Interplast

Note: the review below was completed in 2007. Our current review of Interplast is available here.

In a nutshell

What they do: Interplast is devoted to life-changing surgery, correcting deformities in the developing world both by sending its own personnel overseas and by training and supporting local doctors.
Does it work? Interplast's approach is straightforward and easy to understand, and we are reasonably confident that it is changing lives significantly.
What do you get for your dollar? Depending on the program, we estimate that Interplast spends a total of around $500-1500 per surgery. We believe (from our knowledge of the deformities themselves, and from scanning Interplast's blog) that these surgeries can represent significant life changes but we don't have a strong sense for how often such surgeries represent significant life changes rather than minor cosmetic corrections. Where they rank: Interplast is our top-rated cleft palate charity. The details What do they do? Interplast focuses on surgical corrections of deformities; the activities we understand best (and that make up most of their budget) are Surgical Team Trips (sending doctors overseas to perform surgeries) and Outreach Centers (local surgery centers with training and support from Interplast). Details follow. Activities and budget The following is from Interplast's estimated/projected budgets for 2007 and 2008 (Attachments D-2 and D-3). Program Expenses FY 2007 (000's) Expenses FY 2008 (000's) Surgical Team Trips 1511 1558 Surgical Outreach Centers (cleft) 453 458 Surgical Outreach Centers (burn) 175 226 Visiting Educator Workshops 270 295 Medical Education and Training 118 165 Telemedicine 26 29 Webster Fellowship 138 150 Total: Our Featured Programs 2139 2242 Total: Other Programs 552 639 We received enough documentation on the first three programs listed to have (a) reasonably high confidence that they are changing lives significantly; (b) some sense of how many lives they are changing. These three programs make up around 80% of Interplast's total program expenses, and the third appears to be Interplast's fastest growing component overall (see below). Our review therefore focuses on these three programs, which we think give a strong (if not complete) understanding of what Interplast does. Surgical team trips In a typical surgical team trip (detailed in Attachment A-2 Pg 2-4), Interplast sends teams of 12-15 volunteers (medically trained personnel from the US, including surgeons) into a developing-world hospital, where they perform reconstructive surgeries for around 2 weeks (see Attachment B-1 for trip duration). Roughly 60-80 surgeries are performed over the trip period. (Attachment A-2 Pg 2) Major expenses include travel, logistics (non-medical) personnel, and medical supplies (see budget on Attachment A-2 Pg 3-4). We did not see a line item corresponding to local advertising, and wonder how Interplast alerts those in need as to the availability of its services. As mentioned above, we also have little sense of how Interplast chooses where to send its surgeons, although Interplasts' application noted that it sought out hospitals with significant backlogs of cases. (see Attachment A-2 Pg 1) The conditions treated range from cleft lips and palates, which we consider severely debilitating, to hand deformities and ptosis, which we consider less so. Single conditions, such as burn scars, can also vary widely in severity; see our overview of problems and solutions for details on these conditions. Surgical outreach centers and burn outreach centers Interplast supports centers in developing-world countries where local doctors can repair clefts and burns. We aren't perfectly clear on the nature of Interplast's support (especially because Interplast didn't provide a sample budget breakdown, only total expenses by region), but Interplast's website states that "Interplast provides support to the centers with funding, quality review, technological support and advanced medical training." The range of deformities treated in the surgical outreach centers appears much more narrow that the range of those treated during surgical team trips. It seems (from Attachment B-3) that there are two kinds of centers, each focusing specifically on certain types of deformities. Cleft centers focus on cleft lip and palate operations, though they also perform some fistula repairs. Burn centers treat burn scars; further detail is not available. 6 of 8 cleft centers have been operating since 2003 or before; by contrast, the burn center program appears quite new, as 6 of 12 burn centers have no historical data at all (only projected data) and none have data from before 2005. Other programs • Visiting educator workshops are week-long seminars (Attachment A-2 Pg 1) aiming to train local doctors in reconstructive surgery. • The Medical Scholars Program brings local health care providers to the US for training (see the description on Interplast's website); we are short on details about this program, as it is not one we focused on. • Interplast runs two other relatively small programs, described on their website: the Webster Fellow Program and Interplast Grand Rounds, a telemedicine program that we believe (based on this link) to be best thought of as part of the Surgical/Burn Outreach Center program. Regions Interplast works in many countries, primarily in developing-world Asia and Latin/South