# Schistosomiasis Control Initiative – November 2016 Version

We have published a more recent review of this organization. See our most recent report on the Schistosomiasis Control Initiative.

The Schistosomiasis Control Initiative (SCI) is one of our top-rated charities and we feel that it offers donors an outstanding opportunity to accomplish good with their donations.

Published: November 2016

## Summary

What do they do? SCI ( imperial.ac.uk/schistosomiasis-control-initiative) works with governments in sub-Saharan Africa to create or scale up programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) ("deworming"). SCI's role has primarily been to identify country recipients, provide funding to governments for government-implemented programs, provide advisory support, and conduct monitoring and evaluation on the process and outcomes of the programs. (More)

Does it work? We believe that there is relatively strong evidence for the positive impact of deworming. SCI has conducted studies in about two-thirds of the countries it works in to determine whether its programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but have some methodological limitations. (More)

What do you get for your dollar? We estimate that children are dewormed for a total of around $1.19 per child. This figure relies on several difficult-to-estimate inputs including how to account for (a) donated drugs and (b) in-kind contributions from governments with which SCI works. Excluding drugs and government contributions, we estimate that SCI's cost per treatment is$0.49. 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. (More)

Is there room for more funding? We estimate that SCI could productively use or commit between $9.0 million (50% confidence) and$21.4 million (5% confidence) in additional unrestricted funding in its next budget year. (More)

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.
• Standout transparency – it has shared significant, detailed information about its programs with us.
• Room for more funding – we believe SCI will be able to use additional funds to deliver additional treatments. (More)

Major open questions:

• Although our understanding of SCI's financial position and spending has improved, we continue to have some concerns about SCI's financial reporting and financial management. We have remaining concerns about SCI's use of an accounting system ill-suited to its needs, and also learned in 2016 that SCI made two substantial financial errors that impacted funding from GiveWell-influenced donors and our room for more funding analysis in 2015. (More)
• The evidence we have seen on SCI's track record of reaching those it has targeted for treatment is fairly limited. We have seen results from about two-thirds of the countries SCI has worked in and, for those countries from which we have seen results, we have generally seen one year of results, though SCI has worked in the country for several years. We are somewhat uncertain about the results we have seen because of methodological limitations of the studies and past challenges communicating with SCI about its monitoring (see blog posts from 2013 and 2014).

## Our review process

We began reviewing SCI in 2009. Our review has consisted of:

• Reviewing published studies on SCI's programs.
• Extensive communications with former SCI Director Alan Fenwick and current Director Wendy Harrison to discuss SCI's methods and funding needs.
• Requesting and reviewing SCI internal financial, organizational, and monitoring and evaluation documents.
• Visiting a national schistosomiasis control program meeting and demonstration mass drug administration in Malawi in October 2011 (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).
• Meetings with eight SCI staff members at SCI's London headquarters in October 2014, including leadership, program managers, and monitoring and evaluation and finance staff.
• Meetings with SCI leadership and financial staff in August 2016.

All content on the Schistosomiasis Control Initiative, including past reviews, updates, blog posts and conversation notes, is available here.

## What do they do?

SCI works with governments in sub-Saharan Africa to create or scale up mass drug administration programs (MDAs) for neglected tropical diseases (NTDs), particularly schistosomiasis and soil-transmitted helminthiasis (STH), in school-aged children and other groups determined to be at high risk.1 SCI's role has primarily been to 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's model involves both (a) employing staff for program management, technical assistance, and capacity building and (b) funding governments to carry out infection mapping and treatment programs.

In our November 2015 review, we noted that we found SCI's reporting on its spending and financial position opaque; we were not able to determine how much funding SCI held, and our understanding of how SCI and the governments it supports had spent funding in the past was limited.2 Information SCI provided in 2016 has substantially improved our understanding of SCI's financial position and its recent spending in some of its country programs.

### SCI’s role in mass drug administration programs

SCI's role in mass drug administrations (MDAs) in general is to:3

• Advocate for the benefits of mass drug distributions to government officials.
• Assist with planning and budgeting.
• Deliver funding and drugs to governments.
• Provide financial management and technical support.
• Develop procedures for monitoring and evaluation, analyze data, and write reports.

In 2014, we spoke with four of SCI's program managers to better understand SCI's role in four countries. These conversations were mostly consistent with our general understanding of SCI's work. We selected Côte d'Ivoire, Ethiopia, and Mozambique because SCI has spent significant unrestricted funds, the type of funding GiveWell has recommended, in these countries (more below). SCI selected Uganda as the fourth case study. Summaries follow.

In addition, in 2015, SCI shared some details about its work in Sudan, where it recently began supporting a program, and in Nigeria, where it is considering supporting a program in the future. We have not yet written up summaries of this work (documents SCI shared are listed in footnote).4

In 2016, we did not attempt to update our understanding of SCI's role in MDA programs beyond reviewing spending data (more below).

#### Côte d'Ivoire

• History: There was no large-scale schistosomiasis treatment program in the country prior to SCI's involvement.5 SCI began working in Côte d'Ivoire in 2010, but mapping and treatments did not begin until 2012 due to political turmoil. It has funded mapping and treatment for all qualifying districts.6 SCI expected to fund about 4.9 million treatments during its 2014-15 budget year;7 it reported delivering 3.1 million treatments in that period.8 During its 2015-16 budget year, SCI planned to deliver around 0.6 million treatments and reported delivering 1.4 million treatments.9 SCI previously told us that it spent a small amount of unrestricted funding in the country prior to 2011; we do not know what this funding was for.10
• Current plans (as of October 2016): SCI plans to deliver 2.4 million treatments in its April 2016 to March 2017 budget year11 and 2.6 million treatments in its April 2017 to March 2018 budget year.12
• Funding: SCI has used DFID funding, a grant from the company Vitol, and unrestricted funding in Côte d'Ivoire.13 In the 2014-15 budget year, SCI spent about $250,000 in restricted funding and$820,000 in unrestricted funding in the country, a significant increase over 2013-14, when SCI spent $580,000 in restricted funding and$20,000 in unrestricted funding.14 In 2015-16, SCI spent around $130,000 in unrestricted funding and around$70,000 in restricted funding in Côte d'Ivoire.15
• Impact of unrestricted funds: SCI told us in 2014 that it believed that availability of unrestricted funds had allowed the program to scale up faster than it otherwise could have.16
• Partners: In the early stages of the program, SCI primarily worked with the Ministry of Health and, for mapping, the Université Félix Houphouët-Boigny. Starting in 2014, SCI began working with other partners, including Sightsavers, the END Fund, and Helen Keller International on a more integrated NTD program.17
• Role of SCI staff: SCI's Program Manager for Côte d'Ivoire described her role (as of October 2014) as providing technical expertise, helping create budgets, monitoring training and MDAs, responding to problems (for example, surveying health workers to understand low coverage of non-enrolled children, and advising on how to proceed with the program during a security threat), refining the protocol for the coverage survey, and coordinating with partners for integrated MDAs.18 From November 2013 through November 2014, she traveled to Côte d'Ivoire five times and spent almost four months there in total to assist with and monitor mapping, sentinel site and coverage survey data collection, three MDAs, and budgeting.19 She also noted the role of other SCI staff in the program: the finance team checks receipts against expense reports,20 and the biostatistician analyzes monitoring data and advises government staff on data issues.21

#### Ethiopia

• History: There was no sustained, large-scale schistosomiasis treatment program in the country prior to SCI's involvement, only a one-off, sub-national treatment.22 SCI began conversations with the government of Ethiopia about starting a national schistosomiasis treatment program in 2012. In 2013, it funded planning for the program. It funded mapping between November 2013 and April 2014, and a first round of treatment in 2013.23 In October 2016, SCI sent us a report on the 2013-14 mapping surveys (and on a second round of mapping in 2015); we have not yet reviewed this report in depth.24 In April 2015, Ethiopia treated a reported 2.9 million children for schistosomiasis and STH. SCI conducted a coverage survey following this round of treatment and collected baseline data on infection rates from 22 sentinel schools prior to the treatment round (more on these data collection methods below).25 SCI sent us a report on the baseline sentinel site surveys in October 2016; we have not yet reviewed the report in depth.26 During the remainder of SCI's 2015-16 budget year, SCI reports that an additional 5.3 million children received treatments.27
• Current plans (as of October 2016): SCI plans to deliver schistosomiasis treatments to 6.5 million children (4.5 million of which will also receive STH treatments) in its 2016-17 budget year in Ethiopia,28 and plans to deliver 7.6 million schistosomiasis treatments in its April 2017 to March 2018 budget year.29
• Funding: SCI spent around $2.1 million in unrestricted funding and$0.8 million in restricted funding in Ethiopia between April 2015 and March 2016.30 The END Fund and DFID have now allocated restricted funds for treatment in the country.31
• Impact of unrestricted funds: SCI believes that availability of mapping data significantly improved the chances of securing funding from the END Fund and DFID, and that, at a minimum, the availability of unrestricted funds accelerated the program by a few years.32 Ethiopia's Neglected Tropical Diseases Program Manager told us that the government had not dedicated funding to schistosomiasis and that without SCI's involvement the program would likely not have gone forward. According to him, Ethiopia was not aware of any other potential partners for this work when it began working with SCI.33
• Partners: SCI is funding the Federal Ministry of Health (FMOH) to carry out treatments. It partnered with the Ethiopian Public Health Institute, the technical arm of the FMOH, and the Partnership for Child Development (PCD) on mapping. PCD funded mapping in part of the country and delivered treatments in a pilot program. Deworm the World Initiative is providing technical assistance to the government.34
• Role of SCI staff: SCI's Program Manager for Ethiopia described his role (as of October 2014) as assisting with initial program set up and funder agreements, drafting detailed plans for the next 12 months and general plans for the next 5 years, and providing technical assistance for mapping and some guidance on MDA implementation. At the time, he lived in the country35 and worked closely with the government NTD team.36

#### Mozambique

• History: There was no large-scale schistosomiasis treatment program in the country prior to SCI/FPSU's involvement. SCI had previously funded a small-scale treatment program in Mozambique with unrestricted funding.37 SCI's grant from DFID, which started in 2010, includes funding for a sub-grant to FPSU to run schistosomiasis treatment programs in three countries, one of which is Mozambique.38 SCI and FPSU decided on this arrangement because SCI believed it would increase the chances of DFID awarding the grant.39 From April 2015 to March 2016, SCI reports delivering 4.4 million treatments, out of a targeted 5.8 million.40
• Current plans (as of October 2016): SCI reports that it plans to deliver 8.8 million treatments in Mozambique between April 2016 and March 201741 and 7.3 million treatments between April 2017 and March 2018.42 SCI told us that one of the rounds of MDA originally scheduled for 2016-17 is now scheduled for 2017-18.43
• Funding: SCI has spent both restricted funding from DFID and unrestricted funding in Mozambique. We believe the information on SCI's spending in Mozambique before the 2015-16 budget year may not be fully accurate (see footnote).44 In its 2015-16 budget year, SCI spent around $0.6 million in restricted funding and no unrestricted funds in Mozambique.45 • Impact of unrestricted funds: SCI told us that unrestricted funds have helped the program scale, but perhaps not as much as it might appear, since SCI has shifted DFID funding to other countries with the expectation of using unrestricted funds in Mozambique.46 • Partners: The Ministry of Health implements the program. SCI/FPSU also collaborate with RTI International, which is working on trachoma in Mozambique and has staff in-country. RTI helps to keep SCI/FPSU informed about program progress.47 • Role of SCI staff: FPSU manages the program day-to-day. SCI has provided some assistance with monitoring and evaluation. We do not have more detail on SCI/FPSU's role in the country.48 #### Uganda • History: SCI has worked in Uganda since 2003 and has received funding for this work from each of its large grants: Gates Foundation, USAID, and DFID. There was a gap in SCI's work between the USAID and DFID funding.49 SCI reported that it delivered 23,000 treatments in April 2014 to March 2015.50 It had planned to fund 400,000 treatments this period;51 we haven't discussed with SCI why significantly fewer treatments were delivered than planned. Between April 2015 and March 2016, SCI reports that it delivered 890,000 treatments in Uganda; 1.2 million treatments were planned.52 • Current plans (as of October 2016): SCI plans to deliver 1.1 million treatments in Uganda between April 2016 and March 201753 and 2.0 million treatments between April 2017 and March 2018.54 • Funding: In recent years, SCI has primarily used DFID funding in Uganda (about$280,000 in the fiscal year covering 2013-14, $50,000 in 2014-15, and$380,000 in 2015-16).55 In 2014, SCI allocated a small amount of unrestricted funding to Uganda to increase the number of sentinel sites for operational research purposes.56 SCI also spent about $50,000 in unrestricted funds in Uganda in 2014-15;57 we do not know what these funds were used for. SCI spent around$176,000 in unrestricted funding in Uganda in its 2015-16 budget year, substantially more than previous years.58
• Partners: RTI International, funded by USAID, works in Uganda on an integrated mass NTD treatment program. SCI provides schistosomiasis treatment in those areas where RTI does not.59
• Role of SCI staff: SCI told us that, due to strong in-country capacity, SCI provides only limited technical assistance for MDA. Instead, SCI's technical assistance in the country is focused on operational research on how best to move toward elimination of schistosomiasis.60 SCI's program manager for Uganda describes her role as (as of October 2014) assisting with budgets and plans, talking to the government regularly (largely through email) leading up to an MDA to make sure all the components are prepared, traveling to the country to oversee collection of prevalence and intensity data prior to an MDA, following up with the government after an MDA to get the data needed for reporting to DFID, and participating in activity reviews after each stage of the program (for example, after an MDA and after monitoring and evaluation activities).61

### Major funding sources for SCI's work

#### Large grants

SCI's work has historically been driven by a number of large grants, each with somewhat different program designs and geographic coverage. SCI's major grants:

• Initial Gates Foundation grant: SCI was founded in 2002 through a $32 million grant from the Bill and Melinda Gates Foundation.62 This grant was used to create national treatment programs for schistosomiasis and soil-transmitted helminthiasis (STH) in six countries.63 • 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 STH.64 It received a grant in 2007 to expand its work to Rwanda and Burundi.65 All of these grants were completed in 2011.66 • DFID grants: In 2010, SCI received £10.5 million67 (plus separate funding for drugs) from the UK's Department for International Development (DFID) for treating schistosomiasis and STH68 in eight countries over five years.69 Other NTDs are not covered by the grant, though DFID also provided funding to the Filarial Programmes Support Unit (FPSU; formerly the Centre for Neglected Tropical Diseases) to integrate treatment for lymphatic filariasis with SCI-funded schistosomiasis and STH programs in six countries.70 In 2014, DFID awarded SCI an additional £16.6 million over four and a half years (June 2014 to December 2018) to extend the program and expand it to an additional two countries.71 #### Unrestricted funding Prior to 2011, unrestricted funds accounted for a very small portion of SCI's total funding.72 SCI told us that this funding was primarily used to fund treatments in regions of Côte d'Ivoire and Mozambique.73 In part due to GiveWell's recommendation, since November 2011, SCI has received significantly more unrestricted funds: through September 2016, GiveWell had tracked about$14.6 million in donations to SCI due to our research.74 We estimate that around 63% of the unrestricted funds that SCI raised in April 2013 to March 2016 (the period for which we have seen data) were due to GiveWell's recommendation.75

Unrestricted funds now make up a large portion of SCI's revenue. For April 2015 to March 2016, SCI reports that 48% of its revenue was unrestricted.76

### Breakdown of SCI’s spending

#### 2016 financial update

In the first half of 2016, we focused our research on SCI only on the quality of its financial reporting and financial management, since we felt that seeing significant improvements in the quality of SCI's finances was necessary for us to continue recommending SCI. We discuss what we learned from this research in detail in this blog post.

In short, the financial documents SCI has provided us with in 2016 allow us to answer some questions that we were not able to answer in previous years:

• At the beginning of its 2016-17 budget year, SCI had $15.8 million ($8.6 million from restricted sources and $7.2 million from unrestricted sources) available to allocate to its April 2016 to March 2017 programs, research, central costs, and funding reserve.77 SCI planned to allocate nearly all of its available funding to programs and central costs in its 2016-17 budget year.78 For comparison, in several of our past reviews and updates on SCI, we have noted that we were uncertain about how much funding SCI held.79 • A breakdown of SCI's spending within six country programs during its 2015-16 budget year is below. We wrote in our November 2015 review that we had not seen recent information on how SCI spent funding within country programs. Despite these improvements, we have some remaining concerns about SCI's financial systems and reporting: • SCI is housed within Imperial College London. Because it is not a standalone charity, it does not publish annual financial statements or undergo annual organization-wide audits (as U.S. charities are required to do).80 SCI notes that it has been in discussion with KPMG, Imperial College’s auditors, about certifying SCI’s accounts.81 • It continues to use an accounting system created by Imperial College which breaks up its finances into many different "accounts" rather than giving an overall view of the organization's financial position.82 In February 2016, SCI told us that it would start to use a new accounting software package beginning in April.83 • SCI's financial reports have been prone to containing errors. We detail the errors we have learned about in this footnote (including some errors we found in 2016).84 Of particular note: (1) a July 2015 grant from GiveWell for about$333,000 was misallocated within Imperial College until we noticed it was missing from SCI's revenue in March 2016; and (2) in 2015, SCI provided inaccurate information about how much funding it would have from other sources in 2016, leading us to overestimate its room for more funding by $1.5 million.85 The errors we have found largely pre-date SCI's current Finance & Operations Senior Manager, who started in September 2015.86 #### Spending breakdown by country April 2015 to March 2016 expenditures by country (in millions USD)87 Restricted Unrestricted Total % of total Central expenditure$1.2 $0.8$1.9 17.0%
Ethiopia $0.8$2.1 $2.9 25.5% Tanzania$0.7 $0.6$1.4 12.1%
Malawi $0.7$0.1 $0.8 7.0% Zanzibar$0.2 $0.5$0.7 5.7%
Mozambique $0.6 -$0.6 5.0%
Uganda $0.4$0.2 $0.6 4.9% Madagascar -$0.6 $0.6 4.9% Niger$0.5 $0.002$0.5 4.8%
Rwanda - $0.4$0.4 3.5%
Yemen $0.3$0.02 $0.4 3.2% Democratic Republic of the Congo$0.2 $0.2$0.3 3.0%
Côte d'Ivoire $0.1$0.1 $0.2 1.8% Burundi$0.01 $0.1$0.1 0.8%
Mauritania - $0.1$0.1 0.6%
Senegal - $0.01$0.01 0.1%
Sudan - $0.002$0.002 0.02%
Nigeria - $0.002$0.002 0.01%
Total $5.6$5.7 $11.4 100.00% Notes about this data: • In our November 2015 review, we noted that some expenses recorded as central expenditures were actually used for the Zambia, Liberia, and Mozambique country programs.88 It is our understanding that central expenditures in the table above do not include any such expenses.89 • SCI notes that an error appears to have caused unrestricted funding to be recorded as restricted funding for Malawi.90 We have not corrected the error in the table above. • SCI has shared additional information on its expenditures during the first four months of its 2016-2017 budget year; we have not included this information in the table above.91 For breakdowns of SCI's spending in 2013-14 and 2014-15, see our November 2015 review. #### Spending breakdown within country programs In 2015, SCI began to use a system of country cashbooks, which compare monthly in-country actual spending to budgets.92 SCI sent us country cashbooks covering April 2015 to March 2016 for Niger, Côte d'Ivoire, Democratic Republic of the Congo, Malawi, Tanzania, and Uganda.93 It is our understanding that SCI plans to eventually collect country cashbooks from all country programs.94 Notes about this data: • Activity categories in the country cashbooks sometimes appear to be loosely defined and overlapping. For example, expenditure on drug distribution materials is sometimes classified as "drug distribution" and sometimes as "drug logistics."95 • There are some differences between expenses recorded in country cashbooks and expenses recorded in SCI budget vs. actuals 2015-16 Redacted. For example, for Malawi, the total expenditure recorded for the 2015-16 budget year in both the country cashbook and SCI budget vs. actuals 2015-16 Redacted was$0.8 million, but total expenditure for Tanzania differed substantially in the two sources.96 SCI notes that the discrepancy for Tanzania is due to SCI recording the expenditure when the funds were sent to the country, while the cashbooks record when the funds are spent in-country.97 It is our understanding that SCI is in the process of changing this system.
• The total amount of spending recorded in the six country cashbooks we have seen is $2.1 million, a relatively small proportion of the$9.2 million in total spending within country programs in its 2015-16 budget year.98

In-country SCI spending in six countries, April 2015 – March 201699

Activity % of total spending Description Range across countries
Drug distribution 40% Per diem payments for teachers and officers, fuel costs, communications costs, drug distribution materials (dose poles, registers, etc.) 0% to 80%
Country management 17% Per diem payments and salaries for national NTD program staff, fuel costs, communications 7% to 60%
Drug distribution training 12% Per diem payments for teachers and officers during MDA training, accommodation and meals 0% to 46%
Monitoring & Evaluation 8% Per diem payments for teachers, MDA report writers, and drivers, fuel costs 0% to 23%
Drug distribution supervision 7% Per diem payments for MDA supervisors, fuel costs 0% to 62%
Drug logistics 4% Drug distribution materials (dose poles, registers, etc.), fuel costs 0% to 10%
Strategic planning 3% Expenses related to strategic planning meetings, including per diem payments, travel costs, and accommodation and meals 0% to 6%
Mapping 3% Per diem payments for teachers, travel costs 0% to 14%
Social mobilization 3% Per diem payments, advertising 0% to 25%
Global management 1% Travel costs to an international conference 0% to 3%
Advocacy 1% Per diem payments, fuel costs, communications 0% to 4%
Drug distribution registration 1% Per diem payments for teachers 0% to 5%

We have not yet seen country cashbooks covering SCI's April 2016 to March 2017 budget year so far; in September 2016, SCI told us that the country cashbooks were not yet prepared.100

For breakdowns of spending within countries supported by DFID grants between 2011 and 2013, see our November 2015 review of SCI.

