Background
Restructuring within healthcare systems in recent decades has seen the expansion of market-based provisioning in many settings [
1,
2]. It is a trend that has been accompanied by growth in cross-border travel for healthcare, as people seek care in global healthcare markets for services unavailable to them in their country of origin [
3‐
6]. The expansion of these domestic and global markets for healthcare pose new sets of choices, and with them new bureaucratic and informational barriers and needs for accessing care [
7], and this has opened up commercial opportunities for third-parties to operate as intermediaries in healthcare markets.
The emergence of commercial facilitation services has been a notable feature of healthcare in recent decades, as individuals and companies offer to organise and mediate access to healthcare in return for payments. Often the focus of these activities has been to cater to the growing number of people who cross borders to search of care: one study identified 208 web-based facilitation companies globally [
8], and many more operate on an informal basis in countries such as Mexico [
9], Malaysia [
10] and India [
11]; while some focus on global markets for specific services such as assisted reproduction [
12‐
14] or cosmetic surgery [
15]. There are also small but growing markets for facilitation services in a domestic context, for example the high-end ‘concierge’ services being offered in some countries [
16].
The presence of commercial facilitation in healthcare and its potential implications for healthcare provisioning and financing warrants closer scrutiny. With some important exceptions from the study of cross-border travel for healthcare – including Snyder et al. [
17], Dalstrom [
9] and Hartmann [
11] – researchers have tended to rely on second-hand accounts of facilitation activities using testimonies from healthcare providers [
18,
19]. These analyses have adopted network-based understandings of facilitation to examine its transient social formations: the ‘stabilising and destabilising processes and connections’ ( [
4], p. 133). They consider the socially structured movements of users [
20] that demand continuous mobilising work [
11]; and the array of actors who are drawn together to provide services, for example accommodation vendors, translators, drivers, physiotherapists and cooks who perform ancillary services [
21]. There are tensions involved in these relations, as providers and intermediaries use a range of contractual and other mechanisms to associate more closely or loosely with one another for reasons of legitimacy, exclusivity and responsibility [
4].
Here I use first-hand accounts, generated through interview-based research with people working in domestic and/or international healthcare facilitation in London and Delhi, in order to deepen understanding of commercial healthcare facilitation through attention to its structures, strains and the personalised effects these have. Rather than understanding and analysing healthcare facilitation in terms of its networked connections, I make the case for using a brokerage framework inspired by the social science study of markets and socio-political systems. This devotes greater consideration to the strategic decisions and personal agencies that characterise commercial healthcare facilitation. After explaining the conceptual framework for the research, I outline the methods used for data collection and analysis, and then set out a series of findings. I argue that facilitation companies operate in competitive markets, characterised by alternative and rival channels for accessing healthcare, and that companies are compelled into a continuous pursuit of expansion - to go for broke. Closer consideration of the work of facilitation reveals ways in which the pressures of competition and expansion percolate into the lives of people labouring in precarious arrangements and incentivise commodification of users. In the discussion I reflect on the value of the brokerage framework for studying commercial healthcare facilitation, and highlight areas for further study.
Healthcare facilitation as brokerage
There is a large body of social science literature on brokerage which offers a basis for understanding the social relations for third party-mediated activities such as the commercial facilitation of access to healthcare. Brokerage involves the (often deliberate) positioning of third parties as intermediaries in exchange relations in ways that allow these intermediaries to create and extract value from exchange relations [
22]. There is historical precedent for brokerage as a form of economic activity, from the arbitrage performed by merchants in trading networks [
23], to the opportunities for mediation that arose with markets for financial products and services [
24,
25]. However, such brokerage is not confined to overtly commercial exchanges and indeed much of the social science literature on brokerage considers how members of political networks leverage resources and social relations to assist certain constituencies in return for political support [
26‐
28]. Brokerage relations repeatedly emerge in these scenarios of complexity and exclusion – where there are significant transaction costs that reduce the likelihood of direct exchanges between parties.
