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One of the hardest things about charity entrepreneurship is getting a sense of whether it's a good fit for you. Historically, we have created a blog post aimed at some of the key characteristics, but we also now have a short quiz you can take to start to get a sense of whether you are a good fit. A short quiz will never have perfect predictive abilities and we expect our full interview process (which the people, who apply for the CE program will go through) will be far more predictive overall. That being said, we feel this quiz, if taken self-reflectively, does likely correlate with the people who will be the most effective charity entrepreneurs, and it can be taken right now, contrary to applying for our program, which is still several months away from opening (March 2019).
Take the quiz now
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There are a variety of ways to prepare for founding your own charity. There is, of course, the legal and bureaucratic work, but much more important is getting ready, skill and knowledge-wise. Many charities are founded on a whim or impulse, but the best charities are founded after considerable careful and deliberate thought.
Read, read and read some more Most of the best books on founding things are for-profit books that have cross-applicable lessons. Here is some of the most helpful reading for founding a new charity, regardless of area: Lean Startup Charity Entrepreneurship Blog Doing Good Better How to Measure Anything Getting Things Done Enlightenment Now Effective Altruism forum As to area-specific reading, for example, if you’re interested in global poverty, you might want to read: As well as review these websites: For animal rights you might read: Websites that could be of help: But, of course, reading can only get you so far if you want to start a truly great charity. Get some hands on experience Work, volunteer, or intern at charities! Getting some experience, particularly at a smaller nonprofit in your area of choice, will give you a deeper understanding of the details of how charities work. Generally, you will learn more by getting a wide variety of experiences, e.g. interning at 4 organizations rather than working at a single one for several years. We offer internships explicitly aimed at teaching charitable skills, but do consider organizations working directly in your field of interest, even if they do not mention the intent to train. Don’t get married to a single idea There are hundreds of charities that the world needs, so the real question is, which ones are of the highest priority to found. Thankfully, research has been done by Charity Entrepreneurship, Givewell, and Animal Charity Evaluators in order to pin down what the most effective interventions might be in any given area, and, more specifically, what the overall best charities to found might be. Speak to others who have founded a charity Many people are willing to speak extensively about their field. If you contact the heads of the biggest charities, they will, most likely, not be able to speak to you, but the leaders of smaller organizations in fields related to the ones you are considering will often be interested in talking about their work if you have done your homework beforehand. If you cannot contact them directly, you can listen to them talk at lectures, conferences, or TED talks. I am happy to speak to people who are considering charity entrepreneurship as a career path and help them think over whether it might be a good fit for them. I have also introduced people to other founders across different charities, and many others will likely do the same if you ask them Apply for the Charity Entrepreneurship incubation camp Programming bootcamps can teach in months what schools often take years to teach. Likewise, the Charity Entrepreneurship camp is focused on teaching as much as possible in 2 months to get someone from 0 to founding a great charity. The camp focuses on both the hard and soft skills of building a charity: anything from making your first fundraising proposal to how to hire staff with the expertise you do not personally have. It’s built to apply to a range of people, from students fresh out of school to individuals who have worked in the charity sector for many years. All costs are covered for accepted applicants, including room and board. Applicants who go to the camp and decide to found an effective charity are also given a grant to cover their first ~6 months of charitable operating expenses. Summary The most helpful things you can do to get ready for founding a successful and high impact charities are:
“I’m convinced that half of what separates the successful entrepreneurs from the non-successful ones is pure perseverance.”
- Steve Jobs If you are convinced that charity entrepreneurship might be a high impact and satisfying career, the next question you might ask yourself is whether charity entrepreneurship is a good personal fit for you. Starting a charity involves a lot more risk, stress, open-ended tasks, and heavier responsibility than most other jobs. We’ve listed out the key personality traits and skills we think are necessary for a successful charity entrepreneur. The good news is, your personality is dynamic; you can cultivate certain traits if you want to so if you do not have of these its not set in stone. Successful charity entrepreneurs are:
You’re resilient It goes by many names - grit, determination, resolve, resilience. The strength to keep trying no matter what obstacles crop up (and, believe me, there will be obstacles) is absolutely critical if you are to succeed. Rome wasn’t built overnight, and founding a top charity won’t happen after a week of part-time work. If you want to start a charity, you have to want it even after your plans A through P have all failed. You have to keep trying even after you’ve had a scathing review online, because once you’re doing something big enough that strangers start to comment, there will always be somebody who doesn’t like what you’re doing. Being resilient means being dedicated at the highest level. It does not mean getting stuck on a specific plan or idea. It means aiming for the same goal over a long period of time. For example, if someone with grit were pursuing journalism, they wouldn’t apply for the same position dozens of times and no others. They would apply for hundreds of jobs in journalism and if that didn’t work, they might take an online course and build up their skills, or start reporting on events in a public forum that gets them a following. You’re ambitiously altruistic You want to help so many people over your lifetime that they wouldn’t all be able to fit in a football stadium. You want to wake up knowing you are pushing the limits of what is possible. Most people want to make the world a better place, but the majority only go so far as to be nicer to those around them or put a little extra thought into a present. Those gestures are laudable, but to do what it takes to run a great organization needs more vision, otherwise you’ll be too tempted by easier ways to change the world. You’re results-oriented You worry that a lot of charities, while well-intentioned, are misguided. They often accomplish nothing and sometimes even make the situation worse. You think that the response to knowing that things can go wrong is not to say that making a positive difference is impossible, but that you have to learn as much as you can about the situation before making a decision. You want the analytical, critical, rigorous and empirical thinking which is found in the scientific sector to become the norm in the nonprofit sector too. The stakes are too high for decision-makers to value emotional appeals over evidence and results. You’re open-minded Good charity entrepreneurs always remain open to the possibility that any and all of their assumptions may be incorrect. If you are not open-minded enough to consider new evidence and update your beliefs and actions accordingly, you are almost certain to fail. As a small condolence, you probably won’t realize that you’ve failed because, as Kathryn Schulz explained, how you feel when you are wrong is identical to how you feel when you are correct. On the flip side, if you are open-minded, even if you don’t have the highest IQ, you will eventually outpace many of your peers because you will be able to steadily improve your model of the world. So, even if you initially think that something is incorrect, approach it with an open-mind. Have a ‘scout mindset,’ trying understand situations and concepts as honestly and accurately as possible even when they are not convenient. Remember, changing your mind is the ultimate victory, because in those moments you are improving your model of the world. And how can we ever hope to fix a problem without understanding it? You’re not afraid to admit your mistakes Humans are world class self-deceivers, commonly making excuses for bad decisions, rationalising away negative outcomes, and constructing fantasies to replace unpalatable truths. Charity entrepreneurs need to be able to work hours on end for years and then admit that they made a mistake or that the project isn’t effective enough to continue pursuing. This requires a rare level of self-honesty. Many people end up burying their heads in the sand and rationalizing away negative information. Their fragile pride is more valuable to them than achieving the most positive impact possible. You’re self-motivated As an entrepreneur you have to convince many people that your idea is a great one, but the first person you have to convince is yourself. You have to be able to get yourself up in the morning with no boss threatening to fire you. You have to motivate yourself to do unpleasant but necessary tasks. It's difficult and some people just can’t get the work done without a push. A good way to proxy this style of work is to take an online course. There are thousands online that you can take for free at your own pace. With such a powerful resource publicly available, it is amazing people pay such huge sums of money for a university degree, but it comes down to motivation. Most people cannot complete an online course by themselves without a teacher guiding them to the finish line. As an entrepreneur, you can set up a board or peer group to help you with this, but when it comes down to it, you will also have to be able to motivate yourself. You’re creative Of course coming up with the initial concept takes creativity, but that’s just the tip of the iceberg. Almost every day entrepreneurs need to devise and compare multiple solutions to any given problem. Great entrepreneurs aren’t afraid to think outside the box, do things differently, and bend or break social norms. Difficult problems require creative solutions. That being said, it is possible to have a strong team that can collaborate creatively to build a strong organization. Not all original thinking has to come from the top. We find that encouraging board and staff members to contribute and collaborate freely is a great way to produce brilliant ideas. You’re doing it for the right reasons There are many reasons to start a charity and not all of them are altruistic. Some people do it to impress others, have adventures, or feel good about themselves. If you let these kinds of motivations interfere with the ultimate goal of helping, people will be harmed. For example, if your primary motivation is the warm glow of assisting others and you find out that instead of ministering to the ill, it’s better to prevent the disease in the first place, you may choose to stick to ministering because prevention is not as emotionally rewarding as treatment. Many people will die because of your misguided motivations. Likewise with prestige. A desire to impress others may cloud your judgement. Sometimes the best thing for the charity is to give the credit to somebody else. We created the list of our recommended poverty charities to found in 2016. Our original list included 5 promising interventions:
In the last few years, a couple of things have changed, so updating the list is in order. Excitingly, two of the following charities were, in fact, founded.
Although there is room for the founding of more than one effective charity in the given area (for example, one could easily work on SMS vaccinations in Africa), the founding of these two charities does change the scope of neglectedness in those areas. Thus, both of these ideas were removed from the Top Charities to Found list. Secondly, over the last few years, we have been able to get a deeper understanding of the poverty research space. This occurred as a result of considering and speaking to multiple poverty research organizations, as well as through working more deeply with IDinsight. Given the relative strength and growth of these organizations-particularly IDinsight, which we feel is working on covering much of the ground we see as of highest impact-, we no longer see the founding of a poverty research charity as substantially neglected. Because of this, poverty research has also been removed from our list. Thirdly, we are looking for more specific options in the field of conditional cash transfers. Our initial report did not make a specific recommendation, instead listing a few possible options. By the end of the year, we plan on recommending a specific best condition, or two, to improve the shovel readiness of the area. Our views on tobacco taxation have not changed substantially. We continue to feel that this is a promising area and a very effective charity can be founded here. However, we have updated slightly positively towards it as time has passed, given our increased optimism about the promisingness of working with governments in order to achieve cost-effective metrics. In summary, here is our updated list:
In the past, Charity Entrepreneurship (CE) has been focused on poverty charities, founding one ourselves and supporting the creation of another, both of which were GiveWell incubated. So why the shift in our research focus? Ultimately it comes down to what we think is the highest impact area to focus on. Some of the factors that most influenced us were.
