Simple and effective methods for helping people that nonprofits often ignore (with Kanika Bahl)
Kanika Bahl, CEO and President of Evidence Action, discusses why simple, cost-effective interventions like safe water and deworming are often underfunded. She highlights the importance of leveraging government systems and minimizing behavior change for scalable impact, while also addressing challenges in donor incentives and program evaluation.
Deep Dive Analysis
13 Topic Outline
Underfunded Simple Solutions and Invisible Interventions
The Neglected Crisis of Maternal Syphilis
Evidence Action's Approach to Intervention Verification
Challenges of Behavior Change in Development Work
Leveraging Government Systems for Program Scale
Deworming: A High-Impact, Cost-Effective Intervention
Understanding Long-Term vs. Acute Effects of Deworming
The Complexity of Behavior Change and Program Failure
Incentives and Funding Flexibility in the Nonprofit Sector
Strategies for Broadening Donor Appeal Beyond Statistics
Measuring the Economic Impact of Health Interventions
Anemia Prevention and Treatment: A Future Frontier
Addressing the Funding Bottleneck for Effective Interventions
6 Key Concepts
Invisible Solutions
These are highly effective interventions that are not easily perceived or understood by beneficiaries or governments, such as water chlorination. Their invisibility often leads to a lack of demand and prioritization, resulting in underfunding despite their significant impact on saving lives.
Maternal Syphilis
This refers to syphilis in pregnant women that, if untreated, causes 200,000 stillbirths and newborn deaths, and over 100,000 cases of lifelong disability annually. It is a neglected disease despite a simple, cheap, and highly effective dual-test and penicillin treatment.
Intervention Drop-off
This concept describes the reduction in the overall effectiveness or reach of an intervention due to multiple steps or required behavior changes. The more points at which beneficiaries or implementers can fall off the intended path, the lower the ultimate efficacy of the program.
No Lean Season Program
An Evidence Action initiative in Bangladesh that provided small grants to agricultural laborers during periods of low farming activity. Initially based on promising evidence, the program was ultimately shut down after rigorous re-testing at scale showed limited impact and operational complications.
Unrestricted Funding
Flexible financial resources for nonprofits that are not tied to specific programs or outcomes. This type of funding is crucial for organizations to make agile strategic decisions, invest in high-risk/high-return initiatives, and responsibly adjust or shut down programs without facing existential threats.
Cost of Illness Averted
This refers to the economic benefits gained by preventing illnesses. It includes savings from avoided medical expenses (e.g., clinic or hospital visits) and the prevention of lost wages for families, thereby contributing to overall economic well-being beyond just saving lives.
7 Questions Answered
These solutions are often 'invisible' to beneficiaries and governments, meaning people don't ask for them, and they can fall between the cracks of global development strategies, leading to less donor attention and prioritization.
Maternal syphilis can be prevented by switching to a dual rapid test for HIV and syphilis (costing 35 cents more) and administering a single penicillin shot (under 50 cents) if positive, preventing 80% of severe outcomes. It's neglected because it historically receives less attention and funding compared to diseases like HIV/AIDS, which have established global funds and metrics.
While relying on established medical literature for treatment efficacy, Evidence Action focuses on verifying that the actual delivery of services, like tests and treatments, occurs in clinics and that water is chlorinated at effective levels, rather than redoing large-scale outcome studies.
Governments provide existing infrastructure, supply chains, maintenance systems, and political capital, which are essential platforms for achieving massive scale and impact that parallel systems cannot match.
After scaling the program and conducting rigorous trials, the intervention showed limited impact and operational complications, leading Evidence Action to transparently shut it down to reallocate resources to more effective programs.
There's an asymmetry where the upside of success accrues to beneficiaries, while the downside of failure can damage the NGO's reputation or donor relationships. Additionally, a lack of unrestricted funding makes it hard to absorb the costs of failed programs or pivot strategies.
The biggest bottleneck is predictable funding, as sufficient and flexible financial resources would enable organizations to scale proven interventions and make a much larger difference.
13 Actionable Insights
1. Implement Dual Syphilis-HIV Testing
Integrate dual testing for maternal syphilis alongside existing HIV tests in antenatal clinics. This low-cost intervention (35 cents per test, under 50 cents for penicillin) can prevent 80% of severe outcomes from a neglected disease.
2. Minimize Intervention Behavior Change
Design interventions to require minimal behavior change from recipients or implementers. This approach enhances tractability, reduces drop-off rates, and significantly increases the likelihood of successful, large-scale impact.
3. Partner with Governments for Scale
Prioritize collaborating with governments to scale interventions, as their existing infrastructure, political will, and funding provide an unparalleled platform for reaching vast populations effectively.