Transaction costs, complexity and exclusion are well-known features of healthcare’s provisioning markets [
29,
30], and accordingly there are several examples of intermediation in contemporary healthcare systems. Best documented is the intermediary role for facilitation companies in cross-border travel for healthcare: these companies seek to attract potential clients through glossy websites and personal referrals [
31,
32], an active social media presence [
13], and partnering with medical insurance companies and large employers [
33]. They offer information and arrange travel, alongside more socially attuned and customisable support like accompanying users to offer advice on how to act, travel, eat and speak [
9,
19] and companionship and moral support [
10]. Facilitation companies are approached by, and approach, providers with whom to partner [
18], often at the large trade events that have emerged [
34,
35], and seek to develop a range of possible packages and destinations to offer to prospective clients [
36]. Though less well documented, a set of ‘concierge’ companies offer broadly similar mediation services but often focus within domestic (usually private) healthcare systems [
16] and are an extension into healthcare of the concierge economy that caters to the consumption needs of a global elite.
The intermediary positions, and the negotiated and dynamic relations involved, mark these forms of facilitation out as systems of brokerage, and indeed the notion of the ‘broker’ has previously been used to elaborate social relations in the study of cross-border travel for healthcare. Dalstrom’s ([
9], p. 25) research in Mexico employed the concept of ‘cultural brokerage’ to understand the role of intermediaries in advising travellers how to behave in an unfamiliar setting, while Snyder et al. [
17] distinguished between ‘facilitator’ and ‘broker’ roles, suggesting the latter have less direct contact with healthcare users, although here I follow Skountridaki [
18] and others in using ‘facilitation’ as an umbrella term for these actors. Hartmann’s [
11] recent work on cross-border travel into Delhi’s healthcare system adopted an understanding of brokerage used in mobilities and migration studies which attends to the social processes for developing and maintaining relationships across borders. Here I adopt an understanding of brokerage that draws from social science literature on markets and socio-political systems and which pays close attention to strategic positioning, negotiation and personalised effects.
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. In this article I build on that analysis by adapting and applying the analytical framework to the study of formalised systems of commercial healthcare facilitation in Delhi and London. Despite differing institutional contexts, these settings are similarly characterised by the existence of healthcare provisioning markets and the emergence of systems for third-party mediation.
One line of analysis that I develop further here is a concern with the labour processes in brokerage relations. While there have been calls to devote greater attention to labour in the study of health work, particularly in the context of globalisation [
38], the labour performed by people working in services ancillary to healthcare has attracted less attention. Notable exceptions include research on the time-pressured sales work performed by medical representatives [
39,
40] and the unhealthy working conditions for hospital cleaning staff [
41]. Ancillary services like commercial healthcare facilitation play an important role in the production of healthcare and it is important to understand how structural issues affect the conditions of labour in these areas of work, and how they in turn incentivise particular behaviours that have implications for the health and wellbeing of workers and healthcare users.
Methods
The research was conducted as part of a project on formalised systems of brokerage in healthcare, and ethics approval for the project was provided by King’s College London. Interviews were conducted during 2018 with 33 people who have detailed knowledge of commercial healthcare mediation in and around Delhi (24 respondents) and London (9 respondents), including representatives from 22 facilitation companies. These settings offer a range of specialised healthcare services and are established destinations for domestic and international healthcare users seeking care otherwise unavailable in their home locality [
42]. Delhi is a global destination for relatively low-cost medical tourism [
19], and attracts users from within and beyond India. London is a destination for advanced treatments, particularly for wealthy users travelling to London from countries in the Middle-East [
43], but healthcare providers also offer private services to people living in the UK and there has been a trend for people living in the UK to travel to other countries to seek services that are unavailable, or considered over-priced, in the UK healthcare system.
