From salt intake reduction to labor migration: Announcing top ideas for the AIM 2024 CE Incubation Program
TLDR: In this post, we announce our top four charity ideas to launch through our August 12-October 4, 2024 Incubation Program. They are the result of months of work by our research team, who selected them through a five-stage research process. We pick interventions that exceed ambitious cost-effectiveness bars, have a high quality of evidence, minimal failure modes, and high expected value. We’re also announcing cause areas we’ll investigate for the February-March 2025 IP.
We’re seeking people to launch these ideas through our next Incubation Program. No particular previous experience is necessary – if you could plausibly see yourself excited to launch one of these charities, we encourage you to apply. The deadline for applications is April 14, 2024. You can apply to both August-October 2024 or February-March 2025 programs via the same link below:
In the Incubation Program, we provide two months of cost-covered training, stipends (£1900/month during and for up to two months after the program), seed funding up to $200,000, operational support in the initial months, co-working space at our CE office in London, ongoing mentorship, and access to a community of alumni, funders, and experts. Learn more on our CE Incubation Program page.
One sentence summaries
Advocacy for salt intake reduction
An organization seeking to convince governments and the food industry to lower the content of salt in food by setting sodium limits and reformulating high-sodium foods, thereby improving cardiovascular health.
Facilitating international labor migration via a digital platform
An organization that would facilitate the international migration of workers from low- and middle-income countries using a transparent digital platform paired with low-cost personalized support.
Ceramic filters for improving water quality
An organization focused on reducing the incidence of diarrhea and other waterborne illnesses by providing free ceramic water filters to families without access to clean drinking water.
Participatory Learning and Action (PLA) groups for maternal and newborn health
An organization focused on improving newborn and maternal health in rural villages by training facilitators and running PLA groups – a specific type of facilitated self-help group.
One-paragraph Summaries
Advocacy for salt intake reduction
High salt consumption contributes to poor cardiovascular health. Worldwide, cardiovascular diseases are the leading cause of death and are among the top ten contributors to years lived with disabilities. There is good evidence that reducing the amount of sodium people consume in their diets can reduce the risk of cardiovascular problems. Therefore, several countries have successfully reduced the sodium intake of their population, for example by setting sodium limits, which led to the food industry reformulating certain high-salt products. We think that an organization advocating and assisting in implementing these policies could cost-effectively improve the health of millions.
Facilitating international labor migration via a digital platform
Migrating abroad for work can bring huge financial benefits to people experiencing poverty. Millions of people every year try to tap into these benefits by applying for temporary jobs in higher-income countries. However, the market for matching candidates with jobs is often highly inefficient and riddled with misinformation, putting candidates at financial and personal risk. In many countries, it can cost candidates several years’ worth of salaries to secure a job abroad. Fraud is also highly prevalent, leading to candidates often failing to migrate and instead ending up in debt. This charity will build a semi-automated digital platform that combines a job board, transparent information on how to migrate, and low-cost personalized support with the process. We expect this platform to have multiple effects: lowering recruitment fees, lowering the risk of fraud, enabling the migration of lower-income individuals, improving job satisfaction, and potentially increasing the overall number of migrants. This work is currently highly neglected, and our models indicate that a charity like this could achieve very high cost-effectiveness.
Ceramic filters for improving water quality
In 2022, at least 1.7 billion people worldwide used drinking water sources contaminated with feces. This leads to waterborne disease, which is a common cause of diarrhea and death in children in low-income settings. Studies show that the use of ceramic filters reduces episodes of diarrhea in low- and middle-income countries by an estimated 34-71%. This new organization will provide these ceramic water filters for free to families without access to clean drinking water. This intervention is expected to be similarly cost-effective as other water quality interventions (such as in-line chlorination), yet it does not need as much existing infrastructure, such as water piping or reliable supply chains, and as such, can reach people in more deprived areas.
Participatory Learning and Action (PLA) groups
In 2020, out of the 135 million births worldwide there were approximately 1.4 million stillbirths, 2.4 million neonatal deaths, and 300,000 maternal deaths. Most of this burden occurs in low and middle-income countries. Community-based interventions represent a promising approach better suited for rural populations, where access to institutional healthcare is poor, and mortality rates are often higher. PLA groups are facilitated self-help groups that use a specific framework to guide member participants in identifying, executing, and evaluating the most promising solutions to their problems. Meta-analysis of many randomized studies suggests that running a PLA group reduces maternal mortality by 49% and neonatal mortality by 33% amongst all births in the entire community that the group serves. Based on this evidence, it is the only community-based newborn and maternal health intervention that the WHO recommends. Yet few countries in sub-Saharan Africa, where the burden is highest, have implemented this intervention. An organization focused on training facilitators and running these groups in rural villages would be highly cost-effective, with a large potential for positive externalities.
