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Sightsavers' Deworming Program

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Sightsavers' deworming program is one of our top-rated charities and we believe that it offers donors an outstanding opportunity to accomplish good with their donations.

More information: What is our evaluation process?


Published: November 2018

Summary

What do they do? Sightsavers (http://www.sightsaversusa.org/) is a large organization with multiple program areas that focuses on preventing avoidable blindness and supporting people with impaired vision. We have only reviewed Sightsavers' work to prevent and treat neglected tropical diseases (NTDs), and, more specifically, advocating for, funding, and monitoring programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) ("deworming"); our recommendation is just for Sightsavers' work on deworming. (More)

Does it work? We believe that there is strong evidence that administration of deworming 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. Sightsavers has conducted studies, which cover most of the work that we focus on in this review, to determine whether its programs have reached a large proportion of children targeted. These studies have generally found positive results, but have some methodological limitations. (More)

What do you get for your dollar? Our best guess is that deworming is generally highly cost-effective. We estimate that children are dewormed for a total of around $0.95 per child in Sightsavers-supported programs. 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 Sightsavers works. Excluding drugs and government contributions, we estimate that Sightsavers' cost per treatment is $0.39. 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 believe that without additional funding from donors who use GiveWell's research, Sightsavers' deworming work is likely to be constrained by funding. Sightsavers has provided details of deworming programs that it could fund in 2019-2021 with up to about $11.4 million beyond what we expect it to receive. Sightsavers appears to have limited prospects for funding these programs from other sources. (More)

Sightsavers' deworming program is recommended because of:

  • The strong track record and excellent cost-effectiveness of deworming. (More)
  • Sightsavers' moderately strong process for assessing whether the MDA programs it supports are successfully reaching their intended recipients. (More)
  • Standout transparency – it has shared significant, detailed information about its programs with us.
  • Room for more funding – it can use additional funds to scale up its work on deworming.

Major open questions include:

  • Sightsavers has a limited track record of implementing deworming programs. Deworming has not been a focus or major priority for Sightsavers in the past.
  • Sightsavers is a large organization with significant unrestricted funding and fundraising capacity. (Sightsavers spends considerably more on fundraising than other charities we recommend—about 26% of overall funding and 55% of unrestricted funding, excluding gifts in kind.) It is possible that GiveWell-directed funds will cause Sightsavers to allocate less of its unrestricted funding or fundraising capacity to deworming than it otherwise would have. Sightsavers does not appear to have allocated large amounts of unrestricted funding to deworming in the past and told us that it has limited sources of restricted funding for deworming.

Our review process

We began considering Sightsavers as a potential top charity for its work on deworming in 2015. Our review process has consisted of:

  • Extensive communications with Sightsavers staff.1
  • Reviewing documents Sightsavers sent in response to our queries.
  • Visited Sightsavers' country office in Ghana during one of our 2016 site visits. Sightsavers does not support a deworming program in Ghana, but we were able to have several conversations with Elizabeth Elhassan, Technical Director of NTDs, and Sunday Isiyaku, Country Director in Nigeria and Ghana, as well as other staff.
  • Visited Sightsavers' country office in Guinea during one of our 2017 site visits. Sightsavers had recently supported a round of deworming in Guinea which was supported with GiveWell-directed funds. We met with several staff involved in the deworming program.

What do they do?

Sightsavers focuses on preventing avoidable blindness and improving the lives of those who have visual impairments.2 Sightsavers' work on NTDs accounts for roughly half of its overall program expenditure budget.3 In this review, we evaluate the deworming programs in Sightsavers' neglected tropical diseases (NTDs) portfolio, focusing in particular on the types of programs on which Sightsavers has spent and committed the funding it received due to GiveWell's top charity recommendation starting in November 2016. We refer to that funding as "GiveWell-directed funds."

Sightsavers is primarily focused on adding deworming components to the community-based NTD programs that it already supports in Africa.4 In 2017 Sightsavers used GiveWell-directed funds to add deworming MDAs to integrated NTD programs in the Democratic Republic of the Congo (DRC), Guinea, Guinea-Bissau, and in four Nigerian states, to support a deworming impact survey in Cameroon, and to initiate an integrated NTD program in Benue State, Nigeria.5 In 2018, Sightsavers expects to spend GiveWell-directed funds to continue these programs, to expand its work to an additional state in Nigeria, and potentially to provide deworming treatments in Cameroon.6 Our review focuses on these projects and to a lesser degree on Sightsavers' previous work on deworming.

The deworming programs that Sightsavers supports conduct MDAs which aim to treat the entire population of children within districts or implementation units that meet the World Health Organization (WHO)-defined minimum prevalence thresholds for MDA with deworming pills.7 In some high prevalence settings, Sightsavers supports adult treatments; Sightsavers notes that this support is in line with WHO recommendations and is at the request of governments.8 Sightsavers provides both technical assistance and funding to governments and other implementing partners in the deworming programs it supports (more).

Below, we discuss:

  • How deworming fits in with Sightsavers' other activities
  • The types of deworming programs Sightsavers supports
  • How Sightsavers selects programs to support
  • Sightsavers' role in supporting deworming programs
  • The status of Sightsavers' deworming work by country
  • A breakdown of Sightsavers' recent spending

How does deworming fit in with Sightsavers' other activities?

Background

Sightsavers was founded in 1950 to treat eye conditions in developing countries.9 It continues to focus on eliminating avoidable blindness and supporting people with visual impairments and disabilities in low- and middle-income countries;10 this focus led to its work on integrated NTD programs, particularly programs targeting those NTDs that cause blindness (onchocerciasis and trachoma).11

Sightsavers began its work on deworming programs in 2011 as part of its integrated NTD programs.12 It supports deworming programs in six countries in Africa.13

Sightsavers' integrated NTD programs

Sightsavers began to work on NTD programs in the 1950s.14 It is our understanding that Sightsavers' integrated NTD program is focused on diseases that can be treated via MDAs, primarily onchocerciasis (which can cause blindness), trachoma (which can also cause blindness), lymphatic filariasis, schistosomiasis, and STH.15

Sightsavers has told us that most NTD-focused organizations (including Sightsavers) are prioritizing treating onchocerciasis, trachoma, and lymphatic filariasis, because these diseases have been targeted for elimination in the next decade.16 Schistosomiasis and STH (both of which are treated by deworming programs) are not as highly prioritized because elimination of these diseases is not expected soon.17 Sightsavers has used GiveWell-directed funds to add deworming components to existing NTD programs and to initiate a new integrated NTD program in Benue state, Nigeria;18 Sightsavers is not currently planning new programs that only support deworming in countries where it does not already work.19

What types of deworming programs does Sightsavers support?

There are several different ways to implement mass drug administrations (MDAs). In a community-based MDA, a trained volunteer community drug distributor (CDD) travels from household to household distributing treatments over a period of several days or weeks, or distributes treatments from a fixed location in the community.20 In school-based MDAs, teachers and volunteer community drug distributors are trained to provide treatments to children during normal school hours.21

In many deworming MDAs that Sightsavers supports, it supports a combination of school-based and community-based MDAs. Sightsavers told us that programs are planned to avoid children being treated in both their schools and communities. In some cases, school- and community-based MDAs do not overlap geographically. In locations where school enrollment is low, both methods may be used in the same area and children may be marked in some way (such as on a fingernail) or asked during community-based treatment if they already received treatment.22

Note that two of the other three top charities GiveWell recommends that support deworming programs (the Schistosomiasis Control Initiative and Deworm the World Initiative) primarily support school-based MDA programs. More about Sightsavers' views on the advantages and disadvantages of various types of MDAs can be found in our 2016 site visit notes.

How does Sightsavers select deworming programs to support?

Before supporting a new deworming program, Sightsavers told us that it considers:23

  • The prevalence and intensity of schistosomiasis and STH in the area in which the program would occur.24
  • The availability of funding for the deworming component. Sightsavers prefers to use restricted funding for deworming components because its unrestricted funding is in high demand by its other programs.
  • The feasibility of the program given Sightsavers' partners' capacity and resources.
  • The feasibility of the program given Sightsavers' capacity.

We have not yet asked Sightsavers for concrete examples of how it has applied the above criteria to determine whether or not to support a new deworming program.

What role does Sightsavers play in supporting deworming programs?

The deworming programs that Sightsavers supports are implemented by the governments or partners it works with.25 Sightsavers primarily provides technical assistance to governments and implementing partners, as well as financial support. More details on Sightsavers' role in specific programs below.

What technical assistance does Sightsavers provide?

The assistance Sightsavers provides in each country varies depending on what its implementing partner needs. Sightsavers' role on deworming projects has included the following:

  1. Advocacy. Sightsavers meets with government representatives to encourage them to implement additional NTD programs.26
  2. Developing national plans. Sightsavers assists country governments and partner non-governmental organizations (NGOs) in developing national integrated plans for addressing NTDs.27
  3. Prevalence surveys. Sightsavers has led several projects designed to assess the prevalence of NTDs in a specified area. For example, Sightsavers led the Global Trachoma Mapping Project and mapped the prevalence of STH and schistosomiasis in several states in Nigeria and in Guinea-Bissau, the latter using GiveWell-directed funds.28
  4. Trainings. Sightsavers helps plan and develop trainings for those who will implement the MDA and supports trainings on how to use health management information systems and national NTD databases.29
  5. Drug logistics. Sightsavers provides support in some locations for drug logistics, such as storage.30
  6. Community sensitization. Sightsavers helps with efforts to create awareness within communities about when an MDA will occur and why it is important.31
  7. Monitoring and reports. Sightsavers told us that it aims to periodically conduct coverage surveys on all of its MDA programs,32 and that it plans to conduct coverage surveys for deworming MDA projects supported by GiveWell-directed funds annually.33 A coverage survey involves sending representatives to treatment areas to survey community members about whether they received and ingested a treatment. We discuss the methodology and results from some coverage surveys we have seen below.

    Our review focuses on Sightsavers' coverage surveys, but Sightsavers has also told us about additional monitoring activities it has conducted (see footnote).34 We are not sure how frequently these kinds of monitoring are employed in Sightsavers' deworming programs. Sightsavers told us that it will conduct analyses using its Quality Standard Assessment Tool (QSAT)—Sightsavers' internal project analysis tool—every two years on all GiveWell funded projects.35 Sightsavers also told us that it conducted impact assessments for its deworming programs in Nigeria in 201636 (which we understand to mean measurements of worm prevalence and/or intensity before a program and after one or more rounds of MDA37). Sightsavers shared a draft report with us in July 2018 from an impact assessment conducted in Sokoto state; we do not have permission to share results from this study and Sightsavers expects to share an updated analysis at a later date.

What financial assistance does Sightsavers provide?

Sightsavers supports MDA programs financially when necessary.38 Historically, it has paid for expenses like planning meetings, monitoring and evaluation, vehicles, computers, education materials, sensitization activities, and supervision activities.39 Sightsavers supports its partners' salary costs on some projects, where appropriate for operational reasons and where this has been built into the project and approved by the donor.40 When providing financial support, Sightsavers told us that it asks implementing partners to provide detailed, activity-based budgets;41 we have not yet seen budgets at this level of detail (more).

Descriptions of programs by country

In this section we describe the projects on which Sightsavers has spent or committed GiveWell-directed funds. Information about other Sightsavers projects with deworming components as of 2017 is available here; we did not request this information in 2018.

Nigeria

Nigeria is one of Sightsavers' largest country programs and the first where it implemented deworming; Sightsavers has worked there on various programs for over 40 years and on deworming programs since 2011.42

Sightsavers has used GiveWell-directed funds to support three projects in Nigeria; it has so far committed funds for 2017-2019:43

  • In Kebbi, Kogi, Kwara and Sokoto states, Sightsavers treats children aged 5 to 15 years through a combination of yearly school- and community-based MDAs, using community-based MDAs to target out-of-school children.44 GiveWell-directed funds support schistosomiasis treatments in 34 local government areas (LGAs) and combined schistosomiasis and STH treatments in 17 LGAs, including one LGA where Sightsavers also targets adults consistent with WHO protocols.45 A grant from the Schistosomiasis Control Initiative (another GiveWell top charity) funded deworming work in an additional 28 LGAs across these 4 states in 2017.46
  • In Benue state, Sightsavers conducts annual school-based MDAs for schistosomiasis and STH; in some areas, GiveWell-directed funds also support community-based MDAs for lymphatic filariasis and onchocerciasis.47
  • In Yobe state, Sightsavers began supporting treatments for school-aged children for schistosomiasis in 17 LGAs using GiveWell-directed funds in 2018.48 The MDAs will include both school-based and community-based distribution.49

In addition to GiveWell-directed funds, these integrated NTD projects are funded by the UK government's UK Aid Match, state governments, and Sightsavers' unrestricted funds (details in footnote).50 Our understanding is that lymphatic filariasis and onchocerciasis work in Kebbi, Kogi, Kwara and Sokoto states was fully funded before GiveWell recommended Sightsavers and therefore GiveWell-directed funds support the deworming components of Sightsavers programs in these states.51 In Benue state, Sightsavers did not have funding for other NTD work and GiveWell-directed funds therefore support all of the NTD treatments.52 In Yobe state, our understanding is that GiveWell-directed funds will support deworming specifically; we do not know whether deworming will be integrated with other NTD treatments.53

In Benue, Kebbi, Kogi, Kwara, and Sokoto states, Sightsavers partners with the Nigerian government, which implements the programs, while Sightsavers provides technical assistance, monitoring, financial management support, and donations of items such as vehicles.54 In Yobe state, Sightsavers supports the government through the NGOs CBM and HANDS. Sightsavers' role is providing funding, technical support, and financial monitoring.55

Sightsavers also has funding through March 2019 from the UK government to support an integrated NTD program that includes treatments for STH and schistosomiasis in five other states in Northern Nigeria, in partnership with CBM, Helen Keller International, and MITOSATH.56

Guinea-Bissau

Sightsavers' NTD work in Guinea-Bissau prior to 2017 focused on eliminating trachoma, onchocerciasis, and lymphatic filariasis.57 It has used GiveWell-directed funds to add deworming to its Guinea-Bissau NTD programming, to date committing funding for 2017-2018.58 Its other NTD work is ongoing, funded by UK Aid Match (lymphatic filariasis and onchocerciasis) and its unrestricted funds (trachoma).59

In May 2017 to February 2018, Sightsavers used GiveWell-directed funds to support Guinea-Bissau to conduct a nationwide re-mapping of the prevalence of STH and schistosomiasis; the most recent mapping prior to this was conducted in 2005.60 Sightsavers supported the re-mapping in all provinces except the Bijagos archipelago, where the London School of Hygiene and Tropical Medicine conducted the re-mapping.61 Sightsavers provided support for a combination of school- and community-based MDA in 7 regions in April 2018: five for schistosomiasis and two for STH. It supported MDA in a further 3 regions in 2018.62 As of mid-2018, Sightsavers was in ongoing discussions with its partners about how to interpret the mapping results and which regions to provide treatment to in the future.63

Sightsavers provides technical support (for example, it supports governments in the training of health workers, teachers, and volunteer community drug distributors), financial support, and programme monitoring.64 It also assists the government with the MDA planning process and advocates to the government for increased government ownership of the project.65

Cameroon

Sightsavers has worked on NTD programs in Cameroon since 1996 and school-based deworming programs since 2011.66 Sightsavers' partners include the Ministry of Public Health, Helen Keller International, and other NGOs. In the past, most of Sightsavers' deworming work in Cameroon was funded by USAID.67

Sightsavers has committed GiveWell-directed funds to a three-year project in Cameroon to (1) conduct a survey to measure prevalence and intensity of STH and schistosomiasis in 15 of 16 health districts in the regions where Sightsavers supports deworming68 and (2) develop strategies to deploy in areas where prevalence has remained high after five rounds of MDA. Sightsavers expects that the strategy will focus on training adults (health workers, teachers, etc.) on how to encourage better hygiene behaviors among children.69

As of May 2018, Sightsavers did not have sufficient funding from other donors to continue its MDA work in Cameroon.70 If there is insufficient funding for MDA, scheduled for October or November 2018, Sightsavers may reallocate GiveWell-directed funds to MDA activities.71

Guinea

Sightsavers has worked on NTDs in Guinea since 1993, focusing on onchocerciasis, trachoma and lymphatic filariasis.72 Using GiveWell-directed funds, Sightsavers supported MDA for schistosomiasis and STH in three health districts in May 2017.73 It has committed GiveWell-directed funding to the program through 2018,74 and in 2018 will conduct MDA for schistosomiasis in five additional health districts.75 Deworming in other districts in Guinea is largely supported by Helen Keller International.76

Sightsavers' deworming work targets school-aged children between 5 and 15 years using school-based and community-based MDAs.77 Sightsavers provides logistical support and technical, financial, and human resources to the program.78

Democratic Republic of the Congo

Sightsavers has supported NTD programs in DRC since 2011.79 Sightsavers works in three provinces; its partner in those provinces is the United Front Against Riverblindness (UFAR).80

Sightsavers has allocated GiveWell-directed funds to add deworming to its NTD programming in Ituri Nord, in the northeastern region of the DRC; it has committed funds for 2017 to 2019 so far.81 The program targets school-aged children between 5 and 15 years through yearly school-based and community-based MDAs.82 The first MDA funded with GiveWell-directed funds occurred in December 2017.83

Sightsavers and UFAR support the DRC's Ministry of Health in implementing the program by procuring drugs, providing logistical support and communication materials, providing technical assistance, monitoring and supervising the program, and funding the distribution.84

What is Sightsavers' staff structure?

