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NickLaing

Country Director @ OneDay Health
7581 karmaJoined Working (6-15 years)Gulu, Ugandaonedayhealth.org

Bio

Participation
1

I'm a doctor working towards the dream that every human will have access to high quality healthcare.  I'm a medic and director of OneDay Health, which has launched 35 simple but comprehensive nurse-led health centers in remote rural Ugandan Villages. A huge thanks to the EA Cambridge student community  in 2018 for helping me realise that I could do more good by focusing on providing healthcare in remote places.

How I can help others

Understanding the NGO industrial complex, and how aid really works (or doesn't) in Northern Uganda 
Global health knowledge
 

Comments
1008

I love your framing of this cost and agree with your central thesis, that cash transfers to families with sickle cell might be more cost effective than general cash transfers, while not necessarily being the most cost-effective option. It may well be the most cost-effective of the projects you reviewed as well, so kudos for getting in behind this.

My criticism is more that if the NGO has a great database and connection with families with sickle cell, why not use that infrastructure and the money to help the kids medically in ways more effective than a cash transfer? Buying mosquito nets, deworming and I would argue giving proper medical treatment for sickle cell are more cost-effective than cash transfers.

In this case I would boldly predict you could do more good by actually providing the best medical care you could with that money rather than giving it to the family. Also in sickle cell where medical catastrophes are basically guaranteed, cash transfers might well get used up BEFORE catastrophes happen which would be tragic.

I'm assuming this stuff below is not readily publicly available in Cameroon - some of it might well be then you didn't 

If I had 47 dollars a month to help kids with sickle cell I would set up accounts with local health facilities to provide these services for each kid.

1) Pay for the basic monthly meds for sickle cell (pen-V, folate, malaria prevention, pain relief) ($8 a month)
2) Most of these kids would benefit from hydroxyurea ($10 a month)
3) Send a motorbike to pick the kid to take to hte health center AS SOON as they get sick - fast access to healthcare is critical in sickle cell ($5 per month) 
4) Administrating the project ($15 a month assuming something like one/two people administrating 20 families) 
5) A pool of money which pays for catatrophic hospital admissions when needed ($9)
 
I might be missing something or overstepping with this suggestion but that's my hottish take ;) For background I'm a doctor here in Uganda with a decent amount of experience with Sickle cell.

I love the idea of alumni (and maybe even alumni groups) taking on responsibility for funding uni groups. This could be an inspiring and super sustainable way to keep then funded indefinitely and free up funding elsewhere. Imagine the inspiration when the two people who funded your group come to speak about the cool stuff they have thought/done/given since they left uni

I think the inspiration / comradery / multiplier effects here could hugely boost the cost effectiveness of alumni donations

Yep I agree with the Tech example, except even as you scale there you're likely going to need to continue to invest in government partnerships etc. After the initial investment there might be a real spike in cost effectiveness, which might then level out as growth continues. 

I would consider the Goverment advocacy and to some extent technical assistance project more of a "hits based approach" (which is great) more than thinking about the framing of long term cost-effectiveness

I like these examples. Maybe someone could do a series of Graphs to illustrate how cost-effectiveness over time could work with different types of orgs? This could help donors and investors understand how their investment functions at different stages of org growth.

The value of re-directing non-EA funding to EA orgs might still be under-appreciated. While we obsess over (rightly so) where EA funding should be going, shifting money from one EA cause to another "better" ne might often only make an incremental difference, while moving money from a non-EA pool to fund cost-effective interventions might make an order of magnitude difference.

There's nothing new to see here. High impact foundations are being cultivated to shift donor funding to effective causes, the “Center for effective aid policy”  was set up (then shut down) to shift governement money to more effective causes, and many great EAs work in public service jobs partly to redirect money. The Lead exposure action fund spearheaded by OpenPhil is hopefully re-directing millions to a fantastic cause as we speak.

I would love to see an analysis (might have missed it) which estimates the “cost-effectiveness” of redirecting a dollar into a 10x or 100x more cost-effective intervention, How much money/time would it be worth spending to redirect money this way? Also I'd like to get my head around how much might the working "cost-effectiveness" of an org improve if its budget shifted from 10% non-EA funding to 90% non- EA funding.

There are obviously costs to roping in non-EA funding. From my own experience it often takes huge time and energy. One thing I’ve appreciated about my 2 attempts applying for EA adjacent funding is just how straightforward It has been – probably an order of magnitude less work than other applications. 

Here’s a few practical ideas to how we could further redirect funds

  1. EA orgs could put more effort into helping each other access non-EA money. This is already happening through the AIM cluster, but I feel the scope could be widened to other orgs, and co-ordination could be improved a lot without too much effort. I’m sure pools of money are getting missed all the time. For example I sure hope we're doing whatever we can through our networks to help EA gender based violence orgs / family planning orgs to get hold of some of this 250 million dollars from Melinda.
  2. When assessing cost-effectiveness of new interventions and charities (especially global health), I think potential to access non-EA future funding could be taken into account. If a new charity has a relatively smooth path to millions of dollars of external funding, should our cost-effectiveness bar be lower? Again this might well be happening already.
  3. We might have a blind spot missing cause areas where cost-effectiveness might initially look sub-optimal, but huge available non-EA money-pools might shift the calculus. One example is climate mitigation, where Billions of dollars slosh around, wasted on ineffective interventions. Many “mitigation activities” I see here in northern Uganda might as well be burning money (in a carbon neutral way of course). GiveDirectly have made a great play here re-directing millions of climate mitigations funds to cash transfers. Could other “climate mitigation orgs” be set up to utilise this money better even if the end point of the money wasn't strictly climate related?

I would imagine far smarter people have thought about this far more deeply, but there might still be room for more exploration and awareness here.

That's a good shout thanks Ian. From having a brief look, I would say they're decent examples of orgs that have maintained their cost-effectiveness fairly well but I really doubt they've become much more cost-effective over time. They've done this through continuing to do 1 thing and 1 thing well which I love. In AMF's case the cost have nets have come down which helps their cost effectiveness, but that's not much to do with specialisation or economies of scale within their org specifically..

I think that's a factor like Joey says between the early and mid stage mark. But after that it's more the beuracracy, bloat and mission drift which honestly are hard to avoid.

We had a budget of around 100k at more than 20 employees, depends on the country the employees are in!

This is a fantastic post and I (unusually) think I agree with basically all of it.

Although I agree with this in principle...

"principles of specialisation and economies of scale from the for-profit world suggest we might expect growth in outputs to outpace increases in budget size."

I can't think of many non profit organizations that I'm convinced become more cost effective as they grow, especially when compared with the first 100k-300k they spend. It's often very hard in the non profit world to take advantage of efficiencies. Also there's a problem I think as funding increases orgs kind of find ways to spend it to justify those donations.

Often bigger scope means more middle management, higher salaries at the top and less efficiency, while also as organisations grow with mission creep and widening of scope can also often introduce interventions which might be less cost-effective than what they did originally.

Many non profits as they grow claim second order effects to justify these extra costs, like influencing government or building up other organizations doing similar things. The community health worker organizations are classic for this.

Yes I would probably agree with all that. I think the endorsement is stronger from an EA donor and that's great, but the end value of the money itself seems more likely to be far stronger from a non aligned donor.

I agree. One minor issue with your "low bar" is the giving 10 percent. Giving this much is extremely uncommon to any cause, so for me might be more of a "medium bar" ;)

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