#### Other projects

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.101
• 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.102

## 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.

To evaluate SCI's track record at executing programs, we have considered:

• Coverage surveys from eight of the countries SCI has worked in, including many of the countries where SCI's work has been focused in the past five years. These door-to-door surveys estimate what percentage of individuals who were targeted for treatment actually received treatment. Overall, coverage of school-aged children was above 75% (the WHO-recommended minimum threshold) in a majority of districts surveyed by SCI. We note some limitations of these surveys below.
• Prevalence and intensity studies of infection over time in four of the countries SCI has worked in. The surveys show substantial improvements following SCI treatment programs. These surveys have a number of limitations and represent a relatively small proportion of the total number of treatments delivered in SCI's programs.
• Academic papers that might reflect the treatment coverage achieved by SCI's programs by directly measuring deworming drug uptake or by measuring worm prevalence in countries where SCI has worked. The papers did not provide a clear case for or against programs being executed well.

We have now seen some recent monitoring results from about two-thirds of the countries in which SCI works. For those countries from which we have seen monitoring results, we have generally seen one year of results, though SCI has worked in the country for several years. We are somewhat uncertain about the results we have seen because of methodological limitations of the studies.

In this section, we also discuss how the disease burden in the areas SCI works in compares to the places where the independent studies that form the evidence base for the impact of deworming were conducted. While SCI's programs generally target areas that require mass treatment according to World Health Organization (WHO) guidelines, the disease burden in SCI areas is on average lower than in the study areas, so our expectation is that the average impact per child treated is lower in SCI areas.

### Is there independent evidence that the program is effective?

SCI supports mass school-based deworming programs, the independent evidence for which we discuss extensively in our intervention report on deworming programs. In short, we believe that there is strong evidence that administration of the drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes; we consider deworming a priority program given the possibility of strong benefits at low cost.

There are some important differences between the type and severity of worm infections in the places SCI works and the places where the key studies on improved life outcomes from deworming took place, which we discuss below.

### Are deworming pills delivered to and ingested by recipients?

#### Coverage surveys

We have seen results from coverage surveys that SCI has conducted, or worked with partners to conduct, in Côte d'Ivoire (in 2014), Malawi (2012 and 2014), Uganda (2014), Mozambique (2015 and 2016), Zanzibar (2015), Zambia (2015), Ethiopia (2015), and Madagascar (2016).103 SCI reports that additional coverage surveys have been recently completed in Côte d'Ivoire (2016), Democratic Republic of the Congo (2016), Ethiopia (two in 2016), Malawi (2016), Niger (2016), and Tanzania (2016), but we have not yet received results from these surveys from SCI.104

##### Methods

In each of the surveys, surveyors visit a sample of households and ask children, or in some cases their parents on their behalf, whether they received treatment in the most recent MDA. SCI has told us that villages and households for these surveys are generally selected randomly or quasi-randomly.105 Other survey questions, such as age, gender, where the respondent received the treatment, and why they did not take the drug(s), are often included as well.106 The main results are reported as "survey coverage" figures (the number of school-aged children interviewed who ingested the drug(s) divided by the total number of school-aged children interviewed), and are intended to check the accuracy of governments' "reported coverage" figures (the number of treatments delivered to school-aged children according to government administrative data divided by the estimated number of eligible school-aged children in the area).107

The methodology used in SCI's coverage surveys has differed somewhat across countries and has changed over time. We have summarized the details of the methodologies used in the surveys in this spreadsheet ("Methods" sheet).

"Survey coverage" and "reported coverage" estimates of the proportion of school-aged children that ingested deworming pills can vary substantially.108 We generally believe that coverage surveys provide more reliable information on the proportion of school-aged children that received and ingested deworming pills than "reported coverage" figures calculated by governments of countries with SCI-supported programs (justifications in footnote).109 However, we note some limitations to SCI's coverage surveys:

• Accuracy of survey responses: We have a few concerns about the accuracy of responses from school-aged children, particularly young children (e.g., 5-6 year olds), on whether they received deworming treatments. Some coverage surveys include "verification questions" (e.g., asking children if they recognize pills), but we have not yet seen evidence from these questions that raises our general confidence in the accuracy of SCI's coverage surveys.
• Length of time between MDA and survey: This varied between one and six months in the coverage surveys we have seen from SCI. Intuitively speaking, the more time that passes, the less likely children are to remember accurately and the more likely they are to confuse past MDAs (we discuss one case below, from Mozambique (2015), where there may have been confusion about MDAs). Mozambique (2015) had the shortest interval at 1-2 months and Zambia had the longest at 5-6 months. Other surveys were generally carried out 2-4 months after the MDA.110
• Verification questions: In Côte d'Ivoire, Malawi (2014), Uganda, Zanzibar, Zambia, Ethiopia, and Madagascar, surveyors asked some verification questions, such as whether respondents recognized pills or dose poles presented by the interviewers, what they thought of the pills (praziquantel is very large and tastes bitter), and how many pills they took.111 Answers to these questions were not recorded in Côte d'Ivoire,112 and we do not know if they were recorded in the other surveys. We believe that the answers to questions such as these would provide additional evidence about the quality of the coverage results, and it is unclear to us why SCI has not recorded this information, or if it has recorded it, why it has not shared it. In Mozambique (2015), respondents were asked whether they recognized the dose pole used in schistosomiasis MDAs. However, in that survey parents were surveyed on their children's behalf113 and most children (79%) received drugs at school,114 presumably when parents were not present. We don't know how to interpret the result that a very high percentage of parents (median 90%, ranging 61-94% across provinces) reported recognizing the dose pole.115 SCI hypothesized that parents may either recognize the dose pole from publicity efforts prior to the MDA or remember a similar dose pole from previous MDAs for lymphatic filariasis.116 In either case, this may indicate that the coverage survey is not measuring actual delivery of drugs to children in the most recent MDA.
• Supervision and auditing of surveys: Many of SCI's reports on coverage surveys mention that teams of surveyors were overseen by supervisors. It is our understanding that supervisors provide teams with guidance on the logistics of implementing coverage surveys117 but do not implement any specific data quality or auditing procedures, such as re-surveying a sample of households to check the accuracy of the data collected.118

Additionally, there are limitations that apply only to some of SCI's coverage surveys:119

• Selection of geographic target area: All of the surveys were limited to specific geographic areas (such as districts). In Uganda, Zambia, Côte d'Ivoire, Ethiopia, and Madagascar, these were selected randomly or nearly randomly. In Malawi (both 2012 and 2014 surveys) and Mozambique (2015), the districts were purposefully selected and not intended to be nationally representative. The selection procedures for Zanzibar and Mozambique (2016) were not given in the documents we have seen on the surveys.120 We are aware of one case, in Mozambique (2015), where a selected village was replaced by another because the surveyors could not locate it; this issue was not mentioned in the survey report.121
• Independence from the government: In Mozambique (2015), the survey was carried out by government health staff, who may have had an incentive to bias the results. SCI told us, "[M]ost of the interviews in one district were done by the other district officers with no connection with the district."122 The reports on the Malawi 2014 and Côte d'Ivoire surveys note that the surveyors were independent of the government. SCI told us that university students or staff conducted the surveys in Malawi (2012), Uganda, Zanzibar, and Zambia.123 It is unclear to us who conducted the Ethiopia, Madagascar, and Mozambique (2016) surveys.
• Whether parents or children were interviewed: In Mozambique (2015), parents were interviewed about whether their children took the drugs. In both Côte d'Ivoire and Malawi (both 2012 and 2014 surveys), if children in a household were not available, then their parents were interviewed about whether the children had received deworming drugs. SCI made different choices about whether to include these responses in the results, which slightly inflated the results overall.124 SCI told us that parents were not asked to answer on behalf of their children in Uganda, Zanzibar, Ethiopia, and Madagascar, and that going forward, SCI no longer plans to have parents answer on the behalf of children.125

We report results below from a coverage survey in Mozambique in 2016, but we know very little about the survey's methodology since we have not yet seen a full report.126 SCI notes that it has not yet received a report from FPSU, which it sub-contracts to for the Mozambique program.127

##### Results

The fact that the surveys identified low coverage in several cases increases our confidence in their reliability. Given the smaller sample size, government involvement in the survey, and question about parents recognizing the dose pole noted above, we are more skeptical about the results from Mozambique (2015) than those from other surveys. We also have low confidence in the results from Mozambique (2016) because we have not seen details of how the survey was carried out.

Mass drug administration coverage among school-aged children

Survey Median PZQ coverage and range Median ALB or MEB coverage and range
Malawi (2012) 77% (64%-90%) 59% (33%-85%)
Malawi (2014) 69% (55%-77%) 44% (25%-77%)
Côte d'Ivoire (2014) 82% (67%-88%) 82% (68%-89%)
Uganda (2014) 47% (24%-86%) N/A
Mozambique (2015) 81% (73%-89%) N/A
Zambia (2015) 93% (89%-94%) N/A
Zanzibar (2015) 80% (75%-85%) 87% (84%-89%)
Ethiopia (2015) 85% (65%-97%) 86% (65%-96%)
Madagascar (2016) 92% (85%-100%) 92% (82%-100%)
Mozambique (2016) 89% (47%-100%) N/A

• Results broken down by district (or similar geographic region) are in this spreadsheet.
• PZQ is the drug used to treat schistosomiasis. ALB or MEB is the drug used to treat STH.
• Ranges and medians are calculated from district-level results.
• The results are for school-aged children only. Some of the surveys also measured coverage rates in adults, who are targeted for treatment in some SCI-supported programs.
• The results exclude districts in Uganda that were included in the survey but which do not receive support from SCI.128
• For context, the World Health Organization recommends that treatment programs aim for coverage rates above 75%.129

#### Prevalence and intensity studies

SCI has conducted surveys to track changes in schistosomiasis and STH prevalence and intensity rates following SCI-supported treatment programs. In each of these studies, SCI tracked infection rates at the same schools ("sentinel sites") each year. In general, prevalence and intensity of the parasites decreased over time in each of the countries studied. We note several methodological limitations of these surveys below.

##### Which prevalence and intensity studies provide evidence of SCI's impact?

Below, we discuss results from studies of schistosomiasis and STH prevalence and intensity from four countries: Niger (2004-2006),130 Burundi (2007-2010),131 Malawi (2012-2015),132 and Liberia (2012-2013).133 SCI also shared studies from Uganda134 and Burkina Faso,135 and we included results from these studies in our previous reviews of SCI. We learned in 2013 (and in follow up work in 2014) that participants in the studies in Uganda and Burkina Faso received separate, more intensive treatment than other children in those countries (discussed in blog posts in 2013 and 2014). Therefore, we believe that the results from Uganda and Burkina Faso do not reflect the quality of the national programs which were supported by SCI.

It is our understanding that, in the Niger, Burundi, Malawi, and Liberia studies, study participants received treatment in the same manner as other children in the country, and thus that those studies reflect the performance of the national MDAs.136

SCI has also shared baseline prevalence and intensity studies from DRC, Madagascar, and Ethiopia, and shared its plans for future baseline and follow up prevalence and intensity surveys with us.137

##### Niger, Burundi, Malawi, and Liberia prevalence and intensity studies

As discussed above, SCI has conducted studies to track changes in schistosomiasis and STH prevalence and intensity rates following SCI-supported treatment programs in Niger, Burundi, Malawi, and Liberia. These studies were originally designed as cohort studies, in which the same individuals are repeatedly surveyed over time.138 In the 2015 Malawi and 2013 Liberia studies, SCI switched to a cross-sectional sample, where random children from the same schools were surveyed, rather than the same individuals.139 To partially account for this change, the data from Malawi presented below is for the 6-8 year old age group only. There is no control group for these studies.140

In general, prevalence and intensity for the two main types of parasites that cause schistosomiasis, S. haemotobium and S. mansoni, and for hookworm (more on the other two STHs below), decreased over time in each of the countries studied. Though it is possible that other factors besides the treatment program caused these changes (such as improved sanitation infrastructure), the pattern of decline in a short period following treatment strongly suggests that treatment caused or contributed to the declines.

Changes in worm prevalence and intensity141

Schistosoma haematobium Schistosoma mansoni Hookworm
Country Changes in prevalence Changes in intensity Changes in prevalence Changes in intensity Changes in prevalence Changes in intensity
Niger 75.4% at baseline to 38% at one year142 21.8% prevalence of heavy-intensity infections at baseline to 4.6% at one year143 Very low prevalence at baseline144 N/A Low prevalence at baseline145 N/A
Burundi (pilot) Not reported (SCI reports very low baseline prevalence146) N/A 12.7% at baseline to 1.7% at four years147 20 epg148 at baseline to 1 epg at three years149 17.8% at baseline to 2.7% at four years150 16 epg at baseline to 24 epg at three years151
Burundi (other schools) Not reported (SCI reports very low baseline prevalence152) N/A 6.2% at baseline to 0.7% at three years153 8 epg at baseline to 3 epg at one year154 15.1% at baseline to 5.4% at three years155 15 epg at baseline to 8 epg at one year156
Malawi 9% at baseline, 6% at one year, 4% at two years157 Low rates of heavy infection (note: different results given in first follow up report)158 Low rates at baseline and follow up159 Very low rates of heavy infection at baseline and follow up160 No hookworm found at baseline, 1% at one year, 2% at two years161 No participants heavily infected at baseline or follow up162
Liberia 20.2% at baseline to 9.0% at one year163 9.0% prevalence of heavy infections at baseline to 2.5% at one year164 26.2% at baseline to 15.0% at one year165 0.2% prevalence of heavy infection at baseline to 1.0% at one year166 15.2% at baseline to 9.5% at one year167 No participants heavily infected at baseline or follow up168

For the other two prominent soil-transmitted helminths, ascaris and trichuris, infection prevalence was low in the Niger and Malawi studies.169 In Burundi, prevalence of ascaris and trichuris decreased somewhat (though in a few cases there were temporary increases). Data from Burundi are given in the footnote.170 In Liberia, baseline prevalence of trichuris was low and had decreased further at the one year follow-up; prevalence of ascaris decreased from 12.8% to 1.3% over the same time period.171

Some of the studies also report results for other indicators of disease, such as anemia. We omit discussion of these other indicators because they are more likely to be influenced by external factors than are prevalence and intensity (see our previous review of SCI for discussion of these indicators and SCI Liberia impact survey dashboard 2012-13 for results from Liberia).

Limitations of the prevalence and intensity study data include:

• Monitoring of selected locations. It appears that, in the Niger and Burundi pilot studies, locations included in the study were selectively chosen rather than selected to be a representative sample of treated areas; we are uncertain how locations in the Liberia study were chosen.172
• Low follow-up rates in cohort studies. Follow-up rates were low in two of the three studies using a cohort model for follow-up (89% at the first year follow-up in Niger, 33%-50% in the pilot survey and 53%-80% in the other schools survey in Burundi, and 52% in the first follow-up in Malawi).173 To be included in follow-up surveys, children must be present in school when the surveys are done.174 If those who are present in school are less likely to be infected than those who are not present, this could lead to overstating the impact of the program. The connection between infection status and absenteeism could be a direct relationship (infection could cause absenteeism) or an indirect one (a third factor, such as poverty, could cause both higher levels of infection – perhaps through poor sanitation infrastructure – and absenteeism).
• Substitution of nearby schools for baseline schools. In Liberia, nearly one-third of the schools surveyed during the baseline year could not be re-visited in the follow-up year (likely due to inaccurate school identity numbers, school closures, and/or inaccurate recording of GPS coordinates), and were replaced by nearby schools.175
##### Results from Yemen

In addition, we have two types of results from Yemen:

• Partial sentinel site data: A report SCI shared with us mentions that initial analysis of sentinel site data from July 2014 in Yemen found that prevalence of schistosomiasis decreased substantially.176 These results only include 2,000 of the 8,000 individuals who were surveyed at baseline and the result noted that "a full round of impact evaluation" would be completed in September 2014.177 We have not seen more details about these initial results or any results from the full round.
• Remapping survey: This study compared the number of districts at high-risk, moderate-risk, low-risk for, and uninfected with schistosomiasis at "baseline" (data collected between 2004 and 2010) and in 2014.178 It found large improvements after 2-3 rounds of treatment.179 It is not clear to us whether baseline and follow-up results are directly comparable. Baseline data was collected over several years and details of the methodology used at baseline are not given.

### Are SCI's monitoring results representative of its work overall?

We have now seen recent monitoring results from about two-thirds of the countries in which SCI works. For those countries from which we have seen monitoring results, we have generally seen one year of results, though SCI has worked in the country for several years.

SCI told us that it is sometimes unable to share results because third parties (e.g. governments, WHO, funders) often need to give permission before data can be shared, and because it can take some time for data, once collected, to reach SCI because in some countries it is cleaned and analyzed by country program staff before being shared with SCI.180

For Mozambique, one of SCI's largest recipients of both restricted and unrestricted funds, SCI shared a report from a consultant who visited the country in May 2015 to assist with data cleaning and analysis for prevalence data from 2012, 2013, and 2014. The report notes major problems with this data and the refusal of the government to allow SCI and other international partners to have access to the data outside of Mozambique.181

To provide additional information on SCI's track record, in 2014, we conducted a search for published papers on treatment coverage rates and schistosomiasis and STH prevalence and intensity in countries where SCI has worked. (We revisited this project in 2016 to review a recent paper from Melissa Parker and Tim Allen [Allen and Parker 2016]; we have not yet written up our conclusions. In short, our work in 2016 is largely consistent with the conclusions presented below.)

