Deworm the World Initiative, Led By Evidence Action - 2015 Review | GiveWell

# Deworm the World Initiative, Led By Evidence Action - 2015 Review

We have published a more recent review of this organization. See our most recent report on Deworm the World.

The Deworm the World Initiative, led by Evidence Action, is one of our top-rated charities and an organization that we feel offers donors an outstanding opportunity to accomplish good with their donations.

Published: November 2015

## Summary

What do they do? The Deworm the World Initiative (evidenceaction.org/#deworm-the-world), led by Evidence Action, advocates for, supports, and evaluates government-run school-based deworming programs. (more)

Does it work? We believe that deworming is a program backed by relatively strong evidence. Deworm the World retains monitors whose reports indicate that the deworming programs it supports successfully deworm children. (more)

What do you get for your dollar? We estimate that children will be dewormed for a total of about $0.80 per child, or$0.51 per child excluding the value of teachers’ and principals’ time spent on the program and the cost of donated drugs. The number of lives significantly improved is a function of a number of difficult-to-estimate factors, which we discuss in detail in a separate report. (more)

## Does it work?

Deworm the World-assisted mass drug administration programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective.

We focus this review on Deworm the World’s work in India. There, it commissions third-party monitors to determine whether the deworming activities it supports are occurring. Evidence from the monitors makes a relatively strong case that the programs Deworm the World supports successfully deworm children.

Here we focus on the following questions to understand whether Deworm the World’s activities are having the intended impact (details in the sections that follow).

• Are mass school-based deworming programs effective?
• Have infection rates decreased in target populations?
• Are programs operating as intended?
• How does Deworm the World affect program outcomes?
• What new challenges might Deworm the World face in future programs?
• Are there any negative or offsetting impacts?

### Are mass school-based deworming programs effective?

Deworm the World supports mass school-based deworming programs, the independent evidence for which we discuss extensively in our intervention report on deworming programs. In short, we believe that there is strong evidence that administration of the drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes; we consider deworming a priority program given the possibility of strong benefits at low cost.

There are some important differences between the type and severity of worm infections in the places Deworm the World works and the places where the key studies on improved life outcomes from deworming took place, which we discuss below. In particular, Deworm the World primarily provides support to mass drug administrations (MDAs) that treat populations with fewer infections from soil-transmitted helminths (STH), and no infections from schistosomiasis.18

### Have infection rates decreased in target populations?

Two surveys measuring the prevalence of worm infections in Bihar, one of the states in which Deworm the World operates, are consistent with the notion that the deworming program reduced infection rates in target populations. However, there are also plausible, alternative explanations for these results. (Note that the first survey was not designed to measure a subsequent change in infection rates, so our conclusion is not surprising.)

Before Deworm the World helps to launch a deworming program in a new area, it evaluates whether the prevalence of worm infections is sufficient to justify an MDA for the school-aged population. If no prevalence surveys have been conducted recently, it generally commissions one.19 It also plans to generally conduct follow-up prevalence surveys periodically, and has completed such a follow-up survey in Bihar.20

The original prevalence study in Bihar measured prevalence in four of Bihar’s 38 districts, which were selected to inform a prevalence model based on climatic and socioeconomic variance across the state.21 We are not sure how representative that survey was of the state as a whole since the districts were not chosen randomly.22 Since the survey found >50% prevalence,23 the Government of Bihar planned to follow the WHO’s recommendation to conduct deworming MDAs twice per year, with one round each year led by the National Filaria Control Program (NFCP) and one round through schools that would be assisted by Deworm the World.24 However, according to Deworm the World, only four rounds of deworming took place between the two prevalence surveys in 2011 and early 2015, with one community-based round led by the NFCP and three school-based rounds assisted by Deworm the World.25

Deworm the World’s follow-up survey in early 2015 used random sampling to be representative of the entire state and the three climatic regions.26 The results of both surveys, broken down by climatic region of Bihar, are in the table below; no single district was surveyed in both prevalence surveys.

Indications of STH prevalence in Bihar’s three agro-climatic zones in 2011 and 201527
Hookworm Ascaris (roundworm) Trichuris (whipworm) Any STH
NW Alluvial Plains, 2011 (2 districts, non-random) 47.4% 56.8% 4.2% 71.3%
NW Alluvial Plains, 2015 (5 districts, random) 21.0% 24.0% 12.0% 43.0%
NE Alluvial Plains, 2011 (1 district, non-random) 32.8% 72.1% 11.3% 79.6%
NE Alluvial Plains, 2015 (3 districts, random) 17.0% 38.0% 5.0% 50.0%
S Alluvial Plains, 2011 (1 district, non-random) 40.2% 25.0% 1.7% 49.0%
S Alluvial Plains, 2015 (6 districts, random) 14.0% 6.0% 2.0% 20.0%
Statewide 2011 (4 districts, non-random) 42.2% 52.1% 5.2% 67.5%
Statewide 2015 (14 districts, random) 17.0% 19.0% 6.0% 35.0%

#### Considerations in interpreting the two prevalence surveys in Bihar

We are unsure whether worm prevalence in Bihar would have increased or decreased in the four years between the two prevalence surveys if the three MDAs that Deworm the World supported had not occurred.28 Here we’ve listed some other factors that we weigh when considering these results:

• Methodological limitations of these prevalence surveys. It may be that the original prevalence survey took place in districts with unusually high worm prevalence. Since it is unclear whether the original prevalence survey was representative of the state or its climatic zones and the two prevalence surveys did not sample the same districts, it may be that the decrease in prevalence seen above is the result of comparing different populations rather than a fall in prevalence in the same population over time.
• MDAs for lymphatic filariasis. The NFCP’s program, which is designed to reduce the burden of lymphatic filariasis (LF) as well as STH, claims it conducted MDAs in Bihar in 2012 and 2014 with albendazole, the drug used to treat STH.29 According to the Indian government's program website, the LF treatment program is designed to be annual, and reached 86% of the population in both 2012 and 2014.30 We would not be surprised if the coverage rates reported by the LF program were inaccurate, but we have not tried to verify them. Deworm the World has said that the 2014 round actually occurred in early 2015 after the 2015 prevalence survey.31
• Factors other than MDAs. There are a variety of large-scale changes that could affect worm prevalence, such as improved sanitation infrastructure or general development. According to India’s central bank, inflation-adjusted per-capita income in Bihar increased by a total of 39% over a similar four year period, suggesting that there could have been broad improvements in the region that would be associated with better health and lower worm prevalence.32 Alternatively, it seems possible that population growth combined with poor sanitation infrastructure could have increased worm prevalence over this period if Deworm the World-supported MDAs had not been carried out.

### Are programs operating as intended?

Administration of deworming drugs is a relatively straightforward program, though any MDA could encounter many challenges when operating at a large scale. The information we have seen from third-party monitors hired and trained by Deworm the World in India strongly suggests that the programs are generally operating as intended.

#### Third-party monitors

Deworm the World hires and trains third-party monitors who observe the programs; this footnote includes Deworm the World’s descriptions of the monitor selection process used in the four states with which Deworm the World conducted its standard monitoring program in 2015.33 We focus on the monitors’ work at two points in time:

• Deworming day and mop-up day (DD and MUD): On the days in which deworming takes place, monitors visit schools to observe whether the deworming is taking place, the principal and teacher are prepared and knowledgeable on topics related to deworming, the drugs are stored properly, the teachers are adhering to deworming procedures (such as administering the drugs after the students have eaten and not giving drugs to children who appear sick), and the children are chewing and swallowing the pills.
• Post-deworming: Monitors are asked to visit schools after deworming has concluded to check whether class registers match summary forms and whether students report having been given a tablet.

As far as we know, Deworm the World does not audit monitors’ work.

Results of the monitoring are discussed below.

#### Are targeted children being reached?

Monitors’ direct observations and interviews with children and school officials strongly suggest that a significant portion of enrolled students who attended school on deworming distribution days consumed deworming pills. Government estimates - which report that about 80% of students enrolled in primary and secondary schools were dewormed in 2015 in states supported by Deworm the World - seem plausible based on monitoring results.34

Evidence that many enrolled students were dewormed

Deworm the World asked monitors to survey randomly sampled schools (intended to be representative at the state level) to check whether deworming occurred.35

If the chosen school was closed on the day of the deworming, they were instructed to go to an assigned backup school instead.36 Monitors interviewed principals and randomly selected teachers and students, and made direct observations; the results of some of these interviews and observations are in the table below.37

Evidence of deworming occurring (timing of observation) Bihar Rajasthan Delhi Madhya Pradesh
Monitors observe deworming activities on Deworming Day (DD) 83% 94% 88% 70%
Principal reports having received medicine (on DD or MUD) 90% 98% 99% 83%
Principal reports conducting deworming on DD (same day) 82% 98% 99% 70%
Present children report being dewormed, at schools where principal reported deworming happened (coverage validation day) - GiveWell calculation 97% 96% 94% 93%

Estimates of total coverage

The number of children treated in each school is recorded in classrooms and then aggregated and reported by school staff to government officials. Our understanding is that data is generally aggregated stepwise by officials at several levels (school, node, block, district, and state) to create a reported coverage estimate for the entire state.38 The raw numbers produced by this process and reported by the state governments are here.

Monitors visit a random sample of schools to compare each school’s records of how many children it dewormed to the number of children that were dewormed according to its classroom records. Based on this data, it appears that many schools did not follow the recording protocol, but the schools that did had reasonable agreement on the number of children dewormed between the classroom records and the school-wide records (details in this footnote).39

We believe that Deworm the World does not have a monitoring process to measure the accuracy of the aggregation process beyond the school level. Errors in the aggregation process could occur if those performing the aggregation have an incentive to overreport the number of children dewormed, or if reporting forms are lost (in which case we believe that deworming would be underreported).40

We calculated the portion of children that were dewormed – according to class records in schools which used class records or didn’t do deworming – at the schools monitors visited, and multiplied that fraction by the statewide enrollment in government schools to see if it resulted in a similar estimate of total statewide coverage of enrolled children (details of methodology in this footnote).41

The results of estimating statewide coverage using both government-reported data and monitors’ data are in the below table.

Estimates of total statewide coverage42
2015 deworming round Enrolled Coverage - class records observed by monitors Statewide enrollment in government schools (millions) Students dewormed - enrollment-based estimate (millions) Students dewormed - reported enrolled coverage (millions)
Bihar 65% 23.9 15.6 17.6
Rajasthan 85% 7.3 6.2 6.5
Delhi 77% 2.6 2.0 1.8
TOTAL (may not sum due to rounding) NA 44.9 31.4 36.0

While we don’t put very much weight in the estimates generated by the enrollment figures, the fact that the estimates are reasonably close to the coverage figures reported by the government in most states gives us more confidence that the reported figures are not grossly inaccurate.

#### How consistently are program components implemented as intended?

The data that we have seen from monitors about a variety of aspects of program implementation seem to be broadly consistent with the notion that programs are generally being implemented as intended.

Monitors record observations and responses on a large number of questions.43 A slightly larger sample is surveyed for questions related to verification of deworming coverage than for other questions (see footnotes in table below for details on sample size for each question). Here we present data from a small subset of results from all programs in India that Deworm the World supported in 2015. We present results that we judged were fairly easy to interpret, relevant to assessing the programs' quality, and represented examples from a variety of the program areas monitored.

Previously, we summarized monitoring from the 2013-2014 programs and the 2012 programs, and we’ve compiled some of the more comparable answers from different years for three states in this footnote.44

Sample monitoring results: all schools visited by monitors on deworming days
Schools that had a representative attend deworming training (according to principal/headmaster) 85.8%45 63.8%46 83.0%47 39.8%48 40.6%49 "Did you or any teachers from your school attend official training in the last 4 months for deworming?"50
Schools with sufficient drugs for deworming (according to principal/headmaster) 86.1%56 96.0%57 97.2%%58 79.2%59 95.5%60 "Did you have the sufficient drugs for deworming?"61
Children who knew that the tablet was for deworming (interviews with children) 84.3%62 74.0%63 94.2%64 65.4%65 86.8%66 "Do you know what the medicine was for?"67
Children attending school on Deworming Day or Mop-up Day (interviews with teachers) 53.1%68 72.3%69 47.2%70 63.8%71 68.1%72 "How many students are enrolled in this class?" / "How many students are present in this class today?"73
Schools where monitors observed deworming activities in a randomly selected class (monitors' observations) 82.9% (on Deworming Day) 85.5% (on Mop-up Day)74 94.4% (on Deworming Day) 79.2% (on Mop-up Day)75 87.9% (on Deworming Day) 75.3% (on Mop-up Day)76 69.6% (on Deworming Day) 49.6% (on Mop-up Day)77 Not reported "Can you see any deworming activity taking place in the class?"78

Sample monitoring results: classes where monitors observed deworming activities only79
Classes where teachers followed the correct recording protocol (monitors' observations) 68%80 66%81 85%82 62%83 "Did the teacher tick each child's name/roll no. in the attendance register after giving them deworming medicine?"84
Classes where teachers told children to chew the pill before swallowing it (monitors' observations) 89%85 83%86 96%87 82%88 "If children are getting deworming tablets, is the teacher telling the students to chew the tablet before swallowing it?"89
Classes where teachers identified sick children before administering the tablet (monitors' observations) 80%90 72%91 93%92 73%93 "Did the teacher ask the children if they are sick/under medication before giving the medicine?"94
Classes where there were adverse events (monitors' observations) 5% (vomiting), 0% (diarrhea)95 2% (vomiting), 0% (diarrhea)96 5% (vomiting), 0.8% (diarrhea)97 6% (vomiting), 0% (diarrhea)98 "Did you see any child with adverse effects (nausea, vomiting, stomachache, etc.) after taking the medicine?"99

We see some reason to interpret these data cautiously (for example, much of it was self-reported by people who could be biased to want favorable monitoring results).

### How does Deworm the World affect program outcomes?

Deworm the World may be having an impact in the following ways:

1. It may increase the likelihood that a government implements a deworming program.
2. It may improve the quality of a deworming program that would have been implemented without Deworm the World (leading to more children dewormed effectively or improved cost-effectiveness).

While we have limited evidence to rely on, we would guess that Deworm the World increases the likelihood that (national and subnational) governments implement deworming, particularly when it pays for the majority of financial program costs, as it expects to do in the countries to which it expands. Our intuition is that Deworm the World’s activities increase the quality of the programs it supports, but we are highly uncertain about this.

Note that evaluating the impact of a technical assistance and advocacy organization such as Deworm the World is not as straightforward as evaluating a direct service organization. There are substantial potential advantages to supporting such an organization, as it may be able to have a greater impact per dollar by influencing government policy than it would have by simply carrying out programs on its own. However, the additional steps between the organization’s actions and the desired outcomes complicate impact assessment.

#### Does Deworm the World increase the likelihood that governments implement deworming programs?

While we have limited evidence to rely on, we would guess that Deworm the World increases the likelihood that (national and subnational) governments implement deworming programs. In India, governments seem to heavily utilize Deworm the World when planning, implementing, and monitoring their deworming programs. In future countries, Deworm the World plans to pay the majority of financial program costs, which increases our expectation that the organization is critical to the program happening.

Below, we detail what we know with respect to Deworm the World’s experience in India, including:

1. Our limited understanding of how Indian states have historically decided to launch and maintain health programs with NGO assistance;
2. Deworm the World’s role in the mass school-based deworming programs that were in operation in India before the first national deworming day (NDD) in 2015, including our conversations with government officials in Rajasthan about their decision to launch a deworming program with Deworm the World’s assistance;
3. The national government’s interaction with Deworm the World as part of its decision to launch a national deworming day in India in 2015.

• Reasons new health programs may be started or halted in India
• Deworm the World and Children’s Investment Fund Foundation (CIFF) have told us that Indian state governments often receive funds earmarked for broader health programs but often fail to spend these funds.100
• We asked the Center for Global Development for a recommendation of someone to talk to in order to understand states’ decisions to initiate deworming programs, and CGD referred us to Professor Devesh Kapur.101 Dr. Kapur asserted that it takes significant internal political will or external stimulus (such as from a non-profit) to sufficiently overcome general bureaucratic inertia in India to sustain a new health program. This holds true even in cases where a national mandate exists for a program (as it does for school-based deworming). Dr. Kapur felt that in the majority of cases, nonprofit technical assistance was likely to increase the probability of a program’s going forward.102
• Deworm the World told us that it believes that some school health programs have been stalled in Indian states due to negative media attention;103 one of Deworm the World's goals is to prevent these reports in the states in which it works.104 The documentation that Deworm the World has sent us supports – but does not fully demonstrate – the possibility that negative media undermined consistent mass deworming in Assam before the National Deworming Day in 2015. We have not attempted to independently verify that possibility because we do not think we would likely be able to do so effectively. Nonetheless, it is plausible that were decision-makers in Indian states to have the impression that negative reports could cause a program to be halted, they might be less willing to move ahead, and Deworm the World's assurances that it would help prevent these reports could increase the likelihood that a state agrees to implement deworming.
• Early deworming programs in India and Deworm the World's role
• In 2013 Deworm the World and CIFF told us that the Indian government mandates that all states provide school-based deworming through the larger school-based Weekly Iron and Folic Acid Supplementation program and that states can request funding for deworming through this program.105 At the end of 2013, the only states in India that appear to have been implementing school-based deworming programs were Andhra Pradesh, Bihar, Delhi, Jharkhand, Punjab, Rajasthan, and possibly Assam.106 Deworm the World states that it (or others affiliated with it) played a key role in four of these seven states’ decisions to implement deworming.107 In late 2014, Deworm the World believed that more states were starting to launch their own deworming programs without assistance from Deworm the World but was unsure how many had successfully done so.108
• Without involvement from Deworm the World, Assam initiated a vitamin A supplementation and deworming mass drug administration (MDA) in the 2010-2011 school year but reported low and conflicting coverage for that year.109 In the 2012-2013 school year Assam planned to implement a deworming program through the School Health Program, though we are not sure whether that program happened as planned.110 Assam did approach Deworm the World in late 2013 to explore opportunities for the organization to provide assistance to the state, though as of late 2015 Deworm the World has not become directly involved there.111
• During our site visit to Deworm the World in Rajasthan, India, we spoke with three government officials who were involved in the deworming program.112 Of these, two stressed the importance of Deworm the World's technical assistance, and the person we perceive as having been most responsible (of the three) for the decision to go forward with deworming gave the impression that the availability of this technical assistance had been a key factor in deciding to go forward. It should be noted that one of the three gave the impression that Deworm the World's help was not needed, and all three conversations took place with multiple Deworm the World representatives present. With that said, the highest ranking of the three officials gave what we felt to be a nuanced and realistic picture of Deworm the World's impact that implied a substantial (while not determinative) role. She stated that a) the immediate availability of technical assistance improved her confidence that the program would proceed quickly and smoothly, b) she wasn’t sure whether the program would have proceeded if not for Deworm the World, and c) she was interested in finding a nonprofit technical assistance partner for at least one other program in a different category.113 This suggests that nonprofit technical assistance can be a key factor in progressing a program.
• The National Deworming Day and Deworm the World’s role
• In 2014 Deworm the World told us that the Indian national government was pursuing the idea of having a coordinated national deworming day (NDD), whereby the national government would provide some assistance to states in implementing school-based deworming on a single day to encourage more states to implement the program.114 Deworm the World said that the government asked it to provide technical assistance to the NDD, including helping develop the implementation strategy, designing and developing training and reference materials, community mobilization strategies, and monitoring and evaluation systems and reporting formats.115 The posters, ads for radio and television, training materials, and other documents that Deworm the World helped create for NDD are available at the website in this footnote.116
• Deworm the World told us that, as part of its advisory role in the planning process, it advocated for a delay of the initial program from October 2014 to February 2015 because it believed there weren’t sufficient drug supplies.117
• The NDD occurred in February 2015,118 with 12 states participating (although deworming in one state was delayed until April).119

#### Does Deworm the World's work increase the quality of deworming programs?

Our intuition is that Deworm the World’s activities increase the quality of the programs it supports, but we are highly uncertain about this.

