Foreign aid for health care is directly linked to an increase in life expectancy and a decrease in child mortality in developing countries, according to a new study by Stanford researchers.

The researchers examined both public and private health-aid programs between 1974 and 2010 in 140 countries and found that, contrary to common perceptions about the waste and ineffectiveness of aid, these health-aid grants led to significant health improvements with lasting effects over time.

Countries receiving more health aid witnessed a more rapid rise in life expectancy and saw measurably larger declines in mortality among children under the age of 5 than countries that received less health aid, said Eran Bendavid, MD, an assistant professor in Stanford Medical School's Division of General Medical Disciplines and lead author of the study. If these trends continue, he said, an increase in health aid of just 4 percent, or $1 billion, could have major implications for child mortality.

“If health aid continues to be as effective as it has been, we estimate there will be 364,800 fewer deaths in children under 5,” he said. “We are talking about $1 billion, which is a relatively small commitment for developed countries.”

Does it work?

Bendavid noted that there is much debate around foreign aid. Critics question whether it’s used effectively and reaches its intended recipients. They often argue that it discourages local development and displaces domestic resources that might otherwise be devoted to health. So the researchers devised a statistical tool to address the basic unanswered question: Do investments in health really lead to health improvements?

Bendavid said there are many reasons to suspect the answer would be no, though the findings proved just the contrary, with health-related aid leading to direct, beneficial outcomes.

“I think for many people, that will be surprising,” he said. “But for me, it fits with other evidence of the incredible success of public health promotion in developing countries.” In a previous study, for instance, he found that hundreds of thousands of lives were saved through the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, in which the U.S. government invested billions of dollars in antiretroviral treatment and other AIDS-related prevention and treatment initiatives.

In the latest study, the two investigators used data from the Creditor Reporting System of the Organization for Economic Cooperation and Development, the world’s most extensive source of information on foreign aid. While aid programs for health grew during the 36-year study period, the largest period of growth occurred between 2000 and 2010, they found.

Stepped-up investments

It was during this decade that many governments and private groups stepped up their investments in health, including PEPFAR; the World Bank; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Gates Foundation; and the GAVI Alliance, among others, he said.

As a result, while health aid in 1990 accounted for 4 percent of total foreign aid, it now amounts to 15 percent of all aid, he said. And it’s become an important part of health budgets in recipient countries, accounting for 25-30 percent of all health-care spending in low-income countries, Bendavid said.

The researchers found that these funds were used effectively, largely because of the targeting of aid to disease priorities where improved technologies — such as new vaccines, insecticide-treated bed nets for malarial prevention and antiretroviral drugs for HIV — could make a real difference.

They observed the greatest health impacts between 2000 and 2010, when donor investments were at their peak. During the decade, under-5 child mortality declined from a mean of 109.2 to 72.4 deaths per 1,000, or 36.8 fewer deaths among those children in the countries that received the most health aid, the researchers found (a 34 percent reduction). In the countries receiving the least, under-5 mortality fell from 31.6 to 23.2 deaths per 1,000, or 8.4 fewer deaths per 1,000 live births (a 26 percent reduction), the researchers reported.

Life expectancy increases

During that period, life-expectancy figures also grew faster in countries with a greater infusion of health aid, Bendavid said. Life expectancy rose from 57.5 to 62.3 — an increase of 4.8 years — among the countries receiving the most aid. Among the countries receiving the least health aid, life expectancy increased by 2.7 years, from 69.8 to 72.5 years.

Bendavid said previous experience has shown that, on average, life expectancy has increased by nearly one year every four years in developed countries. But health-aid programs literally cut in half the time it took to reach this goal in developing countries. “In that same four-year span, they increased life expectancy by two years, rather than one year,” he said.

He said the results are not surprising if one considers some of the new health technologies made available to developing nations as a result of foreign aid. Childhood vaccines, including those for diphtheria, tetanus, polio and measles, have all but wiped out what used to be among the top killers of young children in the developing world. Health aid directed to providing insecticide-treated malarial bed nets also has been credited in recent studies with reducing malarial deaths among young children, he noted.

Among both adults and children, aid that has expanded the availability of antiretroviral drugs in the developing world has had a major impact on reducing deaths and improving overall life expectancies, he said. For instance, in a study published in 2012, Bendavid and colleagues found that PEPFAR’s health aid resulted in more than 740,000 lives saved between 2004 and 2008 in nine countries.

The researchers also found that the benefits of aid have a lasting effect: The telltale signs of aid’s relationship to reducing under-5 mortality were detectable for three years following the distribution of aid. The correlation between health aid and longer life expectancy overall was detectable for five years after the aid was distributed.

With aid commitments flattening amid the economic downturn, Bendavid said donors will have to be that much smarter in how they invest future dollars, focusing on the most cost-effective interventions and technologies.

