# Sightsavers – deworming program

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

Published: November 2016 (Previous version here)

## Summary

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

Does it work? We believe there is relatively strong evidence for the positive impact of deworming. Sightsavers has provided us with moderate-quality monitoring indicating that it has achieved fairly high coverage rates for some of its past NTD programs. We have seen very limited results from Sightsavers' deworming programs specifically. For GiveWell-supported programs, Sightsavers has told us it will conduct coverage surveys for each MDA. (More)

What do you get for your dollar? We do not have a robust cost-per-treatment estimate for Sightsavers' deworming program. We estimate a cost-per-treatment based on our estimates for organizations that do similar work to Sightsavers, which have delivered deworming treatments for $0.79 and$1.19, respectively (both are about $0.50 excluding in-kind contributions). The number of lives significantly improved is a function of a number of difficult-to-estimate factors, which we discuss in detail in a separate report. (More) Is there room for more funding? We believe that Sightsavers' deworming work is highly likely to be constrained by funding next year. We do not expect Sightsavers to have funding for new deworming programs without GiveWell's support. We estimate that if Sightsavers received$2.9 million in additional funding, its chances of being constrained by funding would be reduced to 50%. Donors should note that Sightsavers' deworming work is only a small portion of the activities it funds and that we have not evaluated Sightsavers' other work. (More)

Sightsavers' deworming program is recommended because of:

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

Major open questions include:

• Sightsavers has a limited track record of implementing deworming programs. Deworming has not been a focus or major priority for Sightsavers, which may impact how well programs are carried out.
• The monitoring we have seen from Sightsavers is primarily from programs that do not treat for schistosomiasis or STH and is only of moderate quality. While we believe these programs are similar enough to deworming programs that the monitoring is indicative of Sightsavers' expected future performance, we expect to update our opinion based on additional future monitoring of the deworming programs Sightsavers will support.
• We do not have a thorough understanding of Sightsavers' financials because we had limited time to vet the documents we have seen, and we therefore do not have a robust estimate of Sightsavers' cost-effectiveness. Sightsavers spends considerably more on fundraising than other charities we recommend (about 28% overall and 46% of unrestricted funding, excluding gifts in kind).

## Our review process

As we stated in our 2015 plans, we have been interested in finding additional top charities that work on deworming. Sightsavers was one of several charities we invited to apply to be considered for our top charity recommendation. To date, we have:

• Had multiple conversations with Sightsavers staff.1
• Reviewed documents Sightsavers shared with us.
• Visited Sightsavers' country office in Ghana during one of our 2016 site visits. Sightsavers does not support a deworming program in Ghana, but we were able to have several conversations with Elizabeth Elhassan, Technical Director of NTDs, and Sunday Isiyaku, Country Director in Nigeria and Ghana, as well as other staff.

Sightsavers is a new top charity as of November 2016. For most of our other top charities, we have spent several years reviewing and engaging with the charity's work. We feel that we know significantly less about Sightsavers than our other two top charities that also support deworming, the Schistosomiasis Control Initiative and Deworm the World Initiative, and that there are still major open questions about Sightsavers' work.

## What do they do?

Sightsavers focuses on preventing avoidable blindness and improving the lives of those who have visual impairments.2 Although Sightsavers conducts many programs, Sightsavers' work on neglected tropical diseases (NTDs) is its largest portfolio of work.3 In this review we focus on Sightsavers' deworming programs, which are part of Sightsavers' work on neglected tropical diseases (NTDs). Our understanding is that deworming is a small and relatively new part of Sightsavers' work and that Sightsavers is primarily interested in adding deworming components to the community-based NTD programs that it already supports in Africa.4

The deworming programs that Sightsavers supports are focused on executing mass drug administrations (MDAs), in which the aim is to treat the entire population of children within a geographic area by distributing deworming pills.5 Sightsavers' role in the deworming programs it supports is generally to provide both technical assistance and funding to governments and other implementing partners (more).

Below, we discuss:

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

### How does deworming fit into Sightsavers' other activities?

#### Background

Sightsavers was founded in 1950 to treat eye conditions in developing countries.6 It continues to focus on eliminating avoidable blindness and supporting people with visual impairments in low-and-middle-income countries;7 this focus has led to its work on integrated NTD programs, particularly programs targeting those NTDs that cause blindness (onchocerciasis and trachoma).8

Sightsavers began its work on deworming programs recently, in 2011.9 We believe it currently supports deworming programs in Cameroon, Democratic Republic of the Congo (DRC), Nigeria, and Sierra Leone (the countries in which it supported deworming treatments in 2015).10

Deworming programs are part of Sightsavers’ integrated NTD programs.

#### Sightsavers' integrated NTD programs

Sightsavers began to work on NTD programs in the 1950s.11 It is our understanding that Sightsavers' integrated NTD program is focused on diseases that can be treated by chemotherapy via MDAs, primarily onchocerciasis (which can cause blindness), trachoma (which can also cause blindness), lymphatic filariasis, schistosomiasis, and soil-transmitted helminthiasis.12

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.13 Schistosomiasis and soil-transmitted helminthiasis (which are treated by deworming programs) are not prioritized because elimination of these diseases is not expected soon.14 Sightsavers intends to add deworming components to the NTD programs that it already supports, and is not interested in starting new programs that only support deworming.15

### What types of deworming programs will 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.16 In school-based MDAs, teachers are trained to provide treatments to children during normal school-hours.17

As discussed above, Sightsavers intends to add deworming components to its other NTD programs. Treatments for onchocerciasis, trachoma, and lymphatic filariasis are typically distributed via community-based MDAs.18 Additionally, although Sightsavers has supported both school-based and community-based MDAs, it prefers to support community-based MDAs because it believes that such programs will reach more high-risk children.19

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

### How does Sightsavers select deworming programs to support?

Before supporting a new deworming program, Sightsavers told us that it considers:20

• The prevalence and intensity of schistosomiasis and soil-transmitted helminthiasis in the area in which the program would occur.21
• The availability of funding for the deworming component. Sightsavers prefers to use restricted funding for deworming components because its unrestricted funding is in high demand by its other programs.
• The feasibility of the program given Sightsavers' partners' capacity and resources.
• The feasibility of the program given Sightsavers' capacity.

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

### What role does Sightsavers play in supporting deworming programs?

The deworming programs that Sightsavers supports are implemented by the governments or partners it works with.22 We have somewhat limited information on Sightsavers' role in the deworming programs it has supported. Our understanding is that Sightsavers primarily provides technical assistance to governments and implementing partners and may also provide financial support for a program. Sightsavers also assists with managing and organizing coalitions.23

#### What technical assistance does Sightsavers provide?

We do not feel that we have a detailed understanding of what kind of support Sightsavers provides to its partners. The following descriptions are based on several documents Sightsavers sent us that describe its work, as well as our previous understanding of the types of activities that typically constitute "technical assistance" for organizations that support deworming programs.24 Activities that Sightsavers assists with include:

1. Advocacy. Sightsavers meets with government representatives to encourage them to implement additional NTD programs.25
2. Developing national plans. Sightsavers assists country governments and partner NGOs in developing national integrated plans for addressing NTDs.26
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.27
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.28
5. Drug logistics. Sightsavers provides support in some locations for drug logistics, such as storage.29
6. Community sensitization. Sightsavers helps with efforts to create awareness within communities about when an MDA will occur and why it is important.30
7. Monitoring and reports. Sightsavers helps plan monitoring activities for the MDA.31 It also produces reports on the program and the program's monitoring.32 We are unsure how Sightsavers determines what type of monitoring to conduct for each program; it is our impression that Sightsavers does not have standardized monitoring that it uses for all programs.33
• Routine monitoring:34 the monitoring that supervisors do to check whether or not an MDA is running smoothly. Sightsavers told us that these supervisors use a standardized checklist during their visits to CDDs and produce reports on the quality of the program.
• Coverage surveys:35 Sightsavers told us that it aims to periodically conduct coverage surveys on its programs.36 A coverage survey involves sending out 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.

Sightsavers has described other types of monitoring that it conducts; we are not sure if Sightsavers regularly supports additional monitoring for its deworming programs.37

#### What financial assistance does Sightsavers provide?

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

### Descriptions of programs by country

In 2016, Sightsavers sent us a list of its 2015 NTD treatments by country, which indicated that it had supported the distribution of deworming treatments in Cameroon, DRC, Nigeria, and Sierra Leone.42 We do not have detailed information on all of Sightsavers' deworming programs, but we present what we know below.

#### Cameroon

Sightsavers has worked on NTD programs in Cameroon since 1996 and started supporting school-based deworming programs there in 2011.43 Sightsavers' partners include the Ministry of Public Health, Helen Keller International, and other NGOs, and most of the deworming work is funded by USAID.44

Cameroon has a national school-based deworming program, which Sightsavers supports. MDAs are conducted annually.45 Sightsavers told us it supports integrated programs with deworming components in three of the country's ten regions.46 Sightsavers also currently supports a community-based MDA program that treats onchocerciasis and lymphatic filariasis in Cameroon and trachoma activities in the Far North and North regions of Cameroon.47

#### Democratic Republic of the Congo

Sightsavers has supported NTD programs in DRC since 2011.48 Sightsavers works in three provinces; its partner in those provinces is the United Front Against Riverblindness (UFAR).49 In 2015, Sightsavers partnered with the Schistosomiasis Control Initiative (SCI) to support the distribution of deworming treatments in some areas of DRC.50

#### Nigeria

Nigeria is one of Sightsavers' largest country programs and the first where it implemented deworming; Sightsavers has worked there on various programs for over 40 years.51 In 2015, Sightsavers used its unrestricted funding to support deworming in six states in Nigeria, adding deworming components to two different programs that are primarily funded by the UK's Department for International Development (DFID) (details in footnote).52 Sightsavers also received a grant from the Children's Investment Fund Foundation (CIFF) to conduct prevalence mapping of schistosomiasis and STH in 14 states in northern Nigeria between 2013 and 2015.53

In Nigeria, Sightsavers partners with the government, which implements the programs while Sightsavers provides technical assistance and monitoring.54 Sightsavers also helps to coordinate the government's national and state NTD teams and assists these teams in developing their strategies.55 More detail about the programs in Nigeria can be found in Sightsavers, Descriptions of current work - 2015 and 2016.56

#### Sierra Leone

We do not yet have details about Sightsavers' work in Sierra Leone, other than that Sightsavers supports the integrated training of community-based drug distributors there.57

### What is Sightsavers' staff structure?

Sightsavers' work on NTDs is spread across three main departments: finance and planning, NTDs, and policy and program strategy, which includes research.58 These departments work closely with regional office teams in Sub-Saharan Africa on the strategic planning and implementation of NTD projects in each country.59

Sightsavers employs a West Africa regional director, an East and Central Africa regional director, and 11 country directors for 20 country offices in Africa.60 Some country directors supervise multiple countries.61 There are also some countries for which Sightsavers does not have any permanent on-the-ground staff and instead works fully through partners.62 Some country offices include an M&E Manager, and recently Sightsavers has been adding NTD Managers to its country teams.63 Additionally, Sightsavers has technical advisors who travel country to country, disseminating information on best practices for MDAs and monitoring and providing regular remote assistance.64

Within country offices, the standard staff in the office are:65

• Country director. Country directors oversee the program managers. They also oversee the finance and support teams.
• Program managers. Program managers oversee the program officers and work with the finance and support teams.
• Program officers. Program officers do a large portion of Sightsavers' work in the field and spend much of their time on monitoring activities. They visit implementing partners to check that activities are proceeding according to schedule and visit communities to observe whether or not work is being carried out as expected. They also train partners' staff on program delivery.
• Finance and support team. Usually 1-4 people, this team provides the financial and operational support for Sightsavers' activities in the country. The finance team helps to design budgets for programs and regularly monitors partner expenditures to ensure that funds are being spent in accordance with budgets.66

### How has Sightsavers spent funds in the past?

We have seen very high-level summaries of Sightsavers spending in 2014 and 2015.67 The vast majority of this spending was funded by in-kind gifts from other organizations, which are mostly drug donations.68 Excluding in-kind gifts, a rough characterization of Sightsavers' spending in both 2014 and 2015 is that approximately 90% of funding was split roughly equally between fundraising, eye care health programs, and NTD programs.69 This spreadsheet shows our breakdown of Sightsavers' 2014 and 2015 spending (in USD).70

#### Spending on NTD and deworming programs

In both 2014 and 2015, Sightsavers spent slightly more than $50 million in unrestricted funding; slightly less than$5 million of its unrestricted funds were spent on NTD programs, which were largely funded by restricted funding.71 We do not know what portion of Sightsavers' spending supported deworming programs alone: although Sightsavers has shared its 2014 and 2015 spending by NTD program (as well as 2016 projected spending) with us, deworming components are not separated out from the other programs.72 For 2016, Sightsavers' projections indicate that about 19% of total NTD funding will go to integrated programs that have a deworming component.73 We are not sure how much funding has supported deworming programs, or programs with a deworming component, prior to 2016.

