Sightsavers — Deworming in Democratic Republic of the Congo (April 2023)
Note: This page summarizes the rationale behind a GiveWell-recommended grant to Sightsavers. Sightsavers staff reviewed this page prior to publication.
Summary
In April 2023, GiveWell made a $5.8 million grant to Sightsavers. The grant was funded by approximately $5.5 million in donations to our All Grants Fund, $0.2 million in donations to the All Grants Fund through Giving What We Can, and $0.06 million from Doneer Effectief. This grant will support deworming programs in four provinces in the Democratic Republic of the Congo (DRC): Bas-Uele, Haut-Katanga, Ituri, and Lomami. This grant will support four years of deworming in each province (from April 2023 to March 2027).
We recommended this grant because we believe that the work that the grant will support will be cost-effective. Deworming is among the most cost-effective programs we know of, in certain locations. The need for deworming appears to be high in the areas where Sightsavers expects to use this grant. We have followed Sightsavers' work on deworming since 2015 and we believe that Sightsavers is well-positioned to support this work.
Published: June 2023
Table of Contents
Planned activities and budget
This grant will support Sightsavers' provision of technical and financial assistance for deworming programs in four provinces of the DRC: Bas-Uele, Haut-Katanga, Ituri, and Lomami. This includes one province, Ituri, that GiveWell has previously supported, and expansion to three provinces that GiveWell has not previously supported.1 The four provinces (out of 26 total provinces in the DRC)2 were selected based on high cost-effectiveness and anticipated funding gaps for 2023 and beyond. For more information on the type of technical and financial assistance that Sightsavers provides, see our review of Sightsavers' deworming program.
Sightsavers expects to use $1.1 million of this grant to support deworming in Bas-Uele, $1.5 million in Haut-Katanga, $1.8 million in Ituri, and $1.3 million in Lomami.3 See here for a breakdown of how Sightsavers has spent past funding for deworming programs across spending categories.
The case for the grant
- We estimate that this grant will meet our bar for cost-effectiveness. More below.
- We believe that it is unlikely that another funder will cover these costs. More below.
- Sightsavers has a track record of supporting successful deworming programs. More in our review of Sightsavers' deworming program.
Cost-effectiveness
Based on our cost-effectiveness analysis of Sightsavers' planned program in the four provinces in the DRC, we believe it is in the range of cost-effectiveness of programs we expect to direct funding to, as of April 2023 (at least 10 times as cost-effective as unconditional cash transfers,4 or "10x cash" for short). We excluded provinces that we expect are likely to be supported by other funders,5 as well as one province—Tshopo—where we estimated cost-effectiveness above 10x cash but have low confidence in that estimate.6 Our overall cost-effectiveness estimate for this grant (based on weighting each province's cost-effectiveness by the amount of funding allotted) is approximately 15x cash.7
Our cost-effectiveness analysis for this grant is based on the same structure as our model for other deworming grants. While investigating this grant, we updated parameters within that model to use inputs specific to this funding gap. Below, we highlight parameters that vary for different funding gaps and have a substantial impact on our headline cost-effectiveness figures:
- Worm burden: For every deworming grant, we ask the potential grantee to provide data on the prevalence and/or intensity of infections with each species of schistosomiasis and soil-transmitted helminths8 in the locations where it would support deworming. We prefer to use data on the prevalence of moderate-intensity infections and heavy-intensity infections for each species. When this isn't available, we use average intensity of infection or prevalence of any infection. We then apply an adjustment to our cost-effectiveness estimates of deworming programs to account for differences between the prevalence and intensity of worm infections in the geographies targeted by our deworming grantees and the prevalence and intensity of worm infections among the population studied in Miguel and Kremer 2004, the randomized controlled trial (RCT) on which we base our estimate of deworming's impact on consumption. Our previous cost-effectiveness analysis included one worm burden adjustment for the DRC, based on data from Ituri province.9 For this grant, we developed province-level worm burden adjustments.10 Our confidence in these adjustments is somewhat lower than typical for deworming programs, as we do not have access to the primary source reports and cannot confirm the methodology used to collect the original worm burden data (more in our Risks and reservations section below). We cross-checked the worm burden data shared with us by Sightsavers against data from the World Health Organization's (WHO's) Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN).11
- Cost per child dewormed: We estimate a cost of $1.27 per child dewormed through this grant. This estimate is based on the most recent data we have from Sightsavers' program in Ituri province.12 As three of the four provinces covered in this grant have not previously been supported by GiveWell, it is possible that our cost per child dewormed estimate will not accurately project costs in these other provinces.13 It is also possible that the cost per child dewormed through this grant will differ from the historical cost in Ituri, due to the scale of the program increasing from one to four provinces.
