Abstract Background Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries. Methods and Findings We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (−7.6%, 95% confidence interval, −1.0% to −14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables. Conclusions IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis–related health outcomes.

Citation: Stuckler D, King LP, Basu S (2008) International Monetary Fund Programs and Tuberculosis Outcomes in Post-Communist Countries. PLoS Med 5(7): e143. https://doi.org/10.1371/journal.pmed.0050143 Academic Editor: Megan Murray, Harvard School of Public Health, United States of America Received: December 3, 2007; Accepted: May 19, 2008; Published: July 22, 2008 Copyright: © 2008 Stuckler et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors received no specific funding for this article. Competing interests: The authors have declared that no competing interests exist. Abbreviations: DOTS, directly observed therapy; EE, Eastern Europe; FSU, Former Soviet Union; IMF, International Monetary Fund; WHO, World Health Organization

Introduction A major barrier to effective tuberculosis control has been the capacity of health systems to detect and adequately treat infected persons [1–4]. The World Health Organization (WHO) has promoted a policy of expanding directly observed therapy (DOTS) for tuberculosis control, which critically depends upon the availability of doctors, nurses, community health-care workers, and associated laboratory and hospital infrastructure. In resource-poor settings, international donations and financial lending play a crucial part in determining how such programs will expand and how successful they might be [5–7]. The International Monetary Fund (IMF) provides a major source of capital for financially ailing countries, including capital used for health program development. Like most international lending institutions, the IMF seeks to ensure that it will recover its loans from borrowers. To reduce the risk of loan defaults, the IMF requires a set of strict “conditionalities” on its lending, which include economic programs that countries must agree to comply with in order to receive funds. According to the IMF, the objective of these programs is to achieve macroeconomic stability and economic growth: “Our primary objective is growth. In my view there is no longer any ambiguity about this. It is toward growth that our programs and their conditionality are aimed” [8]. Whether these IMF programs have impacted health and health infrastructure has been a source of ongoing controversy. In the mid-1980s, a UNICEF report (Adjustment with a Human Face) suggested that IMF structural adjustment programs had disenfranchised poor populations [7]. A decade later some academics and NGOs suggested that the conservative inflationary targets of IMF programs (being set often lower than 5%) were undermining infectious disease control efforts, particularly in the context of HIV/AIDS and tuberculosis epidemics [9–15]. Such targets constrained public health and social spending, for example by reducing public social expenditure and placing caps on public wage bills, and led to restructured health-care financing and delivery, often via privatizing health services [9,10,12]. (The World Bank and IMF do not advise governments to reduce social expenditures; however, the officials are fully aware that in practice adjustment policies often translate into reduced investment in health, education, and social services in order to meet economic benchmarks) [16]. Linkages between the IMF and health have been hypothesized for a variety of health-related issues, including the emigration of health personnel [11,13], reduction of surveillance and disease testing [14–16], scalebacks of social safety nets [10,12], declining sustainability of subsistence economies [8,14,17], urbanization and migration patterns [14,16,18], and increased impoverishment and inequality [6,7,9,16]. More recently, the Center for Global Development convened a working group of leading economists from the IMF and World Bank, as well as public health experts, to assess the IMF's effect on the health sector (Does the IMF Constrain Health Spending in Poor Countries?) [5]. The final report concluded that “in a number of ways IMF actions have unduly constrained countries' policy choices and that it needs to do more to help explore a broader range of policy options” (page 56, [5]). However, to our knowledge, these hypothesized effects of IMF programs on health and health infrastructure have yet to be tested with empirical data [5,16]. The post-communist Eastern European (EE) and former Soviet Union (FSU) countries provide a quasi-natural experimental setting for studying the relationship between IMF programs and infectious disease control. Nearly every EE/FSU country during the early- to mid-1990s participated in an IMF program for the first time, and country participation in relatively similar IMF programs occurred in different periods, for different loan sizes, and for varying durations (table I in Text S1). We studied how these different IMF programs impacted upon differences in tuberculosis incidence, prevalence, and mortality trends among EE/FSU countries. Tuberculosis was the subject of interest because of the extensive longitudinal data available to study the disease in EE/FSU countries, and because tuberculosis incidence and prevalence is an indicator of societal health [19]. Existing medical and public health literature has suggested a relationship between IMF programs and infectious disease outcomes, and the effect is hypothesized to be mediated via the