Affinity Impact, a social impact initiative founded by the children of a Taiwanese entrepreneur, approached GiveWell in late 2018 with an interest in providing support to excellent charities that work in southeast Asia and Bangladesh. As our top and standout charities primarily operate in sub-Saharan Africa, we agreed to run a grantmaking process to see whether we could solicit applications from promising opportunities in Affinity Impact's geographic area of interest. We considered this a learning opportunity for GiveWell, as a potential new way to engage with donors and to see whether we might have missed promising organizations operating in this region.
In February 2019, we opened up an application process for charities operating programs in global health and development in Bangladesh, Cambodia, East Timor, Indonesia, Laos, Myanmar, Philippines, and Vietnam. We planned to select one organization to receive a $250,000 grant and two finalist organizations to each receive a grant of $25,000. We received 49 applications by the April 1 deadline.
We assessed applicant organizations according to our criteria for potential top charities, adjusted for the constraints of this process. We looked at their evidence of effectiveness, cost-effectiveness, transparency, and ability to use additional funding effectively. Given our limited timeframe for assessing the large group of charity applicants, we were not able to review each at the level of depth we would a typical potential top charity (we generally spend hundreds of hours assessing each top charity before we recommend it, and do so on a rolling basis—without deadline pressure).
We completed our initial assessments of the applicants by April 30, and moved forward with ten finalist organizations that would be informed of their grant status by July 3.
After reviewing this group in greater depth, we selected IPEN, an organization that funds campaigns to regulate the maximum amount of lead in paint, as the recipient of the $250,000 grant. We awarded the $25,000 grants to VisionSpring, which supports programs providing vision screening and eyeglasses at a subsidized cost in Bangladesh, and Vitamin Angels, which supports programs providing vitamin A supplements and deworming treatments to preschool-aged children and multiple micronutrient supplements to pregnant women. Vitamin Angels plans to use additional funding in Indonesia, the Philippines, and Vietnam.
Published: January 2020
Table of Contents
- What were our goals?
- Grant recipients
- Finalists that did not receive grants
What were our goals?
We outlined our goals for the grantmaking process in February:
- "Enable Affinity Impact to support an evidence-backed, cost-effective charity in an area of geographic interest.
- "Help GiveWell better understand the giving opportunities in a geography in which we haven't previously focused, and to learn from the grantmaking process whether doing so is an effective way to engage with philanthropists who don't plan to support our current top charities.
- "We last ran a similar grantmaking process in 2009, and are interested in revisiting this as a potential future outreach strategy for GiveWell.
- "Drive more donations to GiveWell's top charities by increasing donors' confidence in GiveWell's work and illustrating the importance of an evidence-backed approach to giving."
We announced the application process in a blog post published on February 13. We accepted applications until April 1.
We received 49 applications in total. We were impressed by the quality of the applications we received.
One GiveWell research analyst conducted an initial screen of each applicant. She performed a quick review, looking for the following key pieces of information:
- What program is the organization implementing? Is it a program we've reviewed before? If not, does it seem plausibly cost-effective, based on our experience, intuitions, and the information provided (such as the cost per treatment)? This approach to cost-effectiveness was very rough, relative to the next round of review (and both approaches were rough relative to our completed top charity reviews).
- What is the organization? Have we done work in the past that informs how promising they might be?
- What information does the application include? For example, does it include evidence of the organization's track record, information on how it monitors and self-evaluates, and the specifics of what it would do with additional funding?
The reviewer applied a numerical score to each charity based on the answers to the above questions. Two other staff members then reviewed organizations that were filtered out (based on their lower scores) through this process to confirm their agreement. This process winnowed the application pool from 49 to 28 organizations that seemed most promising.
The two staff members conducted a deeper assessment of the 28 most promising organizations, focusing on:
- Evidence of effectiveness
- Estimated cost-effectiveness
- The organization's funding proposal (ability to use $250,000 grant)
- Potential for additional upside (e.g. leverage). This is a qualitative factor that we would also typically consider in our top charity reviews.
These staff discussed their findings with each other and shared them with the full GiveWell research team to solicit feedback. They applied numerical ratings to each organization based on those criteria and selected ten finalists based on those scores.
We informed the applicants on April 30 of their status as either a) finalists moving on to the next round of review or b) no longer moving forward.
We sought phone calls with each of the finalists to answer our open questions from round one. We primarily focused on getting better information about key inputs into our cost-effectiveness estimates, such as the charities' programmatic models and the likely counterfactual impact of their efforts. We asked organizations for additional documentation to support their answers and used the information we learned on the calls and the documents we received to update our cost-effectiveness estimates and views of their work.
The two researchers leading our investigation in the second round presented their tentative conclusions to the GiveWell research team for feedback and to Affinity Impact for its input. We informed the grant recipients and finalists of our conclusions on July 2.
