We have published a more recent review of this organization. See our most recent report on the SCI Foundation, formerly known as the Schistosomiasis Control Initiative.
Published: November 2013
What do they do? SCI works with governments in sub-Saharan Africa to create or scale up deworming programs. SCI's role has primarily been to solicit grants from large funders, identify country recipients, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs.
Does it work? We believe that there is relatively strong evidence for the positive impact of deworming. SCI has provided studies on its own national control programs showing large declines in infection rates. Note: As of November 2013, we are reexamining these studies.
What do you get for your dollar? We estimate that children are dewormed for a total of around $0.73 to $0.99 per child, with SCI paying about 70% of these costs. The number of lives significantly improved is a function of a number of difficult to estimate factors, which we discuss in detail in a separate report.
Is there room for more funds? We continue to recommend unrestricted funding to SCI because we believe that SCI has used unrestricted funds in productive ways in the past and because the overall need for funding in the countries in which it is working remains substantially greater than available funding. We do not know how, specifically, SCI would use additional funds.
SCI is recommended because of its:
- Focus on a program with a strong track record and excellent cost-effectiveness (more).
- Track record – SCI has repeatedly demonstrated success at starting and expanding national deworming programs.
- Room for more funding – we believe SCI will use additional funds productively (more).
Major unresolved issues include:
- The impact of unrestricted funds, which comprise a small portion of SCI's overall budget.
- SCI has provided studies on its own national control programs showing large declines in infection rates. Note: As of November 2013, we are reexamining these studies.
- SCI has shared very limited recent monitoring results.
Our review process
We began reviewing SCI in 2009. Our review has consisted of:
- Reviewing published studies on SCI's programs.
- Extensive communications with SCI Director Alan Fenwick and Deputy Director Wendy Harrison to discuss SCI's methods and funding needs, as well as meetings with other staff at SCI's headquarters in London.
- Requesting and reviewing SCI internal financial and organizational documents.
- Visiting a national schistosomiasis control program meeting and demonstration mass drug administration in Malawi (notes and photos from this visit)
- Following SCI's progress and plans for funds raised as a result of GiveWell's recommendation (see our updates on SCI's progress).
All content on the Schistosomiasis Control Initiative, including past reviews, updates, blog posts and conversation notes, is available here.
- What do they do?
- Does it work?
- Independent evidence of program effectiveness
- Internal monitoring: large-scale programs
- Internal monitoring: activities funded with unrestricted funds
- Possible negative and offsetting impact
- What do you get for your dollar?
- Room for more funds?
- SCI as an organization
What do they do?
SCI works with governments in sub-Saharan Africa to create or scale up mass drug administration programs for neglected tropical diseases (NTD), particularly schistosomiasis and soil-transmitted helminths (STHs), in school-aged children and other groups determined to be at high risk.1 SCI's role has primarily been to solicit grants from large funders, identify country recipients, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs.
SCI does not report a comprehensive budget of all of its expenditures. It reports spending for each of its "accounts." It has accounts for each of the grants it has received, as well as accounts for unrestricted donations. We have seen spending details for many of these accounts, including all of the accounts containing unrestricted funds.
Large grants for mass drug administrations
SCI's work has been driven by a number of large grants, each with somewhat different program designs and geographic coverage:
- Initial Gates Foundation grant: SCI was founded in 2002 through a $32 million grant from the Gates Foundation.2 This grant was used to create national treatment programs for schistosomiasis and soil-transmitted helminths (STHs) in six countries.3
- Grants for integrated NTD control: In 2006, SCI received large grants from USAID and the Gates Foundation to support integrated NTD programs in eight countries for five years to treat lymphatic filariasis, onchocerciasis, and trachoma, in addition to schistosomiasis and STHs.4 It received a grant in 2007 to expand its advisory work to Rwanda and Burundi.5 All of these grants were due to be completed in 2011.6
- DFID grant: In 2010, SCI received funding from the UK's Department for International Development for treating schistosomiasis and soil-transmitted helminths7 in eight countries over five years.8 Other NTDs are not covered by the grant, though DFID also provided funding to the Liverpool School of Tropical Medicine to integrate treatment for lymphatic filariasis with SCI-funded schistosomiasis and STH programs in six countries.9
SCI's role in mass drug administrations in general is to:10
- Advocate for the benefits of mass drug distributions to government officials.
- Assist with planning and fund raising.
- Deliver funding and drugs to governments.
- Provide financial management and technical support.
- Develop procedures for monitoring and evaluation.
DFID grant spending breakdown
The grant from DFID comprises the majority of SCI's current funding, between the start of the project in 2010 and March 2013.11
Under the DFID grant, SCI has spent about 48% on salaries and travel expenses for management and technical staff and 52% on program expenses (this excludes the cost of drugs, which are funded under a separate DFID grant).12 To further break down program expenses, SCI provided a budget for Malawi; program expenses in Malawi account for about 14% of all program expenses.13 The types of expenditures listed were in line with our understanding of SCI's role from past conversations (public and private) and our 2011 site visit, though at a higher level of detail.
In-country spending extrapolated from Malawi example14
|Budget item||% of spending||Description|
|Technical personnel and travel||36%||UK-based Technical Director, country programme managers, health economist, biostatistician, data manager; Ugandan-based capacity building advisor. Technical Assistance: Consultancy fees for expertise.|
|Management personnel and travel||12%||UK-based SCI and Liverpool School of Tropical Medicine personnel undertaking project operational and financial management; project administration.|
|Program: Monitoring||14%||Includes sentinel site monitoring for cohort studies, coverage validation surveys, and knowledge, attitudes and practices surveys.|
|Program: Mass drug administration costs||12%||SCI provided a further breakdown of this category for two example countries. The components of this category overlap with other categories listed here (e.g. training and social mobilization). It isn't clear to us what distinguishes expenses in this category.|
|Program: Training||7%||Includes training of trainers, training of teachers and health workers, and training materials.|
|Program: Supervision||5%||No further information available.|
|Program: Office support and materials||5%||Includes program office support, treatment registers and dose poles.|
|Program: Meetings||3%||Includes pre- and post-program meetings for planning and evaluation.|
|Program: Social mobilization||3%||No further information available.|
|Program: Drug transportation||3%||No further information available.|
Programs funded with unrestricted funds
Prior to 2011, unrestricted funds accounted for a very small portion of SCI's total funding.15 SCI told us that this funding was primarily used to fund treatments in regions of Cote d'Ivoire and Mozambique.16
In part due to GiveWell's recommendation, between November 2011 and October 2013, SCI received about $4.4 million in unrestricted funds. Over the same period it spent about $2.3 million and made spending commitments totaling $1.8 million (details in our October 2013 update). SCI told us that it has spent these funds in three main categories:17
- Supporting country programs not funded by DFID or other restricted funds (71% of spending). These funds have primarily been used to start new deworming programs in countries where SCI has not worked before. SCI hopes that by using unrestricted funds to get national treatment programs started in these countries, it will attract large grants from major donors, such as the UK's Department for International Development (DFID), to continue the programs. As of October 2013, DFID is considering funding deworming programs in two of these countries: Ethiopia and DRC.
