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            You are hereHome » Top Charities » Helen Keller International Helen Keller International's Vitamin A Supplementation Program      FacebookTwitter>Print>Email                         Our Report Charity Response        Donate

  Helen Keller International's vitamin A supplementation program is one of our top-rated charities and we believe that it offers donors an outstanding opportunity to accomplish good with their donations.

 More information: What is our evaluation process? 

 Published: November 2019

 Summary What do they do? Helen Keller International (HKI) supports programs focused on reducing malnutrition and averting blindness and poor vision; this review focuses only on HKI's work on vitamin A supplementation (VAS) in sub-Saharan Africa. HKI provides technical assistance, engages in advocacy, and contributes funding to government-run vitamin A supplementation programs. (More)

 Does it work? There is strong evidence from many randomized controlled trials (RCTs) conducted in the 1980s and 1990s that VAS can substantially reduce child mortality, but weaker evidence on how effective VAS is in the places HKI would work with additional funding in the next few years. HKI has conducted studies to determine whether its mass distribution programs reach a large proportion of targeted children and generally found positive results. We have also investigated the question of what effect HKI's support has on programs and found a number of cases where it seems likely that HKI support is necessary for supplementation to occur. (More)

 What do you get for your dollar? We estimate that it costs $1.23 to deliver a vitamin A supplement in HKI-supported programs. We have only seen limited information on the total expenditures of actors other than HKI involved with mass distribution programs, so we do not think that this estimate is as robust as the "cost per item delivered" estimates for our other top charities. It appears that HKI's vitamin A supplementation work is in the range of cost-effectiveness of our top charities, but there are several key factors about which we have limited information. (More)

 Is there room for more funding? We believe that HKI's VAS work is highly likely to be constrained by funding next year. We estimate that HKI could absorb an additional $15.6 million for VAS mass campaign programs in 2020-2022. HKI appears to have limited prospects for funding these programs from other sources. Update: In the third quarter of 2019, GiveWell received $2.6 million from donors for granting at GiveWell's discretion, which we granted to HKI. Additionally, in November 2019, we recommended that Open Philanthropy grant $9.7 million to HKI, which leaves it with a funding gap of $3.3 million. See this page for a summary of HKI’s expected use of additional funding.(More) 

 HKI's vitamin A supplementation program is recommended because:

 VAS is a program with a strong evidence base and strong cost-effectiveness. Track record – HKI has experience with supporting VAS programs in a large number of countries. Standout transparency – it has shared significant, detailed information about its programs with us. Room for more funding – we believe that HKI could productively use more funding than it expects to receive to scale up its VAS activities. Major open questions include:

 We have not investigated HKI at the same level of depth as some of our other top charities. Our general experience has been that more investigation leads us to learn about more limitations and uncertainties associated with the impact of a program and charity. We remain highly uncertain about current rates of vitamin A deficiency among preschool-aged children in areas where HKI supports VAS programs. If rates of vitamin A deficiency are low, it is likely that the impact of HKI's VAS programs would be limited. Will HKI-supported VAS programs achieve high coverage rates? Will HKI's monitoring provide high-quality evidence of its programs' impact?   Table of Contents   Summary Our investigation process What do they do?  What is vitamin A supplementation? How are vitamin A supplements distributed and administered to preschool-aged children?  Distribution Administration   What is HKI's role in VAS programs? HKI's spending on VAS campaigns   Does it work?  Is there independent evidence that the program is effective? Are programs targeted at areas where they are likely to be effective?  How prevalent is vitamin A deficiency in areas where HKI works? How high are child mortality rates in areas where HKI works?   Are vitamin A supplements delivered to and ingested by recipients?  Mass distribution campaigns Routine delivery   How does HKI's support affect program outcomes? Are there any negative or offsetting impacts?   What do you get for your dollar?  Cost per vitamin A supplement delivered  Our approach Our cost per supplement estimate Shortcomings of our cost per supplement analysis   Cost-effectiveness   Is there room for more funding?  Uncommitted and expected funds  Past sources of funds for VAS programs   Additional spending opportunities Global room for more funding for VAS programs   HKI as an organization Sources    Our investigation process In April 2017, we invited Helen Keller International (HKI) to apply to be considered for a top charity recommendation for its vitamin A supplementation program. To date, our investigation of HKI has consisted of:

 Conversations with HKI staff.1 Reviewing documents HKI shared with us. A visit to Conakry, Guinea in October 2017 to meet with representatives of HKI. What do they do? Helen Keller International (HKI) supports programs focused on reducing malnutrition and averting blindness and poor vision in countries in Africa and Asia; it also provides vision screenings and distributes eyeglasses at schools in the United States.2

 In this review, we focus only on HKI's vitamin A supplementation (VAS) programs, which operate in countries in sub-Saharan Africa.3 The World Health Organization (WHO) recommends that all preschool-aged children (aged 6 to 59 months) in areas where vitamin A deficiency (VAD) is a public health problem receive vitamin A supplements two to three times per year.4 HKI supports countries' VAS programs for preschool-aged children by providing technical assistance, engaging in advocacy, and contributing funding to governments for implementing the programs.

 What is vitamin A supplementation? Vitamin A is an essential nutrient that serves many purposes in the body; in particular, the immune and visual systems require it to function properly.5 Essential nutrients must be obtained through diet since the body cannot produce them on its own.6

 Vitamin A deficiency (VAD) can cause stunting, anemia, xerophthalmia (dry eyes, which can lead to blindness), increased severity of infections, and death.7 WHO notes that people who have diets containing few animal products and little vitamin A-fortified food may be particularly susceptible to VAD.8 WHO estimates that VAD is most common in its Africa and South-East Asia Regions.9 Infants, children, and pregnant or lactating women with low vitamin A intake appear to have a particularly high risk of the negative health impacts caused by VAD.10

 WHO notes that vitamin A from high-dose supplements can be stored in the liver and used as needed in the body for several months.11 To prevent childhood morbidity and mortality, WHO recommends vitamin A supplementation (VAS) every four to six months for all children aged 6 to 59 months in areas where VAD is a public health problem.12

 More information about VAS is available in our vitamin A supplementation intervention report.

 How are vitamin A supplements distributed and administered to preschool-aged children? Distribution HKI-supported VAS programs distribute vitamin A supplements through either mass distribution campaigns or through routine delivery (in which caregivers take their children to facilities to receive VAS every six months).13 We have requested that HKI use GiveWell-directed funding only for mass distribution campaigns because we have a limited understanding of how to measure HKI's impact on routine delivery programs (see below for more details).

 HKI supports two types of VAS mass distribution campaigns:

 Door-to-door campaigns, in which community health workers travel to recipients' homes to distribute and administer vitamin A supplements and other interventions to preschool-aged children.14 Fixed-site campaigns, in which caregivers bring preschool-aged children to health facilities or outreach posts to receive vitamin A supplements and other interventions.15 Fixed-site campaigns use social mobilization activities (e.g., fliers and radio announcements) to remind caregivers to bring their preschool-aged children to nearby distribution sites during the campaign dates.16This spreadsheet lists the distribution methods of VAS mass distribution campaigns HKI supported with GiveWell-directed funding in 2018.

 Administration Health workers implementing VAS programs are instructed to cut vitamin A capsules open with scissors and squeeze the contents of the capsules directly into children's mouths.17 Health workers are also instructed to ask caregivers about the age of the child in order to provide the correct dosage of vitamin A: 100,000 IU for 6-11 month-old infants, and 200,000 IU to 12-59 month-old children.18

 What is HKI's role in VAS programs? HKI provides the following types of support to government-run VAS programs:19 

Technical assistance: HKI assists governments with monitoring and evaluation,20 training health workers and managers,21 policy design,22 planning and budgeting,23 and social mobilization24 for VAS programs (details in footnotes). HKI mainly focuses on providing technical assistance at the sub-national level, particularly to districts or regions that may have low VAS coverage rates.25 Advocacy: HKI encourages national governments to prioritize budgeting for and implementing VAS mass campaigns,26 and advocates for routine distribution of vitamin A supplements through health facilities.27 Funding: HKI provides grants to governments to cover a portion of the implementation costs of VAS programs.28UNICEF and Nutrition International (formerly Micronutrient Initiative) also support VAS programs in countries where HKI works. Nutrition International procures the vitamin A supplements used in the programs, and UNICEF provides technical and financial support to geographic regions in Guinea, Mali, and Burkina Faso not supported by HKI.29

 HKI's spending on VAS campaigns We have seen breakdowns of HKI's spending on VAS campaigns in 2018 (see this spreadsheet). In short:

 HKI spent a total of $3.0 million on VAS campaigns in 2018. HKI spent between $0.5 and $0.8 million in Guinea, Mali, Burkina Faso, and Côte d'Ivoire and $0.7 million on regional support. It also spent a small amount (less than $0.1 million) in Sierra Leone and Niger.30 By category, HKI spent around 32% on grants to governments for program implementation, 50% on direct costs (including personnel, travel, supplies, and other direct costs), and 18% on overheads. We summarize HKI's past spending on VAS programs during its most recent (2013-2016) grant from Global Affairs Canada in this spreadsheet.31

 Does it work? There is strong evidence from many randomized controlled trials (RCTs) conducted in the 1980s and 1990s that VAS can substantially reduce child mortality, but weaker evidence on how effective VAS is in the places HKI would work with additional funding in the next few years.

 We have several sources of uncertainty about how to apply evidence from VAS trials conducted in the 1980s and 1990s to the contexts in which VAS programs operate today, including:

 A 1999-2004 trial with more participants than all previous studies combined (the Deworming and Enhanced Vitamin A, or DEVTA, trial) did not find a statistically significant effect on mortality. We remain uncertain about what could explain this difference in results. Some researchers have suggested that DEVTA did not find a statistically significant effect because it actually reached fewer children than it reported reaching or because of methodological flaws in the study. More children in today's contexts may be receiving vitamin A through food fortification programs or improved diets than children in the earlier contexts did. There appears to be limited information available on current rates of vitamin A deficiency (VAD) in the populations targeted by VAS. Child mortality rates in developing countries have decreased substantially over the past few decades. It is possible that deaths that may have been averted by VAS in worse-off populations in the past may already be averted through other means (e.g., increased immunization rates) in today's contexts. To estimate what effect we should expect from VAS in locations where HKI supports VAS programs, and to evaluate HKI's track record at expanding access to VAS, we have considered the following questions (see discussion in the sections below):

 Is HKI supporting VAS programs in areas where child mortality is high? How prevalent is vitamin A deficiency in areas where HKI works? Has vitamin A fortification (adding vitamin A to common foods) reduced the impact of supplementation? Is there evidence that a large proportion of targeted children receive vitamin A supplements? How does HKI's support affect program outcomes? Is there independent evidence that the program is effective? A large number of RCTs of VAS that were conducted in the 1980s and 1990s found that VAS greatly reduces child mortality. A 1999-2004 trial with more participants than all previous studies combined (the Deworming and Enhanced Vitamin A, or DEVTA, trial) did not find a statistically significant effect on mortality. We remain uncertain about what could explain this difference in results.

 Further details on trials of VAS:

 A Cochrane systematic review and meta-analysis of sixteen randomized controlled trials and one quasi-randomized trial conducted in the 1980s and 1990s (Imdad et al. 2010) finds that VAS reduces mortality of 6 to 59-month-old children by 24% (95% confidence interval 17% to 31% reduction in mortality rates).32 The Deworming and Enhanced Vitamin A (DEVTA) study, a more recent trial (taking place between 1999-2004 and published in 2013) in India with around one million participants, estimates that VAS reduced child mortality by 4% and cannot rule out the possibility that VAS did not affect child mortality at all (the 95% confidence interval ranged from a 3% increase in child mortality to an 11% decrease).33 An updated version of the Cochrane review (Imdad et al. 2017) combined DEVTA and another smaller recent trial (Fisker et al. 2014) with previous trials.34 Its fixed-effect meta-analysis finds that VAS causes a 12% reduction in child mortality (95% confidence interval 7% to 17% reduction) and its random-effects meta-analysis finds that VAS causes a 24% reduction in child mortality (95% confidence interval 17% to 31% reduction).35 (See the following footnote for a description of the differences between fixed-effect and random-effects meta-analyses.)36 Even though the overall effect found in the updated meta-analysis remains statistically significant, it is unlikely that differences between the results of DEVTA and earlier trials were due to random chance alone.37 We are uncertain about what could explain why the earlier trials and DEVTA found such different results. Some potential explanations include: The population treated by DEVTA had lower baseline child mortality rates and may have had better overall health than many previously studied populations.38 Deaths averted by VAS in worse-off populations may have already been averted through other means (e.g., increased vaccination rates) in the DEVTA population.39 This hypothesis is undermined somewhat by the apparent lack of a correlation between how much mortality risk was reduced and baseline mortality rate in non-DEVTA trials.40 Some researchers not involved in the study have pointed to evidence suggesting that DEVTA may have failed to achieve as high a coverage rate as it reported.41 DEVTA may have had methodological weaknesses that caused it to fail to detect a statistically significant mortality effect, even if VAS had a real effect on mortality rates in the population studied (details in footnote).42 For more details, see our vitamin A supplementation intervention report. A shorter summary of our views is available in our blog post on vitamin A supplementation programs.

 Are programs targeted at areas where they are likely to be effective? How prevalent is vitamin A deficiency in areas where HKI works? There is limited recent data on the prevalence of vitamin A deficiency (VAD) among populations targeted by HKI's VAS programs. Our best estimate, using data from a model of VAD prevalence created by the Institute for Health Metrics and Evaluation's Global Burden of Disease project, is that the prevalence of VAD among preschool-aged children in countries where HKI works or plans to work is around 31% on average. We estimate that the prevalence of VAD in populations represented in the meta-analysis of the effect of VAS on mortality was roughly 59%. Based on these estimates, we expect that VAS has a smaller impact on child mortality rates in populations reached by HKI's programs today than the impact on mortality found in populations studied in VAS trials. We incorporate this adjustment into our cost-effectiveness analysis of HKI (see below).

