Sightsavers' Deworming Program

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Published: November 2021

Summary

What do they do? Sightsavers (https://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 recommend deworming programs given the possibility of strong benefits at low cost. Sightsavers has conducted studies to determine whether its programs have reached a large proportion of children targeted. We have seen studies covering about 85% of the programs that we focus on in this review. 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 $0.89 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 child dewormed is $0.35. 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? Our most recent analysis finds that Sightsavers currently has $28.7 million in room for more funding—prior to receiving any grants that GiveWell specifically makes or recommends—to support its deworming portfolio in 2021-24. (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 is a large organization with significant unrestricted funding and fundraising capacity. (Sightsavers spends considerably more on fundraising than other charities we recommend. From 2014-2020, 19-29% of Sightsavers' total spending (excluding in-kind gifts) went to fundraising activities, representing 45-59% of its unrestricted funding; Sightsavers notes that its fundraising activities include "raising voluntary funds and institutional funding and management.")1 It is possible that GiveWell-directed funding will cause Sightsavers to allocate less of its unrestricted funding or fundraising capacity to deworming than it otherwise would have. Sightsavers has not allocated large amounts of unrestricted funding to deworming in the past and notes that deworming was not an organizational priority before it began receiving GiveWell-directed funding in 2017.2 Our understanding is that deworming is not a priority in its use of future unrestricted funding. (In November 2021, Sightsavers informed us that it intended to allocate a small amount of unrestricted funding to support planning for deworming MDAs in four countries.)3

Table of Contents

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.4
  • Reviewing documents Sightsavers sent in response to our queries.
  • Visiting 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.
  • Visiting 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.5 Sightsavers' work on neglected tropical diseases (NTDs) accounts for roughly 60% of its overall program expenditure budget.6 In this review, we evaluate the deworming programs in Sightsavers' NTD 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."

In 2017, Sightsavers used GiveWell-directed funds to add deworming MDAs to the integrated NTD programs that it already supported in the Democratic Republic of the Congo (DRC), Guinea, Guinea-Bissau, and four Nigerian states, to support a deworming impact survey in Cameroon, and to initiate an integrated NTD program in Benue State, Nigeria.7 In 2018 and 2019, Sightsavers used GiveWell-directed funds to continue these programs and to expand its work to Cameroon and two additional states in Nigeria.8 In 2020, Sightsavers continued its support to these programs, though program implementation was delayed in Cameroon and Nigeria and deferred to 2021 in DRC, Guinea, and Guinea-Bissau, primarily because of the COVID-19 pandemic.9 Sightsavers primarily used GiveWell-directed funds to support these programs in 2020, though some locations in DRC and Guinea that were previously supported by GiveWell-directed funds were supported in 2020 by the WHO's Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) or the U.K. government's Ascend program.10 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.11 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.12 Sightsavers provides both technical assistance and funding, either directly to governments or indirectly through local 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
  • 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.13 It continues to focus on eliminating avoidable blindness and supporting people with visual impairments and disabilities in low- and middle-income countries;14 this focus led to its work on integrated NTD programs, particularly programs targeting those NTDs that cause blindness (onchocerciasis and trachoma).15

Sightsavers began its work on deworming programs in 2011 as part of its integrated NTD programs.16 With GiveWell-directed funds, it supports deworming programs in five countries in Africa.17

Sightsavers' integrated NTD programs

Sightsavers began to work on NTD programs in the 1950s.18 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.19

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.20 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.21 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.22

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.23 In school-based MDAs, teachers and volunteer community drug distributors are trained to provide treatments to children during normal school hours.24

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.25

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:26

  • The prevalence and intensity of schistosomiasis and STH in the area in which the program would occur.27
  • 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.28
  • 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.29 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.30
  2. Developing national plans. Sightsavers assists country governments and partner non-governmental organizations (NGOs) in developing national integrated plans for addressing NTDs.31
  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.32
  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.33
  5. Drug logistics. Sightsavers provides support in some locations for drug logistics, such as storage.34
  6. Community sensitization. Sightsavers helps with efforts to create awareness within communities about when an MDA will occur and why it is important.35
  7. Monitoring and reports. Sightsavers told us that it aims to periodically conduct coverage surveys on all of its MDA programs,36 and that it plans to conduct coverage surveys for deworming MDA projects supported by GiveWell-directed funds annually.37 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).38 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.39 We have also seen impact assessments of Sightsavers' deworming programs in Cameroon, Guinea-Bissau, and Sokoto State, Nigeria.40 These assessments measure the prevalence of schistosomiasis and STH in school-aged children for comparison with baseline data.

What financial assistance does Sightsavers provide?

Sightsavers supports MDA programs financially when necessary.41 Historically, it has paid for expenses like planning meetings, monitoring and evaluation, vehicles, computers, education materials, sensitization activities, and supervision activities.42 Sightsavers supports its non-governmental organization partners' salary costs on some projects.43 When providing financial support, Sightsavers told us that it asks implementing partners to provide detailed, activity-based budgets;44 we have not yet seen budgets at this level of detail (more).

How has Sightsavers spent funds in the past?

We have seen high-level summaries of Sightsavers' organization-wide spending between 2014 and 2020.45 See this spreadsheet for details. In short:

  • The majority of Sightsavers' spending was funded by in-kind gifts from other organizations, which were mostly drug donations.46 Excluding in-kind gifts, in 2020, 50% of Sightsavers' spending was on NTD programs, 20% was on fundraising, and the remainder was on other programs, including eye care, education, and social inclusion programs.47
  • Each year, Sightsavers spent around $40-50 million in unrestricted funding.48 The proportion of its unrestricted funding that it spent on NTD programs moderately increased in recent years, from 5-9% in 2014-2017 to 12% in 2018, 18% in 2019, and 11% in 2020.49 However, most of Sightsavers' funding for NTD programs was restricted: in 2018-2020, only about 7-12% of its NTD spending was from unrestricted funds.50
  • We do not know what proportion of Sightsavers' NTD spending supports deworming programs alone.51 In 2018-2020, about 5% of Sightsavers' spending on NTD programs was on the deworming programs supported by GiveWell-directed funds (more details below).52

Spending of GiveWell-directed funds

Between January 2017 and March 2021, Sightsavers spent $9.9 million in GiveWell-directed funds.53 Below, we present a breakdown of this spending by category and country.54

Sightsavers' spending using GiveWell-directed funds (January 2017-March 2021)55

Spending category % of spending
Capital expenditure 1%
Project activities 50%
Staff costs 12%
Administration costs 2%
Monitoring, evaluation and lesson learning 14%
Program management 9%
Overheads 12%
Country % of spending
Nigeria 40%
Cameroon 36%
Guinea 10%
Guinea-Bissau 10%
DRC 4%

Spending on fundraising

From 2014-2020, 19-29% of Sightsavers' total spending (excluding in-kind gifts) went to fundraising activities, representing 45-59% of its unrestricted funding.56 While we typically do not put 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.57 Sightsavers also highlighted that when the value of in-kind gifts are included, Sightsavers’ fundraising costs are under 10%.58

Does it work?

