Market Menagerie: Health and Development in Late Industrial States by Smita Srinivas (review)

Smita Srinivas's book comes with an arresting title, commendations from senior scholars on the dust jacket, and high expectations raised by her earlier empirical work on the pharmaceutical industry. Indeed, Srinivas's starting point holds promise: while India has developed a notable pharmaceutical industry, the access to health care for the bulk of Indians is precarious, for a range of reasons. For example, poor infrastructure (she mentions electricity cuts, water shortages, and an overall lack of public health facilities [p. 122]) makes the delivery of both preventive and curative health-care inputs to rural areas a matter of chance. The book promises to explain the reasons for this bias, whereby policies that so successfully encouraged indigenous drug production accompanied haphazard and fitful initiatives in the provision of health care. It appears as if the Indian government considered that the moral demands of a welfare state required only the production of cheap drugs; all else was left to the individual supplicant of medical care.

To answer the question she poses, Srinivas uses three data sets: material drawn from secondary sources on the macro-historical evolution of the drug industry; her own interview-based survey of industrial units; and, finally, a sort of potted history of health-care initiatives from various parts of the world. The incoherence marking the book stems from the mismatch of these data sets; there is no narrative fluidity in the transitions from one section to the next, leaving a reader with vague impressions of fleeting strings of words. Srinivas's attempt to knit together this data through the use of the menagerie image (of markets and states) of the title fails to provide a compelling forward thrust to her narrative. By "menagerie," she implies that actually existing markets are of various institutional forms, as are states, rather than the singular entities she posits that scholars in development studies often presume.

This idea is well-taken, although it is hardly novel. Much of the empirical part of this book, dealing with India, is presented in a straightforward manner that obviates the need for the throat-clearing that takes place in the first fifty pages. Once we reach the central section (chapters 2-7), it appears to the reader that prospects are improving, based on the historical account and the field-survey results mentioned earlier. Srinivas points out that pharmaceutical policymaking is located in the Industry Ministry (under its various names). This ministry has the political clout to determine production priorities that diverge from the goals of the comparatively feeble Health Ministry. Also, it seems that international vaccine-procurement programs led by WHO, while expanding markets for Indian pharmaceutical products, also have initiated technological advances within the industry. However, the direction of technological advance has not necessarily been such as to improve the health-care prospects of the Indian population. This last insight is a genuine contribution made by the book. However, Srinivas omits even to attempt to explain why the Health Ministry has (apparently) a congenital history of political ineffectiveness.

Among the ex-colonial countries, India is one of the few to have achieved independence under the pressure of a mass movement. To give meaning to this movement, the Indian National Congress, in 1929, began elaborating on its vision of society in an independent India. The National Planning Committee established by the congress in the late 1930s had a specific subcommittee on health. The point here is that in India, one would expect that there would have been political support for a universalized health-care system, which would have pushed developments in the drug industry along socially approved lines. That this did not happen is a historical fact, and there is sufficient secondary literature concerning this subject. Similarly, there is no mention of the more recent initiatives undertaken by the post-1991 neoliberal-policy regime: National Commission on Macroeconomics and Health (2005), National Rural Health Mission (2006), and National Health Insurance Programme (2008). That...