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Book Review
Restructuring Health Services: Changing Contexts and Comparative Perspectives
Kasturi Sen (editor)
ISBN: 1-8427728-9-9 2003 260 pages Zed Books, London, New York
Pauline M Prior
School of Sociology and Social Policy, Queen's University Belfast, Northern Ireland
Students of health policy need to place their national experiences of recent health care trends within an international context because without this comparison it is almost impossible to understand the reasoning behind many of the major political decisions currently impacting on health care provision. For example, though it is widely accepted that the expansion of private health care throughout the world is one of the major trends to emerge from the economic and political pressures of globalization, it is not always clear how this actually happens at a national level.
This text, edited by Kasturi Sen, is a valuable source of information for those who are interested in making international comparisons on the topic of health care reforms. It is a collection of essays exploring recent experiences in four regions of the world, representing a broad range of different political and economic structures. The research for the study was funded by the European Commission and conducted under the direction of local health experts. The four regions are: 1) the USA; 2) Western Europe - with case studies on Spain, Italy and the UK; 3) developing countries - with case studies on Malaysia, Thailand and India; and 4) Cuba - one of the last remaining socialist health care systems in the world.
The book is divided into three parts. Part I presents the prevailing conceptual and legislative framework that governs the international arena and which countries are obliged to observe. In introducing this material, Sen argues that private health care has been enriched through both direct and indirect subsidies from the public purse without necessarily improving overall health care provision. Subsequent discussions in this part of the book present evidence of some of the processes at work in this. On the question of the benefits of competition, for example, Sexton, writing on the impact of the World Trade Organisation (WTO) General Agreement on Trade in Services (GATS) on health care, argues that the evidence shows that competition between the public and private sectors does not necessarily lead to an effective service. It may lead to better health services for people who are healthier - the rich, who can afford private care. In contrast, it may lead to poorer services for the more vulnerable members of society - poorer people, who have more ill-health and who rely on public services.
In a similar vein, but from a different perspective, Qadeer, explores some of the ethical issues raised by the impact of globalization on health care provision. Using India as the backdrop for the discussion, Qadeer expresses concern about the equity issues already raised by Sexton. She points to the negative impact of the expanding multinational pharmaceutical industry on resources available for preventive health programmes, and warns of a growing anti-poor ethos underlying some 'healthy environment' policies.
Part Two of the book, entitled 'The Process of Change', contains three very informative chapters on the international influences on national policies. These are the continuing impact of the policies of the World Health Organisation (WHO), the expansion of multinational corporations (MNCs) in health care, and the growing power of the European Union. In a critical analysis of the conceptual and methodological tools used as a basis for the WHO Report 2000, Travassos clearly demonstrates the complexity of any attempt to make international health comparisons and alerts policy-makers to the need to question some of its underlying assumptions before accepting this report as a good basis for planning.
Even more worrying is the discussion on the role of MNCs in health care provision presented by Hall. Supported by the World Bank, the services provided by MNCs in the sector have been highly diverse throughout the world. Hall presents facts and figures to support his argument that as the power of MNCs has grown in all areas of health care - including hospital services, catering, cleaning, laboratory work, and health insurance - so also has instability in the workforce. Because this is happening on a large scale, it has a direct impact on employment trends in many countries, a consideration that should not be ignored by public policy-makers.
With an equally critical approach, Koivusalo argues that the industrial and employment policies of the European Union have had (and continue to have) a powerful impact on the financing and delivery of health care systems. For example, such policies as the encouragement of cross-national competition, the strengthening of internal market regulations and the standardization of aid policies, have had far-reaching effects on all areas of public policy, including those related to health. Koivusalo urges that the goals of health policy should not be undermined by commercial and trade interests.
The case studies presented in Part Three of the book cover specific experiences in health care reform from more than eight countries. Each is illustrative of some of the points raised in the earlier discussions. In Italy, for example, the implementation of a policy of decentralization of power to regional authorities has led to considerable variation in health care provision and to health inequalities that correspond with this. Other chapters show that Spain, the UK and India have had similar patterns of reform - especially the expansion of the private sector and the retraction of the public sector - but the reasons for this vary from country to country. In Spain, this was mainly due to internal political forces, while in the UK and India, global forces were more influential.
Other case studies demonstrate the centrality of the public versus private debate throughout the world. The problems of financing universal health care in Thailand, and of managing a growing private sector in Malaysia, are matched by the problems faced by the well established system in the USA. There, it is argued, the market has failed. It has led to higher costs throughout the health care system and to an increase in the proportion of the population not covered by health insurance. In complete contrast to the other case studies, Cuba is still committed to a publicly funded and publicly provided system of health care. The Cuban Government has given priority status to health and, with this support, Cuban health workers have worked towards the overall aim of health and unity in their own country and in sixty countries in the developing world. However, it is not clear if the standard of health care is higher in Cuba than elsewhere.
In conclusion, I can recommend this book to health care researchers and to students specializing in health policy at undergraduate and graduate level. It is a valuable source of comparative material on health services and systems that is often difficult to access. My only criticism is that it is not an easy read because of the range and depth of the material. Students and researchers will find it most useful if absorbed in small sections.
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