Practices, regulation and accountability in the evolving private healthcare sector: lessons from Maharashtra State, India

This research is about the expansion and changing face of private sector hospital care and related diagnostic services through an organised, and increasingly transnational, healthcare industry. It responds to concerns, expressed in a recent paper in the Lancet, about how incentive structures within health services may become distorted to meet the economic interests of this industry, and about the risks of regulatory capture and disempowerment of communities and citizens. The research team is composed of social scientists from King's College London and public health researchers and health rights activists from India. To explore this issue, we will construct a detailed case study of the sector in Maharashtra State, India which has many expanding healthcare hubs. Our objectives are first to examine the implications of these emerging forms of healthcare delivery and their business and management practices for the healthcare sector, for medical practitioners and for healthcare users. As there is no central register, we will conduct a mapping of facilities by collating information from various registers and business media reports; we will interview a wide range of medical practitioners, managers, facility owners, regulators, policy makers, patient organisations and health rights advocates; and we will conduct a 'witness seminar' to explore the contemporary history of corporatisation of healthcare in the State. Second, we will consider the nature, successes and failures of past attempts at regulation of the private medical sector in the State. For this we will hold a stakeholder consultation and a witness seminar exploring recent regulations, and obstacles and distortions in implementation. The final stages of the project will be to develop and advocate for mechanisms of 'social regulation', such as patient and citizen involvement in monitoring of enforcement of rules and regulations from a rights-based perspective, and to draw lessons for other low and middle income countries.

A case study of Maharashtra State, India, explores the changing face of private sector hospital care and related diagnostic services and the organised, and increasingly transnational, healthcare industry. Study questions are informed by the concepts of commercialisation; regulatory capture, social accountability and social regulation.
a. What have been the key transformations in the private hospitals and diagnostics sector in Maharashtra state, and in India, since 2000 and what is the likely future trend?
b. What have been the implications for medical and institutional practices, and how have the trends been experienced by medical practitioners and users?
c. What has been the trajectory of regulatory mechanisms in this sector, whose interests have they articulated, and what are the regulatory implications of likely future trends?
d. What could a social accountability approach to regulation look like in such a context?
e. What lessons can be derived for India and for LMICs more broadly in order to facilitate universal access to quality healthcare?
Methods include narrative literature review, collation of statistical data to map formal private healthcare sector; qualitative audio-recorded interviews with purposively sampled doctors, managers, administrators, owners, regulatory bodies, public health academics, specialist medical associations, GPs, patient advocacy groups. Thematic analysis will use NVivo software. Witness Seminars, an oral history technique, will explore i) corporatisation in healthcare and ii) the 1994 Act regulating private sector practice on sex-selection of foetuses. A stakeholder consultation with policy makers, professional organisations, regulatory bodies, facility owners, insurance bodies, patients' rights organisations, will examine regulatory challenges in the private healthcare sector. A modified version of the Clinical Establishments Act will be elaborated employing a social accountability framework.

The beneficiaries of our research will be practitioners and policymakers engaged with:
- Indian healthcare provision, professional regulation, & heath related trade and investment e.g. Ministry of Health & Family Welfare, Indian Medical Council, Nursing Council of India, Ministry of Commerce
- Bilateral and other projects with India e.g. the UK Department for International Development,
- Regional trade and social policy e.g. South Asian Association for Regional Cooperation, Asian Development Bank
- Support & evaluation of India's health system and achievement of Sustainable Development Goals, e.g. World Health Organization (SEARO & Geneva offices), UNDP, World Bank
It will also be of interest to:
- Those wishing to understand transnational aspects of health systems and health related trade
- NGOs (international & Indian national) concerned with issues of equity in access to healthcare
- Civil society organizations
- Corporate hospitals in India (e.g. Fortis, Apollo, Columbia Asia)
- CDC and UK companies investing in Indian health markets e.g. provision of hospital services, health insurance, production of medical goods
- Academic beneficiaries as outlined
Our research will benefit these users in the following ways:
It will contribute to increased effectiveness of regulatory policy, and to possibilities for improved health and wellbeing in India and beyond, by enhancing the understanding of influential practitioners, policy makers and scholars.
Project findings can be expected to provide them with a detailed picture of existing medical practices, market expansion and regulatory challenges, the way such activities are conceptualised and framed, whose interests they serve, and the contributing policy environment. It will highlight an alternative approach to regulation that emphasises its democratisation. Such information will guide Indian public health policymakers, policy makers concerned with trade in health services, and those civil society organisations concerned with health equity and improved access to good quality healthcare, as well as international collaborators and advisers including the UK DFID and WHO.
The project will also engage another important global public policy constituency, that concerned with globalization and the management of its consequences for developing countries providing these with detailed information on networks, activities and engagement of the healthcare industry.