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The Author 2012; all rights reserved. Advance Access publication 13 December 2012
*Corresponding author. Magdalene College, Cambridge CB3 0AG, UK. E-mail: ds450@cam.ac.uk
6 November 2012
Is aid helping, hindering, or having no effect on development and health? The
answer to this question is highly contested, with proponents on all sides adhering
strongly to their competing interpretations. We ask how it is possible for those who
are often using the same data to hold such divergent views. Here, we employ an
epidemiological perspective and find that, in many cases, the arguments are
characterised by methodological weaknesses. There may be selective citation of
results and failure to account for bias and confounding, such as where an
extraneous factor influencing the outcome is correlated with increased aid or, in
confounding by indication, where increased aid is a consequence of a country being
in an especially adverse situation. Studies may also lack external validity, whereby
lack of data (a widespread problem) or similar considerations mean that analyses
are undertaken on an unrepresentative subset of countries. Multiple outcome
measures can also be problematic, where the main outcome of interest is not
specified in advance. Many studies fail to account for differential time lags between
changes in aid and the outcomes being studied. Some studies may also be
underpowered to detect an association where one exists. Although, ideally, this
debate should be informed by large scale randomised controlled trials, this will
often be unfeasible. Given this limitation, it is essential that those engaged in it are
cognisant of the many methodological issues that face any observational study.
Keywords
KEY MESSAGES
Debates on aid effectiveness largely overlook multiple sources of bias that are well recognized from an epidemiological
perspective.
Often aid analyses rely on inappropriate exposure and outcome variables, without specification of time lags, causal
mechanisms and net effects.
Most aid effectiveness analyses are biased towards the null hypothesis of no effect.
Strong policy conclusions about the effectiveness of aid are not justifiable based on the existing quality of data and
evidence.
871
Accepted
872
Introduction
Methodological issues
Narrative reviews
Many of the most widely read texts on the effectiveness of aid
draws heavily on case studies from individual countries. Thus, the
critics of aid draw attention to countries such as Botswana, that
have prospered with little or no development assistance and
others that have received large sums of aid but to little effect
(Easterly 2007) or even been extremely damaging, as in Rwanda
where one author has invoked development assistance as a factor
in the genocide (Andersen 2000). In contrast, the proponents of
aid draw attention to what they see as countries that have
benefited from aid, such as Tanzania and Ghana (Sachs et al.
2004). These reviews often lack a systematic approach to
inclusion, raising the possibility of selective citation with consequent misleading results. They also fail to account for confounding factors and bias (to which we return). Studies of similar
narrative reviews in medicine have shown that the results can be
highly misleading (Schmidt and Gotzsche 2005). Such analyses
often draw on personal stories. These have the ability to capture
the human consequences of the phenomena being discussed and
do influence decision making. However, the influence these
stories exert on policy is still poorly understood, leading the
authors of a recent systematic review of their role in decision
making to call for caution in their use (Winterbottom et al. 2008).
Time lags
Classic analyses have been cross-sectional, inferring expected
effects over varying periods ranging from the same year to
those of 1025 years, often with small sample sizes (Bornschier
et al. 1978; Barro 1991; Sachs and Warner 1995). More recent
studies restrict the analysis to 4 years, so determined not by
theory but the validity of statistical models (Clemens et al.
2004), a practice that seems common in recent analyses
(Burnside and Dollar 2000; Collier and Dollar 2002; Clemens
et al. 2004; Raghuram and Subramanian 2005). Other papers
deploy agnostic time series analysis, using time specifications
that are acknowledged to be largely atheoretical (Hansen and
Headey 2010). Yet it is far from clear what the most appropriate
interval is. Furthermore, the relationship may be asymmetrical,
with any benefits of aid taking some time to accrue, e.g.
