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             You are hereHome » Top Charities » The END Fund The END Fund – deworming program     FacebookTwitter>Print>Email                   Donate

  The END Fund's deworming program is one of our top-rated charities and we feel it offers donors an outstanding opportunity to accomplish good with their donations.

 More information: What is our evaluation process? 

 Published: November 2016 (Previous version here)

 Summary What do they do? The END Fund (end.org) manages grants, provides technical assistance, and raises funding for controlling and eliminating neglected tropical diseases (NTDs). We have only reviewed its programs that treat schistosomiasis and soil-transmitted helminthiasis (STH) ("deworming"); our recommendation is just for this part of the END Fund's work. (More)

 Does it work? We believe that there is relatively strong evidence for the positive impact of deworming. We have not seen compelling evidence that END Fund-supported programs (outside of programs we have separately vetted and recommended) have been effective at delivering deworming treatments. The END Fund has instituted a requirement that grantees conduct coverage surveys and the first results will be available in early 2017. (More)

 What do you get for your dollar? Deworming is generally very cost-effective. We have not performed an in-depth cost-effectiveness analysis of the END Fund's deworming programs. (More)

 Is there room for more funds? We believe the END Fund could substantially increase its deworming grantmaking with additional funds. We roughly estimate that it could use between $10 million (50% confidence) and $22 million (5% confidence) in 2017, in addition to secured funding and our guess about further fundraising. These estimates include some spending on NTD programs other than deworming due to fungibility across programs. (More)

 The END Fund's deworming program is recommended because:

 We consider deworming a priority program given the possibility of strong benefits at very low cost. (More) We believe the END Fund is able to absorb additional funds to start and scale-up deworming programs. (More) Concrete and credible plans for monitoring the quality of its programs in the future. Standout transparency – it has shared significant, detailed information about its programs with us. Major open questions include:

 Whether it will generate high-quality evidence that the programs it supports are reaching a high proportion of children targeted. (More) How cost-effective its programs are. In general we believe that deworming programs are highly cost-effective, but do not have data on this for the END Fund's programs specifically and do not know how its programs compare to other organizations working on deworming that we have reviewed. (More) How much the END Fund will raise (or would have been able to raise) for its priorities from other funders. We have less confidence in our understanding of this question for the END Fund than for our other top charities. (More) There are a number of other questions that we have not investigated in as much depth as for our other top charities. (Examples)  Table of Contents   Summary Our process What do they do?  The END Fund's role in deworming and other NTD programs Overview of spending Angola program spending breakdown   Does it work?  Are mass deworming programs effective when implemented well? Deprioritized questions Are programs targeted at areas of need? Are targeted children being reached? Have infection rates decreased in targeted populations? Does the END Fund cause deworming programs to start or scale up? Does the END Fund improve the quality of deworming programs? Are there any negative or offsetting impacts?   What do you get for your dollar?  What is the cost per deworming treatment in the Angola program?   Is there room for more funding?  Available and expected funds  Our estimate For comparison: cash on hand   Uses of additional funding  GiveWell's prioritization of the END Fund's funding gaps   Considerations relevant to assessing the END Fund’s room for more funding  Multi-year commitments Fungibility   Global need for treatment   END Fund as an organization Sources    Our process As we stated in our 2015 plans, we are interested in finding additional top charities that work on deworming. The END Fund applied to be a GiveWell top charity in 2015. To date, our investigation has consisted of:

 Conversations with END Fund staff. We have published notes from the following conversations: GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015 GiveWell's non-verbatim summary of a conversation with Ellen Agler and Sarah Marchal Murray, July 30, 2015 GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016Reviewing documents the END Fund shared with us. What do they do? The END Fund manages grants, provides technical assistance to programs, and raises funding for programs to control and eliminate neglected tropical diseases (NTDs), with a focus on soil-transmitted helminthiasis (STH), schistosomiasis, lymphatic filariasis, trachoma, and onchocerciasis.1 We focus this review on the END Fund's support for deworming (mass drug administration (MDA) targeting schistosomiasis and soil-transmitted helminthiasis), which we have identified as a priority program.2 

 The END Fund began supporting NTD programs in 2012.3 Through 2015, it had disbursed $22.2 million to NTD programs. By the end of 2016, it expected to have disbursed $34.1 million to programs in 24 countries.4 We do not know how much of this funding was used for deworming programs, but we know that 45% of the treatments that the END Fund reports being due to its funding (including projected treatments through the end of 2016) were STH treatments and 17% were schistosomiasis treatments.5

 The END Fund's implementing partners have included organizations we have conducted in-depth reviews of: the Schistosomiasis Control Initiative (SCI), Deworm the World Initiative, and Sightsavers.6 

 The END Fund's role in deworming and other NTD programs Surveying the global NTD landscape and choosing locations for programs: The END Fund told us that it conducts research on the global NTD landscape, including compiling information on where NTD treatment is needed, what work is being carried out by governments, NGOs, and other funders, and what capacity potential implementing partners have. It uses this information to decide where to fund programs.7 Making grants to create, scale up, or fill funding gaps for NTD programs: The END Fund told us that it makes grants to support several different types of programs, including new NTD programs in countries neglected by other donors, programs to scale up treatment coverage in countries with high NTD burdens, and established programs with small funding gaps.8 The END Fund's grantees include organizations with experience supporting NTD programs (including SCI, Deworm the World, and Sightsavers), organizations without experience implementing NTD programs that operate in areas in need of NTD treatments, and government agencies.9 Monitoring grantees' program operations: The END Fund asks grantees to provide program budgets, work plans, and target treatment schedules, and requires that grantees submit periodic progress reports during the implementation of the program.10 The extent of the END Fund's involvement in programs implemented by its grantees varies, and may include technical assistance from the END Fund.11 In 2016, the END Fund began requiring that most programs (including all large programs) conduct coverage surveys;12 the first results (other than those produced by organizations we conducted in-depth reviews of) are expected in early 2017.13 Raising funding for NTD programs: The END Fund told us that it actively engages with donors and philanthropic foundations (including those without previous involvement with NTDs) to raise funding for NTD programs.14Overview of spending Through the end of 2015, the END Fund had disbursed a total of $22.2 million to NTD programs and expected to disburse an additional $11.9 million in 2016.15

 Countries Total disbursed through 2015 or expected to be disbursed in 2016 (USD millions) % of total Ethiopia 6.58 19% Angola 5.44 16% Democratic Republic of Congo 4.08 12% Nigeria 3.13 9% Mali 2.04 6% Rwanda 1.63 5% Zimbabwe 1.50 4% Kenya 1.50 4% Zambia 1.16 3% Sudan 1.00 3% Yemen 0.92 3% Cote d'Ivoire 0.78 2% India 0.78 2% Namibia 0.59 2% South Sudan 0.42 1% Tanzania 0.32 1% Central African Republic 0.24 1% Liberia 0.18 1% Burundi 0.11 0% Chad 0.10 0% Somalia 0.07 0% Niger 0.06 0% Mauritania 0.05 0% Guinea Bissau 0.01 0% Other 1.45 4% Total 34.14 100% We do not know how much funding has been committed or disbursed for deworming programs specifically. With the exception of the grant to the program in Angola (details below), we have not seen breakdowns of in-country spending.

