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Owain Johnstone

Words and Deeds

So it turns out that philosophers who study ethics aren't actually all that ethical - this according to a recent 

 by Eric Schwitzgebel that I’d encourage you to read. Schwitzgebel writes about his research into the ethical activities of those who study how we should live for a living. He finds, broadly, that they don't act as morally as we might expect them to.

You might disagree with his metrics for assessing how ethical a person is (does it really matter how often you call your mother?), but I think he's hit on an important point, and one we can all recognise in ourselves.

Very often, the beliefs we claim to hold about how one ought to live one's life don't square all that well with the lives we're actually living. That's certainly true of me. In principle I agree wholeheartedly with the argument that I should do as much as I can to improve the lives of others – and continue doing so up until the point at which acting in that way begins to harm me more than it helps someone else.

But although I agree with that I definitely don't act accordingly.

Think of what that would entail in practice. I could sacrifice pretty much the entirety of my worldly possessions (including one of my kidneys), condemning myself to a life of poverty. Even at that point there might be more I could do. Because the levels of misery elsewhere in the world are so great, any sacrifice I perform is almost always going to benefit someone else more than it will inconvenience me.

That's an extreme example, but we can all think of less demanding principles that we say we believe but don’t put into practice (at least not consistently). Most of us probably believe that it's ethically important to consider the effects of our actions on others whenever possible – but often we don't.

One possible reason we don't is that we're fallible. We might firmly believe our principles, but other things get in the way – like our own selfishness.

Alternatively, it might be that instead of being fallible we're just lying to ourselves about what our principles really are – maybe, deep down, I don't really believe that I have an obligation to help others.

In either case, we're dealing with motives for action that are in some sense implicit or subconscious. We say one thing, but we do another. So, crucially, what we say isn't enough to explain what we do.

Why does this matter for effective altruism? The basic logic of effective altruism is a watered down version of the argument that I gave above – if you can, at comparatively little cost to yourself, save someone else's life (or significantly improve it), then you should. It's a reasoned argument about your ethical obligations.

The problem with that is that many people will agree wholeheartedly but won't change how they act on a day to day basis. I'm somewhat ashamed to be an example of this, too, but I don't think I'm the only one.

the force of the argument is difficult to contest, but that's not enough to persuade people to behave differently.

Now I am slightly caricaturing the effective altruism movement here. It is not just the propagation of a reasoned argument. Giving What We Can, for example, organises a variety of 

 and events, in part to enhance the felt attractiveness of effective giving – such as showing those still undecided what acting on the 10% 

However, the making of arguments is a large part of what the effective altruist community does, and I think we should consider how we might go beyond that. Because I am unconvinced that simply reaching more people with the same rational argument is going to persuade large numbers to become effective altruists. By large numbers I mean millions rather than thousands.

What we can do over and above explicit argument is to 

appeal to the implicit or subconscious decision making that people employ.

 One of the most fundamental ways of doing that is to 

make effective altruism the default or easier choice – the norm rather than the exception.

A world in which everyone carefully considered each of their choices so as to maximise the beneficial impact they can have would be a wonderful one. But we need to acknowledge that that actually makes things harder. Most people have enough on their plate that making things more difficult for them won’t prompt them to change how they act.

So how do we make effective altruist choices easier? This is what organisations like 

 set out to do – in their case by giving people the necessary information to decide between different charities. But their research, while excellent, is still too voluminous and complex for most people to bother with.

We could do a lot more to make those choices more straightforward.

Here's one small example of how we might make it easier and more rewarding for people to donate to effective charities. There are a couple of big online fundraising platforms that large numbers of people use, one of which is 

 to have channelled $3.3 billion to charity since their foundation in 2001. That's a lot.

But there's nothing (or nothing I could find) on their site about charitable effectiveness. What if GiveWell's research and ratings were incorporated, in a user-friendly manner, into the site? Or how about promoting particularly effective charities as targets for donation?

By making it easier for large numbers of people to make effective altruist choices the gains are potentially enormous.

embedding effective altruist ideas into the landscape of day to day activity is in the long term more important than pushing the rational argument for effective altruism

. The reason being quite simply that most people do not have large amounts of time or energy to devote to complex reasoned debate about these issues, despite intuitively agreeing with the basic position.