- Supplementing restricted funding in the set of countries supported by a grant from DFID (13% of spending).
- Funding a variety of organizational costs including the salary of a staff member and staff travel (16% of spending).
In addition, SCI has received some smaller grants for a variety of projects, including:
- Research. SCI has received a number of smaller grants to carry out research related to NTD control.18
- NTD treatment programs funded by individuals. SCI has received restricted funds from individuals to fund treatment in Uganda (on islands in Lake Victoria), Burundi, and Rwanda.19
- Other NTD-related activities. SCI has also used funding from individuals for surgeries for hydrocele (a symptom of lymphatic filariasis) in Niger, and health education and water and sanitation programs in Burundi.20
Overall spending breakdown
We have not seen a spending breakdown from SCI that covers all costs in a particular period. However, we believe that the above information on spending from the DFID grant, unrestricted funds, and other small grants, provides a reasonably complete picture of SCI's past spending.
We detail other spending breakdowns that SCI has provided in an older version of this review.
Does it work?
SCI's mass drug administration programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective. SCI has provided studies on its own national control programs showing large declines in infection rates. Note: As of November 2013, we are reexamining these studies.
Independent evidence of program effectiveness
SCI's primary program is mass deworming, which we discuss extensively on another page. There is a very strong case that mass deworming is effective in reducing infections. The evidence on the connection to positive quality-of-life impacts is less clear, but there is a possibility that deworming is strongly beneficial.
Internal monitoring: large-scale programs
Note: As of November 2013, we are reexamining the studies discussed in this section due to questions about the methods used in the studies. We have not yet reached a conclusion about the accuracy or importance of these concerns.
We have seen detailed technical reports for four countries: Burkina Faso, Niger, Uganda, and Burundi. The first three countries accounted for about 74% of SCI funding as of April 2010,21 though the data below covers only the first year or two of these programs, which started in 2003-2004 and continued until at least 2010. We also include Burundi for which we have seen a technical report that appears to cover the full time period of SCI's work in the country. Burundi is the only country for which we have seen data on a program that was not funded by SCI's first Gates Foundation grant. Note that the data from Burundi is from two studies: (a) 2007-2011 results from schools included in a pilot program in three provinces; and (b) 2008, 2009, and 2011 results from schools in the other districts.
We focus on these countries because (a) these countries account for the bulk of SCI's spending prior to April 2010 (and evaluations from more recently-funded countries are not yet available) and (b) we have the most in-depth information on them.
Results from Burkina Faso, Niger, Uganda, and Burundi
All of the following data is from uncontrolled panel studies, i.e. the same individuals were examined before and after treatment and the changes in their disease status reported as the effect of the treatment. Cross-sectional studies of children in the same schools as the cohort children and selected to match, in age and sex, the cohort group were also conducted in Burkina Faso with roughly similar results.22 In the four countries, significant decreases in parasite prevalence and intensity, anemia, and some disease manifestations were observed. All of the changes reported in the below table are statistically significant at p<0.05.23
|Schistosoma haematobium||Schistosoma mansoni||Hookworm|
|Country||Changes in prevalence||Changes in intensity||Changes in prevalence||Changes in intensity||Changes in prevalence||Changes in intensity|
|Burkina Faso||59.1% at baseline to 7.7% at two years||94.2 eggs/10ml urine at baseline to 6.8 at two years||2.8% at baseline to 0.3% at two years||4.6 eggs per gram of feces at baseline to 0.6 at two years||Not reported||Not reported|
|Niger||75.3% at baseline to 28% at one year||22.8% prevalence of heavy-intensity infections at baseline to 4.6% at one year||Not reported||Not reported||Not reported||Not reported|
|Uganda||Not reported (SCI reports very low baseline prevalence24)||N/A||42.4% at baseline to 17.9% at two years||219.6 eggs per gram of feces at baseline to 37.4 at two years||50.9% at baseline to 10.7% at two years||309.4 eggs per gram of feces at baseline to 21.9 at two years|
|Burundi (pilot)||Not reported (SCI reports very low baseline prevalence25)||N/A||12.7% at baseline to 1.7% at four years||Not reported||17.8% at baseline to 2.7% at four years||Not reported|
|Burundi (other schools)||Not reported (SCI reports very low baseline prevalence26)||N/A||6.2% at baseline to 0.7% at three years||Not reported||15.1% at baseline to 5.4% at three years||Not reported|
For the other two prominent soil-transmitted helminths, ascaris and trichuris, very low prevalence of ascaris was reported in the Niger and Burkina Faso studies,27 and low baseline levels with modest decreases at two years were reported for both ascaris and trichuris in Uganda. In Burundi, effects on ascaris and trichuris appear inconsistent; prevalence both rose and fell by statistically significant amounts over the five years of the study (with the exception of trichuris, where the rise in prevalence was not statistically significant). Data from Uganda and Burundi are given in the footnote.28
|Country||Anemia||Mean hemoglobin concentration29||Blood in urine30||Ultrasound abnormalities of the urinary tract prevalence||Ultrasound abnormalities of the bladder||Thinness or wasting||Shortness or stunting||Firm or hard liver||Firm or hard spleen|
|Burkina Faso||65.75% at baseline to 61.59% at one year||10.97 g/dL at baseline to 11.25 g/dL at one year||Micro: 49.56% at baseline to 10.50% at one year||Not reported||Not reported||Not statistically significant||Not statistically significant||Not reported||Not reported|
|Niger||61.9% at baseline to 50.4% at one year||11.0 g/dL at baseline to 11.4 g/dL at one year||Gross: 7.1% at baseline to 0.4% at one year; Micro: 53.5% at baseline to 6.0% at one year||45.6% at baseline to 15.2% at one year||41.6% at baseline to 14.7% at one year||Not reported||Not reported||Not reported||Not reported|
|Uganda||51.6% at baseline to 36.2% at two years||11.4 g/dL at baseline to 12.0 g/dL at two years||Not reported||Not reported||Not reported||Not reported||Not reported||63.3% at baseline to 0.8% at two years||61.6% at basline to 14.1% at one year|
|Burundi (pilot)||25.4% at baseline to 8.3% at four years||Not reported||Not reported||Not reported||Not reported||Not reported||Not reported||Not reported||Not reported|
|Burundi (other schools)||26.0% at baseline to 16.3% at three years||Not reported||Not reported||Not reported||Not reported||Not reported||Not reported||Not reported||Not reported|
Potential issues with the above data
Due to the way in which they were carried out, these studies may overestimate SCI's impact. Potential sources of bias include:
- Monitoring of selected locations. It appears that the authors of the studies we've seen selectively chose locations to monitor, rather than examining a representative sample of treated areas.