This section was last updated in November 2020. The information that Sightsavers has provided since that date is not yet reflected in this section.

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 recommend deworming programs 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. We have seen coverage surveys from four of five locations where Sightsavers used GiveWell-directed funds to support deworming MDA in the period between January 2017 and March 2018,59 and from six of seven locations where Sightsavers used GiveWell-directed funds to support deworming MDA in the period between April 2018 and March 2019,60 representing 85% of Sightsavers' spending of GiveWell-directed funds through March 2019.61 As of this writing, surveys were not yet available from locations where Sightsavers used GiveWell-directed funds to support MDA in the period between April 2019 and March 2020.

In the surveys we have seen, coverage of school-aged children was above 75% (the WHO-recommended minimum threshold),62 except in a few locations discussed below. Across these surveys, median coverage was roughly 80% for both schistosomiasis and STH treatments.63 We note some limitations of these surveys below.

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 Sightsavers' deworming programs in Cameroon, Guinea-Bissau, and Sokoto State, Nigeria.64 These assessments measure the prevalence of schistosomiasis and STH in school-aged children for comparison with baseline data and to inform changes to treatment schedules.65 We have not reviewed their methodology or results in depth. We have also 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.

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 how successful Sightsavers' projects have been.66

Coverage surveys

Sightsavers aims to conduct coverage surveys after every deworming MDA supported by GiveWell-directed funds.67 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.68 We have seen nine reports on Sightsavers' coverage surveys: DRC (2018 and 2019), Guinea (2017 and 2018), Guinea-Bissau (2018 and 2019), Nigeria (2018 and 2019), and Cameroon (2019).69 These reports represent 85% of Sightsavers' spending of GiveWell-directed funds through March 2019.70

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);71 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.72

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). At times, these geographic areas have been selected purposefully rather than randomly for inclusion in coverage surveys from the full set of areas in which MDA occurred. Of the nine surveys we have seen, geographic areas were selected purposefully in three.73 Sightsavers told us that since 2018, it has aimed to select geographic areas randomly where feasible.74 Details on the selection of geographic areas for all of 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.75 Sightsavers told us that it aims to conduct all coverage surveys within one to two months of the MDA and that it does not believe recall bias is a serious concern.76 In the nine surveys we have seen, the length of time between MDA and survey ranges from two weeks to six months. In one of these surveys, no length of time was specified.77 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).
  • 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 to assess the accuracy of responses. Data collectors are instructed to show respondents drug samples when asking questions about treatment, but while these visual aids may improve accurate recall, we do not believe they are used to verify responses (for example, by asking respondents to identify the pills they took among a set of pills).78 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 notes that it monitors data collection in real time, which it believes negates the need for follow-up verification.79
Results

See this spreadsheet, sheets "Results from GW-supported projects" and "Results, Year 2." In the nine surveys we have seen, coverage of school-aged children was above 75% (the WHO-recommended minimum threshold) in all locations surveyed in Guinea, Guinea-Bissau, DRC, and Nigeria in 2018, and in the location surveyed in Guinea-Bissau, one of two locations surveyed in DRC, and most locations surveyed in Cameroon and Nigeria in 2019.80 Sightsavers' 2017 Guinea coverage survey found a 58% coverage rate,81 however, as noted above, coverage improved in 2018.82 In the locations that did not achieve 75% coverage in 2019, coverage ranged from 56% in one location in Nigeria to 73% in one location in Cameroon.83 Across these surveys, median coverage was roughly 80% for both schistosomiasis and STH treatments.84

These results represent 85% of Sightsavers' spending of GiveWell-directed funds through March 2019.85 Security concerns prevented Sightsavers from conducting a coverage survey in Benue, Nigeria, in 201886 and in Yobe, Nigeria, in 2019.87 Sightsavers was also unable to complete a survey in Kogi, Nigeria, in 2019.88 Together, these locations represent the remaining 15% of Sightsavers' spending of GiveWell-directed funds through March 2019.89

Impact assessments

We have seen impact assessments of Sightsavers' deworming programs in Cameroon, Guinea-Bissau, and Sokoto State, Nigeria.90 These assessments measure the prevalence of schistosomiasis and STH in school-aged children for comparison with baseline data. We have not reviewed their methodology or results in depth.

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:91 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).92 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.93
  • A 2015 impact assessment of long-term (1993-2015) treatment of onchocerciasis in fifteen villages in three districts of Uganda:94 District-level onchocerciasis prevalence ranged from 0.8% to 5.5% at the time of the assessment.95 The authors noted that baseline prevalence data (from 2007) was available for only two of the fifteen villages,96 but they did not provide the baseline data from the two villages in the report. The study concluded that the MDAs performed well.97 Other limitations of the study are discussed in this footnote.98
  • An impact assessment on three rounds of trachoma treatment (2009-2012) in three regions of Guinea-Bissau:99 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.100 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.101 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.102

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.103 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.

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 SCI Foundation 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.

For Guinea, there is some evidence to suggest that Sightsavers' assistance led to increased coverage. In Guinea, surveyed coverage increased from 58% in 2017 (the year Sightsavers began supporting deworming MDA in the country) to 77-87% in 2018.104 While other factors may have contributed to the increase in coverage between 2017 and 2018, the timing of the improvement suggests that Sightsavers' assistance played a role.

Are there any negative or offsetting impacts?

Administering deworming drugs seems to be a relatively straightforward program.105 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 SCI Foundation, including one case that led to riots.106 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.107 While the accounts we have heard are from programs supported by the SCI Foundation 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,108 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.109

What do you get for your dollar?

We estimate that, on average, the total cost per child dewormed per year in Sightsavers-supported programs is $0.89.110 Excluding the cost of drugs (which are often donated) and in-kind government contributions to the programs, we estimate that Sightsavers' cost per child dewormed per year is $0.35.111 These estimates rely on a number of uncertain assumptions. Full details of our analysis are in this spreadsheet.