because of the time taken to build new facilities, create new
873
874
Net effects
Critics of health aid correctly point out that too often top-down
and vertical (narrow), development programmes reflect donor
priorities rather than actual health needs. This creates many
disruptions in the system. In the case of health aid it can lead
to some diseases, such as HIV, seeming to be exceptionally
prioritized at the expense of other key health problems, such as
non-communicable diseases (Beaglehole et al. 2011). Yet, one
problem with this argument is the lack of attention to the
nature of aid data. For example, suppose HIV activism has
helped marshal additional aid resources for global health. If
this were the case, it would artificially make resources for some
health conditions appear to drop as a fraction of overall health
Data limitations
875
100
500
50
100
Health Aid Disbursements
150
200
Policy interpretation
Those who argue that aid has not worked in the past conclude
that aid should be abandoned or significantly curtailed in the
future. We have argued that the first part of this argument is not
justified by the evidence. However, even if it were, the second
part does not necessarily follow. Would outcomes be improved
more by removing aid or by attempting to address its shortcomings? Again, an analogy with medicine is helpful. There have
been many interventions that were at first unsuccessful but, as
experience with their application increased, they became routine
therapy (Woods et al. 1992; Costache et al. 2009).
Some aid critics argue that because redistributive welfare has
limitations and potential negative effects, no redistribution
should occur at all. But if the system that provides food stamps
(vouchers) to the hungry is not ending hunger or is subject to
political manipulation that causes some groups and not others
to receive more stamps, does that mean we should not provide
food stamps at all, and simply cut off all assistance to those
unable to afford food? Would this be a better way to reduce
Counterfactuals
What would happen if aid was removed and a country
abandoned to its own devices. We do have some examples to
draw on, such as Somalia. The potential consequences can
easily be identified, such as mass migration, terrorism and
disease outbreaks. However, the use of such examples is subject
to the same methodological problems as those evaluations of
the effect of increasing aid. On the other hand, it can be argued
that the observable fact that such consequences can occur
justifies invoking the precautionary principle (ORiordan and
Cameron 1994). One recent example of the lack of a control
group was the Millennium Villages Project. An analysis based
on its effects was withdrawn from the Lancet after a host of
problems resulting from the failure to plan for a counterfactual
rendered the studys results untenable.
Conclusion
Both aid critics and proponents agree on the need for greater
public scrutiny of aids effectiveness, through a process of
experimentation, evaluation and replication. There are now
876
Description
Aid as permanent
Global social safety net/redistribution (Ooms and Hammond 2009); correct global externalities (e.g. World Bank poverty
strategy reduction papers)
Aid as temporary
Big push out of poverty traps (e.g. Sachs 2005); cope with short-term effects of crisis and disasters (e.g. international
monetary fund lending; Collier 2009)
Aid as distortion
Acknowledgement
We are grateful to Karen Grepin for contributions to background literature and discussions incorporated into various
drafts of this paper.
Funding
None.
Conflict of interest
None declared.
Easterly W. 2006. The White Mans Burden: Why the Wests Efforts to Aid the
Rest have Done So Much Ill and So Little Good. Oxford: Oxford
University Press.
Easterly W. 2007. Was development assistance a mistake? American
Economic Review Papers and Proceedings 97: 32832.
References
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Arellanoa C, Bulrb A, Laneb T, Lipschitzb L. 2009. The dynamic
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Easterly W, Pfutze T. 2008. Where does the money go? Best and worst
practices in foreign aid. Journal of Economic Perspectives 22: 124.
Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. 2009.
Universal voluntary HIV testing with immediate antiretroviral
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Grobbee DE, Hoes AW. 1997. Confounding and indication for treatment in evaluation of drug treatment for hypertension. BMJ 315:
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Klein N. 2007. The Shock Doctrine: The Rise of Disaster Capitalism. London:
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Lipsey RG, Lancaster K. 1956. The general theory of second best. Review
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Schmidt LM, Gotzsche PC. 2005. Of mites and men: reference bias in
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Practice 54: 3348.
