# VillageReach - July 2010 Review

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

Note: This review was published in July 2010. On December 20, 2010, we updated our discussion of VillageReach's funding needs.

VillageReach is a Gold Medal organization. We are confident that VillageReach cost-effectively saves lives and can use additional funds to expand this work.

To see how we rank VillageReach overall, see our list of top-rated charities.

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).

#### 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. Projected expenses have not been updated since mid-2009 and therefore will not fully reconcile with other figures given below.

Funder Bayview Foundation [Currently confidential] [Currently confidential] [Currently confidential] John Snow Inc.
Area Malawi (Kwitanda province) South Africa (KwaZulu Natal province) India Senegal TBD
Description SMS-based logistics for community health workers General health system logistics Vaccine-focused health system logistics General health system logistics Operations research
Expenses $249,961$120,462 $233,568$133,531 $250,000 Fully funded? Yes No Yes Yes Yes Needed from donations$0 $100,000$0 $0$0
More information VillageReach, "President's Report;" VillageReach, "Organization Budget (2010)." VillageReach, "President's Report;" VillageReach, "Organization Budget (2010)";' VillageReach, "South Africa Proposal." VillageReach, "President's Report;" VillageReach, "Organization Budget (2010)." VillageReach, "President's Report;" VillageReach, "Organization Budget (2010)." VillageReach, "John Snow Proposal."

Some additional notes on the South Africa project, as this project is relevant to individual donors:

• VillageReach seeks to improve the general health system capacity in the Zululand district of the KwaZulu Natal province of South Africa17 through "business process mapping and optimization, streamlining data collection, staff training, mentoring, and supervision, expanding quality improvement methodology, and the identification of innovative uses for information and communication technology in patient care coordination at the clinic level."18
• VillageReach's specific plans for assessing its impact are unclear to us. It states that it plans on "A baseline and endline survey to gauge the outcomes and impact of the project" as well as "track[ing] output and outcome indicators that could include stock levels of key commodities, accuracy and frequency of data collection in the clinics, frequency of supervision visits, reports of data use and understanding by clinic staff, and satisfaction of clinic staff with the program."19 It is unclear to us exactly what the impact survey will consist of and, thus, how VillageReach will assess whether it has achieved its long-term goal of "80% improvement in identified primary healthcare indicators."20 On a more short-term basis, it is also unclear to us how VillageReach plans on assessing "accuracy and frequency of data collection in the clinics."21

#### Other plans

VillageReach's other planned activities include continuing to develop and share its management information system, pursuing new contract engagements, and ongoing support to VidaGas, a gas delivery business developed as part of its pilot program.

The following is its overall budget.22 Note that these figures are not taken from exactly the same source, time period and date as the contract engagement figures above.

Program Expense
Mozambique Vaccination Expansion $684,380 Malawi$262,499
Other contract Engagements (aside from Malawi) $390,012 VidaGas Support Activities$60,656
IT Development $184,814 General Program$31,866
Program Development $210,716 Management/general$185,591
Fundraising/marketing $103,868 Including the$100,000 matching requirement over three years detailed above (we count this as $33,333 for the next year), there is a total of$810,844 in expenses over the next year that are neither part of the Mozambique expansion nor included in contract engagements.

## 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 at our report on immunization), 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 evaluation23 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.24

The tables below provide data on the goods VillageReach delivered to Cabo Delgado between 2004 and 2007.25 (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 vaccine26) 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 2007.27. Charts are taken from Kane 2008.28

### 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."29

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 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.30

In 2002, before starting work, VillageReach performed an assessment of access to vaccines in Cabo Delgado province.31 This report claims that, in 2002, there were 22 health facilities in the three districts in Cabo Delgado that VillageReach assessed.32 Of these 22, 4 did not offer access to vaccination services:33 two facilities because they did not have access to a cold chain; 1 because it lacked personnel; and 1 for other reasons.34

#### 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.35

• 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.36
• Outcome data collection: Evaluators randomly selected households in the treatment area (Cabo Delgado province), including 474 children.37 Evaluators then also randomly selected households in the comparison area (Niassa province), thereby including 571 children in the evaluation.38
• 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.39

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.40 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.41 However, it says that its way of comparing the results of surveys done with different methodology "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."42 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."43 (Note, however, that it does not discuss the confounding effect of the civil war recovery that we discussed above.)44

#### 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),45 we collected data on DTP-3 immunizations for countries in Sub-Saharan Africa.46

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.

