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# Schistosomiasis Blogs

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Updated: 47 min 50 sec ago

### Our updated top charities for giving season 2016

Mon, 11/28/2016 - 22:58

We have refreshed our top charity rankings and recommendations. We now have seven top charities: our four top charities from last year and three new additions. We have also added two new organizations to our list of charities that we think deserve special recognition (previously called “standout” charities).

Instead of ranking organizations, we rank funding gaps, which take into account both charities’ overall quality and cost-effectiveness and what more funding would enable them to do. We also account for our expectation that Good Ventures, a foundation we work closely with, will provide significant support to our top charities ($50 million in total). Our recommendation to donors is based on the relative value of remaining gaps once Good Ventures’ expected giving is taken into account. We believe that the remaining funding gaps offer donors outstanding opportunities to accomplish good with their donations. Our top charities and recommendations for donors, in brief Top charities We are continuing to recommend the four top charities we did last year and have added three new top charities: 1. Against Malaria Foundation (AMF) 2. Schistosomiasis Control Initiative (SCI) 3. END Fund for work on deworming (added this year) 4. Malaria Consortium for work on seasonal malaria chemoprevention (added this year) 5. Sightsavers for work on deworming (added this year) 6. Deworm the World Initiative, led by Evidence Action 7. GiveDirectly We have ranked our top charities based on what we see as the value of filling their remaining funding gaps. We do not feel a particular need for individuals to divide their allocation across all of the charities, since we are expecting Good Ventures will provide significant support to each. For those seeking our recommended allocation, we recommend giving 75% to the Against Malaria Foundation and 25% to the Schistosomiasis Control Initiative, which we believe to have the most valuable unfilled funding gaps. Our recommendation takes into account the amount of funding we think Good Ventures will grant to our top charities, as well as accounting for charities’ existing cash on hand, and expected fundraising (before gifts from donors who follow our recommendations). We recommend charities according to how much good additional donations (beyond these sources of funds) can do. Other Charities Worthy of Special Recognition As with last year, we also provide a list of charities that we believe are worthy of recognition, though not at the same level (in terms of likely good accomplished per dollar) as our top charities (we previously called these organizations “standouts”). They are not ranked, and are listed in alphabetical order. Below, we provide: • An explanation of major changes in the past year that are not specific to any one charity. More • A discussion of our approach to room for more funding and our ranking of charities’ funding gaps. More • Summary of key considerations for top charities. More • Detail on each of our new top charities, including an overview of what we know about their work and our understanding of each organization’s room for more funding. More • Detail on each of the top charities we are continuing to recommend, including an overview of their work, major changes over the past year and our understanding of each organization’s room for more funding. More • The process we followed that led to these recommendations. More • A brief update on giving to support GiveWell’s operations vs. giving to our top charities. More Conference call to discuss recommendations We are planning to hold a conference call at 5:30pm ET/2:30pm PT on Thursday, December 1 to discuss our recommendations and answer questions. If you’d like to join the call, please register using this online form. If you can’t make this date but would be interested in joining another call at a later date, please indicate this on the registration form. Major changes in the last 12 months Below, we summarize the major causes of changes to our recommendations (since last year). Most important changes in the last year: • We engaged with more new potential top charities this year than we have in several years (including both inviting organizations to participate in our process and responding to organizations that reached out to us). This work led to three additional top charities. We believe our new top charities are outstanding giving opportunities, though we note that we are relatively less confident in these organizations than in our other top charities—we have followed each of the top charities we are continuing to recommend for five or more years and have only began following the new organizations in the last year or two. • Overall, our top charities have more room for more funding than they did last year. We now believe that AMF, SCI, Deworm the World, and GiveDirectly have strong track records of scaling their programs. Our new top charities add additional room for more funding and we believe that the END Fund and Malaria Consortium, in particular, could absorb large amounts of funding in the next year. We expect some high-value opportunities to go unfilled this year. • Last year, we wrote about the tradeoff between Good Ventures accomplishing more short-term good by filling GiveWell’s top charities’ funding gaps and the long-term good of saving money for other opportunities (as well as the good of not crowding out other donors, who, by nature of their smaller scale of giving, may have fewer strong opportunities). Due to the growth of the Open Philanthropy Project this year and its increased expectation of the size and value of the opportunities it may have in the future, we expect Good Ventures to set a budget of$50 million for its contributions to GiveWell top charities. The Open Philanthropy Project plans to write more about this in a future post on its blog.

Room for more funding analysis

Types of funding gaps

We’ve previously outlined how we categorize charities’ funding gaps into incentives, capacity-relevant funding, and execution levels 1, 2, and 3. In short:

• Incentive funding: We seek to ensure that each top charity receives a significant amount of funding (and to a lesser extent, that charities worthy of special recognition receive funding as well). We think this is important for long-run incentives to encourage other organizations to seek to meet these criteria. This year, we are increasing the top charity incentive from $1 million to$2.5 million.
• Capacity-relevant funding: Funding that we believe has the potential to create a significantly better giving opportunity in the future. With one exception, we don’t believe that any of our top charities have capacity-relevant gaps this year. We have designated the first $2 million of Sightsavers’ room for more funding as capacity-relevant because seeing results from a small number of Sightsavers deworming programs would significantly expand the evidence base for its deworming work and has the potential to lead us to want to support Sightsavers at a much higher level in the future (more). • Execution funding: Funding that allows charities to implement more of their core programs. We separated this funding into three levels: level 1 is the amount at which we think there is a 50% chance that the charity will be bottlenecked by funding; level 2 is a 20% chance of being bottlenecked by funding, and level 3 is a 5% chance. Ranking funding gaps The first million dollars to a charity can have a very different impact from, e.g., the 20th millionth dollar. Accordingly, we have created a ranking of individual funding gaps that accounts for both (a) the quality of the charity and the good accomplished by its program per dollar, and (b) whether a given level of funding is capacity-relevant and whether it is highly or only marginally likely to be needed in the coming year. The below table lays out our ranking of funding gaps. When gaps have the same “Priority,” this indicates that they are tied. When gaps are tied, we recommend filling them by giving each equal dollar amounts until one is filled, and then following the same procedure with the remaining tied gaps. See footnote for more.* The table below includes the amount we expect Good Ventures to give to our top charities. For reasons the Open Philanthropy Project will lay out in another post, we expect that Good Ventures will cap its giving to GiveWell’s top charities this year at$50 million. We expect that Good Ventures will start with funding the highest-rated gaps and work its way down, in order to accomplish as much good as possible.

Note that we do not always place a charity’s full execution level at the same rank and in some cases rank the first portion of a given charity’s execution level ahead of the remainder. This is because many of our top charities are relatively close to each other in terms of their estimated cost-effectiveness (and thus, the value of their execution funding). For reasons we’ve written about in the past, we believe it is inappropriate to put too much weight on relatively small differences in explicit cost-effectiveness estimates. Because we expect that there are diminishing returns to funding, we would guess that the cost-effectiveness of a charity’s funding gap falls as it receives more funding.

Priority Charity Amount, in millions USD (of which, expected from Good Ventures*) Type Comment 1 Deworm the World $2.5 (all) Incentive – 1 SCI$2.5 (all) Incentive – 1 Sightsavers $2.5 (all) Incentive – 1 AMF$2.5 (all) Incentive – 1 GiveDirectly $2.5 (all) Incentive – 1 END Fund$2.5 (all) Incentive – 1 Malaria Consortium $2.5 (all) Incentive – 1 Other charities worthy of special recognition$1.5 (all) Incentive $250,000 each for six charities 3 SCI$6.5 (all) Fills rest of execution level 1 Highest cost-effectiveness of remaining level 1 gaps 4 AMF $8.5 (all) First part of execution level 1 Similar cost-effectiveness to END Fund and Sightsavers and greater understanding of the organization. Expect declining cost-effectiveness within Level 1, and see other benefits (incentives) to switching to END Fund and Sightsavers after this point. 5 END Fund$2.5 (all) Middle part of execution level 1 Given relatively limited knowledge of charity, capping total recommendation at $5 million 6 Sightsavers$0.5 (all) Fills rest of execution level 1 Similar cost-effectiveness to AMF and the END Fund 7 Deworm the World $2.0 (all) Fills execution level 2 Highest-ranked level 2 gap. Highest cost-effectiveness and confidence in organization 8 SCI$4.5 (all) First part of execution level 2 Highest cost-effectiveness of remaining level 2 gaps 9 Malaria Consortium $2.5 (all) Part of execution level 1 Given relatively limited knowledge of charity, capping total recommendation at$5 million 10 AMF $18.6 ($5.1) Part of execution level 1 Expect declining cost-effectiveness within level 1; ranked other gaps higher due to this and incentive effects 11 SCI $4.5 ($0) Fills execution level 2 Roughly expected to be more cost-effective than the remaining $49 million of AMF level 1 * Also includes$1 million that GiveWell holds for grants to top charities. More below.

Summary of key considerations for top charities

The table below summarizes the key considerations for our seven top charities. More detail is provided below as well as in the charity reviews.

Consideration AMF Malaria Consortium Deworm the World END Fund SCI Sightsavers GiveDirectly Estimated cost-effectiveness (relative to cash transfers) ~4x ~4x ~10x ~4x ~8x ~5x Baseline Our level of knowledge about the organization High Relatively low High Relatively low High Relatively low High Primary benefits of the intervention Under-5 deaths averted and possible increased income in adulthood Possible increased income in adulthood Immediate increase in consumption and assets Ease of communication Moderate Strong Strong Strong Moderate Moderate Strongest Ongoing monitoring and likelihood of detecting future problems Moderate Moderate Strong Moderate Moderate Moderate Strongest Room for more funding, after expected funding from Good Ventures and donors who give independently of our recommendation High: less than half of Execution Level 1 filled High: not quantified, but could likely use significantly more funding Low: Execution Levels 1 and 2 filled High: half of Execution Level 1 filled Moderate: Execution Level 1 and some of Level 2 filled Moderate: Execution Level 1 filled Very high: less than 15% of Execution Level 1 filled

Our recommendation to donors

If Good Ventures uses a budget of $50 million to top charities and follows our prioritization of funding gaps, it will make the following grants (in millions of dollars, rounded to one decimal place): • AMF:$15.1
• Deworm the World: $4.5 • END Fund:$5.0
• GiveDirectly: $2.5 • Malaria Consortium:$5.0
• SCI: $13.5 • Sightsavers:$3.0
• Grants to other charities worthy of special recognition: $1.5 We also hold about$1 million that is restricted to granting out to top charities. We plan to use this to make a grant to AMF, which is the next funding gap on the list after the expected grants from Good Ventures.

We estimate that non-Good Ventures donors will give approximately $27 million between now and the start of June 2017; we expect to refresh our recommendations to donors in mid-June. Of this, we expect$18 million will be allocated according to our recommendation for marginal donations, while $9 million will be given based on our top charity list—this$9 million is considered ‘expected funding’ for each charity and therefore subtracted from their room for more funding.

$18 million spans two gaps in our prioritized list, so we are recommending that donors split their gift, with 75% going to AMF and 25% going to SCI, or give to GiveWell for making grants at our discretion and we will use the funds to fill in the next highest priority gaps. Details on new top charities Before this year, our top charity list had remained nearly the same for several years. This means that we have spent hundreds of hours talking to these groups, reading their documents, visiting their work in the field, and modeling their cost-effectiveness. We have spent considerably less time on our new top charities, particularly Malaria Consortium, and have not visited their work in the field (though we met with Sightsavers’ team in Ghana). We believe our new top charities are outstanding giving opportunities, though we think there is a higher risk that further investigation will lead to changes in our views about these groups. A note about deworming Four of our top charities, including two new top charities, support programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) (“deworming”). We estimate that SCI and Deworm the World’s deworming programs are more cost effective than mass bednet campaigns, but our estimates are subject to substantial uncertainty. For Sightsavers and END Fund, our greater uncertainty about cost per treatment and prevalence of infection in the areas where they work leads us to the conclusion that the cost-effectiveness of their work is on par with that of bednets. It’s important to note that we view deworming as high expected value, but this is due to a relatively low probability of very high impact. Our cost-effectiveness model implies that most staff members believe you should use a multiplier of less than 1% compared to the impact (increased income in adulthood) found in the original trials—this could be thought of as assigning some chance that deworming programs have no impact, and some chance that the impact exists but will be smaller than was measured in those trials. Full discussion in this blog post. Our 2016 cost-effectiveness analysis is here. This year, David Roodman conducted an investigation into the evidence for deworming’s impact on long-term life outcomes. David will write more about this in a future post, but in short, we think the strength of the case for deworming is similar to last year’s, with some evidence looking weaker, new evidence that was shared with us in an early form this year being too preliminary to incorporate, and a key piece of evidence standing up to additional scrutiny. END Fund (for work on deworming) Our full review of END Fund is here. Overview The END Fund (end.org) manages grants, provides technical assistance, and raises funding for controlling and eliminating neglected tropical diseases (NTDs). We have focused our review on its support for deworming. About 60% of the treatments the END Fund has supported have been deworming treatments, while the rest have been for other NTDs. The END Fund has funded SCI, Deworm the World, and Sightsavers. We see the END Fund’s value-add as a GiveWell top charity as identifying and providing assistance to programs run by organizations other than those we separately recommend, and our review of the END Fund has excluded results from charities on our top charity list. We have not yet seen monitoring results on the number of children reached in END Fund-supported programs. The END Fund has instituted a requirement that grantees conduct coverage surveys and the first results will be available in early 2017. While we generally put little weight on plans for future monitoring, we feel that the END Fund’s commitment is unusually credible because surveys are already underway or upcoming in the next few months, we are familiar enough with the type of survey being used (from research on other deworming groups) that we were able to ask critical questions, and the END Fund provided specific answers to our questions. We have more limited information on some questions for the END Fund than we do for the top charities we have recommended for several years. We do not have a robust cost per treatment figure, and also have limited information on infection prevalence and intensity. Funding gap We estimate that the END Fund could productively use between$10 million (50% confidence) and $22 million (5% confidence) in the next year to expand its work on deworming. By our estimation, about a third of this would be used to fund other NTD programs. This estimate is based on (a) a list of deworming funding opportunities that the END Fund had identified as of October and its expectation of identifying additional opportunities over the course of the year (excluding opportunities to grant funding to Deworm the World, SCI, or Sightsavers, which we count in those organizations’ room for more funding); and (b) our rough estimate of how much funding the END Fund will raise. The END Fund is a fairly new organization whose revenue comes primarily from a small number of major donors so it is hard to predict how much funding it will raise. The END Fund’s list of identified opportunities includes both programs that END Fund has supported in past years and opportunities to get new programs off the ground. Sightsavers (for work on deworming) Our full review of Sightsavers is here. Overview Sightsavers (sightsavers.org) is a large organization with multiple program areas that focuses on preventing avoidable blindness and supporting people with impaired vision. Our review focuses on Sightsavers’ work to prevent and treat neglected tropical diseases (NTDs) and, more specifically, advocating for, funding, and monitoring deworming programs. Deworming is a fairly new addition to Sightsavers’ portfolio; in 2011, it began delivering some deworming treatments through NTD programs that had been originally set up to treat other infections. We believe that deworming is a highly cost-effective program and that there is moderately strong evidence that Sightsavers has succeeded in achieving fairly high coverage rates for some of its past NTD programs. We feel that the monitoring data we have from SCI and Deworm the World is somewhat stronger than what we have from Sightsavers—in particular, the coverage surveys that Sightsavers has done to date were on NTD programs that largely did not include deworming. Sightsavers plans to do annual coverage surveys on programs that are supported by GiveWell-influenced funding. We have more limited information on some questions for Sightsavers than we do for the top charities we have recommended for several years. We do not have a robust cost-per-treatment figure, though the information we have suggests that it is in the same range as the cost-per-treatment figures for SCI and Deworm the World. We also have limited information on infection prevalence and intensity in the places Sightsavers works. This limits our ability to robustly compare Sightsavers’ cost effectiveness to other top charities, but our best guess is that the cost-effectiveness of the deworming charities we recommend is similar. Funding gap We believe Sightsavers could productively use or commit between$3.0 million (50% confidence) and $10.1 million (5% confidence) in funding restricted to programs with a deworming component in 2017. This estimate is based on (a) a list of deworming funding opportunities that Sightsavers created for us; and (b) our understanding that Sightsavers would not allocate much unrestricted funding to these opportunities in the absence of GiveWell funding. It’s difficult to know whether other funders might step in to fund this work, but Sightsavers believes that is unlikely and deworming has not been a major priority for Sightsavers to date. Sightsavers’ list of opportunities includes both adding deworming to existing NTD mass distribution programs and establishing new integrated NTD programs that would include deworming and spans work in Nigeria, Guinea-Bissau, Democratic Republic of Congo, Guinea, Cameroon, Cote d’Ivoire, and possibly South Sudan. Malaria Consortium (for work on seasonal malaria chemoprevention) Our full review of Malaria Consortium is here. Overview Malaria Consortium (malariaconsortium.org) works on preventing, controlling, and treating malaria and other communicable diseases in Africa and Asia. Our review has focused exclusively on its seasonal malaria chemoprevention (SMC) programs, which distribute preventive anti-malarial drugs to children 3-months to 59-months old in order to prevent illness and death from malaria. The evidence for SMC appears strong (stronger than deworming and not quite as strong as bednets), but we have not yet examined the intervention at nearly the same level that we have for bednets, deworming, unconditional cash transfers, or other priority programs. The randomized controlled trials on SMC that we considered showed a decrease in cases of clinical malaria but were not adequately powered to find an impact on mortality. Malaria Consortium and its partners have conducted studies in most of the countries where it has worked to determine whether its programs have reached a large proportion of children targeted. These studies have generally found positive results, but leave us with some remaining questions about the program’s impact. Overall, we have more limited information on some questions for Malaria Consortium than we do for the top charities we have recommended for several years. We have remaining questions on cost per child per year and on offsetting effects from possible drug resistance and disease rebound. Funding gap We have not yet attempted to estimate Malaria Consortium’s maximum room for more funding. We would guess that Malaria Consortium could productively use at least an additional$30 million to scale up its SMC activities over the next three to four years. We have a general understanding of where additional funds would be used but have not yet asked for a high level of detail on potential bottlenecks to scaling up.

We do not believe Malaria Consortium has substantial unrestricted funding available for scaling up its support of SMC programs and expect its restricted funding for SMC to remain steady or decrease in the next few years.

Details on top charities we are continuing to recommend

Against Malaria Foundation (AMF)

Our full review of AMF is here.

Background

AMF (againstmalaria.com) provides funding for long-lasting insecticide-treated net distributions (for protection against malaria) in developing countries. There is strong evidence that distributing nets reduces child mortality and malaria cases.

AMF provides a level of public disclosure and tracking of distributions that we have not seen from any other net distribution charity.

We estimate that AMF’s program is roughly 4 times as cost effective as cash transfers (see our cost-effectiveness analysis). This estimate seeks to incorporate many highly uncertain inputs, such as the effect of mosquito resistance to the insecticides used in nets on how effective they are at protecting against malaria, how differences in malaria burden affect the impact of nets, and how to discount for displacing funding from other funders, among many others.

Important changes in the last 12 months

In 2016, AMF significantly increased the number and size of distributions it committed funding to. Prior to 2015, it had completed (large-scale) distributions in two countries, Malawi and Democratic Republic of Congo (DRC). In 2016, it completed a distribution in Ghana and committed to supporting distributions in an additional three countries, including an agreement to contribute $28 million to a campaign in Uganda, its largest agreement to date by far. AMF has continued to collect and share information on its past large-scale distributions. This includes both data from registering households to receive nets (and, in some cases, data on the number of nets each household received) and follow-up surveys to determine whether nets are in place and in use. Our research in 2016 has led us to moderately weaken our assessment of the quality of AMF’s follow up surveys. In short, we learned that the surveys in Malawi have not used fully randomized selection of households and that the first two surveys in DRC were not reliable (full discussion in this blog post). We expect to see follow-up surveys from Ghana and DRC in the next few months that could expand AMF’s track record of collecting this type of data. We also learned that AMF has not been carrying out data audits in the way we believed it was (though this was not a major surprise as we had not asked AMF for details of the auditing process previously). AMF has generally been communicative and open with us. We noted in our mid-year update that AMF had been slower to share documentation for some distributions; however, we haven’t had concerns about this in the second half of the year. In August 2016, four GiveWell staff visited Ghana where an AMF-funded distribution had recently been completed. We met with AMF’s program manager, partner organizations, and government representatives and visited households in semi-urban and rural areas (notes and photos from our trip). Our estimate of the cost-effectiveness of nets has fallen relative to cash transfers since our mid-year update. At that point, we estimated that nets were ~10x as cost-effective as cash transfers, and now we estimate that they are ~4x as cost-effective as cash transfers. This change was partially driven by changes in GiveWell staff’s judgments on the tradeoff between saving lives of children under five and improving lives (through increased income and consumption) in our model, and partially driven by AMF beginning to fund bed net distributions in countries with lower malaria burdens than Malawi or DRC. Funding gap AMF currently holds$17.8 million, and expects to commit $12.9 million of this soon. We estimate it will receive an additional$4 million by June 2017 ($2 million from donors not influenced by GiveWell and$2 million from donors who give based on our top charity list) that it could use for future distributions. Together, we expect that AMF will have about $9 million for new spending and commitments in 2017. We estimate that AMF could productively use or commit between$87 million (50% confidence) and $200 million (5% confidence) in the next year. We arrived at this estimate from a rough estimate of the total Africa-wide funding gap for nets in the next three years (from the African Leaders Malaria Alliance)—estimated at$125 million per year. The estimate is rough in large part because the Global Fund to Fight AIDS, Tuberculosis and Malaria, the largest funder of LLINs, works on three-year cycles and has not yet determined how much funding it will allocate for LLINs for 2018-2020. We talked to people involved in country-level planning of mass net distributions and the Global Fund, who agreed with the general conclusion that there were likely to be large funding gaps in the next few years. In mid-2016, AMF had to put some plans on hold due to lack of funding.

We now believe that AMF has a strong track record of finding distribution partners to work with and coming to agreements with governments, and we do not expect that to be a limiting factor for AMF. The main risks we see to AMF’s ability to scale are the possibility that funding from other funders is sufficient (since our estimate of the gap is quite rough), the likelihood that government actors have limited capacity for discussions with AMF during a year in which they are applying for Global Fund funding, AMF’s staff capacity to manage discussions with additional countries (it has only a few staff members), and whether gaps will be spread across many countries or located in difficult operating environments. We believe the probability of any specific one of these things impeding AMF’s progress is low.

We believe there are differences in cost-effectiveness within execution level 1 and believe the value of filling the first part of AMF’s gap may be higher than additional funding at higher levels. This is because AMF’s priorities include committing to large distributions in the second half of 2019 and 2020, which increases the uncertainty about whether funding would have been available from another source.

