Picture credit: Tommyv580, via Wikimedia Commons

We often assume that access to healthcare can be represented in terms of users and providers, a demand-side and a supply-side – an idea reinforced by much health research and policy. In this blogpost Dr Benjamin Hunter discusses a mediating set of influential yet overlooked healthcare ‘brokers’ working in slum communities in Uttar Pradesh. The findings were published last month in Social Science & Medicine.

Healthcare brokerage

One of the key findings of my doctoral research in Uttar Pradesh was the use of intermediaries to access healthcare. We can think of these as third-party brokers – someone who is neither within a user’s immediate family, nor are they a provider of healthcare services. You’re probably already familiar with the concept of insurance brokers who connect people seeking insurance with those providing it. This is similar. These brokers are people and organisations who by and large are paid to facilitate access to services, although in some settings the reward may take other social forms such as improved community standing.

Here I’m focusing specifically on healthcare brokers working in slum communities; the informal end of a spectrum of healthcare brokerage (more to come on the formal end of the spectrum in future blogposts). Community-level brokers provide information on healthcare and accompany people to healthcare facilities. It is a personalised service to support access to care. I interviewed some brokers in the city of Lucknow when researching a USAID-Government of India maternal and reproductive health voucher programme. Women were recruited into the programme to distribute vouchers amongst families in their local area – a role designated as ‘community health volunteer’ (CHV) – yet some had a history of brokerage and some adapted the voucher programme to better suit a brokerage role.

Subversion of a healthcare programme

Contrary to the expectations of designers (and me), I observed CHVs withholding vouchers from prospective users. The CHVs withheld information too – some women who used the voucher scheme seemed to have no idea the scheme existed, let alone the vouchers, and undermined programme designers’ expectations of a competitive healthcare provision market. This created space for CHVs to manipulate the voucher scheme to offer personal services. They emphasised personal connections with the hospitals, accompanied women to the hospital and submitted vouchers on behalf of the women. Although voucher services were expected to be free, empanelled hospitals charged fees for ‘additional’ services and in these cases the CHVs could communicate and negotiate with hospital staff on behalf of users.

A CHV was expected to receive a small payment for each voucher used. But in addition to this, some CHVs took payments from users and from hospitals in return for their personal services. These payments were typically relatively small compared to hospital fees, often a few hundred rupees, but in one case some hospital staff and CHVs were found by the hospital’s manager to be charging voucher users 2,000 rupees for giving birth while submitting the voucher on their behalf. It is worth noting that this was in many ways a great deal for all concerned – hospital staff and CHVs split the money while the price was still approximately half of the cost of fees at the hospital, representing an apparent saving for the user – yet it undermined healthcare entitlements and meant families faced user fees they could scarcely, if at all, afford.

Programmatic myopia

From a programmatic viewpoint the subversion of the voucher scheme by CHVs to suit their brokerage activities and personal benefits wasn’t problematic: women received healthcare, vouchers were used and hospitals were reimbursed for the services they provided. This was reflected in programme evaluations that lauded the success of the voucher scheme in terms of high usage of vouchers: in Lucknow 30,000 vouchers were used in the space two years including 2,000 to give birth. The evaluations did not examine whether there was any effect on out-of-pocket expenditure, nor how many voucher users were simply being discouraged from using government hospitals by CHVs and encouraged to use the private sector instead (another blog on this point will be coming out later in 2018).

This exemplifies a problem with narrow conceived evaluative research on healthcare programmes, driven by the desire for finding ‘solutions’ in global health. There is so much interest in determining and rolling out ‘what works’ according to healthcare usage indicators that less interest is paid to the wider social context for healthcare policies. Here was a programme based on an international model – the competitive healthcare voucher – which ticked donor boxes for expanding markets by empanelling a range of hospitals to promote competition and efficiency and also used vouchers as a performance-based financing tool to track and reward hospital and worker performance. Yet it clearly had unanticipated effects that fell outside the purview of the ‘black-box’ evaluations.

Importance of social context

It is worth highlighting the social context driving healthcare brokerage in Lucknow. In urban slum settings in northern India, intermediaries are often important in accessing public services. Frequently this takes the form of political brokerage: political activists working as part of wider networks to provide services in return for votes or other forms of political support. Corbridge and colleagues highlighted the pivotal role played by community-level agents in service provision, while Barbara Harriss-White described an entire ‘shadow state’ of political networks operating alongside (often instead of) official public service provision.

With this in mind, we can understand better how an international healthcare model based on user choice and entitlements was subverted by those expected to enact it in a setting where access to social welfare programmes is understood in networked terms. Some CHVs had pre-existing relations as community workers or ration card distributors, one had even been accompanying women to hospital for almost 20 years in return for small payments from their families and from the hospital. The voucher programme enabled existing brokers to harness programme entitlements for their own means, and encouraged others to join their ranks. Twelve months after the voucher programme ended many of these women were still functioning as healthcare brokers using the status and connections they’d developed during programme implementation.

Brokerage has important implications for how we understand and use healthcare, and in the coming year our group will be looking in more depth at these kinds of relationships. Keep an eye out for future blogposts on this topic!