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Apologies all, I accidentally posted this without the content at first. Still getting used to the platform.
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The core issue with your post is that one cannot simply state the cost of ownership then use that to calculate the cost-effectiveness, and be taken seriously. To be convincing, you need to actually factor in all the costs of your intervention:
1. The cost of getting each hospital to sign up
2. The cost of delivering the equipment
3. The cost of training people in how to use it
4. Your salaries
5. All your other costs
To do so seems intellectually dishonest, or at least that you're missing out much of the information we need to properly evaluate your intervention. I don't think you are doing this on purpose. It looks like you're doing great work:
- It isn't easy to get founder's pledge to give you money, and their charity evaluations are taken pretty seriously.
- It seems like you're saving a lot of lives that otherwise would not have been saved
- It seems at first inspection like your intervention could be cost-competitive with other top EA charities, which would be an incredible accomplishment. It'd put you in the top >0.1% of charities.
I'd suggest that your presentation of your work is the biggest barrier to getting it taken seriously right now.
1. The post is pretty long and most of the paragraphs are verbose.
2. It took me a while to actually understand what you do. Most readers have probably clicked off before actually knowing what your intervention consists of. I believe the relevant information is in paragraph ~7? It needs to be in paragraph 1 or 2!
3. Your call-to-action (requesting feedback) as at the top. It needs to be at the very bottom
It might be worth getting some external advice on how to present your work better to donors and EA audiences.
I've up-voted your post because I want more people to engage with your work. I've screenshot this to show you that I'm not just criticising you for fun. I want you to succeed.
Dear John,
Thanks a lot for your candid feedback. This is exactly what I hoped to get from this forum.
Honestly speaking it has been quite a struggle to think what could be the right tone and what information should be included and what not. What we do is not that simple and the context in which we operate isn't either. I guess you have captured my failure to strike the right balance well with your feedback.
What might help to better understand what we do is our product video. I didn't include it before because I don't want people to feel like I am here to promote my work. Curious if you feel it should be included.
Regarding the costs remark, actually everything is included in the costs that we presented here. You can find a detailed breakdown with rationale at the bottom of this document from which I took the screenshot below. If we can achieve sufficient scale (>5000 devices) we can deliver and sustain it at the costs presented below and likely for sifnificantly less if we achieve a bigger scale.
Unfortunately I do not have time to rewrite and organize everything right now, but hopefully I can make some improvements over the weekend. If you are open to it, I would gladly receive your feedback before updating the post.
To John's point (which I agree with), these cost estimates just include the cost of purchasing and maintaining the equipment. But there are other costs! As John notes, at the very least there are people costs — the cost of your time, and hospital staff time — and probably if studied carefully we would discover that there are even still other costs.
Hi Ian (and John),
Actually we think these are all costs. To clarify a bit: we are operating as a social enterprise. The prices mentioned here would be what the hospital/NGO/government pays. Implementation is done with local staff which is quite affordable, after implementation everything is done by hospital staff. There is only limited need for support and maintenance which is all done by local teams which keeps costs low. Because (assuming we will reach sufficient volume) there are margins on the product and services this will ultimately pay for all international staff including mine.
Hospital staff time/costs goes down after the intervention, because the system automates repetitive tasks. Moreover we see a 10% shorter admission time, which will also have a positive impact on workload.
Soon we will publish more results showing that both costs for the health system and the patient will go down after the intervention. Based on what we see so far it is even very likely that our intervention is net cost saving over time.
We didn't include that in this analysis because we did not yet have the results and it again complicates it further.
There are different philosophies here of course, but from my perspectives hospital staff time required to set everything up (including training etc), and international staff time, should be treated as costs, while hospital workload improvements and improved hospital or patient costs should be treated as benefits. Among other things, that is because the benefits are somewhat speculative while the costs are more certain.
Hi Ian,
Sorry for a delayed response. But indeed you are right abou this. However, the costs at the hospital staff for availing staff is actually very low. Typically it is 20-30 people for 1 day, the costs are negligible in relation to the 10 year total costs. Moreover in-service training is part and parcel of every nurses job and part of the hospitals responsibilities. That is why we have not counted it so far.
In the coming months we expect to have a proper assessment of the impact on workload and costs and can more clearly describe it as a benefit. Initial results from one hospital indicate that IMPALA is leading to a significant cost-reduction. Will keep you posted about developments.
A question jumped out at me when reading these results. I should caveat this by emphasizing that I am very much not an expert in this kind of evaluation and this question may be naive.