Winning the argument is easy – what we need to focus on is changing the way people act.

This and much of the subsequent discussion has obvious links to recent work in behavioural economics to do with the manipulation of choice architectures - popularly known as nudging. I won’t discuss this any further here, but if you’re interested then you should take a look at Richard Thaler and Cass Sunstein’s 2008 book ‘Nudge’.

Henry Phipps

How Long Will it Take Economic Growth to Eliminate Extreme Poverty?

Many charitable interventions in low-income countries have a significant positive impact, but what such interventions can achieve is frequently constrained by under-development. It is often claimed that economic growth is the only means to completely eradicate poverty. Sometimes this claim is meant to criticise the efficacy of giving to charity. In this report I accept that continued economic growth may be the only means to completely eradicate poverty, but I will argue that we should be sceptical that continued economic growth on our current model will lead to the elimination of extreme poverty over acceptable time-horizons. If we wish to eliminate extreme poverty in less than a century, the poorest people in the world will need to benefit from a much greater share of the growth in global income. One way in which we could achieve this shift in the distribution of income is for those of us living in wealthy countries to dedicate a significant portion of our income to charities that benefit those living in low income countries.

The World Bank defines extreme poverty as living on less than $1.25 a day.[1] A recent study by David Woodward published in the World Economics Review claims that if we assuming pre-crisis levels of growth (1993-2008) continue indefinitely it will take 100 years to bring the world’s population out of extreme poverty and 200 years to bring everyone to the modest income of $5 a day at 2005 purchasing power parity.[2] Global GDP would have to reach 15 times its 2010 levels by 2115 and 173 times its 2010 levels by 2222.

Closing the poverty gap by increasing the income of the 63.2% of the world’s population living beneath $5-a-day to above this line would require an increase of $4.5 trillion to their incomes. Achieving this through our current growth pattern would involve increasing global GDP by more than $11,500 trillion and reaching a GDP per capita of $1.3 million. Attempting to eliminate poverty by this means would thus entail increasing production and consumption by more than 2,000 times the income we are seeking to generate, and still taking two centuries to do this. A process Woodward describes as “at best grotesquely inefficient”.

Woodward’s claim isn’t that global income is too low to alleviate poverty but rather that it is too unequally distributed. For example the poorest 30% the world population received just 1.2% of the additional income generated by global GDP growth between 1999 and 2008, the poorest 60% received 5.0% but the richest 40% accrued 95% of additional income.[3]

Consider a more proportional scenario in which the income of the poorest decile rises at the same rate as global GDP per capita, whilst maintaining growth at the 1993-2008 rate. Everyone will be brought above the $1.25-a-day poverty line by 2068 and above the $5-a-day poverty line by 2076, this path would only necessitate increasing GDP by a factor of 3 and then 9. If we go even further and assume a pro-poor bias in global growth changing the ratio of income growth for the poorest decile to that of global GDP per capita to 1.82 (i.e. incomes of the poorest rise faster than World GDP) the results are even more impressive. Extreme poverty is eliminated by 2042, the entire population is brought over the $5-a-day line by 2076 and the scale of GDP growth required to achieve this is reduced by a factor of more than 28 than on our current projection.[4]

The idea that economic growth on the current model will not eradicate extreme poverty over acceptable time horizons is lent support by other recent literature. A recent study that looked at the relation between increases in GDP per capita and childhood undernutrition between 1970 and 1996 across 36 low and middle-income countries found a very small to non-existent association between increases in GDP per capita and undernutrition.[5] Even those that contested the findings of this study argued only that there was a marginal decrease in undernutrition associated with GDP per capita growth.[6] These findings are echoed in a recent study which looked at the link between GDP per capita growth in Indian states and found no consistent evidence for the relationship between growth and undernutrition.[7] One plausible mechanism for this effect is that many of those groups presently at risk of undernutrition receive such a small share of the rewards of economic growth that they are not able to increase the quality and quantity of the food they consume.

Another recent study claims that on current projections it will take until 2111 for sub-Saharan Africa to reach 100% lower-secondary school completion and at least 100 years for the average scores for students in the developing world to begin to match the average scores of students from developed countries in 2015.[8] Another study indicates that at current rates it will take 96 countries beyond 2040 to achieve the 2015 Millennium Development Goals relating to significant reductions in maternal mortality and providing universal access to reproductive healthcare.[9] This study also claims that it will take 23 sub-saharan African countries beyond 2040 to achieve the 2015 Millennium Goal of reducing child mortality by two thirds.[10]

Given how pessimistic Woodward’s conclusions regarding the current model of economic growth are it is worth asking whether there are any reasons to doubt his reasoning.