We have not seen a detailed breakdown of Sightsavers' spending within any given NTD program, so we do not have a good sense of what Sightsavers spends its funding on other than staff (or what proportion of its spending goes to staff). However, in 2015, Sightsavers shared with us its projected spending for NTD programs in two countries (Nigeria and Guinea-Bissau); we wrote about this breakdown in our interim review.

#### Spending on fundraising

Sightsavers spent 28-29% of its total spending (excluding in-kind contributions), which was 45-48% of its unrestricted funding, on fundraising activities in 2014 and 2015.74 While we typically do not put too much weight on an organization's spending breakdown (for reasons explained in this blog post), this seems higher than we've seen from other top charities—though we recognize that there can be significant variation in how organizations categorize costs. When we asked Sightsavers about its high fundraising costs, it noted that it aims to use less than one third of its total annual budget on fundraising and that this is consistent with industry standards.75 Sightsavers also highlighted that when the value of in-kind gifts are included, Sightsavers’ fundraising costs are under 10%.76

## Does it work?

Sightsavers-assisted MDA programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective. Evidence from Sightsavers' monitoring makes a moderately strong case that the programs Sightsavers supports in the future will successfully deworm children.

The monitoring we have seen from Sightsavers is of moderate quality, but it is primarily from programs that focused on NTDs other than schistosomiasis or STH. While deworming programs are fairly similar to other NTD MDAs, there is a risk that Sightsavers may not achieve as strong results as it has in the past or may not produce similar evidence of its impact for deworming programs.

Here we focus on the following questions to understand whether Sightsavers' activities are having the intended impact (details in the sections that follow).

• What is the independent evidence for the program?
• Is the program targeted at areas with need?
• Are deworming pills delivered to and ingested by recipients?
• Are deworming programs operating as intended?
• What is the effect of Sightsavers' work on program outcomes?
• Are there any negative or offsetting impacts?

### 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. 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.

We do not know how similar the areas that Sightsavers works in are to the places where the key studies on improved life outcomes from deworming took place. It is possible that Sightsavers works in locations where the type and severity of worm infections are significantly different (more in the next section).

### Is the program targeted at areas with need?

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.

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.77 It is possible that deworming programs in areas with lower prevalence or intensity of worm infections might not have the same impacts as were found for those participants.

We have seen some baseline prevalence and intensity data for five of the six areas where Sightsavers would use additional unrestricted funding to scale up deworming programs (more). However, we have some concerns about putting much weight on the data Sightsavers has provided:

• We do not know how most of the data was measured.78
• We don't know when all of the data was collected. Some of the data was collected several years ago, and the data for Guinea-Bissau is from 2005 and earlier.79
• For Nigeria, Sightsavers provided prevalence data with wide ranges which we do not know how to interpret.80
• We do not know if the data was collected before any deworming programs or lymphatic filariasis programs (which use the same drug as is used to treat STH) were started; it is possible that some of the data represents prevalence rates after multiple years of MDA.
• We have not seen any data on the intensity of infections.
• In some cases, we have had to make educated guesses about which areas Sightsavers intends to support deworming programs in.81

For these reasons, we do not have high confidence in the prevalence data we have seen. Because we do not know how all of the data provided by Sightsavers was measured, we are not confident in the extent to which it is comparable to the worm prevalence data in the studies which constitute our key evidence for the impact of deworming. Nonetheless, we have attempted to compare the data we do have with the data from the studies which inform our view on deworming in this spreadsheet.82

Note that we have not seen any prevalence data for Cameroon (more).83

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

We believe there is moderately-strong evidence that pills have been delivered to and ingested by a large proportion of targeted recipients in Sightsavers-supported programs in the past. The evidence we have seen is from Sightsavers-supported NTD MDA programs that did not (with one exception) include a deworming component. Because implementation and monitoring for deworming programs is fairly similar to other NTD MDAs, we believe Sightsavers' track record in this type of work is moderately strong.

The evidence we have focused on includes:

• Reported treatment numbers: Sightsavers has reported supporting a large number of NTD treatments in 2014 and 2015. We do not have much confidence in these figures because (a) we think they are reported by governments and (b) we are not sure what Sightsavers' role was in supporting these treatments.
• Coverage surveys: We believe the coverage surveys Sightsavers has shared with us provide the best evidence of its impact. While they have some methodological limitations, they indicate that Sightsavers is reaching a moderately high proportion of targeted recipients.
• Impact assessments: We have seen impact assessments of several of Sightsavers' trachoma and onchocerciasis programs; the assessments had significant methodological limitations and have not substantially shifted our view on Sightsavers' ability to support future deworming programs.

Details follow.

#### Reported treatment numbers

We have seen figures on reported numbers of treatments delivered for many of Sightsavers' NTD MDA programs, but we are highly uncertain that these figures are accurate.

For 2014, Sightsavers reports that it supported the delivery of about 100 million NTD treatments. Of these, about 14 million (14%) were STH treatments and about 4 million (4%) were schistosomiasis treatments. These deworming treatments (18% of all treatments) were delivered in three countries: Cameroon, Nigeria, and Tanzania.84 2015 looks similar: Sightsavers reports that it supported the delivery of about 142 million NTD treatments, of which about 14.4 million (10%) were STH treatments and about 6.8 million (5%) were schistosomiasis treatments.85 We know that some of the treatments included in the 2015 calculation were ones that Sightsavers supported minimally.86

We do not have an in-depth understanding of exactly how the figures Sightsavers reported were calculated, but we would guess that these figures are calculated by aggregating numbers of treatments reported delivered (recorded by schools or communities) from the lowest implementation level up to the country level. Note that Sightsavers told us that each year, for a random sample of projects, it conducts spot checks on whether aggregated data (e.g., district-level data) matches original tallies for figures such as number of treatments delivered or people trained.87

For one coverage survey Sightsavers shared with us from Nigeria (DFID-UNITED Integrated Post MDA Coverage Survey Report 2014), the coverage rate measured by the survey was substantially lower than reported coverage figures from many communities and local government areas (LGAs).88 We are not sure how accurate the other reported treatment numbers are; we have not attempted to compare reported coverage and survey coverage for other Sightsavers-supported NTD MDA programs.

#### Coverage surveys

Sightsavers hires external consultants to conduct coverage surveys—house-to-house surveys of a sample of a population targeted for an MDA program—in order to estimate the proportion of the population targeted that actually received treatment.89 We have heard conflicting reports about how often Sightsavers conducts prevalence surveys, 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).90

Sightsavers has shared reports on its coverage surveys from Benin (2015), Togo (2015), Burkina Faso (2015), Côte d'Ivoire (2015), Cameroon (2015-16), South Sudan (2015), Nigeria (2014 and 2015), and Malawi (2015); however, not all of these surveys are public.91

We summarize the methodologies of the publicly available coverage surveys we have seen from Sightsavers in this spreadsheet ("Methods" sheet). We are not confident that these surveys report fully accurate and representative estimates of the treatment coverage in Sightsavers' MDA programs due to some limitations to the survey methodologies:

• Selection of geographic areas: Sightsavers' coverage surveys are implemented within specified geographic areas (e.g., districts, regions, or local government areas). It appears that geographic areas are often selected purposefully rather than randomly. For example, for the 2015 coverage surveys in Benin and Togo, it is not clear why Abomey and Sotouboua districts were chosen.92 Full details on the selection of geographic areas for all Sightsavers' coverage surveys we have seen are available in this spreadsheet, "Methods" sheet.
• Length of time between MDA and survey: For some of Sightsavers' coverage surveys, respondents are asked to recall taking drugs up to six months prior, which may have an impact on the accuracy of the responses; for other surveys, the amount of time between the MDA and survey is not clear.93 Sightsavers told us that it aims to conduct all coverage surveys within 1-2 months of the MDA and that it does not believe recall bias is as serious a concern as is often believed.94
• Unclear data quality control processes: There is no mention in the coverage survey results of any re-surveying of households to check the accuracy of the data collected and, although several reports mention data quality verification, specifics are not given.95

Additionally, we have found some limitations specific to certain surveys:

• There appear to be inconsistencies in the praziquantel coverage data from the 2014 coverage survey in Nigeria and in the report from the 2015 coverage survey in Malawi.96
• For the 2014 coverage survey in Nigeria, it appears that distribution of drugs for schistosomiasis was not yet fully completed at the time of the survey, so the surveys may underestimate coverage for the schistosomiasis part of the MDAs.97

For the results of these coverage surveys, see this spreadsheet, "Results" sheet.

Notes on these results:

• Coverage rates found in these surveys vary widely: from 40% coverage for ivermectin and albendazole in Benin from the 2015 survey, to 88% coverage for ivermectin and albendazole in the Northwest region of Cameroon from the 2015-16 survey.98
• We do not believe the coverage surveys we have seen are representative of all Sightsavers NTD programs because we do not believe we have seen all of the coverage surveys Sightsavers has completed (or completed in a specific time frame)99 and because it is not clear how Sightsavers decides which MDAs to conduct surveys of.
• For some areas with low coverage rates, the primary reason given is that community distributors may not have been visiting all households.100

#### Impact assessments

We have reviewed three studies that 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:101 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).102 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.103
• A 2015 impact assessment of long-term (1993-2015) treatment of onchocerciasis in fifteen villages in three districts of Uganda:104 District-level onchocerciasis prevalence ranged from 0.8% to 5.5% at the time of the assessment.105 The authors noted that baseline prevalence data (from 2007) was available for only two of the fifteen villages,106 but they did not provide the baseline data from the two villages in the report. The study concluded that the MDAs performed well.107 Other limitations of the study are discussed in this footnote.108
• An impact assessment on three rounds of trachoma treatment (2009-2012) in three regions of Guinea-Bissau:109 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.110 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.111 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.112

Sightsavers also shared documents on impact assessments on a onchocerciasis control program in Kwara and Kogi states in Nigeria and another onchocerciasis control program in Kibaale District Uganda.113 We have not reviewed these documents in depth. A quick review led us to believe that they would not affect our views on Sightsavers' future deworming programs.

We have not seen impact assessments of Sightsavers' schistosomiasis or STH programs specifically.114

### Are deworming programs operating as intended?

We do not have a good understanding of how often activities in Sightsavers-supported programs operate as Sightsavers intends.

