The END Fund's Deworming Program

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More information: What is our evaluation process?

Published: November 2020

Summary

What do they do? The END Fund (end.org) manages grants, provides technical assistance, designs programs, and raises and directs philanthropic funding for controlling and eliminating neglected tropical diseases (NTDs). We have only reviewed its programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) ("deworming"); our recommendation is just for this part of the END Fund's work. (More)

Does it work? We believe that there is strong evidence that administration of deworming drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes; we consider deworming a priority program given the possibility of strong benefits at low cost. In 2016, the END Fund began requiring that surveys be conducted to determine whether its programs have reached a large proportion of children targeted. We have reviewed coverage surveys for (a non-random sample of) 70% of its 2016 and 2017 deworming grant portfolio. These studies have some methodological limitations. We have not yet reviewed coverage surveys from 2018 and 2019 in Angola, Chad, DRC, and Nigeria. (More)

What do you get for your dollar? Our best guess is that deworming is generally highly cost-effective. We estimate that it costs donors who give to the END Fund, specifically to support deworming, $0.81 per deworming treatment delivered. This figure relies on several difficult-to-estimate inputs, including how to account for (a) donated drugs and (b) in-kind contributions from governments, as well as (c) an adjustment for fungibility—that is, based on experience, we expect the END Fund to reallocate a portion of its unrestricted funding to non-deworming NTD work in response to receiving funding designated for schistosomiasis and STH. Excluding donated drugs and in-kind contributions, the cost per treatment figure is $0.46. (More)

Is there room for more funding? We conduct "room for more funding" analysis to understand what portion of the END Fund's ideal future budget it will be unable to support with the funding it has or should expect to have available. We may then choose to either make or recommend grants to support those unfunded activities. (More)

The END Fund's deworming program is recommended because:

  • We consider deworming a priority program given the possibility of strong benefits at very low cost. (More)
  • The END Fund has exhibited standout transparency; it has shared significant, detailed information about its programs with us.

Major open questions include:

  • Whether END Fund-supported programs are reaching a high proportion of children targeted, given the variable results and quality of coverage surveys we have reviewed from 2016 and 2017. We have not yet reviewed coverage surveys from 2018 and 2019, which the END Fund has shared for Angola, Chad, DRC, and Nigeria; we expect these surveys will provide additional evidence to answer this question. (More)
  • How much the END Fund will raise (or would have been able to raise) for its programs from other funders. The END Fund's revenue comes primarily from a fairly small number of large donations, which makes it more difficult to project what its revenues will be in the future. We have less confidence in our projection of the END Fund's revenue than we do for our other top charities. (More)
  • What effect will fungibility have on the cost-effectiveness of giving to the END Fund for deworming specifically? In other words, what portion of donations made to the END Fund on GiveWell's recommendation ("GiveWell-directed" funds) will be used to increase grant-making for deworming, rather than displacing funding from deworming to other NTDs? To date, we estimate that this effect has been relatively small but we have fairly low confidence in this assessment because it’s difficult to assess how much of the END Fund's funding would have gone to support deworming in the absence of GiveWell-directed funding. (More)

Table of Contents

Our process

We began considering the END Fund as a potential top charity in 2015. To date, our investigation has consisted of:

  • Extensive communications with END Fund staff.1
  • Reviewing documents the END Fund shared with us.
  • Visiting two END Fund-supported programs, in Rwanda and the Democratic Republic of the Congo (DRC), in 2017 (notes and photos from this visit).

What do they do?

