Author: Miranda Kaplan, GiveWell Communications Associate
For many people, GiveWell is practically synonymous with our short list of top charities. But the amount of money we've sent to other organizations, doing other important work, has been increasing. In 2021, we made or recommended about $190 million in grants to non–top charity programs, like water treatment and malnutrition treatment, and in 2022, we set up the All Grants Fund specifically so donors could contribute to programs in this category.
Source: GiveWell, GiveWell Metrics Report — 2021 Annual Review, p. 9
We want to use this blog to give you more frequent, brief insights into these newer areas of our grantmaking before we publish our formal grant write-ups. Below we'll discuss, in light detail, a program that's well outside of our traditional wheelhouse, but that we think significantly improves children's lives—treatment for clubfoot with an organization called MiracleFeet.
Clubfoot is a congenital (i.e., present from birth) abnormality that causes one or both feet to twist inward and upward. Children born with clubfoot must walk on the sides or backs of their feet, which leads to pain, severely limited mobility, and, reportedly, social stigma. If not corrected, clubfoot is a lifelong condition. In January 2023, we recommended a $5.2 million grant to MiracleFeet to expand its existing clubfoot treatment program in the Philippines and launch two new programs in Chad and Côte d'Ivoire.
In the countries where it works, MiracleFeet and its local NGO partners help health facilities diagnose and treat clubfoot, using a process called the Ponseti method. This generally requires placing the affected foot in a series of casts, performing a minor surgical procedure to improve the foot's flexibility, and bracing the foot during sleep for up to five years. MiracleFeet and its partners provide supplies for casting and bracing, train government health care workers in the above procedures, build awareness of clubfoot, and help health systems collect data on treatment. This makes it comparable to a "technical assistance" program: MiracleFeet doesn't perform clubfoot treatment itself; instead, along with its partners, it helps set health facilities up to successfully find and treat clubfoot cases themselves.
The brace and custom shoes supplied by MiracleFeet for clubfoot treatment. Photograph courtesy of MiracleFeet.
We were excited to recommend this grant because we think it will probably result in a lot more kids being treated for a serious, lifelong condition that nevertheless appears neglected. Clubfoot is debilitating but not life-threatening, and affects only about 1 in 800 babies born. In resource-strapped countries, a relatively new and involved treatment like the Ponseti method may not be prioritized unless an NGO like MiracleFeet is there to advocate for and assist with it. We estimate that MiracleFeet will support treatment of about 10,000 children with this grant, and that only about 10% of those children would get treated absent MiracleFeet, though we don't feel very certain about this (more below, under "What we're still learning").
All in all, after adjustments, we think that this grant will lead to about 3,700 cases of clubfoot successfully treated that otherwise wouldn't have been, and that will result in lifelong mobility gains and pain relief for the children treated.
Why this grant is different
MiracleFeet's program is different from our top charities for a few reasons:
The program is expensive compared with our top charities. The Ponseti method requires specialized equipment, training for medical staff, and a multi-step execution with years of subsequent follow-up. In the countries funded by this grant, we estimate that MiracleFeet's program costs a little over $500 per treatment, compared with (for example) about $1 per child given vitamin A supplements through Helen Keller International.
But it's also much more targeted. Our current top charities increase coverage of blanket preventive measures—ones given to all children in the target age group, whether or not they would have eventually become sick. By contrast, all the children in MiracleFeet's program have clubfoot and need an intervention to gain full mobility. The higher cost is offset by closer targeting of the kids who will benefit.
The main benefit is reduced disability, not lives saved or income gained. While our top charities' work primarily saves lives, MiracleFeet's program focuses on reducing or avoiding disability—thus reducing pain and suffering, and indirectly increasing income (since improved mobility means more opportunity to work). In our cost-effectiveness analysis for this grant, we used our moral weights to compare the value of saving lives to that of avoiding disability and raising incomes.
To do that, we also needed to answer the question of how bad clubfoot is. We have a generic value for a year of avoiding disability, but we needed to multiply it by another value that would represent the burden of clubfoot specifically.
The source we typically rely on for measures of disease burden doesn't provide a disability weight for clubfoot, so we had to find a proxy among the conditions it does list. We considered a couple of options that represented higher and lower degrees of severity, and spoke with a disability expert and reviewed related literature to get a better sense of clubfoot's effects. In the end, we settled on a value that seemed to match clubfoot's combination of pain, impairment, and stigma. This was ultimately a judgment call based on what we had learned about clubfoot over time.
What we're still learning
Our preliminary cost-effectiveness estimate put MiracleFeet's program close to meeting our bar for funding. Still, we had a lot of uncertainty about the ultimate impact of this grant, including the counterfactual impact of the program—that is, how many more kids would be treated for clubfoot because of MiracleFeet's work in these countries? Because MiracleFeet provides assistance for treatment, but not the treatment itself, it's tougher to draw a straight line from its work to impact. We were also unsure about existing access to treatment in the three countries where MiracleFeet would be working; we had been told that treatment is scarce in the Philippines, and essentially nonexistent in Chad and Côte d'Ivoire, but we didn't have independent confirmation of that.
