MiracleFeet — Clubfoot Treatment (January 2023)

Note: This page summarizes the rationale behind a GiveWell grant to MiracleFeet. MiracleFeet staff reviewed this page prior to publication.

Published: August 2023

Summary

What we think this grant will do

With this grant, MiracleFeet will partner with local NGOs to support the routine health system to identify and correct cases of clubfoot using the Ponseti method. Clubfoot is a congenital condition where one or both feet twist inward and upward, causing pain and mobility loss if left untreated. The Ponseti method involves correcting clubfoot via serial casting, surgical cutting of the tendon, and use of braces while sleeping for 4-5 years to maintain the correction.

We think this grant will lead to an increase in the number of infants with clubfoot receiving treatment in these countries, which will, in turn, lead to reduced disability and other benefits during the rest of these infants’ lives. (more)

Why we made this grant

• While we estimate that the cost-effectiveness of MiracleFeet’s program over the course of the grant is slightly below our funding bar, we think the grant will also create additional “learning value,” which leads us to believe it’s a cost-effective use of funding overall.

  Our initial work suggests that this program is likely cost-effective because:

  • MiracleFeet causes additional children with clubfoot to get treated. MiracleFeet supports specialized training and materials, which are lacking in facilities currently, and conducts community outreach to encourage caregivers to seek treatment. We estimate MiracleFeet will treat roughly 10,000 children with this funding, and only about 10% of these children would have received treatment without MiracleFeet’s program.
  • Treatment with the Ponseti method is moderately effective at correcting clubfoot long-term. While short-term success is high (roughly 80%), there is limited evidence about long-term outcomes in low-income contexts. We account for this by assuming a high risk of relapse that lowers long-term success to 50%.
  • Clubfoot, if untreated, leads to substantial disability during the child’s entire life. The estimate of clubfoot’s burden we use suggests averting a lifetime of clubfoot is 25% as valuable as averting a child's death. We also think clubfoot could lead to lower earnings in adulthood.
  • While the cost per person treated is much higher than for many other programs we've funded, the benefit per person treated is also much higher. Our top charities typically provide blanket prevention programs with a low cost per child (roughly $5-$10), but any given child has a low chance of dying. Clubfoot treatment, on the other hand, is roughly $500 per child but is targeted specifically to children with clubfoot.

  Our best guess is MiracleFeet’s program over the course of this grant is 8 times as cost-effective as unconditional cash transfers, which is below our funding bar (10x cash). This cost-effectiveness estimate is at an early stage. As a result, we have more uncertainty about this estimate than for some of our other grants. A sketch of our cost-effectiveness analysis and level of uncertainty is in the table below. Key parameters are bolded.

  	Best guess	25th-75th percentile range for key parameters	Cost-effectiveness over that range
  Grant size	$5,2 million
  Disability benefits
  Number of infants with clubfoot treated by MiracleFeet	9,800	8,000-11,000	7x-9x
  Percentage of those infants who would have been treated without MiracleFeet	9%	2%-16%	8x-9x
  Long-term effectiveness of Ponseti treatment	50%	25%-75%	4x-12x
  Cost per clubfoot case averted	$1,200
  Moral weight for each lifetime of clubfoot averted (“units of value”)	30	15-40	4x-11x
  Cost-effectiveness from disability benefits only (times more cost-effective than providing unconditional cash transfers in the world’s poorest communities, “x cash”)	7x
  Primary benefit streams (as % of total)
  Disability benefits	80%
  Increased income in adulthood	20%
  Additional upside and downside adjustments	0.9
  Additional benefits and adjustments	+10%	-10% – +30%	7x-10x
  Cost-effectiveness (x cash)	8x
  Cost per infant treated	$530

  You can see our full cost-effectiveness analysis for this grant here and a simple version here.

  We think this grant has additional value to GiveWell, beyond what’s modeled above, by allowing us to learn more about the cost-effectiveness of this program. One key uncertainty is the extent to which MiracleFeet’s program increases the number of children receiving clubfoot treatment. Through program data collected by MiracleFeet, we expect to learn how many children MiracleFeet treats and compare it to our estimates. We think there’s a 25% chance we would conclude the program is above 10x after seeing these data, which would cause us to direct more funding to clubfoot programs in the future. (more)

• We believe that the grant provides opportunities for qualitative learning beyond clubfoot. We expect to learn more about the feasibility of working with an organization that is less GiveWell-aligned and the promisingness of funding treatment for other types of disabilities and congenital conditions. This additional value is also not included in our cost-effectiveness estimate above. (more)