“To date, there has been little consideration of how to use development aid in the most cost-effective manner,” he said. “That will have to change now that the funding level has reached a plateau.”

The study was funded by the George Rosenkranz Fellowship for Health Policy Research in Developing Countries and by the National Institutes of Health (grant K01AI084582).

Information about Stanford’s Department of Medicine, which also supported the work, is available at http://medicine.stanford.edu.

Ruthann Richter is the director of media relations at the Stanford School of Medicine.

Zack Bonzell came to Stanford with a strong interest in human biology and political science. Last summer, the undergraduate had the chance to fuse his interests while doing field research with faculty at the university’s Freeman Spogli Institute for International Studies (FSI). 

During a two-week internship, he travelled to Guatemala with FSI senior fellows Paul Wise, Beatriz Magaloni, Alberto Díaz-Cayeros and Scott Rozelle to learn about the country’s rural health care system by shadowing doctors and interviewing mothers in an impoverished area about the issues leading to the area’s high rates of child malnutrition.

“That experience was an ideal way to blend my interests and gave me a better idea of how to craft my course of study at Stanford,” said Bonzell, who is now a junior. “One of the things that really struck me was when Paul Wise said the health outcomes we were seeing are the result of extreme material deprivation. These people are sick because they are poor. That gave me more of an interest in political economy.”

Students conduct interviews about nutrition with REAP in China. Photo Credit: Matt Boswell

FSI is now expanding its educational opportunities for students, like Bonzell, who want to do research on global issues in Asia, Latin America, Europe and Africa.

The Stanford Global Student Fellows program (SGSF) is being funded in large part through a $1.25 million anonymous gift that will help grow existing programs and create new offerings for graduates and undergraduates.

“This program deepens FSI’s commitment to its mission of educating the next generation of leaders in international affairs,” said FSI Director Mariano-Florentino Cuéllar. “It also offers outstanding opportunities for Stanford students to work closely with the leading thinkers on global policy issues.”

The program, which is part of FSI’s efforts to expand student opportunities, will build on the institute’s undergraduate mentorship programs that allow students to work on faculty research projects each quarter. Those positions will now be available during the summer. Some of the positions will be connected to projects in FSI’s new International Policy Implementation Lab, an initiative that gives students a close-up view of how academics and policy influencers can address some of the world’s thorniest issues.

PoliSci 114S students work together in a UN conflict simulation. Photo Credit: Rod Searcey

Building on FSI’s experience placing students in research opportunities, the program will create and expand summer field research internships. The two- to six-week internships this summer will give undergraduates the opportunity to work with FSI senior fellows in China, Guatemala, India and Mexico who study global health, conflict resolution, governance and poverty reduction.  In coming years, the program will likely include additional fieldwork projects in Rwanda, Tanzania and Brazil. The SGSF program covers all travel expenses for students and provides students with an opportunity to work closely with a faculty member and a team of other students on an ongoing research project addressing real-world problems in a specific region. 

“What makes FSI such an incredible institution is that it attracts faculty who have very pragmatic interests,” Bonzell said. “It seeks to wed academic work with a more direct impact, and there’s a lot of potential for more students to think along similar lines.”

The Stanford Global Student Fellows will also allow FSI to work closely with its partners, including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students. 

Mexican Ambassador Eduardo Medina Mora and Jorge Olarte, '13, speaking with students at the US-Mex FoCUS event. Photo Credit: Rod Searcey

One of the program’s new initiatives geared toward undergraduates is the Global Policy Summer Fellowships. The fellowships help secure placement and a $6,000 stipend for students interested in interning at international policy and international affairs organizations. This summer,The Europe Center at FSI is placing students at the Center for European Policy Studies and Bruegel, two Brussels-based think tanks. Future positions will be created with six offerings abroad and two based in the United States.including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students. 

The Stanford Global Student Fellows program will also commit $400,000 to create a Mentored Global Research Fellowship that will provide research opportunities for students to conduct their own overseas research under the close mentorship of a faculty member. The program will award stipends of $6,000 for summer undergraduate projects and $9,000 for summer graduate projects, and $1,500 for smaller projects executed during the school year.

Thomas Hendee '13 chatting with children in rural Guatemala. Photo Credit: Maria Contreras

The faculty advisory committee overseeing the development and implementation of these new programs includes Scott Rozelle, the Helen F. Farnsworth Senior Fellow and the co-director of FSI’s Rural Education Action Program; Stephen Stedman, a senior fellow at FSI and the deputy director of CDDRL; and Lisa Blaydes, assistant professor of political science.

The application deadline for all summer programs is Feb. 28, 2015. The deadline to apply for academic quarterly programs is the end of the first week of each quarter, beginning in the fall of 2014. 

For more information, students should contact Elena Cryst at ecryst@stanford.edu and watch for postings on FSI’s student program Facebook page. Students can also sign up for the program’s distribution and announcement list.