Impact of International Monetary Fund programs on child health

Social fund and infant mortality: Evidence from an anti-poverty policy in Northeast Brazil

This paper evaluates the effects of a social fund that meets the needs of the poor in Northeast Brazil, the Fundos Estaduais de Combate e Erradicação da Pobreza (FECEP). The program could have improved infant health by reducing poverty and improving access to health care, sanitation, food, and housing. Using a difference-in-differences approach robust to heterogeneous treatment effects, we confirm that the program has effectively reduced poverty in treated areas. Furthermore, we document that this poverty reduction is associated with a significant decline in infant mortality. These findings provide consistent evidence that targeted public investments can improve living conditions in vulnerable regions.

The impact of austerity on children: Uncovering effect heterogeneity by political, economic, and family factors in low- and middle-income countries

Which children are most vulnerable when their government imposes austerity? Research tends to focus on either the political-economic level or the family level. Using a sample of nearly two million children in 67 countries, this study synthesizes theories from family sociology and political science to examine the heterogeneous effects on child poverty of economic shocks following the implementation of an International Monetary Fund (IMF) program. To discover effect heterogeneity, we apply machine learning to policy evaluation. We find that children's average probability of falling into poverty increases by 14 percentage points. We find substantial effect heterogeneity, with family wealth and governments' education spending as the two most important moderators. In contrast to studies that emphasize the vulnerability of low-income families, we find that middle-class children face an equally high risk of poverty. Our results show that synthesizing family and political factors yield deeper knowledge of how economic shocks affect children.

Decolonising the global to local movement: Time for a new paradigm

Mama Amaan Project (MAP) delivered perinatal education and doula services to underserved refugee and immigrant communities in Seattle, Washington. MAP presented at a 'global to local (glocal)' workshop for US-based global health agencies redirecting their experience and resources to address domestic health crises. Glocal models reference Global South anti-colonial social transformations through Primary Health Care (PHC) - 'health for all as a right' and investment in strong public sectors. As Black women working in our communities, we resisted labelling MAP glocal. Western donors and NGOs appropriate PHC's community participation narratives, meanwhile implementing World Bank/IMF economic structural adjustment health system cuts - thereby shifting austerity-related resource shortfalls to communities. In US contexts of neoliberal shrinking social safety nets and workers' rights, similar strategies to address austerity-related health disparities are promoted as 'global to local'. Projects like MAP cannot substitute quality public services. They expose gaps and build community empowerment to demand quality healthcare. Drawing on MAP and 'global health' experience in Mozambique, we call for re-embracing PHC's activist values - agitating for health as a universal human right for all, rather than putting the burden and blame on underserved communities. We propose decolonising the 'glocal' paradigm by embracing 'transnationality', 'relationality' and 'mutuality'.

The future of human malnutrition: rebalancing agency for better nutritional health

The major threat to human societies posed by undernutrition has been recognised for millennia. Despite substantial economic development and scientific innovation, however, progress in addressing this global challenge has been inadequate. Paradoxically, the last half-century also saw the rapid emergence of obesity, first in high-income countries but now also in low- and middle-income countries. Traditionally, these problems were approached separately, but there is increasing recognition that they have common drivers and need integrated responses. The new nutrition reality comprises a global ‘double burden’ of malnutrition, where the challenges of food insecurity, nutritional deficiencies and undernutrition coexist and interact with obesity, sedentary behaviour, unhealthy diets and environments that foster unhealthy behaviour. Beyond immediate efforts to prevent and treat malnutrition, what must change in order to reduce the future burden? Here, we present a conceptual framework that focuses on the deeper structural drivers of malnutrition embedded in society, and their interaction with biological mechanisms of appetite regulation and physiological homeostasis. Building on a review of malnutrition in past societies, our framework brings to the fore the power dynamics that characterise contemporary human food systems at many levels. We focus on the concept of agency, the ability of individuals or organisations to pursue their goals. In globalized food systems, the agency of individuals is directly confronted by the agency of several other types of actor, including corporations, governments and supranational institutions. The intakes of energy and nutrients by individuals are powerfully shaped by this ‘competition of agency’, and we therefore argue that the greatest opportunities to reduce malnutrition lie in rebalancing agency across the competing actors. The effect of the COVID-19 pandemic on food systems and individuals illustrates our conceptual framework. Efforts to improve agency must both drive and respond to complementary efforts to promote and maintain equitable societies and planetary health.

