Market Research and Entry Strategy for Box Ambulances

THESIS – BACHELOR’S DEGREE PROGRAMME TECHNOLOGY, COMMUNICATION AND TRANSPORT

MARKET RESEARCH

AND ENTRY STRATEGY

Public version report

A u t h o r : Sanne van Leeuwen D a t e : Thursday, 06 June 2019 L o c a t i o n : Iisalmi, Finland 2 (70)

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Field of Study Technology, Communication and Transport Degree Programme Degree Programme in Mechanical Engineering Author: Sanne van Leeuwen [email protected] +31 6 22 103 711

Title of Thesis: Market research and entry strategy for box ambulances Date 26.04.2019 Pages 72 Supervisor Savonia: Supervisor Windesheim Jarmo Pyysalo Paul Touw [email protected] [email protected] +358 44 785 6781 +31 88 469 7793

Client Organization/Partners: Profile Oy Seppo Hatunen [email protected] +358 40 830 7784

Abstract

This report is the result of the market research for Profile Oy. In this report the ambulance industry and various European markets were researched. From this research three countries were chosen for which entry strategies were written. Some applied theories are eight dimensions of quality by Garvin, entry modes by Kotler, Armstrong, Wong and Saunders and entry barriers by Bain.

In the report the European ambulance industry was carefully researched. Types of ambulances, regulations, box versus van ambulances, decision makers and manufacturers were all covered to gain a full understanding of the working of the industry.

Then for each market a market research was completed to determine whether there are possibilities for Profile to enter the market with box ambulances. With the help of a decision matrix, it was defined that Germany, Norway and Sweden have the markets that are the most viable options.

This is because Germany is a market which proves to have a high demand for box ambulances and Profile already is a market leader in Norway and Sweden. In these countries customers already have asked after box ambulances. For these three markets entry strategies were written. In this strategy the barriers, cost and competitiveness, network and marketing possibilities were discussed.

It was determined that direct exporting will be the best option for now. In the future when the demand grows the next step, such as a wholly owned subsidiary, should be evaluated.

There are opportunities in the three selected markets. However, it will require work, time and investments to make it a profitable outcome.

Keywords Market research, Ambulances, Emergency Medical Care, Profile Oy, Entry strategy, Germany, Sweden, Norway, Belgium, the Netherlands, Finland, Luxembourg, United Kingdom, Denmark

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PREFACE

This is the thesis report ‘market research and entry strategy for the box ambulances’ which I have written for the company Profile Oy. In this report I research the ambulance industry and the markets in west and north Europe for box ambulances, followed by an entry strategy for the three most viable markets. This report is the final product for my Bachelors’ Double Degree in Industrial Engineering and Management from Windesheim and Mechanical Engineering and Production Technology from Savonia. I was engaged in researching and writing this thesis from January to April 2019.

The research is done at the request of Profile Oy where I did my thesis. My research questions were formed together with my company supervisor Seppo Hatunen. The goal of the research was to find the markets in which the box ambulance would be a viable option to enter.

I would like to thank my school supervisors Jarmo Pyysalo and Paul Touw for their help and guidance during the process of finding and writing my thesis. I would like to thank Profile Oy for the given opportunities, in special my supervisor Seppo Hatunen, the sales managers and other colleagues who helped me. Lastly, I would like to thank all the respondents who helped me map the markets. Without all these people’s help this research would not have been of the quality it is now.

Iisalmi, Thursday, June 6, 2019

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TABLE OF CONTENTS

1 INTRODUCTION ...... 7

1.1 Need and purpose of this research ...... 7

1.2 Research topics ...... 7

1.3 Confidential material ...... 8

1.4 Scope ...... 8

1.5 Strategic and operational risks ...... 8

2 APPLIED THEORIES ...... 9

2.1 Marketing strategies ...... 9

2.2 Market research ...... 9

2.3 Defining quality ...... 10

2.4 Decision making ...... 10

2.5 Entry modes ...... 11

2.6 Entry barriers ...... 12

3 METHODOLOGY ...... 14

3.1 Study steps ...... 14

3.2 Research strategy ...... 15

3.3 Phasing ...... 15

3.4 Justification for using qualitative research ...... 15

3.5 Justification for using interviews ...... 16

3.6 Data collection process ...... 16

3.7 Data analysis process...... 16

4 THE AMBULANCE INDUSTRY ...... 17

4.1 Types of ambulances ...... 17

4.2 <3.5t and >3.5t markets ...... 19

4.3 Regulations ...... 19

4.4 Box vs van ambulances ...... 21

4.5 Customers view on Box ambulances ...... 22

4.6 Decision makers ...... 23

4.7 Ambulance manufacturers ...... 24

5 MARKETS RESEARCH ...... 25

5.1 Denmark ...... 26 6 (70)

5.2 Germany ...... 28

5.3 The Netherlands ...... 31

5.4 Belgium ...... 34

5.5 Luxembourg ...... 36

5.6 Norway ...... 38

5.7 Sweden ...... 39

5.8 Finland ...... 41

5.9 United Kingdom ...... 42

5.10 Biggest competitors ...... 43

5.11 Markets comparison ...... 47

6 ENTRY STRATEGIES ...... 50

6.1 Entry mode ...... 50

6.2 Germany ...... 50

6.3 Norway ...... 53

6.4 Sweden ...... 55

7 CONCLUSION AND RECOMMENDATIONS ...... 58

BIBLIOGRAPHY...... 59

LIST OF CHARTS ...... 65

LIST OF TABLES ...... 65

LIST OF FIGURES ...... 65

APPENDICES ...... 67

A. Interview questions ...... 67

B. Market research data ...... 69

C. Comparison of online presence ...... 70

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1 INTRODUCTION

In this chapter the need and purpose of the research are explained, then the research topics which are covered in this report are discussed. Lastly it is discussed how material is kept confidential in this report. The objective of this research is to provide Profile Oy (from now on called Profile) with all the information needed to decide whether to enter new markets and build a new product or not.

1.1 Need and purpose of this research

Profile is looking to expand their production and presence in foreign markets. Currently they are market leaders in Finland, Sweden, Norway, Latvia, Estonia and Hungary. Some existing customers have raised the question for box ambulances. Profile also knows that in some other countries the demand for box ambulances exists. To meet customer demand and expand their markets Profile wants to know whether it is sensible to enter certain markets and design and produce a new product. The goal of this report is to research the markets to see where the best environment is to bring box ambulances to the market. For the three markets with the best prospect’s, entry strategies were created.

1.2 Research topics

The topics that are investigated in this research are: • The ambulance industry • Possible new markets • Demand for the new product in new markets • Market entry strategies

To serve readers who are laymen in the ambulance industry there is some introductory information on the ambulance world. In the report, the following topics are discussed: types of ambulances, weight of ambulances, boxes vs van ambulances, regulations and competitors. Subsequent, the research- requiring markets are exposed. With all gathered information the markets with most potentials are chosen. For all the chosen markets, market entry strategies will be created. The following things will be discussed in these strategies: • Entry barriers • Cost and competitiveness • Marketing possibilities

The last section of the report will be a conclusion in which all findings are shortly discussed.

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1.3 Confidential material

In this report information of confidential nature has been used to reach a conclusion. Distributing all this information could be damaging for Profile and their position in the market, therefore sensitive information is removed from this public version of the report.

1.4 Scope

In this report the following questions are answered: • What does the current ambulance industry look like in Europe? • What do the nine researched markets look like? • What pros and cons of box ambulances are there from different points of view? • Who make the decision on what ambulance to buy? • Who are Profile’s main competitors? • Which markets have the most potential for selling box ambulances? • What barriers can be encountered when entering the chosen markets? • What strategy could be used to enter the chosen markets?

There are nine markets to be researched. Of these nine, the three most viable markets will be chosen and then have an entry strategy created. This decision will be made based on a decision matrix that has been checked and approved by the company supervisor.

In the work plan the topics modularity, training, equipment levels, manufacturing methods and change management were discussed. Due to time restrictions and shifted interests it has been decided to leave these subjects outside the scope.

1.5 Strategic and operational risks

The risks of the research itself are not great. It does not cost Profile much time or money. However, how they act on the results can have a big strategic impact. Therefore, it is important that the research is of good quality. Risk factors that can influence the quality of the research are: • Researchers’ opinion • Interviewees’ attitude and opinion, possibility to affect to decision making process • Influence of stakeholders • Amount of respondents • Type / method of interview • Wrong or outdated data

To ensure objectivity, a decision matrix will be used for the final decision. Other ways to ensure objectivity are using experts and supervisors as a sounding board and to validate data. 9 (70)

2 APPLIED THEORIES

Profile wants to build a new product and enter it into new markets. This falls in the diversification quadrant in the Ansoff Matrix (1957). This is the riskiest quadrant and requires a lot of research and resources to be completed successfully. In this chapter theories are explained that influence this market research.

2.1 Marketing strategies

According to Adam Barone from Investopedia a marketing strategy is a business’s overall game plan for reaching people or companies and turning them into customers of the product or service that the business provides (Barone, 2019). For Profile the end goal is to get a bigger revenue stream. They believe that this is possible by extending their sales to new markets and/or bringing a new product to the markets. Choosing a marketing strategy can be difficult, there are over 150 strategies, and a company will almost always combine different types of strategy to fit it to their needs. (Press, 2019) In marketing knowledge is power, to develop a marketing strategy you need to have the have the following things (Hague): • Understand the marketplace • Understand the customer base • Understand the 4Ps (Product, Place, Price, Promotion) • Understand the SWOT (Strengths, Weaknesses, Opportunities, Threats) • Develop a marketing strategy

2.2 Market research

DeMers, 2014 gives the definition for market research as the process of gathering, analyzing and interpreting information about a market and a product to be offered in that market (DeMers, 2014).

Keys to successful B2B market research are (Towery, 2015): • Accessing the right people (only few experts possess the knowledge sought) • Engaging experts in a meaningful conversation • Research and strategy are not separable • Embracing ambiguity • Be nimble and flexible

Mark Towery says in his book Why B2B market research is different from 2015 “The B2B/industrial market researcher must be able to analyze the entire competitive landscape and complete complex business case analyses. Market sizing, market attractiveness, channel strategies, strategic position- ing and a go-to-market strategy that addresses the reality of competitive dynamics must all be part of the equation.” (Towery, Why B2B market research is different - and what to do about it, 2015)

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2.3 Defining quality

The eight dimensions of quality are developed by David A. Garvin, a Harvard Professor, in 1987. The objective of this theory is to identify the quality of a product from the customers’ perspective. By identifying the quality of a product, the company is challenged to compete with quality and distin- guish its products from competitors. According to Garvin the dimensions are performance, features, reliability, conformance, durability, serviceability, aesthetics and perceived quality (Garvin, 1987).

