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Andreas Mogensen

Just over two weeks ago, GiveWell (GW) chose to remove Against Malaria Foundation (AMF) from its list of top charities, citing concerns about AMF’s room-for-more-funding (RFMF). (See GW’s blog post 

.) Having considered this issue and spoken with both AMF and GW, we at Giving What We Can have decided not to remove AMF from our own list of recommended charities, as we continue to believe that AMF represents one of the very best opportunities for those who want to give now. However, Giving What We Can and GW do not really disagree on this issue as much as it might appear. Read on to learn more.

The decision by GW to remove AMF from its list of top charities was made based on concerns related to RFMF. These concerns have arisen in light of AMF’s failure to finalize large-scale distributions over the two-year period in which AMF have been GW’s #1 recommended charity; GW drew particular attention to the recent failure of AMF to negotiate distribution of nets in Sierra Leone. Summarizing their position, GW write: “given the significant amount of time that has passed, it now seems to us that there is a substantial risk that AMF will not accomplish [one or more suitable distributions] in the near future, and that having more funds to commit would steepen rather than lessen its challenges. … Therefore, we believe it is most prudent to donate elsewhere until and unless AMF commits the bulk of the funds it currently holds, at which point we will revisit its ranking.”

GW also criticise certain aspects of AMF’s approach to negotiating distributions, which they believe may have hindered progress. For example, GW suggest that the stringent monitoring and evaluation requirements set out by AMF for potential partners are in some cases too strong. However, GW note that AMF have already taken steps to address concerns of this kind.

AMF were kind enough to speak to us at length about their views on GW’s decision and AMF’s plans for the immediate future. Many details relating to these plans are confidential, and are not discussed in following. Overall, AMF’s position is that GW have underestimated the value of additional funds donated to AMF.

AMF are highly confident that they will have allocated all present funds within the next 6 months. They are currently involved in a number of negotiations. Some of these negotiations have made significant progress and one pre-registration survey is already beginning. Some of these distributions are sufficiently large that AMF could potentially be facing a significant funding gap early in the new year. Consequently, AMF is presently seeking funding of an additional $5m to be able to fund those distributions it is currently discussing that will require a decision before the end of March 2014.

AMF offered a number of reasons to suppose that current negotiations are more likely to succeed than those in which they have been involved in the recent past, particularly Sierra Leone. For example, a smaller number of partners are involved, meaning that negotiations are simpler and more likely to follow through. In addition, AMF suggested that, on the outside chance that longer delays are experienced in disbursing funds, they saw no reason to believe that a distribution of nets carried out in the near future would be significantly less effective. Thus, even if AMF do continue to experience delays in securing large scale distributions, we should expect that money donated now will eventually be used to fund net distributions relevantly similar in cost-effectiveness to what we’ve come to expect from AMF. AMF pointed to the large gap that exists, (and is projected to continue to exist) between the need for nets and the funding available.

What we’ve learned from speaking further to GW

Besides contacting AMF, we’ve gained considerable insight from speaking to GW about their decision, particularly GW Co-Founder Elie Hassenfeld. I found it notable that GW’s views about AMF, as expressed in conversation, were not quite as pessimistic as their blog-post on the 26th of November had led me to expect. GW believe it is more likely than not that AMF will disburse all funds within the next 6 months. They believe that it is definitely defensible to give to AMF at present, though the better policy would be to wait and see whether AMF succeeds in those negotiations which are expected to be finalized within the first quarter of 2014. Furthermore, GW have suggested that part of the reason for their decision to remove AMF from their list of top charities has to do with the public significance of their recommendations and the incentives provided to charities by managing these recommendations as they currently do.

Elie expressed some degree of skepticism with respect to the likelihood that AMF’s current negotiations will yield fruit, appealing to AMF’s underwhelming track record over the previous two years. He did not wish to rule out, however, that current negotiations might have properties that are more likely to lead to success and noted that AMF has made positive steps to address some of GW’s critical comments.