Woodward excludes China from his projection of current economic growth and poverty alleviation. If China were included the resulting numbers would be more optimistic.[11] China is obviously an outlier but one might hope that other countries could follow China’s enormous rates of growth and poverty reduction. However, there is good reason to suppose China’s economic rise is exceptional. Chinese growth is broadly attributable to economic reforms begun in the 1970s. Huge gains in productivity were gained by moving away from collectivised agriculture, relaxing price controls, and easing restrictions on the migration of farmers to cities. Other aspects of the economy were gradually reformed to introduce more private industry and greater competitive pressure on state owned industries.[12] [13] The model of huge economic growth through gradual liberalisation of a centrally planned command economy is clearly not directly applicable to most countries today.

Additionally, even on the very optimistic projections of global growth (an average of 4% growth in GDP per capita per annum), the time horizons for poverty elimination are still extremely unsatisfactory, with extreme poverty elimination only projected to occur by 2072.[14]

One might think that as economic growth occurs the share of this growth amongst the population will eventually become more equal. The economist Simon Kuznets hypothesised that as an economy develops market forces lead to an increase in inequality, increased investment opportunities cause the rich to become richer whilst influxes of labour into the cities keep down wages amongst the working class. Eventually processes associated with the development of industrialisation and the welfare state lead to an increase in equality. This hypothesis can be captured by an inverted U-shaped curve in which income per capita is plotted on the horizontal x axis and inequality on the Y axis.[15] However whether this hypothesis is borne out in reality is highly controversial. [16] [17] [18]

One might be concerned that the line of $1.25 a day adjusted for purchasing power parity might not be the best way to measure poverty. However other indicators do not give a more cheerful prognosis. The Multiple Poverty Indicator which measures material deprivation through questions about housing, healthcare and diet places almost 1.7 billion people in “acute poverty” as opposed to the 1 billion people who live in “extreme poverty” according to the $1.25-a-day metric of the World Bank.[19] [20] There is no reason to think continued economic growth along current lines is any more likely to impact this measure of poverty than the $1.25 dollar a day metric. In any case the number of people who need to be lifted from this form of poverty is even greater to begin with.

Finally there are reasons to think that Woodward’s projections might actually be too optimistic. One such reason cited by Woodward himself is that the growth in income for the poorest decile between 1993-2008 probably reflects a number of favourable shifts for the poor in this period such as increased debt cancellation and more focus on poverty reduction rather than structural adjustment, the adoption of the Millennium Development Goals and a doubling of per capita aid receipts between 2001-2008.[21] Extrapolating income growth rates from this period implicitly assumes a continuation of this pro-poor shift at a similar rate for the indefinite future. And there is no reason to think this will necessarily be the case.

Another issue is that when we consider the increasing carbon and environmental constraints facing the global community it is plausible that this enormous level of growth may not even be viable. On current projections we will need to increase the size of the global economy by a factor of 173 times it’s 2010 size. Even if we expect future growth to be much less carbon and resource intensive the sheer size of the economic growth required may be beyond what carbon and resource constraints allow. This is not just a question of not wanting to pursue economic growth at such a cost to global warming and the environment, but also a question of whether such growth is even possible. Global warming and resource depletion will have a highly negative impact on standards of living, particularly harming the poorest in the world. These factors might be absolute constraints on what levels of economic growth and poverty alleviation can be achieved. [22]

An assessment of the literature indicates that we should be sceptical that “business as usual” economic growth will lead to eradication of extreme poverty over anything approaching an acceptable time horizon. Environmental and carbon constraints may even make it the case that eradicating extreme poverty will be impossible on our current trajectory. To eradicate poverty over a time-period of decades rather than centuries, the world’s poorest people need to receive a much greater share of global income. It may be necessary to radically change our entire approach to economic development to achieve this, but exactly what radical changes would be required and whether such changes would be tractable is unclear. Certainly one means to attempt to achieve this is to encourage many more people living in wealthy countries to give a significant portion of their income to charities operating in low-income countries.