From the customers’ perspective specifications fall into three sections, qualifiers, order winners and delights. When a product does not have some qualifiers, or even is missing just one, a customer will not buy the product but go to the competitor. Order winners are those specifications or services which makes the customer buy the product instead of the product from competitors. Delights are extras that the customer did not expect, but when they are on the product they will be delighted to use it and it will positively boost the product and company. Over time order winners will become qualifiers and delights will become order winners. This makes that a company must constantly improve their products to keep winning customers. (Slack & Lewis, 2017)

2.4 Decision making

To make an objective decision measurable, values need to be assessed. In this research it is chosen to use a decision matrix to reach objective results. In a decision matrix a few things happen, factors are composed, each factor is weighed for importance. Then each option is assessed for each factor. The option(s) with the highest results are deemed the best. An example is shown in Table 1 (Edwards, 2018).

TABLE 1. Decision matrix example Weight Option 1 Option 2 Option 3 Factor 1 1 5 4 1 Factor 2 2 4 2 2 Factor 3 3 3 5 3 Factor 4 2 2 3 4 sum (5*1)+(4*2)+(3*3)+(2*2) (4*1)+(2*2)+(5*3)+(3*2) (1*1)+(2*2)+(3*3)+(4*2) Results 26 29 22

The best option in the example matrix is option 2, followed by option 1 and, lastly, option 3. The weight is based on the importance, in this research the scale 1-3 is used. For the values a score from 1-5 will be applied, in which 1 is the worst and 5 is the best.

Another part of decision making is consulting results with experts. In this research that will mean the company supervisor and in some cases the school supervisor.

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2.5 Entry modes

According to McDonald and Burton there are different degrees of commitment, control and risks of resources that come with various foreign market entry modes and the return on investment they prom- ise (McDonald & Burton, 2002). There are two main types of market entry modes; equity and non-equity. The former is when the main company has a joint venture or daughter company in the market. The latter is when the market is penetrated through export and contractual agreements. (Peng, 2009) Profile is using both types of entry modes, with production facilities in Hungary and Estonia and sales managers and dealers throughout Europe who import Profile to their customers and distributors. There are six types of entry modes (Kotler, Armstrong, Wong, & Saunders, 2008): • Joint venture • Wholly owned subsidiary • Indirect export • Direct export • Licensing • Franchising.

All entry modes are explained below.

Joint venture Šišková writes about four types of joint venturing that company partners with a foreign production facility use to produce the product. These types are: licensing, contract manufacturing, management contracting and joint ownership. (Šišková, 2011) Joint ventures can be a good way to start in a new market because the existing company has the much-needed experience, contacts and resources. A down side of joint ventures can be different company cultures and much teamwork is needed.

Joint venturing can be an option for Profile because the joint venture sells a product, then with the help of Profile the product can be altered for the customer and then be built. Advantage of this is low startup costs and spreading out of the workload. A disadvantage of this is cost, a big investment needs to be made without certainty of return on investment.

Wholly owned subsidiary This means that the exporting company has its own local business in the market. The subsidiary can be both selling and producing. This gives the company full control of the operations in the exporting country. The down side of wholly owned subsidiaries is that there is a high risk because a big investment is needed and there is no guarantee that profits will follow.

Profile already has two wholly owned subsidiaries, one in Hungary and one in Estonia. They started out as competitors and then where bought by Profile. The advantage of this is that resources are already there.

Indirect export 12 (70)

Indirect exporting is when the manufacturer sells the product to an intermediary. The intermediary then sells the product to customers. In this case the manufacturer is not in contact with the end customer.

Indirect export is not being used by Profile because each customer wants a product specifically made for them. Therefore, an intermediary cannot buy a product before they have sold it to an end customer.

Direct export When a company sells its product directly on the international markets, this can be done through intermediaries such as sales representatives or distributors or directly selling the product to the end user. The difference between from indirect exporting is that the manufacturer always in direct contact with the customers, even when using a distributor.

Profile already uses direct exporting throughout some European and Middle Eastern countries for their existing products.

Licensing Ahmad defined licensing in 2015 as “A licensing agreement is an arrangement whereby a firm (licensor) grants the rights to intangible property to another entity (the licensee) for a specified period, and in return, the licensor receives a royalty fee from the licensee” (Ahmad, 2015).

For Profile this could mean that they license their drawings. This would not be a good solution because there are many competitors in the market, this brings many risks.

Franchising Franchising is when a company adopts a smaller company, the smaller company copies all business strategies, it gets the same name, makes the same products, uses the same systems. The difference between this and, for example, a wholly owned subsidiary is that, at a franchise, the mother company does not own the franchises. they have their own owner and CEO they just use the con- cepts.

Out of the six entry modes only joint venture, wholly owned subsidiary and direct exporting are options for Profile. One of these will be chosen to enter the new markets with the box ambulance in Chapter 6.

2.6 Entry barriers

Joe S. Bain, an American economist defined barriers to entry as ‘an advantage of established sellers in an industry over potential entrant sellers.’ (1956) These obstacles can be very diverse and different for each scenario. Barriers can be divided into two parts; government barriers and natural barriers. Government barriers are barriers made by the government to make entering the market difficult. Bar- riers in the ambulance market can be different exterior, different requirements and exporting taxes. Natural barriers can, for example, be brand identity and customer loyalty for the ambulance market. This can be very strong because an ambulance is a big investment, customers will be inclined to go 13 (70)

for a product and company that they are familiar with and know that it is of good quality. (Kenton, 2018) Some entry barriers are straightforward and transparent. Other entry barriers may surface during the process, therefore good research is essential.

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3 METHODOLOGY

This chapter presents the research process. It provides information concerning the used methods in this research and justification. In the first subchapter the study steps are shown, then the research strategy is explained, then the phasing is shown, then justification for used methods is presented. Next the data collection an analysis processes are described.

3.1 Study steps

At the beginning of the thesis a set of study steps were made to see the big picture. In Figure 1 these steps are presented. It starts with figuring out how market research works and how it can be done, this was a big part of the workplan. After that all small questions were answered that Profile set, these are incorporated in Chapter 4, the ambulance industry. Then the most time-consuming part, the actual market research is presented. From all gathered data three viable markets are chosen by using a decision matrix. Then the market entry strategy is written. With the strategy a recom- mendation to the company can be made, this is the final part of the thesis. Then it is up to Profile to decide whether they follow the recommendations and put a new product in the markets.

FIGURE 1. Study steps 15 (70)

3.2 Research strategy

Dinnen stated in 2014 that “A research strategy is a step-by-step plan of action that gives direction to your thoughts and efforts, enabling you to conduct research systematically and on schedule to produce quality results and detailed reporting.” (Dinnen, 2014)

This is an applied research, conducted for Profile. The timeline for this research is fourteen weeks. To make the most out of this time, a good planning and strategy is necessary. In the first three chapters the whys and hows of the research are panned out. Chapter 4 is about the case details, the types of ambulances, weight, boxes and vans, regulations, decision makers and European competitors. In chapter 5 each market is investigated in detail, market size, financial aspects, working of the market, EMS providers, competition, legislation, culture and interviews with people in the market. After that the biggest competitors in the international market are investigated and the potential of markets is compared. For the markets with the biggest potential, entry strategies will be made. The research is finalized with a conclusion and recommendations to Profile.

3.3 Phasing

After the study steps were created the actual research part of the thesis was divided into four stages: Phase 1 – Desk research on the product and the market. In this phase it is first research what the product is, who the competitors are and what regulations are important to consider. Then a close look is taken at each market individually. For each market, data is gathered on size, financial, working, business culture, customers and competitors this will be executed through different internet sources and reports.

Phase 2 – Collecting data from experts. When all the basic data is gathered, experts are interviewed, face to face, by phone or email. Experts are found through connections of employees and by writing to the companies, because the ambulance market is small, the sampling group will be limited. There- fore, it is important that before the interviews take place a careful list of questions is prepared and examined by supervisors. This is done in issue groups (see appendix A).

Phase 3 – Processing collected data. All the data is collected, it now can be processed and analyzed with a decision matrix so the right conclusions can be drawn in the final phase.

Phase 4 – Recommended approach to enter markets. For the selected markets an entry strategy will be made.

3.4 Justification for using qualitative research

Babbie finds that qualitative research a method of observation is to gather non-numerical data. (Babbie, 2014) It refers to the meanings, concept definitions, characteristics, metaphors, symbols and description of things and not their counts or measures. (Berg & Lune, 2012)

In this market research counting and measuring data is not achievable with the amount of resources available. That is why the focus lays on the opinion of experts in the field. In Phase 2 this data is 16 (70)

gathered through thorough desk research. This data is placed in similar formatting for each market. In Phase 3, experts on the markets are questioned to fill in missing information and an experienced view on the research questions.

3.5 Justification for using interviews

One-on-one interview methods allow the researcher to interact with the participants and to observe non-verbal cues during the interview process. (Potter, 1996)

Through using interviews as a method to gather data, the researcher hoped that undocumented information surfaced and wanted to gain a deeper understanding of the markets. As a result, the reporting and analysis of data is reflective of the view of the experts. If information from different experts was contradictory, extra views/information was gathered to find a definitive answer.

3.6 Data collection process

In Phase 1, the data is gathered through school libraries, personal library, supervisors’ recommendations and the internet. In Phase 2, interviewees were gathered firstly through the employees in the Iisalmi plant. They referred the researcher to the sales managers in the markets. The respondents were found by writing to ambulance companies. The researcher also had a few connections in the ambulance market in the Netherlands. These were used as well.

To gather information from experts in the field, lists of interview questions are drafted. They are sorted in eight issues. For each interview, the significant issues will be taken as interview questions. This list can be found in Appendix A.

The numerical data gathered in Phase 1 is placed into tables, categorical data is placed in similar formatting for each country. The gathered data from Phase 2 is saved in meeting minutes and copies of emails and then placed together with the categorical data section of Phase 1.

3.7 Data analysis process

After all data is collected, it can be analyzed. This will be done in chapter 5.11 by using a decision matrix. From this, the three markets with the most potential are selected. Before starting Phase 4 of the research the selection of the markets will be discussed with the supervisors of the research to ensure the right choices are being made.

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4 THE AMBULANCE INDUSTRY

On the web site ‘history of ambulances’ it is explained that the term ambulance comes from Latin, where ‘ambulare’ means to walk or move. Over the course of history, ambulances and their usage changed often. First, they were carts which moved incurable people and during the wars it meant moving the hospital with the army. Since then ambulances are the vehicles that move sick people to (and from) the hospital. The first mass produced ambulance is from 1909, the model 774 can be seen in Figure 2. (History of Ambulances, 2016)

FIGURE 2. Model 774 Automobile Ambulance by Rochester

4.1 Types of ambulances

There are three main types of ambulance;, those built on car chassis (see Figure 3), those built in van chassis (see Figure 4) and those which have a box replacing the loading compartment of any chassis (see Figure 5). In Europe, van ambulances and box ambulances are the most common. The types differ strongly per country and the way the EMS is designed.

In terms of equipment, there are also 3 types of ambulances in Europe. They are types A, B and C. Type A ambulances are designed and equipped for the transport of patients who are not expected to become emergency patients (CEN-CENELEC, 2014). Type B ambulances are designed and equipped for the transport, basic treatment and monitoring of patients (CEN-CENELEC, 2014). C type ambulances are designed and equipped for the transport, advanced treatment and monitoring of a patient (CEN-CENELEC, 2014). C type ambulances come in many different formats, MICU (mobile intensive care unit), XL (for obese patients), neo natal, etc. (CEN-CENELEC, 2014).

