The GiveWell Blog

Our updated top charities for giving season 2016

We have refreshed our top charity rankings and recommendations. We now have seven top charities: our four top charities from last year and three new additions. We have also added two new organizations to our list of charities that we think deserve special recognition (previously called “standout” charities).

Instead of ranking organizations, we rank funding gaps, which take into account both charities’ overall quality and cost-effectiveness and what more funding would enable them to do. We also account for our expectation that Good Ventures, a foundation we work closely with, will provide significant support to our top charities ($50 million in total). Our recommendation to donors is based on the relative value of remaining gaps once Good Ventures’ expected giving is taken into account. We believe that the remaining funding gaps offer donors outstanding opportunities to accomplish good with their donations.

Our top charities and recommendations for donors, in brief

Top charities

We are continuing to recommend the four top charities we did last year and have added three new top charities:

  1. Against Malaria Foundation (AMF)
  2. Schistosomiasis Control Initiative (SCI)
  3. END Fund for work on deworming (added this year)
  4. Malaria Consortium for work on seasonal malaria chemoprevention (added this year)
  5. Sightsavers for work on deworming (added this year)
  6. Deworm the World Initiative, led by Evidence Action
  7. GiveDirectly

We have ranked our top charities based on what we see as the value of filling their remaining funding gaps. We do not feel a particular need for individuals to divide their allocation across all of the charities, since we are expecting Good Ventures will provide significant support to each. For those seeking our recommended allocation, we recommend giving 75% to the Against Malaria Foundation and 25% to the Schistosomiasis Control Initiative, which we believe to have the most valuable unfilled funding gaps.

Our recommendation takes into account the amount of funding we think Good Ventures will grant to our top charities, as well as accounting for charities’ existing cash on hand, and expected fundraising (before gifts from donors who follow our recommendations). We recommend charities according to how much good additional donations (beyond these sources of funds) can do.

Other Charities Worthy of Special Recognition

As with last year, we also provide a list of charities that we believe are worthy of recognition, though not at the same level (in terms of likely good accomplished per dollar) as our top charities (we previously called these organizations “standouts”). They are not ranked, and are listed in alphabetical order.

Below, we provide:

  • An explanation of major changes in the past year that are not specific to any one charity. More
  • A discussion of our approach to room for more funding and our ranking of charities’ funding gaps. More
  • Summary of key considerations for top charities. More
  • Detail on each of our new top charities, including an overview of what we know about their work and our understanding of each organization’s room for more funding. More
  • Detail on each of the top charities we are continuing to recommend, including an overview of their work, major changes over the past year and our understanding of each organization’s room for more funding. More
  • The process we followed that led to these recommendations. More
  • A brief update on giving to support GiveWell’s operations vs. giving to our top charities. More

Conference call to discuss recommendations

We are planning to hold a conference call at 5:30pm ET/2:30pm PT on Thursday, December 1 to discuss our recommendations and answer questions.

If you’d like to join the call, please register using this online form. If you can’t make this date but would be interested in joining another call at a later date, please indicate this on the registration form.

Major changes in the last 12 months

Below, we summarize the major causes of changes to our recommendations (since last year).

Most important changes in the last year:

  • We engaged with more new potential top charities this year than we have in several years (including both inviting organizations to participate in our process and responding to organizations that reached out to us). This work led to three additional top charities. We believe our new top charities are outstanding giving opportunities, though we note that we are relatively less confident in these organizations than in our other top charities—we have followed each of the top charities we are continuing to recommend for five or more years and have only began following the new organizations in the last year or two.
  • Overall, our top charities have more room for more funding than they did last year. We now believe that AMF, SCI, Deworm the World, and GiveDirectly have strong track records of scaling their programs. Our new top charities add additional room for more funding and we believe that the END Fund and Malaria Consortium, in particular, could absorb large amounts of funding in the next year. We expect some high-value opportunities to go unfilled this year.
  • Last year, we wrote about the tradeoff between Good Ventures accomplishing more short-term good by filling GiveWell’s top charities’ funding gaps and the long-term good of saving money for other opportunities (as well as the good of not crowding out other donors, who, by nature of their smaller scale of giving, may have fewer strong opportunities). Due to the growth of the Open Philanthropy Project this year and its increased expectation of the size and value of the opportunities it may have in the future, we expect Good Ventures to set a budget of $50 million for its contributions to GiveWell top charities. The Open Philanthropy Project plans to write more about this in a future post on its blog.

Room for more funding analysis

Types of funding gaps

We’ve previously outlined how we categorize charities’ funding gaps into incentives, capacity-relevant funding, and execution levels 1, 2, and 3. In short:

  • Incentive funding: We seek to ensure that each top charity receives a significant amount of funding (and to a lesser extent, that charities worthy of special recognition receive funding as well). We think this is important for long-run incentives to encourage other organizations to seek to meet these criteria. This year, we are increasing the top charity incentive from $1 million to $2.5 million.
  • Capacity-relevant funding: Funding that we believe has the potential to create a significantly better giving opportunity in the future. With one exception, we don’t believe that any of our top charities have capacity-relevant gaps this year. We have designated the first $2 million of Sightsavers’ room for more funding as capacity-relevant because seeing results from a small number of Sightsavers deworming programs would significantly expand the evidence base for its deworming work and has the potential to lead us to want to support Sightsavers at a much higher level in the future (more).
  • Execution funding: Funding that allows charities to implement more of their core programs. We separated this funding into three levels: level 1 is the amount at which we think there is a 50% chance that the charity will be bottlenecked by funding; level 2 is a 20% chance of being bottlenecked by funding, and level 3 is a 5% chance.

Ranking funding gaps

The first million dollars to a charity can have a very different impact from, e.g., the 20th millionth dollar. Accordingly, we have created a ranking of individual funding gaps that accounts for both (a) the quality of the charity and the good accomplished by its program per dollar, and (b) whether a given level of funding is capacity-relevant and whether it is highly or only marginally likely to be needed in the coming year.

The below table lays out our ranking of funding gaps. When gaps have the same “Priority,” this indicates that they are tied. When gaps are tied, we recommend filling them by giving each equal dollar amounts until one is filled, and then following the same procedure with the remaining tied gaps. See footnote for more.*

The table below includes the amount we expect Good Ventures to give to our top charities. For reasons the Open Philanthropy Project will lay out in another post, we expect that Good Ventures will cap its giving to GiveWell’s top charities this year at $50 million. We expect that Good Ventures will start with funding the highest-rated gaps and work its way down, in order to accomplish as much good as possible.

Note that we do not always place a charity’s full execution level at the same rank and in some cases rank the first portion of a given charity’s execution level ahead of the remainder. This is because many of our top charities are relatively close to each other in terms of their estimated cost-effectiveness (and thus, the value of their execution funding). For reasons we’ve written about in the past, we believe it is inappropriate to put too much weight on relatively small differences in explicit cost-effectiveness estimates. Because we expect that there are diminishing returns to funding, we would guess that the cost-effectiveness of a charity’s funding gap falls as it receives more funding.


Priority Charity Amount, in millions USD (of which, expected from Good Ventures*) Type Comment
1 Deworm the World $2.5 (all) Incentive
1 SCI $2.5 (all) Incentive
1 Sightsavers $2.5 (all) Incentive
1 AMF $2.5 (all) Incentive
1 GiveDirectly $2.5 (all) Incentive
1 END Fund $2.5 (all) Incentive
1 Malaria Consortium $2.5 (all) Incentive
1 Other charities worthy of special recognition $1.5 (all) Incentive $250,000 each for six charities
3 SCI $6.5 (all) Fills rest of execution level 1 Highest cost-effectiveness of remaining level 1 gaps
4 AMF $8.5 (all) First part of execution level 1 Similar cost-effectiveness to END Fund and Sightsavers and greater understanding of the organization. Expect declining cost-effectiveness within Level 1, and see other benefits (incentives) to switching to END Fund and Sightsavers after this point.
5 END Fund $2.5 (all) Middle part of execution level 1 Given relatively limited knowledge of charity, capping total recommendation at $5 million
6 Sightsavers $0.5 (all) Fills rest of execution level 1 Similar cost-effectiveness to AMF and the END Fund
7 Deworm the World $2.0 (all) Fills execution level 2 Highest-ranked level 2 gap. Highest cost-effectiveness and confidence in organization
8 SCI $4.5 (all) First part of execution level 2 Highest cost-effectiveness of remaining level 2 gaps
9 Malaria Consortium $2.5 (all) Part of execution level 1 Given relatively limited knowledge of charity, capping total recommendation at $5 million
10 AMF $18.6 ($5.1) Part of execution level 1 Expect declining cost-effectiveness within level 1; ranked other gaps higher due to this and incentive effects
11 SCI $4.5 ($0) Fills execution level 2 Roughly expected to be more cost-effective than the remaining $49 million of AMF level 1

* Also includes $1 million that GiveWell holds for grants to top charities. More below.

Summary of key considerations for top charities

The table below summarizes the key considerations for our seven top charities. More detail is provided below as well as in the charity reviews.

