Note: This page summarizes the rationale behind a GiveWell Incubation Grant to r.i.ce., a research institute for compassionate economics. r.i.c.e. staff reviewed this page prior to publication.
Summary
In November 2022, GiveWell made a five-year, $2,423,199 grant to r.i.c.e., a research institute for compassionate economics, to continue operating a program for low-birthweight babies focused on kangaroo mother care (KMC) in partnership with Population Health Insights (PHI), an Indian organization, and the Bahraich Medical College in Uttar Pradesh, India. With other researchers, this team will also conduct a matching-based impact evaluation of the program and engage with potential partners to scale the program in other areas.
We are recommending this grant because:
- Our best guess is this program is highly cost-effective. The program is expensive per infant ($430) because it requires hiring and training additional staff and is targeted specifically to low birthweight infants. However, low-birthweight infants have high neonatal mortality rates (estimated at 35% in the target population in Bahraich), and there is evidence from several large randomized controlled trials of KMC, and the program’s own data, that KMC significantly reduces neonatal mortality among low birthweight infants (by 50% based on program data). Because low-birthweight infants are quite common in Uttar Pradesh (we estimate 25% of all births), this roughly equates to $2,500 per neonatal death averted.
- We have a positive assessment of the program’s implementation quality. This program implementation model directly addresses the primary concerns we have about delivering KMC in real-world settings. PHI hires and manages outside nurses, who provide ongoing support both at the hospital and through home visits. This helps mitigate concerns about staff shortages and low uptake of behavior change by caregivers. Program data also indicate high adherence to KMC practices among caregivers, which gives us further confidence in the implementation quality.
- We think additional funding to r.i.c.e. is likely to lead to additional low-birthweight infants receiving KMC. Without additional funding, it seems fairly likely the program would have to cease operations in the near future. We assume that without r.i.c.e.’s involvement, the hospital it works with would be unlikely to be able to provide KMC support to as many infants.
- In addition to the cost effectiveness of the program itself, we think a primary part of the case for this grant is the potential to open up opportunities to expand this model of KMC to other hospitals:
- Funding r.i.c.e. to continue this program could keep open the possibility for r.i.c.e. to support other organizations to implement KMC successfully and cost-effectively in other hospitals.
- Evaluation and advocacy activities covered by this grant may also generate greater political will for KMC among Uttar Pradesh government stakeholders and other hospitals.
These add further value to the grant by potentially creating additional cost-effective funding opportunities for GiveWell or other funders to support KMC over less cost-effective programs in the future.
Our primary reservations are:
- We may be overestimating the program’s mortality effect. In our cost-effectiveness analysis of this grant, we rely on program data. These data show a roughly 80% reduction in neonatal mortality. Because they are based on a pre-post analysis, which we think may overstate impacts, we adjust this downward to 50%. However, this is still substantially higher than a 2016 Cochrane meta-analysis of KMC programs, which finds a roughly 30% reduction in neonatal mortality.
- While the current grant includes an evaluation, we think the evaluation design has substantial limitations, which will limit how much we’re able to resolve our uncertainty on the effect size from this grant.
- We’re highly uncertain about the likelihood of this grant actually opening up opportunities to expand KMC at other hospitals.
- We are uncertain about the feasibility of scaling up this way of implementing KMC to other hospitals. In particular, we are unsure how easily adaptable it will be to other settings and how many hospitals may be suited to this program model.
- We have not yet explored what it would require to facilitate a successful partnership between r.i.c.e. and another organization interested in scaling this program.
GiveWell spoke with Dr. Dean Spears and Dr. Diane Coffey about updates on this grant on June 26, 2023.
Published: July 2023
Table of Contents
The organization
r.i.c.e. is a non-profit research organization focusing on children’s health in India. Two academics affiliated with r.i.c.e. and the University of Texas at Austin, Dean Spears, an associate professor in the Department of Economics and the Population Research Center, and Diane Coffey, an associate professor in the Department of Sociology and the Population Research Center, lead a partnership among r.i.c.e., Population Health Insights (PHI), and a large government medical college, Bahraich Medical College, located in Uttar Pradesh. PHI is a private organization based in Uttar Pradesh that operates a program which provides nurses and support staff to counsel parents on kangaroo mother care (KMC), breast-milk feeding, and newborn care. This is a facility-based program with community-based follow-up, as they work with families in the hospital and follow up after hospital exit through phone calls and home visits. Medical supervision and direction of the program is provided by the Bahraich Medical College Special Newborn Care Unit.
