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

Abstract

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 semistructured 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 ‘reprofessionalisation’ 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 ‘restratification’ 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.

Reforming the regulation of medical education, professionals and practice in India

“…21 When the production of medical professionals increased, resource-constrained public systems struggled to provide employment opportunities to medical graduates, particularly specialists. 6 In the current privatised and increasingly corporatised health system in India, medical professionals are heavily incentivised to work for the private corporate sector, a sector which has thus far not actively supported primary care, particularly for the poor. This may result in even bigger challenges around reprofessionalisation of medicine and medical professionals.…”

“…This may result in even bigger challenges around reprofessionalisation of medicine and medical professionals. 6 Recent decisions by the BoG have allowed profit-making companies and even consortium of companies to start medical colleges, suggesting an emerging corporatisation of medical education too along with overall healthcare system. 22 Moreover, India is the only country where two parallel systems for medical specialisation are running.…”

Going for brokerage: strategies and strains in commercial healthcare facilitation

“…In the findings I have drawn attention to the strains of work as an intermediary in the brokered relations for commercial healthcare facilitation: physical and mental burdens for labour, exploitative employment practices, and a wider atmosphere of mistrust. This echoes research on the vulnerability of intermediary positions in brokerage relations [53][54][55], and on the challenges posed by commercial work in the healthcare sector, for example the pressures faced by medical representatives [39,40], and by health workers in private employment [56,57]. The findings fit within a wider context of precaritisation for work [58], as pressure to be competitive in global markets has incentivised governments and companies to pursue flexibility in employment relations and working time arrangements [59,60], but also chime with concerns regarding the growth of flexible labour in the 'gig' economy [61].…”

Advancing the agenda for people-centred accountability of the private healthcare sector

“…The presentation highlighted the change from individual private practice in the seventies, to small and medium hospitals in the nineties, to the emergence of multi-specialty and corporate hospitals in the new millennium. High fees of private medical colleges, competition from corporate hospitals, patients' expectations, and high investment costs are factors causing many small and medium sized hospitals to shut down (5). On the other hand, corporate hospital chains offer lucrative employment options to medical professionals in terms of monetary benefits, access to infrastructure, technology and prestige.…”

“…Hospitals are run on the profit principle, where doctors need to fulfill targets and are assessed on their ability to generate revenue. The pressure to meet corporate targets undermines the professional autonomy of doctors and the doctor-patient relationship, leading to malpractices and inflated cost of healthcare for patients (5).…”