Sightsavers - Interim Review of Deworming Programs – April 2016 Version | GiveWell

# Sightsavers - Interim Review of Deworming Programs – April 2016 Version

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

Sightsavers is applying to be a top-rated charity. Here we discuss what we have learned so far and our major outstanding questions.

Published: April 2016

## Summary

What do they do? Sightsavers (sightsavers.org) conducts a variety of programs, primarily to cure and prevent blindness. Sightsavers has recently expanded its work to include support for deworming, one of our priority programs, as an addition to a number of its established neglected tropical disease (NTD) programs. This review focuses on Sightsavers' work on deworming. We know little about the role Sightsavers plays in its deworming programs. (more)

Does it work? We believe that there is relatively strong evidence for the positive impact of deworming. Sightsavers has told us that it conducts impact assessments and coverage surveys to determine whether its programs have reached a large proportion of children targeted, and shared a few examples with us. We have questions about the reliability and representativeness of these examples. (more)

What do you get for your dollar? Deworming treatments can be delivered very cost-effectively. We are uncertain about the cost-effectiveness of deworming programs that Sightsavers supports, but it is possible that they are competitive with our top charities. (more)

Is there room for more funding? Our information about Sightsavers' funding needs is now out of date. In 2015, Sightsavers was seeking $2.0 million for deworming activities for three years in Nigeria and Guinea-Bissau, and told us that it would like to scale up deworming in several additional countries. Overall, we expect that funding intended for deworming would be at least partially fungible with funding for other programs. We are uncertain how Sightsavers allocates its unrestricted funding; it had about$13.5 million in unrestricted reserves and in total expected to raise about $100 million in 2015. (more) What are GiveWell’s next steps? Sightsavers has successfully completed the first phase of our investigation process. We now plan to (a) make a$100,000 grant to Sightsavers (as part of our "top charity participation grants," funded by Good Ventures) and (b) continue our review process of Sightsavers to try to answer our remaining questions. We may also expand the scope of our investigation to include other programs (in particular, other NTD programs).

As we mentioned in a blog post on plans for work in 2015, one of our goals is to publish reviews of potential new top charities. We are considering Sightsavers' deworming programs because deworming is one of our priority programs. This page is an update on what we have learned so far in our investigation of Sightsavers.

## Our investigation process

As we stated in our 2015 plans, we are interested in finding additional top charities that work on deworming. Sightsavers was one of several charities we invited to apply to be considered for our top charity recommendation. To date, we have:

## What do they do?

Although Sightsavers conducts various programs, in this review we focus on Sightsavers' deworming programs and include some information on its work on other neglected tropical diseases (NTDs). Deworming (mass treatment for schistosomiasis and soil-transmitted helminthiasis (STH)) is one of our priority programs and is generally underfunded. We discuss deworming in detail in our intervention report on the topic.

Our understanding is that deworming is a small and relatively new part of Sightsavers' work. We have limited information on Sightsavers' role in the deworming programs it supports.

### How does deworming fit into Sightsavers' priorities?

#### Background

Sightsavers was founded in 1950 to treat eye conditions in developing countries,1 and began work on deworming programs in 2011.2 Sightsavers currently supports deworming programs in Cameroon, Democratic Republic of the Congo (DRC), Mali, Nigeria, Sierra Leone, and Tanzania.3

Deworming programs are part of Sightsavers’ integrated NTD programs, which are carried out by Sightsavers country office staff in partnership with national Ministries of Health. Sightsavers' first deworming program was in Nigeria.4 It has worked in Nigeria on various programs for over 40 years.5 Nigeria is the country for which Sightsavers has sent us the most detailed information about its deworming activities. In 2014, Sightsavers supported deworming in three states in Nigeria and made plans to expand its deworming work to a fourth state.6 Sightsavers has also received a grant from the Children's Investment Fund Foundation (CIFF) to conduct prevalence mapping of schistosomiasis and STH in 14 states in northern Nigeria.7

#### Spending overview

We have seen limited information on how Sightsavers has spent funds in the past.8 We have not seen information on what portion of Sightsavers' spending has supported NTD programs or, more specifically, deworming programs.

As of early 2015, Sightsavers expected to spend about $100 million in 2015,9 up from$84 million in 2014 and $75 million in 2013 (details in footnote.)10 Based on this, we guess that deworming represents a fairly small portion of Sightsavers' total spending (more).11 #### Number of treatments For 2014, Sightsavers reports that it supported the delivery of about 100 million NTD treatments. Of these, about 14 million (14%) were STH treatments and about 4 million (4%) were schistosomiasis treatments. These deworming treatments (18% of all treatments) were delivered in three countries: Cameroon, Nigeria, and Tanzania.12 We have not seen a breakdown of deworming treatments by country for other years. Sightsavers' NTD Treatments (millions), 2010 - 201413 NTD 2010 2011 2012 2013 2014 2010-2014 % of 2010-2014 lymphatic filariasis 17.6 34.1 30.5 44.2 44.9 171.3 41% onchocerciasis 23.1 24.4 32.2 34.3 29.4 143.4 34% STH N/A 14.3 12.9 12.6 14.3 54.0 13% trachoma 1.9 4.6 12.1 9.0 9.3 36.9 9% schistosomiasis N/A 2.1 4.1 3.4 4.4 14.1 3% Total NTD treatments 42.6 79.5 91.8 103.6 102.2 419.7 100% Sightsavers' Deworming Treatments (millions), 201414 Program STH Schistosomiasis Total Treatments Nigeria 0.4 1.2 1.6 Cameroon 4.9 0.3 5.2 Tanzania 9.0 2.9 11.9 Total 14.3 4.4 18.7 Sightsavers told us that it also supports deworming in Sierra Leone, Mali, and the DRC.15 No data for those programs is included in the treatment numbers we have seen, and we are uncertain whether Sightsavers’ support in these countries is similar to its work in Cameroon, Nigeria, and Tanzania. Sightsavers has provided us with further information on its NTD work in Nigeria; however, as shown above, deworming in Nigeria represents only about 9% of the deworming work that Sightsavers supported in 2014. The details we have received about NTD work in Nigeria include state-level breakdowns of NTD costs and outputs. The sum of state-level STH treatments matches the value reported above; however, the sum of state-level schistosomiasis treatments is only 0.6 million (half the number of treatments reported above). Additionally, the sum of 2014 NTD state-level costs is$313,000, only 13% of the $2.4 million (£1.4 million) reported for Nigeria's country-level NTD costs. We have not yet asked Sightsavers what accounts for these differences.16 ### How does Sightsavers select programs to support? Sightsavers told us that it selects where to support NTD programs based on the need for treatment (e.g. disease prevalence), the government's capacity, and Sightsavers' ability to build capacity in the area.17 We have not seen more details on this process. ### How is deworming conducted in programs that Sightsavers supports? We know little about the specifics of deworming program activities that Sightsavers supports within its integrated NTD programs. Our understanding is that many of the programs that Sightsavers supports use a combination of community-based and school-based treatments.18 For example, the coverage survey discussed below describes the evaluated deworming distribution as follows:19 "Praziquantel was distributed to school age children (5-15 years) in the schools using a measuring tape to determine the height and subsequently dosage. The dose given ranged from 1 to 5 tablets of the drug. The distribution of Mectizan, Albendazole, Zithromax and tetracycline was community based and house to house." ### What is Sightsavers' role in supporting deworming programs? We know little about the role Sightsavers plays in supporting deworming programs. Our understanding is that Sightsavers partners with the government and other organizations to support NTD programs.20 Sightsavers has partnered with SCI on programs in Tanzania, DRC, and other countries.21 ### Spending breakdown In May 2015, Sightsavers shared 2015-2017 budgets for NTD programs in Nigeria and Guinea-Bissau. Some notes about this data: • These are projections. We have not seen data on what activities funds have been spent on in the past. • We have not seen budgets for Sightsavers' NTD programs in other countries. We do not know what portion of Sightsavers' total spending on NTDs is covered by these two budgets. • We have not seen data on how Sightsavers has spent or plans to spend funds on deworming programs specifically. • We are uncertain whether these budgets are comprehensive of the full NTD programs in these countries; in particular, not all of Sightsavers' NTD activities in Nigeria are included in that country's budget.22 In Nigeria, Sightsavers plans to spend about$1.5 million to treat NTDs across four states from 2015-2017.23 Sightsavers is also seeking additional funding to deliver more deworming treatments in Nigeria over these three years; it would like to raise about $560,000 to scale up its activities in these four states, and about$670,000 to expand to a new state (Benue).24 The table below shows budgets for each of these scenarios.

Sightsavers' Nigeria NTD program, budget summary, 2015-201725

Activity Existing Plans Scale-up Plans Expansion Plans Total % Total
Training26 $623,826$176,786 $114,933$915,546 34%
Monitoring and evaluation27 $248,998$163,837 $198,906$611,740 23%
Information, education, and communication28 $277,977$106,648 $106,875$491,500 18%
Supplies29 $44,811$64,562 $88,807$198,181 7%
Drug transportation30 $96,668$51,296 $10,759$158,723 6%
Trichiasis camps31 $173,112$0 $0$173,112 6%
Salaries32 $0$0 $151,299$151,299 6%
Total $1,465,393$563,129 $671,578$2,700,101 100%

In Guinea-Bissau, Sightsavers currently treats onchocerciasis, lymphatic filariasis (LF), and trachoma. In May 2015, Sightsavers reported that in 2016 and 2017, it would like to scale up lymphatic filariasis activities (budgeted at $700,000 over two years) and start treating schistosomiasis and STH (budgeted at$670,000 over two years). The table below shows budgets for both existing plans and possible scale-up plans.

