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GIVING EFFECTIVELY HOW WE WORK TOP CHARITIES RESEARCH OUR MISTAKES ABOUT UPDATES DONATE HOME » TOP CHARITIES » SCHISTOSOMIASIS CONTROL INITIATIVE » ALL CONTENT » JUNE 2016 VERSION Schistosomiasis Control Initiative (SCI) – June 2016 version Facebook Twitter >Print >Email We have published a more recent review of this organization. See our most recent report on SCI.

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The Schistosomiasis Control Initiative (SCI) is one of our top-rated charities and an organization that we feel offers donors an outstanding opportunity to accomplish good with their donations.

More information: What is our evaluation process? Published: June 2016

Summary What do they do? SCI works with governments in sub-Saharan Africa to create or scale up programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) ("deworming"). SCI's role has primarily been to identify country recipients, provide funding to governments for government-implemented programs, provide advisory support, and conduct monitoring and evaluation on the process and outcomes of the programs. (More)

Does it work? We believe that there is relatively strong evidence for the positive impact of deworming. SCI has conducted studies in about half of the countries it works in (including the countries with the largest programs) to determine whether its programs have reached a large proportion of children targeted. These studies have generally found moderately positive results, but have some methodological limitations. Note that we have not asked SCI for monitoring and evaluation results since September 2015 because we have put other questions on hold while we focused our questions on SCI's finances. (More)

What do you get for your dollar? Our most recent estimate is from late 2015. We estimate that children are dewormed for a total of around $1.26 per child. This figure relies on several difficult-to-estimate inputs including how to account for (a) donated drugs and (b) in-kind contributions from governments with which SCI works. Excluding drugs and government contributions, we estimate that SCI's cost per treatment is $0.53. The number of lives significantly improved is a function of a number of difficult-to-estimate factors, which we discuss in detail in a separate report. (More)

Is there room for more funding? It is our understanding that donations SCI receives now will be allocated to SCI's April 2017 to March 2018 budget year. We have not attempted to understand SCI's room for more funding for its April 2017 to March 2018 budget year in detail, but we think it is highly unlikely that SCI has raised enough funding to cover its planned activities. (More)

SCI is recommended because of its:

Focus on a program with a strong track record and excellent cost-effectiveness. (More) Track record – SCI has repeatedly demonstrated success at starting and expanding national deworming programs. Room for more funding – we believe SCI will be able to use additional funds to deliver additional treatments in 2017-18. (More) Major unresolved issues include:

Although our understanding of SCI's financial position and spending has improved, we continue to have some concerns about SCI's financial reporting and financial management. We have remaining concerns about SCI's use of an accounting system ill-suited to its needs, and also recently learned that SCI made two substantial financial errors that impacted funding from GiveWell-influenced donors and our room for more funding analysis last year. (More) The evidence we have seen on SCI's track record of reaching those it has targeted for treatment is fairly limited. We have seen results from about half of the countries SCI has worked in and, for those countries from which we have seen results, we have generally seen one year of results, though SCI has worked in the country for several years. We have some questions about the results we have seen because of methodological limitations of the studies and past challenges communicating with SCI about its monitoring (see blog posts from 2013 and 2014). Table of Contents Summary Our review process What do they do? Major funding sources for SCI's work Large grants Unrestricted funding SCI’s role in mass drug administration programs Côte d'Ivoire Ethiopia Mozambique Uganda Breakdown of SCI’s spending Financial update Spending breakdown by country Spending breakdown within country programs Other projects Does it work? Are mass school-based deworming programs effective? Are SCI's monitoring results representative of its work overall? Are targeted children being reached? Coverage surveys Have infection rates decreased in targeted populations? Which prevalence and intensity studies provide evidence of SCI's impact? Niger, Burundi, and Malawi prevalence and intensity studies Results from Yemen Additional academic evidence Are there any negative or offsetting impacts? What do you get for your dollar? What is the cost per schistosomiasis treatment? Our approach Our analysis Shortcomings of our analysis Baseline infection status in SCI's deworming locations compared to key deworming study locations Is there room for more funding? Available and expected funding Uses of additional funding in 2017-2018 Sources of uncertainty Communication with SCI about its room for more funding Global need for treatment SCI as an organization Sources Our review process We began reviewing SCI in 2009. Our review has consisted of:

Reviewing published studies on SCI's programs. Extensive communications with SCI Director Alan Fenwick and Deputy Director Wendy Harrison to discuss SCI's methods and funding needs. Requesting and reviewing SCI internal financial, organizational, and monitoring and evaluation documents. Visiting a national schistosomiasis control program meeting and demonstration mass drug administration in Malawi in October 2011 (notes and photos from this visit). Following SCI's progress and plans for funds raised as a result of GiveWell's recommendation (see our updates on SCI's progress). Meetings with eight SCI staff members at SCI's London headquarters in October 2014, including leadership, program managers, and monitoring and evaluation and finance staff. In the first half of 2016, we focused on learning whether SCI would produce higher quality financial data (more in our 2016 SCI research plan). We believed higher quality financial data was necessary for us to continue recommending SCI and put other questions on hold while we determined whether SCI would be able to provide this data. All content on the Schistosomiasis Control Initiative, including past reviews, updates, blog posts and conversation notes, is available here.

What do they do? SCI works with governments in sub-Saharan Africa to create or scale up mass drug administration programs (MDAs) for neglected tropical diseases (NTDs), particularly schistosomiasis and soil-transmitted helminthiasis (STH), in school-aged children and other groups determined to be at high risk.1 SCI's role has primarily been to solicit grants from large funders, identify country recipients, provide funding to governments for government-implemented programs, provide advisory support, and conduct research on the process and outcomes of the programs.

SCI's model involves both (a) employing staff for program management and technical assistance (capacity building) and (b) funding governments to carry out mapping and treatment programs.

In our November 2015 review, we noted that we found SCI's reporting on its spending and financial position opaque; we were not able to determine how much funding SCI held, and our understanding of how SCI and the governments it supports had spent funding in the past was limited.2 Documents SCI sent us in 2016 have substantially improved our understanding of SCI's financial position and its recent spending in some of its country programs.

Major funding sources for SCI's work Large grants SCI's work has been driven by a number of large grants, each with somewhat different program designs and geographic coverage. SCI's major grants:

Initial Gates Foundation grant: SCI was founded in 2002 through a $32 million grant from the Bill and Melinda Gates Foundation.3 This grant was used to create national treatment programs for schistosomiasis and soil-transmitted helminthiasis (STH) in six countries.4 Grants for integrated NTD control: In 2006, SCI received large grants from USAID and the Gates Foundation to support integrated NTD programs in eight countries for five years to treat lymphatic filariasis, onchocerciasis, and trachoma, in addition to schistosomiasis and STH.5 It received a grant in 2007 to expand its work to Rwanda and Burundi.6 All of these grants were completed in 2011.7 DFID grants: In 2010, SCI received £10.5 million8 (plus separate funding for drugs) from the UK's Department for International Development (DFID) for treating schistosomiasis and STH9 in eight countries over five years.10 Other NTDs are not covered by the grant, though DFID also provided funding to the Filarial Programmes Support Unit (FPSU; formerly the Centre for Neglected Tropical Diseases) to integrate treatment for lymphatic filariasis with SCI-funded schistosomiasis and STH programs in six countries.11 In 2014, DFID awarded SCI an additional £16.6 million over four and a half years (June 2014 to December 2018) to extend the program and expand it to an additional two countries.12 Unrestricted funding Prior to 2011, unrestricted funds accounted for a very small portion of SCI's total funding.13 SCI told us that this funding was primarily used to fund treatments in regions of Côte d'Ivoire and Mozambique.14