We made two additional updates to our cost-effectiveness analysis that also affected our final cost-effectiveness estimates:
- We recently incorporated an approximately 10% downward adjustment in all deworming program cost-effectiveness analyses to account for the possible decay of deworming benefits over time, lowering our cost-effectiveness estimates for deworming programs.14 See here to read more about this update.
- We incorporated a downward adjustment for our assumption that there is a 10% likelihood of GiveWell funding crowding out other philanthropic funding for deworming programs in the DRC (see "Funding landscape" for more on our rationale).15
Funding landscape
Other funders of deworming in the DRC that we are aware of include END Fund, Christian Blind Mission International (CBM), and the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN).16 For this grant investigation, we focused on provinces that seemed unlikely to receive support from one of those funders in 2023. Through this process, we identified 10 provinces with likely funding gaps.17 We then evaluated the cost-effectiveness of supporting deworming in those provinces, and determined that the four provinces included in this grant—Bas-Uele, Haut-Katanga, Ituri, and Lomami—met our bar for funding.
We do not yet know how much—if any—support ESPEN may provide for deworming programs in the DRC in 2023.18 As a result, we were unable to exclude provinces on the basis of ESPEN funding, and instead included a 5% adjustment in the cost-effectiveness analysis to account for the risk that we are crowding out ESPEN funding by supporting the four provinces included in this grant.19 We believe the likelihood of this is low, given that ESPEN's support for deworming in the DRC has declined in recent years: while we expect up to about 100 implementation units (districts)20 in the DRC to have deworming funding gaps in 2023, historically ESPEN has only supported between 0 to 31 implementation units annually.21
Risks and reservations
- We expect to receive updated worm burden data for the DRC in 2024,22 which could change our estimate of the cost-effectiveness of the program. Depending on the impact, this could potentially lead to a decision to reduce support for the program, or to cease funding deworming in the DRC entirely. Instead of expanding the program in the DRC now, we could have decided to wait to expand until after reviewing the new worm burden data. However, we believe the risk of lost impact from not moving forward with this grant outweighs the risk that our current worm burden estimates are meaningfully off. Prior to making this grant, we communicated to Sightsavers the possibility that we may not renew funding if the new data suggests lower worm burden; Sightsavers confirmed that it would accept the grant despite that risk.
- We may be over- or under-estimating worm burden in the selected geographies, for several reasons, including, but not limited to:
- We do not have access to the primary source reports on worm burden and cannot confirm the quality or methodology of the data collection.23
- The majority of the data we use was collected in 2014, and it's possible that worm burden has changed durably and significantly in the years since.24
- As previously mentioned, we conducted a rough cross-check of the worm burden data we received from Sightsavers against data from ESPEN. While these cross-checks overall increased our confidence in our worm burden estimates, as the Sightsavers and ESPEN data were largely similar, we only compared data on SCH prevalence, not STH prevalence.25 There is a risk that comparing STH prevalence would reveal greater discrepancies between the Sightsavers and ESPEN data, which would call the accuracy of our worm burden estimates into question.
- We are using historical data on the cost per child dewormed in Ituri province as the basis for our estimate of the cost per child dewormed in all provinces covered by this grant.26 There is a risk that costs may vary across provinces, or that the true cost per child dewormed may be higher or lower than we estimated as a result of the increased scale of the program (now covering four provinces instead of just one). Higher costs may mean we have funded provinces that do not meet our cost-effectiveness bar. Conversely, if costs are lower than the historical cost in Ituri, we may have excluded provinces from this grant that would meet our bar for funding.
- As discussed above, there's a risk this grant may crowd out potential funding from ESPEN, causing it to spend less on deworming mass drug administration (MDA) in the DRC than it otherwise would have, or to fund deworming in provinces with lower cost-effectiveness.