We and AMF have discussed a few possibilities for how AMF might fill funding gaps. AMF favors an approach where it purchases a large number of nets for a small number of countries. This approach has some advantages including efficiency for AMF and leverage in influencing how distributions are carried out. Our view is that the risk of displacing a large amount of funding from other funders using this approach outweighs the benefits. If AMF did displace a large amount of funding which would otherwise have gone to nets, that could make donations applied to these distributions considerably less cost-effective. More details on our assessment of AMF’s funding gap are in our full review.

Deworm the World Initiative, led by Evidence Action

Our full review of Deworm the World is here.

Background

Deworm the World (evidenceaction.org/#deworm-the-world), led by Evidence Action, advocates for, supports, and evaluates deworming programs. It has worked in India and Kenya for several years and has recently expanded to Nigeria, Vietnam, and Ethiopia.

Deworm the World retains or hires monitors who visit schools during and following deworming campaigns. We believe its monitoring is the strongest we have seen from any organization working on deworming. Monitors have generally found high coverage rates and good performance on other measures of quality.

As noted above, we believe that Deworm the World is slightly more cost-effective than SCI, more cost-effective than AMF and the other deworming charities, and about 10 times as cost-effective as cash transfers.

Important changes in the last 12 months

Deworm the World has made somewhat slower progress than expected in expanding to new countries. In late 2015, Good Ventures, on GiveWell’s recommendation, made a grant of $10.8 million to Deworm the World to fund its execution level 1 and 2 gaps. Execution level 1 funding was to give Deworm the World sufficient resources to expand into Pakistan and another country. Deworm the World has funded a prevalence survey in Pakistan, which is a precursor to funding treatments in the country. It has not expanded into a further country that it was not already expecting to work in. As a result, we believe that Deworm the World has somewhat limited room for more funding this year. Overall, we have more confidence in our understanding of Deworm the World and its parent organization Evidence Action’s spending, revenues, and financial position than we did in previous years. While trying to better understand this information this year, we found several errors. We are not fully confident that all errors have been corrected, though we are encouraged by the fact that we are now getting enough information to be able to spot inconsistencies. Evidence Action has been working to overhaul its financial system this year. Our review of Deworm the World has focused on two countries, Kenya and India, where it has worked the longest. In 2016, we saw the first results of a program in another country (Vietnam), as well as continued high-quality monitoring from Kenya and India. The Vietnam results indicate that Deworm the World is using similar monitoring processes in new countries as it has in Kenya and India and that results in Vietnam have been reasonably strong. Evidence Action hired Jeff Brown (formerly Interim CEO of the Global Innovation Fund) as CEO in 2015. Recently Evidence Action announced that he has resigned and has not yet been replaced. Our guess is this is unlikely to be disruptive to Deworm the World’s work; Grace Hollister remains Director of the Deworm the World Initiative. Funding gap We believe that there is a 50% chance that Deworm the World will be slightly constrained by funding in the next year and that additional funds would increase the chances that it is able to take advantage of any high-value opportunities it encounters. We estimate that if it received an additional$4.5 million its chances of being constrained by funding would be reduced to 20% and at $13.4 million in additional funding, this would be reduced to 5%. In the next year, Deworm the World expects to expand its work in India and Nigeria and may have opportunities to begin treatments in Pakistan and Indonesia. It is also interested in using unrestricted funding to continue its work in Kenya, and puts a high priority on this program. Its work in Kenya has to date been funded primarily by the Children’s Investment Fund Foundation (CIFF) and this support is set to expire in mid 2017. It is unclear to us whether CIFF will continue providing funding for the program and, if so, for how long. Due to the possibility that Deworm the World unrestricted funding may displace funding from CIFF, and, to a lesser extent, the END Fund and other donors, we consider the opportunity to fund the Kenya program to be less cost-effective in expectation than it would be if we were confident in the size of the gap. More details in our full review. Schistosomiasis Control Initiative (SCI) Our full review of SCI is here. Background SCI (imperial.ac.uk/schisto) works with governments in sub-Saharan Africa to create or scale up deworming programs. SCI’s role has primarily been to identify recipient countries, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs. SCI has conducted studies in about two-thirds of the countries it works in to determine whether its programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but leave us with some remaining questions about the program’s impact. As noted above, we believe that SCI is slightly less cost-effective than Deworm the World, more cost-effective than AMF and the other deworming charities, and about 8 times as cost-effective as cash transfers. Important changes in the last 12 months In past years, we’ve written that we had significant concerns about SCI’s financial reporting and financial management, and the clarity of our communication with SCI. In June, we wrote that we had learned of two substantial errors in SCI’s financial managment and reporting that began in 2015. We also noted that we thought that SCI’s financial management and financial reporting, as well as the clarity of its communication with us overall, had improved significantly. In the second half of the year, SCI communicated clearly with us about its plans for deworming programs next year and its room for more funding. SCI reports that it has continued to scale up its deworming programs over the past year and that it plans to start up new deworming programs in two states in Nigeria before the end of its current budget year. This year, SCI has shared a few more coverage surveys from deworming programs in Ethiopia, Madagascar, and Mozambique that found reasonably high coverage. Professor Alan Fenwick, Founder and Director of SCI for over a decade, retired from his position this year, though will continue his involvement in fundraising and advocacy. The former Deputy Director, Wendy Harrison, is the new Director. Funding gap We estimate that SCI could productively use or commit a maximum of between$9.0 million (50% confidence) and $21.4 million (5% confidence) in additional unrestricted funding in its next budget year. Its funding sources have been fairly steady in recent years with about half of its revenue in the form of restricted grants, particularly from the UK government’s Department for International Development (this grant runs through 2018), and half from unrestricted donations, a majority of which were driven by GiveWell’s recommendation. We estimate that SCI will have around$5.4 million in unrestricted funding available to allocate to its 2017-18 budget year (in addition to $6.5 million in restricted funding). SCI has a strong track record of starting and scaling up programs in a large number of countries. SCI believes it could expand significantly with additional funding, reaching more people in the countries it works in and expanding to Nigeria and possibly Chad. More details in our full review. GiveDirectly Our full review of GiveDirectly is here. Background GiveDirectly (givedirectly.org) transfers cash to households in developing countries via mobile phone-linked payment services. It targets extremely low-income households. The proportion of total expenses that GiveDirectly has delivered directly to recipients is approximately 82% overall. We believe that this approach faces an unusually low burden of proof, and that the available evidence supports the idea that unconditional cash transfers significantly help people. We believe GiveDirectly to be an exceptionally strong and effective organization, even more so than our other top charities. It has invested heavily in self-evaluation from the start, scaled up quickly, and communicated with us clearly. It appears that GiveDirectly has been effective at delivering cash to low-income households. GiveDirectly has one major randomized controlled trial (RCT) of its impact and took the unusual step of making the details of this study public before data was collected (more). It continues to experiment heavily, with the aim of improving how its own and government cash transfer programs are run. It has recently started work on evaluations that benchmark programs against cash with the aim of influencing the broader international aid sector to use its funding more cost-effectively. We believe cash transfers are less cost-effective than the programs our other top charities work on, but have the most direct and robust case for impact. We use cash transfers as a “baseline” in our cost-effectiveness analyses and only recommend other programs that are robustly more cost effective than cash. Important changes in the last 12 months GiveDirectly has continued to scale up significantly, reaching a pace of delivering$21 million on an annual basis in the first part of 2016 and expecting to reach a pace of $50 million on an annual basis at the end of 2016. It has continued to share informative and detailed monitoring information with us. Given its strong and consistent monitoring in the past, we have taken a lighter-touch approach to evaluating its processes and results this year. The big news for GiveDirectly this year was around partnerships and experimentation. It expanded into Rwanda (its third country) and launched a program to compare, with a randomized controlled trial, another aid program to cash transfers (details expected to be public next year). The program is being funded by a large institutional funder and Google.org. It expects to do additional “benchmarking” studies with the institutional funder, using funds from Good Ventures’ 2015$25 million grant, over the next few years.

It also began fundraising for and started a pilot of a universal basic income (UBI) guarantee—a program providing long-term, ongoing cash transfers sufficient for basic needs, which will be evaluated with a randomized controlled trial comparing the program to GiveDirectly’s standard lump sum transfers. The initial UBI program and study is expected to cost $30 million. We estimate that it is less cost-effective than GiveDirectly’s standard model, but it could have impact on policy makers that isn’t captured in our analysis. We noted previously that Segovia, a for-profit technology company that develops software for cash transfer program implementers and which was started and is partially owned by GiveDirectly’s co-founders, would provide its software for free to GiveDirectly to avoid conflicts of interest. However, in 2016, after realizing that providing free services to GiveDirectly was too costly for Segovia (customizing the product for GiveDirectly required much more Segovia staff time than initially expected), the two organizations negotiated a new contract under which GiveDirectly will compensate Segovia for its services. GiveDirectly wrote about this decision here. GiveDirectly told us that it recused all people with ties to both organizations from this decision and evaluated alternatives to Segovia. Although we believe that there are possibilities for bias in this decision and in future decisions concerning Segovia, and we have not deeply vetted GiveDirectly’s connection with Segovia, overall we think GiveDirectly’s choices were reasonable. However, we believe that reasonable people might disagree with this opinion, which is in part based on our personal experience working closely with GiveDirectly’s staff for several years. Funding gap We believe that GiveDirectly is very likely to be constrained by funding next year. GiveDirectly has been rapidly building its capacity to enroll recipients and deliver funds, while some of its revenue has been redirected to its universal basic income guarantee program (either because of greater donor interest in that program or by GiveDirectly focusing its fundraising efforts on it). We expect GiveDirectly to have about$20 million for standard cash transfers in its 2017 budget year. This includes raising about $15.8 million from non-GiveWell-influenced sources between now and halfway through its 2017 budget year (August 2017) and$4 million from donors who give because GiveDirectly is on GiveWell’s top charity list. $4 million is much less than GiveWell-influenced donors gave in the last year. This is because several large donors are supporting GiveDirectly’s universal basic income guarantee program this year and because one large donor gave a multi-year grant that we don’t expect to repeat this year. GiveDirectly is currently on pace (with no additional hiring) to have four full teams operating its standard cash transfer model in 2017. To fully utilize four teams, it would need$28 million more than we expect it to raise. We accordingly expect that GiveDirectly will downsize somewhat in 2017, because we do not project it raising sufficient funds to fully utilize the increased capacity it has built to transfer money. Given recent growth, we believe that GiveDirectly could easily scale beyond four teams and we estimate that at $46 million more than we expect it to raise ($66 million total for standard transfers), it would have a 50% chance of being constrained by funding.

Other charities worthy of special recognition

Last year, we recommended four organizations as “standouts.” This year we are calling this list “other charities worthy of special recognition.” We’ve added two organizations to the list: Food Fortification Initiative and Project Healthy Children. Although our recommendation to donors is to give to our top charities over these charities, they stand out from the vast majority of organizations we have considered in terms of the evidence base for their work and their transparency, and they offer additional giving options for donors who feel highly aligned with their work.

We don’t follow these organizations as closely as we do our top charities. We generally have one or two calls per year with each group, publish notes on our conversations, and follow up on any major developments.

We provide brief updates on these charities below:

• Organizations that have conducted randomized controlled trials of their programs:
• Development Media International (DMI). DMI produces radio and television programming in developing countries that encourages people to adopt improved health practices. It conducted a randomized controlled trial (RCT) of its program and has been highly transparent, including sharing preliminary results with us. The results of its RCT were mixed, with a household survey not finding an effect on mortality (it was powered to detect a reduction of 15% or more) and data from health facilities finding an increase in facility visits. (The results, because the trial was only completed in the last year, are not yet published.) We believe there is a possibility that DMI’s work is highly cost-effective, but we see no solid evidence that this is the case. We noted last year that DMI was planning to conduct another survey for the RCT in late 2016; it has decided not to move forward with this, but is interested in conducting new research studies in other countries, if it is able to raise the money to do so. It is our understanding that DMI will be constrained by funding in the next year. Our full review of DMI, with conversation notes and documents from 2016, is here.
• Living Goods. Living Goods recruits, trains, and manages a network of community health promoters who sell health and household goods door-to-door in Uganda and Kenya and provide basic health counseling. They sell products such as treatments for malaria and diarrhea, fortified foods, water filters, bednets, clean cookstoves, and solar lights. Living Goods completed a randomized controlled trial of its program and measured a 27% reduction in child mortality. Our best guess is that Living Goods’ program is less cost-effective than our top charities, with the possible exception of cash. Living Goods is scaling up its program and may need additional funding in the future, but has not yet been limited by funding. We published an update on Living Goods in mid-2016. Our 2014 review of Living Goods is here.
• Organizations working on micronutrient fortification: We believe that food fortification with certain micronutrients can be a highly effective intervention. For each of these organizations, we believe they may be making a significant difference in the reach and/or quality of micronutrient fortification programs but we have not yet been able to establish clear evidence of their impact. The limited analysis we have done suggests that these programs are likely not significantly more cost-effective than our top charities—if they were, we might put more time into this research or recommend a charity based on less evidence.
• Food Fortification Initiative (FFI). FFI works to reduce micronutrient deficiencies (especially folic acid and iron deficiencies) by doing advocacy and providing assistance to countries as they design and implement flour and rice fortification programs. We have not yet completed a full evidence review of iron and folic acid fortification, but our initial research suggests it may be competitively cost effective with our other priority programs. Because FFI typically provides support alongside a number of other actors and its activities vary widely among countries, it is difficult to assess the impact of its work. Our full review is here.
• Global Alliance for Improved Nutrition (GAIN) – Universal Salt Iodization (USI) program. GAIN’s USI program supports national salt iodization programs. We have spent the most time attempting to understand GAIN’s impact in Ethiopia. Overall, we would guess that GAIN’s activities played a role in the increase in access to iodized salt in Ethiopia, but we do not yet have confidence about the extent of GAIN’s impact. It is our understanding that GAIN’s USI work will be constrained by funding in the next year. Our review of GAIN, published in 2016 based on research done in 2015, is here.
• IGN. Like GAIN-USI, IGN supports (via advocacy and technical assistance rather than implementation) salt iodization. IGN is small, and GiveWell-influenced funding has made up a large part of its funding in the past year. This year, we published an update on our investigation into IGN’s work in select countries in 2015 and notes from our conversation with IGN to learn about its progress in 2016 and plans for 2017. It is our understanding that IGN will be constrained by funding in the next year. Our review of IGN, from 2014, is here.
• Project Healthy Children (PHC). PHC aims to reduce micronutrient deficiencies by providing assistance to small countries as they design and implement food fortification programs. Our review is preliminary and in particular we do not have a recent update on how PHC would use additional funding. Our review of PHC, published in 2016 but based on information collected in 2015, is here.

Our research process in 2016

We plan to detail the work we completed this year in a future post as part of our annual review process. Much of this work, particularly our experimental work and work on prioritizing interventions for further investigation, is aimed at improving our recommendations in future years. Here we highlight the key research that led to our current recommendations. See our process page for our overall process.

• As in previous years, we did intensive follow up with each of our top charities, including publishing updated reviews mid-year. We had several conversations by phone with each organization, met in person with Deworm the World, SCI, and AMF (over the course of a 4-day site visit to Ghana), and reviewed documents they shared with us.
• In 2015 and 2016, we sought to expand top charity room for more funding and consider alternatives to our top charities by inviting other groups that work on deworming, bednet distributions, and micronutrient fortification to apply. This led to adding Sightsavers, the END Fund, Project Healthy Children, and Food Fortification Initiative to our lists this year. Episcopal Relief & Development’s NetsforLife® Program, Micronutrient Initiative, and Nothing but Nets declined to fully participate in our review process.
• We completed intervention reports on voluntary medical male circumcision (VMMC) and cataract surgery. We asked VMMC groups PSI (declined to fully participate) and the Centre for HIV and AIDS Prevention Studies (pending) to apply. We had conversations with several charities working on cataract surgery and have not yet asked any to apply.
• We did very preliminary investigations into a large number of interventions and prioritized a few for further work. This led to interim intervention reports on seasonal malaria chemoprevention (SMC), integrated community case management (iCCM) and ready-to-use therapeutic foods for treating severe acute malnutrition and recommending Malaria Consortium for its work on SMC.
• We stayed up to date on the research for bednets, cash transfers, and deworming. We published a report on insecticide resistance and its implications for bednet programs. A blog post on our work on deworming is forthcoming. We did not find major new research on cash transfers that affected our recommendation of GiveDirectly.

Giving to GiveWell vs. top charities

GiveWell and the Open Philanthropy Project are planning to split into two organizations in the first half of 2017. The split means that it is likely that GiveWell will retain much of the assets of the previously larger organization while reducing its expenses. We think it’s fairly likely that our excess assets policy will be triggered and that we will grant out some unrestricted funds. Given that expectation, our recommendation to donors is:

• If you have supported GiveWell’s operations in the past, we ask that you consider maintaining your support. It is fairly likely that these funds will be used this year for grants to top charities, but giving unrestricted signals your support for our operations and allows us to better project future revenue and make plans based on that. Having a strong base of consistent support allows us to make valuable hires when opportunities arise and minimize staff time spent on fundraising.
• If you have not supported GiveWell’s operations in the past, we ask that you consider checking the box on our donate form to add 10% to help fund GiveWell’s operations. In the long term, we seek to have a model where donors who find our research useful contribute to the costs of creating it, while holding us accountable to providing high-quality, easy-to-use recommendations.

Footnotes:

* For example, if $30 million were available to fund gaps of$10 million, $5 million, and$100 million, we would recommend allocating the funds so that the $10 million and$5 million gaps were fully filled and the $100 million gap received$15 million.

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### Deworming might have huge impact, but might have close to zero impact

Tue, 07/26/2016 - 12:48

We try to communicate that there are risks involved with all of our top charity recommendations, and that none of our recommendations are a “sure thing.”

Our recommendation of deworming programs (the Schistosomiasis Control Initiative and the Deworm the World Initiative), though, carries particularly significant risk (in the sense of possibly not doing much/any good, rather than in the sense of potentially doing harm). In our 2015 top charities announcement, we wrote:

Most GiveWell staff members would agree that deworming programs are more likely than not to have very little or no impact, but there is some possibility that they have a very large impact. (Our cost-effectiveness model implies that most staff members believe there is at most a 1-2% chance that deworming programs conducted today have similar impacts to those directly implied by the randomized controlled trials on which we rely most heavily, which differed from modern-day deworming programs in a number of important ways.)

The goal of this post is to explain this view and why we still recommend deworming.

Some basics for this post

What is deworming?

Deworming is a program that involves treating people at risk of intestinal parasitic worm infections with parasite-killing drugs. Mass treatment is very inexpensive (in the range of $0.50-$1 per person treated), and because treatment is cheaper than diagnosis and side effects of the drugs are believed to be minor, typically all children in an area where worms are common are treated without being individually tested for infections.

Does it work?

There is strong evidence that administration of the drugs reduces worm loads, but many of the infections appear to be asymptomatic and evidence for short-term health impacts is thin (though a recent meta-analysis that we have not yet fully reviewed reports that deworming led to short-term weight gains). The main evidence we rely on to make the case for deworming comes from a handful of longer term trials that found positive impacts on income or test scores later in life.

For more background on deworming programs see our full report on combination deworming.

Why do we believe it’s more likely than not that deworming programs have little or no impact?

The “1-2% chance” doesn’t mean that we think that there’s a 98-99% chance that deworming programs have no effect at all, but that we think it’s appropriate to use a 1-2% multiplier compared to the impact found in the original trials – this could be thought of as assigning some chance that deworming programs have no impact, and some chance that the impact exists but will be smaller than was measured in those trials. For instance, as we describe below, worm infection rates are much lower in present contexts than they were in the trials.

Where does this view come from?

Our overall recommendation of deworming relies heavily on a randomized controlled trial (RCT) (the type of study we consider to be the “gold standard” in terms of causal attribution) first written about in Miguel and Kremer 2004 and followed by 10-year follow up data reported in Baird et al. 2011, which found very large long-term effects on recipients’ income. We reviewed this study very carefully (see here and here) and we felt that its analysis largely held up to scrutiny.

There’s also some other evidence, including a study that found higher test scores in Ugandan parishes that were dewormed in an earlier RCT, and a high-quality study that is not an RCT but found especially large increases in income in areas in the American South that received deworming campaigns in the early 20th century. However, we consider Baird et al. 2011 to be the most significant result because of its size and the fact that the follow-up found increases in individual income.

While our recommendation relies on the long-term effects, the evidence for short-term effects of deworming on health is thin, so we have little evidence of a mechanism through which deworming programs might bring about long-term impact (though a recent meta-analysis that we have not yet fully reviewed reports that deworming led to short-term weight gains). This raises concerns about whether the long-term impact exists at all, and may suggest that the program is more likely than not to have no significant impact.

Even if there is some long-term impact, we downgrade our expectation of how much impact to expect, due to factors that differ between real-world implementations and the Miguel and Kremer trial. In particular, worm loads were particularly high during the Miguel and Kremer trial in Western Kenya in 1998, in part due to flooding from El Niño, and in part because baseline infection rates are lower in places where SCI and Deworm the World work than in the relevant studies.

Our cost-effectiveness model estimates that the baseline worm infections in the trial we mainly rely on were roughly 4 to 5 times as high as in places where SCI and Deworm the World operate today, and that El Niño further inflated those worm loads during the trial. (These estimates combine data on the prevalence of infections and intensity of infections, and so are especially rough because there is limited data on whether prevalence or intensity of worms is a bigger driver of impact). Further, we don’t know of any evidence that would allow us to disconfirm the possibility that the relationship between worm infection rates and the effectiveness of deworming is nonlinear, and thus that many children in the Miguel and Kremer trial were above a clinically relevant “threshold” of infection that few children treated by our recommended charities are above.

We also downgrade our estimate of the expected value of the impact based on: concerns that the limited number of replications and lack of obvious causal mechanism might mean there is no impact at all, expectation that deworming throughout childhood could have diminishing returns compared to the ~2.4 marginal years of deworming provided in the Miguel and Kremer trial, and the fact that the trial only found a significant income effect on those participants who ended up working in a wage-earning job. See our cost-effectiveness model for more information.

Why do we recommend deworming despite the reasonably high probability that there’s no impact?

Because mass deworming is so cheap, there is a good case for donating to support deworming even when in substantial doubt about the evidence. We estimate the expected value of deworming programs to be as cost-effective as any program we’ve found, even after the substantial adjustments discussed above: our best guess considering those discounts is that it’s still roughly 5-10 times as cost-effective as cash transfers, in expectation. But that expected value arises from combining the possibility of potentially enormous cost-effectiveness with the alternative possibility of little or none.