The intervention
KMC is a program for low birth weight (LBW) infants that involves skin-to-skin contact between a caregiver and infant and early initiation of breastfeeding. Conventional care for LBW neonates, such as a neonatal intensive care unit, is expensive and logistically difficult in many low- and middle-income countries.1 Rather than relying on keeping infants warm in an incubator or radiant warmer, KMC involves using skin-to-skin contact with the caregiver to keep infants warm. It can also include breastfeeding instruction, early discharge from the hospital, and follow-up care after discharge.2 WHO recommends KMC implemented in healthcare facilities as routine care for LBW infants.3
As we describe in our KMC intervention report, which is focused on facility-based KMC, there is strong evidence that KMC reduces neonatal mortality compared to conventional neonatal intensive care.4
We previously expressed concerns around the feasibility of implementing KMC in real-world settings, given that the program requires sustained behavior change from both health providers and caregivers. Major barriers to adoption, discussed in two systematic reviews of barriers and enablers to KMC implementation (Chan et al. 2016a, Chan et al. 2017), include crowding and lack of privacy, burden on caregivers to stay at facilities, staff shortages, staff turnover, and staff time dedicated to KMC.5
The grant
We made a five-year grant to cover the program’s operational costs from 2023-2027, a matching-based evaluation, and advocacy and engagement costs, including the costs of r.i.c.e. working with other organizations and hospital decision-makers to support the expansion of this model of KMC promotion and staffing in other hospitals.
The program
We previously found KMC to be potentially highly cost-effective6 but had concerns around the feasibility of implementing KMC in real-world settings, since it requires substantial hospital staff time and sustained behavior change on the part of both hospital staff and caregivers of infants (see above).
This program directly addresses some of these concerns through its delivery model: It hires and manages local nurses and support staff dedicated to supporting caregivers in providing KMC to their infants at the hospital;7 because these nurses are hired and trained by an outside organization, they have fewer competing priorities and lower turnover rates.8
The nurses engage in KMC activities, including:9
- Supporting both mothers and fathers to keep babies warm using skin-to-skin contact,
- Teaching mothers about breastfeeding or feeding expressed breastmilk,
- Recording babies’ weight gain,
- Home visits and phone calls,
- and continuous training.
r.i.c.e. has told us that because the nurses are able to provide ongoing support to caregivers at the hospital and through several days of home visits, caregivers are more likely to adhere to KMC for multiple days. The program has reached over 500 LBW infants in the past year and found a large mortality reduction between baseline and endline of the program.10
r.i.c.e. anticipated running out of funds for its KMC program by the end of 2022, and the program would likely have had to stop operating without additional funding.11 This grant will cover operational costs to continue implementing the program in Bahraich Medical College from 2023-27.
The impact evaluation
r.i.c.e. plans to conduct a case-control study that will run from the third quarter of 2023 to the third quarter of 2024 and will compare neonatal mortality rates among LBW infants in the Bahraich Medical College, where they operate, to two comparable public hospitals in different districts.12 We expect to have results from the evaluation in late 2024 or early 2025.
This evaluation will generate more data on the neonatal mortality effect of KMC, one of the key drivers of its cost-effectiveness,13 in the setting in which the program is implemented. This could make us more confident in the cost-effectiveness of scaling up this program to other hospitals in similar settings and help generate interest and political will from other hospitals to prioritize KMC programs.14
Advocacy and program scale-up
This program has limited potential to scale, since r.i.c.e. prefers to focus on continuing to implement the program at a smaller scale rather than expanding to a much greater number of hospitals.15 However, it is enthusiastic about supporting other groups to implement the program model in other hospitals across Uttar Pradesh and beyond.16
During the grant period, r.i.c.e. plans to work with other organizations who may be interested in scaling up this type of program to other hospitals and locations.