Main reservations

• How effective is the Ponseti method at correcting clubfoot long-term? While there is strong evidence for the short-term effect of Ponseti treatment on clubfoot correction, there is limited evidence on the short-term effect on levels of disability and limited evidence on how long short-term corrections last. Our 25th-75th percentile for long-term success of Ponseti treatment implies a range of cost-effectiveness of 4x-12x. We don’t expect to be able to update this parameter based on data gathered during this grant.
• What is the appropriate moral weight for clubfoot? Our estimate is based on applying disability weights from the Global Burden of Disease1 that appeared relevant and assuming these persist over the course of an untreated child’s life. We have done little work to sense check this estimate or explore alternative estimation approaches. Our 25th-75th percentile for the moral weight on a lifetime of clubfoot averted implies a range of cost-effectiveness of 4x-11x. We don’t expect to update our moral weight as a result of information collected through this grant.
• MiracleFeet has a more limited background in impact evaluation than typical GiveWell grantees. As a result, there’s a risk the information we receive from this grant won't be as high-quality as we would like. We’ve agreed on what information MiracleFeet will provide on the reach and quality of its program. However, there are a lot of detailed decisions that need to be made when deciding how to collect and summarize this type of information. Based on our conversations with MiracleFeet about its level of confidence in its program, we think there is a risk that MiracleFeet will interpret data in a more optimistic way than GiveWell would. (more)
  
  The infrastructure, processes, and resources in place within a healthcare system to provide regular, standardized, and essential healthcare services.

  This is calculated by dividing the grant size by the average cost per infant treated.

  Calculated as: $5.2 million / (9,800 x (1-9%) x 50%)

  We use moral weights to compare outcomes. Our moral weight of 30 units of value for a lifetime of clubfoot is 25% as large as our moral weight for a child death averted (120 units of value). More on our approach to moral weights here.

  Calculated as: 30 / $1,200 / 0.00335 units of value per dollar from unconditional cash transfers

  Calculated as: 1 / 0.8*0.9.
  Our full cost-effectiveness analysis for this grant incorporates additional benefits of the grant (in particular, increases in adult income from treating clubfoot and benefits from the treatment of walking age children) as well as downside adjustments for potential negative effects (such as skin sores due to casting) or factors that may reduce positive effects (such as risk of wastage). We also account for changes in cost-effectiveness due to leverage (in which the program uses resources from other sources such as the government) and funging (which we define as the potential that GiveWell-recommended funding crowds out funds that would otherwise have been allocated to the program from other sources).

  Calculated as: 7x cash * 1.1

  Calculated as: $5.2 million / 9,800

  Disability weights represent the magnitude of health loss associated with specific health outcomes and are used to calculate years lived with disability for these outcomes in a given population.

  The intervention

  Clubfoot is a congenital condition where one or both feet twist inward and upward, causing pain, mobility loss and possibly reducing income if left untreated. MiracleFeet supports the treatment of clubfoot by the Ponseti method, which we understand to be the gold standard of care. This consists of a series of casts to correct the alignment issue and, in the majority of cases, an Achilles tenotomy (surgical cutting of the tendon under local anesthesia) to improve the foot’s flexibility, followed by the use of braces while sleeping for 4-5 years to maintain the correction.2

  MiracleFeet partners with local NGOs to support treatment of clubfoot through the routine healthcare system, including training providers to identify clubfoot and carry out the treatment, providing supplies for casting and braces, and community sensitization efforts.3 MiracleFeet also supports the use of a monitoring and evaluation app called CAST to collect data on treatment and ideally maintain certain levels of quality.4

  It is our impression based on the literature, discussions with MiracleFeet, and a discussion with one disability expert that clubfoot treatment coverage is low in LMICs in the absence of NGO support. This is because:

  • Clubfoot is a relatively niche issue (affecting approximately 1 in 800 births), so governments in resource constrained countries may not be able to prioritize government-led implementation of treatment.5
  • Treating clubfoot requires providers to be trained in the Ponseti method and requires specialized materials such as braces which may not be readily available in lower income contexts.6
  • Children with clubfoot and their families can face stigma which may result in families being less likely to know about or seek out care in the absence of community sensitization efforts.7

  We think it is plausible that NGO support can increase treatment coverage by providing necessary resources and training and advocating for clubfoot treatment as a priority.8 Treatment coverage is reported to be high (>50%) in certain LMICs, lending plausibility to the idea that this is a solvable problem.9

  At the moment, we have significant uncertainty regarding levels of clubfoot treatment in the absence of NGO support as well as the degree to which NGO support can increase treatment coverage. We are investigating a second potential grant to MiracleFeet to fund baseline and endline data collection on treatment coverage to help us reduce this uncertainty.

