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Henry Phipps

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.

Schistosomiasis is associated with more severe ill-health than STH 

 . Consequently, the disease burden is higher, and treating it might be more cost-effective than treating STH 

 . Even the Cochrane review agrees that there is benefit of treating populations with schistosomiasis:

“The evidence for the benefit of treating populations with schistosomiasis is fairly clear, as the infection has a very substantive effect on health. (Danso-Appiah 2008 as cited in the Cochrane Review by Taylor-Robinson et al. 2015 1)” 

To this end, this review does not substantially affect 

our overall conclusion on the health benefits of population deworming for schistosomiasis as done by the Schistosomiasis Control Initiative

, even though SCI also treats both Schistosomiasis and STH (‘combination deworming’).

our recommendation of the Deworm the World Initiative

, but at this stage we have not significantly changed our position on them.

 took into account an earlier version of this Cochrane Review, which reached similar conclusions about the small effects observed on overall health and educational outcomes. However we chose to continue to recommend Deworm the World, for a number of reasons.

Firstly, a paper that suggested more positive outcomes from treating STH infections was not considered by the Cochrane Review based on their predefined exclusion criteria (even though the paper makes a good case for showing a causal relationship, it was excluded, because it was ‘Not a comparison of deworming with placebo or no treatment.’). 

We considered this paper in our recent report

, and a subsequent analysis of its data by GiveWell:

Another recent paper looked at deworming spillovers during early childhood and suggests that there are improvements in cognitive performance equivalent to between 0.5 and 0.8 years of schooling. However, this paper looked at combination deworming. Givewell conducted a reanalysis of this data looking at the effects of STH by excluding all the schools that received praziquantel against schistosomiasis. They find that not all but many of the results still hold, which means that DtWI’s case of only deworming for STHs in India is still strong with regards to improvement of school performance.

Secondly, even if the health effects of deworming are small, the low cost of the intervention means that it may extremely cost-effective. Not only is mass drug administration cheap to deliver, DtWI provides technical assistance to the Indian government rather than distributing drugs themselves, which enables them to cause more children to be dewormed for a certain donation. Given the low cost of treatment, it is plausible that DtWI is still extremely cost-effective.

Thirdly, while the Cochrane Review does not support mass deworming programs (such as those that DtWI is helping to coordinate in India), it also makes the point that “children with worms should be dewormed”. However, as it is time-consuming and expensive to individually screen children for worms, and the deworming medications do not have harmful side-effects, the most cost-effective ways to treat infected individuals is through mass drug administration. As we noted in 

In the light of this cost-benefit analysis for screening versus mass treatment, the case for mass deworming is still strong, but one might suggest that it is better to focus more on more heavily infected populations and improve trials. Because DtWI provides technical assistance and evaluation of whether an area should be dewormed based among other whether the local worm burden is sufficiently high, they have probably improved the effectiveness of mass deworming programmes in the more recent past.

If it is the case that we should deworm children, then it follows that we should do so using the most effective process — namely, mass drug administration. A recent paper suggests that treating all children at risk for worm infection would cost approximately 300 million dollars a year, but the cost of treating them via screened programs might be 2 billion dollars or more per year 

Deworm the World has a number of programs. Its program in Kenya and Ethiopia treats both STH infections and schistosomiasis and they have plans to move to other African countries where schistosomiasis is present. Given the higher disease burden of schistosomiasis, this particular program is likely to be preventing a significant amount of ill-health irrespective of the value of concurrently treating STH infections.

It’s important to note that one of the Cochrane Review contributors caveats the conclusions of the Review by saying that they should be taken in the context of a world that is different to that of 20 years ago — specifically, with a lower overall worm burden:

“So deworming may have helped in these exceptional, heavily infected, untreated populations from another decade, but this is scarcely a solid base for contemporary policy: public health nutrition has changed, worm burden has declined and this probably accounts for the lack of effect on biomedical outcomes in contemporary studies. 

This suggests that there is still value in treating STH infections in areas of high worm burden. Recent studies in Bihar state in India indicate that worm burdens are still very high 

 and therefore that mass deworming of children — at least in this particular case — might be justified.

