Tomorrow. Trust me, you need an extra day to get ready for this one.

One then two.

Now that Holden and I have finished drafting reviews for Cause 5 (to be made public in a couple of weeks), we’ve moved our focus to Cause 1: Help people in Africa avoid death and extreme debiliation.

Unlike Cause 5, in which organizations roughly followed the same model to help people, organizations applying for a Cause 1 grant take wildly divergent approaches. And, in most cases they are taking not just one approach, but are running a huge set of projects that don’t always have a clear overarching theme or approach. This obviously presents a large challenge, and makes it impossible for us to compare organizations as directly and quantitatively as we did for Cause 5.

Here’s what we’re thinking so far. Mostly, our applicants fall into the following broad categories: comprehensive community aid, providing lots of different kinds of services to a small group of a people; distribution, getting lots of small, inexpensive items to many people; corrective surgery, providing a relatively expensive but life-changing surgery to those with congenital deformities; and mammoths, which do just about everything for everyone everywhere.

Comprehensive community aid. These organizations go into a village and attempt to provide everything for the village including primary health services (for childbirth, pneumonia, etc.), distributing necessary medicine/products (bed-nets, ORS, de-worming pills), education about hygiene and protected sex, economic aid including farming technology, and much more. This is the model with the most intuitive appeal to us. When you’re trying to help people thousands of miles away from a culture you’ll probably never fully understand, it seems smart to work intensely with one group of people and document all the ways in which their lives change – that way you’re more likely to catch unintended consequences, adapt to changing problems, etc., and make sure you’re actually changing their lives for the better. (This seems far superior to deciding in advance on one problem, like AIDS, and attacking it furiously while leaving other problems unaddresed.)

But that documentation is essential – immersion doesn’t equal understanding, and if a charity isn’t measuring and reporting life change, we aren’t going to bet on it. So far (though we’re still working on it), we haven’t been able to get a real picture of the life change effected by an organization using this approach. Organizations do many activities for which they often offer no evidence of the eventual impact (e.g., they tell us how many families attended their HIV/AIDS awareness campaign, but don’t offer evidence for what effect they expect that to have).

Distributors. These organizations distribute cheap and potentially life-saving items: ORS to treat diarrhea, vitamin A supplements to prevent malnutrition and blindness, bednets to fight malaria, condoms to prevent HIV/AIDS, etc. The advantage of this approach, it seems, is the potential cost-effectiveness: by focusing on the cheapest, simplest diseases to treat, you can treat a lot more people.

We estimate that the stronger candidates in this area are saving lives for around $50-120 a pop … but this estimate is based largely on combining reports on number of units sold/distributed with academic research on the effects of these units (e.g., studying the effects of Vitamin A in developed-world hospitals,), plus a lot of guesswork about utilization (i.e., it’s one thing to sell or distribute condoms – but how much are they actually getting used?) Organizations only sometimes monitor the utilization of the products they distribute, and they rarely, if ever, measure the change in actual disease prevalence for the people they serve. So charities in this area may be helping a lot of people, but it’s hard for us to be confident in their effects.

Corrective surgery. These organizations perform a very specific procedure (or set of procedures) for people suffering from an ailment. They perform surgeries to correct debilitating deformities (cleft palate, severe burns, etc.) or correct vision impairment. The best of these organizations can tell us how many surgeries they perform and what conditions they correct, which along with their total expenses gives us a picture of how many lives they’re changing for each dollar they spend. These organizations don’t tell us a lot about how debilitating the conditions they fix truly are (leaving us to question the impact they’re having).

This model is attractive because each surgery affects a specific person. Knowing how many surgeries each organization performs tells how many people’s lives have been changed – there’s not a lot of doubt. But, this model doesn’t come close to achieving the cost-effectiveness of the (albeit somewhat theoretical) distribution model, with $/life impacted at 10-20x the cost. And, without a clear picture of the debilitation these surgeries prevent (to what degree they are somewhat cosmetic), we worry that their impact is even lower.

UNICEF. UNICEF does everything, everywhere. They distribute, perform surgeries, and somtimes just focus on providing all services to a set group of people. We won’t be able to evaluate the entirety of UNICEF’s programs, but we may be able to evaluate their Accelerated Childhood Survival and Development Program, which has an approach similar to “comprehensive community care” above, and which appears to be slated for a very large and growing role in UNICEF’s programming.

