As a public health doctor in a low income country, I read the initial cause areas and had quite a few concerns about implementation. Then when I read the longer summaries I saw you had thought about almost all of them which is impressive—clearly done your homework ;)
Have a few comments
On the kangaroo care rollout frontI have four thoughts
1. My instinct is that a generalist could well struggle with this initiative. They would be dealing at a high level with hospital management and senior staff at hospitals, and without medical expertise or at least a public health background they might not be taken very seriously and struggle to make headway. As you’ve obviously researched yourselves, and you’ve seen on the givewell review, sustaining kangaroo care in facilites is extremely difficult for a range of factors. That 2014 study managed only 5% sustainable practise n 4 African countries. A few NGOs have come around in our Ugandan facilities training midwives, and we are still quite bad at it (I haven’t pushed it as hard as I should either).
2. I believe (moderate uncertainty) that cultural resistance, or even cultral norms are an underappreciated barrier to Kangaroo care. You’ll notice most the stated barriers on Givewell are operational/practical, not cultural. There is a bit of a myth I’ve heard that Kangaroo care is “natural” or similar to “traditional practise”, which might make make implementation easier. In my experience modern-day cultural norms around birth both at home and in healthcare often differ wildly from kangaroo care
3. I strongly agree with your statement that”we note that it relies on very favorable stakeholder relations and management that may not be easy to find in some contexts. It is, therefore, promising but riskier relative to other interventions in global health.”
4. Working through a partner NGO can be a good plan, but as we all know the vast majority of NGOs are both hopelessly in efficient and not very effective. A meticulous in-country check of whether what an NGO Claims to have already implemented or achieved is true or notis essential before considering working with them. Usually an advantage of charity entrepreneurship stuff (I think) is the new NGO can do most of the intervention itself.
On the syphilis test front I have a simple logistics question/suggestion.
Might it not be cheaper and easier to just add a separate syphilis test rather than try to do the dual test?
Doing a combined test is easier and would be the best solution assuming no resource or logistical restrictions, but it has two disadvantages
The cost of the dual test can be considerably higher than the cost of seperate HIV test and syphilis tests combined. Stand alone syphilis tests are very cheap. Our health centers do separate tests as part of our standard antenatal work up—HIV, malaria, syphilis test for all in first trimester.
HIV programs are usually standardised and rigid. Convincing them to change their whole system to dual testing might be difficult or even impossible in some cases. The flipside is if you did convince a country or HIV treatment provider to do this, the ipact could be huge. Obviously some countries already do dual testing but you wouldn’t be working there.
On the free ORS distribution front.
I really like this, and just have a couple ofl thoughts.
First, an important challenge might be finding the best place to trial this intervention where there is both a high prevalence of diarrhoea and poor ORS coverage. In our OneDay Health center communities for example, serious cases of childhood diarrhoea are now surprisingly uncommon and not nearly as much of a problem as it was 10 years ago. And that’s in the most remote parts of Uganda. Clean water and ORS+zinc use has massively reduced diarrhoea death burden in many places (more so than malaria and pneumonia), so I feel this intervention needs to be especially well targeted. Not only on a country level, but to focus on the more remote, underserved parts of those countries.
Second I want to push back a bit on”An organization could also work with local producers, health officials, and stakeholders to improve product design, market awareness, availability, and use of ORS.” This sounds a little likegeneralist ineffective NGO speak to me. I think this could be a real money sink and have limited value. Perhaps focusing on just getting the ORS to the people who need it is a better approach.
Anyway keep up the great work! As someone “on the ground”, I’m always impressed by how realistically tractable your cause suggestions seem to be.
Hi Nick, thank you very much for your thoughtful feedback! I researched the syphilis idea so will address those questions.
1. The dual tests have recently become very cheap too, costing some $0.95 each (largely thanks to CHAI’s work in this area). In our understanding, this is only some $0.15 more expensive than a single HIV test – though I’m sure prices will vary geographically. If there are places where the dual tests are more expensive than two separate rapid tests, then I agree that the dual tests wouldn’t make sense there.
2. You are right that changing the existing system (including updating diagnostic algorithms and training the relevant health workers) is one of the main challenges and one of the reasons why this idea has not already been implemented more widely. However, it seems that what is currently lacking is technical assistance for countries’ health systems to make this switch – and this is exactly the sort of implementational work that we think strong charity entrepreneurs can do well!
