This article was also published at Charity Entrepreneurship's blog.
We’re proud to announce our 2020 Top Charity Ideas!
Each year Charity Entrepreneurship identifies highly effective interventions in chosen cause areas. Our Incubation Program gives participants the skills they need to start high-impact nonprofits based on our top intervention recommendations.
Our 2020 research period focused on four cause areas: mental health, animal advocacy, family planning, and health & development policy. We began with several hundred ideas in each cause area. Progressive stages of our extensive research process whittled down to eight recommended ideas.
Eighty-hour reports linked below illustrate how we came to recommend this year’s top interventions. We also provide Incubation Program participants with implementation reports, which provide specific recommendations to map a path forward for a new charity.
Our 2020 top recommendations are as follows (in no particular order):
1. Guided self-help – Distributing workbooks to enable individuals to work independently on their mental health, supported by short weekly calls from lay health workers.
HEALTH & DEVELOPMENT POLICY:
2. Lead paint regulation – Advocating for tighter regulation of lead paint to reduce the burden of lead exposure on human health and economic prosperity.
3. Alcohol regulation – Advocating for increased alcohol taxation to mitigate the harmful effects of consumption.
4. Shrimp welfare – Improving the welfare of farmed shrimp, e.g. through collaborating with Vietnamese farmers to better oxygenate the water, thus reducing chronic suffering for shrimp.
5. Feed fortification – Fortifying feed with micronutrients to combat deficiencies and improve the health of laying hens.
6. Ask research – Helping organizations and policy-makers decide what best to ask of the animal agriculture industry. (We explored this intervention during our 2019 research period and passed it on to 2020, as despite its promise it was not started.)
7. Mass media campaigns – Broadcasting information about family planning to reduce misconceptions and empower women to make decisions about their fertility.
8. Postpartum family planning – Providing family planning guidance to women at pivotal moments for their health and fertility, such as after giving birth.The above reports are time-capped at eighty hours and follow the chronology of our research process. The reports begin with preliminary research and identifying crucial considerations. Next, we consult with experts. We then create a weighted factor model and a cost-effectiveness analysis. These two methodologies allow us to numerically quantify an intervention; by including both, we balance out their different strengths and weaknesses. Our final section brings together information gained throughout the research process.
We have chosen to organize our reports in this way to increase transparency. Readers are able to follow the research as it unfolds and develops, and can see how an idea performs from multiple perspectives.
For specific questions on the research process, reach out to Karolina Sarek at firstname.lastname@example.org.
Lead researcher: George Bridgwater email@example.com
Our four cause areas achieve impact in different ways, so we tailor our metrics accordingly. In this cause area, our cost-effectiveness analyses quantify impact using two metrics: the satisfaction with life scale (SWLS), and quality-adjusted life years (QALYs). We measure the expected number of incremental increases on the SWLS, and of QALYs per dollar spent. We use two metrics because of how difficult it is to capture subjective well-being: although we believe that the SWLS may more accurately reflect well-being, QALYs offer the benefit of being widely used and thus more comparable. Our metrics report (forthcoming) provides further information on the various metrics used in this space.
Distributing self-help workbooks enables individuals to make progress on their mental health either independently (known as pure self-help) or with minimal support (guided self-help). Our research found strong evidence that guided self-help in particular can significantly improve symptoms of anxiety, depression, and chronic pain – conditions that collectively affect over 2 billion people worldwide.
Demanding much less staff time than face-to-face therapy, self-help can deliver highly cost-effective treatment for mental health issues. Initially, we were concerned about dropout rates because of the low intensity of self-help. However, we found evidence that dropout rates for self-help are similar to those of traditional therapy. For severe cases, the strong interpersonal relationship between therapist and patient may be preferable. But for those with mild and moderate mental health issues, self-help seems a strong alternative to traditional therapy.
