Charity Entrepreneurship Research Summary

After com­plet­ing our first two month phase of re­search across thirty in­ter­ven­tion ar­eas, we have ruled out twenty-two in­ter­ven­tion ar­eas, leav­ing eight broad in­ter­ven­tion ar­eas left. We have now turned those into nu­mer­ous spe­cific char­ity ideas that we will dive deeper into with fur­ther re­search.

Each of these in­ter­ven­tion ar­eas were re­searched for up to forty hours (us­ing this out­line) to de­ter­mine whether our team could and should cre­ate an effec­tive char­ity in that area. While we have ruled out these twenty-two in­ter­ven­tions at this stage for our team go­ing for­ward, we still think many of these in­ter­ven­tions could be worth con­sid­er­ing as dona­tion tar­gets or for other teams to found char­i­ties in. Also, some in­ter­ven­tions were ruled out largely be­cause they already had an ex­cep­tion­ally strong char­ity recom­mended by GiveWell. Ad­di­tion­ally, all rat­ings were rel­a­tive to other in­ter­ven­tion ar­eas on our list, and the in­ter­ven­tions that we ruled out are likely still un­usu­ally cost-effec­tive and ev­i­dence-based rel­a­tive to av­er­age global health pro­grams.

Below we at­tempt to provide a quick sum­mary of the re­search we have con­ducted and pub­lished in­clud­ing links to more de­tailed in­for­ma­tion. This is not meant as a full jus­tifi­ca­tion or ex­pla­na­tion so much as to give a sense of our views on the weak­est and strongest of in­ter­ven­tions we looked at. Over time we will be post­ing many blog posts ex­plain­ing our think­ing and out­lin­ing our re­search on in­ter­ven­tions that did make the cut. We will also even­tu­ally start post­ing our ideas about which con­crete char­i­ties we think may be high value and why.

Sum­mary spread­sheet

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For each of the in­ter­ven­tion ar­eas we are no longer putting re­searcher time into we wrote a brief para­graph cov­er­ing some of the rea­sons why we think they don’t offer as strong spe­cific char­ity op­tions as the in­ter­ven­tions that we are still con­sid­er­ing.

Bed­net Distri­bu­tion: We think bed­net dis­tri­bu­tion is strong in a lot of ways (GiveWell’s full re­port) but we also think there are already mul­ti­ple strong char­i­ties work­ing in this area (2) and do not see a need to add ad­di­tional effort. The Against Malaria Foun­da­tion is both strong and has con­sid­er­able room for fund­ing (3), so we be­lieve it is bet­ter to sup­port them rather than start an­other char­ity in the space.

Po­lio erad­i­ca­tion: We did not feel we could cre­ate and scale a char­ity to be use­ful in this area fast enough to be pro­duc­tive given the cur­rent trends in Po­lio prevalence. Cur­rently only two coun­tries re­main where the dis­ease is en­demic, Afghanistan and Pak­istan (4), and many ar­eas in the most need are ar­guably con­flict zones which likely makes the lo­gis­tics of such a pro­gram very com­plex.

River blind­ness: Our main con­cern with river blind­ness was its ev­i­dence base (5), and al­though we re­viewed some other in­ter­ven­tions that were similarly weak in ev­i­dence base, we feel river blind­ness did not have enough re­deem­ing fea­tures, such as flex­i­bil­ity, lo­gis­ti­cal ease or a lack of crowd­ed­ness to make up for this weak­ness. Fur­ther­more, prevalence rates seem to be de­creas­ing (6), and there are already a few other or­ga­ni­za­tions ac­tive in the area.

Im­mu­niza­tion to pre­vent ma­ter­nal and neona­tal tetanus: We’re con­cerned most about coun­ter­fac­tual scal­a­bil­ity as there seems to be a limited num­ber of cases (7) and a pos­i­tive trend with large and re­cent suc­cesses (8). In­creas­ing im­mu­niza­tion cov­er­age in or­der to pre­vent ma­ter­nal and neona­tal tetanus also seems more lo­gis­ti­cally difficult and less cost-effec­tive than our top in­ter­ven­tions.

