This post will discuss Zusha!, a 2017 GiveWell top charity contender and GiveWell Incubation Grant recipient. We previously highlighted No Lean Season as a potential 2017 top charity originating from our Incubation Grants work.

GiveWell first learned about Zusha! in 2013 following our publication of a shallow investigation into road safety. This month, Good Ventures made a GiveWell Incubation Grant of $900,000 to support the Georgetown University Initiative on Innovation, Development and Evaluation (gui²de) for work on Zusha!. Also this month, two GiveWell staff members visited Zusha! in Nairobi to learn more about its work. We plan to share additional details from their site visit in the future; this post is meant to provide a higher-level overview of Zusha! as a potential GiveWell recommendation.

Road safety campaign

Car accidents are a major cause of preventable death and disability around the globe, killing approximately 1.25 million people each year and injuring an additional 20 to 50 million. On the current trajectory, the World Health Organization (WHO) projects that road traffic crashes will be the 7th leading cause of death globally in 2030. The problem is particularly pronounced in low- and middle-income countries, which account for 90% of all traffic deaths, despite having ~50% of the world’s vehicles, according to the WHO.

Zusha! is a road safety campaign that targets unsafe drivers of public service vehicles. The campaign distributes stickers for buses with messages encouraging passengers to speak up and urge drivers to drive more safely—”Zusha” means “protest” in Swahili. Drivers are incentivized to keep the stickers in their vehicles via enrollment in a weekly lottery with cash prizes. The goal is to reduce traffic deaths and injuries. gui²de has primarily worked in Kenya.

Zusha! is part of gui²de. Professors James Habyarimana and William Jack have conducted two randomized controlled trials (RCTs) of the program in Kenya: first, a small pilot study of ~2,400 vehicles followed by a larger study of ~12,500 vehicles. The researchers found large, statistically significant effects of the program in reducing the number of accidents for vehicles in the treatment group.[1] With support from a Development Innovation Ventures (DIV) grant from USAID, Zusha! scaled up in Kenya following the second RCT. As of March 2016, Professors Habyarimana and Jack estimated that the campaign was reaching 25,000 minibuses and larger buses, out of roughly 40,000 in the country.

gui²de is running three additional RCTs on this program in Rwanda, Tanzania, and Uganda.

A note on terminology in this blog post

In this blog post, we generally refer to the program we’re interested in as Zusha! to distinguish it from gui²de‘s other programs (not related to road safety). However, Zusha! is only the name of the road safety campaign in Kenya; the road safety campaigns in Rwanda, Tanzania, and Uganda have other names. Although the Kenya campaign is the one we’re most knowledgeable about, it’s possible that a GiveWell top charity recommendation would include gui²de‘s road safety work in other countries. We’ve used the term Zusha! in this post for simplicity.

Potential future top charity

We’re interested in Zusha! as a potential future top charity due to the potential strength of the evidence base and cost-effectiveness.

We believe the evidence for Zusha! is compelling. The pilot study finds that driving accidents decreased by a half to two-thirds and the larger Kenya RCT finds that driving accidents decreased by between one-quarter and one-third. These effects seem surprisingly large to us, and we are interested to see whether the intervention will find similar effects in future RCTs. In our most up-to-date cost-effectiveness calculation, we estimate a cost of ~$13,000 per road accident death averted (including injuries and incorporating discounts to account for whether the studies would be likely to replicate and questions around external validity).

GiveWell’s current estimate is that the cost-effectiveness of Zusha! is comparable to the Against Malaria Foundation, one of our top charities, and about 3-4x as cost-effective as direct cash transfers, a baseline we use for comparing interventions, although this may change as we incorporate additional inputs. We incorporated age weights into this estimate that reflect the older average age of passengers on vehicles, relative to average age of people whose deaths are averted by AMF-distributed nets, and approximate GiveWell median staff values for averting an adult death.

GiveWell Incubation Grant

Good Ventures’ recent grant to gui²de is intended to:

• Allow gui²de to continue operating at scale in Kenya and collect higher-quality monitoring data of that work. Strong monitoring data, such as information to demonstrate the stickers are being distributed to the intended vehicles or that the stickers remain in use over time, is a necessary component for a top charity recommendation and is one of our biggest open questions about Zusha!.
• Increase the sample size of the RCT in Uganda by ~50%, improving the study’s power and making it more likely the results will inform our views.
• Potentially improve the quality of data collection for the RCT in Tanzania.
• Provide funding to enable gui²de to continue its ongoing work through the end of 2017, when GiveWell might potentially name Zusha! a top charity, in which case we would expect to direct it substantial funding. Enabling gui²de to continue operating in Rwanda, Tanzania, and Uganda for six additional months would also allow faster scale-up if the RCT results are positive.

A write-up on the February 2017 grant is forthcoming. It will be published here.

Our open questions

We have several open questions about Zusha!‘s work that will be key in helping us decide whether to recommend Zusha! as a top charity:

• We expect that results from the three pending RCTs in Rwanda, Tanzania, and Uganda will substantially affect our view of the likely impact of the program, although we don’t expect to have full results from all three RCTs by the end of 2017.
• Zusha! researchers found a nearly statistically significant impact for the placebo intervention (stickers that had messages like “Travel well”) in the second Kenya study. This finding casts uncertainty on the mechanism by which the intervention works and whether the intervention is having an impact. Additional RCTs may help fill out our understanding.
• Our cost-effectiveness analysis suggests that Zusha! is competitive with—but not far better than—our current top charities, at ~3-4x as cost-effective as cash transfers. GiveWell’s cost-effectiveness analyses tend to become worse (less cost-effective) as we add new inputs and adjustments. Our estimate of Zusha!‘s cost-effectiveness already became significantly worse when a GiveWell Research Analyst, Leon Zhang, identified a mathematical error in one of the studies published on Zusha!‘s program. It’s possible we will conclude that Zusha! is not as cost-effective as our other top charities after spending additional time on this.
• Provision of high-quality monitoring information to demonstrate that the stickers are being used in buses over time. We understand from our recent site visit that Zusha! tentatively plans to do three types of monitoring in Kenya going forward: At National Transport and Safety Authority (NTSA) inspection centers, bus parks where passengers are picked up, and via the lottery. We have questions about the implementation of these processes, but our impression is that Zusha! is working to significantly improve its monitoring, and we expect to have more information by the end of the year.
• Zusha! is a behavioral intervention. Over time, people may get used to seeing the stickers, causing the effect to diminish. We currently have limited information on the extent to which this has occurred or may occur in the future. We hope additional information about long-term impacts of the program will enable us to assess this question over time.

Path to GiveWell top charity

We publish our updated top charities list in November. By then, we expect to have new monitoring information from Kenya as well as preliminary RCT results from Tanzania. We also expect to have partial results from the Uganda RCT. (We do not expect to have results from the Rwanda RCT.) We guess that the information we will have by late 2017 should be sufficient to assess Zusha! for a potential GiveWell recommendation.

Notes

[1]

• Results from the pilot study (published 2010): “Our results indicate that insurance claims fell by a half to two-thirds, from an annual rate of about 10 percent without the intervention, and that claims involving injury or death fell by 60%.” Habyarimana and Jack 2010, p. 1
• Results from the larger study (published 2015): “Overall, the stickers reduce insurance claims of matatus assigned to treatment groups by between one-quarter and one-third on an intent-to-treat (ITT) basis. Among the roughly 8,000 vehicles in the treatment groups, the reduction was 25%, and we estimate that about 140 accidents were avoided per year, and about 55 lives were saved annually.” Habyarimana and Jack 2015, p. 1