Having considered the issue, Giving What We Can has decided to keep AMF on its list of recommended charities. We believe that, for donors looking to give to charity now, AMF remains among the very best opportunities for doing good. Whereas the concerns regarding RFMF raised by GW shouldn’t be taken lightly, we do not believe, based on what we’ve learned, that these are sufficiently serious that the expected value of donating to AMF should not continue to rank very highly. That having been said, we give considerable credence to the view that those who are not committed to giving now may do well to wait and see whether AMF’s current negotiations are successful (but see below).

The question of when to give is a difficult issue that we’ve addressed on a number of occasions (

). I typically give at the beginning of each month, and I’m inclined to believe that there’s value in establishing a rhythm of this kind in terms of ensuring that we follow through on our commitment to give. However, there are other reasons that may lead us to believe that it is better to give later: in particular, we may have better evidence.

Fortunately, there’s a way to give now and give later, all at the same time. As we discussed in 

 earlier this week, it’s possible to give now to the Giving What We Can Trust while choosing to delay the disbursement of one’s donation. Absent this kind of recommendation, the Trust pays out quarterly to our recommended charities. The best strategy may therefore be to give now to the Trust, indicating that you would like your donation to be spent in accordance with Giving What We Can’s recommendations when the Trust pays out at the beginning of the second quarter of 2014, at which point we expect to know a lot more about AMF’s room for more funding.

Why we continue to recommend the Against Malaria Foundation

Alice Ravenscroft

On Thursday 5th December I attended a panel discussion on what makes a charity effective, hosted by the African Development Project at Imperial College London. The speakers included the directors of two of Giving What We Can's top charities: Rob Mather of the Against Malaria Foundation and Prof Alan Fenwick of Schistosomiasis Control Initiative, as well as Caroline Fiennes of Giving Evidence; an organisation which advises donors and charities on improving performance by making evidence-based decisions.

The discussion began with each speaker talking about what makes an effective charity, before opening to questions from the floor.

Rob presented a four-point overview of what he believes makes AMF so effective, and stressed that these principles can be adopted by pretty much any charity to become more effective:

Focus on impact should drive what you do. This means measuring results and reporting your findings.

Efficiency drives how you do it. When setting up AMF, Rob was keen to get things for free where possible, approaching people he knew at businesses to enlist their help, for example PWC, which audits the charity for free.

Accountability ensures that promises are delivered. AMF checks that nets have been distributed as intended, and that they continue to be used. The key to ensuring that nets are distributed and used as intended is engaging with communities and stakeholders and educating them about the whole process: why the nets are important and how they will prevent malaria.

Transparency builds confidence among stakeholders. Thanks to the Internet, it's very easy for charities to be transparent and Rob argues that they should present their accounts in a user-friendly way.

Alan talked about how and why SCI is so effective.

, but as this funding began to dry up, SCI was spotted by 

 and Giving What We Can. Alan believes that smaller charities such as SCI and AMF are more effective than some of the biggest, most famous charities. The key reason SCI is so effective is that donations are highly leveraged: it has persuaded a big pharmaceutical company to donate all the drugs needed, so what donors are actually paying for is for SCI to advocate with ministers in recipient countries and to educate people on why they need the drugs. For example, schistosomiasis is not really a problem in cities, so ministers there might overlook the importance of the drugs.

Giving Evidence works across the whole of the charitable sector and Caroline argues that GiveWell's method of analysis, focusing on QALYs, only works well for a certain kind of charity. There are many organisations doing vital work towards things like systemic and societal change which can't be measured in this way. She gave the example of Stonewall, which advocates for gay rights, arguing that you can't evaluate its work in terms of units of good achieved. Caroline took issue with the concept of "the most effective charity in the world" arguing that different charities are needed to achieve different things. That said, she does think it is essential to compare charities as we have finite resources and an effectively infinite need.