The impact of the cause area of animal rights has been well described by EAs in the past, covering aspects including scale of the problem, tractability and neglectedness. I will address these briefly but will mostly cover fundamental assumptions, as these seem the most likely area for disagreement. The CE team generally believes animals are conscious and morally relevant agents. Given the numbers of animals involved in animal agriculture and other animal-use endeavors, this makes it a high scale and high importance issue. From a neglectedness perspective, animal rights are clearly more neglected than global poverty and many other cause areas, attracting both less money and fewer talented entrepreneurs. In the past, our team has always been most concerned about tractability of issues in this area and about the relatively weak evidence surrounding animal focused interventions. This remains our biggest concern with working in the area. Our team expertise is mostly focused in poverty, but we have developed a secondary knowledge base regarding animal rights. Our co-founders have both been vegan for many years and when Charity Science was founded it was founded with a dual focus on animal rights and poverty, working with THL and AMF in applying for grants. Although our focus moved to poverty, we have stayed relatively informed about the animal rights space throughout the 5 years of Charity Science’s existence. More recently, most senior staff have been vegan and kept up to date with the animal rights movement, with one of them working for ACE after he left Charity Science. In addition our recent hires have been made with animal rights expertise as a key requirement, with our new senior hire coming from Open Cages (a ACE standout charity). A fundamental premise of Charity Entrepreneurship is that many of the skills used to found charities in one area can be cross-applied to other areas. Our team has in the past founded both meta and direct poverty organizations. We found the skill sets between the two had very strong generalizability. Following discussion with individuals in the animal rights community and given our experience with early stage animal focused charities we believe many of these skills will transfer, particularly with regards to consulting and advising. On our announcement post we discussed the benefits of cause rotation, which we see as three fold. First, in the time necessary to feel very confident in prioritizing one cause area over another, we would be able to incubate a good charity in each top cause area. Second, there is a limited pool of people interested in starting organizations in each area, so focusing on putting out marginal recommendations in one field will lead to less output than switching between them periodically. Third, given the extremely uncertain nature of doing good, rotating between cause areas will make the impact more robust in the event that one of our assumptions or beliefs is very wrong. This perspective also aligns well with the recent writing on epistemic humility which we found persuasive. The final major factor that lead us to thinking animal rights would be the most effective area in which to run the next round of CE is the current distribution of funding and talent gaps between the animal and poverty movements. Right now there is a large funding gap in poverty charities and a relatively smaller funding gap in animal rights (despite AR’s historically very large funding gap). This makes founding new charities in animal related fields more promising than founding more GiveWell incubated charities. Overall, we think research on animal focused charities seems like the clear next area for our team to focus on. In future years, we plan on considering other areas, such as mental health and far future. Our current incubation program will accept applicants interested in founding charities from areas we have previously researched. For example our 2019 cycle will consider poverty (research conducted in 2016) or animal rights focused applicants (research conducted in 2018); from 2020 onwards, we will accept animal rights and poverty focused applications as well as applications focused on any additional areas we have researched at that point. About Charity Entrepreneurship:
Charity Entrepreneurship is a research and training program aimed at creating multiple counterfactual EA charities annually but with a different focus area each year. Our first year was focused on poverty research. We ended up recommending 5 charities 2 of which have been founded via the charity science team (Charity Science Health and Fortify Health). We plan on expanding out program by recommending several new charities in animal rights as well as offering wider support for individuals looking to found animal or poverty focused charities. We will have room to support 10-20 charity founders compared to the original 4 we were able to support in our first round. Role Description: The outreach interns will be to find and connect with people who might be a good fit for the CE incubation program. This could included attending college career fairs, polishing content, speaking to EA chapters, attending conferences, and getting the information out to relevant email lists and job boards. A time commitment of 5-40 hours a week is required for this position, and the intern should be comfortable talking to a wide range of people. Requirements:
Bonuses:
Benefits to you:
Details
To apply, please send the following to joey@charityscience.com
About Charity Entrepreneurship:
Charity Entrepreneurship is a research and training program aimed at creating multiple counterfactual EA charities annually but with a different focus area each year. Our first year was focused on poverty research. We ended up recommending 5 charities 2 of which have been founded via the charity science team. There is room for updating and improving the three other options with a particular focus on tobacco taxation. The focus of the research will be systematic, spreadsheet based and directly applicable to recommend charities being founded. It will be very similar to previous research that led to the founding of Charity Science Health and Fortify Health. Role Description: The interns will be tasked with researching key areas of interest in relating to top poverty interventions, for example, what country would be the best to focus on if lobbying the government to increase tobacco taxation. They will work together with a manager and other members of the team to slowly flesh out the best steps forward for people who found charities in these areas. They will be expected to complete their work to a high standard given the limited time that will be spent on each report. A time commitment of 5-40 hours a week is required for this position, and the intern should be familiar with research in other contexts. Requirements:
Bonuses:
Benefits to you:
Details
To apply, please send the following to joey@charityscience.com
Introducing Charity Entrepreneurship: an Incubation and Research Program for New Charities6/14/2018 How do we get more EA charities started? There’s a good case that charity entrepreneurship is high impact for EAs, but it seems not many are starting them. Part of the reason is that it’s intimidatingly hard. Not only do you have to have multiple rare and difficult skills, but you also have to choose a good idea to begin with. And if people are put off by the uncertainty of career selection, that’s nothing compared to the sheer ambiguity of all the potential interventions one could run. That is why we are starting a new program called Charity Entrepreneurship. We will make yearly charity startup recommendations, much like what GiveWell does for donations and 80,000 Hours does for careers. This research will be accompanied by an incubation program, similar to Y Combinator, that will teach people the prerequisite skills to start a nonprofit. In this post I’ll explain more about the rationale, details, history, and plans moving forward.
History The first project undertaken by Charity Entrepreneurship (CE) was 6 months of research in 2016 by 4 full time staff (~24 staff months). This resulted in Charity Science Health being founded, which has since received two GiveWell incubation grants and assisted over 200,000 families in India. This was the primary goal of this project and we feel CE succeeded. However, in a another way, CE was much more successful than we anticipated. Another project, Fortify Health, was founded, helped by our intervention recommendation, mentorship, and seed grants. Not only that, but several other EAs and non-EA charity founders showed a large interest in founding high impact ideas, such as the ones we had researched, although we did not have the ability to support more than two groups at the time. How it will work The organization’s time will be broken down into three sections. The first section will be systematic empirical research into an intervention area focused on finding the highest impact gaps to found a charity in. This will result in a list of “top charities to found in X area”, much like our published list from our last round. The second part will be a two month summer incubation program equivalent to about a summer term university course load, focused on building the practical skills need to found a charity. The third section will be a seed grant and weekly mentoring sessions for the organizations that are founded out of the program, similar to the support we were able to give Fortify Health. We believe this program has potential to found 1-3 GiveWell incubation/ACE recommended equivalent charities a year. Each year a different area will be chosen to focus on, with research being aimed at prioritizing specific possible charities within that area, as opposed to actively comparing across them. This is for multiple reasons. Firstly, in the time it would take to feel very confident in prioritizing one cause area over another, we could have incubated a good charity in each of the top cause areas. Secondly, there is a limited pool of people interested in starting organizations in each area, so focusing on putting out marginal recommendations in one field will lead to less output than switching between them periodically. Thirdly, given the extremely uncertain nature of doing good, rotating between cause areas makes the impact more robust in case one of our assumptions or beliefs are very wrong. This perspective also aligns well with the recent writing on epistemic humility which we found persuasive. The area we are running the first year on is animal rights, and for the next year we are considering far future and mental health, among others. We already have recommendations listed for global poverty and count CSH and Fortify Health as a somewhat informal first year of running this project. Case for impact The case for why charity entrepreneurship is effective has already been made here, here, hereand here. I’ll make the case for how Charity Entrepreneurship as an organization has impact in this section. CE’s impact hinges on two factors - the counterfactuals of the staff running the organization and the counterfactuals of the participants. My personal counterfactuals would be starting another direct nonprofit myself. The benefits of CE compared to this is that, while I think I could start another good charity, it takes about 3-8 years to take a charity from starting to being able to run without the founders. On the other hand, with CE we would be able to launch an expected 2-3 charities through our program every year. While I may be an above average charity founder, I do not predict that I am 6 to 24 times better than the incubatees. Which brings us to their counterfactuals. Some people would undoubtedly start charities without our aid, but many wouldn’t. Fortify Health for instance, has said that they think they wouldn’t have started their organization without my mentorship and initial funding. Making the leap from structured jobs to the uncertainty of entrepreneurship without a guide and some initial money is intimidating enough to turn off a lot of people. Providing a structure, education, guidance, and seed funding can help a lot of people gain the confidence to make the switch. Additionally, the support makes it more likely that they’ll run a higher quality organization, making better decisions and having a broader skill set than simply jumping in. The assistance will also help them stick with it at the beginning when things are particularly challenging. It’s easier to keep going when there’s a setback if you have a coach encouraging you to keep going. Part of the inspiration for this is to be what we wish we had when we had started. Aside from the direct effects of causing more people to join, there’s the benefit of choosing a better idea. Most startups are started based on jumping on the first opportunity the founder sees rather than systematically comparing their options. This can sometimes lead to good ideas but is dominated by comparing between alternatives, which I go into more deeply here. Furthermore, far more time and expertise will be put into prioritizing the interventions. Even if the founder might have put some effort into comparing their best options, it’s hard for an individual to put in the multiple person-years that will go into our research. Lastly, the intervention prioritization will be done by people who have specialized in and have a track record in choosing good ones. All of this combined will lead to higher impact charities getting started than otherwise would have. How you can get involvedIf you want to help this project you can:
There have been previous posts about the impact of founding a new GiveWell charity, the impact of charity founding, and some of the results of charities founded by EAs. This post, however, focuses on a specific question I get a lot. Namely, why should EAs in particular start charities? This is especially a concern for many EAs who are younger or inexperienced.
I think a strong piece of evidence for this is the historical track record of EAs founding high impact charities. Given that I already covered that in a previous post, I want to focus this one on why it's not just fluke or limited to extremely talented EAs, as well as the core reasons I think EAs can outperform other folks aiming to start nonprofits. My experience with this question comes from having worked in several charities founded by EAs and starting multiple ones myself. Overview relative to other founders: EAs will often be better at:
EAs will often be better at cause and intervention selection The first point is one of the clearest. A huge amount of the impact rests on which specific charity gets created. Launching something aimed at being recommended by Animal Charity Evaluators or GiveWell leads to very different interventions than the vast majority of social endeavors. Most nonprofits focus on the personal experience of the founder, not on the most relevant data available. EAs are much more likely to use that data when making an initial charity selection. It’s not shocking that charities like Evidence Action or Charity Science Health go far in GiveWell’s system, as these sorts of charities have similar underlying goals of making the most possible impact per dollar using the available evidence. If EAs generally start fundamentally more high impact ideas, that goes a long way (although far from the whole way) towards having a large impact. EAs will often be better at value alignment It’s easy for any charity, even EA charities, to get mixed up about the goals the charity is trying to accomplish. Are we trying to get bigger as an organization or have more impact? Are we trying to increase the amount we help each individual or focus on preventing the most suffering as a whole? Questions like these come up very often in charities, particularly new ones. The different directions the charities end up taking can have a large impact on their endline effectiveness. For example, a chronic problem in many health charities is the overemphasis on helping fewer individuals more. Often other poverty organizations recommend Charity Science Health to do strategies that will increase our program’s impact on our already existing participants by 20% but at twice the cost. That same funding could have more substantial impact by reaching a larger number of beneficiaries as we scale. Although anyone can make the wrong choices on issues like these, EAs are far less likely to do so compared to typical charity entrepreneurs. In addition to this, EAs are more likely to hire other staff members who also think this way. For example, even my non-EA team members are more focused on cost-effectiveness than the average NGO employee. EAs will often have better networks and resources The EA community has access to a lot of resources that other charities struggle with. Things like early stage funding, social support, mentorship from others who have done similar projects, legal incubation, access to a value-aligned talent pool, and incubation programs are all very rare resources to have outside of the EA movement. Very few of these resources are field or intervention specific. For example, the help I was able to give to Fortify Health was not on the technical details of iron supplementation, but on the broad process of founding charities. This network and pool of resources is one of the things many entrepreneurs find difficult. Many nonprofits, including Charity Science and Fortify Health, would not have been able to get off the ground without this sort of support. EAs will often have better measurement and evaluation Getting team buy-in for a strong measurement and evaluation (M&E) system is a tricky process. Having EAs as the leaders of the organization greatly increases the chance of having quick feedback loops and the strong M&E required for a charity to be highly impactful. EAs will generally think of M&E-focused systems more naturally and be more emotionally invested in applying them across their charity. EAs are far from perfect on this, but it is a stronger part of EA culture than it is of standard animal advocacy, poverty or most other charity areas’ cultures. Many might think that M&E is best done by an expert who has experience at M&E focused organizations, and although I think these experts are very helpful to have on a broader team, I think there are too few of them willing and able to found charities to let them close all the gaps. Often an EA charity might work best with one of these employees hired (a hire many other charities might not make) to work on it full time, with the leadership also being M&E oriented. EAs will often be more dedicated and focused By “dedicated and focused” I mean being focused on the endline charitable goals and objectives. EA orgs that have this focus on doing good can be more flexible in making large-scale pivots towards impact. For example, New Incentives has had several large pivots, but because the founders are focused on and dedicated to preventing suffering (as well as being highly competent), they continue to be a promising charity. If an organization doesn’t have this dedication to the fundamental metrics, then it’s much more likely that a change of direction will mess up its focus on the end goal. EAs will often have better personal ability This point really comes down to what reference class you are comparing with. For example, if you compare to the baseline population of people founding charities, I expect EAs to do better than this reference class on metrics like getting into an Ivy League school. But I can see a case for drawing a much tighter reference class. EAs don’t generally want to start charities that are merely better than average, but charities that will be among the best. The reference class of “founders of the absolute best charities” (e.g. those recommended by Animal Charity Evaluators or GiveWell) is much more comparable to the group of EAs I expect to be able to found charities. In the next section, I’ll explore more deeply the weaknesses that EA founders have. EAs will often be worse at having experience working and managing broadly EA founders will generally be young and, importantly, have much less working and management experience than others who found charities. Although inexperienced entrepreneurs are common in tech startups, in charities it's still often people who have been working for many years. This management and general work experience is hard to teach via school or books and is often learned through personal experience. This is the biggest factor making EAs weaker founders, although I do think there are some slight mitigating factors. Small charities generally grow from a small team to a larger one instead of starting with a very large number of direct reports. EAs can hire more experienced middle management to help compensate, but even with this, there will still be a lot of rapid learning that will need to occur. EAs will often be worse at having experience in the field This is broken out from the other category above because one could, in theory, have work experience broadly, but not experience within the specific field. I think this lack of experience is many EAs’ number one concern. Unlike the above experience, this sort of