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Most used chassis for ambulances are Mercedes-Benz Sprinter and Volkswagen Crafter.

FIGURE 3. Car ambulance Nilsson 'Volvo XC90'

FIGURE 4. Van ambulance Profile 'Progrez'

FIGURE 5. Box ambulance Profile 'Modulanz' 19 (70)

4.2 <3.5t and >3.5t markets

In Europe there are 3 categories in terms of weight of vehicles. Below 3.5t (3500 kg), above 3.5t and above 7.5t (7500 kg). Ambulances are around 3.5t. Type A ambulances are almost always lighter than 3.5t, B ambulances are around the 3.5t border and C type ambulances are almost always above the 3.5t limit. When a vehicle surpasses the 3.5t border, the driver’s license requirements change. Vehi- cles under 3.5t can be driven with a B license, vehicles above 3.5t require a C1 license (UK Government, 2018). Normally, professional drivers with vehicles above 3.5t also require a Code 95/driver qualification car d (European commission, 2012). However, ambulance personnel are excluded from this.

Things to be noted about >3.5t vehicles are: • C1 driver’s license required • Higher road taxes • Lower speed limit in some countries (NKC) • More equipment can be brought along (Interview CEO, 2019)

4.3 Regulations

In this chapter various regulations are discussed that are used and followed by multiple countries within the market research.

4.3.1 EN 1789

In the European union there is an EN norm for medical vehicles and their equipment, namely the EN 1789:2007+A2 (CEN-CENELEC, 2014). The latest version is from 2014. It specifies requirements for design, testing, performance and equipping road ambulances (CEN-CENELEC, 2014). Design requirements include dimensions, wheel arch clearance, braking, acceleration, safety system, electrical requirements, vehicle body, temperature, interior lighting, noise level, mounting systems and more. Testing requirements include the compliance of design requirements, various systems etc. (CEN- CENELEC, 2014).

EN are voluntary standards, however, some governments mandate that they are followed and for all other countries it is viewed as the basic purchasing requirement by customers.

4.3.2 United Nations regulations

The Economic and social council writes regulations to establish the greatest uniformity, to improve road safety, protect the environment and facilitate international road traffic and trade in vehicles (Economic and Social Council, 2014). All UN regulations are legally binding when the regulation is signed by the country (UNECE, 2019). There are many regulations, of which very few are specific to emergency vehicles. An example of a regulation is ‘Addendum 64: Regulation No. 65’, it is a regulation about warning lamps on vehicles (UNECE, 2011). ‘Addendum 103: Regulation No. 104’ is a regulation 20 (70)

from the UN about ‘uniform provisions concerning the approval of retro reflective markings for vehicles of category M, N and O’ (UNECE, 2009).

4.3.3 Vehicle inspection

Before an ambulance can be used as an ambulance it needs to be inspected and approved. For each country these regulations can differ. Most of the countries require that the vehicle is to be individually inspected. For example, in the Netherlands the vehicle needs to meet the requirements of an M vehicle, with chassis type SC and adhere to EN 1789. (RDW, 2016) In the United Kingdom an ambulance needs to apply for an Individual Vehicle Approval (IVA) scheme. (DVSA, 2019)

In Europe it is mandated that each road vehicle is inspected periodically, the terms and recurrence can differ per country and type of vehicle.

4.3.4 Visibility and audibility

Each country has their own rules in terms of visibility and audibility. This includes, reflective stickers on the chassis, warning lights and sirens. (De Lorenzo & Eilers, 1991)

Ambulances are equipped with multi-toned sirens to let people know they’re coming even if they are not visible yet. It is also used to let drivers know they are in a hurry. In most countries it is illegal to turn on the sirens of an ambulance unless it’s high emergency. When the siren is played, flashing lights must be turned on as well. (De Lorenzo & Eilers, 1991)

Ambulances are visible in two ways, the have flashing lights and reflective paint or stickers in certain patterns. For flashing lights there are no regulations on how many lights and the pattern. However, in all researched markets blue lights are mandatory. UN regulations are leading rules, see 4.3.2. Reflec- tive paint and stickering is different in some countries, most countries make use of the Battenburg striping (see Figure 6) on the side of their vehicle. (Harrison, 2004)

FIGURE 6. Battenburg striping

The star of life is another visibility marking that is used in many countries. The star of life was designed for NHTSA to represent the emergency medical services system, the six bars represent: de- tection, reporting, response, on scene care, care in transit, transfer to definitive care, the snake on the staff in the middle is the sign of medicine and healing (NHTSA). The star of life is shown in Fig- ure 7.

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FIGURE 7. Star of life

4.4 Box vs van ambulances

There are different reasons to choose for a box or van ambulance. In Table 2 the differences are shown.

TABLE 2. Box ambulance vs van ambulance Box ambulance Van ambulance The box can be manufactured before the chassis is To start the build, the van must present at delivered and therefore the process is not com- the factory. There are very little pre-assem- pletely dependent on delivery times of chassis. bly parts. Wider than a van or car. Meaning that the patient Fairly narrow, patient can be treated from can be reached and treated from both sides and one side only. more storage space than in a van. (Product manager interview, 2019) Box is heavy; therefore, box ambulances are al- Van is lighter. Therefore, it is possible to ways >3.5t. (Interview Production manager, have vans below 3.5t and above 3.5t 2019) Chassis is altered greatly. Only the roof of the chassis is altered. Modularity is an option for box ambulances. Used When the chassis is old (approximately 5 boxes can be placed on new chassis, making the years or motor has run 400000km) the lifecycle longer than a van ambulance. whole ambulance needs replacing. Leadtime of box ambulance is approximately 27 Leadtime of van ambulance is approxi- weeks. (Interview CEO, 2019) mately 20 weeks. New skills and knowledge are needed to build All knowledge to build is inhouse. boxes. Drivability is considered worse than a van. Good drivability (Interview Sales Manager Sweden, 2019)

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4.5 Customers view on Box ambulances

To look at the product from the customers point of view, the ‘eight dimensions of quality’ by David A. Gavin, a professor from Harvard are used (Garvin, 1987).

1) Garvin says that performance includes acceleration, handling, speed and comfort (Garvin, 1987). For box ambulances drivers state that (in comparison to van ambulances) box ambulances are not as nice to drive, the box has more height, width and is not as aerodynamic. This makes that driving is experienced as less pleasant. Otherwise, the box ambulance can be built on the same chassis as a van ambulance, this means that those performances are equal. How- ever, the patient area is seen as equally or more pleasant. Because there is more working and storing space.

2) Garvin says that features are the order winner aspects of products, that what is extra on top of the basic qualifiers (Garvin, 1987). What makes the product of Profile stand out from the products of competitors. Currently Profile stands out in interior design and hygiene. For a box ambulance this is not yet defined, because the product is not designed yet, therefore many things could be features. For this it is important to look at competitors and what customers are less sat- isfied about and then find solutions for this in the Profile box ambulance.

3) Garvin says that reliability is the probability of a product malfunctioning or failing within a specified time period (Garvin, 1987). Again, the base product (the chassis) is the exact same product. Reliability of the box/van interior should be similar as well. However, because the box ambulance is more spacious, less accidents such as bumping into cabinets should occur. Also, the box ambulance overall is a more high-end product so some parts may be manufactured of better materials. This makes the end product very reliable.

4) Garvin says that conformance is the degree to which a product’s design and operating characteristics meet established standards, so this can differ per market (Garvin, 1987). Profile is known for its quality and high standards. So, for both van and box ambulances they will go far- ther than just conformance. By building according to the EN norm and going through market specific tests the product will have its conformance.

5) Garvin says that durability is the measure of the product life (Garvin, 1987). In the ambulance industry ambulances are replaced every 3 to 5 years. Or around 400 000 km, so the product needs to last at least that amount of time. After that durability is not of importance because there are so many innovations and improvements that new products are introduced.

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6) Garvin says that servicability is the speed, courtesy, competence and ease of repair (Garvin, 1987). For Profile products there are service points in almost every country where products are used. Because many items are standardized, it is easy to repair or replace. When the product range is expanded, it will be more expensive to keep extra parts in stock. This means that, when designing the box ambulance, this needs to be considered so that the products can be repaired with ease and efficiency rather than relying on replacing parts.

7) Garvin says that aesthetics are very subjective. It is how the product looks, feels and even sounds or smells (Garvin, 1987). This means that every customer and designer can have a different opinion on this. Therefore, it is needed to look at what our competitors have in the markets and gain information on the customers perspective beforehand.

8) Garvin says that perceived quality is also very subjective, because customers often do not have the total picture of every product in the market (Garvin, 1987). Therefore, it is needed that the customer is convinced (through marketing and sales) that the product is of high quality and the best choice. In Chapter 5.10 we look at the biggest competitors and their marketing to make a comparison.

4.6 Decision makers

Decision makers in the ambulance market are those who make the final decision on which ambulance to buy. Per country and even per company the process to buy new ambulances differs. From the interviews with companies it became clear that the end decision mostly lies with the management teams of the company. However, often a committee is set up to make a proposition. The committee exists of employees such as paramedics, drivers, ergo dynamic therapists and fleet managers. One of the committee members described the process as follows:

First, they survey all the end users to see what the requirements and needs are for the new series of ambulances. Based on that, they discuss this with experts in the field. After that suppliers are researched to see who can deliver what they want. With the chosen company a design is being made, this will be approved by people who know a lot about ergo dynamics, working spaces etc. Then the quotation is submitted to the management team which decides if it is acceptable.

This shows that almost everyone in the ambulance chain is involved in the procurement of products. The final decision is made by people higher up who have things to say about money and resources.

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4.7 Ambulance manufacturers

In this chapter we look at all the manufacturers throughout Europe. In Chart 1 it can be noted that almost half of all the manufacturers in Europe produce both box and van ambulances, more than a third just manufactures van ambulances and small percentages make just boxes or car-based ambulances.

PRODUCT RANGE AMBULANCE MANUFACTURERS EUROPE Car Box 4% 9%

Box and Van 49%

Van 38%

CHART 1. Product range ambulance manufacturers Europe

In Chart 2 the location of the manufacturers is illustrated. Most (bigger) manufacturers are in Central Europe; in Germany, Poland, Austria, Czech Republic etc. Then in the South and West are many manufacturers as well. In East and North Europe there are fewer manufacturers.

LOCATION OF MANUFACTURERS East 9% North 11% Central 41%

West 17%

South 22% CHART 2. Location of manufacturers

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5 MARKETS RESEARCH

In this chapter the market research is reported. Nine countries were investigated, Profile has given the countries different priorities, resulting in the following list: Denmark, Germany, the Netherlands, Bel- gium, Luxembourg, Norway, Sweden, Finland and the United Kingdom.

The research consists of various topics that are repeated for each country: • Basic country info • Size of the market • Financial aspects • Working of the market • Providers of EMS • Competition

With most countries, also the following topics are presented: • Legislation • Business culture • Experts’ view o This section is taken out of this public version of the report to respect the respondents and make sure that confidentiality is guaranteed.

