Getting health reform right: a guide to improving performance and equity
International Journal of Integrated Care, 5 November 2004 - ISSN 1568-4156
Book review
Getting health reform right: a guide to improving performance and equity
Marc J. Roberts, William Hsiao, Peter Berman, Michael R. Reich
Oxford University Press, 2004, pp 332,
ISBN 0 19 516232 3
Ingvar Karlberg, MD, PhD, Professor of Health Services Research, Göteborg University, Sweden

It was not until I finished reading the book that I realised that “This book fills a major gap in the literature on health reform and health-system performance for low- and middle-income nations”. After having been involved in health care reforms and development in Sub-Saharan Africa as well as in South-East Asia, I can see the need. However, I found this book of great interest also in high-income countries.

The book is divided into two parts, the first half offers in seven chapters systematic methods for analysing health systems, the second part describes in five chapters instruments available for changing health systems: financing, payment, organisation, regulation and behaviour. The five instruments are referred to as “control knobs”.

All of the chapters are relevant to researchers, decision-makers, and managers in low- and middle-income countries as well as in industrialised, however, the first part is of greater general interest. From the first half, several sections can be used for teaching, training and discussion among students in management, economics, political science and medicine. I found of special value the very clear description of the links between ethical theories, health economy, financing, pooling and risk sharing for an equitable health care.

The second half: “the control knobs”, is more directed towards developing systems, where the options are still there. In high-income countries with established health care systems, the resistance to change is monumental. The authors state: “as a result, it often takes some sort of political or economic shock to begin the health-sector reform process. … This means that major changes in a country's health sector are infrequent. Hence, reformers have to be prepared to energetically seize the opportunity for major changes when time arises”. Reading this book to become inspired is one way to be prepared!

The WHO's World Health Report 2000 which ranked health care systems in member countries on a single scale has been much criticised and the ranking questioned. However, the report also focused interest on development and quality issues in health care. In this book the World Health Report is used in several sections as a platform for the discussion on quality and performance of health systems. This link is of great value.

The cooperation between providers as well as the division of tasks between organisations—which can be regarded as the core of integrated care—is discussed in several sections. However, the authors warn against organisational methods as an isolated means to increase effectiveness and efficiency. “We want to warn health-sector reformers not to become overly focused on such strategies (…integrated primary care…). Too often, such reorganisation does little to change the capacities, incentives, or motivation of front-line workers—or their managers.” This might be a perspective coloured by the authors living in a society—USA—with an extremely scattered health care system in which “who-does-what and gets paid for it”, may be more important than a seamless-care from a user perspective.

The systematic approach to health care system performance is supported by a wealth of references, mainly recent and updated. References are given to each chapter and a subject index to the complete text.

In conclusion, I highly recommend this book to students, teachers, and researchers in health services and systems research. I doubt, however, that politicians and managers have the patience, time and inclination to read a book of this size and with these theoretical perspectives. It is a task for us in the academic setting to pick up the best pieces from this comprehensive and scholarly work and deliver to decision-makers. As such a tool, the book is excellent.