The impact of World Bank and International Monetary Fund programme lending on health care delivery, health conditions and health status in sub-Saharan Africa, 1980 to 1992
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The World Bank and the International Monetary Fund have been active in Africa for several decades. In the early 1980s both institutions expanded the role that they play in the restructuring of African economies through the introduction of structural adjustment loans. These programme loans sought to provide the basis for sustainable economic expansion following a period of near economic collapse in the region. In the case of the Fund, public expenditure reducing and expenditure switching policies were encouraged. The Bank, also, was active in these areas and focused on long-term measures to restore efficiency to the ailing economies. These policies, although not novel, were implemented on a large scale were perceived to have a pervasive influence on the economic and social performance of African countries. It was theorised by some that such programme lending would have a long-run beneficial impact on social development. However, other authors, observers and researchers have criticised the activities of the Bretton Woods institutions. First, the loans have been heavily criticised in the past for the supposedly heavy handed nature that Bank and Fund staff use in implementing their programmes. The main idea is that the institutions have too much leverage when bargaining with African governments to undertake reforms. Second, it has been said that the use of programme loans will have adverse consequences for national welfare. UNICEF, the main critic, has pointed out, and provided evidence, to indicate that vulnerable groups in society may suffer under adjustment schemes. This thesis looks at the areas of macroeconomic reforms and the impact that they may have on one part of the social area: the health sector. The thesis examines the pre-adjustment situation in Sub Saharan Africa and reviews the role and the tools that the Bank and the Fund have at their disposal to tackle economic problems. The thesis then moves on to explore the linkages between these policy weapons and changes in health care development. In order to fully understand the implications for Africa considerable attention is devoted to exploring the health problems that the region faces and the health care delivery systems and health conditions that are prevalent in many of the countries. The last part of the thesis provides an aggregate study and a case study analysis of the impact of adjustment in Africa. Although, it is determined that the impact, overall, has not been unfavourable, recommendations for the future design of adjustment programmes is offered in the conclusion.
Thesis, PhD Doctor of Philosophy
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