Thanks on point 1 that makes sense. To add (I should have said before) that often HIV tests will already be supplied through a different donor program and the easies thing might just be to add, so yes being very aware of those dynamics is importnt
On point 2 I don’t think changing the system will necessarl be all that hard in many cases. It is likely to be be more of a financial/logistics issue getting the tests to the health centers than a technical/education problem. If the tests are freely available at facilities people will do them. Most health providers already know women should get a syphilis test even if it’s not available at this point in time. Both staff and patients often love the idea of extra tests in Uganda at least (which might see weird to some people) so I doubt the barriers will be that great. 100% agree that a strong charity entrepreneur could pull this off well.
Hi Nick, Great to hear from you and to get your on-the-ground feedback. I lead the research team at CE.
These are all really really great points and I will make sure they are all noted in the implementation notes we produce for the (potential) founders.
All our ideas have implementation challenges, but we think that delivering on these ideas is achievable and we are excited to find and train up potential founders to work on them!!
–-–
One point of clarification, in case it is not clear: on kangaroo care we are recommended an approach of providing and adding extra staff into healthcare facilities to offer kangaroo care support, rather than trying to get current staff to take on the additional burden of teaching kangaroo care. We hope and expect (based on our conversations with experts) that this approach can sidestep at least some of the implementation issues identified by GiveWell.
Thanks for the clarification—I like that idea of having an extra staff. That staff could easily be a community health worker rather than a nurse or midwife. Having say 1 manager for the program supervising 10 to 20 of those staff in hospitals could be a very efficient way to make it happen, nice one.
Hi Nick! Thanks so much for your thoughtful feedback. My colleagues have answered, but I would like to respond to your comments on kangaroo care, ORS and zinc!
On Kangaroo care 1. Thanks for your note on generalist talent—we will note this down. 2. I agree with you! This intervention includes large behavior change activities (not only from caregivers but also practitioners) - KC can tend to be seen as a “second rate” solution to lack of resources, as well, instead of the proper medical care it is. 4. We will note this down for our future co-founders!
On ORS On trials and targeting. Yes, I fully agree—this intervention must be well targeted to find places where it would be additional; this is something we focus on more in the full report! On NGO speak. Noted—in the full report, we discuss some evidence of plausible intervention models that are a bit more pinned down - having said that, I generally agree that getting the ORS to those that need it is a better option. Other models would be additional (and up to debate).
Great work Charity entrepreneurship!
As a public health doctor in a low income country, I read the initial cause areas and had quite a few concerns about implementation. Then when I read the longer summaries I saw you had thought about almost all of them which is impressive—clearly done your homework ;)
Have a few comments
On the kangaroo care rollout front I have four thoughts
1. My instinct is that a generalist could well struggle with this initiative. They would be dealing at a high level with hospital management and senior staff at hospitals, and without medical expertise or at least a public health background they might not be taken very seriously and struggle to make headway. As you’ve obviously researched yourselves, and you’ve seen on the givewell review, sustaining kangaroo care in facilites is extremely difficult for a range of factors. That 2014 study managed only 5% sustainable practise n 4 African countries. A few NGOs have come around in our Ugandan facilities training midwives, and we are still quite bad at it (I haven’t pushed it as hard as I should either).
2. I believe (moderate uncertainty) that cultural resistance, or even cultral norms are an underappreciated barrier to Kangaroo care. You’ll notice most the stated barriers on Givewell are operational/practical, not cultural. There is a bit of a myth I’ve heard that Kangaroo care is “natural” or similar to “traditional practise”, which might make make implementation easier. In my experience modern-day cultural norms around birth both at home and in healthcare often differ wildly from kangaroo care
3. I strongly agree with your statement that”we note that it relies on very favorable stakeholder relations and management that may not be easy to find in some contexts. It is, therefore, promising but riskier relative to other interventions in global health.”
4. Working through a partner NGO can be a good plan, but as we all know the vast majority of NGOs are both hopelessly in efficient and not very effective. A meticulous in-country check of whether what an NGO Claims to have already implemented or achieved is true or not is essential before considering working with them. Usually an advantage of charity entrepreneurship stuff (I think) is the new NGO can do most of the intervention itself.
On the syphilis test front I have a simple logistics question/suggestion.
Might it not be cheaper and easier to just add a separate syphilis test rather than try to do the dual test?
Doing a combined test is easier and would be the best solution assuming no resource or logistical restrictions, but it has two disadvantages
The cost of the dual test can be considerably higher than the cost of seperate HIV test and syphilis tests combined. Stand alone syphilis tests are very cheap. Our health centers do separate tests as part of our standard antenatal work up—HIV, malaria, syphilis test for all in first trimester.
