The GiveWell Blog

Selecting program-based health interventions

| by Holden

We are doing both region-based and program-based research on developing-world health. First I will discuss our program-based research, which will focus on (a) finding particular interventions (and/or clusters of interventions) that appeal to us; (b) finding organizations that implement these interventions “vertically,” i.e., replicating the same basic program across a variety of regions.

For these purposes, we particularly value interventions that are proven, scalable, and cost-effective.

Unlike most foundations, we are seeking explicitly to serve individual donors – donors who don’t have personal connections to particular organizations or expertise in the issues, and who therefore are better suited to expanding what already works (i.e., interventions that are proven and scalable) than to exploring unproven innovations. More on this idea at our FAQ, as well as in this blog post.

We think of an intervention as proven when:

  • It has been previously carried out and carefully, publicly evaluated (often through academic research) in a way that provides strong empirical evidence for its positive impact on people’s lives. (A future post will further discuss our position on the “evaluation hierarchy” and what sorts of evidence we think are necessary under different circumstances.)
  • The conditions under which it has been evaluated match the conditions under which it is likely to be carried out again, in as many relevant ways as possible.

We think of an intervention as scalable when:

  • There is a significant amount of unmet “need” for the intervention, i.e., conditions under which the intervention would be helpful but has not yet been funded.
  • Donations can be used to replicate the intervention in a variety of areas, while recording enough information about its execution to be reasonably confident that it is working as intended.

Defining “cost-effectiveness” is significantly more complex, and will be discussed in the next post.

Region-based vs. program-based approaches to developing-world health

(updated on: ) | by Holden

Deciding where to give involves making major judgment calls: decisions that rest on subjective and otherwise highly debatable claims (such as the decision of which sort of life change to aim for). We have no pretense of being able to make such judgment calls “objectively” or “perfectly. Rather, we try to:

  • Be explicit about which values we are pursuing and which judgment calls we’re making. For example, we’ve already declared our preference for funding proven and repeatable interventions, and we’ve declared our decision to focus on developing-world direct aid for the coming year.
  • When practical, leave major judgment calls to our donors rather than making them ourselves, by recommending a variety of charities that are strong according to different criteria. This approach is especially important for judgment calls that our donors haven’t agreed to in advance (unlike the two listed directly above).

We are currently focusing on health interventions for the developing world (we will research other aspects of developing-world aid later in our process). One of the major judgment calls involved in choosing a health intervention is the decision between a region-based approach and a program-based approach to giving.

Taking a region-based approach means focusing on a particular part of the world; learning as much as possible about the people who live there, the opportunities they have, and the problems they face; and then finding a program that is well-suited to addressing the particular needs of this region. For regions with many interrelated health problems, such a program will likely be one that aims to strengthen the general quality of health care in the region, which will make it possible to address many health issues at once. (One such program is Partners in Health, a recommended charity from our last round of research that focuses on bringing full-service health care systems to poor rural areas.)

Taking a program-based approach means focusing on a particular intervention (or cluster of interventions); learning as much as possible about the conditions under which this intervention has been shown to improve lives in the past; and then finding a program that replicates this intervention across many regions. (This is the approach we took in evaluating Population Services International, which markets materials such as condoms and bednets across the world.)

A region-based approach has the advantage that it is more likely to be well-fitted to the particular people it serves and their needs. A program-based approach, however, may in some cases be a simpler and/or more cost-effective way to address a particular health problem, which means that it may be a more efficient and reliable way of changing lives for the better.

We will be taking both approaches, and presenting the options for donors that correspond to each. In future posts, we will discuss the specifics of (a) our region-based approach, i.e., how we will be choosing one or more countries to focus on; (b) our program-based approach, i.e., how we will be choosing one or more interventions to focus on.

DALYs and disagreement

(updated on: ) | by Holden

Elie thinks that fistula is worse than death. jsalvati disagrees.

I’d rather bring someone to full health than save an infant’s life. Ryan agrees, but Basti does not and Ron Noble emphatically does not.

It’s possible that we would all agree if we knew more about the lives of people in the developing world, or if we just had a long enough to argue about our values. It’s also possible that we wouldn’t. And as long as we disagree, we’ll have different opinions on what the most “cost-effective” interventions are. For example, if it’s true that fistulas can be repaired for $450 each, is this a better or worse use of donations than preventing children’s deaths for $200 each through vaccinations? My answer would be “It depends on the donor.”

Converting disease burdens and intervention benefits into DALYs doesn’t resolve questions like this. Rather, it obfuscates them, by converting the two interventions into the same terms using a single set of philosophical values. If the numbers above ($200/death averted for vaccinations, $450/surgery for fistula) are accurate, they allow different donors to make their own judgment calls, while being informed about their options. But these aren’t the numbers you’ll find in the Disease Control Priorities Project’s summary tables; instead, you’ll see only that surgical services cost an average of $136 per DALY averted (Jamison et al. 2006, Pg 75) and that the vaccinations interventions costs an average of $7 per DALY averted (Jamison et al. 2006, Pg 77).

Some simplification and information loss is necessary in order to compare different options, but reducing everything to a single unit means being able to serve only a single kind of donor. I’d prefer to estimate the effect of different interventions on a variety of “life outcomes” that different donors might value differently. We will discuss this variety more in a future post, but here’s a quick list:

  • Total life-years saved.
  • Adult lives saved (as it is common to value adult lives more than children’s lives).
  • Cases of extreme misery, such as fistula or perhaps severe elephantiasis, averted.
  • People brought to a “normal” level of health, i.e., without any debilitating nutritional or other conditions.