So, where are we going from here? At the moment, the only organizations that we can confidently say are helping people are those peforming corrective surgeries. But, we’re waiting on more information from distributors which, we hope, gives us more confidence that people are actually using the products they receive. We’re disappointed in what we’ve seen thus far from comprehensive community care. Even though it makes a lot of sense to provide everything to a small group of people (even at higher costs), we’re not convinced of the impact these programs (which are mostly more convential Africa-aid organizations) are having.

One more note: with so many different approaches to helping people, there’s no way that they’re going to be close in terms of cost-effectiveness. There’s no reason to think that an organization distributing inexpensive items across a continent is in the same ballpark as an organization providing corrective surgeries to a few thousand children each year. Donors need to understand what they’re getting for their dollar.

Elie and I have just finished drafting our reviews for Cause 5: help disadvantaged adults become self supporting. We can’t make them public yet because we need to give our applicants a chance to look and point out mistakes (and write any responses they want to write). But here’s a quick story about what we’ve been doing.

First, the moral of the story: deciding where to give is hard. Elie and I have gone through 3-4 completely different approaches, before finding one we’re pretty happy with.

First we tried a pretty quantitative approach: look at how many people each finalist placed “sustainably” in a job (i.e., 12-month retention or above), then estimate how many people would likely have gotten similar jobs on their own, by slicing and dicing Census data to simulate the target population. The difference is “lives changed,” and lives changed divided by expenses should yield “lives changed per dollar,” which can generate a rough ranking. We gave up on this pretty quickly as we realized that many of the differences between our applicants’ populations can’t be captured in any way by the Census (differences in motivation, substance abuse history, etc.)

I then had the bright idea of clumping applicants together when their clients appeared similar. The HOPE Program and Catholic Charities both serve severely disadvantaged adults, similar in most of the ways we have data on; Vocational Foundation and Covenant House both serve disconnected (not employed or in school) youth. I created a big writeup putting the pairs side by side, and arguing that HOPE’s results are so much better than Catholic Charities’ (and VFI’s so much better than Covenant’s) as to imply true “program effects.”

I finished it around 8 this morning, at which point I went to sleep and Elie got up, took a look, and called BS. CCCS takes referrals from the govt; HOPE is working with people who want to work. Covenant House’s clients are over 50% homeless; not so VFI’s. You just can’t compare them like this. The fact is that while we know how many people each charity placed in jobs, we have no way of knowing how a comparable population would do without help. We’ve got to go with what makes sense to us.

And what makes sense to us is that it’s really hard for a 3-12 month program to fundamentally change a person. HOPE’s numbers are strong enough (relative to CCCS’s) to make us think it might be happening, but not enough to blow us away. In the end, everyone’s numbers are consistent with the hypothesis that employment programs can’t help everyone, or even most people; those who are getting jobs are likely the more motivated ones. That doesn’t mean it’s impossible to help people – they might have the willingness, but benefit from picking up specific skills, certifications, or just help with knowing where to look.

So which would you bet on? A program trying to “reform” homeless people at great cost, placing about 30% of them, or a program that finds people who are already willing and able to be a Nurse’s Aide – or Environmental Remediation Technician – and gets them the certification they need? In the end, we answered the latter. The certification model is simple, cost-effective, and makes sense. If I had to bet my life on whether getting people who want to be Nurse’s Aides certified as Nurse’s Aides is helping them, I’d say yes. If I had to bet my life on a 6-month course turning a person around, I’d need a lot more convincing data.

Right now we think the strongest two applicants are St. Nick’s Community Preservation Corp. and Highbridge Community Life Foundation, which follow exactly this model. Both see the vast majority of their clients take the jobs they’re trained for and hold onto these jobs. Both spend relatively little to accomplish this. Both do a million activities we have next to no information about, and both leave us wondering whether their clients could get similar jobs without help.

We prefer St. Nick’s, very slightly, because of the greater variety of jobs it trains for, some of which have much higher pay. A couple other organizations are still falling into our “recommended” category because they have strong numbers, and models that at least plausibly could be responsible for major life change (the HOPE Program is one of these).