  See our intervention report for more details on clubfoot, the Ponseti method, and our assessment of its effectiveness.

  The grant

  This $5,210,581 grant,10 funded by Open Philanthropy and individual donors, will support:

  • Scale up of MiracleFeet’s existing clubfoot treatment program in the Philippines, which we estimate will increase annual treatment coverage in the country from 560 infants as of fiscal year 2023 to approximately 1400 in 2027
  • Establishment of a new MiracleFeet program in Chad, which we estimate will treat approximately 490 infants by 2027
  • Establishment of a new MiracleFeet program in Côte d’Ivoire, which we estimate will treat approximately 660 infants by 202711
  • A fifth year of funding (2028) to serve as exit funding in the event that we decide not to renew the grant, for which we assume treatment numbers would be the same as in 2027.

  Grant activities

  Grant activities will include:

  • Partnering with Ministries of Health to detail the scope of the project
  • Establishing new clubfoot clinics in high-need areas
  • Raising awareness of clubfoot in targeted communities through radio/TV ads, social media, websites, flyers, etc.
  • Conducting Ponseti method trainings for healthcare providers
  • Monitoring treatment quality using CAST (MiracleFeet’s monitoring and evaluation app) and
  • Mentoring healthcare providers to improve treatment quality as needed
  • Educating parents on the importance of completing treatment12

  Budget

  The $5,210,581 budget includes:

  • $3,748,552 for all three country budgets
    • $1,748,230 for the Philippines
    • $881,322 for Chad
    • $1,119,000 for Côte d’Ivoire
  • $667,195 for program management
    • $245,084 for the Philippines
    • $220,936 for Chad
    • $201,175 for Côte d’Ivoire
  • $794,834 for MiracleFeet overhead costs

  See MiracleFeet’s initial budget here and GiveWell’s revised budget adding one year of exit funding here.

  The case for the grant

  We are recommending this grant because of:

  • Potential cost-effectiveness. Our current best guess is that the cost-effectiveness of this grant is likely below our threshold for funding,13 though our cost-effectiveness analysis (CEA) for this program is particularly uncertain and does not incorporate some potential learning benefits of the grant. More below.
  • Learning value. We expect that this grant will allow us to learn more about clubfoot treatment programs, and it could update us toward believing clubfoot treatment is more or less cost-effective than we’ve currently modeled. We also believe that the grant provides opportunities for qualitative learning that may apply outside of the clubfoot space. More below.

  Cost-effectiveness

  Our current CEA for this grant suggests that the program may be about 8 times as cost-effective as unconditional cash transfers over the course of the grant period and about 9 times as cost-effective as unconditional cash transfers at scale.14 This is slightly below our funding threshold as of the time of our recommendation; however, the CEA omits quantitative and qualitative learning value that we expect to gain from the grant (more below).

  Some of the key factors in our CEA include:

  • The number of infant clubfoot cases treated due to grant activities
    • MiracleFeet assumes that treatment coverage rate in these countries will begin at around 20% of the estimated number of children born with clubfoot, then ramp up to around 60% of children born with clubfoot at the end of the grant period.15 In our CEA, we apply a 25% downward adjustment to these targets to account for optimism.16 This adjustment is partially based on data on year-on-year growth from existing MiracleFeet programs that scaled quickly but is mostly subjective. This is one parameter that we hope to learn more about as a result of this grant.
    • Note that MiracleFeet also plans to treat cases of clubfoot in older children (called “neglected cases”)17 but we expect that older children will make up a relatively small portion of treated cases (about 12%) and that treatment of older children will be somewhat less effective than treatment of infants.18 Therefore, the primary benefit we model in our CEA is the benefit to infants.
  • The number of infant clubfoot cases that would be treated in the absence of the grant
    • MiracleFeet has told us that there are limited options for clubfoot treatment outside of its program in the Philippines and no apparent routes to treatment in Côte d’Ivoire and Chad.19 We have input subjective guesses in our CEA for counterfactual treatment coverage in each country, but these are highly uncertain.20 This is one parameter that we hope to learn more about as a result of this grant and the second potential grant funding baseline and endline data collection on treatment coverage.
  • Disability weight for untreated clubfoot
    • Untreated clubfoot is commonly reported to cause disability, deformity and pain. People with untreated clubfoot are also reported to face social exclusion and reduced income.21 We therefore use fairly high disability weights for untreated clubfoot (a weight of 0.237 for bilateral clubfoot and 0.178 for unilateral clubfoot).22
  • The degree to which disability is averted by clubfoot treatment
    • Clubfoot treatment using the Ponseti method appears to be largely successful in the short term. We estimate that 78% of children who undergo treatment through MiracleFeet’s program as part of this grant will achieve near-typical foot function after the casting and tenotomy phases of treatment (but before the bracing period which lasts for several years).
    • However, relapse following initial treatment is fairly common. A 2021 systematic review of long-term outcomes following Ponseti treatment found that 47% of patients experienced relapse.23 We therefore use a fairly stark assumption in our CEA that almost half of children relapse and do not enjoy any benefits of treatment after relapse.24 We have not reviewed additional evidence on this parameter, and we might be underestimating the benefit of MiracleFeet’s program if fewer children relapse than we think or if some portion of children who experience relapse still receive some long-term benefit from treatment.
  • Duration of benefits
    • If not treated in childhood, clubfoot is a lifelong condition.25 Thus, in our CEA we account for 60+ years worth of benefits for each child successfully treated.
  • Cost per child treated
    • MiracleFeet funds clubfoot treatment in a portfolio of 36 countries, and we estimate that cost per child treated varies widely across countries (from a minimum of around $350 to a maximum of $3800 once 18% overhead is included).26 Our understanding is that this wide range is driven at least partially by relatively high fixed costs compared to variable costs. Because of these high fixed costs, treating large numbers of children helps reduce the overall cost per child treated.
    • We currently estimate that cost per child treated has to be relatively low (less than about $370, before accounting for leverage and funging) in order for our estimate of cost-effectiveness for the program to reach our current threshold for funding. We hope to learn through this grant whether MiracleFeet can cause a sufficiently high number of children to be treated for the cost per child treated to be at or under this threshold.