GiveWell isn’t seeking certainty – we’re seeking outstanding opportunities backed by relatively strong evidence, and deworming meets that standard. For donors interested in trying to do as much good as possible with their donations, we think that deworming is a worthwhile bet.

What could change this recommendation – will more evidence be collected?

To our knowledge, there are currently no large, randomized controlled trials being conducted that are likely to be suitable for long-term follow up to measure impacts on income when the recipients are adults, so we don’t expect to see a high-quality replication of the Miguel and Kremer study in the foreseeable future.

That said, there are some possible sources of additional information:

• The follow-up data that found increased incomes among recipients in the original Miguel and Kremer study was collected roughly 10 years after the trial was conducted. Our understanding is that 15 year follow-up data has been collected and we expect to receive an initial analysis of it from the researchers this summer.
• A recent study from Uganda didn’t involve data collection for the purpose of evaluating a randomized controlled trial; rather, the paper identified an old, short-term trial of deworming and an unrelated data set of parish-level test scores collected by a different organization in the same area. Because some of the parishes overlap, it’s possible to compare the test scores from those that were dewormed to those that weren’t. It’s possible that more overlapping data sets will be discovered and so we may see more similar studies in the future.
• We’ve considered whether to recommend funding for an additional study to replicate Baird et al. 2011: run a new deworming trial that could be followed for a decade to track long term income effects. However, it would take 10+ years to get relevant results, and by that time deworming may be fully funded by the largest global health funders. It would also need to include a very large number of participants to be adequately powered to find plausible effects (since the original trial in Baird et al. 2011 benefited from particularly high infection rates, which likely made it easier to detect an effect), so it would likely be extremely expensive.

For the time being, based on our best guess about the expected cost-effectiveness of the program when all the factors are considered, we continue to recommend deworming programs.

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### Weighing organizational strength vs. estimated cost-effectiveness

Thu, 07/14/2016 - 15:00

A major question we’ve asked ourselves internally over the last few years is how we should weigh organizational quality versus the value of the intervention that the organization is carrying out.

In particular, is it better to recommend an organization we’re very impressed by and confident in that’s carrying out a good program, or better to recommend an organization we’re much less confident in that’s carrying out an exceptional program? This question has been most salient when deciding how to rank giving to GiveDirectly vs giving to the Schistosomiasis Control Initiative.

GiveDirectly vs SCI

GiveDirectly is an organization that we’re very impressed by and confident in, more so than any other charity we’ve come across in our history. Reasons for this:

But, we estimate that marginal dollars to the program it implements — direct cash transfers — are significantly less cost-effective than bednets and deworming programs. Excluding organizational factors, our best guess is that deworming programs — which SCI supports — are roughly 5 times as cost-effective as cash transfers. As discussed further below, our cost effectiveness estimates are generally based on extremely limited information and are therefore extremely rough, so we are cautious in assigning too much weight to them.

Despite the better cost-effectiveness of deworming, we’ve had significant issues with SCI as an organization. The two most important:

• We originally relied on a set of studies showing dramatic drops in worm infection coinciding with SCI-run deworming programs to evaluate SCI’s track record; we later discovered flaws in the study methodology that led us to conclude that they did not demonstrate that SCI had a strong track record. We wrote about these flaws in 2013 and 2014.
• We’ve seen limited and at times erroneous financial information from SCI over the years. We have seen some improvements in SCI’s financial reporting in 2016, but we still have some concerns, as detailed in our most recent report.

More broadly, both of these cases are examples of general problems we’ve had communicating with SCI over the years. And we don’t believe SCI’s trajectory has generated evidence of overall impressiveness comparable to GiveDirectly’s, discussed above.

Which should we recommend?

One argument is that GiveWell should only recommend exceptional organizations, and so the issues we’ve seen with SCI should disqualify them.

But, we think that the ~5x difference in cost-effectiveness is meaningful. There’s a large degree of uncertainty in our cost-effectiveness analyses, which is something we’ve written a lot about in the past, but this multiplier appears somewhat stable (it has persisted in this range over time, and currently is consistent with the individual estimates of many staff members), and a ~5x difference gives a fair amount of room for SCI to do more good even accounting both for possible errors in our analysis and for differences in organizational efficiency.

A separate argument that we’ve made in the past is that great organizations have upside that goes beyond the value of conducting the specific program they’re implementing. For example, early funding to a great organization may have allow it to grow faster and increase the amount of money going to their program globally, either through proving the model or through their own fundraising. And GiveDirectly has shown some propensity for potentially innovative projects, as discussed above.

We think that earlier funding to GiveDirectly had this benefit, but it’s less of a consideration now that GiveDirectly is a more mature organization.  We believe this upside exists for what we’ve called “capacity-relevant” funding, which is the type of funding need that we consider to be most valuable when ranking the importance of marginal dollars to each of our top charities, and refers to funding gaps that we expect will allow organizations to grow in an outsized way in the future, for instance by going into a new country.

Bottom line

Our most recent recommendations ranked SCI’s funding gap higher than GiveDirectly’s due to SCI’s cost-effectiveness. We think that SCI is a strong organization overall, despite the issues we’ve noted, and we think that the “upside” for GiveDirectly is limited on the margin, so ultimately our estimated 5x multiplier looks meaningful enough to be determinative.

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### Mid-year update to top charity recommendations

Thu, 06/23/2016 - 17:25

This post provides an update on what we’ve learned about our top charities in the first half of 2016.

We continue to recommend all four of our top charities. Our recommendation for donors seeking to directly follow our advice remains the same: we recommend they give to the Against Malaria Foundation (AMF), which we believe has the most valuable current funding gap.

Below, we provide:

• Updates on our view about AMF, which we consider the most important information we’ve learned in the last half-year (More)
• Updates on other top charities (More)
• A discussion of the reasoning behind our current recommendation to donors (More)

Background

AMF (www.againstmalaria.com) provides funding for long-lasting insecticide-treated net distributions (for protection against malaria) in developing countries. There is strong evidence that distributing nets reduces child mortality and malaria cases. AMF has relatively strong reporting requirements for its distribution partners and provides a level of public disclosure and tracking of distributions that we have not seen from any other net distribution charity. Overall, AMF is the best giving opportunity we are currently aware of. That said, we have concerns about AMF’s recent monitoring and transparency that we plan to focus on in the second half of the year.

Updates from the last six months

We are more confident than we were before in AMF’s ability to successfully complete deals with most countries it engages with. Over the past few years, our key concern about AMF has been whether it would be able to effectively absorb additional funding and sign distribution agreements with governments and other partners. At the end of 2013, we stopped recommending AMF because we felt it did not require additional funding, and our end-of-year analyses in 2014 and 2015 discussed this issue in depth. In early 2016, AMF signed agreements to fund two large distributions (totaling $37 million) of insecticide-treated nets in countries it has not previously worked in. We now believe that AMF has effectively addressed this concern. AMF is in discussions for several additional large distributions. AMF currently holds approximately$23.3 million, and we believe that it is very likely to have to slow its work if it receives less than an additional $11 million very quickly. It is possible that it could also use up to an additional (approximately)$18 million more during this calendar year.

It may be more valuable to give to AMF now than it will be later this year or next year. AMF’s funding gap may be time-sensitive because:

1. AMF is in several discussions about distributions that would take place in 2017. It has told us that it needs to make decisions within a month or two about which discussions to pursue. We don’t have a clear sense for how long before a distribution AMF needs to be able to commit funding, and note that, for example, AMF committed in February 2016 to a distribution in Ghana taking place in June to August 2016. That said, it seems quite plausible that AMF needs to commit soon to distributions taking place in 2017.
2. We don’t know whether there will be large funding gaps for nets in 2018 and beyond. The price of nets has been decreasing and the size of grants from the two largest funders of nets, the Global Fund to fight AIDS, TB, and Malaria and the President’s Malaria Initiative, is not yet known. (The Global Fund is holding its replenishment conference in September, in which donor governments are asked to make three-year pledges, so we may know more before the end of the year.) It’s possible that these funders will fund all or nearly all of the net needs in countries other than those that are particularly hard to work in for 2018. If that happens, gifts to AMF in late 2016 could be less valuable than gifts in the next couple of months. (This could also mean that, if AMF fills gaps in 2017 that would have been filled by other funders in 2018, gifts now are less valuable than they have been in the past. We have added an adjustment for this to our cost-effectiveness analysis, but given the high degree of uncertainty, this could be a more important factor than we are currently adjusting for.)

Notwithstanding the above, we have important questions about AMF that we plan to continue to investigate. None of these developments caused us to change our recommendation about giving to AMF, but they are important considerations for donors:

1. Monitoring data: We have new concerns about AMF’s monitoring of its distributions, particularly its post-distribution check-up (PDCU) surveys. These surveys are a key part of our confidence in the quality of AMF’s distributions. For Malawi, where most of the PDCUs completed to date have been done, our key concern is that villages that surveyors visit are not selected randomly, but are instead selected by hand by staff of the organization that both implements and monitors the distributions, which seems fairly likely to lead to bias in the results. We have also seen results from the first two PDCUs from DRC. We have not yet looked at the DRC results in-depth or discussed them with AMF, but there appear to be major problems in how the surveys were carried out (particularly a high percentage of internally inconsistent data – around 40%-50%) and, if we believe the remaining data, fairly high rates of missing or unhung nets (~20% at 6-months) and nets that deteriorated quickly (65% were in ‘very good’ or ‘good’ condition at 6-months).
2. Transparency: Recently, AMF has been slower to share documentation from some distributions. AMF has told us that it has this documentation and we are concerned that AMF is not being as transparent as it could be. We believe this documentation is important for monitoring the quality of AMF’s distributions; it includes PDCUs, results from re-surveying 5% of households in during pre-distribution registrations (AMF has told us that this is a standard part of its process, but we have not seen results from any distributions), and malaria case rate data from Malawi that AMF has told us it has on hand. AMF attributes the delays to lack of staff capacity. We plan to write more about monitoring and transparency in a future post.
3. Insecticide resistance: Insecticide resistance (defined broadly as “any ways in which populations of mosquitoes adapt to the presence of insecticide-treated nets (ITNs) in order to make them less effective”) is a major threat to the effectiveness of ITNs. Insecticide resistance seems to be fairly common across sub-Saharan Africa, and it seems that resistance is increasing. It remains difficult to quantify the impact of resistance, but our very rough best guess (methodology described in more detail below) is that ITNs are roughly one-third less effective in the areas where AMF is working than they would be in the absence of insecticide resistance. We continue to believe, despite resistance, ITNs remain a highly cost-effective intervention. See our full report for more detail.

• To better understand whether AMF is providing nets that would not otherwise have been funded, we considered five cases where AMF considered funding a distribution and did not ultimately provide funding. We then looked at whether other funders stepped in and how long of a delay resulted from having to wait for other funders. We published the details here. In short, most distributions took place later than they would have if AMF had funded them (on average over a year), which probably means that the people were not protected with nets during that time. We feel that these case studies provide some evidence that nets that AMF buys do not simply displace nets from other funding sources.
• We’ve noted in the past that the delays in AMF signing agreements for distributions may have been due to AMF’s hesitation about paying for the costs of a distribution other than the purchase price of nets. For the distributions that AMF has signed this year, AMF has agreed to pay for some non-net costs, particularly the costs of PDCUs. The Global Fund to fight AIDS, TB, and Malaria is paying for the other non-net costs of the distribution. AMF’s willingness to fund some of the non-net costs may have made it easier for it to sign distribution agreements and put funds to use more quickly.

Updates on our other top charities

Schistosomiasis Control Initiative (full report)

Background

SCI (www3.imperial.ac.uk/schisto) works with governments in sub-Saharan Africa to create or scale up deworming programs (treating children for schistosomiasis and other intestinal parasites). SCI’s role has primarily been to identify recipient countries, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs.

In past years, we’ve written that we had significant concerns about SCI’s financial reporting and financial management that meant we lacked high-quality, basic information about how SCI was spending funding and how much funding it had available to allocate to programs. We decided to focus our work in the first half of 2016 on this issue. We felt that seeing significant improvements in the quality of SCI’s finances was necessary for us to continue recommending SCI.

We believe that deworming is a program backed by relatively strong evidence. We have reservations about the evidence, but we think the potential benefits are great enough, and costs low enough, to outweigh these reservations. SCI has conducted studies in about half of the countries it works in (including the countries with the largest programs) to determine whether its programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but have major methodological limitations. We have not asked SCI for monitoring results since last year.

Updates from the last six months

We published a separate blog post on our work on SCI so far this year. Our main takeaways:

• SCI has begun producing higher-quality financial documents that allow us to learn some basic financial information about SCI.
• We learned of two substantial errors in SCI’s financial management and reporting. 1) a July 2015 grant from GiveWell for about $333,000 was misallocated within Imperial College, which houses SCI, until we noticed it was missing from SCI’s revenue in March 2016; and (2) in 2015, SCI underreported how much funding it would have from other sources in 2016, leading us to overestimate its room for more funding by$1.5 million.
• The clarity of our communication with SCI about its finances has improved, but there is still substantial room for further improvement.

We feel that SCI has improved, but we would still rank our other top charities ahead of it in terms of our ability to communicate and understand their work. Given this situation, we continue to recommend SCI now and think that SCI is reasonably likely to retain its top charity status at the end of 2016. We plan, in the second half of 2016, to expand the scope of our research on SCI.

We have not asked SCI for an update on its room for more funding (due to our focus on financial documents in the first half of the year). It’s our understanding that funds that SCI receives in the next six months will be allocated to work in 2017 and beyond. Because of this, we don’t believe that SCI has a pressing need for additional funds, though our guess is that it will have room for more funding when we next update our recommendations in November and that funds given before then will help fund gaps for the next budget year.

GiveDirectly (full report)

Background

GiveDirectly (www.givedirectly.org) transfers cash to households in developing countries via mobile phone-linked payment services. It targets extremely low-income households. The proportion of total expenses that GiveDirectly has delivered directly to recipients is approximately 83% overall. We believe that this approach faces an unusually low burden of proof, and that the available evidence supports the idea that unconditional cash transfers significantly help people.

We believe GiveDirectly to be an exceptionally strong and effective organization, even more so than our other top charities. It has invested heavily in self-evaluation from the start, scaled up quickly, and communicated with us clearly. It appears that GiveDirectly has been effective at delivering cash to low-income households. GiveDirectly has one major randomized controlled trial (RCT) of its impact and took the unusual step of making the details of this study public before data was collected (more). It continues to experiment heavily.

Updates from the last six months

• GiveDirectly announced an initiative to test a “basic income guarantee” to provide long-term, ongoing cash transfers sufficient for basic needs. The cost-effectiveness of providing this form of cash transfers may be different from the one-time transfers GiveDirectly has made in the past.
• GiveDirectly continues to have more room for more funding than we expect GiveWell-influenced donors to fill in the next six months. Its top priority is funding the basic income guarantee project.
• In late 2015 and early 2016, when GiveDirectly began enrolling participants in Homa Bay county, Kenya, it experienced a high rate of people refusing to be enrolled in the program. The reason for this is not fully clear, though GiveDirectly believes in some cases local leaders advised people to not trust the program. While GiveDirectly has temporarily dealt with this setback by moving its operations to a different location in Homa Bay county, it is possible that similar future challenges could reduce GiveDirectly’s ability to commit as much as it currently projects.
• GiveDirectly has reached an agreement with a major funder which provides a mechanism through which multiple benchmarking projects (projects comparing cash transfers to other types of aid programs) can be launched. The major funder may fund up to $15 million for four different benchmarking projects with GiveDirectly. GiveDirectly plans to make available up to$15 million of the grant it received from Good Ventures in 2015 to match funds committed by the major funder. GiveDirectly and its partner have not yet determined which aid programs will be evaluated or how the evaluations will be carried out.
• We are reasonably confident that GiveDirectly could effectively use significantly more funding than we expect it to receive, including an additional $30 million for additional cash transfers in 2016, though scaling up to this size would require a major acceleration in the second half of the year. We have not asked GiveDirectly how funding above this amount would affect its activities and plans (because we think it is very unlikely that GiveDirectly will receive more than$30 million from GiveWell-influenced supporters before our next update in November).

Deworm the World (full report)

Background

Deworm the World (www.evidenceaction.org/deworming), led by Evidence Action, advocates for, supports, and evaluates government-run school-based deworming programs (treating children for intestinal parasites).

We believe that deworming is a program backed by relatively strong evidence. We have reservations about the evidence, but we think the potential benefits are great enough, and costs low enough, to outweigh these reservations. Deworm the World retains monitors whose reports indicate that the deworming programs it supports successfully deworm children.

Updates from the last six months

• We asked Deworm the World whether additional funding in the next six months would change its activities or plans. It told us that it does not expect funding to be the bottleneck to any work in that time. We’d guess that there is a very small chance that it will encounter an unexpected opportunity and be bottlenecked by funding before our next update in November.
• Deworm the World appears to be making progress expanding to new countries. It has made a multi-year commitment to provide technical assistance and resources to Cross River state, Nigeria for its school-based deworming program (the first deworming is scheduled for the end of this month), and are undertaking a nationwide prevalence survey in Pakistan.
• In the past, we have focused our review of Deworm the World on its work in India. We are in the process of learning more about its work in other locations, particularly Kenya. The monitoring we have seen from Kenya appears to be high quality.

Summary of key considerations for top charities

The table below summarizes the key considerations for our four top charities. With the exception of modest changes to room for more funding, our high-level view of our top charities, as summarized in the table below, is the same as at our last update in November 2015.

Consideration AMF Deworm the World GiveDirectly SCI Program estimated cost-effectiveness (relative to cash transfers) ~10x ~10x Baseline ~5x Directness and robustness of the case for impact Strong Moderate Strongest Moderate Transparency and communication Strong Strong Strongest Weakest Ongoing monitoring and likelihood of detecting future problems Strong Strong Strongest Weakest Organizational track record of rolling out program Moderate Moderate Strong Strong Room for more funding High Limited High Likely moderate (not investigated)

Reasoning behind our current recommendation to donors

Our recommendation for donors seeking to directly follow our advice is to give to AMF, which we believe has the most valuable current funding gap. We believe AMF will likely have opportunities to fund distributions this year which it will not be able to fund without additional funding. Due to the excellent cost-effectiveness of AMF’s work, we consider this a highly valuable funding gap to fill. Our current estimate is that on average AMF saves a life for about every $3,500 that it spends; this is an increase from our November 2015 estimate and reflects changes to our cost-effectiveness model as well as some of our inputs into bed nets’ cost-effectiveness. As always, we advise against taking cost-effectiveness estimates literally and view them as highly uncertain. The below table lays out our ranking of funding gaps for June to November 2016. The first million dollars to a charity can have a very different impact from, e.g., the 20th million dollars. Accordingly, our ranking of individual funding gaps accounts for both (a) the quality of the charity and the good accomplished by its program, per dollar, and (b) whether a given level of funding is highly or only marginally likely to be needed in the next six months. We consider funding that allows a charity to implement more of its core program (without substantial benefits beyond the direct good accomplished by this program) to be “execution funding.” We’ve separated this funding into three levels: • Level 1: the amount we expect a charity to need in the coming year. If a charity has less funding than this level, we think it is more likely than not that it will be bottlenecked (or unable to carry out its core program to the fullest extent) by funding in the coming year. For this mid-year update, we have focused on funds that are needed before our next update in November, with the exception of SCI where we believe funds will not affect its work until next year. • Level 2: if a charity has this amount, we think there is an ~80% chance that it will not be bottlenecked by funding. • Level 3: if a charity has this amount, we think there is a ~95% chance that it will not be bottlenecked by funding. (Our rankings can also take into account whether a gap is “capacity-relevant” or providing an incentive to engage in our process. We do not currently believe that our top charities have capacity-relevant gaps and are not planning to make mid-year incentive grants, so we haven’t gone into detail on that here. More details on how we think about capacity-relevant and execution gaps in this post.) Priority Charity Amount (millions) Type Description Comment 1 AMF$11.3 Execution level 1 Fund distributions in two countries that AMF is in discussions with but does not have sufficient funding for AMF is strongest overall 2 AMF $7.3 Execution level 2 Fund the next largest gap on the list of remaining 2016-17 gaps in African countries – 3 SCI$10.1 Execution level 1 Very rough because we haven’t discussed this with SCI; further gaps not estimated Not as strong as AMF in isolation, so ranked below for same type of gap 4 AMF $10.5 Execution level 3 Fund the final two AMF-relevant gaps on the list of remaining 2016-17 gaps in African countries – 5 GiveDirectly$22.2 Execution level 1 Basic income guarantee program and additional standard transfers Not as cost-effective as bednets or deworming, so lower priority 6 Deworm the World $6.0 Execution level 3 A rough guess at the funding needed to cover a 3-year deworming program in a new country Strong cost-effectiveness, but unlikely to need funds in the short-term 6 GiveDirectly$7.8 Execution level 2 Funding for additional structured projects; further gaps not estimated –

We are not recommending that Good Ventures make grants to our top charities for this mid-year refresh. In November 2015, we recommended that Good Ventures fund 50% of our top charities’ highest-value funding gaps for the year and Good Ventures gave $44.4 million to our top four charities. We felt this approach resulted in Good Ventures funding its “fair share” while avoiding creating incentives for other donors to avoid the causes we’re interested in, which could lead to less overall funding for these causes in the long run. (More on this reasoning available here.) The post Mid-year update to top charity recommendations appeared first on The GiveWell Blog. ### What we’ve learned about SCI this year Mon, 06/20/2016 - 18:19 In past years, we’ve written that we had significant concerns about the financial reporting and financial management of the Schistosomiasis Control Initiative (SCI), one of our top charities since 2011. Our concerns have included: • We had not been able to learn important and basic financial information about SCI. Despite substantial effort, before 2016 we were not able to determine the total amount of funding that SCI held at any one time. We also had very little information on what SCI’s funds were spent on within country programs. • We found that SCI’s financial reports were prone to containing errors. Due to these concerns, we decided to focus our research on SCI in preparation for our June 2016 top charities update only on the quality of its financial reporting and financial management. We felt that seeing significant improvements in the quality of SCI’s finances was necessary for us to continue recommending SCI. Our main takeaways from our research on SCI so far in 2016: • SCI has begun producing higher-quality financial documents that allow us to learn some basic financial information about SCI, including the total amount of funding it holds, how much funding has been allocated to its upcoming budget year, and how it spent restricted and unrestricted funds by country in the previous budget year. We have also been able to learn somewhat more about how its funds are spent within national deworming programs. • We learned of two substantial errors in SCI’s financial management and reporting. 1) a July 2015 grant from GiveWell for about$333,000 was misallocated within Imperial College, which houses SCI, until we noticed it was missing from SCI’s revenue in March 2016; and (2) in 2015, SCI provided inaccurate information about how much funding it would have from other sources in 2016, leading us to overestimate its room for more funding by $1.5 million. • The clarity of our communication with SCI about these financial errors and its plans for the upcoming year has improved in comparison with previous years. Details follow. SCI’s financial documents in 2016 As of the beginning of April 2016, SCI had$15.8 million ($8.6 million in restricted funding and$7.2 million in unrestricted funding) available to allocate to its April 2016 to March 2017 budget year, according to its recent financial documents. Despite our discovery of additional financial errors this year (discussed below), we feel fairly confident that this information is accurate. We’ve seen transaction-level detail for each of SCI’s accounts, asked SCI’s new Finance and Operations Manager questions about the data, and largely received clear and reasonable answers.

