Week 5: Global Health

Background reading

  1. Global economic inequality (Max Roser / Our World In Data, 2022) (15 minutes)

  2. Global Health - The global distribution of the disease burden (Esteban Ortiz-Ospina and Max Roser / Our World In Data) (15 minutes)

Impact of GiveWell's top charities (GiveWell, 2016-2017) (post - 5 mins)

Impact

  • Averting Deaths

    • Secondary: Non-fatal illnesses, Mental or physical development

  • Substantial increase in future income e.g., 15%

    • Secondary: short-term health, school attendance

  • Avert Illness and Death of Children

    • Secondary: children's development, increased future income

  • Allowing recipients to purchase what they most need: basic needs

    • Secondary: investments with high returns

Evidence

  • Individual staff estimates

  • Broad range of cost-effectiveness

    • Value Judgements

    • Intuitions

    • Levels of Uncertainty

Our Top Charities (GiveWell) (page - 5 mins)

Donate based on evidence - not marketing

  • Acknowledging that even well-meaning organizations can fail to have impact

  • 60,000+ hours of annual research

Variables for Prioritization

  • Cost-Effectiveness

  • Evidence of Impact

Donation Option

  • Directly to a specific charity

  • indirectly via a 'Fund'

    • Email you which charity selected & expected impact

How We Produce Impact Estimates (GiveWell, 2021-2023) (post - 10 mins)

General Philosophy

  • Be accurate

    • Don’t imply that a donation will accomplish more (or less) than we expect it to.

  • Be clear

    • To the extent possible, make straightforward claims that are easy to understand.

  • Don’t imply a false level of precision

    • While models may provide estimates down to the dollar, round them so they don’t suggest we believe in that level of specificity.

  • Share the work with those who want it

    • Make the detail behind impact estimates available for anyone who wants it.

Lifetime Impact of GiveWell

From 2009 to 2023, GiveWell directed a total of $1.15 billion

  • Save a total of about 270,000 lives via

    • Distributing 76.6 million insecticide-treated nets to households

    • Treating 65.2 million children with a full course of anti-malarial medicine

    • Providing vitamin A supplements to 120.7 million children

    • Vaccinating 921,000 infants who wouldn’t have been vaccinated otherwise

'We don’t believe that the organization with the lowest average cost per life saved is a better giving opportunity than our other recommendations'

  • Organization may not have the capacity to absorb funding for additional cost-effective opportunities

Focus on Funding Opportunities rather than entire portfolio of an organization's work

  • Why?

    • Organization-level cost-effectiveness estimate would result in recommending funding to only one organization

  • What is a funding opportunity?

    • defined as a specific intervention e.g., seasonal malaria chemoprevention

  • May differ between funding opportunities

How much impact will my donation have?

Weighted Average

Cost vary among programs we recommend funding for

  • $9.9M to distribute malaria medication in Borno, Nigeria at a cost of $6 per child treated with a full course of medicine, resulting in an estimated cost-effectiveness of around $3,500 per life saved

  • $2.0M to distribute malaria medication in Togo at a cost of $12 per child treated with a full course of medicine, resulting in an estimated cost-effectiveness of $6,500 per life saved

Impact of grants rather than donations

  • Due to 'funging' it is difficult to calculate where your donation will eventually be donated to

    • Funging is when your donation is distributed to the next best opportunity rather than the opportunity you assigned it to

      • You donate to Hellen Keller Intl

        • An opportunity with Helen Keller Intl is the most cost-effective, and needs $5M to distribute vitamin A supplements.

        • An opportunity with Against Malaria Foundation (AMF) is the next most cost-effective, and needs $20M to distribute malaria nets.

      • GiveWell has 20M available i.e., your donation will go to AMF

  • Sharing impact of grants gives donors the estimate they are most likely looking for - impact a certain amount of funding has with that program

Are past cost-effectiveness estimates updated regularly?

  • No - Why not?

    • Large administrative burden without substantially improving decisions for upcoming grants

    • Confusing if impact estimates frequently changed

  • Best guess it that cost-effectiveness estimates become less cost-effective over time as the most cost-effective opportunities will be funded

Evidence Action — Scale-Up of In-Line Chlorination in India (20-60 minutes)

Process

  • We spoke with Evidence Action ~30 times.

