Three charitable recommendations for COVID-19 in India

This post was written by the two of us (Manya Gupta and Tejas Subramaniam) as the justification for the charitable recommendations of the Fundraiser for India Debate Workshop Series, with help from Prashasti Saxena (who set up the workshop series), Rohan Goda, and Namita Pandey. It is a list of five recommended charities/fundraisers (on three cause areas) to donate to during COVID-19 in India. We are uncertain about these conclusions, but thought it’s worth posting them here regardless. Some of our recommendations are engineered to maximize donations to the workshop (e.g., placing a higher premium on transparency/accountability to make people more comfortable donating). 

Edit May 25, 2021: We are currently in the process of revising some of our recommendations, both due to recent trends in COVID-19 cases, changes in room for more funding, and this piece by Smarinita Shetty on changing needs (we do not endorse it yet, and are simply thinking about it and asking people we know working on this). 

Some of our key uncertainties on this:

• We are very unclear about the marginal value of oxygen plant construction, given its possible medium-term effects on oxygen supply and second-order effects like improving health capacity or risk-aversion. Jeff Coleman thinks that donations to oxygen plants are less cost-effective than oxygen concentrators and type-B oxygen cylinders. There are also raw material constraints which might make plant construction not as effective in the short run. However, we do not have a strong opinion on this issue and are open to more resources.
• Our prior is that vaccination is the best path forward, but our current best guess is that private donations directed toward vaccination efforts in India – at least at the level of individual donors – is unlikely to substantially change vaccination rates, because the main bottleneck in the short term is vaccine supply, which depends significantly on government action. It is possible that over the next few months, behavioral interventions such as those run by Suvita become much more important as boosting vaccine demand becomes a priority (this is highly uncertain, and we have not looked into Suvita in depth).
• There are potential second- and third-order microeconomic effects of our recommendations that we are not considering, such as donations affecting oxygen prices or expanding the black market. A lot of this depends on precise calculations of supply and demand elasticities that we do not have access to.

Context

At the time of writing (May 4, 2021), India has recorded 20.3 million cases of COVID-19. Last week, India saw over 400,000 recorded cases in one day – more than any country in the world. This is likely a significant underreport, because not enough testing is being done – on May 2, the test positivity rate was 24.2%, and the amount of testing is decreasing due to unavailability. The IHME model, which attempts to correct for the lack of testing, estimates that there were nearly 12 million new cases of COVID-19 on May 3 alone, an unprecedented number. Health capacity in major cities is struggling to keep up. There are severe shortages of oxygen, vaccination rates are very slow and there are shortages in the vaccine stock, and hospital beds are filling up rapidly. The IHME estimates that there have been over 450,000 total deaths due to COVID-19 in India alone, making it one of the world’s most serious humanitarian crises. 

Despite the grim situation, we also think this provides a unique opportunity to do good. We believe that donations to charities focused on public health and relief in India are likely unusually cost-effective, and are comparable to GiveWell’s recommendations for cost-effective charities. Technologist Jeff Coleman, using conservative estimates, finds that most oxygen-related interventions for COVID-19 in India, in the short term, outperform GiveWell-recommended charities. For example, just 22 days of use of an oxygen concentrator will do more good than the equivalent amount of money being donated to a GiveWell-recommended charity. 

Our values

Our list of recommended charities is based on the belief that the most urgent problem to address is the direct effects of COVID-19 in India on public health and poverty. While virtually every community – from marginalized social groups to particular professions and trades (e.g., artisans) – has been impacted negatively by the pandemic, our focus is recommending charitable donations targeted at alleviating the public health and economic crises.

Given this, we used four criteria to select our recommendations:

• Ensuring there are accessible donation methods for as many donors as possible. For this reason, we have omitted some Indian grassroots organizations, which might be comparably effective but don’t offer ways for international donors to donate money. We also recommend charities that allow accessible payment options (e.g., ensuring they accept debit cards and not just credit cards, allowing for some diversity in payment options).
• Looking for charities that have room for more funding. Many highly effective charities have met their funding needs, and often have numerous donors willing to cover funding gaps. This means we prioritize charities that are unlikely to get substantial funding anyway, or have the room to accommodate additional donations. This is due to the principle of diminishing marginal returns. This also means we will likely reevaluate the funding needs of these charities soon.
• Ensuring the charities are cost-effective. This both means choosing causes that are important (by the number of people affected, how tractable the problem is, and how neglected it is), but also ones where significant progress can be made at relatively low cost. For example, in choosing charities within a particular cause area, we placed substantial weight on how much they were paying to engage in service delivery. Due to the lack of rigorous cost-effectiveness estimates, we do have high uncertainty about our recommendations, and rely on both data and “napkin math.” However, the expected value of these donations is likely high.
• Aiming for charities that are transparent and trusted. We looked for organizations that were open about the costs that they faced, what their budget and overheads were, and engaged in due diligence to find out ways to do good. We also heavily used recommendations from groups of people we trust, such as members of the effective altruism community, grantmaking organizations, and researchers in these fields, and aim for relatively well-known organizations and fundraisers. This is important because during crises, a lot of organizations don’t prioritize clarity about where exactly they’re spending their newfound funding.

