The health workforce is hierarchical in structure in terms of skill mix and social composition. Most of the studies on the health workforce are focused on the number of personnel in the public sector. The private sector that has a large presence employs a significant percentage of the total health work force but there is little reliable data on the numbers involved. This is largely due to the lack of regulation of the private health services. Apart from the numbers involved in both the sectors, a few studies have shown the relationship between the work and social hierarchy in health services. While the public sector has a more diverse mix of social backgrounds due to affirmative policies, the private sector ownership is mostly dominated by an upper and middle caste-class combine. There is an under-representation of minorities and women as owners of private health services. The gendered nature of work is visible with the middle and lower rungs constituted by mostly women and men from lower caste-class combine. The terms of work, working conditions and wages paid for this category of workers amounts to exploitation with no forum for redressal. This essay draws together some primary work and references to secondary research and anecdotal evidences to build the scenario of social inequities among the workforce in the private health services.

BackgroundMedical specialization is a key feature of biomedicine, and is a growing, but weakly understood aspect of health systems in many low- and middle-income countries (LMICs), including India. Emergency medicine is an example of a medical specialty that has been promoted in India by several high-income country stakeholders, including the Indian diaspora, through transnational and institutional partnerships. Despite the rapid evolution of emergency medicine in comparison to other specialties, this specialty has seen fragmentation in the stakeholder network and divergent training and policy objectives. Few empirical studies have examined the influence of stakeholders from high-income countries broadly, or of diasporas specifically, in transferring knowledge of medical specialization to LMICs. Using the concepts of socialization and legitimation, our goal is to examine the transfer of medical knowledge from high-income countries to LMICs through domestic, diasporic and foreign stakeholders, and the perceived impact of this knowledge on shaping health priorities in India.MethodsThis analysis was conducted as part of a broader study on the development of emergency medicine in India. We designed a qualitative case study focused on the early 1990s until 2015, analyzing data from in-depth interviewing (n = 87), document review (n = 248), and non-participant observation of conferences and meetings (n = 6).ResultsFrom the early 1990s, domestic stakeholders with exposure to emergency medicine in high-income countries began to establish Emergency Departments and initiate specialist training in the field. Their efforts were amplified by the active legitimation of emergency medicine by diasporic and foreign stakeholders, who formed transnational partnerships with domestic stakeholders and organized conferences, training programs and other activities to promote the field in India. However, despite a broad commitment to expanding specialist training, the network of domestic, diasporic and foreign stakeholders was highly fragmented, resulting in myriad unstandardized postgraduate training programs and duplicative policy agendas. Further, the focus in this time period was largely on training specialists, resulting in more emphasis on a medicalized, tertiary-level form of care.ConclusionsThis analysis reveals the complexities of the roles and dynamics of domestic, diasporic and foreign stakeholders in the evolution of emergency medicine in India. More research and critical analyses are required to explore the transfer of medical knowledge, such as other medical specialties, models of clinical care, and medical technologies, from high-income countries to India.

The way healthy societies are conceptualised shapes efforts to achieve them. This paper explores the features and drivers of frameworks for healthy societies that had wide or sustained policy influence post-1978 at global level and as purposively selected southern regions, in India, Latin America and East and Southern Africa. A thematic analysis of 150 online documents identified paradigms and themes. The findings were discussed with expertise from the regions covered to review and validate the findings.Globally, comprehensive primary healthcare, whole-of-government and rights-based approaches have focused on social determinants and social agency to improve health as a basis for development. Biomedical, selective and disease-focused technology-driven approaches have, however, generally dominated, positioning health improvements as a result of macroeconomic growth. Traditional approaches in the three southern regions previously mentioned integrated reciprocity and harmony with nature. They were suppressed by biomedical, allopathic models during colonialism and by postcolonial neoliberal economic reforms promoting selective, biomedical interventions for highest-burden diseases, with weak investment in public health. In all three regions, holistic, sociocultural models and claims over natural resources re-emerged. In the 2000s, economic, ecological, pandemic crises and social inequality have intensified alliances and demand to address global, commercial processes undermining healthy societies, with widening differences between ‘planetary health’, integrating ecosystems and collective interests, and the coercive controls and protectionism in technology-driven and biosecurity-driven approaches.The trajectories point to a need for ideas and practice on healthy societies to tackle systemic determinants of inequities within and across countries, including to reclaim suppressed cultures; to build transdisciplinary, reflexive and participatory forms of knowledge that are embedded in and learn from action; and to invest in a more equitable circulation of ideas between regions in framing global ideas. Today’s threats raise a critical moment of choice on which ideas dominate, not only for health but also for survival.

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In this paper, we draw upon and build on three presentations which were part of the plenary session on ‘Structural Drivers of Health Inequities’ at the National Conference on Health Inequities in India: Transformative Research for Action, organised by the Achutha Menon Centre for Health Science Studies in Trivandrum, India. The three presentations discussed the influential role played by globalisation and neoliberalism in shaping economic, social and political relationships across developed and developing countries. The paper further argues that the twin process of globalisation and liberalisation have been important drivers of health inequities. The first segment of the paper attempts a broader conceptualisation of neoliberalism beyond the economic realm. Using Stephanie Lee Mudge’s conceptualisation (Soc Econ Rev 6:703–3, 2008) we have analysed how the political, bureaucratic and intellectual domains of neoliberalism have intersected and redefined the role of state and commercialised health services leading to inequities. Neoliberal ideas have reconfigured the role and changed the priorities of non-governmental organisations resulting in a fracture within this movement. n the second segment, we focus on the rise of American philanthro-capitalism, and how the two major foundations, the Rockefeller Foundation (early twentieth century) and the Bill and Melinda Gates Foundation (twenty-first century), have shaped the ideology of institutions engaged in international health and influenced the global health agenda. We discuss how the activities of philanthro-capitalists have transformed the architecture of health governance through their top-down organisational culture and deficit of structures to ensure accountability. The third and final segment of the paper focuses on how neoliberalism as a political project and cultural movement has forged alliances with conservative politics and religious fundamentalisms, resulting in negative consequences for women and other marginalised groups. These alliances have resulted in the control of women’s bodies and contributed to the reversal of hard-won rights for health and gender justice in many parts of the world.