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Alex Mann

Reach for systemic change

GiveWell moved $27.8 million to effective charities

. At the same time, the U.S. government spent over 

mass distribution of insecticide treated nets (LLINs)

. Clearly, the impact of increasing the portion of foreign aid allocated to effective programs focused on evidence-backed interventions could have an enormous impact. The only question is 

: is investing in influencing policy likely to yield results?

A shallow investigation of the impact of lobbying seems to indicate very high initial returns on investment. For example, certain groups have estimated the ROI (return on investment) of lobbying to 

Unlike with direct charity such as AMF, opportunities to influence policy come and go quickly. Issues that originally seemed intractable can 

. Some organizations are able to achieve such an impressive ROI because they have invested in infrastructure and network development. When opportunities arise, they can 

The Reach Act, which prioritizes proven, effective interventions, should be of particular interest to effective altruists. USAID estimates that passing it could save the lives of 

600,000 mothers and 15 million children between 2015 and 2020

While policy wonks such as Amanda Glassman and Lauren Post at the center for Global Development are enthusiastic about the bill, they note that to ensure it delivers real impact, targets need to be 

achievable, measurable, appropriate, and regularly tracked

 while new investments are also brought in. For more thorough analysis of the bill see posts by the Center for Global Development 

Even if USAID’s estimate is overly optimistic, the bill will likely have a very significant impact on global welfare if passed. Given that it will be directly affecting how billions of dollars are spent on high impact interventions, the difference between the best and worst case scenarios might be measured in millions of lives. Effective Altruists should take note.

Ray Kennedy

Where should we donate to do the most good? - Essay Competition Winner

Where should we donate to do the most good?' What is the most effective, scalable, evidence-based, but currently underfunded global health intervention that is already being implemented or could be implemented soon?

In 2004, a World Bank report stated that deaths from malaria could be “all but eliminated” using then available treatment interventions (World Bank, 2004). But ten years later, malaria still kills over 500,000 people every year (World Health Organization, 2014).

One estimate suggested that if use of all the proven effective childhood preventive and treatment interventions were to rise from current levels to 99 % (95% for breastfeeding), the number of under-five deaths worldwide could fall by 63% (Jones, Steketee, Black, Bhutta, & Morris, 2003).

We invest billions of dollars in finding the next vaccine, the next drug, the next possible intervention. But not nearly so much in improving the delivery of interventions we already know work well. These are primarily not scientific or technological challenges. They are challenges of implementation, of delivery.

So what is an example of a delivery intervention we should be trying?

 is a social enterprise founded in 2012. Its key innovation is to use simple vaccine reminder bracelets which are worn by children from birth to age four years old.

Vaccines are highly effective, scalable and have one of the best evidence bases of any intervention in health (according to 

). The number one risk factor in infectious disease is failure to vaccinate (McHugh, Guarecuco, Langer, & Jaklenec, 2015). Yet an estimated one in five children in the world do not receive full or timely immunisation. Vaccines are one of our best weapons against poverty and ill health, yet we aren’t getting them to 

Failure to provide reminders and the forgetfulness of caregivers are key reasons for missed vaccinations across a wide range of contexts (Patel & Pandit, 2011)(Wakadha et al., 2013)(Wilson, 2000)(Quaiyum et al., 2011). Mothers may be illiterate and struggle to understand routine immunisation cards.

 is worn by the child and uses symbols for each disease which are ‘punched out’ when a vaccine has been delivered. The bracelet has been implemented in an initial 6 month pilot study in rural Peru and Ecuador. A bracelet costs $0.10 to produce. Initial results are positive. 91% of mothers said the bracelets helped remind them of vaccination visits. 90% said they would continue to use the bracelets in the future if possible. 87% said they would recommend the bracelets to other mothers. The next step of the innovation is to run a larger 1 year study with 5,000 mothers and babies. Further information is at 

Could this be a viable, practical solution for the challenge of vaccine delivery? Perhaps. We need to test it. Adapt it. Iterate. But this is the sort of innovation needed to get to the 20% of unvaccinated children who are hard to reach.

In Bangladesh, relatively simple innovations such as adding the phone number of vaccinators to immunisation cards helped increase immunisation coverage by 15% in a single year (Save the Children, 2012). Bangladesh is one of the poorest countries in the world but its national immunisation coverage rate (measured using DPT3 rate) is 95% (WHO & UNICEF, 2014). This should be achievable for all countries if the right focus is placed on delivery and experimentation.

