Edit: We added one more idea to the list on Feb 21, 2023.
Apply now to start a nonprofit in Biosecurity or Large-Scale Global Health
In this post we introduce our top five charity ideas for launch in 2023, in the areas of Biosecurity and Large-Scale Global Health. These are the result of five months’ work from our research team, and a six-stage iterative process that includes collaboration with partners and ideas from within and outside of the EA community.
We’re looking for people to launch these ideas through our July - August 2023 Incubation Program. The deadline for applications is March 12, 2023.
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We provide cost-covered two-month training, stipends, ongoing mentorship, and grants up to $200,000 per project. You can learn more on our website. We also invite you to join our event on February 20, 6PM UK Time. Sam Hilton, our Director of Research, will introduce the ideas and answer your questions. Sign up here.
Disclaimers:
In an effort to be brief we have sacrificed nuance, the details of our considerable uncertainties, and the downside risks that are discussed in the longer reports; these shall be published in the upcoming weeks.
Please note that previous incubatees attest to the ideas becoming increasingly exciting over the course of the program.
One-Sentence Summaries
- An organization that addresses antimicrobial resistance by advocating for better (pull) funding mechanisms to drive the development and responsible use of new antimicrobials.
- An advocacy organization that promotes academic guidelines to restrict potentially harmful “dual-use” research.
- A charity that rolls out dual HIV/syphilis rapid diagnostic tests, penicillin, and training to antenatal clinics, to effectively tackle congenital syphilis at scale in low-and middle-income countries.
- An organization that distributes Oral Rehydration Solution and zinc co-packages to effectively treat life-threatening diarrhea in under five year olds in low-and middle-income countries.
- A charity that builds healthcare capacity to provide “Kangaroo Care”, an exceptionally simple and cost-effective treatment, to avert hundreds of thousands of newborn deaths each year in low-and middle-income countries.
- An organization that aims to reduce stock-outs of contraceptives and other essential medicines by improving the way they are delivered and managed within public health facilities.
One-Paragraph Summaries
1. Preventing growth of antimicrobial resistance by advocating for better (pull) funding mechanisms to drive R&D and responsible use of new antibiotics
Antimicrobial resistance (AMR) is where harmful microbes develop the ability to resist treatment. Recent reports suggest that there are 47 million disability adjusted life years (DALYs) per annum attributed to antibiotic resistance (a key type of AMR). The current financial incentives for new antimicrobial drug development are insufficient, and only a handful of novel antibiotics have been brought to market in the last 30 years. There are well-developed proposals for new market mechanisms using a “subscription” model that would solve this issue. This new charity will advocate for these better market mechanisms, to incentivise the creation and responsible deployment of important new antimicrobial drugs. We estimate that government spending on new market mechanisms for antibiotics could lead to a DALY averted for $100-$150.
2. Advocacy for restricting potentially harmful “dual-use” research
Dual-use research of concern (DURC) is well-intended research which can lead to harm, either by accident or through deliberate misapplication of the technology. DURC could be a key risk factor for the occurrence of a particularly deadly pandemic during the next 50 years. This risk should be mitigatable with the development and adoption of good practice. We analyzed a dozen case studies of attempts to ensure research safety, ranging from animal testing to human cloning, and we believe this work needs to be done hand in hand with academia. This expert-led charity will promote guidelines and cultural norms within academia to reduce DURC and its risks. We think that, if successful, this could in expectation save a million lives over the next 50 years, with extremely high uncertainty.
3. Rolling out dual HIV/syphilis rapid diagnostic tests, penicillin, and training to antenatal clinics, to effectively tackle congenital syphilis at scale
Congenital syphilis causes around 150,000 stillbirths and 60,000 neonatal deaths every year. This new charity will roll out dual HIV/syphilis rapid diagnostic tests, penicillin, and training to clinics in low-and middle-income countries. Very strong evidence indicates that treatment leads to a 97% reduction in congenital syphilis and ~81% reduction in the risks of stillbirth and neonatal death. This charity looks highly cost-effective, scalable, and tractable. We estimate it could avert one DALY for $81 and save a life for $1,726.