  Learning value

  This grant should allow us to refine our estimate of the number of children treated by MiracleFeet’s program (though in the event that we do not decide to make the monitoring and evaluation grant we are currently considering, we may have limited confidence in MiracleFeet’s reported treatment numbers). If we learn through this grant that achieving high treatment coverage for clubfoot is more feasible than we currently assume, this may lead us to update our cost-effectiveness estimate of clubfoot treatment programs upward, which could in turn open up small to moderate amounts of cost-effective room for more funding with MiracleFeet and other clubfoot treatment NGOs.27

  We also believe that the grant provides opportunities for qualitative learning that will apply outside of the clubfoot space:

  • Our impression is that many current GiveWell grantees are unusually committed to gathering evidence about their programs’ effectiveness and willing to communicate transparently about their programs’ strengths and weaknesses. Our impression is that MiracleFeet is more typical of many NGOs in its lower alignment with GiveWell on these characteristics. We believe that this presents an opportunity to explore whether we can work efficiently and effectively with MiracleFeet and other groups with similar levels of alignment to find potentially cost-effective opportunities. For example, lessons we learn about how to communicate with MiracleFeet might apply to other potential grantee organizations, which could indirectly support the expansion of GiveWell’s grantmaking. On the other hand, we might learn that there are difficulties of working with organizations with less apparent commitment to evidence generation and transparency than the typical GiveWell grantee. These difficulties could make this a less promising way to expand, which would also be useful learning. (See our reservations for more information on this.)
  • A key claim underlying the case for this grant is that governments don’t prioritize clubfoot treatment because it is relatively rare and requires specialized training and supplies to treat. We expect that these factors might apply to a number of different disabilities or congenital conditions and learnings from this grant might help inform our priors about the availability of treatment in other areas, potentially opening up new funding areas for us.

  Risks and reservations

  We have the following primary reservations about this grant:

  • It’s possible that we should make a smaller investment. Our best guess is that the cost-effectiveness of MiracleFeet’s program is right around our funding threshold, even when accounting for learning value. Given our uncertainty, it’s possible that rather than recommending a grant to fund three countries over five years, we should recommend a smaller amount to fund only one or two countries. More below.
  • Existing evidence for clubfoot treatment is relatively weak. As we discuss in our intervention report on Ponseti Casting for Clubfoot, the existing evidence on clubfoot treatment is not very strong. This grant won’t resolve, or attempt to resolve, many of our fundamental uncertainties around the relationship between treatment and functional outcomes or relapse and functional outcomes. If untreated clubfoot is less bad than we think, treating clubfoot doesn’t avert all the associated disability, or more children experience untreated relapse than we think, clubfoot treatment programs could be less cost-effective than we model.
  • We believe that MiracleFeet as an organization has somewhat less experience with impact evaluation than a typical GiveWell grantee (though we note that it has demonstrated willingness to do the additional work we have recommended around monitoring and evaluation). We see this as both a potential risk and an opportunity. It’s possible that the partnership will be more challenging than we expect or that we may have doubts about the quality of what we learn from this grant. However, we also expect that there are a number of similar organizations with less impact evaluation experience that may be doing cost-effective work, and we see this grant as an opportunity to learn about the feasibility of working with such groups.

