Schistosomiasis Control Initiative – October 2013 Update | GiveWell

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Schistosomiasis Control Initiative – October 2013 Update

Summary

  • SCI has provided a fuller picture of its overall spending than we had seen in the past.
  • The majority of SCI's expenditure of unrestricted funds in the past year has been on starting a national treatment program in Ethiopia. The United Kingdom's Department for International Development (DFID) is now considering providing several years of funding for the program.
  • Other expenditures of unrestricted funds have included assisting new programs in three other countries, supplementing funding in countries funded by DFID, and general organization costs.
  • We have seen only limited recent monitoring and evaluation results. SCI has provided detailed monitoring plans for one country, giving us greater confidence that future monitoring will be similar to past monitoring for which we've seen detailed results.
  • We do not have detailed plans for how SCI will use additional unrestricted funding. However, we believe that SCI has used unrestricted funds in productive ways in the past and the overall need for funding in the countries in which it is working remains substantially greater than available funding.
  • A study of a past SCI program indicates that governments may contribute about 30% of the cost of the program (primarily through in-kind contributions, such as staff time). We have increased our estimates of SCI's cost-per-treatment by 30%.

Published: October 2013

For our SCI review, previous updates, and other SCI-related content, see our content summary page.

Process used for this update

For this update, we decided to focus on two main questions that we determined were most core to our understanding of SCI and its impact. We asked SCI these two questions in mid-2013:

  1. Can SCI share a more detailed and conceptual budget, including details of unrestricted spending? How much, in both monetary and non-monetary contributions, do other actors contribute to the deworming programs that SCI supports?
  2. Can SCI share recent monitoring and evaluation results, including technical details?

SCI provided responses to these questions in SCI report to GiveWell (September 2013) and other supporting documents listed below. The rest of this update summarizes and comments on what we have learned.

Full spending breakdown

We have previously reported that we have been unable to get a comprehensive picture of SCI's total spending. SCI has recently shared with us the most comprehensive spending breakdown we have seen to date. This breakdown increases our confidence in our understanding of how SCI works.

The spending breakdown covers SCI's work under a large, 5-year grant from the UK's Department for International Development (DFID), which comprises the majority of SCI's current funding, between the start of the project in 2010 and March 2013.1 SCI also provided a list of other current grants, which are restricted to (a) national deworming programs in Burundi and Rwanda, and (b) research projects.2 The remainder is unrestricted funding (discussed in the next section).

Under the DFID grant, SCI has spent about 48% on salaries and travel expenses for management and technical staff and 52% on program expenses (this excludes the cost of drugs, which are funded under a separate DFID grant).3 To further break down program expenses, SCI provided a budget for Malawi; program expenses in Malawi account for about 14% of all program expenses.4 The types of expenditures listed were in line with our understanding of SCI's role from past conversations (public and private) and our 2011 site visit, though at a higher level of detail.

SCI spending under DFID grant (October 2010 to March 2013)
In-country spending extrapolated from Malawi example5
Budget item % of spending Description
Technical personnel and travel 36% UK-based Technical Director, country programme managers, health economist, biostatistician, data manager; Ugandan-based capacity building advisor. Technical Assistance: Consultancy fees for expertise.
Management personnel and travel 12% UK-based SCI and Liverpool School of Tropical Medicine personnel undertaking project operational and financial management; project administration.
Program: Monitoring 14% Includes sentinel site monitoring for cohort studies, coverage validation surveys, and knowledge, attitudes and practices surveys.
Program: Mass drug administration costs 12% SCI provided a further breakdown of this category for two example countries. The components of this category overlap with other categories listed here (e.g. training and social mobilization). It isn't clear to us what distinguishes expenses in this category.
Program: Training 7% Includes training of trainers, training of teachers and health workers, and training materials.
Program: Supervision 5% No further information available.
Program: Office support and materials 5% Includes program office support, treatment registers and dose poles.
Program: Meetings 3% Includes pre- and post-program meetings for planning and evaluation.
Program: Social mobilization 3% No further information available.
Program: Drug transportation 3% No further information available.

Activities funded with unrestricted funds

In our last update in November 2012, we reported on how SCI had spent unrestricted funds between November 2011 (when GiveWell first recommended SCI) and October 2012. We reported (after checking this number with SCI) that as of October 2012, SCI held $2.65 million in unrestricted funds.6 As part of this update, we sought to understand SCI's use of unrestricted funds between October 2012 and August 2013. SCI told us that it had held $1.96 million in unrestricted funds as of October 1, 2012,7 about $660,000 less than we previously thought. We have assumed that we miscommunicated with SCI last year; one possibility is that the numbers we received included some restricted funds and we may not have fully excluded all restricted funds in our adjustment. We have used the more recent figure for this update.

