In recent years, the International Monetary Fund (IMF) has re-emerged as a central actor in global economic governance. Its rhetoric and policies suggest that the organization has radically changed the ways in which it offers financial assistance to countries in economic trouble. We revisit two long-standing controversies: Has the policy content of IMF programmes evolved to allow for more policy space? Do these programmes now allow for the protection of labour and social policies? We collected relevant archival material on the IMF's lending operations and identified all policy conditionality in IMF loan agreements between 1985 and 2014, extracting 55,465 individual conditions across 131 countries in total. We find little evidence of a fundamental transformation of IMF conditionality. The organization's post-2008 programmes re-incorporated many of the mandated reforms that the organization claims to no longer advocate and the number of conditions has been increasing. We also find that policies introduced to ameliorate the social consequences of IMF macroeconomic advice have been inadequately incorporated into programme design. Drawing on this evidence, we argue that multiple layers of rhetoric and ceremonial reforms have been designed to obscure the actual practice of adjustment programmes, revealing an escalating commitment to hypocrisy. 'Structural adjustments? That was before my time. I have no idea what it is. We don't do that any more. No, seriously, you have to realise that we have changed the way in which we offer our financial support.'-Christine Lagarde, IMF Managing Director (IMF 2014g). 'Having known the history of [IMF] programmes, […in Iceland] the IMF was really rather flexible. I can't really make sense of this new, cuddly IMF; it can't possibly last.'-Martin Wolf, Financial Times chief economics commentator (Wolf 2011). 1 In addition, the organization's Research Department has also published new research as 'Staff Discussion Notes' (Dabla-Norris et al. 2013; 2015; Ostry, Berg, and Tsangarides 2014) that often go beyond official IMF line, as expressed in press releases, policy statements, or factsheets. The extent to which these findings are taken up in programme design is unclear, but recently, the IMF's own Independent Evaluation Office (IEO 2011 p. vii) reported 'a widespread view among IMF staff' that research findings were misaligned with the organization's policies. These issues are not further explored here.

How do International Monetary Fund (IMF) policy reforms-so-called 'conditionalities'-affect government health expenditures? We collected archival documents on IMF programmes from 1995 to 2014 to identify the pathways and impact of conditionality on government health spending in 16 West African countries. Based on a qualitative analysis of the data, we find that IMF policy reforms reduce fiscal space for investment in health, limit staff expansion of doctors and nurses, and lead to budget execution challenges in health systems. Further, we use cross-national fixed effects models to evaluate the relationship between IMF-mandated policy reforms and government health spending, adjusting for confounding economic and demographic factors and for selection bias. Each additional binding IMF policy reform reduces government health expenditure per capita by 0.248 percent (95% CI -0.435 to -0.060). Overall, our findings suggest that IMF conditionality impedes progress toward the attainment of universal health coverage.

Structural adjustment programmes of international financial institutions have typically set the fiscal parameters within which health policies operate in developing countries. Yet, we currently lack a systematic understanding of the ways in which these programmes impact upon child and maternal health. The present article systematically reviews observational and quasi-experimental articles published from 2000 onward in electronic databases (PubMed/Medline, Web of Science, Cochrane Library and Google Scholar) and grey literature from websites of key organisations (IMF, World Bank and African Development Bank). Studies were considered eligible if they empirically assessed the aggregate effect of structural adjustment programmes on child or maternal health in developing countries. Of 1961 items yielded through database searches, reference lists and organisations’ websites, 13 met the inclusion criteria. Our review finds that structural adjustment programmes have a detrimental impact on child and maternal health. In particular, these programmes undermine access to quality and affordable healthcare and adversely impact upon social determinants of health, such as income and food availability. The evidence suggests that a fundamental rethinking is required by international financial institutions if developing countries are to achieve the Sustainable Development Goals on child and maternal health.Electronic supplementary materialThe online version of this article (doi:10.1186/s40985-017-0059-2) contains supplementary material, which is available to authorized users.

This article highlights an important yet insufficiently understood international-level determinant of inequality in the developing world: structural adjustment programs by the International Monetary Fund (IMF). Studying a panel of 135 countries for the period 1980 to 2014, we examine income inequality using multivariate regression analysis corrected for non-random selection into both IMF programs and associated policy reforms (known as 'conditionality'). We find that, overall, policy reforms mandated by the IMF increase income inequality in borrowing countries. We also test specific pathways linking IMF programs to inequality by disaggregating conditionality by issue area. Our analyses indicate adverse distributional consequences for four policy areas: fiscal policy reforms that restrain government expenditure, external sector reforms stipulating trade and capital account liberalization, financial sector reforms entailing inflation-control measures, and reforms that restrict external debt. These effects occur one year after the incidence of an IMF program, and persist in the medium term. Taken together, our findings suggest that the IMF's recent attention to inequality neglects the multiple ways through which the organization's own policy advice has contributed to inequality in the developing world.