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Health sector reforms

This book is a study of the relationship between macroeconomic interventions and adjustment policies (MAP) in developing countries and health system reforms in developing countries and their impact on health system and services. The volume brings together a series of country case studies undertaken with the support of the International Development Research Centre (IDRC) in these countries. During 1980-99, the six countries namely, Burkina Faso, India, Thailand, Colombia, Mexico, and Zimbabwe, underwent either structural- adjustment- based or sectoral- adjustment- based lending from Bretton Woods institutions followed by the onset of health sector reforms.

The volume traces the experiences of health system reforms in these countries and also the strategies and assumptions that underlie their formulation and impacts. It also offers in its initial chapters, a comprehensive overview of literature in the area and builds a conceptual framework for a comparative analysis of health reforms in these settings. Each of the country case studies in the book also focuses on possible lessons learnt for the future in identifying and “fortifying” policies that would serve to “safeguard the health sector in times of imposed policy choices.”

The themes and questions raised in this volume are not entirely new. The introduction of MAPs in the 1980s and 1990s generated a large number of studies that analysed their welfare agenda and effects on countries, with most author perspectives being coloured by their standpoint as supporters or critics of MAPs. Many studies tended to focus on demand side factors such as changes in health outcomes and supply side studies mostly focused on health expenditure alone. Access to care, utilisation, and quality of care were less researched and there were few studies that situated country experiences and strategies by locating them within the broader socio-economic and political context of the health care system. This book is therefore an important addition to this literature, as it bridges an important gap in both ideas and methodological perspectives and seeks to shift the understanding of macroeconomic adjustment policies away from mechanically sizing up health outcomes alone or to view them selectively, through a “sectoral lens”.

The case studies are particularly interesting and relevant today because they reiterate that critical issues remain in understanding the complex and heterogeneous experiences across and within countries affected by MAPs and that these lessons remain critical in offering short- and long- term perspectives in mapping future policies. This is brought out through an approach in the country studies that brings into focus not only what was implemented but also on the build up of processes and also the discrepancies between the initial programme and the implementation of policies; this is brought out well in particular in the studies in India, Mexico and Zimbabwe.

Health system reforms broadly aimed at improving health system efficiency by increasing health funding, reallocating public spending to primary care, improving quality of care and supporting decentralisation and liberalisation. However, this volume underscores the contingent nature of reforms in these countries and the limited “transformation” generated in these settings with reform impacts being limited and unevenly distributed. In terms of institutional changes, health systems remain poorly managed with only partial decentralisation. Power has continued to be centralised and concentrated as reflected in health budgets and reform planning, and most of the initiatives are generated from the centre.

The macro perspective of the book based on country studies and common frameworks of analysis does tend to leave the reader with the sense that the MAP project needs more detailing in terms of both the country scenarios and its recommendations of the way ahead. While the book aims also to reflect upon the varieties of policy choices and interventions at different moments, some of the studies are unable to offer a meaningful analysis of the shifts and priorities over time and at various levels and their relationship in turn with policy choices over issues such as decentralisation in fiscal, administrative and human resources that are discussed. The India study by Narayana and the Mexico study by Luis Duran and others do offer some insights in tracing these changes such as changing regional politics and priorities as compared to the others.

The studies also echo the important and defining role of political processes in influencing the course of health system reforms especially in the India, Thai and Colombian studies in particular. However, the construct of these processes such as ‘political will’ as a catch-all term are cursorily dealt with and it is unclear as to what it would constitute in each setting.

All of this in no way takes away from the significance — both in terms of the individual studies and collective recommendations. This work will hopefully pave the way forward for more studies along the lines recommended by the authors, on the historical, cultural, political differences between health systems that would further explain the models of performing versus non-performing cases. More importantly, the volume has wider significance in that it underscores that even in times of seemingly disappearing distinctions between global economies and integration within it of nation states, the success of reforms clearly lies in addressing the social demands of citizens and adapting to plural needs and local contexts.

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