One-page Summaries & Full Reports
Advocacy for salt intake reduction
Sodium (usually consumed as table salt) is a silent killer. Each year, diets high in salt contribute to millions of deaths due to cardiovascular disease. The burden of cardiovascular diseases related to sodium consumption is expected to grow due to dietary changes, aging populations, and lifestyle changes.
Limiting salt consumption levels is regarded as a cost-effective way to reduce the burden of cardiovascular diseases at a population level. We recommend that a new nonprofit organization should focus on advocating for sodium policies and assisting food producers to reformulate their products in line with safe limits. We think interventions of this type are promising because they affect the choices available to consumers and, as such, do not rely on individual behavioral changes to reach a large scale.
A new nonprofit organization could combine advocacy and technical assistance to lead the State and food producers to cooperate and reduce the level of sodium in popular high-salt foods. Complementary interventions, such as front-of-pack labeling and fiscal approaches, may support these goals.
This is a high-risk, high-reward intervention. We estimate that nonprofits have successfully led to food reformulation, direct policy change and correct implementation in around ten percent of their advocacy attempts. It may take multiple attempts and careful targeting for a new organization to achieve change. Yet given the cost-effectiveness of this intervention, this low-success scenario is still worth pursuing.
Overall, there is evidence of a reduction in sodium intake due to reformulation, based on primarily observational longitudinal studies documenting the reduction of sodium consumption following reformulation interventions. This is not very high-quality evidence but it is in line with expectations for an evidence base of policy in this space. Experts largely agreed with our conclusions.
Our speculative cost-effectiveness model and other CEAs in the literature suggest that sodium advocacy is highly cost-effective. Our modeling suggests that in Indonesia, this intervention may avert 866 DALYs for every USD 1,000 spent (about $1 per DALY). In Georgia, it may avert 13.8 DALYs for every USD 1,000 spent (about $72 per DALY).
Overall, we believe this is an idea worth recommending for incubation. We are excited by the potential leverage that policy work can have and the possibility of a charity that could have a huge outsized impact on people’s lives and health and address a growing global problem.
Facilitating international labor migration via a digital platform
International labor migration has the potential to create large financial returns for workers and their families. While permanent migration is often not legally possible for citizens of low- and middle-income countries (LMICs), temporary labor migration – also known as guest work – is highly prevalent. LMICs in regions such as South Asia, Southeast Asia, and East Africa collectively send millions of workers every year to richer countries in neighboring regions, such as countries of the Gulf Cooperation Council, Malaysia, or Singapore. Where the migrant workers are not exploited, temporary worker migration leads to an increase in consumption and well-being for the workers and their families. Given that this form of migration is temporary, legal, and tied to specific job vacancies, it also tends to be highly beneficial to the residents of the destination countries.
However, this type of migration is a complex, risky, and often costly process for the migrants. Potential migrants typically learn about and get access to job opportunities via networks of intermediaries who often exploit the information and power asymmetries to charge exorbitant fees. Moreover, they may have an incentive to underinform or misinform their clients, resulting in migrants accepting jobs with lower-than-expected salaries and worse working conditions. Individuals who start the application process but fail to migrate often suffer huge losses and sink their families into debt.
This charity will create a “one-stop shop” service to support potential migrants, avoiding exploitation and reducing the costs of migration. The service will take migrants through the process of learning about working abroad, finding the right job, and fulfilling the necessary requirements for successful migration. It will achieve this by creating a digital platform featuring a job board paired with free, transparent information on the practicalities and pros & cons of migrating, personalized one-to-one support (via a call center), and recommendations to high-quality third-party services.
Additionally, this charity could work directly with employers in destination countries to create new migration opportunities that wouldn’t have happened otherwise. Based on expert interviews, we believe there are countries with legal immigration quotas that are not being filled and employers looking to hire migrant workers but not having good channels through which to do so. Given the large financial returns to working abroad, this could significantly increase the charity’s impact and cost-effectiveness. However, such expansion might be complex and costly to undertake, so we haven’t factored it into our main models.
This topic has been relatively neglected by nonprofits. Although the harms caused in the process of guest work migration have long been known to governments and international organizations, we are not aware of any organizations implementing a digital app or similar information-based solutions to this problem at scale. While this means that the proposed solution is relatively understudied, we believe that all of the proposed activities are tractable.