- In Burkina Faso, monitoring occurred in four out of 13 regions that received treatment. These four regions were selected because they were "known a priori to be places where schistosomiasis is highly endemic."31
- In Niger, survey locations were stratified "to represent the two main transmission patterns in Niger," and all of the survey locations were located near bodies of water.32 SCI told us that these locations "are not representative of the treatment population as a whole. They were selected to indicate the impact of treatment in schools with varying prevalence and intensity of both [types of schistosomiasis]."33
- In Uganda, as in Niger, survey locations "were selected to represent different transmission settings."34
- In Burundi, pilot program "schools were chosen based on 3 zones; each containing different NTD endemicity": the "STHs + Schistosomiasis + onchocerciasis" zone, the "STHs +onchocerciasis" zone, and the "STH only endemic areas."35 For the survey of non-pilot program schools, the report we have seen says only, "The selection of schools was done randomly from the non-pilot provinces; taking into account 11 separate ecological zones."36
- Low follow up rates. Follow up rates tended to be quite low (43-73% over two years of study).37 SCI stated to us that the children that were available for follow up in most or all of the above studies were those children who had not dropped out of school and were not absent on the given day.38 There are a few ways in which this phenomenon could lead to overstatement of effectiveness:
- If schistosomiasis itself contributes to dropping out of school, then the children who are successfully followed up with may be the ones who are most likely to have ceased being infected for reasons unrelated to treatment.
- A similar dynamic could hold if a third factor (for example, low family income or poor hygiene) contributes to both schistosomiasis infection and dropping out of school.
- The children who are successfully found, year after year, seem (intuitively speaking) more likely to be the same children who are successfully treated, year after year. Therefore, effects of treatment on these children aren't necessarily representative of effects on the treated population as a whole.
The baseline characteristics measured in the studies did differ in some ways between those children who were found on follow up and those who were not; however the differences do not exhibit consistent patterns across the three studies (not reported for Burundi).39
- Possibility of unreported measured results. As seen in the above tables, many results are reported for one or two but not all of the countries. It is possible that some of these indicators were measured but not reported in the published studies because they did not show favorable results. This is a speculation only; we have not discussed this question with the studies' authors.
Do these results apply to SCI's large-scale programs generally?
We have limited information on whether the results presented above from Burkina Faso, Niger, Uganda, and Burundi can be generalized to other countries in which SCI has run programs (see footnote for details of where SCI has worked over what years and what results we have seen40). In addition to the published studies discussed above, we requested monitoring reports from Tanzania, which we did not receive.
For its first year or two of work in Mali and Tanzania, SCI posts results, but not details of how the data was collected, on its website. While reported results show positive effects, results are not reported for many indicators and we do not know if the methods used to collect this data were highly rigorous.41
SCI notes that in Zambia, which received support under SCI's initial Gates Foundation grant, implementation was poor and results below expectations.42
In October 2013, SCI reported that it had collected baseline and at least one follow up round (following one or more rounds of treatment) of data from 8 of the 15 countries it is working in and baseline data only from an additional 5 countries.43 Prevalence mapping data only has been collected in the remaining two countries: Cote d'Ivoire and Ethiopia.44 We have seen baseline data and detailed methodology from Liberia only.45 We have not seen follow up data from any country. Judging from the Liberia example, SCI has and will collect data using the same methods that it used in the studies detailed in the previous section.46
We have not seen evaluations of SCI's work on diseases other than schistosomiasis and soil-transmitted helminths and our understanding from conversations with SCI is that it does not monitor these programs. We have not seen evaluations of SCI's work with populations other than schoolchildren. Adults also receive treatment in some SCI-funded programs.47
Internal monitoring: activities funded with unrestricted funds
We have seen limited information on the success of activities SCI has funded with unrestricted funds:
- We have seen a list of treatments given by community in Mozambique in 2008,48 and a narrative report (undated; we received it in 2011) that states, "Since 2006 surveying and treatment has taken place in 14 of the district’s primary schools, in which every child is administered with the correct dosage of Albendazole and Praziquantel annually."49
- We have not seen monitoring from the pilot project in Cote d'Ivoire. The country is now receiving funding from DFID and SCI plans to conduct regular monitoring there in the future (see our November 2012 update).
- SCI has shared non-public reports from staff members' visits to a number of countries (see our November 2012 update).
- SCI shared a government report on the distribution in Senegal in early 2012, which provides treatment coverage data for part of the area that received SCI-funded treatments and notes that not all data is available because some has been withheld by health workers who are involved in a labor dispute.50
- A large portion of SCI's unrestricted funds have been spent or will be spent in 2012-2014 in Ethiopia. We have seen a short description of SCI's monitoring plans for Ethiopia. These plans sound similar to SCI's plans for Liberia (discussed above).51
Possible negative and offsetting impact
- Concerns over whether treatment was sustained: We believe it is important that deworming programs are sustained over time, as re-infection is rapid and a one-time treatment may have little long-term effect.52 SCI told us that it "is hesitant to use one-off donations to fund programs that couldn't be continued over the long run,"53 and seems to have a reasonable record of maintaining national programs over time.54 However, it is not clear to us (a) how likely programs funded by individual donors are to be sustained after the first few years; (b) the extent to which SCI-funded programs have succeeded in treating the same children multiple times, as opposed to simply treating the same areas multiple times (and thus treating different children once each).
