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21 Country Case Studies

• Published: December 2021
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Is there a one-size-fits-all approach to inclusive growth? This chapter looks at four key case studies across advanced and emerging markets—the Nordics, India, Brazil, and Egypt—to try to answer this question. It highlights qualitatively in these countries the key components of inclusive growth models, outcomes from these models, and the road ahead for these models in the respective countries. Some of the analysis focuses on co-operative labor markets in the Nordics, Direct Benefit transfers in India, the role of social assistance and commodity boom in Brazil, and the inequality puzzle in Egypt. The chapter finds that there is a lack of homogeneity among the approaches by these countries and identifies the need for customized solutions to inclusive growth in the respective countries. A one-size-fits-all approach doesn’t seem to work. The more customized the inclusive growth model, the better the overall outcomes.

I. Introduction

Countries’ success in ensuring strong, sustainable, and inclusive growth has varied considerably. 1 In general, the share of the population that has access to basic services such as health, education, infrastructure, and finance is correlated with per capita income (Cerra 2021 ). The level of development is associated with a range of other policies and outcomes too, such as the ability to raise tax revenue and use it effectively for social safety nets and initiatives to strengthen the business environment. However, correlation is not determination, and at every development level, countries’ performances differ. In addition, countries may do well on some dimensions but fall short on others.

Achieving inclusive growth requires policy actions across many fronts. How have countries fared along different dimensions of inclusive growth? What have been countries’ experiences with implementing reforms to improve it? This chapter aims to take a holistic review of policies and actions that were effective in making growth inclusive. The chapter reviews some case studies in countries’ experiences, with examples drawn from different regions and levels of development.

We begin these case studies with the example of the Nordic countries, which are typically among the top performers on nearly every dimension of well-being. For example, the Nordic countries regularly rank at or near the top of the World Happiness Report and score first in other cross-country rankings of quality of life (e.g., the OECD better lives index). We examine the key features of the policy framework that has driven these successes.

Emerging and developing economies face stiff challenges. At lower levels of development, countries have to make difficult choices in prioritizing the use of their limited resources. They face an array of hurdles such as poor infrastructure, a legacy of weak governance, less diversified economies, and a large share of the population in poverty or located in hard-to-reach rural areas. Even so, while it may be difficult to replicate the broad successes of the Nordic countries, EMDEs made progress along some dimensions.

Following the discussion of the Nordic model, we next present case studies of select EMDE countries. The countries of India, Brazil, and Egypt—representing three different regions—have faced different challenges and headwinds based on their circumstances. In many dimensions of inclusive growth, they still have scope for considerable improvements. Even so, they have undertaken successful reforms in some areas, providing hope that a commitment to reform can bear fruit. Their experiences can provide lessons for other countries, especially for other EMDEs with similar resource constraints and challenges.

II. The Nordic Model of Inclusive Growth

The Nordics are widely seen as being successful in achieving inclusive growth, although they still face challenges in some areas (Figure 21.1 ). For this chapter, the Nordics comprise Denmark, Finland, Norway, and Sweden. These countries share some common features in their policy frameworks, often referred to as the “Nordic model,” but there are significant policy differences among this group, and their policy frameworks have evolved over time.

GDP per Capita and Gini Coefficient (x-axis, index; y axis, in thousands USD PPP-20210)

A. Main Features of the Nordic Model

The foundation of the Nordic model is a strong economy, with high levels of employment and productivity, which generates the resources needed to support strong social services. A central theme of the model is maintaining the flexibility to adapt to developments in trade and technology. Key elements of the Nordic model include:

Cooperative labor markets : enterprises and unions seek sustainable wages and conditions, providing an environment conducive for investment and training. Flexibility to adopt new technology or changes to improve efficiency is enabled, such as by employers and unions providing re-employment support for those losing jobs as seen in Sweden. Wage dispersion is low (Figure 21.2 ), reflecting the bargaining priorities of unions to protect low-income workers.

Competitive markets and innovation : productivity is likely promoted by high openness to trade and sound regulation of goods, services, and network industries that limits entry/exit barriers which in turn promote competition and innovation. R&D spending and intangible investment are relatively high and digitalization amongst firms is one of the highest in the OECD. (See Figure 21.3 .)

Strong social services and welfare are underpinned by sound fiscal policy : Investment in public education and health services supports high-quality human capital, while universal social welfare limits poverty, together with promoting social inclusion. As a result, government spending is high relative to GDP (Figure 21.4 ), especially in Finland and Denmark (2nd and 3rd in the OECD at around 55 percent of GDP). 2

  Tax burdens are relatively high , but the tax system seeks to limit the impact on potential growth, by relying to a relatively large extent on income and consumption taxation. In particular, personal income taxes are among the highest in the OECD, yet the labor tax wedge (including social security and payroll taxes) is contained, helping to protect employment (Figure 21.5 ). 3 , 4 Corporate income tax revenue is modestly below OECD average, limiting drag on investment and productivity. Taxes on goods and services are relatively high, yet these have less impact on growth. The prudent medium-term fiscal policy supports moderate public debt, providing fiscal space to cushion shocks, and underpinning public confidence in the ability of the government to sustain strong services and welfare support, which helps make high taxes more acceptable. Kleven ( 2014 ) finds that the high tax levels in the Nordic countries are supported by broad tax bases and substantial third-party reporting, which discourage tax evasion, while the subsidization and public provision of goods that are complementary to working (e.g. subsidized child care) encourages a high labor supply. 5

Gender equity : High female labor participation is promoted through policies including parental leave, subsidized childcare, and scope for shorter working hours for those with young families which made it easier for women to enter the workforce and return following childbirth. Gender wage gaps are among the smallest across OECD countries.

Climate change : The Nordics also have some of the most ambitious climate targets in the world and invest a considerable amount into climate change mitigation making them leaders in this area as well. Most Nordic countries implemented their climate targets into domestic law binding future ruling parties to abide by these reduction goals in the next years to come. Sweden is currently topping the Climate Change Performance Index (CCPI) and Denmark has announced to end all oil and gas activities in the North Sea by 2050. However, challenges remain, while the Nordics are on track to meet their EU climate targets, current annual rates of reductions are below what is required to meet their own targets.

Wage Dispersion(Income decile 9/decile 1)

Firms with High Level of Digital Intensity(Percent of firms)

Note : Data of Australia, New Zealand and Switzerland are from 2017, Austria and Colombia from 2019, and the others from 2018.

Social Services: Public Spending on Health and Education, 2019(Thousands of US dollars per capita and percent of GDP)

Source : OECD

Tax Wedge, 2019(Percent of labor cost)

B. Inclusive Growth Policies in Nordic Countries

The following sections highlight key aspects of the policy frameworks in Denmark and Sweden as an example.

Denmark enjoys one of the world’s highest standards of living. Strong institutions combined with sound economic and social policies have delivered robust economic performance and high social inclusion. The business climate ranks among the best in the world and education levels are high. Measures of well-being suggest Danes are among the happiest people in the world, as in other Nordic countries (IMF 2019a).

Inequality effects of new policies are usually analyzed, reflecting the importance attached to equality by Danish society. If policies are estimated to lead to sizable negative impacts on equality their political feasibility is questionable (IMF 2016). While this approach is not enshrined in law, it is a common practice when new policies are discussed in parliament. 6

The “flexicurity” labor market model has fostered high employment and incomes with low-income inequality. Denmark’s labor market model combines flexibility for businesses with security for its citizens through active labor market policies (ALPMs), high mobility, and a comprehensive income safety net (Figure 21.6 ). Despite high union and collective bargaining coverage, Danish employers can hire and fire employees without large costs, so they can quickly adapt to changing market conditions. In return, laid-off workers are supported for up to two years through an unemployment insurance fund with high replacement rates for low-income groups (up to 90 percent of previous earnings). In addition, they receive extensive job search services and educational training that is matched with current skill shortages, and employers that hire the unemployed or unskilled workers can receive subsidies. 7 Nonetheless, the very high ALMP spending does not translate in higher employment for the low-skilled when compared with countries that spend much less on ALMPs (OECD 2019).

Public Spending on Active Labor Market Policies(2016 or latest available year, percent of GDP)

Recent reforms have succeeded in boosting labor participation rates and reducing long-term unemployment, but challenges remain. Policies have been designed to keep people in employment longer, incentivize labor participation, avoid inactivity traps, upgrade skills, and improve migrant integration. For example, the 2011 pension reform raised the employment rate of older workers by linking the statutory retirement age to life expectancy. More recent initiatives include the 2018 tax reform that increased deductions for pension contributions. Nonetheless, youth inactivity has risen since the crisis due to the high skills needed to enter the Danish labor market. Moreover, skill shortages are increasing and access to skilled foreign labor remains cumbersome.

Strong employment has contributed to enhanced well-being and reduced poverty in Sweden. Sweden is a knowledge-based economy, well-integrated in global value chains, which ensures high standards of living, well-being, income, and gender equality, as well as high environmental quality to its inhabitants.

The policy framework in Sweden, the so-called “Swedish model,” puts inclusive growth at its core and is based on three pillars. In particular, it aims to “increase prosperity to the benefit of all, while safeguarding the autonomy and independence of citizens” and is based on three pillars: (i) a flexible labor market, (ii) a universal welfare system, and (iii) an economic framework that promotes openness and stability. 8 To ensure the effective functioning of these pillars, a number of prerequisites are present in Sweden: strong public finances, trust in the system, high employment, and strong social partners.

The first pillar is a flexible labor market that supports adaptation to new developments and technologies. The characteristics of the Swedish labor market are coordinated wage formation, an active labor market policy including employer-financed “job-security councils,” and generous unemployment benefits. Wages in Sweden are set through collective agreements between the unions and employers rather than through state interventions and laws. For instance, there are no statutory minimum wages in Sweden. In the past, unions have been usually constructive and embraced transformation in return for income security and active labor support measures. This framework resulted in steady real wage growth that has been in line with productivity advancements. Three active labor market policies support mobility in the labor market by (i) providing training to laid-off workers, (ii) providing subsidies to employers that hire unemployed people, and (iii) matching unemployed people with jobs. A unique feature of the Swedish model is job-security councils. These are funded by employers and actively help laid-off workers to find a job as soon as possible through financial support and job counseling. By “not protecting the job but the worker” this active labor market policy is enabling Sweden to support structural economic change. Lastly, generous unemployment benefits provide income security but are made conditional upon active job search or participation in training to incentives work.

The second pillar is a generous welfare policy that aims to achieve high and equitably distributed prosperity while promoting high employment and competitiveness. Swedish welfare policy can be distinguished by a high degree of universality, i.e. public services and transfers are designed as social rights that cover the entire population and not only disadvantaged groups. This approach avoids costly needs-testing and enhances the efficiency of the system. 9 This covers welfare services such as childcare, schools, and healthcare, social transfer systems such as social insurance, parental leave insurance, and unemployment insurance. These services support a high employment rate among women and the highest employment rate in the EU (Figure 21.7 ).

Employment Rates, 2019(Total, annual % of working age population)

The third pillar is the orientation of economic policies towards a stable economy while promoting openness and competition. The mandate of shielding the economy against major fluctuations is with the central bank. The Riksbank is tasked with attaining a 2 percent inflation target and supporting sustainable growth and a high level of employment. Fiscal policy aims to contribute to prosperity and equitable distribution of prosperity gains while stabilizing the economy through unemployment insurance and fiscal support in severe economic situations. An important prerequisite for this is Sweden’s large fiscal buffers.

Sweden Has Adopted Labor Market Reforms in Recent Years, but Challenges Remain

Seeking to raise employment of the low-skilled and migrants, the budget for 2018 boosted resources for education and streamlined active labor market policies with the aim of increasing employer participation. Nonetheless, unemployment rates of the foreign-born and low-skilled much exceed that of natives, partly reflecting bargained high de facto minimum wages which do not allow for a wage adjustment for lower-skilled. 10 , 11 Further reforms, including employment protection and public employment services, should support the employment of the low-skilled and migrants, aided by enhanced education and training (IMF 2019b). Sweden also has a long history of highly concentrated wealth, high regional inequality and has experienced one of the fastest increases in inequality in recent years. 12

The Nordic model may not be easily replicated in a wholesale manner, but it may provide inspiration for policies other countries may consider for improving inclusive growth. The sustainability of the Nordic model hinges on a high level of social trust and responsibility, including strong social norms to be working despite the availability of social supports. These social conditions including a more ethnically and culturally homogeneous population have facilitated high levels of trust and cooperation and high tax compliance. As a result, Nordic policies and institutions cannot be easily exported to other countries that are more heterogeneous or very large. Nonetheless, it is still important to learn from it and adapt parts of it that are transferable. 13 For instance, in 2008 the European Council adopted the common principles of flexicurity and called on the Member States to take them into account when drawing up and implementing “national flexicurity pathways.” 14 To help assess progress made in the implementation of the flexicurity principles, the Employment Committee agreed in 2012 on a set of monitoring indicators. These indicators are used in the annual Joint Employment Report on employment developments in the EU.

III. India: Economic Reforms for Inclusion, 1990–2020

A. introduction.

India has been one of the fastest-growing emerging market economies over the last few decades. The country’s rapid growth combined with a large population, demographics, and abundant natural resources makes it an interesting case study to understand inclusive growth and its challenges (Figure 21.8 ).

Poverty Headcount Ratio at $1.90 a day (2011 PPP) (% of population)

B. Main Features of the Indian Model

The main features of the Indian growth model have been a combination of high growth driven by economic reforms, improved macro-economic stability, and welfare schemes for the poor. All of these have contributed to enormous growth and poverty reduction.

High Growth Through Economic Reforms

GDP has grown almost five-fold since the 1990s and the per capita income has increased by four times over the same time period (Figure 21.9 ). This increase in growth was kick-started by the liberalization reforms in the 1990s and subsequent structural reforms over the years (Ahluwalia 2019 ). These reforms include dismantling of the “license-raj” (industrial licensing), opening up of Foreign Direct Investment (FDI) in many sectors, and liberalization of trade policies. While some of these reforms have taken some time, they have been pursued by various administrations. Recently, the introduction of pro-poor agricultural marketing reforms announced by the National Democratic Alliance (NDA) government is expected to boost growth. 15 Many policymakers consider this rapid growth to be central to the poverty reduction story (Bhalla 2002 ).

GDP and GDP per capita (1990–2020)

The increase in growth is noteworthy when compared with other countries during similar time periods (Table 21.1 ).

Macro-economic Stability

India’s focus on macro-economic stability in recent decades has been pivotal to its growth story. The continuity of economic policies aimed at fiscal prudence along with the Reserve Bank of India’s (RBI) monetary policies has provided a good platform for sustained growth. In addition, much of this growth has been accomplished with a sustainable level of government debt. That is, even though the average ratio of public debt to GDP has been high, much of India’s debt profile is consistent with debt sustainability given that it has been largely held by residents, denominated in domestic currency, and with a relatively long maturity. 16 The ratio of external debt to GDP has been relatively low (Figure 21.10 ).

Ratio of External Debt to GDP (Percentage to GDP, 2001–2020)

Recent policies such as the Goods and Services Tax (GST) and the Insolvency and Bankruptcy Code (IBC) have further provided a stable environment for investors. Furthermore, the introduction of inflation targeting in 2016 by the Reserve Bank of India (RBI) helped to reduce fiscal dominance in the economy and the influence of inflation in reducing real incomes of India’s poor. 17

Redistribution Through Welfare Policies

The welfare policies of successive administrations in the country were major drivers of poverty reduction besides economic growth. Overall, India has a very thin benefit system. Since there is no social security system, welfare benefits are focused on providing income support to the poorest of the poor and comprise mainly of food price subsidies and subsidies for heating oil and fuel. The previous administration (from 2004–2014) focused on food subsidies and cash transfers but this resulted in large leakages in the system (due to corruption) including food wastages. The Mahatma Gandhi Rural Employment Guarantee Scheme (MGNREGS) was one such initiative that was started in 2005. It was one of the world’s largest employment guarantee schemes that provided direct cash to the poor. This accounted for an average of 2.3 percent of GDP in 2008 (Ahmad 2013 ). The employment scheme helped pioneer cash transfers in India until 2014. However, there were leakages in the system that led to the NDA government using digitization and the Direct Benefits Transfer (DBT) system (discussed below) to improve efficiency.

