# VillageReach - December 2009 Review

We have published a more recent review of this organization. See our most recent report on VillageReach.

VillageReach is a top-rated organization, receiving 3 / 3 possible stars (our highest rating). (What do our ratings mean?)

VillageReach aims to improve the systems that distribute medical supplies to rural areas in Africa, so that life-saving supplies get to those who need them. Its programs include both technical support staff and changes in logistical setups (such as moving from a system in which health clinics collect their own supplies to a centralized delivery system).

VillageReach also provided an outline of how much additional funding it would need to expand into additional provinces in Mozambique other than Cabo Delgado and Niassa. It has estimated that it can begin a 3-year project in a new province each year for the next 8 years, with each such project costing just over $1.1 million per year.11 #### Contract engagements Specific parties have offered VillageReach funds to carry out projects in different parts of the world, all on the theme of improving health system logistics but sometimes different in many ways from the pilot project discussed above. Notes on these engagements follow: Funder Bayview Foundation [Currently confidential] [Currently confidential] [Currently confidential] Global Fund Medicines for Malaria Ventures John Snow Inc. Area Malawi (Kwitanda province) South Africa (KwaZulu Natal province) India Senegal Nigeria Malawi (Kwitanda province) TBD Description SMS-based logistics for community health workers General health system logistics Vaccine-focused health system logistics General health system logistics Assessment of health system, prior to investment in malaria medicines SMS-based logistics for community health workers Operations research Expenses$249,961 $120,797$233,569 $131,656$188,325 $36,981$50,000
Fully funded? Yes No Yes Yes Yes Yes Yes

## Does it work?

This section focuses on VillageReach's pilot project in Cabo Delgado, then briefly discusses its work in Nampula and what can be expected of its future activities.

One of VillageReach's primary methods of evaluating success is through tracking the progress made in administering basic immunizations. Such immunizations are a proven, cost-effective way to improve health and save lives in the developing world (more here), and so success in increasing immunization coverage - alone - likely constitutes, in our view, success in saving lives.

Below we examine evidence provided by VillageReach including (a) reporting on vaccines and equipment delivered, progress in vaccination coverage rates, and health clinic inventories; (b) an independent evaluation17 of VillageReach's impact. We conclude that VillageReach's pilot project has been effective in increasing vaccine coverage.

### Delivery of vaccines and medical supplies

A key component of VillageReach's model is a shift from a "collection-based" to a "delivery-based" supply system: rather than clinics' being responsible for picking up their own supplies, VillageReach's logistics team delivers supplies and provides other logistical support.18

The tables below provide data on the goods VillageReach delivered to Cabo Delgado between 2004 and 2007.19 (Note that the project began in April 2002; we aren't sure why data has not been provided pre-2004.)

Vaccine doses

Vaccine type August – December 2004 2005 2006 January – April 2007 Total
BCG 39,000 129,200 131,260 43,700 343,160
DPTHpB 37,640 173,310 171,330 47,020 429,300
Polio 87,800 244,480 303,730 79,020 715,030
Measles 19,580 61,210 77,130 18,390 176,310
Tetanus 42,630 182,720 189,230 61,290 475,870

Injection equipment and gas

Equipment/Gas August – December 2004 2005 2006 January – April 2007 Total
Syringes (0.5 ml) 52,793 134,757 60,073 18,202 265,825
Syringes (0.05 ml) 7,769 25,523 20,570 7,696 61,558
Syringes (5ml) 991 15,209 6,684 2,650 25,534
Safety boxes 906 1,517 2,105 22 4,550
Gas (in cylinders) 485 2,091 2,286 692 5,554
Gas (in Kg) 2,668 11,501 12,573 3,806 30,548

### Increases in immunization coverage

The charts below show that (a) the number of children receiving DTP-3 (third dose of diphtheria-tetanus-pertussis vaccine20) immunizations increased; (b) the number of children who "dropped out" during the DTP-3 sequence - that is, they received one, but not all doses - fell; (c) reported "stock-outs" - centers with no inventory of the vaccine - fell significantly over the course of VillageReach's pilot project, which ran from April 2002 to March 2007.21. Charts are taken from Kane 2008.22