Deworm the World may improve program quality by:

• Increasing the chances that the first deworming round in each state begins earlier than it otherwise would have and that subsequent rounds occur on schedule.120
• Increasing the training quality by simplifying training material and creating a more robust training program for those who train representatives from each school.121
• Ensuring that support roles are staffed.122
• Improving focus and attention to detail, possibly increasing the likelihood that schools receive the materials and instructions necessary to implement the deworming program.123
• Expanding the scope of the program to a broader age group.124
• Increasing community acceptance of mass treatment and the ability of a program to avoid or withstand publicity associated with adverse events or seemingly related adverse events.125
• Implementing or advocating for monitoring systems. This may improve program quality by creating a mechanism through which implementers are held accountable. Also, monitoring systems could generate lessons that Deworm the World and the government could use in future rounds of treatment.126

Evidence that relates to Deworm the World’s impact on the quality of deworming programs includes the following, each discussed in more detail below:

• Testimony of a government official in Rajasthan in 2013
• The number of calls Deworm the World says its monitors made in the run-up to deworming day
• A training we observed in 2013

Testimony of a government official
We believe our strongest piece of evidence in favor of the idea that Deworm the World improves quality is the conversation we had with a Rajasthan nodal officer in 2013, who cited many of the points above and made the case that Deworm the World had played an important role in improving the quality of deworming, backing up an intuition that without external support, such programs would often be significantly disadvantaged. On the other hand, (a) this conversation took place with multiple Deworm the World representatives present, and the nodal officer had worked closely with Deworm the World; (b) another government official (on the same visit) stated that he believed Deworm the World's technical help was not needed and did not add value, as the state was accustomed to running school health programs and deworming is a relatively simple one (we do not put strong weight on (b) alone, since the government official may have had other incentives to give the message he did and had not worked as closely with the program as the Nodal Officer, but in context of the other observations we find (b) worth noting).

Monitoring calls before deworming day
As part of its standard monitoring process, Deworm the World has tele-callers place thousands of calls to government employees at different levels of government during the run-up to deworming day to ensure that preparations are proceeding as intended.127 Deworm the World reports that these calls helped to uncover problems, which were reported on the same day to the appropriate government officials to address.128

It also seems plausible that these calls reduce the likelihood that problems arise after the calls are placed, due to the signal of importance created by the call itself. We are unaware of how common these monitoring calls are as part of other government programs, nor are we aware of any data that could help quantify the size of the impact they have.

Training observed in 2013
We felt that the training we attended in 2013 (the only part of Deworm the World's work that we observed directly) had major limitations in terms of potential to improve program quality.129 Deworm the World has made changes to address these since this visit, though we have not observed a training since that time.130

### What new challenges might Deworm the World face in future programs?

As part of its effort to increase its impact, Deworm the World has started to engage more countries and partner organizations for possible work outside of India and Kenya. It has also considered a wider range of roles related to school-based deworming, including partnering with organizations with local knowledge to support deworming programs, providing technical assistance for programs that include other complementary interventions alongside deworming, and performing evaluations of different deworming-related programs.131

While the expansion decisions that Deworm the World has made so far seem reasonable to us given our limited information, all of these changes make it harder for us to predict future success based on historical results, and in many cases, will make it harder to understand and quantify Deworm the World’s impact even after the program is completed.

### Are there any negative or offsetting impacts?

We discuss several possible considerations but do not see significant concerns.

Administering deworming drugs seems to be a relatively straightforward program.132 However, there are potential issues that could reduce the effectiveness of some treatments, such as:

• Drug quality: For example, if drugs are not stored properly they may lose effectiveness or expire. We believe Deworm the World generally tests the quality of drugs and monitored storage conditions in each of its recent programs, and this information suggests there have been minimal issues.133
• Dosage: If the incorrect dosage is given, the drugs may not have the intended effect and/or children may experience additional side effects. It appears that for STH treatment, all children of a given age group are given the same dose of albendazole and that the dose is generally a single tablet for children 2 years old and above, and half a tablet for those between the ages of 1 and 2.134 Deworm the World monitors reported that, in recent programs, up to 9% of schools observed gave children less than the prescribed dose of albendazole and up to 5% gave more than the prescribed dose of albendazole.135
• Replacement of government funding: We have limited information about whether governments would pay for the parts of the program paid for by Deworm the World in its absence, though our impression is that they would not.136 We also have little information about what governments would use deworming funds for if they did not choose to implement deworming programs. In India, our understanding is that they might spend those funds on other state-government expenses (not necessarily health programs) or return them to the central government.137
• Diversion of skilled labor: Drug distribution occurs only once or twice per year and is conducted by teachers in schools. Based on our site visit in Rajasthan, our impression is that the Nodal Officer (the state official who manages all state school-based programs), the Nodal Officer’s staff, and the people that the Nodal Officer manages throughout the state (Resource Persons and Community Development Project Officers) have significant capacity to take on additional programs, so their taking on this program doesn't impose a significant burden on their time.138 On the other hand, a principal we spoke with commented that he would prefer fewer school-based health programs because they take focus away from the school day, and teachers may not have as much capacity to add deworming to their school schedule in the countries to which Deworm the World expands.139
• Adverse effects and unintended consequences of taking deworming drugs: Our understanding is that expected side effects are minimal and there is little reason to be concerned that drug resistance is currently a major issue (more information from our report on deworming).

## What do you get for your dollar?

This section examines the data that we have to inform our estimate of the expected cost-effectiveness of additional donations to Deworm the World.

Note that the number of lives significantly improved is a function of a number of difficult-to-estimate factors, many of which we discuss below. We incorporate these into a cost-effectiveness model which is available here (.xls).

We focus on the following questions:

• What is the cost per child treated of the deworming programs, and what percentage of this does Deworm the World bear? We estimate that in India children are dewormed for a total of about $0.30 per child, or$0.07 per child excluding the value of teachers’ and principals’ time spent on the program and the cost of donated drugs.140 We expect the cost per treatment to be substantially higher in Deworm the World’s potential new programs outside of India; we are highly uncertain but estimate the potential total cost per treatment at about $0.80 per treatment or$0.51 excluding the value of teachers’ and principals’ time spent on the program and the cost of donated drugs.141
• How much impact do Deworm the World-supported programs have (per child treated) compared with the ones on which the evidence for deworming's positive impact on life outcomes is based? Because the key deworming studies provided treatments in areas of unusually high prevalence and in some cases treated a different group of parasites, we believe that the programs that Deworm the World supports are likely to have less impact on a per-person basis.
• Does Deworm the World "leverage" government funds, such that each dollar it spends mobilizes multiple dollars from other actors? We could imagine that Deworm the World's funds have substantial leverage but could also imagine that other actors’ involvement is causing Deworm the World to pay for things for which other actors would otherwise have paid. We are not confident that Deworm the World will achieve a significant amount of leverage in its future programs.

### What is the cost per treatment

#### India

As of November 2014, Deworm the World had estimated the total cost of each of the last seven deworming rounds in India (three in Bihar and two each in Delhi and Rajasthan).142 These estimates include the costs listed in the following table. Each of the costs were paid by a combination of government, Deworm the World, and other partners. The following table shows the percentage breakdown for one recent round of deworming in Bihar, Delhi, and Rajasthan:143

Deworm the World’s and others’ costs in Indian states’ deworming programs
Cost category Percentage of total costs % paid by DtWI % paid by others
School staff time in training and deworming day 71% 0% 100%
Drug procurement & management 12% 2% 98%
Training & distribution financial costs 7% 8% 92%
Program management 6% 100% 0%
Public mobilization & community sensitization 2% 9% 91%
Prevalence surveys 1% 97% 3%
Monitoring & evaluation 1% 43% 57%
Policy & advocacy 0% 100% 0%
Total 100% 9% 91%

Deworm the World has estimated some of the above costs because it did not have access to full cost data for governments and other partners, and boundaries between the cost categories are not always clear.144 Additionaly, the estimated costs of "School staff time in training and deworming day" are a GiveWell-added cost designed to represent the value of the teacher and principal time that is used for the deworming program, despite not creating an additional financial cost for the government (since they are already paid on salary).145

The table below shows the costs to Deworm the World, its partners, and the governments, as well as estimates of the cost per child treated, for one recent round of treatment in Bihar, Delhi, and Rajasthan.146 About two thirds of the total cost comes from contributions of time from government employees – which have been monetized according to salary levels – rather than financial costs. We would guess that appropriately valuing that time spent, and estimating how much time is spent by teachers and others due to the deworming program, is the largest source of uncertainty in the cost-per-child-treated calculation.147

Total cost per child treated in India
Expense category Recent deworming rounds Cost per child
DtWI $771,371$0.03
Donated drugs $564,050$0.02
Government financial costs $1,293,090$0.04
Government staff time value $6,326,595$0.21
Subtotal without staff time $2,628,511$0.09
Total costs $8,955,106$0.30

#### Outside of India?

We do not expect additional unrestricted funds given to Deworm the World to be spent in India (more below). Thus, when considering the cost-effectiveness of additional donations, it may be more relevant to consider the likely cost per treatment of Deworm the World’s potential new programs outside of India. Deworm the World told us that the cost per treatment in India is unusually low; it expects future programs' cost per treatment to be more similar to (though likely less than) the program that it supports in Kenya.148 We estimate the total cost per treatment in Kenya to be about $0.80 per treatment (details below), but we would not be surprised if the cost per treatment for Deworm the World’s future programs were significantly higher or lower than this estimate.149 In the second round of treatment in Kenya, Deworm the World estimated that the total cost per treatment was$0.51 (not including the value of teachers' time that is paid by the government with or without the deworming program and the cost of donated drugs).150 We have not closely reviewed data from the program in Kenya. We are uncertain if the cost per treatment in the second round of treatment is representative of the program over time. Deworm the World's cost per treatment in Kenya is in the same range as our estimate of SCI's cost per treatment, which averages data across nine programs in Africa and three years.151

Our estimate of Deworm the World’s total cost per treatment in Kenya attempts to include all partners’ costs so that it represents everything required to deliver the treatments.152 Our estimate includes the value of teachers' time, even though this does not represent an additional financial cost to the program (because the government pays the teachers with or without the program). In our analysis of SCI, we estimate that 30% of the total program costs are in-kind support from the government.153 Applying the same approach to Deworm the World (for simplicity and consistency), we estimate that the total cost per treatment in Kenya is $0.80.154 ### Deworm the World's deworming locations vs. key deworming study locations Our intervention report on deworming programs discusses the cost-effectiveness of deworming suggested by independent evidence.155 In this section, we discuss two key differences between Deworm the World's deworming programs in India and the deworming programs discussed in our intervention report: (a) the prevalence of particular worms and the prevalence of high intensity infections and (b) the existence of other neglected tropical disease programs that may treat the same condition. We are uncertain how these considerations would apply to programs that Deworm the World plans to support in the future, such as its planned program in Pakistan (more below). We would guess that future programs would also treat in areas with different worm types (since Deworm the World tends to focus on treating STH) and significantly lower prevalence than those in the key deworming studies, largely because prevalence in those studies was unusually high. #### Difference in worm prevalence and intensity in India Key pieces of evidence that we discuss in our report on deworming (Miguel and Kremer 2004, Baird et al 2012, and Croke 2014) are from deworming experiments conducted in Kenya and Uganda in the late 1990s and early 2000s. Prior to receiving deworming treatment, the participants in those studies had relatively high rates of moderate-to-heavy infections of schistosomes or hookworm.156 We do not yet know what the prevalence and intensity of worm infections will be in the countries where Deworm the World works in the future, but the situation in India is different from the infections in the deworming experiments. Schistosomiasis is not present in the vast majority of India.157 Data that we have seen from Deworm the World’s prevalence surveys show that hookworm prevalence in the states that Deworm the World supports is lower than it was in the key experiments (often substantially lower).158 In the table below, we compare the baseline prevalence of Indian states that Deworm the World currently supports for which we have prevalence surveys (Rajasthan, Bihar, and Madhya Pradesh) to the populations in the Croke study and the Miguel and Kremer study.159 Prevalence comparison Worm (intensity) Rajasthan (baseline) Bihar (after MDAs) Madhya Pradesh (after MDAs) Croke (baseline) Miguel and Kremer (baseline) Schistosome prevalence (moderate/high) 0% 0% 0% 0% 7% Hookworm prevalence (moderate/high) Not measured 3.70% Not reported Not reported 15% Ascaris prevalence (moderate/high) Not measured 8.80% Not reported Not reported 16% Trichuris prevalence (moderate/high) Not measured 0.40% Not reported Not reported 10% Schistosome prevalence (any) 0% 0% 0% 0.03% 22% Hookworm prevalence (any) 1.0% 42.2% 12.0% 55.1% 77% Ascaris prevalence (any) 20.2% 52.1% 0.2% 3.5% 42% Trichuris prevalence (any) 0.2% 5.2% 0.0% 1.4% 55% Note that the WHO does not recommend MDA in areas with a baseline prevalence less than 20% STH prevalence.160 Similarly, after multiple rounds of treatments, the WHO recommends further MDAs for areas with at least 10% STH prevalence, according to Deworm the World.161 The prevalences in the table above for Bihar and Madhya Pradesh were measured after multiple rounds of treatment. #### Difference in worm prevalence and intensity in other countries We do not have detailed information about worm prevalence or intensity in countries that Deworm the World is likely to operate in in the future. Our understanding is that as in India, there is no schistosomiasis in Pakistan (one of the countries Deworm the World may expand into). Beyond that, we would guess that the prevalence and intensity of worm infections in countries that Deworm the World would operate in in the future will be similar to (a) India and (b) other countries from which we have data (such as where the Schistosomiasis Control Initiative works). #### Treatment for lymphatic filariasis India has an existing program to treat lymphatic filariasis (LF).162 Albendazole, the same drug used to treat STH, is usually used to treat LF.163 The intended treatment for LF in India is annual administration of DEC [Diethylcarbamazine] or DEC and Albendazole164 and the WHO recommends annual albendazole treatment for areas with 20-50% prevalence of STH.165 According to the Indian government's program website, the LF treatment program has high coverage across many states (e.g., typically 80-90% in states carrying out the program), including Bihar, Madhya Pradesh, Uttar Pradesh, and Chhattisgarh.166 Deworm the World believes that LF treatments in Bihar and other states have not been delivered as effectively as planned; we do not have additional information about LF treatment delivery in other states beyond limited publicly available data.167 It appears possible that for the areas that have existing LF treatment programs, the effect of Deworm the World’s support may be to transition an area from once-per-year deworming treatment to twice-per-year treatment. We have not yet seen prevalence data for many of the locations Deworm the World works in now and may work in the future, so we are unsure (a) whether the prevalence in those states is sufficiently high to justify twice-per-year treatment and (b) how the impact of a such a transition would compare to the impact of transitioning from no treatment to some treatment. We do not know whether other countries that Deworm the World might go into, such as Pakistan, have active LF treatment programs. ### Are donations to Deworm the World leveraged? We have written before about the complexity involved in trying to understand leverage in charity, and below we lay out the relevant issues worth considering in the case of Deworm the World. Donors to Deworm the World support only the costs paid by Deworm the World, which are generally a fraction of the overall cost of the program in India. The role these funds play in the program is an important consideration in determining the cost-effectiveness of donations. The role Deworm the World funds play, and the resulting cost-effectiveness, could range between: • High leverage, high cost-effectiveness, if Deworm the World leverages government funds or teacher time that otherwise would not have been spent or would have been spent on a less valuable program by causing the government to run deworming programs or by making those programs significantly better than they otherwise would be. In that case a small contribution from Deworm the World has a large impact on the number of children receiving treatment and Deworm the World is highly cost-effective. • Small marginal contribution to the quality of the program, if Deworm the World’s involvement doesn't cause more infected children to be reached, then Deworm the World’s contribution is more appropriately considered a small marginal contribution to the program that would have happened without its help. It is possible in that case that Deworm the World contributes little to increasing the number of children who receive treatment, but may improve the functioning of the program in less obvious ways. We would guess that Deworm the World’s work in India has played a role in increasing the likelihood that state governments conduct deworming programs, so we have estimated that its leverage on funds used for scaleup could reasonably range from less than 1x (i.e., programs would take place without Deworm the World’s involvement) to 4-5x, though we were highly uncertain about this estimate.168 India may have been an especially promising place to achieve leverage because the Indian national government had made money available for state governments interested in implementing deworming, and states may have been more likely to implement deworming with technical assistance.169 In India, Deworm the World’s costs were about 10% of the overall cost of the deworming programs it was supporting.170 Future donations to Deworm the World will likely be used outside of India (more), 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 upside potential for leverage of future donations more limited. For example, we estimate that Deworm the World bears the majority of total program costs in Kenya.171 Deworm the World has told us that it expects the cost per treatment of its future programs to be more similar to its program in Kenya than India, though we have not explicitly asked about whether it expects to pay a similar share of overall program costs as it does in its Kenya program.172 Our full cost-effectiveness model is available here (.xls). ## Is there room for more funding? In short: • Estimated needs: We believe that Deworm the World’s progress may be slowed if it holds less than$11.25 million of unrestricted funds as of early 2016. We also believe that there is a small possibility that (if new projects move forward quickly enough) they would be slowed if they do not have even more funds, perhaps up to twice that amount.
• Cash on hand: Deworm the World has approximately $3.5 million in unrestricted funding, of which it has allocated$1.1 million.173

### Past uses of unrestricted funds

Deworm the World has spent or allocated approximately half of the unrestricted funds it held over the past two years.183 Specifically, it has spent approximately one quarter of the unrestricted funds it held, and allocated another quarter. We detailed its use (and planned use) of some of these funds in this November 2014 blog post.184 It has allocated $1.1 million of unrestricted funding to future activities, including support intended for new programs in Nigeria, Pakistan, and Vietnam.185 ### Considerations relevant to assessing Deworm the World’s room for more funding Multi-year commitments Deworm the World has told us that it prefers to have enough funding to make 3-5 year commitments when attempting to launch a new program. It told us that governments typically ask for multi-year commitments so that they can invest their time and resources into launching the program with less risk that the resources will be wasted. As a result, Deworm the World expects that having multiple years of allocated funding makes partnerships with governments (formalized by signed memoranda of understanding (MOUs)) more likely and reduces the amount of time before programs are launched.186 Additionally, Deworm the World has told us that having multiple years of funding for its programs allows staff to spend less of their time fundraising and more time on other aspects of their work. We have not discussed this topic thoroughly with Deworm the World, so we do not feel confident that 3-5 year commitments are necessary nor do we feel that Deworm the World’s preference is unreasonable. #### Challenges of expanding to new countries using a new operating model Deworm the World’s track record largely consists of work in Kenya and India. Launching programs in new countries may introduce challenges that are hard to predict, such as differences in cultural and bureaucratic expectations, increased difficulty of predicting program costs and success, and political and economic instability. Deworm the World has also told us that it will be using a new operational model for its work in many of the countries to which it expands, including Ethiopia, Vietnam, Pakistan. Our review focuses on its success using its India model, and we are optimistic, though ultimately uncertain, about its ability to succeed using a different model. #### Deworm the World Initiative and Evidence Action The Deworm the World Initiative is an initiative led by Evidence Action. Evidence Action includes other programs, of which the only other large program is Dispensers for Safe Water (DSW).187 This has two important implications relevant to Deworm the World’s room for more funding: First, Evidence Action, Deworm the World’s parent organization, expects to receive about$2.5 million in unrestricted donations from small donors in 2015.188 We are unsure about the conditions under which some of that money would be allocated to Deworm the World.

Second, donations to Evidence Action, even if restricted to Deworm the World, can change the actions that staff take to fundraise (i.e., which grants they pursue, what type of funding they ask for). For example, in 2015, Evidence Action’s plan for using unrestricted funds included a relatively high priority to spend $0.8 million on Deworm the World. After receiving funds related to GiveWell’s recommendation that were designated for Deworm the World, Evidence Action allocated unrestricted funding to other parts of its program instead of Deworm the World. As such, it seems likely that$0.8 million of GiveWell directed funds (70% of GiveWell-directed funds to Deworm the World) caused on the margin more funding to Evidence Action’s other programs, rather than more dewormings to take place.189

### Global need for treatment

There appears to be a substantial unmet need for STH and schistosomiasis treatment globally.

A WHO report estimates that in 2013 about 34% of all children in need of STH deworming received treatment.190 We have not vetted this data, but it is consistent with our impression that there is a large global unmet need for STH deworming.