In 2014, we focused on papers by Melissa Parker and Tim Allen, who were funded by the Bill and Melinda Gates Foundation to provide an anthropological perspective on SCI's work,182 papers cited in papers by Melissa Parker and Tim Allen, and other papers we identified on this topic from a Google Scholar search.183

The papers we identified were all from Tanzania, Uganda, and Zanzibar, perhaps because these are places that Melissa Parker and Tim Allen's work has focused on.

This spreadsheet summarizes the papers we considered. We have not fully vetted these studies. The studies were generally designed for purposes other than to evaluate SCI's programs so in many cases there is uncertainty about SCI's role in the areas studied.  In the discussion below, we have excluded studies that we do not believe were conducted soon after treatment programs in areas targeted by SCI-funded programs. SCI staff and/or SCI funding were involved in many of the studies.184

It is difficult to draw any conclusions from these studies because of small sample sizes and lack of clarity on SCI's role in each location. In summary:185

• Tanzania (excluding Zanzibar): Two studies at the district level, Stothard et al. 2013 and Chaula and Tarimo 2014, show relatively low schistosomiasis prevalence after treatment (4% and 15% respectively; the latter claims that prevalence pre-MDA was 30%). SCI was working in Tanzania at the time of both studies, but it is not clear if SCI was working in the specific areas studied. Chaula and Tarimo 2014 also shows low treatment coverage (around 40%), though the researchers asked in 2013 about treatment provided in 2011 and 2012.
• Zanzibar: All studies were conducted on Unguja, "the largest and most populated island of Zanzibar."186 Two studies, Stothard et al. 2009 and Rudge et al. 2008, each in a single school, found high prevalence of schistosomiasis in areas that had received treatment (65% and 50% prevalence, respectively). However, the sample sizes were small, it is not clear why these particular schools were selected, and, while SCI was working in Zanzibar at the time of both studies, it is not clear if SCI was working in the specific areas studied. Another study, Knopp et al. 2009, in two schools in an area that had received treatment (but perhaps not from SCI) found moderate prevalence of various STHs (e.g., 22% prevalence for hookworm and low infection intensity). The schools were selected because they had been surveyed in 1994, when prevalence was found to be much higher.
• Uganda: We reviewed three studies of schistosomiasis prevalence. Muhumuza et al. 2013 was conducted in part of a district that seems to have received several rounds of treatment (but perhaps not from SCI). Brooker et al. 2005 was conducted across a district that had its first MDA the year before, which was funded by SCI. Standley et al. 2009 was conducted across six districts: one district that had never been treated (but from which only one school, which had low prevalence, was included in the analysis), two districts that seem to have been treated only once, and three districts that seem to have been treated for many years by SCI. Standley et al. 2009 explicitly aimed to "ambush" schools that might not have been reached by treatment programs.187 Each study found moderate to high prevalence of schistosomiasis (Muhumuza et al. 2013: 35%, Brooker et al. 2005: 26%, and Standley et al. 2009: 42%). Muhumuza et al. 2013 and Standley et al. 2009 found fairly high infection intensity (116 and 634 average eggs per gram respectively among positive cases; the WHO threshold for "high intensity" is 400 eggs per gram188). Muhumuza et al. 2013 found 28% coverage in the most recent round of treatment. The coverage survey in Muhumuza et al. 2013 seems to have been six months after treatment.

### What is the likely impact per treatment in SCI's programs compared with the independent studies on the impact of deworming?

In this section, we discuss how the disease burden in the areas SCI works in compares to the places where the independent studies that form the evidence base for the impact of deworming were conducted. While it is our understanding that SCI's programs generally target areas that require mass treatment according to WHO guidelines, the disease burden in SCI areas is on average lower than in the study areas, so our expectation is that the impact per child treated is lower in SCI areas. We adjust our cost-effectiveness estimate (more below) accordingly.

We have seen baseline data on the prevalence and intensity of schistosomiasis and STH infections in about two-thirds of the countries SCI works in. Schistosomiasis and STH prevalence and intensity in these countries was generally fairly low compared to the studies providing the best evidence for the benefits of deworming (Bleakley 2007, Croke 2014, and Miguel and Kremer 2004).189

For the most part, baseline data was collected in schools that had been selected for prevalence and intensity studies. The baseline reports use methodologies that seem similar to the other SCI panel studies discussed above. With the exception of the study discussed above from Malawi, we have not fully vetted the methodology used in these studies.

In Malawi an error in data collection may have resulted in prevalence being underestimated.190 In Zanzibar, treatment has been ongoing,191 so the study does not reflect pre-treatment conditions.

Detailed results and sources are available on the "Intensity of worms" sheet in our most recent cost-effectiveness analysis spreadsheet.

### Are there any negative or offsetting impacts?

We discuss several possible considerations but do not see significant concerns.

Administering deworming drugs seems to be a relatively straightforward program.192 However, there are potential issues that could reduce the effectiveness of some treatments, such as:

• Drug quality: For example, if drugs are not stored properly, they may lose effectiveness or expire.
• Dosage: If the incorrect dosage is given, the drugs may not have the intended effect and/or children may experience additional side effects.
• Concerns over whether treatment is 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.193
• Replacement of government funding: We have limited information about whether governments would pay for the parts of the program paid for by SCI in its absence. We also have little information about what governments would use deworming funds for if they did not choose to implement deworming programs.
• Diversion of skilled labor: Drug distribution occurs only once or twice per year and is conducted by volunteers in communities or teachers in schools. Given the limited time and skill demands of mass drug distribution, we are not highly concerned about distorted incentives for skilled professionals. Planning for the program can take senior government staff time; we are not sure what these staff would spend their time on in the absence of deworming programs, but suspect that they would support other education or health initiatives.
• Adverse effects and unintended consequences of taking deworming drugs: Our understanding is that expected side effects are minimal and there is little reason to be concerned that drug resistance is currently a major issue (more information from our report on deworming). We are somewhat more concerned about potential side effects during integrated NTD programs, since multiple drugs are taken within a short time period, but it is our understanding that organizations follow protocols to space out the treatments to sufficiently avoid adverse effects.
• Popular discontent: We have heard a couple of accounts of discontent in response to SCI's mass drug administration campaigns, including one case that led to riots.194 SCI notes that following episodes of popular discontent, it has worked with governments to improve public education about the programs.195

## What do you get for your dollar?

We estimate that on average the total cost of a schistosomiasis treatment delivered in SCI's programs is $1.19. Excluding the cost of drugs (which are often donated) and in-kind government contributions to the programs, we estimate that SCI's cost per treatment is$0.49. These estimates rely on a number of uncertain assumptions.

There are some significant sources of uncertainty in this estimate. As discussed above, the information we have seen on SCI’s expenses prior to its 2015-16 budget year is possibly unreliable. Similarly, we are not confident in the accuracy of the data we have seen on number of treatments delivered. Given this, we make a number of assumptions and judgments in interpreting the data that we have seen, and this could introduce errors (which could potentially overstate or understate the actual cost). More on our approach below.

Note that the number of lives significantly improved is a function of a number of difficult-to-estimate factors. We discuss how the cost per treatment figure relates to how much it costs to improve a child's health and development at our report on mass treatment programs for schistosomiasis and STHs and we incorporate these into a cost-effectiveness model which is available here.

In 2014, SCI estimated its cost per treatment at $0.80.196 In October 2015, SCI estimated that after April 2016 its cost per treatment, excluding costs for drugs and costs paid for by governments, would generally be about$0.30.197 We are unsure how it calculated these estimates. In October 2016, SCI estimated that it would cost £0.17 on average per additional treatment delivered, or about $0.23 at exchange rates at the time, based on country budgets and an unpublished study.198SCI shared updated cost per treatment estimates with us for a few country programs in early 2016, but we are also uncertain about how these estimates were produced and we have not followed up with SCI about this.199 ### Our approach Our general approach to calculating the cost per treatment is to identify comparable cost and treatment data and take the ratio. We prefer to have a broadly representative selection of treatments in order to mitigate possible distortions, such as using data from a new program, which may incur costs from advocacy, mapping, etc. before it has delivered any treatments. It is our understanding that SCI generally intends to treat for STHs in all places where it treats for schistosomiasis, so the treatments SCI reports can generally be interpreted as combination schistosomiasis and STH treatments,200 though we are aware of several cases in which schistosomiasis-only treatments were delivered either by design or due to problems with implementation, and of some cases where SCI delivered STH-only treatments (SCI told us that STH-only treatments are not counted in its treatment numbers).201 To get the total cost, we attempt to include all partners (not just SCI), such that our cost per treatment represents everything required to deliver the treatments.202 In particular, we include these categories: • SCI’s funding to country programs (e.g., to fund drug delivery). • SCI’s headquarter costs (e.g., for management and technical salaries), including an estimate of costs paid by Imperial College (e.g., office space and some legal and administrative expenses). • Cost of drugs. We include the full market cost of all praziquantel that is needed to deliver the treatments, regardless of whether SCI purchased it or used donated drugs. It is our understanding that DFID funds praziquantel for some countries and that in recent years SCI has not purchased drugs beyond what is funded by DFID and donated by a pharmaceutical company. • Costs incurred by the government implementing the program (e.g., for staff salaries when working on treatment programs). SCI notes that cost per treatment calculations should include sensitivity analysis203—i.e., analysis on the degree to which the cost per treatment varies when various assumptions vary. We have not yet completed such an analysis. ### Our analysis We analyzed several sources of data, which cover different country programs and time periods between October 2010 and March 2016, and developed several different cost per treatment estimates based on the inclusion or exclusion of different types of costs. Full details in this spreadsheet. • SCI’s cost per schistosomiasis treatment, including government costs and drug costs:$1.19
• SCI's cost per schistosomiasis treatment, including drug costs but excluding government costs: $0.83 • SCI's cost per schistosomiasis treatment, including government costs but excluding drug costs:$0.84
• SCI's cost per schistosomiasis treatment, excluding drug costs and government costs: $0.49 ### Shortcomings of our analysis While we believe the estimates described above are reasonable, we want to highlight specific reasons to interpret them with caution. We rely on reported treatment data. Our understanding is that these data can often be inaccurate. We have discounted the number of treatments (by 8%) based on the differences between reported treatment rates and treatment rates found in the coverage surveys discussed above (see footnote for why this is an imperfect comparison).204 We rely on an estimate that 30% of overall program costs are attributable to the government. We derived this from an analysis of a single program in Niger (this footnote elaborates on the details and concerns).205 We do not have data that indicate what proportion of drugs are wasted. We expect that in some cases drugs are purchased or donated but expire before use. We do not know how common this is. In our analysis, we have assumed that 10% of drugs are wasted, which increases the cost per treatment by about$0.05.

We do not have data on Imperial College's expenses that support SCI. Based on a conversation with SCI, we have roughly estimated this support as 10% of SCI's expenses (excluding drugs and government contributions).206

We simply estimate an average cost across programs and do not account for variations in different contexts. SCI told us that costs can vary significantly, for example, due to increased transportation costs in some contexts.207

## Is there room for more funding?

We estimate that SCI could productively use or commit a maximum of between $9.0 million (50% confidence) and$21.4 million (5% confidence) in additional unrestricted funding in its next budget year.

In short:

• Cash on hand: SCI currently holds $2.2 million in unrestricted funding available to allocate to its next budget year. • Expected additional funding: We roughly estimate that SCI will receive an additional$3.2 million in unrestricted funds that it will be able to allocate to its next budget year.
• Past spending: In the past, SCI has generally allocated all unrestricted funding it raised in one budget year to the next budget year, holding back a fairly small amount for reserves.
• Estimated total spending: We estimate that SCI could productively use or commit between $14.4 million (50% confidence) and$26.8 million (5% confidence) in unrestricted funding in its next budget year (inclusive of cash on hand, other sources of funds, and our estimate of SCI's room for more funding). This is in addition to $6.5 million that will be funded by restricted funding. ### Available and expected funding SCI's current budget year began in April 2016 and will end in March 2017.208 It is our understanding that unrestricted funding SCI receives during its current budget year is generally allocated to the next budget year,209 so we expect that donations to SCI now (late 2016 to early 2017) would be used for SCI's April 2017 to March 2018 plans. As of October 2016, we estimate that SCI has received around$2.2 million in unrestricted funding since April 2016 (which will be available to allocate to its April 2017 to March 2018 budget year).210 SCI also expects to allocate $6.5 million in restricted funding from DFID, CIFF, and other funders to its 2017-18 budget year (note that we have excluded the costs that these funds will support from our estimates of SCI's total budget for unrestricted funding, below).211 We expect that SCI will receive additional donations before April 2017, which it will be able to allocate to its 2017-18 budget year, from: • Donors who are not influenced by GiveWell's research: We roughly estimate that this funding would total around$1.4 million.212
• Donors who give based on GiveWell's top charity list, but do not follow our recommendation for marginal funding: GiveWell maintains both a list of all top charities that meet our criteria and a recommendation for which charity or charities to give to to maximize the impact of additional donations, given cost-effectiveness of remaining funding gaps. We estimate that SCI will receive about $1.8 million from donors who use our top charity list but don't follow our recommendation for marginal donations.213 • Donors who follow GiveWell's recommendation for marginal donations: Our estimate of room for more funding is used to make a recommendation to these donors. With$2.2 million in currently available unrestricted funding and $3.2 million expected in additional funding ($1.4 million and $1.8 million from the first two groups, respectively), we estimate that SCI will have around$5.4 million in unrestricted funding available to allocate to its 2017-18 budget year (in addition to $6.5 million in restricted funding).214 ### Uses of additional funding As noted above, we expect that additional unrestricted funding SCI receives in late 2016 and early 2017 will be allocated to its April 2017 to March 2018 budget year. SCI has estimated the number of praziquantel treatments it would support the delivery of by country in its 2017-18 budget year if it raised sufficient unrestricted funding, and estimated the current funding gap for each country program for delivering that number of treatments (as well as funding gaps for SCI's central costs, research, and allocation of funding to reserves).215 We have created our own estimates of SCI's funding gaps by country (modified from SCI's estimates) in this spreadsheet ("GW estimation of funding gaps by country" sheet), and prioritized these funding gaps as Execution Level 1, Level 2, and Level 3 (more discussion of GiveWell's prioritization of funding gaps below). Notes on SCI's planned uses of additional unrestricted funding and our calculations of SCI's funding gaps: • SCI has told us that it would first use additional unrestricted funding to close funding gaps for its current country programs, and then, if it received further funding, for starting up new country programs.216 SCI also told us that, if it received significantly more funding than needed to support the delivery of treatments to school-aged children in countries it currently works in and wishes to expand to, it would consider purchasing praziquantel and supporting the mass administration of praziquantel to adults.217 We have chosen to exclude funding used for the treatment of adults in our calculation of SCI's funding gaps because we believe the strongest case for the cost-effectiveness of mass deworming is based on the possibility of long-term developmental impacts in children who are dewormed. It is our understanding that treating adults may decrease infection rates in children, but we have not yet investigated how large this effect might be. Our best guess at this point is that it would be significantly less cost-effective than treating children. (Note that, in some of SCI's programs, adults who have been identified as high-risk are already receiving treatment.) • SCI recently told us that, due to changes in the timing of mass drug administration programs targeting lymphatic filariaisis, it would like to support the delivery of an additional three million praziquantel treatments in Mozambique during its current budget year (April 2016 to March 2017), which would require an additional £180,000 beyond this year's budget for Mozambique.218 SCI has told us that it would like to use funding it has already raised this year (which would have otherwise been available to allocate to its April 2017 to March 2018 budget year) to cover the costs of this program, so we have added the cost of this program as an additional funding gap for SCI.219 • We have additionally estimated SCI's funding gaps for research costs, central costs, and allocation into reserves.220 • SCI has told us that it would like to expand to Zimbabwe; we have excluded this expansion from SCI's funding gap because it is our understanding that the END Fund is already supporting deworming programs in Zimbabwe and would like to expand them.221 • It is our understanding that SCI has concrete plans (if it receives sufficient unrestricted funding) to support deworming programs in Lagos state and Bauchi state in Nigeria in its 2017-18 budget year.222 SCI also told us that it is possible that it may have further opportunities to support deworming programs in Nigeria in its 2017-18 budget year with sufficient funding, but that it is not yet clear where or if these opportunities will be available.223 SCI has roughly estimated that it may be able to use an additional £2 million in Nigeria for these additional opportunities.224 #### GiveWell's prioritization of SCI's funding gaps We have broken down our top charities' funding gaps and ranked them based on: • Capacity relevance: how important the funding is for the charity's development and future success. • Execution relevance: how likely it is that the charity's activities will be constrained if it does not receive the funding. We believe that "capacity-relevant" gaps are the most important to fill, and "execution"-related gaps vary in importance. More explanation of this model is in this blog post. We do not classify any of SCI's funding gaps as "capacity-relevant." Our understanding is that SCI would use additional unrestricted funding to continue implementing the same types of deworming support activities as it has in the past. If it receives sufficient funding, SCI may expand to support deworming programs in new countries;225 however, since SCI currently supports programs in a large number of countries, we do not believe that expanding to additional countries substantially raises the amount of funding we would expect SCI to be able to use in the future. We consider all SCI's funding gaps to be "execution" gaps and assign them a level (1, 2 or 3) by how likely we believe it is that SCI would be constrained by funding (rather than other factors, such as an inability to grow staff capacity quickly enough, security concerns, another implementer beginning to work on deworming in an area, etc.) if it is unable to fill the funding gap. Level 1 is 50% chance of funding being the constraint, level 2 is 20% chance, and level 3 is 5% chance. These judgments are rough.226 Our estimates: 227 Type of funding gap Amount (millions USD) Cumulative funding need (millions USD) Execution Level 1 14.4 9.0 Execution Level 2 9.0 18.0 Execution Level 3 3.4 21.4 ### Past uses of unrestricted funding Our understanding is that SCI generally allocates all unrestricted funding it raises in one budget year to the next budget year's country programs, central costs, and research costs.228 In 2015, SCI also began annually allocating the equivalent of one month of its total operating costs from its unrestricted funding into reserves.229 SCI told us that it expected to spend all of the unrestricted funding it had raised during its April 2015 to March 2016 budget year during its current April 2016 to March 2017 budget year (i.e., that none of the unrestricted funding it received before its current budget year would be available to allocate to its next budget year).230 ### Sources of uncertainty In the past, changing circumstances have caused SCI to update its target treatment numbers and its own estimate of its room for more funding. For example, political unrest delayed the program in Côte d'Ivoire for 18 months,231 in 2014 SCI was not yet ready to allocate additional funds to Mozambique because of lack of confidence in the program's ability to scale further at that time,232 and the Ebola outbreak has delayed work in Liberia.233 Factors that can shift SCI’s planned uses of unrestricted funding include political unrest, expiring drug supplies, additional donated drugs becoming available, delays and budget changes due to coordination with other actors, results of disease mapping, and grants from other donors.234 SCI notes that estimates are refined in collaboration with ministries of health on a country by country basis between January and March each year.235 In past years, we have had challenges communicating with SCI about its room for more funding. Our understanding of SCI's room for more funding was developed largely through conversations with SCI's leadership, supplemented with details from many other sources. In retrospect, our understanding of how SCI planned to use funds often did not match how SCI decided to allocate funds the next time it set program budgets.236 In October 2015, SCI sent us estimates of its room for more funding for its next three budget years.237 We later learned that these estimates did not include the full amount of restricted funding that DFID planned to provide, which caused us to overestimate its room for more funding for its 2016-2017 budget year in our November 2015 review.238 Our communication with SCI and the quality of SCI's financial information has improved in 2016 (see above), so we have somewhat more confidence than we have had in the past in the accuracy of the information SCI provided us on its room for more funding. ### Global need for treatment There appears to be a substantial unmet need for STH and schistosomiasis treatment globally. In 2016, the WHO released a report on 2015 treatments stating that:239 • 63% of school-age children in need of treatment were treated for STH in 2015. This is a large increase over WHO's report for 2014, which reported 45% coverage.240 Coverage was 51% in African countries in 2015. • 42% of school-age children in need of treatment were treated for schistosomiasis in 2015. We have not vetted this data. ## SCI as an organization • Track record: SCI has consistently gotten national deworming programs to go through, as discussed above. • Self-evaluation: SCI’s self-evaluation is strong compared to the vast majority of organizations we have considered. That said, this evidence is incomplete and has quite a few limitations. In addition, we have a significantly different perspective than SCI 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: In the past, we have struggled to communicate effectively with SCI representatives, and noted that we lacked important and in some cases basic information about SCI's finances. Our communication with SCI about its finances has improved substantially in 2016. More on how we think about evaluating organizations at our 2012 blog post. ## Sources Document Source Alan Fenwick, email to GiveWell, November 3, 2015 Unpublished Alan Fenwick, email to GiveWell, October 1, 2015 Unpublished Alan Fenwick, email to GiveWell, October 15, 2015 Unpublished Alan Fenwick, email to GiveWell, October 29, 2015 Unpublished Alan Fenwick, email to GiveWell, September 28, 2015 Source Alan Fenwick, SCI Director, conversation with GiveWell, October 14, 2014 Unpublished Alan Fenwick, SCI Director, conversation with GiveWell, October 15, 2014 Unpublished Alan Fenwick, SCI Director, email to GiveWell, November 24, 2014 Unpublished Alan Fenwick, SCI Director, phone conversation with GiveWell, February 16, 2011 Unpublished Alan Fenwick, SCI Director, phone conversation with GiveWell, September 15, 2011 Unpublished Alderman et al. 2006 Source (archive) Allen and Parker 2011 Source (archive) Allen and Parker 2012 Source (archive) Allen and Parker 2016 Source (archive) Anna Phillips, SCI Country Program Manager for Burkina Faso and Niger, email to GiveWell, October 13, 2011 Source Benjamin Styles, SCI Senior Biostatistician, phone conversation with GiveWell, August 12, 2011 Unpublished Bleakley 2007 Source (archive) Brooker et al. 2005 Source (archive) Chaula and Tarimo 2014 Source (archive) Croke 2014 Source (archive) Crown Agents Total ICOSA Procurement Spend (updated 2014) Unpublished DFID glossary Source (archive) Dr. Wendy Harrison and Najwa Al Abdallah, conversation with GiveWell, May 4, 2016 Unpublished Dr. Wendy Harrison and Najwa Al Abdallah, conversation with GiveWell, September 27, 2016 Unpublished END Fund, conversation with GiveWell, October 17, 2016 Unpublished Fenwick et al. 2009 Source (archive) Fiona Fleming, conversation with GiveWell, November 5, 2015 Unpublished Fiona Fleming, conversation with GiveWell, September 19, 2016 Unpublished Fiona Fleming, email to GiveWell, March 3, 2016 Unpublished Fiona Fleming, email to GiveWell, November 5, 2015 Unpublished Fiona Fleming, email to GiveWell, October 11, 2016 Unpublished Fiona Fleming, email to GiveWell, September 18, 2015 Unpublished Fiona Fleming, SCI Senior Monitoring & Evaluation Manager, conversation with GiveWell, October 14, 2014 Unpublished Fiona Fleming, SCI Senior Monitoring & Evaluation Manager, conversation with GiveWell, September 21, 2015 Unpublished Fiona Fleming, SCI Senior Monitoring & Evaluation Manager, email to GiveWell, November 9, 2014 Unpublished Gates Foundation, Imperial College London (June 2002) Source GiveWell summary of SCI finances (October 2014) Source GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted Source GiveWell's analysis of SCI cashbook summary 2015-16 Source GiveWell's analysis of SCI spending under DFID grant Source GiveWell's analysis of SCI spending under DFID grant (updated 2015) Source GiveWell's non-verbatim summary of a conversation with Alan Fenwick and Najwa Al Abdallah, September 14, 2015 Source GiveWell's non-verbatim summary of a conversation with Alan Fenwick, SCI Director, July 31, 2015 Source GiveWell's non-verbatim summary of a conversation with Alan Fenwick, SCI Director, June 17, 2010 Source GiveWell's non-verbatim summary of a conversation with Alan Fenwick, SCI Director, October 2, 2015 Source GiveWell's non-verbatim summary of a conversation with Blandine Labry, December 15, 2015 Source GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison and Najwa al Abdallah, February 17, 2016 Source GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison, Najwa Al Abdallah, and Dr. Lynsey Blair, April 6, 2016 Source GiveWell's non-verbatim summary of a conversation with Giuseppina Ortu on June 20, 2014 Source GiveWell's non-verbatim summary of a conversation with Lynsey Blair, October 16, 2014 Source GiveWell's non-verbatim summary of a conversation with Michael French, October 15, 2014 Source GiveWell's non-verbatim summary of a conversation with Oumer Shafi, November 4, 2014 Source GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014 Source GiveWell's non-verbatim summary of a conversation with Wendy Harrison and Najwa Al Abdallah on September 8, 2015 Source GiveWell's non-verbatim summary of a conversation with Yolisa Nalule, October 14, 2014 Source GiveWell's notes from visit to Malawi on October 17-19, 2011 Source GiveWell’s non-verbatim summary of conversations with Grace Hollister on September 21 and October 1, 2015 Unpublished Kabatereine et al. 2001 Source (archive) Kabatereine et al. 2006 Source (archive) Kabatereine et al. 2007 Source (archive) Kieran Bird, SCI Finance Manager, conversation with GiveWell, October 16, 2014 Unpublished Kieran Bird, SCI Finance Manager, email to GiveWell, November 4, 2014 Unpublished Knopp et al. 2009 Source (archive) Knopp et al. 2013 Source (archive) Koukounari 2011 Source Koukounari et al. 2007 Source (archive) Leslie et al. 2011 Source (archive) LSTM Mozambique trip report (May 2015) Unpublished Mapping of Schistosomiasis and Soil-transmitted helminthiasis in Yemen Source Mazigo et al. 2012 Source (archive) Michelle Clements, SCI Senior Biostatistician, conversation with GiveWell, October 15, 2014 Unpublished Miguel and Kremer 2004 Source (archive) Muhumuza et al. 2009 Source (archive) Muhumuza et al. 2013 Source (archive) Muhumuza et al. 2014 Source (archive) Najwa Al Abdallah, Alan Fenwick, and Wendy Harrison, conversation with GiveWell, October 11, 2016 Unpublished Najwa Al Abdallah, conversation with GiveWell, October 22, 2015 Unpublished Najwa Al Abdallah, Dr. Lynsey Blair, and Dr. Wendy Harrison, conversation with GiveWell, September 27, 2016 Unpublished Najwa Al Abdallah, email to GiveWell, May 18, 2016 Unpublished Najwa Al Abdallah, email to GiveWell, October 14, 2016 Unpublished Najwa Al Abdallah, email to GiveWell, October 19, 2016 Unpublished Najwa Al Abdallah, email to GiveWell, September 22, 2016 Unpublished Nigeria NTD stakeholders meeting and potential SCI involvement scoping document Source Nigeria stakeholders meeting summary (May 2015) Source Nigeria trip report (June 2015) Source Parker and Allen 2011 Source (archive) Parker and Allen 2014 Source (archive) Parker, Allen, and Hastings 2007 Source (archive) Pinot de Moira et al. 2010 Source (archive) Rudge et al. 2008 Source (archive) Scheich et al., 2012 Source (archive) Schematic of SCIs Income Sources and Imperial Account structure Apr 2016 Source Schistosomiasis Control Initiative, conversation with GiveWell, October 7, 2016 Unpublished Schistosomiasis Control Initiative, conversation with GiveWell, September 6, 2016 Unpublished SCI Account summary (May 2011) Source SCI advisory board financial report (June 2013) Source SCI advisory board financial report (June 2014) Source SCI allocation table 2016-2017 Source SCI board financial details (June 2014) Unpublished SCI Board management accounts (April 2010) Source SCI budget 3 options October 2016 Redacted Source SCI budget vs. actuals 2015-16 Redacted Source SCI budget vs. actuals April-July 2016 Redacted Source SCI Burundi June 2014 Open Day poster Source SCI Burundi: Impact Source (archive) SCI cashbook Côte d'Ivoire 2015-16 Unpublished SCI cashbook DRC 2015-16 Unpublished SCI cashbook Malawi 2015-16 Unpublished SCI cashbook Niger 2015-16 Unpublished SCI cashbook summary 2015-16 Source SCI cashbook Tanzania 2015-16 Unpublished SCI cashbook Uganda 2015-16 Unpublished SCI CNTD spending data (FY2-FY4) Source SCI contribution to the global effort to control and eliminate schistosomiasis Source SCI Côte d'Ivoire coverage survey 2014 Unpublished SCI Côte d'Ivoire panel study baseline report Unpublished SCI draft budget 2015-2016 Source SCI draft financial statements for 2013/14 and 2014/15 Source SCI draft reserves policy (September 2015) Source SCI DRC baseline impact survey 2015 Unpublished SCI Ethiopia annual treatments 2016 Source SCI Ethiopia coverage survey 2015 Unpublished SCI Ethiopia impact survey baseline report 2015-16 Unpublished SCI Ethiopia mapping of SCH and STH 2014 Source SCI Ethiopia mapping surveys 2013-15 Unpublished SCI Ethiopia treatment campaign summary report (April 2015) Source SCI financial statement 2013/14 and 2014/15 (revised October 2015) Source SCI fundraising targets (November 2014) Source SCI Gates Foundation final report (January 2011) Source SCI GiveWell income reconciliation 2016 Unpublished SCI Global treatment numbers 2015-16 Source SCI IC Trust statement July 2016 Redacted Source SCI IC Trust summary (September 2011) Source SCI ICOSA Mid-Year Report 2014 Source SCI impact and coverage survey plans Source SCI Imperial initiative to protect children from tropical disease awarded ₤25m government backing Source (archive) SCI L-account 2016 Unpublished SCI L-account April-October 2016 Unpublished SCI Liberia impact survey dashboard 2012-13 Unpublished SCI Liberia impact survey follow up recommendations report 2013 Unpublished SCI Liberia panel study baseline report Unpublished SCI M&E survey schedule September 2016 Source SCI M&E timeline (May 2015) Source SCI Madagascar baseline impact survey 2015 Unpublished SCI Madagascar coverage survey recommendation report 2016 Unpublished SCI Malawi coverage survey 2012 Source SCI Malawi coverage survey 2014 Source SCI Malawi impact study – second follow up Source SCI Malawi panel study Source SCI Malawi spending data (November 2011 to August 2013) Source SCI Mozambique coverage survey 2015 Source SCI Mozambique coverage survey presentation 2016 Unpublished SCI Neglected tropical diseases in Mozambique Unpublished SCI Niger panel study 2011 Unpublished SCI Niger spending data (October 2011 to May 2013) Source SCI planned SCH treatment numbers by country by year (October 2015) Source SCI Proposal by SCI, Imperial College to manage the Program for Integrated Control of Neglected Tropical Diseases in Côte d'Ivoire Unpublished SCI report to DFID (October 2013) Source SCI report to DFID (September 2015) Source SCI report to GiveWell (September 2013) Unpublished SCI report to GiveWell (September 2014) Source SCI responses to GiveWell questions on financial statements (October 2015) Source SCI Rwanda June 2014 Open Day Poster Source SCI Rwanda: Strategy Source (archive) SCI Summary sheet of treatments instigated and overseen by SCI Source SCI supporting documents matrix (September 2015) Source SCI Tanzania spending data (March 2011 to July 2013) Source SCI treatment data 2014-16 Source SCI treatment gap forecast 2016 Source SCI treatment numbers (October 2014) Source SCI Uganda coverage survey 2014 Source SCI Uganda panel study baseline report Unpublished SCI Uganda spending data (September 2011 to August 2013) Source SCI Zambia coverage survey 2015 Source SCI Zambia panel study baseline report Unpublished SCI Zanzibar coverage survey 2015 Source Standley et al. 2009 Source (archive) Standley et al. 2010 Source (archive) Stothard et al. 2009 Source Stothard et al. 2013 Source Styles 2011 Source Sudan annual workplan (April 2015 to March 2016) Source Sudan annual workplan for WHO (2015) Source Sudan campaign photos Source Sudan cash book Source Sudan joint request for selected PC medicines Source Sudan NTD concept paper (2015-2018) Source Sudan PZQ and ALB treatments by locality (2015) Source Summary Technical Report: Schistosomiasis Control in Yemen (July 2014) Source Tohon et al. 2008 Source (archive) Top 20 countries, estimated schistosomiasis infections Source Touré et al. 2008 Source (archive) Utroska et al. 1989 Source (archive) Wendy Harrison and Sarah Knowles, SCI Managing Director and Biostatistician, conversations with GiveWell, April 9 and 14, 2014 Source Wendy Harrison, email to GiveWell, October 11, 2016 Unpublished Wendy Harrison, email to GiveWell, September 8, 2015 Unpublished Wendy Harrison, SCI Managing Director, email to GiveWell, March 4, 2014 Unpublished WHO schistosomiasis treatment gap data Unpublished WHO STH factsheet Source (archive) WHO STH treatment report Source (archive) WHO Weekly epidemiological record, 18 December 2015 Source (archive) WHO Weekly epidemiological record, 6 March 2015 Source (archive) WHO, Summary of global update on preventive chemotherapy implementation in 2015 Source (archive) Wikipedia entry for Unguja Source (archive) • 1. "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 anthelmintic 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. • 2. See our November 2015 review here and here. • 3. • 4. Sudan Nigeria • 5. "Prior to SCI’s work in Côte d'Ivoire, there were no large-scale schistosomiasis (SCH) treatment programs." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014. • 6. "SCI first contacted the government and started to discuss a SCH/STH program in 2010. A civil war delayed progress because there was political turmoil, a weakened health system, and dangerous conditions. In 2012 conditions improved, and the contracts between SCI and the Ministry of Health were set up. [...] Treatments started in December 2012: • In 2012: 649,859 school-aged children (SAC) received treatments in 12 districts, some of which had been mapped prior to SCI’s involvement. • In November 2013: 853,708 SAC received treatments in the areas that SCI mapped first, with the help of the Ministry of Health. • In May 2014: 1,425,461 SAC received treatment in the remaining areas of the first phase of mapping. • In November 2014: 3.5 million SAC are targeted for the next treatment, which would correspond to the second phase of mapping. The aim is that by the end of 2014, all SAC in the SCH-endemic districts will have been treated at least once. Some areas that were treated in 2012 were also treated again in May." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014. • 7. "In May 2014: 1,425,461 SAC received treatment in the remaining areas of the first phase of mapping. In November 2014: 3.5 million SAC are targeted for the next treatment, which would correspond to the second phase of mapping." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014. • 8. Alan Fenwick, email to GiveWell, November 3, 2015. Note this is slightly higher than we previously reported in our August 2015 update on SCI. • 9. • 10. "For the smaller donor, we have two or three projects, which we have been supporting and which will hopefully lead to pilot projects in their respective countries. 1. In Côte d'Ivoire, we now have funding from the U.K. Department for International Development (DFID). There will eventually be a national program. 2. 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." • 11. SCI allocation table 2016-2017, "Implementation" sheet, cell B6. • 12. SCI budget 3 options October 2016 Redacted, "Implementation" sheet, cell B5. • 13. As of November 4, 2014, Google states that £1 is worth$1.6.

• 14.
• 15.

GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted, "BVA in USD" sheet, cells I11 and K11.

• 16.

"If the 2014 targets are met, it will be an impressive achievement to have treated all SCH-endemic areas at least once since 2012. With just the funding allocated by DFID, the program could not have scaled up as quickly. In this scenario, it probably would have completed the mapping but delivered fewer treatments." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014.

• 17.
• "SCI conducted national mapping since late 2012, finishing in March 2014. In total, all 82 districts in Côte d'Ivoire were mapped. This was done in two phases because of limited funding. The first phase was done by the Ministry of Health with support from SCI. The second phase was led by Professor Eliézer N’Goran from the Université Félix Houphouët-Boigny with both technical and financial support from SCI. […]
The country will start an integrated treatment program for several diseases in November 2014 […]
Other neglected tropical disease (NTD) organizations have benefitted from the work SCI has done to build a SCH program. SCI has provided cars and developed staff capacity. Organizations have worked to coordinate when sharing these resources and operating an integrated program should make that easier." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014.
• "Cote d’Ivoire is working toward creating an integrated program for the treatment of lymphatic filariasis, onchocerciasis, schistosomiasis, and STH. This will involve collaboration and integration of tools and training, but drugs for all four diseases will not be administered simultaneously. So far, lymphatic filariasis and onchocerciasis treatments have been integrated, and schistosomiasis and STH treatments are administered together but currently delivered separately from lymphatic filariasis and onchocerciasis. [...] SCI's partners in Cote d'Ivoire include Sightsavers, the END Fund, and Helen Keller International." GiveWell's non-verbatim summary of a conversation with Alan Fenwick and Najwa Al Abdallah, September 14, 2015.
• 18.
• 19.

"Dr. Nogaro has visited Côte d'Ivoire several times over the last year, often dealing with multiple activities on each trip:

• One month last November to oversee the sentinel sites activity and obtain baseline information for both prevalence and intensity of infection, help with the MDA, and oversee the start of the second phase of mapping,
• One month in January to work on the coverage survey, work on financial reporting, oversee mapping, and help with drafting the annual work plan and budget (alongside the Ministry of Health),
• Three weeks in May for another MDA,
• One week in June to work with WHO and other partners for the integrated MDA plan and budget work, and
• Three weeks this month to follow up with CHWs in low coverage areas, oversee the sentinel sites activity, and oversee the first integrated MDA and training."
• 20.

"Program staff in each country create annual budgets in collaboration with SCI. The budget ensures money is being spent well and on activities defined in the annual work plan, which is submitted by the country to SCI. Generally, receipts are used to document expenses. In some cases, it takes a long time to get the receipts or receipts are not available at all. SCI hired an accountant and an auditor to better monitor finances." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014.

• 21.

"Data is entered at the country level. For example, data from mapping and sentinel sites can be handled by students at a local university. The data is double entered to ensure accuracy. The original forms stay in the country and the database is sent to SCI, which can then run analyses. SCI is planning to expand its data analysis team. In the spring, SCI’s biostatistician will teach a data cleaning session to program staff in Côte d'Ivoire. In the future, SCI will consider doing more advanced data analysis training in all the countries it supports." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014.

• 22.

"In 2007, prior to SCI’s involvement, Save the Children ran a one-time treatment for about 1 million children for schistosomiasis (SCH) and soil-transmitted helminths (STH)." GiveWell's non-verbatim summary of a conversation with Michael French, October 15, 2014.

• 23.

"In mid-2012, the University of Gondar invited SCI to an international symposium on SCH, which served as an introduction for SCI to Ethiopia. After this, Dr. Fenwick, Director of SCI, and other senior SCI staff established a relationship with senior Federal Ministry of Health (FMOH) officials.

In 2013, SCI moved into more serious conversations with the Ministry of Health. In July 2013 SCI provided support for the launch of the FMOH’s National NTD Master Plan at an international symposium in Addis Ababa. Around the same time, SCI collaborated with the Ethiopian Health and Nutrition Research Institute (EHNRI; now renamed as the Ethiopian Public Health Institute), the technical arm of the FMOH, to plan and fund nationwide mapping. […]
Last year (2013) SCI funded 1.4 million combined SCH/STH treatments. […]
The mapping took longer than planned. Teams were trained in November 2013, and the mapping was completed in April 2014." GiveWell's non-verbatim summary of a conversation with Michael French, October 15, 2014.