In part due to GiveWell's recommendation, since November 2011, SCI has received significantly more unrestricted funds: GiveWell has tracked about $14.2 million in donations to SCI due to our research.15 We estimate that at least 70% of the unrestricted funds that SCI raised in April 2013 to March 2015 (the period for which we've seen data) were due to GiveWell's recommendation.16

Unrestricted funds now make up a large portion of SCI's revenue. For April 2015 to March 2016, SCI reports that 48% of its revenue was unrestricted.17

SCI’s role in mass drug administration programs SCI's role in mass drug administrations (MDAs) in general is to:18

Advocate for the benefits of mass drug distributions to government officials. Assist with planning and budgeting. Deliver funding and drugs to governments. Provide financial management and technical support. Develop procedures for monitoring and evaluation, analyze data, and write reports. In 2014, we spoke with four of SCI's program managers to better understand SCI's role in four countries. These conversations were mostly consistent with our general understanding of SCI's work. We selected Côte d'Ivoire, Ethiopia, and Mozambique because SCI has spent significant unrestricted funds, the type of funding GiveWell has recommended, in these countries (more below). SCI selected Uganda as the fourth case study. Summaries follow.

In addition, in 2015, SCI shared some details about its work in Sudan, where it recently began supporting a program, and in Nigeria, where it is considering supporting a program in the future. We have not yet written up summaries of this work (documents SCI shared are listed in footnote).19

So far in 2016, we have not spent much research time attempting to update our understanding of SCI's role in MDA programs. We have instead focused our research on the quality of SCI's financial information (more below).

Côte d'Ivoire History: There was no large-scale schistosomiasis treatment program in the country prior to SCI's involvement.20 SCI began working in Côte d'Ivoire in 2010, but mapping and treatments did not begin until 2012 due to political turmoil. It has funded mapping and treatment for all qualifying districts.21 SCI expected to fund about 4.9 million treatments during its 2014-15 budget year;22 it reported delivering 3.1 million treatments in that period.23 During its 2015-16 budget year, SCI intended to deliver around 0.6 million treatments; we have not yet seen data on how many treatments were actually delivered.24 SCI previously told us that it spent a small amount of unrestricted funding in the country prior to 2011; we do not know what this funding was for.25 Current plans (as of April 2016): SCI plans to deliver 2.4 million treatments in its April 2016 to March 2017 budget year.26 Funding: SCI has used DFID funding, a grant from the company Vitol, and unrestricted funding in Côte d'Ivoire.27 In the 2014-15 budget year, SCI spent about $250,000 in restricted funding and $820,000 in unrestricted funding in the country, a significant increase over 2013-14, when SCI spent $580,000 in restricted funding and $20,000 in unrestricted funding.28 In 2015-16, SCI spent around $130,000 in unrestricted funding and around $70,000 in restricted funding in Côte d'Ivoire.29 Impact of unrestricted funds: SCI told us in 2014 that it believed that availability of unrestricted funds had allowed the program to scale up faster than it otherwise could have.30 Partners: In the early stages of the program, SCI primarily worked with the Ministry of Health and, for mapping, the Université Félix Houphouët-Boigny. Starting in 2014, SCI began working with other partners, including Sightsavers, the END Fund, and Helen Keller International on a more integrated NTD program.31 Role of SCI staff: SCI's Program Manager for Côte d'Ivoire described her role (as of October 2014) as providing technical expertise, helping create budgets, monitoring training and MDAs, responding to problems (for example, surveying health workers to understand low coverage of non-enrolled children, and advising on how to proceed with the program during a security threat), refining the protocol for the coverage survey, and coordinating with partners for integrated MDAs.32 From November 2013 through November 2014, she traveled to Côte d'Ivoire five times and spent almost four months there in total to assist with and monitor mapping, sentinel site and coverage survey data collection, three MDAs, and budgeting.33 She also noted the role of other SCI staff in the program: the finance team checks receipts against expense reports,34 and the biostatistician analyzes monitoring data and advises government staff on data issues.35 Ethiopia History: There was no sustained, large-scale schistosomiasis treatment program in the country prior to SCI's involvement, only a one-off, sub-national treatment.36 SCI began conversations with the government of Ethiopia about starting a national schistosomiasis treatment program in 2012. In 2013, it funded planning for the program. It funded mapping between November 2013 and April 2014, and a first round of treatment in 2013.37 In April 2015, Ethiopia treated a reported 2.9 million children for schistosomiasis and STH. SCI planned to conduct a coverage survey following this round of treatment and collected baseline data on infection rates from 22 sentinel schools prior to the treatment round (more on these data collection methods below).38 We have not yet seen results. During the remainder of SCI's 2015-16 budget year, SCI reports that an additional 5 million children received treatments.39 Current plans (as of April 2016): SCI plans to deliver schistosomiasis treatments to 6.5 million children (4.5 million of which will also receive STH treatments) and 6.7 million STH-only treatments in its 2016-17 budget year in Ethiopia.40 Funding: SCI spent around $2.1 million in unrestricted funding and $0.8 million in restricted funding in Ethiopia between April 2015 and March 2016..41 The END Fund and DFID have now allocated restricted funds for treatment in the country.42 Impact of unrestricted funds: SCI believes that availability of mapping data significantly improved the chances of securing funding from the END Fund and DFID, and that, at a minimum, the availability of unrestricted funds accelerated the program by a few years.43 Ethiopia's Neglected Tropical Diseases Program Manager told us that the government had not dedicated funding to schistosomiasis and that without SCI's involvement the program would likely not have gone forward. According to him, Ethiopia was not aware of any other potential partners for this work when it began working with SCI.44 Partners: SCI is funding the Federal Ministry of Health (FMOH) to carry out treatments. It partnered with the Ethiopian Public Health Institute, the technical arm of the FMOH, and the Partnership for Child Development (PCD) on mapping. PCD funded mapping in part of the country and delivered treatments in a pilot program. Deworm the World Initiative is providing technical assistance to the government.45 Role of SCI staff: SCI's Program Manager for Ethiopia described his role (as of October 2014) as assisting with initial program set up and funder agreements, drafting detailed plans for the next 12 months and general plans for the next 5 years, and providing technical assistance for mapping and some guidance on MDA implementation. He lives in the country46 and works closely with the government NTD team.47 Mozambique History: There was no large-scale schistosomiasis treatment program in the country prior to SCI/FPSU's involvement. SCI had previously funded a small-scale treatment program in Mozambique with unrestricted funding.48 SCI's grant from DFID, which started in 2010, includes funding for a sub-grant to FPSU to run schistosomiasis treatment programs in three countries, one of which is Mozambique.49 SCI and FPSU decided on this arrangement because SCI believed it would increase the chances of DFID awarding the grant.50 From April 2015 to March 2016, SCI reports delivering 4.4 million treatments, out of a targeted 5.8 million.51 Current plans (as of April 2016): SCI reports that it plans to deliver 5.8 million treatments in Mozambique between April 2016 and March 2017.52 SCI told us that one of the rounds of MDA originally scheduled for 2016-17 is now scheduled for 2017-18.53 Funding: SCI has spent both restricted funding from DFID and unrestricted funding in Mozambique. The data for before the 2015-16 budget year we have seen on SCI's spending in Mozambique is incomplete (see below), but our impression is that Mozambique has been one of SCI's largest programs.54 It has funding from the SCORE project for research on "gaining and sustaining control of schistosomiasis" in one province.55 Impact of unrestricted funds: SCI told us that unrestricted funds have helped the program scale, but perhaps not as much as it might appear, since SCI has shifted DFID funding to other countries with the expectation of using unrestricted funds in Mozambique.56 Partners: The Ministry of Health implements the program. SCI/FPSU also collaborate with RTI International, which is working on trachoma in Mozambique and has staff in-country. RTI helps to keep SCI/FPSU informed about program progress.57 Role of SCI staff: FPSU manages the program day-to-day. SCI has provided some assistance with monitoring and evaluation. We do not have more detail on SCI/FPSU role in the country.58 Uganda History: SCI has worked in Uganda since 2003 and has received funding for this work from each of its large grants: Gates Foundation, USAID, and DFID. There was a gap in SCI's work between the USAID and DFID funding.59 SCI reported that it delivered 23,000 treatments in April 2014 to March 2015.60 It had planned to fund 400,000 treatments this period;61 we haven't discussed with SCI why significantly fewer treatments were delivered than planned. Between April 2015 and March 2016, SCI reports that it delivered 890,000 treatments in Uganda; 1.2 million treatments were planned.62 Current plans (as of April 2016): SCI plans to deliver 1.1 million treatments in Uganda between April 2016 and March 2017.63 Funding: In recent years, SCI has primarily used DFID funding in Uganda (about $176,000 in the fiscal year covering 2013-14, $30,000 in 2014-15, and $378,000 in 2015-16).64 In 2014, SCI allocated a small amount of unrestricted funding to Uganda to increase the number of sentinel sites for operational research purposes.65 SCI also spent about $30,000 in unrestricted funds in Uganda in 2014-15;66 we don't know what these funds were used for. SCI spent around $176,000 in unrestricted funding in Uganda in its 2015-16 budget year, substantially more than previous years.67 Partners: RTI International, funded by USAID, works in Uganda on an integrated mass NTD treatment program. SCI provides schistosomiasis treatment in those areas where RTI does not.68 Role of SCI staff: SCI told us that, due to strong in-country capacity, SCI provides only limited technical assistance for MDA. Instead, SCI's technical assistance in the country is focused on operational research on how best to move toward elimination of schistosomiasis.69 SCI's program manager for Uganda describes her role as (as of October 2014) assisting with budgets and plans, talking to the government regularly (largely through email) leading up to an MDA to make sure all the components are prepared, traveling to the country to oversee collection of prevalence and intensity data prior to an MDA, following up with the government after an MDA to get the data needed for reporting to DFID, and participating in activity reviews after each stage of the program (for example, after an MDA and after monitoring and evaluation activities).70 Breakdown of SCI’s spending Our research on SCI in 2016 so far has focused on the quality of SCI's financial data. We include our updated views on the quality of SCI's financial documents and spending breakdowns by country and within countries below.

