For 2021, we currently recommend three health and development policy ideas: road traffic safety, aid quality, and tobacco taxation. A deeper report on each of these will be released in the coming months; this post is intended only to give a sense of what the final ideas will look like for applicants to the 2022 Incubation Program.
These ideas are the result of a 9-month intensive research process designed to identify the interventions most likely to succeed as high-impact start-up charities. The process began by listing nearly 250 ideas and gradually narrowing down, looking at the options in more and more depth. In order to assess how promising interventions would be for future charity entrepreneurs, we use a variety of different decision-making tools such as group consensus, weighted factor models, cost-effectiveness analyses, quality of evidence assessments, case study analyses, and expert interviews.
This process was exploratory and rigorous – but it was not comprehensive. We did not research all 250 ideas in depth. As such, our decision not to take forward a charity idea to the point of adding it to this list should not be seen as a view that the intervention is not good. You are welcome to apply to the program with your own idea if you can make the case that it is as impactful as the listed options. We may also add more ideas to this list.
Road traffic safety
Description: In the World Health Organization’s most recent global status report on road safety, it was reported that the total number of road traffic deaths across the globe continues to rise steadily, reaching 1.35 million in 2016.
Legislation is a commonly used tool to reduce road traffic injuries and fatalities in high-income countries. However, adequate legislation is often lacking in low- and middle-income countries and, as a result, these countries disproportionately bear the global burden of road-related injuries and deaths. We evaluated legislation across 5 key risk areas - speeding, drink driving, helmet use, seat belt use, and child restraint use - and found that speed limits and seat belt legislation look to be the most promising.
There is strong evidence that speed is a key risk factor in road traffic injuries and fatalities, and that speed limits can reduce speeding. A meta-analysis of 98 studies explored the relationship between average speed and the incidence of road-related injuries and fatalities as well as created a formula that can be used to calculate the expected reduction in injuries/fatalities as a result of a change in speed (as the expected impact depends on the speed before and after). For example, when speed is reduced from 100 km/h to 90 km/h, the number of fatal accidents reduces by 34.4%. A meta-analysis of 51 studies found that speed limits reduce average speeds by 25% of the change of the speed limit.
There is also strong evidence that seat belt use reduces road-related injuries and deaths. A meta-analysis of 30 studies found that wearing a seat belt can reduce fatalities among front-seat occupants by 40-50% and among rear-seat occupants by up to 25%.
Moreover, there is good evidence that advocacy leads to policy change. Looking at 84 case studies of advocacy in this space across the globe, we found an average success rate of ~48% with 40 of 84 campaigns resulting in policy change in an average of 2.6 years.
Our cost-effectiveness analyses also suggest that appropriate speed limits and mandatory seat belt use, for all occupants, are both extremely cost-effective interventions.
Based on these findings, we recommend founding an organization to advocate for these road traffic safety improvements: reducing existing speed limits and improving and introducing seat belt legislation.
We recommend reducing existing speed limits to 50km/h in urban areas in countries where speed limits are currently higher. Promising countries in which to work on reducing speed limits might be Brazil, Egypt, Thailand, Bangladesh, or Malaysia. For seat belt use, we recommend advocacy for both improving existing legislation and introducing new legislation. Existing legislation can be improved upon in countries where it is currently only mandated to wear seat belts as the driver and front-seat passenger. This requirement could be extended to rear-seat passengers. New legislation in countries where it is currently lacking would mandate that all occupants must wear a seat belt. Promising countries in which to work on improving legislation might be Egypt, Vietnam, or Pakistan, and promising countries in which to work on introducing new legislation might be Mexico or Bangladesh.
Personal fit: This intervention has a relatively simple theory of change compared to other policy interventions, so it should be accessible to co-founders with a broad range of skills and previous experience. Co-founders will need to be comfortable with policy work - ie., a focus on building connections and influencing, an acceptance of a significant risk of failure yet higher payoff, and long feedback loops.
Aid quality
Description: Government aid (or development assistance) is the flow of resources from the government of a wealthier country to a developing country with the objective of improving human welfare or promoting economic development. Each year, about $170bn is given in aid. However, there is broad consensus from experts and think tanks in this space that aid effectiveness could be improved. The intervention idea is policy advocacy work to ensure this flow of resources is spent as effectively as possible.