- WHO recently updated its treatment guidelines for schistosomiasis.27 Our understanding based on conversations with grantees is that many countries are currently re-evaluating or planning to reevaluate their deworming strategies and gradually move towards these updated guidelines. This includes moving to more targeted sub-district treatment and expanding target populations beyond school-age children.28 It's not clear to us how the new guidelines will affect funding needs and cost-effectiveness of deworming programs in the DRC over the next few years. Changes could result in us having overfunded or underfunded this program, and could also make it more difficult to evaluate cost-effectiveness in the future.
Plans for follow up
Sightsavers provides annual updates for all GiveWell-supported deworming programs. These updates include narrative progress reports, coverage survey reports, and annual spending reports.29 Sightsavers also shares informal updates by email and in conversation. We plan to use these conversations to update our understanding of the funding landscape for deworming in the DRC.
Internal forecasts
| Confidence | Prediction | By time |
|---|---|---|
| 70% | Cost per child dewormed is <$1.27 (or the inflation-adjusted equivalent) in the DRC at the end of our next grant investigation | January 2025 |
| 10% | ESPEN funds deworming programs in >20 implementation units (IUs) in 2023 | January 2024 |
| 30% | ESPEN funds deworming programs in 10-20 IUs in 2023 | January 2024 |
| 60% | ESPEN funds deworming programs in <10 IUs in 2023 | January 2024 |
Our process
Our process for this grant relied heavily on (a) our prior work on modeling the cost-effectiveness of Sightsavers' deworming program, (b) our discussions with Sightsavers, and (c) our following Sightsavers' work on deworming programs we have funded since 2016.30 For this particular grant, we:
- Updated our cost-effectiveness analysis as described above
- Reviewed the latest coverage evaluation survey reports and latest spending and treatment data from Ituri province31
- Spoke with other funders about the broader deworming funding landscape in the DRC
For internal review, a Senior Researcher and a Senior Program Associate gave feedback on the plan for investigating the grant. A Senior Program Associate who was not otherwise involved in the grant investigation reviewed the case for making the grant and gave feedback prior to final grant approval by a Senior Program Officer.
Sources
- 1
GiveWell began providing support for deworming in Ituri province in 2017. "The new support received from GiveWell responds to the unmet needs in the Ituri Nord project area for SCH [schistosomiasis] and STH [soil-transmitted helminths] control with MDA [mass drug administration]. The project delivers treatment in eight districts that are endemic with SCH and / or STH. Six of these districts required treatment in 2017; five for SCH and one for STH." Sightsavers, DRC country narrative report, 2018
- 2
"DRC is split into 26 provinces, 518 districts (IUs), 9,144 Aire de santé (sub-districts)" Sightsavers, DRC Wishlist 7 Proposal, 2022, p. 1.
- 3
A breakdown of the budget for this grant by expense category and by province can be found here. Note that Sightsavers originally requested a total budget of $6.7 million. However, Sightsavers recently received a $0.9 million donation from a Founders Pledge-influenced donor to support deworming in Nigeria, allowing Sightsavers to roll forward some of the GiveWell funding provided in our recent renewal grant to this grant instead. Thus we subtracted out the size of the Founders Pledge-influenced funding from the total grant amount we had planned for the DRC.
We calculate the adjusted grant size and amount of funding allocated to each province in this spreadsheet.
- 4
Note that (a) our cost-effectiveness analyses are simplified models that are highly uncertain, and (b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. As of early 2023, our bar for directing funding is about 10x as cost-effective as cash transfers. See GiveWell’s Cost-Effectiveness Analyses web page for more information about how we use cost-effectiveness estimates in our grantmaking.
- 5
See the Funding landscape section of this page for more information on how we assessed fundings gaps.
- 6
We identified some errors in the original worm burden data Sightsavers shared for Tshopo. These would require re-calculation of Tshopo's worm burden adjustment to have a level of confidence in the cost-effectiveness estimate in line with the funded provinces. Given this, as well as (1) our general uncertainty in the available worm burden data for the DRC (due to lack of access to primary source reports), and (2) Tshopo's currently estimated cost-effectiveness appearing to be just around our bar (see here), we decided not to invest further time in investigating Tshopo in this grant. We expect to re-investigate Tshopo, along with all provinces in the DRC, once new worm burden data becomes available from ongoing mapping efforts. We have higher confidence that the provinces included in the grant are >10x cash, despite general uncertainty in the available worm burden data for the DRC, given that our current cost-effectiveness estimates are solidly above 10x cash (12x +). We also confirmed with Sightsavers that these errors did not apply to data from other provinces included in this grant and feel confident in moving forward with our current worm burden adjustments for those provinces.