Finally, DtWI is using their donations to conduct research into deworming and its effectiveness — something that in the light of the recent papers seems to be very much needed.

One of the most controversial components of the Cochrane Review are two papers that revisit a well-publicised study that links deworming to improved school attendance.

 have sensationalised some of the findings of the recent papers. We think this unfairly represents their implications. What’s actually going on?

recent re-analysis of the original Miguel and Kremer study

 has recently been published by researchers working at the London School of Hygiene and Tropical Medicine (Davey et. al.). This re-analysis was made possible because Miguel and Kremer released their original data, along with the statistical modelling software that they used to produce their results. This is admirable — very few authors provide this level of transparency and ability for proper peer review, and Giving What We Can commends them for it.

There were two components to the re-analysis. 

The first set out to simply replicate the original study’s results.

 The authors corrected some minor errors in the data (rounding errors etc.) and an error in the original computer code. The replication study reproduced the majority of the results of the original, but called into question the improvements in school attendance.

 set out to compare the results obtained from the original methodology (drawing on conventions in development economics) with those obtained from an epidemiological methodology. As the authors of the re-analysis state:

Our interest in replicating M&K came not from an interest in school-based deworming but in evaluation methodology ... We replicated M&K to learn more about the techniques used in economist-led trials, by re-analysing and presenting this famous trial in a format familiar to epidemiologists.

The re-analysis found that the evidence for improved attendance at schools where treatment was given was weaker than the original claimed, and the authors highlighted concerns that, because of limitations in the data, that the results could be susceptible to bias.

The conclusion drawn from the re-analysis of the data and the updated Cochrane Review are controversial. 

 that their main conclusions regarding school participation gains are robust 

 , and that the results fit in with other studies on deworming that suggest positive impact on labour productivity and education 

 also finds the re-analysis unconvincing and concludes that the results from the original study hold 

 . Givewell has also recently responded to these papers and argues that the evidence still seems to suggest that deworming increases labour productivity. Givewell estimates that:

“Deworming generates a net present value of $55.26, against an average cost of $1.07, i.e. that deworming is ~50 times more effective than cash transfers” 

Obviously the re-analysis suggests that deworming may provide less of an overall benefit in the form of improved educational outcomes, but at this stage, the robustness of these results with regard to school attendance is unclear. Both sets of authors have made decisions regarding methodology that reflects their particular academic discipline (i.e. development economics vs. epidemiology).

However, from Giving What We Can’s perspective, these results are only a small fraction of the whole picture. 

 is not substantially based on the school attendance results of the Miguel and Kremer paper, and so we do not feel that the re-analysis — even if it does prove to be the correct interpretation of the data — significantly updates our position.

Part of Giving What We Can's purpose is to use the best available evidence to inform our charity recommendations. We will be taking some time to incorporate these findings into our recommendation of Deworm the World, and attempt to get in touch with relevant parties to clarify a number of our concerns. However, it’s important to note that the evidence that we based our 

 on has not changed significantly since we made it. At this stage we will continue to list the Deworm the World Initiative as one of our ‘Promising Charities’, while investigating the implications of this Review further.

http://www.cochrane.org/CD000371/INFECTN_deworming-school-children-developing-countries

Reanalysis of Miguel and Kremer deworming study by Davey et al

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv127.full

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv128.full

Miguel and Kremer's response to Davey et al 

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv129.full

Davey et al's counter-response to Miguel and Kremer's response 

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv130.full

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv131.full

http://www.evidenceaction.org/blog-full/worms-win-kids-lose-our-statement

http://blog.givewell.org/2015/07/24/new-deworming-reanalyses-and-cochrane-review/

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000371.pub6/abstract

 Colley, DG. "Human schistosomiasis - The Lancet." 2014. < 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61949-2/abstract

 "PLOS Neglected Tropical Diseases: The Global Burden of ..." 2015. 25 Jul. 2015 < 

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002865

 Kjetland, Eyrun F, Peter DC Leutscher, and Patricia D Ndhlovu. "A review of female genital schistosomiasis." Trends in parasitology 28.2 (2012): 58-65.