health system, to which tuberculosis outcomes are sensitive [10]. During the 1990s, EE/FSU countries experienced significant and increasing variations in their tuberculosis burdens: in the FSU, tuberculosis mortality rates doubled from 1991 to 2002 (from 6.2 to 13.3 per 100,000 population), while mortality in the EE started from a similar level but alternatively fell by roughly 40% (from 5.6 to 3.2 per 100,000 population) (see also table I and II in Text S1). In parallel, among FSU countries the average outstanding IMF debt was $850 million for an average of 10.3 y in 1989–2005, compared to $270 million among EE countries for an average exposure time of 5.5 y. The country with the greatest proportional tuberculosis mortality rate drop over this period, Slovenia, was the only one that did not partake in an IMF program. Today, tuberculosis rates in the FSU countries rank among the worst in the world, and the WHO notes that FSU is the only region lagging behind on Millennium Development Goal number 6 target to “halt and reverse” the spread of tuberculosis [1]. Figure 1 compares average trends in tuberculosis mortality rates for EE/FSU countries participating in IMF programs and countries that were not participating from 1991 to 2003. Countries involved in IMF programs experienced significantly different trajectories in tuberculosis mortality rates than countries that were not under these programs. In this study, we examine the relationship revealed by this figure, by further characterizing the relationship between IMF lending programs and tuberculosis incidence, prevalence, and mortality trends among the post-communist EE and FSU countries. PPT PowerPoint slide

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larger image TIFF original image Download: Figure 1. Trends in Tuberculosis Mortality Rates in Post-Communist European Countries, By Region Data sources: authors' calculations, WHO Global Tuberculosis Database 2007 [20], and World Bank World Development Indicators 2005 edition. https://doi.org/10.1371/journal.pmed.0050143.g001

Methods Four sets of health outcomes data were used in the analysis, all of which are from the WHO. Tuberculosis incidence, prevalence, mortality, and DOTS population coverage levels and treatment success rates were obtained from the WHO Global Tuberculosis Database [20,21]; HIV and AIDS prevalence data were obtained from the WHO/UNAIDS Global HIV database [22]. IMF data were from the World Bank World Development Indicators (WDI) [23]. Control variables were from the WHO European Health For All Database 2007 edition, WDI, and UNICEF TransMONEE database [24]. Data sources are further described in Text S2. Despite evidence of underreporting in homicide and suicide data, in particular for the North Caucuses, the consensus among scholars of mortality data in transition has been that they are sufficiently reliable to permit comparative studies [25–30]. Nonetheless, we coped with data monitoring and quality through the use of several techniques. First, we introduced a set of dummy variables for each country, which holds time-varying effects, such as the strength of national surveillance systems, that are national in scope constant within nations (though see the paragraph on detection biases, below). These variables also correct for factors that differ across countries but remain fixed over time, such as membership in the former Soviet Union or proximity to Western Europe as well as initial transition conditions and country predispositions to higher mortality. This conservative modeling approach isolated how changes within individual countries impacted upon their tuberculosis mortality profiles [31], rendering the available data suitable to answer our research question. Selection bias may be an issue for assessing the effect of IMF programs on tuberculosis incidence and mortality rates. Participating in an IMF program may have been an act of financial desperation, reflecting “how sick the country was to begin with,” which could be linked to higher tuberculosis mortality rates irrespective of taking the IMF programs' “medicine.” We controlled for this “sick patient” possibility using a lag of the change in overall log gross domestic product (GDP) in our main models as well as other observed financial health measures in a series of robustness checks. Our controls for differences between countries also net out potential unobserved selection biases relating to country predispositions to undertake IMF programs. Lastly, we modeled the hazard of participating in an IMF program for each country, and used this constructed variable to explicitly control for potential unobserved selection bias (“Heckman-type” selection model or “control function” approach, see the discussion in Text S7) [32–34]. We considered the impact of detection bias. If IMF programs damaged public health capacity, they would be expected to lead to underreporting of tuberculosis outcomes, which would have reduced the likelihood of observing evidence to support this hypothesis. On the other hand, if IMF programs improved public health infrastructure, then they could have led to improved surveillance, revealed by increasing tuberculosis rates followed by eventual declines in tuberculosis rates. We tested the relationship between IMF programs and public health spending and resources in order to characterize the relationship between IMF programs and actual increases in tuberculosis rates, to determine whether detection biases may have occurred. We also used controls for DOTS treatment success and DOTS population coverage, measures of quality and quantity of tuberculosis treatment, to