experience is very niche. Fortunately that very fact is what makes it not that difficult to acquire because the area of specialization is so narrow you can learn it fairly quickly. For example, there are only a limited number of studies on SMS vaccine reminders in the developing world. As an Executive Director your knowledge set will need to be broader than just that, but you do not need to have a masters degree in public health to work on a global health intervention. You just need to gain a very strong understanding of the very narrow area you work in. My experience has been that EAs can generally get to this level of knowledge in a matter of months, not years, as many might expect, largely because the knowledge needed ends up being more specific than expected. The other common concern people have is that they won’t have the very local and cultural knowledge of the area. This is a fair point, but this is thinking from an individual instead of organizational perspective. You can, and should, hire local people who will be able to guide the organization on this front. EAs will often have worse connections within a field Some charities are started with heavy connections in the field, whether in the form of funders, advisors or co-founders. This network is often essential to having your charity run well. The reason I tend to rank this as less important is that I have found that it’s fairly straightforward to build up a network in your field of interest. For example, if you send out ten emails to field experts asking to speak to them about working in the area, between six to ten will respond, and some of those will be able to connect you to more people in the field (if you ask them to) and from that your network can grow quickly. Many nonprofits are quite happy to talk to others in the field and some of these contacts will end up being advisors and board members long term. I think that people generally expect that not many people will respond to a cold email, but unless the person is fairly famous, I have found that nonprofit people are very willing to do a quick Skype session. However, this approach does require more social skills than the slow build of working in a field for years. EAs will often be worse at having a related degree I think this factor is far less important for founding a charity than many others think it is. The domain-specific knowledge gained through a degree is less important than one might believe, for the same reasons given in the section on experience within a field. And as for the reputational benefits of a degree, it's quite easy to hire a communication director or other staff members with degrees that provide that reputation, and in general this reputation will often quickly be overshadowed by the success of your charity. Think about top EA charities: how many of their founders have degrees in relevant fields? How many do you even know this information for? If you become very knowledgeable in a field, people are usually happy to talk to you and may often assume you have a degree based on your knowledge. EAs will often be worse at personal attachment to the cause This is the least important factor. Being personally attached to a cause area has the benefit of giving you more motivation for that cause area, but it also has the potential to cloud your judgement and lead to worse decision making. Overall, choosing good interventions and having good connections and resources overwhelm counter considerations, which are often less of a problem than anticipated, or can be overcome with intelligent effort or hiring. When considering these factors and the track record of EA-minded people starting strong charities, I think that this is a strong career path for EAs. About Charity Entrepreneurship:
Charity Entrepreneurship is a research and training program aimed at creating multiple counterfactual EA charities annually but with a different focus area each year. 2018-2019 will be focused on animal rights, including: meat alternatives, wild animal suffering, and bug suffering. The focus of the research will be systematic, spreadsheet based and directly applicable to recommending charities to be founded. It will be very similar to previous research that led to the founding of Charity Science Health and Fortify Health. Role Description: The interns will be tasked with researching key areas of interest in animal rights. They will work together with a manager and other members of the team to slowly determine the best charities to found in the field. They will be expected to complete their work to a high standard given the limited time that will be spent on each report. A time commitment of 5-40 hours a week is required for this position, and the intern should be familiar with research in other contexts. Requirements:
Bonuses:
Benefits to you:
Details
To apply, please send the following to joey@charityscience.com
Track record and tractability
Historically, some of the highest impact individuals in the EA movement and across the broader world have been people who founded effective charities. The difference between an average charity and the top charities is likely very large. Estimates for how large this difference is range from 10 to 1,000 times more impactful. But even if we look at the estimated difference between GiveWell’s top charities or between ACE’s top charities, we can see the range is extremely wide. The impact of the individuals who have founded the charities at the very top (e.g. THL and AMF) have been massive. This is not even mentioning the founding of more meta-organizations like GiveWell, who has directed millions of dollars to high impact organizations. There is a perception that founding high impact charities is near impossible or unlikely to happen without the founders having decades of experience and specifically related credentials. However, if we look at the historical evidence it seems this perception is misguided. The following charities were founded by people with less than 4 years experience in a closely related field but had an explicit focus on doing the most good. This is not a complete list, as I do not know the history of many of the other top charities in the EA movement:
Although track record gives us a sense of some tractability, asking whether this can be deliberately replicated is still reasonable. However, I think the evidence weighs up favourably for this as well. If we look at the most recent three charities on this list (all founded within the last 2 years), Charity Science Health has gotten two GiveWell incubation grants and has signed up over 180,000 people to their program. Good Food Institute is both ACE recommended and funded by the Open Philanthropy Project and is seen as a leader in its field. Fortify Health was founded less than 6 months ago and is now doing very well and is on track to potentially becoming a top GiveWell charity. These need to be compared to the relatively few failed direct projects founded by EAs to get a sense of what the odds are of a new charity becoming high impact. Another factor to consider with tractability is the relatively high levels of support the EA movement can give to young projects. Fortify Health for example was legally housed, funded, advised and supported by Charity Science. Similarly, Charity Science Health was given lots of support from other more established charities. Very few charity founders have the strength of community that EA charity founders have which allow them to research a project before founding it or get funding before establishing themselves fully. Neglectedness A big reason why the founding of so many effective organizations was and still is possible is to due with how the charity market works. Sadly, it's fairly rare for a charity to be established at the start with the explicit goal of being high impact from an EA perspective. A huge number of charities are started out of personal passion or being personally affected by a cause, and although these can end up being high impact, their average effects are much lower than a nonprofit started from a research and impact-focused mindset. This inefficiency makes it much easier to start a high impact charity than an equivalently successful for-profit endeavor. Many organizations that have done research into charitable areas, such as GiveWell and Charity Science, have found non-trivial gaps, even in fairly research-focused areas like global poverty. It's also worth noting that it can be high impact to start multiple charities in similar areas but with somewhat different focuses or country targets. GiveWell, for example, has recommended several deworming charities. Even more dramatically, it would be easy for someone to say, “Charity Navigator already exists. Why do we need GiveWell?” when clearly the quality and organizational focuses are sufficiently different that founding GiveWell is likely one of the highest impact charities ever started. Furthermore, Elie and Holden might have joined Charity Navigator and tried to change them from the inside. However, that would have been a lot less efficient than them starting their own organization. From what I have seen, people find it difficult to impossible to transform an existing institution, and this is all the more acute the larger it is. Unless you can get a position near the top, starting your own organization allows you to move much more resources towards more cost-effective or evidence-based methods. This will also true in many other areas. Although EAs have been fairly aggressive on founding meta-charities, relatively few direct charities have been founded by the EA movement, despite the relatively high success levels of the direct charities that have been founded by EA-minded individuals. Aside from the ones listed above, there’s also Evidence Action, New Incentives, The Humane League, and MIRI. Importance Founding an organization is a powerful way of getting more resources into a high impact direction. As an individual, even a very high talent one, you are limited to 40-60 hours a week of work and generally have an earning potential of under $500,000. However, both these numbers pale in comparison to general organizational scales. Even a smaller organization with say 5 staff and a one million dollar budget, greatly increases your ability to make major progress on an issue. If you hire and fundraise exclusively from EAs, you have to compare your counterfactual to the other place they would have donated/worked at, which sometimes is very high impact and other times less so. This also leads to one of the major assets of charity entrepreneurship. If you succeed in founding a charity that’s better than the current top, you can act as a multiplier to all of the donations going to the present best by shifting them to your newly enacted intervention. If somebody starts a charity that is 1.5 times better than AMF, that will multiply future would-be donations to AMF by 50%, which at tens of millions of dollars per year is huge. However, even if you don’t manage to oust the prevailing org of your area, often within an organization you can have your funding and jobs filled by non-EAs, which greatly alleviates counterfactual concerns. In addition to the general force multiplier and chance at being very high impact, charities have a chance of becoming very large. The impact of even a marginally better, but very high budget, charity can be extremely large. For example, if Oxfam was 1% more cost-effectiveness focused, it could save an enormous number of additional lives. Founding charities now gives EAs the opportunity to become the next generation of very large nonprofits. Particularly with initial funding sources such as the EA movement and Open Philanthropy Project, it’s not impossible that a charity founded by EAs could grow to be a field leader, which would have immense impact on the world. Flow through effects In addition to the case for average impact (e.g. a 10% chance of founding a GiveWell recommended charity) and a case for potentially very large hits (e.g. a 0.001% chance of founding the next Oxfam), there is a strong case that founding direct charities has strong movement building effects. It gives EA a very concrete achievement it can point at as an example of EAs doing something clearly good and high impact. Appearing more action-focused can have major benefits and help offset the perception of EAs as exclusively being focused on philosophy and theoretical concerns. This can draw more people into the EA movement, particularly people that want to see actionable, counterfactually caused accomplishments before connecting to a movement. There is also the inspirational effect on others to start a similar organization. Evidence Action was started with deliberate reference to evidence and cost-effectiveness and they got recommended by GiveWell, which inspired us to start Charity Science Health, which in turn inspired Fortify Health. I suspect that at a certain point there will be diminishing returns on this particular aspect, but at the moment it’s still very high. The more people who succeed the more people will see that this wasn’t a one-off fluke, but rather something that can be repeated. An additional effect is if you think value drift is a possible risk, establishing career and social capital in the charity sector is a way to increase the odds of long term altruism. If your CV is in the social sector, even if you value drift, you’re likely to stay in the area because it’s easier to get jobs there. Other writing See previous writing on the value of CE and the expected value of a top charity for more reasons on the impact of charity entrepreneurship. We are also going to write more on this topic soon, including the pros and cons of EAs founding charities and an announcement post for a related organization on this topic.  About Charity Entrepreneurship:
Charity Entrepreneurship is a project with the aim of getting more high impact charities to exist in the world. The project has helped the founding of Charity Science Health and Fortify Health. Role Description: Charity Entrepreneurship produces a lot of written content, both direct research and more meta EA posts as well as smaller writing pieces. This content generally needs a lot of improvement from its original in terms of style and grammar. Sometimes the intern will have to re-write full paragraphs or pages. For some of our team members, English is not a first language and one member of our team has a form of dyslexia. Currently our ability to publish content is limited by the amount of time a few volunteer editors can put in. This role is best for someone remote but who can be online often and edit small things quickly with longer but still fairly quick turn around times for longer written pieces (e.g. 24 hours turnaround time per page, 30 minute response time for single sentence checking). Requirements:
Bonuses:
Benefits to you:
Details
To apply, please send the following to joey@charityscience.com
 About Charity Science Health:
Charity Science Health was launched with the ambition of being the first direct poverty charity started by EAs to become GiveWell-recommended. Eight months into the project, we have received a GiveWell incubation grant and are expanding our team to increase our capacity. We are starting an internship program to help others gain experience with charity startups. This is intended to help them with starting one of their own. We have had multiple employees move on to found EA charities, and we intend to continue the trend. Impact The main sources of impact you will have from getting into this program will be:
Job Description Job responsibilities will be tailored according to the strengths of the candidate, their areas of potential growth, and the needs of Charity Science Health. This can range from doing cost-effectiveness analyses, designing a measurement and evaluation program, writing and editing charity entrepreneurship lessons, and anything in between. Requirements:
Benefits
Details
To apply, please send the following to joey@charityscience.com
This is a job position for a project the Charity Science / Charity Entrepreneurship team advises but which is not part of our organization. High impact charities are just waiting to be founded. This presents us with an opportunity to make a remarkable impact on the lives of others. Put another way, not pursuing these opportunities may come at a sizeable cost to the people who remain unhelped. Charity Science, an organization dedicated to promoting the causes that can best improve the world, has rigorously examined neglected cause areas that have the potential to join GiveWell’s top charities. They were evaluated in terms of cost-effectiveness, scalability, strength of evidence, ease of testing, flexibility, and logistical possibility. Charity Science concluded there are five promising charity ideas that are just waiting for an effective team to make possible. The Charity Science team has already begun to work on one of these charities. With the guidance and advice of Charity Science, I (Brendan Eappen) am assembling a team to found one of the other top charity ideas: Once a co-founder is identified, we would work together to identify which charity we could best implement. You can read more about each charity idea via the links above. Experts in the field, including GiveWell, 80,000 Hours and Charity Science all think this is an effective way to make a difference in the world. You can see a detailed model of the estimated impact here.  What we have to offer
What we need
What we want
Applying Your application should include two files: your resume and a document containing the following. Please download and complete the template linked here.
Start dates are flexible, but ideally we would decide whether or not to found the charity by early April. Please send questions or application materials to Brendan Eappen Eappen@alumni.harvard.edu by March 26, 2017 (extended). Applications will be reviewed on a rolling basis beginning on March 4, 2017. Want to learn more about who I am? Let’s chat! To give you a sense of what I’ve done, you can view my resume. If the right team is formed, I believe my investments in this charity startup will have a higher marginal impact and learning value than they would in an established organization. I’m excited to pursue this opportunity and look forward to reading your application! Brief history:
Charity Entrepreneurship was a project started by the Charity Science team with the intention of founding a highly effective charity (e.g., one that was competitive with the cost-effectiveness of current Givewell recommended charities). After six months of research into different priority program areas we found five ideas we think are worth starting a charity around. We launched Charity Science Health to start one of them. Charity Entrepreneurship in 2017: We consider Charity Entrepreneurship a success, but there were two large areas we could see further working being done on. The first area is the creation of other high impact charities based off our other four top ideas: Given the strength of the remaining ideas, it seems worthwhile to create additional charities following our work. Right now our team does not have the capacity to start more than a single idea at a time, but we have considered and tried a few ideas in this space to hire or inspire others, and excitingly it now looks as though a second charity might be founded based on CE research. An EA we have spoken with is going to create one of the top charity ideas with our support and advice. We think this is an incredibly high impact career and will soon post a job ad to join this EA to our CE website. The second area is a broadening of our research to include other cause areas: Our research was extremely focused on evidence-based poverty interventions. However, there are many other cause areas we think could be high impact and would like to conduct similar research in these other areas, such as expanding GiveWell’s shallow reviews, but focused on what charities could be started rather than funded. Our first step on this project is to do upfront crucial considerations research before being able to dive into comparing a more diverse range of cause areas. How to help out: The speed of Charity Entrepreneurship has slowed down from our initial six month burst because a majority of our team has moved to working on other projects (primarily Charity Science Health). We want to be conscious of not spreading our team too thin, but we could imagine completing the crucial considerations research and then scaling a team to do cause area research. Currently we are not hiring for this project, but we are looking to expand our pool of volunteers and unpaid interns from our other projects. Volunteering/interning is a great way to get to know our team and help us get a sense of your skills and abilities. Earlier this year, GiveWell Experimental predicted that we, the team behind Charity Science Health (CSH), have a 15% chance of becoming a GiveWell top charity by giving season 2019. That sounds pretty cool. But what does it mean for our plans? How good is it to be a top charity? And how does having a 15% chance of achieving top charity status compare to other things we could be doing with our time?