For the markets Finland, Norway and Sweden, the research has been held brief. This because Profile is already a market leader in these markets and with a tight deadline it added less value than spending resources on other topics.

The data in this chapter is gathered through desk research and interviews, by reading up on how the markets work, what the statistics are and what defines the market. After that, interview questions were made based on various topics. These can be found in Appendix A. For each interview, 3 or 4 issues were chosen to discuss. After approval of the supervisor, the interviews were held with all of Profile sales managers. After that various EMS companies in each market were contacted to take part in interviews. This resulted in five responses, one from Sweden and four from the Netherlands. Infor- mation from these interviews are used in the experts’ view paragraph and the final decision making. In regards of confidentiality this information is blurred and/or left out in this version.

Sources that are used for multiple markets: Population (Eurostat, 2018) English language (TNS opinion & social, 2012) Size (World by map, 2017) Currency (Countries of the World) 26 (70)

5.1 Denmark

Introduction Population: 5.8 million Language: Danish. 86% English at conversational level Size: 42434km2 Denmark consists of 500 islands (of which 100 are inhabited) and one peninsula. (Brooke) Currency: Danish Krone Time zone: GMT +1 Name of the EMS: præhospitalet Location, see Figure 8

FIGURE 8. Denmark on the map

Size of the market In Denmark there are approximately 320 ambulances, 20 rapid responders, 23 doctor cars and 3 helicopters. (Christensen) Most ambulances are vans.

Financial In Denmark each region has its own budget. They divide it into all different categories, one of them is ‘præhospitalet’. Pre-hospital is the service from calling 112 until arrival at the hospital. In 2018 these budgets were reserved for præhospitalet: Hovedstaden – 768.0 million DKK ≈ €102.9 million. (Region Hovedstaden, 2014) Midtjylland – 843.2 million DKK ≈ €112.9 million. (Midtjylland, 2017) Nordjylland – 283.5 million DKK ≈ €32.0 million. (Region Nordjylland, 2017) Sjælland – 631.0 million DKK ≈ €84.5 million. (Region Sjælland, 2017) Syddanmark – 443.3 million DKK ≈ €59.4 million. (Region Syddanmark, 2017)

This makes for a total budget of €391.7 million.

The Danish ministry of health states that all health and social services are financed by general taxes and are supported by a system of central government block grants, reimbursements and equalization schemes (Ministry of Health, 2017). According to the OECD Denmark spends 10.2% of the GDP (in 2017) to healthcare. (Ministry of Heatlh, Healthcare Denmark, 2017)

Healthcare is financed through a national health tax of 8% of the taxable income. (Vrangbaek, 2017) 27 (70)

Working of the market In Denmark the system works as follows: The pre-hospital tasks are provided by the regions, they are divided into 20 areas. Every area can have a different private operator. Currently the areas are divided as seen in Figure 9. 12 are contracted by Falck, 2 by Responce (owned by Falck). 3 by Ambulance Syd, 2 by Samsø Redingnskorps and 1 by Hovedstadens Beredskab.

FIGURE 9. Distribution of ambulance suppli-

Every operator needs to arrange the whole operation. This includes; staff, infrastructure and funding. Every six to eight years the regions’ start a tender. This means that companies and municipalities can bid to win the contract. The applicant with the best results wins the tender and is the new EMS operator in the area. Currently Falck has an agreement with 4 of the 5 regions in Denmark for ambulances. (Falck, ei pvm) (Regional abejdsruppe, 2018)

Legislation The CEN 1789 applies for Denmark.

The company that decides if ambulances are allowed as emergency vehicles in Denmark is færd- selsstyrelsen.

The first part is ‘emergency driving’ paragraph 7 of the traffic act. (Ministry of Transport, Building and Housing, 2009) In here it is stated that the minister of transport building and housing can lay down rules.

Then there is a ‘notice on emergency driving’ (Ministry of Justice, 2009). This notice states when, who and how emergency driving is allowed. Emergency vehicles are inspected by an inspection company and need to be registered with SKAT (tax administration) as an emergency vehicle. (Færdselsstyrelsen, 2019).

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Business culture Some things to know about the Danish business culture (Business Culture): • Equality is very important • Danes are modest and unpretentious • Communication is informal • In meetings Danes are more formal, conservative, efficient and they like to go down to business right away. • Meetings are short and well structured. • Greeting is a short handshake with eye contact. • Little hierarchy • Personal relationship is needed to come to a decision for procurement • Appointments are kept • Dress code is relatively casual.

Customers In Denmark the types B and C ambulances are purchased by companies such as Falck Danmark, Responce, Samsø Redingnskorps, Ambulance Syd and Hovedstadens Bevedskab. Type A ambulances are ordered by companies such as DK ambulancetjeneste, Præhospitalet and Swedish Sa- maritans who only organise non-urgent patient transport.

5.2 Germany

Introduction Population: 82,8 million Language: German. 56% English conversational English Size: 348672km2 Currency: Euro Time zone: GMT +1 Name of the EMS: RD/RettD, Rettungsdienst Location, see Figure 10 (How to Germany, 2018)

FIGURE 10. Germany on the map

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Size of the market Germany is divided into sixteen different states and over 300 EMS areas. Some areas have their fleet posted, some not. With some calculations based on averages, it is an estimate that there are 4200 RTW (Rettungstransportwagen, B/C type ambulances) and 900 KTW (Krankentransportwagen, A type ambulances). Most RTW are box ambulances and most KTW are van ambulances. In Germany most areas are covered by multiple organizations. The biggest organizations are Deutsches Rotes Kreuz (DRK), Deutscher Berufsverband Rettungsdienst (DBRD), Malteser Hilfdienst (MHD), Johanniter Un- fall Hilfe (JUH), ASB and the local firefighter stations. See Appendix B for more numerical data.

Financial In 2018 Germany spent about €5 billion on the rettungsdienst. This is approximately €60 per resident. The government gives each municipality a budget, the municipality then decides how much goes to the rettungsdienst. The money for this comes mainly from the healthcare system.

These days the German healthcare is operated on a dual public-private system. If you earn less than €57600 per year you fall under the public system (GKV). Healthcare costs 14.6% of your income, of which your employer pays half. This means that a person pays up to €350 per month on healthcare (Expatica, 2019). The OECD chart shows that this system makes for one of the most expensive healthcare systems in the world (OECD, 2019). See Appendix B.

Working of the market The rettungsdienst in Germany is carried out by the public sector. Tenders are not required. The tender model (a form of public-private partnerships) is mostly used in central, northern and eastern municipalities. The service concession model is used in Baden-Württemberg, Bayern, Hamburg, Hessen and Rhein- land-Pfalz. The service concession model is when the contractor receives the right for commercial use and exploitation in exchange for the service instead of remuneration. (Gerdelmann, Korbmann, & Kutter, 2013)

Legislation Germany adheres to the CEN 1789:2007 + A1. The German EMS is governed by state laws. Under public law the municipalities are state carriers of the ambulance service (kommunale Plichtaufgabe). There are rules that the RTW needs to be equipped for new-borns from the 36th week and for adults up to 220 kg. Devices need to be in accordance with guidelines of ILCOR (International Liaison Com- mittee on Resuscitation).

There are no regulations about appearance of the vehicles. Most RTWs are white with orange reflective (see figure 12). Most KTWs are white or orange with a red/orange horizontal reflective stripe, (see figure 11). (Kreis Steinfurt, 2017) 30 (70)

FIGURE 11. KTW Cologne

FIGURE 12. RTW Berlin

Business culture The German business culture consist of (Business Culture): • Rather than clap, Germans rap their knuckles on tables. • Workhours are until 5 pm Monday – Thursday, Friday until 4 pm. • In conversation Germans are straightforward and only use little small talk. • Half of the Germans speak English, but skills are not always good enough. • German is the preferred business language. • Germans value order, privacy and punctuality. • Written communication is formal. Greetings and closing must not be forgotten. • Use Herr (for Mr.) and Frau (for Mrs./Ms.) with last name in conversation until in- structed otherwise. • Meetings are scheduled well in advance (up to 4 weeks). • Germans are competitive and hard negotiators. • Decisions are based on facts. Bring graphs, research and statistics to a meeting. • Decision making is a slow process. • Once a decision is made it will not be changed. • Greeting is a firm and brief handshake with ‘Guten Tag’. • Business cards are given at the end or after a meeting.

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Providers of EMS In Germany the organizations that arrange the rescue service are: • Aid organizations (mostly volunteer): o Deutches Rotes Kreuz o Arbeiter- Samariter-Bund o Johanniter-Unfall-Hilfe o Deutsche Lebens-Rettungs-Gesellschaft o Malteser Hilfsdienst • Municipal rescue service companies • Fire department • Private ambulance service • Bundeswher (part of ministry of defence)

80% of the EMS are volunteers/non-profit organizations and10% Private EMS companies (such as Falck). Because the requirements are growing these percentages are shifting. (Lippay, 2013)

Competition Germany has at least eight local ambulance manufacturers; Ambulanz Mobile, Binz, Emmert Fahr- zeuge, HospiMobil, Meytec, Miesen, System Strobel and WAS. Other manufacturers from outside Germany can also be present in the German market.

5.3 The Netherlands

Introduction Population: 17.1 million Language: Dutch, 90% conversational English level Size: 33893km2 Currency: Euro Time zone: GMT +1 Name of the EMS: AZN. Ambulance Zorg Nederland Location, see Figure 13

FIGURE 13. the Netherlands on the map

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Size of the market There are 790 ambulances in the Netherlands. Ff these ambulances approximately 690 are type B and 100 type A. Not all ambulances are active at the same time. There are always ambulances on reserve for when maintenance needs to happen or when there is a big disaster. Most ambulances are vans.

The RAV also uses approximately 120 rapid responder vehicles divided over 23 regions and MICU’s in 7 regions. (Ambulancezorg Nederland, 2018) (Ambulancezorg Nederland, 2015)

Besides the AZN organized patient transport there are also some companies who have ambulances for events and non-urgent patient transport.

Financial In the Netherlands the EMS are payed by the government (paid by taxes and health care insurance). The Dutch Health authority distributes the money over all the parties, including each RAV. The ministry of public health, welfare and sport (VWS) calculates every year how much is needed. EMS is purchased by health insurers. In 2017 the AZN had a macro budget of €592.200.000. Per resident this comes down to €34,50 per year. (Ambulancezorg Nederland, 2018)

Working of the market In the Netherlands EMS is regulated by AZN, ambulance zorg Nederland (ambulance care Nether- lands) they have divided the country into 25 regions called RAVs (Regional Ambulance Provision). The RAVs have the responsibilities of all emergency care related aspects (alarm room, providing first aid, vehicles, etc.) The RAV works with partners in the EMS such as; hospitals, general practitioner, GGZ (mental healthcare) and midwives. The RAV also works with police, fire department and GHOR for public order and safety.

Ambulance transport has been divided into three categories (Ambulancezorg Nederland, 2018) (Ambulancezorg Nederland, 2015): A1 – Emergent with life threatening situation. 49% off all transport. A2 – Emergent but not with immediate life-threatening situation. 24% of all transport. B – Non-emergent and planned patient transport. 27% of all transport.