4. Distributing life-saving Oral Rehydration Solution and zinc co-packages to treat life-threatening diarrhea in under five year olds
Diarrheal diseases are the third leading cause of death in children under five, worldwide. Exceptionally strong evidence shows that Oral Rehydration Solution (a simple mixture of water, sugar, and salt) and zinc, can prevent 93% of diarrhea deaths, and avert other consequences of bad diarrhea episodes. However, treatment rates are low in places that need it the most. This relatively straightforward organization can deliver co-packaged ORS and zinc directly to caregivers in their households to increase treatment rates. ORS and zinc are very cheap - a well-targeted charity appears highly cost-effective, potentially at a rate of around $50 per DALY averted.
5. Building healthcare capacity to provide “Kangaroo Care”, an exceptionally simple and cost-effective treatment, to avert hundreds of thousands of newborn deaths a year
Almost 1.9 million newborns died in 2019. Kangaroo Care (KC), a simple and cheap therapy involving skin-to-skin contact, breastfeeding, and close monitoring - is an extremely effective treatment that could avert hundreds of thousands of these deaths per year if scaled. This charity will help high-burden countries scale up KC by embedding capacity in health systems, by setting up KC wards. With its strong evidence base but lackluster progress in scaleup, this charity appears both needed, neglected and highly promising. Funding appears available, and monitoring and evaluation will likely be relatively straightforward. Modeled cost-effectiveness looks good, suggesting that a neonatal death could be averted for ~ $3300.
6. Fixing stock-outs for contraceptives and other essential medicines
In 2019, about 218 million women of reproductive age were not using any method of modern contraception, despite wanting to avoid pregnancy. This resulted in 111 million unwanted pregnancies. Many of these women stopped using contraceptives because they were out of stock, a pervasive problem in low-income countries. An average of 25% of clinics in Sub-Saharan Africa experience stock-outs, but this percentage can creep above 80 in some regions. It is essential that supplies are made reliable and continuous, as well as making a wider range of contraceptive options available. This problem is not unique to contraceptives, other essential medicines are affected too. An organization could improve this situation by optimizing logistics systems, procurement, and inventory management, and by working with pharmacies and shops to expand contraceptive access beyond public health facilities. Improving these systems would not only prevent many unwanted pregnancies, but improve coverage of lifesaving health commodities too.
More Detailed Summaries
In the summaries below, we give a glimpse into what each intervention entails and who might be a good fit for them. Please remember that each charity is typically launched by two co-founders, which in practice means complementary talents and skills. One person may bring research and technical know-how, while the other more generalist communication and operational skills. Furthermore, nobody comes into the program ready to launch; the training and ongoing mentoring will provide you with the skills and support you need. We encourage you not to doubt yourself, and apply even if you are unsure.
1. Advocacy for funding R&D into new antimicrobials:
Antimicrobial resistance (AMR) is where harmful microbes develop the ability to resist treatment. Recent reports suggest that there are 47 million disability adjusted life years (DALYs) per annum attributed to antibiotic resistance (a key type of AMR). The current financial incentives to drive new drug development to address this are insufficient. The pipeline is broken; only a handful of novel antibiotics have been developed in the last 30 years. This new charity will advocate for these better market mechanisms, to incentivise the creation and the responsible deployment and use of important new antimicrobial drugs.
There are well-developed proposals for new market mechanisms using a “subscription” model that would solve this issue. Statements have been issued at the G7 expressing support for subscription models, but pressure is needed to ensure that countries follow up on their commitments. This new organization will likely focus on:
- Advocating for the PASTEUR act to pass in the US
- Advocating for other countries (especially G7 countries within the EU) to adopt pull incentives
- Advocating for representation of countries from the global South to ensure that implemented pull incentives have access clauses.This will ensure antimicrobials can be responsibly used, even in LMICs
Quantifying the potential impact of this advocacy work is difficult. However, we have moderate confidence that new antibiotics (if used appropriately) will reduce the burden of AMR globally; overall, we think the potential scale of this intervention is significant.