Consideration AMF Malaria Consortium Deworm the World END Fund SCI Sightsavers GiveDirectly
Estimated cost-effectiveness (relative to cash transfers) ~4x ~4x ~10x ~4x ~8x ~5x Baseline
Our level of knowledge about the organization High Relatively low High Relatively low High Relatively low High
Primary benefits of the intervention Under-5 deaths averted and possible increased income in adulthood Possible increased income in adulthood Immediate increase in consumption and assets
Ease of communication Moderate Strong Strong Strong Moderate Moderate Strongest
Ongoing monitoring and likelihood of detecting future problems Moderate Moderate Strong Moderate Moderate Moderate Strongest
Room for more funding, after expected funding from Good Ventures and donors who give independently of our recommendation High: less than half of Execution Level 1 filled High: not quantified, but could likely use significantly more funding Low: Execution Levels 1 and 2 filled High: half of Execution Level 1 filled Moderate: Execution Level 1 and some of Level 2 filled Moderate: Execution Level 1 filled Very high: less than 15% of Execution Level 1 filled

Our recommendation to donors

If Good Ventures uses a budget of $50 million to top charities and follows our prioritization of funding gaps, it will make the following grants (in millions of dollars, rounded to one decimal place):

  • AMF: $15.1
  • Deworm the World: $4.5
  • END Fund: $5.0
  • GiveDirectly: $2.5
  • Malaria Consortium: $5.0
  • SCI: $13.5
  • Sightsavers: $3.0
  • Grants to other charities worthy of special recognition: $1.5

We also hold about $1 million that is restricted to granting out to top charities. We plan to use this to make a grant to AMF, which is the next funding gap on the list after the expected grants from Good Ventures.

We estimate that non-Good Ventures donors will give approximately $27 million between now and the start of June 2017; we expect to refresh our recommendations to donors in mid-June. Of this, we expect $18 million will be allocated according to our recommendation for marginal donations, while $9 million will be given based on our top charity list—this $9 million is considered ‘expected funding’ for each charity and therefore subtracted from their room for more funding.

$18 million spans two gaps in our prioritized list, so we are recommending that donors split their gift, with 75% going to AMF and 25% going to SCI, or give to GiveWell for making grants at our discretion and we will use the funds to fill in the next highest priority gaps.

Details on new top charities

Before this year, our top charity list had remained nearly the same for several years. This means that we have spent hundreds of hours talking to these groups, reading their documents, visiting their work in the field, and modeling their cost-effectiveness. We have spent considerably less time on our new top charities, particularly Malaria Consortium, and have not visited their work in the field (though we met with Sightsavers’ team in Ghana). We believe our new top charities are outstanding giving opportunities, though we think there is a higher risk that further investigation will lead to changes in our views about these groups.

A note about deworming

Four of our top charities, including two new top charities, support programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) (“deworming”). We estimate that SCI and Deworm the World’s deworming programs are more cost effective than mass bednet campaigns, but our estimates are subject to substantial uncertainty. For Sightsavers and END Fund, our greater uncertainty about cost per treatment and prevalence of infection in the areas where they work leads us to the conclusion that the cost-effectiveness of their work is on par with that of bednets. It’s important to note that we view deworming as high expected value, but this is due to a relatively low probability of very high impact. Our cost-effectiveness model implies that most staff members believe you should use a multiplier of less than 1% compared to the impact (increased income in adulthood) found in the original trials—this could be thought of as assigning some chance that deworming programs have no impact, and some chance that the impact exists but will be smaller than was measured in those trials. Full discussion in this blog post. Our 2016 cost-effectiveness analysis is here.

This year, David Roodman conducted an investigation into the evidence for deworming’s impact on long-term life outcomes. David will write more about this in a future post, but in short, we think the strength of the case for deworming is similar to last year’s, with some evidence looking weaker, new evidence that was shared with us in an early form this year being too preliminary to incorporate, and a key piece of evidence standing up to additional scrutiny.

END Fund (for work on deworming)

Our full review of END Fund is here.

Overview

The END Fund (end.org) manages grants, provides technical assistance, and raises funding for controlling and eliminating neglected tropical diseases (NTDs). We have focused our review on its support for deworming.

About 60% of the treatments the END Fund has supported have been deworming treatments, while the rest have been for other NTDs. The END Fund has funded SCI, Deworm the World, and Sightsavers. We see the END Fund’s value-add as a GiveWell top charity as identifying and providing assistance to programs run by organizations other than those we separately recommend, and our review of the END Fund has excluded results from charities on our top charity list.

We have not yet seen monitoring results on the number of children reached in END Fund-supported programs. The END Fund has instituted a requirement that grantees conduct coverage surveys and the first results will be available in early 2017. While we generally put little weight on plans for future monitoring, we feel that the END Fund’s commitment is unusually credible because surveys are already underway or upcoming in the next few months, we are familiar enough with the type of survey being used (from research on other deworming groups) that we were able to ask critical questions, and the END Fund provided specific answers to our questions.

We have more limited information on some questions for the END Fund than we do for the top charities we have recommended for several years. We do not have a robust cost per treatment figure, and also have limited information on infection prevalence and intensity.

Funding gap

We estimate that the END Fund could productively use between $10 million (50% confidence) and $22 million (5% confidence) in the next year to expand its work on deworming. By our estimation, about a third of this would be used to fund other NTD programs.

This estimate is based on (a) a list of deworming funding opportunities that the END Fund had identified as of October and its expectation of identifying additional opportunities over the course of the year (excluding opportunities to grant funding to Deworm the World, SCI, or Sightsavers, which we count in those organizations’ room for more funding); and (b) our rough estimate of how much funding the END Fund will raise. The END Fund is a fairly new organization whose revenue comes primarily from a small number of major donors so it is hard to predict how much funding it will raise.

The END Fund’s list of identified opportunities includes both programs that END Fund has supported in past years and opportunities to get new programs off the ground.

Sightsavers (for work on deworming)

Our full review of Sightsavers is here.

Overview

Sightsavers (sightsavers.org) is a large organization with multiple program areas that focuses on preventing avoidable blindness and supporting people with impaired vision. Our review focuses on Sightsavers’ work to prevent and treat neglected tropical diseases (NTDs) and, more specifically, advocating for, funding, and monitoring deworming programs. Deworming is a fairly new addition to Sightsavers’ portfolio; in 2011, it began delivering some deworming treatments through NTD programs that had been originally set up to treat other infections.

We believe that deworming is a highly cost-effective program and that there is moderately strong evidence that Sightsavers has succeeded in achieving fairly high coverage rates for some of its past NTD programs. We feel that the monitoring data we have from SCI and Deworm the World is somewhat stronger than what we have from Sightsavers—in particular, the coverage surveys that Sightsavers has done to date were on NTD programs that largely did not include deworming. Sightsavers plans to do annual coverage surveys on programs that are supported by GiveWell-influenced funding.

We have more limited information on some questions for Sightsavers than we do for the top charities we have recommended for several years. We do not have a robust cost-per-treatment figure, though the information we have suggests that it is in the same range as the cost-per-treatment figures for SCI and Deworm the World. We also have limited information on infection prevalence and intensity in the places Sightsavers works. This limits our ability to robustly compare Sightsavers’ cost effectiveness to other top charities, but our best guess is that the cost-effectiveness of the deworming charities we recommend is similar.

Funding gap

We believe Sightsavers could productively use or commit between $3.0 million (50% confidence) and $10.1 million (5% confidence) in funding restricted to programs with a deworming component in 2017.

This estimate is based on (a) a list of deworming funding opportunities that Sightsavers created for us; and (b) our understanding that Sightsavers would not allocate much unrestricted funding to these opportunities in the absence of GiveWell funding. It’s difficult to know whether other funders might step in to fund this work, but Sightsavers believes that is unlikely and deworming has not been a major priority for Sightsavers to date.

Sightsavers’ list of opportunities includes both adding deworming to existing NTD mass distribution programs and establishing new integrated NTD programs that would include deworming and spans work in Nigeria, Guinea-Bissau, Democratic Republic of Congo, Guinea, Cameroon, Cote d’Ivoire, and possibly South Sudan.

Malaria Consortium (for work on seasonal malaria chemoprevention)

Our full review of Malaria Consortium is here.

Overview

Malaria Consortium (malariaconsortium.org) works on preventing, controlling, and treating malaria and other communicable diseases in Africa and Asia. Our review has focused exclusively on its seasonal malaria chemoprevention (SMC) programs, which distribute preventive anti-malarial drugs to children 3-months to 59-months old in order to prevent illness and death from malaria.

The evidence for SMC appears strong (stronger than deworming and not quite as strong as bednets), but we have not yet examined the intervention at nearly the same level that we have for bednets, deworming, unconditional cash transfers, or other priority programs. The randomized controlled trials on SMC that we considered showed a decrease in cases of clinical malaria but were not adequately powered to find an impact on mortality.

Malaria Consortium and its partners have conducted studies in most of the countries where it has worked to determine whether its programs have reached a large proportion of children targeted. These studies have generally found positive results, but leave us with some remaining questions about the program’s impact.

Overall, we have more limited information on some questions for Malaria Consortium than we do for the top charities we have recommended for several years. We have remaining questions on cost per child per year and on offsetting effects from possible drug resistance and disease rebound.

