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### Revisiting the evidence on malaria eradication in the Americas

Fri, 12/29/2017 - 09:14
Summary
• Two of GiveWell’s top charities fight malaria in sub-Saharan Africa.
• GiveWell’s valuations of these charities place some weight on research by Hoyt Bleakley on the impacts of malaria eradication efforts in the American South in the 1920s and in Brazil, Colombia, and Mexico in the 1950s.
• I reviewed the Bleakley study and mostly support its key findings: the campaigns to eradicate malaria from Brazil, Colombia, and Mexico, and perhaps the American South as well, were followed by accelerated income gains for people whose childhood exposure to the disease was reduced. The timing of these events is compatible with the theory that rolling back malaria increased prosperity. Full write-up here.
Introduction

I blogged three weeks ago about having reviewed and reanalyzed Hoyt Bleakley’s study of the effort in the 1910s to rid the American South of hookworm disease (not malaria). That study, published in 2007, seems to show that the children who benefited from the campaign attended school more and went on to earn more as adults.

For GiveWell, Bleakley’s 2010 study is to malaria parasites as his 2007 study is to intestinal worms. Like the 2007 paper, the 2010 one looks back at large-scale, 20th-century eradication campaigns in order to estimate impacts on schooling and adult income. It too produces encouraging results. And it has influenced GiveWell’s recommendations of certain charities—the Against Malaria Foundation and Malaria Consortium’s seasonal malaria chemoprevention program.

Because GiveWell had already invested in replicating and reanalyzing Bleakley (2007), and because the two papers overlap in data and method, I decided to do the same for Bleakley (2010). And here the parallel between the two papers breaks down: having run the evidence through my analytical sieve, my confidence that eradicating malaria boosted income is substantially higher than my confidence that eradicating hookworm did. I’m a bit less sure that it did so in the United States than in Brazil, Colombia, and Mexico; but the Latin American experience is probably more relevant for the places in which our recommended charities work.

This post will walk through the results. For details, see the new working paper. Because my malaria reanalysis shares so much with the hookworm one, I have written this post as if you read the last one. If you haven’t, please do that now.

How the malaria analysis differs from the hookworm one

Having just emphasized the commonality between Bleakley’s hookworm and malaria eradication studies—and my reanalyses thereof—in order to orient you, I should explain how the two differ:

• The hookworm study is set exclusively in the American South, while the malaria study looks at efforts in four countries. In the United States in the 1920s, no doubt inspired by the previous decade’s success against hookworm, the Rockefeller Foundation and the U.S. Public Health Service promoted a large-scale program to drain swamps and spray larvicides, which cut malaria mortality in the South by 60%. Then in the 1950s, with the discovery of DDT, the World Health Organization led a worldwide campaign against the disease. Partly because of data availability, Bleakley (2010) studies the consequences in Brazil, Colombia, and Mexico.1Bleakley (2010) also chose these countries because they had malarial and non-malarial regions, allowing comparisons. See Bleakley (2010), note 6. For sample maps see this. jQuery("#footnote_plugin_tooltip_1").tooltip({ tip: "#footnote_plugin_tooltip_text_1", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });
• Where the hookworm study groups data two ways—first by place of residence to study short-term effects, then by place of birth to study long-term effects—the malaria study does only the latter.
• I pre-registered my analysis plan for the malaria study with the Open Science Framework and hewed to it. While I did not allow the plan to bind my actions, it serves to disclose which analytical tactics I settled on before I touched the data and could know what results they would produce.2Actually we registered a plan for the hookworm study too, but the malaria plan was better informed—and better followed—precisely because it came on the heels of the similar hookworm reanalysis. For brevity, I skipped this theme in my blog post. I did write about it in the hookworm working paper. jQuery("#footnote_plugin_tooltip_2").tooltip({ tip: "#footnote_plugin_tooltip_text_2", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });
• The Bleakley malaria paper appeared in a journal published by the American Economic Association (AEA), which requires its authors to post data and computer code on the AEA website. This aided replication and reanalysis. Unfortunately, as appears to be the norm among AEA journals, the Bleakley (2010) data and code only reproduce the paper’s tables, not the graphs that in this case I see as central.
• For Brazil, Colombia, and Mexico, I mostly relied on that publicly posted data for the crucial information on which regions within a country had the most malaria, rather than trying to construct those variables from old maps and books in Spanish and Portuguese. I also relied on the public data for geographic control variables. I think it can be valuable to go back to primary sources, but for the time being at least, this step looked too time-consuming. I did update and expand the Latin outcome data, on such things as literacy and income, because it is already conveniently digitized in IPUMS International. And I reconstructed all the U.S. data from primary sources, simply by copying what we assembled for the hookworm reanalysis.
Results

In showing you what I found, I’ll follow nearly the same narrative as in my previous post’s section on the “long-term impact on earnings.” To start, here is a key graph from the Bleakley (2010) paper—or really four graphs. In each country’s graph, as with the hookworm graphs, each dot shows the association between historical disease burden in a state (or municipio) and the average income in adulthood of people born there in a given year. In all but Colombia, the leftmost dots line up with the negative range on the vertical axis, meaning that, initially, coming from a historically malarial area stunted one’s income. For example, some of the early U.S. dots are around –0.1 on the vertical axis, which means that being native to swampy Mississippi instead of arid Wyoming cut one’s adult earnings by about 10%.3For cross-country comparability, Bleakley (2010) normalizes the malaria mortality and ecology indexes so that the 5th- and 95th-percentile geographic units—Wyoming and Mississippi in the U.S. case—score 0 and 1. Income proxies are taken in logs. jQuery("#footnote_plugin_tooltip_3").tooltip({ tip: "#footnote_plugin_tooltip_text_3", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); The dots later rise, suggesting that the liability of coming from malarial areas faded, and even reversed. In Colombia, the dots start around zero but also then rise.

As in the hookworm study, here, Bleakley (2010) superimposes on the dots the step-like contour representing how malaria eradication is expected to play out in the data. The steps reach their full height when the campaigns are taken to have started—1920 in the United States and 1957 in the Latin nations. All babies born after these points were alike in that they grew up fully in the post–eradication campaign world. The step contours begin their rises 18 years earlier, when the first babies were born who would benefit from eradication at least a bit by their 18th birthdays.4These graphs incorporate all of Bleakley’s control variables. In my hookworm post, I began both results sections with “basic” graphs that did not include all the controls, imitating Bleakley (2007). In contrast, all the Bleakley (2010) graphs incorporate full controls. So I do the same. jQuery("#footnote_plugin_tooltip_4").tooltip({ tip: "#footnote_plugin_tooltip_text_4", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });

Next is my closest replication of the key Bleakley (2010) graphs. These use Bleakley’s data, as posted, but not Bleakley’s computer code, since that was not posted:

The next version adds the latest rounds of census data from the Latin nations and the newer, larger samples from old census rounds for the United States. It also redefines childhood as lasting 21 instead of 18 years, because I discovered that the Bleakley (2010) code uses 18 but the text uses 21. That budges the first dashed lines back by three years:

I avoided superimposing step contours on these data points because I worried that it would trick the brain into thinking that the contours fit the data better than they do. But whether the step contour fits the plots above is exactly what you should ask yourself now. Does it seem as if the dots rise, or rise more, between each pair of vertical, dashed lines? I could see the answer being “yes” for all but Mexico. And that could be a fingerprint of malaria eradication.

I ask that question more formally in the next quartet, fitting line segments to successive ranges of the data. The dots in the four graphs are the same as above, but I’ve taken away the grey confidence intervals for readability. The p values in the lower-left of each pane speak to whether any upward or downward bends at the allowed kink points are statistically significant, i.e., hard to ascribe to chance alone. Where the p values are low—and they mostly are, even in Mexico—they favor the Bleakley (2010) reading that rolling back malaria raised incomes.

In Brazil, Colombia, and Mexico, this statistical test is fairly confident that red lines bend upward at the first kinks (p = 0.00 for Brazil and Colombia and 0.07 for Mexico). That is: in high-malaria areas, relative to low-malaria areas, as the first babies were born who could benefit in childhood from eradication, future incomes rose. The test is less confident for the United States, where the first allowed kink, in 1899, gets a high-ish p value of 0.39. However, the U.S. trend clearly bends upward—just earlier than predicted by the Bleakley (2010) theory. That might mean that the Bleakley (2010) theory is slightly wrong: maybe when it came to impacts on future earnings, malaria exposure continued to matter into one’s twenties, at least in the United States 100 years ago. Then, people born in the South even a bit before 1899 (the date of the first U.S. kink point) would have benefited from the eventual campaign against malaria; and that first kink should be moved to the left, where it would match the data better and produce a lower p value. Or perhaps that high p value of 0.39 signifies that the Bleakley (2010) model is completely wrong for the United States, and that forces other than malaria eradication drove the South’s catch-up on income.

Now, in addition to the four measures of income studied above–one for each country—the Bleakley (2010) paper looks at eight other outcomes. Six are literacy and years of schooling completed, tracked separately in Brazil, Colombia, and Mexico. In addition, there is, for Brazil, earned income—as distinct from total income (“earned” meaning earned through work). And there is, for the United States, Duncan’s Socioeconomic Index (SEI), which blends the occupational income score, explained in my last post, with information about a person’s education level. Your Duncan’s SEI is highest if you hold what is typically a high-paying job (as with the occupational income score) and you have a lot of education.

The first public version of the Bleakley study makes graphs for the additional eight outcomes too. But the final, journal-published version drops them, perhaps to save space. Since for me, the graphs are so central, I generated my own graphs for the other eight outcomes:

These figures hand us a mixed bag. In the United States, the trend on Duncan’s index appears to bend as predicted at the first allowed kink (p = 0.04) but not the second. Seemingly, relative income gains continued in the South well after malaria eradication could cause them. In Brazil, while relative progress on earned income slows when expected (second kink, p = 0.04), it does not appear to accelerate when expected (first kink), perhaps owing to small samples in the early years. In none of the Latin countries does relative progress on adult literacy or years of schooling slow with much statistical significance at the expected time (second kink points in bottom six graphs). The trend bends in all six at the first kink point, and with statistical significance—but the wrong way in Mexico.

In fact, the mixed bag partly corroborates Bleakley (2010), which also questions whether rolling back malaria increased schooling. The new results depart from Bleakley (2010) in also questioning the benefit for literacy. And they cast some doubt on the income impact in the United States. In both the U.S. plots—in the upper-left of the last two sets of graphs above—it’s clear that the income gap between the South and the rest narrowed over many decades. It’s less clear that it did so with a rhythm attributable to the malaria eradication effort of the 1920s.

Conclusion

For me, this reanalysis triggers a modest update to my understanding of the impacts of malaria prevention. With regard to adult income in Latin America, and perhaps the United States, the Bleakley (2010) theory withstands reexamination. It holds up less well for literacy, but this is not very surprising given that Bleakley (2010) also did not find clear impacts on schooling.

I wouldn’t say that my confirmation proves that malaria eradication campaigns in the Americas boosted income in the way that a large-scale randomized study might. But then neither, if you read him closely, does Bleakley. Rather, the evidence “indicates” impact. The theory that malaria eradication in the Americas increased earnings fits pretty well to the data we have. And that is probably about as much certainty as we can expect from this historical analysis.

Much of the data and code for this study are here (2 GB). Because of IPUMS licensing limitations, the download leaves out the census data for Brazil, Colombia, and Mexico. The included “read me” file explains how to obtain this data. The full write-up is here.

Notes   [ + ]

1. ↑ Bleakley (2010) also chose these countries because they had malarial and non-malarial regions, allowing comparisons. See Bleakley (2010), note 6. For sample maps see this. 2. ↑ Actually we registered a plan for the hookworm study too, but the malaria plan was better informed—and better followed—precisely because it came on the heels of the similar hookworm reanalysis. For brevity, I skipped this theme in my blog post. I did write about it in the hookworm working paper. 3. ↑ For cross-country comparability, Bleakley (2010) normalizes the malaria mortality and ecology indexes so that the 5th- and 95th-percentile geographic units—Wyoming and Mississippi in the U.S. case—score 0 and 1. Income proxies are taken in logs. 4. ↑ These graphs incorporate all of Bleakley’s control variables. In my hookworm post, I began both results sections with “basic” graphs that did not include all the controls, imitating Bleakley (2007). In contrast, all the Bleakley (2010) graphs incorporate full controls. So I do the same. function footnote_expand_reference_container() { jQuery("#footnote_references_container").show(); jQuery("#footnote_reference_container_collapse_button").text("-"); } function footnote_collapse_reference_container() { jQuery("#footnote_references_container").hide(); jQuery("#footnote_reference_container_collapse_button").text("+"); } function footnote_expand_collapse_reference_container() { if (jQuery("#footnote_references_container").is(":hidden")) { footnote_expand_reference_container(); } else { footnote_collapse_reference_container(); } } function footnote_moveToAnchor(p_str_TargetID) { footnote_expand_reference_container(); var l_obj_Target = jQuery("#" + p_str_TargetID); if(l_obj_Target.length) { jQuery('html, body').animate({ scrollTop: l_obj_Target.offset().top - window.innerHeight/2 }, 1000); } }

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### Key questions about Helen Keller International’s vitamin A supplementation program

Thu, 12/28/2017 - 11:46

One of our two new top charities this year is Helen Keller International (HKI)’s vitamin A supplementation program. We named HKI’s vitamin A supplementation program a top charity this year because:

• There is strong evidence from many randomized controlled trials of vitamin A supplementation that the program leads to substantial reductions in child deaths.
• HKI-supported vitamin A supplementation programs are inexpensive (we estimate around $0.75 in total costs per supplement delivered) and highly cost-effective at preventing child deaths in countries where HKI plans to work using GiveWell-directed funds. • HKI is transparent—it has shared significant, detailed information about its programs with us, including the results and methodology of monitoring surveys HKI conducted to determine whether its vitamin A supplementation programs reach a large proportion of targeted children. • HKI has a funding gap—we believe it is highly likely that its vitamin A supplementation programs will be constrained by funding next year. HKI’s vitamin A supplementation program is an exceptional giving opportunity, but as with the case for donating to any of our other top charities, not a “sure thing.” I’m the Research Analyst who has led our work on HKI this year. In this post, I discuss some key questions about the impact of Helen Keller International’s vitamin A supplementation program and what we’ve learned so far. I also discuss GiveWell’s plans for learning more about these issues in the future. In short: • Is vitamin A deficiency still a major concern? Our best guess is that vitamin A deficiency is considerably less common today where HKI works than it was among children who participated in past trials of vitamin A supplementation, but not so rare that vitamin A supplementation would not be cost-effective. We are quite uncertain about our estimate of the prevalence of vitamin A deficiency where HKI works because little high-quality, up-to-date data on vitamin A deficiency is available. We plan to consider funding new surveys of vitamin A deficiency to improve our understanding of the effectiveness of HKI’s programs. • Have improvements in health conditions over time reduced the need for vitamin A supplementation? Child mortality rates remain quite high in areas where HKI plans to use GiveWell-directed funding for vitamin A supplementation programs. We think it’s unlikely that health conditions in these countries have improved enough for vitamin A supplementation to no longer be effective. • How strong is HKI’s track record of supporting fixed-point vitamin A supplement distributions? HKI expects to primarily support fixed-point vitamin A supplement distributions (rather than door-to-door campaigns) going forward. Results from monitoring surveys have found that, on average, HKI’s fixed-point programs have not reached as high a proportion of targeted populations as its door-to-door programs, but these monitoring surveys may not have been fully representative of HKI’s programs overall. Our best guess is that future fixed-point programs will achieve moderate to high coverage. Is vitamin A deficiency still a major concern? Vitamin A deficiency, a condition resulting from chronic low vitamin A intake, can cause loss of vision and increased severity of infections. If vitamin A deficiency is less common today than it was among participants in trials of vitamin A supplementation, today’s programs may prevent fewer deaths than the evidence from the trials suggests. We estimate that the prevalence of vitamin A deficiency was high (around 60%) in the populations studied in trials included in the Cochrane Collaboration review of vitamin A supplementation programs for preschool-aged children, Imdad et al. 2017.1See the “Imdad 2017 – VAD prevalence estimates” sheet here for details. jQuery("#footnote_plugin_tooltip_1").tooltip({ tip: "#footnote_plugin_tooltip_text_1", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); The map below, from Our World in Data, presents the World Health Organization (WHO)’s most recent estimates of the prevalence of vitamin A deficiency among preschool-aged children by country, covering the period from 1995 to 2005. WHO categorizes prevalences of vitamin A deficiency among preschool-aged children of 20% or above as a severe public health problem.2WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 8, Table 5. jQuery("#footnote_plugin_tooltip_2").tooltip({ tip: "#footnote_plugin_tooltip_text_2", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); Since WHO’s most recent estimates are now considerably out-of-date, we decided to investigate a variety of additional sources in order to create best-guess estimates of rates of vitamin A deficiency today in countries in sub-Saharan Africa where HKI works. We learned that there is very little useful, up-to-date data on vitamin A deficiency in countries in sub-Saharan Africa. In many countries, the most recent surveys of vitamin A deficiency were completed ten or more years ago. Many governments have also recently mandated the fortification of vegetable oil or other foods with vitamin A, but little information is available on whether foods are actually adequately fortified in practice.3See this spreadsheet for the information we collected on the most recent vitamin A deficiency surveys and on vitamin A fortification programs in countries where HKI has supported vitamin A supplementation programs. jQuery("#footnote_plugin_tooltip_3").tooltip({ tip: "#footnote_plugin_tooltip_text_3", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); Taking the limited available data into account, our best guess is that prevalence of vitamin A deficiency in countries where HKI works today is likely to be considerably lower than the prevalence of vitamin A deficiency among children who participated in vitamin A supplementation trials—closer to 20% prevalence than 60% prevalence. We find that HKI’s vitamin A supplementation programs still appear highly cost-effective, even when taking our estimate of the change in the prevalence of vitamin A deficiency over time into account (see our most recent cost-effectiveness analysis for full details). But we remain quite uncertain about our estimate of the prevalence of vitamin A deficiency in countries where HKI works—new information could cause us to update our views on HKI’s cost-effectiveness considerably. Next year, we’ll continue to follow research relevant to estimating vitamin A deficiency rates where HKI works. We also plan to consider funding new vitamin A deficiency surveys ourselves through a GiveWell Incubation Grant. Have improvements in health conditions over time reduced the need for vitamin A supplementation? In a blog post last year, we wrote that vitamin A supplementation has a mixed evidence base. There is strong evidence from many randomized controlled trials conducted in the 1980s and 1990s that the program reduces child mortality, but a more recent trial in northern India with more participants than all the other trials combined (the Deworming and Enhanced Vitamin A trial, or DEVTA) did not find a statistically significant effect. There have been broad declines in child mortality rates over the past few decades. Participants in the control group in the DEVTA trial had a mortality rate of 5.3 deaths per 1,000 child-years, lower than the mortality rates in the control groups in earlier trials that found statistically significant results (ranging from 10.6 to 126 deaths per 1,000 child-years). One potential explanation for the difference between the results of the DEVTA trial and earlier trials is that the some types of deaths prevented by vitamin A supplementation in previously studied populations had already been prevented through other means (e.g., increased access to immunizations and medical care) in the DEVTA population. We looked into child mortality rates in countries in sub-Saharan Africa where HKI plans to use GiveWell-directed funding in the near future—Guinea, Burkina Faso, and Mali—as well as other countries where HKI has recently worked. Mortality rates among preschool-aged children in Guinea, Burkina Faso and Mali remain quite high—around 13 deaths per 1,000 child-years, within the range of mortality rates among control groups in vitamin A trials that found statistically significant results.4The control group mortality rate in the DEVTA trial was 5.3 per 1,000 child-years. See this spreadsheet for child mortality rates in Burkina Faso, Guinea, and Mali (13 deaths per 1,000 child-years is the simple average of “Average of GBD and UN IGME data” child mortality rates for the three countries), and see here for more information on control group mortality rates in other vitamin A supplementation trials. jQuery("#footnote_plugin_tooltip_4").tooltip({ tip: "#footnote_plugin_tooltip_text_4", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); Based on these high child mortality rates, we don’t believe it’s very likely that overall health conditions have improved enough in these countries for vitamin A supplementation to no longer be effective at preventing deaths. It is also possible that changes in causes of child deaths between the 1980s and 1990s and today could mean that vitamin A supplementation is now less effective than it was in the past. Different vitamin A experts have different views on whether vitamin A primarily prevents deaths due to a few specific causes (we’ve seen diarrhea and measles most frequently pointed to) or whether it reduces deaths due to a wider range of conditions by, perhaps, strengthening the immune system against infection. In our view, the research on this is inconclusive. According to the data we’ve seen, infectious disease overall and diarrhea in particular cause a similar proportion of total deaths among young children today as they did in the 1980s and 1990s; measles causes a substantially lower proportion of total deaths today than it did in the past.5See the final bullet point in this section of our review of HKI for more on this topic. jQuery("#footnote_plugin_tooltip_5").tooltip({ tip: "#footnote_plugin_tooltip_text_5", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); We’ve added an adjustment to our cost-effectiveness analysis to account for changes in the composition of causes of child mortality since the vitamin A trials were implemented—HKI’s work still appears highly cost-effective following this adjustment. We may conduct additional research next year to learn about child mortality rates in places where HKI works at a more granular (e.g., regional or sub-regional) level. We may also conduct additional research on the impact of changes in cause-specific mortality rates on the effectiveness of vitamin A supplementation. How strong is HKI’s track record of supporting fixed-point vitamin A supplement distributions? In many past HKI-supported campaigns, healthcare workers have traveled door-to-door to administer vitamin A supplements to preschool-aged children. Funding was already available from other sources for sending teams of healthcare workers door-to-door to administer polio vaccinations, and adding vitamin A supplementation to these campaigns was relatively simple and cheap. In fixed-point distributions, caregivers are expected to bring their children to a central location to receive vitamin A supplements. Due to recent progress in polio elimination, many door-to-door programs have recently been scaled-down or eliminated, so HKI expects to primarily be supporting fixed-point distributions going forward. It may be more challenging to reach a large proportion of a targeted population with fixed-point distributions. HKI’s recent monitoring surveys have found that, on average, its door-to-door distributions have achieved higher coverage rates (around 90%) than its fixed-point distributions (around 60%). The average of around 60% for fixed-point programs reflects surveys finding high coverage in a few campaigns in the Democratic Republic of the Congo and Mozambique, and relatively low coverage in campaigns in Nigeria, Tanzania, and Kenya. A complication for assessing HKI’s track record is that HKI often chose to conduct coverage surveys in areas where it expected coverage to be particularly low, so we would guess that these results are not fully representative of HKI’s work on fixed-point distributions. Based on the available information, our best guess is that HKI-supported fixed-point vitamin A supplementation distributions next year will achieve moderate to high coverage.6To be more precise about what I mean: in Guinea (the program I am most familiar with, following our site visit in October), I’m 70% confident that coverage surveys representative of the distribution as a whole will indicate that the first vitamin A supplement distribution in 2018 reached at least 55% of targeted children across the country. jQuery("#footnote_plugin_tooltip_6").tooltip({ tip: "#footnote_plugin_tooltip_text_6", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); HKI has told us that it will conduct representative monitoring surveys (not only in areas where it expects coverage to be low) following its vitamin A supplement distributions supported with GiveWell-directed funding next year—we expect that these surveys will provide data useful for assessing how successful the programs were overall. Notes [ + ] 1. ↑ See the “Imdad 2017 – VAD prevalence estimates” sheet here for details. 2. ↑ WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 8, Table 5. 3. ↑ See this spreadsheet for the information we collected on the most recent vitamin A deficiency surveys and on vitamin A fortification programs in countries where HKI has supported vitamin A supplementation programs. 4. ↑ The control group mortality rate in the DEVTA trial was 5.3 per 1,000 child-years. See this spreadsheet for child mortality rates in Burkina Faso, Guinea, and Mali (13 deaths per 1,000 child-years is the simple average of “Average of GBD and UN IGME data” child mortality rates for the three countries), and see here for more information on control group mortality rates in other vitamin A supplementation trials. 5. ↑ See the final bullet point in this section of our review of HKI for more on this topic. 6. ↑ To be more precise about what I mean: in Guinea (the program I am most familiar with, following our site visit in October), I’m 70% confident that coverage surveys representative of the distribution as a whole will indicate that the first vitamin A supplement distribution in 2018 reached at least 55% of targeted children across the country. function footnote_expand_reference_container() { jQuery("#footnote_references_container").show(); jQuery("#footnote_reference_container_collapse_button").text("-"); } function footnote_collapse_reference_container() { jQuery("#footnote_references_container").hide(); jQuery("#footnote_reference_container_collapse_button").text("+"); } function footnote_expand_collapse_reference_container() { if (jQuery("#footnote_references_container").is(":hidden")) { footnote_expand_reference_container(); } else { footnote_collapse_reference_container(); } } function footnote_moveToAnchor(p_str_TargetID) { footnote_expand_reference_container(); var l_obj_Target = jQuery("#" + p_str_TargetID); if(l_obj_Target.length) { jQuery('html, body').animate({ scrollTop: l_obj_Target.offset().top - window.innerHeight/2 }, 1000); } } The post Key questions about Helen Keller International’s vitamin A supplementation program appeared first on The GiveWell Blog. ### How uncertain is our cost-effectiveness analysis? Fri, 12/22/2017 - 15:22 When our cost-effectiveness analysis finds robust and meaningful differences between charities, it plays a large role in our recommendations (more on the role it plays in this post). But while our cost-effectiveness analysis represent our best guess, it’s also subject to substantial uncertainty; some of its results are a function of highly debatable, difficult-to-estimate inputs. Sometimes these inputs are largely subjective, such as the moral weight we assign to charities achieving different good outcomes (e.g. improving health vs increasing income). But even objective inputs are uncertain; a key input for anti-malaria interventions is malaria mortality, but the Institute for Health Metrics and Evaluation estimates 1.6 times more people died in Africa from malaria in 2016 (641,000) than the World Health Organization does (407,000; pg. 41).1Differences in their methodology have been discussed, with older figures, in a 2012 blog post by the Center for Global Development. jQuery("#footnote_plugin_tooltip_1").tooltip({ tip: "#footnote_plugin_tooltip_text_1", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); Before we finalized the recommendations we released in November, we determined how sensitive our results were to some of our most uncertain parameters. In brief: • Comparisons between charities achieving different types of good outcome are most sensitive to the relative value we assign to those outcomes (more on how and why we and other policymakers assign these weights in this post). • Our deworming models are very uncertain, due to the complexity of the evidence base. They are also sensitive to the choice of discount rate: how we value good done today vs. good done in the future. • Our malaria models (seasonal malaria chemoprevention and long-lasting insecticide-treated nets) are less uncertain than our deworming models, but are particularly sensitive to our estimate of the long term effects of malaria on income. In this post, we discuss: • The sensitivity of our analysis to moral weights (more) and other parameters (more). • How this uncertainty influences our recommendations (more). • Why this sensitivity analysis doesn’t capture the full scope of our uncertainty and ways in which we could improve our assessment and presentation of uncertainty (more). The tornado charts at the bottom of this post show the results of our full sensitivity analysis. For a brief explanation of how we conducted our sensitivity analysis see this footnote.2Each contributor to our cost-effectiveness analysis inputs their own values for particularly uncertain parameters in our cost-effectiveness analysis. We use the median of contributors’ final cost-effectiveness results for our headline cost-effectiveness figures. To simplify the sensitivity analysis, we used the median of contributors’ parameter inputs to form a central cost-effectiveness estimate for each charity. The results below therefore differ slightly from our headline cost-effectiveness figures. To determine how sensitive the model is to each parameter, we flexed each parameter between the highest and lowest contributors’ inputs, while holding all other parameters constant. For more details, see our sensitivity analysis spreadsheet. jQuery("#footnote_plugin_tooltip_2").tooltip({ tip: "#footnote_plugin_tooltip_text_2", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); Sensitivity to moral weights Some of the inputs in our model rely on judgement calls, which reasonable, informed people might disagree on. For example, we assign quantitative weights to our relative valuations of different good outcomes. These inputs capture important considerations in our decision-making, but are often difficult to justify precisely. We ask contributors to our cost-effectiveness analysis (mostly staff) to input how many people’s income would have to double for 1 year to be equally valuable to averting the death of a child under 5. Contributors’ values vary widely, between 8 and 100 (see Figure 1).3You can see each of our contributors’ inputs for moral weights, and other uncertain parameters, on the Moral weights and Parameters tabs of our cost-effectiveness analysis. This year, contributors were also asked to provide a brief justification for their inputs in the cell notes. jQuery("#footnote_plugin_tooltip_3").tooltip({ tip: "#footnote_plugin_tooltip_text_3", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); Differences in cost-effectiveness between charities which primarily prevent child deaths (Helen Keller International, Malaria Consortium, Against Malaria Foundation) and charities which primarily increase income (Deworm the World Initiative, Schistosomiasis Control Initiative, Sightsavers, No Lean Season, End Fund) are highly sensitive to different plausible moral weights (See Figure 2). The orange points represent the median estimated cost-effectiveness of our charities (in terms of how many times more cost-effective than GiveDirectly we model them to be). The blue bars represents the range of cost-effectiveness for different valuations of preventing the death of an under-5 child between 8x and 100x as good as doubling consumption for one person for one year (holding all other parameters in the model constant). Deworming sensitivities Our deworming models are very uncertain, due to the complexity of the evidence base, and the long time horizons over which we expect the potential benefits to be realized. Aside from our moral weights, our deworming charities are highly sensitive to three inputs: • Replicability adjustment. We make a “replicability adjustment” for deworming to account for the fact that the consumption increase in a major study we rely upon may not hold up if it were replicated. If you’re skeptical that such a large income increase would occur, given the limited evidence for short-term health benefits and generally unexpected nature of the findings, you may think that the effect the study measured wasn’t real, wasn’t driven by deworming, or relied on an atypical characteristic shared by the study population but not likely to found among recipients of the intervention today. This adjustment is not well-grounded in data. (For more discussion see our deworming intervention report and blog posts here, here, here and here).4You can read more about how contributors settled on the values they used for this parameter in the cell notes in row 16 of the Parameters sheet of our November 2017 cost-effectiveness model. jQuery("#footnote_plugin_tooltip_4").tooltip({ tip: "#footnote_plugin_tooltip_text_4", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); • Adjustment for years of treatment in Baird et al. vs. years of treatment in charities’ programs. Our charities aim to deworm children for up to 10 years, which is longer than the intervention studies in Baird et al. 2015 (where children in the treatment group received 4 years of deworming). There may be diminishing returns as the total years of treatment increase, although this is difficult to estimate. • Discount rate. The discount rate adjusts for benefits that occur at different points in time. For a number of reasons, individuals may believe it is preferable for income to rise now than at some point in the future. Figure 3 shows how the cost-effectiveness of Deworm the World Initiative5The sensitivity of other deworming charities is largely dependent on the same parameters. Charts are presented in the Appendix jQuery("#footnote_plugin_tooltip_5").tooltip({ tip: "#footnote_plugin_tooltip_text_5", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); varies depending on different contributor inputs for different parameters (more on how to interpret these parameters here). The orange line represents the median estimated cost-effectiveness of our charities (in terms of how many times more cost-effective than GiveDirectly we model them to be). The blue bars represents the range of cost-effectiveness for different inputs from our contributors for that parameter (holding all other parameters in the model constant). The figures in square brackets represent the range of contributor inputs for those parameters. Malaria sensitivities Our malaria models are less uncertain than our deworming models, but are still sensitive to our estimate of the long term effects of malaria on income (see Figures 4 and 5). Interpreting the evidence base for the effect of malaria prevention on long run income is complex, and contributors differ widely in their interpretation. We’re planning to do more research on this topic further but summarize our current understanding here. What does this mean for our recommendations? When we model large differences in cost-effectiveness, we generally follow those recommendations. When charities are closer on cost-effectiveness, we pay more attention to qualitative considerations, such as the quality of their monitoring and evaluation, and potential upside benefits which are difficult to quantify (e.g. scaling a novel program). What counts as a meaningful difference in modelled cost-effectiveness depends on a number of factors, including: • Do the programs target the same outcomes? We place less weight on modelled differences between charities which have different good outcomes because our cost-effectiveness analysis is sensitive to different reasonable moral weights. • How similar are the programs? We’re more confident in our comparison between our deworming charities than we are between deworming charities and other charities targeting income such as GiveDirectly. This is because we expect the most likely errors in our deworming estimates (e.g. based on our interpretation of the evidence) for different charities to be correlated. • Are there important qualitative reasons to differentiate between the charities? We place less relative weight on cost-effectiveness analysis when there are important qualitative reasons to differentiate between charities. For a more detailed explanation of how we made our recommendations this year, see our recent announcement of our top charities for giving season 2017. What are the limitations of this sensitivity analysis? This sensitivity analysis shouldn’t be taken as a full representation of our all things considered uncertainty: • The charts above show the sensitivity of the cost-effectiveness analysis to changing one input at a time (holding all other constant). The ranges don’t necessarily imply any particular credible interval, and are more useful for identifying which inputs are most uncertain than for reflecting our all things considered uncertainty around the cost-effectiveness of a particular charity. • We don’t ask multiple contributors to input their own values for all uncertain inputs (e.g. because we think the benefits of using the inputs of the contributors with most context outweigh the benefit of getting inputs from many contributors). These inputs have not been included in the sensitivity analysis. • Model uncertainty. Explicitly modelling all the considerations relevant to our charity would be infeasible. Even if all our inputs were fully accurate, we’d still retain some uncertainty about the true cost-effectiveness of our charities. We’re considering a number of different options to improve our sensitivity analysis and communication of uncertainty in the future, such as expressing inputs as probability distributions or creating a Monte Carlo simulation. But we’re uncertain whether these would create sufficient decision-relevant information for our readers to justify the substantial time investment and additional complexity. If you’d find such an analysis helpful, let us know in the comments. Appendix In this section, we present tornado charts for each of our top charities. You can see more detailed descriptions of how to interpret these parameters here, or in the cell notes of our cost-effectiveness analysis. Notes [ + ] 1. ↑ Differences in their methodology have been discussed, with older figures, in a 2012 blog post by the Center for Global Development. 2. ↑ Each contributor to our cost-effectiveness analysis inputs their own values for particularly uncertain parameters in our cost-effectiveness analysis. We use the median of contributors’ final cost-effectiveness results for our headline cost-effectiveness figures. To simplify the sensitivity analysis, we used the median of contributors’ parameter inputs to form a central cost-effectiveness estimate for each charity. The results below therefore differ slightly from our headline cost-effectiveness figures. To determine how sensitive the model is to each parameter, we flexed each parameter between the highest and lowest contributors’ inputs, while holding all other parameters constant. For more details, see our sensitivity analysis spreadsheet. 3. ↑ You can see each of our contributors’ inputs for moral weights, and other uncertain parameters, on the Moral weights and Parameters tabs of our cost-effectiveness analysis. This year, contributors were also asked to provide a brief justification for their inputs in the cell notes. 4. ↑ You can read more about how contributors settled on the values they used for this parameter in the cell notes in row 16 of the Parameters sheet of our November 2017 cost-effectiveness model. 5. ↑ The sensitivity of other deworming charities is largely dependent on the same parameters. Charts are presented in the Appendix function footnote_expand_reference_container() { jQuery("#footnote_references_container").show(); jQuery("#footnote_reference_container_collapse_button").text("-"); } function footnote_collapse_reference_container() { jQuery("#footnote_references_container").hide(); jQuery("#footnote_reference_container_collapse_button").text("+"); } function footnote_expand_collapse_reference_container() { if (jQuery("#footnote_references_container").is(":hidden")) { footnote_expand_reference_container(); } else { footnote_collapse_reference_container(); } } function footnote_moveToAnchor(p_str_TargetID) { footnote_expand_reference_container(); var l_obj_Target = jQuery("#" + p_str_TargetID); if(l_obj_Target.length) { jQuery('html, body').animate({ scrollTop: l_obj_Target.offset().top - window.innerHeight/2 }, 1000); } } The post How uncertain is our cost-effectiveness analysis? appeared first on The GiveWell Blog. ### Update on our work on outreach Tue, 12/19/2017 - 11:33 GiveWell’s impact is a function of the quality of our research and the amount of money we direct to our recommended charities (our “money moved”). Historically, we’ve focused mostly on research because we felt that the quality of our recommendations was a greater constraint to our impact than our money moved. This has changed. Outreach is now a major organizational priority. The goal of this work is to increase the amount of money we direct to our top-recommended charities. In April 2014 I wrote about our work on outreach to explain why we hadn’t prioritized it: in brief, our growth had largely been driven by inbound interest in GiveWell, and proactive outreach efforts (beyond building relationships with existing donors) hadn’t yielded results that were worth the cost. What changed? • We believe that the amount of money we move is now a greater constraint to our impact than additional improvements in the quality of our research. Over the last two years, we’ve added five new top charities (three of which implement programs that weren’t previously represented on our top charities list), and we expect that our top charities, collectively, will have more than$200 million in unfilled funding gaps once they’ve received the funding that we expect to direct to them. (This calculation excludes GiveDirectly, which we believe could absorb and distribute hundreds of millions of dollars.) At the same time, the quality of our research and our capacity for research is higher than it’s ever been, so the returns to adding staff there (in terms of the pace at which we identify significantly better giving opportunities) are now lower.
• Increased capacity for outreach. In our 2014 post, we wrote that one of our key constraints was that senior staff (which at the time meant primarily GiveWell Co-Founder Holden Karnofsky and me) were necessary for most outreach-related work. This has changed. We now have capacity to take on outreach work as other staff have been hired and trained on this type of work.
• Better information on the impact of GiveWell’s outreach. We now have better information about the returns to outreach because:
1. We’ve collected better data (via an improved donations processing system and outreach efforts) about where donors find out about us. Because of our ability to track donors, we know that a single appearance on NPR or major podcasts tends to drive $50,000+ in annual donations. 2. More time passing has demonstrated that the lifetime value of the donations of a first time donor is higher than we expected. In several cases, we’ve seen major donors (i.e., those giving$10,000-$100,000) increase their annual giving by a factor of 10 or more. We’re in the early stages of figuring out how we can proactively invest time and money in outreach to significantly increase our money moved. For now, we’ve taken some opportunities that we think will have positive returns; these are the three that we’ve invested the most time and money in to date: • Podcast advertising. We’ve been advertising on podcasts that we believe our target audience listens to, based on interviews with current donors and GiveWell staff. In February and March, we ran a small experiment with a few ads on FiveThirtyEight’s Politics podcast and Vox’s The Weeds.1We’ve also been running ads on Julia Galef’s Rationally Speaking podcast since then. Because it’s much smaller and more targeted, we’ve excluded it from this analysis. Measured returns to advertising on Rationally Speaking have been significantly better than the more mainstream podcasts discussed in this post. jQuery("#footnote_plugin_tooltip_1").tooltip({ tip: "#footnote_plugin_tooltip_text_1", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); In total, we spent approximately$20,000 on ads for this initial experiment. We ask donors who give via our website to tell us where they learned about GiveWell when they donate. GiveWell received approximately $8,000 in donations between February 1 and November 20 from donors who reported that they had learned about us via these podcasts. The donations we received were from first-time donors; to assess the impact of our advertising, we need to estimate the lifetime value of acquiring a new donor. In work we’ve done to assess our retention rate, we’ve seen that (a) approximately 20-25% of the donors who make a first-time donation of less than$1,000 give again in the subsequent year but (b) because many first-time donors increase the size of their donation over time, collectively, the donors who recur give more than 100% of the value of what they give in their first year.

At higher donation levels ($1,000-$100,000), we measure 40-45% retention among donors, which leads to retention of approximately two-thirds of dollars given.2I say “measure” retention because we’ve learned that many donors give subsequent donations directly to our top charities and don’t report those donations to us. We’ve tried to follow up with lapsed donors and with charities to track these donors down. jQuery("#footnote_plugin_tooltip_2").tooltip({ tip: "#footnote_plugin_tooltip_text_2", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });

We therefore estimated the net present value of expected future donations (over the next five years) from these podcasts ads as somewhere between approximately $20,000 (assuming two-thirds dollar retention for the first two years and 100% dollar retention subsequently) and$45,000 (assuming 100% dollar retention).3We only projected donations over five years. This is fairly arbitrary because we don’t have long-term enough data to know whether or not this is a reasonable assumption. We capped it to prevent our assessment being driven by speculation about how much money would be donated many years in the future. jQuery("#footnote_plugin_tooltip_3").tooltip({ tip: "#footnote_plugin_tooltip_text_3", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });

A few additional facts are worth keeping in mind about the above figures:

• We ran this experiment in February and March; most donors give at the end of the calendar year. We consistently see donors who find out about GiveWell during the course of the year, but donate in December. Other things equal, we expect that our advertising would have had greater measured returns in December than earlier in the year.
• We are only able to track donors who (a) fill out our donation form telling us where they learned about us and (b) give directly through our website rather than to our top charities. Less than 50% of donors who give via credit card (and a smaller percentage of donors who give via check) tell us where they learned about GiveWell. Also, roughly speaking, approximately 50% of the donors and dollars we influence come through GiveWell rather than going to our top charities.4I took this rough estimate from footnote 26, on page 15, of GiveWell’s 2015 metrics report. jQuery("#footnote_plugin_tooltip_4").tooltip({ tip: "#footnote_plugin_tooltip_text_4", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });
• It’s certainly possible that donors who learn about us via podcast would be more likely to give through our website than an average donor, more likely to report on how they found us (since their source is clear), or less likely to be retained. My best guess is that donors who learn about us via podcast ads behave similarly to our other donors, but I won’t be surprised if they don’t.

With all that in mind, I believe that the impact of our podcast advertising is higher than what we directly measured.