When possible, we prefer to rely on past results over projected future results, as projections can be overly optimistic. For Sightsavers, we have only limited data on the deworming programs it supported prior to 2017. In our analysis, we use actual cost data and reported treatment numbers from 2017 through 2020, to estimate a to-date cost per child dewormed per year of $0.89.112

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 child dewormed 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 child dewormed represents everything required to deliver the treatments. In particular, in our cost per child dewormed 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 child dewormed is uncertain:

  • 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.113
  • Estimated number of treatments: Sightsavers' deworming programs typically distribute albendazole, praziquantel, or both medications to a given area, depending on the prevalence of STH and schistosomiasis infections in the area.114 We assume that consuming only albendazole, only praziquantel, or both counts as being dewormed.115 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.116
  • Possible excluded costs: Some costs might be excluded from our estimate because we are not sure what costs are included in the cost summaries 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.117

Is there room for more funding?

We conduct "room for more funding" analysis to understand what portion of Sightsavers' ideal future budget it will be unable to support with the funding it has or should expect to have available. We may then choose to either make or recommend grants to support those unfunded activities. Our most recent analysis finds that Sightsavers currently has $28.7 million in room for more funding—prior to receiving any grants that GiveWell specifically makes or recommends—to support its deworming portfolio in 2021-24.

Room for more funding analysis

In general, we assess top charities' funding needs over a three-year period.118 We ask top charities to report their ideal budgets over the next three years, along with information about their current available funding and funding pipeline. The difference between a charity's three-year budget and the funding we project that it will have available to support that budget is the charity's "room for more funding."

For this analysis, we focus on the portion of Sightsavers' portfolio that is funded by GiveWell-directed funding.

The main components of our room for more funding analyses are:

  • Available funding. We ask top charities to report how much funding they currently hold in the bank, including in reserves,119 and how much of this funding is committed or expected to be spent on specific future activities. The difference between these figures is the amount available to allocate to the charity's unfunded spending opportunities.
  • Expected funding. We project the amount of additional funding that top charities will receive to support their work over the next three years. These projections represent our best guesses based on top charities' past revenue and our understanding of their funding pipelines. They typically include funding currently held by GiveWell to be granted to the top charity, projected funding due to being a GiveWell top charity,120 and, if the top charity is part of a larger organization, projected unrestricted funding from that parent organization. They exclude any funding we may specifically recommend to the top charity subsequent to the analysis. We add this projected funding to the amount available to allocate to the charity's unfunded spending opportunities.
  • Spending opportunities. We ask top charities to report their ideal budgets in each of the next three years and to provide details on the specific spending opportunities included in these budgets. These opportunities are typically presented as one program year in a specific implementation geography (for example, deworming in Cameroon in 2023), and they can represent either an extension of the top charity's previous support to a geography or an expansion of support to a new geography. We ask top charities to report the order in which they would prioritize funding these opportunities, which helps us to understand how available and expected funding will be allocated and what the marginal impact of additional funding beyond that amount would be.

A charity's room for more funding represents the total budget for the charity's spending opportunities, less its available and expected funding. For example, if a charity proposes spending $50 million over the next three years and holds $10 million in uncommitted funding, and we project that it will receive an additional $15 million in revenue over the next three years, that charity's room for more funding is $25 million. (Note that a charity's total room for more funding figure includes funding gaps at all levels of cost-effectiveness—see below.) Our most recent analysis of Sightsavers' room for more funding can be found in this spreadsheet.

Grant investigation process

Room for more funding analysis is a key part of our grant investigation process. We periodically request the information described above from top charities and update our room for more funding analyses. Our default is to update each top charity's room for more funding analysis annually, though we may choose to do so more or less frequently. The cadence on which we conduct updates depends largely on how often we grant funding to a top charity121 and how much we expect that charity's funding and budgets to have changed since our most recent funding decision.122 We have typically updated our analysis of Sightsavers' room for more funding on an annual basis. Our most recent analysis of Sightsavers' room for more funding can be found in this spreadsheet.

After completing such an update, we may then choose to investigate potential grants to support the spending opportunities that we do not expect to be funded with the charity's available and expected funding, which we refer to as "funding gaps." The principles we follow in deciding whether or not to fill a funding gap are described on this page.

The first of those principles is to put significant weight on our cost-effectiveness estimates. We use GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding gaps, which we describe in multiples of "cash." Thus, if we estimate that a funding gap is "10x cash," this means we estimate it to be ten times as cost-effective as unconditional cash transfers. As of this writing, we have typically funded opportunities that meet or exceed a relatively high bar: 8x cash, or eight (or more) times as cost-effective as GiveDirectly's unconditional cash transfers. (Note that a charity's total room for more funding figure includes funding gaps at all levels of cost-effectiveness.)

If we decide to fill a funding gap, we either make a grant from our Maximum Impact Fund123 or recommend that another funder—typically Open Philanthropy124 —makes a grant. This page lists all grants made or recommended by GiveWell. Typically, when GiveWell donors make a donation to a top charity,125 we don't expect that donation to be directed to a specific funding gap, but rather to contribute to supporting the overall portfolio of opportunities included within a charity's room for more funding.

Sightsavers' room for more funding

Our most recent analysis of Sightsavers' room for more funding can be found in this spreadsheet. In that analysis, we estimate that Sightsavers has $28.7 million in room for more funding—prior to receiving any grants that GiveWell specifically makes or recommends—to support its deworming portfolio in 2021-24. In sheet "RFMF projections," we present this figure broken down by funding gap.

We will consider making or recommending grants to fill each of these funding gaps. As of this writing, we expect to have sufficient funding at our discretion to fill all funding gaps we identify among our top charities that meet our current cost-effectiveness bar of 8x cash or better; we also expect to fill some funding gaps in the 5-8x cash range (for more details, see this blog post). Our top recommendation to GiveWell donors seeking to do the most good possible is to donate to the Maximum Impact Fund, which we allocate quarterly to the charity with the highest-priority funding gap(s).

