Beginning in the 1980s and 1990s, the International Monetary Fund (IMF) and the World Bank implemented neoliberal structural adjustment programmes (SAPs) across most countries in Asia, Africa and Latin America. SAPs imposed austerity, privatisation and economic deregulation and have been associated with severe negative impacts on human welfare, including (a) declining real wages and working-class consumption, (b) increased rates of poverty and basic-needs deprivation, (c) increased neonatal and maternal mortality and (d) reduced health system access. Structural adjustment also created conditions for increased financial outflows and drain from the global South through unequal exchange. This paper reviews evidence of these damages and proposes possible options for reparations and distributive justice. We argue that the IMF and the World Bank should be democratised and restructured—or otherwise replaced by alternative institutions—to prevent further harm.