4. Utilize Existing Delivery Platforms
Identify and leverage existing, easily accessible platforms, such as schools for deworming, to efficiently reach target populations. This simplifies intervention delivery and maximizes overall impact.
5. Prioritize Invisible High-Impact Solutions
Focus on implementing ‘invisible’ yet highly effective solutions like water chlorination. These interventions can save many lives at low cost (e.g., $1.50 per person per year), even if public demand isn’t immediately apparent.
6. Verify Last-Mile Intervention Delivery
Actively confirm that interventions are effectively delivered at the ’last mile’ by examining records and ensuring individuals receive tests and treatments. This ensures actual impact rather than solely relying on general medical literature for efficacy.
7. Transparently Shut Down Ineffective Programs
Continuously test programs at scale, be transparent about all results (including failures), and be willing to shut down programs that prove ineffective. This builds trust with stakeholders and ensures optimal resource allocation.
8. Secure Flexible Funding and Reserves
Seek flexible, unrestricted funding and maintain financial reserves to cover operational costs and allow for strategic adjustments or program closures without existential risk. This enables more principled and optimal decision-making.
9. Prevent Anemia with Supplements
Implement programs for anemia prevention and treatment using low-cost iron and folic acid supplements. This simple intervention can significantly boost children’s cognitive function (IQ scores by 4-5 points) and future productivity.
10. Combine Diverse Evidence Types
Adopt a Bayesian approach to evaluating interventions by synthesizing multiple types of evidence, including randomized control trials, medical literature, and field observations. This helps make informed decisions while acknowledging the complexity and limitations of each evidence source.
11. Evaluate Holistic Economic Benefits
Assess interventions not only by their immediate health outcomes but also by their broader, long-term economic benefits. This includes increased productivity, reduced healthcare costs, and improved educational attainment, which can unlock human potential.
12. Combine Stories and Statistics
To appeal to a wider donor base, effectively combine compelling statistics about cost-effectiveness and economic benefits with accessible, real-world stories of impact. This dual approach can be more persuasive than relying solely on one or the other.
13. Use Conservative Impact Estimates
When modeling the impact of interventions, especially in situations with significant uncertainty (e.g., future benefits or unprecedented scenarios), always use conservative estimates. This helps avoid overstating potential outcomes and maintains credibility.
6 Key Quotes
I think that's exactly right, Spencer. I've spent the last nearly decade of my career at Evidence Action, and I have been so surprised at how some of the simplest and most effective solutions just go underfunded.
Kanika Bahl
It's a dual test. It there's right now, most women who are going to antenatal clinics, pregnant women go to antenatal clinics in rural, even rural Africa, and they are typically getting tested at pretty high rates for HIV AIDS. There's a rapid test, it's a lot like a COVID rapid test, you know, you get results very quickly, very easy to read. And it turns out that you can actually use a dual test, which tests for syphilis and HIV AIDS. And you just need to switch to that. And that costs 35 cents more per test. And then when a woman is found to be positive, they need a single shot of penicillin, that shot costs less than 50 cents. And that prevents 80% of these like really terrible outcomes that I mentioned that it's same day, get the results in minutes, their same day treatment. I don't know, it's about as turnkey as you get in global health.
Kanika Bahl
I'm going to be honest here, Spencer, I think the narrative that low-income country governments can't scale or too corrupt to scale isn't just wrong. It's really holding back meaningful progress in this era.
Kanika Bahl
You know, we sometimes say just the best breakthroughs aren't aren't what we invent, but how we reach people, we think really deeply about what are the simplest, most straightforward, fail safe ways to reach people, because that's how you get the scale. That's how you get the cost effectiveness. That's how you get the impact.
Kanika Bahl
I think there's a ton of misaligned incentives in the development sector.
Kanika Bahl
I think if you had to pick between the story and statistics, yours, the story will win. Obviously, you don't have to pick, you can do both. And I think doing both is value add on top of just doing one.
Spencer Greenberg
2 Protocols
Maternal Syphilis Prevention Protocol
Kanika Bahl- Pregnant women attending antenatal clinics are typically already tested for HIV.
- Switch to a dual rapid test that screens for both syphilis and HIV (costs 35 cents more per test).
- If a woman tests positive for syphilis, administer a single shot of penicillin (costs less than 50 cents).
- This same-day diagnosis and treatment prevents 80% of severe outcomes like stillbirths, newborn deaths, and lifelong disabilities.
School-Based Deworming Protocol
Kanika Bahl- Identify schools as the primary platform to reach hundreds of millions of children who need deworming.
- Work with governments to use public schools to deliver deworming treatment.