The END Fund manages grants, provides technical assistance to programs, and raises funding for programs to control and eliminate neglected tropical diseases (NTDs), with a focus on soil-transmitted helminthiasis (STH), schistosomiasis, lymphatic filariasis, trachoma, and onchocerciasis.2 We focus this review on the END Fund's support for deworming (mass drug administration [MDA] targeting schistosomiasis and soil-transmitted helminthiasis), which we have identified as a priority program.3

The END Fund began supporting NTD programs in 2012.4 Through 2019, it had disbursed $91.9 million to NTD programs.5 Many END Fund grants include funding for both deworming and other NTD treatments; from 2017 to 2019, deworming grantmaking ranged from 29% to 52% of total grantmaking.6

The END Fund's implementing partners have included organizations we have reviewed in depth: the SCI Foundation (SCI), Deworm the World Initiative, and Sightsavers.7

The END Fund's role in deworming and other NTD programs

  • Surveying the global NTD landscape and choosing locations for programs: The END Fund told us that it conducts research on the global NTD landscape, including compiling information on a) where NTD treatment is needed, b) what work is being carried out by governments, NGOs, and other funders, and c) what capacity potential implementing partners have. It uses this information to decide where to fund programs.8
  • Making grants to create, scale up, or fill funding gaps for NTD programs: The END Fund told us that it makes grants to support several different types of programs, including new NTD programs in countries neglected by other donors, programs to scale up treatment coverage in countries with high NTD burdens, and established programs with small funding gaps.9 These grants are used primarily to support activities including program implementation, disease prevalence mapping, and technical assistance.10 The END Fund's grantees include organizations with experience supporting NTD programs (including SCI, Deworm the World, and Sightsavers), organizations without experience implementing NTD programs that operate in areas in need of NTD treatments, and government agencies.11 In addition to its planned grants, the END Fund keeps a flexible fund to support last-minute grant-making opportunities.12
  • Monitoring grantees' program operations: The END Fund asks grantees to provide program budgets, work plans, and target treatment schedules, and it requires that grantees submit periodic progress reports during the implementation of the program.13 The extent of the END Fund's involvement in programs implemented by its grantees varies, and may include technical assistance from the END Fund.14 In 2016, the END Fund began requiring that most programs (including all large programs) conduct coverage surveys;15 see below for a discussion of the coverage surveys we have seen from END Fund-supported programs.
  • Raising funding for NTD programs: The END Fund told us that it actively engages with donors and philanthropic foundations (including those without previous involvement with NTDs) to raise funding for NTD programs.16

Levels of involvement in NTD programs

The level of the END Fund's involvement in the NTD programs implemented by its grantees varies. Below is a rough breakdown of the services it provides and rough estimates of the percentage of its spending that goes to programs in each level of involvement, from most intensive to least intensive:17

  • Hands on (~20% of spending): capacity-building assistance, detailed planning support, technical assistance, and procurement support. Examples include programs in Nigeria18 and DRC.19
  • Substantive involvement (~20% of spending): review of program design, budget support, work planning guidance, and networking support. Examples include Zimbabwe20 and Angola.
  • Engaged (~20% of spending): review of program design, budget support, technical review, and networking support. Examples include Liberia and Côte d'Ivoire.
  • Light touch (~40% of spending): review of program design, negotiation of budget, and ongoing review of program output. Examples include Rwanda, Ethiopia, and Kenya.

The END Fund expects the breakdown of its spending between these four categories to remain roughly similar over time.21

We learned in more depth about the END Fund's work in Rwanda and Idjwi, DRC during a site visit in 2017:

  • In Rwanda, where the END Fund provides light-touch support to biannual deworming programs for preschool- and school-aged children,22 its role primarily involves providing funding, monitoring program spending, and advocating for government support of deworming.23 It also provides support for a Rwandan technical advisor who oversees the program for the Ministry of Health, which runs the deworming distributions and conducts monitoring of the program.24 The END Fund's goal is for the Rwandan government to fully fund the program in the future.25
  • In Idjwi, where the END Fund provides hands-on support for deworming and other NTD treatment,26 it has played many roles, including:27
    • Facilitating initial discussions between the Ministry of Health's national NTD program and Amani Global Works (AGW), the END Fund's implementing partner in the DRC.
    • Writing a budget for the program.
    • Planning distribution logistics and trainings.
    • Connecting AGW with technical experts in the Ministry of Health to help with monitoring and prevalence mapping.
    • Sending its staff to aid in building community support for deworming.
    • Facilitating meetings with local government.
    • Helping to secure drugs.
    • Instructing AGW staff in World Health Organization (WHO) guidelines for NTD programs.