 The END Fund's expenses other than grantmaking (program support, management, fundraising, and other general expenses) accounted for about 25% of its total spending in 2014-2015.16 

 Angola program spending breakdown The END Fund provided us with detailed documentation on its grant to support an NTD program in Angola (its largest grant commitment at the time of this exchange) as an example of its work; we have not yet requested similar documentation for the END Fund's other grants.17

 The END Fund's five-year grant to the MENTOR Initiative was intended to support NTD-prevalence mapping (of soil-transmitted helminthiasis, schistosomiasis, and lymphatic filariasis) in three provinces in Angola, school and community-based mass drug administration, and a school-based handwashing education program. (Lymphatic filariasis mapping was not completed.)18

 We have seen a breakdown of the MENTOR Initiative's spending by activity and by expenditure category for the first two years of the program (April 2013 – March 2015):19

 The MENTOR Initiative, spending breakdown by activity, April 2013 - March 2015

 Program activity Spending % of total spending Program Management and Administration $873,013 43% NTD Mapping $291,046 15% Training and Workshops $247,586 12% Supervision $214,577 11% Mass Drug Administration $195,947 10% NTD Capacity Building $99,034 5% IEC/ACSM20  $33,330 2% Water, sanitation, and hygiene $32,329 2% Assessments and Surveys $19,803 1% Support to Health Facilities $275 0% Total $2,006,940 100% The MENTOR Initiative, spending breakdown by expenditure category, April 2013 - March 2015

 Expenditure category Spending % of total spending Human Resources $642,620 32% Infrastructure and Other Equipment $357,975 18% Planning and Administration $284,504 14% Training $234,702 12% Overheads $171,001 9% Technical Assistance $102,814 5% Health Products and Health Equipment $69,686 3% Procurement and Supply Management Costs $67,207 3% Monitoring and Evaluation $53,651 3% Communications Materials $22,734 1% Living or Other Support to Beneficiary Population(s) $46 0% Total $2,006,940 100% The END Fund also provided more detail on the expenditures included in the above categories.21

 Our understanding is that the mass drug administration in the MENTOR Initiative's spending breakdowns refers to two rounds of school-based MDA: one round of albendazole in October and November 2013 for the treatment of STH and one round of praziquantel in November 2014 for the treatment of schistosomiasis (albendazole was unavailable during the November 2014 distribution).22 

 Does it work? END Fund-supported mass deworming programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective.23

 We are uncertain overall about the proportion of targeted children reached through the program. We have not seen the types of monitoring from END Fund-supported programs that have increased our confidence in similar programs conducted by Deworm the World, SCI, and Sightsavers. 

 It seems plausible to us that the END Fund has an impact by causing deworming programs to start. The END Fund may also have a positive impact on deworming programs by providing non-monetary assistance to its grantees, but we have not investigated this question in depth.

 Note that, in this section, we exclude the END Fund's grants to support other organizations that work on deworming that we have separately reviewed (Deworm the World, SCI, and Sightsavers) because we see END Fund's value added as identifying and supporting opportunities that we have not identified through other means. 

 Details follow.

 Are mass deworming programs effective when implemented well? We discuss the independent evidence for deworming programs extensively in our intervention report. 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 may be important differences between the type and severity of worm infections in the places where the END Fund supports programs and the places where the key studies on improved life outcomes from deworming took place. More below.

 Deprioritized questions Our other reviews of organizations that work on deworming have gone into more depth on a number of questions. Questions we have not yet attempted to answer in-depth about the END Fund include:

 Are END Fund programs targeted at areas of need? For other groups we have asked for evidence of baseline infection rates, in order to compare expected impact in their programs to the impact found in the locations we discuss in our deworming evidence review. The END Fund shared some information on this question from Angola, Namibia, and Democratic Republic of the Congo (discussed below); we have not requested this information from the END Fund for other countries. We have not asked for details of how programs have operated; for example, what portion have been school-based or community-based, or how many treatments per year children receive (including through lymphatic filariasis programs). We discuss some details for an END Fund-supported program in Angola in our interim review. What would have likely happened in the END Fund's absence? Did programs exist prior to the END Fund's involvement? Did the END Fund cause the program to reach greater scale than it otherwise would have? Is there evidence that the END Fund improved the quality of programs? We discuss some limited information for an END Fund-supported program in Angola below. Are programs targeted at areas of need? In general, mass deworming programs treat everyone in a targeted demographic, regardless of whether each individual is infected (more), so the benefits (and therefore the cost-effectiveness) of a program are highly dependent on the baseline prevalence of worm infections. The END Fund told us that it only supports programs where the disease prevalence requires treatment according to World Health Organization (WHO) standards (which we have summarized in the table below).24 

 Summary: WHO recommended deworming treatment for school-aged children25

  Category Prevalence Recommendation STH High-risk Over 50% Twice a year treatment STH Low-risk 20-50% Annual treatment Schistosomiasis High-risk Over 50% Annual treatment Schistosomiasis Moderate-risk 10-50% Treatment once every two years Schistosomiasis Low-risk Under 10% Treatment twice during primary school In Angola, mapping conducted in 2013-2014 assessed the prevalence of schistosomiasis and STH in three provinces (Huambo, Uíge, and Zaire). The table below summarizes these results (in all three provinces, results note that "[schistosomiasis] distribution [was] moderate and focalized.")26

 Angola: Prevalence of schistosomiasis and STH in 3 provinces (2013-2014)27

  Huambo Uíge  Zaire Schistosomiasis 23.4% 14.1% 17.6% STH (Hookworm) 0.1% 16.8% 4.8% STH (Ascaris) 11.5% 49.2% 17.6% STH (Trichuriasis) 1.0% 7.9% 3.3% The MENTOR Initiative described using these mapping results and WHO's guidelines to create an MDA treatment strategy for the third year of the Angola program.28

 These baseline prevalence figures are roughly similar to the figures for some of SCI's and Deworm the World's programs, but lower than the prevalence from studies providing the best evidence for the benefits of deworming (SCI discussed here and Deworm the World discussed here).29 We have not closely vetted the methodology used for the mapping studies and note that in some cases mapping studies are not directly comparable to baseline prevalence surveys. The mapping studies in Angola do not appear to have measured infection intensity.

 The END Fund also shared mapping data from Namibia and Democratic Republic of the Congo. We have not tried to determine how this data relates to END Fund-supported treatment programs or summarized the results here.30

 Are targeted children being reached? The END Fund recently began requiring that the programs it supports (excluding ones that receive only limited support) conduct coverage surveys to determine what portion of targeted children receive and ingest pills.31 It expects results to begin to be available in late 2016 and early 2017.32 It expects summary results to be public;33 it isn't clear to us whether the full details will be available to the public or to us.

 We think there are reasons to be cautious about putting weight on an organization's plans for monitoring and evaluation. We have seen a number of cases where an organization had plans to implement new monitoring and evaluation and these plans were then changed or delayed. In addition, the details of how monitoring is carried out are very important to our view of the results (see the discussion in this blog post, for example).

 In the END Fund's case, these concerns are mitigated somewhat by:34

 The END Fund's plans are relatively specific and short-term. The END Fund gave us a list of 11 programs in 8 countries and told us that "coverage surveys for most of these programs will be carried out between November 2016 and early 2017." We are familiar with deworming program coverage surveys from our research on other organizations and were able to ask the END Fund specific questions about how the surveys will be carried out. The END Fund's answers were fairly detailed. Details in these conversation notes. Have infection rates decreased in targeted populations? A type of evidence that would increase our confidence in a deworming program is measurements of infection rates before the program starts and following one or more rounds of MDA.35 Our impression is that this type of evidence is more expensive to collect and more complex methodologically, so we've largely relied on coverage surveys (discussed in the previous section) to evaluate organizations' track records.

 We have not seen this type of evidence from the END Fund and our understanding is that the END Fund has not collected this type of evidence from its grantees.

 Does the END Fund cause deworming programs to start or scale up? We have not attempted to answer this question in-depth. It is our understanding from discussions with other groups that fund deworming programs that it is rare for governments to allocate their own funding to national-scale deworming programs,36 so our guess is that in many places where END Fund has provided funding for a new program, this program would not have happened without this support.

