leeuw²⁵. Moreover, Baarda en de Goede²⁶ state the commonness of distinguishing the problem statement in a research objective and a research question and Verschuren²⁷ speaks in this context of translating a bottleneck in an objective by verifying what knowledge (research question) is required. The research objective indicates for whom the research is carried out, why the research is carried out and what the resulting product will be. The research question indicates the desired content of the research and shows together with its sub questions what is examined. Also, a problem statement consists of limiting conditions that give restrictions to the research product and the research process.

2.1.1 Inducement of the research

Toshiba previously lost its position in the Dutch and Belgian cardiology market and wants to regain this position. Toshiba Medical Systems provides modalities for different clinical departments. Various examples are radiology, cardiology and gynaecology. They used to be a very big player within the cardiology department. They provided a large share of the market with their equipment; in the modality ultrasound even over 50%. Nowadays, their market share within cardiology in Belgium is approximately 9%, where in The Netherlands it’s even less than 8%.²⁸ This research is done to describe the current situation of the cardiology market and to provide Toshiba with valuable information for the possible improvement of their market position.

2.1.2 Research objective

To provide Toshiba Medical Systems with information about the cardiology market to help them gain a better insight in this market and to include recommendations for a possible improvement in their market position within the cardiology segment in Belgium and The Netherlands.

Obtaining the research objective must lead to adequately answering the formulated research question stated right beneath.

24 Source: De Leeuw, 1996, page 85

26 Source: Baarda and De Goede, 1998, page 19

27 Source: Verschuren, 2002

28 Source: Internal information, further discussed in paragraph 6.1

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2.1.3 Research question

What does the cardiology market look like in Belgium and The Netherlands, what opportunities and threats arise from this market, what are Toshiba’s strengths and weaknesses in this market and what recommendations can be made for a possible improvement of their market position?

Definitions:

Cardiology market: The market for medical equipment, in specific for CT, MRI, X- ray, Nuclear Medicine and Ultrasound within the clinical department cardiology.

Recommendations: Providing relevant information for the company how they can possibly adjust the current situation and where upon they can base their decisions.

Market position: The amount of sales or percentage of market share within the cardiology market.

To answer the research question, an external and internal analysis will be made. To maintain an unbiased look, I will start with the external analysis and decide on the outside what is possible to do or change on the inside.

The external analysis will consist of a market analysis, a competitor analysis and a customer analysis. These analyses will reveal the opportunities and threats in the market. The internal analysis comprises the strengths and weaknesses of Toshiba Medical Systems and a determination of their limitations and restraints.

The final part of this thesis will consist of a confrontation of these analyses in a SWOT- analysis. Based on this confrontation recommendations will be made.

2.1.4 Sub questions

During the diagnosis phase the desk research took place (paragraph 2.5.1). By means of desk research sub questions could be drawn up to enhance the diligence of the research. Sub questions enable to find an answer to the research question and to reach the research goal.

Before actually starting field research (paragraph 2.5.2), the sub questions were tested for relevance by means of internal and a few external conversations. During these conversations, these sub questions produced enough interesting information what proved the relevance of the sub questions. In their turn, interview questions were submitted to enable to answer the sub questions.

The sub questions are organized by analysis.

External analysis:

1. Market analysis

• What does the cardiology market look like?

o What do the general environment factors of the cardiology market look like?

o What do the aggregated market criteria of the cardiology market look like?

o What do the industry environment factors of the cardiology market look like?

• What opportunities and threats arise from the market analysis?

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2. Customer analysis

• Who are the (potential) customers?

• What does the buying process look like within the cardiology market?

• What product characteristics do the customers rate as important?

• To what extent does Customer Relationship Management fit the cardiology market?

• What opportunities and threats arise from the customer analysis?

3. Competitor analysis

• Who are the (potential) competitors?

• What are their strengths and weaknesses?

• What opportunities and threats arise from the competitor analysis?

Internal analysis:

• What occurred in the previous period?

• What are Toshiba’s limitations and restraints within the cardiology market?

• To what extent is Toshiba performing Customer Relationship Management in the cardiology market?

• What are Toshiba’s strengths and weaknesses?

2.1.5 Conceptual model

The conceptual model shows the different sub questions. It visualizes the different phases that appear in the research and their relations. It describes the global view, which is the fundamental view of the research.²⁹

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Figure 2.1: Conceptual model³⁰

30 Based on Aaker, 1998, page 23

External analysis Market analysis

• What does the cardiology market look like?

o What do the general environment factors of the cardiology market look like?

o What do the aggregated market criteria of the cardiology market look like?

o What do the industry environment factors of the cardiology market look like?

