CROSS-BORDER HEALTH CARE SERVICES AS INWARD INTERNATIONALIZATION

Main results: Results showed that, in the cases studied, international experience and international networking are relevant characteristics of the physician-entrepreneur, besides country reputation, cultural and language similarities, and physician reputation. In addition, the decision processes of the physician-entrepreneurs in these organizations are based on an effectual logic. The offer of cross-border health care services was a combination of given means and contingencies, which helped the entrepreneurs to discover, or to create, the opportunity, and then develop it.


INTRODUCTION
Most of the literature on international services focuses on the outward activities of firms (e.g., Coviello & Martin, 1999;Dunning & Kundu, 1995;Javalgi, Griffith, & White, 2003;Javalgi & Grossman, 2014), or, at best, on the relationship between inward and outward activities. However, as pointed out by Welch (2004, p.147), "for many companies, inward internationalization may be the critical arena for entrepreneurial activities." Despite this, inward internationalization is an under-researched subject in international business (Bianchi, 2010(Bianchi, , 2011Moreira, Ferreira, & Da Silva, 2018;Turunen & Nummela, 2017). Among the phenomena included under the umbrella of inward internationalization, there are activities as different as importing, tourism, educational services, and medical services. The average, patients spend around 3,550 thousand dollars per visit, and their main motivation is to reduce the costs of the treatment in their own country of origin (Patients Beyond Borders, 2021). However, these figures vary depending on the source due to "inconsistencies in defining medical travel and a lack of verifiable data at the country level" (Patients Beyond Borders, 2021).
The provision of health care services to international patients offers advantages to the countries of destination because it is a source of foreign trade revenues. For the countries of origin of the patients, it can reduce health costs and waiting lists (Smith, Martinez-Alvarez, & Chanda, 2011). For the individual patient, cost reduction, service quality, and country reputation are major reasons to look for medical services abroad. Also, the patients and those that travel with them can have the opportunity of visiting and enjoying a tourism destination (Heung, Kucukusta, & Song, 2010). Latin America and Asia are the leading world regions in inbound health care services (Patients Beyond Borders, 2021), and the United States is a key origin of medical patients to foreign countries, due mainly to high costs of medical care and bureaucratic and legal problems (Cortez, 2008). In the last years, the attractiveness of Brazil as a medical destination has declined, possibly because of cost disadvantages compared to other countries in Latin America and Asia. In 2019, it was estimated that the average costs of using Brazilian clinics were 20 to 30% lower compared to U.S. costs, while Mexico's was 40 to 65% lower, South Korea 30 to 45%, and India 65 to 90% (Patients Beyond Borders, 2021).
In addition to the limited number of studies concerning inward internationalization and specifically CBHCS in the international business literature, the marketing and tourism literatures have also given scant attention to this type of inward activities. In fact, the small number of marketing studies that deal with CBHCS tend to look at the consumer of these services (e.g., Han, Lee & Ryu, 2018;Kim, Lee & Ko, 2016). However, very little is known about medical organizations that bring their patients to the supplier's location, in such a way that their services are delivered in the supplier's home country, and not in the home country of the patient (Bjorkman & Kock, 1997), taking advantage of the patient's mobility. In fact, we have not identified studies that look specifically at how entrepreneurs in medical organizations take the decision to attract international patients.
The present study, therefore, investigates the favorable conditions and the decision-making process by which physician-entrepreneurs adopt CBHCS as part of their business. Accordingly, two research questions inspired the study: (i) What are the factors that favor the development of CBHCS by an entrepreneurial medical organization? and (ii) How does the decision-making process of developing an international clientele take place in an entrepreneurial medical organization? To our knowledge, these questions have not been addressed in the literatures that investigate this subject. Entrepreneurial medical organizations are conceptualized in this study as organizations that offer health care services and are founded, owned, and managed by physicians. Physician-entrepreneur is the term used to designate the founder, owner, and chief executive officer of these organizations. The study uses the case study method of investigation and the theoretical perspective of effectuation (Saravasthy, 2001(Saravasthy, , 2014, which adopts the lens of processes to understand entrepreneurial actions and privileges the logic of control over the logic of forecasting regarding entrepreneurial decisions under uncertainty.

LITERATURE REVIEW
This section examines the literature on inward internationalization and the literature on entrepreneurial decision-making processes, focusing on effectuation.

