Trying (and failing) to find more funding gaps for delivering proven cost-effective interventions

There are interventions that we believe are – or may be (pending a literature review) – very well supported by evidence, that we’ve been unable to find charities focused on. In 2012, we put a significant amount of effort into trying to find ways donors could pay for further delivery of these interventions, even if it required working with a large organization (such as UNICEF or GAVI) rather than with a small charity dedicated to the intervention in question. Good Ventures played a major role in these investigations and was particularly helpful in getting engagement from these larger organizations.

The bulk of our efforts focused on immunizations – which we consider to have the strongest evidence base of any intervention we know of – and micronutrient supplementation (particularly salt iodization and vitamin A supplementation, which we perceive as the most evidence-supported micronutrient interventions; writeups on these interventions are forthcoming).

Despite substantial effort, we did not find any such giving opportunities. The basic pattern we saw was that:

  • Government and multilateral funders provide substantial funding for these interventions.
  • It often appears that the greatest obstacle to universal coverage is a logistical bottleneck rather than a simple lack of funding for more direct execution.
  • We asked persistently for areas where more funding was needed to do more direct delivery. In many cases, we were told that there were opportunities, but then (a) these opportunities became funded by others while we were investigating them, or (b) we tried to follow up on these opportunities and ultimately were met with unresponsiveness, and/or concluded that funding was not the primary bottleneck to progress in these cases.

Overall, this pattern of observations fits a model in which the most proven, cost-effective interventions are often already being appropriately funded by the international community (though not in every single case; LLIN distribution is the clearest exception we’ve found).

Unfortunately, many of the details of our investigations cannot be shared, because the organizations we worked with sometimes shared information only under condition of confidentiality. What we can share is the following:

  • Immunizations. Our immunization landscape writeup shares most of what we’ve learned about immunization funding. In brief, it appears that developing-world governments fund much of the basic costs of routine immunization, while GAVI provides substantial support for routine immunizations, newer more expensive vaccines, and campaigns (additional opportunities for children to receive a few key vaccines, as a way to reach children missed by the routine vaccination system and to provide additional doses to increase immunity to the targeted diseases). GAVI exceeded its fundraising target for 2011-2015 as of June 2011 (with much of the funding coming from developed-world governments, as seen on page 4 of this PDF) and is currently raising funds for 2016 and beyond (as discussed in this conversation (DOC)). We looked into several other organizations, speaking with UNICEF, the World Health Organization, and several campaign-focused organizations, and in no cases found the sorts of funding opportunities we were looking for.
  • Salt iodization. We investigated two apparent funding opportunities in depth: (a) a project with GAIN in Ethiopia, in which we concluded that the key issue to be resolved was not one of funding (more detail at the link), and (b) the possibility of funding in Eastern Europe (which a conversation with UNICEF highlighted to us), which we investigated but have not produced publicly available information on.
  • Vitamin A supplementation. It appears to us that the Canadian government is a major funder of vitamin A supplementation (for example, it recently granted ~$150 million for this purpose), and that UNICEF is a major supporter/implementer (see this link). We spoke with UNICEF and others in an attempt to find areas where more funding was needed to directly deliver more vitamin A supplementation, and were unable to identify such funding opportunities. The details are mostly confidential, with the exception of an initial conversation with UNICEF.
  • Other programs. Our 2012 efforts also included looking into the evidence behind zinc supplementation (both therapeutic and non-therapeutic), which had been highlighted to us as an area with large funding gaps by the Micronutrient Initiative. We concluded that the evidence case and likely cost-effectiveness were inferior to those of our top charities’ interventions.

For the time being, we’ve provisionally concluded that

  • The path of trying to fund the most proven interventions, when we can’t find charities that focus on them, doesn’t appear promising in the short term. This is partly because a lack of charities focusing on an intervention may be correlated with a lack of room for more funding to deliver the intervention directly; it is also because we’ve found it very difficult to work with and learn from large diverse organizations. We do expect to return to this path at some point, but we don’t expect to make it a major priority over the coming year.
  • In general, it appears that the most proven interventions do attract substantial funding from governments and others. There are some funding gaps (the best example being bednets); but overall, it appears that the most proven, cost-effective interventions are often already being appropriately funded by the international community.

