Mission hospitals in India: exploring responses to health system change
MetadataShow full item record
BACKGROUND: The Indian healthcare system is undergoing rapid change. While the country seeks to provide universal health coverage (UHC), aspirations for UHC require linkage with non-government providers (including charitable providers) who provide 60-70% of patient care. One of the largest groups of charitable providers in India are Mission Hospitals, whose historic role of healthcare delivery to the poor and underserved is challenged by external and internal pressures. This study explored the main challenges facing mission hospitals, their response to those challenges, and the role they might play in healthcare delivery going forward. METHODS: The study employed interdisciplinary, mixed methodology to assess the top challenges and responses between 2010-2017. The theory of everyday resilience was used to categorize challenges as chronic stresses or acute shocks and explore features of resilience in responses to challenges along with the underlying capabilities that enable resilience responses. The study included site visits to 11 mission hospital facilities, 5 mission hospital associations, and 83 key informant interviews. Interviews were thematically analyzed using NVivo and triangulated with other study data. RESULTS AND DISCUSSION: Mission hospitals were impacted by social, political, and health system changes. Most challenges operated as “stressors”, for example, strained governance structures and human resource shortages. “Shocks” included major changes in health policy and increasing competition from for-profit providers. In response, some mission hospitals exhibited traits of everyday resilience, traversing between absorptive, adaptive, and transformative strategies. Among mission hospitals that appeared to be successfully navigating challenges, three core capacities were present: 1) cognitive capacity, understanding the challenge and developing appropriate response strategies; 2) behavioral capacity, having agency to deploy context-specific response; and 3) contextual capacity, having adequate resources, including hardware (money, people, infrastructure) and, importantly, software (e.g. values, relationships, networks), to exercise the first two capacities. CONCLUSION: While mission hospitals face a series of internal challenges, many exhibit features of everyday resilience and retain strong commitment to population health and service to the poor. These features make them potentially strong partners in the realization of UHC, in addition to continued or expanded provision of services that complement government efforts.