INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, VOL. 11,359-365 (1996)

BOOK REVIEWS

CALUM PATON, Health Policy and Management: The health+are agenda in a British political context, London: Chapman & Hall, 1996, ix+ 360pp. Price E19.99.

The title of Paton’s book exactly describes its aim and contents: it is about the link between policy and management issues in health policy, acknowledging that these are not easily separated; it is about both the general character of these issues and about their particular nature in Britain; and it is about how Britain looks when set against experience elsewhere. The book is divided into three sections: the fist is a set of chapters examining such policy issues as financing, priority setting and purchasing; the second part has chapters on management issues like commissioning and audit; the third part, on ‘Understanding and Learning’, is the most ambitiously cross-national section of the book.

The summary of aims and content shows that Paton’s is an ambitous work. That ambition is heightened by the targeted audiences: he wants to speak to academic social scientists, to health care practitioners, and to managers at different levels of the service. Successfully addressing these very different audiences is a tall order. Paton solves the problem by a direct style, obviously honed by long experience of communicating with ‘practitioner’ audiences, and partly by a variety of presentational devices: clear separation in each chapter of exposition, discussion, conclusion, extensive use of bullet points; the relegation of almost all academic references to bibliographies at the end of chapters. These last are useful in their own right, and would be of even more use to non- academic audiences were they to be annotated.

Paton has added a distinctive voice to the discussion of British health reforms in recent years. He is one of the few political scientists with an interest in the area. He knows both the old system and the reformed NHS inside out. And he is, in one way, an old-fashioned political scientist (the attribution is meant as a compliment): he has an interest not only in understanding how institutions work but also in prescribing how they might work better. It is this traditional interest in prescription, allied to a political scientist’s ‘nose’ for the interests at work, that have created Paton’s distinctive critique of the British reforms. That critique starts from scepticism about the rhetoric in which policy prescriptions are couched; it emphasizes the often contradictory aims that have characterized the various stages of reform; and it unravels the many different things that are going on in different parts of the policy package, like the purchaser/provider split and medical audit. In this last connection the chapter written jointly with Ann McBride is especially helpful: it links the audit movement and traditional quality control mechanisms; it ‘sets’ audit in the wider context of the reforms; and it presents a set of detailed case studies of audit in operation. In its mixture of the ‘big idea’ and the close institutional detail it is exemplary. It is also a very good example of all that is best in Paton’s approach to the study of health policy.

MICHAEL MORAN University of Manchester

UK

BIE NIO ONG, Rapid Appraisal and Health Policy, London: Chapman & Hall, 1996, 14O+xpp. €19.99.

It was with trepidation that Susan Riflcin and I acquiesced to Bie Nio Ong’s request some 10 years ago that we work with her and her colleagues in Sefton, Liverpool in their search for innovative means of planning a locality’s health services. The approach

CCC 0749-6753/96/040359-07 01996 by John Wiley 8z Sons, Ltd.

360 BOOK REVIEWS

adopted was a rapid appraisal (RA) methodology evolved for the WHO in the developing world. In the intervening years Dr Ong has been a key figure in the further development and adaptation of RA for application in the micro-planning of health initiatives in the UK. This book reflects this substantial experience. In the introduction a dual purpose is identified for the book: ‘it seeks to demonstrate the way in which the Rapid Appraisal methodology is linked to a number of contemporary theoretical debates about health policy, and it intends to provide guidance for the implementation of its methodological principles’. The book succeeds in both its aims but its particular value is in relation to the former; doing RA successfully requires reading to be supplemented by an apprenticeship.

It was practitioners, particularly those pursuing rural development in developing countries in the 1980s, rather than theoreticians who were the driving force for RA methodologies. Consequentially the theoretical underpinning of RA has lagged behind its practice. In this book Dr Ong makes a substantial contribution to re-dressing this imbalance. The practitioners of RA had working assumptions, not always made su!Eciently explicit, about such fundamental issues as the definition of health, what constitutes need, the nature and importance of community involvement, and the nature and exercise of power. This book examines each of these issues through a thorough review of the relevant theoretical literature and critically relates them to RA methodology. In her discussion of the making of health policy and the setting of priorities Dr Ong persuasively argues that RA methodology can make a valuable contribution to effective change in the nature of health services and the manner in which they are offered at the local level; the relevance of RA at macro-level health planning is very limited.