We modeled the cost-effectiveness of self-help under six scenarios. These vary according to the income level of the country of operations, support available to beneficiaries, and whether the workbooks distributed are new or reused. The most likely scenarios involve distributing new workbooks and offering telephone support.
In a high-income country, modeling our most likely scenario suggests a cost-effectiveness of $78 per incremental increase in SWLS score, or $20,016 per QALY. In a low-income country, cost-effectiveness rises to $20 per SWLS increase, and $1,203 per QALY. All of these figures account for the counterfactual impact of funding and co-founders.
Our research suggests that supporting individuals with short phone calls strikes a good balance between factors like cost and effect size. Online options such as Skype-based support or the use of avatars seem promising and may be worth exploring in future, but currently the evidence for these is weaker. We also would like to see more evidence in low-income countries, as most of the randomized controlled trials on self-help took place in high-income countries.
Involving largely independent work means that self-help may be a promising way to deliver therapy in contexts where stigma surrounds mental health, and where people are therefore reluctant to visit a therapist. Depending on the context, workbooks may need to be culturally adapted, ideally with input from the local community. An expert we spoke to suggested this could be done in three months, although the time frame will depend on various factors and could easily extend longer.
A key advantage of self-help is its flexibility. A new charity will be able to explore various therapeutic techniques and target a range of beneficiaries. Based on unmet needs and available evidence, we think that Overcoming Anxiety, Overcoming Depression, and Living With Your Pain are promising workbooks for a self-help charity to distribute, but we expect co-founders of this charity to experiment and pivot according to their findings.
Our research on self-help has left us confident in our recommendation, but we still have some remaining questions and space for development. We’d like to see further studies in different contexts, and into other types of support (e.g. avatars). We also have remaining concerns over how best to recruit beneficiaries and over the logistics of management at large scale (i.e., upwards of 10,000 beneficiaries).
HEALTH & DEVELOPMENT POLICY
Lead researcher: Ali Ladak firstname.lastname@example.org
For our policy research, impact flows from two main channels: health outcomes and economic gain. Health can be measured using disability-adjusted life years (DALYs), and economic impacts using years of income. To combine both channels of impact in our analysis, we use GiveWell’s moral weights to roughly convert between DALYs and monetary terms. We ultimately express cost-effectiveness in benefit-cost ratio (converting health outcomes into monetary terms) as well as cost per DALY equivalent (converting economic gains to DALYs).
As of May 31 2020, less than 40% of countries have confirmed lead paint regulations. Yet there is no safe level of lead exposure, whose effects give rise to a range of negative health and economic consequences. Advocating for policy change in countries without regulations on lead paint, particularly those with large and growing paint markets, could alleviate some of these harmful consequences and create positive externalities. Our cost-effectiveness analysis found that lead paint regulation could avert a DALY equivalent for $156; for every dollar spent, we can expect a return of $74.*
Roughly 1% of the global burden of disease is due to exposure to lead, which can cause strokes and heart disease among others. Through harming brain development, lead exposure can result in lower IQ. This creates intellectual disabilities in more severe cases, and reduces productivity among those with higher IQs. One study estimates the productivity costs of lead exposure in low- and middle-income countries to be almost $1 trillion. The impact of lead regulation on IQ alone could create a range of positive outcomes, enabling people to increase their earnings and potentially sparking innovation. However, the link from lead exposure to earnings involves quite a long and uncertain causal chain: as such, we have concerns about the strength of the evidence here.
Policy interventions tend to have a lower chance of success than interventions in our other cause areas: shaping a political process involves uniting a lot more moving parts and competing goals than delivering vaccines or bed nets. However, several factors suggest that lead paint regulation could be reasonably tractable. It’s pretty uncontroversial, and is unlikely to face much opposition from the broader industry and other stakeholders.
There’s also a reasonably clear path forward for organizations working on lead paint. Resources available include the UNEP toolkit and model law, and the support of the International Pollutants Elimination Network (IPEN), which has a track record of success, having passed lead paint regulation in over 20 countries to date. IPEN flags three elements as key to effecting policy change: providing the data, getting media attention, and working consistently.