Since 2014, a variety of other schemes have also been introduced to reduce leakages through digitization, and also improve sanitation and health care among the poor. The Swachh Bharat initiative, which was started with the goal of universal sanitation coverage for all Indians, has improved the lives of poor Indians significantly. 18 The scheme helped to improve the coverage of sanitation in the country from less than 50 percent in 2014 to almost 100 percent in 2019. 19

C. Inclusive Growth in India

Inequality in India has been increasing in recent years driven largely by urban inequality (Balasubramanian, Kumar, and Loungani 2021 ). As seen in Figure 21.11 , the net Gini coefficient for consumption has been gradually increasing in the last few decades. Compared to other countries such as China and Indonesia, the increase in inequality is not as large. 20

Comparative Consumption Gini Coefficients: China, India, and Indonesia

One can also measure inequality through the Growth Incidence Curves (GIC). The GIC could be represented in terms of growth rate in incomes for a percentile of the income distribution (Ravallion and Chen 2003 ) or by using the mean income in the quantile group for a percentile of the income distribution as in (Lakner and Milanovic 2016 ). As shown in Figure 21.12 , we use the mean income in the quantile group similar to (Lakner and Milanovic 2016 ). 21 For every decile of the population and subpopulation (rural, urban) we compute annual consumption growth rates in 2011 PPP dollars. An upward sloping GIC indicates higher growth among relatively richer groups (more unequal) while if all growth is equally shared by all quantiles of the population, then the GIC should be flat. As seen in Figure 21.12 , for the national aggregate, the 1st decile bottom 10 percent grew by only 1.7 percent whereas the 10th decile (topmost decile) top 10 percent grew by almost 2.38 percent from 1983–2011. 22 Similarly, for the rural areas, the 1st decile bottom 10 percent grew by 1.75 percent whereas the 10th decile top 10 percent grew by almost 1.95 percent. Unsurprisingly, much of the inequality seems to be in the urban areas with the 1st decile bottom 10 percent growing by 1.25 percent (lesser than the rural bottom 10 percent, 1 st decile) and the 10th decile top 10 percent growing by 2.5 percent (much higher than the rural top 10 percent, 10th decile) respectively. This further corroborates that much of the Indian inequality story is driven by urban inequality than anything else.

Growth Incidence Curve (1983–2011)

Poverty reduction in India has been achieved through a combination of rapid growth and redistributive welfare policies in the country. Even though many efforts have been done to eradicate poverty, approximately 270 million people are still considered to be poor.

Economic growth has played an important role in eradicating poverty. Besides improving the quality of life in the upper and middle classes, rapid growth has also reduced poverty significantly. Table 21.2 below highlights the impact economic growth had on poverty in the last few decades:

Note : The annual averages are for the period preceding the year indicated. Thus, 6.2% is the annual average growth of GDP from 1993–1994 to 2004–2005.

As seen in the table, the percentage of the population in poverty fell from 403.7 million (45.3 percent) to 269.8 million (21.9 percent) people within the span of two decades. Much of this correlation can be attributed to the vast set of opportunities that opened up for the poor as a result of rapid growth during this time. It was also during this phase that education and health indicators for the poor improved significantly. Besides growth, redistribution policies mentioned earlier also helped achieve inclusive growth.

One of the main recent re-distribution initiatives has been the Direct Benefit Transfers (DBT) to the lowest income people in India. With the aim of improving the efficiency of welfare schemes to improve targeting of beneficiaries, de-duplication, and reduction of fraud, the DBT was formally announced as a flagship initiative in 2013 (Narayanan 2013 ). 23 The JAM trinity (Economic Survey 2015 /2016)—Jan Dhan, Aadhar, and Mobile—has further improved the efficiency of the DBT scheme. 24 The Aadhar initiative has ensured that over a billion Indians have a digital ID and there has been an equal number of mobile connections in the country. Both of these have been integrated with the Pradhan Mantri Jan Dhan Yogana scheme (Today 2019 ) which has created more than 410 million bank accounts for Indians who are poor. One of the biggest advantages of the DBT scheme is that the transfers are targeted to persons with incomes below the poverty line, i.e the 10th and 20th decile levels in the GIC shown earlier. While there are still data challenges in terms of micro-data, general trends seem to indicate substantive progress in uplifting the poor.

The evolution of DBT in recent years has improved the efficiency of direct transfers significantly. Figure 21.13 below shows the evolution of DBT transfers from 2013 onwards until early 2021. The DBT transfers have increased from almost 1,034 million USD in 2013/14 to almost 33,660 million USD in 2018 (approximately 1.3 percent of India’s GDP) followed by approximately further 27,757 million USD till early-2021. There has been a more than 50 percent increase in transfers since data was first shared in 2013. The integration of the JAM Trinity has accelerated significantly and the resulting improvements in efficiency have further improved the outcomes especially in the context of identification of fake accounts and reduction of corruption due to the elimination of middlemen in many of these transactions (Kumar 2019 ).

DBT Overall Progress vs Year 2013–2020/21

Note : *2020–21 as of 2/14/2021

There are many plausible scenarios through which this could impact inequality in India. Since the DBT scheme is targeted at the lower decile levels, i.e. the transfers are directly transferred to the 10th and 20th decile of the population, if all of the efficiency gains are transferred back to the DBT schemes, it could result in strong income growth of the poor and could reduce inequality between the lower and top decile levels. If the efficiency gains were used elsewhere other than the DBT schemes, the reduction in inequality could be lower. Lastly, if the expansion of DBT continues for the next 5–10 years, there could be substantial growth in incomes for the 10th and 20th decile levels, further reducing inequality between the lower and the top decile levels.

There are also challenges within the DBT system that needs to be met to sustain outcomes. These include the need for greater penetration of the JAM trinity among the remaining population, more tracing and elimination of fake recipients, and improvements in the infrastructure to sustain these transfers at a larger scale. Data privacy concerns, and as a consequence, access to micro-data for researchers also need to be addressed as India ramps up these initiatives.

In retrospect, the Indian inclusive growth model provides an important perspective in addressing inequality. While it is still a work in progress, it provides a large enough case study for other countries to learn from, especially on the impact efficacy of the welfare schemes mentioned above. A combination of rapid growth, macro-economic stability, and targeted welfare schemes can promote inclusive growth as shown in India.

IV. Growth and Equity in Brazil

Brazil has been striving to strengthen its inclusive growth since the early 2000s. The commodity boom of 2000 to 2014 and social policies of the 2000s improved GDP growth and equity and reduced both informality and poverty. At the same time, growth in Brazil was still lower than that of its peers. The 2015–2016 crisis and subsequent slowdown once again reinforced the need for Brazil to improve its inclusive growth. The case of Brazil allows us to explore how long-standing growth constraints and successful macroeconomic and social reforms affect development.

A. Growth Dynamics

Since 2000, growth in Brazil, on average, underperformed average growth in EMDEs and emerging Asian economies (Figure 21.14 , left chart). Albeit slower than in its peers, growth had been accelerating in the 1990–2000s, supported by the commodity boom and increasing external demand. However, in 2015–2016, large macroeconomic imbalances, a loss of investors’ and consumers’ confidence, lower commodity prices, and tight financing conditions triggered a deep recession.

Growth Dynamics

Brazil grew slower than its peers with similar income per capita. Figure 21.14 (right chart) illustrates a standard growth theory idea that countries at a higher income level grow slower. Since per capita GDP in Brazil in 2000 was above that of Emerging Asian economies, the theory predicts that Brazil should have grown slower than them in the years that followed. Slower convergence with advanced economies and slower growth would, in this model, be explained by the smaller gap between Brazil and advanced economies. However, between 2000 and 2015, Brazil grew even slower than most economies with similar income per capita due to country-specific growth constraints (Figure 21.14 , right chart accordingly shows that economies with income per capita broadly similar to Brazil grew faster, as indicated by their position above Brazil).

Hausmann et al. (2005) and Arnold ( 2011 ) found that low domestic savings and high cost of finance were binding constraints for growth. Hausmann et al. (2005) noted that both saving and investment rates were low. 25 At the same time, Brazil actively borrowed abroad and was limited by external borrowing constraints. Brazil also had high real interest rates and loan-deposit interest spreads. These high interest rates and accumulating external debt indicated that Brazil’s growth constraint stemmed from low domestic savings rather than low return on investment. 26 Entrepreneurs wanted to invest despite a weak business environment, high taxes, inadequate infrastructure, and insufficient human capital but were limited by Brazil’s constrained financial resources.

Accumulated fiscal imbalances contributed to the 2015–2016 recession and became an important constraint on subsequent growth. Unsustainable public finances and a governance crisis caused large macroeconomic and policy uncertainty. As of 2018, Brazil had higher debt and taxes, and a weaker business environment relative to its peers (Balasubramanian et al. 2021 ). Given its relatively young population, public pension spending in Brazil is high, amounting to about 14 percent of GDP in 2018. Large pension expenditure stemmed from low retirement age (54 vs 64 years in the OECD economies), generous benefits relative to earnings (70 vs 53 percent in the OECD), and special regimes for civil servants and armed forces (IMF 2019). High-skilled workers and public employees benefited from the pension system more than the low-skilled and those in rural areas, as (the present discounted value of) the difference between lifetime pension benefits and contributions were higher (IMF 2019). Reducing pension and other current expenditures became a key near-term task.

Between 2016 and 2019, Brazil passed several important laws improving fiscal sustainability. It introduced a fiscal rule imposing a ceiling on current expenditure. The landmark pension law, approved in October 2019, was expected to reduce spending by 11 percent of GDP over ten years relative to the counterfactual without this reform. The new pension law was also intended to improve domestic savings and address an important growth constraint.

B. Inclusive Policies

With growth in 2000 to 2014 being higher than in the 1990s, Brazil achieved significant progress in the reduction of poverty and informality before the recent recession of 2015–2016. Between 2000–2014, the poverty rate declined from 9.9 to 2.4 percent but somewhat increased during the 2015–2016 recession (Figure 21.15 , left chart). The female labor force participation rate continued its rising trend in the early 2000s and stabilized around 55 percent after 2004. Available survey data shows a decline in informality from 34 to 28 percent of adults between 2005 and 2015. 27

Inequality and Poverty

Brazil was able to reduce its poverty rate more than many other counties with similar GDP growth rates and initial poverty rates (Figure 21.15 , right chart). The 2003–2013 commodity boom that drove GDP growth was particularly helpful in reducing poverty rates, as it created a demand for a low-skilled labor force. In addition, innovations in social assistance contributed to poverty reduction in Brazil.

The 2000–2014 commodity boom reduced poverty and informality rates by boosting demand for a low-skilled labor force and providing resources for fiscal expenditure (IMF 2018). Labor-intensive domestic mineral mines were especially helpful in reducing poverty, as they increased employment. Capital-intensive offshore oil and gas producers contributed to the reduction of poverty mostly through the fiscal channel: the government had resources to increase public investment and employment. Higher-income due to the commodity boom also increased domestic demand and drew labor from agricultural and informal sectors into services and construction.

Brazil has been at the forefront of anti-poverty government policies. In 2003, Brazil launched the Bolsa Familia Program (BFP). In 2015, this program constituted 0.44 percent of GDP or one-third of the annual spending on the social safety net program (almost two-thirds belonged to social pensions) (World Bank 2018 ). This program provides conditional cash transfers (CCTs) to the extremely poor while supporting human capital accumulation by requiring better school attendance, vaccination, and pre-natal visits. About 60 percent of the poorest quintile receive CCTs and about 80 percent of CCTs go to the two poorest quantiles (World Bank 2018 ). In 2018, more than 20 percent of the population was enrolled in the BFP. The BFP helps increase women’s share in the household income, as 90 percent of direct recipients are women.

While the BFP has clearly been instrumental in supporting the poor, its effects on (formal) employment have been the focus of many studies. Potentially, larger social assistance and higher tax rates on marginal earnings can reduce labor supply (Moffit 2002; Borjas 2005 ). In addition, the BFP eligibility criteria can potentially create incentives to stay in the informal economy: informal workers can underreport their incomes to become eligible for stable BFP transfers. However, Fruttero et al. (2020) found that the BFP has been instrumental in reducing informality and supporting formal labor market participation for both men and women, especially in younger cohorts. Fruttero et al. (2020) offer two explanations why CCTs improve formal labor market participation: (i) transfers cover the costs of job searching; (ii) they also improve psychological well-being that is necessary to break free from a cycle of poverty (Mullainathan and Shafir 2013 ).

Brazil has reduced the gender gap between 1990 and 2014. The female labor force participation rate increased from 42 percent in 1990 to about 55 percent in 2004 and plateaued afterward. Women’s relative wages have also improved: women’s wages were only 53 percent of men’s wages in 1995; this share increased to 70 percent in 2014 (Pinheiro et al. 2016 ). According to the WEF’s Global Gender Gap Index, the gender gap declined from 35 percent to 31 percent between 2006–2014. 28 A decline in the educational gap between men and women played a major role in these improvements: by 1991 women had more years of education than men and by 2000 this gap had increased further, while overall years of education continued to increase both for women and men (Beltrão and Alves 2013 ). Policies also contributed to this positive dynamic. For example, the administration of President Lula de Silva introduced the National Plan for Women’s Policies in 2004 focusing on women’s access to education, financial services, the labor market, health services, and protection against violence.

While Brazil has reduced inequality to an extent, it remains one of the most unequal economies in the world. Between 2000–2014, the Gini coefficient declined from 58.4 to 51.9 (Figure 21.15 , left chart). Using state-level Gini coefficients, Goes and Karpowicz (2017) found that labor income growth, formalization, and schooling contributed to the decline in inequality during 2004–2014. However, the Gini coefficient is based on surveys and may not take into account the income of top earners. Tax data provided by the World Inequality Database shows that the top 10 percent of earners received around 55 percent of total income between 2001–2018 and that this share was stable. Assouad et al. ( 2018 ) explained persistently high inequality by large regional inequality stemming from the colonial and slave-owning period. In the twentieth century, meanwhile, industrialization favored a minority of formal workers, while a limited agrarian reform led to the high concentration of land ownership. Education is still unequally distributed, and most adults do not have secondary schooling (Medeiros 2016 ). Providing access to education and closing the quality gap between private and public schools is necessary to reduce inequality.

In summary, Brazil provides an important case for development economists and policymakers. Some long-term constraints, such as low domestic savings, limited Brazil’s growth in the 2000s. Accumulated fiscal imbalances became an important growth constraint and contributed to a deep recession in 2015–2016. The public pension system that had required reforms for many years connected these two constraints: large spending on pensions reduced incentives to accumulate private savings, limiting public saving, and undermining public sustainability. At the same time, Brazil achieved progress in reducing poverty rates and informality. It did so by boosting employment during the commodity boom and creating an effective social assistance system.

V. The Middle East: The Case of Egypt

Egypt has averaged economic growth of about 4 percent over the past two decades, mainly driven by capital deepening. While Egypt is considered as a fast-growing economy in the Middle East (MEs) region (Figure 21.16 , left side), economic growth has been insufficient to improve the living standards in a context marked by high population growth. Figure 21.16 shows the GDP per capita during the past decade, 2010–2019, which point to a wide gap between Egypt and MEs and EMDEs. This performance could be explained by the growth model relying mainly on capital deepening, while labor and productivity contributions were lagging (IMF 2018a).

Average Growth and GDP per capita from 2010–2019

Like many other emerging market economies, Egypt is perceived as a country with high inequality. During the Arab Spring in 2011, inequality and poverty have been cited as the main cause of the uprisings. Since then, inequality and poverty have been an important concern for both policymakers and the general public (World Bank, 2015 ).

Looking at official measures of income inequality suggests low-income inequality, in stark contrast with the general perception. For instance, Enbaby and Galal (2015) confirm that the wide perceptions of income inequality are at odds with standard measurements, such as the Gini index, which shows only slightly declining levels of income inequality. The conflict between perceptions and evidence from available data has given rise to a “MENA inequality puzzle” (Verme et al. 2014 ), which is particularly relevant to Egypt. This section explores this puzzle, together with measurement issues, and provides some explanations from the literature.

On the macroeconomic front, Egypt implemented in the past inconsistent macroeconomic policies which, by 2016, had led to a build-up of significant imbalances. Large budget deficits, loose monetary policy, and a fixed exchange rate had resulted in a drastic reduction in foreign exchange reserves, high inflation, and unsustainably high levels of public debt. Growth had fallen and unemployment increased, especially among women and youth. As part of an IMF program concluded in late 2019, an Extended Fund Facility (EFF), Egypt paid special attention to policies and reforms to reduce inequality and alleviate poverty. These reforms consist of targeted cash transfers, reducing energy subsidies, and policies to increase female labor participation.

A. Inequality Between Perceptions and Official Data

The Gini coefficient is arguably the most commonly used measure of inequality. Since 1958, the Egyptian income distribution has been relatively egalitarian by the standards of developing countries, with the Gini index ranging from a high of 32.8 in 1999 to a low of about 31.5 in 2017. This narrow range points to the relative stability of income inequality in Egypt despite facing significant economic changes and shocks over this period. However, as highlighted in Verme et al. (2014), Gini estimates in Egypt are characterized by a large discrepancy between different studies in the literature.

