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Michelle Hutchinson

Welcome to our new website!

Welcome to the brand new Giving What We Can website! It has a new look, new structure and new features. Have look around, and 

The new website aims to be more accessible than the previous one. We’ve tried to give a new reader a clear pathway to follow through it, ending in a call to action – joining Giving What We Can. Since joining Giving What We Can is a substantial commitment, which not everyone is ready to take right away, the new website puts more emphasis on 

. Try Giving allows people to choose the percentage they’d like to donate, and over what period they’ll do that. People can use it to trial donating 10% for a short period, or to build up their giving gradually towards 10%. The website also makes it easier to donate through the Giving What We Can Trust (having that option always available in the top bar), in keeping with our core mission to move money to the most effective charities.

Building this website has been an immense project, for the successful completion of which we’re grateful to a great number of people. The largest share of the credit goes to our Director of Communications, Steph (regardless of how much she’ll try to deny it!). She oversaw the project from its beginnings, and managed the large number of people all working on different parts. She made sure that everything ran smoothly and that the result was the polished product you’re now looking at. Our Webmaster, Jacob, has been working tirelessly on the project alongside his PhD. As well as building new features and pages, he’s been responsible for bug fixing – a task which has at times led to anguished cries, (tame) swearing, and head banging. Thankfully, he’s survived to this point.

We’re also very grateful to the designers, and to Peter Orr who wrote all the new copy for the website. A large amount of the coding was expertly done by our Director of Operations, Tom. We are also incredibly grateful to and Adam Malone and Aurelien Navarre- two highly skilled volunteers from Drupal, who we met through ‘.impact’. Finally, we have been fortunate enough to have received help on coding, editing and bug finding from many dedicated and talented volunteers – thank you all very much!

I hope you’ll enjoy exploring the new website. I particularly recommend checking out the 

. A page you might like to look over, as providing what we hope is a useful call to action, is 

. The page to keep an eye on in the future is 

. It allows you to track your giving and shows you the impact you’re having on people’s lives. We hope you’ll find it to be a useful resource!

Andreas Mogensen

Call for registration – GOOD DONE RIGHT: a conference on effective altruism

 at All Souls College, one of the constituent colleges of the University of Oxford. We’re very pleased to announce that registration for the conference is now open. The conference will be from the 7th to the 9th of July. It seeks to bring together leading thinkers to address issues related to effective altruism in a shared setting. Speakers will include Derek Parfit (Oxford), Thomas Pogge (Yale), Rachel Glennerster (MIT Poverty Action Lab), Nick Bostrom (Oxford), Norman Daniels (Harvard), Toby Ord (Oxford), Jeremy Lauer (WHO), William MacAskill (Cambridge), Larissa MacFarquhar (the New Yorker), Nick Beckstead (Oxford), and Owen Cotton-Barratt (Oxford). The speakers are drawn primarily from within moral philosophy, but there will also be academics who specialize in development and health economics. There will also be a conference dinner on the 8th in the Hall at All Souls. You can learn more about the conference at 

 , which also contains instructions for how to register and suggestions for finding accommodation. We very much hope to see you at the event.

Giving What We Can’s six month review

Giving What We Can carries out reviews of its progress and plans every six months. This post and the following describe the results of our most recent round of these. In the second half of 2013 we focused in large part on improving our pathway from interest to membership. That focus seemed to pay off with the rate of new members joining almost doubling from the first to the second half of 2013.

Giving What We Can's vision is a world without extreme poverty. We aim to contribute to that vision becoming a reality by inspiring donations to the organisations which are most effective in helping those in the developing world. Our key metric is our number of members, where each of our members have pledged at least 10% of their lifetime income to the most effective charities. Over this period we 

, increasing our average member growth from 8 to 10 per month. In fact, we gained over 80 new members, which increased our donations pledged to the most effective charities by $30million.