Sightsavers' Guinea-Bissau NTD program, budget summary, 2015-201733

Activity Existing Plans34 Scale-up Plans35 Total % Total
Monitoring and evaluation36 $247,476$210,121 $457,597 18% Drug collection and delivery37$353,046 $97,515$450,561 17%
Training38 $114,131$277,398 $391,529 15% Supplies39$168,011 $79,677$247,688 10%
Trichiasis camps40 $145,799$0 $145,799 6% Information, education, and communication41$58,572 $67,242$125,814 5%
Environmental improvement42 $68,812$0 $68,812 3% Salaries43$15,162 $0$15,162 1%
LF elimination scale up44 $0$700,000 $700,000 27% Total$1,171,010 $1,431,952$2,602,962 100%

## Does it work?

Mass administration of deworming drugs has been independently studied in rigorous trials and found to be effective.

We have limited evidence about whether Sightsavers' deworming programs have reached a large proportion of children targeted. In summary:

• Sightsavers reports that its programs have delivered tens of millions of deworming treatments. We are uncertain about the reliability of this data.
• Sightsavers has shared examples of its monitoring and evaluation (M&E) data from NTD programs with us. We do not know how consistently Sightsavers evaluates its deworming mass drug administrations (MDAs). We believe there are important limitations to the NTD evaluations that we have seen so far.
• We find it plausible that Sightsavers’ involvement may increase the probability that a deworming program starts up or scales up, but we have not seen evidence supporting this.

### Independent evidence of program effectiveness

This review focuses on Sightsavers' work to scale up mass combination deworming, which we discuss extensively on another page. There is a very strong case that mass deworming is effective in reducing infections. The evidence on the connection between reduced infections and positive quality-of-life impacts is less clear, but there is a fairly strong possibility that deworming is highly beneficial.

### What is the impact of the deworming programs that Sightsavers supports?

Sightsavers told us that it uses a variety of M&E tools to assess whether drugs are being delivered in NTD MDAs, including:45

• Government-reported statistics on treatment numbers and coverage
• Independent treatment coverage surveys
• Impact assessments at sentinel sites to measure changes in the prevalence and intensity of infections
• Spot checks of data aggregation

We are uncertain to what extent Sightsavers consistently uses these tools across all (or most) of the NTD MDAs it supports. To date, we have only asked Sightsavers to share M&E reports from countries where it would like to add or scale up deworming, rather than all of the studies it has completed. Sightsavers shared one coverage survey, three impact assessments (of onchocerciasis and trachoma programs), and a spot check report with us.

#### Reported treatment numbers and coverage data

Sightsavers reports that from 2011-2014 its programs delivered about 68 million deworming treatments across three programs in Cameroon, Nigeria, and Tanzania (see tables above). We do not have a clear understanding of the process for reporting this data. Sightsavers shared with us a coverage survey (discussed below) which found lower coverage rates than were reported by drug distributors.46

#### Coverage survey

Sightsavers shared with us a coverage survey that aimed to "validate the reported coverage of recent MDA campaigns (2014) for Onchocerciasis, Lymphatic Filariasis (LF), Schistosomiasis, Soil-transmitted Helminths (STH) and Trachoma in Zamfara State."47 The survey found that the coverage rates (the percentage of the population targeted who took the relevant drugs) were 71% for onchocerciasis and LF48 and 77% for trachoma49; it appears that the coverage rate was 68% for schistosomiasis,50 though there appears to be an inconsistency in how this is reported (details below). The survey identified several areas with very low coverage rates,51 which increases our confidence in the survey methods. For comparison, we discuss coverage surveys of SCI-supported deworming programs here.

Survey methodology is discussed in the survey report, including sample selection, interval between drug distribution and coverage survey (up to three months), and usage of drug samples and packaging to aid in recall (additional details in this footnote).52 Some issues with the drug distribution are discussed in the coverage survey report, including poor record keeping, drug diversion, selective treatment by community distributors, and overlap with Ramadan (additional details in this footnote).53 The survey was conducted prior to "mop-up" activities (attempts to treat those who were missed by the distribution); results from the survey were used to determine where mop-up activities were needed.54

Limitations of this study as evidence of Sightsavers' impact include:

• We have not seen details of the role Sightsavers had in supporting the MDAs evaluated in this survey.55 Sightsavers told us that it supported all NTD treatments in Zamfara (the state in which the survey was conducted), with funding from DFID.56
• There appear to be inconsistencies in schistosomiasis coverage data.57
• The survey was conducted in two local government areas (LGAs) that were purposefully selected to address potential programmatic concerns, rather than to be representative of the MDA in Zamfara as a whole.58
• The distribution of drugs for schistosomiasis was not yet fully completed at the time of the survey, so the survey may underestimate coverage for the schistosomiasis part of the MDA.59
• Survey respondents were asked to recall drugs taken up to three months prior.60
• The report does not explain how "don't know" responses were recorded or how often answers were given by a proxy on behalf of someone else.61

#### Impact assessments

Sightsavers shared three impact assessments that reported on the impact of MDAs on the prevalence of onchocerciasis or of trachoma. The studies suggest that past treatment programs have been successful, but the studies have a number of limitations, particularly because it is unclear whether these programs are representative of Sightsavers' work and whether changes can be attributed, at least in part, to Sightsavers' work.

• A 2008 impact assessment of long-term (1991-2008) treatment of onchocerciasis in Kaduna, Nigeria:62 Baseline data from 1987 indicated a median onchocerciasis prevalence of 52%. In 2008, after 15-17 years of treatment, onchocerciasis prevalence had dropped to 0% in all surveyed communities (none of the 3,703 individuals screened were infected).63 Limitations of the study include: (1) the difficulty of attributing the change to Sightsavers' work given the possibility that other concurrent work or improvements during the long interval between baseline and follow up may have impacted onchocerciasis prevalence, (2) selection of study areas based on criteria that may be correlated with larger changes in prevalence, and (3) a high non-participation rate among targeted respondents.64
• A 2015 impact assessment of long-term (1993-2015) treatment of onchocerciasis in fifteen villages in three districts of Uganda:65 District-level onchocerciasis prevalence ranged from 0.8% to 5.5% at the time of the assessment.66 The authors noted that baseline prevalence data (from 2007) was available for only two of the fifteen villages,67 but they did not provide the baseline data from the two villages in the report. The study concluded that the MDAs performed well.68 Other limitations of the study are discussed in this footnote.69
• An impact assessment on three rounds of trachoma treatment (2009-2012) in three regions of Guinea-Bissau:70 Sightsavers has told us that it has run a trachoma program in Guinea-Bissau since 2011; we are uncertain about the details of Sightsavers' trachoma support in these three regions, and about the role other organizations play in this program.71 This study concluded that after three years of MDA, trachoma prevalence in children 1-9 years of age was below 5% in all three regions, indicating that further treatment was not needed.72 The study did not include baseline data (or state how much prevalence dropped). However, Sightsavers has elsewhere reported what may be comparable 2005 baseline data for these three regions, which suggests that trachoma prevalence decreased from 20-30% to 1-5% in these regions.73

We have not seen impact assessments of Sightsavers' schistosomiasis or STH programs specifically.74

#### Spot check of data aggregation

Sightsavers told us that each year for a random sample of projects, it conducts spot checks on whether aggregated data (e.g. district-level data) matches original tallies for figures such as number of treatments delivered or people trained.75 Sightsavers has shared with us its spot check procedure and an example of a spot check report.76 This example reports finding essentially no error in the aggregation of reported number of people treated for onchocerciasis in DRC.77 We believe checks like this could help to uncover some data aggregation errors but may miss errors at other steps of the reporting process. We have not yet asked Sightsavers how often these spot checks uncover concerns, nor how Sightsavers handles any concerns.

### What impact does Sightsavers have on the programs it supports?

We are uncertain about the impact that Sightsavers has on the deworming programs that it supports. It seems plausible that Sightsavers increases the likelihood that deworming mass drug administrations occur, or improves their quality, but we have not seen direct evidence of this.

### Are there negative or offsetting impacts of the programs Sightsavers supports?

We have not looked closely into negative or offsetting impacts of Sightsavers' programs. We discuss possible negative or offsetting impacts of other deworming programs in our intervention report on deworming, and in previous reviews of deworming charities here and here. From the information we have reviewed, we do not have any significant concerns unique to Sightsavers.

## What do you get for your dollar?

Deworming is potentially very cost-effective.

We have not yet evaluated the cost-effectiveness of Sightsavers’ deworming programs in a way that is comparable to our top charities. In this section, we consider two factors that we expect are important to cost-effectiveness and relatively easy to understand: the cost per deworming treatment, and worm prevalence. We have limited data on these factors.

### What is the cost per deworming treatment?

Sightsavers shared with us estimates of the cost to deliver additional NTD treatments in Nigeria ($0.08-$0.10 in 2015-2017)78 and additional deworming treatments in Guinea-Bissau ($0.57-$0.92 in 2016-2017).79 We have not seen cost per treatment data (or sufficient information to calculate this) for the other countries where Sightsavers works. Sightsavers' estimates are not directly comparable to our cost per treatment estimates for other deworming charities we have reviewed because:

• For other charities, we have calculated the average cost of the program. Sightsavers' estimates are marginal costs: the additional cost to add treatments to existing NTD programs.
• Sightsavers' estimates are based off of projected, not actual, costs.
• We do not know whether Sightsavers’ program costs include costs covered by governments, or costs covered by other partner organizations. For example, Sightsavers notes that deworming scale up in Guinea-Bissau will be supported by the WHO country office; we are unsure whether this support is included in the reported costs.80
• The budget estimates we have seen do not include a portion of Sightsavers' central or regional costs.81
• These costs do not include the value of donated drugs.82

In addition, we have not vetted Sightsavers' estimates and have not yet asked Sightsavers why there is a significant difference in the estimates for Nigeria and Guinea-Bissau.

