[The Forum found an unexpected way to help! A previous version of this post mistakenly suggested that a large donation from GiveWell risked changing r.i.c.e. from a public charity to a private foundation. We previously experienced this sort of risk with funding from the Bill and Melinda Gates Foundation. We are very excited to learn from a Forum poster that GiveWell poses no such risk! Thank you! While we are still accepting additional donations to improve the health of a larger number of babies, there is no additional urgency to maintain the charity status of r.i.c.e.]
I’m writing on behalf of my team at r.i.c.e., which is honored to be highlighted in GiveWell’s “Our recommendations for giving in 2022” post. In this post, I present the details of our program that prevents neonatal deaths inexpensively by causing the implementation of a Kangaroo Mother Care program in India.
A description of our work, in brief
Some of you may be familiar with my work in population ethics or as Director of the Population Wellbeing Initiative at UT-Austin (or, more likely, for distributing utilitarianism t-shirts). Since long before this phase of my career, I’ve also been Executive Director of r.i.c.e., a 501(c)3 public charity working on early-life health in rural north India.
In collaboration with the Government of Uttar Pradesh and an organization in India, we support a Kangaroo Mother Care program to promote neonatal survival in a context where low birth weight babies would not otherwise receive such lifesaving care. KMC is a well-established tool for preventing deaths that we did not invent. Instead, our contribution is managerial innovation: We developed a public-private partnership to cause the government’s KMC guidelines to in fact be implemented cost-effectively in a public hospital where many low birth weight babies are born. That public healthcare systems in developing countries fail to implement life-saving policies and programs is a well-known problem in global health and in development economics. Because KMC is known to prevent neonatal death, and because the collaboration that we fostered found new ways to overcome the barriers to implementation in a context where many babies are not otherwise receiving needed care, it is not surprising that we can prevent neonatal deaths inexpensively.
Our statistics show that we save lives very cost-effectively; indeed, about as inexpensively as any life-saving program known to EA. These statistics led to investments this year by two EA funders: first by Founders Pledge and then by GiveWell, after in-depth investigations of our work and our evidence. We have big plans for 2023, including continuing to save lives, starting a formal impact evaluation, and doing the advocacy and partnership-building needed to scale up the program to more districts.
If you would like to further support this work, please donate to r.i.c.e. at this link to PayPal. It will let you donate either one time or by establishing a recurring monthly donation. If you don’t like PayPal, you can mail a check to RICE Institute, Inc., 472 Old Colchester Rd, Amston, CT 06231.
Longer set of details
What is Kangaroo Mother Care and why is it good?
Kangaroo Mother Care (KMC) is a way to inexpensively keep low birth weight babies (and other neonates) clean, fed, and warm. Here is GiveWell’s summary of Kangaroo Mother Care in general. It is a bit broader than our program. To emphasize: KMC has been well-known to save lives for years. Our workwomanlike contribution is merely to get it implemented in a place where there are lots of low birth weight babies, in part because mothers are themselves often underweight.
One important fact is that little babies can’t regulate their own temperatures very well. Our bodies have to be in a certain temperature range to function. So temperature management is a big part of neonatal health. When I wrote my book about environmental health for children in India, I worried that hot and humid days due to climate change would be bad for newborns who could not shed heat effectively. But by far and away the bigger and more common problem is that neonates can’t keep their heat.
The way that KMC solves this problem is skin-to-skin contact with a caregiver. The program trains parents to keep their babies on their chests. We provide them with a safe and clean place to do this. Mothers receive a special cloth wrap, sewn by local tailors, to hold the babies safely in place.
Once the babies are in place, the stage is set for early initiation of breastfeeding. Part of a KMC nurse's work is lactation consulting, which includes both teaching moms and troubleshooting. There are many options for moms whose babies aren't breastfeeding well. Such tiny babies eat a little bit, many times a day. Weight gain is carefully monitored. When they eventually go home—sometimes after weeks—a new mom and baby move into the now-available bed. The phone and home team follows up with phone calls, home visits, and supplies like thermometers and weighing scales that the family can borrow for their home.
There are now many impact evaluations published in high-quality peer-reviewed journals showing that this sort of neonatal care saves lives cost-effectively. This sentence links to a Cochrane review. If you’re up on that literature, the fact that we have actually managed to implement this is strong evidence that the program saves lives. But there is another important fact: The counterfactual care that the babies would receive in the absence of our program is much more limited than the counterfactual care in published impact evaluations of KMC. This is a very resource-constrained setting. Babies of a similar size and gestation born in rich countries would be kept in intensive care in an incubator for weeks. In this setting, neonatal care is so limited that most would, in fact, receive almost no medical care. That means this program's treatment effect per baby is even larger than in the published literature. (More on this point later.)