 It appears unlikely that low rates of vitamin A deficiency (VAD) explain the DEVTA results, but it is still plausible that low rates of VAD in an area may indicate that VAS programs will have a limited effect on mortality there.43 (See footnote for arguments on ways in which VAD rates may not be indicative of the impact of VAS on child mortality; we have not yet evaluated these arguments carefully.)44

 The prevalence of VAD in a population can be estimated using representative surveys of serum retinol concentrations or retinol-binding protein (measured in blood samples), clinically assessed eye signs of VAD (e.g., Bitot's spots, xerophthalmia), or other measures.45 WHO defines VAD as being indicated by a serum retinol concentration lower than 0.70 μmol/L, and severe VAD as a serum retinol concentration lower than 0.35 μmol/L.46

 Our estimates for the prevalence of VAD among populations studied in trials included in Imdad et al. 2017 are in this spreadsheet ("Imdad 2017 - VAD prevalence estimates" sheet). We consider our weighted average estimate of 59% prevalence of VAD in populations studied in VAS trials to be a rough best guess, based on limited data. Our process and sources for creating this estimate are outlined in the following footnote.47

 We remain uncertain about the prevalence of VAD among preschool-aged children in areas where HKI works after considering the following sources of information: 

Vitamin A deficiency surveys: We have listed the most recent serum retinol and retinol-binding protein surveys of preschool-aged children in countries where HKI supports or plans to support VAS mass campaign programs in this spreadsheet. Notes on this data: Of the nine countries where HKI supports or plans to support VAS mass campaign programs, two have completed nationally-representative surveys of VAD (using serum retinol or retinol-binding protein biomarkers) among preschool-aged children in the past ten years. The remaining countries completed VAD surveys more than ten years ago, or have not ever completed any.48 The majority of these surveys find VAD prevalence among preschool-aged children in the "severe" range as defined by WHO (above 20% prevalence).49 But one of the more recent surveys, from Kenya in 2012, found prevalence rates in the "mild" range.50 Malawi and Ghana have not received support from HKI for VAS programs, but have implemented VAD surveys in the past five years—a very low prevalence of VAD among preschool-aged children was reported from a 2015-16 survey in Malawi (4%), and a relatively high rate (21%) was found in Ghana in 2017.51 VAS appears to have only a temporary impact on measures of serum retinol and retinol-binding protein concentrations.52 Accordingly, measures of serum retinol or retinol-binding protein may not be useful for evaluating the impact of a VAS program—instead, they may reflect whether or not dietary vitamin A intake is adequate.53 We have not searched for recent surveys of the prevalence of Bitot's spots or other eye signs of VAD; our understanding is that these indicators of VAD may be responsive to VAS, and so would not be useful as an indicator of "underlying" VAD in a population reached by a VAS program, but we have not investigated this issue in depth.54Stevens et al. 2015 incorporates the most recent available VAD surveys and other relevant information (e.g., availability of animal-source foods) into a mathematical model to estimate rates of VAD as of 2013.55 We have not carefully reviewed the methodology used in this paper. Stevens et al. 2015 concludes that VAD was likely to be high (above 40%) in 2013 throughout sub-Saharan Africa.56 Three more recent vitamin A deficiency surveys from Sierra Leone, Malawi, and Kenya found considerably lower rates of VAD among preschool-aged children than the lower bound estimate for sub-Saharan African countries in Stevens et al. 2015.57 Vitamin A food fortification: Excluding the Democratic Republic of the Congo, all countries in which HKI supports or plans to support VAS mass campaign programs mandate that vegetable oil be fortified with vitamin A. A few others mandate or allow fortification of wheat flour or sugar with vitamin A as well. (Some countries also have programs encouraging the consumption of crops biofortified with vitamin A, but we have not investigated these programs in depth.)58 See details in this spreadsheet. We are uncertain about whether these food fortification programs have had impacts on rates of VAD among preschool-aged children in these countries. Our key findings: In most countries in which HKI has recently supported or plans to support VAS mass campaign programs, we have not seen any household- or market-level surveys testing whether food samples are adequately fortified.59 A market-level survey of vegetable oil in the city of Abidjan, Côte d'Ivoire, found that nearly all samples were adequately fortified, but other surveys we have seen found relatively low rates of adequately-fortified oil.60 Engle-Stone et al. 2017 found that rates of VAD among preschool-aged children in two cities in Cameroon did not significantly decline between 2009 and 2012, despite vitamin A fortification of vegetable oil becoming mandatory in 2011.61Conversations with HKI and experts on vitamin A deficiency: We have discussed our concerns about the lack of recent data on vitamin A deficiency with HKI. HKI told us that it believes it would be very surprising if vitamin A deficiency were no longer a problem throughout sub-Saharan Africa, especially in countries with high child mortality and malnutrition rates.62 Dr. Sherry Tanumihardjo, an expert on vitamin A status assessment, has told us that since many vitamin A oil fortification programs in countries in sub-Saharan Africa are relatively new, it would not be surprising if many of the programs were not yet functioning well enough to have an impact on VAD rates among preschool-aged children.63In 2018, we took the information above into account to form a subjective best guess of VAD prevalence among populations targeted by HKI's VAS campaigns.64 In 2019, following a conversation with the Institute for Health Metrics and Evaluation (IHME), we decided to instead use VAD prevalence estimates from its Global Burden of Disease (GBD) project.65 IHME's modeling takes past vitamin A deficiency survey results, vitamin A supplementation coverage, a socio-demographic index, and an estimate of the availability of vitamin A in a country's food supply into account (excluding fortified foods).66 IHME's estimates indicate that, as of 2017, VAD prevalence ranged from 28% to 36% among children aged 6- to 59-months in countries where HKI is supporting or plans to support VAS campaigns, with a weighted average of 31%.67

 We would guess that IHME's estimates of the prevalence of VAD are more likely to be accurate than our subjective best-guesses, but our confidence in this judgment is limited for the following reasons:

 IHME told us that its model does not take vitamin A food fortification into account.68 We are uncertain how much we should expect vitamin A food fortification programs to affect VAD prevalence. IHME's vitamin A deficiency modeling takes vitamin A supplementation coverage into account, so a country with high coverage for vitamin A supplementation over time would be estimated to have lower vitamin A deficiency.69 To estimate the impact of VAS, we would ideally like to consider estimates of what VAD prevalence would be in absence of VAS programs. IHME has explained its methodology for creating vitamin A deficiency prevalence estimates to us, but we do not have access to the full data sets it used for its calculations.70How high are child mortality rates in areas where HKI works? Child mortality rates in countries where HKI works are lower than child mortality rates of some populations studied in trials of VAS in the 1980s and 1990s, but not so much lower that we would expect that HKI's programs would be unlikely to be effective on average. (See above for an explanation of why VAS may have a limited impact on preventing additional child mortalities in populations where baseline rates are already relatively low.)

 For the nine countries where HKI is supporting or plans to support VAS mass campaign programs, we estimate an average child mortality rate of 12.9 per 1,000 child-years as of 2017.71 Some major VAS trials took place in contexts where baseline mortality rates were considerably higher than 12.9 per 1,000 child-years (see Table 1 below). Trials listed in Table 1 with baseline child mortality rates of 10.6 per 1,000 child-years or higher found that VAS significantly reduced child mortality, but the trials with lower baseline rates did not find statistically significant effects.72

 Three out of the nine countries where HKI supports or plans to support VAS programs have mortality rates below 10.6 per 1,000 child-years.73 

 For comparison with our estimate of 12.9 deaths per 1,000 child-years, control group child mortality rates in the six main trials included in Imdad et al. 2017 are presented in the following table. 19 trials are included in the all-cause mortality meta-analysis in Imdad et al. 2017, but we focus on these six trials because they account for around 90% of Imdad et al. 2017's weighted mean estimate of the effect of VAS on mortality.74

Table 1: Characteristics of the six main studies used in the Cochrane review's estimate of the effect of VAS on all-cause mortality

 Study Age group Control group mortality per 1,000 child-years Mortality risk ratio (95% CI) Deaths/Child-years in treatment vs. control Awasthi et al. 2013 (DEVTA) 12 to 72 months 5.3 0.96 (0.89 – 1.03)75 12,467/2,464,490 vs. 13,217/2,496,62076  Ross et al. 1993 6 to 90 months 29.9 0.81 (0.68 – 0.98) 397/16,508 vs. 495/16,77977West et al. 1991 6 to 72 months 16.4 0.70 (0.56 – 0.88) 152/13,175 vs. 210/12,79578Herrera et al. 1992 9 to 72 months 5.3 1.06 (0.82 – 1.37) 120/21,515 vs. 112/21,22479  Daulaire et al. 1992 1 to 59 months 126 0.74 (0.55 – 0.99) 138/1,480 vs. 167/1,32380 Sommer et al. 1986 0 to 71 months 10.6 0.73 (0.54 – 0.99) 101/12,991 vs. 130/12,20981 There are major limitations to our analysis so far of baseline child mortality rates in areas where HKI works. In particular:

 We have only reviewed data on national average child mortality rates. It would be more appropriate to use regional or local mortality data to evaluate the impact of HKI's sub-national technical assistance work. We have not yet looked into whether reasonably high-quality data exist at the sub-national level. It seems unlikely to us that there is a real baseline mortality rate "threshold" for the effectiveness of VAS (i.e., that VAS has an impact on child mortality when baseline rates are above 10.6 per 1,000 child-years, but no effect when baseline rates are below 10.6 per 1,000 child-years). We compare baseline mortality rates in areas where HKI works to 10.6 per 1,000 child-years because it may be useful as a general indication of where VAS programs are more or less effective at reducing mortality. We are uncertain whether VAS might have an impact on all mortalities caused by infectious diseases, or only a subset of specific infectious diseases. (It does not seem plausible to us that VAS could have an impact on other causes of child mortality, like accidents.) The only statistically significant cause-specific mortality reduction effect found in a meta-analysis of trials of VAS for preschool-aged children was for diarrhea.82 The same meta-analysis found a statistically significant reduction in measles incidence, but not mortality.83 Very roughly, we estimate that the proportion of child mortalities caused by infectious diseases generally (and diarrhea specifically) in countries in sub-Saharan Africa where HKI supports VAS mass campaigns or would do so with additional funding has declined only slightly since 1990, but that the proportion of child mortalities caused by measles is now substantially lower than it was in 1990.84 Are vitamin A supplements delivered to and ingested by recipients? HKI has conducted door-to-door coverage surveys to estimate what percentage of individuals who were targeted for treatment actually received treatment. 

 HKI began supporting mass distribution campaigns for VAS with GiveWell-directed funds in 2018. There were eight of these campaigns, two each in Mali, Burkina Faso, Côte d'Ivoire and Guinea. As of July 2019, we have seen coverage survey results from all five surveys that took place; surveys did not take place for three campaigns. The surveys generally found positive results. 

 HKI has also shared coverage surveys from VAS campaigns conducted prior to 2018. We have reviewed these surveys to understand the methodology used in HKI's coverage surveys, but we put limited weight on what coverage levels they measured because they cover a relatively small portion of HKI's past work and many were conducted in areas where HKI expected coverage to be low. Also, the evidence we have seen on coverage rates achieved through routine distribution systems is much more limited—for this reason, we have limited our consideration of HKI's room for more funding to mass distribution campaigns only (see below).

 Mass distribution campaigns We use coverage survey results in our cost-effectiveness analysis to estimate the number of children who receive vitamin A supplements. We also look at past coverage surveys to determine whether HKI has a track record of monitoring its work such that, if we recommend additional funding to HKI for VAS, we could expect to learn whether the additional work was effective.

 HKI collaborates with governments to implement post-event coverage surveys (PECS) following VAS mass distribution events.85 In each of the surveys, surveyors visit a sample of households and ask parents (or other caregivers) whether preschool-aged children in their household took vitamin A supplements during the recent campaign.86 HKI sent us documents on the general guidelines used to design these surveys, as well as reports with details on methodology, results from the surveys it has conducted after campaigns supported by GiveWell-directed funds, and example reports from other campaigns.87 

 We have summarized the details of the methodologies of the recent coverage surveys we have reviewed in this spreadsheet ("Methods" sheet). We generally believe that these coverage surveys provide more reliable information on the proportion of preschool-aged children that received and ingested vitamin A supplements than "administrative coverage" figures calculated by governments of countries with HKI-supported programs.88 Our main concern about HKI's coverage surveys (similar to surveys for other mass distributions) is whether what survey respondents say is likely to be accurate. First, their ability to recall the information may be flawed. Some of the surveys took place up to six weeks after the VAS distribution. Second, their responses may be biased towards what they believe surveyors want to hear. We would have more confidence in a survey that tested the reliability of responses in some way, for example by asking participants if they received some other service known not to have been distributed (e.g. a vaccine). With one exception, HKI's survey reports do not indicate that there were tests for this type of bias included; in one case (Mali, 2018 round 1) the caretaker was shown the Vitamin A capsule and asked to identify and name it before being asked if the child received it.89 

 We have summarized the results of recent coverage surveys we have seen in this spreadsheet ("Results summary" and "Full results" sheets). For the coverage surveys we have seen from countries supported by GiveWell-directed funds in 2018, coverage ranged between 92% (HKI focus areas in Côte d'Ivoire) and 44% (urban areas of Burkina Faso).90 Some of these surveys are nationally-representative, while others are conducted only in districts or regions that are special focus areas for HKI’s technical assistance. Out of the 2018 VAS mass campaigns supported by GiveWell-directed funds, we have seen survey results for both campaigns in Mali, and one of two campaigns that were conducted in each of Burkina Faso, Guinea, and Côte d'Ivoire. The surveys covered campaigns that represent around 60% of HKI's total spending on VAS mass campaigns in 2018.91 In 2019, we expect HKI to conduct nationally-representative coverage surveys for the first VAS mass campaign of the year in Guinea, Mali, and Niger and for the second VAS mass campaign of the year in Côte d'Ivoire and Burkina Faso.92 HKI is considering a shift in how it samples for coverage surveys starting in 2020 in order to reduce costs and, at GiveWell's request, make the results more representative overall of work funded with GiveWell-directed funding. Its tentative plan is to reduce the sample size in each survey, such that it would sample approximately a quarter of the sample size it previously did in nationally-representative coverage surveys, and sample after each round, rather than after only some rounds.93

 We put more limited weight on coverage levels measured in the surveys we have reviewed from before 2018 because they cover a relatively small portion of HKI's past work94 and many were conducted in areas where HKI expected coverage to be low.95 Overall, coverage was above 80% (HKI's target) in around 59% of surveys and the median coverage rate across all surveys was 84%. In the two surveys that covered the largest target population (Mali 2018 round 1, National, and Guinea 2018 round 1, Boké, Kindia, Labé, Mamou, Nzérékoré) the coverage estimates were 81% and 61% respectively.96 Coverage was above the 80% target in 68% of surveys of door-to-door distributions, and was above the 80% target in around 31% of fixed and outreach Child Health Day distributions.97 

 Routine delivery HKI supports creating a "contact point" at six months of age for VAS in infants' immunization schedules (see above for details).