Inward Internationalization
The international business literature gives limited attention to inward internationalization as an international firm strategy, or from the perspective of industries that depend, to develop international activities, on bringing clients to their location (Bjorkman & Kock, 1997). Knight (1999), in a review of studies on the internationalization of services between 1980 and 1998, included among the services that most benefitted from inward internationalization health care, education, tourism, retailing, and air transportation. At the time, he claimed for additional studies that could answer questions dealing with the characteristics of "the customer importation process" and "modes and strategies […] for maximizing the performance of companies that seek to import customers" (Knight, 1999, p.354). Also, in an early study, Welch and Luostarinen (1993, p.44) claim that inward operations can be seen "as a mirror image of the outward process." Studies on inward internationalization are scarce, and even those that address the issue are more concerned with how inward activities interfere in outward internationalization (e.g., Gu & Lu, 2011;Haiyang, Xiwei, & Geng, 2017;Stucchi, Pedersen, & Kumar, 2015;Zhou, Wu, & Luo, 2007). The inwardoutward link has been studied in the context of firm internationalization, in which inward internationalization moves are often antecedents of outward internationalization, because "suppliers and customers with international connections represent a potential linking point from the domestic to the international arena" (Korhonen, Luostarinen, & Welch, 1996, p.317). Also, several authors have looked at inward activities in a global value chain (e.g., Pananond, 2016). Child and Rodrigues (2005, p.389) indicate that one of the routes to internationalization followed by Chinese firms is a type of inward internationalization, characterized by "the partnership route through OEM or joint venturing." Inward-outward connections seem to improve firms' performance (Hernández & Nieto, 2016), although an in-depth case study (Karlsen et al., 2003) indicated that it is not easy to take advantage of the potential connections between inward and outward internationalization.
Countries need to develop a reputation for the specific inward services offered internationally. An early study by Björkman and Kock (1997, p.374) looked at Finnish tourism firms for which "the facilities and environment needed for producing the services are not movable." These authors point out that the psychic distance phenomenon does not work for tourism choices: distant and exotic foreign destinations are more attractive than those that are similar to the home country. Studying the case of Australian organizations in the education industry, Bianchi (2008) describes the nature of the international marketing activities performed by these institutions in order to attract students to the country and develop the international awareness of Australia as a country of destination for university studies. In a later work, the same author (Bianchi, 2011) examines five different service sectors and finds out that to be successful, service firms need to combine firmspecific and country-specific advantages (in particular, country image and government support).
The study suggests that often CBHCS face several environment restrictions such as bureaucracy (particularly immigration), cultural differences (including language), and exchange rate problems. From a different perspective, Viladrich and Baron-Faust (2014), analyzing the case of Argentina, show that the country reputation in cosmetic plastic surgery and the image of sexuality associated with tango (Argentinian national rhythm) enhance the attractiveness of the country to this specific type of surgery.
As to marketing and tourism studies concerning specifically the inward internationalization of medical services, or CBHCS, this literature tends to focus more on consumer (patient) behavior. Lee (2016) studies how consumers deal with risk and ambiguity in choices of cross-border health care services. The author points out the home-bias effect, which could prevent the adoption of medical services in a different country. In domestic medical services, particularly in developed countries, there is often a known probability of failure (or success). However, when using foreign medical service providers in a host country (even if costs are lower), the patient may not be able to estimate the risk. Uncertainty would thus generate ambiguity aversion behavior. Suspicion is another cause of rejection of medical services abroad. Kim, Lee and Ko (2016), studying the satisfaction of foreign consumers in Korea, and Musa, Doshi and Wong (2012) in Malaysia did not point out rejection issues, but their study was limited to medical travelers, and did not include those that did not consider such alternative.
There are a few frameworks used to study CBHCS. These frameworks tend to look from the patients' perspective and suggest several motivations and intervening factors in their decision-making. For example, Smith and Forgione's (2007) framework proposes that the choice of location (based on economic conditions, political climate, and regulatory policies) precedes the choice of the medical facility in the host country (based on quality, costs, physician training, and accreditation). However, it seems that the decision process of medical travelers is not uniform; "not only does the decision process change, but so too does the ranking of the factors that affect [the] decision" (p.244). In the case of life-threatening surgeries or high-risk medical care, the medical patient may consider more the reputation of the surgeon and of the hospital, while a dental care patient may be more sensitive to costs and travel destinations. Heung, Kucukusta, and Song (2010) present a framework to analyze both the demand side and the supply side. Accordingly, the authors see the supply side as "all of the efforts, facilities, and services offered by the medical tourism host destination" (p.245).
