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Purpose: Industrialized world-based healthcare providers are increasingly off-shoring low-end healthcare services such as medical transcription, billing and insurance claims. High-skill medical jobs such as tele-imaging and tele-pathology are also being sub-contracted to developing countries. Despite its importance, little theory or research exists to explain what factors affect industry growth. The article's goals, therefore, are to examine economic processes associated with developing economies' shift from low- to high-value information technology enabled healthcare services, and to investigate how these differ in terms of legitimacy from regulative, normative and cognitive institutions in the sending country and how healthcare services differ from other services., Design/methodology/approach: This research is conceptual and theory-building. Broadly, its approach can be described as a positivistic epistemology., Findings: Anti off-shoring regulative, normative and cognitive pressures in the sending country are likely to be stronger in healthcare than in most business process outsourcing. Moreover, such pressures are likely to be stronger in high-value rather than in low-value healthcare off-shoring. The findings also indicate that off-shoring low-value healthcare services and emergent healthcare industries in a developing economy help accumulate implicit and tacit knowledge required for off-shoring high-value healthcare services., Research Limitations/implications: The approach lacks primary data and empirical documentation., Practical Implications: The article helps in understanding industry drivers and its possible future direction. The findings help in understanding the lens through which various institutional actors in a sending country view healthcare service off-shoring., Originality/value: The article's value stems from its analytical context, mechanisms and processes associated with developing economies' shift to high-value healthcare off-shoring services.

Recent findings have shown that wastewater from bulk drug production can be a source of very high environmental concentrations of drugs in certain locations. The release of active ingredients is often not specifically regulated, and thus rapid initiatives from the industries themselves are warranted. Possible ways to stimulate action include changes in local and international regulations, including the implementation of appropriate environmental standards within existing industry guidelines as well as demands from prescribers and consumers of medicines. The lack of readily available information regarding the origin of drugs and the environmental impact of the production, however, prevents consumers from making informed decisions. Here, we investigated the origin of active pharmaceutical ingredients (APIs) in 242 selected products on the Swedish market. By comparing registers from Sweden and India we found that the APIs in 71 products (31%) originated from Indian manufacturers sending their waste to a treatment plant where unprecedented amount of environmental pollution with broad-spectrum antibiotics and other drugs recently has been documented. We propose that increased transparency throughout the production chain would be one of several important steps to reducing pollution from the manufacturing of drugs.