While falling short of claiming that the World Bank and the IMF kill people, a massive study on the social determinants of health by the World Health Organisation (WHO) and another on tuberculosis treatment in Eastern Europe each fault the IFIs for exacerbating inequality in access to health care.
The WHO’s Commission on the Social Determinants of Health (CSDH) released its findings at the end of August after a three-year programme of research and analysis. It found that the “toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible.”
The commission saves overt criticism of the World Bank and IMF for its discussion of global governance, where it critiques the lack of democracy in the institutions; but the report also faults the lack of investment in universal health care systems and primary health care. As a result of reforms pushed by “a combination of international agencies, commercial actors, and medical groups whose power they enhance” the report finds “on the one hand an increasing commercialisation of health care, and on the other, a medical and technical focus in analysis and action that have undermined the development of comprehensive primary health-care systems that could address the inequity in social determinants of health”
Its recommendations imply: “a need for changes in the interactions of national economies with global markets, and in the activities of international institutions, for example, WTO agreements and IMF- and World Bank-supported programmes.”
Specifically the commission echoes civil society concerns about the budgetary limitations set by the IMF (see Update 57, 56, 51) through the use of the medium-term expenditure framework (MTEF) as part of the Fund’s lending. “Although not explicitly placing a cap on recurrent costs such as recruitment and salaries for much-needed health-care staff, the MTEF has been found to discourage such expenditure, leading to underinvestment in the human capacity critical for health-care systems.”
“The report draws attention to the need for universal and integrated health systems that allow cross-subsidisation and risk pooling,” commented David McCoy a senior research fellow at the University College London’s Centre for International Health and Development. “In addition, it stresses the inherent failures of health care markets and thus calls greater emphasis to be placed on strengthening effective and democratically accountable public institutions in the health sector. Without saying so directly, the CSDH rejects the neoliberal basis of much World Bank policy in the health sector”.
David Woodward, a development consultant and member of one of the knowledge networks that fed into the report, called it “an extraordinarily radical agenda” for such an international commission. “Despite its specific criticisms of both their policies and their governance systems, neither the IMF nor even the World Bank has so much as acknowledged the existence of the report. But their silence speaks volumes. It makes it quite clear that they have no interest in pursuing findings which differ from their own agendas – even when these are backed up by an impressive array of evidence, compiled by nine knowledge networks of leading global experts in relevant fields. So now it is up to civil society to take up the gauntlet, to develop a shared vision of a global economy ‘as if people matter’, and to demand change.”
World Bank health strategy slipping
The Bank’s new strategy for the health nutrition and population (HNP) unit (see Update 60, 56), focused on strengthening health systems rather than supporting disease-specific approaches. However, implementation of the strategy has gone nowhere, according to a senior European official at the Bank, because the HNP team simply does not have the expertise nor staff to implement it. The official blamed senior management and entrenched ideas on health for preventing resources being allocated; especially after record IDA subscriptions (see Update 59). A planned September update to the executive board on strategy implementation was delayed and has not yet been rescheduled.
This view that the Bank is not on track was echoed by former and current ministers of health from developing countries in a preliminary report of a May meeting of a high level working group coordinated by the global economic governance programme of Oxford University. The report of the group – which includes ministers from Indonesia, Tanzania, Uganda, and Kenya – says, “The World Bank was cited by several ministers as a very poor donor, dictating how money is used, how programmes should be implemented, and how evaluation and monitoring should be undertaken.”
The IMF and tuberculosis
The IMF has been reeling from a paper in a peer-reviewed medical journal that links IMF loans to increased mortality from tuberculosis. The paper, published in July in the Public Library of Science by David Stuckler and Lawrence King of Cambridge University and Sanjay Basu of Yale University, studied health outcomes in 21 post-communist countries between 1992 and 2002. It found that “IMF economic reform programmes are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries.”
The authors did not claim that the IMF spread tuberculosis, but instead theorised that countries with IMF programmes spent less on public health and thus saw worse outcomes. Perhaps as telling as the study was the IMF’s quickly issued rebuttal, with one Fund official calling the study “phoney science”. The Fund seemed more interested in damage control in the media than trying to learn from the research.
In a detailed five-page response to the IMF’s criticisms, the study authors describe the robust analytical approach they used including controlling for dozens of other variables, the use of control groups and the use of time-series data. They also note that the IMF’s claim that IMF programmes are associated with increased health spending only refers to the health spending as a percentage of GDP and not the actual amount of money supporting the health system.
Study author Basu commented, “the reason we use such heavy statistics is precisely to factor in other issues – incarceration, HIV, changes to the economy, changes to the healthcare infrastructure. We found a statistically independent effect of the IMF.”