"Priority" programs for international aid: proven health interventions

As of December 2011, we still have a substantial amount of content that refers to the Disease Control Priorities Report estimates; we have not yet fully revised this content but have included disclaimers above it. At this point its estimates have shaped some of our strategic priorities in deciding which areas to explore (for example, our list of priority programs) but we do not rely on it for final recommendation decisions; we feel this use is appropriate. We initially identified promising programs using two publications (detailed below). We then investigated each program in detail. We consider a program to be "priority" (a definition that is important for our heuristics) if it is:

• "Low burden-of-proof." Some medical treatments have very strong evidence of basic effectiveness (i.e., evidence connecting successful adherence to a drug regime with recovery from tuberculosis). Rather than demonstrating long-term impact on mortality and other health outcomes, a charity may be able to make a substantial case for its impact simply by demonstrating successful delivery of proven treatments. See the "Conditions under which program is effective" column; programs requiring behavior change are generally (with one exception, noted below) not considered to lower the burden of proof enough to fall in this category.
• Reasonably cost-effective: in the range of $100 per disability-adjusted life-year (DALY) averted1, $50 per life-year significantly changed, or $1000 per life significantly changed. (Specifics of the type of life change associated with each intervention are included in the table.) More on the DALY metric here; more on our use of cost-effectiveness estimates here.

All of the programs we have identified as priority programs are in the area of health. For more information on the evidence for other types of programs, see our overviews of developing-world education and economic empowerment.

Priority programs

Disease	Program	Writeup	Conditions under which program is effective	Cost per DALY (best case)	Cost-effectiveness in life/life-year terms (best case)
Vaccine-preventable diseases	Expanding immunization coverage	Click here	Functional vaccines administered to at-risk populations	$7-$438, depending on region	$205-$3,540 per death averted, depending on region
Malaria	Distribution of insecticide-treated nets (ITNs)2	Click here	ITNs consistently used by at-risk people (infants and pregnant women)	$5-$31	$182-$1126 prevents one death and 320 less severe malaria episodes
Malaria	Drug treatment including artemisinin combination therapy (ACT)	Click here	Appropriate drug regimen adhered to by patients	In the range of $150	Range of $5450 per death (and 320 less severe malaria episodes) averted
Tuberculosis	Tuberculosis case finding and treatment	Click here	Appropriate drug regimen adhered to by patients	$5-$50	$150-$750 per death averted
Lymphatic filariasis	Mass drug administraiton to control lymphatic filariasis	Click here	Appropriate drugs administered to at-risk populations	$4.40-$29	$100 prevents 15-85 total years of lymphedema (swollen limbs) and 25-165 total years of hydrocele (swollen scrotum)
River blindness (onchocerciasis)	Mass drug administraiton to control river blindness	Click here	Appropriate drugs administered to at-risk populations	$7-$40	$100 prevents 2.5-14 years of blindness; 3.5-20 years of irritating skin disease; and 3-17 years of impaired vision
Schistosomiasis and soil-transmitted helminths	Combination deworming program (mass drug administration)	Click here	Appropriate drugs administered to at-risk populations	$3.36-$19	$3.50 per additional year of school attendance for students
Surgery-correctable conditions	Surgeries (missions and support of local surgeons)	Click here	Surgeries appropriately executed	$87-$300	$35-$1400 per surgery performed; impact of surgeries varies widely
HIV/AIDS	Prevention of mother-to-child transmission (PMTCT)	Click here	Appropriate drugs administered to at-risk populations	$6-$12	$150-$300 HIV infection averted
Malnutrition	Vitamin supplementation/fortification3	Writeups forthcoming	Forthcoming	Forthcoming	Forthcoming

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Non-priority programs we've investigated

Disease	Program	Writeup	Conditions under which program is effective	Cost per DALY (best case)	Cost-effectiveness in life/life-year terms (best case)
Diarrheal disease	Water infrastructure programs	Click here	Even clean water may not lead to significant health impact.	$159	~$5000 averts a death and ~2100 less severe diarrhea episodes
HIV/AIDS	Antiretroviral therapy	Click here	Appropriate drug regimen adhered to by patients	$350-$1,494	$129.50-$552.78 per year spent on ART, which partially but not fully alleviates AIDS symptoms
HIV/AIDS	Condom promotion and distribution	Click here	Condoms used consistently by at-risk individuals	$52-$112	$1020-$2240 per HIV infection averted
Maternal mortality	A variety of interventions	Click here	Varies by specific intervention	Unclear	Unclear effectiveness and cost-effectiveness
Trachoma	SAFE Strategy to control trachoma	Click here	Surgeries appropriately executed; appropriate antibiotics administered to population	Surgeries: $4-82. Antibiotics: ~$4,000. Other components: unknown.	Surgeries: $100 prevents 1-30 years of blindness and 1-30 years of low vision. Other components: highly costly or unknown.
Polio / guinea worm	Disease eradication programs	Click here	Vary by disease	Depends heavily on whether eradication achieved	Depends heavily on whether eradication achieved
Unwanted pregnancies	Family planning services4	Writeups forthcoming	Forthcoming	Forthcoming	Forthcoming

How we identified programs for investigation

We initially sought to identify promising programs by reviewing two sources:

• The Copenhagen Consensus, the only case we have seen of an independent panel of experts attempting to identify the most promising philanthropic investments (discussed more here)
• Millions Saved, the best collection we have found of large-scale, well-documented past successes in international aid (discussed more here)

If a program was both featured in one of these two publications and similar to a program focused on by one or more of the charities we reviewed, we generally conducted further investigation into the program. Details on which programs are featured in these two publications, which similar programs are focused on by the charities we've reviewed, and which programs we investigated are available here (XLS). Over time, our criteria have shifted and we now focus on identifying programs that "lower the burden of proof" as well as being reasonably cost-effective.

• 1. $100 per DALY is also the threshold used by the Millions Saved publication discussed here.
• 2. The track record of ITN distribution programs leaves some room for interpretation regarding the importance of ensuring use of the ITNs, vs. simply distributing them to at-risk populations. The track record of ITN distribution programs appears quite strong. We feel that evidence of use is necessary for full confidence (as the table above states), but we also believe that simply demonstrating delivery is enough to instill some confidence in impact. We have thus marked ITN distribution as a priority program.
• 3. Micronutrient supplementation/fortification appears to be a promising program type, but we have found very few charities focusing on it. We've found that these charities don't currently provide the information we would need to have confidence in them, regardless of how promising micronutrient supplementation/fortification is in general. This is why we have not yet created writeups on these interventions despite their meeting our basic criteria for writeups.
• 4. Based on preliminary investigation, family planning services appear to clearly require behavior change in order to be effective, and thus do not meet our revised criteria despite meeting our initial criteria. We still plan to investigate this program area (and associated charities) further, as a low priority.