We saw a grant to MiracleFeet as a learning opportunity, in addition to the direct benefit it would have on children's lives. MiracleFeet and its partners already collect some data on the program, but if we could fund additional information-gathering on the number of children treated before program launch (or expansion, in the case of the Philippines), then measure the same numbers a few years later, we'd have a clearer idea of what a program like this accomplishes with philanthropic support. We could use that information to make better decisions not only about whether to fund MiracleFeet again in the future, but also about whether to fund other clubfoot treatment programs.
When we factored in what we'd get out of a separate grant for monitoring and evaluation—what we call "value of information"—the whole opportunity looked cost-effective. In May 2023, we recommended a separate grant of about $600,000 for an external evaluator in each of the three countries to conduct those before-and-after surveys of clubfoot treatment levels, which we hope will give us the extra data we're looking for.
It's possible, of course, that these monitoring activities will tell us that the program doesn't have much of an effect—meaning we might look back several years from now and decide that we wouldn't have made the initial grant, given what we learned. It's a risk inherent in all the work GiveWell does, and, we think, a greater risk for newer-to-us programs like this one. But the upside of a positive finding is considerable! Even learning that the program isn't very effective would be valuable, since it would allow us to more confidently steer our funding toward more cost-effective uses.
There's a lot we don't know about clubfoot treatment, and a lot we hope to learn in the coming years. We're grateful for the more flexible funding we get from our donors so we can continue to invest in our learning and expand our funding's reach beyond top charities.
"Congenital talipes equinovarus (CTEV), also known as clubfoot, is a congenital condition characterized by one (unilateral) or both (bilateral) feet twisting inward…. In a shallow literature review, we found that 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. We have not vetted these claims but they appear plausible given that clubfoot is not expected to resolve without treatment and there are theoretical and empirical associations between physical disability and worse economic outcomes." GiveWell, Ponseti Casting for Clubfoot, December 2022 ↩︎
We plan to publish a formal write-up and cost-effectiveness analysis for this grant in the near future. Much of the information in this blog post that is specific to MiracleFeet's program comes from conversations with MiracleFeet and materials that are still unpublished. ↩︎
"The Ponseti casting method of treating clubfoot aims to correct foot alignment and typically includes: Stretching the affected foot and using a series of casts over approximately 6 weeks, which is designed to gradually change the foot’s alignment, A surgical procedure (percutaneous achilles tenotomy) aiming to improve the foot’s flexibility, and Use of a final cast for three weeks and then use of splints/braces at night in order to maintain the alignment" GiveWell, Ponseti Casting for Clubfoot, December 2022
"Fortunately, clubfoot is treatable with the nonsurgical Ponseti method—a simple, highly effective, and low-cost solution that restores full functionality and mobility in 95% of cases. It involves a series of weekly casts to gently reposition the feet and a simple outpatient procedure to release the Achilles tendon, followed by use of a foot abduction brace, worn for 4-5 years while sleeping to prevent relapse." MiracleFeet, "MiracleFeet Proposal for GiveWell," December 2022 (unpublished)
- "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."
- "To monitor treatment quality and support our partners in providing safe and effective care, MiracleFeet uses a sophisticated monitoring and evaluation system, known as CAST (discussed more in the section below). CAST gives us visibility to treatment data at the patient, clinic, country, and global levels so that issues can be quickly identified and addressed."MiracleFeet, "MiracleFeet Proposal for GiveWell," December 2022 (unpublished)
"Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is one of the most common congenital conditions, affecting 1 in 800 births." Clinton Health Access Initiative, "Preventing Lifelong Impairment: Access to Clubfoot Treatment in Low- and Middle Income Countries," 2021, p. 1 ↩︎
We base this statement on notes from an unpublished conversation between GiveWell staff and an expert on disability that took place December 13, 2022. ↩︎
The more precise estimates from our unpublished cost-effectiveness analysis are 9,785 cases treated, 9% of which would have been treated absent MiracleFeet. ↩︎
This estimate factors in a 78% estimated initial correction rate (i.e., 78% of the time, the Ponseti method works to restore the affected foot to proper alignment) and a 47% estimated relapse rate among those initially corrected (i.e., in 47% of these cases, we expect that the corrected foot will lose some of its mobility gains). Thus, 9,785 x 91% (to account for those who would otherwise receive treatment) x 78% (initial correction rate) x 53% (who don't relapse) = 3,681. In addition, we expect that even children who experience relapse will still benefit from treatment through the benefits experienced before relapse, and our intuition is that cases of relapse after treatment will be less severe than those that are never treated. ↩︎
We typically use the Institute for Health Metrics (IHME)'s Global Burden of Disease (GBD) study. The IHME value we chose for clubfoot is described as "disfigurement level 2 with pain and moderate motor impairment due to congenital limb deficiency." ↩︎
"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 and 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." MiracleFeet, "MiracleFeet Proposal for GiveWell," December 2022 (unpublished) ↩︎
A write-up about this grant is forthcoming. ↩︎