Free and Public
Currently Browsing: Global Health Governance

IMF conditionality: still undermining healthcare?

Last year, the IMF tried to counter long-running accusations that its programmes damage health outcomes in developing countries, but the independent evidence points in the opposite direction. The question is whether the IMF will use this year’s reviews of its lending to switch approach and start helping Sustainable Development Goal (SDG) three to “ensure healthy lives and promote well-being for all at all ages.”

The IMF claims to protect health expenditure

An IMF blog from March last year claimed that: “A number of studies have found that IMF support for countries’ reforms, on average, either preserve or increase public health spending.” However, the evidence provided was weak. Of the six studies referenced, one, by Oxford and Cambridge university researchers, which we discuss below, flatly contradicts this claim.  Two were not related to health expenditure: one looked at revenue, not expenditure, and the second had a broader remit and contained no new evidence on the IMF and health. One was over a decade old and did not directly support the claim; while another was a link to an IMF page on the Ebola crisis. In fact  the only referenced study that supported the claim was written by the staff who authored the blog.

In another blog, the IMF Managing Director, Christine Lagarde stated  that “our latest research shows that health and education spending have typically been protected in low-income country programs.”

Again, it’s worth looking into the evidence cited to back up this claim, which is provided by an internal review of the IMF’s programmes in LICs.  The review covered the period since a change in the Fund’s policy in 2009 which mandated the use of conditionality to protect social spending.

Essentially, the IMF is arguing that this policy change has had two impacts. Firstly, that IMF programmes are no longer associated with austerity. Secondly, that the IMF has used conditionality to ring-fence social spending. Unfortunately, neither of these claims hold up well under scrutiny. We examine the first below, and will detail the second in a forthcoming blog.

The IMF: no longer the champion of austerity?

The internal review’s claim that “LIC programs are broadly divided between those entailing fiscal expansion and those seeking fiscal consolidation” is not supported by the evidence in the review. This graph, taken from the review, gives totals for the number of IMF programmes in LICs according to whether they mean cuts in expenditure or increases, with a small number, that are ‘fiscally neutral,’ having neither. This shows that 34 of the 68 programmes studied mandated cuts in government expenditure while fewer (29) supported fiscal expansion.

However, including all types of IMF programmes is misleading. It makes sense to compare the two main types of IMF programme alone: the Extended Credit Facility (ECF) for medium to long term lending, and the Standby Credit Facility (SCF) for shorter term lending. Here the gap is quite large, with 28 programmes associated with budget cuts versus 17 with expansion. The other two programmes excluded in this comparison are the Policy Support Instrument– which is advisory and entails no IMF lending, and the Rapid Credit Facility – an emergency programme for countries in trouble, which unsurprisingly has a majority of programmes that increase expenditure.


Fiscal Adj in LICs IMF programs



The second problem is that the statistical analysis in the review showing “no evidence that fiscal adjustment policies in LIC programmes come at the expense of health and education spending,” is disputed by independent experts. Researchers at Oxford and Cambridge Universities published a review of the IMF’s claims, finding that “the methodological strategy employed in the IMF analysis is unsound.” The researchers ran their own analysis, covering the same years as the IMF study and found that “an additional year of IMF programme participation decreases health spending, on average, by 1.7 percentage points as a share of GDP.”

This chimed with an earlier study by the same researchers of IMF programmes between 1995 and 2015 in 16 West African countries which found that “IMF policy reforms reduce fiscal space for investment in health, limit staff expansion of doctors and nurses, and lead to budget execution challenges in health systems.”

What next for the IMF?

The IMF’s concern not to be seen to be impacting health expenditure in the poorest countries can be viewed as an improvement. However, it is clear that IMF conditionality can constrain expenditure on health and other related services, and is at odds with the SDG commitment to achieve universal health coverage.

The next scheduled review of IMF funding to low-income countries is planned this year. Unfortunately, judging by the questions posed in a public consultation last year, the IMF review may be missing the point. The impacts on health and other social expenditure arise not primarily because of the access to IMF financing – which the questions focus on – but on the conditionality attached to that financing. More promisingly, the IMF 2018 Executive Board work programme also promises a review of conditionality, but, as yet, there is no public information on the scope of this review.