The last six months have seen many exciting developments. We moved into new offices at the University of Oxford. We share these with our parent organisation, the Centre for Effective Altruism (CEA) and our sister organisation 80,000 Hours. We also now work next to Oxford researchers working on big challenges faced by our world - the Future of Humanity Institute and Uehiro Centre for Practical Ethics. Our ideas were introduced to high-level policy makers: our President, Toby Ord, visited No. 10 Downing Street on multiple occasions to advise on a range of policies for achieving good. Twenty interns joined us for a fortnight in September, producing among other things valuable research and a video for our home page. We improved our model for getting new members, resulting in a large increase in member growth. Below I explain how we achieved this. Over the first six months of 2013, we seemed to find that our strategy of getting a brief message about Giving What We Can to a very large number of people was not as effective as we had hoped in encouraging people to actually pledge. Therefore, in the year from summer 2013 to summer 2014 we are trialling an approach we hope to be more promising - of providing a personal and gradual pathway to joining. This begins with someone learning about effective giving and Giving What We Can through either an event, or through social media. We hope that people will then visit the website or show interest in a way that we can individually follow up on - providing their email address or engaging with our social media content. Over the second half of 2013, we focused on researching good ways to implement these various stages, and building capacity for them. Our market research indicated that social media is very important to our target audience (young professionals), and also that they are happy to attend events. Over this period, we tried a range of different kinds of events - Giving Games, talks and joint events with other organisations. Joint events appeared promising, since they are a good way to increase the size of the audience. We also tested a range of different kinds of social media posts, and have produced a range of online content, from posts to videos. The aim of this is to increase levels of engagement with our content, so that we can reach out to individuals to chat to them individually about effective giving. The next step for many people will be to visit our website. The website needs to have a straightforward path through it to taking action. It also needs to be informative but clear, and to make sure that we are presented as the kind of community people would like to be a part of. To achieve that, we have been making a new website. Over this period, we did the design and wrote the copy for new website, and began the coding. In order to allow people a more gradual way of getting involved, we believed that emphasising Try Out Giving to a greater extent would be effective. Try Out Giving allows people to challenge themselves to donate a percentage they choose for a period of time they choose. We were concerned, however, that this might result in people donating less than 10%, when they would otherwise have been willing to pledge 10%. Therefore, we talked to the people who had taken part in TOG so far. The majority expressed an interest in renewing their commitment when it ran out, and some took the 10% pledge. This indicates that people see TOG as a good way to work up to joining Giving What We Can fully. Our market research among young professionals indicated that people are unlikely to immediately take a 10% pledge, and that having an interim stage would work better. We worked to improve the joining process in a number of ways. We increased the number of ways of joining, by making an online form, and trialling people joining by phone (the latter turned out not to be popular). We tested out different amounts of follow up for people who had shown interest but not actually joined. We were surprised by how much follow up people appreciated, and how little of an imposition reminders were seen as. Improving this process made a big impact on our member growth. We presented our review to the Trustees of the Centre for Effective Altruism, and to our Advisory Board. Summaries of their comments can be found 

. Both were very pleased with the progress over the period, and feel that it shows that the focus on membership seems to be an effective strategy. The review period is a good time to reflect on the impact that we can collectively have. $30million pledged to the most effective charities, the increase in pledged donations over this period, can help people in the developing world a really amazing amount. Donated to AMF, that would save around 10,000 lives. Rather than having their lives tragically cut short, each of those 10,000 people can go on to lead full and prosperous lives. It's truly remarkable that we are in a position to help others so much. You can also read our 

Stephanie Crampin

India fights polio- and wins.

Three years ago, India faced its last confirmed case of polio, in Rukhsar Khatoon, in the CNN video above. Today, while she and the remaining Indian polio victims cannot be cured, there is hope for India’s future population, as the World Health Organisation has declared it polio free.

Polio is a crippling and potentially fatal infectious disease. It is caused by a virus which invades the nervous system and potentially causes irreversible paralysis. It was one of the most feared diseases in industrialised countries at the beginning of the 20th century, and was only combated after the introduction of effective vaccines in the 1950s and 1960s.

While the global effort to end polio was launched in 1988, India was still one of the four remaining endemic countries in 2006, along with Afghanistan, Nigeria and Pakistan. The keys to the success of the eradication efforts have included innovative refrigerator design, to deliver vaccines to remote villages. Vaccines are very cheap (at 12 cents per vaccine), but preserving them for long enough to reach people in remote locations is crucial for complete coverage. Another key element of the success was combating behaviour induced by cultural objections to taking the vaccines. This included communications work to prove the vaccines were safe, and build trust between administrators and the public.

Eradicating a disease anywhere is a huge milestone, given the multitude of practical, logistical and social aspects that it involves. Not only must effective and cheap vaccines be produced, but they must be transported and stored safely. People must be taught to accept and use these vaccines through social marketing, and the strategy used for targeting people to vaccinate could mean the difference between an 80% coverage goal and a 10% coverage goal.

We celebrate with India in this success. Disease eradication makes a huge impact on the wellbeing of people globally, now and in the years to come. To take smallpox as an example, the eradication of this disease has saved easily as many lives as world peace post 1800 would have done. We hope that by 2018, we will see similarly massive benefits with the end of polio.

Polio Eradication and Endgame Strategic Plan 2013–2018

Olga Kuznetsova

How cost-effective is it to treat multidrug-resistant tuberculosis?

Every year on the 24th of March, World TB Day raises awareness of the global threat posed by tuberculosis. Although much progress has already been made in combatting the disease, challenges still remain. In particular, the rise of drug-resistant tuberculosis has made efforts to control the disease very difficult, and it is necessary to assess the effectiveness of different treatment strategies.