 We have some limited information for an END Fund-supported program in Angola. It seems likely to us that the deworming program in three provinces in Angola would not have occurred in the absence of the END Fund. The END Fund noted that its early activities in Angola included approaching the government of Angola about an MDA program, raising funding from Dubai Cares and the Helmsley Trust to support the program, and approaching and partnering with the MENTOR Initiative to implement the program (which had no previous involvement with deworming programs).37 The END Fund also told us that it believes that the Angola program would not have occurred without its involvement.38 

 Does the END Fund improve the quality of deworming programs? The END Fund's grant management process (including requiring periodic progress reports from implementing organizations and providing technical guidance on implementation issues) may improve the quality of deworming programs, but we have not investigated this question in depth.39

 Are there any negative or offsetting impacts? Administering deworming drugs seems to be a relatively straightforward program.40 We have not looked closely into negative or offsetting impacts of programs the END Fund supports. We discuss possible negative or offsetting impacts of other deworming programs in our intervention report on deworming, and in previous reviews of deworming charities.41 From the information we have reviewed, we have not seen any significant concerns unique to the END Fund. We discuss several potential issues that could reduce the effectiveness of some treatments below:

 Drug quality: For example, if drugs are not stored properly they may lose effectiveness or expire. Dosage: If the incorrect dosage is given, the drugs may not have the intended effect and/or children may experience additional side effects. Concerns over whether treatment is 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.42 Replacement of government funding: We have limited information about whether governments would pay for the parts of the program paid for by the END Fund in its absence. We also have little information about what governments would use deworming funds for if they did not choose to implement deworming programs. Diversion of skilled labor: Drug distribution occurs only once or twice per year and is conducted by volunteers in communities or teachers in schools. Given the limited time and skill demands of mass drug distribution, we are not highly concerned about distorted incentives for skilled professionals. Planning for the program can take senior government staff time; we are not sure what these staff would spend their time on in the absence of deworming programs, but suspect that they would support other education or health initiatives. Adverse effects and unintended consequences of taking deworming drugs: Our understanding is that expected side effects are minimal and there is little reason to be concerned that drug resistance is currently a major issue (more information from our report on deworming). We are somewhat more concerned about potential side effects during integrated NTD programs, since multiple drugs are taken within a short time period, but it is our understanding that organizations follow protocols to space out the treatments to sufficiently avoid adverse effects.43 Popular discontent: We have heard a couple of accounts of discontent in response to mass drug administration campaigns, including one case that led to riots.44 While the accounts we have heard are from programs supported by the Schistosomiasis Control Initiative, we think it is possible that other deworming programs could cause similar discontent. What do you get for your dollar? Deworming is potentially very cost-effective. 

 We have not evaluated the cost-effectiveness of the END Fund's support for deworming programs at a level of detail that is comparable to our other top charities. In this section, we primarily focus on the END Fund-supported program in Angola, the program for which we have seen detailed documentation. 

 What is the cost per deworming treatment in the Angola program? For the first two rounds of MDA of the END Fund-supported program in Angola (October-November 2013 and November 2014), we estimate that the cost per deworming treatment was $1.55.45 A few notes on this estimate:

 We have not examined the inputs into this estimate as closely as we have for our other top charities. The estimate excludes the Angolan government's costs and the value of donated drugs and teachers' time administering the drugs. We have included these costs in our cost per treatment estimates for SCI and Deworm the World. It is our understanding that the costs include program start-up costs, so it is possible that cost per treatment will fall in the future. We are unsure if the past cost per treatment of the deworming program in Angola is representative of the END Fund's other work. Is there room for more funding? We estimate that the END Fund could productively use between $10 million (50% confidence) and $22 million (5% confidence) in the next year to expand its work on deworming. By our estimation, about a quarter of this would be used to fund other NTD programs (see below).

 In short, we calculate this from (more details in the sections below and in this spreadsheet):

 Total opportunities to spend funds productively: We roughly estimate that the END Fund could productively spend between $22.2 million (50% confidence) and $34 million (5% confidence) in 2017. Estimated funds available: We roughly guess that with additional fundraising, the END Fund will have $12.1 million total for 2017. This is consistent with the END Fund's secured and committed funds as of October 2016: the END Fund projects that, without further revenue or commitments, it will have $8.3 million for 2017. More details follow, as do discussions of (a) our decision to not include funding for multi-year commitments in the estimate of room for more funding, and (b) fungibility—our expectation that a portion of funds given, regardless of whether they are restricted to deworming, will effectively fund other NTD programs.

 Available and expected funds Our estimate As a very rough guess, we assume that the END Fund will raise the average of what it raised in 2014 and 2015 so that it will have a total of $12.1 million to spend in 2017, of which $9.2 million will be available for grants to programs (assuming END Fund continues to spend 76% of expenses on grants as it did in 2014-2015).46 Note that this estimate is derived from data on past revenue rather than the information the END Fund shared with us about cash on hand, but is consistent with the latter (see next section). 

 For comparison: cash on hand The END Fund projects that, without further revenue or commitments, it will have $6.1 million in cash on hand or committed revenue available for making grants in 2017,47 of which $2 million is restricted to schistosomiasis and STH programs, $1.5 million is restricted to onchocerciasis programs, and the rest is unrestricted or with very broad restrictions.48 It also has $2.2 million to support its other costs in 2017,49 bringing the total to $8.3 million.

 It has told us that it is not able to project how much additional revenue it will raise,50 and that the plausible possibilities range from no additional funding to fully filling its funding needs.51 This is consistent with its short history of annual revenues for which there has not been a clear trend (growth rates over the last three years were 62%, 120%, and -21%, respectively52).

 Uses of additional funding We have broken down the END Fund's future spending into three categories and estimated each:

 Deworming grant-making: The END Fund provided a list of 24 grants it would like to make to schistosomiasis/STH programs totaling $13.3 million. Excluding grants that we have included in our room for more funding estimates for Deworm the World, SCI, and Sightsavers, the other deworming organizations we recommend (which the END Fund also funds), the list totals $11.7 million.53 In addition, the END Fund told us that it identifies additional opportunities on an ongoing basis and, in 2017, would likely have more opportunities than were in the list it provided us.54 Other NTD grant-making: We roughly estimate that the END Fund made $6.5 million worth of grants to support treatments for NTDs other than deworming in 2016.55 Assuming that, if it received a large increase in funding designated for deworming, the END Fund would continue to support, with unrestricted funds, other NTD programs at the same level in 2017 as it did in 2016, the END Fund will have $18.2 million in grant opportunities (not including new opportunities it might identify over the course of the year). Non-grant-making costs: The END Fund estimates that it will need $4 million to support its central costs in 2017, bringing the total budget to $22.2 million.56 Note that above we estimated that at expected levels of funding (i.e., without GiveWell-influenced funding), the END Fund would spend $2.9 million on central costs. The difference may be due to the roughness of our assumptions and/or to the END Fund projecting higher central costs in the scenario in which it had a larger grantmaking budget (e.g., with substantial GiveWell-influenced funding). GiveWell's prioritization of the END Fund's funding gaps We have broken down our our top charities' funding gaps and ranked them based on:

 Capacity relevance: how important the funding is for the charity's development and future success. Execution relevance: how likely the charity's activities will be constrained if it does not receive the funding. We believe that "capacity-relevant" gaps are the most important to fill, and "execution"-related gaps vary in importance. More explanation of this model is in this blog post. 

 In the table below, we have not ranked any of the funding gaps "capacity relevant" because we do not see a strong case that filling those gaps would increase our confidence in the END Fund's performance (we expect that additional confidence will largely come from following the END Fund's work over time and that it will have sufficient funding to maintain some grantmaking in 2017) or would have an outsized impact on unlocking additional funding opportunities in the near future. 

 We consider the funding gaps to be "execution" gaps and assign them a level (1, 2 or 3) by how likely we believe it is that the END Fund would be constrained by funding (rather than other factors, such as available grantmaking opportunities) if it is unable to fill the funding gap. Level 1 is 50% chance of funding being the constraint, level 2 is 20% chance, and level 3 is 5% chance. These judgments are rough and largely based on a) what the END Fund has told us about the opportunities it has identified to date and b) caution given our limited history of following the END Fund's work and our expectation of providing funding to other deworming groups, which might reduce the END Fund's ability to identify additional grantmaking opportunities.

 Note that the END Fund told us that, if it were not funding constrained, it would have a 75% chance of being able to make, by November 2017, $8 million more in grants for deworming than the opportunities it had identified as of October 2016.57 This may indicate that we have been overly cautious in our estimates, detailed above, of its ability to scale. But note that this does not take into account the possibility that GiveWell-influenced donors may fund other deworming groups, leaving fewer deworming opportunities for the END Fund to fund.