The beauty of this Alma Sana vaccine bracelet is that it has the potential to improve service delivery of all childhood vaccinations- an enormous potential impact at a very low cost. Vaccinations are already seen as a ‘best buy’ in public health and highly cost-effective (World Health Organization, UNICEF, & World Bank, 2009).

When considering whether to fund an innovation, we should think about both the impact it could have and the likelihood of achieving that impact. At this stage we cannot say for certain whether the vaccine bracelets will be effective at increasing immunisation rates despite early positive indications. But for approximately $1m this intervention will be rigorously trialled in three different countries to establish whether it works. Given the very low intervention cost even a small improvement in vaccination rates is highly likely to be cost-effective.

Giving What We Can rightly has a focus on what areas are underfunded. As an organisation that can only realistically hope to direct or steer a minority of philanthropic donations this is an absolutely appropriate goal. But Giving What We Can should also consider its comparative advantage when compared to other funding organisations.

Facing a choice between donating to two equally effective organisations, GWWC donors should choose the more obscure, the smaller, less well-known alternative. They are less likely to get the money some other way. Alma Sana is a small social enterprise that has to date received a small grant from the Gates Foundation and some money from a crowdfunding campaign. I do not know their internal financial picture, but it seems unlikely that they currently have the money to fund worldwide trials and they certainly do not have the resources to scale this intervention nationally should it prove successful.

This is where Giving What We Can donors should put their money. Not in the ‘sexy’ development of new drugs, or in the already well-funded, tried and tested rollout of malaria bednets. But in the vital, dull yet risky work of optimising the delivery of proven interventions to make sure they reach everyone who needs them. Alma Sana is an excellent example of the sort of service delivery innovation that is so badly needed.

Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., & Morris, S. S. (2003). 

How many child deaths can we prevent this year? Lancet (London, England), 362(9377), 65–71.

McHugh, K. J., Guarecuco, R., Langer, R., & Jaklenec, A. (2015). 

Single-injection vaccines: Progress, challenges, and opportunities. Journal of Controlled Release : Official Journal of the Controlled Release Society.

Why infants miss vaccination during routine immunization sessions? Study in a rural area of Anand District, Gujarat. Indian Journal of Public Health, 55(4), 321–3.

Quaiyum, M. A., Gazi, R., Khan, A. I., Uddin, J., Islam, M., Ahmed, F., & Saha, N. C. (2011). 

Programmatic aspects of dropouts in child vaccination in Bangladesh: findings from a prospective study. Asia-Pacific Journal of Public Health / Asia-Pacific Academic Consortium for Public Health, 23(2), 141–50.

Immunisation for All: No Child Left Behind.

Wakadha, H., Chandir, S., Were, E. V., Rubin, A., Obor, D., Levine, O. S., … Feikin, D. R. (2013). 

The feasibility of using mobile-phone based SMS reminders and conditional cash transfers to improve timely immunization in rural Kenya. Vaccine, 31(6), 987–93.

WHO, & UNICEF. (2014). Bangladesh: WHO and UNICEF estimates of immunisation coverage: 2014 revision. Retrieved August 31, 2015, from 

http://www.who.int/immunization/monitoring_surveillance/data/bgd.pdfWilson

Factors influencing the immunization status of children in a rural setting. Journal of Pediatric Health Care : Official Publication of National Association of Pediatric Nurse Associates & Practitioners, 14(3), 117–21.

The Millennium Development Goals for Health: Rising to the Challenges.

World Health Organization. (2014). WORLD MALARIA REPORT 2014 SUMMARY.

World Health Organization, UNICEF, & World Bank. (2009). 

State of the world’s vaccines and immunisation.

Luke Freeman

Giving What We Can for People of Faith

Giving What We Can is an alliance of people both religious and non-religious, united in the belief that where we can relieve suffering without having to make serious sacrifices, we should do so. It is a belief supported by many traditions and philosophies, both religious and otherwise.

The following member stories highlight the experiences of some members who have religious motivations for giving:

If you would like to talk about effective giving, effective altruism or 

 with other religious members, please contact:

Is there a faith-based community within Giving What We Can?

Yes! There are many religious members of both Giving What We Can and the broader effective altruism community around the world. You can find many of these groups and individuals on the 

Effective Altruism Forum community directory

Can I give to faith-based international development charities (e.g. Christian Aid)?

