Cost-effectiveness analysis of Lafiya Nigeria intervention

Rethink Priorities; Tom Hird; Greer Gosnell; Jamie E

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Thank you for your hard work on this report, Rethink Priorities team! I would be happy to be a point of contact if anyone has any questions regarding Lafiya's model or internal inputs used for the analysis.

Rethink Priorities

Thank you!

Milli🔸

$1 increase in women’s income

What kind of income is this? Monthly, yearly, lifetime?

Mo Putera

12mo

RP's CEA of LN is done by quarter, so it's quarterly. More pertinently to the part you quoted, row 144 is saying the income of the women reached for counselling is modelled as increasing by $1 for every $1.17 of all-in program cost in Q1 '24, the latter quickly dropping to just $0.25 by Q4 '25. If you're wondering what this corresponds to in terms of % increase in earnings, it's 19%, from Canning and Schultz (2019) with -20% and -40% discounts for internal and external validity respectively.

Vasco Grilo🔸

Thanks for sharing. Do you think children born from unwanted pregnancies have positive lives? If so, would the family planning intervention still be beneficial accounting for the welfare loss of the children who would have been born from the prevented unwanted pregnancies? This seems like a crucial consideration.

jordanve🔸

I remember the Collins’ being emphatically pro abortion and contraception to increase the cultural prestige and frequency of having children - so the poster couple of population=good seems to think contraception and abortion access does not reduce the population, all things considered. I’m not sure if the lives of unwanted children are worth starting, but I should flag that I’m generally pessimistic about which lives are worth starting.

Edit: I’m not familiar with the culture of Nigeria. My intuitions about this developed in a western context and maybe there are relevant differences in Nigeria.

Vasco Grilo🔸

-1

Thanks for the comment. Joey Savoie, the director of strategy of Charity Entrepreneurship, which incubated Lafiya Nigeria, said:

I am far less convinced that life saving interventions are net population creating than I am that family planning decreases it.

It looks like life saving interventions decrease fertility, but still increase population. So the above suggests family planning interventions do decrease population.

The section “How Many People Have Positive Wellbeing?” of Chapter 9 of What We Owe the Future mentions a few data points about neutral life satisfaction:

The relative nature of the scale means that it is difficult to interpret where the neutral point should be, and unfortunately, there have been only two small studies directly addressing this question. Respondents from Ghana and Kenya put the neutral point at 0.6, while one British study places it between 1 and 2.

I think Nigeria is more like Ghana and Kenya than the United Kingdom, so people in Nigeria may put the neutral point at around 0.6. From the 2024 World Happiness Report, Nigeria had a mean life satisfaction from 2021 to 2023 of 4.88, which is significantly higher than 0.6. I assume unwanted pregnancies will be more frequent in families with life satisfaction below the mean, but 4.88 is 8.13 times (= 4.88/0.6) as large as 0.6, so I expect a random child that would have been born from a prevented unwanted pregnancy to have a positive life.

My low confidence best guess is that Lafiya Nigeria decreases human welfare after accounting for the effect above. Difference assumptions may lead to different conclusions, but I believe one should at least discuss the potential loss of welfare of the children whose lives are prevented.

I would be curious to know your thoughts, @Klau Chmielowska. Thanks anyway for your hardwork.

Nithin Ravi🔸

How about modeling the flow through effects on animal welfare? This may negate any decrease in human welfare, but I haven't seen a BOTEC of this that models the income increase on the meat eating problem. I suspect it would likely still be very positive for animal welfare.

Vasco Grilo🔸

-2

Thanks for the comment, Nithin.

This may negate any decrease in human welfare, but I haven't seen a BOTEC of this that models the income increase on the meat eating problem.

As suggested by the graph below, the increased income of the helped families will tend to increase their consumption of animals, which is harmful if animals have negative lives.

However, since I think family planning interventions decrease human population, I believe they decrease the consumption of animals. Yet, I am not sure this is good because farmed animals' lives may become net positive in the next few decades, and the children who would be born from unwanted pregancies would live longer than that.

