This is a welcome sequel to the seminal 1985 Rockefeller Foundation study Good Health at Low Cost, which investigated the determinants of good health care in countries which, despite other poor indicators, did better than many wealthier ones. The five chosen were China, Costa Rica, Cuba, the state of Kerala — treated as a country for the purpose — and Sri Lanka. This second Rockefeller-funded study, by the London School of Hygiene and Tropical Medicine with four other partner institutions, examines Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu, and Thailand, and revisits the earlier four, but Cuba does not figure in either volume.
The work follows the World Health Organization by focusing on health systems, seeing them as institutions working with other institutions to promote well-being rather than simply providing treatment. In that sense, the aims the United Nations set out in the 1978 Alma-Ata Declaration have been retained, and the authors also note the significance of education and literacy programmes in improving maternal health and child survival rates. Countries have been chosen on the basis of national health system reforms, population and global region, and models of governance, among other factors, and the researchers analyse their findings in detail.
There is a wealth of material here. Bangladesh, one of the world's poorest countries, has made great advances in life expectancy, child health, and literacy, mainly as a result of strong emphases on community and household level health and family planning services. In South Asia, the country has among the highest life expectancy, together with the lowest total fertility rates and some of the lowest perinatal and maternal mortality rates, all of which have been achieved in under 30 years from a dauntingly bad start.
Other countries are impressive in their own ways. Landlocked Ethiopia, a victim of vicious Cold War rivalry, terrible famines, and brutal civil war in which starvation was a weapon, has greatly reduced infant mortality with a national programme to distribute insecticidal bednets and improved prevention and treatment strategies. Substantial improvements have been made in the primary health care workforce based on districts and neighbourhoods, and in arrangements for doctors to travel to rural areas despite the poor transport infrastructure; the high incidence of HIV/AIDS has also been tackled with antiretrovirals and public education programmes.
Even the systems of the former Soviet Union are assets. Kyrgyzstan introduced compulsory health insurance after gaining independence in 1991, and has drawn upon pre-existing administrative experience as well as remarkable dedication on the part of ex-Soviet medical staff to maintain standards of care.
Tamil Nadu, for its part, has successfully ignored what is now a central government view of health policy as a matter of illness episodes and nothing else. The IIT Madras research team shows the state to be ‘unique' for its strong body of public health managers at district level, and for having trained and deployed village health nurses since the late 1970s; Tamil Nadu has better indices than most other states for fertility, and for perinatal and maternal mortality.
While the first four examples rely on a sometimes uneasy combination of public and private provision, Thailand, with a mainly public health care system, has outperformed many other countries; free antenatal care, skilled birth attendance, family planning, and immunisation, were all universal by the 1990s, and all Millennium Development Goals were met in the next decade.
Of course all is not rosy. In Ethiopia, out-of-pocket expenses account for 80 per cent of citizens' health spending, and tuberculosis is still widespread; India faces similar issues, including the airborne spread of resistant TB bacilli from the habit of spitting. Tamil Nadu has poor levels of nutrition, and high levels of maternal anaemia. In Kyrgyzstan, the collapse of the Soviet Union ended systems of support for young mothers.
The collection rightly avoids making easy statements of causal links between policy and results, though many of the patterns identified and the evidenced conclusions reached make very good sense. Secondly, in health policy around the world, documented questions still stand about, for example, the influence of the GAVI Alliance and pharmaceuticals manufacturers on health policy around the world.
All the researchers here do, however, discover three factors central to good health policy and successful health care delivery. One is the strong involvement of women at all levels. Another is the honest evaluation of policies; this has, for example, made funding bodies see that the vertical interventions they favour cannot accommodate the complexities of health policy and health care delivery. The third is political will with, above all, a commitment to equitable access. This book will therefore be of great value to practitioners and policymakers.