Mass Drug Ad­minis­tra­tion to com­bat Lym­phatic filari­a­sis (MDA LF): MDA LF is much less cost-effec­tive (un­pub­lished CEA es­ti­mate) com­pared to other in­ter­ven­tion ar­eas we looked at. Since the pro­gram is a mass drug ad­minis­tra­tion rather than a tar­geted ap­proach, the prevalence has to be above a cer­tain rate for it to be cost-effec­tive. The micro­filaria prevalence is too low for MDA LF to be cost-effec­tive in In­dia (9). In­fec­tion rates in other coun­tries are also not suffi­ciently high. The ma­jor­ity of those in­fected never ex­hibit symp­toms (10), of those who do, only a small per­centage de­velop se­vere symp­toms that cause large prob­lems like so­cial os­tra­ciza­tion and de­pres­sion. Fur­ther­more, crowd­ed­ness in this in­ter­ven­tion is fairly high. There are already eight char­i­ties ac­tive in the area, and the crowd­ed­ness in the ar­eas of greater micro­filaria prevalence is es­pe­cially high. The In­dian gov­ern­ment claims to cover 85% (11) of the coun­try with pre­ven­ta­tive med­i­ca­tion. While there is a prob­lem of peo­ple not tak­ing the med­i­ca­tion once re­ceivedthey re­ceive it (12), this is not a straight­for­ward or cost-effec­tive prob­lem to solve.

Malaria treat­ment: Malaria treat­ment in­ter­ven­tions are very difficult lo­gis­ti­cally and don’t score strongly enough in any other area to over­come this weak­ness. While in­di­vi­d­ual cost-effec­tive­ness es­ti­mates varied a lot, we are in­clined to think malaria treat­ment is less cost-effec­tive than the top in­ter­ven­tions we are con­sid­er­ing. This area also does not ap­pear ne­glected, as there are quite a few strong or­ga­ni­za­tions already work­ing on malaria treat­ment (13).

Un­con­di­tional Cash Trans­fers (UCTs): Much like bed­nets,UCTs are strong in a lot of ways (14) but we think GiveDirectly is already a very strong char­ity work­ing in this area that has con­sid­er­able room for fund­ing (15) and fo­cus should be on ex­pand­ing GiveDirectly rather than cre­at­ing a new or­ga­ni­za­tion. We also feel as though we could likely get bet­ter cost-effec­tive­ness from a con­di­tional cash trans­fer char­ity if at­tached to the right con­di­tion, even if it was just a la­beled con­di­tion (LCT).

Tu­ber­cu­lo­sis case find­ing and first-line treat­ment: This was one of the most lo­gis­ti­cally com­plex in­ter­ven­tions we looked at. Di­ag­nos­tics looked hard, treat­ment looked hard, and pre­vent­ing de­fault­ing looked very hard (16). The length and un­pleas­ant­ness of treat­ment causes many of those with tu­ber­cu­lo­sis to de­fault. Although it scored mid-range in most other ar­eas, ex­cept for scor­ing low on scal­a­bil­ity (17), we felt it was be­yond our cur­rent skill level to found a char­ity in this area.

Tra­choma con­trol: There are a few differ­ent ways to do tra­choma con­trol meth­ods but we found prob­lems­ma­jor flaws with them all. The recom­mended SAFE (Surgery, an­tibiotics, face wash­ing and en­vi­ron­men­tal con­trol) strat­egy could not com­pete in cost-effec­tive­ness with our top in­ter­ven­tions (DCP2) and some sec­tions of it had very weak ev­i­dence (18). The most promis­ing and cost-effec­tive part of SAFE was surgery but it seems lo­gis­ti­cally com­pli­cated and hard to scale with few benefits to out­weigh the flaws.

Preven­tion of mother-to-child trans­mis­sion of HIV: The biggest fac­tor against this in­ter­ven­tion was that there seem to be com­pe­tent bod­ies work­ing in this area. For in­stance, globally 73% (19) of preg­nant women liv­ing with HIV had ac­cess to an­tiretro­viral medicines to pre­vent mother-to-child trans­mis­sion of HIV to their ba­bies in 2014; and new HIV in­fec­tions among chil­dren were re­duced by 58% from 2000 to 2014. Ad­di­tion­ally there is a char­ity called New In­cen­tives work­ing in this area in a very similar way to what we think would be best.

Ther­a­peu­tic Zinc Sup­ple­men­ta­tion (TZS): TZS has rea­son­ably strong ev­i­dence it re­duces the du­ra­tion and sever­ity of child­hood di­ar­rhea yet limited ev­i­dence it re­duces mor­tal­ity. There is some rea­son to be con­cerned that the weak­limited data for mor­tal­ity re­duc­tion ev­i­dence means a new large RCT may show that TZSthe mor­tal­ity re­duc­tion rates are over­stated for TZS (20). Since mor­tal­ity re­duc­tion is im­por­tant for the TZS cost-effec­tive­ness of TZS, this is a sig­nifi­cant con­cern. Ad­di­tion­ally, it’s worth not­ing that we feel TZS would be best done alongside the ad­minis­tra­tion of oral re­hy­dra­tion salts.