The Schistosomiasis Control Initiative shared an unpublished World Health Organization (WHO) estimate of the number of school-aged children and adults who require treatment for schistosomiasis and those who received treatment in 2014. We do not have permission to publish this data, but we note that only a small portion of those who WHO believes need treatment received it in 2014.191

## Deworm the World as an organization

We believe that the Deworm the World Initiative, led by Evidence Action, is a strong organization:

• Track record: Deworm the World has a track record helping to start deworming programs where they do not already exist, particularly in Indian states, and providing ongoing support to programs in India and Kenya. Deworm the World has minimal experience starting new programs outside of India, as it now hopes to do with unrestricted funds.
• Self-evaluation: Deworm the World collects a large amount of relevant data about its programs demonstrating a commitment to self-evaluation.
• Communication: Deworm the World has generally communicated clearly and directly with us, given thoughtful answers to our critical questions, and shared significant, substantive information.
• Transparency: Deworm the World is very transparent.

More on how we think about evaluating organizations at our 2012 blog post.

## Sources

Document Source
Alderman et al. 2006 Source (archive)
Alix Zwane conversation August 30th 2013 Unpublished
Alix Zwane conversation June 4th 2013 Source
Alix Zwane, DtWI Executive Director, email exchange with GiveWell, November 2013 Unpublished
Alix Zwane, DtWI Executive Director, phone call with GiveWell, November 2013 Unpublished
Assam 2010 guidelines for deworming Source
Assam midday meal report 2013 Source (archive)
Assam reproductive and child health 2011-2012 Source (archive)
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CIFF conversation September 10th 2013 Source
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Devesh Kapur conversation October 14th 2013 Source
DSW 2012 GiveWell site visit Source
DtWI 2013 GiveWell government interviews Source
DtWI 2013 GiveWell site visit Source
DtWI Assam research 2013 Source
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DtWI Bihar 2011 coverage data Source
DtWI Bihar 2011 monitoring data for deworming day Source
DtWI Bihar 2011 monitoring data for mop-up day Source
DtWI Bihar 2011 Monitoring Form for Deworming Day Source
DtWI Bihar 2011 monitoring form for mop-up day Source
DtWI Bihar 2011 prevalence survey report Source
DtWI Bihar 2011 program report Source
DtWI Bihar 2012 cost data Source
DtWI Bihar 2012 cost data details Unpublished
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DtWI Bihar 2012 monitoring report Source
DtWI Bihar 2014 cost data Unpublished
DtWI Bihar 2014 program report Source
DtWI Bihar 2014 program report annex 1 Source
DtWI Bihar 2014 program report annex 2 Source
DtWI Bihar 2015 independent monitoring tables Source
DtWI Bihar 2015 monitoring data for coverage validation, schools Source
DtWI Bihar 2015 monitoring data from deworming day, schools Source
DtWI Bihar 2015 monitoring data from mopup day, schools Source
DtWI Bihar 2015 monitoring survey for coverage validation, schools Source
DtWI Bihar 2015 monitoring survey from deworming day, schools Source
DtWI Bihar 2015 monitoring survey from mopup day, schools Source
DtWI Bihar 2015 Prevalence Survey report Source
DtWI Bihar 2015 Program report Source
DtWI budget vs actual spending of Good Ventures 2013 grant, October 2015 Unpublished
DtWI Chhattisgarh 2015 coverage validation report Source
DtWI Chhattisgarh 2015 independent monitoring tables Source
DtWI Chhattisgarh 2015 monitoring data for coverage validation, anganwadis Source
DtWI Chhattisgarh 2015 monitoring data for coverage validation, schools Source
DtWI Chhattisgarh 2015 monitoring survey for coverage validation, anganwadis Source
DtWI Chhattisgarh 2015 monitoring survey for coverage validation, schools Source
DtWI class register audits 2013 Source
DtWI cost narrative 2013 Source
DtWI Cost per treatment blog post January 2015 Source (archive)
DtWI cost per treatment summary 2013 Source
DtWI coverage data 2013 - 2014 Source
DtWI Delhi 2012 cost data Source
DtWI Delhi 2012 coverage data by anganwadi Source
DtWI Delhi 2012 coverage data by school Source
DtWI Delhi 2012 coverage report Source
DtWI Delhi 2012 monitoring data Source
DtWI Delhi 2012 monitoring form deworming day Source
DtWI Delhi 2012 prevalence survey design Source
DtWI Delhi 2012 prevalence survey report Source
DtWI Delhi 2012 program report Source
DtWI Delhi 2013 cost data Unpublished
DtWI Delhi 2013 program report Source
DtWI Delhi 2015 independent monitoring tables Source
DtWI Delhi 2015 monitoring data for coverage validation, anganwadis Source
DtWI Delhi 2015 monitoring data for coverage validation, schools Source
DtWI Delhi 2015 monitoring data from deworming day, anganwadis Source
DtWI Delhi 2015 monitoring data from deworming day, schools Source
DtWI Delhi 2015 monitoring data from mopup day, anganwadis Source
DtWI Delhi 2015 monitoring data from mopup day, schools Source
DtWI Delhi 2015 monitoring survey for coverage validation, anganwadis Source
DtWI Delhi 2015 monitoring survey for coverage validation, schools Source
DtWI Delhi 2015 monitoring survey from deworming day, anganwadis Source
DtWI Delhi 2015 monitoring survey from deworming day, schools Source
DtWI Delhi 2015 monitoring survey from mopup day, anganwadis Source
DtWI Delhi 2015 monitoring survey from mopup day, schools Source
DtWI Delhi 2015 program report Source
DtWI Kenya 2013-2014 cost per treatment data Source
DtWI Kenya 2013-2014 program report Source
DtWI Monitoring Improvements 2014 Source
DtWI NDD blog post February 2015 Source (archive)
DtWI NDD Year 1 M&E review July 2015 Source
DtWI Rajasthan 2012 cost data Source
DtWI Rajasthan 2012 cost data details Unpublished
DtWI Rajasthan 2012 coverage data for anganwadi Source
DtWI Rajasthan 2012 coverage data for schools Source
DtWI Rajasthan 2012 monitoring data for coverage validation in anganwadis Source
DtWI Rajasthan 2012 monitoring data for coverage validation in schools Source
DtWI Rajasthan 2012 monitoring form coverage day Source
DtWI Rajasthan 2012 monitoring form pre-deworming day Source
DtWI Rajasthan 2012 monitoring report Source
DtWI Rajasthan 2012 prevalence survey report Source
DtWI Rajasthan 2013 cost data Unpublished
DtWI Rajasthan 2013 prevalence survey report Source
DtWI Rajasthan 2013 program report Source
DtWI Rajasthan 2015 independent monitoring tables Source
DtWI Rajasthan 2015 monitoring data for coverage validation, anganwadis Source
DtWI Rajasthan 2015 monitoring data for coverage validation, schools Source
DtWI Rajasthan 2015 monitoring data from deworming day, schools Source
DtWI Rajasthan 2015 monitoring data from mopup day, schools Source
DtWI Rajasthan 2015 monitoring survey for coverage validation, anganwadis Source
DtWI Rajasthan 2015 monitoring survey for coverage validation, schools Source
DtWI Rajasthan 2015 monitoring survey from deworming day, schools Source
DtWI Rajasthan 2015 monitoring survey from mopup day, schools Source
DtWI Rajasthan 2015 program report Source
Evidence Action 2014 budget Unpublished
Evidence Action 2015 draft budget Unpublished
Evidence Action 2015 funding gap analysis Source
Evidence Action cover letter 2013 Source
Evidence Action launch announcement 2013 Source (archive)
Evidence Action website 2013 Source (archive)
Evidence Action website announcement April 2014 Source (archive)
Evidence Action website, Deworm the World Initiative (October 2015) Source (archive)
Evidence Action website, Evidence Action Beta (October 2015) Source (archive)
GiveWell analysis of Deworm the World 2014 Financial summary Source
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GiveWell enrollment-based student coverage check 2015 Source
GiveWell's non-verbatim summary of a conversation with Alix Zwane and Jessica Harrison on November 4th, 2014 Source
GiveWell's non-verbatim summary of a conversation with Alix Zwane and Karen Levy on May 14, 2013 Source
GiveWell's notes from site visit to India, October 2013 Source
GiveWell’s non-verbatim summary of a conversation with Alix Zwane on December 20th, 2013 Source
GiveWell’s non-verbatim summary of a conversation with Alix Zwane on February 18th, 2014 Source
GiveWell’s non-verbatim summary of a conversation with Alix Zwane on October 23rd, 2014 Unpublished
GiveWell’s non-verbatim summary of a conversation with Grace Hollister and Alix Zwane on March 30, 2015 Source
GiveWell’s non-verbatim summary of a conversation with Grace Hollister on April 8, 2015 Unpublished
GiveWell’s non-verbatim summary of a conversation with Grace Hollister on February 24, 2015 Source
GiveWell’s non-verbatim summary of a conversation with Grace Hollister on July 22, 2015 Unpublished
GiveWell’s non-verbatim summary of a conversation with Grace Hollister on June 24th, 2014 Source
GiveWell’s non-verbatim summary of conversations with Alix Zwane and Grace Hollister on February 26 and March 17, 2014 Source
GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015 Source
Grace Hollister conversation June 19th 2013 Source
Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 Unpublished
Grace Hollister, DtWI Director, email exchange with GiveWell, October 2013 Unpublished
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### Uncited supplementary materials

Document Source
DtWI Bihar 2011 monitoring forms phase I Source
DtWI Bihar 2012 monitoring data deworming day anon Source
DtWI Bihar 2012 monitoring data mop-up anon Source
DtWI Bihar 2014 program report annex 3a Source
DtWI Bihar 2014 program report annex 3b Source
DtWI Bihar 2014 program report annex 3c Source
DtWI Bihar 2014 program report annex 3d Source
DtWI Bihar 2014 program report annex 4a Source
DtWI Bihar 2014 program report annex 4b Source
DtWI Bihar 2014 program report annex 4c Source
DtWI Bihar 2014 program report annex 5a Source
DtWI Bihar 2014 program report annex 5b Source
DtWI Bihar 2014 program report annex 6a Source
DtWI Bihar 2014 program report annex 6b Source
DtWI Bihar 2014 program report annex 7 Source
DtWI Bihar 2014 program report annex 8 Source
DtWI cost per child description Source
DtWI Kenya site visit 2012 Source
DtWI Rajasthan 2012 monitoring data anganwadi deworming day anon Source
DtWI Rajasthan 2012 monitoring data anganwadi mop-up anon Source
DtWI Rajasthan 2012 monitoring data anganwadi prep anon Source
DtWI Rajasthan 2012 monitoring data schools deworming day anon Source
DtWI Rajasthan 2012 monitoring data schools mop-up anon Source
DtWI Rajasthan 2012 monitoring data schools prep anon Source
• 1.
• 2.

CIFF conversation September 10th 2013

• 3.
• "[In Vietnam] Deworm the World’s partnership with both the government and Thrive Networks is a new working model for Deworm the World; elsewhere, it has supported government implementation or run its program independently. Deworm the World has only one staff member in the country.

Dubai Cares provides most of the program funding. All funding goes to Thrive Networks, which provides money to the government for implementation expenses. The costs of training over the full three years of the program had been underestimated, so the program budget has been revised upwards. To cover this, Deworm the World has allocated an additional $200,000 from its unrestricted funding. Thrive Networks has also been working in Vietnam on sanitation hardware (for example, latrine installments). Deworm the World is not involved with this work directly, but it is advising on the program’s impact evaluation. This will include a randomized controlled trial on hygiene education in combination with deworming, which will look at the impact on reinfection rates." GiveWell’s non-verbatim summary of a conversation with Grace Hollister on February 24, 2015, Pgs 3-4 • "If funding permits, the Kenyan government may begin a lymphatic filariasis treatment program along its coast. If it does so, Deworm the World will provide process monitoring and coverage validation for the treatments." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 3. • "[In Pakistan, Deworm the World] plans to contract with a local organization to do these [prevalence] surveys, but does not yet have a signed agreement." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 7 • "We are contributing approx$111k to the TUMIKIA and TakeUp studies, complementary studies leveraging the Kenya program to look at the potential for breaking STH transmission." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• 4.

"In January 2007, the [Young Global Leaders] launched the Deworm the World campaign with the goal of improving children’s health and education by massively expanding deworming programs." Harvard Business School Kenya Case Study A 2010 Pg 7.

• 5.
• 6.
• "As such, the states themselves have to make the decision to conduct a deworming campaign; DtW can only encourage that decision by showing that it can be done and offering assistance to help implement the program in a robust fashion that involves intensive monitoring of the program."
Alix Zwane conversation June 4th 2013, Pg 2.
• "The Nepalese government’s planning commission initiated contact with Deworm the World , which sent its India country director, Priya Jha, to Kathmandu for a meeting, which J-PAL facilitated. The conversation revealed that school-based health programs are not fully operating in all areas of the country, and Nepalese officials have expressed interest in getting technical assistance from Deworm the World, particularly with scaling up their programs. Deworm the World has contacted the government about further steps and is awaiting a response from health and education officials." GiveWell’s non-verbatim summary of a conversation with Grace Hollister and Alix Zwane on March 30, 2015, Pg 1
• "Deworm the World does not yet have an agreement with the government in Pakistan to conduct the surveys, but hopes to accomplish this in the next month, and anticipates that the prevalence surveys will be conducted beginning in January or February of 2016. It is expected that a clear articulation of need will be an important factor in building a strong case to the government in favor of deworming programs, and it may be best to wait until the results of the surveys are available in the second quarter of 2016 before beginning discussions with the government on a scaled school-based program. Treatment may not begin until 2017." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 7
• 7.
• "Six districts were identified within [Andhra Pradesh] where deworming would be piloted. DtW conducted prevalence surveys in those six districts, finding that worms existed in less than 20% of the population in the districts, which is the World Health Organization-recommended threshold for treating all children." Grace Hollister conversation June 19th 2013, Pg 1.
• "DtW did two stages of prevalence surveys between August 2010 and February 2011. They found that over 50% of school-aged children had worms, a level at which the World Health Organization (WHO) recommends deworming twice a year, rather than just once a year. Bihar already had a statewide albendazole treatment." Grace Hollister conversation June 19th 2013, Pg 2.
• "In 2011 DtW conducted a prevalence survey throughout the National Capital Territory. The average infection rate was below the 20% threshold, although there were large disparities in prevalence between different areas of the city." Grace Hollister conversation June 19th 2013, Pg 3.
• "DtW’s prevalence survey found that around 20% of the children were infected with at least one type of STH, particularly in the Western part of the state. Based on elevations and other climatic factors, it is estimated that hookworm is a lot more prevalent in the Eastern part of the state. Taken together, the data led DtW to recommend a mass treatment for the whole state once a year." Grace Hollister conversation June 19th 2013, Pg 4.
• 8.

For example, Deworm the World told us that monitors it commissions visit a sample of schools to observe whether principals and teachers are prepared for deworming day, drugs and supplementary materials are available, teachers are knowledgeable on topics related to deworming, and students are aware of the upcoming deworming day. Tele-callers reach out to thousands of schools and education officials to assess preparedness and notify government officials of problems so they can take corrective action.

• Bihar 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Our tele-callers made approximately 19,567 successful calls[20] made during the period of January to March 2015. These calls were made to 534 blocks across 38 districts to assess preparedness on all program areas. Daily tracking sheets outlining issues arising at districts, blocks, and schools were identified during the process and were shared with the state to assist the government to take real-time corrective action." DtWI Bihar 2015 Program report, Pg 16
• Rajasthan 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Evidence Action’s tele-callers tracked the status of training sessions and availability of drugs and IEC materials at the district, block, and school/anganwadi levels through approximately 14,485 successful[19] calls. Tele-callers made 258 calls to the Department of Health and 7,717 calls to ICDS at district, project, and sector level. Another 4,598 calls were made to block and district-level education officials to track various program components. In total 734 calls were made to schools covering 249 blocks across the 33 districts to assess preparedness.

Tele-callers created tracking sheets to outline issues identified during calls and monitoring visits. Issues at the districts, blocks, and schools/anganwadi levels were shared with the state government to ensure that the government was able to take corrective action to address the gaps in real time as necessary." DtWI Rajasthan 2015 program report, Pg 15

• Delhi 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Our tele-callers tracked the status of training, drugs, and IEC material availability at the district, and school/anganwadi through phone calls. Approximately 8,504 successful[12] calls were made to the education, health, and WCD departments during this period." DtWI Delhi 2015 program report, Pg 15
• Madhya Pradesh 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Our tele-callers placed phone calls to track the delivery and availability of training, drug, and IEC materials at the district, block, and school/anganwadi levels as Deworming Day approached. Approximately 4,840 successful[13] calls were made from February 1 to 14, including 1,097 calls to schools across 313 blocks and 51 districts, and another 3,586 calls to block and district officials.

Tele-callers created tracking sheets to outline issues identified during calls and monitoring visits. Issues at the district, block, and school levels were shared with the state government to ensure that the government was able to take corrective action to address the gaps in real time as necessary." DtWI Madhya Pradesh 2015 program report, Pgs 16-17

Deworm the World’s contributions
• Prevalence survey...
• Operational support
• Helped government develop operational plans and budgets
• Coordinated cross-sectoral partners through the establishment of a State School Health Coordination Committee, bringing together health and education departments and other stakeholders (such as the microfinance partner SKS)
• Coordinated drug donation made by Feed the Children
• Designed a monitoring and evaluation (M&E) system
• Created government tableau for community awareness
• Trainings
• Conducted a master training session for program
• Designed training cascade for the master trainees to train the rest of the implementors
• Designed training materials
• Developed materials and campaigns for community sensitization

Bihar…
Deworm the World’s contributions to the deworming program in Bihar were similar to those in Andrha Pradesh (see above). In Bihar, DtW coordinated drug donations for Rounds 2 and 3 of the program through the WHO…

Delhi…
In addition to the standard contributions (see Andrha Pradesh, above), DtW helped set up a technical secretariat within the School Health Scheme of the Delhi government to support program monitoring. In Delhi, DtW coordinated drug donations for school-age children through Feed the Children.

Rajasthan…
DtW’s prevalence survey and recommendation to treat annually thus increased the efficiency of the program significantly, as well as decreasing the required government funding contribution. Additionally DtW successfully encouraged the government to include preschoolers in the program as well. DtW coordinated drug donations for school-age children through the WHO." Grace Hollister conversation June 19th 2013, Pg 1-4.

• 9.

Examples where this has been done or considered include:

• 10.

GiveWell’s non-verbatim summary of a conversation with Alix Zwane on October 23rd, 2014

• 11.

GiveWell analysis of Deworm the World 2014 Financial summary. Note that these figures include central costs, so this reflects Deworm the World’s full budget.

• 12.
• "Kenya’s National School-Based Deworming Program started in 2009. In 2012, it expanded to a nationwide program aimed at treating all at-risk Kenyan children each year for at least five years. Implemented by the Ministry of Education, Science, and Technology and the Ministry of Health. With support of Evidence Action’s Deworm the World Initiative, the Government of Kenya successfully reached 5.9 million preschool and school-age children in 2012/13 and 6.4 million children in 2013/14, surpassing targets by 18% and 12% respectively. School year 2014/15 results will be released in October. Technical and operational assistance to the program will continue through 2017." Evidence Action website, Deworm the World Initiative (October 2015)
• "Deworm the World is planning a strategy to sustain and institutionalize the program after its current grants expire in June 2017." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 4
• 13.

"It is important to note that there are fundamental differences between the Kenya and India programs, as funding to Evidence Acton supports direct implementation costs in Kenya (where the government does not pay those costs, but rather provides in-kind support), and India, where the government pays the lion’s share of implementation costs." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015

• 14.
• 15.
• "Innovations for Poverty Action (IPA) is pleased to announce the launch of a new organization created with IPA’s support and dedicated to taking cost-effective programs to scale to improve the lives of millions in Africa and Asia. Evidence Action has been created to bridge the gap between evidence about what works to alleviate poverty around the world and what is actually implemented. The organization scales interventions based on rigorous evidence and crafts resilient business models for long run success.

Two IPA initiatives that touch millions of people in Africa and Asia – Dispensers for Safe Water and the Deworm the World Initiative – will spin off from IPA to be managed by Evidence Action." Evidence Action launch announcement 2013

• "Evidence Action Beta investigates what interventions might be suitable for massive scale up – finding the next thing that works." Evidence Action website, Evidence Action Beta (October 2015)
• 16.

Evidence Action 2015 draft budget

• 17.

See the Is there room for more funding? section below.