For more examples of the END Fund's roles in the countries it has worked in, see our February 2017 conversation notes.

Overview of spending

Through 2019, the END Fund had disbursed a total of $91.9 million to NTD programs.28 The countries that had received the most grant funding from the END Fund were Ethiopia ($17.4 million), Angola ($10.3 million), DRC ($9.6 million), and Nigeria ($9.1 million); together, these four countries accounted for approximately half of the END Fund's grantmaking. In total, the END Fund had made grants to support work in 29 countries.29

Many END Fund grants include funding for both deworming and other NTD treatments. Both the total amount of funds granted for deworming programs and the proportion of total grantmaking allocated for deworming has fluctuated in recent years, comprising $6.8 million or 52% of total grantmaking in 2017, $5.8 million or 29% of total grantmaking in 2018, and $9.2 million or 38% of total grantmaking in 2019.30

In 2019, 74% of the END Fund's spending went to grants, 15% to other program costs (such as program oversight and communications), and 10% to overhead costs (such as management and fundraising). These proportions were similar in 2017 and 2018.31

Angola program spending breakdown

We use the Angola program as an example of how funds may be used by implementing partners.

The END Fund funds and collaborates with the MENTOR Initiative to run NTD programs in six provinces in Angola.32 This program falls under the "substantive involvement" category of the END Fund's work.33 The END Fund's role in this program includes providing technical assistance, helping with program design, deciding which diseases to treat, and doing high-level advocacy with the Ministry of Health.34

The END Fund provided us with detailed documentation on one of its grants to support an NTD program in Angola as an example of its work; we have not yet requested similar documentation for the END Fund's other grants.35

The END Fund's five-year grant to the MENTOR Initiative was intended to support NTD-prevalence mapping (of soil-transmitted helminthiasis, schistosomiasis, and lymphatic filariasis) in three provinces in Angola, school and community-based mass drug administration, and a school-based handwashing education program. (Lymphatic filariasis mapping was not completed.)36

We have seen a breakdown of the MENTOR Initiative's spending by activity and by expenditure category for the first two years of the program (April 2013 – March 2015):37

The MENTOR Initiative, spending breakdown by activity, April 2013 - March 2015

Program activity Spending % of total spending
Program Management and Administration $873,013 43%
NTD Mapping $291,046 15%
Training and Workshops $247,586 12%
Supervision $214,577 11%
Mass Drug Administration $195,947 10%
NTD Capacity Building $99,034 5%
IEC/ACSM38 $33,330 2%
Water, sanitation, and hygiene $32,329 2%
Assessments and Surveys $19,803 1%
Support to Health Facilities $275 0%
Total $2,006,940 100%

The MENTOR Initiative, spending breakdown by expenditure category, April 2013 - March 2015

Expenditure category Spending % of total spending
Human Resources $642,620 32%
Infrastructure and Other Equipment $357,975 18%
Planning and Administration $284,504 14%
Training $234,702 12%
Overheads $171,001 9%
Technical Assistance $102,814 5%
Health Products and Health Equipment $69,686 3%
Procurement and Supply Management Costs $67,207 3%
Monitoring and Evaluation $53,651 3%
Communications Materials $22,734 1%
Living or Other Support to Beneficiary Population(s) $46 0%
Total $2,006,940 100%

The END Fund also provided more detail on the expenditures included in the above categories.39

Our understanding is that the mass drug administration in the MENTOR Initiative's spending breakdowns refers to two rounds of school-based MDA: one round of albendazole in October and November 2013 for the treatment of STH and one round of praziquantel in November 2014 for the treatment of schistosomiasis (albendazole was unavailable during the November 2014 distribution).40

Does it work?

We believe that there is strong evidence that administration of deworming drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes; we consider deworming a priority program given the possibility of strong benefits at low cost.41

We are uncertain overall about the proportion of targeted children reached through END Fund-supported programs. We have seen some monitoring from END Fund-supported programs that is similar to the monitoring that has increased our confidence in similar programs conducted by Deworm the World, SCI, and Sightsavers.

