COMMENT ON GOLDSTEIN, ZIVIN, AND THIRUMURTHY
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Issues of corruption, of waste, and of favoritism of treatment that would likely have to be dealt with in a publicly run system may not have to be considered for AMPATH, or at least to a much smaller degree. Presumably, it is much easier for AMPATH to staff the system with high-quality medical staff than it would be for the government. To illustrate the problem, during my recent visit to a hospital very much like the AMPATH system in rural southeastern Uganda, a manager explained that a key difficulty was in attracting high-quality medical staff, even though the hospital was private and foreign run. One reason was that the area was so isolated. The hospital had set up and was supplying free satellite Internet access for staff, to make living in that area more agreeable. In this regard AMPATH may have some advantages because population densities are higher in rural Kenya than in other parts of rural Sub-Saharan Africa and there are towns and cities in the area that offer some amenities. The ability of AMPATH to deliver services and attain high rates of proper intakes of medicine may be high. (It is claimed to be more than 80 percent, but the data on which that claim is based are not absolutely accurate.) Whether a publicly run system would be able to achieve the same level is unclear. If not, then of course the worries about emerging ARV-resistant types of HIV would be at issue. These private-public distinctions are important because where delivery is in private or nongovernmental organization hands, as with AMPATH, the full costs are undoubtedly far higher than they would be under a public system. It is highly doubtful that the authors have data on all the costs, many of which would originate in Bloomington, Indiana. As an aside, in the case of the Ugandan hospital I visited, 100 percent of capital costs and more than 80 percent of operating costs, including all the costs of the ARV drugs, were borne by foreign sources. Continued foreign aid is certainly essential to the sustainability of AMPATH-like centers. Concerning the evaluation of the social benefits and costs of ARV, the best discussion is still found in the World Bank report Confronting AIDS (World Bank 1997). Although the costs of ARV have dropped phenomenally since 1997, when Confronting AIDS was published, the economic arguments contained in that volume are still the starting place for any serious economic evaluation of the trade-offs involved. Nevertheless, Goldstein, Graff Zivin, and Thirumurthy have made an essential contribution to the evaluation of ARV treatment. As noted, the analysis is not complete as a benefit-cost study or as an assessment of the ability to scale up this intervention and pass a benefit-cost test. The study does, however, raise interesting and valuable issues of the pricing of ARV treatment and thus of the ability to perhaps reach many more HIV-infected patients than might have been thought possible.
References Glick, Peter. 2005. “Scaling Up HIV Voluntary Counseling and Testing in Africa: What Can Evaluation Studies Tell Us about Potential Prevention Impacts?” Evaluation Review 29 (4): 331–57.