SCI also sent us detailed breakdowns of in-country spending in its 2015-16 budget year for six of its country programs. Although this spending data gives us some information about what SCI’s funds were spent on within country programs last year, we note that we have not seen spending breakdowns for the eleven other deworming programs supported by SCI in 2015-16 (additional concerns about this spending data are discussed in our full review of SCI.)

Despite the improvements in SCI’s financial reporting that have allowed us to learn some basic financial information, we remain concerned about SCI’s use of Imperial College’s accounting system, which seems ill-suited to SCI’s needs. SCI has told us that it began using new accounting software in April 2016; we’re uncertain about the degree to which this will alleviate our concerns.

Financial errors we learned about in 2016

We’ve learned about two financial errors this year:

• Not realizing that it had not received a transfer of funds from GiveWell: In July 2015, we granted $333,414 to SCI, which included all donations we received designated for supporting SCI between February and May 2015. After reviewing SCI’s financial documents in March 2016, we informed SCI that the July 2015 funding did not appear to be accounted for. After investigating the issue, SCI found that the funds had been misallocated by Imperial College to a different part of the college. SCI did not receive the funds until April 2016. SCI has asked Imperial College why the error occurred, but has not yet received a substantive response. • Underreporting available funding from DFID: In October 2015, SCI sent us its target treatment numbers for each national deworming program it supports, amounts of funding available from DFID and other large donors, and the amounts of additional funding required to deliver the targeted number of treatments and cover central expenditures for its April 2016 to March 2017 budget year. In March 2016, SCI sent GiveWell documents that indicated that around$1.5 million more funding was available from DFID to allocate to SCI’s 2016-2017 budget year than indicated in the October 2015 document. SCI told us that the October 2015 document included funding that was available from DFID to allocate to national deworming programs, but omitted $1.5 million in funding available from DFID to allocate to SCI’s central expenditures. We consider both of these errors to be substantial. We are uncertain whether SCI would have ever received the funding from donations we collected on SCI’s behalf between February and May 2015 if we had not brought the issue to SCI’s attention. Our room for more funding analysis is a major factor in determining our funding recommendations to donors and to Good Ventures; an overestimation of SCI’s room for more funding by$1.5 million could have caused us to recommend donations to SCI that would have been better allocated to filling other funding gaps.

Our communication with SCI

Although we think that the financial errors we learned about in 2016 were substantial, we believe that it is a good sign that we were able to learn of these errors by communicating with SCI. In the past, we’ve noted that we’ve struggled to communicate effectively with SCI’s representatives, which sometimes meant that we were unable to clear up our confusion about inconsistencies we found in SCI’s documents.

We also feel that we’ve communicated clearly with SCI about its plans for the upcoming year and gained a better understanding of the factors that limit the delivery of additional deworming treatments in different contexts.

Bottom line

Given the improvements, we continue to recommend SCI now and think that SCI is a contender for a top charity recommendation at the end of 2016. We plan, in the second half of 2016, to expand the scope of our research on SCI to include looking at recent monitoring and evaluation, cost per treatment, and room for more funding in 2017 and beyond. We continue to have some concerns about SCI’s financial reporting and management (most notably, the errors noted above) and will be following up with SCI about our outstanding questions.

The post What we’ve learned about SCI this year appeared first on The GiveWell Blog.

### Our updated top charities for giving season 2015

Wed, 11/18/2015 - 14:06

We have refreshed our top charity rankings and recommendations. Our set of top charities and standouts is the same as last year’s, but we have introduced rankings and changed our recommended funding allocation, due to a variety of updates – particularly to our top charities’ room for more funding. In particular, we are recommending that Good Ventures, a foundation with which we work closely, support our top charities at a higher level than in previous years. This post includes our recommendations to Good Ventures, and gives our recommendations to individual donors after accounting for these grants.

Overall, we think the case for our top charities is stronger than in previous years, and room for more funding is greater.

Our top charities and recommendations for donors, in brief

Top charities

1. Against Malaria Foundation (AMF)
2. Schistosomiasis Control Initiative (SCI)
3. Deworm the World Initiative, led by Evidence Action
4. GiveDirectly

This year, we are ranking our top charities based on what we see as the value of filling their remaining funding gaps. Unlike in previous years, we do not feel a particular need for individuals to divide their allocation between the charities, since we are recommending that Good Ventures provide significant support to each. For those seeking our recommended allocation, we simply recommend giving to the top-ranked charity on the list, which is AMF.

Our recommendation takes the grants we are recommending to Good Ventures into account, as well as accounting for charities’ existing cash on hand and expected non-GiveWell-related fundraising, and recommends charities according to how much good additional donations (beyond these sources of funds) can do. (Otherwise, as explained below, Deworm the World would be ranked higher.) Thus, AMF’s #1 ranking is not based on its overall value as an organization, but based on the value of its remaining funding gap.

Standout charities

As with last year, we also provide a list of charities that we believe are strong standouts, though not at the same level (in terms of likely good accomplished per dollar) as our top charities. They are not ranked, and are listed in alphabetical order.

Below, we provide:

• An explanation of major changes in the past year that are not specific to any one charity. More
• A summary of our top charities’ relative strengths and weaknesses, and how we would rank them if room for more funding were not an issue. More
• A discussion of our refined approach to room for more funding. More
• The recommendations we are making to Good Ventures, and how we rank our top charities after taking these grants (and their impact on room for more funding) into account. More
• Detail on each of our top charities, including major changes over the past year, strengths and weaknesses for each, and our understanding of each organization’s room for more funding. More
• The process we followed that led to these recommendations. More
• A brief update on giving to support GiveWell’s operations vs. giving to our top charities. More

Conference call to discuss recommendations

We are planning to hold a conference call at 5:30pm ET/2:30pm PT on Tuesday, December 1st to discuss our recommendations and answer questions.

If you’d like to join the call, please register using this online form. If you can’t make this date but would be interested in joining another call at a later date, please indicate this on the registration form.

Major changes in the last 12 months

Below, we summarize the major causes of changes to our recommendations (since last year).

Overall, the case for our top charities is stronger than it was in past years. The Deworm the World Initiative shared new monitoring and evaluation materials with us, so we are more confident than we were a year ago that it is a strong organization implementing high-quality programs. In addition, the extra year of work we have seen from AMF and GiveDirectly bolsters our view that they will be able to utilize additional funding effectively.

Our top charities have increased room for more funding. Last year, we expected donors following our recommendations to fully fill the most critical funding gaps of our top charities (excluding GiveDirectly) because they had limited room for more funding: GiveDirectly had a total funding gap of ~$40 million and our other three top charities had a total gap of ~$18 million. This year, all of our top charities have more room for more funding. We believe that GiveDirectly could absorb more than $80 million and other top charities together could collectively utilize more than$100 million. We do not expect donors following our recommendations to fully fill these gaps.

We are recommending that Good Ventures make larger grants to top charities. For reasons we will be detailing in a future post, we are recommending that Good Ventures make substantial grants to our top charities this year, though not enough to close their funding gaps.

Continued refinement of the concept of “room for more funding.” We’ve tried to create a much more systematic and detailed room for more funding analysis, because the stakes of this analysis have become higher due to (a) increased room for more funding across the board and (b) increased interest from Good Ventures in providing major support.

In past years, we’ve discussed charities’ room for more funding as a single figure without distinguishing between (a) the amount the charity would spend in the next 12 months, (b) the amount the charity needs to prevent it from slowing its work due to lack of funds, and (c) funding that would be especially important to the organization’s development and success (a dual benefit) in addition to expanding implementation of its program. This year, we’ve made three changes to our room for more funding analysis:

• We’ve made (a) an assessment of whether additional funds merely allow a charity to implement its program (“execution”) or (b) whether additional funds would be especially important to the charity’s development and success as an organization (“capacity-relevant”). We also explicitly note the role of incentives for meeting GiveWell’s top-charity criteria in our recommendations (we seek to ensure that each top charity receives at least $1 million, to encourage other organizations to seek to meet these criteria). • We are explicitly assessing “execution”-related room for more funding based on our estimate of the probability that lack of funding will lead to a charity slowing its progress. We distinguish between Level 1, Level 2, and Level 3 “execution” funding gaps; a higher number means the money is less likely to be needed. • We are now ranking “funding gaps,” not just ranking charities, because the first million dollars to a charity can have a very different impact from, e.g., the 20th million dollars. For example, if Charity A accomplishes more good per dollar with its programs than Charity B, we would rank Charity A above Charity B for a given type of gap (we would rank Charity A’s “Execution Level 1” gap above Charity B’s), but we might rank Charity B’s “Execution Level 1” gap (the amount of funding it will likely need) above Charity A’s “Execution Level 3” gap (the amount of funding gap it might, but probably will not, need to carry out more of its programs in the coming year). We discuss these ideas in greater depth below. Summary of key considerations for top charities The table below summarizes the key considerations for our four top charities. More detail is provided below as well as in the charity reviews. Consideration AMF Deworm the World GiveDirectly SCI Program estimated cost-effectiveness (relative to cash transfers) ~10x ~10x Baseline ~5x Directness and robustness of the case for impact Strong Moderate Strongest Moderate Transparency and communication Strong Strong Strongest Weakest Ongoing monitoring and likelihood of detecting future problems Strong Strong Strongest Weakest Organizational track record of rolling out program Moderate Moderate Strong Strong Room for more funding, after accounting for grants we are recommending to Good Ventures (more below) Very high Limited Very high High Overall, our ranking of the charities with room for more funding issues set aside (just considering a hypothetical dollar spent by the charity on its programs, without the “capacity-relevant funding” and “incentives” issues discussed below) would be: 1. AMF and Deworm the World 3. SCI 4. GiveDirectly However, when we factor in room for more funding (including the impact of the grants we’re recommending to Good Ventures), the picture changes. More on this below. Room for more funding analysis Capacity-relevant funding and incentives Capacity-relevant funding: additional funding can sometimes be crucial for a charity’s development and success as an organization. For example, it can contribute to a charity’s ability to experiment, expand, and ultimately have greater room for more funding over the long run. It can also be important for a charity’s ability to raise funds from non-GiveWell donors, which can be an important source of long-term leverage and can put the organization in a stronger overall position. We think of this sort of funding gap as particularly important to fill, because it can make a big difference over the long run; in particular, it may substantially affect the long-term quality of our giving recommendations. “Capacity-relevant” funds can include (a) funds that are explicitly targeted at growth (e.g., funds to hire fundraising staff); (b) funds that enable a charity to expand into areas it hasn’t worked in before, which can lead to important learning about whether and how the charity can operate in the new location(s); and (c) funds that would be needed in order to avoid challenging contractions in a charity’s activities which could jeopardize the charity’s long-term growth and funding prospects. Some specific examples: • The grant that Good Ventures made to GiveDirectly earlier this year is capacity-relevant because it will be used for: (a) building a fundraising team that will aim to raise substantial donations from non-GiveWell donors, and (b) developing partnerships with bilateral donors and local governments to deliver cash transfers or to run experiments comparing standard aid programs to cash transfers. • Early funding that GiveDirectly received was capacity-relevant because it enabled GiveDirectly to rapidly grow from a small organization moving a few hundred thousand dollars per year to a much larger organization moving more than$10 million per year. If this funding hadn’t been forthcoming, GiveDirectly might be much smaller today and have much less room for more funding.
• We now think that some additional funding to AMF and Deworm the World will be capacity-relevant because each organization has only operated in a very small number of countries and new funding will enable each to enter new countries. This will allow them to learn how to operate there, and demonstrate that they can do so, increasing our willingness (and likely that of other donors) to recommend more to these organizations in the future.

It’s hard to draw sharp lines around capacity-relevant funding, and all funding likely has some effect on an organization’s development, but we have tried to identify and prioritize the funding gaps that seem especially relevant.

Execution funding allows charities to implement more of their core program but doesn’t appear to have substantial benefits beyond the direct good accomplished by this program. We’ve separated this funding into three levels:

• Level 1: the amount we expect a charity to need in the coming year. If a charity has less funding than this level, we think it is more likely than not that it will be bottlenecked (or unable to carry out its core program to the fullest extent) by funding in the coming year.
• Level 2: if a charity has this amount, we think there is an ~80% chance that it will not be bottlenecked by funding.
• Level 3: if a charity has this amount, we think there is a ~95% chance that it will not be bottlenecked by funding.

Incentives: we think it is important that charities we recommend get a substantial amount of funding due to being a GiveWell top charity, because this ensures that incentives are in place for charities (and potential charity founders) to seek to meet our criteria for top charities and thus increase the number of charities we recommend and the total room for more funding available, even when they don’t end up being ranked #1. We seek to ensure that each top charity gets at least $1 million as a result of our recommendation, and we consider this to be a high-priority goal of our recommendations. The charity-specific sections of this post discuss the reasoning behind the figures we’ve assigned to “capacity-relevant” and “Execution Level 1” gaps, but they do not provide the full details of how we arrived at these figures (and do not explicitly address the “Execution Level 2” and “Execution Level 3” gaps). We expect to add this analysis to our charity reviews in the coming weeks. Funding gaps The total (i.e., Capacity-relevant, Execution Levels 1, 2, and 3, and Incentive) funding gaps (in millions of dollars, rounded to one decimal place) for each of our top charities are: • AMF:$98.2
• Deworm the World: $19.0 • GiveDirectly:$84.0
• SCI: $26.3 However, for reasons described above, the first million dollars to a charity can have a very different impact from, e.g., the 20th million dollars. Accordingly, we have created a ranking of individual funding gaps that accounts for both (a) the quality of the charity and the good accomplished by its program, per dollar (as laid out above), and (b) whether a given level of funding is capacity-relevant and whether it is highly or only marginally likely to be needed in the coming year. The below table lays out our ranking of funding gaps. When gaps have the same “Priority,” this indicates that they are tied. The table below includes the amount we are recommending to Good Ventures. For reasons we will lay out in another post, we are recommending to Good Ventures a total of ~$44.4 million in grants to top charities. Having set that total, we are recommending that Good Ventures start with funding the highest-rated gaps and work its way down, in order to accomplish as much good as possible.

When gaps are tied, we recommend filling them by giving each equal dollar amounts until one is filled, and then following the same procedure with the remaining tied gaps. See footnote for more.*

Priority Charity Amount Type Recommendation to Good Ventures Comments 1 DtWI $7.6 Capacity-relevant$7.6 DtWI and AMF are strongest overall 1 AMF $6.5 Capacity-relevant$6.5 See above 1 GD $1.0 Incentive$1.0 Ensuring each top charity receives at least $1 million 1 SCI$1.0 Incentive $1.0 Ensuring each top charity receives at least$1 million 2 GD $8.8 Capacity-relevant$8.8 Not as cost-effective as bednets or deworming, so lower priority, but above non-capacity-relevant gaps 2 DtWI $3.2 Execution Level 2 / possibly capacity-relevant$3.2 Level 1 gap already filled via “capacity-relevant” gap. See footnote for more** 2 AMF $43.8 Execution Level 1$16.3 Exhausts remaining recommendations to Good Ventures 3 SCI $4.9 Execution Level 1 0 Not as strong as DtWI and AMF in isolation, so ranked below them for same type of gap 3 AMF$24.0 Execution Level 2 0 – 4 DtWI $8.2 Execution Level 3 0 – 4 AMF$24.0 Execution Level 3 0 – 4 SCI $11.6 Execution Level 2 0 – 5 GD$24.8 Execution Level 1 0 – 5 SCI $8.8 Execution Level 3 0 – 6 GD$20.9 Execution Level 2 0 – 7 GD $28.6 Execution Level 3 0 – Our recommendations to Good Ventures and others Summing the figures from the above table, we are recommending that Good Ventures make the following grants (in millions of dollars, rounded to one decimal place): • AMF:$22.8
• Deworm the World: $10.8 • GiveDirectly:$9.8
• SCI: $1 We also recommend that Good Ventures give$250,000 to each of our standout charities. These grants go to the outstanding organizations and create additional incentives for groups to try to obtain a GiveWell recommendation.

After these grants, AMF will require an additional ~$27.5 million to close its Execution Level 1 gap (i.e., to make it more likely than not that it is able to proceed without being bottlenecked due to lack of funding). We rank this gap higher than any of the other remaining funding gaps for our top charities, as laid out in the table above. We estimate that non-Good Ventures donors will give approximately$15 million between now and January 31, 2016. Because we do not expect AMF’s remaining ~$27.5 million Execution Level 1 funding gap to be fully filled, we rank it #1 and recommend that donors give to AMF. We rank the remaining charities for donors who are interested in having the greatest impact per dollar based on how highly their highest-rated remaining gap ranks in the table above. That results in the following rankings for individual donors: 1. AMF 2. SCI 3. Deworm the World Initiative 4. GiveDirectly Details on top charities We present information on our top charities in alphabetical order. Against Malaria Foundation (AMF) Our full review of AMF is here. Background AMF (www.againstmalaria.com) provides funding for long-lasting insecticide-treated net distributions (for protection against malaria) in developing countries. There is strong evidence that distributing nets reduces child mortality and malaria cases. AMF has relatively strong reporting requirements for its distribution partners and provides a level of public disclosure and tracking of distributions that we have not seen from any other net distribution charity. In 2011, AMF received a large amount of funding relative to what it had received historically, so it began to focus primarily on reaching agreements for large-scale net distributions (i.e., distributions on the order of hundreds of thousands of nets rather than tens of thousands of nets). In its early efforts to scale up, AMF struggled to finalize large-scale net distribution agreements. At the end of 2013, we announced that we planned not to recommend additional donations to AMF due to room for more funding-related issues (more detail in this blog post). In 2014, AMF committed most of its funds to several new distributions — some in Malawi, some in the Democratic Republic of the Congo (DRC) — and we recommended it as a top charity again. Important changes in the last 12 months Previously, our confidence in AMF’s ability to scale had been limited by the fact that it had only completed large-scale distributions with one partner (Concern Universal) in one country (Malawi). However, AMF carried out its largest distribution to date (~620,000 nets) with a new partner in the DRC in late 2014. We have not yet seen some key documentation from the large DRC distribution, but early indications suggest that the distribution generally went as planned, despite our concern that the DRC may have been an especially challenging place to work (more details here). We see this as a positive update that AMF will be able to carry out high-quality large-scale distributions in a variety of locations in the future. AMF has continued to collect and share follow-up information on its past large-scale distributions, and this information seems to support the notion that these distributions are high-quality (i.e., that nets are reaching the target population and are being used). We provide a summary of these reports in our review. Funding gap AMF currently holds$18.5 million, and we estimate it will receive an additional $1.6 million before January 31, 2016 (excluding donations influenced by GiveWell) that it could use for future distributions. AMF has told us that it has a pipeline of possible future net distributions that add up to roughly$100 million beyond what it currently holds (details in our review).

We believe that AMF’s progress would be slowed due to lack of funding were it to receive less than $50.3 million in additional funding (this is its total capacity-relevant and “Execution Level 1” gap as presented earlier in the post). In particular, we view the first additional$6.5 million that AMF would receive as capacity-relevant (and thus particularly valuable) because it would enable AMF to fund a distribution in a 5th country with a 5th partner, generating additional information about its ability to expand beyond the contexts in which it has worked to date. (Note that AMF already has funds on hand to enter its 3rd and 4th countries.)

