Helen Keller International — Vitamin A Supplementation (August & September 2024)

Note: This page summarizes the rationale behind a GiveWell grant to Helen Keller Intl. Helen Keller staff reviewed this page prior to publication.

Published: April 2025

The organization

Helen Keller Intl (Helen Keller) supports programs focused on reducing malnutrition and averting blindness and poor vision in countries in Africa and Asia. It also provides vision screenings and distributes eyeglasses at schools in the United States.1 Helen Keller Intl is a GiveWell Top Charity. In part, this means that we've directed significant funding to the organization and have seen it operate effectively,2 and we think further grants to Helen Keller have a high likelihood of substantial impact (more about our criteria for Top Charities). For more information on Helen Keller Intl, including what they do and our qualitative assessment of the organization, see this page.

The intervention

Vitamin A deficiency (VAD) is a common condition in low- and middle-income countries that can lead to blindness, increased susceptibility to infection, and death.3 Vitamin A supplementation (VAS) involves getting 6-59 month old children to swallow a small amount of fluid containing vitamin A, delivered via a single-use capsule. VAS is delivered to children through the following approaches:4

• Mass campaigns involve large-scale distribution of VAS to households, either door-to-door or through central distribution sites in a community. In these campaigns, VAS is often co-delivered with other public health interventions, including deworming, polio vaccination, "mop-up" immunizations (for children who have missed scheduled immunizations), and screening for severe acute malnutrition and moderate acute malnutrition.5
• Routine delivery of VAS involves giving children VAS at primary health facilities at other touchpoints they might have with the national healthcare system (e.g., during routine immunizations).

GiveWell primarily funds mass campaigns for vitamin A supplementation.

VAS campaigns take place under the leadership of governments in low- and middle-income countries. Our understanding is that the workers implementing VAS programs are employees (or volunteers paid a stipend) recruited by the government.6 In many cases, these governments receive support and funding from NGOs. The largest of these are Helen Keller Intl, Nutrition International, and UNICEF (as of April 2025, GiveWell currently funds Helen Keller Intl and Nutrition International to support VAS campaigns).

Helen Keller Intl’s role in campaigns in locations where it supports VAS (largely funding campaigns and providing technical assistance to national and local governments to support effective delivery) is discussed in detail in our separate page on Helen Keller Intl.

Does vitamin A supplementation work?

Our best guess is that VAS reduces child mortality. We estimate that receiving VAS reduces child mortality by about 3% to 10% in the locations supported by this grant, varying by location.7 The starting point for this figure is an estimate from a meta-analysis of randomized controlled trials (RCTs) that VAS reduces mortality by 24%.8 We then conducted our own meta-analysis from the trials underlying this meta-analysis, to account for potential publication bias.9 This gives us a starting estimate of a 19% reduction in mortality.10

We apply two main adjustments to this:

• A -20% adjustment to account for possible weaknesses in the underlying RCTs.11
• A -57% to -77% adjustment (varying by location) to account for improved child health since the VAS trials were conducted.12 This incorporates estimates of the share of VAS-susceptible causes of death (primarily diarrhea and measles) and contemporary rates of vitamin A deficiency, compared to when the trials were conducted.

We think VAS probably has additional benefits beyond reducing child mortality. These include:

• Long-term income increases. We think that VAS probably increases children’s incomes in later life. Other child health programs we have investigated (malaria and deworming) have found evidence that averted illness in childhood leads to increased income and consumption in later life. We would guess that VAS has similar benefits, but we have not found any studies directly investigating this issue. In total, we estimate that these effects account for approximately 20% of the total modeled benefit of VAS.13
• Other supplemental adjustments. We think that VAS leads to several other possible benefits, including reduced morbidity from some illnesses (especially diarrhea and measles), improved vision, and averted costs that would have been spent on treatment. We incorporate these benefits as rough percentage best guesses, leading to an upwards adjustment of 57%.14

We have a number of major open questions about the impact of VAS, discussed below. Additional details on the intervention and our open questions are available in our vitamin A supplementation intervention report.

You can see how much of the program's value we attribute to these different benefits in the cost-effectiveness sketch below.

The grant

We recommended an approximately $5.8 million grant to Helen Keller Intl for VAS in six countries through June 2026. Our best guess, based on our current cost-effectiveness estimates,15 is that this grant will serve as:

• Renewal funding ($2.5 million): Democratic Republic of the Congo and two states in Nigeria (Adamawa and Taraba).
• Possible exit funding ($3.3 million): Burkina Faso, Cameroon, Côte d'Ivoire, Guinea, and three Nigerian states (Benue, Ebonyi, and Nasarawa).