Our conversation with IPEN raised several key points. Firstly, IPEN considers that funding is a major bottleneck among organizations advocating lead paint regulation. Rather than founding a new organization, they suggest it may thus be more effective to support NGOs currently working in the space. This said, there are promising countries in sub-Saharan Africa where IPEN does not yet have a partner, and where a new EA organization could be valuable.
Regulating lead paint is an important first step, but it does not fully solve the problem. Although lead paint is known to be a key source of lead exposure, it’s unclear what proportion of exposure it causes: we conservatively assume this figure to be 25%. Additionally, the proposed regulations would not remove lead from the environment, but rather aim to prevent more from coming in. Once regulations are in place, compliance may also be an issue (as touched on in this expert conversation).
Fully eradicating the harmful effects of lead paint will take time. Even so, lead paint regulation looks to be a promising intervention for a new charity. Moving forward, we will continue to discuss with IPEN how best to fit into this space.
With 4.3% of the global burden of disease attributable to alcohol, advocating for regulation has the potential to be highly cost-effective. It’s also quite neglected, so the counterfactual impact of a successful new charity is strong. Our analysis explored several variations of alcohol regulation, including availability, pricing, and advertising. Of the WHO’s best buys, taxation looks particularly promising based on its cost-effectiveness and the strength of the evidence. Although 155 countries already tax alcohol, less than a quarter adjust these taxes for inflation, so they become less effective with time.
Alcohol consumption causes both short and long-term health problems, as well as negative economic impacts. It is a risk factor for over 200 conditions, including cancers and cardiovascular diseases; it leads to injuries (e.g. road accidents) and violence (e.g. domestic abuse). Several meta-analyses provide strong evidence that taxation lowers consumption: it seems that a 10% increase in price reduces consumption by 5%. Given the wide-ranging costs associated with consumption, tighter regulation looks highly impactful.
Our research models the cost-effectiveness of an 18% increase in price. This figure is roughly in line with WHO’s models and with the highest rates in the EU and Asia. We expect such a price increase to avert a DALY equivalent for $96. Expressed differently, this suggests an expected return of $115 for every dollar invested.*
Two key issues are that regulation could be paternalistic and could hit low-income consumers hardest. We can’t neatly resolve these criticisms, as at a certain point it boils down to values. But to offer some brief thoughts, the negative impact of alcohol taxation on low-income consumers’ wallets is arguably outweighed by the positive impacts on their health. Spending revenue from the tax on health care could also counterbalance this concern. Moreover, as a critique, paternalism implies that consumer choices are truly free. Such an assumption ignores, for example, the influence of external factors (e.g. the industry) in shaping decisions.
The overarching problem with alcohol regulation (and a reason it’s so neglected), is that it’s hard. Policy interventions are generally tricky, and alcohol regulation particularly so. Advocates face a powerful industry lobby and the weight of popular opinion (itself to an extent crafted by the industry). A new charity advocating for alcohol regulation would need to be highly attuned to the local context and sensitive to cultural values.
As this intervention is quite controversial, we expect fundraising to be difficult for a new charity, particularly outside the EA movement. Negative narratives around regulation are pervasive: for example, prohibition in 1920s USA casts a long shadow, even though this intervention does not seek to ban alcohol. Aligning with established actors in the space (e.g. the WHO, GAPA) could increase the chances of success for a new charity. Even so, we’re cautious about recommending alcohol regulation due to concerns over funding.
*Please note that these figures depend on model assumptions, consistently estimated within our health and development research but not necessarily beyond.
Lead researcher: Vicky Cox email@example.com
To compare interventions in this space, we created a weighted animal welfare index. Researchers score each animal’s welfare on this index to arrive at an overall score in welfare points, adjusting for probability of sentience and expected lifespan. Our cost-effectiveness analyses quantify the number of such welfare points we expect to affect per dollar spent. To read more about how we created the welfare index, refer to this blog post.
