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Jessica Costello

Evidence Action - August Update

This post is part of a monthly series of updates on Evidence Action. The one about progress in July can be found 

. You can find this and more information in their 

Last month, Evidence Action’s Deworm the World Initiative and the Government of Kenya announced the results of the second Kenya National School-Based Deworming Programme. This was the largest deworming exercise ever conducted in the country, targeting soil-transmitted helminthes (STH, common worms) and schistosomes (which cause bilharzia).

The programme was highly successful, and national targets were surpassed!

Notably, more than 6.4 million children were successfully dewormed, exceeding the target of 5.7 million children by 12%. After two successful rounds of treatment, the prevalence of STH dropped from 33% in 2012 to 6% in 2014 in 20 observed sub-counties.

More than 890,000 children were also treated for schistosomiasis, exceeding the national target of 600,000 children by 33%.

Deworming took place in nearly 16,000 schools in 28 counties that are endemic for parasitic worms, again exceeding the target of 11,000 schools. Further to this, 143 Sub-Counties successfully implemented deworming, out of 144 Sub-Counties planned for; 28,248 teachers were trained to administer deworming tablets to children, and 3,534 Sub-County and Ward personnel from the Health and Education ministries were trained in successfully implementing deworming.

This is great news, because school-based deworming is proven to be an effective intervention with tangible health, education, labour productivity and earnings benefits, and is one of the most cost-effective methods of increasing overall school attendance and participation.

The success of Evidence Action’s Deworm the World Initiative in achieving its goals was recognized by Ezra Klein from Vox Media, who donated to Deworm the World as part of the 

EvidenceAction thanked him for his support by 

Overall, it's well worth celebrating the success of Evidence Action’s Deworm the World Initiative across Kenya, which surpassed its initial goals. It is also good to see the enthusiastic public support it has garnered!

Peter Hurford

Where is the money in development spending?

Relatively wealthier countries certainly spend a lot of money on developing world [1] aid. But how much money is being moved? And by whom? If we’re interested in understanding and influencing aid spending, it’s important to know how it’s distributed and where it comes from.

Figure 1 shows spending on public health and public education, as well as money moved by Official Development Assistance [2], charitable giving, remittances (money sent back home by migrant workers), and foreign investment (money invested in developing world companies).

The green and orange columns refer to spending (either in aid or from the governments themselves) in Low Income Countries (LI) [3] and Lower Middle Income Countries (LMI) [4] respectively. The red column refers to spending in higher income countries and is available for Official Development Aid (ODA) data, but not for any of the others. Blue columns are columns for which information on income is unavailable.

Data reported in the first three columns refer to year 2011 (most recent comparable year). Data in columns four, five and six from ‘The Index of Global Philanthropy and Remittances 2012’ refer to the year 2010. They are expressed in current USD and thus are not adjusted for Purchasing Power Parity (PPP).

PPP is a ratio that expresses the amount of good or services that one USD can buy in different countries which makes the figures comparable even if they are spent in different places. However, at the present time data required to do this adjustment were not available. Note that figures in USD will tend to underestimate the real value of the services provided in the poorest countries because services like education and health cost less to provide there.

Overall, in 2011, spending on public health was $92bn and spending on education was $231bn. Significantly more money was spent in LMI countries than LI countries. This is because much of the money in public health and education is spent by the countries themselves, and LMI countries have more money to spend -- with higher GDP per capita and, in the case of India, enormous population.

ODA is defined as disbursement of loans and grants made on “concessional terms”, or terms at which the ODA nations will overall lose money and don’t stand to gain any profit [5]. For example, ODA assistance must include at least 25% in grants (money given with no expectation that it be later returned).

ODA has provided $134bn in aid over 2011, of which $42.6bn went to LI countries and $37.3bn to LMI countries. ODA spending is therefore larger than spending on public health in LMI and LI countries and furthermore is the majority of all spending in LI countries. However, as described in the Department for International Development report “Aid for the Poorest?” [6], ODA does not focus on the poorest countries as much as one would expect.

Research from The Center for Philanthropy at Indiana University [7] found that the United States represents the largest charitable sector in the world, at least in terms of absolute amount of dollars given. About 2% of US GDP was donated, representing $298.42B. However, according to this report, only 8% of this total, or around $22.68B (8% of donations), went to “international causes”, with 32% of donations being given to religious charities, 13% given to education in the US, 8% to health in the US, 3% given to environmental and animal organizations, and 36% being given to other causes.

