But…I’m a TB Activist? Perspectives from a Health Advocate on the Ground from the World Bank & International Monetary Fund Spring Meetings
Contact: Erin McConnell, erin.mcconnell@treatmentactiongroup.org
The collapse of global health aid in 2025 revealed the fragility of health financing. Despite successes against TB and HIV in recent years, health aid has not generated sustainable, country-led financing for health. Now, governments are scrambling to fill funding gaps to provide life-saving care.
Though the crisis seems acute, the conditions that created it were built long before health aid was abruptly withdrawn. These conditions are the obvious outcome of an international financial architecture in which decisions made at the International Monetary Fund (IMF) and World Bank (“the Bank”) have limited countries’ ability to direct funds to their own health spending. This dynamic produced a deep reliance on health aid that left millions of people vulnerable to service disruptions in 2025 and beyond when that aid was suddenly cut.
TAG was on the ground at the 2026 Spring Meetings of the World Bank and IMF to understand how both institutions are reacting to health aid cuts and the solutions being offered within these halls of power. While health was discussed at the smaller civil society sessions and in oblique terms at a few sessions in the main meetings, it occupied a small part of the overall agenda. TB advocates, and their allies across the health sector, must show up in spaces like the Spring Meetings to ensure that these issues are discussed with nuance, care, and attention to the needs of those most affected — lest we continue to allow decisions to happen in our absence.
Indebted to Health: Doing Less with Less
At one of the few panels focused on health at the Spring Meetings’ Civil Society Policy Forum, a Bank representative opined that countries “hadn’t stepped up to fund their own health programs” in the wake of USAID’s destruction. This bold statement glossed over the fact that low- and lower middle-income countries simply don’t have money to invest in health — even if they were keen to “step up.”
Many of the countries most impacted by the withdrawal of USAID and other cutbacks to health aid were already facing immense debt crises — with more money going to interest payments than to health. Even less indebted countries struggle with low domestic tax revenues due to pro-corporate tax policies that incentivize profit-shifting between jurisdictions to minimize tax burdens, robbing all countries of tax revenue. Worse, when countries turn to the IMF in debt distress, the Fund often responds by demanding austerity and open trade policies that limit investment in the public sector, such as in bolstering nursing staff, weakening health systems in the process. While these policies have yet to realize the Bank and IMF’s goal of doing more with less, they have ensured countries do less with less agency (and more debt).
Adding insult to injury, the primary solution offered to address countries’ inability to rapidly adapt to health aid cuts was…more debt and tax breaks — a recommendation that sounds like it was issued in an echo chamber, with seemingly little input from civil society and communities. When countries are spending US$4 of every US$10 on debt servicing compared to US$1 on health, the Bank’s recommendation to take on more debt feels arguably cruel and certainly shortsighted. A system which demands that countries practice austerity to honor obligations to lenders but become indebted to meet obligations to constituents is a broken system.
How many LIC-DSFs does it take to get to the center of a debt crisis? Since its introduction in 2006, the low-income country debt sustainability framework (LIC-DSF) has been used by the Fund and the Bank to understand the risk of debt distress of low-income countries. The LIC-DSF is key to unlocking debt relief when debt burdens strain the ability to fund a state’s social responsibilities — including health. However, the LIC-DSF has chronically failed to warn of distress before countries have to start divesting from public services like healthcare.
Since its introduction, the LIC-DSF has changed in tandem with the global economy. The original iteration focused on public and publicly guaranteed external debt, which was a reasonable choice when LICs primarily borrowed from bilateral (e.g., Paris Club) lenders or multilateral lenders. In 2026, the financing landscape is radically different, with more domestic borrowing (i.e., debt held by residents), privately held external debt (e.g., debt held by private corporations), and ever-increasing burdens from existing debt. Despite this new world, and against increased investment needs to meet the Sustainable Development Goals, the LIC-DSF has not strayed much from its original design — begging the question of whether the LIC-DSF is fit for purpose in an increasingly unstable world.
Civil society groups have welcomed the news that the IMF is conducting another review of the LIC-DSF in 2026 as an opportunity to address issues such as:
- inadequately capturing the investments needed to ensure provision of basic social goods like healthcare;
- overly favorable projections that assume robust economic growth;
- failure to account for countries’ social and climate priorities;
- the importance of development to realize economic gains;
- high risk of false positives (i.e., debt distress that never manifests) and false negatives (healthy debt burdens that turn into default).
A LIC-DSF that flags debt distress before countries are unable to provide social services would be the first step towards ensuring that healthcare is not threatened during debt crises. But this won’t happen unless the next LIC-DSF can get to the center of debt burdens and address them before countries can no longer provide basic services.
Talk Finance to Me
In the health advocacy world, we are constantly scheming on how to get the attention of Ministers of Finance and convince them to devote more money to health. Early results from an ODI Global survey of Minsters of Finance revealed an exciting truth: Ministers of Finance across Asia, Africa, and Latin America ranked investment in social services as the number one priority. Ministers want to invest in healthcare and social goods. Yet, in the walls of the World Bank and the International Monetary Fund, the narrative is that economic efficiency is the key priority everywhere. The survey exposed opportunities to push back against that narrative and advocate for bigger health budgets. Ministers of Finance want to invest in this, they just need to be welcomed into conversation with civil society, community groups, and Ministers of Health to develop plans for how best to do so.
The Room Where It Happens
The IMF and World Bank carry outsized influence over monetary and fiscal policy worldwide. Yet too often health is flattened into a single dimension or treated like an afterthought in the Spring Meetings. Health actors that long benefited from dedicated aid funding from development agencies have neglected engagement with development banks and financial institutions like the Bank and the IMF. As the world responds to the collapse of the global health funding ecosystem, health actors must join these conversations and demand that health is embraced in its full nuance in the Bank and the IMF.
Conversations that will dictate how health is financed are happening all the time — with or without us. In our efforts to navigate the post-USAID world and to realize sustainable country-led investment in health systems, affected communities must be a part of these conversations. The agenda of the Fund and the Bank — jobs, universal healthcare, electrification — all have potential to shape the future of TB care, and TB has the potential to shape the agenda of the Fund and the Bank. But we shouldn’t let those decisions happen to us, but rather with us if we hope to build an international financial architecture to finally realize the end of TB, HIV, and HCV.
Over the coming year, TAG will undertake work related to two parts of the international financial architecture. We will be exploring advocacy opportunities around the IMF’s Special Drawing Rights (SDRs), a reserve currency held by the Fund, and developing an activist’s guide to understanding how SDRs can be used to finance critical health initiatives (e.g., procurement of a future TB vaccine). We will also be working with the Global TB CAB and allies to engage in advocacy around the United Nations Framework Convention on International Tax Cooperation (UNTC) negotiations to advocate for tax cooperation policies that boost domestic revenues of high-TB-burden countries to support investment in TB programs and research and development.