Sightsavers' work on NTDs is spread across three main departments: finance and planning, NTDs, and policy and program strategy, which includes research.85 These departments work closely with regional office teams in Sub-Saharan Africa on the strategic planning and implementation of NTD projects in each country.86

As of 2017, Sightsavers employed a West Africa Regional Director, an East, Central and Southern Africa Regional Director, and 16 Country Directors for 20 country offices, working in 28 countries in Africa.87 Some Country Directors supervise multiple countries.88 There are also some countries for which Sightsavers does not have any permanent on-the-ground staff and instead works fully through partners.89 Some country offices include monitoring and evaluation (M&E) staff, and recently Sightsavers has added NTD technical staff to its program management team.90 Additionally, Sightsavers has technical advisors who travel country to country, disseminating information on best practices for MDAs and monitoring and providing regular remote assistance.91 In 2017, Sightsavers used GiveWell-directed funds to recruit new program officers in Guinea-Bissau and Guinea Conakry.92

Within country offices, the standard staff are:93

  • Country director. Country directors oversee the program managers. They also oversee the finance and support teams.
  • Program managers. Program managers oversee the program officers and work with the finance and support teams.
  • Program officers. Program officers do a large portion of Sightsavers' work in the field and spend much of their time on monitoring activities. They visit implementing partners to check that activities are proceeding according to schedule and visit communities to observe whether or not work is being carried out as expected. They also train partners' staff on program delivery.
  • Finance and support team. Usually 1 to 4 people, this team provides the financial and operational support for Sightsavers' activities in the country. The finance team helps to design budgets for programs and regularly monitors partner expenditures to ensure that funds are being spent in accordance with budgets.94

How has Sightsavers spent funds in the past?

We have seen very high-level summaries of Sightsavers spending between 2014 and 2017.95 The vast majority of this spending was funded by in-kind gifts from other organizations, which are mostly drug donations.96 Excluding in-kind gifts, in 2017, Sightsavers spent about 40% of its total spending on NTDs and approximately 25% each on fundraising and eye care programs.97 This spreadsheet shows our breakdown of Sightsavers' 2014-2017 spending (in USD).98

Spending on NTD and deworming programs

From 2014-2017, Sightsavers spent around $50 million in unrestricted funding each year.99 Between 2014 and 2017, Sightsavers spent 5-7% of its unrestricted funding on NTD programs.100 Most of the funding for NTD programs was from restricted funding sources. In 2014, 18% of NTD programs were funded by unrestricted funds and this percentage has steadily decreased each year to 6% in 2017.101

We do not know what portion of Sightsavers' spending supported deworming programs alone: although Sightsavers has shared its 2014, 2015, and 2016 spending and its 2017 projected spending by NTD program with us, deworming components are not separated out from the other programs.102 Sightsavers' 2017 projections and 2016 spending indicate that between 30% and 34% of total NTD funding is allocated to integrated programs for onchocerciasis, lymphatic filariasis, schistosomiasis, and STH, with the remainder spent on trachoma.103 Projects Sightsavers has allocated GiveWell-directed funds to comprised about 4% of 2017 spending on NTD programs.104

Between November 2016 and early 2018, Sightsavers received $5.5 million in GiveWell-directed funds. It has shared budgets for its projected spending of those funds and, for most projects, actual disbursements through March 2018 (see this spreadsheet).105 Below, we present a breakdown of projected spending by category and country.

Sightsavers projected spending using GiveWell-directed funds (2017-2019)106

Spending category % of projected spending
Capital expenditure 2%
Project activities 43%
Staff costs 11%
Administration costs 1%
Monitoring, evaluation and lesson learning 22%
Program management 10%
Overheads 10%
Country % of projected spending
Nigeria 42%
Guinea 26%
Guinea-Bissau 17%
Cameroon 7%
DRC 8%

Spending on fundraising

Sightsavers spent 26-29% of its total spending (excluding in-kind contributions), which was 45-55% of its unrestricted funding, on fundraising activities between 2014 and 2017.107 While we typically do not put too much weight on an organization's spending breakdown (for reasons explained in this blog post), this seems higher than we've seen from other top charities—though we recognize that there can be significant variation in how organizations categorize costs. When we asked Sightsavers about its high fundraising costs, it noted that it aims to use less than one third of its total annual budget on fundraising and that this is consistent with industry standards.108 Sightsavers also highlighted that when the value of in-kind gifts are included, Sightsavers’ fundraising costs are under 10%.109

Does it work?

We believe that there is strong evidence that administration of deworming drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes, such as increased income and consumption. We consider deworming a priority program given the possibility of strong benefits at low cost.

To evaluate Sightsavers' track record at executing programs, we have focused on results from coverage surveys of programs supported by GiveWell-directed funds. These door-to-door surveys estimate what percentage of individuals who were targeted for treatment actually received treatment. Coverage of school-aged children was above 75% (the WHO-recommended minimum threshold) in four out of five surveys of Sightsavers' GiveWell-funded work. We note some limitations of these surveys below.

We have seen reports on coverage surveys from four of five projects where Sightsavers has used GiveWell-directed funds to support deworming MDA,110 representing 80% of Sightsavers' spending of GiveWell-directed funds to date.111 We expect to see such surveys annually for all GiveWell-funded programs.

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

What is the independent evidence for the program?

Sightsavers supports MDAs to treat communities for NTDs, including schistosomiasis and STH. While we do not have a strong view on the evidence behind and cost-effectiveness of integrated NTD programs, we have reviewed the independent evidence for deworming programs, which we discuss extensively in our intervention report on deworming. 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 small possibility of strong benefits at a very low cost.

Are deworming pills delivered to and ingested by recipients?

The evidence we have focused on includes:

  • Coverage surveys: We believe the coverage surveys Sightsavers has shared with us provide the best evidence of its impact. We discuss the results and some methodological limitations of these surveys below.
  • Impact assessments: We have seen impact assessments of several of Sightsavers' trachoma and onchocerciasis programs; the assessments have significant methodological limitations and have not substantially shifted our view on Sightsavers' ability to support deworming programs. We have also seen a draft impact assessment of Sightsavers' deworming work in Sokoto State, Nigeria. Sightsavers expects to share updated results in future; we do not have permission to publish the draft results.112

Details follow. We note that Sightsavers has told us about other types of monitoring it conducts; we do not discuss this monitoring in detail because we find it less useful for understanding the how successful Sightsavers' projects have been.113

Coverage surveys

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.114

Sightsavers aims to conduct coverage surveys after every deworming MDA supported by GiveWell-directed funds.115 We have seen five reports on Sightsavers' coverage surveys: Democratic Republic of Congo (2018), Guinea (2017 and 2018), Guinea-Bissau (2018), and one of two projects in Nigeria (2018),116 representing 80% of Sightsavers' spending of GiveWell-directed funds.117 Sightsavers has also shared reports on its coverage surveys from some previous NTD MDA programs (not funded by GiveWell-directed funds): Benin (2015), Togo (2015), Burkina Faso (2015), Côte d'Ivoire (2015), Cameroon (2015-16), South Sudan (2015), Nigeria (2014 and 2015), and Malawi (2015);118 we only have permission to share results from five of these surveys. We focus on results from programs funded by GiveWell-directed funds because we are unsure how representative these additional results are of Sightsavers' overall work on NTD MDAs.119

Methodology

We summarize the methodologies of the publicly available coverage surveys we have seen from Sightsavers in this spreadsheet ("Methods" sheets). We note some limitations to the survey methodologies that impact our confidence in their accuracy and representativeness of treatment coverage in Sightsavers' MDA programs:

  • Selection of geographic areas: Sightsavers' coverage surveys are implemented within specified sub-regions of the area targeted for MDA (e.g., districts, regions, or local government areas). It appears that these geographic areas are often selected purposefully rather than randomly for inclusion in coverage surveys from the full set of areas in which MDA occured. Of the five surveys we have seen, geographic areas were selected purposefully in two.120 Details on the selection of geographic areas for all Sightsavers' coverage surveys are available in this spreadsheet ("Methods" sheets).
  • Length of time between MDA and survey: As is often the case in coverage surveys for deworming programs, respondents in Sightsavers' coverage surveys are asked to recall taking drugs weeks or months after an MDA has occurred, which may have an impact on the accuracy of the responses.121 Details on the length of time between the MDA and the coverage survey for all Sightsavers' coverage surveys that are publicly available can be found in this spreadsheet ("Methods" sheets). Sightsavers told us that it aims to conduct all coverage surveys within 1-2 months of the MDA and that it does not believe recall bias is a serious concern.122
  • Unclear data quality control and verification processes: The coverage survey reports from projects supported with GiveWell-directed funds do not mention any re-surveying of households to check the accuracy of the data collected or use of verification questions (such as whether respondents can recognize the pills they took among a set of pills) to assess the accuracy of responses. Some of the surveys note that supervisors monitored the data collection but do not specify what these processes were, how common errors were, or how they were corrected. Sightsavers noted that it monitors data collection in real time, which is believes negates the need for follow-up verification.123

Additionally, the 2018 coverage survey from the GiveWell-supported MDA in the DRC was not able to analyze data from 14% of households due to unexplained data entry errors, potentially biasing the results.124

Results

See this spreadsheet, "Results" sheets.

In short, in the four coverage surveys on Sightsavers' GiveWell-supported projects from 2018, the coverage rate for deworming treatments exceeded the WHO coverage target of 75% or more school-aged children treated (range: 77%-99%)125 Sightsavers' 2017 Guinea coverage survey found a 58% coverage rate,126 however, coverage improved in 2018.127 Security concerns prevented Sightsavers from conducting a coverage survey in 2018 in Benue, Nigeria; based on administrative data, Sightsavers reports coverage of 54% for praziquantel (which is used to treat schistosomiasis) and 40% for albendazole (which is used to treat STH).128

Impact assessments

We have reviewed three studies Sightsavers shared that reported on the impact of MDAs on the prevalence of onchocerciasis or of trachoma. The studies suggest that past treatment programs have been successful, but the studies have a number of limitations, particularly because it is unclear whether these programs are representative of Sightsavers' work and whether changes can be attributed, at least in part, to Sightsavers' work.

  • A 2008 impact assessment of long-term (1991-2008) treatment of onchocerciasis in Kaduna, Nigeria:129 Baseline data from 1987 indicated a median onchocerciasis prevalence of 52%. In 2008, after 15-17 years of treatment, onchocerciasis prevalence had dropped to 0% in all surveyed communities (none of the 3,703 individuals screened were infected).130 Limitations of the study include: (1) the difficulty of attributing the change to Sightsavers' work given the possibility that other concurrent work or improvements during the long interval between baseline and follow up may have impacted onchocerciasis prevalence, (2) selection of study areas based on criteria that may be correlated with larger changes in prevalence, and (3) a high non-participation rate among targeted respondents.131
  • A 2015 impact assessment of long-term (1993-2015) treatment of onchocerciasis in fifteen villages in three districts of Uganda:132 District-level onchocerciasis prevalence ranged from 0.8% to 5.5% at the time of the assessment.133 The authors noted that baseline prevalence data (from 2007) was available for only two of the fifteen villages,134 but they did not provide the baseline data from the two villages in the report. The study concluded that the MDAs performed well.135 Other limitations of the study are discussed in this footnote.136
  • An impact assessment on three rounds of trachoma treatment (2009-2012) in three regions of Guinea-Bissau:137 Sightsavers has told us that it has run a trachoma program in Guinea-Bissau since 2011; we are uncertain about the details of Sightsavers' trachoma support in these three regions, and about the role other organizations play in this program.138 This study concluded that after three years of MDA, trachoma prevalence in children 1-9 years of age was below 5% in all three regions, indicating that further treatment was not needed.139 The study did not include baseline data (or state how much prevalence dropped). However, Sightsavers has elsewhere reported what may be comparable 2005 baseline data for these three regions, which suggests that trachoma prevalence decreased from 20-30% to 1-5% in these regions.140

Sightsavers also shared documents on impact assessments of an onchocerciasis control program in Kwara and Kogi states in Nigeria and another onchocerciasis control program in Kibaale District Uganda.141 We have not reviewed these documents in depth. A quick review led us to believe that they would not affect our views on Sightsavers' deworming programs.

We have not seen impact assessments of Sightsavers' schistosomiasis or STH programs specifically.142 Sightsavers told us that it completed an impact assessment of its deworming work in Sokoto state, Nigeria. We have received draft results from this study but we do not have permission to discuss them publicly.143

What is the effect of Sightsavers' work on program outcomes?

Sightsavers may be having an impact in the following ways:

  • It may increase the likelihood that a government implements a deworming program by advocating for deworming programs, by offering to provide technical assistance, and/or by funding implementation.
  • It may improve the quality of a deworming program (leading to more children dewormed effectively or improved cost-effectiveness).

We have not yet asked Sightsavers for its guess as to what would have happened in the locations where it supports deworming programs if it had not provided support, so we have limited evidence on which to judge how Sightsavers affects programs. Sightsavers operates a program similar to the programs that Deworm the World Initiative and the Schistosomiasis Control Initiative operate, and much of our confidence that Sightsavers' technical assistance causes additional children to receive deworming treatments comes from what we have learned about those two organizations' models.

We would guess that Sightsavers increases the likelihood that (national and subnational) governments implement deworming, particularly when it pays for the majority of financial program costs.

We are uncertain about whether or not Sightsavers' assistance increases the quality of the programs it supports.