It is time for a much broader reform of IMF conditionality. Eurodad’s detailed study, in 2014, found that the IMF conditions are often highly controversial and intrusive on key economic policy issues that should be the crux of democratic debate in country, not mandated from Washington. Crucially, we also found that “almost all the countries [that had IMF lending programmes during the period studied] were repeat borrowers from the IMF, suggesting that the IMF is propping up governments with unsustainable debt levels”.

As the IMF warns that a new debt crisis may be developing, it is time to table real solutions that increase fiscal space for health and social protection, including cracking down on tax dodging, and the creation of an independent debt work-out mechanism to tackle the unsustainable and illegitimate debt that holds many countries back.

The IMF must stop its damaging conditionality practices. A simple way to do this would be by extending the approach of its little-used Flexible Credit Line to all IMF facilities – requiring no conditionality other than the repayment of the loans on the terms agreed. Only bold steps such as this will remove the conditionality that is at the heart of so much of the damage that the IMF can do in developing countries.

Gino Brunswijck, Research and Advocacy Officer and Jesse Griffiths, Director of Eurodad



Will WHO candidates for the big job commit to ending user fees? By Aishah Siddiqa, Global Inequality Campaign Officer

Every year one billion people worldwide are denied medical care because they cannot afford to pay for it. At the same time, 100 million people are pushed into poverty due to having to find or borrow money to pay for health care[1].

My father’s family is one of those nameless millions. They live in rural Bangladesh where healthcare is inaccessible because of having to pay for services. My family had to delay mortgage payments so that my grandmother could get the cancer treatment she desperately needed. They also struggled to get medicines for my little cousin, Ismael, so that he could continue at school and one day hope to escape the cycle of poverty.


For countless others, however, such options aren’t available so they are denied medical care altogether. Sometimes people are even imprisoned in hospitals until their families can pay their bills.

The World Bank president, Jim Kim, described user fees as “unjust and unnecessary” and said that “even tiny out-of-pocket charges can drastically reduce use of needed services”. In her address to the World Health Assembly last year, the current WHO Director-General Dr Chan said: “User fees punish the poor. User fees discourage people from seeking care until a condition is severe and far more difficult and costly to manage. User fees waste resources as well as human lives. Yet too little has been done since then to help those millions of people to access health services without paying user fees.

That is why, ahead of the elections for the next Director General of the World Health Organisation, more than 200 NGOs, academics, health professionals and influentials have signed an open letter to the three shortlisted candidates: Dr. Tedros Adhanom Ghebreyesus, Dr. David Nabarro and Dr. Sania Nishtar. The letter urges the candidates to publicly pledge to support countries to replace user fees with progressive, publicly financed health care that is free at the point of use. Signatories include Dr Gro Brundtland, the former DG of the WHO and former PM of Norway, Dr. Ricardo Lagos, former President of Chile, Ms. Hina Jilanni, Human Rights defender and Advocate of the Supreme Court, and organisations and networks such as Action for Global Health and Oxfam International.

Removing user fees is essential to achieve the SDG target of Universal Health Coverage.


[1]Xu K, Evans D, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending, Health Aff airs 2007; 26: 972–983.


The High Level Panel Report: to gather dust or create real change on access to live saving medicines?


There is hardly a day that goes by without some headline about a highly priced medicine that is beyond the means of those who need it. For decades, access to medicines was automatically associated with problems in poor countries. However, it has now become clear that the high price of medicines is crippling healthcare systems everywhere in the world. Patients’ stories from South Africa to Sweden and from Colombia to the UK tell the difficult reality of people’s struggle to get access to life-saving medicines.

For example, the price of effective medicines to treat Hepatitis C can be over $100,000 per patient. The Dutch government’s submission to the High Level Panel states that “We have an estimated 20,000 patients with this disease. Such costs make our healthcare unaffordable. If we continue in this way, it will become nearly impossible to reimburse patients for these medications”.


The prices of cancer medicines are beyond the reach of many patients who need them especially in developing countries.