We selected IPEN to receive the $250,000 grant. Among other activities, IPEN funds campaigns aimed at reducing lead exposure by regulating the maximum allowed amount of lead in paint; the overall goal is to eliminate the production, sale, and use of lead paint. IPEN works with partner organizations in pursuit of these goals.1 It primarily plans to use grant funding to support campaigns in Indonesia and Vietnam.2
GiveWell has recently begun to expand our scope to include research into policy interventions, which we think have the potential to be very cost-effective. Lead paint regulation is in the broad category of policy intervention that we see as promising and are interested in learning more about.3 In addition, work to reduce or eliminate lead paint appears to receive few philanthropic dollars relative to our best guess of its burden. We estimate that roughly $3 million is spent on lead paint regulation advocacy each year.4
The case for lead paint regulation appears to center on its potential positive impact on IQ and earnings.5 We don't have a strong view on the true size of the effect of lead exposure on IQ and earnings, or how much lead paint contributes to exposure, but we think the qualitative case is fairly strong. The existing evidence is weak but consistent with the hypothesis that lead paint affects blood lead levels. Our impression is that there's a consensus that lead is a highly toxic metal and that exposure can have harmful effects on health, including on brain development.6 The World Health Organization has called for the elimination of lead paint (citing a number of harmful health effects), and it is banned in the United States and European Union.7
Preventing the manufacture of lead paint would reduce lead exposure for workers as well as consumers. IPEN told us that paint sales have risen in Asia, increasing the possibility that more workers and consumers are exposed to lead in paint, and that paint sales are projected to increase further with increased growth in these regions. IPEN plans to focus on preventative efforts to ensure that the expanding paint market does not include lead paint.8
IPEN appears to be the primary giving opportunity focused on lead paint regulation. We see suggestive evidence that IPEN has a strong track record of funding as well as supporting with technical, policy and communication expertise Participating Organizations (POs, i.e. IPEN members) that cause lead paint to be banned. It appears that countries in which IPEN POs work were substantially more likely to pass lead regulation than countries in which IPEN did not fund POs.9 This is consistent with IPEN POs making policy change more likely, although we are highly uncertain about the magnitude of the effect (for example, we think it is likely that IPEN chooses to fund partner organizations in countries that would be more likely to change policy in any case).
While we consider this a highly promising grant opportunity and are excited to follow IPEN's progress, we do have open questions and uncertainty about its work. For example, we're not sure how well lead paint regulation is enforced after it is passed. IPEN told us that it works with paint manufacturers to facilitate voluntary shifts away from lead paint production10 and promote independent, third-party certification that the produced paints are "lead-safe."11 In addition, IPEN told us that—where funding is available—it supports follow-ups such as analytical paint studies to see if paint contains lead after regulations are passed. However, IPEN told us that it does not have this information for every country due to limited financial resources and we haven't reviewed the results it does have in detail.12 We're also unsure how much weight to place on the quantitative evidence for the effect of lead paint on IQ. We discounted our cost-effectiveness estimates for the program to account for our uncertainty.13
We had a very high degree of uncertainty about our cost-effectiveness estimates for this program; while it looked promising, we wouldn't have been comfortable recommending the grant without a strong qualitative case. We feel that there was such a case.
We recommended a $25,000 grant to VisionSpring to support its work to expand programs providing vision screenings and subsidized reading glasses or prescription eyeglasses in Bangladesh.14 We are interested in this program because of the potential for individuals with corrected vision to earn higher incomes.15
We roughly estimate that additional funding for VisionSpring's programs in Bangladesh is 5x as cost-effective as cash transfers, the intervention to which we typically compare programs.16 We spent significantly less time making this cost-effectiveness estimate than we would on a typical top charity cost-effectiveness estimate, due to the time constraints of the grantmaking process. This estimate is based on the results of a randomized controlled trial (RCT) of providing eyeglasses to tea pickers in Assam, India. We discount the results from that trial to capture our uncertainty about how well they generalize to the populations that VisionSpring would target in Bangladesh with additional funding (mostly garment factory workers).17
VisionSpring's data indicate that a large proportion of its program beneficiaries are first-time glasses-wearers,18 but we have limited information on how long glasses last or whether recipients wear them regularly. We're highly uncertain about whether the discounts we applied to the tea pickers RCT are reasonable (especially our estimation of the proportion of gains in productivity that translate to increased income for workers) and our estimate that glasses last for two years on average.
This program stood out for its potential cost-effectiveness, relative to other applicants.
Vitamin Angels ($25,000)
We recommended a $25,000 grant to Vitamin Angels, which supports programs providing vitamin A supplements and deworming treatments to preschool-aged children and multiple micronutrient supplements to pregnant women.19 Vitamin Angels works in 70 countries across the world. It noted in its application that its highest-priority countries within the geographical constraints of this grantmaking process were Indonesia, the Philippines, and Vietnam.20
We think that vitamin A supplementation (VAS) may be one of the most cost-effective ways to save lives when the program is high quality and delivered in locations with high child mortality rates. We currently recommend one top charity, Helen Keller International (HKI), for its VAS program. Of the three programs Vitamin Angels applied for, we were particularly interested in its work on VAS.
Given the geographical parameters set by the grantmaking process, Vitamin Angels proposed to focus on providing VAS to hard-to-reach populations in Indonesia and the Philippines.21 We used national child mortality rates in Indonesia and the Philippines to estimate the cost-effectiveness of Vitamin Angels' proposed work in those countries, though we are unsure how these national rates compare to those of the hard-to-reach populations Vitamin Angels targets. The national child mortality rates in Indonesia and the Philippines are lower than the mortality rates in the countries in Africa in which HKI and Vitamin Angels work.22 We thus estimate that Vitamin Angels' work on VAS in Indonesia and the Philippines is less cost-effective than that of VAS programs in Africa.
Vitamin Angels also proposed to spend grant funding in support of deworming and multiple micronutrient supplementation programs. We have conducted a very shallow review of the evidence base for multiple micronutrient supplementation for pregnant women and consider it promising.23 We have done significantly more research on the impact of deworming programs. Taking these three programs into account, we roughly estimated that additional funding for Vitamin Angels in Indonesia, the Philippines, and Vietnam is 2x as cost-effective as cash transfers.24
Vitamin Angels stood out for the VAS program it is implementing. Because we recommend a top charity that focuses on vitamin A supplementation, we have a good sense of the way its VAS program could be having an impact, relative to other applicant organizations.