Another report from the 2012 Index of Global Philanthropy and Remittances [8] calculated that the US actually spends $39bn on the developing world, with 36% coming from private and voluntary organizations, 19% coming from corporations, 18% coming from religious organizations, 12% coming from foundations, 10% coming from volunteering, and 5% coming from universities and colleges.

Remittances are transfers of income across borders, sent back home by friends or family working abroad. They are a very significant source of cash flow into the developing world - at $190bn, they represent more than six times charitable spending.

This can be seen as an argument for the importance of opening up opportunities for migration in order to get more money into the developing world. Unfortunately, the poorest of the poor are unlikely to be able to migrate and therefore will never benefit from remittances, so this cannot be the complete solution for poverty.

The largest flow of money into the developing world was investment in developing world companies from foreign investors, topping out at $329bn. This was not always the case, and can arguably be read as a hopeful sign for the future economic growth of developing countries.

Overall, breaking down the spending in the developing world has interesting implications for foreign aid. When we imagine the trillions of dollars in aid money that have been spent over the past half century, we don’t really imagine that not all that much of it is going to those who need it the most -- the poorest of the poor. This shows that, from a humanitarian perspective, there is plenty of potential to improve investment in the developing world.

But, perhaps most importantly, it shows the scope of charitable giving. There isn’t a whole lot of giving to the developing world relative to the total amount of charitable giving. But it still stacks up quite well, being only less than half of ODA. Thus, charitable giving has an important role to play. And we should continue to shape this role by encouraging more, and more effective, giving to the developed world.

World Bank: Lower Middle Income Countries

The Index of Global Philanthropy and Remittances 2012

Stephanie Crampin

Blindness: an opportunity for effective giving?

This article is a summarised form of an upcoming report by Josh Goldenberg on the topic of blindness. Keep an eye out for when the report is published for further details of this area.

Blindness and visual impairment are significant issues worldwide, causing loss of employment, self-esteem and productivity. The most recent estimates from PwC state that 32.4 million people worldwide are blind, and 190.6 million suffer from low vision. Out of these, 1.4 million children are blind, and 19 million visually impaired. This is down from the 37-38 million people living with blindness in 1990, suggesting progress, and a rapid decline in blindness rates.

90% of visually impaired people live in the developing world, in large part their blindness caused by easily preventable conditions such as trachoma-induced cataracts and river blindness caused by blackflies. An astonishing 80% of visual impairment in the world could be prevented by good hygiene and basic medical care. This makes blindness an attractive candidate when looking for a particularly effective charity.

PwC estimated that it would take $392bn (on top of the current $5.9tn) from 2011-2020 to eliminate avoidable blindness entirely, though only $128.2bn to eliminate avoidable blindness in the low and middle income countries. 

, for the cost of one guide dog, over a thousand surgical treatments for trachoma could be provided. But does this yield any specific steps we can take to make an impact on blindness? Below is what you need to know.

Cataract is responsible for at least 33% of global visual impairment and at least 51% of global blindness, according to the WHO. It is clouding of the lens of the eye which prevents clear vision. Overall, the cost-effectiveness of surgery in the South Asia region has been estimated at about $60 per disability adjusted life year, and an analysis of the current literature on cataract prevention suggests that the most likely figure is somewhere around $40-150, with $90/DALY around the median of each of the estimates, a figure promising enough to be worth investigating further.

Despite the very promising numbers, cataract treatment requires a lot of factors to be in place before it can start to be effective. A lot of training is required for the surgeons who carry out the treatments, as well as assistance from health providers, and education if the community to dispel fears of surgical treatments. Compared to deworming, it requires a much greater investment of time and money, but fewer people are needed, and surgeries need only be administered once, rather than yearly.

Although we can’t be confident that donating to combat cataracts is as effective as donating to our top charities, it is likely that it will be a very effective investment.

Trachoma is the result of infection of the eye with Chlamydia trachomatis. If the infection is left untreated and the eye is re-infected, it can cause the eyelid to turn inwards, meaning that eyelashes come into contact with the eye, causing scarring, immense pain and eventually irreversible blindness. The WHO recommended strategy for combatting trachoma is ‘SAFE’ – surgery, antibiotics, facial cleanliness and environmental changes.