While it would take a lot of time to treat this question rigorously, a rough initial sketch seems very prudent for guiding our staff plans as we enter 2017 and decide whether to continue as-is, scale up, or scale down, with a keen mind to what we could be doing instead. An initial analysis and back of the envelope calculation seemed like the best way to inform our intuitions on this topic, so we set out to make one. Our estimate is based on assuming that GiveWell top charities have impact according to four factors: (1) funding from GiveWell (both from Good Ventures and directed by the interest of GiveWell donors, which will likely add up to $108M a year or more), (2) funding from non-GiveWell sources (e.g., other foundations), (3) how cost-effective they are, and (4) the total room for more funding of the organization. Funding from GiveWell Between 2011 and 2015, the four top GiveWell charites collectively received $166M, with $108M coming from just 2015. If we divide the $166M over five years evenly among all four charities, that’s $8.3M per year per charity. A 15% chance of us achieving this is thus worth an expected value of $1.3M a year, which divided among three full-time employee equivalents (FTE) is $433K in expected value per person. However, GiveWell is moving a lot more money now than it used to, especially with Good Ventures (though due to an unusually large 2015 grant from GiveWell to GiveDirectly, the trend may be exaggerated). Additionally, there’s somewhat of a power law even within GiveWell top charities. In 2015, GiveDirectly got ~50% of all the funding, the Against Malaria Foundation (AMF) got 35% of the funding, and SCI only got 3% of the funding. While we have a 15% chance of being a top charity, there’s still a good chance we’d end up on the lower half and get only 3%. So let’s assume now that instead of it being the 2011-2015 track record of $166M over five years (averaging to $33.2M per year), giving instead continues linearly at roughly $80M a year. We’ll also assume that we’ll break up our 15% chance into a 5% chance of getting into the top three (along with AMF and GiveDirectly) and receiving roughly one third of the funding and a 10% chance of getting ~5% of the funding like Deworm the World and SCI. 5% chance of 33% of $80M/yr plus a 10% chance of 5% of $80M/yr is $1.32M/yr + 400K/yr = $1.72M/yr or $344K per person per year. Lastly, it seems quite plausible that the addition of a new GiveWell top charity would bring in more overall money to GiveWell top charities. At minimum, an eighth top charity would likely lead Good Ventures to make an additional incentive grant of $2.5M that they would not have otherwise made. However, it also seems plausible to me that a new charity, especially one focused on something other than malaria or deworming, would bring additional interest to GiveWell from new donors or old donors interested in new areas. If we thought this effect would, together with the additional Good Ventures grant, boost the total money moved by an additional $10M, this would boost our expected of $344K per person per year to $364K per person per year. Comparative cost-effectiveness Another major factor is how cost effective we will be, relative to other GiveWell top charities. For example, if we take GiveWell’s 2016-2017 estimates literally, AMF is ~4x as cost-effective as GiveDirectly (though I expect GiveWell would kindly ask us not to take these estimates literally). While our current estimates don’t place us to be as cost-effective as AMF, we think we have a good shot of being more cost-effective than GiveDirectly (GD). If we could even be 2x GD (or 0.5x AMF) and shared 50/50 with GD for money from GiveWell’s sources, we’d be effectively doubling the impact value of that share. To make this more concrete, GD got $19M in 2015 excluding Good Ventures and AMF got $15M. If we adjusted those numbers to the literal cost effective estimates and did not adjust for diminishing marginal returns, we might be able to say something roughly like the $19M to GD being worth the same as $4.75M to AMF, or 1.9M in cost-effectiveness adjusted dollars. The total among AMF and GD would then be 19.75M cost-effectiveness adjusted dollars. If Charity Science Health was a 2x GD charity, and we still assumed that AMF got $15M but split the remaining money 50-50 between GD and CSH (So that GD got $9.5M and CSH got $9.5M), the new cost-effectiveness adjusted total (relative to AMF) would be 15M cost-effectiveness adjusted dollars derived from AMF’s impact, 2.375M cost-effectiveness adjusted dollars from GD and 4.75M cost-effectiveness adjusted dollars from CSH, for a total of 22.125 cost-effectiveness adjusted dollars. Thus the addition of CSH could be modeled as a net gain of 2.375M cost-effectiveness adjusted dollars, even though the total amount of money donated has not changed. The more cost-effective the new top charity, the better. If CSH were instead the same as AMF and still split with GD 50/50, the net gain would increase from 2.375M cost-effectiveness adjusted dollars to 7.125M cost-effectiveness adjusted dollars. Overall, while I think the concept of “cost-effectiveness adjusted dollars” is useful for sketching out one potential area of impact for CSH, I hestitate to take the notion literally and think that a lot more work would be needed to sketch out the concept more rigorously. In practice, however, comparing our internal rough guess cost-effectiveness estimate of Charity Science Health with a rough guess of the average cost-effectiveness of GiveWell top charities from 2016-2017, the two numbers seem to be roughly even, so I don’t expect any practical benefit from this factor. Funding from sources outside GiveWell While people in the EA movement may not think about it much, GiveWell and Good Ventures are not the biggest funders of non-profits out there. A potential GiveWell top charity could also hope to vie for the attention of other funders, like the Gates Foundation, the Lampert Family Foundation (funders of New Incentives), the Global Innovation Fund, YCombinator, and others. While the GiveWell stamp of approval could certainly help lead these funders to a charity, the best charities could certainly find funding independently from GiveWell’s endorsement. A new GiveWell top charity could unlock hundreds of thousands, if not millions, of dollars from large funders, and it’s quite likely the money counterfactually would not have gone to as good of a charity (by GiveWell’s standards). Room for more funding It doesn’t matter if you can attract tens of millions of dollars if you cannot effectively spend tens of millions of dollars. For example, GiveWell determined that Deworm the World could only make use of ~$15.5M in “execution level 1 and 2” funding over 2017. We’re highly uncertain about our own potential for room for more funding in future years, so this could really cap our potential for impact even if we otherwise succeed. If we were only able to take in $5M, our ability to move $20M would not matter. Staff allocation Right now, we have all our high-talent “senior” staff allocated to running CSH. However, there could come a time when we could run CSH in a more “passive” mode, continuing to have nearly as high impact, though without seeking as strongly to scale. This is similar to what CSH staff have already done with our prior project of Charity Science Outreach, dropping the team from ~5.5 FTE to ~1 FTE while still continuing to move a good amount of money. Thus, in a hypothetical future, perhaps CSH could spend $10M per year almost indefinitely while the CSH “senior” staff move on to start a different charity. If we assumed that “passive” mode lasted for a decade, the present value of that $100M over ten years would be worth $55.8M today (assuming a 6% interest rate), or $18.6M per current “senior” staff member (3 FTE), though we still would have to adjust for the counterfactual value of the non-senior staff members. Conclusion A new GiveWell top charity will have impact by (a) attracting some new funding through GiveWell that would not have otherwise been attracted, (b) being more cost-effective than current GiveWell top charities, and (c) by attracting new funding from non-GiveWell foundations. However, it is capped by a large chance of failure, room for more funding, staff time from people who could otherwise be doing other great things. When I try to model all these factors out in the following Guesstimate model, I get an estimate that the total efforts of our team (including senior staff, non-senior staff, and volunteers) are roughly equal to, in expectation, the work of a team of full-time equivalent people each earning to give $400K a year to GiveWell top charities, with our 95% confidence interval ranging from $220K/yr to $720K/yr. This compares favorably, as $400K donated per year is, I think, higher than what a typically ambitious and skilled EA could be expected to earn to give and is much higher than the earning to give levels found in 80,000 Hours 2014 report. However, more work has to be done to refine this estimate. For example, this does not take into account the tricky aspect of double counting, since our impact would be partially in moving the donations of others. Also, this does not separate out the fact that the counterfactuals and individual impact of all our staff and volunteers are definitely not the same. Using the same model, attributing 100% of the impact to senior staff and 0% of the impact to anyone else, shifts the estimate to $4.1M per senior staff year ($550K/yr to $25M/yr). But overall, this makes founding a GiveWell top charity could be a very high earning (though also somewhat high variance) career choice. Hopefully this estimate will continue to be further refined as we learn more about our chances of success and failure! When considering which charity idea would be the best one to create, we accounted for standard factors such as cost-effectiveness and the strength of the evidence that goes into the cost-effectiveness estimate. However, this analysis still left us rather uncertain, with a nagging feeling that we could be somewhere between mildly inaccurate and terribly wrong. What if we picked an intervention that turned out not to be very cost-effective or we picked an intervention that was effective generally speaking but beyond our ability to implement correctly?
The fear that we could be wrong drew us to our favorite metric for evaluating ideas -- flexibility. This is “keep your options open” applied to charity. How easily could we shut down this project and move to another project if this project turned out to not be very good?
The Value of Flexibility
We’ve been wrong a lot over the years, dramatically changing our beliefs, values, and career paths several times as we update on new information. It’s unlikely that the first thing you stumble upon will be the highest impact thing to do, any open minded person would experience a fair degree of change. While we’d like to think things are more stable now, chances are good that we will change our beliefs again as time goes on and that this will require yet another change.
Lastly, even if we don’t change our minds, the world itself is constantly changing. New laws and regulations could make our previous plans untenable. New opportunities could open up that didn’t exist when we first started putting our plan into action. New competitors could arise implementing our intervention just as well or better, rendering our work obsolete.
The more likely it is that change will occur and the more important you think the change will be, the more value you should put on flexibility.
Flexibility Over Robustness
Flexibility is the ability to change if circumstances change. Robustness is the ability to withstand change. For example, if there’s a flood in a village, a flexible population might move to another village. A robust population would have built flood-protecting walls around the village so that it’s not harmed by the flood. If there’s a disaster that prevents farming corn, a flexible population might switch to farming beans, whereas a robust population would have already known to genetically engineer their corn ahead of time to be immune to the disaster.
We definitely see the merit of robustness and would like to be as robust as we can. However, we see robustness as requiring stronger predictive ability about how things may go wrong plus the ability to create effective mitigation strategies, whereas flexibility can be reactive without needing to anticipate. In our examples, the village would have already needed to know to build flood-protecting walls and genetically engineered corn, which may have been hard to know in advance and costly to implement. For instance, maybe they worry about a flood so they build walls, but the disaster that actually strikes is a drought. Since we believe that anticipating and mitigating problems would be nearly impossible given that we face so many unknown unknowns, we think flexibility beats out robustness, at least for us.
Flexibility and The Lean Non-Profit
Flexibility is discussed a lot as a value for start-up for-profit companies. This philosophy, emphasized by Eric Ries’s book The Lean Startup, strongly encourages building just the minimum viable product (MVP), testing for user demand before scaling, and pivoting if your initial idea doesn’t work. The start-up world emphasizes that you are frequently wrong about the world (called “product-market fit”) and that you will fail many times before you succeed. Thus, the most successful start-up teams are the ones that are the most flexible.
We think this philosophy should equally apply to start-up non-profits too, though we seek “skills - capacity for impact” fit rather than “product-market fit”. While this idea has not taken off as much in the non-profit world, Luke Muelhauser wrote in 2013 about how the Machine Intelligence Research Institute was operating as a lean non-profit that emphasized MVPs, A-B testing, and pivoting. Since then, there have been two articles in the Stanford Social Innovation Review showing one particular experience implementing lean methodology in the non-profit world and another advocating for the benefits of pivoting and the lean methodology. Charity Science has also followed this model since 2013.
The Many Kinds of Flexibility
How can we increase flexibility? We found that flexibility can be increased in a wide variety of different ways. Here are some of them:
Intervention flexibility
A flexible intervention can be adjusted at a moment’s notice and doesn’t require that much upfront cost before seeing results.
Organizational flexibility
A flexible organization is able to quickly act differently based on new evidence.
Staff flexibility
While we already have flexible senior staff and management that can pivot from one project to another, we’ll also need to hire additional staff and ideally these people could fit into our flexible mindset. The following are a few ideas to increase our chances of coming into contact and hiring such people.
