The GiveWell Blog

Recommending Population Services International

I understand that a lot of you have been sitting on the edge of your seats, wondering when GiveWell is going to recommend an organization for fighting diarrheal illness. Your wait is over.

My research on diarrhea began as an interest in the cause of “water.” It’s a very popular cause, and a very marketable one: hard to argue with the idea of giving people water. In my research, the first thing I learned was that the main problem of “water” is lack of clean water (not lack of access to water entirely), and that the main thing contaminating the water is fecal material. And the main problem caused by this, in turn, is diarrhea so severe it can actually lead to death by dehydration.

But the problem goes well beyond water. People lack access to adequate sanitation facilities, as well as sanitation education. Fecal matter gets everywhere (their hands, their food, and their water), and all of this contributes to the death toll of diarrhea.

Even though there are a few cost-effective strategies for reducing diarrheal illness, most of the organizations with which I spoke focused on expensive approaches, something that both former Secretary of the Treasury Paul O’Neill and I find confusing and frustrating. Part of the issue may be that focusing on clean water is more marketable–but less cost-effective–than focusing on the root problem, diarrhea.

But then, I investigated Population Services International. PSI is a large ($260 million budget last year) organization focused on basic health issues in the developing world. To reduce diarrheal illness, they offer Oral Rehydration Therapy (ORT) and water purification at point-of use. Uniquely, instead of distributing the products for free, they sell them through local vendors allowing them to recoup some of their production costs and reduce distribution costs. We estimate that PSI’s ORT program saves lives at less than $50/life. Holden’s made a big deal about numbers like this before (he did grossly understate ORT’s cost at 5c/life), but $50/life is hard to process. $50 … per … life. Jeez.

Along with its focus on the most cost-effective strategies, I’m a big fan of PSI’s evaluation approach – they keep careful records of exactly how much ORT and water-purification solution they distribute and have a research department devoted to evaluating PSI’s work.

Now, PSI isn’t perfect. It didn’t give me a detailed breakdown of its total budget – its diarrheal illness programs only make up about 2.5% – and it doesn’t comprehensively or systematically evaluate each program. Also, it’s been relatively difficult to get information from PSI, even after I made a reasonable donation.

Right now, I’m working on the review, which should be up on GiveWell in the next week.


  • ShanonP on January 8, 2007 at 8:37 pm said:

    [Not directly related to previous post, but I couldn’t find another way to post to the blog so I’m just hitting reply.]

    I just got a forward about this site from my bud Ryan, so I checked it out. To the founders, I wanted to express that I think that Givewell is an excellent idea with major potential. In case it is helpful in your formulation of the site, I wanted to share a couple take home points that I got out of a recent one-year research fellowship at the [ Harvard Initiative for Global Health (HIGH)] last year, analyzing what governments and organizations spend on aid for different health causes and evaluating the impact of their expenditures.

    *Haphazard qualities such as salience and “donor-attractiveness” of an issue play an unfortunately large role in determining how much charitable money goes towards it. To paraphrase my boss, Dr. Christopher Murray’s, speech at Davos last year, “fecal-oral transmission [diarrhea] will never be sexy” but it is the duty of those who care to make sure that those with the money and influence, including governments, large organizations, and even small potential donors like you or me, know how many lives can be saved and how much suffering averted by spending money to combat it.

    *The best weaponry in combating that randomness and the waste that goes into horrendously cost-ineffective projects which soak up political will and limited donor funds is BALANCED METRICS and the diligent use of them in evaluating projects. When numbers are fuzzy or unavailable, important causes fall to the wayside… but when numbers are easily accessible and reliable, those same diseases will get more attention. To this end, Murray and his colleagues at the WHO came up with a system that gaining speed in the field of health policy (though I can imagine similar systems being devised for topics such as education or political empowerment), termed Disability Adjusted Life Years. DALYs are basically a measure of years of life lost or lived in suboptimal conditions, with adjustments down in value for disease/pain conditions (eg. a year with quadriplegia might be given 0.3 DALYs compared to a healthy year’s 1.0), age when lived (eg. the next year of life for a one-month old or a ninety year old are assigned a smaller DALY value than that for a 30-something), and time-discounting (eg. the next year of life is worth more than a year lived in 2040). Though subject to some controversy, the values and formulas obtained were derived from the input of vast numbers of health professionals and regular folks. Basically, DALYs allow one to objectively compare how much harm different diseases do on a population level, how effective different interventions are at preventing, curing, or alleviating them, AND how cost effective those interventions are against one another. They’re not perfect, but I think DALYs are a phenomenal start to objectively looking at where our health dollars should go and I’d be glad to dig up / prepare some rudimentary charts on some of the most effective disease to treat using this metric.