Some studies have approached the subject of inward internationalization from the perspective of entrepreneurial firms (Etemad, 2018). For example, a study in China (Zhao & Ma, 2016) finds that small entrepreneurial Chinese firms use inward internationalization as a tool to build a reputation in the domestic market. Another study by Turunen and Nummela (2017) in Finland examines location-bound entrepreneurial firms in the tourism industry. The authors claim that in the internationalization of this type of firms "the individual and organisational level elements are tightly intertwined due to the central role of the entrepreneur as a decision-maker" (p.42).
They propose a framework to examine three different types of entrepreneurs: passive developers of internationalization, emerging developers, and international entrepreneurs. The first type, passive developers, focus on the domestic market and adopt a passive stance towards international business. The second group, emerging developers, presents a growing interest towards international business. Finally, the third group is formed mostly by international new ventures, which target international markets since their inception. The three types of firms also differ regarding entrepreneurial capabilities. While the last group shows a global mindset, international orientation, and superior language skills, as well as superior network competence, these characteristics are either absent or in a less developed stage in the other two groups. Table 1 presents a summary of the literature on inward internationalization examined in this study.  Knight, 1999;Bjorkman & Koch, 1997 Link between inward and outward internationalization Gu & Lu, 2011;Haiyang et al., 2017;Hernandez & Nietto, 2016;Karlsen et al., 2003;Kohonen et al., 1996;Stucchi et al., 2015;Welch & Luostarinen, 1993;Zhou et al., 2007 Inward activities in the global value chain Child & Rodrigues, 2005;Pananond, 2013 Inward internationalization, country image and reputation Bianchi, 2008Bianchi, , 2011Björkman & Koch, 1977;Viladrich & Baron-Faust, 2014. Inward internationalization and patient behavior Han et al., 2018;Heung et al., 2010;Kim et al., 2016;Lee, 2016;Musa et al., 2012;Smith & Forgione, 2007. Inward internationalization and entrepreneurship Etemad, 2018;Turunen & Nummela, 2017;Welch, 2004;Zhao & Ma, 2016.

Entrepreneurial Decision Process
Which is, however, the decision process by which entrepreneurial firms adopt CBHCS as part of their business? To examine this issue, we use the theoretical perspective of effectuation (Saravasthy, 2001). According to this perspective, entrepreneurial decision processes can follow basically two paths: causation or effectuation. In the first case, decisionmakers choose the means to achieve a preestablished goal; in the second, they use a set of means they have available to achieve one (or more) possible effects that can result from this set of means. While causal decision-making is based on a logical model, effectual decision-making is based on contingencies and aspirations of a very general nature. The author proposes that the starting points ("givens") in entrepreneurial effectual decision making are: who they are, which comprises their characteristics and abilities; what they know, that is, "the knowledge corridors they are in" (p.250); and who they know, their social networks. In addition, effectuation works with "affordable loss rather than expected returns" (p.252). In a later work, Saravasthy et al. (2014, p.74) explain that partnerships are "the central method to expand resources" in an effectual approach. Also, serendipities are opportunities that can be developed.
Several studies have supported the theoretical work of Saravasthy. For example, Read, Song, and Smit (2009) present a meta-analytic review of the research on effectuation and venture performance; Perry, Chandler and Markova (2011) review conceptual and empirical studies on effectuation and provide suggestions for future research; and Reuber, Fischer and Coviello (2017) provide suggestions for the conceptual development of the theory, and new avenues for future research. Some scholars, however, have criticized effectuation theory for having "insufficient empirical testing and critical analysis" (Arend, Sarooghi and Burkemper, 2015, p. 830). This is typically the situation of an emerging theoretical paradigm, given that "effectuation research is still in its infancy" (Perry, Chandler, & Markova, 2011, p.840). These authors claim that one of the reasons why effectuation research has not grown faster is that it "represents a challenge to conventional, entrenched entrepreneurial strategy wisdom" (p.838), it is complex, and measures are still under development. In fact, a recent literature review (McKelvie et al., 2020) covering 81 empirical studies showed several challenges associated with measurement issues. This situation led some scholars to focus on developing and testing measures of the constructs (e.g., Chandler et al., 2011). Effectuation theory has also been criticized for not paying enough attention to how networks impact effectual decisionmaking. For example, Kerr and Coviello (2020, p.1) claim that effectuation processes can only be fully understood using the lenses of network theory since effectuation is "a network-driving and a networkdependent phenomenon." Finally, Hauser, Eggers and Güldenberg (2020) suggest that the absence of strategy should not be confused with effectual decision making.