Is there any seasonal effect on mortality in Malawi? If so, is it ok for the pre-intervention period to be 12-months while the post-intervention period is 18-months?
Hi Toby,
Apologies for a belated response. You are correct that there are quite large seasonal influences. So we matched everything with the respective months in the same period to compensate for it. 2 weeks ago we also got the individual patient level data. This data shows that the post-intervention group was actually on average in a worse condition than the pre-intervention group. If this is taking into account the mortality reduction is close to 50%.
Regards,
Niek
As a donor to global health and development causes, what I would be looking for are:
I haven’t spent any time picking apart this particular program but one thing I see missing here is any skepticism about the results. Usually when it comes to charitable interventions, the headline number overstates things by a lot, because when you dig into it, it turns out there are various confounding or offsetting considerations that lower one’s confidence. What are some reasons that the intervention might actually not accomplish anything at all (or even be counterproductive), that would be consistent with these results so far?
You might also ask GiveWell what it would take to get their attention.
Hi Ian, thank you for your thoughtful feedback. We fully agree that independent evaluations and randomized controlled trials (RCTs) are an important tools for understanding impact. However, we must also acknowledge that RCTs come with significant costs, long timelines, and often produce results that don’t fully translate into real-world settings. Our experience has shown that the complexity of low-resource healthcare environments requires adaptable, on-the-ground solutions that are continuously tested and refined in real-time.
That’s why, at GOAL 3, continuous evaluation and learning are embedded into our approach, aimed at Real World Evidence. We feel that waiting for a one-off trial to tell us whether IMPALA works is not appropriate. Instead, we are committed to assessing our effectiveness at every site in the real-world, following up over time, and ensuring year-on-year improvement. This approach allows us to make iterative and localized changes based on the needs of health workers and patients, ensuring we create a sustainable impact that lasts. Our goal is to see a measurable improvement not just immediately after implementation but as a consistent part of the health system's development.
Of course we do want this to be evaluated independently, to also assess unanticipated negative and/or positive impact from the intervention. We know we are biased and we understand that we are not the best evaluators. That is why we leverage the Founders Pledge grant to ensure independent research institutes can do this evaluation across different settings. This will strenthen the evidence on effectiveness across different settings with a larger poule (7) hospitals, over time (>1year follow-up) while also assessing differences.
On a personal note, while I understand and endorse the rigorous processes that donors and evaluators require, I sometimes feel frustrated by the lack of urgency. The slowness of decision-making in global health is an enormous barrier to innovation. Many life-saving solutions are delayed because innovators and startups simply don’t have the time or resources to wait for trial results. During COVID-19, we saw how innovations were fast-tracked to address an urgent crisis. It feels unfair that the 5 million pediatric deaths every year are not considered urgent enough to prioritize similarly fast solutions. Basically the risk of unanticipated consequences should be balanced against the potential positive impact and use that to navigate decisions about
Ultimately I agree with the process and I should not complain after receiving a grant from Founders Pledge to support us in building the evidence base that is needed. Its just that I am frustrated because it feels like a continuous fight to move things forward or even survive, while deep in my heart I know we are right and that every delay will hinder us from preventing deaths that are unneeded.
Thanks Niek for your thoughts.
Regarding this:
I don't mean to speak for anyone but myself, but I sense that there has been an increase in skepticism in recent decades, as interventions that seemed promising and which "we know work" turn out not to have any measurable effect, or even to have negative effects, when carefully studied. My prior, at least, regarding any new intervention that I hear about is that any effect is probably illusory or minimal.
It's not that there is no urgency about the problems in the world — those are indeed urgent and demanding — but rather, our resources are so limited, and good interventions so hard to find, that we should probably dedicate only a small amount of our funding to more speculative projects, so that we can build evidence over time and not waste funding on projects that turn out not to work. As an example of what we want to avoid doing, look at what happened with microfinance.
Of course the situation would be different if we had already fully funded well-studied projects like bednets, deworming, Vitamin A, etc.; but sadly that's not the world we actually inhabit.
I guess then it's just my title: In God we trust, but all others must bring data. It just feels frustrating sometimes, also because people actually don't say they don't believe you. So if you don't call me a liar, then why don't you help or support me?
I would really like it if a more systematic way of identifying, testing and scaling successful innovations was available.
My post are definitely not intended to complain by the way. I am blessed with a great and supportive team and have great partners as well. It's a genuine interest to understand, learn and improve.
PS. over the next days I will try to add a bit more background about the solution and our evidence, where we think it needs to be strenthened. I was a bit reluctant to put too much information in, because I thougt people might not read it.