The impact of economic sanctions on health and health systems in low- and middle-income countries

Background:
Economic sanctions understood as restrictions to customary commercial and financial ties imposed by a state or group of states on a target usually a state to induce change in its political constitution or conduct pursue a variety of foreign policy goals including humanitarian objectives. Nevertheless risk assessment procedures are not customarily incorporated in the administrative machinery of sanctions and experience of past episodes suggests that there may be adverse consequences for health and health systems in targeted countries that governments and societies ought to consider when facing international disputes. In this report we review the evidence to date in terms of whether – and if so how – economic sanctions influence health and health systems in low- and middle-income countries (LMICs).

Methods:
Broad systematic searches of PubMed and Google Scholar complemented with snowballing approaches were used to retrieve English-language peer-reviewed and grey literature published from 1970 to 2021. We identified studies providing quantitative impact estimates approached them by conceptualizing sanctions as natural experiments assessed their quality according to a semi-structured risk-of-bias procedure based on the ROBINS-I bias domains and synthesized them by vote counting to test for the existence of adverse effects of sanctions on all health and health system outcomes. We then contextualized our core findings by integrating quantitative and qualitative information in a thematic narrative.

Results:
We find a considerable amount of literature covering the topic in question (185 sources) but only a comparatively small share of studies that provide quantitative analysis. Within the pool of quantitative studies 31 met our definition of supplying an impact estimate. Within the pool of these core studies only a minority explicitly address extant methodological challenges including control for relevant confounding and selection bias. Most of these studies (28) focus on health outcomes from common indicators of early-age mortality to a diverse range of diseases and sequelae. Fewer studies (10) examined health system indicators mostly in relation to access to pharmaceuticals. Excluding those with data integrity issues a significant proportion of studies (21/27) reported consistently adverse effects of sanctions across examined outcomes with no apparent association to quality focus on early (as opposed to more recent) sanction episodes or publication period. Contextualizing this evidence base in the broader literature provides important insights on the possible dimensions and mechanics of exposure producing these impacts.

Conclusions:
Estimating the impact of economic sanctions on health or health systems is a challenging task as effects can be confounded by correlated shocks and impaired and selective reporting and collection of data. A full elucidation of the impact is precluded by a lack of information about important impact components such as the legal and operational characteristics of sanctions and behavioural and policy responses by households and governments. Future research should draw on qualitative knowledge to collect domain-relevant data and combine these with better estimation techniques and study design. However only the adoption of a risk-assessment framework based on prospective data collection and monitoring can certify claims that civilians are adequately protected from the impact of sanctions.