We arrived at the capacity-relevant and Execution Level 1 figure by noting that AMF has $70.4 million worth of deals it is actively negotiating (5 deals in 4 countries) that it can only continue with if it holds the funds to do so. Subtracting the$20.1 million we expect to be available (the $18.5 million it currently holds plus the$1.6 million we expect it to receive in the coming months) leaves a $50.3 million funding gap. AMF failed to reach new distribution agreements in 2015; there is still significant uncertainty regarding AMF’s ability to finalize agreements with new partners and countries. Nevertheless, we see providing a large amount of additional funds to AMF as a reasonable bet, and see AMF as a very strong giving opportunity. We think it is possible that in November 2016 (when we next expect to complete a full refresh of our recommendations), we will recommend significantly less funding to AMF. We consider the funding we’re recommending to AMF now to be a good bet, but a risky one, because AMF currently has a relatively limited track record: it has worked with only two partners in two countries. Because of the lag between the time we provide funding and the time net distributions take place (often 2 years) and the additional lag caused by the time it takes to monitor distributions, we may not have additional information about whether or not AMF’s additional distributions were successful for 2-3 years. Next year, it is possible that we will choose to recommend significantly less funding to AMF while we wait for additional data to become available. There still appears to be a large global funding gap for bednets; a global bednet coordination group estimated that about 245 million additional nets would be needed in 2015-2017 (details in our review). Key considerations: • Program impact and cost-effectiveness. We estimate that bednets are ~10x as cost-effective as cash transfers. Our estimates are subject to substantial uncertainty. All of our cost-effectiveness analyses are available here. Our 2015 cost-effectiveness file is available here (.xlsx). • Directness and robustness of the case for impact. We believe that the connection between AMF receiving funds and those funds helping very poor individuals is less direct than GiveDirectly’s and more direct than SCI’s or Deworm the World’s. The uncertainty of our estimates is driven by a combination of AMF’s challenges historically disbursing the funds it receives and a general recognition that aid programs, even those as straightforward as bednets, carry significant risks of failure via ineffective use of nets, insecticide resistance, or other risks we don’t yet recognize relative to GiveDirectly’s program. AMF conducts extensive monitoring of its program; these results have generally indicated that people use the nets they receive. • Transparency and communication. AMF has been extremely communicative and open with us. We feel we have a better understanding of AMF than of SCI, and a similar level of knowledge about AMF as we have for Deworm the World, though our understanding is not as strong as our understanding of GiveDirectly. In particular, were something to go wrong in one of AMF’s distributions, we believe we would eventually find out (something we are not sure of in the case of SCI), but we believe our understanding would be less quick and complete than it would be for problems associated with GiveDirectly’s program (which has more of a track record of consistent intensive follow-up). • Risks: • We are not highly confident that AMF will be able to finalize additional distributions and do so quickly. AMF could struggle again to agree to distribution deals, leading to long delays before it spends funds. We view this as a relatively minor risk because the likely worst-case scenario is that AMF spends the funds slowly (or returns funds to donors). • We remain concerned about the possibility of resistance to the insecticides used in bednets. There don’t appear to be major updates on this front since our 2012 investigation into the matter; we take the lack of major news as a minor positive update. Our full review of AMF is here. Deworm the World Initiative, led by Evidence Action Our full review of Deworm the World is here. Background Deworm the World (www.evidenceaction.org/deworming), led by Evidence Action, advocates for, supports, and evaluates government-run school-based deworming programs (treating children for intestinal parasites). We believe that deworming is a program backed by relatively strong evidence. We have reservations about the evidence, but we think the potential benefits are great enough, and costs low enough, to outweigh these reservations. Deworm the World retains monitors whose reports indicate that the deworming programs it supports successfully deworm children. Important changes in the last 12 months In 2015, Deworm the World continued to support the scale-up and monitoring of deworming programs in India and Kenya. One of its notable activities this year was providing technical assistance to the Indian national government in support of India’s first national deworming day: a program in which the government provided assistance to Indian states to implement school-based deworming on a single day to encourage more states to implement the program. The first national deworming day took place in February 2015, and 12 states participated in the program (more details here). The quality of the monitoring that we saw from Deworm the World improved in 2015. Deworm the World continued to hire and train third-party monitors to directly observe deworming activities, and it slightly improved its estimates of how many children were treated. This information strongly suggests that the programs are generally operating as intended. More details in our review. Last year, Deworm the World stated to us that it could not use significant additional funding to scale up deworming programs. Deworm the World now believes that it has identified countries where it could use additional funds to support the scale-up of deworming programs, beginning with a potential program in Punjab province, Pakistan (more). (Deworm the World also plans to use funds it already holds or expects to receive to expand into Ethiopia and Nigeria.) Future donations to Deworm the World will likely be used outside of India, and in those cases governments may have less funding to support deworming. This may cause Deworm the World to pay a higher fraction of the overall cost of the program, making the potential for leverage of future donations more limited. Overall program costs may also be higher outside of India. More details in our review. A significant organizational update is that Alix Zwane stepped down as Executive Director of Evidence Action in August; she left to join the Global Innovation Fund as CEO. Evidence Action has since hired Jeff Brown (formerly Interim CEO of the Global Innovation Fund) as Executive Director. Grace Hollister remains Director of the Deworm the World Initiative. Overall, our impression is that Dr. Zwane has been a highly effective leader of Evidence Action and her departure risks disruptions that could lead to us changing our view of the organization, though we would guess that this will not be the case. In July, researchers published two new analyses of a key study regarding deworming (the most important piece of evidence we rely on), and the Cochrane Collaboration published an updated review of the evidence for mass deworming programs. The new papers did not change our overall assessment of the evidence on deworming. More in our blog post. Funding gap We believe that Deworm the World has significant opportunities to use additional funding to expand its program. We believe it may have opportunities to enter at least two more countries (in addition to Nigeria and Ethiopia, which it will be able to enter with funds it already has or expects to receive). We estimate its funding need using the two countries it is most likely to enter — Pakistan and Nepal — though note that in both cases, we see these as representative of the types of opportunities it may have, rather than the specific opportunities we expect it to take. Altogether, Deworm the World estimates that it would need$11.25 million to commit to fully funding three years of deworming programs in both countries. Because it holds (or expects to receive shortly) funding that will total $3.6 million, we estimate its funding gap for this work at$7.6 million.

Funding this gap is capacity-relevant, and is therefore a high priority, because we would like to see Deworm the World try to work in additional countries beyond India and Kenya, where it has worked historically. Next year, Deworm the World will also enter Nigeria and Ethiopia (with funding already available), so it will likely end the year having had some experience in five or more countries. This could substantially increase Deworm the World’s long-term room for more funding.

A complicating factor in thinking about Deworm the World’s funding gap is that Deworm the World is part of a larger organization, Evidence Action. Funding for Deworm the World may be fungible with funding for Evidence Action’s other activities, such as its Dispensers for Safe Water initiative (which we believe to be substantially less cost-effective than deworming). Because of this, it is difficult to determine Deworm the World’s true funding gap, and it is possible that some additional funds given to support Deworm the World could effectively lead to additional funds for a non-Deworm the World project. We understand that Evidence Action has received approximately $2.4 million in unrestricted funding over the past year. Fully funding Deworm the World could potentially cause Evidence Action to redirect some or all of these funds to its other programs. More details on all of the above are in our review. Key considerations: • Program impact and cost-effectiveness. We estimate that Deworm the World-associated deworming programs are ~10x as cost-effective as cash transfers. Our estimates are subject to substantial uncertainty. It’s important to note that we view deworming as high expected value, but this is due to a relatively low probability of very high impact. Most GiveWell staff members would agree that deworming programs are more likely than not to have very little or no impact, but there is some possibility that they have a very large impact. (Our cost-effectiveness model implies that most staff members believe there is at most a 1-2% chance that deworming programs conducted today have similar impacts to those directly implied by the randomized controlled trials on which we rely most heavily, which differed from modern-day deworming programs in a number of important ways.) Our 2015 cost-effectiveness file is available here (.xlsx). • Directness and robustness of the case for impact. Deworm the World doesn’t carry out deworming programs itself; it advocates for and provides technical assistance to governments implementing deworming programs, making direct assessments of its impact challenging. We have seen evidence that strongly suggests that Deworm the World-supported programs successfully deworm children. While we believe Deworm the World is impactful, our evidence is limited, and in addition, there is always a risk that future expansions will prove more difficult than past ones. • Transparency and communication. Deworm the World has been communicative and open with us. We believe that were something major to go wrong with Deworm the World’s work, we would be able to learn about it and report on it. • Risks: • Deworm the World is part of a larger organization, Evidence Action. It is possible that some additional funds given to support Deworm the World could effectively lead to additional funds for a non-Deworm the World project due to fungibility. Also, changes that affect Evidence Action (and its other programs) could indirectly impact Deworm the World. For example, if a major event occurs (either positive or negative) for Evidence Action, it is likely that it would reduce the time some staff could devote to Deworm the World. • Deworm the World is now largely raising funds to support programs that will be carried out under a different model in new countries, which makes it harder for us to predict future success based on historical results and may make it harder to understand and quantify Deworm the World’s impact even after the program is completed. Our full review of Deworm the World is here. GiveDirectly Our full review of GiveDirectly is here. Background GiveDirectly (www.givedirectly.org) transfers cash to households in developing countries via mobile phone-linked payment services. It targets extremely low-income households. The proportion of total expenses that GiveDirectly has delivered directly to recipients is approximately 85% overall. We believe that this approach faces an unusually low burden of proof, and that the available evidence supports the idea that unconditional cash transfers significantly help people. We believe GiveDirectly to be an exceptionally strong and effective organization, even more so than our other top charities. It has invested heavily in self-evaluation from the start, scaled up quickly, and communicated with us clearly. It appears that GiveDirectly has been effective at delivering cash to low-income households. GiveDirectly has one major randomized controlled trial (RCT) of its impact and took the unusual step of making the details of this study public before data was collected (more). It continues to experiment heavily, to the point where every recipient is enrolled in a study or a campaign variation. Important changes in the last 12 months GiveDirectly continued to scale up significantly, utilizing most of the funding it received at the end of last year. It continued to share informative and detailed monitoring information with us. Overall, it grew its operations while maintaining the high quality of its program. In August, Good Ventures granted$25 million to GiveDirectly to support potentially high-upside opportunities, such as (a) building a fundraising team that will aim to raise substantial donations from non-GiveWell donors, and (b) developing partnerships with bilateral donors and local governments to deliver cash transfers or to run experiments comparing standard aid programs to cash transfers.

GiveDirectly’s increased efforts to network with potential government and donor partners have led to some results in 2015. For example, GiveDirectly will be implementing cash transfers in a randomized controlled trial in Rwanda that will be funded by a bilateral aid donor and Google. The study will test cash transfers against another still-to-be-chosen aid program. GiveDirectly is currently in several preliminary conversations with partners for similarly large projects in the future.

Funding gap

GiveDirectly believes it could move a total of ~$94 million to poor households in the year following March 1, 2016, for which it expects to have ~$12.6 million available by March 1. We have classified ~$34.5 million of this as the total “Execution Level 1,” capacity-relevant, and incentive funding gap (more on what this means above). We arrived at this figure by assuming that GiveDirectly could double its operations in Kenya (from ~$16.5 million/year to ~$33 million/year) and scale up to ~$12.1 million/year in Uganda. This would cost a total of ~$45.1 million, of which GiveDirectly already has ~$10.6 million on hand (ignoring $2 million that we exclude due to donor coordination issues), which results in a ~$34.5 million gap.

We’ve classified some of this as a “capacity-relevant” funding gap for our purposes (making it higher priority). First, we view the ~$12.1 million it would hope to spend in Uganda as capacity-relevant, in the sense that providing it could make a major difference to GiveDirectly’s long-term development. GiveDirectly told us that operating in Uganda is more challenging than in Kenya and that it expects to learn a significant amount as it grows. It is therefore planning to grow more slowly in Uganda than it did in Kenya. GiveDirectly made two arguments for Uganda being important for its long-term trajectory: 1. If GiveDirectly lost the ability to operate in Kenya, this would significantly diminish its ability to move funds out the door. Operating in Uganda is an important hedge against this risk. 2. Kenya is a particularly easy environment in which to operate because of the existence of M-PESA, a powerful and ubiquitous provider that enables GiveDirectly to transfer funds to recipients via mobile phones. The mobile payments network is significantly less developed outside of Kenya. As such, Uganda offers an important test case for operating in a more standard environment, which could be particularly valuable to GiveDirectly as it encourages aid agencies and country governments to expand direct cash assistance. It’s harder to estimate how much of the Kenya funding needs are properly classified as “capacity-relevant” (an important distinction for our purposes, as discussed above). We guess that were GiveDirectly to be operating at a level 50% its current size (such that it only spent ~$8.25 million/year in Kenya), it would be able to build capacity from that level to its current level (and beyond) as quickly as it did in its recent past. We therefore classify ~$8.25 million of the ~$16.5 million it hopes to spend in Kenya as “capacity-relevant” and ~$8.25 million as “execution.” We note that we are highly uncertain about these estimates and that were GiveDirectly to receive no additional funding, this would cause it to contract in Kenya and lay off some of its middle management, an action that would cause it to incur reasonably high costs; we think much more contraction than that would be significantly more challenging for GiveDirectly as an organization. Based on the above, and based on GiveDirectly’s existing available funds (with some adjustments for coordination issues, along the lines of this discussion from last year) we estimate that GiveDirectly has ~$9.8 million worth of unfunded opportunities that we ought to classify as capacity-relevant or incentive funding. (We arrive at this estimate based on: ~$20.35 million (total amount we classify as capacity-relevant from Kenya and Uganda) – ~$10.6 million (funds on hand, excluding donations we ignore due to coordination issues) = ~$9.75 million.) Longer-term, we expect to continue to view funding ~$8.25 million in Kenya as capacity-relevant support and would expect to consider future expansion in Uganda (up to the current level of Kenya, i.e., ~$16.5 million/year) capacity-relevant, as well. Once GiveDirectly reaches ~$16.5 million in Uganda and proves that it can operate at that level, we only expect to view ~$8.25 million as capacity-relevant and hope that it can raise funds from other sources to support its work. More details in our review. Key considerations: • Program impact and cost-effectiveness. Our best guess is that deworming or distributing bednets achieves ~10x times more humanitarian benefit per dollar donated than cash transfers. Our estimates are subject to substantial uncertainty. All of our cost-effectiveness analyses are available here. Our 2015 cost-effectiveness file is available here (.xlsx). • Directness and robustness of the case for impact. GiveDirectly collects and shares a significant amount of relevant information about its activities. The data it collects show that it successfully directs cash to very poor people, that recipients generally spend funds productively (sometimes on food, clothing, or school fees, other times on investments in a business or home infrastructure), and that it leads to very low levels of interpersonal conflict and tension. We are more confident in the impact of GiveDirectly’s work than in that of any of the other charities discussed in this post; we believe that cash transfers face a lower burden of proof than other interventions. • Transparency and communication. GiveDirectly has always communicated clearly and openly with us. It has tended to raise problems to us before we ask about them, and we generally believe that we have a very clear view of its operations. We feel more confident about our ability to keep track of future challenges than with any of the other charities discussed in this post. • Risks: • GiveDirectly has scaled (and hopes to continue to scale) quickly. Thus far, it has significantly increased the amount of money it can move with limited issues as a result. The case of staff fraud that GiveDirectly detected is one example of an issue possibly caused by its pace of scaling, but its response demonstrated the transparency and rigor we expect. Our full review of GiveDirectly is here. Schistosomiasis Control Initiative (SCI) Our full review of SCI is here. Background SCI (www3.imperial.ac.uk/schisto) works with governments in sub-Saharan Africa to create or scale up deworming programs (treating children for schistosomiasis and other intestinal parasites). SCI’s role has primarily been to identify recipient countries, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs. Despite SCI sharing a number of spending reports with us, we do not feel we have a detailed and fully accurate picture of how SCI and the governments it supports have spent funds in the past. We don’t feel that SCI has ever purposefully been indirect with us, but we have often struggled to communicate effectively with SCI representatives. We still lack important and in some cases basic information about SCI’s finances, and we find this problematic. We believe that deworming is a program backed by relatively strong evidence. We have reservations about the evidence, but we think the potential benefits are great enough, and costs low enough, to outweigh these reservations. SCI has conducted studies in about half of the countries it works in (including the countries with the largest programs) to determine whether its programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but have some methodological limitations. Important changes in the last 12 months SCI reports that it has continued to scale up its deworming programs and that it has supported some programs in new countries, though we have limited monitoring information from these programs (e.g., we have not seen monitoring from its programs in Ethiopia, Sudan, Madagascar, and the DRC). This year, SCI has shared a few more coverage surveys that found reasonably high coverage of its programs. We have continued to have communication challenges with SCI. In particular: • We have a limited understanding of SCI’s work because we still lack important and basic information about how SCI spends money. SCI recognizes that its financial management system is disorganized, and some spending reports that SCI has sent us have contained errors. • We have struggled to gain a confident understanding of how SCI will use additional funds, and we cannot check how its funds were used after the fact because we lack information about its spending. In some cases, SCI has not spent additional funds as expected and it is unclear what caused the shift (more detail on one example in our August 2015 update). In July, researchers published two new analyses of a key study regarding deworming (the most important piece of evidence we rely on), and the Cochrane Collaboration published an updated review of the evidence for mass deworming programs. The new papers did not change our overall assessment of the evidence on deworming. More in our blog post. Funding gap SCI estimates that it would use the following amounts of unrestricted funding in each of the next three years (in millions of US dollars): • April 2016 – March 2017:$9.5
• April 2017 – March 2018: $13.6 • April 2018 – March 2019:$13.3

Our impression is that GiveWell-influenced donors contribute most of SCI’s unrestricted funds.

Our best guess is that, excluding the funds SCI may receive due to GiveWell’s recommendation, SCI will hold approximately $1.5 million in April 2016 that it could allocate to the above gaps. Also, after SCI set its fundraising targets, a funder committed$6 million over the next three years ($2 million per year) to deworming programs in Ethiopia, with which SCI is involved. Our best guess is that this funding reduces SCI’s “Execution Level 1” and incentive funding gap for the coming year from$9.5 million to $5.9 million. (We arrive at this estimate by subtracting ~$1.5 million and another $2 million from the total Level 1/incentive gap for the coming year). We do not classify any of this as “capacity-relevant” because we have little understanding of how it will be spent, and we do not expect to be able to understand how it was spent after the fact, either. More details on SCI’s funding gap are in our review. Key considerations: • Program impact and cost-effectiveness. Our best guess is that deworming programs implemented by SCI are ~5x as cost-effective as cash transfers. Our estimates are subject to substantial uncertainty. It’s important to note that we view deworming as high expected value, but this is due to a relatively low probability of very high impact. Most GiveWell staff members would agree that deworming programs are more likely than not to have very little or no impact, but there is some possibility that they have a very large impact. (Our cost-effectiveness model implies that most staff members believe there is at most a 1-2% chance that deworming programs conducted today have similar impacts to those directly implied by the randomized controlled trials on which we rely most heavily, which differed from modern-day deworming programs in a number of important ways.) Our 2015 cost-effectiveness file is available here (.xlsx). • Directness and robustness of the case for impact. SCI doesn’t carry out deworming programs itself; it advocates for and provides technical assistance to governments implementing deworming programs, making direct assessments of its impact challenging. We have seen some evidence demonstrating that SCI-supported programs successfully deworm children, though this evidence is relatively thin. Nevertheless, deworming is a relatively straightforward program, and we think it is likely (though far from certain) that SCI-supported deworming programs successfully deworm people. We have had difficulties communicating with SCI, which has reduced our ability to understand it. We have also spent significant time interviewing SCI staff and reviewing documents over the past 6 years and have found minor but not major concerns. • Transparency and communication. We don’t feel that SCI has ever purposefully been indirect with us, but we have often struggled to communicate effectively with SCI representatives. Specifically, (a) we had a major miscommunication with SCI about the meaning of its self-evaluations (more) and (b) although we have spent significant time with SCI, we remain unsure how SCI has spent funds and how much funding it has available (and we believe SCI itself does not have a clear understanding of this). Importantly, if there is a future unanticipated problem with SCI’s programs, we don’t feel confident that we will become aware of it. This contrasts with our other top charities, which we feel we have a strong ability to follow up on. • Risks: There are significantly more unknown risks with SCI than our other top charities due to our limited understanding of its activities. Our full review of SCI is here. Standouts As we did last year, we recommend four organizations as “standouts.” These charities score well on some of our criteria, but we are not confident enough in them to name them top charities. This year, we retain the same four standout organizations: Development Media International (DMI), the Global Alliance for Improved Nutrition’s Universal Salt Iodization program (GAIN-USI), the Iodine Global Network (IGN), and Living Goods. We followed all four of these charities in 2015, but have only published an updated review for DMI. We expect to publish updated reviews for GAIN-USI, IGN, and Living Goods in the near future. We provide brief updates on these charities below: • DMI. DMI produces radio and television programming in developing countries that encourages people to adopt improved health practices. It is a standout because of its commitment to monitoring and the possibility that it is implementing a highly cost-effective program. DMI has recently completed a randomized controlled trial of its program. Last year, we had midline results from this trial, which generally looked promising.In November 2015, DMI privately shared preliminary endline results from the RCT. These results did not find any effect of DMI’s program on child mortality, and found substantially less effect on behavior change than was found in the midline results. We (understandably) cannot publicly discuss the details of the endline results we have seen, because they are not yet finalized and because the finalized results will be embargoed prior to publication. DMI believes that there were serious problems with endline data collection (note that we have not yet tried to independently assess this claim). With the support of the trial’s Independent Scientific Advisory Committee, DMI is planning to conduct another endline survey in late 2016, with results available in 2017.We are impressed by DMI’s openness with us about its results (and its willingness for us to share the high-level summary), and we hope to have discussions with DMI about how it might be able to work toward becoming a top charity in the future. Our full review of DMI is here. • GAIN-USI. GAIN’s Universal Salt Iodization (USI) program supports national salt iodization programs. There is strong evidence that salt iodization programs have a significant, positive effect on children’s cognitive development. GAIN-USI does not work directly to iodize salt; rather, it supports governments and private companies to do so, which could lead to leveraged impact of donations or to low impact, depending on its effectiveness. Last year, we wrote, “We tried but were unable to document a demonstrable track record of impact; we believe it may have had significant impacts, but we are unable to be confident in this with what we know now. More investigation next year could change this picture.” In 2015, we continued our assessment of GAIN, focusing on its work in India and Ethiopia, including a site visit to Ethiopia in July.Overall, we tried but were unable to establish clear evidence of GAIN successfully contributing to the impact of iodization programs. This is primarily due to (a) the difficulty in attributing impact to specific activities that GAIN carried out and (b) challenges we have had communicating with GAIN about its work. We have not yet completed our final report on GAIN but hope to publish it in the near future. We have published notes from some of the conversations that were part of this research and they are available here. Our 2014 review of GAIN is here. • IGN. Like GAIN-USI, IGN supports (via advocacy and technical assistance rather than implementation) salt iodization, and as with GAIN-USI, we tried but were unable to establish clear evidence of IGN successfully contributing to the impact of iodization programs. Unlike GAIN-USI, IGN is small, operating on a budget of approximately$0.5-$1 million per year, and relies heavily on volunteer time. We are planning to post an updated review in the near future. Our 2014 review of IGN is here. • Living Goods recruits, trains, and manages a network of community health promoters who sell health and household goods door-to-door in Uganda and Kenya and provide basic health counseling. They sell products such as treatments for malaria and diarrhea, fortified foods, water filters, bednets, clean cookstoves, and solar lights. Living Goods completed a randomized controlled trial of its program and measured a 27% reduction in child mortality. We estimate that Living Goods saves a life for roughly each$10,000 it spends, approximately 3 times as much as our estimate for the cost per life saved of AMF’s program. We spoke with Living Goods and reviewed documents about their progress in 2015. We do not have major updates to report but are planning to post an updated review in the near future. Our 2014 review of Living Goods is here.

Our research process in 2015

This section describes the new work we did in 2015 to supplement our previous work on defining and identifying top charities. See the process page on our website for our overall process.

This year, we did not put a substantial amount of senior staff time into new top charities research work because (a) we were largely focused on building capacity, and (b) we reallocated a significant amount of capacity to the Open Philanthropy Project (see our post on our plans for 2015 for more details).

We focused the bulk of our research capacity for top charities work on staying up-to-date on our recommended charities. We also did an intensive evaluation of GAIN-USI, including a site visit (more details forthcoming).

We completed investigations of vitamin A supplementation and maternal and neonatal tetanus immunization campaigns. Both programs seem potentially competitive with our other priority programs, but we were not able to identify charities that worked on these programs that were willing to apply for a recommendation. We also made substantial progress on investigating several other programs, such as measles immunization, meningitis A vaccination, folic acid fortification, voluntary medical male circumcision for the prevention of HIV, and “Targeting the Ultra-Poor” (or “Ultra-Poor Graduation”) programs.

We stayed up to date on the research for bednets, cash transfers, and deworming.

We did not conduct an extensive search for new charities this year. We feel that we have a relatively good understanding of the existing charities that could potentially meet our criteria, based on past searches (see the process page on our website for more information). Instead, we solicited applications from organizations that we viewed as contenders for recommendations. A March post laid out which organizations we were hoping to investigate and why.

We did some initial research on several charities that we had not investigated before, but we did not complete the reviews in time for our 2015 recommendations. The organizations that we began investigating were:

We plan to complete these reviews in 2016.

Giving to GiveWell vs. top charities

We have grown significantly over the past few years and continue to raise funds to support our operations. This includes work on GiveWell’s top charities and the Open Philanthropy Project.

We plan to post an update on our funding situation before the end of the year.