America, and has recently expanded into Africa as well. We don't have a clear account of how it chooses which countries to work in, aside from its statement that "Interplast teams will be reaching some of the poorest children in the world – children who do not have access to this type of medical care" (Attachment A-2 Pg 2). • The Surgical Team Trips program (see Attachment B-1) operates mostly in Asia (Bangladesh, China, India, Myanmar, and 9 different sites in Vietnam) and Latin/South America (Bolivia, Honduras, Nicragua, and multiple sites in Ecuador and Peru); it has recently expanded into Africa, conducting one trip to Ethiopia and one trip to Mali in 2006-2007. • The Surgical Outreach Center program (see Attachment B-3) operates about 60% in Asia (Bangladesh and Nepal), 30% in Latin/South America (Ecuador, Nicaragua and Peru), and 10% in Africa (Zambia and a new location in Ghana). • The Burn Outreach Center program is a rapidly expanding program (Attachment B-3) that looks to be about 50% in Asia (Bangladesh, India, Nepal and Sri Lanka), 25% in Latin/South America (Ecuador, Nicaragua, and Peru) and 25% in Africa (Ghana and Zambia). Does it work? We cannot state with full confidence that Interplast significantly improves people's lives, because we don't know how (or whether) it ensures that those receiving care do not have other avenues for receiving it. However, we have much more confidence in Interplast's ability to make a significant difference than we do in the same ability of our other applicants (the exceptions being PSI and PIH) both because we have a relatively complete understanding of its activities (as described above) and because it directly observes and reports the surgeries it carries out. The doubts we have about the tangible impacts of the education, promotion and distribution campaigns run by our other applicants do not apply to Interplast; its reports of surgeries conducted - combined with our limited knowledge of the deformities it corrects - lead us to believe it is significantly changing people's lives. The question of how much good Interplast accomplishes is far more difficult, without more detail on the people it treats. We have very little sense of how many of the conditions they correct are severely debilitating, as opposed to more minor deformities (more on this in the section immediately below). The above analysis applies to the programs we have focused on (Surgical Team Trips; Surgical Outreach and Burn Outreach Centers). Other programs rely on training locals and, insofar as we can tell, have no monitoring and evaluation programs in place to ensure their own efficacy; we are thus not confident that these programs actually result in more surgeries' being executed. However, as stated above, these programs are relatively small in the overall picture of Interplast's work. What do you get for your dollar? Below we estimate how many surgeries each program performs on a per-dollar basis. The translation between surgeries performed and lives changed (our definition) is not entirely clear. As our overview of problems and solutions explains, we are believe that a cleft lip or palate generally means severe debilitation, and that a single surgery can make a huge difference in someone's life. However, we don't know how many cleft surgeries are initial vs. followup surgeries, and we have little sense of what sort of life change can be expected from an initial surgery that does not receive followup. We know very little about the severity and consequences of the burn scars, hand deformities, ptosis, and other issues (unspecified) that are treated. We acknowledge that correcting any deformity is valuable, but for purposes of comparing Interplast's activities to other organizations', we wish to focus on severely debilitating conditions; there is unfortunately no clear way to do this. Surgical team trips Attachment B-1 provides both budget information and a breakdown of surgeries executed, by region, for each of the last four years. There doesn't seem to be a strong relationship between the cost of a trip and the number of surgeries performed, either logically (since the main costs are travel- and logistic-related) or empirically (the correlation between the number of surgeries performed and the cost is 2%). Although costs for the program have risen steadily, the number of trips has not (16 in 2006-2007 vs. 18 in 2005-2006), nor has the number of surgeries. Going forward, therefore, our best estimate of what to expect is roughly the same number of surgeries and the same costs as 2006-2007. Note, however, that the costs given in Attachment B-1 appear to understate the true costs, as they do not account for general organizational overhead. (The attachment does not specify this, but the detailed budget given in Attachment A-2 Pg 3-4 - which does account for overhead costs - has significantly higher expenses than any line item in B-1, even for Africa and China, which Attachment A-2 Pg 2 states are the more expensive regions to visit.) As a rough way of adjusting for these costs, we observe (from Attachments D-2 and D-3) that total expenses are ~37% higher than program expenses in the budget estimates for both 2007 and 2008, so we take$1.5M (the budget for Surgical Team Trips in both 2007 and 2008 - see Attachments D-2 and D-3) and add in a 37% premium. The result is an estimate of about $2M for 1400 surgeries, or about$1400 per surgery.