Despite the multifactorial approach recommended by the WHO, surgery is the best investment for donors at the moment, as it is not subject to the same limitations as the other factors: Antibiotics are mass-distributed, facial hygiene interventions involve mass education, and environmental change involves large projects, such as improving sanitation. Funding surgeries has the potential to make way for many future operations (such as hospital building) and it is also a necessary part of an eradication programme.

A 2012 WHO article on the situation of trachoma paints a positive picture on the current state of affairs regarding this disease. From the 53 countries that are endemic in blinding trachoma:

28 reported data on implementing the SAFE strategy.

6 countries reported that trachoma was no longer a public health problem in 2012 (<0.1% suffer from trichiasis, <5% of 1-9 year olds suffer from active trachoma).

The number of people living in trachoma endemic districts reduced from 317m in 2010 to 241m in 2012 – almost a 25% decrease in just two years.

48.8 million people received antibiotics.

169,000 trachoma surgeries were carried out.

A 2006 estimate also stated that the number of people affected by trichiasis fell from 360m in 1985 to just 80m in 2006. So great progress is being made.

Onchocerciasis is responsible for 0.8% of global visual impairment (1.5 million) and 4% of blindness (0.6 million). It is also regarded as particularly painful and debilitating. To quote the WHO’s pleasant description:

“Onchocerciasis is a parasitic disease caused by the filarial worm Onchocerca volvulus. It is transmitted through the bites of infected blackflies of Simulium species, which carry immature larval forms of the parasite from human to human. In the human body, the larvae form nodules in the subcutaneous tissue, where they mature to adult worms. After mating, the female adult worm can release up to 1000 microfilariae a day. These move through the body, and when they die they cause a variety of conditions, including blindness, skin rashes, lesions, intense itching and skin depigmentation.”

Cost effectiveness estimates range from 4 to 130 $/DALY. More work is needed to come to a more confident conclusion about the effectiveness of interventions in this area.

Other forms of blindness include corneal opacities, glaucoma, diabetic retinopathy, age related macular degeneration, and childhood blindness.

The charities investigated are ones which are partners of the WHO or International Trachoma Initiative, and which are working in the developing world on cataract, trachoma or onchocerciasis (and not working on a range of other causes that seem less effective). There are some more, though the ones below likely include most of the major charities.

 works in a very broad range of areas, including cataract surgeries, trachoma fighting, antibiotic provision, and eye screenings. Out of a total of A$41.5m on program expenses, the Fred Hollows Foundation likely spent between A$10 and A$20 million on the most effective interventions. The $/DALY figure of FHF is around 180-450 (taking cataract surgery at $90/DALY).

 received $77,876,062 of in-kind medical supplies and medicine – very close to the figure for the distribution of in-kind medicines. As a result, it seems likely that additional donations will go towards the other programs. A significant proportion of other expenditure seems to be spent very effectively – a combination of effective interventions. The focus is on nutrition, which it is outside the scope of the report to consider, but seems promising. As such, HKI should be investigated further, though predominantly from the perspective of nutrition.

 do not publicly provide data on the amount spent on areas within eye health. On their page on cataract, they put screening above provision of surgery, suggesting surgery is not their focus. In their financial reports, under surgery they specified the causes of blindness in brackets –“cataract, glaucoma, diabetic retinopathy, trichiasis in that order – suggesting that their focus is not exclusively on the most effective causes. We have emailed them to find out more but have not currently received a response.

From the above, the charity that seems most effective is Helen Keller International because of the high proportion spent on effective programs. However, to be sure of this, one will need to research their nutrition interventions in greater depth. SightSavers’ lack of transparency on the distribution of expenditure on eye care is surprising given the amount of other financial information they provide, but it seems likely that a significant proportion will not be spent on effective interventions. The Fred Hollows Foundation similarly seems to spend a significant proportion on less effective interventions.

While blindness is a promising area, donors should look elsewhere to have confidence in finding effective donation targets. It will be worth re-evaluating in a few years whether more can be done by charities to increase cataract surgery provision, and whether trachoma and onchocerciasis continue moving towards eradication.

Max Dalton

How valuable is medical research?