Availability of unrestricted funding

Our understanding is that Sightsavers does not expect to allocate unrestricted funding to the deworming programs supported by GiveWell-directed funding. One concern we have about our funding of these programs is that this may be causing Sightsavers to allocate less of its unrestricted funding to deworming than it otherwise would have. Historically, we saw this as a minor concern: the proportion of Sightsavers' unrestricted funding that it spent on NTD programs in 2014-17 was low, ranging from 5-9%,126 which suggested to us that there was limited unrestricted funding available to support these programs. This proportion has increased in recent years, to 12% in 2018, 18% in 2019, and 11% in 2020,127 which could suggest that Sightsavers' NTD programs are a growing priority in its use of unrestricted funding. However, in 2020, Sightsavers told us that this trend is due to an increase in restricted spending on NTD programs, and a resulting increase in the proportion of central spending that Sightsavers accounts for as being in support of those programs;128 unrestricted spending on direct NTD program costs has in fact declined since 2015.129 We therefore continue to believe that NTD programs are not a priority in Sightsavers' use of unrestricted funding. (In November 2021, Sightsavers informed us that it intended to allocate a small amount of unrestricted funding to support planning for deworming MDAs in four countries.)130

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.

Sightsavers as an organization

We use qualitative assessments of our top charities to inform our funding recommendations. See this page for more information about this process and for our qualitative assessment of Sightsavers as an organization.

Sources

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Sightsavers, 2019 and 2018 organizational expenditure Source
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Sightsavers, annual report 2018 Source
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Sightsavers, Benue project overview Source
Sightsavers, Cameroon Annex 1 Source
Sightsavers, Cameroon country report year 3 Source
Sightsavers, Cameroon impact assessment Unpublished
Sightsavers, Cameroon Wishlist 4 country narrative, 2019 Source
Sightsavers, Cameroon wishlist 5 narrative Source
Sightsavers, Case studies and photos from MDA in Guinea Bissau, 2018 Source
Sightsavers, Chad wishlist 5 narrative Source
Sightsavers, Cost per treatment, Cameroon 2015 Source
Sightsavers, Cost per treatment, Kebbi 2015 Source
Sightsavers, Country narrative report 4 States, Nigeria, 2019 Source
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Sightsavers, Country narrative report Cameroon, 2019 Source
Sightsavers, Country narrative report DRC, 2018 Source
Sightsavers, Country narrative report DRC, 2019 Source
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Sightsavers, Country narrative report Guinea Conakry, 3 health districts, 2019 Source
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Sightsavers, Coverage survey Benin and Togo 2015 Source
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Sightsavers, Coverage survey Cameroon 2019 Unpublished
Sightsavers, Coverage survey Cameroon 2020 Source
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Sightsavers, Coverage survey DRC 2019 Source
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Sightsavers, Coverage survey Guinea 2018 Source
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Sightsavers, Coverage survey Guinea-Bissau 2019 Source
Sightsavers, Coverage survey Malawi 2015 Source
Sightsavers, Coverage survey Nigeria 2019 Source
Sightsavers, Coverage survey Nigeria Four States Project 2018 Source
Sightsavers, Coverage survey South Sudan 2015 Unpublished
Sightsavers, Coverage surveys presentation, August 2016 Unpublished
Sightsavers, Data on in-kind drug donations Source
Sightsavers, Descriptions of current work - 2015 and 2016 Source
Sightsavers, Deworming program consolidated logframe, September 2017 update Source
Sightsavers, Deworming wishlist 2018 and 2019 Unpublished
Sightsavers, Deworming wishlist 3, April 2019 to March 2022, Room for more funding analysis Source
Sightsavers, Deworming wishlist 3, April 2019 to March 2022, Summary cover note Source
Sightsavers, Deworming wishlist notes, 2016 Source
Sightsavers, Deworming wishlist, 2016 - v1 Source
Sightsavers, Deworming wishlist, Bauchi State, Nigeria 2018-19, explanatory narrative Source
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Sightsavers, Deworming wishlist, Guinea Conakry 2018-19, explanatory narrative Source
Sightsavers, Deworming wishlist, Yobe State, Nigeria 2018-19, explanatory narrative Source
Sightsavers, Disease prevalence in Sightsavers proposed areas of expansion Source
Sightsavers, DRC Annex 1 Source
Sightsavers, DRC wishlist 5 narrative Source
Sightsavers, Finances 2016 actual and 2017 planned Source
Sightsavers, Financial report for GiveWell funded projects for year 1 activities, 2018 Source
Sightsavers, Financial report narrative for GiveWell funded projects for year 1 activities, 2018 Source
Sightsavers, Financial report year 3 Source
Sightsavers, GiveWell Annual Reports, 2019 Source
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Sightsavers, GiveWell Y4 Financial Report Source
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Sightsavers, Global report year 3 Source
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Sightsavers, Guinea Conakry Annex 2 Source
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  • 1
    • Sightsavers, comment on a draft of this review, October 31, 2019.
    • Sightsavers also requested that we share its 2018 annual report for more information on its spending: Sightsavers, annual report 2018
    • For information about fundraising expenses, see this spreadsheet, sheet "2014-2020 total spending," row "Fundraising."

  • 2

    "Prior to GiveWell funding commencing in 2017 deworming had not been a focus," Sightsavers, comments on a draft of this page, October 2020 (unpublished).

  • 3

    "We also wanted to let you that Sightsavers is planning to direct some unrestricted funding to support SCH sub districts analysis from 2021 onwards. Across 4 countries, we’re allocating £310,000 in order to support the work needed to enable the Ministries of Health to order Praziquantel from WHO (following the new WHO guidance). This is a one off allocation to respond to the pressing need to facilitate Praziquantel orders, to enable GiveWell funded MDA to go ahead." Sightsavers, comments on a draft of this page, November 2021

  • 4

  • 5

    "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.

  • 6
    • Of Sightsavers' 2020 total expenditure, excluding gifts in kind, 80% was spent on program activities (i.e., activities other than fundraising). For information about fundraising expenses, see this https://docs.google.com/spreadsheets/d/19iUx5rskAQneoBIK9oCXyhIrEFgQcGX…, sheet "2014-2020 total spending," G11.
    • NTDs accounted for about 63% of this program expenditure. This figure has increased each year since 2014. See this spreadsheet, sheet "2014-2020 total spending," row 34.

  • 7

  • 8

  • 9

    Cameroon:

    • "This year, COVID-19 has caused major disruption to the implementation of planned project activities in Cameroon. All project activities had to stop in March 2020, when the Cameroon government began to put restrictions on travel and mass gatherings, and schools were closed. From the beginning of June, many restrictive measures were lifted." Sightsavers, Year 4 country narrative report Cameroon, 2020-2021, Pg. 1.
    • "A RAMA [risk assessment and mitigation access] process was conducted and approved in September for a SCH/STH mini campaign in 3 health areas in the West Region, as an urgent response to an outbreak of haematuria. In October 2020, the RAMA process was conducted and approved to resume SCH/STH MDA [mass drug administration] in all 7 Regions. The MDA for all 7 regions was successfully completed in January 2021." Sightsavers, Year 4 country narrative report Cameroon, 2020-2021, Pg. 1.