Figure 21.17 shows that Egypt is more egalitarian than many emerging economies and several advanced countries. The most unequal countries are on the right with a high Gini index. Egypt’s Gini is just over 0.3, which is low by international standards and even by the standards of the rest of the MENA countries.

Gini Index for 75 Countries from Around the World in 2015

However, there are significant perceptions of high inequality in Egypt. Measures of public perceptions come from the World Values Survey (WVS). The WVS is a global survey of views and opinions across a wide range of issues and is conducted every five years. The survey asks a question on people’s attitudes toward inequality, measured on a scale from one to ten, where one indicates a desire for more equality and ten indicates a tolerance for higher inequality.

Figure 21.18 depicts the results from WVS surveys during 2001, 2008, and 2012 for the same question on inequality. The figure clearly shows that the group in favor of income equality has been rising over time—comprised more than 35 percent of respondents in 2012 (up from 2.6 percent in 2001). At the same time, the group tolerant for inequality has become smaller, reaching 10 percent of respondents in 2012 (down from 32.8 percent in 2001). The increase in aversion to inequality in Egypt is comparable to MENA countries, while greater than elsewhere in the world (WVS 2001, 2008, 2012).

Public Perception of Inequality (as % of Respondents)

Overall, the change in people’s perceptions observed over the period from 2000 to 2012 has been a result of two factors. First, economic aspects became more important as the country experienced various shocks. For instance, spillovers from the Global Financial Crisis (GFC) in 2008 and the economic crisis following the uprisings of 2011 had a major impact on people’s lives and wellbeing. Second, regional factors have been also behind the changing perceptions on inequality, as rising globalization during 2000–2012 and the opening to GCC countries have made people more aware of income distribution in the region. 29

The relatively low and stable measured inequality is at odds with the general perception of high inequality. This observation could hide a few data issues as raised in Alvaredo and Piketty ( 2014 ). Data sources relying on income surveys are insufficient to derive reliable estimates of income inequality in Middle East countries, and particularly in Egypt. Household income and expenditure surveys could underestimate the level of inequality possibly by a very large margin (e.g. Latin America). To check the reliability of Gini coefficient estimates, one would need reliable fiscal data on income tax in order to complement survey results, as household surveys often fail to account for top incomes.

B. Solving the Puzzle: Data vs Perceptions

Several studies investigate whether inequality is underestimated or misreported. Hlasny and Verme ( 2018 ) focus on understanding whether the low estimates for the Gini coefficient in Egypt are a result of top households systematically under-representing their incomes in surveys. Their main finding is that households’ income survey data do not appear to suffer from this potential systematic bias. However, Van der Weide, Lakner, and Ianchovichina (2016), using data on house prices to estimate the top tail of the income distribution, find evidence that inequality is considerably underestimated in Egypt, where the Gini coefficient for urban Egypt was revised from 0.36 to 0.47. Johannesen ( 2015 ) provides evidence of high wealth inequality using data on financial assets held abroad by MENA individuals. The author uses a dataset from the Bank of International Settlements (BIS) on cross-border bank deposits to estimate the size of wealth hidden in tax haven bank deposits. The findings indicate that the size of haven deposits is not linked to expenditure inequality, suggesting that quantitative evidence does not support the perception of such wealth held abroad while. 30 Using different approaches and data sources, these papers show mixed results on the accuracy of Gini estimates.

Another stream of this literature, such as Assaad et al. (2018), has examined inequality of opportunity, which can better capture the notion of unfairness and social injustice that may lie at the root of popular perceptions. Assaad et al. (2018) use survey data between 1988 and 2012 to link individual wages to parental education as well as household consumption to parental education of the household head. While inequality of opportunity did not show any increase during the study period, the paper shows that the wealth of those born to middle-class families collapsed toward those born to lower-class families, and the gap between the latter and those with an upper-middle-class background narrowed. At the same time, those at the higher end of the income distribution have remained quite apart from the rest. This finding shed light on the growing discontent of the middle class, which is potentially behind rising inequality perceptions.

Moreover, one of the sharp observations on the inequality of opportunity is related to education. As shown by Assaad ( 2013 ), the probability of a boy from a poor family enrolling in university is estimated to be only 9 percent compared to 97 percent for a boy from a most advantaged family. In addition, estimates of inequality of opportunity in educational achievement (TIMSS scores for eighth-graders) also show considerable inequality in Egypt.

Attempts to solve the inequality puzzle for Egypt clearly indicate mixed results suggesting that there are several factors at play. Missing top incomes, data quality issues, and inequality of opportunity are all good candidates for an underestimated Gini coefficient, which is one piece of the puzzle. On the other hand, people’s beliefs are also important to examine in order to explain the other piece of the puzzle. Indeed, perceptions about inequality and the unfairness of the distribution could be determined by regional or global inequality, and not only on a national level. Also, the middle-class growing discontent could be related to upward mobility rigidity. People judge inequality not only by the perceived gap between their own income and the income of others but also by the perceived gap between their actual income and their expected income. With high growth rates in the run-up to the GFC, people feel frustrated that benefits of growth are not shared, and their income did not grow as expected.

C. Policies in Favor of More Inclusion

Inconsistent economic policy management, together with other structural factors and the economic hit of the 2011 revolution, led to large imbalances. Low economic growth and investment, rising inflation, high government debt, and high unemployment characterized this period. To counter these imbalances Egypt engaged in a home-grown economic reform program, supported by the IMF over three years, starting from November 2016. The program achieved its key objective of macroeconomic stability, which is a precondition to attract investment, raise growth, and create jobs. This sets the stage for broader reforms, such as improving the business climate and fostering inclusive growth.

Indeed, one component of the authorities’ program was to address extensive fuel subsidies, which were a significant drain on the budget and benefited the rich. These subsidies made fuel in Egypt one of the cheapest in the world, encouraging excessive consumption and benefiting the well-off far more than the poor because those with means consumed more. Phasing out fuel subsidies created more room in the budget for better-targeted social spending, as well as more investment in health, education, and public infrastructure.

The authorities’ reform program also entailed a modern social spending system of a couple of cash transfer programs targeted to those most in need. For example, Takaful and Karama, which were implemented in March 2015 and expanded during the program, are conditional and unconditional cash transfer programs. “Takaful” or “Solidarity” is a conditional (on school attendance among other criteria) cash transfer program aimed at supporting vulnerable families’ consumption, reducing poverty while encouraging families to keep children in school and providing them with needed health care. The main goal of this program is to build the “human capital” of the next generation and give them an opportunity for upward mobility. On the other hand, “Karama” or “Dignity” is an unconditional cash transfer program aiming at supporting poor elderly citizens. These programs were the most cost-effective way to ensure that the poor did not bear the costs of these economic adjustments. Social policy centered around Takaful and Karama was critical to ensuring public support for the broader reforms Egypt needed to undertake to stabilize the economy and to lay the foundation for higher and more inclusive growth.

These cash transfer programs have enrolled about 2.25 million families with a significant social and economic impact. The International Food Policy Research Institute (IFPRI) has conducted an evaluation of these programs in late 2018 through a survey conducted across the country (IFPRI 2018). The findings of this assessment point to about 89 percent of the sample are either very satisfied or somewhat satisfied. About 93 percent of transfer recipients reported no difficulties in receiving this support. On the economic impact, these programs have helped households to increase their consumption by about 8.4 percent, compared to people who did not receive the transfers.

Policies were also implemented to foster job creation for women and the youth. Policies in favor of women inclusion in the labor market, implemented in 2017, were centered around allocating more public expenditure to improve the availability of public nurseries and other facilities to enhance the ability of women to actively seek jobs. Efforts in this area also included establishing a joint Ministerial committee as well as representatives of the Women’s council, academia, and business community with the objective to improve women’s participation rate in the labor force. The committee is working with UN women to introduce and effectively implement gender budgeting in the future. It is also responsible for simplifying rules and facilitating registration of home-based nurseries, to expand job opportunities for women and child-care for working mothers (IMF 2018b). The outcome of these policies was positive but somehow limited to the extent that female labor participation has increased only slightly from 21.8 percent in 2017 to 22.1 percent in 2020. Other programs included Forsa, a program that helps create job opportunities, launched in early 2018, and Mastoura, a program for microcredit directed to women, which covered more than 6000 projects in its first phase of inception in 2017.

Further, Egypt’s recent policies are focused on revamping the growth model allowing more room for the private sector to take the lead in job creation. The government has undertaken several structural reforms to promote inclusive growth. For instance, the authorities have initiated reforms in areas related to competition policy, the public procurement system, management and transparency of State-Owned Enterprises, industrial land allocation, and management of public finances. These reforms have the potential to significantly improve the investment climate and, therefore, boost job creation, which would absorb a large and growing young population.

More broadly, the path to inclusive growth and more equality in income is tied to the opportunities offered by the economy. Significant progress has been achieved with a positive impact on, both, social and economic levels. Looking forward, broadening and better targeting these programs together with sustainable economic growth are sine qua non conditions to make growth more inclusive.

VI. Lessons and Conclusions

The country cases demonstrate that achieving inclusive growth requires a multipronged approach to policies. In each country example, government policies address several facets of the economy and society that are key to inclusion. For example, these range from labor market policies to business regulation and policies for trade, migration, and capital flows to the use of tax policy and public spending. Programs also need to target different groups that fall behind, especially the extreme poor, who are also often women or youth.

The Nordic model represents some of the best practices in inclusive growth and exemplifies the wide span of policies that bear on success. The policy framework creates an extensive role for government, but not just in terms of redistribution. The government facilitates a strong business environment for stable and sustainable growth by ensuring macroeconomic stability. It fosters competition and innovation in domestic markets and promotes integration with international markets. Social partners cooperate in labor markets to reduce wage inequality while ensuring labor market flexibility and social cohesion. The government combines broad safety net programs to support incomes and assure access to public services, with policies such as retraining to help people find new jobs and adjust to changing economic conditions.

The efficacy of policy measures depends on their interaction with other measures and the country’s economic conditions. For instance, Sweden does not have a minimum wage, yet protects worker wages through a strong collective bargaining system. With Sweden’s high rate of employment and strong capacity in mobilizing fiscal revenue, it can afford a system of universal social services. In contrast, a system of universal income services is out of fiscal reach for most developing countries, as in the case of India.

The cases show that policies to promote high and stable economic growth are still relevant for achieving inclusion. High rates of growth were especially pivotal in reducing poverty in India and Brazil over much of the past two decades. Growth led to increases in jobs and incomes in the private sector. Growth also expanded public resources to raise social assistance programs. Conversely, bouts of economic instability or episodes of crises have set back progress in inclusion, especially in poverty reduction.

Growth is not a panacea though and well-designed public programs can go a long way in fostering inclusion. Brazil realized more poverty reduction than Chile, despite having lower growth per capita during 2000–2015. Its Bolsa Familia Program covered a large share of the extreme poor and coupled its income support with conditionality to improve education, health, and support to women. Unconditional and conditional cash transfers were successful features of social assistance in Brazil and Egypt and direct benefit transfers in India. Education has been important across the board for helping people escape from poverty and raising the labor force participation of women.

Likewise, poorly designed or targeted policies can impede inclusive growth. Although on the surface it may seem that a generous pension system could be a feature of inclusion, the case of Brazil demonstrated that an overly generous and poorly targeted system contributed to fiscal deficits and low domestic savings, which factored into high-interest rates and lower growth relative to peer countries. Prior to the reform introducing the direct benefit transfers, India’s social assistance was plagued by leakages and corruption. Egypt’s extensive energy subsidies mainly benefited higher-income households and were large drains on public finances that could have been used for programs more targeted to the poor. And even well-managed inclusive growth frameworks, such as in Denmark and Sweden, have room for improvement on some dimensions, such as enhancing work opportunities for the low-skilled and foreign-born workers.

Technology can drastically improve the scope for implementing effective policies, even in developing countries. This is illustrated best in the case of India, where the use of digital IDs has enabled the expansion and more efficient administration of public transfers, with less corruption, as well as spurred the creation of millions of bank accounts that increased financial inclusion.

Statistics on distribution are important for understanding the state of inclusiveness and for designing the policy response. The case of Egypt demonstrates that official data on inequality had not suitably reflected the perception of it. More work is required, for all countries, to fill in data gaps related to misreported income and wealth. The example also suggests that the public’s tolerance for inequality may not be adequately represented by the Gini coefficient as an indicator. It may also depend on perceptions of the scope for social mobility over time and over generations, and whether improvements in economic and social match expectations of them.

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We thank Valerie Cerra, Martin Schindler, Barry Eichengreen, Craig Beaumont, Miguel Segoviano, Khaled Sakr, Yuanyan Sophia Zhang, Valentina Flamini, Prakash Loungani and other IMF collegues as well as participants in the Inclusive Growth book seminar series organized by the IMF Institute for Capacity Developments for their comments.

OECD statistics: https://data.oecd.org/gga/general-government-spending.htm

OECD statistics on income revenues: https://data.oecd.org/tax/tax-revenue.htm#indicator-chart

OECD statistics on labor tax wedge: https://data.oecd.org/tax/tax-wedge.htm#indicator-chart

Kleven ( 2014 ) also considers social and cultural influences and finds that correlations are quite striking and favor the notion that the Nordics are more socially motivated, but that the evidence is difficult to interpret.

According to Danish officials, before policies are enshrined in law, there are opportunities to discuss their impact on inequality during parliamentary debates. However, “inequality impact studies” are not mandatory.

Government Offices of Sweden ( 2017 ) “The Swedish Model.”

While need-tested services also exist in Sweden, there are intended to work as the last social safety net when the rights-based system is insufficient.

Legally there are no minimum wages in Sweden.

Ljungqvist and Sargent ( 2008 ) show how unemployment dynamics depend upon a country’s labor market policies through their effect on job separation and finding rates, which depend on the interaction of policies and shocks.

https://nordregio.org/nordregio-magazine/issues/state-of-the-nordic-region-2020/sweden-inequality-in-sweden-grows-much-faster-than-in-the-nordics-overall/

https://theconversation.com/what-the-world-can-learn-about-equality-from-the-nordic-model-99797

http://ec.europa.eu/social/BlobServlet?docId=1515&langId=en

https://www.ifpri.org/blog/covid-19-crisis-opportunity-long-delayed-agricultural-reforms-india

https://www.imf.org/en/News/Articles/2019/12/23/pr19488-india-imf-executive-board-concludes-2019-article-iv-consultation

https://economictimes.indiatimes.com/news/economy/indicators/india-adopts-inflation-target-of-4-for-next-five-years-under-monetary-policy-framework/articleshow/53564923.cms

The initiative “aimed at eliminating open defecation in rural areas during the period 2014 to 2019 through mass behavior change, construction of household-owned and community-owned toilets and establishing mechanisms for monitoring toilet construction and usage.” https://swachhbharatmission.gov.in/SBMCMS/about-us.htm

These and other key structural reforms, and their contribution to enhancing gender and income equality, are described in recent IMF India Article IV Staff Reports and India Selected Issues papers (see IMF, India: 2017 Article IV Consultation Staff Report. IMF Country Report No. 17/54, 2017a, (IMF, India: 2017 Selected Issues. IMF Country Report No. 17/55, 2017b)) and the references contained therein.

It’s important to use this as a benchmark but the Gini on its own has many shortcomings. An important caveat here is that all the countries have consumption survey data so the comparison is relevant.

Note that this GIC is anonymous and that we are not accounting for movement of individuals between deciles over time.

The decile levels arrange the data in order from lowest to highest and are done on a scale of one to ten where each successive number corresponds to an increase of 10 percentage points. In the case of GIC, the 1st decile represents the 10th percentile of the consumption distribution whereas the 10th decile value represents the 100th percentile of the consumption distribution.

See IMF, India: 2017 Article IV Consultation Staff Report. IMF Country Report No. 17/54, 2017a.

Pradhan Mantri Jandan Yogana (PMJY) is the flagship scheme to open bank accounts for the poor. Aadhar is the world’s largest bio-metric exercise which has created more than a billion digital IDs for residents in India. Mobile refers to more than 700 million mobile phones in India. The JAM trinity integrates all these three features to enable DBT transfers.

Gross national saving and total investment averaged 18–19 percent of GDP in the 2010s and declined by 1–2 percent of GDP in the 2010s.

Capital inflows could not compensate for low domestic savings and provide enough financing for investment. In emerging market economies, domestic saving is positively correlated with investment—the empirical puzzle named after Feldstein and Horioka (FH). Using panel data analysis, David et al. ( 2020 ) show that lower domestic saving causes lower investment, particularly in emerging market economies.

An informal worker is a salaried worker in small firms, non-professional self-employed, and zero-income worker.

The Global Gender Gap Index consists of four sub-categories: economic participation and opportunity, educational attainment, health and survival, and political empowerment.