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.144 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.
  • Replacement of government funding: We have limited information about whether governments would pay for the parts of the program paid for by Sightsavers 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 mass drug administration campaigns supported by the Schistosomiasis Control Initiative, including one case that led to riots.145 Additionally, during deworming activities supported by Evidence Action's Deworm the World Initiative in Ogun State, Nigeria in December 2017, rumors of students collapsing after receiving deworming pills reportedly generated panic that led some parents to take their children out of school; Ogun State government denied that any students collapsed.146 While the accounts we have heard are from programs supported by the Schistosomiasis Control Initiative and Evidence Action's Deworm the World Initiative, we think it is possible that other deworming programs could cause similar discontent.

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

In general, mass deworming programs treat everyone in a targeted demographic, regardless of whether each individual is infected (more). Because of this, the benefits (and therefore the cost-effectiveness) of a program are highly dependent on the baseline prevalence of worm infections.

In this section, we discuss how the disease burden in the areas where Sightsavers works 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 Sightsavers programs generally target areas that require mass treatment according to WHO guidelines,147 the disease burden in areas where Sightsavers works is on average lower than in the study areas, so our expectation is that the impact per child treated is lower in the areas where Sightsavers works. We adjust our cost-effectiveness estimate (more below) accordingly.

In this spreadsheet, we compare the prevalence of the places in which Sightsavers currently supports a program to the prevalence from the studies providing the best evidence for the benefits of deworming. Note that we used a number of approximations to arrive at an estimate that could be used in our cost-effectiveness analysis.

Key pieces of evidence that we discuss in our report on deworming (Miguel and Kremer 2004, Baird et al. 2012, and Croke 2014) are from deworming experiments conducted in Kenya and Uganda in the late 1990s and early 2000s. Prior to receiving deworming treatment, the participants in those studies had relatively high rates of moderate-to-heavy infections of schistosomes or hookworm.148

What do you get for your dollar?

We estimate that on average the total cost of a schistosomiasis and/or STH treatment delivered in Sightsavers-supported programs is $0.95. Excluding the cost of drugs (which are often donated) and in-kind government contributions to the programs, we estimate that Sightsavers' cost per treatment is $0.39. These estimates rely on a number of uncertain assumptions. Full details of our analysis are in this spreadsheet. For results, see sheet "Overall cost per treatment."

When possible, we prefer to rely on past results over projected future results, as projections can be overly optimistic (as was the case for Sightsavers' projections in 2016—see below). For Sightsavers, we have used projected costs and treatments in combination with limited past data.

Note that the number of lives significantly improved is a function of a number of difficult-to-estimate factors. We incorporate these into a cost-effectiveness model which is available here.

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 costs and 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.

To get the total costs of the program, we attempt to include all partners such that our cost per treatment represents everything required to deliver the treatments. In particular, in our cost per treatment analysis for Sightsavers, we have attempted to include these categories:

  • Sightsavers' costs from providing technical assistance or financially supporting a program.
  • Value of donated drugs. We attempt to include the full market value of all praziquantel and albendazole that is needed to deliver the treatments.
  • Costs incurred by the government implementing the program (e.g., for staff salaries when working on treatment programs). We do not have estimates from Sightsavers for these costs.

We start with this total cost figure and apply adjustments in our cost-effectiveness analysis to account for cases where we believe the charity's funds have caused other actors to shift funds from a less cost-effective use to a more cost-effective use ("leverage") or from a more cost-effective use to a less cost-effective use ("funging"). More discussion of leverage and funging in this blog post.

Shortcomings of our analysis

There are several ways in which our analysis of Sightsavers’ cost per treatment is uncertain:

  • Limited data from previous deworming programs: We have only limited data from past programs that Sightsavers has supported with a deworming component. Our analysis relies on actual cost data and reported treatment numbers from the first year of GiveWell-directed funds in 2017, combined with budgets and projected treatment numbers for how it expects to use GiveWell-directed funds in 2018-2019. These projections may turn out to be under- or overestimated. We have applied a small discount to the number of expected treatments based on Sightsavers' past coverage rates, as seen in coverage surveys.
  • Integrated NTD programs: Sightsavers' NTD programs combine treatment for schistosomiasis and STH with other MDA programs, such as for onchocerciasis, trachoma, and lymphatic filariasis. In cases where Sightsavers is adding a deworming component to an existing MDA program, there are several approaches we could take:
    1. Only incorporate the additional costs of adding deworming into our cost per treatment analysis.
    2. Include the full cost of the integrated program and estimate the total benefits from all components of the program.
    3. Include the full cost of the integrated program, but only consider the benefits from deworming treatments.

    Our preferred approach would be the second of these, but we are not currently able to do that analysis because (a) we do not have data from Sightsavers on the full costs of the integrated programs, and (b) we have not yet completed a full analysis of the benefits of MDA programs for other NTDs. We are currently taking the first approach, which may undercount costs that are shared across components of the program.

    In cases where GiveWell-directed funds support the full costs of an integrated MDA program (e.g. in Benue state, Nigeria) we include the full costs of the program and count deworming treatments as the only benefits of the program.

  • Limited data on partners' costs: We have very limited data on the contributions of Sightsavers' partners, particularly contributions from governments. We have data from third parties on the value of donated drugs. We do not have any direct information on the value of government staff or volunteer time used in the program; the approach we have taken to roughly estimate government contributions for Sightsavers' programs, as well as SCI-, END Fund-, and some Deworm the World-funded programs, is to base the estimate on a single, likely outdated study from an SCI-funded program.149
  • Estimated number of treatments: We assume that consuming only albendazole, only praziquantel, or both counts as being dewormed. This is consistent with how we count the number of treatments delivered by SCI, Deworm the World, and the END Fund. Because we generally do not have detailed enough data from Sightsavers to determine what portion of children received only albendazole or only praziquantel, we have assumed that the figures we have received fully overlap within each country.150
  • Possible excluded costs: Some costs might be excluded from our estimate because we are not sure what costs are included in the budgets Sightsavers has shared with us. For example, the following may not be included: start-up costs (e.g., for setting up operations in a new location), the cost of office space, and vehicle costs.151
  • Pooled funding across actors in DRC: In DRC, Sightsavers is one of several donors working with local partners. We are not sure how closely the treatment numbers reported in DRC by Sightsavers alone reflect the contribution that it has made to the local partner who supports deworming MDA. We believe that using data on the total costs and treatments across all actors in DRC is more likely to give a representative estimate of Sightsavers' cost per treatment there.152

Is there room for more funding?

Sightsavers has provided details of deworming programs that it could fund with up to about $11.5 million in its 2019-2021 fiscal years.153

In short:154

  • Total opportunities to spend funds productively: Sightsavers has identified $11.5 million worth of opportunities to:
    • Add deworming to existing NTD programs or support standalone deworming programs ($10.3 million):155 This includes funds to extend commitments to 2021 for programs where GiveWell-directed funds have been committed to fund the programs through 2019 and new opportunities to add deworming to NTD programs.
    • Fund integrated programs ($1.2 million):156 For these opportunities, GiveWell-directed funding would continue to fund NTD programs that would treat several NTDs, including schistosomiasis and STH, in areas where Sightsavers has used GiveWell-directed funds to support integrated programs in the past two years.
  • Cash on hand: Sightsavers has committed all of the GiveWell-directed funding that it has received to programs and has no other uncommitted funding on hand.157
  • Expected additional funding: We expect that Sightsavers will receive a small amount (~$170,000) due to being on GiveWell's top charity list (independent of specific funding recommendations we make).158
  • Additional considerations: Sightsavers is a large organization and funds multiple programs. GiveWell-directed donations to Sightsavers specifically support its deworming programs.

More detail in the sections below and in this spreadsheet.

Uncommitted and expected funds

Our impression is that Sightsavers will not fund the work listed above from its unrestricted funds, and all of the GiveWell-directed funding for deworming programs that Sightsavers currently has in hand has been committed to specific programs.159 There is a possibility that some of this work would be funded by restricted grants if Sightsavers does not receive sufficient GiveWell-directed funds.

When we first engaged with Sightsavers about the possibility of funding its deworming programs in 2015, it told us about opportunities to scale up deworming treatments in Nigeria and Guinea-Bissau.160 In 2016, Sightsavers had not made progress on scaling up deworming treatments in these areas because it had not received funding to do so.161 This increases our confidence that Sightsavers is unlikely to allocate its unrestricted funding to deworming programs in the absence of other donors, and that other donors are difficult to find.

In 2016, before we had directed funding to Sightsavers, Sightsavers provided us with a list of opportunities to scale up deworming treatments. We asked Sightsavers multiple times if it expected to fund any of these opportunities in the next year if it did not receive a recommendation from GiveWell; Sightsavers told us that it would not, because:162

  • Sightsavers does not expect to use significant amounts of its unrestricted funding to scale up deworming treatments. Deworming programs are not Sightsavers’ highest priority and there are many other demands on Sightsavers' limited amount of unrestricted funding.
  • Sightsavers would be surprised if it were to receive enough restricted funding from another donor to scale up deworming. Sightsavers has not yet seen significant interest from large donors in funding the deworming programs it discussed with us. This may be because, according to Sightsavers and other deworming groups we've spoken to, two of the largest donors for NTD programs, the US and UK governments, are primarily interested in funding NTD programs that are focused on lymphatic filariasis, onchocerciasis, and trachoma. The UK government funds some programs that are focused on schistosomiasis.163

In 2017, we again asked Sightsavers about other potential funders for deworming. It mentioned four possible funders:

  • USAID, the US government's aid program, has been funding MDAs for several NTDs in Cameroon through the ENVISION project. USAID has informed partners that it will provide limited support for SCH/STH impact surveys in 10-12 selected areas in Cameroon, but that starting in 2018 it will not support SCH/STH MDAs. Sightsavers is seeking funding to support activities in areas where USAID has withdrawn ENVISION funding.164
  • The UK government's Department for International Development announced in 2017 that it will increase support for NTDs.165 The first grants from this round of funding are expected in early 2019.166
  • Sightsavers has been in conversations with a private funder and has discussed the possibility of that funder supporting the Cameroon program.167
  • Sightsavers was in early conversations with a potential funder who did not end up funding its deworming programs.

We expect that Sightsavers will receive a small amount of funding (~$170,000) due to being on GiveWell's top charity list (independent of specific funding recommendations we make). This projection is based on what Sightsavers received last year from donors who cited GiveWell as their reason for giving, excluding the grant we recommended Good Ventures make to Sightsavers.168

Additional spending opportunities

Sightsavers has provided us with a list of opportunities it hopes to raise funding for, which consist of supporting deworming MDAs, and in some cases other NTD MDAs, in the five countries in which GiveWell-directed funds are funding MDAs in 2018: DRC, Guinea, Nigeria, Cameroon, and Guinea-Bissau. We have summarized the opportunities in this spreadsheet ("Spending opportunities" sheet).

In short, Sightsavers is seeking funding for the following:

  • Extension of commitments for current programs that add deworming to existing programs or standalone deworming programs through 2021 ($5.3 million): GiveWell-directed funds have been used to commit to adding deworming to programs in DRC (Ituri Nord),169 Guinea,170 Nigeria (4 states),171 and Cameroon (West, Northwest, and Southwest regions)172 through 2019 and to Guinea-Bissau through 2018.173 Additional funds would allow Sightsavers to continue those programs through 2021.
  • Adding deworming to existing programs in new geographies ($5.0 million): Sightsavers is seeking funding to add deworming to other NTD work in Bauchi State, Nigeria174 and five additional regions of Cameroon,175 and to support a second annual round of STH MDA in four additional districts in Guinea.176
  • Integrated NTD programs ($1.2 million): Sightsavers is seeking funding to extend work to 2021 in Benue State, Nigeria (which has been previously funded with GiveWell-directed funds through 2018).177

In total, Sightsavers would need $11.5 million to fund all of the work in the above list.178

Past uses of unrestricted funding

We have some high-level data from Sightsavers on its past uses of unrestricted funding. In 2017, Sightsavers spent about $45 million in unrestricted funding. About 55% of this went to fundraising (about $25 million), and about 5% was spent on Sightsavers' NTD program (about $2.1 million), down from 6% ($2.8 million) in 2016. Aside from this decrease and a decrease in its level of spending on eye care, Sightsavers' 2016 expenditures were similar.179

Sightsavers has supported some deworming treatments with unrestricted funding in the past. However, given limited amounts of unrestricted funding, Sightsavers has told us that it does not expect to use much additional unrestricted funding in the future to support new or larger deworming programs.180

Additional considerations relevant to assessing Sightsavers' room for more funding

  • Sightsavers is a large organization and spends money on many programs that are not deworming, including other NTDs, eye health, education, cataract surgeries, job training for the disabled, and more. Because deworming programs are not a major priority for Sightsavers in its use of unrestricted funding, we have asked Sightsavers to use GiveWell-directed funding to support scale-up of deworming (including central costs needed to support such an increase in programming). Donors who would like their donation to Sightsavers to support deworming should consider giving to GiveWell for the support of Sightsavers' deworming work or, if giving directly to Sightsavers, communicating to Sightsavers that their gift was due to GiveWell's recommendation. Note that Sightsavers does not accept restrictions on donations less than $10,000, so donors giving smaller amounts who would like to support Sightsavers' deworming program should consider giving to GiveWell and designating their donation for Sightsavers.
  • For the funding opportunities listed above, Sightsavers has requested funding to allow it to commit funding for the following three years. We ask top charities to consider GiveWell-directed funds to be multi-year grants. The amount of GiveWell-directed funding that a top charity receives can vary greatly from year to year, and spending the funds over two to three years can help smooth these fluctuations. Sightsavers also told us that it is easier to work with governments and communities if it can commit to working multiple years. This is also something that the Deworm the World Initiative has argued.

Global need for treatment

There appears to be a substantial unmet need for STH and schistosomiasis treatment globally.

In 2017, the World Health Organization (WHO) released a report on 2016 treatments stating that:181

  • 69% of school-age children in need of treatment were treated for STH in 2016, up from 63% in 2015 and 45% in 2014. Coverage was 65% in African countries in 2016, up from 51% in 2015 and 45% in 2014.
  • 52% of school-age children in need of treatment were treated for schistosomiasis in 2016, up from 42% in 2015.

We have not vetted this data.

Sightsavers as an organization

We have spent less time investigating Sightsavers and have less insight into its activities and track record than we do for top charities we have followed for many years. As such, we have a somewhat limited view on the qualities below.

  • Track record: Sightsavers has a somewhat limited track record of assisting governments with deworming programs, but a stronger track record of assisting governments with integrated NTD programs.
  • Self-evaluation: Sightsavers' self-evaluation is strong compared to the vast majority of organizations we have considered. We discuss limitations to this evidence above.
  • Communication: To date, Sightsavers has generally communicated reasonably clearly with us.
  • Transparency: Sightsavers has provided the information we’ve asked for and has not hesitated to share it publicly (unless it had what we felt was a good reason).

More on how we think about evaluating organizations at our 2012 blog post.

Sources

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  • 1.
  • 2.

    "Sightsavers is one of the world’s leading non-profit organizations dedicated to combating avoidable blindness and promoting equal opportunities for people with disabilities in developing countries. We work with local partners in over 30 countries in Africa, Asia and the Caribbean, restoring sight through specialist treatment and eye care. We also support people who are irreversibly blind by providing education, counselling and training." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 1.

  • 3.

    Of Sightsavers' 2017 total expenditure excluding gifts in kind, 74% was spent on program activities ("charitable activities," i.e. activities other than fundraising), including 38% on NTDs; NTDs accounted for about 51% of program expenditure (excluding gifts in kind) and 86% of total expenditure including gifts in kind.

    See this spreadsheet, Sheet "Total spending 2014-2017," columns F and G.