  Option to make a smaller investment

  Given our borderline cost-effectiveness estimate for this grant, it’s possible that rather than recommending a $5.2 million grant to fund 3 countries over 5 years, we should recommend a smaller amount to fund only one or two countries. We are recommending funding all three countries because:

  • We think that funding the program in three countries will better enable us to learn about the feasibility of achieving high treatment coverage. We expect that treatment coverage might be dependent on country-specific factors such as current healthcare access, the potential local NGO partners available in the country, or weather conditions or events that affect travel. Observing the program across three countries might make it slightly easier for us to assess whether high coverage is achievable and sustainable.
  • Funding the two most cost-effective countries does not significantly change our best guess of the cost-effectiveness of the grant. We estimate that the programs in the Philippines, Côte d’Ivoire, and Chad will be 8.1 times as cost-effective as unconditional cash transfers over the course of the grant period. By comparison, we estimate that the programs in only the Philippines and Côte d’Ivoire would be 8.5 times as cost-effective as unconditional cash transfers over the course of the grant period.28

  Plans for follow up

  We plan to follow up with MiracleFeet via calls and informal reports every 6 months. We will consider this program for renewal in July 2027. The current grant includes one year of exit funding in the event that we decide not to renew in 2027.

  We also plan to consider a separate small grant in early 2023 to support external evaluation of the activities funded by this grant.

  Internal forecasts

  For this grant, we are recording the following forecasts:

  Confidence	Prediction	By time
  In one country - 60% In two countries - 40% In all three countries - 20%	Estimated treatment coverage will exceed 50% in MiracleFeet’s FY2027 (from July 2026-June 30 2027)	December 2027
  65%	We will recommend funding additional clubfoot treatment program grants.	December 2028
  55%	There will be at least $2 million in room for more funding that is 8x or greater for clubfoot treatment globally (including MiracleFeet and other clubfoot treatment NGOs)	December 2028

  Our process

  We did the following as part of this grant investigation:

  • Requested, received, and reviewed MiracleFeet’s proposal.
  • Asked additional questions and received answers and additional data from MiracleFeet, which we reviewed and used to update our cost-effectiveness analysis for the grant.
  • Performed sensitivity analyses for our cost-effectiveness estimates.
  • Spoke with an expert on clubfoot treatment.

  Sources

  Document	Source
  Bina et al. 2020	Source
  Drew, Gooberman-Hill, Lavy, 2018	Source
  GiveWell, "Ponseti Casting for Clubfoot"	Source
  GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023	Source
  Global Burden of Disease Collaborative Network, Global Burden of Disease Study 2019 (GBD 2019) Disability Weights, 2020	Source
  Global Health Data Exchange, "Global Burden of Disease Study 2019 (GBD 2019) Disability Weights" 2023	Source
  Grimes et al. 2016	Source
  Harmer and Rhatigan 2014	Source
  Institute for Health Metrics and Evaluation, Global Burden of Disease Study 2019, Disability Weights (accessed April 18, 2023)	Source
  MiracleFeet, 3 Country Grant Budget, 2022	Source
  MiracleFeet, Proposal for GiveWell, 2022	Source
  Owen, Capper, and Lavy 2018	Source
  Penny 2005	Source
  Penny et al. 2021	Source
  Rastogi and Agarwal 2021	Source
  The Clinton Health Access Initiative, Preventing Lifelong Impairment: Access to Clubfoot Treatment in Low- and Middle-Income Countries, 2021	Source
  van Wijck, Oomen, van der Heide, 2015	Source
  World Health Organization, "Congenital anomalies"	Source
  World Health Organization, World Report on Disability, 2011	Source

  • 1

    “The Global Burden of Disease Study 2019 (GBD 2019), coordinated by the Institute for Health Metrics and Evaluation (IHME), estimated the burden of diseases, injuries, and risk factors for 204 countries and territories and selected subnational locations.

    Disability weights, which represent the magnitude of health loss associated with specific health outcomes, are used to calculate years lived with disability (YLD) for these outcomes in a given population. The weights are measured on a scale from 0 to 1, where 0 equals a state of full health and 1 equals death. This table provides disability weights for the 440 health states (including combined health states) used to estimate nonfatal health outcomes for the GBD 2019 study.” Global Burden of Disease Collaborative Network, Global Burden of Disease Study 2019 (GBD 2019) Disability Weights, 2020

  • 2

    “The Ponseti casting method has become common practice in high-income countries during the last decade and a half [4]. It has changed the treatment of clubfoot so that complex posterior medial release of multiple tendons and joint capsules, which was once the standard, is now rarely needed. This new treatment involves sequentially stretching the deformed foot and holding the stretches in a series of casts to restore the correct alignment of the foot gradually (Fig. 2) [1]. Following the stretching sequence, a minor surgical procedure, percutaneous tenotomy, is nearly always required but can often be done in an outpatient clinic with local anesthetic [4].” Harmer and Rhatigan 2014, p. 839.

