606 Book reviews

REFERENCES Collins, P. D. (1989). ‘Strategic planning for state enterprise performance in Africa: public

Heald, D. A. (1990). ‘The relevance of privatisation to developing countries’, Public Adminis-

Hemmings, R. and Mansoor, A. M. (1988). Privatisation and Public Enterprises, International

versus private options’, Public Administration and Development, 9,65-82.

tration and Development, 10,3-18.

Monetary Fund, Washington, D.C., (occasional paper 56).

PAUL D. COLLINS Management Development Programme,

United Nations Development Programme New York

HEALTH INSURANCE IN DEVELOPING COUNTRIES. THE SOCIAL SECURITY APPROACH Aviva Ron, Brian Abel-Smith and Giovanni Tamburi International Labour Office, Geneva, 1990,231 pp.

Financing for health care in developingcountries has, over recent years, become well recognized as a major policy issue. Attention to this area is increasingly being given both by academics and by international agencies, in particular the World Bank, with its Agenda for Reform, WHO and UNICEF with the Bamako Initiative. The policy thrust of these bodies is predomi- nantly towards community-based financing or user-charges, often linked to mechanisms such as revolving drug funds.

The ILO has also had an interest in the issue for many years, but with a particular interest in the social security approach (and its links with employment) which stems from that agency’s area of work. This book stems from an ILO Asian Region seminar held in 1989 which focused on social security. However, the book is far more than a seminar report. Part I, which comprises slightly more than a third of the book, provides the background, with chapters setting out the historical evolution, types of system, benefits, options, payment mechanisms and the organi- zation of social security. Part I1 comprises 16 country profiles in Asia. In addition, there are three annexes including a useful glossary.

For newcomers to the field, the first part is an extremely useful and readable introduction to the subject. The complexity of social security is well brought out, together with the large number of possible variations and permutations in approach. Despite the useful wealth of detail, the reader is still left with a clear overview of social security.

As a primer on the subject I would thoroughly recommend it. In particular its easy style will endear it to policy-makers who will find it an accessible source of information. There were three areas, however, that were perhaps neglected and to which I would have liked to have seen more space devoted.

For most developing countries the major difficulty in providing cover and ensuring payment for health care in a public rather than a private way stems from the dual nature of dispersed rural populations and a large informal or semi-subsistence ill-paid labour force. Development of social security in such countries poses particular problems of either limiting schemes to a small and normally elite workforce, with the equity implication inherent in this, or developing costly payment mechanisms. Whilst it may be argued that the resultant short-term inequities are an acceptable price to pay for the longer term economic benefits of a healthy workforce, this is by no means obvious. None of the alternative financing options open to developing countries is simple to assess. The application of the criteria often used for assessing the impli- cations of different systems+quity, efficiency and net revenue generating ability-give ambi- guous results. Which alternative system is adopted will depend largely on the ideological position and value judgements of the policy makers of a country.

It is perhaps fair to say that the book was written by social security evangelists and, in this sense perhaps, played down some of the inherent difficulties of such systems. However, for policy makers contemplating new means of financing health care, a chapter comparing social security as an approach to alternatives would have been welcome.

Book reviews 607

Secondly, one of the interesting features of social security as a source of finance is its potential to provide health care as one component of a wider integrated welfare system. The potential advantages of this could also have been usefully addressed.

The regional case studies included in Part I1 varied considerably in detail ranging from two to 12 pages and the connections with Part I were not always clear. Whilst the inclusion of country information is very helpful in such a book, future editions might consider bringing the key aspects, explored in Part I, together in tabular form, allowing both easy comparison of different systems and illustrating the wide diversity in existence.

Lastly, though Part I dwelt in general terms with social security, all of Part I1 related to Asia and the Middle and Far East. Whilst the context of the origin of the book explains this regional bias, a number of Latin American countries have had a long history of such schemes and exclusion of these meant that readers were denied the opportunity to learn from such experiences.

However, these are minor points of omission. To students in general, and policy makers in particular with an interest in the key area of health care financing, the book is recommended.

A. GREEN Head of the International Division

Nufield Institute for Health Services Studies University of Leeds

OUTPUT AND PERFORMANCE MEASUREMENT IN GOVERNMENT: THE STATE OF THE ART Martin Cave, Maurice Kogan and Robert Smith Jessica Kingsley Publishers, London, 1990, 191 pp.

Few governments were immune from the managerialist trend of the 1980s, but few pursued it with the vigour of the Thatcher Administration in Britain. The dominant model in public administration became that of the firm in the market place: civil servants were increasingly regarded as ‘managers’ responsible for ‘businesses’ delivering services to ‘consumers’. The buzzword was performance (defined in terms of the ‘three Es’-conomy, efficiency and effec- tiveness): public managers were exhorted to set clear objectives and develop measures to evaluate performance against those objectives. This has resulted in a proliferation of perform- ance indicators. Indeed, as Pollitt observes in this timely book about the development of performance indicators in Britain, their absence has become the exception among public services. Although widely resisted, especially by professional groups, the increasing use of new technology has improved the reliability of information systems and allowed some managers to use indicators as an instrument of ‘hands-off managerial control over service delivery. However, as the book reveals, many problems remain. Designers of performance indicators face complex conceptual and technical constraints. The implementation of performance indicators often generates serious organizational maladies, such as goal displacement, gaming and a lowering of morale.

This book contains a mixture of practitioner and academic contributions. The inputs of the practitioners are informative if largely uncritical. The academic chapters frequently read like conference papers, making interesting observations, stimulating good discussion points but lacking penetrating analysis. The case studies work best, particularly Cave and Hanney on higher education and Burningham on planners in local government (which is probably of particular interest to an LDC audience). However, this undisguised ‘book of a conference’ does lack coherency. Consequently, without a comprehensive overview of the findings the reader could be forgiven for still wondering just what is the ‘state of the art’ in performance measurement.

N. CARTER University of York