I'm a doctor working towards the dream that every human will have access to high quality healthcare. I'm a medic and director of OneDay Health, which has launched 53 simple but comprehensive nurse-led health centers in remote rural Ugandan Villages. A huge thanks to the EA Cambridge student community in 2018 for helping me realise that I could do more good by focusing on providing healthcare in remote places.
Understanding the NGO industrial complex, and how aid really works (or doesn't) in Northern Uganda
Global health knowledge
Great comment and welcome to the forum! looking forward to hearing more of your thoughts :).
Only one small comment which may help understanding @Vasco Grilo🔸 can say if I'm representing him incorrectly. I agree that the uncertainty is so high here that it doesn't make sense to make strong practical recommendations. Vasco though is a mathematical utilitarian in a pretty pure form, so he's seemingly happy to make strong recommendations where there's little evidence and probabilities are close to 50/50. he'll then even change those recommendations immediately after doing some more calculations. I don't really understand how this can work in practice as communities of EA doers obviously can't switch from advocating eating less meat to advocating huge farms on the basis of an extremely uncertain BOTEc. I've made a similar point to you on as few of his posts in the past.
great question Lucas! i think it's highly unlikely (verging on implausible) that this could make a GiveWell grant net negative - those particular charities do so much good, that even in the unlikely scenario that a GiveWell charity plucked many of their staff from high good-yielding jobs i struggle to imagine it could pull their work to net negative.
I also doubt it could lower their cost effectiveness by more than say 2x, but this is intuition. A 2x negative multiplier though would be significant and important.
Those staff they hire will also be replaced in time as well to some extent, which mitigates some of the harm
like I mentioned above in my reply though this problem could be remedied relatively easily by GiveWell chaities in most cases by making sure they pay less than high government salaries for most of all positions.
hey there interesting question! As a policy I would doubt it. interestingly sometimes NGO policies pay as minority of jobs at or below market rate. for example a NGO hospital close to my home pays everyone with a degree the same amount. So most of their staff then get 50 to 100 percent more than they market rate, but they struggle to even hire radiographers (there's a shortage) who get paid double other degree holders on the open market. The health center I work at (which pays 20% more than market) recently had to hire a radiographer paid twice as much as the in-charge of the facility!
At OneDay health we do something like that, although it's not an official policy. Although In management positions I'll be honest that we pay a bit more and say I'm partially guilty of my own accusations. Not even in the ballpark of many NGOs though.
Thanks so much for writing this @DavidNash. I think that this awkward but important negative externality is little discussed in EA Global health circles, and I've never seen seen this included as a negative adjustment in a cost-effectiveness analysis (would be tricky tho). Hiring the best people away from their burgeoning new business or a government job could cause a horrendous counterfactual of lost value - that of course you'll never see or know.
I think many NGOs unfortunately see their hiring situation a kind of failure of game theory. For the individual NGO the best option seems to be to hire the best worker they can for a high salary. NGOs don't co-operate and pay market wage, so most NGOs just defect and they all pay more. You then get a weird NGO world which operates on a different plane from the local market. When I talk to NGO leader and they mostlyadmit that paying so much is bad for the reasons you outline, but then shrug and respond.
"what choice do we have to get the best staff"
I think in general though the NGOs are wrong even about having to pay this much to get super capable people. Unemployment rates are so high in LMICs, that there are thousands of super talented and capable people that would happily take a 30% or 50% lower salary that than they are paying - and with support and guidance would often do a great job. This might not be the case at top management level, but holds at most other levels of an organisation.
Pushback - Government pays HIGH
One pushback I have, is that "There are also variations in government pay as well with some countries having relatively high pay for government workers" misrepresents the situation - government pay is usually much higher than the market. In Uganda, government jobs are seen as the "Mecca" because they pay so much more than the market, and often at least as much as NGO jobs. Many NGOs then make the mistake of benchmarking to government salaries even though that doesn't represent market salaries at all. I think many government salaries are absurdly high in Uganda, and this matches the situation in other countries. This International Labour Org listshows that in most Sub-Saharan African countries government salaries average more than double the private market, which is kind of crazy...