    "The Ponseti method is now considered to be the gold standard of treatment in the USA, and its use has spread widely throughout high-income countries (HICs),2–4 largely replacing previously used surgical and conservative techniques. It is also more cost-effective, less invasive and has lower risks of complications than surgical treatments.5 As such, it is an ideal solution for low-resource settings." Owen, Capper, and Lavy 2018.

  • 3

    “MiracleFeet’s approach to addressing the global problem of untreated clubfoot is to strengthen local treatment capacity in LMICs and reduce the barriers to treatment that families typically face. By partnering with local NGOs working in disability and rehabilitation, we build upon each country’s existing health infrastructure to create and support a nationwide network of clinics—located in existing district or provincial hospitals—capable of delivering high-quality care. We train providers in the Ponseti method and ensure clinics are equipped with all necessary treatment supplies, including braces. We establish early detection and referral pathways by raising awareness of clubfoot in communities and training frontline health workers (such as nurses and midwives) in clubfoot identification, with the goal of ensuring families access treatment before a child’s first birthday (when treatment is easier on the child and optimal results are most likely). Once children are enrolled, our clinic teams educate and follow-up with parents to minimize patient dropout and optimize long-term outcomes. MiracleFeet complements this grassroots approach with “top-down” advocacy efforts with Ministries of Health to mainstream clubfoot care and ensure that high-quality Ponseti will be routinely available to children in the long-term.” MiracleFeet, Proposal for GiveWell, 2022, p. 1.)

  • 4

    In addition to increasing enrollments and geographic reach each year, MiracleFeet is highly focused on the quality of treatment delivered. We invest heavily in the ongoing mentorship of providers, and all partners are trained in the use of MiracleFeet’s mobile phone-based patient management and M&E [monitoring & evaluation] system, known as CAST. Built on Dimagi’s Commcare platform, CAST is currently used by providers in 30 LMICs to track enrollments, record treatment data, and manage appointments. Providers enter patient data during in-clinic appointments, and data then flows into a Salesforce database where individual patient records are aggregated into key performance indicators on treatment quality. These are measured against the following globally accepted benchmarks based on standards for best clinical practice:

    - At least 75% of children enrolled in treatment are less than one year old
    - Each child receives 4-6 casts (the average number of casts needed to achieve a full correction)
    - At least 80% of children receive a tenotomy
    - Less than 10% of children drop out of the casting stage of treatment
    - Less than 20% of children drop out of the bracing stage of treatment

    Real-time reports and dashboards are visible by local partners, the MiracleFeet team, and regional program managers, democratizing access to key information and empowering data-driven decision-making. MiracleFeet’s regional program managers work with our Technical Team to review performance against targets at the clinic and country levels on a monthly and quarterly basis to identify areas of concern and devise action plans to address issues through additional organizational support, clinical training, community awareness, and/or parent education. MiracleFeet, Proposal for GiveWell, 2022, p. 7.

  • 5
    • “Congenital talipes equinovarus (CTEV), commonly known as clubfoot is one of the most common congenital conditions, affecting 1 in 800 births. Left untreated, it can lead to life-long impairment, impacting participation in society, education, and employment. Most children with clubfoot can be successfully treated with the Ponseti method, a low-cost, cost-effective, and minimally invasive treatment protocol. Despite progress, less than 1 in 5 children born with clubfoot in low- and middle-income countries (LMICs) currently receive treatment.” The Clinton Health Access Initiative, Preventing Lifelong Impairment: Access to Clubfoot Treatment in Low- and Middle-Income Countries, 2021, p. 1.
    • GiveWell conversation with a disability expert, December 13, 2022 (unpublished)

  • 6
    • E.g. “Across the studies, a lack of access to resources was identified as a barrier to service delivery, including a lack of casting materials [14, 25, 26] and poor quality mate- rials [26, 27]. Acquiring abduction braces was difficult for some [8, 26–28] and healthcare professionals in Brazil were concerned that there were a lack of stores that could manufacture them to the required standard [8].” Drew, Gooberman-Hill, Lavy, 2018.
    • The disability expert we spoke with reported that no shops in Ethiopia make the braces that are necessary for Ponseti method clubfoot treatment without the support of Cure International because the braces require specialized materials and technical expertise to produce properly.