  • 4.
    • "Currently, Sightsavers only wants to add deworming programs in countries where it already has an NTD program." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, Pg 6.
    • "Sightsavers takes an integrated approach to NTD elimination, as it is the most cost-effective, efficient and sustainable approach. Sightsavers has well established programs supporting the elimination of river blindness, trachoma and lymphatic filariasis (LF), and is leading efforts to scale up integrated treatments where needed, and to integrate deworming where possible." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 2.
    • "STH is more problematic as it has the potential to be an indefinite control programme (until current treatment strategy changes; this will be a long way off) and we would only continue with STH support as part of school health programmes which also include eye health." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 13.
    • "We will confine our geographic spread in NTD work to Africa. There are three exceptions to this strategic choice: if funding is available to support trachoma and onchocerciasis in Yemen we will expand there; if we are invited or we choose to bid for contract management work globally we will undertake work outside Africa; and, if NTD work is linked to a programme covering other work ... we would seize this as an opportunity." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 11.
  • 5.
  • 6.
    • See:
    • On Cameroon: "Sightsavers was supporting MDA to tackle SCH and STH in the three regions of South West, North West and West Cameroon with funding from Helen Keller International (USAID) and Sightsavers unrestricted funds. However, this funding is no longer available due to the withdrawal of funding. Sightsavers is currently in negotiations with the Ministry of Health to establish how much of the MDA activity they can contribute to and how much of a funding gap there is. As our planned WASH activities are aimed at complementing SCH/STH MDA, if there is insufficient funding for a national MDA programme, Sightsavers suggests reallocating the GiveWell budget and the quarterly payments to fill MDA funding gaps in the first instance and continuing to support complementary WASH and SBCC activities where possible. This decision can only be made once the impact survey results have informed the Ministry of Health which regions require MDA and therefore what proportion of the overall MDA budget the Cameroonian government can financially support. The impact survey was completed in in the West region in March 2018. Data is currently being analysed and treatment decisions will be taken based on the results in May." Sightsavers, Country narrative report Cameroon, 2018, Pg. 3.
  • 7.

    For more information on MDAs, see this justification for MDAs from Evidence Action's Deworm the World Initiative (another GiveWell top charity with a focus on deworming programs): "Is mass treatment justified? On cost-effectiveness grounds we believe that it clearly is, as the cost of treatment is cheaper than individual screening. The WHO states that the cost of screening is four to ten times that of the treatment itself. Because the drugs are very safe and has no side effects for the uninfected, the WHO does not recommend individual screening. The WHO instead recommends mass drug administration in areas where more than 20% of children are infected." Evidence Action website, Deworm the World Initiative (March 2016).

  • 8.

    Julia Strong, International Foundations Executive, edits to GiveWell's draft 2017 review, November 14, 2017.

  • 9.

    "It was on 5 Jan 1950 that the doors of the British Empire Society for the Blind, as we were known back then, opened for the first time. [...] As well as being the decade of teddy boys, petticoats and rock and roll, the 1950s were when Sightsavers made our first groundbreaking achievement in the fight against avoidable blindness. In 1953 a survey was conducted by Dr Freddie Rodger in West Africa. It showed that the majority of blindness was actually preventable, and led to a pioneering disease control programme for onchocerciasis, also known as river blindness." Sightsavers, Our history.

  • 10.

    "In 2015, Sightsavers supported approximately 252,000 cataract surgeries through 55 projects in roughly 20 countries. Its larger cataract projects are located in Southeast Asia (for example in Bangladesh, India, and Pakistan), and it also has projects in Sub-Saharan Africa. Sightsavers works with governments to strengthen countries' cataract surgery systems. It also seeks to integrate this work with its eye health-related neglected tropical disease programs." GiveWell's non-verbatim summary of a conversation with Julia Strong, Dr. Imran Khan, and Mike Straney, April 14, 2016, Pg 1.

  • 11.
    • "Our work also covers low vision, diabetic retinopathy, childhood blindness and the group (17 diseases in total) known as neglected tropical diseases, which incorporates not only trachoma and river blindness, but also buruli ulcer, Chagas disease, dengue/severe dengue, dracunculiasis, echinococcosis, foodborne trematodiases, human african trypanosomiasis, leishmaniasis, leprosy, lymphatic filariasis, rabies, schistosomiasis, soil transmitted helminthiases, taeniasis/cysticercosis and yaws." Sightsavers, What We Do - Sight
    • "Integrated NTD programs (including deworming, when it is needed) represent just one of Sightsavers’ top priorities. For the past few years, programs for trachoma and onchocerciasis have been specifically identified as “fast-­track” initiatives. Sightsavers has historically been known for providing services such as cataract surgery, ophthalmologist training, and hospital support, but it aims to make its NTD work as much as or even more of a priority than its traditional work." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pgs 4-5.
  • 12.
  • 13.

    Julia Strong, Sightsavers International Foundations Executive, edits to GiveWell's draft 2017 review, November 14, 2017.

  • 14.
    • "We have long been committed to the elimination of devastating neglected tropical diseases (NTDs). Sightsavers’ earliest work was in Ghana in the 1950s, where our Founder Sir John Wilson, Dr Geoffrey Crisp and Dr Freddie Rodger initially led the first ever surveys into the extent and transmission of river blindness and the introduction of rehabilitation services for people who are irreversibly blind. Sightsavers has also been involved in the control of trachoma since 1952, working with partners in 35 countries." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 1.
    • Sightsavers believes that there can be significant efficiency gains from integrated NTD programs.
  • 15.
  • 16.
  • 17.
    • We have heard this from conversations with several organizations working on deworming or integrated NTD programs.
    • GiveWell's notes from its 2016 site visit to Ghana
    • "To achieve and sustain elimination we must promote multi-sectoral integration and proactively develop strategic partnerships in all areas of work. For example, soil transmitted helminths (STH) programmes need to go beyond schools if national control targets are to be met. STH is more problematic as it has the potential to be an indefinite control programme (until current treatment strategy changes; this will be a long way off) and we would only continue with STH support as part of school health programmes which also include eye health. Onchocerciasis, lymphatic filariasis (LF) and trachoma elimination programmes, which are traditionally community focused, should also look towards school programming to achieve their elimination targets." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 13.
  • 18.

    Sightsavers, Global report for all GiveWell funded projects, 2018.

  • 19.
  • 20.
  • 21.

    Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018.

  • 22.
    • "Programmes are planned to avoid children being treated twice. In some cases this is
      achieved through the different strategies (school versus community based) being
      used in different implementation units. Where both strategies are used in the same area specific efforts are made to ensure an appropriate level of mass sensitisation and
      in some cases markers are used. [...] [In Nigeria] in a few instances (and not most) where school coverage is very low, school and community based strategies are both used (to reach children at Islamic schools or out of school children etc). In these areas a marker is placed on the children to avoid treating them twice. [...] [In Guinea Conakry] children are asked if they’ve been treated before." Sightsavers, Responses to GiveWell questions, October 2017.
    • During a visit to Sightsavers' office in Guinea Conakry in October 2017, Sightsavers staff told us that children's fingernails had been marked to indicate that they had received deworming pills. Notes from a site visit to Sightsavers in Conakry, Guinea in October 2017, Pg 2.
    • Sightsavers' 2018 project narrative of its project in four Nigerian States noted: "The markers (on participating children’s fingernails) used during school based treatment was successful in avoiding double treatment and cross over with community based treatment." Sightsavers, Country narrative report Nigeria 4 states, 2018, Pg 5.
  • 23.
    • "Sightsavers has well established programs supporting the elimination of river blindness, trachoma and lymphatic filariasis (LF), and is leading efforts to scale up integrated treatments where needed, and to integrate deworming where possible. We integrate deworming into programs where we are able to meet two key criteria:
        1. That evidence from mapping on co-endemicity with other NTDs demonstrates that it is desirable and feasible to integrate deworming, thus improving quality of life and school attendance, as well as equitable access to medicines and the cost-effectiveness of the program.
        2. That Sightsavers is able to source the funding required to integrate deworming into the program. Like many NGOs, Sightsavers’ unrestricted income is under substantial
        pressure and is subject to competing priorities. We are therefore better able to integrate deworming activities into programs if we have restricted funding available for deworming activities. This is a key reason why the support of GiveWell would make a significant difference to our ability to deliver deworming activity on a larger scale."

      Sightsavers, Descriptions of current work - 2015 and 2016, Pg 2.

    • "Before Sightsavers commences support to any partner, including government partners, it undertakes a due diligence assessment in a participatory manner with the partner. We use tools we have developed which have been tested and modified over a number of years. The tools assess the vision, goals, human resource, financing and risks of the partner, and are shared with them in advance of the assessment.
      During the assessment, we ask the partner a series of questions, review the evidence and jointly grade the answers using a grading scale. After the assessment a strengths, weaknesses, opportunities and threats (SWOT) analysis is undertaken and a capacity development plan is developed, with timelines. Capacity development is then assessed annually to determine progress to ensure the partner is empowered to deliver on agreed objectives and systems are established to minimise risks.
      We assess Sightsavers’ capacity to implement in terms of skills, human resource
      and the availability of funding (see point 2 above). Where necessary, we recruit additional project staff to support implementation for the period of the project and identify institutions, consultants and coalitions with whom we wish to work for technical support." Sightsavers, Approach to deciding where to support deworming
  • 24.

    "Sightsavers’ country programs work with a country’s ministry of health (MOH) to identify implementation units (such as districts) in need of MDAs for each disease. This determination is based on data about the disease’s prevalence in the area obtained through mapping...Sightsavers uses mapping data to establish baseline prevalence for a particular disease in the area. It then uses guidelines from the World Health Organization (WHO) to determine what drug regime is needed in areas where prevalence exceeds minimum thresholds." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pgs 1-2.

  • 25.

    "Sightsavers has Memorandums of Understanding in place with Ministries of Health in the countries we work in and Sightsavers staff teams work in direct collaboration with Government ministry staff and partner organizations on all program activity. Sightsavers works closely with frontline service delivery teams and is in a unique position to influence and advocate effectively to Government partners." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 1.

  • 26.
  • 27.
    • "The key to this integration is supporting in-country ownership by working with national NTD Master Plans. NTD Master Plans need to be of good quality and based on recent robust prevalence data both for planning and for progress tracking – hence initiatives like Tropical Data. We have a role to play in supporting the development of these quality, comprehensive and budgeted master plans, including involvement in the renewal of existing plans and need to support capacity to deliver this crucial area of work. National NTD task forces need to own these plans and be vibrant and supported to deliver. Where required we can support these task forces financially – the country, however, must remain in the leadership position." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 12.
    • For example, in Nigeria: "Sightsavers supports the national and state NTD teams for better program coordination at various levels. Support is also provided to the National NTD Steering Committee which provides a forum for discussing the overall strategic direction for the national NTD program. At the local government area level Sightsavers has facilitated the establishment of NTD Task Force committees which has improved ownership of the program." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 3.
    • In Cameroon: "Community participation is observed at every stage of program implementation. Community representatives took part in planning meetings at national, regional and district level. At health area level, community meetings were held before the campaign began. This led to increased community awareness and ownership of the program so communities understood their roles and responsibilities during MDA." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 13.
    • GiveWell's notes from its 2016 site visit to Ghana
    • "Sightsavers provides funding to and works with in-country partners, such as national NGOs and governments, to identify programming gaps, develop plans and budgets, and provide the necessary support for program implementation." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, April 5, 2016, Pg 1.
    • This sometimes includes sharing project management tools that Sightsavers has developed.
      • "Sightsavers has entered into relationships with Schistosomiasis Control Initiative (SCI), Liverpool School of Tropical Medicine, London School of Hygiene and Tropical Medicine, and the Kilimanjaro Centre for Community Ophthalmology to provide technical advice and operational research to improve our programmes. With SCI and Liverpool we have arrangements where we also support them with implementation and financial management." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 20.
      • "We will work to leverage existing tools to add value to other Sightsavers programmes. Our suite of bespoke tools developed for programme management of the large grants (e.g. CLAIMS, project management tool for the UNITED programme in Nigeria, etc.) and tools developed for the consortia programmes could be cross-purposed to support other programmes, particularly when matched to tools such as Quality Standards Assessment Tool (QSAT). These systems should create efficiencies and not more work for country staff." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 17.
  • 28.
    • "With the support of the Children’s Investment Fund Foundation (CIFF), DFID and USAID, 19 states and the federal capital territory were mapped for schistosomiasis and STH from November 2013 to May 2015. CIFF provided funding to map 14 states and the remaining states were supported by the DFID funded Global Trachoma Mapping Project, RTI/ENVISION project and Sightsavers." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 7.
    • "We were recently nominated by a group of organizations with expertise in the fields of NTDs and water and sanitation to lead a global project to map trachoma. This was the largest infectious disease survey ever undertaken and the project came to a close in 2015 as the 29th country was mapped." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 1.
    • "Sightsavers’ country programs work with a country’s ministry of health (MOH) to identify implementation units (such as districts) in need of MDAs for each disease. This determination is based on data about the disease’s prevalence in the area obtained through mapping. Sightsavers may conduct the mapping itself, or it may be done by other organizations. For example, Sightsavers has received funding from the Children’s Investment Fund Foundation (CIFF) to map the prevalence of schistosomiasis and soil-­transmitted helminthiasis (STH) in Nigeria. Sightsavers also coordinates the Global Trachoma Mapping Project (GTMP), funded by the U.K.’s Department for International Development (DFID), which has supported a great deal of trachoma mapping." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pgs 1-2.
    • "The project started with a workshop in May 2017, which was attended by regional health and education directors from all 11 health regions of Guinea Bissau, as well as senior Ministry of Health and Ministry of Education officials at the national level. Following this meeting, World Health Organisation / Regional Programme Review Group (RPRG) and Sightsavers conducted a high-level technical support visit to Guinea Bissau to help the national team to develop a roadmap. This visit also finalised the SCH and STH re-mapping protocol. This was necessary as the existing baseline data was from 2005 and was therefore unlikely to give an accurate picture of current prevalence rates. The Ministry of Health with support from Sightsavers developed the protocol for the re-mapping. In October 2017, the survey protocol was finalised and submitted to the National Ethics Committee for review and approval. Training then began for those involved in the mapping exercise. From November 2017 to February 2018, the nationwide re-mapping of the diseases sampled 122 schools across the country. The objective of the re-mapping was to re-evaluate the SCH and STH prevalence by region." Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 2.
  • 29.
  • 30.

    "On shipment, drugs are initially delivered to National Central Medical Stores in Lagos. Drugs are then distributed to Sightsavers-supported State Ministry of Health Central Medical Stores, and through the health system to local government area medical stores for delivery in Sightsavers’ target areas." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 4.

  • 31.
  • 32.
    • "Sightsavers’ selection criteria for Treatment coverage surveys: It will not be possible to conduct the survey after every round of MDA but if there is funding it is recommended a coverage survey is conducted:
      • After the first round of MDA in an area
      • If there are suspected issues with the health system or Community Health Worker (CHW) records or census data that need to be verified e.g poor population data, discrepancies between the drug store records/logs and the Community health Worker records or large variations in doses given year to year
      • If the health system or Community Health Worker records show particularly low coverage e.g less than 60% or high coverage e.g 95 to over 100%
      • If there have been issues in the area of operation with MDA coverage reporting in the past"

      Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016

    • "Dr. Elhassan noted that Sightsavers has always followed a WHO protocol recommending that coverage surveys be conducted at a program's 1-, 3-, and 5-year marks." GiveWell's notes from its 2016 site visit to Ghana, Pg 6.
  • 33.

    Sightsavers originally planned to conduct coverage surveys every 1-2 years and on our request plans to increase that to all MDAs (i.e., annually).