  • We traveled to India to meet with key stakeholders, including government officials.

  • We spoke with more than 20 experts, including several recommended by Evidence Action, to discuss the grant's theory of change, the plausibility of some of the estimates in our cost-effectiveness model, and other topics.

  • We put the grant recommendation through an unusually intensive peer review process, during which GiveWell's internal peer reviewers provided feedback approximately weekly for the final two months of the grant investigation.

Justification for Grant Recommendation of ~38.8 million USD to Evidence Action for Inline-Chlorination (ILC)

  • Cost-Effectiveness

    • Positive Secondary Effects

      • Averting medical costs, positive spillover effect on nearby communities

    • 22x times as cost-effective as unconditional cash transfers

    • Reducing Deaths

    • Applying 'discounts' / 'minus adjustments'

      • Due to uncertainty

      • e.g., Experts mentioning specific data may be inflated

  • Qualitative Factors

    • Government Interest

      • Indian Government is prioritizing delivering piped water to all rural Indian households

    • Evidence Action is well-placed to deliver this program

    • Experts found the program's theory of change plausible

    • Provide valuable data to inform future grants

  • Neglect

    • Indian government is prioritizing water access rather than water chlorination

    • Government would be unlikely to pay for chlorination

  • Small Start

  • Most of cost-effectiveness lies here:

    • Potential adoption of other areas i.e., ~26 million more people over 10 years

Key Uncertainties

  • Cost-Effectiveness i.e., Chlorination on Mortality

    • 'We think piped water is contaminated in India, based on data from neighboring countries and survey data on risk factors for contamination. However, this is only indirect information, so we could easily be wrong.'

  • If adoption of other areas is successful

  • High risk of NGOs implementing technical assistance programs being discontinued

    • due to e.g., government buy-in, infrastructure development, and rolling out a new technology

  • We're not sure if Evidence Action is excited about the grant for the same reasons we are

    • non-aligned reasons e.g., large number of people reached or the potential for long-term sustainability of the program

Approach to Key Uncertainties

  • 'Gates' that the program must pass in order to receive more funding

    • For example, if a state government hasn't signed an agreement to work with Evidence Action by a certain date, we would not release the rest of our funding.

Grant Activities

  • Grant Requester demanded $56 million, however only $38.8 million was granted due to uncertainty

  • Political Attention

    • Meeting with bureaucrats

    • Developing accountability mechanisms

    • Media presence to help people accept & possibly demand

  • Quality Management

    • Advocating for the inclusion of ILC over less-effective technologies

    • Monitoring government-installed ILC

  • Quantity

    • Plan to install 1,700 ILC devices covering ~2.4 million people

    • Government expcted to run tenders to identify third-party firms to install and maintain further ILC devices

  • Grant Allocation

    • 38% - Personnel Costs

    • 21% devices

    • 17% indirect expenses

    • Administrative, operating expenses

Africa needs malaria vaccines (10-15 minutes)

Importance

  • Malaria thrives in areas with poor public health resources and hot and humid climates

  • Nearly all of the 600,000 annual malaria deaths are in Africa

  • It claimed the lives of 5 percent of the humans who’ve ever existed

  • Kills someone under the age of five every two minutes

Solvability

  • Independence

    • Building a domestic vaccine supply chain won’t just help support the fight against malaria, it will ensure that the continent is able to deliver life-saving vaccines in the future as well.

  • Lack of Funding

Neglect

  • Lack of funding by Gavi

  • Vaccine CEO of the Serum Institute of India said, “We have the capacity, the demand, and the will of the people to want this vaccine, now we just need to get enough funding from Gavi [the vaccine alliance] and donors to be able to support that.’

Lead Exposure Action Fund (Explore site for 10 minutes)

Importance

  • 1.5 million deaths / year

  • Adverse development of brain

  • Nervous system, kidney function, cardiovascualr system

  • goal: world free of lead exposure

Solvability

  • How?

    • Measurement

      • Blood Lead level, Paint, Spices

    • Mitigation

      • Paint, Spices

    • Mainstreaming awareness

      • Aid agencies, funding commitments

  • Track Record

    • substantial reductions achieved through targeted interventions in countries like the USA, Bangladesh, and Malawi.

