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31. Making Markets for Merit Goods: The Political Economy of Antiretrovirals

Author:
Ethan Kapstein and Josh Busby
Publication Date:
08-2009
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
This paper examines the role of policy entrepreneurs and global activists in shaping the international market for antiretroviral drugs to combat HIV/AIDS. When ARVs first came on the market in the 1990s they were exceedingly expensive; the cost of treatment was upwards of $10,000 per year. These drugs were thus accessible only to those patients who had high incomes. But in 2006, the “international community,” meeting at a United Nations General Assembly Special Session (UNGASS), made an astonishing pledge to those who were infected with HIV. It proclaimed that there should be universal access to ARV treatment. This UNGASS, following up on an earlier historic UN special session devoted entirely to AIDS in 2001, marked the first time in history that the international community pledged itself to chronic care for the ill, which in this case includes the approximately 30 million people around the world estimated to be HIV positive. How do we explain the transformation of ARVs from private goods, which only a few could afford, into merit goods that were (at least declaratively) to be made available to everyone? In other words, how does a norm of “universal access to treatment”—that no person should be denied these life-extending drugs—become the ethical basis for global public policy with respect to pharmaceutical allocation? What are the lessons of the ARV story for other global issues? These are the primary questions we explore in this paper. Briefly, we argue that the policy entrepreneurs and activists who promoted the creation of a universal access to treatment regime—of the transformation of ARVs into global merit goods—relied on a combination of moral arguments and ideas with favorable material circumstances. From the ethical perspective, the task of these entrepreneurs was to convince the “international community” that access to ARVs was a “human right,” or conversely to convince decision-makers that it was morally wrong to allocate these life-enhancing drugs solely on the basis of ability to pay. But from a material standpoint, these arguments were greatly facilitated by the lowering prices of ARVs caused by a combination of differential pricing (that is, lower prices for drugs in the developing world than in the advanced welfare states) and competition from generics producers, coupled with increases in foreign aid spending devoted to HIV/AIDS and other diseases.
Topic:
Health, Human Welfare, Humanitarian Aid, and Political Economy

32. Performance Incentives for Global Health: Potential and Pitfalls

Author:
Rena Eichler and Ruth Levine
Publication Date:
05-2009
Content Type:
Policy Brief
Institution:
Center for Global Development
Abstract:
Global health donors, like national governments, have traditionally paid for inputs such as doctors' salaries or medical equipment in the hope that they would lead to better health. Performance incentives offered to health workers, facility managers, or patients turn the equation on its head: they start with the performance targets and let those most directly affected decide how to achieve them. Funders pay (in money or in kind) when health providers or patients reach specified goals. Evidence shows that such incentives can work in a variety of settings. But making them effective requires careful planning, implementation, and monitoring and evaluation.
Topic:
Health, Humanitarian Aid, Third World, and Foreign Aid

33. Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It - Working Paper 144

Author:
Mead Over
Publication Date:
05-2008
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
U.S. global AIDS spending is helping to prolong the lives of more than a million people and is widely seen as a foreign policy and humanitarian success. Yet this success contains the seeds of a future crisis. Life-long treatment costs are increasing as those on treatment live longer, and the number of new HIV infections continues to outpace the number of people receiving treatment. Escalating treatment costs coupled with neglected prevention measures threaten to squeeze out U.S. spending on other global health needs, even to the point of consuming half of the entire U.S. foreign assistance budget by 2016.
Topic:
Foreign Policy and Humanitarian Aid
Political Geography:
Africa and United States

34. Through the Looking-Glass, and What OLS Found There: On Growth, Foreign Aid, and Reverse Causality

Author:
David Roodman
Publication Date:
01-2008
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
The cross-country literature on foreign aid effectiveness has relied on the use of instruments to distinguish causality from mere correlation. This paper uses simple non-instrumental techniques in the spirit of Granger to demonstrate that the main aid-growth connection is a negative causal relationship from growth to aid—aid, that is, as a fraction of recipient GDP. Coarsely, when GDP goes up, aid/GDP goes down. The endogeneity of aid, long-suspected, is real. Less understood is that adding certain common controls to regressions puts this relationship through the looking-glass, flipping both its sign and apparent direction: aid seems to cause growth. Ideally, instrumentation expunges the endogeneity shown here. In practice, estimates of aid's impact have run into problems. Autocorrelation in the errors is widespread, and can render endogenous lagged variables used as regressors or instruments. The pitfalls of “difference” and “system” include invalidity and proliferation of instruments. Multicollinearity in term pairs of interest, such as aid and aid or “project” and “program” aid, can amplify endogeneity bias. The combination of specification problems and widespread fragility (shown in earlier work) leads to pessimism about the ability of cross-country econometrics to demonstrate aid effectiveness. This does not rule an average positive effect, nor does it contradict the fact that aid has saved millions of lives, but it does suggest that the average effect on economic growth is too small to be detected statistically.
Topic:
Economics, Humanitarian Aid, and International Political Economy

35. Inexcusable Absence: Why 60 Million Girls Still Aren't in School and What to do About It

Author:
Marlaine Lockheed and Maureen Lewis
Publication Date:
04-2007
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
The images of girls returning to school in Afghanistan after the fall of the Taliban drew attention to the lack of educational opportunities for girls all too common in many developing countries. Girls' education is indisputably crucial to development, and the development community has worked hard to get more of them into school. The result: since 1960, there have been remarkable increases in primary school enrollment rates for both boys and girls in developing countries. In most countries, girls' participation has converged with that of boys, bringing gender equity to the educational systems of many poor countries. But the international community has largely overlooked a key issue: that out of the remaining 60 million girls ages 6-11 still not in school, 70 percent belong to socially excluded groups.
Topic:
International Relations, Education, Gender Issues, and Humanitarian Aid
Political Geography:
Afghanistan and Taliban