- 7
See our calculations here.
- 8
For more information on these types of parasitic infections, see our deworming intervention report.
- 9
Sightsavers, DRC SCH mapping report, 2017 (unpublished).
- 10
Worm burden adjustments are here in our cost-effectiveness analysis. This is the supplemental sheet from which these estimates are pulled.
- 11
We conducted an unpublished comparison of the schistosomiasis (SCH) prevalence data we received from Sightsavers (see here) to ESPEN data on SCH prevalence in the provinces considered for this grant (ESPEN data can be downloaded here). We focused on SCH rather than STH prevalence as SCH infections are weighted far more heavily in our worm burden adjustments for these provinces (see the "Simplified charity program data" tab, "Prevalence of moderate intensity infection equivalents" section of this spreadsheet).
The results of this comparison increased our confidence in our worm burden adjustments, as the Sightsavers data and ESPEN data were largely similar. In the case of discrepancies, the ESPEN prevalence figures were more likely to be higher than the Sightsavers' figures, indicating that we may be underestimating the cost-effectiveness of this grant (as a higher prevalence of infections would increase the benefits of deworming and thus the cost-effectiveness of this program).
- 12
We use data from 2019-2021 to estimate the cost per child dewormed. See our calculations here.
- 13
- GiveWell has not previously supported deworming in Bas-Uele, Haut-Katanga, and Lomami.
- "There will likely be a small level of variance between provinces, that we expect to level out in the medium term. Therefore, we don’t believe the cost per child will be higher in those provinces than in Ituri." Sightsavers, email to GiveWell, January 24, 2023 (unpublished).
- 14
See the adjustment we incorporated here, and where it feeds into our cost-effectiveness analysis of Sightsavers' program here. See here for the impact this change had on our cost-effectiveness estimates (note that we incorporated this adjustment into our cost-effectiveness analysis before developing province-level estimates of cost-effectiveness in the DRC, so change in cost-effectiveness by province is not shown).
- 15
See the adjustment we make here.
- 16
"Sightsavers, Schistosomiasis Control Initiative Foundation (SCIF), END Fund, Christian Blind
Mission International (CBM), and the Expanded Special Project for Elimination of Neglected
Tropical Diseases (ESPEN) have working relationships with, and provide financial support to,
the national NTD program and United Front Against River blindness (UFAR)." Sightsavers, DRC Wishlist 7 Proposal, 2022, p. 6.We do not include Unlimit Health (formerly known as the Schistosomiasis Control Initiative Foundation) on this list of other funders as GiveWell's support for Unlimit Health's deworming program in the DRC ended in March 2023 as described here. "The grant will also support deworming in Côte d'Ivoire, Democratic Republic of Congo (DRC), Liberia, Malawi, Sudan, and Tanzania for one year (April 2022-2023)." GiveWell, "SCI Foundation – Support for Deworming and Worm Burden Mapping (January 2022)"
- 17
We asked Sightsavers to conduct a scoping exercise to identify provinces with expected funding gaps for deworming. Sightsavers identified 16 provinces with expected funding gaps in 2023. However, we assumed that provinces supported in 2022 would have a high likelihood of receiving support again in 2023, with the exception of Lomami, leaving 10 provinces with a low likelihood of funding in 2023.
- "At the request of Givewell, Sightsavers carried out a scoping exercise in 2022. This exercise sourced information on SCH and STH in all 26 provinces, of which 16 have confirmed SCH/STH funding gaps from 2023." Sightsavers, DRC Wishlist 7 Proposal, 2022, p. 1.
- END Fund supported deworming in Lomami in 2022 but informed us it was not planning on renewing that support in 2023. As a result, we have assumed that Lomami will require funding in 2023. END Fund, conversation with GiveWell, January 12, 2023 (unpublished).
- See how we arrived at this list of 10 provinces here.
