This is from a blog post at the Center for Global Development about a new working paper available at CGD. Sorry it’s been so long for me to post here again, but I hope to channel a few new pieces here periodically.

Our research on the political economy of antiretrovirals (ARVs) is motivated by a key puzzle: why were AIDS activists and AIDS policy entrepreneurs successful in putting universal access to treatment on the international agenda when so many other global campaigns–whether in health care or other issue areas like climate change–have either failed or struggled to have much impact. In our paper, we make the case that the market for ARVs was politically constructed, meaning that activists had to bring the demand and supply sides of the market together through a variety of tactics and strategies (Tim Bartley makes a similar argument on forest certification schemes).

Merit Goods and Market Failures. The idea that motivated the activists was that AIDS drugs should ideally be “merit goods,” meaning goods that are available to everyone regardless of income. However, when ARVs first came on the market, poor people in the developing world lacked the financial resources to buy the drugs, which were exceedingly expensive. AIDS activists successfully lobbied donor nations to use foreign aid to buy the drugs, and they pressured pharmaceutical companies to lower their prices, while encouraging generic firms to enter the market which had an even bigger impact on affordability.

How did these developments evolve into the universal access to treatment regime? We focus on three factors in this piece:

- Permissive Material Conditions. The success of this strategy was ultimately conditional upon permissive material conditions—falling ARV prices, increases in foreign aid, and a growing global economy. However, these favorable material conditions were not enough.

- A Compelling Moral Argument. The effort to extend treatment would not have happened without a compelling moral argument, which helped build broad political support for the policy.

- Convergence on a Prescription. Finally, activists were fortunate to converge on a single policy in the treatment arena. AIDS prevention policies, by contrast, have been much more politically contested and suffered accordingly (see Jeremy Shiffman’s CGD working paper for a similar argument).

Looking ahead, we worry the lack of success in AIDS prevention may compromise the treatment regime’s long-term trajectory (see Mead Over’s CGD paper for expression of similar concerns).

Lessons for Other Campaigns. We believe that activists who focus on other issue-areas, again whether in the health care space or in other domains, could learn something of importance from our research. The basic difficulty and costs of certain policies may make some problems harder to solve than others. Even where a policy enjoys favorable material conditions—low costs, large benefits, demonstrated feasibility—this may not be enough. A clear prescription and a resonant moral argument may be necessary for an issue to receive adequate political support.

In 2007, the UK surpassed the United States as the largest donor to IDA, the World Bank’s wing for the poorest countries in the world. The UK has also shouldered a disproportionate share o funding for global AIDS efforts. Should Brown be ousted in a leadership competition or if the Conservatives win, will Brown’s successor be as pro-development? Will Britain even be able to sustain its contributions at the level it has over the past decade? Donors haven’t come close to meeting their pledges of an additional $50bn per year by 2010. With advanced industrialized country economies struggling, campaigners should be worried that foreign assistance funds may subject to much greater fiscal discipline by donors and AIDS funding may be subject to donor fatigue.

Given the variety of demands from advocates, competition for those funds will likely increase, and campaigners in the public health arena need to be thinking about political priorities — sustained and/or deepened provision of ARV’s, more support for health systems, a turn towards other health priorities like maternal health and child survival, a focus on other issues like climate change and education, etc. These are critical times for the global economy and could signal a turning point in the political effectiveness of the development advocacy in coming years.

Postscript: We may be poised to be entering a global recession or at least a downturn among the world’s advanced economies. One of the most prescient and clear voices on the global economy, Nouriel Roubini, had this to say this morning in the FT:

The real economic side of this financial crisis will be a severe US recession. Financial contagion, the strong euro, falling US imports, the bursting of European housing bubbles, high oil prices and a hawkish European Central Bank will lead to a recession in the eurozone, the UK and most advanced economies.

Even if foreign assistance constitutes a small proportion of donor budgets, aid and development circles are worried their concerns are among the most vulnerable to cuts, or at the very least, stagnant budgets.

A pharmaceutical plant in Uganda this week will begin production of generic antiretroviral drugs following an order from the Ugandan
government for drugs worth 17 billion Ugandan shillings, or about $10 million, the East African Business Week reports (Etyang, East African Business Week, 1/28).

Ugandan President Yoweri Museveni in October 2007 commissioned the 15-acre pharmaceutical plant, which will produce triple-therapy combination antiretroviral and first-line malaria treatments. Ugandan pharmaceutical importer Quality Chemical Industries and Indian
pharmaceutical company Cipla will produce the drugs. The factory will manufacture the antiretroviral combination therapy Triomune, which contains lamivudine, stavudine and nevirapine. In addition, the factory will produce the first-line antimalarial combination treatment Lumartem, which contains artemisinin and lumefantrin (Kaiser Daily HIV/AIDS Report, 11/26/07)…

…According to the Business Week, about 100,000 Ugandans currently have access to no-cost antiretroviral treatment, but about
238,000 people in the country are expected to need the drugs by 2012. In 2005, about 42% of people in need of antiretrovirals had access to them, according to statistics (East African Business Week, 1/28).