The results we saw from February to November this year were promising enough that we decided to increase the size of our experiment by spending approximately $100,000 on podcast ads. We’re currently running ads on FiveThirtyEight’s Politics podcast and Ezra Klein’s podcast and The Weeds at Vox. • Earned media outreach. Mentions of GiveWell in the media have historically been a strong driver of growth. We aimed to increase mentions of GiveWell in high-quality, high-profile media where we’ve had the most past success as measured by dollars donated (i.e., media like The New York Times, NPR, The Wall Street Journal, and Financial Times). We retained a PR firm that came strongly recommended; we also increased 1-to-1 outreach by GiveWell staff to members of the media who have covered GiveWell in the past. It’s very hard to attribute the impact of the additional effort we’ve invested—overall, our effort has been fairly limited, and it’s hard to easily draw the causal lines between our work and the stories that appear—but my guess is that our increased efforts have led to more coverage of GiveWell and our top charities this giving season than in the recent past. • Website improvements. Companies that sell products online invest significant effort into optimizing their websites and checkout pages to maximize their revenues. We retained a marketing consultant, Will Wong of Mission Street, and we’ve been A/B testing different donation pages and plan to test other pages on our website such as our homepage or top charities page to see whether we can increase our conversion rate (i.e., the percentage of visitors to our website who give to one of our top charities). For context, our current conversion rate is 1%. Our understanding is that a standard conversion rate for e-commerce companies is 2%, and that international nonprofits have a similar conversion rate.5See Pg 51 of the study downloadable here. jQuery("#footnote_plugin_tooltip_5").tooltip({ tip: "#footnote_plugin_tooltip_text_5", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); An increase in our conversion rate to the industry average would lead to a significant increase in the amount of money we direct to our top charities. Notes [ + ] 1. ↑ We’ve also been running ads on Julia Galef’s Rationally Speaking podcast since then. Because it’s much smaller and more targeted, we’ve excluded it from this analysis. Measured returns to advertising on Rationally Speaking have been significantly better than the more mainstream podcasts discussed in this post. 2. ↑ I say “measure” retention because we’ve learned that many donors give subsequent donations directly to our top charities and don’t report those donations to us. We’ve tried to follow up with lapsed donors and with charities to track these donors down. 3. ↑ We only projected donations over five years. This is fairly arbitrary because we don’t have long-term enough data to know whether or not this is a reasonable assumption. We capped it to prevent our assessment being driven by speculation about how much money would be donated many years in the future. 4. ↑ I took this rough estimate from footnote 26, on page 15, of GiveWell’s 2015 metrics report. 5. ↑ See Pg 51 of the study downloadable here. function footnote_expand_reference_container() { jQuery("#footnote_references_container").show(); jQuery("#footnote_reference_container_collapse_button").text("-"); } function footnote_collapse_reference_container() { jQuery("#footnote_references_container").hide(); jQuery("#footnote_reference_container_collapse_button").text("+"); } function footnote_expand_collapse_reference_container() { if (jQuery("#footnote_references_container").is(":hidden")) { footnote_expand_reference_container(); } else { footnote_collapse_reference_container(); } } function footnote_moveToAnchor(p_str_TargetID) { footnote_expand_reference_container(); var l_obj_Target = jQuery("#" + p_str_TargetID); if(l_obj_Target.length) { jQuery('html, body').animate({ scrollTop: l_obj_Target.offset().top - window.innerHeight/2 }, 1000); } } The post Update on our work on outreach appeared first on The GiveWell Blog. ### Maximizing the impact of your donation: saving on fees means more money for great charities Fri, 12/15/2017 - 14:09 We recently discussed how you can give to reduce the administrative burden on charities. This post will focus on how you can save money on fees and give tax-efficiently so that more of your charitable budget can go directly to the organizations you want to support. This is an updated version of a post we originally ran in 2012; some content is the same, other content has been added or updated. 1. Don’t wait until the last minute. Many donors wait until the very end of the calendar year to give. If you’re hoping to make a donation by that deadline, we strongly advise against this. Here’s why: • Some methods of donating require some planning and preparation, such as giving appreciated stock. • Checks are tax-deductible according to the postmarked date on the envelope—you can’t write a check in 2018, backdate it to 2017, and claim a deduction. So, please head to the post office before the new year if you’re looking to get a tax deduction this year. • Leaving little time between making your donation and the deadline means you’ll have limited time to react if something unexpected happens, such as your credit card charge being declined. We recommend building in a cushion of a week or two if you’re aiming to donate by a particular deadline. The earlier you can give, the less likely you’ll have any issues. For end-of-year giving, we recommend a target date of December 24 or earlier. 2. Try to get a tax benefit. Details vary by country and personal situation, but a tax deduction can allow you to give much more to charity at the same cost to yourself. (That said, as discussed later in the post, we believe it is more important to give to the most effective possible charity than to get the maximum tax benefit.) Below, we discuss our understanding of donation methods for tax-advantaged giving, although please note that none of this information should be construed as legal or tax advice. Donors in the United States may make tax-deductible gifts to any of our nine top charities by giving to GiveWell. There are also a large number of tax-deductible options for giving to our top charities in other countries; please see the table here for more information. Donors in certain U.S. states and income brackets who are interested in maximizing their tax deduction may also consider “donation bunching,” or making two donations in one year rather than one donation in each of two years to take advantage of the standard deduction in one year and maximize the size of their itemized charitable deduction in a subsequent year. Considerations related to donation bunching are discussed in this post by former GiveWell intern Ben Kuhn. 3. Avoid the large transaction fees and delays associated with large online donations. When donating via credit card, you will almost always be charged standard credit card processing fees. Making a large donation via credit card may also trigger your card’s fraud protection (though a call to the credit card company can generally resolve the situation quickly). We discussed some of the tradeoffs between the ease of donating via certain platforms and the fees for donors and the administrative costs to charities for processing them in a previous post. In short, we do not advise making donations via credit card if you’re planning to give$1,000 or more.

4. Give appreciated stock and cryptocurrency. In the U.S., if you give stock or cryptocurrency (such as Bitcoin) to a charity, neither you nor the charity will have to pay taxes on capital gains (as you would if you sold the stock yourself). If you have stock or cryptocurrency that you acquired for $1,000 (and has a cost basis of$1,000) but is now worth $2,000, you can give the stock to charity, take a deduction for$2,000, and not have to pay capital gains tax on the $1,000 of appreciation. This can result in significant savings. Due to the administrative cost associated with processing donations of stock, we ask that donors donate stock directly to GiveWell only if the value of the stock at the time of transfer is estimated at approximately$1,000 or more. More information on giving appreciated stock to GiveWell, either through E*Trade or GiveWell’s Vanguard donor-advised fund, is available here. You can also use Betterment to donate appreciated stock to GiveWell. If you’re interested in making a Bitcoin donation to GiveWell, please email us at donations@givewell.org to receive instructions on how to give.

5. Look into donor-advised funds to make the process smoother and more consistent year-to-year. Donor-advised funds allow donors to make a charitable donation (and get a tax deduction) now, while deciding which charity they’d like to support later. The donation goes into a fund that is “advised” by the donor, and the donor may later recommend a grant from the fund to the charity of his/her choice.

We see a couple of advantages to this setup. One advantage is that you can separate your “decision date” (the date on which you decide which charity you’d like to support) from your “transaction date.” That means that if you aren’t ready to decide which charity to support yet, you can still get started on the process of transferring funds and getting a tax deduction for the appropriate year. Another advantage is that if you change the charity you support from year to year, you’re still working with the same partner when it comes to transactions, so the process for e.g. donating stock will not change from year to year. Donor-advised funds are often set up to easily accept donated stock or non-traditional assets, whereas charities may or may not be.

Many large investment companies—Vanguard, Fidelity, Schwab—offer donor-advised funds. They generally charge relatively modest management fees. We also maintain our own donor-advised fund for donors interested in supporting our recommended charities; the minimum size for a donation is $5,000. The GiveWell donor-advised fund is likely most helpful for donors interested in giving certain types of securities, such as Vanguard mutual funds, that are not accepted by E*Trade. 6. Find out if your company offers donation matching. Many companies offer to match employees’ gifts up to a certain amount. We recommend checking with your employer if you’re unsure whether they offer this option. Some employers have a limited list of charities to which they will match donations; consider asking your employer whether they would add the charity of your choosing if it isn’t already on the list. 7. Consider the political environment. If you believe that your likelihood of taking charitable deductions is higher in 2017 than it will be in 2018, consider increasing your giving this year. 8. Choose your charity wisely. Saving money on taxes and transaction fees can be significant, in some cases approaching or exceeding a 50 percent increase in the amount you’re able to give. However, we believe that your choice of charity is a much larger factor in how much good your giving accomplishes. Our charity recommendations make it possible to support outstanding, thoroughly vetted organizations—which we’ve investigated by reviewing academic evidence, interviewing staff, analyzing internal documents, conducting site visits, assessing funding needs, and more—without needing to do your own research. We publicly publish the full details of our process and analysis, so you can spot-check whatever part of our work and reasoning you’d like to. Final notes If you support our recommended charities (on the basis of our recommendation) but you don’t give through our website, please fill out this form to let us know about your gift; doing so helps GiveWell track our impact. We believe that even when dealing with a relatively complicated gift (for example, a gift of stock), it’s possible to give quite quickly and with only minor hassle. The much more difficult challenge is choosing a charity, and we’ve tried to make that easy as well. We hope you’ll give this season, even if you’re just starting to think about it now. If you’d like more advice about how to donate, please don’t hesitate to contact us. We’re happy to talk. ### December 2017 open thread Fri, 12/15/2017 - 11:18 Our goal with hosting quarterly open threads is to give blog readers an opportunity to publicly raise comments or questions about GiveWell or related topics (in the comments section below). As always, you’re also welcome to email us at info@givewell.org or to request a call with GiveWell staff if you have feedback or questions you’d prefer to discuss privately. We’ll try to respond promptly to questions or comments. You can view our September 2017 open thread here. The post December 2017 open thread appeared first on The GiveWell Blog. ### Give efficiently and reduce the work for charities Wed, 12/13/2017 - 11:42 GiveWell’s research aims to help donors by recommending charities we believe can put donations to use efficiently to save or improve lives. Our research focuses on maximizing the good donors can accomplish with their gifts by identifying where to donate effectively. This is the first of two posts discussing another important aspect of giving effectively: how you donate. The second post will discuss how to maximize your gift (via tax deductions, employer matches, and other strategies) and to ensure the greatest percentage of your donation reaches the charity, rather than being taken up by fees. This post will discuss how to reduce the administrative burdens on charities by choosing your donation method wisely. How you choose to donate—whether you write a check, fill out a PayPal form, or enter your credit card online—can make a huge difference for the charities that receive your gift. You can save charities time and administrative headaches by being strategic about your method of donation. Our advice follows. 1. Give predictably. We’re often asked whether it’s better to give a recurring monthly donation or to give once every year. We don’t think one is inherently better than the other. We do think it’s important that you communicate with charities about your plans; this enables them to budget for your donation. 2. Consider the fees and processing costs of your donation method. Some donation methods require more administrative work for charities to process than others. For example, check donations require multiple manual steps (such as mail retrieval, scanning, data entry, and composing a receipt), whereas online donations can be recorded and thanked automatically. The table below summarizes administrative burden and fees for donations made to GiveWell via the following methods: Processing burden Fees GiveWell recommends for what size gift? Online credit card form Low 2.15% (3.20% for AMEX) +$0.28 on each transaction. GiveWell pays the fee. Under $1,000 Check High None for domestic checks. Currency conversion and vetting fees may apply for international checks. GiveWell pays these fees. Over$1,000 Wire transfer Medium Variable. Donor pays the fee. Over $1,000 Appreciated securities High Variable. For E*Trade and Vanguard, GiveWell pays the fee. Over$1,000

The fees associated with each method also matter. Online credit card donations generally have the highest fees, but the lowest processing time for GiveWell. Checks, on the other hand, have no fees but the highest processing time.

As a result, we recommend that donors giving under $1,000 make a donation via our online credit card form. For donors giving over$1,000, the calculus changes – we recommend giving via a check. Note that due to the high processing time required for each check we receive, we would advise donors giving via check to make an annual gift, rather than dividing their gift into monthly check payments.

3. Tell charities where you heard about them and why you chose to support their work. Knowing how donors who use our research or support our operations found GiveWell and why they chose to make a donation is extremely helpful for improving our outreach and research product. We recommend giving charities this basic information. Supporters of GiveWell and our recommended charities can do this by filling out this survey.
4. Keep in touch! Charities love hearing from their supporters. Ask them questions about their work, let them know if your giving plans change, and offer them feedback on how to improve.

A separate post will discuss how you can save money on fees and give tax-efficiently so that more of your charitable budget can go directly to the organizations you want to support.

The post Give efficiently and reduce the work for charities appeared first on The GiveWell Blog.

### Staff members’ personal donations for giving season 2017

Mon, 12/11/2017 - 08:25

For this post, GiveWell staff members and contributors wrote up the thinking behind their personal donations for the year. We made similar posts in previous years (2013, 2014, 2015, 2016). Staff and contributors are listed in order of their start dates at GiveWell.

Elie Hassenfeld

This year, I’m planning to donate to GiveWell for granting to top charities at its discretion.

GiveWell is currently producing the highest-quality research it ever has, which has led to more thoroughly researched, higher-quality recommendations that have been compared to more potential alternatives than ever before. Personally, I only spent about a third of my time on top-charities-related research in 2017, so I’m thrilled by the quality of the research the GiveWell research team produced this year.

In making this decision I also talked to Lewis Bollard (about animal welfare) and Nick Beckstead (about effective altruism movement building and long-term future giving opportunities) but ultimately felt that the funding gaps that GiveWell’s top charities face were more pressing given the Open Philanthropy Project’s support of their respective portfolios.

Natalie Crispin

I continue to believe that GiveWell top charities are the best option for impact-focused giving for individuals and I plan to give my annual gift this year to GiveWell for granting at its discretion to top charities. I am grateful for all the work, thoughtfulness, and hours of debate that my colleagues put into the recommendations, and I believe that the recommendations are as strong as they’ve ever been. I am excited to support the most effective charities I know of.

Josh Rosenberg

This year I’m planning to give:

• 80% to GiveWell to grant to top charities at its discretion. I believe that GiveWell’s top charities are among the most effective ways to help people. I know how intensely our team has scrutinized these giving opportunities and am excited to give based on our research.
• 10% to the long-term future EA Fund. I would like to see future generations thrive. This podcast provides a good summary of some arguments for the moral importance of helping future generations. Based on my experience following the Open Philanthropy Project, I believe that donations to this fund will be put to good use.
• 10% to charities focused on farm animal welfare. I believe that the welfare of farm animals is a particularly important and neglected problem. I expect to choose a farm animal welfare charity to give to based on Animal Charity Evaluators’ recommendations. I look forward to using its research and would be excited to see similar charity evaluation organizations exist in other domains (e.g., policy-related giving).

I chose to diversify a portion of my giving because I want to signal my interest in a variety of important cause areas that I believe people should be considering and I want to continue to engage with the strongest giving opportunities in other domains to help myself reflect on which donations seem to be most effective. I focused most of my giving on global health and development since GiveWell’s top charities have the most pressing funding gaps I am aware of. If I knew of a strong case for a particular giving opportunity in another cause area, I would be open to changing my allocation in the future.

I also considered giving to the global development EA Fund. I think that this fund would be a good option for donors who (a) are open to higher-risk, higher-reward giving opportunities in global development, and (b) have a high degree of trust in GiveWell (Elie is the manager of the fund). The description of the fund notes that GiveWell’s Incubation Grants (GIG) program has not been hampered by insufficient funding to date. However, I think it may be useful to know if there is a large pool of donors who would like to see more GIG-type giving on the margin; giving to this fund would be a good way to show support for GIG. I ultimately chose not to donate to this fund because a substantial portion of my job is to work on GIG, and I would rather leave it to external observers to assess whether they think it deserves further support. (I see GiveWell’s top charities differently because we’ve thoroughly publicly justified the case for giving to these charities.)

Sophie Monahan

I believe that all of GiveWell’s recommended charities are excellent giving opportunities. I believe that donating to GiveWell for granting to recommended charities is an excellent option (allowing valuable flexibility) for donors whose values align well with GiveWell’s. (On values: more, more, more.)

This year, I am giving to No Lean Season for the following reasons:

• I place greater value on reducing near-term poverty for adults and children of all ages relative to preventing deaths of very young children, compared to GiveWell as a whole. I also value certainty in the near-term impact of programs relatively more. According to my values, No Lean Season and GiveDirectly are undervalued by GiveWell. Therefore I believe that their funding gaps are a higher priority for people with values like mine.
• I am giving to No Lean Season despite the fact that this year, GiveWell recommended sufficient funding to No Lean Season to fill its highest priority funding gap (to implement its program in Bangladesh in the next three years), citing reasons other than pure considerations of cost-effectiveness,1“While No Lean Season’s cost-effectiveness is at the lower end of our top charities (~5x cash transfers), we see additional reasons to prioritize this gap. We believe No Lean Season is the top charity where there is the strongest case to be made for “upside”; our cost-effectiveness analysis may not capture the potential impact of scaling a new program that could lead to greater visibility and funding for a novel type of program.” GiveWell blog: Our top charities for giving season 2017 jQuery("#footnote_plugin_tooltip_1").tooltip({ tip: "#footnote_plugin_tooltip_text_1", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); which may not repeat in future years. Therefore, I believe that marginal donations to No Lean Season are likely to increase No Lean Season’s multiyear funding.
• I am also moved by reasons of sentiment—I led GiveWell’s evaluation of No Lean Season and was very impressed—and to promote the visibility of this new top charity.

Catherine Hollander

I plan to give 90% of my donation to the Against Malaria Foundation (AMF) and 10% to No Lean Season. I trust GiveWell’s review process and its recommendation of AMF as having one of the highest-value funding gaps to fill.

Like Sophie, I plan to support No Lean Season to increase the visibility of a new charity on the list, and because it was the charity review I engaged with most deeply and personally in my time at GiveWell—I traveled with Sophie and Christian to Bangladesh to visit No Lean Season and review its work in September. I plan to limit my donation to No Lean Season to 10% of my total gift because I do not believe its need for funding is as pressing as that of AMF.

Andrew Martin

This year, I’m planning to donate to GiveWell for granting to top charities at its discretion.

I think the case remains as strong as ever that donating to GiveWell’s top charities is an exceptional opportunity for donors who want to maximize their impact. Even after accounting for Good Ventures’ $75 million in grants based on GiveWell’s recommendations this year, we believe that our top charities still have a large amount of room for more funding and that additional donations will accomplish a lot of good. I’ve decided to donate to GiveWell for granting to top charities at its discretion—rather than donating directly to individual top charities—because I believe it’s valuable for GiveWell to have the flexibility to provide funding to whichever top charities have the most pressing funding needs. Chelsea Tabart I plan to donate to GiveWell for granting to top charities at its discretion this year. Another year of exposure to the thoughtful, rigorous work of my colleagues has increased my belief in GiveWell’s research process, and I’m excited that my giving can be a small part of the exceptional work our top charities do. Christian Smith I’m planning to direct all of my year-end donations to GiveWell for granting to top charities at its discretion. Several of our charities have large, high-priority funding gaps, and I’m excited to be supporting work that I expect to have a large positive impact. I think there are reasonable worldviews and ethical positions that would make thoughtful giving in other cause areas (e.g. basic research, animal welfare, or improving the far future) appear much more cost-effective than thoughtful giving to organizations involved in global health and development. I considered directing some of my donations towards these cause areas, but ultimately had a preference for supporting causes in global health and development. I feel fine about this decision, but I may have approached my giving differently if I was not working for GiveWell. Isabel Arjmand The allocation of my charitable giving this year will be quite similar to what I did last year, though with a slightly higher proportion going to GiveWell’s top charities. As a general note, I’m inclined to diversify my giving between (1) organizations that are promising from a utilitarian point of view (like GiveWell’s top charities) and (2) those that appeal to different moral considerations. I’m excited to give 75% of my donation to GiveWell for granting to recommended charities at its discretion. My understanding of GiveWell’s research is much deeper than it was at this point last year (when I was a fairly new staff member), and I remain very enthusiastic about the quality of GiveWell’s recommendations. Especially as someone whose moral values are very close to the median values in our cost-effectiveness analyses, I think giving for granting at GiveWell’s discretion is my best option for impact-focused giving. I considered giving directly to Malaria Consortium’s seasonal malaria chemoprevention program, as I think that it may have the highest-impact remaining funding gap of our top charities, but ultimately the flexibility of giving to GiveWell’s discretionary fund and my trust in GiveWell’s judgment lead me to prefer that option. Additionally, I plan to give 5% of my donation to GiveDirectly, a GiveWell-recommended organization that I also supported last year. I’m supporting GiveDirectly because I think it’s an exceptionally strong, innovative organization with high potential for ‘upside,’ including the potential to serve as a model for other organizations. I’m thinking of the rationale for this portion of my giving as somewhere in between what I describe in the previous paragraph and what I describe below. Like last year, I’m thinking of the remainder of my charitable contribution (in this case, 20%) as serving a different, less impact-focused purpose. My goals with this portion of my giving are to promote more justice-focused causes, further my own civic engagement, and signal support for work I’d like to see more of. I’d be surprised if any of the organizations below were as cost-effective as GiveWell’s top charities; I also haven’t vetted them with an intensity that comes anywhere close to the rigor of GiveWell evaluations. Of the four organizations among which I plan to divide this donation, the first two are organizations I supported last year, and the remaining two are new to my list. • Causa Justa :: Just Cause: As I wrote last year, I see supporting Causa Justa :: Just Cause—a Bay Area-based grassroots organization supporting housing rights, immigrant rights, and racial justice—as a means of supporting the community in which I live. • Planned Parenthood: Reproductive justice and access to healthcare continue to be important to me. Particularly given the absence of a GiveWell-recommended organization providing these services abroad (which I’d guess may be more cost-effective), I’m happy to donate to a U.S.-based organization that I’m personally familiar with and have confidence in. • ProPublica: I’m donating to ProPublica in support of its high-quality independent journalism, which I think is critical to a well-functioning civic society. • Earthjustice: I decided this year to support an organization working on climate change and environmental justice, and after researching the space briefly, I found Earthjustice—which focuses on environmental protection via legal advocacy—most compelling. James Snowden (Research Consultant) This year, I donated monthly through the Effective Altruism Global Health and Development Fund, so I’ve already made the majority of my personal annual donations this year. At the end of year, I set my priorities for the next year, and adjust my automatic monthly donations accordingly. In practice, donating to the Global Health and Development Fund is similar to donating to GiveWell for granting to top charities at its discretion, as Elie is the fund manager. My primary reason for donating to Effective Altruism Funds rather than directly to GiveWell is that I want to signal support for a project I think is valuable. I plan to continue giving 80% of my donations to the Global Health and Development fund, but now donate 10% each to the Animal Welfare fund and Long-term Future fund. I think animal welfare and improving the long-term future are extremely important (more so than I did last year). I don’t feel I have enough context to independently evaluate organizations in this area so want to outsource my decisions to Lewis Bollard (for animal welfare), and Nick Beckstead (for global catastrophic risks). I’m uncertain whether, given Good Ventures’ support for animal welfare and the relatively small number of funding opportunities, there’s substantial room for more funding in that area. But I think the ‘worst case scenario’ is that I funge with Good Ventures, which I’d still think was a reasonably good outcome. I also considered: • Donating to the Centre for Pesticide Suicide Prevention. I was the primary researcher working on this GiveWell Incubation Grant and believe it’s a potentially very cost-effective (though risky) giving opportunity. I decided not to donate because the Incubation Grant is intended to fully cover their costs for two years. • Donating to Malaria Consortium’s Seasonal Malaria Chemoprevention (SMC) program. Having spent more time looking into SMC this year, I believe it’s a more cost-effective giving opportunity than Against Malaria Foundation (our recommendation to donors this year is 70% Against Malaria Foundation and 30% Schistosomiasis Control Initiative). I decided not to donate to the SMC program this year because (i) we recommended Good Ventures grant$27.9m to Malaria Consortium this year (vs $2.5m for AMF), and I don’t have a strong view that SMC would be more cost-effective on the margin after this grant (ii) I think allowing GiveWell to regrant at its discretion allows for more flexibility (iii) I place more weight in GiveWell’s aggregate view than the inside view of any individual researcher (including myself!)—although I think there’s value in thinking about this independently to identify if GiveWell is making decisions I disagree with. • Continuing to donate only to the Global Health and Development fund. I think there’s a strong argument for just donating to the opportunity you think is best in expectation, rather than diversifying. I decided to diversify a fairly small amount because (i) it more accurately signals that I care about those areas (ii) it motivates me to learn more about those areas than I otherwise would have (although I don’t expect this to be a major priority for me). • Donating a larger proportion to the Animal Welfare and Far Future funds. Given my relatively greater knowledge in global health and development, I don’t yet feel comfortable giving a greater proportion to areas I know less about. Aside from my personal giving, I advise a small foundation on their grantmaking. We haven’t yet decided where to give this year, and this will partly depend on the priorities of others involved in the decision. Notes [ + ] 1. ↑ “While No Lean Season’s cost-effectiveness is at the lower end of our top charities (~5x cash transfers), we see additional reasons to prioritize this gap. We believe No Lean Season is the top charity where there is the strongest case to be made for “upside”; our cost-effectiveness analysis may not capture the potential impact of scaling a new program that could lead to greater visibility and funding for a novel type of program.” GiveWell blog: Our top charities for giving season 2017 function footnote_expand_reference_container() { jQuery("#footnote_references_container").show(); jQuery("#footnote_reference_container_collapse_button").text("-"); } function footnote_collapse_reference_container() { jQuery("#footnote_references_container").hide(); jQuery("#footnote_reference_container_collapse_button").text("+"); } function footnote_expand_collapse_reference_container() { if (jQuery("#footnote_references_container").is(":hidden")) { footnote_expand_reference_container(); } else { footnote_collapse_reference_container(); } } function footnote_moveToAnchor(p_str_TargetID) { footnote_expand_reference_container(); var l_obj_Target = jQuery("#" + p_str_TargetID); if(l_obj_Target.length) { jQuery('html, body').animate({ scrollTop: l_obj_Target.offset().top - window.innerHeight/2 }, 1000); } } The post Staff members’ personal donations for giving season 2017 appeared first on The GiveWell Blog. ### Questioning the evidence on hookworm eradication in the American South Thu, 12/07/2017 - 09:40 Summary • Four of GiveWell’s top charities support deworming—the mass distribution of medicines to children in poor countries to rid their bodies of schistosomiasis, hookworm, and parasites. • GiveWell’s recommendation relies primarily on research from western Kenya finding that deworming in childhood boosted income in adulthood. GiveWell has also placed weight on a study by Hoyt Bleakley of the hookworm eradication effort in the American South 100 years ago. • I reviewed the Bleakley study and reach a different conclusion than he did: the deworming campaign in the American South did not coincide with breaks in long-term trends that would invite eradication as the explanation. • GiveWell research staff took the conclusions of this post into account when updating their recommendations for the 2017 giving season. GiveWell continues to recommend deworming charities. • I also reviewed a separate Bleakley study of the impacts of malaria eradication in the United States, Brazil, Colombia, and Mexico. My reading there is more supporting. I’m finalizing the write-ups now and will share them soon. Introduction After the latest refresh, GiveWell’s list of top charities includes four that support deworming—the mass distribution of medicines to children to rid their guts of certain parasites. Several dozen randomized studies measure the short-term effects of deworming programs (within a year or so) on everything from body weight to being in school.1The 2016 Campbell review finds 52 short-term studies with follow-up duration under five years. Most last one to two years. jQuery("#footnote_plugin_tooltip_1").tooltip({ tip: "#footnote_plugin_tooltip_text_1", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); If intestinal worms were often fatal, then short-term gains against them might be measured in lives saved, which could on its own make a decisive case for deworming. But the symptoms are normally subtler. On the other hand, some research finds that the aftereffects last into adulthood. This is why the long-term effects of deworming dominate GiveWell’s estimates of the cost-effectiveness of charities that support it. Unfortunately, only a handful of experimental studies assess deworming’s impacts over the long haul, and most of those are based on a single experiment in Kenya. For summaries, see this 2016 post, in the section entitled “The research on the long-term impacts of deworming.” This paucity of experimental evidence has led GiveWell to place weight on a non-experimental, historical study of deworming. Hoyt Bleakley‘s 2007 paper tracks the impacts of the campaign to eradicate hookworm from the American South a century ago. As part of an ongoing effort to scrutinize the evidence on the long-term impacts of deworming (this, this), GiveWell worked over the past year to revisit the Bleakley study. With huge assists from Christian Smith, Zachary Tausanovitch, and Claire Wang, I have formed a fresh and critical assessment of the evidence. The hookworm eradication effort in the American South did not coincide with breaks in long-term trends that would invite eradication as the explanation. For example, after the eradication campaign, outcomes such as school attendance indeed rose faster for children in historically worm-endemic areas, which could be taken as a sign of success. But that trend began decades before eradication. The full write-up is in this new working paper. As John D. Rockefeller, arguably the richest human in history, entered philanthropy just over a century ago, he was persuaded to back large-scale, scientifically informed public health campaigns—not unlike Bill Gates in our era. In 1910, he gave$1 million to create the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease. Across eleven southern states from North Carolina to Texas, the RSC soon launched what today would be called the War on Worms. Drugs were dispensed to treat infected children. Doctors, teachers, and the public were educated about the importance of sanitation, especially the use of proper privies.