    • See "Output Indicator 2.3: Number of treatment coverage surveys conducted with data disaggregated by age group and gender and school attendance" and cells E123-129, G123-129, Sightsavers, Deworming program consolidated logframe, September 2017 update, Sheet "Consolidated."
    • "[GiveWell:] Would it be feasible to do coverage surveys in for MDAs in 2018 as well? None are currently scheduled. Approximately, how much would this cost (so we can add it to the wishlist)?
      [Sightsavers:] Treatment coverage surveys have been partially budgeted for in Sightsavers’ new wishlist recently submitted to GiveWell, as such:
      • Guinea Conakry - TCS are included in our 2018 and 2019 wishlist budget requests
      • Cameroon – TCS are included in our 2018 and 2019 wishlist budget requests
      • DRC – TCS are included in our 2018 and 2019 wishlist budget requests
      • Nigeria Bauchi State – TCS are included in our 2018 and 2019 wishlist budget requests
      • Nigeria Yobe State - TCS are included in our 2018 and 2019 wishlist budget requests

      However, we omitted to include TCS for each individual state in the Nigeria 4 States project, and also in the Benue state project. For these to be added into the programs in 2018, Sightsavers would wish to request the following additional funding added into our wishlist request. [...] Looking ahead, we would wish to add 2019 TCS budget requests for the same locations into a 2019 wishlist, should this become a possibility." Sightsavers, Responses to GiveWell questions, October 2017, Pg 2.

  • 34.
    • Quality standards assessments:
      • "Our quality standards manual is operationalised via the QSAT (our quality standards assessment tool). It is during a QSAT exercise that Sightsavers will review the listed means of verification per requirement, and rate each accordingly. A QSAT exercise may be conducted at one or more points of a project, including baseline, during implementation or at evaluation. When QSATs are required is established at the design phase of a project. To support a QSAT exercise, Sightsavers has developed means of verification guidance per technical theme. This guidance is to help an assessment team make a rating decision as it outlines what Sightsavers expects for a requirement to achieve a rating of fully met, mostly met and so on. The review of the means of verification is conducted at the source location. Where an interview is a means of verification, a list of questions to be asked should be agreed at the QSAT planning stage." Comment provided by Sightsavers in response to a draft of this page in November 2017.
      • "In Guinea for example, a thematic QSAT, conducted in December 2017, contains requirements grouped under the subheadings of; service delivery; health workforce; and programme effectiveness. Each of these requirements can be; not applicable; not met; partially met; mostly met; or fully met, subject to a score derived through the set means of verification (MoV). MoV’s include a mix of published documentation, such as drug stock ledgers or NTD master plans, and interviews with key stakeholders." Sightsavers, Global report for all GiveWell funded projects, 2018, Pg. 8.
    • Spot checks on program data by the central Program Systems and Monitoring Team (PSMT): "The NTD team are backed-up centrally by the Sightsavers PSMT team, who oversee all monitoring within Sightsavers. Team members are based in the UK Head Office, as well as in West and East Africa Regional Offices. Their role includes supporting programme staff with proposal and project development, developing programme monitoring guidance and tools, facilitating the input and finalisation of project and organisational data and undertaking spot checks of programme data." Sightsavers, Global report for all GiveWell funded projects, 2018, Pg. 8. See also GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pg. 3-4.
    • Prevalence surveys at sentinel sites: see GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pg. 2 for more details. Note also the following caveat from Sightsavers: "Assessing the impact of treatment programs on schistosomiasis and STH prevalence levels generally requires conducting pre- and post-treatment prevalence surveys. However, for routine programming, treatment plans are based on prevalence mapping results, and post-treatment surveys are unlikely to be undertaken, particularly while the program is ongoing. As treatments are effective when taken properly, high coverage rates likely result in a reduction in prevalence levels over time." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, April 5, 2016, Pg 3.
  • 35.

    Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018. Note that as of May 2018, GiveWell has not yet reviewed a completed QSAT analysis.

  • 36.

    Comment provided by Sightsavers in response to reviewing a draft of this page in November 2016.

  • 37.

    See our review of SCI.

  • 38.
  • 39.

    GiveWell's notes from its 2016 site visit to Ghana

  • 40.
  • 41.

    These budgets are supposed to provide enough detail for Sightsavers to know, for example, what the programs are paying in per diems. GiveWell's notes from its 2016 site visit to Ghana

  • 42.
  • 43.
  • 44.
    • "SCH and STH MDA generally uses a school based treatment strategy in all LGAs, and community based treatments in those LGAs with a prevalence rate of over 50%. Due to learning arising from this project, we have changed to a combination of school and community based treatments in all states in order to target out-of-school children. This is particularly important in areas where enrolment in public schools is low, for example in Northern states where the majority of children attend Islamic schools." Sightsavers, Country narrative report, Nigeria Four States, Pg 1.
    • "Output 2 - Treat school aged children between 5-15 years for STH and for schistosomiasis through MDA. … Activities … Conduct monitoring and supportive supervision of school based and community based MDA.", Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pg 6.
  • 45.
    • "GiveWell’s support is enabling MDA in a total of 51 local government areas (LGAs) across the four states, including the following numbers in each state:
      • Kebbi state: Schistosomiasis – 12 LGAs / STH - 0
      • Kogi state: Schistosomiasis –13 LGAs / STH – 9 LGAs
      • Kwara state: Schistosomiasis –11 LGAs / STH – 5 LGAs
      • Sokoto state: Schistosomiasis –15 LGAs / STH – 3 LGAs"

      Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pg 2.

    • "In Sokoto state, one Local Government Area, Kebbe, has a prevalence of >50% for Schisto, as per WHO protocol, the Mass drug administration strategy in that LGA will include treating adults. The target is 75,631." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Nigeria 4 States Project," Cell C10.
    • See map of Sokoto state indicating that Kebbe will be treated for both schistosomiasis and STH: Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pg 5.
  • 46.
    • "In 2017 Sightsavers has received additional complementary funding from the Schistosomiasis Control Initiative (SCI) to support scaling up our deworming work in these four states to full capacity as well as supporting work in Jigawa state. SCI have recently (March 2017) provided Sightsavers with a grant of £398,898 to support activity until September 2017." Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pg 1.
    • Number of SCI-supported LGAs derived from the maps presented at Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pgs 2-5.
    • We note we do not know why Sightsavers applies GiveWell-directed funds to certain LGAs and SCI funds to others. We have not pursued this question as we think it is unlikely to affect our decision-making.
  • 47.
    • "School aged children between 5-15 years in all schools and communities within the intervention zone are effectively treated with mebendazole/albendazole and praziquantel yearly. This will be integrated with onchocerciasis and Lymphatic Filariasis (LF) activities to provide 17.3 million treatments for onchocerciasis and LF in an integrated manner." Sightsavers, GiveWell Project Narrative, Benue State Nigeria 2017, Pg 1.
    • Sightsavers set out how it integrates treatment in Benue state as follows: "In LGAs co-endemic with SCH, STH, onchocerciasis and LF, we aim to integrate CDD [community drug distributor] training, community sensitization and advocacy. If all necessary drugs arrive at the same time, we are also able to integrate drug distribution, taking into account an interval of two weeks for the distribution of the actual drugs (as required by the Standard Operating procedures for NTDs in Nigeria Sept 2015 – see document 6.1).

      "For example, in an onchocerciasis, LF and SCH endemic community, CDD training, community sensitization and advocacy will happen together. Mectizan® and albendazole are then administered simultaneously, whilst praziquantel will be distributed two weeks later. We do not implement triple drug treatments even when other activities are integrated.
      Although Benue MDA has not yet begun due to delays in the arrival of albendazole and praziquantel, the drug order has been approved and national drug deliveries are expected in September.

      "Once the drugs arrive in state, the deworming programme will immediately begin. Training of CDDs and teachers to administer treatments is timed to coincide with the arrival of the drugs. It is beneficial for trainees to be able to start drug administration immediately after the training whilst it’s still fresh in their minds, rather than having a break between completing the training and beginning their work." Sightsavers, Country narrative report, Benue State Nigeria, Pgs 2-3.

    • "MDA in Benue was delivered under time pressure due to the late arrival in the state of both albendazole and praziquantal. We expected the drugs to arrive in October but the praziquantal only arriving at the end of December. Due to schools being closed for the Christmas holidays, MDA activities such as teacher training could not commence until early January 2018 when the schools were back in session.
      In year 1, as the drugs did not arrive all together, the project team delivered pre MDA activities for STH and SCH separately from all other NTD activities. This meant that MDA training and sensitisation could not be fully integrated in year 1." Sightsavers, Country narrative report Benue State, Nigeria, 2018, Pg. 2.
    • "Only school aged children will be targeted in Benue state as none of the LGAs qualitify [sic] for community MDA. However, a very small proportion of adults will be targeted within the schools - ie. teachers. Teachers are targeted after students are treated and there is balance of drugs." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Nigeria Benue State Project," Cell C10.
    • "In Benue State, all treatment for schistosomiasis and STH has been school-based; only onchocerciasis and LF treatments have been community-based." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, June 7, 2018, Pg. 2.
    • For more detail on which diseases are treated in which local government areas in Benue state see the graphic on Sightsavers, GiveWell Project Narrative, Benue State Nigeria 2017, Pg 1.
  • 48.
  • 49.

    "Implementation of the proposed project
    The following activities will be conducted:
    ...

    • Mobilization and sensitization of communities and schools to participate in MDA activities. The strategy for reaching non-enrolled school aged children will be for health workers and/or community members to distribute praziquantel in communities, especially targeting Qur’anic/Sangaya schools in the evenings as is done in Kano and Jigawa states. The project will work with CDDs, health workers and women’s community groups to mobilize the community members.
    • Teachers to conduct MDA in schools and front line health facility staff to implement MDA in the communities."

    Sightsavers, Deworming wishlist, Yobe State, Nigeria 2018-19, explanatory narrative, Pg. 3.

  • 50.
    • "In addition [to GiveWell-directed funding], for our wider NTD work within these integrated NTD programs, funds are made available from:
      - Sightsavers unrestricted funds
      - The UK Government's UKAID match - who are funding Sightsavers oncho and LF elimination program in four states (Kebbi, Kogi, Kwara and Sokoto states with a grant of £1,435,440 from April 2016 – March 2019". Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Nigeria 4 States Project," Cell C8.
    • "In 2017, Kogi State released a financial contribution to the State NTD unit of N16 million ($50,000). The Kogi State NTD Unit (which Sightsavers works in partnership with) supports activities to tackle onchocerciasis, lymphatic filariasis, STH and SCH." Email from Amanda Jordan, Trusts Manager, Sightsavers dated 3 July 2018.
    • "In addition [to GiveWell funding], funds are made available from:
      - The UK Government's UKAID match - who are funding Sightsavers oncho and LF elimination program with a grant of £108,103 from April 2016 - March 2019.
      - Sightsavers unrestricted funds." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Nigeria Benue State Project," Cell C8.
    • "Delivering this project will be cost effective as it is a part of NTDs programme which is already ongoing in all the beneficiary states." Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pg 16 and Sightsavers, GiveWell Project Narrative, Benue State Nigeria 2017, Pg 11.
  • 51.
    • Sightsavers used its unrestricted funding to support deworming in Kebbi, Kogi, Kwara and Sokoto states in 2015: see the charts in Sightsavers, Descriptions of current work - 2015 and 2016, Pgs 4 and 6.
    • "The four projects Sightsavers submitted information on to GiveWell in May 2015, Kebbi state, Kogi state, Kwara state and Sokoto state, all took place as planned….Looking forward, 2016 budget expenditure for the onchocerciasis and LF elements of these four state programs is now expanded due to securing a new grant through the UKAID match program run by the UK government’s Department for International Development. This funding is for three years, 1 April 2016 – 30 March 2019, and will support the scale up of onchocerciasis and LF activities specifically in the four states." Sightsavers, Descriptions of current work - 2015 and 2016, Pgs 4-5.
    • "We secured further new funding for the Sokoto State integrated NTD program from the Jersey Overseas Aid Commission, who will support the programme with a grant over three years from January 2016." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 6.
  • 52.

    Commencing a project in Benue state was proposed to GiveWell by Sightsavers:

    "2016 estimated costs featured in Sightsavers Phase 1 submission (to scale up in 4 states and begin work in Benue state at $415,973)." GiveWell, Analysis of Sightsavers deworming wishlist, 2016, Sheet "Deworming wishlist," Cell F14.

  • 53.

    "Yobe state has been supported by the NGOs CBM / HANDS for the implementation of MDA for the five NTDs over the years. There is, however, an existing gap in the ability to scale-up support for schistosomiasis control to all the endemic LGAs in the state." Sightsavers, Deworming wishlist, Yobe State, Nigeria 2018-19, explanatory narrative, Pg. 4.

  • 54.
    • "Sightsavers’ Nigeria country office is based in Kaduna with 35 staff, led by Country Director Sunday Isiyaku. Sightsavers also has a small annex office in the capital city of Abuja. The Government of Nigeria is responsible for program implementation in Sightsavers-supported state programs. Training on mass drug administration (MDA) is cascaded, with the Federal Ministry of Health supporting the training of the State NTD Teams, who in turn train the local government area (LGA) NTD teams. The LGA teams train the frontline health facility workers who train the community directed drug distributors. Supply of drugs flows through the same levels. Similarly, monitoring of MDA follows through the same channels and cascaded monitoring is undertaken. Reporting flows from the community level up to the federal level. NGO staff in all states provide technical support and conduct targeted monitoring and supportive supervision." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 3.
    • "Sightsavers - Inputs to be provided:
      • Advocacy to state and other stakeholders.
      • Facilitate the distribution of NTDs control drugs to endemic communities working with the Federal Ministry of Health (FMOH).
      • Procurement of NTDs control drugs for each state.
      • Logistical support - donation of vehicles, equipment and instruments.
      • Provide information, education and communication materials.
      • Provide technical oversight on programme and financial activities for the programme.
      • Undertake monitoring and supervision."

      Sightsavers, GiveWell Project Narrative, Nigeria Four States 2017, Pg 3 and Sightsavers, GiveWell Project Narrative, Benue State Nigeria 2017, Pg 3.

  • 55.
  • 56.
  • 57.

    "Sightsavers' broader NTD elimination projects in Guinea Bissau are funded through the following means:
    - Trachoma elimination project - funded in 2017 through use of Sightsavers unrestricted funds.
    - Oncho and LF elimination project - funded through the UK Government's UKAID match scheme - in all 11 regions with a grant of £840,000 from April 2016 - March 2019," Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Guinea Bissau project," Cell C7.

  • 58.
    • "Country: Guinea Bissau … Duration: Two years, in the first instance, January 2017 – December 2018", Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 1.
    • "The support from Givewell will enable the Ministry of Health (MOH) NTD programme to scale up to support programming for schistosomiasis and STH; this will start with a reassessment of baseline endemicity levels and corresponding treatment plans. The surveys supported by Givewell will support all provinces with the exception of the Bijagos archipelago – wherein high resolution baseline mapping is being supported by the London School of Hygiene and Tropical Medicine." Sightsavers, GiveWell Project Narrative, Guinea-Bissau 2017, Pg 1.
  • 59.

    "Sightsavers' broader NTD elimination projects in Guinea Bissau are funded through the following means:
    - Trachoma elimination project - funded in 2017 through use of Sightsavers unrestricted funds.
    - Oncho and LF elimination project - funded through the UK Government's UKAID match scheme - in all 11 regions with a grant of £840,000 from April 2016 - March 2019," Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Guinea Bissau project," Cell C7.

  • 60.