We also need to integrate more direct evidence from medical research on the efficacy of concentrators into the post, which we expect to add soon. 

Our recommendations

We prioritize the following three cause areas (in order of priority).

Oxygen supply

Our highest priority is oxygen supply. 

Why?

A large cause behind the many deaths and severe cases of the second wave of COVID-19 in India is a shortage of oxygen. The BBC notes that India currently “has the greatest demand for oxygen out of all other low, lower-middle and upper-middle-income countries,” that “[d]emand has been growing between 6–8% each day,” and thus that “hospitals across India are also experiencing oxygen shortages, with some forced to put up signs warning of a lack of supplies.” There’s countless stories of single hospitals losing 10 patients each night because of not having oxygen, and of families turned away at hospitals that have run out. Hence, we believe that oxygen is the most urgent priority, and donations to organizations that improve access to oxygen is our top recommendation. 

Oxygen concentrators, cylinders, and generators 

What we’ve read also indicates that oxygen concentrators are, on balance, a better investment than oxygen cylinders, though there is lots of uncertainty. This is because oxygen concentrators can be imported (through flights), while only empty oxygen cylinders can be imported. Empty oxygen cylinders would need to be filled or refilled at local plants, and there’s currently extremely long delays at such plants. This suggests that importing devices that can directly increase oxygen supplies is the better bet. Concentrators are also reusable – if multiple members of a family or people living close together are affected, which is likely, a single concentrator can be used for a long time. It functions almost like an air conditioner by constantly generating oxygen. 

In addition, oxygen cylinders have higher recurring costs. Jeff Coleman estimates that if these costs are borne by donors, then it takes 33 days for B-type oxygen cylinders to beat equivalent investments in GiveWell top charities (as opposed to 22 days for concentrators), and that D-type oxygen cylinders do not beat GiveWell top charities. So while B-type oxygen cylinders are a very good investment, concentrators are a better use of limited resources. Edit May 6, 2021: SammyDMartin estimates that “it seems like, very roughly, three quarters to twice as good as Givewell's top charities is a reasonable range of uncertainty.”

A common objection to this argument is that concentrators cater to people with less-severe cases and only cylinders can be used in ICUs. Experts suggest that roughly 2% patients require critical care (only possible through cylinders) and 8% could recover at home with appropriate support. Right now, those 8% either worsen and become severe cases, burdening the already overstretched system, or die without support. Concentrators make a huge difference for moderate COVID patients, and in doing so, help the healthcare system and could cater to patients who can’t access beds.

We are much more uncertain about the value of oxygen generators. They offer a more long-term solution, but their costs are much  higher, so needs for oxygen generators might be better met by big philanthropists and governments. 

Recommendations

Our recommended charitable donations for oxygen are the following:

1. GiveIndia Oxygen fundraiser (for its reputation among effective altruists, transparency about costs, and the fact that it pays among the lowest prices for concentrators, cylinders, and generators)
2. Oxygen for All concentrator fundraiser on Milaap (for its ties to the established and credible public health accelerator Swasti, its focus on oxygen concentrators rather than cylinders and generators, and the transparency and accessibility of their team in direct communication with us).
3. Swasth’s Oxygen for India concentrator fundraiser on Milaap (for the price at which they are buying oxygen concentrators, room for more funding, and transparency about procurement and funding). We didn’t initially include this because our document was prepared for a debate lecture series, and there are fewer options (particularly among our target audience) to donate to this fundraiser internationally. However, we think this could also be a cost-effective opportunity – thanks to Ian David Moss for their comment on this! (This was added on May 6, 2021.)

Direct cash transfers 

Our second highest priority is direct cash transfers. 

Why? 

The pandemic in India has caused severe economic disruptions, with a major recession, high unemployment, overburdened welfare systems, and many families losing earning family members. We believe that a low-risk option is to donate to direct, unconditional cash transfers for low-income families in India. Especially given that healthcare costs are also serious for low-income families, economic relief is a priority concern. 