Pro­vi­sion of an­tiretro­viral ther­apy to treat HIV/​AIDS: An­tiretro­viral ther­apy is no­tice­ably less cost-effec­tive than our other in­ter­ven­tions, (21) though op­por­tu­ni­ties may ex­ist that will de­crease the costs in­volved with this in­ter­ven­tion (22) many of these had in­creased lo­gis­ti­cal difficulty. HIV/​AIDS is also quite crowded and well-funded rel­a­tive to other in­ter­ven­tion ar­eas we looked at (23).

De­worm­ing: De­worm­ing has pos­si­bly higher cost-effec­tive­ness (24) than other in­ter­ven­tions, but there are already two out­stand­ing de­worm­ing char­i­ties, Ev­i­dence Ac­tion and SCI and we saw lit­tle rea­son to cre­ate a third. Fur­ther­more, we were dis­cour­aged by this in­ter­ven­tion’s some­what thin ev­i­dence-base.

Oral Re­hy­dra­tion Ther­apy (ORT): We like ORT in a lot of ways, how­ever, it is quite crowded as a nu­mer­ous ma­jor in­ter­na­tional global health play­ers are already in­volved in try­ing to in­crease ORT us­age rates (25). Th­ese efforts have been on­go­ing in some places for decades, of­ten with­out much suc­cess (26). This gives some rea­son to be­lieve scale-ups may be difficult. Fur­ther, while the cost of ORT ma­te­ri­als per treat­ment is very low, the cost of ac­tu­ally im­ple­ment­ing a suc­cess­ful pro­gram, ac­count­ing for de­liv­ery costs and in­creas­ing com­pli­ance rates, is less clearly es­tab­lished and could be quite high (26, 27). There might be a op­por­tu­nity for an in­no­va­tive ap­proach in this area but we did not see any in our re­search that seemed promis­ing enough for in­clu­sion into our next stage of re­search.

Pneu­mo­nia Treat­ment: Treat­ing pneu­mo­nia was a sur­pris­ingly ne­glected area (28) given the scale of the prob­lem (29,30) and the ev­i­dence-base was mid to weak (31). Over­all it was stronger than sev­eral other ar­eas we con­sid­ered. The most promis­ing solu­tion to this seems to be im­prov­ing the ex­ist­ing health­care in­fras­truc­ture, in­clud­ing pro­vid­ing prac­ti­tion­ers with de­ci­sion aids for di­ag­nos­ing and treat­ing pneu­mo­nia (30). Ul­ti­mately, we de­cided that other similar health­care in­ter­ven­tions were stronger picks and that pneu­mo­nia treat­ment could be ruled out.

Hand Wash­ing: Although there was some de­cent ev­i­dence hand wash­ing is quite effec­tive at re­duc­ing di­ar­rhea, there was only weakly ev­i­denced or rel­a­tively not cost-effec­tive hand wash­ing in­ter­ven­tions (31). It’s a re­cur­ring be­hav­ior change as well as a soap/​clean wa­ter dis­tri­bu­tion prob­lem (32). There might be a op­por­tu­nity for an in­no­va­tive ap­proach in this area but we did not see any in our re­search that seemed promis­ing enough for in­clu­sion in our next stage. How­ever, we can see hand wash­ing be­ing an effec­tive part of a larger mHealth or mass me­dia pro­gram.

Breast­feed­ing: Over­all we like a lot of el­e­ments of breast­feed­ing and it’s pos­si­bly very cost-effec­tive (33). How­ever, breast­feed­ing car­ries some of the same challenges as hand wash­ing and all other be­hav­ior changes. It’s difficult lo­gis­ti­cally, par­tic­u­larly in scal­ing to ar­eas with differ­ent cul­tural fac­tors or rea­sons for low breast­feed­ing rates. Fur­ther­more, the area seems crowded and given large in­creases in breast­feed­ing rates in a short time pe­riod based on re­cent gov­ern­ment efforts (34), there seems to be a sig­nifi­cant chance that a gov­ern­ment pro­gram would make a large differ­ence in this area that would swamp char­ity efforts be­fore we could be­come es­tab­lished. We can imag­ine this be­ing an effec­tive part of a larger mHealth or mass me­dia pro­gram.

