Reductions in official development assistance can lead to a significant increase in death among mothers, children, and infants, according to a new Stanford-led study that reviewed three decades of sanctions on foreign aid. The researchers estimate that aid sanctions to low-resource countries lasting five years or more can negate 64% of progress against maternal mortality, 29% of the progress for infants, and 26% for children under 5.
The study, which began in 2022, is the first of its kind to assess the global impact of aid sanctions on human health - particularly maternal and child health. The authors hope government officials can use the findings to better understand how foreign policy decisions impact the health of local populations, then take steps to minimize unintended humanitarian harm, including waivers for lifesaving programs.
"Foreign policy can be strategic in advancing national interests while also protecting the health of mothers and children," said lead author Ruth Gibson, a postdoctoral fellow at Stanford Health Policy and, by courtesy, the Center for International Security and Cooperation. "We used cutting-edge analytic methods to assess the impact of this targeted geopolitical tool so we could make clear policy recommendations for governments considering foreign aid sanctions or cuts to foreign aid."
The study published in The Lancet Global Health contributes to a growing foreign policy conversation about the use of foreign aid restrictions. The U.S. Congress has been considering ways to minimize the negative impacts of aid sanctions, while the shutdown of USAID has sparked additional debate on the removal of foreign aid and its impact on health.
Assembling and examining decades of data
After more than a decade working on maternal and child health for foreign health ministries and humanitarian organizations, Gibson was struck by the serious toll that sanctioning foreign assistance took on the health and lives of women and children. In 2022, she set out to systematically study their impact as a postdoctoral scholar at the Stanford Center for Innovation in Global Health.
Gibson and a multidisciplinary team from Stanford, Drexel University, and the University of Washington developed a study that analyzed the extent to which past aid sanctions affected maternal and child mortality between 1990 and 2019.
Using population health metrics from multiple databases, as well as assembling a new aid sanctions dataset for this study, the authors examined the relationship between aid sanctions, official development assistance for health, and measures of infant mortality, child, and maternal mortality. They found sanctions to foreign aid reduced roughly 2.4% of a country's total health care spending through decreases to development assistance for health. This led to increases in mortality of 6.4% for mothers, 3.6% for children under 5, and 3.1% for infants - negating much of the progress made against maternal and child mortality in these countries over the last three decades.
Controlling for diverse variables
The team took particular care to address concerns related to other factors that could impact mortality in countries experiencing aid sanctions, such as changes in gross domestic product, battle-related deaths, and other sanctions. Using state-of-the-art econometric analysis designed to prove causal relationships, they took numerous steps to control for variables that could confound the results and compared sanctioned countries with those that have never been sanctioned. They have provided open-source files so that their methods can be tested, replicated, and used to study the impacts of other foreign policies.
"We believe our work stands out for its careful application of econometric methods and use of novel data," said senior author and lead economist on this project, Sebastien Bradley, an associate professor of economics at Drexel University. "We take seriously the concern that the set of conditions that precipitate the imposition of aid sanctions may affect mortality directly, so we implemented a variety of modeling techniques to avoid conflating this effect with the true effect of sanctions themselves."
Life-saving policy interventions recommended
The researchers also recommended policy interventions to reduce the impact of aid sanctions on maternal and child health while ensuring national interests and security.
They outlined, for example, health-related questions for any legislative body considering strategic changes in foreign aid commitments. They also proposed an additional fragility assessment for nations in conflict, such as food insecurity and displacement.
"In a world where disease knows no borders, our national interests are well served by maintaining the health and stability of people in other nations," said Michele Barry, Stanford's senior associate dean of global health and a study author. "This new research shows that we can shape foreign aid in strategic ways that advance national interests while also minimizing harm to vulnerable populations."
Bendavid is also a senior fellow at the Stanford Woods Institute for the Environment, a member of Stanford Bio-X, a faculty affiliate of the Institute for Human-Centered Artificial Intelligence (HAI), and a member of the Maternal & Child Health Research Institute (MCHRI). Darmstadt is also a member of Bio-X, MCHRI, and the Wu Tsai Neurosciences Institute, and a faculty affiliate of HAI. Wise is also a senior fellow at the Freeman Spogli Institute for International Studies and a member of the Cardiovascular Institute and MCHRI.
Additional co-authors are from the University of Washington, Drexel University, and the Ifo Institute in Munich, Germany.
This research was funded by the Center for Innovation in Global Health and the Maternal and Child Health Research Institute. Ruth Gibson is funded by the Department of Health Policy, Stanford University, and as a Banting Postdoctoral Scholar by the Vanier-Banting Secretariat, Government of Canada.
