Good points. Agree that “always go for a big push instead of incrementalism” is waaayyyy too simple and sweeping a lesson to draw from PEPFAR. Also, three cheers for not lying. I think the World Bank was right not to suppress its data on the low cost-effectiveness of ARV drugs circa the mid-2000s. But in retrospect, I think people drew bad policy conclusions from that data.
My piece above is largely a plea for a little bit of intellectual humility and introspection on the part of the cost-effectiveness crowd (of which I’m often an active participant). If we find our analytical framework leads us to oppose the core of PEPFAR (i.e., the distribution of free ARVs in poor countries), then we ought—in the face of its historic achievements—to pause and reflect a bit, rather than shrugging and insisting “yeah, but I could’ve done better.”
Your first paragraph gets at one reason why I think that kind of confidence isn’t credible. Successful trials don’t automatically translate into successful national or multi-national, multi-billion dollar programs. So we should be more skeptical that something that scored higher on cost-effectiveness terms ex ante would’ve converted into a massive global policy win. I genuinely don’t think cost-effectiveness analysis, at least as practiced in global development/global health, really takes those questions of ‘scalability’ and implementation feasibility seriously enough. As a result, we confuse stuff that really could be done a million times over if money was available with stuff that looks cheap but faces much deeper political and organizational hurdles.
When we find something that works and really can scale with an influx of cash, we should run with it. With the benefit of hindsight, PEPFAR seems to fit that description. And, coincidentally, setting aside broader philosophical debates to stick with this concrete case, PEPFAR happens to be up for reauthorization in congress this year...
I noticed that much of the political tractability discussion has focussed on counterfactuals involving other diseases (e.g. malaria) but I’m more confused why the government prioritised treatment over prevention.
Oster’s article argued that prevention would be a better bet than treatment and that was written in 2005 when Congress had approved the budget and the prices of the drugs had come down. You also highlight the importance of, “the evidence from those who had worked in the field that antiretroviral drugs and preventive measures could be deployed effectively and at reasonable cost, even in very poor settings”. (emphasis added)
So both options had evidence of feasibility and efficacy, the money was already there, and it seems like, at that time, they didn’t know which option would scale better or get cheaper quicker.
I’m struggling to see what Oster got wrong. Was the decision to prioritise treatment over prevention mostly driven by the emotional appeal of the ‘Lazarus effect’?
Good points. Agree that “always go for a big push instead of incrementalism” is waaayyyy too simple and sweeping a lesson to draw from PEPFAR. Also, three cheers for not lying. I think the World Bank was right not to suppress its data on the low cost-effectiveness of ARV drugs circa the mid-2000s. But in retrospect, I think people drew bad policy conclusions from that data.
My piece above is largely a plea for a little bit of intellectual humility and introspection on the part of the cost-effectiveness crowd (of which I’m often an active participant). If we find our analytical framework leads us to oppose the core of PEPFAR (i.e., the distribution of free ARVs in poor countries), then we ought—in the face of its historic achievements—to pause and reflect a bit, rather than shrugging and insisting “yeah, but I could’ve done better.”
Your first paragraph gets at one reason why I think that kind of confidence isn’t credible. Successful trials don’t automatically translate into successful national or multi-national, multi-billion dollar programs. So we should be more skeptical that something that scored higher on cost-effectiveness terms ex ante would’ve converted into a massive global policy win. I genuinely don’t think cost-effectiveness analysis, at least as practiced in global development/global health, really takes those questions of ‘scalability’ and implementation feasibility seriously enough. As a result, we confuse stuff that really could be done a million times over if money was available with stuff that looks cheap but faces much deeper political and organizational hurdles.
When we find something that works and really can scale with an influx of cash, we should run with it. With the benefit of hindsight, PEPFAR seems to fit that description. And, coincidentally, setting aside broader philosophical debates to stick with this concrete case, PEPFAR happens to be up for reauthorization in congress this year...
I noticed that much of the political tractability discussion has focussed on counterfactuals involving other diseases (e.g. malaria) but I’m more confused why the government prioritised treatment over prevention.
Oster’s article argued that prevention would be a better bet than treatment and that was written in 2005 when Congress had approved the budget and the prices of the drugs had come down. You also highlight the importance of, “the evidence from those who had worked in the field that antiretroviral drugs and preventive measures could be deployed effectively and at reasonable cost, even in very poor settings”. (emphasis added)
So both options had evidence of feasibility and efficacy, the money was already there, and it seems like, at that time, they didn’t know which option would scale better or get cheaper quicker.
I’m struggling to see what Oster got wrong. Was the decision to prioritise treatment over prevention mostly driven by the emotional appeal of the ‘Lazarus effect’?