'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.

Contextualising tobacco use in the social, economic and political transformation of Punjab.

This review article provides a historical context of tobacco use in Punjab, determined by the sociopolitical transitioning of this pre-colonial province to an autonomous Indian State. Although these events were marked by a complex historical process, the state's retention of its culture offers an interesting aspect of this development. For instance, these events have been marked from the conception of Sikhism to the changing borders of the territory of Punjab while positioning the use of tobacco within these boundaries. This social, economic and developmental history of Punjab has therefore been a subject of interest to the academic scholars and makers of tobacco-related policies.

Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review.

BACKGROUND: Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system. METHODS: The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis. RESULTS: Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems. CONCLUSIONS: Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

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.

Universal health care: the changing international discourse.

Nearly 34 years ago, in 1978 in the face of a looming crisis in the health of the world's populations and rising health inequality, 134 countries came together to sign the historic Alma Ata Declaration where the idea of primary health care as the chosen path to "Health for All" was formulated. However even before the declaration and more so since, countries have diverse interpretations of Universalism, each setting it in the context of its own health care model. These have ranged from the minimalist to the more comprehensive welfare state. Today, as health statistics reveal, the crisis has deepened, not only in the developing world but also in the developed world. It is important to debate the nature of the crisis and understand current policy initiatives and their ideological legitimations. The paper attempts to trace, clarify and account for the shifts in international discourse on universal health care (UHC). It argues that the idea of UHC is still with us, but there have occurred substantial shifts in discourse and meaning, shaped by changing international and national contexts and social forces impinging on health systems. The current concept of universal health coverage has only a notional allusion to universality of Alma Ata and disregards its fundamental principles. It concludes that the shifts are detrimental and its value in promoting health for all is likely to be severely limited.

Understanding health systems, health economies and globalization: the need for social science perspectives.

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.

Understanding India, globalisation and health care systems: a mapping of research in the social sciences.

National and transnational health care systems are rapidly evolving with current processes of globalisation. What is the contribution of the social sciences to an understanding of this field? A structured scoping exercise was conducted to identify relevant literature using the lens of India - a 'rising power' with a rapidly expanding healthcare economy. A five step search and analysis method was employed in order to capture as wide a range of material as possible. Documents published in English that met criteria for a social science contribution were included for review. Via electronic bibliographic databases, websites and hand searches conducted in India, 113 relevant articles, books and reports were identified. These were classified according to topic area, publication date, disciplinary perspective, genre, and theoretical and methodological approaches. Topic areas were identified initially through an inductive approach, then rationalised into seven broad themes. Transnational consumption of health services; the transnational healthcare workforce; the production, consumption and trade in specific health-related commodities, and transnational diffusion of ideas and knowledge have all received attention from social scientists in work related to India. Other themes with smaller volumes of work include new global health governance issues and structures; transnational delivery of health services and the transnational movement of capital. Thirteen disciplines were found represented in our review, with social policy being a clear leader, followed by economics and management studies. Overall this survey of India-related work suggests a young and expanding literature, although hampered by inadequacies in global comparative data, and by difficulties in accessing commercially sensitive information. The field would benefit from further cross-fertilisation between disciplines and greater application of explanatory theory. Literatures around stem cell research and health related commodities provide some excellent examples of illuminating social science. Future research agendas on health systems issues need to include innovative empirical work that captures the dynamics of transnational processes and that links macro-level change to fine-grained observations of social life.

COVID-19 and the burden of ill-health: a double crisis of disruptions and inequalities.

In this paper, we attempt to show how the novel coronavirus disease (COVID-19) has disrupted routine health services in India and has created further inequalities in the society. By taking a few examples of non-COVID diseases and conditions like immunization, maternal health services, tuberculosis and non-communicable diseases, this paper shows how these services have been disrupted by the pandemic. The paper argues that these disruptions have not emerged only as a result of the current crisis, but because of the paradigm shifts in the healthcare delivery in the country towards privatization which have disproportionately marginalized particular sections of the society. The paper concludes by stating that if adequate measures are not taken now to transform the health system and strengthen the public healthcare system, it might lead to catastrophic consequences in the future, especially for the marginalized sections.

Peri-Urbanism in Globalizing India: A Study of Pollution, Health and Community Awareness.

This paper examines the intersection between environmental pollution and people's acknowledgements of, and responses to, health issues in Karhera, a former agricultural village situated between the rapidly expanding cities of New Delhi (India's capital) and Ghaziabad (an industrial district in Uttar Pradesh). A relational place-based view is integrated with an interpretive approach, highlighting the significance of place, people's emic experiences, and the creation of meaning through social interactions. Research included surveying 1788 households, in-depth interviews, participatory mapping exercises, and a review of media articles on environment, pollution, and health. Karhera experiences both domestic pollution, through the use of domestic waste water, or gandapani, for vegetable irrigation, and industrial pollution through factories' emissions into both the air and water. The paper shows that there is no uniform articulation of any environment/health threats associated with gandapani. Some people take preventative actions to avoid exposure while others do not acknowledge health implications. By contrast, industrial pollution is widely noted and frequently commented upon, but little collective action addresses this. The paper explores how the characteristics of Karhera, its heterogeneous population, diverse forms of environmental pollution, and broader governance processes, limit the potential for citizen action against pollution.