• What opportunities and threats arise from the market analysis?

Customer analysis

• Who are the (potential) customers?

• What does the buying process look like within the cardiology market?

• What product characteristics do the customers rate as important?

• To what extent does Customer Relationship Management fit the cardiology market?

• What opportunities and threats arise from the customer analysis?

Competitor analysis

• Who are the (potential) competitors?

• What are their strengths and weaknesses?

• What opportunities and threats arise from the competitor analysis?

Internal analysis

• What occurred in the previous period?

• What are Toshiba’s limitations and restraints within the cardiology market?

• To what extent is Toshiba performing Customer Relationship Management in the cardiology market?

• What are Toshiba’s strengths and weaknesses?

Opportunities and Threats Strengths and Weaknesses

SWOT- analysis

Recommendations

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Modalities

The sub questions are discussed gradually in the model. Where the external analysis forms the opportunities and threats for Toshiba, the internal analysis forms its strengths and weaknesses.

These two analyses will be brought together in a SWOT analysis. From this analysis recommendations will be given.

2.1.6 Limiting conditions

The limiting conditions are an essential condition before one can effectively start with the research; the research must be conducted within these boundaries. According to De Leeuw³¹ there are two sorts of limiting conditions. The product conditions regarding the research results and the process conditions which relate to the research process.

Product conditions

• This research should lead to clear conclusions and recommendations about a possible improvement in Toshiba’s market position.

• The research will restrict itself to Belgium and The Netherlands and will not specify the situation in other countries where Toshiba is active.

• Since the research is time limited (as it is in the shape of a graduation project as can be read in the process conditions and in paragraph 2.1.7), possible new developments in the area of medical systems that do not fall in the defined period of time cannot be taken into account in this research.

• Due to the time limitation and the accessibility of the financial means, the financial consequences of the alternative strategies or recommendations will not be considered in this research.

• The research will not include research of the products itself.

• The research will restrict itself mainly to the clinical department cardiology, as can be seen in figure 2.2.

• Furthermore, the research will mainly focus on the products Toshiba actually markets in Belgium and the Netherlands, which are Ultrasound, Computed Tomography, and X-ray (indicated with double X in figure 2.2). But will also include MRI and Nuclear Medicine, since these modalities together form the market and therefore to make a full diagnosis possible (indicated with single X in figure 2.2). The 0’s in the figure represent the other markets in which Toshiba is active in Belgium and The Netherlands, but will not be part of this research.

Clinical departments

Radiology Cardiology Gynaecology Neurology Other

Figure 2.2: scope of the research

Process conditions

• The research is conducted in the shape of a graduation project at the Faculty of Management and Organization, of the University of Groningen.

• The author of this thesis will conduct the research personally.

0 XX 0 0 0 0 XX 0 0 0 0 XX 0 0 0 X

X

Ultrasound Computed Tomography X-ray

MRI

Nuclear Medicine

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2.1.7 Research process

The following model represents the way the research will be conducted. The time frame concerned with the model, will not be divided equally over the different phases. The first three phases will cover the first three months of the research period. Phase four and five will be done in the following three months and the final two phases will be done in the final months.

Figure 2.3: Research process³²

2.2 Problem haver analysis

The problem haver analysis is an instrument whereby the position of the problem can be viewed. It indicates if it is a true problem, to whom it may concern, or that can be spoken of a perception problem.³³

Looking at the context of the problem there can be determined that this problem is a real problem. One cannot speak of a perception problem. The problem situation as sketched above (paragraph 2.1) is showing a clear vision of the fact that the market share of the last eight years has dropped from market leader to close to zero. The problem haver does not only lie in the position of the entrusted, but concerns the entire corporation. The problem is acknowledged throughout the entire organization, what makes them accessible for possible recommendations.

2.3 Research type

The research will be a “descriptive” research.³⁴ The research contains a description of the current market conditions, and how Toshiba can intervene in this market. The choice for the type of research depends on the answer to the question why you want to collect new

32 Based on Burgers and Kense, 1992

33 Source: De Leeuw, 1996

34 Source: Baarda and De Goede, 1998

1. Defining the problem statement

2. Determining the need for information

7. Reporting the results 6. Analyzing the information 5. Conducting field research

4. Determining remaining need for information 3. Conducting desk research

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information.³⁵ The reason why I want to collect new information is to be enabled to describe the market so Toshiba can intervene. The research could also be called “policy supporting”.³⁶ Policy supporting research strives for producing knowledge that is useful in a specific situation of demonstrable customers and satisfies a part of the total need for knowledge. This research provides the knowledge, which is needed to intervene as optimally as possible in the cardiology market.