Finalists that did not receive grants
In every case, we had to make judgment calls based on limited information and with limited time to make our assessment. We did not review these groups with the same intensity as our top charities.
We indicate our open questions on the finalists below. They should not be taken as evidence that a charity's program is ineffective—but rather that we were unable to resolve our questions in the time allotted or had to make our best guess based on limited information.
We are not planning to make public information about the organizations that applied and were not made finalists, as indicated in the call for applications.
We consider tuberculosis (TB) case finding and treatment a promising program,25 though our assessment is out of date and not up to GiveWell's current standards. We would want to know whether a charity that works on this program is reducing TB mortality and morbidity.
We think that TB is a particularly complicated area due to our understanding that a significant amount of existing funding supports government-run TB programs and many individuals access treatment via private sector clinics. With the information we had, we were unable to arrive at a credible estimate for the extent to which these organizations' activities reduce mortality or morbidity.
- Operation ASHA applied for funding to support the expansion of its tuberculosis detection and treatment monitoring program in Cambodia.26
- Friends for International TB Relief (FIT) applied for funding to support active case finding campaigns, treatment for TB, and treatment for latent TB infection (LTBI) on islands off the coast of Vietnam.27
We have completed reviews of cataract surgery and fistula surgery and consider both to be promising programs. A key question we have for charities that work on surgery programs is the extent to which they cause additional surgeries to happen that would not have otherwise occurred.28 This is a particularly important question because a typical constraint faced by charities that support surgery programs is the surgeons' available time. If surgeons are at capacity, increasing one type of surgery may mean decreasing their availability to perform another—a counterfactual we'd want to understand.
- Sightsavers applied for funding to support cataract surgery programs in Bangladesh.
- EngenderHealth applied for funding to support three activities in Bangladesh related to fistula care and reproductive health services.
Sightsavers proposed to use the grant funding to support its work to train community health workers to conduct cataract screenings, train surgeons and other hospital staff on conducting cataract surgery, pay for part of the costs of cataract surgeons' salaries, and purchase supplies for cataract surgery in Bangladesh.29
EngenderHealth requested funding for running a workshop on reproductive health services, expanding a fistula education program for adolescent girls, and for community-based fistula and prolapse diagnosis events at a Rohingya refugee camp in Cox's Bazar, Bangladesh.30
With the information we had, we were unable to arrive at credible estimates for the extent to which Sightsavers' or EngenderHealth's activities cause more high-quality surgeries.
Other charities (MiracleFeet, PATH, and AIP Foundation)
MiracleFeet applied for funding to scale up its work to increase access and adherence to a method for treating clubfoot by providing support to partners in four countries in the relevant region: Bangladesh, Myanmar, the Philippines, and Cambodia. MiracleFeet's proposed activities included awareness campaigns, training healthcare providers, and purchasing treatment supplies.31
Similar to organizations working to increase the number of surgeries performed, our key questions about MiracleFeet's program were whether MiracleFeet's intervention increased the number and/or quality of clubfoot treatments that occurred relative to what would have happened in the absence of its support. We have limited information on these questions and, based on the information we had, we estimated that the cost-effectiveness of the grantees we selected would be higher. We thus decided not to select this application for a grant.
PATH applied for funding to support its Ultra Rice® program in Myanmar.
Ultra Rice® is rice fortified with micronutrients.32 PATH proposed to undertake three additional activities with the grant funding: (1) "demand generation" for Ultra Rice® through social safety net programs; (2) improving a school nutrition program in one township in Myanmar; and (3) conducting a systematic review of the evidence for rice fortification.33
Activities (2) and (3) seemed to us unlikely to lead to short-term increases in consumption of Ultra Rice® and we did not have sufficient time in this project to investigate potential longer-term impact. For activity (1), we created a very rough cost-effectiveness model, which suggested that the grants we chose would be more cost-effective than funding PATH's application in this case.
Given our limited time to assess grant opportunities under this framework and the harder-to-assess impact of the activities proposed, we decided not to select this application for a grant.
AIP Foundation applied for funding for its program in Vietnam to deliver helmets to school-aged children (grades 2-5) and to train teachers to educate children on the benefits of helmet use.34
Our back-of-the-envelope cost-effectiveness estimate suggested that its work was unlikely to be competitive with the cost-effectiveness of our current top charities. We deprioritized additional research as a result.
Did we achieve our goals?
Reflecting on the goals listed above:
- Enable Affinity Impact to support an evidence-backed, cost-effective charity in an area of geographic interest. We believe we achieved this goal. We consider IPEN a potentially cost-effective funding opportunity that operates in the relevant geography.
- Help GiveWell better understand the giving opportunities in a geography in which we haven't previously focused, and to learn from the grantmaking process whether doing so is an effective way to engage with philanthropists who don't plan to support our current top charities. We were impressed by the quality of applicants for the grant, and believe we have a clearer sense of opportunities in Southeast Asia and Bangladesh. We believe this was an effective way to engage with Affinity Impact; we are unsure whether other funders would be interested in similar processes.
- Drive more donations to GiveWell's top charities by increasing donors' confidence in GiveWell's work and illustrating the importance of an evidence-backed approach to giving. It's too soon to say. We wouldn't expect donations to our top charities to result from this grantmaking process in the short term. We will continue monitoring this going forward.
We think that this grantmaking process was a useful way to learn about organizations working in Southeast Asia and Bangladesh as well as to consider whether running a grant application process is something we should do in the future to identify new opportunities and to work with donors who have constraints on their giving.
