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

Abstract

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.

Going for brokerage: strategies and strains in commercial healthcare facilitation

“…Systems of brokerage are conceived as dynamic arrangements in which intermediaries must continually justify and assert their role to avoid obsolescence and the loss of control over exchange and the revenue it brings [22]. These systems are characterised by tension between serving the needs of different parties [51], concerns with perceptions [46] and rivals [52], and the need to adapt and evolve activities in the face of shifting institutional landscapes [37]. By analysing commercial healthcare facilitation in terms of its brokerage relations, we can better understand the activities performed by this group of actors and the implications for healthcare provisioning.…”

“…This approach interrogates data using pre-determined questions and entails five steps: familiarisation, identification of a thematic framework, indexing, charting and interpretation. Six framework charts were created, corresponding to the six areas of interest used in an earlier analysis of brokerage relations in healthcare facilitation: activities performed by intermediaries; social relations that permit facilitation; benefits to different groups engaged in brokered relations; expansion and consolidation of intermediary positions; costs and tensions for brokerage relations, and responses to changing institutional landscapes [37]. A set of columns were added to each chart based on pre-determined categories and were added to or revised as necessary during the analysis process.…”

“…In earlier work, I used a novel analytical framework to study informal systems of brokerage as performed by lay community health workers in an aid-funded health voucher scheme in northern India [37]. That study showed how workers exercised varying degrees of personal agency when interpreting their roles within the context of a healthcare market; they attempted to consolidate their intermediary roles and pursue opportunities for personal benefit.…”

Market making and the production of nurses for export: a case study of India–UK health worker migration

“…The topic guide was developed based on findings from interviews as part of the larger research project as well as a structured online search about key developments in the field of India–UK health worker migration between 2019 (the year the 2019 NHS Long-term Plan was launched, laying out the strategy for international health worker recruitment) and 2023, using the search terms ‘nurse/nursing’, ‘health worker’, ‘UK’, ‘India’, ‘migration’, ‘recruitment’ and ‘NHS’ connected by Boolean operators. It was also guided by previous work by BH examining brokers in healthcare 28 29. Respondents were informed that all data would be anonymised and that they could withdraw from the study any time before the end of the data collection period.…”

Neoliberalisation enacted through development aid: the case of health vouchers in India

“…In some cases women we interviewed who had accessed private maternity care via the vouchers seemed completely unaware of this and thought the community worker had assisted them in getting treatment using personal influence. So, as we have described in more detail elsewhere (Hunter, 2018b), while the project discourse described the community workers in the slums as 'facilitators', in practice the reward structure encouraged them to become self-interested intermediaries -brokers who quickly learnt how to commodify their privileged knowledge and relationships with hospitals and to view friends and neighbours as clients with cash value.…”