Brexit, aid and the value of money: is ‘aid’ what is given, or what is received?

Let me start of by admitting that thinking about the impact of a Trump president is a bit more interesting (and frightening) than the issue of foreign exchange and aid disbursements. But as so often, those seemingly boring things can actually be quite important for the lives and well-being of those who are most marginalised and have the least power.

The genesis for this post was back in late 2015, on a trip to the Republic of Georgia for a research project. Talking to some staff in the national office of an international NGO, I was told that the national office was having to substantially cut back on its programming due to a significant shortfall in funding from its Canadian funding partner. During 2015, the value of the Canadian dollar fell. When funds from that partner were exchanged into the Georgian Lari, the effect was to immediately wipe the equivalent of Can$400,000 from the value of the grant. The Canadian funding organisation was still giving the amount it had agreed, but from the perspective of the recipient, not only was significantly less actually being received, but programmes designed to support child and community development were being cancelled as a result.

Flash forward six months to the outcome of the Brexit referendum, and the sudden and dramatic collapse of sterling. What, I wondered, was the impact of Brexit on UK aid flows – not the headline figures as published by DFID and that appear in official aid statistics, but the more meaningful impact on what was received by its recipients, and on programming as a result?

I have been asking a few organisations how they cope with the issue of fluctuating exchange rates, and, in particular, whether they revisit their initial grants when shortfalls emerge as a result; and whether the unusually large fall after the 23rd June referendum had had an impact. The answer, universally, was no: the grant is the grant, and recipients must operate within those budgetary parameters, however they may fall.

One NGO explained that because currency fluctuation is to be expected over the course of a project, it undertook regular (re)forecasting exercises to try and calculate potential losses and gains in the grants it received, and ensure effective financial management. But whereas gains might lead to it being able to re-investment in the programme (subject to donor approval), losses would lead to scaling back in funded activities. As a recipient of large-donor funding, losses would be expected to be absorbed by the NGO, and it would not receive extra funds.

This same NGO followed similar principles when making grants to its own partner organisations: reforecasting at least twice a year, and an expecting country programmes to stay in budget. However, when exceptional losses were made, a business case could be made to access flexible funds to cover losses.

The Financial Controller of another British NGO outlined their strategy for coping with movement in forex rates. As well as the emphasis on effective forecasting and re-forcasting models common to all organisations, they identified a number of other coping strategies:

  1. Trying to build in flexibility in agreements with donors: either allowing for amendment of the grant budget when fluctuations are especially severe (as has been the post-June situation for sterling); or including a contingency budget for unforeseen costs, including forex movements.
  2. Seeking to ‘achieve a natural hedge’ by matching currency assets and liabilities on a currency basis, where possible.
  3. Making use of foreign exchange hedging contracts (i.e. locking into a particular rate over a period of time) if cost-effective.

In answer to a parliamentary question by Labour MP Paula Sherriff on the impact of the fall in the value of sterling since June 23rd 2016, Aid Minister Rory Stewart did not directly answer the question but stated in his written response that (a) fluctuations are not new, (b) payments are made in sterling so additional costs would be imposed upon DFID; and (c) recipients are ‘carefully selected’ to ensure they have sufficiently strong financial mechanisms to cope with such shocks.

I also sent in an FOI to DFID, asking specifically about the impact on recipients (not the impact on UK department finances), and whether there was a policy to make up shortfalls in disbursements when fluctuations were especially severe. The response acknowledged that when aid paid in sterling was converted to other currencies post-June 2016, its value would fall. However, managing risk of fluctuations was the responsibility of the recipient, and they assumed all the currency risk. DFID’s Strategic Risk Register is responsible for monitoring and forecasting the potential impact of strong fluctuations, but shortfall grants were not an option.

Although fluctuations are indeed a normal occurrence, and can be mitigated to an extent by forecasting and hedging, the 15% fall after the referendum was far in excess of the normal range of ups and downs, and will inevitably have had a major impact on programming. It is still far from clear to me that this impact has been acknowledged (from the perspective of programming, rather than impact on UK finances), never mind addressed.

