James Snowden

Is Charity About Helping the Poorest?

Giving What We Can focuses on finding the charities which result in the most benefit to the greatest number of individuals. But should we give more weight to benefitting the worst off? Should we care more about equality and distributive justice?

Giving What We Can aggregates the benefits to different people 

 rather than giving extra weight to worse off individuals. While our top charities tend to help some of the worst off people in the world, we do not explicitly factor considerations of fairness and equity into our cost-effectiveness calculations. There are good reasons for this:

. It can be very complex to add together different benefits and also weight them differently for different people. This is why academic literature on cost-effectiveness tends to aggregate benefits additively.

. Aggregating these benefits additively relies on the ethical intuitions everyone actually has. While egalitarians care about the distribution of benefits, they also care about total benefits. Different people may have very different ideas about how much weight to place on considerations of equity. It is easier to add your own weighting than to adjust ones that we have assumed.

. Those who are worst off are usually the easiest to help as there are more “low hanging fruit” so to speak.

 is the only plausible ethical theory (as has sometimes been suggested

). But we do think that aggregating benefits additively provides a good starting point, which can then be supplemented by considerations of equity and fairness if required

. We are aware that many of our members (and staff) think that prioritising helping the worst off may be of 

 reasons (for the purposes of this post we will refer to both as egalitarian

). Recently, we’ve been thinking more about how our recommended charities fare on these ethical dimensions.

If aggregating benefits in an additive or egalitarian manner always came to the same answer (as it often does), that would be the end of the matter. Occasionally however, we may have to make a tradeoff between helping people who are worse off or helping a larger number of people. This post is intended to give the reader some additional considerations, which may help them think about how to weigh egalitarian concerns in choosing the most effective charities.

Additive benefits are the most important consideration when choosing an effective charity

. However, when the cost-effectiveness of charities is sufficiently close, it may be reasonable to factor in considerations of fairness and equity.

All our top charities fare well on considerations of fairness and equity

. This is unsurprising given that they are all charities which help children with preventable diseases in poorer countries.

Against Malaria Foundation (AMF) fares particularly well

 on fairness and equity grounds as it prevents a disease with a high individual disease burden which affects the economically disadvantaged.

It is possible that there are other comparably cost-effective charities which do better than some of our charities on fairness and equity. However, AMF sets a high bar, as it is estimated to save a life for about 

, and children who die under the age of five are certainly among the very worst off globally.

In 2014, the World Health Organisation published 

Making Fair Choices on the path to Universal Health Coverage

, which attempts to provide a framework for incorporating considerations of fairness and equity into healthcare prioritisation

. The report was authored by a diverse group of 18 health economists, ethicists and practitioners in order to represent broad ethical consensus. Several members of Giving What We Can contributed to the report

 suggests three different considerations when deciding which interventions to prioritise:

: How many people can be helped and how much they can be helped for a given level of resources?

: Are the people helped particularly disadvantaged?

: How much does the intervention reduce the risk of impoverishment due to catastrophic health expenditure?

Figure 1: Framework for integrating cost-effectiveness with other criteria when selecting services (Source: 

Not all these considerations should be given equal weight. The suggested decision procedure is to separate interventions into priority categories by setting overlapping thresholds for the cost-effectiveness of interventions. Where an intervention lies in the overlapping segment between different categories, considerations of priority for the worse off and financial risk protection are applied to determine which category it falls into. So while priority for the worse off is explicitly recognised as a relevant criteria for assessing which interventions to prioritise, it is only taken into account when the cost-effectiveness of two interventions is sufficiently close.

Under the example thresholds laid out in the report, all the interventions recommended by Giving What We Can fall firmly in the high priority category. That is, even if there were substantial reasons of fairness and equity to prioritise other interventions, this would only be relevant if those interventions were also within the high priority category.

However, there is still likely to be a substantial range of interventions which fall into the highly effective category and so, when the cost-effectiveness of interventions is sufficiently close, considerations of fairness and equity may come into play

One difficulty with factoring in priority for the worst off is that people can be worse off across a number of different dimensions. One solution would be to use a covering value of wellbeing which would incorporate all these considerations (such as subjective reported well being). Unfortunately, such a covering value would be very difficult to base on reliable data and highly controversial as different people value the various aspects of welfare in different ways. This mirrors the difficulties in evaluating charities on direct hedonistic grounds. In practice, consideration of who is worse off should be based on a number of different dimensions which contribute to welfare. The case studies accompanying the report (not yet released) make some suggestions

 In the absence of the intervention, would the beneficiary bear a large individual burden of disease? The individual burden of disease can be proxied by measures such as average years of life lost (AYLL).

