Practices, regulation and accountability in the evolving private healthcare sector: lessons from Maharashtra State, India
Lead Research Organisation:
King's College London
Department Name: International Development
Abstract
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.
Technical Summary
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.
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.
Planned Impact
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.
- 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.
Publications
Marathe S
(2020)
The impacts of corporatisation of healthcare on medical practice and professionals in Maharashtra, India.
in BMJ global health
Hunter B
(2020)
Neoliberalisation enacted through development aid: the case of health vouchers in India
in Critical Public Health
Hunter B
(2019)
Deconstructing the Financialization of Healthcare
in Development and Change
Shweta Marathe
(2019)
In the name of charity
in EPW
Hunter, B M
Decentred regulation: the case of private healthcare in India
in World Development
Hunter BM
(2022)
Decentred regulation: The case of private healthcare in India.
in World development
Marathe S
(2022)
A How-To Guide on Conducting Witness Seminars
Description | Analysing the transnational provisioning of services in the social sector: the case of commercialisation of NHS services in China and India |
Amount | £722,325 (GBP) |
Funding ID | ES/S010920/1 |
Organisation | Economic and Social Research Council |
Sector | Public |
Country | United Kingdom |
Start | 09/2019 |
End | 06/2023 |
Description | King's College London, International Development and SATHI, Pune |
Organisation | Anusandhan Trust |
Department | SATHI (Support for Advocacy and Training to Health Initiatives) |
Country | India |
Sector | Charity/Non Profit |
PI Contribution | health systems and social science expertise, intellectual input, the training of staff in interview techniques, data collection, data analysis. |
Collaborator Contribution | close local and national knowledge, intellectual input, access to stakeholders and gatekeepers, dissemination and impact networks, skills, influence. |
Impact | Multi-disciplinary collaboration between UK social scientists, and Indian public health researcher and an NGO active in the health advocacy field in India. Outputs are listed under project. |
Start Year | 2016 |
Description | 5th Global Symposium on Health Systems Research, satelite meeting 8 - 12 October 2018, Liverpool, UK |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Presentations of findings from two team members in symposium designed to stimulate increased interest in research on the impact of private sector involvment in healthcare sustems in developing countries |
Year(s) Of Engagement Activity | 2018 |
Description | AMCCON 2019 Presentation |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Postgraduate students |
Results and Impact | Presentation at AMCCON 2019 meeting on Health System Management held at the Achutha Menon Centre for Health Science Studies (AMCHSS),Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, Kerala |
Year(s) Of Engagement Activity | 2019 |
Description | COPASAH global symposium, Delhi |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | COPASAH (Cimmunity of Practitioners on Accountability and Social Action in Health) global symposium held in Delhi. on Citizenship, Governance and Accountability, presentation of findings by team memberm alongside contributions form Nepal and S Africa. Chaired by PSI |
Year(s) Of Engagement Activity | 2019 |
Description | Centre for Social Medicine and Community Health JNU presentation |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Postgraduate students |
Results and Impact | March 28th 2019 Weekly Guest Lecture series for postgraduate students of Public Health |
Year(s) Of Engagement Activity | 2019 |
Description | Consultation on documentation of violations of patients' rights and patients' rights charter in India, held in Delhi |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Members of the research team took part in a consultation that included state representatives of Jan Swasthya Abhiyan (JSA) and Peoples' Health Movement India Chapter, at which violations in private sector of patients' rights were discussed, highlighting the need to document them systematically, and discussion on Clinical Establishments Act ( which is a focus of the research study) and adoption of a patients' rights charter in India |
Year(s) Of Engagement Activity | 2019 |
Description | Consultation with special interest groups (activists and policy makers) on documentation of violation of patients' rights and patients' rights charter in India |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | This consultation was attended by three of our India team members. It was attended by state representatives of Jan Swasthya Abhiyan. It was focused on the need to document violations of patients' rights in India and included a discussion of the Clinical Establishments Act. We fed in findings from a witness seminar conducted by our project and other interviews. |
Year(s) Of Engagement Activity | 2019 |
Description | Health Systems Global Asia workshop, Delhi |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Other audiences |
Results and Impact | 15th October 2019, Health Systems Global Asia workshop, in Delhi Out of 100 submissions selected 20 abstracts for a lightening presentation only of 4.30 mins and team member presented on impacts of corporatisation of private healthcare in India on doctors |
Year(s) Of Engagement Activity | 2019 |
