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Stephanie Crampin

World Malaria Day

Today is World Malaria Day 2014. It’s a day for gathering support and spreading the word about combating malaria. Malaria is a huge drain on developing economies, and rates of the disease are intimately related with rates of poverty throughout the developing world. It affects development in many ways, including premature mortality, school absenteeism, fertility, population growth and medical costs. Mosquitoes transmit malaria parasites, and symptoms of the disease are flu-like, including headaches, fever and vomiting.

The economic benefits of combating malaria are huge. Whilst it is estimated that each year, US$5.1 billion is needed to fight malaria, the annual cost to Africa of lost GDP due to malaria is at least $12 billion - over double. And yet there is currently a lack of help in this area. In 2012, only US$2.5 billion was available for programmes to fight malaria worldwide.

That’s where we come in. Malaria can be prevented, simply by purchasing and distributing bed nets in areas that need them most. The Against Malaria Foundation (AMF), one of Giving What We Can’s top charities, does just this. At $3 per net, and with an expectation of saving a child’s life per $3,600, they are an extremely cost-effective giving opportunity. AMF currently have plans to make their largest ever distribution in the Democratic Republic of Congo, and we are hoping to see more from them soon. Please help us combat this deadly disease - donate a net today!

http://www.theglobalfund.org/special/2014-World-Malaria-Day/

http://www.rbm.who.int/cmc_upload/0/000/015/330/415680a_r.pdf

A conversation with Alix Zwane of Evidence Action

We had a chance to catch up with Alix Zwane of 

, who was in Oxford for the Skoll World Forum, on the 10th April. She gave us an update on what Evidence Action is up to.

It’s always a pleasure to touch base with the Executive Directors of our recommended charities, not just because of their dedication to work that we find so important and interesting, but because they are all lovely people to get on with. This was the first time we’d met Alix in person, and we enjoyed catching up in the cafe of Modern Art Oxford.

We were particularly interested to hear about the 

’s progress, the importance of which was summed up neatly by Alix: a great measure of a country’s equity in health services is progress against neglected tropical diseases, as these affect the poorest and most marginalized. The DtW Initiative is as strong as ever and still expanding. DtWI is exploring beginning work in additional states in India, and beginning work in Vietnam with new partners. Another of their potential new projects involves a collaboration with 

- it’s great to hear that two such effective charities are working together!

We also chatted about other, broader work being done in the field. Currently there is new scientific interest in the potential to break transmission of soil transmitted helminths via mass drug administration. There have been some big wins for deworming recently, including a new $120 million commitment to control STH’s, spearheaded by the Children’s Investment Fund Foundation and the Bill & Melinda Gates Foundation.

Evidence Action is also exploring a range of new projects less focused around water or NTDs. These include a remedial education programme for young children in Kenya, in partnership with the government there. The evidence base for this work has been documented by the 

 (J-PAL), which advocates for “teaching at the right level” as a cost effective education approach in developing countries.

Evidence Action remains focused on projects in health and development that work, and we can look to them and their sister organizations, J-PAL and 

 (IPA) for first-hand knowledge of how to effectively tackle some of the world’s most pressing, preventable and lingering problems.

Carolina Flores

Celebrity endorsement: the curse of good causes?

A recent article in the Guardian [1] calls celebrity endorsement ‘the curse of good causes’. The article comes across as a personal attack on celebrity culture as ‘a dystopia seething with hypocrisy and soaked with vanity’ transferred to its relation to charitable causes. The arguments for disdaining celebrity involvement in charity are surely familiar:

1. Celebrities are not sincere in their support of good causes: all they care about is getting positive publicity and feeding their narcissistic impulses;

2. Celebrity endorsement trivialises the important causes it is related to;

3. People will only pay attention to the cause because of the celebrity’s association with it, and not because of its importance;

4. Celebrity endorsement sometimes goes badly wrong – for example, when a celebrity’s actions go directly against the ethos of the charity they are supporting;

5.�� Celebrity culture is narcissistic and shallow in itself, and celebrity endorsement of charities is a part of it.

I believe that these fail to establish that celebrity endorsement should be avoided. In fact, my aim it to show that there are good grounds on which to support it.

**First of all, what is the value of celebrity endorsement? **

Argument 1. seems to be based on the assumption that the value of someone’s involvement in a cause comes from the motivation behind it. If their motivation is selfish or insincere, then their involvement is worthless. This seems very implausible. If someone chooses to donate to charity because it makes them happier, or because it will improve their public image, the money they donate will still have a valuable impact: it could save lives, prevent suffering, decrease inequality, or improve someone’s chances of success in life. All of these things seem very valuable.