offset differences in tuberculosis infrastructure. Lastly, we used a set of period effects to control for secular trends in the mortality data that may have occurred as a result of changes in detection capacity. Several variables were introduced as controls, to examine the independent association of IMF programs with tuberculosis outcomes. We controlled for overall economic development; democratization, which has been theorized to exert positive effects on health [35] and captures political changes in each country; the occurrence of military or ethnic conflict, which has been shown to adversely impact disease incidence and mortality surveillance [21]; urbanization, which may facilitate the transmission of tuberculosis but also provide access to better health-care services, and serves as a proxy for overall social development; population dependency ratios, which reflect the stage of demographic transition and population age-structure; and population education levels, which captures the stock of human capital. Thus, we specify the following log-linear regression model: In Equation 1, i is country and t is year. IMF is a dummy variable for whether a country was receiving IMF funding; GDP is logged per capita in constant USD for the year 2000; GDPc is the lag of GDP change; DEM is an index of democratization from the Freedom House democracy indicators database [36]; WAR is a dummy variable for whether a country experienced military or ethnic conflict; URBAN is the percentage of the country's population living in urban settings; EDUC is the percentage of the population that has received tertiary education; μ and η are sets of dummy variables that control for country and period effects, as described above. We subsequently add further variables to test the associations of the duration of exposure to IMF programs and the size of IMF loans with tuberculosis outcomes. We also performed Granger- and Sims-causality tests, which use the longitudinal nature of the data to test (i) whether IMF programs preceded and/or were contemporaneous with tuberculosis outcomes (“precedence”) and (ii) whether the future values added predictive value beyond these measures as a negative check on our findings (based on the principle that the future does not cause the past) (see Text S4 for more details) [37,38]. Data were analyzed using xtreg with the fe and cluster options in STATA version 9.2.

Discussion Our results show that IMF economic reform programs are strongly associated with rises in tuberculosis mortality rates in post-communist Eastern European and FSU countries, even after correcting for potential selection bias, tuberculosis surveillance infrastructure, levels of economic development, urbanization, and HIV/AIDS. We estimated an increase in tuberculosis mortality rates when countries participate in an IMF program, which was much greater than the reduction that would have been expected had the countries not participated in an IMF program. On the other hand, we estimated a decrease in tuberculosis mortality rates associated with exiting an IMF program. Both the duration and amount of IMF lending have an estimated dose-response relationship with tuberculosis mortality rates: each additional year of participation in an IMF program was associated with increases in tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increases in tuberculosis mortality rates by 0.9%. Debt to non-IMF lenders was found to have a slightly favorable association with tuberculosis mortality rates. The robust results observed help to account for puzzling differences in why countries such as Russia, which was exposed to the IMF's economic program for 13 y (corresponding to a ∼50% higher level in tuberculosis mortality rates) did so much worse than Slovenia, which did not undertake an IMF program. Similarly, Russia's level of DOTS coverage in 2003 was only 25%, whereas in Slovenia DOTS coverage had reached 100% already by 1996. Clearly, IMF programs are not the only explanation for variations in tuberculosis control, but these results offer a partial account of the ultimate correspondents of cross-country differences. Our findings were robust to a broad set of socioeconomic measures. However, there are several important limitations to our analysis. First, as with all cross-country analysis, the potential exists for ecologic fallacies, though we have employed a number of well-accepted statistical tests for causal inference that strongly support the link between IMF policies and tuberculosis outcomes. The mechanism we hypothesize for the IMF's relationship to tuberculosis outcomes is plausible, given the numerous studies suggesting such a relationship between IMF conditionalities and infectious disease outcomes [6,7,9–18]. We also applied statistical methods less frequently used in epidemiology both to examine the nature of selection bias (Heckman) and to describe temporal causality (Granger and Sims) in a manner that could be applied to future epidemiological studies [37,38]. Another limitation to our findings is the potential for detection biases arising from temporal variations in tuberculosis surveillance within countries. However, our results are robust to a wide variety of health measures that can reasonably be expected to serve as proxies for the observed changes. If IMF programs did somehow lead to improved tuberculosis surveillance, net of controls, they might have lead to artifactual short-term increases in tuberculosis rates. Yet all of our evidence points to the contrary: IMF programs were linked to reduced government spending, less health resources per capita, and decreased tuberculosis treatment