  • 7
    • E.g., “The public opinion about clubfeet also influences the parents in seeking treatment for their children... In Buenos Aires, it was not uncommon that parents carrying a baby with plaster casts are frowned upon, because they are accused of child abuse. One of the interviews in Indonesia revealed that the daughter always stayed at home to avoid entering the public space showing her handicap. The majority in Indonesia indicated that children with clubfeet are treated differently from other children, especially when they were not able to walk.” van Wijck, Oomen, van der Heide, 2015.
    • "Also, beliefs that the clubfoot is caused by evil spirits, or that the disability is a result of misdeeds of the family together with societal stigma can cause a barrier for the caregivers to seek or continue the Ponseti treatment [12]." van Wijck, Oomen, van der Heide, 2015.

  • 8
    • MiracleFeet told us that the Ponseti method is fairly straightforward and most of the casting / bracing can be achieved by physical therapists with highly trained orthopedists only needed for the tenotomy. So MiracleFeet can achieve increased coverage by advocating for clubfoot as a priority and providing training and materials (for casting and bracing) without needing to vastly increase the supply of orthopedists.
    • “These NGOs collaborate with ministries of health on the planning of clubfoot treatment programs. They also typically provide technical support, funding, products (including braces), monitoring and evaluation tools, management support and support for awareness raising and training initiatives. Governments on their end allocate clinic space, staff time and, on occasion, supplies and treatment materials.” The Clinton Health Access Initiative, Preventing Lifelong Impairment: Access to Clubfoot Treatment in Low- and Middle-Income Countries, 2021, p. 7.

  • 9

    “Examples of countries with a coverage over 50% include Bangladesh, Rwanda, Paraguay, Nicaragua, Malawi, and El Salvador.” The Clinton Health Access Initiative, Preventing Lifelong Impairment: Access to Clubfoot Treatment in Low- and Middle-Income Countries, 2021, p. 5-6.

  • 10

    GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023, "Children treated by country" sheet, cell Q25.

  • 11
    • FY2023 treatment numbers for the Philippines come from MiracleFeet, 3 Country Grant Budget, 2022.
    • MiracleFeet’s target is to treat 1900 infants in the Philippines, 650 in Chad, and 883 in Côte d’Ivoire in 2027 (MiracleFeet, 3 Country Grant Budget, 2022). We discount these figures by 25% to account for optimism in MiracleFeet’s targets. See adjusted infants figures on the “Children Treated by Country” sheet. If MiracleFeet reaches its intended targets, the grant may be more cost-effective than we’ve modeled.

  • 12

    MiracleFeet, Proposal for GiveWell, 2022, p. 4.

  • 13

    Our cost-effectiveness threshold for directing funding to particular programs changes periodically. As of early 2023, our bar for directing funding is about 10 times as cost-effective as unconditional cash transfers. See GiveWell, "Cost-Effectiveness Analyses" for more information about how we use cost-effectiveness estimates in our grantmaking.

  • 14
    • See GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023 for CE estimate during the grant period.
    • See GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023 for CE estimate at scale.
    • Note that our cost-effectiveness analyses are simplified models that are highly uncertain.

  • 15

    See MiracleFeet, 3 Country Grant Budget, 2022, rows 32-34.

  • 16

    See GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023, "Cost-effectiveness analysis (CEA)" sheet, row 5.

  • 17

    See MiracleFeet, 3 Country Grant Budget, 2022.

  • 18
    • “With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery.” Penny et al. 2021, p. 1.
    • “We also tabulated what authors noted as weaknesses or barriers to success. Eight studies reported late presentation or older age at the beginning of treatment as a major contributor to failure [9, 18, 20–24].” Harmer and Rhatigan 2014, p. 843.

  • 19
    • On the Philippines: “The flip side to having a more sophisticated health system is that there is some clubfoot treatment available in the Philippines outside of MiracleFeet’s program (obtaining true estimates for the amount of treatment available is something we will investigate during the baseline situational analysis phase of this project). Wealthy families are able to access surgery for clubfoot (even though surgery was proven years ago to result in chronic complications and worse clinical outcomes than the Ponseti method), and some Ponseti treatment is available at private hospitals, although quality varies widely, and costs can be very high. (As a result, we see many children who started treatment in private hospitals who then end up at MiracleFeet clinics when they do not get good results or find the costs unmanageable.)" MiracleFeet, Proposal for GiveWell, 2022, p. 2-3.
    • On Chad: “Over 1,000 children are born with clubfoot every year in Chad, and (as far as we know) there is no existing clubfoot treatment available and no other clubfoot NGOs are working there.” MiracleFeet, Proposal for GiveWell, 2022, p. 3.
    • On Côte d’Ivoire: “MiracleFeet plans to launch a program in Côte d’Ivoire for similar reasons as Chad. It is a high-priority country for MiracleFeet because, to our knowledge, there is no clubfoot treatment available (Ponseti or surgery) and a clubfoot population of over 1,400 clubfoot births each year.” MiracleFeet, Proposal for GiveWell, 2022, p. 3.

