The GiveWell Blog

The Carter Center – part II

(updated on: ) | by Elie

In Part I, I laid out my case for The Carter Center, and why we think they’re worth investigating deeply. I also said that we’re not yet ready to recommend them because we have some unanswered questions. Here they are:

Relevance of your donation

When I give, I want to know that the organization needs my support and is going to accomplish more good (than they otherwise would have) because of my support. Because of The Carter Center’s strong track record, I wonder whether they can already effectively raise all the money they want. That is, I wonder whether money isn’t the bottleneck to serving more people. That question is supported by looking at Carter’s current financial situation. Revenues have risen roughly in-line with expenses over the past few years (see chart 1 below), maintaining their (relatively large) assets:expense ratio of 3:1 (see chart 2, below). All data comes from Carter Center annual reports, available on their website here.

Chart 1
 

Chart 2
 

Less-proven and less-monitored programs.

Many of The Carter Center’s programs have extremely strong independent evidence supporting them (e.g., their guinea worm, river blindness, lymphatic filariasis, and schistosomiasis programs). These programs also have the type of strong, consistent monitoring I mentioned in the previous post. However, the evidence case for some of their other programs is weaker (in particular their trachoma, agriculture, and public health training initiative), and the monitoring provided for those programs is both a) less consistent and b) less compelling than the monitoring provided for the others.

Running some less-proven projects doesn’t necessarily mean we won’t recommend them, especially if those programs are relatively small, but:

Lack of financial transparency

The Carter Center is one of the (if not the) most transparent organizations I’ve ever come across when it comes to monitoring their activities. Carter not only lays out what they do in extreme detail — for the intrepid, the most recent river blindness program report (PDF) is representative of Carter Center monitoring — they discuss program trade-offs they make, lessons they’ve learned, and potential future obstacles. But, they don’t publish any cost data on their website, other than the very broad and general 990 data and some sporadic program-specific information. To properly evaluate The Carter Center, we need to know the portion of the budget that’s allocated to any less-proven programs. In addition, we want tell you what your donation accomplishes to The Carter Center. Does $1,000 prevent 1 case of blindness? 2? 10? We need better information on costs to make that call.

Those are the questions we’re working on answering now. Whatever we find, you’ll get our answers soon.

Malaria “success story” questioned

(updated on: ) | by Holden

Aid Watch on questionable claims of success against malaria:

Real victories against malaria would be great, but false victories can mislead and distract critical malaria efforts. Alas, Mr. and Mrs. Gates are repeating numbers that have already been discredited. This story of irresponsible claims goes back to a big New York Times headline on February 1, 2008: “Nets and New Drug Make Inroads Against Malaria,” which quoted Dr. Arata Kochi, chief of malaria for the WHO, as reporting 50-60 percent reductions in deaths of children in Zambia, Ethiopia, and Rwanda, and so celebrated the victories of the anti-malaria campaign. Alas, Dr. Kochi had rushed to the press a dubious report. The report was never finalized by WHO, it promptly disappeared, and its specific claims were contradicted by WHO’s own September 2008 World Malaria Report, by which time Dr. Kochi was no longer WHO chief of malaria.

Video with the Gateses available here.

Trachoma: An example of the need for long-term monitoring

(updated on: ) | by Elie

When is a measured program-impact not a real impact? When it doesn’t last.

A study published today in PloS NTDs evaluated the impact of four doses of azithromycin (one every 6 months), and monitored trachoma prevalence throughout the drug administration period and for 2 years after the last dose.

In the first 24 months (from the start of the program through 6 months after the last treatment) prevalence decreased from 63.5% to 2.6%. In the 18 months after the last treatment, prevalence increased to 25.2%.

There was wide village-to-village variation in the prevalence before, during, and after treatment. While all villages ended up with lower infection rates of trachoma than they started with, in some (in particular village numbers 10 and 12 in this table), the infection rate 18 months post-treatment was close to pre-treatment levels.

Another reason to think that more monitoring is probably worth the cost.

The Carter Center

(updated on: ) | by Elie

I’ve spent a good part of the past month reviewing The Carter Center in depth. We found out about The Carter Center though referrals from an advisor and donor, and through the Gates Award for Global Health.

We chose to investigate The Carter Center further for four reasons:

  1. Strong track record of success. The Carter Center has been credited with leading the global effort to eradicate guinea worm. In 1986, when Carter got involved, there were 3.5m annual cases of guinea worm. In 2008, there were fewer than 5,000. Guinea worm has been eliminated from 12 of the 18 countries that were once endemic. This chart shows the decline in cases from 1989-2007 (PDF). (More information about guinea worm and its symptoms is available on The Carter Center website.)
  2. Strong program selection. Other Carter Center programs have strong evidence of effectiveness supporting them. The interventions they implement to control or eliminate neglected tropical disease including river blindness, trachoma, lymphatic filariasis, and schistosomiasis are recommended by the experts at the Disease Control Priorities Project.
  3. Monitoring and evaluation. For its health programs, The Carter Center often monitors not only the number of drugs distributed in each region but disease prevalence directly. This monitoring isn’t evident for every single program or region, but it is far more consistent than any other complex organization we’ve seen before.
  4. Transparency. All the information we’ve used to research The Carter Center is available publicly on their website. For example, the detailed program reports I mentioned above are available here. For an example of the type of monitoring conducted for its guinea worm program, see the latest monthly report linked here.

I still have some large, unanswered questions about The Carter Center, and we aren’t yet ready to recommend them.

Financial Times on microfinance (and the need for better info about it)

(updated on: ) | by Holden

PDF here (via Innovators for Poverty Action, whose research is featured). After discussing the Karlan/Zinman study showing benefits for loans (which we summarize here), it continues:

Karlan is the first to warn against extrapolating too much from a single experiment. “This is the last thing in the world that I would use to develop policy,” he warns. “You’ve got to replicate.”