One final reason this project is possible and so cost-effective is that KMC is already the policy of the Government of Uttar Pradesh and the Government of India. We did not have to persuade leading policy-makers that KMC was a good idea. To the contrary, a visionary and insightful Secretary for Medical Education in Lucknow made this whole program possible. All we had to do was step in with a new public-private partnership that provides the staff and management who make KMC happen in practice.
How did you estimate the cost-effectiveness of the program?
We have not yet done an econometric impact evaluation of the sort that could be published in a journal. Indeed, that is part of what GiveWell has funded, and what we will be working on during the coming year. (The details of study inclusion and tracking can be hard.) In partnership with medical faculty in India, we will do a matching-based impact evaluation, generating a counterfactual control group from babies at other public hospitals in other districts of Uttar Pradesh.
In the meantime, and in conversation with GiveWell, we produced cost-effectiveness estimates from the administrative records of the program and from other sources. Cost effectiveness (lives saved per dollar) is the product of these two dimensions:
Babies helped per dollar
This is the more straightforward part. But it’s worth pausing on, because it is not what impact evaluations in development economics usually emphasize. A paper in a journal like Journal of Development Economics would typically focus on the first term: lives saved per baby helped. To know how outcomes are really going to change, though, you need to know how many babies are going to be helped.
Here the partnership with the Government of Uttar Pradesh is essential. The program operates in a hospital where a lot of babies need more help than they are getting. Remember Peter Singer’s classic parable about pulling a drowning child from a pond? Rather than wait for a drowning child on our daily walk, we spent years searching for a fabled pond in the distant woods that children keep falling into. Then, we collaborated with our partners to build and staff a lifeguard station.
The program has been spending about $5,000 a week, mostly on salaries for the nurses who directly interact with the mothers and babies, but also on program costs like materials, the cars and drivers for the home-visit teams, and food and rent for the nurses’ apartments and offices.
As of the early summer, the program took in about 11 low-birthweight babies per week (slightly less than two per day!). So we spend about $455 per baby. This number being low is an important part of the project being cost-effective.
Lives saved per baby helped
Lives saved per baby helped is the fraction of babies who die despite going through our program minus the fraction of babies who would have died in the absence of our program. We keep track of the fraction of babies who were intaked, but who nevertheless die. That leaves quantifying the number of babies who would have died in the absence of the program. In our conversations with GiveWell, we did this a number of ways. Perhaps the best approach, because it best captures what we know and what we don’t know, is to look at the Cochrane Review estimates and think about them. The Cochrane review found that KMC reduced neonatal mortality by about 40%:
“KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants)”
That’s pretty good! In our high-mortality, many-babies context, that’s already a lot of lives saved. But we think that our impact per baby is even higher. Here’s why. The Cochrane review is aggregating studies where the counterfactual healthcare is, in fact, conventional neonatal healthcare:
“Given that the control group in studies evaluating continuous KMC was kept in incubators or radiant warmers, the potential beneficial effects of KMC on morbidity and mortality of LBW infants would be expected to be greatest in settings in which conventional neonatal care is unavailable.”
Unfortunately many of the babes who we are helping would not be able to receive conventional neonatal care, due to the resource constraints in this context. So the outcome without our program would generally be worse than the outcome without the programs that the Cochrane review has data about.
Returning to the formula above, we can say
Our estimate for dollars per baby helped is $455.
We think the lives saved per baby helped is probably around 1-in-4. To see why, one important background fact is that about a third of these babies would be likely to die without the program. About a tenth of them die with it. 1/3 - 1/10 is close to 1/4. This gives an estimate of dollars per life saved of $455 / (1/4) = $1,800 on average.
For an alternative estimate, we can use the Cochrane review. 1/3 dying without the program * 0.4 saved according to the Cochrane Review is 0.12 percentage points saved, ignoring the fact that the counterfactual in our case is worse than the counterfactual in the Cochrane studies. This gives an estimate of dollars per life saved of $455 / (0.12) = $3,800 on average.
When we get overprecise in a spreadsheet, our best guess is that the average cost per life saved is somewhere between $2,000 and $3,000. Compare that with the approximate $5,000 of some of the best interventions supported by the Effective Altruism community. But even if it is twice our best guess, or even a little more, it is an excellent value for cost-effective life-saving. Your donation can help us maintain the program, do a better job, help more babies, do a better impact evaluation, and build towards expanding it to other hospitals someday, if we find the right implementation partners.
Credit for this work needs to be widely shared. r.i.c.e. has partnered with an Indian organization and a large public medical college in Uttar Pradesh to expand that hospital’s services for low birth weight and preterm babies, and follow them up at home after they leave the hospital. Together, the Indian organization and the staff of the public hospital operate the program. r.i.c.e. provides funding, advice, and advocacy. Where this post says “we” and “our,” it often refers to the entire partnership.