Therapeutic Borderlands: Austerity, Maternal HIV Treatment, and the Elusive End of AIDS in Mozambique

"End of AIDS" requires ambitious testing, treatment, and adherence benchmarks, like UNAIDS' "90-90-90 by 2020." Mozambique's efforts to improve essential maternal/infant antiretroviral treatment (ART) exposes how austerity-related health system short-falls impede public HIV/AIDS service-delivery and hinder effective maternal ART and adherence. In therapeutic borderlands-where household impoverishment intersects with health-system impoverishment-HIV+ women and over-worked care-providers circumnavigate scarcity and stigma. Worrisome patterns of precarious use emerge-perinatal ART under-utilization, delayed initiation, intermittent adherence, and low retention. Ending HIV/AIDS requires ending austerity and reinvesting in a public sector health workforce to ensure universal health coverage as household and community safety nets.

For the children? A mixed methods analysis of World Bank structural adjustment loans, health projects, and infant mortality in Latin America

Background

The World Bank wields immense financial and normative power in health in the developing world. During the 1980s and 1990s, in the face of intense criticism of its structural adjustment policies, the World Bank purportedly turned its attention to “pro-growth and pro-poor” policies and new lending instruments. One focus has been an investment in maternal and infant health. My analysis uses a mixed methods approach to examine the relationship between traditional structural adjustment and health loans and projects and infant mortality in Latin America and the Caribbean from 2000 to 2015.

Results

My answer to whether the World Bank’s projects in Latin America worked “for the children” is: somewhat. The results are heartening in that quantitatively, health projects are associated with lower infant mortality rates, net of controls, whereas traditional structural adjustment loans do not appear to be negatively associated with infant mortality, though examined across a short time horizon. Qualitative data suggest that infants, children, and mothers are considered in World Bank loans and projects in the context of an economic logic: focusing on productivity, economic growth, and human capital, rather than human rights.

Conclusion

Taken together, my results suggest that the World Bank appears to, at least partially, have amended its approach and its recent work in the region is associated with reductions in infant mortality. However, the World Bank’s economistic approach risks compartmentalizing healthcare and reducing people to their economic potential. As such, there remains work to do, in Latin America and beyond, if health interventions are to be effective at sustainably and holistically protecting vulnerable groups.

The Impact of Macroeconomic Policies on Healthcare Delivery in Kenya: An Analysis of the National Sexual Violence Prevention and Care Response

Sexual violence is one of the most common forms of violence against women in Kenya. This study documents the care of sexual violence survivors from the perspective of health care practitioners based on an analytic framework developed in studies of the political-economy of health to examine the effects of International Financial Institutions' conditionalities on the allocation of national fiscal resources. The study documented the working conditions of practitioners and myriad challenges that they experience in providing quality services to sexual violence survivors. The issues reflected in the results are grounded in social structural inequities driven by the global political economic policies that perpetuate poverty and dependency throughout Africa and the developing world. Macro-level variables associated with health care provision are assessed with a focus on global macroeconomic policies established by the International Monetary Fund and World Bank, their impact on Kenya's health economy and their ultimate impact on the capacity of the health system to meet the complex needs of survivors of sexual violence. In this paper, study results are analysed within the context of these macroeconomic policies and their legacy.