Neglect

  • Only $15 million / year in funding focused on lead exposure in LMIC prior to 2024

What USAID does, and why Trump and Musk want to get rid of it (5-10 minutes

What is US AID?

  • Founded by Then-President John F. Kennedy.

  • U.S. Agency for International Development during Cold war

  • Original Objective

    • Efficient way to counter Soviet influence abroad through foreign assistance

  • Updated Objective

    • Counters Russian and Chinese influence

How much?

  • Roughly $40 billion in foreign aid in the 2023 fiscal year

  • U.S. is the largest provider of humanitarian assistance globally

What is being reduced?

  • Why?

    • Focus on what makes 'America safer, stronger or more prosperous.'

  • Examples of current US AID

    • Sub-Saharan Africa

      • $6.5 billion in humanitarian assistance last year

    • Mexico

    • Venezuela

      • A program to provide mental health support for LGBTQ+ youth fleeing Venezuela was disbanded

    • Colombia, Costa Rica, Ecuador and Guatemala

      • so-called “Safe Mobility Offices” where migrants can apply to enter the U.S. legally have shuttered.

Investing in science and technology research (5-15 minutes)

Hits-based Giving Examples

Malnutrition

  • RTC to Improve Ready-to-Use Therapeutic Food (RUTF)

  • Impact

    • Updated formulation requirement adopted by UNICEF

    • Boost cognitive development & educational outcomes for millions of children world wide

Ageing

  • Research into blood

  • Impact

    • New Perspectives in blood affecting aging

Malaria

  • MB, a naturally occuring symbiont, shows promise in blocking the transmission of malaria (within mosquitos)

  • R21 Vaccine support

Hepatitis E Vaccine

  • Provide data required for WHO to 'prequalify' the vaccine

Promoting economic growth (10 minutes)

Support economic grwoth in LMICs via minimum $30 million in grants over first three years

Importance

  • Economic growth improves well-being of the global poor

    • e.g., China has lifted 800 million people out of extreme poverty

    • Afford food, better housing, education, healthcare, infrastructure

  • ~2bn (25% of human population) who live on less than $3.65 / day

Solvability

  • Themes

    • Economic policy advice

      • Providing independent advice > biased, dependent

    • Advocating for policy changes to promote developing country exports

      • Lowering Non-Tariff Barriers ( administrative hudrles, quotas, licenses)

      • African Growth & Opportunity Act (AGOA) Renewal

        • Gives Sub-Saharan African countries duty-free access to e.g. apparel in the American market

    • Illicit financial flows

  • Strategies

    • Country-Focused

      • Focus on a specific region

      • Focus facilitates wisdom and momentum

    • Thematic Approach

      • e.g., exportation

      • Facilitates applying this to multiple regions i.e., greater impact

    • Opportunistic Approach

Neglect

  • Broad field of economic growth is fairly crowded

    • For decades, international organizations have invested many hundreds of billions of dollars to accelerate economic growth

  • Niches might be neglected

    • hits-based giving

    • Grant approval process is often faster

    • Small size allows to make smaller grants

    • As a private philanthropy: complement traditional development actors by experimenting

Factors for Deciding to Fund Economic Growth

  • Expert Advice

  • Encouraging preliminary outcomes for exploratory grants

Potential Risks & Downsides

  • Respecting the autonomoy & freedom of grant-recipients

  • Imposing policy are unlikely to suceed

  • High Uncertainty

    • Indicators e.g., policy milestones, engagement with key decision-makers

Alexander Berger on improving global health and wellbeing in clear and direct ways

Open Philantropy's 'Global Health & Wellbeing' programme

  • $175 million / year in grants

  • For what?

    • Easily-prevented illnesses among the world’s poorest people

    • offer cash to people living in extreme poverty

    • prevent cruelty to billions of farm animals

    • advance biomedical science

    • improve criminal justice and immigration policy in the United States

Prioritization of Neartermism / Global Health & Well-being

  • Actual opportunities

  • Direct feedback & potential to improve > one shot to get it right

  • Contra Longtermism

    • Don't have good answers on longtermism

    • Uncertainty

Cluelessness

  • Not give up altruism

  • Humility

10x cost-effective compred to GiveWell Charities

  • Optimistic that advoacy (policy) and science

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