Purpose: The purpose of this paper is to explore how different country-specific institutional healthcare settings affect an international new venture’s (INV’s) selling strategies and internationalization process when commercializing a medical technology innovation.

Design/methodology/approach: The study is based on a longitudinal in-depth case study approach with a comparative healthcare analysis in Sweden, UK, Germany and the USA.

Findings: An institutional framework helps elucidate the regulative, normative and cultural-cognitive dimensions in different healthcare settings. National markets differ when operating in a healthcare setting and thus affect both sales patterns and the internationalization process. In this study, three different sales patterns emerged from the countries’ and even regions’ distinctive institutional differences. Although the actual internationalization process starts from the INV’s inception, the subsequent internationalization process was both slow and focused due to institutional diversity and complexity.

Practical implications: Every nation has its own unique healthcare structure, indicating the importance of choosing markets that facilitate a swift uptake of a specific medical technology innovation. Commercializing a medical technology innovation in different country-specific healthcare settings is a lengthy, complex and costly process, especially if new behaviors and routines need to be created.

Originality/value: The paper contributes to the international entrepreneurship-marketing interface by developing an analytical framework for understanding country differences in relation to regulative, normative and culture-cognitive dimensions and by advancing six propositions related to the role of institutional healthcare settings and their impact on INVs’ sales patterns and internationalization processes. © 2018, Emerald Publishing Limited.