How valuable is medical research? Finding the solution to a problem in medical research is not only difficult, but it’s difficult to know just how difficult. Given that, how could we know the return we can expect on investing in medical research? Owen Cotton-Barratt is trying to find a framework for tackling precisely these kinds of questions. This post gives a sketch of his current model, and what it might be able to teach us about the value of medical research.

Owen Cotton-Barratt is Giving What We Can’s director of research, and also works on the Global Priorities Project (GPP) [1] within the Centre for Effective Altruism. The GPP works to try to find out how we should compare the different causes that we could be working on. This is closely tied to Giving What We Can’s aim of finding out how individuals can help people the most with their donations.

Owen’s current project is developing a framework to treat problems of unknown difficulty. It’s a work in progress, but he wanted to see whether the kinds of results the model produced would be useful by working through a specific example – the value of medical research. In this post I present a brief sketch of both his model and his results. Note that this work is very preliminary, and my statement of it is rough!

How might you go about finding out how much benefit you can get for an investment in medical research?

You need to build a simplified model that can start to give us a handle on what’s going on, but that gets the major effects approximately correct. This model aims to find a best guess for the average benefit (measured in Quality Adjusted Life Years (QALYs)) produced by an extra unit of resources (measured in dollars) invested in medical research, as well as some idea of how robust this estimate is. It starts by finding the general shape that returns to medical research would have, and then uses rough numbers about the world’s actual research spending and life expectancy increases to find out how many QALYs we might expect to generate per million dollars we put into medical research.

How do the outputs of medical research vary as resources go in?

In research in preparation, Owen argues that we should think the beneficial knowledge from a research area will scale approximately logarithmically, in expectation, with the resources invested. If the research area has many small discoveries rather than a few large discoveries, its development should also exhibit roughly logarithmic behaviour. In the case of medical research, this appears to be a reasonable assumption.

This means that a doubling of resources is equally good regardless of starting point. So money would have diminishing marginal value when put into research, as we might expect. Of course, this model does not hold for arbitrarily large values, but it is a fair approximation over the range we’re interested in.

How many QALYs are produced per $ invested in medical research?

The very rough model above seems to indicate that the knowledge generated by medical research varies logarithmically with money put in. That’s an interesting result, but what we really want to know is how many QALYs we could generate by donating a certain amount to medical research. To assess that, we need to ask how useful extra knowledge is. At first glance, it seems like it generates health benefits in a stream of constant size into the future, so even a small amount of extra research today will produce very large numbers of QALYs.

However, we should assess the value of extra research by the counterfactual where we don’t do this research. Whereas the obvious counterfactual considers the research never happening, the correct counterfactual is generally that the research will happen, but later. Of course the resources that would have been used to undertake this research later will now be freed up, often for further research. But we get diminishing marginal returns from research as the low-hanging fruit are taken, so although there will be a stream of counterfactual benefits going into the future, it will be decaying and its total size may well be finite.

To figure out the actual value, we need some numbers about current medical research. The numbers below are rough, as this is a proof-of-concept calculation. Where they aren’t sourced, they’re Owen’s best guesses. Putting more work into getting good data to use in the model could be a good way to produce more accurate outputs.

How much money is spent on medical research in total in a year? Around $270billion, of which around $100billion is publicly funded.[2]

What about other resources? If we doubled the funding, we wouldn’t double the number of talented people willing to work in the field. And some progress in other areas, such as hardware manufacture, may help medical research. Properly we could consider the elasticity of medical research with respect to these different factors (that is, the responsiveness of the field to change in these factors), with the observation that the elasticities should sum to 1. Alternatively we could estimate the dollar-equivalent value (to progressing medical research) of all of the resources going into the field. We might guess this is between $400 billion and $900 billion, with a median guess of $600 billion.

How fast is the investment growing? Probably between 2% and 5% per year. [3] The median guess is 3%.

How much has life expectancy increased per decade? 2 years. [4]

Not all of that life expectancy increase is due to medical research. On the other hand, medical research also improves quality of life. Given that, how many QALYs per person does medical progress create each decade? 0.15 to 1.5, median guess 0.5. Hence 0.05 QALYs are added to an expected life per year due to medical progress.

It’s possible that not everyone benefits from medical research, because its results don’t reach those in the developing world. How many people are benefited by medical research? Somewhere between 1.5 billion and 7 billion. Median guess: 3 billion.

