While I cannot do justice to the vast literature on aid effectiveness, let me provide a snapshot of how aid has dramatically improved human health and what cuts mean for the world’s poorest.

We’ll start with the big picture – has international aid actually helped? After reviewing global progress on infant mortality, smallpox and HIV, I’ll share my research from Zambia, where the government has dramatically reduced maternal mortality through data-driven accountability. Finally, we’ll consider USAID’s groundbreaking collaboration with UNICEF, Open Philanthropy and the Gates Foundation to tackle lead poisoning.

Global Progress on Health!

At the big macro level, Lant Pritchett considers whether aid has helped. As you can see, there has been a massive reduction in infant mortality and an expansion of schooling - more than would be expected from growth alone. One compelling explanation for these improvements is international aid.

Smallpox

Smallpox previously killed more people throughout history than all wars combined, causing disfigurement, blindness, and death to millions. At a relatively small cost of $1.5 billion, it was successfully eradicated in 1980.

As Owen Barder calculates, even if this was all that aid had ever achieved, then it would still have been extraordinarily cost-effective at just $78,300 per death averted - far below standard health spending thresholds in high-income countries. The smallpox program itself was actually much more remarkable, costing just $25 per death averted, making it arguably the most cost-effective intervention in human history.

HIV/AIDS

Since its creation in 2003, the United States President’s Emergency Plan For AIDS Relief (PEPFAR) has directed over $100 billion toward fighting HIV/AIDS globally. It has saved more than 25 million lives and prevented millions of new infections.

Experts should correct me, but to the best of my knowledge, no other interventions have been effective. What worked is building healthcare systems and providing life-saving drugs, which also suppressed the virus and reduced risk of transmission.

Currently, PEPFAR provides lifesaving treatment to 20.6 million, including half a million children. Halting this funding risks triggering a resurgence of HIV.

Trump’s Cuts to Demographic & Health Surveys

Cuts are also hitting Demographic and Health Surveys. For many low and middle-income countries, these are the only sources of nationally representative data on maternal and child health, mortality, nutrition and HIV infections.

Why does data matter? Well, my research in Zambia suggests data was actually vitally important - enabling performance accountability and peer competition.

Safe Motherhood!

Over the past three decades, Zambia has achieved remarkable success in reducing maternal mortality, while increasing skilled birth attendance and family planning.

When I first saw this data in 2012, I was instantly curious! What had enabled this fantastic improvement in women’s lives? I had just finished my PhD, and had neither a job nor any grant money, but I was fluent in Bemba (a local language) and wanted to learn! Scrimping together my savings, I returned to Zambia.

Methodology: Studying the Drivers of Change

Keen to understand Zambia’s exceptional success, I investigated both the political prioritisation of maternal health and also effective implementation. This required a multi-level ethnography over several years, working with both local and central government. Supported by Zambia’s Permanent Secretary for Health, I joined frontline healthcare workers in rural clinics, district health managers, provincial administrators, national health officials, parliamentarians, and former Ministers of Health. In total, I conducted in-depth interviews with over 50 participants, many interviewed repeatedly over several days.

I was seriously embedded. For three months, I lived alongside parliamentarians at the National Assembly Motel and separately with a government minister. Together, we attended parliamentary sessions and workshops. Generously, the Ministry of Health let me join a shared office alongside other civil servants.

At the frontline, I joined three neighbouring rural District Health Management Teams. These each had similar socio-economic and geographic profiles but different maternal healthcare indicators. I wanted to understand why some districts performed better than others. With their support, I was observed daily realities.

After completing my research, I shared and discussed my written summary with senior civil servants, Cabinet Ministers and even the Vice President.

How I Built Trust & Connections?

My fluency in Bemba - for which I created my own dictionary and studied an old grammar book made by missionaries - helped convey respect. I was repeatedly invited to discuss my findings on television and radio, and since there weren’t many channels, these were widely seen and I became rather well known..

Whether I was wedged in a bus traversing pot-holed roads in Kalulushi, hailing an unmarked taxi in Kitwe, queuing at Shoprite in Luanshya (90 km west) or passing provincial ministers in Lusaka (388 km south), many people knew my Bemba name (Mapalo) and my research on safe motherhood. Sometimes I would board a bus, get spotted and then everyone would start singing!