The relationship between effectuation versus causation decisions and internationalization has been considered in the literature. For example, Andersson (2011) examines a case of a born global firm and finds that effectuation can explain the internationalization process of the firm as it moves to global markets. Furthermore, his study emphasizes the critical role of the founder's previous experience and his/her embeddedness in international networks to speed the internationalization process. Harms and Schiele (2012) looked at the antecedents and consequences of effectuation versus causation in a sample of international new ventures. Their results show that entrepreneurs that use causation tend to engage in exporting, while those that use effectuation do not show a pattern in terms of entry mode. In a multiplecase study, Chetty, Ojala and Leppäaho (2015) found that entrepreneurs tend to use both effectuation and causation in their market selection and entry process. Those that had already relationships in foreign markets used effectuation in the market selection and market entry process. However, when facing high levels of uncertainty in foreign market entry, entrepreneurs would be more likely to use causation. In addition, Galkina and Chetty (2015, p.647) showed that entrepreneurs that use effectuation logic "enter markets wherever an opportunity emerges and commit to network relations that increase their means." Finally, Ciszewska-Mlinaric, Obloj and Wasowska (2016) found that new ventures in the early stages of internationalization may shift from effectual to causal decision making and vice-versa.

METHOD
The method used is the case study, which is considered adequate to examine contemporary events in situations where the researcher cannot manipulate variables (Yin, 1989), and when the interest is on how the events developed over time (Hassett & Paavilainen-Mäntymäki, 2013). Aharoni (2011, p.49) claims that the method "is very wellsuited to produce […] context-dependent knowledge." The present study analyses a contemporary, context-dependent phenomenonthe decision process by which Brazilian physicianentrepreneurs engage in inward internationalization -using a longitudinal approach.
Case selection followed four criteria: (i) the clinic had to be involved with inward internationalization; (ii) it should be small or medium-sized; (iii) it should offer one of the top specialities searched by inbound patients, according to a list provided by the organization Patients Beyond Borders (2018); and (iv) it should be run by the founder. To select the cases the authors had the advice of specialists from an export promotion agency in Brazil. Contacts were made with five clinics, and two clinics agreed to participate in the study. One is a clinic specialized in plastic surgery, and the other a clinic specialized in human reproduction, both located in the city of Rio de Janeiro. These two specialties are among those considered the most desired by international patients, with cosmetic surgery ranked first and reproductive procedures ranked sixth by the organization Patients Beyond Borders (2021). Although the choice of the location (Rio de Janeiro) was based on convenience, the city became famous for plastic surgery due to the pioneering work of Dr.
Ivo Pitanguy (Patients Beyond Borders, 2018). As to human reproduction, there is no particular reputation of the city in this area, but Rio de Janeiro is, nevertheless, one of the most attractive tourist destinations in Brazil. Table 2 presents background information on the two cases. The names of the clinics and physicians are disguised. Data collection was based on personal interviews with the owners, collected using a semi-structured instrument. The interviews were taped with the permission of the interviewees and transcribed. In addition, information available on the sites, newspapers and magazine articles, and several technical reports on the cross-border health care industry were used.
Data analysis was performed in four stages, following Ghauri's (2014) recommendation. First, we examined the context in which the organizations have developed their activities. Second, we wrote detailed descriptive reports of each case study, in order to get a holistic view of the phenomenon studied. Third, we developed a cross-case analysis, to examine the similarities and differences between the cases. Some categories used in the analysis came from the literature review, while others emerged from the field. Fourth, we did a pattern-matching analysis, comparing our findings to the extant literature.

Case 1: Antonnelli Clinic
The Antonnelli Clinic is located in an expensive neighborhood in the city of Rio de Janeiro. The owners are a couple of physicians. One of the owners, Dr. Pedro Antonnelli, studied plastic surgery with the world-renowned plastic surgeon Dr. Ivo Pitanguy, while the other worked with Dr. Pitanguy as a dermatologist for five years. According to the site Patients Beyond Borders, Dr. Pitanguy established the highest standards of plastic surgery in the world and trained more than 4,000 physicians in his clinic. The site suggests Rio de Janeiro as a premium destination choice for plastic surgery: "Rio de Janeiro is generally acknowledged as the 'World Capital of Plastic Surgery.' More plastic and cosmetic surgeries are performed in metropolitan Rio de Janeiro than anywhere else in the world. Although Brazil is known for its high-quality plastic surgery, its innovations in the field, and its surgical safety, it is not the cheapest place in the world to receive plastic surgery. Patients can, nonetheless, achieve a 30-40 percent savings over comparable costs in the US, and prices have been dropping of late. Two of the most famous facilities in Brazil are in the Ivo Pitanguy Clinic and the Hospital da Plastica, both in Rio. Both have been around for about 40 years, achieving high success rates and low infection rates that are envied around the world." (Patients Beyond Borders, 2018) The Antonnelli Clinic offers a wide range of surgical, non-surgical, and aesthetic services. Its team is composed of professionals specialized in plastic surgery, dermatology, nutrition, psychology, and aesthetics. And although aesthetic surgeries are the main service offered by the clinic, around 20% of the patients seek the so-called reparative surgeries, which can be covered by health plans. The clinic started with a small office in a middle-class neighborhood in Rio. After marrying a dermatologist, Dr. Antonnelli expanded the business and moved to a more sophisticated area of the city.
