The GiveWell Blog

Health system strengthening + sustainability + accountability

We’ve written a lot about our top-rated charity, VillageReach (in particular, see our official review and our 2009 blog post). Consistent with our focus on individual/casual donors, we generally emphasize effectiveness over ambition, and so we have mostly focused on VillageReach’s fit with our criteria: its strong case for effectveness, cost-effectiveness, and room for more funding.

However, VillageReach has some other major strengths as well – strengths that make it a good fit not just for individual donors looking to help people cost-effectively, but also for more ambitious donors hoping to contribute to transformative change.

Health system strengthening – with tangible results

One of the ongoing debates/discussions over health aid involves “vertical” vs. “horizontal” interventions. I recommend William Easterly’s Can The West Save Africa? (start on page 57) for an overview of the issue, but briefly:

  • “Vertical” programs focus on global large-scale campaigns addressing a particular health condition, often focusing on the supply of appropriate medical materials (for example, vaccines and antiretroviral drugs for treating HIV/AIDS) while “horizontal” aid tries to strengthen the health system in general in a particular region.
  • “Vertical” programs have had some major demonstrable successes (for example, most of the cases in Millions Saved). However, many believe that once the major opportunities have been capitalized on, these sorts of initiatives hit diminishing returns, as medical supplies outstrip the health system’s ability to deliver them. Over-funding a particular campaign may even get in the way and undermine other health efforts.
  • “Horizontal” programs have the worthy goal of making the health system stronger as a whole, including reaching those who are hardest to reach. However, perhaps because these programs often involve more complex goals and more leeway for the funded, these programs do not have the same track record of demonstrable success, and arguably have inferior mechanisms for accountability (i.e., making sure that money is spent well and produces actual results). See this Aid Watch post for more on these problems.

VillageReach’s program, focused on health system logistics, is fundamentally more “horizontal” than “vertical” – it’s focused on improving health system capacity. For example, one of the major changes its pilot project brought about was creating a specialized team for delivery of vaccines, which relieved local health system personnel of the responsibility to collect their own vaccines. The aim was not only to get supplies out to the villages in a more reliable way, but to reduce demands and constraints on the many local health system personnel. In the future it may expand this model to other health supplies. It’s not just using donations to purchase supplies – it’s reorganizing the system to improve overall efficiency and even reduce total costs.

Yet unlike many “health system strengthening” initiatives, VillageReach’s program holds itself accountable with specific deliverables, promising – for example – a drastic drop in the frequency with which health centers run out of vaccines. It has run surveys of vaccination rates, comparing the province it worked in to a nearby province. Looking at vaccination rates cannot capture all of the benefits VillageReach aims to provide, but it provides a strong reality check on the model and suggestive evidence for whether it is indeed improving efficiency.

The program thus addresses one of the thornier, and difficult-to-evaluate, areas of global health, while maintaining strong accountability and demonstrable results.

Ambitions of transformation and sustainability – with tangible results in the meantime

Two other constant tensions we perceive in health initiatives are between (a) short- and long-term impact; (b) tangible and transformative impact. In neither case are the two goals clearly contradictory, yet in practice there often seem to be tradeoffs.

For our part, we have focused on short-term, tangible impact. As we lay out in our process overview, we are focused on serving individual/casual donors, and we feel these donors should look first and foremost for accountability and results. A chance at “hitting the jackpot” (creating a permanent and/or far-reaching change) ought to be considered a bonus, not a requirement, especially when the short-term tangible impacts are as good as saving a life for every $1,000 (or less) spent.

Yet the best charity we’ve found for these short-term, tangible impacts turns out to be very ambitious, with very high upside should they succeed. As detailed in our review, VillageReach isn’t just implementing a new health system – it’s advocating for this system as a new approach to health logistics all across the country of Mozambique. It has produced cost analysis concluding that the government will save money, long-term, by adopting its model; with this analysis and its superior results in hand, it has won the endorsement of the national Ministry of Health. It appears to have as good a chance at a lasting impact on how the government operates as any other charity we’ve seen.

Its impact need not even end within Mozambique. Getting supplies to hard-to-reach areas is a challenge that applies throughout the world of global health (and indeed VillageReach has been retained as a contractor in Senegal, Malawi and India).

If you’re hoping your donation has a chance to be a part of a new innovation with global impact, VillageReach gives you that chance. Of course, many other charities have equal or grander ambitions. The difference is that VillageReach is (from what we’ve seen) holding itself far more accountable, producing tangible – and cost-effective – impact as it goes.

What’s not to like?

Our process has been accused of over-focusing on tangible impact and evaluation, and thus favoring larger, more conservative organizations. This accusation has some truth to it (and we accept this bias in view of what kind of donor we’re serving). And yet, the organization we’ve found that performs best on our criteria is in fact relatively small, and highly innovative. Indeed, of all the organizations out there with big ambitions, we believe VillageReach – with its high accountability and its focus on producing results, not just hopes, in the meantime – to be the best bet to actually deliver.