### Were improvements attributable to VillageReach?

The evaluation of the project notes that during this time period, "Mozambique and most sub-Saharan African countries achieved significant improvements in their DTP-3 coverage, probably due to GAVI and its support for infrastructure development and provision of new vaccines and safe injection equipment."23

To evaluate the question of VillageReach's role in improvements, we look at three types of information:

1. Reports from VillageReach about the problems interfering with immunizations in Cabo Delgado before their arrival.
2. An evaluation report published by VillageReach explicitly focused on addressing this question, comparing the change in immunization coverage rates in Cabo Delgado to that of another province in Mozambique, Niassa.
3. Examining the changes in immunization coverage in several countries in Africa over this period to put the observed change in context.

We also observe that the above charts showing "stock-outs" above have stock-outs falling from a very high level prior to the start of the project to a very low level shortly after the project began. While it is possible that this change occurred for some reason other than VillageReach's involvement in the area, such an outcome seems unlikely.

#### VillageReach reports of pre-arrival conditions

VillageReach provides a report of the obstacles to immunization coverage in Cabo Delgado before its arrival. We would prefer to have better documentation of these conditions, but nevertheless, we believe the report offers some support to the idea that VillageReach's services were needed in Cabo Delgado.

VillageReach reports,

Prior to the [project], health facilities were individually responsible for picking up vaccines and supplies from the DPS cold stores or district stores and taking them back to their health facility for use. This system encountered various problems....
• Intermittent closing of health facilities during business hours so health workers could pick up vaccines and supplies.
• Challenges securing transport to go to the DPS cold stores. Each district generally had one vehicle, which was for all health service trips by all health system personnel, and was also the ambulance in case of emergencies. Often, when the vehicle was needed to pick up or deliver vaccines, it was out on an emergency, in use by someone else for some other health-system function, broken down, or out of gas.
• Difficulty maintaining proper vaccine temperatures during transport.
• Uncoordinated vaccine supply requirements.
• Frequent stock-outs of vaccines in health facilities.
• Funds were often liberated late – both quarterly from the provincial level to the districts, and monthly from the district administrator to the PAV Chief who needed to purchase gas for the refrigerators, fuel up the district vehicle, and pick up and distribute vaccines.24

In 2002, before starting work, VillageReach performed an assessment of access to vaccines in Cabo Delgado province.25 This report claims that, in 2002, there were 22 health facilities in the three districts in Cabo Delgado that VillageReach assessed.26 Of these 22, 4 did not offer access to vaccination services:27 two facilities because they did not have access to a cold chain; 1 because it lacked personnel; and 1 for other reasons.28

#### VillageReach evaluation document

VillageReach compared improvements in vaccine delivery in Cabo Delgado to improvements in the nearby Niassa province, which was not served by VillageReach.29

• Baseline data collection: Because VillageReach did not have baseline data (i.e., data from a time prior to the start of the project) available for Niassa, it used data from the 1997 and 2003 Demographic and Health Surveys, which surveyed a large number of households and provided data on DTP-3 coverage.30
• Outcome data collection: Evaluators randomly selected households in the treatment area (Cabo Delgado province), including 474 children.31 Evaluators then also randomly selected households in the comparison area (Niassa province), thereby including 571 children in the evaluation.32
• Results: The study found that DTP-3 coverage rates increased substantially in both provinces during this period, but rates improved more in Cabo Delgado (treatment area) than Niassa (control area). The chart below shows the change in coverage rates in the two areas during this time period; the 1997 and 2003 data points are based on Demographic and Health Surveys, while the 2008 data points are from VillageReach's independent data collection.33

On one hand, we believe that this chart creates an inflated picture of VillageReach's impact. We have reason to believe that there were significant improvements in immunization coverage between 1997-2001 that were more related to Cabo Delgado's recovery from the aftermath of a civil war than to VillageReach's activities.34 However, the jump to extremely high levels of coverage as of 2008 - a change not mirrored in the nearby province - give some reason to attribute impact to VillageReach.

