Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA.
Health Systems Program, Department of International Health and International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Int J Health Policy Manag. 2018 Nov 1;7(11):993-1006. doi: 10.15171/ijhpm.2018.55.
Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India - international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015.
We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the 'Framework' approach in our analysis.
Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization.
The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity.
医学专科化是一个在低中等收入国家（LMICs）中研究较少但日益重要的卫生系统方面。在印度，医学专科化正在逐步显著地改变服务提供、劳动力分配和融资方式。然而，印度和其他 LMICs 几乎没有关于医学专科如何发展和监管的证据，以及这些过程如何影响卫生系统。急诊医学的发展轨迹似乎包含了印度医学专科化的更广泛趋势——国际交流与合作、专业协会的形成，以及与印度医学理事会（MCI）的漫长监管过程。通过对政治优先事项设定的分析，我们的目的是探讨急诊医学作为印度的一个医学专科的出现和认可，从 20 世纪 90 年代初到 2015 年。
我们使用定性案例研究方法，借鉴 Shiffman 和 Smith 框架。我们进行了 87 次深入访谈，审查了 122 份文件，并观察了六次会议和会议。我们在分析中使用了“框架”方法的修改版本。
20 世纪 90 年代，将急诊医学作为改善印度薄弱急诊护理系统的可行解决方案的势头逐渐增强。公共和私营部门利益相关者经常通过跨国专业医学协会积极寻求 MCI 的认可。尽管网络内部存在分裂，但利益相关者对专业认可的必要性有着相似的信念，并最终实现了这一目标。然而，网络内部的分裂使得围绕急诊医学的更广泛政策议程难以协调，最终导致了不确定的长期途径。最后，由于监管系统的复杂性，利益相关者推动了多种形式的培训计划，扩大了急诊医师的劳动力，但协调和标准化程度有限。
研究生医学教育的理念核心、具有挑战性的国家治理体系以及跨国利益相关者网络的分裂，构成了印度急诊医学的发展特点。随着医学专科化继续塑造和影响全球卫生系统，对 LMICs 中新医学专科发展的研究可以增强我们对专业化、卫生系统和公平之间联系的理解。
