From Public Servant to Entrepreneurial Physician: Neoliberal Reform and the Transformation of Medical Professionalism in Georgia

Abstract

This article examines how neoliberal healthcare reforms have transformed medical professionalism in Georgia by reshaping the institutional position, professional self-understanding, and everyday working conditions of physicians. The study focuses on the post-Soviet transformation of the Georgian healthcare system, where the Soviet Semashko model of centralized public provision was gradually replaced by a market-oriented system characterized by large-scale privatization, expanded private service delivery, and public financing organized mainly through the state’s purchaser role. Although the Universal Healthcare Program expanded public coverage after 2013, most healthcare institutions had already been privatized, creating a hybrid arrangement in which public funds flow largely through private providers. Drawing on eighteen semi-structured interviews with physicians and clinical managers working in private and state medical institutions in Georgia, the article explores how doctors interpret commercialization and how these institutional changes affect professional identity, career strategies, clinical decision-making, and professional autonomy. The findings show that commercialization has encouraged a shift from the model of the physician as a state-serving professional toward a more entrepreneurial form of medical professionalism. Physicians increasingly describe specialization choices, professional development, workplace mobility, reputation building, and visibility in terms connected to income, competitiveness, patient flow, and market value. Medical expertise remains central, but it is increasingly reinterpreted as a form of professional capital that must be continuously developed, strategically positioned, and made visible within a competitive healthcare market. The article also shows that commercialization affects clinical practice through financial incentives and managerial forms of control. Per-case remuneration, clinic-level revenue expectations, DRG-related cost constraints, and internal financial monitoring introduce economic considerations into the environment of clinical judgment. These mechanisms do not mechanically determine physicians’ behavior, but they narrow the practical space in which professional autonomy is exercised. At the same time, the interviews do not support a simple narrative of ethical decline. Many physicians continue to emphasize patient welfare, professional responsibility, and clinical judgment, and some describe resisting financially advantageous but clinically unnecessary interventions. The article therefore argues that commercialization does not simply eliminate medical professionalism; rather, it reconfigures it. Physicians operate within hybrid institutional environments where professional commitments coexist with economic incentives, organizational constraints, and market-oriented expectations. Differences in interpretation appear to reflect not age alone, but physicians’ different institutional experiences and working environments, including earlier state-centered healthcare arrangements and contemporary commercialized private-sector settings. The Georgian case contributes to sociological debates on neoliberalism, professional change, and post-socialist healthcare reform by showing that healthcare commercialization reshapes not only ownership, financing, and service delivery, but also the social meaning of medical work and the conditions under which professional ethics and autonomy are practiced.