Now that Holden and I have finished drafting reviews for Cause 5 (to be made public in a couple of weeks), we’ve moved our focus to Cause 1: Help people in Africa avoid death and extreme debiliation.
Unlike Cause 5, in which organizations roughly followed the same model to help people, organizations applying for a Cause 1 grant take wildly divergent approaches. And, in most cases they are taking not just one approach, but are running a huge set of projects that don’t always have a clear overarching theme or approach. This obviously presents a large challenge, and makes it impossible for us to compare organizations as directly and quantitatively as we did for Cause 5.
Here’s what we’re thinking so far. Mostly, our applicants fall into the following broad categories: comprehensive community aid, providing lots of different kinds of services to a small group of a people; distribution, getting lots of small, inexpensive items to many people; corrective surgery, providing a relatively expensive but life-changing surgery to those with congenital deformities; and mammoths, which do just about everything for everyone everywhere.
Comprehensive community aid. These organizations go into a village and attempt to provide everything for the village including primary health services (for childbirth, pneumonia, etc.), distributing necessary medicine/products (bed-nets, ORS, de-worming pills), education about hygiene and protected sex, economic aid including farming technology, and much more. This is the model with the most intuitive appeal to us. When you’re trying to help people thousands of miles away from a culture you’ll probably never fully understand, it seems smart to work intensely with one group of people and document all the ways in which their lives change – that way you’re more likely to catch unintended consequences, adapt to changing problems, etc., and make sure you’re actually changing their lives for the better. (This seems far superior to deciding in advance on one problem, like AIDS, and attacking it furiously while leaving other problems unaddresed.)
But that documentation is essential – immersion doesn’t equal understanding, and if a charity isn’t measuring and reporting life change, we aren’t going to bet on it. So far (though we’re still working on it), we haven’t been able to get a real picture of the life change effected by an organization using this approach. Organizations do many activities for which they often offer no evidence of the eventual impact (e.g., they tell us how many families attended their HIV/AIDS awareness campaign, but don’t offer evidence for what effect they expect that to have).
Distributors. These organizations distribute cheap and potentially life-saving items: ORS to treat diarrhea, vitamin A supplements to prevent malnutrition and blindness, bednets to fight malaria, condoms to prevent HIV/AIDS, etc. The advantage of this approach, it seems, is the potential cost-effectiveness: by focusing on the cheapest, simplest diseases to treat, you can treat a lot more people.
We estimate that the stronger candidates in this area are saving lives for around $50-120 a pop … but this estimate is based largely on combining reports on number of units sold/distributed with academic research on the effects of these units (e.g., studying the effects of Vitamin A in developed-world hospitals,), plus a lot of guesswork about utilization (i.e., it’s one thing to sell or distribute condoms – but how much are they actually getting used?) Organizations only sometimes monitor the utilization of the products they distribute, and they rarely, if ever, measure the change in actual disease prevalence for the people they serve. So charities in this area may be helping a lot of people, but it’s hard for us to be confident in their effects.
Corrective surgery. These organizations perform a very specific procedure (or set of procedures) for people suffering from an ailment. They perform surgeries to correct debilitating deformities (cleft palate, severe burns, etc.) or correct vision impairment. The best of these organizations can tell us how many surgeries they perform and what conditions they correct, which along with their total expenses gives us a picture of how many lives they’re changing for each dollar they spend. These organizations don’t tell us a lot about how debilitating the conditions they fix truly are (leaving us to question the impact they’re having).
This model is attractive because each surgery affects a specific person. Knowing how many surgeries each organization performs tells how many people’s lives have been changed – there’s not a lot of doubt. But, this model doesn’t come close to achieving the cost-effectiveness of the (albeit somewhat theoretical) distribution model, with $/life impacted at 10-20x the cost. And, without a clear picture of the debilitation these surgeries prevent (to what degree they are somewhat cosmetic), we worry that their impact is even lower.
UNICEF. UNICEF does everything, everywhere. They distribute, perform surgeries, and somtimes just focus on providing all services to a set group of people. We won’t be able to evaluate the entirety of UNICEF’s programs, but we may be able to evaluate their Accelerated Childhood Survival and Development Program, which has an approach similar to “comprehensive community care” above, and which appears to be slated for a very large and growing role in UNICEF’s programming.
So, where are we going from here? At the moment, the only organizations that we can confidently say are helping people are those peforming corrective surgeries. But, we’re waiting on more information from distributors which, we hope, gives us more confidence that people are actually using the products they receive. We’re disappointed in what we’ve seen thus far from comprehensive community care. Even though it makes a lot of sense to provide everything to a small group of people (even at higher costs), we’re not convinced of the impact these programs (which are mostly more convential Africa-aid organizations) are having.
One more note: with so many different approaches to helping people, there’s no way that they’re going to be close in terms of cost-effectiveness. There’s no reason to think that an organization distributing inexpensive items across a continent is in the same ballpark as an organization providing corrective surgeries to a few thousand children each year. Donors need to understand what they’re getting for their dollar.