• 24.

SCI Ethiopia mapping surveys 2013-15

• 25.
• "In total 2.9 million school-aged children received treatment against both schistosomiasis and STH (coverage of 74.0%), comprised of 2.3m enrolled SAC and 571,000 non-enrolled. These numbers are currently being validated using coverage validation surveys in representative districts. These results will be presented as soon as the data is analysed." pg. 1.
• "Demographic and parasitological data were collected from 22 sentinel sites prior to the April 2015 campaign. Each sentinel site comprised of a school, with 125 children recruited from each school. Each child provided stool and urine samples on two consecutive days in order to estimate the level of parasite prevalence and average intensity of infection. These 22 sentinel sites will be supplemented by a further 15 sites prior to the October 2015 round of treatment to complete the picture on the baseline level of infection. These schools will be followed up annually, just prior to treatment, to understand changes in infection across the course of the programme." pg. 4.
• 26.

SCI Ethiopia impact survey baseline report 2015-16

• 27.
• 28.
• 29.

SCI budget 3 options October 2016 Redacted, "Implementation" sheet, cell B7.

• 30.
• 31.

Alan Fenwick, email to GiveWell, September 28, 2015. First transfers from END Fund and DFID funds occurred in 2015. Also:

• 32.

"He does not know if The END Fund/DFID would have gotten involved without the mapping data. At a minimum, the mapping effort significantly increased the probability of attracting external funding and accelerated the program by a few years." GiveWell's non-verbatim summary of a conversation with Michael French, October 15, 2014.

• 33.

"FMOH [Federal Ministry of Health] began working with SCI about 2.5 years ago. Mr. Shafi's predecessor began speaking to SCI about the possibility of working together on a schistosomiasis program. SCI was the only organization that the government spoke to about this, as it wasn't aware of any other organizations working on schistosomiasis. [...]
Without SCI's involvement, the program would likely not have gone forward. With the exception of filling small funding gaps on an ad hoc basis, the government has not been able to allocate funding to NTDs. It was interested in doing disease mapping but did not have the funding to do so, and it likely would not have received drug donations without the mapping data." GiveWell's non-verbatim summary of a conversation with Oumer Shafi, November 4, 2014.

• 34.

"In July 2013 SCI provided support for the launch of the FMOH’s National NTD Master Plan at an international symposium in Addis Ababa. Around the same time, SCI collaborated with the Ethiopian Health and Nutrition Research Institute (EHNRI; now renamed as the Ethiopian Public Health Institute), the technical arm of the FMOH, to plan and fund nationwide mapping. […]
The Deworm the World Initiative (DtWI) will be providing technical advice to Ethiopia, based on its experience in Kenya. […]
With funding from Dubai Cares, the Partnership for Child Development (PCD) implemented a small pilot program in 30 schools in the southern region (SNNPR) to look at feasibility of a comprehensive school health and nutrition program, which includes deworming, nutrition, and WASH [water, sanitation, and hygiene] interventions and home-grown school-feeding. Related to this, the grant included funding for a region-wide situational analysis, covering an area with about 17 million people. Therefore, the decision for this to be included in the broader national mapping and to include the distribution of SCH, STH, WASH facilities, and school-feeding needs. SCI and PCD partnered on the design, implementation, and analysis of this national mapping. Overall, PCD provided both technical assistance and about 20%-25% of the funding for the national mapping." GiveWell's non-verbatim summary of a conversation with Michael French, October 15, 2014.

• 35.

"Examples of Dr. French's work to assist the Ethiopia program:

1. Initial program setup activities: creating processes and scheduling meetings to lay groundwork for future activities; developing and finalizing contracts between funders, Imperial Collage [sic] and implementers (the contracts are more complicated than normal because there are 2 funders and 2 implementing agencies).
2. SCH/STH action plan: This will provide a detailed plan for next 12 months and more general plan for 5 years. The FMOH have tasked Dr. French and SCI to drive this this forward, e.g providing an outline that can be adapted by the country.
3. Mapping plan: Dr. French was the main technical advisor from SCI. He worked very closely with people from EHNRI to a) write the research protocol, b) advise on the recruitment of trainers, and c) train technicians, d) supervise activities, e) help with data collection and analysis.
4. Last year’s mass drug administration (MDA): Dr. French was less involved with the MDA than with the mapping but was involved in developing the plans. The Ministry of Health was responsible for running the program and delegating work to regional governments. It had experience from other mass distribution programs. For technical training, it worked with health workers who already had extensive general experience and then provided NTD expertise largely from WHO guidelines, though SCI provided some technical guidance.

Dr. French has been living in Ethiopia, which has helped him build relationships, enabled him to hear more activity details, and allowed him to provide timely advice. For example, he has stronger relationships with the officials in Ethiopia and a clearer sense of whom to go to for various requests. Also, by being close to the activities, some problems with data flowing back to central level have been clearer, which makes it easier for him to help develop solutions." GiveWell's non-verbatim summary of a conversation with Michael French, October 15, 2014.

• 36.

"Mike French, SCI's program manager for Ethiopia, works in the same office as the government NTD program." GiveWell's non-verbatim summary of a conversation with Oumer Shafi, November 4, 2014. In June 2016 when we sent a draft of this review to SCI, SCI edited this to "works closely with."

• 37.

"Prior to SCI’s involvement in 2010, there was a mapping project in 2008. Dr. Blair does not think there were any schistosomiasis (SCH) treatment programs (other than a small program funded by SCI). If there were, they would have been small-scale." GiveWell's non-verbatim summary of a conversation with Lynsey Blair, October 16, 2014.

• 38.

"The SCH program in Mozambique is run by the Center for Neglected Tropical Diseases (CNTD). Funding for the program is provided to SCI by DFID, and SCI funds CNTD as part of its agreement with DFID." GiveWell's non-verbatim summary of a conversation with Lynsey Blair, October 16, 2014.

• 39.

“When we bid for the DFID grant, I was advised that DFID favored grants that involved partnerships. CNTD does a lot of the work on lymphatic filariasis. DFID was providing 20 million pounds for lymphatic filariasis and 20 million for schistosomiasis. Working with CNTD demonstrated a degree of integration. CNTD does both lymphatic filariasis and schistosomiasis in Mozambique." Alan Fenwick, SCI Director, conversation with GiveWell, October 14, 2014.

• 40.

SCI treatment data 2014-16, cells E12:F12.

• 41.
• 42.

SCI budget 3 options October 2016 Redacted, "Implementation" sheet, cell B12.

• 43.

Dr. Wendy Harrison, Najwa Al Abdallah, and Dr. Lynsey Blair, conversation with GiveWell, April 6, 2016

• 44.
• 45.

SCI did not spend any unrestricted funding on the program in Mozambique in its 2015-2016 budget year and spent $573,281 in restricted funding. GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted, "BVA in USD" sheet, cells I18:K18. • 46. See our June 2014 update on SCI. • 47. "SCI and CNTD are working closely with RTI International in Mozambique. This has been a great working relationship. RTI is funding some capacity development around drug logistics. It is working on trachoma; currently, this work is focused on mapping, but it will likely fund treatment when mapping is finished. RTI has staff in-country and reports to SCI and CNTD on issues, which can provide some verification that the program is progressing as expected. The organizations coordinate to ensure multiple sources of funding aren't allocated for the same purpose. For example, RTI emailed SCI and CNTD saying that the government had indicated that it was going to drop the SCH program; the staff from the organizations communicated quickly to sort out the confusion." GiveWell's non-verbatim summary of a conversation with Lynsey Blair, October 16, 2014. • 48. "The SCH program in Mozambique is run by the Center for Neglected Tropical Diseases (CNTD). Funding for the program is provided to SCI by DFID, and SCI funds CNTD as part of its agreement with DFID. [...] CNTD will continue to run the mass drug administration (MDA), but SCI has become more directly involved with the M&E as it has the technical expertise to manage these activities." GiveWell's non-verbatim summary of a conversation with Lynsey Blair, October 16, 2014. • 49. "SCI’s program in Uganda is fully funded by DFID (other than one use of unrestricted funding, discussed below). SCI had previously worked in Uganda with funding from the Bill & Melinda Gates Foundation. After this funding ended, USAID funded work by RTI International in Uganda. Around 2006, Uganda started an integrated NTD program in districts endemic with more than one NTD. Districts with only schistosomiasis (SCH) were not treated. When SCI re-entered Uganda, it started SCH programs in the districts not receiving treatment." GiveWell's non-verbatim summary of a conversation with Yolisa Nalule, October 14, 2014. • 50. See our August 2015 update on SCI. • 51. SCI report to GiveWell (September 2014), Annex 1. • 52. SCI treatment data 2014-16, cells E18:F18. • 53. SCI allocation table 2016-2017, "Implementation" sheet, cell B20. • 54. SCI budget 3 options October 2016 Redacted, "Implementation" sheet, cell B19. • 55. • 56. "SCI’s program in Uganda is fully funded by DFID (other than one use of unrestricted funding, discussed below)... In deciding on the budget, there might be some disagreement around whether impact M&E (having sentinel sites) is worth the expense. The government might prefer to provide more treatments. Mrs. Nalule and other researchers argue for the value of M&E. Last year, M&E funding was augmented by £23,000 from SCI unrestricted funding. Without this, there likely would have been cuts in the number of sentinel schools. This M&E is enabling research to compare different treatment strategies in areas where prevalence is low. DFID was not interested in funding this research." GiveWell's non-verbatim summary of a conversation with Yolisa Nalule, October 14, 2014. Note that SCI has only reported$2,220 in unrestricted spending to us in financial reports. GiveWell summary of SCI finances (October 2014), Sheet Combined with previous updates.

• 57.
• SCI draft financial statements for 2013/14 and 2014/15
• As of November 4, 2014, Google states that £1 is worth $1.6. • 29,914 * 1.6 =$47,862.
• 58.

GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted, "BVA in USD" sheet, cell K25.

• 59.

"When SCI re-entered Uganda, it started SCH programs in the districts not receiving treatment. Also, in about 30 districts, USAID stopped treating SCH because prevalence dropped below 20%, so SCI supported the continuation of these treatments with an aim towards elimination. […]
Also, SCI is taking over treatment from RTI in a 15 districts that have higher prevalence, and, in these districts, it will treat adults. Since prevalence is over 50%, WHO guidelines say to treat children and high risk adults (e.g. fisherman), though usually programs will just try to treat all adults." GiveWell's non-verbatim summary of a conversation with Yolisa Nalule, October 14, 2014.

• 60.

"In some cases (for example, Uganda and Niger), the government program manager understands SCH well and does not require a lot of technical guidance. [...] Uganda is an interesting example. The program had been relatively straightforward to manage. It is now focusing on elimination, which is unknown territory so will require much more guidance. There is a lot of research to do to determine guidelines for how often to treat." GiveWell's non-verbatim summary of a conversation with Lynsey Blair, October 16, 2014.

• 61.
• 62.

"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).

• 63.

"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 helminthiasis 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 -
• 64.
• "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 SCI Board management accounts (April 2010)
• 65.
• 66.
• 67.
• 68.

"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." SCI Imperial initiative to protect children from tropical disease awarded ₤25m government backing.

• 69.

”DFID has allocated 50 million GBP for control of neglected tropical diseases over 5 years, of which £25 million is going through SCI for schistosomiasis control in 8 countries (including Malawi) over five years.” GiveWell's notes from visit to Malawi on October 17-19, 2011, pg. 1.

• 70.

"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." SCI Imperial initiative to protect children from tropical disease awarded ₤25m government backing.

• 71.
• 72.
• 73.

"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.

1. In Côte d'Ivoire, we now have funding from the U.K. Department for International Development (DFID). There will eventually be a national program.
2. 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."
• 74.

Donations to SCI due to GiveWell's research through January 2016 are listed here and total about $14.2 million. GiveWell tracked an additional$400k to SCI between February and September 2016 (internal data).

• 75.
• We estimate that SCI received about $11.2 million due to GiveWell's recommendation between April 2013 and March 2016 (internal data). Over that period, SCI reports$17.8 million in unrestricted revenue. SCI's total for April 2013 to March 2015 may include some restricted funds. More details here.
• March 2013 to April 2015 SCI unrestricted funding, $12.4 million: SCI financial statement 2013/14 and 2014/15 (revised October 2015), "Fin statement in USD" sheet, cells F8 and J8 ($4,591,396 + $7,828,759 =$12,420,155).
• Between April 2015 and March 2016, we estimate that SCI received around $5.4 million in total unrestricted revenue. Internal calculations based on: •$12.4 million plus $5.4 million is$17.8 million. $11.2 million /$17.8 million = 63%
• 76.

SCI allocation table 2016-2017, "Income analysis" sheet:

• Unrestricted funding total: Income balance at IC Trust at 31 March 2016 (2,133,898 GBP) plus Income balance at L-account at 31 March 2016 (3,428,676 GBP) = 5,562,574 GBP. Cells B2 and B3.
• Restricted funding total: "Committed from DFID" (4,285,439 GBP) plus "Committed from UBS" (257,753 GBP) plus "Committed from CIFF' (261,645 GBP) plus "Committed from END Fund" (908,860 GBP) plus "Committed from Score" (95,000 GBP) plus "Committed from Gates" (79,105 GBP) plus "Committed from MRC" (45,461 GBP) = 5,933,263 GBP. Cells B5:B11.
• 5,562,574 /(5,562,574 + 5,933,263) = 48%
• 77.

SCI allocation table 2016-2017, "Summary" sheet:

• The sum of income carried forward for DFID, UBS, CIFF, END Fund, Score, Gates, and MRC is £5,933,263.
• The sum of income carried forward for Unrestricted ICT and Unrestricted IC is £4,934,550
• As of May 20, 2016, Google states that £1 is worth $1.45 • 78. • SCI's total budget for its April 2016 to March 2017 budget year (£10,985,319) is £117,506 higher than its total amount of available funding (£10,867,813) SCI allocation table 2016-2017, "Summary" sheet, cells C4, C11, and C13. • A July 2015 transfer of$333,414 from GiveWell was initially misallocated by Imperial College; SCI was not aware of this funding until April 2016. This funding is not included in the total amount of available funding in SCI allocation table 2016-2017, "Summary" sheet.
• SCI told us that it may use the July 2015 funding to fill its £117,506 funding gap. If SCI chose to do so, it would have £112,237 in unrestricted funding remaining ($333,414 is worth £229,743; £229,743 minus £117,506 equals £112,237). Dr. Wendy Harrison and Najwa Al Abdallah, conversation with GiveWell, May 4, 2016 • As of May 22, 2016, Google states that$1 is worth roughly £0.69.
• 79.
• 80.

SCI notes, "Imperial College has charitable status as a UK Higher education establishment and is audited in line with the requirements of the UK charity commission." Comment provided in response to our draft of this page in June 2016.

We have looked at Imperial College's financial statements and did not find that they helped us understand SCI's finances.

• 81.

Comment provided in response to our draft of this page in June 2016.

• 82.
• 83.

"SCI plans to implement a new, standalone accounting software package starting April 1, which will allow SCI to be more flexible and to rely less on Imperial College London's accounting system. SCI only plans to use this system for financial data collected going forward (not for past data)." GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison and Najwa al Abdallah, February 17, 2016

• 84.

• In our November 2012 update on SCI (see footnote 1 of that report), we noted inconsistencies in the spending data SCI shared with us. In one case, we asked SCI about a discrepancy we have noticed and SCI's reply was implausible.
• In our next update on SCI, in October 2013, we reported having a fuller view of how SCI had spent funds, though noted a discrepancy in funds held: "We reported (after checking this number with SCI) that as of October 2012, SCI held $2.65 million in unrestricted funds. As part of this update, we sought to understand SCI's use of unrestricted funds between October 2012 and August 2013. SCI told us that it had held$1.96 million in unrestricted funds as of October 1, 2012, about $660,000 less than we previously thought. We have assumed that we miscommunicated with SCI last year; one possibility is that the numbers we received included some restricted funds and we may not have fully excluded all restricted funds in our adjustment. We have used the more recent figure for this update." • In October 2014, SCI shared reports of spending since our last update and balance of unrestricted funds at the end of the period. Combining these figures with our previously published figure for balance of unrestricted funds as of our last update implied negative revenue over the period. We asked SCI to explain the discrepancy. SCI first told us that the discrepancy was due to counting some restricted funds in the unrestricted balance. At the same time, SCI provided data on unrestricted revenue over the period, giving us a double check on these figures. There was a discrepancy between actual revenue and revenue implied by the starting and ending balances and spending over the period of about £528,000. When we asked SCI about this discrepancy, SCI told us that there was an additional expenditure of £595,420 that was missing from the report previous, as well as a small amount of additional income, which reduced the discrepancy to £11,651. • In June 2015, SCI shared financial statements for 2013/14 with us that showed no spending in Ethiopia in that year (SCI draft financial statements for 2013/14 and 2014/15). We asked SCI about this because other communications with SCI indicated that SCI had been active in Ethiopia in that year. SCI noted that this was an error and was likely due to confusion by newer staff on how to interpret older financial data: "The three transfers which were made to Ethiopia during 2013/2014 were recorded to the L‐account which is an account the Imperial College currently use to record unrestricted income. In the past however, the L‐account was also used to record expenditures ‐ but later we changed our recording system whereby expenditures were accredited to 'NX' accounts which were created to capture country expenses. Because the transfers went straight from the L account [SCI staff member] did not identify them as being for Ethiopia." Alan Fenwick, email to GiveWell, October 1, 2015. • "In October 2015, SCI shared estimates for its April 2016-March 2017 budget year with GiveWell on target treatment numbers by country, amounts of funding available from DFID and other large donors, and the amounts of additional funding required to deliver the targeted number of treatments in each country and cover SCI's central expenditures (http://www.givewell.org/files/DWDA%202009/SCI/SCI_planned_SCH_treatment_...(October_2015).xlsx). GiveWell interpreted the estimates for SCI's projected central expenditures in the document as part of SCI's funding gap for its 2016-2017 budget year. "Documents SCI sent GiveWell in March 2016 indicate that around$1.5 million more in funding from DFID is available to allocate for SCI's 2016-2017 budget year than GiveWell had previously expected. This is because the document from October 2015 included funding available from DFID that could be allocated to in-country programmatic expenditures, but did not include the funding from DFID that SCI planned to allocate to central expenditures (included in the March 2016 documents)." GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison, Najwa Al Abdallah, and Dr. Lynsey Blair, April 6, 2016

• In July 2015, GiveWell granted $333,414 to SCI, which included all donations received between February and March 2015. In March 2016, after reviewing a preliminary version of SCI L-account 2016, GiveWell told SCI that the July 2015 funding did not appear to be accounted for. SCI then learned that the funding had been misallocated by Imperial College. SCI received the funding in April 2016. Dr. Wendy Harrison and Najwa Al Abdallah, conversation with GiveWell, May 4, 2016 • 85. See previous footnote. • 86. Wendy Harrison, email to GiveWell, September 8, 2015 • 87. GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted, "BVA in USD" sheet. • 88. See our November 2015 review of SCI. • 89. • "Central programme costs include programme management, travel, monitoring &evaluation, payments to partners, and overhead costs. Previous figure Including 303K to LSTM related to Mozambique rolled from previous fiscal year." GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted, "BVA in USD" sheet, Cell N7. • We believe that the "previous figure" referred to is from an earlier version of this document. • 90. GiveWell's analysis of SCI budget vs. actuals 2015-16 Redacted, "BVA in USD" sheet, cell N16. • 91. SCI budget vs. actuals April-July 2016 Redacted • 92. "In 2015, SCI implemented the use of cashbooks by its country programs to report monthly spending. Countries where SCI receives funding from the Department for International Development (DFID) implemented this system first, and it has now been rolled out to all of SCI's country programs. A few countries are currently delayed in submitting cashbooks to SCI because of limited capacity." GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison and Najwa al Abdallah, February 17, 2016 • 93. • 94. "In 2015, SCI implemented the use of cashbooks by its country programs to report monthly spending. Countries where SCI receives funding from the Department for International Development (DFID) implemented this system first, and it has now been rolled out to all of SCI's country programs. A few countries are currently delayed in submitting cashbooks to SCI because of limited capacity." GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison and Najwa al Abdallah, February 17, 2016 • 95. SCI notes, "SCI carries out capacity development of and actively trains in-country accountants on the activity terminology and types of expenses that fall under each which are clearly defined e.g Drug distribution is for expenses related to conducting MDA at a site while drug logistics refer to the transportation of drugs from the source to MDA sites." Comment provided in response to our draft of this page in June 2016. • 96. • 97. "The reason for the differences: SCI BvA is prepared based on imperial college information system (ICIS) -expenditure is recorded when a transfer is made to a country while the cash book record when the money is being spent. Example of Tanzania 2 transfers were made: on 16 Dec. 2015 for the amount GBP 344,018 from DFID and GBP 406,696 from unrestricted. In the cash books Tanzania didn’t spend all the money received in Dec. 2015 as the MDA was delayed and took place during Jan-March 2016." Comment provided in response to a draft of this page in June 2016. • 98. • 99. • 100. Najwa Al Abdallah, email to GiveWell, September 22, 2016 • 101. SCI's summary of active accounts as of June 2014 lists six research grants totaling £2.6 million, or about$4.1 million over 2010-2014. SCI advisory board financial report (June 2014), pg. 5.