 Our estimates of the END Fund's execution gaps (includes central costs of $4 million):

 Opportunity Total additional cost (millions USD) Cumulative funding need (millions USD) GiveWell's prioritization Possible deworming grantmaking that END Fund has identified as of Oct. 2016 and maintaining non-deworming grantmaking 22.2 10.1 Execution level 1 50% more deworming grantmaking 5.9 16.0 Execution level 2 100% more deworming grantmaking 5.9 21.8 Execution level 3 Total 34.0 21.8  For execution level 1, our model assumes that 67% of marginal funding will be spent on deworming grant-making, 23% on other NTD grant-making, and 10% on non-grant-making expenses.58

 Considerations relevant to assessing the END Fund’s room for more funding Multi-year commitments Other organizations we have talked to about funding their work on deworming have told us that it is helpful to have enough funding at the start of a project for more than one year because governments typically ask for multi-year commitments. Our understanding is that governments make this request because a) deworming programs must be sustained over time to cause the desired impacts and b) governments want assurance that support will be sustained so that they can better plan how to use their funding.59 We have incorporated multi-year funding into our room for more funding estimates for these groups.

 We have not incorporated multi-year funding into our room for more funding estimate for the END Fund, because the END Fund told us that it does not commit multi-year funding up front for a grantee's program. It signs multi-year agreements with some grantees in which they agree that the program will be reviewed annually to determine whether the END Fund will renew support. There are cases where donors have committed to providing the END Fund with several years of support for a program. Our understanding is that, when using unrestricted funds, the END Fund raises funding for programs each year rather than setting aside funding for future years up front.60

 We are unsure whether this is a better approach than setting funding aside for multi-year grants, but have chosen to express the END Fund's room for more funding consistent with how it would likely use funds.

 Fungibility Roughly half of the treatments the End Fund supported or expected to support in 2016 were deworming treatments. The others were treatments for lymphatic filariasis, onchocerciasis, and trachoma.61

 Of the $6.1 million that the END Fund expects to have on hand or committed for grantmaking in 2017, $2 million is restricted to deworming, $1.5 is restricted to onchocerciasis, and $2.6 million is unrestricted.62 The END Fund told us that the portion of its funding that has been restricted and unrestricted has varied over its short history; most recently at the end of 2015, about 90% was unrestricted.63 Therefore, our best guess is that the majority of the additional funding it raises will be unrestricted.

 Because the END Fund will likely have a pool of unrestricted funds to reallocate across NTDs, we would guess that a dollar to the END Fund for deworming will not result in an increase in deworming funding by a full dollar; that some of that dollar will support other NTD programs. We have not yet fully evaluated these other NTD programs, but our initial read of the evidence is that they are likely less cost-effective than deworming. 

 We have guessed that in order to fully fund the END Fund's deworming work that we have classified as execution level 1, it is also necessary to assume that some funding will be used to support other NTD programs.

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

 In 2016, WHO released a report on 2015 treatments stating that:64

 63% of school-age children in need of treatment were treated for STH in 2015. This is a large increase over WHO's report for 2014, which reported 47% coverage.65 42% of school-age children in need of treatment were treated for schistosomiasis in 2015. We have not vetted this data.

 END Fund as an organization We have spent significantly less time investigating the END Fund and have substantially less insight into its activities and track record than we do for our other top charities. As such, we have a limited view on the qualities below.

 Track record: The END Fund made its first grants in 2012 and has a fairly limited track record. Self-evaluation: The END Fund has not, in our opinion, demonstrated a track record of evaluating its work. The END Fund has told us about its plans for doing more evaluation in the future,66 which, if implemented well, will be similar to the monitoring we have seen from SCI and Sightsavers. Communication: We have not spent as much time communicating with the END Fund as we have with the charities we have recommended for several years. To date, the END Fund has generally communicated fairly clearly with us. Transparency: The END Fund is very transparent. It has not hesitated to share information publicly (unless it had what we felt was a good reason). More on how we think about evaluating organizations in our 2012 blog post.