About a third of the world’s population has tuberculosis (TB), a bacterial infection caused by 

. TB spreads from one person to another in airborne droplets from the throat and lungs. While in the majority of people the infection is latent, meaning that they carry the bacteria but are not ill or infectious, a significant proportion develop disease. TB affects the lungs and causes symptoms such as cough (sometimes with sputum and blood), chest pains, weakness, weight loss, fever and night sweats [1]. Despite the fact that TB is both preventable and curable, it currently ranks as the second leading cause of death worldwide from a single infectious agent after HIV, with 8.6 million new cases and 1.3 million deaths reported in 2012 [2]. The main brunt is borne by the world’s poorest people: 95% of all deaths from TB occur in low- and middle-income countries. The probability of developing TB is higher in immunocompromised people, such as those infected with HIV, malnourished, diabetic, or those who use tobacco [1]. The interventions most often used today are preventative measures such as vaccination, and treatment with antibiotics, which can be very cost-effective. However, poor adherence to the treatment can result in bacteria developing resistance to the antibiotics, giving rise to multidrug-resistant TB (MDR-TB). This article will discuss the various options for treating MDR-TB, as well as their cost-effectiveness.

Reassuringly, TB incidence and mortality worldwide are dropping. Following the World Health Organisation’s (WHO) Global Plan To Stop TB with several targets to be achieved by 2015 [4], TB incidence is falling in most parts of the world, and mortality has reduced by 45% since 1990 [3]. This success results from the implementation of the DOTS/Stop TB Strategy, launched by the WHO in the 1990s. Key elements of the strategy include improving TB detection by bacteriology, standardised treatment and sustained drug supply, and recording and evaluating patient data. DOTS (Directly Observed Treatment, Short-Course) is a six-month chemotherapy course using first-line antibiotics, where the administration of drugs is directly supervised by a trained individual to ensure the patient adheres to and completes the treatment [5]. The cost-effectiveness of DOTS has been researched in a number of countries. The principle of cost-effectiveness is to assess the cost of an intervention (compared to another intervention or compared to doing nothing) against the benefit to the population. This is typically expressed in $ per DALY (Disability Adjusted Life-Year) averted [6]. For more information on DALYs, please refer to the latest Giving What We Can blog post on this topic [7]. The cost-effectiveness of DOTS ranges from US$5 to $50 per DALY averted, except for Eastern and Central Europe, where the cost is higher [8, 9].

Despite the recent success in treating drug-sensitive TB, there is a threat to the TB control programme from bacterial resistance to first-line antibiotics. MDR-TB, caused by bacteria resistant to at least two of the most effective anti-TB drugs (isoniazid and rifampicin), is now a serious public health problem in several countries. At the moment, only 3.6% of new TB cases are multidrug-resistant, compared to 20% among previously-treated patients. However, in some countries such as Azerbaijan, Belarus, and some regions in the Russian Federation, the percentage is much higher (see figure). MDR-TB arises from poor compliance with treatment or incorrect use of drugs [3, 10]. Combatting MDR-TB is included in the Global Plan To Stop TB, which recommends testing for drug resistance in high-risk patients and treatment with second-line antibiotics such as amikacin and kanamycin. However, so far only 34 out of 107 countries have achieved the 2015 target of successfully treating ≥75% of MDR-TB patients. This may be in part due to low detection rates: only 18% of the estimated global MDR-TB cases were reported to the WHO in 2012 [10].

Figure: Percentage of new TB cases with MDR-TB, from the WHO Global TB Report 2013

Although second-line therapy is more effective at curing MDR-TB patients than DOTS, it is more expensive, requires longer treatment, and can have more side-effects [11]. It is therefore important to identify the most cost-effective models of treatment, especially in poorer regions where the burden is highest. The cost-effectiveness of different MDR-TB interventions has already been analysed for several low- and middle-income countries. One study evaluated five different treatment programmes used in Peru. These were DOTS, standardised second-line drug courses for previously-treated patients, with or without testing for drug resistance (STR1 and STR2, respectively), and individualised treatment following drug susceptibility tests for previously-treated cases or all TB cases (ITR1 and ITR2, respectively) [12]. With such studies, a range of assumptions must be made about the prevalence of MDR-TB in the country, the rate of transmission, and cure rate probability for each intervention. The results are gives as incremental cost-effectiveness, i.e. the net extra cost per net benefit of one strategy compared to another. Overall, DOTS-Plus strategies (testing a previously-treated patient for MDR-TB and treating them with second-line drugs) were more cost-effective than DOTS on its own. STR2 would prevent 4.8 deaths per 100,000 over 30 years, at an incremental cost of $990 per DALY averted compared to DOTS. STR1 provides the same benefit as SRT2 but at a higher cost, and is therefore less effective. The WHO considers an intervention to be cost-effective if the cost per DALY averted is lower than three times the per capita GDP of that country, and highly cost-effective if it is lower than one per capita GDP [13]. All things considered, ITR1 was determined to be the optimal strategy for Peru, preventing 0.9 deaths per 100,000 over a 30-year period at an incremental cost of $990/DALY averted compared to STR2 (below the $2,360 per capita GDP in Peru), or $6400/DALY averted compared to DOTS.

