Studying transnational markets in health education through a moral economy lens

Sibille Merz

Transnational markets in healthcare services are expected to grow significantly by 2030. Beyond the focus on the movement of patients and health workers across borders, these include services in the training of health workers, telemedicine, second opinion and referral services, healthcare management and advisory services, and services related to health education and training (Hanefeld and Smith 2019). This may have significant consequences for healthcare provisioning and training, as well as the broader social and cultural value systems within which health education is delivered. Social science research has been slow to examine these evolving transnational markets; the small existing literature referring to trading in these activities to date has predominantly focused on mapping  the breadth and scope of activity (Hanefeld and Smith 2019).

In this presentation, in contrast, we will draw on sociological scholarship on moral economies (Sayer, 2000; Busfield, 2021) to examine one such transnational market, namely the trading of services in health worker education and training between the UK and India. Sociological approaches to moral economies, in brief, analyse how economic practices are legitimised as fair (or unfair) by those involved, and how broader norms and values may be compromised by these practices (Sayer, 2000). In contrast to historical scholarship, they do not assume a principal opposition between moral and market economies but focus on their intrinsic entanglements; we apply this lens to explore what a moral economy lens illuminate about the evolving transnational market of UK-India trading in health worker education. Based on publicly available materials on existing UK-India collaborations as well as primary data from interviews with key stakeholders in India and the UK (including government departments, arms-length bodies, NHS Trusts, trade associations, recruitment agencies and private providers), we illustrate the key discursive strategies used to legitimate engagement in these markets, and the complex and contested moral economies unfolding between and across these stakeholders and contexts. We illustrate, first, how trading is constructed as producing the best healthcare systems and outcomes, foregrounding patient and health system benefits. Second, it allows the institutions and individuals involved to thrive in increasingly competitive environments. And third, engagement in these markets is often seen, by those involved, as a more equitable and reciprocal way of ‘doing’ global health; in contrast to charitable or aid-based approaches, trading is cast as more partnership-focused approach wherein UK and Indian stakeholders meet a par as producers and consumers with similar decision-making power.

As such, situating cross-border trade in health worker education and training in a moral economy framework illuminates the social work that goes into the making and rendering acceptable of health worker education and training as a transnational market. It lays bare the discursive constructions involved in making commercialisation of health worker training palatable, and provides insight into the changing values and sentiments around entrepreneurial values and practices in social service provision. Not least, it also illuminates the complex assemblage of actors, structures, and value systems involved in justifying commercialisation, testament to the multiple and overlapping transnational moral-economic entanglements. A moral economy lens is thus highly valuable in examining both the structural underpinnings and the more latent values and meaning-making practices in the increasing transnationalisation and commercialisation of health-related services. However, we have also had to adjust the framework to account for our findings in two main ways: first, we have found moral economies approaches to often foreground a rather static approach that invisibilises tensions and frictions that emerge at the interface of moral frameworks which often coexist, or even overlap, in the sector (also see Rasmussen, 2004). Second, studying transnational markets meant we needed to account for what Klaus Trentmann (2007) has called the transnationalisation of moral regimesin the wake of post-colonial globalisation which often foreground discursive constructions of obligation and debt to former colonies. This has proven highly important for our analysis of the moral economies UK-India markets in health education.