A vulture flies off as others stand on the roof of the maternity ward in the government hospital in Koidu, Kono district in eastern Sierra Leone, Dec. 20, 2014. (Baz Ratner/Reuters)

Following Chris Blattman’s post, “Did the International Monetary Fund help make the Ebola crisis?”, the authors of the Lancet Global Health article, Alexander Kentikelenis, Lawrence King, and Martin McKee, have written the following response.

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What is the legacy of decades of IMF programs for the health systems of the three Ebola-stricken West African countries? In a recent article for the Lancet Global Health, we examined the IMF’s own archival documents — loan agreements with Sierra Leone, Guinea, and Liberia — and identified three ways consecutive lending programs contributed to weak health systems: overall fiscal constraints, reductions in public sector employment, and the premature decentralization of health policy.

Responding to our article, Chris Blattman disagreed. His general point was that the IMF is irrelevant in discussions of health policy in poor countries. We wish we could agree. However, a large body of research demonstrates the many and varied effects of IMF programs on a range of social indicators, including health (more recently, on tuberculosis, HIV, poverty and inequality, and environmental pollution). In particular, Blattman raised a number of specific objections to which we respond below.

First, Blattman argues that the main reason behind weak health systems is the lack of state capacity resulting from years of civil war. We fully agree, and we never denied that civil wars and poorly functioning states were not key reasons for weak health systems in these countries. Our argument, however, is that the policies promoted by the IMF exacerbated problems of state capacity.

Second, Blattman argues that these countries were ‘awash with more outside money than ever before.’ Yet, even if development assistance for health may have poured into these countries in recent years, that is not to mean that it would actually translate to additional government health spending. Indeed, evidence suggests that so-called health aid displacement is greater among IMF borrowers. In addition, notwithstanding recent aid trends, the impact of the IMF has manifested itself over many years. Since 1990, Guinea and Liberia have been under IMF tutelage for about two decades, and Sierra Leone for seven years. The legacy of austerity measures and structural reforms is cumulative and easily missed if only examining the most recent period.

Third, Blattman asserts that these governments were not interested in investing in building up their health systems because they had spending priorities related to averting violent conflict. This view assumes that these countries are unwilling or incapable of pursuing an agenda broader than narrow law-and-order priorities. This claim involves an analytical challenge and overlooks the actual experience of countries. Analytically, the issue is how to establish ‘government intent.’ If we consider declarations of governments and rising public health spending trends (from extremely low initial levels), then the governments of these three nations were committed to strengthening health policy. Indeed, as evidenced in their Poverty Reduction Strategies, governments wanted to spend even more. Further, country policies document the intention to build up health policy. For instance, Sierra Leone launched its ambitious and lauded Free Healthcare Initiative in 2010 that provided access to services to pregnant women, new mothers, and children.

Finally, Blattman criticizes us for ‘assum[ing] the IMF had any real influence over health policy and spending.’ By ‘real influence’, Blattman — presumably — means direct influence. We are in agreement with him, that this type of influence is likely very limited. Health ministry officials do not routinely meet IMF missions to discuss the conditions of bailouts. However, this is a very limiting way to understand power. Indeed, the effects of the IMF — as we demonstrated in our paper — are mostly indirect, but still very ‘real.’ Bailout programs by the IMF stipulate extensive conditions for public spending and, until very recently, on the number or remuneration of public sector employees. Health policy can thus be subject to collateral damage, despite rhetoric of the IMF to the contrary. For example, as the Guinean authorities reported to the IMF in 2013, ‘unfortunately, because of the reduction in spending, including on domestic investment, it was not possible to respect the indicative targets for spending in priority sectors.’ This kind of IMF influence — one step removed from those affected — arguably is all the more dangerous, as it precludes direct negotiations and influencing.

To conclude, we understand the IMF as exercising a powerful influence over borrowing countries’ policy making. In addition to serving as a de facto lender of last resort, it catalyzes aid from the donor community and its symbolic capital can legitimize domestic actors. Consequently, the organization is often able to influence the domestic balance of power, sometimes in decisive ways. To suggest that the IMF had no influence whatsoever on health system development (or other social policies) in three of the very poorest countries in the world, while they were under IMF-supported programs for extended periods of time, strikes us as completely implausible.

In his critique, Blattman accuses us for ‘doing research from afar’ and not understanding ‘how weak states actually work.’ As our response suggests, the arguments by Blattman — despite having been developed in geographical proximity to the IMF — fail to consider ‘how the IMF actually works.’ The IMF’s acronym is occasionally interpreted as ‘It’s Mostly Fiscal.’ Pretending that fiscal effects and structural reforms have little to do with health or social policy areas is problematic. If anything, this can lead to complacency about the very tangible effects that the IMF has for the policies of its borrowers. More evidence-based debates are essential, rather than simply assuming the IMF away.

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Alexander Kentikelenis is a Research Associate in Political Economy and Sociology at the University of Cambridge. You can follow him on Twitter at @KentikelenisLawrence King is a Professor of Political Economy and Sociology at the University of Cambridge. Martin McKee is a Professor of European Public Health at the London School of Hygiene and Tropical Medicine.