تاثیر مشروعیت صندوق بین المللی پول بر هزینه های بهداشتی دولت: یک تحلیل متقابل بین 16 کشور آفریقای غربی The impact of IMF conditionality on government health expenditure: A cross-national analysis of 16 West African nations

1. Introduction Strengthening public healthcare systems is central to achieving Universal Health Coverage (UHC), a key objective of the United Nation’s Sustainable Development Goals (UNGA, 2015; WHO, 2014). Yet, in low-income countries (LICs), especially those dependent on aid or subject to fluctuating commodity prices, it is unclear how progress can be sustained. Recent studies highlight the importance of funding UHC through increasing domestic tax revenues and employer contributions (O’Hare, 2015; Reeves et al., 2015). Success will also depend on the ability to overcome longstanding barriers to health system expansion, including legacies of conflict, state failure, and underinvestment in healthcare facilities and personnel (Benton & Dionne, 2015). Foreseeably, a multitude of global actors will contribute to shaping the design, implementation, and ultimate outcome of these endeavours (Chorev, 2012; Patel & Phillips, 2015). Quite possibly the most important international institution setting the fiscal priorities of LICs is the International Monetary Fund (IMF). Established in 1944, a core function of the organization has been to provide financial assistance to countries in economic turmoil. In exchange for this support, countries agree to implement IMF-designed policy reform packages phased over a period of one or more years—so-called ‘conditionalities’. Over the past two decades, the 59 countries classified by the IMF (2015b) as LICs have been exposed to conditionalities for 10.3 years on average, or one out of every two years. The IMF’s extended presence in LICs has spurred a great deal of controversy. Critics stress inappropriate or dogmatic policy design (Babb & Buira, 2005; Babb & Carruthers, 2008; Stiglitz, 2002), adverse effects on the economy (Dreher, 2006), and negative social consequences (Abouharb & Cingranelli, 2007; Babb, 2005; Oberdabernig, 2013).