Budget for grant activities
The total budget is $2,423,199 to cover five years of grant activities. It breaks down as follows:17
- Operational costs: $2,223,951
- Evaluation: $113,423
- Advocacy and engagement with potential expansion partners: $85,825
The case for the grant
We are recommending this grant for the following primary reasons:
- Our best guess is that the newborn care program, with its focus on KMC, is highly cost-effective. (more)
- This implementation of KMC directly addresses some of the major feasibility concerns we previously had about delivering KMC in real-world settings, and its program seems to have successfully achieved high adherence and mortality reductions in the past year.18 Funding r.i.c.e. to continue this program could keep open the possibility for r.i.c.e. to support other organizations to implement KMC successfully and cost-effectively in other hospitals. The evaluation and advocacy activities covered by this grant may also generate greater political will for KMC among Uttar Pradesh government stakeholders and hospitals. Together, those activities could potentially open up room for more funding for us to support other implementers to deliver KMC in the future in other hospitals in Uttar Pradesh and beyond. (more)
- There seems to be a real funding gap for this program. r.i.c.e. anticipated running out of funds for its KMC program by the end of 2022, and it seems fairly likely that it would have had to cease operations of the program in the near future without additional funding.19 (more)
Cost-effectiveness
Based on our preliminary cost-effectiveness analysis, our best guess is that this program is within the range of cost-effectiveness of opportunities we expect to direct marginal donations to.20 For more detail on our view on KMC programs in general, see our intervention report.
High cost-effectiveness for this program is primarily driven by:
- High neonatal mortality among low birthweight infants in the setting where the program is implemented21
- Our best guess is that this implementation of KMC significantly reduces neonatal mortality:
Opening up opportunities to expand to other hospitals
This grant could open up options to expand this way of implementing KMC to additional hospitals. r.i.c.e. told us it is enthusiastic about supporting other groups to implement the program model in other hospitals across Uttar Pradesh and beyond. We plan to scope out potential implementers who are well-positioned to implement newborn care programs focusing on KMC at a larger scale and facilitate partnerships between those groups and r.i.c.e.
This program could have substantial cost-effective room for more funding. We estimate that covering 10% of low birth weight babies in Uttar Pradesh alone, at the same cost per infant covered as r.i.c.e. and PHI’s current program in Bahraich Medical College, would lead to approximately $69 million in annual room for more funding.24
Moreover, this grant has some learning value. We expect the evaluation portion of this grant to generate more data on the mortality effect of this way of implementing KMC. The program’s effect on mortality is one of the key drivers of its cost-effectiveness,25 and having more context-specific data could make us more confident in the cost-effectiveness of scaling up this program to other hospitals in similar settings.
Funding gap
r.i.c.e. anticipates running out of funds for this program by the end of 2022. The two academics at r.i.c.e. who are leading the program have been using a small bridge grant to cover the program in the past year, but will run out of funds by the end of 2022.26
They haven’t had success in fundraising from other sources, and it seems fairly likely that they will have to cease operations of the program in the near future without additional funding.27 This grant both allows the program to continue and keeps open the option of r.i.c.e. supporting other implementers in expanding this program to other hospitals.
In addition, much of the capacity of the two r.i.c.e. academics who are leading the program has recently gone to fundraising, and securing funding for this program could free up their capacity to continue improving their program and work with other implementers to expand KMC to more hospitals.
Risks and reservations
We have the following primary reservations about this grant:
- We are uncertain about the feasibility of scaling up this way of implementing KMC to other hospitals. We have open questions about the path to scale in Uttar Pradesh and whether or not this program model can easily be adapted to other hospitals. We are also uncertain about how many hospitals may be suitable and amenable to this type of program model, and about the care that infants are receiving currently in other hospitals. However, r.i.c.e. has been working on advocacy for the program in Uttar Pradesh and seems knowledgeable about the policy environment and what it would require for the program to be expanded to more hospitals there.