• 18.
• India: "…absent from most of the country, [Schistosomiasis] risk exists only in restricted areas." World Schistosomiasis Risk Chart 2012, Pg 1.
• "INDIA - Risk is limited to the area around Gimvi in Ratnagiri district (Maharashtra) in the hills along the Konkan coast south of Mumbai (approximately 16km from shore)." World Schistosomiasis Risk Chart 2012, Pg 3.
• See section on worm prevalence and intensity in India below.
• 19.
• 20.
• 21.
• 22.
• "The prevalence of STH (including hookworm, A. lumbricoides, and T. trichiura) across these states in Bihar was 67.5% with district prevalence ranging from 49.0% to 79.6%." DtWI Bihar 2011 prevalence survey report, Pg 4.
• 67% = 782/1159. From "Table Three: Cumulative prevalence of each species by district": "Total - Number Students" = "1159"; "Total - % Any infection" = "(782) 67.5%". DtWI Bihar 2011 prevalence survey report, Pg 4.
• Selection of districts and schools: "Four districts of Bihar were selected to complement the existing STH model and twenty schools, five from each district were randomly selected from the state schools database." Pg 9.
• Selection of students: "Within each school 65 children aged 6 and above representing both sexes equally from class 1 to 6 were randomly selected, class by class, using random number tables." Pg 9.
• Technique: "Screening of infection for STH was based on a double Kato-Katz smear of 41.7 mg prepared from fresh stool samples." Pg 11.
• Participation rate: "From a total of 1,281 school children registered in the survey and provided with pots, 1,159 returned samples." (90.5%) Pg 11.
• Note on two stages of first prevalence survey based on DtWI Bihar 2011 prevalence survey report and Grace Hollister, DtWI Director, email exchange with GiveWell, October 2013
• Based on the timing of the decision to deworm in Bihar, there was only time to collect prevalence surveys from two districts before the annual LF treatment in 2010. Results from that first stage of surveying were sufficient to convince the state to carry out a full deworming program 6 months after the LF treatment, although the methodology did not meet DtWI's typical standard of quality.
• Before the DtWI-managed deworming program in early 2011, a second stage prevalence survey was conducted in an additional four states. These states were selected based in part on their complementarity with the original two states. DtWI Bihar 2011 prevalence survey report, Pg 9.
• Since the quality of the second stage was higher, our analysis excludes results from the first stage of the survey. Since the second stage districts were selected in part based on complementarity with the first stage, there may be bias introduced into the statewide estimates from lack of randomness. (Grace Hollister, DtWI Director, email exchange with GiveWell, October 2013)
• 23.

"The prevalence of STH (including hookworm, A. lumbricoides, and T. trichiura) across these states in Bihar was 67.5% with district prevalence ranging from 49.0% to 79.6%." DtWI Bihar 2011 prevalence survey report, Pg 4.

• 24.
• Albendazole is used for treatment of both lymphatic filariasis (where it is used in combination with either DEC [Diethylcarbamazine] (as in India) or ivermectin) and of STH. Therefore, a round of treatment for lymphatic filariasis also treats STH. In this review, the term "deworming round" includes any MDA of albendazole.
• "A Memorandum of Understanding (MOU) was signed on March 5, 2010 among State Health Society Bihar, Bihar Education Project Council, and Deworm the World Initiative to implement the school-based deworming program in the state for treatment of STH. Based on Prevalence Survey findings, which suggested treatment recommendation of WHO, the Government of Bihar decided to implement biannual state-wide deworming beginning in 2011. Since then, Evidence Action has extended technical assistance to an annual round of deworming for all school-age children through a school-based model. The second round of deworming treatment was provided through the National Filaria Control Program (NFCP), which conducts annual mass drug administration of albendazole to the 2 years and above population at the community. In 2011, a total of 16.7 million children were dewormed at schools, earning the distinction of being the world's largest school-based deworming program. In 2012, 16.33 million children were dewormed in Round 2. 17.47 million, including 16.2 school-age children, were dewormed as part of Round 3 in 2014." DtWI Bihar 2015 Program report, Pg 6.
• "￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼Since the launch of the school-based deworming program, the National Filaria Control Program has taken place once, in April 2012. Four deworming rounds or distribution of albendazole during LF-MDA were missed during the period" DtWI Bihar 2015 Prevalence Survey report, Pg 5.
• 25.
• "Evidence Action - Deworm the World provided technical assistance for Round 1 in February 2011, followed by second and third rounds in September 2012 and January 2014 respectively. The National Filaria Control Program, which co-administers albendazole and diethylcarbamazine citrate annually to all people in the community older than 2 years (excluding pregnant women and the seriously ill), targets all 38 districts in Bihar. The treatment for lymphatic filariasis was therefore intended to serve as the second annual dose of albendazole for school-age children, ideally timed to take place six months apart. Since the launch of the school-based deworming program, the National Filaria Control Program has taken place once, in April 2012." DtWI Bihar 2015 Prevalence Survey report, Pg 5.
• "The ‘2014’ [LF-MDA] occurred in February/March 2015. There was no LF MDA in the calendar year of 2014. But, since the LF MDA occurred prior to the closing of the 2014 - 2015 financial year (March 31, 2015). This is apparently common practice and acceptable to the government of India, and that is what is reported on the website. There was no LF MDA in the calendar year of 2014, as there was no DEC [Diethylcarbamazine] in Bihar until February 2015. Therefore a round did not occur prior to the second survey." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• 26.
• Prevalence figures
"On the basis of the collected and analyzed data, the overall weighted prevalence of any STH in Bihar was calculated as 35%. Prevalence in different agro-climatic zones ranged from 20% to 50%" DtWI Bihar 2015 Prevalence Survey report, Pg 2.
• Representative survey design
"Per the 2011 census, there were 18,884,945 children aged 5-10 years in Bihar. Assuming one sentinel school is required for 300,000 targeted children, we needed at least 63 schools (rounded to 65) to monitor the performance of the deworming program. Collecting samples from 50 children per school, the minimum sample size required for estimation of prevalence using the sentinel site method was 3,250.
Bihar is divided into three agro-climatic zones (Figure 2) – the North West Alluvial Plains (Zone 1) consisting of 12 districts, the North East Alluvial Plains (Zone 2) consisting of 9 districts and South Bihar Alluvial Plains consisting of 17 districts (Zone 3). The three zones respectively accounted for 42%, 22% and 36% of 5-10 years population in the state. NIE randomly selected 65 schools from the three zones, proportionate to the percentage of 5-10 year population in each of the zones. Thus, the study needed 28, 14 and 23 schools from zones 1, 2 and 3 respectively.
NIE followed a 2-stage sampling procedure for selecting sentinel schools. In the first stage, NIE randomly selected 14 districts from Bihar (six from zone 1, three from zone 2 and six from zone 3) to meet logistical (teams could not spend too much time traveling and setting up temporary field laboratories, because it reduced the number of samples the teams could analyze), geographic dispersion (the survey needed to be geographically dispersed to ensure the best estimates of prevalence), and time constraints (there were only 20 days available for the survey). In the second stage, NIE line-listed all the primary schools (with the total strength of ≥ 60 children) of the districts selected from each zone. They then selected the required number of schools for each zone randomly from the list of schools in the selected districts. To select the required number of children, we assigned a random number (between one and five) to classes of the selected school. The survey was initiated from the class corresponding to the random number assigned for the school and field teams enumerated the children present in the class starting from roll number one on the attendance register. If the number of children in the selected class was &lt 50, children from the next class were selected. This procedure was followed until 50 children from each school were selected." DtWI Bihar 2015 Prevalence Survey report, Page 8.
• 27. DtWI Bihar 2015 Prevalence Survey report
• 28.

Deworm the World has supported three MDAs in Bihar over the last four years: "Evidence Action - Deworm the World provided technical assistance for Round 1 in February 2011, followed by second and third rounds in September 2012 and January 2014 respectively. The National Filaria Control Program, which co-administers albendazole and diethylcarbamazine citrate annually to all people in the community older than 2 years (excluding pregnant women and the seriously ill), targets all 38 districts in Bihar. The treatment for lymphatic filariasis was therefore intended to serve as the second annual dose of albendazole for school-age children, ideally timed to take place six months apart. Since the launch of the school-based deworming program, the National Filaria Control Program has taken place once, in April 2012." DtWI Bihar 2015 Prevalence Survey report, Pg 5.

• 29.
• The National Vector Borne Disease Control Programme LF treatment coverage 2015
• The treatment for LF in India is annual administration of DEC [Diethylcarbamazine] or DEC and Albendazole:
"Annual Mass Drug Administration with single dose of DEC was taken up as a pilot project covering 41 million population in 1996-97 and extended to 74 million population. This strategy was to be continued for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease.
Interruption of transmission of filariasis by Annual MDA for 5 years or more to the population except:
- children below 2 years
- pregnant women
- seriously ill persons
(DEC + Albendazole in selected distt & DEC in other distt)" LF treatment drugs 2012.
• "Evidence Action - Deworm the World provided technical assistance for Round 1 in February 2011, followed by second and third rounds in September 2012 and January 2014 respectively. The National Filaria Control Program, which co-administers albendazole and diethylcarbamazine citrate annually to all people in the community older than 2 years (excluding pregnant women and the seriously ill), targets all 38 districts in Bihar. The treatment for lymphatic filariasis was therefore intended to serve as the second annual dose of albendazole for school-age children, ideally timed to take place six months apart. Since the launch of the school-based deworming program, the National Filaria Control Program has taken place once, in April 2012." DtWI Bihar 2015 Prevalence Survey report, Pg 5.
• 30.
• "Revised Strategy
Annual Mass Drug Administration with single dose of DEC [Diethylcarbamazine] was taken up as a pilot project covering 41 million population in 1996-97 and extended to 74 million population. This strategy was to be continued for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease.
Interruption of transmission of filariasis by Annual MDA for 5 years or more to the population except: - children below 2 years - pregnant women - seriously ill persons (DEC + Albendazole in selected distt & DEC in other distt)" LF treatment drugs 2012
• The National Vector Borne Disease Control Programme LF treatment coverage 2015
• 31.
• "The ‘2014’ MDA occurred in February/March 2015. There was no LF MDA in the calendar year of 2014. But, since the LF MDA occurred prior to the closing of the 2014 - 2015 financial year (March 31, 2015). This is apparently common practice and acceptable to the government of India, and that is what is reported on the website. There was no LF MDA in the calendar year of 2014, as there was no DEC [Diethylcarbamazine] in Bihar until February 2015. Therefore a round did not occur prior to the second survey." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• "￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼Since the launch of the school-based deworming program, the National Filaria Control Program has taken place once, in April 2012. Four deworming rounds or distribution of albendazole during LF-MDA were missed during the period" DtWI Bihar 2015 Prevalence Survey report, Pg 5.
• "The Bihar program was originally designed so that one round of albendazole administration would come from community-based lymphatic filariasis (LF) treatment (LF is endemic throughout the state) and a second round would come through the school-based deworming program. For a variety of reasons, LF treatment has not been consistently implemented. It is possible that more consistent albendazole administration as part of LF treatment would have resulted in a more significant drop in STH prevalence." GiveWell’s non-verbatim summary of a conversation with Grace Hollister on July 22, 2015, Pg 2
• "Kenya and India are the countries where Deworm the World operates two of its biggest programs and where Ms. Hollister has the greatest familiarity with the state of LF treatment. In both countries, LF programs have generally been either unfunded or underfunded, resulting in sporadic treatment." GiveWell’s non-verbatim summary of a conversation with Grace Hollister on April 8, 2015, Pg 1
• 32.
• 33.
• "A competitive RFP process is now used to identify a professional survey organization to provide independent monitors. There are requirements placed on the experience of these monitors." DtWI Monitoring Improvements 2014, Pg 1.
• Deworm the World was also involved in Chhattisgarh, but as it was engaged relatively late in the process, it did not conduct all of its standard monitoring activities in the state: "Although we place great emphasis on understanding the extent to which the school and health systems are ready to implement deworming, the extent to which deworming processes are being followed, and the extent to which coverage has occurred as planned, in Chhattisgarh we supported only with the coverage validation activity at schools due to time constraints." DtWI Chhattisgarh 2015 coverage validation report, Pgs 2-3.
• Bihar: "Through a competitive selection process, Evidence Action hired GfK Mode Private Limited as the independent monitoring agency that provided 125 monitors, who conducted monitoring activities of the deworming program across the state… Evidence Action held a detailed training on February 15 and 16 to ensure the monitors were equipped with the necessary knowledge on the deworming program to conduct monitoring effectively." DtWI Bihar 2015 Program report, Pg. 15.
• Rajasthan: "Through a competitive selection process, Evidence Action hired the State Institute of Health and Family Welfare (SIHFW), Jaipur as the independent monitoring agency. SIHFW provided 125 monitors who conducted monitoring activities of the deworming program across the state... Evidence Action held a detailed two-day training at the SIHFW campus in Jaipur to ensure the monitors were equipped with the necessary program knowledge to conduct monitoring effectively." DtWI Rajasthan 2015 program report, Pg 14.
• Madhya Pradesh: "Evidence Action hired an experienced independent research agency, SPECTRA Research and Development Private Limited, to conduct field-level process monitoring and coverage validation across 125 blocks in 50 districts of the state. A two-day training was held with 125 independent monitors and supervisors to equip them with knowledge to monitor the deworming program effectively." DtWI Madhya Pradesh 2015 program report, Pg 15.
• Delhi: "[Evidence Action] hired an independent research agency, Sigma Research and Consulting Private Limited that has experience in implementing field-based surveys, to conduct process monitoring and coverage validation in schools and anganwadis in Delhi. A two-day training was held with 80 independent monitors and supervisors to equip them with the knowledge to undertake the deworming program and undertake monitoring effectively." DtWI Delhi 2015 program report, Pg 14.

What procedures do the monitors follow?

Monitoring procedures vary somewhat among the states and rounds of deworming, but in most cases the process includes:

The monitors use field observations at a sample of schools and, in some instances, training sessions to gather information on the program in advance of treatment days, during treatment days, and after treatment days. State-by-state details below and in the cited documents:

• Bihar 2015: "Through a competitive selection process, Evidence Action hired GfK Mode Private Limited as the independent monitoring agency that provided 125 monitors, who conducted monitoring activities of the deworming program across the state. The objective of independent monitoring is to determine whether deworming is being implemented according to planned protocols. Two-stage probability sampling was used to select schools for coverage validation on deworming day and mop-up day. First, 125 blocks were selected from all 38 districts by probability proportional to size sampling, followed by random sampling of schools to provide statewide estimates of indicators. Evidence Action held a detailed training on February 15 and 16 to ensure the monitors were equipped with the necessary knowledge on the deworming program to conduct monitoring effectively. The monitors visited the 123 randomly selected schools on deworming day and an additional 124 schools on mop up day to check for adequacy of drug supplies, awareness materials, whether teachers had received training, knowledge of adverse event management protocols, and reporting processes. The monitors gathered data through observation of deworming and interviews of headmasters, teachers, and randomly selected students.
During coverage validation an additional 748 randomly sampled schools were surveyed after deworming days to check whether deworming occurred, if reporting protocols were followed, and to validate the coverage reporting. Coverage validation data was gathered through interviews with headmasters and 3 students (in 3 different randomly selected classes in each school), and by checking of all class registers and reporting forms." DtWI Bihar 2015 Program report, Pg. 15.
• Rajasthan 2015: "The process of monitoring and evaluation in each deworming round are performed in three ways: (1) process monitoring, (2) coverage reporting and (3) coverage validation. In Rajasthan, both process monitoring and coverage validation were carried out in schools, while only coverage validation was done at anganwadis. This is because the four-day long (10-13 February) deworming program in anganwadis made process monitoring a challenge.
Process Monitoring, Coverage Reporting, and Coverage Validation: Process monitoring assesses the preparedness of the schools, anganwadis, and health systems to implement mass deworming and the extent to which they have followed correct processes to ensure a high quality deworming program. Evidence Action assesses the program preparedness during pre-deworming phase and selected independent monitors observe [sic] the deworming processes on Deworming Day and mop-up day. We conduct process monitoring in two ways: a) telephone monitoring and cross verification and b) physical verification by visiting schools and training venues. Through a competitive selection process, Evidence Action hired the State Institute of Health and Family Welfare (SIHFW), Jaipur as the independent monitoring agency. SIHFW provided 125 monitors who conducted monitoring activities of the deworming program across the state. The objective of independent monitoring is to determine whether the program is being implemented according to planned protocols. Two-stage probability sampling was used to select schools for independent monitoring on Deworming Day and mop-up day. First 125 blocks were selected from all 33 districts by probability proportional to size (PPS) sampling, followed by random sampling of schools to provide state-wide estimates of indicators. Evidence Action held a detailed two-day training at the SIHFW campus in Jaipur to ensure the monitors were equipped with the necessary program knowledge to conduct monitoring effectively. These 125 monitors visited 125 schools on Deworming Day and an additional 125 on mop-up day to check for adequate drug supplies and awareness materials, to confirm whether teachers had received training, and to assess knowledge of adverse event management protocols and reporting processes. Monitors gathered data through observation of deworming and through interviewing headmasters, teachers, and randomly selected students." DtWI Rajasthan 2015 program report, Pg 14.
• Madhya Pradesh 2015: "In Madhya Pradesh, as preschool-age deworming was implemented through the BSM, monitoring efforts focused on the school-age program through the NDD. In the future, it will be important to expand monitoring to anganwadis to better understand program preparedness and performance…
Evidence Action assesses the program preparedness during pre-deworming phase and selected independent monitors observe the deworming processes on Deworming Day and mop-up day. We conduct process monitoring in two ways: a) telephone monitoring and cross verification, and b) physical verification by visiting schools and training venues.
A two-stage probability sampling process was followed to select schools for NDD, mop-up day and coverage validation. Evidence Action hired an experienced independent research agency, SPECTRA Research and Development Private Limited, to conduct field-level process monitoring and coverage validation across 125 blocks in 50 districts of the state. A two-day training was held with 125 independent monitors and supervisors to equip them with knowledge to monitor the deworming program effectively. The monitors visited 125 randomly selected schools on NDD, and an additional 125 schools on mop-up day (February 14) to check for adequacy of drug supplies and awareness materials, and assess whether teachers had received training, and had knowledge of adverse event management protocols and reporting processes. Monitors gathered data by observing deworming and by interviewing headmasters, teachers, and randomly selected students. An additional 750 randomly sampled schools were surveyed from February 18-26 to check whether deworming occurred and reporting protocols were followed, and to validate the coverage reporting." DtWI Madhya Pradesh 2015 program report, Pg 15.
• Chhattisgarh 2015 (coverage validation only): "The school database for random sampling in the 11 districts was obtained from the Ministry of Drinking Water and Sanitation, Government of India website. We visited 10 randomly selected schools in each block from the 55 blocks in these 11 districts. Therefore, they visited a total of 550 randomly sampled schools for coverage validation activities. In addition to the headmster's interview and verification of the deworming related documents, three randomly selected children from three different randomly selected classes were interviewed in each school. In addition, we also visited any anganwadis attached to the sampled schools. We could not achieve the targeted sample of 550 schools as two districts, Sukma and Bijapur, could not be covered given the high risk due to insurgency in these areas." DtWI Chhattisgarh 2015 coverage validation report, Pg. 3.
• Delhi 2015: "Evidence Action assesses the program preparedness during the pre-deworming phase and selected independent monitors observe the processes on deworming and mop up days. We conduct process monitoring in two ways: a) telephone monitoring and cross verification, and b) physical verification by visiting schools and training venues.
• Bihar 2014: "In its attempt to evaluate the adherence of each process to guideline and time plan, Deworm the World supported a two-way monitoring strategy; a) Telephone monitoring and cross verification, and b) Physical verification by visiting the sites, schools, and training venues." DtWI Bihar 2014 program report, Pg 22. Pgs 23-30 describe activities over the various days.
• Delhi 2013: "In order to carry out robust M&E activities, Deworm the World retained short-term resources comprised of district coordinators and telecaller to a) assess the readiness of the system to implement deworming, and b) to follow-up with districts and nodal officers (for anganwadis) for the return of data post-deworming. In addition, independent monitors were hired and trained by Deworm the World to assess preparedness, visit schools and anganwadis on deworming and mop-up days and carry out coverage validation post mop-up day. The Deworm the World team and officials from SHS and DHFW also made several field visits to monitor the entire deworming program before, during, and after deworming day." DtWI Delhi 2013 program report, Pg 12.
• Rajasthan 2013: "In order to carry out robust M&E activities, Deworm the World hired district coordinators, telecallers and independent monitors as detailed below. In addition, staff and officials from DMHFW, RCEE and DWCD also made several field visits to monitor the entire deworming program before, during, and after deworming day." DtWI Rajasthan 2013 program report, Pg 11.
• Bihar 2012:
• Process: "Independent monitors visited a randomly selected sample of schools over four days – Deworming Day, Mop-Up Day, and two days post-deworming allocated for coverage validation. A multi-stage sampling strategy was used to select the 1216 schools (1.75% of 69,299 schools in Bihar) targeted for monitoring. From each of the 38 districts in Bihar, 2 blocks were selected by simple random sampling, for a total of 76 blocks. 2 clusters were randomly selected from each of the 76 blocks, excluding clusters with fewer than 8 schools. In each of these 152 clusters, 8 schools were randomly selected for a total of 1216 schools. Each monitor was assigned a block comprising 16 schools to be monitored. From this list of 16 schools, the monitor could visit any 4 schools on Deworming Day, another 4 on Mop-Up Day, and 8 more schools over the two Coverage Validation days. Out of the total sample of 1216 schools, monitors were able to survey 1196 schools comprising 302 schools on Deworming Day, 296 on Mop-Up Day, and 598 on Coverage Validation days." DtWI Bihar 2012 monitoring report, Pg 1.
• What we’ve seen: Monitoring forms used for data collection, full monitoring data from deworming day, mop-up day, and coverage validation days following deworming, and a summary report of results (DtWI Bihar 2012 monitoring report).
• Delhi 2012:
• Process: "Monitoring visits were conducted by senior government officials. Random site visits by independent auditors occurred at a subset of training sessions and participating institutions. Coverage validation engaged independent auditors who conducted random site visits at a representative sample of schools and anganwadis to validate coverage statistics. This source of information was carefully compared with programme reports collated from each school and anganwadi to arrive at an accurate assessment of programme coverage." DtWI Delhi 2012 program report, Pgs 7-8.
• What we’ve seen: Monitoring forms used for data collection, full monitoring data from deworming day, mop-up day, and coverage validation days following deworming, and a summary report of results (DtWI Delhi 2012 program report, Pgs 17-22).
• Rajasthan 2012:
• Process: "In order to evaluate the efficacy of the deworming protocol and process, independent monitors visited a randomly selected sample of schools and anganwadis over five days – one day before deworming for preparation monitoring, on Deworming Day, on Mop-Up Day, and two days post-deworming allocated for coverage validation. A multi-stage sampling strategy was used to select the 990 schools (1.1% of 90,488 schools in Rajasthan) targeted for monitoring. From each of the 33 districts in Rajasthan, 2 blocks were selected by simple random sampling. In each of these 66 blocks, 15 schools were randomly selected for a total of 990 schools. One monitor was assigned to each of these blocks. From the list of 15 schools in a block, the monitor could visit any 3 schools before Deworming Day for Preparation Monitoring, another 2 schools on Deworming Day, 2 more schools on Mop-Up Day, and 4 more schools over the two Coverage Validation days. The remaining 4 schools served as a buffer in case a particular school could not be visited. Hence, the actual sample size was 726 schools (0.8% of all schools)." DtWI Rajasthan 2012 monitoring report, Pg 1.
• What we’ve seen: Monitoring forms used for data collection, full monitoring data from deworming day, mop-up day, and coverage validation days following deworming, and a summary report of results (DtWI Rajasthan 2012 monitoring report).
• Bihar 2011:
• Process: "Moreover, independent monitors were mobilized in each block (560 total) to visit 5% of all government schools on deworming and mop-up days to ensure that an adequate quantity of drugs were available, trained teachers were administrating drugs according to protocol, and community sensitization initiatives were successful in mobilizing non-enrolled children to attend. One auditor per district was in charge of supervising monitors to ensure quality monitoring of all schools." DtWI Bihar 2011 program report, Pg 9.
• What we’ve seen: Monitoring forms used for data collection and full monitoring data from deworming day and mop-up day. We have not seen a summary of this data and have not analyzed it ourselves. (DtWI Bihar 2011 program report)
• 34.
• We have more confidence in the quantity of enrolled students dewormed (in contrast with unenrolled students and pre-school children) since Deworm the World collects higher quality monitoring data on this population, as discussed in the rest of this section.
• In this estimate we are not including the deworming programs in Indian states that launched as part of the National Deworming Day (NDD) in 2015, even though Deworm the World believes that it was critical to the NDD happening. We do not have detailed data on the number of children reached in states that launched programs for NDD, do not expect those numbers to be as reliable as the ones for which Deworm the World has run its coverage validation process (discussed below), and we are unsure how to credit Deworm the World for its role in causing those deworming programs to happen.
• 80% figure: total 36.0 million enrolled children reported dewormed by government, divided by 44.9 million children enrolled statewide (See “Estimates of total statewide coverage” table in main text.)
• 35.
• Bihar: "Two-stage probability sampling was used to select schools for coverage validation on deworming day and mop-up day. First, 125 blocks were selected from all 38 districts by probability proportional to size sampling (Probability proportional to size sampling (PPS) selected blocks in Bihar, according to the number of schools in that block. PPS corrects for unequal selection probabilities in random sampling of unequally sized blocks. Schools were then randomly selected from the selected blocks.), followed by random sampling of schools to provide state-wide estimates of indicators. Evidence Action held a detailed training on February 15 and 16 to ensure the monitors were equipped with the necessary knowledge on the deworming program to conduct monitoring effectively. The monitors visited the 123 randomly selected schools on deworming day and an additional 124 schools on mop up day to check for adequacy of drug supplies, awareness materials, whether teachers had received training, knowledge of adverse event management protocols, and reporting processes. The monitors gathered data through observation of deworming and interviews of headmasters, teachers, and randomly selected students.
During coverage validation an additional 748 randomly sampled schools were surveyed after deworming days to check whether deworming occurred, if reporting protocols were followed, and to validate the coverage reporting. Coverage validation data was gathered through interviews with headmasters and 3 students (in 3 different randomly selected classes in each school), and by checking of all class registers and reporting forms." DtWI Bihar 2015 Program report, Pg. 15.
• Rajasthan: "Two-stage probability sampling was used to select schools for independent monitoring on Deworming Day and mop-up day. First, 125 blocks were selected from all 33 districts by probability proportional to size (PPS) sampling (Blocks were selected by Probability proportional to size sampling (PPS) in Rajasthan, according to the number of schools in that block. PPS corrects for unequal selection probabilities in random sampling of unequally sized blocks. Schools were then randomly selected from the selected blocks.), followed by random sampling of schools to provide state-wide estimates of indicators." DtWI Rajasthan 2015 program report, Pg. 14.
• Madhya Pradesh: "A two-stage probability sampling process (Blocks were selected by Probability Proportional to Size (PPS) sampling, followed by random sampling of schools to provide state-wide estimates of indicators. We used PPS sampling to select blocks in Madhya Pradesh, according to the number of schools in that block. PPS corrects for unequal selection probabilities in random sampling of unequally sized blocks. After selecting blocks, we randomly selected schools from within these blocks.) was followed to select schools for NDD, mop-up day and coverage validation." DtWI Madhya Pradesh 2015 program report, Pg. 16.
• Delhi: "The method of stratified random sampling using proportional allocation approach (A random sample of population in which the population is first divided into distinct subgroups or strata, and random samples are then taken separately for each stratum proportional to the size of the subgroup.) was followed for selection of schools and anganwadis for deworming day, mop-up day, and coverage validation monitoring to provide state-wide estimates of indicators." DtWI Delhi 2015 program report, Pg. 14.
• 36.

For example, in Delhi, monitors are instructed in the survey instrument, "Is the school open? [If not,] Did you go to the buffer school?" DtWI Delhi 2015 monitoring survey from deworming day, schools Pg 3.

• 37.
• "Please choose a class Randomly for questions from class teacher." DtWI Bihar 2015 monitoring survey for coverage validation, schools, Pg. 12.
• "Select a child randomly and Take the child outside the class/away from the teacher." DtWI Bihar 2015 monitoring survey for coverage validation, schools, Pg. 14.
• Bihar "First, 125 blocks were selected from all 38 districts by probability proportional to size sampling, followed by random sampling of schools to provide state-wide estimates of indicators. Evidence Action held a detailed training on February 15 and 16 to ensure the monitors were equipped with the necessary knowledge on the deworming program to conduct monitoring effectively. The monitors visited the 123 randomly selected schools on deworming day and an additional 124 schools on mop up day to check for adequacy of drug supplies, awareness materials, whether teachers had received training, knowledge of adverse event management protocols, and reporting processes. The monitors gathered data through observation of deworming and interviews of headmasters, teachers, and randomly selected students." DtWI Bihar 2015 Program report Pgs 15-16
• Chhattisgarh "We visited 10 randomly selected schools in each block from the 55 blocks in these 11 districts. Therefore, they visited a total of 550 randomly sampled schools for coverage validation activities. In addition to the headmaster’s interview and verification of the deworming related documents, three randomly selected children from three different randomly selected classes were interviewed in each school." DtWI Chhattisgarh 2015 coverage validation report, Pg 3

Selected results from monitoring

• Definitions
• Monitors observe deworming activities on DD: At the schools monitors observed (not closed), monitors, randomly chose one classroom in which to observe deworming activities taking place. E.g. in the Delhi survey instrument, "Check if students in the class are being given or preparing to be given deworming medicine. Can you see any deworming activity taking place in the class? [Yes or No]" DtWI Delhi 2015 monitoring survey from deworming day, schools, Pg 17.
• Principal reports having received medicine (on DD or MUD): asked of principals by monitors when they visit schools on deworming day and mop-up day; this figure counts all answers on either day, though each principal was only asked on at most one day. E.g. in the Delhi survey instrument, "Did your school receive the deworming tablets/syrups? [Yes or No]" DtWI Delhi 2015 monitoring survey from deworming day, schools, Pg 11.
• Principal reports conducting deworming on DD (same day): asked of principals on deworming day. E.g. in the Delhi survey instrument, "Are students getting deworming drug in your school today?" DtWI Delhi 2015 monitoring survey from deworming day, schools, Pg 13.
• Present children report being dewormed, at schools where principal reported deworming happened (coverage validation day) - GiveWell calculation: On coverage validation day, monitors went to schools and asked principals whether their school had conducted a deworming. If they said yes, the monitor randomly chose three classes, and in each class, interviewed one student. For each student, if they were marked as present on the class attendance register for either deworming day or mop-up day, the monitor took them to a place to interview them privately and asked them - among other things - (a) whether they consumed a deworming pill, and (b) if so, how they consumed it. This metric is the portion of present students interviewed that said yes to (a) and didn’t say, in response to (b), that they [actually] didn’t consume it. E.g. in the Delhi survey instrument, "Did you consume the medicine that was given to you? [Yes or No]... If you got a tablet, how did you consume it? [Prompt with options 1. Chewed tablet before swallowing, 2. Swallowed tablet directly, 3. Didn’t consume it, 4. Don’t know / don’t remember, 5. Other, specify, 6. No response.]" DtWI Delhi 2015 monitoring survey for coverage validation, schools, Pgs 21, 23.
• We believe coverage validation was a few days or up to a couple weeks after deworming days. For example:
• Delhi 2015: "These monitors were to visit total of 400 randomly selected schools and 400 randomly selected anganwadis; 80 schools and 80 anganwadis on deworming day and mop up day each (April 16 & April 20); and 240 schools and 240 anganwadis during coverage validation (April 23-27, 2015)." DtWI Delhi 2015 program report, Pg 14
• Sources
• We did not include Chhattisgarh in this table since Deworm the World conducted a coverage validation process but not the other elements of the monitoring process on which this table draws.
• 38.
• For example, the nodal headmasters add the school totals from their respective jurisdictions and report them to the block-level officials, who use those to calculate the total children dewormed in their block and report that figure to the district, who do the same in reporting to the state level, where the grand total is calculated.
• Bihar 2015: "With close support from our teams, the State Health Society Bihar and Bihar Education Project Council collected and compiled the coverage report for the round within the reporting timelines in the prescribed reporting format (Annexure H.1). Coverage reporting structure and timeline is shown below in Figure 4:" (see source for annexure and figure) DtWI Bihar 2015 Program report, Pg 16.
• Delhi 2015: "In this round, each school and anganwadi was supposed to fill a one-page reporting form (annexure III). In order to improve the accuracy of coverage reporting by the schools and anganwadis, every participating school and anganwadi was instructed to follow a recording protocol for deworming. Every teacher and anganwadi worker was required to put a single tick (√) next to a child’s name in the school/anganwadi register if they were administered albendazole on deworming day and double-tick mark (√√) if dewormed on mop up day. School headmasters and anganwadi workers were responsible to compile the number of dewormed children, fill the reporting format and submit it to the next level. Reporting structure of coverage data from schools and anganwadis and timelines are given in the below flow chart:" (see source for chart) DtWI Delhi 2015 program report, Pg 15.
• Rajasthan 2013: "School headmasters were required to hand over the completed reporting form to their respective nodal headmasters – a senior headmaster of a school looking after a cluster of schools – who in turn would submit these forms to the respective BEO office. Apart from the forms, the nodal headmasters also submitted the collated information. This information further gets consolidated first at block level, then at district level and finally at state level. Education department shared this compiled information with all the stakeholders." DtWI Rajasthan 2013 program report, Pg 14.
• Bihar 2014 was an exception; aggregation of data for that round of treatment was done centrally, by an independent firm. "In Round 3, each school was supposed to fill a one-page, simple school summary form (Form S), capturing only the essential details on the school such as total enrollment, total number of dewormed children by date and by enrollment status, number of adults dewormed, availability of drugs, drug usage and wastage, remaining drug stocks and contact details of the headmaster. In order to ensure that coverage reporting by the schools is accurate, every participating school was instructed to follow a special recording protocol for deworming. Every teacher was required to put a single tick mark (9) next to a child’s name in the attendance register if they had consumed the tablet on Deworming Day. The teachers were instructed to put a double-tick mark (99) next to a child’s name if s/he had been administered the tablet on Mop-Up Day. These tick marks are intended to be the basis for the numbers reported by every school in the S forms. Schools were supposed to provide the number of enrolled children dewormed by counting the single and double tick marks in the attendance registers. In addition, the provision for dewormed non-enrolled children was to be maintained along with the details of adults dewormed. School headmasters were supposed to submit the filled summary form to BRP by January 30 2014. Blocks were to submit all the collected forms, without any consolidation or compilation, at DEO office by February 5 2014. Districts were instructed to submit these forms at BEPC by February 20 2014. [...] Simplification of consolidation process by replacing data consolidation at block and district level with only collection of forms and submission at higher level. [...] Further, DtWI changed its prior strategy of relying on a single and small data entry partner, and selected a reputed agency with significant experience in large scale surveys across India to do data entry. This data entry partner subsequently dedicated significant data entry resources to Bihar form entry." DtWI Bihar 2014 program report, Pgs 26-27
• 39.
• Monitors find that the number of students dewormed according to school records was greater than the number according to those schools' classroom records for each state that Deworm the World supported in 2015; the median over-report amount was 15%.
• Process: For each state for which we have 2015 deworming coverage validation survey data, we calculated a state-level inflation rate according to the surveyors' observations. We calculated inflation rate as the difference between reported treatments and recorded treatments, out of the total recorded treatments: (treatments reported on the school reporting form​ minus treatments recorded as tick marks in class records)/(treatments recorded as tick marks in class records). In the raw dataset, some entries are marked as missing data using error codes described in the associated code sheet; these were treated as contributing zero tickmarks or zero reported treatments (as appropriate) to the total count.
• Bihar: 22% inflation rate: (141,377-115,889)/115,889 DtWI Bihar 2015 monitoring data for coverage validation, schools (Deworm the World also reports this figure as 22%: "The state level verification factor for Bihar was found to be 0.81972, indicating that for every 82 enrolled children who were recorded as deworming in the schools, the school reported that 100 enrolled children had been dewormed. This corresponds to an overall 22% inflation of reporting in the state, meaning that reported numbers appear to be approximately 22% higher than the numbers recorded in attendance registers." DtWI Bihar 2015 Program report, Pg 19)
• Rajasthan: 15.0% inflation rate: (42,845-37,256)/37,256 DtWI Rajasthan 2015 monitoring data for coverage validation, schools
• Delhi: 1.9% inflation rate: (170,060-166,956)/166,956 DtWI Delhi 2015 monitoring data for coverage validation, schools
• Chhattisgarh: 100.0% inflation rate: (63,162-31,582)/31,582 DtWI Chhattisgarh 2015 monitoring data for coverage validation, schools
• This over-reporting results from schools that reported deworming students in the school summary but did not mark any classroom records as the program protocol instructed. After excluding schools in which no classroom records were marked, the number of students dewormed according to the school records was similar to those schools' classroom records for the same states (the median over-report amount was 0.4%).
• 40.
• In Bihar's 2015 program, 99.8% of schools reported deworming data, so we believe minimal school-level data was missing from the aggregation process. DtWI Bihar 2015 Program report, Pg 4 (Table 1)
• In Rajasthan's 2015 program, 94.0% of schools reported deworming coverage, so it seems possible that any deworming conducted in the remaining 6% of schools was left out of the reported coverage. DtWI Rajasthan 2015 program report, Pg 4 (Table 1)
• In Delhi's 2015 program, 100% of schools and AWCs [anganwadi child-care centres] reported deworming. DtWI Delhi 2015 program report, Pg 4 (Table 1)
• In Madhya Pradesh's 2015 program, 100% of schools and AWCs reported deworming. DtWI Madhya Pradesh 2015 program report, Pg 5 (Table 1)
• In Bihar’s 2014 program, roughly 10% of schools’ summary reports were missing ("In total, 64,724 schools out of the 70,675 targeted schools submitted their summary forms."), and it sounds as if these were simply left out of the reported coverage data ("The result of this modified data cleaning and data entry process was that the coverage data was available to share from the 64,724 schools within 3 months of the deworming date. This cleaned data indicated that 16,225,546 children were dewormed in Bihar out of which 15,489,334 were enrolled children and 736,212 were non-enrolled children.") DtWI Bihar 2014 program report, Pg. 27.
• In Delhi’s 2013 program, Deworm the World reports that missing reports were excluded from the reported coverage figures: "The program targeted 3,032 schools and 10,500anganwadis. As on the cutoff date for report collection, 15 December 2013, data from 603 schools was pending. The above data is based on a dataset comprising 2,417 schools and 10,591 anganwadis." DtWI Delhi 2013 program report, Pg. 2.
• We have not seen information about missing data for Rajasthan’s 2013 program.
• 41.
• Methodology:
• Schools included: all schools monitors visited during coverage validation day, except those for which no classes records showed any dewormings (because we believe many schools just didn’t use that protocol despite deworming students) unless the principal said that no deworming had taken place in the school. We also excluded schools with missing total enrollment data.
• Students dewormed in included schools: total ‘tick marks’ in school register for all classes in included schools. Note that we are unsure whether this measure sometimes includes unenrolled students as well.
• Enrollment in included schools: total enrollment as reported by the monitor's check of the attendance register.
• Total students enrolled in each state (public and private): Sum of primary, upper primary, secondary, and higher secondary enrollment figures for the 2014-2015 school year from India’s District Information System for Education (DISE). Primary and upper primary total enrollment: U-DISE Elementary Thematic Maps 2015, Pgs 60-61. Secondary and upper secondary total enrollment: 2014-15 totals U-DISE Secondary Flash Statistics 2015, Pg 34.
• Total students enrolled in government and government-aided schools: Sum of (total enrollment * percentage of enrollment in government and government-aided schools) for primary, upper primary, secondary, and upper secondary schools. Percentage of students enrolled in government and government-aided schools by state: U-DISE Elementary Thematic Maps 2015, Pgs 62-63 and U-DISE Secondary Thematic Maps 2015, Pgs 33-34.
• U-DISE Secondary Thematic Maps 2015, Pg 34 reports the percentage of students who are enrolled in private unaided managements. We are assuming that the remainder of students are in government or government-aided schools. U-DISE Elementary Thematic Maps 2015, Pgs 62-63 reports the percentage of students enrolled in "government management schools." We are uncertain whether "government management schools" includes government-aided private schools, but we are assuming so for these figures.
• According to the table of contents, the map on Pg 33 of U-DISE Secondary Thematic Maps 2015 reports data on "Percentage of Secondary Enrollment by Private Unaided Management." However, the title of the map on Pg 33 is "Percentage of Professionally Qualified Teachers: Secondary Level." Based on the context in which the map appears, and because there is another map in the document with the title "Percentage of Professionally Qualified Teachers: Secondary Level" our best guess is that the table of contents is correct and the map title on Pg. 33 is an error.
• Estimated statewide enrolled students dewormed: (Dewormed enrolled students / Enrolled students) * Statewide enrollment in government and government-aided schools.
• Numbers
• Bihar (DtWI Bihar 2015 monitoring data for coverage validation, schools)
• Included schools: 557/748 schools surveyed: 234 schools without tick marks, but in 43 of those those the principal said no deworming happened; 748 - 234 + 43 = 557.
• Enrolled students dewormed in sample: 115,815
• Enrollment in sample: 177,464
• Statewide enrollment in government and government-aided schools: 23,902,897
• Estimated statewide enrolled students dewormed: 15,599,299
• Rajasthan (DtWI Rajasthan 2015 monitoring data for coverage validation, schools)
• Excluded schools: 46
• Enrolled students dewormed in sample: 37256
• Enrollment in sample: 44316
• Statewide enrollment in government and government-aided schools: 7,289,229
• Estimated statewide enrolled students dewormed: 6,180,557
• Delhi (DtWI Delhi 2015 monitoring data for coverage validation, schools)
• Note that Delhi didn’t deworm students in grade 11 due to examinations. We didn’t adjust any of the numbers from the raw data because it appears that grade 11 classes were still sampled by monitors, so the monitored coverage should still reflect the low participation from that grade.
• Excluded schools: 3
• Enrolled students dewormed in sample: 166956
• Enrollment in sample: 218098
• Statewide enrollment in government and government-aided schools: 2,564,953
• Estimated statewide enrolled students dewormed: 1,963,495
• Excluded schools: 178
• Enrolled students dewormed in sample: 35834
• Enrollment in sample: 52472
• Statewide enrollment in government and government-aided schools: 11,151,527
• Estimated statewide enrolled students dewormed: 7,615,563
• Chhattisgarh (DtWI Chhattisgarh 2015 monitoring data for coverage validation, schools)
• Excluded schools: 247
• Enrolled students dewormed in sample: 31535
• Enrollment in sample: 40575
• Statewide enrollment in government and government-aided schools: 4,644,179
• Only students 10-19 were dewormed so we are not able to generate a similar estimate of students dewormed in this state.
• Our calculations in this spreadsheet: GiveWell enrollment-based student coverage check 2015
• 42.
• Chhattisgarh is excluded because only some districts in the state were covered, so we are not able to apply the same methodology.
• The calculations for the first three columns of this table are in this spreadsheet: GiveWell enrollment-based student coverage check 2015
• Reported enrolled student coverage
• Bihar: 17,600,122 ("Number of enrolled children dewormed (age 6-19 years)") DtWI Bihar 2015 Program report, Pg 4
• Rajasthan: 6,463,898 ("Total enrolled children (6-19 years) dewormed at schools") DtWI Rajasthan 2015 program report, Pg 4
• Delhi: "The coverage data from the schools in Delhi indicated that 1,828,562 enrolled children were dewormed in the state during deworming day and mop up day against the total target of 2,240,573 enrolled children from class 1 to 12." DtWI Delhi 2015 program report, Pg 18.
• Madhya Pradesh: 10,073,830 ("Number of enrolled children (Class 1 to 12) dewormed at schools") DtWI Madhya Pradesh 2015 program report, Pg 5
• Chhattisgarh: "The coverage data from the state indicated that 916,596 children in the age group 10-19 years were dewormed against the target of 978,008. These include 849,797 enrolled children at schools and 128,211 out-of-school children." DtWI Chhattisgarh 2015 coverage validation report, Pg 7
• 43.
• For details on the monitoring process by state and year, see this footnote.
• 44.