"IPEN has been campaigning to ban lead paint since 2007. In 2010, in response to an IPEN initiative, the World Health Organization and the United Nations Environment Programme established a global partnership to eliminate lead paint. Within this partnership, IPEN is the leading representative of global civil society. IPEN and its national NGO partners have developed a proven methodology to create market pressure on paint companies and achieve strong national regulatory controls on the lead content of paints." IPEN lead paint case statement
"IPEN POs [Participating Organizations] in Indonesia and Vietnam already have ongoing campaigns but available funding is decidedly insufficient to reach the goal of eliminating lead paint. IPEN would therefore like to use the main portion of the funding to support these activities, with the aim of having regulations on all uses of lead paint (including for children's products) adopted within the next two- three years." Sara Brosché, IPEN, Global Lead Paint Elimination Campaign Manager and IPEN Science Advisor, email to GiveWell, April 1, 2019
"We expect this expansion of our work to take us in a number of new directions, some of which we have begun to explore over the past few years. We have considered, in a few cases, the impact our top and standout charities have through providing technical assistance (for example, Deworm the World and Project Healthy Children), supported work to change government policies through our Incubation Grants program (for example, grants to the Centre for Pesticide Suicide Prevention and Innovation in Government Initiative, and begun to explore areas like tobacco policy and lead paint elimination." GiveWell blog, "How GiveWell's research is evolving," February 7, 2019
"My best guess is $3 million is spent on advocacy for lead paint elimination each year." GiveWell excerpt from unpublished document on public health regulation
See, for example Attina and Trasande 2013, an attempt to estimate the economic cost of chronic lead exposure. Note that we have not completed a full review of the evidence underlying that estimate and would guess it is more likely to overstate the impact than understate it.
"Lead exposure can have serious consequences for the health of children. At high levels of exposure, lead attacks the brain and central nervous system to cause coma, convulsions and even death. Children who survive severe lead poisoning may be left with mental retardation and behavioural disorders. At lower levels of exposure that cause no obvious symptoms, and that previously were considered safe, lead is now known to produce a spectrum of injury across multiple body systems. In particular lead can affect children’s brain development resulting in reduced intelligence quotient (IQ), behavioural changes such as reduced attention span and increased antisocial behaviour, and reduced educational attainment. Lead exposure also causes anaemia, hypertension, renal impairment, immunotoxicity and toxicity to the reproductive organs. The neurological and behavioural effects of lead are believed to be irreversible." World Health Organization, Lead poisoning and health
- "Reducing the adverse health effects from lead paint necessitates controlling exposures. National controls on the manufacture, import, sale, use, and export of lead paints are far more cost-effective in reducing exposure risks than any future remediation programmes to remove lead paint and contaminated dust and soil. Legislation and/or regulation is needed to stop the use of lead paint and to protect human health and the environment. Even when restrictions are put in place there will remain a legacy of lead-painted homes and structures. Thus the sooner action is taken to restrict lead paint the better." World Health Organization, The need to eliminate lead paint
- World Health Organization, Member states with legally-binding controls on lead paint, as of September 2018
- “IPEN’s lead paint work targets developing nations where lead paint has only recently begun to spread. Therefore, IPEN’s work focuses on establishing national regulations that will prevent the lead paint markets in these countries from growing. It is reasonable to assume that [blood lead levels] in these nations would rise in the next two decades if national 5 regulations are not established, although it is difficult to know by how much.” GiveWell's non-verbatim summary of a conversation with Bjorn Beeler and Sara Brosché, October 23, 2017
- ”Childhood lead exposure already incur significant costs to a country. In the grant countries, this cost is estimated to 3-6% of their GDP, or more than a total of 80 billion USD. As one of the most widespread sources of lead exposure and with a rapidly growing paint market in Asia, lead paint contribute to a significant amount of that cost and the cost is likely to increase if not prevented.” Sara Brosché, IPEN, Global Lead Paint Elimination Campaign Manager and IPEN Science Advisor, email to GiveWell, April 1, 2019
Sheet “GiveWell data analysis,” cells B3-C4, IPEN lead paint regulations after 1990, all countries.
“IPEN's partners engage directly with industry stakeholders, providing technical support and ensuring that industry is involved in the process for developing national regulation. IPEN has found that some paint manufacturers, after understanding the harmful nature of lead paint, begin independently reformulating their products.” GiveWell's non-verbatim summary of a conversation with Bjorn Beeler and Dr. Sara Brosché, May 19, 2019, Pg. 3
“Paint producers around the world often seek third-party verification for lead-free paints in order to ensure customer trust. In 2015, upon realizing that no third-party service was available, IPEN worked with the Philippine Association of Paint Manufacturers to develop the Lead Safe Paint® certification…Paint producers in Sri Lanka and Bangladesh also currently utilize the Lead Safe Paint® certification, and producers in Mexico have expressed strong interest.” GiveWell's non-verbatim summary of a conversation with Bjorn Beeler and Dr. Sara Brosché, May 19, 2019, Pgs. 3-4
"IPEN has been unable to consistently conduct follow-up studies to evaluate the effects of its national-level campaigns for lead paint regulation, except in a select few projects that received sufficient funding. Follow-up studies typically cost IPEN approximately $5,000, and when it has limited resources, it prioritizes the allocation of available funding to campaign activities—specifically in countries where no action on lead paint has yet been taken. Ideally, IPEN would like to always conduct studies of lead paint both before and after regulations have been passed." GiveWell's non-verbatim summary of a conversation with Bjorn Beeler and Dr. Sara Brosché, May 19, 2019, Pg. 3.
