Internationalization of small to medium-sized enterprises (SMEs) in the healthcare industryhas experienced rapid growth in the recent decade. Although research on understanding thisprocess and what drives it has been conducted, previous studies are limited in recognizing thefull influence of both domestic and foreign institutional environments. This study investigatesthe internationalization of four Swedish SMEs operating in healthcare markets through aninstitutional-based perspective, asking how and why SMEs internationalize and how theymanage different institutional environments. By analyzing the empirical case findings in thelight of a theoretical framework based on internationalization theory, institutional theory andinstitutional entrepreneurship we attempt to answer our research questions mentioned above.The thesis concludes that internationalizing SMEs experience a large range of barriers ofwhich most can be effectively overcome by cooperation and access to networks with keyopinion leaders. Findings on managing the institutional environment pointed to that thedomestic institutional environment can act as a driver for internationalization, while theability to influence and change foreign institutional environments were found to be nearimpossible for a single firm. However, our study shows that attempts at institutional changecan be achieved through cooperation together with other firms, organizations and mostimportantly influential networks with key opinion leaders. Internationalizing SMEs within thehealthcare industry might not be institutional entrepreneurs in its true sense; however theyhave the possibility of getting there.