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").115 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.116

The program supervisor conducting routine monitoring in Kogi State found that issues identified in the last monitoring visit had been addressed, the targeted number of teachers were trained on time, and program expenditures were on track to stay on budget.117

In Kebbi State, the program supervisor reported observing community drug distributors entering data and using dose poles; the report did not state whether or not community drug distributors were performing these activities appropriately.118

We have not seen other routine monitoring reports from Sightsavers, and are uncertain how often routine monitoring visits occur.119 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.120 Sightsavers intends the QSAT reports to supplement the routine monitoring reports it has shared with us.121

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

Sightsavers may be having an impact in the following ways:

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

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

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

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

### Are there any negative or offsetting impacts?

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

Administering deworming drugs seems to be a relatively straightforward program.122 However, there are potential issues that could reduce the effectiveness of some treatments, such as:

• Drug quality: For example, if drugs are not stored properly they may lose effectiveness or expire.
• Dosage: If the incorrect dosage is given, the drugs may not have the intended effect and/or children may experience additional side effects.
• Concerns over whether treatment is sustained: We believe it is important that deworming programs are sustained over time, as re-infection is rapid and a one-time treatment may have little long-term effect.123
• 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, including one case that led to riots.124 While the accounts we have heard are from programs supported by the Schistosomiasis Control Initiative, we think it is possible that other deworming programs could cause similar discontent.

## What do you get for your dollar?

This section examines the data that we have to inform our estimate of the expected cost-effectiveness of additional donations to Sightsavers. Note that the number of lives significantly improved is a function of a number of difficult-to-estimate factors, many of which we discuss below. We incorporate these into a cost-effectiveness model which is available here.

We have very limited information on the full cost of an STH or schistosomiasis treatment delivered in a Sightsavers-supported program. When we attempted to analyze the data we have seen from Sightsavers on treatments and costs from existing and projected programs, we estimated a wide range of cost per treatments. Additionally, we make a number of assumptions and judgment calls in interpreting the data that we have seen, and this could introduce errors which might overstate or understate the actual cost. As a result, we have low confidence in our estimates of Sightsavers' cost per treatment and instead rely on deworming cost per treatment estimates from Deworm the World and SCI to estimate Sightsavers' cost-effectiveness.

We discuss how the cost per treatment figure relates to how much it costs to improve a child's health and development at our report on mass treatment programs for schistosomiasis and STHs.

### Our approach

Our general approach to calculating the cost per treatment is to identify comparable cost and treatment data and take the ratio. We prefer to have a broadly representative selection of costs and treatments in order to mitigate possible distortions, such as using data from a new program, which may incur costs from advocacy, mapping, etc. before it has delivered any treatments.

To get the total costs of the program, we attempt to include all partners such that our cost per treatment represents everything required to deliver the treatments. We believe that this gives the best view of what it costs to achieve a particular impact (such as saving a life) and also avoids the lack of clarity and complications of leverage in charity. In particular, in our cost per treatment analysis for Sightsavers, we have attempted to include these categories:

• Sightsavers' costs from providing technical assistance or 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.

Sightsavers sent us several estimates of its cost per treatment; however, these estimates did not include all costs that we typically include in our analyses.125

#### Shortcomings of our analysis

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

• Limited data from previous deworming programs: Sightsavers only began to support deworming programs a few years ago, so we do not have a large amount of data to rely on from actual programs.126 We do not have data for all programs that Sightsavers has supported with a deworming component. Additionally, Sightsavers has not broken down the costs of past programs such that we can see the cost of the deworming component alone. In some cases, we have used budgets for future programs; we are unsure how Sightsavers' budgets will compare to its actual costs.127 We have used budgets for some countries that Sightsavers is unlikely to enter in the next year, in part because they are particularly challenging (and, therefore, likely more expensive) to work in, because we had limited data to work with.128
• Integrated NTD programs: Sightsavers' NTD programs combine treatment for schistosomiasis and STH with other MDA programs, such as for onchocerciasis, trachoma, and lymphatic filariasis. It is our understanding that the deworming programs that Sightsavers would support with additional funding will be components of these integrated programs. In cases where Sightsavers is adding a deworming component to an existing MDA program, there are several approaches we could take:
1. Only incorporate the additional costs of adding deworming into our cost per treatment analysis.
2. Include the full cost of the integrated program and estimate the total benefits from all components of the program.
3. Include the full cost of the integrated program, but only consider the benefits from deworming treatments.

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

• Limited data on partners' costs: We have very limited data on the contributions of Sightsavers' partners, such as the value of donated drugs or government staff time. 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- and Deworm the World-funded programs, is to base the estimate on a single, likely outdated study from an SCI-funded program.129
• Possible excluded costs: Some costs might be excluded from our estimate because we are not sure what costs are included in the budgets Sightsavers has shared with us. For example, the following may not be included: Sightsavers' headquarters costs (e.g., for management and technical salaries), start-up costs (e.g., for setting up operations in a new location), or office space and vehicle costs.
• Limited review of financials: We have only spent a limited amount of time reviewing Sightsavers' documents; while we have asked Sightsavers some questions about them (in footnote), we do not yet fully understand how well the documents match with each other.130 We have had past experiences with other charities where, when we looked more closely at documentation, we found errors and inconsistencies that we previously did not notice.

### Our analysis

We analyzed past spending and treatment data for multiple locations from 2014 and 2015, and several budgets spanning 2016-2018 for future programs. We estimate Sightsavers’ cost per treatment to be somewhere between $0.51 and$2.29. We have low confidence in our estimates. Full details in this spreadsheet, sheet "GiveWell's cost-per-treatment analysis."

Several assumptions in our analysis:

• We assume that consuming either albendazole, praziquantel, or both counts as being dewormed. This is consistent with how we count the number of treatments delivered by SCI and Deworm the World. Because we do not have detailed enough data from Sightsavers to determine what portion of children received only albendazole or only praziquantel, we have assumed that the figures we have received fully overlap within each country.131 We guess that this is fairly close to accurate because it is our understanding from conversations with SCI and Deworm the World that a high proportion of children who are infected with schistosomiasis are also infected with STH, and so almost all children who receive treatment for schistosomiasis also receive treatment for STH.
• Our guess is that other NTD treatments are much less cost-effective than deworming, and we have modeled both no impact from other NTD treatments and impact comparable to deworming. Our guess is that the former is much closer to accurate.132 It is possible that funding Sightsavers to support deworming programs will be significantly more expensive per deworming treatment than funding SCI or Deworm the World: because Sightsavers only supports integrated programs, for some future programs it will be necessary to fund treatments for other NTDs in order to fund deworming.
• We rely on reported treatment data. Our understanding is that these data can overstate treatments (see our discussion above). We have discounted this data by 10%. This is a fairly arbitrary guess: it is similar to the discount we have used for SCI, which is based on data but relies on a significant assumption.
• We rely on an estimate that 30% of overall program costs are attributable to the government. See discussion above.
• We have included an indirect cost of approximately 15% for all programs. This is based on Sightsavers' estimate of its indirect costs.133
• We do not have data that indicate what proportion of drugs are wasted. We expect that in some cases drugs are purchased or donated but expire before use. We do not know how common this is. In our analysis, we have assumed that 10% of drugs are wasted.

We have estimated SCI's cost per treatment at $1.19 and Deworm the World's at$0.79 per treatment in most programs. All estimates include an estimated value of government in-kind costs, most notably the value of government staff (e.g., teachers) or volunteer time. While we have low confidence in our $0.51 to$2.29 estimated range of cost per treatment for Sightsavers, we are somewhat reassured by the fact that the estimates for SCI and Deworm the World, which operate similar programs, fall in that range.

Because there are so many shortcomings to this analysis and we have spent little time vetting Sightsavers' financial information, we have decided to assume that Sightsavers' cost per treatment is roughly on par with SCI and Deworm the World; both organizations do similar work to Sightsavers on deworming. To account for our uncertainty, we assume that Sightsavers has slightly worse cost-effectiveness than both organizations in our cost-effectiveness model. We hope to improve our estimate of Sightsavers' cost per treatment in the future by reviewing more Sightsavers-specific data.