We remain unsure about how many treatments are needed to impact health. SCI told us that its views on what groups should be treated and how often "is largely based on intuition and common sense, though it usually works and SCI collects sufficient data to know when it isn't working. In general, in high endemicity areas re-infection is a major issue; in lower endemicity areas, a single treatment can be sufficient."55 One example of the variation in treatment patterns is what SCI told us about its program in Yemen:SCI distinguishes between high, medium and low prevalence areas. In high prevalence areas, SCI treats the whole population once, and children for five years. In medium prevalence areas, SCI treats the whole population once, and children every other year. In low prevalence areas, SCI treats children every other year.56
- Replacement of government funding: In the past, SCI has largely supported programs that did not exist before its support.57 We have not seen data on government spending on NTDs before and after receiving SCI support.
- Diversion of skilled labor: Drug distribution occurs only once or twice per year and appears to be conducted by teachers, community drug distributors (who receive minimal training to fulfill this role), and health center staff.58 Given the limited time and skill demands of mass drug distribution,59 we are not highly concerned about distorted incentives for skilled professionals.
What do you get for your dollar?
The details of our calculation of SCI's full cost per treatment are in this spreadsheet. In short, we have used the following information to estimate SCI's cost per treatment delivered:
- Data on the value of SCI's grants from 2002-2010
- The number of schistosomiasis and STH treatments it reports delivering during that period
- Conversations with SCI about how the grants were used
- A study of the costs of a SCI-funded deworming program in four districts of Niger in 2004-2006,60 which we used to estimate non-SCI contributions to SCI's deworming programs. The study aimed to account for all costs of the program including costs funded by the government and non-financial costs such as the value of volunteers' time.61 The study is of a single country, looked at a program that was carried out 7-9 years ago, and the program may differ in some ways from current programs,62 but overall it is of high quality and provides us with a sense for the portion of resources contributed by SCI versus non-SCI parties.
Non-SCI costs were 18% of the total cost of the program and 33% of the cost of school-based deworming (the program also included community-based deworming).63 It is our understanding that in recent programs SCI has continued to do some community-based deworming but that most of its treatments are delivered through schools. Therefore, we conservatively estimate that non-SCI actors contribute 30% of the cost of a SCI deworming program.
- The upper-bound on the cost-per-treatment during the period studied was $1.13. This analysis includes all grants received by January 2011 in "SCI's costs," with the exception of the DFID grant, which was awarded in late 2010.
- Our best guess excludes a few more grants that, based on conversations with SCI, we believe can reasonably be excluded from the cost of treatment. This best guess is intended to be fairly conservative. Under these assumptions, we estimate the cost-per-treatment at $0.99.
- A less conservative estimate, that attempts to subtract out research costs that SCI told us were above and beyond normal monitoring and evaluation costs, yields $0.72 per treatment.
- An estimate based on the funding received from DFID and the number of treatments committed under that grant, yields an expected cost of additional treatments of $0.73, though (a) this does not include costs such as organizational overhead and (b) SCI notes that it is possible that this funding will be supplemented with other funding to achieve the treatment goals.
Note that SCI's USAID grants involved some treatments for diseases other than schistosomiasis and STHs; we do not include these on either side of the calculation, i.e., we do not include the treatments in the denominator of "cost per treatment" or the value of donated drugs in the numerator of "cost per treatment."
We discuss how the above figures relate to how much it costs to improve a child's health and development at our report on mass treatment programs for schistosomiasis and STHs.
Room for more funds?
SCI told us in November 2013 that it could effectively absorb up to $10 million in additional unrestricted funds in the next year. These funds would allow it to expand programs to reach additional at-risk populations in the countries it is currently working in and to plan with more confidence for activities in 2015.
As of November 2013, SCI's top unfunded priorities are:64
- Cote d'Ivoire: About $1 million is needed to deliver donated drugs in 2014. DFID is funding about $600,000, leaving a funding gap of $400,000. SCI expects to use unrestricted funds to fill this gap.
- Mozambique: SCI estimates that there are 8 million people requiring treatment in Mozambique. SCI has allocated about $1 million from DFID for this purpose and needs an additional $3 million to reach national coverage.
- Mauritania: SCI aims to raise $1 million to fund the first three years of a deworming program in Mauritania, including the costs of mapping. SCI would aim to raise the full amount prior to starting the program.
- Ugandan islands: SCI aims to raise $200,000 per year to treat over 200,000 people living on islands in Lake Victoria. Funding is available from DFID and USAID to treat populations living on the Ugandan mainland, but has not been available for the island populations because of the relatively high cost to reach them. SCI would ideally like to have enough funding to ensure that it can provide treatment for at least the next few years before starting the program.
These four projects total about $4 million for the next year (including only the first year of work in Mauritania). If SCI were to receive more than $4 million, it would use the funds for a combination of:65
- Saving funds to ensure that it can continue treating populations it has treated for one or more years with unrestricted funds.
- Expanding programs in other countries it is working in (most of which do not have enough funding to treat all at-risk populations).
- Starting programs in countries it is not yet working in, such as Sudan.
SCI believes it could productively absorb up to $10 million in 2014; some of these funds would not be spent in 2014 but would allow it to better plan for activities in 2015.
It is our understanding that SCI's priorities can change due to factors such as availability of donated drugs in particular countries, delays due to coordination with other actors, results of disease mapping, and grants from other donors. GiveWell encourages unrestricted funding to allow SCI flexibility to change its plans as necessary.
Note that DFID is in the final stages of considering a second grant to SCI in 2014 totaling £15 to 18 million (about $24-29 million), including funding for Ethiopia, which was previously supported with unrestricted funds.66 The funding gaps above take into account this expected funding.
SCI as an organization
- Track record: SCI has consistently gotten national deworming programs to go through, as discussed above. As of November 2013, we are reexamining the impact of these programs.
- Self-evaluation: SCI’s self-evaluation is among the best we’ve seen from any organization (as of November 2013, we are reexamining these studies). That said, it has generally been done by academics and SCI hasn’t always been able to provide the details of what was done (and thus to answer concerns about possible weaknesses in the evaluations), and we have not seen evaluations from more recent programs. In addition, we differ strongly on the strength of the evidential case for deworming (see our 2012 post on deworming and the comments that follow it).