 Sources Document Source Allen and Parker 2011 Source (archive) Ellen Agler, Chief Executive Officer, email to GiveWell, October 14, 2016 Unpublished END Fund 2012 Financial Summary Source (archive) END Fund 2013 Financial Summary Source (archive) END Fund 2014 Financial Summary Source (archive) END Fund Aggregate Portfolio Figures 6 May 2014 Source END Fund Aggregate Portfolio Figures 9 Sept 2014 Source END Fund Aid Memoire notes from Mentor Angola meeting Redacted 2 July 2015 Source END Fund Angola MENTOR Annex 1 - Organizational chart 2015 Source END Fund Angola MENTOR Annex 2 - List of Partners 2015 Source END Fund Angola MENTOR Annex 3 - Huambo Mapping Report 9 October 2014 Source END Fund Angola MENTOR Annex 3 - Uige Mapping Report 20 October 2014 Source END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014 Source END Fund Angola MENTOR Annex 5 - Huambo Workplan September 2014 Source END Fund Angola MENTOR Annex 5 - Mentor Angola P6 Periodic Reporting and Cash Request, 31 Oct 2014 Source END Fund Angola MENTOR Annex 5 - MENTOR Workplan Yr2-S2 With targets 2015 Source END Fund Angola MENTOR Annex 6 - Justification - BNA regime 2015 Source END Fund Angola MENTOR Annex 6 - Justification - Fuel taxes 1 Oct 2014 Source END Fund Angola MENTOR Annex 8 - Human Interest Story Interview-Zaire July 2014 Source END Fund Angola MENTOR Annex 8 - Human Interest Story Uige March 2014 Source END Fund Angola MENTOR Annex 9 - Training photo 2015 Source END Fund Angola MENTOR Cost Share 2014-2015 Source END Fund Angola MENTOR Cronograma Oct 2014 Source END Fund Angola MENTOR Initiative USAID audit report 2009 Source END Fund Angola MENTOR Initiative USAID audit report 2010 Source END Fund Angola MENTOR Initiative USAID audit report 2011 Source END Fund Angola MENTOR M173 Abbreviated Accounts 2011 Source END Fund Angola MENTOR M173 Accounts 2009 Source END Fund Angola MENTOR M173 Accounts 2010 Source END Fund Angola MENTOR MDA Training of Area Coordinators, Uige Roleplaying 2, 21 Oct 2014 Source END Fund Angola MENTOR MDA Training of Area Coordinators, Uige Roleplaying, 21 Oct 2014 Source END Fund Angola MENTOR MDA Training of Area Coordinators, Uige Sample for Distribution 22 Oct 2015 Source END Fund Angola MENTOR MDA Training of Trainer, Uige 22 Oct 2014 Source END Fund Angola MENTOR MDA Training of Trainer, Uige Microplaning 22 Oct 2014 Source END Fund Angola MENTOR MDA Training of Trainer, Uige Rulers in the making 2, 22 Oct 2014 Source END Fund Angola MENTOR MDA Training of Trainer, Uige Rulers in the making 3, 22 Oct 2014 Source END Fund Angola MENTOR MDA, Uige October November 2014 12, 28 Oct 2014 Source END Fund Angola MENTOR MDA, Uige October November 2014 13, 29 Oct 2014 Source END Fund Angola MENTOR MDA, Uige October November 2014 14, 31 Oct 2014 Source END Fund Angola MENTOR MDA, Uige October November 2014 3, 06 Nov 2014 Source END Fund Angola MENTOR MDA, Uige Praziquantel Arriving, Inside the Truck, 22 Oct 2014 Source END Fund Angola MENTOR P6 Periodic Reporting and Cash Request Template 31 Oct 2014 Source END Fund Angola MENTOR P7 150126 MDA report November 2014 Source END Fund Angola MENTOR P7 Annex 1 - NTD treatment strategies Y3 updated, 2015 Source END Fund Angola MENTOR P7 Annex 10 - Human Interest Story Huambo November 2014 Source END Fund Angola MENTOR P7 Annex 2 - Bios new personnel, 2014 Source END Fund Angola MENTOR P7 Annex 3 - Mentor AO organogram International staff- Jan 2015 Source END Fund Angola MENTOR P7 Annex 4 - Mentor AO Organogram NTD provincial - Jan 2015 Source END Fund Angola MENTOR P7 Annex 5 - MENTOR Workplan Yr2-P8, 2015 Source END Fund Angola MENTOR P7 Annex 6 - Report Narrative Jan 2015 Source END Fund Angola MENTOR P7 Annex 7 - List of Partners, 2015 Source END Fund Angola MENTOR P7 Annex 8 - Human Interest Story MDA PZQ Zaire 4 November 2014 Source END Fund Angola MENTOR P7 Annex 9 - Human Interest Story Uige October 2014 Source END Fund Angola MENTOR P7 Budget Summary 02 April 2014 Source END Fund Angola MENTOR P7 Periodic Reporting and Cash Request 31 Dec 2014 Source END Fund Angola MENTOR P7 Periodic Reporting and Cash Request 31 Dec 2014 - 24 Feb 2015 Source END Fund Angola MENTOR P7 Periodic Reporting and Cash Request-signed, 31 Dec 2014 Source END Fund Angola MENTOR P7 Tecnicos aumentam conhecimentos 28 Oct 2014 Source END Fund Angola MENTOR Planificacao DMM 2015 Source END Fund Angola MENTOR Proposal, Budget Draft Year 3, V10, 25 March 2015 Source END Fund Angola MENTOR Proposal, Budget Draft Year 4, V4, 25 March 2015 Source END Fund Angola MENTOR Proposal, Budget narrative with comments, Year 3, Redacted 2015 Source END Fund Angola MENTOR Proposal, Budget Simulation Years 2-5, 25 March 2015 Source END Fund Angola MENTOR Proposal, HR Analysis 2015 Source END Fund Angola MENTOR Proposal, Performance Assessment Framework Year 3, 24 March 2015 Source END Fund Angola MENTOR Proposal, proposal strategy with comments Years 3-5, Redacted 27 March 2015 Source END Fund Angola MENTOR Proposal, Workplan Year 3, 24 March 2015 Source END Fund Angola MENTOR Representation Letter, 21 Sept 2012 Source END Fund Angola MENTOR Revised Plan, Budget draft Year 3, V16, 21 April 2015 Source END Fund Angola MENTOR Revised Plan, Budget narrative, Year 3, V8, Redacted 2015 Source END Fund Angola MENTOR Revised Plan, Budget Summary Years 3-4, 22 April 2015 Source END Fund Angola MENTOR Revised Plan, Performance Assessment Framework Year 3, 23 April 2015 Source END Fund Angola MENTOR Revised Plan, Proposal, 22 April 2015 Source END Fund Angola MENTOR Revised Plan, Workplan Year 3, 3 April 2015 Source END Fund Angola MENTOR, cover letter for level 3 projects, 21 Sept 2012 Source END Fund Angola Program Log 2015 Source END Fund Angola Program Partnership Agreement signed 17 April 2014 Source END Fund Angola Trip Report Final Redacted October 2014 Source END Fund Angola trip report Redacted June 2014 Source END Fund Annex A Standard Terms and Conditions v3 2014 Source END Fund Annex B Angola Program Assessment Framework 2015 Source END Fund Annex B Program Assessment 2 Years Template 2015 Source END Fund Annex C Angola Budget Summary 2015 Source END Fund Annex C Budget Summary Template 2015 Source END Fund Annex D Communications and Branding Guidelines 2015 Source END Fund Close Out Letter Example from India 2014 Source END Fund document flow chart through process of granting 2015 Source END Fund DRC mapping - final report Source END Fund DRC mapping, 2014 Source END Fund Due Diligence Program Analysis Scoresheet 2015 Source END Fund Due Diligence Program Analysis Tool 2007 Source END Fund Grant Tracking 2015 Source END Fund Information for GiveWell, 2016 Source END Fund MENTOR Program Assessment Tool Worksheet Redacted 2015 Source END Fund MENTOR Scoresheet 2015 Source END Fund MENTOR, NTD Budget 14 Oct 2012 Source END Fund MENTOR, NTD Budget Narrative 14 Oct 2012 Source END Fund MENTOR, NTD Proposal 14 Oct 2012 Source END Fund Namibia mapping - Phase 1 report Source END Fund Namibia mapping - Phase 2 report Source END Fund Narrative Periodic Reporting Template 2015 Source END Fund Periodic Reporting and Cash Request Worksheets 2015 Source END Fund Program Close Out Check List 2015 Source END Fund Program Partnership Agreement version 3 2014 Source END Fund Program Process Overview 2015 Source END Fund Proposal Application Template 2015 Source END Fund Visit Plan Options 2015 Source GiveWell's non-verbatim summary of a conversation with Ellen Agler and Sarah Marchal Murray, July 30, 2015 Source GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015 Source GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016 Source GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016 Source SCI Malawi coverage survey 2012 Source Summary of END Fund financial information (October 2016) Source 1. "The END Fund works to control and eliminate neglected tropical diseases (NTDs). This work includes, but is not limited to, deworming initiatives. The END Fund is aligned with the London Declaration on Neglected Tropical Diseases, which was launched in January 2012 and aims to eliminate or control 10 neglected diseases by 2020. The END Fund’s portfolio currently covers the five most common NTDs that, together, cause up to 90% of the NTD burden in sub-Saharan Africa." GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015 "The END Fund focuses on tackling the five most prevalent NTDs: intestinal worms, schistosomiasis, lymphatic filariasis, trachoma, and river blindness - all of which can be treated by medicines generously donated by pharmaceutical companies for national mass drug administration programs." @END Fund website, What we do@ "Intestinal worms, or soil-transmitted helminths (STH), are the most common NTDs worldwide. STHs are caused by a group of parasitic worms, most commonly hookworm, roundworm (ascariasis) and whipworm (trichuriasis) that are either transmitted through contaminated soil or by ingesting parasite eggs." @END Fund website, Intestinal worms@ "Onchocerciasis (also known as river blindness) is an eye and skin infection that is caused by a parasitic worm (onchocerca volvulus), transmitted by the bite of a black fly that lives and breeds on the banks of fast-flowing rivers and streams." @END Fund website, River blindness@ "The END Fund, in collaboration with government partners and non-governmental organizations on the ground, treats NTDs by following a proven implementation model that is tailored to meet the needs of individual countries. Successful implementation involves understanding the scale of the problem and designing a robust MDA campaign targeted to reach and treat the right people. It is a process that catalyzes resources, builds capacity among health professionals, and mobilizes communities to distribute medicines for maximum impact at minimal cost." @END Fund website, Our strategy@ GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015: "The END Fund also aims to increase capacity of existing non-governmental organizations (NGOs) working on NTDs and expanding the field of organizations working on NTDs by giving direct grants and working with ministries of health and local and international NGOs. When the END Fund re-grants to another program, it is often involved in programming design." "The END Fund aims to increase the number of philanthropies that work on NTDs. It often starts conversations with people and organizations that aren’t currently engaged in the field." "The END Fund is always looking to find donors who might be interested in the NTD opportunities that it has identified."  2. We have not completed up-to-date intervention reports for the other NTD programs the END Fund supports; our published intervention report on lymphatic filariasis is outdated (as of October 2016).

  3. Beneficiaries of programs reported beginning in 2012 in END Fund Aggregate Portfolio Figures 9 Sept 2014, "Beneficiaries" sheet.