This bring us to problems of how aid is seen and officially defined, and misleading assumptions about how much is actually spend on aid programming – you know, the stuff that the money is supposed to be used for. Official aid is defined from the perspective of the donor, not the recipient. So when you look at OECD data, what you will see is what donor governments gave to a particular country or organisation. That is not what was necessarily received. As an example, back in 2003 gross official aid to Africa (the headline figure for how much aid was made available) totalled $25.9 billion (of which $20.8b. was in grants, the rest in new loans). However, when we look at it from the perspective of the recipient, the total amount of aid received by African governments was $10.7b (and taking out support for debt repayments, the total falls again to $7.2b).

Whilst that ‘missing’ $10 billion or so was spent on ‘development’ activity, much of it was spent in donor countries and regions: on consultants, administration, services and equipment, grants to multi-lateral organisations and NGOs and so on. So, assuming it was spent wisely and had a positive impact (a big assumption, but let’s go with it), there should have been a positive impact on the African region. But nonetheless, if the headline figure for, say, DFID aid to Tanzania is one amount, and what arrives in banks in Dar es Salaam is another, there is an issue here.


When thinking about aid flows, should we really be looking from the perspective of the donor? We know that some European aid spending is being directed to manage the migration crisis within Europe – is that really international aid? Does the donor-focus make it easier for aid Ministers like Priti Patel to re-orientate aid spending to support UK post-Brexit trade-deals? A recipient-focused definition may lead to some surprising findings about what donors think is aid, and what the impact of that thinking has on the programmes they support. As the experience of the NGO in Georgia shows us, this is not just about semantics and dry definitions: the shift in perspective can uncover some very real consequences, not only for the local NGO, nor aid-recipient governments, but for the poor, marginalised and vulnerable.

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The Global Gag is back, and more women will die from unsafe abortions as a result

To absolutely no-one’s surprise (and as I wrote a few blog posts back), on his first working day in the presidential office Donald Trump signed an executive order reinstating the Mexico City Policy. Also known as the Global Gag, the policy restricts US funding for NGOs and other organisations who ‘perform or promote’ abortion services.

The Global Gag is, of course, a moral issue, embedded not just in debates around sexual and reproductive health, but also in women’s rights, equality and equity, participation in planning health services and packages, and questions of power (power of donors to control what goes on in other countries, power of a group of overwhelmingly middle-aged white men to determine the fate of overwhelmingly non-white, often young women). But engaging with the morality of the Mexico City Policy is to invite a response from proponents in which they simply assert the primacy of their own moral universe.

With that in mind, rather than engage with the politics, the morality, the rights issues at the heart of the Global Gag (critical though these are), let us focus instead on whether it works. If we accept that the premise of the Gag is to reduce the number of abortions taking place globally, does it achieve that aim? If it does, then its supporters may have a case that as a policy it does have the desired effect (however much I may disagree with that objective). Of course, if it doesn’t, and if it not only fails in that but makes the problem substantially worse, then any justification for the policy simply vanishes.

A 2011 study examining the impact of the Global Gag on abortion rates concluded:

“Our study found robust empirical patterns suggesting that the Mexico City Policy is associated with increases in abortion rates in sub-Saharan African countries.”

Although the authors point out that their data cannot draw definitive conclusions about causes, the association between ‘highly exposed’ countries (where the policy had its biggest impacts) and the rise in abortion rates is ‘strong’. Moreover, the timing of the growing gap in abortion rates between high and low exposure countries coincides with the reinstatement of the Global Gag in 2001.


[Source Eran Bendavid, Patrick Avila & Grant Miller (2011), ‘United States aid policy and induced abortion in sub-Saharan Africa’, Bulletin of the World Health Organisation 89, 873-880C. Available here]

Other studies, such as this one in Ghana, have similarly found an association between the imposition of the Global Gag, and rising abortion rates. In other words, the Mexico City Policy is associated not with a decline in abortion rates, but with an increase. It quite clearly fails.

If the Global Gag is not reducing (and is, as the data suggests, increasing) abortion rates, it is doing so especially for unsafe abortions. There are around 36 million abortions each year. Of these, 21.6 million are categorised as ‘unsafe’, contributing to the deaths of 47,000 women each year as a result of complications arising from unsafe abortions (and accounting for around 13% of all maternal deaths). In 2005, the Ethiopian government reformed its abortion laws in an effort to reduce the numbers of women dying from unsafe abortions (estimated at over 10,000 each year). Highly dependent on aid for its health sector (and the US being by far and away the largest provider of aid for health), the Global Gag reduced the scope for putting the reforms into practice, and undermined progress in reducing maternal deaths. Ethiopia’s experience is not uncommon.