Based on case studies, expert views, and stakeholder analysis, we think that a well-run advocacy campaign in this space might increase the chance of pull incentives being adopted by approximately 15% and could have a cost-effectiveness of $0.10/DALY (if only charity costs are considered, or $110/DALY if government costs are also included).
In the long run, this organization could scale to designing and advocating for pull funding mechanisms for other key health technologies, such as UVC sterilization or point of care diagnostics.
Challenges
This space is somewhat crowded with several funders, academics and other multilateral organizations in favor of pull incentives across the US and Europe. This new charity will need to be strategic to ensure that it makes a meaningful additional contribution to this space.
Co-founder Fit
As this is a policy issue, co-founders will need to be comfortable with policy work - ie., a focus on building connections and influencing, an acceptance of long feedback loops, and a significant risk of set backs with potential higher payoffs.
This is an intervention that would benefit from some combination of economic expertise, and an understanding of antimicrobial resistance and its nuances. However, we think that the requisite expertise that would be necessary for this intervention is unlikely to be significantly difficult to acquire, and anticipate that talented co-founders could scope this out within their first six months. Experience in modeling could also be very useful. It will be beneficial for one of the founders to understand this R&D space, or have advocacy experience.
Conclusion
The quality of evidence is moderate, the Theory of Change has uncertainty and each step is multiplicative, and feedback loops are relatively long. However, the cost-effectiveness looks good, seed funding is available, experts are very positive, negative externalities (risks) seem low, it’s moderately scalable and relatively neglected (depending on the country).
2. Advocacy for restricting dangerous “dual-use” research
Dual-use research of concern (DURC) is well-intended research which can lead to harm, either by accident or through deliberate misapplication of the technology. An example might be the development of a synthetic pathogen to study its growth, that is then leaked into the population unintentionally. Considering the rate of past pandemic deaths, lab incidents and future forecasts, it appears that DURC could be a key risk factor for the occurrence of a particularly deadly pandemic during the next 50 years, which we estimate to be an expected ~1.5 million deaths per year. However, we note that this is based on small chances of very bad events,and that if measured in terms of likely number of future outbreaks, then natural causes are highly likely to dominate.
Based on our analysis of a dozen case studies of attempts to ensure research safety, ranging from animal testing to human cloning, we believe that this work needs to be done hand in hand with academia. This new charity will work with academics and universities to put in place guidelines and cultural norms to prevent DURC. When more academics are on board, policy change can follow. Specifically, the charity will:
A. Advocate for stricter regulations from within the academic community
B. Improve funders’ ability and willingness to assess risks associated with research
With the right founders, we think this is achievable for a small charity, potentially in regions such as the United Kingdom, Germany, France, Japan, India, or the EU. There is considerable evidence that expert activists can influence academic institutions, and small charities have played a role in limiting research to date.
Challenges
Although tractable, we think this work will be challenging and take considerable time. There are a number of limiting factors such as finding the right founders, gaining access, and tackling entrenched academic interests.
Experts are generally supportive and excited about the idea. They feel it’s a pressing problem; however, they vary in how tractable they think it is. They also flagged various risks such as infohazards, actors just switching to different locations to carry out dangerous research, and the risk of the issue being politicized.
Co-founder Fit
We believe this intervention, more than most, requires a very specific skill set and professional background. Success will depend on whether such a pair of co-founders can be found. Credibility is crucial when it comes to policy interventions in the biosecurity sector, particularly when dealing with academics. The ideal co-founding team will have experience in medical work, policy, consulting, or advocacy. Apart from being good negotiators, the team will have to build, scale and maintain sustainable alliances with key actors in the biosafety and biosecurity space. Doing so will likely require years of relevant experience and a solid track record.