From a researcher’s point of view, the suddenness and success of the campaign, and its broad geographic sweep, offer hope for credible impact assessment. If, for example, school attendance rates jumped just as infection rates plunged, that could be a compelling sign of the knock-on effects of mass deworming of children. The Bleakley (2007) study recognizes and exploits this opportunity for impact assessment. Paralleling the modern research out of Kenya, the study finds that after the RSC campaign, children in formerly worm-afflicted areas went to school more (a short-term development) and earned more as adults (a long-term effect).

In this post, I’ll explain how the GiveWell reanalysis of the Bleakley (2007) hookworm research differs from Bleakley’s original. Then I will show you some graphs that tell most of the analytical story.

I have also reviewed the related Bleakley (2010) study of the impacts of malaria eradication in the United States, Brazil, Colombia, and Mexico. There, my conclusion is more positive. I hope to release and blog that review in the next few weeks.

What we did

The reanalysis of the Bleakley (2007) hookworm study included the following steps:

• Returning to primary sources to reconstruct the data set. The data and computer code for the study are not publicly available. In correspondence starting a year ago, Hoyt Bleakley stated that they are effectively inaccessible now. Re-gathering the data was a major undertaking because Bleakley culled nearly 50 variables from obscure, century-old books and articles. Some, such as the student-teacher ratio in each county of the eleven southern states, were found in state government reports that varied in completeness and reporting conventions. Christian Smith, Claire Wang, and, especially, Zachary Tausanovitch, poured many hours into this effort.
• Expanding the census data sets. Bleakley (2007) tracks outcomes such as school attendance, literacy, and income using U.S. census data. These come to us not from old books, but from the IPUMS online database. Until recently, all the IPUMS data sets were samples from a given year’s census records, taking, for example, one household from every fifth page of the enumeration. (Here’s a sample page from 1920 with my great-grandparents and family in rows 3–6.) When carrying out this research in 2003–05, Bleakley appears to have used the biggest sets then available, such as the 1-in-250 sample from the 1910 census and the 1-in-100 sample from 1920. No data were then to be had from 1930. The GiveWell reanalysis takes advantage of the newer, bigger samples, including preliminary 100% samples for 1910–40. In aggregate, the new data set is about 100 times larger than that in Bleakley (2007).
• Copying choices from one Bleakley (2007) table or figure to another. For example, one table in the paper estimates impacts on school enrollment, school attendance, and literacy. A corresponding figure, discussed soon, only depicts impacts on attendance. In the new paper, I rerun the figure for all three outcomes.
• Imposing an arguably tougher standard for proof of impact. I concur with Bleakley that after the eradication campaign swept through the South in 1911–14, prospects improved disproportionately for children born in areas historically prone to hookworm. This catch-up, or convergence, surfaces in the data whether comparing counties within the South (low-lying counties tended to have more hookworm than mountainous ones), or comparing southern states to other states. But that observation alone leaves me unconvinced that ridding children’s bellies of hookworm was the cause. What if the trend began well before eradication or continued well after? I therefore focus on this question: Did convergence temporarily accelerate in tandem with eradication? The Bleakley (2007) tables and figures do not approach this question so aggressively.

We shared drafts of the paper and this post with Hoyt Bleakley. This did not yield any additional insight into why our analysis differs from the original.

The short-term impact on schooling

The figure below, adapted from one edition of the Bleakley study, illustrates the finding that I just mentioned, that after eradication, school attendance surged among kids living where hookworm had been common.2Versions of Bleakley (2007) appeared in the Quarterly Journal of Economics, a World Bank report, and the site of the National Center for Biotechnology Information. They are nearly the same. jQuery("#footnote_plugin_tooltip_2").tooltip({ tip: "#footnote_plugin_tooltip_text_2", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); I will convey the gist of the figure first, then explain it more precisely. You can see that the central red line stays essentially flat from 1870 to 1910. Then it jumps to about zero between 1910 and 1920, census years bracketing the Rockefeller campaign. Thereafter, the red line mostly again holds steady. The one-time jump looks like a fingerprint of eradication.

What does the red line mean exactly? For each census round with available data between 1870 and 1950, Bleakley (2007) computes the association within Southern counties between the school attendance rate of 8–16-year-olds and the hookworm infection rate as measured at the start of eradication, circa 1910.3The regressions for each census year control for the interactions of sex and race on the one hand and age on the other. They do not include the other Bleakley (2007) controls. Samples are restricted to eleven Southern states. The unit of observation is the State Economic Area, which is an aggregation of several counties. jQuery("#footnote_plugin_tooltip_3").tooltip({ tip: "#footnote_plugin_tooltip_text_3", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] }); That the red line starts around –0.1 in 1870 means that on average, if a county’s child hookworm infection rate was 10 percentage points higher when measured around 1910, its school attendance rate in the 1870 census was 1 percentage point lower. More plainly, counties with more worms in kids had fewer kids in school. But between the 1910 and 1920 censuses, that bad-news association abruptly faded. As of 1920, a child in a historically high-hookworm county was no less likely to be in school. The black, dashed lines show confidence intervals for these census-by-census estimates—probably 95% confidence, but I cannot tell for sure.

Here is the best replication of that graph using the reconstructed data and code. I have drawn it differently to emphasize that we only have data from certain decennial censuses, and to depict the gradations of confidence within the 95% confidence intervals.4The 1890 census records were destroyed in a fire. 1930 records had not been digitized at the time Bleakley did this work. jQuery("#footnote_plugin_tooltip_4").tooltip({ tip: "#footnote_plugin_tooltip_text_4", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });

I discern a resemblance between the original graph and the reconstruction. In both, school enrollment rises especially quickly between 1910 and 1920 and then declines slightly. But there is a difference too, and it is more than cosmetic. Now it appears that children in hookworm-infested areas gained substantially on school attendance not just between 1910 and 1920 but between 1880 and 1900 as well—and maybe throughout 1880–1910. For lack of access to Bleakley’s data and code, I cannot explain the discrepancy between this reconstruction and the original. There could be an error in the new or the old, or some subtle difference in data or method.

The new graph’s ambiguous mix of confirmation and contradiction forces a question that is at once conceptual and practical. How do we systematically judge whether the signal of hookworm eradication is present amidst the noise of other influences? To what degree does the new graph confirm or contradict the old?

I think there is no one best way to answer that question. One approach that I took is depicted with the red lines in the reconstructed graph above, and in the p values in the bottom-left corner. I drew the red lines to connect the dots that surround the eradication campaign. I wanted to quantify how much the red contour bends upward in 1910 and downward in 1920—as in Bleakley’s graph—and with what statistical significance. That is: Suppose the education gains took place at a constant pace between 1900 and 1940 with no acceleration around the campaign in the early 1910s. (I would have substituted 1930 for 1940 were 1930 data available in this graph.) What is the chance that we would see as much bending in the red line as we do? The computer says that for the upward kink at 1910, the answer is 0.37, which is not very low. On the other hand, the deceleration around 1920 is quite hard to ascribe to pure chance, at p = 0.03. Still, the new graph casts doubt on the proposition that the campaign brought a big break with the past.

Having settled on an analytical approach, the next step was to add all the census data that has been digitized since Bleakley did his work. This brings an obvious change (see below; now that 1930 data are included, I extend the third red line only that far). Now it looks far more as though the high-hookworm parts of the South began closing the schooling gap with low-hookworm parts around 1880, some 30 years before the hookworm campaign:

In a final test, I recomputed the graph while incorporating all the Bleakley (2007) control variables. Hookworm eradication was hardly a clean experiment, in the sense that the geographic reach of the disease was not random going in. The South had it more than the rest of the country; within the South, the coastal plains had it most. If the beneficiaries of eradication differed systematically from the rest before eradication, they could continue to differ after for reasons having little to do with hookworm prevention, creating a false appearance of impact. Striving to statistically remove such initial differences, Bleakley (2007) introduces into some of the regressions an aggressive set of controls. They relate to education, health, agriculture, and race. The paper includes these controls in some of the schooling regressions reported in a table, but does not bring them to the schooling graph shown above. It turns out that doing so (in our expanded-data graph) removes most signs of any long-term gains:

The lack of upward trend here does not mean that the historically hookworm-burdened parts of the South did not after all close a schooling gap between 1880 and 1920. It does suggest that the closure was correlated with, and therefore potentially caused by, the non-hookworm factors that Bleakley sometimes controls for.5Consistent with this graph, while the Bleakley (2007) full-controls regressions continue to put a statistically significant coefficient on the treatment proxy, the reconstructions do not. This is one of the few cases where the original results are not recognizable in the reconstruction. See Table 6, panel B, of the new paper. jQuery("#footnote_plugin_tooltip_5").tooltip({ tip: "#footnote_plugin_tooltip_text_5", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });

In sum, I do not see robust evidence that schooling and literacy improved at an historically anomalous rate circa 1910, in a way naturally attributable to hookworm eradication.

The long-term impact on earnings

What the first half of the Bleakley (2007) study does for short-term impacts on schooling, the second does for long-term impacts on earnings. Here too, the conclusion is encouraging. “Long-term follow-up,” writes Bleakley, “indicates a substantial income gain as a result of the reduction in hookworm infection.” This finding resonates strongly with the GiveWell cost-effectiveness analysis, which makes a key assumption about how much deworming children boosts future income. The number we use for that impact comes from modern, experimental research in Kenya; yet Bleakley’s inference from American history had boosted our confidence in the Kenya number. (That said, GiveWell has discounted the Kenya number by 80–90% out of fear that it won’t replicate to other settings.6See the “Replicability adjustment for deworming” row of the “Parameters” tab of the cost-effectiveness analysis spreadsheet. jQuery("#footnote_plugin_tooltip_6").tooltip({ tip: "#footnote_plugin_tooltip_text_6", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });)

The Bleakley (2007) graph I will focus on draws together data from censuses as ancient as 1870 and modern as 1990. One problem with measuring impacts on income over this span is that not until 1940 did Census takers begin asking people how much money they made. For this reason, the IPUMS census database provides proxies for income that reach back farther. One is the occupational income score (OIS), which is, approximately speaking, the average income in 1950 associated with a person’s census-reported profession. Thus, if lawyers averaged $10,000 in income in 1950, then any self-described lawyer between 1870 and 1990 is taken to earn that much. The OIS is expressed in hundreds of dollars of 1950, and is an example of an index of “occupational standing.” Before scrutinizing the evidence of long-term impacts on occupational standing, I need to describe a twist that Bleakley (2007) introduces in moving from short- to long-term. As one tries to follow people over longer periods of time, the analytical tack that Bleakley took for schooling starts to break down. For it looks at how the people in given places fared over time. The problem is that sometimes people move—across the state or across the country. And in this analytical set-up, the researcher does not follow them. If deworming gave children in coastal Georgia more agency in life—better health, more education—perhaps they exercised that agency by moving to Atlanta. If we only looked at the incomes of the people who stayed behind, we would miss the full story. To minimize this attrition from migration, in studying long-term impacts, Bleakley (2007) groups census records not by place of residence at the time of census, but by place of birth. Then, if a person was born in Georgia in 1915, showed up in the census in 1940 as a bricklayer in Atlanta, in 1950 as a general contractor in Lexington, and in 1960 as the manager of a construction company in Phoenix, all three census records would be associated with Georgia in 1915. After organizing the data this way, Bleakley (2007) could study whether children born in certain areas after eradication went on to earn more than those born in the same places before eradication. Reorganizing the data this way generates two ripple effects. First, while census takers record place of residence with extreme precision, they only record place of birth by state. We cannot differentiate people by whether they were born in hookworm-prone areas within, say, Mississippi. We can only differentiate by whether they were native to a historically high-hookworm state such as Mississippi or a low-hookworm one such as Michigan. Thus, while the short-term analysis compares counties within 11 southern states, the long-term analysis compares states across the continental U.S. The second ripple effect is that the data come to us at higher temporal resolution: by birth year, not census decade. In response, Bleakley (2007) hypothesizes that how much hookworm depressed adult earnings depended on the percentage of one’s childhood spent where it was endemic. If we take eradication to have occurred in 1910 and assume with Bleakley (2007) that childhood lasts 19 years, then babies born in or before 1891 would have reached adulthood before eradication, too soon to benefit. Babies born in endemic areas in 1892 would have been helped for one year (between their 18th and 19th birthdays); in 1893 for two; and so on. Those born in 1910 or later stood to reap the full 19 years of benefit. Bleakley (2007) therefore hypothesizes that the impact of eradication follows a sort of diagonal step shape with respect to birth year. The step starts rising in 1891 and stops in 1910. Bleakley depicted that contour with dashed lines in this figure: As you can see, Bleakley (2007) fit this contour to data, to see how well it could explain historical patterns. These dots are derived much as in the earlier Bleakley (2007) figure. For example, the leftmost dot is for the year 1825, and has a vertical coordinate of about –2. That means that among people born in 1825, being native to a state whose hookworm infection rate circa 1910 was 10 percentage points (0.1) higher corresponded to having an Occupational Income Score 0.20 lower. That means$20/year less income throughout adulthood, in the dollars of 1950. The graph shows that this association was generally negative in the mid-19th century and generally positive after 1910: formerly, coming from a hookworm zone depressed lifetime earnings. And the graph suggests that the transition followed the step pattern expected if the cause was hookworm eradication.

Below is my best reproduction of that graph. As before, I have plotted both the dots and their 95% confidence intervals. I have avoided superimposing the step-like contour the way Bleakley (2007) does because I worry that it tricks the eye into believing that the contour fits the data better than it really does. But I have marked the years when the contour kinks, 1891 and 1910:

Here is the same graph when using the 100-times-bigger census data sets now available7In addition to adding data, this version mimics the rest of the Bleakley (2007) analysis in adding blacks and in fitting directly to census microdata rather than aggregates, in order to include controls for race, sex, and their interaction. jQuery("#footnote_plugin_tooltip_7").tooltip({ tip: "#footnote_plugin_tooltip_text_7", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });:

And here is the graph when I copy Bleakley (2010) in incorporating all the controls for cross-state differences in health and health policy, education policy, and other traits8As I noted, when looking at short-term impacts on education, Bleakley (2007) does not plot a graph while incorporating all controls. But now, when looking at long-term impacts on occupational standing, Bleakley (2007) does also include such a graph. See the bottom right of this figure. jQuery("#footnote_plugin_tooltip_8").tooltip({ tip: "#footnote_plugin_tooltip_text_8", tipClass: "footnote_tooltip", effect: "fade", fadeOutSpeed: 100, predelay: 400, position: "top right", relative: true, offset: [10, 10] });:

Does it look to you like the upward trends in these last two graphs accelerated around 1891 and decelerated around 1910, as predicted by the Bleakley (2007) theory? To me, I have to say, not much. The climbs look steady and longer-term.

Since “not much” is muddy, I moved once again to formalize my interpretation. In analogy with my earlier graphs for schooling, I fit lines to the data points in the 19 years between 1891 and 1910, as well as to the 19 years on either side. Then I checked whether any bending in 1891 and 1910 is statistically significant. The final two graphs fit lines to the dots in the previous two. The dots in these next graphs are the same as in the previous two. It doesn’t look that way because I erased the grey confidence bars in order to expand the vertical scales.

In the both graphs the trend looks quite straight over the three generations surrounding the eradication campaign. The p values, shown in the bottom-right of each plot, are high.

Conclusion

Reanalyzing the Bleakley (2007) study left me unconvinced that the children who benefited from hookworm eradication went to school more or earned more as adults. Conceivably, if I had access to the original data and code, the confrontation with the reconstructed versions would expose errors in the GiveWell version that would alter my view. But this seems unlikely. The new census data sets are much bigger than the old, which improves precision. And most of the differences probably do not arise from clear-cut errors on either side, but from minor differences in implementation, such as taking education spending from a different edition of an annual government report. If the conclusions swing on such modest and debatable discrepancies, then they are not robust and reliable.

Finally, even if the two versions of the data matched exactly, I might still disagree on interpretation, since I use tests, illustrated above, that focus more exclusively on whether the time trends contain the temporal fingerprint of hookworm eradication. For me, that fingerprint is characterized not merely by once-high-hookworm areas catching up with low-hookworm ones, but catch-up that accelerates and decelerates at times that fit the timing of the eradication campaign.

The data and code for this study are here (1.6 GB). The full write-up is here.