• 102.

"Once we have people that want to give at least $100,000, we talk to them directly. [...] 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.

Alan Fenwick, SCI Director, phone conversation with GiveWell, February 16, 2011.

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." GiveWell's notes from visit to Malawi on October 17-19, 2011.

• 103.
• 104.

SCI M&E survey schedule September 2016, cells G5, G6, G9, G16, G19, and G21.

• 105.
• For a full description of the methodology used in each survey (and sources for the statements below), see this spreadsheet, "Methods" sheet.
• SCI has told us (in reports on the coverage surveys or through personal communication) that villages are selected randomly within districts that the coverage survey is implemented in (often with adjustments to account for differing population sizes of villages).
• SCI has told us (in reports on coverage surveys or in personal communication) that households are either chosen through random selection from a village register or through a "random walk" method. A description of a "random walk" method for choosing households:
• "Households were selected using the random walk procedure. A central point in the village was designated and a bottle was spun to randomly select a direction of walk. All households along the direction of walk were counted. A sampling fraction was calculated and the households selected." SCI Madagascar coverage survey recommendation report 2016, Pgs 4-5.
• Note that the selection process for villages and households is not fully clear to us for all coverage surveys we have seen. Also note that coverage surveys are implemented in a selection of districts covered by the MDA program, and the selection of districts for coverage surveys is not always random or intended to be representative of the MDA program as a whole. See here, "Methods" sheet for sources and details.
• 106.

For a full description of the methodology used in each survey, see this spreadsheet, "Methods" sheet.

• 107.
• "The primary objectives of this coverage survey were to:
1. Quantify and validate PZQ and MBD treatment coverage for SCH and STH, respectively;
2. Assess coverage rates disaggregated by school attendance and gender for SAC;
3. Collect information on why targeted eligible individuals did not receive or accept treatment.

Reported coverage was defined as, number of SAC ingesting drugs / eligible SAC population x 100
Survey coverage defined as, number of SAC interviewed that ingested the drug / total number of interviewed
SAC x 100" SCI Madagascar coverage survey recommendation report 2016, pg. 4.

• For a comparison between survey coverage and reported coverage rates, see this spreadsheet.
• Our understanding (formed over several conversations with SCI) is that the governments of countries with SCI-supported programs calculate "reported coverage" figures. The numerator of these figures (the number of treatments delivered to school-aged children according to government administrative data) is calculated by aggregating data from each school in the program on the number of reported treatments delivered. The denominator of this figure (estimated number of eligible school-aged children in the area) is calculated by referencing the most recent government census in the area, which may be adjusted to estimate the effect of population growth since the last census, or by using school enrollment data.
• 108.

For a comparison between survey coverage and reported coverage rates, see this spreadsheet.

• 109.
• It seems plausible to us that there may be an incentive for schools to over-report the number of treatments delivered, or for districts or regions to over-report aggregated treatment figures.
• We have not seen calculations used by governments to find the denominator of the reported coverage calculation (estimated number of eligible school-aged children in the area), but it seems that these estimates are sometimes substantially inaccurate. For example, note that in this spreadsheet, "Results" sheet, that some reported coverage estimates are over 100% (which means that the aggregated reported treatment figures to school-aged children are greater than the government's estimate of the total number of school-aged children in the area).
• Several people have told us that it is difficult to get accurate government administrative data and that data is often missing from some portion of schools/clinics/etc.
• 110.

See this spreadsheet, "Methods" sheet, cells D3:D12.

• 111.
• Côte d'Ivoire: “The surveyors may ask additional questions to remind the children and see if the answers seem believable, for example:
• Show children the dose poll and ask if the children remember it
• Ask the children what they remember about the pills (it is normal to remember praziquantel's bitter taste, size and smell)
• Ask the children how many pills they took (while trying to judge how many they should have received by getting them to stand near the dose pole)."
• For Malawi (2014), SCI told us that verification methods were used, but the data was not included in the survey report. Fiona Fleming, email to GiveWell, November 5, 2015.
• For Uganda, Zanzibar, and Zambia, SCI told us that the survey "asked if [respondents] recognised pills / dummy pills and dose poles." Fiona Fleming, email to GiveWell, November 5, 2015.
• "Verification methods, including the demonstration of pills and dose poles, were used to minimize recall bias." SCI Ethiopia coverage survey 2015, pg. 4.
• For Madagascar (2016), SCI told us that similar verification methods to those in Ethiopia were used. Fiona Fleming, conversation with GiveWell, September 19, 2016
• 112.

"The surveyors only record if the children say they took the drug, didn’t take the drug, or are unsure; currently, the surveyors do not track answers or concerns from the additional questions, though going forward SCI will consider including these as well." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014

• 113.

"The actual sample included caretakers of 578 children." SCI Mozambique coverage survey 2015, pg. 5. Note that we have only received permission to publish a summary of this report. Quotation is from the full, unpublished report.

• 114.

SCI Mozambique coverage survey 2015, pg. 23. Note that we have only received permission to publish a summary of this report. Quotation is from the full, unpublished report.

• 115.

SCI Mozambique coverage survey 2015, pg. 24. Note that we have only received permission to publish a summary of this report. Quotation is from the full, unpublished report.

• 116.

"Pole doses were used as a proxy for the medication – rather than showing the medication we showed them the poles. Only parents (not teachers) can authorize medication to kids in Mozambique and they need to be involved and informed during the social mobilization which is conducted usually by the district officers and the activists, in the week preceding the distribution of the medication. The activists use posters and poles when they inform the community and the poles are very recognizable. The poles are also used in the integrated campaigns – and in most of these districts campaigns have been conducted for a number of years. So…they may be recognized as part of a preventive medication campaign rather than related to the PZQ only." Fiona Fleming, conversation with GiveWell, November 5, 2015 quoting from an email from FPSU.

• 117.
• Fiona Fleming, conversation with GiveWell, September 19, 2016
• Email from SCI's partner FPSU, quoted to us by SCI:
"Further to our conversation, here is a recount of the supervision of the survey:
1. Initially there were 6 teams with Cabo Delgado and Nampula divided into two. All of them were supervised by Don and myself during 2 days of intense data collection in Nampula Cidade to ensure the areas selected were visited, the random selection of houses and respondent and the correct administration of the questionnaire plus the team organization and supervision.
2. Teams were then reduced to 4 as it made more sense to complete districts before traveling to the next.
3. Each team had one or two supervisors, one being the provincial NTD or M&E staff in the case of Zambezia, the national supervisor being NTD or other MISAU Departments (Cabo Delgado, Zambezia). The district officers worked in teams so that most of the interviews in one district were done by the other district officers with no connection with the district. In fact in most cases the district officer of that particular district was solving logistical and administrative issues which are quite intense in Mozambique (permission by the provincial delegate, permission by the district and the locality chief letters of introduction all signed and stamped, motorcycles rental and bills etc).
4. Nampula was identified as the most complex area and the team was supervised by me during the completion of Ilha and Mossuril districts plus Cidade Nampula while Don supervised District Nampula and again the finalization of Cidade Nampula which was pretty complicated. In other areas the survey was easier but in Chinde Islands where Dr Xose went from one island to the next to find the selected village and got lost for a few days because the district has been divided into two and we had to select again the villages. All other supervisors provided daily reports to Don. They also wrote a report of the questionnaires received every day, reviewed and sent.
5. In most cases, data was sent to the database and reviewed every day. Once the supervisor had sent the questionnaire editing was only allowed to Don Whitson. Some areas did paper based questionnaires and this was again submitted and reviewed."
• 118.

See notes in the "data quality control" column of this spreadsheet, "Methods" sheet.

• 119.

Citations for all statements in this list can be found in this spreadsheet, "Methods" sheet, see comments.

• 120.
• 121.

"In other areas the survey was easier but in Chinde Islands where Dr Xose went from one island to the next to find the selected village and got lost for a few days because the district has been divided into two and we had to select again the villages." Fiona Fleming, email to GiveWell, November 5, 2015 (quoting from email from FPSU, which runs the program in Mozambique).

• 122.

Fiona Fleming, email to GiveWell, November 5, 2015 (quoting from email from FPSU, which runs the program in Mozambique).

• 123.
• 124.
• For Côte d'Ivoire, coverage reported by parents was lower than coverage reported by children. In Malawi, coverage reported by parents was similar to coverage reported by children. In Côte d'Ivoire, parents' answers were excluded from the reported results: "Calculation of validated coverage rates initially included answers from both proxy and direct interviews across all 4 districts. As shown in Figure 2, coverage rates calculated based on direct interviews were higher than those which included responses given by proxy (p < 0.001), perhaps due to the parent erring on the side of caution when giving their answer. As direct interviews are believed to be more robust, we omitted data from proxy interviews when calculating final coverage rates (Table 4)." SCI Côte d'Ivoire coverage survey 2014, pg. 10.
• In Malawi, parents' answers were included in reported results. Proxy results were similar to results from direct interviewing in Malawi, and were included in the headline analysis. SCI Malawi coverage survey 2012, pg. 11, Figure 4.
• About 9% of the responses in Côte d'Ivoire were from parents. SCI Côte d'Ivoire coverage survey 2014, pg. 9, Table 3.
• Number of yes/no answers obtained in person (summed across four districts): 2178
• Number of proxy yes/no answers obtained (summed across four districts): 228
• 228 / (228 + 2178) = ~.09
• 125.
• 126.

We have only seen slides from a presentation (in Portuguese) covering the results of the survey, not a full report. SCI Mozambique coverage survey presentation 2016

• 127.

Comment provided by SCI in response to a draft of this review in November 2016

• 128.

"MDA of PZQ across the 30 ICOSA districts were supported by the two partner organisations, SCI (ICOSA programme) and RTI (ENVISION programme), responsible for supporting SCH treatment in the country. ICOSA supported delivery in80 sub-counties and ENVISION in 47. Since the drug delivery may vary between the programmes, and thus potentially affect coverage, it was decided that stratification would be by the partner programme who supported the delivery of the MDA by the MoH i.e. ICOSA and ENVISION." SCI Uganda coverage survey 2014, pg. 6.

• 129.
"We found significant differences between districts in validated coverage rates, with three out of the four districts surveyed having an overall validated coverage rate above the target of 75% set by the WHO." SCI Côte d'Ivoire coverage survey 2014, pg. 3.
• 130.

Tohon et al. 2008. In 2014, SCI sent us a more recent report, SCI Niger panel study 2011. SCI Niger panel study 2011 is our only source of data on the second to fifth year followups. This analysis excludes three of the eight schools that were originally in the study as well as the 56% of participants lost to follow-up in the remaining five schools. Participants who were followed up for some years but lost to follow-up by the end of the study are completely excluded rather than being included in a separate analysis of the earlier follow-ups. The 3 schools were apparently dropped because they were not surveyed in some years:

• "Of these eight sentinel sites, five had data available in all six years of the study up to 2010." SCI Niger panel study 2011, pg. 19.
• "455 out of 1024 (44%) children recruited at baseline from November 2004 to April 2005 were successfully followed up for the full duration of the 6-year sentinel site monitoring." SCI Niger panel study 2011, pg. 25.

For this reason, we feel that the results from SCI Niger panel study 2011 are hard to interpret, and we don't present them here, relying instead on Tohon et al. 2008.

• 131.

We have seen two reports on the Burundi study, Styles 2011 and Koukounari 2011, which use different methods of analysis and included different numbers of participants. Which individuals they included in their analyses is not always clear, however the fact they report similar results for prevalence provides some evidence that the results are not highly dependent on these choices. (Both Dr. Koukounari and Dr. Styles are statisticians who formerly worked at SCI.)

• Pilot study: Styles 2011 and Koukounari 2011 have strengths and weaknesses in defining the sample for the pilot study. Styles 2011 includes a much larger number of individuals (Styles 2011, pg. 3, Figure 1b compared to 710 in Koukounari 2011, pg. 7, Figure 2). However, it is unclear whether the individuals in the follow-up were all in the original cohort or whether some were added to the sample later. The two reports indicate different numbers of students included in the study and retraced at each followup. We have seen two explanations for the differences:
(1) "Dr. Koukounari only included students who were in first grade during the first year of the study and who were successfully surveyed every year of the study. In addition to the children counted by Dr. Koukounari, Dr. Styles included students who entered first grade and were added into the study in subsequent years, as well as students who were missing data from some years. Each of these strategies for data analysis has benefits and drawbacks. SCI initially planned to do a cross-sectional evaluation of sixth grade students every year, because each year the current sixth grade class would have received more rounds of treatment over the course of elementary school than the previous year. SCI did not complete this plan, but Dr. Koukounari included the data from the sixth grade students in the baseline data. Dr. Styles did not include this data." GiveWell's non-verbatim summary of a conversation with Giuseppina Ortu on June 20, 2014.
(2) "In addition to the longitudinal studies at each follow-up newly recruited children were added to these surveys. At 1st follow-up (2008) 2288 newly recruited children were added to these surveys with range age: 6-21 years old and median age: 12 years old. Of these 2288, only 210 i.e. (9.18 %), were of age 6 and eligible to be included in the specific cross sectional data analysis. At 2nd follow-up (2009) 2311 newly recruited children were added to these surveys with range age: 5-20 years old and median age: 11 years old. Of these 2311, only 160 i.e. (6.92 %), were of age 6 and eligible to be included in this specific data analysis. Finally, at 3rd follow-up (2010) 2224 newly recruited children were added to these surveys with range age: 6-20 years old and median age: 12 years old. Of these 2224 only 189 i.e. (8.50 %) were of age 6 and eligible to be included in this specific data analysis." Koukounari 2011, pg. 6. Koukounari 2011 notes that it only includes the 20% of participants in the pilot study who were tracked through all follow-ups: "Finally at 3rd follow-up (2010) there were 713 children successfully followed-up (i.e. follow-up rate=19.71%). Longitudinal analyses for the 4 years are presented in the next pages for these 713 children." Koukounari 2011, pg. 6.
• Other schools: Koukounari 2011 claims that 5,700 participants were recruited at baseline: "At baseline (2008) there were recruited 5700 children while the follow-up rate one year later was 53.42 % (3045/5700)." Koukounari 2011, pg. 16. Styles 2011 pg. 13, Table 8 claims there were 3,781 participants recruited at baseline. SCI later told us that this may be because Koukounari 2011 included data from a group of students who were surveyed for a concurrent cross-sectional study, which was not completed: "SCI initially planned to do a cross-sectional evaluation of sixth grade students every year, because each year the current sixth grade class would have received more rounds of treatment over the course of elementary school than the previous year. SCI did not complete this plan, but Dr. Koukounari included the data from the sixth grade students in the baseline data. Dr. Styles did not include this data." GiveWell's non-verbatim summary of a conversation with Giuseppina Ortu on June 20, 2014. Both studies include a similar number of participants at the first follow up: "At baseline (2008) there were recruited 5700 children while the follow-up rate one year later was 53.42 % (3045/5700)." Koukounari 2011, pg. 16; Styles 2011 pg. 13, Table 8 shows about 3030 students were included in the first year follow-up analysis.
• 132.

"The baseline impact survey was carried out in March 2012 with the 1st follow (FU1) up being done in March 2014 prior to the mass drug administration in April 2014. This report summarises and discusses the results from the 2nd follow-up survey (FU2) which was carried out in the 22 sentinel schools in the districts of Balaka,Blantyre, Chiradzulu, Lilongwe, Mwanza, N. and S. Mzimba, Neno, Ntcheu and Ntchisi in March 2015." SCI Malawi impact study – second follow up, pg. 3.

• 133.
• We have seen reports on a baseline impact survey from 2012 (SCI Liberia panel study baseline report) and one follow-up survey from 2013 (SCI Liberia impact survey follow up recommendations report 2013) and (SCI Liberia impact survey dashboard 2012-13).
• Implementation of the follow-up survey as described in SCI Liberia impact survey follow up recommendations report 2013:
• "The survey aimed to revisit all of the schools that were visited in 2012 for the baseline survey to determine changes in prevalence and intensity over time. The schools were randomly selected at baseline and the sampled children within each school were also randomly selected at baseline, with stratification by gender and grade." Pg 3.
• "There were some difficulties in matching pupils to schools, and also matching schools between years. This was because the school identity numbers became muddled making matching not possible. This was fixed by going back to the paper records to determine the data associated with each school." Pg 4.
• "Eleven of the baseline schools (with code 1, 7, 9, 16, 17, 18, 20, 23, 24, 25, 28) could not be re-visited in 2013 and were substituted by schools as close as possible. Three of these new schools (code 39, 41, 48) were deemed to be too far away from the corresponding baseline schools to serve as their follow up and were added to the analysis as independent new schools." Pg 4.
• "The original protocol was originally designed as a ‘cohort’ study where the same children are surveyed repeatedly across a number of years. Issues with identification numbers meant that children could not be matched between the years and consequently we analysed the data as a cross-sectional study. Any future surveys of these schools in Liberia will be cross-sectional and SCI has moved away from cohort studies across all its programmes. In addition, as time that has passed since the original baseline study in 2012 many of the original children surveyed will no longer be at school." Pg 4.
• 134.

Kabatereine et al. 2007

• 135.
• 136.