  4. END Fund Information for GiveWell, 2016, sheet "Updated Program Financing."

  5. END Fund Information for GiveWell, 2016, sheet "Treatments by Disease."

  6. END Fund Information for GiveWell, 2016, sheet "Updated Program Financing."

  7. GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015:

 "The END Fund works to identify the highest need NTD areas globally and then attempts to address the gaps where there is high burden and little available treatment." "Ms. Agler and Mr. Lancaster spend a lot of their time surveying the evolving landscape of NTD prevalence and related philanthropic, governmental, and NGO activity." "END Fund staff members are constantly researching opportunities where additional philanthropic dollars would make a difference and where the END Fund could ensure additive coverage. The END Fund asks: Is there a need? Is the need sufficient to justify treatment? Does the implementing partner have the capacity to meet results (i.e., reducing prevalence and intensity of infection) within the timeline?"  8. GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015:

 "The END Fund is interested in the following kinds of opportunities: Ensuring additive coverage in high burden countries – E.g., Nigeria, Ethiopia, and the Democratic Republic of the Congo (DRC). There are opportunities to scale up coverage in these countries because many people aren’t getting treated and there are possible implementing partners already on the ground. The END Fund spends a lot of time looking into these opportunities. Providing coverage in “orphan countries” with few donors and local partners – E.g., Angola, the Central African Republic, and South Sudan. Investing in specific projects that have a potential high return on investment: For example, the END Fund has been working with the Zimbabwean government on a school-based deworming campaign because it may be especially cost-effective. Three million children were treated last year. The END Fund is hoping another two million children will be treated this year. With additional funding, the END Fund would help the Zimbabwean government scale up the program to treat 4.7 million children in 2016. There may be an especially high return on investment in South Sudan as well. Due to the recent conflict, there is no NTD program there and few implementing agencies. There has been no mapping to identify NTD prevalence. If an organization made a substantial grant by the end of 2015, the END Fund would be in position to use that money in South Sudan. There is also a need for funding in (northern) Sudan, where 4.3 million children need treatment for NTDs. The END Fund is looking at partnering with the Ethiopian Federal Ministry of Health on a national deworming campaign to treat intestinal worms and schistosomiasis for over 20 million children, which will require increased investment and donor coordination." "The END Fund identified a large gap in Angola: there was high NTD burden, little treatment provided by the government, and none of the traditional aid donors were involved. Since the end of the civil war there has been little bilateral funding and institutional aid. Angola is now a middle-income country, but there is incredible health inequality. Before The Helmsley Trust was involved, the END Fund had some funding for the area through Dubai Cares, but there was the potential to do a bigger project. […] "The END Fund also identified a local partner, the MENTOR Initiative. The MENTOR Initiative had not worked broadly in the NTD space, but it was a grantee of the President’s Malaria Initiative and had successfully reduced malaria burden in Angola. […] "The END Fund wants to aid in the building of a large and scalable national deworming program, in line with the control and elimination agenda. It worked closely with the MENTOR Initiative to ensure this program would be a 3-year collaboration." "India – A few years ago a Deworm the World project to reach 17 million children in Bihar had a gap in funding. The END Fund provided a small grant that allowed the program to continue. Now, Evidence Action in partnership with the Children’s Investment Fund Foundation and the Indian government have funded the program, so the END Fund was able to cover a 'gap' year of funding to ensure continuity of the program."  9. GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015: "The END Fund also aims to increase capacity of existing non-governmental organizations (NGOs) working on NTDs and expanding the field of organizations working on NTDs by giving direct grants and working with ministries of health and local and international NGOs. When the END Fund re-grants to another program, it is often involved in programming design. Ideally, the END Fund works with governmental and local NGO implementing partners. This approach usually works best. However, in some cases, the END Fund will directly fund and work with the government. It is currently funding government projects in Zimbabwe and Ethiopia; the government has executed programs successfully." "The END Fund also identified a local partner, the MENTOR Initiative. The MENTOR Initiative had not worked broadly in the NTD space, but it was a grantee of the President’s Malaria Initiative and had successfully reduced malaria burden in Angola." SCI and Deworm the World (which have experience supporting NTD programs) and the MENTOR Initiative (which did not have prior experience with NTD programs) are listed as implementing partners in END Fund Aggregate Portfolio Figures 9 Sept 2014, "Number of GsPsIPs" sheet. For more partners, see END Fund Information for GiveWell, 2016, sheet "Updated Program Financing."  10. END Fund Program Process Overview 2015: "Partnership Agreement - Draft PA and supporting annexes; review, negotiate and finalize with IP the budget, work plan, PAF and target numbers, reporting dates, disbursement schedule, and special conditions; if an agreement is used other than our standard PA template then have reviewed by the SVP Finance and Administration" Pg 3. "Periodic Reports - Review periodic reports and cash requests as necessary to ensure IP is fulfilling conditions of PA, use Project Cycle Management approach and provide systematic feedback to IPs on performance; standard practice is for the END Fund to receive quarterly program updates from grantees" Pg 4. The END Fund provided several documents produced by the MENTOR Initiative (which received a grant from the END Fund to implement an NTD program in Angola) on program budgets, workplans, and program operations, including: END Fund Angola MENTOR Annex 5 - MENTOR Workplan Yr2-S2 With targets 2015 END Fund Angola MENTOR P7 Periodic Reporting and Cash Request 31 Dec 2014 END Fund Angola MENTOR P7 Budget Summary 02 April 2014 END Fund Angola MENTOR P7 150126 MDA report November 2014 END Fund Angola MENTOR P7 Annex 1 - NTD treatment strategies Y3 updated, 2015 END Fund Angola MENTOR Proposal, Budget narrative with comments, Year 3, Redacted 2015 END Fund Angola MENTOR Revised Plan, Workplan Year 3, 3 April 2015  11. END Fund Program Process Overview 2015:

 "The primary function of the END Fund programs team is to manage grants in a professional manner that meets the standard expectations for good practice in the NTD sector. In doing so, the team must ensure that all aspects of a program are consistent with WHO guidelines for delivery of NTD interventions and treatment. Team members monitor programs and provide technical assistance to partners when necessary to ensure minimal risk to funds provided by the END Fund and our donors. With the overall objective to deliver high performing projects, the team works collegially at different levels of involvement with our various partners. Depending on their existing capacity and the complexity of the program, the team takes an approach of light touch, moderate engagement, or substantial involvement to also ensure that donors and the END Fund receive a maximum return on their investment." Pg 1. "Substantive Involvement - PD to be in regular communication with IPs to discuss implementation issues and assist in any necessary decision making or technical guidance; communicate any material program variances to Senior Management Team so donor communications and financial impact can be assessed" Pg 4. "Program Visit - Schedule and complete in-country monitoring site visits; minimum one per program year, record findings in TOR and trip report template" Pg 4.  12. "Over the past year, the END Fund and its partners have been discussing the use of coverage surveys – i.e., surveys of children participating in mass drug administration (MDA) programs to monitor the delivery of a treatment. The END Fund has determined that coverage surveys will be required for all its substantial investments in neglected tropical diseases (NTD) programs. Coverage surveys have been scheduled for 11 of its grantees’ MDA programs to treat schistosomiasis and soil-transmitted helminthiasis, and all other major NTD control and eradication programs it funds will do coverage surveys.

 "Smaller grants – e.g., several thousand dollars to a local government’s ministry of health to help implement a program – will not be subject to the coverage survey requirement, but countries will always be encouraged to adopt good practice." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016, Pg 1

  13. "The MDAs in these countries were carried out in September or are planned for October. Coverage surveys for most of these programs will be carried out between November 2016 and early 2017. [...] Results of surveys conducted in 2016 are expected to become available in the first or second quarter of 2017." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016, Pg 2-4

  14. GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015:

 "The END Fund is always looking to find donors who might be interested in the NTD opportunities that it has identified." "The END Fund aims to increase the number of philanthropies that work on NTDs. It often starts conversations with people and organizations that aren’t currently engaged in the field." "The Helmsley Trust has a longstanding interest in education and children, but it had never funded a NTD related project and was just beginning to develop its Africa portfolio. The END Fund began speaking with The Helmsley Trust staff about the importance of deworming. The Helmsley Trust wanted to work in Sub-Saharan Africa because of the high NTD burden and asked the END Fund what areas current funders were neglecting. The END Fund directed them to the Angola deworming project. While this is a restricted donation, The Helmsley Trust tailored its donation to the END Fund’s assessment of current needs and the donor space." "An anonymous donor had previously funded initiatives focused on child health and education in Africa, but it had never funded NTD interventions. As with the Helmsley Trust, the END Fund persuaded the anonymous donor of the importance of deworming. The donor and the END Fund discussed structuring its support as unrestricted funding."  15. END Fund Information for GiveWell, 2016, sheet "Updated Program Financing."