    Nigeria:

    • "The project continued to provide SCH and STH treatments to school aged children (SAC) across Kebbi, Kogi, Kwara, Sokoto states for the fourth year, Yobe for the third year and Taraba for the second year. The GiveWell fund continued to provide preventive treatments for SCH and STH in endemic LGAs in Benue for the fourth year, while oncho and LF were no longer treated by GiveWell as their funding was displaced by Ascend West for one year. . . . Year 4 has been another successful year for our deworming project across the Nigeria programme, with initial data showing good coverage rates despite COVID-19 and security issues in some states." Sightsavers, Year 4 country narrative report Nigeria 7 states, 2020-2021, Pg. 1.
    • "As COVID-19 restrictions were implemented across Nigeria between April and June 2020, Sightsavers, our Nigeria Country Office and the Ministry of Health decided, as per WHO guidelines, to place all NTD activities on hold until safe to proceed. COVID-19 also impacted the drug procurement process and delivery. Activities in Kebbi, Benue, Kwara and Sokoto planned for this time were postponed. Between July and September 2020, activities were still on hold across the country." Sightsavers, Year 4 country narrative report Nigeria 7 states, 2020-2021, Pg. 2.
    • "Drug distribution began in December 2020, with many districts resuming MDA in January 2021, after the festive season." Sightsavers, Year 4 country narrative report Nigeria 7 states, 2020-2021, Pg. 3.

    Democratic Republic of Congo (DRC)

    • "All activities, including MDA and coverage evaluation survey (CES), planned to take place in 2020-21 were postponed due to COVID-19." Sightsavers, Year 4 country narrative report DRC, 2020-2021, Pg. 2.
    • "MDAs in DRC, Guinea and Guinea Bissau have now been carried out, between May and Sept 2021." Sightsavers, comments on a draft of this review, November 2021.

    Guinea

    • "This project aimed to deliver treatment to 11 districts that are endemic to both SCH and STH, 3 in the Forest Region and 5 in urban and peri-urban areas and 4 districts for a second round of MDA. All activities including MDA and CES planned to take place from April 2020 to March 2021 were postponed due to COVID-19, the Ebola outbreak and political instability." Sightsavers, Year 4 country narrative report, Guinea, 2020-2021, Pg. 2.
    • "MDAs in DRC, Guinea and Guinea Bissau have now been carried out, between May and Sept 2021." Sightsavers, comments on a draft of this review, November 2021.

    Guinea-Bissau

    • "The project aims to deliver treatments to six regions that are endemic to SCH or STH. In Year 4, of these six regions, four (Bafata, Cacheu, Farim and Gabu) need treatment for SCH, and two (Biombo and Tombali) need treatment for STH. All activities, including MDA and CES, planned to take place in 2020-21 have been postponed due to COVID-19 and also to the MoH’s prioritisation of oncho/LF MDAs." Sightsavers, Year 4 country narrative report, Guinea-Bissau, 2020-2021, Pgs. 2-3.
    • "MDAs in DRC, Guinea and Guinea Bissau have now been carried out, between May and Sept 2021." Sightsavers, comments on a draft of this review, November 2021.

  • 10
    • Cameroon: "This project year, Sightsavers has been supporting SCH/STH MDA in seven regions of North, Far North, East, West, South, Adamaoua, and Littoral, with funding from GiveWell." Sightsavers, Year 4 country narrative report Cameroon, 2020-2021, Pg. 1.
    • Nigeria: "The project continued to provide SCH and STH treatments to school aged children (SAC) across Kebbi, Kogi, Kwara, Sokoto states for the fourth year, Yobe for the third year and Taraba for the second year. The GiveWell fund continued to provide preventive treatments for SCH and STH in endemic LGAs in Benue for the fourth year, while oncho and LF were no longer treated by GiveWell as their funding was displaced by Ascend West for one year." Sightsavers, Year 4 country narrative report Nigeria 7 states, 2020-2021, Pg. 1.
    • DRC: "The project aimed to deliver treatment to 23 districts endemic with SCH/ STH in Ituri Sud and 8 districts in Ituri Nord. In 2020-21 (Year 4), 25 of these districts in Ituri Nord and Sud required treatment, 19 for SCH and 6 for STH.
      However, ESPEN was able to displace GiveWell funding in 12 districts in Ituri Sud in Year 4, of which 10 were scheduled for MDA. Therefore, the scope of the GiveWell project was reduced and savings were made.
      The remaining 11 districts in Ituri Sud continue to be funded with GW recommended funds, of which 7 are scheduled for MDA in Year 4. Ituri Nord was unable to benefit from ESPEN funding and the 8 districts in Ituri Nord remain part of the GiveWell funded scope of work for Year 4." Sightsavers, Year 4 country narrative report DRC, 2020-2021, Pg. 2.
    • Guinea: "We are pleased to report, we were able to displace GiveWell funding in Year 4, in 3HDs in the Forest Region. Two separate factors enabled this; funding becoming available for one round of MDA from ESPEN for SCH/STH MDA for SAC in the N’Zerekore region; and there was the opportunity to incorporate adult SCH treatment into Ascend West’s MDA campaign. The ESPEN funded MDA targeted 174,386 SAC for SCH/STH, the Ascend West funded MDA targeted 323, 686 adults for SCH treatment in these 3HDs." Sightsavers, Year 4 country narrative report, Guinea, 2020-2021, Pg. 2.
    • Guinea-Bissau: "The GiveWell funded project in Guinea-Bissau has entered into Year 4 across six regions Bafata, Cacheu, Farim, Gabu, Biombo and Tombali." Sightsavers, Year 4 country narrative report, Guinea-Bissau, 2020-2021, Pg. 1.

  • 11

    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).

  • 12

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

  • 13

    "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.

  • 14

    "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.

  • 15
    • "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, Protecting 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.

  • 16

  • 17

    "Project title: Delivering schistosomiasis and soil transmitted helminths MDA in: DRC (Ituri Nord) Nigeria 6 States (Kogi, Kebbi, Kwara, Sokoto, Taraba and Yobe State), Cameroon (Far North, North, East, West and Adamaoua regions), Guinea Bissau and Guinea Conakry." Sightsavers, Global report year 3, Pg. 1.

  • 18
    • "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.