Notes   [ + ]

1. ↑ The 2016 Campbell review finds 52 short-term studies with follow-up duration under five years. Most last one to two years. 2. ↑ Versions of Bleakley (2007) appeared in the Quarterly Journal of Economics, a World Bank report, and the site of the National Center for Biotechnology Information. They are nearly the same. 3. ↑ The regressions for each census year control for the interactions of sex and race on the one hand and age on the other. They do not include the other Bleakley (2007) controls. Samples are restricted to eleven Southern states. The unit of observation is the State Economic Area, which is an aggregation of several counties. 4. ↑ The 1890 census records were destroyed in a fire. 1930 records had not been digitized at the time Bleakley did this work. 5. ↑ Consistent with this graph, while the Bleakley (2007) full-controls regressions continue to put a statistically significant coefficient on the treatment proxy, the reconstructions do not. This is one of the few cases where the original results are not recognizable in the reconstruction. See Table 6, panel B, of the new paper. 6. ↑ See the “Replicability adjustment for deworming” row of the “Parameters” tab of the cost-effectiveness analysis spreadsheet. 7. ↑ In addition to adding data, this version mimics the rest of the Bleakley (2007) analysis in adding blacks and in fitting directly to census microdata rather than aggregates, in order to include controls for race, sex, and their interaction. 8. ↑ As I noted, when looking at short-term impacts on education, Bleakley (2007) does not plot a graph while incorporating all controls. But now, when looking at long-term impacts on occupational standing, Bleakley (2007) does also include such a graph. See the bottom right of this figure. function footnote_expand_reference_container() { jQuery("#footnote_references_container").show(); jQuery("#footnote_reference_container_collapse_button").text("-"); } function footnote_collapse_reference_container() { jQuery("#footnote_references_container").hide(); jQuery("#footnote_reference_container_collapse_button").text("+"); } function footnote_expand_collapse_reference_container() { if (jQuery("#footnote_references_container").is(":hidden")) { footnote_expand_reference_container(); } else { footnote_collapse_reference_container(); } } function footnote_moveToAnchor(p_str_TargetID) { footnote_expand_reference_container(); var l_obj_Target = jQuery("#" + p_str_TargetID); if(l_obj_Target.length) { jQuery('html, body').animate({ scrollTop: l_obj_Target.offset().top - window.innerHeight/2 }, 1000); } }

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### Want to talk to someone at GiveWell about your giving decision?

Tue, 12/05/2017 - 10:12

If you’re thinking about where to give to charity this year and it would be helpful to speak with a member of GiveWell’s staff about your decision, please let us know. We’re happy to answer questions sent to info@givewell.org or to schedule a call via the form here.

We know we publish a lot of information, and we’re glad to provide a brief overview of our headline recommendations. We can also answer questions about our process for finding top charities, the strengths and weaknesses of our top charities, or how your personal values might point you toward one organization we recommend over another. Conversations like these also help us understand how people use our research and what questions they have.

Due to limited staff capacity, it’s possible we won’t be able to speak with everyone who requests a call, although based on past experience we hope to be able to connect with anyone who gets in touch.

We look forward to hearing from you!

The post Want to talk to someone at GiveWell about your giving decision? appeared first on The GiveWell Blog.

### Our top charities for giving season 2017

Mon, 11/27/2017 - 14:33

This year, we added two new top charities, Evidence Action’s No Lean Season program and Helen Keller International’s vitamin A supplementation program, and retained our seven top charities from 2016. We also added Evidence Action’s Dispensers for Safe Water program to our list of standout charities.

We recommend that donors give to GiveWell for granting to top charities at our discretion so that we can direct the funding to the top charity or charities with the most pressing funding need. For donors who prefer to give directly to our top charities, we recommend giving 70 percent of your donation to the Against Malaria Foundation (AMF) and 30 percent to the Schistosomiasis Control Initiative (SCI) to maximize your impact. We expect Good Ventures, a foundation with which we work closely, to provide significant support to each top charity; our recommendation to give to AMF and SCI is based on how much good we believe additional donations can do.

Our top charities and recommendations for donors, in brief

Top charities

We now have nine top charities. They are:

Standout charities

We also provide a list of standout charities. We believe they are implementing programs that are evidence-backed and may be extremely cost-effective. However, we do not feel as confident in the impact of these organizations as we do in our top charities.

Conference call to discuss recommendations

We are planning to hold a conference call at 1:30pm ET/10:30am PT on Thursday, November 30 to discuss our charity recommendations and answer your questions.

If you’d like to join the call, please register using this online form. If you can’t make this date, but would be interested in joining another call at a later date, please indicate this on the registration form.

Below, we provide:

• An explanation of changes to our recommended charity list and of major changes to our review process in the past year that are not specific to any one organization. More
• A discussion of our approach to determining how much funding charities can use effectively (“room for more funding”) and our ranking of charities’ funding gaps. More
• Reasoning behind how we have ranked charities’ funding gaps. More
• Details about each of our new top charities, including an overview of what we know about their work and our understanding of their funding needs. More
• Details about each of the top charities we are continuing to recommend, including an overview of their work, major changes over the past year, and our understanding of their funding needs. More
• A brief overview of each of our standout charities. More
• The process we followed that led to these recommendations. More
• An update on giving to support GiveWell’s operations versus giving to our top charities. More
Major changes in the last 12 months

Major changes to our recommended charities list and review process over the past year include:

• Overall, we believe our top charities are able to absorb more funding than they could in previous years. This is a result both of recent additions to the top charities list with large funding gaps (particularly Malaria Consortium) as well as expansion by top charities that have been on the list for a longer time (particularly Deworm the World and AMF).

We expect overall “room for more funding” to continue to expand as we gain more confidence in recently-added top charities and continue to add new top charities, particularly through GiveWell Incubation Grants, our program to grow the pipeline of potential future top charities and improve our understanding of our current top charities.

• We added two new programs to our list of top charities: vitamin A supplementation (VAS) and seasonal migration subsidies. We have not previously recommended charities that work on these programs.

We had considered VAS a priority program for a number of years but had not found an organization that was able to answer our key questions. While we have some remaining questions, we can now make a strong case for supporting HKI’s work on VAS.

We initially supported No Lean Season through GiveWell’s Incubation Grants program. No Lean Season is the first organization we have added to our top charity list through our Incubation Grants program.

• Last year, the charities we recommended on the margin were estimated to be about three times as cost-effective as unconditional cash transfers, the program implemented by top charity GiveDirectly. This year, we believe that the charities we are recommending on the margin are about six times as cost-effective as cash transfers. For the most part, this change was due to (a) a series of small adjustments to our cost-effectiveness model and (b) changes in which individuals contribute to the model and the values entered into the model by these and other contributors.

We now feel fairly confident that there will be large amounts of room for more funding in this range. As more time has passed without identifying opportunities that are considerably more cost-effective than this, we have become more pessimistic about finding such opportunities. Our current best guess is that, if they exist, they will be in the area of policy advocacy in developing countries, on issues like lead regulation and tobacco taxation. We intend to do further research in those areas.

• We made a significant change to our cost-effectiveness analysis to more formally incorporate adjustments for the way in which our top charities’ funding affects funding from other sources by (a) attracting more resources to the programs they work on (e.g., governments contributing staff time to support implementation of the programs) or (b) displacing resources that would have otherwise supported the programs. We will be writing more about this in a future post.

• We continued to analyze the complex evidence base for deworming (treating intestinal parasites), the program implemented by four out of our nine top charities.

At the end of 2016, David Roodman, a Senior Advisor to GiveWell, conducted a detailed review of the core evidence underlying our deworming recommendation (blog posts here and here).

This year, we saw new follow-up results on the main study that leads us to recommend deworming, which continued to show similar long-term impacts of deworming on adult earnings as were estimated previously.

Further investigation and updates based on new data led us to believe that two deworming studies (Croke 2014 and Bleakley 2007) no longer provide substantial support for the theory that deworming has long-term impacts. We plan to write more about this in the future. All together, this work led us to the same conclusion about deworming: that it is a reasonable bet to take based on its strong cost-effectiveness (which incorporates our uncertainty about the impact).

Room for more funding analysis

Types of funding gaps

In the last two years, we used a framework of “capacity funding” and “execution levels” to compare funding gaps (unfilled funding needs) across charities. This framework was intended to capture whether funding would enable a charity to expand or grow in important ways and how likely it was, in our estimation, that each top charity would be constrained by funding in the next year.

We developed this approach in response to a situation where we expected to direct more funding to several of our top charities than they would be able to use (commit or spend) in that year. We used capacity funding to describe opportunities to increase the amount of funding a charity might be able to absorb in the future (by, say, investing in expanding to a new location) and execution levels to describe the likelihood, down to the 5 percent level, that a charity would be able to make use of additional funding before encountering non-funding bottlenecks to their work.

This year, because we have added new top charities and most of our other top charities have more room for more funding than in previous years, we expect that the funding we will direct to each organization will not reach the level where they will encounter significant non-funding bottlenecks. As a result, we have moved away from describing capacity funding and execution levels.

Ranking funding gaps

The first million dollars to a charity can have a very different impact from the 20th million dollars. Accordingly, we have created a ranking of individual funding gaps that accounts for our best guess of the impact of additional funds at each level.

The below table lays out our ranking of funding gaps, up to $75.7 million in total funding. We expect Good Ventures to give$75 million to GiveWell’s top charities this year, so this table is our recommendation to Good Ventures, plus the allocation of funding that GiveWell holds to allocate at its discretion (currently $0.7 million). We then discuss our recommendation for all other donors. The Open Philanthropy Project, which was incubated at GiveWell but is now a separate organization, plans to write more soon about the reasons for Good Ventures increasing its support of GiveWell top charities from$50 million last year to $75 million this year. In short, the amount was based on discussions about how to allocate funding across time and across cause areas. It was not set based on the total size of top charities’ funding gaps or the projection of what others would give. Charity Description Amount (millions) All top charities Incentive grants:$2.5 million per charity 22.5 All standout charities Standout grants: $100,000 per charity 0.7 Deworm the World Funding gaps in India and Kenya over the next three years (including central costs) 3.0 Helen Keller International Funding gaps over three years in Burkina Faso, Mali, and Guinea—countries that have missed recent vitamin A campaigns due to lack of funding 4.7 No Lean Season Full funding gap over three years for implementing the program in Bangladesh 9.0 Deworm the World Three years of funding for a new program in Pakistan and reserves to protect against funding shortfalls in India 10.4 Malaria Consortium Part of the funding gap for SMC in Burkina Faso, Nigeria, and Chad over the next three years 25.4 In total, we are recommending that Good Ventures make the following grants: • Malaria Consortium’s seasonal malaria chemoprevention program:$27.9 million
• Evidence Action’s Deworm the World Initiative: $15.2 million. We are also recommending that GiveWell’s Board of Directors grant the$0.7 million in discretionary funds that we currently hold from the third quarter (from donors who selected to give to “Grants to recommended charities at GiveWell’s discretion” on our donation form) to Deworm the World, bringing the total to $15.9 million. • Evidence Action’s No Lean Season program:$11.5 million
• Helen Keller International’s vitamin A supplementation program: $7.2 million • Schistosomiasis Control Initiative:$2.5 million
• Against Malaria Foundation: $2.5 million • Sightsavers’ deworming program:$2.5 million
• END Fund’s deworming program: $2.5 million • GiveDirectly:$2.5 million

Our recommendation to donors

For donors who are interested in directing funding to whichever recommended charity or charities GiveWell believes has the most pressing funding need at the time the funds are granted, we recommend giving to “Grants to recommended charities at GiveWell’s discretion.” These grants will respond to the greatest funding need we see; they may not match the recommended allocation outlined below.

For donors (other than Good Ventures) who are interested in donating directly to our top charities, we recommend splitting your donation as follows:

• 70 percent to the Against Malaria Foundation
• 30 percent to the Schistosomiasis Control Initiative
Why these recommendations?

Our recommendations to donors, including Good Ventures, are based on:

1. Overall cost-effectiveness of the charity. Our cost-effectiveness model is a key input into our decision-making process, and large differences in modeled cost-effectiveness impact our recommendations. We try not to put significant weight on relatively small differences in cost-effectiveness according to the model because many inputs are highly uncertain.

Our model this year found relatively small differences between many top charities, with Deworm the World at ~12 times as cost-effective as cash transfers, four top charities in the ~6-10x cash transfers range, and three top charities in the ~3-5x cash transfers range. We consider differences between charities implementing the same intervention or interventions that have similar inputs and output in the model more meaningful (e.g., malaria nets and seasonal malaria chemoprevention) than differences between charities implementing quite different interventions.

We have completed a sensitivity analysis of our cost-effectiveness analysis to get a better sense for which parameters are most sensitive. We are more hesitant to consider differences in the cost-effectiveness as meaningful when they rely on very sensitive inputs.

2. Cost-effectiveness of particular funding opportunities. Charities’ work can vary significantly in cost-effectiveness across locations due to different costs, disease burdens, uptake in the targeted population, or probability that other funders would step in in GiveWell’s absence. While not a part of our formal cost-effectiveness model, we ran supplementary analyses of cost-effectiveness for some locations for which our top charities were seeking additional funding and considered the output as part of our prioritization of funding gaps.
3. Qualitative factors not captured in our cost-effectiveness model. The main factors we focused on were:
• Proportion of the global funding need for the program that is filled. We expect that funders will generally (but imperfectly) select the areas where cost-effectiveness is higher first, leaving the areas with higher costs, lower disease burden, lower cultural acceptance of the program, etc. for last. We believe we have captured some of the consequences of this in our cost-effectiveness analysis. For example, we use national level disease burden estimates for the countries in which each charity has worked and/or plans to work; charities working in higher burden countries are therefore modelled as more cost-effective. But we do not use sub-national estimates to distinguish the highest priority regions within a country; if charities are filling the lowest priority funding gaps within a county, they will likely be less cost-effective than our model suggests. This was an important consideration in comparing AMF and Malaria Consortium. We estimate that ~80 percent of the global funding need for nets (the program AMF implements) has been filled, and ~35 percent of the global funding need for seasonal malaria chemoprevention (the program Malaria Consortium implements).
• Our level of knowledge about the organization. We have recommended AMF, Deworm the World, SCI, and GiveDirectly for many years. We know less about Malaria Consortium and No Lean Season and the least about HKI. We seek to be somewhat conservative about recommending large amounts of funding to organizations where there is a relatively high chance that additional research could lead us to believe the program was less cost-effective than we previously thought.
• Ease of communication with the organization. It is important to us that we are able to learn over time about the charities we recommend, to enable us to improve our decisions. The ability to communicate effectively with an organization is a key factor in our ability to learn from the organization’s experiences.
• Ongoing monitoring and likelihood of detecting future problems. Evaluating an organization’s monitoring processes and results is an important part of our charity reviews and for the most part is not captured in our cost-effectiveness analysis. As with ease of communication, we have more confidence in recommending funds to an organization if we believe that we will learn about how successful its work has been.

Summary of key considerations for top charities

The table below summarizes the key considerations for our nine top charities. More detail is provided below, as well as in the charity reviews.

Estimated cost-effectiveness (relative to cash transfers) Our level of knowledge about the organization Primary benefits of the intervention Ease of communication Ongoing monitoring and likelihood of detecting future problems Room for more funding, after expected funding from Good Ventures and donors who give independently of our recommendation Other major considerations AMF ~6x High Deaths averted and possible increased income in adulthood Strong Strong High: could absorb tens of millions of dollars High proportion (~80%) of global gap for program is filled Malaria Consortium (SMC program) ~7x Moderate Under-5 deaths averted and possible increased income in adulthood Strong Strong High: could absorb tens of millions of dollars Relatively low proportion (~35%) of global gap for program is filled Helen Keller International (VAS program) ~9x Moderate Under-5 deaths averted Strong Moderate High: could absorb tens of millions of dollars Learning benefits Deworm the World ~12x High Possible increased income in adulthood Strong Strong Moderate: could absorb millions of dollars END Fund (deworming program) ~4x Moderate Possible increased income in adulthood Moderate Moderate Moderate: could absorb millions of dollars SCI ~10x High Possible increased income in adulthood Moderate Moderate High: could absorb tens of millions of dollars Sightsavers (deworming program) ~5x Moderate Possible increased income in adulthood Moderate Moderate Moderate: could absorb millions of dollars No Lean Season ~5x Moderate Immediate increase in consumption Strong Moderate Low: further funding would be used for different types of activities Potential upside GiveDirectly Baseline High Immediate increase in consumption and assets Strong Strong Very high: could absorb over 100 million dollars

Reasons for this funding gap ranking

Prioritization of funding that we have recommended to Good Ventures (we recommend Good Ventures fill the highest-priority funding needs first, to ensure these are funded):

1. We start by recommending that each top charity receive $2.5 million as an “incentive grant.” These grants are intended to be a major contribution to the charity’s work in recognition of the fact that they have met GiveWell’s criteria and have dedicated significant time to working with us to help us follow their progress and plans each year. We don’t want our top charity funding process to be winner-takes-all because we believe that charities would be less likely to want to participate in that case. 2. After incentive grants, we believe the next most valuable funding to provide is for Deworm the World’s work in Kenya and India over the next three years. Deworm the World’s work in Kenya and India is the most cost-effective opportunity we have found. We estimate that its work in Kenya is ~20x as cost-effective as cash transfers and in India is ~30x+ as cost-effective as cash transfers. 3. We rank providing funding to our two new top charities, Helen Keller International (HKI)’s VAS program and No Lean Season, next. We estimate that HKI could use$7.2 million over three years to support VAS campaigns in countries with high child mortality rates that have recently missed campaigns due to lack of funds. HKI’s cost-effectiveness is at the high end of the range for top charities (~9x cash transfers). We believe HKI could absorb more than $7.2 million in additional funding for VAS effectively but that this$7.2 million gap is likely more cost-effective than HKI’s average cost-effectiveness. Also, because HKI is a new top charity of ours, we expect this first part of its gap to have significant learning benefits for us: by giving this money, we’ll be better positioned to follow HKI’s work and review its monitoring, which we believe will make it more likely that we have a more accurate estimate of its impact in future years.

We decided to recommend funding all of No Lean Season’s funding gap in Bangladesh for the next three years. While No Lean Season’s cost-effectiveness is at the lower end of our top charities (~5x cash transfers), we see additional reasons to prioritize this gap. We believe No Lean Season is the top charity where there is the strongest case to be made for “upside”; our cost-effectiveness analysis may not capture the potential impact of scaling a new program that could lead to greater visibility and funding for a novel type of program.

4. We think the next highest priority funding to provide is $10.4 million to Deworm the World. This funding would support a new program in Pakistan and provide reserve funding for programs supported with restricted funds. We estimate that the program in Pakistan will be roughly ~7x as cost-effective as cash transfers, though this estimate is very sensitive to estimates of worm burdens in the locations where Deworm the World plans to work. The reserve funding is intended to make it unlikely that the India program, which we believe is very highly cost-effective, will be interrupted—Deworm the World relies on restricted funding for this program and there is some chance that this funding will not be available in the future. It may use this GiveWell-directed funding for other opportunities if it is not needed to backstop restricted funding in India; we expect that it will have unfunded opportunities remaining in the next few years, particularly in Nigeria. 5. The last funding gap on our list of recommendations for Good Ventures is$23.6 million to Malaria Consortium for its work on SMC. When choosing which gap to recommend for the remainder of Good Ventures’ $75 million, we focused on the remaining funding needs for Malaria Consortium’s SMC program, AMF, and SCI, which we believe to have the next highest-value gaps. Our cost-effectiveness model indicates that SCI is the most cost-effective of these three organizations (~10x cash transfers, compared with ~6-7x cash transfers for AMF and Malaria Consortium), but when the difference in modelled cost-effectiveness between two charities is relatively small, we also put significant weight on qualitative factors. We believe that AMF and Malaria Consortium are stronger on some qualitative factors, particularly the likelihood that we will be able to learn about the programs’ performance through the monitoring they conduct. Between AMF and Malaria Consortium, we have prioritized Malaria Consortium’s funding gap primarily due to the qualitative considerations discussed above around the proportion of the global funding need that is filled. After following Malaria Consortium for a second year, we believe that Malaria Consortium and AMF are comparable on other major qualitative factors, such as quality of ongoing monitoring and likelihood of detecting future problems. The total amount we are recommending for Malaria Consortium’s SMC program represents a rough compromise between providing a high level of funding to a program that we prefer to the next funding gap on the list and not wanting to make too large of a bet on an organization that we have less experience with than some other top charities. Prioritization for non-Good Ventures donors: 1. Our current recommendation for donors is to give to GiveWell for making grants to top charities at our discretion. Our goal is for SCI to receive$9 million, in addition to the $2.5 million incentive grant that we are recommending to Good Ventures, and AMF to receive the remainder of expected GiveWell-directed funding because AMF and SCI represent the next highest-value funding opportunities we see. Giving us funding to grant at our discretion allows GiveWell to better target this allocation, and to adapt if we learn new information about pressing, high-value funding needs at our top charities. 2. For donors who prefer to give directly to charities, we recommend giving 70 percent to AMF and 30 percent to SCI. These percentages are our best guess of what will achieve our target allocation given our projections of total donations driven by our recommendations. This allocation comes from a belief that, at these margins, it is difficult to distinguish between the quality of AMF and SCI’s funding gaps. SCI has better modeled cost-effectiveness, while AMF appears to be better on several qualitative factors, including monitoring of program performance. We have roughly targeted a two-to-one ratio between the two. Details on new top charities Helen Keller International (HKI) for work on vitamin A supplementation Our full review of HKI’s work on vitamin A supplementation is here. Overview HKI (http://www.hki.org/) is a large organization with multiple programs focused on reducing malnutrition and averting blindness and poor vision. Our review focuses on HKI’s work on vitamin A supplementation (VAS) and our recommendation is specific to its VAS program. HKI provides technical assistance, engages in advocacy, and contributes funding to government-run VAS programs. There is strong evidence from many randomized controlled trials (RCTs) conducted in the 1980s and 1990s that VAS can substantially reduce child mortality, but weaker evidence on how effective VAS is in the places HKI would work with additional funding in the next few years. In particular, there is little available information on current rates of vitamin A deficiency in areas where HKI works. We have adjusted our cost-effectiveness analysis for our best guess of how much less effective VAS is today (~25 percent as effective as in the trials in the 1980s and 1990s); the intervention remains cost-effective with that adjustment. We feel that the monitoring data that we have seen from HKI’s programs gives us limited information on HKI’s past performance, but demonstrates the types of data HKI is able to collect on program performance. We have requested that HKI collect this monitoring data of all programs funded with GiveWell-directed funds. Overall, we have not yet investigated HKI at the same level of depth as some of our other top charities, which we have recommended for several years. We have reviewed documents from HKI, had a number of conversations with their staff, and spent three days meeting with HKI and observing a VAS campaign in Guinea. We have remaining questions about HKI’s work that we will seek more information on in the future, but overall we believe this program is, like our other top charities, an excellent giving opportunity. Funding gap We believe that HKI’s VAS work is highly likely to be constrained by funding next year. HKI has provided details of VAS programs that it could support with additional funding of up to about$41.4 million in 2018-2020. HKI appears to have limited prospects for funding these programs from other sources.