- Additionally, we have not yet explored what it would require to facilitate a successful partnership between r.i.c.e. and another organization interested in scaling this program. It’s possible that the grant doesn’t result in any successful partnerships between r.i.c.e. and other potential implementers.
- We may be overestimating the program’s mortality effect. We use estimates of mortality reduction from r.i.c.e.’s program data, which are higher than reported in the literature.28 We think it’s plausible that the program does lead to higher mortality effects than found in the literature, because there seems to be little medical care in the counterfactual scenario (whereas in the literature, infants stay in neonatal intensive care units).29 If the mortality effect size ended up being closer to what was found in the Cochrane review, the program could be considerably less cost-effective. We apply a 60% internal validity adjustment to account for potential biases in the pre/post mortality effect size.30 We plan to learn more about this in the impact evaluation.
- While the current grant includes an evaluation, we think the evaluation design has limitations. The evaluation will be directly comparing a small number of hospitals, meaning that there will be low power to detect results, and that we won’t be able to causally attribute differences to the KMC program. These factors could limit how much we’re able to resolve our uncertainty on the effect size from this grant.
Plans for follow up
We expect to have results from the evaluation in late 2024 or early 2025.
During this grant period, we will continue the conversation with r.i.c.e. to support its engagement with other implementers to scale up the program in other hospitals.
Internal forecasts
For this grant, we are recording the following forecasts:
- Once we receive the results of the evaluation, we think there is a 70% chance that the direct impact of the program is more than 10 times as cost-effective as unconditional cash transfers in the hospital that the program currently operates in.
- We think there is a 60% chance that by the beginning of 2025, r.i.c.e. will have successfully established a relationship with another implementer who is interested in scaling up KMC to other hospitals.
- We think there is a 30% chance that by January 2027, we will fund scale-up of KMC in at least 15 hospitals beyond the one r.i.c.e. is currently operating in.
Our process
- We conducted a literature review of KMC’s impact and modeled the cost-effectiveness of a general KMC program (see our intervention report on KMC).
- We had two calls with Drs. Spears and Coffey to discuss this program.
- We exchanged emails with Drs. Spears and Coffey. They shared program data and indicators, including their own cost-effectiveness analysis of their program under different assumptions.
- Drs. Spears and Coffey shared a budget and proposal with GiveWell.
Sources
- 1
“Conventional care for low birth weight neonates, which requires expensive medical equipment, trained personnel, and permanent logistical support, is generally expensive to implement. Many health facilities in low- and middle-income countries lack resources to adequately treat all their patients, and a lower cost alternative to conventional neonatal intensive care may free up resources to be used elsewhere.” GiveWell, "Kangaroo mother care," 2021.
- 2
- “Kangaroo mother care (KMC) is intended as a low-cost alternative to conventional neonatal intensive care for low birth weight infants during their stay at a healthcare facility and primarily involves keeping infants warm through skin-to-skin contact with their mothers. KMC can also include exclusive breastfeeding and relaxing the criteria for discharge from the facility in order to reduce length of hospitalization, though these components of KMC are not implemented consistently in studies on KMC. In contrast, conventional neonatal intensive care for low birth weight infants consists of keeping infants warm in an incubator or radiant warmer with minimal contact from their mothers.” GiveWell, "Kangaroo mother care," 2021.
- “We screened 1035 articles and reports; 299 contained data on KMC and neonatal outcomes or qualitative information on KMC implementation. Eighty–eight of the studies (29%) did not define KMC. Two hundred and eleven studies (71%) included skin–to–skin contact (SSC) in their KMC definition, 49 (16%) included exclusive or nearly exclusive breastfeeding, 22 (7%) included early discharge criteria, and 36 (12%) included follow–up after discharge.” Chan et al. 2016b, p. 1.
- 3
“Kangaroo mother care is recommended for the routine care of newborns weighing 2000 g or less at birth, and should be initiated in health-care facilities as soon as the newborns are clinically stable. Newborns weighing 2000 g or less at birth should be provided as close to continuous Kangaroo mother care as possible. Intermittent Kangaroo mother care, rather than conventional care, is recommended for newborns weighing 2000 g or less at birth, if continuous Kangaroo mother care is not possible.” WHO, "Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants," 2019.
