Unlimit Health — Exit Grant for Burundi and Mauritania (June 2023)

Note: This page summarizes the rationale behind a GiveWell-recommended grant to Unlimit Health. Unlimit Health staff reviewed this page prior to publication.

Funding for the grant

This grant was funded by about $1.4 million in donations to GiveWell's All Grants Fund, about $64,000 from Doneer Effectief, and about $41,000 from Effective Altruism New Zealand.

Planned activities and budget

This grant will extend support for ongoing deworming programs in Mauritania and Burundi through March 2026. Our previous grant to Unlimit Health supported its work in these countries through March 2024.1 Unlimit Health provides financial and technical assistance for deworming programs.2 For more information on deworming programs and the type of assistance Unlimit Health provides, see this section of our review of Unlimit Health.

• Approximately $500,000 to support two years of deworming mass drug administration (MDA) in Burundi.4
• Approximately $1 million to support two years of deworming MDA in Mauritania.5
• Approximately $200,000 to support a reassessment survey of worm burden in Mauritania.6
• Approximately $40,000 to support domestic resource mobilization activities in Mauritania and Burundi.7

We do not expect to renew support for these activities following this grant.

The case for an exit grant

• Our assessment of these programs is outdated and we believe the amount of work that would be required to update our assessment may be better spent investigating other opportunities with greater impact potential.8 (more below)
• We believe it is our responsibility to ensure exit funding is available when deciding not to renew support for programs we have previously supported. (more below)

High opportunity cost

We have not meaningfully updated our cost-effectiveness analysis of Unlimit Health since 2020, so we do not believe our previous cost-effectiveness estimates are an accurate assessment of Unlimit Health's current work in Burundi and Mauritania. We believe it would take significant research capacity to update our cost-effectiveness analysis, and we believe that capacity may be better spent investigating other opportunities with greater impact potential.

Updating our cost-effectiveness analysis would require:

• Revisiting our worm burden adjustments for each geography. Our cost-effectiveness estimates depend on estimates of the intensity and prevalence of worm infections in each geography.9 We generally aim to revisit these worm burden adjustments when new worm burden data becomes available or when other factors which impact the calculations, such as treatment strategy or geographic scope of the program, change. We have found this process to be complicated and time-intensive, and we are often left with lingering uncertainties around the true worm burden where the program is being implemented.10
• Considering the impact that new treatment strategies would have on costs, treatment numbers, and overall cost-effectiveness. In 2022, WHO updated its treatment guidelines for schistosomiasis, suggesting expanding target populations beyond school-age children and targeting treatment to focus on at-risk regions.11 As a result of these changes, it has become more difficult to understand exact treatment strategies and the rationale behind them in countries where we support deworming. We found this particularly challenging while investigating this grant, in part because much of the work to operationalize these new guidelines is still ongoing. Detailed discussion with Unlimit Health ultimately resulted in the proposed treatment numbers and annual budget decreasing substantially. It's not clear to us how the updated treatment strategies and any future changes will affect the cost-effectiveness of deworming programs in Burundi and Mauritania over the next few years, and properly accounting for these dynamics in new cost-effectiveness estimates would take time.
• Updating our cost per child assumptions. Our previous cost-effectiveness analysis assumed the same cost per child dewormed across all countries.12 For other deworming programs we typically use geography-specific cost per child estimates, calculated based on country or state-specific treatment and spending data. If we were to update our analysis, we would need to generate country-specific cost per child estimates as we expect costs may vary meaningfully across geographies. In the past, we have found generating these estimates to be more challenging with the information provided by Unlimit Health than with other deworming grantees.
• Reviewing the latest coverage surveys from each geography. Typically, coverage surveys are what give us confidence that the program is being implemented as expected and thus is likely to have the impact we model. Reviewing both the results and methods of coverage surveys, ideally on an annual basis, takes time and does not scale with program size.

Due to these research capacity requirements, we have generally found deworming grants quite time-intensive to investigate. At the same time, at a cost of around $250,000 to $500,000 per country per year,13 Unlimit Health's programs in Burundi and Mauritania offer much less room for more funding than other deworming programs we support.14 As a result, we believe the research capacity that would be required to decide on an ongoing basis whether to continue funding this grant's activities would have a greater impact if it was spent investigating opportunities with greater room for more funding relative to the time required to investigate them.

Exit funding

We typically aim to provide a minimum of two years of funding runway when deciding to exit from supporting a program (though we consider this on a grant-by-grant basis and may opt for a shorter period). In our experience, grant recipients believe this is a reasonable timeframe for planning a smooth transition. Our guess is that this length of funding runway enables us to maintain strong relationships with partners and for those partners to maintain strong relationships with the governments they support and others they work with.

