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

Social Service Professional or Market Expert? Maternity Care Relations under Neoliberal Healthcare Reform

Recent developments in the organization and practice of healthcare, driven by the introduction of (quasi-) markets and privatization, are altering traditional forms of professionalism found in high- and middle-income countries. Yet there remains debate about whether these neoliberal trends are universal or country specific, and whether they have any effect (positive or negative) on health service delivery. This article develops a comparative analysis that focuses on changes in maternity service systems in four countries in Northern Europe and the Americas with primarily publicly financed healthcare systems: the UK, Finland, Chile and Canada. The article begins with a discussion of the continuum of professional forms found in the post-Second World War period and their relationship to different kinds of welfare e states. It then focuses on the impact of recent neoliberal reforms on the ideological projects of the medical and allied health professions in the four case examples. The results show that variation across time and place is mainly the result of structural/ economic factors and that various forms of professional discourses are the result of the public/private ways that healthcare systems are organized. The article concludes with suggestions for further comparative sociological research

Children perceive speech onsets by ear and eye*

Adults use vision to perceive low-fidelity speech; yet how children acquire this ability is not well understood. The literature indicates that children show reduced sensitivity to visual speech from kindergarten to adolescence. We hypothesized that this pattern reflects the effects of complex tasks and a growth period with harder-to-utilize cognitive resources, not lack of sensitivity. We investigated sensitivity to visual speech in children via the phonological priming produced by low-fidelity (non-intact onset) auditory speech presented audiovisually (see dynamic face articulate consonant/rhyme b/ag; hear non-intact onset/rhyme: −b/ag) vs. auditorily (see still face; hear exactly same auditory input). Audiovisual speech produced greater priming from four to fourteen years, indicating that visual speech filled in the non-intact auditory onsets. The influence of visual speech depended uniquely on phonology and speechreading. Children – like adults – perceive speech onsets multimodally. Findings are critical for incorporating visual speech into developmental theories of speech perception

Men’s roles in abortion trajectories in urban Zambia

Context: The actions and inactions of men can shape women’s sexual and reproductive health in positive and negative ways. However men’s influence on and involvement in women’s pathways to either safe or unsafe abortion are little understood. As maternal morbidity and mortality from unsafe abortion persists, especially in Africa, there is a pressing need to understand the various factors that shape abortion trajectories. In this paper, we consider the influence of men in those trajectories. Methods: We interviewed women (N=112) who attended hospital for safe abortion (n=71) or care following an incomplete (unsafe) abortion (n=41) at the largest provider of abortion-related care in Zambia between January-December 2013. We analysed their narratives using the Framework method. Results: Men influenced whether or not women sought safe or unsafe abortion and the complexity of trajectories to abortion-related care. Their actions, inactions, or anticipated actions – negative and positive – reflected broader gender inequities. Men’s abandonment or denial of paternity, and women’s desire to avoid disclosing pregnancy to men through fear, were significant influences on some women’s decision to seek abortion and on the secrecy, urgency and risk with which abortion was pursued. However other women discussed men’s positive influences in their abortion trajectories. In this setting of low awareness of the legality and availability of abortion, men used their greater social and economic resources to facilitate safe abortion by providing information and paying for care. Conclusions: Interventions to address unsafe abortion should target a much wider population than sexually-active women

‘Not in it for huge profits but because it’s right’: the contested moral economies of UK–India exports in health worker education and training

While the growth of global markets in health-related services may have significant consequences for healthcare provisioning and training, it has received relatively little attention from the social sciences. This article examines UK–India, and specifically England–India, exports in health worker education and training as one such global market, drawing on sociological scholarship on moral economies to understand how trading in this field is constructed and legitimated by the individuals and organisations involved, what tensions evolve, and what is at stake in them. We employ a qualitative mixed methods approach using publicly available materials on existing UK–India collaborations and primary data from interviews with key stakeholders in India and the UK, including government departments, arms-length bodies, NHS Trusts, trade associations and private providers. Our analysis illustrates the key discursive strategies used to legitimate engagement in these markets, and the complex and contested moral economies unfolding between and across these stakeholders and contexts. Not least, we demonstrate the conflicting moral sentiments and the boundary work required to realise commodification. Situating cross-border trade in health worker education and training in a moral economy framework thus illuminates the social context and moral worlds in which this evolving trade is embedded