### What is the prevalence and intensity of schistosomiasis and STH where Sightsavers plans to support deworming?

In general, mass deworming programs treat everyone in a targeted demographic, regardless of whether each individual is infected (more). Because of this, the benefits (and therefore the cost-effectiveness) of a program are highly dependent on the baseline prevalence of worm infections. Sightsavers has shared prevalence data with us for areas in Nigeria and Guinea-Bissau where it has delivered or is considering delivering deworming treatments. This data indicates that prevalence of worm infections may be as high or almost as high as in the studies which constitute our key evidence about the impact of deworming (see below). However, we have some concerns about the data Sightsavers has provided:

• We do not know how this data was measured.
• The data for Guinea-Bissau is from 2005 and earlier.83 We do not know when the data for Nigeria was measured.84
• For some states in Nigeria, Sightsavers provided prevalence data with wide ranges which we do not know how to interpret.

For these reasons, we do not have high confidence in the prevalence data we have seen (data in footnote).85

## Is there room for more funding?

### Is funding a constraint to scaling up deworming programs?

Our information about Sightsavers' funding needs is now out of date because we took significantly longer than expected to publish our interim review. In 2015, Sightsavers had a funding gap of approximately $2.0 million for the scale up of deworming in Nigeria and Guinea-Bissau in 2015-2017.86 It could potentially use additional funding in other countries. Sightsavers has told us that there are benefits of coordinating NTD programs and (as and when funding permits) it is hoping to increasingly accommodate government requests for support for programs that coordinate treatment of several NTDs.87 Sightsavers has shared with us scale-up budgets for Nigeria and Guinea-Bissau, as detailed above. In Nigeria, Sightsavers projects costs of about$560,000 to scale up deworming in four states, and about $670,000 to expand to an additional state (Benue); a total of$1.2 million is expected to cover three years of scale-up work.88 Sightsavers has identified some sources of potential funding for programs in three of these states.89 In May 2015, the UK government committed an additional $2.6 million (£1.7 million) in funding towards the Northern Nigeria Integrated NTD Programme.90 Our understanding is that this is a distinct program from the proposed expansion represented in the Sightsavers budget we have reviewed.91 In Guinea-Bissau, Sightsavers projects costs of about$730,000 to scale up deworming over two years (in addition to about $700,000 for scaling up LF elimination activities).92 Sightsavers told us in May 2015 that it had not identified potential funders of for its deworming work in Guinea-Bissau.93 ### Are funds for deworming scale up fungible with Sightsavers' other funds? Funding to Sightsavers could (at least nominally) be restricted to deworming.94 However, it is possible that these funds would be fungible with other Sightsavers programs. In other words, receiving funds restricted to deworming might cause Sightsavers to reallocate other funds it has available, so that the additional funding would effectively expand programs other than deworming. #### Fungibility with unrestricted funding It seems likely that funding for deworming programs is at least partially fungible with Sightsavers’ unrestricted funding. Sightsavers' overall organizational budget for 2015 was about$100 million, and at the beginning of 2015 it held about $13.5 million in unrestricted funding reserves (about$4.4 million more than its target of about $9.1 million).95 Sightsavers has told us that it would consider using unrestricted funding for deworming, and also told us that if GiveWell provided funding restricted to deworming, Sightsavers might fund the other portions of an integrated NTD program with unrestricted funding.96 We do not have a good understanding of how Sightsavers allocates its unrestricted funding across the organization.97 It seems possible that Sightsavers could use unrestricted funding to fill its deworming funding gaps. It is also possible that additional funding for deworming would leverage funds from other funders or cause Sightsavers to allocate additional unrestricted funds to integrated NTD programs. For example, Sightsavers has told us that its proposed expansion into Benue, Nigeria, is conditional on receipt of enough funding for a full integrated NTD program in that state, and that it would try to raise that funding from other funders and might fill the gap with unrestricted funding.98 ### Will other sources fill the deworming funding gaps? We do not know whether any external funders are likely to fill some or all of the existing funding gaps for deworming programs. Sightsavers has received funding for support of NTD programs from several sources.99 As we have previously written, there appears to be a substantial unmet need for deworming globally. ## Major questions for further investigation We have spent significantly less time investigating Sightsavers and have substantially less insight into Sightsavers' activities, spending, and track record than we do for our current top charities. As such, we have a number of outstanding, high-level questions about its work supporting deworming. We may also explore similar questions about its other NTD programs. We hope to learn significantly more, answer many of these questions, and publish updates as our views evolve. • How does Sightsavers use information about worm prevalence and program capacity to decide which programs or regions to support? • What is Sightsavers' role in the deworming programs it supports? • How has Sightsavers spent funds in the past? We would like to see data on spending across (a) the organization overall, (b) NTD programs, and (c) deworming specifically. • In Sightsavers-supported regions, would deworming occur absent Sightsavers’ support? (E.g. supported by other organizations?) • Does Sightsavers have additional coverage and sentinel site studies it can share? Do these studies provide high-quality information on the impact of the programs studied? How representative are the studies of Sightsavers’ programs overall? • How does Sightsavers plan to monitor and evaluate its deworming programs in the future? • What is the average worm prevalence in areas where Sightsavers plans to support deworming, and how reliable is this data? • How are reported treatments counted and how reliable is this data? • What are the total costs of Sightsavers' deworming and/or NTD programs, including costs covered by other funders? • What are Sightsavers' total deworming and NTD funding gaps? • Was Sightsavers able to fill the funding gaps for deworming programs in Nigeria and Guinea-Bissau that it told us about in early 2015? • How does Sightsavers allocate unrestricted funding across the organization? Why hasn't it used unrestricted funding to fill its deworming funding gaps? ## Sources Document Source Bailey 2013 Source Checklist of documents sent Source DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014 Source GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017 Source GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017 Source GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015 Source GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015 Source Lakwo et al. 2015 Unpublished Oanda's historical exchange rates calculator Source Sightsavers Annual Report 2013 Source (archive) Sightsavers Annual Report 2014 Source (archive) Sightsavers Benue project overview Source Sightsavers brief on the school deworming project in Nigeria Source Sightsavers Guinea-Bissau NTD prevalence maps Source Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015 Source Sightsavers Nigeria deworming prevalence and estimated cost Source Sightsavers Nigeria NTD program budget accompaniment Source Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015 Source Sightsavers Nigeria NTD support map Source Sightsavers operational budget, 2015 Source Sightsavers organizational expenditure and outputs, 2014 Source Sightsavers quality standards manual, public excerpts Source Sightsavers spot check process and methodology Source Sightsavers spot check report, DRC Source Sightsavers website, Extra funding in Nigeria, May 2015 Source (archive) Sightsavers website, Our history Source (archive) Sightsavers, email to GiveWell, March 8, 2016 Unpublished Summary of documents Source Tekle et al. 2012 Source (archive) UN Country Profile: Guinea-Bissau Source (archive) • 1. "It was on 5 Jan 1950 that the doors of the British Empire Society for the Blind, as we were known back then, opened for the first time. [...] As well as being the decade of teddy boys, petticoats and rock and roll, the 1950s were when Sightsavers made our first groundbreaking achievement in the fight against avoidable blindness. In 1953 a survey was conducted by Dr Freddie Rodger in West Africa. It showed that the majority of blindness was actually preventable, and led to a pioneering disease control programme for onchocerciasis, also known as river blindness." Sightsavers website, Our history. • 2. • "The mandate of the organization and Royal Charter was changed in 2009 to accommodate the non-blinding NTDs. It was only in 2010 that Sightsavers recorded its first non-blinding neglected tropical disease treatment (LF, followed by schistosomiasis and STH in 2011) in its output statistics." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, p. 3. • See also the overview of treatments here, which shows deworming treatments recorded in 2011 but not 2010. • 3. • 4. "Nigeria is the country in which Sightsavers began its deworming programs and has been the flagship country for the organization’s integrated approach. Since 2011, when Nigeria’s deworming treatment program started in Zamfara and Sokoto states, Sightsavers has provided a total of about 14 million treatments per year for STH, and around 3 million treatments per year for schistosomiasis." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, p.6. • 5. "Sightsavers has been working in Nigeria for over 40 years, in partnership with the Ministry of Health. During this time we have supported eye care programs to address conditions amongst the population including cataract and glaucoma, human resource development programs to increase the number of practising ophthalmologists, cataract surgeons and eye health professionals, and widespread NTD programs focused on the elimination of five NTDs." Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 1. • 6. "Q1b. Results from recent years' activities, including # of people treated for each disease and amount spent" in Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, pp. 2-3, shows schistosomiasis and STH treatment in Sokoto state, Kwara state, Kogi state, and plans for a 2015 distribution in Kebbi state. • 7. Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 5, shows funding from the Children’s Investment Fund Foundation (CIFF) for mapping of schistosomiasis and STH in 14 states of northern Nigeria. • 8. Sightsavers' annual reports break down spending by country and by broad program area: "Health - Eye Care," "Health - Mectizan," "Education," "Social Inclusion," and "Policy and Research." Sightsavers Annual Report 2013, p. 40; see also Sightsavers Annual Report 2014, p. 64. • 9. • 10. • “2015 income is planned at £64m” (Sightsavers Annual Report 2014, p. 45), or approximately$97 million (converted to USD using the average historical exchange rate for January-May 2015 (1.5166 GBP/USD) as found on Oanda's historical exchange rates calculator). This is close to the projected income in the Sightsavers operational budget, 2015; however, it is still noticeably larger than total expenditures excluding gifts in kind in 2014 and 2013.
• The 2015 budget does not include gifts in kind. Sightsavers, email to GiveWell, March 8, 2016.
• Total expenditures excluding gifts in kind in previous years were $84 million (£51 million) in 2014 and$75 million (£47 million) in 2013. We have converted to USD using the average historical exchange rates for 2014 (1.6474 GBP/USD) and 2013 (1.5644 GBP/USD) as found on Oanda's historical exchange rates calculator. Summary from Sightsavers Annual Report 2014, p. 52 (calculations of the USD figures here are based on unrounded GBP figures in the source—not the rounded GBP figures in this table—multiplied by the applicable exchange rates from Oanda's historical exchange rates calculator):
Category 2014 2013
Charitable expenditures $280 million (£170 million)$296 million (£189 million)
Gifts in kind $221 million (£134 million)$238 million (£153 million)
Charitable expenditures (excluding gifts in kind) $59 million (£36 million)$58 million (£37 million)
Total expenditures $305 million (£185 million)$313 million (£200 million)
Total expenditures (excluding gifts in kind) $84 million (£51 million)$75 million (£48 million)
Charitable expenditures as % of total expenditures (all excluding gifts in kind) 70% 77%
• Sightsavers told us that these documents reflect expected growth in Sightsavers' income and expenditures in 2015, driven by increased fundraising and large grants. Sightsavers, email to GiveWell, March 8, 2016. See also Sightsavers Annual Report 2014, p. 45: "Sightsavers plans to maintain increased levels of fundraising investment in 2015 as a continuation of the strategy to grow the base of committed givers across all fundraising markets. The aim for 2015 is to grow voluntary funding by £5m. Growth is also expected in institutional funding within the year as several of the large NTD grants hit peak levels."
• Sightsavers told us that the figures for 2013, 2014, and 2015 are comparable. Sightsavers, email to GiveWell, March 8, 2016.
• 11.