Conclusion
There has been a sharp increase in funding for projects in the biosecurity and biosafety space, including measures for the prevention and the preparedness for pandemics. The evidence is moderate, the proxy feedback loops for implementation will be short, the chances of success are on the lower side but with huge upsides, it’s somewhat scalable (as pivoting to other dangers is plausible), and neglectedness appears high.
3. Enabling antenatal clinics to easily tackle congenital syphilis
Congenital syphilis is estimated to be among the leading causes of perinatal mortality, causing around 150,000 stillbirths and 60,000 neonatal deaths every year.
Detecting and treating syphilis is extremely easy. With modern rapid finger-prick tests, the disease can be detected within 20 minutes, and treatment requires as little as a single injection of penicillin. Antenatal clinics seem to be the ideal touchpoint for both screening and treatment, since the majority of women in LMICs nowadays attend them at least once during their pregnancy.
Despite the scale and the tractability of the problem, syphilis screening and treatment has been highly neglected, with global infection rates having been flat for the past decade.
This new charity will roll out dual HIV/syphilis rapid diagnostic tests (RDTs) and support its treatment with benzathine penicillin G (BPG). While large historical investments in HIV have resulted in widespread use of HIV RDTs, syphilis is often either not screened for or is tested by much more cumbersome laboratory blood tests. By simply replacing HIV RDTs with the dual RDTs – and ensuring that BPG is available at antenatal clinics for immediate treatment – syphilis screening and treatment rates could quickly be brought up to match the rates for HIV.
There is very strong evidence for syphilis screening and treatment. The rapid tests have ~90% sensitivity, and penicillin is extremely effective at treating syphilis. A meta-analysis of 24 studies found that this treatment is associated with:
- A 97% reduction in congenital syphilis
- An 82% reduction in the risk of stillbirth
- A 64% reduction in the risk of preterm birth
- An 80% reduction in the risk of neonatal death
This intervention could be impactful in some 5-20 countries in sub-Saharan Africa and Asia. There is actually a pre-existing interest for the roll-out, but most governments have not had sufficient capacity or technical capability.
Challenges
The charity may need to operate in multiple countries in order to achieve a high impact. However, different countries will likely face different barriers to implementing this intervention, so the solutions will have to be tailored. This may be a challenge to the charity’s growth.
Co-founder Fit
This intervention is simple. Strong generalists should be able to get up to speed with the issue relatively quickly. A healthcare background is preferred, but not a requirement.
Conclusion
This charity looks highly cost-effective, scalable and tractable. GiveWell is keen to fund work in this space, and we estimate it could avert one DALY for $81 and save a life for $1,726.
4. Mass scaling of oral treatment for diarrhea in under fives
Diarrheal diseases are the third leading cause of death in children under five, worldwide. There is exceptionally strong evidence (over decades) that treatment with Oral Rehydration Solution (ORS), a mixture of water, sugar, and salt, is effective in reducing mortality. ORS and zinc treatment for diarrhea is recommended by the WHO, but each year hundreds of thousands fail to get this life-saving and extremely cheap treatment.
We propose that an organization focus on treating diarrhea with ORS and zinc in areas of the world where many children die as a consequence of this illness. By leveraging existing household outreach programmes, this organization would purchase and deliver ORS and zinc co-packs directly to caregivers, for them to have in case of a diarrhea case. Because diarrhea cases can worsen very quickly after starting, having treatment on hand at all times is particularly important. An organization could also work with local producers, health officials, and stakeholders to improve product design, market awareness, availability, and use of ORS.
A meta-analysis of 157 studies estimates ORS prevents 93% of diarrhea deaths at 100% treatment coverage, and observational studies also show drastic results. RCTs on the distribution of ORS show the feasibility of this intervention - delivering ORS to caregivers for free increased ORS treatment by 20% and ORS+zinc treatment by 36%.