Tyler KM, Normand SL, Horton NJ. 2011. The use and abuse of multiple
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878
Appendix
Table A1 Summary of aid commitments by the UK, reported by DFID to the OECD CRS, 199193
Year
USD
commitment
deflated
(millions)
Description
Title
Recipient
1991
16.37
Malaysia
1991
0.17
Medical equipment
1991
0.12
Medical clinic
1991
0.92
1991
0.19
Tanzania
1991
1.84
Bilateral, unspecified
1991
0.04
Ghana
1991
0.42
Bilateral, unspecified
0.62
Nutrition
MALNTRNINFTCHLDMTHR4719
Bilateral, unspecified
0.60
Health/health services
Nigeria
1991
3.78
Rural clinics/dispensaries
Namibia
1991
1.71
Doctors training
Zambia
1991
0.74
Nurses/paramedics training
Zambia
1991
0.63
Nurses/paramedics training
Zambia
1991
6.84
Health/health services
Zimbabwe
1991
3.40
Uganda
1991
3.72
Doctors training
MED.TRNG.SCHL.OF.MED-UNZA
Zambia
1991
0.30
Rural clinics/dispensaries
Tanzania
1991
0.38
Health/health services
Namibia
1992
19.40
Health education
India
1992
0.70
Tanzania
1992
2.12
Tanzania
1992
0.63
Bilateral, unspecified
1992
1.16
Solomon Islands
1992
24.97
Pakistan
1992
5.80
India
1992
0.69
Health education
Bangladesh
1992
0.56
1992
1.24
1992
1.02
Zimbabwe
1992
0.44
Nurses/paramedics training
Tanzania
Gambia
1992
1.45
1992
0.87
Rural clinics/dispensaries
1992
0.90
Hospitals
Gambia
1992
2.69
Health/health services
MNGT.STRENGTH.PROJ MANAGEMENT
STRENGTHENING PROJ.
Gambia
1992
2.90
Kenya
1992
0.62
Kenya
1992
0.19
Lesotho
1992
1.32
Health/health services
Lesotho
1992
0.01
AIDS
Malawi
(continued)
1991
1991
879
Table A1 Continued
Year
USD
commitment
deflated
(millions)
Description
Title
Recipient
0.56
Health/health services
LINK-HSMC-CIESS
Mexico
1992
1.59
Rural hospitals
Kenya
1992
0.67
Hospitals
Sierra Leone
1992
2.90
AIDS
Zambia
1992
1.28
Health/health services
India
1992
5.57
Hospitals
Nepal
1992
21.30
Rural clinics/dispensaries
Sri Lanka
1992
3.03
Bilateral, unspecified
1992
4.00
Health/health services
Bilateral, unspecified
1992
3.59
Bilateral, unspecified
1992
3.20
Bilateral, unspecified
1992
3.15
Health/health services
Bilateral, unspecified
1992
1.27
Health/health services
Bilateral, unspecified
1992
5.31
Health/health services
WP HLTH ECON/FINANCING
Bilateral, unspecified
1992
1.97
Nutrition
Bilateral, unspecified
1992
0.40
Rural clinics/dispensaries
Bilateral, unspecified
1992
1.26
Nutrition
INFANT MORBIDITY/VIT A
Bilateral, unspecified
1992
2.06
Doctors training
Fiji
1992
0.36
Rural clinics/dispensaries
Ethiopia
1992
0.84
Rural clinics/dispensaries
Kenya
1992
1.46
Kenya
1992
1.45
Health/health services
Kenya
1992
0.87
Health education
Senegal
1992
1.00
Health/health services
Sierra Leone
1992
11.70
Tanzania
1992
0.97
Health education
Tanzania
1992
1.13
Health/health services
Uganda
1992
1.70
Health/health services
Uganda
1992
0.58
Rural clinics/dispensaries
Bolivia
1992
2.09
Rural clinics/dispensaries
Brazil
NUTRITION PROGRAMME
1992
0.31
Nutrition
1992
0.84
Peru
Dominica
1992
0.70
Medical services
Bangladesh
1992
0.86
1992
0.63
Health/health services
1992
0.53
Health education
Pakistan
1992
1.96
Rural clinics/dispensaries
1992
0.82
Clinics/dispensaries
South Africa
1992
0.46
Health/health services
Chile
Cambodia
(continued)
1992
880
Table A1 Continued
Year
USD
commitment
deflated
(millions)
Description
Title
Recipient
0.87
Health/health services
Uganda
0.33
Health/health services
Kenya
1992
1.39
Nurses/paramedics training
Malawi
1992
1.37
Health/health services
Uganda
1992
1.36
Health/health services
Cambodia
1992
0.30
Health/health services
India
1992
0.59
Health/health services
India
1992
0.48
1992
0.59
Kenya
1992
0.40
Health/health services
Bilateral, unspecified
1992
0.70
Health/health services
Bilateral, unspecified
1992
0.47
VISCERAL LEISHMANIASIS.