Financial update We wrote in our November 2015 review that SCI's accounting system seemed ill-suited to its needs and that SCI's financial information was limited in scope and prone to containing errors. In December 2015, we spoke to SCI's former Finance and Operations Manager, who confirmed that the financial systems SCI was using were not well suited for NGO grant management, and that SCI had not allocated sufficient staff capacity to managing its finances.71 Due to these concerns, we decided to focus our research in 2016 on the quality of SCI's financial documents.72 We felt that seeing significant improvements in the quality of SCI's financial documents was necessary for us to continue recommending SCI, and we put other research questions on hold for the first half of 2016.73

The financial documents SCI has provided us with in 2016 so far allow us to answer some questions that we were not able to answer in previous years:

At the beginning of its 2016-17 budget year, SCI had $15.8 million ($8.6 million from restricted sources and $7.2 million from unrestricted sources) available to allocate to its April 2016 to March 2017 programs, research, central costs, and funding reserve.74 SCI planned to allocate nearly all of its available funding to programs and central costs in its 2016-17 budget year.75 For comparison, in several of our past reviews and updates on SCI, we have noted that we were uncertain about how much funding SCI held.76 A breakdown of SCI's spending within six country programs during its 2015-16 budget year is below. We wrote in our November 2015 review that we had not seen recent information on how SCI spent funding within country programs. Despite these improvements, we have some remaining concerns about SCI's financial systems and reporting:

SCI is housed within Imperial College London. Because it is not a standalone charity, it does not publish annual financial statements or undergo annual organization-wide audits (as U.S. charities are required to do).77 SCI notes that it has been in discussion with KPMG, Imperial College’s auditors, about certifying SCI’s accounts as a separate organization.78 It continues to use an accounting system created by Imperial College which breaks up its finances into many different "accounts" rather than giving an overall view of the organization's financial position.79 In February 2016, SCI told us that it would start to use a new accounting software package beginning in April.80 We have not yet seen financial data produced using the new software. Based on our experiences with SCI's financial reports, we believe that they are prone to containing errors. We detail the errors we have learned about in this footnote (including some errors we found in 2016).81 Of particular note: (1) a July 2015 grant from GiveWell for about $333,000 was misallocated within Imperial College until we noticed it was missing from SCI's revenue in March 2016; and (2) in 2015, SCI provided inaccurate information about how much funding it would have from other sources in 2016, leading us to overestimate its room for more funding by $1.5 million.82 Spending breakdown by country April 2015 to March 2016 expenditures by country (in millions USD)83

Restricted Unrestricted Total % of total Central expenditure $1.2 $0.8 $1.9 17.0% Ethiopia $0.8 $2.1 $2.9 25.5% Tanzania $0.7 $0.6 $1.4 12.1% Malawi $0.7 $0.1 $0.8 7.0% Zanzibar $0.2 $0.5 $0.7 5.7% Mozambique $0.6 - $0.6 5.0% Uganda $0.4 $0.2 $0.6 4.9% Madagascar - $0.6 $0.6 4.9% Niger $0.5 $0.002 $0.5 4.8% Rwanda - $0.4 $0.4 3.5% Yemen $0.3 $0.02 $0.4 3.2% Democratic Republic of the Congo $0.2 $0.2 $0.3 3.0% Côte d'Ivoire $0.1 $0.1 $0.2 1.8% Burundi $0.01 $0.1 $0.1 0.8% Mauritania - $0.1 $0.1 0.6% Senegal - $0.01 $0.01 0.1% Sudan - $0.002 $0.002 0.02% Nigeria - $0.002 $0.002 0.01% Total $5.6 $5.7 $11.4 100.00% Notes about this data:

In our November 2015 review, we noted that some expenses recorded as central expenditures were actually used for the Zambia, Liberia, and Mozambique country programs.84 It is our understanding that central expenditures in the table above do not include any such expenses.85 SCI notes that an error appears to have caused unrestricted funding to be recorded as restricted funding for Malawi.86 We have not corrected the error in the table above. For breakdowns of SCI's spending in 2013-14 and 2014-15, see our November 2015 review.