If you are interested in getting a comprehensive picure of Caroline's views on effectice giving, she recently published a book on the topic. You can read our review of her book 

Is it fair to use GiveWell's metric for all charities?

 The metric is only appropriate for certain charities. He is excited to see what will come of 

, the initiative which is moving beyond (relatively) simple-to-quantify areas to look at things like scientific research and political advocacy. Rob thinks that the focus for any charity should be to work on processes which make them more cost-effective, whatever it is they are doing.

How do you collect data and measure your work?

: AMF works with partners in-country to collect data. It's actually incredibly cheap to do. Local health providers go round a village knocking on doors to find out exactly how many nets are needed in each home.

What about the use of surveys and opinion polls?

: Caroline argues that what a lot of charities are essentially undertaking is social science research, but they often lack rigour. For example, a charity might use a survey to chart attitudes before and after a campaign, but too often they will infer causation from correlation. To gather meaningful evidence, these organisations need to carry out 

How far can charities be compared to businesses? Can charities work on branding to become more successful?

: Charities should strive to be "business-like" in that they should be professional and efficient, trying to maximise outcome.

: While charities can learn from businesses, Caroline feels that the analogy is overplayed. There are fundamental differences between the two: businesses produce private benefit and are driven by financial results, whereas charities are aiming to achieve varied and complex outcomes for public benefit and are in the business of giving things away, including intellectual property.

If you could change one thing about the way the charity world works, what would it be?

: Donations being made based on evidence and the value of what is actually being delivered, rather than on how famous a charity is.

: There are certain organisations and campaigns which bring in vast sums of money every year, for example Comic Relief and Children in Need, who don't tell donors exactly what is being achieved with their money. Greater accountability and transparency is needed.

: Greater accountability is needed. Charities should measure and report to donors exactly what is being achieved with their money.

How to run the most effective charity in the world

Michelle Hutchinson

Should we donate in the future when we have more information rather than right now? If we put off donating, we miss out on important benefits like Gift Aid and commitment to giving. But there is a way to get these benefits, while putting off the decision of which charity to donate to - putting your money in a charitable trust.

There are various reasons that you might want to 

. One is that you could invest the money you would otherwise donate, and by gaining interest on it, end up donating more than you would if you did so now. That's contentious, since giving to charities earns a 'social return' - people who get deworming tablets will get a better education, and therefore a better job. That will benefit not only them, but also others around them. That said, because this social return isn't reinvested in the charitable intervention, over the very long-term it may be that 

Another reason for delaying donating is if you think you'll have better information in future about which charities will be most effective with your donation. That possibility is particularly salient at the moment. The 

 has been thought by many to be the most effective charity in world, having been the number one recommended charity by GiveWell. However, in their most recent round of recommendations, GiveWell dropped AMF. They feel AMF has no room for more funding at present because it hasn't been able to secure a large distribution of nets recently.

Many people think that AMF, if it did have room for more funding, would be more effective than the other options GiveWell now recommends. It's uncertain how soon AMF will find a partner to distribute nets. Therefore, AMF might very soon become their top recommended charity again, or it may have no room for funding for a long while. (We will release a more detailed blog post about AMF next week.) More speculatively, there are other causes which may be the most effective to donate to, but which it's currently unclear how to affect. These considerations are by no means conclusive, but some people might still want to put off donating until we have more information.

 about how much we care about ending extreme poverty - we can encourage others to join us in donating, and possibly governments to take poverty alleviation more seriously. By donating to the most effective charities, we can encourage other charities to care more about their own impact. By not donating on the other hand, we run the risk of falling out of the habit of giving every year. And there's even a risk of missing out on some gift aid or tax deductions you could receive (since you can only claim back as much tax as you paid in a year; and in the US only 50% of that).