This charity has the potential to be very cost-effective. Even if it only reduces the cost of migrating – and doesn’t create additional migration – we estimate it could achieve income benefits equivalent to 22 doublings of consumption per $1000 spent for a charity operating in Nepal. If the charity also managed to create additional migration, it could achieve income benefits equivalent to 87 doublings of consumption per $1000 spent (note, if we adjusted the above numbers based on GiveWell’s 2020 moral weights, this would be equivalent to $105 per DALY and $26 per DALY, respectively). Finally, if the charity adopted a social enterprise model and charged its successfully-migrating users a modest $50 fee, it could be even more cost-effective.
Overall, we believe this is an idea worth recommending for incubation. We are excited about this idea. It offers a scalable way of transforming the livelihoods of people experiencing poverty and addresses a decades-old problem with a modern solution.
Ceramic filters for improving water quality
In 2022, one in four people did not have access to clean drinking water. For example, in the same year, at least 1.7 billion people worldwide used drinking water sources contaminated with feces. This is a major health risk, causing more than a million deaths each year.
Moreover, lack of access to clean water is the leading risk factor for many infectious diseases, including diarrhea and cholera. It also exacerbates other health issues such as malnutrition and, in particular, childhood stunting.
The solution we propose is straightforward and has been shown to have a strong protective benefit on the incidence of diarrhea in under-5s and adults. It involves manufacturing and distributing free ceramic water filtration devices in low-income settings.
Various randomized controlled trials, included in a meta-analysis from Cochrane, support using ceramic water filters to reduce the burden of diarrheal disease. These studies find that the use of these filters can reduce episodes of diarrhea in low- and middle-income countries by an estimated 34-71%. In 2019 alone, diarrheal disease is estimated to have killed 1.5 million people, which is more than tuberculosis or malaria. 0.5 million of these deaths were in children under the age of 5.
There is room for a new organization working in the space. Most existing filtration efforts are small and locally-led. This means that there are many countries and regions that are not covered by existing work and would benefit greatly from a new charity providing free filters.
This intervention is expected to be highly cost-effective and can reach people in more deprived areas. It is expected to be similarly cost-effective as other water quality interventions (such as chlorination) with an average estimated cost-effectiveness of $77 per DALY (ranging from $15-$118 depending on the country modeled), yet it does not need there to be as much existing infrastructure such as water piping or reliable supply chains, and as such can reach people in more deprived areas.
There are a number of considerations and uncertainties that founders working on this idea would need to work through. Different water treatment solutions affect different pathogens. Ceramic water filters stop bacteria and protozoa but not viruses, whereas chlorination kills bacteria and viruses but not protozoa. This means that in some cases where there is a higher prevalence of viruses, it would be more appropriate to use chlorination rather than ceramic filters. Founders should consider the burden caused by different pathogens when choosing a location to work in. Also, this intervention may need an RCT fairly early on. The current evidence base only measures the reduction in episodes of diarrhea from ceramic water filter use, so it would be beneficial to demonstrate more directly the effect on child mortality.
Overall, we believe this is an idea worth recommending for incubation. Addressing the burden of unclean drinking water is a global health priority. We think that the provision of free ceramic water filters will significantly aid in achieving this goal at a low cost and can reach populations that might be missed by existing water quality interventions, such as chlorination.
Participatory Learning and Action (PLA) groups
Maternal and neonatal disorders are significant causes of global mortality. In 2020, out of the 135 million births worldwide, there were approximately 1.4 million stillbirths and 2.4 million neonatal deaths. Maternal mortality is also high, with an estimated 300,000 women dying during pregnancy.
Despite strides in maternal and neonatal health (MNH), the burden remains disproportionately high in low- and middle-income countries (LMICs). Over 90% of maternal deaths occur in these regions – Sub-Saharan Africa and Southern Asia, in particular, account for 68% and 19% of these deaths, respectively.
Community-based interventions represent a promising approach that is better suited for rural populations, where access to institutional healthcare is poor. There is often a significant difference between mortality rates in rural and urban areas, and access to care is much worse in rural areas.
Participatory learning and action (PLA) groups are a simple yet well-evidenced community-based intervention that could be promising to reduce maternal and neonatal deaths. It involves holding facilitated group meetings for women of reproductive age, particularly pregnant women, to foster local strategies that enhance care-seeking behaviors and adopt preventive health practices for better maternal and newborn health. PLA groups are facilitated to develop their own solutions to health challenges. Common solutions that the groups develop include pooling community funds into an emergency fund, community bicycle ambulance services, and community-based health campaigns.
Strong evidence supports the effectiveness of PLA in reducing neonatal and maternal mortality. A meta-analysis conducted by Prost et al. (2013), which included seven trials involving approximately 119,000 births, found that when >30% of all pregnant women participated in groups, PLA reduced maternal mortality by 49% and neonatal mortality by 33% amongst all births in the community. In such cases, pregnant women who did not participate also benefited from the group-led solutions.