- 18
Sightsavers' estimation of 2023 funding gaps did not include potential support from ESPEN, as ESPEN's capacity to support deworming in 2023 was unknown. Consequently, Sightsavers may have overestimated the size of the funding gap in 2023, should ESPEN provide support for deworming in some of the provinces Sightsavers predicted would remain unfunded.
"ESPEN’s positioning will become clearer once the national program has signed contracts with its
traditional partners, after which ESPEN will decide on its level of capacity to fill the gaps
highlighted below." Sightsavers, DRC Wishlist 7 Proposal, 2022, p. 9. - 19
See the adjustment we make here.
- 20
"DRC is split into 26 provinces, 518 districts (IUs), 9,144 Aire de santé (sub-districts)" Sightsavers, DRC Wishlist 7 Proposal, 2022, p. 1.
- 21
After accounting for the number of implementation units likely to be covered by other funders (including those covered by this grant), we expect 101 implementation units will still have funding gaps in 2023. See our calculations here.
In the last five years, ESPEN has supported deworming in anywhere from 0 to 31 implementation units (IUs) in the DRC. ESPEN supported 0 IUs in 2021 and, as far as we are aware, supported 7 IUs for STH treatment in 2022. We track ESPEN's historical support for deworming in this spreadsheet.
Our best guess, based on the recent decline in ESPEN funding, is that ESPEN will fund deworming in <10 implementation units in 2023. See our Internal forecasts section.
- 22
In January 2022, we recommended a grant to SCI Foundation to fund worm burden mapping in the DRC, among other activities.
- "Planned activities and budget: . . . Fund worm burden mapping in DRC and Madagascar ($2.9 million, 14% of the grant). SCI Foundation will collect fecal and urine samples from children selected from across DRC and Madagascar and test the samples for presence and intensity of schistosomiasis and soil-transmitted helminth eggs. These results will be used to inform where and how often to conduct deworming in the future." GiveWell, "SCI Foundation – Support for Deworming and Worm Burden Mapping (January 2022)"
- "Worm burden mapping activities in DRC and Madagascar are expected to extend into the April 2023-March 2024 fiscal year, so we'd guess that we'll see results in 2024." GiveWell, "SCI Foundation – Support for Deworming and Worm Burden Mapping (January 2022)"
- 23
That being said, Sightsavers informed us it has no reason to believe that WHO data collection protocols were not followed. Sightsavers, email to GiveWell, January 24, 2023 (unpublished).
- 24
See the "Primary source data on charity programs" tab, "Survey date" column, of this spreadsheet.
- 25
We focused on SCH rather than STH prevalence as SCH infections are weighted far more heavily in our worm burden adjustments for these provinces (see the "Simplified charity program data" tab, "Prevalence of moderate intensity infection equivalents" section of this spreadsheet).
- 26
We calculate our cost per child dewormed estimate based on 2019-2021 costs in Ituri. See our calculations here.
- 27
"Last year, WHO launched a new road map for 2021-2030 that aims to end the suffering from NTDs by 2030, in line with the Sustainable Development Goals. The road map specifically targets the elimination of schistosomiasis as a public health problem, globally." World Health Organization, "WHO guideline on control and elimination of human schistosomiasis," 2022.
- 28
- "In endemic communities with prevalence of Schistosoma spp. infection ≥10%, WHO recommends annual preventive chemotherapy with a single dose of praziquantel at ≥75% treatment coverage in all age groups from 2 years old, including adults, pregnant women after the first trimester and lactating women, to control schistosomiasis morbidity and advance towards eliminating the disease as a public health problem." World Health Organization, "WHO guideline on control and elimination of human schistosomiasis," 2022, p. xvii.
- "Community mapping of the epidemiology of schistosomiasis can reduce the need for praziquantel, as treatment can be better targeted to communities and at-risk regions." World Health Organization, "WHO guideline on control and elimination of human schistosomiasis," 2022, p. xvi.
- 29
See past narrative reports, coverage surveys, and spending reports in the Sources section of our Sightsavers page. The most recent coverage surveys are reviewed and linked in our monitoring review here. Sightsavers' most recent spending and treatment data are linked from our cost per child analysis here.
- 30
GiveWell first recommended funding to Sightsavers in 2016. GiveWell, “Our updated top charities for giving season 2016"
- 31
See the latest coverage surveys results from Ituri here. For the latest spending and treatment data from Ituri, see here.