36. Cost-Effective Prevention of Diarrheal Diseases: A Critical Review

Author:
Michael Kremer and Alix Peterson Zwane
Publication Date:
04-2007
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
This paper critically reviews the existing research on the cost-effective prevention and treatment of diarrheal diseases, and identifies research priorities in this area aimed at finding ways to reduce the diarrheal disease burden. In contrast to the empirical knowledge base that exists for traditional child health programs to reduce diarrheal morbidity and mortality, evidence on the relative effectiveness and cost-effectiveness of various environmental health interventions is limited and subject to significant methodological concerns. There is a limited understanding of the determinants of long-term water and sanitation technology adoption and behavior change at the individual level. Even less is known about how collective action problems in water and sanitation infrastructure maintenance can be overcome. An agenda for future research includes evaluating alternative transmission interruption mechanisms, improving understanding of the determinants of individual-level technology adoption in the water and sanitation sector, and assessing the quality of infrastructure maintenance under different management schemes.
Topic:
Health, Human Welfare, Humanitarian Aid, and Poverty

37. Income Distribution: Effects on Growth and Development

Author:
Nancy Birdsall
Publication Date:
04-2007
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
I review the literature on the effects of inequality on growth and development in the developing world. Two stylized facts emerge from empirical studies: inequality is more likely to harm growth in countries at low levels of income (below about $3200 per capita in 2000 dollars); and it is at high levels of inequality (at or above a Gini coefficient of .45) that a negative association emerges. Between 15 and 40 percent of the developing world's population lives in countries with these characteristics, depending on the inclusion of China, whose level of inequality has recently been measured at almost .45. Theory and evidence suggest that high inequality affects growth: (1) through interaction with incomplete and underdeveloped markets for capital and information; (2) by discouraging the evolution of the economic and political institutions associated with accountable government (which in turn enable a market environment conducive to investment and growth); and (3) by undermining the civic and social life that sustains effective collective decision-making.
Topic:
Development, Humanitarian Aid, Political Economy, and Poverty
Political Geography:
China

38. Performance-based Incentives for Health: Demand- and Supply-Side Incentives in the Nicaraguan Red de Protección Social

Author:
Ferdinando Regalía and Leslie Castro
Publication Date:
04-2007
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
Nicaragua's Red de Protección Social (RPS) is one of the first conditional cash transfer (CCT) programs implemented in a low-income country. Demand-side incentives, in the form of monetary transfers, are provided to poor households on condition that their children attend school and visit preventive health care providers. The design of the program is unique among CCT programs because these demand-side incentives are complemented by supply-side incentives aimed at improving the provision of health care. Health care providers are paid on the basis of their performance against predetermined targets. Both private and nonprofit health care providers contracted by the government extend the coverage of services to previously underserved areas.
Topic:
Development, Health, and Humanitarian Aid
Political Geography:
Latin America

39. Performance-Based Incentives for Health: Conditional Cash Transfer Programs in Latin America and the Caribbean

Author:
Amanda Glassman, Jessica Todd, and Marie Gaarder
Publication Date:
04-2007
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
In order to support poor families in the developing world to seek and use health care, a multi-pronged strategy is needed on both the supply and the demand side of health care. A demand-side program called Conditional Cash Transfers (CCTs) strives to reduce poverty and also increase food consumption, school attendance, and use of preventive health care. Since 1997, seven countries in Latin America have implemented and evaluated CCT programs with health and nutrition components. The core of the program is based on encouraging poor mothers to seek preventive health services and attend health education talks by providing a cash incentive for their healthy behavior (with healthy behavior representing performance). Evaluations of these programs measured outputs in the utilization of services; health knowledge, attitudes, and practice; food consumption; the supply and quality of services; as well as outcomes in vaccination rates; nutritional status; morbidity; mortality; and fertility.
Topic:
Development, Health, and Humanitarian Aid
Political Geography:
Latin America

40. Performance-Based Incentives for Health: Six Years of Results from Supply-Side Programs in Haiti

Author:
Amanda Glassman, Jessica Todd, and Marie Gaarder
Publication Date:
04-2007
Content Type:
Working Paper
Institution:
Center for Global Development
Abstract:
USAID launched a project in 1995 to deliver basic health services in Haiti. The project began by reimbursing contracted NGOs for documented expenditures or inputs. In 1999, payment was changed to being based partly on attaining performance targets or outputs. The project also provided technical assistance to the NGOs, along with opportunities to participate in an NGO network and other cross-fertilization activities. Remarkable improvements in key health indicators have been achieved in the six years since payment for performance was phased in. Although it is difficult to isolate the effects of performance-based payment on these improved indicators from the efforts aimed at strengthening NGOs and other factors, panel regression results suggest that the new payment incentives were responsible for considerable improvements in both immunization coverage and attended deliveries. Results for prenatal and postnatal care were less significant, perhaps suggesting a strong patient behavioral element that is not under the influence of provider actions.
Topic:
Development, Health, and Humanitarian Aid
Political Geography:
Caribbean and Haiti