- Transparency: SCI has consistently been strong in its commitment to transparency. It has generally provided the information we’ve asked for and has never hesitated to share it publicly (unless it had what we felt was a good reason). It has allowed a lot of public dialogue that other charities may have been uncomfortable with.
- Communication: We don’t feel that SCI has ever purposefully been indirect with us, but we have often struggled to communicate effectively with SCI representatives, and we still are not as clear on some issues as we'd like to be.
More on how we think about evaluating organizations at our 2012 blog post.
"Objectives of SCI
- To encourage development of sustainable schistosomiasis and STH control programmes in sub-Saharan Africa.
- In the selected countries: to reach at least 75% of school-aged children (which in most countries would be from 6 to 15-year-old) and other high-risk groups with chemotherapy, namely PZQ and ALB; and thereby reducing prevalence and intensity of schistosomiasis and STH infections; as well as reducing schistosomiasis-related morbidity in high risk groups; and burdens due to STH infections in the targeted populations.
- To create a demand for sustained schistosomiasis and STH control.
- To promote access to anthelminthic drugs and good case management in the regular health system.
- To develop a rigorous monitoring and evaluation plan which will generate the information required to determine whether or not the objectives have been met."
Fenwick et al. 2009, Pg 3.
"The move towards national control programmes in sub-Saharan Africa was facilitated by an award from the Bill and Melinda Gates Foundation (BMGF; http://www.gatesfoundation.org) Global Health Program in 2002, to the SCI for the implementation and evaluation of control of schistosomiasis." Fenwick et al. 2009, Pg 2. Amount at Gates Foundation, Imperial College London (June 2002).
"Six countries were selected by October 2003 for full support: Burkina Faso, Mali, Niger, Uganda, Tanzania and Zambia. The countries each proposed a different implementation approach and management structure for their large-scale schistosomiasis control. This was readily accepted because the BMGF required SCI to test the ‘proof-of-principle’ of national scale, Ministry of Health (MoH)-led schistosomiasis control programmes. SCI is based in Imperial College London and operated with the principle that all programmes were country owned and run, with SCI staff offering technical and other assistance, but not as expatriates living in-country. Programmes were based in the MoH in the respective country, and SCI offered support to improve the national health system." Fenwick et al. 2009, Pg 2.
Between 2003 and 2008, SCI provided treatment for schistosomiasis and soil-transmitted helminths to the following number of people (Fenwick et al. 2009, Pg 3, Table 1).
Number treated by country (millions) Year Uganda Burkina Faso Niger Mali Tanzania Zambia 2003 0.43 - - - 0.10 - 2004 1.23 1.03 0.67 - 0.44 - 2005 2.99 2.30 2.01 2.60 2.95 - 2006 1.51 2.82 1.56 2.18 0.38 0.56 2007 1.81 0.75 2.07 0.65 2.65 0.25 2008 1.50 2.70 5.28 - 1.24 -
"Current and future rounds of treatment in all six countries are being delivered in an integrated manner to include schistosomiasis, STH, lymphatic filariasis, onchocerciasis and trachoma." Fenwick et al. 2009, Pg 10. The "six countries" refers to the six countries funded by SCI's first Gates Foundation grant.
Countries and dates from Schistosomiasis Control Initiative, Board management accounts (April 2010)
"A team from Imperial College London has been awarded 25 million funding from the UK Government to continue its fight against neglected tropical diseases, it was announced this week. The money will enable the Schistosomiasis Control Initiative (SCI) to provide 75 million treatments to protect some of the world’s poorest children against schistosomiasis – an illness caused by parasitic worms – and soil-transmitted helminths (STH). £15 million of the funding will be spent directly on procuring drug treatments, through an organisation called Crown Agents. The rest will be administered by SCI." Schistosomiasis Control Initiative, Imperial initiative to protect children from tropical disease awarded ₤25m government backing.
"SCI will be assisted in their drug delivery by the Centre for Neglected Tropical Diseases at Liverpool School of Tropical Medicine via a sub contract through LATH (Liverpool Associates in Tropical Health). In six countries, this will lead to treatment for lymphatic filariasis – another worm disease – becoming integrated with schistosomiasis and STH treatment." Schistosomiasis Control Initiative, Imperial initiative to protect children from tropical disease awarded ₤25m government backing.
- Alan Fenwick, SCI Director, phone conversation with GiveWell, June 17, 2010.
- Schistosomiasis Control Initiative, Summary sheet of treatments instigated and overseen by SCI
- Schistosomiasis Control Initiative, Proposal by SCI, Imperial College to manage the Program for Integrated Control of Neglected Tropical Diseases in Côte d'Ivoire
Data from Schistosomiasis Control Initiative report to GiveWell (September 2013), Pgs 2-4.
As of July 2011, it had received about $580,000 in unrestricted funding (Schistosomiasis Control Initiative, IC Trust summary (September 2011)) and $108 million overall (Schistosomiasis Control Initiative, Gates Foundation final report (January 2011) Pg. 20).
"For the smaller donor, we have two or three projects, which we have been supporting and which will hopefully lead to pilot project in their respective countries.
- In Cote d'Ivore, we now have funding from the U.K. Department for International Development (DFID). There will eventually be a national program.
- In Mozambique, we have a doctor running a practice for 70,000 people. We have been funding her to test people, do surveys and give drugs to treat people. Up until now, that has taken all the individual funding that comes in."
See our October 2013 update on SCI.
Spending breakdown in Schistosomiasis Control Initiative financial update (September 2013), Sheet Combined with previous updates.
SCI's summary of active accounts as of May 2013 lists five research grants totaling £2.4 million, or about $3.9 million. Schistosomiasis Control Initiative advisory board financial report (June 2013).
"Once we have people that want to give at least $100,000, we talk to them directly. Two examples:
- Someone wanted to do something special with his money, so we're doing hydrocele surgery in Niger. He gave us $200,000 and we told him we could do ~1000 hydrocele surgeries.
- Another person was interested in Uganda. So, we identified islands there in Lake Victoria that are relatively accessible and provided treatments there."
Alan Fenwick, SCI Director, phone conversation with GiveWell, February 16, 2011.
Schistosomiasis Control Initiative advisory board financial report (June 2013), Pg 2 notes programs in Burundi and Rwanda:
- Schistosomiasis and STH in Burundi: £1,040,000, June 2011 to May 2014.
- Rwanda Phase II programme: £355,441, March 2012 to February 2015.
