Introduction
In modern societies, the healthcare sector is grappling with significant challenges such as the impact of an aging population, fierce competition for employees, financial constraints due to government cuts driven by rising national healthcare costs, and the advent of new technologies like e-health. These issues arise within a dynamic and complex healthcare environment characterized by stringent national regulations, regulatory authorities, medical specialist associations, diverse professionals, and patient associations, social partners including trade unions and works councils, as well as national and local governments. These developments lead to increased complexity, reduced flexibility, and greater public transparency. Consequently, there is a dynamic interplay between competition (scarce resources, the need for economies of scale) and cooperation. This paper focuses on cooperation and competition within the healthcare sector, examining the effectiveness of various variables in moderating the intensity of cooperation among competitors. The current research aims to identify and explain the effects of these moderating variables on the intensity of competition within the health supply chain.
Methodology
In the first phase of the research, a qualitative approach and semi-structured interviews were used to identify these variables. Then, using the Delphi approach, the effect of the moderator variables was evaluated. The statistical population of the research consisted of health supply chain experts from Kashan, Aran, and Bidgol cities. To ensure the validity of the results, the study involved returning the codes to the participants for confirmation, describing the characteristics of the interviewees, and using methods such as confirmation by two external observers and a secondary coder.
Results and Discussion
As a result of the first phase of the research, 16 moderator variables were identified for co-competition: "company size," "member motivation," "number of competitors," "technological challenges," "market size," "company reputation and credibility," "contract quality," "quality of supervision and control," "information management," "member responsibility," "conflict resolution skills," "degree of self-interested behavior," "degree of complementarity of capabilities," "degree of complementarity of resources," "degree of perceived benefits," and "degree of interdependence." The results of the second phase showed that "company size" and "number of competitors" have a U-shaped moderating effect, while "level of self-interested behavior" has a negative moderating role. The other identified variables have a positive moderating effect, meaning that as these variables increase, the intensity of cooperation among competitors also increases. Although the adjustment of competitive intensity has been emphasized in some previous studies, including the study by Yusuf and Waheed (2024), no research has specifically focused on identifying these factors. To a limited extent, previous research has observed the moderating role of some variables. For example, Rabii and Cyrine (2024) emphasized organizational learning and information sharing as effective factors on competitive intensity in the field of "information management." Various studies, such as those by Garraffo and Siregar (2022) and Xie et al. (2023), have highlighted the cultural aspects expressed by the variables of "members' responsibility" and "level of self-interested behavior." Additionally, research by Garraffo and Siregar (2022) and Crick et al. (2017) has noted the moderating role of "technological challenges," while the "number of competitors" was also emphasized by Garraffo and Siregar (2022), although its effect was considered low.
Conclusion
As the results indicated, out of 16 variables, 13 play a positive moderating role. Therefore, if the nature of these variables is favorable, they should be enhanced. Among these, 9 variables have a positive aspect and need to be increased. These variables include "member motivation," "market size," "company reputation and credibility," "contract quality," "quality of supervision and control," "information management," "member responsibility," "conflict resolution skills," and "perceived benefits." In this context, improving the human resources system to enhance "member motivation" and "member responsibility" is essential. To increase "market size," it is necessary to move towards new markets such as health and wellness tourism. Given Iran's unique conditions and desirable expertise in health and medical care, focusing on health tourism can facilitate the development of a cooperative market. Regarding "company reputation and credibility," various supply chain members need to engage in branding efforts. Marketing and branding activities in this area are weak; thus, utilizing marketing consultants is crucial. To improve "contract quality," it is essential first to identify the challenges and drawbacks of cooperation and incorporate preventive measures into the contracts. Subsequently, strong legal consultants should be employed. For variables such as "degree of interdependence," where excessive dependence is harmful and complete independence is unfeasible due to inflationary conditions, maintaining an equilibrium can lead to stability and preserve the advantages of cooperation. Additionally, improving the information infrastructure, recruitment, strengthening the educational system, and employing legal and marketing consultants are required to ensure cooperation benefits.

Methodology: In the first phase of the research, a qualitative approach and semi-structured interviews were used to identify these variables. Then, using the Delphi approach, the effect of the moderator variables was evaluated. The statistical population of the research consisted of health supply chain experts from Kashan, Aran, and Bidgol cities. To ensure the validity of the results, the study involved returning the codes to the participants for confirmation, describing the characteristics of the interviewees, and using methods such as confirmation by two external observers and a secondary coder.
Results and Discussion: As a result of the first phase of the research, 16 moderator variables were identified for co-competition: "company size," "member motivation," "number of competitors," "technological challenges," "market size," "company reputation and credibility," "contract quality," "quality of supervision and control," "information management," "member responsibility," "conflict resolution skills," "degree of self-interested behavior," "degree of complementarity of capabilities," "degree of complementarity of resources," "degree of perceived benefits," and "degree of interdependence." The results of the second phase showed that "company size" and "number of competitors" have a U-shaped moderating effect, while "level of self-interested behavior" has a negative moderating role. The other identified variables have a positive moderating effect, meaning that as these variables increase, the intensity of cooperation among competitors also increases. Although the adjustment of competitive intensity has been emphasized in some previous studies, including the study by Yusuf and Waheed (2024), no research has specifically focused on identifying these factors. To a limited extent, previous research has observed the moderating role of some variables. For example, Rabii and Cyrine (2024) emphasized organizational learning and information sharing as effective factors on competitive intensity in the field of "information management." Various studies, such as those by Garraffo and Siregar (2022) and Xie et al. (2023), have highlighted the cultural aspects expressed by the variables of "members' responsibility" and "level of self-interested behavior." Additionally, research by Garraffo and Siregar (2022) and Crick et al. (2017) has noted the moderating role of "technological challenges," while the "number of competitors" was also emphasized by Garraffo and Siregar (2022), although its effect was considered low.
Conclusion: As the results indicated, out of 16 variables, 13 play a positive moderating role. Therefore, if the nature of these variables is favorable, they should be enhanced. Among these, 9 variables have a positive aspect and need to be increased. These variables include "member motivation," "market size," "company reputation and credibility," "contract quality," "quality of supervision and control," "information management," "member responsibility," "conflict resolution skills," and "perceived benefits." In this context, improving the human resources system to enhance "member motivation" and "member responsibility" is essential. To increase "market size," it is necessary to move towards new markets such as health and wellness tourism. Given Iran's unique conditions and desirable expertise in health and medical care, focusing on health tourism can facilitate the development of a cooperative market. Regarding "company reputation and credibility," various supply chain members need to engage in branding efforts. Marketing and branding activities in this area are weak; thus, utilizing marketing consultants is crucial. To improve "contract quality," it is essential first to identify the challenges and drawbacks of cooperation and incorporate preventive measures into the contracts. Subsequently, strong legal consultants should be employed. For variables such as "degree of interdependence," where excessive dependence is harmful and complete independence is unfeasible due to inflationary conditions, maintaining an equilibrium can lead to stability and preserve the advantages of cooperation. Additionally, improving the information infrastructure, recruitment, strengthening the educational system, and employing legal and marketing consultants are required to ensure cooperation benefits.