title: International Monetary Fund programs and tuberculosis outcomes in post-communist countries.
abstract: BACKGROUND
  Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries.
  
  
  RESULTS
  We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (-7.6%, 95% confidence interval, -1.0% to -14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables.
  
  
  CONCLUSIONS
  IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis-related health outcomes.
authors.affiliation: Faculty of Social and Political Sciences, University of Cambridge and King's College, Cambridge, United Kingdom. ds450@cam. ac.uk
authors.forename: David
authors.initials: D
authors.lastname: Stuckler
authors.forename: Lawrence P
authors.initials: LP
authors.lastname: King
authors.forename: Sanjay
authors.initials: S
authors.lastname: Basu
mesh_terms: D003148:Communism; D005061:Europe, Eastern / Q000453:epidemiology; D005376:Financial Management; D006801:Humans; D009313:National Health Programs / Q000191:economics / Q000592:standards; D011787:Quality of Health Care; D014376:Tuberculosis / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control*; D014586:USSR; D014480:United Nations; D014944:World Health Organization