## Is there room for more funding?

We believe that Sightsavers could effectively use more funding than it expects to receive and is very likely to be constrained by funding next year. We estimate that if it received an additional $2.9 million its chances of being constrained by funding would reduce to 50%. In short, we calculate this from (more detail in the sections below): • Total opportunities to spend funds productively: We believe Sightsavers could productively use or commit between$2.9 million (50% confidence) and $10.1 million (5% confidence) in funding restricted to programs with a deworming component in 2017. This excludes funding that Sightsavers has already allocated to previous programs with a deworming component. • Cash on hand: We have not seen comprehensive documentation of Sightsavers’ cash on hand, but, based on our discussions with Sightsavers, we do not believe Sightsavers has funding available for scaling up its support of deworming programs. • Expected additional funding: Sightsavers has told us that it does not expect to receive funding for deworming programs from other donors. Below, we also discuss: • Past spending: We have limited information about how Sightsavers has used unrestricted funding in the past, although we know only a small portion of unrestricted funding has supported its NTD programs in recent years. • Additional considerations: Sightsavers is a large organization and funds multiple programs. We have asked Sightsavers to use GiveWell-influenced donations to specifically support deworming programs.134 ### Available and expected funds We do not have information on how much total funding Sightsavers has available for its programs. However, we are primarily interested in how much funding Sightsavers expects to be available for opportunities to scale up deworming treatments. It is our impression that this amount is quite low. Sightsavers has provided us with a list of opportunities to scale up deworming treatments. We have asked Sightsavers multiple times if it expects to fund any of these opportunities next year if it does not receive a recommendation from GiveWell; Sightsavers has told us that it would not, because:135 • Sightsavers does not expect to use significant amounts of its unrestricted funding to scale up deworming treatments. Deworming programs are not Sightsavers’ highest priority and there are many other demands on Sightsavers' limited amount of unrestricted funding. • Sightsavers would be surprised if it were to receive enough restricted funding from another donor to scale up deworming. Sightsavers has not yet seen significant interest from large donors in funding the deworming programs it has discussed with us. This may be because, according to Sightsavers and other deworming groups we've spoken to, two of the largest donors for NTD programs, the US and UK governments, are primarily interested in funding NTD programs that are focused on lymphatic filariasis, onchocerciasis, and trachoma. When we first engaged with Sightsavers about the possibility of funding its deworming programs in 2015, it told us about opportunities to scale up deworming treatments in Nigeria and Guinea-Bissau.136 In 2016, Sightsavers had not made progress on scaling up deworming treatments in these areas because it had not received funding to do so.137 This increases our confidence that Sightsavers is unlikely to allocate its unrestricted funding to deworming programs in the absence of other donors, and that other donors are difficult to find. We discuss one opportunity below for which we believe that Sightsavers might use unrestricted funding in the absence of additional donations. ### Uses of additional funding Sightsavers has provided us with a list of opportunities it hopes to raise funding for, which consist of supporting deworming MDAs in six countries and a behavior change research project to increase the effectiveness of a deworming program in one country.138 We have laid out the opportunities Sightsavers presented in the following table; further detail follows the table. Note that all opportunities include indirect costs (14.3% of the total) that supports Sightsavers' central costs.139 The gaps are in order of GiveWell's prioritization (more discussion of our prioritization below), and Sightsavers may chose to allocate funding in a different order.140 Opportunity Total cost (millions USD) Cumulative funding need (millions USD) GiveWell's prioritization Expand Sightsavers' deworming program in four states in Nigeria for 2 years 0.5 0.5 Capacity relevant Add deworming to Sightsavers' program in Guinea-Bissau for 2 years 1 1.6 Capacity relevant Add deworming to Sightsavers' program in Ituri Nord, DRC for 2 years 0.1 1.7 Capacity relevant Add deworming to three districts in Guinea for 2 years 0.3 2 Capacity relevant Support a new integrated NTD program in Benue, Nigeria for 2 years 0.6 2.6 Execution level 1 Behavioral change study in Cameroon 0.4 3 Execution level 1 Expand Sightsavers' deworming program in four states in Nigeria for an additional 1 year 0.2 3.2 Execution level 2 Support a new integrated NTD program in Benue, Nigeria for an additional 1 year 0.2 3.4 Execution level 3 Add deworming to Sightsavers' program in Guinea-Bissau for an additional 3 years 1.3 4.7 Execution level 3 Add deworming to Sightsavers' program in Ituri Nord, DRC for an additional 3 years 0.2 5 Execution level 3 Add deworming to three districts in Guinea for an additional 3 years 0.6 5.6 Execution level 3 Add deworming to one district in Cote d'Ivoire for 5 years 0.2 5.9 Execution level 3 Expand deworming to three additional regions in DRC for 1 year 1.2 7 Execution level 3 Develop deworming program in three states in South Sudan for 1 year 3.1 10.1 Execution level 3 Total 10.1 10.1 -- More detail: • Nigeria: Sightsavers would like to expand the number of deworming treatments that it supports in four states in Nigeria: Kebbi, Kogi, Kwara, and Sokoto; the budgets it has provided cover three years.141 Sightsavers has also proposed supporting an integrated NTD program in another state in Nigeria (Benue); the budget for this activity also covers three years.142 It is our understanding that Benue has a program that treats for onchocerciasis and some lymphatic filariasis; Sightsavers would like to work with the state to improve this program and support its scale up to treat areas endemic for lymphatic filariasis, STH, and schistosomiasis.143 Sightsavers told us that it has already committed to supporting the integrated NTD program in Benue, so it must find funding to support the program; we believe this means that Sightsavers will use its unrestricted funding to support Benue if no other donors contribute additional funding.144 • Guinea-Bissau: Sightsavers told us that all eleven regions of Guinea-Bissau need schistosomiasis treatments, five regions need an additional round of STH treatment (for a biannual treatment strategy), and three regions need lymphatic filariasis treatments (which include the drug that is also used to treat STH but are given to the full population rather than being targeted at children).145 It has provided us with a budget for supporting a five-year program to fill these gaps.146 • DRC: Sightsavers is interested in adding a deworming component to an integrated NTD program that it currently supports in Ituri Nord.147 It has also identified three other regions that could benefit from additional deworming, onchocerciasis, and lymphatic filariasis treatments.148 However, Sightsavers may not have the capacity to scale up to those three additional districts in 2017.149 • Guinea: Although Helen Keller International has supported deworming treatments in most endemic areas of Guinea, Sightsavers has identified three districts that are in need of both STH and schistosomiasis treatments.150 Helen Keller International has not supported deworming in these three districts because it is focused on lymphatic filariasis treatments, and these districts are not endemic for lymphatic filariasis.151 Sightsavers has provided a five-year budget for scaling up its support in Guinea to cover these three districts.152 • Cote d'Ivoire: As in Guinea, in Cote d'Ivoire most districts already have deworming programs (supported by SCI). Sightsavers believes there is one district that is not currently fully supported, in which it would like to treat at-risk adults and out-of-school children in the community.153 It has provided a five-year budget for supporting a deworming program in that district.154 • Cameroon: There is already a deworming program in Cameroon.155 However, despite multiple years of MDAs, the program has been unable to achieve low STH and schistosomiasis prevalence rates. Sightsavers believes this is likely because recipients are not ingesting the pills or are engaging in sanitation practices that lead to reinfection.156 Sightsavers would like to test several behavioral change interventions attempting to improve the program's impact (details in footnote).157 We have not asked for details on which interventions Sightsavers would test or how it would evaluate them. • South Sudan: While Sightsavers originally proposed expanding its program in South Sudan to include a deworming component in three states, security concerns have caused it to put plans for expansion on hold.158 However, we have included this funding gap in our analysis, because it's possible the region will stabilize in the near future, allowing for additional work. Because Sightsavers only supports deworming treatments in programs that treat for other NTDs as well, for a few of the funding opportunities that Sightsavers has shared with us, a portion of the funding is budgeted to support other NTDs (note that we do not consider lymphatic filariasis treatments to be deworming treatments in this analysis as many of these treatments will go to adults):159 • We estimate that approximately 59% of the funding for the five-year program in Guinea-Bissau will be used to support deworming treatments. • We roughly estimate that 45% of the funding for the new integrated NTD program in Benue, Nigeria will be used to support deworming treatments.160 • While all of the funding for Ituri Nord is budgeted to support deworming treatments, if Sightsavers were to scale up its program in DRC to the additional three regions, we estimate that only 25% of the additional funding would support deworming treatments. • If the situation in South Sudan stabilized enough for Sightsavers to support a deworming program there, we estimate that 55% of the funding for its expansion there would support deworming treatments. If not otherwise noted above, all funding for the opportunity will support deworming. #### GiveWell’s prioritization of Sightsavers’ funding gaps We have broken down our our top charities' funding gaps and ranked them based on: • Capacity relevance: how important the funding is for the charity's development and future success. • Execution relevance: how likely it is that the charity's activities will be constrained if it does not receive the funding. We believe that "capacity-relevant" gaps are the most important to fill, and "execution"-related gaps vary in importance. More explanation of this model is in this blog post. In the table above, we have ranked several of the funding gaps "capacity relevant" because we we believe that filling those gaps would allow Sightsavers the opportunity to develop its track record as an organization that can support high-quality deworming programs. In discussions with Sightsavers, Sightsavers noted that it is helpful to have at least two years worth of funding available for a program, so that partners feel that setting up the program is worth their time.161 We have assigned the funding required for the first two years of most of the programs Sightsavers proposed to us "capacity-relevant," because we believe it will be difficult for Sightsavers to start the programs without two years worth of funding. If Sightsavers successfully carried out the activities for the funding gaps we have labeled "capacity-relevant," we would feel more confident recommending additional funding to Sightsavers in the future. We consider all of the other funding gaps to be "execution" gaps and assign them a level (1, 2 or 3) by how likely we believe it is that Sightsavers would be constrained by funding (rather than other factors, such as an inability to grow staff capacity quickly enough, security concerns, another implementer beginning to work on deworming in an area, etc.) if it is unable to fill the funding gap. Level 1 is 50% chance of funding being the constraint, level 2 is 20% chance, and level 3 is 5% chance. These judgements are rough.162 ### Past uses of unrestricted funding We have some high level data from Sightsavers on its past uses of unrestricted funding. We know that in 2015 Sightsavers spent approximately$55.5 million of its unrestricted funding. Nearly 50% of this went to fundraising (about $26.7 million) and about 9% was spent on Sightsavers' NTD program (approximately$4.7 million). Sightsavers' 2014 expenditures were similar.163 We do not know how much unrestricted funding Sightsavers had available in these years.

Sightsavers has supported some deworming treatments with unrestricted funding in the past. For example, it currently delivers some deworming treatments in Nigeria (although it would like to scale up the deworming program there) which are supported by unrestricted funding. However, given limited amounts of unrestricted funding, Sightsavers does not expect to use much additional unrestricted funding in the future to support new or larger deworming programs.164

### Additional considerations relevant to assessing Sightsavers' room for more funding

• Sightsavers is a large organization and spends money on many programs that are not deworming, including other NTDs, eye health, education, cataract surgeries, job training for the disabled, and more. Because deworming programs are not a major priority for Sightsavers in its use of unrestricted funding, we have asked Sightsavers to use GiveWell-influenced 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.
• For many of the funding opportunities listed above, Sightsavers has requested multiple years of funding. Sightsavers told us that it is easier to work with governments and communities if it can commit to working multiple years. This is also something that the Deworm the World Initiative has argued. We are not confident that Sightsavers needs multiple years of funding to make significant progress over the next year, but we do not think this argument is unreasonable.
• Although we think it is unlikely (see above), it is possible that funding Sightsavers' deworming programs might cause Sightsavers to move significant amounts of unrestricted funding it would have spent on deworming to other programs. We think this is especially a concern with funding Sightsavers' expansion into Benue: because Sightsavers has already committed to supporting Benue, we believe Sightsavers is willing to use its unrestricted funding on activities in Benue if no other donors contribute additional funding.165

### Global need for treatment

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

In 2016, the World Health Organization (WHO) released a report on 2015 treatments stating that:166

• 63% of school-age children in need of treatment were treated for STH in 2015. This is a large increase over WHO's report for 2014, which reported 45% coverage.167 Coverage was 51% in African countries in 2015.
• 42% of school-age children in need of treatment were treated for schistosomiasis in 2015.

We have not vetted this data.

## Sightsavers as an organization

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

• Track record: Sightsavers has a limited track record of assisting governments with deworming programs, but a stronger track record of assisting governments with integrated NTD programs.
• Self-evaluation: Sightsavers' self-evaluation is strong compared to the vast majority of organizations we have considered. That said, this evidence is incomplete and has methodological limitations.
• Communication: We have not spent as much time communicating with Sightsavers as we have with the charities we have recommended for several years. To date, Sightsavers has generally communicated reasonably clearly with us.
• Transparency: Sightsavers is fairly transparent. It has allowed us to publish most of the information it has shared with us.

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

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• 1.
• 2.

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

• 3.

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

• 4.
• "Currently, Sightsavers only wants to add deworming programs in countries where it already has an NTD program." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, Pg 6.
• "Sightsavers takes an integrated approach to NTD elimination, as it is the most cost-effective, efficient and sustainable approach. Sightsavers has well established programs supporting the elimination of river blindness, trachoma and lymphatic filariasis (LF), and is leading efforts to scale up integrated treatments where needed, and to integrate deworming where possible." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 2.
• "STH is more problematic as it has the potential to be an indefinite control programme (until current treatment strategy changes; this will be a long way off) and we would only continue with STH support as part of school health programmes which also include eye health." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 13.
• "We will confine our geographic spread in NTD work to Africa. There are three exceptions to this strategic choice: if funding is available to support trachoma and onchocerciasis in Yemen we will expand there; if we are invited or we choose to bid for contract management work globally we will undertake work outside Africa; and, if NTD work is linked to a programme covering other work ... we would seize this as an opportunity." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 11.
• 5.

For example, see Evidence Action's (another NGO with a focus on deworming programs) justification for MDAs: "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)

• 6.

"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.

• 7.

"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.

• 8.
• "Our work also covers low vision, diabetic retinopathy, childhood blindness and the group (17 diseases in total) known as neglected tropical diseases, which incorporates not only trachoma and river blindness, but also buruli ulcer, Chagas disease, dengue/severe dengue, dracunculiasis, echinococcosis, foodborne trematodiases, human african trypanosomiasis, leishmaniasis, leprosy, lymphatic filariasis, rabies, schistosomiasis, soil transmitted helminthiases, taeniasis/cysticercosis and yaws." Sightsavers, What We Do - Sight
• "Integrated NTD programs (including deworming, when it is needed) represent just one of Sightsavers’ top priorities. For the past few years, programs for trachoma and onchocerciasis have been specifically identified as “fast-­track” initiatives. Sightsavers has historically been known for providing services such as cataract surgery, ophthalmologist training, and hospital support, but it aims to make its NTD work as much as or even more of a priority than its traditional work." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, Pgs 4-5.
• 9.
• 10.

See Sightsavers, NTD data by country and disease - 2015. Although in GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, p. 6, it was stated that Sightsavers supports deworming treatments in Mali, this was actually only a reference to the fact that Sightsavers supports LF treatments in Mali, which also treat STH:

• "Sightsavers has supported lymphatic filariais MDA in Mali as part of our integrated NTD programs. In our phone calls in February and March 2015 Dr. Susan Walker referred to Sightsavers’ support of LF and STH activity in Mali. Dr. Walker was referring to the fact that the albendazole treatments as part of the LF chemotherapy regimen also treat STH." Sightsavers, Response to document questions, October 5, 2016, Pg 3.
• 11.
• "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.
• 12.
• 13.
• 14.
• 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-sectorial 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.
• 15.
• 16.
• 17.