 We currently have a limited understanding of how HKI measures coverage rates for these programs. We have seen some results from one set of surveys before and after the six-month contact points were implemented, but we are unsure whether HKI and governments continue to implement these surveys beyond the program's pilot phase.98 We have not prioritized this question because we expect donations we direct to HKI to primarily support mass distribution campaigns.

 How does HKI's support affect program outcomes? We have found strong evidence in some cases that HKI's financial support enables VAS mass campaigns to occur.

 HKI's support may impact the outcome of VAS mass campaigns in the following ways:

 Increasing coverage rates: HKI identifies districts or regions participating in mass campaigns that have low VAS coverage rates and provides sub-national governments in those regions with technical support.99 Causing VAS campaigns to occur: In the absence of external technical assistance and funding, HKI told us that VAS campaigns and programs would not occur at all in some countries.100We have completed case studies on the types of impact HKI's involvement may have on VAS mass campaigns for a selection of HKI's past country programs. HKI selected the countries for these case studies based on the availability of in-country staff for phone interviews; we are uncertain how representative our five country case studies are of the thirteen countries in which HKI has recently supported VAS programs.

 In our case studies, we found strong evidence in a few cases that HKI's financial support enables mass distributions of VAS to occur. We have not yet seen evidence we find convincing that HKI's technical assistance enables mass distribution programs to achieve higher coverage rates than the programs would achieve in HKI's absence, primarily because we lack information about coverage rates in areas without HKI-supported programs (details in footnote).101 

 The full details of our case studies are available in this spreadsheet.

 Are there any negative or offsetting impacts? We discuss a few possible considerations but do not see significant concerns.

 Potential VAS interaction with vaccines and increased mortality in some groups: Benn et al. 2009 reanalyzed data from an earlier VAS trial in Ghana to test the hypothesis that VAS reduced mortality in children whose most recent vaccine was a live vaccine (e.g., measles), but could lead to increased mortality in children (particularly girls) whose most recent vaccine was an inactivated vaccine (e.g., DTP).102 The data re-analysis found that VAS was associated with nonsignificant increases in mortality among girls who had received vaccinations.103 The authors of Fisker et al. 2014, a 2007-2010 trial in Guinea-Bissau of VAS, intended for the trial to test for interactions between VAS, live or inactivated vaccines, and gender.104 The trial found no significant effect on mortality overall, a nonsignificant increase in mortality for boys, and no evidence of a differential effect based on receiving live or inactivated vaccines.105 Based on the results of Fisker et al. 2014, it does not appear that increased mortality following VAS and live or inactivated vaccinations for boys or girls is a substantial concern. We have also completed research on the biological plausibility of interactions between VAS, vaccines, and sex, and did not find reasons to believe that harmful impacts are highly plausible (details in footnote).106 Adverse side effects of vitamin A supplements: Some preschool-aged children experience side effects after taking vitamin A supplements, including loose stools, headache, irritability, fever, nausea, and vomiting.107 WHO cites an estimate of the prevalence of these types of side effects of 1.5% to 7%; we have not vetted this estimate.108 Potential vitamin A overdose: Chronic excessive vitamin A intake can cause a serious condition called vitamin A toxicity (also known as hypervitaminosis A).109 Our understanding is that cases of vitamin A toxicity are very rare globally, and that VAS programs are not thought to be a cause of cases of vitamin A toxicity.110 Diversion of skilled labor: VAS mass campaigns involve Ministry of Health staff, nurses, and other health workers.111 We are uncertain of the degree to which participating in VAS programs reduces their ability to complete other duties, but we note that our understanding is that VAS campaigns usually take between a few days and a few weeks to complete.112What do you get for your dollar? Cost per vitamin A supplement delivered We estimate that on average the total cost to deliver a vitamin A supplement through HKI-supported mass distribution programs is $1.23. We have relied on projected costs and treatments and have only seen limited information on the total expenditures of all actors involved with mass distribution programs, so we do not think that this estimate is as robust as the "cost per item delivered" estimates for many of our other top charities.

 Our approach For programs that distribute health commodities, our general approach for calculating a "cost per item delivered" estimate is to identify comparable data on costs and items delivered and take the ratio.

 We try to include all costs incurred to carry out a project, not just those that the charity in question pays for itself. We start with this total cost figure and apply adjustments in our cost-effectiveness analysis to account for cases in which we believe the charity's funds have caused other actors to shift funds from a less cost-effective use to a more cost-effective use ("leverage") or from a more cost-effective use to a less cost-effective use ("funging").

 We prefer to calculate average "cost per item delivered" estimates using data from a broadly representative sample of mass distribution rounds, since costs may vary considerably in different contexts.

 We have used the following inputs to construct our cost per supplement estimate for HKI:

 HKI's actual expenditures for VAS distribution rounds in 2018 and its budgets for 2019 in Guinea, Mali, and Burkina Faso.113 Rough estimates of expected spending by other organizations supporting VAS distribution rounds in Guinea, Mali, and Burkina Faso in 2018 and 2019, including UNICEF, Nutrition International, the World Health Organization (WHO), World Vision, and Save the Children.114 We have not yet seen detailed budgets for these organizations for all distribution rounds in 2018 and 2019.115 An assumption about the amount that the governments of Guinea, Mali, and Burkina Faso will contribute to VAS programs in the form of in-kind contributions.116 An estimate of the number of children who will be treated, based on estimates from HKI of the number of children in Guinea, Mali, and Burkina Faso between the ages of 6-59 months and the results of HKI's coverage surveys we have seen from GiveWell-supported campaigns.117 Our cost per supplement estimate Using the approach described in the section above, we estimate that it costs $1.23 on average to deliver a vitamin A supplement in HKI-supported VAS mass distribution programs. Full details are in this spreadsheet.

 Shortcomings of our cost per supplement analysis We do not believe our cost per supplement delivered estimate for HKI is as robust as our cost per item delivered estimates for many of our other top charities due to the following:

 We have limited information on the contributions of organizations other than HKI supporting Child Health Days in Guinea, Burkina Faso, and Mali in 2018 and 2019 (UNICEF, Save the Children, Nutrition International, WHO, and World Vision).118 We have only seen information on how much funding these organizations have budgeted for government grants to support program implementation, but our cost per supplement estimate also relies on rough estimates of how much additional funding these organizations will use for other expenses, including personnel and overhead costs.119 We have also only seen budget totals for these organizations for the first VAS campaign rounds in 2018 and 2019, but not the second rounds of each year.120 We rely on an estimate that 30% of overall program costs are indirect government costs (e.g., time-use of salaried government officials), the same estimate we use for the Schistosomiasis Control Initiative's deworming programs. We would guess that VAS programs and deworming programs require similar types of contributions from governments, but we note that the 30% estimate is derived from a single deworming program in Niger.121 Our cost per supplement estimate also relies on HKI's estimates of the population of 6-to-59-month-old children in Guinea, Mali, and Burkina Faso.122 We are uncertain about the accuracy of these population estimates. We only have cost per supplement estimates for Guinea, Mali, and Burkina Faso, but HKI also currently supports VAS campaigns in Niger, Côte d'Ivoire, and Kenya.123 We have not created cost per supplement estimates for Niger, Côte d'Ivoire, and Kenya because we have seen limited information from HKI's programs in those countries to date (details in footnote).124Cost-effectiveness See our most recent cost-effectiveness model for estimates of the cost per life saved through HKI's VAS programs.

 There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

 HKI-supported VAS campaigns also deliver additional interventions alongside VAS, including deworming, polio vaccination, "mop-up" immunizations (for children who have missed scheduled immunizations), and screening for severe acute malnutrition and moderate acute malnutrition.125 A major limitation of our cost-effectiveness analysis of HKI is that we do not directly include benefits resulting from interventions delivered alongside VAS in HKI-supported programs.126

 Is there room for more funding? We believe that HKI could productively use more funding than it expects to receive to support VAS programs and that it is likely to be constrained by funding. We estimate that HKI could absorb an additional $15.6 million for supporting VAS mass campaigns in nine countries in sub-Saharan Africa over the next three years (2020-2022). Update: In the third quarter of 2019, GiveWell received $2.6 million from donors for granting at GiveWell's discretion, which we granted to HKI. Additionally, in November 2019, we recommended that Open Philanthropy grant $9.7 million to HKI, which leaves it with a funding gap of $3.3 million. See this page for a summary of HKI’s expected use of additional funding.

 In short, we calculate this from (more detail in the sections below):

 Total opportunities to spend funds productively: HKI has identified opportunities to spend $31.6 million between July 2019 and December 2022 to support VAS mass campaigns in Guinea, Mali, Burkina Faso, Nigeria, Côte d'Ivoire, Niger, Cameroon, Democratic Republic of the Congo, and Kenya (and a research project in Mozambique). HKI would likely use funding beyond this level to extend these programs to 2023 and/or seek out additional opportunities to support VAS mass campaigns. Cash on hand: We estimate that HKI holds $15.2 million for its VAS mass campaign programs, of which it expects to spend $14.8 million to continue supporting current VAS programs in 2019-2022, leaving $0.4 million in uncommitted funding. Expected funding: We expect that HKI will receive around $0.8 million next year for its work on VAS from donors who give based on GiveWell's top charity list, but do not follow our recommendation for marginal funding.Below, we also discuss:

 Past sources of funding for VAS programs: Before 2016, HKI's VAS programs were primarily supported by Global Affairs Canada. Global room for more funding for VAS programs: Global Affairs Canada is now providing significantly less per year to VAS programs overall than it did between 2013 and 2016. It appears that there is now a substantial funding gap for VAS mass campaigns at the global level. Uncommitted and expected funds The sum of HKI's uncommitted and expected funding is $1.2 million.127

 We estimate that, as of June 30, 2019, HKI held $15.2 million for VAS campaigns, $14.8 million of which is committed to future programs, leaving $0.4 million in uncommitted funding.128

 We expect that HKI will receive additional donations over the next year for its VAS mass campaign programs from donors who give based on GiveWell's top charity list, but do not follow our recommendation for marginal funding. GiveWell maintains both a list of all top charities that meet our criteria and a recommendation for which charity or charities to give to in order to maximize the impact of additional donations, given the cost-effectiveness of remaining funding gaps. We estimate that HKI will receive about $0.8 million next year from donors who use our top charity list but do not follow our recommendation for marginal donations.129

 HKI told us that it does not expect to receive funding for VAS mass campaign programs from donors not influenced by GiveWell's research.130 It is possible that this will change over the next three years.

 HKI does not expect to allocate any unrestricted funding to its VAS mass campaign programs. Unrestricted funding comprises a small proportion of HKI's overall budget (around 5% of its total spending in recent years, excluding the use of in-kind donations) and has been used to cover fundraising expenses and overhead expenses not covered through restricted grants.131

 Past sources of funds for VAS programs Between 2006 and 2016, HKI's VAS programs were primarily funded by Global Affairs Canada.132 Most recently, Global Affairs Canada granted $29 million CAD to HKI to support VAS programs in 13 countries in sub-Saharan Africa between 2013 and 2016.133 HKI submitted a concept note to Global Affairs Canada for the continuation of these programs between 2016 and 2021, but HKI did not receive a new grant.134

 Global Affairs Canada has also made grants to UNICEF and Nutrition International to support VAS programs in sub-Saharan Africa.135 HKI told us that, going forward, Global Affairs Canada planned to grant funds only to UNICEF for VAS programs in order to ease administrative burdens.136

 Additional spending opportunities In addition to its commitments to spend $14.8 million on VAS mass campaigns, HKI has identified $16.8 million in spending opportunities over the next three years to continue supporting VAS mass campaigns in Guinea, Mali, Burkina Faso, Kenya, Niger and Côte d'Ivoire and to support VAS mass campaigns in Cameroon, Democratic Republic of the Congo, and Nigeria.137 

 We ask top charities to consider GiveWell-directed funds to be multi-year grants. The amount of GiveWell-directed funding that a top charity receives can vary greatly from year to year, and spending the funds over two to three years can help smooth these fluctuations.