Our understanding is that with additional funds, HKI would cause additional rounds of VAS to occur in some countries, while in other countries, HKI primarily aims to increase coverage rates in rounds of VAS that would take place regardless of its involvement. We have asked HKI to prioritize use of GiveWell-directed funding in countries where it expects to cause additional rounds of VAS to occur. HKI’s funding gap for countries that have recently missed VAS campaigns due to lack of funds is $7.2 million. HKI’s VAS work was supported by the Canadian government in the past. That funding ended in 2016 and has not been renewed. Over the past year, several VAS campaigns have been skipped in countries HKI previously supported. Evidence Action’s No Lean Season program Our full review of No Lean Season is here. Overview No Lean Season (https://www.evidenceaction.org/beta-no-lean-season/) provides no-interest loans to poor rural households during the season of income and food insecurity (‘lean season’) between planting and the major rice harvest in rural northern Bangladesh. Loans are conditional on a household member stating their intention to migrate to urban or other rural locations to seek short-term employment. Several randomized controlled trials (RCTs) of subsidies to increase migration provide moderately strong evidence that such an intervention increases household income and consumption during the lean season. An additional RCT is ongoing. We estimate that No Lean Season is roughly five times as cost-effective as cash transfers (see our cost-effectiveness analysis). Evidence Action has shared some details of its plans for monitoring No Lean Season in the future, but, as many of these plans have not been fully implemented, we have seen limited results. Therefore, there is some uncertainty as to whether No Lean Season will produce the data required to give us confidence that loans are appropriately targeted and reach their intended recipients in full; that recipients are not pressured into accepting loans; and that participants successfully migrate, find work, and are not exposed to major physical and other risks while migrating. Funding gap We expect No Lean Season to have opportunities to spend$11.5 million more than we expect it to receive over the next three years to implement and monitor the program in Bangladesh. We expect it to have a further $3.9 million in opportunities to expand to other countries and do further research, in Bangladesh and other locations. Evidence Action is seeking funding beyond this level to allow it to build reserves for No Lean Season. Details on top charities we are continuing to recommend Against Malaria Foundation (AMF) Our full review of AMF is here. Background AMF (againstmalaria.com) provides funding for long-lasting insecticide-treated net (LLIN) distributions for protection against malaria in developing countries. AMF has conducted post-distribution surveys of all completed distributions to determine whether LLINs have reached their intended destinations and how long they remain in good condition. AMF’s post-distribution surveys have generally found positive results (with some exceptions); we believe they have some methodological limitations. We estimate that AMF’s program is roughly six times as cost-effective as cash transfers (see our cost-effectiveness analysis). This estimate seeks to incorporate many highly uncertain inputs, such as the effect of mosquito resistance to the insecticides used in nets on how effective they are at protecting against malaria, how differences in malaria burden affect the impact of nets, and how to discount for displacing funding from other funders, among many others. Important changes in the last 12 months Prior to this year, we had seen results from AMF’s “post-distribution check ups” (PDCUs) from two countries, Malawi and the Democratic Republic of the Congo, and had significant uncertainties about the methodology used in each location. We have now also seen results from Ghana. We have more confidence in our understanding of AMF’s PDCUs than we did previously, though this work is ongoing. In particular, we commissioned IDinsight, an organization with which we are partnering as part of our Incubation Grants program, to observe post-distribution surveys in Malawi and Ghana and report their findings (see links). Further discussion of the strengths and weaknesses of PDCUs here. In 2017, AMF signed relatively few new agreements to fund LLIN distributions and, as a result, has a balance of$58 million in uncommitted funds, or $35 million if distributions where AMF believes agreements are imminent are counted as committed. Our understanding is that many of AMF’s conversations with countries could not progress until decisions were made about how much Global Fund funding each country would allocate to LLIN distributions (as opposed to other malaria control efforts). This decision-making process extended into late 2017. Global Fund funding is allocated on three-year cycles and we do not expect this to continue to be a bottleneck for AMF in 2018. Funding gap We believe that AMF is very likely to be constrained by lack of funding. There is high uncertainty in the maximum amount of funding that AMF could use productively, though we expect the maximum to be much greater than what AMF is likely to receive. To fund all of the distributions that it is currently in detailed discussions about, AMF would need$50 million more than we project it will receive. The total funding gap for LLINs for 2018-2020 appears to be hundreds of millions of dollars.

With additional funding, AMF’s top priorities would be to fund a portion of the next round of distributions, in 2018-2020, in each of the countries in which it has recently funded distributions.

END Fund (for work on deworming)

Our full review of the END Fund’s work on deworming is here.

Background

The END Fund (end.org) manages grants, provides technical assistance, and raises funding for controlling and eliminating neglected tropical diseases (NTDs). We have focused our review on its support for deworming.

Slightly more than half of the treatments the END Fund has supported have been deworming treatments, while the rest have been for other NTDs. The END Fund has funded SCI, Deworm the World, and Sightsavers. We see the END Fund’s value-add as a GiveWell top charity as identifying and providing assistance to programs run by organizations other than those we separately recommend, and our review of the END Fund has excluded results from charities on our top charity list.

We have seen limited monitoring results on the number of children reached in END Fund-supported programs. In 2016, the END Fund began requiring that surveys be conducted to determine whether its programs have reached a large proportion of children targeted; we have seen coverage surveys for (a non-random sample of) 35 percent of its 2016 deworming grant portfolio. These studies leave us with some remaining questions about the program’s impact.

Important changes in the last 12 months

We significantly improved our understanding of the END Fund’s cost per treatment and the baseline prevalence in areas that the END Fund works (which is used in our cost-effectiveness analysis), though we continue to have lower confidence in our estimates than we do for the deworming organizations that we have recommended for several years. We also saw some monitoring from END Fund programs; previously our recommendation of the END Fund was based on specific monitoring plans that we found credible.

Funding gap

We believe the END Fund could substantially increase its deworming grantmaking with additional funds. We roughly estimate that there is gap of $18 million between the amount of funding the END Fund will have available for grants for deworming and the amount of funding it would need to make all of the potential grants it has identified. Sources of major uncertainty in this estimate include whether the END Fund will encounter non-funding bottlenecks in some of its identified and early-stage opportunities, the amount of funding it will receive from other sources, the proportion of funding it will allocate to deworming, and costs other than grants. Evidence Action’s Deworm the World Initiative Our full review of Deworm the World is here. Background Evidence Action’s Deworm the World (evidenceaction.org/#deworm-the-world) advocates for, supports, and evaluates deworming programs. Its main countries of operation are India, Kenya, and Nigeria, and it is considering expanding to Pakistan. Deworm the World retains or hires monitors who visit schools during and following deworming campaigns. We believe its monitoring is the strongest we have seen from any organization working on deworming. Monitors have generally found high coverage rates and good performance on other measures of quality. As noted above, we believe that Deworm the World overall is the most cost-effective charity we have found. We estimate that it is ~12 times as cost-effective as cash transfers, but note that, due to differences in worm burdens and costs across countries, there is significant variation in cost-effectiveness across the countries in which it works. We estimate that its work to date in India has been more than 30 times as cost-effective as cash transfers, while its planned work in Nigeria is around three times as cost-effective as cash transfers (though this estimate is based on low-quality information). Important changes in the last 12 months We estimate that Deworm the World could absorb considerably more funding this year than we estimated last year, due to opportunities it has identified to expand its geographic reach. (More in the next section.) The quality of the monitoring that we have seen from Deworm the World has remained high. To date, we have seen limited monitoring from Nigeria, which is a new addition to Deworm the World’s portfolio and is expected to become a major portion of its work in the future. This is of minor concern given the strong monitoring track record elsewhere and how new the program is in Nigeria. Funding gap We believe that Deworm the World is very likely to be constrained by funding. We expect Deworm the World to have opportunities to spend$18.9 million more than we expect it to receive over the next three years. Funding beyond this level would allow Deworm the World to build its reserves and take advantage of unanticipated opportunities.

With additional funding, Deworm the World would sustain its current work in Kenya and India, and would seek to expand its work in Nigeria and India to additional states and support the government in Pakistan to initiate a deworming program.

GiveDirectly

Our full review of GiveDirectly is here.

Background

GiveDirectly (givedirectly.org) transfers cash to households in developing countries via mobile phone-linked payment services. It targets extremely low-income households. The proportion of total expenses that GiveDirectly has delivered directly to recipients is approximately 82 percent overall. We believe that this approach faces an unusually low burden of proof, and that the available evidence supports the idea that unconditional cash transfers significantly help people.

We believe GiveDirectly to be an exceptionally strong and effective organization, even more so than our other top charities. It has invested heavily in self-evaluation from the start, scaled up quickly, and communicated with us clearly. We believe that GiveDirectly has been effective at delivering cash to low-income households. GiveDirectly has one major randomized controlled trial (RCT) of its impact and took the unusual step of making the details of this study public before data was collected. It continues to experiment heavily, with the aim of improving how its own cash transfer programs are run as well as those of governments. It has recently started work on a universal basic income trial and has started partnering with major funders on evaluations of cash transfers in new geographies with the aim of influencing the broader international aid sector to use its funding more cost-effectively.

We believe cash transfers are less cost-effective than the programs our other top charities work on, but have the most direct and robust case for impact. We use cash transfers as a “baseline” in our cost-effectiveness analyses and only recommend other programs that are robustly more cost-effective than cash.

Important changes in the last 12 months

We had previously expressed reservations about GiveDirectly’s targeting strategy: that by excluding the least poor households in each village, the program might lead to negative reactions by non-recipients, increase costs per household reached, and exclude households that were still quite poor. In 2017, GiveDirectly largely switched to a “saturation” approach of making transfers to all households in selected villages. It will continue to use a targeted approach in Rwanda, where government regulations require such an approach, but the saturation approach will be used in Kenya and Uganda.

In 2016, GiveDirectly built up its operations in Uganda and Kenya with the anticipation of revenue growth in 2017. Revenue growth has been slower than expected and GiveDirectly had to lay off some staff as a result.

GiveDirectly launched its universal basic income project this month.

In 2015, Good Ventures made a grant of $25 million to GiveDirectly on GiveWell’s recommendation. GiveDirectly’s goals for the grant were to expand its ability to raise funds from donors not influenced by GiveWell’s recommendation and to collaborate with large aid institutions or governments to address their questions about cash transfers. We expect to write more about the performance of the grant in the future, but, in short, our impression is that fundraising has progressed slower than expected and collaborative projects have progressed more quickly than expected. Funding gap We believe that GiveDirectly is highly likely to be constrained by funding next year. It expects to use additional funding primarily for standard cash transfers and for additional collaborative projects. For collaborative projects, GiveDirectly’s potential partners require it to contribute funding, which the partner matches (at a one-to-one ratio, minimum). These projects would largely be in countries GiveDirectly has not worked in before and many are at an early stage of discussion. We estimate that GiveDirectly could use more than$200 million in additional funding in 2018-2019.

Malaria Consortium (for work on seasonal malaria chemoprevention)

Our full review of Malaria Consortium’s seasonal malaria chemoprevention program is here.

Background

Malaria Consortium (malariaconsortium.org) works on preventing, controlling, and treating malaria and other communicable diseases in Africa and Asia. Our review has focused exclusively on its seasonal malaria chemoprevention (SMC) programs, which distribute preventive anti-malarial drugs to children 3-months to 59-months old in order to prevent illness and death from malaria.

There is strong evidence that SMC substantially reduces cases of malaria. The randomized controlled trials on SMC that we considered showed a decrease in cases of clinical malaria but were not adequately statistically powered to find an impact on mortality.

Malaria Consortium and its partners have conducted studies in all of the countries where it has worked to determine whether its programs have reached a large proportion of children targeted. These studies have generally found positive results, though past surveys have been conducted after four rounds of SMC (SMC is given in a maximum of four treatment courses at monthly intervals) and may be subject to error due to the inaccurate recall or recordkeeping. Starting in 2017, Malaria Consortium is conducting coverage surveys after each round of SMC, to reduce recall error.

Important changes in the last 12 months

We have increased our confidence in Malaria Consortium’s monitoring, though we have not yet seen all of the research that Malaria Consortium expected to share in 2017 (in particular, tracking of malaria cases and deaths over time in areas where Malaria Consortium works). Coverage survey results from 2016 were generally positive, with a couple of outliers. The change from conducting coverage surveys after four treatment cycles to conducting them after each cycle will increase our confidence in the results.

Last year, we had only a rough estimate of how much additional funding Malaria Consortium could use productively. We have significantly improved our understanding of its room for more funding this year.

Funding gap

We believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities. It appears that there is a large remaining global need for additional funding for SMC programs and that Malaria Consortium is well-positioned to fill these gaps, if it has sufficient funding to do so.

Malaria Consortium estimates that it could spend $28-30 million per year on SMC in each of the next three years and that this level of funding would largely fill the global funding gap for SMC, with the exception of Nigeria, where the scale of the gap would be beyond Malaria Consortium’s operational capacity in the short term. It appears to have limited prospects for major funding from other sources. The major grant for Malaria Consortium’s work on SMC previously, from Unitaid, is ending and Malaria Consortium told us that it will not be renewed. Schistosomiasis Control Initiative (SCI) Our full review of SCI is here. Background SCI (imperial.ac.uk/schisto) works with governments in sub-Saharan Africa to create or scale up deworming programs. SCI’s role has primarily been to identify partner countries, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs. SCI has conducted studies to determine whether its programs have reached a large proportion of children targeted. These studies cover (a non-random sample of) about 40 percent of treatments SCI reports having delivered over the past few years. The studies have generally found moderately positive results, but leave us with some remaining questions about the program’s impact. As noted above, we believe that SCI is less cost-effective than Deworm the World and more cost-effective than Sightsavers and the END Fund. Given the uncertainty in our cost-effectiveness model, we are hesitant to say that SCI is more cost-effective than AMF and Malaria Consortium, though taken literally, SCI is 1.5 times as cost-effective as AMF and Malaria Consortium (~10x cash transfers vs. ~6-7x cash transfers). Important changes in the last 12 months We continued to follow SCI’s progress in 2017 and there have not been many major changes to its work. As in the past, SCI shared monitoring of deworming coverage levels for a portion of its programs with us; there continue to be several SCI-supported countries for which we have not seen monitoring results. In the past, we have noted that we had low confidence in the accuracy of the financial information that SCI provided and that SCI made significant improvements to its financial systems in 2016; our remaining concerns about SCI’s financial management and reporting are fairly minor. In 2017, SCI allocated nearly all available funding to programs in its 2017-2018 budget year. This was a large increase in spending over the previous budget year ($9.6 million in 2016-2017 compared with $22.5 million in 2017-2018), driven in large part by a large increase in GiveWell-directed funding ($3.7 million in 2015 compared with $16.6 million in 2016). We believe this decision was due in part to a miscommunication with GiveWell—in a conversation with SCI in early 2017, we recommended that they treat the funds like a multi-year grant because of the risk of large fluctuations in GiveWell-directed funding, but we did not emphasize this point. SCI told us that it plans to allocate future funding over multiple years, noting that its funding allocation decisions in 2016-2017 were due to the desire to avoid allowing drugs to expire as well as a misunderstanding with GiveWell about how the funding was intended to be used. Funding gap We estimate that SCI could productively use about$30 million more than it expects to receive to deliver treatments to school-aged children over the next three years. It could use almost three times this amount if it were to follow World Health Organization guidelines, which include treating many adults; we are not recommending funding to treat adults because we haven’t seen sufficient evidence on the impact of treating adults.

The primary use of this funding, and SCI’s top priority, would be to sustain and expand work in current countries of operation. A smaller portion would be used to expand to up to four additional countries.

Sightsavers (for work on deworming)

Our full review of Sightsavers is here.

Background

Sightsavers (sightsavers.org) is a large organization with multiple program areas that focuses on preventing avoidable blindness and supporting people with impaired vision. Our review focuses on Sightsavers’ work to prevent and treat neglected tropical diseases (NTDs) and – more specifically – advocating for, funding, and monitoring deworming programs. Deworming is a fairly new addition to Sightsavers’ portfolio; in 2011, it began delivering some deworming treatments through NTD programs that had been originally set up to treat other infections.

Sightsavers has shared surveys for some of its past NTD programs that measure whether these programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but leave us with some remaining questions about the program’s impact. We have seen very limited results from Sightsavers’ deworming programs specifically. For GiveWell-supported programs, Sightsavers has told us it will conduct coverage surveys for each round of deworming; we have reviewed one of those surveys to date.

Important changes in the last 12 months

In 2017, as expected, we learned relatively little about the performance of Sightsavers’ deworming programs, because programs funded with GiveWell-directed funds were at early stages. We did not expect to receive any monitoring results from programs funded with GiveWell-directed funds; however, Sightsavers shared a coverage survey from Guinea with us earlier than expected. The survey found middling coverage results.

We significantly improved our understanding of Sightsavers’ cost per treatment and the baseline prevalence in areas where Sightsavers works (which is used in our cost-effectiveness analysis), though we continue to have lower confidence in our estimates than we do for the deworming organizations that we have recommended for several years.

Funding gap

We believe that Sightsavers’ deworming work is likely to be constrained by funding next year. Sightsavers has provided details of deworming programs that it could fund with additional funding of up to about $6.4 million in 2018 and 2019. Sightsavers appears to have limited prospects for funding these programs from other sources. We believe it is likely that Sightsavers could absorb funding beyond this amount to extend programs to 2020 and/or seek out additional opportunities to fund deworming programs. Of the$6.4 million, $2.8 million would be used to add deworming to existing NTD programs and$3.7 million would be used to fund NTD programs that would treat several NTDs in addition to schistosomiasis and STH. We will request that Sightsavers prioritize the first set of opportunities, because we believe they will likely be more cost-effective.

Standout charities

In addition to our top charities, we recognize standout charities—organizations that support programs that may be extremely cost-effective and are evidence-backed but for which we have less confidence in their impact than we do for our top charities. We have reviewed their work and feel these groups stand out from the vast majority of organizations we have considered in terms of the evidence base for the program they support, their transparency, and their potential cost-effectiveness. These organizations offer additional giving options for donors who feel highly aligned with their work.

We’ve added one organization to the list this year: Evidence Action’s Dispensers for Safe Water.

We don’t follow standout organizations as closely as we do our top charities. We generally have one or two calls per year with representatives from each group and publish notes on our conversations. We provide brief updates on these charities below.

New addition to the standout list:

• Evidence Action’s Dispensers for Safe Water. The Dispensers for Safe Water program provides chlorine dispensers for decontamination of drinking water to prevent diarrhea and associated deaths of young children. We believe that there is strong evidence that chlorination is biochemically effective at inactivating most diarrhea-causing microorganisms, but weaker evidence on the causal relationship between water chlorination programs and reductions in under-5 diarrhea and death. Our rough cost-effectiveness analysis of Dispensers for Safe Water suggests that the program is in a similar range of cost-effectiveness as unconditional cash transfer programs. Our review of Dispensers for Safe Water is here.

Organizations that have conducted randomized controlled trials of their programs:

• Development Media International (DMI). DMI produces radio and television programming in developing countries that encourages people to adopt improved health practices. It conducted a randomized controlled trial (RCT) of its child survival media campaign in Burkina Faso and has been highly transparent, including sharing preliminary results with us. The results of its RCT were mixed, with a household survey not finding an effect on mortality (it was powered to detect a reduction of 15 percent or more) and data from health facilities finding an increase in facility visits. (The results have not yet been published.) We believe there is a possibility that DMI’s work is highly cost-effective, but we see no solid evidence that this is the case. DMI is conducting an RCT of its family planning radio campaign in Burkina Faso and it is planning work on early child development in Burkina Faso and child survival in Mozambique. It is our understanding that DMI will be constrained by funding in the next year. Our full review of DMI is here and notes from our most recent conversation with DMI are here.
• Living Goods. Living Goods recruits, trains, and manages a network of community health promoters who sell health and household goods door-to-door in Uganda and Kenya and provide basic health counseling. They sell products such as treatments for malaria and diarrhea, fortified foods, water filters, bednets, clean cookstoves, and solar lights. Living Goods completed a RCT of its program and measured a 27 percent reduction in child mortality. Our best guess is that Living Goods’ program is less cost-effective than our top charities, with the possible exception of GiveDirectly. It is conducting a second RCT of its program and results are expected in 2020. Living Goods recently expanded the number of family planning products it offers and is interested in expanding to a third country. Living Goods is scaling up its program and could scale up more quickly with additional funding. Our review of Living Goods is here and notes from our most recent conversation with Living Goods are here.

Organizations working on micronutrient fortification:

We believe that food fortification with certain micronutrients can be a highly effective intervention. For each of these organizations, we believe they may be making a significant difference in the reach and/or quality of micronutrient fortification programs but we have not yet been able to establish clear evidence of their impact. The limited analysis we have done suggests that these programs are likely not significantly more cost-effective than our top charities—if they were, we might put more time into this research or recommend a charity based on less evidence.