And to back that up here's my experience of certificate nurse salaries in Uganda.
Goverment - $350 monthly
NGO - $300 monthly (and you have to work harder than in government)
Us - $130 monthly (junior staff)
Other private - $100 monthly
I think your arguments against the problem are weak, you say "This could be wrong. Maybe NGO experience provides valuable skills people later use elsewhere. Maybe in contexts with few good jobs, NGOs are the best available option for keeping talented people in-country and employed. This seems like a straw man to me, because the counterfactual isn't hiring no-one, its paying people less. Why not just hire 2 people at slightly above the market rate rather than one for double the rate as is common practice. Then more people get the skills to later use elsewhere and more people get decent jobs which could keep them in-country.
I think NGOs could largelty solve this problem through benchmarking against similar private sector salaries, then maybe add 20%-30% to that. This should be a good balance where you can
1. Hire great staff
2. Retain your staff
3. Avoid misallocation of staff from other more (or similarly) important work
One positive development is that NGO salaries have reduced over the last few years, in Uganda at least. I think that NGO budgets have been tighter, and also NGOs have realised they don't actually need those high salaries to retain staff. Post USAID I hope this situation improves even more.
One area salaries are still stupid-high is in research projects run by foreign universities/institutions. I think foreign researchers are usually so far removed from local realities they have even less of a clue about the local economy than NGOs. At OneDay Health we've been involved in a couple of research projects recently, and salaries people in this field have been wanting are even higher than I've seen in NGOs - sometimes close to on par with Western Salaries. I actually cracked up laughing on the phone at one salary request (probably rude of me).
A parting shot
I want to call out EA-affiliated orgs as often no better than the average here. GiveWell funded Orgs like Clinton Health Access Initiative (CHAI) and PATH follow the pattern @DavidNash describes. One time a staff from (i think, can't remember 100 percent( one of these orgs exclaimed...
"we have this amazing ex-government worker who really knows how government works and can help us make change there".... Sad story...
When I balked at the high salaries in a CHAI Project here, @GiveWell responded with their unusually wonderful transparency.
"Our understanding is that salaries are set based on globally-benchmarked salary ranges and localized equity adjustments to account for organizational equitable pay standards and differential cost of living across different geographies. A portion of the compensation costs is also due to benefits (such as health insurance) that may be standard to each location.
To which I would respond - yes if that's the approach, you'll end up paying extremely high salaries and often pinch staff from similarly/more important work. Better to benchmark against the market, not "Organisational equitable pay standards". Also (by the by) I would doubt that health insurance is "standard" in any Sub-Saharan country.
This especially is a great take in a competitive job market which I hadn't thought about before - as much as it might be hard for some personality traits.
"Aim to be a spikier candidate - i.e., someone with some chance of being a fantastic hire, but lower confidence of being an average hire. If you’re getting to the mid-stages of many processes, there’s a chance you’re seen as a ‘good but not great’ candidate across the park. I see many very well-meaning, well-intentioned applicants like this - clearly value-aligned with AIM but without any standout traits that get me excited about their potential as a founder. Like with dating, it’s better to be a perfect fit for one role than a decent fit for every role: it’s much better to be a 2/10 for 5 hiring managers, and a 10/10 for 1 hiring manager, than a 6/10 for every process you go through. Don’t just aim to tick the boxes in your application submissions; highlight what makes you more unique in terms of your experience, knowledge, or approach to working. Can you bring a novel angle to the test task you’ve been presented, that might fall flat, but might also make you stand out?"
As much as I mostly agree with this, I selfishly want to soak up a little of your love and "entertainment" from time to time. I'm keen to keep the forum vibrant and nurturing to our souls, it's going to be hard to avoid fun from time to time.
So when the gratuitous, meaningless fun hits the forum, I might not be reporting to @Toby Tremlett🔹 and the fun police.... ;)
thanks. how do you know the recruiters have been "successful". Open Phil would get lots of incredibly capable applicants for every job, how can you know the counterfactual effect vs. a more experienced recruiter?
This comment does concern me a bit, why do you think experience wasn't important for this job? I know EA orgs do value experience less than others....
"Most of our team had ~no previous recruiting experience before joining the team"