Funding gap

We have not yet attempted to estimate Malaria Consortium’s maximum room for more funding. We would guess that Malaria Consortium could productively use at least an additional $30 million to scale up its SMC activities over the next three to four years. We have a general understanding of where additional funds would be used but have not yet asked for a high level of detail on potential bottlenecks to scaling up.

We do not believe Malaria Consortium has substantial unrestricted funding available for scaling up its support of SMC programs and expect its restricted funding for SMC to remain steady or decrease in the next few years.

Details on top charities we are continuing to recommend

Against Malaria Foundation (AMF)

Our full review of AMF is here.

Background

AMF (againstmalaria.com) provides funding for long-lasting insecticide-treated net distributions (for protection against malaria) in developing countries. There is strong evidence that distributing nets reduces child mortality and malaria cases.

AMF provides a level of public disclosure and tracking of distributions that we have not seen from any other net distribution charity.

We estimate that AMF’s program is roughly 4 times as cost effective as cash transfers (see our cost-effectiveness analysis). This estimate seeks to incorporate many highly uncertain inputs, such as the effect of mosquito resistance to the insecticides used in nets on how effective they are at protecting against malaria, how differences in malaria burden affect the impact of nets, and how to discount for displacing funding from other funders, among many others.

Important changes in the last 12 months

In 2016, AMF significantly increased the number and size of distributions it committed funding to. Prior to 2015, it had completed (large-scale) distributions in two countries, Malawi and Democratic Republic of Congo (DRC). In 2016, it completed a distribution in Ghana and committed to supporting distributions in an additional three countries, including an agreement to contribute $28 million to a campaign in Uganda, its largest agreement to date by far.

AMF has continued to collect and share information on its past large-scale distributions. This includes both data from registering households to receive nets (and, in some cases, data on the number of nets each household received) and follow-up surveys to determine whether nets are in place and in use. Our research in 2016 has led us to moderately weaken our assessment of the quality of AMF’s follow up surveys. In short, we learned that the surveys in Malawi have not used fully randomized selection of households and that the first two surveys in DRC were not reliable (full discussion in this blog post). We expect to see follow-up surveys from Ghana and DRC in the next few months that could expand AMF’s track record of collecting this type of data. We also learned that AMF has not been carrying out data audits in the way we believed it was (though this was not a major surprise as we had not asked AMF for details of the auditing process previously).

AMF has generally been communicative and open with us. We noted in our mid-year update that AMF had been slower to share documentation for some distributions; however, we haven’t had concerns about this in the second half of the year.

In August 2016, four GiveWell staff visited Ghana where an AMF-funded distribution had recently been completed. We met with AMF’s program manager, partner organizations, and government representatives and visited households in semi-urban and rural areas (notes and photos from our trip).

Our estimate of the cost-effectiveness of nets has fallen relative to cash transfers since our mid-year update. At that point, we estimated that nets were ~10x as cost-effective as cash transfers, and now we estimate that they are ~4x as cost-effective as cash transfers. This change was partially driven by changes in GiveWell staff’s judgments on the tradeoff between saving lives of children under five and improving lives (through increased income and consumption) in our model, and partially driven by AMF beginning to fund bed net distributions in countries with lower malaria burdens than Malawi or DRC.

Funding gap

AMF currently holds $17.8 million, and expects to commit $12.9 million of this soon. We estimate it will receive an additional $4 million by June 2017 ($2 million from donors not influenced by GiveWell and $2 million from donors who give based on our top charity list) that it could use for future distributions. Together, we expect that AMF will have about $9 million for new spending and commitments in 2017.

We estimate that AMF could productively use or commit between $87 million (50% confidence) and $200 million (5% confidence) in the next year. We arrived at this estimate from a rough estimate of the total Africa-wide funding gap for nets in the next three years (from the African Leaders Malaria Alliance)—estimated at $125 million per year. The estimate is rough in large part because the Global Fund to Fight AIDS, Tuberculosis and Malaria, the largest funder of LLINs, works on three-year cycles and has not yet determined how much funding it will allocate for LLINs for 2018-2020. We talked to people involved in country-level planning of mass net distributions and the Global Fund, who agreed with the general conclusion that there were likely to be large funding gaps in the next few years. In mid-2016, AMF had to put some plans on hold due to lack of funding.

We now believe that AMF has a strong track record of finding distribution partners to work with and coming to agreements with governments, and we do not expect that to be a limiting factor for AMF. The main risks we see to AMF’s ability to scale are the possibility that funding from other funders is sufficient (since our estimate of the gap is quite rough), the likelihood that government actors have limited capacity for discussions with AMF during a year in which they are applying for Global Fund funding, AMF’s staff capacity to manage discussions with additional countries (it has only a few staff members), and whether gaps will be spread across many countries or located in difficult operating environments. We believe the probability of any specific one of these things impeding AMF’s progress is low.

We believe there are differences in cost-effectiveness within execution level 1 and believe the value of filling the first part of AMF’s gap may be higher than additional funding at higher levels. This is because AMF’s priorities include committing to large distributions in the second half of 2019 and 2020, which increases the uncertainty about whether funding would have been available from another source.

We and AMF have discussed a few possibilities for how AMF might fill funding gaps. AMF favors an approach where it purchases a large number of nets for a small number of countries. This approach has some advantages including efficiency for AMF and leverage in influencing how distributions are carried out. Our view is that the risk of displacing a large amount of funding from other funders using this approach outweighs the benefits. If AMF did displace a large amount of funding which would otherwise have gone to nets, that could make donations applied to these distributions considerably less cost-effective. More details on our assessment of AMF’s funding gap are in our full review.

Deworm the World Initiative, led by Evidence Action

Our full review of Deworm the World is here.

Background

Deworm the World (evidenceaction.org/#deworm-the-world), led by Evidence Action, advocates for, supports, and evaluates deworming programs. It has worked in India and Kenya for several years and has recently expanded to Nigeria, Vietnam, and Ethiopia.

Deworm the World retains or hires monitors who visit schools during and following deworming campaigns. We believe its monitoring is the strongest we have seen from any organization working on deworming. Monitors have generally found high coverage rates and good performance on other measures of quality.

As noted above, we believe that Deworm the World is slightly more cost-effective than SCI, more cost-effective than AMF and the other deworming charities, and about 10 times as cost-effective as cash transfers.

Important changes in the last 12 months

Deworm the World has made somewhat slower progress than expected in expanding to new countries. In late 2015, Good Ventures, on GiveWell’s recommendation, made a grant of $10.8 million to Deworm the World to fund its execution level 1 and 2 gaps. Execution level 1 funding was to give Deworm the World sufficient resources to expand into Pakistan and another country. Deworm the World has funded a prevalence survey in Pakistan, which is a precursor to funding treatments in the country. It has not expanded into a further country that it was not already expecting to work in. As a result, we believe that Deworm the World has somewhat limited room for more funding this year.

Overall, we have more confidence in our understanding of Deworm the World and its parent organization Evidence Action’s spending, revenues, and financial position than we did in previous years. While trying to better understand this information this year, we found several errors. We are not fully confident that all errors have been corrected, though we are encouraged by the fact that we are now getting enough information to be able to spot inconsistencies. Evidence Action has been working to overhaul its financial system this year.

Our review of Deworm the World has focused on two countries, Kenya and India, where it has worked the longest. In 2016, we saw the first results of a program in another country (Vietnam), as well as continued high-quality monitoring from Kenya and India. The Vietnam results indicate that Deworm the World is using similar monitoring processes in new countries as it has in Kenya and India and that results in Vietnam have been reasonably strong.

Evidence Action hired Jeff Brown (formerly Interim CEO of the Global Innovation Fund) as CEO in 2015. Recently Evidence Action announced that he has resigned and has not yet been replaced. Our guess is this is unlikely to be disruptive to Deworm the World’s work; Grace Hollister remains Director of the Deworm the World Initiative.

Funding gap

We believe that there is a 50% chance that Deworm the World will be slightly constrained by funding in the next year and that additional funds would increase the chances that it is able to take advantage of any high-value opportunities it encounters. We estimate that if it received an additional $4.5 million its chances of being constrained by funding would be reduced to 20% and at $13.4 million in additional funding, this would be reduced to 5%.

In the next year, Deworm the World expects to expand its work in India and Nigeria and may have opportunities to begin treatments in Pakistan and Indonesia. It is also interested in using unrestricted funding to continue its work in Kenya, and puts a high priority on this program. Its work in Kenya has to date been funded primarily by the Children’s Investment Fund Foundation (CIFF) and this support is set to expire in mid 2017. It is unclear to us whether CIFF will continue providing funding for the program and, if so, for how long. Due to the possibility that Deworm the World unrestricted funding may displace funding from CIFF, and, to a lesser extent, the END Fund and other donors, we consider the opportunity to fund the Kenya program to be less cost-effective in expectation than it would be if we were confident in the size of the gap.

More details in our full review.

Schistosomiasis Control Initiative (SCI)

Our full review of SCI is here.

Background

SCI (imperial.ac.uk/schisto) works with governments in sub-Saharan Africa to create or scale up deworming programs. SCI’s role has primarily been to identify recipient countries, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs.