Based on the evidence above, we feel that the VillageReach program improved capacity to deliver vaccines in Cabo Delgado. However, the Cabo Delgado project officially became the local government's responsibility in 2007,47 and a later report stated, "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."48 (Emphasis ours.) VillageReach's representatives stated to us that "When we turned it over to the government they let it slide back into the old collection-based system."49

The fact that VillageReach has been monitoring the program's continuing performance, and has been open about setbacks, is encouraging; but news of program deterioration is cause for concern. As discussed above, VillageReach has now reactivated its support role in Cabo Delgado.

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 in our report on immunization.) 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 2008,50 and stated to us that the data became unreliable (due to internal contradictions) after that point.51 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). Based on multiple conversations with VillageReach representatives, it is our impression that the very limited role VillageReach took is not representative of VillageReach's typical or future activities.

### Possible negative/offsetting impact

As stated at our discussion of impact analysis, 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.52 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?

As discussed above, the activities in Mozambique will be fundamentally similar to the pilot project, and evaluation will be similar as well, in that VillageReach will conduct before and after surveys of immunization coverage.53

The full six-year plan does not call for surveys in a "comparison province" without VillageReach's support (which the original evaluation had). However, they do call for surveys of immunization coverage in each province, both when VillageReach enters and when it exits. VillageReach will be entering different provinces in different years,54 and depending on exactly when implementation and measurement end up occurring, we feel that the final figures could be quite revealing even without "comparison" provinces. VillageReach has stated that baseline surveys will be publicly available for 3 provinces by year-end 2010.55

In addition, VillageReach plans on tracking a set of key indicators such as deliveries and "stock-outs" over time, as it did with its pilot project.56

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.

As of December 20, VillageReach has received $509,109 towards its total fiscal year 2011 budget of$1,029,848, leaving VillageReach with a 2011 funding gap of $520,739. (Note that as discussed above, VillageReach has stated it can productively absorb up to about$1.5 million in 2010 - i.e., it could productively absorb more than the budgeted amount for 2011.) VillageReach has a $4,060,371 funding gap for the entire six-year projected Mozambique expansion. ## Financials/other All data comes from VillageReach's IRS form 990s for 2002-2008.68 Revenue and expense growth (about this metric): VillageReach reached a large five-year,$3.3 million grant agreement with the Gates Foundation in 2004,69 which explains the large jump reported revenues in 2004.70

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, email to GiveWell, December 18, 2009.

• 8.

"The program, started in January 2010, is expected to cover eight of ten provinces over six years." VillageReach, "Health System Strengthening in Mozambique," Pg 3.

• 9.

See VillageReach, "Health System Strengthening in Mozambique," Pg 8.

• 10.

"Based on the documented success of the demonstration project, the Mozambique Minister of Health has formally directed officials in each of Mozambique's provinces to pursue implementation of the model." VillageReach, "Health System Strengthening in Mozambique," Pg 7.

• 11.

"Specific program objectives [include] ... Integrate additional key commodities – such as rapid diagnostic tests – into the dedicated logistics system." VillageReach, "Health System Strengthening in Mozambique," Pg 7.

• 12.

"The three provinces of Cabo Delgado, Maputo and Niassa are already engaged in the preparation and implementation phases of the program. We expect to extend the program to Gaza, Inhambane, Manica, Sofala and Tete provinces." VillageReach, "Health System Strengthening in Mozambique," Pg 7.

• 13.

John Beale, email to GiveWell, June 21, 2010.

• 14.

"The program is being launched in three provinces in 2010. Funding is the chief determinate of deploying the model in future provinces." VillageReach, "Health System Strengthening in Mozambique," Pg 3.

• 15.

"Based on the documented success of the demonstration project, the Mozambique Minister of Health has formally directed officials in each of Mozambique's provinces to pursue implementation of the model." VillageReach, "Health System Strengthening in Mozambique," Pg 7.

• 16.

VillageReach, "Mozambique Expansion Budget."

• 17.

VillageReach, "South Africa Proposal," Pg 4.

• 18.