Because many of the organisations involved in abortion services and advice are also key actors in wider sexual and reproductive health services, the Mexico City Policy has a wider impact on health:

  • A 2006 report on the impact of the Global Gag in Zambia found that the main NGO providing reproductive health clinics had lost 40% of its staff, been forced to scale back services and end community-based distribution of contraceptive supplies and wider health information.
  • Another report for Kenya showed, that reproductive health care providers were also closing clinics and scaling-back services. In most cases, these clinics were the only sources of health care for those communities. Community-outreach services, essential for HIV and AIDS programmes, were being cut. And child-health services were also being curtailed.
  • In Ghana, supplies of contraceptives increased when the Mexico City Policy was rescinded under President Clinton, and declined when it was reinstated by President George W Bush.
  • In Lesotho, famously, US shipments of condoms to the country were stopped as the organisation responsible for disbursement (the Lesotho Planned Parenthood Associated) lost its funding as the Global Gag was reintroduced by Bush (at a time when an estimated one-in-four women were living with HIV).

So not only is the Global Gag undermining sexual and reproductive health services, with all the implications for maternal and child mortality that this creates, and the negative impact on efforts to control HIV and AIDS; it is actually making the problem worse. Around four-fifths of all contraceptive supplies in sub-Saharan Africa are provided by external organisations of precisely the type targeted by the Mexico City Policy. By restricting access to contraception (through denial of funding to those organisations), more unwanted pregnancies occur, more women therefore are pushed into having unsafe abortions, and more women die. By restricting sexual and reproductive health work, efforts to control HIV and AIDS are critically undermined.

The evidence is quite clear: the Global Gag does not work. More than just not working, indeed, it has an opposite effect to that intended. So if the purpose of the proponents of the Mexico City Policy is to try and lower the number of abortions, then its architects ought to think again (here’s an idea, why not refuse funding to those organisations who promote abstinence-only campaigns, or refuse to provide contraceptives?).

But they won’t. And not just because in the new US knowledge-economy ‘facts’ can be challenged with ‘alternative facts’ made-up to order. The Global Gag isn’t really about the acceptable use of aid, or the effort to ensure US aid reflects particular ‘values’. It’s not even really about the number of abortions undertaken around the world. The Mexico City Policy is a totemic signal that reflects and speaks to domestic US politics. Its negative impact may occur outside the US, but it is intended to broadcast the character of the incoming administration within the US, to appeal to certain groups of voters, and to attract the support of certain lobby groups.

Targeting vital services of the global poor and marginalised for domestic political gain is bad enough, no matter which government does it. To do so with a policy that exacerbates maternal mortality, creates more unwanted pregnancies and leads to more unsafe abortions; that undermines HIV and AIDS prevention work; that worsens the health of entire communities; and that undermines any meaningful idea of human rights and gender equity, is simply disgraceful.

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Ethiopia’s Spice Girls, and a manufactured outrage

One of the joys of UK newspapers is the headline: those small sentences that sell the story and attract the reader. Headlines are supposed to grab the eye, entice the reader in, perhaps generate a chuckle or wry smile. They are also, it should go without saying, supposed to bear some relation to the actual content. But journalists often complain that the headline is at odds with their carefully nuanced and balanced piece of reporting and analysis.  One of the most famous of these mismatches, for Africanists at least, is the classic Economist cover in May 2002, ‘The Hopeless continent’, a headline which the then-editor decried and has continued to do so when asked about it. 

Sometimes a headline in one newspaper generates ripples throughout the media as a whole, as the headline becomes the reported story. At the end of last week, news reports about DFID were dominated by one particular story – one generated by a report in a national UK newspaper: the cancellation of a £5 million grant for what was described variously as an ‘Ethiopian girl band’ (© The Independent, BBC News, ITV News, The Express), or ‘Ethiopia’s Spice Girls’ (The Telegraph, The Mirror). The story was first reported (to no-one’s great surprise) in The Daily Mail, part of its ongoing campaign to force the government to backtrack on the 0.7% commitment, to reduce aid spending to programmes that meet the Mail’s approval, and spend the money on the needy at home (though given the coverage of Britain’s most vulnerable in that newspaper, one suspects sympathy for the British poor wouldn’t last very long if it did happen). 