It seems plausible to us that the END Fund has an impact by causing deworming programs to start or scale up. The END Fund may also have a positive impact on deworming programs by providing non-monetary assistance to its grantees, but we have not investigated this question in depth.

Note that, in this section, we exclude the END Fund's grants to support other organizations that work on deworming that we have separately reviewed (Deworm the World, SCI, and Sightsavers) because we see END Fund's value added as identifying and supporting opportunities that we have not identified through other means.

Details follow.

Are mass deworming programs effective when implemented well?

We discuss the independent evidence for deworming programs extensively in our intervention report. In short, we believe that there is strong evidence that administration of deworming drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes; we consider deworming a priority program given the possibility of strong benefits at low cost.

There may be important differences between the type and severity of worm infections in the places where the END Fund supports programs and the places where the key studies on improved life outcomes from deworming took place. More below.

What is the likely impact per treatment in the END Fund's programs compared with the independent studies on the impact of deworming?

In general, mass deworming programs treat everyone in a targeted demographic, regardless of whether each individual is infected (more). Because of this, the benefits (and therefore the cost-effectiveness) of a program are highly dependent on the baseline prevalence of worm infections.

In this section, we discuss how the disease burden in the areas the END Fund works in compares to the places where the independent studies that form the evidence base for the impact of deworming were conducted. While it is our understanding that END Fund programs generally target areas that require mass treatment according to WHO guidelines,42 the disease burden in END Fund areas is on average lower than in the study areas, so our expectation is that the impact per child treated is lower in END Fund areas. We adjust our cost-effectiveness estimate (more below) accordingly.

In this spreadsheet, we compare the prevalence in places in which the END Fund currently supports a program to the prevalence rates from the studies providing the best evidence for the benefits of deworming.

Key pieces of evidence that we discuss in our report on deworming (Miguel and Kremer 2004, Baird et al 2012, and Croke 2014) are from deworming experiments conducted in Kenya and Uganda in the late 1990s and early 2000s. Prior to receiving deworming treatment, the participants in those studies had relatively high rates of moderate-to-heavy infections of schistosomes or hookworm.43

Are targeted children being reached?

This section is out of date. Note that we have received, but not yet reviewed, coverage surveys for the END Fund's grantmaking in 2018 and 2019 in Angola, Chad, DRC, and Nigeria. These surveys are not covered in the discussion that follows.

In 2016, the END Fund began requiring that the programs it supports (excluding ones that receive only limited support) conduct coverage surveys to determine what portion of targeted children receive and ingest pills.44 For the grants the END Fund made in 2016 and 2017, we have seen coverage surveys covering roughly 70% of total grant-making for deworming. The coverage numbers for the distributions we are most interested in (i.e. MDAs that target school-age children) are generally middling, with median coverage around 50-70%. These surveys are from a non-random sample of the END Fund's work and therefore may not be representative of its overall results. Additional surveys were expected but have been delayed. We note some methodological limitations of the surveys below; it is our impression that the quality of the surveys we have seen from the END Fund may be more variable than what we have seen from some of our other top charities such as Evidence Action's Deworm the World Initiative and, to a lesser extent, the SCI Foundation. We believe that END Fund staff may generally be less directly involved in the implementation of program monitoring than the staff of those organizations.

More details below and in this spreadsheet.

Are these monitoring results representative of END Fund-supported programs overall?

In total, for the grants the END Fund made in 2016 and 2017, we have seen coverage surveys covering 69% of total grant-making for deworming.45 The results we have seen could overstate the impact of the average END Fund-supported program if coverage surveys are more likely to be skipped or the results withheld in countries with lower coverage rates. There are a couple of reasons this might be the case:

  • Country programs that have more capacity and experience are likely to be those that both carry out high-quality distributions and complete all the steps necessary for coverage surveys to be implemented and for the results to be shared with the END Fund (and thus with GiveWell).
  • Coverage surveys are more likely to be skipped or results withheld if implementers recognize that the surveys are likely to show low coverage results and reflect poorly on them. We have no evidence that this has occurred for END Fund-supported programs, and note this only as a general possibility.

