There is a wide-ranging debate about possible redefinitions of the role and structure of the IMF itself, and of the Bretton Woods Institutions more generally. This paper has a more restricted focus, on the way in which the IMF interacts with the low-income countries amongst its constituents. It addresses four related topics. The first two are concerned with whether the Fund could remain fully engaged with these countries without actually making loans, and what would be required for it to deliver on its commitment to a more flexible macroeconomic approach. The others examine the Fund’s approach to the debt sustainability issue and the nature of its technical assistance, and how well tailored these are to the circumstances of low-income countries. There is a strong case for strengthening the underpinnings of the Fund’s technical assistance, to develop a more focused low-income analytic perspective, to build its own capacity to assist countries to explore their macroeconomic options, and more systematically to evaluate its technical advice in the light of the outcomes it has helped induce.