 HKI's additional spending opportunities by country:138 

Guinea, Mali, and Burkina Faso: Several VAS campaign rounds were skipped in these countries between 2016 and 2018; HKI did not provide financial and technical support for VAS in these countries during that period.139 Between January 2018 and June 2019, we estimate that HKI has spent $3.9 million in GiveWell-directed funding on VAS campaigns in Guinea, Mali, and Burkina Faso, and has committed to spending $7.9 million more between July 2019 and December 2022.140 HKI estimates it could use an additional $4.4 million to continue its work through 2022 and to fill relatively small funding gaps between July 2019 and December 2021.141 Côte d'Ivoire: HKI used $0.5 million in GiveWell-directed funding to fill funding gaps for two VAS campaigns in Côte d'Ivoire in 2018.142 We do not believe that VAS campaigns were skipped in 2016-2018, when HKI was not supporting VAS in the country, but HKI has told us that it expects that the 2018 campaigns would have been partially or entirely cancelled if HKI were not able to contribute funding.143 HKI received a $2 million grant from a foundation to support VAS campaigns in Côte d'Ivoire between 2019 and 2022 and an additional $0.5 million from another donor for VAS campaigns in Côte d'Ivoire in 2019.144 HKI expects that it needs an additional $1.1 million to continue supporting VAS campaigns and avoid campaign cancellations in Côte d'Ivoire between 2019 and 2022.145 Niger: HKI received a $2 million grant from a foundation to support VAS campaigns in Niger between 2019 and 2022.146 HKI told us that in the second half of 2018, in absence of its support, it expected that VAS campaigns would be skipped in roughly half the districts in the country.147 HKI estimates that an additional $1.2 million would allow it to support VAS campaigns in all unfunded districts in Niger in 2020-2022.148 Kenya: HKI budgeted $0.7 million for supporting VAS campaigns in Kenya in 2019, and has committed to using an additional $0.5 million to support VAS campaigns in 2020 and 2021.149 HKI has told us that about half of the counties in Kenya were not receiving external support in 2018 and 2019 and that VAS campaigns in the unsupported counties likely achieved low (~20%) coverage rates.150 HKI estimates that it could use an additional $1.5 million to ensure that all counties in Kenya receive technical and financial support for conducting VAS campaigns in 2020-2022.151 Democratic Republic of the Congo: HKI told us that VAS campaigns were skipped in several provinces in DRC in 2017 and 2018 because insufficient funding was available following the end of HKI's support in 2016.152 HKI told us that it would require $4.5 million in funding available to commit to DRC over three years in order to re-open its office in the country.153 Cameroon: HKI told us that in the latter half of 2018, VAS campaigns were skipped among 70% of the population of Cameroon; HKI was not supporting VAS in the country at the time.154 HKI estimates that it could use $1.8 million between 2020 and 2022 to support VAS campaigns in two regions in Cameroon.155 Nigeria: HKI has proposed using additional funding to support VAS campaigns in Bauchi state, Nigeria.156 HKI believes that VAS coverage in 2018 was low (~30%).157 HKI told us that it could use $2.4 million between 2020 and 2022 to support VAS campaigns in Bauchi.158The total of HKI's additional spending opportunities listed above is $16.8 million.159 We expect that HKI will be able to use $1.2 million in uncommitted and expected funding for these additional spending opportunities, leaving a funding gap of $15.6 million.160 See our room for more funding spreadsheet for additional details.

 We believe it is likely that HKI could absorb funding beyond this level to extend these programs to 2023 and/or seek out additional opportunities to support VAS mass campaigns.161

 Global room for more funding for VAS programs Global Affairs Canada granted 70 million CAD to HKI and UNICEF for VAS programs between 2013 and 2016 and made a new grant of 70 million CAD to UNICEF for VAS programs between 2016 and 2020.162 Due to declines in the value of the Canadian dollar relative to the US dollar, granting 70 million CAD over four years rather than three years, and an increase in the proportion of the grant intended to cover immunization activities, it appears that Global Affairs Canada is now granting considerably less funding per year for VAS programs in total than it did between 2013 and 2016.163

 Our understanding is that prior to 2016, Global Affairs Canada was the only large funder supporting the implementation of VAS programs, and that no other major funders have begun supporting VAS programs since 2016.164

 HKI as an organization We use qualitative assessments of our top charities to inform our funding recommendations. See this page for more information about this process and for our qualitative assessment of HKI as an organization.

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Canada DFATD VAS Project 2015 Unpublished HKI grant agreement VAS Project 2013 - 2016 Unpublished HKI integrated 6-month contact point pilot project report Mozambique 2015 Source HKI lessons learned on VAS in six urban health districts in Cameroon 2014 Source HKI mobile data collection presentation 2014 Source HKI monitoring tools: multiple use of LQAS for VAS Source HKI monitoring tools: quality of care checklist for supportive supervision of VAS services Source HKI monitoring tools: supporting the supply chain for the provision of VAS services Source HKI monitoring tools: VAS community assessment guide Source HKI monitoring tools: VAS sustainability assessment checklist Source HKI Nigeria PECS report 2016 Source HKI performance monitoring framework for VAS Source HKI post-event coverage survey data analysis manual 2014 Source HKI post-event coverage survey manual 2014 Source HKI post-event coverage survey report Côte d'Ivoire (French) 2012 Source HKI post-event coverage survey report Nigeria - Ekiti and Katsina states 2014 Source HKI post-event coverage survey report Sierra Leone 2013 Source HKI post-event coverage survey report Tanzania 2015 Source HKI post-event coverage survey report, Burkina Faso round 1 2018 Source HKI post-event coverage survey report, Côte d'Ivoire round 2 2018 Source HKI post-event coverage survey report, Guinea round 1 2018 Source HKI post-event coverage survey report, Mali round 1 2018 Source HKI post-event coverage survey report, Mali round 2 2018 Source HKI poster - nutrition - Nigeria Source HKI poster - SIAN vitamin A supplementation - Mali Source HKI poster - vaccination and supplementation calendar - Cameroon Source HKI poster - VAS administration - Mali Source HKI poster - vitamin A - DRC Source HKI poster - vitamin A supplementation - Nigeria Source HKI poster - vitamin A supplementation - Tanzania Source HKI poster: VAS and vaccination calendar - Senegal Source HKI poster: VAS at 6 months - Niger Source HKI poster: VAS at 6 Months (poster 1) - Senegal Source HKI poster: VAS at 6 months (poster 2) - Senegal Source HKI poster: Vitamin A Rich Foods - Senegal Source HKI preliminary coverage survey results in 2018 for the first round of VAS distribution in Mali and Burkina Faso 2018 Source HKI presentation abstract: Reaching the hard to reach with vitamin A supplementation in low-performing health zones of DR Congo Source HKI presentation abstract: Routine delivery of Vitamin A Supplementation at six months in Senegal using SMS reminder messages Source HKI presentation abstract: Strengthening district support to the micronutrient program in a low income setting-rural Mali 2014 Source HKI presentation abstract: Validation of administrative coverage for vitamin A supplementation and deworming through Integrated National Immunization Days in Guinea Source HKI presentation: Impact of ebola on mass vitamin A supplementation and deworming coverage in Sierra Leone Source HKI presentation: Kenya VAS integrated into Early Childhood Development Centers 2016 Unpublished HKI presentation: Reaching the hard to reach with vitamin A supplementation in low-performing health zones of DR Congo Unpublished HKI presentation: Routine Delivery of Vitamin A Supplementation at Six Months in Senegal using SMS Reminder Messages Source HKI presentation: Senegal Successful M-Health strategy: The routine delivery of Vitamin A Supplementation at six months using SMS appointment reminders Source HKI presentation: SMS reminders and vocal messages increase adherence to immunization and 6-month vitamin A supplementation 2016 Source HKI presentation: Strengthening District Support to the Micronutrient Program in a Low Income Setting: Rural Mali Source HKI presentation: Using Mobile Phones for Data Collection to Improve Program Operation Source HKI presentation: Using results from coverage assessment surveys to improve program operation 2014 Source HKI proposed VAS activities October 2017 Source HKI responses to GiveWell's questions May 2017 Unpublished HKI room for more funding report July 2018 Source HKI room for more funding report July 2019 Source HKI routine VAS pilot project report Kenya 2016 Source HKI SMS reminder pilot study report Côte d'Ivoire 2015 Source HKI Tanzania social mobilization toolkit: deworming dosage card (Swahili) Source HKI Tanzania social mobilization toolkit: fact sheet on lives saved Source HKI Tanzania social mobilization toolkit: factsheet for community leaders Source HKI Tanzania social mobilization toolkit: mobilization script Source HKI Tanzania social mobilization toolkit: mobilization script (Swahili) Source HKI Tanzania social mobilization toolkit: tally sheet VASD Source HKI Tanzania social mobilization toolkit: VAS administration guide Source HKI Tanzania social mobilization toolkit: VAS administration guide (Swahili) Source HKI Tanzania social mobilization toolkit: VASD job aids for district health management team Source HKI Tanzania social mobilization toolkit: VASD Logos Source HKI Tanzania social mobilization toolkit: VASD posters Source HKI Tanzania social mobilization toolkit: vitamin A dosage card (Swahili) Source HKI Tanzania social mobilization toolkit: vitamin A logo Source HKI Tanzania social mobilization toolkit: vitamin A rich foods (photo) Source HKI unrestricted funding summary FY 2014-16 Source HKI VAS administration guide: DRC - side 1 (French) Source HKI VAS administration guide: DRC - side 2 (French) Source HKI VAS administration guide: Guinea (French) Source HKI VAS administration guide: Tanzania (Swahili) Source HKI VAS brochure Cameroon Source HKI VAS brochure Côte D'Ivore Source HKI VAS brochure Guinea Source HKI VAS brochure Sierra Leone Source HKI VAS brochure Tanzania Source HKI VAS concept note Unpublished HKI VAS costs presentation 2016 Source HKI VAS documents guide for GiveWell 2017 Unpublished HKI VAS expense summary 2018 Unpublished HKI VAS expense summary 2018 redacted Source HKI VAS overview brochure Source HKI VAS project year 1 report 2014 Unpublished HKI VAS project year 2 report 2015 Unpublished HKI VAS project year 3 report 2016 Unpublished HKI VAS summary table Unpublished HKI VAS supervision checklist: DRC (French) Source HKI VAS supervision checklist: Mali (French) Source HKI VAS supervision checklist: Tanzania Source HKI VAS supervision checklist: universal Source HKI VAS television commercial: DRC (French) Source HKI website About Us Source (archive) HKI website Where we work Source (archive) Hodges et al. 2013 Source (archive) Hodges et al. 2014 Source (archive) Hodges et al. 2015 Source (archive) Imdad et al. 2010 Source (archive) Imdad et al. 2017 Source (archive) Imdad et al. 2017 RevMan data Source Ismael Teta, Country Director, HKI Cameroon, conversation wtih GiveWell, October 2, 2018 Unpublished Janmohamed and Doledec 2017 Source (archive) Janmohamed, Klemm, and Doledec 2017 Source (archive) Josette Vignon Makong, Country Director, HKI Niger, conversation with GiveWell, October 4, 2018 Unpublished Josette Vignon Makong, HKI Niger Country Director and Thierno Faye, HKI Niger Deputy Country Director, conversation with GiveWell, October 4, 2017 Unpublished Kagin et al. 2015 Source (archive) Katcher et al. 2014 Unpublished Klemm et al. 2016 Source (archive) Kupka et al. 2016 Source (archive) Lucille Bonaventure, Country Director, and Osvaldo Neto, Program Coordinator, HKI Mozambique, conversation with GiveWell, September 24, 2018 Unpublished Lyatuu et al. 2016 Source (archive) Malawi micronutrient survey 2017 Source (archive) Marily Knieriemen, HKI Mali Country Director, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, August 25, 2017 Unpublished Masanja et al. 2006 Source (archive) Nankap et al. 2013 Source Neidecker-Gonzales et al. 2007 Source (archive) Nicholas Manchus, Country Director, HKI Côte d'Ivoire, conversation with GiveWell, October 3, 2018 Unpublished Nicholas Mancus, HKI Cote d'Ivoire Country Director, conversation with GiveWell, August 30, 2017 Unpublished Palmer et al. 2012 Source (archive) Patricia Manyari, HKI Chief Financial Officer, and Sobana Prasad, HKI Controller, conversation with GiveWell, October 4, 2017 Unpublished Rolf Klemm, email to GiveWell, July 31, 2018 Unpublished Rolf Klemm, email to GiveWell, October 22, 2018 Unpublished Rolf Klemm, HKI Vice President of Nutrition, and David Doledec, HKI Regional VAS Program Manager, conversation with GiveWell, April 23, 2018 Unpublished Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell on July 14, 2017 Unpublished Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, June 5, 2019 Unpublished Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, October 12, 2018 Unpublished Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, October 19, 2017 Unpublished Ross et al. 1993 Source (archive) Saitowitz et al. 2001 Source (archive) Schemann et al. 2003 Source (archive) Sesay et al. 2015 Source (archive) Sommer and West 1996 Source (archive) Sommer et al. 1986 Source (archive) Sommer, West, and Martorell 2013 Source (archive) Stevens et al. 2015 Source (archive) Stevens et al. 2015 appendix Source (archive) Tanumihardjo et al. 2016 Source (archive) Thierno Faye, HKI Niger Deputy Country Director, email to GiveWell, October 10, 2017 Unpublished UN Inter-agency Group for Child Mortality Estimation report 2017 Source (archive) UN Inter-agency Group for Mortality Estimation website 2016 estimates Source (archive) UNICEF 2007 Source (archive) UNICEF vitamin A supplementation interactive dashboard 2016 Source (archive) USAID HKI Final Report - OFDA Guinea fortification 2014 Source (archive) West et al. 1991 Source (archive) WHO Adverse events following administration of vitamin A supplements Source (archive) WHO Global Database on Vitamin A Deficiency: Cote d'Ivoire 2006 Source (archive) WHO Global Database on Vitamin A Deficiency: DRC 2007 Source (archive) WHO Global Database on Vitamin A Deficiency: Kenya 2006 Source (archive) WHO Global Database on Vitamin A Deficiency: Mozambique 2006 Source (archive) WHO Global Database on Vitamin A Deficiency: Nigeria 2007 Source (archive) WHO Global Database on Vitamin A Deficiency: Tanzania 2007 Source (archive) WHO Global Prevalence of Vitamin A Deficiency 1995 Source (archive) WHO Global prevalence of vitamin A deficiency in populations at risk 2009 Source (archive) WHO Guideline: Vitamin A supplementation in infants and children 6-59 months of age 2011 Source (archive) WHO Preventive chemotherapy in human helminthiasis Source (archive) WHO regional offices Source (archive) WHO vitamin A supplements adverse events Source (archive) WHO vitamin A supplements usage guide 1997 Source (archive) Wirth et al. 2016 Source (archive) Wirth et al. 2017 Source (archive) 1. We have published notes from some of our conversations with HKI staff: 

 GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017 GiveWell's non-verbatim summary of a conversation with Helen Keller International, April 9, 2018 GiveWell's non-verbatim summary of a conversation with Helen Keller International, April 23, 2018 

 2. "Founded in 1915, Helen Keller International is dedicated to saving and improving the sight and lives of the world's vulnerable by combatting the causes and consequences of blindness, poor health and malnutrition. "We currently have more than 120 programs in 20 African and Asian countries.