Funding flexibility
A lot of funding in the charity world is tied to particular ideas. But this is bad for the charity that wants to be able to change quickly, as changes will result in disruption of funds, which disincentivizes flexibility.
Other Areas
We think it is important to be flexible in other areas as well, such as with connections (e.g., people on the board, contacts in public and private sectors, relationships with academics) and with personal situations (e.g., location independence, being independently wealthy).
Conclusion
Overall, improving organizational flexibility by iterating quickly, building a culture that improves pivoting and open-mindedness, by putting a lot of work into hiring and skill training, and by building a broad, diversified funding base looks to be a relatively easy and high-value way of improving an organization’s potential for making an impact. Do you want to play a pivotal role in founding one of the most effective charities in the world? Join us and you will work on some of the most challenging problems, making decisions that will potentially influence hundreds of thousands of lives. This is a job where your day to day work can make a huge impact on the world.
The Charity Science team has spent hundreds of hours researching the most important poverty charities. Our top charity, SMS vaccine reminders, has the potential to increase immunization rates and decrease death and disease around the world. And this is just the beginning -- if we execute well, we could be in a good position to start other promising mobile health charities. This is a competitive job but we have non-traditional standards so we encourage a wide range of people to apply. We do not expect our applicants to fulfill all our needs and wants What we offer:
What we need:
What we want:
This position would start at a fairly senior level and the employee would be expected to be able to make hard calls and come up with intelligent ways to progress the project soon after joining the team and getting up to speed on the pre-existing research. Your application should include a (1) cover letter explaining what you bring to the team, your (2) resume and a (3) clear list of which of our needs and wants you meet. We do not expect our applicants to fulfill all our needs and wants, but we’d like to know how you fit before the interview. We’re flexible on start dates and all jobs start with a one month trial period to assess fit prior to extending a permanent offer. Send your application or questions to joey@charityscience.com by June 30th We have completed our second phase of research which was to narrow a list of about thirty charity ideas to a more concise list of five top prospects worth further exploration. Below is a chart comparing these five possibilities. The rankings are relative to each other, not absolute and based on a primary and time limited review of the data on these causes.  We have written a detailed summary for each of these options elaborating on their strengths and weaknesses:
It is difficult to compare charities at this level, especially when the metrics we use to measure their respective impacts are so different (e.g. research vs. direct benefit). However, we still feel as though we have a front runner among these possibilities. SMS reminders to encourage vaccinations is currently our top pick for an intervention to pilot. Though we are tentatively feel that our front-runner (SMS reminders) is the most promising intervention to proceed with, we have not closed the book on the other four options. We recognize that the difference in impact between the best and second best options could be very large, and thus feel that there can be “no stone unturned” with regards to making the right choice. To help make this the case, we are offering a one-time $500 prize to anyone who can significantly sway our decision by providing material that may challenge our conclusion thus far. How significant? We challenge you to change our top option by either weakening the case for SMS reminders or strengthening the case for another option. Why are we doing this? We need to make sure our decision is as airtight as possible before moving forward. Consider this an opportunity not only to get you (or a charity of your choice) $500 richer, but to make a hugely impactful contribution in the fight for global health. Email joey@charityscience.com for more information. This is one of our charity profiles, where we present our shallow, preliminary research on a potential, promising charity idea. We believe that this idea could be a potential contender for a GiveWell top charity, if further research confirmed the idea and if someone started the charity, executed it well, and resolved some of our outstanding questions and reservations.
Basic Idea Lobbying lower and middle-income country (LMIC) governments to legislate mandatory iron and folic acid fortification of a staple food (such as flour or salt). Summary Cost-effectiveness: High -- Iron fortification has been estimated to be $70 per DALY and appears to have a positive impact on a relatively large number of different metrics. Folic acid fortification is less cost-effective, with an estimate of $11K per life saved, but can be combined with iron fortification in the same efforts so there is little actual increase in cost. Strength of Evidence: Medium -- The case for iron and folic acid fortification are covered by several studies, including some systematic reviews. However, like with tobacco taxation, significant government lobbying would be needed and the effectiveness of such campaigns are less clear. Counterfactual Scalability: Medium -- There appear to be over a dozen countries and Indian states with large populations that aren’t currently being lobbied for fortification. However, there are a fair number of organizations focusing on this already, and it may be a matter of time before they focus on these areas. Ease of Testing: Low -- Performing an impact evaluation on a lobbying campaign is exceedingly difficult due to high interference from other campaigns, the all-or-nothing nature of lobbying, and an inability to effectively randomize. Flexibility: Medium -- While it appears we could move lobbying efforts to other areas as we gain more generalized skills and contacts, we would likely not build much infrastructure that is useful for areas outside lobbying. Logistical Possibility: Medium -- Lobbying poses significant logistical challenges and draws on skills we do not yet possess. Why We Think This Could be an Effective Opportunity Iron Iron deficiency is perhaps the most common micronutrient deficiency in the world (Baltussen, Knai, & Sharan, 2004). Fortifying food with iron could have immense benefits. A Copenhagen Consensus report notes that iron fortification is one of the top cost-effective interventions (Hoddinott, Rosegrant, & Torero, 2012, p33). The DCP-2 estimates that iron fortification results in $70 per DALY and costs $0.09-$0.12 per year per person treated (DCP2, p560)[1], though we haven’t yet vetted any of these estimates. Anemia is frequently linked to iron deficiency (and also to other factors). Increasing iron intake can decrease a significant portion of anemia cases (Guo, et. al., 2014; Gera, et. al., 2012; Zimmermann, et. al., 2004; Andersson, et. al., 2008; Sari, et. al., 2001; Lakshmy, et. al., 2007) which reduces fatigue, irritability, dizziness, shortness of breath, and other conditions. Increased iron is also possibly connected with decreased premature births (Pena-Rosas, et. al., 2012), increased income (Thomas, et. al., 2006; Niemesh, 2012), and decreased behavioral problems of children (Zhou, et. al., 2006). Iron has also been linked to decreased depression rates (Beard, et. al., 2008; Ballin, et. al., 1992; Rahn, et. al., 2008; Luca, et. al., 2008), though this effect is less well established than other conditions, as it’s mostly observational data. Lastly, it has also been linked to increased cognitive abilities of children (Baumgartner, et. al., 2012; Low, et. al., 2013), though this has been undermined by a more recent meta-analysis from Guo, Liu, and Qian (2015) and we’ve noted before that we have concerns with the importance of improving IQ. While many of these studies are for iron supplementation instead of iron fortification, the effects should be similar, since fortification also increases iron intake but at a lower dose (Hoa, et. al., 2005; Le, et. al., 2006). Iron fortification seems to us logistically more easy to do, because you can add it to a staple food people already get and eat, rather than create new distribution plans and behavior changes to get people to have and consume an iron supplement. This could be why some studies have shown iron fortification is also likely more cost-effective than iron supplementation (Baltussen, Knai, & Sharan, 2004; Le, et. al., 2006; Ramsay & Charles, 2015). Folic Acid Folic acid is a form of folate, also known as vitamin B9. Maternal folic acid deficiency caused over 300,000 annual neural tube defects (NTDs) in 2012 and 2013 (CDC, 2012; Pachón, et. al., 2013), though now the number appears to be below 280,000 annually (WHO, 2015). NTDs frequently result in death or severe lifetime mental and/or physical disability for newborns (Ibid.). Folic acid deficiency can be reduced through folic acid supplementation (De-Regil, Peña-Rosas, Fernández-Gaxiola, & Rayco-Solon, 2015). Folic acid fortification is less cost-effective than iron fortification, estimated at $1200 per NTD averted and $11K per life saved (Llanos, et. al., 2007). However, folic acid fortification can be done alongside iron fortification (Copenhagen Consensus, 2008; WHO, 2012) and one could lobby the government to do both forms of fortification with the same lobbying effort. This means additional folic acid fortification would likely have some additional benefit with very little additional cost, resulting in what would likely be a marginally better cost-effectiveness than iron fortification alone. A Possible Implementation Plan If we were to explore iron and folic acid fortification, we’d aim to hire a local expert with expertise in fortification and local politics. We’d aim to find a country that has a large population, a relatively centralized production of the staple food, doesn’t have other charities already working in that area, and has a stable government without any armed conflicts. Once we had identified a country that fit these criteria, would would talk to experts to understand if this country was neglected for a particular reason. It’s important to keep in mind that lobbying the government to make fortification mandatory is likely the best way to implement fortification. The government is able to pass along the costs of fortification to the consumer, which is a negligible $0.00063 per kg of flour (0.16% of current retail price) (Food Fortification Initiative FAQ). Other models, such as paying companies for fortification, cannot take into account these economies of scale and would have to end up paying a lot of money and undercut any potential for political change. Who is Already Working in this Area? We found a few big organizations working on this, such as the Micronutrient Initiative, which works primarily on lobbying for iron and folic acid fortification. While GAIN works primarily in salt iodization, they do have some iron and folic acid fortification programs. UNICEF works on iron fortification of flour, among many other things. Food Fortification Initiative does a variety of food fortification programs, including iron and folic acid fortification. Project Healthy Children works to encourage the implementation of mandatory food fortification programs by governments. Helen Keller International also works on iron fortification, among many other programs. Smarter Futures works on food fortification, including iron and folic acid. They are a partner of GAIN. Our understanding from talking to experts is that it is very common for these organizations to partner together, so any additional work we did would likely be in partnership with some of these groups. Reservations Lobbying The evidence for lobbying succeeding in LMIC is far weaker than the evidence for the impact of successfully implemented fortification. It’s often difficult to credit responsibility for legislative change to particular players in advocacy campaigns because multiple campaigns operate simultaneously and it’s unclear whether the government would have changed anyway, absent lobbying efforts. While there is considerable evidence that government implementation of fortification is highly cost-effective, there is a dearth of analysis on the return of investment of actual lobbying campaigns. We find the difficulty of testing this project to be a barrier to attempting an implementation, given our desire for rigorous impact evaluation and prioritizing against other charity ideas, as well as this making it difficult to receive feedback to refine our lobbying approach. However, depending on policy, this specific charity idea may be able to be completed at the state level before attempting it on the national scale. We’re also not enthusiastic about would could be the zero-sum and all-or-nothing nature of lobbying. It would very likely be necessary to hire local lobbyists to reach the needed policy makers, which could be expensive. This also creates flexibility concerns, as the contacts we build would likely not be useful for a charity other than lobbying. Moreover, if lobbying requires a high degree of specialization, it may not even be possible to move easily between different lobbying campaigns. Access to Fortification We would guess it is plausible that the people in most need of iron fortification would be less likely to buy their food from a centralized source; instead, being more likely to grow it on their own or trade with other locals. This would prevent these people from being reached by a centralized food fortification effort. However, we have not seen any literature one way or another on this effect and we are unsure how it would affect the cost-effectiveness for iron even if the effect was true. Long-term, Large-scale Track Record While many countries have already implemented large-scale mandatory iron fortification programs targeting wheat flour, there are very few studies that seek to evaluate these programs. More troublingly, evaluations that have taken place have found that in half the countries where large-scale iron fortification has taken place, iron deficiency did not decline in children, though it did for women (Pachón, Spohrer, & Serdula, 2015). However, most of the countries studied did not fortify according to WHO standards, which can dramatically impact the effectiveness of the iron (Ibid., p12). Ultimately, we’re unsure about how heavily to weigh this consideration. There are also no studies we could find that seek to verify the long-term effects of iron fortification. This means it remains possible that the positive effects found so far could be fleeting over a longer time-horizon. For one example, Protzko (2015) found evidence of a fade-out effect in raising IQ, and GiveWell raises concerns about fadeout effects in their review of salt iodization (GiveWell, 2014). Side-effects of Fortification There has been some concern that iron supplementation might negatively affect malaria rates, which is why the WHO recommends fortification to be done in conjunction with improved anti-malarial practices. However meta-analyses drawing on over 20 RCTs (Shankar, 2000; Gera, 2002) found no significant effect on malaria. This would be especially true for fortification, which is at much lower levels than supplementation. Our overall conclusion is to avoid high malaria zones whenever possible, but not to put too much weight on this concern. Another potential “side effect” is masking Vitamin B12 deficiency. B12 deficiency is often detected by the presence of anemia (NIH Fact Sheet, 2016) and the deficiency can cause long-term neurological damage (Lachner, Steinle, & Regenold, 2012), which means that a decrease of anemia through iron fortification could delay diagnosis. Iron supplementation may also result in excess iron, which can slow physical development (Ianotti, Tielsch, Black, & Black, 2006; Paricha, Hayes, Kalumba, & Biggs, 2013). It’s not clear whether iron fortification would carry the same risk because only small amounts are added to the staple food. While folate supplementation prevents cancerous tumors, folate can also increase the growth rate of existing cancerous tissue (Smith, Kim, & Refsum, 2008). This makes it unclear whether folate increases or decreases cancer risk (see discussion in Kim, 2007; Mason, et. al., 2007; Kim, 2008; Luebeck, et. al., 2008; Hirsch, et. al., 2008). Any rollout of iron and folic acid fortification may need to carefully target specific populations to reduce the risk of negative side-effects. Differences between Fortification and Supplementation Lastly, it’s worth noting that we’re suggesting a fortification program, but in the process we rely on evidence of the effect of supplementation (though we also do use evidence of fortification). As we discussed in the section on side-effects, the dosage of fortification is meaningfully lower than the dosage involved with supplementation, which can involve changes in effects. We have not yet thought seriously about how much, if at all, this would undermine the case for fortification. Remaining Questions
Footnotes [1]: DCP has had flaws in the past which overestimated cost-effectiveness (GiveWell, 2011) which could make the true estimate worse. Additionally, the DCP estimate does not account for effects on income, depression, and irritability, which could make the true cost-effectiveness estimate better. This is one of our charity profiles, where we present our shallow, preliminary research on a potential, promising charity idea. We believe that this idea could be a potential contender for a GiveWell top charity, if further research confirmed the idea and if someone started the charity, executed it well, and resolved some of our outstanding questions and reservations.
