S. Haddad, E. Baris and D. Narayana (Eds), Safeguarding the health sector in times of macroeconomic instability. Policy lessons for low- and middle-income countries, Africa World Press: International development research centre, Ottawa, 2008, 360pp. ISBN-10: 1-59221-597-1

✍ Scribed by Gavin Mooney

• Publisher: John Wiley and Sons
• Year: 2008
• Tongue: English
• Weight: 40 KB
• Volume: 23
• Category: Article
• ISSN: 0749-6753
• DOI: 10.1002/hpm.941

✦ Synopsis

The book is set against the background of the debates and controversies surrounding macroeconomic adjustment policies (MAPs). These as the book indicates (p1) have been 'the subject of intense debate'. It argues (p1) that they 'remain controversial not only in terms of the scope and nature of policy dialogues, interventions and implementation processes, but also because of their purported effects on the overall economy, on the poorest and most vulnerable households, and on the financing and provision of social services such as education and health'.

On page 4 the editors write: 'the research initiative that led to this book was designed to provide a comparative ex-post evaluation of health sector reform initiatives in middle-and low-income countries so as to document which measures, and which policy environments, are more likely to be successful in safeguarding the health sector'. The countries covered in the book are Burkina Faso, Colombia, India (with a separate chapter on Kerala), Mexico, Thailand and Zimbabwe.

Trying to evaluate at this level is a very difficult task. That needs to be recognised up front in reading this book and in particular in reviewing or judging it. It is a sometimes frustrating read through no fault of the authors or the editors. There is no simple coherent picture that emerges; but then, given the variation in the applications of these MAPs and the very different country environments in which they were applied, it would be wrong to look for any overarching conclusion that was neat and tight.

The country chapters are useful in their own right. As I was in India (including Kerala) while reading this book (interspersed with chunks of The Shock Doctrine from Naomi Klein (Klein, 2007), clearly covering some overlapping territory but from a seemingly very different perspective-but maybe not so different!) I was especially fascinated by the chapter on India and yet more that on Kerala. Both are well documented, the former somewhat depressing, the latter much more hopeful but intriguing in the lack of any clear unambiguous simple explanation of why Kerala population health does so well.

The lessons from the chapter on Mexico are almost certainly universal: the need to respect the democratic will of the people in planning health care reform and to ensure that such reform avoids 'being imposed from above'. The authors also caution 'against the application of master recipes for policy around the world'.

What is particularly useful, if concerning, is that the book concludes with what are essentially very pessimistic findings with respect to a number of features of MAP. These have been tried in many countries in many forms. They have often been imposed by outside agencies and especially such global agencies as the World Bank and the IMF. The editors state (p332): 'Beyond regulatory and organizational functions, we have been unable to establish any tangible link between the changes implemented and the overall performance of health systems'. That is pretty damning stuff. But it gets worse as they continue: 'Even where reforms were accompanied by substantial increases in resources allocated to the health services or in capital expenditures, the impact on the population remains to be demonstrated'. And again: 'with 176