 "Part of this work is focused on preventing blindness and vision loss for millions of vulnerable people through cataract surgery, vision correction, vitamin A supplementation, screening and treatment for diabetic retinopathy, and distribution of treatments and cures for neglected tropical diseases.

 "We also work to reduce malnutrition by promoting solutions aimed at improving nutrition practices for millions of families. These include vitamin A supplementation, maternal and child nutrition education, fortification of staple foods with essential nutrients, globally recognized family-led agricultural programs and community-based management of acute malnutrition." HKI website About Us

 "United States: We provide the gift of clear vision to tens of thousands of children every year by providing free school-based vision screenings, prescription eyeglasses, and referral for further care through our innovative ChildSight program." HKI website Where we work 

 3. "Helen Keller International (HKI) has been on the forefront of the development and scaling up of strategies to effectively deliver micronutrients, starting with our programs in vitamin A supplementation (VAS) in the early 1970s. Historically most of HKI’s work in combating vitamin A deficiency (VAD) and other micronutrient deficiencies began in Asia. Since 1997, HKI has aggressively built the program base in sub-Saharan Africa and currently operates 13 country programs in Sub-Saharan Africa." HKI VAS project year 3 report 2016, Pg 1.  HKI External Evaluation and HKI Response - Canada DFATD VAS Project 2015: "The current project provides technical assistance to 13 countries identified as suffering from chronic vitamin A deficiency. These countries are Burkina Faso, Mali, Senegal, Tanzania, Cameroon, Mozambique, Kenya, Niger, Nigeria, Sierra Leone, Côte d’Ivoire, the Democratic Republic of the Congo, and Guinea." Pg vi. "The current grant amounts to CDN$29,000,000 over a three-year period (2013–2016) and is entitled 'Scaling Up Nutrition through Integrated Life-Saving Interventions.'" Pg 1 HKI is currently using GiveWell-directed funds to support VAS programs in Guinea, Mali, Burkina Faso, and Côte d'Ivoire: HKI room for more funding report July 2018: "Following an extensive and comprehensive review of Helen Keller International (HKI) procedures, activities and performance, GiveWell recognized HKI as a Top Charity for its Vitamin A Supplementation (VAS) program in November 2017. Along with Top Charity designation, Good Ventures/GiveWell provided HKI USD $7.2 million to cover funding gaps for VAS programs in three priority countries -- Guinea, Mali and Burkina Faso." Pg 2. HKI has also allocated $141,825 in GiveWell-directed funds to support VAS in Côte d'Ivoire. Pg 5, Table 1. 

 4. WHO Guideline: Vitamin A supplementation in infants and children 6-59 months of age 2011: "In settings where vitamin A deficiency is a public health problem, vitamin A supplementation is recommended in infants and children 6–59 months of age as a public health intervention to reduce child morbidity and mortality (strong recommendation). The quality of the available evidence for all-cause mortality was high, whereas for all other critical outcomes it was moderate to very low. The quality of the available evidence for outcomes in human immunodeficiency virus (HIV)- positive children was moderate for all-cause mortality." Pg 1. One dose of 100,000 IU of vitamin A is recommended for infants aged 6 to 11 months of age, and a 200,000 IU dose of vitamin A is recommended for children 12 to 59 months of age every four to six months. Table 1, Pg 5. WHO defines vitamin A deficiency to be of mild public health importance when rates of vitamin A deficiency (defined as a measure of serum or plasma retinol <0.70 µmol/l) among preschool-aged children or pregnant women are between 2% and 10%, moderate public health importance when rates of vitamin A deficiency among preschool-aged children or pregnant women are between 10% and 20%, and severe public health importance when rates of vitamin A deficiency among preschool-aged children or pregnant women are greater than or equal to 20%. WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 8, Table 5. 

 5. "Vitamin A is an essential nutrient needed in small amounts for the normal functioning of the visual system, and maintenance of cell function for growth, epithelial integrity, red blood cell production, immunity and reproduction. Essential nutrients cannot be synthesized by the body and therefore must be provided through diet." WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 1. "Vitamin A is required for normal functioning of the visual system, maintenance of cell function for growth, epithelial integrity, red blood cell production, immunity, and reproduction (Sommer 1996)." Imdad et al. 2017, Pg 8. See Sommer and West 1996 (cited in Imdad et al. 2017 in the bullet point above) chapters 8 and 9 for a detailed description of how vitamin A is understood to function in visual, immune, and other bodily systems. 

 6. "Vitamin A is an essential nutrient needed in small amounts for the normal functioning of the visual system, and maintenance of cell function for growth, epithelial integrity, red blood cell production, immunity and reproduction. Essential nutrients cannot be synthesized by the body and therefore must be provided through diet." WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 1.

 

 7. WHO Global prevalence of vitamin A deficiency in populations at risk 2009: "Deficiency of sufficient duration or severity can lead to disorders that are common in vitamin A deficient populations such as xerophthalmia (xeros = dryness; -ophthalmia = pertaining to the eye), the leading cause of preventable childhood blindness, anaemia, and weakened host resistance to infection, which can increase the severity of infectious diseases and risk of death." Pg 1. "The term xerophthalmia encompasses the clinical spectrum of ocular manifestations of VAD, from milder stages of night blindness and Bitot’s spots, to potentially blinding stages of corneal xerosis, ulceration and necrosis (keratomalacia). . . . The stages of xerophthalmia are regarded both as disorders and clinical indicators of VAD, and thus can be used to estimate an important aspect of morbidity and blinding disability as well as the prevalence of deficiency. As corneal disease is rare, the most commonly assessed stages are night blindness, obtainable by history, and Bitot’s spots, observable by handlight examination of the conjunctival surface. Standard procedures exist for assessing xerophthalmia. Although night blindness and Bitot’s spots are considered mild stages of eye disease, both represent moderate-to-severe systemic VAD, as evidenced by low serum retinol concentrations, and increased severity of infectious morbidity (i.e. diarrhoea and respiratory infections) and mortality in children and pregnant women." Pgs 2-3. "Vitamin A deficiency (VAD) impairs body functions and may cause death. Adverse health consequences may also include xerophthalmia (dry eyes), susceptibility to infection, stunting, and anaemia (Sommer 1996; Rice 2004)." Imdad et al. 2017, Pg 8. 

 8. WHO Global prevalence of vitamin A deficiency in populations at risk 2009:

 "The main underlying cause of VAD as a public health problem is a diet that is chronically insufficient in vitamin A that can lead to lower body stores and fail to meet physiologic needs (e.g. support tissue growth, normal metabolism, resistance to infection)." Pg 1. "Dietary deficiency can begin early in life, with colostrum being discarded or breastfeeding being inadequate, thereby denying infants of their first, critical source of vitamin A. Thereafter, into adulthood, a diet deficient in vitamin A lacks foods containing either preformed vitamin A esters, such as liver, milk, cheese, eggs or food products fortified with vitamin A or lacking its carotenoid precursors (mainly beta-carotene), such as green leaves, carrots, ripe mangos, eggs, and other orange-yellow vegetables and fruits. Where animal source or fortified foods are minimally consumed, dietary adequacy must rely heavily on foods providing beta-carotene. However, while nutritious in many ways, a diet with modest amounts of vegetables and fruits as the sole source of vitamin A may not deliver adequate amounts, based on an intestinal carotenoid-to-retinol conversion ratio of 12:1. This ratio reflects a conversion efficiency that is about half that previously thought, leading to greater appreciation for why VAD may coexist in cultures that heavily depend on vegetables and fruits as their sole or main dietary source of vitamin A. "Usually, VAD develops in an environment of ecological, social and economical deprivation, in which a chronically deficient dietary intake of vitamin A coexists with severe infections, such as measles, and frequent infections causing diarrhoea and respiratory diseases that can lower intake through depressed appetite and absorption, and deplete body stores of vitamin A through excessive metabolism and excretion. The consequent 'synergism' can result in the body’s liver stores becoming depleted and peripheral tissue and serum retinol concentrations decreasing to deficient levels, raising the risks of xerophthalmia, further infection, other VADD and mortality." Pg 1. 



 9. "WHO regional estimates indicate that the highest proportion of preschool-age children affected by night blindness, 2.0%, is in Africa, a value that is four times higher than estimated in South-East Asia (0.5%). This also means that Africa has the greatest number of preschool-age children affected with night blindness (2.55 million), and corresponds to almost half of the children affected globally (Table 10). A comparable and high proportion of pregnant women affected by night blindness are in Africa (9.8%) and South-East Asia (9.9%), each of which is estimated to have over 3 million pregnant women affected, or one third of the pregnant women affected globally. The estimates show that the Africa and South-East Asia regions also contain the highest proportions of preschool-age children with biochemical VAD, as indicated by a serum retinol concentration <0.70 µmol/l, with South-East Asia having the greatest number of children and pregnant women affected." WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pgs 10-11. See WHO regional offices for countries included in the Africa and South-East Asia Regions. 

 10. "Low vitamin A intake during nutritionally demanding periods in life, such as infancy, childhood, pregnancy and lactation, greatly raises the risk of health consequences, or vitamin A deficiency disorders (VADD)." WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 1.

 

 11. "Provision of high doses of vitamin A every 6 months until the age of 5 years was based on the principle that a single, large dose of vitamin A is well absorbed and stored in the liver, and then mobilized, as needed, over an extended period of time. A dose of 100 000 International Units (IU) in infants 6–11 months of age and 200 000 IU in children 12–59 months of age is considered to provide adequate protection for 4–6 months, with the exact interval depending on the vitamin A content of the diet and the rate of utilization by the body." WHO Guideline: Vitamin A supplementation in infants and children 6-59 months of age 2011, Pg 3. "Vitamin A is a term used for a subclass of retinoic acids, a family of lipid-soluble compounds (Bates 1995). Vitamin A is found in two main forms: provitamin A carotenoids and preformed vitamin A. Provitamin A carotenoids are found in plants; beta-carotene is the only one that is metabolised by mammals into vitamin A. Though fruits and vegetables are nutritious in other ways, normal dietary intake of plants may not deliver adequate amounts of vitamin A because the intestinal carotenoid-to-retinol conversion ratio varies with type of food, ranging from 6:1 to 26:1 (US Institute of Medicine, Food and Nutrition Board; Van Lieshout 2005). Consequently, VAD can exist in places with high vegetable and fruit consumption (West 2002). Preformed vitamin A (retinol, retinal, retinoic acid, and retinyl esters), is the most active form of vitamin A and is found in animal sources. Supplements usually use preformed vitamin A (Shenai 1993; Bates 1995)." Imdad et al. 2017, Pg 8. 

 12. WHO Guideline: Vitamin A supplementation in infants and children 6-59 months of age 2011: "In settings where vitamin A deficiency is a public health problem, vitamin A supplementation is recommended in infants and children 6–59 months of age as a public health intervention to reduce child morbidity and mortality (strong recommendation). The quality of the available evidence for all-cause mortality was high, whereas for all other critical outcomes it was moderate to very low. The quality of the available evidence for outcomes in human immunodeficiency virus (HIV)- positive children was moderate for all-cause mortality." Pg 1. One dose of 100,000 IU of vitamin A is recommended for infants aged 6 to 11 months of age, and a 200,000 IU dose of vitamin A is recommended for children 12 to 59 months of age every four to six months. Table 1, Pg 5. WHO defines vitamin A deficiency to be of mild public health importance when rates of vitamin A deficiency (defined as a measure of serum or plasma retinol <0.70 µmol/l) among preschool-aged children or pregnant women are between 2% and 10%, moderate public health importance when rates of vitamin A deficiency among preschool-aged children or pregnant women are between 10% and 20%, and severe public health importance when rates of vitamin A deficiency among preschool-aged children or pregnant women are greater than or equal to 20%. WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 8, Table 5. 

 13. "Mass distribution campaigns are the main delivery mechanism for VAS. These campaigns are organized at least every 6 months...

 "Because mass campaigns take place only every 4 to 6 months, children who reach the age of 6 months between two campaigns, may have to wait several months before they get their first dose of Vitamin A despite being the most vulnerable age group.

 "To remedy this, HKI is working closely with country-level health sector experts to add a contact point in national immunization calendars – at 6 months, when no other vaccination is scheduled.

 "Additionally, HKI supports routine facility-based and outreach delivery of vitamin A for all children under 5 in countries where stronger health systems offer sufficient access to quality services. Few countries are ready for this approach and these still need to develop social mobilization actions to create demand to match the capacity to offer services." HKI VAS overview brochure, Pg 2.