One story from March 2007 reported on the new life insurance market for HIV+ residents in South Africa signaling a dramatic shift in access to HIV treatment. Interestingly, life insurance can be one requirement for securing a home mortgage.  According to the report, until recently without a life insurance policy, even well-off HIV+ individuals would have had a more difficult time trying to buy a home.

Save the Children hopes Mr. Frist will open doors, and it is still in the process of recruiting senior Democratic leaders, to make its appeal bipartisan.

“The children and mothers who die are in huts beyond the end of pathways with no direct access to political or
media leaders,” Mr. MacCormack said. “We need people who can walk into prime ministers’ and presidents’ offices.”

The children and mothers live in countries whose leaders are clearly failing them.  Their leadership, not ours alone, should be plying the wide halls of prime ministers and the fine offices of presidents.  I work in East Africa and still remember clearly the local constituent outrage over Uganda’s very public problems with the Global Fund.  Taxpaying Ugandans, as citizens anywhere, demand performance and accountability from government.  More of that grassroots, old fashioned constituent involvement is needed if external efforts are to have any lasting impact.

*Matobo was the fictional African country in The Interpreter.

This is a couple of years old but the idea resonates with more recent calls for horizontal programming to meet the wider health needs of populations with high HIV prevalence.  The CDC created the Basic Preventive Care Program, recently mentioned again in the KaiserNetwork news summary. 

In the last few years, there has
been a substantial increase in funding for HIV programmes, but how can
antiretroviral treatment be delivered in a setting where few people
have access to even the most basic health care?

“To begin to cope with providing
HIV care in this context” said Dr. Mermin “we felt that it would be
important to prevent illness as well as treat it. particularly in rural
areas where the majority of people live several kilometres from a
health centre and heath centres have only limited diagnostic and
treatment capacity.”

Rather than make people travel to
care, his team explored what types of basic care could be delivered to
people directly in their own homes, by providing people with as many of
the tools for prevention of illness as possible.

“Our goal was to develop a
standard package of evidence-based preventions that will reduce
morbidity and mortality among persons with HIV and lower the chance or
HIV transmission,” said Dr. Mermin.

Since people with HIV live within
a family and community context in rural Africa, the CDC approached
interventions through the lens of treating the whole family…

OK, so this is a bit of a public service announcement, but I just wanted to give a shout out to anyone with a computer that may be often idle.  You know you’re the one if you’ve got a slick new machine and it basically is a fancy web browser and text editor with occasional number crunching during the dissertation or that last field report … Consider donating that down time to the World Community Grid.

The World Community Grid has been operating in its current form since November 2005 (you can read about the 2005 launch in the KaiserNetwork archives).  They run a few extremely large research efforts on fundamental health science that require extremely large amounts of computer time.  You can simply visit WCG, download the secure software, and you’re done.  It runs in the background when you’re not using your machine and you contribute to research on genetics, cancer, and HIV.  Something to consider anyway. 

Global AIDS fund wants more private donor money
05 Mar 2007 16:22:21 GMT
Source: Reuters

By John Acher

OSLO,
March 5 (Reuters) – A global fund that combats AIDS, tuberculosis and
malaria hopes to attract more money from private donors, fund officials
said on Monday.

Launched in 2002 with the backing of then U.N.
Secretary-General Kofi Annan, the Global Fund to Fight AIDS,
Tuberculosis and Malaria has raised $10 billion but is looking to raise
a further $15 billion in 2008-2010.

So far about 96 percent of
the Fund’s money has come from governments, including the G8 countries,
but private sources, such as corporations, foundations and individuals,
should provide more in the future, they said.

“We have a major
effort under way to increase private financial contributions to the
Global Fund and also private contributions of other kinds,” the Fund’s
Executive Director Richard Feachem said at the start of a two-day donor
meeting.

The Fund supports 450 programmes in 136 countries.

Feachem said it was also exploring avenues for private non-financial contributions, such as donations of goods and services.

One
part of that is a “Product Red” campaign which allows consumers to give
a fraction of their monthly mobile phone bill, a percentage of a
special red American Express card bill or proceeds from goods such as a
red Armani watch to the Fund.

He said it had raised over $20 million and was growing fast.

Chairwoman
Carol Jacobs said the Fund did not have a target for funding from
private donors, but added: “Between 10 and 20 percent — I do not think
would be unreasonable.”

By far the biggest private contribution
so far is $650 million from the Bill and Melinda Gates Foundation, set
up by the Microsoft founder, Feachem said.

About $250 million of that pledge has been paid so far.

About
35 of the Fund’s 50 donor governments were expected to attend the Oslo
meeting, but pledges were not expected until a conference in Berlin in
September.