Spending breakdown within country programs In 2015, SCI began to use a system of country cashbooks, which compare monthly in-country actual spending to budgets.87 SCI sent us country cashbooks covering April 2015 to March 2016 for Niger, Côte d'Ivoire, Democratic Republic of the Congo, Malawi, Tanzania, and Uganda.88 We have only seen country cashbooks for six country programs, but it is our understanding that SCI plans to eventually collect country cashbooks from all country programs.89 Notes about this data:

Activity categories in the country cashbooks sometimes appear to be loosely defined and overlapping. For example, expenditure on drug distribution materials is sometimes classified as "drug distribution" and sometimes as "drug logistics."90 We do not have a clear understanding of the relationship between expenses recorded in country cashbooks and expenses recorded in SCI budget vs. actuals 2015-16 Redacted. For example, for Malawi, the total expenditure recorded for the 2015-16 budget year in both the country cashbook and SCI budget vs. actuals 2015-16 Redacted was $0.8 million, but total expenditure for Tanzania differed substantially in the two sources.91 SCI notes that the discrepancy for Tanzania is due to SCI recording the expenditure when the funds were sent to the country, while the cashbooks record when the funds are spent in-country.92 It is our understanding that SCI is in the process of changing this system. The total amount of spending recorded in the six country cashbooks we have seen is $2.1 million, a relatively small proportion of the $9.2 million in total spending within country programs in its 2015-16 budget year.93 In-country SCI spending in six countries, April 2015 – March 201694

Activity % of total spending Description Range across countries Drug distribution 40% Per diem payments for teachers and officers, fuel costs, communications costs, drug distribution materials (dose poles, registers, etc) 0% to 80% Country management 17% Per diem payments and salaries for national NTD program staff, fuel costs, communications 7% to 60% Drug distribution training 12% Per diem payments for teachers and officers during MDA training, accommodation and meals 0% to 46% Monitoring & Evaluation 8% Per diem payments for teachers, MDA report writers, and drivers, fuel costs 0% to 23% Drug distribution supervision 7% Per diem payments for MDA supervisors, fuel costs 0% to 62% Drug logistics 4% Drug distribution materials (dose poles, registers, etc.), fuel costs 0% to 10% Strategic planning 3% Expenses related to a strategic planning meetings, including per diem payments, travel costs, and accommodation and meals 0% to 6% Mapping 3% Per diem payments for teachers, travel costs 0% to 14% Social mobilization 3% Per diem payments, advertising 0% to 25% Global management 1% Travel costs to an international conference 0% to 3% Advocacy 1% Per diem payments, fuel costs, communications 0% to 4% Drug distribution registration 1% Per diem payments for teachers 0% to 5% For breakdowns of spending within countries supported by DFID grants between 2011 and 2013, see our November 2015 review of SCI.

Other projects In addition, SCI has received some smaller grants for a variety of projects, including:

Research. SCI has received a number of smaller grants to carry out research related to NTD control.95 Other NTD-related activities. SCI has also used funding from individuals for surgeries for hydrocele (a symptom of lymphatic filariasis) in Niger, and health education and water and sanitation programs in Burundi.96 Does it work? SCI's mass drug administration programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective.

SCI has conducted surveys in some of the countries it has worked in to determine whether its programs have reached a large proportion of children targeted. We have now seen some recent monitoring results from about half of the countries in which SCI works, including the five countries where SCI has delivered the largest number of treatments. For those countries from which we have seen monitoring results, we have generally seen one year of results, though SCI has worked in the country for several years. We have some questions about the results we have seen because of methodological limitations of the studies. In 2016, we have focused our research on the quality of SCI's financial documents (more above), and have not attempted to update our understanding of its monitoring data.

To determine SCI's track record at executing programs, we have considered:

Surveys of changes in prevalence and intensity of infection over time in three of the countries SCI has worked in. The surveys show substantial improvements following SCI treatment programs. These surveys have a number of limitations and represent a small portion of SCI's past work. Treatment coverage surveys from six of the countries SCI has worked in, including many of the countries where SCI's work has been focused in the past five years. These surveys track what percentage of individuals who were targeted for treatment actually received treatment. Overall, the surveys found moderate rates of coverage. We note some limitations of these surveys below. Other published papers that might reflect the treatment coverage achieved by SCI's programs by directly measuring deworming drug uptake or by measuring worm prevalence in countries where SCI has worked. The evidence is mixed, but makes a weak case for low coverage in the areas studied. Details follow.

Are mass school-based deworming programs effective? SCI supports mass school-based deworming programs, the independent evidence for which we discuss extensively in our intervention report on deworming programs. In short, we believe that there is strong evidence that administration of the drugs reduces worm loads but weaker evidence on the causal relationship between reducing worm loads and improved life outcomes; we consider deworming a priority program given the possibility of strong benefits at low cost.

There are some important differences between the type and severity of worm infections in the places SCI works and the places where the key studies on improved life outcomes from deworming took place, which we discuss below.

Are SCI's monitoring results representative of its work overall? We have now seen recent monitoring results from about half of the countries in which SCI works, including the five countries were SCI has delivered the largest number of treatments. For those countries from which we have seen monitoring results, we have generally seen one year of results, though SCI has worked in the country for several years.

Details in this spreadsheet.

For countries or years for which we have not seen monitoring data, it is generally unclear to us whether SCI collected additional monitoring data that it has not shared with us or whether it did not collect monitoring data. SCI told us that it is sometimes unable to share results because third parties (e.g. governments, WHO, funders) often need to give permission before data can be shared and because it can take some time for data, once collected, to reach SCI because in some countries it is cleaned and analyzed by country program staff before being shared with SCI.97

For Mozambique, one of SCI's largest recipients of both restricted and unrestricted funds, SCI shared a report from a consultant who visited the country in May 2015 to assist with data cleaning and analysis for prevalence data from 2012, 2013, and 2014. The report notes major problems with this data and the refusal of the government to allow SCI and other international partners to have access to the data outside of Mozambique.98

Are targeted children being reached? Coverage surveys SCI has conducted, or worked with partners to conduct, surveys in Côte d'Ivoire (in 2014), Malawi (2012 and 2014), Uganda (2014), Mozambique (2015), Zanzibar (2015), and Zambia (2015) to determine what proportion of people targeted for mass drug administration received treatment.