A more recent extensive review compared MDR-TB interventions in four regions: Estonia, Peru, Philippines and Tomsk Oblast in the Russian Federation [14]. While in Estonia and Tomsk patients were treated predominantly in hospital, Peru and the Philippines employed mostly ambulatory care. In terms of treatment strategies, Peru used a standardised regimen, while the Philippines, Estonia and Tomsk all used individualised regimens with drug resistance tests. Due to the higher costs of hospital stays compared to ambulatory care and differences in drug costs, the cost of treatment per patient varied from $2423 in Peru to $14,657 in Tomsk. The costs per DALY averted were $163 in Peru, $1156 in the Philippines, $598 in Estonia and $745 in Tomsk. While the costs of treatment per patient differed greatly depending on the region, the cost per DALY averted was still below the per capita GDP in all four regions, making the interventions highly cost-effective. Even better cost effectiveness was achieved for outpatient care compared to hospitalisation. If the health effects observed for these regions are possible in other countries, an outpatient model of care would be recommended for treatment of MDR-TB. However despite the promising result, the quality of the data in the paper is limited, as none of the four studies were conducted in association with a randomised controlled trial and there was no comparison of different types of interventions within one region, as was the case for the 2006 Peru study. However, randomised controlled trial data are rarely used in economic evaluations, and the studies scored highly according to standard checklists for determining economic data quality.

Overall, the analyses suggest that treatment of MDR-TB using second-line drugs coupled with an individualised approach is highly cost-effective in low- and middle-income countries, particularly if the patients are not hospitalised. The challenge remains to implement such an intervention in all countries with a high burden of MDR-TB, but this can only be made possible with better detection rates. In the meantime, it is worth to investigate charities that work in this sector and make recommendations to donors based on the research.

WHO: Cost effectiveness and strategic planning (WHO-CHOICE)

Giving What We Can Blog: Measuring benefits

Baltussen R, Floyd K and Dye C. Cost Effectiveness Analysis of Strategies for Tuberculosis Control in Developing Countries. BMJ. 2005;331(7529):1364

Resch S, Salomon J, Murray M et al. Cost-Effectiveness of Treating Multidrug-Resistant Tuberculosis. PLOS Medicine. 2006;3(7):e241

WHO: CHOosing Interventions that are Cost Effective (WHO-CHOICE)

Fitzpatrick C and Floyd K. A Systematic Review of the Cost and Cost Effectiveness of Treatment for Multidrug-Resistant Tuberculosis. Pharmacoeconomics. 2012;30(1):63-80

David Mathers

World Water Day

Currently, a large proportion of the world’s population lacks access to clean and safe drinking water, and this is a major cause of infant mortality in the developing world. Diahorrea is the second largest cause of death worldwide, amongst children under the age of 5, killing around 760 000 a year, and most cases are caused by lack of access to clean drinking water, or lack of proper sanitation (toilets, etc.). (Interventions designed to improve access to clean water, proper sanitation and to improve hygiene are known collectively as WASH interventions.) Further, improved access to clean water and better sanitation and hygiene may help prevent many deaths from other diseases, such as acute respiratory infections, which kill well over a million children every year.

So it is clear that improving access to clean water and sanitation in the developing world has the potential to save very many lives.

So, the ability to provide access to clean water to those who currently lack such access (and to get people to make use of it) has the potential to save many lives. With this in mind, it is incredibly important to know how to design a charitable intervention which actually improves such access. This is much less easy than it sounds. For example, it is one thing to build a new well, but wells can often fall into disrepair relatively rapidly, and clean water can become re-contaminated in various ways after being removed from the well. We need to use evidence to inform our decisions of where to combat these important issues.

