Sunday, 22nd of April 2012 Print

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It is helpful to divide sub-Saharan Africa into three groups: southern Africa (Botswana, Lesotho, Mozambique, Namibia, South Africa and Swaziland), where HIV infection rates have soared over the past decade and have only recently started to stabilise; high-aid recipients (Kenya, Malawi, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe); andthe remainder. Figure 8 tells the story: southern Africa has seen infection rates rocket, the high aid countries started with initially high levels of infection but have since made good progress, and the remaining, low-aid countries have low infection rates which have also recently started to fall.

Our case study country, Botswana, is a major aid recipient and the only southern African country to have seen infection rates fall since 2002. These are descriptive statistics, not an attempt to determine a causal relationship, and there is a great deal of variation around these averages. See Appendix 2 for full details and Figures A2.4 and A2.5.

Our analysis, excluding the southern African group of countries, shows that, since 2002, the average country receiving $10 of additional annual aid per capita, roughly the difference between a high-aid and a low-aid country in the data, has reduced childhood infection rates by 0.2 children per 1,000 of population. So, between 2002 and 2009,high-aid countries reduced HIV infection by an additional 1.4 children per 1,000 total population.

This is a big number in this context: in 2009 the (unweighted) average rate of infection in the group of southern African countries was nine children per 1,000 population; in the rest of sub-Saharan Africa, it was 2.5 children per 1,000, and it was 6.5 in the cluster of high-aid countries.



• In 2010, 89% of the world’s population had access to improved water, compared with 77% in 1990 – an extra 1.2 billion people.

• Progress has been slower in sub-Saharan Africa than in other regions. Only 61% of sub-Saharan Africa’s population has access to improved water sources, up from 49% in 1990. The greatest progress (a 23 percentage point increase) has been in east Asia.

• Over the past 20 years, an additional 1.8 billion people worldwide have gained access to improved sanitation,54 rising from 54% of the world’s population with access in 1990 to 63% in 2010.



Immunisation coverage for six major vaccine preventable diseases – pertussis, childhood tuberculosis, tetanus, polio, measles and diphtheria – has risen significantly since the World Health Organization (WHO) began its Expanded Programme on Immunisation (EPI) in 1974. At the time, only 5% of the world’s children were immunised against the six key vaccine-preventable diseases. By 1980, DTP3 (three doses of vaccinations against diphtheria, tetanus and polio) coverage in the first year of life was estimated at 20% of the world’s children; it increased to an estimated 85% by the end of 2010. Polio is on the verge of eradication. Deaths from measles, a major killer of children under five, declined by 78% worldwide and by 92% in sub-Saharan Africa between 2000 and 2008 (CDC, 2009).

Immunisation against tetanus has saved hundreds of thousands of mothers and newborns, and 20 low- and middle-income countries have eliminated maternal and neonatal tetanus.8 New immunisations have been introduced in recent years, protecting children against pneumococcal disease and rotavirus (the cause of 50% of diarrhoea, the foremost killer of young children).

Provision of these vaccines in 40 low-income countries should avert up to 7 million deaths.9 Donors have played a significant role in progress on immunisation: WHO and UNICEF have been major funders of national immunisation programmes, typically with increasing contributions from developing country governments over time. Since the formation in 2000 of the GAVI Alliance (formerly Global Alliance for Vaccines and Immunization; a public–private partnership dedicated to increasing levels of immunisation against vaccine-preventable diseases),10 substantially larger donor funds have been mobilised for immunisation. These funds haveenabled the introduction of new vaccines and increased coverage of longer-standing vaccination programmes.11 The private sector has also played a key role, both in developing vaccines and in extending access. GAVI’s role as catalyst and NGOs’ advocacy for reduced prices were partly responsible for major drug companies agreeing in 2011 to cut prices for key vaccines in developing countries. These vaccines included rotavirus and pentavalent vaccines, which protect against diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B.12

Ongoing challenges: 1.7 million children still die from vaccine-preventable illnesses a year – mostly poor children in remote areas or conflict-affected countries, or those whose mothers have limited education.13 Further funding and efforts are needed to achieve 90% vaccination levels for key diseases. As of the end of 2010, 23.2 million children under 12 months had not received all three recommended doses of the DTP3 vaccine and 23.7 million children in the same age group had not received a single dose of the measles vaccine.14




To answer this question, we have estimated the relationship between the average annual quantity of aid per capita received by each country, over the last decade for which data are available, and the average annual improvement in childhood outcomes over the same period.

These are descriptive statistics, not an attempt to determine a causal relationship, and thus must be treated with appropriate caution. Moreover, there is considerable variation around these averages. Our analysis was restricted to sub-Saharan Africa.See Appendix 2 for full details.

We found that the average high-aid country reduced childhood malnutrition98 by an additional 2 percentage points over the course of the decade, compared with the average low-aid country. If malnutrition rates fell by an additional 2 percentage points across all of sub-Saharan Africa, 2.7m children would no longer be malnourished.

The average high-aid country reduced infant mortality by an additional 4 deaths per 1,000 over the course of the decade, compared with the average low-aid country. If the rate of infant mortality fell by an additional 4 per 1,000 across all of sub-Saharan Africa, that would save 63,000 infant lives each year.

The case of childhood HIV is more nuanced. In Southern Africa, child infection rates have recently stabilised after a sharp rise. Aid has been particularly important in Botswana (see Case Study 3). Comparing high- and low-aid countries in the rest of sub-Saharan Africa, we found that the typical high-aid country had reduced the number of children living with HIV by 1.4 children by 1,000 population over the past seven years, as a result of good progress by a group of high-aid countries with initially high infection rates. The average rate of child HIV infection in this group of high-aid countries was 6.5 children per 1,000 population.