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Sally Murray

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

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 

Rob Wiblin

Iron Deficiency: Are the Answers Already out There?

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.

Ben Hoskin

Should you only donate to one charity?

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.

Suppose you donate $100 to SCI. By doing so, you're saying that SCI is the best use of $100. Now suppose you donate another $100 to AMF instead. By doing this, you're saying that AMF is a better charity to donate to. This can only be true if your past donation to SCI was a mistake (and therefore you should have given all $200 to SCI) or the $100 you gave to SCI fulfilled all their need for funding.

But SCI has lots of room for more funding, so unless you're donating millions of dollars, you're unlikely to have changed which charity was the best. So either your second donation should have gone to SCI, or the first should have gone to AMF. Either way, all your money should be going to the same place.

There might be some good reasons to donate to multiple charities, for example if you're a millionaire and can overwhelm an organization's room for more funding, or if you get new information and change your mind on which organization is the best. But there also are some reasons that aren't up to snuff.

Bad Reason #1: We don't know exactly which is better.

True, our knowledge is never 100%, but we have to choose somehow. Your donation to AMF simply means that, 

given what you know, taking into account our 

 for different outcomes, to the best of our judgement, as far as we can tell,

 AMF is the most cost-effective charity for your first $100. And that means it's probably still the best charity (as far as our evidence shows, in our best judgement, as far as we can tell) for your second $100.

If you have two charities, one is going to be a better place for your money than the other. If you split between them, you have a 100% chance of picking the winner, but you also have an 100% chance of picking the loser. Think of it like two lottery tickets - one that wins 60% of the time and one that wins 50% of the time. While it's true that the first ticket might lose and the second one might win, it's less likely. Therefore you should put your money only into the first ticket. Likewise, you should only put your money into the charity you think has the highest chance of being best.

Bad Reason #2: Just like I diversify my stock portfolio to reduce risk, I should diversify my donation portfolio.

It is important that we try many different approaches to solving poverty, hunger, and other global problems. After all, some might fail while others work better than expected - by having a variety of charities, we reduce our risk. Because of this, you should take into account how much each charity aids the global diversification effort when judging its effectiveness, and 

give all your donation to the charity you think is currently most underfunded

. Because it's the charities we want to be diversified, rather than your individual donations, the argument still applies: give all your 10% to the best charity - which might be best because it contributes most to the diversification of the global charity portfolio.

We diversify our financial portfolios because we care about the risk to ourselves, not just to the global economic system. With charities, we instead fundamentally care about the people we're helping, and reducing the risk to them. Donating to just one charity might increase the risk that my donation is less effective but reduce the risk to the beneficiary, it insured them against a tail risk. As we are donating to help people, rather than for self-gratification, this is a worthwhile tradeoff.

Alternatively, think about the size of your efforts compared to the overall problem. With your portfolio, you buy Google or Microsoft to work on the 'not having any tech stocks in your portfolio' problem. You buy enough stock to completely solve the 'being underexposed to tech' problem - so the rest of your investment can go into other stocks. With AMF, however, your donation is unlikely to solve the 'SCI doesn't have enough funding' problem - so further donations should still go to SCI.

Bad Reason #3: This is unfair to big charities.

You might think this means we should always donate to small charities, because donations make more difference to them. But the important thing isn't the percentage increase in charity revenues, but how much good the extra funding does; if a big charity is more cost-effective than small ones, we should donate to the big one. Larger charities might have more trouble with fungibility though.

Bad Reason #4: But I want to show my support to all the charities I like.

If you really liked a certain charity, presumably that means you believe in its mission and want that mission to succeed. But if you believe in its mission, you should want to donate to a charity not because you want to be nice to the charity, but because you want the mission to be accomplished. Therefore, you should give to whatever one organization you think best accomplishes that mission.

Bad Reason #5: If everyone did this, one charity would have all the funding in the world and every other charity would have nothing.

This wouldn't happen because it's impossible to get everyone to coordinate that well. Secondly, even if everyone in the world were on board with Giving What We Can, people would still take into account room for more funding. A general strategy of "everyone donates to the charity that does the most good" would lead to different people donating to different charities; people would donate to SCI until it no longer had room for more funding, and then the next people would donate to AMF until it no longer had room for more funding, then the next people to Deworm the World, and so on.

