About this pageGiveWell aims to find the best giving opportunities we can and recommend them to donors (why we recommend so few charities). We tend to put a lot of investigation into the organizations we find most promising, and de-prioritize others based on limited information. When we decide not to prioritize an organization, we try to create a brief writeup of our thoughts on that charity because we want to be as transparent as possible about our reasoning. The following write-up should be viewed in this context: it explains why we determined that (for the time being), we won't be prioritizing the organization in question as a potential top charity. This write-up should not be taken as a "negative rating" of the charity. Rather, it is our attempt to be as clear as possible about the process by which we came to our top recommendations.
Published: October 2012
SummaryDoctors Without Borders (Médecins Sans Frontières, MSF) is a large, international medical humanitarian organization, focused on providing care “to people whose survival is threatened by violence, neglect, or catastrophe.”1 We have a positive view of MSF and have recommended them for disaster-relief donations in the past. We considered evaluating MSF more thoroughly for a potential “top charity” recommendation, because we perceive them to be unusually transparent. However, we currently have decided to not prioritize additional analysis of MSF because:
- Although MSF is unusually transparent, it is not one of the most transparent organizations we have encountered.
- We believe that the overall cost-effectiveness of MSF's activities are unlikely to compare well with those of our top charities.
Table of Contents
Why we decided to consider MSFWe considered MSF for an in-depth evaluation for several reasons:
- In the aftermath of the 2011 Japan Earthquake/Tsunami, we recommended MSF to donors interested in supporting disaster relief based on its transparency about (a) its activities and spending in past disasters (see our report on the Haiti earthquake) and (b) need for funding.
- MSF allows meaningful and sometimes critical information about its activities to be public, something that we believe to be rare (and needed) in the nonprofit sector. For example:
- A report from its tuberculosis program in China which contained frank and negative conclusions on the program.2 In our experience, charities rarely publish evaluations that directly conclude a program has failed.
- In late 2011, a GiveWell staff member attended a public event at which MSF representatives frankly discussed weaknesses in a program they had recently run. Multiple GiveWell supporters have also told us that they have attended events MSF has convened where programs are critically evaluated.
- MSF provides additional information about its activities on a site called “MSF Crash.”3 We have scanned, though not closely analyzed this site.
Why we decided not to go further with our researchNevertheless, we have currently decided to not prioritize additional analysis of MSF for two reasons.
Types of activities implementedWe believe that there is a set of global health and nutrition interventions that provide particularly promising opportunities for donors because these interventions are relatively proven, cost-effective, and scalable. (We provide a more complete articulation of this view this blog post.) MSF’s activities include highly cost-effective interventions (such as providing basic vaccinations and distributing bednets), but also include activities with lower or poorly understood cost effectiveness (such as HIV treatment, outpatient health care and mental health care).4 We therefore would guess that our top charities -- which focus solely on programs that meet these criteria -- offer donors more impact for their donation than supporting MSF's activities as a whole.
Possibility of restricting funding to specific activitiesOne way to lessen the uncertainty around cost-effectiveness might be to restrict funding to specific activities known to be especially cost effective. MSF's answer to our question regarding the effects of restricting a donation is among the clearest and most informative we have seen. We asked MSF, "If we direct funding to MSF and request that the funding be used for vaccination, how will MSF's programs change (if at all)?" MSF replied:5
MSF creates its operational budgets based on operational needs and priorities. The operations/finance team then checks with the fundraising departments internationally that funding can be raised to meet the goals outlined. So far the goals have been achievable. 90% of the funds raised are unrestricted, so what that means is that funds are directed to priority medical projects first and foremost, not to specific project envelopes (such as vaccinations)… We can and will accept restricted funds for vaccinations, but a restricted gift for this project may not mean that we do 'more.' Our vaccination budget is huge, tens of millions of dollars every year. So, unless we were awarded an extraordinarily large grant (we are talking something like $50 million+ here) for a specific purpose like vaccines, we would not necessarily do 'more.' Even then we would have to determine if we have the human resources or medical tools available to do more than we already are doing.We appreciate the frankness of this reply, and take it as a positive sign about MSF's commitment to transparency.
TransparencyWhile MSF is more transparent than the vast majority of charities we have considered, it is not as transparent as the most transparent charities we have found. In particular, MSF has shared only limited examples of its monitoring and evaluation reports:
- MSF told us that it regularly conducts evaluations of its programs. We have only found a small number of publicly available evaluations of a limited set of MSF’s programs,6 which did not allow us to get a representative picture of the quality of MSF’s work. We do not know how these evaluations were selected for publication.
- MSF told us that program leaders in the field provide monthly progress updates to staff in operational centers in Europe. MSF shared one example report from 2004 and a report template with us.
- Doctors Without Borders. Activity report (2011) (PDF).
- Doctors Without Borders. China tuberculosis assistance project: End of evaluation report (2002) (PDF).
- Doctors Without Borders. History and principles. http://www.doctorswithoutborders.org/aboutus/ (accessed September 7, 2012). Archived by WebCite® at http://www.webcitation.org/6AVgvGNe8.