In any case, I worry the meat-eater problem is mostly a distraction. If one values 1 unit of welfare in animals as much as 1 unit of welfare in humans, and does not think Rethink Priorities' welfare ranges are wildly off, the best animal welfare interventions will be much more cost-effective than the best global health and development interventions. I estimate the cost-effectiveness of Shrimp Welfare Project’s (SWP’s) Humane Slaughter Initiative (HSI) is 64.3 k times that of GiveWell's top charities.

Nithin Ravi🔸

Hmm, I hadn't considered farmed animals lives becoming net positive as a case against the meat eating problem! Thanks for pointing that out.

> the best animal welfare interventions will be much more cost-effective than the best global > health and development interventions.

I'm a bit confused by this point. It still seems like if we value this framework, we should still be considering flow-through effects in questions of cause prioritization and which GHD interventions to support. I think there are also reasonable edge cases where we may be able to influence GHD interventions to have better positive flow-through effects, if the donor is not onboard with AW.

Vasco Grilo🔸

You are welcome!

we should still be considering flow-through effects in questions of cause prioritization and which GHD interventions to support. I think there are also reasonable edge cases where we may be able to influence GHD interventions to have better positive flow-through effects, if the donor is not onboard with AW.

Agreed. By "I worry the meat-eater problem is mostly a distraction", I meant a distraction for cause prioritisation. My sense is that people (like me) who consider the meat-eater problem to be a relevant consideration for prioritising within global health and development value 1 unit welfare in humans sufficiently similarly to 1 unit of welfare in animals to conclude that the best animal welfare interventions are much more cost-effective than the best human welfare interventions.

David Mathers🔸

Vasco, where do you stand on the worry that farmed animal welfare interventions might be bad because less farmed animals=more wild animals, and wild animals have net negative lives. (I'm thinking any interventions that raise costs for farms might reduce meat consumption, and therefore number of farmed animals, at least a bit.)

Vasco Grilo🔸

Interesting question, David!

I think it is very unclear whether wild animals have positive/negative lives, so I guess it is fine to neglect the effects on wild animals of interventions aiming to improve the welfare of farmed animals or humans. I have posted about these effects, and I believe their discussion can still be useful as a way of raising awareness for wild animal welfare.

In addition, as with the meat-eater problem, I suspect the effects on wild animals are mostly a distraction for cause prioritisation. If one is confident the effects on wild animals are positive/negative, and that their magnitude is significant, then I would expect interventions explicitly aiming to improve the welfare of wild animals to be more cost-effective than those targetting farmed animals or humans.

jordanve🔸

Wow, thank you for this. You're far more across this topic than I am, haha.

As for the effects of family planning on population levels, it's interesting that there's such wide disagreement, although maybe it's just that the Collins' are mistaken (wouldn't shock me). I'd have to dig into the underlying research.

I distrust self-reports as a reliable guide in this case due to various biases (discussed by Kahneman), and my thoughts on that have been much better expressed in chapter 4 of the human predicament. I'll need to revisit chapter 9 of WWOTF and see how their arguments and evidence compare. I would agree that an absence of positive lives (wherever the right line is) is somewhat bad, and should be a factor in decision making, although I am not a totalist or even a consequentialist (for example, I think the threshold for a live worth starting is quite above a life worth continuing). I agree that for totalists, this issue matters a lot, and for anyone uncertain about population ethics, it matters somewhat.

To clarify for certain readers, I think that the right of the woman to family planning comes first and shouldn't be restricted. I think that foregone positive lives only has implications for prioritising among our positive obligations, not negative rights or liberties. I'm sure you agree.

Vasco Grilo🔸

To clarify for certain readers, I think that the right of the woman to family planning comes first and shouldn't be restricted. I think that foregone positive lives only has implications for prioritising among our positive obligations, not negative rights or liberties. I'm sure you agree.

My views are pretty close to Ariel Simnegar's.

