There is an established tradition of comparing the economic performance of Latin America to that of various parts of Asia, but less has been done to develop regional comparisons of welfare performance. James McGuire's book does much to fill this gap and will also be of interest to anyone concerned with the relationship between politics and public policy. This is an ambitious volume, both in terms of its geographical scope and the scale of the issues it addresses. McGuire's fundamental question is whether democracy can be demonstrably linked to improved health outcomes for the poor. His answer is that it can.
Chapter 1 reviews orthodox explanations of mortality decline, including the ‘wealthier is healthier’ view and the effect of total public health spending. It also justifies the book's focus on child mortality, with reference to wider indicators of well-being, human capability and development. This is followed by a chapter providing a multiple regression of key factors understood to be associated with mortality reduction across 105 low- and middle-income countries in 1990. As well as the conventional socio-economic factors (female education, nutrition, and so on), McGuire includes a set of political determinants based on the quality of democracy (including electoral competition, executive power concentration and strength of opposition). Interestingly, these show that democracy is associated not with overall levels of health spending, but rather with higher rates of utilisation of the sorts of basic services that do the most to reduce infant and child mortality. Put simply (and doing some injustice to the sophistication of McGuire's argument), he demonstrates that ‘democracy’ (according to his criteria) is good for pro-poor health policies.
This large-scale comparative analysis is followed and complemented by eight country chapters, which provide case studies of four Latin American countries (Argentina, Chile, Costa Rica and Brazil) and four Asian ones (Taiwan, Thailand, South Korea and Indonesia). These country studies form the main part of the book and provide a satisfying combination of statistical analysis and more informed and nuanced work. McGuire selects countries that do not fit neatly into the predictions of his regression analysis and explores mortality trends over a 50-year period. A final chapter includes some comparative analysis of the case studies and relates them back to the quantitative analysis.
Each country chapter follows the same structure. Initial sections review available data on growth, poverty and mortality rates. This is then followed by a discussion of the wider determinants of infant and child mortality, such as access to education, nutrition and sanitation. Each chapter then focuses on health services, providing an overview of the health sector (including its historical development) and assessing the extent to which it has helped or hindered infant mortality reduction. Finally, each chapter examines the wider political drivers of health services and public policy, including the development of democratic traditions, the role of interest groups and the strength of pro-poor electoral incentives. By following this structure, each chapter provides a comprehensive and sure-footed analysis of mortality trends linked to wider national development experiences.
McGuire's main argument is that infant mortality rates, as well as other health outcomes, are significantly determined by the provision of cheap, basic and relevant health services to the poor. He rightly observes that these services are easily affordable, regardless of national economic performance, but that different countries have implemented them to varying degrees. McGuire argues that this variation is primarily driven by political factors and that, defined broadly, an established democratic tradition is associated with better service provision for the poor.
McGuire's thesis stands up remarkably well against the wealth of evidence reviewed in the book, and I had no sense that evidence had been filtered to support it. McGuire recognises that the link between electoral politics and health for the poor is neither inevitable nor simple. In the case of Argentina, for example, the dominance of Peronism reduced genuine competition for the votes of the poor and hence the urgency of pro-poor health policies. Labour aristocracies can capture notionally democratic regimes and promote policies focused on relatively privileged groups. McGuire does not deny that non-democratic regimes, most notably Chile under Pinochet, did rather more to reduce child mortality than their democratic predecessors, although he attributes much of the credit for this to the establishment of democratic traditions over previous decades. Rather than weakening McGuire's main argument, demonstrating the complexity and, in many cases, indirect nature of links between democracy and pro-poor health policies makes his position more nuanced and persuasive.
In fleshing out his main argument, McGuire makes a large number of important and sometimes original observations. For example, he questions the widely held view that decentralising health services enhances outcomes, showing that this is context-dependent. He shows that Indonesia's decentralisation has probably done more harm than good, leading to a shortfall of funding at the local level and a disconnection between central policy-making and local implementation. Brazil's decentralisation appears to have done more to enhance outcomes, but was linked to the establishment of a unified, universal health system and upgraded resourcing. McGuire questions the usefulness of health insurance in enhancing access to basic services, observing that it can deflect resource allocation to less essential services. This focus on the supply of basic service provision challenges a strong demand-side bias in global health policy. More generally, the discussion of influential individuals such as Chile's Miguel Kast and Brazil's José Serra, and of issue networks, is both revealing and fascinating. The Asian chapters are less rich in this respect, but this is understandable since McGuire's main expertise is in Latin America.
Given the importance of the issues it addresses and the range and depth of its analysis, this book is a must-read for anyone interested in public health and development, or the relationships between political processes and social policy. It will be going straight to the top of my course reading lists.