Childhood health and the changing distribution of foreign aid: Evidence from Nigeria's transition to lower-middle-income status

With sustained economic growth in many parts of the developing world, an increasing number of countries are transitioning away from the most subsidized development finance as they exceed income and other qualification requirements. Cross-country evidence suggests that Development Assistance Committee (DAC) donors view the crossing over of the World Bank's International Development Association (IDA) eligibility threshold to signal that a country needs less aid, with subsequent reductions in both IDA and other donors' concessional funding. Within the health sector, it is particularly important to understand the implications of these status changes for children under five years of age since improving early childhood health is critical to fostering health and social and economic development. Therefore, we examine the implications of the IDA transition by measuring the extent t which World Bank commitments—including both IDA and IBRD—are directed to infant and child health needs in Nigeria. Ordinary Least Squares (OLS) models were used in a difference-in-differences (DID) strategy to compare World Bank IBRD/IDA lending before and after the crossover to regions with varying initial levels of under-five and infant need. We find that the infant need orientation of World Bank aid has increased post-crossover. Conversely, alignment of World Bank commitments to regional child needs appears to have diminished after Nigeria crosses the IDA threshold. However, these effects are statistically insignificant and therefore provides inconclusive evidence. This research addresses an important policy question because the transition away from concessional funding mechanisms will result in difficult tradeoffs in allocating limited health resources; without providing conclusive evidence that crossover results in changes in need-based allocation, it does offer an essential path for future research. These results are directly relevant to policy debates about what we know and do not know about aid in transition and health. This research's value is especially important in the Sustainable Development Goal (SDG) era in understanding how donor exits could derail progress in health improvement.

Predicting women's height from their socioeconomic status: A machine learning approach

The social determinants of health literature routinely deploy socio-economic status (SES) as a key factor in accounting for women's height-an established indicator of human welfare at the population level-using traditional regression. However, this literature lacks a systematic identification of the predictive power of SES as well as the possible non-linear relationships between the measures of SES (education, occupation, and material wealth) in predicting variation in women's height. This study aims to evaluate this predictive power. We used the Demographic and Health Surveys (DHS) from 66 low- and middle-income countries (women = 1,273,644), sampled between 1994 and 2016. The analysis consisted of training seven machine-learning algorithms of different function classes and assessing their predictive power out-of-sample, vis-à-vis OLS regression. In an OLS framework, SES accounts for 0.7%, R2, of the total variance in women's height (from σOLSFix2 = 31.82 to σOLSSES2 = 31.57), adjusting for country, community, and sampling year fixed effects. The country-specific variances range from as low as 25.10 units in Egypt to as high as 74.46 units in Sao Tome and Principe. With the same set of SES measures, the best performing learner, a Bayesian neural net, produces a predictive variance of σBnnSES2 = 31.52. This is a negligible improvement in variance explained by 0.3% (σBnnSES2-σOLSSES2). Given our selection of algorithms, our findings indicate no relevant non-linear relationships between SES and women's height, and also the predictive limits of SES. We recommend that scholars report both the average effect of SES on health outcomes as well as its contribution to the variance explained. This will improve our understanding of how key social and economic factors affect health, deepening our understanding of the social determinants of health.

Testing the socioeconomic and environmental determinants of better child-health outcomes in Africa: a cross-sectional study among nations

OBJECTIVE

We sought to test hypotheses regarding the principal correlates of child-health performance among African nations based on previous evidence collected at finer spatial scales.

DESIGN

Retrospective, cross-sectional study.

SETTING

All countries in Africa, excluding small-island nations.

PRIMARY AND SECONDARY OUTCOME MEASURES

We defined a composite child-health indicator for each country comprising the incidence of stunting, deaths from respiratory disease, deaths from diarrhoeal disease, deaths from other infectious disease and deaths from injuries for children aged under 5 years. We also compiled national-level data for Africa to test the effects of country-level water quality, air pollution, food supply, breast feeding, environmental performance, per capita wealth, healthcare investment, population density and governance quality on the child-health indicator.

RESULTS

Across nations, child health was lowest when water quality, improved sanitation, air quality and environmental performance were lowest. There was also an important decline in child health as household size (a proxy for population density) increased. The remaining variables had only weak effects, but in the directions we hypothesised.

CONCLUSIONS

These results emphasise the importance of continued investment in clean water and sanitation services, measures to improve air quality and efforts to restrict further environmental degradation, to promote the UN's Sustainable Development Goal 3 target to '… end preventable deaths of newborns and children under 5' and Goal 6 to '… ensure access to water and sanitation for all' by 2030.

Globalization and health equity: The impact of structural adjustment programs on developing countries

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.