Comments

Trying (and failing) to find more funding gaps for delivering proven cost-effective interventions — 12 Comments

  1. I don’t understand how can it be that 15% of children in the world, and 23% in Africa, do not receive the recommended set of childhood vaccines, and one can still say that cost-effective interventions are often already being appropriately funded by the international community.
    Does it become prohibitively expensive to reach this sort of “last mile” of 15% in the world and 23% in Africa? Isn’t there room for funding the logistics?
    Because if this is not the case, if it would still be extremely cost effective for governments to reach these millions of people, then it would not be possible to say that they are doing enough, do you agree?
    Could a project like this one (http://www.thedailybeast.com/articles/2012/09/25/coke-applies-supply-chain-expertise-to-deliver-aids-drugs-in-africa.html) have room for more funding?

  2. > “There are some funding gaps (the best example being bednets); but overall, it appears that the most proven, cost-effective interventions are often already being appropriately funded by the international community.”

    – This surprises me and it sounds like you were surprised too. Do you have a running explanation for why this is the case? Is it because when there’s a proven price in lives saved per dollar this is reliably sufficient to motivate at least some non-probabilistically rational donors (i.e. they can respond to definite proofs) to donate, like the Gates Foundation or something? Is our civilization advanced enough to contain some philanthropic actors who reliably jump on non-probabilistic demonstrations of great cost efficacy? Or is there so much money sloshing around charity that probabilistic diffusion with a statistical trend towards higher proven efficacy will reliably reach all the proven targets? Why the gap with bednets, what’s different about bednets?

    I don’t expect you to necessarily have these answers on hand but it’s certainly an interesting state of affairs, and it sounds like it was unexpected to you too.

  3. Could it be that there is a lack of proven, cost-effective interventions, and that more (funded) work should be done for identifying such interventions ?

  4. > Salt iodization. We investigated two apparent funding opportunities in depth: (a) a project with GAIN in Ethiopia, in which we concluded that the key issue to be resolved was not one of funding (more detail at the link), and (b) the possibility of funding in Eastern Europe (which a conversation with UNICEF highlighted to us), which we investigated but have not produced publicly available information on.

    The conversation with Timmer seems to identify far more opportunities, and at quite a modest cost, than just Ethiopia and ‘Eastern Europe’.

  5. So… when something is cheap, effective, and isn’t being done, lack of money usually isn’t the problem?

  6. > Overall, this pattern of observations fits a model in which the most proven, cost-effective interventions are often already being appropriately funded by the international community (though not in every single case; LLIN distribution is the clearest exception we’ve found).

    Shouldn’t you add deworming and cash transfers to the list of exceptions? Does that affect the generalization much?

    I’m also wondering how much the intuitive plausibility of this conclusion depends on where you draw the line for “most proven, cost-effective,” and how you cut up intervention types (e.g. “micronutrients” vs. “zinc supplementaiton, iodine supplementation, and vitamin A supplementation”). If I had to list the proven, cost-effective interventions GiveWell knows most about, I’d list: immunization, LLINs, deworming, cash transfers, and micronutrient supplementation. If you list it that way and you say that LLINs, deworming, and cash transfers are underfunded, I guess you could say that “often” the best ones are adequately funded, but you could also have said that the best ones are *often not adequately funded*, which would have made the current system sound much worse.

    If you break it up so that you say something like: measles immunization, meningitis immunization, maternal neonatal tetanus immunization, etc. it looks like a more robust generalization. Maybe this is the more relevant way to think about it.

    Maybe the main action-relevant takeaway is that you can’t just name some very proven, cost-effective developing world intervention and assume you’ll find a way to fund more of it if you look hard. A few years ago, I would have assumed you could. That seems like a good takeaway from GiveWell’s experience.

  7. The unfunded cost effective “interventions” are pretty clearly upstream from where you are looking Holden.

    The reason immunizations and LLINs are deemed so cost effective has less to do with their intrinsic characteristics, than with their amenability to delivery (where necessary) by good-hearted donors and international NGOs. In countries with weak health systems (where so many of the people who need the products live), a network of collaborators and funders supports immunization and bednet distn via national campaigns.
    For micronutrient deficiencies susceptible to food fortification, partnerships with (often) a small number of food producers can achieve pretty high coverage.
    These things can be done without helping countries strengthen their health service delivery systems. And, happily, they are being done.
    It sounds to me like the phenomenon you are describing is that global health charities have picked the low-hanging fruit. That is, there isn’t much to be done to improve healthcare and health for poor people in developing countries without expanding their efforts into those which involve strengthening health services and health systems. Perhaps this is what you are referring to as “logistical bottlenecks”?