Respondents were identified based on their geographical base of operations in and around Delhi and London, and based on their knowledge of domestic or international facilitation in the healthcare sector. The majority worked in facilitation companies: in London, seven had set up and run small facilitation companies (between one and five employees), and two worked for small companies; in Delhi, four were founders of small companies, six were founders of larger companies (greater than five employees), and several worked for larger companies - four as business development managers, one as a mid-level manager and one as a case worker. I also interviewed two people in Delhi who work in the international marketing teams of large private hospitals, two who had worked as interpreters with facilitation companies, and four people who worked in investment and consultancy industries and had knowledge of the sector.
Respondents were contacted by email or by phone, informed of the aims of the project and invited to participate by interview at a time and location of their choosing, or via Skype or phone. Before commencing each interview, the aims of the project were explained to respondents, and during the interview I took notes that summarised the discussions taking place. These notes were then written up in detail immediately after the interview. Interview questions varied depending on the professional role of the respondent, but generally related to the activities they performed, their motivations and the challenges faced personally, and broader issues faced by facilitation companies. Informal meetings with two additional respondents – one a case worker in a facilitator company and the other a community leader who regularly worked with healthcare users visiting Delhi from an Eastern African country – were written up as field-notes after those discussions took place.
Notes from the interviews were analysed using a framework approach [
44]. 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. I went through the interview- and field-notes and summarised any passages relevant to an analytical category - adding them to the respective column in a chart - and then used the charts to map the range of issues discussed and to find associations between charts. During analysis I identified two cross-cutting themes which are used to present the findings below: structural issues and strategic responses for facilitation companies; and the personalised strains this places on people who perform the work of facilitation.
Discussion
The study aims to provide new insights in an area of growing commercial activity in healthcare: commercial facilitation of access. This is an area characterised by commercial sensitivities which pose a challenge for research and which limited the range of data that could be collected; there were many emails and calls that went unanswered, and informal systems of brokerage proved particularly difficult to access. Despite these limitations, the focused approach to sampling permitted valuable in-depth data collection and the findings are likely to have salience in settings where commercial facilitation of access to healthcare is an established or emerging phenomenon.
The findings point to a strained existence for facilitation that stems from competition with rival facilitation companies and the activities of users and providers who seek to bypass, and even ban, facilitation. This extends previous research on challenges faced in facilitation: there is volatility in cross-border user flows [
20], in an area ‘subject to shifts in fashion, finance, flight paths and medical technology’ ( [
3], p. 532); and tensions that arise from the divergent interests of actors, including antagonistic relationships between facilitators and referring doctors [
17,
18], and between interpreters and other actors [
10,
19].
I have drawn attention to the strategies adopted by facilitation companies in the study settings which see them respond to pressured commercial environments by seeking to maintain and increase demand for their services. Recent work has looked in some detail at the mobilising work performed by facilitation companies to increase user flows [
11], and here I point to the structural pressures of intermediary work as context for these activities. The findings in this article indicate strategic positioning by companies in ways that consolidate their intermediary roles: the adoption of differentiated roles and services that appeal to specific user groups, and the continuous search for new populations and activities to mediate, domestically and internationally.
The commercial environment for healthcare facilitation is marked by labour-intensive processes for organising healthcare (and its payment) in domestic and global markets, and by employment conditions displaying varying degrees of precarity. In spite of some examples of collaboration, this environment appears to incentivise exploitation and a commodification of users whose associated commissions are highly prized and who become targets for “snatching”. There are reported instances of exploitative practices being performed by facilitation companies in a range of settings: Holliday et al. [
15] open their article with a powerful account of unethical practice as a healthcare user in Tunisia is left with unexpectedly limited support after the surgeon left with a suitcase of money and the facilitator followed soon after; Kaspar and Reddy [
19] describe interpreters requesting inflated bills in order to receive higher commission, and taking healthcare users elsewhere if a provider refuses to oblige them; while several commentators have voiced concerns with the selective representation of information on facilitator websites [
8,
48‐
50].