Structural adjustment, state capacity and child health: evidence from IMF programmes

BACKGROUND

Consensus is growing that policy reform programmes by the International Monetary Fund (IMF)-an international organization mandated with upholding global financial stability and assisting countries in economic turmoil-produce adverse effects on public health. However, this consensus is unclear about which policies of these programmes underlie these effects. This article fills parts of this gap by examining the impact of four kinds of IMF policies (fiscal policy, public-sector employment, privatization of state-owned enterprises and price liberalization) on public-health expenditure, child vaccination and child mortality.

METHODS

We conducted time-series cross-section analyses for up to 128 developing countries over the 1980-2014 period using observational data on health outcomes and IMF conditionality for different policy areas. IMF effectiveness research faces two types of potential biases: self-selection into IMF programmes and IMF policy conditions. We deployed instrumental variables in a seemingly unrelated regression framework to address both types of endogeneity, besides traditional remedies such as the use of fixed effects on countries and years.

RESULTS

IMF policy conditions on public-sector employment are negatively related to child health. A change from the minimum to the maximum number of such policy conditions decreases vaccination (which ranges from 0 to 100) by 10.97% [95% confidence interval (CI): 1.16 to 20.79]. This effect is robust against different sets of control variables. In addition, IMF programmes increase the share of government expenditure devoted to public health in developing countries by 0.91 percentage points (95% CI: 0.15 to 1.68).

CONCLUSIONS

These findings suggest that IMF policies-particularly those that require public-sector reforms-undermine health by weakening the capacity of states to deliver vaccination. Therefore, international financial institutions need to increase their awareness of the public-health impact of their policy prescriptions. Strengthening state capacity in times of economic crisis would ensure that increased health spending also delivers quality healthcare.

Stalls in Africa's fertility decline partly result from disruptions in female education

Population projections for sub-Saharan Africa have, over the past decade, been corrected upwards because in a number of countries, the earlier declining trends in fertility stalled around 2000. While most studies so far have focused on economic, political, or other factors around 2000, here we suggest that in addition to those period effects, the phenomenon also matched up with disruptions in the cohort trends of educational attainment of women after the postindependence economic and political turmoil. Disruptions likely resulted in a higher proportion of poorly educated women of childbearing age in the late 1990s and early 2000s than there would have been otherwise. In addition to the direct effects of education on lowering fertility, these less-educated female cohorts were also more vulnerable to adverse period effects around 2000. To explore this hypothesis, we combine individual-level data from Demographic and Health Surveys for 18 African countries with and without fertility stalls, thus creating a pooled dataset of more than two million births to some 670,000 women born from 1950 to 1995 by level of education. Statistical analyses indicate clear discontinuities in the improvement of educational attainment of subsequent cohorts of women and stronger sensitivity of less-educated women to period effects. We assess the magnitude of the effect of educational discontinuity through a comparison of the actual trends with counterfactual trends based on the assumption of no education stalls, resulting in up to half a child per woman less in 2010 and 13 million fewer live births over the 1995-2010 period.

The influence of maternal agency on severe child undernutrition in conflict-ridden Nigeria: Modeling heterogeneous treatment effects with machine learning

Nigeria is one of the fastest growing African economies, yet struggles with armed conflict, poverty, and morbidity. An area of high concern is how this situation affects vulnerable families and their children. A key pathway in improving the situation for children in times of conflict is to reinforce maternal agency, for instance, through education. However, the state of the art of research lacks a clear understanding of how many years of education is needed before children benefit. Due to mother’s differing social context and ability, the effect of maternal education varies. We study the heterogeneous treatment effects of maternal agency, here operationalized as length of education, on severe child undernutrition in the context of armed conflict. We deploy a repeated cross-sectional study design, using the Nigeria 2008 and 2013 Demographic and Health Survey (DHS). The sample covers 25,917 children and their respective mothers. A key methodological challenge is to estimate this heterogeneity inductively. The causal inference literature proposes a machine learning approach, Bayesian Additive Regression Trees (BART), as a promising avenue to overcome this challenge. Based on BART-estimation of the Conditional Average Treatment Effect (CATE) this study confirms earlier findings in that maternal education decreases severe child undernutrition, but only when mothers acquire an education that lasts more than the country’s compulsory 9 years; that is 10 years of education and higher. This protective effect remains even during the exposure of armed conflict.