We exclude END Fund partnerships with our other top charities that work on deworming from this analysis. The END Fund notes that its other partnerships, which tend to be with local organizations and governments, may systematically implement less robust monitoring and evaluation processes than its partnerships with other GiveWell top charities.46

Methods

We note some methodological choices that somewhat limit our confidence that coverage survey results represent fully accurate estimates of coverage that are representative of the country program as a whole. These themes are similar to what we have noted for SCI's coverage surveys. More details and citations in this spreadsheet.47

  • In four cases (in 2016 MDA reports from anonymous Country A), districts were purposively selected for coverage surveys based on having the most extreme (highest and lowest) reported coverage. In one case (Angola), districts were non-randomly selected using a few factors including reported coverage rates.48 In the other three surveys (DRC, Chad, and the Republic of the Congo), we are uncertain how districts were chosen. In nearly all cases, villages and households within districts were selected randomly; see this footnote for the only exception of which we are aware.49
  • The eight coverage surveys we have seen from the END Fund vary in terms of clarity and thoroughness. For example, the surveys we have received from Country A answer most of our methodology questions, while the survey from DRC answers our methodology questions less clearly and thoroughly.
  • Four of the coverage surveys took place at least five months after the relevant MDAs took place; some people may have been surveyed more than a year after the relevant MDA. In several cases, it is unclear how much time had elapsed since the relevant MDA.
  • In several of the eight surveys, we are uncertain whether there were procedures of data quality control, how 'don't know' responses were counted (if they were accepted), and whether any questions to check the accuracy of respondents' answers were asked.50
  • We place limited weight on the survey from DRC because it primarily interviewed adults rather than children, had a small sample size, and was carried out by government health workers rather than individuals independent of the MDA implementation.
  • In the survey from Chad and one of the surveys from Country A, it appears that a sample of the entire population was interviewed regarding ivermectin and albendazole coverage, and a sample of the school-age population was interviewed regarding mebendazole coverage. We are uncertain whether this means that school-age children in these areas were targeted in both albendazole and mebendazole distributions, were excluded from albendazole distributions, or something else.

Results

Full results are in this spreadsheet.

The coverage numbers for the distributions we are most interested in (i.e. MDAs that target school-age children) are generally middling, with median coverage around 50-70% and coverage rates varying widely from location to location. In one location in Country A, mebendazole coverage is reported at less than 1%, indicating that the distribution may not have happened. The fact that the surveys found extremely low coverage rates in one case and variable coverage overall increases our confidence in their reliability.

Have infection rates decreased in targeted populations?

A type of evidence that would increase our confidence in a deworming program is measurements of infection rates before the program starts and following one or more rounds of MDA.51 Our impression is that this type of evidence is more expensive to collect and more complex methodologically, so we've largely relied on coverage surveys (discussed in the previous section) to evaluate organizations' track records.

We have not seen this type of evidence from the END Fund and our understanding is that the END Fund has not collected this type of evidence from its grantees.

Does the END Fund cause deworming programs to start and/or scale up?

We do not have high confidence in our answer to this question. It seems plausible to us that some of the new and existing deworming programs funded by the END Fund would not otherwise receive funding.

Does the END Fund cause more funding to be spent on NTD programs than would have been spent in its absence?

In our experience funding deworming programs, the funding available for this work has not been sufficient to reach all at-risk populations with MDA. It is a major goal of the END Fund to bring funding to NTD programs that would not have been spent on NTDs in its absence. Our understanding is that many of the END Fund's funders did not fund NTD programs before funding the END Fund, but this not something we have discussed in detail with the END Fund and we are interested in understanding this better in the future. This is not a question we have focused on to date because the END Fund has told us that it would use funding it received due to GiveWell's recommendation for grant-making and technical assistance rather than for expanding fundraising efforts.52

What's the case for GiveWell directing funding to the END Fund rather than directing this funding to other top charities that work on deworming?

