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Bulletin of the World Health Organization

Print version ISSN 0042-9686

Bull World Health Organ vol.81 n.7 Genebra Jan. 2003 



Restructuring health services — changing contexts and comparative perspectives



Birte Twisselmann

Technical editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR, England (email:



Edited by: Kasturi Sen
Publisher: London: Zed Books; 2003
Pb ISBN 1 84277 289 9, price UK£ 14.95, US$ 22.50
Hb ISBN 1 84277 288 0, price UK£ 45, US$ 55

In 2001 the European Commission funded a meeting in Maastricht, the Netherlands, to evaluate experiences of 20 years of privatization in health care services worldwide. This publication brings together the contributions to the meeting from eminent public health academics, doctors, researchers, and policy-makers from different regions of the world that have been particularly affected by restructuring and reorganization of health services. The editor, Cambridge-based (UK) public health scholar Kasturi Sen, has grouped these into three sections: the conceptual and legislative framework, the process of change, and case studies from individual countries.

The findings make discouraging reading. Globalization of business, financial transactions, and profits; fiscal pressure on welfare provision; privatization of infrastructure; the introduction of the market model into public sector provision; the Bretton Woods institutions and their role in developing countries' indebtedness; and, perhaps most of all, the renegotiation of the World Trade Organization's General Agreement on Trade in Services (GATS) are rapidly creating conditions where only those who can pay will have access to medical services. And this process is set to accelerate.

The argument that fiscal pressures enforce this change does not really hold; as two strikingly contrasting case studies show, state provision is not dependent on national wealth. The chapter on the United States argues that making profits integral to the delivery of care totally undermines the principle of universality; administrative costs are high, choices limited, and quality of care not assured. Contrasted with this is Cuba — which is conspicuously not indebted to international donors and is thus in some ways beyond the reach of the global capitalist system and the dictates of neoliberal reform. Cuba has some of the best health indicators in the world, although the choices for the users of its health service may be limited.

A poignant example of the way in which welfare provision has come to depend on the methods of shopkeeping is provided in a critique of WHO's World health report 2000, which attempted to measure the performance of the health systems of member states by using an elaborate scoring and ranking system. The World Bank had used the same approach in the early 1990s, the chapter observes, and although it provides a convenient rationale for making payments, it falls well short of providing "valid, meaningful and useful information" about human well-being or how to provide for it.

Overall, the gloomy conclusions bring to mind those of US journalist Laurie Garrett in her analysis of the collapse of global public health, Betrayal of trust. She attributes this collapse to the erosion of the pact between governments and their citizens, caused by greed and corruption on the part of the former, and describes examples of the dramatic consequences. Kasturi Sen, while her argument is essentially a moral one, analyses health services as one component of the modern nation state that is particularly vulnerable to economic trends and global capitalism. She thus presents us with a historical or even evolutionary explanation for the decline in provision by the state for its people. Or maybe the most accurate word for the operative factor is greed.

The core question is perhaps that raised in the case study on the United Kingdom: should all economic life be run in the interests of the few seeking ever higher profits, instead of meeting the social and public needs of future generations? Although the obvious answer is "no", the book does not inspire too much hope for progress in this sense.