  • 20

    See GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023, "Cost-effectiveness analysis (CEA)" sheet, row 17.

  • 21
    • “If left untreated it can result in long-term disability, deformity and pain.” Bina et al. 2020.
    • “If left untreated, clubfoot can result in physical deformity, pain in the feet, and impaired mobility, all of which can limit community participation, including access to education.” World Health Organization, World Report on Disability, 2011, p. 99.
    • “Untreated CTEV can lead to severe deformity, but with timely and correct management it is curable. CTEV is defined as an inward rotation of the foot, with four components: cavus, forefoot adductus, hind foot varus and equinus. Two of three patients occur in boys and in every other case, the condition affects both feet.The deformity causes patients to walk on the side or back of their feet leading to callus formation, and potential infections in the skin and bone. With severely hampered mobility, these patients are unable to work; thus, this deformity contributes not only to ill health but also to poverty.” Grimes et al. 2016, p. 1.
    • “Qualitative research in Uganda indicated that the neglected clubfoot deformity was indeed a significant disability for village children, preventing access to education and other social activity. The stigma is a very obvious one and children are often considered cursed or unworthy of advancement in education or social status. There is pain and difficulty with locomotion over longer distances. The pain occurs primarily in the skin and subcutaneous tissues on the dorsum of the foot. There is also abnormal pressure distribution across the midtarsal joints and through the malaligned ankle joint causing pain. Recurrent skin breakdown with infections is not uncommon in the skin bearing weight on the dorsal and lateral aspect of the foot. Severe ulceration in adults can lead to amputation. There is an inability to wear footwear, which aggravates all of the previously stated problems.” Penny 2005, pp. 155-56.

  • 22
    • “Disability weights, which represent the magnitude of health loss associated with specific health outcomes, are used to calculate years lived with disability (YLD) for these outcomes in a given population. The weights are measured on a scale from 0 to 1, where 0 equals a state of full health and 1 equals death.” Global Health Data Exchange, "Global Burden of Disease Study 2019 (GBD 2019) Disability Weights" 2023.
    • As of the 2019 Global Burden of Disease study, clubfoot has not been assigned a disability weight. Here we use the disability weight for "disfigurement level 2 with pain and moderate motor impairment due to congenital limb deficiency" as an approximation. Institute for Health Metrics and Evaluation, Global Burden of Disease Study 2019, Disability Weights (accessed April 18, 2023), row 1878.

  • 23

    "There were 365 patients (530 feet) with relapses (mean 47%; 365/774) at long-term follow-up." Rastogi and Agarwal 2021.

  • 24

    See GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023, "Cost-effectiveness analysis (CEA)" sheet, row 31.

  • 25

    “Clubfoot is an inborn deformity of the foot, where either or both feet are twisted inward, causing the child to walk on his ankles. Left untreated, the condition causes severe lifelong disability.” World Health Organization, "Congenital anomalies"

  • 26

    See GiveWell, Cost-effectiveness analysis of MiracleFeet, 2023, “Intraorg funging - Whole portfolio” sheet, “Cost per child (including overhead costs)” row.

  • 27
    • We’ve very roughly estimated that MiracleFeet could have approximately $1 million in annual room for more funding above our 10x threshold (or more, if we are currently underestimating cost-effectiveness).
    • While writing our intervention report on Ponseti treatment for clubfoot, we identified 10 additional NGOs that support clubfoot treatment programs. “We are aware of ten non-governmental organizations (NGOs) (eight of which are coordinated by the umbrella group The Global Clubfoot Initiative) that support programs in low- and middle-income contexts that aim to increase treatment of clubfoot with the Ponseti method.” GiveWell, "Ponseti Casting for Clubfoot"

  • 28

    Calculated as total units of value generated in the Philippines and Côte d’Ivoire (71,679 + 40,307), divided by the total cost of the program in those countries ($2,352,111 + $1,557,807), divided by the units of value generated per dollar spent on unconditional cash transfers (0.00335). This gives an estimate of 8.5 times as cost-effective as unconditional cash transfers.