As we state above, we don't have a good sense for how many of these surgeries represent a significant life change. We believe it's appropriate to expect around 35% of these surgeries to be cleft repair surgeries (the same proportion as last year), and based on our analysis of the consequences of cleft, we believe that most cleft repair surgeries represent a significant life changed (putting aside questions about how many surgeries are initial vs. follow-up surgeries); so we believe it is somewhat safe to assume that at least 35% of surgeries corrected represent significant life changes (i.e., the "cost per significant life change" is no higher than ~$4000 for this program, though it is also no lower than$1400).

As we state above, Surgical Team Trips have not increased in recent years, and we believe that Interplast's focus for expansion is its Outreach Centers (see below).

Outreach centers: cleft

Attachment B-3 gives expenses and surgeries for each cleft and burn center.

Data on cleft centers is much easier for us to interpret, since it goes further back in time (nearly all burn data is projected) and is specific about what kinds of surgeries were done. We used the number of "primary operations" - that is, bone grafts, fistula repairs, primary cleft palate operations, and primary lip/nose operations - as a proxy for lives significantly changed by these outreach centers, though much other good is done here in the form of other, "secondary," operations. The following summarizes activities and expenses for these cleft centers.

Center Primary surgeries (2003/2004) Primary surgeries (2004/2005) Primary surgeries (2005/2006) Primary surgeries (2006/2007) Expense per surgery (2003/2004) Expense per surgery (2004/2005) Expense per surgery (2005/2006) Expense per surgery (2006/2007)
Bangladesh 454 389 480 424 $233$247 $240$247
Ecuador 48 16 38 48 $479$1,375 $711$628
Ghana 0 0 0 9 N/A N/A N/A $1773 Nepal 671 619 621 524$176 $234$236 $238 Nicaragua 0 5 43 27 N/A$3,721 $619$769
Lima, Peru 29 39 28 48 $767$728 $872$595
Piura, Peru 50 135 106 51 $490$350 $385$501
Zambia 72 86 88 121 $380$414 $405$332
Total 1324 1289 1404 1252 $242$305 $296$312

For a given cleft center, expenses and surgeries performed do not vary much from year to year; but looking across centers, the pattern is that centers that perform fewer surgeries cost more per surgery (presumably due to economies of scale). If and when the Outreach Center program expands, its cost-effectiveness will depend greatly on the size and reach of centers.

To look at the cost-effectiveness of the current configuration, we use the same method we used for Surgical Team Trips above: examining total program surgeries and costs. For surgeries, we use 1300, roughly the average of the last four years. For costs, we use $400,000 (the most recent total) plus a 37% overhead estimate (same reasoning as for Surgical Team Trips above), bringing estimated expenses to$550,000 for 1300 surgeries, or ~$400 per surgery. Since nearly all of these surgeries are addressing clefts (see our problems and solutions overview for more on this deformity), we would guess that many to all represent significant life changes. Surgical Outreach Centers: burn Attachment B-3 gives expenses and surgeries for each burn center, though for 6 out of 12 of the centers, the only available data is projected, implying that the center is new. Between this and the large projected increase in expenses for this program (~$175K in 2007 vs. ~$225K projected in 2008, a large enough increase to account for the entire increase in Interplast's overall operating expenses - see Attachments D-2 and D-3), we believe that burn centers are the most likely program to be expanded with additional funds. Below we look at projected surgeries and expenses by center, to get a sense of cost-effectiveness. Center Patients (projected) Expenses (projected) Implied cost per patient Bangladesh 40$21645 $541 Ecuador 35$20395 $583 Accra, Ghana 20$16645 $832 Kumasi, Ghana 50$24145 $483 Dehradun, India 70$29145 $416 Jalandhar, India 20$16645 $832 Nepal 230$69145 $301 Nicaragua 20$16645 $832 Lima, Peru 30$19145 $638 Piura, Peru 20$16645 $832 Sri Lanka 20$16645 $832 Zambia 130$44145 $340 Total 685$310990 $454 As with cleft centers, burn centers that treat more people are more cost-effective in terms of patients treated per dollar. To look at the cost-effectiveness of the current configuration, we use the same method we used for clefts above: examining total program surgeries and costs. For surgeries, we use 685, the projected number for next year. For costs, we use$310,000 (the number projected for next year) plus a 37% overhead estimate (same reasoning as for Surgical Team Trips above). These numbers suggest that expenses are ~$425,000 for 685 surgeries, or about$620 per surgery.

As we state on our problems and solutions overview, we have little sense for the range of severity of burn scars, and Interplast was unable to provide this data. It may be that nearly all burn scar corrections represent significant life changes, but it may also be that only a fraction do.