“I was diagnosed with breast cancer in 2013. My insurance refused to cover my Herceptin treatment because of the high price. Now the cancer has spread all over my body. I need Herceptin so that I can live and bring up my two boys”.
“Tobeka Daki from South Africa”


While the high medicine prices is one side of the access problem, the Ebola crisis highlighted the other side: lack of innovation for public health needs. The current global system relies on intellectual property (IP) rules that create monopolies in order for pharmaceutical companies to generate profits and thus to finance research and development (R&D). Where companies see they can make money, they even invent new disease’ names for medical conditions to market their medicines – as in the latest case of opioid-induced constipation. In that case, clinicians who found a way to ease the suffering of the dying got investors to bring a drug to market only when a broader market was identified – the opioid dependence that has reached crisis levels in the United States. But where there is no profit, such as in the case of Ebola, there is no investment from companies.

In December 2015, the UN Secretary General established a High Level Panel (HLP) to “recommend solutions for remedying the policy incoherence between the justifiable rights of inventors, international human rights law, trade rules and public health in the context of health technologies.” The HLP is a unique opportunity to advance access to health technologies for several reasons. The HLP acknowledges the potential conflict of interest between the human right to health and IP rules. Moreover, unlike other initiatives that have tended to focus on neglected diseases, the HLP tackles all health technologies for all diseases in all countries.

The HLP published its report in September 2016, which includes recommendations that represent positive steps to advance access to medicines[1]. On the innovation side, the report recommends that the UN Secretary General start a process for UN member states to negotiate a binding R&D convention that delinks the cost – and hence financing – of R&D from the price of the final product. This is a critically important initiative. The pharmaceutical industry justifies the ever increasing prices of medicines by citing the high cost of their R&D even though all information related to those costs is shrouded in secrecy. The industry also fails to recognize the important role of public financing for R&D. The HLP report calls for increased public financing through domestic resources as well as innovative sources like the financial transaction tax. However, increasing public financing for R&D is not enough unless there are binding agreements for affordable prices of the resulting products.

Nearly all issues related to medicines are shrouded in secrecy. Therefore, it is important that the HLP report recommends transparency of information involving R&D costs, medicine pricing, patent status and clinical trials, as well as negotiation of Free Trade Agreements (FTAs).

On the access side, the report recognises the political and commercial pressures that countries face when they try to use the flexibilities enshrined in the World Trade Organization’s (WTO) Trade Related Aspects on Intellectual Property Rights (TRIPS) Agreement, which allows governments to adopt specific policies to protect public health. Free Trade Agreements (FTAs) include measures that actually restrict governments’ ability to adopt pro-health policies. While the report recommended that countries register any pressure they face at the WTO, and countries to conduct impact assessment on potential effect of FTA measures on access to medicines, it fell short of proposing an immediate ban on excessive IP protections in FTAs.

Unfortunately, the US government and pharmaceutical companies started attacking the report even before it was published. The unholy alliance between rich country governments and the pharmaceutical industry employs extensive resources and pressures to stop the development or promotion of alternatives to the current IP system to finance R&D, which is based on conferring monopoly power to extract the highest profit from the end product. But this system is failing patients around the world. Now is the time for change, for a system that places the human right to health as the determinant of the R&D agenda and enables affordable pricing of products.

Good recommendations require active engagement that leads to action if they are to bring about beneficial change. Concerted efforts are now needed for the UN system and member states to adopt and implement the HLP recommendations. Otherwise the report will simply end up gathering dust on some shelves in a UN office. It is now in the hands of the UN Secretary General to move this process forward. His action would be a valuable parting gift to the world as he leaves office at the end of this year, a critical step toward ensuring access to medicines for all so no one is left behind.

[1]These recommendations have limitations, which are explained in the Commentary included in the report’ Annex, by three panel members, including Winnie Byanyima, Executive Director of Oxfam International.



The race has begun to select the new WHO Director General By Mohga Kamal-Yanni

The WHO has announced that the election process for the new Director General (DG) is now open. The election comes at a critical time in the organisation’s history. WHO was criticised by many for failing to respond to Ebola sufficiently quickly, while the fact that Member States had de-prioritised WHO’s emergency work and cut WHO funding was not widely acknowledged.