The benefits of delaying choosing a charity and of donating immediately can be combined by donating to a charitable trust (or in the US a donor advised fund). That's one of the reasons we had for setting up the Giving What We Can Trust. A trust is a scaled down charity in its own right, so you can claim Gift Aid when donating to it (if you're in the UK). However, the money can stay in the Trust for a prolonged period before being paid out. If someone gives to the GWWC Trust, the default is that it is paid out quarterly to whichever of our recommended charities the donor chose. But people can ask for it to be paid out immediately or for it to be left in the Trust until some future time.

Unlike donor advised funds, charitable trusts typically do not charge management fees. By default, they are ordinary bank accounts. For that reason, money in the GWWC Trust currently neither diminishes nor accrues interest. However, we have the option of using a linked savings account, or of investing the money in bonds or stocks. The latter would involve some administrative work on our part, since trusts are regulated by the Charities Commission. That's an option we'll explore further if any donors come forward wanting to put a substantial donation (perhaps over £1000) in the trust for a prolonged period.

If you'd like to wait to give in order to make sure you're donating to the most effective charity, but want to make sure you get the benefits of giving now, the answer is to donate to a trust! Please feel free to 

Should you donate now or in the future? Here is how to do both

Giving What We Can

 of a high quality mobile video game, marking the event of production company Psyop joining the fight against malaria, in conjunction with the Against Malaria Foundation.

The launch is in conjunction with the launch of a video, narrated by Susan Sarandon. The 90-second spot, starts as a sweet tale about a little girl drifting to sleep at night.

Things turn dark, though, when a giant mosquito impales the child, infecting her with malaria and plunging her into her own bloodstream. A twisted series of psychedelic visuals ensues, taking the viewer on a wild ride through the symptoms of malaria.

The nightmare ends abruptly when mosquitoes hit a net draped around the child’s bed. The call to action is simple: three dollars buys a mosquito net, effectively preventing a malaria infection and limiting the spread of the deadly disease.

“EGG is our chance each year to step outside our comfort zone and push the boundaries a bit” says Marco Spier, Director and Founding Partner at Psyop. “This year, we also decided to make a game inspired by the spot. We’ve never done that before.”

In “Nightmare: Malaria,” players make their way through 18 levels of fever-dream visuals, avoiding killer mosquitoes and collecting hard-to-reach teddy bear tokens along the way.

The game is now available in the iTunes App Store and the Google Play store for Android.

The nightmare is real

This Sunday, GiveWell released their official 

update of their top recommended charities for the giving season 2013

. The most recent charity to make the list is a Giving What We Can recommended charity, 

. Deworm the World (DtW) operates under the umbrella of Evidence Action. Evidence Action also manages Dispensers for Safe Water, which Giving What We Can is looking into separately.

Here is GiveWell's justificationf for recommending DtW:

In isolation, our best guess is that DtWl's deworming program is likely less cost effective than SCI's (about 50-100% as cost effective) and GiveWell staff differ about its cost-effectiveness relative to cash transfers (1.5-3x as cost effective). This is because worm infections appear less prevalent and (particularly) less intense where DtWI works than where SCI works. However, DtWI focuses on influencing government spending rather than covering all costs with its own funds, and we think it is therefore appropriate to give it some degree of credit for "leverage" - making your dollars go further than they otherwise would.

 remained a top charity supported by GiveWell, 

despite recent concerns over it's effectiveness

 also remained on the list of recommendations, following a 

, GiveWell dropped AMF from their list of recommended charities, due to a percieved lack of room for funding. We will be Skyping Rob Mather to discuss GiveWell's most recent decision at 2.30pm GMT on Wednesday 04/12/2013. If you have any questions you'd like to put to him, please get in touch at 

A good weekend for a top charity!

Sally Murray

This Tuesday, charity evaluator GiveWell removed the Against Malaria Foundation (AMF) from their top-recommended charities list. What was the reason?