However, we do not plan to finalize our decision on whether we're renewing our funding for or exiting the above locations until late 2024, after completing additional work and further refining our cost-effectiveness estimates.

For all locations except Taraba State, Nigeria, this funding will support VAS from July 2025 to June 2026. For Taraba State, this funding will support VAS from July 2024 to June 2026. See table below.

For a detailed description of the activities this grant will fund, see our write-up on Helen Keller Intl.

Budget for grant activities

Helen Keller submitted funding requests for renewals in the following locations through June 2026, which we're funding in full.16

In addition, Helen Keller also shared the following funding gaps for FY26:17

• Cameroon: $997,416
• Côte d'Ivoire: $1,557,544

Through a miscommunication with Helen Keller, we initially understood these to be "expansion" funding gaps (to support Helen Keller working in new locations within these countries), which we did not consider as part of our August 2024 grant. However, after recommending our August 2024 grant, we learned that Helen Keller was already operating in these locations in Cameroon and Cote d'Ivoire.18 As a result, we recommended an additional grant to fill these two gaps in September 2024.

Simple cost-effectiveness analysis

Our cost-effectiveness estimates for the locations supported by this grant vary from 4.4 times as cost-effective as unconditional cash transfers ("4x cash"), the benchmark against which we compare programs, in Cote d'Ivoire to 15x cash in Taraba State.19

We think that VAS programs can be highly cost-effective because:

• VAS can be very inexpensive (~$1 per supplement delivered, in some locations)20
• Helen Keller works in locations with high mortality (over 1% risk of death per child per year in the absence of VAS, in some locations)21
• We estimate that VAS can significantly reduce child mortality, by up to 6.2% in the locations supported by this grant.22

A simple CEA (below) quantifies this intuition for one of the countries we're supporting with this grant (Democratic Republic of the Congo), which we model as ~13x cash. You can see our full cost-effectiveness model here.

The case for the grant

We recommended this grant to provide Helen Keller with funding visibility while we decide whether to renew our support for an additional year. We expect to make that decision in late 2024, after conducting additional research into the program model and refining our cost-effectiveness estimates. If we decide not to renew our support for any locations supported by Helen Keller at that time, we expect this grant to serve as exit funding to cover the cost associated with wrapping up the program or looking for alternative funders.

Prior to making a decision about renewing funding, we plan to address some of our key questions about our current cost-effectiveness estimates, including:23

• What source(s) of mortality data should we be using, and how should we weight them?
• Is more recent data available about rates of vitamin A deficiency?
• What's driving the difference in cost per supplement across locations?
• How many children would receive VAS without Helen Keller's program?
• How likely are VAS campaigns to be paired with polio or measles immunization campaigns going forward?
• Can we work with an external evaluator to triangulate Helen Keller's coverage survey results?

Our rough best guess is that this work may lead to changes in cost-effectiveness of up to 30% (positive or negative) when we complete this additional work. This could lead to changes in which locations are above or below our funding bar of 8x cash for top charities.24

Risks and reservations

Uncertainties about exit needs

We're uncertain whether the amount of funding runway provided by this grant is well-calibrated to Helen Keller's needs for exit, because we do not have a strong understanding of what the exit process would look like. We would guess two years of funding runway are sufficient for this transition, but we remain uncertain.

Uncertainties about the case for VAS

Overall, we have greater uncertainty about the case for VAS compared to the programs implemented by GiveWell's other top charities. This uncertainty would not have prevented us from recommending this grant, because we would still want to provide exit funding if we thought all countries were below our grantmaking bar.

The key reasons we're more uncertain about VAS are:

• The findings of the studies we rely on to estimate the effect of VAS on mortality vary significantly, with some finding large effects, others a small or no effect, and we do not have a good sense of what explains these changes.
• The main studies we rely on were primarily conducted in the 1980s and 1990s, when the infectious disease landscape was different and child health was significantly worse than today. We attempt to adjust for the change in environment, but since we do not have a strong understanding of what mediates the impact of VAS on mortality, we’re unsure what factors to adjust for.
• We're very uncertain about vitamin A deficiency rates today. We rely on a combination of data sources about which we're uncertain to estimate these.

We discuss our biggest open questions about VAS in more detail in our intervention report on vitamin A supplementation.