In Nigeria, Sightsavers’ planned NTD budget (which includes deworming) is approximately $1.5 million over three years (2015-2017). Sightsavers' proposed expansion of NTD activities in Nigeria projects additional spending of$1.2 million over those three years. (GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017, p. 1. Planned work: "Budget - NTD work (planned)" sum of cells D45, E45, F45. Proposed expansion: "Budget - NTD work (additional)" cell F48 plus "Budget - Benue (additional)" cell F26.) We're unsure how the size of the Nigeria NTD program compares to NTD budgets in other countries in which Sightsavers works. Nigeria is "the country in which Sightsavers began its deworming programs and has been the flagship country for the organization’s integrated approach" (GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, p. 6). However, in 2014, only about 9% (1.6 million of 18.7 million) of the deworming treatments that Sightsavers supported were in Nigeria (see table in the following section).

• 12.

See Sightsavers organizational expenditure and outputs, 2014, "By Country" row 10 for "Total no. of NTD Treatments (NOT UNIQUE PEOPLE)", total in cell BY10. For STH treatments, see row 15, which has entries in cells I15, AS15, BI15, and a total in cell BY15. For schistosomiasis treatments, see row 16, which has entries in cells I16, AS16, BI16, and a total in cell BY16.

• 13.

2010-2013 data from Sightsavers Annual Report 2013, p. 12, and 2014 data from Sightsavers organizational expenditure and outputs, 2014, "By Country". For 2014 trachoma treatments we take the sum of cells BY11 and BY12, which matches the number of trachoma treatments reported in the Sightsavers Annual Report 2014, p. 19.

• 14.

Sightsavers organizational expenditure and outputs, 2014, "By Country". For STH treatments, see cells I15, AS15, and BI15. For schistosomiasis treatments, see cells I16, AS16, and BI16.

• 15.
• 16.

The cost of $2.4 million (£1.4 million) for Nigeria's NTD program in 2014 is reported in Sightsavers organizational expenditure and outputs, 2014, "Spend by theme and country", cell H27. We have converted to USD using the average historical exchange rates for 2014 (1.6474 GBP/USD) as found on Oanda's historical exchange rates calculator. Sightsavers' Deworming Treatments by State, Nigeria 2014 Nigerian State STH Schistosomiasis Cost (GBP) Cost (USD) Kebbi 0 0 £60,000$98,000
Kogi 87,000 65,000 £40,000 $66,000 Kwara 216,000 342,000 £47,000$78,000
Sokoto 86,000 169,000 £43,000 $71,000 Total 389,000 576,000 £190,000$313,000
• 17.
• 18.

"Many of Sightsavers’ MDA programs provide a hybrid of school-based treatment (in which drugs are administered at school sites) and community-based treatment (in which drug distributors travel from house to house in a community)." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, p. 7. In Guinea-Bissau, prospective STH treatments in 2015-2017 target "those reached through LF MDA and school based de-worming." GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Outputs". In Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 10, Sightsavers notes that "Non-enrolled school age children would be invited to visit schools on de-worming days, or would be reached through house to house activities."

• 19.
• 20.

"Because the scale of work in Africa is so great, Sightsavers works with other organizations and frequently manages a group of partners. Sightsavers also implements treatment in some areas, but it has developed particular expertise in managing partnerships and coalitions." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, p. 1.

• 21.

GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015: “Tanzania – Sightsavers works in partnership with SCI and others” (p. 6); “Sightsavers has a strong relationship with SCI, and the two work closely together on many programs and sometimes in the same countries. One such country is DRC…. Both organizations also have a presence in Côte d’Ivoire, where Sightsavers’ NTD adviser … works closely with SCI’s adviser. In both DRC and Côte d’Ivoire, the ministries of health usually hold an annual review and planning meetings, which Sightsavers will attend along with SCI. Sightsavers and SCI use this opportunity to discuss overall plans and budgeting for each country” (pp. 7-8).

• 22.

The budget in Nigeria includes only a subset of Sightsavers' NTD work in the country. Sightsavers, email to GiveWell, March 8, 2016. The budget includes the states of Kebbi, Kogi, Kwara, Sokoto, and Benue (GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017); Sightsavers is also involved in the DFID-funded UNITED project, which works in Katsina, Kano, Zamfara, Kaduna, and Niger, and the CIFF-funded prevalence mapping across northern Nigeria (Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 5). A map Sightsavers shared with us marks Sightsavers as active in Kebbi, Kogi, Kwara, Sokoto, Zamfara, and Kaduna. Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 3. Additionally, the budget for expansion to Benue appears to include staff costs, while the budgets for planned and scale-up work in Kebbi, Kogi, Kwara, and Sokoto do not appear to include staff costs. GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017. Budgets in Nigeria do not appear to include costs of drug distribution beyond the cost of collecting drugs from the Central Medical Store and delivering them “to the State and LGAs,” while budgets in Guinea-Bissau include additional line items related to drug distribution. GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017; GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017. We are uncertain whether the budget from Guinea-Bissau is comprehensive.

• 23.

GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017, "Budget - NTD work (planned)", sum of cells D45, E45, F45.

• 24.

GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017. Three-year scale-up cost is found in "Budget - NTD work (additional)", cell F48. Three-year cost of expansion to Benue is found in "Budget - Benue (additional)", cell F26.