Alan Fenwick, SCI Director, phone conversation with GiveWell, September 15, 2011. Note: "SCI generally doesn't do water and sanitation programs because of the expense. In Burundi they're doing water and sanitation programming because they have been successful there with running a program and treating schistosomiasis, but soil-transmitted helminth infections remain persistent." Alan Fenwick, SCI Director, conversation with GiveWell, October 17, 2011.
Data on spending by country is from Schistosomiasis Control Initiative, Board management accounts (April 2010) Pg 1. Funding, as of April 2010, was concentrated in Burkina Faso (34% of country-specific funding), Niger (33%), Uganda (10%), Burundi and Rwanda (10%; we don't have data for these countries independently), and Tanzania (7%).
"In addition to the cohort follow-up, a cross-sectional survey was conducted during the second follow-up (2 years post-treatment), in which a group of children (7–14 years old) outside the original cohort were randomly selected and examined in the sentinel schools. The number, age and sex structures were matched to those in the cohort who were present at the second follow-up in each school. Infection status in these children should represent the quality of treatment in children outside cohorts in schools, to confirm and validate the cohort data, i.e. no preferred treatment was given to cohort children…As in the cohort data, the proportion of heavy [S. haematobium infections was reduced from 25% to just 3.2% (Fig. 2). However, these children outside the cohort did show a slightly higher prevalence and intensity of S. haematobium infection than those in the cohort as in Table 1 (P<0.01) at 2 years post-treatment…In baseline children (7–14 years old) in the original cohort in this region, prevalence of S. mansoni infection was 14.2% (95% CI: 10.8–17.6; n = 408) [13.6% in the cohort baseline] and intensity of infection was 23.0 epg (95% CI: 11.8–34.2; n = 408) [22.4 epg in cohort] before treatment. Two years after treatment, S. mansoni prevalence in this region was 7.6% (95% CI: 4.4–11.0; n = 248) [1.5%in cohort] and intensity of infection was 16.5 epg (95% CI: 1.9–31.0; n = 248) [2.9 epg in cohort] (both P>0.05)." Touré et al. 2008, Pg 781-783.
Sources for the data in the tables:
- Burkina Faso: Touré et al. 2008 and Koukounari et al. 2007.
- Niger: Tohon et al. 2008.
- Uganda: Kabatereine et al. 2007.
- Burundi: Schistosomiasis Control Initiative, Monitoring and evaluation report for Burundi
- 24. "S. haematobium occurs only in a small focus and is of minor public health significance." Kabatereine et al. 2007, Pg 91.
- 25. Alan Fenwick, SCI Director, phone conversation with GiveWell, November 28, 2011.
- 26. Alan Fenwick, SCI Director, phone conversation with GiveWell, November 28, 2011.
- "Very low prevalence (0.3 to 0.7%) of Ascaris lumbricoides infection was observed in 5 schools, while 3% of the schoolchildren were infected in 1 school (Sanguile) and no infection was observed in 2 schools (Kaou and Tabalak)." Tohon et al. 2008, Pg 3.
- "For both years examined, Ascaris lumbricoides infection was absent, and the prevalence of Trichuris trichura infection was estimated to be 1.1% at baseline and totally absent 1 year later." Koukounari et al. 2007, Pg 663.
Results from Kabatereine et al. 2007, Pg 93, Table 2 (see source for 95% confidence intervals) and Schistosomiasis Control Initiative, Monitoring and evaluation report for Burundi (see source for statistical significance). We report "as measured results" for Burundi; SCI also reports model results.
Baseline Year 1 Year 2 Year 3 Year 4 Ascaris in Uganda 2.8% 1.6% 0.6% - - Trichuris in Uganda 2.2% 2.5% 1.6% - - Ascaris in Burundi (pilot) 14.9% 12.9% 20.1% 10.6% 10.1% Trichuris in Burundi (pilot) 3.2% 1.8% 3.9% 1.5% 2.4% Ascaris in Burundi (other schools) 21.6% 11.7% - 9.1% - Trichuris in Burundi (other schools) 10.4% 10.0% - 4.3% -
- 29. Hemoglobin is a component of blood containing iron. Anemia is defined as a hemoglobin concentrations below an age-dependent threshold.
- 30. Gross haematuria: visible blood in the urine; Micro-haematuria: blood in the urine that is detectable by microscopic inspection.
"The SCI-supported schistosomiasis control program was implemented during 2004 and had treated 3,322,564 school-aged children in the 13 regions of the country through October 2006...For the present study, parasitological and morbidity data were collected from a cohort of 1727 Burkinabé children 6–14 years old, randomly sampled from 16 schools before and 1 year after chemotherapy (2004 and 2005, respectively). The schools included in these surveys were randomly selected from all schools in 4 Regional Health Directorates known a priori to be places where schistosomiasis is highly endemic." Koukounari et al. 2007. Pg 660.
"Eight villages located in schistosomiasis endemic regions were randomly selected to represent the two main transmission patterns in Niger: six villages located near permanent (Tabalak, Kokorou) or semi-permanent (Kaou, Mozague, Rouafi, and Sabon Birni) ponds and two (Saga Fondo, Sanguile) located along the Niger River. The villages represented the south-western region (Tillabe´ry) and the central-northern region (Tahoua) of the country, with four villages from each region. One village is located in the Sudanian climatic zone and the seven others are in the Sahelian climatic zone." Tohon et al. 2008, Pg 2.
Kabatereine et al. 2007, Pg 92.
- Uganda: "We enrolled 4351 children from 37 schools, of which 2815 (64.7%) were traced and treated at one year follow-up and 1871 (43.0%) at two year follow-up." Kabatereine et al. 2007, Pgs 93-94.
- Burkina Faso: "Of 1727 schoolchildren recruited at baseline, 763 were successfully traced and re-examined at both follow-ups with three complete sets of longitudinal parasitological data on S. haematobium... Among 763 children, 322 had valid data entry for S. mansoni at all three surveys." Touré et al. 2008, Pgs 781-782.