GW: "In our current review, when discussing prevalence and intensity sentinel site surveys, we write, 'It is our understanding that, in the Niger, Burundi, and Malawi studies, study participants received treatment in the same manner as other children in the country, and thus that those studies reflect the performance of the national MDAs.' Would it be accurate to include the Liberia study in the statement above?
Fiona Fleming: "Yes it would, participants in all these surveys receive treatment as part of the national programme and not at the time of the survey. Participants only received treatment in surveys in Uganda in the first 2 years back in 2003 and no surveys have treated participants since that time."
Fiona Fleming, email to GiveWell, October 11, 2016

• 137.
• 138.
• Niger: “Praziquantel (using dose-pole corresponding to 40 mg/kg) and Albendazole (400 mg) were given to the target population regardless of infection status, during the mass drug administration campaign that took place 3–4 weeks after the surveys were conducted.” Tohon et al. 2008, pg. 3. “A total of 89% of the initial sample group were re-examined one year after baseline data collection and the first round of treatment with praziquantel and albendazole.” Tohon et al. 2008, pg. 4.
• Burundi pilot: “At baseline (2007) there were recruited 3616 children. At 2008 the 1st follow-up took place where 1188 children were retraced since baseline (i.e. follow-up rate=32.85 %). At 2nd follow-up (2009) there were 1004 children successfully followed up since baseline (i.e. follow-up rate=27.77%). Finally at 3rd follow-up (2010) there were 713 children successfully followed-up (i.e. follow-up rate=19.71%). Longitudinal analyses for the 4 years are presented in the next pages for these 713 children.” Koukounari 2011, pg. 6.
• Burundi other schools: “At baseline (2008) there were recruited 5700 children while the follow-up rate one year later was 53.42% (3045/5700).” Koukounari 2011, pg. 15.
• Malawi: “A longitudinal survey design requires baseline data collection from schools prior to the initiation of large-scale distribution of praziquantel and albendazole or mebendazole through the school-based platform. Follow up surveys will be conducted immediately prior to subsequent rounds of treatment for the life of the programme to monitor the impact of the health intervention.” SCI Malawi panel study, pg. 3. “During the baseline survey, cohorts of 125 children from Standards 1, 2 and 3 (aged approximately 6, 7 and 8 years) were randomly selected in each of the schools and enrolled into the study. [...] This group of selected children, now in standards 2, 3, and 4, as well as a new group of 40 Standard 1 children, were re-tested to measure the same indicators during the 1st follow-up.” SCI Malawi panel study, pg. 4.
• Liberia: "The original protocol was originally designed as a ‘cohort’ study where the same children are surveyed repeatedly across a number of years. Issues with identification numbers meant that children could not be matched between the years and consequently we analysed the data as a cross-sectional study. Any future surveys of these schools in Liberia will be cross-sectional and SCI has moved away from cohort studies across all its programmes." SCI Liberia impact survey follow up recommendations report 2013, Pg 4.
• For all four studies, the methodology does not discuss a control group, and with context, it is sufficiently clear that there was not one.
• 139.
• "This survey year saw a switch from a longitudinal survey design to a cross-sectional design which occurred following internal SCI reviews of the data and issues arriving from field surveys. The change in survey design led to the ages of children included in the study to be altered slightly to allow for like for like comparison over time and to capture those with the highest burden of infection." SCI Malawi impact study – second follow up, pg. 3.
• "The original protocol was originally designed as a ‘cohort’ study where the same children are surveyed repeatedly across a number of years. Issues with identification numbers meant that children could not be matched between the years and consequently we analysed the data as a cross-sectional study. Any future surveys of these schools in Liberia will be cross-sectional and SCI has moved away from cohort studies across all its programmes." SCI Liberia impact survey follow up recommendations report 2013, Pg 4.
• 140.

SCI notes that because children in a control group would be tested for infection, ethical guidelines would require that those found to be infected receive treatment and thus would no longer serve as controls.

• 141.
Sources for the data in the tables:
• 142. “Before treatment, the overall prevalence of S. haematobium infection was 75.4% of the 1,642 enrolled children...One year after a single-dose praziquantel treatment (administered using the WHO PZQ dose pole) co-administered with albendazole (400 mg single dose) for deworming, the prevalence of S. haematobium infection was 38%.”
Tohon et al. 2008, Abstract.
• 143.
• "Before treatment...21.8% of children excreted more than 50 eggs/10 ml urine." Tohon et al. 2008, Abstract.
• "The overall prevalence of S. haematobium infection was 38% and 4.6% of children had heavy-intensity infections; only three (4.6%) among the latter excreted more than 500 eggs/10 ml." Tohon et al. 2008, pg. 4.
• 144. "S. mansoni infection was observed only in 2 schools: Sabon Birni (3%) and Sanguile ́ (1.1%)." Tohon et al. 2008, pg. 3
• 145. "Hookworm infection was observed in 3 schools; Sabon Birni, where the prevalence was 18.8 and in 2 other villages were the prevalence was 0.6%. Hookworm infection was not observed in the schoolchildren of the 5 other villages." Tohon et al. 2008, pg. 3
• 146. Alan Fenwick, phone conversation with GiveWell, November 28, 2011.
• 147. Styles 2011, Table 2 pg. 2. The same means seem to be presented in Figure 1, pg. 3.
• 148. Eggs per gram. All epg data are the average over all participants, including those not infected.
• 149. Koukounari 2011, Figure 6, pg. 10.
• 150. Styles 2011, Table 3, pg. 4.
• 151. Koukounari 2011, Figure 6, pg. 10.
• 152. Alan Fenwick, phone conversation with GiveWell, November 28, 2011.
• 153. Styles 2011, Table 9, pg. 15.
• 154. Koukounari 2011, Figure 21, pg. 20. Note that the values are only visible in the Word version of the document.
• 155. Styles 2011, Table 10, pg. 16.
• 156. Koukounari 2011, Figure 21, pg. 22.
• 157. SCI Malawi impact study – second follow up, Table 3, pg. 11, columns for 6-8 year olds only.
• 158. SCI Malawi impact study – second follow up, Table 3, pg. 11. The first follow up report stated that there were no heavy infections at baseline:

We don't know the reason for the change in results.

• 159. 2.2% at baseline to 0.0% at one year to 1.5% at two years. SCI Malawi impact study – second follow up, Table 3, pg. 11, columns for 6-8 year olds only.
• 160. 0.2% at baseline to 0.0% at both one and two years. SCI Malawi impact study – second follow up, Table 3, pg. 11, columns for 6-8 year olds only.
• 161. SCI Malawi impact study – second follow up, Table 3, pg. 11, columns for 6-8 year olds only.
• 162. SCI Malawi impact study – second follow up, Table 3, pg. 11 columns for 6-8 year olds only.
• 163. Decrease in prevalence statistically significant (p<0.001) SCI Liberia impact survey dashboard 2012-13, Pg 1.
• 164. Decrease in prevalence statistically significant (p=0.014) SCI Liberia impact survey dashboard 2012-13, Pg 1.
• 165. Decrease in prevalence statistically significant (p<0.001) SCI Liberia impact survey dashboard 2012-13, Pg 1.
• 166.
• 167. Decrease in prevalence statistically significant, but p-value not reported SCI Liberia impact survey dashboard 2012-13, Pg 1.
• 168. "All infections were light infections." SCI Liberia impact survey dashboard 2012-13, Pg 1.
• 169.
• Niger: "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. “The very low prevalence of soil-transmitted helminth infection is in accordance with previous observations made in Niger [32] and in 2 other African countries, Mali and Chad [22,33], areas that are subjected to climatic conditions comparable to the most inhabited regions of Niger.” Tohon et al. 2008, pg. 5.
• Malawi: No Ascaris or Trichuris infection reported. SCI Malawi impact study – second follow up, Table 3, pg. 11, columns for 6-8 year olds only.
• 170.
Results from Styles 2011. We report "as measured" results for Burundi; SCI also reports model results.
Baseline Year 1 Year 2 Year 3 Year 4
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% -
• 171.
• 172.
• Niger:
• "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.
• 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]." Anna Phillips, SCI Country Program Manager for Burkina Faso and Niger, email to GiveWell, October 13, 2011.
• Burundi pilot survey: “More precisely, the 12 schools were chosen based on 3 zones-believed at the time that they would have the majority of NTDs. 4 schools were selected randomly so that they represent the ‘STHs +Schisto +oncho’ zone (these were Musenyi, Nyamibu, Munyika, Rukinga); then another 4 schools were selected randomly so that they represent the ‘STHs +oncho’ zone (Mirombero, Kizuga, Ruzibira, Mudende) and finally 4 schools were selected randomly so that they represent STHs only endemic areas (Gatwe, Ruko, Condi, Gitobo). Such decisions were based on available historic data. Thus, SCI Programme Manager advised not to stratify the statistical analysis by province and so such results (i.e. stratification by province) are not presented anywhere in this report.” Koukounari 2011 pg. 6.
• Burundi other schools: it appears that schools were selected to be representative, though this is not fully clear in the reports we have seen.
• Styles 2011 says, "The selection of schools was done randomly from the non-pilot provinces; taking into account 11 separate ecological zones." pg. 13.
• Koukounari 2011 says, “At baseline (2008) there were recruited 5700 children while the follow-up rate one year later was 53.42% (3045/5700). For these set of studies as they were designed to cover almost all of the country, it is worthwhile to also examine stratifications of analyses by district and such results are also presented in the following subsections. However, in most of the districts the children were coming only from 1 school (see relevant graphs for district whenever n<200; when this is the case then this is only 1 school per district and thus results should be treated there with caution and programmatic decisions to be taken with reservations). Whenever/wherever this is the case, results should be interpreted with caution as just 1 school would be quite ‘risky’ to represent inference/decisions for a whole district.” pg. 16.
• Malawi: The schools seem to have been selected in a way that makes them representative of districts with moderate to high prevalence, which are those districts that receive annual treatment (low prevalence districts receive more limited treatment). The schools were selected only from districts found to have moderate schistosomiasis prevalence in SCI's mapping: "Method of sentinel site selection: SCI’s protocol is to monitor only in those districts where prevalence of schistosomiasis is moderate or high i.e. SCI does not monitor in non-endemic or low prevalence districts where a full control program is not implemented. All districts except Mzuzu City surveyed in the mapping in February 2012 were determined to have moderate prevalence of S. haematobium, and consequently all districts except Mzuzu City were included in the selection of sites to be monitored for this species (see Table 1). S. mansoni infection was more focal and only present at moderate prevalence in Chiradzulu, Blantrye Rural, Lilongwe City and Lilongwe Rural East. Following district stratification by S. mansoni infection, such that the number of schools selected for S. mansoni monitoring, reflected the frequency of moderate risk areas in the monitoring areas, 22 schools were selected that would be monitor S. haematobium infection with a subset of 9 schools which also monitor S. mansoni infection. Due to the low prevalence of STH’s, STH infection was only monitored in those schools where the Kato-Katz slides were already prepared for S. mansoni." SCI Malawi panel study, pg. 4; SCI's senior biostatistician told us that the sampling method would produce a sample representative of the treated districts. Michelle Clements, SCI Senior Biostatistician, conversation with GiveWell, October 15, 2014.
• Liberia: Selection process for sentinel sites not described in SCI Liberia panel study baseline report
• 173.
• Niger: "A total of 89% of the initial sample group were re-examined one year after baseline data collection and the first round of treatment with praziquantel and albendazole." Tohon et al. 2008, pg. 4.
• Burundi: Pilot schools: 33%: “Without taking into consideration the parasitological exams, at baseline (2007) there were recruited 3616 children. At 2008 the 1st follow-up took place where 1188 children were retraced since baseline (i.e. follow-up rate=32.85 %).” Koukounari 2011. 50%: Styles 2011 pg. 1, Table 1. Other schools: 53%: “At baseline (2008) there were recruited 5700 children while the follow-up rate one year later was 53.42 % (3045/5700).” Koukounari 2011, pg. 16. 80%: Styles 2011 pg. 14, Table 8. The discrepancy between the populations included in Koukounari 2011 and Styles 2011 is described in more detail below.
• Malawi: "Overall, the drop-out rate was higher than expected for both species of schistosomiasis. 48% of those pupils monitored for S. haematobium dropped out the study between baseline and follow-up, and 64% of those pupils monitored for S. mansoni dropped out of the study." SCI Malawi panel study, pg. 17. Since the most meaningful results from Malawi were for Schistosoma haemotobium, we focus on the follow-up rate for that species.
• Liberia: Although the Liberia study was originally designed as a cohort study, the survey implementers switched to a cross-sectional methodology at the first follow-up: "The original protocol was originally designed as a ‘cohort’ study where the same children are surveyed repeatedly across a number of years. Issues with identification numbers meant that children could not be matched between the years and consequently we analysed the data as a cross-sectional study." SCI Liberia impact survey follow up recommendations report 2013
• 174.
• 175.
• "Baseline Impact M&E surveys took place in 38 schools in three provinces of Liberia (Bong, Nimba, Lofa) in Nov-Dec 2012, as part of the ICOSA programme." SCI Liberia panel study baseline report, Pg 3.
• SCI Liberia impact survey follow up recommendations report 2013:
• "Eleven of the baseline schools (with code 1, 7, 9, 16, 17, 18, 20, 23, 24, 25, 28) could not be re-visited in 2013 and were substituted by schools as close as possible. Three of these new schools (code 39, 41, 48) were deemed to be too far away from the corresponding baseline schools to serve as their follow up and were added to the analysis as independent new schools." Pg 4.
• Survey recommendations table, Pg 6:
• "School identity numbers were not always correct."
• "Many of the GPS coordinates were not recorded correctly."
• "Schools closed between years of data collection."
• 176.

"An initial analysis of approximately 2,000 individuals in selected sentinel sites has demonstrated an over 50% reduction in infection markers (both prevalence and intensity) following two rounds of treatment. Infection with either species of schistosomiasis has fallen from 19.8% at baseline to 8.3%, following two rounds of treatment, with less than 4% now harbouring heavy infections (and who are those most likely to develop severe morbidity)(Table 2)." Summary Technical Report: Schistosomiasis Control in Yemen (July 2014), pg. 4. Table with results for S. haematobium and S. mansoni is on pg. 5.

• 177.

"As part of this, a cohort of 8,000 individuals (6,500 school-aged children and 1,500 adults) from 36 representative districts across the country were sampled for demographic and parasitological markers at baseline prior to intervention and following treatment. An initial analysis of approximately 2,000 individuals in selected sentinel sites has demonstrated an over 50% reduction in infection markers. [...] To confirm these results, and to determine whether they are reflected elsewhere, a full round of impact evaluation in all 36 districts will be implemented in September 2014 prior to the next treatment campaign." Summary Technical Report: Schistosomiasis Control in Yemen (July 2014), Pgs 4-5.

• 178.

"At baseline in 2010, prior to the first treatment campaign, a small-scale mapping survey was carried out in in areas without previous mapping data. The results from these surveys (120 schools in 9 governorates) were combined with mapping surveys conducted from 2002-2010, along with ecological information relevant to schistosomiasis transmission obtained from the literature." Summary Technical Report: Schistosomiasis Control in Yemen (July 2014), pg. 3.
Results from "2010" include 333 districts, which seems to indicate that only a portion of this data (120 of 333 districts) was collected in 2010 and the remainder was collected several years before. Mapping of Schistosomiasis and Soil-transmitted helminthiasis in Yemen, pg. 42.

• 179.

"After 2-3 rounds of treatment a prevalence re-mapping survey was conducted to map the distribution of infection and provide an overview of the programme’s impact on NTD prevalence from baseline levels in 2010, as well as set the control approach for upcoming years of the programme." Mapping of Schistosomiasis and Soil-transmitted helminthiasis in Yemen, pg. 9. Full results on pg. 42, Table 13.

• 180.
• 181.

LSTM Mozambique trip report (May 2015)

• "With authorization of Dra Olga, I am sharing with you the EXCEL file with results (not the databases), and she reminds me that the data belongs to MISAU." pg. 2.
• "The Team reviewed the results for 2012-2013-2014 and they confirmed that only 2 sentinel sites were strictly comparable for 2013-2014 (Mecula and Mandiba) and none of the Sentinel Sites for 2015 are going to be comparable to 2014. They decided to review the location of the new sentinel sites, to be able to have a better and stronger comparisons." pg. 2.
• 182.

"The research summarised in this paper is based upon field-work funded by the Schistosomiasis Control Initiative (SCI), Imperial College, under the auspices of the Bill and Melinda Gates Foundation. [...] We are grateful to Professor Alan Fenwick, director of SCI, for his unfailing support, and his encouragement of our work, even when our findings made uncomfortable reading. We are also grateful to other staff from SCI, some of whom have disagreed with our analysis, but who have continued to provide assistance, including Lynsey Blair, Fiona Fleming and Artemis Koukounari." Allen and Parker 2011, pg. 114.

• 183.
We examined the references from Parker, Allen, and Hastings 2007, Allen and Parker 2011, Parker and Allen 2011, Allen and Parker 2012, and Parker and Allen 2014, Muhumuza et al. 2013 and Standley et al. 2009. We searched on Google Scholar for "niger schistosomiasis prevalence," “niger deworming uptake," "niger praziquantel uptake," "Burundi schistosomiasis prevalence," "Burundi deworming uptake," "Burundi praziquantel uptake," "schistosomiasis prevalence Africa," "deworming uptake Africa," "praziquantel coverage Africa," "Uganda schistosomiasis prevalence," and "Uganda praziquantel uptake."
• 184.
For example:
• SCI Director Alan Fenwick and SCI-affiliated researcher Narcis Kabatereine were coauthors on Brooker et al. 2005 and Standley et al. 2010.
• Narcis Kabatereine, SCI Africa Capacity Building Adviser, was a co-author on Standley et al. 2009.
• Lynsey Blair, SCI Senior Project Manager, was a coauthor on Stothard et al. 2013.
• Knopp et al. 2009 was funded in part by SCI: "Financial support: This study received funding from the Swiss National Science Foundation (projects PPOOB–102883 and PPOOB– 119129), the Natural History Museum (supported through The Health Foundation,United Kingdom),the World Health Organization (OD/TS- 07-00331), the European Union (FP6 STREP CONTRAST project, contract 032203), and the Schistosomiasis Control Initiative." pg. 1077.
• 185.
See the spreadsheet for details and citations.
• 186.
Wikipedia entry for Unguja
• 187.

"The study was designed specifically to target schools on an ad hoc basis as an 'ambush' strategy, to prevent visiting only schools which are commonly surveyed or well-known by local health officers. By doing so, some of the more overlooked schools may have been sampled here, which correspondingly had lower incidences of treatment, irrespective of their prevalence levels." Standley et al. 2009, pg. 50.

• 188.

SCI Côte d'Ivoire panel study baseline report, pg. 7.
• 189.

Sources for this data:

Bleakley 2007, Croke 2014, and Miguel and Kremer 2004, are discussed in greater detail here.

The WHO definition of "heavy" infection, which seems to have been used across all of the studies, is given in this table:

• 190.

"In Malawi, urine volumes were not accurately recorded thus it is possible that data is indicating lower overall prevalence in sentinel sites. ICOSA will be undertaking further data analysis to quantify underestimates using mapping data from 2012 and baseline data in appropriate districts." SCI report to DFID (October 2013), pg. 15.

• 191.

"The NTD programme in Zanzibar has recently completed the 3rd round of MDA." SCI report to DFID (October 2013), pg. 17.

• 192.
• Our intervention report discusses this briefly.
• Other conversations and observations have reinforced our impression that administering deworming drugs is fairly straightforward.
• The WHO factsheet on STH: "The WHO recommended medicines – albendazole (400 mg) and mebendazole (500 mg) – are effective, inexpensive and easy to administer by non-medical personnel (e.g. teachers)." WHO STH factsheet
• 193.

"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.

• 194.
• "In Tanzania matters came to a head in places around Morogoro in 2008. Distribution in schools of tablets for schistosomiasis and soil-transmitted helminths provoked riots, which had to be contained by armed police. It became a significant national incident, and one of the consequences has been the delay in Tanzania adopting a fully integrated NTD programme, and the scaling back some existing drug distributions." Allen and Parker 2011, pg. 109.
• "From these reports a number of problems with the MDA were raised which included fear of side effects from the tablets, particularly following the mass hysteria and death in Blantyre and Rumphi respectively and may explain some of the geographic heterogeneity seen. Furthermore most districts reported that MDA occurred after standard 8 students had finished exams and left school, and due to having inadequate resources for drug distribution...The side-effects incident in Blantyre and death in Rumphi had a large effect on districts and with many district reports stating that after the incidence many families refused to participate." SCI Malawi coverage survey 2012 Pgs 5, 21.
• 195.
• 196.
• 197.

