Below is our basic outline for identifying the best options for donors within developing-world health. (Economic empowerment and possibly other developing-world causes will come after we have completed our report on direct health interventions.)
Focus on two priority regions and several priority interventions
As this post explains, we are simultaneously taking two approaches: a region-based approach (studying a particular region in depth, and aiming to fund interventions targeted to the specific needs of the region) and a program-based approach (identifying particularly promising interventions and funding their scale-up throughout the world).
Priority interventions: focus on the most proven, scalable, and cost-effective
Our general criteria for selecting program-based interventions are discussed here. To start, we are prioritizing what we call straightforward interventions, or interventions that can be carried out infrequently and for which the burden of monitoring and evaluation is relatively low. As discussed here, these interventions are also rated among the most cost-effective interventions by existing studies of cost-effectiveness. They are:
- Vitamin supplementation programs, providing nutrients such as vitamin A (which reduces the risks of infant mortality, development of blindness, and deaths in childbirth – reference here).
- Mass drug administration programs, particularly those aiming to treat school-age children who suffer from intestinal parasites. (Such interventions have been shown to improve school attendance and likely nutritional status.)
- Vaccination campaigns to cost-effectively save lives.
- Vitamin fortification programs such as the iodization of salt.
- Surgical programs to correct deformities such as cleft palate and fistula.
We may add other priority interventions, particularly if we see particularly strong donor demand for interventions with fundamentally different goals.
Priority regions: help those in great need and those with great potential
Our region-based research will be less focused on strict definitions of “cost-effectiveness” and more on finding programs that address a region’s needs broadly and holistically, somewhat along the lines of Partners in Health (and more in line with the vision of the WHO commission on macroeconomics and health than that of the Copenhagen Consensus). The first step will be picking two priority regions.
Priority region 1: one priority region will reflect a goal of helping those in the most need. We are currently in the process of identifying countries that have both high and drastic disease burdens and relatively stable, low-corruption environments in which aid can likely be productive. Preliminarily, our strongest candidates are:
- Zambia
- Mozambique
- Mali
- Rwanda
- Tanzania
- Burkina Faso
The process for identifying these six countries is detailed here.
Priority region 2: the other priority region will reflect more of a triage approach: identifying an area where health conditions are poor and help is needed but strong economic opportunities exist for those at a reasonable level of personal health and productivity. Preliminarily, we are guessing that our work in this area will likely focus on somewhere in India, but we have not yet completed this analysis.
Comments
Thanks for this blog post about the research agenda, and for the post about selecting countries for region 1 It all sounds great. Your approach to the problems and your reasoning about them are compelling.
A few thoughts…
(1) I think Jeffrey Sachs might argue that it’s a mistake to intentionally avoid programs in countries that suffer from corruption and poor governance. And probably William Easterly would disagree with Jeffrey Sachs. So who knows. But I can see how there might be an argument for intentionally focusing on countries that suffer from corruption, just as you intentionally focus on countries with low HDI levels.
(2) In the old 2004 Copenhagen Consensus book (Global Crises, Global Solutions), there was a chapter about “Conflicts” that was interesting. It seemed to suggest that it when trying to pick which countries to focus on, it might make sense to intentionally prioritize the countries that have recently had civil wars or armed conflicts. By providing aid, you may help minimize the chance of later “aftershock” conflicts. I think the correlation with aid was pretty small, but the outcome might still be significant just because any sort of war or armed conflict has such a devastating impact (in terms of DALYs, or by any other metric). That might argue that you should not use the Failed State Index to exclude countries from consideration.
(3) On the question of regions to focus on, speaking just for myself, I am far more interested in your efforts in sub-Saharan Africa than in India or some other more developed region. If we had a few hours sometime we could discuss and debate all the questions involved, but my guess is that you’ll end up doing more good for more people by focusing on the places where people’s average level of opportunity is lowest.
(4) On the question of health conditions and interventions, I want to bring up the subject of tobacco. On the GiveWell website and the GiveWell blog there’s a good deal of material discussing malaria, tuberculosis, HIV, etc. — but there’s almost no mention at all of tobacco. That seems like a huge problem to be ignoring.
According to the World Health Organization (WHO):
“Tobacco is the second major cause of death in the world. It is currently responsible for the death of one in ten adults worldwide (about 5 million deaths each year). If current smoking patterns continue, it will cause some 10 million deaths each year by 2020. Half the people that smoke today -that is about 650 million people- will eventually be killed by tobacco.”
So that means tobacco is killing almost twice as many people per year as AIDS. And banning cigarettes would save twice as many lives per year as providing routine immunizations for children. Smoking rates have been declining in the U.S. and other industrialized nations, but in Africa and East Asia it’s still a big problem. For example, according to Forbes, “In Namibia, … half of the country’s two million citizens smoke.”
And completely separate from morbidity and mortality impact, there’s also a significant economic impact every time you get somebody to quit smoking. Quoting WHO again:
“Many studies have shown that in the poorest households in some low-income countries as much as 10% of total household expenditure is on tobacco. This means that these families have less money to spend on basic items such as food, education and health care.”
I don’t know much about the cost-effectiveness of different tobacco control interventions, but I know that some interventions do work, and it seems entirely possible that tobacco control might be just as cost-effective as immunizations or other health interventions.
I’d be interested to hear what you think, or to see what you’re able to come up with in terms of proven, scalable, and cost-effective interventions.
Brian, thanks for the comments.
Your point about working in regions with recent conflicts is interesting. I checked out the paper you suggested on this topic; to me the key quote (page 18) is:
The analysis they provide seems somewhat questionable (heavily quantitative at a macro level), but it’s still an interesting argument for working in countries a few years removed from conflict – something we will look into as we finalize our choice of regions.
Regarding SSA vs. India, we believe that donors will differ on this question; that both sides feel relatively strongly; and that we’re unlikely to firmly resolve the debate using facts. That’s why we’re doing both.
On the other points, we have chosen for this round of research to focus on direct aid, which excludes both research-only projects and projects focused on political advocacy and political change. It’s not that we don’t think such projects are valuable, but examining them would open a whole extra set of questions that we’re choosing not to deal with now for practical purposes. (For one thing, it seems particularly difficult to find ways to spend money on political change that are proven and scalable.)
Fighting corruption would seem to fall under the category of political advocacy and political change. According to the DCP chapter on tobacco, the best interventions for that problem do as well.
For region 2, if you are reluctant to try India, perhaps rural southeast Asia would be an alternative. Malaysia, Indonesia, and Thailand come to mind as a spread of options in that area. On the other hand, it may be difficult to find an appropriate location in those countries that can also get you the necessary data.
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