2.4 Research method

To answer the sub questions, “primary” and “secondary” data are collected.³⁷ Primary data are data specifically generated for this research, for example the results of interviews. These data are used for this research, since it was necessary to collect the information from the deciders themselves. Secondary data are data that are overall generated for other purposes, for example data from literature and internal reports. This research also makes use of these existing data, since they provide an insight in the market and the position of Toshiba and it is out of the reach of this research to generate all data personally.

The character of the problem situation (“providing Toshiba Medical Systems with information about the cardiology market to help them gain a better insight in this market and to include recommendations for a possible improvement in their market position within the cardiology segment in Belgium and The Netherlands”) demands a qualitative approach.³⁸ The goal is not to quantify and generalize data, but to provide an insight in the processes and factors that the qualitative research methods serve. In paragraph 2.5.2 the choice for qualitative research will be further discussed.

The data are formulated in words and collected in a semi-structured way.³⁹ The choice for semi-structured interviews relies on the wish for next to some structure of the interview, the option to go deeper into questions on a specific topic.

2.5 Data collection method

During the different phases of the research the necessary information to provide an answer to the different sub questions was collected by means of “desk research”⁴⁰ and “field research”⁴¹.

2.5.1 Desk research

For collecting the secondary data I conducted desk research. Desk research is researching available data, which are beneficial to the main question, but are already collected by other people on behalf of their research.⁴² Desk research comes before collecting primary data, because desk-research generally produces more global results, but is also cheaper compared to field-research since it is available on demand.⁴³

37 Source: Malholtra, 1996

38 Source: Saunders and Thonhill, 2000

40 Source: Baarda and de Goede, 1998

42 Source: Kooiker and van den Heuvel, 1992

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By means of the results of the desk research a large amount of ideas about the market problems or market developments can be reduced to some relevant ideas. Depending on the need for information, the available financial means and the available time, there can be decided to examine the relevant ideas by means of a specific closer research.⁴⁴

It is of course impossible to research every detail about the market for medical equipment.

With the desk research several ideas arose about the market conditions as they are today. This way, sub questions could be drawn up, which have a need for more detailed information, to answer the research question.

Disadvantages of desk research are that the data are never completely up to date compared to field research. But, on the other hand, secondary data are, most of the time, collected from a lot of different sources and point of views, what gives the research less of a narrow-minded image. Another advantage is that different time-eras are brought together what makes different trends and market developments visible.

This is a specific advantage in this research since the last ten years a lot has changed in the market. Differing from competitors that merged, to the construction of the society that has been subject to obsolescence the last decades. This all is valuable information for the external analysis and could be collected by means of desk research.

The sources of desk research can be divided in two groups:⁴⁵

• Internal sources (information available within the company)

• External sources (information obtained outside the company at different organizations and offices)

Within this research both sources will be consulted. As well internal information, like information from the company website and annual reports, as information from external sources, like market information from the ‘Economische Voorlichtings Dienst’ (Dutch Economic Informing Service) and the usage of articles from the Internet.

2.5.2 Field research

According to Gordon and Langmaid⁴⁶ there are two kinds of market research: quantitative research and qualitative research. Whereas quantitative research is based upon the interviewing of statistically representative samples of the relevant population, focuses qualitative research upon small, carefully selected numbers of individuals and does not claim any statistical validity but offers valuable insights into the behaviour and motivations of consumers in their day to day lives and their interactions with the aforementioned products and services.

Qualitative research is frequently conducted to examine consumer attitudes and behaviour in relation to a product category or service, usually with the specific aim of understanding consumer relationships to a brand.

Also qualitative studies are very frequently conducted when markets change or develop and up-to-date information is required to understand changing attitudes and behaviour.

44 Source: Kooiker and van dan Heuvel, 1992

46 Source: Gordon and Langmaid, 1988

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According to Gross⁴⁷, business-to-business market research tends to seek more rough estimates through qualitative interviews, whereas consumer research studies use highly structured quantitative questionnaires yielding precise measurements bracketed by statistical confidence limits. Since Toshiba works with a business-to-business market⁴⁸, qualitative research is therefore recommended.