SCI planned SCH treatment numbers by country by year (October 2015)

• $0.30 comes from the "0.25 cents per treatment" plus an additional 20% for "Central cost required (normally 20%)" since these assumptions are applied to most programs from April 2016 through December 2019. • One exception is for Nigeria, where SCI estimates$0.40 per treatment and an annual central cost of $300,000 (roughly$0.50 per treatment from April 2016 - December 2019).
• For comparison, our estimate of SCI's cost per treatment, excluding drugs and in-kind government contributions, based on SCI's recent programs, is $0.53 per treatment (a portion of our total estimate of$1.26, with the remainder accounting for drug costs and government contributions).
• 198.
• SCI budget 3 options October 2016 Redacted, "Implementation" sheet, cell D25. Currency conversation by Google on November 2, 2016.
• To estimate its in-country cost per treatment for each of its country programs, SCI used its 2015-16 budgeted cost per treatment if SCI had previously worked in the country. For countries SCI would like to expand to, it has used an estimate of £0.23 per treatment, from a forthcoming paper by Fitzpatrick et al. See SCI treatment gap forecast 2016, "Funding gap analysis" sheet, comment on cell N5.
• 199.
• "Happy to share cost per treatment estimates with you for several of our countries – Malawi £0.16, and Cote d’Ivoire £0.15. This includes all in-country related costs e.g. in-country expenditure and central level procurement." Fiona Fleming, email to GiveWell, March 3, 2016
• Converted to USD, the cost per treatment estimate for Malawi is $0.23 and the estimate for Côte d'Ivoire is$0.22.
• As of May 24, 2016, Google states that £1 is worth $1.46 • 200. This understanding is from undocumented conversations with SCI from early in our investigation of SCI. • 201. • "Ordering of ALB is carried out by the Ministry Of Health Programme Manager for Lymphatic Filariasis (LF) Elimination. Previously the ALB had been used for the LF program and stocks had not been replenished in time for the SCH campaign which contributed to the low ALB coverage. Treatments were also carried out in conjunction with the child health days which may have caused confusion with who was eligible for treatment and prioritising the younger children. Furthermore due to the complexities of distributing PZQ compared to ALB there may have been more focus during the training and distribution on reporting and dispensing PZQ." SCI Malawi coverage survey 2012, Pgs 20-21. • "Miscommunication between the national Program Managers for lymphatic filariasis and schistosomiasis led many districts to believe that the ALB which they received should have been made available for the MDA but was not used." SCI Malawi coverage survey 2014, pg. 37. • "Unlike in Sub-Saharan Africa, where SCI distributes praziquantel for schistosomiasis and albendazole for STH in equal amounts, Sudan has many areas where schistosomiasis is a problem but STH are not, and SCI distributes more praziquantel than albendazole. However, a small number of areas including Kassala and eastern Sennar have STH and no schistosomiasis. In these areas, the Ministry distributes more albendazole than praziquantel." GiveWell's non-verbatim summary of a conversation with Alan Fenwick and Najwa Al Abdallah, September 14, 2015. • "Albendazole (ALB) was also distributed in some of the 30 districts under different partners, however ICOSA programme did not support its procurement, distribution or data collection in 2013/2014." SCI Uganda coverage survey 2014, pg. 4. • Schistosomiasis Control Initiative, conversation with GiveWell, September 6, 2016: • In Ethiopia, the SCI-supported program has delivered STH-only treatments in some districts where schistosomiasis prevalence was low. • SCI told us that its reported treatment numbers were total numbers of schistosomiasis treatments. • 202. We explain why we take this approach in this blog post. • 203. Alan Fenwick, SCI Director, email to GiveWell, November 24, 2014 • 204. See this spreadsheet for details. Note that this is not an ideal comparison because reported coverage rates are calculated from reported treatment numbers and an assumed target population. We would like to adjust the reported treatment numbers, rather than the reported coverage rate, but don't have the data to do so. It is possible that the difference in the reported coverage rate and the coverage rate from the coverage surveys is due to errors in the numbers used for the target population rather than the reported treatment numbers. • 205. We used Leslie et al. 2011, a study of the costs of a SCI-funded deworming program in four districts of Niger in 2004-2006, to estimate non-SCI contributions to SCI's deworming programs. Three of the authors of the study were affiliated with SCI. 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: “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, pgs. 2-3. The study is of a single country, looked at a program that was carried out years ago, and the program may differ in some ways from current programs, 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. Two examples of how the area where the study was conducted 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. 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). • ”Programme cost: 75% • Government cost: 18% • International tech. support: 7%” Leslie et al. 2011, pg. 5, Table 2. It is our understanding from the paper and our past conversations with SCI that "programme expenditure" was fully funded by SCI. We believe that "international tech. support" refers to SCI staff time and travel costs; we're somewhat less confident in this than in our understanding of “programme expenditure.” 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: “The total economic cost per treatment was $0.58. This includes programme, government and international costs.” Leslie et al. 2011, Author Summary. 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.

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.

• 206.

"Imperial College pays the majority of SCI’s overhead costs, including rent and utilities, and offers free services such as legal assistance. Imperial’s legal department prepares all of SCI’s contracts. The college also covers some risks and liabilities that SCI may face. In return, SCI pays Imperial 6% of its funding from DFID, but this does not cover the full cost of the services that SCI receives. The 6% of the DFID funding that is paid to the college is not included in SCI’s budget, but is included in the total size of the DFID grant. SCI may perform an analysis of the costs covered by Imperial College, but this is not currently a high priority." GiveWell's non-verbatim summary of a conversation with Wendy Harrison and Najwa Al Abdallah on September 8, 2015, pg. 4.

• 207.

“Program costs can vary. For example, in Sudan, it can be expensive to transport drugs. In Darfur, it might cost about 40-50 pence per treatment, while in Khartoum it could be 10 pence per treatment.” Alan Fenwick, SCI Director, conversation with GiveWell, October 15, 2014.

• 208.

"SCI budget summary 1 April 2016 to 31 March 2017 in GBP" SCI allocation table 2016-2017, "Summary" sheet.

• 209.

Najwa Al Abdallah, email to GiveWell, May 18, 2016

• 210.
• SCI L-account April-October 2016
• SCI IC Trust statement July 2016 Redacted
• Wendy Harrison, email to GiveWell, October 11, 2016:
• "Income received- L-account from 1 April to 10 Oct. 2016= GBP 1,477,696
Income received-IC Trust from 1 April to 31 July 2016= GBP 225,532"
• "We receive the IC Trust statement every quarter of Imperial College fiscal year; next report is due in Nov. for the period Aug-Oct."
• As of October 19, 2016, Google states that 1 GBP = 1.23 USD.
• 1.23 * (1,477,696 + 225,532) = $2,094,970 • Additionally, GiveWell made a transfer of$81,347.32 to SCI in September 2016 (internal records) which had not yet reached SCI's L-account by October 2016. Including this funding, we estimate that SCI's total cash on hand is $2,176,317 ($2,094,970 + $81,347 =$2,176,317).
• Of the 1,477,696 GBP received in the L-account between April 1 and October 10, 2016, SCI's records indicate that 984,445 GBP was due to GiveWell. This amount includes both large transfers from GiveWell and individual donations. We have not fully vetted this estimate. SCI L-account April-October 2016
• We have checked that SCI received all of the large transfers from GiveWell that we expected it to receive during this time period. Dr. Wendy Harrison and Najwa Al Abdallah, conversation with GiveWell, September 27, 2016 and internal calculations.
• The total of 984,445 GBP (1.23 * 984,445 = ~$1.21 million USD) includes a July 2015 transfer from GiveWell of that reached SCI in April 2016. Najwa Al Abdallah, email to GiveWell, October 19, 2016 • According to internal calculations, we believe that the total amount of GiveWell-influenced funding held in the L-account as of October 10, 2016 (984,445 GBP / ~$1.21 million USD) also includes a transfer of funds from GiveWell in February 2016 of $651,292, which reached SCI in April 2016. • Our understanding is that funding held in the Imperial College Trust ("ICT") is all unrestricted funding, and that GiveWell-influenced funding is not directed to the Imperial College Trust, so we expect that all of the funding (235,532 GBP) received at the Imperial College Trust between April and July 2016 is not GiveWell-influenced. Schematic of SCIs Income Sources and Imperial Account structure Apr 2016 • 211. • Sum of funds committed from DFID, UBS, CIFF, END Fund, and MRC for 2017-18 is 5,284,958 GBP. SCI budget 3 options October 2016 Redacted, "Income Analysis" sheet, cell C10. • As of October 19, 2016, Google states that 1 GBP = 1.23. • 1.23 * 5,284,958 GBP =$6,500,498
• SCI notes that, for the 315,200 GBP ($387,696) out of this total from the END Fund, "there is no signed contract with End Fund Yemen but there is a high probability to get the funds; if not then the costs of Yemen will be cut down unless we find another donor." SCI budget 3 options October 2016 Redacted, "Income Analysis" sheet, cell F6. • 212. • We base our rough estimate on the amount of non-GiveWell-influenced funding SCI has received so far this budget year (April 2016 to March 2017) and on the distribution by month of non-GiveWell-influenced funding in SCI's April 2015 to March 2016 budget year. See this spreadsheet for sources and calculations. We estimate that SCI would receive$1,402,895 in additional non-GiveWell-influenced funding before April 2017 absent a renewed GiveWell recommendation in November 2016.
• For our calculations, we assume that no GiveWell-influenced funding is directed to the IC Trust account (see Schematic of SCIs Income Sources and Imperial Account structure Apr 2016) and we exclude transfers from Imperial College Foundation to the L-account and other donations SCI marked as GiveWell-influenced in SCI L-account 2016 in our sum of total non-GiveWell-influenced funding.
• Note that SCI estimated that it would receive substantially a lower amount (~$600,000) in the rest of its budget year absent a renewed GiveWell recommendation in November 2016: • "To the IC Trust from August 2016 to March 2017: GBP 240,000 (average 30K/month) To IC: Nov 2016 to March 2017 an estimated GBP 250,000 (average 50K/month)." Najwa Al Abdallah, email to GiveWell, October 14, 2016 • As of October 19, 2016, Google states that 1 GBP = 1.23. • 1.23 * (240,000 + 250,000) =$602,700
• 213.

This is based on internal records of how much GiveWell-influenced donors gave to SCI in the last year (as of early November 2016) when SCI was on GiveWell's top charity list but was not the recommendation for marginal funding.

• 214.
• The sum of $2,176,317 (in currently available unrestricted funding),$1,402,895 (in expected unrestricted funding from donors not influenced by GiveWell), and $1,800,000 (in expected unrestricted funding from donors influenced by GiveWell but not following our recommendation for marginal donations) is$5,379,212.
• The sum of $6,500,498 (in restricted funding) and$5,379,212 (in unrestricted funding) is $11,879,710. • 215. • SCI budget 3 options October 2016 Redacted, "Implementation" sheet and "Summary" sheet. • "Scenario 1: the fundraising target for our current program. Scenario 2: adding Chad, Zimbabwe, and additional GBP 1 M for Nigeria and the additional personnel and central costs needed. Scenario 3: adding the treatments of adults (please see the separate file for the treatment numbers) and additional GBP 1 Million for Nigeria and the additional personnel and central costs needed." Najwa Al Abdallah, email to GiveWell, October 14, 2016 • 216. • SCI budget 3 options October 2016 Redacted, "Implementation" sheet and "Summary" sheet. • "Scenario 1: the fundraising target for our current program. Scenario 2: adding Chad, Zimbabwe, and additional GBP 1 M for Nigeria and the additional personnel and central costs needed. Scenario 3: adding the treatments of adults (please see the separate file for the treatment numbers) and additional GBP 1 Million for Nigeria and the additional personnel and central costs needed." Najwa Al Abdallah, email to GiveWell, October 14, 2016 • 217. • 218. • 219. • 220. See this spreadsheet, "GW estimation of funding gaps by country" sheet for calculations. • 221. END Fund, conversation with GiveWell, October 17, 2016 • 222. Schistosomiasis Control Initiative, conversation with GiveWell, October 7, 2016 • 223. Schistosomiasis Control Initiative, conversation with GiveWell, October 7, 2016 • 224. • 225. • SCI budget 3 options October 2016 Redacted, "Implementation" sheet and "Summary" sheet. • "Scenario 1: the fundraising target for our current program. Scenario 2: adding Chad, Zimbabwe, and additional GBP 1 M for Nigeria and the additional personnel and central costs needed. Scenario 3: adding the treatments of adults (please see the separate file for the treatment numbers) and additional GBP 1 Million for Nigeria and the additional personnel and central costs needed." Najwa Al Abdallah, email to GiveWell, October 14, 2016 • 226. We considered the following when deciding how to rank SCI's funding gaps by execution level: General considerations: • We compared SCI's stated room for more funding and the number of treatments it planned to support as of October 2015 for its April 2016 to March 2017 budget year to the number of treatments it planned to deliver in April 2016, when its budget for 2016-17 was finalized. SCI received less funding than its target, and planned to support roughly proportionally fewer treatments. Although the number of treatments by country varied considerably (see this supplemental spreadsheet, "Changes in SCI's plans for 2016-17 over time" sheet) the total number of treatments SCI planned to deliver remained in proportion with its earlier expectations. • For sources and calculations for the following statements, see this supplemental spreadsheet, "Retrospective analysis of 2016-17 RFMF" sheet. • In October 2015, SCI told us that it hoped to have an$16.9 million available (in restricted and unrestricted funding) for its 2016-17 budget year.
• In March 2016, SCI actually budgeted around $16.4 million to its 2016-17 budget year, around 3% less than its target. • As of October 2015, SCI roughly planned to support the delivery of 55.1 million treatments in 2016-17. • In April 2016, SCI planned to deliver 52.5 million treatments, around 5% fewer than its original target. Country-specific considerations • For many of SCI's current country programs, SCI's plans to deliver around the same number of treatments or fewer in its 2017-18 budget year as it planned to in its 2016-17 budget year (see this supplemental spreadsheet, " 2016-17 vs 2017-18 planned treatments" sheet. • For these countries (which we count as Burundi, Cote d'Ivoire, Ethiopia, Liberia, Malawi, Mauritania, Niger, Sudan, Tanzania (excluding Zanzibar), Zambia, and Zanzibar), we would expect that it's highly likely (90%) that SCI will be able to implement its programs roughly according to its current plans if it receives sufficient unrestricted funding. • For a few of SCI's current country programs (Democratic Republic of the Congo, Madagascar), SCI's current plans are to substantially scale-up the number of treatments it supports compared to planned treatment numbers from 2016-17. We expect that it is less likely that SCI will need the full amount of funding it requested for these countries, since we intuitively guess that large-scale ups are more difficult to manage and more subject to changes based on changing circumstances than country programs which are maintaining around the same number of treatments. • If it receives sufficient funding, SCI would like to expand to support programs in Chad and Zimbabwe. We have excluded Zimbabwe from our estimation of SCI's funding gap (see above). • We roughly expect that starting a new country program is more likely to be delayed than the continuation of a current country program, so we assign a smaller portion of SCI's funding gaps for new countries to our Execution Level 1 ranking. • 227. See this spreadsheet, "Summary" sheet, for details and calculations. • 228. Najwa Al Abdallah, email to GiveWell, May 18, 2016 • 229. • SCI allocated 628,024 GBP (1/12 of its total annual expenses, see cell formula) to its reserves in March 2016. "Income analysis" sheet, cell B12. • The source of this funding was the Unrestricted Imperial College account; see the cell formula in cell L4, "Summary" sheet. • 230. Najwa Al Abdallah, email to GiveWell, October 19, 2016 • 231. • 232. • 233. “In extreme circumstances, committed money could be shifted to other opportunities. For example, SCI had planned to do work in Liberia, but the Ebola outbreak has put that work on hold and so the committed funding could be reallocated.” Alan Fenwick, SCI Director, conversation with GiveWell, October 14, 2014 • 234. • ”SCI first contacted the government [in Côte d'Ivoire] and started to discuss a SCH/STH program in 2010. A civil war delayed progress because there was political turmoil, a weakened health system, and dangerous conditions. In 2012 conditions improved, and the contracts between SCI and the Ministry of Health were set up.” GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014, pg. 1. • ”Using drugs that are about to expire is a key factor used to prioritize between programs in strategic budget decisions.” Alan Fenwick, SCI Director, conversation with GiveWell, October 15, 2014. • “Factors that could affect SCI’s plans include country capacity (countries not being prepared to use planned funding or asking to expand more quickly than planned), WHO praziquantel donations (countries getting more or less drugs than expected), and new countries asking for assistance. New restricted funding could shift unrestricted funding to another use.” Alan Fenwick, SCI Director, conversation with GiveWell, October 15, 2014. • Treatment frequency is determined by mapping results: "World Health Organization (WHO) guidelines suggest different treatment frequencies depending on prevalence: • Low (1-10% prevalence): treat twice during primary school (once every 3-4 years) • Moderate (10-50% prevalence): treat every other year, and • High (prevalence over 50%): treat every year. Only 3 districts have high prevalence so the plan for next year is to treat those areas, as well as those that need treatment every other year and were not treated in 2014. Others districts have moderate or low prevalence and would be treated again in future years, following WHO guidelines." GiveWell's non-verbatim summary of a conversation with Sarah Nogaro, October 16, 2014, pg. 2. • 235. Comment provided in response to a draft of this page in June 2016. • 236. • Comparing our conversations from 2013 to what happened in 2014 provides some context. In October 2014, SCI told us that if it had received an additional £1 million (about$1.6 million) at the beginning of 2014 it would have used the money to increase the size of each country's budget by 10-20%, which would have been used to make the programs more comfortable but would not have led to more treatments. Alan Fenwick, SCI Director, conversation with GiveWell, October 15, 2014. (As of November 4, 2014, Google stated that £1 is worth $1.6.) In November 2013, SCI told us that it would likely use additional funding to fund two existing programs and to start two additional programs. Expectations as of November 2013 for how it would spend an additional$4 million:
1. Côte d'Ivoire: expected to need $400,000 and actually spent about$350,000.
2. Mozambique: expected to need as much as $3 million and actually spent$1.4 million.
3. Mauritania: expected to need $1 million and didn’t spend anything. 4. Ugandan islands: expected to need about$600,000 and didn’t spend anything.
5. The $1.75 million spent in Côte d'Ivoire and Mozambique represents about 80% of the spending. 6. Expectations as of 2013 are listed in our November 2013 review of SCI. 7. Actual spending is through mid-September 2014 from GiveWell summary of SCI finances (October 2014). • See also our discussion of budget revisions in 2015 in our August 2015 update on SCI. • 237. SCI planned SCH treatment numbers by country by year (October 2015) • 238. "In October 2015, SCI shared estimates for its April 2016-March 2017 budget year with GiveWell on target treatment numbers by country, amounts of funding available from DFID and other large donors, and the amounts of additional funding required to deliver the targeted number of treatments in each country and cover SCI's central expenditures (http://www.givewell.org/files/DWDA%202009/SCI/SCI_planned_SCH_treatment_...(October_2015).xlsx). GiveWell interpreted the estimates for SCI's projected central expenditures in the document as part of SCI's funding gap for its 2016-2017 budget year. "Documents SCI sent GiveWell in March 2016 indicate that around$1.5 million more in funding from DFID is available to allocate for SCI's 2016-2017 budget year than GiveWell had previously expected. This is because the document from October 2015 included funding available from DFID that could be allocated to in-country programmatic expenditures, but did not include the funding from DFID that SCI planned to allocate to central expenditures (included in the March 2016 documents)." GiveWell's non-verbatim summary of a conversation with Dr. Wendy Harrison, Najwa Al Abdallah, and Dr. Lynsey Blair, April 6, 2016

• 239.

WHO, Summary of global update on preventive chemotherapy implementation in 2015, pg. 456-457, Table 1.

• 240.