Because of his Italian origin (his father was an Italian physician who immigrated to Brazil), Dr. Antonnelli had lived for one year in Italy. He explains his decision to spend time in Italy: So Dad decided to start a new life here in Brazil, as several other Italians, but he always had this nostalgia for one day to return to his homeland. Then he realized that the land he knew no longer existed. So he did not have as much motivation to go back, but he expected that somebody in the family would still go back someday. It was more a matter of satisfaction.
However, what was initially a young man's adventure, fulfilling his father's expectations, turned into an opportunity: Then I saw the opportunity. By the time I graduated plastic surgery was developing in Italy, so I also saw a commercial possibility. I thought, "I can make money." And at the beginning, I can tell you that I made good money. After he returned to Brazil, he kept a small clinic in Italy for a few years, but afterwards he decided that the frequent trips to Italy were becoming tiresome. He then started receiving Italian patients at his clinic in Brazil, and, later, patients from several other countries, including, by importance, Portugal, the United States, Spain, Mozambique and Angola. Portugal, Mozambique and Angola are Portuguesespeaking countries. He still travels to Italy but much less than in previous years: "Nowadays, I use some local clinics in Italy to make appointments and arrange surgeries." The process of attracting new foreign patients is totally passive, based on word-of-mouth. Dr. Antonnelli explained: "Many of my patients came to the clinic on the recommendation of diplomats who have had surgery with me…" In addition, patients from abroad also receive referrals from relatives or friends who have already undergone surgery in the clinic. In his view, there is a high correlation between patient satisfaction and the opinion of friends and family. In addition, according to the physician, the prices of plastic surgery in Brazil are lower than in most developed countries, and the country has developed a strong reputation in this field. Finally, there is the referral of other physicians that know the clinic and the surgeon, especially from Italy.
However, there are some shortcomings. First, a foreign patient implies an additional complication that can eventually compromise his image as a plastic surgeon. A good postoperative follow-up is critical to ensure patient satisfaction with the final result. In fact, the clinic has a partnership with two Italian physicians to assure the quality of the follow-up services after the patient goes back to Italy. Second, the clinic does not work with medical tourism agencies, because the owners do not want to be seen as a commercial operation. Also, medical tourism agencies offer a package of services, usually including surgery. However, the surgeon does not know whether a patient should have or not a surgery before he sees the patient. Unlike other medical specialties, plastic surgery does not allow a detailed assessment of the patient's condition via the Internet. After the patient arrives in Brazil, he or she has to do all the clinical tests, and only then the surgery is scheduled. Recovery time can take a week or a month, depending on the case.
Cultural differences are often behind the type of outcome expected by foreign patients. For example, African patients tend to expect a more significant change in their appearance. In contrast, European and American patients seek more natural results so that others do not realize they have undergone plastic surgery. The frequency of bathing, which is often culturally determined, can also interfere with the outcome. Language problems can make it more difficult to ensure that the patient understands the possible post-surgery complications and, eventually, the need for his or her stay for a longer period of time in Brazil. Sometimes the clinic uses bilingual nurses to make sure that the patient's needs are being taken care adequately. However, bilingual nurses are not easy to find in Brazil. Also, the lack of government support (bureaucracy, visas, etc.) is seen as an impediment to the further development of crossborder plastic surgery in Brazil.

Case 2 -Kingston Clinic
Dr. Kingston specialized in reproductive medicine in France, where he worked with a pioneer French specialist. He had the opportunity to participate in the first experiences of in vitro fertilization (IVF) in that country. He also did a six-month internship at the Johns Hopkins Hospital in the United States. After these experiences abroad, Dr. Kingston started his practice in a small office he opened in Rio de Janeiro. He remembered the early days: I came from France and started my practice. Because, as a doctor, you open the door and there's no queue. So you go a little bit ... I started then to attend gynecology patients in general but talking about the human reproduction specialty. With the support of his French professor, the project was conceived for the installation of a functional fertilization clinic, which would have both the doctor's office responsible for the diagnosis and a laboratory to perform the procedures for the prescribed treatment. However, it took eight years for this project to materialize, and only in 1989 Dr. Kingston opened the first IVF clinic in Copacabana, a renowned neighborhood in Rio de Janeiro.