coverage. This suggests that IMF programs damaged health surveillance infrastructure, and any residual detection bias in our models rendered our conclusions conservative. It would be appropriate to further investigate the relationship between IMF policies and other diseases and their related infrastructure, as this analysis is restricted to tuberculosis outcomes and program variables. While our preliminary analysis suggests a weak negative connection between IMF programs and life expectancy levels more generally (unadjusted Pearson's R = −0.18, p < 0.01) that was similarly observed for non-IMF debt albeit less significant (unadjusted Pearson's R = −0.09, p = 0.11), we cannot rule out that IMF programs are not associated with some health improvements in other ways we have not examined in this study. Another limitation to our study is that the implementation of IMF conditionalities themselves were not directly observed, but rather reflected by entry into and exit from IMF program participation, the size of the IMF loan, and the duration of exposure to IMF lending. While IMF programs typically involve a similar set of economic reforms, the specific package is likely to vary across countries. However, given the similar set of economic distortions in post-communist countries, the IMF economic reform programs were much more homogenous than those implemented in more diversified economic contexts [42]. Analyzing the unique EE/FSU setting that enjoyed relatively strong public health programs restricts our ability to generalize the results to low-income countries with weaker health infrastructure. Subsequent research should focus on resolving which specific policy components of the IMF programs drove the adverse tuberculosis outcomes identified in this study. Although our findings support the hypothesis that the adverse associations of IMF programs with tuberculosis outcomes are constituted by reductions in tuberculosis control infrastructure, more research is needed to specify the mechanisms in greater detail and compare their relative magnitude. Some possible mediating factors include abridged access to, or decreased quality of, tuberculosis care that may arise from shifting the burden of treatment costs onto patients, or from privatizing health care services that may exclude marginalized groups [6,43–45]. It is likely that our results reflect the distributional consequences of IMF programs for societies, especially since previous studies have suggested that IMF programs have disproportionately hurt the poor [46,47]. To analyze whether IMF programs have increased poverty in the EE/FSU context, however, is beyond the scope of our current study. Future research should also attempt to resolve how tuberculosis program outcomes observed in this study might be affected by reforms to IMF programs. The Center for Global Development report on whether IMF programs constrain health spending notes “So humility is required when pronouncing on the appropriate macro framework unless country-specific evidence on such relationships is available. In practice, policy choices must inevitably be made under considerable uncertainty and need to take account of the implied costs of different types of potential mistakes. For example, risks to macroeconomic stability have to be weighed against foregone opportunities for additional public spending” (page 6, [5]). This study begs the same question, but in the opposite direction: can the foregone opportunities for health expenditure and the toll of human lives be justified by the macroeconomic stability the IMF might have created? Our regressions give us further insight to this issue. The IMF has argued that “Wealthier is Healthier,” (to quote Pritchett and Summers [48]); that is, by promoting economic development, public health will be improved. We can ask how much wealthier a country has to be as a result of an IMF lending program in order to offset the tuberculosis associations identified here. The coefficient on country income per capita reveals that each 10% increase in GDP is associated with decreases in tuberculosis by close to 2.5%. Since an IMF program is connected with an increase in tuberculosis by 17%, this means that per capita income would have to nearly double to offset the rise in tuberculosis. Unfortunately, no EE/FSU country has come near that level of growth. The results presented here suggest that while macroeconomic stability might spare some lives, the magnitude needed to offset the tuberculosis-related harms is implausible at present. On the other hand, the World Bank has recently shown that reducing tuberculosis in EE/FSU countries would boost economic growth and has urged countries to fully implement the Global Plan to Stop TB (see [49] and http://www.stoptb.org). The results of this analysis suggest that the IMF should take into account the potential impact of its programs on tuberculosis control systems. Although in recent years the IMF has begun to play a direct role in supporting tuberculosis and HIV/AIDS control efforts via poverty reduction programs [50,51,13], the IMF should critically evaluate the indirect effects of its economic programs on tuberculosis control efforts. Securing health systems that are robust to tuberculosis should be a first-order concern for international financial institutions when attempting to create the conditions needed for sustainable economic development.

Author Contributions DS formulated the study question and project design and performed the statistical analysis. LPK and SB contributed to the study design and analysis. DS, LPK, and SB contributed to the writing of the manuscript.