GiveWell back-of-the-envelope calculation, cost-effectiveness of IPEN
- "Aligned with Affinity Impact’s priority to support organizations in Southeast Asia and Bangladesh with global health and development programs, VisionSpring would respectfully apply a grant of $250k to help fill the funding requirement for the RGIL [Reading Glasses for Improved Livelihoods] program in Bangladesh." Aminah Yoba, VisionSpring, Development Officer, email to GiveWell, April 1, 2019
- "Although consumers pay for glasses distributed through the RGIL program, the cost is philanthropically subsidized." GiveWell's non-verbatim summary of a conversation with Ella Gudwin, Aminah Yoba, Khanindra Kalita, and Kristen Shaw, May 17, 2019, Pg. 4.
- We believe that funding RGIL enables VisionSpring to direct unrestricted funding toward other programs focused on the workplace and pharmacies. See Option 1, VisionSpring, 250k unrestricted funds impact.
- Descriptions of the RGIL, pharmacy, and workplace programs from GiveWell's non-verbatim summary of a conversation with Ella Gudwin, Aminah Yoba, Khanindra Kalita, and Kristen Shaw, May 17, 2019:
- "VisionSpring developed its Reading Glasses for Improved Livelihoods (RGIL) program in collaboration with BRAC, a Bangladeshi NGO which operates one of the largest community health worker (CHW) networks in the world (approximately 60,000 CHWs). Through the RGIL program, BRAC CHWs—who sell a wide variety of health products and act as community educators—are trained to conduct basic vision screenings and sell reading glasses if appropriate." Pg. 1.
- "Approximately 200,000 rural medical providers (typically family businesses without pharmacy training) operate in Bangladesh, although these pharmacies are fragmented and not an official component of the health system. Rural medical providers typically sell general health products such as toothbrushes, as well as a variety of medicines. While most do not have medical certifications, they are often the first place community members turn to for care. VisionSpring aims to increase its market penetration in Bangladesh by distributing eyeglasses through rural medical providers, a project which has never before been attempted in the country. The same training, product, marketing materials, and other core components of the RGIL program are being applied to VisionSpring's pharmacy program, although the specific costs and prices as well as the management structure are different." Pg. 5.
- "VisionSpring is beginning to expand vision services to workplaces, primarily garment factories, through its Clear Vision Workplaces (CVW) program. In addition to using the RGIL training to enable workers to identify peers in need of vision correction and dispense reading glasses, the CVW program includes the employment of optometrists to provide prescription glasses to workers." Pg. 6.
"Those suffering from visual impairment may experience a loss of productivity at work, which may, in turn, affect their incomes and employment opportunities. These economic effects are likely to be especially pronounced for individuals who rely on their manual dexterity (fine motor control) and/or visual discrimination for their work." GiveWell report on eyeglasses to improve workers' manual dexterity.
- VisionSpring indicated that if it received a $250,000 grant, it would spend around an additional $174,000 on its workplace screening program. VisionSpring, 250k unrestricted funds impact, Option 1.
- "VisionSpring is beginning to expand vision services to workplaces, primarily garment factories, through its Clear Vision Workplaces (CVW) program. In addition to using the RGIL training to enable workers to identify peers in need of vision correction and dispense reading glasses, the CVW program includes the employment of optometrists to provide prescription glasses to workers." GiveWell's non-verbatim summary of a conversation with Ella Gudwin, Aminah Yoba, Khanindra Kalita, and Kristen Shaw, May 17, 2019, Pg. 6.
"Community health workers effectively mobilize the right people to attend the vision camps such that the majority of participants (64%) present with presbyopia and could benefit from reading glasses. Routine program monitoring and a 2017 representative demographic survey reveal that of people acquiring reading glasses through RGIL [Reading Glasses for Improved Livelihoods Program]:
- 69% live on less than $2.50 per day (defined according to the Bangladesh Progress out of Poverty Index).
- 75% are purchasing their first-ever pair of glasses
- 74% are in their prime working years (between ages 35 to 54 years old)
- 63% are women"
“Vitamin Angels provides evidence-based nutrition interventions during critical periods of children’s growth and development, and specifically targets pregnant women, new mothers, and children under the age of five. Its three primary interventions are:
- Vitamin A supplementation (VAS) for children under five
- Deworming for children under five
- Multiple micronutrient supplements for pregnant women”
"In 2018, Vitamin Angels reached over 70 million children under five and pregnant women in 70 countries through a network of over 1,600 field partners. VA operates programs in all 8 countries listed in Affinity Impact’s portfolio of interest (Bangladesh, Cambodia, East Timor, Indonesia, Laos, Myanmar, Philippines, Vietnam). In 2018, VA’s programs served approximately 11.6 million beneficiaries through 76 field partners in 7 of these countries. Within these countries, VA’s largest programs and opportunities for growth are in Indonesia, Philippines, and Vietnam." Kristen Hurley, Vitamin Angels, Director of Programs, email to GiveWell, April 1, 2019
- "Vitamin Angels (VA) is a 501(c)(3), US-based non-profit organization, focused on the global public health problem of undernutrition. Our mission is to help at-risk populations in need – specifically pregnant women, new mothers, and children under five – gain access to life-changing vitamins and minerals. To achieve this mission, VA provides annual grants of vitamin A supplements (VAS) and albendazole (a deworming agent) for children ages 6-59 months, and multiple micronutrient supplements (MMS) for pregnant women to qualified field partners. These field partners have an intimate understanding of the communities they serve and target hard-to-reach women and children. Hard-to-reach is defined as individuals not reached or underserved by national health services, thereby representing a critical coverage gap among vulnerable populations in need of essential nutrition interventions." Kristen Hurley, Vitamin Angels, Director of Programs, email to GiveWell, April 1, 2019
"Vitamin Angels targets hard-to-reach populations – those that are not already receiving evidence-based nutrition interventions from national healthcare services or other organizations. Though coverage varies by country, on average governments are able to reach ~70% of their population with health services; the remaining ~30% is Vitamin Angels’ target population.