Market making and the production of nurses for export. A case study of India-UK health worker migration

Background: High-income countries increasingly look to the international recruitment of health workers to address domestic shortages, especially from low-income and middle-income countries. We adapt conceptual frameworks from migration studies to examine the networked and commercialised nature of the Indian market for nurse migration to the UK. Methods: We draw on data from 27 expert interviews conducted with migration intermediaries, healthcare providers and policymakers in India and the UK. Findings: India–UK nurse migration occurs within a complex and evolving market encompassing ways to educate, train and recruit nursing candidates. For-profit actors shape the international orientation of nursing curricula, broker on-the-job training and offer language, exam and specialised clinical training. Rather than merely facilitate travel, these brokers produce both generic, emigratory nurses as well as more customised nurses ready to meet specific shortages in the UK. Discussion: The dialectic of producing emigratory and customised nurses is similar to that seen in the Post-Fordist manufacturing model characterised by flexible specialisation and a networked structure. As the commodity in this case are people attempting to improve their position in life, these markets require attention from health policy makers. Nurse production regimes based on international market opportunities are liable to change, subjecting nurses to the risk of having trained for a market that can no longer accommodate them. The commercial nature of activities further entrenches existing socioeconomic inequalities in the Indian nurse force. Negative repercussions for the source healthcare system can be anticipated as highly qualified, specialised nurses leave to work in healthcare systems abroad

Phonological Priming in Children with Hearing Loss:Effect of Speech Mode, Fidelity, and Lexical Status

OBJECTIVES: Our research determined 1) how phonological priming of picture naming was affected by the mode (auditory-visual [AV] vs auditory), fidelity (intact vs non-intact auditory onsets), and lexical status (words vs nonwords) of speech stimuli in children with prelingual sensorineural hearing impairment (CHI) vs. children with normal hearing (CNH); and 2) how the degree of hearing impairment (HI), auditory word recognition, and age influenced results in CHI. Note that some of our AV stimuli were not the traditional bimodal input but instead they consisted of an intact consonant/rhyme in the visual track coupled to a non-intact onset/rhyme in the auditory track. Example stimuli for the word bag are: 1) AV: intact visual (b/ag) coupled to non-intact auditory (−b/ag) and 2) Auditory: static face coupled to the same non-intact auditory (−b/ag). Our question was whether the intact visual speech would “restore or fill-in” the non-intact auditory speech in which case performance for the same auditory stimulus would differ depending upon the presence/absence of visual speech. DESIGN: Participants were 62 CHI and 62 CNH whose ages had a group-mean and -distribution akin to that in the CHI group. Ages ranged from 4 to 14 years. All participants met the following criteria: 1) spoke English as a native language, 2) communicated successfully aurally/orally, and 3) had no diagnosed or suspected disabilities other than HI and its accompanying verbal problems. The phonological priming of picture naming was assessed with the multi-modal picture word task. RESULTS: Both CHI and CNH showed greater phonological priming from high than low fidelity stimuli and from AV than auditory speech. These overall fidelity and mode effects did not differ in the CHI vs. CNH—thus these CHI appeared to have sufficiently well specified phonological onset representations to support priming and visual speech did not appear to be a disproportionately important source of the CHI’s phonological knowledge. Two exceptions occurred, however. First—with regard to lexical status—both the CHI and CNH showed significantly greater phonological priming from the nonwords than words, a pattern consistent with the prediction that children are more aware of phonetics-phonology content for nonwords. This overall pattern of similarity between the groups was qualified by the finding that CHI showed more nearly equal priming by the high vs. low fidelity nonwords than the CNH; in other words, the CHI were less affected by the fidelity of the auditory input for nonwords. Second, auditory word recognition—but not degree of HI or age—uniquely influenced phonological priming by the nonwords presented AV. CONCLUSIONS: With minor exceptions, phonological priming in CHI and CNH showed more similarities than differences. Importantly, we documented that the addition of visual speech significantly increased phonological priming in both groups. Clinically these data support intervention programs that view visual speech as a powerful asset for developing spoken language in CHI