The clinic has quickly become known, reaching the mark of 4,000 successful pregnancies. As in the case of the Antonnelli Clinic, the Kingston Clinic grew by word-of-mouth of patients satisfied with the results obtained (25% of all referrals) and from specialists from related areas (50%), such as gynecology and urology. Similarly, no promotional effort has been carried out by the clinic, which has a passive stance in getting new patients. Presently, IVF accounts for 95% of the cases. The remainder comes from small clinical or surgical treatments. In addition, recent technological advances have made it possible to treat cancer patients who are at risk of becoming sterile. In such a case, the eggs or sperm are collected, frozen and stored for future pregnancies.
The internationalization of the Kingston Clinic only started in 2005. The first foreign patient was a woman from Angola, who was in search of IVF, which was not available in her home country. She was referred by a Brazilian gynecologist. Since then, Angola became the first foreign market served by the clinic and remained as such until now, with hundreds of successful cases of pregnancy. A small number of patients come from the U.S., but they are typically Brazilians who live there and whose treatment is not covered by health plans. They are in search of less expensive treatments.
The foreign patient makes the initial contact to make an appointment. Depending on the distance, there is a pre-consultation with the patient via the internet to know his/her medical records and identify the problem. This step allows a tentative timetable that includes complementary tests to confirm the diagnosis. In this way, the foreign patient can better plan the stay in Rio de Janeiro. On average the treatment lasts 45 days, but most patients stay for three to four months. They typically rent apartments during this period, but the clinic does not become involved in the structure for the patients' stay. Once the pregnancy is confirmed, the patient returns to her home country and is followed up by a local doctor. The clinic then uses the internet to keep in contact with the patient and the local physician. The relationship with the local doctors has generated new referrals of patients. In the case of Angola, a partnership was established with a local clinic: We met at a congress, me and the owner of the Angolan clinic, and since then he has sent us a lot of patients. It happens to be a clinic whose owner is a gynecologist. And it is a big clinic in Angola ... So in medicine, it works basically with word of mouth: initially from the patient and then from the doctors.
The appointment of Angolan doctors is considered a delicate situation and has to be conducted with caution. In the first place, the appointment of another professional requires knowledge and trust, difficult to be gained at a distance. In addition, if the patient already has a physician, the indication of another may lead to conflict. The main problem with foreign patients is the delay in payments. There is a monthly payment necessary to keep a frozen embryo, and the remittance of payments often takes substantial time.
The clinic has also engaged in the "exporting" of fertilized eggs donated anonymously to a patient. As demand exceeded supply, the clinic has engaged in additional partnerships with clinics in Spain and the U.S. In this type of partnership, the patient does part of the treatment in Brazil and part abroad. To establish these partnerships, Dr. Kingston made use of his network of relationships in other countries: In medicine it works like this: when you are in this environment and you attend many conferences -I go to conferences abroad at least three times a year -you end up meeting a lot of people. And all these years, I've met a lot of people, especially since I studied both in France and the United States. You create a lot of friendship out there. Then, if you have a problem and you have a friend, you call, email and ask "help me". It works the same way as them for me, so you start to have that kind of partnership. Although Dr. Kingston had considered at some point opening a human reproduction clinic in Angola, the lack of infrastructure made him give up the plan: Because if I were to do a market research, I had the market at hand. If my practice did not depend on infrastructure, then certainly I would have opened something there. But as I am absolutely dependent on the infrastructure ... Instruments, equipment, construction, opening a clinic would be a disaster. The problem is the lack of technology and of technicians. In addition, the legal process for the release at the borders of Angola of the chemicals used for the cultivation of embryos is slow, causing the product to be withheld at the customs without adequate storage. Thus, the little experience of Angolans with the importation of products vital for IVF was another factor that discouraged the entry of the Kingston Clinic in that country.

CROSS-CASE ANALYSIS AND DISCUSSION
This section discusses the evidence concerning the two issues examined in this study: the factors that favor the adoption of CBHCS and the entrepreneurial decision-making process.

