Brokerage in commercialised healthcare systems: a conceptual framework and empirical evidence from Uttar Pradesh

In many contexts there are a range of individuals and organisations offering healthcare services that differ widely in cost, quality and outcomes. This complexity is exacerbated by processes of healthcare commercialisation. Yet reliable information on healthcare provision is often limited, and progress to and through the healthcare system may depend on knowledge drawn from prior experiences, social networks and the providers themselves. It is in these contexts that healthcare brokerage emerges and third-party actors facilitate access to healthcare. This article presents a novel framework for studying brokerage of access to healthcare, and empirical evidence on healthcare brokerage in urban slums in Lucknow, Uttar Pradesh. The framework comprises six areas of interest that have been derived from sociological and political science literature on brokerage. A framework approach was used to group observational and interview data into six framework charts (one for each area of interest) to facilitate close thematic analysis. A cadre of women in Lucknow's urban slums performed healthcare brokerage by encouraging use of particular healthcare services, organising travel, and mediating communications and fee negotiations with providers. The women emphasised their personal role in facilitating access to care and encouraged dependency on their services by withholding information from users. They received commission payments from healthcare programmes, and sometimes from users and hospitals as well, but were blamed for issues beyond their control. Disruption to their ability to facilitate low-cost healthcare meant some women lost their positions as brokers, while others adapted by leveraging old and new relationships with hospital managers. Brokerage analysis reveals how people capitalise on the complexity of healthcare systems by positioning themselves as intermediaries. Commercialised healthcare systems offer a fertile environment for such behaviours, which can undermine attainment of healthcare entitlements and exacerbate inequities in healthcare access

CARMIL family proteins as multidomain regulators of actin-based motility

CARMILs are large multidomain proteins that regulate the actin-binding activity of capping protein (CP), a major capper of actin filament barbed ends in cells. CARMILs bind directly to CP and induce a conformational change that allosterically decreases but does not abolish its actin-capping activity. The CP-binding domain of CARMIL consists of the CP-interaction (CPI) and CARMIL-specific interaction (CSI) motifs, which are arranged in tandem. Many cellular functions of CARMILs require the interaction with CP; however, a more surprising result is that the cellular function of CP in cells appears to require binding to a CARMIL or another protein with a CPI motif, suggesting that CPI-motif proteins target CP and modulate its actin-capping activity. Vertebrates have three highly conserved genes and expressed isoforms of CARMIL with distinct and overlapping localizations and functions in cells. Various domains of these CARMIL isoforms interact with plasma membranes, vimentin intermediate filaments, SH3-containing class I myosins, the dual-GEF Trio, and other adaptors and signaling molecules. These biochemical properties suggest that CARMILs play a variety of membrane-associated functions related to actin assembly and signaling. CARMIL mutations and variants have been implicated in several human diseases. We focus on roles for CARMILs in signaling in addition to their function as regulators of CP and actin. </jats:p

The impacts of corporatisation of healthcare on medical practice and professionals in Maharashtra, India

A heterogeneous private sector dominates healthcare provision in many middle-income countries. In India the contemporary period has seen this sector undergo corporatisation processes characterised by emergence of large private hospitals and the takeover of medium-sized and charitable hospitals by corporate entities. Little is known about the operations of these private providers and the effects on healthcare professions as employment shifts from practitioner-owned small and medium hospitals to larger corporate settings. This article uses data from a mixed-methods study in two large cities in Maharashtra, India, to consider the implications of these contemporary changes for the medical profession. Data were collected from semi-structured interviews with 43 respondents who have detailed knowledge of healthcare in Maharashtra, and from a witness seminar on the topic of transformation in Maharashtra’s healthcare system. Transcripts from the interviews and witness seminar were analysed thematically through a combination of deductive and inductive approaches. Our findings point to a restructuring of medical practice in Maharashtra as training shifts towards private education and employment to those corporate hospitals. The latter is fuelled by substantial personal indebtedness, dwindling appeal of government employment, reduced opportunities to work in smaller private facilities, and the perceived benefits of work in larger providers. We describe a ‘re-professionalisation’ of medicine encompassing changes in employment relations, performance targets and constraints placed on professional autonomy within the private healthcare sector, that is accompanied by trends in cost inflation, medical malpractice, and distrust in doctor-patient relationships. The accompanying ‘re-stratification’ within this part of the profession affords prestige and influence to ‘star doctors’ while eroding the status and opportunity for young and early career doctors. The research raises important questions about the role that government and medical professionals’ bodies can, and should, play in contemporary transformation of private healthcare, and the implications of these trends for health systems more broadly

"Beyond aid" investments in private healthcare in developing countries

No abstract available

Going for brokerage: strategies and strains in commercial healthcare facilitation

Background The formation of domestic and global marketplaces during the past 50 years has opened up new commercial opportunities for third-party activity in healthcare systems. Commercial mediation of access to healthcare is one recent area of activity that sees companies and individuals offering to organise healthcare and travel in return for payment. With varying degrees of control over the location, type, cost and experiences of healthcare provisioning, these intermediaries occupy potentially influential positions in healthcare systems and yet much of their work is poorly understood. Methods Drawing on social science theories of brokerage, this article presents a novel analysis of commercial healthcare facilitation. It focuses on facilitation companies and their workers as central, intermediating actors for people to access healthcare in markets characterised by complexity. Semi-structured interviews were conducted with people working in domestic and international healthcare facilitation in London and Delhi, and data were analysed using a framework approach that emphasises the structural features and personal agencies for this area of work. Results Findings point to an institutional environment for commercial healthcare facilitation marked by competition and the threat of obsolescence. The activities of rivals, and the risk that users and providers will bypass intermediaries, compels facilitation companies to respond strategically and to continuously pursue new populations and activities to mediate – to go for broke. These pressures percolate into the lives of people who perform facilitation work and who describe a physical and mental burden of labour incurred by onerous processes for generating and completing facilitation work. The need for language interpretation services introduces an additional set of relations and has created further points of tension. It is an environment that engenders mistrust and anxiety, and which incentivises exploitation and a commodification of users whose associated commissions are highly prized. Conclusion Brokerage analysis provides valuable insights into the strategies and strains for commercial mediation of access to healthcare, and the findings indicate opportunities for further research on the contributions of interpreters, diplomatic and business networks, and new technologies, and on the growth of new forms of mediation in domestic and overseas settings