The evaluation report is forthright about many limitations of this comparison analysis, including limited sample size, uncertainty about the appropriateness of Niassa as a "comparison province," and issues with taking baseline and endpoint data from different sources.35 However, it says that its way of comparing the results of surveys done with different methodology is "is consistent with international practice." And it concludes that it appears that the Project is responsible for the immunization coverage rising more in the treatment province, Cabo Delgado, than in the comparison province Niassa; although "additional information about the conditions in Niassa compared to those in Cabo Delgado is needed to better understand and interpret the comparison data."36 It also notes that "it is ... unlikely that the activities of other NGO's, which are not very involved in immunization activities in Cabo Delgado, were responsible for the improvement."37 (Note, however, that it does not discuss the confounding effect of the civil war recovery that we discussed above.)38

#### Our comparison of Cabo Delgado to other areas in the developing world

We took a broader look at changes in African immunization coverage over the time period in question in order to further investigate the idea that Cabo Delgado's improvements may simply have reflected a wider phenomenon. Using the Demographic and Health Surveys (Measure DHS),39 we collected data on DTP-3 immunizations for countries in Sub-Saharan Africa.40

The table below summarizes this data, sorted by the country's arithmetic percentage change in immunization coverage.

Country First year Last year % immunized: first year % immunized: last year Change
Mali 1995 2006 38% 68% 30%
Ghana 1993 2008 62% 89% 26%
Senegal 1992 2005 59% 78% 20%
Niger 1992 2006 20% 39% 19%
Cameroon 1991 2004 47% 65% 18%
Burkina Faso 1993 2003 41% 57% 16%
Namibia 1992 2006 70% 83% 14%
Mozambique 1997 2003 60% 72% 12%
Madagascar 1992 2003 54% 61% 8%
Tanzania 1992 2004 80% 86% 6%
Zambia 1992 2007 77% 80% 3%
Nigeria 1990 2008 33% 35% 3%
Chad 1996 2004 20% 20% 1%
Benin 1996 2006 67% 67% 0%
Rwanda 1992 2005 91% 87% -4%
Malawi 1992 2004 89% 82% -7%
Kenya 1993 2003 87% 72% -15%
Zimbabwe 1994 2005 85% 62% -23%

This table provides information at a country level rather than province level, and variation within countries could be significant. There does not appear to be strong evidence of a continent-wide positive trend in immunization rates, but it does not appear, on its own, to rule out the idea that the observed change in Cabo Delgado purely reflected a broader (country-wide or continent-wide) change. We note, however, that Cabo Delgado's 2003 coverage rate was slightly below the Mozambique overall rate, while its post-project rate was above the Mozambique overall rate (and above every other country's overall rate).

### Bottom line on the Cabo Delgado program between 2001-2008

We do not feel that any of the pieces of evidence above is highly compelling by itself. But we are persuaded of VillageReach's impact by the combination of the observations that VillageReach's program (a) entered an area with clearly documented logistics problems; (b) reduced stockouts - one of the clearest measures of the logistics improvement it was aiming for - to near-zero levels; (c) brought Cabo Delgado from an "average" (for the country) level of coverage to an extremely high level of coverage; (d) was reported not to have been supplemented by other nonprofits' programs.

### Can improvements be maintained?

Based on the evidence above, we feel that the VillageReach program has improved capacity to deliver vaccines in Cabo Delgado. However, the Cabo Delgado project officially became the local government's responsibility in 2007,41 and a recent report states, "The data suggests that following the discontinuation of field coordinator teams delivering supplies and performing supervision, the districts and health centers are having difficulty reliably picking up supplies, stock-outs of vaccines are beginning to occur again, there is some (not statistically significant) evidence that immunization coverage is beginning to fall, and district level budgets are not being maintained for these activities."42 (Emphasis ours.) VillageReach's representatives have stated to us that the government has been "slid[ing] back into the old collection-based system."43

The fact that VillageReach is monitoring the program's continuing performance, and being open about setbacks, is encouraging; but news of program deterioration is cause for concern. As discussed above, VillageReach is now planning to reactivate its support role in Cabo Delgado while continuing to push for the government to adopt its model.