This understanding comes from many conversations with representatives from NGOs supporting NTD programs.

• 18.

"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.

• 19.
• Children that are missed by school-based programs are often those that are highest-risk, since they spend their days playing in areas that are prone to worm infection. GiveWell's notes from its 2016 site visit to Ghana
• "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 and Katie Cotton, February 26, 2015, Pg 7.
• 20.
• "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."
• "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
• 21.

"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 and Katie Cotton, February 26, 2015, Pgs 1-2.

• 22.

"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.

• 23.

"We are an NTD leader globally in terms of treatments provided and project management of large grants/contracts from donors. We are recognised for our strengths in advocacy, policy, influencing, resource mobilisation, programme delivery and coalition management." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 9.

• 24.

"Sightsavers' approach to schistosomiasis and soil-transmitted helminthiasis (STH) programs is therefore similar to that of organizations such as the Schistosomiasis Control Initiative (SCI) and the Deworm the World Initiative." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, April 5, 2016, Pg 1.

• 25.
• 26.
• "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.
• 27.
• "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 and Katie Cotton, February 26, 2015, Pgs 1-2.
• 28.
• 29.

"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.

• 30.
• 31.
• In Nigeria: "Monitoring and supportive supervision of all activities are provided by health workers, state and LGA NTDs teams, staff of the Ministry of Education, Sightsavers and the Federal Ministry of Health to ensure quality." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 4.
• In Cameroon:
• "Supervision and monitoring are ensured by national and regional NTD coordination teams and NGO staff." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 10.
• "Mhealth has been piloted in two regions and was used to monitor census and drug distribution, enabling quality campaign monitoring and timely data transmission." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 12.
• "A coverage survey took place in January 2016 focused upon oncho and LF drug distribution. Results were broadly in line with those reported during the campaign in the North West and West regions. However, differences were identified in two out of 20 health districts in the West region. The survey investigated the causes and in-depth and provided recommendations which are now being implemented. Looking ahead, we plan to undertake one further post treatment coverage survey in 2016 on MDA community coverage for onchocerciasis and LF. Further ahead we hope to implement a comprehensive survey for school based MDA for STH and Schistosomiasis in Sightsavers-supported regions in 2017 in liaison with the national program." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 13.
• GiveWell's notes from its 2016 site visit to Ghana
• "In-country staff provide district-level authorities with program implementation support. Depending on the program, this might include supporting community distributors, doing information and education work around behavior change, or providing support for training, program monitoring and supervision, or data collection and analysis." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, April 5, 2016, Pg 2.
• 32.

GiveWell's notes from its 2016 site visit to Ghana

• 33.

"Details of each program are decided at the country level or by central headquarters, depending on the capabilities in each country. In some countries, Sightsavers has a very strong staff on the ground that works closely with the relevant ministry. In others, programs rely more heavily on guidance from Sightsavers’ headquarters staff, who will, for example, monitor how many rounds of MDA have been conducted and inform the country staff when it’s time for an impact assessment. The practice of independent assessments of coverage has been promoted by Sightsavers’ central leadership." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, Pg 5.

• 34.

GiveWell's notes from its 2016 site visit to Ghana

• 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.
• 38.
• 39.

GiveWell's notes from its 2016 site visit to Ghana

• 40.
• 41.

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

• 42.
• Sightsavers, NTD data by country and disease - 2015.
• Sightsavers used to support deworming treatments in Tanzania, but that program was transferred to a partner: "Sightsavers has historically supported treatments for all five NTDs in Tanzania under a partnership with the African Programme for Onchocerciasis Control (APOC). In mid-2015, following the end of the WHO’s APOC programme, responsibility for treatment distribution in those regions of Tanzania supported by Sightsavers was allocated to the NGO IMA World Health, funded by USAID." Sightsavers, Response to document questions, October 5, 2016, Pg 4.
• 43.
• "Sightsavers Cameroon has partnered with the Ministry of Public Health (MoH) since 1996, with our early work focused on the fight against onchocercisasis in Cameroon. This work comprised of a community-based onchocerciasis control project in Haute Sanaga Division, Centre Region." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 9.
• "Sightsavers has supported school based mass drug administration as part of integrated NTD programs in three regions of Cameroon since 2011, South-West, North West and West." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 8.
• 44.
• "Sightsavers Cameroon has partnered with the Ministry of Public Health (MoH) since 1996, with our early work focused on the fight against onchocercisasis in Cameroon. This work comprised of a community-based onchocerciasis control project in Haute Sanaga Division, Centre Region. Following the advent of the African Programme for Onchocerciasis Control (APOC) and the Community Directed Treatment with Ivermectin (CDTI) strategy, Sightsavers expanded program activities to the South West and North West regions in 1998 and 2003 respectively. In 2003, in order to ensure that NGOs had a regional focus, the Haute Sanaga Project was ceded to Helen Keller International." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 9.
• "On an annual basis, a fixed obligation grant agreement is signed with Helen Keller International (USAID grantee) for implementation of regional program activities with USAID funds. Agreements are also signed with regional delegation teams to ensure fulfilment of annual obligations." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 9.
• "All projects in Cameroon are integrated schistosomiasis/STH programs. Most of the current funding is provided by USAID, and the key recipient is Helen Keller International (HKI). Sightsavers is one of the non-­governmental organization (NGO) partners with which HKI works." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, Pg 6.
• 45.

"Mass drug administration of Mebendazole and Praziquantel (in schistosomiasis endemic areas) takes place nationwide through schools and training institutions once a year. This is spearheaded by a large-scale sensitization and mobilization campaign during which all stakeholders are mobilized. Drugs are distributed to school aged children (5-15 years old) by school teachers, who have been previously trained by health staff. Supervision and monitoring are ensured by national and regional NTD coordination teams and NGO staff." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 10.

• 46.
• 47.
• 48.