The most up-to-date information available on this topic is linked from our June 2015 board meeting. The short story is that we are still seeking additional donations and encourage donors who feel they are sufficiently confident in our impact to give to us.

Footnotes:

* For example, if $30 million were available to fund gaps of$10 million, $5 million, and$100 million, we would recommend allocating the funds so that the $10 million and$5 million gaps were fully filled and the $100 million gap received$15 million.

This rule is material to the three gaps tied at priority level 2. It causes us to recommend that Good Ventures’ last $28.3 million to recommended charities is used to fully fill GiveDirectly’s$8.8 million capacity-relevant gap and Deworm the World’s $3.2 million Execution Level 2 (possible capacity-relevant) gap, but only fill$16.3 million of AMF’s Execution Level 1 gap.

** This gap can’t be cleanly classified because we think the funding is relatively unlikely to be needed, but if it is needed, it is likely to have capacity-relevant effects. Thus, it is technically classified as Execution Level 2, but we think it has similar value to Execution Level 1.

The post Our updated top charities for giving season 2015 appeared first on The GiveWell Blog.

### New deworming reanalyses and Cochrane review

Fri, 07/24/2015 - 13:54

On Wednesday, the International Journal of Epidemiology published two new reanalyses of Miguel and Kremer 2004, the most well-known randomized trial of deworming. Deworming is an intervention conducted by two of our top charities, so we’ve read the reanalyses and the simultaneously updated Cochrane review closely and are responding publicly. We still have a few remaining questions about the reanalyses, and have not had a chance to update much of the content on the rest of our website regarding these issues, but our current view is that these new papers do not change our overall assessment of the evidence on deworming, and we continue to recommend the Schistosomiasis Control Initiative and the Deworm the World Initiative.

Key points:

• We’re very much in support of replicating and stress-testing important studies like this one. We did our own reanalysis of the study in question in 2012, and the replication released recently is more thorough and identifies errors that we did not.
• We don’t think the two replications bear on the most important parts of the case we see for deworming. Both focus on Miguel and Kremer 2004, which examines impacts of deworming on school attendance; in our view, the more important case for deworming comes from a later study that found impacts on earnings many years later. The school attendance finding provides a possible mechanism through which deworming might have improved later-in-life earnings; this is important, because (as stated below) the mechanism is a serious question.
• However, the replications do not directly challenge the existence of an attendance effect either. One primarily challenges the finding of externalities (effects of treatment on untreated students, possibly via reducing e.g. contaminated soil and water) at a particular distance. The other challenges both the statistical significance and the size of the main effect for attendance but we believe is best read as finding significant evidence for a smaller attendance effect. Regardless, the results we see as most important, particularly on income later in life, are not affected.
• The updated Cochrane review seems broadly consistent with the earlier version, which we wrote about in 2012. We agree with its finding that there is little sign of short-term impacts of deworming on health indicators (e.g., weight and anemia) or test scores, and, as we have previously noted, we believe that this does undermine – but does not eliminate – the plausibility of the effect on earnings.
• In our view, the best reasons to be skeptical about the evidence for deworming pertain to external validity, particularly related to the occurrence of El Nino during the period of study, which we have written about elsewhere. These issues are not addressed in the recent releases.
• At the same time, because mass deworming is so cheap, there is a good case for donating to support deworming even when in substantial doubt about the evidence. This has consistently been our position since we first recommend the Schistosomiasis Control Initiative in 2011. Our current cost-effectiveness model (which balances the doubts we have about the evidence with the cost of implementing the program) is here.
• While we think that replicating and challenging studies is a good thing, it looks in this case like there was an aggressive media push – publication of two papers at once coinciding with an update of the Cochrane review and a Buzzfeed piece, all on the same day – that we think has contributed to people exaggerating the significance of the findings.

Details follow. We also recommend the comments on this issue by Chris Blattman (whose post has an interesting comment thread) and Berk Ozler.

The reanalyses of Miguel and Kremer 2004Aiken et al. 2015 and Davey et al. 2015 participated in a replication program hosted by the International Initiative for Impact Evaluation (3ie), in which Miguel and Kremer shared the data from their trials and Aiken, Davey and colleagues reanalysed them. Working paper versions of these reanalyses were published on the 3ie website dated October 2014, and Joan Hamory Hicks, Miguel and Kremer responded to both of them there. The World Bank’s Berk Ozler wrote a blog post in January reviewing the reanalyses and Hicks, Miguel, and Kremer’s replies.

Aiken et al. 2015 straightforwardly attempts to replicate Miguel and Kremer 2004’s results from data and code shared by the authors. They do a much more thorough job than when we attempted something similar in 2012, and find a number of errors.

Amongst a number of smaller issues, Aiken et al. find a coding error in Miguel and Kremer’s estimate of the externality impacts of deworming on students in nearby schools, in which Miguel and Kremer only counted the population of the nearest 12 schools. That coding error substantially changes estimates of the impact of deworming on both the prevalence of worm infections in nearby schools and the attendance of students in nearby schools, particularly estimates of the impact of further out schools, between 3 and 6 km away.

Aiken et al. state: “Having corrected these errors, re-analysis found no statistically significant indirect-between-school effect on the worm infection out- come, according to the analysis methods originally used. However, among variables used to construct this effect, a parameter describing the effect of Group 1 living within 0–3 km did remain significant, albeit at a slightly smaller size (original -0.26, SE 0.09, significant at 95% confidence level; updated -0.21, SE 0.10, significant at 95% confidence). The corresponding parameter for the 3–6- km distances became much smaller and statistically insignificant (original -0.14, SE 0.06, significant at 90% confidence; updated -0.05, SE 0.08, not statistically significant).” Aiken et al.’s supplementary material and Hicks, Miguel, and Kremer’s response to the 3ie replication working paper clarifies this explanation. In short, fixing the coding error does not much affect estimates of the externality within 3 km of treatment schools, but does significantly change estimated externalities between 3 and 6 km out, and following the original Miguel and Kremer 2004 process for synthesizing those estimates into an overall estimate of the cross-school externality on worm prevalence, the resulting figure is not statistically significant. However, if you simply drop the 3-6 km externality estimate, which is now negative and no longer statistically significant, then you continue to see a statistically significant cross-school externality (see the second to last row of Table 1).

The same coding error also affects estimates of the externality effect on school attendance, in a broadly similar way. Aiken et al. write: “Correction of all coding errors in Table IX thus led to the major discrepancies shown in Table 3. The indirect-between-school effect [on attendance] was substantially reduced (from +2.0% to -1.7%) with an increased standard error (from 1.3% to 3.0%) making the result non-significant. The total effect on school attendance was also substantially reduced (from 7.5% to 3.9% absolute improvement), making it only slightly more than one standard error interval away [from] zero, hence also non-significant.” The correction to the coding error significantly increases the standard error of the 3-6km externality estimate, which then increases the standard error of the overall estimate significantly. The increased uncertainty, rather than the change in the point estimate of the externality, is what drives the conclusion that the total effect on school attendance is no longer statistically significant. As in the prevalence externality case, dropping the 3-6km estimate altogether preserves a statistically significant cross-school externality (and total effect).

We are uncertain about what to believe about the externality terms at this point. It seems fairly clear that had Miguel and Kremer caught the coding error prior to publication, their paper would have ignored potential externalities beyond 3km, and the replication done today would have found that the analysis up to 3km was broadly right. The replication penalizes the paper for having initially (incorrectly) found externalities further out. While we continue to be worried about the possibility of specification searching in the externality terms, and we see a case for treating the initial paper as a form of preregistration, we don’t see it as at all obvious that we should penalize the Miguel and Kremer results in the way that Aiken et al. suggest.

The Aiken et al. replication, like the original paper, finds no evidence of an impact on test scores.

Davey et al. 2015 is a more interpretive reanalysis, in which the authors use a more “epidemiological” analytical approach to reanalyze the data. The abstract states:

Results: Quasi-randomization resulted in three similar groups of 25 schools. There was a substantial amount of missing data. In year-stratified cluster-summary analysis, there was no clear evidence for improvement in either school attendance or examination performance. In year-stratified regression models, there was some evidence of improvement in school attendance [adjusted odds ratios (aOR): year 1: 1.48, 95% confidence interval (CI) 0.88–2.52, P = 0.150; year 2: 1.23, 95% CI 1.01–1.51, P = 0.044], but not examination performance (adjusted differences: year 1: −0.135, 95% CI −0.323–0.054, P = 0.161; year 2: −0.017, 95% CI −0.201–0.166, P = 0.854). When both years were combined, there was strong evidence of an effect on attendance (aOR 1.82, 95% CI 1.74–1.91, P < 0.001), but not examination performance (adjusted difference −0.121, 95% CI −0.293–0.052, P = 0.169).
Conclusions: The evidence supporting an improvement in school attendance differed by analysis method. This, and various other important limitations of the data, caution against over-interpretation of the results. We find that the study provides some evidence, but with high risk of bias, that a school-based drug-treatment and health-education intervention improved school attendance and no evidence of effect on examination performance.

Reviewing the key conclusions in order:

• “In year-stratified cluster-summary analysis, there was no clear evidence for improvement in either school attendance or examination performance.” The results of the year-stratified cluster-summary analysis are substantively the same as the results of the year-stratified regression models that Davey et al. use (next bullet), with wider confidence intervals resulting from the reduction in sample size of caused by using unweighted school-level data (N=75). Table 2 reports a 5.5 percentage point impact on attendance in 1998 (corresponding to an odds ratio of 1.78) and a 2.2 percentage point impact for 1999 (corresponding to an odds ratio of 1.21). Davey et al.’s regressions find an odds ratio for 1998 of 1.77 (unadjusted, p=0.097) or 1.48 (adjusted, p=0.150) and for 1999 of 1.23 (unadjusted, p=0.047, or adjusted, p=0.044), i.e. the same point estimates with tighter confidence intervals. We don’t see it as surprising or problematic that collapsing a large cluster-randomized trials’ data to the cluster level results in a loss of statistical significance.
• “In year-stratified regression models, there was some evidence of improvement in school attendance [adjusted odds ratios (aOR): year 1: 1.48, 95% confidence interval (CI) 0.88–2.52, P = 0.150; year 2: 1.23, 95% CI 1.01–1.51, P = 0.044], but not examination performance (adjusted differences: year 1: −0.135, 95% CI −0.323–0.054, P = 0.161; year 2: −0.017, 95% CI −0.201–0.166, P = 0.854).” The lack of a result on exam performance echoes Miguel and Kremer 2004’s results. The “some evidence of improvement” result for school attendance is more striking, since the year 2 results are positive and statistically significant while the year 1 results are more positive but not statistically significant (due to a wider confidence interval). We read this as the test in year 1 being underpowered; treating years 1 and 2 as two independent randomized control trials, a fixed-effects meta-analysis would find a statistically significant overall effect.
• “When both years were combined, there was strong evidence of an effect on attendance (aOR 1.82, 95% CI 1.74–1.91, P < 0.001), but not examination performance (adjusted difference −0.121, 95% CI −0.293–0.052, P = 0.169).” These results accord with the Miguel and Kremer 2004 results.
• “We find that the study provides some evidence, but with high risk of bias, that a school-based drug-treatment and health-education intervention improved school attendance and no evidence of effect on examination performance.” The authors make two main arguments for the high risk of bias. First, they note (in Figure 3) that the correlation across schools between attendance rates and the number of attendance observations appears to differ across the treatment and control groups, with a broad tendency towards positive correlation between observations and attendance rates in the intervention group and a negative correlation in the control group, which would lead to estimates weighted by the number of observations to overestimate the true impact. However, we see three reasons not to regard this evidence as particularly problematic:
• Hicks, Miguel, and Kremer report conducting a test for the claimed change in the correlation and finding a non-statistically significant result (page 9). As far as we know, Davey et al. have not responded to this point, though we think it is possible that Hicks, Miguel, and Kremer’s test is underpowered.
• As noted above, the unweighted (year-stratified cluster-summary) estimates are not lower than the year-stratified regression models (which Davey et al. report do weight by observation–“we used random-effects regression on school attendance observations, an approach which gives greater weight to clusters with higher numbers of observations”), they just have wider confidence intervals. In order for the observed correlation to be biasing the weighted results, the weighted estimates would need to be meaningfully different from the unweighted ones, which is not the case here. Accordingly, we see little reason even in Davey et al.’s framework for preferring the less precise year-stratified cluster-summary results to the year-stratified regressions, which use significantly more information to reach virtually the same point estimates.
• Hicks, Miguel, and Kremer report results weighted by pupil instead of observation (Table 3), and find results strongly consistent with their attendance-weighted results, without the risk of being biased by attendance observations. However, their results imply treatment effects that are larger than the odds ratios reported in Davey et al.’s year-stratified regression models, which Davey et al. report do weight by observation. We’re not sure what to make of this discrepancy, and we haven’t see Davey et al. respond on this point.

Second, and relatedly, Davey et al. note that the estimated attendance effect in the combined years analysis is larger than in either of the underlying years, and they suggest that the change is due to the inclusion of a before-after comparison for Group 2 (which switched from control in year one to treatment in year two) in the purportedly experimental analysis. We see this concern as more plausible, and don’t have a conclusive view on it at this point, but we think it would affect the magnitude of the observed effect rather than its existence (since we read the year-stratified regressions, which are not subject to this potential bias, as supporting an impact on attendance).

To summarize, we see no reason even based on Davey et al.’s own choices to prefer the year-stratified cluster-summary, which discards a significant amount of information, to the year-stratified regression models, which together point to a statistically significant impact on attendance. Hicks, Miguel, and Kremer make a variety of other arguments against decisions made by Davey et al., and they, along with Blattman and Ozler, argue that many of the changes are jointly necessary to yield non-significant results. We haven’t considered this claim fully because we see the Davey et al. results as supporting a statistically significant attendance impact, but if we turn out to be wrong about that, it would be important to more fully weigh the other deviations they make from Miguel and Kremer’s approach in reaching a conclusion.

School attendance data has never played a major role in our view about deworming (more on our views below), but we see little reason based on these re-analyses to doubt the Miguel and Kremer 2004 result that deworming significantly improved attendance in their experiment. We see much more reason to be worried about external validity, particularly related to the occurrence of El Nino during the period of study, which we have written about elsewhere.

The new Cochrane ReviewThe new Cochrane review on deworming reaches largely the same conclusions as the 2012 update, which we have discussed previously.

The new review incorporates the Aiken et al. and Davey et al. replications of Miguel and Kremer 2004 and the results of the large DEVTA trial, but continues to exclude Baird et al. 2011, Croke 2014, and Ozier 2011.

We agree with the general bottom line that there is little evidence for any biological mechanism linking deworming to longer term outcomes, and that that should significantly reduce one’s confidence in any claimed long-term effects of deworming. However, the Cochrane authors make some editorial judgments we don’t agree with.

They state:

• “The replication highlights important coding errors and this resulted in a number of changes to the results: the previously reported effect on anaemia disappeared; the effect on school attendance was similar to the original analysis, although the effect was seen in both children that received the drug and those that did not; and the indirect effects (externalities) of the intervention on adjacent schools disappeared (Aiken 2015).” As described above, in summarizing the results of Aiken et al. 2015, we would have noted that estimated cross-school externalities remain statistically significant in the 0-3km range.
• “The statistical replication suggested some impact of the complex intervention (deworming and health promotion) on school attendance, but this varied depending on the analysis strategy, and there was a high risk of bias. The replication showed no effect on exam performance (Davey 2015).” We think it is misleading to summarize the results as “[impact on school attendance] varied depending on the analysis strategy, and there was a high risk of bias.” Our read is that Davey et al. reported some analyses in which they discarded a significant amount of information and accordingly lost statistical significance, but found attendance impacts that were consistently positive and of the same magnitude (and statistically significant in analyses that preserved information).
• “There have been some recent trials on long-term follow-up, none of which met the quality criteria needed in order to be included in this review (Baird 2011; Croke 2014; Ozier 2011; described in Characteristics of excluded studies). Baird 2011 and Ozier 2011 are follow-up trials of the Miguel 2004 (Cluster) trial. Ozier 2011 studied children in the vicinity of the Miguel 2004 (Cluster) to assess long-term impacts of the externalities (impacts on untreated children). However, in the replication trials (Aiken 2014; Aiken 2015; Davey 2015), these spill-over effects were no longer present, raising questions about the validity of a long-term follow-up.” This last sentence seems problematic from multiple perspectives:
• Davey et al. 2015 does not mention or look for externalities or spill-over effects.
• Aiken et al. 2015 replicates Miguel and Kremer 2004’s finding of a statistically significant externality within 0-3 km, so summarizing it as “these spill-over effects were no longer present” seems to be an over-simplification.
• The lack of geographic externality is a particularly unpersuasive explanation for excluding Ozier 2011, which focuses on spill-over effects to younger siblings of children who were assigned to deworming, especially given that Aiken et al. confirm Miguel and Kremer’s finding of within-school externalities (which seems more similar to the siblings case). More generally, the fact that one study failed to find a result seems like a bad reason to exclude a follow-up study to it that did.

More generally, we agree with many of the conclusions of the Cochrane review, but excluding some of the most important studies on a topic because they eventually treated the control group seems misguided. Doing so structurally excludes virtually all long-term follow-ups, since they are often ethically required to eventually treat their control groups.

Our case for dewormingAs we wrote in 2012, the last time the Cochrane review on deworming was updated, our review of deworming focuses on three kinds of benefits:

• General health impacts, especially on haemoglobin. We currently conclude, partly based on the last edition of the Cochrane review: “Evidence for the impact of deworming on short-term general health is thin, especially for soil-transmitted helminth (STH)-only deworming. Most of the potential effects are relatively small, the evidence is mixed, and different approaches have varied effects. We would guess that deworming populations with schistosomiasis and STH (combination deworming) does have some small impacts on general health, but do not believe it has a large impact on health in most cases. We are uncertain that STH-only deworming affects general health.” This last claim continues to be in line with Cochrane’s updated finding of no impact of STH-only deworming on haemoglobin and most other short-term outcomes.
• Prevention of potentially severe effects, such as intestinal obstruction. These effects are rare and play a relatively small role in our position on deworming.
• Developmental impacts, particularly on income later in life. The new Cochrane review continues to exclude the studies we see as key to this question. Bleakley 2004 is outside of the scope of the Cochrane review because it is not an experimental analysis, and Baird et al. 2011 is excluded because its control group eventually received treatment. However, as before, the Cochrane review does discuss Miguel and Kremer 2004, which underlies the Baird et al. 2011 follow-up; in their assessment of the risk of bias in included studies, Miguel and Kremer 2004 continues to be the worst-graded of the included trials. We also do not think that the Aiken et al. or Davey et al. papers should substantially affect our assessment of the Baird et al. 2011 results. Aiken et al.’s main finding is about the coding error affecting the 3-6km externality terms. I’m not clear on whether the coding error in the construction of the externality variable extends to Baird et al. 2011, but, regardless, the results we see as most important, particularly on income, do not rely on the externality term. Davey et al.’s key argument is against the combined analysis in which Group 2 is considered control in year one and treatment in year two. I remain uncertain about whether this worry is fundamentally correct, but Baird et al. is not subject to it because their estimates treat Group 2 as consistently part of the treatment group.

Nonetheless, we continue to have serious reservations about these studies and would counsel against taking them at face value.

We think it’s a particular mistake to analyze the evidence in this case without respect to the cost of the intervention. Table 4 of Baird et al. 2012 estimates that, not counting externalities, their results imply that deworming generates a net present value of $55.26, against an average cost of$1.07, i.e. that deworming is ~50 times more effective than cash transfers. We do not think it is appropriate to take estimates like these at face value or to expect them to generalize without adjustment, but the strong results leave significant room for cost-effectiveness to regress to the mean and still beat cash. In our cost-effectiveness model, we apply a number of ad-hoc adjustments to penalize for external validity and replicability concerns, and most of us continue to guess that deworming is more cost-effective than cash transfers, though of course these are judgment calls and we could easily be wrong.

The lack of a clear causal mechanism to connect deworming to longer term developmental outcomes is a significant and legitimate source of uncertainty as to whether deworming truly has any effect, and we do not think it would be inappropriate for more risk-averse donors to prefer to support other interventions instead, but we don’t agree with the Cochrane review’s conclusion that it’s the long-term evidence that is obviously mistaken in this case. (We have noted elsewhere that most claims for long-term impact seem to be subject to broadly similar problems.)

The importance of data sharing and replicationWe continue to believe that it is extremely valuable and important for authors to share their data and code, and we appreciate that Miguel and Kremer did so in this case. We’re also glad to see the record corrected regarding the 3-6km externality terms in Miguel and Kremer 2004. But our overall impression is that this is a case in which the replication process has brought more heat than light. We hope that the research community can develop stronger norms supporting data sharing and replication in the future.

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### Top charities’ room for more funding

Fri, 04/03/2015 - 11:55

In December, we published targets for how much money we hoped to move to each of our top four charities, with the expectation of revisiting these targets mid-year:

In past years, we’ve worked on an annual cycle, refreshing our recommendations each December. This year, because we anticipate closing (or nearly closing) the funding gaps of some of our top charities during giving season and moving a significant amount of money (~$5 million) after giving season before our next scheduled refresh, we plan to update our recommendations based solely on room for more funding in the middle of next year. We’re tentatively planning to do this on April 1st, the earliest we will realistically be able to post an update on charities’ ongoing funding needs that accounts for the funds they will receive over the next few months. These targets were based on a guess that GiveWell-influenced donors would give$7.5 million to our top four charities in December 2014 to March 2015 (excluding Good Ventures and a $1 million gift to SCI from an individual that we knew about prior to setting the targets). Our actual money moved for this period was about$8.7 million to the top four charities, plus $0.4 million that we can allocate at our discretion and have not yet allocated. Over the past couple of months, we have spoken with each of our top charities to get updates on how much funding they have received from GiveWell-influenced and other donors and their current room for more funding. In sum, the amounts that our top charities raised as a result of our recommendations were broadly consistent with what we expected and there have not been any significant updates to the charities’ room for more funding. Therefore, we are not revising our recommended allocation (for every$7.5 given, $5 to AMF,$1 to GiveDirectly, $1 to SCI, and$0.5 to Deworm the World) at this time.