Basic idea Incentivize positive behavior with conditional cash transfers (CCTs) in lower and middle-income countries (LMIC). Summary Cost-effectiveness: Low-High -- Cost-effectiveness will largely be determined by specific behaviour incentivised and the extent to which the incentive is successful. The added benefits of the transfer on income will also play a part in overall cost-effectiveness. Strength of Evidence: Medium -- A significant number of studies have explored a variety of potential behaviors that could be incentivized. However, the variation in CCTs -- in incentive delivery and amount, and which action is incentivized -- calls for a larger amount of research. Counterfactual Scalability: Medium -- There are no major funders or organizations in this specific area. However, because of the growing popularity of cash transfers, the field may become more crowded. Ease of Testing: High -- It is relatively easy to perform a randomized controlled trial for a CCT, though ease may vary according to intervention specifics. Flexibility: Medium -- It seems limited work would be required to shift a CCT program incentivizing one behavior to incentivizing a different behavior. A conditional cash transfer charity also seems like it would be able to update on new information at a faster rate and to a greater extent than charities in most other intervention areas. Logistical Possibility: Medium -- Some challenges associated with this specific charity idea are identifying an ideal targeting approach, a reliable and convenient cash transfer system, and a preferred monitoring method. Why We Think This Could be an Effective Opportunity CCTs entail giving someone a cash incentive for completing a certain activity. CCTs can incentivize behavior that improves wellbeing while also improving well-being by increasing wealth. GiveDirectly, a GiveWell top charity, has a well-evidenced, high-impact intervention through unconditional cash transfers (UCTs), where money is unconditionally given to some of the world’s poorest (see GiveWell’s review of GiveDirectly). A CCT seems like it may be able to achieve higher cost-effectiveness than UCTs by successfully incentivizing highly valuable health behaviors. However, the beneficial effects of the cash transfer may be much lower than in the UCT since the ability to target the poorest is compromised. There are numerous behaviors that could be incentivized and many different incentive sizes and delivery methods. Additionally, it is easy to randomly assign participants to different conditions, including a control condition. Thus, there’s much room to experiment with CCTs, which makes it a flexible, testable and possibly cost-effective intervention class. CCTs for Healthcare Utilization Akresh, et al. (2012) reported that CCTs to incentivize quarterly childhood growth monitoring resulted in significantly more clinic visits than an UCT control group. Rai (2014) reported that Kenya’s traditional birth attendant encouragement program increased the number of clinic births and Lim, et. al (2010) reported a similar result for a large scale Indian program. Lagarde, Haines, and Palmer’s (2009)’s Cochrane review also suggested CCTs could be used to increase health care utilization. However, we’re concerned about the quality of some clinics (Fraker, et. al., 2013, Chapter 3) which may provide minimal health services, though we think this concern could be somewhat mitigated by selecting clinics that score well on evaluations (see ICDS, 2015; Lee, Madhaven, & Bauhoff, 2016). CCTs for Healthcare Worker Performance There are some areas of standard healthcare worker performance that if incentivised correctly might increase health outcomes. For example, Banerjee, Duflo, and Glennerster (2008) reported as many as 35% of healthcare workers were absent on a given day, while Chaudhury, et. al. (2006) estimated a 43% Indian medical worker absenteeism rate. Also, workers that are present may be low skilled, with one survey suggesting 67% of Indian healthcare providers had no formal medical qualifications (Das, et. al., 2012). There are some concerns CCTs based on patient outcomes create perverse incentives (rejecting sick patients, gaming hospitalization admission dates, etc.) but we think there are reasonable ways this can be avoided. Some apparently successful trials involved performance pay among a fixed beneficiary population (Miller & Babiarz, 2013). Other trials have focused on incentivizing community health workers, who generally lack medical training, to refer patients to hospitals under certain conditions (Rai, 2014). Another interesting program adopted a mystery shopper method, paying based on observed quality of healthcare given to people pretending to be customers (Wilson, Morris, & Gilbert, 2012). However, systematic reviews have suggested the general state of evidence for “pay for performance” in LMIC to be relatively low (Witter, Fretheim, Kessy, & Lindahl, 2012; Grittner, 2013; Gopalan, Mutasa, Friedman, & Das, 2014; Das, Gopalan, & Chandramohan, 2016). CCTs for Increasing Immunizations Immunizations have a strong evidence base for cost-effectively improving health (see GiveWell’s page on immunizations and DCP3) and a major reason for people with partial immunizations or lacking immunizations is a problem of demand (Rainey, et. al., 2009, Megiddo, et. al., 2014; see also The Wire Magazine and Live Mint Magazine) and a lack of knowledge in particular (Nath, Kaur, & Tripathi, 2015). This creates an opportunity to increase IC by increasing demand, leveraging the existing supply of vaccines. While inadequately trained health workers could be addressed with CCTs for healthcare worker performance, immunizations could also be increased through CCTs providing a cash incentive to increase immunization demand (see Barham & Maluccio, 2009; Banerjee, Duflo, Glennester, & Kothari, 2010; Chandir, et. al., 2010; Sato, 2015). A Possible Implementation Plan We think that a good way of implementing CCTs would be to explore the range of CCT implementations further before making an initial commitment to a particular form. If we were to do this idea we lean towards piloting many different CCT approaches, varying transfer size, transfer mechanisms, enforcement mechanisms, participant recruiting strategies, and the behavior promoted. This seems relatively feasible given Haushofer & Shapiro (2013) were able to experiment with recipient gender (wife vs. husband), transfer timing (lump-sum transfer vs. monthly installments over 9 months), and transfer magnitude (USD 404 vs. USD 1,520) in one study. Who is Already Working in this Area? CCT programs are most frequently implemented by governments. Evans, Holtemeyer, and Kosec (2015) note that CCT programs are present in almost every Latin American country and in over a dozen African countries. For example, by 2011, CCTs had spread to 18 countries in Latin America, with as many as 129 million combined beneficiaries (Stampini & Tornarolli, 2012, p3). The biggest non-profit we know of implementing CCTs is New Incentives, which incentivizes prevention of mother to child transmission (PMTCT) of HIV by incentivizing birth in clinics, antiretroviral adherence, and HIV screenings for newborns. GiveWell concluded that “there appears to be strong independent evidence that CCTs and PMTCT are effective programs” and that “New Incentives' PMTCT CCT program could potentially be in the same range of cost-effectiveness as our top charities” (GiveWell review of New Incentives). VillageEnterprise provides CCTs for entrepreneurs, giving $150 to each three-person new business founded by someone in extreme poverty with no prior business experience. TrickleUp also seems to provide CCTs for entrepreneurs, though they have a more complex model. Reservations Logistics The logistics of running a CCT may be challenging. Lahariya, et. al. (2011) found that poor planning, lack of public awareness, and the risk of corruption were non-trivial challenges to implementing a CCT. Dr. Bhargava notes lack of public awareness, targeting errors, execution gaps, payment errors, inadequate dispute resolution, inadequate service quality, and unclear graduation processes as the “Seven Deadly Sins in Conditional Cash Transfer Programs”. Additionally, a more simple problem may just be availability of bank accounts to transfer cash, which may be a problem in India (The Wall Street Journal, 2012; Indian Express, 2015; TechVibes, 2015) and other countries. Warping Incentives We also think a badly done CCT could warp incentives negatively, incentivizing the wrong behavior and producing net negative results. For example, Singh, et. al. (2015) found that low remuneration for community health workers could undermine their intrinsic motivation and foster discontent. a CCT for healthcare visits could incentivize frivolous clinic visits solely so people could get into the program. Also, a CCT for healthcare performance could lead to hospitals denying treatment to patients who would be most likely to reduce patient care metrics. It could be difficult to craft and enforce an incentive structure to lessen the possibility of these unintended effects. We are also concerned about the possible tendency of cash incentives to erode intrinsic motivation for the action in question, which could have negative long-term effects. For example, This effect of incentives on intrinsic motivation has been found by multiple meta-analyses (Tang & Hall, 2006; Marianne & Marteau, 2013; Cerasoli, Nicklin, & Ford, 2014), but it’s unclear if it would generalize to CCTs for health behaviours in LMIC. We would like to survey the literature more and even see long-term studies of the effects of CCTs to assess this concern’s validity. Cost-effectiveness Another potential worry is CCTs may take too much of a middle-ground approach and end up not be as cost-effective as either direct work on the behavior incentivized or an unconditional cash transfer. For example, using incentives to improve immunization rates may be more expensive than other methods to increase immunization rates, like SMS reminders. The cost of the transfer as well as the compliance monitoring to ensure the transfer is merited may get expensive, relative to just administering the program. More precise cost-effectiveness estimates would have to be made on particular CCT programs in order to assess this effect. There may also be degraded impact from the transfer itself, since it is possible (though not backed up one way or another by any studies we know of) that those with access to a particular CCT intervention may be more wealthy than those without access to that intervention, which would decrease the impact of the wealth transfer by a significant amount[1]. We’re not sure how much the relative cost-effectiveness of the incentivized behavior would be relative to the wealth transfer, though we expect generally that uptake in the behavior to be more impactful. Remaining Questions
Endnotes [1]: We roughly approximate the impact of a wealth transfer by how much it increases the log (base 2) of the income of the person receiving the wealth, on the principle that wealth has a log-relationship with happiness (Stevenson & Wolfers, 2008). However, we admit that there is a weakness in this approximation since it is not clear whether this doubling effect applies to very low levels of income. However, if the doubling effect is true and if an extremely poor person targeted by a UCT earns $1/day but a poor person targeted by a CCT earns $4/day, a UCT transferring $100 would have ~3x more impact than the CCT. This is one of our charity profiles, where we present our shallow, preliminary research on a potential, promising charity idea. We believe that this idea could be a potential contender for a GiveWell top charity, if further research confirmed the idea and if someone started the charity, executed it well, and resolved some of our outstanding questions and reservations.