• 25. GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017. Note that we have made some judgments in categorizing expenses to facilitate consolidating different budgets. In addition, calculations of the totals in this table are based on unrounded dollar figures in the source, so the sum of the rounded individual figures here may not equal the total in every case.
• 26. The Sightsavers budget lines which we have here categorized as "Training" are: GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 5, 16, 26, 36, labeled along the lines of "Conduct training of Health workers, Community Volunteers and School teachers"; "Budget - NTD work (additional)" rows 3, 13, 23, 33, labeled "Capacity Building for teachers and healthworkers"; and "Budget - Benue (additional)" row 10, labeled "Capacity Building of Health Staff, Community Volunteers and Teachers".
• 27. The Sightsavers budget lines which we have here categorized as "Monitoring and evaluation" are: GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 9-11, 20-22, 30-31, 40-42, labeled "To provide Supportive supervision, improve therapeutic (80%), geographic (100%) coverage and ensure quality data management", including the following ”Specific Objectives”: "To conduct Planning Meeting with relevant stakeholders for NTDs Programme Implementation", "Review programme implementation, collate outstanding data", "Monitoring and supervision", and "Treatment coverage Survey"; "Budget - NTD work (additional)" rows 7, 17, 27, 37, 43, labeled "Monitoring, Supervision and Evaluation of the activities" and "Monitoring and Supervision"; and "Budget - Benue (additional)" rows 7, 11-18, including activities related to planning and review meetings, supervision and monitoring, and surveys and assessments.
• 28. The Sightsavers budget lines which we have here categorized as "Information, education, and communication" are: GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 6-8, 17-19, 27-29, 37-39, labeled "To Improve awareness, community participation and treatment compliance", including the following “Specific Objectives”: "To Produce Information, Education and Communication Materials and Management Information system forms", "To hold sensitization meeting with District Heads to improve community support", and "Social Marketing Campaigns"; "Budget - NTD work (additional)" rows 5-6, 8, 15-16, 18, 25-26, 28, 35-36, 38, labeled "Mobilisation and Sensitization of Schools, School Education Boards and Parents", "Production of Information, Education and Communication (IEC) Materials", and "Production of Management Information System (MIS) forms"; and "Budget - Benue (additional)" rows 4-6, 8, labeled "Advocacy visits Key Policy makers", "Information Education and Communication (IEC) Production", "Management Information System (MIS) Production", and "Sensitisation and Mobilisation of Community leaders and community members". For scale-up and expansion plans, we categorize activities related to Management Information System (MIS) forms as part of information, education, and communication because Sightsavers categorizes them as such in "Budget - NTD work (planned)": "To Produce Information, Education and Communication Materials and Management Information system forms".
• 29. The Sightsavers budget lines which we have here categorized as "Supplies" are: GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 13, 23, 32, 43, with labels indicating costs of office supplies, laptops, and vehicles; "Budget - NTD work (additional)" rows 9, 19, 29, 39, 44, labeled "Production of Measuring Sticks" and "Vehicle Purchase for National coordination"; and "Budget - Benue (additional)" rows 20-23 and 25, including office costs and vehicles.
• 30. The Sightsavers budget lines which we have here categorized as "Drug transportation" are: GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 4, 15, 25, 35, labeled "To collect drugs from the Federal Central Medical Stores and deliver them to the State and LGAs in preparation of treatment" and “To conduct Planning Meeting with relevant stakeholders for NTDs Programme Implementation”; "Budget - NTD work (additional)" rows 4, 14, 24, 34, labeled "Drug Collection from FMOH Medical Store"; and "Budget - Benue (additional)" row 9, "Drugs Collection & Deliver from Federal Medical Store to States".
• 31. GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - NTD work (planned)" includes costs in rows 12 and 44, labeled "To provide support for Project and conduct camps for Lid Surgeons for TT cases".
• 32. The Sightsavers budget lines which we have here categorized as "Salaries" are: GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017: "Budget - Benue (additional)" rows 19 and 24: "Staff Cost" and "Programme Officer to be stationed in the state". Note that these budgets do not appear to include salary costs for existing or scale-up plans in states other than Benue.
• 33. GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017. Note, we have made some judgments in categorizing expenses to facilitate consolidating different budgets. In addition, calculations of the totals in this table are based on unrounded dollar figures in the source, so the sum of the rounded individual figures here may not equal the total in every case.
• 34. This column reports projected costs from two projects: the Guinea-Bissau onchocerciasis & LF elimination project and the Guinea-Bissau trachoma elimination project. The trachoma elimination project accounts for about 77% of these costs. ($905,000 compared to$266,000 for the onchocerciasis & LF elimination project.) See GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (planned)".
• 35. This column reports projected costs from the Guinea-Bissau Schistosomiasis/STH and LF scale-up projects and includes costs for national coordination & reporting. GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (additional)".
• 36. The Sightsavers budget lines which we have here categorized as "Monitoring and evaluation" are: GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 8-10, 14-17, 26-35, with labels indicating activities related to planning and review meetings, supervision and monitoring, surveys and evaluations, and data management; and "Budget - NTD work (additional)" rows 6, 10, 16, 18, 23, with labels indicating activities related to surveys, monitoring and evaluation, supervision, data management, review and planning meetings, and national monitoring and supervision.
• 37. The Sightsavers budget lines which we have here categorized as "Drug collection and delivery" are: GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 11 and 42, labeled "Mass drug distribution of ivermectin" and "mass drug distribution of zithromax" (we are uncertain about what costs are represented by these budget lines, and have assumed that they represent costs similar to the more detailed drug distribution line items in "Budget - NTD work (additional)"); and "Budget - NTD work (additional)" rows 7, 14, 17, 19, labeled "Drug Collection from MOH Medical Store", "Management of SE (Side-effects)", "Drug distribution (transport for CDD)", and "Drug distribution ( snack for children for PZQ taking)*".
• 38. The Sightsavers budget lines which we have here categorized as "Training" are: GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 6-7, 43, with labels indicating various types of training; and "Budget - NTD work (additional)" rows 4-5, with labels indicating training of teachers, health workers, and community drug distributors.
• 39. The Sightsavers budget lines which we have here categorized as "Supplies" are: GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 12-13, 23, 25, with labels indicating costs of equipment, vehicles, and consumable supplies; and "Budget - NTD work (additional)" rows 12-13, 15, 24, with labels indicating costs of measuring sticks, school/community registers, office supplies, and vehicles.
• 40. In GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (planned)", we have categorized rows 36-38 (within "Trichiasis operation camps and screenings") as non-education costs of trachiasis camps (education costs related to Trichiasis camps are included in the “Information, education, and communication” category in the next row of the table).
• 41. The Sightsavers budget lines which we have here categorized as "Information, education, and communication" are: GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017: "Budget - NTD work (planned)" rows 4-5, 24, 39-40, labeled "Education for Health, Awareness, Advocacy & Engagement", "Communications", "Community sensitization", and "IEC activities (interviews and songs on local radio & tv)"; and "Budget - NTD work (additional)" rows 8-9, 11, labeled "Mobilisation and Sensitization of Schools/communities, School Education Boards and Parents", "Production of Information, Education and Communication (IEC) Materials", and "Production of Management Information System (MIS) forms/Photocopies".
• 42. This category consists of GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (planned)" row 41, labeled "Rehabilitation of water points and construction of latrines".
• 43. The Sightsavers budget lines which we have here categorized as "Salaries" are: GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017: "Budget - NTD work (planned)" row 22, labeled "Salaries"; note that "Budget - NTD work (additional)" does not appear to include additional salary costs.
• 44. This category consists of GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (additional)" row 28, indicating the total costs for the scale up of LF elimination activities.
• 45.

GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, pp. 1-4. Sightsavers also shared a version of Sightsavers quality standards manual, public excerpts which included details of the metrics Sightsavers plans to track for its deworming programs. Sightsavers requested that we not share these sections publicly because they were not yet finalized.

• 46.

DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014

• The coverage survey protocol explains that during a distribution, "The dosage and quantity of drugs given is recorded on the register or tally sheet. This data is then used to calculate the population coverage of MDA, however there is often issues with the data including poor census data and inaccuracies in recording the data." (survey protocol, p. 3; p. 43 of pdf)
• "A comparison of the surveyed Oncho/LF data with reported coverage in Bugundu LGA shows that Asako, Danguro and Dogon daji had reported treatment coverages that were very close to the surveyed coverages obtained (Annex 3). This shows that a good reporting system is in place in these communities and the drug distributors should be commended. However, in Birnin Mallam, Kaikai, Ka Ida, Nahuce, Tazame, Yar Labe and Gada communities, reported coverages were higher than surveyed coverages." (p. 23)
• "Reported coverage for Zithromax was consistently much higher that obtained from survey in all communities. A survey coverage of 46.4% was obtained at Tungar Gobirawa, yet coverage from health system records indicated a 97% coverage. Again, this calls for close supervision of drug distributors as it also indicates poor recording keeping skills." (p. 24)
• "There was evidence of poor record keeping at all levels of programme implementation. It was most serious at the community level; and this unfortunately is the primary source of data for information collated at both LGA and State levels. Treatment records kept at community level were not properly entered neither was there evidence of census been carried out by the drug distributors. In Nahuce community only the 616 individuals treated were recorded in the treatment register and in Yar Labe the drug distributor could not make available the community treatment register for vetting. He claimed he had none. This community recorded 1.2% in the survey coverage, yet Local Government records should a high coverage of about 80%." (p. 28)
• 47.
• 48.

"Household surveys involving 2603 sample of eligible population showed that 71.3% received treatment...." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 14. See also Table 4 on p. 18.

• 49.

"77% of the respondents in Shinkafi reported that they swallowed the drugs...." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 22. See also Table 9 on p. 22.

• 50.

"[I]t is observed that the overall treatment coverage was 68.4% of the children eligible for treatment (ie ages 5-15 years) were treated." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 20. See also Table 7 on p. 21.

• 51.

“In Bungudu LGA where only 58.7% had received treatment as against WHO/APOC threshold standard of 75%, treatment coverage ranged from as low as 1.8% in Yar Labe to 98.6% in Hommawa community (Figure 2). This LGA was marred with partial treatments within communities and this accounts for the low coverages (Figure 2) recorded in Yar Labe (1.8%), Kortokoshi (2.2%), Birnin Mallam (16.2%), Gada (31.6%), Nahuce (44.5%) and Ka Ida (48.1%).” DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, pp. 14-15.

• 52.

Highlights of the survey methodology:

• The regions targeted by the coverage survey (two out of six local government areas (LGAs) covered in the distribution) were purposefully selected based on the following criteria. We are uncertain about further details of how the two LGAs were selected—e.g. if they were selected because post-MDA records indicated particularly low or particularly high coverage.
"The survey will be conducted in Shinkafi and Bungudu LGAs. These LGAs were selected for one or more of the following reasons:
• The post MDA records show particularly low or high coverage attained at the LGA level, or a large range of coverage attained at the community level - with for example a concerning number of communities with notably low coverage.
• There are suspected issues with the MDA records or census data that need to be verified e.g. poor population data or large population movements around the time of the MDA, discrepancies between the drug store records/logs and the community records or large variations in doses given year to year.
• Representation of the different combinations of drugs administered"

DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, survey protocol, p. 4 (p. 44 of the pdf).

