The GiveWell Blog

Update on our work on Fistula Foundation

Although our list of top charities is short (just eight excellent organizations), we’re always on the lookout for other groups to add. Fistula Foundation is one of the charities we’re planning to prioritize highly for further evaluation. Donating to Fistula Foundation is not yet one of our recommendations—as it’s still under active investigation—but we’re excited to share an update on our work so far and next steps.

Living with fistula

An obstetric fistula is an abnormal opening between the vagina and the bladder or rectum, which causes leakage of urine and/or feces through the vagina.[1] This type of fistula[2] is typically caused by a prolonged obstructed labor in which the fetus presses on the mother’s pubic bone and cuts off blood flow to the tissue nearby.[3]

Living with fistula may cause harm in many ways: physically, through skin conditions and constipation; economically, as it may be hard to get or keep a job, due to odor; and socially, as fistula is associated with divorce and isolation, also due to the odor.[4] Describing a fistula patient’s experience in 2016, New York Times columnist Nicholas Kristof referred to people with fistulas as “modern-day lepers.”[5]

Surgery may be used to repair fistulas in many cases.[6] Fistula Foundation supports fistula repair surgeries and a variety of activities to increase the number of fistula patients who receive treatment.[7]

GiveWell and Fistula Foundation

We first reviewed Fistula Foundation as a potential top charity in 2011, two years after it expanded its mission to treat fistula globally.[8] We decided that it did not then meet our strict top charity requirements due to our uncertainty about the success of surgeries and our lack of confidence in the degree to which Fistula Foundation’s support caused surgeries to take place that otherwise would not have.[9]

Our charity review process evolved over the years that followed. We began placing more emphasis on completing independent evidence reviews for promising programs as a first step in our research process, before looking at individual charities implementing the most promising programs that we identify: our “priority programs.”

As part of our work to complete more evidence reviews, we looked into surgery to repair obstetric fistula in 2017. We estimated that fistula surgery was potentially in the range of cost-effectiveness of our priority programs, although we had major open questions about the cost of surgery and patients’ long-term outcomes.[10] Despite these questions, we felt that fistula surgery met our criteria to be named a priority program and we continued our work to better understand it.

We partnered with a group called IDinsight through GiveWell’s Incubation Grants program to improve our understanding of the cost of fistula surgery. This was particularly challenging for us to estimate due to our uncertainty over (a) the cost to reach potential patients, who may be in remote areas and socially disconnected, and (b) the costs and impact of training surgeons and providing equipment (typical activities conducted by fistula management charities) on the long-term success of the surgeries.[11] Though we were interested in fistula management charities broadly, IDinsight identified Fistula Foundation as a promising group and produced an estimate of Fistula Foundation’s cost per surgery in Kenya, including outreach and indirect costs such as training.[12]

Our evidence review and work with IDinsight led us to revisit Fistula Foundation as a potential top charity. We made a $100,000 participation grant to Fistula Foundation after publishing an interim review of its work.[13]

Top charity contender

We consider Fistula Foundation a top charity contender. Our next steps are to determine which evidence will help us understand the effect Fistula Foundation’s programs have had on the number of surgeries performed, which is a key input into our understanding of its cost-effectiveness, and to review recent studies on the impact of fistula surgery at one to two years post-surgery.

Our open questions and next steps

Open questions

We plan to prioritize several key questions as we continue our review of Fistula Foundation. We want to better understand:[14]

  • the role Fistula Foundation plays in supporting additional surgeries;
  • the long-term outcomes of surgeries supported by Fistula Foundation;
  • the counterfactual impact of Fistula Foundation (i.e. the degree to which it is increasing the number of fistula surgeries performed, relative to what would have occurred in its absence); and
  • the opportunity costs of fistula surgery (e.g. what the doctors who treat fistulas would have done in the absence of this program).

Next steps

We’re unsure when we will complete our review. The timing will depend on our overall research capacity as well as how we prioritize Fistula Foundation alongside review of other potential top charities. We very roughly estimate that there’s a 30% chance we will review Fistula Foundation in 2020.

We’re still in the process of vetting Fistula Foundation and have more confidence in our current list of top charities. We’re excited to continue learning about the work of this promising organization in the future.


Sources for this post may be found here.