A commentary arguing the International Monetary Fund (IMF) helped to weaken health care in the West African countries struggling with Ebola caused a bit of a debate between academics. Critics of the commentary say the connection between the IMF and Ebola in West Africa is tenuous and assumes the large money lender has far more power than it has in reality.
The announcement by the IMF to provide $430 million in funding to Guinea, Liberia and Sierra Leone in the middle of December caused UK-based researchers Alexander Kentikelenisemail, Lawrence King, Martin McKee and David Stuckler to raise concerns in the British medical journal The Lancet. The said IMF policies encouraged three major things: the reduction in government spending, caps on salaries for government employees, thus limiting what health professionals get paid, and a decentralized national health system. These policies hampered the development of proper health care systems that would have been better able to respond to the emergence of Ebola.
“The IMF’s widely proclaimed concern about social issues has had little effect on health systems in low-income countries. Although [IMF Director Christine] Lagarde’s comment on prioritising public health instead of fiscal discipline is welcome, similar comments have been made by her predecessors,” wrote Kentikelenisemail, et al.
Initially, the commentary was slow to garner discussion. The IMF, naturally, did not like it. Deputy Director for the IMF Fiscal Affairs Department Sanjeev Gupta wrote a letter to the Lancet disputing the commentary. Gupta’s most significant claim was that health spending in the three countries actually went up slightly while taking IMF loans.
Some people who disagreed with the assessment pointed to previous work on the issue from Center for Global Development health researcher Amanda Glassman. She refuted claims that IMF policies led to money not being spent on public health, made in 2011 by Stucker (one of the Lancet co-authors) and others. Both she and at-the-time PhD student Matt Collin said comparing countries who do and do not get IMF loans is impractical. The reason a country would get a loan from the IMF, generally a lender of last resort, means that thing are not going great.
“There is an urgent, painfully obvious problem with concluding anything causal here: countries which decide to accept IMF loans are likely to be very different than those that don’t, and these differences are going to have impacts on health spending, above and beyond the restrictions imposed by IMF conditions,” wrote Collin.
Many of the same problems described by Collin and Glassman in 2011 were noted about the Lancet commentary. However, it was a post by Columbia University political scientist Chris Blattman in the Washington Post’s Monkey Cage blog that really got things going. Blattman picked up on some of the earlier points made by Collin and Glassman and went further to say that the IMF blame ignored the political history of the three countries and over-stated what the IMF is capable of doing with its loans.
“When you’re three steps removed from war or a coup, and you don’t have a functioning police or justice system, building a fine public health system is not your first investment,” wrote Blattman.
His piece was followed up by responses in the same blog from US-based researchers Adia Benton and Kim Yi Dionne, and a rejoinder from the authors of the original Lancet piece. First, Benton and Dionne refuted Blattman’s claim that there is a lack of evidence linking the IMF and problems with healthcare by sharing five research articles and books that show otherwise. One of the articles describes how IMF and World Bank loans to Sierra Leone ‘nurtured widespread discontent’ that led to a civil war which destroyed hospitals and clinics in the country.
They are more cautious in linking the IMF to the Ebola outbreak, but say there is enough evidence to say the IMF contributed negatively to health care development in the three countries.
“Though we wouldn’t go so far as to say that the IMF is wholly to blame for the Ebola outbreak, the IMF and organizations like it have played an important role in creating a political environment in which the epidemic could emerge and become the deadliest on record,” write Benton and Dionne.
A day later, Kentikelenis, King and McKee went point-by-point to show why they think Blattman was wrong. They concede that the three countries were left weak states after civil wars, but say evidence shows the IMF made things worse, not better. All three countries have policies committed to strengthening healthcare, the three say that is evidence that Blattman is wrong in arguing that the only priorities are related to law and order. Most importantly, the idea that the IMF has little influence is wrong. IMF loans require certain conditions from recipient countries, those conditions then impact spending decisions.
“This kind of IMF influence — one step removed from those affected — arguably is all the more dangerous, as it precludes direct negotiations and influencing,” say Kentikelenis, King and McKee.
Opinions on the subject began to pile on. Blattman came back, further stressing the points he made earlier and concluding that he is more favorable of the IMF’s work in West Africa. PhD student Lee Crawfurd said he agreed with Blattman. He said it is wrong to assume that countries can spend as much money as they want and still maintain a responsible fiscal policies when they are in need of an IMF loan.
Ken Opalo, another PhD student, was swayed by both arguments. He too questioned the proof that IMF policies caused health systems not to develop, but said that the political ramifications brought forward by Benton and Dionne give reason to pause. Economist Morten Jerven also took a moderate stance on the debate. He quickly knocked down the numbers touted by the IMF saying that they show minimal growth at best and are not proof that their loans were making things better. More importantly, asking whether the IMF is to blame is the wrong question altogether.
“Contesting who is to blame, and who causes one or another dollar increase will inevitably rely on too many implausible counterfactuals…I suspect that how convincing different stakeholders find the evidence that is put forward ultimately reflects their prior beliefs as much the quality of the evidence,” said Jerven.
By the end, the debate found itself with three camps. One said the IMF is to blame, another says it is not and a third saying yes and no. As with anything it appears the truth might be found in the middle of the extremes.
“It is still too early to make definitive statements about who is to blame, especially since the end of the West African Ebola outbreak is not yet on the horizon,” say Benton and Dionne. “Nonetheless, there’s something to be learned from the experience of earlier epidemics and responses, and that record suggests that the IMF and organizations like it are — at least partly — blameworthy.”