WHO has been facing serious financial difficulties for more than 6 years. The crisis prompted Margaret Chan to launch a reform process in 2010.  Implied in the reform plan was a correction of the imbalance in the WHO budget whereby ear-marked project funds outweighed flexible core funding in a ratio of 80/20. Six years later and the financial imbalance has not improved. It is also not clear what different member states require from the reform. WHO is in danger of becoming a ‘pay-as-you-go’ service organisation, far from its constitutional mandate.

The results of underfunding its core budget are not only limited to decreased WHO ability to perform its functions, but it also threatens its independence. Countries rely on WHO’ guidance on the assumption that advice is independent from commercial and political interests and is based on science and evidence.

Previous elections lacked transparency and failed to allow public scrutiny of the process. The global health community did not know the “manifestos” of the candidates or how they would prioritise and deal with global health problems.

The prestigious medical journal The Lancet has attempted to fill the manifesto gap by inviting candidates to share their visions. The journal also did its own ranking of the candidates according to the key competences needed for the job.

In the new recruitment processes, the WHO has announced some changes aimed at enhancing transparency. These include a forum for Member States to interact with the candidates, and allowing the WHA to choose from three candidates – instead of simply approving one.

The new DG will have to face huge challenges in terms of the impact of years of financial stringency on core functions and on moral and mandate as well the difficulties facing the role of the WHO in the complex global health field. Given the critical importance of the DG role and the challenges he/she will face, we recommend that mechanisms be put in place to enable public scrutiny of the candidate’s vision for the WHO. In order to enable this public engagement we propose:

  1. Each candidate publicly presents his/her manifesto including:
  • Their vision for what WHO would look like at the end of his/her term
  • Their key priority reform issues
  • How they will secure WHO’s independence while enhancing its financing
  • How to prioritise work areas across the complexity of global health issues and the various requirements of member states
  • Their aspiring legacy
  1. Open public debates with stakeholders to discuss the candidates’ manifestos. This can be done as a webcast to allow participants from all countries with a moderator to organise the debate

As countries begin to nominate their candidates, the global health community is entitled to know where candidates stand on key health questions as well as on the fundamental challenges and issues facing the WHO.



EBOLA AND WHO REFORM: WHO CARES? By Charles Clift, Senior Consulting Fellow, Centre on Global Health Security, Chatham House

The ongoing Ebola story has highlighted the importance of the World Health Organization (WHO) in coordinating international action to combat emerging infectious disease threats. But it has also revealed the deficiencies in its performance which have now allowed a disease outbreak in West Africa to turn into a major international emergency. But in the current crisis in West Africa blame for its performance has been more prevalent than praise. As even its senior officials now admit WHO was too slow to recognize the potential seriousness of the outbreak – while also blaming the cutbacks in its emergency response capability agreed by its member states, as well as the unusual nature of the outbreak which it says caught the international community as a whole on the hop. The officials also point out that WHO is a technical assistance agency: there to help and advise governments on how to respond and supply needed expertise rather than run emergency healthcare operations on its own account.

On the other hand, some NGOs such as MSF, working to combat Ebola on the frontline, have criticized WHO’s slow response. They say that it should have recognized much earlier than it did the need to take the lead in mobilizing funding and personnel from other international actors to strengthen the weak healthcare infrastructures in the affected countries, as well as intensifying its own efforts to support governments with technical assistance and expertise.

Others blame WHO’s slowness and lack of leadership on its fundamental structural problems, which the reform programme launched by Margaret Chan in 2010 was intended to address. These structural problems include both its funding and its unique structure of regional offices which elect their own leaders. Much adverse comment has been directed at the role of WHO’s Africa regional office in Brazzaville which Peter Piot recently described as being staffed with political appointees rather than the most capable people, and the alleged lack of good cooperation between Brazzaville and Geneva. While there is undoubtedly financial stringency in WHO, and a severe shortage of experienced staff in HQ, the case is different with country staffing. The three most affected countries have country office staff exceeding 100 in total, there are nearly 750 in the country offices in the West African region as a whole, and there is nearly 600 staff in the regional headquarters in the Congo. In addition the African region has nearly 2500 contracted staff involved in polio eradication. It is hard to believe that more could not have been done with all these staff on the ground if properly mobilized and managed.

