ABSTRACT
The structural adjustment policies refer to a set of macroeconomic measures designed to address the underlying structural problems that led to the economic collapse of several developing countries in the 1980s and 1990s. These policies usually start by a stabilization package financed basically by the International Monetary Fund (IMF) to cut the budget deficit and control the inflation rate.
This initial stabilization is then followed with structural reforms to reduce the state involvement in the productive, financial and social fields and to encourage the private and non-governmental sectors to replace the state in these fields.
Governments are required to bring in new legislative and legal frames required to put the adjustment activities into action. These activities include privatization of the state-owned enterprises, elimination of control over prices, liberalization of the trade and financial regimes and cutting back governmental expenditure.
The ultimate goal of the structural adjustment is to achieve positive economic growth rates.
The impact on health of the structural adjustment policies has emerged as a controversial debate in international health. Some economists and public health researchers and some government and non-government commentators allege that the structural adjustment programs have had a detrimental health impact.
Some have even alleged that the health outcomes of the structural adjustment programs have been so adverse as to reverse many of the gains made in the earlier post world war II decades.
This study was undertaken to ascertain and identify means of improving the impact on public health in developing countries of their structural adjustment programs. For doing that, the “Deductive pragmatism” design was innovated, its principles were laid, and tools were developed. Deductive pragmatism is a research method aiming at helping researchers communicate qualitative assumptions about cause-effect relationships, elucidate the ramifications of such assumptions and drive causal inferences from a combination of assumptions, experiments, observations and case studies. This unique methodology couples the affirmative nature of causal effects tracing measures
(such as correlational studies) with the interpretive nature of process tracing schemes usually found in case studies and other qualitative methods.
Furthermore, it bridges the gap between the academic interests of research and the prescriptive demands of policy-making.
The study has basic three features. First, analysis toke place within a consistent causal model: rich enough to be comprehensive in causal factors– including background conditions and other external shocks as well as the structural adjustment program, be able to identify the separate contribution of each key component of a country’s structural adjustment program, and be attentive to the time path of health effects, distinguishing between the short, medium and long run. Such a comprehensive disaggregate consistent framework is required to sort out which causes contribute to each health outcome, and where there are multiple causes, the differential magnitudes of their respective contributions. Second, Emphasis on the intermediate causal links between structural adjustment programs and health outcomes. These are where a scope for intervening is anticipated to alleviate or even reversing adverse health impacts. Third, emphasis on early warning indicators that can be used in assessing the detrimental effects of the structural adjustment program on health, distinguishing between short, medium and long run effects, and the effectiveness of interventions in alleviating those detrimental effects.
According to the deductive pragmatism model, three direct causal pathways were drawn and examined for the potential impact of structural adjustment on health. The first encompassed a direct pathway on survival and health, which included survival indicators, mortality indicators and summary (composite) health indicators. The second traced a direct causal pathway on health system performance, including health system performance on health, responsiveness and fairness of financial contribution. The third examined a direct causal pathway on health system financing, including levels of financing and patterns of spending.
Furthermore, four indirect pathways between structural adjustment were drawn and examined. The first traced the allegation that the introduction of cost recovery and user fees schemes has led to severe under-utilization of health care services, especially by the poor. The second examined the assumption that
the privatization of health system has led to deterioration in the quality of health services by fostering the uncontrolled practice of the private sector. The third ascertained the impact of adjustment on poverty and income inequalities.
The fourth pathway traced the impact of structural adjustment on education and literacy.
For the empirical analysis, data about indicators of these casual domains were compared between adjusting and non-adjusting countries and before and after adjustment. Furthermore, the levels and trends of these indicators were examined in relation with the duration of structural adjustment implementation.
Analysis was stratified by region and by national income category to control and minimize the effect of these two variables. The analysis included 90 low and middle income countries, 63 countries were classified as adjusting and 27 as non-adjusting countries. With respect to region, 39 countries were from sub- Saharan Africa, 14 countries from the Middle East and North Africa, 21 countries from the Latin and Middle America and 16 countries from the Asia and Pacific region.