- Niger: "Of the 1656 children recruited at baseline, 1193 (72.04%) were successfully followed-up in both year 1 and year 2 surveys." Schistosomiasis Control Initiative, Niger: Impact
- Burundi: In the pilot program survey, 53.3% of children surveyed at baseline were found for disease prevalence testing at the fourth follow up; however, only 49.6% were found at the first follow up, indicating that not all children found at the fourth follow up were found in all four follow ups. 64.8% were found for anemia testing at the fourth follow up (but only 60.5% at the first follow up). In the other schools survey, 56.5% of children surveyed at baseline were found for disease prevalence testing at the second follow up. 56.7% were found for anemia testing at the fourth follow up. Schistosomiasis Control Initiative, Monitoring and evaluation report for Burundi Pgs 1 and 13.
- Burkina Faso: "Baseline characteristics of children successfully followed-up showed that they had a lower mean age (9.6 years versus 11.0 years; P<0.01), a lower proportion of boys (54.1% versus 59.1%; P<0.05), higher S. haematobium prevalence (59.9% versus 53.1%; P$lt;0.01) but a similar intensity of S. haematobium infection (93.3 e/10 ml versus 91.2 e/10 ml; P<0.05), compared with those who had dropped out." Touré et al. 2008, Pgs 781-782.
- Niger: "Compared to those children who remained in the study cohort, the 216 children who dropped out after the initial survey differed significantly in the prevalence of S. haematobium infection (75.4% vs. 78%, respectively), but had less frequently heavy-intensity infections (22.8% vs. 16.5%, respectively). On the other hand, they did not differ in mean age (8.7 vs. 8.9 years, respectively), in the prevalence of anaemia (61.9% vs. 59.7%, respectively) nor in mean haemoglobinemia (11.04 g/dl vs. 11.03 g/dl, respectively)." Tohon et al. 2008, Pg e241.
- Uganda: "The baseline characteristics did not differ significantly among those included in the evaluation one-year post treatment and those lost to follow-up (see Table 1, available at http://www.who.int). However, we found the prevalence and mean intensity of S. mansoni to be significantly higher among those children who were lost to follow-up compared to those successfully followed up two years post treatment." Kabatereine et al. 2007, Pgs 93-94.
Funding sources in table below are compiled from:
Schistosomiasis Control Initiative, Summary sheet of treatments instigated and overseen by SCI
Alan Fenwick, SCI Director, phone conversation with GiveWell, June 17, 2010
Schistosomiasis Control Initiative, Board management accounts (April 2010)
April 2012, November 2012, and October 2013 updates on SCI.
Funding for mass treatment | Have we seen disease prevalence/intensity or morbidity results? 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Burkina Faso - Gates | Results with details Gates | Results with details Gates/ USAID | Results with details Gates/ USAID | Results without details Gates/ USAID | No results Gates / USAID | No results Gates / USAID | No results Gates / USAID | No results (Taken over by HKI) - Burundi - - - - GNNTDC | Results with details GNNTDC | Results with details GNNTDC | Results with details GNNTDC | Results with details Individual | Results with details Individual | No results yet Individual | No results yet Cote D'Ivoire - - - - - - - - - DFID | No results yet DFID | No results yet Liberia - - - - - - - - DFID | No results DFID | No results yet DFID | No results yet Malawi - - - - - - - - DFID | No results DFID | No results yet DFID | No results yet Mali - Gates | Results without details Gates | Results without details Gates/ USAID | Results without details USAID | No results USAID | No results USAID | No results (Taken over by HKI) - - - Mozambique - - - - - - - - DFID | No results DFID | No results yet DFID | No results yet Niger - Gates | Results with details Gates | Results with details Gates/ USAID | Results without details Gates/ USAID | No results Gates/ USAID | No results Gates/ USAID | No results Gates/ USAID | No results DFID | No results DFID | No results yet DFID | No results yet Rwanda - - - - GNNTDC | No results GNNTDC | No results GNNTDC | No results GNNTDC | No results ? End Fund | No results yet End Fund | No results yet Tanzania / Zanzibar Gates | Results without details Gates | Results without details Gates | No results Gates | No results Gates | No results Gates | No results Gates | No results Gates | No results DFID | No results DFID | No results yet DFID | No results yet Uganda Gates | Results with details Gates | Results with details Gates | Results with details Gates/ USAID | Results without details Gates/ USAID | No results Gates/ USAID | No results Gates/ USAID | No results Gates/ USAID | No results DFID | No results DFID | No results yet DFID | No results yet Yemen - - - - - - - - Unrestricted SCI funds | No results World Bank and unrestricted funds | No results yet World Bank and unrestricted funds | No results yet Zambia - Gates | Known failure Gates | Known failure Gates | Known failure Gates | Known failure - - - DFID | No results DFID | No results yet DFID | No results yet
Schistosoma haematobium Schistosoma mansoni Hookworm Anemia Country Follow up rate Changes in prevalence Changes in intensity Changes in prevalence Changes in intensity Changes in prevalence Changes in intensity Changes in prevalence Changes in mean haemoglobinemia Mali 58% over two years About 90% at baseline to about 50% at two years About 30% prevalence of heavy-intensity infections at baseline to about 3% at one year About 21% at baseline to about 13% at two years Not reported About 7% at baseline to about 2% at two years Not reported Not reported Not reported Tanzania 65% at one year Not reported Not reported in aggregate; about 3-52% at basline to 2-10% at follow up Not reported Not reported 39.81% at baseline to about 17.36% at one year Not reported 47.15% at baseline to about 32.97% at one year Not reported
"Zambia has been less successful in reaching its original programme target of expanding coverage to treating 2 million school-aged individuals and had only achieved, according to incompletely reported coverage, around 25% of this target by July 2007." Fenwick et al. 2009, Pg 9.
"In order to demonstrate in more detail an on-going monitoring and evaluation process within a designated country supported by SCI we have taken the example of Liberia (see below)." Schistosomiasis Control Initiative report to GiveWell (September 2013), Pg 11. Data on Pgs 12-14.
"Who has been treated (adults/school children/pre-school children):
Burundi: For STH: children 1-14 yrs, pregnant women under 49 yrs; For schisto: children 5-14 yrs, adults in high prevelance areas…
Malawi: School aged children 4.4 m and adults 1.2 m…
Senegal: MDA in April 2012 - private and public schools, islamic schools (called Dahara) and communities…
Uganda: Communities on Lake Victoria islands…
Yemen: Children and adults…
Zimbabwe: Predominantly school aged children but adults if justified."
Schistosomiasis Control Initiative, Program update (September 2012), sheet “By county 2012”.