SCI has conducted studies in about two-thirds of the countries it works in to determine whether its programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but leave us with some remaining questions about the program’s impact.

As noted above, we believe that SCI is slightly less cost-effective than Deworm the World, more cost-effective than AMF and the other deworming charities, and about 8 times as cost-effective as cash transfers.

Important changes in the last 12 months

In past years, we’ve written that we had significant concerns about SCI’s financial reporting and financial management, and the clarity of our communication with SCI. In June, we wrote that we had learned of two substantial errors in SCI’s financial managment and reporting that began in 2015. We also noted that we thought that SCI’s financial management and financial reporting, as well as the clarity of its communication with us overall, had improved significantly. In the second half of the year, SCI communicated clearly with us about its plans for deworming programs next year and its room for more funding.

SCI reports that it has continued to scale up its deworming programs over the past year and that it plans to start up new deworming programs in two states in Nigeria before the end of its current budget year.

This year, SCI has shared a few more coverage surveys from deworming programs in Ethiopia, Madagascar, and Mozambique that found reasonably high coverage.

Professor Alan Fenwick, Founder and Director of SCI for over a decade, retired from his position this year, though will continue his involvement in fundraising and advocacy. The former Deputy Director, Wendy Harrison, is the new Director.

Funding gap

We estimate that SCI could productively use or commit a maximum of between $9.0 million (50% confidence) and $21.4 million (5% confidence) in additional unrestricted funding in its next budget year.

Its funding sources have been fairly steady in recent years with about half of its revenue in the form of restricted grants, particularly from the UK government’s Department for International Development (this grant runs through 2018), and half from unrestricted donations, a majority of which were driven by GiveWell’s recommendation. We estimate that SCI will have around $5.4 million in unrestricted funding available to allocate to its 2017-18 budget year (in addition to $6.5 million in restricted funding).

SCI has a strong track record of starting and scaling up programs in a large number of countries. SCI believes it could expand significantly with additional funding, reaching more people in the countries it works in and expanding to Nigeria and possibly Chad.

More details in our full review.

GiveDirectly

Our full review of GiveDirectly is here.

Background

GiveDirectly (givedirectly.org) transfers cash to households in developing countries via mobile phone-linked payment services. It targets extremely low-income households. The proportion of total expenses that GiveDirectly has delivered directly to recipients is approximately 82% overall. We believe that this approach faces an unusually low burden of proof, and that the available evidence supports the idea that unconditional cash transfers significantly help people.

We believe GiveDirectly to be an exceptionally strong and effective organization, even more so than our other top charities. It has invested heavily in self-evaluation from the start, scaled up quickly, and communicated with us clearly. It appears that GiveDirectly has been effective at delivering cash to low-income households. GiveDirectly has one major randomized controlled trial (RCT) of its impact and took the unusual step of making the details of this study public before data was collected (more). It continues to experiment heavily, with the aim of improving how its own and government cash transfer programs are run. It has recently started work on evaluations that benchmark programs against cash with the aim of influencing the broader international aid sector to use its funding more cost-effectively.

We believe cash transfers are less cost-effective than the programs our other top charities work on, but have the most direct and robust case for impact. We use cash transfers as a “baseline” in our cost-effectiveness analyses and only recommend other programs that are robustly more cost effective than cash.

Important changes in the last 12 months

GiveDirectly has continued to scale up significantly, reaching a pace of delivering $21 million on an annual basis in the first part of 2016 and expecting to reach a pace of $50 million on an annual basis at the end of 2016. It has continued to share informative and detailed monitoring information with us. Given its strong and consistent monitoring in the past, we have taken a lighter-touch approach to evaluating its processes and results this year.

The big news for GiveDirectly this year was around partnerships and experimentation. It expanded into Rwanda (its third country) and launched a program to compare, with a randomized controlled trial, another aid program to cash transfers (details expected to be public next year). The program is being funded by a large institutional funder and Google.org. It expects to do additional “benchmarking” studies with the institutional funder, using funds from Good Ventures’ 2015 $25 million grant, over the next few years.

It also began fundraising for and started a pilot of a universal basic income (UBI) guarantee—a program providing long-term, ongoing cash transfers sufficient for basic needs, which will be evaluated with a randomized controlled trial comparing the program to GiveDirectly’s standard lump sum transfers. The initial UBI program and study is expected to cost $30 million. We estimate that it is less cost-effective than GiveDirectly’s standard model, but it could have impact on policy makers that isn’t captured in our analysis.

We noted previously that Segovia, a for-profit technology company that develops software for cash transfer program implementers and which was started and is partially owned by GiveDirectly’s co-founders, would provide its software for free to GiveDirectly to avoid conflicts of interest. However, in 2016, after realizing that providing free services to GiveDirectly was too costly for Segovia (customizing the product for GiveDirectly required much more Segovia staff time than initially expected), the two organizations negotiated a new contract under which GiveDirectly will compensate Segovia for its services. GiveDirectly wrote about this decision here. GiveDirectly told us that it recused all people with ties to both organizations from this decision and evaluated alternatives to Segovia. Although we believe that there are possibilities for bias in this decision and in future decisions concerning Segovia, and we have not deeply vetted GiveDirectly’s connection with Segovia, overall we think GiveDirectly’s choices were reasonable. However, we believe that reasonable people might disagree with this opinion, which is in part based on our personal experience working closely with GiveDirectly’s staff for several years.

Funding gap

We believe that GiveDirectly is very likely to be constrained by funding next year. GiveDirectly has been rapidly building its capacity to enroll recipients and deliver funds, while some of its revenue has been redirected to its universal basic income guarantee program (either because of greater donor interest in that program or by GiveDirectly focusing its fundraising efforts on it).

We expect GiveDirectly to have about $20 million for standard cash transfers in its 2017 budget year. This includes raising about $15.8 million from non-GiveWell-influenced sources between now and halfway through its 2017 budget year (August 2017) and $4 million from donors who give because GiveDirectly is on GiveWell’s top charity list. $4 million is much less than GiveWell-influenced donors gave in the last year. This is because several large donors are supporting GiveDirectly’s universal basic income guarantee program this year and because one large donor gave a multi-year grant that we don’t expect to repeat this year.

GiveDirectly is currently on pace (with no additional hiring) to have four full teams operating its standard cash transfer model in 2017. To fully utilize four teams, it would need $28 million more than we expect it to raise. We accordingly expect that GiveDirectly will downsize somewhat in 2017, because we do not project it raising sufficient funds to fully utilize the increased capacity it has built to transfer money. Given recent growth, we believe that GiveDirectly could easily scale beyond four teams and we estimate that at $46 million more than we expect it to raise ($66 million total for standard transfers), it would have a 50% chance of being constrained by funding.

Other charities worthy of special recognition

Last year, we recommended four organizations as “standouts.” This year we are calling this list “other charities worthy of special recognition.” We’ve added two organizations to the list: Food Fortification Initiative and Project Healthy Children. Although our recommendation to donors is to give to our top charities over these charities, they stand out from the vast majority of organizations we have considered in terms of the evidence base for their work and their transparency, and they offer additional giving options for donors who feel highly aligned with their work.

We don’t follow these organizations as closely as we do our top charities. We generally have one or two calls per year with each group, publish notes on our conversations, and follow up on any major developments.

We provide brief updates on these charities below:

  • Organizations that have conducted randomized controlled trials of their programs:
    • Development Media International (DMI). DMI produces radio and television programming in developing countries that encourages people to adopt improved health practices. It conducted a randomized controlled trial (RCT) of its program and has been highly transparent, including sharing preliminary results with us. The results of its RCT were mixed, with a household survey not finding an effect on mortality (it was powered to detect a reduction of 15% or more) and data from health facilities finding an increase in facility visits. (The results, because the trial was only completed in the last year, are not yet published.) We believe there is a possibility that DMI’s work is highly cost-effective, but we see no solid evidence that this is the case. We noted last year that DMI was planning to conduct another survey for the RCT in late 2016; it has decided not to move forward with this, but is interested in conducting new research studies in other countries, if it is able to raise the money to do so. It is our understanding that DMI will be constrained by funding in the next year. Our full review of DMI, with conversation notes and documents from 2016, is here.
    • Living Goods. Living Goods recruits, trains, and manages a network of community health promoters who sell health and household goods door-to-door in Uganda and Kenya and provide basic health counseling. They sell products such as treatments for malaria and diarrhea, fortified foods, water filters, bednets, clean cookstoves, and solar lights. Living Goods completed a randomized controlled trial of its program and measured a 27% reduction in child mortality. Our best guess is that Living Goods’ program is less cost-effective than our top charities, with the possible exception of cash. Living Goods is scaling up its program and may need additional funding in the future, but has not yet been limited by funding. We published an update on Living Goods in mid-2016. Our 2014 review of Living Goods is here.
  • Organizations working on micronutrient fortification: We believe that food fortification with certain micronutrients can be a highly effective intervention. For each of these organizations, we believe they may be making a significant difference in the reach and/or quality of micronutrient fortification programs but we have not yet been able to establish clear evidence of their impact. The limited analysis we have done suggests that these programs are likely not significantly more cost-effective than our top charities—if they were, we might put more time into this research or recommend a charity based on less evidence.
    • Food Fortification Initiative (FFI). FFI works to reduce micronutrient deficiencies (especially folic acid and iron deficiencies) by doing advocacy and providing assistance to countries as they design and implement flour and rice fortification programs. We have not yet completed a full evidence review of iron and folic acid fortification, but our initial research suggests it may be competitively cost effective with our other priority programs. Because FFI typically provides support alongside a number of other actors and its activities vary widely among countries, it is difficult to assess the impact of its work. Our full review is here.
    • Global Alliance for Improved Nutrition (GAIN) – Universal Salt Iodization (USI) program. GAIN’s USI program supports national salt iodization programs. We have spent the most time attempting to understand GAIN’s impact in Ethiopia. Overall, we would guess that GAIN’s activities played a role in the increase in access to iodized salt in Ethiopia, but we do not yet have confidence about the extent of GAIN’s impact. It is our understanding that GAIN’s USI work will be constrained by funding in the next year. Our review of GAIN, published in 2016 based on research done in 2015, is here.
    • IGN. Like GAIN-USI, IGN supports (via advocacy and technical assistance rather than implementation) salt iodization. IGN is small, and GiveWell-influenced funding has made up a large part of its funding in the past year. This year, we published an update on our investigation into IGN’s work in select countries in 2015 and notes from our conversation with IGN to learn about its progress in 2016 and plans for 2017. It is our understanding that IGN will be constrained by funding in the next year. Our review of IGN, from 2014, is here.
    • Project Healthy Children (PHC). PHC aims to reduce micronutrient deficiencies by providing assistance to small countries as they design and implement food fortification programs. Our review is preliminary and in particular we do not have a recent update on how PHC would use additional funding. Our review of PHC, published in 2016 but based on information collected in 2015, is here.