Summary for December 2014 to March 2015 (all figures in USD millions):

Charity Target from individuals (Dec 2014) Max from individuals (Dec 2014) Actual from individuals Summary Against Malaria Foundation 5 5 4.5 Close to target Schistosomiasis Control Initiative 1 1 1.1 On target Deworm the World Initiative 0.5 1 0.7 Reached target but did not exceed max GiveDirectly 1 25 2.4 Reached target but did not exceed max

Against Malaria Foundation (AMF)

Donations to AMF from GiveWell-influenced donors were short of our target by about $0.5 million. AMF is currently in discussions about funding several large-scale bednet distributions. It is our understanding that the amount of funding AMF has available is a limiting factor on both how many nets it can provide to each distribution it is considering and on how many discussions it can pursue at one time. We have written before about AMF’s lack of track record at signing agreements for and successfully completing large-scale distributions with partners other than Concern Universal in Malawi. In 2014, AMF signed its first agreement to fund a large-scale distribution with another partner in a different country: IMA World Health in the province of Kasaï Occidental in the Democratic Republic of the Congo (more). The Kasaï Occidental distribution was scheduled to be completed in late 2014. We have not yet seen results from this distribution, and AMF’s track record of completing and reporting on successful large-scale distributions remains limited. AMF expects to be able to share information from this distribution in the next few weeks. We plan to continue recommending funds to AMF for now and to reassess AMF’s progress later in the year. GiveDirectly In December, we noted that GiveDirectly could likely absorb up to$25 million in funding from GiveWell-influenced individuals. We tracked $2.4 million to GiveDirectly from these individuals and it is possible that GiveWell influenced several million dollars more – between February 2014 and January 2015, GiveDirectly received several million dollars from individuals who did not provide information on how they learned about the organization. We continue to believe that GiveDirectly has substantial room for more funding. Schistosomiasis Control Initiative (SCI) In December we set a target of SCI receiving$1 million from GiveWell-influenced individual donors and set the max we aimed for SCI to receive from this group at the same amount. We estimate that SCI received about $1.1 million based on GiveWell’s recommendation. We have fairly limited information on SCI’s room for more funding because (a) SCI recently began working with a new financial director and is in the process of reorganizing its financial system, and so has not yet been able to provide us with a comprehensive financial update; and (b) SCI held a meeting on March 24 to allocate unrestricted funds and sent us a report from that meeting recently, which we have not yet had time to review. We will be following up with SCI to learn more about its plans and funding needs. We plan to continue recommending funds to SCI because (a) our room for more funding estimates for SCI are rough and we believe there is a reasonable chance that SCI has room for more funding; (b) we expect to learn more about SCI’s room for more funding in the next few months; and (c) we do not expect SCI to receive a large amount of funding due to our recommendation over the next few months (since most donors give in December). Deworm the World Initiative, which is led by Evidence Action In December we set a target of$0.5 million from GiveWell-influenced individual donors to Deworm the World and set the max we aimed for Deworm the World to receive from this group at $1 million. We estimate that Deworm the World received about$0.66 million based on GiveWell’s recommendation.

It’s our understanding that Deworm the World may have opportunities over the next few years to support up to three deworming programs which could each cost several million dollars. We are in the process of following up with Deworm the World to learn more about how likely these programs are to require unrestricted funding from Deworm the World and when funding might become a bottleneck to moving forward with these programs.

We plan to continue recommending funds to Deworm the World.

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### Our updated top charities

Mon, 12/01/2014 - 12:35

Our top charities are (in alphabetical order):

We have recommended all four of these charities in the past.

We have also included four additional organizations on our top charities page as standout charities. They are (in alphabetical order):

In the case of ICCIDD, GAIN-USI, and DMI, we expect to learn substantially more in the coming years (both through further investigation and through further progress by the organizations); we see a strong possibility that these will become top-tier recommended charities in the future, and we can see reasons that impact-minded donors could choose to support them today.

Ranking our top charities against each other is difficult and laden with judgment calls, particularly since:

• Our cost-effectiveness analyses are non-robust, and reasonable people could reach a very wide variety of conclusions regarding which charity accomplishes the most good per dollar.
• The charity we estimate as having the weakest cost-effectiveness (GiveDirectly) is also the one that we feel has the strongest organizational performance and the most direct, robust connection between donations and impact.
• We do not currently feel highly confident in our cost-effectiveness estimates. We changed a number of inputs to our estimates recently. We did not have time to fully consider and vet them, and we plan to put more work into these estimates over the next few months. We do not expect our estimates to change significantly but given the fact that we have been updating them very recently, we would not be surprised if they do. We plan to publish a post soon detailing the major changes and most debatable assumptions in our current estimates. We consider the lateness of major revisions to this year’s estimates a shortcoming (and will be adding it to our mistakes page when we do our annual review).
• This year we expect to influence a significant amount of donations. In some past years, we’ve been able to assume that each dollar of donations to an organization is about equally effective. This year, we could easily see one or more of our top charities reach the point of diminishing returns to additional donations and/or close its funding gap entirely.
• We’ve been trying to predict and coordinate donations from Good Ventures, from individual donors, and from major donors who have given us private information about their plans. In so doing, we’ve run into game-theoretic challenges. If two donors are interested in funding the same organization, each has an incentive to downplay his/her interest in the hopes that the other will provide more of the funding. We’ve been trying to avoid reinforcing such incentives. We discuss how these considerations affected our targets below, and we plan to elaborate on this issue in a future post.
• In past years, we’ve worked on an annual cycle, refreshing our recommendations each December. This year, because we anticipate closing (or nearly closing) the funding gaps of some of our top charities during giving season and moving a significant amount of money (~$5 million) after giving season before our next scheduled refresh, we plan to update our recommendations based solely on room for more funding in the middle of next year. We’re tentatively planning to do this on April 1st, the earliest we will realistically be able to post an update on charities’ ongoing funding needs that accounts for the funds they will receive over the next few months. This plan also raises questions about donor agency and coordination; we plan to discuss this in a future post. We’ve tried to balance these considerations against each other and come up with an “ideal allocation” of the ~$7.5 million in estimated “money moved” we expect to influence (not counting grants from Good Ventures) over the next 4 months. Details are below. Based on this allocation, for any donors looking to give as we would, we recommend an allocation of $5 to AMF (67%),$1 to SCI (13%), $1 to GiveDirectly (13%) and$.50 to DtWI (7%) for every $7.50 given. Good Ventures is planning to make grants of$5 million to each of AMF and GiveDirectly, $3 million to SCI, and$250,000 to DtWI. Good Ventures also plans to make grants of $250,000 to each of the standout organizations. We advised on these grants a few weeks ago, and did so while weighing our funding targets for each charity and forecasts of what other donors are likely to do; parts of our picture have since changed, and these grants do not represent the allocation we would advise donors to use nor do they reflect our views about the relative ranking of these organizations. We made sure to settle on and announce these grants before giving season so that no donor would have to grapple with questions about Good Ventures’s likely actions (more in our upcoming post on donor coordination), and Good Ventures will not be making additional grants to these charities in the near to medium future (6-12 months) unless there are substantive updates on things like evidence bases and capacity for absorbing money (i.e. Good Ventures will not be giving further simply in response to new information about donor behavior over the next 4 months). Below we provide: • Additional detail on each of these eight organizations, including (for past recommendations) major changes over the past year, strengths and weaknesses for each, and our understanding of each organization’s room for more funding (which forms the basis for our funding targets and recommended allocation). More • The thinking behind our funding targets and recommended allocation. More • The process we followed that led to these top charities. More • Brief notes on giving now vs. giving later and giving to GiveWell vs. our top charities. More Conference call to discuss our recommendationsWe are planning to hold a conference call at 5:30pm EST on Wednesday, December 3rd to discuss our recommendations and answer questions. If you’d like to join the call, please register using this online form. If you can’t make this date but would be interested in joining another call at a later date, please indicate this on the registration form. Top charitiesWe present information on our top charities in alphabetical order. Against Malaria Foundation (AMF)Our full review of AMF is here. Important changes in the last 12 months We named AMF our #1-ranked charity at the end of 2011. Over the next 2 years, AMF received more than$10 million on the basis of our recommendation but struggled to identify opportunities to use the funds it had received. At the end of 2013, we announced that we planned not to recommend additional donations to AMF until it committed the bulk of its current funds. This did not reflect a negative view of AMF; instead it reflected room for more funding related issues. More detail in this blog post.

In 2014, AMF finalized several distributions in Malawi and the Democratic Republic of the Congo (DRC) with three different implementing partners (two of which account for the bulk of the nets to be distributed). In 2014, it committed approximately $8.4 million to distributions which will take place before January 1, 2016 (some of which have already begun) and now has$6.8 million available for future distributions. $1.7 million of this is committed to a distribution scheduled for 2017 (and could potentially be allocated to distributions taking place sooner). Excluding the 2017 distribution, AMF has committed approximately$11.2 million to distributions in its history.

AMF continued to collect and share follow up information on its programs. We covered these reports in our August 2014 AMF update.

Funding gap

AMF requires access to funding in order to negotiate deals because it cannot initiate discussions with potential partners unless it is confident that it will have sufficient funding to support its future agreements. The funding it currently holds would enable it to fund approximately 3 distributions at a scale similar to what it has funded recently.

AMF has told us that it has a pipeline of possible future net distributions that add up to $36 million (details in our review). We see some reason for caution in thinking about AMF’s room for more funding. It has made strong progress on being able to negotiate distributions and commit funds. However, as of today there have only been two large-scale distributions that have moved forward far enough for data to be available. Both of these are significantly smaller than distributions AMF has recently or will soon fund, and both are in the same area with the same partner as each other. Some of the recently negotiated distributions could prove more challenging (since they are in DRC). If AMF received an additional$10 million in total over the next 4 months, it would have about twice as much funding available as the total it committed to large-scale distributions in 2014. (As stated above, it committed $8.4 million to distributions taking place before 2017 and has$6.8 million available for further commitments.) If it received $25 million, it would have about 4 times that total. 2-4 times past distributions seems like a range that would allow AMF to do significantly more than it has in the past, without going so far beyond its past capacity as to raise serious scaling concerns. We believe that$10 million total (the low end of that range), which means $5 million after the Good Ventures grant, is an appropriate target after which further donations are likely better off going to other charities. Key considerations: • Program impact and cost-effectiveness. Our best guess is that distributing bednets is in the same cost-effectiveness range as deworming programs and more cost-effective than cash transfers by a factor of 5-10. Our estimates are subject to substantial uncertainty. (Note: all our cost-effectiveness analyses are available here. Our file for bednets is here (.xls), and the comparison to deworming, cash transfers and iodine is here (.xls).) • Directness and robustness of the case for impact. We believe that the connection between AMF receiving funds and those funds helping very poor individuals is less direct than GiveDirectly’s and more direct than SCI’s or DtWI’s. The uncertainty of our estimates is driven by a combination of AMF’s challenges historically disbursing the funds it receives and a general recognition that aid programs, even those as straightforward as bednets, carry significant risks of failure via ineffective use of nets, insecticide resistance or other risks we don’t yet recognize relative to GiveDirectly’s program. AMF conducts extensive monitoring of its program; these results have generally indicated that people use the nets they receive. • Transparency and communication. AMF has been extremely communicative and open with us. We feel we have a better understanding of AMF than SCI and worse than GiveDirectly. In particular, were something to go wrong in one of AMF’s distributions, we believe we would eventually find out (something we are not sure of in the case of SCI), but we believe our understanding would be less quick and complete than it would be for problems associated with GiveDirectly’s program (which has more of a track record of consistent intensive followup). • Risks: • Two of AMF’s recent distributions (and much of its future pipeline) will take place in the DRC. Our impression is that the DRC is a particularly difficult place to work, and it is possible that AMF’s distributions there will struggle or fail. We view this as a moderate risk. • We are not highly confident that AMF will be able to finalize additional distributions and do so quickly. AMF could struggle again to agree to distribution deals, leading to long delays before it spends funds. We view this as a relatively minor risk because the likely worst case scenario is that AMF spends the funds slowly (or returns funds to donors). • We remain concerned about the possibility of resistance to the insecticides used in bednets. There don’t appear to be major updates on this front since our 2012 investigation into the matter; we take the lack of major news as a minor positive update. A note on how quickly we expect AMF to spend the funds it receives. AMF works by sourcing, evaluating and negotiating deals for net distributions. This process takes time and requires AMF to have significant access to funding – it cannot approach a country to begin negotiations unless it is confident that it will have sufficient funding to pay for the nets it offers. We would not be surprised if AMF fails to reach additional deals in the next 12 months. We do expect it to commit the majority of its available funds (that it will have as of this coming January) within the next 24 months. If AMF does not make much progress in committing funds in the next 12 months, we will adjust our recommendation for 2015 accordingly, possibly recommending a lower target level of funds or suspending the recommendation entirely (depending on the specifics of the situation). Our full review of AMF is here. Deworm the World Initiative, (DtWI), led by Evidence ActionOur full review of DtWI is here. Important changes in the last 12 months Dr. Kevin Croke released a new study of a randomized controlled trial of a deworming program showing large, long-term impacts from deworming programs (for more, see this blog post). This study is a significant positive update on the impacts of deworming and increased our confidence that deworming programs have significant long-term impacts. DtWI spent the funds it received due to GiveWell’s recommendation largely as we anticipated; it now has some (though limited) room for more funding. In 2014, two events affected DtWI’s projection of the additional funding it would require to scale up in India: • The Children’s Investment Fund Foundation (CIFF), a major foundation that had supported DtWI’s programs in Kenya, agreed to a 6-year,$17.7 million grant to support DtWI’s expansion to additional states in India and technical assistance to the Government of India for a national deworming program. With these funds, DtWI does not require significant additional funding to support its India expansion.
• The new Indian government expressed interest in conducting a single deworming day nationally with increased national attention and resources. Advocating for such a policy and assisting the national government in creating a plan became the major focus of DtWI’s India work in 2014, which both reduced the amount of time it was able to spend generating interest in heavy DtWI involvement in new states and also required little funding since there were few costs of that project aside from staff time. We see this as positive news regarding DtWI’s potential impact; it may simply reduce DtWI’s further need for funds from individual donors.

Together, these changes led DtWI to the conclusion that funding is no longer the bottleneck to reaching more people in India. (More detail in this blog post.)

Funding gap

DtWI told us that it seeks $1.3 million over the next two years. We expect it to allocate approximately 30% of the additional funds it receives for work related to expanding school-based, mass deworming programs (including related operating and impact evaluation expenses) and will allocate other funds to priorities that are less directly connected to expanding and evaluating deworming programs (investigating ways to combine other evidence-based programs with deworming rollouts, supplementing a project supported by another funder). Good Ventures has announced a$250,000 grant to DtWI, leaving it with $1.05 million in remaining room for more funding over the next two years. We would ideally like DtWI to receive an additional$500,000 (for a total of $750,000) to provide it with more than half of its two-year gap. Key considerations: • Program impact and cost-effectiveness. Our current calculations indicate that DtWI-associated deworming, when accounting for DtWI’s potential “leverage” in influencing government funds, has extremely strong cost-effectiveness, better than bednets and 10-20 times better than cash transfers. Our estimates are subject to substantial uncertainty. (Note: all our cost-effectiveness analyses are available here. Our file for deworming, cash transfers and iodine is here (.xls).) • Directness and robustness of the case for impact. DtWI doesn’t carry out deworming programs itself; it advocates for and provides technical assistance to governments implementing deworming programs, making direct assessments of its impact challenging. There are substantial potential advantages to supporting such an organization, as it may be able to have more impact per dollar by influencing government policy than by simply carrying out programs on its own, but this situation also complicates impact assessment. While we believe DtWI is impactful, our evidence is limited, and in addition, there is always a risk that future expansions will prove more difficult than past ones. In addition, DtWI is now largely raising funds to support research projects that are not directly connected to short-term implementation of deworming programs. We do not have a view about the value of these research projects. • Transparency and communication. DtWI has been communicative and open with us. We have only recommended DtWI for one year and therefore have less history with it than AMF, GiveDirectly, or SCI, but we believe that were something to go wrong with DtWI’s work, we would be able to learn about it and report on it. • Risks: • DtWI is part of a larger organization, Evidence Action, so changes that affect Evidence Action (and its other programs) could indirectly impact DtWI. For example, if a major event occurs (either positive or negative) for Evidence Action, it is likely that it would reduce the time some staff could devote to DtWI. • Most of DtWI’s funding is in the form of restricted funding from large, institutional funders. We are not sure how DtWI’s plans would change in response to a large funder offering it significant support to undertake a project not directly in line with its current plans. Our full review of DtWI is here. GiveDirectlyOur full review of GiveDirectly is here. Important changes in the last 12 months GiveDirectly continued to scale up significantly, utilizing most of the funding it received at the end of last year. It continued to share informative and detailed monitoring information with us. Overall, it grew its operations while maintaining high quality. In June, three of its board members launched Segovia, a for-profit company aimed at improving the efficiency of cash transfer distributions in the developing world (see our blog post on Segovia for more information). GiveDirectly is working with other researchers to begin a very large study on cash transfers and the impact they have on broader economic factors such as inflation and job growth. This study will include a long-term follow up component as well. GiveDirectly told us that the ideal sample size for this study, which is randomized at the village level, would require$15 million for cash transfers. Baseline data collection for the study began in August 2014. GiveDirectly has preregistered its plans for measurement and analysis (more information in our review).

Funding gap

GiveDirectly has scaled up significantly over the past year, spending (or committing to spend by enrolling recipients) approximately $13.6 million of the$17.4 million it received last year. (It also allocated an additional $1.8 million to other organizational costs.) It now believes that it could spend up to$40 million in a year.

We believe this is a reasonable cap for GiveDirectly and would not hesitate to see it receive this amount. However, due to other charities’ significantly superior estimated cost-effectiveness, we are seeking larger total amounts for them. We hope that GiveDirectly will receive at least $1 million from individual donors (excluding Good Ventures) this giving season as a result of our recommendation. Key considerations: • Program impact and cost-effectiveness. Our best guess is that deworming or distributing bednets achieves 5-10 times more humanitarian benefit per dollar donated than cash transfers. Our estimates are subject to substantial uncertainty. (Note: all our cost-effectiveness analyses are available here. Our file for deworming, cash transfers and iodine is here (.xls).) • Directness and robustness of the case for impact. GiveDirectly collects and shares a significant amount of relevant information about its activities. The data it collects show that it successfully directs cash to very poor people, that recipients generally spend funds productively (sometimes on food, clothing, or school fees, other times on investments in a business or home infrastructure), and that it leads to very low levels of interpersonal conflict and tension. We are more confident in the impact of GiveDirectly’s work than in that of any of the other charities discussed in this post. • Transparency and communication. GiveDirectly has always communicated clearly and openly with us. It has tended to raise problems to us before we ask about them, and we generally believe that we have a very clear view of its operations. We feel more confident about our ability to keep track of future challenges than with any of the other charities discussed in this post. • Risks: GiveDirectly has scaled (and hopes to continue to scale) quickly. Thus far, it has significantly increased the amount of money it can move with limited issues as a result. The case of staff fraud that GiveDirectly detected is one example of an issue possibly caused by its pace of scaling, but its response demonstrated the transparency we expect. Our full review of GiveDirectly is here. Schistosomiasis Control Initiative (SCI)Our full review of SCI is here. Important changes in the last 12 months As discussed above regarding DtWI, Dr. Kevin Croke released a new study of a randomized controlled trial of a deworming program showing large, long-term impacts from deworming programs (for more, see this blog post). This study is a significant positive update on the impacts of deworming and increased our confidence that deworming programs have significant long-term impacts. We continued our work revisiting SCI’s case for impact (detailed here). There appear to have been major problems with some, though not all, of the studies we had relied on (pre-2013) to assess SCI’s impact. SCI shared some additional monitoring information with us which supported the conclusion that its programs have generally succeeded, though these reports have significant limitations. We also reviewed the papers of several academics who had previously been critical of SCI’s activities. We found little in this literature to change our views on SCI’s programs. We spent significantly more time with SCI in 2014 (including a 3-day visit to its headquarters in London) than we had in previous years, aiming to improve our understanding of its operations and spending. The picture that emerged was more detailed though largely consistent with what we believed before. Specifically: • We are less confident in our understanding of how SCI has spent unrestricted funds. At the end of 2013, we believed we had a relatively strong understanding of SCI’s unrestricted spending, but after spending additional time reviewing reports and discussing with SCI staff, we have more questions today than we did a year ago. • We have better information about how SCI plans to use additional funds it receives and the constraints, besides funding, that SCI faces in utilizing additional funding (more in our review). Funding gap SCI told us that it has approximately$3.8 million worth of opportunities that it would be highly likely to undertake if it had the funding available. (Some of this would be spent in 2015 and some held for the following year to ensure programs can continue once started). It believes it could possibly absorb an additional $4.5 million (up to$8.3 million total) for opportunities that are more speculative. Overall, our best guess is that SCI will use up to approximately $6.3 million and, beyond that, would build up reserves. Partly for reasons of donor coordination, we have set its target at$6.8 million total (more below). We hope that SCI will receive $1 million from individual donors (excluding Good Ventures) this giving season as a result of our recommendation. Key considerations: • Program impact and cost-effectiveness. Our best guess is that deworming is roughly as cost-effective as distributing bednets and more cost-effective than cash transfers by a factor of 5-10. Our estimates are subject to substantial uncertainty. (Note: all our cost-effectiveness analyses are available here. Our file for deworming, cash transfers and iodine is here (.xls).) • Directness and robustness of the case for impact. We have seen some evidence demonstrating that SCI successfully deworms children, though this evidence is relatively thin. Nevertheless, deworming is a relatively straightforward program, and we think it is likely (though far from certain) that SCI is successfully deworming people. We have had difficulties communicating with SCI (see below), which has reduced our ability to understand it; we have also spent significant time interviewing SCI staff and reviewing documents over the past 5 years and have found minor but not major concerns. • Transparency and communication. We have had consistent difficulties communicating with SCI. Specifically, (a) we had a major miscommunication with SCI about the meaning of its self-evaluations (more) and (b) although we have spent significant time with SCI, we remain unsure of how SCI has spent funds and how much funding it has available (and we believe SCI itself does not have a clear understanding of this). Importantly, if there is a future unanticipated problem with SCI’s programs, we don’t feel confident that we will become aware of it; this contrasts with AMF and GiveDirectly, both of which we feel we have a strong ability to follow up. • Risks: There are significantly more unknown risks with SCI than our other top charities due to our limited understanding of its activities. We hope for SCI to have$6.8 million available, which is significantly more unrestricted funding than it has had available in the past.

Our full review of SCI is here.

SummaryThe table below summarizes the key considerations for our four top charities.

Consideration AMF DtWI GiveDirectly SCI Program estimated cost-effectiveness (relative to cash transfers) 5-10x 10-20x 1x 5-10x (and possibly more) Directness and robustness of the case for impact Strong Weakest Strongest Moderate Transparency and communication Strong Strong Strongest Weakest Ongoing monitoring and likelihood of detecting future problems Strong Strong Strongest Weakest Organizational track record of rolling out program Moderate Moderate Strong Strong Room for more funding (more below) High Limited Very high Limited when accounting for all donors

Note the absence of two criteria we have put weight on in years past:

• Program evidence of effectiveness. With the new evidence about deworming, we think differences on this front are much reduced, though we still think net distribution and cash transfers have more robust cases than deworming.
• Potential for innovation/upside. All of these organizations are fairly mature at this point, and we expect each to get significant revenue this giving season.