People tend to approach inequality thinking about the region (MENA) as a single community. The middle class in Egypt compares themselves not only to rich people in Egypt but also to the middle class in GCC countries, which raises inequality perceptions (Verme et al. 2014 ).

Expenditure inequality stands for the measurement of inequality from households’ expenditures as opposed to households’ income.

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• Development Co-operation Report

Development Co-operation Report 2018

Case studies from developing countries: what works and why, joining forces to leave no one behind.

When Member States of the United Nations approved the 2030 Agenda for Sustainable Development in 2015, they agreed that the Sustainable Development Goals and Targets should be met for all nations and peoples and for all segments of society. Governments and stakeholders negotiating the 2030 Agenda backed the ambition of leaving no one behind, an ambition increasingly referred to in development policies, international agendas and civil society advocacy.

How can we transform this ambition into reality? Policy makers, civil society and business are asking for more clarity on how to ensure that no one is left behind in practice. What does it mean for the design and delivery of economic, social and environmental policies? How should development co-operation policies, programming and accountability adapt? What should governments, development partners and the international community do differently to ensure that sustainable development goals benefit everyone and the furthest behind first?

The 2018 Development Co-operation Report: Joining Forces to Leave No One Behind addresses all of these questions and many more. Informed by the latest evidence on what it means to be left behind, it adopts a wide range of perspectives and draws lessons from policies, practices and partnerships that work. The report proposes a holistic and innovative framework to shape and guide development co-operation policies and tools that are fit for the purpose of leaving no one behind.

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These five case studies show initiatives already in place to deliver on the Sustainable Development Goals for all people in specific countries and regions. In Indonesia, an electronic food voucher programme supports the most vulnerable of households. In Benin, the government is applying a new approach that focuses on the needs of the poorest 20% of the country’s people. Around Latin America, financial inclusion is integrated within social protection programmes to help the region’s poorest accumulate savings. In Muthithi, Kenya, a multidimensional study on welfare has informed local government interventions to help those furthest behind. And in West Africa, neighbouring countries are working together to improve economies and lives in remote border regions.

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The future of work has recently attracted much attention from a variety of institutions, from governments to universities to private companies and news outlets: a simple Google search of the term future of work produces more than two billion results. Our world of work—both in rich and poor countries—is changing fast. Technology, globalization, environmental changes, and shifting demographics are impacting workplace environments and the types of jobs that will be available in the future. Everyone can relate to these issues, since people depend on work for their livelihoods. This volume presents a summary of the future of work discussion in developing countries and provides insights from four country case studies: Brazil, India, Kazakhstan and Nigeria.

Much of the current discussion on the future of work centers on fast-paced technological changes and the perceived job losses and transformations in Western economies. The focus is on the pace of impact of the Fourth Industrial Revolution (4IR), that is, how the interaction of automation, robotics, artificial intelligence, and other technological drivers will have an unprecedented and distinctive disruption in the labor market in terms of its “velocity, scope and systems impact”. In the developing world, other forces beyond technology stand poised to impact labor markets. First, these countries are rapidly urbanizing, creating challenges for cities in terms of infrastructure, job creation, and basic social services. Second, different regions are following varied demographic transition paths that will affect the number of potential workers, the composition of the workforce, and the types of jobs created. Third, global trends like increased trade, environmental challenges, and migration will also continue to create challenges and opportunities in labor markets around the world. At the same time, many economies are facing “jobless growth” and grappling to create meaningful work opportunities for their citizens.

Managing the future of work challenges will require responses from individuals, governments, educational institutions, non-government and civil society organizations (CSOs), and companies on several fronts. Better education systems and reskilling to adapt to changing technological disruptions will without doubt be important, but economies also need to create more and better jobs, and safety nets and social protection systems will need strengthening to help workers transition through the different stages of their working lives. Economies will need to create more and better work opportunities, even with the disruptions taking place. We cannot simply give up on work—we need to shape its future and defend it.  

Romina Bandura is a senior fellow with the Project on Prosperity and Development and the Project on U.S. Leadership in Development at CSIS. MacKenzie Hammond is a program coordinator for the CSIS Project on Prosperity and Development (PPD) and Project on U.S. Leadership in Development (USLD)

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• v.5(12); 2020

A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems

Austin carter.

1 Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA

Nadia Akseer

2 Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada

3 Gates Ventures, Kirkland, Washington, USA

Oliver Rothschild

Niranjan bose, agnes binagwaho.

4 University of Global Health Equity, Kigali, Rwanda

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5 Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA

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6 Last Mile Health, Boston, Massachusetts, USA

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Raj panjabi, matthew c freeman.

7 Department of Environmental Health, Emory University, Atlanta, Georgia, USA

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8 Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA

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Associated data.

bmjgh-2020-002938supp001.pdf

This paper introduces a framework for conducting and disseminating mixed methods research on positive outlier countries that successfully improved their health outcomes and systems. We provide guidance on identifying exemplar countries, assembling multidisciplinary teams, collecting and synthesising pre-existing evidence, undertaking qualitative and quantitative analyses, and preparing dissemination products for various target audiences. Through a range of ongoing research studies, we illustrate application of each step of the framework while highlighting key considerations and lessons learnt. We hope uptake of this comprehensive framework by diverse stakeholders will increase the availability and utilisation of rigorous and comparable insights from global health success stories.

Summary box

• Mixed methods research provides a powerful tool for studying research questions, and stories of success among ‘exemplars’ provide invaluable learnings for replicating and accelerating health or health systems gains across contexts.
• The Exemplars in Global Health (EGH) Partnership presents a systematic and comprehensive framework for conducting mixed methods research (including methods for identifying exemplar countries, selecting and engaging topic experts, collating and summarising evidence, undertaking qualitative and quantitative analysis, and preparing dissemination products for diverse audiences) when studying health and health systems outcomes in low and middle-income exemplars.
• The EGH mixed methods approach to case studies can be used by diverse groups (including academics, NGOs and policy makers) to study and understand improvements in the most pressing health outcomes and implementation strategies in low and middle-income countries.
• Learning from these stories of success could enable prioritisation of investments and programmatic action towards achieving the Sustainable Development Goals 2030.

Introduction

Starting in the early 2000s, the Millennium Development Goals (MDGs) aligned countries towards achieving measurable targets for health and survival ( box 1 ). By the end of the MDG period, several health success stories had emerged. These exemplars provided an opportunity to understand ‘what works’ for attaining the Sustainable Development Goals (SDGs) ( box 1 ). 1–3

The Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs)

In the early 2000s, the world adopted eight MDGs to achieve by 2015 and aligned on 21 targets to track progress. 39 Several of these targets are relevant to health, either directly or indirectly. Three of these health-relevant targets – reduced incidence of malaria, reduced incidence of tuberculosis, and improved access to safe drinking water – were achieved at a global level; yet, several targets were missed, including reduction in child mortality (Goal 4), improvements to maternal health (Goal 5), reduction in the spread of HIV/AIDS (Goal 6) and sustainable access to sanitation (Goal 7). Targets to halve the proportion of individuals suffering from hunger were also not met. However, several regions and countries have achieved individual success in one or many of these indicators.

To build on and scale up momentum from the MDGs, in 2015, the United Nations General Assembly set 17 Sustainable Development Goals (SDGs) to achieve by 2030. These goals resulted from consensus derived from extensive multisector and multi-stakeholder consultations. Several of the SDGs are either directly or indirectly related to human health, including the following:

• SDG 2. Zero hunger: End hunger, achieve food security and improved nutrition and promote sustainable agriculture (indicators include stunting, wasting, and overweight)
• SDG 3. Good health and well-being: Ensure healthy lives and promote well-being for all at all ages (indicators include maternal mortality ratio, under-five mortality rate, vaccine coverage, and health worker density)
• SDG 6. Clean water and sanitation: Ensure availability and sustainable management of water and sanitation for all (indicators include proportion of population using safely managed drinking water and sanitation services)

Many groups, such as the Countdown to 2030 collaborative and WHO success stories initiative, have highlighted policy successes to facilitate adoption of lessons in other contexts. 4–12 Building on such efforts using standardised, rigorous and holistic mixed methods approaches can further the evidence base and ensure comparability across contexts. The Exemplars in Global Health (EGH) Partnership (established in 2017) aims to do precisely this ( box 2 ). EGH conducts systematic and comprehensive mixed methods studies in priority health and development areas to generate evidence of impact at scale. We hope that lessons from ‘exemplar’ countries, which have achieved success in given areas (eg, child survival and nutrition), will support evidence-based decision-making among donors, governments and the global community.

What is Exemplars in Global Health?

Exemplars in Global Health (EGH) is a partnership between academic researchers, implementers, policymakers, and donors that seeks to capture lessons from positive outlier countries that have achieved success in either solving health challenges in low-resource contexts or implementing programs at scale. To date, several EGH projects are ongoing based on an initial selection of diverse priorities spanning health, nutrition and key interventions within health systems: Stunting, Under-5 Mortality, Community Health Workers, Mass Drug Administration, and Vaccine Delivery.

Each area has seen tremendous improvement in the past two decades. A core set of principles drives EGH work and gave rise to the framework that we draw upon across our research. We aim to understand national and subnational successes and positive deviant examples through analysis that is: (a) methodologically rigorous; (b) objective; (c) comparable across countries; and (d) conducted in close partnership with in-country experts. EGH case studies attempt to capture not only the “what,” but also the “how” behind successful strategies and interventions (e.g., decision making, strategies and tactics, adaptation of programs over time). In sharing these lessons, we aim to enable policy makers, funders, global stakeholders, and implementing organizations to identify relevant lessons learned, and to adapt and emulate successes.

The EGH approach is rooted in the recognition that data and research from isolated methods are useful, yet incomplete in revealing the full picture. Hence, EGH applies comprehensive mixed methodologies while ensuring triangulation and corroboration of inferences across research activities and with input from technical and national experts. We believe this holistic process reveals novel and nuanced insights, while humbly acknowledging methodological and data limitations.

This paper presents our mixed methods research approach for studying positive outlier countries ( figure 1 ). We discuss the process of identifying exemplar countries, selecting and engaging topic experts, collating and summarising available evidence, undertaking qualitative and quantitative analyses, and preparing dissemination products for diverse audiences. Of note, ours is far from the first framework developed to collect and analyse health data for use by policy makers. In fact, there is a rich tradition of similar methods used across social science disciplines. 13–17 We have, however, formalised a mixed methods approach and applied it consistently across case studies of different topics and countries. To demonstrate, we share illustrative examples from ongoing EGH research. In describing the EGH framework, we encourage its uptake by diverse stakeholders when narrating the stories of positive outliers.

Exemplars in Global Health research approach.

Framework components

EGH employs a framework to identify exemplar countries for a given topic, and then to assemble, generate, analyse and synthesise evidence for disseminating their stories ( figure 1 ). Before identifying exemplar countries, a global health topic area —either a health outcome or an evidence-based health programme—is selected via consultations between subject matter experts and funding partners while considering relevance and evidence of impact in low-resource settings. The topics selected to date are detailed in box 3 . Below, we provide a step-by-step overview of how we execute a common EGH research approach. Methods details for the various EGH topics are included in online supplemental file 1.

Exemplar Types

Exemplar topics fall into two broad categories: outcomes and programs. Outcome topics investigate countries’ efforts in addressing a specific health outcome (e.g., stunting, under-5 mortality). Program topics look at which countries were most successful in implementing specific evidence-based programs, interventions, policies or practices (e.g., vaccine delivery, community health worker programs). For program topics, we focus less on causal evaluation of program impact and more on lessons in implementation.

Ongoing EGH Projects by Type

Health Outcomes:

• Under-5 mortality
• Neonatal and maternal mortality
• Community health workers
• Mass drug administration
• Vaccine delivery

Technical Advisory Group selection and activities

For each topic, we convene Technical Advisory Groups (TAGs) of global experts to provide support throughout the research process. The role of a TAG is to ensure rigour, offer new ideas and avenues for exploration, and facilitate connections with in-country research partners and dissemination partners. In practice, similar to other groups that have used TAGs, 18 EGH selects advisers who are renowned content and methods experts and represent a diverse group of stakeholders. TAG members are identified by project teams through self-nomination or through snowball sampling approaches, whereby experts are recommended by others in the field. The TAG is continuously engaged through all aspects of the project, including methods and inferences, strengths/limitations, prior knowledge, discourse on dissemination and partnerships.

Exemplar country selection

EGH selects exemplar countries based on their exceptional performance relative to secular or global trends. Historically, economic development has been a primary driver of improvements in health, but a close look at the data reveals that health outcomes vary considerably between countries with similar economic conditions and trajectories. The EGH approach aims to identify true positive deviants by selecting countries that outperform expectations from economic gains alone. Therefore, we select exemplar countries by assessing performance conditional on changes in the most relevant economic measures: gross domestic product (GDP) or gross national income per capita, programme-specific expenditures or other proxies for a country’s capacity to achieve improvement. The selected topics are studied across the past two decades, when data is of reliable quality and when significant improvements in the outcome are observed.

For some topics, we use a range of country-level time series estimates from multiple institutions. As shown in figure 2 , an initial critical step is to generate visuals (eg, scatter plots) of average annual rate of change (AARC) in the outcome of interest as a function of the AARC in an economic indicator (eg, GDP per capita). This comparison enables identification of countries’ actual change relative to their expected change in the outcome given economic improvement only. Inspection of these quantitative measures is combined with qualitative considerations regarding feasibility of conducting research in-country, the generalisability of findings from a country given its size, diversity of government type, policy relevance and, when appropriate, representation across geographic regions. The shortlist of countries is shared with the TAG, which subsequently ranks contenders for the final list of exemplar countries. In the case of our under-five mortality research, this process resulted in the selection of seven exemplar countries, shown in figure 2 .

Exemplar country selection process: under-five mortality example. GDP, gross domestic product.

Evidence collection and collation

Understanding the complex chain of context, policies, programmes and interventions that drive large-scale national change is challenging. And although establishing causality with retrospective studies is aspirational, triangulating evidence across a broad range of data sources and methods brings us closer to the truth (see figure 3 for an example of under-five mortality data triangulation in Rwanda). The EGH approach to evidence collection is to first systematically and comprehensively review existing evidence to identify knowledge gaps that could be filled with empirical analysis. Subsequently, we triangulate analyses from qualitative, quantitative and policy data to uncover a holistic narrative of what contributed to a given country’s success. In addition to critical insights from the TAG, an appropriate in-country partner is identified for each exemplar country; this partner plays a key role in collecting, generating and synthesising evidence across analyses. To illustrate, each of the evidence collection steps is discussed through EGH research examples below.

Triangulation across data: under-five mortality example, Rwanda.

Literature review

The EGH approach involves conducting one or more literature reviews for the topic of interest. The type of literature review conducted is dependent on several factors, including (1) the existing breadth of information available; (2) the need to assess evidence systematically versus more broadly; (3) the intended final output (eg, a meta-analysis or descriptive summary); and (4) the available time and financial resources. The main objective of the literature review is to assemble the latest evidence on the topic of interest that can be cited and from which insights can be extracted and gaps identified. Detail on the literature review features of EGH projects is provided in box 4 .

Literature review features of EGH projects

The EGH approach encourages use of one or multiple literature review methodologies as appropriate to the question at hand. It is typical to deliberate such decisions a priori and adjust the literature review scope to research needs. For instance, in some cases, a systematic literature review may be the best approach. If the topic scope is too large, however, targeted searches may be more practical and allow for deeper dives into areas that emerge as important after an initial, more cursory literature review.

The EGH Stunting Project, for example, aims to collate causal evidence on “factors that were linked to stunting decline.” Given the existing breadth of literature on this topic in many countries, in addition to the need to assess quantitative associations systematically and objectively, researchers opt to conduct a thorough systematic literature review inclusive of statistical meta-analysis when possible. They explore more then 15 online databases (e.g., PubMed, Scopus, CINAHL) for peer-reviewed literature and more than 10 grey literature repositories (including government websites, NGO databases, and UN websites). They set inclusion and exclusion criteria (against which articles were identified, screened, and shortlisted for abstraction) and also conduct hand-searches of bibliographies. This process, applied to literature assessing stunting reduction determinants in Peru from 1990-2018, yielded 500 unique records, of which 159 underwent full text review, and of which 141 relevant studies were ultimately included in the final literature synthesis.

The EGH Under-5 Mortality Project, in contrast, opted to conduct a broad, iterative scoping review of literature using similar databases. This rapid review enabled researchers to identify emergent themes within a vast existing evidence base, while concurrently planning research goals and methods to fill existing evidence gaps. Similar work was done within the implementation science literature to identify relevant frameworks for adaptation.