"This 30% of the population may not be reached for a variety of reasons including living in geographically isolated areas, having access to healthcare services with limited or no supplies, or being part of a migrant population." GiveWell's non-verbatim summary of a conversation with Dr. Kristen Hurley, Amy Steets, and Jamie Frederick, January 8, 2019, Pgs. 1-2.
- Vitamin Angels SEA RFP application materials, Q4.1. Program Opportunity & Financials (unpublished)
- We estimate an average mortality rate of 12.9 deaths per 1,000 child-years for children 6 months to 59 months in the countries in Africa where HKI supports vitamin A supplementation programs. See sheet “Weighted Averages,” cell B1, GiveWell HKI VAS - information for country-level cost-effectiveness analyses.
- We estimate a national mortality rate of 2.3 deaths per 1,000 child-years for children 6 months to 59 months in Indonesia and the Philippines. See sheet “Weighted Averages,” cell B1, GiveWell country-level cost-effectiveness analysis of Vitamin Angels.
"The included trials compared pregnant women who supplemented their diets with multiple micronutrients (including iron and folic acid) with pregnant women who received iron (with or without folic acid) or a placebo. Overall, we found that pregnant women who received multiple‐micronutrient supplementation had fewer babies that were born too small (weighing less than 2500 g), fewer babies who were smaller in size than normal for their gestational age, and fewer births that occurred before week 37 of pregnancy. The evidence for the main outcomes of low birthweight and small‐for‐gestational age was found to be of high quality and moderate quality, respectively." Keats et al. 2019 (Keats et al. 2019 is a Cochrane systematic review of multiple-micronutrient supplementation for women during pregnancy.)
"When strictly followed, the treatment regimen cures TB and prevents death. DOTS has been a documented, large-scale success in two countries, detailed below." GiveWell report on tuberculosis case finding and treatment ("DOTS" approach), 2009
"How shall we use $250,000:
"Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed. Accelerating TB detection is an urgent need in Cambodia which has a very high prevalence of TB, that is 630 patients per 100,000 population. But the incidence (detection of new cases) is only 326 per 100,000. There is a huge detection gap; the number of unreached patients across the country is 58,862. They continue to suffer and die, and each untreated patients infects 12 -15 others annually, resulting in spread of contagion. Improving detection in Cambodia is therefore an immediate need.
"We shall use $245,531 to detect every missing patient in a population of 420,000 people. We shall hire and train 14 CHWs [Community Health Workers], 1 Team Supervisor, and 1 Technology Officer. CHWs will find all missing cases in the area work (which will be 1397 TB patients) over 3 years so nobody will be left to infect others.
"CHWs will carry out the following activities; raising awareness, preventing stigma, finding people with symptoms of TB using the eDetection app loaded on low cost tablets, and finally carrying sputum samples from symptomatics to the government labs for TB testing. CHWs will be responsible for collecting the test reports and visiting new patients. They facilitate the check-up of new patients by specialist doctors in the government facility, thus providing the vital link with existing public infrastructure. They will carry out intensive counselling of patients and their families to cover all aspects of TB treatment, including the need for adherence, how to prevent infection to others, and how to prevent drug resistance. They will inform patients about the side effects of TB medicines well before starting treatment, and how to minimise these adverse effects. They will address issues of stigma, discrimination and myths. They will link every diagnosed patients to the National TB control program for further management. We shall carry our monitoring and evaluation activities and a regular basis, and do a data analysis including cost benefit analysis at the end of the project." Dr. Shelly Batra, President, Operation Asha, email to GiveWell, March 30, 2019
"In January 2019, FIT and the Vietnamese government collaborated on a TB case finding campaign on Cu Lao Cham, a small island off the coast of central Vietnam. The campaign targeted the island's entire population with mass screening for TB and latent TB infection (LTBI). (LTBI is defined as the presence of TB bacteria without any clinical signs of TB disease.)
"FIT notes that it works on TB case finding campaigns on islands in Vietnam because of high TB prevalence among island populations and because of the possibility of achieving TB elimination among relatively isolated populations. With additional funding, FIT could expand its case finding work to additional islands." GiveWell's non-verbatim summary of a conversation with Luan Vo, Andrew Codlin, and Rachel Forse, May 8, 2019, Pg. 1.
- "If FIT receives the larger $250,000 grant, it would likely plan to:
- Run a program on Cat Ba, an island in the north of the country with a population of about 16,000. FIT could cover the entire island.
- Revisit the island of the January campaign [Cu Lao Cham] to get an understanding of the medium- to long-term impact of its program on TB prevalence.
- Synthesize its results and attempt to publish them in international journals."
- For additional details on the FIT campaign in Cu Lao Cham, including treatment, see GiveWell's non-verbatim summary of a conversation with Luan Vo, Andrew Codlin, and Rachel Forse, May 8, 2019.
"Before recommending a charity that funds local surgeons, we would require a compelling answer to the question of how more funds will translate to more surgeries - for example, credible data on surgeons eligible for funding but not receiving it because of limited available funds." GiveWell report on developing-world corrective surgery
"If it received an additional $250,000 through the 2019 GiveWell Grants for Global Health and Development in Southeast Asia and Bangladesh, Sightsavers would allocate approximately 95% of the funding to supporting additional cataract surgeries and 5% of the funding to supporting a school-based vision impairment screening.