International financial institutions and human rights: implications for public health

Serving as lender of last resort to countries experiencing unsustainable levels of public debt, international financial institutions have attracted intense controversy over the past decades, exemplified most recently by the popular discontent expressed in Eurozone countries following several rounds of austerity measures. In exchange for access to financial assistance, borrowing countries must settle on a list of often painful policy reforms that are aimed at balancing the budget. This practice has afforded international financial institutions substantial policy influence on governments throughout the world and in a wide array of policy areas of direct bearing on human rights. This article reviews the consequences of policy reforms mandated by international financial institutions on the enjoyment of human rights, focusing on the International Monetary Fund and World Bank. It finds that these reforms undermine the enjoyment of health rights, labour rights, and civil and political rights, all of which have deleterious implications for public health. The evidence suggests that for human rights commitments to be met, a fundamental reorientation of international financial institutions' activities will be necessary.

Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal

BACKGROUND

The recent economic and financial crisis in Portugal urged the Portuguese Government in April 2011 to request financial assistance from the troika austerity bail out program to get aid for its government debt. The troika agreement included health reforms and austerity measures of the National Health Service (NHS) in Portugal to save non-essential health care costs. This research aimed to identify potential barriers among the elderly population (aged 65 and above) to healthcare access influenced by the economic crisis and the troika agreement focussing on the Memorandum of Understanding on Specific Economic Policy Conditionality (MoU) in Lisbon metropolitan area, Portugal.

METHODS

The qualitative study is including 13 semi-structured interviews of healthcare experts, municipality authority, health care providers, negotiator of the troika agreement, hospital managers, health economists and elderly. A content analysis was performed to evaluate the interviews applying Nvivo2011 software. The barriers identified were clustered towards the five areas of the 'Conceptual framework on health care access' by Levesque et al. (Int J Equity Health 12:18, 2013).

RESULTS

Healthcare access for the elderly was found inadequate in four areas of the framework: availability; appropriateness; approachability; and affordability. The fifth area on acceptability was not identified since the study neither followed a gender nor ethnic specific purpose. The main identified barriers were: current financial situation and pension cuts; insufficient provision and increased user fees in primary care; inadequate design and availability of hospital care service; lack of long-term care facilities; increased out-of-pocket-payment on pharmaceuticals; limitations in exemption allowances; cuts in non-emergent health transportation; increased waiting time for elective surgery; and poor unadapted housing conditions for elderly.

CONCLUSIONS

The health reforms and health budget cuts in the MoU implemented as part of the troika agreement have been associated with increasing health inequalities in access to healthcare services for the elderly population. The majority of responses disclosed an increasing deficiency across the entire National Health Service (NHS) to collaborate, integrate and communicate between the different healthcare sectors for providing adequate care to the elderly. An urgent necessity of restructuring the health care system to adapt towards the elderly population was implied.

Structural adjustment programmes adversely affect vulnerable populations: a systematic-narrative review of their effect on child and maternal health

Structural adjustment programmes of international financial institutions have typically set the fiscal parameters within which health policies operate in developing countries. Yet, we currently lack a systematic understanding of the ways in which these programmes impact upon child and maternal health. The present article systematically reviews observational and quasi-experimental articles published from 2000 onward in electronic databases (PubMed/Medline, Web of Science, Cochrane Library and Google Scholar) and grey literature from websites of key organisations (IMF, World Bank and African Development Bank). Studies were considered eligible if they empirically assessed the aggregate effect of structural adjustment programmes on child or maternal health in developing countries. Of 1961 items yielded through database searches, reference lists and organisations' websites, 13 met the inclusion criteria. Our review finds that structural adjustment programmes have a detrimental impact on child and maternal health. In particular, these programmes undermine access to quality and affordable healthcare and adversely impact upon social determinants of health, such as income and food availability. The evidence suggests that a fundamental rethinking is required by international financial institutions if developing countries are to achieve the Sustainable Development Goals on child and maternal health.