Ultimately, we are skeptical about VillageReach's ambitions of handing over its model to the government. However, we note that VillageReach could be making lasting differences in individuals' lives even if its effects on health care are only temporary, since 1-3 doses of most vaccines are sufficient to immunize children against diseases. (Details here.) Our recommendation of VillageReach is made under the assumption that it will not succeed in getting its model adopted by the government, while recognizing that its ultimate cost-effectiveness would be much higher if it could.

### Nampula activities

As described above, VillageReach briefly worked in the Nampula province of Mozambique before handing its activities off to a local organization in January 2007.

VillageReach provided us with internally collected data from this project through August 2008, and stated to us that the data became unreliable (due to internal contradictions) after that point. We have not yet received clearance to post the data publicly. Overall, it showed encouraging trends that resemble the trends outlined above: increasing numbers of immunizations and substantial drops in the rates of stockouts and other logistical problems. However, because of the fact that the data terminates at an apparently arbitrary point, we have serious doubts about the impact of this project.

This project's expenses, overall, were equal to about 20% of the expenses associated with the pilot project (details in our cost-effectiveness section). VillageReach representatives have stated to us that the very limited role VillageReach took is not representative of VillageReach's typical or future activities.

### Possible negative/offseting impact

As stated here, we are generally concerned about charities' potential diversion of skilled labor and/or interference with government responsibilities. However, we believe these concerns are smaller with VillageReach than with other charities we've seen.

VillageReach's focus is on improving logistics rather than on increasing the available resources in an area. Its cost analysis argues that its program ultimately ends up saving the government money (more below), and a conversation with its representatives implies that it does not attempt to repurpose skilled labor from other areas or sectors.44 In addition, it appears to be seriously committed to handing off its programs to the government over time, as it has done in Cabo Delgado. It does not appear to grant funds directly to governments.

### What can be expected of future activities?

We feel that the planned Mozambique activities are highly similar to the pilot project analyzed above - and will be evaluated with a similar level of rigor. Because there has only been one demonstrated success, these activities should be considered to have a reasonable risk of failure, but they are - to us - clearly good investments because they are highly similar to activities that have worked before, and we believe VillageReach has made a credible commitment to continue documenting their success or failure.

We are less positive on VillageReach's contract engagements, many of which we have very little information about. The South Africa project that VillageReach must raise $100,000 in "matching donations" for is particularly worrisome to us, as we find the proposal for activities and impact assessment relatively vague. ## What do you get for your dollar? ### Past cost-effectiveness: pilot program We do not attempt to quantify the full benefits of the VillageReach program. Instead, we observe that even a relatively conservative estimate of its cost per child vaccinated would imply quite strong cost-effectiveness (in terms of cost per death averted). The Disease Control Priorites report (Jamison et al. 2006) estimates the cost per fully-immunized child with a basic set of vaccines at$14.21 in sub-Saharan Africa.45 According to Jamison et al. (2006), this implies a cost per death averted of approximately $200.46 • VillageReach's estimate: VillageReach sent us a draft of its internal review of the Cabo Delgado project's cost-effectiveness. VillageReach estimates that its program is significantly more cost-effective than the government's program, at a cost of$5.76 per child receiving three doses of each DTP and hepatitis B vaccines (which VillageReach asserts is a proxy for a fully immunized child), including both VillageReach and government costs.47 This would imply a cost-per-death averted that is significantly lower than the DCP's estimate of $200, and thus easily within the range we consider highly cost-effective (discussed here). • GiveWell's conservative estimate: We assumed that all VillageReach costs are attributable to the Cabo Delgado project (including costs associated with Nampula activities, due to our uncertainty about these activities' impact), and that there is no impact of VillageReach on immunization coverage beyond 2008 (the last year for which we have data). We also assumed that starting in 2003, the difference in immunization coverage between Cabo Delgado and Niassa can be attributed to VillageReach's program. These assumptions yield an estimate of one additional child fully immunized for every ~$41 of VillageReach's expenses.48 If the Disease Control Priorities Report is correct to estimate that $15 per fully immunized child corresponds to$200 per death averted, this would imply that VillageReach is averting a child death for every ~$545 it spends, still well within the range discussed on our overview of cost-effectiveness estimates. (This estimate ignores government costs entirely, in order to give a sense of what is accomplished for donor money.)49 ### Cost-effectiveness of future activities? We feel that the planned Mozambique activities are highly similar to the pilot project analyzed above. However, we have little idea of what to expect from the contract engagements - most importantly, the South Africa project for which VillageReach must raise$100,000 over 3 years in "matching donations."

