Search

This commentary reviews the health systems preparedness during the COVID-19 epidemic in China and India. It provides insight into how nonmedical measures were employed to contain and control the epidemic in Wuhan which was the epicenter. The methods employed by the Chinese provided the roadmap for the countries as the epidemic became pandemic. It provides contrasts in health system preparedness between China and India.

Regulation is essential to health systems and is central to advancing equity-oriented policy objectives in health. Regulating new medical specialties is an emerging, yet underexplored, aspect of health sector governance in low- and middle-income countries (LMICs), such as India. Limited research exists regarding how regulatory institutions in India decide what specialties should be formally recognized and how training programmes for these specialties should be organized. Understanding these regulatory functions provides a lens into how policymakers envision the role of these specialties in the broader health system and how they view the linkages between medical education, health system needs and equity. Drawing upon the recent development of emergency medicine in India, the goal of this study was to understand how recognition and training for new medical specialties are regulated in India. Building on previous frameworks, we examined the institutions, functions, enforcement, mechanisms and institutional relationships that make up the regulatory architecture, and situated our analysis in historical context. Two data sources were iteratively utilized: document review (n = 93) and in-depth interviews (n = 87). Our analysis reveals a plurality of institutions involved in regulating recognition and training for new medical specialties in India, characterized by a lack of coordination, limited collaboration and weak accountability. We also found an absence of clear responsibility for the systematic, planned development of specialties, particularly in terms of health system in strengthening and achieving health equity. As medical specialization continues to shape health systems in LMICs, further streamlining and coordination in the regulatory system will enable policymakers, researchers, practitioners and civil society to proactively plan for how these specialties can better integrate with health systems, and to advance their contribution to improving health outcomes.

The regulation of medical education and health professionals is an important aspect of the governance of health systems. This has been an area of concern and institutional weakness in many low and middle-income countries (LMICs) including India.1 2 In 2019, the Indian government addressed the long-standing demand to reform medical education by dismantling the Medical Council of India (MCI), a regulatory body formed during the preindependence era, and established a new institution, the National Medical Commission (NMC).3 The NMC comes at a crucial phase for the Indian health sector, where reforms over the last few decades have taken an unmistakable turn towards privatisation.4 Like several other LMICs with an underfunded public sector and poorly regulated private sector, the expanding role of commercial actors in healthcare and medical education in India has posed major regulatory challenges. Compounding these issues are a growing lack of trust between doctors and patients and diminishing autonomy for doctors in the face of corporate demands.5 6 It is well recognised that the health workforce is key for achieving universal health coverage (UHC), but few analyses have focused on the coherence between education and training policies for the health workforce and UHC.7 Recent experiences in India are illustrative in unpacking these thorny dynamics between financing and service delivery reforms, health workforce production and regulation. What does the establishment of NMC in India during this conflicting trend of increased corporatisation and a professed commitment to UHC imply for overall health systems? In this commentary, we situate the reform being envisaged through NMC in this wider health policy and systems context in India. After providing contextual background, we focus our arguments around three themes—medicalisation, corporatisation and centralisation. We conclude our piece by discussing the implications of these trends on public health and health systems …

In many countries, professional councils are mandated to oversee the training and conduct of health professionals, including doctors, nurses, pharmacists and allied health workers. The proper functioning of these councils is critical to overall health system performance. Yet, professional councils are sometimes criticized, particularly in the context of low- and middle-income countries, for their misuse of power and overtly bureaucratic nature. The objective of this paper is to understand how professional councils use their bureaucratic power to shape health policy and systems, drawing upon the recent development of emergency medicine in the context of the former Medical Council of India. We undertook a qualitative case study, conducting 87 interviews, observing 6 meetings and conferences, and reviewing approximately 96 documents, and used the Framework method to analyze our data. The passive exercise of bureaucratic power by the Council resulted in three challenges – 1) Opaque policy processes for recognizing new medical specialties; 2) Insular, non-transparent training policy formulation; 3) Unaccountable enforcement for regulating new courses. The Council did not have the requisite technical expertise to manage certain policy processes, and further, did not adequately utilize external expertise. In this time period, the Council applied its bureaucratic power in a manner that negatively impacted emergency medicine training programs and the development of emergency medicine, with implications for availability and quality of emergency care in India. The successor to the Council, the National Medical Commission, should consider new approaches to exercising bureaucratic power in order to meet its objectives of strengthening medical education in India and ensuring access to high-quality services. Future studies should also explore the utilization of bureaucratic power in the health sectors of low- and middle-income countries in order to provider a deeper understanding of institutional barriers to improvements in health.