GiveWell’s central concern is that AMF may fail to use new donations to fund bed nets, or only purchase these bed nets with great delay. In the past two years, AMF have spent less than one tenth of the funds they have received (~$1m, out of over $12m) and although AMF say they are currently in talks about distributions worth $40m,[1] GiveWell want more evidence that AMF really can ‘scale-up’ to this sort of level; if and when AMF distribute the $12m they currently hold, GiveWell will review their case and say they are likely to recommend them once again.

It might seem odd that AMF are failing to distribute their funds. There seem to be plenty of at-risk people who don’t have insecticide-treated bed nets… So what’s the problem?

Well, it seems that although many health charities and Ministries of Health want nets, many won’t accept them under AMF’s conditions- particularly, their conditions for strong monitoring of net distributions. To receive nets from AMF, for example, an organisation must take photos and videos of net distributions, and this imposes some cost and hassle for the distributor. Although AMF’s intention with such requirements is to deter the stealing of nets, net distributors may prefer to avoid the hassle, and hold out for the chance of obtaining nets from less demanding donors.

We have all sorts of questions to pose to AMF, and we hope to soon hold a Skype conversation with AMF’s founder Rob Mather. What would you like us to ask? What do you think of GiveWell’s demotion of AMF? Which charity will you be donating to following this update?

NB GiveWell suggest other possible reasons AMF has struggled to use its funding, and we recommend you to read their 

Thought the question of the most effective charity was settled? There are always more questions.

Rob Wiblin

Iron deficiency, or getting insufficient iron, is a large problem, affecting approximately two billion people worldwide. Iron deficiency commonly causes anaemia, higher levels of maternal mortality, and perinatal mortality. It even can increase the likelihood of contracting a disease[1]. Iron deficiency contributes substantially to global death and disability, particularly in developing countries. Pregnant women, perinatal women and young children are the most affected by iron deficiency, largely because of the high iron demands associated with pregnancy and growth.[1]

But this could be treatable. Iron deficiency has been called "the most common preventable nutritional deficiency"[2]. Interventions to reduce the health burden associated with iron deficiency, such as fortification and supplementation, have been claimed by some organizations to significantly reduce mortality and the risk of disease within a population. But are they correct?

What are the resultant health improvements following the introduction of interventions aimed to reduce iron deficiency in developing countries? Unfortunately, a quick review of the literature revealed that few studies have quantitatively measured the total health benefits from micronutrient fortification in countries where the disease has a substantial impact.

Due to the lack of directly-relevant data available, we looked to indirectly calculate the total health gain for an intervention by searching for data on four important parameters often reported within studies, albeit separately:

Health damage per person with a nutrient deficiency;

Share of the deficiency reduced through the intervention;

Share of the population with the deficiency;

Number of people within the study population.

We first searched key repositories of health related publications including PubMed, the World Health Organisation (WHO) and Cochrane websites using a variety of combinations of disease and Disability-Adjusted Life Years (DALY)-related search terms. Disability-Adjusted Life Years (DALYs) per person or across a population are a simple way to assess the health damage related to a disease, as they take into account the decrement to both length and quality of life that a person experiences as a result of the condition in question.

A total of 58 pertinent papers were identified. In addition to looking directly for information fulfilling at least one of our four defined parameters, we also noted additional information, such as other outcomes measured and the population sub-group studied.

Unfortunately, the low amount of evidence available means it's difficult to make claims with certainty. The results of our search demonstrated that iron deficiency anaemia, a key outcome of iron deficiency, was associated with a considerable and detrimental impact upon health. For instance, one study reported that the total global burden due to iron deficiency anaemia in 2004 was over 35 million DALYs.s Our spreadsheet containing our data 

It is important to bear in mind that iron deficiency is not the sole cause of anaemia, and anaemia is often used as an inappropriate proxy for iron deficiency anaemia. For example, anaemia can also be caused by other factors, such as P. falciparum malaria.[1] In 2009, WHO estimated that 60% of anaemia was due to iron deficiency in non-malarial areas and 50% in malarial areas.[3]