ASYMPTOMATIC CARRIERS
Bilateral, unspecified
1992
0.38
Health/health services
Fiji
1992
0.62
Medical research
PARASITIC NEMATODES
Bilateral, unspecified
1992
0.48
Nurses/paramedics training
MIDWIFERY TRAINING
Bangladesh
1992
2.32
Health/health services
India
1992
1.43
BLINDNESS PROGRAMME
India
1992
1.48
Medical research
HAEMOGLOBINOPATHY CONTROL
India
1992
2.17
VIRAL HEPATITIS
India
1992
1.23
India
1992
1.41
Medical research
CERVICAL CANCER
India
1992
26.10
Rural clinics/dispensaries
India
1992
0.39
Medical research
ROTAVIRUS INFECTION
India
1992
0.84
Rural clinics/dispensaries
1992
26.55
Health/health services
1992
0.85
AIDS INITIATIVE
1992
0.68
Bilateral, unspecified
1992
1.16
Health/health services
Uganda
1992
2.91
Uganda
1992
1.21
Rural clinics/dispensaries
Afghanistan
1992
1.45
Health education
OPHTHALMIC PROGRAMME
Mozambique
1992
0.32
PROTOZOAN CYSTS
Bilateral, unspecified
1992
0.37
Rural clinics/dispensaries
Bilateral, unspecified
1992
0.57
Nutrition
Bilateral, unspecified
1992
0.44
Health/health services
Bilateral, unspecified
1992
0.51
Health/health services
Brazil
1992
0.43
Health/health services
Ghana
1992
0.29
Health/health services
Bilateral, unspecified
1992
4.33
Rural clinics/dispensaries
Bilateral, unspecified
1992
3.07
Health/health services
EPIDEMIOLOGY PROGRAMME
Bilateral, unspecified
(continued)
1992
1992
881
Table A1 Continued
Year
USD
commitment
deflated
(millions)
Description
Title
Recipient
Bilateral, unspecified
2.67
Health/health services
1992
1.64
Medical laboratories
LABORATORY SERVICES
Bilateral, unspecified
1992
2.10
Nurses/paramedics training
Pakistan
1992
0.38
Medical/veterinary services
Yemen
1992
0.64
Health/health services
Peru
1992
0.93
Doctors training
ASS-FAC OF MEDICINE
Ethiopia
1992
2.90
Health/health services
India
1992
3.77
Medical research
Bilateral, unspecified
1992
5.74
Rural clinics/dispensaries
Solomon Islands
1992
7.86
Health/health services
Tanzania
1992
0.49
Ethiopia
1992
0.86
Health/health services
Nicaragua
1992
2.62
Health/health services
Ghana
1992
0.87
Health/health services
Nigeria
1992
1.09
Rural clinics/dispensaries
PRIMARY HEALTH
Bolivia
1992
12.78
Nurses/paramedics training
Bangladesh
1992
7.90
Health/health services
Bangladesh
1992
3.71
Health/health services
Bangladesh
1992
0.84
Bangladesh
1992
0.72
Health/health services
Bangladesh
1992
8.24
Health/health services
1992
0.66
Doctors training
Kenya
1992
2.28
Health/health services
India
1992
0.76
Rural clinics/dispensaries
Kenya
1992
3.28
Medical/veterinary services
India
1992
1.45
Doctors training
India
1992
0.58
Health/health services
Bilateral, unspecified
1992
0.62
Medical laboratories
BLOOD TRANSFUSION
India
1992
1.45
Clinics/dispensaries
Ghana
1992
1.75
Health/health services
1992
0.43
Health/health services
Bilateral, unspecified
1992
3.16
Health/health services
St. Helena
1992
8.82
Health/health services
Pakistan
1992
2.61
Rural clinics/dispensaries
Solomon Islands
1992
1.67
Health/health services
Bilateral, unspecified
1992
0.43
Health/health services
Y CARE INTERNATIONAL
Bilateral, unspecified
1992
1.10
Health/health services
