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In order to progress towards more equitable social welfare systems we need an improved understanding of regulation in social sectors such as health and education. However, research to date has tended to focus on roles for governments and professions, overlooking the broader range of regulatory systems that emerge in contexts of market-based provisioning and partial state regulation.In this article we examine the regulation of private healthcare in India using an analytical approach informed by ‘decentred’ and ‘regulatory capitalism’ perspectives. We apply these ideas to qualitative data on private healthcare and its regulation in Maharashtra (review of press media, semi-structured interviews with 43 respondents, and three witness seminars), in order to describe the range of state and non-state actors involved in setting rules and norms in this context, whose interests are represented by these activities, and what problems arise.We show an eclectic set of regulatory systems in operation. Government and statutory councils do perform limited and sporadic regulatory roles, typically organised around legislation, licensing and inspections, and often prompted by the judicial arm of the state. But a range of industry-level actors, private organisations and public insurers are involved too, promoting their own interests in the sector via the offices of regulatory capitalism: accreditation companies, insurers, platform operators and consumer courts. Rules and norms are extensive but diffuse. These are produced not just through laws, licensing and professional codes of conduct, but also through industry influence over standards, practices and market organisation, and through individualised attempts to negotiate exceptions and redressal.Our findings demonstrate regulation in a marketised social sector to be partial, disjointed and decentred to multiple loci, actively representing differing interests. Greater understanding of the different actors and processes at play in such contexts can inform future progress towards universal systems for social welfare.

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.

BackgroundDemand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising ‘healthy behaviours’. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health.MethodsA secondary analysis (using an adapted Supporting the Use of Research Evidence framework – SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health.ResultsThe article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women’s groups.ConclusionsEvaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.

BackgroundCash transfers and vouchers are forms of `demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years.MethodsThis systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637).ResultsData from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes.ConclusionFuture research should use multiple intervention arms to compare cost-effectiveness with utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects. similar investment in public services, and should look beyond short- to medium-term service

Background Harm reduction is an evidence-based, effective response to HIV transmission and other harms faced by people who inject drugs, and is explicitly supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. In spite of this, people who inject drugs continue to have poor and inequitable access to these services and face widespread stigma and discrimination. In 2013, the Global Fund launched a new funding model-signalling the end of the previous rounds-based model that had operated since its founding in 2002. This study updates previous analyses to assess Global Fund investments in harm reduction interventions for the duration of the rounds-based model, from 2002 to 2014. Methods Global Fund HIV and TB/HIV grant documents from 2002 to 2014 were reviewed to identify grants that contained activities for people who inject drugs. Data were collected from detailed grant budgets, and relevant budget lines were recorded and analysed to determine the resources allocated to different interventions that were specifically targeted at people who inject drugs. Results 151 grants for 58 countries, plus one regional proposal, contained activities targeting people who inject drugs–for a total investment of US$ 620million. Two-thirds of this budgeted amount was for interventions in the "comprehensive package" defined by the United Nations. 91% of the identified amount was for Eastern Europe and Asia. Conclusion This study represents an updated, comprehensive assessment of Global Fund investments in harm reduction from its founding (2002) until the start of the new funding model (2014). It also highlights the overall shortfall of harm reduction funding, with the estimated global need being US$ 2.3billion for harm reduction in 2015 alone. Using this baseline, the Global Fund must carefully monitor its new funding model and ensure that investments in harm reduction are maintained or scaled-up. There are widespread concerns regarding the withdrawal from middle-income countries where harm reduction remains essential and unfunded through other sources: for example, 15% of the identified investments were for countries which are now ineligible for Global Fund support.

BackgroundThe use of sets of indicators to assess progress has become commonplace in the global health arena. Exploratory research has suggested that indicators used for global monitoring purposes can play a role in national policy-making, however, the mechanisms through which this occurs are poorly understood. This article reports findings from two qualitative studies that aimed to explore national policy-makers’ interpretation and use of indicators from country profiles and reports developed by Countdown to 2015.MethodsAn initial study aimed at exploring comprehension of Countdown data was conducted at the 2010 joint Women Deliver/Countdown conference. A second study was conducted at the 64th World Health Assembly in 2011, specifically targeting national policy-makers. Semi-structured interviews were carried out with 29 and 22 participants, respectively, at each event. Participants were asked about their understanding of specific graphs and indicators used or proposed for use in Countdown country profiles, and their perception of how such data can inform national policy-making. Responses were categorised using a framework analysis.ResultsRespondents in both studies acknowledged the importance of the profiles for tracking progress on key health indicators in and across countries, noting that they could be used to highlight changes in coverage, possible directions for future policy, for lobbying finance ministers to increase resources for health, and to stimulate competition between neighbouring or socioeconomically similar countries. However, some respondents raised questions about discrepancies between global estimates and data produced by national governments, and some struggled to understand the profile graphs shown in the absence of explanatory text. Some respondents reported that use of Countdown data in national policy-making was constrained by limited awareness of the initiative, insufficient detail in the country profiles to inform policy, and the absence of indicators felt to be more appropriate to their own country contexts.ConclusionsThe two studies emphasise the need for country consultations to ensure that national policy-makers understand how to interpret and use tools like the Countdown profile for planning purposes. They make clear the value of qualitative research for refining tools used to promote accountability, and the need for country level Countdown-like processes.

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.

Background Injecting drug use has been documented in 158 countries and is a major contributor to HIV epidemics. People who inject drugs have poor and inequitable access to HIV services. The Global Fund to Fight AIDS, Tuberculosis and Malaria is the leading multilateral donor for HIV programmes and encourages applicants to include harm reduction interventions in their proposals. This study is the first detailed analysis of Global Fund investments in harm reduction interventions. Methods The full list of more than 1000 Global Fund grants was analysed to identify HIV grants that contain activities for people who inject drugs. Data were collected from the detailed budgets agreed between the Global Fund and grant recipients. Relevant budget lines were recorded and analysed in terms of the resources allocated to different interventions. Results 120 grants from 55 countries and territories contained activities for people who inject drugs worth a total of US$ 361million, increasing to US$ 430million after projections were made for grants that had yet to enter their final phase of funding. Two-thirds of the budgeted US$ 361million was allocated to core harm reduction activities as defined by the United Nations. Thirty-nine of the 55 countries were in Eastern Europe and Asia. Only three countries with generalised HIV epidemics had grants that included harm reduction activities. Conclusion This study represents the most comprehensive assessment of Global Fund investments in harm reduction. This funding, while substantial, falls short of the estimated needs. Investments in harm reduction must increase if HIV transmission among people who inject drugs is to be halved by 2015.