Risks and reservations

• We may be missing cost-effective opportunities for impact. Our decision to exit was largely driven by the limited room for more funding in these countries relative to the research capacity required to investigate potential renewal grants. We believe this tradeoff is particularly pronounced in this case, as we have found deworming investigations to be particularly time-intensive. However, if these programs were highly cost-effective then it is possible that small renewal grants may be highly impactful relative to other opportunities (though we have not modeled these tradeoffs). We previously estimated these programs to be 19 times as cost-effective as unconditional cash transfers (19x cash) for Burundi and 32x cash for Mauritania.15 While these estimates have not been comprehensively updated since 2020 and have always carried meaningful uncertainties,16 it is possible that further investigation could confirm our prior estimates of cost-effectiveness well above our funding bar of 10x cash.17

Plans for follow up

We do not plan to conduct extensive follow-up for this grant given that it is an exit grant. We plan to have a check-in call with Unlimit Health approximately six months after this grant decision (and every 6 to 12 months thereafter through the end of the grant period), to ask the following questions:

• Is MDA in Burundi and Mauritania on track?
• Has the worm burden reassessment survey in Mauritania occurred or has it been scheduled?
• How are domestic resource mobilization activities progressing? Have you been able to raise any funds for deworming in Burundi or Mauritania?

Unlimit Health has agreed to share spending and treatment data from each year of this grant, coverage evaluation survey results from each year of this grant, and results from the Mauritania worm burden reassessment survey and their implications for future deworming treatment strategy in Mauritania.

Internal forecasts

Confidence	Prediction	By time​​
70%	Unlimit Health-supported deworming will occur in Mauritania within the next year.18	June 2024
20%	Unlimit Health will raise external funds to continue deworming programs in line with WHO guidelines in both Mauritania and Burundi after GiveWell funding ends.	March 2026

Our process

We did not conduct an in-depth grant investigation, given that we are exiting from these programs. For this particular grant, we:

• Reviewed Unlimit Health's budget, proposed treatment strategies for each country,19 and proposal for domestic resource mobilization.
• Had two calls with Unlimit Health to discuss our exit and the activities that would be supported by this grant.

Sources

Document	Source
GiveWell, 2022 SCI Foundation CEA	Source
GiveWell, 2023 Unlimit Health CEA	Source
GiveWell, Analysis of SCI's cost per person dewormed per year [2020]	Source
GiveWell, Summary of 2020 Worm Burden Model	Source
Unlimit Health Mauritania and Burundi Budget Analysis 2023	Source
Unlimit Health, “How we work”	Source
Unlimit Health, Burundi deworming program proposal, May 2023	Source
Unlimit Health, Domestic resource mobilization proposal	Source
Unlimit Health, Mauritania deworming program proposal, May 2023	Source
World Health Organization, "WHO guideline on control and elimination of human schistosomiasis," 2022	Source

• 1At the time the previous grant was made, Unlimit Health was known as SCI Foundation. It changed its name in early 2023.
  
• 2 “Over the last two decades, we have provided technical and financial support to enhance countries’ own strategic plans for tackling schistosomiasis, soil-transmitted helminths, and other neglected tropical diseases (NTDs).” Unlimit Health, “How we work”
• 3
  • See our Unlimit Health Mauritania and Burundi Budget Analysis 2023 spreadsheet for our budget calculations.
  • Note that the budget breakdown given here totals more than the final grant amount of $1,495,745. The final grant amount does not include an existing ￡97,178 budget surplus, which will be put towards the Mauritania program activities for this grant. The grant amount also does not include ￡150,336 for the worm burden reassessment survey in Mauritania, as Unlimit Health already has this funding on hand due to excess funding from a prior GiveWell grant. The budget for the worm burden reassessment survey is still included in the budget breakdown, as GiveWell approved the use of those excess funds during this grant investigation.
  • The currency conversions in this section were calculated using the British Pounds (GBP) to US Dollars (USD) exchange rate of 1.267. This was the exchange rate according to Google's foreign exchange calculator at the time the final grant amount was calculated on June 14, 2023. See our Unlimit Health Mauritania and Burundi Budget Analysis.

• 4The total Burundi program budget is ￡419,118. See our Unlimit Health Mauritania and Burundi Budget Analysis, “GiveWell calculations” table, “Total budget per country (GBP)” row.
  GBP to USD exchange rate at the time the grant amount was calculated: 1.267
  ￡419,118 x 1.267 = $531,023
  
• 5The total Mauritania program budget is ￡824,733. See our Unlimit Health Mauritania and Burundi Budget Analysis, “GiveWell calculations” table, “Total budget per country (GBP)” row.
  GBP to USD exchange rate at the time the grant amount was calculated: 1.267
  ￡824,733 x 1.267 = $1,044,937
  