Basic idea Conduct high-quality research establishing which global poverty interventions are the most promising. Summary Cost-effectiveness: Low-High -- While it may be possible to estimate the historical cost-effectiveness of global poverty research, we are not aware of any estimates and we would be concerned about whether they would generalize to our specific case. It’s possible for research to be highly cost-effective but there are far too many unknowns. Strength of Evidence: Low-Medium -- The case for the impact of global poverty research is intuitively strong. However, the causal chain is long enough that it ought to be established by empirical evidence before it’s thought to have a strong strength of evidence. Counterfactual Scalability: Low-High -- There are a considerable number of competent organizations conducting global poverty research. It may be better to support them than start another organization in this space. However, we feel there’s possibly a large quantity of valuable high-quality studies that can be done. Scaling this research organization could be difficult and there’s some risk that no one acts upon research we complete. Also, scale matters less for this kind of organization as it could be possible to have a very large impact with just a few number of studies. Ease of Testing: Low -- It would be very difficult to measure the impact of research, let alone quantify impact on endline metrics. Flexibility: Medium-High -- A research organization can more easily change its research focus than a direct charity can change its programs. However, a research program would still be limited to doing research. Logistical Possibility: Medium -- We feel that producing high-quality research may be more challenging than implementing a specific charity idea. We also may lack the formal academic credentials required to implement a research organization. Additionally, there may be a difficult lobbying component to ensuring others take our research into account. Why We Think This Could be an Effective Opportunity While some scholars have attempted to empirically quantify the impact of developed world medical research (e.g., HERG, OHE, & RAND, 2008), we are not aware of anyone who has quantified the impact of global poverty research. However, we see the case for such research as intuitively promising. GiveWell writes in their list of charities they’d like to see that they would be excited to see “[c]harities that collect or generate information and data relevant to [their] recommendations.” For example, GiveWell sees more information on large-scale bednet distributions implemented by groups other than the Against Malaria Foundation (AMF), salt iodization programs, and tetanus immunization programs as valuable, but seem not to know of organizations collecting this data. They also write about a desire for more randomized control trials (RCTs) pertaining to their priority programs that could potentially be more cost-effective than their current top charities. Similarly, our initial intervention research identified some potentially promising ideas that we ultimately eliminated because they had a poor evidence base. This problem could be solved with more high-quality global poverty research. The principal benefit of performing global poverty research is likely the chance of finding a charity more cost-effective than GiveWell’s current top-rated charity, AMF. As of the end of 2015, AMF has an estimated cost-effectiveness of $2838 per life saved (see GiveWell’s analysis) and receives $22.8M from Good Ventures (see GiveWell’s blog post), which results in an estimated ~8000 lives saved. However, if our research could identify an underfunded intervention with a cost-effectiveness of $2000 per life saved, $22.8M could save ~11,000 lives. Our research could then be taken to have contributed toward saving an additional 3000 lives. If we assume a typical “gold standard” RCT costs $500K[1] and that two such RCTs would be needed to establish an existing pretty close charity as more cost-effective than AMF, and if we assume that we hit on the right charity 20% of the time, it would have taken $5M to save those 3000 lives, which works out to an estimated ~$1500 per life saved. Of course, the assumption of a 20% success rate of discovering charities with a cost-effectiveness of $2000 per life saved or lower is a complete guess and could be wildly inaccurate. Moreover, there still would need to be a lot of additional work and due diligence on the part of GiveWell, or some similar funder, and our research would only be a part of that. A Possible Implementation Plan A research organization could interview those founding (e.g., Evidence Action, us) or reviewing (e.g., GiveWell, the Global Innovation Fund) effective charities and compile a list of studies that would most benefit these reviewers/founders. This list could then be prioritized by other research organizations so that the highest-priority studies are done first. Replications It’s well known that replication research is a neglected but very important area of research. We’d love to see replications of studies that significantly inform views of priority programs. For example, replications of studies analyzing cost-effectiveness of deworming interventions could verify its impact. We think external validity is a concern when attempting to scale an intervention that has impact evidence in one particular area to significantly different areas. For this reason, we’d also be interested in experimental replications of studies in different contexts. Research on highly promising interventions While researching particular interventions, we found a lot of unanswered questions that would be amenable to future research. One such example is conditional cash transfers (CCTs). The large variation in CCTs -- in incentive delivery and amount, and which action is incentivized -- create an immense opportunity for research. Data on intervention costs Commonly global poverty research aims to correlate an intervention to a positive outcome and it seems usually there’s less investment in researching the cost-effectiveness of that program. When reviewing literature for interventions, we found that research elaborating on intervention costs to be quite useful in advancing our understanding of the intervention’s relative potential. While GiveWell has provided some considerations against more investment in cost-effectiveness estimates, outlining problems with these estimates being wrong, highly sensitive to assumptions, and not reality-checked, better reporting of costs could help correct these three problems. More endline metrics We have written previously about the dangers of measuring “incomplete metrics” and have argued our concerns that measuring improvements in IQ could be one of these metrics. We’d like to see more studies focus on endline metrics that are directly connected to well-being, such as income, health, and subjective well-being. More high-quality “gold standard” studies GiveWell has laid out a case for focusing on more “gold standard” studies that are well-designed and well-executed, which help fight against the problems of drawing misleading conclusions based on other research that all tend to have the same flaws. While conducting high-quality studies is difficult, we think there are some relatively simple techniques that will ensure increased study quality. Pre-registration can mitigate inappropriate data analysis, soliciting peer feedback can improve the experimental design, and large sample sizes can reduce the chance of an underpowered study. Who is Already Working in this Area? Many organizations already provide high quality studies, such as the Institute for Health Metrics and Evaluation, IDinsight, the Center for Global Development, the World Health Organization, the Center for Disease Control, Cochrane, the Campbell Collaboration, the Abdul Latif Jameel Poverty Action Lab, Innovations for Poverty Action, and the International Initiative for Impact Evaluation. Other organizations help curate, summarize, and synthesize these studies, such as Copenhagen Consensus, the Disease Control Priorities Project, Our World in Data, and GiveWell. Though there are many global poverty research organizations, we see the potential value in further studies as enough to justify there’s ample room for more research and data collection in the area of global poverty. Reservations Our biggest reservation is the large number of unknowns in committing to research. It seems that this process involves a substantial gamble on finding a “white whale” of a highly cost-effective intervention or charity with very slow feedback loops. Not only might this task be very difficult, it may be impossible. We also put some weight on the idea that it could be easier to produce high-quality research just by implementing a particular intervention. For any charity idea we select to implement, we already plan to produce pilot studies and eventual RCTs as the idea allows. Additionally, we’re nervous about how we’d acquire funding for starting and scaling our activities. Certainly we could hope to get funding from those who would potentially consume our research, such as GiveWell or the Open Philanthropy Project. However, we think there could still be concerns for seeking large amounts of funding, as a conversation between GiveWell and Development Media International notes that “[t]here are not many funders that support this type of [research] work [because m]ost foundations prefer funding projects that maximize the number of lives saved, rather than evidence-gathering work”. Lastly, we are also unsure of whether people would be willing to act on our research once we produce it. From speaking with experts, we have found that many large aid departments in different countries may be slow to update practices based on new evidence, if they update at all. It seems that for as much effort as we put into producing high-quality studies, we may have to put equal or more effort into lobbying relevant decision makers to utilize the findings, which could be very hard to do. Remaining Questions
Endnotes [1]: This is a high-end guess based on a few figures: Replication grants from 3IE are $15K at maximum plus $10K to the author to prepare their study for replication; IPA RCTs range from $50K to $500K; and 3IE funds up to $100K for a systematic review. Update 07/12/16: The post below has been updated to more accurately represent some studies
This is one of our charity profiles, where we present our shallow, preliminary research on a potential, promising charity idea. We believe that this idea could be a potential contender for a GiveWell top charity, if further research confirmed the idea and if someone started the charity, executed it well, and resolved some of our outstanding questions and reservations. Basic Idea Send SMS reminders for scheduled immunizations to improve childhood immunization coverage (IC) in low and middle-income countries (LMIC). Summary Cost-effectiveness: High -- Rough back-of-the-envelope cost-effectiveness estimates from ourselves and others suggests a comparable cost per DALY averted to top GiveWell charities . This estimate is heavily dependent on uncertain inputs for participant acquisition costs, IC increases attributed to SMS reminders and benefits of marginal immunizations. Strength of Evidence: High -- There is a considerable amount of studies, including systematic reviews, which suggest SMS reminders can increase IC across a wide variety of contexts. Counterfactual Scalability: Medium -- There appears to be no significant funders or organizations in this specific area, so it seems a new charity would initially operate in a relatively uncrowded environment. However, given the increasing popularity of mobile health (mHealth), the field may become more crowded. Ease of Testing: High -- It would be relatively easy to do an RCT on this specific charity idea because the intervention is low cost, has quick feedback loops, and individuals can be the unit of randomization. Flexibility: High -- It appears that the SMS infrastructure could be relatively easily used to promote other valuable behavior changes. Logistical Possibility: High -- Some of the main challenges to this specific charity idea seem to be determining optimal enrollment strategies, preferred locations and specific message details and content. These challenges seem less difficult than those associated with other specific charity ideas. Why We Think This Could be an Effective Opportunity SMS immunization reminders may be easier logistically, less crowded, more flexible, more testable, more scalable, as well as being relatively evidence-based and perhaps more cost-effective than the other specific charity ideas we’re considering. Immunizations have a strong evidence base for cost-effectively improving health (see GiveWell’s page on immunizations and DCP3) and a major reason for people with partial immunizations or lacking immunizations is a problem of demand (Rainey, et. al., 2009, Megiddo, et. al., 2014; see also The Wire Magazine and Live Mint Magazine) and a lack of knowledge in particular (Nath, Kaur, & Tripathi, 2015). This creates an opportunity to increase IC by increasing demand, leveraging the existing supply of vaccines. It’s possible demand can be increased cost-effectively via SMS reminders to comply with a specific immunization schedule. In order to implement this specific idea, a charity may complete some combination of the following: recruiting parents/guardians, recording age of child(ren), generating appropriate vaccination schedules, and sending SMS reminders at appropriate times. Our review of the literature indicated a wide variety of research that generally suggested SMS reminders were able to improve health outcomes. A systematic review found that 13 out of 14 studies showed a positive effect of SMS on some health-related behavior, such as tobacco cessation or diabetes self-management, though there were some methodological issues identified that undermined this result somewhat (Fjedsoe, Marshall, & Miller, 2009). A more recent review found that 5 out of 7 studies found an impact of mHealth SMS programs on health education outcomes (Hurt, et. al., 2016). Lastly, a Cochrane review of four randomised controlled trials involving 3547 participants also found positive increases in attendance at healthcare appointments (Car, et. al., 2012). However, the vast majority of studies cited in these mentioned reviews are from higher income areas than where we would like to implement this specific charity idea. When looking at literature directly connected to SMS reminders to improve IC in LMIC, we found five studies with a positive effect ranging from an increase of 8.7 to 17.5% percentage points in IC (Bangure, et. al., 2015; Haji, et. al., 2016; Uddin, et. al., 2016; Schlumberger, et. al., 2015; Eze & Adeleye, 2015; Brown, et. al., 2015) and two studies finding no effect (Gibson, 2015; Domek, et. al., 2016). We also found five upcoming studies that closely relate to the effect of SMS immunization reminders: JPAL (location: India, timeline: 2015-2017), JPAL (Mozambique, 2014), WHO (Pakistan, 2013), John Hopkins (Kenya, 2013-2014), and Bandim Health Project (Guniea-Basseau, 2016). We contacted an author of all these studies, asking if they had any shareable results. One author confirmed they did, and we have seen the results of the study, but we will wait until publication when we can review the full analysis and methodology before commenting further. We eagerly await the final results from these and other possible additional studies. Lastly, we examined research that fit only some of our criteria. Our preliminary conclusion is this evidence aligns with the view that SMS immunization reminders are a promising idea. Some evidence suggested that IC could be improved through a combination of SMS and conditional cash transfers (CCTs) (Wakhada, et. al., 2013) and through reminder systems other than SMS (Berhane & Pickering, 1993; Busso, Cristia, & Humpage, 2015) Two of the previously mentioned seven main studies report costs involved with the intervention. Haji, et. al. (2016) reported in Kenya total messaging cost of $0.27 per child for a +7%-point increase in IC of second pentavalent vaccine dose at 10 weeks of age and +13%-point increase in IC of third pentavalent vaccine dose at 14 weeks of age). Eze, et. al. (2015) (table 3) reports in Nigeria a cost of $0.15 USD per additional immunization of a child (original figure in Naira). Busso, et. al. (2015) (table 8) did a related intervention where they gave community health workers in rural Guatemala an updated list of children who needed vaccinations. They estimate that the cost per child who completed their full vaccination schedule due to the intervention is $7.53. We have not thoroughly vetted any of these numbers and hold some reservations about them. SMS immunization reminder costs can be split into initial user acquisition costs and marginal reminder costs. We probably would send three texts per immunization per user, though we could revise this based on pilot testing. A brief analysis of five different automated SMS providers suggests a cost of $0.001 to $0.06 per text, but the cost could vary depending on our method for acquiring users, country choice, and the desired amount of texts to be sent. This suggests marginal SMS costs of $0.003 to $0.18 per immunization reminder. Predicting 4% of our users would receive a counterfactual immunization means the marginal SMS costs per additional immunization are $0.075 to $4.50. The initial costs for acquiring a user are much less clear to us and we would hope to get a better sense of this during this specific charity idea’s piloting phase. SMS also seems adaptable to a variety of interventions. We found some evidence suggesting that SMS reminders worked in LMIC for increasing Vitamin A supplementation coverage (Thiaw, et. al., 2013), improving breastfeeding practices (Lee, et. al., 2016), and increasing utilisation of antenatal care (Watterson, Walsh, & Madeka, 2015). Note that this list isn’t exhaustive and we expect that there are other valuable behaviour changes that SMS’s could cause. Thus, SMS-related infrastructure could potentially be used for other health-related interventions, though we currently think they’re less cost-effective and have a lower strength of evidence than focusing on immunization reminders. Lastly, assuming we could recruit participants relatively easily and measure their immunization status, we could relatively easily randomize participants to determine if our system increases IC. The low cost per intervention and quick feedback loops makes a pilot study especially promising. A Possible Implementation Plan Broadly, we’d want to follow these steps for implementing this specific charity idea: Step 1: Determine areas where immunization supply is substantially higher than demand and where SMS immunization reminders seem likely to increase IC. Step 2: Investigate how to acquire reminder system users cost-effectively, experimenting with a few different approaches. We may experiment with cash incentives, partnering with advertising firms or peer-to-peer acquisition strategies. PATH’s mHealth Mobile Messaging Toolkit could be a helpful guide for rolling out some of these approaches. Step 3: Determine optimal number, timing, and content of messages. Step 4: Seek results relating to SMS immunization reminders and update accordingly. Step 5: Decide on a scaling process if it’s thought to be worth doing. Step 6: Partner with academics to run a RCT on the intervention. Step 7: Evaluate results of RCT and act accordingly. Who is Already Working in this Area? Multiple experts we spoke to agreed that mHealth suffers from “pilot-itis”, where most charities run a small pilot but never scale. None of the experts we talked to seemed to know why this is the case, though one person suggested it was because the government was not involved. As far as we could find, there are four organizations working in India that mostly provide SMS reminders, Vaccidate, eSwasthyaSeva, Immunize India, UNICEF, and mMitra. Vaccidate and eSwasthyaSeva seem small, internet-based, and focused on more wealthy Indian residents. Immunize India is larger (with over 700,000 users) but a large number of its signups are from the Indian middle class who are less in need. UNICEF is just running a pilot, which could very well suffer the same problems as all the other mHealth charities. mMitra is very small, only reaching about 42,000 people. When we talked to middle class locals in India, none of them reported receiving any sort of health reminder over SMS or any other medium. However, our impression is mHealth is becoming increasingly popular, so this idea may soon be expanded upon. For example, UNICEF is working with the Bangladeshi government to start a program to send reminders to do post-natal visits with a charity health worker (CHW) for both the CHW and the mother (mHealth Compendium, 2015, p79). Reservations To what extent do SMS reminders increase IC, after delays are taken into account? Some of the main studies report differences in IC only a few weeks after scheduled immunization date. For instance, Haji, et. al. (2016) and Bangure, et. al., (2015) report a 13% and 16% point increase in DPT3 coverage a few weeks after it being scheduled to be delivered at 14 weeks after birth. However, two systematic reviews identified a median delay of 6.2 and 6.3 weeks for DTP3 immunization in LMIC (Akmatov & Mikolajczyk, 2012; Clark & Sanderson, 2009). Studies that report differences in DTP3 IC only a few weeks after its scheduled delivery may give a misleading view of longer term IC increases attributable to the intervention because some children will receive DTP3 after the study finishes endline data collection. As a result, the counterfactual IC increases, say six months after scheduled immunization date, is likely less than the reported IC increases for some of these main studies but we aren’t sure to what extent. If the increase in IC attributable to SMS reminders six months after the scheduled immunization date was substantially less than the reported difference a few weeks or months after the scheduled immunization date this would significantly affect how promising we feel this specific charity idea is. Should we put less weight on these main studies? The ease of completing small scale studies on this intervention may make it particularly susceptible to publication bias and it’s worth noting that some of the main studies don’t appear to have been registered. Also, the lack of pre-analysis plan and independent re-analysis of the data makes it quite possible that inappropriate data analysis practices causes results to not replicate. What’s more, as the main studies are very recent, no reviews have commented on their quality or risk of bias and our own interpretation could miss some possible flaws. Will there be any limitations to sending texts? Potentially there are sizable limitations to sending reminder SMS’s at scale. Twilio, a cloud communications service that automates SMS sending mentions that, in India, the following limitations for sending automatic SMS:
Remaining Questions
This is one of our charity profiles, where we present our shallow, preliminary research on a potential, promising charity idea. We believe that this idea could be a potential contender for a GiveWell top charity, if further research confirmed the idea and if someone started the charity, executed it well, and resolved some of our outstanding questions and reservations.