In each of the surveys, surveyors visited a sample of households and asked children, or their parents on their behalf, whether they received treatment in the most recent MDA. Other survey questions, such as age, gender, where the respondent received the treatment, and why they did not take the drug(s), were often included as well. The methodology used differed somewhat across countries. We have summarized the details of the methodologies used in the surveys in this spreadsheet ("Methods" sheet). Key differences in the methods used across countries include:99

Selection of geographic target area: All of the surveys were limited to specific geographic areas (such as districts). In Uganda, Zambia, and Côte d'Ivoire, these were selected randomly or nearly randomly. In Malawi (both 2012 and 2014 surveys), the districts were purposefully selected and not intended to be nationally representative. The selection procedure for Zanzibar was not given in the survey report.100 We are aware of one case, in Mozambique, where a selected village was replaced by another because the surveyors could not locate it; this issue was not mentioned in the survey report.101 Independence from the government: In Mozambique, the survey was carried out by government health staff, who may have had an incentive to bias the results. SCI told us, "[M]ost of the interviews in one district were done by the other district officers with no connection with the district."102 The reports on the Malawi 2014 and Côte d'Ivoire surveys note that the surveyors were independent of the government. SCI told us that university students or staff conducted the other surveys (Malawi 2012, Uganda, Zanzibar, and Zambia).103 Length of time between MDA and survey: This varied between one and six months. Intuitively speaking, the more time that passes, the less likely children are to remember accurately and the more likely they are to confuse past MDAs (we discuss one case below, from Mozambique, where there may have been confusion about MDAs). Mozambique had the shortest interval at 1-2 months and Zambia had the longest at 5-6 months. Other surveys were generally carried out 2-4 months after the MDA. Whether parents or children were interviewed: In Mozambique, parents were interviewed about whether their children took the drugs. In both Côte d'Ivoire and Malawi (both 2012 and 2014 surveys), if children in a household were not available then their parents were interviewed about whether the children had received deworming drugs. SCI made different choices about whether to include these responses in the results, which slightly inflated the results overall.104 SCI told us that parents were not asked to answer on behalf of their children in Uganda or Zanzibar.105 The report on the Zambia survey does not mention adults answering for children. In addition to limitations in specific surveys, we note some cross-cutting limitations to the methods used:

Use of verification methods: In Côte d'Ivoire, Malawi (2014), Uganda, Zanzibar, and Zambia participants were asked a number of questions about the treatment program, such as whether they recognized pills or dose poles presented by the interviewers, what they thought of the pills (praziquantel is very large and tastes bitter) and how many pills they took.106 Answers to these questions were not recorded in Côte d'Ivoire,107 and we do not know if they were recorded in the other surveys. We believe that the answers to questions such as these would provide additional evidence about the quality of the coverage results and it is unclear to us why SCI has not recorded, or if it has recorded it, why it has not shared this information. In Mozambique, respondents were asked whether they recognized the dose pole used in schistosomiasis MDAs. However, in that survey parents were surveyed on their children's behalf108 and most children (79%) received drugs at school,109 presumably when parents were not present. We don't know how to interpret the result that a very high percentage of parents (median 90%, ranging 61-94% across provinces) reported recognizing the dose pole.110 SCI hypothesized that parents may either recognize the dose pole from publicity efforts prior to the MDA or remember a similar dose pole from previous MDAs for lymphatic filariasis.111 In either case, this may indicate that the coverage survey is not measuring actual delivery of drugs to children in the most recent MDA. Accuracy of responses from young children: SCI told us, "It can be difficult to get clear, accurate answers from young children (5-6 years old). Children, especially younger ones, may be influenced by others who are around during the survey. This is especially so because surveyors often interview older children first, in front of younger siblings."112 Supervision and auditing of surveys: There is no mention in the coverage survey results of any re-surveying of households to check the accuracy of the data collected and, although "supervisors" are mentioned in several reports, it is not clear what role they played.113 SCI described to us the supervision used in the Mozambique survey (details in footnote); audits were not mentioned.114 The fact that the surveys identified low coverage in several cases increases our confidence in their reliability. Given the smaller sample size, government involvement in the survey, and question about parents recognizing the dose pole noted above, we are more skeptical about the results from Mozambique than those from other countries.

Mass drug administration coverage among school-aged children

Survey Median PZQ coverage and range Median ALB coverage and range Malawi (2012) 77% (64%-90%) 59% (33%-85%) Malawi (2014) 69% (55%-77%) 44% (25%-77%) Côte d'Ivoire (2014) 82% (67%-88%) 82% (68%-89%) Uganda (2014) 47% (24%-86%) N/A Mozambique (2015) 81% (73%-89%) N/A Zambia (2015) 93% (89%-94%) N/A Zanzibar (2015) 80% (75%-85%) 87% (84%-89%) Notes about these results:

Results broken down by district (or similar geographic region) are in this spreadsheet. PZQ is the drug used to treat schistosomiasis. ALB is the drug used to treat STH. Ranges and medians are calculated from district-level results. The results are for school-aged children only. Some of the surveys also measured coverage rates in adults, who are targeted for treatment in some SCI-supported programs. The results exclude districts in Uganda that were included in the survey but which do not receive support from SCI.115 For context, the World Health Organization recommends that treatment programs aim for coverage rates above 75%.116 Have infection rates decreased in targeted populations? SCI has conducted surveys to track changes in schistosomiasis and STH prevalence and intensity rates following SCI-supported treatment programs. In each of these studies, SCI tracked infection rates at the same schools ("sentinel sites") each year. In general, prevalence and intensity of the parasites decreased over time in each of the countries studied. We note several methodological limitations of these surveys below.

Which prevalence and intensity studies provide evidence of SCI's impact? Below, we discuss results from studies of schistosomiasis and STH prevalence and intensity from three countries: Niger (2004-2006),117 Burundi (2007-2010),118 and Malawi (2012-2015).119

SCI also shared studies from Uganda120 and Burkina Faso,121 and we included results from these studies in our previous reviews of SCI. We learned in 2013 (and in follow up work in 2014) that participants in the studies in Uganda and Burkina Faso received separate, more intensive treatment than other children in those countries (discussed in blog posts in 2013 and 2014). Therefore, we believe that the results from Uganda and Burkina Faso do not reflect the quality of the national programs which were supported by SCI.

It is our understanding that, in the Niger, Burundi, and Malawi studies, study participants received treatment in the same manner as other children in the country, and thus that those studies reflect the performance of the national MDAs. However, we are not highly confident in this conclusion because we had difficulties communicating clearly with SCI about the methodology of these studies (discussed in more detail in the blog posts linked above).

SCI told us that it is currently conducting similar studies in Mozambique, Ethiopia, DRC, Liberia, Côte d'Ivoire, Zambia, Tanzania, Uganda, and Niger (for more recent years). We have not yet seen results from any of these studies.122

Niger, Burundi, and Malawi prevalence and intensity studies As discussed above, SCI has conducted studies to track changes in schistosomiasis and STH prevalence and intensity rates following SCI-supported treatment programs in Niger, Burundi, and Malawi. In each study, with one exception, the same individuals were examined before the initial round of treatment and before each subsequent round of treatment.123 In the 2015 Malawi study, SCI switched to a cross-sectional sample, where random children from the same schools were surveyed, rather than the same individuals.124 To partially account for this change, the data from Malawi presented below is for the 6-8 year old age group only. There is no control group for these studies.125

In general, prevalence and intensity for the two main types of parasites that cause schistosomiasis, S. haemotobium and S. mansoni, and for hookworm (more on the other two STHs below), decreased over time in each of the countries studied. Though it is possible that other factors besides the treatment program caused these changes (such as improved sanitation infrastructure), the pattern of decline in a short period following treatment strongly suggests that treatment caused or contributed to the declines.