 How badly off is the individual in terms of income, education or occupation?

So how do our top charities fare on these grounds?

Do our top recommended charities help the worst off?

all of Giving What We Can’s top charities help people who could be considered to be among the worst off in the world

. This is unsurprising given that they are all charities which help people with preventable diseases in relatively poor countries. We encourage donors who value equity and fairness highly to take these considerations into account to supplement our recommendations. In practice, however, it appears that substantial tradeoffs between total benefits and considerations of fairness are rarely required. We therefore plan to continue evaluating charities on the basis of their additive benefits.

Against Malaria Foundation helps people who could plausibly be described as the very worst off in the world (children who die under the age of five). 

For donors who place a very high weight on justice and equality, you could do a lot worse than 

We look at the evidence regarding the economic benefits of malarial eradication

The Economic Benefits of Malaria Eradication

Estimates of the cost-effectiveness of malarial prevention have tended to focus on the number of deaths which can be averted. 

 currently estimates that it costs $2,838 to avert one death from malaria.

There may however be supplementary reasons to favour these interventions. In particular, improving the health of the population has important knock-on effects on economic productivity. This post gives an overview of the evidence regarding the extent to which fighting malaria can lead to economic growth and the various mechanisms by which this may occur.

Assessing the aggregate economic system-wide effects of health interventions is a difficult process and as a result there remains considerable uncertainty about the overall economic impact of malaria reduction. Nevertheless, we believe that, on balance, 

it seems likely that reducing malaria prevalence may have a substantial positive impact on long term productivity through a mechanism analogous to that of mass deworming.

Developmental, educational and cognitive effects: Getting malaria as a child substantially affects lifetime income

Recently, there has been increased attention on the long term productivity impact of having malaria early in life. This is similar to the case for 

 and potentially hugely important. There are a number of plausible mechanisms by which getting malaria early in life could have a long term impact on future earnings:

Malaria exposure impacts cognitive performance directly

Malaria in pregnant women produces anemia which is associated with worse cognitive development

Disruption to education caused by malaria may have a long term impact on future earnings

Catastrophic health expenditures may limit resources which can be invested in human capital by the family

The long timescales involved and the many confounding factors makes the extent of this impact difficult to evaluate.

One important study by Bleakley (2010) uses a difference-in-differences method to compare the average yearly income of cohorts born shortly before and after malaria eradication campaigns in Latin America and the USA. It found that cohorts born after the anti-malaria campaign in infected areas earned approximately 25% more than the previous generation, after controlling for the differences between cohorts in malaria-free areas. The equivalent number for the USA was 12%.

These are very substantial results (the increases apply to the whole population rather than just those infected with malaria) but have limited external validity because the data examined were from Latin America and the US (where the predominant strain of malaria differs substantially in its effects to the predominant strain of malaria in Sub-Saharan Africa

), and the 1920s in the US and 1950s in Latin America (when the economic ecosystem was very different).

An additional study by Barofsky (2011) in Uganda found that malaria eradication produced 0.3 more years of schooling in the intervention area compared to the rest of Uganda, which corresponds to an annual income gain of between 3% and 11% depending on the conversion rate used

. While these effects are less substantial than the Bleakley paper they are important for two reasons. First, they have greater external validity in Sub Saharan Africa. Second, because the prevalent strain of malaria in Uganda has a higher mortality rate, the results include the countervailing selection effect of removing lower lifetime income people from the population. Barofsky found that the long term impact of malarial prevention on productivity is substantial, even net of this selection effect. 

Barofsky’s paper lends credence to the belief that malaria eradication could have long term productivity effects

 although we would welcome further research in this area.

Costs to individuals and health care system: treating malaria is very expensive, preventing malaria is very cheap

The most direct economic benefit to reduced malaria prevalence is the associated reduction in household health expenditures. Getting malaria is not only deadly but it’s also very expensive. This cost is relatively easy to measure. Household expenditure on malaria treatment in Malawi ranges from about 7% of household income for the average household to 32% of household income for the poorest groups.