Legislation The space for the patient must adhere to the technical requirements of the EN norm 1789, the list of equipment is excluded from this. Besides that, the ambulance must adhere to the permanent and individual requirements. (RDW, 2016) Currently there is a temporary law which regulates the EMS called Twaz. Per 2020 a new law will be implemented which can change the EMS. Striping on Dutch ambulances are defined by the OOV, there are 2 types, one for active and one for supporting vehicles. (IFV) primary striping is shown in figure 14. 33 (70)

FIGURE 14. Striping Dutch ambulance

Business culture Some distinctive features in the Dutch way of working are (Labour Mobility, 2018): • Little hierarchy. • Informal work atmosphere. • Very direct communication, little small talk, straightforward and very outspoken. • Manager is not expert; details are passed on to experts. • Decisions based on consensus, thus time consuming. • Meetings are often informal, but time and location are respected. • Dutch people are known to be tough, forceful and stubborn negotiators. • Greeting is a short handshake with eye contact. • Dress code is mostly informal. • Reliability and honesty are very important. • Business cards are given at the end or after a meeting.

Providers of EMS In the Netherlands all EMS is covered by the same company. This makes that there is only one main customer and that all rules and requirements are the same. AZN is divided over 25 RAVs which all can separately purchase their ambulances.

Then there are a few type A and B ambulance which are bought by companies and non-profit organizations such as the Red Cross, Oranje Kruis, Witte kruis, Falck and airports.

Competition There is only one ambulance manufacturer in the Netherlands, Visser. This company is the market leader in the Netherlands, they supply most RAVs with their vehicles. Other big competitors are Miesen, WAS and Ambulanz Mobile (Ambulancezorg Groningen, 2015) (VGGM, 2012)

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5.4 Belgium

Introduction Population: 11.4 million Language: Dutch (60%), French (40%), German (<1%). 38% English conversational level Size: 30278km2 Currency: Euro Time zone: GMT +1 Name of the EMS: DGH. Dringende Geneeskundige Hulpverlening Location, see Figure 15 (Sumner, 2018)

FIGURE 15. Belgium on the map

Size of the market In Belgium any company or non-profit organization can operate an ambulance (if approved by the government). Currently there are 115 approved EMS companies. Regulations are very loose, this makes that most ambulances are vans in which a stretcher, first aid bag, oxygen and a defibrillator are placed. Resulting in A type ambulances. Of these types of vehicles there are approximately 400 in Belgium. Ambulances in Belgium are vans.

Then there are approximately 25 PIT vehicles, these vans are equipped like B type ambulances. They are operated by hospitals. Regular nurses are staffing these vehicles. There are approximately 80 MUG vehicles, these are rapid responders. So, in total there are around 500 EMS vehicles.

In Belgium an ambulance is called upon more often than in its neighbouring countries. The problem is known, and it is expected that the emergency care system will be reformed in the upcoming years. (Wouter, 2017) (Vlaanderen) (KCE, 2016)

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Financial In 2019 a new financing model is implemented. Belgium has been investing extra money in the last few years to improve the DHG. In 2016 they invested €12m and in 2018 €35m extra. Changes in the new model are (Thiery & Van Peel, 2018): • When calling for an ambulance the patient always pays €60. • DGH receives €73 million, almost tripling the 2014 budget of €25 million.

Working of the market In Belgium ambulance services can be organized by the government or private ambulance services. EMS in Belgium is called ‘Dringende Geneeskundige Hulpverlening’ or DGH for short. All DGH ambulances need to be approved by a qualified minister from the ‘federale overheidsdienst’ for short FOD. (FOD, 2016)

Currently Belgium is in the planning phase of reorganizing the DGH.

Legislation In 2017 the Belgian state published a report on how the exterior of the ambulances should be. All the vehicles should have this design within five years. All vehicles intended for non-urgent patient transport are white as a basis. All vehicles intended for urgent patient transport are yellow with yellow-green battenburg striping on the sides. On the back a chevron print with yellow-green-orange. (See Figure 16)

On the back of the vehicle also the words ‘ambulance’ or ‘ziekenwagen’ are displayed in reflective red. (FOD Volksgezondheid en veiligheid, 2017) The United Nations regulations on the warning lamps and sounds on ambulances are followed, Ad- dendum 64: Regulation No. 65. (United Nations, 2011)

The FOD also published a document in which all needed equipment is mentioned. (FOD, 2016)

FIGURE 16. Exterior Belgian Ambulance

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Business culture Some distinctive features for the Belgian way of working are (Business Culture Belgium): • Greetings are done by handshake and a greeting word. This is also the moment to hand out business cards. • Meetings are mostly scheduled well in advance. • Face-to-Face meetings are preferred over calls or Skype. • Non-hierarchical. • Skilled but sympathetic negotiators. Willing to compromise unlike neighbouring countries. • Preparations before a meeting are necessary to ensure achieving objectives. • Main language is mostly English. • After a meeting it is customary to send out minutes with made decisions and deadlines. • There is a difference between Walloons and Flemish. Flemish tend to be more task oriented like the Dutch, whereas the Walloons tend to be more oriented on relationships like the French.

Providers of EMS All type B ambulances are owned by hospitals. There are 115 companies approved by the government. Some of the bigger providers are: • Belgian Red Cross • Ambuce Rescue team • Firefighter departments

Competition There is one ambulance manufacturer in Belgium, Autographe. Other companies that are in the Belgian market are: Miesen, WAS and medicop.

5.5 Luxembourg

Introduction Population: 0.6 million Languages: Luxembourgish, French and German. 56% English conversational level Size 2586km2 Currency: Euro Time zone: GMT +1 Name of the EMS: CSU, Central des Secours d’Urgence (Le gouvernment) Location, see Figure 17 37 (70)

FIGURE 17. Luxembourg on the map

Size of the market In Luxembourg the EMS is operated by 2 companies, by CIS Luxembourg in the capital and by CGDIS in the rest of the country.

There are 64 active ambulances (type B) and 13 reserve ambulances. Then there are 4 special ambulances, such as MICU and XL. (CGDIS, 2018) Ambulances are stationed over 25 fire and rescue centres. Non-emergent transport is executed by the Luxembourgish Red Cross.

Financial According to Expatica the government provides free basic healthcare to all citizens, employed citizens contribute through payments to the Luxembourg’s social security system (Expatica, 2018), the contri- bution is 5.9% of which the employer and employee pay equal amounts (Expatica, 2018). About three quarter of the population have some extra form of private health insurance (Expatica, 2018). Emer- gency cases are always treated for free, even if the patient is not insured. (Expatica, 2018)

Working of the market The CGDIS operates all EMS in Luxembourg. (CGDIS, 2018) CGDIS is a state-owned department, which means that there is no competition.

Ambulances are placed at 25 CIS (fire and rescue centre) all over the country. (CGDIS, 2017)

The Red Cross and 27 other parties also take care of non-urgent transport (Le gouvernement Du Grand-Duche de Luxembourg, 2018).

Business culture Some distinctive features in the Luxembourg way of working are (Business Culture): • Good in English. • Subtlety is preferred over directness. • When discussing things tact and diplomacy are important. • Business cards are important. They are given to the receptionist or secretary and to each person met. • The main spoken and written languages in companies is French. 38 (70)

• Luxembourgers do not talk about personal matters with people who are not close. • Luxembourgers are polite but reserved, loudness, assertiveness and familiarity are considered inappropriate. • Patience is necessary. Bureaucracy and administrative procedures are far more important than efficiency or flexibility. • Agendas are strictly kept during meetings. Information is distributed within 24 hours before the meeting. • People are addressed with Monsieur (Mr.) or Madame (Mrs./Ms.) without surname. • Punctuality is important. • Dress code is formal.

Providers of EMS There are 2 providers, CIS and CGDIS. (CGDIS, 2018)

Competition Luxembourgish ambulance are mainly built by System Strobel.

5.6 Norway

Since Profile is a market leader in Norway this chapter is held very brief.

Introduction Population: 5.3 million Language: Norwegian, 90% English conversational level Size: 304282km2 Currency: Norwegian krone Time zone: GMT +1 Name of the EMS: Ambulansetjesnesten Location, see Figure 18

FIGURE 18. Norway on the map 39 (70)

Size of the market In 2016 there were 528 ambulances in operation in Norway. (Ingar Oestrund, 2016) In Norway there are four health regions (RHFs): (Statistik Sentralbyrå, 2017) • South-East; Sør-Øst • West; Vest • Central Norway; Midt-Norge • North; Nord Ambulances are mainly Volkswagen and Mercedes-Benz vans. See Appendix B.

Financial In 2016 6 billion NOK (€615.822.503) was spent on ambulance services. This represented a 4% of the total cost of specialist health service. This translates to €117.12 per inhabitant. Costs vary greatly between the regions, in the south where the population is most densely, cost are lowest (€88.38 per inhabitant). In the north where people live further apart, and air ambulances are much more used costs are much higher (€299.94 per inhabitant). (Statistik Sentralbyrå, 2017)

Working of the market Norway is divided into four health regions, under these health regions there are health trusts, (Helseforetak, HF in Norwegian) in total there are 43 HFs. The HFs organizes collected tenders every five years. It is divided into three sections; manufacturers of ambulances, equipment and services. (Sykehusinnkjøp, 2015)

Providers of EMS and competitors EMS is organized by the HFs. Acquisition of all (R)HF goes through sykehusinnkjøp. They have a tender every five years for different ambulance vehicles. The current tenders with current suppliers: passenger car <3500kg via Nilsson, van <3500kg via Handicare AS, Van >3500kg and 2-car, long and short are both via Falck Emergency Norge AS.

5.7 Sweden

Since Profile is a market leader in Sweden this chapter is held very brief.

Introduction Population: 10 million Language: Swedish. 86% English conversational level Size: 410335km2 Currency Swedish krone Time zone: GMT +1 Name of the EMS: ambulanssjukvård Location, see Figure 19

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FIGURE 19. Sweden on the map

Size of the market In Sweden there are approximately 750 ambulances, these are divided over 21 regions (Sweden.se, 2018). In Sweden all three types of ambulances are widely used. See Appendix B.

Financial Ambulances are financed by the common tax funds. The budget in 2018 is €446 million for all healthcare (Tikkanen, 2018).

Working of the market The Swedish government site states that thecountry is divided into 21 regions (Sweden.se, 2018). The government role is to establish principles and guidelines (Sweden.se, 2018). In Sweden the operators are chosen by tenders per region (Sweden.se, 2018).

Providers of EMS EMS is provided by various companies. These companies can shift throughout the years because they are chosen by tender. Some of the current providers are Falck, Samaritans, PreMedic but also hospitals are providers of EMS.

Competition There are two Swedish manufacturers, Eurolans and Nilsson. Nilsson is the biggest competitor for Profile.

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5.8 Finland

Since Profile is a market leader in Finland this chapter is held very brief.