We’re using a combination of intuition (our feeling about certification vs. general training), outcomes (we’re not recommending anyone if they don’t have retention numbers to back up the idea that they’re successfully placing clients), and calculations (a rough look at “cost per person placed sustainably” backs up our intuition that certification programs will be most cost-effective). There’s no one magic formula or metric that we’re hanging this decision on, and we know that we’ve made debatable leaps in judgment. But when I read over what we’ve written, and ask myself, “Holden, would you bet on this? If you were responsible for your donors’ karma, would this be your best shot at keeping them safe from lightning?” my answer is yes.

That said, I’ll feel a lot better about it once we put it out there and see what others think (should be within a couple weeks). I seriously cannot believe that other foundation people make these kinds of decisions talking to no one but each other. Does that really happen? That’s crazy.

Smarter Spending on AIDS: How the Big Funders Can Do Better. When I saw that title, linked here, I quickly opened the link expecting a report critically evaluating which strategies work in the fight against HIV/AIDS.

Should we fund condom distribution or programs promoting monogamy? Is ARV distribution enough or do non-profits need to follow-up with clients to make sure each takes their medication? What progress has been made on an AIDS vaccine – does that need more funding? Instead, I found a report full of corporate gobbledygook, which endorsed the following best practices – “working with the government; building local capacity; keeping funding flexible; selecting appropriate recipients; making the money move; and collecting and sharing data.”

Seriously? “Selecting appropriate recipients?” “Making the money move?” Does anyone think a paper like this can, will, or should change anyone’s behavior?

This is just the latest example I’ve seen of reports that seem to actually say nothing. By “nothing” I mean one of two things: either 1) the conclusions a paper offers are so general and vague and offer such scant evidence and reasoning that they’re practically useless or 2) the paper asserts conclusions which are so obvious that no one could possibly argue with them.

There’s the paper on practices of high-impact nonprofits that’s been floating around the blogosphere; I thought Albert’s post (linked) did a good job pointing out its shortcoming, but I also want to mention that its 6 attempts at “debunking myths” (pg 34-35) seem to come down to saying: “Effective nonprofits can come in all shapes and sizes.” Really? This changes everything!

There’s the Hard Lessons paper many have praised as a breakthrough in foundation self-criticism. Hard lessons taught here include “Allow room for the definition of success to shift and evolve as people learn what is possible and effective, as relationships deepen, and as the work matures”; “Match evaluation tools to their purposes”; and “Cultivate a flexible learning stance” (pg vii). They don’t, though, include any lessons about program design itself.

We often say we’d like to see more self-evaluation in the nonprofit sector. Papers like these are not what we’re referring to.

Nothing but Nets had a simple idea: kids in Africa need bed-nets to protect them from malaria-carrying mosquitoes, and there’s already a huge distribution network in place, through the Measles Initiative. Why not utilize the existing infrastructure to reduce the cost that a bed-net-alone charity would incur, and distribute more nets for fewer dollars? Saving people from malaria and measles – what could be better?

The Global Network for Neglected Tropical Disease Control proposes something similar: organize the handful of organizations distributing medicine to fight the so-called neglected tropical diseases, which include River Blindness, Hookworm, and Elephantiasis. More efficiency means lower costs and ultimately more lives saved.

But, here’s the thing that bugs me. Last year, when I first did research into diarrhea, I learned about something called Oral Rehydration Salts, a packet of which cures diarrhea and costs 5 cents. And, that’s not all: condoms cost pennies and prevent HIV/AIDS transmission, a 50-cent dose of antibiotics cures pneumonia, iron pills reduce incidence of anemia, and Vitamin A pills prevent blindness. And, for the most part, all these conditions affect the same communities: poor, rural areas of Sub-Saharan Africa.
It makes no sense that it takes more than three different organizations to distribute all the small, cheap items mentioned above. Why isn’t someone distributing everything? It’s great that Nothing but Nets and GNNTDC recognized the opportunity in some cases, but why haven’t we seen anyone giving out the whole goodie bag?

There are certainly a lot of good reasons to run a program focused on providing everything – necessary medicine in addition to health and other poverty-reducing servies – for a contained group of people. More about that to come soon. But, if you’re running a distribution program as many organizations do … how can you distribute bed-nets but not ORS? How can you distribute Vitamin A without bringing some bed-nets along? And, why distribute condoms without some good ol’ Ivermectin?