Cambodia
1992
1.67
Nutrition
INCAPTRG.NUTRITION SCIENCE TO
STRENGTHEN INCAPS CAPACITY
America, regional
1992
(continued)
882
Table A1 Continued
Year
USD
commitment
deflated
(millions)
Description
Title
Recipient
1.45
Health/health services
HEALTH SERVICES
Anguilla
0.41
Health/health services
Malawi
1992
0.67
Malawi
1992
1.88
Doctors training
MED.COLL-INSTTNL.DEV.PRJ
Malawi
1992
0.87
AIDS PHASE II
Kenya
1992
0.43
Bilateral, unspecified
1992
1.78
Health/health services
1992
0.57
Health/health services
INDUCED ABORTION
Bilateral, unspecified
1992
1.09
Health/health services
Uganda
1992
1.82
Medical laboratories
1992
0.59
Health/health services
Bilateral, unspecified
1992
2.28
Doctors training
POST-GRADUATE MEDICAL
TRAININGPROJECT
Seychelles
1992
5.76
Health/health services
Uganda
1992
0.52
Medical research
Bilateral, unspecified
1992
2.90
1992
1.50
Nurses/paramedics training
1992
2.04
Medical/veterinary services
1992
0.86
Medical research
1992
58.00
Health/health services
India
1992
4.20
Health/health services
South Africa
1992
0.43
Health/health services
Brazil
1993
2.33
Clinics/dispensaries
1993
2.82
Cambodia
1993
14.39
Medical supplies
EQUIPMENT INSTALLATION
Ghana
1993
0.46
Medical services
1993
0.79
Rural clinics/dispensaries
1993
1.26
1993
3.50
1993
Pakistan
Ghana
Zimbabwe
PRIMARY HEALTH CARE
Cambodia
Rural clinics/dispensaries
Nepal
0.56
Health/health services
Anguilla
1993
3.69
Basic nutrition
South Africa
1993
1.09
Bilateral, unspecified
1993
2.38
Jamaica
Bilateral, unspecified
1993
0.32
Basic nutrition
1993
0.34
Health/health services
Bilateral, unspecified
1993
3.57
Rural clinics/dispensaries
Pakistan
1993
3.83
Rural clinics/dispensaries
Pakistan
1993
1.11
Health/health services
Namibia
1993
0.85
Rural clinics/dispensaries
Solomon Islands
1993
18.45
Rural clinics/dispensaries
Uganda
Bilateral, unspecified
(continued)
1992
1992
883
Table A1 Continued
Year
USD
commitment
deflated
(millions)
Description
Title
Recipient
1993
1.27
INT.CNTRE.DIARRHOEAL DISEASE
RES.DEM.SURV.SYST.COORDINATOR
Bilateral, unspecified
1993
5.07
Medical research
Bilateral, unspecified
1993
0.93
Rural clinics/dispensaries
Vanuatu
1993
0.85
Niger
1993
0.42
CHRIS ALLISON
Bilateral, unspecified
1993
0.52
Health/health services
HEALTH FINANCING
Kyrgyz Republic
1993
0.58
Medical/veterinary services
Cambodia
0.37
Rural clinics/dispensaries
Cambodia
1993
0.43
Rural clinics/dispensaries
India
1993
0.71
Rural clinics/dispensaries
Laos
1993
0.81
Bilateral, unspecified
1993
0.40
Rural clinics/dispensaries
Laos
1993
1.14
Kenya
1993
0.78
Medical/veterinary services
ANAESTHETIC TRAINING
Malawi
1993
1.01
Zimbabwe
1993
0.53
Medical/veterinary services
Cambodia
1993
16.31
Health/health services
Ghana
1993
0.34
Clinics/dispensaries
1993
0.70
Health/health services
Cambodia
1993
1.79
Health/health services
South Africa
1993
2.02
Health/health services
South Africa
1993
0.70
India
1993
0.68
Bilateral, unspecified
1993
0.42
Uganda
1993
0.31
Hospitals
NAIROBI HOSPICE
Kenya
1993
0.16
Health/health services
Bilateral, unspecified
1993
0.43
Bilateral, unspecified
1993
0.56
Bilateral, unspecified
1993