    *The previous points by extension would argue that after enough research, we would arrive on one disease condition (the cheapest to treat/prevent per averted DALY) which we should focus all of our resources on alleviating, and only start focusing on condition 2 when so much of condition 1 has been alleviated that it becomes more expensive to find residual cases to treat, and condition 2 is now more effective. One could think of a number of reasons though, that this would be a faulty strategy; and I think one of the more compelling arguments against said strategy can be expressed in the Eastern metaphor (and VC adage) of “letting a thousand flowers bloom.” When many innovative charitable projects with different goals, magnitudes, outcomes, and levels of effectiveness are given the relatively smaller amounts of money needed to nourish their ideas, some emerge as extraordinarily worthy of charitable support. Perhaps the most effective way to give is to invest in the “only somewhat proven but hugely promising” category of projects. I’d say that this strategy applies especially to certain high net worth individuals seeking to gain some public recognition for a sucessful charitable project: if your donations have the potential to provide great services to humanity but you don’t want your name to be lost amidst a huge organization like Unicef, supporting a charity in this category is the perfect solution. (I see no problem in people wanting some recognition for what they do in this realm; it both sets an example for others in their circles and is a far better alternative to them doing nothing.)

    To these ends, I’d recommend that Givewell post somewhere on their site an evidenced-based list of 5 or so top charities to donate to, aimed at the busy but generous professional just wanting to do something good; as well as longer list of some of the innovative, smaller projects out there showing promise which might catch inquisitive reader’s attentions.

    Thanks for reading- this post got awfully long, but again its a subject in which I’m passionately interested. To this site’s founders- I’d love to get involved in the site, especially if you need a medical perspective / background scientific research on some of the issues you’ll be posting on and are willing to take it from a lowly 1M such as myself =) Anyway, keep up the good work!

    Shanon Peter

  • Holden on January 12, 2007 at 4:17 pm said:

    Hi Shanon, I really appreciate the thoughtful comments.

    First off, I completely agree with your central observation: that where the dollars go is currently determined way too much by fads and marketing savvy, and not enough by how much good you can accomplish per dollar. That’s what we’re trying to fight.

    I hadn’t heard about the DALY stat, and I’m adding it to our list of things to look into. Honestly, my first impression is that it seems like overkill (in terms of putting nonprofits’ causes in the same terms.) Trying to assess the value of saving an impoverished child from death (ORTs), vs. saving one from a miserable life (corrective surgery), vs. addressing a person’s needs more expensively and comprehensively (boarding schools, adoption programs), vs. unlocking opportunities for a U.S. citizen, vs. helping animals, vs. helping the disabled, involves highly philosophical decisions. I’d find a number that tries to make these decisions for me to be unsatisfying and untrustworthy, and I imagine others would as well.

    I think the basic GiveWell strategy will establish a reasonable compromise between comparing causes against each other and leaving people free to make certain philosophical decisions. The idea is to organize different nonprofits/causes according to what can be easily compared, then compare them and put them side by side so the donor can clearly see their options. Roughly along the lines of “You can save a child for $50, or correct a surgery for $500, or provide a scholarship for $5000” (although these numbers won’t always be available and reliable, we try to give an idea of what you get for your money).

    Having all of these causes analyzed in this way in the same place, it becomes much easier to notice the most cost-effective charities and avoid the mistake of giving to whatever is well-marketed or on your mind at the moment. But it also leaves you with the freedom to choose some philosophies over others, rather than boiling it down to a single number.

    That said, I would love to see any analysis you can find of what the DALY method points to as the most effective causes. I’m particularly interested in the numbers that go into the analysis (i.e., not just the conclusions). We want to look at all the things the DALY metric looks at, we just don’t necessarily want to aggregate them the same way. So more information would be extremely helpful.

    One more thing–we are maintaining a single list of the best charities to donate to, as you suggest. You can find it on our main site under “Recommended organizations.” I wouldn’t confidently call these the “5 best charities in the world” simply because we have a lot more work to do in understanding the nonprofit sector. But that is the goal.

  • All Criminal Records in One Database on September 6, 2007 at 4:39 am said:

    All Criminal Records in One Database…

    All Criminal Records in One Database…

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