  • 19

  • 20

  • 21
    • 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.

  • 22

    "Project title: Delivering schistosomiasis and soil transmitted helminths MDA in: DRC (Ituri Nord) Nigeria (Kogi, Kebbi, Kwara and Sokoto states), Guinea Bissau and Guinea Conakry (3 districts in Forest region).
    Delivering an integrated NTD programme for soil transmitted helminths, schistosomiasis, river blindness and lymphatic filariasis in Nigeria’s Benue state." Sightsavers, Global report for all GiveWell funded projects, 2018, p. 0.

  • 23
    • "Many of Sightsavers’ MDA programs provide a hybrid of school‐based treatment (in which drugs are administered at school sites) and community‐based treatment (in which drug distributors travel from house to house in a community). School‐based treatment tends to be used in areas where school enrollment is high. In areas where STH and LF are co‐endemic, if LF is treated on a community level, deworming is achieved at the same time." GiveWell's non-verbatim summary of a conversation with Susan Walker, Katie Cotton, and Julia Strong, February 26, 2015, Pg 7.
    • The CDD does not watch people apply or swallow their treatments. Rather, when the CDD visits a household, the CDD asks how many people live in that household and leaves the appropriate number of treatments with someone who was home during the visit. That person is then expected to distribute the treatments to the rest of the family. Grace Hollister, Global Director of Deworm the World Initiative, conversation with GiveWell, August 11, 2016
    • Example from Nigeria (we don't know whether this is true elsewhere): "Where community based approaches are used, the community decides themselves whether it is house to house or fixed point." Sightsavers, Responses to GiveWell questions, October 2017, Pg 1.
    • "Front line health facilities are used for passive treatment of cases missed in school and in the community." Sightsavers, comment on a draft of this review, October 31, 2019.

  • 24

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

  • 25
    • "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.

  • 26
    • "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

  • 27

    "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.

  • 28

    Sightsavers notes, "The majority of unrestricted funds are donated by the public on the basis of our mission statement which is to reduce avoidable blindness." Sightsavers, comments on a draft of this page, October 2020 (unpublished).

  • 29

    "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.

  • 30

  • 31
    • "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.

  • 32
    • "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.

  • 33

  • 34

    "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.

  • 35

  • 36
    • "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.

  • 37

    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.

  • 38
    • 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.

  • 39

    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.

  • 40

  • 41

  • 42

    GiveWell's notes from its 2016 site visit to Ghana

  • 43

  • 44

    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

  • 45

    Sightsavers, Organizational expenditure 2014 and 2015, Sightsavers, Finances 2016 actual and 2017 planned, sheet "Organisational expenditure," Sightsavers, Organizational expenditure 2016 and 2017, Sightsavers, Organizational expenditure 2018 and 2017, Sightsavers, 2019 and 2018 organizational expenditure, and Sightsavers 2020 and 2019 organizational expenditure.

  • 46

  • 47

    See this spreadsheet, sheet "2014-2020 total spending," column "% of Total Expenditure without Gifts in Kind."

  • 48

    See this spreadsheet, sheet "2014-2020 total spending," row "Total Expenditure without Gifts in Kind," for details.

  • 49

    See this spreadsheet, sheet "2014-2020 total spending," row "Health - Neglected Tropical Diseases," for details.

  • 50

    See this spreadsheet, sheet "2014-2020 total spending," row 31.

  • 51

    Sightsavers has shared its 2014, 2015, and 2016 spending and its 2017 projected spending by NTD program with us, but deworming components are not separated out from the other programs.

    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. See our spreadsheet, sheet "2014-2017 spending by NTD," cells K114 and L114.

  • 52

    See this spreadsheet, sheet "2017-2021 spending of GW-directed funds," cell B26.

  • 53
    • See this spreadsheet, sheet "2017-2021 spending of GW-directed funds," cell B14.
    • From April 2020 through March 2021, spending was less than budgeted because of program disruptions caused, in part, by COVID-19: "​​In year 4, actual expenditure across the programme was 66% of what was budgeted. In several countries: Guinea, Guinea Bissau and DRC, expenditure was either displaced or was not able to take place due to the COVID-19 pandemic. In Nigeria and Cameroon, most of the activities went ahead, but some were delayed. Where activities were missed in year 4, we have worked with the countries to amend the year 5 budgets to include the activities which are still necessary." Sightsavers, GiveWell Y4 Financial Narrative Report, 2021

  • 54

    Sightsavers' description of these categories: "For each country, expenditure is shown broken down into 7 categories: Capital Expenditure, Project Activities, Staff Costs, Administration Costs, Monitoring Evaluation and Lesson Learning, Programme Management, and Overheads. The first 5 categories make up the ‘Country Total’ which represents the in-country cost of the activities. Generally, with the exception of staff and some office running costs, this expenditure is variable and spend only occurs when activities take place. The programme management category captures expenditure incurred in providing support and technical advice to the countries. This cost is split proportionately across the countries based on their annual expenditure." Sightsavers, GiveWell Y4 Financial Narrative Report, 2021

  • 55

    See this spreadsheet, sheet "2017-2021 spending of GW-directed funds."

  • 56
    • See this spreadsheet, sheet "2014-2020 total spending," row "Fundraising."
    • Sightsavers notes that its fundraising activities include "raising voluntary funds and institutional funding and management." Sightsavers, comment on a draft of this review, October 31, 2019

  • 57

    Sightsavers staff, conversation with GiveWell, October 2, 2016

  • 58

    Sightsavers staff, conversation with GiveWell, October 2, 2016

  • 59

    See this spreadsheet, sheet "Comprehensiveness," rows 9-13.

  • 60

    See this spreadsheet, sheet "Comprehensiveness," rows 15-21.

  • 61

    See this spreadsheet, sheet "Comprehensiveness," cell E23.

  • 62

    See this spreadsheet, sheet "Results from GW-supported projects."

  • 63

    See this spreadsheet, sheet "Results from GW-supported projects," row 40.

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    "These assessments measure the prevalence of schistosomiasis and STH...with a view to changing treatment schedules based on updated prevalence data." Sightsavers, comment on a draft of this review, October 31, 2019.

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    • 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.)

  • 67

    "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. 18.

  • 68
    • "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.

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    See this spreadsheet, sheet "Comprehensiveness," cell E23.

  • 71

  • 72

    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.