 

 14. GiveWell's notes from a site visit with HKI to Conakry, Guinea, October 9-11, 2017: "In polio vaccination campaigns–also known as national immunization days (NIDs)–health workers go door-to-door providing oral polio vaccines. These campaigns generally occur one or more times per year. Because teams are already going door-to-door, it is relatively simple and inexpensive to add an additional person to each distribution team to deliver VAS to children aged 6 to 59 months." Pg 3. "Mobile CHDs [Child Health Days] involve health workers going door-to-door to provide communities with vitamin A supplements and other health services. This strategy is operationally very similar to polio NIDs." Pg 3. 

 15. "Fixed-site distribution In fixed-site CHDs [Child Health Days], caregivers must bring their children to health centers or other fixed distribution sites to receive the package of health services. Many CHD programs utilize a 'fixed + outreach' strategy, in which they implement outreach activities to encourage caregivers to bring their children to the fixed site to receive health services."  GiveWell's notes from a site visit with HKI to Conakry, Guinea, October 9-11, 2017, Pg 3.

 

 16. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 We have not seen the social mobilization materials HKI is using in Guinea, but HKI has sent us some examples of social mobilization materials it has used in past campaigns: HKI Tanzania social mobilization toolkit: VASD posters HKI Tanzania social mobilization toolkit: mobilization script HKI Tanzania social mobilization toolkit: mobilization script (Swahili) HKI VAS television commercial: DRC (French) 

 17. "For distribution sites visited by an independent HKI supervisor, 86% met the criteria for minimum quality threshold for service delivery defined as 1) health worker used scissors to cut the capsule 2) health worker asked the age of the child 3) health worker squeezed the drops into the child’s mouth 4) health worker used the correct dose of VAS and 5) were there no stock-outs of VAC." HKI VAS project year 1 report 2014 See the guidelines for health workers in HKI VAS supervision checklist: universal and HKI Tanzania social mobilization toolkit: VAS administration guide. 

 18. HKI Tanzania social mobilization toolkit: VAS administration guide: "Ask the age of the child to determine the appropriate dose of vitamin A (6-59 months) and whether the child is old enough for a deworming tablet (12-59 months)." "If the distribution point runs out of red (200,000 IU) capsules, two blue (100,000 IU) capsules can be given in place of one red capsule. If the distribution points runs out of blue capsules squeeze half the number of drops from a red capsule into the mouth of a child aged 6-11 months." See additional guidelines for dosage selection in HKI VAS supervision checklist: universal. 

 19. "To date, HKI’s VAS project has undertaken three main types of activities, which can roughly be categorized as disbursing sub-grants to the government, providing technical assistance, and engaging in advocacy efforts." HKI External Evaluation and HKI Response - Canada DFATD VAS Project 2015, Pg 35. "HKI provides a package of interventions and services that include training, policy development, advocacy, monitoring & evaluation, service delivery, behavior change communication, social mobilization and supervision in all 13 countries where HKI assists host-country governments to implement universal preschool vitamin A supplementation programs." HKI country-level technical support related to vitamin A supplementation, Pg 1. "In concrete terms, HKI, in consultation with national government counterparts, directs its support to low performing areas to help local program managers identify and solve VAS coverage barriers. This involves organizing workshops with state and district health authorities to analyze what worked and what did not. HKI teams then spend time with health managers to help them identify feasible and cost-effective solutions to improve performance of the targeted services and accompany them through the whole programming cycle (i.e. planning, budgeting, implementation, real time supervision and monitoring, and finally evaluation of the progress made). One cycle sometimes proves insufficient so the HKI teams continue working with each targeted health district until minimum thresholds of performance are met. Funds are used to support deployment of HKI teams in remote areas, to support financing workshops and joint field supervisions, to provide training for field actors, or to organize coverage surveys and review meetings at the end of the exercise. In some cases, HKI provides funds directly to the local authorities to fill financial gaps they may experience ensuring rigorous financial accountability. When conditions for a change of approach are met, HKI provides technical assistance to local authorities to design, implement and monitor with them innovative approaches such as the 6-month contact point or SMS messaging." HKI VAS documents guide for GiveWell 2017, Pg 4. 

 20. Coverage surveys: HKI assists governments with implementing surveys to assess coverage (i.e., the percentage of targeted children who actually received vitamin A supplements) following VAS mass distribution campaigns: "Since 2010, HKI has developed a methodology to assess the true coverage of vitamin A supplementation and identify barriers and determinants of high coverage. Based on a cross sectional survey methodology, the Post-Event Coverage Surveys (PECS) are conducted by health system personnel using mobile phones and allow multiple indicators to be collected. More than 50 surveys have been conducted in 15 countries and provide data to improve performance of VAS programs and ensure that all children have equitable access to essential child survival services." HKI VAS overview brochure, Pg 2. See this spreadsheet for a summary of the results and methodology of HKI's recent coverage surveys. Administrative data: "HKI helps to track national VAS coverage through the governments tally-sheet system (also referred to as 'Administrative Data')." HKI VAS documents guide for GiveWell 2017, Pg 6. We have not yet seen specific descriptions of how HKI assists governments with tracking administrative data. Process monitoring: HKI recruits and organizes "independent" (not affiliated with countries' ministries of health) monitoring teams to conduct process monitoring during VAS campaigns. Process monitoring involves assessments (using checklists) of randomly-selected VAS distribution sites. Process monitors report their findings daily to HKI using mobile phones. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 We have seen examples of checklists used by independent process monitors, but we have not yet seen documents reporting on data collected by process monitors: HKI monitoring tools: quality of care checklist for supportive supervision of VAS services HKI VAS supervision checklist: DRC (French) HKI VAS supervision checklist: Mali (French) HKI VAS supervision checklist: Tanzania HKI VAS supervision checklist: universal HKI told us that it also provides technical support for process monitoring conducted by ministries of health. Like independent process monitoring, process monitoring conducted by ministries of health also involves visits to randomly selected VAS distribution sites, but checklists and formal reporting are not often required. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 

 21. Developing training materials: "In all countries, HKI developed comprehensive training packages to allow governments conduct training and organized training of trainers." HKI country-level technical support related to vitamin A supplementation, Pgs 1-2. "All of HKI’s work in VAS/CHDs programs focuses on alignment with and use of existing national systems. This requires significant engagement of human resources at national and decentralized levels and a sound understanding of national systems, and how they can be leveraged to achieve program scale. Critical entry points for HKI engagement include supporting development of national policy, catalyzing national and district level planning, training front-line delivery agents and program managers, supporting formative supervision and strengthening monitoring systems and encouraging use of data for program quality improvement and management for results." HKI VAS project year 3 report 2016, Pg 2. Specific examples we have seen of this type of activity: HKI Tanzania social mobilization toolkit: VAS administration guide HKI Tanzania social mobilization toolkit: VASD job aids for district health management team HKI VAS administration guide: Guinea (French) Direct training of health workers: "Facilitate refresher training of 62786 Community workers and health worker (24747 in 1st Round and 38039 in second Round)" HKI VAS project year 1 report 2014, Pg 42 (in list of HKI's activities in Democratic Republic of the Congo during the year). 

 22. HKI assists governments with designing "6-month contact point" policies: "Because mass campaigns take place only every 4 to 6 months, children who reach the age of 6 months between two campaigns, may have to wait several months before they get their first dose of Vitamin A despite being the most vulnerable age group. "To remedy this, HKI is working closely with country-level health sector experts to add a contact point in national immunization calendars – at 6 months, when no other vaccination is scheduled." HKI VAS overview brochure, Pg 2.

 See HKI 6-month contact point standard methodology for a detailed description of the policy. 

 23. "In concrete terms, HKI, in consultation with national government counterparts, directs its support to low performing areas to help local program managers identify and solve VAS coverage barriers. This involves organizing workshops with state and district health authorities to analyze what worked and what did not. HKI teams then spend time with health managers to help them identify feasible and cost-effective solutions to improve performance of the targeted services and accompany them through the whole programming cycle (i.e. planning, budgeting, implementation, real time supervision and monitoring, and finally evaluation of the progress made). One cycle sometimes proves insufficient so the HKI teams continue working with each targeted health district until minimum thresholds of performance are met. Funds are used to support deployment of HKI teams in remote areas, to support financing workshops and joint field supervisions, to provide training for field actors, or to organize coverage surveys and review meetings at the end of the exercise. In some cases, HKI provides funds directly to the local authorities to fill financial gaps they may experience ensuring rigorous financial accountability. When conditions for a change of approach are met, HKI provides technical assistance to local authorities to design, implement and monitor with them innovative approaches such as the 6-month contact point or SMS messaging." HKI VAS documents guide for GiveWell 2017, Pg 4. Specific example of this type of work: "Meeting with State Director of Public Health to initiate the VAS workplan development in 8 States" and "Obtain annual costed workplan from HKI-supported states" are listed as activities completed by HKI in 2013 in Nigeria. HKI VAS project year 1 report 2014, Pg 96, Table 72. 

 24. "Creating demand by promoting healthy behaviors: "HKI promotes social mobilization campaigns that inform caregivers of children aged 6 to 59 months of the importance of VAS and that a supplementation campaign is taking place in their neighborhood. Some of HKI’s achievements include: Using of SMS reminders sent to every caregiver; Cooperating with religious and traditional leaders; Involving community health workers and volunteers to organize regular population census that ensure that each child is reached at home; Developing with health authorities and rolling-out comprehensive social mobilization toolkits that include multi-media communication and sensitization tools and messages; and Associating social mobilization with comprehensive social & behavior change strategies."  HKI VAS overview brochure, Pg 3.

 Examples of social mobilization and marketing materials: HKI Tanzania social mobilization toolkit: VASD posters HKI Tanzania social mobilization toolkit: mobilization script HKI Tanzania social mobilization toolkit: mobilization script (Swahili) HKI VAS television commercial: DRC (French) HKI told us that it uses more time and funding on social mobilization in countries where caregivers bring children to receive vitamin A supplements at fixed sites than in countries using door-to-door distributions. Among countries where HKI is currently supporting VAS mass distribution campaigns, Guinea uses fixed-site distributions and Mali and Burkina Faso use door-to-door distribution. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 

 25. "HKI teams work closely with national governments to support the policy, strategy and tool development mentioned above, but HKI’s major added value is its capacity to rapidly deploy technical support to the sub national level to assist local health authorities with implementing national VAS strategies. HKI focus its efforts sub-nationally because local level (at state and/or district level) health system performance is key to ensuring high VAS coverage. It also allows HKI to support other health system functions that also improve the delivery of other maternal and child health services. "In concrete terms, HKI, in consultation with national government counterparts, directs its support to low performing areas to help local program managers identify and solve VAS coverage barriers. This involves organizing workshops with state and district health authorities to analyze what worked and what did not. HKI teams then spend time with health managers to help them identify feasible and cost-effective solutions to improve performance of the targeted services and accompany them through the whole programming cycle (i.e. planning, budgeting, implementation, real time supervision and monitoring, and finally evaluation of the progress made). One cycle sometimes proves insufficient so the HKI teams continue working with each targeted health district until minimum thresholds of performance are met. Funds are used to support deployment of HKI teams in remote areas, to support financing workshops and joint field supervisions, to provide training for field actors, or to organize coverage surveys and review meetings at the end of the exercise. In some cases, HKI provides funds directly to the local authorities to fill financial gaps they may experience ensuring rigorous financial accountability. When conditions for a change of approach are met, HKI provides technical assistance to local authorities to design, implement and monitor with them innovative approaches such as the 6-month contact point or SMS messaging." HKI VAS documents guide for GiveWell 2017, Pgs 3-4.

 See this spreadsheet, "HKI population targets" sheet, for a list of the regions HKI is supporting in current programs supported by GiveWell-directed funds in Guinea, Mali, and Burkina Faso. HKI told us that it selected regions in Guinea, Mali, and Burkina Faso that it judged would be most in need of technical support. UNICEF is providing technical support to the remainder of the regions in each country. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 

 26. "In most countries, HKI teams spent around 10% of their time working with the national government to advocate for VAS. HKI advocated for domestic budgets to take a greater proportion of the costs of VAS, to integrate VAS in national health and nutrition policy documents and in pluriannual strategies or action plans, supporting coordination between actors and sectors and promoting monitoring of VAS at national level to provide the government with a comprehensive vision of the services for the whole country." HKI country-level technical support related to vitamin A supplementation, Pg 1.

 

 27. "Because mass campaigns take place only every 4 to 6 months, children who reach the age of 6 months between two campaigns, may have to wait several months before they get their first dose of Vitamin A despite being the most vulnerable age group.

 "To remedy this, HKI is working closely with country-level health sector experts to add a contact point in national immunization calendars – at 6 months, when no other vaccination is scheduled." HKI VAS overview brochure, Pg 2.

 

 28. "In concrete terms, HKI, in consultation with national government counterparts, directs its support to low performing areas to help local program managers identify and solve VAS coverage barriers. This involves organizing workshops with state and district health authorities to analyze what worked and what did not. HKI teams then spend time with health managers to help them identify feasible and cost-effective solutions to improve performance of the targeted services and accompany them through the whole programming cycle (i.e. planning, budgeting, implementation, real time supervision and monitoring, and finally evaluation of the progress made). One cycle sometimes proves insufficient so the HKI teams continue working with each targeted health district until minimum thresholds of performance are met. Funds are used to support deployment of HKI teams in remote areas, to support financing workshops and joint field supervisions, to provide training for field actors, or to organize coverage surveys and review meetings at the end of the exercise. In some cases, HKI provides funds directly to the local authorities to fill financial gaps they may experience ensuring rigorous financial accountability." HKI VAS documents guide for GiveWell 2017 "To date, HKI’s VAS project has undertaken three main types of activities, which can roughly be categorized as disbursing sub-grants to the government, providing technical assistance, and engaging in advocacy efforts." HKI External Evaluation and HKI Response - Canada DFATD VAS Project 2015, Pg 35. For VAS programs HKI supported between 2013 and 2016, spending categorized as "Service Delivery" is funding HKI has granted to governments for program implementation. See this spreadsheet, "By category" sheet, for details. HKI's budgets for VAS programs between 2018 and 2020 are in this spreadsheet, "HKI three-year budget" sheet. Budgets for "sub-agreements" are funds that HKI plans to grant to governments for program implementation. 