We might make progress on our estimates of vitamin A deficiency in modern contexts by funding new surveys. We do not expect to make significant progress on the other questions in the near term, although we're interested in funding any studies that could improve our understanding of the impact of VAS on mortality.

Other uncertainties

Our main reservations about Helen Keller Intl’s VAS program are:

• While we think it is valuable overall, we have some reservations about Helen Keller’s monitoring. This reduces our confidence that its programs are reaching a high proportion of targeted children.
• We have sometimes found information from Helen Keller difficult to interpret. This means that we have not been able to understand differences between the delivery models used in different locations in as much detail as we would like.

We discuss these reservations in more detail in our write-up on Helen Keller Intl's vitamin A supplementation program.

Plans for follow up

• We plan to make a decision in late 2024 about (i) renewing our support for another year, or exiting and (ii) expanding to new geographies through June 2026, following additional work to refine our understanding of the program's theory of change and cost-effectiveness.25
• We plan to receive data from Helen Keller annually on:
  • VAS coverage
  • Target populations reached
  • Spending by Helen Keller
  • Spending on VAS by other actors (e.g. domestic governments and other philanthropic actors)
  • Funding gaps
• We plan to take additional steps to improve our understanding of vitamin A supplementation and the cost-effectiveness of this work, beyond our next Helen Keller grant investigation. Topics for future research include:
  • Considering support for vitamin A deficiency surveys to inform our estimate of current vitamin A deficiency rates.
  • Investigating what happened when we did not fund VAS campaigns.26

Forecasts

For this grant, we are recording the following forecasts:27

Our process

• We conducted multiple external conversations related to this grant with staff from Helen Keller Intl and several local government officials.28
• We refined our cost-effectiveness model. As part of this, we exchanged messages with the Institute for Health Metrics and Evaluation (IHME) to improve our understanding of changes in estimates from their Global Burden of Disease study, which we use for estimates of figures such as baseline mortality and cause-specific mortality.
• We received information from Helen Keller on cost drivers by location, funding gaps, coverage data, target populations, and spending data.
• We completed several rounds of internal review of the case for the grant and our cost-effectiveness model.

Relationship disclosures

None

Sources

• 1

  “Today, Helen Keller Intl helps children and families in 20 countries across Asia, Africa, Europe and the United States grow and eat nutritious food, stave off malnutrition, build strong immune systems, access life-saving medical treatments, and prevent and treat blindness and vision loss.
  By providing the right support at the right time, we help millions of families and communities overcome long standing cycles of poverty, helping them create lasting change in their own lives.” Helen Keller, ‘What we do’ page. Accessed June 2nd 2023.
  “42 states require regular vision screenings for students, but many school districts are unable to secure the budget to screen the youngest members of society. For just $35 a student, Helen Keller bridges this gap by partnering with schools to reach every child with a vision screening, and when needed, a pair of prescription eyeglasses.” Helen Keller, ‘Protecting Vision in the United States’ page. Accessed June 2nd 2023.

• 2

  See a table of all grants we've recommended to Helen Keller here.

• 3

  From the WHO page on VAD, “In its more severe forms, vitamin A deficiency contributes to blindness by making the cornea very dry, thus damaging the retina and cornea. An estimated 250 000–500 000 children who are vitamin A-deficient become blind every year, and half of them die within 12 months of losing their sight. Deficiency of vitamin A is associated with significant morbidity and mortality from common childhood infections, and is the world’s leading preventable cause of childhood blindness. Vitamin A deficiency also contributes to maternal mortality and other poor outcomes of pregnancy and lactation. It also diminishes the ability to fight infections. Even mild, subclinical deficiency can be a problem, because it may increase children's risk for respiratory and diarrhoeal infections, decrease growth rates, slow bone development and decrease the likelihood of survival from serious illness.”

• 4

  "Mass distribution campaigns are the main delivery mechanism for VAS. These campaigns are organized at least every 6 months…"
  "Because mass campaigns take place only every 4 to 6 months, children who reach the age of 6 months between two campaigns, may have to wait several months before they get their first dose of Vitamin A despite being the most vulnerable age group.
  "To remedy this, [Helen Keller Intl] is working closely with country-level health sector experts to add a contact point in national immunization calendars – at 6 months, when no other vaccination is scheduled.
  "Additionally, [Helen Keller Intl] supports routine facility-based and outreach delivery of vitamin A for all children under 5 in countries where stronger health systems offer sufficient access to quality services. Few countries are ready for this approach and these still need to develop social mobilization actions to create demand to match the capacity to offer services." Helen Keller Intl, VAS overview brochure, p. 2.