We have more information about and are generally more confident in Deworm the World's and SCI's track records of directly supporting deworming programs than the END Fund's track record with the programs it has supported. This is in part because we have recommended Deworm the World and SCI for longer and because the END Fund plays a less direct role for many of its programs than the other organizations do for their programs. Our recommendation of the END Fund rests primarily on the expectation that the END Fund will be able to reach populations that Deworm the World, SCI, and Sightsavers are not likely to reach. In other words, our recommendation of the END Fund expands the amount of room for more funding in deworming to which GiveWell can direct funding. It is also possible that the END Fund is able to reach populations with higher worm loads and/or at a lower cost; we have attempted to account for this in our cost-effectiveness analysis, though the estimates are rough.

Some reasons to believe that the END Fund may be able to reach populations that Deworm the World, SCI, and Sightsavers are not likely to reach are:

  • The END Fund has worked with organizations that previously had little to no involvement in the NTD sector and are now implementing deworming programs at a large scale; one of these organizations told END Fund staff that it would not have begun working on deworming if not for the END Fund's support.53
  • The END Fund keeps a flexible budget for last-minute deworming funding opportunities and has told us that it has gained a reputation for being able to move quickly to fill urgent funding gaps.54
  • The END Fund has funded programs in conflict areas. For example, the END Fund made a grant to the World Food Programme to support deworming programs serving populations in conflict areas.55

In December 2016, Good Ventures, on GiveWell's recommendation, made a grant for $5 million to the END Fund.56 Other GiveWell-directed donors also gave to the END Fund in late 2016 and early 2017, totaling about $300,000.57 In late 2017, we spoke with the END Fund about how this funding had changed what grants it made in 2017. The END Fund told us that it planned to use $4.7 million of the GiveWell-directed funding it had received in 2017. This funding was largely used to maintain the END Fund's grant portfolio, as it lost other revenue at the same time: its total grant-making in 2016 was $13.0 million and was expected to total $13.4 million in 2017.58 Of the END Fund's disbursed and planned grant-making for 2017, 75% supported projects the END Fund had supported in 2016, 14% supported new grants in Afghanistan, Central African Republic, Republic of the Congo, and DRC, and 11% supported other GiveWell top charities.59

Below we discuss two examples of the END Fund's role and what the END Fund's value added may be: one in which the case for its impact seems relatively clear to us and one in which it seems less clear.

Angola

It seems likely to us that the deworming program in six provinces in Angola would not have occurred in the absence of the END Fund. The END Fund noted that its early activities in Angola included approaching the government of Angola about an MDA program, raising funding from Dubai Cares and the Helmsley Charitable Trust to support the program, and approaching and partnering with the MENTOR Initiative to implement the program (which had no previous involvement with deworming programs).60 The END Fund also told us that it believes that the Angola program would not have occurred without its involvement,61 and that the program has not scaled to areas outside of those funded by the END Fund, due to lack of funding.62

Rwanda

Rwanda may be an example of a case in which the END Fund's value added was more limited. This program was started by Geneva Global in 2007; national prevalence and intensity mapping of STH and schistosomiasis was done in collaboration with SCI.63 Geneva Global funded four MDAs in 2008-2011.64 When the END Fund was established in 2011, it negotiated a contract with the government under which the END Fund would provide funding and SCI would provide technical support for the deworming program.65 The END Fund told us that they have been told that without their involvement there would not have been enough funding to support the program at this time because Geneva Global no longer had funding for it (its donor having switched to supporting the END Fund) and SCI was not planning to support it.66 Two MDAs were missed during the 2011 contract negotiations.67

In 2016, the END Fund concluded a further two year contract directly with the government on the basis that parties would work toward the government taking financial ownership of the program.68

Does the END Fund improve the quality of deworming programs?

There may be cases where the END Fund adds value to programs through its grant management process (including requiring periodic progress reports from implementing organizations and by providing technical guidance on implementation issues).69 Value add of this type is difficult to assess, and we do not have evidence on how the END Fund has affected the quality of programs.