The pledge commits you to give the charity you believe will do the most good in the world. If you believe that a faith-based international development charity will do the most good, giving to that charity would fulfil your pledge. We ask you to think carefully about which charity uses your money most effectively to make the world a better place, and consider the 

 provided by organisations like Giving What We Can.

Are any of the recommended charities faith-based?

Currently none of the Giving What We Can recommended charities are directly faith-based. However, the founders of many of the charities we support (such as 

) report faith-based motivations for starting these charities.

Andrea Mestrov

Maternal Age Matters: for a lifetime, and longer

Maternal age matters—for the mother's own health and survival, for her child's well-being throughout his or her lifetime, and even longer if the well-described intergenerational cycle of growth failure continues into the next generation, according to a recent article published in The Lancet Global Health[1]

Causes and effects of young (≤19 years) maternal age

Despite an almost universal decline in the adolescent birth rate since 1990, adolescent fertility still accounts for 11% of all births worldwide, with 95% of these births occurring in low income countries and low middle income countries. In 2014, the average global birth rate among 15–19-year-olds was 49 per 1000 girls (1 in 20), with startling differences in rates between countries (from 1 to 299 per 1000), the highest rates occurring in sub-Saharan Africa. Early marriage remains a strong factor underlying adolescent fertility, with most adolescent childbearing (90%) occurring within marriage, although premarital conception for first births that occur within marriage is common[2].

A new study is adding to a growing body of evidence that young (≤19 years) and advanced maternal age (≥35 years) are associated with adverse birth and child outcomes. As described in The Lancet Global Health[3], the COHORTS Collaboration mustered the enhanced statistical power of pooling data from 19 403 participants located in five birth cohorts in Brazil, Guatemala, India, the Philippines, and South Africa, to identify an increased risk of low birthweight, preterm birth, stunting at 2 years, failure to complete secondary schooling, and lower adult height in children of young mothers (≤19 years) compared with mothers aged 20–24 years. Mothers were recruited for the study before or during pregnancy, and the children followed up to adulthood.

The article also points out different underlying factors responsible for preterm birth (in younger and older mothers) including socio-economic, biological and behavioural factors. Such factors have implications for designing cost-effective public health interventions. For instance, if effects are mostly explained by socioeconomic factors that happen to correlate with age, then interventions that simply delay age at marriage may have little effect.

Concomitant policy changes in other areas may have unintended consequences on adolescent childbearing. One example is the decision in Chile to lengthen the school day, resulting in a 5% reduction in adolescent pregnancy prevalence[4]. Introducing legislation on mandatory schooling, statutory rape, or a minimum marriage age may be similarly effective in decreasing adolescent pregnancies.

Ultimately, the challenge is to identify a combination of measures that is feasible within the financial and societal contexts of low income and lower middle income countries (LMICs). The study concludes that children of young mothers in LMICs are disadvantaged at birth and in childhood nutrition and schooling and recommends efforts to prevent early childbearing should be strengthened[5]. It also makes a strong case for continued and uninterrupted allocation of resources (even in situations of scarcity) through the life cycle, well beyond the current international mobilization around the “first 1000 days of life”[6] .

Interventions to address young (≤19 years) maternal age

Another recent systematic review,[7] specifically examining LMICs, identified various interventions aimed at reducing adolescent fertility. These included improved communication, peer education, school-based interventions, health counselling, and cash transfer programmes, many offered in combination. Programmes promoting or facilitating school attendance among adolescent girls reduced marriage and childbearing significantly. Conditional cash transfers performed best, [delaying] the age of marriage, and reducing the rate of, marriage, total fertility rates, and the prevalence of adolescent pregnancy. Evidence from a recent study on one of the pioneer conditional cash transfer programs in the world, The Female Secondary Stipend Program (FSSP) in Bangladesh introduced in 1994, estimates age at first marriage to be delayed by at least 0.4 years and finds age at first marriage to be lower on average for Muslim girls compared to non-Muslim girls[8][a].

The number of programs to address child marriage has grown significantly in the last five to ten years. However, this growth is still not keeping pace with the needs of the millions of girls who are at risk of child marriage every year, and the tens of millions of girls who are already married[9] . Some argue that interventions in this area are still largely research-driven i.e. theories are still being tested, with no roll-out of national initiatives in any LMIC.