In the past decade, health sector reform has resulted in a major shift in the way health care is conceived and organized in the UK and many other developed countries; similar trends are being pursued in the developing world. The aspects of these innovations which are relevant to the theme of the book are critically examined and the practical consequences of relating agencies responsible for purchasing services as well as those providing services with communities considered. A notable innovation is a consideration of the relevance of RA to futures research in health.

An important and persistent criticism of RA is that the way in which data are collected and analysed is insufficiently rigorous and objective to yield reliable information for planning. The chapter on this subject, as well as consideration elsewhere of the value of lay knowledge, is particularly helpful. It provides substantive support to the arguments of Robert Chambers and other leading RA authorities that properly done RAS produce information of real value, much of which could not be readily obtained by other means. While the book acknowledges that there has been very inadequate evaluation of the impact of RAs on health policy and practice, it could make more substantive proposals as to how this very important shortcoming should be addressed. In the developing world, RA has evolved in a variety of directions but I get the impression that RA as practised in relation to health in the UK has been especially influenced by a particular variant of RA methodology. A useful addition to the material discussed would have been an overview of the forms and different emphasis of RA as practised in different countries and sectors. Nevertheless, the theoretical underpinning of RA developed here and the demonstration of its relevance in policy discourses is pertinent to RA generally. A not inconsiderable virtue of this book is that it is a good as well as a useful read.

HUGH ANN^ Aga Khan Health Services, Aiglemont, France

DAVID A. WISE (Ed.), Studies in the Economics of Aging, Chicago: University of Chicago Press, 1994, 368 pp. Price US$65.

This book contains 11 papers which were presented at a National Bureau of Economic Research conference. The papers are highly technical and employ sophisticated

BOOK REVIEWS 361

quantitative methodologies in examining a wide range of various aspects of the economics of aging, including: life expectancy, the demographic transition, saving for retirement, retirement age, housing and long-term care. In addition to co-authoring three of the papers, the editor, David Wise, provides a splendid guide and overview of the book in a concise nine-page introduction.

All but one of the papers are empirical investigations based on United States data, although the two chapters on retirement include comparisons with Taiwan and Germany. The only paper that does not include US data is the life expectancy paper, which uses ‘the most reliable database on mortality’ (that of Statistics Sweden) covering the 19W1990 period. Despite the fact that these papers are overwhelmingly driven by US issues and based on US databases, several of them should be of interest to researchers and policy makers in all countries. Five of the studies deal specifically with aspects of health and health policy and are the most likely to be of interest to the readership of this journal.

One of these five is particularly provocative and has applicability for developing countries as they try to sort out the role of government in the health sector. In ‘The Impact of the Demographic Transition of Government Spending’, John B. Shoven, Michael D. Topper and David A. Wise investigate how public expenditure is likely to change as the population gets older. They identify the age-specificity of 22 different federal, state and local government programs that account for 40 per cent of total government expenditure. The distribution of the (1986) expenditure by age of household head is eye-opening. For married couples, the average government expenditure per household is $858 for 15- to 25-year-olds. Thereafter it slowly increases, reaching $2305 for 45- to 55-year-olds, before it increases dramatically: averaging $6542 for 55- to 65-year-olds, then jumping to $16 353 for 65- to 75-year- olds and attaining an astounding $19 859 for those 85 years or older. The bulk of the expenditure consists of Social Security and other retirement programs and the Medicare and Medicaid health care programs, which explains their concentration among the elderly population. Next, assuming that age-specific real per capita beneficiary program costs are constant, the authors assess the impact of growth in the size and age composition of the population on government expenditures for these programs. They estimate that the real costs of these programs (i.e., adjusted for inflation) will increase from $669 billion in 1990 to $1106 billion in 2040, an increase of 65 per cent.