• The sample size was determined based on several assumptions: "Assuming an estimated coverage of 80%, 95% confidence limit, a design effect (1) of 4, non-response of 12% and presuming that an average household size of eligible school [age] children of 5 (for Schistosomiasis distribution), a minimum sample size of 246 households was required to be sampled per LGA, but taking into account the design effect and the non-response a total of 1,101 individuals had to be sampled to get the required sample size. This way a minimum of 16 clusters, 14 households per cluster were surveyed in each LGA (Table 1)" DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, pp. 8-9.
• “The study teams were selected from individuals who were not involved in the MDA campaign. Each team was made up of a supervisor, two enumerators who worked closely with a local guide. […] For quality control purposes, there was a consultant designated as survey co-ordinator, with overall responsibility for the conduct of the survey and team supervisors. Each team had a supervisor who stayed with the interviewers all through the survey in the communities to ensure the quality of the data being collected.” DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 12.
• Selection of households to interview "followed a two-stage cluster sampling method, with the primary cluster (primary sampling unit), the village and the secondary cluster, the household." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 9. See also the further description on pp. 10-11, and the survey protocol on pp. 40-54 of the pdf.
• "Once in a household, the purpose and procedure of the survey explained and the household head was requested to provide verbal consent for his household to take part in the survey. Once consent was given, the names of all individuals who are permanently resident in the household were written down in the questionnaire (Annex 3) and the enumerator proceeded with collecting information as outlined in Annex 3. Where possible the eligible individuals were asked if they swallowed the drug and the person was not available, another household member or caregiver gave information on their behalf. Primary caregivers responded on behalf of children aged 1-10 years old, except where drugs were given in a school based distribution. In this case the children themselves were asked if they received the drugs at school. Samples of the drugs and the packages used during the recent MDA were shown to respondents to assist recall. The MDA schedule given in Annex 1 outlines the different times of the various drug distributions to avoid potential drug interactions. Therefore, the period between the survey and the distribution of the first set of drugs (for Onchocerciasis and Lymphatic Filariasis) was about 3 months, which was significantly longer than for Trachoma. The implications this might have on recall was an important consideration and so, in order to reduce errors introduced through recall bias, the survey team ensured drug samples (and the packaging of the drugs were given in packages) of the different drugs distributed were shown to each respondent during discussions. All individuals listed in the household were asked about each drug in question. If they are not eligible this was recorded on the questionnaire sheet either as not eligible or in cases where the intervention was not applicable (e.g Praziquantel was only administered to school) to the individual it was recorded as not applicable." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p 11. See also the questionnaire in Annex 3, pp. 33-34, which includes the wording of the questions used in the survey; for example: "Did you swallow the drugs for Schistosomiasis (show tablets) given to you at school in the recent MDA round in 2014?"
• 53.
• The coverage survey report indicates that the compensation plan for community drug distributors (CDDs) may not have been adequately communicated to the communities included in the MDA, and that CDDs were not compensated commensurate with their expectations, potentially leading to a lack of incentive to perform the job well. "Though there was no tool to quantify the extent of community contributions towards CDD incentive, drug distributors expressed dissatisfaction over none remuneration by the government. This calls for an intensive mobilisation exercise at community level, since communities are expected to provide incentive for drug distributors and not the Government. The State and Local NTD teams would need to inform community leaders and emphasise the responsibilities of communities during supervisory visits." (p. 27)
• Community drug distributors may have hoarded drugs or sold them to cattle farmers. "There were indications of drug hoarding by distributors because drug inventory showed that adequate drugs were supplied to communities where selective treatment where carried out. It is not clear what would have prompted the behaviour among distributors especially since drug supply was adequate. Community members believe the CDDs hoarded the drugs and since animal husbandry is a major economic activity in Zamfara State, the distributors could most likely be marketing the drugs to cattle farmers. The lack of incentive for these distributors by communities could promote the commercialisation of the drugs especially Mectizan." (p. 27); "The very low geographic and therapeutic coverage in Kortokoshi was due to the withdrawal of the drugs by the state NTD coordinator during the campaign for reasons associated with alleged report of drug divertion." (p. 14)
• Community drug distributors selectively treated households, possibly for political reasons. "Majority of the people who did not receive treatment attributed it to the inability of the CDDs to visit their households for drug distribution. Closer investigation revealed that these discordant voices came from communities where drug distributors operated 'selective treatment of households' Political affiliation could be the major undertone in this practice. For instance in Birnin Mallam one of the segments selected for the survey was completely ignored by the drug distributor." (p. 16)
• There are general indications that community drug distributors kept inadequate records of distributions, complicating evaluation of the distributions’ effectiveness. E.g. "The high treatment coverages reported by the health system is because the drug distributors do not keep proper records and they are the primary source of data for the health system." (p. 24) This is potentially due to ineffective training. "So, aside record keeping the drug distributors need to be re-trained before the next round of MDA." (p. 28)
• The schedule for drug distribution overlapped with Ramadan, and 27% of the population attended quranic schools, which were not targeted by the MDA. “The timing of distribution of drugs conflicted with the Ramadan fast and the closure of schools a result of the Ebola scare, accounting for the low treatment coverage for Praziquantel…. The survey revealed that 27 % of school aged children attended Qur’anic schools. These schools are out of the population targeted by the MDA for praziquantel and so the low coverage reported in the survey could be alluded to this. However, the State has a very proactive NTD team who had observed the skewed pattern in treatment of children with praziquantel and had devised strategy of identifying the quaranic schools for mop up treatment.” (pp. 27-28)
• 54.
• The coverage survey report indicates that the survey directed mop-up activities. "A list of the communities like Kotorkorshe, Nahuce, Birnin mallam, Yar Labe where either treatment was not given or where selective treatment of households was conducted were made available to the State team by the post MDA survey team for re-visitation and mop up exercise. Mop up exercises had commenced in the affected communities before the team left the field." (p. 28)
• There is some indication that previous recommendations to target qu’ranic schools had not been efficacious, but that some efforts to do so were under way. "The high proportion of children who claimed that the drug was not distributed in school is not surprising, as 27% of the eligible population children attended qu’ranic schools. These schools were not initially captured in the MDA programme. The team had suggested that the NTD team target qu’ranic schools in its MDA and efforts were being made by the state coordinator to reach out to children who attend qu’ranic schools during the coverage survey." (p. 20)
• 55.

Sightsavers did not include Zamfara on a list of Nigerian states where it delivers interventions, but later clarified that it does work in Zamfara.

• 56.
• 57.

DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014. The report's summary states that Praziquantel (PZQ) coverage rates were 46% in Bungudu and 54% in Shinkafi, the two LGAs studied (p. 4). The data table later in the report shows PZQ coverage rates were 68% in total, 55% in Bungudu and 88% in Shinkafi (p. 21). The report mentions that some PZQ treatment was delayed partly due to the MDA timing conflicting with Ramadan and schools shutting down due to the Ebola outbreak, and some PZQ treatment was still ongoing at the time of the coverage survey (p. 27). It is possible that the larger numbers include mop-up treatment that was done due to low initial coverage (p. 28).

• 58.

The regions targeted by the coverage survey (two out of six LGAs covered in the distribution) were purposefully selected based on the following criteria. We are uncertain about further details of how the two LGAs were selected—e.g. if they were selected because post-MDA records indicated particularly low or particularly high coverage.

"The survey will be conducted in Shinkafi and Bungudu LGAs. These LGAs were selected for one or more of the following reasons:
• The post MDA records show particularly low or high coverage attained at the LGA level, or a large range of coverage attained at the community level - with for example a concerning number of communities with notably low coverage.
• There are suspected issues with the MDA records or census data that need to be verified e.g. poor population data or large population movements around the time of the MDA, discrepancies between the drug store records/logs and the community records or large variations in doses given year to year.
• Representation of the different combinations of drugs administered"

DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014 protocol, p. 4 (p. 44 of the pdf).

• 59.

"The surveyed data for Praziquantel could not be compared health system records because treatment was still on-going in most communities and the records for the health system were not complete." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 5.

• 60.

"The MDA schedule given in Annex 1 outlines the different times of the various drug distributions to avoid potential drug interactions. Therefore, the period between the survey and the distribution of the first set of drugs (for Onchocerciasis and Lymphatic Filariasis) was about 3 months, which was significantly longer than for Trachoma. The implications this might have on recall was an important consideration and so, in order to reduce errors introduced through recall bias, the survey team ensured drug samples (and the packaging of the drugs were given in packages) of the different drugs distributed were shown to each respondent during discussions." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p 11.

• 61.
• For onchocerciasis and schistosomiasis, the data in the report shows that no respondents said that they "don't know" whether they received treatment. DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, pp. 20-21. This raises the possibility of a methodological issue in the survey implementation. For example, it is possible that the surveyors asked questions in a way that generated "Yes" or "No" answers (even when the respondent may have been uncertain) or did not properly record answers that were uncertain.
• The report indicates that in some cases a proxy answered in the place of a family member, but does not indicate the frequency of proxy responses. "Where possible the eligible individuals were asked if they swallowed the drug and the person was not available, another household member or caregiver gave information on their behalf. Primary caregivers responded on behalf of children aged 1-10 years old, except where drugs were given in a school based distribution. In this case the children themselves were asked if they received the drugs at school." DFID-UNITED Integrated Post MDA Coverage Survey Report, 2014, p. 11.
• 62.
• 63.

Tekle et al. 2012, p. 1.

• "Methods: In 2008, an epidemiological evaluation using skin snip parasitological diagnostic method was carried out in two onchocerciasis foci, in Birnin Gwari Local Government Area (LGA), and in the Kauru and Lere LGAs of Kaduna State, Nigeria. The survey was undertaken in 26 villages and examined 3,703 people above the age of one year. The result was compared with the baseline survey undertaken in 1987."
• "Results: The communities had received 15 to 17 years of ivermectin treatment with more than 75% reported coverage. For each surveyed community, comparable baseline data were available. Before treatment, the community prevalence of O. volvulus microfilaria in the skin ranged from 23.1% to 84.9%, with a median prevalence of 52.0%. After 15 to 17 years of treatment, the prevalence had fallen to 0% in all communities and all 3,703 examined individuals were skin snip negative."
• 64.
• The report does not appear to address confounding factors that could have also impacted prevalence. The treatment was carried out over a long time period: treatments began in 1991, the Community Directed Treatment with Ivermectin was introduced in 1997 (and Sightsavers became involved), and treatment continued for 15-17 years through 2008 (when this survey was conducted) (p. 2). Given this, it seems possible that other improvements (e.g. in economic and/or health systems or environment) could have played a role in the observed decline in infection.
• The surveyed communities were selected partially because they had the longest treatment periods and high coverage rates: "The two foci were selected for the following reasons: i) communities in these foci had pre-control epidemiological data; among the areas where large-scale ivermectin treatment was first introduced in Africa were these two foci in Kaduna in which treatment of a sample of the population started as part of a randomised controlled trial of ivermectin in 1988 and 1989, and where skin-snip surveys had been done in preparation for the trial [6,17]. ii) the foci included hyper-endemic villages, i.e. villages with a prevalence of microfilaridermia > 60% [15-17]; iii) the area was located along a river with known breeding sites of Simulium damnosum s.l., iv) the communities had had 15 - 17 years of annual treatment with ivermectin using the community-based programme since 1991, and subsequently through the community-directed treatment with ivermectin (CDTI) strategy from 1997 with more than 65% treatment coverage" (p. 3).
• "A limitation of the epidemiological surveys is that a third of the population in the selected communities did not participate in the skin-snip examination. Though some of these had valid reasons for non-participation (age < 1 year, illness, absence from the village etc), for a large majority the reasons for non-participation were not known. This high non-participation rate could have created a bias in the survey results if those who did not participate in the survey were also more likely not to have participated in ivermectin treatment" (p. 8).
• The study does not discuss the methods of the baseline survey.
• 65.
• 66.