A report on WHO reform published in May this year, based on the deliberations of a working group convened by Chatham House, noted that WHO’s core functions as defined by WHO excluded explicit reference to promoting and maintaining global health security, specifically including its response to disease outbreaks and public health emergencies.

But the report focused mainly on the WHO’s structural problems that the ongoing internal reform process in WHO was not dealing with. The Ebola story illustrates many of these. The report asked: whether WHO really needed six semi-autonomous regional offices? Was this not a recipe for conflict and slow and poor decision-making? And did it need 150 country offices? How did politicization and the politics of patronage adversely affect WHO’s performance, credibility and effectiveness at all three levels of the organization? Was its complex governance structure not the main reason that it spends one third of its budget on administration and management at the expense of its technical programmes? Were there not more efficient ways to do what WHO needed to do? Why was WHO often reluctant to lead rather than to follow its member states? Why did the member states countenance this state of affairs?

The report has evoked practically no response at all – from governments, the academic community, NGOs or anyone else for that matter. Why is this?

A plausible explanation, which was suggested often by one of the members of the Chatham House working group, is that no one cares sufficiently about WHO reform to do anything about it. The status quo is too comfortable, or not sufficiently uncomfortable, for any member state to want to change things.

The weird financing arrangements, whereby 75% or more of WHO’s income is in the form of voluntary contributions, suits member states for different reasons. A few rich countries (and charities such as the Bill and Melinda Gates Foundation), by directing their voluntary contributions in ways of their own choosing, get to control what WHO does in spite of being a small minority in the World Health Assembly, or not in it at all. Yet because of this effective subsidy, poorer countries pay contributions which are a quarter of what they would be if WHO was wholly financed by member state subscriptions. Thus for the great majority of member states WHO membership is a bargain. They get a WHO country office whose budget (paid for by WHO) will normally exceed by a large margin their WHO contribution.

Because WHO regional offices are run as semi-autonomous replicas of WHO in Geneva, ministries of health also get the opportunity to influence appointments to regional and country offices where those chosen can access UN-related salary and benefit packages. Thus it is not just a financial bargain but often carries actual or personal benefits for senior country officials. So there is little mystery about why change should be resisted. Even where it is recognized that a WHO country office may have outlived its utility (in a country like Thailand for instance) it would be a brave politician or official who suggested closing what is essentially a free gift from the international community.

So no mystery there. The non-response of the ‘public interest’ NGO movement is more puzzling on the face of it. But perhaps the answer is not totally dissimilar. These NGOs have no financial stake in WHO and therefore no direct influence on its governance. Many regard the WHO as a forum where they may express their views and the annual World Health Assembly as a perfect gathering of notables in the global health community to pursue advocacy and influence member state delegates. While NGOs may be critical of the WHO, as in the case of Ebola, they also hold it in great esteem as the one international organization with the responsibility of striving for “the attainment by all peoples of the highest possible level of health”. The NGO mindset is therefore to seek to defend this noble objective and, in particular, protect it from political and commercial pressures which are seen as a threat to this mission.

Moreover the WHO secretariat is generally regarded as providing objective technical leadership and support to member states in a world dominated by governments and corporations whose motivations and interests may run counter to health objectives. For that reason NGOs are generally only likely to be critical of the WHO secretariat if it appears to be supine in its dealings with commercial stakeholders, or with governments deemed to be unduly influenced by commercial rather than public health interests.

At the same time NGOs, notably Oxfam, have campaigned actively for member states to increase their secure funding of WHO to protect its core functions, such as those which support enhanced access to essential medicines. But member states have to date paid little heed.

So it seems that the political preconditions for fundamental reforms of WHO funding and governance are absent. Nevertheless the world badly needs a global body that can take on a leadership role in global health policies and help control disease outbreaks before they turn into international crises. The panic engendered by the Ebola crisis should result in a reality check for all concerned. The WHO reform process, begun 4 years ago, does not seem to be on course to deliver a WHO that can be relied upon as fit for purpose.



« Previous Entries

Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni