GiveWell aims to find the best giving opportunities we can and recommend them to donors. 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
Doctors 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:
In short, while we continue to hold a positive view of MSF, and expect to recommend them in future disaster-relief situations, we believe that our top charities are likely to be a better giving opportunity for donors who are not committed to the cause of disaster relief.
For the previous version of this page, see our 2009 review of MSF.
We considered MSF for an in-depth evaluation for several reasons:
Nevertheless, we have currently decided to not prioritize additional analysis of MSF for two reasons.
We 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.
One 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
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.
While 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 has stated that sharing more program reports would take excessive time and resources. The fact that we have not seen more program reports does not necessarily make MSF a less effective organization, but it makes evaluation of it more difficult (from our perspective) than evaluation of charities that are a completely "open book" from our perspective.
“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.”
"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.
MSF CRASH, "Homepage."
Examples of activities mentioned in Doctors Without Borders, “Activity Report (2011),” include:
"Every year, Doctors Without Borders/Médecins Sans Frontières (MSF) provides emergency medical care to millions of people caught in crises in more than 60 countries around the world. MSF provides assistance when catastrophic events — such as armed conflict, epidemics, malnutrition, or natural disasters — overwhelm local health systems. MSF also assists people who face discrimination or neglect from their local health systems or when populations are otherwise excluded from health care.
On any given day, more than 22,000 doctors, nurses, logisticians, water-and-sanitation experts, administrators, and other qualified professionals working with MSF can be found providing medical care around the world.
In 2009, MSF medical teams carried out more than 7.5 million outpatient consultations; delivered 110,000 babies; treated 1.1 million people for malaria; treated 200,000 severely and moderately malnourished children; provided 165,000 people living with HIV/AIDS with antiretroviral therapy; vaccinated 7.9 million people against meningitis; and conducted 50,000 surgeries." Doctors Without Borders, "How We Work."
Jennifer Tierney, email to GiveWell, September 6, 2012.
Doctors Without Borders, "OCG Response to Cholera in Haiti (October 2010–March Oosterloo and Djoumessi 2010.
van den Boogaard 2011.