To be fair to the Mail, the headline wasn’t as entirely misleading as to what followed in the main body of the piece, with large omissions, heavy editorialising masquerading as fact, and rentaquote Tory MPs gloating over their Victory for Common Sense. In essence, the story ran as follows: DFID had spent £4 million on an all-girl pop group, Yegna, and was due to spend a further £5.2 million, before common sense kicked in and the grant was cancelled. In addition, a further £38.9 million had been earmarked for the wider Girl Effect programme of which Yegna was a part (I won’t link to The Mail, but if you google it, you’ll see there is some confusion in the piece over what had been spent and what allocated for future disbursements). Other media outlets largely followed suit in their reporting and their headlines. 

On the headline, this does sound like a colossal waste of money. The description of the band as being like the Spice Girls is deliberate: it appears that there is a certain spectrum of middle aged male editors and journalists, for whom any pop group comprised of young women espousing such radical beliefs such as equality and equity for all, ensuring access of all girls to education, helping them make choices over their own bodies, not be physically, sexually or psychologically harassed (you know, those basic human rights things) can only be described through reference to a girl band who first came to prominence in the UK 20 years ago. And it plays well into the Mail’s campaign against UK aid: if DFID is throwing such sums at what is clearly a preposterous idea, then what else is it funding?

The problem with this story is not that some media outlets, led by The Daily Mail, are criticising a perfectly good programme (we’ll come to that later) unfairly. It is that so much of it is half-truth, with significant omissions of detail and fact. The main problem is that the programme being funded is absolutely not Ethiopia’s answer to the Spice Girls, or even a ‘girl band’ as others have put it. Yegna is a self-described entertainment ‘brand’ that has been designed to appeal to young women and adolescent girls, articulate their needs and aspirations, and give information about their rights and their options. There is a music element of this, the ‘band’ part. But other components include radio drama and chat shows to highlight issues of young women’s development and rights. Yegna is more properly seen as a platform through which these messages can be accessed, and has been used by around 8.5 million people.

Moreover, Yegna is only one part of the programme, run by an organisation called ‘Girl Effect’ which seeks to empower young women and girls through the ‘brands’ that are linked to the NGO. Its focus is on encouraging girls to stay on in education, ensuring appropriate health services are available, reducing early marriage. They have made a not unreasonable assumption that entertainment is an important source of news, information and ideas for youth.

The missing background doesn’t even stop there. Funding for this programme was part of an initiative in partnership with the Nike Foundation, ‘Girl Hub’, established in 2010 to focus on addressing the needs and rights of adolescent girls, and ensure their needs were given greater prominence in development planning and policy (it’s quite hard to argue that this wasn’t a necessary objective). Programmes were established with the Nike Foundation in Nigeria, Rwanda and Ethiopia, Girl Effect being one outcome of this initiative in the latter country.

So what looks like a misguided attempt to Get Down with the Kidz by sponsoring a pop group is actually part of a much wider collaboration. It’s not quite as interesting a story, but that’s the annoying thing about facts.

This is not to suggest, as some detractors of The Daily Mail’s version have done, that DFID should have carried on funding the programme. Questions about its effectiveness and approach were raised back in 2012, with the Independent Commission for Aid Impact (ICAI) giving the Girl Hub programme an amber-red warning flag, and calling for greater clarity, transparency and more rigorous evaluation of its activities. Others had questioned the appropriateness of the messages espoused by Girl Effect. (Interestingly, the piece in The Guardian on the affair last week, which offers a defence against some of the attacks from Tory MPs and the Mail, ignored one of its own previous pieces from 2012 which highlighted some of these criticisms: lack of institutional memory, or because this fact, too, didn’t fit the particular spin on the more recent story?) At best, this was a programme requiring careful monitoring – and the decision to end the funding was almost certainly the result of such scrutiny, not the posturing of a certain section of the media (whether that decision was right or not)

Yes, we all know that headlines can mislead, and that newspaper stories can often be more story than news. But the effect is nonetheless insidious, not least because comparatively few outlets contested the narrative established in the Mail’s piece to a meaningful extent. And when one newspaper in particular is repeatedly allowed to get away with misleading stories, and a highly political campaign, facts and truth are all too easily lost. You don’t have to outright lie to mislead (as those brought up as Catholics know, a sin of omission is as serious as a sin of commission).

UK aid should be scrutinised, challenged, expected to be wisely spent. The media storm cooked up over the weekend did nothing to help in that endeavour.

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What does Trump mean for sub-Saharan Africa?

On the scale of some of the things that emerged from the mouth of now US president-elect Donald Trump on the campaign scale, allegedly calling the Kenyan athletics team ‘frauds’*, and mispronouncing Tanzania, hardly counts as anything serious at all. We have few clues as to what Trump thinks of the region, and how he intends his administration to engage with its countries and leaders. But are there any indications, even at this stage, of what a Trump presidency might mean for sub-Saharan Africa and development?

It was probably inevitable that Africa would feature less prominently no matter who replaced Obama. Although Hillary Clinton, through her role as Secretary of State, and the work of the Clinton Foundation in Africa, certainly has closer ties and a more detailed understanding of the region.

The return of the nativist: The big political story of 2016 has been the rise to victory of the nativists, whether in the form of Brexit in the UK, the physical and ideological barriers put up on Europe’s borders in the face of the mass movement of people, or, now, the victory of Trump. Whatever the reasons for why people voted for him, they have chosen someone whose aspiration appears to be the creation of a more isolationist, inward looking US, one less concerned with the international stage, and more concerned with domestic politics and economy.

There will be some who welcome this, after the foreign policy adventures of the last couple of decades. They would be wrong, however. An internationally engaged US does not have to be a militarily-engaged one. And yes there will always be charges of hypocrisy against any major power that seeks to raise issues of human rights, respect for international law and so on with other powers. But the dangers of a non-engaged US are worse.

The main issue, and the one that will have the biggest potential impact on Africa, is Trump’s climate-change denying, and the possibility that he will now ditch the, albeit imperfect, Paris Agreement. A US withdrawal on this would have catastrophic consequences for global cooperation in tackling what is one of the biggest challenges facing sub-Saharan African countries and the poor within them.

A more isolationist US is also likely to focus what external attention it bestows on a few key areas: Russia, China, and the Middle East. Sub-Saharan Africa will slip further down in US priorities, with consequences beyond just the diplomatic circle. If aid becomes increasingly linked to US strategic interests, not being one of those strategically-important areas could see aid spending diverted away. Funding for multi-lateral organisations could suffer as America seeks to do more on its own through bilateral agreements, and with those strategically important regions. Almost certainly, the securitisation of aid will be given renewed impetus, with efforts to tackle poverty, control epidemic disease, understand the drivers of mass migration, efforts to negotiate peace in conflict-torn societies, seen ever more through the prism of US security interests. Sub-Saharan Africa will increasingly be noticed by the US only when it is of importance or use to the US (not a new trend, but one likely to be exacerbated far beyond the current form).

The ping-pong battle of the Mexico City Policy:  In 1984, President Reagan instituted the Mexico City Policy (also known as the global gag), which placed a requirement upon all NGOs and other organisations received US federal funding to refrain from ‘performing or promoting’ abortion services. Since then, the global gag has become a political football: repealed by Democratic presidents, brought back by Republicans. Given Trump’s stated position on abortion, and his support base, it is almost certain that the policy will be back on the table.

This is disastrous for efforts to promote not just sexual and reproductive health, but public health more widely, across sub-Saharan Africa, as the evidence has shown from its previous iterations. Quite apart from the issue of whether abortion is a human right, and essential for the health of women, many of the organisations that provide abortion services, or even just advice on where to access them, are also providing other vital health services. In some cases, they may be the only health centre in a particular area. Removing funding from that organisation does not just stop abortions (actually, that’s the one thing it doesn’t do – it just makes them more dangerous); it prevents wider health services from being delivered too.

Funding for HIV and AIDS was treated separately from the Mexico City Policy under George W Bush’s administration, but the restrictions imposed nevertheless had an impact on the ability of organisations to function effectively and provide all the services necessary for a strong and effective anti-HIV and AIDS programme.