 "Cost-Effectiveness in $/DALY for Deworming ... - GiveWell." 2011. 26 Jul. 2015 < 

http://www.givewell.org/international/technical/programs/deworming/cost-effectiveness

 Note that the cited paper does not say much about the health benefits of deworming for schistosomiasis, and is more to illustrate that even the authors of the Cochrane review agree that Schistosomiasis population deworming is indicated

 Ahuja, A. "When Should Governments Subsidize Health? The Case of ..." 2015. < 

 Greenland, K. "The Epidemiology of Soil-Transmitted Helminths in Bihar ..." 2015. < 

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003790

 "Re-analysis of health and educational impacts of a school ..." 2015. 23 Jul. 2015 < 

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv127.abstract

 "Full Text - International Journal of Epidemiology - Oxford ..." 2015. 23 Jul. 2015 < 

 "Worm Wars: A Review of the Reanalysis of Miguel and ..." 2015. 23 Jul. 2015 < 

http://blogs.worldbank.org/impactevaluations/worm-wars-review-reanalysis-miguel-and-kremer-s-deworming-study

 "New deworming reanalyses and Cochrane review | The ..." 2015. 26 Jul. 2015 < 

Daniel Selwyn

How your student loan can save lives

What do you want to be when you’re older?

It’s probably one of the first questions we can remember our response to. Back then our vivid imaginations could transport us from being astronauts on spaceships to princesses in beautiful dresses with an entourage of seven dwarves (only one of those was an actual childhood dream of mine).

The unbounded nature of childhood dreams is surely universal, innate to every child.

It should thus both deeply sadden and anger us that so many children across the world die before they even reach the age of five. Nine million a year, one every four seconds.

 at the hands of preventable diseases that rob families, communities and continents of the prosperity and livelihood that it is so easy to take for granted.

The fact that where you are born determines to such a cruel extent the scope of your response to that age-old question about the future is strikingly unjust. The globe is polarized between those who are allowed to dream and those who can only live in nightmares.

The perennial nature of extreme poverty is precisely the reason why it so often escapes the headlines. It also contributes to a perception that the reasons for its persistence are inevitably structural and insurmountable, beyond the comprehension or capacities of ordinary people.

effective altruism, especially for a student armed with nothing more than a government loan and a desire to do something purposeful, is both shocking and inspiring.

Rigorous research and extensive evidence can demonstrate just how conceivable the eradication of poverty really is - when our charitable giving is used in the right way.

For the price of a pint we could deworm fifty children, keeping them healthy enough to attend school and exercise their right to an education of their own. Mosquito nets could protect the beds of almost thirty people for around three to four years for the same amount as a weekly shop. (If you would like to check, use this 

This does not mean that you have to either starve yourself or be a recluse at university in order to truly help others. Such a degree of self-sacrifice is neither necessary nor desirable.

But it does raise a fundamental question: 

if students were aware of just how far even a small amount of money can go - making a tangible difference to such a significant number of people’s lives -, would we continue to spend it on ourselves?

Judging by the success with which the effective altruism movement has been embraced at university campuses across the globe, the answer to that question from the student body appears at best to be a resounding no, at worst, a ‘probably not as often’.

If an entire generation of millennials changed their spending patterns for a lifetime to include the most effective charities we would see astonishing results.

But such bold claims are all well and good coming from a privileged group of society, of whom many don’t even know what it’s like not having a three-month summer holiday, let alone working a full-time job.

What’s to stop a student with high-minded ideals reneging on them once they have to pay their taxes, bills and rent and find that they have very little left over?

Blog

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

Is deworming really effective? A response to recent deworming studies

How your student loan can save lives

What I learnt from talking to over 100 Giving What We Can members

Tell All Your Friends!

Want to be a good altruist? Check your biases.

The Economics of Morality

Our ultimate fundraising idea list: What kind of fundraiser are you?

Giving Is Receiving

When is systemic change a good idea?