- 4
According to a 2016 Cochrane meta-analysis consisting of nine studies on standard KMC and one large and reasonably strong RCT on community-initiated KMC, KMC appears to reduce neonatal mortality in low birth weight infants by around 30% compared to conventional neonatal care, which is corroborated by reductions in morbidity and increases in early-life growth. See our intervention report for more details on mortality and morbidity outcomes of KMC.
- 5
"We identified two systematic reviews of barriers and enablers to KMC implementation (Chan et al. 2016a, Chan et al. 2017). These reviews identify the following barriers to adoption:
- Burden on caregivers: KMC required caregivers to stay at the facility for extended periods of time or make long and costly commutes to the facility.
- Crowding and lack of privacy in facilities: Many facilities lack the necessary space and equipment for caregivers to stay for extended periods of time to conduct KMC. Moreover, facilities that lacked private areas made it less likely for caregivers to feel comfortable conducting KMC.
- Staff shortages and high staff turnover: Staff shortages and a high rate of staff turnover hindered sustained practice of KMC.
- Staff buy-in: Many health providers did not see neonatal care in general as a high priority, and KMC in particular was perceived as a sub-standard, cheaper method of care compared to routine neonatal care.
- Staff time: Health providers commonly believed that KMC increased their workload and limited the time they could spend attending to other newborns in the NICU." GiveWell, "Kangaroo mother care," 2021.
- 6
See our cost-effectiveness analysis of KMC, “KMC” sheet, “Cost-effectiveness in multiples of cash” row. As of 2022, our bar for funding is 10 times as cost-effective as unconditional cash transfers.
- 7
"Many very-low birthweight babies are born in or come to the Bahraich Medical College.
Our team of 15 nurses, 4 managers, and 11 support staff handle them inexpensively." r.i.c.e., KMC Cost Effectiveness in Bahraich, India, September 2022, slide 25. - 8
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 9
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 10
- "We have already helped 540 infants under 1,800g, plus more who qualified for our program in other ways." r.i.c.e., KMC Cost Effectiveness in Bahraich, India, September 2022, slide 26.
- “Line 7 of the Stata code finds that as the program was ramping up, 65% of babies under 1800 grams survived to the end of their first months of life. After the Project got its own space, 94% of babies with high adherence survived the first month. Among those with low adherence, 84% survived the first month of life. A weighted average of one month survival among the high and low adherence groups after the Project got its own space is 90%. That is a 70% reduction in one month mortality between the two periods (0.35 - 0.35*.7 = 0.1).” r.i.c.e., KMC in Bahraich budget, 2022
- 11
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 12
- “For the evaluation, we are planning on a matching-based impact evaluation. We will create two data-collection teams and send each to a comparable public hospital in a different district. The most challenging aspect of the impact evaluation will be ensuring that the inclusion criteria are constant across locations. … We plan for a year of data collection starting in the third quarter of 2023. We have included in the budget funding for a researcher or “evidence broker” in India to work with the data and spread the word after the evaluation is complete.” r.i.c.e., KMC in Bahraich budget, 2022.
- Dean Spears, Co-executive Director, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 13
Mortality accounts for 80% of the benefits in our cost-effectiveness analysis.
- 14
This evaluation will generate additional data on the effect of KMC on neonatal mortality and the baseline rates of neonatal mortality without KMC, two key drivers of cost-effectiveness, in the setting in which the program is implemented.
- 15
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 16
Diane Coffey, Co-executive Director, r.i.c.e., email to GiveWell, May 27, 2022 (unpublished).
- 17
For a full breakdown of the budget, see here.
- 18
- r.i.c.e. measures high adherence as caregivers who stay three or more days in the KMC hospital ward, which allows staff more time to assess a baby and make feeding recommendations. In the past 18 months, 65% of caregivers have complied at this level.