To be conservative, we assume that the South Africa project and VillageReach's "development" projects will have zero impact - in other words, that VillageReach's full operating expenses, minus the funds coming from contract engagements, are the full costs of its Mozambique activities. Doing so implies total costs of around $1.6 million per year (see above). The pilot project spent around$4 million over 6 years, or around $650,000 per year; the projected total organizational expenses are$1.6 million for the next year, or ~2.5 times as much. Mozambique activities will be larger-scale than previous activities, with estimated vaccinations of 71,640 in the next year and presumably more in future years.50 This implies that the scale exceeds the pilot project's by at least 15%.51

If we conservatively assume ~2.5x as much expenses as the pilot project with ~15% more impact, applying the multiple to our conservative estimate from above would yield around $1150 per life saved. Because this estimate makes so many conservative assumptions, we feel it is overall reasonable to expect future activities to result in lives saved for under$1000 each.

## Room for more funds?

Because VillageReach is a small organization with a constantly changing funding situation, its budget is generally in flux. Our latest update, in mid-December 2009, assembles the picture as follows:52

Program Earmarked revenue Projected expenses Gap
Mozambique activities $292,784$738,775 $445,991 South Africa matching requirement N/A$33,333 $33,333 Misc$124,532 $181,218$56,686
Prog Development $14,947$86,944 $71,997 IT Development$9,258 $140,886$131,628
VidaGas $8,260$55,460 $47,200 Other Social Enterprise$147,237 $131,887 -$15,350
Social Enterprise Development $9,827$82,603 $72,776 General operating$658,438 $143,312 -$515,126
Total $1,265,283$1,594,418 $329,135 Bottom line: • Donations will be used first to fund matching requirements for the South Africa program, then to fund the planned Mozambique activities and associated operating expenses, then to fund new program development and social enterprise support. • The total funding gap is$329,135 for the next year. If revenue exceeds this amount, the most likely short-term use will be ensuring that VillageReach can complete all three years of its planned Mozambique activities, approximately $1.2 million over 3 years.53 Funds beyond that point would be used to expand further in Mozambique, at a cost of about$1 million per year per province.
• We feel that VillageReach could productively absorb up to around $2.5 million in additional funding over the next year. This would ensure that it could meet its current needs, complete its planned Mozambique activities, and begin (i.e., pay for one year of) expanded activity in Mozambique. ## Financials/other All data comes from VillageReach's IRS form 990s for 2002-2007, 54 Revenue and expense growth (about this metric): VillageReach reached a large five-year,$3.3 million grant agreement with the Gates Foundation in 2004,55 which explains the large jump reported revenues in 2004.56

In 2007, both revenues and expenses fell. It's possible that this is because VillageReach had completed its work in Mozambique and was largely focused on reviewing and evaluating that project.

Assets-to-expenses ratio (about this metric): VillageReach has maintained an assets:expenses ratio of between approximately 1:1 and 2:1, aside from the year (and year after) they received the Gates Foundation grant.

## Sources

• 1.

"For nearly ten years, VillageReach's health systems strengthening programs have maintained a clear focus on the last mile healthcare access. Our approach focuses on the logistics of medical supply and service delivery to increase reliable access to healthcare in the poorest, most remote locations." VillageReach, "About VillageReach."

• 2.

"VillageReach was founded in Seattle, Washington in 2000 by Blaise Judja-Sato." VillageReach, "About VillageReach."

• 3.

Kane 2008, Pg 10.

• 4.

"We have transitioned the VillageReach model and program to the local Ministry of Health in Cabo Delgado province, home to 88 vaccination clinics. VillageReach and FDC, our local implementation partner, will continue to provide technical assistance and data reporting." VillageReach, "Milestones."

• 5.