 29. "Micronutrient Initiative (MI) (the name of the organization changed ~1 month ago to Nutrition International or NI) is only active in 4 of the 13 countries were HKI is operational, however MI provides the needed number of vitamin A capsules to all countries where HKI works. MI’s role essentially takes place at the national level, providing technical and policy guidance to governments. In most cases, MI delivers the vitamin A capsules to UNICEF, who organizes their management with the national government and ensures that they reach the field. UNICEF’s role is mainly at national level to support all aspects of maternal and child health. This large portfolio gives them the capacity to weigh strongly on decisions at national level but also prevents them from providing specific technical assistance, especially at the sub-national and district levels, where needed. HKI, being more flexible and specialized, takes on this technical support role, and builds evidence, and adjusts its activities to the evolving needs of the program." HKI country-level technical support related to vitamin A supplementation, Pg 2. In current programs in Guinea, Mali, and Burkina Faso, regions not listed as being supported by HKI in this spreadsheet, "HKI population targets" sheet, receive technical and financial support from UNICEF. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 

 30. "In Sierra Leone, HKI supports the scale up of routine delivery of VAS as campaigns are phasing out. This program, funded by Irish Aid and UNICEF and implemented by HKI and the MoH, consists of a package of services delivered through health facilities beginning when children reach 6 months of age: VAS, deworming, counseling on family planning, reproductive health services, counseling on infant and young child feeding, growth monitoring and promotion and routine immunization. After 1 year of implementation, aa survey conducted in October 2018 showed VAS coverage of between 70 and 90% for all children under five in the three districts where the package has been piloted. Givewell funds were also allocated to fill a gap of funding for this program between the ending of one and signature of a new grant from UNICEF." HKI annual report to GiveWell 2018, Pg 4.

 

 31. Global Affairs Canada granted 29 million CAD to HKI to support VAS programs in thirteen countries in sub-Saharan Africa between 2013 and 2016: "Since 2002, Helen Keller International (HKI) has partnered with UNICEF and the Department of Foreign Affairs, Trade and Development of Canada (DFATD), formerly the Canadian International Development Agency (CIDA), to work towards increasing and sustaining vitamin A supplementation (VAS) coverage in countries with a high burden of child mortality and nutrition-related disease. The partnership started in five sub-Saharan countries, and expanded during the 2005–2008 period to nine countries, where it focused primarily on shifting to twice-yearly distribution, sustainability and building national capacity. The subsequent project (Scaling up Child Health and Nutrition in Sub-Saharan Africa) ran from 2009–2013 and operated in 13 countries. "The current grant amounts to CDN$29,000,000 over a three-year period (2013–2016) and is entitled “Scaling Up Nutrition through Integrated Life-Saving Interventions.” The two primary anticipated outcomes of the project are:

  enhanced healthy nutritional practices for children 6–59 months through maintained high coverage of child health and nutrition services; and increased national ownership of child survival activities (in transitioning countries)." HKI External Evaluation and HKI Response - Canada DFATD VAS Project 2015, Pg 1.

 "Annex 1 - History of grants devoted to VAS implemented by HKI with support from GAC [Global Affairs Canada]" lists a grant of $29 million CAD from Global Affairs Canada to HKI for 13 countries in sub-Saharan Africa implemented between February 2013 and May 2016. HKI VAS concept note, Pg 22. 

 32. Imdad et al. 2010:

 “Vitamin A was associated with a 24% reduction in all-cause mortality (RR = 0.76 (95% CI 0.69 to 0.83)), though there was moderate heterogeneity.” Imdad et al. 2010, Pg 18. "One [additional randomized trial] reported no events [i.e. deaths] (Lin 2008)” and therefore had zero weight in the analysis. Pg 18. "Post hoc, we included two studies in which participants were assigned using a quasi-random method (Herrera 1992; Stansfield 1993)." Pg 10. Only one of these, Herrera et al. 1992, was included in the analysis of all-cause mortality. Pg 18. The quasi-randomized trial included in the all-cause mortality meta-analysis, Herrera et al. 1992, "reported no effect (RR = 1.06 (95% CI 0.92 to 1.37)), indicating that these trials were not likely to influence [Cochrane’s] results in a positive direction." Pg 19. 

 33. Awasthi et al. 2013: “Deaths per child-care centre at ages 1.0–6.0 years during the 5-year study (the primary trial endpoint) were 3.01 retinol versus 3.15 control (absolute reduction 0.14 [SE 0.11], mortality rate ratio [RR] 0.96, 95% CI 0.89–1.03, p=0.22), suggesting absolute risks of death between ages 1.0 and 6.0 years of approximately 2.5% retinol versus 2.6% control. Although this finding suggests that overall child mortality was 4% lower in vitamin A than in control blocks, this 4% reduction includes the possibility of no benefit and the possibility of appreciable benefit (95% confidence limit for reduction 11%).” Pg 1473. "In these 72 blocks, 8338 child-care centres were followed up, with total population at ages 1·0–6·0 years 1 million and 5 million child-years at risk in the 5 years between May, 1999, and April, 2004." Pg 1470. "DEVTA trial 2013... Eligibility: children aged 1-6 years were eligible for inclusion in the review Sample: total clusters were 72, of which 36 clusters received vitamin A supplementation while 36 acted as control. Authors claimed to include 1 million children in the trial." Imdad et al. 2017, Pg 55. 

 34. Imdad et al. 2017, Pg 18, Figure 3.

 

 35. Imdad et al. 2017:

 "At longest follow-up, there was a 12% observed reduction in the risk of all-cause mortality for vitamin A compared with control using a fixed-effect model (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.83 to 0.93; high-quality evidence)." Pg 2. "A sensitivity analysis using a random-effects model found a 24% reduction in mortality, essentially the same as our original estimate (RR 0.76, 95% CI 0.69 to 0.83), published previously (Imdad 2010a)." Pg 25. 

 36. Cochrane Handbook section 9.5.4: Incorporating heterogeneity into random-effects models:

 "A fixed-effect meta-analysis provides a result that may be viewed as a ‘typical intervention effect’ from the studies included in the analysis. In order to calculate a confidence interval for a fixed-effect meta-analysis the assumption is made that the true effect of intervention (in both magnitude and direction) is the same value in every study (that is, fixed across studies). This assumption implies that the observed differences among study results are due solely to the play of chance, i.e. that there is no statistical heterogeneity." "When there is heterogeneity that cannot readily be explained, one analytical approach is to incorporate it into a random-effects model. A random-effects meta-analysis model involves an assumption that the effects being estimated in the different studies are not identical, but follow some distribution. The model represents our lack of knowledge about why real, or apparent, intervention effects differ by considering the differences as if they were random. The centre of this distribution describes the average of the effects, while its width describes the degree of heterogeneity. The conventional choice of distribution is a normal distribution. It is difficult to establish the validity of any distributional assumption, and this is a common criticism of random-effects meta-analyses. The importance of the particular assumed shape for this distribution is not known." "If variation in effects (statistical heterogeneity) is believed to be due to clinical diversity, the random-effects pooled estimate should be interpreted differently from the fixed-effect estimate since it relates to a different question. The random-effects estimate and its confidence interval address the question ‘what is the average intervention effect?’ while the fixed-effect estimate and its confidence interval addresses the question ‘what is the best estimate of the intervention effect?’ The answers to these questions coincide either when no heterogeneity is present, or when the distribution of the intervention effects is roughly symmetrical. When the answers do not coincide, the random-effects estimate may not reflect the actual effect in any particular population being studied." 

 37.  The DEVTA researchers conducted a meta-analysis of DEVTA and eight previous large trials where pre-school children were provided with multiple doses of VAS per year. They found “heterogeneity between DEVTA and subtotal of eight previous trials p = 0.0010.” Awasthi et al. 2013, Pg 1475.

 

 38. See our vitamin A intervention report for sources and details.

 

 39. “The biggest specific cause of death that VAS reduces is diarrhea. Deaths from diarrhea are falling but still a leading cause of childhood mortality globally.” GiveWell's non-verbatim summary of a conversation with Evan Mayo-Wilson, June 10, 2013, Pg 2.  “In a reanalysis of one of the original eight trials, the beneficial effect was limited to unvaccinated children and there were strong sex-differential effects of vitamin A supplementation in vaccinated children. Hence, the roll-out of the vaccination programme might be one environmental factor that has modified the effect of vitamin A.” Benn, Fisker, and Aaby 2013, Pg 593. 

 40. Beaton et al. 1993: "The second consideration might be overall mortality rates. Figure 5.3 portrays the relative effectiveness of vitamin A supplementation in relation to control group mortality rates (a poor proxy for baseline mortality rate). No particular relationship is apparent and none could be detected in statistical analyses involving a variety of models in which individual projects were weighted (see Technical Annex)." Pg 67. See Figure 5.3, Pg 68. Beaton et al. 1993's analysis includes eight VAS trials. We have not completed an up-to-date analysis of this type for all the VAS trials that measured all-cause mortality included in Imdad et al. 2017. 

 41. "Coverage was ascertained from logbooks of overworked government community workers (anganwadi workers), and verified by a small number of supervisors who periodically visited randomly selected anganwadi workers to question and examine children who these workers gathered for them. Both anganwadi worker self-reports, and the validation procedures, are fraught with potential bias that would inflate the actual coverage . . . Although 76% of children aged 0–71 months in 2005–06 lived in areas covered by an anganwadi worker, only 22% of children received any service from the anganwadi worker. Thus, it is hard to understand how DEVTA ramped up coverage to extremely high levels (and if it did, why so little of this effort was sustained). DEVTA provided the anganwadi workers with less than half a day’s training and minimal if any incentive." Sommer, West, and Martorell 2013, Pg 591. 

 42. In our vitamin A supplementation intervention report, we note that DEVTA did not target children in remote areas, who may have been more likely than other children to suffer from VAD (see here and here). We also note that some control group members may have received some doses of vitamin A (see here). Additionally, HKI told us the following: "DEVTA represented an earnest attempt to evaluate the impact of Anganwadi delivery of vitamin A capsules on preschool child mortality and vitamin A deficiency. The DEVTA trial included about a million children and found a small mortality benefit (~4%) for vitamin A supplementation, although not statistically significant. The DEVTA findings generated controversy because many experts believe that the methods for the delivery of the intervention and the assessment of the primary outcome (i.e. all-cause mortality) were not rigorous (Habicht 2013; Mannar 2013; Mayo-Wilson 2013; Sloan 2013; Sommer 2013). For example, investigators did not count children at baseline or obtain informed consent, and methods of follow up and data collection were not [r]igorous (Mannar 2013; Sommer 2013). In this cluster-randomized trial, vitamin A capsules were distributed by Anganwadi workers who had contact with only 26% of the children living in the study area (Sommer 2013). In reply to [t]his extensive criticism, authors of DEVTA emphasized that results of this trial need to be interpreted alongside previously published studies (Peto 2013)." HKI responses to GiveWell's questions May 2017, Pg 6. We have not yet vetted the sources cited in the bullet point above. 

 43. See our vitamin A supplementation intervention report for details about rates of VAD among DEVTA participants. "There is likely a threshold of VAD prevalence below which VAS is unlikely to have much impact on mortality. If there is high-quality data showing low VAD in a region, HKI thinks it is reasonable not to expect VAS to have a mortality impact there. "Organizations in the Global Alliance for Vitamin A (GAVA) currently use 10% VAD as the threshold at or above which VAS programs ought to be maintained in a region. The World Health Organization (WHO) classifies VAD rates of 20% or greater among preschool-aged children as a serious public health problem. VAD rates of less than 5% are accepted as not much of a concern." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pg 2.

 WHO only recommends VAS programs in areas where VAD is a public health concern. WHO Guideline: Vitamin A supplementation in infants and children 6-59 months of age 2011: "In settings where vitamin A deficiency is a public health problem, vitamin A supplementation is recommended in infants and children 6–59 months of age as a public health intervention to reduce child morbidity and mortality (strong recommendation). The quality of the available evidence for all-cause mortality was high, whereas for all other critical outcomes it was moderate to very low. The quality of the available evidence for outcomes in human immunodeficiency virus (HIV)- positive children was moderate for all-cause mortality." Pg 1. One dose of 100,000 IU of vitamin A is recommended for infants 6 to 11 months of age, and a 200,000 IU dose of vitamin A is recommended for children 12 to 59 months of age every four to six months. Table 1, Pg 5. WHO defines vitamin A deficiency to be of mild public health importance when rates of vitamin A deficiency (defined as a measure of serum or plasma retinol <0.70 µmol/l) among preschool-aged children or pregnant women are between 2% and 10%, moderate public health importance when rates of vitamin A deficiency among preschool-aged children or pregnant women are between 10% and 20%, and severe public health importance when rates of vitamin A deficiency among preschool-aged children or pregnant women are greater than or equal to 20%. WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 8, Table 5. 

