Evidence Action's Deworm the World Initiative — India (January 2023)

Note: This page summarizes the rationale behind a GiveWell-recommended grant to Evidence Action's Deworm the World. Deworm the World staff reviewed this page prior to publication.

Published: April 2023

Planned activities and budget

This grant will support Deworm the World's technical assistance to eight state deworming programs in India between 2023 and 2025. The grant size is based on our estimates of the following funding gaps:1

• $1.5 million for Deworm the World to wind down work in six states.2 These are states where Deworm the World plans to exit from in-person technical assistance (as it hands over its activities to state governments) within 2-3 years.
• $1.0 million for Deworm the World to extend its technical assistance in Uttar Pradesh and Bihar, where in-person technical assistance is expected to be needed for 3-5 more years.3

The case for the grant

Until around 2020, Deworm the World's work in India was primarily funded by non-GiveWell funding.4 GiveWell made a grant to Deworm the World in 2017 to provide reserves to protect against funding shortfalls; see more about that grant here. When Deworm the World's funding from other sources ended, it began using the reserve funding from GiveWell. Typically, we aim to maintain roughly 2 years of funding runway for any program we are supporting. We then either annually renew that funding or communicate that we are not renewing our support. We did not follow this approach with Deworm the World's India program, resulting in Deworm the World encountering a short funding runway. As Deworm the World's largest funder across geographies,5 and because we had previously signaled interest in funding the India program, we felt responsible for providing an exit grant to the India program. We have done this by filling 2023-2025 funding gaps for the six states from which Deworm the World expects to exit from in-person technical assistance by 2025. Note that we may have decided not to continue supporting these states after 2025 regardless of Deworm the World's plans to exit from in-person technical assistance. That is because it is very difficult to assess the cost-effectiveness of Deworm the World's technical assistance in India, particularly in states where the government is playing a major role in the program. In the absence of Deworm the World, it seems likely the programs would continue but may achieve lower coverage. However, there are plausible arguments at both ends of the spectrum: from (a) the program would achieve similar coverage without Deworm the World, which largely provides "nice to have" activities such as additional management support and monitoring and evaluation; to (b) Deworm the World's support is necessary for making the program happen and also helps leverage government resources and build government capacity. This degree of uncertainty is unique relative to many other GiveWell-funded deworming programs in which we expect deworming would likely not occur at all without the support of our grantees.

There are two states, Uttar Pradesh and Bihar, which Deworm the World has prioritized for longer term technical assistance. We have decided to continue funding these states, with the potential to renew support beyond 2025, because we trust Deworm the World's prioritization of these states (given its efforts to exit from in-personal technical assistance in other states, and the fact that it has chosen to cover nearly two-thirds of the program costs with non-GiveWell funds)6 and we believe it is likely that these programs have high cost-effectiveness (10 or more times as cost-effective as unconditional cash transfers, or "10x" for short).7 In our model, two of the key drivers of cost-effectiveness for deworming programs are worm burden and cost per child dewormed per year. We have moderately high estimates of worm burden for Uttar Pradesh and Bihar,8 and India has a low cost per child for deworming relative to other Deworm the World geographies.9

We also believe there is a low risk of crowding out other funders with this grant, including a low risk of crowding out non-GiveWell funds held by Deworm the World:

• We do not expect other funders to fill these funding gaps. Our understanding is based on 1) Deworm the World sharing that there are other states in India with no donor funding to support Deworm the World-style work (e.g., technical support, monitoring and evaluation), and 2) suspected lack of interest from historical major funders of deworming (namely, the UK government which has exited from supporting deworming,10 the U.S. which does not support deworming in India as part of its USAID-funded programs,11 and the Children's Investment Fund Foundation (CIFF) which appears to have significantly reduced support for deworming in India).12
• Deworm the World has internally allocated approximately $4 million of non-GiveWell directed funds to several programs in 2023-2025, including some we estimate to have cost-effectiveness below 10x.13 However, based on discussions with Deworm the World, we believe that the allocation of non-GiveWell funds is reasonably aligned with how Deworm the World would allocate these funds if GiveWell did not make further grants to Deworm the World. We are also cognizant of the mis-incentive that could be created (i.e., an incentive not to fundraise) if GiveWell was to consider all use of non-GiveWell funds below our cost-effectiveness bar to be crowding out other funding.

  Lastly, Deworm the World has a track record of supporting successful deworming programs.14 More in our review of Deworm the World.

