Global Health Policy

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May 10, 2007

Child Health in Egypt and Iraq: Our Tax Dollars at Work

Posted by Ruth Levine at 04:11 PM

Iraqi children

A new report on child health from Save the Children presents perhaps the most striking contrast I have ever seen between the impact of "soft power" and the consequences of "hard power." That contrast is manifested in the remarkable improvement in child well being in Egypt over 15 years, and in the devastating loss of young life in recent years in Iraq.

As Celia Dugger noted in the New York Times, the Save report ranks developing countries that have managed to dramatically improve child health and well being over the past 15 years -- and the countries where the child death rate has skyrocketed during the same period because of conflict and the rampages of HIV/AIDS. On the top of the list of winners is Egypt, a country that for nearly 30 years has received a tremendous amount of support from the U.S., more than $800 million on average each year since 1979 through Economic Support Funds (ESF) (although much less in recent years). Much of that money, which was provided specifically because of Egypt's geopolitical importance, has been channeled through USAID's development programs, often ending up in child health and family planning programs. It supported the successful scale-up of oral rehydration programs, expansion of water and sanitation systems, and many other large-scale efforts to prevent and treat common diseases affecting the poor. Combined with the priority placed on child health by the Government of Egypt, those U.S. tax dollars contributed to a truly remarkable result: between 1990 and 2005 the child death rate declined by almost 70%, from 104 to 33 per 1,000. Compared to earlier generations, the Egyptian parents who are building their families today can be much more confident about their babies' chances of thriving through childhood and beyond. A similar scenario has been played out in Nepal, Bangladesh and other countries that have benefited from significant, long-term U.S. development spending on child health.

If Egypt and other countries represent one way to spend U.S. tax dollars, Iraq, another country that because of geopolitical forces has drawn vast financial resources from the U.S., represents quite another. The years of sanctions and war have had corrosive effects on health and families, and Iraq has made its way to the top of Save's list of losers. In 1990, the rate of death of children under 5 years old was 50 per 1,000; in 2005, it was estimated to be 150 per 1,000, with 122,000 Iraqi children dying in 2005.

Has the development assistance "won the hearts and minds" of Egyptians, or contributed more powerfully than military intervention might have to maintaining a delicate balance in that part of the world? This is not a question that has a simple answer. But when foreign aid effectively supports programs that make mothers, children and families so much better off -- when it helps to foster a sense that the prospects for lives and livelihoods are improving -- it's impossible not to imagine that this has collateral benefits.

If the welfare of children in countries of strategic importance were used as one of the metrics of success of foreign policy interventions, I suspect that the balance across military, diplomatic, and economic and social development efforts would be quite different than it now is. For a start, the FY08 budget would not propose spending more than one-fifth of the federal budget on defense, and less than one-half of one percent on all development assistance. And the budget request for child survival and health programs this year certainly would not be $154 million less in 2008 than it was in 2007. Official Washington would, in short, be contributing quite differently to building a better world.

Something to think about, for Mother's Day.

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Comments

Excellent post Ruth.

The only thing I'd add is that the ~800 million USD in annual ESF aid to Egypt has come alongside ~1.3 billion USD in annual Foreign Military Financing (FMF) over the last 30 years. While these military financing funds should clearly be evaluated using a different set of criteria than the ESF aid, there seems to me a strong economic reason to flag the fact that over ~1.3 billion USD of US foreign assistance has gone to support the military in an undemocratic, albeit US-allied, police state. While there may be a priori reasons to believe that authoritarian regimes may not be bad for development per se—witness Chile and Indonesia—the fact remains that Egypt has consistently failed to sustain poverty-reducing growth rates, and unlike the exceptional Chiles and Indonesias, Egypt still remains under an authoritarian yoke with the early 1990s rhetoric of the nascent (Asian) Tiger on the Nile long subdued.

In fact, Egypt has been under a state of emergency, roughly equivalent to marshal law in the US, since 1981. The country’s most recent Freedom House scores on political and civil liberties place it among the least free countries on Earth, and its voice and accountability score in the World Bank's governance indicators has been progressively worsening over the last decade. Having lived in Egypt for about 6 months, it was quite apparent that the face of US aid in Egypt is unfortunately not that of the hugely successful ORT programs, but rather of an oppressive police/military force subsidized in part by US taxpayers.

For a more direct justification of the strong economic reason abovementioned, it is worth noting that Egyptian journalists and academics have begun to uncover and understand the mounting evidence of excessive military control over certain productive sectors of the civilian economy. What's certain at this point, though, is that the military spending burden and consolidation over the economy have proved a serious hindrance to the reform and privatization of Egypt's massive and inefficient state-owned enterprises. The unfortunate irony is that the FMF aid has supported one of the major institutions standing in the way of USAID’s own efforts to support and facilitate privatization in Egypt.

Nevertheless, the fact of FMF aid does not in any way diminish or detract from the huge success of the ORT efforts led by USAID. Rather, I simply pose the counterfactual that US foreign assistance might have been even more effective at improving global (and Egyptian) health had the roughly ~$30+ billion USD spent on FMF aid to Egypt over the last 30 years been redirected, at least in part, to foreign assistance programs with a stronger welfare-enhancing component.

In keeping with the message of your post and the main arguments put forward in a recent CGD assessment of the FY08 budget (Billions for War, Pennies for the Poor), I would argue that the ~1.3 billion USD in Egypt's annual FMF aid would be better spent, in terms of improving global welfare, on expanding ORT programs (and/or any of the other proven successful health interventions in Millions Saved) in some of the poorest recipients of US aid. A reallocation of just 12% of Egypt’s annual FMF earmark to USAID’s Child & Survival Health (CSH) programs would have meant a slight increase instead of the 154 million USD reduction in the CSH account.

Thanks again for the great post.

Nevertheless, the fact of FMF aid does not in any way diminish or detract from the huge success of the ORT efforts led by USAID. Rather, I simply pose the counterfactual that the roughly ~$30+ billion USD spent on FMF aid to Egypt over the last 30 years might possibly have been redirected, at least in part, to foreign assistance programs with a stronger welfare-enhancing component.