• 5

  This spreadsheet lists the distribution methods and co-delivered interventions for VAS mass distribution campaigns that Helen Keller supported with GiveWell-directed funding in 2018 through 2021.

• 6

  This understanding is based on many conversations with Helen Keller and other VAS stakeholders over time.

• 7

  See this row of our cost-effectiveness model.

• 8

  We discuss the meta-analysis, Imdad et al. 2017, and our interpretation of it further in our page on VAS.

• 9

  See here for our discussion of concerns about publication bias.

• 10

  See our analysis here and discussion in cell note here.

• 11

  See this input into our cost-effectiveness model. We discuss the reasoning behind the adjustment in this section of our page on VAS. Note: at the time we wrote that page, we used a -25% adjustment. We have since updated this input to -20% after generating our own meta analysis to account for publication bias concerns, based on our understanding that the previous IV was intended to partially capture those concerns.

• 12

  See this row of our cost-effectiveness model. See our discussion of this adjustment in this section of our page on VAS.

• 13

  See this row of our cost-effectiveness model. See our discussion of long-term income increases in this section of our page on VAS.

• 14

  See this row of our cost-effectiveness model. See our discussion of these additional benefits in this section of our page on VAS. Note: at the time we wrote that page, we used a 67% adjustment. We have since updated this adjustment to 57% by incorporating an additional -10% adjustment to account for our best guess that children reached by VAS campaigns may have lower than average baseline mortality rates. This is a rough guess, intended to account for the fact that children reached by VAS may have better access to the healthcare system or other factors that could result in lower mortality rates in this group.

• 15

  You can see our full cost-effectiveness model here. As of the time we recommended this grant, our funding bar for directing support to top charities was eight times as cost-effective as unconditional cash transfers, or "8x cash." Our best guesses of which locations will receive renewal funding and for which this grant will serve as exit funding is based on their estimated cost-effectiveness, relative to our bar, at the time we recommended this grant. See this page for a discussion of our funding bar and why we compare programs to unconditional cash transfers.

• 16

  Source: Funding proposal submitted by Helen Keller Intl (unpublished)

• 17

  Source: unpublished conversations with Helen Keller Intl

• 18

  Source: unpublished conversations with Helen Keller Intl

• 19
  • To date, GiveWell has used GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding opportunities, which we describe in multiples of "cash” (more). In 2024, we re-evaluated the cost-effectiveness of direct cash transfers as implemented by GiveDirectly and we now estimate that their cash program is 3 to 4 times more cost-effective than we’d previously estimated. (more)
  • For the time being, we continue to use our estimate of the cost-effectiveness of unconditional cash transfers prior to the update to preserve our ability to compare across programs, while we reevaluate the benchmark we want to use to measure and communicate cost-effectiveness.
  • Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.

• 20

  See this row in our cost-effectiveness analysis for our estimated cost per supplement across locations.

• 21

  See this row in our cost-effectiveness analysis for our estimated baseline child mortality rates.

• 22

  See this row in our cost-effectiveness analysis for our estimated reduction in child mortality from receiving VAS

• 23

  Since drafting this page, we have made progress on these research questions. However, this page is meant to represent our thinking at the time we made this grant.

• 24

  We discuss more about our funding bar on this page.

• 25

  Note: as of the time of publication, we have concluded our investigation and plan to publicize our decision in the coming months. However, we have published this page as-is to document our thinking at the time the grant was made.

• 26

  In our cost-effectiveness analyses, we include the potential for our funding of programs to crowd out funding that would otherwise have come from other sources. We call this “funging” (from “fungibility”). While we make our best guesses for whether a given opportunity would receive funding in our absence, these are very uncertain and investigating what happened when we decided not to fund a given VAS campaign may increase our confidence in these estimates. For more on how we think about funging, see this post.

• 27

  Note: as of the time of publication, the timeframe for resolving these predictions has passed. However, we have published this page as-is to document our thinking at the time the grant was made.

• 28

  These officials were:

  • Mr. Augustin Kamanda Bishimini, Head of Standardization and Quality Control Division at PRONANUT, National Coordinator for the Fight Against Micronutrient Deficiencies, DRC
  • Dr. Hassan Ben bachire, Directeur du Département de Promotion de la Santé, Cameroon
  • Dr. Facely Camara, Directeur Adjoint de la Santé Familiale et de la Nutrition, Guinea