Once, after many hours of hitch-hiking on lorries, I arrived at a Maternal and Child Health Coordinator’s home and presented my formal letter of introduction, signed by the permanent secretary. Beatrice laughed:

“Oh there’s no need for that! I already know who you are, Mapalo!”

We had never met, nor had I ever before been to this very remote region. Yet Beatrice was instantly at ease, inviting me to stay at her house. Parliament was much the same - a former Minister publicly chided me for not having interviewed him sooner!

In December 2012, I got really lucky. My flight was full of American and European diplomats and aid workers going home for Christmas. Alas, our plane journey interrupted by heavy snow and forced to land in Madrid, where we were stranded at the same hotel for several days. Naturally, I interviewed them all!

Yes, I get around. Now let’s dig into the data!

Amplifying accountability by benchmarking results at district and national levels

Around 2006, Zambia’s senior civil servants and politicians realised that other African countries were making much faster progress toward Millennium Development Goal 5 - on safe motherhood. Senior leaders expressed their embarrassment of lagging behind.

“MDGs - we have to be part of the world … We found that we are not on track. The commitment has been there but it was enhanced by the MDGs”.

“We are a stable country; to be put in that place is a shame [points to sharing rankings with conflict-afflicted states]”.

“If you look at our performance towards the MDGs, the only indicators that are quite a challenge are MDGs 4 and 5, so it prompted us to say, “what can we do?” To meet the targets we need to do some extraordinary things”.

When shown regional statistics during planning meetings, one Maternal and Child Health Coordinator exclaimed, “No, Zimbabwe can't do better than us!”.

Performance benchmarking led Zambian politicians and civil servants to see that other African countries were successfully making progress. Leaders soon realised that maternal health could be rapidly improved, and this was increasingly part of their geopolitical standing. With increased gusto, the Zambian Ministry of Health institutionalised a series of reforms:

• Institutionalised MDG Target 5.2 (the proportion of deliveries attended by skilled health personnel) as its own Performance Assessment Indicator

• Launched a national program in 2007 to strengthen Emergency Obstetric and Neonatal Care

• Created a separate budget line in 2009 for reproductive health

• Implemented Maternal Death Reviews in all districts, and

• Increased government expenditure on family planning commodities.

Previously, in annual meetings, maternal health indicators were quickly skimmed. With greater prioritisation and conditional funding from donors, health officials increasingly scrutinised the data and underlying bottlenecks. Together, they developed a shared mission. As managers explained,

“There would be threats of delayed release of money [by donors providing Sector Budget Support], if there were poor indicators. It helped us mobilise more resources, they said, ‘Why is it not improving?’ It allowed us to raise issues”.

“By putting in that indicator on skilled attendance that was a trigger to recruitment, to have more nurses and midwives, so that brought in the Human Resource Strategic Plan, scaling up the Retention Scheme and increased funding for medical training institutions. After two years we had doubled the production for nurses”.

“When issues came in, everyone in management was very supportive and wanted to be involved. When budgeting, they [the government] agreed to include reproductive health commodities, e.g. contraceptives”.

Benchmarking Results Drove Local Competition

As senior civil servants increasingly prioritised maternal health indicators, district health officers quickly sought to improve.

“All of a sudden, we dropped to among the last districts in terms of MCH performance” explained one District Maternal and Child Health Coordinator. “So a number of follow-ups have been made both by the national office and the provincial office. That’s what made people sit up”.

This changed her District Medical Officer's behaviour: “If the indicators are going down, he will make an appointment with me. He will ask questions like, ‘Is it me that makes you not perform well? If there's anything I'm doing let me know”.

Because he knows that at the end of the day his name is tarnished. He will be said to be a non-performer, so he gets concerned, he tries to dig deeper to find out why the district does not perform to expectation”.

Top-down accountability and benchmarking results enabled learning, emulation and competition between districts. One district manager explained how seeing data from neighbouring areas motivated improvement: “When you see that District X is doing better than us, we sit down and say “What can we learn from them?’”

In better-performing districts, health workers consistently emphasised the importance of supportive supervision - with managers providing both genuine concern, compassion and rigorous analysis of the data. As one healthcare worker explained, without monitoring

“you become relaxed a bit. But when they come for Technical Support they've got no time to see all our records. They just depend on what we tell them, so you can lie”

As part of my research, I also investigated the possible impacts of community-driven accountability and awareness-raising. These paled in comparison to top-down accountability and benchmarking results.

