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.