Favorable Pre-Conditions
The study provides some evidence of certain favorable pre-conditions to adopting CBHCS in the two cases studied. These variables are country-level, organization-level and physician-level (Figure 1). Although host country's costs in comparison with the home country may play a significant role in patients' choice, country reputation and cultural similarities (including language) also seem to have been relevant considerations in the two cases studied. In the case of plastic surgery, Brazil has long established a reputation of excellence, which permits attracting foreign patients. Language and cultural similarities may also play an important role, since patients may be afraid of communication problems with the physician or with the hospital/clinic's staff. This specific aspect creates an opportunity for Brazilian physicians to attract foreign patients from Portuguese-speaking countries, particularly Portugal's former colonies in Africa. Because of the similarities between Portuguese and other Latin languages, such as Spanish and Italian, patients from these countries of origin may also feel more comfortable coming to Brazil for medical care than to other countries (for instance, English-speaking countries).
However, not all physicians are able to take advantage of the country's competitive advantages to attract foreign patients. Certain physician characteristics seem to distinguish the two cases examined in terms of starting a CBHCS business. The most important appears to be previous international experience, which is the starting point to develop an international network, that acts both to generate referrals and to support follow-up procedures that need to be carried out after the patient goes back to his/her country of origin. Of course, personal reputation and positive word of mouth are required for long-term success.

The Decision-Making Process
Departing from these preconditions, the two physicians started their businesses and attracted cross-border patients to their clinics. The study examined specifically the process of developing CBHCS by the two physician-entrepreneurs. Comparing the two cases with the extant literature on international entrepreneurship, one can say that the Antonnelli Clinic is a case of a born-global firm (Andersson, 2011), which "imports" patients from several countries since its inception. The Kingston Clinic, on the other side, is not a born global, but can still be considered an international new venture. Table 2 presents a comparison of the elements of initial entrepreneurial choices, based on Saravasthy (2001).

Who I Am and What I Know
The first entrepreneur, Dr. Antonnelli, became a physician as his father and grandfather. Because of his Italian origin, he spent one year in Italy, at the time plastic surgery was burgeoning in that country. Fortunately for him, Brazil was the leading country in plastic surgery, and he had had an internship with the best surgeon in the world. He was thus the right man at the right place, although he was not previously aware of the opportunity. Once the opportunity was discovered, he opened an office in Italy and even after his return to Brazil he kept his practice in the other country. As his fame grew among Italians, he started to attract patients to Brazil, who combined leisure and aesthetic surgery. Since Europeans are concerned with disguising the use of plastic surgery, the period in Brazil was a good excuse for these patients. As he married a dermatologist, new resources were made available to him, and he opened an aesthetics clinic that combined both specialties.
The second physician-entrepreneur, Dr. Kingston, on the other side, was an innovator, since he introduced in Rio de Janeiro in vitro fertilization. He did not benefit from an established market or country reputation; quite the contrary, he had to develop his business from nothing. Accordingly, it took him ten years to open the clinic and a few additional years for the clinic to be known. Internationalization started only six years after, by a contingency: an Angolan patient who came to him by referral of a Brazilian gynecologist. This started a chain of patients from that country, where these services were not at all available.
Therefore, in both cases, the entrepreneurs started with a series of means, combined with several contingencies. In the first case, the opportunity was discovered: it was already there. In the second case, the opportunity had to be created. During the evolution of their businesses, both entrepreneurs made frequent use of their networks (Table 3). Both entrepreneurs make strong use of their networks (Table 4). Their use of international networks serves two purposes. The first one is referrals from clients and from doctors. The importance of referrals is critical, because no promotional effort is typically made by these medical organizations, since both physician-entrepreneurs considered it unethical practice. The second one is to establish support partnerships, either for clinical follow-up, or to overcome difficulties in the practice. For both entrepreneurs, this was also extremely important due to potential problems that could arise when the foreign patient was back home. In fact, especially in the case of patients of less-developed countries and lower-income patients, it was a real concern to pass all the instructions about the standard procedures to be followed after the surgery or the IVF. Language differences and cultural differences could interfere and affect the outcome. Also, the physicianentrepreneurs needed to establish long-term relationships with local doctors. Once trust was established, the relationship with them would be smoother. Therefore, networks were a critical issue for effectual decisions (Saravasthy, 2001(Saravasthy, , 2014. Foreign partners are not selected, but relationships are rather established unintentionally (Galkina & Chetty, 2015). In addition, as pointed out by Read, Song and Smit (2009, p.574), effectual partnerships need to "share the risk" and "benefit from the success of the venture", which was typically the case. The risk is shared because, by referring the patient to a Brazilian physician, the foreign doctor becomes co-responsible for the results obtained. In fact, if something goes wrong, there is a good chance that the foreign doctor loses the patient. This is the reason why trust is a necessary ingredient in the relationship between the Brazilian physicianentrepreneurs and their foreign counterparts. The closer the relationship between the physicians in the two countries, the highest the chances of a continuing partnership. Thus, in this specific context, we do not find support for the arguments concerning the dangers of "overtrust" in foreign partnerships (e.g., Chetty, Ojala, & Leppaho, 2015).