Introduction Population: 5.5 million Language: Finnish (89%), Swedish (5%). 70% English conversational level Size: 303815km2 Currency Euro Time zone: GMT +2 Name of the EMS: ensihoito Location, see Figure 20

FIGURE 20. Finland on the map

Size of the market In 2016 there were 456 ambulances of which 123 part time, two thirds of them are B type, and the other ones are C type ambulances. (2018)

Financial In 2017 the total costs of pre hospital care was €217 million healthcare in Finland is mainly payed through taxes. Besides taxes the patient fee helps pay for the costs (Social and health care client fees, 2018). These are predetermined charges with maximums (Public Healthcare & Services in Finland, 2016).

Working of the market Finland is divided in 21 hospital districts. Municipalities are responsible for providing health care services in Finland. Some produce the service on their own, some in co-operation with other hospital districts or fire services, some acquire third party services.

Providers of EMS As stated in the previous section EMS is organized differently in each hospital district, the biggest private companies are 9lives Oy and Med Group Oy (Ambulanssi, 2018) (Repo, Repo, & Ojala, 2017)

Competition 42 (70)

In Finland there are three manufacturers, Profile, Tamulans and J5L. In terms of turnover Profile is by far the biggest. (Repo, Repo, & Ojala, 2017)

5.9 United Kingdom

Introduction Population: 66 million Language: English Size: 241930km2 Currency: Pound sterling Time zone: GMT Location see figure 20

FIGURE 21. United Kingdom on the map

Size of the market In the UK there are 5650 ambulances. Of this 4820 belong to England, the rest to the other countries (Wales, Scotland, Northern Ireland). There also are private ambulance services and voluntary ambulance services, they are used for example for patient transport and medical cover at large events. See appendix B.

Financial In 2015 and 2016 the emergency ambulance services provided by the NHS cost £1.78bn, roughly €2bn. The NHS receives 98.8% of their funds through taxes and national insurance (National Audit Office, 2017). The other money comes from patient charges (Department of Health, 2016).

Working of the market The NHS (national health services) commissions most emergency services throughout the UK. Healthcare is divided into trusts, one of the trusts is ‘ambulance trust’. The trust is divided into 10 trusts in England and one in Wales, one in Scotland, one in Northern Ireland. (NHS, 2016) In the UK there are three types of ambulance companies, the first is the biggest, the NHS they take care of all 999/112 calls. Then there are 31 private ambulance. They are registered with the National Association of Private Ambulance Services (NAPAS Membership list, 2015). The last group are the 43 (70)

voluntary ambulance services, there are four organisations. The last two groups mainly do non-emergent patient transport and events. However, when there is a high need of ambulances (i.e. during disasters) they can be called upon by the NHS. (Freedom of Information Coordinator, 2014)

Legislation In the UK the VCA (vehicle certification agency) certifies ambulances for the road. VCA refers to the CEN 1789 standards. Ambulances will undergo the Basic IVA (individual vehicle approval) for this no documentary evidence are necessary, there is just a visual inspection and some tests. (Gov.uk) (VCA)

Business culture Some things that are important in the British business culture (UK Business Communication): • Punctuality is important. • No denim in professional business meetings. • A handshake is only when meeting a person for the first time. • English is the only language for most British people. • An agreement is only final when a contract is signed. • Offence is tried to avoid; this may make detecting disagreements difficult. • Flat hierarchical structure, people address each other with first names.

Providers of EMS Generally spoken EMS is only carried out by the NHS. Non urgent transport can be carried out by private or voluntary ambulance services. If the 112/999 demands of the NHS cannot be met, they can choose to temporarily get support from volunteering or private services.

Competition There are three companies established in the UK that convert vehicles to Ambulances, these are Babcock, VCS and O&H Vehicle Conversions. Other competitors in the market are bigger companies who produce both boxes and van ambulances companies such as BAUS, Ambulanz mobile and Mey- tech.

5.10 Biggest competitors

According to all the conducted interviews there are three companies who are the biggest competitors, BAUS-AT and WAS for box ambulances in Europe and Nilsson who is the biggest competitor in the Nordic markets. To find out more about these companies a small research has been executed. In the search online presence and product information have been investigated and compared.

BAUS-AT BAUS-AT is a producer of special vehicles, mostly ambulances and emergency vehicles. The manufacturing location is in Łysomice, Poland. They also have an office in Berlin, Germany. Partners are in Strasbourg in France, Prague in Czech Republic, Gretzenbach in Switzerland, Abu Dhabi in United Arab Emirates, Melbourne Australia and Singapore.

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Their catchphrase is ‘BAUS AT …. Quality without Compromise’. BAUS AT states that they have nearly 200 employees.

BAUS builds box and van ambulances. A box ambulance is shown in Figure 22

FIGURE 22. BAUS box ambulance

Online presence When Googling ‘baus at’ the company website comes up as first result, then their Facebook and LinkedIn. When Googling ‘ambulance manufacturer Europe’ they do not come up, when Googling ‘ambulance manufacturer Poland’ they come up as first non-advertised website.

BAUS-AT has its own website www.baus-at.com it is very limited with only a few lines on their company, contact information, some pictures and videos and old posts of deliveries.

The company is more active on Facebook via @baus.at. There they post a few times per week pictures of projects. Most post have been liked around 50 times, but this runs up to a little over 200. Other interaction with posts is slim, they are shared less than 5 times and seldomly have any comments. Reviews on Facebook are good, with 45 reviews they have a 4.3/5 rating, but most do not have any text.

Instagram presence is not very active, the last post is from September 2018. There are 21 posts, all with less than 50 likes. Instagram handle is @baus_at there are 178 followers and 107 following.

Presence on Twitter could not be found.

On LinkedIn Baus has the name ‘b.a.u.s.-at-sp.-z-o.o.’ they have 80 followers and a bit more elaborate ‘about us’ than on their website. 13 employees are connected to the company. Only one post could be found of 3 weeks old, with one like and comment from themselves.

On Google Maps Baus has in total 17 reviews, only 4 of them have text. The total rating is 4.8/5. Information and photos are available.

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Product information BAUS AT makes both box and van ambulances. They are conform the EN 1789 and crash tests. They produce around 500 unites ambulances per year. Their most ordered ambulance is a Mercedes- Sprinter Box ambulance by Hong Kong customers. Prices of ambulances (B type) can vary greatly between 60 to 150 thousand euro for a complete unit, depending on type of chassis and medical equipment (E-mail: Enquiry Ambulances, 2019).

WAS WAS, Wietmarscher Ambulanz- und Sonderfahrzeuge, (ambulance and special vehicles) is in Wietmarschen, Germany. With 350 employees they produce around 1400 ambulances per year and 200 special vehicles. In Germany they have 15 service centers. Since 2001, 10 years after founding the company, WAS started producing box ambulances. (See Figure 23)

40% of their products are for customers in Germany, 30% for Europe with focus on UK, France and Benelux customers, remainders are for MENA area.

WAS’s slogan is ‘WAS making vehicles special’.

FIGURE 23. WAS Box ambulance

(RTW) Online presence When Googling ‘WAS ambulance’ the first results are all from the company. Googling ‘ambulance manufacturer Europe’ gives WAS as 7th result. When Googling ‘ambulance manufacturer Germany’ WAS comes up as first.

WAS’s website is www.was-vehicles.com and is available in German, English, French and Polish. The site is very extensive, all products are displayed with pictures, specifications, downloadable sheets. A post is published biweekly, posts are extensive and originate from the WAS customer magazine ‘Safety First’.

On Facebook WAS can be found via @was.vehicles almost daily posts are published. Some posts are in English, some in German and some in both languages, there is no clear directive. The posts are very interactive, from 50 to 500 likes, multiple likes and shares the numbers on this are varying much. 77 people reviewed WAS on Facebook with a final score of 4.8/5 approximately a quarter of them has text.

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There is no Instagram presence. There is a WAS UK page @wasambulances with only 4 posts, with the last from August 2018. The account follows 64 people and 18 follow them.

WAS can be found on LinkedIn via ‘was-vehicles’ they have 42 followers. They post a few times per week but have very little interaction; less than 10 likes and sometimes a comment or two.

On Google Maps they have some information and photos. With 36 reviews they have a 4.2/5 average rating, approximately one out of three ratings have an explanatory text.

Product information WAS makes both box and van ambulances. On their website for each individual product a lot of information is available. By enquiring it was found out that a Mercedes Sprinter is their most ordered chassis, a B type ambulance costs around €118000. (e-mail Enquiry Ambulances, 2019)

NILSSON Nilsson special vehicles is an ambulance manufacturer located in Laholm, Sweden. With 74 employees they build Ambulances, hearses, commander vehicles and vehicles for multiple coffins. Besides the headquarters there is one Nilsson company in Norway and there are seven distributors spread throughout North, Central and West Europe.

The main ambulance they produce is a box construction on top of a Volvo XC90 (see figure 24)

FIGURE 24. Nilsson XC90

Online Presence When Googling ‘Nilsson ambulance’ the first result is the English Nilsson website to their deliveries page. Googling ‘ambulance manufacturer Europe’ Nilsson does not show up in the first two pages. When Googling ‘ambulance manufacturer Sweden’ Nilsson comes up as third result.

The website of Nilsson is www.nilsson.se is available in Swedish and English. The website shows their four product categories on the home page. When looking at the English website and the ambulance products, it comes up with two types, the XC90 and the Mercedes Sprinter. On the XC90 quite a lot information can be found, not everything is in English. Brochures that can be downloaded are not in English. On the Sprinter page there is very little information. The website is not kept up to date, the last post is from November 2018. 47 (70)

On Facebook Nilsson can be found via @nilssonspecialvehiclesab they post in Swedish every 2-3 months. 1609 people follow their page, the last posts have gained up to 190 likes and 13 comments. 16 people reviewed their company page with a 4.8 out of 5.

Nilsson does not have Instagram account, however with the #nilssonspecialvehicles are 168 posts.

The LinkedIn platform is not used either. 26 people say that they are employees, 90 people follow them but there is no information or posts.

On Google Maps they can be found, here they have their address, phone number, website and open- ing hours. There are 8 reviews of which one has pictures and one has text. With a 4.6/5.

Product information As explained before, Nilsson makes many different products. In terms of ambulances the only active product they show is the XC90. The basic version costs €108500 according to teknikensvarld, a Swe- dish car magazine. (Hedberg, 2017)

Conclusion In Appendix C the comparison of above information with Profile can be found. From this information it can be concluded that Profile has a strong website, they are active on all social media platforms but interaction with followers can be improved greatly. Found information in this section will be used further in Chapter 6.

5.11 Markets comparison

To be able to decide which markets to enter with the box ambulance, an analysis of given data needs to be made. In Table 3 the decision matrix is shown. Each statement is assessed per country on the scale of 1 to 5, where 1 is least true and 5 is most true. Each statement is weighed for importance on a scale of 1 to 3. The result is a ranking of the countries. This will be discussed and from there the countries are chosen for which an entry strategy will be written. In Table 4 explanations of statement and scaling can be found.