Exactly what changes should be advocated for depends on the country, but we identify a few key focus areas for a new organization, including: advocating for more aid to be given, improvements to development agency decision-making, and better targeting of giving to poorer countries, top multilateral agencies, and effective best-buy programs. The scale of potential for such changes is huge. Successful campaigns may be able to influence government funds from £10m-£bns and have the potential to improve how resources are spent by up to an order of magnitude.
Based on an analysis of six case studies, one review of this topic by a charity evaluator, and one academic paper, we think that a well-run advocacy campaign in this space has a reasonable chance of being successful, maybe 20-30%.
This space is relatively crowded with think tanks, such as the Center for Global Development, and campaign groups, such as the ONE campaign, working on the topic across both the US and Europe. A new charity would need to think carefully about its approach and strategy to determine how they could be different from existing actors in the space in order to find an unoccupied niche. Locations to focus on might be the US, India, South Korea, Japan, the UAE, the EU, the UK, Germany, France, and other smaller EU countries.
Our highly tentative cost-effectiveness analysis suggests that a campaign spending $1.5m could expect to have an influence equivalent to directing $300m of additional funds to the world's poorest.
Our main concern with this intervention derives from our analysis of high-level trends. The data indicates that, even though individual campaigns can be successful, global aid effectiveness has not shown much improvement over time. The reasons for this are unclear, but it suggests that there may be some strong countervailing effects. For example, one donor giving effectively might lead to other donors giving less effectively or a political backlash that lowers aid or aid effectiveness.
Personal fit: This intervention is fairly complex and founders would benefit considerably from an understanding of policy in order to decide what to campaign for. This intervention may be suited to founders from the countries listed above who are interested in working within a country they have some familiarity or expertise in. Co-founders will need to be comfortable with policy work - ie., a focus on building connections and influencing, an acceptance of a significant risk of failure yet higher payoff, and long feedback loops.
Tobacco taxation
Description: Tobacco kills more than 8 million people each year. More than 80% of the world’s tobacco users live in low- and middle-income countries.
There is very good evidence linking smoking to many negative health outcomes, both for direct and secondhand smokers. These negative health effects include increases in lung cancer, chronic obstructive pulmonary disease (COPD), heart disease, stroke, and various other cancers.
There is also very strong evidence that increasing tobacco taxes reduces tobacco consumption. This is, in fact, one of the strongest results in tobacco control research. Because of this effectiveness, and its relatively low cost compared to other tobacco control initiatives, tobacco taxation has been shown to be the most cost-effective way to reduce tobacco use and health care costs while increasing revenue.
There is evidence that this intervention can be effectively delivered by the government. Indeed, to date, there are 38 countries, 15 of which are LMIC, implementing tobacco taxation at its highest standard (75% of the product retail price).
In terms of the probability of success of advocacy for this intervention, looking at a total of 172 case studies, we see an average success rate of ~27.33-54.65%. Note that there may potentially be some double-counting here as much of this advocacy work cannot be attributed to just one organization.
Despite the promise of this intervention, there are some concerns. There are two main significant funders in the space, but they favor large, well-established organizations, so funding might be a limiting factor. Two previously incubated CE tobacco taxation charities, Good Policies and Policy Entrepreneurship Network, shut down after a year of operation. This was in part due to co-founder issues but seems to have also been influenced by difficulties in getting funding. Another concern about this intervention is neglectedness. There are a few organizations working in this space that appear to be quite successful, are well-funded, and are targeting high burden countries. A successful strategy might lie in focusing on less burdened countries that other organizations are not working in, such as Mongolia or Lebanon.
Personal fit: This intervention is likely the one, of all those considered, where co-founders would benefit greatly from experience as skilled policy advocates, though some progress was made by CE’s previously incubated charities who didn’t have the background or relevant experience in the space. The tobacco lobby is a strong opposition that co-founders will have to be comfortable with going against. Driven advocates must be ready to tackle any of the challenges this opposition brings, as they will be actively trying to slow down your progress at every step of the way. As with the other interventions, co-founders will need to be comfortable with policy work - ie., a focus on building connections and influencing, an acceptance of a significant risk of failure yet higher payoff, and long feedback loops.
If you are interested in starting one of these interventions, applications will soon be open to our 2022 and 2023 Incubation Programs.