Changes in worm prevalence and intensity126

Schistosoma haematobium Schistosoma mansoni Hookworm Country Changes in prevalence Changes in intensity Changes in prevalence Changes in intensity Changes in prevalence Changes in intensity Niger 75.4% at baseline to 38% at one year127 21.8% prevalence of heavy-intensity infections at baseline to 4.6% at one year128 Very low prevalence at baseline129 N/A Low prevalence at baseline130 N/A Burundi (pilot) Not reported (SCI reports very low baseline prevalence131) N/A 12.7% at baseline to 1.7% at four years132 20 epg133 at baseline to 1 epg at three years134 17.8% at baseline to 2.7% at four years135 16 epg at baseline to 24 epg at three years136 Burundi (other schools) Not reported (SCI reports very low baseline prevalence137) N/A 6.2% at baseline to 0.7% at three years138 8 epg at baseline to 3 epg at one year139 15.1% at baseline to 5.4% at three years140 15 epg at baseline to 8 epg at one year141 Malawi 9% at baseline, 6% at one year, 4% at two years142 Low rates of heavy infection (note: different results given in first follow up report)143 Low rates at baseline and follow up144 Very low rates of heavy infection at baseline and follow up145 No hookworm found at baseline, 1% at one year, 2% at two years146 No participants heavily infected at baseline or follow up147 For the other two prominent soil-transmitted helminths, ascaris and trichuris, infection prevalence was low in the Niger and Malawi studies.148 In Burundi, prevalence of ascaris and trichuris decreased somewhat (though in a few cases there were temporary increases). Data from Burundi are given in the footnote.149

Some of the studies also report results for other indicators of disease such as anemia. We omit discussion of these other indicators because they are more likely to be influenced by external factors than are prevalence and intensity (see our previous review of SCI for discussion of these indicators).

Limitations of the prevalence and intensity study data include:

Monitoring of selected locations. It appears that, in the Niger and Burundi pilot studies, locations included in the study were selectively chosen rather than selected to be a representative sample of treated areas.150 Low follow-up rates. Follow up rates were low in two of the three countries (at the first year follow-up, 89% in Niger, 33%-50% in the pilot survey and 53%-80% in the other schools survey in Burundi, and 52% in the first follow up in Malawi).151 To be included in follow up surveys, children must be present in school when the surveys are done.152 If those who are present in school are less likely to be infected than those who are not present, this could lead to overstating the impact of the program. The connection between infection status and absenteeism could be a direct relationship (infection could cause absenteeism) or an indirect one (a third factor, such as poverty, could cause both higher levels of infection – perhaps through poor sanitation infrastructure – and absenteeism). Because the second follow up in Malawi was done as a cross-sectional study among children present in school on the day of the study and we present results for children ages 6-8 only, absenteeism and dropout are less likely to bias the results than in the panel studies. Results from Yemen In addition, we have two types of results from Yemen:

Partial sentinel site data: A report SCI shared with us mentions that initial analysis of sentinel site data from July 2014 in Yemen found that prevalence of schistosomiasis decreased substantially.153 These results only include 2,000 of the 8,000 individuals who were surveyed at baseline and the result noted that "a full round of impact evaluation" would be completed in September 2014.154 We have not seen more details about these initial results or any results from the full round. Remapping survey: This study compared the number of districts at high-risk, moderate-risk, low-risk for, and uninfected with schistosomiasis at "baseline" (data collected between 2004 and 2010) and in 2014.155 It found large improvements after 2-3 rounds of treatment.156 It is not clear to us whether baseline and follow up results are directly comparable. Baseline data was collected over several years and details of the methodology used at baseline are not given. Additional academic evidence To provide additional information on SCI's track record, in 2014, we conducted a search for published papers on treatment coverage rates and schistosomiasis and STH prevalence and intensity in countries where SCI has worked.

We focused on papers by Melissa Parker and Tim Allen, who were funded by the Bill and Melinda Gates Foundation to provide an anthropological perspective on SCI's work,157 papers cited in papers by Melissa Parker and Tim Allen, and other papers we identified on this topic from a Google Scholar search.158

The papers we identified were all from Tanzania, Uganda, and Zanzibar, perhaps because these are places that Melissa Parker and Tim Allen's work has focused on.

This spreadsheet summarizes the papers we considered. We have not fully vetted these studies. The studies were generally designed for purposes other than to evaluate SCI's programs so in many cases there is uncertainty about SCI's role in the areas studied. In the discussion below, we have excluded studies that we do not believe were conducted soon after treatment programs in areas targeted by SCI-funded programs.

SCI staff and/or SCI funding were involved in many of the studies.159

It is difficult to draw any conclusions from these studies because of small sample sizes and lack of clarity on SCI's role in each location. In summary:160

Tanzania (excluding Zanzibar): Two studies at the district level, Stothard et al. 2013 and Chaula and Tarimo 2014, show relatively low schistosomiasis prevalence after treatment (4% and 15% respectively; the latter claims that prevalence pre-MDA was 30%). SCI was working in Tanzania at the time of both studies, but it is not clear if SCI was working in the specific areas studied. Chaula and Tarimo 2014 also shows low treatment coverage (around 40%), though the researchers asked in 2013 about treatment provided in 2011 and 2012. Zanzibar: All studies were conducted on Unguja, "the largest and most populated island of Zanzibar."161 Two studies, Stothard et al. 2009 and Rudge et al. 2008, each in a single school, found high prevalence of schistosomiasis in areas that had received treatment (50% and 65% prevalence, respectively). The sample sizes were small, it was not clear why these particular schools were selected, and, while SCI was working in Zanzibar at the time of both studies, but it is not clear if SCI was working in the specific areas studied. Another study, Knopp et al. 2009, in two schools in an area that had received treatment (but perhaps not from SCI) found moderate prevalence of various STHs (21% prevalence for hookworm and low infection intensity). The schools were selected because they had been surveyed in 1994, when prevalence was found to be much higher. Uganda: We reviewed three studies of schistosomiasis prevalence: Muhumuza et al. 2013 was conducted in part of a district that seems to have received several rounds of treatment (but perhaps not from SCI). Brooker et al. 2005 was conducted across a district that had its first MDA the year before, which was funded by SCI. Standley et al. 2009 was conducted across six districts, one district that had never been treated (but from which only one school, which had low prevalence, was included in the analysis), two districts that seem to have been treated only once, and three districts that seem to have been treated for many years by SCI. Standley et al. 2009 explicitly aimed to "ambush" schools that might not have been reached by treatment programs.162 Each study found moderate to high prevalence of schistosomiasis (Muhumuza et al. 2013: 35%, Brooker et al. 2005: 28%, and Standley et al. 2009: 42%). Muhumuza et al. 2013 and Standley et al. 2009 found fairly high infection intensity (116 and 634 average eggs per gram respectively among positive cases; the WHO threshold for "high intensity" is 400 eggs per gram163). Muhumuza et al. 2013 found 28% coverage in the most recent round of treatment. The coverage survey in Muhumuza et al. 2013 seems to have been six months after treatment. Are there any negative or offsetting impacts? Concerns over whether treatment was sustained: We believe it is important that deworming programs are sustained over time, as re-infection is rapid and a one-time treatment may have little long-term effect.164 It is not clear to us the extent to which SCI-funded programs have succeeded in treating the same children multiple times, as opposed to simply treating the same areas multiple times (and thus treating different children once each).