VillageReach, "Northern Mozambique Project."

• 6.
• "The Project has already been replicated in Nampula, where it is currently being implemented by the FDC." Kane 2008, Pg 8.
• "August 2006: Began deliveries in 85 health centers (in North and Central zones in12 districts) in Nampula." Kane 2008, Pg 16.
• 7.

"We officially transitioned Nampula province to FDC in January 2007, and they officially ended the project in August 2009- which means the technical assistance and support ended but the Ministry continues to do the activities." Becca Miller, e-mail to GiveWell, December 18, 2009.

• 8.

VillageReach, "Funding Gap Memo," Pg 1.

• 9.

"VR recommends a plan including a province level baseline and end line in Cabo Delgado, Niassa and a third comparison province. We have included the full range of monitoring & evaluation options in the table below to show how and why we prefer this option. This preferred plan is included as option number 8 in the table below and is the basic assumption in all funding gap projections." VillageReach 2009, "Funding Gap Memo," Pg 2.

• 10.

VillageReach, "Funding Gap Memo," Pg 3.

• 11.

VillageReach, "Expansion Graph."

• 12.

VillageReach, "South Africa Proposal," Pg 4.

• 13.

VillageReach, "South Africa Proposal," Pg 7.

• 14.

VillageReach, "South Africa Proposal," Pg 12.

• 15.

VillageReach, "South Africa Proposal," Pg 7.

• 16.

Allen Wilcox and Becca Miller, phone call with GiveWell, November 10, 2009.

• 17.

"This report was compiled by Mark Kane, MD, MPH, a consultant, following review of these materials and extensive discussions with VillageReach staff. Many of the opinions and viewpoints in this report are those of the reviewer, and do not necessarily represent the views of the VR, its staff, or Project implementation partners." Kane 2008, Pg 12. Dr. Kane is listed on VillageReach's Board of Advisors, see VillageReach, "Board of Directors and Advisors."

• 18.

"Under the previous system of distribution, clinic workers in need of vaccines and other medical supplies were required to travel many miles, often on foot, to a provincial or district warehouse to obtain supplies that were not always available. Today, in Cabo Delgado, health workers at 90 rural clinics receive monthly deliveries from one of VillageReach's three delivery trucks, specially outfitted to navigate the difficult terrain of rarely maintained roads and sustain the cold chain necessary for the safe transport of vaccines. As the VillageReach drivers leave from the provincial warehouse for two-week excursions, they bring with them the necessary vaccines, medical supplies, and energy needed by each clinic to serve their communities." VillageReach, "Supply Chain."

• 19.

Kane 2008, Pgs 17-18.

• 20.

World Health Organization, "Glossary."

• 21.

Kane 2008, Pg 10.

• 22.

Kane 2008, Pgs 19-20.

• 23.

Kane 2008, Pg 24.

• 24.

Kane 2008, Pg 14

• 25.

VillageReach, "Mission Report - VillageReach: Logistics Support to Health Services - MISAU Mozambique."

• 26.

VillageReach, "Mission Report - VillageReach: Logistics Support to Health Services - MISAU Mozambique," Pg 9, Table 1.1.

• 27.

VillageReach, "Mission Report - VillageReach: Logistics Support to Health Services - MISAU Mozambique," Pg 10, Table 2.1.

• 28.

VillageReach, "Mission Report - VillageReach: Logistics Support to Health Services - MISAU Mozambique," Pg 10, Table 2.2.

• 29.

"Comparison data was obtained from a 2007 immunization coverage cluster survey conducted by DPS in the neighboring province of Niassa, in which the Project did not operate." Kane 2008, Pg 6.

• 30.

"This study used data from the 2003 Mozambique Demographic and Health Survey (DHS 2003) as baseline data. DHS surveys are cross-sectional household surveys that are representative on both a national and provincial level...12,315 households were included in the study...The variable 'DTP 3' was computed using the following variables from the Mozambique DHS 2003 dataset: 'received DTP 1,' 'received DTP 2,' and 'received DTP 3.' 'DTP 3' was defined as those children who received all DTP doses (DTP 1-3) according to card or history." Leach-Kemon, DionÃ­sio, and Taimo 2008, Pg 9.