"Withholding of the data by the health unionists since 2010. Negotiation was started during the meetings and the great importance of the MDA had was also highlighted as well as the negative consequences the MoH might have to face regarding the future of partnership, in case of not being able to get data and reports."; "Due to health information withholding, it was impossible to collect all data." Government of Senegal Report on MDA (2012) Pgs 10 and 12.
Date of MDA (April 2012) from Schistosomiasis Control Initiative, Program update (September 2012).
"As part of the national control programme, a longitudinal cohort of individuals will be recruited in order to help monitor the health impact of the programme. These individuals (mostly school-aged children) will be taken from a representative sample of areas across the country, with the size of the cohort estimated using a statistical sample-size calculator. These individuals will be followed up prior to mass treatment at baseline and every year in order to provide an estimate of the impact of the control programme on those people who receive treatment." Schistosomiasis Control Initiative report to Ethiopia donor (August 2013), Pg 3.
"Single-dose oral therapies can kill the worms, reducing ... infections by 99 percent ... Reinfection is rapid, however, with worm burden often returning to eighty percent or more of its original level within a year ... and hence geohelminth drugs must be taken every six months and schistosomiasis drugs must be taken annually." Miguel and Kremer 2004, Pg 161.
See table "Funding for mass treatment | Have we seen disease prevalence/intensity or morbidity results?" in previous footnote.
- Uganda: "The first country to implement a control programme on a national scale...Uganda implemented the SCI-supported control programme in April 2003." Kabatereine et al. 2007, Pg 91.
- Burkina Faso: "Some small-scale control activities with treatment had taken place in some areas in the past,11,13 but the national control programme did not start until 2004." Touré et al. 2008, Pg 780.
- Niger: "Niger’s National Schistosomiasis and Soil-Transmitted Control Programme (PNLBG) was launched at 2004." Fenwick et al. 2009, Pg 5.
- Mali: "In the following years many planned activities were not implemented due to limited financial resources but finally in 2004 national control activities recommenced in the country with support from the SCI." Fenwick et al. 2009, Pg 5.
- Tanzania: "The failure to embrace a national treatment programme has been due primarily to the costs involved in reaching the millions of individuals estimated to be at risk of infection, and the Ministry of Health was never able to support treatment within their budget. In October 2003, the Tanzanian National Plan was approved for funding by the SCI as a step towards developing a sustainable control programme." Kabatereine et al. 2006, Pg 334.
- Zambia: "'The Zambian Bilharzia Control Programme' (ZBCP) was established in 2004 to develop a MoH and MoE joint strategy for bilharzia and worm control. The MoE was already in receipt of a grant from the United States Agency for Inter- national Development (USAID) for implementing training and treatment in some schools on a small scale in two provinces, Eastern and Southern, which was known as the ‘School Health and Nutrition programme’ (SHN)." Fenwick et al. 2009, Pg 4.
"Drug distribution channels:
- School-based delivery for school children. School teachers will be trained to carry out drug distribution at schools.
- Community-based delivery for school-aged children who are not attending school and for community adults at high risk. Community Drug Distributors (CDD) will be trained to deliver the drugs at community.
- Health centre-based delivery. Drugs will be made available at health centres for those in the community who do not qualify for MDA and who request for treatment. Health workers at the centres will be trained.
Drug distributors need a minimum of one day’s training to understand the basis for calculating dosages, the necessary actions to deal with side-effects and treatment record keeping and reporting." Schistosomiasis Control Initiative, Neglected tropical diseases in Mozambique, Pg 23.
"For schistosomiasis and STHs, treatment will be conducted through schools by the teachers. For LF, treatment will be conducted through community directed treatment, by the CDDs and community health agents, managed by the district medical officer." Schistosomiasis Control Initiative, Proposal by SCI, Imperial College to manage the Program for Integrated Control of Neglected Tropical Diseases in Côte d'Ivoire, Pg 23.
See our overview of priority programs.
“This was a retrospective study which covered a two year period from April 2004 to May 2006, including the first and second years of MDA and related programme activities in four health districts. All data on first year costs at national, regional, district, and sub district levels were taken from the PNLBG accounts and receipts and records of staff missions or activities. Second year cost data for national and regional level activities were taken from receipts. District and sub district, school and community MDA resource use data for 2005 were collected in June 2006 through a retrospective survey…
The main cost elements include: the programme specific expenditure; the opportunity cost or value of government contributions related to in-kind costs of using local government staff and vehicles and the value of CDD’s time (taken as the daily agricultural labour rate); and the international costs of programme co-ordination, reporting and technical support." Leslie et al. 2011, Pg 3.
Two examples of how the area of study may not be representative of all areas in which SCI works:
- Due to low school enrollment rates, a substantial portion of the program was through community distribution. Current SCI programs focus on school-based distribution. "The primary school net enrolment rate (NER) in 2004 in Niger was 41%... To achieve high treatment coverage in targeted school age children and at risk adults two treatment strategies, school-based and community-based distribution, were established." Leslie et al. 2011, Pg 2.
- "The cost per treatment and prevalence figures relate to the study sample of four districts located in the Niger River Valley. This was and is an area of high disease prevalence and high population density relative to other parts of the country. The costs per person treated may be higher in lower density and more remote areas." Leslie et al. 2011, Pg 8.
- Programme expenditure: 75%
- Government cost: 18%
- International tech. support: 7%
Leslie et al. 2011, Pg 5.
It is our understanding from the paper and our past conversations with SCI that "programme expenditure" was fully funded by SCI. It is also our understanding that "international tech. support" refers to SCI staff time and travel costs; we're somewhat less confident in this than in the former understanding. Government costs are "related to in-kind costs of using local government staff and vehicles and the value of CDD’s time (taken as the daily agricultural labour rate)." Leslie et al. 2011, Pg 3.
Calculating non-SCI costs of school-based delivery:
- The average cost/treatment in the study was $0.58. At 7% of the total cost, international tech. support accounts for $0.04/treatment.
- “The full economic delivery cost of school based treatment in 2005/06 was $0.76, and community treatment was $0.46. If only programme costs are included these figures are $0.47 and $0.41 respectively.” Leslie et al. 2011, Pgs 7-8.
- Therefore, non-program costs (government and international tech. support) are $0.29 ($0.76 - $0.47) of the $0.76 cost of each school based treatment. Since $0.04 is international tech. support, that leaves $0.25 of government costs, or 33% of the total cost.
More in our October 2013 update on SCI