We remain unsure about how many treatments are needed to impact health. SCI told us that its views on what groups should be treated and how often "is largely based [on] WHO recommendations, but also on government wishes and on intuition and common sense, though it usually works and SCI collects sufficient data to know when it isn't working. In general, in high endemicity areas re-infection is a major issue; in lower endemicity areas, a single treatment can be sufficient."165 One example of the variation in treatment patterns is what SCI told us about its program in Yemen:

SCI distinguishes between high, medium and low prevalence areas. In high prevalence areas, SCI treats the whole population once, and children for five years. In medium prevalence areas, SCI treats the whole population once, and children every other year. In low prevalence areas, SCI treats children every other year.166 Displacement of government funding for deworming: This could be a concern if, due to SCI's spending on national deworming programs, government funds that otherwise would have been spent on deworming are spent on other, less worthwhile budget items. In the past, SCI has largely supported programs that did not exist before its support.167 We have not seen data on government spending on NTDs before and after receiving SCI support. Ethiopia's Neglected Tropical Diseases Program Manager told us that the government had not dedicated funding to schistosomiasis and that without SCI's involvement the program would likely not have gone forward.168 Diversion of skilled labor: Drug distribution occurs only once or twice per year and appears to be conducted by teachers, community drug distributors (who receive minimal training to fulfill this role), and health center staff.169 Given the limited time and skill demands of mass drug distribution, we are not highly concerned about distorted incentives for skilled professionals. Popular discontent: We have heard a couple accounts of discontent in response to SCI's mass drug administration campaigns, including one case that led to riots.170 SCI notes that following episodes of popular discontent, it has worked with governments to improve public education about the programs.171 What do you get for your dollar? This section examines the data that we have to inform our estimate of the expected cost-effectiveness of additional donations to SCI.

Note that the number of lives significantly improved is a function of a number of difficult-to-estimate factors, many of which we discuss below. We incorporate these into a cost-effectiveness model which is available here.

We focus on the following questions:

What is the cost per schistosomiasis treatment? We estimate that on average the total cost of a schistosomiasis treatment delivered in SCI's programs is $1.26. Excluding the cost of drugs (which are often donated) and in-kind government contributions to the programs, we estimate that SCI's cost per treatment is $0.53. These estimates rely on a number of uncertain assumptions. How much impact do SCI's programs have (per child treated) compared with the ones on which the evidence for deworming's positive impact on life outcomes is based? Because the key deworming studies provided treatments in areas of unusually high prevalence, we believe that SCI's programs are likely to have less impact on a per-person basis. We have not seen complete treatment data on SCI's treatments in its 2015-16 budget year, so our cost per treatment analysis is based on earlier data. As discussed above, the information we have seen on SCI’s expenses prior to its 2015-16 budget year is limited and possibly unreliable. Similarly, we are not confident in the accuracy of the data we have seen on number treatments delivered. Given this, we make a number of assumptions and judgments in interpreting the data that we have seen and this could introduce errors (which could potentially overstate or understate the actual cost, though we generally try to conservatively err on the side of counting fewer treatments and more costs).

In 2014, SCI estimated its cost per treatment at $0.80.172 In October 2015, SCI estimated that after April 2016 its cost per treatment excluding costs for drugs and costs paid for by governments would generally be about $0.30.173 We are unsure how it calculated these estimates. In September 2015, SCI told us that it expects to improve its cost-effectiveness analysis by the end of the year.174 SCI shared updated cost per treatment estimates with us for a few country programs in early 2016, but we are also uncertain about how these estimates were produced.175

We discuss how the cost per treatment figure relates to how much it costs to improve a child's health and development at our report on mass treatment programs for schistosomiasis and STHs.

Our calculations and sources for our cost per treatment analysis are shown in more detail in this spreadsheet.

What is the cost per schistosomiasis treatment? Our approach Our general approach to calculating the cost per treatment is to identify comparable cost and treatment data and take the ratio. We prefer to have a broadly representative selection of treatments in order to mitigate possible distortions, such as using data from a new program, which may incur costs from advocacy, mapping, etc. before it has delivered any treatments.

It is our understanding that SCI generally intends to treat for STHs in all places where it treats for schistosomiasis, so the treatments SCI reports can generally be interpreted as combination schistosomiasis and STH treatments,176 though we are aware of several cases in which schistosomiasis-only treatments were delivered either by design or due to problems with implementation.177

To get the total cost, we attempt to include all partners (not just SCI) such that our cost per treatment represents everything required to deliver the treatments.178 In particular, we include these categories:

SCI’s funding to country programs (e.g. to fund drug delivery). SCI’s headquarter costs (e.g., for management and technical salaries), including an estimate of costs paid by Imperial College (e.g., office space and some legal and administrative expenses). Cost of drugs. We include the full market cost of all praziquantel that is needed to deliver the treatments, regardless of whether SCI purchased it or used donated drugs. Costs incurred by the government implementing the program (e.g. for staff salaries when working on treatment programs). SCI notes that cost per treatment calculations should include sensitivity analysis179 – analysis on the degree to which the cost per treatment varies when various assumptions vary. We have not yet completed such an analysis.

Our analysis We analyzed several sources of data, which cover different time periods, and developed several estimates, two of which we summarize here. Full details in this spreadsheet.

SCI’s recent programs: $1.26 per treatment. The ICOSA program (the name for SCI's DFID-funded work) covers eleven country programs and has been funded primarily by SCI’s first DFID grant, with additional funding from both restricted and unrestricted sources. We have seen data that we think provide a relatively comprehensive picture of spending and treatments over the first five years of the program (October 2010 - March 2015). We have not included the cost of research programs (which are funded separately) in these countries. It is possible that some of this research funding contributed to the treatments we are counting. A more conservative estimate, including about $1.8 million of research expenses in the same countries, is $1.32 per treatment. SCI’s early programs, adjusted for inflation: $1.76 per treatment. SCI previously shared with us a summary of the treatments it delivered and the costs it incurred during its early programs (from about 2003-2009). There is some ambiguity in the treatment data that we have interpreted conservatively (in other words, this estimate may be too high, as described in the footnote).180 Shortcomings of our analysis While we believe the estimate described above is reasonable, we want to highlight specific reasons to interpret it with caution.

We rely on reported treatment data. Our understanding is that these data can overstate treatments, so we have discounted this data (by 10%) based on the differences between reported treatment rates and treatment rates found in the coverage surveys discussed above (see footnote for why this is an imperfect comparison).181

We rely on an estimate that 30% of overall program costs are attributable to the government. We derived this from an analysis of a single program in Niger (this footnote elaborates on the details and concerns).182

We do not have data that indicate what proportion of drugs are wasted. We expect that in some cases drugs are purchased or donated but expire before use. We do not know how common this is. In our analysis, we have assumed that 10% of drugs are wasted, which increases the cost per treatment by about $0.05.

We do not have data on Imperial College's expenses that support SCI. Based on a conversation with SCI, we have roughly estimated this support as 10% of SCI's expenses (excluding drugs and government contributions).183

We simply estimate an average cost across programs and do not account for variations in different contexts. SCI told us that costs can vary significantly, for example, due to increased transportation costs in some contexts.184

Baseline infection status in SCI's deworming locations compared to key deworming study locations SCI's current and future programs may be less cost-effective than past programs or than programs discussed in our report on deworming because of lower baseline infection rates in current and future programs.