Recently there have been some promising preliminary results in randomized clinical trials run by ‘Innovation for Poverty Action’ and ‘Poverty Action Lab’, on the provision of dispensers for chlorine, which sterilisers water, in the developing world. These results have lead to the founding of ‘

’, which we have already looked at in some depth. This intervention seems to avoid many of the problems with other WASH interventions, for example, chlorine remains in the water for up to 24 hours, preventing recontamination in many cases. Our report on this new charity can be found 

Although donations to Dispensers for Safe Water are potentially very high impact, they are not among our highest recommended charities. However, this is one of the most promising charities we have seen in the area of WASH; one which may well prove highly effective (they claim a cost effectiveness ratio of 1 DALY averted per/$67.50 donated), if results from the early Randomised Controlled Trials prove replicable. If you’re looking to donate in recognition of World Water Day, Dispensers for Safe Water looks to be a great investment!

http://www.who.int/mediacentre/factsheets/fs330/en/

An academic reference for this claim is given 

Clasem TF, Roberts IG, Rabie T, Schmidt WP, Cairncross S. (2009) Interventions to improve water

https://www.givingwhatwecan.org/blog/2014-01-28/dispensers-for-safe-water

Carolina Flores

Medical Aid Films: targeting deaths at childbirth

 (MAF) is a young charity which wants to reduce childbirth-related mortality in the developing world by creating and distributing health education films. Taking in account the scale of the problem, interventions in this area have the potential to make a big difference. Is MAF a good opportunity for giving?

The Problem of Newborn and Maternal Mortality

MAF was born out of the experience of midwife Fiona Laird while working for Medecins sans Frontieres in a refugee camp in Darfur. Witnessing newborns and mothers die due to basic mistakes in hygiene, delivery, and care-as basic as cutting umbilical cords with dirty knives-she decided to set up training in the camp. This was tremendously well attended, showing that women were thirsty for education with the potential to save their lives.

The problem Fiona witnessed affects a large portion of the population of the developing world. It is estimated that, every year, over 350 thousand women die as a result of pregnancy and childbirth, and that almost three million newborns die a year - 44 per cent of all under-five deaths. This has been recognized to be a priority: two of the 

 are reducing child mortality and improving maternal health. However, progress has been somewhat disappointing. The aim to reduce child and maternal mortality by two thirds between 1990 and 2015 is still far from being met: as of 2012, these had only dropped 47 per cent, remaining very high in Sub-Saharan Africa and Southern Asia. A staggering 80 per cent of these deaths are considered to be easily preventable by basic medical care and education. It seems, then, that by improving childbirth provision and newborn care, it would be possible to have an extraordinary impact.

A big part of the problem is that in regions where there is a shortage of skilled medical workers, health education is usually unavailable. Medical Aid Films aims to address that lack. Their films teach practices which can increase maternal and newborn health, and being made in collaboration with local production companies, they are adapted for different cultures. Most importantly, a single film can be widely distributed and left in different health and community centres, where it can be watched and re-watched by both health care providers and local women. Other important advantages are that films can overcome lack of literacy and allow for clearer, and possibly easier-to-remember, explanations of the relevant practices.

Since Fiona's trip to Darfur in 2006, Medical Aid Films has produced films on 26 child and female health topics (and translated them into several different languages) and distributed more than 17 thousand copies of these to over 850 partners in 60 different countries. They have made changes to their methods according to the ongoing feedback they receive from the field. Small case studies seem to indicate that the approach has had positive effects.

The most detailed study of the effectiveness of their work conducted so far was an external evaluation by 

 on the Chitambo Film Education Project. This project ran for 12 months in rural Zambia, centred at the Chitambo hospital, which has a catchment area of over 100 000 people over a 90 km radius, and has only one doctor. Maternal and newborn mortality rates are high in the district and only three in ten women deliver their babies in the hospital.

MAF provided films on five different topics and support to staff. The films were screened on portable projectors bi-weekly at the antenatal care clinics at the hospital and during outreach sessions held once a month at 14 rural healthposts. Between March and August, over 2000 people attended screenings (non-unique individuals). Though there was no change in hospital attendance, audiences reported high levels of engagement with the films and changes in individual behaviour of mothers, and health workers claimed that the films had improved the content and quality of health education. Further, hospital staff noted that, without the films, no education would have been provided at the sessions.

Is this an area of intervention with potential for effectiveness?

 looked at different interventions in maternal mortality. Despite the high number of maternal deaths considered avoidable (i.e. which could be prevented by the use of existing technologies) by the 

, they concluded that there was only good evidence for effectiveness for government-level interventions. This has been attributed to providing broad, free access to health services, professionalizing midwives, using data to guide policy-making, and targeting vulnerable groups.

As for specific interventions, no good evidence for effectiveness was found, though some of the programmes studied had positive effects. Give Well investigated training traditional birth-attendants, providing skilled birth attendants, antenatal care, community mobilization, and clean delivery kits.

Of the ones relevant to MAF's work, training traditional birth-attendants was found to have an effect in reducing child mortality and increasing knowledge, but not in reducing maternal mortality. This may be due to lack of medical services to which to refer women with major complications, barriers to learning, and insufficient training to give skills to perform life-saving interventions. Community mobilization was found to be the intervention with the most potential. The study cited attributed a statistically significant reduction of maternal and newborn mortality to setting up facilitator-led groups, though the estimated cost per infant life saved was still higher than for the most effective charities.