How much total benefit is produced in one year from the resources we currently put into medical research? The added QALYs are to a person’s total expected QALYs, not the number they get each year. So we model the benefit as just accruing to people dying in a particular year: 1 in 70 people. What we get is 0.05 * 3,000,000,000 / 70, which is approximately 2 million QALYs.

What are the long term benefits and effectiveness of medical research?

You might think that the benefit that medical research produces in a year will continue every year from then on, because once you’ve found a vaccine or cure you can continue to use it. However, we shouldn’t be comparing the case of us finding the vaccine with the case in which it was never found – chances are it would have been found, just later on. On the other hand, the money that would have been used to find that vaccine later on, can now be used to fund other medical research. What we have effectively done is moved medical progress as a whole forward. Therefore, the benefit from funding medical research does last into the future.

In order to find the total value of funding medical research, we need to know how long into the future our funding continues to be a benefit. Since medical funding is increasing each year, the benefit from a particular donation decays over time. How quickly this happens depends on how the benefits from medical research vary with resources put in. Using the result that this is log-linear gives that the benefit of research today decays at a discount rate equal to the rate of increase of medical funding. With a 3% annual increase, the sum of the infinite series generated is equal to 33 times the benefit generated in one year without accounting for this.

The total benefit produced by the $600billion put yearly into medical research is the number of QALYs benefit in a year (around 2 million), times the effective number of years the benefit continues for (33.3). Therefore, the total benefit is around 70 million QALYs. That means per million dollars put in, 110 QALYs are produced. That is $8,500 per QALY. Assuming that the error in our estimates by component are independent, Owen also worked out a rough 90% confidence interval, of between $2,000 and $36,000 per QALY. Accounting for model uncertainty might make it a little wider again.

The result we got – that the return of medical research is around $8,000 per QALY - is very rough, and has a high variance. However, it does give us an idea of its value, which is very useful. There are two particularly interesting things it tells us: This estimate indicates that we are under-investing in medical research. The NHS is typically happy to fund treatments up to around $50,000 per QALY. If medical research on average is more cost-effective than that, rich countries should be investing more in it.

The estimate indicates that medical research as a whole is not typically as effective as the very best direct interventions (like providing people with bed nets). Despite the initial appeal of research as something which will have far ranging ramifications, on average deworming children is more effective.

However, our estimate has been for the average effectiveness of medical research. It is quite plausible that particular research efforts are highly cost-effective, particularly if they are in fields which are likely to be neglected because the beneficiaries would be very poor (for example, developing a vaccine for malaria or schistosomiasis). With further work we could begin to make comparisons of these areas.

An Update on Evidence Action

Evidence Action, one of Giving What We Can’s recommended charities, is an organization which scales proven development interventions, and now leads both the Deworm the World Initiative and Dispensers for Safe Water (DSW). We will be keeping abreast of Evidence Action’s on-going endeavours through a series of monthly updates, of which this is the first. This month, the focus is on the progress made so far with their DSW program, the research behind it, and the sustainable financing methods employed to maintain it.

In many developing countries, central water infrastructure is not available or reliable, leading to unsafe water at the tap. In Uganda, for instance, approximately 29% of the rural population have no access to safe drinking water.

In such cases, decentralized water treatment can be used. This is where 

DSW uses a proven and highly effective, low greenhouse gas emitting water purification technology (with chlorine), to increase access to safe drinking water. This product was developed following the observation that a mere 10% of the Kenyan population used chlorine for water purification, despite its known benefits. A research team set up in 2006 began to investigate the behaviour behind these patterns of (non-)use through a randomized controlled trial, and concluded that the population who received chlorine for free at the point of collection had a six-fold increase in use over the control group. Two years later, the high adoption rate was maintained. It was therefore determined that for uptake of a water purification product to be successful, it would need to be; a. free, b. easy to use, and c. located directly at the water source. Accordingly, the product currently used by DSW is just that.

DSW currently support a set of principles for water sector service delivery, 

, which was developed to sustainably improve access to water services for approximately two million people in developing countries such as Kenya, Uganda and Malawi, at no cost to them. It involves:

Universal access for every individual and institution starting at the district level (with the ultimate aim of covering a national level)

Long-term indicators of sustainable service delivery; and

Meaningful, financial engagement with communities and governments.