Evidence

While our guess is that this is less cost-effective than donations to oxygen, this also probably has less uncertainty, for two reasons. 

1. First, we think cash transfers have to meet an unusually low burden of proof. Giving cash to a low-income family – thus reducing the extent of poverty they are in – is good in itself, by expanding their choices and allowing them to consume and save more, it does not necessitate a rigorous analysis of the instrumental or flow-through effects.
2. Second, from other contexts, we think the evidence on unconditional cash transfers is broadly positive. Randomized controlled trials have demonstrated positive effects on various metrics, including health (which is especially important during the pandemic), quality of life, and regional economic growth. For example, a literature review by the Cochrane Collaboration finds improvement in “some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), one social determinant of health (i.e. the likelihood of attending school), and healthcare expenditure.” A randomized controlled trial by Banerjee et al. (2020) found that cash transfers during COVID-19 “significantly improved well-being on common measures such as hunger, sickness and depression in spite of the pandemic, but with modest effect sizes.” Egger et al. (2020) also find a positive fiscal multiplier from unconditional cash transfers, implying positive effects on aggregate demand without significant inflation. This is in line with recommendations from the effective altruist community for the charity GiveDirectly.

Hence, we think direct cash transfers are our second highest priority (after oxygen). 

Recommendation

Our recommended charitable donation in this area is the GiveIndia Cash Transfer fundraiser, which gives one-time cash transfers of over $400 to low-income families that have recently experienced a COVID-related death in their family. Our recommendation is because of GiveIndia’s positive track record, recommendations for GiveIndia’s cash transfer fundraisers in the effective altruism community last year, and its strict “due diligence framework” to verify the authenticity of recipients. We also think GiveIndia works with trusted charitable organizations, such as ActionAid. 

Community-based responses

Our third highest priority is broad community-based responses.

Why?

We recognize that a lot of the harms and causes of the current pandemic wave include systemic issues: a lack of healthcare capacity, food shortages, information gaps about risk mitigation, no vaccine access, and broken supply chains. In many areas where normal supply chains are disrupted, cash transfers might not be enough to support families in need. For supporting healthcare capacity, it’s possible that a vertical, narrow approach addressing a single capacity issue like oxygen shortages might not be enough. In cases like this, a more flexible approach where the real-time needs of on-ground partners are considered and responded to might be better, whether those be oxygen, support in setting up field hospitals,  PPE, or telemedicine. This is especially important as a consideration considering how quickly disasters like this one change and information gaps can exist for distant donors. It is expected that the locations most affected by the second wave will also change from highly populated cities like Delhi and Bangalore to regions like rural Uttar Pradesh, which makes broad community networks and adaptability important. The conclusion here is that what is most effective will change throughout the second wave and differs for each place, therefore, funding organizations that can account for that change is valuable.

We recognize the risk with this approach, for it requires placing trust in a few organizations’ ability to use the funds effectively and honestly without our strict control. Our conversations with mentors, like people at the International Rescue Committee who have worked on public health in disasters before, suggest that unrestricted funding is a critical need for organizations in crisis settings. Otherwise, they are legally bound to fund a specific campaign even if that’s not what is most required or most manageable on ground. This is a less certain approach than the others, but could allow for more community-led and adaptable solutions.

Recommendation

Our recommended charity here is SEEDS India. SEEDS operates in 11 states and union territories in India. It has a history of working in disaster management and crisis response, and their response to COVID’s first wave in India was very large-scale. Their response to the second wave focuses on medical capacity support. We chose it over other organizations because in this category of community centered organizations, very few accept foreign funding, and SEEDS’ recommendation by groups like IndiaCOVID SOS’s funding team suggested legitimacy to us. Here is a press release explaining their plans. This is less certain in terms of effectiveness than our other recommendations, and we are seeking conversation with their team to get more information. 

Why not include another organization?

The reason we have chosen to not recommend large international organizations based in the US, like Oxfam, MSF, or Project HOPE, is that we expect those organizations will likely be able to fundraise from US based large donors anyway. Their inclusion on this list might also mean they crowd out other options due to being more well-known, even if their effectiveness is just as unclear. We also have a prior favoring local nonprofits who might have deeper relationships with the communities they serve. 

We strongly considered and compared other oxygen providers before narrowing down on the two we mention. These include Hemkunt Foundation, Oxygen on Wheels, Oxygen for India, Mission Oxygen, Khalsa Aid, SEWA International, and other Milaap fundraisers. They were removed if they focused primarily on ventilators/cylinders or less evidence-backed interventions like oxygen ambulances, had met their funding targets, had transparency gaps, or did not allow you to choose which of their projects to donate to.