So some things we do know already, when the global gag is reinstated (as it is almost certain to be): abortions will not be reduced, but many more women will have serious medical complications and will die from an increase in the number of unsafe abortions; many health service NGOs will find their ability to provide services compromised, whether in terms of being able to offer a full range of services and advice, or even being forced to stop completely due to a drying up of funding – or take the Faustian pact and give advice and a service they know is flawed and incomplete.

In a region with such high maternal mortality rates (830 women dying every day due to preventable causes); with such high numbers still of new HIV infections (around 1.4 million every year), the Mexico City Policy is not just a terrible policy, it is a disgraceful piece of ideological nonsense that just ends up hurting and killing the already vulnerable and marginalised.

A ban on Muslims? As with so much of what Trump says, you have to be sceptical that even a third of what has been promised will make it into the White House (although even a third of some of the bile that has emerged is a horrifying prospect). And his once-mooted idea of banning all Muslims from entering the country already saw significant roll back almost straight after it was announced.

However, rhetoric matters, and there would appear to be little doubt that perception of Islam, of Muslims, and of countries in which Muslims are the dominant religion or a significant one will worsen, and many will have plenty to worry about from a Trump presidency. At the most basic level, will gaining visas become harder for those wishing to travel to the US; and will Muslims transiting through the country face increased monitoring and even restrictions? Will African countries with large Muslim populations be treated less favourably in aid, trade and other deals than others?

More insidiously, how will US perceptions of Africa develop over the next five years? There has often been a lack of nuance in the way sub-Saharan Africa is perceived globally. This is not likely to change, and there is every chance that negative stereotypes, promulgated by the administration, or not robustly challenged, will flourish. The picking of Alt-Right standard bearer, Steve Bannon, as a key advisor, a person accused of racism and who edits the website Breitbart – a site accused of promoting white supremacy, homophobic and sexist ideologies – cannot be good news. And thus far new appointments have not given much hope for alternative voices.

So what can sub-Saharan Africa expect? At best, perhaps it will spend the next four years being largely ignored, not loved but neither suffering directly from policies emerging from some of the rhetoric and ideology that have been a hallmark of the campaign. But whether or not Africa is a focus for the Trump administration, other policies and narratives about certain groups, religions and ideologies will negatively impact upon the region. The idea that ‘Africa’ (and I doubt it will get much more nuanced than that) is a haven for terrorists and anti-Americanism may well flourish in Republican circles. Trump’s supporters champion his excellence as an investor and businessman. Perhaps that expertise will lead to increased investment across sub-Saharan Africa. But his record suggests caution there: is that the kind of business investment the region wants or needs (Scotland, like to advise on that?).

My advice, hunker down, and pray that mispronouncing your country’s name is the worst thing that happens.


* Given the extent of false news stories in this US election, I can’t be sure this actually happened.

** This did actually happen, but to be fair if we are going to start a list of people who pronounce Tanzania, Tan-zay-nee-ah, it’s going to be a long, long list.

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Who ‘does’ development?

Where to start with the piece by new Minister for International Development, Priti Patel, in the Daily Mail this week? Her assertions that too often aid doesn’t get through to the people who need it most, whether because the EU has squandered it (Patel was a prominent Brexit campaigner) or because of corruption (evidence for the extent of which she was unable to provide for her appearance before a parliamentary committee)? Or claiming that the focus of UK aid is simultaneously the world’s poorest, to reduce the pressure for mass migration to Europe, and to ‘help build the UK’s trading partners of tomorrow’ (the latter two foci, critics might suggest, reflect the interests of the UK, not the world’s poorest)? Her priorities seem clear. In the accompanying interview, Patel makes it clear that the £12 billion aid budget needs to ‘deliver for our national interests’ (code for stopping immigration and linking development to national security).

The new minister has been taken to task for many of these assertions, especially by NGOs who see her vague, Daily Mail-friendly soundbites (there is remarkably little content or depth to any of the statements of intent) as further proof of the redirection of DFID away from its explicit focus on the poorest of the poor, towards boosting trade and investment as the solution for poverty (conveniently ignoring evidence gathered over the almost 90 years since the UK’s first overseas aid act, the 1929 Colonial Development Fund, showing that the rising tide of economic development not only doesn’t lift all boats, but leaves many stuck in the mud as the water rises above them).