The figures below aggregate data collected on Deworming Day and Mop-up Day unless otherwise noted. Note that GiveWell has not verified these figures from raw data, and we are not sure how consistent the method of asking these questions is between years in a given state. The following sources were used in these tables:

Bihar

2015 data 2014 data 2012 data
Percentage of schools that had a representative attend training 85.8% 76.9% 79.3% (Deworming Day), 75.2% (Mop-up Day)
Percentage of schools that report receiving deworming drugs 90.3% 96.0% 95.8% (by deworming day)
Percentage of children who report receiving a deworming tablet 83.0% Not reported 99.3% (on Deworming Day), 97.4% (on Mop-up Day)
Percentage of schools where a monitor observed the teacher following the correct reporting protocol 68.4% 85.9% (not specified as a monitor's observation) 93.9% (on Deworming Day), 72.6% (on Mop-up Day)
Percentage of schools where a monitor observed a teacher telling students to chew the pills before swallowing 89.3% 95.0% Not reported
Percentage of schools where monitors observed children receiving more than one deworming tablet Not reported 2.2% 2.2% (on Deworming Day), 4% (on Mop-up Day)
Percentage of children who were aware of the purpose of the tablet 84.3% 89.8% Not reported

Delhi

Percentage of... 2015 data 2013 data 2012 data (Deworming Day only)
Children who report receiving a deworming tablet 94.6% (schools) Not reported 98% (schools)
Schools where a monitor observed a teacher telling students to chew the pills before swallowing 96.4% (schools) 83.5% (schools) 82.5 % (anganwadis) Not reported
Schools/anganwadis where monitors observed children receiving more than one deworming tablet 0.8% (schools) 10.6% (anganwadis) Not reported 6% (schools)
Children who were aware of the purpose of the tablet 94.2% (schools) 70.7% (schools) "Nearly all" (schools)

Rajasthan

Percentage of... 2015 data 2013 data 2012 data
Schools that had a representative attend training 62.4% 91.1% 92.6% (by Deworming Day) 88.2% (for Mop-up Day)
Schools that report receiving deworming drugs 98.0% 86% (by deworming day) 97% (by Deworming Day)
Children who report receiving a deworming tablet 85.60% 98.3% 89% (on Deworming Day)
Schools where a monitor observed the teacher following the correct reporting protocol 66.4% 85.5% 96.1% (on Deworming day) 84.2% (on Mop-up Day)
Schools where a monitor observed a teacher telling students to chew the pills before swallowing 82.8% 99.4% Not reported
Schools where monitors observed children receiving more than one deworming tablet 1.6% 3.1% (schools and anganwadis) 5.8% (on Deworming Day) 5.2% (on Mop-up Day)
Children who were aware of the purpose of the tablet 74.0% 82.9% 96.4% (on Deworming Day) 94.9% (on Mop-up Day)
• 45. Aggregate level analysis (N = 995 schools) DtWI Bihar 2015 independent monitoring tables, Pg 10
• 46. Aggregate level analysis (N = 625) DtWI Rajasthan 2015 independent monitoring tables, Pg 10
• 47. Aggregate level analysis (N = 400 schools), DtWI Delhi 2015 independent monitoring tables, Pg 26
• 48. Aggregate level analysis (N = 1000 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 12
• 49. Coverage validation survey (N = 490 schools), DtWI Chhattisgarh 2015 independent monitoring tables, Pg 1
• 50. DtWI Madhya Pradesh 2015 monitoring survey for coverage validation, schools, Pg 3
• 51. Deworming Day and Mop-up Day (N = 247 schools), DtWI Bihar 2015 independent monitoring tables, Pg 3
• 52. Deworming Day and Mop-up Day (N = 250) DtWI Rajasthan 2015 independent monitoring tables, Pg 3
• 53. Deworming Day and Mop-up Day (N = 147 schools), DtWI Delhi 2015 independent monitoring tables, Pg 4
• 54. Deworming Day and Mop-up Day (N = 250 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 3
• 55. DtWI Madhya Pradesh 2015 monitoring survey from deworming day, schools, Pg 7
• 56. Coverage Validation (N = 748 schools) DtWI Bihar 2015 independent monitoring tables, Pg 5
• 57. Coverage validation (N = 375) DtWI Rajasthan 2015 independent monitoring tables, Pg 5
• 58. Coverage validation (N = 253 schools), DtWI Delhi 2015 independent monitoring tables, Pg 9
• 59. Coverage validation (N = 750 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 5
• 60. Coverage validation survey (N = 490 schools), DtWI Chhattisgarh 2015 independent monitoring tables, Pg 1
• 61. DtWI Madhya Pradesh 2015 monitoring survey for coverage validation, schools, Pg 5
• 62. Deworming Day and Mop-up Day (N = 247), DtWI Bihar 2015 independent monitoring tables, Pg 2
• 63. Deworming Day and Mop-up Day (N = 250), DtWI Rajasthan 2015 independent monitoring tables, Pg 2
• 64. Deworming Day and Mop-up Day (N = 147), DtWI Delhi 2015 independent monitoring tables, Pg 4
• 65. Deworming Day and Mop-up Day (N = 250), DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 2
• 66. Coverage validation survey (N = 490 schools), DtWI Chhattisgarh 2015 independent monitoring tables, Pg 3
• 67. DtWI Madhya Pradesh 2015 monitoring survey from deworming day, schools, Pg 22
• 68. Aggregate level analysis (N = 995 schools) DtWI Bihar 2015 independent monitoring tables, Pg 10
• 69. Aggregate level analysis (N = 625) DtWI Rajasthan 2015 independent monitoring tables, Pg 6
• 70. Deworming Day and Mop-up Day (N = 147 schools), DtWI Delhi 2015 independent monitoring tables, Pg 22
• 71. Aggregate level analysis (N = 1000 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 6
• 72. Coverage validation survey (N = 490 schools), DtWI Chhattisgarh 2015 independent monitoring tables, Pg 2
• 73. DtWI Bihar 2015 monitoring survey from deworming day, schools, Pg 11
• 74. Deworming Day (N= 123 schools) and Mop-up Day (N = 124 schools), DtWI Bihar 2015 independent monitoring tables, Pg 1
• 75. Deworming Day (N = 125 schools) and Mop-up Day (N = 125 schools), DtWI Rajasthan 2015 independent monitoring tables, Pg 1
• 76. Deworming Day (N = 58 schools) and Mop-up Day (N = 89 schools), DtWI Delhi 2015 independent monitoring tables, Pg 2
• 77. Deworming Day (N = 125 schools) and Mop-up Day (N = 125 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 1
• 78. DtWI Madhya Pradesh 2015 monitoring survey from deworming day, schools, Pg 12
• 79.

Monitors only did coverage validation in Chhattisgarh, and did not conduct monitoring activities on deworming day or mop-up day.

• 80. Deworming Day and Mop-up Day (N = 247 schools), DtWI Bihar 2015 independent monitoring tables, Pg 2
• 81. Deworming Day and Mop-up Day (N = 250), DtWI Rajasthan 2015 independent monitoring tables, Pg 2
• 82. Deworming Day and Mop-up Day (N = 147 schools), DtWI Delhi 2015 independent monitoring tables, Pg 2
• 83. Deworming Day and Mop-up Day (N = 250 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 2
• 84. @DtWI Madhya Pradesh 2015 deworming day monitoring form@, Pg 13
• 85. Deworming Day and Mop-up Day (N = 247 schools), DtWI Bihar 2015 independent monitoring tables, Pg 2
• 86. Deworming Day and Mop-up Day (N = 250), DtWI Rajasthan 2015 independent monitoring tables, Pg 1
• 87. Deworming Day and Mop-up Day (N = 147 schools), DtWI Delhi 2015 independent monitoring tables, Pg 2
• 88. Deworming Day and Mop-up Day (N = 250 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 2
• 89. @DtWI Madhya Pradesh 2015 deworming day monitoring form@, Pg 13
• 90. Deworming Day and Mop-up Day (N = 247 schools), DtWI Bihar 2015 independent monitoring tables, Pg 1
• 91. Deworming Day and Mop-up Day (N = 250), DtWI Rajasthan 2015 independent monitoring tables, Pg 1
• 92. Deworming Day and Mop-up Day (N = 147 schools), DtWI Delhi 2015 independent monitoring tables, Pg 2
• 93. Deworming Day and Mop-up Day (N = 250 schools) DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 1
• 94. @DtWI Madhya Pradesh 2015 deworming day monitoring form@, Pg 13
• 95. Deworming Day and Mop-up Day (N = 247 schools), DtWI Bihar 2015 independent monitoring tables, Pg 4
• 96. Deworming Day and Mop-up Day ( N = 250), DtWI Rajasthan 2015 independent monitoring tables, Pg 4
• 97. Deworming Day and Mop-up Day (N = 147 schools), DtWI Delhi 2015 independent monitoring tables, Pg 6
• 98. Deworming Day and Mop-up Day (N = 250 schools), DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 4
• 99. @DtWI Madhya Pradesh 2015 deworming day monitoring form@, Pg 14
• 100.

"In India, DtW facilitates the expenditure of resources that the states already have available." Alix Zwane conversation June 4th 2013, Pg 2.

"India is an appealing place to implement a deworming program because the Indian government has policies in place mandating deworming and makes money available to states to implement deworming programs, but many states don't have the background or the expertise to implement deworming programs effectively." CIFF conversation September 10th 2013, Pg 2.

• 101.

Professor Devesh Kapur Biography 2013

• 102.

Devesh Kapur conversation October 14th 2013

• 103.

"Some school health programs, such as the WIFS program in Delhi, are rolled out too quickly and their trainings are carried out poorly. Then they receive negative media attention because of students’ adverse reactions to treatments. Negative media can cause delays or cancellation of school health programs. The WIFS program has also received negative media attention in the states of Haryana and Odisha." DtWI 2013 GiveWell site visit, Pg 10.

• 104.

"There have been very few adverse reactions to deworming treatments in DtWI-supported states because of the quality of Deworm the World's trainings." DtWI 2013 GiveWell site visit, Pg 10.

• 105.
• "National funds for deworming are part of the [Weekly Iron Fortification Supplements] WIFS program and the national government mandates that states should adopt the WIFS program. Indian national policy indicates that deworming should take place biannually." DtWI 2013 GiveWell site visit, Pg 12.
• "Wherever possible, Deworm the World works to get deworming added as a line item in the budget. Otherwise, it is difficult to ensure that long-term funding will exist for the program." DtWI 2013 GiveWell site visit, Pg 10.
• "India is an appealing place to implement a deworming program because the Indian government has policies in place mandating deworming and makes money available to states to implement deworming programs, but many states don't have the background or the expertise to implement deworming programs effectively." CIFF conversation September 10th 2013, Pg 2.
• 106.
• Alix Zwane conversation August 30th 2013
• "Last year Jharkhand launched a deworming as part of the WIFS Program, without any direct advocacy from DtWI. The program had no formalized protocols, didn’t measure coverage, and focused on children aged 10 to 19. In 2014 Deworm the World has been meeting with relevant officials in the state to see if there is an opportunity to improve the quality of the program with technical assistance. Deworm the World is hoping to sign a Memorandum of Understanding (MOU) with the state soon, and its work there would be funded by a grant from USAID." GiveWell’s non-verbatim summary of conversations with Alix Zwane and Grace Hollister on February 26 and March 17, 2014, Pg 3.
• Assam has also announced its intentions to move forward with its deworming program in March 2013: "Status of School Health Programme with special focus on provision of micronutrients, Vitamin-A, de-worming medicine, Iron and Folic acid, Zinc, distribution of spectacles to children with refractive error and recording of height, weight etc. As reported by NRHM, Assam any [sic] school has not been covered under School Health Programme during 2012-13. The programme is being implemented from March/2013. They have completed the training of Multipurpose Worker (MPW) and Lady Health Visitor (LHV) for the purpose. Recruitment of dedicated Medical officer, Dental Surgeon and Block Health Programme officer have been made for implementation of the programme. The weekly Iron and Folic Acid Supplementation Programme among the adolescent students of Class VI to VIII is also being implemented from the March/ 2013. The training programme for District trainers of all the districts have been completed in Dec./12." Assam midday meal report 2013, Pg 11.
• According to Deworm the World, "No schools in Assam have been covered under the School Health Program to provide deworming in 2012/13. The programme was then re-scheduled to begin in March 2013. No evidence of this actually having taken place." DtWI Assam research 2013, Pg 1.
• "[Deworm the World is] also widely acknowledged by the deworming community to be the only technical assistance available in India." CIFF conversation September 10th 2013, Pg 2.
• Originally Deworm the World didn’t believe that Jharkhand conducted a school-based deworming MDA in 2013, but learned of it by early 2014.
• 107.
• Deworm the World was not involved in Punjab, Jharkhand, nor Assam launching their statewide school-based deworming programs.
• "Last year Jharkhand launched a deworming as part of the WIFS Program, without any direct advocacy from DtWI. The program had no formalized protocols, didn’t measure coverage, and focused on children aged 10 to 19. In 2014 Deworm the World has been meeting with relevant officials in the state to see if there is an opportunity to improve the quality of the program with technical assistance. Deworm the World is hoping to sign a Memorandum of Understanding (MOU) with the state soon, and its work there would be funded by a grant from USAID." GiveWell’s non-verbatim summary of conversations with Alix Zwane and Grace Hollister on February 26 and March 17, 2014, Pg 3.
• "DtW has been involved in deworming programs in four different states, and is still actively involved of three of those. Of the states DtW has worked with in the past, none of them had school-based deworming programs before DtW's involvement." Grace Hollister conversation June 19th 2013, Pg 1.
• "In 2009, DtW and the World Bank had conversations with the Chief Minister of Andhra Pradesh, in which they advocated for a broad school-based deworming program, which hadn't happened before in the state. In a public announcement with health and education ministers following this interaction, the Chief Minister announced the plan to do so, and deworming became the flagship of the state’s school health program." Grace Hollister conversation June 19th 2013, Pg 1.
• "In January 2010 the Jameel Poverty Action Lab (J-PAL) hosted a regional development and policy conference, at which evidence on school-based deworming was presented, as well as experiences from Andhra Pradesh. Immediately following the conference, discussions started among the state of Bihar, J-PAL, led by members of the DtW Board of Directors, and DtW about the possibility of a deworming initiative there. In August a memorandum of understanding (MoU) was formalized between DtW and the relevant players in Bihar (School Health Society Bihar and Bihar Education Project Council) for program implementation." Grace Hollister conversation June 19th 2013, Pg 2.
• "DtW leveraged its networks to engage the support of the Minister of Health, Women, and Child Welfare [in Delhi]. Education stakeholders were also brought in so that the program could reach beyond preschool to older grades as well. DtW conducted a great deal of advocacy, maintaining continuous interactions and significant support among all relevant departments to bring the program to fruition Due to the complicated agency system, there were many other government stakeholders as well, requiring a high degree of coordination by DtW to ensure program objectives could be achieved." Grace Hollister conversation June 19th 2013, Pg 3.
• "After the deworming program launched in Delhi, Rajasthan saw the results generated by the DtW- supported program in Delhi and committed to doing a deworming program, allocating funding for it in their budget. In March 2012 they brought DtW in to help. In this case, the state already knew what it wanted and already had a school health program. They sought DtW's technical expertise, mapping ability, general program support, stakeholder coordination, etc. Deworm the World coordinated signature of a MoU between the Departments of Women and Child Development, Education, and Health, UNICEF and DtW to guide program implementation, and helped establish of a technical secretariat housed within the Education Department." Grace Hollister conversation June 19th 2013, Pg 3.
• "DtW has worked in Delhi, Bihar, Rajasthan, and Andhra Pradesh (AP).
• In Bihar, according to documentation provided by DtW, the program began because of previous Poverty Action Lab (J-PAL) work in Bihar. DtW also noted that Rajasthan approached them because of the success (as highlighted in the media) of the Delhi program. DtW supported a pilot program and prevalence survey in AP, and though DtW didn't continue to engage with AP, the AP government seems to have recently conducted a school-based deworming program.
• More recently, Punjab approached DtW, but DtW didn't have the funding to move forward with Punjab, and Punjab is now implementing deworming on its own.

It's not possible to be certain whether or not DtW has caused deworming to happen that otherwise would not have, but it's important to note that DtW took the opportunities presented to help run better programs where possible as well as improve data quality and did so on a limited budget. They are also widely acknowledged by the deworming community to be the only technical assistance available in India." CIFF conversation September 10th 2013, Pg 2.