Causal process tracing in this study used a hybrid approach between linear and convergent colligation. The "linear colligation," depicts “a straightforward chain of events" which is often a simplification of a complex phenomenon.
Convergent colligation depicts the outcome to be explained as flowing from the convergence of several conditions, independent variables, or causal chains.
The overall model for the causal relation was designed using the linear colligation form. Using that form, the causal chain including all the seven causal domains of the model was linked with each other. These causal domains are a direct detrimental effects on health, health system performance, health system financing, poverty and income inequalities and education and literacy. Within each domain, a complicated causal limb was proposed using the convergent colligation form of process tracing.
The results of the study showed that the levels and trends of the majority of the indicators included in the empirical analysis did not differ between adjusting and non-adjusting countries in a statistically significant manner. In the few cases where a statistically significant difference was obtained, the difference was either in favor of adjusting countries or disappeared when the analysis was
stratified by region or by national income. Furthermore, a dose-response relationship between the duration of structural adjustment implementation and all the indicators was not established. The causal tracing supported these results with the qualitative evidence.
The conclusion to be drawn from this study is that the claims that structural adjustment has had a detrimental impact on health in developing countries is baseless. Furthermore, it shows that structural adjustment failed to have positive impact on the health status or its proximal determinants. The study asserts that the previous two decades of economic and structural reforms fell short from exerting any real impact on the vast majorities of the population in developing countries.
The study advances the opinion that the adjustment lending was a political interaction between the lending agencies and the national elites in the recipient countries. The concerns about the negative effects of the structural adjustment have been voiced by the middle class, entitled to research and policy making in these countries. Structural adjustment policies affect basically the benefits of these groups. The poor on the other side were shown to have very little benefits from the current system of power relations in developing countries.
This was shown to be the case of developing countries with and without structural adjustment.
ACKNOWLEDGEMENT
I would like to express my gratitude to my advisors, Prof. Dr Ulrich Laaser and Prof. Dr Alexander Kraemer, for their support, patience, and encouragement throughout my research. It is not often that one finds advisors who always find the time for listening to the little problems and roadblocks that unavoidably crop up in the course of performing research. Their technical and editorial advice was essential to the completion of this dissertation and has taught me innumerable lessons and insights on the workings of academic research in general.
My thanks also go to the members and students of the Section of International Public Health at the University of Bielefeld School of Public Health for reading previous drafts of this dissertation and providing many valuable comments that improved the presentation and contents of this dissertation. I would like to particularly thank my friend and colleague Ibrahim Khan for his help in producing this dissertation.
The contribution of Prof. Dr. Robin Pope and Prof. Dr. Reinhard Selten from the Center for Interdisciplinary Research is much appreciated and has led to many interesting and good-spirited discussions relating to this research. They inspired me in the development of the “deductive pragmatism” design and in several other areas of health economics.
I am also grateful to several friends and colleagues at the World Bank and the World Health Organization who provided me with the databases I needed for this research. They made available whatever documents and reports I asked for.
TABLE OF CONTENTS
Chapter 1. Introduction, background and rationale 1
Chapter 2. Study design: Deductive pragmatism as an alternative methodology 26
Chapter 3. Structural adjustment and life expectancy at birth 75
Chapter 4. Structural adjustment and childhood mortality 92
Chapter 5. Structural adjustment and maternal mortality 115
Chapter 6. Structural adjustment and disability adjusted life expectancy 138
Chapter 7. Structural adjustment and health system performance 172
Chapter 8. Structural adjustment and health system financing 198
Chapter 9. Structural adjustment, user fees, utilization and quality of health services 237
Chapter 10. Structural adjustment and privatization of health services 270
Chapter 11. Structural adjustment, poverty and income inequalities 299
Chapter 12. Structural adjustment, education and literacy 379
Chapter 13. Discussion and conclusion 412
Bibliography 439