Bad Reason #6: I care about multiple issues! I want to end disease so I give to an anti-disease charity, I want to end crime so I give to an anti-crime charity, and I want to end poverty so I give to an anti-poverty charity.

Yes, we have many different values. But at any given time, one of these will be the most pressing; one of them will be easiest to make headway on. And that's the one we should concentrate on. By focusing all our resources on one cause, we have the greatest chance of accomplishing our cause.

Giving What We Can Oxford

You give ten thousand pounds, and we'll give ten thousand pounds.

Today, Giving What We Can: Oxford is launching the Big Match campaign! Every time you donate to the Against Malaria Foundation on their fundraising page, until early December, the Oxford Committee and many generous society committees from Oxford University will match your donation! There is enough funding to keep matching donations until £20,000 has been raised collectively (or £10,000 of public donations)! This is enough to buy over 6,500 bednets!

The Oxford Committee is following the Giving What We Can Warwick Committee, who last year, ran a hugely successful matching campaign for AMF, and is [still ongoing](http://www.AgainstMalaria.com/BigMatch3), currently doing a final push to match the £5,000 supporting their campaign. We hope to raise even more this year in the hope of generating a significant amount of publicity for this amazing charity, and saving a huge number of lives while we do it!

So please give today to ensure your donations make twice as much of a difference! The generous societies that have made this possible are:

Oxford Philosphy, Politics and Economics Society

Thank you very much to all giving at this time! 

Stephanie Crampin

Y The Freud Not?!

On Thursday 21st November, at 7pm at Freud's in Oxford, Giving What We Can is launching its first joint event with The Funding Network, and simultaneously launching its Oxford Big Match Campaign, which will be matching donations up to £10,000 for AMF in the next week.

£10 entry is charged, which will be donated to your charity of choice, three of our 

. Representatives from each charity (taken from our to recommended charities); Against Malaria Foundation, Schistosomiasis Control Initiative and Project Healthy Children, will give a pitch to try and to convince the audience of their chosen cause.

The best part of it all is that this coincides with the Big Match Campaign of Giving What We Can Oxford; meaning that for every ticket sold, a sponsor has offered to match the price of that ticket! So for your £10 donation you'll be raising £20 for these charities!

Alongside this crowd-funding aspect, there will be some fantastic performances and locally famous bands, including the Oxford Gargoyles. And of course, it is Freud's which makes it a whole lot better.

If you are in or near Oxford next week. bring your friends, your colleagues and anyone else who enjoys good music and great company!

Michelle Hutchinson

Giving What We Can's Plans

Giving What We Can aims to review its progress and plans every six months, and to publish the conclusions on the blog. This is the second of two blog posts, and contains a brief summary of our six month plan for the second half of 2013. In this period we are developing and trying out a system based around more personal contact and gradual involvement in Giving What We Can than we have previously employed.

Giving What We Can aims to move as much money as we can to the most effective charities we can find by growing our membership base of people giving at least 10% of their income to the most effective charities. Therefore, our key metric is the number of members we have. Over this period, we hope to gain sixty new members, which means increasing our average new member rate from eight per month to ten per month. The recent impact evaluation done on Giving What We Can estimated the return from gaining one member as being $17,000 to the most effective charities, counterfactually adjusted and time discounted (with a very large range).

During the coming period, Giving What We Can aims to focus primarily on outreach, and in particular on increasing the number of members it has, rather than on research. We will continue doing research into effective causes and charities, but cut back on more methodological research. We think we can have more impact working on outreach, given our progress over the last period.

Talking to members, we have found that individual conversation was crucial for convincing people of the importance of donating to the most effective charities, and doing so substantially. Following the media attention we received in December and January, membership growth was somewhat lower than we were expecting. Given that, we hypothesise that since joining Giving What We Can is a large commitment it would be more effective to have a lower bar to entry, and then encourage people to increase their giving more gradually. (

We are aiming to develop and try out a structured way to increase the number of people committed to giving to effective charities. Our current expectation for how that will work is the following. We would expect the first contact people have with us to be at an event that a representative of Giving What We Can speaks at, or through social media. We will then reach out to the people who show interest in effective giving, to answer their questions and chat with them more generally. We will aim to get people involved in a concrete way. For example, to sign up to 

. This allows people to become part of the community, to get into the habit of donating to effective charities, and hopefully to find that giving a proportion of their income is not the sacrifice it might appear to be. We will have regular contact with people signed up for 

, to support them and help them to maximise the good their donations do.