The authors believe that the magnitude of this increase-owing only to changes in the demographic structure of the US-is likely to undermine the sustainability of these programs. ‘(T)he age-specific generosity of these programs will be difficult to maintain. There will be strong pressures to cut the benefits of these programs . . . (and) new initiatives with budgetary costs will be crowded out by the growing expense of the existing programs (page 26).

This type of exercise - one which is seldom performed in the developing world - would be worthwhile to conduct in any country. While most developing countries are currently engaged in redefining the nature and role of government in the health sector, the approach to date has been piecemeal and very short-run oriented. Applied specifically to government health expenditures, this type of analysis could provide an important starting point as well as a framework for assessing the government’s current role and impact in the health sector. Moreover, this approach can provide a powerful tool for simulating alternative scenarios by which to explore how government’s role could be made to change. This could be a particularly useful tool for assessing alternative options for confronting (or not confronting) the epidemiological transition that is currently unfolding in the developing world.

JOHN L. FIEDLER Social Sectors Development Strategies,

USA

362 BOOK REVIEWS

GRIFFITH EDWARDS et al., Alcohol Policy and the Public Good, New York: Oxford University Press, 1994. Price not known.

This book provides an overview of the current status of alcohol problems and policy, and provides suggestions for future policy decisions. It begins by discussing the inherent complexity involved with development of alcohol policy given the diverse nature of alcohol problems, styles of drinking, and the normative context in which problems are ascribed to the use of alcohol. The authors note the diversity of policy solutions, or attempts at solutions, which prevail and argue that there is now a need to review progress and reformulate policy with an eye toward the future. There are now better data on causes of unhealthy drinking as well as the consequences of different drinking patterns, and, they argue, the political climate is right for changes in policy. This sets the stage for the remainder of the text and ultimately the concluding chapter identifying specific policy recommendations.

Part one of the text, in addition to laying the groundwork for the remainder of the book, reviews trends in alcohol-related mortality around the world. It also provides some international data on the social and economic costs of unhealthy drinking. Trends in alcohol consumption are described. Also noteworthy is their discussion of the considerable variation in drinking patterns and health outcomes in different nations-and in many cases, even between countries with similar economies and demographic characteristics.

Part one also includes a review of current research on the association between different measures of individual drinking behaviors and adverse consequences. Data linking population-level measures of alcohol use patterns and health outcomes are also described. The authors discuss the research challenges posed by lack of a standard measure of alcohol use, poor data collection in some nations, and different methods of data collection, which make comparison difficult from study to study.

Part two of the text reviews various policy options and their relative strengths and weaknesses. This section is well-researched, easy to follow and very thorough. I t includes an assessment of the efficacy of alcohol taxation and various pricing policies. Policies designed to prevent alcohol use, or misuse, under certain conditions (e.g. drunkdriving laws, minimum legal drinking age, server laws, etc.) are also described and discussed. One chapter in this section reviews treatments for alcohol-related problems and the role of such programs in an overall, comprehensive, alcohol policy. Part two concludes by reiterating and summarizing earlier arguments for the tractability of alcohol problems and the importance of coherent, well-informed policy toward that effort. They identify characteristics of an effective policy. Issues salient to particular nations (e.g. lesser developed countries) are noted. Sample program or policy options are suggested and those most likely to be successful, in the short and long run, are identified.

Following part two of the text is an appendix identifying the need and opportunities for future research. It is a summary of the gaps in current knowledge and may help guide individual agencies in distributing funds solicited for alcohol-related research endeavours.

Alcohol Policy and the Public Good, while written for those in a position to develop policy, it is not a ‘how to’ book (it does not discuss development of constituencies or getting a policy implemented). Rather, it is a reference book, providing good background information about the causes and nature of alcohol problems, relevant policy choices, their pros and cons, and possible future directions for alcohol research to take. It is a good choice for policy makers seeking general information, and who want a ‘big-picture’ international perspective on alcohol consumption and related problems as well as ideas about ways to solve these problems. It should be useful in setting research priorities and, thus, may also be a good resource for individuals responsible for the distribtuion of funds for alcohol- and/or health-related research.

