London School of Hygiene & Tropical Medicine

Reforms advocated by the International Monetary Fund (IMF) for chronically under-funded and insufficiently staffed health systems in Guinea, Liberia and Sierra Leone, have contributed to "lack of preparedness" of West African health systems to cope with disease and emergencies such as Ebola, according to researchers writing in Lancet Global Health.

Professor Martin McKee from the London School of Hygiene & Tropical Medicine, with colleagues from Oxford University and Cambridge University, examined the links between the IMF and the Ebola outbreak in West Africa. According to the authors, IMF programs over the years have imposed heavy constraints on the development of effective health systems of Guinea, Liberia and Sierra Leone - the cradle of the Ebola outbreak that has killed more than 6,800 since March this year.

The researchers say that economic policy reforms advocated by the IMF have undermined the capacity of health systems in these three nations - systems already fragile from legacies of conflict and state failure - to cope with infectious disease outbreaks and other such emergencies.

By reviewing the policies enforced by the IMF before the outbreak - extracting information from the IMF lending programs between 1990 and 2014 - the researchers were able to examine the effects on the three West African nations, and identified three key policy impacts that led to the weakening of the already fragile healthcare systems in these countries:

Firstly, the IMF required economic reforms that reduced government spending. "Such policies have been extremely strict, absorbing funds that could be directed to meeting pressing health challenges," write the researchers. Although the IMF responded to concerns raised about the impact of these policies by incorporating "poverty-reduction expenditures" that aimed to boost health budgets, the researchers found these conditions were often not met.

Secondly, the IMF often requires caps on the public-sector wage bill, directly impacting the capacity of these nations to hire and adequately pay key healthcare workers such as doctors and nurses. An independent evaluation of the IMF in 2007 stated that these limits are "often set without consideration of the impact on expenditures in priority areas".

Thirdly, the IMF campaigns for decentralised healthcare systems. While the idea behind this is to make healthcare more responsive to local needs, the researchers say that in practice this makes it difficult to mobilise coordinated responses to outbreaks of deadly diseases such as Ebola.

However, in recent months, the IMF has announced $430m of funding to help combat Ebola in West Africa, leading IMF Director Christine Lagarde to say it is "good to increase the fiscal deficit when it's a matter of curing the people […] The IMF doesn't say that very often."

The authors of the Lancet article point to that journal's own Commission on Investing in Health, which calls for increases in public health spending and attention to hiring and training health workers. "The experience of Ebola adds a degree of urgency to the implementation of its recommendations," they write.

Publication

• Alexander Kentikelenis, Lawrence King, Martin McKee, David Stuckler. The International Monetary Fund and the Ebola outbreak. The Lancet Global Health. DOI:10.1016/S2214-109X(14)70377-8