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

• 49.
• " Our project operates in three areas of Lubutu Nord in Maniema province, Ituri Nord in Oriental province and Katanga Sud in Katanga province. Sightsavers provides support for this work through the United Front Against Riverblindness (UFAR) – a US-based non-profit organization established in 2004, which has been involved since 2006 in the control and elimination of onchocerciasis in DRC. Through established agreements Sightsavers has been providing support to UFAR to support the CDTI projects of Lubutu and Ituri Nord since 2011 and the CDTI project of Katanga Sud since 2013. All three projects are targeted for the elimination of onchocerciasis by 2025." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 14.
• "Our partners in the DRC include:
Ministry of Health, United Front Against River Blindness (UFAR), SCI, RTI USAID Envision Project, and academic partners – including Imperial College London, Filariasis Programme Support Unit – Liverpool School of Tropical Medicine, Integrated Control of Schistosomiasis in Sub Saharan Africa (ICOSA)" Sightsavers, Descriptions of current work - 2015 and 2016, Pg 15.
• 50.
• "During 2015, we were additionally able to support 17,317 treatments for STH and schistosomiasis in the Ferekeni area of Lubutu, in partnership with Schistosomiasis Control Initiative (SCI). Sightsavers will support this mass drug administration for one final year in 2016." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 14.
• "Sightsavers has a strong relationship with SCI, and the two work closely together on many programs and sometimes in the same countries. One such country is DRC, where Sightsavers has no country office but provides support for an onchocerciasis partner, United Front Against Riverblindness. Sightsavers has facilitated SCI’s entry into the DRC and collaborates with SCI, providing financial coordination and technical support. Both organizations also have a presence in Côte d’Ivoire, where Sightsavers’ NTD adviser (who also covers Burkina Faso) works closely with SCI’s adviser. In both DRC and Côte d’Ivoire, the ministries of health usually hold an annual review and planning meetings, which Sightsavers will attend along with SCI. Sightsavers and SCI use this opportunity to discuss overall plans and budgeting for each country." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, Pgs 7-8.
• 51.
• 52.
• See the charts in Sightsavers, Descriptions of current work - 2015 and 2016, Pgs 4 and 6.
• "The four projects Sightsavers submitted information on to GiveWell in May 2015, Kebbi state, Kogi state, Kwara state and Sokoto state, all took place as planned….Looking forward, 2016 budget expenditure for the onchocerciasis and LF elements of these four state programs is now expanded due to securing a new grant through the UKAID match program run by the UK government’s Department for International Development. This funding is for three years, 1 April 2016 – 30 March 2019, and will support the scale up of onchocerciasis and LF activities specifically in the four states." Sightsavers, Descriptions of current work - 2015 and 2016, Pgs 4-5.
• "We secured further new funding for the Sokoto State integrated NTD program from the Jersey Overseas Aid Commission, who will support the programme with a grant over three years from January 2016." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 6.
• "The Sightsavers led-UNITED consortium is a four year program aiming to control NTDs in five states in Northern Nigeria, including blinding trachoma, schistosomiasis, lymphatic filariasis (LF), onchocerciasis and soil transmitted helminths (hookworm, whipworm and roundworm). Fully funded by the UK Government DFID, the UNITED program is making concerted efforts to ensure women participate actively in all program activities through the mobilization of women’s groups and involvement of women in capacity building activities. Treatment data collection tools are disaggregated by gender to ensure treatments are delivered in a targeted manner.
Sightsavers leads the program and partners include CBM, Helen Keller International and MITOSATH. The program has scaled up its reach from one to five states in Nigeria, and has undertaken successful mobilization in the five states of Zamfara, Kaduna, Niger, Kano and Katsina. This covers 20% of Nigeria’s entire population. Sightsavers is directly supporting implementation in Zamfara and Kaduna."
Sightsavers, Descriptions of current work - 2015 and 2016, Pg 6.
• "Because Sightsavers’ most established deworming program is in Nigeria, Nigeria is a good example of Sightsavers’ work in this realm and a model for its other deworming programs. Sightsavers carried out the first integrated mapping exercise in Nigeria, in Sokoto and Zamfara states, which led the national program to begin exploring a more integrated approach. The results of that mapping exercise also led DFID to invest about £10 million ($16 million) in an NTD program in five of Nigeria’s northern states. This is an example of how a relatively small investment, such as a mapping project, can lead to a large infusion of funds." GiveWell's non-verbatim summary of a conversation with Sightsavers staff, March 19, 2015, Pg 5. • 53. • Sightsavers, Nigeria NTD program information prepared for GiveWell, May 2015, pg. 5, shows funding from the Children’s Investment Fund Foundation (CIFF) for mapping of schistosomiasis and STH in 14 states of northern Nigeria. • "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. Findings from the survey showed that all 19 States and the federal capital territory are endemic for schistosomiasis or STH and in some cases both." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 7. • 54. "Sightsavers’ Nigeria country office is based in Kaduna with 35 staff, led by Country Director Sunday Isiyaku. Sightsavers also has a small annex office in the capital city of Abuja. The Government of Nigeria is responsible for program implementation in Sightsavers-supported state programs. Training on mass drug administration (MDA) is cascaded, with the Federal Ministry of Health supporting the training of the State NTD Teams, who in turn train the local government area (LGA) NTD teams. The LGA teams train the frontline health facility workers who train the community directed drug distributors. Supply of drugs flows through the same levels. Similarly, monitoring of MDA follows through the same channels and cascaded monitoring is undertaken. Reporting flows from the community level up to the federal level. NGO staff in all states provide technical support and conduct targeted monitoring and supportive supervision." Sightsavers, Descriptions of current work - 2015 and 2016, Pg 3. • 55. "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. • 56. See Pgs 3-7. • 57. Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016 • 58. • 59. Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016 • 60. • 61. Countries that don't have a country director based in-country include Guinea, Cote d'Ivoire, Guinea-Bissau, Burkina Faso, Togo, Benin, Niger, and DRC. GiveWell's notes from its 2016 site visit to Ghana • 62. • 63. • 64. The technical advisors also review Program Managers' reports and discuss any issues with the reports, and help analyze the data Sightsavers collects via monitoring. GiveWell's notes from its 2016 site visit to Ghana, pg 2. • 65. GiveWell's notes from its 2016 site visit to Ghana • 66. Partners are assessed for financial competence before projects are initiated and the frequency of reporting is agreed upon at that point – for most partners reporting is required either every month or on a quarterly basis. The finance team often visits partners with the program officers to help assess partners' work. Julia Strong, International Foundations Executive, edits to GiveWell's review, November 9, 2016 • 67. Sightsavers, Organizational expenditure 2014 and 2015 • 68. • 69. Sightsavers, Organizational expenditure 2014 and 2015. Also see our summary of Sightsavers' spending in the table below. • 70. • 71. Sightsavers, Organizational expenditure 2014 and 2015. Also see our summary of Sightsavers' spending in the table below (which shows spending in dollars rather than pounds). • 72. Sightsavers, NTD Project Expenditure, 2014-2016. See our spreadsheet for a breakdown in USD. Note that the final figures for NTD spending in this document do not match the final figure in Sightsavers, Organizational expenditure 2014 and 2015; this is because the figures in Sightsavers, NTD Project Expenditure, 2014-2016 do not include the indirect cost allocation that Sightsavers adds to all projects for its central costs. Sightsavers, Response to document questions, October 5, 2016 • 73. See our spreadsheet, "2014-2016 spending by NTD" sheet, cell J101. • 74. See this spreadsheet, "Total spending in 2014 and 2015" sheet, cells G2 and C2. • 75. Sightsavers staff, conversation with GiveWell, October 2, 2016 • 76. Sightsavers staff, conversation with GiveWell, October 2, 2016 • 77. • 78. • Sightsavers has shared details on how some of the more recent data from Nigeria was collected in Sightsavers, Nigeria Epidemiological Mapping of SCH and STH Report 2015. But for all of the other data, we do not know how it was collected. • Methodology from Sightsavers, Nigeria Epidemiological Mapping of SCH and STH Report 2015: • Timing: "This report provides epidemiological information on 19 States and the Federal Capital Territory (FCT) that were mapped for schistosomiasis and STHs from November 2013 to May 2015." Pg vi. • Location: "The study area comprised 19 States and the FCT as shown in Figure 1. Altogether the 19 States and the FCT have 456 LGAs and an estimated population of 106,243,198 projected 2006 population (NPC 2006). The survey was conducted in 433 out of the 456 LGAs, 21 were previously mapped and two were not mapped due to security challenges." Pg 3. • Sample selection: • "A sample of 50 - 55 children from five randomly selected schools in each of the 433 LGAs in 19 States and four Area Councils of the FCT were examined for schistosomiasis and STHs… The Kato-Katz technique, dipsticks (Haemastix), syringe filtration and sedimentation techniques were used to examine stool and urine samples collected from the school children." Pg viii. • "There was a randomised selection of schools from the sampling frame followed by a randomised systematic selection of children in the schools surveyed. The sampling frame was the list of all primary schools in each ward. A stratified random cluster sampling procedure was used in line with the FMOH protocol on integrated epidemiological mapping and baseline survey for schistosomiasis and STHs (FMOH 2013). Primary schools in northern Nigeria included non-formal schools ('Madrasat'/Islamic Schools). The survey was based on standard diagnostic procedures for collection and examination of urine and faecal samples from school age children for the presence of schistosome and intestinal helminth eggs. Enrolled school age children were targeted from the surveyed communities. Males and females were selected on pro rata basis." Pg 4. • "In all the LGAs of the States surveyed, five schools were randomly selected from different communities; however, schools in areas with large water bodies were prioritised. A sampling frame was developed and used for selection of pupils in each selected school. A range of 50-55 pupils of both sexes from 5 – 16 years old from each school was sampled (Photos 1a & 1b)." Pg 4. • Surveyors: "A training was cascaded for the field teams; comprising staff of State Ministries of Health and Education (including SUBEB) on the mapping methodology and community mobilization. Laboratory staff were trained on sample collection and examination while the recorders were trained on the use of electronic data capturing devices (Photos 4). Practical sessions and post training tests were also conducted. At the end of each State’s training, field teams were selected based on post-training performance. Micro planning meetings were held to discuss schools and community mobilization, survey approach and detailed implementation plans developed. In each State, a team was constituted of recorders, scientists, technicians, State NTD programme officer, SUBEB representative, in-country consultant, FMOH supervisor and NGDO technical officer (Photo 5). This team was further divided into five sub-teams made up of a recorder, laboratory technician, scientist, a supervisor, a driver and a local guide." Pgs 6-7. • Data analysis: "Data cleaning by FMOH and NGDOs data managers/technical officers was carried on completion of the mapping activities using specified guidelines. State specific linked datasets from the cloud server were downloaded and cleaned using excel add-in (Ablebit®). This was to validate any observed discrepancy between uploaded data and entries on back-up forms. Statistical analyses were carried out using IBM SPSS® version 20 and Epi Info 7." Pg 8 • 79. • 80. See our summary spreadsheet of the data Sightsavers has sent us. • 81. In particular, we have guessed at the Health Zones within which it will support treatments for STH and schistosomiasis within DRC, and we are not sure if Sightsavers intends to support deworming treatments in all of Guinea-Bissau (but we have assumed so). • 82. Sources for and notes on the spreadsheet: Nigeria: Guinea-Bissau • Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, pgs. 6, 8. This data is from 2003 - 2005. We have not seen more recent data and would guess that prevalence rates may have changed significantly since it was collected. • Sightsavers, Guinea-Bissau NTD prevalence maps • Sightsavers, Disease prevalence in Sightsavers proposed areas of expansion • Sightsavers provided data for Guinea-Bissau subdivided into eleven regions: "In the Sightsavers supported regions of Bafata and Gabu, Albendazole treatment is currently given through the Ivermectin + Albendazole drug distribution package for LF, once per year though a house to house distribution platform using community volunteers. The prevalence of STH in Guinea Bissau ranges between 13% to 93% (See Map 2.) This once per year treatment is also in line with WHO guidelines for the treatment of STH in school age children, in areas where the baseline STH prevalence is ≥20% but <50%. Sightsavers is working towards scaling up once per year drug distribution to reach all endemic areas in the remaining 9 regions for the first time in 2016. Our partners in STH in Guinea Bissau are APOC, WHO and the World Food Programme. However, in areas where the baseline prevalence is ≥ 50% the WHO guideline is to treat all school age children twice per year. As seen in the table below, prevalence is higher than 50% in nearly all regions, highlighting a need to scale up drug distribution to twice per year in all these regions." Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, Pg 6. • We don't know whether there have been other deworming programs in the country since prevalence data was taken in 2003-2005. The World Health Organization and World Food Programme planned to fund schistosomiasis treatments beginning in 2015, but that program has been delayed: "Mass drug administration has not taken place before, however the table below shows a clear need. It has been planned for funding from the World Health Organisation and World Food Programme to support initial MDA in Oio/Farim and Biombo regions in 2015, however, a fire which recently destroyed the drug supply has delayed 2015 activity. According to WHO guidelines, areas with a baseline disease prevalence of <10% should treat school age children twice during primary school year e.g. once on entry and once on exit." Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, Pg 8. Cote d'Ivoire Guinea DRC • 83. Sightsavers, Disease prevalence in Sightsavers proposed areas of expansion included Cameroon, but did not have any prevalence data. • 84. See Sightsavers, Organizational expenditure and outputs, 2014, "By Country" sheet, row 10 for "Total no. of NTD Treatments (NOT UNIQUE PEOPLE)", total in cell BY10. For STH treatments, see row 15, which has entries in cells I15, AS15, BI15, and a total in cell BY15. For schistosomiasis treatments, see row 16, which has entries in cells I16, AS16, BI16, and a total in cell BY16. • 85. • 86. For example, 1.7 million treatments on onchocerciasis were recorded for Malawi, yet Sightsavers expenditures showed no costs in Malawi. When we asked about this, Sightsavers explained: "Sightsavers manages the order of Mectizan® for oncho elimination for the Government of Malawi. We do not implement the MDA in country as this has been totally devolved to the government, hence not showing expenditure in document 10.b." Sightsavers, Response to document questions, October 5, 2016, pg. 3. We are not sure what kind of support Sightsavers provides for all of the other treatments listed in Sightsavers, NTD data by country and disease - 2015. • 87. • "At least once a year for each project, Sightsavers’ monitoring and evaluation team performs a spot check, whereby headquarters requests initial data records from the program. Projects are randomly selected to provide this backup information for spot-checking. These constitute a separate tool from the quality standard assessment tools. Currently the data examined in a spot check include figures related to human resources and service delivery, such as treatment numbers and numbers of people trained. The check is not intended to provide proof of treatment, but to make sure that the numbers indicated for each community tally up to the reported district total." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, pgs. 3-4. • Sightsavers has shared with us its spot check procedure and an example of a spot check report. Sightsavers, Spot check process and methodology and Sightsavers, Spot check report, DRC. This example reports finding essentially no error in the aggregation of reported number of people treated for onchocerciasis in DRC; two instances of manual entry rather than formula summation resulted in a difference of 6 treatments on a total of almost 1.3 million. “For the majority of rows a formula is used to add the number of males and females who have received treatment but for some rows a number has been entered directly, this led to a miscalculated total on two occasions[…] the total treatments (column T) were 5 and 1 treatments out.” Sightsavers, Spot check report, DRC. • We believe checks like this could help to uncover some data aggregation errors but may miss errors at other steps of the reporting process. We have not yet asked Sightsavers how often these spot checks uncover concerns, nor how Sightsavers handles any concerns. • 88. DFID-UNITED Integrated Post MDA Coverage Survey Report 2014 • The coverage survey protocol explains that during a distribution, "The dosage and quantity of drugs given is recorded on the register or tally sheet. This data is then used to calculate the population coverage of MDA, however there is often issues with the data including poor census data and inaccuracies in recording the data." Survey protocol, pg. 3 (pg. 43 of pdf) • "A comparison of the surveyed Oncho/LF data with reported coverage in Bugundu LGA shows that Asako, Danguro and Dogon daji had reported treatment coverages that were very close to the surveyed coverages obtained (Annex 3). This shows that a good reporting system is in place in these communities and the drug distributors should be commended. However, in Birnin Mallam, Kaikai, Ka Ida, Nahuce, Tazame, Yar Labe and Gada communities, reported coverages were higher than surveyed coverages." pg. 23. • "Reported coverage for Zithromax was consistently much higher that obtained from survey in all communities. A survey coverage of 46.4% was obtained at Tungar Gobirawa, yet coverage from health system records indicated a 97% coverage. Again, this calls for close supervision of drug distributors as it also indicates poor recording keeping skills." pg. 24. • "There was evidence of poor record keeping at all levels of programme implementation. It was most serious at the community level; and this unfortunately is the primary source of data for information collated at both LGA and State levels. Treatment records kept at community level were not properly entered neither was there evidence of census been carried out by the drug distributors. In Nahuce community only the 616 individuals treated were recorded in the treatment register and in Yar Labe the drug distributor could not make available the community treatment register for vetting. He claimed he had none. This community recorded 1.2% in the survey coverage, yet Local Government records should a high coverage of about 80%." pg. 28. • 89. • "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 and Katie Cotton, 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. • 90. • "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. • 91. • 92. The report on the coverage surveys in Benin and Togo does not discuss how Abomey district was chosen in Benin or Sotouboua district in Togo (translated from French): "On the basis of this manual, Sightsavers in collaboration with MURAZ Centre conducted an independent evaluation to assess the ivermectin treatment coverage and populations’ attitudes, knowledge and practices related to onchocerciasis CDTI projects in the health districts of Abomey (Benin) and Sotouboua (Togo). This independent evaluation also assessed the albendazole treatment coverage rate in Abomey district." Sightsavers, Coverage survey Benin and Togo 2015, Pg 12. • 93. • The length of time between the MDA and the 2014 coverage survey in Nigeria was around 1 to 3 months: • "The drug supplies were received in April 2014 and actual distribution of the drugs commenced in July 2014 in a staggered manner to avoid cross reaction between drugs. The last set of drugs that was distributed was in September; with Zithromax. Two weeks after the distribution of the last set of drugs, the Sightsavers International-lead partner of the UNITED consortium in collaboration with Zamfara State Ministry of Health initiated conducted a post MDA coverage survey principally to validate the reported coverage. This activity which took place from 15 th to 30th October 2014 was sponsored by the UNITED consortium." DFID-UNITED Integrated Post MDA Coverage Survey Report 2014, Pg 4. • The report of the 2015-16 survey in Cameroon does not state when the MDA program occurred: • "Technical preparation, data collection / analysis and report writing were carried out from December 10th 2015 to January 31th, 2016 ) according to the chronogram." Sightsavers, Coverage survey Cameroon 2015-16, Pg 11. • Full details on the length of time between the MDA and the coverage survey for all Sightsavers' coverage surveys that are publicly available in this spreadsheet, "Methods" sheet. • 94. "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. • 95. • Full details on data quality control processes for all Sightsavers' coverage surveys we have seen available in this spreadsheet, "Methods" sheet. • 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 • 96. • DFID-UNITED Integrated Post MDA Coverage Survey Report 2014 The report's summary states that Praziquantel (PZQ) coverage rates were 46% in Bungudu and 54% in Shinkafi, the two LGAs studied (p. 4). The data table later in the report shows PZQ coverage rates were 68% in total, 55% in Bungudu and 88% in Shinkafi (pg. 21). The report mentions that some PZQ treatment was delayed partly due to the MDA timing conflicting with Ramadan and schools shutting down due to the Ebola outbreak, and some PZQ treatment was still ongoing at the time of the coverage survey (pg. 27). It is possible that the larger numbers include mop-up treatment that was done due to low initial coverage (pg. 28). • We have found the report on the 2015 coverage survey in Malawi to be difficult to interpret due to several inconsistencies. Sightsavers, Coverage survey Malawi 2015: • It is not clear whether the survey took place in 8 districts or 9 districts: • "Coverage surveys were conducted between November and December 2015 in 9 of the 13 districts (Nsanje, Zomba, Machinga, Mwanza, Neno, Ntcheu, Lilongwe East, Dowa and Ntchisi) that implemented MDA in 2015." Pg 1. • "The survey that was conducted using the standard 30 by 7 methodology for coverage surveys, and the compact segment sampling. 30 clusters (villages) were sampled randomly in each of the 8 districts." Pg 2. • The report states that surveys were not conducted in Lilongwe West, but also reports survey coverage for Lilongwe West: • "Surveys were not conducted in Kasungu, Nkhotakota, Salima and Lilongwe West." Pg 1. • "Coverage by survey - before mop-up" reported as 83.9% for Lilongwe West in Table 3 on page 5. • Coverage rates from the survey by district are reported in Table 2 on pg 4 and Table 3 on pg 5. Both tables report the same survey coverage rates for Nsanje, Mwanza, Neno, Ntchisi, and Lilongwe West districts, but survey coverage rates differ between the two tables for Ntcheu, Machinga, Dowa, and Zomba districts. • Our best guess is that some of the data in the rows in one of the tables may have been reshuffled, but we are uncertain which of the two tables is correct. • 97. "The surveyed data for Praziquantel could not be compared health system records because treatment was still on-going in most communities and the records for the health system were not complete." DFID-UNITED Integrated Post MDA Coverage Survey Report 2014, pg 5. • 98. For the results of these coverage surveys, see this spreadsheet, "Results" sheet. • 99. For example, Sightsavers shared some sample coverage survey results with us and we have not seen reports from some of those surveys. Sightsavers, Coverage surveys presentation, August 2016, Pg 5. • 100. Translated from French: "Among the population that did not take ivermectin during the last treatment campaign, the primary reason was community distributors not going to their homes and village, particularly in the health district of Abomey (67.8%)." Sightsavers, Coverage survey Benin and Togo 2015, Pg 28. • 101. • 102. 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." • 103. • 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. • 104. • 105. “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. • 106. "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. • 107. 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. • 108. Lakwo et al. 2015: A few observations: • "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. • 109. • 110. • "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. • 111. • “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). • 112. In Sightsavers, Guinea-Bissau NTD program information prepared for GiveWell, May 2015, p. 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% • 113. • 114. • It seems plausible to us that Sightsavers has not yet had time to complete this type of study on its deworming programs. • Sightsavers told us that "Sightsavers follows recommended WHO guidelines with regard to the establishment of sentinel sites. For deworming programs sentinel sites are typically established at schools. Impact indicators track change in prevalence and intensity of infection (intensity is recognized as a more sensitive indicator of impact)." GiveWell's non-verbatim summary of a conversation with Susan Walker and Katie Cotton, February 26, 2015, pg. 2. It is possible that impact assessments conducted at sentinel sites (where programs may be higher quality) may not be representative of impact at other sites. Of the three impact assessments discussed above, the first (Tekle et al. 2012) explicitly selected sentinel sites for assessment. We are unsure whether the other two impact assessments took place at sentinel sites. • 115. "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. • 116. • 117. • 118. "CDDs were observed conducting census updates using the treatment register and conducting treatment. Health workers and LGA teams also conducted supervision using the supervision plan developed at the LGA level. The NTD checklist was used for supervision by the independent monitors. The supervisory checklist was uploaded into an android phone and information collected was uploaded to a cloud server. The following activities were supervised: i. Presence of CDDs. ii. Correct register data entry iii. Appropriate use of dose pole. iv. Drug availability and sufficiency. v. Presence of water sources in the community vi. Presence of adverse effects" Sightsavers, Kebbi monitoring trip report 2016, Pg 2. • 119. • 120. "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. • 121. "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 • 122. • 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 • 123. "Single-dose oral therapies can kill the worms, reducing ... infections by 99 percent ... Reinfection is rapid, however, with worm burden often returning to eighty percent or more of its original level within a year ... and hence geohelminth drugs must be taken every six months and schistosomiasis drugs must be taken annually." Miguel and Kremer 2004, pg. 161. • 124. • "In Tanzania matters came to a head in places around Morogoro in 2008. Distribution in schools of tablets for schistosomiasis and soil-transmitted helminths provoked riots, which had to be contained by armed police. It became a significant national incident, and one of the consequences has been the delay in Tanzania adopting a fully integrated NTD programme, and the scaling back some existing drug distributions." Allen and Parker 2011, pg. 109. • "From these reports a number of problems with the MDA were raised which included fear of side effects from the tablets, particularly following the mass hysteria and death in Blantyre and Rumphi respectively and may explain some of the geographic heterogeneity seen. Furthermore most districts reported that MDA occurred after standard 8 students had finished exams and left school, and due to having inadequate resources for drug distribution...The side-effects incident in Blantyre and death in Rumphi had a large effect on districts and with many district reports stating that after the incidence many families refused to participate." SCI Malawi coverage survey 2012 Pgs 5, 21. • 125. • 126. "Though we were undertaking small-scale lymphatic filariasis (LF) work as early as 2007, it was only in 2010 that we recorded our first LF treatment, followed by schistosomiasis and soil transmitted helminths (STH) in 2011." Sightsavers, Now is the time to say goodbye to neglected tropical diseases, Pg 9. • 127. For example, we use data from GiveWell, Analysis of Sightsavers deworming wishlist, 2016 • 128. In particular, we use budgets for areas in the DRC and South Sudan that Sightsavers has told us it is not seeking funding for in 2017 (although it was previously seeking funding for these opportunities: Sightsavers, Deworming wishlist, 2016 - v1. • 129. The study assumes that government staff costs account for approximately 30% of the programs expenses. See our review of SCI for more. • 130. We found some potential discrepancies in some of Sightsavers' documents that we asked Sightsavers about. • 131. 