All of these things need to be separately estimated to produce DALY estimates. The DCP report did so with admirable thoroughness and far more people than we have (Jamison et al. 2006, Pgs xxiii-xxxiv). Yet because they published only their DALY estimates (not, with some exceptions, the estimates of different health problems that went into them), they buried a great deal of this work, and produce cost-effective estimates that are useful only if you’re completely on board with all of their values (from how bad each disability is to how to value different years of life). We’re currently trying to get in touch with the authors so we can get access to more of the details; if we don’t, we’ll have to repeat much of their work (with less capacity to do so).

Sources

Previously in series:

Donors don’t have to pay for their own philanthropic advice

(updated on: ) | by Holden

Tactical Philanthropy:

Sooner or later, donors are going to start being willing to pay for advice on how to give. This will transform philanthropy.

I agree that donors should be willing to pay for advice on how to give. I certainly would have done so back when I was in the for-profit sector, if I could have found an advisor I had confidence in for a price I could afford.

But it’s conceivable that donors – especially small donors – will never have to pay for philanthropic advice, because someone else will pay to give them that advice. To give a simplified example: say that you care passionately about the cause of K-12 education, but know little about it. Now say that for $1,000, you can fund a philanthropic researcher to produce a report for other donors whose gifts to K-12 education charities will total $10,000. That means you have the choice of giving $1,000 directly to a K-12 charity (though you don’t have much to go on in picking one), or spending that $1,000 to “redirect” $10,000 of uninformed giving to the charities recommended by researchers.

The latter can be a pretty good deal. Unlike in investing, in philanthropy it makes perfect sense to pay for the privilege of redirecting other people’s money. (In fact, this practice is already widespread – large donors often fund fundraising campaigns, with the aim of raising money from others, and lots of people are happy to fund advocacy charities that are ultimately aiming to redirect government funding.)

Picture a world where some donors use philanthropic research for free, and other donors pay for that research with the knowledge that it’s redirecting the first group’s money. This isn’t the only, or necessarily the most aesthetically appealing, way for philanthropic research to get funded. But it’s a perfectly good deal for all parties involved (the donors that get the free research and the donors that pay to improve others’ giving). It’s a model that couldn’t work in for-profit investing, but when it comes to philanthropy where donors are seeking to create public goods rather than add to their own wealth, I see nothing unsustainable about this setup.

That’s the basic arrangement we’re currently pursuing. We are seeking GiveWell Pledges from donors who might be happy to use our research, but don’t necessarily want to pay for it. Meanwhile, a different set of donors pays our operating expenses, in the hopes that we’ll be able to move money from the first group.

Fistula

(updated on: ) | by Elie

Coming across the current feature on the DCPP’s home page reminds me of how much I care about the issue of obstetric fistula.

The following are highlights from the article linked above (emphasis mine):

For countless women in developing countries, going into labor is the painful beginning of a lifetime of unremitting shame and misery as a despised social outcast—destitute, childless, and abandoned by family and friends.

These women have a condition called obstetric fistula. A fistula, the Latin word for “pipe,” is an “abnormal passage” between organs — in this case, between the vagina and the bladder, the rectum, or both. The hole makes the woman uncontrollably incontinent of urine or feces or both and transforms a healthy person into someone viewed as a leaking, reeking, “moving latrine,” in the words of Veronica Yakobe, a Malawian woman who endured 23 years of indignity before an operation at Nkhoma Hospital in her country’s central region closed the fistula.

  • 2 million to 3.5 million women worldwide currently [live] with obstetric fistula.
  • Statistics from Ethiopia, Nigeria, India, Pakistan, and elsewhere show that the majority of fistula sufferers are abandoned by their families, divorced by their husbands, and forced to fend for themselves, often by begging. Some, like a group of Somali women who leapt from a pier chained to one another, end their lives in despair.
  • Studies of patients undergoing fistula surgery find the majority in their early twenties or younger. In one Nigerian study, 72 percent were between the ages of 10 and 20, 82 percent having married between 10 and 15.
  • A number of facilities, most prominently the renowned Addis Ababa Fistula Hospital, in Ethiopia, repair thousands of fistulas each year at a cost of about $450 for each operation and related care.

The disability weight used for fistula in DALY calculations is .430 (Pg 121 of the Global Burden of Disease report (PDF)). For context, the disability weight for blindness is .600 (Pg 120). To me, fistula seems much worse. Not only does a person undergo severe physical trauma, but she also often suffers severe social consequences such as communal ostracization and abandonment by her family.

In fact, it’s hard for me to imagine a cause I’d rather attack. I’d much rather prevent a fistula than save a life. The fate described above seems worse than death.

We’re planning to look into fistula carefully, and I hope we’ll find donors a great option for helping those afflicted.

Health education is tricky

(updated on: ) | by Holden

In theory, you can fight HIV/AIDS by teaching safe sexual behavior; fight diarrhea by promoting hygienic practices; reduce child mortality by educating mothers; etc. However:

  • Research on the effectiveness of these sorts of programs is thin; and programs that combine documented effectiveness with clear replication models are, so far as we can tell, rare to nonexistent.
  • Changing people’s behavior isn’t straightforward. For an example, consider the finding – regarding hygiene education – that “The interventions promoting the single hygiene practice of washing one’s hands with soap tended to achieve greater reductions in disease than those that promoted several different behaviors … numerous messages dilute each other in the minds of the target audience” (see DCP pg 785 – references given there).

If it’s true that education works best when it’s focused, that means that planning an education program right means not just identifying behaviors that need changing, but analyzing which changes would be most beneficial. That’s a complex undertaking, and so is changing how people from another culture live their daily lives.

I’m generally not very optimistic about this category of intervention given what we know about it. Handwashing programs appear to be pretty well-documented and are a possible exception.