Top-Down Accountability and Benchmarking Results

Data is no panacea, it can certainly be ignored. But in this specific case, data was absolutely fundamental! Zambian leaders saw that other African countries were making rapid progress, which raised their expectations about what was achievable, catalysed status competition, and led to top-down prioritisation of maternal health.

Trump’s cuts to USAID and DHS threaten to undermine the very mechanisms that drove remarkable progress: data-driven benchmarking and accountability. Without accurate data, governments lose the ability to compare to their peers and identify areas for improvement.

Developing countries with limited statistical capacity rely heavily on international support for their data systems. Without these systems, Africa’s impressive gains in health are at risk. Problems become invisible and accountability weakens.

A Lead-Free Future?

Lead poisoning rots children’s brains - thwarting their cognitive development, educational progress and risk of violence. 800 million children worldwide have elevated blood lead levels, predominantly in low and middle-income countries.

In 2024, a fantastic breakthrough came with USAID, UNICEF, Open Philanthropy and the Gates Foundation launching “The Partnership for a Lead-Free Future”. This alliance brings together 30 governments and 36 civil society organisations to tackle a poison that kills over 1.6 million people annually.

Change is certainly possible! Coordinated efforts in Georgia reduced elevated blood lead levels in children from 60-80% to just 20% within five years. In Bangladesh, targeted interventions rapidly reduced exposure from adulterated turmeric.

In Nigeria, USAID was supporting the government’s efforts to protect children from lead exposure - caused by lead-acid battery recycling. Trump’s cuts threaten to derail this progress.

Aid Saves Lives

Thanks to global partnerships and scientific advances, we’ve seen massive improvements in maternal and infant health. PEPFAR saved 26 millions helped reduce HIV counts, reduced transmission and enabled people to enjoy their lives!

In Zambia, I witnessed first-hand how data-driven accountability enabled safe motherhood. Peer comparisons motivated improvements at multiple levels – government officials concerned about national rankings, health administrators concerned for performance metrics, district teams eager to outperform and compete! Demographic Health Surveys weren’t just providing statistics – they enabled governments to build systems of accountability that saved mothers' lives.

Looking ahead, the Partnership for a Lead-Free Future was ready to clean up terrible pollutants. With 800 million children worldwide suffering from elevated blood lead levels, this initiative promised to unlock vast human potential.

Trump’s cuts to USAID threaten all these vital programs - from life-saving drugs to data-driven accountability, to ending lead poisoning. I remain extremely concerned about a resurgence in HIV/AIDS.

To prevent suffering, the world needs a seriously big injection of money.

Further Reading!

• , “On American aid cuts/disruptions”

• Monica Mark, ‘Samkelo depended on USAID-backed drugs to stay alive. Then came Trump’s order’

• Owen Barder, “Is Aid a Waste of Money?”

• Alice Evans, “Amplifying accountability by benchmarking results at district and national levels”

In this podcast we discuss his new theory of culture, what drives liberty and prosperity, the limitations of democracy, and the importance of geography!

1. Culture

   1. What is culture? How does ‘culture’ causally influence behaviour? What drives conformity?

   2. Did Confucianism enable democratisation, or was it more about high employment in manufacturing?

   3. How does your model account for the fact that religions with similar theological foundations (Judaism and Islam) have since diverged?

2. ‘The Narrow Corridor’

   1. Do you downplay the importance of top-down nation-building?

   2. Do strong societies necessarily mobilise for liberty?

   3. What’s the main constraint in India: caste or protectionism?

3. Is democracy always good for growth?

   1. Did authoritarianism enable effective industrial policy in East Asia?

   2. Might democracy actually inhibit growth in poor countries?

4. Geography

   1. Did MENA’s patchwork of agriculture and pastoralism contribute to weak states?

A full transcript is below. You can also listen on Spotify, or iTunes, or watch on YouTube.

Below is a full transcript of our conversation, autogenerated by Riverside studios.

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1. Why do you think East Asia is the only region to have converged with the West?

2. How have big data and computational tools changed our understanding of structural transformation?

You can listen to our podcast on Spotify, iTunes, or watch on YouTube.

Below, I include our transcript.

Oliver Kim has a great Substack, ‘Global Developments’. And here’s his website with research papers.

Read more

As everyone knows, China has achieved remarkable success in taking millions out of poverty. However, many were still sceptical as to whether it could upgrade, innovate and export more sophisticated products. Without ‘good institutions’ (i.e. property rights and democracy), was China’s spurt short-lived?