Description | Information sheet for civil society |
Form Of Engagement Activity | A magazine, newsletter or online publication |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Third sector organisations |
Results and Impact | Information brochure in Marathi language on the Clinical Establishments Act and suggested modifications relating to accountability, transparency and patients' rights |
Year(s) Of Engagement Activity | 2019 |
Description | Interview for city news |
Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Media (as a channel to the public) |
Results and Impact | team member Shweta Marathe was interviewed by the Pune Mirror following publication of study findings in BMJ Global Health. Intended purpose: to broaden audience for a discussion of the tension between profit and ethical medical practices from health scholars to the broader public in one of the two cities (Pune) that were the case studies for the project. A number of doctors' views on the issues were also sought and reported, including Dr Avinash Bhondwe, president of Indian Medical Association and Dr Sanjay Patil, chairman of the Hospital Board of India, Pune chapter. |
Year(s) Of Engagement Activity | 2020 |
URL | https://punemirror.indiatimes.com/pune/civic/profit-over-ethics-by-hospitals/articleshow/74325452.cm... |
Description | Launch of project webpages on the Unsettling Healthcare website |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Other audiences |
Results and Impact | The project webpage was launched on the Unsettling healthcare website and announced via various Twitter feeds. A blog written by a member of the research team critiquing the new health insurance programme entitled Modi-care's for whom? was also published on the site., and several other blogs on themes related to aspects of the project methodology (witness seminars) and its findinga were published over the life of the project |
Year(s) Of Engagement Activity | 2018,2019,2020 |
URL | https://unsettlinghealthcare.org/projects/corporatisation-and-regulation/ |
Description | Mumbai dissemination meeting |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Professional Practitioners |
Results and Impact | June 8th 2019 Mumbai YMCA. Day of presentation of study findings & Witness Seminar 1 Report circulated, 38 participants: medical practitioners, medical students, health system academics, health activists,government officials, healthcare industry, |
Year(s) Of Engagement Activity | 2019 |
Description | Participation to present some findings to a special interest group (health practitioners)'s conference Alliance of Doctors for Ethical Healthcare (India) |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | Dr Chakravarti (Co-I) took part in a panel discussion on the corporatisation of healthcare and presented some of our findings on its impact on doctors in India. This sparked discussion of ethical dimensions. |
Year(s) Of Engagement Activity | 2018 |
Description | Policy brief |
Form Of Engagement Activity | A magazine, newsletter or online publication |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Other audiences |
Results and Impact | Research & policy brief with key insights from study prepared by the NGO partner in India and distributed through its networks |
Year(s) Of Engagement Activity | 2021 |
Description | Training session on witness seminar method |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Postgraduate students |
Results and Impact | One-hour training session on witness seminar method with postgraduate students (MA in Public Policy and Governance) at Tata Institute of Social Sciences (TISS), Hyderabad. |
Year(s) Of Engagement Activity | 2023 |
Description | Training session on witness seminar method |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Postgraduate students |
Results and Impact | One-hour training session on witness seminar method for postgraduate (MPH and PhD) students at Centre for Social Medicine and Community Health, Jawaharlal Nehru University, Delhi. |
Year(s) Of Engagement Activity | 2023 |
Description | Workshop : Initial end user consultation involving doctors, researchers and health activists |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Other audiences |
Results and Impact | This workshop, held in Mumbai , was the initial end-user consultation involving doctors, researchers and health activists, held to share proposed project activities along with study methodology, to explore useful themes and questions. |
Year(s) Of Engagement Activity | 2017 |
Description | lecture to post grad students at TISS |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Postgraduate students |
Results and Impact | Lecture as part of Ethics and Equity module for students of Masters in Health Administration (MHA) at School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai. July 1 2019 |
Year(s) Of Engagement Activity | 2019 |
Description | local doctors meeting, Bijnor |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | ADEH and Indian Medical Association Bijnor Uttar Pradesh May 26th 2019 Meeting on "Ethics in Private Healthcare" For local medical doctors |
Year(s) Of Engagement Activity | 2019 |
Description | talk at the People's Health Assembly, Savar, Bangladesh (special user group) |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Third sector organisations |
Results and Impact | Talk given by team member at a sub-plenary of the Assembly on Commercialisation and Privatisation in the health sector, and patients' rights charters |
Year(s) Of Engagement Activity | 2018 |