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TABLE 3. Decision matrix, blurred

TABLE 4. Explanation and scaling 1. High ambulance to inhabitant ratio – How many ambulances there are per inhabitants. Scaling: 1 <1:30000, 2<1:25000, 3<1:20000, 4<1:15000, 5<10000 2. Amount of box ambulances – Estimated total amount of ambulances in the country in %. Scaling: 1 ≤1, 2 ≤5, 3 ≤10, 4 ≤25, 5 ≥50 3. Population growth – growth rate of population according to Worldometers with United nations information. Scaling: 1 <0.2, 2 <0.4, 3 <0.6, 4 <0.8, 5>0.8 4. View of sales managers – what the Profile sales managers think of box ambulance in the market. Scaling: 1 no opportunities, 2 neutral, 3 some opportunities, 4, good opportunities, 5 guaranteed opportunities 5. Easy to enter – how many expected obstacles to over come Scaling: 1 many obstacles, 2 some obstacles, 3 few obstacles, 4 no obstacles, 5 already in market 6. Financial – total expenditure on health per capita in $ from WHO https://www.who.int/countries Scaling: 1 <$3500, 2 <$4500, 3 <$5500, 4 <$6500, 5 <$7500 7. Stable legislation – whether there are any announced changes for the near future Scaling: 1 many changes are coming, 2 -, 3 some changes are coming, 4 -, 5 no changes expected. 8. Customer demand – probability of customers who would order more than 10 (box)ambulances at a time Scaling: 1 none, 2 slim, 3 some, 4 many, 5 most 9. Competitors – how many competitors are active in this market Scaling: 1 >9, 2 >7, 3 >5, 4 >3, 5 ≤2

Conclusion The top five ranking results of the decision matrix are as followed: 1. Germany 2. Norway 3. Sweden 4. United Kingdom 5. Luxembourg

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In consultation with the company supervisor it is discussed that the entry strategies will be written for the top three countries. The United Kingdom is, due to current political status, was ruled out as an option. After that comes Luxembourg, which scored significantly lower, and the demand will be low for this country solely based on size/population.

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6 ENTRY STRATEGIES

Profile is a company that already exports a big portion of their products. In this chapter entry strategies are presented for box ambulances in Germany, Norway and Sweden. These three markets were rated best from the decision matrix.

First, the entry mode will be chosen and discussed. Then for each market the decision matrix results, entry barriers, cost and competitiveness, business partners and marketing possibilities will be discussed.

6.1 Entry mode

In Chapter 2.2 all different entry modes were displayed. There were three that were an option in this case. Because Profile is looking to expand to multiple countries without any guarantee of return on investment, it is advised to start with direct exporting which means that the company sells straight to the customers in various countries. This type of export already is widely used by Profile through sales managers in various parts of Europe and MENA. By using direct exporting, the only immediate costs would be finding sales managers for the new markets. However, Profile already has sales managers in Germany and Sweden and there is a distributor in Norway. This means that this will not be an extra cost. In the future when demand is high, it is a good option to have a wholly owned subsidiary that solely focuses on building box ambulances. The location of this could be in a country where manufacturing costs are lower than in Finland.

6.2 Germany

First, we will look at the decision matrix in Chapter 5.11 (Table 3). After that the entry strategy is divided into different sections that will discuss important aspects to be considered before entering the market with a new product.

To define the answers which are not numerical facts a short explanation will be stated below.

Factor 4: It was made clear that there is a market for box ambulances in Germany by the German sales manager.

Factor 5: The obstacle they currently face is that the Finnish product does not fit in the German market, so only 20-30 vans have been sold in the past 3 years. However, the sales manager and Profile’s CEO are in a phase where they are testing a van designed for the German market. They are also looking at box manufacturers to explore further options. (Enquiry DACH and Benelux market, 2019)

Factor 7: Legislation is very stable and similar to other countries.

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Factor 8: Because Germany is a big country where there are many customers who order bigger batch sizes.

6.2.1 Entry barriers

To enter the German market with box ambulances, Profile will be faced with a few barriers.

One of the barriers to enter is cost, Profile has a relatively high cost price in comparison to competitors in the German market because values lie differently.

Another entry barrier is that there are many ambulance manufacturers in Germany. Finland is a long distance away from the intended customers. Customers have many options to buy locally from brands they know.

A third entry barrier is knowledge and skills. Box ambulances (RTW) are very common in Germany, whereas the product is new to Profile. This leads amongst other things to learning curves, development and economies of scale, resulting in a longer lead-time.

A fourth entry barrier is that German customers demand that dynamic crash tests are completed before they consider buying an ambulance.

A fifth barrier to entry is that German customers demand German tests on the product. The sales manager estimates that this will cost anywhere between €60000 to €80000.

The last entry barrier is a demo product. Because the two biggest European trade fairs are held in Germany it is important that there is a demo product there that matches the requirement from the German customers.

These barriers combined mean that a lot of changes and effort need to be made before box ambulances could be sold successfully in Germany.

6.2.2 Cost and competitiveness

To calculate the cost of entering a market is very difficult, because it consists of many factors that can change at any given moment. One of them being that there is no product yet. But it is very important to take the cost of entering a new market into account. To give an idea of the costs, factors will be discussed.

The first cost is the sales manager, the current sales manager is responsible for many different markets namely Germany, Austria, Switzerland, Belgium, the Netherlands, Luxembourg and in special cases the United Kingdom. To get better results it might be a good solution to let the sales manager focus on solely the German. This will relatively cost more per market, but it can result in better sales numbers.

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The second cost is the development of the product, which, according to the R&D manager, will take 4 to 5 months. It is important that there will be special attention to the German requirements. This because they require different things than the Nordic countries.

A third example of cost is the dynamic crash tests. According to the sales manager this will cost around €70000.

The last-mentioned cost is a demo vehicle. Currently sales of vans are not very high in Germany because there is not a special German product. When the product is designed in accordance with German requirements in mind, it is good to have a demo vehicle to visit exhibitions, fairs and potential customers with it to show that the product works for their needs.

In terms of competitiveness the German market will be difficult. In Germany alone there are already eight manufacturers that produce box ambulances. They have many advantages such as; knowledge, experience, existing customers and proximity. To be able to compete with these existing German and foreign suppliers it is of the utmost importance that the to be developed product is very cost efficient, meets all requirements and can offer things that the competitor cannot. An example of a selling point could be better drivability by better aerodynamics and a low center of gravity.

6.2.3 Network

The current network in Germany revolves around the sales manager. There also are two distributors which will arrange registration and service, one is located close to the border with Czech Republic and one in the North West of the country. This makes that service points are accessible within a few hours’ drive all over Germany.

Buyers of box ambulances are municipalities with many inhabitants, professional firefighter squads and the German Red Cross. Building a network with these potential customers mainly goes through trade fairs, calls and visits. However, in the current world social media is becoming more and more important in networking. So, for Profile it is important that the social media network is being updated more frequently with a clear goal in mind. Also having the right flyer/catalogue material that is attrac- tive, informative and brief.

6.2.4 Marketing possibilities

To market the product well can be a stepping stone to good sales. When looking at the biggest competitors, they have active social media pages with facilitates interaction with end-users. Profile already makes use of the social media outlets, but this can be improved by uploading more consistently, ac- cessibility by posting in English with all posts and increasing interaction. The only platform that is not used fully yet is LinkedIn. This is a missed opportunity because this is the place where all the profes- sionals come together. It would be good for both the company webpage and the sales manager to improve this network by connecting with (potential) customers and posting regularly.

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A good marketing move that Profile already has taken is producing their website in German.

Other good marketing opportunities are exhibitions, Profile is attending many events where their products are showcased, and potential customers can be met. Some attended exhibitions are RETTmobil and Interschutz. They are both held in Germany and attract visitors from all over world.

The biggest question is, how Profile can stand out among all competitors. Options can be by embracing the fact that the product is foreign or by showing the customer why the product is better than the box ambulances of competitors. This can be done through social media outlets, events, sales visits etc.

6.2.5 Conclusion entry strategy Germany

Barriers to entry are many competitors, and that a special crash test is needed, Profile products are more expensive than competitors’, Profile is located quite far from Germany and German market requires different products than the Nordic markets do.

To be more competitive, it is important that Profile designs a box ambulance that fits within the needs of the German customers, both price and product wise. Besides that, it is important that Profile gains more recognizability amongst potential customers. This can be done through clever marketing, attending trade fairs with a demo vehicle and utilizing the social media more.

6.3 Norway

First, we will look at the decision matrix in Chapter 5.11 (Table 3). After that the entry strategy is divided into different sections that will discuss important aspects to consider before entering the market with a new product.

To define the answers which are not numerical facts a short explanation will be stated below.

Factor 4: In Norway there currently is no sales manager from Profile, but a distributing partnership. From found information it is estimated that 10% of ambulances in Norway are some form of boxes.

Factor 5: Because Profile currently has quite a few ambulances in the Norwegian market.

Factor 7: Stable legislation was scored high because there are not any changes scheduled and there is already a quite steady market in Norway so changes should be heard of early in the process.

Factor 8: For customers a lower mark has been given because there are 43 HFs, but all the ambulances are bought through the buying party from the health care sector, Sykehusinnkjøp.

6.3.1 Entry barriers

Profile is already a supplier for ambulances in the Norwegian market. This means that there is plenty of in-house knowledge on the market. 54 (70)

The interesting thing about Norway is, is that there they are not part of the European Union. But they are a part of the European Economic Area (EEA), this means that all products will be taxed with VAT and/or excise duties. VAT for Norway is 25% and excise duties are calculated per vehicle. On top of the costs of importing it takes time to arrange all needed documents, however this will be done by the distributor, VBK Nordics AS.

The distributor is helpful, but it also causes difficulties because Profile is not in charge of them. It is very important to keep communicating openly to receive set goals.

6.3.2 Cost and competitiveness

To determine the cost and competitiveness, the current resources are evaluated, and competitors are compared. In Norway there is one customer who buys all the ambulances, the sykhusinnkjøp. Every five years they put out a tender. This makes it a relatively cheap market to sell to because only once every five years one company needs to be convinced that Profile products are the best for their needs.

It also is very helpful that there are few competitors, of which Nilsson is the biggest. Other companies that have won the tenders last period are Falck and Handicare. Handicare sells Tamulans ambulances in the Norwegian market. Noticeable is that none of these suppliers are manufacturing their products in Norway, this makes that everyone faces the same barriers and cost to complete in the market.

When looking at competitiveness we look at the core values of the competitors and Profile. Firstly, Nilsson. They advertise with the fact that their products are of high quality and precision. Other aspects they deem important are function, reliability and total cost of ownership. Nilsson does supply box ambulances; these are assembled in Poland.

Other competitors are Falck Norge and Handicare. Handicare is a distributor of Tamlans ambulances.

6.3.3 Network

Profile has a distributor partnership in Norway with VBK Nordic AS. They handle all the Profile ambulance sales in the Norwegian market, when needed they seek advice and help from Profile. Besides sales, VBK also organizes the service of the Norwegian vehicles. For Profile this partnership is helpful because only once every five years there is the opportunity to sell ambulances in Norway because all the sales are tender based and go through sykehusinnkjøp. The disadvantage of the distributor partnership is that Profile has very little influence in the process and network.