Our research process in 2016

We plan to detail the work we completed this year in a future post as part of our annual review process. Much of this work, particularly our experimental work and work on prioritizing interventions for further investigation, is aimed at improving our recommendations in future years. Here we highlight the key research that led to our current recommendations. See our process page for our overall process.

  • As in previous years, we did intensive follow up with each of our top charities, including publishing updated reviews mid-year. We had several conversations by phone with each organization, met in person with Deworm the World, SCI, and AMF (over the course of a 4-day site visit to Ghana), and reviewed documents they shared with us.
  • In 2015 and 2016, we sought to expand top charity room for more funding and consider alternatives to our top charities by inviting other groups that work on deworming, bednet distributions, and micronutrient fortification to apply. This led to adding Sightsavers, the END Fund, Project Healthy Children, and Food Fortification Initiative to our lists this year. Episcopal Relief & Development’s NetsforLife® Program, Micronutrient Initiative, and Nothing but Nets declined to fully participate in our review process.
  • We completed intervention reports on voluntary medical male circumcision (VMMC) and cataract surgery. We asked VMMC groups PSI (declined to fully participate) and the Centre for HIV and AIDS Prevention Studies (pending) to apply. We had conversations with several charities working on cataract surgery and have not yet asked any to apply.
  • We did very preliminary investigations into a large number of interventions and prioritized a few for further work. This led to interim intervention reports on seasonal malaria chemoprevention (SMC), integrated community case management (iCCM) and ready-to-use therapeutic foods for treating severe acute malnutrition and recommending Malaria Consortium for its work on SMC.
  • We stayed up to date on the research for bednets, cash transfers, and deworming. We published a report on insecticide resistance and its implications for bednet programs. A blog post on our work on deworming is forthcoming. We did not find major new research on cash transfers that affected our recommendation of GiveDirectly.

Giving to GiveWell vs. top charities

GiveWell and the Open Philanthropy Project are planning to split into two organizations in the first half of 2017. The split means that it is likely that GiveWell will retain much of the assets of the previously larger organization while reducing its expenses. We think it’s fairly likely that our excess assets policy will be triggered and that we will grant out some unrestricted funds. Given that expectation, our recommendation to donors is:

  • If you have supported GiveWell’s operations in the past, we ask that you consider maintaining your support. It is fairly likely that these funds will be used this year for grants to top charities, but giving unrestricted signals your support for our operations and allows us to better project future revenue and make plans based on that. Having a strong base of consistent support allows us to make valuable hires when opportunities arise and minimize staff time spent on fundraising.
  • If you have not supported GiveWell’s operations in the past, we ask that you consider checking the box on our donate form to add 10% to help fund GiveWell’s operations. In the long term, we seek to have a model where donors who find our research useful contribute to the costs of creating it, while holding us accountable to providing high-quality, easy-to-use recommendations.

Footnotes:

* For example, if $30 million were available to fund gaps of $10 million, $5 million, and $100 million, we would recommend allocating the funds so that the $10 million and $5 million gaps were fully filled and the $100 million gap received $15 million.

New Incentives update

We’re planning to release updated top-charity recommendations in mid-November, and one of the questions our staff has been debating recently is whether to recommend New Incentives as a top charity.

We’ve decided that New Incentives doesn’t currently meet our criteria for a top charity because its program doesn’t have sufficient evidence supporting it. However, we have been extremely impressed with and think very highly of New Incentives’ staff and are considering how best to support them in the future and incentivize others to found an organization like they did.

In this post, we summarize the answers to the key questions we asked to determine whether New Incentives meets our criteria for a top charity recommendation and the options we’re considering for future support.

Background

New Incentives operates a conditional cash transfer (CCT) program in Nigeria to incentivize pregnant women to deliver in a health facility. New Incentives originally intended its CCT program to focus primarily on prevention of mother-to-child transmission (PMTCT) of HIV. However, under this model the program did not reach enough HIV-positive pregnant women to justify its operating costs, and in 2015, New Incentives expanded its program to target both HIV-positive women and HIV-negative women.

New Incentives was the first organization we supported as part of our experimental work to support the development of future top charities. It has been about two and a half years since New Incentives received its initial grant, and it now has a long enough track record implementing its program to be considered for a top charity designation.

Is New Incentives’ intervention evidence-backed?

New Incentives’ impact is made up of three components: (a) delivering cash to very poor people, (b) incentivizing HIV-positive pregnant women to deliver in clinics and get the medicines that prevent mother-to-child transmission of HIV, and (c) incentivizing pregnant women to deliver their babies in a health facility.

Because a relatively small portion of New Incentives’ beneficiaries are HIV-positive, because it costs New Incentives more than GiveDirectly to deliver each dollar, and because it is likely reaching individuals with higher incomes than GiveDirectly does, the impact that has the dominant effect on our view about whether or not New Incentives meets the standard we have for a top charity’s cost-effectiveness is the impact of facility delivery on neonatal mortality.

The evidence we have for the impact of facility delivery comes from (1) relevant randomized controlled trials (RCTs), (2) monitoring that New Incentives carries out, and (3) non-RCT evidence on the impact of facility delivery.

Overall, the evidence from the RCTs increases our confidence that an intervention that offers improved neonatal care could have a significant impact on neonatal mortality, but the evidence we have seen and New Incentives’ current monitoring of its program is insufficient to convince us that increasing the number of women who deliver at facilities has a similar impact.

Randomized controlled trial evidence

Two RCTs of low-intensity training programs for traditional birth attendants found significant (30-45%) reductions in neonatal mortality. These interventions are different than New Incentives’ intervention but may have a similar effect since they aim to increase the knowledge of traditional birth attendants so that they offer similar care to that which is offered in health facilities. We did not find any RCTs on facility delivery itself; these two RCTs are the most similar ones to New Incentives’ program that we identified. The interventions varied:

  • In Gill et al. 2011, the intervention group received training and supplies related to common practices to reduce neonatal mortality immediately following birth. The study observed significant differences between the treatment and control group on practices such as drying the baby with a cloth and then wrapping it in a separate blanket (as opposed to using the same blanket), clearing the baby’s mouth and nose with a suction bulb (instead of a cloth), and using a pocket resuscitator (instead of mouth to mouth) (see Table 5, Pg. 8).

    We have not closely vetted this study but note some significant-seeming differences between the treatment and control birth attendants–in particular, the treatment group had significantly more education than the control group (see Table 1, Pg. 4).

  • In Jokhio et al. 2005, the intervention group received supplies and 3 days of training focused on antepartum, intrapartum, and postpartum care, including activities such as: “how to conduct a clean delivery; use of the disposable delivery kit; when to refer women for emergency obstetrical care; and care of the newborn.” The intervention group was “asked to visit each woman at least three times during the pregnancy (at three, six, and nine months) to check for dangerous signs such as bleeding or eclampsia, and to encourage women with such signs to seek emergency obstetrical care.”

New Incentives’ monitoring

New Incentives’ staff interviews a nurse and conducts additional inspection at each health facility it considers working with. New Incentives reports the results of these interviews. Two questions are most relevant to our assessment of the similarity between the interventions studied in the RCTs discussed above and the care offered in facilities New Incentives works with.

New Incentives asks nurses at each health facility: 1) “What multiple steps do you take immediately after delivery?” and 2) “What are the essential steps immediately after birth in ensuring that the baby can breathe and is warm?”