• 31.

Leach-Kemon, DionÃ­sio, and Taimo 2008, Pg 10.

• 32.

Leach-Kemon, DionÃ­sio, and Taimo 2008, Pg 16.

• 33.

Kane 2008, Pg 23.

• 34.

Leah Barrett, e-mail exchange with GiveWell, June, 2009.

• 35.

"The Statistical Analysis for the quantitative surveys carefully describes the factors that could bias the evaluation results:

• Baseline surveys were not done at the inception of the project
• A “comparison” Province (or Provinces) was not designated at the initiation of the project
• Comparing the results of surveys done with different methodologies (DHS and EPI cluster surveys) creates certain potential biases
• Relatively small sample sizes made it difficult to detect small changes in coverage between the two age groups
• Uncertainty about the reasons districts were chosen for the Niassa survey
• Uncertainty about the comparability of Niassa as a “comparison” province."

Kane 2008, Pg 23.

• 36.

Kane 2008, Pg 24.

• 37.

Kane 2008, Pg 24

• 38.

"You are right that a lot happened in Cabo Delgado between 1997-2001 and the coverage rates reflect that. Cabo Delgado was particularly hard hit by Mozambique's civil war from 1977-1992, which the health system in a very poor state and landmines prevented people from traveling to the facilities that did exist. In 1994, Mozambique had their first multi-party elections and major rehabilitation efforts followed. In the 1997-2001 time period, there was a lot of effort put into building new health centers in Cabo Delgado, which greatly increased access to immunization services in the province." Leah Barrett, e-mail exchange with GiveWell, June, 2009.

• 39.

Measure DHS, "Statcompiler." We accessed data through the StatCompiler tool and looked at all available surveys for Sub-Saharan Africa.

• 40.

We downloaded data on DTP-3 immunizations. The percentages in the table reflect reports either from (a) the child's vaccination card or (b) a mother's report (called "either source" in the Measure DHS tables). We only include countries that had at least one survey during or before 1997 and at least one survey during or after 2003; 1997-2003 was the period over which VillageReach provided Measure DHS surveys for Cabo Delgado.

• 41.

"We have transitioned the VillageReach model and program to the local Ministry of Health in Cabo Delgado province, home to 88 vaccination clinics. VillageReach and FDC, our local implementation partner, will continue to provide technical assistance and data reporting." VillageReach, "Milestones."

• 42.

Kane 2008, Pg 26.

• 43.

"When we turned it over to the government they let it slide back into the old collection-based system. That's what led to the minister and the government said this system works and we should implement it nationwide. The government did recognize that the newer system is better and decided to reverse going back to the old system." John Beale, Allen Wilcox, and Becca Miller, phone conversation with GiveWell, May 21, 2009.

• 44.

"The people that we hired initially were retired MOH employees; in Nampula they remained MOH employees and were just under our management for a period of time." John Beale, Allen Wilcox, and Becca Miller, phone conversation with GiveWell, May 21, 2009.

• 45.

Jamison et al. 2006, Pg 401. For more, see our discussion of the cost-effectiveness of immunization programs.

• 46.

Jamison et al. 2006, Pg 401. For more, see our discussion of the cost-effectiveness of immunization programs.

• 47.

VillageReach, "Comparison of Costs Incurred in Dedicated and Diffused Vaccine Logistics Systems."

• 48.

For Cabo Delgado, we have (a) the number of children receiving 3 doses of DTP (which Kane 2008, following GAVI, asserts is a proxy for "fully immunized") in 2001-2007 (Kane 2008, Pg 19) and (b) the percentage of children immunized in 2003 and 2008 (Kane 2008, Pg 23). For Niassa, we have the percentage of children immunized in 2003 and 2008 (Kane 2008, Pg 23).

The use of DTP-3 as a proxy for full immunization is supported by data from Cabo Delgado (reported by Leach-Kemon, DionÃ­sio, and Taimo 2008, Pg 63, Table 1-11). Coverage rates of BCG, polio 3, and measles vaccinations were at least as high as DTP-3 coverage. In addition, 92.8% of children in the 24-35 months age group were "fully-vaccinated," while 95.4% were immunized with DTP-3.