Incrementum ad Absurdum: Global Growth, Inequality and Poverty Eradication in a Carbon-Constrained World

Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countries

Association between economic growth and early childhood nutrition

Is Economic Growth Associated with Reduction in Child Undernutrition in India?

[](Why Wait 100 Years? Bridging the Gap in Global Education. 

http://www.brookings.edu/research/reports2/2015/06/100-years-gap-global-education-winthrop-mcgivney

Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis

Understanding Chinese Growth: Past, Present and Future

Linking Equity and Growth in Bangladesh pp 1-3

Acute Multidimensional Poverty: A New Index for Developing Countries p.45

Larissa Hesketh-Rowe

7 Tips for More Cost-Effective Giving

Have you taken the Giving What We Can pledge? Maybe you’re trying giving. Or you’ve switched your old donations to more effective ones. Perhaps you’re fundraising for effective charities.

Thanks to Giving What We Can we know donating to a top charity makes a huge difference. What you might be missing to make your giving go even further are just a few tips on the method or timing of your giving.

Here are 7 tips to make your giving that bit more effective.

 on their donations, down from 42% in 2011. 

Gift Aid allows charities to claim an extra 25p for every £1 you give without it costing you anything. In 2012 the collective charitable tax relief schemes were worth £3.85 billion. To allow your charity to claim Gift Aid when you donate you need to declare it by signing a form or ticking a box when you donate. Your donations 

 as long as they’re not more than four times what you have paid in tax in that tax year (6 April to 5 April). Higher rate taxpayers can claim the difference between the rate they pay and basic rate on their donation. Just complete a Self Assessment tax return or ask HMRC to amend your tax code. By 

 on a donation of £100 you could raise an extra £25 for your charity through standard Gift Aid and personally claim back £25 (20%, the difference between the base rate of tax and your higher, 40% tax rate). 



Don’t forget that the tax relief you can claim might depend on which country your charity is registered in. 

, SCI is a registered charity only in the UK. But Deworm the World Initiative is registered as a charity in the US. If you live in the UK you can claim Gift Aid on all the top charities by donating to 

, which will then transfer your donation to your chosen effective charities.

 are made during the holiday season. Understandably many people save their money throughout the year and see what they have left to donate at the end. It may seem more impactful to send over a large sum once a year but you and your charity could likely benefit by you donating monthly. By donating monthly you are getting into the habit of giving. You also allow your charity to plan. Monthly donations tend to be much more predictable than yearly ones, allowing your charity to make better decisions and plan long term projects. They can also 

 on trying to persuade you to donate again as you stop looking like a one-off donor.

Back in 2010 when the crisis broke out in Haiti there was also 

 over the fact that credit card companies were making money off of the donations pouring in. If you’re donating to your charity using a credit card or payment service they may well be taking a percentage of your donation. With the most effective charities even 2% or 3% can add up to a lot of missed opportunities for treatment or prevention. Nerd Wallet gives some 

 into the different fees different payment methods incur. Often a simple standing order, whilst involving slightly more paperwork, is well worth all of your money going to your chosen charity.

Similar to donating to directly to a charity, if you’re fundraising it pays to shop around when setting up your fundraising page. Different fundraising sites such as Justgiving or Virgin Money Giving have different amounts that they charge charities for the service and different percentages they take from each donation. Bear in mind your charity will need to be registered for the service for you to use it and it may not be cost effective for them to join lots of different services. That said, support for newer services with little or no fees such as 

 will only encourage charities to use them. One easy answer on which fundraising site to use is to ask your charity where they are registered and discuss the fees. Money Saving Expert also has a 

 of the costs associated with the most popular fundraising sites.

 how you can raise money for charities by free by installing the 

 bars on your computer. Now, in conjunction with Give As You Live Sainsbury’s have released an Everyday Shopper card. Top it up with the money you plan to spend in store and Sainsbury’s 

 of that amount to a chosen charity –including the Schistosomiasis Control Initiative.

Some companies have charitable giving schemes where you can 

. Because the donation is given before tax the charity automatically gets more, regardless of what level of tax you pay. Speak to your HR department where possible and see if this is something your company offers.