While not all of the information located fell neatly into our defined parameters, it was evident that simple interventions can have a major impact on health. For example, one report estimated that providing 50% of the global population with iron fortification would increase health by 59 million DALYs and ion supplementation would increase health by 59 million DALYs, when implemented over a 10-year period.[4]

Real life studies support this impressive estimate as realistic. A 21% reduction in perinatal mortality was seen in Africa after iron supplementation at a cost of only $16.59 over a year per pregnant woman, and fortification cost only $0.13 per person.[5] Put into context, the average cost-effectiveness of iron supplementation and fortification at 95% coverage in Africa was $66 and $20 per DALY averted, respectively.[5] These values are significantly below the widely accepted DALY cost-effectiveness threshold proposed by the World Bank of $150 per DALY for an intervention to qualify as an "attractive" investment for a low income country.[6]

Whilst researching, it became clear that sub-groups are affected differently by iron deficiency, with pregnant women and infants the most severely impacted, due to higher iron demands. For example, one study demonstrated that iron deficiency was responsible for 0.4% of all deaths in South Africa, but 7.4% of all deaths of pregnant women.[7] Indeed, many of the studies only considered the sub-groups of mothers and infants, or provided separate figures for them. Further investigation is warranted, as the data for the sub-groups could be weighted by their proportion of the overall population to give a more accurate picture of the total health impact.

Again, these conclusions should be looked at with a note of caution due to lack of evidence. The results are generalized from just a few epidemiological studies, and further investigation is warranted. But it does seem like that the large number of preventable DALYs caused by iron deficiency, as highlighted by our research, is just one piece of evidence in the mounting case for further action against the condition. Intervention could be promising as it could prevent large numbers of deaths as well as increasing the productivity of the workforce; in fact, annual productivity losses due to iron deficiency are thought to amount to approximately 0.57% of GDP in developing countries.[8]

There is a silver lining. Iron deficiency may be the "most common preventable nutritional deficiency"[2], but with the facts on the cost-effectiveness and health benefits of interventions laid out, one can but hope that its days as holder of that title are numbered.

By Ruth McElhone, working pro bono on behalf of Costello Medical Consulting, with Robert Wiblin

1. Stoltzfus R, Mulllany L, Black R. Iron deficiency anaemia. In: Ezzati M et al, ed. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Volume 1. Geneva, Switzerland: WHO, 2004:163-209.

2. De-Regil L, Suchdev P, Vist G, et al. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database of Systematic Reviews. 2011, Issue 9.

3. Mathers C, Stevens G, Mascarenhas M, et al. Global Health Risks: Mortality and burden of disease attributable to selected major risks. Volume Annex A: WHO, 2009:32-54.

4. WHO. The World Health Report. Chapter 5. 2002. Available at: 

www.who.int/whr/2002/chapter5/en/index5.html

5. Baltussen R, Knai C, Sharan M. Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world. J Nutr. 2004;134:2678-84.

6. Shillcutt S, Walker D, Goodman C, Mills A. Cost-effectiveness in low- and middle-income countries. PharmacoEconomics. 2009;27(11):903-917.

7. Nojilana B, Norman R, Dhansay M, et al. Estimating the burden of disease attributable to iron deficiency anaemia in South Africa in 2000. S Afr Med J. 2007;97:741-6.

8. Horton S, Ross J. The economics of iron deficiency. Food Policy. 2003;28:51-75.

Iron Deficiency: Are the Answers Already out There?

Ben Hoskin

When donating, we have the option of giving all our donation to a single charity, or smaller amounts to multiple charities. We sometimes have an intuition that we should divide up our donations. If 

 are all good charities, don't they all deserve my support? But there is a strong argument that, if you're interested in doing the most good, you should donate it all to one charity with plenty of room for more funding.