Structural adjustment and health: A conceptual framework and evidence on pathways

Abstract

Economic reform programs designed by the International Monetary Fund and the World Bank-so-called 'structural adjustment programs'-have formed one of the most influential policy agendas of the past four decades. To gain access to financial support from these organizations, countries-often in economic crisis-have reduced public spending, limited the role of the state, and deregulated economic activity. This article identifies the multiple components of structural adjustment, and presents a conceptual framework linking them to health systems and outcomes. Based on a comprehensive review of the academic literature, the article identifies three main pathways through which structural adjustment affects health: policies directly targeting health systems; policies indirectly impacting health systems; and policies affecting the social determinants of health. The cogency of the framework is illustrated by revisiting Greece's recent experience with structural adjustment, drawing on original IMF reports and secondary literature. Overall, the framework offers a lens through which to analyze the health consequences of structural adjustment across time, space and levels of socioeconomic development, and can be utilized in ex ante health impact assessments of these policies.

Impact of International Monetary Fund programs on child health

“…However, this gap shrinks under programs. We offer some potential explanations of these observations by highlighting the broader relationship between IMF programs and the societal effects of austerity (5,7,13,32,(38)(39)(40). Our study raises four main questions.…”

“…The success of IMF programs and the degree of collateral damage they produce for public health is an ongoing controversy (2,(4)(5)(6). Already in the 1980s, the years of recession and omnipresent IMF programs especially in Africa and Latin America, the United Nations Children's Fund (UNICEF) cautioned against endangering vulnerable households and child health (7).…”

Access to health care in an age of austerity: disabled people’s unmet needs in Greece

“…Since late 2009, Greece has been dealing with the effects of a financial crisis and subsequent recession (Kentikelenis, 2017). In order to remain in the Eurozone and fulfil its fiscal responsibilities, the Greek state accepted three consecutive structural adjustment programmes/bailouts -in 2010, 2012 and 2015 -from the International Monetary Fund (IMF), the European Commission and the European Central Bank, collectively known as the Troika.…”

“…In order to remain in the Eurozone and fulfil its fiscal responsibilities, the Greek state accepted three consecutive structural adjustment programmes/bailouts -in 2010, 2012 and 2015 -from the International Monetary Fund (IMF), the European Commission and the European Central Bank, collectively known as the Troika. These programmes were guided by the neoliberal principles of deregulation, liberalisation, stabilisation and privatisation (see Kentikelenis, 2017 for an overview of these principles and their application in Greece), with the main requirement being a reduction of public spending through an austerity-driven fiscal policy. This led to what Labonté and Stuckler (2016, p. 313) described as a roll-back of health and social protection spending and a 'roll-out of neoliberalism' .…”

The enduring influence of institutions on universal health coverage: An empirical investigation of 62 former colonies

“…These organizations may bend the trajectories established by colonial legacies and, in some cases, may even create 'critical junctures' that set these countries and their institutions on new paths (Thelen 2003). There is still debate concerning whether, how, and under what circumstances international financial institutions affect health, with some documenting negative effects (Coburn, Restivo, and Shandra 2015;Daoud et al 2017;Kentikelenis 2017;Stuckler et al 2008) and others suggesting their influence on health is largely positive or at least benign (Gupta 2015(Gupta , 2017. More recent work, has illuminated how the impact of these international organizations may be contingent on the institutional forms already established within countries.…”