Between October 2012 and August 2013, SCI received an additional $2.34 million, spent about $1.65 million, and committed to spend an additional $1.83 million (primarily between September 2013 and June 2014).8

As of August 31, 2013, SCI had about $2.65 million in unrestricted funds on hand, of which about $813,000 were uncommitted. In September 2013, GiveWell granted about $191,000 to SCI,9 bringing the uncommitted total to just over $1 million.10

Since November 2011, SCI has received $4.41 million in unrestricted funds,11 of which we can confidently attribute about $2.1 million to GiveWell's recommendation.12

Spending since October 2012

Since October 2012, SCI has spent unrestricted funds in the following ways:13

  • Supporting country programs not funded by DFID or other restricted funds ($1,374,000, 83% of funding):
    • Ethiopia ($929,000, 56% of spending): In addition, a donor has committed £100,000 per year for the next five years to Ethiopia. The first £100,000 has been spent and is included in the figures below. SCI's spending includes funds that have been transferred to Ethiopia and not yet spent by the country. In-country spending to date:
      • $324,000 to distribute 1.4 million combination deworming treatments and 6.8 million STH-only treatments to school-aged children in September 2013. The drugs for this distribution have been donated.14
      • $402,000 to conduct disease mapping of schistosomiasis and STHs. A further $351,000 will be spent by the end of 2013 to complete this mapping (these funds have already been transferred to Ethiopia).15
      • $50,000 to launch Ethopia's NTD Master Plan.16
    • Zimbabwe ($172,000, 10% of spending): SCI provided $158,000 in October 2012 for prevalence mapping and baseline data collection in Zimbabwe;17 we do not know how the remaining $14,000 was spent.
    • Senegal ($141,000, 9% of spending): SCI has conducted schistosomiasis prevalence mapping in Senegal.18
    • Mauritania ($62,000, 4% of spending): SCI has funded delivery costs for schistosomiasis treatment and training for nurses.19
    • Yemen ($58,000, 4% of spending): SCI provided assistance (likely technical assistance) to the second round of treatment in Yemen.20
    • Democratic Republic of the Congo and Madagascar ($13,000, 1% of spending): The programs in DRC and Madagascar are currently in exploratory phases. We do not have details on how this funding was spent.
  • Supplementing DFID funding in four countries ($90,000, 5% of spending): Most of this amount was spent in Cote D'Ivoire and Mozambique.21 The remainder was spent on programs in Liberia and Uganda. It is not clear to us why additional funding was required in these countries, but we have not inquired on this point because spending in DFID countries made up a small portion of overall unrestricted spending.
  • General organization costs ($163,000, 10% of spending): This includes salaries and travel expenses for general staff not supported by large grants. These staff work on investigating possible new country programs, supporting established programs, and fundraising.22
  • Other ($36,000, 2% of spending): SCI spent small sums on programs in Rwanda (primarily funded by the End Fund) and on "enhanced monitoring and evaluation."23

In total, of the funds SCI has spent since October 2012 (including funds transferred to Ethiopia that Ethiopia expects to spend in the coming months), about 64% was spent on prevalence mapping surveys, 20% on treatment, 10% on general organization costs, and 7% on other uses or unspecified uses.24

SCI has also continued work in Rwanda and Burundi with funds restricted to those countries.25 A large portion of the treatments in these two countries have been STH-only treatments, instead of the combination STH and schistosomiasis treatments that SCI has traditionally focused on, and some treatments have been provided to pre-school children and adults, instead of the school-aged children that SCI has traditionally focused on.26

Funding commitments

SCI has committed about $1.8 million in unrestricted funds to future activities. About 70% of this is committed to mapping and treatment in four countries in the next year: Mozambique, Ethiopia, Zimbabwe, and DRC. The remainder is primarily for research, including operational research in Burundi,27 monitoring and evaluation in Senegal for a USAID-funded program,28 and four projects in the category "Enhanced Monitoring and Evaluation," which includes funds to match a grant from the Gates Foundation to study cysticercosis in Malawi (details in footnote).29

Spending category Amount Expected date of expenditure
General organization costs $46,776 Oct 2013
Enhanced monitoring and evaluation $186,130 Sep - Dec 2013
Burundi – capacity building research $70,164 Sep 2013
DRC – mapping $93,552 Aug 2014
Ethiopia – mapping and treatment $346,922 Dec 2013
Mozambique – treatment $623,680 Mar 2014
Senegal – M&E support for USAID program $249,472 Over the next 4 years
Zimbabwe – mapping and treatment $218,288 Jun 2014

Has SCI used and committed unrestricted funds well?

