Governing and Measuring Health Security: The Global Push for Pandemic Preparedness Indicators.

Providing collective solutions to global pandemics requires the coordination of information that is accurate and accountable. In recent years there has been a global push for reliable pandemic preparedness indicators. This push has come from U.S. foreign policy, the World Health Organization (WHO), NGOs, and private foundations. These actors want control over how data for preparedness indicators is collected, analysed, and promoted. Governments want to influence how they are assessed, using poor performance to attract attention and good performance to deflect blame. In this article we discuss how the push for pandemic preparedness indicators comes from the dual aims of repelling national risk, the spread of disease, while reducing global harm through stronger transnational governance arrangements. We delve into the development of indicators from the WHO and the privately-run Global Health Security Index, and examine how their claims to authority measure-up against standards of transparency, veracity, and accountability. We stress the importance of understanding how these indicators are composed. This is vital given the current drive to include social and governance metrics in revised efforts at data collection, as well as efforts to include pandemic preparedness indicators in how intergovernmental organizations, NGOs, donors, and funders devise health and development policies.

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.

How structural adjustment programs affect inequality: A disaggregated analysis of IMF conditionality, 1980-2014.

This article highlights an important yet insufficiently understood international-level determinant of inequality in the developing world: structural adjustment programs by the International Monetary Fund (IMF). Studying a panel of 135 countries for the period 1980 to 2014, we examine income inequality using multivariate regression analysis corrected for non-random selection into both IMF programs and associated policy reforms (known as 'conditionality'). We find that, overall, policy reforms mandated by the IMF increase income inequality in borrowing countries. We also test specific pathways linking IMF programs to inequality by disaggregating conditionality by issue area. Our analyses indicate adverse distributional consequences for four policy areas: fiscal policy reforms that restrain government expenditure, external sector reforms stipulating trade and capital account liberalization, financial sector reforms entailing inflation-control measures, and reforms that restrict external debt. These effects occur one year after the incidence of an IMF program, and persist in the medium term. Taken together, our findings suggest that the IMF's recent attention to inequality neglects the multiple ways through which the organization's own policy advice has contributed to inequality in the developing world.

Impact of International Monetary Fund programs on child health.

Parental education is located at the center of global efforts to improve child health. In a developing-country context, the International Monetary Fund (IMF) plays a crucial role in determining how governments allocate scarce resources to education and public health interventions. Under reforms mandated by IMF structural adjustment programs, it may become harder for parents to reap the benefits of their education due to wage contraction, welfare retrenchment, and generalized social insecurity. This study assesses how the protective effect of education changes under IMF programs, and thus how parents' ability to guard their children's health is affected by structural adjustment. We combine cross-sectional stratified data (countries, 67; children, 1,941,734) from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys. The sample represents ∼2.8 billion (about 50%) of the world's population in year 2000. Based on multilevel models, our findings reveal that programs reduce the protective effect of parental education on child health, especially in rural areas. For instance, in the absence of IMF programs, living in an household with educated parents reduces the odds of child malnourishment by 38% [odds ratio (OR), 0.62; 95% CI, 0.66-0.58]; in the presence of programs, this drops to 21% (OR, 0.79; 95% CI, 0.86-0.74). In other words, the presence of IMF conditionality decreases the protective effect of parents' education on child malnourishment by no less than 17%. We observe similar adverse effects in sanitation, shelter, and health care access (including immunization), but a beneficial effect in countering water deprivation.

Structural adjustment and health: A conceptual framework and evidence on pathways.

Economic reform programs designed by the International Monetary Fund and the World Bank-so-called 'structural adjustment programs'-have formed one of the most influential policy agendas of the past four decades. To gain access to financial support from these organizations, countries-often in economic crisis-have reduced public spending, limited the role of the state, and deregulated economic activity. This article identifies the multiple components of structural adjustment, and presents a conceptual framework linking them to health systems and outcomes. Based on a comprehensive review of the academic literature, the article identifies three main pathways through which structural adjustment affects health: policies directly targeting health systems; policies indirectly impacting health systems; and policies affecting the social determinants of health. The cogency of the framework is illustrated by revisiting Greece's recent experience with structural adjustment, drawing on original IMF reports and secondary literature. Overall, the framework offers a lens through which to analyze the health consequences of structural adjustment across time, space and levels of socioeconomic development, and can be utilized in ex ante health impact assessments of these policies.

International organizations and migrant health in Europe.

International organizations have defined and managed different aspects of migrant health issues for decades, yet we lack a systematic understanding of how they reach decisions and what they do on the ground. The present article seeks to clarify the state of knowledge on the relationship between international organizations and migrant health in Europe. To do so, we review the operations of six organizations widely recognized as key actors in the field of migrant health: the European Commission, the Regional Office for Europe of the World Health Organization, the International Organization on Migration, Médecins du Monde, Médecins Sans Frontières, and the Open Society Foundation. We find that international organizations operate in a complementary fashion, with each taking on a unique role in migrant health provision. States often rely on international organizations as policy advisors or sub-contractors for interventions, especially in the case of emergencies. These linkages yield a complex web of relationships, which can vary depending on the country under consideration or the health policy issue in question.

Structural adjustment and public spending on health: evidence from IMF programs in low-income countries.

The relationship between health policy in low-income countries (LICs) and structural adjustment programs devised by the International Monetary Fund (IMF) has been the subject of intense controversy over past decades. While the influence of the IMF on health policy can operate through various pathways, one main link is via public spending on health. The IMF has claimed that its programs enhance government spending for health, and that a number of innovations have been introduced to enable borrowing countries to protect health spending from broader austerity measures. Critics have pointed to adverse effects of Fund programs on health spending or to systematic underfunding that does not allow LICs to address health needs. We examine the effects of Fund programs on government expenditures on health in low-income countries using data for the period 1985-2009. We find that Fund programs are associated with higher health expenditures only in Sub-Saharan African LICs, which historically spent less than any other region. This relationship turns negative in LICs in other regions. We outline the implications of these findings for health policy in a development context.