    Other discussions about global health aid ofter refer to this as the “product pile up”. I discussed this in a CGD blog a few years ago http://www.cgdev.org/blog/beyond-prices-patents-and-logistics-deeper-look-challenges-expanding-access-life-saving

  8. Thanks for all the thoughtful comments and questions. Some responses:

    Carl, I’m honestly not sure. My best-guess theory goes something like

    • Delivery of interventions that are both proven and cheap (in the sense of “low cost per population covered,” not in the sense of “low cost per DALY”) tends to get sufficiently funded.
    • LLINs are relatively expensive on a per-population basis. (Vitamin A supplementation costs well under a dollar per person treated and applies only to people under 5; LLINs cost well over a dollar per person covered per year and apply to the entire population).
    • Vaccines are also relatively expensive on a per-population basis, and I think that prior to the 2011 set of commitments to GAVI, delivery of them was underfunded. I have the impression that the Gates Foundation played a major role in advocating for more funding for these interventions, and that the Gates Foundation tends to be selective about where it puts its most intensive advocacy efforts (it currently appears to be placing a high priority on polio eradication).

    But this is all conjecture. What I’m more confident in is that it’s been much easier to identify a funding gap for LLINs than for other interventions of comparable evidential support.

    Mordatar, I think there is absolutely room for more funding in trying to improve logistics. Logistics-oriented projects, however, tend to be more difficult to evaluate in the framework of “dollars spent -> quantified outcomes delivered.” It’s possible that we will at some point recommend interventions in this category, but if so, the recommendations won’t be backed by the same sort of evidential support that our current recommendations are.

    Eliezer, we have indeed been surprised. I think all of the possible explanations you listed are factors. I do think that being able to measure, quantify, and demonstrate tangible benefits helps create a pitch that is very appealing to certain people. GiveWell fans include some such people; government aid agencies also include some such people.

    Generally I’d say the world of philanthropy is pretty diverse in terms of what the major funders are looking for – many are looking primarily for a good emotional story, but some are looking for quantifiable impact and others are looking for ambitious “moon shots” that others neglect. Since it only takes a small number of appropriately positioned people to make a big difference in a funding situation, determining what’s “underfunded” is difficult and takes substantial legwork. We’ll be writing more on this general theme.

    Robert Daoust, I think the answer is yes to some degree.`There are certainly interventions that I think an ideal philanthropic community would spend more effort studying.

    Gwern, we investigated the two opportunities that seemed most likely to pan out from that conversation. Once they didn’t, we didn’t feel that further investigations would be a good use of our time.

    Nick, I think the evidence for the benefits of deworming and cash transfers is much weaker than the evidence for bednets, though still strong enough for us to issue a recommendation.

    The way we normally prioritize interventions is via a combination of asking “What’s proven?” and “What have we found charities focusing on?” That’s why we normally present deworming as one of our top few, and we don’t talk as much about immunizations and vitamin A supplementation. However, the investigations described in this post took a different perspective, looking at the interventions that seem most likely to have strong evidential backing and going from there. For that list, I’d put just about all immunizations at the top, followed by bednets, followed by some micronutrient supplementation (vitamin A, iodine).

    April, I agree with your comment, and you are correct in terms of what we’re thinking when we say “logistical bottlenecks.” I agree that “strengthening health systems” might be the more appropriate framing (per our Twitter exchange).

    All (including Doug): we are not saying that the cause of “proven cost-effective interventions” isn’t underfunded broadly. More money may be needed for funding studies to expand the list of proven cost-effective interventions; more money may be needed for finding new ways to deliver proven cost-effective interventions to those they aren’t currently reaching. However, both of these endeavors are themselves not “proven cost-effective”; they involve more risk and less linear than simply paying for delivery. It’s paying for delivery that we focus on in this post.

  9. Holden, you seem to be saying that there is currently enough money to make a perfect match between the list of proven cost-effective interventions and the list of known ways to deliver those interventions to people they are currently reaching. We are saying “of course!”, and we suggest that if finding more funding gaps is the question, the answer is rather to be found in expanding the list, or finding new ways, or reaching new beneficiaries… The bed nets exception is interesting : could it be that there is a funding gap with them because there is constantly a ‘free’ supply of ‘new’ beneficiaries who are in fact the old beneficiaries who need a net replacement?

    What I am suggesting is way over my head because I don’t know much in interventions, fundings or bed nets… However, this thread interests me because I am convinced that there might be a system by which we could bring down and maintain to zero the number of individual personal problems that MUST be solved and that are SOLVABLE. Money, though, cannot be the only solution, many other resources must be mobilized.

  10. Robert, my earlier comment gives my best guess as to why bednets are an exception. I do believe that if there were a higher general level of interest and resources in global health, we would reach substantially more people. But we wouldn’t do it by focusing all funds on delivery of proven cost-effective interventions.