Broadly, SCI has used or committed unrestricted funds in ways that seem likely to assist the goal of starting and expanding national deworming treatment programs. We do not, however, have a clear understanding of the specific impact of these funds on the number of children receiving treatment or on the quality of programs. A few observations that contribute to our thinking on the impact of unrestricted funds:

  1. DFID funding is restricted to eight specific countries. To date, SCI has largely used unrestricted funds in countries that are not funded by DFID, suggesting that it would not have been able to do this work without unrestricted funding.
  2. As discussed more below, DFID is now considering funding deworming programs in Ethiopia and DRC, where SCI previously used unrestricted funds to do program planning, prevalence mapping and regional treatment (Ethiopia) and some limited exploratory work (DRC). There is a possibility that unrestricted funds played an key role in allowing SCI to secure a large grant (if the grant is awarded) for these new programs (i.e. "leveraging" funds from other funders). We are interested in investigating this possibility further through conversations with DFID, but have not yet been able to do so.
  3. On the other hand, there is a possibility that other funders are leveraging SCI's unrestricted funds. For example, SCI plans to use unrestricted funds to provide monitoring and evaluation in Senegal for a USAID-funded program and to provide additional treatments in Mozambique, which is funded by DFID. USAID and DFID may have provided funding for these activities if SCI had not been able to use unrestricted funds to provide them.

Does SCI have room for more funding?

Unmet global need for schistosomiasis treatment

SCI reports that there is a substantial unmet need for schistosomiasis treatment in the countries in which it is working. According to one source that SCI sent us, only 26% of the need in these countries will be filled in 2013; 30 the treatment numbers in this source conflict with numbers from another source SCI sent us,31 though both sets of numbers suggest that total treatments are well below the World Health Organization's estimate of population at risk.

Need for unrestricted funds

While we generally have a good sense for where unrestricted funds are being spent, it remains somewhat unclear to us how unrestricted funds fit in with funds from other sources. In particular, SCI's largest source of funding is from DFID. In 2010, DFID awarded £10 million to SCI, plus £15 million to purchase drugs, to deliver 75 million combination deworming treatments. DFID is currently considering a second grant of £25 million to increase the total number of treatments to 200 million. SCI has proposed that the second grant be divided two-thirds to SCI and one-third for drugs. The proposal also includes an expansion of the program to include Ethiopia and DRC,32 countries where SCI previously used only unrestricted funds or grants from private donors.

This proposal seems to suggest that the expected cost of the program has declined by about 25%, allowing the program to cover more people and expand to an additional two countries. All of the savings is in the average cost of drugs, perhaps due in part to increased drug donations from Merck.33

2010 DFID award With proposed 2013 award
SCI budget £10 million £26.6 million
Drug budget £15 million £23.4 million
# of treatments 75 million 200 million
SCI cost per treatment £0.13 £0.13
Drug cost per treatment £0.20 £0.12
Total cost per treatment £0.33 £0.25

If SCI receives the additional grant from DFID, it would mean a significant increase in SCI's budget. Scaling up quickly can be challenging for many organizations due to limited staff capacity, ability to hire well and quickly, and other bottlenecks, but we believe this is somewhat less of a concern in SCI's case because (a) SCI has a track record of expanding programs relatively quickly after receiving large grants; (b) the grant would be largely used to expand existing country programs to more children (the only country out of the ten where SCI is not already funding a treatment program is DRC), which we would guess presents a clearer and less uncertain path to scale-up than starting in a new country.

At the same time, SCI has committed $624,000 in unrestricted funds to fund treatments in Mozambique, a DFID-funded country, in 2014 (see above). This raises the question of whether unrestricted funds are replacing funding that DFID would have provided otherwise, and what the true impact is of unrestricted funds on the margin.

Bottom line

We continue to recommend unrestricted funding to SCI because we believe that SCI has used unrestricted funds in productive ways in the past and because the overall need for funding in the countries in which it is working remains substantially greater than available funding.

Evaluation of previously funded activities

As in previous updates, at this point, we do not have a concrete sense of the impact of the programs that SCI has funded with the unrestricted funds it has received since November 2011. Partly this is because the full process from committing funding to executing programs to collecting data on them can take years; partly this is because SCI has shared only limited data with us.

SCI reports that it has collected baseline and at least one follow up round (following one or more rounds of treatment) of data from 8 of the 15 countries it is working in and baseline data only from an additional 5 countries.34 Prevalence mapping data only has been collected in the remaining two countries: Cote d'Ivoire and Ethiopia.35

We have not seen an update on what portion of SCI-funded treatments have been given to school-aged children versus other groups.