  • 73
    • 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 2017 (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.
    • Guinea-Bissau (2019): "As mentioned above, contrary to Sightsavers preferred approach to randomly select health districts during coverage surveys, Oio was purposefully selected due to operational challenges, which were partly due to prolonged strikes within the civils service and Sightsavers’ desire to mitigate recall bias." Sightsavers, Coverage survey Guinea-Bissau 2019, Pg. 5.

  • 74

    "For the Year 2 reporting period between April 2018 and March 2019 where security allowed, the treatment coverage survey locations and households for all GiveWell funded MDA was randomly selected. The exception in 2018 was DRC, where security issues prevented the random selection of locations. However, the selection of villages and households was random. Going forward, where feasible, the random selection of locations, villages and households for GiveWell funded deworming treatment coverage surveys will continue. (Prior to 2018, deworming treatment coverage surveys carried out by Sightsavers were conducted for internal programmatic planning purposes; the survey locations were selected with a view to making changes to MDA treatment plans, where needed)." Sightsavers, comment on a draft of this review, October 31, 2019.

  • 75

    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."
    Sightsavers, comment on a draft of this review, August 23, 2018.

  • 76
    • "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

    • In 2019, Sightsavers decided not to conduct a coverage survey in Kogi State, Nigeria because delays in other states caused too much time to elapse between when the MDA in Kogi State was conducted and when a coverage survey could be conducted: “A TCS is no longer planned for Kogi because of the lapse in time since MDA occurred. The program had planned to carry out TCSs for the states at the same time once they had all completed their MDA. However further delays in drug availability pushed back MDA schedules in all states but Kogi. These delays now mean that it has been too long since the MDA in Kogi to carry out a TCS that would give meaningful results.” Morna Lane, Head of Major Donors & Trusts, Sightsavers, email to GiveWell, August 7, 2019.

  • 77

    See this spreadsheet, sheet "Methods from GW-supported projects (I)," column "Length of time between MDA and survey," and sheet “Methods from GW-supported projects (II),” row "Survey design."

  • 78
    • See this spreadsheet, sheet "Methods from GW-supported projects (I)," column "Verification questions asked?", and sheet "Methods from GW-supported projects (II)," rows "Survey design" and "Survey implementation."
    • In Cameroon, Nigeria, DRC, and Guinea-Bissau in 2019, tablets were shown to respondents, but it is unclear if they were used to verify answers:
      • “To mitigate recall bias, the survey team ensured the following: Samples of praziquantel and mebendazole tablets/boxes were shown to each surveyed participant during questionnaire administration d.” Sightsavers, Coverage survey Cameroon 2019, Pg 4.
      • “Sample tablets of the drugs and the packages used during the recent MDA was shown to the household member to assist their recall.” Sightsavers, Coverage survey Nigeria 2019, Pg. 7.
      • “Sample tablets of the drugs and the packages used during the recent MDA were shown to the household member to assist their recall.” Sightsavers, Coverage survey Guinea-Bissau 2019, Pg. 5.
      • "Sample tablets of the drugs and the packages used during the recent MDA were shown to the household member to assist their recall." Sightsavers, Coverage survey DRC 2019, Pg. 5.
      • "Our TCS surveys show drug samples to each surveyed participant during questionnaire administration. This does show the TCSs are designed to counter recall bias." Sightsavers, comments on a draft of this page, October 2020 (unpublished).

  • 79
    • Sightsavers, Coverage survey Guinea 2018, Sightsavers, Coverage survey Guinea-Bissau 2018, Sightsavers, Coverage survey DRC 2018, and Sightsavers, Coverage survey Guinea-Bissau 2019 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. Further details are not provided.
    • Sightsavers, Coverage survey Nigeria 2019 notes that “For quality control purposes, there was a designated survey coordinator from Sightsavers’ team and a consultant, with overall responsibility for the conduct of the enumerators and team supervisors. Four supervisors were mobilized, and each state was assigned a supervisor. The supervisors and consultant spent time in the communities with each team to ensure the quality of the data being collected was standard.” Pg. 9. Further details are not provided.
    • Details on data quality control processes for all Sightsavers' coverage surveys we have seen are available in this spreadsheet, sheet "Methods from GW-supported projects (I)," column "Data quality control?", and sheet "Methods from GW-supported projects (II)," row "Survey implementation."
    • 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."
    • In Cameroon in 2019, data collection could not be monitored in real time: "The survey could not be monitored real time using the metabase platform (online application) because of the 24 hours synchronization time needed for it to update data sent by surveyors. This made it challenging to correct some errors encountered in the field." Sightsavers, Coverage survey Cameroon 2019, Pg 18.

  • 80

    See this spreadsheet, sheet "Results from GW-supported projects," columns "Praziquantel coverage, from survey" and "Albendazole/mebendazole coverage, from survey."

  • 81

    "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 2017 (English translation), Pg 3.

  • 82

    "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.

  • 83

    See this spreadsheet, sheet "Results from GW-supported projects."

  • 84

    See this spreadsheet, sheet "Results from GW-supported projects," row 40.

  • 85

    See this spreadsheet, sheet "Comprehensiveness," cell E23.

  • 86

    "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." Email from Amanda Jordan, Sightsavers Trusts Manager, July 20, 2018

  • 87

    "TCS was not conducted due to security issues," Sightsavers, Global report year 3, Pg. 4

  • 88

    In 2019, Sightsavers decided not to conduct a coverage survey in Kogi State, Nigeria, because delays in other states caused too much time to elapse between when the MDA in Kogi State was conducted and when a coverage survey could be conducted: “A TCS is no longer planned for Kogi because of the lapse in time since MDA occurred. The program had planned to carry out TCSs for the states at the same time once they had all completed their MDA. However further delays in drug availability pushed back MDA schedules in all states but Kogi. These delays now mean that it has been too long since the MDA in Kogi to carry out a TCS that would give meaningful results.” Morna Lane, Head of Major Donors & Trusts, Sightsavers, email to GiveWell, August 7, 2019.

  • 89

    See this spreadsheet, sheet "Comprehensiveness," cell E24.

  • 90

  • 91

    Tekle et al. 2012.

  • 92

    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."

  • 93

    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.

  • 94

    Lakwo et al. 2015

  • 95

    “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.

  • 96

    "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.

  • 97

    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.

  • 98

    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.

  • 99

    Bailey 2013

  • 100
    • "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.

  • 101
    • “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.

  • 102

    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%

  • 103

  • 104

    See this spreadsheet, sheet "Results from GW-supported projects," rows 6-8.

  • 105
    • 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

  • 106
    • "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.

