Here are the actual numbers. For Norway, the most generous nation in the world, it’s less than 3 percent. For the United States, it’s less than 1 percent.
One percent of the U.S. budget is about $30 billion a year. Of that, roughly $11 billion is spent on health: vaccines, bed nets, family planning, drugs to keep people with HIV alive, and so on. (The other $19 billion goes to things like building schools, roads, and irrigation systems.)
This graphic shows you a few of the programs supported by aid from the United States and other donors. As you can see, the impact is quite impressive.
One of the most common stories about aid is that some of it gets wasted on corruption. It is true that when health aid is stolen or wasted, it costs lives. We need to root out fraud and squeeze more out of every dollar.
Melinda and I would not be supporting The Global Fund, or any other program, if the money were being misused in a large-scale way. Malaria deaths have dropped 80 percent in Cambodia since The Global Fund started working there in 2003. The horror stories you hear about—where aid just helps a dictator build a new palace—mostly come from a time when a lot of aid was designed to win allies for the Cold War rather than to improve people’s lives. Since that time, all of the actors have gotten much better at measurement. Particularly in health and agriculture, we can validate the outcomes and know the value we’re getting per dollar spent.
Another argument from critics is that aid holds back normal economic development, keeping countries dependent on generosity from outsiders.
This argument makes several mistakes. First, it lumps different kinds of aid together. It doesn’t differentiate aid that is sent directly to governments from funding that is used for research into new tools like vaccines and seeds. The money America spent in the 1960s to develop more productive crops made Asian and Latin American countries less dependent on us, not more. The money we spend today on a Green Revolution for Africa is helping countries grow more food, making them less dependent as well. Aid is a crucial funding source for these “global public goods” that are key for health and economic growth. That’s why our foundation spends over a third of our grants on developing new tools.
Second, the “aid breeds dependency” argument misses all the countries that have graduated from being aid recipients, and focuses only on the most difficult remaining cases. Here is a quick list of former major recipients that have grown so much that they receive hardly any aid today: Botswana, Morocco, Brazil, Mexico, Chile, Costa Rica, Peru, Thailand, Mauritius, Singapore, and Malaysia. South Korea received enormous amounts of aid after the Korean War, and is now a net donor. China is also a net aid donor and funds a lot of science to help developing countries. India receives 0.09 percent of its GDP in aid, down from 1 percent in 1991.
Even in sub-Saharan Africa, the share of the economy that comes from aid is a third lower now than it was 20 years ago, while the total amount of aid to the region has doubled. There are a few countries like Ethiopia that depend on aid, and while we all—especially Ethiopians themselves—want to get to a point where that is no longer true, I don’t know of any compelling argument that says Ethiopia would be better off with a lot less aid today.
Critics are right to say there is no definitive proof that aid drives economic growth. But you could say the same thing about almost any other factor in the economy. It is very hard to know exactly which investments will spark economic growth, especially in the near term. However, we do know that aid drives improvements in health, agriculture, and infrastructure that correlate strongly with growth in the long run. Health aid saves lives and allows children to develop mentally and physically, which will pay off within a generation. Studies show that these children become healthier adults who work more productively. If you’re arguing against that kind of aid, you’ve got to argue that saving lives doesn’t matter to economic growth, or that saving lives simply doesn’t matter.
- “A vaccination campaign in southern Africa virtually eliminated measles as a killer of children.”
- “An international effort eradicated smallpox worldwide.”
- “A program to control tuberculosis in China cut the number of cases by 40 percent between 1990 and 2000.”
- “A regional program to eliminate polio in Latin America after 1985 has eliminated it as a public health threat in the Americas.”
The last point is worth expanding on. Today there are only three countries left that have never been polio-free: Afghanistan, Pakistan, and Nigeria. Last year the global health community adopted a comprehensive plan aimed at getting the world polio-free by 2018, and dozens of donors stepped up to fund it. Once we get rid of polio, the world will save about $2 billion a year that it now spends fighting the disease.
Many low- and middle-income countries will develop enough to pay for this convergence themselves. Others will need continued generosity from donors, including investments in health-related R&D. Governments will also have to set the right policies. For example middle-income countries should look at taxing tobacco, and at cutting fossil-fuel subsidies to free up funding for health.