Are there any negative or offsetting impacts?

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

Administering deworming drugs seems to be a relatively straightforward program.70 However, there are potential issues that could reduce the effectiveness of some treatments, such as:

  • Drug quality: For example, if drugs are not stored properly, they may lose effectiveness or expire.
  • Dosage: If the incorrect dosage is given, the drugs may not have the intended effect and/or children may experience additional side effects.
  • Replacement of government funding: We have limited information about whether governments would pay for the parts of programs paid for by the END Fund in its absence. We also have little information about what governments would use deworming funds for if they did not choose to implement deworming programs.
  • Diversion of skilled labor: Drug distribution occurs only once or twice per year and is conducted by volunteers in communities or teachers in schools. Given the limited time and skill demands of mass drug distribution, we are not highly concerned about distorted incentives for skilled professionals. Planning for the program can take senior government staff time; we are not sure what these staff would spend their time on in the absence of deworming programs, but suspect that they would support other education or health initiatives.
  • Adverse effects and unintended consequences of taking deworming drugs: Our understanding is that expected side effects are minimal and there is little reason to be concerned that drug resistance is currently a major issue (more information from our report on deworming). We are somewhat more concerned about potential side effects during integrated NTD programs, since multiple drugs are taken within a short time period, but it is our understanding that organizations follow protocols to space out the treatments to sufficiently avoid adverse effects.71
  • Popular discontent: We have heard a couple of accounts of discontent in response to mass drug administration campaigns supported by the SCI Foundation, including one case that led to riots.72 Additionally, during deworming activities supported by Evidence Action's Deworm the World Initiative in Ogun State, Nigeria in December 2017, rumors of students collapsing reportedly generated panic that led some parents to take their children out of school; the Ogun State government denied that any students collapsed.73 While the accounts we have heard are from programs supported by the SCI Foundation and Evidence Action's Deworm the World Initiative, we think it is possible that other deworming programs could cause similar discontent.

What do you get for your dollar?

This section examines the data that we have to inform our estimate of the expected cost-effectiveness of donations to the END Fund. Note that the number of lives significantly improved is a function of a number of difficult-to-estimate factors. We incorporate these into our cost-effectiveness model. In this section, we focus on the cost per treatment delivered, which is an important input in our cost-effectiveness model.

What is the cost per treatment?

We estimate that on average the total cost of a schistosomiasis and/or STH treatment delivered in END Fund-supported programs is $0.81, which includes an adjustment to account for a portion of GiveWell-directed displacing unrestricted END Fund funding from deworming into non-deworming NTD work. Excluding the cost of drugs (which are often donated) and in-kind government contributions to the programs, we estimate that the END Fund's cost per treatment is $0.46. These estimates rely on a number of uncertain assumptions. Details in this spreadsheet and discussed in following sections.

Our approach

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

To get the total cost, we attempt to include all partners (not just the END Fund), such that our cost per treatment represents everything required to deliver the treatments.74 In particular, we include these categories:

  • Two types of END Fund grants: (1) grants for schistosomiasis and/or STH MDA only; and (2) grants for MDAs for both schistosomiasis/STH and other NTDs. For the latter, we multiply the total by the percentage of total treatments delivered under the grant that were schistosomiasis or STH treatments.75
  • A proportional allocation of the END Fund's operating costs.
  • Assumed value of donated drugs.
  • A rough estimate of costs incurred by the governments implementing the programs (e.g., for staff salaries when working on the MDA).

We start with this total cost figure and apply adjustments in our cost-effectiveness analysis to account for (a) fungibility with funds the END Fund spends on programs for NTDs other than deworming (see below), and (b) cases where we believe the charity's funds have caused other actors to shift funds from a less cost-effective use to a more cost-effective use ("leverage") or from a more cost-effective use to a less cost-effective use ("funging").

