Analysing the transnational provisioning of services in the social sector: the case of commercialisation of NHS services in China and India

This study addresses the contemporary attempts by public and private organisations to position the UK within a globalised commercial healthcare economy. It asks how and why this ambition is being realised in England and in two major 'emerging economies' perceived as potential areas of market growth (India and China), and considers the implications for public or state-owned healthcare, health training organisations and healthcare users in the three settings. The study objectives are to:
1) describe and analyse the key drivers, actors, markets and supporting social and political infrastructures of commercialised transnational provisioning of healthcare;
2) investigate these and their everyday workings and moral economies through three detailed qualitative case studies of UK-India and UK-China healthcare provisioning in the areas of a) labour sourcing and processes, b) training and management consultancy and c) joint infrastructure ventures, and
3) consider the implications for healthcare planning and governance in the three countries, and communicate these to scholarly, practitioner, advocacy and policy audiences.

The context for this research is a period of globalisation in which there have been significant changes in how service sectors are organised, and how public services are managed and provided. In the healthcare sector, there has been an increasing expansion of markets and of opportunities for investment in a global healthcare industry; greater cross-border consumption of healthcare, and increased consumer rights consciousness among patients. In England there have been cumulative market-based reforms to the structure of the National Health Service (NHS), while China and India have seen trade policy reforms, growth of specialist private hospital care and related diagnostic services, and expansion of fee-based provision.

The run up to the UK's 'Brexit' departure from the European Union is posing new demands for recruitment of international staff, and public healthcare organisations are facing pressure to 'become more entrepreneurial' to cope with budgetary pressures. Labour markets in middle-income countries are proving a vital source of health workers - provisioned either by third-party commercial agencies or by private hospital chains - while the rising burden of non-communicable diseases amongst ageing and middle-class populations in China and India is driving new demand for healthcare services that offer potential new markets and sources of revenue for UK-based healthcare organisations, notably hospitals, insurance companies, professional bodies and university health schools. In what seems to be a significant step change for the 'NHS identity', marketing has begun with sights set on offshore provisioning to new audiences, primarily in these emerging economies.

This project seeks to understand these new developments, which reflect wider global trends in commercialisation, labour markets and trade in social sector services. The case studies will include the transnational outsourcing of back-office administrative activities, training and management consultancies, and joint ventures for hospital development. It will explore projects between organisations in England and in Guangdong, Fujian and Jiangsu (China) and in Delhi, Andhra Pradesh and Maharashtra (India) examining all elements of the 'provisioning chain' from governance and financing, through to production, delivery of / access to healthcare facilities and services, and consumption.

Our study findings will be important for raising public awareness and understanding in the three settings of the increasingly globalised nature of the healthcare economy, the types of changes being promoted, and their possible effects. Our public and policy engagement activities will aim to inform policy development within healthcare organisations directly, and also indirectly through engagement with local community organisations.

We aim to provide an evidence base to inform policy and practices of publicly owned and quasi-public organisations engaging in global healthcare markets, and to raise public awareness and understanding of the changes taking place in healthcare systems and their relationship to the global economy more broadly. We have established an advisory network to inform our policy and public engagement strategy. Members of the network represent a range of relevant expertise including professional organisations, INGOs, health journalism and business organisations from the three countries and will be consulted regularly via bimonthly emails and annual meetings. (See Pathways to Impact).

We will regularly engage with a range of public organisations in the UK, China and India to stimulate interest in the research and its findings amongst these organisations, and to optimise design of outputs. This will be achieved through consultations in months 3 and 4, respondent meetings and interviews, overview policy briefs in years one and three, public panel discussions in years two and three, and end-user meetings in year three. Project legacy will come from the evidence base on the processes and conflicts that characterise transnational healthcare provisioning. The first policy brief will focus on identifying relevant policies and regulatory systems in each country, and describing the range of activities taking place, the regulatory gaps and the key issues. The second brief will update this information, summarise the project's main findings and highlight challenges faced by the public organisations involved in the markets of interest.

Public engagement will bring to the fore the deepening inter-relationships between health systems in these countries and enable greater understanding of activities performed by English healthcare organisations. We aim to use public panel discussions and media to generate debate around the engagement of resource-constrained public organisations in commercial practices beyond their original public service mandate. Potential beneficiaries include civil society such as journalists, health and trade non-governmental organisations and activists. For example, HealthWatch, King's Fund, Nuffield Trust, Centre for Health and the Public Interest, Public Health Foundation of India, Support for Advocacy and Training to Health Initiatives (SATHI), and the People's Health Movement.

Trainee practitioners in public administration and in health and development will be another target user group. Invitations for workshops on transnational healthcare and the social sciences will be extended to trainee practitioners at: Sun Yat-sen University's Schools of Nursing, Medicine, Public Health and Sociology and Anthropology, and at Jawaharlal Nehru University's Centre for Social Medicine and Community Health and other universities in and around Delhi. Topics covered will include the historical trajectory of national healthcare systems, drivers of change, opportunities for using social science approaches for studying health and healthcare, and mechanisms to communicate findings to policy and public audiences. Findings will also be incorporated into teaching in the Department of Political Economy and Department of International Development at King's College London.