EA - Did Economists Really Get Africa's AIDS Epidemic "Analytically Wrong"? (A Reply) by TomDrake

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Did Economists Really Get Africa's AIDS Epidemic "Analytically Wrong"? (A Reply), published by TomDrake on August 30, 2023 on The Effective Altruism Forum.To demonstrate CGD's cherished principle of not taking organisation positions, here is a response from a couple of us in the health team to our colleague Justin Sandefur's recent(ish) blog on cost-effectiveness evidence and PEPFAR.Our concern was that readers might come away from Justin's blog thinking that cost-effectiveness evidence wasn't useful in the original PEPFAR decision and wouldn't be useful in similar decisions about major global health initiatives. We disagree and wanted to make the case for cost-effectiveness as well as addressing some of Justin's specific points along the way.A recent, thought-provoking blog by our colleague, Justin Sandefur, titled "How Economists got Africa's AIDS Epidemic Wrong", has sparked a debate about the historical role of cost-effectiveness analysis in assessing the investments of the President's Emergency Plan for AIDS Relief (PEPFAR) and, implicitly, the value of such analysis in making similar global health decisions. Justin tells the story of PEPFAR and concludes that economists that raised concerns over the cost-effectiveness of antiretroviral therapies got PEPFAR "analytically wrong", a conclusion that some readers may interpret as a reason to discard cost-effectiveness analysis for such decisions in the future. The original blog draws three lessons:Lesson #1. What persuaded the White House was evidence of feasibility and efficacy, not cost-effectivenessLesson #2. The budget constraint wasn't fixed; PEPFAR unlocked new moneyLesson #3. Prices also weren't fixed, and PEPFAR may have helped bring them downIn this blog we argue that while Justin's observations hold some truth, they do not discredit the value of cost-effectiveness analysis in decision-making. Specifically, we contend that:Because there were many feasible and effective options at the time, this was not sufficient criteria for such a large decision. It should have considered the cost-effectiveness of other options, to explore the relative impact.PEPFAR may have unlocked some new money, but it wasn't all new money, and it will have had short- and long-term opportunity costs. Moreover we cannot be certain that PEPFAR was uniquely able to increase available funding. Thus the decision could have considered cost-effectiveness analysis to reveal likely trade-offs.Price reductions could have been analytically explored for PEPFAR and for alternative options as part of cost-effectiveness analysis during decision-making.The bigger lesson, we conclude, is that when the next PEPFAR-sized decision happens, our systems and their stakeholders must strive for higher standards, embracing analysis that models a range of good options and assesses them against key criteria. Cost-effectiveness analysis is a necessary component of this, but it is not sufficient, and additional analysis and scenarios should be considered through a deliberative process, before settling on a final decision.Below we offer reflections on each of Justin's three lessons, in order, then draw out the overall conclusions.Response 1: Feasibility and efficacy are not enoughJustin uses an analogy of giving to a homeless person to invite the reader to agree that cost is not really the relevant issue when considering whether to do a good deed. True enough, if something can be considered not effective or not feasible then it's a non-starter and we don't need to trouble ourselves over cost or cost-effectiveness. But when there are multiple feasible and effective options with different levels of effectiveness and cost, understanding which does the most good for the money is absolutely worth knowing. Indeed we agree that there is a moral imperative to...