Actually, Beijing has continued to lead major innovations and export prowess, especially in the new frontier of green technologies. What explains this puzzle?

China’s rapid ascent as a global economic powerhouse is partly due to strategic industrial policies, which have enabled technological catch-up and enhanced economic competitiveness. One of the most consequential and controversial elements of China’s policy toolkit has been ‘technology extraction’.

Technological extraction

This refers to policies that make foreign access to the Chinese market conditional on technology transfers to domestic firms. Essentially, these policies leverage China's large and growing domestic market as a bargaining chip to acquire advanced foreign technologies.

Curiously, however, China has not been able to impose these conditions uniformly. What explains this heterogeneity?

To explore this puzzle, John David Minnich employed a mixed-methods approach, combining statistical analysis of an original industry-level dataset (1995-2015) with case studies of wind power and semiconductors. Minnich ploughed through Chinese language regulations, meticulously tracking 3 types of tech extractors:

1. Joint venture mandates and FDI ownership restrictions,

2. Local content requirements (encouraging partnership and technology sharing), and

3. Government procurement policies, which give preferential treatment to products made by firms with Chinese investment or Chinese intellectual property.

What does he find?

Tech extractor use increased six-fold between 2002-2012, covering about 25% of all industries. (This is inconsistent with China’s WTO pledge not to condition market access on technology transfer).

Strategic industries (defined by promising the highest returns in terms of national competitiveness, principally those with great economic or military utility, which generate positive spillovers for the rest of the economy and spillover effects), account for 85% of this increase.

But even if Beijing wants to pursue technology extraction in strategic industries, its capacity to do so is limited by its relative bargaining power over foreign firms that invest in China.

Size (and positioning) matter

Minnich demonstrates that China’s bargaining power (to extract technology) is shaped by its position in global value chains (GVCs) and central state enforcement capacity. China is more likely to use tech extractors in strategic industries where it’s downstream in GVCs (as a final market), and less likely when it’s intermediate (relying on foreign firms for exports).

• If the foreign firm simply wants to make widgets, it can easily do so in Vietnam, so has no compunction to make any concessions. China’s bargaining power is low (since it is competing for assembly jobs and exports).

• However, if the foreign wants to profit from China’s massive consumer market, then it only has one option - to share technology.

  

  

State capacity

Institutional reforms in 1998-2003 increased ‘central enforcement capacity’.

• The National Development and Reform Commission (NDRC) gained policy authority over major projects, including large scale inward FDI. Centralisation of power enabled it to drive ‘hard bargains with foreign investors as the key gatekeeper to China’s market’.

• In 2005, for instance, the NDRC agreed to buy $10 billion in aircraft from Airbus in exchange for the establishment of training facilities, local sourcing, and a final assembly line.

Minnich (2023) thus gets to the heart of China’s success: by leveraging the appeal of its ginormous consumer market, a strong and strategic state successfully persuaded buyers to share their technology, which ultimately enabled local technological upgrading!

China’s massive population and position in global value chains augmented its bargaining power to extract technology.

Revving Up the Local Car Industry!

In just a few decades, China transformed from having virtually no domestic car production to becoming the world's largest automobile market. How did Beijing achieve this remarkable feat?

Again, the Chinese government required foreign carmakers to form joint ventures with domestic firms in exchange for market access. If a US company wanted to sell in China, it had to share its technology.

To investigate this policy’s effectiveness, Jie Bai, Panle Barwick, Shengmao Cao, Shanjun Li examined how quality improvements in specific dimensions (e.g. engine performance, fuel efficiency) spread from foreign joint ventures to domestic automakers. They found:

1. Strong evidence of knowledge spillovers from joint ventures to domestic firms, especially for companies that are part of the same business group. When a joint venture improves quality in a particular area, affiliated domestic brands show similar improvements.

2. Proximity also matters. Firms located in the same city as joint ventures benefit from spillovers even without formal affiliations, as they may have the same parts suppliers, and China has extremely high labour mobility, enabling the dissemination of valuable skills.

3. Modelling exercises indicate that without the joint venture policy, the quality of domestic brands would have been about 12% lower by 2015. However, geographical effects appear even more important, accounting for a 29% quality gap (Bai et al. 2020).

The Electric Vehicle Revolution: China's Evolving Strategy

Building on its success in the traditional automotive sector, China has recently orientated its industrial policy towards new green technologies.