• 108.
• 109.

"Keeping in view the problem of worm infestation of children in Assam it has been decided to conduct two rounds of De-worming every year in the month of March and September. The first round will be conducted during March’ 2010. On every Wednesday (VHND/Immunization Day) medicine for De-worming will be given to all children between the age group 1 to 5 years along with vitamin A supplementation." Assam 2010 guidelines for deworming, Pg 1.

976,192 "children below 5 years provided vitamin A syrup" as of November/December 2010 Assam reproductive and child health 2011-2012, Pg 73.

The National Rural Health Mission reported the progress for 2010-2011 as 92,957 "Students given IFA/ de-worming tablets". Assam state programme implementation plan 2011-2012, Pg 21.

Assam is "supposed to provide deworming to all children, but AWC services provided in Assam are some of the worst performers for deworming coverage." DtWI Assam research 2013, Pg 1.

• 110.

"Status of School Health Programme with special focus on provision of micronutrients, Vitamin-A, de-worming medicine, Iron and Folic acid, Zinc, distribution of spectacles to children with refractive error and recording of height, weight etc. NB. As reported by NRHM, Assam any school has not been covered under School Health Programme during 2012-13. The programme is being implemented from March/2013. They have completed the training of Multipurpose Worker (MPW) and Lady Health Visitor (LHV) for the purpose. Recruitment of dedicated Medical officer, Dental Surgeon and Block Health Programme officer have been made for implementation of the programme. The weekly Iron and Folic Acid Supplementation Programme among the adolescent students of Class VI to VIII is also being implemented from the March/ 2013. The training programme for District trainers of all the districts have been completed in Dec./12." Assam midday meal report 2013, Pg 11.

• 111.
• 112.
• 113.

"If Deworm the World had not been there, how would the deworming program be different?

• Since Deworm the World have already implemented deworming programs in Delhi and Tamil Nadu, they brought experience.
• If a state government decides to do something, nothing is impossible. However, Deworm the World's presence helped Rajasthan to roll out the program quickly and error-free. If the government did not have Deworm the World's experience, there could have been more problems.
• The government received important support from DtWI, particularly with distributing the deworming tablets, implementing the trainings, and developing training materials."

"Have you ever wanted to do a program but been unable to find a technical partner?

• Ms. Gupta is still looking for a technical partner on specific issues. For example, Rajasthan has a large population with special needs. It has generally been able to find partners for helping the visually impaired, but very few organizations work with autistic children, children with cerebral palsy, or children with mental retardation. If there were a partner to support the Rajasthan government in this area, this would be very welcome. The Rajasthan government has funds for this type of program, but are looking for a technical partner.
• An NGO called Sight Savers works with blind children. Before Sight Savers, she was not aware of problems with low vision. Many children need magnifying glasses and large print books. Sight Savers helped them to identify doctors and hospitals to work with such children."
• 114.

"Additionally the national government of India has expressed interest in possibly
implementing a deworming program nationwide, rather than waiting for each state to
launch separate programs. They have expressed interest in receiving technical assistance
from DtWI for this project." GiveWell’s non-verbatim summary of conversations with Alix Zwane and Grace Hollister on February 26 and March 17, 2014, Pg 2

• 115.
• "Deworm the World Initiative at Evidence Action will be the technical assistance partner to MoHFW, Government of India. The specific responsibilities are as follows:
Support in development of National Deworming Day implementation strategy
Design and develop training and reference materials, community mobilization strategies for increased awareness and coverage of target beneficiaries, Monitoring and Evaluation (M&E) Systems and reporting formats" India Ministry of Health and Family Welfare Deworming Guidelines Draft 2015, Pg 10.
• "Additionally the national government of India has expressed interest in possibly
implementing a deworming program nationwide, rather than waiting for each state to
launch separate programs. They have expressed interest in receiving technical assistance
from DtWI for this project." GiveWell’s non-verbatim summary of conversations with Alix Zwane and Grace Hollister on February 26 and March 17, 2014, Pg 2
• "The Indian national government has recently demonstrated an increased interest in deworming programs. The Child Health Division of the Ministry of Health & Family Welfare (MoHFW) has been particularly interested in deworming. Deworm the World Initiative (DtWI)’s program in India is working with Ajay Khera, the leader of the Child Health Division, and other staff members in the division to encourage the division to continue promoting deworming. DtWI has also been meeting with the Joint Secretary of MoHFW and requesting appointments with the Minister of Health & Family Welfare. Deworming has been proposed to be included in the 100 Day Agenda of the new administration in India. DtWI is a stakeholder supporting this effort. DtWI has proposed to assist with several aspects of the program including planning, guideline development and other technical issues." GiveWell’s non-verbatim summary of a conversation with Grace Hollister on June 24th, 2014, Pg 1
• "States which did not receive technical support from Deworm the World may not have had adequate time or support for planning the February deworming round. This may have resulted in lower coverage and weaker monitoring. Some states would likely appreciate assistance from Deworm the World or another similar organization." GiveWell’s non-verbatim summary of a conversation with Grace Hollister on February 24, 2015, Pg 2
• 116.

India NDD documents 2015

• 117.
• 118.

"A program of the Government of India, the February 10 event in eleven states targeted 140 million children with school-based deworming treatment." DtWI NDD blog post February 2015

• 119.
• 120.

"DtWI's presence helped Rajasthan to roll out the program quickly and error-free. If the government did not have Deworm the World's experience, there could have been more problems." Veenu Gupta, Principal Secretary to School Education Department, Government of Rajasthan DtWI 2013 GiveWell government interviews, Pg 7.

• 121.

"DtWI has helped to improve deworming trainings. Last year, Deworm the World helped to develop the content for the trainings. Deworm the World made the content more concise and easy to understand than the government would have done on its own. Deworm the World also improves trainings by tracking when people do not show up to trainings and following up with them and by determining aspects of training that could be improved in future years." Girish Bharbwag, Nodal Officer in Rajasthan DtWI 2013 GiveWell government interviews, Pg 4.

• 122.

The District Coordinator position, for example, is not always staffed in other school-based health programs. "The state government paid for District Coordinators for the hand washing program in 2008. However, the payment for this position was low. In the first year, there were 15-16 independent monitors. This year, there are only 7 District Coordinators. The government is finding it difficult to fill these vacancies." DtWI 2013 GiveWell government interviews, Pg 5.

"District Coordinators (temporary Deworm the World employees that play a monitoring and evaluation role) are important because they provide reliable feedback to the government about any problems with the deworming program. Typically, the government must rely on government officers to monitor school health programs. However, these officers often fix any problems that they see and then do not report them to the state government because they are worried that the existence of problems will reflect negatively on them. District Coordinators hired and managed by non-governmental organizations are more likely to report problems.
The presence of District Coordinators, combined with the independent monitors hired by Deworm the World that were known to show up unannounced to inspect the program, makes everyone more careful and more likely to implement the program properly because they know that people are paying attention and that they will receive feedback about any mistakes that they make." DtWI 2013 GiveWell government interviews, Pg 4.

• 123.

"The presence of District Coordinators, combined with the independent monitors hired by Deworm the World that were known to show up unannounced to inspect the program, makes everyone more careful and more likely to implement the program properly because they know that people are paying attention and that they will receive feedback about any mistakes that they make." DtWI 2013 GiveWell government interviews, Pg 5.

• 124.
• 125.

Grace Hollister, DtWI Director, email exchange with GiveWell, October 2013

• 126.
• 127.
• Bihar 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Our tele-callers made approximately 19,567 successful calls[20] made during the period of January to March 2015. These calls were made to 534 blocks across 38 districts to assess preparedness on all program areas. Daily tracking sheets outlining issues arising at districts, blocks, and schools were identified during the process and were shared with the state to assist the government to take real-time corrective action." DtWI Bihar 2015 Program report, Pg 16
• Rajasthan 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Evidence Action’s tele-callers tracked the status of training sessions and availability of drugs and IEC materials at the district, block, and school/anganwadi levels through approximately 14,485 successful[19] calls. Tele-callers made 258 calls to the Department of Health and 7,717 calls to ICDS at district, project, and sector level. Another 4,598 calls were made to block and district-level education officials to track various program components. In total 734 calls were made to schools covering 249 blocks across the 33 districts to assess preparedness.

Tele-callers created tracking sheets to outline issues identified during calls and monitoring visits. Issues at the districts, blocks, and schools/anganwadi levels were shared with the state government to ensure that the government was able to take corrective action to address the gaps in real time as necessary." DtWI Rajasthan 2015 program report, Pg 15

• Delhi 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Our tele-callers tracked the status of training, drugs, and IEC material availability at the district, and school/anganwadi through phone calls. Approximately 8,504 successful[12] calls were made to the education, health, and WCD departments during this period." DtWI Delhi 2015 program report, Pg 15
• Madhya Pradesh 2015: "Telephone Monitoring and Cross Verification for Process Monitoring: Our tele-callers placed phone calls to track the delivery and availability of training, drug, and IEC materials at the district, block, and school/anganwadi levels as Deworming Day approached. Approximately 4,840 successful[13] calls were made from February 1 to 14, including 1,097 calls to schools across 313 blocks and 51 districts, and another 3,586 calls to block and district officials.

Tele-callers created tracking sheets to outline issues identified during calls and monitoring visits. Issues at the district, block, and school levels were shared with the state government to ensure that the government was able to take corrective action to address the gaps in real time as necessary." DtWI Madhya Pradesh 2015 program report, Pgs 16-17

• 128.
• See citations in previous footnote.
• "These calls helped to uncover problems, which are reported on the same day to the appropriate government officials to address" Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• We have not seen any detailed data of the calls made or the issues uncovered or whether they are resolved.
• We are only aware of one specific example of the type and magnitude of problems uncovered: In the Bihar 2014 program, Deworm the World-led monitoring uncovered that 18% of schools that were called had not received the drugs at the scheduled time, and it seems plausible that the issue was largely addressed before deworming day (though we have not vetted detailed data supporting this).
"BEO [Block education officer] offices distributed the drugs among the school headmasters at block level trainings. In monitoring phone calls, 82% of the 354 schools contacted by Deworm the World tele-callers across 27 districts confirmed receiving drugs two days prior to Deworming Day. When this potentially problematic information came to light, the tele-calling team and DCs hired by Deworm the World contacted all the BEO offices to ensure delivery of drugs to all the schools before Deworming Day along with instructions issued from the BEPC nodal officer. Subsequent independent monitoring data (from visits to schools during Deworming Day and Mop-Up Day) shows that approximately 96% schools had received drugs by Deworming Day. This was a significant jump from the 82% polled only two days earlier." DtWI Bihar 2014 program report, Pg 13.
• 129.

Our observations are noted here: DtWI 2013 GiveWell site visit.

• 130.

In 2014, Deworm the World reported improvements to the training process, including focusing on areas where problems were identified in previous rounds, simplifying materials, and testing if participants are learning key messages. DtWI Monitoring Improvements 2014, Pgs 1-2.

• 131.
• "[In Vietnam] Deworm the World’s partnership with both the government and Thrive Networks is a new working model for Deworm the World; elsewhere, it has supported government implementation or run its program independently. Deworm the World has only one staff member in the country.

Dubai Cares provides most of the program funding. All funding goes to Thrive Networks, which provides money to the government for implementation expenses. The costs of training over the full three years of the program had been underestimated, so the program budget has been revised upwards. To cover this, Deworm the World has allocated an additional $200,000 from its unrestricted funding. Thrive Networks has also been working in Vietnam on sanitation hardware (for example, latrine installments). Deworm the World is not involved with this work directly, but it is advising on the program’s impact evaluation. This will include a randomized controlled trial on hygiene education in combination with deworming, which will look at the impact on reinfection rates." GiveWell’s non-verbatim summary of a conversation with Grace Hollister on February 24, 2015, Pgs 3-4 • "If funding permits, the Kenyan government may begin a lymphatic filariasis treatment program along its coast. If it does so, Deworm the World will provide process monitoring and coverage validation for the treatments." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 3. • "[In Pakistan, Deworm the World] plans to contract with a local organization to do these [prevalence] surveys, but does not yet have a signed agreement." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 7 • "We are contributing approx$111k to the TUMIKIA and TakeUp studies, complementary studies leveraging the Kenya program to look at the potential for breaking STH transmission." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• 132.
• Our intervention report discusses this briefly
• Other conversations and observations have reinforced our impression that administering deworming drugs is fairly straightforward.
• The WHO factsheet on STH: "The recommended medicines – albendazole (400 mg) and mebendazole (500 mg) – are effective, inexpensive and easy to administer by non-medical personnel (e.g. teachers)." WHO STH factsheet
• 133.

For example, drug quality was tested in each program that Deworm the World supported in India in 2013-2014.

• Bihar 2014:
• "The drugs were safely stored in State Health Depot in Patna until November 2013. At that point, the districts began to pick up their share of the drugs from the depot. In October, Deworm the World had coordinated for lab testing of the stored drugs via ASCHO NIBULA INDUSTRIES LTD, an independent lab which approved the quality of the drugs." DtWI Bihar 2014 program report, Pg 13.
• "The quality of drug storage was satisfactory in most schools that were monitored. 98.7% of them stored the drugs in a clean location, 91.1% of them were stored away from direct sunlight and 97.4% of them were stored away from the direct reach of children." DtWI Bihar 2014 program report annex 1, Pg 7.
• Delhi 2013:
• "Once the procured syrups and donated tablets were delivered to Directorate of Health Services central storage room, they were tested in a government-accredited laboratory to ensure drug quality prior to administration." DtWI Delhi 2013 program report, Pg 6.
• From its monitoring results: "Drug storage conditions were satisfactory in almost all schools and anganwadis." DtWI Delhi 2013 program report, Pg 24. A table of results is also presented on the same page.
• Rajasthan 2013:
• "To instill confidence among the stakeholders that the drugs were of good quality, Deworm the World arranged for sample testing of the donated drugs by two independent labs7. Similarly, Rajasthan Medical Services Corporation sample tested the syrups they procured." DtWI Rajasthan 2013 program report, Pg 6.
• From its monitoring results: "Drug storage conditions were satisfactory in almost all schools and anganwadis." DtWI Rajasthan 2013 program report, Pg 40. A table of results is also presented on the following page.
• 134.
• "Note that National Deworming Day operational guidelines state that only tablets should be used. Albendazole dosage is the same for all children aged 2 and above; it is only children aged 1-2 that require a different (half) dose." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• From Deworm the World's report on the Delhi 2013 program: "A key discussion from round one was the administration of drug to younger children in the pre-school age for whom chewing a tablet was seen as a difficulty. Hence keeping in mind the scale of the program, with an objective of making it a safe public health initiative the committee decided that deworming would be implemented across all districts following the World Health Organization (WHO) sanction in administering albendazole 400 mg tablets and the GOI guidelines under the WIFS program for administering the syrup vial. They also decided to opt for Albendazole 200mg dose suspension for 2-6 year children as it is a single dose for this age group which leads to lesser error in administration, while Albendazole 400mg tablets for older children." DtWI Delhi 2013 program report, Pg 6.
• The WHO factsheet on STH cites only a single recommended dosage (depending on which drug is used): "The recommended medicines – albendazole (400 mg) and mebendazole (500 mg) – are effective, inexpensive and easy to administer by non-medical personnel (e.g. teachers)." WHO STH factsheet
• 135.
• Bihar 2015: In 8.8% of trained schools and 5.4% of untrained schools, monitors observed children given less than one tablet; in 2.6% of trained schools and 4.7% of untrained schools, monitors observed children given more than one tablet. DtWI Bihar 2015 independent monitoring tables, Pg 9 (Table 10)
• Rajasthan 2015: In 6.0% of schools, monitors observed children given less than one tablet; in 1.6% of schools, monitors observed children given more than one tablet. DtWI Rajasthan 2015 independent monitoring tables, Pg 2 (Table 2)
• Madhya Pradesh 2015: In 9.3% of schools, monitors observed children given less than one tablet; in 2.7% of schools, monitors observed children given more than one tablet. DtWI Madhya Pradesh 2015 independent monitoring tables, Pg 2 (Table 2)
• Delhi 2015: In 2.5% of schools and 10.6% of anganwadis, monitors observed children given less than the prescribed dose of albendazole; in 0.8% of schools and 6.0% of anganwadis, monitors observed children given more than the prescribed dose of albendazole. DtWI Delhi 2015 independent monitoring tables, Pgs 2, 16 (Tables S1 and A1)
• Bihar’s 2014: 8% of schools observed gave children less than one tablet and 2% gave more than one tablet. DtWI Bihar 2014 program report annex 2, Pgs 2 and 4.
• "In 3.1% of schools and anganwadis, monitors observed children being given more than one tablet/syrup bottle. As per protocol, the children should not have been given more than one tablet. Therefore in cases such as these, the monitors were trained to intervene and prevent the administration of an additional dose." (The percentage of schools using less than one pill/bottle per child was not reported.) DtWI Rajasthan 2013 program report, Pg 38.
• Monitors in Delhi in 2013 did not report on either of these observations. See DtWI Delhi 2013 program report, Pgs 21-25.
• 136.
• "There's limited data available on current access to deworming in India because very few prevalence surveys have been done and because the deworming that does occur is not always reported, or, if it is, state-wide data is difficult to access. The poorest states are unlikely (in CIFF's view) to have the capacity to implement evidence-based statewide deworming programs on their own. CIFF notes that many parts of India are extremely poor with high percentages (60%) of the population practicing open defecation; limited access to sanitation services makes it likely that deworming is needed." CIFF conversation September 10th 2013, Pg 2.
• "District Coordinators (temporary Deworm the World employees that play a monitoring and evaluation role) are important because they provide reliable feedback to the government about any problems with the deworming program. Typically, the government must rely on government officers to monitor school health programs. However, these officers often fix any problems that they see and then do not report them to the state government because they are worried that the existence of problems will reflect negatively on them. District Coordinators hired and managed by non-governmental organizations are more likely to report problems. The presence of District Coordinators, combined with the independent monitors hired by Deworm the World that were known to show up unannounced to inspect the program, makes everyone more careful and more likely to implement the program properly because they know that people are paying attention and that they will receive feedback about any mistakes that they make. The District Coordinators and Deworm the World's tele-callers were valuable because they were able to confirm that schools received the appropriate amount of drugs and that teachers had been trained. Deworm the World called a random sample of 8,000 schools.
The prevalence survey would not have happened without Deworm the World's support." DtWI 2013 GiveWell government interviews, Pg 5.
• 137.

"India is an appealing place to implement a deworming program because the Indian government has policies in place mandating deworming and makes money available to states to implement deworming programs, but many states don't have the background or the expertise to implement deworming programs effectively. It is possible that DtW brings its expertise to the table and leverages these available resources." CIFF conversation September 10th 2013, Pg 2.

• 138.

"RPs tend to have enough capacity that adding further school health programs would not take away from the work they do for other school-based health programs." DtWI 2013 GiveWell site visit, Pg 3.

• 139.

"[The Nodal Headmaster said] that most aspects of the program are excellent, but he had 2 suggestions:

• Deworm students in private schools as well (even though they have more money and can often buy treatment, they will often not do so)
• Reduce the number of health programs throughout the year; it takes away from teaching time. His school has school health programs on 40 to 42 days each year." DtWI 2013 GiveWell site visit, Pg 6.
• 140.

GiveWell DtWI 2013-2014 cost data summary shows costs of $2,628,511 ($0.089 per treatment), excluding school staff time. Unpublished data show the imputed cost of tablets (which we assume were donated) as $43,200 in Delhi,$373,383 in Bihar, and $147,467 in Rajasthan. Removing these brings the total cost to$2,064,461, or $0.07 per treatment. • 141. GiveWell analysis of Deworm the World cost per treatment • 142. Deworm the World does not yet have finalized information about its costs and its partners’ costs in 2015. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 • 143. GiveWell DtWI 2013-2014 cost data summary • 144. Alix Zwane conversation August 30th 2013 • 145. We estimated the staff time costs based on DtWI’s estimate of similar costs from the same states in 2012. DtWI had imputed those costs based on estimates of government employee salaries; for example, in Rajasthan it estimated 300,000 teacher- and principal-days were used in deworming day and mop-up day, and valued that time at 150 rupees per day (about$2.50) (DtWI Rajasthan 2013 cost data).