Explicitly seeking universal access in a district, meaning everyone in a district can quickly and easily walk to a chlorine dispenser at a water source. Typically, the aim is for more than one dispenser per square kilometre; conveniently, the denser a network of dispensers, the lower the running costs in that area. Universal access to dispensers may also reduce rates of recontamination during transport and storing of water in the home, ensuring that people can expect and receive safe drinking water.

Ensuring ongoing maintenance and support.

Ensuring financial sustainability with a plan to fund 100% of on-going service delivery costs from revenues earned from sales of carbon credits, together with fees for other services and public financing.

Monitoring and accountability for on-going service.

As an example, 872 dispensers have so far been installed in the Hamisi District of Kenya, with 5.5 dispensers per square kilometre. This means that the household furthest from a dispenser is less than a 10 minute walk away.

Funding such a program requires innovative financing approaches. Carbon credits are thus generated from communities’ use of dispensers; as the technology consists of a clean water treatment, these credits can be sold to private companies seeking to offset their own emissions. This long-term revenue stream is reinvested in the program, covering all operations and maintenance costs. In this way, fully-loaded costs for operating dispensers reaching 25 million people will be covered by 2018.

Of note, Evidence Action was officially registered under South Pole Carbon’s International Water Purification Programme last month, to generate carbon credits for DSW in Uganda. The project is to be jointly registered with the Gold Standard Foundation, meaning that it meets the highest standards of sustainable development for the involved communities. This comes in addition to the existing registration status in Kenya.

Additional revenue streams, including bundling charges and local government contracting, may also ensure safe drinking water for communities without access to major piped systems. Engagement with local governments also takes place, relying on key decision makers for involvement in the initial setup process, promotion in the community, and direct financial contributions.

Finally, long-term commitment to monitoring, through a system enabling any community member to report a dispenser service delivery issue in real-time for resolution, contributes to the sustainability of the program. In Kenya, a 97% service uptime rate is achieved among the dispensers.

 program owes its success to the granularity of 

’s initial investigation into the unmet needs in the area, and the development of a suitable solution to the problem. The program is maintained by the establishment of sustainable long-term revenue streams, which will allow its stable growth, district by district, reaching millions of people worldwide.

Olga Kuznetsova

What you need to know about school-based deworming from SCI

This is the first in a series of posts about the Schistosomiasis Control Initiative (SCI), one of our highly-recommended charities. Based in Imperial College, London, they work with a number of African countries to control and eliminate schistosomiasis in regional and national-scale programmes. Clearing an entire country of a disease is no small feat, and a lot of time and effort is spent researching the distribution of the disease and promoting the programme to the population before any drugs are distributed. This is a summary of a presentation given at SCI’s Open Day by Jane Whitton, the Country Programme Manager for Malawi, and describes how a typical project is run.

Schistosomiasis is caused by the two species of Schistosoma worm that live in the blood vessels of either the urinary tract or the intestines and cause anaemia, stunted growth and poorer school performance in children, while chronic infection can cause organ damage, increased risk of HIV infection, and eventually be fatal [1]. People come into contact with worm larvae carried by snails in freshwater sources. Inadequate sanitation and hygiene play a big part in the spread of the disease. As with other worm infections, schistosomiasis is easily treatable with safe drugs (usually praziquantel) and can be controlled by preventative treatment of the population [2]. However as a neglected tropical disease (NTD), it has not been addressed on a large enough scale, and in 2012 only 14% of people in at-risk populations were treated [3].

Until 2000, Egypt was the only African country that had a schistosomiasis control programme. The disease was prevalent in sub-Saharan Africa, and in 2003, SCI received a donation from the Bill and Melinda Gates Foundation for three years to prove the concept that people could be treated at scale in 6 countries in endemic areas. Following on from this, projects were carried out with support from the United States Agency for International Development (USAID), UK’s Department for International Development (DFID) and private donors such as Giving What We Can members. Currently, SCI runs projects in 16 African countries and in Yemen, while in two countries (Mali and Burkina Faso) the projects have been taken over by other organisations and no longer rely on SCI. These have become “legacy countries”.