Subsidies for Electric Vehicles have shot right up.

Initially, the Government China focused on stimulating EV demand through consumer subsidies - of up to $8,500 for private pure electric vehicles and up to $71,000 for public electric buses. This pilot was expanded to more cities, establishing market interest in EVs (Wu et al. 2021).

Interestingly, Chinese consumers could use these subsidies to buy imported electric cars, such as from General Motors and Ford. Local firms were thus exposed to global competition (instilling market discipline).

But on one condition..

Foreign firms had to share key technologies with Chinese companies. Back in 2011, for instance, General Motors divulged that its Chevrolet Volt would only qualify for Chinese subsidies worth up to $19,300 a car if it agreed to handover the engineering secrets to a Chinese joint venture… Companies like Ford, Nissan, Toyota, Volkswagen have spent billions on developing electric cars, and were eager to profit from China’s consumer market.

From 2016, consumer subsidies became conditional on using batteries from Chinese owned factories (Bradsher 2024). By encouraging these technology transfers, Beijing gave its producers a helping hand.

From 2016 to 2020, China transitioned towards more supply-side policies, introducing new incentives and regulations targeting manufacturers. This new system sets increasingly stringent targets for manufacturers, requiring them to produce more EVs and improve the fuel efficiency of their conventional vehicles. By 2023, the policy mandates that 18% of a manufacturer's fleet must be new energy vehicles (Wu et al. 2021).

One more thing! The state also subsidises steel, a main supplier of inputs to the car industry. Rotunno and Ruta (2024) find targeting upstream industries made downstream industries more globally competitive. Cheaper steel is great for BYD!

Beyond Subsidies: Comprehensive Support for the EV Industry

Beijing also supports industry by providing cheap land for factories, highways for freight trucks and bullet trains.

Labour repression is another way in which Beijing keeps factory costs low: independent labour unions are banned. Illicit organisers would be detained.

Human capital is equally pivotal. Edward White reports that in 2020, China had 3.6 million STEM graduates (compared with 820,000 in the US). Chinese company BYD now employs 100,000 people in research and development. On average, BYD research apply for 19 new patents every single day.

It’s worth noting that within China, there is significant regional heterogeneity in EV adoption. Shenzhen, for instance, has achieved far greater success than Suzhou. Gomes, Pauls, and ten Brink (2023) suggest this is due to coordinated governance, ensuring the requisite charging infrastructure. They underscore the importance of state capacity.

Combined, these efforts have achieved remarkable success. BYD is now the world’s second-biggest electric battery producer, with rapidly growing global sales (White 2024). China is also expanding production in emerging markets, like Brazil (Lakshmi et al. 2024).

Big Picture

A highly capable, coordinated state built up a strategic industrial policy, which wielded the carrot of a humongous consumer market, to extract foreign technology, which it then adopted, finessed, and successfully exported, thanks to its highly-skilled, globally-competitive workers.

Some scholars doubted whether an authoritarian state could really upgrade and innovate, but China continues to rock those priors…

How might such scholars respond?

Well, they might double down and insist that ‘good institutions’ are necessary to develop technological innovations, which China subsequently extracted. Though this would seem to omit China’s genuine success in building on that expropriated technology.

Now let me add a final Evansy point.

The Cultural Impact of China's Tech Exports

Have you stepped into a BYD car?

I’m no China shill, but I can faithfully report that it is an extremely smooth ride. Back in Tashkent, a factory manager generously took me for a tour. I was suitably wowed - much to my host’s delight! He grinned, as I lavished praised on the shiny new motor.

A week later in Fergana Valley, I spent a day with a fun and relatively affluent Uzbek woman. She too wanted to take me for a spin! Another impressive BYD - her pride and joy!

The Chinese carmaker is actually establishing a factory in Uzbekistan, with hopes of producing 300,000 units a year, anticipating strong demand for affordable luxury.

Right there and then, I realised the overlooked cultural value of exports. Goods and services aren’t just things we truck and trade, they’re also powerful signals of national capabilities.

Back in the 2000s, when I lived in Zambia, Chinese goods were generally seen as ‘cheap’ (with questionable longevity..). But as ‘made in China’ increasingly becomes associated with high quality status goods, then global consumers may come to revise their priors, giving China far greater respect and prestige.

So that’s a little sample! Here’s the full table of contents for my forthcoming book,

“THE GLOBAL DEVELOPMENT PUZZLE”.