Programme Aid and Development: Beyond Conditionality (Routledge Studies in Development Economics)

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Social protection is currently high on the development agenda, though it does not figure in the Millennium Development Goals.

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Nonetheless, it has existed in low-income countries in one form or another for a long time. In African countries both governments, NGOs, donor agencies and the private sector have been involved in social protection initiatives which run alongside local and informal mechanisms of social support.

In the s and s food subsidies were popular, for example wheat in Egypt and maize in Tanzania. Initially social protection was conceived as a response to an emergency or a crisis situation. Increasingly the emphasis has shifted to the provision of regular and predictable support to vulnerable people before shocks occur. Social protection, in this broad sense, entails prevention, by reducing the occurrence and severity of shocks, mitigation, by reducing the impact of shocks when they occur, coping, by helping people deal with shocks, and revival, by helping people rebuild their lives to their pre-shock level of well-being Horman Chitonge, Social protection interventions range from public policy measures, such as minimum labour standards, through contributory social insurance schemes, to a wide range of social transfers in the form of cash, food, inputs or assets.

Social protection is in essence a poverty-reducing strategy and a key policy challenge in African countries is how to align social protection with poverty reduction programmes. Lack of political commitment, weak institutional capacity and inappropriate social welfare models, together with inadequate financial resources, have worked against the expansion of social protection in many African countries. However, there are signs that this may be changing. At the Livingstone Call for Action summit in March , 13 eastern and southern African countries pledged to develop national social protection strategies and integrate them into their national development plans.

There is an emerging consensus that a minimum package of essential social protection should cover essential health care, and benefits for children, informal workers, the unemployed, older persons and persons with disabilities. Raschky, Michael J. Parks, Austin Strange, Michael J. Tierney , AidData Working Paper 46, Aid and Growth. Tierney , Journal of Development Economics Foreign aid with Valentin F. Lang and Sebastian Ziaja , in: T. Risse, T. Draude eds.

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Tierney , International Studies Quarterly Parks, Michael J. Finally, privatisation describes the transferal of enterprise from state to private ownership, thereby fostering competition and market efficiencies. Yet, recent studies find this ostensible shift to have changed little in practice [ 22 ].

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Contrary to the rhetoric, conditionalities continue to advance a neoliberal conception of economic development [ 22 , 32 ]. Regional development banks have offered little alternative to the precedent set by the Bretton Woods twins. In Sub-Saharan Africa—the region accounting for the greatest proportion of structural adjustment programmes [ 8 ]—the AfDB fulfils a similar function to its global counterparts.

However, the oil price hikes of the s eroded its capital sharply and produced massive debt among member nations, compelling the AfDB to gradually favour structural adjustment lending over project lending to ensure debts would be repaid [ 9 ]. Despite its early intention to maintain an African character, in practice its loans bear little point of distinction from those administered by the IMF and World Bank.

We systematically review four electronic databases, with additional documents from the websites of the IMF, World Bank, and AfDB, to synthesise empirical evidence and hypotheses on the relationship between IFIs and child and maternal health in the developing world. We consider empirical aggregate-effect studies on structural adjustment programmes conducted by three international organisations: the IMF, World Bank, and AfDB. Strategies for the other databases are identical in substance, with minor adjustments to suit the idiosyncrasies of each search engine. Our pilot database search limited results to English language texts published from January onward with human subjects.

The final search, conducted in March , amended the inclusion date to to increase sensitivity. Intervention key terms included the names of IFIs and policy levers associated with structural adjustment.

Search form

Outcome key terms included various indices of mortality, pregnancy complications, school absenteeism, diseases and other health conditions, and broad measures of health and wellbeing for fetal, infant, child, and maternal populations. Setting key terms covered clustered geographical areas coded in MeSH terms. Where MeSH terms were not available, additional terms were added to maintain sensitivity.

Search strategies on the websites of IFIs were adapted to suit the less sophisticated search functionality.


Articles were screened in three phases. First, texts were downloaded to Endnote X7 if their title and abstract appeared relevant to the research question. Second, article abstracts were screened against the selection criteria outlined above, barring restrictions on study design. Third, full-text screening distinguished empirical studies for systematic review from conceptual and review articles to be retained for subsequent discussion, and further eliminated texts with misleading relevancy to the selection criteria, or only a secondary focus on the research question of this review.

A total of records were downloaded to EndNote X7 following the initial database search. A further 13 texts were identified through scanning reference lists, and searching IFI websites yielded another 17 entries. Ninety-three texts were obtained for full-text screening, and 13 were identified as meeting the inclusion criteria. An important methodological consideration in this review was the extent to which these studies distinguish programme effects from selection effects.

IFI programmes are not random events, as typically only countries whose economies experience severe economic and financial difficulties participate [ 3 , 48 ].

Studies failing to adequately control for initial conditions faced by countries—including unobserved factors like political will of the government—will thus confound the effect of adjustment with the underlying factors prompting participation in the first place. Scholars typically employ four econometric strategies to overcome selection bias: matching methods, instrumental variables approaches, system GMM estimation, and Heckman selection models [ 48 ].