Liberia baseline and detailed methodology: We have seen baseline data and detailed methodology from Liberia only.36 We have not seen follow up data from any country. Judging from the Liberia example, SCI has and will collect data using the same methods that it used in earlier programs, which we have detailed in our full review of SCI.37

Ethiopia monitoring plans: We plan to pay particular attention to results in Ethiopia, where a large portion of SCI's unrestricted funds have been spent or will be spent in the next year. We have seen only a short description of SCI's monitoring plans for Ethiopia. These plans sound similar to SCI's plans for Liberia.38

Burundi coverage survey: In our November 2012 update on SCI, we reported that a treatment coverage survey had been conducted in Burundi in September 2012 and that we had not yet seen the results. Since then, SCI has shared some results; we have not seen detailed methodology or full results. SCI reports that 98% of children "swallowed ALB/PZQ";39 we are unsure whether this means that 98% of targeted children took drugs or whether 98% of those who received drugs took them. Because Burundi is not funded by unrestricted funds, we have not made it a priority to follow up on this question.

We also reported in our last update that SCI had conducted a “KAP” (knowledge, attitude, practice) survey in Yemen. We have not seen results from this survey.

Update to cost-per-treatment

Our cost-per-unit-delivered estimate for the Against Malaria Foundation (AMF), includes both costs incurred by AMF and costs incurred by other parties, such as local governments. Our estimate of cost-per-unit-delivered for SCI has not included this information, because of difficulties obtaining information on the costs incurred by other parties and because it was our understanding from SCI that the vast majority of costs of the program were contributed by SCI, while governments provided some in-kind assistance, such as office space.

We revisited the issue of costs incurred by other parties for this update. SCI pointed us to a paper, published in 2011, on the costs of a SCI-funded deworming program in four districts of Niger in 2004-2006.40 The study aimed to account for all costs of the program including costs funded by the government and non-financial costs such as the value of volunteers' time.41 The study is of a single country, looked at a program that was carried out 7-9 years ago, and the program may differ in some ways from current programs,42 but overall it is of high quality and provides us with a sense for the portion of resources contributed by SCI versus non-SCI parties.

Non-SCI costs were 18% of the total cost of the program and 33% of the cost of school-based deworming (the program also included community-based deworming).43 It is our understanding that in recent programs SCI has continued to do some community-based deworming but that most of its treatments are delivered through schools. Therefore, we conservatively use a figure of 30% to adjust our cost-per-treatment estimates.

To account for these costs, we do a simple adjustment by adding a government portion to our estimate of SCI’s costs that accounts for 30% of the total cost-per-treatment. Details are in this spreadsheet. In our analysis of SCI’s cost-per-treatment, we have not yet incorporated recent spending and treatments; we have instead used data from completed Gates Foundation and USAID grants and other grants that SCI received concurrently. To incorporate recent data, we would need recent estimates of donated drugs and drugs purchased with DFID funds. We have not yet sought out this data.

In short, we estimate:

  • The upper-bound on the cost-per-treatment during the period studied was $1.13. This analysis includes all grants received by January 2011 in "SCI's costs," with the exception of the DFID grant, which was awarded in late 2010.
  • Our best guess excludes a few more grants that, based on conversations with SCI, we believe can reasonably be excluded from the cost of treatment. This best guess is intended to be fairly conservative. Under these assumptions, we estimate the cost-per-treatment at $0.99.
  • A less conservative estimate, that attempts to subtract out research costs that SCI told us were above and beyond normal monitoring and evaluation costs, yields $0.72 per treatment.
  • An estimate based on the funding received from DFID and the number of treatments committed under that grant, yields an expected cost of additional treatments of $0.73, though (a) this does not include costs such as organizational overhead and (b) SCI notes that it is possible that this funding will be supplemented with other funding to achieve the treatment goals.

Note that SCI's USAID grants involved some treatments for diseases other than schistosomiasis and STHs; we do not include these treatments in the denominator of "cost per treatment" or the value of donated drugs in the numerator of "cost per treatment."

Sources

Document Source
Leslie et al. 2011 Source
SCI advisory board financial report (June 2013) Source
SCI advisory board strategic direction (June 2013) Source
SCI cost per treatment (October 2013) Source
SCI director's presentation (June 2013) Source
SCI financial details and summary (November 2011 to October 2012) Source
SCI financial update (September 2013) Source
SCI Liberia cohort study protocol Source
SCI presentation on Burundi, Rwanda, Senegal, and Mauritania (June 2013) Source
SCI report to Ethiopia donor (August 2013) Source
SCI report to GiveWell (September 2013) Source
SCI support of the distribution of donated drugs in Ethiopia (August 2013) Source