NICOLE BELL Social Sectors Development Strategies, Inc.

Boston, Ottawa and St Lucia

BOOK REVIEWS 3 63

JOHN HUMPHREYS and FRANCIS M. QUINN, Health Care Education: The Challenge of the Market, London: Chapman & Hall, 1994. Price €16.99.

This title is certainly not for leisurely reading. Every chapter means serious business. I would liken the book to an extremely nutritious diet. Every paragraph is so rich in content that it is worth slowly chewing and digesting for proper absorption and utilization.

The authors are clearly focused on the contemporary problems surrounding health education. They have put forward challenging, yet convincing arguments about current issues. The concepts and terms that commonly trouble novice health educators and managers are clearly and adequately explained in the book. Examples are ‘pedagogy versus andragogy’ (Chapter I), APEL, CAT, NVQ (Chapter 2) and ‘the reflective practitioner’ (Chapter 3). The inclusion of various professions like nursing, midwifery and physiotherapy enables a broader vision to be developed about general principles in health education.

The incorporation of case studies chapters greatly enhances the value of the book. The authors have carefully and adequately illustrated not only the educational and management concepts, but also how these concepts can be utilized in practice. For example, in Chapter 8, the authors guide the readers from the explanation of marketing concepts in health education through the changes of a corporation to the development of quality. Despite the different cultural and contextual backgrounds, the experience discussed in the chapter serves as a guide and a model in the evolution of any organization in other parts of the world.

In Hong Kong, the formation of the Hospital Authority in the early nineties has seen the adoption of business principles to the health care sector. Health care education is not carried out in an ivory tower, but rather in an open system affected by the currents of continuing change. Amidst the growing awareness of issues such as client satisfaction, value-added practices and business process re-engineering, this book is an invaluable companion to health care educators, managers and policy makers.

One minor point, though, in the Index section on p. 175, the full term for PREP should be ‘Post-registration education and practice’.

ROSA CHOW School of Midwifery and Continuing Nursing Education

Hong Kong

M. PARMAR and D. MACHIN, Survival Analysis: A Practical Approacb, Chichester: John Wiley and Sons Ltd, 1995, 255 pp. Price €29.95 (hb).

The text is aimed at researchers working in medical statistics and so is not specifically for statisticians. However, it is likely to appeal to statisticians inexperienced in the use of survival analysis and to trainee statisticians.

This book starts with a simple and non-mathematical introduction to survival analysis. Although it assumes some knowledge of basic statistics, it does cover basic concepts in the first chapter, which makes it more accessible to the general researcher. After looking at the general ideas behind survival curves, it then proceeds into more advanced territory. First, it examines the importance of the exponential and weibull distributions and then extends the analysis beyond single survival curves into looking at two or more groups.

An in-depth look at Cox’s Proportional Hazards model then takes the basis for most of the rest of the text; starting with a general building up of the model using different types of variables (binary, categorical, etc.) and it includes the selection of variables for

364 BOOK REVIEWS

the model. The authors then introduce variables whose values may change over time (‘time dependent’ variables) and use the model to determine prognostic indices so that patients can be classified into different risk groups.

It is good to see that this is followed by a chapter dedicated to the important topic of determining sample sizes for survival studies as well. The text ends with a chapter dedicated to ‘miscellaneous topics’ in which ‘ . . . standard survival analyses have been adapted to allow different analyses to be performed’ (p. 208). These include topics such as meta-analysis and sequential trials.

There is an extensive list of references, although it would have been beneficial to have provided a list of further reading at the end of each chapter for the interested reader.

All through the text there is good use of examples from the literature to explain the various procedures, making their understanding easier. This gives the text a much more practical approach. Although the authors have aimed to make the book as non- technical as possible, obviously the subject itself demands that they can only go so far down this road and, therefore, readers would benefit from having a reasonable basic statistics background.

