Reforming Healthcare Systems

Edited By Theodore R Marmor and Claus Wendt . Published by Edward Elgar Publishing Ltd. 01 March 2011 . Hardback , 1352 pages . ISBN 1848443455 , rrp $696.70.

Reviewed by Vivian Lin

School of Public Health, La Trobe University

At the recommended retail price, this is a book for libraries. This is a pity, as it is a collection of classic articles and book chapters that would be useful as a reader for postgraduate students and health professionals finding themselves in the middle of health reforms.

There are 2 volumes, each more than 600 pages. Volume I is about ideas, interests and institutions, with 25 chapters divided into five parts: theoretical approaches, methodological frameworks for cross-national comparison, healthcare reforms and the power of ideas, interests and actors in the healthcare arena, and institutional change and persistence. Volume II has 28 chapters in six sections, under the theme of retrenchment, priority-setting, and solidarity which largely reflect what has been happening in various countries; the sections are titled: lessons for health reform from cross-country comparison, healthcare and the market, health policy and retrenchment, priority setting and rationing, the principle of solidarity, and intended and unintended consequences of healthcare reforms.

The 53 articles selected for these two volumes span some 34 years, from 1975 to 2006, and cover the experiences of several countries – including US, UK, Sweden, Germany, Netherlands, Japan, New Zealand – along with comparisons within continents of Asia, Europe, and Latin America. It is not surprising, however, that given Anglophone writers and journals, North American and British authors dominate.

This is not just a smorgasbord of papers that the editors happen to like. They have deliberately set out with a historical institutionalist approach to public policy studies and selected classics that illustrate the debates and how our knowledge base about health policy and health reforms has evolved. These articles consider the inter-relationship between behaviours of institutions and political actors (including decision-makers, corporate interests, civil society). Moreover, the editors are also interested in how ideas intersect with interest groups and institutional contexts as critical factors in the health reform process. Many of the giants of the field are represented – Marmor himself, David Mechanic, Rudolph Klein, Robert Evans, Alain Enthoven, Ellen Immergut, Carolyn Hughes Tuohy, Brian Abel-Smith, Joseph Newhouse, Ronald Dworkin, Chris Ham, Richard Saltman, Uwe Reinhardt, amongst others. If there is a consistent theme about lessons from cross-national comparisons of health reforms, it is that the idea of market efficiency being suited as an organising principle for the healthcare system is dubious.

Marmor and Wendt are interested in comparative analyses because 1) learning about other health systems and policies make us reflect and learn more about our own, and 2) understanding why institutional settings have developed in relation to different political contexts push us to generate explanations about what contextual factors matter. When it comes to methodology for comparative analysis, they point to the absence of an agreed typology for comparing health systems, while several approaches are reviewed. However, it is through various comparisons (by a wide range of authors) that they start to point to some lessons about health reforms:

  • • Preconditions for successful reform require knowledge (technical capacity), power (institutional capacity) and political will (political capacity).
  • • There is a negative correlation between public funding and total health care expenditure.
  • • Compared with other social policy systems, healthcare is distinctively provider influenced. A high-cost healthcare system results in higher income for those in the industry.
  • • Cost containment is easier when healthcare facilities are owned by the state and providers are remunerated on a salary basis.
  • • Where service provision is predominantly private, there is a key role for the state in setting healthcare standards and regulation the remuneration system.
  • • Countries that leave the decision for financing healthcare to the individual are not better at controlling healthcare costs than countries where the state directly intervenes in healthcare policy.
  • • Neoliberal reforms fail when there is inadequate administrative capacity to control the market.
  • • The promise of greater efficiency from market-based reforms has never been realised.
  • • Micro-level innovation (such as an efficient hospital sector) does not constitute a reliable basis for making the overall healthcare system more efficient or better in quality.

The editors recognise that most writings about health systems and health reform seldom address the health of populations. Several of the readings suggest that there is no evidence that institutional arrangements affect health outcomes, although comprehensive and preventive services can simultaneously result in better health and restrained expenditure. Indeed, the field of public health systems is relatively new and have emerged largely in the US in response to the Institute of Medicine's 1988 report on the future of public health. Empirical studies are still emerging on financing, organisation, and provision of public health services, and perhaps none have considered sufficiently the interrelationship between public health system and healthcare system to warrant inclusion in these volumes.

The selection in these two volumes are focused on OECD countries, and skewed towards US and Western Europe, but there is much that Australians can learn about the underlying dynamics of health system change through understanding the history of developments and contests in these countries. Indeed, the average MPH graduate in Australia learns little about health policy and has had little exposure to comparative and historical studies of health systems. This book would be invaluable reference, and given the constancy of health reforms in Australian jurisdictions, all public health professionals would benefit from knowing more about and reflecting on health reform experiences around the world.

A serious student of health policy should always read the classics in the field. In the era of the ERA (Excellence in Research Australia), it is noteworthy that the classics for health policy include book chapters, and many of the source journals for this volume do not have A or A* ranking. A somewhat annoying feature of the book is that the chapters literally look like re-prints, i.e. some look a little fuzzy, like an old photocopied version had been used to print.