In this paper, we draw upon and build on three presentations which were part of the plenary session on ‘Structural Drivers of Health Inequities’ at the National Conference on Health Inequities in India: Transformative Research for Action, organised by the Achutha Menon Centre for Health Science Studies in Trivandrum, India. The three presentations discussed the influential role played by globalisation and neoliberalism in shaping economic, social and political relationships across developed and developing countries. The paper further argues that the twin process of globalisation and liberalisation have been important drivers of health inequities. The first segment of the paper attempts a broader conceptualisation of neoliberalism beyond the economic realm. Using Stephanie Lee Mudge’s conceptualisation (Soc Econ Rev 6:703–3, 2008) we have analysed how the political, bureaucratic and intellectual domains of neoliberalism have intersected and redefined the role of state and commercialised health services leading to inequities. Neoliberal ideas have reconfigured the role and changed the priorities of non-governmental organisations resulting in a fracture within this movement. n the second segment, we focus on the rise of American philanthro-capitalism, and how the two major foundations, the Rockefeller Foundation (early twentieth century) and the Bill and Melinda Gates Foundation (twenty-first century), have shaped the ideology of institutions engaged in international health and influenced the global health agenda. We discuss how the activities of philanthro-capitalists have transformed the architecture of health governance through their top-down organisational culture and deficit of structures to ensure accountability. The third and final segment of the paper focuses on how neoliberalism as a political project and cultural movement has forged alliances with conservative politics and religious fundamentalisms, resulting in negative consequences for women and other marginalised groups. These alliances have resulted in the control of women’s bodies and contributed to the reversal of hard-won rights for health and gender justice in many parts of the world.

Background Medical specialization is a key feature of biomedicine, and is a growing, but weakly understood aspect of health systems in many low- and middle-income countries (LMICs), including India. Emergency medicine is an example of a medical specialty that has been promoted in India by several high-income country stakeholders, including the Indian diaspora, through transnational and institutional partnerships. Despite the rapid evolution of emergency medicine in comparison to other specialties, this specialty has seen fragmentation in the stakeholder network and divergent training and policy objectives. Few empirical studies have examined the influence of stakeholders from high-income countries broadly, or of diasporas specifically, in transferring knowledge of medical specialization to LMICs. Using the concepts of socialization and legitimation, our goal is to examine the transfer of medical knowledge from high-income countries to LMICs through domestic, diasporic and foreign stakeholders, and the perceived impact of this knowledge on shaping health priorities in India. Methods This analysis was conducted as part of a broader study on the development of emergency medicine in India. We designed a qualitative case study focused on the early 1990s until 2015, analyzing data from in-depth interviewing (n = 87), document review (n = 248), and non-participant observation of conferences and meetings (n = 6). Results From the early 1990s, domestic stakeholders with exposure to emergency medicine in high-income countries began to establish Emergency Departments and initiate specialist training in the field. Their efforts were amplified by the active legitimation of emergency medicine by diasporic and foreign stakeholders, who formed transnational partnerships with domestic stakeholders and organized conferences, training programs and other activities to promote the field in India. However, despite a broad commitment to expanding specialist training, the network of domestic, diasporic and foreign stakeholders was highly fragmented, resulting in myriad unstandardized postgraduate training programs and duplicative policy agendas. Further, the focus in this time period was largely on training specialists, resulting in more emphasis on a medicalized, tertiary-level form of care. Conclusions This analysis reveals the complexities of the roles and dynamics of domestic, diasporic and foreign stakeholders in the evolution of emergency medicine in India. More research and critical analyses are required to explore the transfer of medical knowledge, such as other medical specialties, models of clinical care, and medical technologies, from high-income countries to India.

The complex relationship between globalization and health calls for research from many disciplinary and methodological perspectives. This editorial gives an overview of the content trajectory of the interdisciplinary journal ‘Globalization and Health’ over the first six years of production, 2005 to 2010. The findings show that bio-medical and population health perspectives have been dominant but that social science perspectives have become more evident in recent years. The types of paper published have also changed, with a growing proportion of empirical studies. A special issue on ‘Health systems, health economies and globalization: social science perspectives’ is introduced, a collection of contributions written from the vantage points of economics, political science, psychology, sociology, business studies, social policy and research policy. The papers concern a range of issues pertaining to the globalization of healthcare markets and governance and regulation issues. They highlight the important contribution that can be made by the social sciences to this field, and also the practical and methodological challenges implicit in the study of globalization and health.