It is a little disappointing that there is not more description or examples illustrating the use of statistical computer packages relevant to survival analysis but, even so, the book is highly recommended for anyone setting foot into the clinical research area.

KELVIN JORDAN Centre for Health Planning and Management

Keele University, UK

BOOKS RECEIVED: AN ANNOTATED LIST

CROMBIE, I . with DAVIES, H., Research in Health Care, Chichester: Wiley, 1996, 302pp. Price E14.99.

Health services research has attained new prominence in many western countries. In the British context it has become a high priority with the move towards evidence-based care. Many health care professionals are, however, insufficiently trained in carrying out scientific research methods or in properly interpreting research findings. This book aims to provide guidance to these important areas and provides a practical approach to ‘design, conduct and interpretation of health services research’, as its sub-title states.

The authors basically tackle the questions of what (to do to conduct successful research), why (it needs to be carried out in a particular way) and how (can this be achieved) of research. After addressing general issues such as the nature of research, developing research questions and reviewing the literature, the book discusses a number of key approaches; surveys, cohort studies, clinical trials, case-control studies and qualitative methods. Links are made with other disciplines such as health economics, psychology, medical sociology and health promotion. Practical issues in design, data collection, data analysis and communicating the findings form the closing chapters of this useful book.

KASONDE, J . and MARTIN, J. (Eds), Experiences with Primary Health Care in Zambia, Geneva: World Health Organisation, 1994, 118 pp. Price Sw.fr.26 (in developing countries Sw.fr. 18.20).

Since the International Conference on Primary Health Care in 1978, continued international debate has taken place concerning the question of whether PHC has been

BOOK REVIEWS 365

a success or failure. Yet, much wider questions have to be posed relating to the degree of economic development of individual countries and their ability to sustain PHC within this broader developmental framework. In the introduction of this book it is argued that ‘the principles of PHC are guidelines whose application will increase a country’s ability to achieve health for all, but only within the parameters of its own economic realities’.

There are examples world-wide that PHC can work, and that lessons can be learned from these specific successes. This edited collection on Zambia provides some examples of both successes and continuing difficulties. Particular attention is given to the need for a clear national policy, strong management capabilities and commitment to PHC implementation, decentralization in order to get closer to local concerns, active community participation, sustained financing and making health technologies affordable to poor people. The chapters, discussing specific issues and projects can be assessed against the above principles in order to gauge whether they constitute a PHC

Contributions range from planning, design and implementation of PHC in Zambia, the experience of an NGO, Oxfam, in working within Eastern province, the Kaputa project, which aimed to meet local health needs by using available professional and community resources, community involvement in AIDS care in a rural hospital, management development in primary care, monitoring and evaluation in PHC to examining the role of traditional healers. The last two chapters evaluate the lessons learned and attempt to map out the future for Zambia’s health system. By focusing on many aspects of PHC in one country, Zambia, a more in-depth analysis has been possible and, as such, this book offers an important contribution to the debate as to the role of PHC in developing countries.

success.

PERCY-SMITH, J. (Ed.), Needs assessment in public policy, Buckingham: Open University Press, 1996, 149pp. Price €12.99.

The starting point of this edited collection is that meeting needs is the prime function of public services. Needs assessment itself is still developing, but several authors have warned that it should not be used to hide the fact that in many countries public resources are becoming tighter and that the question of equity remains important. The collection is concerned with drawing together needs assessment work from various policy areas and through the use of case studies to highlight theoretical and conceptual issues. The focus is on how to define need, methods used to assess needs and the relationship between need and services.

The broader context is sketched in Part 1 with chapters on the theory and practice of needs assessment, the centrality of the needs debate in public services and methodologies used for needs assessment. Part 2 brings together case studies from community care, health, housing, legal services, labour market and training needs. A number of themes are outlined in the short concluding chapter, such as meeting needs as a criterion of effectiveness and whether a coherent theory of need underpins policy development. The skills and methods available for needs assessment are still developing, which limits the scope and impact of needs assessment. However, this book demonstrates that a focus on needs is essential to more effective public services.