Managing levels of dissolved oxygen tackles chronic suffering for farmed aquatic animals. With insufficient oxygen in the water, the animals struggle to breathe. Our 2019 research period identified managing dissolved oxygen for farmed finfish as a promising intervention, and led to the founding of Fish Welfare Initiative. This year, we explored whether this could be a promising intervention for shrimp, another neglected farmed animal.
Although our report focuses on oxygenation, we look forward to further work on shrimp welfare, as this is highly neglected. For example, conversations with Daniela R. Waldhorn highlighted another potentially promising intervention: preventing eyestalk ablation, the practice of cutting off female shrimp’s eyestalks. A new charity’s primary aim should be to improve welfare for shrimp as effectively as possible, whether this be through managing dissolved oxygen, preventing eyestalk ablation, or another well-evidenced intervention.
In our eighty-hour report, we specifically model the effect of subsidizing aeration for farmers of whiteleg shrimp in Vietnam. Although we are less sure that shrimp are sentient than larger crustaceans, the immense scale at which they are farmed led us to prioritize their welfare. Our analysis suggests that managing dissolved oxygen would cost-effectively improve their welfare. Through subsidizing aeration, we can affect almost 90 welfare points per dollar. This figure takes into account co-founder and funding counterfactuals.
Conversations with experts suggested that Vietnam would be the best place for an oxygenation intervention for shrimp, due to the scale of the problem and the need for climate change resilience. As temperatures rise, dissolved oxygen levels decrease. In a warming world, aeration will become increasingly necessary.
A concern with this intervention is that farmers may increase stocking density, crowding a greater number of shrimp into the same space. This said, higher stocking density creates various other costs: feed, labor, maintenance, disease rates, and the size of the shrimp are negatively affected. As such, it is not in a farmer’s interest to drastically increase stocking density. However, given the potential to harm shrimp welfare, this issue is worth addressing. If a new charity decides to subsidize aeration equipment, subsidies could be conditional upon a certain maximum stocking density.
We expect a new charity working on shrimp welfare to face no insurmountable challenges. Currently no established funding landscape exists, as shrimp welfare is highly neglected. But there are promising signs that effective altruist funding would be available (e.g. this request for proposals). Depending on the co-founders’ backgrounds, cultural barriers may pose an issue, as most of the top shrimp farming countries are in Asia. However, hiring local talent could help bridge this gap.
While we were only able to model the impact of a dissolved oxygen intervention, our research revealed several promising pathways for improving shrimp’s welfare. A new charity may wish to address water quality in general, for example with an ask that encompasses pH as well as dissolved oxygen levels. They may also choose to work on preventing other forms of suffering for farmed shrimp, such as the practice of eyestalk ablation mentioned above.
Overall, although we recommend dissolved oxygen, we encourage a new charity to be flexible and open-minded in their approach. As they explore the issue further through farm visits and micro pilots, entrepreneurs should not lose sight of their first priority: improving the welfare of shrimp.
Micronutrient fortification can be a highly cost-effective intervention (e.g. Fortify Health). Repeatedly laying eggs takes a significant toll on farmed hens, depleting their nutrient levels and leading to fractures and broken bones. To counter these and associated welfare problems among egg-laying hens, a new charity could advocate for fortifying their feed with calcium, phosphorus, and vitamin D3.
Strong evidence supports the potential for feed fortification to reduce suffering. We found ten studies on the effect of calcium on hen welfare, fourteen on phosphorus, and six on vitamin D3.
Our models suggest a new charity could affect roughly 7.5 welfare points per dollar when including counterfactual considerations for co-founders and funding. To put this another way, each dollar invested in this intervention spares on expectation roughly two hens from broken bones. If we do not account for counterfactuals in our calculation, cost-effectiveness increases to almost thirty welfare points.
