JAMIE M. SOMMER, JOHN M. SHANDRA, MICHAEL RESTIVO AND HOLLY E. REED
Department of Political Science, Stockholm University; Department of Sociology, State University of
New York at Stony Brook; Department of Sociology, State University of New York at Geneseo; Department of
Sociology, Queens College, City University of New York
Email: jamie.sommer@statsvet.su.se, Email: john.shandra@stonybrook.edu, Email: restivom@geneseo.edu,
Email: holly.reed@qc.queens.edu
The African Development Bank, Organized Hypocrisy,
and Maternal Mortality
A Cross-National Analysis of Sub-Saharan Africa
ABSTRACT We draw on the theory of organized hypocrisy and examine how different forms of lending by
the African Development Bank affect maternal mortality in Sub-Saharan Africa. We do so by using a two-way
fixed effects model for a sample of 33 Sub-Saharan African nations from 1990 to 2010. We find that the bank’s
structural adjustment lending in the health sector is associated with increased maternal mortality, and its repro-
ductive health investment lending is associated with decreased maternal mortality, consistent with the orga-
nized hypocrisy approach. These findings remain stable and consistent even when controlling for World Bank
lending and other relevant control variables. We conclude by discussing the implications of these findings for
global health and development. KEYWORDS maternal mortality, cross-national, African Development Bank
INTRODUCTION
The United Nations () estimates that women die during pregnancy each year for
every , live births in Sub-Saharan Africa—the region with the highest maternal
mortality globally. Maternal mortality has important regional, social, and individual conse-
quences. At the individual level, children who lose their mother during childbirth are more
likely to experience stunting and wasting (Ainsworth and Semali ). They are also more
likely to die before the age of five. If such a child survives beyond five years of age, then they
are less likely to be enrolled in school and more likely drop out if enrolled (Foster and
Williamson ). This pattern is more pronounced for girls because they are responsible
for the majority of household labor (Burroway ).
These adverse consequences have led sociologists interested in health to examine the
causes of maternal mortality. One line of inquiry stresses the role multilateral financial
institutions may play in this process—see Thomson, Stubbs, and Kentikelenis () for an
overview. Coburn et al. () use the theory of organized hypocrisy to argue that the
World Bank engages in contradictory lending practices, which have different impacts on
maternal mortality. The authors find support for the theory in World Bank structural ad-
justment loans being related to increased maternal mortality, while its reproductive health
investment lending corresponds to less maternal mortality.
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31
, TABLE 1. Trends in Maternal Mortality and African Development Bank Health
and Adjustment Lending
1990 1995 2000 2005 2010
Maternal mortality ratio n/a 696.65 639.25 557.88 467.65
AfDB structural adjustment lending 18.01 9.76 1.32 5.43 n/a
AfDB reproductive health lending 0.66 5.31 0.59 1.17 n/a
Notes:
1. Maternal mortality is deaths per 100,000 live births.
2. Lending is USD per capita.
3. Maternal mortality data from United Nations (2016).
4. Lending data from AidData (2016).
This line of research serves as the starting point for our study. However, we extend
the research frontier in a novel way. We apply the theory of organized hypocrisy to the
African Development Bank (AfDB), the regional lender, and carry out the first empiri-
cal evaluation of how its lending affects maternal mortality. The lack of research on the
AfDB is surprising because it plays an important role in the region. The AfDB was es-
tablished in by African nations and provides Sub-Saharan African nations with
structural adjustment loans designed to help nations resolve balance-of-payment issues
by requiring the borrowing government to implement macroeconomic policy reforms.
These are quite similar to the World Bank’s offerings, which, require cuts to public
health spending, user fees, privatization, and trade liberalization (Babb ). The
AfDB’s investment lending funds reproductive health projects such as maternity-ward
construction, obstetrics training, family planning campaigns, and drug and equipment
purchases, which may decrease maternal mortality (AfDB ).