These results suggest that tackling the problem may require a broader intervention in the health systems of the affected countries. But they also indicate that MAF is a promising intervention. The fact that films can reach far and stay with the communities allows for a sustainable provision of education, in many cases where there was none before. The films may improve education of un-skilled midwives by transcending language barriers, and they may facilitate community mobilization. MAF also seems committed to improving standards based on feedback, and they are aware of the need to collect more quantitative data before and after their interventions.

http://www.un.org/millenniumgoals/pdf/Goal_5_fs.pdf

http://www.un.org/millenniumgoals/pdf/Goal_4_fs.pdf

http://www.givewell.org/international/technical/programs/maternal-mortality

The Chitambo Film Education Project: Summary of External Evaluation

Suhail Patel

Malaria scales new heights

Researchers have warned that future climate warming could lead to an increase in malaria cases, according to a study published in the journal 

Last week, scientists from the University of Michigan and London School of Hygiene & Tropical Medicine, published strong evidence linking increases in temperature with the movement of malaria to higher altitude areas which have normally been safe from the disease. According to the paper 'The impact of global warming on insect-borne diseases and on highland malaria in particular remains controversial. We provide evidence for an increase in the altitude of malaria distribution in warmer years, which implies that climate change will, without mitigation, result in an increase of the malaria burden in the densely populated highlands.' The study found that when temperatures increase, mosquitos infected with the Plasmodium parasite are able to move to colder areas, whereas before the lower temperatures would slow down both the mosquito and the development of the parasite within it.

As mosquitos are able to move outside the 'malaria belt' due to global warming, densely populated regions of South America and Africa would be left vulnerable to a malaria epidemic. Using records spanning over 15 years from the highland regions of Ethiopia and Colombia, the scientists predicated a three million increase in annual cases if temperatures were to rise by 1.8 degrees Fahrenheit. 'This is indisputable evidence of a climate effect,' said Mercedes Pascual, a disease ecologist at Michigan and one of authors of the 

 paper. 'Our findings here underscore the size of the problem and emphasize the need for sustained intervention efforts in these regions, especially in Africa.'

Sam Donald

Why We (Still) Don’t Recommend Microfinance

Microfinance is the provision of financial services - loans, savings, and insurance - to those living in poverty. Like those in the developed world, the poor benefit from access to financial services through the ability to fund short and long term consumption needs, cope with unexpected shocks to income and expenses, and invest in business or household items (Matin et al 1999). However, the poor have limited access to more formal financial services, and have thus traditionally relied on a range of institutions, which often charge high premiums or interest rates (Matin et al 1999, Steel et al 1997). Microfinance institutions hope to provide access to those services to a wider range of people living in poverty, in the hope that they will benefit from them. The majority of microfinance institutions, charities, and research projects focus on microcredit - the provision of small collateral-free loans to those who cannot usually get access to credit. We shall do the same here, as the profile and scale of microcredit mean it is the most likely recipient of donations within the microfinance category, and there is more evidence for which we are able to judge its effectiveness.

There are three main benefits to microcredit which have been most commonly mentioned. Firstly, small landholders and businessmen can use credit to make investments in their farms/businesses to create a return greater than the cost of the loan, creating a cycle of improvement and growth which brings them out of poverty. These are the case studies most typically cited by microfinance charities, and have an intuitive appeal and logic, as well as fitting well with the 'poverty trap' model espoused by Jeffrey Sachs. Secondly, that the provision of credit can enhance the freedom of those in poverty, by giving them options and choices which were otherwise unavailable to them. Thirdly, that microcredit may empower and enhance the status of women, and improve the allocation of household resources towards women and children.

Although there have been studies which have shown positive effects of microcredit on labour supply, school enrolment, expenditure per capita and non-land assets (Pitt & Khandler 1998, USAID studies in Peru, India, Zimbabwe), others have failed to replicate the results and similar studies have received significantly less favourable results and criticised the methodology and data involved (Duvendack et al 2011). Randomised controlled trials (RCTs), often seen as the gold standard for assessing the impact of interventions (although not without issues) have previously been thin on the ground in the area of microcredit, but they have increased in number over the last year, and the majority of recent studies have shown that as a tool to escape poverty - the most commonly cited benefit of microcredit - it does not perform well. Studies from the past year have found no statistically significant evidence of an increase in socio-economic indicators such as income, consumption, health, and education (despite businesses expanding) after RCTS of microcredit in a variety of countries: Morocco (Crépon et al. 2013), Ethiopia (Tarozzi et al. 2013) Bosnia-Herzegovina (Augsburg et al. 2014), Mexico (Angelucci et al. 2013) and India (Banerjee et al. 2013). This is a conclusion reached by the majority of individual methodologically sound studies, as well as major systematic reviews of the available evidence (van Rooyen et al., Duvendack et al 2011, Banerjee 2013).