The literature review can also reveal existing frameworks, models and methods for conducting research or analyses, to be considered for the topic of interest. For instance, the International Initiative for Impact Evaluation (3ie) produces evidence gap maps (EGM) that summarize evidence on the effects of development policies and programs in a particular sector, sub-sector, or thematic area, structured around a framework of interventions and outcomes. 40 Previously developed EGMs, including those developed using the 3ie approach, on topics of interest may be a useful addition to the EGH toolkit. In the same vein, systematic tools for economic evaluation or other niche methods can be identified through this process.

As a final note, methods for synthesizing collated evidence dictated both by research objective and by available literature. The Vaccine Delivery Project team uses a literature review to assemble and harmonize operational frameworks for vaccine systems to develop a working model for the research. As shown in the EGH Stunting and Under-5 Mortality examples, the availability of several data-rich objective studies can facilitate quantitative meta-analyses, while qualitative reports may require syntheses for emergent themes. While a complete review of types, conduct, and syntheses of literature reviews is out of the scope of this protocol paper, we stress the importance of mobilizing literature review methodologies effectively at the outset and throughout the conduct of the case study to inform study planning and enrich results interpretation.

Qualitative analysis

EGH research involves conducting consultations with key informants. These consultations can be in-depth interviews and/or focus group discussions as required for the study question and target population. Potential informants include international experts, donors, researchers, representatives of multilateral or bilateral institutions, current and former Ministry of Health members, programme implementers such as national and international non-governmental organisations, front-line workers, and community members or direct beneficiaries of programmes implemented at scale at the local level. Snowball sampling was used across projects to identify additional key informants. Once data were retrieved, qualitative data analysis of the appropriate level of rigour was carried out according to an evidence-based conceptual framework.

The Community Health Worker (CHW) Project, which incorporates research visits to each exemplar country, illustrates how the EGH project collaborates with local partners. Prior to a research visit, the research team works closely with the local partner to identify stakeholders. These trips include site visits to observe programmes and in-person, semi-structured interviews with key stakeholders.

Quantitative analysis

Data sources.

Although data quality is a substantial concern in many low-income countries, rich data sources for measures of health outcomes, health systems and contextual factors, including education, income distribution and population density, are plentiful. Household surveys are readily accessible and provide representative snapshots of changes in health and intervention coverage over time. Along with primary data sources, there are numerous sources that provide estimates of disease burden and intervention coverage which incorporate data into models that produce full time-series for every country. In addition, estimates summarising the state of a country’s economy, education system and infrastructure offer helpful context for describing the combination of factors that contributed to changes in outcomes. Critically, care must be taken when incorporating modelled estimates as inputs into analysis since these are developed based on already-known relationships.

Descriptive statistics

The aforementioned data sets enable independent calculation of relevant statistics and the development of insightful novel measures. Our work uses a number of novel measures produced internally, like the slope index of inequality and concentration index, 19 to measure absolute and relative socioeconomic inequalities in health outcomes, as well as externally produced numbers, like geospatial estimates from the Institute for Health Metrics and Evaluation (IHME), which leverage location data to estimate the subnational distribution of outcomes at a 5×5 km level of granularity. 20 Through the development of descriptive statistics that span multiple strata, we explore variation across a range of dimensions, including space, time, gender, economic status and more.

Causal quantitative evaluation

Causal evaluation combines data used in generating descriptive statistics with a hypothesised conceptual framework, enabling synthesis of multiple sources of quantitative data. There are numerous approaches to decomposing past outcomes into explainable and unexplainable factors, but EGH projects primarily use two types of approaches. One quasi-experimental approach involves using data from within the country being analysed and employing regression techniques in combination with hierarchical causal diagrams to identify effect sizes of each hypothesised causal factor. Alternatively, meta-analysis of pooled data from randomised control trials can produce estimates of risk factor effect sizes that are either the same across locations, or at least influenced by the observed effects in other countries.

In each approach, effect sizes are combined with estimates of changes in each explanatory factor to calculate how much each factor contributed to observed changes in the outcome of interest over the time period. The final product is a proportioning of explainable changes to a group of causal factors, many of which fall under the health system. Causal inference, already a difficult task, is further complicated by limited data and uncertainty about the pathways through which multiple factors combine to impact outcomes. Despite these concerns, causal evaluation can provide critical support for hypothesised high-impact activities.

Policy/programme analysis

Organising information on a country’s policies, programmes, and financing during the time period of evaluation can enable a clearer understanding of how that country was able to realise success. While details of some policies may be readily accessible without the support of in-country informants, conversations with key stakeholders often identify additional documentation of processes, financing and policies that were critical to the country’s success. Following up on these documents, combining them with the literature review and distilling them into a clear timeline of actions that each country took provides a clearer view of the policy mechanisms behind a country’s success. Extracting data on the financials behind policies can provide substantial additional insight, but often this is difficult to do given a lack of data availability. Drafting a policy timeline for expert stakeholders to review can be useful, as it enables them to point out missing initiatives that require further investigation. Multiple iterations of timeline review enable convergence towards a consensus timeline endorsed by experts (see figure 4 for a consensus stunting-related policy and programme timeline from Peru).

Policy and programme timeline: stunting example, Peru.

Evidence synthesis and triangulation of evidence

While application of each of the aforementioned methods can independently contribute to the literature for a given country or topic area, our goal is to combine these pieces to tell comprehensive stories and fortify the weaknesses of each method. We undertake a rigorous and iterative triangulation process whereby each research output is synthesised collectively to build a coherent story of success factors. Although led by the research team, it is critical that input from country experts and TAG be incorporated during this process. To assist with the evidence synthesis process, it can be helpful to draw on pre-existing frameworks. For example, the CHW Project uses the ExpandNet scaling up framework to organise the outputs from each of the employed methods. 21

Dissemination products

Finally, research on exemplars should be accessible by and applicable to a wide audience, for instance, through national level dissemination events geared towards policy and actionable decision-making to drive progress. Accordingly, the narrative can be assembled into a variety of dissemination products (see table 1 for a table of EGH dissemination products) that align with preferences of various target audiences (see figure 5 for an example of user testing conducted to identify preferred dissemination formats).

Exemplars in Global Health output formats and intended audiences

Insights on preferred types of content from user testing.

Several other outputs can be created to reach diverse audiences. Users of the EGH framework are encouraged to consider which products are best for their intended audiences. For instance, material from the CHW Project has been incorporated into ‘Strengthening Community Health Worker Programmes’, an open, online, university-level course hosted on HarvardX that reaches over 10 000 current and future health systems leaders in over 170 countries.

Finally, in-person and virtual discussions can serve as both opportunities for dissemination and means of refining research findings for policy and action. Significantly, it will be important for stakeholders to interpret and adapt information from exemplar countries to their respective contexts. EGH provides a range of interactive services to support this interpretation and adaptation.

Patient and public involvement

Our research question was developed to identify drivers of exemplary national performance. For this reason, patients were not involved in the design of the study.

The EGH framework offers guidelines and recommendations for conducting rigorous and objective research on global health success stories. With oversight by leading global experts, we propose mixed methods studies to develop systematic and comprehensive narratives of exemplar countries’ success stories. Data are presented in a way that enables other national or subnational governments, as well as global funding and implementing mechanisms, to prioritise strategies proven to work at scale. In short, EGH’s research-based implementation narratives explain how countries implemented, adapted and scaled interventions that work.

The merits of conducting systematic case studies to highlight global health successes is evident in the sheer number of previous published efforts. The Countdown to 2030 consortium 22 has published dozens of country case studies, several as scientific articles. 3 23–25 The International Food Policy Research Institute 26 has published success narratives as book chapters, reports, brochures, and journal articles. 27 Similarly, the 3-year multidisciplinary, multicountry series of ‘success factor’ studies coordinated by Partnership for Maternal, Newborn and Child Health (PMNCH), WHO, World Bank and the Alliance for Health Policy and Systems Research aimed to understand how some countries accelerated progress to reduce preventable maternal and child deaths. 28–30 The EGH framework builds on and consolidates lessons from these efforts, positing one common systematic approach that can be used across diverse topics and research groups. 31–35

Each of the framework elements aims to complement one another and strengthen emergent themes. We assemble topical technical advisors at the outset of each project. Their role is critical in identifying exemplar countries, fostering in-country partnerships, overseeing methods design and analyses, and commenting on interpretation of final results. Conducting an environmental scan of existing evidence shapes the required methodological approaches, provides context for research teams and technical advisors, and informs the overall research process and final results synthesis. Undertaking robust quantitative, qualitative and policy analyses provides the most useful inputs to understanding the exemplar story. Triangulation of all existing and novel analyses under the oversight of technical advisors and country experts is the critical final step in developing evidence-based narratives of success and actionable insights.

Implications of EGH approach

The merits of studying stories of success to understand transferable lessons cannot be understated. Methodologically rigorous, comprehensive and systematic narratives provide valuable insights that enable learnings from the past to be applied to current and future global health challenges. We believe that the EGH approach can be applied across diverse disciplines to catalyse such efforts. Importantly, the standardised EGH framework proposes cross-cutting principles while allowing room for flexibility by topic of research and/or researcher area of expertise.

That said, the EGH approach is merely a starting point. Additional steps are required to translate lessons into implemented policy. The EGH Partnership offers support for implementation in the form of direct technical assistance in policy-making and connection to experts. Other organisations provide similar support, as well as funding.

Limitations

Despite the potential of the EGH approach, several limitations are worth noting. First, retrospective analyses are challenging even in the most data rich settings. Often, direct measures of key variables are not collected, poorly measured or simply inaccessible due to poor institutional memory (eg, due to staff turnover) or data storage. Measuring some important constructs such as food security or quality of care is elusive and quantitatively challenging. 36 Thus, reliance on ‘proxy’ measures is commonplace in retrospective studies, even though they may threaten reliability and accuracy if not carefully selected. Confounders of key associations may also be unavailable for analyses; therefore, exposure-outcome associations should be carefully interpreted. Additionally, quantitative analyses of ecological associations may be subject to ecological fallacy and the choice of statistical models may also influence results if incorrectly specified; 37 conducting sensitivity analyses of key associations is thus critical to ensuring objective inferences. Key informants for qualitative research can be difficult to identify and connect with for interviews. Other important data (eg, dietary intake, from food frequency questionnaires) is almost always based on participant recall across long or short-term windows. Thus, recall bias in administered surveys and among interviewed country experts and beneficiaries is an ongoing challenge, and efforts to mitigate this bias in primary data collection must be considered. 38 Triangulating qualitative and quantitative evidence mitigates risk of bias or uncertainty in inferences.

Future work

The EGH Consortium will continue to evolve and expand our research portfolio, with the framework presented in this paper underpinning all of our studies. Our aim is to not only provide funding agencies, multilateral agencies, governments and researchers with our learnings organised into a methodical framework, but also to share transferable and actionable knowledge for countries and foster partnerships with those interested in studying EGH. We also hope to promote improvements in the quality and comprehensiveness of data collection, as well as alignment on the appropriate quantitative methods for making inferences from data, by continuing to document EGH experiences in subsequent studies.

We believe that the methodical EGH approach to understanding case studies of successes in global health will provide objective evidence that can be used across diverse groups to accelerate improvements in the most pressing health outcomes and implementation strategies in low and middle-income countries. Learning from these stories of success could enable prioritisation of investments and programmatic action towards achieving the SDGs by 2030.

Supplementary data

Handling editor: Seye Abimbola

Twitter: @nakseer, @niranjanbose, @mattprice

Contributors: ZAB, NB, OR, KH and NA conceived the study idea. NA designed the study methodology with inputs from AC and KH. All authors contributed content, including methods and critical analysis from their research to support drafting this paper. AC, NA and KH prepared the first draft of the manuscript. ZAB provided overall technical support and guidance and is the guarantor of the study. All authors reviewed and contributed to the final manuscript.

Funding: This work was funded by Gates Ventures, LLC, Kirkland, WA, USA.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer-reviewed.

Data availability statement: All data relevant to the study are included in the article or uploaded as supplementary information.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Development Co-operation Report 2018: Joining Forces to Leave No One Behind

Case studies from developing countries: what works and why.

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Case Study of the Development of an Emerging Country ( Edexcel GCSE Geography: B (1GB0) )

Revision note.

Geography Lead

Location & Significance

Site and situation.

• Located to the north of the equator
• Most of India is a peninsula with water on three sides
• It has a diverse landscape with mountains, deserts and plains
• India is located in Asia between the Arabian Sea and the Bay of Bengal
• It has borders with six countries - Bangladesh, Nepal, Myanmar, Pakistan, China and Bhutan 

Significance

• India is the seventh largest country in the world
• It is a rapidly developing nation
• Predictions suggest it will be the second largest economy in the world by 2050

Political, Social, Cultural & Environmental Context

India's Political, Social, Cultural and Environmental Context

Key Economic Trends

Gross domestic product (gdp).

• In 2021 GDP was US$3.176 trillion
• GDP per capita was US$2,256
• Since 1990 there has been a 500% increase in GDP

India's GDP per capita

• Annual growth of the Indian economy is approximately 8.7%

Gross National Income (GNI)

• India has the seventh highest GNI in the world
• The GNI per capita was US$2,320 in 2022

Economic sectors

• The contribution of economic sectors to GDP has changed from being dominated by agriculture to being dominated by service activities

Contribution of the economic sectors to GDP

• By 2019 decreased to 43%

Economic sectors - employment %

• Imports (2019) US$478 billion
• Exports (2022) US$323billion
• Petroleum products, jewellery, chemicals, pharmaceuticals, machinery, clothes
• Petroleum, gold/silver, electronic goods, pearls and precious stones
• China, USA, UAE, Saudi Arabia and Iraq
• USA, UAE, China, Hong Kong and Singapore

Foreign Direct Investment (FDI)

• Foreign Direct Investment (FDI) has rapidly increased since 1990
• In 2021 India's total FDI inflows were $45 billion
• Investments in the automobile industry, electrical machinery and textiles have increased significantly
• Singapore (27%)
• Mauritius (16%)
• Netherlands (8%)
• In 2022 Google announced a US$1 billion investment in Bharti Airtel an Indian telecommunications company
• In 2020 Facebook invested $5.7 billion in Reliance Bio an Indian telecommunications company
• India firms also invested in other countries $17.24 billion
• Mastek has invested £79 million to create 1600 jobs in the UK
• TVS Motors have invested £100 million in Norton Motorcycle

The Role of Globalisation

• Globalisation has led to increasing investment by other countries in India (FDI)

Infrastructure

• India has 24 International Airports and 13 major ports (212 non-major)
• India has the second largest telecommunications network in the world (telephone users) and internet users

Transnational Corporations (TNCs)

• Skilled, low cost 
• Mainly English speaking
• Well educated

Government policy 

• Since 1991 the government has taken less control over what industries produce -  economic liberalisation
• They have reduced import tariffs to encourage imports
• Special Economic Zones have been set up to reduce taxes for TNCs
• In 2017 India received US$4,240.34 million with more than 50% of being donated by Japan
• Aid is focussed on poorest states in India such as Madhya Pradesh
• A new policy announced in 2003 stated that they would no longer accept tied aid except from certain countries including UK, USA and Germany
• India is now a donor of aid as well as a recipient
• In 2009 primary education became free
• In 2020 a National Education Policy was launched to improve equality and overall education
• Education gives the population more skills increasing their employability
• Encourages the positive multiplier effect

Multiplier effect

• Improves trade links with other countries
• Increases investment in education/healthcare/infrastructure

Worked example

Explain one way in which outsourcing affects economic development in an emerging country..

• Capital investment by TNCs for infrastructure (electricity / rail / telephone) (1) , encourages multiplier effects as other companies co-locate (1)  creating further job opportunities (1)
• Increased manufacturing / production (1) could grow bilateral trade links with surrounding countries (1) providing income for government spending (health / education etc) (1)
• Training and education upskills the labour force making them more employable (1) over time demand higher wages  (1)  which might in turn raise consumer spending power (1)

Rapid Economic Growth & Demographic Change

• Rapid economic growth has led to significant change in the demographic characteristics of India
• Death rates and infant mortality rates have fallen

Population pyramid for India 2022

• Diets have improved
• Healthcare is more available and has improved
• Water quality and access has improved
• Women are more educated
• More women work
• Greater access to contraception
• Education about family planning

Urbanisation

• This amounts to 475 million people
• Urbanisation is increasing by approximately 2% a year
• Approximately 20 million people migrate from rural to urban areas each year in India

Regional differences

• There are stark regional differences in India

Table Showing Differences Between Delhi and Bihar

• Delhi has a much higher population density
• People move to Delhi for work (pull factor) from rural areas
• Bihar suffers recurring floods which hampers development (push factor)
• Many people from Bihar migrated to other areas reducing the working population in Bihar
• Poor infrastructure in Bihar makes it difficult to attract investment

For a named emerging country, explain two socio-economic differences between regions

• There are a number of socio-economic differences which can be identified the maximum you will get for identifying these is 2 marks
• The second set of 2 marks is awarded for explaining the differences
• Possible socio-economic differences - Population density and rates of growth, average income levels, ethnic differences, migration history and trends, levels of economic growth and structure, health and education provision (2 marks)
• Reasons given to explain the differences – geographic location/isolation and the ease of historical trade, differences in land fertility and topography, the development of industry and the cycle of growth idea, a flow of skilled labour to the core, government policies (2 marks)
• In India, Maharashtra has a higher population density than Bihar (1) Mumbai is in Maharashtra which attracts migrants from rural areas for work (1)
• Shanghai has a higher population density than Gansu (1) Shanghai’s coastal location has seen it grow as an important port attracting workers (1)

Social Impacts of Economic Development

Positive impacts.