  • 107

    "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

  • 108

  • 109

  • 110

    See this spreadsheet, sheet "Summary," cell B9. Cells C9-J9 show a cost per child dewormed estimate for each location in which Sightsavers supported deworming programs in 2017-2020.

  • 111

    See this spreadsheet, sheet "Overall estimates," cell B5.

  • 112

    See this spreadsheet, sheet "Overall estimates."

  • 113

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

  • 114
    • The World Health Organization recommends treatment with albendazole for STH infections and praziquantel for schistosomiasis infections. @World Health Organization, Preventive chemotherapy in human helminthiasis@, Pg 10.
    • Sightsavers' quality control standards set out its treatment regimen:
      • "Benchmark: School and community-based treatment programmes for schistosomiasis with praziquantel (PZQ) are supported by effective and sustainable drug procurement and delivery mechanisms to districts, front line health facilities (FLHF), and ultimately to schools and communities." Sightsavers' Quality Standards Manual, Pg. 67.
      • "Benchmark: School and community-based treatment programmes for soil transmitted helminths with albendazole/mebendazole (ALB/MEB), are supported by effective and sustainable drug procurement and delivery mechanisms to districts, front line health facilities (FLHF), and ultimately to schools and communities." Sightsavers' Quality Standards Manual, Pg. 73.

  • 115

    Our understanding from conversations with our deworming top charities is that targeting of albendazole and praziquantel MDA sometimes occurs at the sub-district level, meaning children living in those sub-districts are either targeted to receive albendazole only, praziquantel only, or both. However, the treatment information we receive from Sightsavers is typically aggregated at the regional- or district-level and simply provides the total number of albendazole treatments and the total number of praziquantel treatments delivered in that district. This makes it difficult to determine which of these treatments were delivered in sub-districts receiving albendazole only, praziquantel only, or both, and therefore whether they were delivered to children receiving one or both treatments. In the absence of this information, we assume full overlap (i.e., that the greater of albendazole treatments delivered or praziquantel treatments delivered is the total number of children dewormed, and therefore that all treatments of the other drug were to children receiving both). We do this in order to avoid double-counting children dewormed (i.e., to avoid counting one albendazole treatment delivered and one praziquantel treatment delivered as two children dewormed, if in reality both treatments were to one child).

  • 116
    • 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). We assume maximal country-level overlap in 2017.
    • We have seen district-level data on treatments from 2018, 2019, and 2020. We thus assume maximal district-level overlap in those years. See this spreadsheet, sheets "2018 treatment numbers," "2019 treatment numbers," and "2020 treatment numbers."

  • 117

    For an example of Sightsavers' budget categories, see this spreadsheet, sheet "Sightsavers' costs by country and year," column A.

  • 118

    For a discussion of why we consider funding a charity's work up to three years in the future, see this blog post.

  • 119

    Some of our top charities have a policy of holding funding reserves. In our room for more funding analyses, we typically include reserved funding as funding available to support program activities. We do this both to ensure consistency across top charities (as not all top charities hold reserves) and to understand the true effect of granting additional funding (i.e. whether additional funding would support undertaking additional program activities versus building or maintaining reserves).

  • 120

    GiveWell maintains a list of all charities that meet our criteria, along with a recommendation to donate to our Maximum Impact Fund. Some donors give based on our top charity list but do not follow our donation recommendation. In our projections of future funding, we typically count only one year of funding that an organization receives as a result of being on our list of top charities in order to retain the flexibility to change our recommendations in future years.

  • 121

    We update a top charity's room for more funding analysis more frequently if we grant funding to it more frequently.

  • 122

    We update a top charity's room for more funding analysis more frequently if we have reason to believe that its funding and budgets have changed substantially.

  • 123

    For a list of grants we have made from our Maximum Impact Fund, see this page, section "Past recipients of the Maximum Impact Fund."

  • 124

    Open Philanthropy, a philanthropic organization with which we work closely, is the largest single funder of our top charities. The vast majority of Open Philanthropy's current giving comes from Good Ventures. We make recommendations to Open Philanthropy each year for how much funding to provide to our top charities and how to allocate that funding among them. An example of these recommendations from November 2020 can be found on this page.

  • 125

    This includes donations made to charities on our checkout page, donations made directly to the organizations, and donations through other third-party organizations that share GiveWell’s recommendations (e.g., One for the World).

  • 126

    See this spreadsheet, sheet "2014-2020 total spending," row "Health - Neglected Tropical Diseases," for details.

  • 127

    See this spreadsheet, sheet "2014-2020 total spending," row "Health - Neglected Tropical Diseases," for details.

  • 128

    "This does not represent a general trend of increased allocation of unrestricted funding towards the implementation of specific NTD activities...Instead, the rest of the increase is down to revisions in the way that costs from elsewhere in the organisation were allocated across thematic areas in the accounts, in line with SORP requirements. We are required to allocate organisational support costs across our themes in line with the effort / time that different cost centres within the organisation spend supporting those areas and the proportion of spend on each theme. There were significant shifts in some of these allocation percentages in 2019, especially in West Africa to reflect the significant increase in NTD activity in the region as a result of the GiveWell, Accelerate, and Ascend programme activity that scaled up in 2019. There was also an increase in overall organisational expenditure on general support activities in 2019 as spend increased on governance, safeguarding, resilience, finance and monitoring support etc leading to a higher level of costs to be allocated thematically. As a result, the allocation of unrestricted costs to NTDs in the accounts was larger than in 2018 but most of this unrestricted allocation, therefore, was spend across other parts of the organisation, not specifically on NTD activities. In essence, this increase relates to statutory accounting mechanisms rather than programme allocation decisions." Sightsavers, email to GiveWell, October 13, 2020

  • 129

    "Sightsavers has not increased its actual allocation of unrestricted funding for direct NTD activities and the table below shows the actual allocation of unrestricted funding to direct NTD activities between 2015 -2020 indicating a decline...2015: 2,839,291...2016: 2,133,972...2017: 1,962,041...2018: 1,102,435...2019: 793,428." Sightsavers, email to GiveWell, October 13, 2020

  • 130

    "We also wanted to let you that Sightsavers is planning to direct some unrestricted funding to support SCH sub districts analysis from 2021 onwards. Across 4 countries, we’re allocating £310,000 in order to support the work needed to enable the Ministries of Health to order Praziquantel from WHO (following the new WHO guidance). This is a one off allocation to respond to the pressing need to facilitate Praziquantel orders, to enable GiveWell funded MDA to go ahead." Sightsavers, comments on a draft of this page, November 2021