The impact of aid sanctions on maternal and child mortality, 1990–2019: a panel analysis

BACKGROUND: Aid sanctions are a type of financial punishment imposed on a country by other countries or international organisations in response to a political coup, armed conflict, or human rights abuses. Humanitarian catastrophes in Burkina Faso, Sudan, and Myanmar have brought aid sanctions to the centre of the foreign affairs strategy debate because of their inadvertent negative effects on human health. Our analysis investigates the effects of aid sanctions from 1990 to 2019 on maternal and child mortality. These questions are particularly relevant in the context of the abrupt shift in US foreign aid policy in 2025, leading to aid prohibitions that might resemble aid sanctions in their effects. METHODS: Data were drawn from a broad set of sources, including population health metrics databases, established sanctions databases, and a novel global dataset on aid sanctions created for this study. We assessed the prevalence of the use of aid sanctions worldwide during 1990-2019 and estimated their impact on official development assistance (ODA) and development assistance for health (DAH). We investigated the effect of aid sanctions on infant (age <1 year), children younger than 5 years (hereafter referred to as under-5), maternal (within 42 days of the end of pregnancy), and all-age mortality rates using panel difference-in-differences ordinary least squares estimation. We applied linear regression methods and included country and year fixed effects, country-specific time trends, and multiple control variables. We also conducted a series of sensitivity analyses, including entropy balancing, to confirm the validity of our results. FINDINGS: During our study period, 67 low-income or middle-income countries (LMICs) and sovereign territories (hereafter referred to as countries) were targeted by 88 unique aid sanction episodes. Relative to our control group of 66 never-sanctioned countries, aid sanctions reduced ODA by an estimated US$213·07 million per year (95% CI 502·28 to -76·12) for the average target country and reduced DAH by $16·42 million (32·57 to 0·27)--a 17% reduction in DAH. Aid sanctions resulted in an additional 129·3 infant deaths per 100 000 livebirths (11·7 to 246·9), an additional 47·1 under-5 deaths per 100 000 livebirths (-2·8 to 97·0), and an additional 10·9 (2·2-19·6) maternal deaths per 100 000 livebirths, per year. Relative to mean in-sample mortality rates, aid sanctions thus increased infant, under-5, and maternal mortality rates by 3·1%, 3·6%, and 6·4%, respectively, on an annual basis. INTERPRETATION: Over the period 1990-2019, infant, under-5, and maternal mortality rates among LMICs declined at average annualised rates of 2·6%, 3·2%, and 2·0%, respectively. Aid sanction episodes lasting 5 years-the median duration observed in our sample-would thus negate nearly 30% of the overall improvements in infant and under-5 mortality seen in the average LMIC over this period and approximately 60% of the improvements in maternal mortality. Our findings suggest that aid sanctions are leading to increases in child and maternal mortality via reductions to ODA and DAH and they can inadvertently compound human suffering. This research provides quantitative evidence to support growing legislative awareness of the importance of assessing health impacts while aid sanctions are imposed, and highlights the need to monitor the consequences of foreign aid policies by donor countries, such as foreign aid prohibitions and restrictions. FUNDING: Center for Innovation in Global Health and the Maternal and Child Health Research Institute, Stanford University. TRANSLATIONS: For the Arabic, French, Mandarin and Russian translations of the abstract see Supplementary Materials section.

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