International Journal of Epidemiology 2003;32:323
© International Epidemiological Association 2003
Book Review |
Distributing Health Care. Economic and Ethical Issues.
Paul Dolan and Jan Abel Olsen. Oxford: Oxford University Press, 2002, pp. 153, £27.50. ISBN: 0-19-263253-1.
Since most health economics articles outside the specialist literature deal with issues surrounding economic evaluations, there is a danger that recent theoretical and empirical work outside the field of economic evaluation is ignored by clinicians and health services researchers. However, for many researchers wishing to gain a better understanding of health economics there are few texts which set out in an accessible manner the principal efficiency and equity issues inherent in alternative methods of distributing health care. Many existing textbooks are written primarily for health economists and incorporate large chapters devoted to theoretical issues in microeconomics. Furthermore, these often focus on the US system and do not provide adequate reference to the philosophical underpinnings of European systems of health care.
The emphasis of this book is, therefore, on the distribution of health care in publicly funded systems. It provides an account of the economics and ethics of such systems which is readable but which does not oversimplify what are some very interesting philosophical and practical issues. The first chapter introduces the fundamental issue of what is health and how it can be influenced. In so doing it puts into context the focus that many economists maintain on the effects that health care can have upon the nation’s health. Given that health care is a scarce resource it is natural for the authors to present an exposition of demand and supply theory, which they do in chapter two in a succinct yet informative manner. Perhaps the only failing is that they do not explore sufficiently well the dependence of willingness to pay upon income, which would help strengthen their point that economics does naturally involve itself with distributional issues. In chapter three the authors explain the basis of utilitarianism, which underpins much of economics, and go on to show how alternative methods of espousing equity can be pursued.
In the next two chapters the reasons why markets might fail on efficiency and equity grounds are explored. This split is important because arguments over health insurance too frequently blur the two. Concepts such as the distinction between the individual as consumer versus the individual as citizen are introduced and should prove useful to researchers involved with the elicitation of preferences and priority setting in health care.
Chapter six describes how the financing and regulation of a health service can be maintained and introduces the problem of rising health care expenditure. This leads quite naturally into the practicalities of priority setting. Chapter seven deals with the principles of economic evaluation and explains issues such as the basis of quality adjusted life years (QALY) and the arguments for and against the discounting of future health benefits and costs. In the next chapter the authors go on to explore the difficulties in aggregating individual benefits to obtain some measure of societal welfare. Issues such as ageism and discrimination against smokers in the provision of health care are explored.
To conclude, the authors raise some final questions that health economists should address concerning how health care should be distributed in publicly funded systems. Attention is drawn to issues such as whether health or utility should be the maxim and the extent to which health economists should be concerned with non-health care interventions which influence health. They call for research into whether individuals do possess dual roles as consumers and as citizens and the normative issues that may result.
The book succeeds in explaining how health economics can be useful and how a better understanding of the depth of the problems that society faces in the distribution of health care can help us address problems in a systematic and incremental fashion. Whilst it is not intended to be a stand-alone health economics text, it provides useful references and web links for readers who wish to explore the issues raised in more detail. Furthermore, for health services researchers working in publicly funded health care systems, it is a remarkably comprehensive yet accessible text and should prove to be a valuable addition to their bookshelf.
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