Diane Coffey, Co-executive Director, r.i.c.e., email to GiveWell, April 25, 2023 (unpublished). - “Line 7 of the Stata code finds that as the program was ramping up, 65% of babies under 1800 grams survived to the end of their first months of life. After the Project got its own space, 94% of babies with high adherence survived the first month. Among those with low adherence, 84% survived the first month of life. A weighted average of one month survival among the high and low adherence groups after the Project got its own space is 90%. That is a 70% reduction in one month mortality between the two periods (0.35 - 0.35*.7 = 0.1).” r.i.c.e., KMC in Bahraich budget, 2022.
- r.i.c.e. measures high adherence as caregivers who stay three or more days in the KMC hospital ward, which allows staff more time to assess a baby and make feeding recommendations. In the past 18 months, 65% of caregivers have complied at this level.
- 19
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 20
- As of late 2022, our bar for directing funding is 10 times as cost-effective as unconditional cash transfers.
- Our preliminary cost-effectiveness analysis estimates that r.i.c.e.’s program could be around 13 times as cost-effective as unconditional cash transfers. See our Kangaroo Mother Care with r.i.c.e. in Uttar Pradesh BOTEC, “Direct impact” sheet, "Cost-effectiveness" row.
- 21
- “...as the program was ramping up, 65% of babies under 1800 grams survived to the end of their first months of life.” r.i.c.e., KMC in Bahraich budget, 2022. This estimate refers to children alive after four weeks.
- This corresponds to a baseline neonatal mortality rate of 35% among low birthweight infants in the hospital where the program is operating.
- 22
See our intervention report on KMC.
- 23
“After the Project got its own space, 94% of babies with high adherence survived the first month. Among those with low adherence, 84% survived the first month of life. A weighted average of one month survival among the high and low adherence groups after the Project got its own space is 90%. That is a 70% reduction in one month mortality between the two periods (0.35 - 0.35*.7 = 0.1).” r.i.c.e., KMC in Bahraich budget, 2022.
- 24
We estimate that approximately 25% of babies are born with low birth weight. If 10% of these babies were covered by KMC, at a cost of $434 per infant, this would result in approximately $69 million in annual costs. See here for calculations.
- 25
Mortality accounts for 80% of the benefits in our cost-effectiveness analysis.
- 26
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 27
Dean Spears and Diane Coffey, Co-executive Directors, r.i.c.e., conversation with GiveWell, June 10, 2022 (unpublished).
- 28
- Before adjustments, we estimate that this program reduces neonatal mortality by 83%, based on data reported in the r.i.c.e., KMC in Bahraich budget, 2022:
- "Line 7 of the Stata code finds that as the program was ramping up, 65% of babies under 1800 grams survived to the end of their first months of life. After the Project got its own space, 94% of babies with high adherence survived the first month. Among those with low adherence, 84% survived the first month of life. A weighted average of one month survival among the high and low adherence groups after the Project got its own space is 90%. That is a 70% reduction in one month mortality between the two periods (0.35 - 0.35*.7 = 0.1)."
- We estimate a reduction in neonatal mortality by calculating the difference in mortality between baseline (100%-65%=35%) and after program implementation among those with high adherence (100%-94%=6%). This gives a reduction in mortality of 83%.
- The Cochrane review finds a 33% reduction in neonatal mortality: “At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence)" Conde-Agudelo and Díaz-Rossello 2016, p. 2.
- Before adjustments, we estimate that this program reduces neonatal mortality by 83%, based on data reported in the r.i.c.e., KMC in Bahraich budget, 2022:
- 29
- From the Cochrane review: "Objectives: To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care..." Conde-Agudelo and Díaz-Rossello 2016, abstract.
- For more about the literature we used to assess KMC, see GiveWell, "Kangaroo mother care," 2021.
- 30
We make a downward adjustment to account for the fact that r.i.c.e.’s mortality effect size is based on pre/post treatment data, which means that mortality may have been going down over time, and program introduction may have coincided with other changes. We also make an upward adjustment to account for the pre-treatment data collection occurring during warm months, and post-treatment data collection during cold months, when r.i.c.e. reported that mortality is generally higher. On net, we make a 40% downward adjustment. After applying this adjustment, we estimate that this program reduces neonatal mortality by 50%.