VillageReach, "South Africa Proposal," Pg 7.

• 19.

VillageReach, "South Africa Proposal," Pg 12.

• 20.

VillageReach, "South Africa Proposal," Pg 7.

• 21.

VillageReach, "South Africa Proposal," Pg 12.

• 22.

VillageReach, "Organization Budget (2010)."

• 23.

"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."

• 24.

"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."

• 25.

Kane 2008, Pgs 17-18.

• 26.

World Health Organization, "Glossary."

• 27.

Kane 2008, Pg 10.

• 28.

Kane 2008, Pgs 19-20.

• 29.

Kane 2008, Pg 24.

• 30.

Kane 2008, Pg 14.

• 31.

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

• 32.

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

• 33.

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

• 34.

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

• 35.

"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.

• 36.

"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.

• 37.

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

• 38.

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

• 39.

Kane 2008, Pg 23.

• 40.

Leah Barrett, email exchange with GiveWell, June 2009.

• 41.

"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.

• 42.

Kane 2008, Pg 24.

• 43.

Kane 2008, Pg 24.

• 44.

"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, email exchange with GiveWell, June 2009.

• 45.

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

• 46.

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.

• 47.

"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."

• 48.

Kane 2008, Pg 26.

• 49.

John Beale, Allen Wilcox, and Becca Miller, phone conversation with GiveWell, May 21, 2009.

• 50.

VillageReach, "Nampula Indicators."

• 51.

John Beale, email to GiveWell, December 23, 2009.

• 52.

"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.

• 53.

"Measurement is a critical component of our methodology and model. An initial baseline survey and a concluding endline survey will be conducted for each provincial deployment. Data from these surveys will be publicly available upon approval from the government of Mozambique." VillageReach, "Health System Strengthening in Mozambique", Pg 3.

• 54.

See individual province budgets in VillageReach, "Mozambique Expansion Budget."

• 55.

John Beale, phone conversation with GiveWell, July 23, 2010.

• 56.

See:

• VillageReach, "Monthly Key Indicator Tabular Report," for a sample (not using real data) of the data it plans to collect.
• VillageReach, "Key Indicator Descriptions," for a guide to the meanings of these indicators.
• John Beale, email to GiveWell, June 21, 2010, for how frequently the indicators will be tracked.
• 57.

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

• 58.

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

• 59.

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

• 60.

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 (August 17, 2009)." 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.

• 61.

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.

• 62.

VillageReach, "Health System Strengthening in Mozambique," Pg 7.

• 63.

VillageReach, "Health System Strengthening in Mozambique," Pg 7.

• 64.
• Total projected cost for Mozambique: $5,635,439.49. VillageReach, "Mozambique Expansion Budget." • Total projected incremental children vaccinated: 184,281. VillageReach, "Health System Strengthening in Mozambique," Pg 7. • Cost per incremental child vaccinated:$5,635,493.49 / 184, 281 = $30.58 • 65. • Total projected cost:$5,635,439.49 for Mozambique (VillageReach, "Mozambique Expansion Budget") plus $810,844.00 per year for six years in non-Mozambique, non-contract costs (see above) =$10,500,503.49.
• Total projected incremental children vaccinated: 184,281. VillageReach, "Health System Strengthening in Mozambique," Pg 7.
• Cost per incremental child vaccinated: $10,500,503.49 / 184,281 =$56.98
• 66.

See VillageReach, "Organization Budget (2010)" and VillageReach, "Mozambique Expansion Budget." The total 2011 cost of the Mozambique expansion (cells I34-L34 in "Mozambique Expansion Budget") is $1,029,848.00, with$225,000 in reserves available for it ("Organization Budget (2010)").

• 67.

"Considering what we believe are the limitations of the provinces, we think it's reasonable that we could accelerate the start of three new provinces by 3 – 6 months, which would require approximately $6-700k in additional funds, for a total of$1.5M for next year. It's reasonable to think the remaining two provinces might react to seeing the accelerated deployments and requesting to start earlier also, which would translate into additional need for funds." John Beale, email to GiveWell, July 2, 2010.

• 68.

VillageReach, "IRS Form 990 (2002-2008)."

• 69.

Bill and Melinda Gates Foundation, "VillageReach."

• 70.

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.