• 6
  • The worm burden reassessment survey will measure the prevalence and intensity of worm infections and would be conducted at least six months after the next round of deworming MDA. Unlimit Health, email to GiveWell, June 1, 2023 (unpublished)
  • We believe the data from this survey could allow the program to target future rounds of deworming towards areas with the greatest need for treatment. Since the deworming program may be funding-constrained following GiveWell's exit, we believe a reassessment survey may help the program allocate its limited resources more efficiently.
  • The budget for the worm burden reassessment survey in Mauritania is ￡150,336. See our Unlimit Health Mauritania and Burundi Budget Analysis, “GiveWell calculations” table, “Worm burden reassessment survey in Mauritania (GBP)” row.
    GBP to USD exchange rate at the time the grant amount was calculated: 1.267
    ￡150,336 x 1.267 = $190,476

• 7
  • The aim of domestic resource mobilization activities will be to develop a plan to transition deworming programs in Burundi and Mauritania to sustainable sources of domestic funding. "With generous funding from GiveWell, Unlimit Health has been the sole technical partner providing support to the programmes in Burundi and Mauritania. To address the changing funding landscape, this proposal aims to develop a feasible transition strategy focused on domestic resource mobilisation (DRM), toward sustained deworming funding in the long-term." Unlimit Health, Domestic resource mobilization proposal, p. 1.
  • The budget for domestic resource mobilization activities is ￡33,500. See our Unlimit Health Mauritania and Burundi Budget Analysis, “GiveWell calculations” table, “Budget for domestic resource mobilization activities in both countries (GBP)” row.
    GBP to USD exchange rate at the time the grant amount was calculated: 1.267
    ￡33,500 x 1.267 = $42,445

• 8Impact is a function of both the room for more funding associated with a grant opportunity and the cost-effectiveness of that room for more funding. See more at GiveWell, “Our Criteria.”
• 9“The worm burden adjustment is an important component of GiveWell's deworming cost-effectiveness analysis that compares the aggregate baseline worm prevalence for each charity deworming program to worm prevalence in the Miguel & Kremer 2004 (MK) deworming RCT study population, weighted by both worm species and infection intensity.” GiveWell, Summary of 2020 Worm Burden Model, p. 2.
• 10See our grant page for Sightsavers — Renewal for Deworming in Nigeria, Chad, and Cameroon (January 2023) for more about the challenges associated with accurately estimating worm burden, as well as changing treatment strategies.
• 11
  • "In endemic communities with prevalence of Schistosoma spp. infection ≥10%, WHO recommends annual preventive chemotherapy with a single dose of praziquantel at ≥75% treatment coverage in all age groups from 2 years old, including adults, pregnant women after the first trimester and lactating women, to control schistosomiasis morbidity and advance towards eliminating the disease as a public health problem." World Health Organization, "WHO guideline on control and elimination of human schistosomiasis," 2022, p. xvi.
  • "Community mapping of the epidemiology of schistosomiasis can reduce the need for praziquantel, as treatment can be better targeted to communities and at-risk regions." World Health Organization, "WHO guideline on control and elimination of human schistosomiasis," 2022, p. xvii.

• 12For the previous Unlimit Health cost-effectiveness analysis (CEA), see our 2022 SCI Foundation CEA, “Cost per person dewormed (per year) — SCI” row. See GiveWell, Analysis of SCI's cost per person dewormed per year [2020] for how this number was calculated. Note that at the time these analyses were published, Unlimit Health was known as SCI Foundation.
• 13See the budget breakdown above, where we estimate two years of deworming support costs around $500,000 in Burundi and $1 million in Mauritania (or approximately $250,000 and $500,000 per year, respectively).
• 14 For example, earlier this year we recommended an $11.2 million grant to Sightsavers to extend support for deworming programs in Nigeria, Chad, and Cameroon through March 2026, and a $5.2 million grant to Deworm the World to extend support for deworming programs in Nigeria, Pakistan, and Kenya for an additional year through 2025.
• 15 See our most recent Unlimit Health CEA, “Cost-effectiveness in multiples of cash transfers, after all adjustments” row.
• 16In particular, we have uncertainties in regards to worm burden (see GiveWell, Summary of 2020 Worm Burden Model) and cost per child (see GiveWell, Analysis of SCI's cost per person dewormed per year [2020]).
• 17As of mid-2023, our bar for directing funding is about 10x as cost-effective as unconditional cash transfers. See GiveWell’s Cost-Effectiveness Analyses web page for more information about how we use cost-effectiveness estimates in our grantmaking.
• 18There has not been an MDA in Mauritania since January 2021 due to delayed drug availability. Unlimit Health has informed us that it expects these delays to be resolved moving forward and that the drug supply for the planned 2022 MDA has now been shipped and the drug supply for the planned 2023 MDA has been approved. Unlimit Health, email to GiveWell, June 12, 2023 (unpublished)
• 19See Unlimit Health, Burundi deworming program proposal, May 2023 and Unlimit Health, Mauritania deworming program proposal, May 2023.