In Table , we report trends in maternal mortality from to along with
AfDB structural adjustment and reproductive health investment lending from to
. Maternal mortality declined during the period, from a high of women dying
during childbirth per , live births in to a low of in . AfDB struc-
tural adjustment lending peaked in , which is not surprising as Sub-Saharan African
nations were emerging from the debt crisis—see below. AfDB reproductive health lend-
ing peaked in . AfDB structural adjustment lending outpaced its reproductive in-
vestment lending in this period.
Do AfDB lending instruments have contradictory impacts on maternal mortality?
We seek to address this important question in the cross-national literature. We begin
with a discussion of the theory of organized hypocrisy, which describes why organiza-
tions put contradictory policies in place. We then apply it to the AfDB. To empirically
assess our hypotheses, we describe the data and variables we use in our analysis, provide
an account of our methodology, and review the findings. We conclude this article by
summarizing the findings and highlighting their theoretical and methodological impli-
cations, and then offering policy recommendations and potential directions for future
research.
32 SOCIOLOGY OF DEVELOPMENT SPRING 2019
, THE THEORY OF ORGANIZED HYPOCRISY
The theory of organized hypocrisy, which can be traced to Brunsson (), has been used by
organizational sociologists to explain why institutions pursue contradictory agendas or display
a gap between their “talk” and their “actions.” While Brunsson () was the first to theorize
the concept, Brunsson and Olsen () went on to apply the theory to organizational reform.
The theory draws on the literatures of institutionalism and resource dependency. Any organi-
zation depends on its external environment for financial support and legitimacy (Weaver
). However, external constraints in the institutional environment that do not align with
the organization’s internal goals can create conflicting demands on the organization (Brunsson
). Organizations must be responsive to external demands to survive, while satisfying inter-
nal institutional mandates—and these two factors come together to bring about change.
Another source of conflict may emerge for an organization when external pressures exerted
on it are constituted by “inconsistent expectations” (Weaver ). Weaver (:) writes,
“If the nature of the dependency is such that organizations must placate multiple masters to
attain needed material resources and conferred legitimacy, neither acquiescence nor defiance
is a viable option.” Rather, as Oliver (:) contends, the most likely response involves an
organization implementing “rules, guidelines, and procedures” that allow it to incorporate the
inconsistent expectations into its operations and thereby “exhibit conformity with external
demands.” This “hypocrisy” takes the form of incorporating contradictory mandates into its
organizational structure, or what has been described as “paradigm maintenance” (Wade ).
Research on organized hypocrisy tends to focus on corporations and governments—
see Brunsson and Olsen (), Oliver (), or Barnett and Coleman (). Weaver
() demonstrates how organized hypocrisy plays out at the World Bank. The author
argues that organized hypocrisy theory is ideal to apply to the World Bank because the
bank must act in a way “that reflects not only the interests of those that provide critical
material resources but also prevailing international ideals and norms in the broader
global development regime” ().
Weaver describes how external pressure is exerted on the World Bank from private capital
markets and the U.S. Treasury, which provide it funding. Thus, it pursues a “finance ministry
agenda” by providing nations with structural adjustment and other development policy loans,
which favor export-led growth, privatization, and trade liberalization (Wade ). These
policies open a borrowing nation’s economy to investment by companies from wealthy donor
countries. In return, the World Bank receives money during periods of capital replenishment
from the U.S. Treasury and maintains a high bond rating from creditors (Weaver ).
The World Bank is also pressured to be deferential to issues raised by U.N. agencies,
NGOs, and lawmakers of donor governments, who appropriate funding and are concerned
with social issues (Weaver ). These actors push the World Bank to adopt a “civil soci-
ety agenda” that takes the form of investment lending for projects in sectors including
health, education, environment, and gender (Weaver ). The World Bank integrates
project lending of this sort to ensure that funding is allocated by legislators and to maintain
legitimacy on the international stage (Wade ).
The World Bank provides borrowing nations with structural adjustment and investment
loans that can affect a country in different ways. Weaver (:) writes, “The World Bank,
Sommer et al. | The African Development Bank, Organized Hypocrisy, and Maternal Mortality 33