Universal child support grants should be given closer attention as a cost-effective intervention to address child marriage and thus adolescent childbearing. Namibia and South Africa are at the forefront of such systems in LMICs. These are not specifically set up to address child marriage but rather to protect the most vulnerable children. Evidence from the Impact Assessment of the Child Support Grant in South Africa on adolescent risky behaviours reports[10]

reduced sexual activity and a fewer sexual partners, particularly when the adolescent also received the grant in early childhood

reduced pregnancy, again particularly when the adolescents also received the grant in early childhood

The assessment also concludes that the Child Support Grant promotes nutritional, educational and health outcomes. Early receipt significantly strengthens a number of these impacts. This is an investment in people that reduces multiple dimension indicators of poverty, promotes better gender outcomes and reduces inequality. The Assessment also finds that adolescents receiving the Child Support Grant are more likely to have some positive educational outcomes, are somewhat less likely to experience child labour, and are significantly less likely to engage in behaviours that put their health and well-being at serious risk.

Child support grants are relatively easy to administer and scale up. Namibia is about to expand its comprehensive social protection system to provide a universal child grant system, replacing the current grants targeted at just a few groups of particularly vulnerable children.

In 2004, the Ministry of Gender equality and Child Welfare (MGECW) inherited responsibility for the administration of child welfare grants from the Ministry of Health and Social Services (MOHSS). Between 2002 and 2014, child welfare grants expanded from 9,000 to approximately 164,000. Despite this expansion (both in terms of numbers of grantees and resources allocated to administration) and a considerable parallel drop in child poverty from 43.5% in 2003/2004 to 34% in 2009/2010[11], one in three children in Namibia were still growing up in a poor household according to the Child Poverty in Namibia report published in 2012[12].

This report also provides evidence on the effectiveness of social grants in reducing child poverty, and simulates some options for expanding child welfare grants and the impact this would have on household poverty. The analysis of simulated options projects a drop in child poverty rates from 34% to 13% upon introduction of universal child welfare grants for all children under 18.

Global evidence on inclusive child-sensitive social protection, meanwhile, has demonstrated that the impact of social grants on child poverty, vulnerability, and social inclusion can be maximized when coupled with investments in public social services in health care, nutrition, education and protection[b][13]. This combination of cash and services has the potential to be truly transformative for children’s lives with significant impact on adolescent risky behaviours - reducing sexual activity and pregnancy in adolescent girls, particularly when the adolescent receives the grant early in childhood.

Meanwhile, in Botswana, a randomized control trial on Young 1ove´s “sugar daddy” HIV education intervention is underway[14]. Modeled after a similar intervention delivered and studied in Kenya, it attempts to educate young adults about the relative likelihood of HIV infection among men of different age groups and to correct the misconception that young men are more likely to carry the virus. In fact, “sugar daddies” (older partners) are nine times riskier.

In Kenya, this intervention was shown to reduce pregnancy - a proxy for unprotected sex and HIV - by 28%. Young 1ove has adapted the intervention to Bostwana and already reached 32,010 youth. If the evaluation of the intervention shows a large, positive result in Botswana and there is a clear path to scaling-up, Evidence Action[15] plans to support Young 1ove´s scaling-up across other southern African countries with high HIV rates. The “sugar daddy” intervention has the potential to be low cost and sustainable because it can be integrated into existing government curricula.

Moving Forward – Giving What We Can´s approach to address young maternal age

In closing, exploring emerging thinking on “systems change” and “collective impact” which may be better suited to the endeavour of child marriage prevention[16], and understanding the cost effectiveness of cash transfers and universal child support grants in addressing adolescent childbearing are themes to be investigated further by Giving What We Can. One place to start is the Pixel Project[17], which lists 16 organisations involved in ending the practice of child marriage. Progress on measuring the impact tailored “sugar daddy” education programs have on protecting adolescent girls from HIV and pregnancy should also be followed up and incorporated into Giving What We Can´s research on cost-effective interventions that address young maternal age and HIV in adolescent girls.

In the meantime, 39,000 adolescent girls become child brides every single day, often married to much older men[18]. UNICEF Namibia is quoted in the media this year[19] saying that “according to the 2011 National Census, about 26% of Namibian girls gave birth to their first child before their 18th birthday. Across Eastern and Southern Africa, 12% of the girls are already married before they turn 15, while 38% are married before their 18th birthday. Children in rural areas and those from the poorest families are most at risk of child marriage and teenage pregnancy.” UNICEF is therefore pledging its commitment to the Namibian government’s strategies to empower families economically through child welfare grants.

