Do Institutions Matter? A Comparative Pathology of the HIV-Infected Blood Tragedy

Abstract

The introduction of HIV (human immunodeficiency virus) into the blood systems of many different countries, developed and developing, during the late 1970s and early 1980s and its subsequent transmission to recipients of blood transfusions and blood products has precipitated a public health catastrophe of proportions unparalleled, at least in developed countries, in recent decades, leaving thousands of people dead or facing the inevitability of premature and agonizing death, and a legacy of fatal illness and financial and emotional devastation for many of their families and loved ones. This catastrophe has not only provoked critical scrutiny of the performance of existing institutional actors in a number of countries, but also has led, in some countries, to consideration of changes in the institutional framework for the collection and distribution of blood. The main purpose of this paper is to contribute to the ongoing debates over institutional re-design by attempting a comparative analysis of the actual performance of different blood systems in different countries in response to the HIV crisis. We examine the performance of blood collection, distribution and fractionation systems in seven developed, industrialized countries: Australia, Canada, France, Germany, Britain (excluding Scotland, which operates its own bloodsystem), Switzerland, and the United States. Our aim is not to make an overall judgment about the performance of these systems, either against efficiency or other criteria, but to understand the capacity of these systems to respond to a crisis that threatened the integrity of the blood supply.As the title of this Article suggests comparative study of institutional performance with respect to the crisis of HIV-infected blood is also relevant to the more general debate in the political economy literature over whether and how institutions matter to policy outcomes. Generally speaking the political economy debate over whether institutions matter has focused largely on comparative governmental performance. And to date, most official and scholarly inquiries into the performance of national blood systems with respect to the risk of HIV infection have focussed on perceived weaknesses in each country's system. By broadening the focus to seven countries, similar in stages of economic development and in many cases with like cultural values, we hope to be able to identify patterns in structure and performance that will enable students of political economy to infer more robust institutional prescriptions. The HIV-infected blood case study also offers the possibility of broadening this analysis to examine not just the comparative performance of governmental institutions across a range of countries, but also the comparative performance of both governmental and private (either non-profit or for-profit) institutions. Moreover, as will become clear when we assess and attempt to explain differences in performance, some of the institutional choices that may matter most to real world outcomes have not been well captured by the focus on profit vs. non-profit provision.