A new charity should be open to various options, and pivot should their own research and farm visits suggest a better path forward than our modeled approach. This said, our research indicates that working with farmers in India is most promising. India is among the top five egg-producing countries, and nutrient levels are below par on many farms as its feed standards are only recommendations.
Within India, we considered a few possible strategies for this intervention, including corporate and government campaigns and partnering with certification bodies. We believe subsidizing fortification to be the most promising approach, at least in the short term. It presents the highest chance of convincing farmers to raise feed quality, and the lowest risk of hampering the progress of ongoing corporate campaigns such as cage-free commitments. A new charity should collaborate with the major players of these campaigns to avoid this concern.
A few potential challenges are worth touching on. Offering subsidies means that the charity will need to fundraise well and rapidly, which may thus be a key bottleneck for this intervention. We have also assumed that fortification will be as simple as providing farmers with a micronutrient premix; based on our research, this seems a reasonable assumption but will require confirmation. Finally, although one expert raised humane washing as a possible concern, we found little empirical evidence to settle the question, and feel that the amount of suffering this intervention could alleviate justifies the risk.
Note: Our research into feed for laying hens also covered alternate methods of feed restriction, which change the quality rather than quantity of feed. In practice, this would involve reducing the energy or protein content of feed. However, we concluded that these methods do not substantially improve welfare for hens, and ultimately could even harm their well-being (e.g. by increasing feather pecking, and discouraging the switch to slower growing breeds). For this reason, we do not recommend a new charity advocating alternate methods of feed restriction.
Our 2019 research indicated that researching possible asks for the animal movement holds promise. A new ask institute would conduct deep research to maximize the impact of governmental and corporate campaigns. We estimate that the best ask could create three times as much benefit for farmed animals as the worst.
For further information, see this blog post.
Lead researcher: Juliette Finetti firstname.lastname@example.org
This cause area is particularly sensitive to one’s ethical perspective, so we encourage readers to explore our considerations and assumptions in the supplementary report. We estimate cost-effectiveness both in dollars per additional user of contraceptive, and in dollars per unintended birth averted. Modeling unintended births averted allows us to more easily cross-compare family planning interventions, and better captures the impact of an intervention on outcomes we care about, such as women’s health and well-being.
After a woman gives birth (i.e. the postpartum) is a particularly crucial time for family planning. Short-spaced pregnancies pose a risk for the health of both mother and child, with infant mortality rising at shorter intervals. This intervention would provide postpartum women with family planning information and counseling as well as contraceptive options to mitigate the risk of unintended pregnancies.
Lack of information about family planning can lead to an unexpected and potentially dangerous pregnancy. For example, a new mother can unknowingly be fertile before her menses return. As well as providing valuable information, open discussions about family planning can help combat stigma. Raising the topic when a woman is already at a health care facility also ensures she can readily access contraceptives should she so choose.
Our report considers several potentially opportune moments for discussing family planning, including during pregnancy, after an abortion*, shortly after childbirth, and with childhood vaccination appointments. The evidence base for postpartum family planning is stronger than that for any other intervention we explored in this cause area. Offering services shortly after childbirth is particularly well evidenced, although we cannot be certain when generalizing the research to other contexts. The best path forward would likely be to broach the topic at more than one moment, so that a woman has enough time to reflect on her decision and discuss options with her partner.
Government buy-in will be important for the success of this intervention, as it requires training health workers. Such a partnership could be difficult for a new charity to achieve, especially since it would add to health workers’ regular duties. It would be vital to explore ways to support health workers so that they are not overworked. Although there are difficulties here, we estimate a 70% probability of successfully partnering with the government through collaborating with existing organizations. Still, logistics and execution seem challenging for this intervention, particularly given the difficulty of finding good hires – ideally, team members would be well connected as well as talented.