...get a cash back card instead. Whilst the name may be enticing and raising money for charity whilst you spend sounds like a great idea, you can do 

. If your charity credit card gives you 25p every time you spend £100 but your cashback card gives you £5 and you can just donate it, which is the better deal? 

And there you have it. These small actions don’t have any where near the impact that switching to a more 

 do but if you’re already donating to the top charities why not get as much money for them as possible?

When you think that deworming tablets cost as little as 50p every little really does help.

Do you have any tips for raising more money for the best charities you can share? Just post them in the comments box and help others do that little bit more good.

Strengthening Health Systems in Low-income Countries: Is Giving What We Can Missing a Better Strategy For Saving Lives?

A large amount of recent literature on global health makes the suggestion that a major barrier to improved health outcomes in low income countries is the general weakness of their healthcare systems.[1] [2] Some literature suggests that some targeted programs to control certain diseases may even be acting to weaken health care systems in low-income countries through creating superfluous parallel delivery systems and disrupting the day to day activities of the health system. [3] [4]

These observations parallel concerns sometimes expressed to Giving What We Can that the organisation’s recommendation of charities that target specific diseases such as the Against Malaria Foundation and Schistosomiasis Control Initiative shows a lack of attention to the need to strengthen healthcare systems in the developing world.

In this report I will assess the current literature on this subject and relate it to our recommended charities.

The concern with strengthening health systems in low income countries can be seen in a debate in the aid literature over the comparative benefits of “vertical” and “horizontal” interventions. A stereotypical horizontal programme would seek to tackle overall health problems on a wide front and on a long-term basis through the creation of a system of permanent institutions. This is one thing people have in mind when they talk about the need to “strengthen health systems”. By contrast a stereotypical vertical intervention would be a free-standing program focussing on a single goal which it achieves through specific interventions. Smallpox and malaria eradication programmes are examples of vertical interventions. AMF and SCI would best be classified as vertical programmes.

There has been debate about the relative merits of both forms of intervention with some enthusing about the ability of vertical interventions to create large and immediate improvements in health and take pressure off general health services with others claiming that much of the good done by vertical health interventions is outweighed by disruption of general health services and inefficiencies caused through the lack of integration between different health services. 1-4, [5]

The first thing to note is that the debate over the relative effectiveness of vertical and horizontal programmes takes place at such a high degree of generality that it is difficult to come to any strong conclusions. Another issue is that existing healthcare systems tend to involve a mixture of both horizontal and vertical programmes making it difficult to make assessments of relative effectiveness. In light of these issues a recent report by the WHO states that:

“The available evidence on the relative benefits of vertical versus integrated delivery of health services is limited and too weak to allow for clear conclusions about when vertical approaches are desirable”[6]

The same problems seem to be faced even by more limited studies. A recent literature review of programmes targeting Neglected Tropical Diseases argues that the lack of studies on the impact of targeted NTD interventions on health systems means that:

“Further research is therefore timely and needed to go beyond opinion-based discussions on effects of NTD campaigns on health systems and health care delivery”.[7]

It is worth bearing in mind the lack of a good evidential basis when discussing concerns around strengthening general health-care systems.

Despite these concerns the WHO report suggests that there are circumstances in which it is plausible to think that vertical programmes are more effective than horizontal ones. One of these circumstances is programmes operating in countries which have very poor health infrastructure. This is the case for a variety of reasons, in some countries health infrastructure may be so poor as to make vertical interventions the only feasible option for providing high levels of coverage. Additionally the ability of vertical interventions to achieve results more quickly means that they are a better route to immediate improvements in public health that have positive follow on effects. Due to these considerations we might think that worries about the relative effectiveness of vertical interventions are just misplaced when applied to AMF and SCI given that they operate exclusively in some of the poorest countries in the world.

How Vertical Interventions Can Undermine General Health Systems

We might still be concerned about the potential of vertical programmes to undermine general health systems, if this is true of a specific programme then we should revise our estimates of it’s effectiveness. The way in which some vertical programmes are thought to weaken general health systems is through the creation of “parallel subsystems” for the delivery of healthcare. These create problems such as

Duplications: running parallel systems for delivering drugs to health facilities will increase transport costs, and increase the number of forms that health workers need to complete to secure their drug supply

Distortions: creating a separate cadre of better paid health workers for the specific tasks of a programme may deplete staff from other key functions and/or demotivate staff who do not benefit from higher pay or better conditions.