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). • 132. Note: We also allow users to include an estimate that includes benefits from funding LF treatments. LF is treated with mebendazole or albendazole, which also treats for STH. We think it might be reasonable to assume that 20-30% of LF treatments go to children who would not have otherwise received deworming treatments, but we are highly uncertain about this estimate. • 133. GiveWell, Analysis of Sightsavers deworming wishlist, 2016 • 134. Note that Sightsavers would prefer not to have the funding be restricted: "The first method GiveWell have suggested of providing unrestricted funding would be Sightsavers' preference, on the understanding that the funding would be used to scale up deworming components in existing integrated NTD programs and to initiate new work in deworming as part of integrated NTD programs, as we have proposed in our wish list documents. As we have discussed we feel the most effective use of funding would be to support our wider integrated NTD activities, for example as shown in our oncho wishlist document, and would be pleased if GiveWell would consider this option. The second suggestion of providing funding restricted to programs with deworming components would be our second choice. The third suggestion of provision of funding that was restricted to deworming activities only would be more challenging for Sightsavers to administer given the integrated nature of our NTD program portfolio." Julia Strong, International Foundations Executive, email to GiveWell, October 6, 2016 • 135. Sightsavers staff, conversation with GiveWell, October 2, 2016 • 136. See our interim review of Sightsavers. • 137. • "As previously submitted during Sightsavers’ Phase 1 submission to GiveWell, Nigeria represents a country where Sightsavers is keen to expand its operations to increase schisto and STH integrated control. Whilst we have secured new funding to expand our oncho and LF elimination work in Nigeria over the past year (detailed in document 16.1), the situation as regards how we would like to expand STH and schisto activities remains similar to our submission to GiveWell in May 2015. We have incorporated summary information from our 2015 submission in the table." Sightsavers, Deworming wishlist notes, 2016, Pgs 1-2. • "As previously presented in Sightsavers’ Phase 1 submission to GiveWell, Guinea-Bissau represents a country where Sightsavers is keen to expand its operations to include schistosomiasis (schisto) and soil-transmitted helminths (STH) integrated control. While we have secured new funding from UK Aid Match to expand our oncho and LF elimination work in Guinea Bissau between 2016-19, the situation as regards how we would like to expand STH and schisto activities remains similar to our submission to GiveWell in May 2015." Sightsavers, Deworming wishlist notes, 2016, Pg 1. • 138. Note that we asked Sightsavers to include the costs of annual coverage surveys in its assessment, because we expect to see annual monitoring from our top charities, and Sightsavers does not typically conduct yearly coverage surveys. We also asked Sightsavers to include the administrative costs of supporting additional programs in its analysis. Sightsavers resubmitted its list of funding opportunities after our requests; readers can compare the two: Sightsavers, Deworming wishlist, 2016 - v1 and GiveWell, Analysis of Sightsavers deworming wishlist, 2016. • 139. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "GW summary of funding gaps" sheet. • 140. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "GiveWell ranking" sheet. Note that we have made some assumptions about the costs of coverage surveys in our analysis. • 141. • "As previously submitted during Sightsavers’ Phase 1 submission to GiveWell, Nigeria represents a country where Sightsavers is keen to expand its operations to increase schisto and STH integrated control. Whilst we have secured new funding to expand our oncho and LF elimination work in Nigeria over the past year (detailed in document 16.1), the situation as regards how we would like to expand STH and schisto activities remains similar to our submission to GiveWell in May 2015. We have incorporated summary information from our 2015 submission in the table." Sightsavers, Deworming wishlist notes, 2016, Pgs 1-2 • Sightsavers staff, conversation with GiveWell, October 2, 2016 • 142. • 143. Sightsavers, Benue project overview • 144. Julia Strong, International Foundations Executive, conversation with GiveWell, October 19, 2016 • 145. • "As previously presented in Sightsavers’ Phase 1 submission to GiveWell, Guinea-Bissau represents a country where Sightsavers is keen to expand its operations to include schistosomiasis (schisto) and soil-transmitted helminths (STH) integrated control. While we have secured new funding from UK Aid Match to expand our oncho and LF elimination work in Guinea Bissau between 2016-19, the situation as regards how we would like to expand STH and schisto activities remains similar to our submission to GiveWell in May 2015. The UK Aid Match Project will support the treatment of LF in 8 of Guinea Bissau’s 11 regions: Bafata, Gabu, Bijagos, Oio, Farim, Bissau, Biombo and Bolama. It should be noted that treatment used for LF will also treat STH during the MDA in the intervention regions. Five of the regions would need a second round of STH treatment, in accordance with WHO guidelines, should additional funding become available. Three further regions in the country - Quinara, Cacheu and Tombali are not covered by the UK Aid Match project - and full funding for these regions would be required. Full support for schisto remains a need that is not currently supported." Sightsavers, Deworming wishlist notes, 2016, Pg 1. • Also see GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "Guinea-Bissau" sheet. • 146. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "Guinea-Bissau" sheet. • 147. • "Sightsavers has worked with the United Front Against River Blindness (UFAR) as its local partner since 2011. UFAR additionally receives funds from END Fund and Schistosomiasis Control Initiative (SCI). Currently, Sightsavers works with UFAR in Ituri Nord and Katanga Sud to implement the MoH integrated onchocerciasis (oncho) and lymphatic filariasis (LF) program in 17 health zones. In Katanga Sud, support for schisto and STH is provided by SCI. In Ituri Nord, no support is provided for schisto and STH deworming. Expansion into deworming in Ituri Nord is vital to maximize efficiency and provide essential deworming in an area already supported by Sightsavers." Sightsavers, Deworming wishlist notes, 2016, Pg 2. • "Sightsavers supports Oncho/LF in 10/13 health zones, 3 health zones are non-endemic for Oncho/LF. Schisto in 4 health zones, STH in 1 health zone. Schisto prevalence range 13-92%, STH 23%." GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "DRC" sheet, cell N7. • 148. • GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "DRC" sheet. • "Further, in the Kasongo area of Maniema Province, no support is provided for schisto and STH control. Support for schisto and STH in this area, with prevalence of 38.4 and 49.5 percent, respectively, is a critical need to ensure that the entire area has fully integrated NTD control. Lastly, two areas that currently have no supporting partner and are highly endemic for all four NTDs mentioned herein are Ituri Sud and Uélé in Orientale Province. To date, there has been limited MDA for oncho and no treatment for LF, schisto, and STH. Expansion into these areas would move towards a comprehensive state level program in areas geographically contiguous in DRC and mitigate the external threat these areas may pose to the elimination efforts of neighboring programs in Uganda, principally, and South Sudan. If funds were available, Sightsavers would be keen to support a full programmatic expansion in these areas, noting that the area is highly endemic for LF and has lacked a partner for oncho since the closure of APOC." Sightsavers, Deworming wishlist notes, 2016, Pg 2. • 149. "Whilst we have kept our proposed budget for activity in Ituri Nord on the 'DRC' worksheet, we have greyscaled the other three regions, and reduced the amount of our request to GiveWell. Ituri Nord is a region where we already operate and wish to scale up from 2017. We would wish to request the additional financial support for three further regions of Kasongo, Ituri Sud and Uele from GiveWell in the future." GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "Deworming wishlist" sheet. • 150. "Sightsavers has three active programmes focused on MDA for oncho and LF in Guinea. STH and schisto are endemic in 17 and 31 health districts respectively, and are co-endemic in 15 health districts. Mass drug administration for both diseases is supported in most areas in need by Helen Keller International (HKI) / ENVISION. A gap has been identified for the expansion of support for schisto and STH MDA in three districts; N'Zérékoré, Lola and Yomou, districts which have amongst the highest prevalence in the country." Sightsavers, Deworming wishlist notes, 2016, Pg 4. • 151. "In Guinea, USAID funds through HKI/ENVISION are focused on LF endemic and co-endemic districts; whilst the three districts of Nzerekore, Lola and Yomou are not endemic for LF." Julia Strong, International Foundations Executive, email to GiveWell, October 6, 2016 • 152. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "Guinea" sheet. • 153. • "Sightsavers operates in fragile environments and has developed a deep understanding of the potential security risks associated with our programs and as a result, created a strong operating capability. We currently have a program in Cote d’Ivoire to reduce the prevalence of oncho and LF. Sightsavers supports the distribution of Mectizan® to 6.2 million people living in endemic areas. This includes 2.8 million people who reside in 14 LF endemic districts and 3.4 million treatments in 13 districts which are co-endemic with oncho and LF. Sightsavers is engaging with stakeholders in government to facilitate the approval of a national NTD masterplan plan and is working in collaboration with other partners including WHO, HKI, FHI 360 and SCI. The majority of districts have MDA programs for schisto and STH supported by SCI. However, a review of districts indicates that Mankono district has a gap for schisto and STH MDA. Sightsavers would like to fill this gap if funding allows in order to ensure that all qualified districts are receiving MDA." Sightsavers, Deworming wishlist notes, 2016, Pg 4. • "In Cote d’Ivoire, support from SCI is focused on the school age population. The Ministry of Health national program (PNLSGF) have decided to follow WHO guidelines by targeting adults at risk for treatment, hence the inclusion of this district for community based MDA in Sightsavers wishlist proposal." Julia Strong, International Foundations Executive, email to GiveWell, October 6, 2016 • 154. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "Cote d'Ivoire" sheet. • 155. "The Cameroon MoH implements an integrated NTD elimination program nationwide in collaboration with partners including Sightsavers. The MoH and partners focus elimination efforts on the five priority NTDs (oncho, LF, schisto, STH, and trachoma). Sightsavers supports the MoH for the implementation of NTD elimination in the South West, North West and West regions for oncho, LF, STH and Schisto, and in the North and Far North regions for trachoma. Please see Sightsavers submission to Givewell Q.16.1, for full details of this program. STH is endemic in all the 57 health districts of the South West (18), North West (19) and West (20) regions with a total population of 4,925,681 people across 5,330 communities. Schisto is endemic in 13 health districts across the South West (5), North West (3) and West (5) regions. There are currently MDA campaigns ongoing for the treatment of the STH and schisto." Sightsavers, Deworming wishlist notes, 2016, Pg 3. • 156. "The MDA programmes are confronted with the problem of low compliance by the target groups, which may be due to a low level of awareness amongst the population, and poor attitudes and practices as regards the transmission of the diseases….Ultimately, behavior change is essential to reducing the likelihood of reinfection with STH and schisto in the event individuals are unable or unwilling to participate in MDA. This initiative is important in the context of Cameroon, which has had years of MDA yet still frustratingly high prevalence rates." Sightsavers, Deworming wishlist notes, 2016, Pgs 3-4. • 157. "In order to ensure effective elimination of STH and schisto, a behavior change communication (BCC) strategy needs to be developed and implemented in order to improve treatment compliance and promote healthy attitudes and behaviors amongst the population. Accordingly, if funds from GiveWell were available Sightsavers could launch a BCC initiative in partnership with the MoH to focus on five key objectives: 1. To carry out a formative research to identify the knowledge, attitudinal and behavioral barriers and possible solutions. 2. To develop a comprehensive evidence based BCC strategic document. 3. To develop and produce BCC materials. 4. To implement BCC activities. 5. To ensure effective learning management and knowledge sharing. Ultimately, behavior change is essential to reducing the likelihood of reinfection with STH and schisto in the event individuals are unable or unwilling to participate in MDA. This initiative is important in the context of Cameroon, which has had years of MDA yet still frustratingly high prevalence rates." Sightsavers, Deworming wishlist notes, 2016, Pgs 3-4. • 158. • GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "South Sudan" sheet. • "Political stability is essential to operating in South Sudan. Recent events are cause for concern and whilst we have kept our proposed budget for a first year of activity on the 'South Sudan' worksheet, we have greyscaled this, and removed the amount from our request to GiveWell here. As soon as the security situation improves we would wish to request this financial support from GiveWell, beginning with work in Western Equatoria state where Sightsavers has been previously operating." GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "South Sudan" sheet, cell A3. • "The disease burden of NTDs in South Sudan is considered to be one of, if not, the highest in the world. While efforts to launch NTD control programs in the past have not succeeded due to inconsistent funding streams, the MoH remains deeply invested in encouraging support for NTD control. To date, large scale MDA for oncho has occurred in Western Equatoria under APOC and with support from Sightsavers; in Central Equatoria in 2011 for schisto and STH by Malaria Consortium with support from UNICEF/USAID; and, in Eastern Equatoria for trachoma control, supported by The Carter Center. Many areas of the country have been mapped and the disease burden known. Sightsavers currently supports oncho MDA in Western Equatoria with MDA currently underway. Recent security concerns have slowed progress in this program but it remains active. Sightsavers would like to assist the MoH in expanding its NTD control program if the security situation allows." Sightsavers, Deworming wishlist notes, 2016, Pgs 2-3. • 159. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "GiveWell Summary of funding gaps" sheet. • 160. This estimate is particularly rough because we have only considered LF and deworming treatments here. We are not sure if the budget Sightsavers has provided us will also support onchocerciasis and trachoma treatments. GiveWell, Analysis of Sightsavers deworming wishlist, 2016, "GiveWell Summary of funding gaps" sheet. • 161. Sightsavers staff, conversation with GiveWell, October 2, 2016 • 162. We have labelled the opportunity to expand to Benue as an Execution Level 1 gap because we believe that the Benue opportunity is one of Sightsavers' highest priorities, so it will choose to use additional funding in Benue before many of the other opportunities. However, we also believe there is a reasonable chance that Sightsavers would fund that program if no other donor steps in. We chose to consider Sightsavers' proposed expansion in Cote d'Ivoire as an "Execution Level 3" gap because it is for treating adults as well as out-of-school children, and it's unclear if this will have a strong impact on prevalence rates in children, which is the outcome we care about (since it's been linked to improvements in quality of life). We have chosen to label the opportunities for expansion beyond 2 years in the countries listed and for expansion in DRC and in South Sudan as "Execution Level 3" gaps because we think there is only a small chance that Sightsavers would be able to productively use funding raised for these programs in the next year or two. In particular, for DRC and South Sudan, Sightsavers has told us that capacity constraints or security constraints will be the limiting factor to Sightsavers' scale-up in those locations. (Sightsavers staff, conversation with GiveWell, October 2, 2016) For the other programs, there is a small chance that lack of more than two years of funding will result in Sightsavers not being able to move forward with these programs. • 163. See our spreadsheet of Sightsavers' spending in USD. In 2014, Sightsavers spent approximately$53.6 million of its unrestricted funding. About 45% of this went to fundraising (about $24.3 million) and only about 7% was spent on Sightsavers' NTD program (about$4 million).

• 164.

Sightsavers staff, conversation with GiveWell, October 2, 2016

• 165.

Julia Strong, International Foundations Executive, conversation with GiveWell, October 19, 2016

• 166.
• 167.