This intervention may risk overloading new mothers with information, at a time when there’s already so much for them to focus on. The evidence we found (e.g. this High Impact Practices brief) suggests this is unlikely to have a negative impact. Even so, we think entrepreneurs should be mindful of this issue.
Like our other recommended family planning intervention, we think Ghana would be a good place for a postpartum family planning charity. We could plausibly reach almost 600,000 postpartum women per year in Ghana, so it looks promising in terms of scale. Additionally, low stock-out rates of contraception suggest that supply is not an issue. Our model suggests that by training health workers in Ghana in partnership with the government, we could achieve a cost-effectiveness of $39 per additional user of contraception, or $67 per unintended birth averted.
*Given the difficulties of reaching women post abortion, we ultimately decided to exclude this approach from the bulk of our research.
Running mass media campaigns would aim to counter misinformation and foster discussion surrounding contraception, and in this way support women’s decisions about their fertility. Upfront investment is needed to create and tailor the campaign. But once the initial roadblocks are past, mass media campaigns can reach a broad audience and have the potential to be highly cost-effective.
Intuitively, media campaigns are a useful tool. Think of the enduring power of the iconic 1943 “We Can Do It!” campaign: to this day, Rosie the Riveter is a well-known cultural symbol. But measuring impact is difficult in this space, and feedback loops are minimal. Questions about the evidence base for other mass media campaigns (e.g. see GiveWell on DMI’s child survival campaigns) meant that our team initially had reservations. However, a recent randomized controlled trial of DMI’s family planning campaign in Burkina Faso shows encouraging signs. The study found, for example, that contraceptives use increased by almost 6 percentage points. The four experts we spoke to were also positive about the promise of mass media campaigns.
For this intervention to achieve impact, contraceptives must be available. Helping a woman to make an informed decision about her fertility is not enough if she then cannot access those contraceptives. Other difficulties flagged in our research process relate to logistics, e.g. electricity shortages and fostering partnerships with broadcasting companies, though limited field operations even at large scale favors the ease of execution. Given the skill set needed to run this intervention (management, experience with media, etc.), we also expect finding talent to be tricky.
Development Media International (DMI) is already doing great work on evidence-based mass media campaigns. Their saturation+ approach involves three strands: saturation (repetition, reach); science (robust M&E); and stories (engaging messaging). Of course, that DMI exists raises the question of a new charity’s counterfactual impact. We believe that a charity could learn from DMI, and add independent value by filling the gaps rather than reinventing the wheel with a wholly new strategy. Our preliminary research suggests that Ghana could be a promising location: the barriers to contraception seem connected to misinformation more than to access, and DMI does not plan to expand to Ghana. See our expert conversation with Roy Head, CEO of DMI, for further details on some of these questions.
Our cost-effectiveness analysis assumes that a new charity will operate in Ghana, disseminating radio campaigns using DMI’s saturation+ approach. In this scenario, we estimate the cost per additional user of contraception to be less than $9, and the cost of preventing an unintended birth to be $43.
Running this intervention well requires deep engagement with the local communities served. Understanding the cultural values and contextual barriers to contraception will help ensure that the campaigns increase use in a way that respects and enhances women’s decision-making power. Our research suggests that the key barriers relate to lack of information and social perceptions, but a new charity should look more closely at such questions within the specific cultural context.
Cost-effectiveness analysis is vital as we seek to create the greatest positive impact with limited resources. But given their reliance on model assumptions, we cannot take such expected value estimates literally.
Please note that the scenarios we model in our cost-effectiveness analyses do not necessarily reflect how a charity should implement that intervention. Rather, they seek to provide a sense of the possibilities and sketch out plausible impact per dollar spent.
The CE team is deeply grateful to everyone who has offered their time and expertise throughout the 2020 research process. Thank you to all the experts who shared thoughts on potential interventions and provided valuable feedback on our reports. Thank you also to our dedicated team of volunteer interns, who helped variously with research, graphics, and proofreading.
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