For the first question, New Incentives counts how many of the following steps nurses say they take (without being prompted by the New Incentives staff member asking the question): a) Dry baby with cloth, b) Slightly rub baby, c) Clear airways, d) Use air mask if necessary, e) Regulate temperature (put on mother’s belly), f) Don’t know/refused to answer. For the second question, New Incentives captures a free form answer.

We have limited information about the differences in practices between the intervention and control groups in Jokhio et al. 2005, but we do have this information for Gill et al. 2011. (See Gill et al. 2011, Table 5, Pg. 8.) It does not appear that the way New Incentives evaluates answers to its first question can tell us whether nurses in the facilities with which it works follow the improved practices from Gill et al. 2011.

We aggregated the answers to the second question, and 17 of 54 answers explicitly mentioned using a bulb syringe or mucus extractor, which we would guess is equivalent to clearing the baby’s mouth and nose with a suction bulb in Gill et al. 2011 (another 11 mentioned ‘clear airways’ or ‘suck’ which might refer to the procedure used in Gill et al. 2011). We were not able to get additional relevant information from nurses’ answers to the second question.

New Incentives does not appear to ask questions that fully address the other major difference between the intervention and control groups in Gill: use of a resuscitation intervention.

The intervention offered by Jokhio et al. 2005 includes antenatal care in addition to intrapartum and postpartum care, and we don’t know what impacts each part of the intervention had.

Note that New Incentives does not systematically collect data on the type of care women who enroll in its program would have received had they not delivered in a facility, though it has done some limited surveys of traditional birth attendants in the areas it works in.

Non-randomized evaluations of the impact of facility delivery

We have not carefully reviewed these studies, and the studies we identified found mixed effects (including some studies finding higher neonatal mortality in facilities) but we have major questions about these studies’ ability to assess facilities’ causal impact.[1] In particular, women may be more likely to go to a facility for childbirth when they are experiencing complications, which could bias the results.

What is our best guess about New Incentives’ cost-effectiveness?

The most important questions in assessing New Incentives’ cost-effectiveness are (a) the impact its cash transfers have on rates of facility delivery and (b) the impact that increased facility delivery has on neonatal mortality.

New Incentives is conducting an RCT of its impact on (a) and preliminary results indicate that it had a significant impact on facility deliveries: 48% of women in the treatment group (i.e., all those who were offered the opportunity to enroll in the program even if they chose not to do so) delivered in a facility versus 27% in the control group. However, there are differences between the program studied by New Incentives’ RCT and its current program; the RCT only targeted HIV-positive women, so some portion of the impact may be attributable to educating women about the importance of PMTCT. The program studied in the RCT also provided larger cash transfers than New Incentives will provide in its ongoing program: the program originally gave 6,000 naira (approximately 19 US dollars) for enrollment, 20,000 naira for delivery, and 6,000 naira for an HIV test; the program currently gives 1,000 naira for enrollment and 10,000 naira for delivery.

As noted above, we have very limited information to rely on when forming an estimate of the impact of facility delivery on neonatal mortality, and we do not see the evidence from the RCTs described above as particularly relevant or informative.

However, in trying to arrive at our best guess of the impact of the program, we also considered the facts that:

  • The interventions described in Gill et al. 2011 and Jokhio et al. 2005 are relatively low cost and of limited intensity, and they find significant decreases in neonatal mortality. This increases the plausibility that merely referring women to facilities for childbirth could have a similar, significant impact.
  • Our intuition (supported by what appears to be conventional wisdom in the global health community) strongly implies that delivering in a facility (in general, without respect to the specific facilities New Incentives works with in Nigeria) is likely to lead to lower mortality than alternatives.

Philosophical value judgments

Based on the results from the RCTs, we would expect New Incentives’ program to primarily prevent deaths of very young children (largely those within the first days or week of life). In internal, staff discussions about New Incentives, we have asked ourselves how we value the lives of newborn children vs. the lives of those saved by malaria nets (the other life-saving intervention we currently recommend). We have not completed a thorough assessment of the ages at which people die from malaria, but our impression is that the median age of death is approximately 1.[2]

We believe there is no “right” answer to this question, but depending on one’s values, the answer could have a significant impact on the relative cost-effectiveness of New Incentives vs. the Against Malaria Foundation, and by extension our other top charities.

Key considerations include:

  • One could simply sum the number of remaining years of life lost due to a death of a newborn vs a 1-year-old.
  • One could focus solely on lives saved and treat all lives as equivalent.
  • One might say that families and society have invested more in 1-year-olds and that 1-year-olds have more self-awareness and “personhood” than newborns, leading to valuing the 1-year-old more than the newborn.

Primarily for the last reason, the GiveWell staff who participated in these discussions tend to value 1-year-old lives over newborns, though our relative weights vary considerably.

Best guess cost-effectiveness estimate

Ultimately, we don’t have enough information to arrive at a reliable estimate of the impact of facility delivery on neonatal mortality. Our best guess is extremely rough, based primarily on intuitions formed based on limited data, and one that could easily shift significantly. We asked all staff who primarily work on GiveWell research to (a) guess the likely effect of New Incentives’ program on neonatal mortality and (b) enter the philosophical values discussed above. This yielded a median staff estimate that New Incentives was approximately as cost-effective as cash (in GiveDirectly’s program). Our cost-effectiveness model is here (.xlsx).

Is New Incentives transparent?

Yes – extremely. New Incentives has shared all of the information we have requested (and more) in a timely fashion. We feel that it is as good as any other organization we have ever engaged with on this criterion.

Options we’re considering for future support of New Incentives and/or its staff

We have discussed each of the following options with New Incentives and plan to let New Incentives’ preference drive our decision about which one to choose. In considering these options, we took into account (a) the likely direct impact funding would have and (b) the incentives that funding would create for others considering starting a new organization like New Incentives.

  1. Recommend that Good Ventures (a foundation with which we work closely that has provided past funding for our experimental work) provide an “exit grant” of approximately $1.2 million to New Incentives. New Incentives relied heavily on funding we recommended in its scale up, and abruptly stopping funding could cause it significant harm. Our impression is that funders often give grantees exit grants to offer them time to comfortably adjust their plans for fundraising and spending; this has been GiveWell’s experience with support from institutional funders. We would plan to benchmark our recommendation to the level of support New Incentives could have expected from us over the next two years (January 2017 – December 2018) as of the last time Good Ventures made a grant (March 2016). $1.2 million represents half what we would have projected New Incentives spending to be in 2017 and 2018 as of March 2016. (It grew faster than we expected since March 2016, so this is less than 50% of its projected operating expenses.)
  2. Recommend that Good Ventures agree to support some portion of New Incentives’ ongoing operations and a randomized controlled trial of New Incentives’ program’s impact on neonatal mortality. New Incentives’ program doesn’t seem cost-effective enough that we’d be willing to recommend that Good Ventures fully fund an RCT and New Incentives’ ongoing operations, but we’d consider recommending some, significant support (very roughly, we’d cap a recommendation at 50% of the total cost) if New Incentives could raise the rest of the funding elsewhere. This option would provide New Incentives with the opportunity to demonstrate that its program is more effective/cost-effective than we currently expect it to be as long as it is able to convince other funders to provide some support as well.
  3. Provide support to New Incentives/the New Incentives team to do something new. If New Incentives or its staff were interested in starting a new charity aiming to be a GiveWell top charity or significantly changing its program to focus on something more cost-effective, we would recommend that Good Ventures provide support.

We hope to decide soon about which option to pursue.

Notes
[1] We identified two relevant meta-analyses. Chinkhumba et al. 2014, a meta-analysis of six prospective cohort studied of perinatal mortality in sub-Saharan Africa found 21% higher perinatal mortality in home deliveries compared to facility deliveries (OR 1.21 [1.02-1.46]) using a fixed-effects model, but this difference was not significant using a random effects model (OR 1.21 [0.79-1.84]).

We are also concerned that studies limited to the perinatal period may not capture longer-term neonatal effects. Tura et al. 2013, a meta-analysis of 19 studies (of various methodology) of the effect of facility delivery on neonatal mortality, found mixed results. Pooled results from low- and middle-income countries showed 29% reduction in risk of neonatal death associated with facility delivery. However, results of the studies were highly heterogeneous. Of the 8 studies in sub-Saharan Africa, 4 found effect near the pooled mean, and the other 4 did not find a statistically significant effect. (Of the four that did not find a significant effect, two studies found a nonsignificant effect close to the pooled mean of all studies, and two found no effect.)

A retrospective study based on the demographic and health surveys in Nigeria found that facility delivery is associated with increased neonatal mortality (adjusted odds ratio 1.28 [1.11-1.47], Fink et al. 2015, Figure 1, Pg. 5).

[2] Here is one paper we found. We have not vetted this paper. The simple average age of death in it is approximately 1.2 years (see Table 1).

Updates on AMF’s transparency and monitoring

In our mid-year update, we continued to recommend that donors give to the Against Malaria Foundation (AMF), and we wrote that we believe AMF has the most valuable current funding gap among our top charities. We also briefly wrote about some new concerns we have about AMF based on our research from the first half of 2016.