In addition to maternal and neonatal mortality, we are also excited by the potential positive externalities that PLA groups may have. There is weak evidence that PLA groups could benefit maternal mental health, family planning, under-five child health, community resilience to crop failures, and individual and community agency.
PLA is estimated to be highly cost-effective. The groups can be extremely low-cost to run. Our cost-effectiveness analysis estimated that hiring community workers to run PLA groups full-time would cost ~$20-$70 per DALYs averted. This is equivalent to ~14-47 DALYs per $1000 spent.
Although the maternal and neonatal space is not as neglected, this is a relatively neglected intervention within the space. Growing attention and funding are devoted to maternal and neonatal health, and the burden is slowly decreasing. However, this intervention has only been implemented in about 15 countries, with few at scale.
Experts are excited by the prospect of a new nonprofit implementing this intervention. GiveWell has been interested in funding this intervention as they think it meets their bar for cost-effectiveness. However, they’ve been finding it challenging to find implementation partners. Women and Children First, the pioneer of the intervention, serves a technical assistance role and is excited to support a potential CE-incubated charity.
There are some challenges and remaining uncertainties regarding the intervention. The new nonprofit would have to work out how to recruit pregnant (or soon-to-be pregnant) women, as reaching a sufficient percentage of them is crucial for effect size. Maintaining a high level of cost-effectiveness as the organization scales might also be a challenge. There is also a weak concern about the external validity of the intervention, as most of the RCTs were conducted in South Asia, although the RCT with the highest effect size on neonatal mortality was from Malawi.
Overall, we believe this is an idea worth recommending for incubation. A new organization focused on running and scaling PLA groups for maternal and neonatal health will likely be highly cost-effective.
Cause areas for February-March 2025 Incubation Program
You can now also apply (using the same form) to the February-March 2025 Incubation Program that will focus on: Expert-sourced neglected interventions in the areas of Global Health and Development and Farmed Animal Advocacy.
How to apply
To apply, fill out the [APPLICATION FORM], which should only take around 30 minutes. We have designed the application process also to give you a better sense of whether you are excited by this career path.
Application deadline: April 14, 2024
More information about the application process: https://www.charityentrepreneurship.com/apply
More information about how the program is run: https://www.charityentrepreneurship.com/how-it-works
Contact us with any questions about the program: ula@charityentrepreneurship.com
On the LMIC migration platform, I found this UK based for-profit doing what looks like a similar thing:
https://www.getborderless.io/about-us
Hi Gemma, thanks for sharing! That platform indeed has several similarities with our proposed nonprofit idea (though also some differences, such as our focus low- and mid-skilled workers and on a specific country of origin rather than a specific destination country). Exciting to see more work being done in this otherwise quite neglected space!
That’s great that you are focusing on low and mid-skill workers. Its a complicated question, but I think that moderate high skill workers leaving low and middle income for western jobs can be net-negative, especially in the healthcare field—for example the flood of West African doctors and nurses heading to Europe and the Middle east at the moment. I really like that some countries like Nigeria are bonding medical staff for 2+ years after they complete their training.
https://www.semafor.com/article/02/15/2024/nigerian-nurses-reject-rules-attacking-japa
Sometimes though there can be claims of “overproduction” of positions such as nurses like in Kenya, but when public hospitals are grossly understaffed then why is the governement spending money on training nurses rather than actually putting the resources directly into their medical system?
https://ntvkenya.co.ke/news/we-are-overproducing-graduates-health-ps-defends-govt-plan-to-export-nurses/
CGD has a different take on this type of migration.
”Between the start of 2021 and 2022, the number of Nigerian-born nurses joining the UK nursing register more than quadrupled, an increase of 2,325. Becker’s human capital theory would suggest that this increase in the potential wages earned by Nigerian-trained nurses should lead to an increase in Nigerians choosing to train as nurses. So what happened? Between late 2021 and 2022, the number of successful national nursing exam candidates increased by 2,982—that is, more than enough to replace those who had left for the UK.”
″To fully realise these benefits, Nigeria would need to embrace emigration, realising that nurses are likely going to leave anyway and doing everything they can to reap the benefits. Yet, they appear to be doing the opposite. New guidelines announced on 7 February 2024 state that nurses must work for two and half years before being allowed to work overseas, a move nurses contest. This policy is far from optimal; restrictions on emigration are inefficient, inequitable, and unethical. Indeed, Ghana had a similar scheme, but ended up scrapping it because they were unable to employ all of their nurse trainees at home.”
