The empirical studies identified in our systematic review are virtually unanimous in finding a detrimental association between structural adjustment and child and maternal health outcomes. However, these studies treat structural adjustment as a ‘black box’—assessing its aggregate effect on child and maternal health outcomes rather than delineating pathways. Identifying plausible mechanisms is also important insofar as there are some aspects of structural adjustment that are beneficial to health outcomes, even while the net effect is detrimental. Applying Kentikelenis’ framework for assessing the potential health effects of structural adjustment programmes, we organise the mechanisms linking IFI programmes with child and maternal health outcomes into (a) those mediated via direct effects on health systems, (b) those mediated via indirect effects on health systems, and (c) those related to the social determinants of health . Pathways discussed in this section include those hypothesised in the empirical studies reviewed above, as well as additional empirical, conceptual, and review articles identified through the literature search process.
Changes to child and maternal health via direct effects on health systems
Policies adopted in adherence with structural adjustment programmes frequently bear consequence to the functioning of health systems, with implications for child and maternal health outcomes. First, structural adjustment is hypothesised to affect government health expenditure, which in turn alters the quality and quantity of services provided to children and mothers [2, 3, 9, 12, 24, 49, 54, 55]. Governments may be under explicit or implicit pressure to cut social spending in order to meet fiscal targets, thereby reducing the fiscal space in which healthcare systems can operate [8, 55–57]. Consequently, countries experience medical supply shortages , loss of human capital , and replacement of defunded maternal health services with ineffective traditional birth attendant programs . One study found that reduced government funding weakened health services, such that responses to HIV/AIDS in Sub-Saharan Africa were significantly impaired . Empirical studies assessing the effect of health expenditures or government spending more broadly find a significant and detrimental relationship with infant mortality [58, 60, 61], under-5 mortality , and other health outcomes . IFI-affiliated authors contest the notion that structural adjustment programmes reduce health spending  or claim they are associated with increased spending [19, 20, 64, 65]. Conversely, independent scholars tend to present a conditional account in which spending increases only in Sub-Saharan African low-income countries and autocracies, while decreasing in other low-income settings .
Structural adjustment can similarly affect the healthcare workforce, thereby altering the quality and quantity of healthcare staff available to treat child and maternal health conditions [7, 66]. Adjustment programmes may include conditions that specify ceilings on the public sector wage bill, which can force government cuts to wages and personnel in the healthcare sector . Reduced wages and job security often creates incentives for health workers to move elsewhere, producing ‘brain drain’ . In 2007, the IMF changed their wage bill ceiling policy in recognition of its adverse effects [19, 67, 68] and have argued this issue no longer stands [64, 69]. Nevertheless, wage bill ceilings remain a persistent, if subtle, feature of recent programmes .
Structural adjustment programmes frequently introduce cost-sharing or user fees to enhance the fiscal sustainability of healthcare services [4, 70]. While fee introduction can increase the range of services available to middle classes and wealthy elites, they can greatly reduce access to even the most rudimentary health services for the poor [4, 6, 56, 71]. A World Bank directive to introduce a US$0.33 charge for outpatient health centre visits saw a 52% reduction in visits, followed by a 41% recovery when user fees were suspended . Furthermore, user fees are associated with greater incidence of stunted growth in children , dramatic reductions in women’s use of STI clinics , and barriers to access for antimalarial medication and antibiotics . A design simulation model of 20 African countries employing user fees for health concluded that abolition of fees could prevent an estimated 233,000 under-5 deaths annually or 6.3% of such deaths in these settings . As per wage bill ceilings, user fees are no longer endorsed by IFIs .
IFIs commonly prescribe changes to the public-private mix in the health sector. Increasing private provision of health services is hypothesised to broaden access to services for the middle and upper classes, but raises financial barriers for poor women and children as providers shift to a profit-driven business model [8, 9, 54].
IFIs also endorse state retrenchment in the provision of healthcare and other services to promote a greater role for non-governmental organisations (NGOs) [10, 54]. An empirical study on the link between the increasing role of NGOs in health provision and maternal mortality rates found support for what the authors term the “political opportunity structure hypothesis”, whereby NGO provision of healthcare produces greater reductions in maternal mortality as nations become more democratic. According to this account, popular mandates increase the leverage that civil society organisations wield in relation to government decision-making, thereby increasing their capacity to influence health spending . While this may suggest NGOs are an adequate substitute for public healthcare in democratic settings, the study was severely limited by data availability.
Similarly, adjustment programmes commonly promote decentralisation of health systems in favour of increased local autonomy . Decentralised systems allow services to address region-specific demands, but may produce a more fractious and unequal implementation of services—including those for child and maternal health—nationally. Furthermore, lack of co-ordination in decentralised systems can hinder efforts to combat major disease outbreaks .
Finally, in recent years IFIs have made an increasing effort to include priority spending floors, which protect health spending from fiscal consolidation [21, 65, 72, 73]. IFI-affiliated authors claim that these floors have increased access to, and supply of, health services—including those for children and mothers—by ring-fencing health spending . In support of this appraisal, archival evidence on IMF programmes in West African nations shows that, in select instances, priority spending floors contributed to increases in budgetary allocations for health, as was the case for Gambia in 2012 and Benin in the late 1990s [27, 55]. As noted above, fund programs are also associated with higher health expenditures in Sub-Saharan African low-income countries, which historically spent less than any other region . However, despite some successes, the evidence shows social spending targets are upheld less than half the time, while fiscal targets are rarely breached [22, 23].