This post describes our new concerns about AMF’s transparency and monitoring in more depth. We continue to believe that AMF stands out among bed net organizations, and among charities generally, for its transparency and the quality of its program monitoring. AMF makes substantial amounts of useful information on the impact of its programs—far more than the norm—publicly available on its website, and has generally appeared to value transparency as much as any organization we’ve encountered. But our research on AMF in 2016 has led us to moderately weaken our view that AMF stands out for these qualities. In short, this is because:

  • The first two post-distribution check-up surveys following AMF’s bed net distribution in Kasaï-Occidental, Democratic Republic of the Congo (DRC) were poorly implemented. AMF told us that it agrees that the surveys were poorly implemented and is working to improve data quality in future surveys.
  • We learned that the methodology for selecting communities and households for post-distribution check-up surveys in Malawi is less rigorous than we had previously thought.
  • AMF was slower to share information with us in 2016 than we would have liked. Unfortunately, we aren’t fully confident about what caused this to happen. We believe that AMF misunderstood the type of information we would value seeing, and this may have caused some (but not all) of this issue.

These updates somewhat lower our confidence in AMF’s track record of distributing bed nets that are used effectively (i.e., present, hanging, and in good condition) over the long term and in its commitment to transparency; however, this is only a moderate update, and we don’t think what we’ve learned is significant enough to outweigh AMF’s strengths. We continue to recommend AMF and believe that it has the highest-value current funding gap of any of our top charities.

Going forward, we plan to continue to learn more about AMF’s transparency and monitoring through reviewing the results of additional post-distribution surveys and continued communication with AMF.

Background on AMF’s strengths and evidence of impact

We recommend AMF because there is strong evidence that mass distribution of long-lasting insecticide-treated bed nets reduces child mortality and is cost-effective, and because of AMF’s strengths as an organization: a standout commitment to transparency and self-evaluation, substantial room for more funding to deliver additional bed nets, and relatively strong evidence overall on whether bed nets reach intended destinations and are used over the long term.

In particular, AMF requires that its distribution partners implement post-distribution check-up surveys every six months among a sample (around 5%) of recipient households for 2.5 years following a bed net distribution, and has publicly shared the results of these surveys from several of its bed net distributions in Malawi. It’s our understanding that AMF is quite unusual in this regard—other organizations that fund bed nets do not typically require post-distribution check-up surveys to monitor bed net usage over time, and do not publicly share monitoring data as AMF does.

Evidence of the impact of AMF’s bed net distribution in Kasaï-Occidental, DRC

AMF has sent us reports and data from two post-distribution check-up surveys (from eight months and twelve months after the distribution) from Kasaï-Occidental, DRC.

Donors may not realize that AMF has a short track record of major distributions. It has historically primarily worked with Concern Universal in Malawi, so these are the first surveys we’ve seen from large-scale AMF bed net distributions outside of Malawi. AMF’s post-distribution check-up surveys are intended to provide evidence on how many AMF nets are used effectively over the long-term, but we (and AMF) believe that these surveys in Kasaï-Occidental, DRC were poorly implemented (details in footnote).[1]

Due to the extent of the implementation issues, we don’t think the post-distribution check-up surveys provide a reliable estimate of the proportion of bed nets distributed in Kasaï-Occidental, DRC used effectively over the long term. (Note that AMF earlier provided a distribution report, registration data, and photos and videos as evidence that bed nets originally reached intended destinations.) It seems plausible to us that the reported rates of nets in-use (hung over a sleeping space) from the AMF distribution in the 8-month post-distribution check-up survey (~80%) and the 12-month post-distribution check-up survey (64-69%) are either substantial overestimates or substantial underestimates.

Non-random sampling in post-distribution surveys in Malawi

This year, we learned that Concern Universal, AMF’s distribution partner in Malawi, does not use a completely random process to select participants for post-distribution surveys. We have received some conflicting information from AMF and Concern Universal on the specifics of how the selection process deviates from pure randomization, so we aren’t confident that we fully understand how the selection process works in practice (details in footnote).[2]

Our earlier understanding was that Concern Universal randomly selected villages and households for post-distribution surveys without any adjustments.

We are now concerned that the results from post-distribution surveys from Malawi could be somewhat biased estimates of the long-term impact of AMF’s distributions (though we wouldn’t guess that the effect of the bias on the results would be very large, since AMF and Concern Universal described selection processes that seem likely to produce reasonably representative samples).

AMF told us that it may reconsider its requirements for random selection of participants in future post-distribution surveys and invited us to make suggestions for improvement.

AMF’s transparency and communication

Although we still believe that AMF stands out among bed net organizations for its commitment to transparency, AMF has recently been less transparent with us than we’ve come to expect.

In early 2016, we requested several documents from AMF (including the 8-month and 12-month post distribution surveys from Kasaï-Occidental, DRC, malaria case rate data from clinics in Malawi, and audits of household registration data from Malawi), which AMF told us it had available and would share once it had the capacity to review and edit them. Although we eventually received reports and data from the two DRC post-distribution surveys in June, we still haven’t seen the other documents we requested. AMF responded to these concerns here.

We are concerned that AMF did not tell us about the poor implementation of the first two Kasaï-Occidental, DRC surveys earlier, and that we only recently learned about the details of Concern Universal’s adjustments to random sampling for post-distribution surveys in Malawi. AMF told us it agrees that it should have communicated more clearly with us about these two issues and believes that it did not because it misunderstood the type of information we would value seeing. We are not confident that this fully explains AMF’s lack of transparency.

What we hope to learn going forward

AMF’s track record of providing evidence of impact on its bed net distributions outside of Malawi is currently very limited. Our impression is that DRC is a difficult country for charities to work in; we’re uncertain whether the methodological issues with the first two surveys from Kasaï-Occidental were due to the difficulty of working in DRC specifically, to more general issues with AMF starting programs in new countries and working with new implementing partners, or to the relatively poor performance of an implementing partner.

AMF has told us that it expects the implementation of future post-distribution surveys in DRC to improve, and that it has made several changes to its practices in response to the issues discussed above, including:

  • Hiring a Program Director, Shaun Walsh, whose primary job is to work in-country with distribution partners on planning, executing, and monitoring bed net distributions.
  • Requiring more detailed budgets and plans from distribution partners for upcoming post-distribution surveys in Ghana, Uganda, and Togo.
  • Focusing on improving timeliness of reporting on distributions and post-distribution surveys.

We plan to communicate closely with AMF on its upcoming post-distribution surveys, and update our views on AMF’s track record outside of Malawi when more survey results are available.

Notes
[1]
AMF’s reports on the surveys indicate that:

  1. It seems likely that different data collectors interpreted ambiguously-worded questions differently for both the 8-month and 12-month surveys. “Number of nets available” (translated from French) was variously interpreted as the number of nets hung, the number of nets hung plus the number of nets present but not hung, or the number of nets present but not hung. This led to internally inconsistent data (e.g. different numbers of nets reported for a single household for different survey questions) for a large proportion of households (42% in the 8-month post-distribution survey and around half in the 12-month post-distribution survey). AMF excluded households with internally inconsistent data from its analysis of the proportion of nets from the distribution still in use.
  2. AMF addressed this issue by re-writing survey questions after the 8-month survey, but the corrected survey questions were not put onto the data collectors’ smartphones before the 12-month survey.
  3. Household members sometimes reported inaccurate information to data collectors when survey questions were asked outside of a home. Data collectors later confirmed that the information was inaccurate (e.g. the household owned more bed nets than reported) by direct observation inside the home, but were not able to correct the data already entered into their smartphones.
  4. Data collectors did not distinguish between nets from the late 2014 AMF distribution and bed nets from other sources. AMF notes that the average level of previously-owned nets was around 2.5% so this would not have materially influenced the results of the post-distribution survey.

[2]

  • AMF told us:
    Concern Universal selects villages for post-distribution surveys in each health center catchment area where AMF nets were distributed. Concern Universal divides each health center catchment area into three “bands:” a short distance, medium distance, and far distance away from the health center. In each band, Concern Universal randomly selects between 25% and 50% of the villages. In each of those villages, Concern Universal randomly selects around 20% of the households.

  • In April 2016, we spoke with a representative of Concern Universal, who told us that, in addition to the stratification of villages by geographic location described by AMF, that villages selected in one post-distribution survey are excluded from being selected for the following post-distribution survey.

September 2016 open thread

Our goal with hosting quarterly open threads is to give blog readers an opportunity to publicly raise comments or questions about GiveWell or related topics (in the comments section below). As always, you’re also welcome to email us at info@givewell.org or to request a call with GiveWell staff if you have feedback or questions you’d prefer to discuss privately. We’ll try to respond promptly to questions or comments.

If you have questions related to the Open Philanthropy Project, you can post those in the Open Philanthropy Project’s open thread.

You can view our June 2016 open thread here.

Would other organizations have funded AMF’s bednet distributions if AMF hadn’t?

An important question to ask when deciding where to give is “what would happen if this charity didn’t receive my donation?”

To investigate this, we focus on charities’ “room for more funding,” i.e., what will additional funding for this organization allow it to do that it would not be able to do without additional support from the donors GiveWell influences?