• Access to education and increased literacy rates - though still lower than males
• Improved family planning and access to contraception
• Increased work/career opportunities
• Health has improved in all age groups
• Average incomes have increased

India's per capita income

Negative impacts

• Children in rural areas are more likely to work
• Migration of younger people leaves older population in rural areas
• Investment in rural areas is much lower
• Lack clean water supply
• Increased spread of disease
• Poor quality housing

Environmental Impacts of Development

Air pollution - causes.

• In 2019 21 of the 30 most polluted cities in the world were in India
• Increased car ownership - New Delhi has over 10 million vehicles
• Fossil fuel power stations - increased burning of fuels due to increased energy demands
• Factories - there are between 3-4,000 factories in New Delhi
• Burning of stubble
• Construction dust
• Cooking fuel - over 100 million people rely on biomass for cooking
• It is estimated that life expectancy is on average 5 years lower due to air pollution
• In 2019 over 1.5 million people died due to air pollution
• Increased levels of asthma, lung diseases and cardiac problems
• Contributes greenhouse gases leading to global climate change

India's CO 2  emissions

Water pollution - causes

• Only 30% of all sewage in India is treated
• Of the remaining rivers in India 33% are moderately or severely polluted
• The use of pesticides in agriculture is common with chemicals, such as DDT, which are banned in many countries, still being used in India
• Waste water from industry contains many toxic metals such as mercury, lead and arsenic which are found in both surface and groundwater
• Approximately 70% of surface water is unfit for human consumption
• Damaging to aquatic life 
• Increases in liver and kidney disease, gastric cancers and birth defects
• Decreases crop yields and quality

Land pollution - causes

• Increasing population leads to more waste
• There are more than 3,000 landfills across India
• Ghazipur is the largest in Delhi at 65 meters high
• An average of 2.01 billion tonnes of waste is generated each year
• About 90% of waste goes to landfill
• Increased methane emissions
• Leaching of toxins into ground and surface water
• Fires - in March 2022 Ghazipur caught fire increasing air pollution 

Explain two negative impacts of the rapid economic development of an emerging country on different age groups

• Air pollution (1) leads to breathing problems amongst the elderly / young people  (1)
• Often there are not enough jobs leading to unemployment for young people (1) as a consequence of rapid rural to urban migration  (1)
• Rapid rural to urban migration  (1) leads to an ageing population in rural areas who have no-one to look after them (1)
• TNCs in emerging countries are known to employ young children resulting in them not attending school  (1) and their education suffering as a consequence  (1)
• Rural to urban migration (1) leads to an inactive ageing population in rural areas who are often economically inactive (1)

Geopolitical Influence

• India's geopolitical influence has increased over the last 40 years
• It has increasing influence in the  Association of Southeast Asian Nations (ASEAN)
• BRICS (Brazil, Russia, India, China and Singapore)
• G20 - intergovernmental forum which addresses issues related to the global economy
• UN Security council
• According to the International Monetary Fund (IMF) India is responsible for 15% of global growth

Relationship with EU and USA

• The EU is India's third largest trading partner
• In 1994 EU-India Cooperation Agreement was signed
• Imports and exports to the EU are balanced (exports €46.2bn, imports €41.9bn)
• India exports more (US$49.7bn) to the USA than they import from the USA (US$26.6bn)

Other political issues

• In 1947 the partitioning of India and Pakistan led to social unrest, one million deaths and the displacement of 15 million people
• There remain tensions between India and Pakistan
• It impacted on development and still affects trade with other countries such as China

Costs & Benefits of Changing International Relations

Costs and Benefits of Changing International Relations

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A country which is under-populated - Australia

A country which is under-populated – Australia

Australia has one of the lowest population densities in the world. With a low population of 23 million and a land area of over 7.6 million km² its density is around 3 people per km². This is very low compared to the Monoco, the most densely populated area in the world with 26150 people per km².

Australia is rich in natural resources with large reserves of natural gas, oil, gold, uranium and metal ores. Uranium is important in the development of nuclear power around the world. Australia attracts migrant workers to support the exploitation of these natural resources. Australia has the 9th highest immigrant population in the world with 6.7 million, which makes up 28.2% of its population.

The 15 countries with the most immigrants – Gilles Pison, based on United Nations data

Australia has more resources available than it uses, which means surplus resources can be exported. Exports in 2017 we worth over $220 billion. This contributes to Australia’s high GDP per capita of over $49,000 per person. The unemployment rate in Australia is very low.

With low birth and death rates, Australia’s natural increase is low. Health care provision is very good which contributes towards the low infant mortality rates. Adult literacy is high at 99%.

Population density is higher around the coast where climates are more favourable. Moving inland the land becomes desert and semi-desert. Semi-desert areas could be developed for future population growth. However, water shortages could limit population growth and development in the future.

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Poland + 1 more

Grand Bargain Localization Commitments (Poland Case Study) June 2024

• NGO Forum - Razem

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Grand Bargain Localization Commitments (Poland Case Study) by Groupe URD for NGO Forum “Razem”

Financing Partners: CARE Poland, Oxfam Foundation in Poland, Norwegian Refugee Council in Poland, Contributing Partners: Plan International Poland, Save the Children International (Poland)

Steering Committee composed by representatives of: Foundation Ukraine, Migration Consortium and Mudita Association, CARE Poland, Oxfam Foundation in Poland, Norwegian Refugee Council in Poland

Operator: Polish Humanitarian Action

Authors, Groupe URD: Dominika Michalak, Véronique De Geoffroy, Rana Gabi, Elie Keldani, Karina Melnytska

REPORT SUMMARY:

Within the first month of Russia's full-scale invasion of Ukraine on 24 February 2022, over two million refugees crossed into Poland. Many continued to other European countries or overseas, but a year later, over a million refugees from Ukraine were registered for Temporary Protection in Poland. In 2024, refugees are still arriving in Poland from Ukraine, and the number of registered refugees remains similar to the previous year. This report evaluates the involvement of international humanitarian actors in response to the challenges related to this forced migration movement, as compared against the Grand Bargain Localization Commitments .

Its aim is to support the common work on better relationships between international actors, such as INGOs and UN agencies, and their local partners in Poland, as well as to contribute to the global localization debate.

The research employs the NEAR Localisation Performance Measurement Framework but also draws directly on analytical categories from the research material, i.e., on how the research participants understood the localization dynamics. The data were collected between March and May 2024. It provides information on the NGO landscape before the 24th of February 2022 and the development of the response up to the beginning of May 2024. In total**, 85 persons from 55 organizations took part in the research and 6 INGOs shared their partnership agreement templates for our analysis**.

Overall, the evaluation of the response dynamics against the Grand Bargain Commitments (as operationalized by the NEAR framework) showed positive results. Adherence to the commitments was highest with regard to financing: in the case of Poland, the main strengths of the localization processes were the high availability of direct funding , the high share of overhead costs covered by INGOs, and the good availability of financial support for organizational development. Capacity sharing and the quality of partnerships are areas where improvement was expected by all the actors involved. Capacity development often focused on facilitating local actors’ adaptation to the humanitarian system and rarely assumed the character of capacity sharing. Excessive formalization of partnerships after the emergency phase of the response, often combined with inconsistencies related to these formal requirements, meant office work overshadowed matters related to field challenges and impacted the quality of partnerships.

The report identifies 13 barriers and 10 enablers of localization in Poland .

THE BARRIERS include proximity bias in identification of projects’ participants and their needs; decontextualized character of humanitarian models, standards and commitments; no shared definition of success between local and international actors; excessive administrative burden on local actors; insufficient awareness raising about the key characteristics of the humanitarian cycle among L/NNGOs; high rotation of INGO and UN employees and language barriers.

THE ENABLERS include abundant direct funding available, including funding covering overhead costs and organizational development; availability of non-competitive funding; reliability of L/NNGOs as partners; horizontal networks facilitating cooperation between organizations sharing interests and facing similar challenges; local actors with adequate experience assuming the role of intermediaries (e.g., engaging in re-granting or facilitating coordination); high social legitimacy of providing support to Ukrainian refugees; authentic work on improving partnerships; acknowledgment of local expertise and capacity. We stress that localization is largely a matter of balance: some of the enablers, when applied without monitoring or on too wide a scale, can become barriers.

HIGHLIGHTED RECCOMENDATIONS:

- Strengthening networks of cooperation , i.e., horizontal networks between local actors and similar cooperation ties between international actors, has been instrumental in overcoming some of the localization barriers and is worth considering at other sites of humanitarian intervention.

- Capacity sharing instead of capacity building to acknowledge and properly employ the expertise of local actors is recommended in any context.

- Ensuring more equity in contracting , especially with regard to prioritizing the local law as the governing law and in terms of termination is recommended, especially for contexts where the rule of law is sufficient to ensure both sides a fair trial. Ensuring availability of contracts in the local language is recommended as general good practice.

- The report also concludes that reconnecting with social movements is beneficial to international humanitarian actors wherever these movements address questions at the heart of humanitarian ethics, such as human rights, civil participation or protection from violence.

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The Sydney Jewish Museum was established three decades ago by Holocaust survivors who came to Australia. The Museum’s tagline, ‘Where history has a voice’, encapsulates both the origins and mission of the Museum, while also fitting perfectly with the newly installed feature exhibit Reverberations: A Future for Memory . 

This interactive, high-tech attraction shines a light on the humanity and life experiences of Holocaust survivors who, in recent years, have shared their stories in person with visitors. Created in collaboration with the USC Shoah Foundation – The Institute for Visual History and Education, the unique visitor experience uses cutting-edge technology, including components from the Shure Stem Ecosystem , to transform the life stories of Sydney-based Holocaust survivors into interactive, on-screen biographies capable of conversation with visitors.

“The aim of our exhibition is to provide an opportunity for future generations to have a conversation with a Holocaust survivor,” explained the Sydney Jewish Museum’s Senior Curator Shannon Biederman. “It’s really about keeping their memories alive for the time when, sadly, there will no longer be any living Holocaust survivors.”

USC SHOAH FOUNDATION

The wider project of collecting video testimonies from actual witnesses to the Holocaust owes much to Steven Spielberg. He was inspired to establish the USC Shoah Foundation after meeting survivors of the Holocaust who visited the set of his movie Schindler’s List in 1994. Since then, tens of thousands of their stories have been filmed and preserved for future generations in the Visual History Archive, the largest collection of genocide witness testimony in the world.

Building on this, the USC Shoah Foundation’s new initiative Dimensions in Testimony was created to record and display testimony in a way that will enable actual dialogue between Holocaust survivors and visitors far into the future. With the aid of AI-based language processing computer

“We have a very close relationship with the USC Shoah Foundation,” explains Shannon Biederman. “We’ve had the Visual History Archive on site for about 15 years now, so we’ve been watching their  Dimensions in Testimony  project unfold over the years and we’ve always been really keenly interested in joining it here.” 

CAPTURING SURVIVOR TESTIMONIES 

The opportunity arrived during the Covid pandemic when recording of testimony in the United States had to be suspended. The complex recording system was brought to Australia and used to capture the intimate recollections of six Holocaust survivors from Sydney. Each survivor answered around 1000 questions about their experiences in the Holocaust, their lives, interests and hopes for the future, while being filmed within a specialized rig with 23 cameras. The many hours of footage from these interviews were then catalogued and processed, ready to be transformed into an interactive biography for the Reverberations  exhibit.

With the editing of the video footage underway, the team from AV integrators Interactive Controls came on board to install the technology for the Museum exhibit itself. The striking, minimalist design brings the visitor face to face with a life size image of a survivor waiting patiently on an 86-inch monitor screen, hung in portrait mode on the wall. There are no visible buttons or controls. All interaction with the AI controls is driven by voice, captured by a Shure Stem Ceiling microphone that hovers above. 

The microphone, from the Shure Stem Ecosystem, connects across a digital network to a Stem Hub that interfaces via USB directly with the computer. The PC responds to visitor questions by instantly selecting the most appropriate answer from the hundreds of stored clips and sending the video to the monitor, and sound, via the Hub, to the Shure Stem Speaker mounted in the ceiling. 

INTELLIGENT CONVERSATION 

From months spent in training the voice recognition systems, curator Shannon Biederman understood only too well how crucial it was to have accurate capture of the visitor’s voice interactions – even on the sometimes noisy Museum floor. “Because you’re dealing with so many different speech patterns and so many different accents, the software has quite a lot of work to do” she observed, “so the clearer the audio, the better the software can work. If it’s always getting interrupted, you’re going to get a lot of errors in the responses that the system is pulling. And that will really be detrimental to the user experience.” 

Having worked with the USC Shoah Foundation on the prototype technology, Shure US enrolled the assistance of Jands , as Shure’s distributor in Australia, to provide specialized advice and assistance in installation and programming of the Shure components in the Sydney Jewish Museum system.

USC Shoah Foundation was set up to operate in what’s called an ‘audio fencing’ mode,” Jands’ own Christopher Ling explained. “Essentially audio fencing uses its built-in DSP and 100 separate microphone elements to create a conical pickup area directly under the microphone and reject audio from outside of that space.” 

EFFECTIVE APPLICATION 

While originally devised for videoconferencing applications in meeting rooms, the unique intelligent beamforming capabilities of the microphone and the simple, elegant architecture of the entire Shure Stem Ecosystem work brilliantly to enable true duplex conversation with the AI language processing system. 

Shannon Biederman believes that the simplicity of voice interaction is an important part of Reverberations . “What we find is that the technology quickly falls away for the visitor, creating a really impactful and emotional experience,” she reflected. “Having Holocaust survivors tell this history makes it personal. It’s no longer dates, it’s not numbers. Having these stories with us into the future is really important in making history meaningful.” 

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The first carbon tax on farms has been set, and it’s in Europe

26-Jun-2024 - Last updated on 26-Jun-2024 at 08:16 GMT

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In a ‘world first’, Denmark is set to become the first to introduce a carbon tax on livestock emissions from 2030 onwards.

This week, the Danish government agreed that to help meet the country’s 2030 climate goals, as well as improve its natural landscape and drinking water quality, a tax on carbon emissions from livestock should be implemented.

The tax is expected to be formally approved by the Danish parliament in August.

Danish farmers taxed according to CO2e output ​

According to the tax, in 2030 a fee of 300 Danish crowns (€40.13) will be charged to farmers per ton of CO2e. The fee is set to increase to 750 Danish crowns per ton of CO2e in 2035.

An income tax deduction of 60% will be available to farmers, which means that in real terms they would be charged 120 Danish crowns per ton of CO2e in 2030, and 300 Danish crowns per ton of CO2e in 2035.

Denmark’s finance minister Nicolai Wammem welcomed the news, describing the day as ‘truly historic’ for Denmark. “We are investing in the future of our agricultural sector, initiating a transition with shared ambitions and goals – laying the tracks to what our country will look like in five, 10 and 20 years from now.

“We know that a CO2 tax model aligned across all sectors gives us the lowest societal costs in total. What we have now done from industry sectors to agriculture shows us that an ambitious green transition is possible.”

Government invests in more trees and forest protection ​

At the same time, the Government plans to spend more than 30m Danish crowns on the removal of approximately 140 hectares of carbon-rich lowland soils and plant 240,000 hectares of forest.

A subsidy scheme is also being set up for the storage of biochar by pyrolysis, whereby biochar is made by heating organic materials, such as wood, without oxygen.

The Government expects the agreement will create ‘major changes’ in the industry, and across Denmark more generally, in the ‘coming years and decades’.

“With this agreement, we will reach our climate goals in 2030, and we will take a big step closer to becoming climate neutral in 2045,” said tax minister Jeppe Bruus.

Could Denmark be the first of many to implement a carbon tax? ​

Denmark is now set to become the first country to implement a carbon tax on agriculture, but only after New Zealand scrapped plans for a similar tax ​ earlier this month.

As to whether other countries will follow suit, the jury is out. But Bruus suggested it could incite action: “We will be the first country in the world to introduce a real CO2e tax on agriculture. Other countries will be inspired by it.”

