Main Thesis: Ms Sen and her colleagues argue that systematic seismographic political and economic changes directly led to transformational global reforms in most national health systems. The core of the major reorientation was to accept the neo-conservative operating system from the 1970s and to replace the neo-liberal tenants. This neo-conservative revolution was led by key decision makers in the UK and USA, then adopted in Europe, Latin America, many developing countries, enshrined and legitimized in international institutions of the World Trade Organization (particularly through the General Agreement on Trade and Services), The World Bank, World Health Organization and by the globalization of multinational/transnational corporations. While these 'sea changes' affected key service sectors in health, the conscious economic and finance decisions were to replace first principles of welfare delivered through public subsidy and apparatus with efficiency provided by the private interests predominately focused on their 'bottom line'. This strategy and operations (with Cuba the exception) at national level resulted in significantly greater inequity and not necessarily improvements in health status, and correspondingly increased growth in health/medical care expenditure.
Presentation: The arguments are well presented and, in general, substantiated in three parts: Conceptual and Legislative Framework, The Process of Change, and Case Studies (9) of Restructuring: Comparative Perspectives-though these could have been even more potent were the strident rhetoric less pervasive. Due to the general nature of the restructuring health services do we believe decision makers were consciously selected to 'be on the same page' or did financial constraints dictate the pace? One wonders why major transformations in health policy from North to the South and among European countries apparently were introduced without adequate trials since the resultant dissatisfaction among health/medical professionals, administrators and families are clearly revealed. It is particularly unnerving to read of the complicit nature of politicians and international bureaucrats setting health policies, finance and systems which negatively impact billions of people in the third world who have no voice in their own affairs.
Dynamic Reforms: Can the 'ship be righted', as it were? Clearly health economics, policy and finance are under continual and increasing pressure in all countries, North and South. It would have been useful if Ms Sen and her colleagues had shared their keen insights on sets of real reforms that could lead to improved access and effective health systems. Cost-effectiveness is not incorrect; it may be in the current market oriented health policies and context; but why would we expect Cuban health planners not to embrace 'cost-effectiveness' with the fiscal constraints that they