The effects of cash transfers and vouchers on the use and quality of maternity care services: a systematic review

Background Cash transfers and vouchers are forms of 'demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years. Methods This systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637). Results Data from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes. Conclusion Future research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects

Pengurangan Waste Pada Proses Produksi Botol X Menggunakan Metode Lean Sigma

Waste merupakan semua aktivitas kerja yang tidak memberikan nilai tambah dalam proses pembuatan produk sehingga harus segera direduksi atau dihilangkan dari proses produksi. Penelitian ini bertujuan untuk mengidentifikasi jenis-jenis waste yang terjadi dalam proses produksi, menganalisis faktor-faktor penyebab waste, serta memberikan usulan rekomendasi perbaikan untuk meminimasi waste. Metode yang digunakan dalam penelitian ini adalah lean Sigma, yaitu perpaduan antara metode lean manufacturing dan six Sigma yang bertujuan untuk mengidentifikasi dan meminimasi waste, memperbaiki proses, serta meningkatkan kualitas dari proses produksi. Penelitian ini dilakukan sebagai upaya continuous improvement untuk perbaikan proses dalam langkah kerja six Sigma (DMAIC). Dari tujuh kategori waste, teridentifikasi empat jenis waste dalam proses produksi botol X, yaitu defect, overproduction, waiting, dan inventories. Rekomendasi perbaikan yang diusulkan dalam penelitian ini ini didasarkan dari hasil identifikasi CTQ waste yang telah dianalisis menggunakan fishbone diagram dan pemilihan prioritas rekomendasi menggunakan FMEA. Hasil rekomendasi dari penelitian ini adalah mengenai peningkatan kedisiplinan operator maupun pihak manajemen

Human capital, risk and the World Bank’s reintermediation in global development

This article examines an attempt to reconstitute global development governance in a context of growing influence for private finance. We focus on the World Bank’s Human Capital Project (HCP) and Human Capital Index (HCI), which have stated aims of promoting economic growth and accelerating progress towards achievement of the Sustainable Development Goals. Informed by a review of publicly available World Bank materials, we argue that, through its HCP and HCI, the World Bank is responding to its own institutional sidelining in development financing and governance with a strategy of reintermediation. Its leaders have pursued a system of governance in which the World Bank creates and instrumentalises knowledge on human capital – an asset to be accumulated through judicious investments in markets for self-betterment. Through its HCI the World Bank has expanded its global benchmarking practices, encompassing new domains and quantified predictions of future productivity, in the hope of shaping domestic policy processes. Its leaders propose to use HCI scores to signal risk to investors and political leaders, triggering political shocks that will spur policy reform. Crucially, these efforts seek to reassert the World Bank’s epistemic authority and financing clout as the influence of its own lending wanes

Constructing healthcare services markets: networks, brokers and the China-England engagement

Background Healthcare services is an expanding international market with which national healthcare systems engage, and from which they benefit, to greater and lesser degrees. This study examines the case of the China-England engagement in healthcare services as a vehicle for illuminating the way in which such market relationships are constructed. Findings China and England have different approaches to the international healthcare services market. Aware of the knowledge and technology gaps between itself and the leading capitalist nations of the West in healthcare, as in other sectors, the Chinese leadership has encouraged a variety of international engagements to facilitate the bridging of these gaps including accessing new supply and demand relationships in international markets. These engagements are situated within an approach to health system development based on establishing broad policy directions, allowing a degree of local innovation, initiating and evaluating pilot studies, and promulgating new programmatic frameworks at central and local levels. The assumption is that the new knowledge and technologies are integrated into this approach and implemented under the guidance of Chinese experts and leaders. England’s healthcare system has the knowledge resources to provide the supply to meet at least some of the China demand but has yet to develop fully the means to enable an efficient market response, though such economic engagement is supported by the UK’s trade related departments of state. As a result, the development of China-England commercial relationships in patient care, professional education and hospital and healthcare service development has been led largely by high status NHS Trusts and private sector organisations with the entrepreneurial capacity to exploit their market position. Drawing on their established international clinicians and commercial teams with experience of domestic private sector provision, these institutions have built trust-based collaborations sufficiently robust to facilitate demand-supply relationships in the international healthcare services market. Often key to the development of relations required to make commercial exchange feasible and practicable are a range of international brokers with the skills and capacity to provide the necessary linkage with individual healthcare consumers and institutional clients in China. Integral to the broker role, and often supplied by the broker itself, are the communication technologies of telemedicine to enable the interaction between consumer and healthcare provider, be this in patient care, professional education or healthcare service development. Conclusions Although England’s healthcare system has the knowledge required to respond to China’s market demand and such economic engagement is supported and actively encouraged by the UK’s trade related departments of state, the response is constrained by multiple domestic demands on its resources and by the limits of the NHS approach to marketisation in healthcare