"Additional cataract surgeries
"Funding for Sightsavers' District Eye Care Program ceases at the end of 2019, and it does not expect to receive additional funding for this work from any other donors. Additional funding from GiveWell would enable Sightsavers to continue its current operations, improving coverage of cataract surgery within the eight districts where it already works.
"Two of the leading causes of vision impairment are refractive error and cataracts. Sightsavers formerly operated a child blindness program that included school-based screenings to identify children with refractive errors, cataracts, or other eye health issues—followed by the provision of corrective glasses if necessary. The child blindness program ended in 2018, but Sightsavers still supports school-aged children through the district eye care program.
"Sightsavers would use additional funding from GiveWell to conduct vision screenings for children in one school as well as for adults in the same district. Upon identification of refractive error, Sightsavers would provide patients with the appropriate glasses. Children with other eye health problems such as cataracts would also be identified and treated."
- "Sightsavers' District Eye Care Program supports cataract surgeries through hospital partners across eight districts in Bangladesh. Sightsavers' core responsibilities for the program include:
- "District selection – Districts are targeted based on parameters including prevalence of blindness, cataract surgery coverage, and poverty rate. Only three hospital partners operate across the eight targeted districts, which have a total backlog of 58,000 cataract surgeries. Data on cataract surgeries is typically collected from hospital partners or through past government surveys, although Sightsavers also sometimes conducts surveys.
- "Program planning and needs assessments – Sightsavers plans programs at the district level based on its assessment of a district's needs relating to infrastructure (e.g. operating microscopes), human resources (e.g. surgical training), outreach, and policy.
- "Support to partner hospitals – Sightsavers provides NGO hospitals and government hospitals (where ophthalmologists are available) with supplies, capacity-building support, and training.
- "Capacity-building support – Sightsavers financially supports the recruitment of new clinical and non-clinical employees to hospitals experiencing staff shortages. It typically pays partial salaries, with the remaining staff costs treated as in-kind contributions from partner hospitals (one partner hospital incurs the full cost of additional staff). Sightsavers also assists hospitals with improving their quality control and monitoring systems to ensure that correct protocols for examining and treating patients are followed and that surgical outcomes are properly measured and evaluated.
- "Training – Need-based training on cataract surgery is provided both to doctors and nurses and requires travel to an institute in Kolkata, India (some short courses are available within Bangladesh). Sightsavers also supports trainings on hospital administration, financial management, and other topics.
- "Outreach camps – Sightsavers supports community-based outreach camps to clinically confirm vision impairment issues and identify patients for cataract surgery. Partner hospitals typically operate eight to ten outreach camps monthly. Outreach camps are located in areas where there is limited access to eye health facilities. Sightsavers also provides transport to patients who would otherwise not be able to travel to a hospital for their cataract surgery.
- "Policy formulation and implementation – Sightsavers is involved in national-level policy formulation and district-level policy implementation. It sometimes invites government experts to visit program areas and observe the quality of its work. It also sometimes requests technical assistance from government.
- "Monitoring – Sightsavers monitors program outputs, verifies the quality of data collection, and compiles district-level reports. Specifically, it collects data on all targeted patients' visual acuity before and after receiving cataract surgery. Sightsavers also attempts to collect follow-up data on visual acuity (patients are advised to return to the hospital 7-10 days after surgery and again within 4-6 weeks), although many patients do not return for follow-up visits if they are not experiencing any problems. If any refractive error correction is determined to be necessary upon follow-up examination, a prescription is provided to the patient."
- "An additional $250,000 will restore, improve or save the sight of 13,890 people with little access to eye health services.
"Funding would be used to screen 117,000 people for eye health problems and visual impairments, support 11,890 cataract surgeries and dispense 2,000 free glasses to school children and low income adults.
"Funding will increase demand for cataract surgery in communities unaware treatment is available and will increase accessibility to eye health services, especially for marginalized groups; including women, people with disabilities, people living in rural areas and lower income groups.
"The activities we will need to complete to achieve these goals are as follows:
- "Raising awareness of eye conditions such as cataract, including how and where such conditions can be treated and then ensuring people have a pathway through to receiving treatment.
- "Delivering primary eye care including establishing ‘eye corners’ at primary health facilities to offer eye examinations, dispense spectacles and refer patients with more complex conditions.
- "Training community health workers to identify and treat people in need of eye care services or to refer patients for further assessment / treatment.
- "Working with all providers of eye care in Bangladesh to boost the quality of services and develop standard indicators and improved monitoring."
"EngenderHealth would be grateful for an additional $250,000 to be able to expand the reach of the FC [Fistula Care]+ program beyond the scope of the current USAID grant, reach more people with fistula services and education in Bangladesh. The priority for additional funds would be to organize two community-based fistula and prolapse diagnoses events at the Rohingya refugee camp in Cox’s Bazaar, in partnership with the University Fistula Center, Bangabandhu Sheikh Mujib Medical University and the Obstetrical and Gynecological Society of Bangladesh...
"We anticipate that through holding community-based events we will identify approximately 50 fistula and prolapse cases. EngenderHealth would arrange repair surgery for all of these women with fistula and prolapse, identified through these events.