Disruptions: programmes often train health workers by taking them away from their jobs for several days or weeks, leaving their posts vacant. This training tends to be uncoordinated across programmes, and may result in the same worker receiving several training courses in a year, with a substantial loss of services being delivered.

Distractions: similarly, the specific and uncoordinated reporting requirements of donors can lead to several forms being filled by a sole health worker for the same problem, distracting them from more productive uses of their time.”[8]

We can look at the work of our recommended charities AMF and SCI in detail to assess to what extent we think that they risk creating these problems.

We can be confident that duplication of service provision is minimised in the case of AMF. In deciding where to distribute nets AMF looks at the Alliance for Malaria Prevention’s list of countries with significant net gaps and discusses where to distribute nets with other malaria-control funders, the relevant National Malaria Control Program and the African Leaders Malaria Alliance. When investigating a country AMF works with partners already present on the ground and requires these partners to carry out pre-distribution surveys to ensure that they are not distributing nets to areas that already have them.[9]

What is more difficult to establish is to what extent the work of AMF might cause distortion, distraction or disruption to provision of other services. Nets are distributed by low level government health workers and staff at the NGOs AMF are working with. In Malawi for instance government workers called Health Surveillance Assistants were used to distribute nets. HSAs are the first line of response to public health issues. They disseminate health related information conduct basic nutrition support, report levels of stunting, wasting and common communicable diseases to clinicians and carry out immunization programs. Distribution of nets would appear to fit well with their other duties although more information is needed to know whether the distribution of bed nets hampers or complements their other responsibilities. It might be that distributing malaria nets means that HSAs do not have time to do other work but it might also be the case that by going into communities and giving out nets increases their standing within the community and provides information to them which facilitates their other work. Regardless the fact that net distribution only takes a couple of days seems to indicate that any negative impact is minimal.[10]

As with AMF duplication of services does not seem to be a problem with SCI. SCI works with governments to roll out treatment programs through financing these programs and providing technical expertise and support if necessary. For the most part they operate in countries that had no treatment program before SCI began working there.[11]

It appears that the capacity for distortion, disruption and distraction through SCI initiatives is limited. Distribution of treatments only takes a couple of days each year. Additionally the distributors of treatment are not trained health professionals but rather teachers and community drug distributors who receive a day’s training in measuring correct dosages. It therefore seems reasonable to suppose that SCI is not causing disruption through using the time of professional health workers in a suboptimal manner.[12]

How AMF and SCI Strengthen Health Systems

There are two clear means by which AMF and SCI strengthen health-care systems. The first is that covering some of the cost of malaria control programmes and deworming makes these programmes less expensive for governments to administer leaving more money and resources to be spent elsewhere. The second is that they reduce the burden of diseases which would otherwise be placed on other parts of the health system.Malaria is a huge burden on global health with 3.3 billion people at risk of being infected with malaria and developing the disease and a further 1.2 billion at high risk.[13] Distribution of insecticide treated bednets as carried out by AMF is a highly cost-effective way to combat the disease. AMF supports the work of vertical National Control Programmes for Malaria which have positive effects on other areas of the health system. For example the 2011 WHO World Malaria report states:

“In Rwanda it has been estimated that while it would cost US$ 265 million to sustain the malaria control programme over the next five years, the public health system could avert about US$ 267 million in the costs of diagnosing and treating malaria; and households could avert about US$ 547 million in direct and indirect costs, equivalent to about 7% of household income.”[14]

A recent study looking exclusively at the use of insecticide treated bed-nets concludes that:

“The use of mosquito treated nets can induce a 6.2 percent reduction in outpatient costs, a 6.6 percent reduction in inpatient treatment costs, a 6.3 percent reduction in productivity losses, and a 22.6 percent reduction in disability adjusted life years (DALY), all on an annual basis.”[15]

SCI’s deworming initiatives target a number of parasites including soil transmitted helminths and schistosomiasis. 3 billion people in the world’s poorest countries are infected by STHs and 261 million by Schistosomiasis.[16] [17] As well as more severe symptoms these diseases cause anemia, malabsorption of nutrients and stunting of growth and development which are general causes of ill-health.[18] [19]Deworming programmes are a highly cost-effective means to combat these problems and it is reasonable to assume that the general improvements in health caused by such programmes must take pressure off other components of the health systems.