Other programs

We have little sense for what (or how much) Interplast's other programs accomplish, but we believe that the programs we've already discussed account for both the bulk of Interplast's activities and the likely focus of any future expansion.

Overall cost-effectiveness

We estimate that Surgical Team Trips perform one surgery for every ~$1400; projects that use local capacity appear much cheaper (although we're not sure whether the surgeries are of comparable quality) - about$400-600 per surgery.

Taken by itself, this range is comparable to what we've seen in other strong programs, including PSI's programs and CSHGP programs. However, these other programs - while less concrete and more difficult to quantify than Interplast's - have other advantages:

• Interplast's surgeries do not necessarily represent significant life changes - in particular, we aren't sure what proportion of burn scar corrections (the most rapidly expanding program) represent minor rather than major changes.
• PSI's programs, CSHGP programs, and PIH's programs all have significant benefits beyond saving lives: for example, distributing bednets reduces non-fatal cases of malaria, and improving children's health may lead to better overall quality of life even when it does not impact mortality.

Therefore, a straight comparison of Interplast's "cost-effectiveness" figure to other programs' will significantly overstate Interplast's impact relative to other programs'.

The organization

Size and scope. Interplast is significantly smaller (and less broad in its mission) than most of our finalists, with about $10 million a year in expenses (of which over half is in-kind donations, i.e., donations of medical supplies and/or volunteer time). We feel that we understand, and have discussed, the organization relatively broadly. Personnel. Interplast's 24-member board (Attachment C-1) has strong representation from the corporate for-profit world, particularly finance and consulting, and also has several people with medical credentials. Interplast provided biographies of its President/CEO and its Chief Medical Officer (Attachment C-4); the former's background is in political science and broadcasting, while the latter is a doctor with a degree in public health. Financials. (see attachments under heading D for sources). Year Cash revenues (thousands$) Cash expenses (thousands $) In-kind donations 2005 3044 3099* 6516 2006 3887 3423* 6492 2007 (est) 3756 3689 6699 2008 (proj) 3860 3943 6200 *Exact operating expenses not specified; estimated by deducting in-kind donations from total expenses. Interplast's expenses have grown fairly steadily over the last four years, though revenues are projected to remain stable after a jump in 2006. As of the 2006 audit, Interplast held around$3.2M in assets (Attachment D-1 Pg 4), implying that it has about one year's worth of cash on hand.

In providing its sources of income (Attachment C-3), Interplast itemizes all donations over the last three years, which add up to about $7 million (presumably part of its 2007 revenue is projected, explaining the discrepancy between the 2005-2007 revenue above and what we have). Two charities - Ronald McDonald House and Smile Train - gave about$1 million each to Interplast, accounting for around 30% of its total donations over this time period; major gifts from foundations ($50,000+) accounted for another$500,000; and the remaining ~\$4.5 million came from individuals, estates, and smaller gifts from foundations (we'd guess these are family foundations, based on the names and the grant sizes).

Neither the audit nor the other budgets in the application (with the exception of the Surgical Team Trip sample budget on Attachment A-2 Pg 3-4) give a line-item breakdown of financials. We are interested in seeing one.

Conclusion

We see Interplast as an organization that can change lives significantly, reliably, and cost-effectively. Its activities are simple and focused enough - and its monitoring is complete enough - that it is relatively easy for us to have confidence in its impact, and we therefore prefer it to all finalists other than PSI and PIH. We prefer PSI to Interplast because its cost per life changed is likely at least as good, while its benefits beyond "lives saved" appear greater. We narrowly prefer PIH to Interplast, even though Interplast likely costs slightly less per "life significantly changed," because we have higher confidence in PIH's approach (which allows it more direct interaction with and observation of its community) and because we would guess that PIH's impact beyond "lives saved" is much higher (i.e., better overall health).

We'd like to know more about:

• Target regions. How does Interplast determine which regions to work in, and how does it determine that these regions are likely in need of free surgeries?
• Advertising for surgical team trips. Does Interplast take any measures to make as many local people as possible aware of its upcoming surgical team trips?
• Outcomes data for the Visiting Educator Workshop and Medical Scholar programs. Interplast has stated that this information is not currently available (see Attachment A-4 Pg 2-3), but we to hope it will be collected in time and help us to improve our understanding of the organization.
• Financials. We are interested in seeing a traditional line-item breakdown of Interplast's budget over the last few years.