The length and scope of projects in a given country can vary, depending on how much treatment had taken place before, how much is known about the disease epidemiology in the country, what infrastructure is available for drug delivery and the goals of that specific program. The endemic country needs to be committed to the programme and to provide the necessary resources, which includes putting together a national NTD strategic plan and nominating a focal person to manage the programme e.g. the NTD Programme Manager from the Ministry of Health. SCI works closely with governments to draw up a contract and generate a plan of action, which includes yearly work plans and budgets.

Once plans have been drawn up a less-obvious aspect of a project needs to take place that can nevertheless take a lot of time: mapping the disease prevalence within the country. Often, there would be little or no knowledge of the distribution of schistosomiasis in different regions. Sometimes previous maps are available, and knowledge of geographical factors (e.g. climate, water location) can also give an indication of where schistosomiasis is likely to be found [4]. The survey begins with school testing in a few areas of the country, and several phases of mapping are needed to build up a picture such as the one shown below for Liberia. The prevalence in each region dictates how frequently treatment should be carried out. For areas with over 50% of the population infected, drugs are administered once a year [5], whereas moderate prevalence areas (less than 50% but more than 10% prevalence of infection) treatment once every two years is recommended. In low-prevalence areas (less than 10% of the population) - recommendations are that children be treated twice during their primary-school years.

After the distribution of the disease is established, preparations for treatment can begin. SCI ensures that the target country has enough resources and staff to deliver the medication to all who need it without relying on manpower from abroad (SCI only have one or two people working with each target country!). The drugs are usually administered to children by community health workers or school teachers, who may not be familiar with schistosomiasis and need specialised training. This training is given in a capacity-building cascade, where information on disease biology and programme logistics is passed down from the Ministry of Health to the provincial level, then to the district and finally to the community level. However, capacity building is only half of the challenge: the second stage in the preparation is reaching out to the population and publicising the campaign emphasising the benefits but also giving information on the mild side effects that very occasionally occur. If infected communities are not given enough information, the campaign risks not reaching enough children or poor compliance with the treatment. To avoid this, radio and printed media, community meetings and health days in schools are used to raise awareness of schistosomiasis and the importance of good hygiene in lowering the risk of infection. The capacity-building and social mobilisation prepare the community for treatment and ensure that everybody is clear about their roles and expectations.

Weeks before the treatment, drugs and equipment are delivered to the target country. This is done in advance to allow distribution of drugs to all communities, including hard-to-reach ones. The storage of the drugs are monitored to ensure that the medications are distributed on a first-in, first-out basis and do not pass their use-by date. On certain days, after a well-publicised campaign, the drugs are administered to children in schools.

Although it may seem that after population treatment the project is finished, but the story doesn’t end here. At every step of the way, monitoring and evaluation takes place to assess how well the programme is working and what factors influence its success, which in turn allows improvements to be made. SCI also reports its findings both to the local communities and to donors. In fact, monitoring and evaluation is so important that 10% of SCI’s funds are dedicated to it [6]. The process can be divided into the three categories:

This ensures that every stage of drug delivery, personnel training and mobilisation is timely and correct, the training is carried out to a high enough standard, and enough people are reached in sensitisation/mobilisation campaigns.

This analyses the treatment coverage, i.e. how many people actually received the drugs. SCI aims for at least 75% coverage of school-age children, a target set by the World Health Organisation and household surveys are carried out to confirm the numbers. This is also an opportunity to identify regions with low coverage and see how this can be improved in the future. People involved in drug administration (such as teachers and community workers) are interviewed to assess their knowledge and attitudes, and assist in finding out why the drugs are not reaching enough people.

This is to show the impact of the programme on reducing the morbidity of infection. For this, longitudinal cohort studies are set up to monitor children before and after each round of treatment, as well as untreated children for comparison. Some of the factors analysed are: number of parasite eggs present in urine and faeces (dependent on species), health indicators such as anaemia and presence of blood in urine, and also the quality of sanitation in the community. To give an example, combination treatment of nearly 2000 children in Uganda with praziquantel and albendazole led to an 82% reduction in Schistosoma infection after two years [7].

This overview should give an idea of the efforts that go into a schistosomiasis control and elimination projects. Although we might think it’s as simple as giving medication to children, a huge body of behind-the-scenes work - planning, communications, monitoring - is necessary to make it happen. SCI has already carried out successful projects in a number of African countries, but a question remains: is it possible to eradicate schistosomiasis entirely? This will be the topic of the next SCI blog.

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