“Results: […] The prevalence of onchocerciasis ranged from 0.8% to 5.5% while the CMFL ranged from 0.01 to 0.11 mf/ss.” Lakwo et al. 2015, p. 3.

• 67.

"One of the shortcomings is inadequate mf [microfilariae] prevalence data in this focus. Baseline data on mf prevalence is only available for Nyakabale and Kyeramya villages Hoima district which was collected in 2007. This information is very vital for decision making within the framework of elimination." Lakwo et al. 2015, p. 4.

• 68.

Lakwo et al. 2015, p. 3.

• "Conclusion: The performance of mass treatment in Budongo focus has been good since out of the 15 villages assessed only three of them have mf prevalence >5% and CMFL far below the threshold of >5 mf/s."
• "Results: A total of 2,728 people were examined, composing of 55% (1494/2728) females and 45% (1231/2728) males. The overall mf [microfilariae] prevalence was 2.6% (73/2728) and CMFL [Community Microfilaria Load] was 0.04 mf/s and varied significantly in the communities (p <0.05). The prevalence of onchocerciasis ranged from 0.8% to 5.5% while the CMFL ranged from 0.01 to 0.11 mf/ss [microfilariae per skin snip]. Infection was recorded more among the males (3.7%) compared to the females (1.7%). Mf prevalence was recorded highest in Masindi district (5.5%) and lowest in Hoima district (0.8%). The CMFL recorded was far <5 microfilariae per skin snip, i.e. recognized by WHO as threshold value in certifying the communities to be free of onchocerciasis as public health problem, thus, signifying the possibility of onchocerciasis elimination in the focus." See also discussion of results on pp. 15-17.
• 69.

Lakwo et al. 2015: A few observations:

• "Methods: Villages were selected in each of the districts following APOC procedures. Mobilizations were conducted by use of local authorities in each respective village. Questionnaires were administered among those who participated in the study. Skin snip was conducted in the selected communities (n=15) in Hoima, Buliisa and Masindi districts. Microfilaria prevalence and CMFL were calculated for each village" (p. 3). Participation in the prevalence study appears to have been opt-in and nonrandom. "Those eligible from 5 years and above from household were invited to participate in the survey. Participants were recruited consecutively from families until the required sample size was achieved" (p. 6). Participation rate or representativeness of the sample are not discussed apart from listing "Low turn up of participants in some of the villages in some districts" as a challenge (p. 17).
• The report does not appear to address confounding factors that could have impacted prevalence. The treatment was carried out over a long time period: treatment started in 1993, the Community Directed Treatment with Ivermectin was introduced in 1999, and an elimination policy was launched in 2007, with treatment presumably ongoing. “Mass treatment with ivermectin started in the 1993 with support from Sightsavers International. In 1999, the Community Directed Treatment with Ivermectin (CDTI) strategy was introduced to ensure sustainability of the program. When elimination policy was launched in 2007, bi-annual treatment and vector elimination strategies were adopted to enhance elimination” (p. 3). Given this, it seems possible that other improvements (e.g. in economic and/or health systems, or the environment) could have played a role in the reported improvements.
• 70.
• 71.
• "The Guinea-Bissau Programa Nacional de Saude Visuel(PNSV) , with support from Sightsavers International has conducted three rounds of azithromycin distribution between 2009-2012 -in the regions of Oio, Bafata and Farim(formerly part of Oio)." Bailey 2013, p. 1.
• "Sightsavers’ Guinea Bissau trachoma elimination program has run since 2011 and is working to ensure Guinea Bissau can be declared free of blinding trachoma by 2020. The project is supporting the implementation of the full SAFE strategy for trachoma elimination (Surgery to treat trichiasis, Antibiotics to treat infection, Facial cleanliness and Environmental improvement to interrupt disease transmission). Project activities include the distribution of the antibiotic treatment Zithromax, the training of trichiasis (TT) surgeons and the provision of TT surgeries, and the improvement of environmental sanitation in target areas through the construction of water points and latrines, alongside behaviour change activities to ensure their use.” Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 2.
• "Sightsavers is the key Ministry of Health partner for trachoma elimination activities in Guinea Bissau and is supporting the distribution of the antibiotic treatment Zithromax, the training of trichiasis (TT) surgeons and the provision of TT surgeries, and the improvement of environmental sanitation in target areas through the construction of water points and latrines, alongside behaviour change activities to ensure their use. The prevalence of trachoma in Guinea Bissau ranges between 10%-39.9%. (see Map 1)We are supporting the MoH to meet the WHO recommended target of reducing the prevalence of active trachoma (TF) to less than 5% among children aged 1-9 years, to reduce the prevalence of TT to less than 1 case per 1000 population above 15 years old, and to maintain (TT) recurrence to below 10%. The implementation of the SAFE strategy has resulted in the reduction of prevalence as shown in Table 2. Other NGO partners involved in implementing the SAFE strategy for trachoma elimination in Guinea Bissau include The International Trachoma Initiative (supporting Zithromax distribution). Sightsavers plans to support the writing of a trachoma Action Plan for Guinea Bissau in October 2015, in partnership with the International Trachoma Initiative and the London School of Hygiene and Tropical Medicine." Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 4.
• 72.
• “Following three rounds of MDA the estimated prevalence of TF in 1-9 year olds is below the 5% threshold in Oio, Bafata and Farim: 2.9% in Oio, 1.4% in Bafata and 4.2% in Farim. There seems to be no need for further distribution in these regions.” Bailey 2013, p. 3.
• Methodology is discussed in Bailey 2013, pp. 1-2, including that households absent at the time of the survey were excluded rather than revisited at a later time: "In the event that the 15 households did not contain 50 children, or that the selected households were unavailable reserves were used until 50 children had been examined" (p. 1). Diagnosis and grading of trachoma was performed by "ophthalmic nurses and cataract surgeons from the PNSV who had received training in the grading of trachoma according to the WHO simplified system, and had received training in the field in the study procedures" (p. 2).
• 73.

In Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 4, Sightsavers sent us a table of trachoma (TF) and trichiasis (TT) prevalence rates in 2005 compared to prevalence found in the 2013 impact study. 2005 data is available for eleven regions, including the three regions targeted by the 2013 study. We have not seen the methodology for the 2005 prevalence survey and we are unsure whether it is appropriately comparable to the 2013 survey.

Region Trachoma prevalence (2005) Trachoma prevalence (2013)
Bafata 28.7% 1.38%
Oio 21.7% 2.94%
Farim 21.7% 4.21%
• 74.
• It seems plausible to us that Sightsavers has not yet had time to complete this type of study on its deworming programs.
• Sightsavers told us that "Sightsavers follows recommended WHO guidelines with regard to the establishment of sentinel sites. For deworming programs sentinel sites are typically established at schools. Impact indicators track change in prevalence and intensity of infection (intensity is recognized as a more sensitive indicator of impact)." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, p. 2. It is possible that impact assessments conducted at sentinel sites (where programs may be higher quality) may not be representative of impact at other sites. Of the three impact assessments discussed above, the first (Tekle et al. 2012) explicitly selected sentinel sites for assessment. We are unsure whether the other two impact assessments took place at sentinel sites.
• 75.

"At least once a year for each project, Sightsavers’ monitoring and evaluation team performs a spot check, whereby headquarters requests initial data records from the program. Projects are randomly selected to provide this backup information for spot-checking. These constitute a separate tool from the quality standard assessment tools. Currently the data examined in a spot check include figures related to human resources and service delivery, such as treatment numbers and numbers of people trained. The check is not intended to provide proof of treatment, but to make sure that the numbers indicated for each community tally up to the reported district total." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, pp. 3-4.

• 76.
• 77.

Two instances of manual entry rather than formula summation resulted in a difference of 6 treatments on a total of almost 1.3 million. “For the majority of rows a formula is used to add the number of males and females who have received treatment but for some rows a number has been entered directly, this led to a miscalculated total on two occasions[…] the total treatments (column T) were 5 and 1 treatments out.” Sightsavers spot check report, DRC.

• 78.

GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017, sheet "Summary & comparison", Row 23 ("Total Impact: The number of additional children reached for NTD treatment per additional $1 donated"). Values are 10 for 2015, 11 for 2016, and 13 for 2017. We have converted dollars per treatment from the given treatments per dollar. • 79. GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, sheet "Summary & comparison", Row 17 ("Total impact: dollar cost per child treated"). Values are "n/a" for 2015 due to no deworming spending in that year, 0.92 for 2016, and 0.57 for 2017. • 80. • "2015 Planned schisto treatments are being supported by WHO Guinea Bissau country office" (cell F6). • "As noted in accompanying narrative document, de worming in 2015 will be supported by; • Sightsavers-supported LF MDA in two regions • WHO Guinea Bissau country office in two new regions" (cell F7). • 81. "This is direct project support costs for three multi-country projects." Sightsavers, email to GiveWell, March 8, 2016. • 82. • 83. Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015. "Table 4. showing STH prevalence rates, assessed in 2005", p. 6. "Table showing schistosomiasis prevalence rates, assessed in 2005", p. 8. • 84. See Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 4, which includes no information about the source of the prevalence data. • 85. Prevalence of schistosomiasis and STH in selected states in Nigeria Sightsavers provided us with the following prevalence data for the four Nigerian states where Sightsavers currently supports mass drug administrations, and for Benue State, where Sightsavers would like to begin support of deworming. (Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 4.) State Schistosomiasis STH Benue 1.4% - 24.8% 20.2% - 36.8% Kebbi 0.8% - 68.3% 3.8% - 22.0% Kogi 0.0% - 21.4% 16.2% - 39.0% Kwara 0.0% - 38.3% 8.3% - 57.0% Sokoto 3% - 56.1% 3.2% - 27.1% Prevalence of schistosomiasis and STH in Guinea-Bissau Sightsavers also provided prevalence data for Guinea-Bissau. The data is from 2003-2005. (Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, pp. 6, 8.) We have not seen more recent data and would guess that prevalence rates may have changed significantly since it was collected. • Sightsavers provided data for Guinea-Bissau subdivided into eleven regions: "In the Sightsavers supported regions of Bafata and Gabu, Albendazole treatment is currently given through the Ivermectin + Albendazole drug distribution package for LF, once per year though a house to house distribution platform using community volunteers. The prevalence of STH in Guinea Bissau ranges between 13% to 93% (See Map 2.) This once per year treatment is also in line with WHO guidelines for the treatment of STH in school age children, in areas where the baseline STH prevalence is ≥20% but <50%. Sightsavers is working towards scaling up once per year drug distribution to reach all endemic areas in the remaining 9 regions for the first time in 2016. Our partners in STH in Guinea Bissau are APOC, WHO and the World Food Programme. However, in areas where the baseline prevalence is ≥ 50% the WHO guideline is to treat all school age children twice per year. As seen in the table below, prevalence is higher than 50% in nearly all regions, highlighting a need to scale up drug distribution to twice per year in all these regions." Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 6. • We don't know whether there have been other deworming programs in the country since prevalence data was taken in 2003-2005. The World Health Organization and World Food Program planned to fund schistosomiasis treatments beginning in 2015, but that program has been delayed: "Mass drug administration has not taken place before, however the table below shows a clear need. It has been planned for funding from the World Health Organisation and World Food Programme to support initial MDA in Oio/Farim and Biombo regions in 2015, however, a fire which recently destroyed the drug supply has delayed 2015 activity. According to WHO guidelines, areas with a baseline disease prevalence of <10% should treat school age children twice during primary school year e.g. once on entry and once on exit." Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 8. Region Schistosomiasis STH Bafata 16% 31% Bijagos 0% 88% Biombo 5% 93% Bissau 0% 13% Bolama 0% 67% Cacheu 1% 64% Gabu 2% 49% Oio/Farim 5% 67% Quinara 4% 55% Sao Domingos 11% 63% Tombali 4% 65% Comparison to worm prevalence in key deworming studies For a table summarizing worm prevalence in key deworming studies, see our review of Deworm the World. Because we do not know how the data provided by Sightsavers was measured, we are not confident in the extent to which it is comparable to the worm prevalence data in the studies which constitute our key evidence for the impact of deworming. • 86. Sum of GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017, "Budget - NTD work (additional)" cell F48, "Budget - Benue (additional)" cell F26, and GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (additional)" cells E20, F20, E25, F25. • 87. • 88. GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017. Costs are reported in USD. Total 3-year cost of scale up in the four states where Sightsavers currently supports programs is found in "Budget - NTD work (additional)" cell F48. 3-year cost of expansion to Benue is found in "Budget - Benue (additional)" cell F26. • 89. • “Sokoto State: Potential funders: 2015-2018 pending proposal (c.50% of planned costs) with Isle of Man International Development Committee. Result due June 2015.” • “Kebbi State: Sightsavers work is not currently donor funded.” • “Kwara State: Potential funder: 2015 pending request for part-funding with Dickens Sanomi Foundation.” • “Kogi State: Existing funder: AG Leventis Foundation, c.$50,000.”
• 90.

"The amount of people Sightsavers can protect against neglected tropical diseases (NTDs) in Nigeria is set to expand, after the UK government announced it would add £1.7 million in funding towards the Northern Nigeria Integrated NTD Programme." Sightsavers website, Extra funding in Nigeria, May 2015. We have converted to USD using the average exchange rate (1.5166 GBP/USD) for January 2015 through May 2015, as reported on Oanda's historical exchange rates calculator.

• 91.
• 92.

GiveWell analysis of Sightsavers Guinea-Bissau NTD program budget, 2015-2017, "Budget - NTD work (additional)". Cells E20 and F20 project about $667,000 for "Guinea Bissau Schisto / STH scale up budget"; cells E25 and F25 project an additional$65,000 for "National Coordination & Reporting" to support this scale up. Additionally, Sightsavers projects costs of about $700,000 to scale up LF elimination activities over the same two years (sum of cells E28 and F28). • 93. • "2015 existing and potential Sightsavers’ funders include: • Sightsavers Guinea Bissau trachoma elimination project is c.50% funded by Isle of Man International Development Committee. • Sightsavers Guinea Bissau onchocerciasis and LF elimination project has a proposal for funding activity in two regions between 2015-2019 pending with OPEC, result due in July 2015.” • “2015 existing external funders include: • The WHO and the World Food Programme are supporting STH and Schisto work in the following areas: Farim/ Oio and Biombo • the Spanish NGO Igreja Evangelica is supporting activity" • 94. "Sightsavers would see no problem, either programmatic or financial, if GiveWell were to recommend funding restricted to deworming programs only." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, p. 6. • 95. "Reserves Policy Sightsavers ensures the continuity of its programs through active use of its general reserves whilst ensuring these remain at agreed target levels. It is our policy to retain sufficient reserves to safeguard ongoing commitments and operations. The current reserves policy is to maintain a level of unrestricted reserves of £6.0 million, +/- £1.5 million. Total fund balances were £11.2 million at the end of 2014, of which, £9.9 million is unrestricted. This includes designated funds of £1.9 million, of which £0.9 million is cash held overseas. The baseline to compare to the reserves target is calculated by subtracting the designated funds from the unrestricted funds and adding back the cash held overseas, which is available for use. This gives a reserves figure of £8.9 million. This level of reserves is above policy guidelines. The trustees believe this level of reserves is acceptable given the continued requirement for additional investment in fundraising and plans for ongoing programmatic expansion in 2015 and beyond." Sightsavers operational budget, 2015; total expenditures for 2015 are estimated at £64.5 million. We have converted to USD using the average exchange rate (1.5166 GBP/USD) for January 2015 through May 2015, as reported on Oanda's historical exchange rates calculator. • 96. • 97. Our understanding of how Sightsavers allocates its unrestricted funding is based on two conversations with Sightsavers staff: • 98. "Sightsavers wants enough funding to implement fully integrated programs in other states in Nigeria, as mapping reveals that these areas need a complete package of NTD treatment. Expansion into Benué state, for example, will require an integrated program to ensure that Sightsavers can treat all NTDs effectively there. […] If GiveWell were to provide deworming-restricted funding in Benué state or any other area Sightsavers is considering entering, Sightsavers would only be able to use that funding if it also received matching funds to carry out the rest of the NTD program there. Sightsavers’ budget shows that there are many expenses that apply to all of its programs and cannot be isolated to deworming only. If GiveWell wanted to focus specifically on deworming, Sightsavers would look for other donors that wanted to fund the onchocerciasis and trachoma work. It might also try to make up the remainder of the program budget with unrestricted funding. This would be most difficult in Nigeria, where Sightsavers would have to fund a whole integrated program itself if it couldn’t find a matching donor, or possibly give up on the program entirely." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, p. 6. • 99. For example: • Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 5. • "Sokoto State: Potential funders: 2015-2018 pending proposal (c.50% of planned costs) with Isle of Man International Development Committee. Result due June 2015." • "Kwara State: Potential funder: 2015 pending request for part-funding with Dickens Sanomi Foundation." It is unclear to us whether this request is for part-funding for planned activities, scale-up activities, or both. • "Kogi State: Existing funder: AG Leventis Foundation, c.$50,000." For comparison, the cost of planned activities in Kogi State is about $320,000 over three years, and the cost of scale up is about$130,000 over three years. (GiveWell analysis of Sightsavers Nigeria NTD program budget, 2015-2017, "Budget - NTD work (planned)" cells D14+E14+F14 and "Budget - NTD work (additional)" cell F20.)
• Through the United project, DFID is funding integrated NTDs in the Nigerian states of Kaduna, Kano, Katsina, Niger, and Zamfara. Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 5; and Sightsavers website, Extra funding in Nigeria, May 2015 (“The Department for International Development (DFID) agreed the extra budget in March 2015, allowing Sightsavers to expand the project from three to five states (Zamfara, Katsina, Kano, Niger, Kaduna) and to reach 27 million people with 112 million treatments.”). DFID also supports trachoma mapping. “Sightsavers also coordinates the Global Trachoma Mapping Project (GTMP), funded by the U.K.’s Department for International Development (DFID), which has supported a great deal of trachoma mapping.” GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, pp. 1-2.
• The Children’s Investment Fund Foundation (CIFF) is funding mapping of schistosomiasis and STH in northern Nigeria. Sightsavers Nigeria NTD program information prepared for GiveWell, May 2015, p. 5.
• Sightsavers Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 10.
• "Sightsavers Guinea Bissau trachoma elimination project is c.50% funded by Isle of Man International Development Committee [between 2013-2015]."
• "Sightsavers Guinea Bissau onchocerciasis and LF elimination project has a proposal for funding activity in two regions between 2015-2019 pending with OPEC, result due in July 2015."
• "2015 existing external funders include:
• The WHO and the World Food Programme are supporting STH and Schisto work in the following areas: Farim/ Oio and Biombo
• the Spanish NGO Igreja Evangelica is supporting activity"
• Sightsavers does not list existing or potential funders for its potential scale up of deworming in Guinea-Bissau.