"EngenderHealth would also carry out a workshop at Cox’s Bazaar on 'Integration of Reproductive Health Services in Emergencies' in collaboration with the MOHFW, University Fistula Center and Obstetrical and Gynecological Society of Bangladesh. The MOHFW requested EngenderHealth conduct this workshop to identify gaps and duplication in RH services at the camps, and all organizations active in Rohingya camps will be invited to the workshop. This would help ensure that the RH needs of women in the camps are understood and considered by implementing organizations carrying out other work in the camps.
"Additionally, we would further support an existing EngenderHealth initiative for adolescent girls called 'School Girls for Fistula Free Bangladesh,' through which girls are educated, empowered, and engaged in the community for ending fistula from their villages, and given the opportunity to become a “fistula champion” by carrying out activities, including referring women for pregnancy care and delivery, identifying fistula cases, etc. This initiative is highly publicized in Bangladesh through newspapers, radio, and other media, and it has had ripple effects, as the girls in the program in turn educate neighboring communities about the things they learn. With additional funds, we will expand the program to two new schools, covering 1,000 additional girls, and produce a video documentary on the program." Samina Piracha, EngenderHealth, Senior Resource Mobilization Advisor, Foundations, email to GiveWell, March 27, 2019
"MiracleFeet’s long-term goal in every country is to expand our coverage to reach 70% of all children born with clubfoot. This is done by training healthcare workers in the Ponseti method, hiring and training parent educators, ensuring medical supplies are available (especially braces), adding more clinics to reduce travel time for families, investing in clubfoot awareness campaigns, and creating early diagnosis and referral processes. In the process, MiracleFeet creates a comprehensive national clubfoot program, which strengthens the national health system, and works closely with ministries of health to integrate the program into the local public health infrastructure for a long term and permanent solution to clubfoot management.
"An additional $250,000 would support key components of our expansion plans: healthcare provider trainings, treatment supplies and clinical equipment, awareness campaigns, early identification efforts, and monitoring and evaluation programs. This would provide MiracleFeet with more support to reach its target of 70% coverage in Bangladesh, Cambodia, Myanmar, and the Philippines. Currently, we are reaching 30% in Bangladesh (1,200 out of 3,900 children born with clubfoot each year), 39% in Cambodia (200 out of 508 children born with clubfoot each year), 36% in Myanmar (420 out of 1,166 children born with clubfoot each year), and 20% in the Philippines (650 out of 3,253 children born with clubfoot each year.) Expanding treatment coverage to 70% increases the total number of children treated in these countries to approximately 6,100 each year, and unleashes an average of $68,615 in gained additional lifetime earnings per child. For an average treatment cost of only $232 per child, this is a remarkable return on investment. Very simplistically, $250,000 would totally change the trajectory of the lives of approximately 1,070 children, potentially generating an additional $74M in future earnings, and contributing to a permanent solution to clubfoot for future generations in the Philippines, Myanmar, Cambodia and Bangladesh." Andrea Norris, MiracleFeet, Assistant Director of Development, email to GiveWell, April 1, 2019
"PATH’s Ultra Rice technology is a culturally appropriate and cost-effective micronutrient delivery system that packs vitamins and minerals, including iron, zinc, thiamin, vitamin A, folic acid, and other B vitamins, into extruded grains made from a rice flour base. Grains fortified using the Ultra Rice technology resemble traditional rice in size, shape, and color. When blended with milled rice, typically at a 1:100 ratio, the resulting fortified rice is nearly identical to unfortified rice in aroma, taste, and texture." PATH, Ultra Rice® Technology, October 2013
- "With an additional $250,000 in funding, AIP Foundation will be able to provide life-saving helmets for approximately 14,500 students additional over the upcoming years—almost double the number of helmets set to be provided already throughout the next three years. Consequently, Helmets for Kids can expand to additional schools in the existing program provinces as well as potentially expanding to other provinces in remote, underserved areas with large populations of ethnic minorities or less fortunate students." Mirjam Sidik, AIP Foundation, Chief Executive Officer, email to GiveWell, April 1, 2019
- "For the purpose of the GiveWell Grant, AIP Foundation is seeking additional funding for helmet distribution activities through our Helmets for Kids program implemented in Vietnam, which provides quality child helmets to students and children in rural, underserved communities for free in addition to other critical program activities. As such, AIP Foundation is the direct implementer of the program with responsibility of program ideation; partnership facilitation; helmet design, procurement, and distribution; school selections; stakeholder engagement; awareness raising; and monitoring and evaluation." Mirjam Sidik, AIP Foundation, Chief Executive Officer, email to GiveWell, April 1, 2019
- "Helmet distribution through other programs – AIP Foundation's recent work in Vietnam has focused on students in grades 2-5, as the Vietnamese government provided helmets to all first-grade students in 2018 and will provide helmets to incoming first-grade students in 2019. However, the students that the AIP Foundation plans to reach with additional funding from GiveWell will not have received helmets from government and other companies." GiveWell's non-verbatim summary of a conversation with Alex Nguyen, Trang Truong, Linh Pham, Mirjam Sidik, May 21, 2019, Pg. 2.
"For any particular school, AIP Foundation supports road safety education for the entire student population (the Vietnamese government's helmet distribution program does not include education). Teachers directly educate children through training from AIP Foundation that includes workshops as well as physical materials (e.g. handbooks). The amount of helmet-use and other road safety education each student receives varies by province and school (some students receive a full day of education), and schools also integrate this education into extracurricular activities.
"After AIP Foundation implements its intervention in a school, it continues the partnership—working with the school to remind students about the importance of helmets and ensure that parents and other local stakeholders such as the police are enforcing helmet use." GiveWell's non-verbatim summary of a conversation with Alex Nguyen, Trang Truong, Linh Pham, Mirjam Sidik, May 21, 2019, Pg. 2.