IMF programs and tuberculosis outcomes in post-communist countries

Jul 22 2008

International Monetary Fund (IMF) loans were associated with a 16.6% rise in death rates from tuberculosis (TB) in the former Soviet Union and Central and Eastern European countries between 1992 and 2002, finds a study in this week's PLoS Medicine.

The study, by David Stuckler and colleagues from the University of Cambridge, UK, and Yale University, USA, also found that IMF loans were linked with a 13.9% increase in the number of new cases of TB per year and a 13.2% increase per year in the total number of people with the disease.

Between 1992 and 2002, most of the countries studied in this analysis received IMF loans for the first time. As Stuckler and colleagues note, "According to the IMF, the objective of these programs is to achieve macroeconomic stability and economic growth...", yet a recent report from the Center for Global Development has suggested that countries receiving IMF loans may constrain spending on health and social services. For example, countries receiving IMF loans might need to reduce social spending in order to meet the targets set as a condition of the loan, and do so by placing caps on public wage bills or by privatizing healthcare services. However, previously it has not been clear whether IMF loans are actually linked to any changes in measurable health outcomes.

For their analysis, Stuckler and colleagues used data on health outcomes from the World Health Organization (WHO), and IMF data from the World Bank's World Development Indicators. They set up models to test whether entry to, and exit from, IMF programs was linked with changes in TB outcomes in these countries, while controlling for other factors that might have had an effect (such as the level of economic development, financial desperation, HIV/AIDS, and so on). The authors also tried to understand what mechanisms might be responsible for the increase in TB death rates that they found. Using a separate set of models, the authors suggest that IMF programs are linked to an 8% drop in government spending, a 7% drop in the number of doctors per head, and lower coverage of TB control using the "directly observed treatment, short course" (DOTS) strategy recommended by the WHO. Together, these findings suggest that countries receiving IMF loans make cutbacks in their TB control infrastructure and that this might be responsible for the increase in TB death rates.

In an expert commentary on the study, Megan Murray and Gary King from Harvard University, USA, who were not involved in the study, discuss the difficulties involved in doing such research and the conclusions that can be drawn from the findings. Despite the key limitations they outline (in particular, the fact that IMF loans are not randomly assigned, but are likely given to countries which are "doing badly" economically), they conclude: "we are convinced that at least the authors went very far in testing assumptions and mitigating uncertainties, and so the study and its conclusions should be taken seriously."

Before applying these findings directly to policy, it would be important to understand whether IMF spending has an effect on health outcomes other than TB, and also to more clearly understand the possible mechanisms which link these loans to worsened health outcomes

http://medicine.plosjournals.org/