• Food Fortification Initiative (FFI). FFI works to reduce micronutrient deficiencies (especially folic acid and iron deficiencies) by doing advocacy and providing assistance to countries as they design and implement flour and rice fortification programs. We have not yet completed a full evidence review of iron and folic acid fortification, but our initial research suggests it may be competitively cost-effective with our other priority programs. Because FFI typically provides support alongside a number of other actors and its activities vary widely among countries, it is difficult to assess the impact of its work. FFI’s recent work includes advocating for legislation to mandate that rice imported to West Africa is fortified with vitamins and minerals. Our full review is here and notes from our most recent conversation are here.
• Global Alliance for Improved Nutrition (GAIN) – Universal Salt Iodization (USI) program. GAIN’s USI program supports national salt iodization programs. We have spent the most time attempting to understand GAIN’s impact in Ethiopia. Overall, we would guess that GAIN’s activities played a role in the increase in access to iodized salt in Ethiopia, but we do not yet have confidence about the extent of GAIN’s impact. GAIN has focused its recent USI work on Tanzania, Mozambique, Ethiopia, and Kenya, which it targeted based on relatively low levels of coverage of iodized salt and strong relationships with stakeholders. It is our understanding that GAIN’s USI work will be constrained by funding in the next year. Our review of GAIN is here and notes from our most recent conversation are here.
• Iodine Global Network (IGN). Like GAIN-USI, IGN supports (via advocacy and technical assistance rather than implementation) salt iodization. IGN is small, and GiveWell-directed funding has made up a large part of its funding in recent years. It expects to have data from before and after its recent work in Madagascar, Lebanon, and possibly Israel by the end of 2018; this data may provide additional evidence of IGN’s impact. It is our understanding that IGN will be constrained by funding in the next year. Our review of IGN is here and notes from our most recent conversation here.
• Project Healthy Children (PHC)/Sanku. PHC/Sanku aims to reduce micronutrient deficiencies by providing assistance to small countries as they design and implement food fortification programs and by enabling fortification among small-scale millers. PHC is scaling up its Sanku project, which equips small millers with a machine that enables them to fortify their flour with micronutrients; we have not done as much formal analysis of Sanku as of PHC’s core work on advocacy and technical assistance to countries to implement fortification. PHC/Sanku expects to be constrained by funding in the future. Our review of PHC/Sanku is here and notes from our more recent conversation are here.
Our research process in 2017

We plan to detail the work we completed this year in a future post as part of our annual review process. A major focus of 2017 was improving our recommendations in future years, in particular through our work on GiveWell Incubation Grants and prioritizing promising programs for further investigation.

Below, we highlight the key research that led to our current charity recommendations. This page describes our overall process.

• Following existing top charities. We followed the progress and plans of each of our 2016 top charities. We had several conversations by phone with each organization, met in person at least once with each top charity (including a three-day visit to Rwanda and the Democratic Republic of the Congo with the END Fund), and reviewed documents they shared with us.
• Identifying new top charities.
• No Lean Season. We had recommended a series of Incubation Grants to No Lean Season beginning in 2014 and have followed its progress since then. This year, due to the scale at which No Lean Season was operating and the track record it had established, we decided that the No Lean Season program was at a stage of development where we could evaluate it as a potential top charity. In addition to extensive communications with No Lean Season staff over the phone and reviewing documents they shared with us, GiveWell staff spent five days visiting the program in Bangladesh.
• Helen Keller International’s vitamin A supplementation program. Earlier this year, Research Analyst Chelsea Tabart began reaching out to organizations that might be a fit for our criteria, but with which we had limited or no previous contact with. As a result of that process, we reconnected with Helen Keller International (which we first considered as a potential top charity in 2007) and began to consider its vitamin A supplementation program as a potential top charity. In addition to extensive communications with HKI staff over the phone and reviewing documents they shared with us, GiveWell staff spent three days meeting with HKI staff in Guinea and observing a vitamin A supplementation program.
• Completing intervention reports on obstetric fistula surgery and measles vaccination campaigns; completing interim intervention reports on SMS reminders for vaccination, Sayana® Press (an injectable contraceptive), oral rehydration solution, and antiretroviral therapy for HIV/AIDS; and expanding our interim intervention report on seasonal malaria chemoprevention to a full intervention report.
• Staying up to date on the research for malaria nets, cash transfers, and deworming. We did not find major new research on cash transfers, nets, or deworming that affected our recommendation of GiveDirectly, AMF, or the organizations we recommend for their work on deworming. David Roodman published an in-depth review (parts 1 and 2) of the deworming studies that form the primary basis of our views on the impact of deworming (though much of this work was completed in 2016 and informed our top charity recommendations last year).
• Making extensive updates to our cost-effectiveness model and publishing several updates to the model over the course of the year. We instituted a process to track and report publicly on updates to the model to reduce the possibility of errors and make our process more transparent. This year, staff members have also provided substantially more detail in our cost-effectiveness file about why they have chosen particular inputs.
Giving to GiveWell vs. top charities

GiveWell is currently in a stable financial position. We project that our revenue and our expenses will be approximately equal in the future. However, this projection forecasts some growth in the level of operating support we receive.

In the long term, we seek to have a model where donors who find our research useful contribute to the costs of creating it, while holding us accountable to providing high-quality, easy-to-use recommendations. We retain our “excess assets policy” to ensure that if we fundraise for our own operations beyond a certain level, we will grant the excess to our recommended charities.

We cap the amount of operating support we ask Good Ventures to provide to GiveWell at 20 percent, for reasons described here. We thus ask that donors who use GiveWell’s research consider the following:

• If you have supported GiveWell’s operations in the past, we ask that you maintain your support. Having a strong base of consistent support allows us to make valuable hires when opportunities arise and to minimize staff time spent on fundraising for our operating expenses.
• If you have not supported GiveWell’s operations in the past, we ask that you designate 10 percent of your donation to help fund GiveWell’s operations. This can be done by selecting the option to “Add 10% to help fund GiveWell’s operations” on our credit card donation form or letting us know how you would like to designate your funding when giving another way.

We’re happy to answer questions in the comments below. Please also feel free to reach out directly with any questions.

The post Our top charities for giving season 2017 appeared first on The GiveWell Blog.

### How GiveWell and mainstream policymakers compare the “good” achieved by different programs

Tue, 11/07/2017 - 12:44

In a previous blog post, we described how we use cost-effectiveness analyses when deciding which charities to recommend to donors.

Today, we published a report that discusses how GiveWell and other actors, such as governments and global health organizations, approach one of the most subjective and uncertain inputs into cost-effectiveness analyses: how to morally value different good outcomes.

For example, GiveDirectly, one of GiveWell’s seven top charities, increases recipients’ consumption, while the primary benefit we see from our top charity the Against Malaria Foundation is that it averts the deaths of young children. How can one make a direct comparison between the amount of “good” achieved by each of these charities?

GiveWell does this by assigning quantitative “moral weights” to different outcomes in our cost-effectiveness analyses. As a check on how sensitive our recommendations are to our moral assumptions, we investigated how others typically answer these questions in their cost-effectiveness analyses.

For a full discussion of the findings from our investigation, see our detailed report.

The summary of the report is:

We focus on the following questions:

• Why does GiveWell explicitly include moral weights in our cost-effectiveness analyses, and how do we decide on moral weights?
• Is there a “standard” approach to moral weights in cost-effectiveness analyses? How do other actors, such as governments and the World Health Organization, make these judgments?
• How much would GiveWell’s cost-effectiveness analyses change if we took a “standard” approach to moral weights?

In brief:

• We include moral weights in our cost-effectiveness analyses because they are an important part of any giving decision and we think it is valuable to be transparent about them. The moral weights that drive our cost-effectiveness estimates are based on our staff’s personal values.
• Governments and other prominent actors often use “value of a statistical life” estimates to compare the value of improving health relative to raising incomes. These estimates often imply that a year of healthy life is roughly 2-3x as valuable as a year of doubling someone’s income. However, there is little relevant research to inform such estimates in low- and middle-income country (LMIC) contexts; we understand that how income is valued relative to health may shift when a population is much poorer.
• There does not seem to be a standard approach for comparing the value of life at different ages; the most commonly used framework that we have seen (the disability-adjusted life year framework) explicitly does not provide judgments on this topic. Nevertheless, most other analyses that we have seen assume that averting death during childhood is about 1-2x more valuable than averting death during adulthood.
• Our initial analysis suggests that using relatively “standard” moral weight assumptions (i.e., the assumptions in the previous two bullet points) instead of our staff’s moral weights would not change our overall view of the relative cost-effectiveness of our current top charities. It may affect how we view some interventions in the future, particularly those that disproportionately focus on averting deaths for young children or adults. We plan to include explicit comparisons between staff moral weights and relatively “standard” moral weights in our analyses going forward.

For more detail, see the full report here.

### Interim update on GiveWell’s money moved and web traffic in 2016

Fri, 09/29/2017 - 21:17

In 2016, we tracked a total of $91.6 million given to our top charities as a direct result of our research. In addition to this$91.6 million, we also directed $13.3 million to our Incubation Grants program. A note about this report: We have yet to complete all of the work necessary to publish our 2016 metrics report. There are a number of reasons the report has been difficult to produce this year. In our view the main factors responsible for this delay were the increasing number and complexity of the data sources used to track donors giving to our recommended charities and competing priorities that required the attention of the staff member who produced the 2016 report. The delay was not a result of a decreased dedication to transparency. In mid-September, we committed to publishing an update on our key metrics (money moved and web traffic) by October 1st even if we were unable to complete our report by then. We have failed to complete our full report, and, today, are publishing an interim update consistent with our commitment. Unfortunately, we don’t have an updated estimate about when we’ll publish our full metrics report. It is possible that it will take us several months or more to complete it. We view this as a major failing on our part, and we plan to correct this in the future. For the purpose of this report, please note: • We report on “metrics years” that run from February through January; for example, our 2016 data cover February 1, 2016 through January 31, 2017. • We differentiate between our traditional charity recommendations, the work of the Open Philanthropy Project, and our work aiming to support the development of future GiveWell top charities. GiveWell and Open Philanthropy are now separate legal organizations, but during 2016 Open Philanthropy was part of GiveWell, so we report its grantmaking here. • More context on the relationship between Good Ventures, Open Philanthropy, and GiveWell can be found here. Summary of influence: In 2016, GiveWell influenced charitable giving in several ways. The following table includes (a) donations from donors who cited our research when donating to a third party (or cited a source that recommended our top charities because of our recommendation), (b) donations to GiveWell that we granted to top charities and standout organizations, and (c) grants made on our recommendation, through GiveWell Incubation Grants and the Open Philanthropy Project. Total money moved: In 2016, GiveWell tracked$91.6 million in money moved to our recommended charities. Our money moved figure only includes donations that we are confident were influenced by our recommendations. In our full metrics report, we plan to include our best guess of the total funding that was given to our top and standout charities due to our research; the numbers in this blog post include only donations that we could specifically track as being due to our research. The methodology used to generate the numbers in this post was very similar to what is described in our 2015 metrics report, with the exception that, for 2016, we counted more donations through partner organizations such as Giving What We Can. We now believe that we should have included those donations last year.

Open Philanthropy gave an additional $13.3 million to the GiveWell Incubation Grants program, to support the development of future top charities, and GiveWell granted$400,000 in participation grants to organizations that applied for a top charity recommendation, from funding provided by Good Ventures for this purpose. We do not count either of these grant types in our headline money moved figure.

Money moved by charity:

Our seven top charities received the majority of our money moved. Our six standout charities received a total of about $3.1 million. The post Interim update on GiveWell’s money moved and web traffic in 2016 appeared first on The GiveWell Blog. ### September 2017 open thread Tue, 09/12/2017 - 12:39 Our goal with hosting quarterly open threads is to give blog readers an opportunity to publicly raise comments or questions about GiveWell or related topics (in the comments section below). As always, you’re also welcome to email us at info@givewell.org or to request a call with GiveWell staff if you have feedback or questions you’d prefer to discuss privately. We’ll try to respond promptly to questions or comments. You can view our June 2017 open thread here. The post September 2017 open thread appeared first on The GiveWell Blog. ### Why we’re allocating discretionary funds to the Deworm the World Initiative Wed, 08/30/2017 - 10:13 Many donors who give through GiveWell’s website choose to donate to support “Grants to recommended charities at GiveWell’s discretion,” rather than selecting a specific recommended charity or charities as the target of their gift. We periodically grant these “discretionary funds” to what we see as the highest-value funding opportunities among our top charities. We last granted discretionary funds in April; then, we granted$4.4 million to the Against Malaria Foundation and $0.5 million to the Deworm the World Initiative. Since we last allocated funds, we received an additional$1.25 million in discretionary funds that we recently granted out. We also hold roughly $1 million in discretionary funds that we plan to grant out in the next month or two. We plan to grant all of this funding to the Deworm the World Initiative. Recommendation for donors We continue to recommend that donors give 100% of their donation to the Against Malaria Foundation (AMF). In other words, although we’re choosing to grant discretionary funds to Deworm the World, we don’t believe that donors who rely on our recommendations should adjust their giving at this time. We explain the rationale for this below. Summary This post will discuss: Deworm the World’s funding gap Deworm the World recently told us that they have a pressing funding need. We model Deworm the World as the most cost-effective of our top charities (~10x as cost-effective as cash transfers). Last November, we recommended what we estimated was enough funding to make it 80 percent likely that Deworm the World would not be constrained by funding in the next year. (Due to donors following GiveWell’s recommendations, this recommendation generally tracks with what charities receive as a result.) The existence of a funding gap today thus surprised us. We understand Deworm the World’s funding gap is driven by two primary factors. First, our estimate of Deworm the World’s room for more funding made assumptions about how much funding it would receive from other funders, and so far this year revenue has been lower than projections. Second, global costs (salaries, office space, travel, etc. for staff based outside of countries where programs operate) were erroneously left out of our cost-effectiveness analysis for Deworm the World last year. Deworm the World did not include these costs in its list of ways it might spend money and we did not recognize that they were not built into the budget. The existence of this gap, and some time-sensitive considerations discussed below, led us to decide to recommend the current discretionary funds go to Deworm the World. We also considered granting them to AMF, which is our current top recommendation for donors; we believe AMF has significant room for more funding. However, we decided that Deworm the World’s funding need was more pressing. We don’t expect this decision to change the total amount that AMF and Deworm the World each receive as a result of GiveWell’s recommendation in 2017, so the cost of not choosing AMF today is delaying when AMF receives this funding. Benefits of granting discretionary funds to Deworm the World now Deworm the World is currently in discussions with the government of Kenya to sign a memorandum of understanding (MOU) to continue its deworming program in Kenya for the next five years. Deworm the World had enough funding committed to the program to fund two years and believes that if it had a larger funding commitment, the government would see the MOU as a higher priority and might speed up the process to finalize the MOU. When we spoke with Deworm the World about additional funding in June and July, of particular concern were the upcoming elections in Kenya on August 8. Because elections tend to take government officials away from other work, Deworm the World feared that delaying the MOU process could delay its deworming work and, in a worst-case scenario, cause the 2017-2018 round of deworming in Kenya to be missed. Though we understand from Deworm the World that the MOU was not signed prior to the elections, our expectation is that receiving this funding several months earlier than it otherwise would have will decrease the likelihood of Kenya missing a round of deworming. In addition, Deworm the World may have opportunities this year to fund work in Pakistan and additional work in India (it currently works in only a portion of the states in India). Receiving additional funding now may allow Deworm the World to accelerate its work in those locations. We have not completed a full room for more funding analysis of Deworm the World since last October and are unsure how much additional room for more funding Deworm the World has. Risks of granting discretionary funds to Deworm the World now We believe that granting GiveWell’s discretionary funds to Deworm the World now has the following risks: • We may later come to believe that Deworm the World needed less than$2.25 million this year.

We have not seen complete financial information from Deworm the World and we are unsure how much additional funding would be needed to bring them to the level of being 80 percent likely that they won’t be bottlenecked by funding (we generally target our most cost-effective top charities receiving this level of funding).

Discretionary funds allocated now will reduce our estimation of Deworm the World’s 2017 end-of-year room for more funding, which we incorporate into our annual year-end recommendations. It’s possible, although we think highly unlikely, that once we see Deworm the World’s full financial information (which we expect to before our end-of-year recommendation decisions), we will conclude that the amount we want to recommend to them this year is less than $2.25 million. We don’t think this is likely; our best guess is that granting funds to Deworm the World today will accelerate when they receive funds from GiveWell but not change the overall amount of funding they receive in 2017 due to our recommendation. It’s also possible that receiving GiveWell discretionary funds now will, for example, allow Deworm the World to lay more groundwork in Pakistan this year and create new opportunities to fund deworming in Pakistan next year, thus increasing our estimate of Deworm the World’s room-for-more funding at the end of the year. • If we decide at the end of the year that Deworm the World is no longer a top charity, we may not think it should have received$2.25 million a few months before. We think this is highly unlikely.
• Funding for and implementation of Kenya’s deworming program is complex. It involves the government of Kenya, multiple funders (including GiveWell-influenced donors, the Children’s Investment Fund Foundation, and the END Fund), and the Deworm the World Initiative, among others. We’d recommend any donor considering major gifts to Deworm the World before we publish our updated review of Deworm the World in November contact us one-on-one to discuss these considerations.

Recommendation to individuals

We continue to recommend that donors give to our current top recommendation: the Against Malaria Foundation. We are not changing the recommendation to donors because:

1. We are unsure how much additional funding we would like to see Deworm the World receive this year. Making it our new recommendation for donors could drive enough funding in the next few months to overshoot the total Deworm the World could effectively use in the near future.
2. The main benefit of giving to Deworm the World now, rather than at the end of the year, is to accelerate the timeline for the MOU in Kenya and possibly work in Pakistan and India. We anticipate that much of the funding driven by a GiveWell recommendation to donors (e.g., as we currently recommend giving 100% to AMF) would not reach Deworm the World until about the time when we will have completed a full room for more funding analysis of Deworm the World’s work, so we see limited benefit in changing our recommendation now, while we do see the cost noted above.

The post Why we’re allocating discretionary funds to the Deworm the World Initiative appeared first on The GiveWell Blog.

### From the archive: 6 tips on disaster relief giving

Mon, 08/28/2017 - 13:32

We’ve received several questions about donating in response to Tropical Storm Harvey. We wanted to share this post, which was originally published in 2013, with our advice for disaster relief giving. We’re unsure if bullet points #4 and #5 still apply, as it has been a few years since we last investigated giving opportunities for disasters, and we have mostly considered international disasters.

Our general advice on disaster relief giving:

1. Give cash, not clothes (or other goods). Giving away unwanted items makes donors feel good, and relief agencies can be under substantial pressure to accept their gifts-in-kind. But shipping and sorting these gifts can be a substantial expense and hassle, and such gifts can literally get in the way. If you have items you don’t want, consider selling them and donating the proceeds. Gifts-in-kind burden relief organizations with figuring out how to use what they have; cash allows them to quickly get what they need. More

2. Support an organization that will help or get out of the way. Logistics can be a major challenge in disaster situations. For example, when we followed up on the Haiti earthquake relief effort a year after the incident, we found that much of the disaster relief money had still not been spent, and that ~80%+ of the rubble had still not been cleared. A highly professional, experienced organization with a pre-existing presence in the affected country will likely help where it can, and stay out of the way where it can’t. But a less professional organization could easily detract from the relief effort.

3. Give proactively, not reactively. Don’t give to a charity just because it calls you on the phone, advertises on your Google search or otherwise connects with you first. That rewards the most aggressive organizations instead of the most competent and responsible ones. Instead, give not just money but thoughtfulness – take the time to find the best giving option you can.

4. Allow your funds to be used where most needed – even if that means they’re not used during this disaster. Disasters attract a great deal of media attention and money, yet in many cases the biggest challenge is logistics. The result can be that money isn’t the limiting factor in the immediate relief effort. We found evidence of this both for the 2010 Haiti earthquake and the 2011 Japan tsunami.

That doesn’t mean money isn’t needed. The rebuilding effort can be very expensive. Beyond that, there are many disasters – and cases of everyday suffering – that aid organizations struggle to address, without being able to raise nearly as much funding for them as they can for a media-dominating disaster. It’s common for charities to use a disaster as an opportunity to raise funds for their other work.

We recommend giving to an organization that does outstanding work around the world (not just in the affected area), with no strings attached.

5. Give to organizations that are transparent and accountable. In general, we’ve found that relief organizations disclose very little about what activities they undertake and how they spend relief funds (more at our reports on the 2010 Haiti earthquake and the 2011 Japan tsunami). In general, when a disaster strikes, the first organizations we turn to are:

• Doctors Without Borders (MSF), which has distinguished itself with well-above-average transparency in both of the cases listed above. In the case of the 2011 Japan tsunami, it straightforwardly disclosed that it was not seeking more funding for use in the relief effort, and was one of the only organizations to do so. We believe it’s worth rewarding MSF for its unusual transparency, and if it doesn’t use your money on this disaster, it will likely use it to address a less-publicized crisis.
• The local Red Cross. The Red Cross generally takes a leading role in a relief effort and (it seems to us) is assigned credit/blame for how the overall effort goes, to a greater degree than other nonprofits. The American Red Cross will often redirect donations to the local Red Cross, minus a sometimes-substantial fee.

We wrote more about these two options when we made recommendations about how to respond to the 2011 Japan earthquake/tsunami.

6. Think about less-publicized suffering. Every day, people die from preventable and curable diseases, in many cases because they lack access to proven life-savers such as insecticide-treated nets. Their day-to-day suffering isn’t well-suited to making headlines, and they generally don’t attract the attention and dollars that disaster relief victims do – yet we believe that donations targeting these populations do more good than disaster relief donations.

If a recent disaster has given you a strengthened desire to reduce suffering and help others, consider asking whether you might be able to broaden this desire and make it part of your everyday life. Consider joining the community of effective altruists seeking to make their hours and their dollars go as far as possible toward making the world a better place. GiveWell’s role in that community is to put thousands of hours of research into identifying the best giving opportunities possible – not the ones that make the news, but the ones that will make your dollars go the farthest.

The post From the archive: 6 tips on disaster relief giving appeared first on The GiveWell Blog.

### Update on GiveWell’s intervention research in 2017

Thu, 08/24/2017 - 12:39

One of our major goals for 2017 is “intervention prioritization,” our work to assess a large number of programs (interventions) as potential GiveWell priority programs we’d be interested in recommending charities working on.