In this section, we review empirical evidence on the effect of structural adjustment programmes on child and maternal health respectively. Eight of the ten studies found a detrimental relationship between structural adjustment and child health outcomes, while one found no association and one established a beneficial effect.

Characteristics of studies on the aggregate effect of structural adjustment programmes on child health.

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We begin with studies yielding detrimental effects. Two cross-country quantitative studies of Sub-Saharan African nations from the period to find a positive relationship between infant mortality and the presence of an AfDB and IMF structural adjustment loan, respectively [ 2 , 49 ]. Both studies explicitly control for a standard battery of initial conditions, including a series of domestic health, political, and economic factors, as well as two-way fixed effects.

To account for non-random selection into the programmes, the former uses a two-step Heckman selection approach and the latter deploys an instrumental variable approach, both of which are well-established procedures in the literature [ 48 ]. A third study examines the impact of AfDB structural adjustment loans on child mortality for Sub-Saharan African nations for the same period using generalised least square random effects regression models within a two-step Heckman procedure, again finding a positive relationship [ 9 ].

The study attributes an additional Fourth, a recent study deploys multi-level modelling techniques to investigate the effect of IMF structural adjustment loans on child malnutrition in 67 countries for almost two million children for circa year [ 50 ].

The study claims this is due to IMF reforms that make it harder for parents to reap the benefits of their education, such as wage contraction and welfare retrenchment. A further four studies assess child health outcomes without addressing non-random selection into programmes.

Research and Publications Prof. Dr. Axel Dreher Department of Economics - Heidelberg University

One tests the impact of World Bank structural adjustment on child mortality across sub-Saharan African nation for to using two-way fixed effects regression models, finding a positive association between the two [ 12 ]. Another exploits a quasi-experimental design using pooled cross-sectional data from two Demographic and Health Surveys conducted in and to measure changes in childhood malnutrition in response to World Bank and IMF structural adjustment in Cameroon [ 11 ].

The authors attribute greater levels of malnutrition in children born between and than those born between and to government health expenditure cuts experienced during structural adjustment programmes between and In addition, a comparative case study compares the effects of World Bank and IMF structural adjustment on health in Argentina and Uruguay [ 51 ]. However, the study is limited by its inability to isolate the contribution of structural adjustment from confounding factors, such as the extent of the underlying economic crisis and the political will of the government.

Finally, a study examines the effects of IMF structural adjustment on infant mortality based on a lagged dependent variable panel regression on a sample of 59 developing countries in [ 52 ]. It finds no effect for the IMF variable in isolation. However, the interaction between the IMF variable and political democracy yielded a detrimental effect on infant mortality, which was greater at lower levels of democracy than at higher levels. Only one study finds no association between structural adjustment and child health outcomes [ 53 ]. It examines the relationship between compliance with World Bank conditions—including macroeconomic stabilisation polices, public sector management, and private sector development—and infant mortality across Sub-Saharan African countries in 5-year periods from to , but did not account for non-random country selection into programmes.

Another study finds a beneficial relationship between adjustment and child health [ 5 ]. The study then interacts the IMF variables with growth, finding growth that occurs under concessional loans results in an additional decline in infant mortality of 0. However, the study does not correct for non-random country selection into structural adjustment: it erroneously claims that its two-way fixed effects approach adequately addresses these methodological concerns.

The three studies—all having one co-author in common—show that structural adjustment has an adverse impact on maternal mortality. Characteristics of studies on the aggregate effect of structural adjustment programmes on maternal health. Two studies deploy a cross-country regression design with Sub-Saharan African samples for the period to [ 3 , 8 ]. Deploying a two-step Heckman procedure to account for non-random selection, both studies find detrimental changes to maternal mortality associated with IMF and AfDB structural adjustment loans, respectively. The former reports that an additional maternal deaths per , live births are attributable to IMF structural adjustment; while the latter shows that approximately additional maternal deaths per , live births are attributable to AfDB structural adjustment.

A final study analyses a sample of 65 developing countries for using lagged dependent variable panel regression, finding a positive relationship between structural adjustment and maternal mortality [ 54 ]. However, the study design does not account for selection bias. The empirical studies identified in our systematic review are virtually unanimous in finding a detrimental association between structural adjustment and child and maternal health outcomes.

Identifying plausible mechanisms is also important insofar as there are some aspects of structural adjustment that are beneficial to health outcomes, even while the net effect is detrimental. Pathways discussed in this section include those hypothesised in the empirical studies reviewed above, as well as additional empirical, conceptual, and review articles identified through the literature search process. Policies adopted in adherence with structural adjustment programmes frequently bear consequence to the functioning of health systems, with implications for child and maternal health outcomes.

First, structural adjustment is hypothesised to affect government health expenditure , which in turn alters the quality and quantity of services provided to children and mothers [ 2 , 3 , 9 , 12 , 24 , 49 , 54 , 55 ].