The predicted greenhouse gas emissions are significant, which indeed could encourage the development of more agricultural taxes around the globe. Overall, it’s expected that Denmark’s greenhouse gas emissions will be reduced by 1.8m tonnes of CO2e by 2030, with the potential for up to 2.6m tonnes.

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Bird Flu (H5N1) Explained: Finland Will Start Vaccinating Humans In A Global First

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Here’s the latest news about a global outbreak of H5N1 bird flu that started in 2020, and recently spread among cattle in U.S. states and marine mammals across the world, which has health officials closely monitoring it and experts concerned the virus could mutate and eventually spread to humans, where it has proven rare but deadly.

A sign warns of a outbreak of bird flu.

June 25 Finland said it plans to begin vaccinating vulnerable populations like farm workers against bird flu as early as next week using 10,000 vaccine series—each with two doses—acquired as part of a European Union deal with vaccine maker CSL Seqirus to provide up to 40 million vaccines to 15 countries.

June 11 The World Health Organization announced a four-year-old child in India was infected with H9N2 bird flu—a different flu strain from H5N1—but recovered after suffering from seizures, respiratory distress, fever and abdominal cramps; H9N2 has infected around 100 people globally since 1998, and this is the second human case in India.

June 6 Dozens of cows infected with bird flu have either died or been slaughtered in Colorado, Ohio, Michigan, South Carolina and Texas, which is unusual since—unlike poultry—cows cost more to slaughter and around 90% usually make a full recovery, Reuters reported .

June 5 A new study examining the 2023 bird flu outbreak in South America that killed around 17,400 elephant seal pups and 24,000 sea lions found the disease spread between the animals in several countries, the first known case of transnational virus mammal-to-mammal bird flu transmission.

May 30 Another human case of bird flu has been detected in a dairy farm worker in Michigan—though the cases aren’t connected—and this is the first person in the U.S. to report respiratory symptoms connected to bird flu, though their symptoms are “resolving,” according to the Centers for Disease Control and Prevention.

May 23 A new study with mice suggests that drinking infected milk can spread the disease—and that a certain type of pasteurization may not always be effective in killing the virus.

May 22 Michigan reported bird flu in a farmworker—the second U.S. human case tied to transmission from dairy cows—though the worker had a mild infection and has since recovered.

May 21 Australia reported its first human case of bird flu after a child became infected in March after traveling to India, though the child has since recovered after suffering from a “severe infection,” according to the Victorian Department of Health.

May 16 The USDA conducted a study, and discovered that after high levels of the virus was injected into beef, no trace was left after the meat was cooked medium to well done, though the virus was found in meat cooked to lower temperatures.

May 14 The Centers for Disease Control and Prevention released influenza A waste water data for the weeks ending in April 27 and May 4, and found several states like Alaska, California, Florida, Illinois and Kansas had unusually high levels, though the agency isn’t sure if the virus came from humans or animals, and isn’t able to differentiate between influenza A subtypes, meaning the H5N1 virus or other subtypes may have been detected.

May 10 The Food and Drug Administration announced it will commit an additional $8 million to ensure the commercial milk supply is safe, while the Department of Agriculture said it will pay up to $28,000 per farm to help mitigate the spread of the disease, totaling around $98 million in funds.

May 9 Some 70 people in Colorado are being monitored for bird flu due to potential exposure, and will be tested for the virus if they show any symptoms, the Colorado Department of Public Health told Forbes—it was not immediately clear how or when the people were potentially exposed.

May 1 The Department of Agriculture said it tested 30 grocery store ground beef products for bird flu and they all came back negative, reaffirming the meat supply is safe.

May 1 The Food and Drug Administration confirmed dairy products are still safe to consume, announcing it tested grocery store samples of products like infant formula, toddler milk, sour cream and cottage cheese, and no live traces of the bird flu virus were found, although some dead remnants were found in some of the food—though none in the baby products.

April 30 Wenqing Zhang, head of WHO's Global Influenza Programme, said during a news briefing "there is a risk for cows in other countries to be getting infected," with the bird flu virus, since it’s commonly spread through the movement of migratory birds.

April 29 The Department of Agriculture told Forbes it will begin testing ground beef samples from grocery stores in states with cow outbreaks, and test ground beef cooked at different temperatures and infected with the virus to determine if it's safe to eat.

April 24 The USDA said cow-to-cow transmission may be occurring due to the cows coming into contact with raw milk—and warned against humans and other animals, including pets, consuming unpasteurized milk to prevent potential infection.

April 18 Jeremy Farrar, chief scientist for the World Health Organization, said during a press conference the threat of bird flu spreading between humans was a “great concern,” since it’s evolved and has increasingly been infecting mammals (on land and sea), which means it could possibly spread to humans.

April 1 The CDC reported the second U.S. human case of bird flu in a Texas dairy farmer who became infected after contracting the virus from infected dairy cows, but said the person was already recovering.

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Can Bird Flu Spread Between Humans?

Bird flu doesn’t “transmit easily from person-to-person,” according to the World Health Organization. Bird flu rarely affects humans, and most previous cases came from close contact with infected poultry, according to the CDC. Because human-to-human spread of bird flu poses “pandemic potential,” each human case is investigated to rule out this type of infection. Though none have been confirmed, there are a few global cases—none in the U.S.—where human-to-human transmission of bird flu was thought to be “probable,” including in China , Thailand , Indonesia and Pakistan .

Is Bird Flu Fatal To Humans?

It is very deadly. Between January 2003 and March 28, 2024 there have been 888 human cases of bird flu infection in humans, according to a report by the World Health Organization. Of those 888 cases, 463 (52%) died. To date, only two people in the U.S. have contracted H5N1 bird flu, and they both were infected after coming into contact with sick animals. The most recent case was a dairy worker in Texas who became ill in March after interacting with sick dairy cows, though he only experienced pink eye. The first incident happened in 2022 when a person in Colorado contracted the disease from infected poultry, and fully recovered.

Is It Safe To Drink Milk Infected With Bird Flu?

Raw, unpasteurized milk is unsafe to drink, but pasteurized milk is fine, according to the FDA. Bird flu has been detected in both unpasteurized and pasteurized milk, but the FDA recommends manufacturers against making and selling unpasteurized milk since there’s a possibility consuming it may cause bird flu infection. However, the virus remnants in pasteurized milk have been deactivated by the heat during the pasteurization process , so this type of milk is still believed safe to consume.

Is It Safe To Consume Meat Infected With Bird Flu?

The CDC warns against eating raw meat or eggs from animals “confirmed or suspected” of having bird flu because of the possibility of transmission. However, no human has ever been infected with bird flu from eating properly prepared and cooked meat, according to the agency. The possibility of infected meat entering the food supply is “extremely low” due to rigorous inspection, so properly handled and cooked meat is safe to eat, according to the USDA. To know when meat is properly cooked, whole beef cuts must be cooked to an internal temperature of 145 degrees Fahrenheit, ground meat must be 160 degrees and poultry must be cooked to 165 degrees. Rare and medium rare steaks fall below this temperature. Properly cooked eggs with an internal temperature of 165 degrees Fahrenheit kills bacteria and viruses including bird flu, according to the CDC. “It doesn’t matter if they may or may not have [avian] influenza… runny eggs and rare pieces of meat” are never recommended, Francisco Diez-Gonzalez, director and professor for the Center for Food Safety at the University of Georgia, told Forbes. To “play it safe,” consumers should only eat fully cooked eggs and make sure “the yolks are firm with no runny parts,” Daisy May, veterinary surgeon with U.K.-based company Medivet, said .

What Are Bird Flu Symptoms In Humans?

Symptoms of bird flu include a fever, cough, headache, chills, shortness of breath or difficulty breathing, runny nose, congestion, sore throat, nausea or vomiting, diarrhea, pink eye, muscle aches and headache. However, the CDC advises it can’t be diagnosed based on symptoms alone, and laboratory testing is needed. This typically includes swabbing the nose or throat (the upper respiratory tract), or the lower respiratory tract for critically ill patients.

How Is Bird Flu Affecting Egg Prices?

This year’s egg prices have increased as production decreased due to bird flu outbreaks among poultry, according to the USDA. A dozen large, grade A eggs in the U.S. costed around $2.99 in March, up almost a dollar from the fall. However, this price is down from a record $4.82 in January 2023, which was also spiked by bird flu outbreaks . Earlier this month, Cal-Maine Foods—the country’s largest egg producer—temporarily halted egg production after over one million egg-laying hens and chickens were killed after being infected with bird flu.

Why Do Poultry Farmers Kill Chickens With Bird Flu?

Once chickens have been infected with bird flu, farmers quickly kill them to help control the spread of the virus, since bird flu is highly contagious and fatal in poultry. The USDA pays farmers for all birds and eggs that have to be killed because of bird flu, as an incentive to responsibly try and curb the spread of the disease. The USDA has spent over $1 billion in bird flu compensation for farmers since 2022, according to the nonprofit Food & Environment Reporting Network.

Is There A Vaccine For The Bird Flu (h5n1)?

The FDA has approved a few bird flu vaccines for humans. The U.S. has a stockpile of vaccines for H5N1 bird flu, but it wouldn’t be enough to vaccinate all Americans if an outbreak were to happen among humans. If a human outbreak does occur, the government plans to mass produce vaccines, which can take at least six months to make enough for the entire population. CSL Seqirus, the maker of one of the approved vaccines, expects to have 150 million vaccines ready within six months of an announcement of a human bird flu pandemic. Although there are approved vaccines for other variants designed for birds, there are none for the H5N1 variant circulating. However, the USDA began trials on H5N1 animal-specific vaccines in 2023.

Key Background

As of May 30, more than 92 million poultry (primarily chickens) in 48 states have been euthanized because of bird flu since 2022, and 57 dairy cow herds across nine states have tested positive, according to data from the CDC (unlike chickens, cows appear to recover from the virus). The USDA believes wild migratory birds are the original source of the cow outbreaks that recently has experts concerned it may mutate and spread more easily in humans, though the CDC said its risk to the public remains low . Farrar called the cattle infections in the U.S. a “huge concern,” urging public health officials to continue closely monitoring the situation “because it may evolve into transmitting in different ways.” The increased number of mammal bird flu infections since 2022 “could indicate that the virus is looking for new hosts, and of course, moving closer to people,” Andrea Garcia, vice president of science, medicine and public health for the American Medical Association, said . The first report of a walrus dying from bird flu was detected in April on one of Norway’s Arctic Islands, and the first U.S. dolphin infected with bird flu died back in 2022, according to a report published April 18. More than 10 human bird flu cases were reported to the World Health Organization in 2023, and all but one survived. Bird flu has devastated bird populations, and 67 countries reported the deaths of 131 million poultry in 2022 alone. Although bird flu typically infects wild birds and poultry, it’s spread to other animals during the outbreak, and at least 10 countries have reported outbreaks in mammals since 2022. Around 17,400 elephant seal pups died from bird flu in Argentina in 2023, and at least 24,000 sea lions died in South America the same year. Besides cattle, bird flu has been detected in over 200 other mammals—like seals, raccoons and bears—in the U.S. since 2022. Although rare, even domestic pets like dogs and cats are susceptible to the virus, and the FDA warns against giving unpasteurized milk to cats to avoid possible transmission.

On June 5, WHO confirmed the first human death of a strain of bird flu that’s never before been seen in humans and is separate from H5N1. A 59-year-old man in Mexico contracted H5N2, and died on April 24 after being hospitalized and developing a fever, diarrhea, nausea, shortness of breath and general discomfort. Cases of H5N2 have been reported in poultry in Mexico, but the man had no history with poultry or animals, WHO said. It’s unclear how he became infected. He was bedridden for weeks prior to the infection, and suffered from several other health conditions.

Further Reading

Another Bird Flu Variant Reaches Humans: What To Know About H5N2—After First-Ever Confirmed Death

WHO Warns Threat Of Bird Flu Spreading To Humans Is ‘Great Concern’ (Forbes)

One In Five Milk Samples From Across US Had Traces Of Bird Flu Virus, FDA Says (Forbes)

Can Pets Get Bird Flu? Here’s What To Know (Forbes)

Avian H5N1 (Bird) Flu: Why Experts Are Worried—And What You Should Know (Forbes)

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Research/Study Research/Study

Inside Project 2025's attack on reproductive rights: IVF

Special Programs Abortion Rights & Reproductive Health

Written by Sophie Lawton , Jacina Hollins-Borges & John Knefel

Published 06/24/24 1:30 PM EDT

At least 22 partner organizations of Project 2025, a coalition of over 100 conservative groups looking to staff the next potential administration of former President Donald Trump, have publicly criticized in vitro fertilization, according to a Media Matters review.

Project 2025 is organized by conservative think tank The Heritage Foundation, and has laid out a radical plan for governance during a second Trump term. The initiative's wide-ranging policy proposals are laid out in its “ Mandate for Leadership ,” a staunchly anti-choice document. Although the Mandate itself doesn’t mention IVF, Heritage has published several pieces opposing the procedure and celebrated a ruling by the Alabama Supreme Court that extended de facto personhood rights to frozen embryos, severely curtailing access to IVF. After abrupt political backlash , Alabama’s governor passed a law protecting IVF providers from legal liability, which some Project 2025 partner organizations have criticized for rendering the original “fetal personhood” ruling moot.

The organizations and individuals associated with Project 2025 who oppose IVF have raised various objections, none of which are scientifically or medically sound. Some opponents, for example, have elided the difference between the legal definition of “viable” — like that used by Louisiana, which has the most restrictive anti-IVF laws in the country — and the medical definition. Louisiana allows IVF but prohibits the destruction of embryos, forcing fertility clinics to ship them to other states for storage. These organizations will often point out that despite this law, Louisiana has more babies born through IVF than Alabama, though they fail to mention that both states have some of the lowest rates of IVF births in the country.

Similarly, some partner organizations have suggested following European countries' leads in regulating IVF, several of them naming Italy as a suitable example. Italy once had laws classifying embryos as living people and severely regulating IVF procedures; all of them were repealed after IVF became more difficult to access and less likely to succeed.

Other Project 2025 associates have argued that IVF is a form of eugenics or that it will lead to cloning or extreme forms of genetic modification and experimentation. Still others have baselessly claimed that IVF is underregulated, ignoring the multiple federal and state guidelines and licensing requirements that providers must meet. 

For the full report on Project 2025's attack on reproductive rights, click  here .

Select a Partner Organization

The heritage foundation, alabama policy institute, alliance defending freedom, the american conservative, american family association, american principles project, americans united for life, amac action, california family council, concerned women for america, discovery institute, eagle forum, ethics and public policy center, family policy alliance, family research council, independent women’s forum, dr. james dobson family institute, liberty university, media research center, mississippi center for public policy, students for life of america, susan b. anthony pro-life america, turning point usa.