    "The project started with a workshop in May 2017, which was attended by regional health and education directors from all 11 health regions of Guinea Bissau, as well as senior Ministry of Health and Ministry of Education officials at the national level. Following this meeting, World Health Organisation / Regional Programme Review Group (RPRG) and Sightsavers conducted a high-level technical support visit to Guinea Bissau to help the national team to develop a roadmap. This visit also finalised the SCH and STH re-mapping protocol. This was necessary as the existing baseline data was from 2005 and was therefore unlikely to give an accurate picture of current prevalence rates. The Ministry of Health with support from Sightsavers developed the protocol for the re-mapping. In October 2017, the survey protocol was finalised and submitted to the National Ethics Committee for review and approval. Training then began for those involved in the mapping exercise. From November 2017 to February 2018, the nationwide re-mapping of the diseases sampled 122 schools across the country. The objective of the re-mapping was to re-evaluate the SCH and STH prevalence by region." Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 2.

  • 61.

    "The support from Givewell will enable the Ministry of Health (MOH) NTD programme to scale up to support programming for schistosomiasis and STH; this will start with a reassessment of baseline endemicity levels and corresponding treatment plans. The surveys supported by Givewell will support all provinces with the exception of the Bijagos archipelago – wherein high resolution baseline mapping is being supported by the London School of Hygiene and Tropical Medicine. Sightsavers is in close communication with LSHTM about this mapping and as planned will support the MOH with any required interventions in this archipelago." Sightsavers, GiveWell Project Narrative, Guinea-Bissau 2017, Pg 1.

  • 62.
    • "In April 2018, SCH/STH MDA was successfully delivered in seven regions; five for SCH, two for STH" Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 3.
    • Sightsavers described how those regions were chosen following the remapping as follows:
      "An external consultant was appointed to analyse data and provide a final report on the mapping results and treatment recommendations to the Ministry of Health. Sightsavers technical staff analysed the same data as the consultant, but due to differences in interpretation of World Health Organisation guidelines, came to different prevalence figures and therefore different treatment recommendations. Both sets of results were presented to the Ministry of Health and it was decided to start treatment on the non-contentious regions in early April 2018. In early May a decision was taken to treat the contentious areas highlighted in the impact survey, based on the Ministry of Health’s desire to treat the maximum number of people potentially at risk. These three areas will be treated in May 2018 and are not included in the output table below. We will report on these treatment numbers separately to year 1 and year 2 output reporting." Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 2.
    • "Treatments for school aged children in Guinea Bissau will be delivered through both school based treatment and community based treatment." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Guinea Bissau project" Cell C11.
    • "Output 2 … Treat school aged children between 5-14 years for STH and for schistosomiasis through mass drug administration (MDA).
      Activities: Collaborate with the NTD team of the Ministry of Health (MoH), Ministry of Education (MoE) and other partners to annually plan MDA, targeting both schools and communities." Sightsavers, GiveWell Project Narrative, Guinea-Bissau 2017, Pg 3.
  • 63.
    • "An external consultant was appointed to analyse data and provide a final report on the mapping results and treatment recommendations to the Ministry of Health. Sightsavers technical staff analysed the same data as the consultant, but due to differences in interpretation of World Health Organisation guidelines, came to different prevalence figures and therefore different treatment recommendations. Both sets of results were presented to the Ministry of Health and it was decided to start treatment on the non-contentious regions in early April 2018. In early May a decision was taken to treat the contentious areas highlighted in the impact survey, based on the Ministry of Health’s desire to treat the maximum number of people potentially at risk." Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 2.
    • "Spot-check of prevalence will continue within the three contentious regions to monitor the need for treatment in future years." Sightsavers, Country narrative report Guinea-Bissau, 2018, Pg. 5.
  • 64.
    • Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018.
    • "Sightsavers - Inputs to be provided:
      • Provide technical and financial support throughout the project cycle;
      • Support in capacity building for partners, programme monitoring and quality assurance;
      • Advocate for increased government ownership;
      • Ensuring that donor requirements are met."

      Sightsavers, GiveWell Project Narrative, Guinea-Bissau 2017, Pg 5.

    We're not sure what activities, specifically, "quality assurance" refers to.

  • 65.
    • "Output 2 Treat school aged children between 5-14 years for STH and for schistosomiasis through mass drug administration (MDA). Activities … Collaborate with the NTD team of the Ministry of Health (MoH), Ministry of Education (MoE) and other partners to annually plan MDA, targeting both schools and communities." Sightsavers, GiveWell Project Narrative, Guinea-Bissau 2017, Pg 3.
    • "Sightsavers - Inputs to be provided:
      • Provide technical and financial support throughout the project cycle;
      • Support in capacity building for partners, programme monitoring and quality assurance;
      • Advocate for increased government ownership;
      • Ensuring that donor requirements are met."

      Sightsavers, GiveWell Project Narrative, Guinea-Bissau 2017, Pg 5.

  • 66.
    • "Sightsavers Cameroon has partnered with the Ministry of Public Health (MoH) since 1996, with our early work focused on the fight against onchocerciasis in Cameroon. This work comprised of a community-based onchocerciasis control project in Haute Sanaga Division, Centre Region." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 9.
    • "Sightsavers has supported school based mass drug administration as part of integrated NTD programs in three regions of Cameroon since 2011, South-West, North West and West." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 8.
  • 67.
    • "Sightsavers Cameroon has partnered with the Ministry of Public Health (MoH) since 1996, with our early work focused on the fight against onchocercisasis in Cameroon. This work comprised of a community-based onchocerciasis control project in Haute Sanaga Division, Centre Region. Following the advent of the African Programme for Onchocerciasis Control (APOC) and the Community Directed Treatment with Ivermectin (CDTI) strategy, Sightsavers expanded program activities to the South West and North West regions in 1998 and 2003 respectively. In 2003, in order to ensure that NGOs had a regional focus, the Haute Sanaga Project was ceded to Helen Keller International." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 9.
    • "On an annual basis, a fixed obligation grant agreement is signed with Helen Keller International (USAID grantee) for implementation of regional program activities with USAID funds. Agreements are also signed with regional delegation teams to ensure fulfilment of annual obligations." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 9.
    • "All projects in Cameroon are integrated schistosomiasis/STH programs. Most of the current funding is provided by USAID, and the key recipient is Helen Keller International (HKI). Sightsavers is one of the non-­governmental organization (NGO) partners with which HKI works." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pg 6.
    • "Sightsavers was supporting MDA to tackle SCH and STH in the three regions of South West, North West and West Cameroon with funding from Helen Keller International (USAID) and Sightsavers unrestricted funds. However, this funding is no longer available due to the withdrawal of funding." Sightsavers, Country narrative report Cameroon, 2018, Pg. 3.
  • 68.
  • 69.
    • "The project has three key outcomes:
      1) To complete sub-district level population-based SCH/STH prevalence surveys
      2) To develop a Behaviour Change Communications (BCC) plan and evaluation strategy based on the use of environmental cues ('nudges') which engage unconscious decision-making processes to prompt behavior change (see recent research of Dreibelbis et al. 2015).
      3) To train field actors (health professionals, community members) and teachers to undertake BCC activities in schools and communities where the prevalence of schistosomiasis or STH is determined to still be >50%* after five effective rounds of MDA (>75% coverage of school-aged children)." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Cameroon project," Cell C6.
      • "Objective 1: Complete population-based schistosomiasis / STH prevalence surveys in 15 districts in the three regions. ...
      • Objective 2: Develop a behaviour change communication plan and evaluation strategy based on recent research by Dreibelbis et al. in the three supported regions. ...
      • Objective 3: Train field actors (health professionals, community members and teachers) to undertake behaviour change communication activities in schools and communities. ...
      • Objective 4: To improve hygiene and sanitation practices amongst school aged children (SAC) and parents in communities."

      Sightsavers, GiveWell Cameroon Project Concept Note, Pg 10.

    • "Based on the parasitological survey to be conducted in February 2018, the most SCH endemic health districts will be chosen to conduct SBCC activities related to SCH and STH. During this survey, sentinels sites will be established and will serve as reference points during impact assessment studies. A total of six health districts will be targeted by the project." Sightsavers, GiveWell Project Document Cameroon, Pg 8.
    • "The six chosen health districts for this SBCC project (highlighted in red [in the table "Treatments to date in 2017") show high baseline prevalence; therefore, effective SBCC and WASH activities are likely to significantly reduce transmission of SCH and STH," Sightsavers, Country narrative report, Cameroon, Pg 1
  • 70.

    "Sightsavers was supporting MDA to tackle SCH and STH in the three regions of South West, North West and West Cameroon with funding from Helen Keller International (USAID) and Sightsavers unrestricted funds. However, this funding is no longer available due to the withdrawal of funding. Sightsavers is currently in negotiations with the Ministry of Health to establish how much of the MDA activity they can contribute to and how much of a funding gap there is." Sightsavers, Country narrative report Cameroon, 2018, Pg. 3.

  • 71.
    • "As our planned WASH activities are aimed at complementing SCH/STH MDA, if there is insufficient funding for a national MDA programme, Sightsavers suggests reallocating the GiveWell budget and the quarterly payments to fill MDA funding gaps in the first instance and continuing to support complementary WASH and SBCC activities where possible." Sightsavers, Country narrative report Cameroon, 2018, Pg. 3.
    • MDA is expected to take place in required regions in October/November 2018." Sightsavers, Country narrative report Cameroon, 2018, Pg. 3.
  • 72.
    • "Sightsavers has supported NTDs in Guinea since 1993 through community directed treatment with ivermectin (CDTI) for onchocerciasis control, when it initiated a pilot project covering the sub-districts of Kègnèko, Saramoussaya and Ourékaba in the district of Mamou," Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
    • "In more recent years Sightsavers has extended its work in Guinea to support trachoma and LF elimination activities in 23 Health Districts (15 districts for trachoma and 8 districts for LF). This narrative project plan presents how Sightsavers support will now expand to support mass drug distribution for schistosomiasis and STH in districts with high prevalence, with the explicit intention of helping the Guinea government effect disease control." Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
  • 73.
    • "In more recent years Sightsavers has extended its work in Guinea to support trachoma and LF elimination activities in 23 Health Districts (15 districts for trachoma and 8 districts for LF). This narrative project plan presents how Sightsavers support will now expand to support mass drug distribution for schistosomiasis and STH in districts with high prevalence, with the explicit intention of helping the Guinea government effect disease control." Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
    • "Sightsavers Deworming Programme - Guinea GiveWell Schistosomiasis / STH Project Narrative
      Project Name: Guinea GiveWell schistosomiasis and STH project
      Country: Guinea
      Location: Districts of N’zérékouré, Lola and Yomou.
      Duration: Two years, in the first instance, January 2017 – December 2018" Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
    • "A gap exists in three health districts which have the highest prevalence in the country; N'Zérékoré, Lola and Yomou." Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
    • "MDA for SCH and STH was successfully completed in Guinea Conakry in May 2017." Sightsavers, Country narrative report Guinea, 2018, Pg. 2.
  • 74.

    "Sightsavers deworming programme Guinea Conakry ... Duration: Two years, January 2017 – December 2018". Sightsavers, Country narrative report Guinea, 2018, Pg. 1.

  • 75.

    "As per our project plan, we will expand SCH MDA activities in 2018 to include five additional health districts in need of treatment; Fria, Coyah, Dubreka, Matoto and Ratoma. Two of these districts are urban. MDA in urban areas is new for Sightsavers in Guinea and different delivery methods are needed. For example, more education is needed in urban areas as people request more detailed information before agreeing to accept treatment.
    In the urban areas, school based treatments should proceed well, due to high enrolment rates in urban areas, but house to house delivery can be challenging due to people not working near their residence.
    In 2018, utilising GiveWell funding for year 2, we will continue to support SCH and STH treatments in N'Zérékoré, Lola and Yomou, as well as, support SCH treatments in the additional five health districts." Sightsavers, Country narrative report Guinea, 2018, Pg. 5-6.

  • 76.
    • "Soil-transmitted helminthiasis (STH) and schistosomiasis are endemic in 17 and 31 health districts respectively, and co-endemic in a further 15. Mass Drug Administration (MDA) for both diseases is largely supported by Helen Keller International / ENVISION." Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
    • "In more recent years Sightsavers has extended its work in Guinea to support trachoma and LF elimination activities in 23 Health Districts (15 districts for trachoma and 8 districts for LF). This narrative project plan presents how Sightsavers support will now expand to support mass drug distribution for schistosomiasis and STH in districts with high prevalence, with the explicit intention of helping the Guinea government effect disease control." Sightsavers, GiveWell Project Narrative, Guinea Conakry 2017, Pg 1.
  • 77.
  • 78.

    "Sightsavers: Inputs to be provided:

  • 79.

    "Sightsavers has been supporting an onchocerciasis elimination project in the Democratic Republic of the Congo (DRC) since 2011, supporting the community directed distribution of Ivermectin (CDTI)." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 14.

  • 80.

    "Our project operates in three areas of Lubutu Nord in Maniema province, Ituri Nord in Oriental province and Katanga Sud in Katanga province. Sightsavers provides support for this work through the United Front Against Riverblindness (UFAR) – a US-based non-profit organization established in 2004, which has been involved since 2006 in the control and elimination of onchocerciasis in DRC. Through established agreements Sightsavers has been providing support to UFAR to support the CDTI projects of Lubutu and Ituri Nord since 2011 and the CDTI project of Katanga Sud since 2013. All three projects are targeted for the elimination of onchocerciasis by 2025." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 14.

  • 81.
    • "Sightsavers deworming programme, Democratic Republic of the Congo (DRC)...GiveWell schistosomiasis (SCH) and soil transmitted helminths (STH) project... … Location: Ituri Nord, Ituri Province … Duration of project: Three years, January 2017 – December 2019", Sightsavers, Country narrative report DRC, 2018, Pg 1.
    • "The support from GiveWell covers eight districts that are SCH and/or STH endemic. Six of these districts required treatment in 2017 and as such, MDA was undertaken." Sightsavers, Country narrative report DRC, 2018, Pg. 1.
    • "Within the Ituri Nord project area, five of the eight health zones eligible for STH / schistosomiasis MDAs overlap with those in the oncho /LF elimination programme. As such, some support for deworming activities in these five health zones may be leveraged from the existing MDA program." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "DRC Project," Cell C8.
  • 82.
  • 83.
  • 84.

    "Stakeholder: Sightsavers / UFAR; Inputs to be provided:

    • Advocacy to state and other stakeholders;
    • Facilitate in collaboration with Ministry of Health, the distribution of NTD control drugs to endemic communities;
    • Lead on procurement of NTD control drugs for the country;
    • Logistical support, including donation of equipment and instruments;
    • Provide information, education and communication materials to projects;
    • Provide technical oversight on programme and financial activities for the programme;
    • Undertake monitoring and supervision;
    • Provide timely funds for field activity."

    Sightsavers, GiveWell Project Narrative, DRC 2017, Pg 5.

  • 85.

    GiveWell's notes from its 2016 site visit to Ghana, Pg 1.

  • 86.

    Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016

  • 87.

    Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018.

  • 88.