Emplacing India's "medicities".

Plans for 'medicities', announced in the Indian press from 2007 onwards, were to provide large scale 'one-stop-shops' of super-speciality medical services supplemented by diagnostics, education, research facilities, and other aspects of healthcare and lifestyle consumption. Placing this phenomenon within the recent domestic and global political economy of health, we then draw on recent research literatures on place and health to offer an analysis of the narration of these new healthcare places given in promotional texts from press media, official documents and marketing materials. We consider the implications of such analytic undertakings for the understanding of the evolving landscapes of contemporary health care in middle-income countries, and end with some reflections on the tensions now appearing in the medicity model.

Demand-side financing measures to increase maternal health service utilisation and improve health outcomes: a systematic review of evidence from low- and middle-income countries.

BACKGROUND: In many countries financing for health services has traditionally been disbursed directly from governmental and non-governmental funding agencies to providers of services: the 'supply-side' of healthcare markets. Demand-side financing offers a supplementary model in which some funds are instead channelled through, or to, prospective users. In this review we considered evidence on five forms of demand-side financing that have been used to promote maternal health in developing countries: OBJECTIVES: The overall review objective was to assess the effects of demand-side financing interventions on maternal health service utilisation and on maternal health outcomes in low- and middle-income countries. Broader effects on perinatal and infant health, the situation of underprivileged women and the health care system were also assessed. INCLUSION CRITERIA: This review considered poor, rural or socially excluded women of all ages who were either pregnant or within 42 days of the conclusion of pregnancy, the limit for postnatal care as defined by the World Health Organization. The review also considered the providers of services.The intervention of interest was any programme that incorporated demand-side financing as a mechanism to increase the consumption of goods and services that could impact on maternal health outcomes. This included the direct consumption of maternal health care goods and services as well as related 'merit goods' such as improved nutrition. We included systems in which potential users of maternal health services are financially empowered to make restricted decisions on buying maternal health-related goods or services - sometimes known as consumer-led demand-side financing. We also included programmes that provided unconditional cash benefits to pregnant women (for example in the form of maternity allowances), or to families with children under five years of age where there was evidence concerning maternal health outcomes.We aimed to include quantitative studies (experimental, observational and descriptive), qualitative studies (including designs based on phenomenology, grounded theory, ethnography, action research and feminist research), and economic studies (cost-effectiveness, cost-utility and costs studies). SEARCH STRATEGY: The Joanna Briggs Institute methodology for mixed-method systematic reviews was adopted. A three-step systematic search strategy was used to: 1) identify key terms, 2) search bibliographic databases and 3) retrieve additional publications from reference lists and sources of grey literature. DATA COLLECTION: Data were extracted from papers included in the review using the standardised data extraction tools for quantitative, qualitative and economic data from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information. DATA SYNTHESIS: The quantitative and economic findings are presented in narrative form. Qualitative research findings were pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. This involved the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings), and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice or policy. CONCLUSIONS: Seventy-two studies were included in the review. Drawing on work from several continents, many of the included studies were reports and evaluations for relevant government or funding agencies and represented important lesson-learning about implementation issues. However, fewer than half were published in peer reviewed journals and few were of high research quality.For three modes of demand-side financing (conditional cash transfers, payments to offset costs of access to maternal healthcare, and vouchers for maternity services) we found evidence relevant to review questions on the utilisation of maternal health services, barriers to the provision of demand-side financing and supply-side preconditions to implementing demand-side financing schemes. There was insufficient evidence to provide comprehensive answers for review questions on the effect of demand-side financing interventions on maternal, perinatal and infant health outcomes and on the social and financial situation of underprivileged women. There was also insufficient evidence on the cost-effectiveness of demand-side financing interventions and preconditions for sustainability and scale-up of demand-side financing schemes.Salient recommendations for policymakers regarding demand-side financing for maternal health derived from the current evidence are:There is a pressing need for large, robust studies on the short- and longer-term impact of demand-side financing on maternal and infant mortality and morbidity, which should also reflect 'good practice' indicators such as the uptake and duration of exclusive breastfeeding and compliance with infant immunisation programmes. It is also important that the impact on outcomes of subsequent pregnancies is evaluated. Moderate and large-sized demand-side financing programmes that have recently or will soon be scaled up, such as those in Kenya, Uganda and Bangladesh, represent the most obvious sites for such evaluations, and lessons may be learnt from Mexico's PROGRESA/ Oportunidades about how to establish a well-embedded monitoring and rigorous evaluation structure.Other important areas that require further study include.