> [!NOTE] Abstract > Why were AIDS activists successful in putting universal access to treatment on the international agenda when so many other global campaigns have either failed or struggled to have much impact? We focus on: (1) permissive material conditions; (2) convergence on a policy prescription; (3) attributes of the activists; and (4) the broad political support for their cause. In our view, the market for antiretroviral (ARV) drugs was politically constructed; activists had to bring the demand and supply sides of the market together through a variety of tactics and strategies. The idea that motivated the activists was that ARVs should ideally be ‘merit goods’, goods that are available to everyone regardless of income. But, when ARVs first came on the market, poor people in the developing world lacked the resources to buy them. Activists successfully lobbied donor nations to use foreign aid to buy ARVs, and they pressured pharmaceutical companies to lower their prices, while encouraging generic firms to enter the market. However, even where a policy enjoys favorable material conditions – i.e. low costs, large benefits, demonstrated feasibility – this may not be enough. A clear prescription, credible messengers and resonant arguments may be necessary for an issue to receive adequate political support. > [!NOTE] Policy Implications > - Global activists are playing an increasingly important role in world politics, but global activism influences policy outcomes only under certain conditions. > - Global activists can only succeed when they couple compelling moral arguments with permissive material conditions. > - Global activists need to build broad coalitions in order to be politically successful. > - Despite the success of the access to treatment regime, questions remain about its sustainability in light of the great recession that began in 2008, donor fatigue regarding AIDS and the emergence of other policy priorities in the foreign aid community. # Introduction How do we explain the transformation of ARVs from private goods, which only a very few AIDS patients could afford, into global merit goods or entitlements, defined as goods that should be made available to everyone, irrespective of their ability to pay for them (Musgrave, 1959)? But few if any of these demands have been met by multilateral declarations of support which are then backed by ample funding. This fact raises the question: under what circumstances does the international community make both the political and financial commitment that is required to generate global merit goods? “The question then arises: if a monopolist will ‘naturally’ engage in Ramsey pricing, why did the pharmaceutical industry not follow suit by offering low prices for ARVs to the developing world at the outset of the AIDS crisis? There are several reasons as to why the drug companies did not act in this way. To begin with, the multinational pharmaceutical companies doubted whether the developing world even provided a market for these drugs at any price, given the limitations of the existing health infrastructure coupled with skepticism about whether patients would follow a strict treatment regimen. They also doubted whether they could enforce market segmentation and prevent the re-exportation of low-cost drugs back to the industrial world. There were thus supply-side constraints that prevented firms from promoting the globalization of ARV treatment” (Kapstein and Busby, 2010, p. 8) “On the demand side, poor countries had no interest in importing high-cost ARVs because the price was much more than they could afford. Further, the absence of or deficiencies in health infrastructure meant that extending access entailed substantial costs beyond the purchase of drugs, placing a strain on stretched health budgets; and in any event, it was unclear whether ARV purchases would be or even should be the first priority of developing world health ministries. Even if they were, procurement and delivery mechanisms would have to, in many cases, be created from scratch, delivering drugs over poor roads to rural areas, with irregular electricity, that needed clinics and storehouses (Kremer, 2002 summarizes market failures for pharmaceuticals in the developing world).” (Kapstein and Busby, 2010, p. 8) # Conclusion “When asked why his company had reduced the prices of ARVs in developing countries, for example, the CEO of Abbott Laboratories said: ‘Frankly, because it is required. If I don’t provide our products in Africa, governments will license our intellectual property to others who can. Governments will intervene. Make no mistake, they will do that’” (Kapstein and Busby, 2010, p. 13) “As these comments suggest, the market for ARVs, which includes but is not limited to differential pricing, was no less a political than an economic construction. If the merit goods model (and the role of differential pricing within it) is to play a more expanded role in other areas, then policy makers may need to build institutions that enable the private sector to embrace this scheme in order to avoid some of the more bruising confrontations between advocates and the business community (for example by ensuring effective market segmentation, protecting property rights or transforming the intellectual property rights regime through cooperative licensing arrangements such as patent pools).” (Kapstein and Busby, 2010, p. 13) “very specific development programs (like PEPFAR) are much more politically popular than broad-based financial assistance to well-run governments to spend as they see fit (i.e. the Millennium Challenge Corporation).” (Kapstein and Busby, 2010, p. 13) In conclusion, if activists are to succeed, they must bring together a broad coalition of interests as they transform private goods into merit goods that are available to all. This coalition, in turn, must be joined by a convergent idea of what can and should be done. It is only through the fusion of a compelling set of ideas about how the world should work with favorable material conditions that activists will bring change to the global economy.