Co-founder Fit
We think this intervention is relatively simple to run, and is reminiscent of many GiveWell top charities. Generalists could likely attain the requisite experience within a few months. Expertise could be helpful, but is not necessary. Specific skills such as marketing, health commodity design, and supply chain/logistics would be beneficial, as would in-country experience in healthcare and/or in dealing with relevant stakeholders. But none are hard requirements here.
Challenges
We think that the one potential challenge for this may be getting sufficient funding for large scaleup efforts. Several experts mentioned that large global health funders have moved on to other priorities.
Conclusion
The evidence base is particularly strong. Funding would appear likely; this is a highly scalable and tractable solution that is unfortunately neglected. Feedback loops will be short, making measurement and evaluation relatively straightforward. Relevant experts are supportive of this charity idea, despite key uncertainties, and we estimate that depending on location, cost-effectiveness will range between ~$50 and ~ $200 per DALY.
5. “Kangaroo Care” to avert newborn deaths in low-and middle- income countries.
Almost 1.9 million newborns died in 2019, with the vast majority of these coming from low or middle-income countries. Approximately 80% of these were born underweight (<2.5kgs).
“Kangaroo Care” (KC) is a simple and cheap therapy involving skin-to-skin contact with the caregiver, exclusive breastfeeding, and close monitoring. It is medically proven and could avert close to a third of these deaths - meaning hundreds of thousands saved each year (Bhutta et al., 2014).
Moderate-certainty evidence suggests that KC also contributes to lower morbidity for conditions such as sepsis and hypothermia, and we believe that in the high-burden contexts where a charity could work, the mortality effects of KC may be even higher (Conde-Agudelo & Díaz-Rossello, 2016).
Scaling up KC involves changing provider and caregiver behavior. It frequently encounters issues such as a lack of physical and human resources, and opposition due to entrenched practices. Despite support from the WHO and a large body of evidence, coverage is still low. Still, some countries appear to have successfully scaled KC through government programs, technical assistance, and external support.
A charity could help high-burden countries scale up KC by embedding capacity in the health system, for instance, by setting up KC wards within healthcare facilities and ensuring effective operations (e.g., staffed and run by a nonprofit partner). r.i.c.e, is piloting this model in India. Our research suggests Pakistan, Mali, Benin, Cote d'Ivoire, Lesotho, Central African Republic, Sierra Leone, Guinea-Bissau, and Burkina Faso as potential locations.
Challenges
Although we believe this model is promising, 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. KC faces significant implementation and operational challenges (GiveWell,2021) and, therefore, will require much effort and innovation to succeed at scale.
Co-founder fit
A generalist could be a fit for this charity. “Nice-to-haves” in ideal co-founders for this intervention include a healthcare background (in particular in neonatal care, with KC) and in-country experience with health stakeholders (particularly healthcare providers). Finding talent for the wards is unlikely to be a major bottleneck.
Conclusion
With its strong evidence base, high scalability, and simple intervention, this charity appears both needed, neglected and highly promising. Renewed interest in supporting high-burden, low-resource countries with neonatal and maternal mortality means that funding is unlikely to be a bottleneck, particularly as monitoring and evaluation to demonstrate impact will likely be relatively straightforward. Modeled cost-effectiveness looks good at ~$97 per DALY averted, and estimates of similar interventions suggest a cost-effectiveness of $1,485 - $3,713 per death averted.
6. Fixing stock-outs for contraceptives and other essential medicines
In 2019, about 218 million women of reproductive age were not using any method of modern contraception, despite wanting to avoid pregnancy. This resulted in 111 million unwanted pregnancies. Fulfilling all currently unmet needs for modern contraception would result in 70,000 fewer maternal deaths each year.
This unmet need is partly caused by the discontinuation of use as a result of stock-outs. Stock-outs occur in an average of 25% of clinics in Sub-Saharan Africa, but this percentage can sometimes be over 80, depending on the contraceptive method and country. We also see frequent stock-outs of other important health commodities, from diagnostics and tests, to treatments and medicines.