Are There Better Ways to Strengthen General Health Systems?

It’s important to comparatively assess other options for foreign donors to strengthen general health systems other than supporting charities that are minimally disruptive and massively reduce the burden of disease. One option might be supporting charities that engage in horizontal interventions, Living Goods for instance runs networks of Community Health Promoters who provide health advice and sell basic healthcare goods. However there is no reason to think that NGOs engaging in horizontal interventions are any less likely to face the problem of “parallel subsystems” than vertical programs. We might think that simply giving money directly to the Ministries of Health in low income countries would strengthen health systems. But presently Ministries of Health are often choosing to engage in deworming and malaria control programs themselves, indicating that they see spending in these areas as the most effective use of available resources.[20] [21] [22]Furthermore recent evidence suggests that whilst health assistance for development directed to NGOs increases government spending on health-care, giving money directly to governments displaces money that would have otherwise been spent on health-care.[23] We might consider spending money on organisations that advocate for strengthening health systems, but we are not aware of any organisations that advocate for this. Further, it is worth noting that all of these efforts to directly strengthen health-care systems may end up being less effective than indirectly strengthening health-care systems by reducing the burden of disease through successful vertical interventions.

Finally we should note that strengthening health-care systems is just one component that should factor in our assessment of charities. Just because one intervention strengthens the general health-care system more than another does not mean that it is necessarily more cost-effective. It may be that at this time the benefits of combating specific diseases outweigh the benefit of any attempt to directly increase the general standard of healthcare.

Ultimately there is a lack of good evidence regarding the cost-effectiveness of taking steps to directly improve the general health-care systems of a country through horizontal rather than vertical programmes. Nevertheless the threat of undermining general health-care systems through the creation of parallel subsystems is something that we ought to account for when estimating the cost-effectiveness of our charitable giving. In the case of Giving What We Can’s top charities we can see that concerns about disrupting health-care systems may simply be misplaced to begin with given that they operate in countries which have extremely weak health-care systems. Furthermore when we examine the model for how parallel subsystems are supposed to emerge and weaken general health-care systems and compare this to the work of AMF and SCI we see that there is little reason to think that they conform to this model. Additionally it is clear that AMF and SCI must strengthen general health-care systems insofar as they reduce the burden of disease that would otherwise be met by the rest of the health-system. Indeed it might be the case that the best way for foreign donors to strengthen health-care systems is to support the work of these charities, particularly given the apparent lack of other options at this time.

Overcoming health-systems constraints to achieve the Millennium Development Goals

Neglected tropical disease (NTD) control in health systems: The interface between programmes and general health services.

Meningococcal vaccine introduction in Mali through mass campaigns and its impact on the health system

How can measles eradication strengthen health-care systems?

When do vertical (stand-alone) programmes have a place in health systems?

Analysis of the Cost of Malaria in Children and Use of Insecticide‐treated Bednets in Africa

Giving What We Can: Neglected Tropical Diseases

480bn spent annually on malaria treatment

Public financing of health in developing countries: a cross-national systematic analysis

Giving What We Can

Is deworming really effective? A response to recent deworming studies

Are mass deworming programs valuable? Giving What We Can’s position on the recent Cochrane Review.

Updated 26/07/2015: We made some changes to this blog post based on feedback

an excellent and detailed analysis of on the new deworming

 and concluded “Our current view is that these new papers do not change our overall assessment of the evidence on deworming, and we continue to recommend the Schistosomiasis Control Initiative and the Deworm the World Initiative”.

A recent Cochrane review paper by Taylor-Robinson and colleagues 

 has called into question the effectiveness of mass deworming programmes. Specifically, it suggests that there is not good evidence that mass deworming contributes significantly to overall childhood health and nutrition, educational attainment, or school attendance.

This has implications for Giving What We Can, because two of our charities focus on delivering mass deworming programmes. We wanted to update our members on the current state of play.

Health benefits of treating populations with schistosomiasis are not questioned by the review

An important takeaway from this is that the conclusions of the review specifically focuses on soil-transmitted helminths (STH) — these include whipworm (Trichuris), roundworm (Ascaris), and hookworm. The conclusions of the review on health outcomes do not relate to schistosomiasis.

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