Contingencies
Risk and uncertainty are inherent to the CBHCS business, due to the difficulty in controlling the environment and context in which patients live after they return to their home countries. For example, in the case of plastic surgery, hygiene habits, which are culturally acquired, have a strong influence on the results of medical procedures. Therefore, although essentially the same service is delivered, the results can vary due to uncontrollable reasons. To some extent, however, there is a small chance of problems with a foreign patient to 'contaminate' the clinic's reputation in Brazil. First of all, for both types of medical procedures, clients tend to be secretive about their use. Second, these cases would tend to be rare. They fit, therefore, Saravasthy's concept of "affordable loss". Interestingly, both physicianentrepreneurs do not intend to expand their businesses anymore; they are satisfied with their present size. In addition, both entrepreneurs do not want to expand their share of foreign business, neither want to expand their businesses by establishing clinics in other countries. The main reason is that there is no organizational slack. The main resources -the doctor's competence and reputation -cannot be expanded, except by adding partners, or hiring professionals. Yet there they see considerable risk to both paths, due to the danger of damaging (or even expropriating) the doctor's reputation, on which rests the clinic's image.
Finally, the findings suggest that the attraction of international patients in the cases examined was not the result of a pre-conceived, strategic plan, but rather the result of an effectual decision-making process (Saravasthy, 2001). Nevertheless, as the clinics developed their international clientele, the entrepreneurs have considered some strategic issues, including the size of their international business and the limits to growth (Hauser et al., 2020).

FINAL CONSIDERATIONS
Using the case study method of investigation, this study's results suggest that (i) certain pre-conditions -related to country, organization, and physician characteristics -may be relevant to attract international patients to perform medical procedures in another country; (ii) the decision-making process of physician-entrepreneurs may not follow a strategic plan but use instead an effectual logic. In both cases examined, the adoption of CBHCS was a combination of given means and contingencies, which helped the entrepreneurs to discover, or to create, the opportunity, and then develop it. The process of opportunity development was more difficult and took longer for the entrepreneur that created the opportunity than for the other one, as expected. Although the study did not intend to look at CBHCS from a consumer perspective, the results also suggest that the decision-making process of consumers is probably not as rational as predicted by existing frameworks.
Thus, the study contributes to the understanding of inward internationalization from the perspective of the provider of health care services by combining the literatures on effectuation and inward internationalization to uncover the process by which two entrepreneurial medical organizations founded, owned, and managed by physicians have attracted international patients and built a CBHCS business. Because this is an unconventional locus of research, we believe we bring a new perspective from the entrepreneurial decision-making literature to the understanding of inward internationalization of health care services.
The research has several limitations. The method adopted in the study does not allow for statistical generalizations, but only analytical generalizations (Yin, 1989). Only two cases were examined, and both from a single destination (Rio de Janeiro, Brazil). Also, medical specialties included in the study were not life-threatening (plastic surgery and reproduction), and therefore many issues may differ from other specialties, which may require large hospitals instead of smaller clinics, and may have different suppliers' decision-making processes involved.
Because the phenomenon of CBHCS has been under-researched, there are several avenues to expand the knowledge on this phenomenon. First, this study examined only the perspective of the founder, but future studies could also examine the perspective of other actors involved in this process, such as other physicians in the same medical organization, and physicians from the patient's country of origin who provided referrals of their colleagues in the country of destination. Second, more research is needed to bring light on the decision-making process of foreign patients that use CBHCS, as well as on their socio-economic profile and other characteristics. Third, using remote procedures and conducting medical consultations at a distance have become more frequent during the pandemic. The adoption of these and other technological advances deserves to be studied since they can reduce the length of stay of patients in another country. Further research on these and other topics will improve our understanding of the phenomenon of CBHCS. Objetivo: El estudio tuvo como objetivo investigar las características y los procesos de decisión asociados con la internalización hacia adentro en los servicios de salud.
Contribuciones teóricas: El estudio contribuye a la literatura al identificar ciertas condiciones previas y proporcionar un análisis en profundidad del uso de la lógica de la efectuación por parte de los médicos emprendedores en su proceso de toma de decisiones para la adopción de servicios de salud transfronterizos.