(2000). Another Reason: Science and the Imagination of Modern India. History: Reviews of New Books: Vol. 28, No. 2, pp. 84-84.

Another Reason: Science and the Imagination of Modern India

Rights and Reason: United Nations Universal Declaration of Human Rights

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00955-1.pdf

Assuring health coverage for all in India

Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.

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Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review.

Medical Tourism: treatments, markets and health system implications: a scoping review

http://www.environmentportal.in/files/Medical%20Tourism%20in%20India.pdf

Medical tourism in India: progress or predicament?

Objective
To investigate ethical issues in informed consent for decisions regarding embryo transfer and fetal reduction in commercial gestational surrogacy.

Design
Mixed methods study employing observations, an interview-guide and semi-structured interviews.

Setting
Fertility clinics and agencies in Delhi, India, between December 2011 and December 2012.

Population
Doctors providing conceptive technologies to commissioning couples and carrying out surrogacy procedures; surrogate mothers; agents functioning as links for surrogacy.

Methods
Interviews using semi-structured interview guides were carried out among 20 doctors in 18 fertility clinics, five agents from four agencies and 14 surrogate mothers. Surrogate mothers were interviewed both individually and in the presence of doctors and agents. Data on socio-economic context and experiences among and between various actors in the surrogacy process were coded to identify categories of ethical concern. Numerical and grounded theory-oriented analyses were used.

Main outcome measures
Informed consent, number of embryos transferred, fetal reduction, conflict of interest among the involved parties.

Results
None of the 14 surrogate mothers were able to explain the risks involved in embryo transfer and fetal reduction. The majority of the doctors took unilateral decisions about embryo transfer and fetal reduction. The commissioning parents were usually only indirectly involved. In the qualitative analysis, difficulties in explaining procedures, autonomy, self-payment of fertility treatment and conflicts of interest were the main themes.

Conclusions
Clinical procedural decisions were primarily made by the doctors. Surrogate mothers were not adequately informed. There is a need for regulation on decision-making procedures to safeguard the interests of surrogate mothers.

Informed consent in medical decision-making in commercial gestational surrogacy: a mixed methods study in New Delhi, India.

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy.

/pdf/medical-tourism-in-india-perceptions-of-physicians-in-3xs0lh751z.pdf

Medical tourism in India: perceptions of physicians in tertiary care hospitals.

As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents’ demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.

Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India

Existing research on the formation of Asian medical travel destinations has highlighted a variety of activities that attract and accommodate patients from abroad. This paper contributes to the literature by drawing insights from an Indian case study, a major transnational health-care hub in Asia that has gained little scholarly attention thus far. Using connectivity as an analytical lens, we understand medical travel destinations as a contingent product of relating, connecting and assembling. We study how connectivity is embodied and how it unfolds in care encounters at corporate hospitals in the capital of New Delhi and surrounding urban areas. The following entities are the most effectual in the networks that constitute medical travel destinations in the National Capital Region: (i) circulating narrations of personal experiences; (ii) language interpreters; and (iii) commission fees. We further elaborate on how these connectors work to link foreign patients with Indian hospitals and how they affect itineraries as well as patients and other involved actors. Finally, we suggest that the approach deployed provides a suitable framework for future research aimed at gaining a better understanding of the wider impacts of medical travel by following these connections and examining their workings at places both close and distant.

Sunita Reddy

Papers

Medical tourism in India: progress or predicament?

Informed consent in medical decision-making in commercial gestational surrogacy: a mixed methods study in New Delhi, India.

Medical tourism in India: perceptions of physicians in tertiary care hospitals.

Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India

Spaces of connectivity: The formation of medical travel destinations in Delhi National Capital Region (India)