Celebrities’ motivations for supporting a charity are irrelevant to the impact they have. Furthermore, even if in some cases they are driven exclusively by self-interest, it seems unlikely that that is always the case. Celebrities like Angelina Jolie, Bono, or Elton John, who have shown a long-term commitment to a cause accompanied by generous donations and knowledge about it, are probably driven at least in part by a serious concern for the causes they engage with.

If it isn’t their motivation, what is the value of celebrity endorsement? Like any individual’s support of a charity, it lies in raising awareness of a problem – which may in the long term contribute to social or political change regarding the issue – and in moving donations to the charity – both from the individual and from people she reaches out to. Due to celebrities’ public presence, access to media platforms, and the admiration people often have for them, their support of a cause stands the chance of scoring highly both in raising awareness and in driving donations. If people only pay attention to the cause because of the celebrity, it is still good that they are paying attention to the cause (so argument 3. does not carry much weight). There is some evidence for celebrities’ involvement increasing donations: researchers at Rutgers-Camden looked at a sample of 500 non-profit organisations and concluded that donors gave 1.4% more to charities associated with celebrities than to those without celebrity endorsement. As celebrity endorsement can also reduce the resources a non-profit needs to allocate to fundraising, this means that a lot more can be invested in the charities’ goals. The positive impact of celebrity endorsement on support for a cause seems to indicate that people learn more about it and take it more seriously, not that it becomes trivial, as stated in argument 2. above. [2, 3]

It is true that sometimes celebrity endorsement goes wrong, as argument 4 states. If a celebrity is incoherent in her support of a cause – for example, when Naomi Campbell wore a fur coat while supporting PETA – this will make her lose credibility and appear hypocritical, which won’t have a good effect on the charity. But this only means that celebrity endorsement needs to be done well, as does any activity to help a charity. Ideally, the celebrities involved will have knowledge and interest in the cause: this will make them more persuasive and effective in reaching their aims.

The case for celebrity endorsement of charities is much the same as for any other marketing campaign. To address point 5., whatever one thinks of celebrity culture, it is part of the society we live in, and we must work with what there is to bring change. If celebrity endorsement is a good way of reaching more people and getting more funds, as it seems to be, one may make the case that it should be encouraged and celebrated.

http://www.theguardian.com/commentisfree/2014/apr/02/angelina-jolie-celebrity-endorsement-curse-good-causes?commentpage=1

http://news.rutgers.edu/news-release/celebrity-endorsements-lead-increases-charitable-donations-public/20130926#.U0Z212RdU64

http://trendandtonic.thefuturescompany.com/celebrity-attached-charity-actually-bring-dollars/

Peter Hurford

The Failures of Foreign Aid (And Some Potential Fixes) Part 1

 that individuals can make a large difference in the lives of others through donations, as long as they choose very cost-effective charities. However, while our donation does make a difference to a few people, there are also massive institutions working to make much bigger differences in the well-being of those in other countries — through 

Foreign aid aims to eliminate extreme hunger, extreme poverty, and disease from the world altogether and usher everyone into lives in which they can be happy and live to their potential. Because foreign aid is perhaps the biggest attempt to make the world a better place, it is important to me that we get this right.

Unfortunately, we haven’t gotten it right quite yet. Fifty years of foreign aid efforts later, and extreme poverty, extreme hunger, and disease still exist. While it may seem wildly idealistic to believe that extreme poverty, extreme hunger, and disease can be eliminated soon, Peter Singer in his book 

 argues that the elimination of all three plights is within our reach if only we studied foreign aid, looked at its failures, and made some modifications. In this essay, I explore his chapter on foreign aid.

Peter Singer starts off by quoting a prominent foreign aid critic, William Easterly, who makes the following argument:

The West spent $2.3 trillion on foreign aid over the last five decades and still had not managed to get twelve cent medications to children to prevent half of all malaria deaths. The West spent $2.3 trillion and still had not managed to get four-dollar bed nets to poor families….It’s a tragedy that so much well-meaning compassion did not bring these results for needy people.

However, as Peter Singer notes, $2.3 trillion on foreign aid over five decades is $46 billion a year, which distributed over all developed nations works out to $60 per person per year, or 0.3% of the economic output of these nations (30 cents per $100). In 2011, America was one of the least generous developed nations, giving 0.18% of GDP — though America still gave the most at the dollar by dollar level, sending $32 billion overseas. Other nations, like Sweden, give closer to 1% of their GDP.