  16. See this spreadsheet. 

  17. @Sarah Marchal Murray, END Fund Chief Operating Officer, email to GiveWell, May 1, 2015@ See "Total disbursements and commitments to NTD programs (in millions USD) as of August 2014" table above.  18. "In 2012 The MENTOR Initiative, commenced a 5 year grant with END Fund to work with the Government of Angola to build the capacity and reach of their Neglected Tropical Diseases programme. Specifically the programme was to map three key NTDs in Uíge, Zaire and Huambo provinces and work to reduce disease burden through biannual mass drug administrations through school and community networks, whilst building capacity of health workers through training and supervisions, coupled with a school-based programme to encourage hand-washing in children. "Working through MENTOR’s existing structure and relationships at national level and in the 3 provinces the programme initiated mapping and an initial mass drug administration (MDA) of albendazole (ALB) to school aged children and subsequently a larger MDA with Praziquantel (PZQ) in year 2. The mapping had been planned to integrate soil transmitted helminths (STH), schistosomiaisis (SCH) and lymphatic filariasis (LF) in the 3 provinces in the centre and north of Angola, however, mapping of LF mapping was not possible and was ultimately dropped from the protocol." END Fund Angola MENTOR Revised Plan, Proposal, 22 April 2015, Pg 2.

  19. @GiveWell's analysis of END Fund Angola MENTOR Revised Plan Budget Summary Years 3-4 22 April 2015@, "GW calculations" sheet.

  20. IEC stands for Information, Education, and Communication. We have not seen ACSM defined in the END Fund's documents. "Information, Education and Communication (IEC) in order to educate children and communities on the ways of identifying and preventing NTDs, and on the places where they can find a treatment." END Fund Angola MENTOR Revised Plan, Proposal, 22 April 2015, Pg 14. 21. @GiveWell's analysis of END Fund Angola MENTOR Revised Plan Budget Summary Years 3-4 22 April 2015@, "Definitions" sheet.

  22. "Two rounds of school based MDA have been completed in the first two years of the grant, one in October/November 2013 and another in November 2014 in Uíge, Zaire and Huambo provinces as well as comprehensive disease mapping of STH and SCH." END Fund Angola MENTOR Proposal, proposal strategy with comments Years 3-5, Redacted 27 March 2015, Pg 13. "Working through MENTOR’s existing structure and relationships at national level and in the 3 provinces the programme initiated mapping and an initial mass drug administration (MDA) of albendazole (ALB) to school aged children and subsequently a larger MDA with Praziquantel (PZQ) in year 2." END Fund Angola MENTOR Revised Plan, Proposal, 22 April 2015, Pg 2. "For Y2, MDA school campaign will target PZQ only given that Albendazole didn't arrive the country due to delays in placing the order from WHO." END Fund Angola MENTOR P7 Periodic Reporting and Cash Request 31 Dec 2014, Program Progress Outputs sheet, cell N25 See our deworming intervention report for WHO recommendations for drugs to treat STH and schistosomiasis.  23. See our intervention report on deworming for more detail.

  24. "The END Fund also uses World Health Organization (WHO) guidelines to determine when intervention is necessary, though it will adapt these to local conditions. Mr. Lancaster shared that the END Fund only works in countries that have a level of disease prevalence that would require treatment according to WHO guidelines." GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015

  25. @World Health Organization. Preventive chemotherapy in human helminthiasis@, Pg 41 26. END Fund Angola MENTOR Revised Plan, Proposal, 22 April 2015, Table 2, Pg 8 Data from mapping conducted in 2005 generally showed higher prevalence (included in same table). In 2005, schistosomiasis prevalence was >30% in all three provinces; STH prevalence was 20%-50% in Huambo, >50% in Uíge, and <50% in Zaire. Further information on focalized infections: ”even though overall and municipality levels are moderate to low (<50%), we were able to identify higher foci of infection such as School no. 115 in Mbanza Congo (63% prevalence of S. haematobium) and School no. 253 in Mbanza Congo (70% of S. mansoni). See Appendix 6 for details on school-level prevalence.” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014 Pg 13  27. END Fund Angola MENTOR Revised Plan, Proposal, 22 April 2015, Table 2, Pg 8. 28. "The 2014 mapping results show a lower disease burden than expected, compared to the mapping results from 2005. The lower endemnicity means that Zaire and some municipalities of Huambo and Uíge fall below the threshold of two MDA rounds per year according to WHO recommendations. Being the most up to date mapping, we have used our 2014 results to inform the MDA strategy for this document. MDA plan for 2015: ALB one round in Zaire and 2 municipalities of Huambo, 2 rounds in Uíge, PZQ : 1 round in 1 municipality of Uíge (see submit treatment MDA treatment schedule ALB and PZQ till 2017)." END Fund Angola MENTOR P7 Annex 1 - NTD treatment strategies Y3 updated, 2015, Pg 2

  29. See our November 2016 cost-effectiveness analyses spreadsheet, "Intensity of Worms" sheet, to see prevalence rates of STH and schistosomiasis in studies providing the best evidence for the benefits of deworming and in countries where SCI, Deworm the World, and Sightsavers support deworming programs. We have seen reports from each of the three provinces. So far, we have only reviewed the report from Zaire since the other two are in Portuguese. Further information from the Zaire report follows: At least some schools had received treatment prior to the mapping in Zaire (conducted in March and April 2014). “Data gathered during the questionnaire informs us that coverage of this campaign was extremely high, with 86% of schools having received treatment in 2013 and 91% of schools having received treatment in the recent past.” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Pg 9. “Importantly, we found this moderate transmission even though a highly efficient Albendazole distribution campaign had taken place less than four months prior. This clearly shows that these infections are not only prevalent, but also well established, which allowed for this rapid re-infection process.” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Pg 20 Sample: “In the 56 primary schools visited, 1,680 children were screened using rapid diagnostic tests for schistosomiasis.” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Pg 12 “This enabled the structured random sampling of the schools, making sure geographical representation was achieved.” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Pg 6 We have not seen a description of how the students were selected. A photo in the appendix is labeled “Random sample selection.” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Pg 36 END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Appendix 5, Pg 29 displays confidence intervals on the results. In some schools, results from new technology seem to increase confidence in the general findings: “Our data suggests that both the microhaematuria test and the CCA test performed well - microhaematuria sensitivity 92% and specificity 91%; CCA sensitivity 100% and specificity 93%. These performances were estimated based on the few schools where both microscopy and the rapid diagnostic tests were employed (11 schools) and it clearly indicates that the infections identified by these two tests in the schools where microscopy was not employed (remaining 56 schools) were correctly diagnosed. These results are similar to those found elsewhere.13,14” END Fund Angola MENTOR Annex 3 - Zaire Mapping Report 16 April 2014, Pg 17  30. END Fund DRC mapping - final report END Fund DRC mapping, 2014 END Fund Namibia mapping - Phase 1 report END Fund Namibia mapping - Phase 2 report  31. "Over the past year, the END Fund and its partners have been discussing the use of coverage surveys – i.e., surveys of children participating in mass drug administration (MDA) programs to monitor the delivery of a treatment. The END Fund has determined that coverage surveys will be required for all its substantial investments in neglected tropical diseases (NTD) programs. Coverage surveys have been scheduled for 11 of its grantees’ MDA programs to treat schistosomiasis and soil-transmitted helminthiasis, and all other major NTD control and eradication programs it funds will do coverage surveys.

 Smaller grants – e.g., several thousand dollars to a local government’s ministry of health to help implement a program – will not be subject to the coverage survey requirement, but countries will always be encouraged to adopt good practice." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016, Pg 1

  32. "The MDAs in these countries were carried out in September or are planned for October. Coverage surveys for most of these programs will be carried out between November 2016 and early 2017. [...] Results of surveys conducted in 2016 are expected to become available in the first or second quarter of 2017." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016, Pg 2-4

  33. "The END Fund has a high level of confidence that a brief summary of the results and conclusions drawn from the data by those who conducted the survey can be made publicly available." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016, Pg 4

  34. GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016

  35. See our reviews of Deworm the World and SCI for examples.

  36. Exceptions that we have heard about: India, Vietnam, and Ghana. For Vietnam and Ghana the programs were not reaching national scale.