• In a post to X, The Heritage Foundation appeared to express support for the Alabama IVF ruling, writing, “FACT: The Alabama Supreme Court decision does not threaten access to IVF,” and claiming that the decision “reassures parents” that frozen embryos will be safer.  [Twitter/X, 3/7/24 ]
• Senior legal fellow Thomas Jipping wrote that the Alabama Supreme Court ruling on embryos that imperiled IVF “got it right” and further suggested that abortion should not be legal.  Jipping also denied the ruling is “an attack on IVF technology itself ... or could have revolutionary ripple effects,” belittling “the media, politicians, and activists” who discussed the ruling’s consequences. He concluded that while this case was about destroyed embryos, “causing the death of an unborn child by abortion is legal [in] more than half of the United States.” [The Heritage Foundation, 4/2/24 ]

The Heritage Foundation's Emma Waters has written extensively against assisted reproductive technologies, particularly IVF and surrogacy. Her opposition draws on unsubstantiated concerns about possible harms to children who lack access to both biological parents and on biblical teaching about proper procreation. [Media Matters, 3/1/24 , 4/2/24 ] 

In a March article titled “Why the IVF Industry Must Be Regulated,” Waters laid out policy recommendations that would impose heavy medical restrictions on IVF and make the procedure more difficult for couples to access and harder for facilities to perform. [Media Matters, 3/19/24 ]

In an article describing her biblical reasoning for not supporting IVF, Waters argued that it is important for Protestants specifically to “take a firm and authoritative stance on reproductive technology” because “Protestants necessarily hold a central place in America’s political and institutional life.” [The Heritage Foundation, 1/24/24 ]

Waters celebrated the Alabama Supreme Court ruling on IVF, calling it “an unqualified victory” and claiming “parents should be grateful that their embryos will receive greater protection.” In another piece on the ruling, Waters suggested states adopt stricter laws around IVF procedures, like those that exist in some European countries. [The Heritage Foundation, 2/27/24 , 2/28/24 ]

In a 2023 article, Waters complained about a California bill that would allow single parents or same-sex couples to access IVF through their health care service plans, stating, “No amount of technology or health insurance coverage can alter God’s created order.” She also claimed that allowing more widespread use of IVF procedures would create a “human trafficking market.” [The Heritage Foundation, 6/20/23 ]

Waters repeated her complaints about LGBTQ couples using IVF and other assisted reproductive technologies in another article titled “Radical ‘Right to Build Families Act’ Would Unleash IVF and Commercial Surrogacy.” In the article, Waters claimed that “the pro-abortion and the LGBTQ coalitions” are pushing assisted reproductive technologies, writing that both coalitions “have been quite hostile to the rights of children and the unborn.” [The Heritage Foundation, 1/13/23 ]

In an interview with the Family Policy Alliance, Alabama Policy Institute president and CEO Stephanie Smith claimed, “The Alabama Supreme Court ruled — correctly, in our opinion — that those embryos were children and should be treated as children under our wrongful death statutes.” Referencing Louisiana’s strict IVF laws, she went on to suggest new parameters that would make the treatment more difficult to receive. [YouTube, 2/29/24, 2/29/24 ]

API released a joint statement with Susan B. Anthony Pro-Life America criticizing Alabama’s stop-gap measure to protect providers of IVF from criminal charges. The statement said, “It is unacceptable the Alabama Legislature has advanced a bill that falls short of pro-life expectations and fails to respect the dignity of human life.” [The New York Times, 2/28/24 ]

In an article titled, “In IVF case, Alabama Supreme Court protects life from conception,” Alliance Defending Freedom senior counsel Denise Burke claimed the Alabama ruling was “a victory for life and the rights of parents.” Burke argued, “Cases like this one demonstrate that being pro-life entails more than just protecting unborn children from abortion.” [Alliance Defending Freedom, 3/18/24 ]

In a statement, Burke called the Alabama ruling “a tremendous victory” for “unborn children created through assisted reproductive technology.” [The New York Times, 2/22/24 ]

An article in the American Conservative by contributor Carmel Richardson claimed IVF is helping the “LGBT movement” distort the meaning of family. Richardson wrote, “To limit the baby-making industry is to give hard answers to those who would like a chicken in every pot and a baby in every lesbian, gay, bisexual, and transgender arm.” Richardson later disparaged IVF for allowing even a “transgender pedophile” to have a child. [The American Conservative, 3/1/24 ]

Contributor Christopher Brunet argued in a piece titled, “A personal IVF story” that he “should be allowed to condemn IVF” because “while one may born as the result of a rape, for example, it does not mean that they can’t condemn rape.” Brunet called IVF “the hope and despair of professional women in middle management” and “propaganda against nature, persuading a generation of collegiate women that they're not losing fertility every day after they turn 20.” Brunet also admonished Republicans for caving to pressure to support IVF, writing, “Just as there is now no going back on IVF, there is also no going back on gay marriage, civil rights, demographic replacement.” [The American Conservative, 2/28/24 ]

Them Before Us President Katy Faust published a story in The American Conservative titled “Alabama sets the stage for a Supreme Court fight over IVF,” in which she praised the Alabama ruling and claimed Louisiana has similar guidelines about embryos. Faust claimed these laws “protect children from their rampant destruction at the hands of #BigFertility” and called on conservatives to “not only challenge the baby-taking industry, but the baby-making industry.” [The American Conservative, 2/24/24 ]

In a call to action against Mississippi’s “anti-life” bill HB 1688, American Family Association claimed the bill would grant an “unrestricted right to destroy unborn children” through procedures such as IVF. The organization called it a “very bad amendment” and asked readers to contact their local lawmakers about the bill. HB 1688 would protect the right to assisted reproductive procedures in Mississippi. [American Family Association, 3/8/24 ; Mississippi Today, 3/7/24 ]

In a second call to action against Mississippi’s HB 1688, AFA Vice President Walker Wildmon stated that the bill “creates an unrestricted right to destroy unborn children as part of very broadly defined ‘treatments or procedures.’” [American Family Association, 3/11/24 ]

On his podcast At The Core , Wildmon claimed, “The ruling in Alabama had to do with wasting embryos, or dumping embryos or discarding” and went on to state “eyes are being opened to how much of a disregard as a culture we’ve had for babies with this IVF discussion.” [American Family Radio, At The Core , 2/28/24 ]

In a Facebook live panel hosted by AFA about the Alabama IVF ruling, Wildmon claimed, “An embryo is a baby,” and stated, “IVF is not being threatened here.” [Facebook, American Family Association Action, 3/1/24 ]

American Principles Project President Terry Schilling tweeted about IVF: “If America isn’t careful, we could actually create a government backed institution of buying and selling human beings. Which, I thought, we decided long ago was wrong.” American Principles Project previously tweeted a statement by Schilling where he told Republicans to “come up with reasonable policy” and that “they should come up with what they actually believe and support and stand for.” [Twitter/X, 3/7/24 , 2/27/24 ]

In a February statement posted to its website, Americans United for Life praised Sen. Cindy Hyde-Smith (R-MS) for blocking legislation that would protect the right to reproductive treatments. The statement claimed that “embryonic children are typically treated as property rather than persons” and that there is a “near-total lack of patient health and safety regulations and meaningful regulatory oversight” in the IVF industry. [Americans United for Life, 2/28/24 ]

Chief legal counsel for AUL Steve Aden spoke with The Washington Post, criticizing Trump’s statement about IVF treatments and stating that “the ethical approach to IVF is to ensure that human lives are not wantonly created and destroyed in the process.” The Post also highlights the “model legislation to limit the number of embryos created per IVF cycle” that AUL previously drafted. [The Washington Post, 2/24/24 ]

In 2022, Aden compared IVF treatments to “eugenics,” telling The Guardian he considers “most” kinds of IVF “untenable in a culture that respects all human life.” [The Guardian, 5/12/22 ]

In a piece on the Association of Mature American Citizens Action website, author John Moor suggested giving the Alabama Supreme Court credit for “having the courage” to make the ruling limiting IVF. He went on to compare a “preborn child” to people who “fall under a government protected characteristic,” claiming the government protects individuals from discrimination “based on age, mental capacity and appearance like skin color” and therefore should protect embryos as well. [AMAC Action, 3/18/24 ]

On Instagram, the California Family Council claimed, “By the numbers the IVF Industry is responsible for the loss of more embryonic life every year than the abortion industry.” [Instagram, 3/6/24 ]

In a statement on its website, the CFC claimed there are “grave moral concerns inherent to IVF,” and, “We cannot ignore the plight of our embryonic brothers and sisters.” The statement heavily doubled down on the idea that embryos are humans and advocated for the adoption of laws like those regulating IVF in Louisiana and countries like Germany, Italy, France, Poland, New Zealand, and Australia. [California Family Council, 3/8/24 ]

In 2023, CFC attacked a California bill it claimed “would require employers to provide insurance plans that cover all nonexperimental fertility treatments, including … for a surrogate hired by any couple or single person.” The CFC statement criticized the bill for expanding fertility treatments to include LGBTQ families, stating, “Children have the natural right to their biological father and mother, and they suffer tremendously in every area of life when this right is infringed upon.” [California Family Council, 6/19/23 ]

Valerie Bynog, a legislative strategist for Concerned Women for America Legislative Action Committee, wrote in a blog on the organization’s website, “An embryo … is a living being.” Bynog criticized the American IVF industry for not having laws like “many European countries” that have “common sense regulations” around IVF. [Concerned Women for America, 2/29/24 ]

Discovery Institute Chair and Senior Fellow Wesley J. Smith wrote in 2017 that IVF is lacking the “moralistic restriction” of only being used by infertile married couples, and referred to the treatment as “positive eugenics.” [Discovery Institute, 10/27/17 ]

Smith previously wrote in 2013 that IVF opens the door for “polyamorous threesomes or lesbian couples” to have children and claimed it must be stopped. He also claimed, “We already know that children born via IVF have poorer health outcomes than children conceived naturally,” and compared IVF treatments to cloning animals. [Discovery Institute, 9/26/13 ]

In a statement on its website, Eagle Forum claimed, “Other states and countries are performing IVF in ethical ways,” referencing Louisiana and European countries, and claimed Louisiana’s IVF regulations “clearly haven’t deterred fertility clinics.” The statement attacked Sen. Tammy Duckworth’s (D-IL) Access to Family Building Act, saying it expands reproductive protections too widely to include “not only IVF, but cloning, gene editing, experimentation on embryos, commercial surrogacy, ‘designer babies’, and more,” and that it removes “religious conscience protections” around IVF. [Eagle Forum, 2/29/24 ]

Appearing as a guest on a Facebook live panel hosted by the American Family Association, Eagle Forum executive director Becky Gerritson claimed the Alabama ruling “did not stop IVF, it did not regulate IVF” and told the panel that Eagle Forum is “promoting and pushing” more regulation of the IVF industry. [Facebook, American Family Association Action, 3/1/24 ] 

The Ethics and Public Policy Center published a piece on its website by fellow Patrick Brown in which he claimed that Republicans are making “a mistake” by criticizing the Alabama ruling and called for Republicans to refuse “broad progressive legislation that would make access to IVF an ‘individual right.’” Brown pushed back on calls for IVF to be an individual right, claiming that it has “weakened” the “family as an institution,” and suggested policy that would cover IVF for only “legally married couples using their own sperm and egg.” He also called the Alabama ruling a “modest” case against IVF. [Ethics and Public Policy Center, 3/2/24 ]

EPPC President Ryan Anderson published a piece titled, “The truth about Alabama’s ruling on IVF” wherein he claimed that “the media … falsely claimed IVF was about to be banned— and Republicans fell for the claim.” Anderson’s whole piece referred to IVF embryos as “frozen embryonic children” and called IVF “morally and emotionally fraught.” [Ethics and Public Policy Center, 2/28/24 ]

EPPC fellow Andrew Walker criticized Christians and pro-life Americans for not having a stronger stance against IVF. He called IVF “morally problematic” for taking sexual intercourse out of conception, breaking a “holy and inviolable seal,” and for creating embryos that won’t be used, claiming, “In Christian language, these embryos are our neighbors.” [Ethics and Public Policy Center, 2/28/24 ]

EPPC fellow Aaron Kheriaty wrote a piece for Newsweek titled “After Alabama ruling, it's time for a serious look at the ethics of the IVF industry,” in which he claimed that “there is no morally just solution” for modern IVF treatments. [Newsweek, 2/29/24 ]

In a Family Policy Alliance podcast, Director of Public Policy Joseph Kohm stated, “Each of those fertilized embryos that are frozen is a unique human life,” before praising the Alabama Supreme Court for addressing the issue of IVF. [YouTube, 2/29/24 ]

Family Research Council President Tony Perkins told The Associated Press that the Alabama Supreme Court’s decision was “a beautiful defense of life.” [The Associated Press, 2/23/24 ]

On X, Perkins asserted that Sen. Tammy Duckworth’s (D-IL) bill protecting reproductive services was “an overreach designed to advance the Democrats’ radical, Frankensteinian agenda.” He also claimed the bill would legalize “creation of animal-human hybrids (‘chimeras’)” and “trafficking and destruction of human embryos.” In a later post, Perkins pushed for more “IVF safeguards.” [Twitter/X, 2/28/24 , 2/28/24 ] 

On his podcast, Washington Watch, Perkins claimed Duckworth’s bill “raises numerous moral and bioethical issues that go far beyond ensuring the IVF issue” and again claimed it would allow the creation of human-animal hybrids. [YouTube, Washington Watch, 2/28/24 ]

On the Independent Women’s Forum’s She Thinks Podcast, Natural Womanhood editor Grace Emily Stark argued that “all across the board people, even medical professionals, have this really inflated idea of how successful IVF is that does not match reality.” [Independent Women’s Forum, She Thinks Podcast , 2/17/23 ]

On the High Noon podcast, IWF senior fellow Emily Jashinsky argued, “The pro-life movement should lead with the reality that there is a way for IVF to be done ethically where you’re not discarding embryos.” Later, host Inez Stepman asked: “Do we really want to live in a world where we’re eugenically selecting babies, where we are commodifying the act of pregnancy?” [Independent Women’s Forum, High Noon , 2/28/24 ] 

IWF cross-posted an article originally written for Fox News by IWF visiting fellow Emma Waters, warning that “AI will fuel disturbing ‘build-a-child’ industry.” Waters claimed: “Seventy-five percent of IVF clinics in the U.S. offer genetic testing. This allows parents to create multiple embryos and select the one that matches their preferred sex and eye, hair, and skin color.” She added: “They can also gauge if a child will develop certain health problems. In one controversial case, deaf parents tried to create a child who would inherit their deafness. Of course, clinics destroy the unwanted embryos.” [Independent Women’s Forum, 8/4/23 ]

In a Q&A post on the Dobson Digital Library, James Dobson declared that he is “strongly opposed to the practice of creating fertilized eggs from ‘donors’ outside the immediate family (this would include the donation of sperm or eggs from a brother or sister of the husband and wife wishing to conceive),” because such activity would be to “play God.”  Dobson added that IVF is “less problematic” if “all the fertilized eggs are inserted into the uterus (i.e., no ova are wasted or disposed of after fertilization.” He also argued that implanting an already existing frozen embryo is akin to “adoption.” [Dobson Digital Library, accessed 4/2/24 ]

Liberty University posted a summary of a law school panel discussion on reproductive rights after the Dobbs decision, highlighting comments from The Justice Foundation’s Allan Parker on “how to advance that victory [Dobbs] by abolishing in vitro fertilization to protect frozen eggs that have already been fertilized, which he explained is an expansion of the idea that life begins at conception.” Parker said: “I think we need more scholarly research and more public education (on this topic) before the Supreme Court is willing to accept the argument that the right to life under the constitution protects life from the moment of conception.” He added, “It takes time to change culture. But we need to do the historical research, get the education about it to where the judges, based on the appropriate case with the appropriate evidence, will be comfortable making that judicial determination.” [Liberty University, 2/14/24 ]

Media Research Center’s Tierin-Rose Mandelburg responded to the Alabama Supreme Court decision in a blog post, writing, “This is a good thing. Regardless of whether a child is conceived naturally or by artificial implantation, that child has value and has sanctity and deserves to be treated as such. Throwing embryos away should be considered murder, as, now in Alabama, it is.” Mandelburg’s blog began with the line, “Sweet Home Alabama just got even sweeter for babies.” [NewsBusters, 2/19/24 ]

Media Research Center’s Jorge Bonilla argued that the mainstream media’s response to Alabama’s ruling was disingenuous and simply a cover to advocate for abortion rights, writing, “The panic point for the media is the Court’s grant of personhood to human embryos.” “Such a finding, were it to be upheld by the United States Supreme Court, drives a dagger into efforts to codify Roe,” he continued. He later added: “Personhood, even if not uttered out loud, is the whole ball game and the media know it. It’s hard to imagine the liberal media caring too much about IVF except that these stories enable advocacy for a Roe restoration. Personhood gets in the way of that.” [NewsBusters, 2/23/24 ]

Similar to the Heritage Foundation, the Mississippi Center for Public Policy argued more than a decade ago in support of a proposed “personhood amendment” to the state’s constitution, claiming it was “unlikely” to “be used to justify a ban on in vitro fertilization (IVF).” MCPP added: “IVF procedures can be performed without destroying human embryos, and therefore would still be permissible under Initiative 26. As is currently being done in many cases, any excess embryos not implanted in the womb could be frozen and implanted later or adopted out to other parents.” [Mississippi Center for Public Policy, 11/3/11 ]

Students for Life of America argued that a “consistent, intellectually-honest stance holds that human life begins at conception/fertilization,” and views discarding embryos as “a human rights violation,” claiming that the current process of IVF encourages “targeted killing” based on “undesirable traits” and “leads to eugenics.” [Students for Life of America, 1/27/22 , 4/21/22 , 2/23/24 ]

In a blog post, Students for Life of America prepared supporters to discuss IVF by raising the argument that “more die from IVF than abortion.” [Students for Life America, 2/23/24 ]

Susan B. Anthony Pro-Life America has advocated against federal bills drafted to protect IVF after the Alabama ruling. SBA Pro-Life America argued against Rep. Nancy Mace’s (R-SC) non-binding resolution that states “strong support” for IVF, arguing that it “leaves no room for reasonable laws like the one in Louisiana that for decades has protected human embryos while also allowing IVF.” The organization also heavily criticized Sen. Tammy Duckworth’s (D-IL) bill, saying it “would even codify a right to human cloning and genetic engineering of human embryos.” [Susan B. Anthony Pro-Life America, 2/28/24 , POLITICO, 2/27/24 ]

Turning Point USA’s Alex Clark, who frequently criticizes fertility care and birth control, has written about her changing stance on IVF, concluding in 2022 that IVF is not “really any different than an early abortion.” [Turning Point USA, 8/11/22 , 8/29/22 ; Media Matters, 6/11/23 , 2/14/23 ]