Changes to child and maternal health via indirect effects on health systems
The effects of structural adjustment policies on health systems are often indirect. One mechanism by which health systems are indirectly affected is via currency devaluation. Devalued currencies promote export competitiveness, but increase the real cost of imports, including pharmaceutical goods and health equipment [4, 6, 8, 49], which may plausibly have negative implications for child and maternal health outcomes; however, we identified no empirical studies verifying the link.
Structural adjustment programmes also promote trade and capital account liberalisation measures, such as the removal of tariffs and capital controls, to encourage growth and foreign direct investment. While tax revenues can increase in the long run if these measures stimulate growth, scholars raise concerns about both the short-run loss of tariff revenue available for healthcare and the long-term repatriation of profits by multinationals receiving tax holidays [6, 8, 9, 12, 49, 52, 53]. One study reports that the mass migration of smallholder farming families to urban areas caused by aggressive trade liberalisation policies was a major contributor to the HIV epidemic in Sub-Saharan Africa . Despite claims by critics to the contrary, IFIs maintain they are not ideologically predisposed to trade liberalisation .
Privatisation outside the health sector can have indirect influences on health systems as well. The sale of state-owned enterprises may produce a windfall in the short-term, but the cumulative loss of profits from such businesses reduces government revenues in the mid-term. Accordingly, fewer resources are available to finance healthcare subsidies and services for children and mothers [4, 49, 59]. Privatisation may also result in public sector job loss that is not necessarily substituted by the establishment of new positions in the private sector. For example, more than 150,000 workers were displaced when Ghana privatised 42 of its largest state enterprises between 1984 and 1991. Such unemployment disproportionately affects women, who are likely to be lower skilled and made redundant, which in turn increases commercial sex uptake, and—due to greater risks of contracting STIs—can lead to complications during child birth .
In addition, countries receiving structural adjustment loans must devote government revenue to facilitate debt servicing. Unless protected or substituted via external sources, resources devoted to debt servicing may impinge upon health sector budgets, thereby reducing spending dedicated to improving child and maternal health outcomes [2, 3, 8, 9, 12, 49, 53]. While this association seems plausible, we identified no empirical studies investigating the connection.
Finally, structural adjustment programmes can catalyse aid inflows by signalling to donors that a country possesses sound governance and fiscal management . These increased inflows may help to offset negative effects on child and maternal health outcomes by channelling resources back into healthcare provision. Indeed, a doubling of health aid is associated with a 2% reduction in infant mortality rate . However, a recent study examining the types of aid catalysed by IFI programmes found no significant effect on health aid inflows .
Changes to child and maternal health via effects on social determinants
Structural adjustment policies may influence child and maternal health in ways which bypass health systems, and instead act upon the social determinants of health . One example is the increased reliance on unsanitary water accompanying increasing privatisation and deregulation. Water and sanitation facilities under private ownership may introduce unaffordable fees for water access, leading the poor to rely on water from degraded sources. Pathogens in such waterways can lead to diarrhoea infections, which disproportionately affect children, while improved water sources and sanitation both improve child mortality by removing exposure to such pathogens .
Trade liberalisation and currency devaluation can lead to a rising real price of food, which in turn reduces maternal and child nutritional intake . A World Bank study into the link between commercialisation of agriculture and child malnutrition in Malawi found that children who came from households dependent on cash crop production were more vulnerable to stunting in response to food price shocks than those from less reliant households . This implies that dependence on cash crop production for subsistence magnifies vulnerability to global market conditions, to the detriment of child nutrition. Liberalisation has also been linked to a ‘nutrition transition’ owing to the penetration of multinational supermarkets and fast food brands, leading to the double burden of both malnutrition and obesity in the same settings .
IFI fiscal consolidation policy justifies short-run economic contraction on the grounds that resolving balance-of-payment issues and transitioning to a model of export-oriented, private sector-led growth will maximise economic growth in the long run. However, increased short-run unemployment may reduce income available to pay for healthcare even as privatisation and user fees increase the cost of services . Moreover, IFIs may miscalculate the duration and depth of fiscal contraction. The IMF’s own Independent Evaluation Office noted a “tendency to adopt fiscal targets based on overoptimistic assumptions about the pace of economic recovery” (p. vii), thus multiplying the negative impact of economic contraction . Further, the ubiquity of export-led growth strategies worldwide as per the Washington Consensus may constitute a fallacy of composition, in that it necessarily depends on regional trade partners running trade deficits .
Finally, structural adjustment affects broader psychosocial dynamics. For instance, changes to social and labour policies can heighten psychosocial stress, with implications on health outcomes, including child and maternal health; or, alternately, prompt greater social cohesion as communities work to overcome adversity . Adjustment policy may also provoke social unrest, thereby exacerbating existing social, economic and health problems .