  37.  END Fund Angola Program Log 2015: "October-December 2011: Decision to focus on Angola "Proposal submitted to DC: Start date project for April 2012 "Official request made to Govt of Angola for engagement 15 March "Mentor Initiative able to work with smaller amounts in two to three northern provinces "22-May-13: HT Concept Note finalised  "20-Feb-14: Notice of HT Board approval passed along" "The END Fund also identified a local partner, the MENTOR Initiative. The MENTOR Initiative had not worked broadly in the NTD space, but it was a grantee of the President’s Malaria Initiative and had successfully reduced malaria burden in Angola." GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015  38. "Ms. Agler thinks that the Angola project would definitely have not happened without the END Fund's involvement." GiveWell's non-verbatim summary of a conversation with END Fund staff, February 25, 2015

  39. Steps in the End Fund's grant management process from END Fund Program Process Overview 2015: "Periodic Reports - Review periodic reports and cash requests as necessary to ensure IP is fulfilling conditions of PA, use Project Cycle Management approach and provide systematic feedback to IPs on performance; standard practice is for the END Fund to receive quarterly program updates from grantees" Pg 4. "Substantive Involvement - PD to be in regular communication with IPs to discuss implementation issues and assist in any necessary decision making or technical guidance; communicate any material program variances to Senior Management Team so donor communications and financial impact can be assessed" Pg 4.  40. Our intervention report discusses this briefly. Other conversations and observations have reinforced our impression that administering deworming drugs is fairly straightforward. The WHO factsheet on STH: "The recommended medicines – albendazole (400 mg) and mebendazole (500 mg) – are effective, inexpensive and easy to administer by non-medical personnel (e.g. teachers)." @WHO STH factsheet@  41. For example,  here and here. 

  42. "Single-dose oral therapies can kill the worms, reducing ... infections by 99 percent ... Reinfection is rapid, however, with worm burden often returning to eighty percent or more of its original level within a year ... and hence geohelminth drugs must be taken every six months and schistosomiasis drugs must be taken annually." @Miguel and Kremer 2004@, pg. 161.

  43. We have heard this several times in conversation with several groups.

  44. "In Tanzania matters came to a head in places around Morogoro in 2008. Distribution in schools of tablets for schistosomiasis and soil-transmitted helminths provoked riots, which had to be contained by armed police. It became a significant national incident, and one of the consequences has been the delay in Tanzania adopting a fully integrated NTD programme, and the scaling back some existing drug distributions." Allen and Parker 2011, pg. 109. "From these reports a number of problems with the MDA were raised which included fear of side effects from the tablets, particularly following the mass hysteria and death in Blantyre and Rumphi respectively and may explain some of the geographic heterogeneity seen. Furthermore most districts reported that MDA occurred after standard 8 students had finished exams and left school, and due to having inadequate resources for drug distribution...The side-effects incident in Blantyre and death in Rumphi had a large effect on districts and with many district reports stating that after the incidence many families refused to participate." SCI Malawi coverage survey 2012 Pgs 5, 21. 45. For the first two rounds of MDA of the program (October-November 2013 and November 2014), our calculated cost per deworming treatment was $1.55: Total spending Year 1 (1 Apr 2013 – 31 Mar 2014) and P5-P7 of Year 2 (1 Apr 2014 – 31 Dec 2014): $1,674,244. END Fund Angola MENTOR Revised Plan, Budget Summary Years 3-4, 22 April 2015, "Budget Summary" sheet, sum of cells I29, K29, M29, and O29. We are including all program spending from 1 Apr 2013 to 31 Dec 2014 to estimate the MENTOR Initiative's total costs to implement two rounds of MDA (in October-November 2013 and November 2014). The END Fund's non-grant-making expenses (management, fundraising, and other general expenses) accounted for around 15% of its total spending in 2012-2014. See this spreadsheet for details. Total cost estimate for delivering two rounds of MDA (including the MENTOR Initiative's spending and an allocation of the END Fund's organizational costs): $1,674,244 *1.15 = $1,925,381 Reported treatments: total of 1,244,114 (sum of 570,891 STH treatments in October-November 2013 and 673,223 schistosomiasis treatments in November 2014). END Fund Angola MENTOR P7 Periodic Reporting and Cash Request 31 Dec 2014 - 24 Feb 2015, "Program Progress Outputs" sheet, indicators 3.1.3, 3.2.1 and 3.2.2, cells L25, L31 and L32 Average cost per treatment is $1.55 ($1,925,381 / 1,244,114)  46. Calculations here.

  47. Ellen Agler, Chief Executive Officer, email to GiveWell, October 14, 2016

  48. GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016, Pg 4

  49. @Sarah Marchal Murray, END Fund Chief Operating Officer, email to GiveWell, October 20, 2016@

  50. "We currently project we will have $6,072,500 of funds 'left over' and/or committed funds available for direct granting to partners in 2017. Funds raised beyond these current commitments could be highly variable, depending on renewals of a number of grants ending in 2017." Ellen Agler, Chief Executive Officer, email to GiveWell, October 14, 2016

  51. GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016

  52. See this spreadsheet, "Data and calculations"

  53. See this spreadsheet, sheet "Deworming opportunities"

  54. "The END Fund typically spends several million dollars per year on deworming funding opportunities that it was not aware of at the beginning of the year […] It is very likely that unexpected funding opportunities will arise in the next year." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016, Pg 2

  55. See this spreadsheet for calculations.

  56. See this spreadsheet

  57. "The END Fund noted the following probabilities that its deworming work will be funding-constrained if it receives below a given level of funding (i.e. the probability that it will be able to commit certain levels of funding within a given time period):

 99% chance it will be funding - constrained if it receives less than $11 million in the next year. 75-80% chance it will be funding-constrained if it receives less than $16 million by the end of the second quarter of 2017. 75% chance it will be funding-constrained if it receives less than $21 million by November 2017. If the END Fund knew by the beginning of the year that it would have this funding, the probability that it would be able to commit the funding by November 2017 would be higher. The deworming funding opportunities that The END Fund is currently aware of for the next year total $13 million." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016, Pg 2

  58. See this spreadsheet for calculations.

  59. See, for example, discussion in our review of Deworm the World.

  60. "The END Fund makes two kinds of multi-year commitments:

 Commitments to fundraise: The END Fund and CIFF have committed to finding funding for a 5-year deworming program in Ethiopia run by the federal ministry of health, despite not having the whole amount of funding ($10 million) on hand. Commitments such as this involve annual evaluations of the strength of the program, progress it has made, and whether the END Fund has the capacity and funding to continue supporting it. Commitments to provide funding: The END Fund sometimes receives donations that are restricted to a multi-year commitment in a certain country. One donor has made such a donation to support multi-year programming in Angola, and the END Fund is dispersing this funding as the implementing partner reaches certain targets." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016, Pg 4

  61. See this spreadsheet, "Number of treatments"

  62. GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016, Pg 4

  63. "There is no typical balance between restricted and unrestricted funding. In 2013, a large proportion of The END Fund's funding was restricted. At the end of 2015, its committed funding for 2016 was 90% unrestricted but had to be spent by the end of 5 2016 or early 2017. Some of this funding was restricted broadly to Sub-Saharan Africa, but otherwise unrestricted." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 17, 2016, Pg 4-5

  64. @WHO, Summary of global update on preventive chemotherapy implementation in 2015@, Pg 456, Table 1.

  65. @WHO Weekly epidemiological record, 18 December 2015@, Pg 707 (Table 1)

  66. "Over the past year, the END Fund and its partners have been discussing the use of coverage surveys – i.e., surveys of children participating in mass drug administration (MDA) programs to monitor the delivery of a treatment. The END Fund has determined that coverage surveys will be required for all its substantial investments in neglected tropical diseases (NTD) programs. Coverage surveys have been scheduled for 11 of its grantees’ MDA programs to treat schistosomiasis and soil-transmitted helminthiasis, and all other major NTD control and eradication programs it funds will do coverage surveys.

 "Smaller grants – e.g., several thousand dollars to a local government’s ministry of health to help implement a program – will not be subject to the coverage survey requirement,. but countries will always be encouraged to adopt good practice." GiveWell's non-verbatim summary of a conversation with END Fund staff, October 7, 2016, Pg 1

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