Summary

This post will provide a brief overview of our intervention work this year, focusing on the interim and full intervention reports we’ve published in 2017.

Programs we plan to continue investigating:

Programs we decided not to prioritize additional research on:

Intervention prioritization process

We aim to do low-intensity research on a large number of promising interventions as part of our intervention prioritization work. We typically start by spending a few hours assessing a program before deciding whether to move forward with a more intense (say, 20-40 hour) “interim intervention report.” If the program looks promising following an interim intervention report, we’ll move on to a full intervention report, which generally involves about 80-200 total hours of work. We may do additional research after this point, as well, as we did with David Roodman’s research on deworming, one of GiveWell’s priority programs, last year.

Priority programs

This section will discuss programs we have researched in 2017 and see as promising.

Sayana® Press

Sayana® Press is an injectable contraceptive in a prefilled single-use package. We decided to look into Sayana® Press after a charity described the program to us as a potential GiveWell priority program. Sayana® Press seemed promising because community health workers or recipients themselves may be able to administer it, which could make it a viable contraceptive for women without regular access to health facilities. Sayana® Press, a single injection of which is intended to provide protection for three months, also requires less frequent adherence than daily birth control pills. Our initial estimate suggests that family planning programs involving Sayana® Press have the potential to be be in the same range of cost-effectiveness as our current top charities.

After this review, we prioritized initial investigation of charities that work on family planning programs.

Antiretroviral Therapy to Treat HIV/AIDS

Antiretroviral therapy (ART) refers to using a combination of drugs to treat (not cure) human immunodeficiency virus (HIV) to increase life expectancy for those who have the disease and to reduce HIV transmission rates. We prioritized investigating ART as we learned that it had become more cost-effective (due to falling prices) and because of our perception that despite significant funding for ART, funding gaps remain. If that were the case, we’d be interested in identifying giving opportunities that demonstrate they are filling such gaps, similar to how the GiveWell top charity the Against Malaria Foundation works in the insecticide-treated net space.

We’re in the process of having conversations with charities that implement ART programs to better understand whether a funding gap for direct delivery of ART exists. If there is room to fund marginal direct ART delivery, our key question will be around patient adherence rates to treatment when charities implement this program. We will want to see strong monitoring from charities to demonstrate that outcome.

SMS Reminders for Vaccination

We’re trying to grow the pipeline of potential future GiveWell top charities through our GiveWell Incubation Grant program. We funded Charity Science Health with an Incubation Grant for its program to send Short Message Service (SMS) messages to caregivers’ cell phones to remind them of upcoming vaccination dates for young children. We decided to investigate SMS reminders for vaccination as part of our ongoing review into Charity Science Health’s work and our impression that this intervention had the potential to be highly cost-effective.

The available randomized controlled trial (RCT) evidence on the program, upon which GiveWell generally places high weight, varies quite a bit and we’re hesitant to generalize from the findings. We don’t expect to recommend SMS reminders for vaccination based on the existing evidence. In order to recommend Charity Science Health as a top charity, we would likely require additional independent evidence for the program or an RCT of Charity Science Health’s program in particular.

Surgery to Repair Obstetric Fistula

In 2016 and 2017, we decided to revisit the evidence for promising corrective surgery programs, including the evidence for surgery to repair obstetric fistula.

An obstetric fistula is an abnormal opening between the vagina and bladder or rectum that typically results from prolonged obstructed labor. Our impression is that fistula can have a very negative impact on well-being and that some obstetric fistulas may be repaired with surgery.

We have a number of open questions about this intervention, including the success of surgery in (a) closing the fistula and (b) leading to improved psychosocial outcomes. Fistula management programs may also involve other activities, such as outreach to women with fistula, training surgeons, and counseling. We would like to better understand the impact of these activities on improving life outcomes as well as their cost.

We are working with IDinsight to closely examine a Fistula Foundation program to better understand the cost-effectiveness of this work. If the cost-effectiveness appears to be in the range of our other priority programs, we will then work with IDinsight to identify organizations with which they can develop improved monitoring to help us answer our remaining questions about patient outcomes.

Read our report on surgery to repair obstetric fistula here. We have also published a blog post on our work in this space.

Interventions to Promote Handwashing

We understand that washing hands can remove pathogens that transmit infectious diseases. We investigated a variety of interventions intended to promote handwashing, including hygiene education and the distribution of posters and leaflets.

We looked for RCTs of the impact of handwashing on reducing diarrhea, pneumonia, and worm infections, as well as the impact handwashing might have on improving nutrition (via reducing diarrhea). While we did see some evidence of a reduction in diarrhea incidence and pneumonia, we have not seen strong evidence for the impact of promoting handwashing on worm infections or nutrition indicators. Research was conducted on a variety of approaches to promote handwashing and the results were heterogeneous, such that we couldn’t draw generalizable conclusions from the literature.

To consider groups working on handwashing promotion for a potential GiveWell recommendation, we would need to learn more about their individual activities and monitoring, which could also give us better information with which to assess their cost-effectiveness.

Other programs considered

Distribution of Eyeglasses in Developing Countries

We reviewed the evidence for providing free or subsidized eyeglasses to individuals with poor vision. We saw some evidence that offering free corrective eyeglasses to children has some effect on test scores; we did not find strong evidence assessing whether distributing eyeglasses increased economic productivity in the short or long run. We decided not to move forward with our research and do not consider the distribution of eyeglasses a GiveWell priority program. If we were to come to the conclusion that increasing test scores reliably led to improved life outcomes, we would likely revisit our conclusion about eyeglasses interventions.

Oral Pre-exposure Prophylaxis (PrEP) for HIV

Oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative individuals to prevent HIV acquisition. We think the evidence that PrEP reduces HIV acquisition rates among high-risk individuals is strong, but we have not found evidence that large-scale charity programs have successfully increased PrEP coverage rates in sub-Saharan Africa. Our latest cost-effectiveness estimate for this program suggests that PrEP programs are less cost-effective than voluntary medical male circumcision (VMMC) for preventing new HIV infections, though there are a few key parameters about which we’re uncertain. We are not planning to prioritize additional work on this program at this time, but would revisit our conclusion if charities provided us with information that could substantially change our cost-effectiveness estimate for PrEP programs.

Read our full report on oral pre-exposure prophylaxis to prevent HIV here.

Conclusion

Reviewing a large number of interventions is a major research priority for GiveWell in 2017. A separate post will discuss our “intervention prioritization” work in detail.

The post Update on GiveWell’s intervention research in 2017 appeared first on The GiveWell Blog.

### Our approach to processing undesignated donations

Thu, 08/03/2017 - 16:46

Though GiveWell donors typically indicate how they would like their donations to be designated—e.g., for the support of one or more specific recommended charities, or for granting at GiveWell’s discretion—we occasionally receive donations without any designation information. It is important to us that donors understand our process for handling these donations: as a general rule, we treat all undesignated donations as unrestricted gifts, which means they will most likely be used to fund GiveWell’s operating expenses.

In this post, we will:

1. Discuss undesignated donations more in-depth and outline our rationale for treating them as unrestricted gifts.
2. Explain how our thinking on processing these types of donations has evolved over time to better meet our donations processing goals—to make it easy for donors to communicate their designation preferences, be transparent about where donations are allocated, and keep our administrative costs low.
3. Provide information on how to make sure that, as a donor, your designation preferences are communicated to us.

If you have any questions about the designation of a future or past donation to GiveWell, please email us at donations@givewell.org.

What is an undesignated donation?

GiveWell grants most of the donations we receive to our top and standout charities. Donors usually indicate which organizations they prefer to support with their donation—we refer to this as a designation. On our donation forms, donors can choose one or more recommended charities, grants to recommended charities for granting at our discretion, or unrestricted (which we will likely use for GiveWell’s operating expenses).

Donors giving online through our website must select one or more designation options when making a donation. However, we occasionally receive donations through other payment methods—e.g., checks, wire transfers, securities donations, or donations through employer giving platforms such as Benevity—that do not include any designation information.

Our current process and how our thinking has evolved

As a general practice, when a donor does not communicate a designation to us, we treat their donation as unrestricted funding. If the donor has provided us with an email or physical address, we send them an email or letter and ask if they would prefer to have their donation designated differently.

Our initial process when receiving undesignated donations was to designate them according to the donor’s past giving history (when applicable). For example, if a donor had previously given in support of Against Malaria Foundation and Schistosomiasis Control Initiative, we would designate their subsequent donations accordingly.

However, in practice, we learned that the process of determining a donor’s pattern of giving is often time-consuming and prone to error. Donors may support a variety of charities with donations in varying amounts, and since our recommendation for what charities to support changes over time, it is reasonable to expect that donors’ preferences for where to allocate their gifts would also change from how they’ve given in the past. Due to the subjective nature of this process, we found it required a significant amount of time and resources to be spent on donations processing and auditing.

Another option for undesignated donations that we considered was allocating these gifts to our discretionary fund for recommended charities. We believed that donors might expect undesignated donations to go toward GiveWell’s most up-to-date recommended allocation. We have not systematically surveyed donors, but our impression from speaking with donors in the past is that some donors expected undesignated donations to support our recommended charities (at our discretion), while others preferred that we decide whether to allocate their donation to our operations or to our recommended charities.

A desire for a more standardized and transparent process led us to our current approach. Allocating gifts without clear designations towards unrestricted funds simplifies our donations and accounting processes, which in turn lowers the administrative cost of these processes. It also provides donors with more agency to choose another designation, if they wish—we are less likely to grant out unrestricted gifts to one or more of our recommended charities before donors have a chance to follow up on our no-designation email or letter and request a different designation.

How to communicate or modify a designation

To ensure that your donation to GiveWell is designated according to your preference, please be sure to email us back at donations@givewell.org if you receive an email or letter from us that indicates your donation did not include a specific designation.

To ensure that your designation preferences are communicated to us at the time when we receive your donation:

• Be sure to fill out and enclose this form with each check you send. It is also helpful to add a note about the designation on the check itself. (If you are a recurring check donor and find it burdensome to fill out the check form with each donation, you may communicate your designation preferences for future donations via email at donations@givewell.org. Some online banking platforms will also allow you to add a memo to a recurring check payment that will appear on each check.)
• If giving by bank transfer, please fill out this form before donating and indicate your designation preference.
• If donating securities, please fill out this form before donating and indicate your designation preference.
• If donating through an employer giving platform such as Benevity, be sure to select the charity or charities you would like to support, or indicate this in the comment section along with your donation.
• If you are donating through a donor-advised fund (managed by, e.g., Vanguard or Schwab Charitable), please be sure to include your designation in the paperwork you submit to recommend a grant to GiveWell. You may also communicate your designation to us via email at donations@givewell.org. Note that we treat donations from donor-advised funds that are designated “Where it is needed most” as unrestricted funding.
• When submitting paperwork for a matching donation from your employer, be sure to specify how you would like the match to be designated. We treat all employer matches without a clear designation as unrestricted funding.

Donors are always welcome to email us at donations@givewell.org with any questions about the designation process or to communicate a designation for their future donations.

The post Our approach to processing undesignated donations appeared first on The GiveWell Blog.

### Mid-year update on GiveWell’s progress

Wed, 07/12/2017 - 11:55

This post will provide a brief overview of GiveWell’s progress in a number of areas so far this year. In summary,

1. Research: We are making progress on reaching charities that might be a good fit for a GiveWell recommendation and asking them to apply. We are also moving forward with GiveWell’s intervention prioritization goals.
2. Operations: The separation of GiveWell and the Open Philanthropy Project was a major organizational priority in the first half of the year and was finalized on June 1. We’ve also increased the specialization on the operations team and outsourced some of GiveWell’s operations work.
3. Outreach: Outreach is now a major organizational priority. We hope to develop a strategy for significantly increasing money moved to our recommended charities by September.

We hope you will let us know if you have any questions about our work this year in the comments.

Research

Our work on research now falls into two primary categories: Traditional top charities work, consisting of research into promising programs and evaluations of charities implementing them as potential GiveWell top charities, and GiveWell Incubation Grants, our work to grow the pipeline of potential top charities and improve our understanding of our current recommended charities.

Top charities

• Encouraging charities to apply for a GiveWell recommendation. In recent years, we were surprised by how few charities reached out to GiveWell to apply for a recommendation. We guessed that some part of this may be driven by (a) a lack of understanding of GiveWell’s research priorities and which organizations we might be interested in recommending, and (b) a lack of understanding or misconceptions about GiveWell’s charity review process or the value added of a GiveWell recommendation in increasing a charity’s funding.

We took two steps to address this problem in 2017. First, GiveWell Research Analyst Chelsea Tabart is now serving as GiveWell’s “charity liaison.” In this role, Chelsea connects with groups that may be a good fit for a GiveWell recommendation to learn more about their work and to encourage them to apply if a fit seems promising, and to explain GiveWell’s review process and value added. Second, we published a blog post on why we think more charities should consider applying for a GiveWell recommendation. We are now considering a number of charities as potential top-charity contenders and attribute this in part to taking the steps described above.

• Intervention prioritization. A major goal this year is to assess a large number of interventions as potential GiveWell priority programs. This “intervention prioritization” work involves surveying the literature for a variety of interventions to identify the most cost-effective and evidence-backed programs.

We have made good progress on intervention research in 2017. (We plan to write about our progress in more detail in a future post.) We completed 50 quick evidence assessments in the first half of the year and published interim intervention reports on:

We also published an intervention report on surgery to repair obstetric fistula.

GiveWell Incubation Grants

We continue to expand our work on GiveWell’s Incubation Grants program:

Recruiting

We hired Caitlin McGugan as a Senior Fellow and James Snowden started working with us as a research consultant. We hope they will increase GiveWell’s output of intervention reports. We also have one summer research analyst, Scott Weathers, working with us.

Operations

The separation of GiveWell and the Open Philanthropy Project was a major priority for GiveWell’s operations team in the first half of 2017. The separation was finalized on June 1.

The operations team continues to increase in specialization (historically, GiveWell operations work has been done by generalists on staff). We hired Maryana Pinchuk to serve as a Donations Manager and Erin Wolff as a Donations Relations Assistant; a search for a Controller to manage our finance and accounting is underway. We have also started to work with new vendors to outsource some operations work, which we hope will increase our available staff capacity and improve the quality of our operations.

Outreach

Outreach is now a major organizational priority for GiveWell. In the past, we focused very little on efforts to reach new potential donors with GiveWell’s work. Now, we think outreach is more of a limiting factor than research—the high-value funding gaps we’ve identified exceed the amount of donations we expect to direct to those gaps.

We have developed a list of ideas for how to significantly increase the money GiveWell directs to our recommended charities, and are planning to work on the most promising ideas over the next few months. For example, we think there may be relatively low-intensity steps to take in areas like podcast advertising; in February, we advertised on a small number of podcasts and plan to do so again based on the cost of running advertisements and the additional donations to top charities we tracked as a direct result of those ads.

We are also trying to hire another Research Analyst, Outreach Focus to expand our capacity to communicate with donors and other individuals who rely on GiveWell’s research.

The post Mid-year update on GiveWell’s progress appeared first on The GiveWell Blog.

### Deciding whether to recommend fistula management charities

Thu, 07/06/2017 - 15:32

We’ve long been interested in fistula surgery as a potential GiveWell priority program. However, as with other surgery charities, we have struggled to identify an organization that meets GiveWell’s criteria. Now, we’re working with a group called IDinsight and are excited that we may be able to consider a fistula surgery organization as a potential GiveWell top charity.

Our longstanding interest in interventions to treat fistula can be attributed in part to the popular narrative presented about fistula. The condition, which is often associated with social ostracization, appears to cause a significant amount of suffering, and seems to be treatable. We’re not sure how representative the popular narrative is, but as donors, it has contributed to our continued interest in better understanding this intervention, along with the feeling that surgery charities in general may offer low-cost, life-changing impacts.

Summary

This post will discuss:

• Fistula management, including surgery, as an intervention.
• Our open questions and uncertainty around fistula management programs, particularly their costs.
• Our plans to partner with IDinsight to help answer some of our questions about fistula management.

Surgery charities and GiveWell

We recently published a blog post describing our work to better understand charities that implement cataract surgery programs and to assess whether they might be a fit for a GiveWell top-charity recommendation. As we discussed in that post, surgical interventions in general seem to intuitively appeal to donors due to their potential to offer inexpensive, large impacts on quality of life. However, our uncertainty about surgery charities’ room for more funding and monitoring information has generally led GiveWell to deprioritize research on charities implementing these programs in the past.

Now, as part of GiveWell’s Incubation Grants program to grow the pipeline of potential future top charities and improve our understanding of our current top charities, we’re researching organizations that work on cataract surgery and fistula surgery as potential future top charities.

This post focuses on the latter. Although both interventions are surgical, fistula surgery is distinct in a number of ways from cataract surgery and other interventions GiveWell recommends. Fistula surgery may be a major, invasive procedure. In addition, the largest negative effects of fistula may be psychological, economic, and social, rather than physical.

Fistula management as an intervention

An obstetric fistula, or gynecologic fistula, is an abnormal opening between the vagina and the bladder or rectum. Obstetric fistula is often caused by prolonged obstructed labor, where pressure from the fetus on the mother’s pelvic bone cuts off blood flow to soft tissues, which then die, leading to a hole through which urine or feces may leak through the vagina. Fistula can have physical, economic, and psychological consequences, including social isolation.

Fistula may be treated with surgery to close or partially close the opening. (In some cases, small fistulas may not require surgical treatment; in other cases, the damage may be too extensive for surgical repair.) Job counseling and life skills training aimed at social reintegration may also be part of fistula treatment. “Fistula management” describes all of these interventions, including surgery.

Our very rough cost-effectiveness estimate for fistula surgery is \$1,400 per successful surgery performed. The severity of suffering, combined with the cost per surgery, may mean that fistula surgery is in the same range of cost-effectiveness as GiveWell’s current priority programs.

Our open questions

We recently published an intervention report on the evidence for surgery to repair obstetric fistula. We have a number of remaining questions that we’d like to answer before making a recommendation of an organization implementing a fistula management program. Key aspects of this intervention that we’d like to better understand include:

Outreach and cost-effectiveness

It may be challenging to identify and diagnose potential fistula cases. Fistula most often occurs in women who are located in very geographically remote areas or who are too poor to access health systems for delivery care in the event of prolonged obstructed labor. Women located in very remote areas may be hard to reach in general; women with obstetric fistula may be very hard to reach in particular, because they may be more likely to be socially disconnected or unreachable through regular community health systems.

In addition, fistula may not be well known, post-birth complications may be stigmatized, or the symptoms may not be recognized. It may be shameful for women to discuss fistula symptoms; for that reason, we’re unsure whether information about incontinence would be provided to a researcher or surveyor. Even in cases where symptoms are shared, they can be caused by other urological issues, complicating diagnosis of fistula.

We’d like to better understand what the most cost-effective methods of outreach to women with fistula are. We understand that outreach activities have included media outreach; training health workers, nurses, midwives, and doctors in fistula identification to strengthen referrals to treatment; and having women who have had treatment for fistula help identify and encourage women with fistula in their communities to seek medical care. We’re not sure what approach to outreach is most cost-effective.

How cost-effective are fistula management programs?

We’re unsure how the above outreach contributes to the overall cost per patient of fistula treatment. In addition to outreach activities, our impression is that fistula surgery programs often involve training surgeons and the purchase of equipment. We remain very unsure about the costs and benefits of these activities.

Fistula management programs may also involve a number of non-surgical interventions for patients. Some fistula centers offer rehabilitation activities for patients, such as counseling or job training. We’re not sure how common these types of rehabilitation are or what other types of support might entail, or how effective they are at improving social or economic outcomes; this could have a large impact on our overall estimate of fistula management charities’ cost-effectiveness.

What is a ‘successful’ surgery, and what proportion of surgeries are successful?

Obstetric fistulas vary in their size and suitability for surgical repair. For women who do receive surgical treatment, a “successful surgery” may not lead to continence. We’re unsure what proportion of operations successfully close fistulas due to a lack of available data in this space.

Among women whose surgeries do result in continence, we’re unsure of the extent to which that leads to positive social, economic, and psychological outcomes in turn. A major open question is whether operations that succeed in closing a fistula will address any possible social impacts of fistula.

In addition, the prolonged obstructed labor that caused the fistula could also lead to other health complications, such as infertility, scarring, and neurological damage. Repair of the fistula would generally not address these other issues, which could also have social and economic as well as physical consequences.

We are thus very interested in monitoring a) the success of surgery in repairing fistulas and b) the social and economic outcomes for women who receive fistula surgery with or without non-surgical interventions such as counseling. We have not looked closely at the studies that have been done on post-surgical outcomes, although our impression is that most studies in this space have been small. As the economic and social consequences of fistula may be among the greatest burdens of those who have fistula, we are particularly interested in understanding the impact surgery has on those outcomes.

Our plans with IDinsight

GiveWell partnered with IDinsight, an international NGO that focuses on providing clients with information to increase their social impact, as part of our work on GiveWell Incubation Grants. The “GiveWell embedded team” at IDinsight is working with us on a project to better understand the potential of fistula management organizations to become GiveWell top charities.

IDinsight plans to begin this work by focusing on the cost-effectiveness of fistula management, including surgery, as an intervention. It plans to work closely with Fistula Foundation, an organization that funds fistula treatment in Asia and Africa, to understand its costs per surgery for one country to help inform GiveWell’s assessment of the cost-effectiveness of fistula management programs in general. (Even though information from a single country will have limitations in its applicability elsewhere, we think starting at this scale is the right first step.)

If this intervention appears cost-effective—competitive with our current priority programs—following this initial phase of work, then IDinsight will likely work with GiveWell to identify one or more fistula management charities with which to develop and implement a high-quality monitoring system. With additional, high-quality monitoring information, we may better be able to understand whether a fistula management charity should be included in GiveWell’s list of top charities.

We expect this work to take several years, due to the amount of time required to set up and gather data from a new monitoring system, and do not expect this to impact GiveWell’s charity recommendations in 2017.

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