Restructuring health services — changing contexts and comparative perspectives.

Books & Electronic Media Perspectives on health and exercise Editors: Jim Mckenna & Chris Riddoch Publisher:Basingstoke:PalgraveMacmillan;2003 ISBN 0 333 78700 5; price UK£ 17.99 (Pb) This 300-page multi-authoured publication examines the relationship between physical activity and health. Broadly, it covers in valuable detail the science of physical activity, its effects on health, and the biological mechanisms related to those effects. Of particular interest is the chapter by Carless & Faulkner on how mental health is affected by physical activity. For coronary heart disease, stroke, colon cancer, breast cancer, and diabetes the evidence is well established and unequivocal, but for mental health questions remain. The authors provide an excellent and comprehensive review of the research in this field. The evidence they cite clearly shows that participation in physical activity reduces the severity of mental ill- nesses, depression and anxiety. However, it is their treatment of how it relates to aspects of mental health such as self-esteem, auton- omy and self-image that are the most enlightening. Few good studies exist in this area, but these authors have brought them together illuminatingly here. Some writers on this subject extol the benefits of physical activity without the supporting evidence, but Carless & Faulkner recommend a more open-minded and science-based view until more specific studies have been undertaken. In the chapter about health outcomes, the review of the literature is not as comprehensive or up to date as might have been expected. It is certainly adequate, but more recent studies and large meta-analyses have been done in this area and were not included here. For example, the relative risk estimates provided for the impact of physical inactivity on coronary heart disease are based on a meta-analysis done in 1992. More recent work was not included. The relative risk estimates from the earlier studies prob- ably overstate the benefits of physical activity by combining and confusing physical fitness and physical activity studies. Physical fitness and physical activity may have different relationships with health. A new meta-analysis undertaken by this reviewer, to be published later this year as part of the WHO Comparative Risk Assessment study, will show that for coronary heart disease the impact of 30 minutes of moderate physical activity a day, although substantial, may not be as great as was previously thought. Although it overlooks more recent data, the chapter still provides a good introduction to the premise that ‘‘participation in physical activity improves physical andmental health’’. Overall, the authors make a welcome contribution to the growing literature on physical activity and health. Their work is well organized, referenced and presented, with a box at the start of each chapter indicating the topics covered and giving a concise summary. n Tim Armstrong1 Restructuring health services — changing contexts and comparative perspectives 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 world- wide. 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 particu- larly affected by restructuring and reorgani- zation 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 findingsmake discouraging reading. Globalization of business, financial transac- tions, 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 tomeasure 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 con- venient rationale for making payments, it falls well short of providing ‘‘valid, mean- ingful 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. n Birte Twisselmann2 1 STEPS Project Manager, Noncommunicable Diseases and Mental Health, Surveillance, World Health Organization, 1211 Geneva 27, Switzerland (email: armstrongt@who.int). 2 Technical editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR, England (email: btwisselmann@bmj.com). 546 Bulletin of the World Health Organization 2003, 81 (7)