Whereas Gordon and Langmaid⁴⁹ state that there are only two qualitative methodologies, derived from the conservation method, Kooiker and van den Heuvel⁵⁰ make another distinction before these two methodologies; they start with dividing qualitative research into three different groups:

• The question / conversation method (further referred to as conversation method)

• The observation method

• The experimental method

In both the internal as the external analysis I will make use of the conversation method. This method is most appropriate for the specific information, which is needed to answer the main question. Conversations are a very appropriate method to collect information concerning decision making, which is required to answer the sub questions.⁵¹ The choice for the conversation method will be further discussed together with the following distinction.

Both Kooiker and van den Heuvel⁵² as Gordon and Langmaid⁵³ make a further distinction within the conservation method:

• The group interview (discussion)

• The interview (depth)

All other qualitative methodologies are a derivation or combination of these two approaches.

To gather more detailed information about the (potential) market, I will make use of (depth) interviews. This is a method especially suited for descriptive and explanatory research.⁵⁴ The information there was to be collected mostly consisted of opinions, knowledge and attitudes of specialists. Since it is not possible to observe for example if somebody has specific demands in his products, you have to ask the person. An interview enables to go deeper into a specific topic, structure the conversation or find out what the thought behind the answer is.

2.5.3 Interviews and sub questions

In appendix A the interview framework as well as two model interviews are shown that were used for answering the sub questions and the research question. The final elaboration of the sub questions is not only based upon the results of the interviews, but also on secondary data that are shown in this research in the acknowledgements.

47 Source: Gross a.o., 1993, page 26

48 Further discussed in paragraph 2.6.1

51 Source: Saunders and Thonhill, 2000

52 Source: Kooiker and van den Heuvel, 1992

54 Source: Saunders and Thonhill, 2000, page 279

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2.6 Theoretic framework

Two kinds of approaches can be taken within this research: a marketing approach or a resource approach.⁵⁵ With a marketing approach the environment is seen as a focus point, in the shape of a market. With a resource approach the focus point of the research is the company and its resources. This research will work outside in, a marketing approach, because by looking outside, there can be decided what should change inside.

Several authors can be distinguished within this approach, in this research I chose to combine Alsem⁵⁶ and Aaker⁵⁷, since they both provide useful theories to describe the market situation of a company and its position within this market. Both of them formulate a strategy by means of an external analysis, an internal analysis and a SWOT. The SWOT analysis is a mean to confront the two analyses to be enabled to make recommendations.

Aaker tries to improve the long-term perspective of the management – to prevent the arising of weaknesses or problems because the short term or operational goals overrule. A possible approach is for example concentration on company sources and capabilities and not (anymore) on the financial short-term data. This research also neglects the financial discussion and focuses on long-term market influences and internal ‘capabilities’ of the organization.

Alsem sees the internal and the external analysis as a situation analysis. The goal of the internal analysis is to give insight in the strengths and weaknesses of the own company. The external analysis must be useful for the identification of opportunities and threats. This view connects perfectly with the research goal.

The theoretic framework is complemented with customer relationship management. Within a business-to-business market customer relationship management is a very important notion, as can be read in paragraph 2.6.2.

Furthermore, the theoretic framework is fed by business-to-business literature. Business-to- business differs from business-to-consumer and therefore the theories for the analyses need to be supplemented. In the following paragraph the supplements will be discussed.

2.6.1 Business-to-Business

The business Toshiba is concerned with is a business-to-business market, whereas Toshiba sells their products to the hospitals and clinics and not to the actual consumers.⁵⁸ A business- to-business market can be defined as: markets where the buyer procures goods and services necessary for his own business.⁵⁹ The hospitals and clinics buy the products, and the consumers on their turn come to the hospitals and clinics to make use of these products. The actual consumers can therefore be described as the patients of the hospitals and clinics. A typical criterion of a business-to-business market is that buyers procure goods by means of a derived demand. This means that this demand is derived from demand further in the hierarchic structure. Eventually this is always the primary demand, practised by consumers.

As a consequence, it is very important for the companies to know how the customers of their buyers behave and to follow the external factors that influence this demand. The future size of

55 Source: Alsem, 2001 and Aaker, 1998

56 Source: Alsem, 2001

57 Source: Aaker, 1998

58 Source: Gross a.o., 1993, page 7

59 Source: Kort, 1988, page 133

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its market is dependant on this.⁶⁰ The final customers for example could prefer less radiation in their products. Hospitals and clinics have to adapt their product range in this way, otherwise the patient goes somewhere else. In what way the business-to-business market differs from the business-to-consumer market is discussed in table 2.1.