The trouble is that the replication just isn’t happening. For all the optimism about microfinance – and the [Karlan/Zinman] experiment only encourages that optimism – it is striking how much we do not know about when it works, and why.

This matters because non-commercial microfinance projects often depend on donor subsidies. And while microfinance has a good reputation among development professionals, that doesn’t mean guaranteed access to those subsidies. Not everyone is convinced that a donor grant is best used to subsidise a loan rather than, say, pay directly for a primary school. More credible evaluation would help preserve the programmes that deserve to be preserved.

Already, solidly held beliefs about microfinance have been shaken. The “group liability” system, in which a group of borrowers guarantee one another’s loans, is still supposed by many to be the secret behind Grameen Bank’s low default rates. But a randomised trial in the Philippines conducted by Karlan and aWorld Bank economist, Xavier Gine, found that group liability was discouraging new customers without improving repayment rates. Grameen itself quietly dropped group liability some time ago.

Another sacred cow of microfinance is that women make best use of the money – the Grameen Bank says that 97 per cent of its borrowers are women. But another randomised trial, conducted in Sri Lanka by a team of researchers including David McKenzie of the World Bank, found that male borrowers seemed to make a far higher return on their capital. As with the ZaFinCo study, it’s just one experiment in one country. Yet it raises a worrying question: for how long will donors fund microfinance projects with so little compelling evidence about exactly what kinds of project really work?

It also discusses why the Karlan/Zinman’s results might not be generalizable:

[The experiment’s] clients were ideal customers for a commercial lender: they were city-dwellers and therefore cheap to reach; they were poor enough to want loans but rich enough that the loans were profitably chunky. A peasant farmer in Ethiopia or Sudan ticks none of those boxes: living in the middle of nowhere, he is expensive to reach and he is so poor that he can only afford tiny loans. Trapped in a barren economic ecosystem, he has no job that a ZaFinCo-style loan can help preserve, and no business prospects either. A mere loan will not catapult him into the ranks of the entrepreneurial class. Then there are the destitute, the disabled, the elderly and the orphans. Such people cannot repay loans at a rate that would cover costs. Heavy subsidies or outright grants would be needed. “All people are entrepreneurs,” says Muhammad Yunus. If only he were right.

And indeed, a more recent randomized trial of microfinance has preliminarily found far less encouraging results (discussed in this interview on Philanthropy Action, co-maintained by GiveWell Board member Tim Ogden).

Microfinance/education program didn’t work as expected

(updated on: ) | by Holden

A reader was good enough to send in a Lancet article (free registration required for full text) about a well-designed study of a combination microfinance/education program in South Africa.

Study design, strengths and weaknesses

A program consisting of both loans and group meetings was rolled out to 8 villages in rural South Africa, but the villages were randomly split into 4 that received it right away and 4 that received it 3 years later. Meetings included a curriculum that “covered topics including gender roles, cultural beliefs, relation ships, communication, intimate-partner violence, and HIV, and aimed to
strengthen communication skills, critical thinking, and leadership” (pg 1975).

Researchers hypothesized that (a) women in the loan groups would have fewer experiences of intimate-partner violence (presumably due to being financially/culturally more empowered); (b) this in turn would be connected with less unprotected sex in their households; (c) this in turn would slow the spread of HIV in their villages. A very ambitious theory of how to slow the spread of HIV – but to the researchers’ credit, they specified their hypotheses formally before conducting the study, as well as registering it on ClinicalTrials.gov. Combined with the use of randomization, this study had just about all the ingredients for avoiding the plague of publication bias.

A problem with the study, which the researchers partially acknowledge (pg 1981), is that it was only conducted in 8 villages total (4 receiving the program and 4 not receiving it). Therefore, it’s hard to say with confidence that any observed differences were due to the program as opposed to other differences between one randomly chosen set of 4 villages and another. Villages were similar on most observable characteristics, but very different on a few (see pg 1980).

Results

The study concludes that the program resulted in less intimate-partner violence, but not in less safe sex or in slowing the spread of HIV.

A few possible interpretations of this result:

  • The researchers’ interpretation is that the program was responsible for reductions in violence, but that these simply didn’t translate into slowing the spread of HIV. Definitely a possibility. (If this is right, by the way, I’d call this a great program solely on the basis of its successfully reducing intimate-partner violence. That would be a great accomplishment in its own right, even if it didn’t have the hoped-for effect on the spread of HIV.)
  • It’s also possible that the program had no effect, and that the observed change was a change in reported episodes of violence. Perhaps women who participated in the program came to feel more shame about reporting these episodes. (It’s also possible that the measurement error is in the other direction – that women in the program felt more pressure to report episodes, and that the fall in violence was greater than what was measured. This is the researchers’ theory, given on pg 1982.)
  • And it’s possible that random fluctuations simply swamped any effects of the program itself. As mentioned above, it examined only 8 villages; and there was definitely a lot else happening in these villages over the time period in question. For example, the unspecified measure of “greater food security” had a huge rise across all villages studied, whether or not they received the program (see pg 1980). I can’t help but wonder: if this had been a more typical (less rigorous) study without a comparison group, would this increase in food security have been touted as a success of the program?

The one thing I feel fairly sure of after reading this study is that the researchers’ elaborate, multi-step theory of how loans and education can slow the spread of HIV didn’t come out looking great when all the facts were in. For every community program that publishes a study like this (and this is one of the very few I’ve seen), there are many more similar programs, with similarly involved theories of the linkages between credit, knowledge, health, empowerment, etc. that have simply never been checked in any way.