    Countries that don't have a country director based in-country include Guinea, Cote d'Ivoire, Guinea-Bissau, Burkina Faso, Togo, Benin, Niger, and DRC. GiveWell's notes from its 2016 site visit to Ghana

  • 89.
    • GiveWell's notes from its 2016 site visit to Ghana
    • For example, the project in the DRC that is supported by GiveWell-directed funds is implemented through Sightsavers' partner office, UFAR (United Front Against River Blindness). Sightsavers, Responses to GiveWell questions, May 2017, Sheet "DRC project", Cell C7 describes the staffing of UFAR's office and how its staff allocate time to the projects GiveWell-directed funds support.
    • "Sightsavers has a strong in-country presence in each of the countries we work in. Sightsavers has country offices in 24 countries led by experienced Country Directors and supported by teams of expert staff. Where we do not have an established country office, Sightsavers’ staff are embedded with the partner organization. Please see the map below detailing where we work." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 1.
  • 90.
    • "Several of the country offices also have an M&E manager, who works with the NTD team but reports to the country director. Sightsavers also works closely with the NTD departments at the countries’ ministries of health and often has an NTD manager working inside the ministries’ offices." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pg 6.
    • Other M&E staff include:
      • Monitoring and Evaluation Officers. For example, in 2017 Sightsavers hired dedicated Monitoring and Evaluation officers to support projects in Guinea-Bissau and Guinea Conakry. Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Guinea Bissau project", Cell C7 and Sheet "Guinea Conakry project", Cell C7.
      • Data Officers. For example, in 2017 a Data Officer in the Nigeria Country office was devoted (10% time) to "provid[ing] data management support to [Benue, Kebbi, Kogi, Kwara and Sokoto] states on data entry, analysis and cleaning of data to ensure its accuracy." Sightsavers, Responses to GiveWell questions, May 2017, Sheet "Benue state project", Cell C7.
    • "We have promoted the idea of having NTD Managers in country (reporting to the country director/regional office) and a number of these positions are in place. We need to review if this structure has worked and also if capacity building/training is required in core areas of NTD work." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 27.
    • “[R]ecently Sightsavers has added NTD technical staff to its program management.” Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018.
  • 91.

    The technical advisors also review Program Managers' reports and discuss any issues with the reports, and help analyze the data Sightsavers collects via monitoring. GiveWell's notes from its 2016 site visit to Ghana, Pg 2.

  • 92.

    Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018.

  • 93.

    GiveWell's notes from its 2016 site visit to Ghana

  • 94.

    Partners are assessed for financial competence before projects are initiated and the frequency of reporting is agreed upon at that point – for most partners reporting is required either every month or on a quarterly basis. The finance team often visits partners with the program officers to help assess partners' work. Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016

  • 95.

    Sightsavers, Organizational expenditure 2014 and 2015, Sightsavers, Finances 2016 actual and 2017 planned, Sheet "Organisational expenditure" and Sightsavers, Organizational expenditure 2016 and 2017.

  • 96.
  • 97.

    Sightsavers, Organizational expenditure 2016 and 2017. Also see our summary of Sightsavers' spending in the table below.

  • 98.

    Sightsavers, Organizational expenditure 2014 and 2015, Sightsavers, NTD Project Expenditure, 2014-2016, Sightsavers, Finances 2016 actual and 2017 planned, Sheet "Organisational expenditure" and Sightsavers, Organizational expenditure 2016 and 2017.

  • 99.

    See this spreadsheet for details.

  • 100.

    See this spreadsheet for details.

  • 101.

    See this spreadsheet, row 25.

    Also see our summary of Sightsavers' spending in the table below.

  • 102.

    Sightsavers, NTD Project Expenditure, 2014-2016 and Sightsavers, Finances 2016 actual and 2017 planned, Sheet "Organisational expenditure." See our spreadsheet for a breakdown in USD.

    Note that the final figures for NTD spending in these documents do not include the indirect cost allocation that Sightsavers adds to all projects for its central costs. See note from Sightsavers: "Expenditure includes project values only and does not include the cost recovery or large programmatic core spend," Sightsavers, Finances 2016 actual and 2017 planned, Sheet "NTD Portfolio 2016-2017," Cell A87.

  • 103.

    See our spreadsheet, Sheet "2014-2017 spending by NTD," Cell K112.

  • 104.

    See this spreadsheet, Sheet "Budget for/disbursements of GW-influenced funds," cell B30.

  • 105.

    Note the data for Guinea-Bissau was not available due to a delay in the MDA: "In order to accommodate the impact survey, the MDA was rescheduled for April 2018. Therefore expenditure figures for this activity were unavailable at the time of creating this report. We have provided an estimate of the expenditure on the project activities, budget line, and will submit final figures, along with verified outputs when these are available." Sightsavers, Financial report narrative for GiveWell funded projects for year 1 activities, 2018 Pg. 1-2.

  • 106.

    See our spreadsheet, Sheet "Budget for/disbursements of GW-influenced funds."

  • 107.

    See this spreadsheet, Sheet "Total spending 2014-2017," Row 8.

  • 108.

    Sightsavers staff, conversation with GiveWell, October 2, 2016

  • 109.

    Sightsavers staff, conversation with GiveWell, October 2, 2016

  • 110.
    • As of March 2018, Sightsavers had supported six projects using GiveWell-directed funds, five projects delivering deworming treatments via MDA and one research project. Sightsavers, Global report for all GiveWell funded projects, 2018, Pg. 1.
    • Sightsavers did not conduct a coverage survey in Benue, Nigeria in year 1 of its GiveWell-supported work: "Due to the security situation in Benue, we have not been able to access the Year 1 MDA locations. We prefer not to run a TCS more than 3 months after MDA as there is an increased chance of poor recall and confusion. Therefore, we have decided not to run the Year 1 TCS in Benue." Amanda Jordan, Trusts Manager, email to GiveWell, July 20, 2018.
  • 111.

    See this spreadsheet, "Comprehensiveness" sheet.

  • 112.

    For more detail about the study and its methodology, see GiveWell's non-verbatim summary of a conversation with Sightsavers staff, June 7, 2018, Pg. 2.

  • 113.
    • Sightsavers told us that its program supervisors conduct monitoring visits to check that program activities at national and local levels are being implemented as intended ("routine monitoring"): "In all MDAs, supervisors should conduct routine monitoring of the work of community CDDs by using checklists for each monitoring level (for example, local and national) and produce reports for the implementation areas. Sightsavers told us that it could share these reports, which differ from those generated through Sightsavers' newly developed quality standard assessment tool (QSAT)." GiveWell's notes from its 2016 site visit to Ghana, pg. 7.
    • Sightsavers has shared two of these routine monitoring reports covering programs in Nigeria in 2016 (one from a trip to Kebbi state, and another from a trip to Kogi state), as well as templates for quarterly and annual monitoring reports. Sightsavers' templates suggest that monitoring reports are produced quarterly and annually, but we are uncertain if reports are produced with this frequency in practice.
    • Sightsavers has also told us that it has developed a Quality Standard Assessment Tool (QSAT) to assess (using checklists) whether programs are generally operating as intended:
      • "In all MDAs, supervisors should conduct routine monitoring of the work of community CDDs by using checklists for each monitoring level (for example, local and national) and produce reports for the implementation areas. Sightsavers told us that it could share these reports, which differ from those generated through Sightsavers' newly developed quality standard assessment tool (QSAT)." GiveWell's notes from its 2016 site visit to Ghana, Pg 7.
      • "Sightsavers QSAT does not replace routine monitoring, it is additional to it. The action plans developed after a QSAT assessment are typically followed up in routine monitoring visits following the QSAT. QSATs can be undertaken to inform project design at baseline, during the course of project implementation or at the end of a project." Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016
      • Sightsavers told us it expects to conduct a QSAT every two years on all GiveWell funded projects. (Amanda Jordan, Trusts Manager, edits to GiveWell's draft 2018 review, July 18, 2018.)
  • 114.
    • "Independent coverage assessments
      "Sightsavers conducts independent assessments of treatment coverage in order to:
      • Estimate actual treatment coverage and compare this against reported treatment coverage (the official MOH statistics)
      • Assess service delivery, or whether the treatment has been administered as recorded
      • Investigate reasons for low coverage

      "Methodology for independent assessments of treatment coverage
      "To conduct these independent assessments on a community level, Sightsavers first calculates a statistically robust sample size, then randomly selects households for surveying within randomly selected villages. All members of each household are surveyed. Sightsavers aims to minimize recall re-bias (i.e. whether respondents forget what treatments they’ve received after a long period of time elapses) by undertaking assessments within 12 weeks of the distribution and showing the tablets to the household members who are being interviewed. The survey asks each respondent whether s/he has received treatment; if treatment has not been received the reason for this is recorded (e.g. ineligibility, concern over side effects, not offered, etc.)." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pgs 2-3.

    • "Sightsavers hires external consultants to carry out coverage surveys. The process is managed by its policy and strategy department. The coverage surveys that GiveWell received are the first that were fully funded by Sightsavers; previous ones were funded by other organizations." GiveWell's notes from its 2016 site visit to Ghana, Pg 5.
  • 115.

    "Output targets: At least one TCS is included for each country and/or region, each year", Sightsavers, Global report for all GiveWell funded projects, 2018, Pg. 19.

  • 116.
  • 117.

    See this spreadsheet, "Comprehensiveness" sheet.

  • 118.
  • 119.

    We have heard conflicting reports about how often Sightsavers conducts coverage surveys across its other NTD projects, but our impression is that it does not have a regular schedule; it tends to only conduct coverage surveys after the first round of MDA or if it suspects there are issues with the program (e.g., because reports of coverage seem implausibly high or low).

    • "Sightsavers’ selection criteria for Treatment coverage surveys: It will not be possible to conduct the survey after every round of MDA but if there is funding it is recommended a coverage survey is conducted:
      • After the first round of MDA in an area
      • If there are suspected issues with the health system or Community Health Worker (CHW) records or census data that need to be verified e.g poor population data, discrepancies between the drug store records/logs and the Community health Worker records or large variations in doses given year to year
      • If the health system or Community Health Worker records show particularly low coverage e.g less than 60% or high coverage e.g 95 to over 100%
      • If there have been issues in the area of operation with MDA coverage reporting in the past"

      Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016

    • "Dr. Elhassan noted that Sightsavers has always followed a WHO protocol recommending that coverage surveys be conducted at a program's 1-, 3-, and 5-year marks." GiveWell's notes from its 2016 site visit to Ghana, Pg 6.
  • 120.
    • Guinea (2017): "Three health districts received mass treatment in May 2017: N'Zérékoré, Lola and Yomou. The coverage survey was conducted in the district of N'Zérékoré due to constraints of time and logistics. The health district N'Zérékoré was chosen according to the following criteria:
      • It has the largest number of health centers (16 in total);
      • Its strategic position in the region of the same name;
      • All the villages in this district have a school;
      • Its population is cosmopolitan, made up of people from other districts of the region (Gueckedou, Macenta, Beyla, Lola and Yomou)."

      Sightsavers, Guinea Conakry Treatment coverage survey (English translation), Pg 4-5.

    • DRC 2018: Health zones were selected for co-endemicity and for security reasons. Sightsavers, comment on a draft of this review, August 23, 2018.
  • 121.

    Sightsavers notes:
    "It would be problematic to shorten the length of time between the MDA and the TCS. It is essential that the MoH has submitted all the MDA coverage survey results and that they have been analysed before the TCS is conducted. This ensures complete separation of TCS results and MDA coverage results.
    "It is not common for children to take tablets in the communities and schools where we work. Therefore, we are confident of their recall 4 to 6 weeks post MDA."
    Comment on a draft of this review, August 23, 2018.

  • 122.

    "For context, ideally we look to do within 1-2 months after the distribution. The anomaly was in Nigeria where we decided to do an integrated treatment coverage survey which took into account multiple MDAs for different drugs over a wider timeframe, this is the exception rather than the norm for programs.

    Recall bias could be an issue but research into the recall bias of MDA has suggested that it is not as big an issue as feared and actually even 1 year after the MDA can give valid and relevant results.

    Budge et al (2016) PLOS NTD https://www.ncbi.nlm.nih.gov/pubmed/26766287"
    Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016

  • 123.
      Sightsavers, Coverage survey Guinea 2018, Sightsavers, Coverage survey Guinea-Bissau 2018, Sightsavers, Coverage survey DRC 2018 do not describe procedures to ensure that data collected was high quality.
    • Sightsavers, Coverage survey Nigeria Four States Project 2018 notes that "The supervisor ensured the quality of the data collected and transmitted … [that d]ata was monitored online to check for errors and corrections made where errors were detected." Pg. 4, however further details are not provided.
    • Details on data quality control processes for all Sightsavers' coverage surveys we have seen are available in this spreadsheet, "Methods" sheets.
    • Sightsavers told us about some informal verification processes it uses:
      • "Supervisors monitor the data that surveyors are collecting. For example, in a survey that took place in Cote d'Ivoire and Burkina Faso, there were six teams of three surveyors. Four supervisors (two teams of two supervisors) accompanied surveyors on their visits to listen to their interviews and check their forms to be sure they had been correctly filled in. If there were mistakes, these were corrected on the spot so that surveyors could improve as the day went on." GiveWell's notes from its 2016 site visit to Ghana, Pg 6.
      • "For context, we ensure supervisors work closely with teams when collecting data to ensure they are following protocol, check questionnaires at the end of the day for data quality and completeness and also have regular team and feedback meetings. We are now using electronic data capture which allows for basic consistency checks during data collection and also tracks the GPS location of the teams so we can provide some additional external support supervision of the teams." Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016
    • In a comment on a draft of this review (August 2018), Sightsavers noted, "All data collectors are monitored in real time. Their data is instantly uploaded and verified by staff in the field and in the office. This ensures good data quality control and negates the need to conduct follow ups to monitor the TCS."
  • 124.
  • 125.
  • 126.

    "The results of this survey showed that coverage of MDA was 57.58% (95% CI: 46.91 to 67.60) overall. … In our survey, considering the main target of treatment, which are the children in the schools, the results of the survey showed that 69.9% (95% CI: 58.0 to 80.0) of children enrolled were treated." Sightsavers, Guinea Conakry Treatment coverage survey (English translation), Pg 3.

  • 127.

    "The purpose of the survey [was] to verify and validate mass drug administration coverages for SCH and STH was effectively achieved in Lola and N'Zérékoré health districts. ... the post MDA coverage survey revealed 80.1% in Lola and 76.3% in N'Zérékoré." Sightsavers, Coverage survey Guinea 2018, Pgs. 10-11.

  • 128.
    • "Due to the security situation in Benue, we have not been able to access the Year 1 MDA locations. We prefer not to run a TCS more than 3 months after MDA as there is an increased chance of poor recall and confusion. Therefore, we have decided not to run the Year 1 TCS in Benue." Amanda Jordan, Trusts Manager, email to GiveWell, July 20, 2018.
    • "Our country based therapeutic coverage rates (outcomes) exceed attainment of the World Health Organisation target to reach 75% at risk SAC in all projects with the exception of Benue." Sightsavers, Global report for all GiveWell funded projects, 2018, Pg. 6.
    • "Treatment coverage rates:...
      • % of all targeted people among targeted local government areas (LGAs) treated with praziquantel for SCH (ultimate threshold at least 75%) = 54%
      • % of all targeted people among targeted local government areas (LGAs) treated with at least one round of albendazole/mebendazole against STH (ultimate threshold at least 75%) = 40%."

      Sightsavers, Country narrative report Benue State, Nigeria, 2018, Pg. 3-4.

    • Benue accounts for 20% of Sightsavers' past spending of GiveWell-directed funds, see this spreadsheet, "Comprehensiveness" sheet.
  • 129.

    Tekle et al. 2012.

  • 130.

    Tekle et al. 2012, Pg 1.

    • "Methods: In 2008, an epidemiological evaluation using skin snip parasitological diagnostic method was carried out in two onchocerciasis foci, in Birnin Gwari Local Government Area (LGA), and in the Kauru and Lere LGAs of Kaduna State, Nigeria. The survey was undertaken in 26 villages and examined 3,703 people above the age of one year. The result was compared with the baseline survey undertaken in 1987."
    • "Results: The communities had received 15 to 17 years of ivermectin treatment with more than 75% reported coverage. For each surveyed community, comparable baseline data were available. Before treatment, the community prevalence of O. volvulus microfilaria in the skin ranged from 23.1% to 84.9%, with a median prevalence of 52.0%. After 15 to 17 years of treatment, the prevalence had fallen to 0% in all communities and all 3,703 examined individuals were skin snip negative."
  • 131.