Further, while some may benefit from microcredit, there is significant evidence that for some it has potential for harm (van Rooyen et al 2012, Roodman 2012), in a similar manner perhaps to payday loans in the developing world, a 

 which GiveWell have drawn. While some recent studies do not find evidence of harm on income (Angelucci et al. 2013), even they do not find significant positive impact. Even if for many microcredit was a tool to escape poverty (which is far from clear) donors would rightly be concerned about funding an intervention which may actually cause harm to some. Further, some studies have found a decline in school attendance for those aged 16-19 in families who have had access to microcredit as family businesses expand and draw in labour supply from young adults; the long-term consequences of which are uncertain (Augsburg et al. 2014).

The evidence is more supportive of the ability of microcredit to promote the freedom of those in poverty, but it depends on the situation, and again, credit still has the ability to entrap some people through bad luck or bad judgement (Roodman 2012); moreover, in some areas there is evidence of overlending, with some either borrowing too much or borrowing from multiple borrowers (Planet Rating March 2013). A positive effect of microcredit which is related to freedom is that there is fairly strong evidence that microcredit leads to a decline in consumption on 'temptation goods' such as alcohol and tobacco (Banerjee 2013, Banerjee et al. 2013, Augsburg et al. 2014) for reasons that are unclear.

The effect of microcredit on female empowerment had been contested, with some studies finding positive, but non-uniform effects, and other systematic reviews finding they can neither support nor deny the notion that microcredit is pro-women (Duvendack et al 2011). However, the most recent RCTs from the past year have found no evidence of an increase in female empowerment (Augsburg et al. 2014, Tarozzi et al. 2013, Banerjee et al. 2013, Crepon et al. 2013), although we should note the difficulty of measuring such impacts (van Rooyen et al. 2012)

For the above reasons, we cannot recommend microcredit as a good choice for charitable giving. (Given the lack of any conclusive evidence of reliably positive impact, and evidence of some being harmed by microcredit, it is neither worthwhile nor possible to calculate a cost-effectiveness measure of microcredit in order to compare to other interventions). However, there are also other issues which cause us to recommend against microfinance as an avenue for charitable giving at this moment.

Firstly, there is a possibility that better research in the coming years could perhaps reveal which microfinance interventions are the most effective, and create opportunities for giving to microfinance which do have strong, measurable impacts. Indeed, GiveWell recommends the Small Enterprise Foundation as a standout 

, against a backdrop of strong misgivings over 

, suggesting that charities with a commitment to self-evaluation may in the future produce significant, measurable, and repeatable impacts. RCTs from the past year have shifted the balance of debate decisively towards the conclusion that current microfinance initiatives have at best limited effects in experimental studies, and perhaps the next generation of studies will diagnose the reasons for this and design more effective forms of microcredit. Relatedly, there may develop greater opportunities within microfinance in areas other than microcredit, such as microsavings, which has shown promise (Duvendack et al 2011, van Rooyen et al 2012)

Secondly, "microfinance activities and finance have absorbed a significant proportion of development resources, both in terms of finances and people" (Duvendack et al 2011), and have also seen the entrance of many commercial operations. This raises questions over whether there is room for more funding, and even in some areas whether additional funding would result in overlending and actually cause harm, 

Thirdly, GiveDirectly performs a similar role - the only difference being that the 'loan' is not repaid - and has strong 

Despite a strong narrative and intuitive appeal, we cannot recommend microfinance institutions as a recipient of effective-giving. The available evidence finds no statistically significant improvement on poverty-related outcomes or female empowerment (and indeed it may negatively affect some recipients), while the effect on most freedom-related outcomes is varied and inconclusive. Further, microfinance has received significant attention and resources while other less heralded interventions which have shown significant effects have received far less funding. Recent RCTs strongly support the conclusion that the impact of microcredit on poverty is limited at best, and more high-quality research from academia and microfinance institutions is necessary to reveal the effects and pathways more clearly, as well as to inform best practice.

Angelucci, M., D. Karlan, and J. Zinman (2013). Win some lose some? Evidence from a randomized microcredit program placement experiment by Compartamos Banco. Working Paper.

Attanasio, O., B. Augsburg, R. D. Haas, E. Fitzsimons, and H. Harmgart (2013). Group lending or individual lending? Evidence from a randomised field experiment in Mongolia. EBRD Working Paper No. 136.

Augsburg, B., De Haas, R., Harmgart, H., Mehgir, C., (2014). Microfinance at the margin: experimental evidence from Bosnia and Herzegovina. Working Paper.

Banerjee, A. (2013). Microcredit under the microscope: What have we learned in the past two decades, and what do we need to know? Annual Reviews of Economics 5, 487{519.

