HEALTH ECONOMICS

Health Econ. 7: 183 (1998)

BOOK REVIEW

BOOK REVIEW

An introduction to Health Economics for Eastern Europeand the Former So6iet Union by S. WITTER and T.ENSOR. John Wiley & Sons, Chichester, 1997. No. ofpages: 202. ISBN 0-471-96663-0.

Health economics textbooks seem to have proliferatedrecently, so a home-grown product is welcome. For thoseof us teaching in public health schools with a sizeableproportion of students with no previous exposure toeconomics, it is also welcome to find a text that requiresno prior knowledge of economics.

After an initial chapter on microeconomics and mar-ket failure, sections are structured by major policy/man-agement area (financing, purchasing, providing, with afinal chapter on health reform), with chapters on specifictopics within sections (for example, the provider sectionincludes chapters on methods of payment, providerplanning and costing, contracting, option appraisal, andthe private sector). This structure leads to some odditiesin the presentation of both techniques and issues. Forexample economic evaluation has a chapter to itselfunder purchasing, but option appraisal has its ownchapter under providing. There are two separate discus-sions on user fees, in chapters 2 and 5, with no crossreferencing between them. The William’s diagram of thestructure of health economics makes a familiar appear-ance at the start, but it is clear that the aim of the bookis to introduce economic ideas in discussion of policy andimplementation issues and problems in this respect. Thetitle of the book is a bit misleading and the book drawsalso on other disciplines—as indeed it should given itsfocus on policy and management issues.

Inevitably with an introductory text, and especiallyone that discusses real-life issues, it is possible to quibblewith aspects of the presentation and content. The chapteron health care funding deals with the dilemma of theintimate relationship between financing and provision—whereby, it becomes difficult to conclude on the implica-tions of different funding systems without presuminghow services are provided and paid for—by confiningthe latter to a later chapter, not an entirely comfortablesolution. I was surprised that private insurance wasinterpreted by implication as solely the commercial typeinvolving risk-rating—perhaps a reflection of the book’sgeographical focus. In other parts of the world privateinsurance organised by NGOs and community-basedgroups is of relevance. While the policy and managementfocus is valuable, I found myself at times wanting rather

more systematic presentation of certain key concepts—such as horizontal and vertical equity, for example. Textboxes are encountered for the first time in this chapter,but without explanation or indeed reference in the text,making it somewhat unclear why material is presented ina box. The fact that the box concerns medical savingsaccounts in Singapore and is placed within a section onmanaged care adds to the confusion.

I would have liked to have seen a more extensivediscussion of user charges, and acknowledgement ofsome of the dangers in trying to structure them toinfluence demand. For example, it is suggested thatrevenue should be retained largely by the facilities, andthat charges should be lower for more effective treat-ments. However, there is evidence from other parts of theworld that in such a situation providers may supply moreof the higher priced services because they generate morerevenue.

The chapter on economic evaluation of health care setsitself an ambitious agenda to cover the main techniquesof economic evaluation, including practical examples, ina single chapter. I was disappointed at the start by thefocus on clinical health services. Economic evaluationtools have a much broader scope for application and Iwould have preferred a treatment of the subject whichpermitted ready discussion of preventive and promotiveprogrammes, as well as broader policy changes thatpromote health (such as alcohol and smoking controlpolicies). The importance of these policies is recognisedin the Introduction, but not in this chapter.

The chapter on the private sector introduces a wel-come breath in its treatment of the topic. There isrecognition that simple distinctions between public andprivate are unhelpful, and for instance the chapterincludes consideration of decentralisation of manage-ment within the public sector. The final chapter on healthreforms successfully pulls the book together and makesclear the logic of its structure. I was left wishing that thischapter had come first rather than last in the book.

In conclusion, I am sure that this will be a useful textfor enabling health sector planners and managers toacquire some health economics knowledge while consid-ering policy and management issues. Given the scantreferencing and lack of extended treatment of theory, itis perhaps most suited for use in a short course or asintroductory reading at the start of a longer course.

ANNE MILLS

London School of Hygiene and Tropical Medicine

CCC 1057–9230/98/020183–01$17.50© 1998 John Wiley & Sons, Ltd.