This question is relevant to the Against Malaria Foundation (AMF), currently our #1 rated charity, which provides funding to support malaria net distributions in Sub-Saharan Africa. In the past, we focused intensely on the question of whether AMF would be able to absorb and commit additional funds.

Recently, we asked another question: how likely is it that the bednet distributions that AMF supports would have been funded by others if AMF hadn’t provided funding? That is, would another funder have stepped in to provide funding in AMF’s absence?

If this were the case, our assessment of AMF’s impact would be diminished because it would seem likely that, in the absence of giving to AMF, the distributions it might have supported would occur anyway.

We can’t know what other funders might do in the future, so to learn more about this we looked back at cases from 2012 and 2013 where AMF had initially considered a distribution but then didn’t end up providing funding. We asked whether, and when, those distributions were eventually funded by others.

Our investigation

We looked at five cases where AMF considered funding a distribution but did not end up moving forward. In short:

  • In two cases, major delays (18 months and ~36 months) occurred before people in the area received bednets from other sources.
  • In two cases, other funders filled the gap six to nine months later than AMF would have.
  • In one case, funding was committed soon after AMF’s talks fell through.

(For context, we use an “8%-20%-50%” model to estimate the longevity of bednets, which assumes that 92% of nets are still in use through the first year, 80% through the second, and 50% through the third (and none after the end of the third year). On average, then, we estimate that nets last about 27 months.)

More details are available in our full report on this investigation.

Of course, these cases aren’t necessarily predictive:

  • It’s possible that the distributions were atypical, and that the reasons that led AMF to not carry out these distributions were the same reasons that led other funders to not fund them. This would mean that a typical AMF distribution might, in fact, be more likely to be funded by someone else, if AMF doesn’t fund it, than these results predict.
  • It’s possible the global funding situation has changed since the cases we investigated in 2012 and 2013 – if more funding is now available overall, it would make it more likely that if AMF didn’t carry out a given distribution, another funder would step in.

That said, even if other funders would always step in if AMF didn’t carry out a distribution, it’s still possible that AMF is increasing the total number of bednets distributed, if there’s an overall funding gap for bednets globally. We’ve written more about the global bednet gap here. For this to be the case, it would likely require there exists some additional pool of funding that can be directed to bednets when necessary.

Overall, we think that the cases we looked at offer support to our conclusion that there is a real need for additional funding for bednets, and that AMF is not primarily displacing other funding for bednets.

Deworming might have huge impact, but might have close to zero impact

We try to communicate that there are risks involved with all of our top charity recommendations, and that none of our recommendations are a “sure thing.”

Our recommendation of deworming programs (the Schistosomiasis Control Initiative and the Deworm the World Initiative), though, carries particularly significant risk (in the sense of possibly not doing much/any good, rather than in the sense of potentially doing harm). In our 2015 top charities announcement, we wrote:

Most GiveWell staff members would agree that deworming programs are more likely than not to have very little or no impact, but there is some possibility that they have a very large impact. (Our cost-effectiveness model implies that most staff members believe there is at most a 1-2% chance that deworming programs conducted today have similar impacts to those directly implied by the randomized controlled trials on which we rely most heavily, which differed from modern-day deworming programs in a number of important ways.)

The goal of this post is to explain this view and why we still recommend deworming.

Some basics for this post

What is deworming?

Deworming is a program that involves treating people at risk of intestinal parasitic worm infections with parasite-killing drugs. Mass treatment is very inexpensive (in the range of $0.50-$1 per person treated), and because treatment is cheaper than diagnosis and side effects of the drugs are believed to be minor, typically all children in an area where worms are common are treated without being individually tested for infections.

Does it work?

There is strong evidence that administration of the drugs reduces worm loads, but many of the infections appear to be asymptomatic and evidence for short-term health impacts is thin (though a recent meta-analysis that we have not yet fully reviewed reports that deworming led to short-term weight gains). The main evidence we rely on to make the case for deworming comes from a handful of longer term trials that found positive impacts on income or test scores later in life.

For more background on deworming programs see our full report on combination deworming.

Why do we believe it’s more likely than not that deworming programs have little or no impact?

The “1-2% chance” doesn’t mean that we think that there’s a 98-99% chance that deworming programs have no effect at all, but that we think it’s appropriate to use a 1-2% multiplier compared to the impact found in the original trials – this could be thought of as assigning some chance that deworming programs have no impact, and some chance that the impact exists but will be smaller than was measured in those trials. For instance, as we describe below, worm infection rates are much lower in present contexts than they were in the trials.

Where does this view come from?

Our overall recommendation of deworming relies heavily on a randomized controlled trial (RCT) (the type of study we consider to be the “gold standard” in terms of causal attribution) first written about in Miguel and Kremer 2004 and followed by 10-year follow up data reported in Baird et al. 2011, which found very large long-term effects on recipients’ income. We reviewed this study very carefully (see here and here) and we felt that its analysis largely held up to scrutiny.

There’s also some other evidence, including a study that found higher test scores in Ugandan parishes that were dewormed in an earlier RCT, and a high-quality study that is not an RCT but found especially large increases in income in areas in the American South that received deworming campaigns in the early 20th century. However, we consider Baird et al. 2011 to be the most significant result because of its size and the fact that the follow-up found increases in individual income.

While our recommendation relies on the long-term effects, the evidence for short-term effects of deworming on health is thin, so we have little evidence of a mechanism through which deworming programs might bring about long-term impact (though a recent meta-analysis that we have not yet fully reviewed reports that deworming led to short-term weight gains). This raises concerns about whether the long-term impact exists at all, and may suggest that the program is more likely than not to have no significant impact.

Even if there is some long-term impact, we downgrade our expectation of how much impact to expect, due to factors that differ between real-world implementations and the Miguel and Kremer trial. In particular, worm loads were particularly high during the Miguel and Kremer trial in Western Kenya in 1998, in part due to flooding from El Niño, and in part because baseline infection rates are lower in places where SCI and Deworm the World work than in the relevant studies.

Our cost-effectiveness model estimates that the baseline worm infections in the trial we mainly rely on were roughly 4 to 5 times as high as in places where SCI and Deworm the World operate today, and that El Niño further inflated those worm loads during the trial. (These estimates combine data on the prevalence of infections and intensity of infections, and so are especially rough because there is limited data on whether prevalence or intensity of worms is a bigger driver of impact). Further, we don’t know of any evidence that would allow us to disconfirm the possibility that the relationship between worm infection rates and the effectiveness of deworming is nonlinear, and thus that many children in the Miguel and Kremer trial were above a clinically relevant “threshold” of infection that few children treated by our recommended charities are above.

We also downgrade our estimate of the expected value of the impact based on: concerns that the limited number of replications and lack of obvious causal mechanism might mean there is no impact at all, expectation that deworming throughout childhood could have diminishing returns compared to the ~2.4 marginal years of deworming provided in the Miguel and Kremer trial, and the fact that the trial only found a significant income effect on those participants who ended up working in a wage-earning job. See our cost-effectiveness model for more information.

Why do we recommend deworming despite the reasonably high probability that there’s no impact?

Because mass deworming is so cheap, there is a good case for donating to support deworming even when in substantial doubt about the evidence. We estimate the expected value of deworming programs to be as cost-effective as any program we’ve found, even after the substantial adjustments discussed above: our best guess considering those discounts is that it’s still roughly 5-10 times as cost-effective as cash transfers, in expectation. But that expected value arises from combining the possibility of potentially enormous cost-effectiveness with the alternative possibility of little or none.

GiveWell isn’t seeking certainty – we’re seeking outstanding opportunities backed by relatively strong evidence, and deworming meets that standard. For donors interested in trying to do as much good as possible with their donations, we think that deworming is a worthwhile bet.

What could change this recommendation – will more evidence be collected?

To our knowledge, there are currently no large, randomized controlled trials being conducted that are likely to be suitable for long-term follow up to measure impacts on income when the recipients are adults, so we don’t expect to see a high-quality replication of the Miguel and Kremer study in the foreseeable future.

That said, there are some possible sources of additional information:

  • The follow-up data that found increased incomes among recipients in the original Miguel and Kremer study was collected roughly 10 years after the trial was conducted. Our understanding is that 15 year follow-up data has been collected and we expect to receive an initial analysis of it from the researchers this summer.
  • A recent study from Uganda didn’t involve data collection for the purpose of evaluating a randomized controlled trial; rather, the paper identified an old, short-term trial of deworming and an unrelated data set of parish-level test scores collected by a different organization in the same area. Because some of the parishes overlap, it’s possible to compare the test scores from those that were dewormed to those that weren’t. It’s possible that more overlapping data sets will be discovered and so we may see more similar studies in the future.
  • We’ve considered whether to recommend funding for an additional study to replicate Baird et al. 2011: run a new deworming trial that could be followed for a decade to track long term income effects. However, it would take 10+ years to get relevant results, and by that time deworming may be fully funded by the largest global health funders. It would also need to include a very large number of participants to be adequately powered to find plausible effects (since the original trial in Baird et al. 2011 benefited from particularly high infection rates, which likely made it easier to detect an effect), so it would likely be extremely expensive.

For the time being, based on our best guess about the expected cost-effectiveness of the program when all the factors are considered, we continue to recommend deworming programs.