CRITERIA

Business-to-business markets Business-to-consumer markets

Derived demand Primary demand

Complex buying process Relatively easy buying process Professional buyers Buyers have limited knowledge Firm durable relationship Casual relationship

Fewer sellers More sellers

Table 2.1: Differences between business-to-business and business-to-consumer markets⁶¹

These differences will be further discussed in the following paragraph.

2.6.2 External analysis

Toshiba cannot control the external factors, but they are of great influence on their products.

By describing the external factors, it becomes possible to interact on the external factors in the future.

The external analysis of Aaker⁶² consists of a customer analysis, a competitor analysis, a market analysis and an environment analysis. Alsem⁶³ makes use of a customer analysis, a competitor analysis, a market analysis and he also includes the distribution analysis, which will be left out of this research. At the moment no possible opportunities and threats are foreseen in this sector, neither in the future. An extended analysis of this sector therefore does not seem relevant. Like Alsem, this research contains no separate environment analysis, but includes this analysis in the market analysis. Alsem recommends this composition, because the environmental factors are equal to general environmental factors, which will be discussed in the market analysis.

Market analysis

Since the demand of the products in a business-to-business market is derived from the final consumers, it is of great importance to have a total view on the market. Because of governmental regulations a product market is usually a country. The product markets in a business-to-business environment are usually much less diffuse than in a business-to- consumer market. Business goods are less dependant on regional tastes and preferences.⁶⁴ The company is enabled to view the entire population and trends, and therefore in this analysis, The Netherlands and Belgium are viewed completely.

The market analysis discusses the attractiveness of the market as well as opportunities and threats that arise from the market. A market becomes less attractive when the intensity of the competition is high. Strong competition leads to higher marketing activity and therefore raises the costs, which will lower the profitability of the organization.

60 Source: Burgers and Kense, 1992, page 13

61 Based on Burgers and Kense, 1992

62 Source: Aaker, 1998

64 Source: Gross a.o., 1993

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The cardiology market will be described by means of discussing the general, the industry and the competitor environment. General environment factors are factors that can hardly be influenced by the different suppliers, for example governmental rules. Even though Toshiba cannot actually influence these factors, by analysing them Toshiba can adapt to it and follow a more efficient policy.⁶⁵

The aggregated market criteria are criteria that directly decide on the attractiveness of a market, like the size and growth of the market.

The industry environment factors are factors that decide on the competitive situation. These factors will be discussed by means of the five-forces-model of Porter⁶⁶. Alsem⁶⁷ states the five forces model shows the intensity of the competition. The different competitors can cause more threats, but also more opportunities.

Customer analysis

The customer analysis will obtain insight in the (potential) customers, what the buying process looks like, what product characteristics they rate as important and how they value relationships with suppliers. Customers are essential because they are where the life of an organization begins.⁶⁸ Once customers think enough about your product, you are in business.

With this analysis, we want to find out what the (potential) customers of Toshiba think.

In a business-to-business market there is often a phased buying process in which a lot of attention is being paid to different stages (orientation, selection). This enlarges the decision making process.⁶⁹ To be able to positively intervene in the selling process, Toshiba has to know what the buying process looks like and what factors can influence this.

Furthermore whereas business-to-consumer markets are composed of customer bases ranging from the thousands to the millions, business-to-business consumers range from as a few as one major buyer to a few thousand.⁷⁰ For this reason, it is very important for business-to- business companies to be closer to their customers and value the importance of the continuity of the relation. Therefore, in this analysis, there will be discussed how customer relationship management fits the cardiology market.

Customer Relationship Management

Customer relationship management can be seen as entering a long-term relationship between suppliers and customers, whereby value is created for both parties.⁷¹ Customer relationship management (CRM) is derived from relationship marketing, which was the source of CRM.

Relationship marketing (RM) can be described as follows: RM is to identify and establish, maintain and enhance and when necessary also to terminate relationships with customers and other stakeholders, at a profit, so that the objectives of all parties are met, and that this is done by a mutual exchange and fulfilment of promises.⁷² The difference between RM and CRM is the additional C. It states that CRM focuses on entering into a relationship with the buyer, and not necessary with the stakeholders.

65 Source: Jägers and Jansen, 1998

66 Source: Porter, 1980

68 Source: Dalrymple and Parsons, 1995, page 43

69 Source: Kort, 2000

70 Source: Gross a.o., 1993

71 Source: Beltman a.o., 2000

72 Source: Grönroos, 1994