In 2014, SCI shared baseline data from countries it had recently started work in. We compare these rates to rates observed in the best evidence for the effectiveness of deworming, in order to understand how similar SCI's impact is likely to be to that observed in the studies. Schistosomiasis and STH prevalence and intensity in these countries was generally fairly low compared to the studies providing the best evidence for the benefits of deworming (Bleakley 2007, Croke 2014, and Miguel and Kremer 2004) and compared to some of SCI’s earlier prevalence and intensity studies (from Burkina Faso, Uganda, Niger, and Burundi).185

For the most part, baseline data was collected in schools that had been selected for prevalence and intensity studies. The baseline reports use methodologies that seem similar to the other SCI panel studies discussed above. With the exception of the study discussed above from Malawi, we have not examined how representative these schools are of the full treatment area or fully vetted the methodology used. For Ethiopia, we have used data collected during disease mapping and made several assumptions to make that data comparable to the data from other countries.186

In Malawi an error in data collection may have resulted in prevalence being underestimated.187 In Zanzibar, treatment has been ongoing,188 so the study does not reflect pre-treatment conditions.

Detailed results and sources in this spreadsheet.

Is there room for more funding? In short:

Funding SCI receives now will likely be allocated to its April 2017 to March 2018 activities. In April 2016, SCI allocated almost all of its available unrestricted funding to its current April 2016 to March 2017 budget year, so we do not expect that SCI currently has much funding available to allocate to its next budget year. Although SCI has room for more funding for its 2017-18 activities, we do not think that it is urgent to fill this funding gap. It is our understanding that SCI will plan its programs for its April 2017 to March 2018 budget year in February and March 2017, so it makes little difference whether SCI receives additional funding now or after our next update in November 2016. We have had challenges communicating with SCI about its room for more funding in the past, which caused us to substantially overestimate its room for more funding in November 2015. We have not asked SCI for a more recent update on its room for more funding. Available and expected funding SCI's current budget year began in April 2016 and will end in March 2017. It is our understanding that funding SCI receives during its current budget year is generally allocated to the next budget year.189 A donor giving funds to SCI now likely would not impact SCI's April 2016 to March 2017 activities, but would instead provide more funding for implementing SCI's April 2017 to March 2018 plans. It is possible that, if SCI received additional funding earlier in the 2016-2017 budget year, it might affect its discussions with partners and other preparations that could impact 2017-2018 and beyond; we have not discussed this possibility with SCI.

It is also our understanding that SCI currently has little unallocated unrestricted funding. As of May 2016, SCI told us that it was allocating all or nearly all of its available unrestricted funding (with the exception of funding SCI holds in reserve) to its 2016-17 budget year.190 At the time of this writing (June 2016) we would guess that SCI has received little funding that it can allocate to its 2016-17 plans since it is still early in its budget year. Absent a GiveWell recommendation, we expect that SCI would continue to receive some unrestricted funding from donors not influenced by GiveWell, but we have not attempted to estimate how much funding this would be.

Uses of additional funding in 2017-2018 We very roughly estimate that SCI has $10.1 million in room for more funding for its next budget year (between April 2017 and March 2018).191

For the reasons discussed above, we have not asked SCI for a more recent update on how it would use additional funding.

SCI notes that it allocates funding "to align with drug availability in country, capacity to deliver and ministry of health planned activities for the year."192

Sources of uncertainty In the past, changing circumstances have caused SCI to update its target treatment numbers and its own estimate of its room for more funding. For example, political unrest delayed the program in Côte d'Ivoire for 18 months,193 in 2014 SCI was not yet ready to allocate additional funds to Mozambique because of lack of confidence in the program's ability to scale further at that time,194 and the Ebola outbreak has delayed work in Liberia.195 Factors that can shift SCI’s planned uses of unrestricted funding include political unrest, expiring drug supplies, additional donated drugs becoming available, delays and budget changes due to coordination with other actors, results of disease mapping, and grants from other donors.196 As such, we do not place much weight on the preliminary room for more funding estimates for SCI's work in 2017-2018. SCI notes that estimates are refined in collaboration with ministries of health on a country by country basis between January and March each year.197

Communication with SCI about its room for more funding We have had challenges communicating with SCI about its room for more funding. In the past, our understanding was developed largely through conversations with SCI's leadership, supplemented with details from many other sources. In retrospect, our understanding of how SCI planned to use funds often did not match how SCI decided to allocate funds the next time it set program budgets.198

In October 2015, SCI sent us estimates of its room for more funding for its next three budget years.199 We later learned that these estimates did not include the full amount of restricted funding that DFID planned to provide, which caused us to overestimate its room for more funding for its 2016-2017 budget year in our November 2015 review.200

Global need for treatment There appears to be a substantial unmet need for schistosomiasis treatment globally.

SCI shared an unpublished World Health Organization (WHO) estimate of the number of school-aged children and adults who require treatment for schistosomiasis and those who received treatment in 2014. We do not have permission to publish this data, but we note that only a small portion of those who WHO believes need treatment received it in 2014.201

SCI as an organization Track record: SCI has consistently gotten national deworming programs to go through, as discussed above. We know fairly little about how effectively these programs have delivered treatments. Self-evaluation: SCI’s self-evaluation is strong compared to the vast majority of organizations we have considered. That said, this evidence is incomplete and has quite a few limitations. In addition, we have a significantly different perspective than SCI on the strength of the evidential case for deworming (see our 2012 post on deworming and the comments that follow it). Transparency: SCI has consistently been strong in its commitment to transparency. It has generally provided the information we’ve asked for and has never hesitated to share it publicly (unless it had what we felt was a good reason). It has allowed a lot of public dialogue that other charities may have been uncomfortable with. Communication: In the past, we have struggled to communicate effectively with SCI representatives, and noted that we lacked important and in some cases basic information about SCI's finances. Our communication with SCI about its finances has improved substantially in 2016. More on how we think about evaluating organizations at our 2012 blog post.

Sources Document Source Alan Fenwick, email to GiveWell, November 3, 2015 Unpublished Alan Fenwick, email to GiveWell, October 15, 2015 Unpublished Alan Fenwick, email to GiveWell, October 1, 2015 Unpublished Alan Fenwick, email to GiveWell, October 29, 2015 Unpublished Alan Fenwick, email to GiveWell, September 28, 2015 Source Alan Fenwick, SCI Director, conversation with GiveWell, October 14, 2014 Unpublished Alan Fenwick, SCI Director, conversation with GiveWell, October 15, 2014 Unpublished Alan Fenwick, SCI Director, email to GiveWell, November 24, 2014 Unpublished Alan Fenwick, SCI Director, phone conversation with GiveWell, February 16, 2011 Unpublished Alan Fenwick, SCI Director, phone conversation with GiveWell, September 15, 2011 Unpublished Alderman et al. 2006 Source (archive) Allen and Parker 2011 Source (archive) Allen and Parker 2012 Source (archive) Anna Phillips, SCI Country Program Manager for Burkina Faso and Niger, email to GiveWell, October 13, 2011 Source Benjamin 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