6.3.4 Marketing possibilities

Because the Norwegian market is handled through a distributor Profile has no direct influence. By presence at the various exhibitions and social media outlets, they can give a good image for the Profile product, which might help the customer to choose. Another way to positively influence the market is by giving the distributor the right tools and information to transfer to customers. 55 (70)

6.3.5 Conclusion entry strategy Norway

The biggest entry barrier is that Norway is not an EU country. This brings costs and paperwork when importing. Fortunately, Profile has a distributor who does this work for them. The downside of the distributor is that Profile does not have real control over the sales process. The only way to influence the market is to have a good online presence which is accessible for the Norwegian customers. One of the big risks is that there is only one tender every 5 years for (box) ambulances, which means you either get all the demand or none for five years.

6.4 Sweden

Factor 4: Because the sales manager has heard for years that customers are interested in box ambulances. But none of the competitors are producing them.

Factor 5: The market is very easy to enter because Profile has all the resources already there. Sweden is already one of their biggest customers and they have an office and employees in Sweden. Besides that, Swedish is one of the official languages in Finland so there is a relatively small language gap.

Factor 7: A high mark because there are few changes and presence in Sweden is high these things will be picked up easily.

Factor 8: A lower mark is given, meaning there is a slim chance that there are customers who would buy 10 or more box ambulances. This is because box ambulances will be solely used for type C ambulances and there are not that many of them.

6.4.1 Entry barriers

Sweden has no new entry barriers. Because Profile is already very active in the market. Of the three countries The Swedish market is expected to give the fewest obstacles to overcome because: • Profile has been in the Swedish market for approximately 30 years. Customers know the brand and have faith in the products. • Finland and Sweden share a border, making the location most favorable. • Sweden is one of the biggest customers for Profile in return Profile is the biggest supplier to Swedish emergency service operators. Therefore, there is a lot of knowledge of the market and there are lasting relationships in place with customers. • There is an office in Sweden with employees who fully commit their time to the Swedish market.

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Some things that need to be taken in to account are that in Sweden they do not pay with the euro and there are local ambulance manufacturers such as Nilsson and Eurolans who are strong competition.

6.4.2 Cost and competitiveness

It is important to take the expected costs into account. Therefore, the following questions need to be answered: • Which cost can be expected to enter this market? To enter this market the product needs to be developed and tested before it can be sold, however the designing and sourcing of suppliers only needs to be done once for all markets. Since each (series of the) product is already altered to the customers’ needs this is not a new occurrence. It might be a good investment to make a prototype of the final product for exhibitions and events, this is a cost that also can be combined with the entry to the Norwegian market.

• What are the costs of comparable products in the market? There is only one manufacturer who produces box ambulances, in low numbers and on a car instead of a van, this is making a comparison unfair but in a videoclip they show that their product will cost approximately €260000. Also, the Swedish sales manager mentioned that in the Swedish market quality comes before costs. Swedish customers are willing to pay more if it means they get better quality and use of the product.

• What is the gap between product specifications and customer requirements? In Sweden the ambulances specifications traditionally differ quite a lot between customers (and geo- graphical areas). This is something Profile must deal with while making product planning. Making the product as modular as possible is of high interest for the other markets as well. This will make it easier and cheaper to alter the product to customer specifications.

6.4.3 Network

It is very fortunate that in Sweden there already is an extensive network in place. Profile has a sales and service point with a few employees in Trollhättan which lies in the south of Sweden between Gothenburg and the Norwegian border.

The current sales manager has been with the company for more than a decade, the Swedish market is the highest priority, but Norway, Denmark and Faroe Islands fall under his area too.

The biggest buying parties are the 21 regions which buy their ambulance services through tenders (same for operators and equipment). Other customers are private companies which make out only a very small segment of the market.

Improving the network can be done by having an active LinkedIn page, both from the company and sales manager.

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6.4.4 Marketing possibilities

In the Swedish market the biggest competitor is the Swedish brand Nilsson. When looking at their website it becomes clear that they only have 2 types of ambulances, one based on the Volvo XC90 and on based on the Mercedes Sprinter. Furthermore, their website is not focused on ambulances, they have little information on the ambulance products. They do go to exhibitions in Sweden

On social media the activity is low, they post on average twice a month on Facebook with quite a lot of interactions, up to 200 likes, up to 15 comments and shares. They are not present on Instagram and LinkedIn. With this Profile already stands out from the competitors, but big improvements can be made.

Flisa, an association for Swedish ambulance services, organizes a congress each year in Septem- ber/October. This is one of the opportunities to showcase the Profile product to the customers. Profile is already a gold sponsor of this event.

6.4.5 Conclusion entry strategy Sweden

Sweden might be the easiest market to enter, with an office in Trollhättan and a big presence in the van ambulance market segment. With 21 different districts of which almost each one individually tenders their ambulances it means that there are quite a lot of opportunities to sell the box ambulance. The current sales manager knows the market, the area and its customers well. By making sure that the product is designed based on modularity customer specific products can be easily made.

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7 CONCLUSION AND RECOMMENDATIONS

There are three types of ambulances in the European market. The box ambulance is mainly used for the type C ambulance. In some countries, such as Germany, type B box ambulances exist, too. Box ambulances will always be above 3.5t. This is not a problem because most B type van ambulance already cross this weight as well, meaning that most ambulance drivers throughout Europe already have a C1 drivers license.

The regulations need to be considered when designing the box ambulance. The European standard is EN 1789 and the United Nations have regulations as well. Besides the European standards, each country can differ in regulations, most countries even have their own testing.

There are many pros and cons about box ambulances. In some cases it does not matter whether a box or van is used. However, in most cases box ambulances are a heavier type of equipment and therefore more expensive and lower in demand.

Most manufacturers, almost 50%, produce both box and van ambulances, Profile is one of the almost 40% who does not produce box ambulances.

With the decision matrix, it became clear that the three markets who have good prospects. Those are Germany, Norway and Sweden. For these three markets entry strategies were made. Because the three markets have very different outlooks and demands toward box ambulances, each market got its own strategy.

The different markets require different product specifications and layouts. This can even differ per customer. Therefore, it is very important that this will be considered when designing the product. A solution could be modularity. By making it easy to change or exchange parts of the box ambulance for different settings it can be made easier to alter the product to the demands of each individual customer.

Experience has shown that a market specific product is needed to sell products. This leads to the possibility that a different product needs to be designed for the German market all together. The Ger- man market differs a lot from the Norwegian and Swedish market.

Profile is already very active at exhibitions. They have a good website and they try to keep social media up to date. Especially for social media there is improvement to be made. Sales managers need to actively use the LinkedIn network for more professional marketing.

There are opportunities in the three selected markets, however. It will require work, time and investments to make it a profitable outcome. 59 (70)

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LIST OF CHARTS CHART 1 - Product range ambulance manufacturers Europe CHART 2 - Location of manufacturers

LIST OF TABLES TABLE 1 - Decision matrix example TABLE 2 - Box ambulance vs van ambulance TABLE 3 - Decision matrix, blurred TABLE 4 - Explanation and scaling TABLE 5 - Appendix B Market Research data TABLE 6 - Appendix C Comparison of competitors in online presence

LIST OF FIGURES FIGURE 1 Study steps Sanne van Leeuwen FIGURE 2 Model 774 Automobile Ambulance https://libwww.freelibrary.org/digital/item/41373 FIGURE 3 Nilsson XC90 http://www.nilsson.se/en/tag/ambulance/ FIGURE 4 Progrez Internal Profile picture FIGURE 5 Modulanz Internal Profile Picture FIGURE 6 Battenburg striping https://commons.wikimedia.org/wiki/File:Battenburg-ambulance.svg FIGURE 7 Star of life https://www.ems.gov/staroflife.html FIGURE 8, 10, 13, 15, 17, 18, 19, 20, 21: Map of Europe GeoNames by Bing (Microsoft Office charts) FIGURE 9: Distribution of ambulance suppliers in Denmark 66 (70)

(Regional abejdsruppe, 2018) FIGURE 11: KTW Cologne Miesen Facebook page FIGURE 12: RTW Berlin https://www.flickr.com/photos/berliner-feuerwehr/5118672536/ FIGURE 14: Striping Dutch ambulance https://www.ifv.nl/kennisplein/Documents/20103-tno-rapport-striping-van-voertuigen-voor-openbare- orde-en-veiligheid.pdf FIGURE 16: Exterior Belgian ambulance (FOD Volksgezondheid en veiligheid, 2017) FIGURE 22: BAUS Box ambulance http://www.baus-at.com/ FIGURE 23: WAS RTW https://www.was-vehicles.com/de/produkte/rettungsfahrzeuge-deutschland/rtw-rettungswagen.html FIGURE 24: Nilsson XC90 http://www.nilsson.se/nilsson-xc90-ambulans/

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APPENDICES A. Interview questions Issue 1: Function and work • What does your function entail? • How long have you been working for the company? • How long have you been in this function? • With which people do you work a lot? • What are key issues in your job?

Issue 2: Markets • In which markets are you most active? • Who are the main competitors in these markets? • In which markets are you sometimes active? • How is marketing of ambulances done in these countries? • How does the potential customer meet Profile? • What makes this market different than others? • How many Profile are sold to this market? • How many ambulances do you think is the total market volume?

Issue 3: Tenders • How does tendering work? • Who are involved in a tender? • Who decides who wins a tender? • Is the reasoning for the winner published? • For how many vehicles do you make tenders? • How often is a tender published? • How long before the first need of an ambulance is a tender published?

Issue 4: Decision-making process • Who is involved in the decision-making process? • What is your function in the decision-making process? • What are the steps in the decision-making process? • How are aspects are weighed? What is more important, cost, reliability, manufacturer, etc. • Why were Profile chosen?

Issue 5: Ambulances • What type ambulance do you use/sell/buy mostly? • Who is your supplier of previous ambulances? • Do you have more than one supplier/make/model in use in your ambulance fleet? • If yes, is there a strategy to share the volume between suppliers/makes/models? • Do you have boxes and van ambulances? Which are most common? • Which type of ambulance do you prefer? 68 (70)

• How often is an ambulance replaced? • Is there a difference between recommended life time between makes/models/types?

Issue 6: Demand • How do you plan the demand for ambulances? • What is the demand for the next 3-5 years? • How do you decide on requirements of new vehicles? • Who is involved in making a requirements/demand list? • How far do you (have to) look into the future?

Issue 7: Box ambulances • Do you use box ambulances? • If yes, what do you think are the pros and cons relative to van ambulances? • Do you expect that in your market/company there is a demand for box ambulances? • What would make you decide to purchase a box instead of a van ambulance? • Do you foresee demand for box ambulances will increase or decline in the next ten years and why?

Issue 8: Profile emplOyees • What is your view on box ambulances? • Do you think it is a good idea to offer and build box ambulances for customers? • What are some issues expect to surface when manufacturing boxes? • What are the key selling points of profile products? • What contacts do you have in the market; can you connect me so that I can interview some customers?

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B. Market research data

TABLE 5. Appendix B Market Research data

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C. Comparison of online presence

TABLE 6. Appendix C Comparison of competitors in online presence