BOOKS & ELECTRONIC MEDIA

Getting health reform right: a guide to improving performance and equity

Rifat A Atun

Director, Centre for Health Management, Tanaka Business School, Imperial College London, Exhibition Road, London SW7 2PG, England (email: r.atun@imperial.ac.uk)

Authors: Marc J Roberts, William Hsiao, Peter Berman, Michael R Reich
Publisher: Oxford University Press, Oxford; 2003
ISBN: 0-19-516232-3; hardcover, 332 pages;
price £29.99

The Director-General of WHO, Dr LEE Jong-wook, identifies comprehensive engagement with, and strengthening of, health systems as necessary starting points for managing global public health challenges. Addressing health systems issues and strengthening the health systems within which health programmes operate, rather than investing in programmes alone, will improve programme effectiveness and the chances of sustainability.

This book has a number of strengths. First, it is written by an eminent group of scholars who have handson experience of health reforms in a range of settings. Second, it seamlessly links theory and practice and elegantly blends concepts with practical examples to paint a picture of reforms and their associated complexities. Third, it offers a number of analytical frameworks to enable those involved in designing, implementing or evaluating reforms to consider critically the value system within which the reforms take place. Fourth, it describes health system "control knobs" (health system financing, payment, regulation, organization and behaviour) which policy-makers can use to achieve their set goals and objectives. Fifth, it establishes the continuum between outcomes, objectives and interventions (control knobs) to enable policy-makers to consider health reform as a whole rather than separately.

The book consists of two parts: Part I concentrates on health system analysis, emphasizing that ethical and political economy considerations are the starting points for reforms; and Part II describes the five control knobs available to policy-makers, with the final chapter linking analysis with execution.

The authors argue that a clear understanding of the context, and in particular the value system within a given country, is critical for understanding and shaping the goals and objectives of health reforms. Distinguished are three value systems which shape societal and political preferences in terms of health system goals, objectives and elements: utilitarianism, liberalism and communitarianism. Two variants of each of these value systems are described: 1) subjective and objective utilitarianism (the former emphasizes that individuals can judge best about their own welfare, whereas the latter uses rational approaches to decide what is "best" for society); 2) libertarians, who want minimal interference from the state to pursue their own life (and health) preferences and egalitarians, who eschew positive rights, emphasizing that people should be given the "opportunity" to realize rights, such as health; and 3) universal communitarians (who share a common value system and espouse this) and relative communitarians (who celebrate diversity). The authors maintain that it is the value system (or balance of different value systems) which shapes the equilibrium of reform objectives. Hence, the way the evidence is "interpreted" and the emphasis with which evidence-based policies/interventions are applied are determined by the value system of the executive. Health system reforms are therefore context specific: shaped by the value systems and the political economy within which they are embedded. Reductionist, "one-size-fits-all" approaches — which transplant "technical solutions" to complex settings — are inappropriate and unlikely to succeed. Thorough and ongoing analysis of the context is critical to understanding the fine nuances that create enabling or retarding environments for policies and determine their chances of success.

This book encourages adoption of an analytical approach to health reform. It provides a rich set of tools and frameworks for analysis, objective setting, and planning for health reforms. I strongly recommend it as essential reading to policy-makers and practitioners involved in the design, execution and evaluation of health reforms. The book is well-structured, clearly presented and pedagogically sound — drawing on the long experience of the authors, who are well recognized educators. It is suitable for scholars and graduate students of health policy, political economy, health management and public health.

In summary, this is an invaluable book, suitable for use in developing and developed countries alike, which has successfully brought together and synthesized a body of knowledge from various disciplines to fill an existing gap in the literature.