Making a wide range of contraceptive options available, as well as ensuring continuous and reliable supplies, is an essential part of increasing the use of modern contraceptives. Moreover, better inventory management and distribution through improved logistics management information systems could improve coverage of lifesaving health commodities beyond contraception, using the same pathways, allowing access to lifesaving medicine and health for all.
By changing either the ordering and delivery system, or the information system underlying delivery, health facilities across the country would get a reliable supply of contraceptives and other essential medicines, adjusted to the needs of the community they serve, at lower cost and with lower effort. Shifting the tasks of managing inventory and supply from pharmacists and health workers to dedicated, trained personnel could not only improve logistics outcomes, but also increase the time health workers can dedicate to providing services. Moreover, ensuring the supply of diagnostics, for example, could reduce the transmission of diseases, and then ensuring the supply of medications for the treatment of these diseases would ultimately decrease disease burden and mortality for a large number of people across a wide range of diseases and disabilities.
Challenges
This intervention will mostly consist of working with the government and establishing partnerships with private providers, therefore strong relationship management and ensuring favorable stakeholder relations is key, which may not be easy to find in some contexts.
We also note that it may not be the case that increasing supply alone would actually increase the use of these health commodities - though there is moderate observational evidence and many sound theoretic arguments for this - without additional demand-side interventions. However, ensuring reliable supply of these essential medicines is an integral part of the theory of change to provide access to health for all, and also an essential step in the theory of change for enabling demand-side interventions.
Co-founder fit
While a background in working with governments would be beneficial, we don’t feel it is necessary. Capable generalists will be able to do this work well. Success will likely hinge on the ability to develop good relationships with ministries and other stakeholders, and to push forward consistently in the face of setbacks. Additionally, experience in supply chain management is favorable.
Conclusion
Ensuring the reliable supply of contraceptives and other essential medicines is an integral part of the theory of change to provide access to health for all. It is also an essential step in the theory of change for enabling demand-side interventions for these health commodities. This is an obvious gap for a new charity to fill, which doesn’t seem likely to be solved by market forces or other actors.
Our cause areas for the February- March 2024 Incubation Program
You can now also apply (use the same form) to our Feb-Mar 2024 program that will focus on farmed animals and global health and development mass media interventions. We encourage you to apply early, doing so gives you:
- Access to a resource list that will help you prepare for the application process
- Faster processing
- Opportunity to learn how the application process works and assess your fit for nonprofit entrepreneurship as a career path
- The possibility to reapply in the next round of applications if you don’t make it in this round
Application process
Apply here
- Application deadline: March 12, 2023
- Programs dates: July 1- August 2, 2023 or February- March 2024
- Funding: We expect each project to receive up to $200,000 in initial seed funding through our network
- Costs: All costs covered, including travel and accommodation in London for 2 weeks and an extended post-program stipend if needed
- Training: Online 6 weeks, in-person 2 weeks
Our Application Process
Predictive, quick, and valuable. We select on the basis of potential, not track record alone. We are experienced in spotting those that, with training, will likely succeed in starting a high-impact charity, so the application process itself is the best indicator of potential fit.
The first stage consists of uploading a CV and filling in an application form and some multiple choice questions.
At stage two, candidates will be given a robust framework and methodology to compare and contrast their top career options, and are invited to explore and detail their own priorities and tradeoffs. Candidates repeatedly report how practical and clarifying this exercise is for them.
Stages three, four and five consist of two interviews and a written test task where we explore motivations, rationales, and relevant experience.
Each successive stage is more challenging and time consuming. We only ask participants to invest more in the process if we believe it is well worth their time.
For those who make it far into our process but don’t quite make it into the cohort, we provide resources and recommendations for growth, suggest alternative options and paths to impact, and even make introductions to relevant opportunities in EA.
For those who make it to final interviews, the total time investment will be ~10 hours.
As we expect to accept around 10-20 candidates per program, we encourage early applications and we recommend exploring resources like our book, blog and videos.
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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
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!!
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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).