The Lancet: Maternal Age Matters, for a Lifetime and Longer

The Lancet: Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration). Lancet Glob Health. 2015;(published online May 19.)

Journal of Public Economics: Risky behavior among youth: incapacitation effects of school on adolescent motherhood and crime in Chile.

The Lancet: Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration).

The efficacy of reduced adolescent childbearing in low- and middle-income countries: a systematic review.

Effect of Girl’s Secondary Stipend on Schooling and Age at Marriage:Evidence from Bangladesh

ICRW-Power to her: How empowering girls can end child marriage

The South African Child Support Grant Impact Assessment

The Namibia household Income and Expenditure Survey (NHIES) 2009/2010

Child Poverty in Namibia – a child-centered analysis of the NHIES 2009/2010, National Statistics Agency, 2012

Evaluation report - Unicef." 2015. 2 Nov. 2015

Young 1ove is an organisation with the sole aim of protecting girls from HIV by highlighting the risks of "sugar daddies" who trade gifts for sexual relationships.

Evidence Action scales proven development solutions to benefit millions of people around the world. We fill the gap between knowing “what works” and having impact at scale. "

Giving What We Can: Child marriage report

The Pixel Project: 16 Organisations Working to Stop Child Marriage

Namibia sun: over 5400 child marriages in Namibia

Erwan Atcheson

How To Overcome the Disappointment of Not Receiving This Year's Nobel Prize for Medicine

Thirty-two times in a row now I've failed to win the Nobel Prize. Each year I have to swallow the same bitter medicine. These Nobel Prizes celebrate the extraordinary achievements of extraordinary people and they show me how worm-like I am in comparison. But there is a way to overcome this. If you, like I, have the post-Nobel blues, then this article might help.

 is well-deserved, as usual. Youyou Tu, William C. Campbell and Satoshi Omura have been awarded the prize for two separate anti-parasitic drug discoveries.

Youyou Tu has been awarded the prize for developing the anti-malarial drug artemisinin. 

, in the middle of the Vietnam war, Mao Tse-Tung realised he needed a new antimalarial; more soldiers were falling to malaria than to enemy bullets. There was an existing drug, chloroquine, but malaria parasites had largely 

. Hundreds of Chinese scientists were engaged, and Youyou trawled through ancient Chinese literature for an alternative cure for malaria and discovered artemisinin.

Malaria is a single-celled parasite transmitted by mosquitoes, killing 

 people every year, most of whom are children under five in sub-Saharan Africa. The major symptoms are fevers, anaemia as the parasite destroys the red blood cells, coma, and death. Artemisinin, in the past 15 years, has averted about 

The other two winners, Omura and Campbell, discovered a compound called avermectin and proved it has potent deworming effects. A few chemical modifications later, avermectin became ivermectin and is now used to treat people for onchocercial worms (which cause river blindness) and filarial worms (which cause elephantiasis).

 are irreversibly blind as a result of onchocerciasis, caused by larvae dying in the eye. 

 are affected by lymphatic filariasis. Filarial worms block the lymphatic system, often in the leg or genitals, causing swelling and hardening due to bacterial infections. The disease is stigmatising, resulting in sufferers sometimes becoming outcast from their own society.

For decades before ivermectin was developed, the only treatment for onchocerciasis was 

. A major side-effect of this drug was to make the patient blind. An alternative, Suramin, was worse, producing fatal side-effects. In contrast to DEC, ivermectin kills the worms slowly, preventing a dangerous immune response to the killed worms. Since the 1980s ivermectin has reduced the burden of onchocerciasis alone by 

9 million disability adjusted life-years (DALYs)

Blog

Reach for systemic change

Where should we donate to do the most good? - Essay Competition Winner

Giving What We Can for People of Faith

Maternal Age Matters: for a lifetime, and longer

How To Overcome the Disappointment of Not Receiving This Year's Nobel Prize for Medicine

Confessions of a Giving What We Can member - how the pledge saves lives

Would you save two strangers or your partner? A review of 'Strangers Drowning'

Reaching for Greater Impact Through US Legislation

Explain like I'm five: Essential surgeries

A Statement from Giving What We Can