• 146.
• We have not adjusted these data for inflation or changes in exchange rates over time.
• Deworm the World's 2013 and 2014 budgets stopped estimating the financial value of government employees’ time spent on the deworming program after the deworming rounds in 2012: "We have consulted with JPAL on the costing model approach and they have suggested, in line with papers they've done, not to quantify teachers' time nor principals' time for the actual deworming day; we still have included the cost of teachers attending the training since there is a direct cash transfer to the teachers for their coming to the training." Jessica Harrison, DtWI Associate Director, email exchange with GiveWell, November 2014
• Deworm the World cited JPAL CEAs in education 2011 for this approach.
• The change is most relevant for teachers and principals, large numbers of whom attend a training and administer the pills to children. While we have seen direct costs of paying teachers and principals that attend deworming training, we are unsure whether those costs should be counted as per-diems (perhaps necessary for some trainees to pay for transport, but not accounting for the lost work time at school) or as optional extra wages (that don’t result in lost work time at school and are sufficient to incentivize the necessary labor), or something in between.
• In order to include the value of teachers and principals’ time for the three recent rounds, we have copied the relevant expenses from the prior year’s budget of the same state (which were imputed costs) and replaced the allowances that were paid directly to teachers and principals during trainings. We believe this methodology is likely to result in some inaccuracies and we may revise it as we become confident of a more accurate method.
• 147.

We estimated the staff time costs based on Deworm the World's estimate of similar costs from the same states in 2012. It had imputed those costs based on estimates of government employee salaries, for example, in Rajasthan it estimated 300,000 teacher- and principal-days were used in deworming day and mop-up day, and valued that time at 150 rupees per day (about $2.50). • 148. • 149. • 150. • 151. Excluding drug costs and the value of teachers' and principals' time, we estimate that Deworm the World's cost per treatment is$0.51 and that SCI's cost per treatment is $0.57. Supporting data and calculations are shown in GiveWell analysis of Deworm the World cost per treatment. Additional explanation follows: • Our discussion of SCI's cost per treatment is here. • Our best guess is that the total cost per treatment for SCI-supported programs is$1.26, split between 3 categories:
1. 42% ($0.53) are SCI's program costs 2. 28% ($0.35) are drug costs
3. 30% ($0.38) are an estimate of the governments' contributions (which we believe are primarily the value of time spent by teachers and principals supporting the program.) • We estimate that Deworm the World's drug costs in Kenya are$0.05 per treatment. We believe that drug costs are lower for the program in Kenya than most of SCI's programs because SCI generally treats for schistosomiasis, but a relatively small proportion of deworming in Kenya includes schistosomiasis treatment, because relatively few areas have high enough prevalence.
• In Kenya, the program treated about 890,000 children for schistosomiasis and about 6.4 million children for STH. DtWI Kenya 2013-2014 program report, Pg 6. (Our understanding is that all of the treatments we included in our analysis of SCI included treatment for schistosomiasis.)
• Our understanding is that to treat for schistosomiasis, an average of 2.5 praziquantel tablets is used, and to treat for STH, one albendazole tablet is used; for example, see WHO Preventive chemotherapy in human helminthiasis, Pgs 48-49.
• The manufacturer cost per tablet for albendazole is $0.02 and for praziquantel is$0.10. WHO Weekly epidemiological record, 3 April 2015, Pg 135
• Deworm the World does more extensive prevalence surveying in Kenya than it does in other countries and than we believe SCI does; this may cause an overestimate of Deworm the World’s costs in other countries.
• "Please also note that our cost per child estimates include the costs of prevalence surveying (in Kenya and in India). The Kenya program has more surveying (including pre and post MDA testing annually) than does the India program (where we undertake baseline surveys and follow-up surveys). Where there are not prevalence survey costs each year, we amortize the costs over rounds." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• "For the NSBDP, three prevalence and intensity surveys for STH and one for schistosomiasis are expected to be or have been completed by KEMRI. The implementation costs of these surveys were divided among the program's expected duration of five years. Therefore, this model includes 1/5 of the total survey-associated costs." DtWI Kenya 2013-2014 cost per treatment data, Introduction sheet.
• We have not adjusted these data for inflation or changes in exchange rates over time.
• 152.
• 153.
• See our discussion of the rationale and limitations of this estimate here.
• For comparison, Deworm the World previously estimated the value of in-kind support from the governments in Bihar and Rajasthan. Our understanding is that these estimates suggested in-kind cost of $0.31 per treatment in Bihar 2012 and$0.20 in Rajasthan 2012.
• For both states, Deworm the World shared detailed data behind its cost per treatment data. This included a sheet for imputed costs. We aggregated these line items, excluding expenses from non-government partners (e.g. WHO and UNICEF), and we believe the result largely accounts for teachers' time during training and deworming day. Treatments from DtWI cost per treatment summary 2013
• Bihar 2012: DtWI Bihar 2012 cost data details shows $5.21 million, which implies$0.31 per treatment, given 16,867,388 treatments. $5.21 million is converted from INR 276.1 million at 53 INR per USD (based on the source), and is a total of these line items: • Master Trainers as Trainers in Block Level Trainings • Master Trainers as Trainers in Sector Level Trainings • Block Level Training • Sector Level Training • Honorarium: Teachers and Headmasters • Honorarium: Health Department (Doctors and ANMs) • Rajasthan 2012: DtWI Rajasthan 2012 cost data details shows$2.06 million, which implies $0.20 per treatment, given 10,132,535 treatments.$2.06 million is converted from INR 109.1 million at 53 INR per USD (based on the source), and is a total of 23 line items, with these 5 largest line items accounting for over 90% of the total:
• Teachers and Headmasters as Trainees
• Block Level Training
• 154.

See GiveWell analysis of Deworm the World cost per treatment, sheet "GiveWell estimate"

• 155.
• 156.
• 157.

"…absent from most of the country, risk exists only in restricted areas." World Schistosomiasis Risk Chart 2012, Pg 1.

"INDIA - Risk is limited to the area around Gimvi in Ratnagiri district (Maharashtra) in the hills along the Konkan coast south of Mumbai (approximately 16km from shore)." World Schistosomiasis Risk Chart 2012, Pg 3.

• 158.
• 159.

Notes on the data we have included:

• Baseline prevalence data for populations studied in Miguel and Kremer 2004 and Croke 2014 are provided in this table for comparison, as these papers represent what we believe to be the strongest pieces of evidence of long term damages from intestinal parasites (see discussion in this section).
• The table uses Miguel and Kremer 2004 definitions of moderate intensity, which are not the same epg [eggs per gram] levels as WHO definitions for all worms. "Following Brooker, Miguel, et al. (2000), thresholds for moderate infection are 250 epg for Schistosomiasis. mansoni and 5,000 epg for Roundworm, the WHO standards, and 750 epg for Hookworm and 400 epg for Whipworm, both somewhat lower than the WHO standard." Miguel and Kremer 2004, Pg. 167.
• Bihar, Madhya Pradesh, and Rajasthan schistosome prevalence was not measured by Deworm the World. We assume 0% based on World Schistosomiasis Risk Chart 2012.
• We also have worm infection data from Delhi, but do not include it here as Deworm the World has told us that Delhi had lower prevalence than a region it would normally prioritize for mass school-based deworming, but that it has particular political and cultural significance as the capital of India. Additionally, the deworming round in 2013 is the last for which Deworm the World is expecting to assist Delhi significantly. See DtWI Delhi 2012 prevalence survey report.
• We have seen more recent prevalence data for Bihar (discussed here). We do not include that data here because it is unclear how it should affect our expectation of the cost-effectiveness of deworming in Bihar. Intuitively, we would expect that, since the prevalence has dropped, the benefits of future deworming will be lower than earlier rounds of deworming. However, our cost-effectiveness analysis is generally not this precise, and (roughly) aims to estimate the average cost-effectiveness over an entire program.

Sources and comments for the data:

• Miguel and Kremer 2004
• Miguel and Kremer 2004, Table II, Pg 168.
• We provide data from year one of the Miguel and Kremer study, which is the time period before El Niño weather conditions set in and increased the prevalence and intensity of local infections.
• Croke 2014:
• Kabatereine et al. 2001, Pg 284, Table 1, Average for eastern districts.
• Kabatereine et al. 2001 was a disease mapping study conducted in southern Uganda in 1998, two years before the study underlying Croke 2014 began, i.e. these are not results from the individuals enrolled in the study underlying Croke 2014.
• Note that the districts in the eastern district average in Kabatereine et al. 2001 are not an exact match for the districts included in Croke 2014, though four of the five districts included in Croke 2014 (Busia, Iganga, Mbale, and Tororo) are included in the Eastern district average.
• The districts for Croke 2014 were selected because Kabatereine et al. 2001 had found high worm prevalence in eastern districts: "Five districts in the eastern region of Uganda were selected (Busia, Iganga, Mbale, Palissa, and Tororo) because a survey had indicated that about 60% of children aged 5-10 years were infected with intestinal nematodes, most commonly hookworm." Alderman et al. 2006, pg 1.
• Bihar
• DtWI Bihar 2011 prevalence survey report
• There is a pre-existing LF program that provides albendazole to a large portion of the population in Bihar annually.
• Based on the timing of the decision to deworm in Bihar, there was only time to collect prevalence surveys from two districts before the annual LF treatment in 2010. Results from that first stage of surveying were sufficient to convince the state to carry out a full deworming program 6 months after the LF treatment, although the methodology did not meet Deworm the World's typical standard of quality.
• Before the Deworm the World-managed deworming program in early 2011, a second stage prevalence survey was conducted in an additional four states. These states were selected based in part on their complementarity with the original two states. DtWI Bihar 2011 prevalence survey report, Pg 9.
• Since the quality of the second stage was higher, our analysis excludes results from the first stage of the survey. Since the second stage districts were selected in part based on complementarity with the first stage, there may be bias introduced into the statewide estimates from lack of randomness. (Grace Hollister, DtWI Director, email exchange with GiveWell, October 2013)
• Rajasthan
• 160.

"When prevalence of any STH infection is less than 20%, large-scale preventive chemotherapy interventions are not recommended. Affected individuals should be dealt with on a
case-by-case basis." Preventive chemotherapy in human helminthiasis 2006, Pg 41.

• 161.
• "Based on the findings of the prevalence survey and WHO guidelines, Evidence Action recommends an annual school based deworming program for school-age children in the state. [...] Given the pre-existing deworming treatments described above, this prevalence survey cannot be considered a baseline survey to assess STH infection rates in a treated population, to determine an optimal treatment strategy." DtWI Madhya Pradesh 2015 program report, Pg 38.
• "Our recommendation is explained in the prevalence survey report. The prevalence and intensity rates from the survey are not "baseline" data, given that there has been relatively regular administration of albendazole in MP through the BSM program that treated PSAC since 2005, and the LF program which provided community-wide treatment of 11 districts of MP (the number of endemic districts had fallen to 8 by 2014). As a result, these deworming efforts have likely had an impact on STH prevalence and MP could not be considered an untreated baseline population. We therefore did not apply the WHO guidelines for baseline STH prevalence.
Annexure 10 of the WHO guidelines suggest continuing annual treatment for populations which have received deworming for several years, and prevalence is still greater than 10%. In addition, the high rate of open defecation in the state, and the planned ending of the LF program in MP, increased the risk of infection and a potential resurgence in prevalence." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015
• 162.

The National Vector Borne Disease Control Programme LF treatment coverage 2015

• 163.
• 164.

"Annual Mass Drug Administration with single dose of DEC was taken up as a pilot project covering 41 million population in 1996-97 and extended to 74 million population. This strategy was to be continued for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease.
Interruption of transmission of filariasis by Annual MDA for 5 years or more to the population except:
- children below 2 years
- pregnant women
- seriously ill persons
(DEC + Albendazole in selected distt & DEC in other distt)" LF treatment drugs 2012.

• 165.
• 166.
• 167.
• 168.

See our 2014 review.

• 169.
• "In India, DtW facilitates the expenditure of resources that the states already have available." Alix Zwane conversation June 4th 2013, Pg 2.
• "India is an appealing place to implement a deworming program because the Indian government has policies in place mandating deworming and makes money available to states to implement deworming programs, but many states don't have the background or the expertise to implement deworming programs effectively." CIFF conversation September 10th 2013, Pg 2.
• "National funds for deworming are part of the [Weekly Iron Fortification Supplements] WIFS program and the national government mandates that states should adopt the WIFS program. Indian national policy indicates that deworming should take place biannually." DtWI 2013 GiveWell site visit, Pg 12.
• 170.
• 171.

$0.51 /$0.80 = 63%. See GiveWell analysis of Deworm the World cost per treatment.

• 172.
• 173.
• 174.
• "Up to $2.5 million unrestricted": Evidence Action estimates it will receive about$3 million in 2015 including GiveWell influenced donations, and we have subtracted $0.5 million that we have tracked as GiveWell-influenced donations. • "We believe we're on track to receive ~$3m this year. [... This $3m] is the total amount of unrestricted funding that we expect for Evidence Action; this will be a combination of funds directed by GiveWell and those from other sources, however the breakdown is unknown at present." Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015. • 175. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 • 176. "Deworm the World is in preliminary discussions with a potential partner which is based in Karachi and does a lot of work on health, including supporting a hospital network and doing tuberculosis treatments in Pakistan and elsewhere. This organization works in several countries, has a large presence in Pakistan, seems to have a high capacity, and uses a research-based approach. It is interested in working with Deworm the World on deworming and met with Deworm the World recently to discuss prevalence surveys. Deworm the World will fund its own costs in Pakistan, including personnel and travel costs, but most of its funding will be sub-granted to the partner organization to support on-the-ground operations." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 7 • 177. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 • 178. "Funding timeline and potential sources Deworm the World would like to secure the funding needed for this program as soon as possible. Although it has enough funding to sustain its activities for another six months to a year, it cannot adequately plan the program (e.g., by scheduling trainings) without an assured source of implementation funding. Nepal differs from India in this way, because India has an ongoing deworming program that will continue as soon as the government gets the funds to execute it. If Deworm the World can only commit to providing technical assistance to Nepal, with no funds for implementation, the government will not agree to a program, so lack of funding becomes a constraint at an earlier stage. Deworm the World has committed to carrying out a diagnostic survey, which would involve members of its India team visiting Nepal to make an assessment. The cost of this trip is already covered. However, at some point afterward, Deworm the World would have to commit to a prevalence survey, and at a later point, after the survey results are in, it would commit to implementation. Both would require an assured source of funding, although the cost of the survey would be lower than that of implementation. As it does in India, Deworm the World could sign a letter of intent with the Nepalese government to get approval for the prevalence survey, then sign a memorandum of understanding (MoU) only once the survey is complete and has demonstrated a need for deworming. This would mitigate the risk of entering into a contract before prevalence is established. Deworm the World could also conduct its survey before the end of the year, so it can demonstrate to GiveWell that there is a need for the program by the time the giving season begins. Nominal grant from Good Ventures Deworm the World has entered into agreements in the past without having all the funding needed, and so can afford to be somewhat flexible. For instance, Good Ventures could provide some assistance outside of its normal giving season by giving Deworm the World a small grant (e.g.,$25,000–$30,000) up front, to ensure that it can cover travel costs and give it time to develop a more precise budget. Good Ventures could also sign a contract with Deworm the World stating that upon the signing of an MoU with the Nepalese government, or another similar milestone, Good Ventures will provide further funding in an amount to be determined. Although Deworm the World could cover the amount of the nominal grant itself from general funds, the combination of a nominal grant and the contract would help Deworm the World signal its level of commitment to the Nepalese government and get approval for the program. The contractual amount could be for one year’s worth of implementation funds or for a percentage of one year (e.g.,$500,000–$1 million), which would leave a significant gap to be filled by GiveWell-influenced donors. The nominal grant will not be needed until the Nepalese government contacts Deworm the World to set up further meetings. However, Deworm the World would like to have a better understanding of its funding situation going into these meetings. Other potential funders It is unlikely that other institutions will provide any funding for Deworm the World’s efforts in Nepal. As an example, one large funder is focused on deworming in countries that the World Health Organization has identified as particularly high-burden and high-population, which does not include Nepal. ....[Note: After this conversation, on April 25, Nepal suffered a major earthquake. As a result, Deworm the World’s plans to scale up deworming efforts in Nepal have been delayed indefinitely.]" GiveWell’s non-verbatim summary of a conversation with Grace Hollister and Alix Zwane on March 30, 2015, Pgs. 2-3. GiveWell’s non-verbatim summary of a conversation with Grace Hollister on April 8, 2015 • 179. • 180. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 • 181. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 • 182. • 183. • Our estimate of Deworm the World’s unrestricted funds over the past two years: • Pre-GiveWell funds Deworm the World had at least$0.4 million in unrestricted funding at the end of 2013. Deworm the World previously existed as a 501(c)3 and had an account that still held funds. As of October 2014, there was about $0.4 million available. Evidence Action 2015 draft budget. We are unsure if there were additional funds in that account at the end of 2013 that were spent down by October 2014. • GiveWell-influenced funds Since 2013, GiveWell has tracked approximately$3.7 million in donations to Deworm the World due to GiveWell’s influence. ($2.1 million in 2013,$1.1 million in 2014 (see our impact), and approximately $0.5 million in 2015 (as of October 2015, according to our internal records)). • Recent funds not influenced by GiveWell In 2014, Evidence Action received$1.7 million in unrestricted, retail donations not attributed to GiveWell, of which roughly 10% was designated for Deworm the World. In 2015, Evidence Action estimates that it is on track to receive about $3 million in unrestricted, retail donations including donations influenced by GiveWell. Since GiveWell has tracked$0.5 million in donations influenced by GiveWell in 2015, we estimate a total of roughly $4.2 in non-GiveWell influenced donations in 2014 and 2015. We estimate that 10% of that total is restricted to Deworm the World based on that ratio from 2014, or about$0.4 million. (GiveWell asked: "Additional insight, if any, into the source of the $1.7M retail donors to Evidence Action last year. Does Evidence Action expect similar donations this year?" Deworm the World answered: "Major donors and small online donors. 90% or so of that was not designated to Deworm the World. We believe we're on track to receive ~$3m this year.") Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015"
• Cash on hand As of October 2015, Deworm the World told us it had available funding of about $3.3 million. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 We are not including the$0.2 million in receivables in this figure.
• Allocations of cash on hand Deworm the World has allocated $1.1 million of unrestricted funding to future activities, including support intended for new programs in Nigeria and Pakistan. Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015 • Summary of total unrestricted funds, spent funds, and allocated funds over the past two years: • Estimated total unrestricted funds over the past two years =$0.4M + $3.7M +$0.4M = $4.5M • Estimated total spent unrestricted funds over the past two years =$4.5M - $3.3M =$1.2M
• Total allocated unrestricted funds = $1.1M • 184. Note that this post details more than$1.2 million in spending and allocated spending. Our impression is that Deworm the World has not spent all of the funds that this post describes as allocated.

• 185.
• 186.
• "[In Nigeria] Deworm the World would ideally like to make a 3-year commitment in Cross River to increase the chance of government approval, increase stability, enable Deworm the World to establish a partnership with the government, and take steps toward institutionalization of deworming programs.
There is some inherent risk in multi-year commitments, but one year is not always enough time to build a new program that runs effectively, and governments would be reluctant to work with Deworm the World if they were limited to one year. [...] One-year commitments can be costly for Deworm the World because governments typically expect that programs will continue past the first year, and it can be difficult to find funding." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 7
• "[In Pakistan] A multi-year funding commitment will be important to encourage the government to work with Deworm the World. Ms. Hollister would like to aim for a 5-year commitment and has had a 5-year budget created. While it is unlikely that Deworm the World will get an up-front 5-year funding commitment, it may be difficult to reach an agreement with the government without having funding for all 5 years. Deworm the World could begin with a 3-year commitment and indicate its intention to stay for 5 years and find funding to fill the gap." GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015, Pg 8
• 187.

"Two programs evaluated and incubated within Innovations for Poverty Action which are currently making a difference in the lives of millions of people in Africa and Asia – Dispensers for Safe Water and the Deworm the World Initiative - are transitioning to Evidence Action." Evidence Action website 2013, homepage.

GiveWell conducted a site visit to DSW in November 2012 and published notes. DSW 2012 GiveWell site visit

See GiveWell's review on water quality interventions.

• 188.

Grace Hollister, Deworm the World Director, email exchange with GiveWell, October 2015

• 189.
• 190.
• 191.