Comments

Vasco Grilo🔸

-1

Thanks for the comment. Joey Savoie, the director of strategy of Charity Entrepreneurship, which incubated Lafiya Nigeria, said:

I am far less convinced that life saving interventions are net population creating than I am that family planning decreases it.

It looks like life saving interventions decrease fertility, but still increase population. So the above suggests family planning interventions do decrease population.

The section “How Many People Have Positive Wellbeing?” of Chapter 9 of What We Owe the Future mentions a few data points about neutral life satisfaction:

The relative nature of the scale means that it is difficult to interpret where the neutral point should be, and unfortunately, there have been only two small studies directly addressing this question. Respondents from Ghana and Kenya put the neutral point at 0.6, while one British study places it between 1 and 2.

I would be curious to know your thoughts, @Klau Chmielowska. Thanks anyway for your hardwork.

Summary and Key Takeaways

We model the near-term cost-effectiveness (2024-2025) of Lafiya Nigeria’s (n.d.) intervention, in which they upskill trained female health workers to provide family planning counseling and distribute injectable contraceptives (Sayana Press, or DMPA-SC) to women in remote parts of rural northern Nigeria.

We estimate that the cost-effectiveness of the intervention is $19 per unintended pregnancy averted at the beginning of 2024, falling to $7 per unintended pregnancy by the end of 2025 when approximately calibrating the model to the current and planned rate of intervention scaling.

We provide additional cost-effectiveness estimates, including cost per DALY averted (maternal, child, total), death averted (maternal, child, total), couple-year protection, additional contraceptive user, unsafe abortion averted, and $1 increase in women’s income, which can be found here.
Our crude estimate of the effect of the intervention on women’s income suggests that increasing the income of women serviced by Lafiya Nigeria by $1 cost $1.20 at the beginning of 2024, and will decline to $0.20 by the end of 2025. Reproducing GiveWell’s approach to understanding these benefits in terms of multiples of cash transfers, we find that the intervention’s impact on income increases from approximately 11x cash transfers at the beginning of 2024, increasing to 53x cash transfers by the end of 2025.

We conduct uncertainty analysis using a Monte Carlo simulation to gain insight into the effect of uncertainties from 15 inputs/factors on our cost-effectiveness estimates (Figure 1).

Looking at the effect of uncertainty on cost per unintended pregnancy averted, in Q1 2024 the 90% highest density interval (HDI) falls in the range of $17-$20 per unintended pregnancy averted (mean cost-effectiveness is ~$18). This uncertainty narrows over time, with a 90% HDI between $3.50 and $4.30 in Q4 2025 (mean cost-effectiveness is ~$4).
Uncertainties affect our cost-effectiveness estimation for other modeled outcomes similarly, except for the intervention’s impacts on income in multiples of cash where significant uncertainty in this estimate results in quite wide HDIs, getting wider over time with mean cost-effectiveness estimates growing from 10.8x (90% HDI 4.7x, 17.5x) in Q1 2024 to 49.9x (90% HDI 22.2x, 81.8x) in Q4 2025.
Overall, our uncertainty analysis did not show significant variation in estimates and therefore increases our confidence in the findings of the model.

Figure 1: Uncertainty analysis summary statistics for multiple outcomes. Points represent the mean of the Monte Carlo simulation (as do numbers on the outside of the ring), with error bars representing the 90% HDI. Numbers on the inside of the ring represent the year and quarter for each estimate.

Acknowledgments

Rethink Priorities’ Greer Gosnell and Jamie Elsey wrote this report under the supervision of Tom Hird. Rethink Priorities is a research and implementation group that identifies pressing opportunities to make the world better. We act upon these opportunities by developing and implementing strategies, projects, and solutions to key issues. We do this work in close partnership with foundations and impact-focused nonprofits. We thank Lafiya Nigeria for commissioning and funding this research report. The views expressed here are not necessarily endorsed by Lafiya Nigeria. We are grateful for the invaluable input of our interviewees, and for the support and data that Klau Chmielowska and Céline Kamsteeg of Lafiya Nigeria provided throughout the project.

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