Standouts

Much of the work we did this year went into investigating potential new additions to our top charities list. The strongest contenders we found are discussed below.

Ultimately, none of these made it into our top tier of recommendations, but that could easily change in the future. We believe that more investigative effort could result in a much better understanding of GAIN-USI (discussed below) and potentially a top-tier recommendation. Meanwhile, ICCIDD and DMI (also discussed below) do not have the track record we’d want to see for our top tier of recommendations, but in both cases we expect major developments in the next year. Specifically, ICCIDD will have a substantially larger working budget (due to GiveWell money moved), and DMI may have new data from its randomized controlled trial that could cause a significant upgrade in its status.

These are all strong giving opportunities, and we’ve vetted them all relatively thoroughly. Two work on a program (universal salt iodization) that we believe has excellent cost-effectiveness and a strong evidence base, and the other two have recently released data from randomized evaluations of their own programs (something that is very rare among charities). We have thoroughly vetted each of these organizations, including site visits. And we can see arguments for supporting these organizations in lieu of our top charities this year, though we ultimately recommend our top charities above them.

Below are some brief comments on each standout organization. Donors interested in learning more should read our full reviews of each organization.

Development Media International (DMI) produces radio and television broadcasts in developing countries that encourage people to adopt improved health practices, such as exclusive breastfeeding of infants and seeking treatment for symptoms associated with fatal diseases. Its programs reach many people for relatively little money, so if its program successfully changes listeners’ behavior, it may be extremely cost-effective. It is in the midst of running a randomized controlled trial of its program; the midline results were released earlier this year, at which point we blogged about them.

At midline, the study found moderate increases (relative to the control group) in self-reported health behaviors. Our attempt to estimate the likely mortality impact of these behaviors – when accounting for other concerns about the generalizability of the study – implied cost-effectiveness worse than AMF’s. This isn’t sufficient for a recommendation this year, as DMI has much less of a track record than our top charities. However, if endline results hit DMI’s targeted mortality impact, we would expect to adjust our estimate significantly, and DMI could become a top charity.

DMI’s current budget is approximately $2.5 million; it has told us it expects to receive approximately$2.5-$4 million from existing funders in the next year and could absorb an additional$6-$7.5 million, which it would either use to supplement a program already broadcasting in a country or move into a new country, depending on how much it received. Our cost-effectiveness analysis for DMI is here (.xls). Our full review of DMI is here. GAIN-USI. GAIN’s Universal Salt Iodization (USI) program supports salt iodization programs. There is strong evidence that salt iodization programs have a significant, positive effect on children’s cognitive development, and we consider the program to accomplish (very roughly speaking) comparable good per dollar to bednets and deworming (see our intervention report). GAIN-USI does not work directly to iodize salt; rather, it supports governments and private companies to do so, which could lead to leveraged impact of donations or to diminished impact depending on its effectiveness. We tried but were unable to document a demonstrable track record of impact; we believe it may have had significant impacts, but we are unable to be confident in this with what we know now. More investigation next year could change this picture. GAIN’s USI program was one of the recipients of a large, multi-year grant from the Bill and Melinda Gates Foundation. The grant ends in 2015 and has yet to be renewed; we are unsure of whether it will be. Donors whose primary interest is supporting a strong intervention, and who are comfortable supporting a large and reputable organization whose role is to promote and support the intervention (but whose track record we cannot assess at this time), should strongly consider supporting GAIN’s USI program. GAIN is a large organization running many programs, so donors should consider the possibility that funds restricted to GAIN’s USI program might effectively support its other efforts (more on this general concern here). GAIN told us that it has very little unrestricted funding, so it is unlikely to be able to reallocate funds from other programs to continue to support USI work. It is possible that resources that are shared across programs (such as some staff) could be shifted toward other programs if resources for USI increased, but we would guess that this effect would be small. Our cost-effectiveness analysis for deworming, cash transfers and iodine is here (.xls). Our full review of GAIN is here. International Council for the Control of Iodine Deficiency Disorders Global Network (ICCIDD). Like GAIN-USI, ICCIDD supports (via advocacy and technical assistance rather than implementation) salt iodization, and as with GAIN-USI, we tried but were unable to establish a track record of successfully contributing to iodization programs. Unlike GAIN-USI, ICCIDD is small, operating on a budget of approximately half a million dollars per year, and relies heavily on volunteer time. We believe that additional funding in the range of a few hundred thousand dollars could have a significant positive impact on its operations. Good Ventures has granted a total of$350,000 to ICCIDD this year ($100,000 as a participation grant and$250,000 with the grants announced today), and we would be happy to see ICCIDD receive a few hundred thousand dollars more, after which point we would be more hesitant as it would be more than doubling its budget. We hope that ICCIDD will use the additional funding to improve its capacity and potentially become a top charity in the future.

Our cost-effectiveness analysis for deworming, cash transfers and iodine is here (.xls).

Our full review of ICCIDD is here.

Living Goods recruits, trains, and manages a network of community health promoters who sell health and household goods door-to-door in Uganda and Kenya and provide basic health counseling. They sell products such as treatments for malaria and diarrhea, fortified foods, water filters, bed nets, clean cook stoves and solar lights.

It completed a randomized controlled trial of its program and measured a 27% reduction in child mortality. We estimate that Living Goods saves a life for roughly each $10,000 it spends, approximately 3 times as much as our estimate for the cost per life saved of AMF’s program. Living Goods has been operating on a budget of$3 million per year and aims to scale up to operate on a budget of $10 million per year, of which it expects to receive approximately two-thirds from existing funders. Our cost-effectiveness analysis for Living Goods is here (.xls). Our full review of Living Goods is here. Funding targets by charityIn order to give guidance to donors seeking to give as we would, we’ve come up with funding targets for each charity. These targets are based on “dividing up”$7.5 million in money moved, which is our best guess for how much individual donors will give based on our recommendations over the next 4 months.

We are using the following principles in setting targets:

• We’d like each top charity to receive a substantial amount of funding. When a charity receives substantial funding at our recommendation, it (a) gives that charity good reason to continue working with us, reporting to us, and helping us learn further about its activities; (b) gives that charity the opportunity to continue building its track record and demonstrating its capabilities, information we will use in future years; and (c) continues to reinforce the idea that GiveWell-recommended charities receive substantial funding – the main incentive charities have to participate in our process.
• All else equal, we’d like stronger overall charities – defined as those that accomplish more good per dollar, taking all considerations into account – to receive more funding.
• Each charity has a conceptual “maximum” past which we think donations would hit strongly diminishing returns. We aren’t allocating any “money moved” to a charity in excess of the max; beyond that point, we think the money is better spent supporting other top charities.

We are also taking the announced Good Ventures grants into account. These grants were recommended using similar considerations, though some of our information has changed.

Our targets are as follows. Note the distinction between “total max” (the most we’d be comfortable seeing a charity take in, at which point we would make an announcement), “total target” (the total amount we would like to see this charity take in, including Good Ventures grants and other donations), “target from individuals” (the amount we are seeking specifically from GiveWell-influenced individual over the next four months), and “max from individuals” (the most we’d be comfortable seeing a charity take in, taking into account what we know about other donors’ plans).

• Against Malaria Foundation: $5 million target from individuals,$5 million max from individuals. As discussed in the section on AMF, our ideal amount for AMF to take in would be $10 million this giving season, and Good Ventures has already committed$5 million. We therefore target $5 million for AMF. • Deworm the World Initiative:$0.5 million target from individuals, $1 million max from individuals. We think Deworm the World Initiative is an outstanding giving opportunity with limited room for more funding, as discussed above. • Schistosomiasis Control Initiative:$1 million target from individuals, $1 million max from individuals. We believe SCI will end the giving season with$3 million from Good Ventures, $1 million from a major donor who discussed his plans with us,$1 million in donations that we expect to come from non-GiveWell-related sources (based on projections from past years rather than on knowledge of specific donors). We also believe it has $1 million in cash available for the$6.3-$8.3 million in opportunities we describe above. In total, then, SCI already can expect to have$6 million available, which would be around the maximum we’d recommend in isolation. However, our discussion with the possible $1 million donor has led us to set a higher overall “total target” than we would have otherwise, settling on a total target of$6.8 million. (We plan to elaborate on our thoughts about donor coordination and donor agency in a future post.) Since we are hoping for SCI to have a total of $6.8 million available for its activities, we are recommending$1 million in donations from GiveWell-influenced individuals this giving season. (We are rounding $0.8 million in estimated remaining gap to$1 million in recommended giving since these figures are not precise, and we see value in round numbers for our targets.)
• GiveDirectly: $1 million target from individuals,$25 million max from individuals. We believe GiveDirectly could absorb up to $40 million total ($5 million from the Good Ventures grant, $10 million we expect it to receive from non-GiveWell-related sources already, and$25 million on top of that). However, our revised cost-effectiveness estimates (which we will discuss more in a future post) now classify cash transfers as significantly less cost-effective than bednet distribution and deworming, by a factor of around 5-10. In addition, the $5 million grant from Good Ventures and the funds we expect it to receive from elsewhere means that GiveDirectly will raise nearly as much in its next fiscal year as it did last year. Given that we anticipate moving roughly$7.5 million from individual donors in the next four months, we’d like to direct roughly $1 million of those donations to GiveDirectly. Note that GiveDirectly is, by a substantial amount, the organization we feel has performed best and most consistently in carrying out its intervention and providing quality data on the results, and people who are particularly skeptical of cost-effectiveness estimates are likely to find it the most appealing. We also are very excited about the future of GiveDirectly, in terms of its continuing ability to produce useful information via studies and its potential to grow and raise more from sources unconnected to GiveWell, though at this point we feel GiveDirectly is mature enough that further donations are not crucial in helping it toward this goal. Summary table (all figures in USD millions): Charity Total max (including all donations) Total target (including all donations) Donations committed or expected from Good Ventures and non-GiveWell sources Target from individuals Max from individuals Against Malaria Foundation 10 10 5 5 5 Schistosomiasis Control Initiative 6.8 6.8 6 1 1 Deworm the World Initiative 1.3 0.75 0.25 0.5 1 GiveDirectly 40 16 15 1 25 For donations beyond the ~$7.5 million total we’re projecting over the next four months, we think the decision of which charity to support would be particularly difficult. Of our top charities, only GiveDirectly would have clear room for more funding after receiving an amount in line with the above, but the others – and to a lesser extent, some of our standout charities – have significantly superior estimated cost-effectiveness according to our latest analyses. We will be continuing to stress-test and reflect on these analyses as we reflect on the question of how to modify our recommendations once the above targets are hit.

Our research process in 2014This section describes the new work we did in 2014 to supplement our previous work on defining and identifying top charities. See the process page on our website for our overall process.

This year, we completed an investigation of one new intervention (salt iodization). We made substantial progress on several others (maternal and neonatal tetanus immunization campaigns, mass drug administration for lymphatic filariasis, and vitamin A supplementation) but did not complete them.

We also stayed up to date on the research for bednets, cash transfers and deworming and made a substantial update to our view on deworming, based on a new study by Kevin Croke.

We did not conduct an extensive search for new charities this year. We feel that we have a relatively good understanding of the existing charities that could potentially meet our criteria, based on past searches (see the process page on our website for more information). Instead, we solicited applications from organizations that we viewed as contenders for recommendations. (Living Goods is an exception; it contacted us with the results from its randomized controlled trial.)

A February post laid out which organizations we were hoping to investigate and why.

In addition to the 4 standout charities, we also considered Nothing but Nets (a bednets organization that declined to participate in our process), Evidence Action’s Dispensers for Safe Water program (which is forthcoming), the Center for Neglected Tropical Disease and UNICEF’s maternal and neonatal tetanus program. In the case of the latter two, we ran out of time to complete the relevant intervention reports this year (due to prioritizing other work, which seemed more likely to lead to new recommendations) and plan to complete them in 2015.

Brief notes on giving now vs. later and supporting GiveWell vs. top charitiesGiving now vs. giving later

Last year, some staff members chose to save some of their charitable giving budget for future giving opportunities, and we discussed the considerations about giving now vs. later in this post.

This year, we think the situation is a bit different, as AMF has returned to our top charities list, the case for both SCI and GiveDirectly has improved (due to new evidence on deworming and GiveDirectly’s strong performance in disbursing cash transfers), and we have extensively investigated possible other options. With these changes, we feel that (unlike last year) this year is an excellent year to give a substantial amount if you are interested primarily on our top charities work. We think our top charity recommendations are unlikely to improve a great deal (i.e. they’re unlikely to improve enough to make saving worthwhile) in the coming years. A couple considerations that might be relevant in weighing the decision to give now versus later:

• Will the giving opportunities available in the future be better than the ones we have identified now? There are competing factors. On one hand, our research capacity has expanded significantly over the past 2 years, and this has given us the ability to research more opportunities both in our traditional, top charities work and the Open Philanthropy Project. On the other, the world is getting better and some of the best opportunities available today (e.g., deworming, bednets, salt iodization) may no longer be available 10 years from now. We now feel that we’ve investigated a large proportion of realistic short-to-medium-term contenders for top charity recommendations. If money moved ends up exceeding the ~\$7.5 million we’re projecting over the next four months, a stronger case for waiting may emerge, as many of the strongest charities will be near what we think they can productively absorb in the short term (and our standout charities may become recommended next year, as discussed in the section on standouts).
• How much funding will be available in the future to the opportunities we identify? Our impression is that funding available for the opportunities we identify has and will continue to grow significantly. Good Ventures is a part of this, but we hope that other future, major philanthropists will consider supporting our recommendations as Good Ventures has.

Donors interested in supporting opportunities that come from the Open Philanthropy Project have a stronger case for saving to give later. Note that it could be several years before the Open Philanthropy Project has recommendations suitable for individual donors, and these recommendations will likely reflect a very different process, very different criteria, and a much higher tolerance for high-risk opportunities that are difficult to fully explain and defend in writing (though we will work hard to lay out the basic case).

Giving to GiveWell vs. our top charities

We have grown significantly over the past 2 years and continue to raise funds to support our operations. The funds we have received have enabled us to expand our staff. Without this increased capacity, we would not have been able to consider as many organizations as we did this year.

We plan to post an update soon about our budget situation. The most up to date information available is linked from our August board meeting. The short story is that we are still seeking additional donations. For the first time this year, our checkout form will ask donors to consider allocating 10% of their donation to our operating expenses. This option is not yet live on our website; we hope to implement this change in the next few weeks.

The post Our updated top charities appeared first on The GiveWell Blog.

### Update on SCI’s evidence of impact

Sun, 10/26/2014 - 19:02

Note: Consistent with our usual practices, SCI reviewed a draft of this post prior to publication, but the final product is ours.

We wrote last year about reevaluating studies we relied on in our evaluation of the Schistosomiasis Control Initiative (SCI), which is one of our top charities. We noted at the time that we were planning to continue learning about the studies. We have now revisited these studies and discussed them in depth with SCI. We have two main takeaways from this investigation:

1. We now feel that some of the panel studies we previously relied on in our evaluation of SCI do not in fact provide evidence that SCI’s national programs have reached a large proportion of children targeted. We wrote last year that in one of the four studies, participants received extra deworming treatment from researchers if they were found to be infected with worms. We learned this year that participants in at least one of the other three studies received treatment separately from and under closer supervision than other students in the country. Where participants received more treatment or more careful treatment than other students in the country, we believe that the results of the studies do not reflect the treatment coverage achieved by the national programs.
2. We are concerned about SCI’s external communications around these panel studies. We first published the view that all of SCI’s panel studies provided evidence of effective national programs in 2009, along with our interpretation of how the studies were carried out. It is concerning to us that (a) the published papers on the studies, which had SCI staff as coauthors, imply or explicitly say that the studies reflect the performance of the national programs, (b) SCI did not correct this interpretation, which we published and asked them to review, and (c) when we asked SCI about the methodological issue specifically, SCI leadership gave us information that SCI program staff later contradicted.

SCI has told us that it has standardized and made significant improvements to its procedures for more recent monitoring, including treating children at sentinel schools as part of MDAs. SCI recently shared with us a more recent panel study and two studies of MDA coverage rates. We plan to write about these studies in our upcoming review of SCI.

On the whole, we continue to view SCI as an outstanding giving opportunity, and it will likely maintain its status as a top charity when we refresh our recommendations in December.

Our updated views on four SCI panel studies

In our 2011 and 2012 recommendations of SCI, we emphasized a set of four panel studies from Uganda, Burkina Faso, Niger, and Burundi. In each of the studies, a set of sentinel schools was chosen, and children at each sentinel school were tested for worm infections before the start of an SCI-led control program. The same children were followed up and tested again in subsequent years. The studies show a fairly consistent picture of dramatic drops in disease prevalence among the study participants. We acknowledged multiple limitations to these studies, but felt that they gave relatively strong suggestive evidence that the SCI-led control programs had reached a large proportion of the children they targeted.

Last year, we learned that in the Uganda study (Kabatereine et al. 2007), study participants who tested positive for infection in the course of the study were directly treated by the researchers. Thus, improvements measured over time could be attributable to the activities of the researchers carrying out the study rather than necessarily to the coverage of the national control program.

This year, we have revisited the methodology used in the other three studies through conversations with SCI. We have learned that the Burkina Faso study has similar methodological issues to the Uganda study. We are unsure whether researchers participated in treatment in the studies in the other two countries.

In the Burkina Faso study, which began in 2004, drug administration at the sentinel sites was not part of the national mass drug administration (MDA) program. Researchers working for the national schistosomiasis control program supervised teachers as they administered deworming treatment to all children in the sentinel schools on the day researchers took samples, a few weeks before the MDA. SCI told us that the national control program staff ran the study in this way to meet ethical guidelines laid out by the countries’ ethics boards as well as to produce more impressive results than might have been obtained by treating children as part of the national MDA. In addition to their ethical commitment and strong desire to ensure that all children tested were treated, the researchers were more knowledgeable about deworming than the district-level health workers who administered treatment in the MDA. Supervision from the researchers may have caused teachers to do a more thorough job administering deworming treatment. For this reason, and because drug administration in sentinel schools was logistically separate from the MDA, we do not consider this panel study to reflect the coverage achieved by the national MDA.

We are unsure whether participants in the Niger study received treatment in the same manner as the other students throughout the country, or whether they were treated separately under the supervision of the researchers as in Burkina Faso. SCI leadership originally told us that participants were treated in the same way as other students in the country. SCI’s current Program Manager for Niger and Burkina Faso (who was not the Program Manager at the time of the study) later said that participants were treated separately under the supervision of the researchers (note 1). After we discussed the Program Manager’s comments with SCI leadership, SCI contacted Dr. Amadou Garba, National Coordinator of the Schistosomiasis and Soil-transmitted Helminth Control Program in Niger at the beginning of the panel study. According to SCI, he stated that participants were treated as part of the MDA. We believe that participants were most likely treated as part of the MDA, but feel that we cannot be sure given the conflicting positions expressed by SCI staff.

Note that we believe that each SCI staff member we spoke to told us what they believed to be the truth about the methodology of the studies, and we do not think that any of them intentionally misled us.

SCI’s Program Manager in Burundi confirmed SCI leadership’s statement that the children in the sentinel schools there received treatment in the same manner as children throughout the country (note 2).

Note that other substantial concerns about these studies remain even in cases where children in sentinel schools were treated as part of the national MDAs. As we wrote in our 2012 review of SCI, we are concerned because the sentinel sites selected may not be representative of the whole country, and because only about half of the students initially surveyed were followed up. We are also concerned that treatment teams and teachers may have known which schools were sentinel schools and may have administered deworming treatment more carefully in the sentinel schools (note 3). We have had these concerns since first evaluating the studies and they should not be taken as an update, but it is important to note that they are still live concerns.

Additionally, given that it took us years to discover the issues regarding different protocols for treating children at sentinel sites, we feel that it is reasonably likely that the Niger and Burundi studies have weaknesses that we have not yet discovered.

We have seen little monitoring data outside of the panel studies that we believe shows that national programs supported by SCI reach a high proportion of the children they attempt to treat. Thus, we are unsure of the impact of SCI’s programs. Also, considering that the Burkina Faso study does not seem to reflect the coverage achieved by the MDA, we now have somewhat lower confidence that SCI has been able to effectively use its research results to improve its programs.

SCI’s external communications about the four studies

Our conversations with SCI staff about the panel studies have reduced our confidence in SCI’s external communications, particularly its communication with us. There are three reasons for this:

1. The published papers on the studies, which had SCI staff as coauthors, either imply or explicitly say that the Uganda and Burkina Faso studies reflect the performance of the national programs, even though we now believe that the studies do not necessarily reflect the performance of the national programs (note 4).
2. We treated the panel studies as central evidence of the impact of SCI’s MDAs in our 2011 and 2012 reviews of SCI. SCI vetted those reviews but did not note to us that in some studies, children in the sentinel schools were treated separately from the national MDAs.
3. This year, we asked SCI’s leadership about whether the Niger and Burkina Faso studies had methodological issues similar to the Uganda study. They told us, “All students were treated as part of the national treatment program (at the same time and with the same treatment strategy) as the purpose of the sentinel sites was to assess the impact of the national control program.” When we later spoke with program staff who had been involved in the studies, they contradicted this picture (though we believe that all SCI staff told us what they believed to be the truth).

We previously noted difficulties communicating with SCI. We feel that our struggle to communicate effectively with SCI about the panel studies was more serious than previous difficulties. We credit SCI with connecting us with staff who could provide more detailed answers to our questions, even where those answers contradicted SCI leadership. Still, the fact that it took this much time and effort to gain this information reflects poorly on our ability to communicate with SCI.

More recent studies

The Uganda and Burkina Faso studies began in 2003 and 2004 respectively. SCI has continued to collect monitoring data as part of its ongoing programs. SCI has told us that it has standardized and made significant improvements to its procedures for more recent monitoring, including treating children at sentinel schools as part of MDAs. SCI recently shared with us a more recent panel study and two studies of MDA coverage rates. We have begun to analyze these new studies and feel that they likely provide some degree of additional evidence that national programs supported by SCI achieve relatively high coverage. We plan to write about these studies in our upcoming review of SCI.

Bottom line

Our concerns about SCI’s evidence of effectiveness and its external communications discussed in this post cause us to take a less positive view of SCI. However, we continue to believe that the program SCI supports, combination deworming, is among the most cost-effective programs we have considered and that the program has room for more funding globally. We recently wrote about a new study that seems to bolster the evidence for the long-term effects of deworming. In addition, SCI recently sent us the more recent studies discussed above and hosted us for three days of meetings with staff to update and expand our understanding of SCI’s work. When we refresh our top charity rankings later this year, we will likely include SCI.