Our main aim in this period is to test out and improve the various parts of our outreach. During this development stage, our full-time team will remain small. The following describes how we intend to carry out the outreach. It is separated into its two main sections. They will be run by the Director of Communications, Steph Crampin, and the Director of Community, Ben Clifford, respectively.

The first stage of outreach is making people aware of Giving What We Can and effective giving, and attracting their interest. Over the coming period, our focus will be on generating interest among young professionals. We have a number of reasons for appealing to this audience in particular. They have immediate, measurable giving power, but also flexibility in their spending. In addition, a young professional vibe will appeal to students, while the reverse is not true. Therefore, this increases the breadth our appeal. To start off with, our geographic focus will be on London and Oxford.

We aim to generate interest by holding and speaking at events, as well as by producing interesting content for social media, in the form of blog posts and infographics. These channels are both personal, making clear that Giving What We Can is a group of real people who have made a commitment, and also highlighting that the idea of effective giving is relevant to the person reading or attending. In the past, this kind of personal contact seems to have been more effective than less personal but more widespread media.

We intend for these activities to drive traffic to the website. Therefore, the website needs to be user-friendly and modern, matching the expectations of young professionals audience. It also needs to have a clear path through it, encouraging people to get further involved if they are interested. To achieve these, we will improve the layout and design of the website. We will make it simpler, in order to make it more visually appealing and to create a clear pathway through it. We will implement personal dashboards, allowing people to track how much they have donated and how much good they have thereby done. (This is also important for impact tracking, as discussed in the previous blog post.)

In order to develop the system described above, we are investigating the most appropriate events to appeal to young professionals. This takes the form of research into the kinds of events which are held and attended in general among that demographic, and also trying out different types of events ourselves. At all these events, we distribute feedback forms in order to be able to work out to what extent the events interested and engaged people. The metrics we use to determine success in this area are number of events, number of people per event and number of people who provided us with contact details and reported their interest in future involvement.

Our surveys of both members and non-members indicated that personal conversation is very important when people are making decisions about significant donations. Therefore, the second part of our model is an emphasis on engaging people in dialogue. Our aim is to start conversations with people who are interested in donating to effective charities but unsure how to act on that interest. For example, people who have come to our events and expressed an interest, or who are discussing effective giving on social media. We would begin these conversations via email or messaging, and provide the option of continuing them over the phone or in person.

In conversations, we will aim to answer any questions and concerns people may have. We will also suggest signing up to 

. Many of our members reported expecting it to be a sacrifice to donate 10% of their salary, but then not finding it so when they did it. That indicates it would be beneficial for people to set themselves a target for a set time, allowing them to discover that giving a percentage of their income won’t affect their life as much as they expected.

Again, our aim in this period is to try to find out what works. We will send out a certain number of messages to various different groups of people who have shown interest in effective charities, to see which are receptive. We intend to find out how well-received and how effective our 

 system is. It has been an option on the website for a while, but it has not previously been strongly promoted. We are therefore starting by talking to the people who have already signed up to it, to see how they have found it. We are also trying out promoting it at events, to see if that is successful. We keep track of the number of messages sent out and number of conversations had, in order to compare those against the number of people who sign up to Try Giving and the number of people who take the 10% pledge.

As described in the previous blog post, we have found that it is important to provide personal discussion and support, as well as a gradual way to increase levels of giving. Therefore, in this period we are developing and testing a method of outreach which incorporates these lessons. In particular, we are reaching out to people face to face and through individual messages, we are encouraging people to join 

, and we are finding the best ways to follow up on these.

Carolina Flores

G8: KEEPING PROMISES?-Governance, Peace and Security

The G8 contribution to governance is rated as good. According to the Ibrahim Index on African Governance, between 2006 and 2011, 70% of African countries improved overall governance indicators, despite uneven performance. Fighting corruption and ensuring that democratic processes are clear tackles some of the root causes of poverty and provides an enabling environment for economic growth, and for the development of fairer and more inclusive societies. As the G8 has the potential to offer expertise and guidance in governance, this is an important area of intervention.

the African Peer Review Mechanism (APRM),

the Extractive Industries Transparency Initiative (EITI).