We credit VillageReach with each child immunized in Cabo Delgado above and beyond the percentage immunized in Niassa for the same year, starting in 2003 (the year after the VillageReach program began), interpolating data (linearly) when it is missing. While far from ideal, we find this a reasonably appropriate comparison, as we estimate the Cabo Delgado coverage rate prior to VillageReach's involvement to have been close to the Niassa coverage rate (see Leah Barrett, email exchange with GiveWell, June, 2009).

Year CD: # of children vaccinated CD: % of children immunized Niassa: % of children immunized Children in Cabo Delgado needing immunizations Calculated: Additional children immunized in CD
2003 50,588 69% 55% 73,316 10,264
2004 54,584 76% 58% 72,297 12,652
2005 58,861 82% 61% 71,782 15,074
2006 64,772 89% 64% 73,189 17,931
2007 71,044 95% 67% 74,783 20,939
2008 71,250 95% 70% 75,000 18,750
• Immunization rates: Evidence suggests that immunization rates fell slightly between 2007-2008 as VillageReach handed over responsibility for the program (see the Can Improvements be Maintained section on this page). We don't know how much rates fell, so to err on the conservative side, we assign the same rate to 2007 that is assigned to 2008. We linearly interpolate the immunization rate between 2003-2007 (in Cabo Delgado) and 2003-2008 (in Niassa).
• Children in need of vaccination: Calculated as follows: (# of children immunized in Cabo Delgado) / (% of children immunized in Cabo Delgado).
• Addtional children immunized: Calculated as follows: [(% of children immunized in Cabo Delgado) - (% of children immunized in Niassa)] * (Total number of children in need of immunizations in Cabo Delgado).

Our total impact estimate comes to 95,610 additional children immunized (we do not apply a discount rate; a moderate discount rate would make little difference due to the short time period under discussion).

Costs are detailed in VillageReach, "Cost Estimates, 8/17/09." We include all costs, even those allocated to the Nampula activities, for which we assume no impact. Between 2001 and 2006 (the year VillageReach stopped financially supporting the program in Cabo Delgado), VillageReach spent a total of $3,910,411, implying (with the impact estimate above)$40.90 spent by VillageReach for every additional child immunized between 2003-2008.

• 49.

If one assumes that the government spends an additional $15 per child - consistent with the Jamison et al. (2006) estimate of the costs for a standard expansion program, and probably an overstatement (since some of VillageReach's costs likely substitute for government costs) - the implied total cost per death averted rises to ~$745, still well within the range discussed on our overview of cost-effectiveness estimates.

• 50.

VillageReach 2009, "Expansion graph," slide 1. More vaccinations are projected in future years, but this is under the assumption that VillageReach expands further into the Tete province - we find it likely but not a given that vaccinations are also projected to rise even if expansion into Tete does not happen.

• 51.

See our table of immunizations for the pilot project (in footnote 53 above), which averaged 61,850 per year. 71,640 (next year's projection) is about 15% greater than 61,850.

• 52.

Sources:

• VillageReach, "2010 Budget."
• John Beale, email to GiveWell, December 21, 2009.
• Becca Miller, email to GiveWell, December 23, 2009.
• Allen Wilcox and Becca Miller, phone call with GiveWell, November 10, 2009.
• VillageReach, "President's Report, September 12, 2009."
• VillageReach, "Funding Gap Memo."
• VillageReach, "South Africa Proposal."

Details and calculations in GiveWell, "VillageReach Funding Gap Analysis-December 2009."

• 53.

VillageReach 2009, "Funding Gap Memo."

• 54.

VillageReach, "IRS Form 990," 2002-2007. These forms are also available for download through the National Center for Charitable Statistics at http://nccsdataweb.urban.org/PubApps/showVals.php?ft=bmf&ein=912083484 (accessed May 3, 2010).

• 55.

Bill and Melinda Gates Foundation, "VillageReach."

• 56.

Organizations report income on their tax forms in the year a grant agreement is reached. VillageReach received funds from this grant over the five-year period.