Folic acid: The pri­mary strengths of this in­ter­ven­tion are its ev­i­dence, met­ric fo­cus, and abil­ity to be synced with other food for­tifi­ca­tion or sup­ple­men­ta­tion pro­grams. There’s quite strong ev­i­dence for folic acid for­tifi­ca­tion and sup­ple­men­ta­tion re­duc­ing neu­ral tube defects (NTDs) (35) and many coun­tries have seen a sig­nifi­cant drop in their NTD rates af­ter man­dat­ing folic acid for­tifi­ca­tion (un­pub­lished GW folic acid re­view). Ad­di­tion­ally, folic acid for­tifi­ca­tion could be paired with iron for­tifi­ca­tion be­cause they both are of­ten added to flour. The weak­nesses of this in­ter­ven­tion are its scal­a­bil­ity, side effects and cost-effec­tive­ness. Scal­a­bil­ity is weak with only 300,000 NTDs per year globally in­clud­ing the roughly 70 coun­tries that already man­date folic acid for­tifi­ca­tion. Fur­ther­more, only 20-60% of NTDs can be pre­vented with for­tifi­ca­tion, though that num­ber is likely higher in coun­tries with higher baseline rates of NTDs. Another weak­ness of folic acid for­tifi­ca­tion, how­ever, is the list of pos­si­ble and doc­u­mented side effects (36) . Folic acid for­tifi­ca­tion and sup­ple­men­ta­tion also has some minor nega­tive side effects (on anti-malar­ial drugs, vi­tamin B12 defi­ciency and can­cer). Nev­er­the­less, we think this very eas­ily could be part of a strong micronu­tri­ent or for­tifi­ca­tion pro­gram al­though we do not see it as strong enough to found a char­ity fo­cused on folic acid.

Salt iodiza­tion: Salt iodiza­tion was one of the hard­est in­ter­ven­tions for us to eval­u­ate. It scored mid­dling to high in al­most ev­ery area and this would nor­mally put it in our top in­ter­ven­tions. How­ever the benefits of salt iodiza­tion are al­most en­tirely IQ in­creases (37) and we are un­sure how to value IQ in­creases as we can­not find strong con­nec­tions be­tween in­creased IQ and other things, like hap­piness, in­come, or im­proved health in the third world. We are broadly util­i­tar­ian so we ul­ti­mately care about what leads to greater well-be­ing in the world.

Char­i­ties that col­lect or gen­er­ate in­for­ma­tion and data: This was one of the hard­est in­ter­ven­tions to eval­u­ate and we are notleast con­fi­dent in our con­clu­sion on it. There does seem to be some short­age of data, in­for­ma­tion, high qual­ity RCTs and repli­ca­tion stud­ies. How­ever, as­sign­ing the marginal value of cre­at­ing in­for­ma­tion in a given area was very difficult. We looked at a few differ­ent ways of com­par­ing re­search to di­rect work in terms of ex­pected value and could not find a refer­ence group that we felt was rep­re­sen­ta­tive. Many cost-effec­tive­ness analy­ses were fo­cused on first world re­search and a few were based on clear out­liers and thus un­rep­re­sen­ta­tive.

Ul­ti­mately, it came down to a ques­tion of pri­or­ity. We felt as though there were already some strong or­ga­ni­za­tions in this area (Eg, IDI, DCP, CC, JPAL, IPA and 3IE) and it seemed like there was more of a fund­ing gap than a tal­ent gap. We saw only a few char­i­ties try­ing ex­plic­itly to ad­dress the gap be­tween re­search and im­ple­men­ta­tion and feel as though this is needed more in the poverty world right now. Ad­di­tion­ally, we felt we would get some of the benefits of a re­search or­ga­ni­za­tion by run­ning an RCT on the di­rect in­ter­ven­tion we find most promis­ing.

Whilst re­search­ing in In­dia we have also writ­ten up a cou­ple of more soft and sub­jec­tive ex­pe­riences, such as, our re­flec­tions on a slum tour and our thoughts on the treat­ment of an­i­mals in In­dia. We hope to write a cou­ple more of these posts which will in­clude our re­flec­tions on a visit to a lo­cal clinic and some more gen­eral les­sons.

We also rec­og­nize that our in­ter­nal re­search is out­pac­ing our cur­rent ex­ter­nal pub­li­ca­tion of that re­search and that peo­ple may have ques­tions and feed­back that could help us do bet­ter re­search. While we do in­tend to write up more over the com­ing months, we thought the eas­iest way to bridge the gap in the mean­time was to hold an open re­search call about our re­search. More de­tails on how to join our re­search call.

Sub­scribe to our re­search blog if you want to get up­dates more of­ten, al­though we will also post ma­jor up­dates on the EA fo­rum.