Thanks David appreciate the article—I think its a good indication of how complex the question of immigration is and how I don’t think its a slamdunk in either direction.
My impression is though that the article is a pretty poorly researched and misleading piece—even though some of its arguments might still stand in many cases despite that.
First its weird that the article makes zero mention of the state of the Nigerian health system, nor how this mass emmigration might be affecting it. Is staffing getting better or worse? Are outcomes getting better or worse? How many nurses are actually needed in the system? Building your entire argument on “nurses trained” vs “nurses immigrating to England” seems quite short sighted and reductionst.
Second (probably most important), they only taken into account nurses leaving for England—a weird comparison decision. That 2300 nurses left for england that year is fairly irrelevant, what matters is the total number. Nurses leave for other european countries and the middle east too .The Nigerin government says 42,000 nurses left in the last 3 years, that’s 14,000 a year, more than they are even training per year.
https://africa.cgtn.com/nigeria-says-42000-nurses-left-the-country-in-3-years/
So their basic argument that enough new nurses are being trained is bogus
In addition, you must consider the increasing population. The population of Nigeria has grown by 5,000,000 people in that one year (2.5% increaser ). Nigeria has something like 180,000 nurses. This means even just to maintain their already poor nursing ratios, they would need to train and put into the workforce an extra 3000 or so nurses each year just to maintain the status quo, without even improving nurse/population ratios.
Its also likely that many of the the best and brightest that are leaving Nigeria. They are more likely to pass English exams and be accepted (unless they cheat as ofen happens) and have the drive and gumption to try and move overseas. My guess would be its most likely that England is taking the better nurses to work in a health system that is 10x better while leaving the lower quality nurses in Nigeria, the health system which really needs the best nurse to lead and drive the system. The qualification itself is only a small part of the story, the difference in ability, skills and leadership potential between nurses is immense.
There are also other second order effects, If you’ve ever been in a country where many people are trying to emmigrate because many people are leaving, its hard to retain stability in your hospitals and health systems. People are distracted and staff turnover is high and morale can be low. This can really hurt productivity of those who remain.
I’m also more concerned about Doctors than nurses—but that’s a whole nother story.
I probably wasted too much time hacking away at this poor article, but it annoyed me a little ;). I’m not anti immigration at all, but I am for medical staff in this kind of scenario and there are many, many factors to consider in the discussion.
Thanks for raising this point, Nick, and for the many good arguments you’re making!
Out of all the forms of labor emigration, I find physician and nurse migration to be the most concerning. I’d stress that the idea proposed in our report doesn’t focus on skilled workers (only as a potential later extension, needing careful consideration), so it largely avoids this concern. We focus on low- and mid-skilled workers, as those are poorer to begin with, much more numerous, and there’s an oversupply of them in many LMICs (as opposed to shortages).
I did spend a little bit of time looking into the literature on brain drain and didn’t arrive at a clear conclusion. There are many factors pointing in different directions, and whether the overall effect is net positive or net negative may vary between countries and professions.
Aside from the considerations that you and David mentioned, there are also remittances, the effects of return migration (the rates of which vary a lot) and associated “brain gain”, or the fact emigrating physicians are more likely to come from well-staffed urban areas. E.g. this (very old) article by Clemens and McKenzie says that, in Kenya, some 66% of physicians live in Nairobi where only 8% of the national population lives. They argue that low incentives to work in rural areas are a much bigger problem than the total supply of physicians (and how that supply is affected by emigration).
Concerning the CGD, I’m actually quite excited about their efforts to push for so-called global skills partnerships in the skilled space. Within these programs, countries like the UK would pay countries like Nigeria to train nurses and have agreed quotas on how many nurses can stay vs migrate. This seems like a more sophisticated solution to the issue than saying “nurse emigration is good.” Here is their proposal specifically for Nigeria.
In any case, this is not a topic that we at CE decided to focus on at this point. If we do look into skilled migration in the future, we will do a much more thorough dive (and will be keen to get your input!).
Thanks those are all great points nice one and I agree with almost all of that. Again love the focus on low skill workers
On supply and medical staff
”They argue that low incentives to work in rural areas are a much bigger problem than the total supply of physicians (and how that supply is affected by emigration).”
The funny thing is that a big part of that exact issue there may well be supply! If there were more than enough doctors to fill roles in cities, and they struggled to emigrate (doctors find this far easier than other professionals) then doctors would be pushed into working in rural places as that’s where the jobs
My example to back this up is that in Uganda there’s a massive oversupply of nurses, and it means in search of jobs many open drug shops in the village and many are willing to work in rural areas. We have no problem at all recruiting at OneDay Health. Supply is a huge factor.