Here, I want to explore her assertion that ‘wealth is ultimately created by people, not by the state …  that we need to empower the poorest to work and trade their way out of poverty, not treat them as passive recipients of our support’.

In the global health literature, there has been an argument between those who posit the ‘wealthier is healthier’ argument of, amongst others, Lant Pritchett and Lawrence Summers; and the opposing ‘healthier is wealthier’ argument of their critics. Sure, health is not a proxy for development in its entirety, but I think it has some useful ideas for us to look at.

In their famous 1996 article, Pritchett and Summers argued that, using infant mortality and life expectancy as markers for improvements in health, the data shows that health improves as countries get richer (the article is behind a paywall, you can access the original working paper here). They write:

Since rising income causes improved health (most likely through increased public and private spending on goods that directly or indirectly improve health), raising per capita incomes will be an important component of any country’s health strategy.The estimates imply that if income were 1 percent higher in the developing countries, as many as 33,000 infant and 53,000 child deaths would be averted annually.

This would seem to give support for Patel’s arguments that investment, trade, jobs and so on are the best ways to improve social indicators such as health. And if you believe that economic development is best delivered by the market, then that would suggest that states, as Patel suggests, do not create wealth. And wealth, once created, reduces poverty and the impact of poverty.

But actually the evidence on ‘wealthier is healthier’ is much more murky than its advocates allow for. The evidence that most draw upon seeming to link life expectancy and national income per capita is demonstrated in what is known as the Preston Curve, which does indeed show a correlation between increased GDP and increased life expectancy. Unfortunately for the wealthier is healthier advocates, Preston himself questions the assumptions taken from that curve, arguing public health is the key to improved health outcomes; and improved wealth may actually flow from improved health. In other words, states do create development.

Take the UK for example. Mortality began to fall throughout the nineteenth century, reflecting the discoveries of germ theory, the importance of hygiene in child-birth, and so on. But it is from around 1900 that it begins to fall more steadily. But was it economic development that fueled this drop in mortality? Far from it: there was no great or rapid increase in income per capita that preceded, or even accompanied, the shifts in health in the first half of the twentieth century.

So what was happening? There was a massive increase in state intervention in health and health-related areas: the adoption of compulsory, free education by 1899; local councils made responsible for the compulsory provision of children with free school meals in 1914; the establishment of the official state birth register in 1907; the introduction of a tax allowance to assist the poor in 1909, the first attempts the following year to introduce a redistributive tax system, and the creation of the National Insurance system the next year; and free medical treatment for poor children in 1912. Thirty years later came the construction of the welfare state: compulsory free education, family allowances, unemployment support, the construction of council houses and the responsibility placed upon councils for the provision of adequate housing and care for children; and the creation in 1948 of the NHS, still one of the most important achievements of any British government.

It was public policy that led to improved health outcomes. Incomes did not start to rise rapidly in the UK until after the 1960s, after the health improvements had been secured. And the UK is not the only example which can be brought against the wealthier is healthier hypothesis. In India and China, there appears to be a negative correlation between economic growth rates and infant mortality rates. Even in the US itself, the biggest falls in mortality occurred after 1970, when real income growth was stagnant. Cuba, of course, is the example most often used to show the problems of linking national income levels to health outcomes, with its higher life expectancy than the US. This suggests that far from impeding economic development, public policy and public investments in key social infrastructure areas are essential for it. For healthier people are more productive, can work more, can earn more. Just as a better educated population can do more, achieve more, make better use of existing and new opportunities.

Even more importantly, the evidence seems to be clear that inequality is the key factor in health outcomes (even in countries such as the UK where, in theory, health services are provided equally to all, regardless of wealth). The poor, everywhere, tend to die earlier. And economic growth which does not reduce the inequality gap does not reduce these inequalities in health outcomes. Wealthier nations does not create healthier people, unless inequality is reduced alongside. And this is a task that only the state can address through public policy.

There is something of a tradition where people grow into their role at DFID, as they begin to see the day-to-day realities of the difficulties and challenges of the development task. Patel may find her current views challenged by the evidence, as others have before her. But starting your tenure repeating the uninformed, un-evidenced and vague criticisms of the Daily Mail and some of her Tory backbench colleagues is not the best start. Now it’s time to move to listening and learning mode.

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