The G8 provide respectively 70% and 60% of the funding for each of these projects. The Peer Review Mechanism promotes democratic processes, citizens' rights, and the rule of law in 30 out of 54 African countries. Though the amount spent by G8 countries on government and civil society sectors has increased from to between 2007 and 2011, the gross disbursement for anti-corruption sectors has decreased significantly.

The Extractive Industries Transparency Initiative involves companies, who publish what they pay for, governments, who publish what they receive, and civil society, to whom they are held accountable. This allows for checking where revenues are going astray. As many poor countries have very good resources but don't explore them effectively or sustainably due to corruption and poor management, this is of critical importance.

Some problems which need to be acted on are conflict resources (e.g. 'blood diamonds') and the enforcement of foreign bribery laws. The Overseas Development Office disagrees with the rating based on the fact that all the commitments are based on a narrow transparency agenda and not on broader development goals.

The report evaluates G8 work on peace and security as good, claiming that there has been excellent progress on the regional centres of excellence for peace support, on transport and on logistics. G8 members have donated over 60% of the funding for the peace and security sector. The pledge to train and equip 75 thousand troops for peace support operations was exceeded. G8 support has contributed to successful peacekeeping missions in African countries such as Mali, Somalia, and the Central African Republic. This has resulted in the African Union, African countries and regional organisations becoming able to lead the mediation and resolution of conflicts independently. There has also been a continuous investment on Disarmament, Demobilisation and Reintegration is countries in post conflict situations.

Maritime security has improved. The G8 has successfully supported efforts to:

build the capacity of African states to cooperate on this domain,

construct information-sharing mechanisms.

The Overseas Development Office also disagrees with the rating in this area, considering that the report is very unclear and uses inadequate benchmarking.

Interview with the World Health Organisation

, a project of the World Health Organization to encourage cost-effectiveness via both research and communication with policy-makers. Rob Wiblin and I sat down to interview Jeremy and learn about WHO-CHOICE. Jeremy's main points were:

WHO-CHOICE is about giving countries the tools needed to establish priorities in the health sector and make good, high-impact-for-money policy.

The landscape of global public health is starting to shift to a time where, more and more, "best buys" and "magic-bullet solutions" such as vaccines are fully funded. This is exciting because it means people are getting important treatments, but it is also daunting because the next generation of interventions will involve more complex technical work and clearer communication with the public.

If you have a strong economics background, are quantitatively minded, and also have interests in epidemiology, biostatistics, or computer programming, a career at WHO-CHOICE or a similar organization could be rewarding and impactful.

WHO-CHOICE is a program in the World Health Organization that helps countries decide priorities and figure out what they should be doing based on considerations of impact and cost-effectiveness. While other tools might be available to them to tell them how to do things, WHO-CHOICE is unique in this focus on establishing priorities.

RW and PH: What's your methodology for determining cost-effectiveness?

JL: Well, first I'd like to clarify that we don't look just at interventions that are considered cost-effective, but we try to include any activities that may be considered policy-relevant: either because they're highly cost-effective or the opposite. What we do is we get a list of things we'd like to look at that include best practices developed by WHO programmes and then add to it a list of things we feel we'd like to analyze - usually things that have tremendous upside if they turn out right, for example vaccines. We then begin to solicit the opinions of experts.

This kind of analysis usually involves epidemiological and clinical evidence of impact, oriented by clinical trials. We want to know what the impact on the population of interest is when you give a certain population a certain technology. What is the impact on a disease parameter that is of interest to us? Does it reduce fatality rates/disease rates/ remission rates? This gives our estimate of effectiveness. For cost, we add the costs of administration, training, and programme elements to the cost of operations as determined from best practice guidelines.

Right now it's exciting because WHO-CHOICE is working with a number of world-class disease modellers that are perhaps the best in the world. It could be a real coup to bring all this expertise together and demonstrate with the best available scientific evidence that there's a couple of interventions that are the best buys in the health sector.

What has been your most interesting or significant results so far?