  Risks and reservations

  • We have not modeled cost-effectiveness for this grant because of the challenges we would encounter in doing so and the time investment required relative to the total amount of funding affected ($1 million for Uttar Pradesh and Bihar).15 While we have good reason to believe this grant will be highly cost-effective as discussed above, it is possible further analysis would change our perspective. In particular, through detailed stakeholder conversations, we could learn that Deworm the World is only increasing coverage very slightly relative to what coverage would be in the absence of its technical assistance.
  • We could have provided only two years of exit funding (through 2024) to the six India states from which Deworm the World plans to exit from in-person technical assistance. We decided to fund 2025 given the relatively modest amount of funding required (approximately $840,000)16 and the value we see in supporting a smooth, appropriately paced exit of technical assistance in these states.17 We hope that supporting this transition will allow the program to continue and maintain high coverage rates. However, this decision carries some risk, as our uncertainty around the cost-effectiveness of Deworm the World's support increases as the government's involvement increases. We have agreed with Deworm the World that, if transition to the government happens in two years rather than three, any excess funds will be deployed to other Deworm the World programs which meet GiveWell's cost-effectiveness bar.
  • It is possible that Deworm the World will require funding beyond 2025 for the six states from which it plans to exit from in-person technical assistance:
    • Deworm the World's timelines for exiting from in-person technical assistance could be delayed in some or all of these states. Based on our conversations with Deworm the World, we believe the likelihood of meaningful delays is moderately low.18 We have communicated to Deworm the World that it is our intent not to grant additional funding for in-person technical assistance in these states. At this point, we do not believe that this intent will negatively impact a successful transition of the program to state governments, as the technical assistance exit timelines were driven by Deworm the World's programmatic considerations, rather than by GiveWell's suggestion.
    • Deworm the World is likely to have an opportunity in the future to use a smaller amount of funding to support longer-term remote technical assistance in these states.19 We may consider such a funding request once the program needs are clarified.

  Plans for follow up

  Deworm the World provides annual updates on program monitoring, coverage validation results, and spending for each program it supports. It also shares informal updates through email and monthly update calls.

  Internal forecasts

  Confidence	Prediction​​	By time​​
  60%	Deworm the World will exit from in-person technical assistance in all six planned states.	end of 2025
  80%	Deworm the World will exit from in-person technical assistance in five of six planned states.	end of 2025
  95%	Deworm the World will require additional funding for Uttar Pradesh and Bihar post-2025.	end of 2023 (timeline for 2025 renewal grant)
  40%	Deworm the World will require additional funding for Uttar Pradesh and Bihar post-2027.	end of 2025 (timeline for 2027 renewal grant)

  Our process

  Our process for this grant relied heavily on our following Deworm the World's work on the deworming programs we have funded since 2013, including frequent discussions with Deworm the World and reports on program monitoring, coverage achieved, and funding spent. We did an abbreviated investigation for this grant, which primarily consisted of reviewing Deworm the World's assessment of each of the eight states in India, analyzing its room for more funding analysis, and discussions with Deworm the World. We did not estimate cost-effectiveness for any portion of this grant.

  For internal review, a Senior Program Officer gave feedback on the plan for investigating the grant. A Program Officer reviewed the case for making the grant and gave feedback prior to final grant approval by a Senior Program Officer and GiveWell's CEO.

  Sources

  Document	Source
  Children's Investment Fund Foundation, "India National Deworming Programme"	Source (archive)
  Children's Investment Fund Foundation, Grant Portfolio	Source (archive)
  Devex, "72 million people to miss treatment for NTDs due to UK aid cuts," January 2022	Source (archive)
  Deworm the World, India State Assessment and Strategy, 2022 (unpublished)	Unpublished
  GiveWell Blog, "Our top charities for giving season 2017," 2017	Source
  GiveWell, "Evidence Action's Deworm the World Initiative – August 2022 version"	Source
  GiveWell, "GiveDirectly – November 2020 version"	Source
  GiveWell, "GiveWell's Cost-Effectiveness Analyses," 2023	Source
  GiveWell, "Summary of GiveWell's 2020 Worm Burden Adjustment Model"	Source
  GiveWell, 2023 Worm burden adjustment: moderate infection equivalent model	Source
  GiveWell, Deworm the World spending [2022]	Source
  GiveWell, GiveWell's estimates of Deworm the World's cost per child dewormed per year, 2022	Source
  GiveWell, Room for more funding analysis for Deworm the World, 2022	Source
  USAID, Neglected Tropical Diseases Program, Where We Work, 2023	Source (archive)

  • 1

    See our room for more funding analysis, sheet "RFMF projections," table "RFMF by project." Note that the grant also includes $0.04 million to support investigating cost-effective approaches for surveying soil-transmitted helminths (STH) at low prevalence, which is a research priority for Deworm the World India that will be primarily funded by non-GiveWell funds.