 In countries with undeveloped healthcare systems, where out of pocket health expenditures are common, 

malaria can lead to catastrophic health expenditures and financial impoverishment

Where healthcare costs are subsidised, the direct costs of treating malaria fall on the government. The 2015 WHO World Malaria report estimates that, since 2000, 263 million cases of malaria which would have been treated in the public sector have been averted. This is equivalent to a $900m saving for government budgets, of which $610m is attributable to distribution of ITNs/LLINs.

 The 2011 version of the same report noted that “in Rwanda it has been estimated that while it would cost US$ 265 million to sustain the malaria control programme over the next five years, the public health system could avert about US$ 267 million in the costs of diagnosing and treating malaria; and households could avert about US$ 547 million in direct and indirect costs, equivalent to about 7% of household income.”

Figure 1: Estimated number of fever cases seen at public health facilities in Africa in 2015 according to different levels of ITN

for a given number of cases prevented/treated, preventative strategies have an advantage over treatment because they avoid catastrophic health expenditures and reduce the burden on the public health system (see Figure 1).

Labour productivity benefits: are people less productive due to malaria?

The economic cost of malaria is not limited to the direct costs of treatment. Working when you are seriously ill is very unpleasant. As a result, the sick take time off work (or at least are less productive) and those with sick children take time off to care for them.

Time lost per episode varies significantly across settings due to the variability of different types of malaria strains, type of economic activity and access to treatment amongst other factors. The average time lost per adult varies between 1 and 5 days.

 One recent RCT found that a group of farmers who were assigned bednets increased their harvest value by 15%

 have questioned the validity of this result due to baseline imbalances between the treatment and control groups). However, 

there remains considerable debate as to how much malaria impacts short term productivity

. For example, in Malawi, only 52% of adults reported that their illness affected their work.

 Moreover, a larger RCT which looked at 81,597 smallholder contract farmers in 1,507 clusters found no significant impact on cotton production from bednet distribution.

 One possible explanation for this result is that when people are ill they deprioritise less lucrative activities such as basket weaving rather than cotton farming. 

It seems likely that people who have malaria are less productive in the short term but the scale of this impact is highly uncertain.

Evidence on the macroeconomic effects of malarial eradication

Macroeconomic impact of health improvements is particularly difficult to measure. Early attempts used simple country cross-sectional regressions of health on GDP per capita

 but these seem doomed to failure because of omitted variable bias and the causal circularity of health and income (improved health may lead to increased income but increased income also leads to improved health). As a result, much of the literature prefers to extrapolate overall macroeconomic impact from microeconomic productivity gains.

More promising is the use of time-series data and simulations to evaluate the impact of a health shock on income per capita. Ashraf et al. simulated the impact of the immediate eradication of two diseases, malaria and tuberculosis.

 They found that, while the eradication of tuberculosis may lead to immediate increases in income per capita, the eradication of malaria may lead to short term reductions in income per capita. The difference is explained by the different demographic effects of the two diseases. While tuberculosis primarily affects workers in their prime, malaria disproportionately kills children under the age of 5. Malarial eradication therefore increases the dependency ratio of children to workers in the short term, leading to a fall in income per capita. In the long term, declining endogenous fertility rates, combined with the productivity improvements discussed above mean income per capita rises again (see Figure 2).

Figure 2: Simulated impact of elimination of malaria and tuberculosis on income per capita (from Ashraf et al.)

These results have been thoughtfully critiqued by Bleakley.

 While Bleakley agrees that demographic effects mean the impact of malaria eradication is likely to be realised in the long term rather than the short term, he notes, among other things, that the mechanisms through which malaria impacts productivity may not be limited to cases of acute fever (which is assumed by Ashraf et al.) but rather may have more insidious effects on long term productivity. Bleakley concludes that Ashraf’s estimates may be an order of magnitude too low. The debate seems to hinge on the scale of these long term productivity effects, which are discussed above.

James is a former Research Analyst and Chapter Coordinator for Giving What We Can. He has a first class degree in Philosophy, Politics and Economics from Oxford University, graduating in the top 5 of his year, and a Masters in Economics and Philosophy from LSE. Before joining Giving What We Can, James worked as a strategy consultant to FTSE 100 companies. He has provided expertise on healthcare prioritisation to the World Health Organization.

James Snowden

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Articles

Is Charity About Helping the Poorest?

The Economic Benefits of Malaria Eradication