Banerjee, A., E. Duflo, R. Glennerster, and C. Kinnan (2013). The miracle of microfinance? Evidence from a randomized evaluation. MIT Department of Economics.

Crépon, B., F. Devoto, E. Duflo, and W. Pariente (2013). Estimating the impact of microcredit on those who take it up: Evidence from a randomized experiment in Morocco. Working Paper.

Duvendack, M., Palmer0Jones, R., Copestake, J., Hooper L., Loke Y. and Rao, N., (2011), 'What is the evidence of the impact of microfinance on the well-being of poor people?', August 2011, London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London

Matin, I., Hulme, D., Rutherford., S (1999). Financial services for the poor and poorest: deepening understanding to improve provision. Finance and development research programme working paper series no. 9. Manchester: IDPM, University of Manchester Pitt, M., Khandker, S., (1998) The impact of group-based credit programmes on poor households in Bangladesh: does the gender of participants matter? Journal of Political Economy, 106 (5): 958-996.

Roodman, D., (2012). Due Diligence: An impertinent inquiry into microfinance. Centre for Global Development

Steel, W. F., Aryeetey, E., Hettige, H. and Nissanke M. (1997), 'Informal Financial Markets Under Liberalization in Four African Counties', World Development, vol. 25, no. 5, pp. 817-830, Elsevier Science Ltd.

Stewart, R., van Rooyen, C., Korth, M., Chereni, A., Rebelo Da Silva, N., de Wet, T., (2012) Do micro credit, microsavings and microleasing serves as effective financial inclusion interventions enabling poor people, and especially women, to engage in meaningful economic opportunities in low and middle income countries. A systematic review of the evidence. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London

Tarozzi, A., Desai, J., Johnson, K., (2013), On the impact of microcredit: evidence from a randomized intervention in rurar Ethiopia. Working Paper

Jessica Costello

Measuring benefits

By investing in the most effective charities, we can extend people's lives. We can improve the quality of their lives. Sometimes we can do both. But how do we measure and compare the potential benefits that charities provide, to ensure we are indeed investing in the most effective ones? We use metrics known as Health-Adjusted Life Years (HALYs), which involve the trade-off between duration and quality of health in a single numerical unit. [1] There are two types: Quality-Adjusted Life Years (QALYs) and Disability-Adjusted Life Years (DALYs). These measure health gain and loss, respectively,[2] and as such, may very broadly be considered inverse metrics.[3] Quality-adjusted life years (QALYs) have been used in the assessment of health interventions for three decades[4] as an aid to resource allocation.[5] Although the measure is well-established, the assumptions underlying it are ever debated.[6]

Individuals move through health states over time; these consist of varying levels of functioning within a set of health domains, which may include mobility, cognition, pain, emotional functioning, self-care, and so on.[7] The domains considered are contingent on the instrument used to measure the health state, such as the EuroQol five dimensions (EQ5D) or the Health Utilities Index.[8] Each health state is assigned a certain value (or utility) which is determined by assessing the preferences of a group of individuals for being in any one state (using methods like the standard gamble or time trade-off). A value of zero represents death, while a value of one represents full health. It follows that any state in between (of less than perfect health, e.g. living in a wheelchair) is also assigned a value in between.[4]

A QALY score is obtained by multiplying (or weighting) the amount of time spent in a health state by the utility score assigned to that health state.[4] For example, it takes one additional year of perfect health (utility score of one) to obtain one QALY. It also takes four additional years in a health state valued at 0.25 to obtain one QALY. Again, if the quality of an individual's life is improved by 0.25 over four years, a QALY is gained.

The QALY framework provided a basis for the development of the disability-adjusted life year (DALY) in the early 1990s.[4] The DALY tends to be used in the developing world, and has been widely adopted by the 

. Members of Giving What We Can also use DALYs, and have been involved in designing recent adjustments to the metric.[9] The DALY is primarily a measure of disease burden, and thus relates to an entire disease (rather than a health state, as with the QALY). This burden may be a reduction in full health (such as suffering from malaria, for instance), or even premature death. The DALY thus represents a loss of functioning, and can be thought of as one life year in full health lost.[2]

To determine the number of years lost due to a disease, a weight factor that reflects the severity of the disease on a scale from zero (perfect health) to one (death) is assigned. This is the inverse to the QALY.

When calculating the number of years lost due to premature death, the life expectancy of the afflicted individual would need to be known. As this is not possible, a typical life expectancy is predetermined. Giving What We Can uses a life expectancy of 60 years, which is the typical life-expectancy at birth for the developing countries in which our charities operate.

When calculating the number of years lost due to disability, the severity of the disease state is presented as a percentage of the burden of premature death. For instance, a year of blindness would be considered 60% as burdensome as a year lost.[10]