- Doctors Without Borders. How we work. http://www.doctorswithoutborders.org/aboutus/activities.cfm (accessed September 13, 2012). Archived by WebCite® at http://www.webcitation.org/6AeCkvWJm.
- Doctors Without Borders. OCG response to cholera in Haiti (October 2010–March 2011) (PDF).
- MSF CRASH. Homepage. http://www.msf-crash.org/en (accessed September 10, 2012). Archived by WebCite® at http://www.webcitation.org/6AZqznP21.
- Oosterloo, Jan, and Jean Claude B. Djoumessi. 2010. Knowledge, attitude and practice in the use of insecticide-treated mosquito nets distributed through antenatal and vaccination consultations in the “Cercle de Kangaba” region of Koulikoro, Mali (PDF). Brussels: MSF.
- Urrego, Zulma, et al. 2009. Evaluation of results from a single-session psychotherapeutic intervention in population affected by the Colombian internal armed conflict (PDF). MSF.
- van den Boogaard, Wilma, et al. 2011. Reducing malaria in Mail: Effective diagnostics and treatment are not enough (PDF). Brussels: MSF.
- 1. “Today, MSF provides independent, impartial assistance in more than 60 countries to people whose survival is threatened by violence, neglect, or catastrophe, primarily due to armed conflict, epidemics, malnutrition, exclusion from health care, or natural disasters. MSF provides independent, impartial assistance to those most in need. MSF also reserves the right to speak out to bring attention to neglected crises, challenge inadequacies or abuse of the aid system, and to advocate for improved medical treatments and protocols.” Doctors without Borders, “History and Principles.”
- 2. "MSF started the Nujiang TB assistance program in March 1999, after signing a Memorandum of understanding with the Nujiang Prefecture Health Bureau and the Public Health Bureau's in Fugong and Gongshan Counties. The Directly Observed Treatment Short-course (DOTS) WHO TB control guidelines were followed. After the initial set-up phase of nine months, enrollment of patients started in January 2000. In April 2000 low cure rates (< 60%) were registered which led to a mid-term evaluation of the program under supervision of Professor Zhao Fengzeng in August 2000. Professor Zhao and his team recommended increasing the patient detection rate, to strengthen DOTS and the laboratory work, to consolidate the training and (implicitly) to cooperate well with county governors and PHB directors. MSF wrote a response document to the evaluation report, revised the TB control guidelines, organized refresher training together with PHB and implemented new working methods from February 2001 onwards. In June 2001 the MSF-H Health Advisor visited the project and came to the conclusion that these changes had had little impact on the treatment outcomes. In August the TB advisor of MSF-H performed a technical evaluation and recommended to stop enrollment of patients." Doctors Without Borders, "China Tuberculosis Assistance Project: End of Evaluation Report (2002)," Pg 2.
- 3. MSF CRASH, "Homepage."
Examples of activities mentioned in Doctors Without Borders, “Activity Report (2011),” include:
- ” MSF admitted 2,500 new patients to Chagas treatment programmes in 2011.” Pg 10.
- ”MSF treated 130,800 people for cholera in 2011.” Pg 10.
- ”During serious outbreaks of disease or epidemics, MSF provides people with information on how the disease is transmitted and how to prevent it, what signs to look for, and what to do if someone becomes ill.” Pg 10.
- ”MSF provided care for 228,700 people living with HIV/AIDS, and antiretroviral treatment for 205,000 people in 2011.” Pg 10.
- ” MSF registered 7,600 new patients for kala azar treatment in 2011.” Pg 11.
- ” In endemic areas, MSF systematically distributes nets to pregnant women and children under the age of five, who are most vulnerable to severe malaria, and staff advise people on how to use the nets.” Pg 11.
- ”MSF treated 1,422,800 people for malaria in 2011.” Pg 11.
- ”MSF admitted 348,000 malnourished patients to nutrition programmes in 2011.” Pg 11.
- ”MSF treated 126,500 people for measles and vaccinated more than 5,000,000 people in 2011.” Pg 12.
- ”MSF treated 5,900 patients for meningitis and vaccinated 952,600 people against the disease in 2011.” Pg 12.
- ”MSF staff held 189,000 individual and group counselling sessions in 2011.” Pg 12.
- ”MSF distributed 225,500 relief kits in 2011.” Pg 12.
- ”MSF held more than 821,800 antenatal consultations in 2011.” Pg 12.
- ”MSF treated more than 14,900 patients for sexual violence-related injuries in 2011.” Pg 12.
- ”MSF admitted 1,400 new patients for sleeping sickness treatment in 2011.” Pg 13.
- ”MSF treated 30,700 people for tuberculosis, and 1,060 for MDR-TB, in 2011.” Pg 13.
- ”In countries where vaccination coverage is generally low, MSF strives to offer routine vaccinations for all children under five as part of its basic healthcare programme.” Pg 13.
- ”In 2011, MSF distributed more than 96,000,000 litres of safe water.” Pg 13.
- 5. Jennifer Tierney, email to GiveWell, September 6, 2012.
- 6. Doctors Without Borders, "OCG Response to Cholera in Haiti (October 2010–March Oosterloo and Djoumessi 2010. van den Boogaard 2011. Urrego 2009.