One of the proposed responses to these kinds of exploitative practices has been to encourage greater regulation and professionalisation in the sector [
17]. Findings reported here suggest the need for careful consideration of how such regulation relates to existing stratifications in a sector where providers and users possess significant agency, and where exploitative practices take place in the context of a pressured commercial environment. The introduction of NABH accreditation in India marks an attempt by a corporate segment of the healthcare industry to formalise facilitation work in this setting, and in doing so promotes the interests of the better-resourced facilitation companies. It is unclear what effects this has had on the users who rely upon more informal networks of mediation to access alternative, possibly cheaper, forms of healthcare.
The brokerage analysis used here provides a basis for deeper theorisation on 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.
In the findings I have drawn attention to the strains of work as an intermediary in the brokered relations for commercial healthcare facilitation: physical and mental burdens for labour, exploitative employment practices, and a wider atmosphere of mistrust. This echoes research on the vulnerability of intermediary positions in brokerage relations [
53‐
55], and on the challenges posed by commercial work in the healthcare sector, for example the pressures faced by medical representatives [
39,
40], and by health workers in private employment [
56,
57]. The findings fit within a wider context of precaritisation for work [
58], as pressure to be competitive in global markets has incentivised governments and companies to pursue flexibility in employment relations and working time arrangements [
59,
60], but also chime with concerns regarding the growth of flexible labour in the ‘gig’ economy [
61]. The locally and globally competitive nature of commercial healthcare facilitation, and the need to cater to the demands of healthcare consumers and providers, appears to encourage a particularly pernicious set of employment relations that rely on overwork and labour flexibility.
The growing body of social science research on cross-border travel for healthcare is providing valuable insights into the social relations and circulations that characterise one form of commercial healthcare facilitation [
3‐
5], however the findings from this study point to several new directions for research: the role of diplomatic and business networks in facilitating access to care across borders, the new activities being mediated by facilitation companies in other countries, and the extent to which new technologies such as telemedicine are affecting facilitation work. Further research is needed to better understand the work of interpreters in commercial healthcare facilitation, and their exposure to exploitative employment relations.
The role of facilitation companies in domestic healthcare-seeking remains poorly understood and findings reported here point to opportunities for further research in this area. There are the domestic operations of facilitation companies that work in both global and domestic markets, and the concierge companies that hold aspirations to expand from an elite user-base to middle-class groups in many settings. There is also a corpus of online marketplace platforms, including ZocDoc, WeDoctor and Practo, which aim to facilitate access to healthcare in domestic settings and which have attracted significant investment from global financial capital to fuel their intra- and inter-national growth. These emergent forms of commercial healthcare facilitation have yet to be studied in detail and it will be important to understand the implications of their expansion for healthcare systems.
Conclusion
The expansion of domestic and global markets for healthcare provisioning has created opportunities for third parties to position themselves as intermediaries who can connect users and providers of healthcare on a commercial basis. In Delhi and London this commercial mediation of access to healthcare is characterised by a pressured environment of competition and threatened obsolescence. Facilitation companies are faced with competition from rivals, and with users and providers seeking to selectively engage with, or bypass, their services, and so attempt to protect and expand their intermediary roles by offering new services, user flows and commercial activities that can ensure their continued relevance.
For people working in facilitation companies in these settings, competition and threats of obsolescence manifest in an onerous working environment in which they must meet the demands of users, providers and employers. There is a physical and mental burden incurred by the labour-intensive processes for generating and performing facilitation work, and for ensuring timely and complete payments. The presence of interpreters creates an additional component of work and new points for exploitation and tension in the facilitation process. In spite of some areas of collaboration, mistrust and anxiety appear to be key features for a commercial activity which incentivises the strategic out-manoeuvring of rivals.
Brokerage analysis provides valuable insights into the strategies and strains for commercial healthcare facilitation’s systems of mediation, in which facilitation companies extract revenue through their positioning in the centre of exchange relations and seek to motivate users and providers to continue mediated forms of exchange. The article indicates new avenues for further examination, including on the contributions to facilitation of interpreters, diplomatic and business networks, and new technologies, and on the growth of new forms of mediation in domestic and overseas settings. Future research in these areas will deepen our understanding of these influential systems for accessing healthcare.
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