Basic Idea Lobby low and middle-income countries (LMIC) to increase tobacco taxes. Summary Cost-effectiveness: High -- Studies claim this to be one of the most cost-effective interventions, with $/DALY figures more cost-effective than estimates for most other interventions. (However, these cost-effective estimates shouldn’t be taken literally and expect the true cost-effectiveness to potentially be much lower.) Strength of Evidence: Medium -- The case for tobacco taxation is covered by several studies, including some systematic reviews. However, we are concerned there is a lack of research on key lobbying related factors, such as counterfactuals, average campaign time, and the base rate of successful campaigning. Counterfactual Scalability: High -- If this was successful in one country, it seems like we could easily adapt the infrastructure to other countries. Moreover, there is only a few large organizations and two large funders working in the area, suggesting large room to grow. Ease of Testing: Low -- Performing an impact evaluation on a lobbying campaign is exceedingly difficult due to high interference from other campaigns, the all-or-nothing nature of lobbying, and an inability to effectively randomize. Flexibility: Medium -- While it appears we could move lobbying efforts to other areas as we gain more generalized skills and contacts, we would likely not build much infrastructure that is useful for areas outside lobbying. Logistical Possibility: Medium -- Lobbying poses significant logistical challenges and draws on skills we do not yet possess. Why We Think This Could be an Effective Opportunity There’s strong evidence that increasing tobacco taxation reduces tobacco consumption and that reduced tobacco consumption results in improved health outcomes (International Agency for Research on Cancer, 2011; Jha, et. al., 2013). Without cessation increases, tobacco use may account for some 10 million deaths per year by 2030, with most deaths occurring in LMIC (Ibid.). For example, in India, smoking accounts for nearly 40 percent of tuberculosis deaths among middle-aged males, or about 120,000 deaths annually. (Jha 2012). WHO (2011) estimates a 10% price increase in tobacco causes a 4% reduction in tobacco consumption. Jha, et. al. (2013b) estimates that increasing taxes to the World Health Organization (WHO) recommended level of 70% of total sale price in all LMIC would result in an 11-27% decrease in smoking mortality and therefore save tens of millions of lives. There are also numerous pieces of evidence suggesting that government implementation of tobacco taxation is highly cost-effective. Savedoff and Alwang, (2015), writing for the Center for Global Development, price tobacco taxation as $3 - $70 per DALY averted. Jha, et. al., (2013), writing for the Copenhagen Consensus, estimates a 4000% return, with a $500M/yr tobacco control program averting more than one million deaths annually. Jha, et. al., (2013) also states that tobacco taxation is the most important and most cost-effective portion of the tobacco control campaign. A systematic review of 84 studies also found that taxation was among one of the more effective tobacco control initiatives (Thomas, et. al., 2008). Experts we spoke to at tobacco lobbying campaigns and evaluative organizations (e.g., the DCP3) also broadly agreed that this was a strong area. A Possible Implementation Plan The most plausible route we identified was hiring local lobbyists and tobacco control experts to implement tobacco taxation legislation at the national level. Our starting point would be consulting the Framework Convention on Tobacco Control, which provides tax policy specifics, refutations of tobacco industry talking points, and guides for lobbying policy makers. The WHO Framework for Tobacco Control also contains additional information. We think it is best to focus tobacco taxation campaigns on lobbying LMIC because the costs of lobbying are significantly lower than the developed world and there is less existing lobbying efforts in place. There are many LMIC that fall beneath the WHO policy prescriptions for tobacco control which recommend taxation make up 70% of cigarette costs. Campaign for Tobacco-Free Kids (CTFK), a large non-profit working in the area, has prioritized their campaigns in most LMIC with a high burden of disease from tobacco that are also not facing violent internal conflict. If we were to work in one of those countries it would make sense to partner with them. We might be interested in working where CTFK isn’t, so that we can test our counterfactual impact free from the involvement of other campaigns. We very weakly think that Ethiopia may be a promising place to start, based on some preliminary research. CTFK has not prioritized Ethiopia, perhaps because of their low overall smoking rates. However, Ethiopia has a large population and they recently banned smoking in public places, which suggests political will may exist for further tobacco control. Who is Already Working in this Area? Our research suggests that Bloomberg Philanthropies and the Bill and Melinda Gates Foundation are currently the dominant funders in this area. Callard (2010) estimated no more than $240M is spent annually on tobacco control, worldwide, but this could be out of date due to more recent grants and GiveWell has argued that this study makes fairly aggressive assumptions (GiveWell report on tobacco control). Between 2007 and 2015, Bloomberg Philanthropies reportedly committed $600 million to combat tobacco use worldwide (Bloomberg press release, 2015), which amounts to $75M/yr. In 2008, the Bill and Melinda Gates Foundation pledged $125M over five years ($25M/yr) to tobacco control, including a $24M grant to Bloomberg (BMGF press release, 2008). CTFK has several tobacco control initiatives, including a focus on taxation. PSI in India ran Quitline from 2011 to 2013, which was a telephone help line primarily offering counselling to help people quit tobacco addiction. They encouraged the Indian government to continue the campaign, which, according to PSI, the government is planning to do but has not (Ibid.). In 2015, PSI in India also started a campaign to reduce exposure to second-hand smoke and tobacco use among minors (Ibid.). WHO offers technical assistance for governments trying to implement tobacco control. Resource Centre for Tobacco Free India is an advocacy and research group that has implemented various tobacco control initiatives, including taxation. The Economics of Tobacco Control Project, based in South Africa, creates new research and train NGOs about tobacco control initiatives, including taxation. Reservations The evidence for lobbying succeeding in LMIC is far weaker than the evidence for the impact of successfully implemented tobacco taxation. It’s often difficult to credit responsibility for legislative change to particular players in advocacy campaigns because multiple campaigns operate simultaneously and it’s unclear whether the government would have changed anyway, absent lobbying efforts. While there is considerable evidence the government implementation of tobacco taxation is highly cost-effective, there is a dearth of analysis on the return of investment of actual lobbying campaigns. We find the difficulty of testing this project to be a barrier to attempting an implementation, given our desire for rigorous impact evaluation and prioritizing against other charity ideas, as well as this making it difficult to receive feedback to refine our tobacco taxation approach. However, depending on local tax policy, this specific charity idea may be able to be completed at the state level before attempting it on the national scale. We’re also not enthusiastic about would could be the zero-sum and all-or-nothing nature of lobbying. We may not only have to be effective enough to lobby the government and beat the status quo but we may have to be more effective than the pro-tobacco interests lobbying the government. It seems quite possible that we could spend a significant amount of resources lobbying and not accomplish any actual legislative outcomes. According to some experts we spoke to, legal attacks on lobbying efforts from tobacco companies are also somewhat common. It would very likely be necessary to hire local lobbyists to reach the needed policy makers, which could be expensive. This also creates flexibility concerns, as the contacts we build would likely not be useful for a charity other than lobbying. Moreover, if lobbying requires a high degree of specialization, it may not even be possible to move easily between different lobbying campaigns. Funding could be a concern, especially if we were seeking a diversity of sources. While this intervention has large support from the global health community, there aren’t many large funders in this specific area. This could, however, suggest that the area is neglected. Remaining Questions
Everything takes longer
One of the biggest things we noticed while in India was that it takes large amounts of time even to accomplish fairly routine tasks relative to trying to do them in Canada. This no doubt was in part due to our unfamiliarity with the country, but based on what we saw, we think this could also be true even for natives, though to a lesser extent. For example, basic tasks like getting a vaccine or getting a cell phone set up were far cheaper but took far longer than doing the equivalent task in Canada. For example, getting a vaccine required considerable time and many different small steps for payments and waits (getting the appointment, for getting the consultation, prescription, getting prescription filled, getting injection, paying for each step). Mobility is really important One thing we noticed was that mobility was far more important in the locations we visited in India than almost anywhere in Canada. Sidewalks were narrow and paved inconsistently. It was hard for even the most able bodied individuals to cross many streets. Whenever we considered the impact of a health problem that impaired mobility it seemed like it would have a far greater impact in India than in Canada. Cellphones get a lot of texts Our cellphones got a very large and consistent number of advertising texts (5-10 a day) starting from the first day we got local cellphones. We could not find good data on whether this was average or abnormal but it made us more cautious about SMS interventions than we were originally. If we do any intervention based on SMS, we’d have to find a way to establish authority and make it clear that any health messages sent were not merely advertising. People mostly hang out in their own wealth brackets Unsurprising like in most countries there are pretty large deviations between different wealth brackets. When we talked to most individuals about their connections to others it was very often in the same wealth bracket and general socio-economic status. Pollution is really bad The pollution was shockingly bad. We had a sense of this from the statistics going in, but it was a whole different experience to feel it in person. At nighttime burning garbage and wood cook stoves made the air extremely polluted. Even far outside of large cities there was still the feel of some pollution in the air. There were many different languages spoken There was a huge variety of languages spoken in India that we encountered. Some of the people we met were trilingual and said they still had major translation problems in some places. The ability to speak fluent English was extremely correlated with wealth, although most people we encountered could speak a few English sentences. A surprisingly large number of signs and written language that we encountered were in English. This helped remind us that we would really need to have a good sense of what specific area we are working in before hiring staff or we would risk having major language problems. Different newborn health practices We learned there’s a tradition in many parts of India to not take a newborn or the mom out of the house until months after birth. This can cause problems because this holds true even if the newborn is sick and needs care. We found quite a few differences like this that could affect different programs we were considering. People self reported money and jobs as more important than health Quite a few times we asked impoverished people what they most desired or what they thought would improve their happiness most. The most common answer we got was the desire for employment or a better job. People's happiness seemed to vary a lot depending on their job and it also came up a lot in general conversations. The second and third most common things we heard were money and food. We almost never heard about health issues or loss of family members due to health concerns. We are not sure what causes this or if it would be different in different areas. The smallest city we stayed in was still over 100,000 people and we suspect this could affect the answers quite a bit. People we talked to seemed to think life was getting better Many different people we talked to commented about how their personal life was getting better or mentioned that life in India is generally improving. India has experienced huge income and health gains historically, but it was interesting to see how many people had actively noticed and appreciated the improvements. |
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