    Tekle et al. 2012.

    • The report does not appear to address confounding factors that could have also impacted prevalence. The treatment was carried out over a long time period: treatments began in 1991, the Community Directed Treatment with Ivermectin was introduced in 1997 (and Sightsavers became involved), and treatment continued for 15-17 years through 2008 (when this survey was conducted) (pg. 2). Given this, it seems possible that other improvements (e.g. in economic and/or health systems or environment) could have played a role in the observed decline in infection.
    • The surveyed communities were selected partially because they had the longest treatment periods and high coverage rates: "The two foci were selected for the following reasons: i) communities in these foci had pre-control epidemiological data; among the areas where large-scale ivermectin treatment was first introduced in Africa were these two foci in Kaduna in which treatment of a sample of the population started as part of a randomised controlled trial of ivermectin in 1988 and 1989, and where skin-snip surveys had been done in preparation for the trial [6,17]. ii) the foci included hyper-endemic villages, i.e. villages with a prevalence of microfilaridermia > 60% [15-17]; iii) the area was located along a river with known breeding sites of Simulium damnosum s.l., iv) the communities had had 15 - 17 years of annual treatment with ivermectin using the community-based programme since 1991, and subsequently through the community-directed treatment with ivermectin (CDTI) strategy from 1997 with more than 65% treatment coverage." Pg 3.
    • "A limitation of the epidemiological surveys is that a third of the population in the selected communities did not participate in the skin-snip examination. Though some of these had valid reasons for non-participation (age < 1 year, illness, absence from the village etc), for a large majority the reasons for non-participation were not known. This high non-participation rate could have created a bias in the survey results if those who did not participate in the survey were also more likely not to have participated in ivermectin treatment." Pg 8.
    • The study does not discuss the methods of the baseline survey.
  • 132.

    Lakwo et al. 2015

  • 133.

    “Results: […] The prevalence of onchocerciasis ranged from 0.8% to 5.5% while the CMFL ranged from 0.01 to 0.11 mf/ss.” Lakwo et al. 2015, Pg 3.

  • 134.

    "One of the shortcomings is inadequate mf [microfilariae] prevalence data in this focus. Baseline data on mf prevalence is only available for Nyakabale and Kyeramya villages Hoima district which was collected in 2007. This information is very vital for decision making within the framework of elimination." Lakwo et al. 2015, Pg 4.

  • 135.

    Lakwo et al. 2015, Pg 3.

    • "Conclusion: The performance of mass treatment in Budongo focus has been good since out of the 15 villages assessed only three of them have mf prevalence >5% and CMFL far below the threshold of >5 mf/s."
    • "Results: A total of 2,728 people were examined, composing of 55% (1494/2728) females and 45% (1231/2728) males. The overall mf [microfilariae] prevalence was 2.6% (73/2728) and CMFL [Community Microfilaria Load] was 0.04 mf/s and varied significantly in the communities (p <0.05). The prevalence of onchocerciasis ranged from 0.8% to 5.5% while the CMFL ranged from 0.01 to 0.11 mf/ss [microfilariae per skin snip]. Infection was recorded more among the males (3.7%) compared to the females (1.7%). Mf prevalence was recorded highest in Masindi district (5.5%) and lowest in Hoima district (0.8%). The CMFL recorded was far <5 microfilariae per skin snip, i.e. recognized by WHO as threshold value in certifying the communities to be free of onchocerciasis as public health problem, thus, signifying the possibility of onchocerciasis elimination in the focus." See also discussion of results on Pgs 15-17.
  • 136.

    A few observations from Lakwo et al. 2015:

    • "Methods: Villages were selected in each of the districts following APOC procedures. Mobilizations were conducted by use of local authorities in each respective village. Questionnaires were administered among those who participated in the study. Skin snip was conducted in the selected communities (n=15) in Hoima, Buliisa and Masindi districts. Microfilaria prevalence and CMFL were calculated for each village," Pg 3. Participation in the prevalence study appears to have been opt-in and nonrandom. "Those eligible from 5 years and above from household were invited to participate in the survey. Participants were recruited consecutively from families until the required sample size was achieved," Pg 6. Participation rate or representativeness of the sample are not discussed apart from listing "Low turn up of participants in some of the villages in some districts" as a challenge, Pg 17.
    • The report does not appear to address confounding factors that could have impacted prevalence. The treatment was carried out over a long time period: treatment started in 1993, the Community Directed Treatment with Ivermectin was introduced in 1999, and an elimination policy was launched in 2007, with treatment presumably ongoing. “Mass treatment with ivermectin started in the 1993 with support from Sightsavers International. In 1999, the Community Directed Treatment with Ivermectin (CDTI) strategy was introduced to ensure sustainability of the program. When elimination policy was launched in 2007, bi-annual treatment and vector elimination strategies were adopted to enhance elimination,” Pg 3. Given this, it seems possible that other improvements (e.g. in economic and/or health systems, or the environment) could have played a role in the reported improvements.
  • 137.

    Bailey 2013

  • 138.
    • "The Guinea-Bissau Programa Nacional de Saude Visuel(PNSV) , with support from Sightsavers International has conducted three rounds of azithromycin distribution between 2009-2012 -in the regions of Oio, Bafata and Farim(formerly part of Oio)." Bailey 2013, Pg 1.
    • "Sightsavers’ Guinea Bissau trachoma elimination program has run since 2011 and is working to ensure Guinea Bissau can be declared free of blinding trachoma by 2020. The project is supporting the implementation of the full SAFE strategy for trachoma elimination (Surgery to treat trichiasis, Antibiotics to treat infection, Facial cleanliness and Environmental improvement to interrupt disease transmission). Project activities include the distribution of the antibiotic treatment Zithromax, the training of trichiasis (TT) surgeons and the provision of TT surgeries, and the improvement of environmental sanitation in target areas through the construction of water points and latrines, alongside behaviour change activities to ensure their use.” Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, Pg 2.
    • "Sightsavers is the key Ministry of Health partner for trachoma elimination activities in Guinea Bissau and is supporting the distribution of the antibiotic treatment Zithromax, the training of trichiasis (TT) surgeons and the provision of TT surgeries, and the improvement of environmental sanitation in target areas through the construction of water points and latrines, alongside behaviour change activities to ensure their use. The prevalence of trachoma in Guinea Bissau ranges between 10%-39.9%. (see Map 1)We are supporting the MoH to meet the WHO recommended target of reducing the prevalence of active trachoma (TF) to less than 5% among children aged 1-9 years, to reduce the prevalence of TT to less than 1 case per 1000 population above 15 years old, and to maintain (TT) recurrence to below 10%. The implementation of the SAFE strategy has resulted in the reduction of prevalence as shown in Table 2. Other NGO partners involved in implementing the SAFE strategy for trachoma elimination in Guinea Bissau include The International Trachoma Initiative (supporting Zithromax distribution). Sightsavers plans to support the writing of a trachoma Action Plan for Guinea Bissau in October 2015, in partnership with the International Trachoma Initiative and the London School of Hygiene and Tropical Medicine." Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, Pg 4.
  • 139.
    • “Following three rounds of MDA the estimated prevalence of TF in 1-9 year olds is below the 5% threshold in Oio, Bafata and Farim: 2.9% in Oio, 1.4% in Bafata and 4.2% in Farim. There seems to be no need for further distribution in these regions.” Bailey 2013, Pg 3.
    • Methodology is discussed in Bailey 2013, Pgs 1-2, including that households absent at the time of the survey were excluded rather than revisited at a later time: "In the event that the 15 households did not contain 50 children, or that the selected households were unavailable reserves were used until 50 children had been examined," Pg 1. Diagnosis and grading of trachoma was performed by "ophthalmic nurses and cataract surgeons from the PNSV who had received training in the grading of trachoma according to the WHO simplified system, and had received training in the field in the study procedures," Pg 2.
  • 140.

    In Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, Pg 4, Sightsavers sent us a table of trachoma (TF) and trichiasis (TT) prevalence rates in 2005 compared to prevalence found in the 2013 impact study. 2005 data is available for eleven regions, including the three regions targeted by the 2013 study. We have not seen the methodology for the 2005 prevalence survey and we are unsure whether it is appropriately comparable to the 2013 survey.

    Region Trachoma prevalence (2005) Trachoma prevalence (2013)
    Bafata 28.7% 1.38%
    Oio 21.7% 2.94%
    Farim 21.7% 4.21%
  • 141.
  • 142.

    Sightsavers told us that "Sightsavers follows recommended WHO guidelines with regard to the establishment of sentinel sites. For deworming programs sentinel sites are typically established at schools. Impact indicators track change in prevalence and intensity of infection (intensity is recognized as a more sensitive indicator of impact)." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pg 2. It is possible that impact assessments conducted at sentinel sites (where programs may be higher quality) may not be representative of impact at other sites. Of the three impact assessments discussed above, the first (Tekle et al. 2012) explicitly selected sentinel sites for assessment. We are unsure whether the other two impact assessments took place at sentinel sites.

  • 143.

    For more detail about the study see: GiveWell's non-verbatim summary of a conversation with Sightsavers staff, June 7, 2018, Pg. 2.

  • 144.
    • 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 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
  • 145.
    • "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 and 21.
  • 146.

    "There was confusion on Wednesday in some public primary and secondary schools in Ogun State, over the administration of anti-worm tablets. Nigerian Tribune gathered that some students reportedly collapsed in the cause of administering the tablets on them. This resulted into rumour that spread like wildfire across the length and breadth of the state, as parents stormed various school to withdraw their wards. When the Nigerian Tribune visited Egba High School, Asero and Asero High School both in Abeokuta South Local Government Area of the state, some parents were sighted at the school gate, who had come to confirm the incident and probably withdraw their wards. There was calmness in both schools as students in the Senior Secondary Classes were said to be preparing for their examinations. Meanwhile, the Ogun State Government through the State Commissioner for Health, Dr Babatunde Ipaye, has denied any case as a result of the anti-worm drug. Ipaye in a statement made available to the Nigerian Tribune in Abeokuta, said that no pupil or student to the best of his knowledge had reacted to the drug in the state. He explained that the exercise was done by his Ministry in collaboration with Evidence Action." Nigerian Tribune, "Panic in Ogun schools over deworm exercise," December 2017

  • 147.
  • 148.
  • 149.

    The study assumes that government staff costs account for approximately 30% of the program's expenses. See our review of SCI for more information.

  • 150.

    For example, if Sightsavers reports treating 100 children in Country X with albendazole and 90 children in Country X with praziquantel, we assume the populations fully overlap, so Sightsavers has treated 100 children (90 children with albendazole + praziquantel and 10 children with just albendazole).

  • 151.

    For an example of Sightsavers' budget categories, see this spreadsheet, "Sightsavers budget for GW-influenced funds" tab, column A.

  • 152.

    The data on total costs and treatments across all actors in DRC can be found in this spreadsheet, "GW summary" tab. In this spreadsheet, we then divide Sightsavers' total costs, excluding program management and overhead costs (to make it comparable to the figure from the first spreadsheet, which we believe does not include program management and overhead costs), by the overall cost per treatment estimate for DRC to back out an estimate of Sightsavers' total treatments.

  • 153.

    See this spreadsheet for more detail.

  • 154.

    See this spreadsheet for more detail.

  • 155.

    See this spreadsheet, "Spending opportunities" tab, Cells B26 and B35.

  • 156.

    See this spreadsheet, "Spending opportunities" tab, Cell B39.

  • 157.

    See this spreadsheet, "Funds on hand and projected revenue" tab.

  • 158.

    See this spreadsheet, "Funds on hand and projected revenue" tab.

  • 159.

    See this spreadsheet, "Funds on hand and projected revenue" tab.

  • 160.

    See our interim review of Sightsavers.

  • 161.
    • "As previously submitted during Sightsavers’ Phase 1 submission to GiveWell, Nigeria represents a country where Sightsavers is keen to expand its operations to increase schisto and STH integrated control. Whilst we have secured new funding to expand our oncho and LF elimination work in Nigeria over the past year (detailed in document 16.1), the situation as regards how we would like to expand STH and schisto activities remains similar to our submission to GiveWell in May 2015. We have incorporated summary information from our 2015 submission in the table." Sightsavers, Deworming wishlist notes, 2016, Pgs 1-2.
    • "As previously presented in Sightsavers’ Phase 1 submission to GiveWell, Guinea-Bissau represents a country where Sightsavers is keen to expand its operations to include schistosomiasis (schisto) and soil-transmitted helminths (STH) integrated control. While we have secured new funding from UK Aid Match to expand our oncho and LF elimination work in Guinea Bissau between 2016-19, the situation as regards how we would like to expand STH and schisto activities remains similar to our submission to GiveWell in May 2015." Sightsavers, Deworming wishlist notes, 2016, Pg 1.
  • 162.

    Sightsavers staff, conversation with GiveWell, October 2, 2016

  • 163.

    See our review of the Schistosomiasis Control Initiative

  • 164.
    • "USAID has informed partners that the FY18 budget for Cameroon will not include support for SCH/STH MDAs previously supported. However, USAID will provide limited support for SCH/STH impact surveys in 10-12 selected areas. While USAID has been clear that they are committed to supporting NTD control and elimination efforts in Cameroon, any funding support for SCH/STH MDAs will need to be supported by the government or other funding partners starting in 2018. While the emphasis on conducting impact assessments in 2018 will be helpful in developing new treatment strategies, the fact remains that the West, North West, and South West Regions, will not have any funding from USAID for SCH/STH MDA in 2018. This support has been requested as part of Sightsaver’s GiveWell wish-list submission."
      Julia Strong, Sightsavers International Foundations Executive, edits to GiveWell's draft 2017 review, November 14, 2017.
    • "During the 2018 ENVISION planning session in Cameroon, it was announced that the ENVISION programme will end in 2019 with a significant reduction of the budget in 2018. ... the Cameroon wish list provides for support in the three regions currently supported by Sightsavers, for:
  • 165.

    "In 2017 the UK Government Department for International Development announced a doubling of its support to fight neglected tropical diseases over the next 5 years.This will support programme implementation and research, further information is available online: https://www.gov.uk/government/news/uk-to-protect-200-million-people-from...." Sightsavers, Other Funding Opportunities (2017; unpublished source)

  • 166.

    Conversation with the Schistosomiasis Control Initiative, October 2017.

  • 167.

    Sightsavers, Other Funding Opportunities (2017; unpublished source)

  • 168.

    Internal donation records

  • 169.
  • 170.
  • 171.
  • 172.
  • 173.
  • 174.

    For details, see Sightsavers Nigeria Bauchi State Project Narrative, GiveWell Wishlist 3.

  • 175.

    For details, see Sightsavers Cameroon Project Narrative, GiveWell Wishlist 3.

  • 176.

    For details, see Sightsavers Guinea Conakry Project Narrative, GiveWell Wishlist 3.

    Note that one of these districts (Nzérékoré) is already supported by GiveWell-directed funds.

  • 177.
  • 178.

    Due to rounding, the above values do not add up to exactly $11.5 million. For more detail, see this spreadsheet.

  • 179.

    See this spreadsheet.

  • 180.
  • 181.

    WHO, Summary of global update on preventive chemotherapy implementation in 2016, Pg 590, Table 1.
    WHO, Summary of global update on preventive chemotherapy implementation in 2015, Pg 456, Table 1.
    WHO Weekly epidemiological record, 18 December 2015, Pg 707, Table 1.