Abstract
Background: 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.
Methods: 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.
Results: 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.
Conclusion: 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.