Above all, I hope we can stop discussing whether aid works, and spend more time talking about how it can work better. This is especially important as you move from upstream research on global public goods into the downstream effort of delivering these innovations. Are the recipient countries in charge of figuring out where health clinics should be built and training the workers? Are donors helping local teams build up the expertise they need to put the Western experts out of business? Are the best performers sharing the lessons they’ve learned so other countries can follow suit? This has been a big area of learning for the foundation.
I have believed for a long time that disparities in health are some of the worst inequities in the world—that it is unjust and unacceptable that millions of children die every year from causes that we can prevent or treat. I don’t think a child’s fate should be left to what Warren Buffett calls the “ovarian lottery.” If we hit this goal of convergence, the ovarian lottery for health outcomes will be closed for good.
When children are well-nourished, fully vaccinated, and treated for common illnesses like diarrhea, malaria, and pneumonia, the future gets a lot more predictable. Parents start making decisions based on the reasonable expectation that their children will live.
Death rates are just one of many factors that affect birth rates. For example, women’s empowerment, as measured by age of marriage and level of education, matters a great deal. Girls who marry in their mid-teens tend to start getting pregnant earlier and therefore have more children. They usually drop out of school, which limits their opportunities to learn about their bodies, sex, and reproduction—and to gain other kinds of knowledge that helps them improve their lives. And it’s typically very difficult for adolescent brides to speak up in their marriages about their desire to plan their families. I just traveled to Ethiopia, where I had a long conversation with young brides, most of whom were married at 11 years old. They all talked about wanting a different future for their children, but the information they had about contraceptives was spotty at best, and they knew that when they were forced to leave school their best pathway to opportunity was closed off.
In fact, when girls delay marriage and stay in school, everything changes. In a recent study of 30 developing countries, women with no schooling had three more children on average than women who attended high school. When women are empowered with knowledge and skills, they start to change their minds about the kind of future they want.
I recently spent an afternoon with a woman named Sadi Seyni, who scratches out a living for five children on an arid farm in a desert region of Niger. She didn’t know about contraceptives when she got married as a teenager. Now she knows, and she’s spacing her pregnancies several years apart, to protect her health and the health of her newborns. I visited the place where she learned about family planning: her village’s well, where women go to talk. And talk. And talk. While we were telling stories, a young bride came to get water. Through a translator, this girl told me that her pregnancies were “God’s will” and therefore out of her control. Sadi suggested that as long as this girl keeps coming to the well and listening, she’ll change her view over time. Even the informal education that happens when a little knowledge spreads among friends transforms the way people think about what’s possible.
In this version of the future, currently poor countries are healthier, richer, and more equal—and growing sustainably. The alternate vision summed up by the Malthusian myth—a world where sustainability depends on permanent misery for some—is a misreading of the evidence and a failure of imagination.
Saving lives doesn’t lead to overpopulation. In fact, it’s quite the opposite. Creating societies where people enjoy basic health, relative prosperity, fundamental equality, and access to contraceptives is the only way to secure a sustainable world. We will build a better future for everyone by giving people the freedom and the power to build a better future for themselves and their families.
If you read the news every day, it’s easy to get the impression that the world is getting worse. There is nothing inherently wrong with focusing on bad news, of course—as long as you get it in context. Melinda and I are disgusted by the fact that more than six million children died last year. But we are motivated by the fact that this number is the lowest ever recorded. We want to make sure it keeps going down.
We hope you will help get the word out on all these myths. Help your friends put the bad news in context. Tell political leaders that you care about saving lives and that you support foreign aid. If you’re looking to donate a few dollars, you should know that organizations working in health and development offer a phenomenal return on your money. The next time you’re in an online forum and someone claims that saving children causes overpopulation, you can explain the facts. You can help bring about a new global belief that every life has equal value.
We all have the chance to create a world where extreme poverty is the exception rather than the rule, and where all children have the same chance to thrive, no matter where they’re born. For those of us who believe in the value of every human life, there isn’t any more inspiring work under way in the world today.