Still, billions of dollars a year sounds like an awful lot, though it’s also equally fair to describe it as $90 per person, per year — less than people tend to typically donate on their own from their after tax income, and much less than people give up in taxes.

Interestingly, the American population feels like a lot more goes to foreign aid than 0.18% of the GDP. Peter Singer quotes a poll done by the University of Maryland, which asked 848 respondents “What percentage of the federal budget goes to foreign aid?”. 

, or $900 billion annually (the US budget has typically been $3.6 trillion per year), or $3000 per person — more than 33 times larger than the actual budget.

More interestingly, these same respondents were asked how much they thought the government should spend on aid. Here, the median response was for the government to 

, or 13 times larger than it actually is. At 10% of GDP, the aid budget would work out to $360 billion annually, or $1200 per person.

Whether $900 billion annually or $27 billion annually, these numbers for aid — both potential and actual — mean little without a baseline to compare them to. Just how much would it actually cost to do what William Easterly suggests — use medications and bednets to prevent half of all malaria deaths?

To consider the cost, Peter Singer looks to a more broad initiative — the 

, a UN-lead project to “Eradicate extreme poverty and hunger; Achieve universal primary education; Promote gender equality and empower women; Reduce child mortality rates; Achieve universal access to reproductive health; Combat HIV/AIDS, malaria, and other disease; Ensure environmental sustainability; and Develop a global partnership for development”. One of these subgoals is to prevent half of all malaria deaths.

The World Bank has estimated that in order to meet these goals, it would require around an additional $60 billion per year for twenty-five years, though this is a rough guess. However, for the United States to do this alone, this would work out to $200 per person per year, or require roughly 0.4% of US’s GDP. This is even more doable when we internationalize the issue -- for all nations in the 

Organization for Economic Cooperation and Development

, it would be $50.36 per person per year, or roughly 0.13% of the combined GDP.

So even if our aid was solely focused on the Millenium Development Goals, it still would fail because it is simply not large enough. However, Peter Singer does spend some of his chapter arguing that the way America picks its foreign aid targets isn’t really all about 

Andreas Mogensen

An update on AMF

At the end of the last year, concerns were raised by GiveWell regarding AMF’s room for additional funding. Although we took GiveWell’s concerns seriously, 

we chose to keep AMF on our list of recommended charities

. AMF were known to be involved in negotiations for three major distributions in Sub-Saharan Africa that could in principle create a significant funding gap in early 2014. In light of AMF’s outstanding qualities as a charity and the open nature of these negotiations, we didn’t feel there was a sufficient case for overturning our recommendation. In light of the expected time of completion on the negotiations mentioned earlier, we hoped to have a better picture of AMF’s position by April of this year and would review our position at this time. That’s what this blog-post is intended to do.

We were very pleased to learn, at the end of March, that AMF has secured its largest distribution to date, worth nearly $2,000,000. 676,000 nets will go to the Democratic Republic of Congo (DRC), to be distributed between July and October 2014. A distribution in the DRC is challenging but also especially needed, as it is one of the worst affected countries.

We feel that this recent distribution goes some way to vindicating the confidence we placed in AMF in December. Not only is this the largest distribution to date for AMF, it also preserves core features of the AMF model, such as a commitment to rigorous monitoring and to partnering with other organisations to fund non-net costs. In light of past failures to secure distributions, these features of AMF’s programme came under critical scrutiny. It is encouraging to see they have posed no significant obstacle in securing a large distribution in a country that otherwise poses significant logistical challenges.

While this constitutes a significant success for AMF, we should note that this is only one of the three potential distributions mentioned earlier. In fact, it is the smallest of the three. We had reasonably hoped to see each distribution having reached a decision by the end of March 2014. However, the other distributions are still progressing and have yet to be concluded. The next largest is a potential distribution of 680,000 nets, and the largest is a potential distribution of 3.1 – 4.6 million nets. AMF is still hoping to raise additional funds to cover these distributions, as they would require more funds than are currently available. AMF’s policy is to agree to distributions only if they are already fully funded, which is why they need to raise money prior to commitment.

Although we note that the largest of these distributions is being planned for 2015 and therefore can run on a longer timeframe, we are disappointed that these negotiations have not advanced to the same extent. Nonetheless, in light of their recent success in the DRC, we will continue to recommend AMF as a top charity. We wish them the best of luck with their current negotiations. And we encourage all of you to continue supporting AMF through your donations.

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!

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 

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