Shortcomings of our analysis

Some reasons to interpret our estimates with caution include:

  • We are interested in estimating the cost of delivering a schistosomiasis/STH treatment when giving to the END Fund and specifying that the funding should be used to support these NTDs in particular. This estimate is complicated by fungibility between schistosomiasis/STH and other NTDs (see next section) and by the fact that, for many END Fund-supported programs, the END Fund's grant supports treatment for both schistosomiasis/STH and other NTDs. The approach we have taken is to, in our analysis, (a) only include the costs of grant-making that supported, at least in part, MDA for schistosomiasis/STH; (b) for grants that include both schistosomiasis/STH and other NTDs, take the amount of the grant multiplied by the proportion of total NTD treatments delivered in that program that were for schistosomiasis/STH; and (c) adjust by the proportion of GiveWell-directed funds that we believe, in effect, supported schistosomiasis/STH (see below). This approach relies on the assumption that it costs the same amount to deliver each type of NTD treatment and that the treatment numbers the END Fund has provided are accurate.
  • For many END Fund-supported programs, the END Fund is not the only donor to the program. We have asked the END Fund for information on what other donors and governments have contributed to the programs it has supported. The END Fund has noted uncertainty about this data in several cases and a number of cases where data on contributions may be missing.76 We have excluded two grants where we lacked information on spending by others and where we expected spending by others to be a major part of the total cost.77 We have also compared the average financial cost in END Fund-supported programs to that of SCI- and Deworm the World-supported programs; this comparison led us to believe that we were likely missing some costs and we have made an adjustment to our estimate of the END Fund's cost per treatment to account for this.78
  • We do not have any direct information on the value of government staff or volunteer time used in END Fund-supported programs; the approach we have taken to roughly estimate government contributions for END Fund programs (as well as for SCI-, Sightsavers-, and some Deworm the World-funded programs) is to base the estimate on a single study from an SCI-funded program that is now several years old.79
  • We only have information on the direct program costs (i.e. grants to governments) paid by other donors. We do not have estimates of most of these other donors' other costs (e.g. central costs and technical assistance). As an approximation, we inflate other donors' contributions to programs by the proportion of total spending that SCI and Deworm the World spend on other costs.

Fungibility

We first recommended funding to the END Fund in late 2016. We wrote at the time:

Because the END Fund will likely have a pool of unrestricted funds to reallocate across NTDs, we would guess that a dollar to the END Fund for deworming will not result in an increase in deworming funding by a full dollar; that some of that dollar will support other NTD programs. We have not yet fully evaluated these other NTD programs, but our initial read of the evidence is that they are likely less cost-effective than deworming.

In 2017, the END Fund spent about $4.7 million in GiveWell-directed funds in the form of grants to other organizations. Our best guess is that, of this $4.7 million, 83% funded MDA for schistosomiasis and STH, while the rest displaced unrestricted END Fund funding from deworming into grants for other diseases: lymphatic filariasis, onchocerciasis, and trachoma.80

Prior to 2019, the END Fund's allocation of funding between deworming and other NTDs did not seem to be driven by donor restrictions; only a small portion of funding received in 2016 and 2017 was restricted to use on other NTDs.81 In 2019, the END Fund told us that its funding situation had changed and that unrestricted funding comprised a smaller proportion of its funding. The majority of restricted funding raised in 2017 and 2018 was generally not available for deworming and, as a result, the END Fund expected to use all available unrestricted funding for grants that included deworming. (The majority of the END Fund's operating costs are funded by a restricted grant for that purpose.)82

Is there room for more funding?

We conduct "room for more funding" analysis to understand what portion of the END Fund's ideal future budget it will be unable to support with the funding it has or should expect to have available. We may then choose to either make or recommend grants to support those unfunded activities.

Room for more funding analysis

In general, we assess top charities' funding needs over a three-year period.83 We ask top charities to report their ideal budgets over the next three years, along with information about their current available funding and funding pipeline. The difference between a charity's three-year budget and the funding we project that it will have available to support that budget is the charity's "room for more funding."

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


Source URL: https://www.givewell.org/charities/end-fund