• By Kevin Mount
  • Posted on Tuesday 25th March, 2008

Prevention science gets a big bang theory

Most policy makers working in the Prevention Action arena would say that their primary objective is to improve child outcomes. But behind closed doors the clinching factor in their decision making is likely to be down to the money. Not only do researchers and program developers need to prove the effectiveness of their programs, they also need to demonstrate how much “bang for the buck” they deliver. If the two equations can be put in the same harness, the policy argument is likely to be irresistible. To demonstrate the principle – and rejuvenate the argument – Steve Aos, Assistant Director of the Washington State Institute for Public Policy, presented his Blueprints audience with some hard facts about crime, violence and prison population figures in the state of Washington (the focus of many Blueprints programs). During the 1980s, he said, the incarceration rate was about three adults per 1000. By 2005 this figure had doubled, and, based on current predictions, it was set to rise to about eight per 1000 by 2020. Typically, increasing the number of people in prison by 10 per cent cut crime by between two and four per cent, he explained, and in that respect the investment was paying off: crime was down 20 per cent in Washington State.But the rise in incarceration rates was at a cost; since the 1980s the US taxpayer had borne a 90 per cent increase in monies being directed into the prison system. And as with Starbuck coffee houses, so with the prisons: the law of diminishing returns was at work, Aos said. The more you saturated a market the harder it became to make additional gains. Thus, in Washington, a position had some time ago been reached where adding to the prison population was not justified by the dwindling benefits. Something different was needed. Blueprints could demonstrate what interventions worked in terms of their impact of children's health and development. What about the economic costs and returns?Aos and his team had conducted cost-benefit analysis of most Blueprints programs. So far all showed gains. Multisystemic Therapy, for example, cost just over $5,000 per adolescent, but saved nearly $15,000. For every dollar spend, 2.6 dollars was saved in the long-run (most of it accruing as a result of not locking kids up). The same analysis also highlighted approaches that signally did not work: lack of cost benefit in such cases frequently went hand-in-hand with poorer child outcomes. Scared Straight, for example, aimed to reduce drug use by scaring children witless with warnings about the dire consequences. It only cost about $50 per child, but the negative impact of the program actually cost the state an estimated $11,000 per child. It was enough to scare the crookedest economist straight – and the program was nowhere to be seen on the Blueprints lists. So, Aos explained, on the basis that Blueprints was able to show which initiatives worked, and the Washington State Institute project could demonstrate the attractive economics underpinning those that worked best, there was an opportunity to move the investigation on to another level: how might a portfolio of evidence-based programs (as opposed to an individual prescription) affect statewide outcomes?The Institute’s modeling made it possible to compare the impact of the current level of service provision with “moderate” or “aggressive” portfolios of prevention and treatment initiatives. Predictably, the bigger and more aggressive the portfolio the greater the return on investment, the lower the crime rate (and – presumably – the better the outcomes for children). But the bigger the portfolio, the greater the upfront cost.Had Aos got through to the policy makers in Washington State? Yes, he said; the money was talking. While the most aggressive strategy looked to be the most appealing, the annual up-front cost of the portfolio ($85 million) was prohibitive. But rather than carrying on as before with diminishing returns (costing $41 million annually) they had adopted a “moderate” investment in proven interventions to tackle crime ($63 million per annum).As for whether the strategy would live up to the predictions, much would be down to programs being implemented with fidelity and with supports sufficient to sustain the monumental effort. But it had the potential to persuade those still unconvinced that an ounce of prevention really could lead to a pound of cure.

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