  • 2

    Tripura, Haryana, Uttarakhand, Chhattisgarh, Karnataka, and Jharkhand.

  • 3

    Deworm the World, India State Assessment and Strategy, 2022 (unpublished)

  • 4

    As shown in the 2022 summary of Deworm the World's spending, 2021 is the first year in which unrestricted funding for India is greater than funds which are restricted to a specific project (with the latter being entirely non-GiveWell funds). In prior years, restricted funding for India (which is entirely non-GiveWell funds) was much greater than restricted funding: 2020, 2019, 2018, 2017.

  • 5

    For July 2021 to June 2022, Deworm the World received approximately $2.2 million in non-GiveWell directed unrestricted funding, as shown here. Assuming Deworm the World received approximately $2 million in non-GiveWell directed unrestricted funding each year historically, and the breakdown of restricted vs. unrestricted funding as shown here (where restricted funding is non-GiveWell funding and unrestricted is a combination of GiveWell and approximately $2 million in non-GiveWell funding), GiveWell would have become Deworm the World's largest funder as of 2021. In 2020, Deworm the World received approximately $5.1 million in restricted and non-GiveWell unrestricted funding vs. approximately $3.7 million in GiveWell unrestricted funding. In 2021, these figures were approximately $3.8 million and approximately $7.5 million respectively.

  • 6

    See our room for more funding analysis, sheet "Source: DtWI RFMF (GW-Adjusted)," for Deworm the World's planned allocation of non-Givewell directed funds.

  • 7
    • We use GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding gaps. Thus, if we estimate that a funding gap is "10x" this means we estimate it to be ten times as cost-effective as unconditional cash transfers.
    • We think it's likely that these programs would meet our cost-effectiveness bar for directing funding, which is 10x as of January 2023. See GiveWell’s Cost-Effectiveness Analyses for more information about how we use cost-effectiveness estimates in our grantmaking.

  • 8

    See GiveWell, 2023 Worm burden adjustment: moderate infection equivalent model, rows "DtW_UttarPradesh" and "DtW_Bihar."

  • 9

    See GiveWell's estimates of Deworm the World's cost per child dewormed per year, 2022, sheet "Summary," row "total cost per child dewormed per year."
    

  • 10

    "Despite the U.K. government’s historical status as a leader in fighting NTDs, it has now performed a 'complete withdrawal' from the field, according to Simon Bush, director of NTDs at Sightsavers." Devex, "72 million people to miss treatment for NTDs due to UK aid cuts," January 2022

  • 11

    India is not listed as a country where USAID's neglected tropical disease program works. USAID, Neglected Tropical Diseases Program, Where We Work, 2023

  • 12

    CIFF's grant for Deworm the World in India ended in September 2021, and Evidence Action told us that it was not renewed. Based on our review of CIFF's grant portfolio, that grant does not appear to have been replaced with another one to support deworming mass drug administration in these states in India, though Deworm the World has heard that CIFF may support deworming in two other states (Himachal Pradesh and Telangana).
    

  • 13

    See our room for more funding analysis, sheet "Source: DtWI RFMF (GW-Adjusted)," for Deworm the World's planned allocation of non-Givewell directed funds.

  • 14

    "Deworm the World sends monitors to schools during and, for most distributions, after deworming to determine whether the programs it supports have reached a large proportion of children targeted. We have reviewed data from each of its major programs, which overall indicate strong results." GiveWell, "Evidence Action's Deworm the World Initiative – August 2022 version"

  • 15

    The case for granting $1.5 million to the six other states is based on the need for exit funding, regardless of cost-effectiveness.

  • 16
    • See our room for more funding analysis, sheet "RFMF projections," table "RFMF by project," column "2025."
    • Tripura ($0) + Haryana ($220,000) + Uttarakhand ($130,000) + Chhattisgarh ($160,000) + Karnataka ($190,000) + Jharkhand ($140,000) = $840,000.

  • 17

    Deworm the World noted in its feedback on a draft of this page that exit of technical assistance would be from states that have reached the WHO 2030 STH disease targets as evidenced by recent survey results.

  • 18

    Deworm the World expressed moderately high confidence in its ability to exit within the planned time frame and very low likelihood that substantial additional funding would be needed for these states post-2025. Deworm the World, conversation with GiveWell, November 18, 2022 (unpublished)

  • 19

    Deworm the World noted that remote technical assistance could be focused on surveillance to ensure there is no resurgence of prevalence. Deworm the World, conversation with GiveWell, November 18, 2022 (unpublished)