<i>Unhealthy Health Policy – a Critical Anthropological Examination</i> Edited by Castro, A. and Singer, M. and <i>Political and Economic Determinants of Population Health and Well‐being – Controversies and Developments</i> by Navarro, V. and Muntaner C.

Castro, A. and Singer, M. (eds) Unhealthy Health Policy – a Critical Anthropological Examination. Maryland : Altamira Press , 2004 . £28 (pbk) 408pp . ISBN 0-7591-0511-1 . Navarro, V. and Muntaner, C. Political and Economic Determinants of Population Health and Well-being – Controversies and Developments. NY : Baywood Publishing Company , 2004 . £29.95 (pbk) 575pp . ISBN 0-89503-279-1 . The long, frustrating wait for a body of critical analysis of the prevailing neo-liberal and market-style ‘reforms’ to global healthcare systems has shown itself remarkably similar to the wait for the proverbial London bus. You pace around for what seems like years . . . and then two come along together. These two new chunky volumes (390 pages and 576 pages respectively) are unashamedly partisan in propounding their critical view: they want to hold to account the prevailing orthodoxy which has held sway for at least 20 years. There have been many important critical articles, of course (a few of which are reproduced in the Navarro-Muntaner book) and significant books and collections, mostly from a political economy perspective, addressing more limited objectives (see Drache and Sullivan 1997, Armstrong et al. 2001, Lee et al. 2002, Sen 2003). But while each of these has its strengths and offers some important insights, they are not an organised resource and reference point in the way that these two new books set out to be. And, while the two new books come from separate publishers, appear to embrace diverging methodologies, and largely feature different authors (with minimal overlap) both volumes combine effectively to reinforce one common theme. This theme has been all too seldom explored in a world in which the vast patronage of the World Bank's $100 m annual research spend, and ideological pressure from organisations like USAID and national governments, have helped sway academic research and opinions in a neoliberal direction. Now in these two collections, a wide range of authors, drawing heavily, but by no means exclusively, on experiences and data from the poorest developing countries, conclude that not only is there little or no evidence to support the introduction of the neo-liberal policies promoted by the World Bank, IMF, the State Department funded USAID and a number of Western governments – there is a considerable body of evidence to show that these policies deliver precisely the opposite of the promised results. Neoliberal and pro-market policies, they argue, reinforce and maintain health inequalities; they reduce efficiency and increase overheads through the extension of costly and bureaucratic markets, competition and separation of purchaser from provider; they lead to the imposition of user fees, which in any context serves to restrict access to care for the poorest; and they undermine public services and promote the role of the private sector, which always and everywhere seeks to pick and choose the areas of care it will provide, studiously avoiding genuine risk, and concentrating its resources on the areas with greatest potential revenue – again excluding the poor and elderly. What evidence is produced to back up these damaging allegations? Both volumes offer a veritable war-chest of ammunition for those fighting the critical corner. Navarro and Muntaner offer a wide range of articles written from a ‘political economy’ viewpoint – which in practice ranges from relatively non-political, quantitative economic analysis of links between social and economic inequalities and inequalities in health, to relatively low-key, unannounced, versions of marxism (Canada's David Coburn noting that ‘business is the predominant “interest group” with an influence far outweighing that of any other group (in Canada)’ p. 226). This collection is the least up to date of the two, and some of the statistical data – although still useful – are very definitely of historical rather than contemporary relevance. This same book also has the largest component of articles located in the experience of the wealthier OECD countries, although some of the most powerful evidence is drawn from the developing countries (Chapter 10). It features a number of articles reprinted after relatively wide circulation elsewhere, and many of its list of contributors will be familiar to readers of Navarro's International Journal of Health Services, itself a distinctive landmark, standing in contrast to the prevailing wisdom of officially-sponsored research endorsing the neoliberal status quo. Navarro himself contributes three chapters and a joint overview chapter with Muntaner summing up the lessons, and setting a research agenda. What is striking is that while Navarro's political analysis appears razor sharp in contrast to the woolly conclusions of the WHO's controversial 2000 World Health Report (Chapter 11), and in dissecting the confused and disorientating notion of ‘social capital’ (Chapter 22), he is astonishingly ineffective in teasing out any distinction between rank and file trade union members and their leaders, or discerning the real politics of the labour movement or the Communist Party (Chapter 22). For a critical analyst so eager to refer back to key concepts of ‘class’, Navarro seems to have closed his eyes to the very significant political differentiation within each class, and to the problems of bureaucracy and the corrosive politics of Stalinism. The essential lines of the critique, however, including empirical data to make the link between higher health status and lower levels of social inequality (Chapter 4), are all present in the collection, even if some of the argument is a little dry, statistical and abstract. By contrast the ‘critical anthropological examination’ offered up by Castro and Singer has much more immediacy and capacity to strike the unexpected note. Anthropology's focus on human behaviour, for example, allows James Pfeiffer (Chapter 3) to explore the behaviour patterns of the staff of NGOs brought in to deliver services in developing countries as a result of the bias of the World Bank and USAID against public sector service provision. Pfeiffer notes the high admin costs and relatively high wages paid by the NGOs to their workforce of expatriates flown in to work on short-term contracts, many with little if any awareness of the conditions of the health workers and wider society they will be working with. He stresses the corrosive effects of hiring local staff on daily rates equivalent to 10–20 times the prevailing local salary scales, and the blinkered focus of the NGO staff and apparatus in measuring the (short-term) successes and failures of each discrete project, with little if any reference to other projects run by other NGOs. Another anthropological hallmark, the comparative study, offers a revealing contrast between the health status of two Caribbean islands, Haiti and Cuba, and goes on to offer explanations and lessons. The editors explain that the methodological approach embodies a theoretical approach known as ‘critical medical anthropology’ (p. xiv): but it is more simply expressed as: using research to critically review the intended or unintended negative impact of policy on the lives and well-being of people targeted by social policies (p. xiii). Underlying both this approach and that of the political economists is the recognition that despite the widespread happy clappy rhetoric of market-style reforms, in which reference is repeatedly made to issues such as equity, access, and quality, in a world shaped by neo-liberal ideology: health policies are shaped by a number of factors, only one of which (and sometimes the least of which) is concern with public health (p. xiii). When it comes to exploring the actual consequences of the policy agenda of neoliberalism, the Castro and Singer book offers a variety of approaches reflecting a range of different geographical and social circumstances – leaving no room for doubt that the policies have proved negative for the very poorest sections of society that most need access to healthcare services. For my personal taste, neither book makes enough out of the elementary but inescapable fact that healthcare can never succeed in a completely deregulated competitive market because the section of the world's population that is the most natural ‘market’ consists of the poor – and they lack the ability to pay a market rate for healthcare or (as Castro and Singer in Chapter 6 point out), even for the drugs they require (see also Lister 2005). Nor is there any discussion of the bizarre relationship between neo-liberalism (small government, low tax) and the extravagant overhead costs and inefficiencies of the ‘new public management’ approach which accompanies market-style reforms. But both volumes offer valuable source material, argument and references that should reinforce the line against neo-liberalism and market-style reforms wherever they raise their head. My only regret as a reviewer is that neither volume was available to me when I was completing my book on healthcare reforms, struggling to identify some of the sources they contain, and to discuss some of the issues that these studies have now succinctly addressed.

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