HIV programs are usually standardised and rigid. Convincing them to change their whole system to dual testing might be difficult or even impossible in some cases. The flipside is if you did convince a country or HIV treatment provider to do this, the ipact could be huge. Obviously some countries already do dual testing but you wouldn’t be working there.
On the free ORS distribution front.
I really like this, and just have a couple ofl thoughts.
First, an important challenge might be finding the best place to trial this intervention where there is both a high prevalence of diarrhoea and poor ORS coverage. In our OneDay Health center communities for example, serious cases of childhood diarrhoea are now surprisingly uncommon and not nearly as much of a problem as it was 10 years ago. And that’s in the most remote parts of Uganda. Clean water and ORS+zinc use has massively reduced diarrhoea death burden in many places (more so than malaria and pneumonia), so I feel this intervention needs to be especially well targeted. Not only on a country level, but to focus on the more remote, underserved parts of those countries.
Second I want to push back a bit on”An organization could also work with local producers, health officials, and stakeholders to improve product design, market awareness, availability, and use of ORS.” This sounds a little like generalist ineffective NGO speak to me. I think this could be a real money sink and have limited value. Perhaps focusing on just getting the ORS to the people who need it is a better approach.
Anyway keep up the great work! As someone “on the ground”, I’m always impressed by how realistically tractable your cause suggestions seem to be.
Hi Nick, thank you very much for your thoughtful feedback! I researched the syphilis idea so will address those questions.
1. The dual tests have recently become very cheap too, costing some $0.95 each (largely thanks to CHAI’s work in this area). In our understanding, this is only some $0.15 more expensive than a single HIV test – though I’m sure prices will vary geographically. If there are places where the dual tests are more expensive than two separate rapid tests, then I agree that the dual tests wouldn’t make sense there.
2. You are right that changing the existing system (including updating diagnostic algorithms and training the relevant health workers) is one of the main challenges and one of the reasons why this idea has not already been implemented more widely. However, it seems that what is currently lacking is technical assistance for countries’ health systems to make this switch – and this is exactly the sort of implementational work that we think strong charity entrepreneurs can do well!
Thanks on point 1 that makes sense. To add (I should have said before) that often HIV tests will already be supplied through a different donor program and the easies thing might just be to add, so yes being very aware of those dynamics is importnt
On point 2 I don’t think changing the system will necessarl be all that hard in many cases. It is likely to be be more of a financial/logistics issue getting the tests to the health centers than a technical/education problem. If the tests are freely available at facilities people will do them. Most health providers already know women should get a syphilis test even if it’s not available at this point in time. Both staff and patients often love the idea of extra tests in Uganda at least (which might see weird to some people) so I doubt the barriers will be that great. 100% agree that a strong charity entrepreneur could pull this off well.
Hi Nick, Great to hear from you and to get your on-the-ground feedback. I lead the research team at CE.
These are all really really great points and I will make sure they are all noted in the implementation notes we produce for the (potential) founders.
All our ideas have implementation challenges, but we think that delivering on these ideas is achievable and we are excited to find and train up potential founders to work on them!!
–-–
One point of clarification, in case it is not clear: on kangaroo care we are recommended an approach of providing and adding extra staff into healthcare facilities to offer kangaroo care support, rather than trying to get current staff to take on the additional burden of teaching kangaroo care. We hope and expect (based on our conversations with experts) that this approach can sidestep at least some of the implementation issues identified by GiveWell.
Thanks for the clarification—I like that idea of having an extra staff. That staff could easily be a community health worker rather than a nurse or midwife. Having say 1 manager for the program supervising 10 to 20 of those staff in hospitals could be a very efficient way to make it happen, nice one.
Hi Nick! Thanks so much for your thoughtful feedback. My colleagues have answered, but I would like to respond to your comments on kangaroo care, ORS and zinc!
On Kangaroo care
1. Thanks for your note on generalist talent—we will note this down. 2. I agree with you! This intervention includes large behavior change activities (not only from caregivers but also practitioners) - KC can tend to be seen as a “second rate” solution to lack of resources, as well, instead of the proper medical care it is. 4. We will note this down for our future co-founders!
On ORS
On trials and targeting. Yes, I fully agree—this intervention must be well targeted to find places where it would be additional; this is something we focus on more in the full report! On NGO speak. Noted—in the full report, we discuss some evidence of plausible intervention models that are a bit more pinned down - having said that, I generally agree that getting the ORS to those that need it is a better option. Other models would be additional (and up to debate).