 44. "A threshold like this might not be observed if vitamin A had a pharmacological effect (i.e., if a large dose of vitamin A directly primed the immune system in some way, regardless of deficiency). However, Dr. Klemm thinks there is not any clear evidence to substantiate this hypothesis." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pg 2. "Studies from the 1980s and early 1990s showed that vitamin A deficiency (VAD) was associated with increased overall child mortality and high-dose vitamin A supplementation (VAS) reduced overall mortality. This has led to the long-lived and strong assumption that VAS works by preventing VAD. Though intuitive, this assumption is contradicted by several facts. "First, high-dose VAS has no sustained effect on VAD, as measured by serum retinol or other biochemical markers. Frequent intakes of vitamin A in physiological doses—e.g., through food-based approaches, including fortification, and through regular low-dose supplementation—are highly effective in increasing serum retinol and reducing VAD. However, when the dose of vitamin A is as high as 200,000 IU (about 100 times the daily allowance), the liver may not be able to store it, and the excess is broken up and excreted. Thus, the rise in serum retinol resulting from 6-monthly VAS is small, transient, and lasts only for 1–3 months. "Second, if VAS worked by preventing VAD, then one would expect a clear linear association between the degree of underlying VAD and the effect of VAS: the higher the prevalence of VAD in a community, the larger the effect of VAS. However, this is not the case. Already, the first meta-analysis of the initial eight studies of the mortality effect of VAS noted that there was no association between the effect of VAS on mortality and the degree of underlying VAD at the population level. As presented in a recent review, this conclusion is substantiated when more recent studies are included." Benn 2017, Pg 1. 

 45. "The main objective of assessing vitamin A status is to determine the magnitude, severity and distribution of VAD in a population. Most surveys assess its prevalence in young children and, with increasing frequency, in pregnant or lactating women, as reported here. Although VAD is likely to be widespread following the preschool years, few data exist to reveal the extent of VAD in school-age and young adolescent children (16). Estimating the national prevalence is to be encouraged as such data aids in targeting regions for interventions, and provides baseline values for monitoring population trends and intervention programme impact over time. "Two sets of indicators of VAD are commonly used for population surveys: clinically assessed eye signs and bio-chemically determined concentrations of retinol in plasma or serum. The term xerophthalmia encompasses the clinical spectrum of ocular manifestations of VAD, from milder stages of night blindness and Bitot’s spots, to potentially blinding stages of corneal xerosis, ulceration and necrosis (keratomalacia) (17), as listed in Table 1. The stages of xerophthalmia are regarded both as disorders and clinical indicators of VAD, and thus can be used to estimate an important aspect of morbidity and blinding disability as well as the prevalence of deficiency. As corneal disease is rare, the most commonly assessed stages are night blindness, obtainable by history, and Bitot’s spots, observable by handlight examination of the conjunctival surface. Standard procedures exist for assessing xerophthalmia (17). Although night blindness and Bitot’s spots are considered mild stages of eye disease, both represent moderate-to-severe systemic VAD, as evidenced by low serum retinol concentrations (19), and increased severity of infectious morbidity (i.e. diarrhoea and respiratory infections) and mortality in children (5) and pregnant women (6, 20).

 "Measuring serum retinol concentrations in a population constitutes the second major approach to assessing vitamin A status in a population, with values below a cut-off of 0.70 μmol/l representing VAD (21), and below 0.35 μmol/l representing severe VAD. Although there is not yet international consensus, a serum retinol concentration below a cut-off of 1.05 μmol/l has been proposed to reflect low vitamin A status among pregnant and lactating women (22). While the distribution of serum retinol concentrations below appropriate cut-offs are considered to reflect inadequate states of vitamin A nutriture, a low biochemical concentration of retinol in circulation is not considered a VADD. Also, while an inadequate dietary intake of vitamin A or beta-carotene likely reveals an important and preventable cause of VAD in a population, it is not an indicator of vitamin A status." WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 2.

 Measures of the concentration of serum retinol-binding protein (RBP) are used as a "proxy" for concentrations of serum retinol. Complications of using RBP as a proxy for serum retinol are described in Tanumihardjo et al. 2016: "Serum RBP is used as a proxy for serum retinol concentrations in the identification of vitamin A deficiency. As discussed above, serum retinol correlates with liver vitamin A stores only when liver stores are very low. When stores are replete, serum retinol concentrations are homeostatically regulated and do not correlate with liver stores. Because the RBP-retinol complex is released by the liver as part of this homeostatic process, serum RBP correlates closely with serum retinol concentrations, at least in subjects with normal kidney function who are not obese." Pg 19S. "RBP is not always 100% saturated with retinol; therefore, a 1:1 molecular equivalence between retinol and RBP in the blood does not usually occur. Thus, one cannot generally use the retinol cutoffs for RBP unless liver stores are hypervitaminotic, as discovered in Zambian preschool children (85) in whom the ratio was 1.0 (144). In addition, the added variability in differences in kidney function (e.g., low glomerular filtration rate can cause an increase in RBP but not retinol) among subjects as well as the apparent contribution of adipose tissue to serum RBP (which may not reflect tissue stores in the same way as liver-derived RBP) make it unlikely that the same retinol-RBP correlation that might be observed in 1 population would be appropriate for another. It is possible that certain populations, such as young children not at risk of obesity and with normal kidney function, may be relatively homogeneous with regard to this association, but such associations have not been systematically examined." Pg 19S. See Table 6, Pg 15S, for a list of all vitamin A biomarkers. 

 46. "Measuring serum retinol concentrations in a population constitutes the second major approach to assessing vitamin A status in a population, with values below a cut-off of 0.70 µmol/l representing VAD (21), and below 0.35 µmol/l representing severe VAD." WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 2.

 

 47. Our process for creating our weighted average estimate of VAD prevalence in populations studied in VAS trials is as follows:

 We downloaded Imdad et al. 2017 RevMan data to find the weight of each study included in Analysis 1.1. Comparison 1 Vitamin A versus Control, Outcome 1 All-cause mortality at longest follow-up when analyzed as a random-effects model. "A meta-analysis for all-cause mortality included 19 trials (1,202,382 children). At longest follow-up, there was a 12% observed reduction in the risk of all-cause mortality for vitamin A compared with control using a fixed-effect model (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.83 to 0.93; high-quality evidence). This result was sensitive to choice of model, and a random-effects meta-analysis showed a different summary estimate (24% reduction: RR 0.76, 95% CI 0.66 to 0.88); however, the confidence intervals overlapped with that of the fixed-effect model." Imdad et al. 2017, Pg 2. Imdad et al. 2017 completed a random-effects meta-analysis on all-cause mortality (see bullet point above, but did not report on the weights of each individual study in the meta-analysis. See our most recent cost-effectiveness analysis of HKI for a description of why we prefer the random-effects estimate of the mortality effect of VAS. We then reviewed the original papers for the trials included in Imdad et al. 2017 to see whether the researchers had taken any measurements of serum retinol levels among trial participants at baseline, or in the control group at baseline or during the course of the study. We also noted if measures of the prevalence of xerophthalmia among trial participants had been recorded. For trials for which serum retinol concentrations among trial participants had not been measured, we used a combination of the following sources to create a best-guess estimate of the prevalence of VAD: Rates of xerophthalmia, if measured in the trial. Data on the most recent (as of 1995, close to the time of many of the trials) national-level surveys on serum retinol levels recorded in WHO Global Prevalence of Vitamin A Deficiency 1995. Regional-level (e.g., sub-Saharan Africa) estimates of the prevalence of VAD in 1991 (close to the time of many of the trials) in Stevens et al. 2015. We then created a weighted average of the VAD prevalence estimates, weighting each estimate by its weight in the overall estimate of the effect of VAS on mortality in the random-effects meta-analysis. 

 48. See this spreadsheet, Sheet "VAD where HKI works (or plans to work)."

 

 49. See this spreadsheet, "VAD where HKI works (or plans to work)" sheet. "For countries reporting VAD prevalence, we used the WHO guidelines [33] to classify the severity of the public health problem in children 6–59 months, which considers a VA prevalence of 2%–9% a mild public health problem, 10%–19% a moderate public health problem, and ≥20% a severe public health problem." Wirth et al. 2017, Pg 4. See WHO Global prevalence of vitamin A deficiency in populations at risk 2009, Pg 8, Table 5 for "Prevalence cut-offs to define vitamin A deficiency in a population and its level of public health significance." 

 50. See this spreadsheet, Sheet "VAD where HKI works (or plans to work)."

 

 51. See this spreadsheet, Sheet "VAD in other countries in sub-Saharan Africa."

 

 52. "Repeated measures of a population’s SROL distribution provide an effective tool for tracking the adequacy of dietary VA intakes over time. High-potency VA supplementation is intended to boost liver stores, enabling the gradual release and delivery of VA to tissues in children with dietary VA deficits. However, semi-annual supplementation does not resolve underlying dietary inadequacies. Thus we see only a transient shift in the SROL distribution. Overall, experimental data suggest that high-potency VA supplements protect children aged 6–59 months from hyporetinolaemia for approximately 8 to 10 weeks(19–23)." Palmer et al. 2012, Pg 1207. See Palmer et al. 2012, Pgs 1202-1207, for details on the data from trials of vitamin A supplementation used to support this claim. 

 53. "Serum retinol distribution curves are used to evaluate program impact (111). However, the lack of change in serum retinol distribution over time in several countries that have sustained >70% coverage with vitamin A supplementation has raised the concern about the appropriate indicator (219). For this reason, the impact of supplementation programs is not measured by a change in the prevalence of low serum retinol concentrations but may be better served by evaluating coverage rates. Retinol concentrations may respond to sustained, improved dietary intakes and therefore can guide programmatic decisions about whether to maintain or change interventions (219). Thus, the use of serum retinol distributions among preschool children from cross-sectional surveys to assess the need for vitamin A interventions is still recommended." Tanumihardjo et al. 2016, Pgs 16S-17S. "There is a growing interest in measuring the impact of VA programs in countries that have implemented national-scale programs for several years. Serum retinol concentrations do not respond to VAS, except in a transient manner (ie, for 1-2 months). While the kinetics of this transient effect have not been well characterized, it presumably reflects the rapid use of VA to support its biological functions when background dietary intake is low and/or VA losses resulting from infections. Serum retinol concentration is therefore not recommended as an impact indicator where VAS is the only strategy for addressing VAD. For this reason, the impact of VAS programs is not measured by a change in VAD prevalence in the population, and the mortality impact is instead modeled using coverage data. Serum retinol concentrations are, however, responsive to improved dietary intakes, sustained over time, and therefore can guide programmatic decisions about whether to maintain or change intervention mixes. Thus, using serum retinol distributions among preschool-aged children— in conjunction with other vitamin A status markers or demographic/ecologic risk factors—from cross-sectional surveys to assess the need for VA interventions is still recommended, even in countries that have sustained high semiannual VAS coverage over several years." Klemm et al. 2016, Pgs 5-6. 

 54. Incidence of Bitot's spots was significantly lower in treatment groups in trials of VAS included in the meta-analysis Imdad et al. 2017: RR 0.42, 95% CI 0.33 to 0.53. Pg 5.

 

 55. Stevens et al. 2015:

 "We collated 134 population-representative data sources from 83 countries with measured serum retinol concentration data. We used a Bayesian hierarchical model to estimate the prevalence of vitamin A deficiency, defined as a serum retinol concentration lower than 0·70 μmol/L. We estimated the relative risks (RRs) for the effects of vitamin A deficiency on mortality from measles and diarrhoea by pooling effect sizes from randomised trials of vitamin A supplementation. We used information about prevalences of deficiency, RRs, and number of cause-specific child deaths to estimate deaths attributable to vitamin A deficiency. All analyses included a systematic quantification of uncertainty." Pg e528. "The hierarchical model shares information to a greater degree where data are non-existent or weakly informative (ie, have large uncertainty), and to a lesser degree in countries or regions and in years with more data. We modelled trends over time as a linear trend. We did not include a non-linear term, as done for stunting, underweight, or anaemia,28–30 because fewer countries had several data sources for vitamin A deficiency than for other nutritional indicators; this data scarcity limits robust estimation of non-linear trends. The estimates were also informed by covariates that might help to predict vitamin A deficiency at the population level, including national income (logarithm of per-person gross domestic product [GDP] in inflation-adjusted international dollars), maternal education, proportion of population that lived in urban areas, mean weight-for-age Z score, and an aggregate metric of availability of calories and animal-source foods.31,32 The model included a variance term that accounted for unobserved design factors (sample design, season, retinol measurement method, etc) that led to variability in the data beyond that expected because of sample size. Finally, the model accounted for the fact that subnational data might have larger variation than national data by including an additional, empirically estimated, random effect for subnational data." Pg e530. 

 56. Stevens et al. 2015:

 "Regional prevalences in 1991 ranged from more than 40% in sub-Saharan Africa, south Asia, and east and southeast Asia and Oceania, to less than 25% in Latin America and the Caribbean, and in the region of central Asia, the Middle East, and north Africa. Nationally, the prevalence of vitamin A deficiency was at least 8% in every country; 100 countries had a prevalence of at least 20%, and hence would be classified as having a public health problem by WHO. Trends in the prevalence of deficiency from 1991 to 2013 varied by region, with a slight improvement at the worldwide level to 29% (17–42; PP of being a true decline=0·81). Deficiency significantly decreased in only one region: east and southeast Asia and Oceania, from 42% (19–70) to 6% (1–16; PP=0·99). The prevalence of deficiency might have decreased in Latin America and the Caribbean to 11% (4–23) in 2013 (PP=0·89) and in central Asia, Middle East, and north Africa to 11% (2–27) in 2013 (PP=0·76). In sub-Saharan Africa and south Asia, little change in prevalence occurred during the analysis period; both regions had prevalences of more than 40% for all years during the analysis period." Pg e532. "In 1991, 39% (95% credible interval 27–52) of children aged 6–59 months in low-income and middle-income countries were vitamin A deficient. In 2013, the prevalence of deficiency was 29% (17–42; posterior probability [PP] of being a true decline=0·81). Vitamin A deficiency significantly declined in east and southeast Asia and Oceania from 42% (19–70) to 6% (1–16; PP>0·99); a decline in Latin America and the Caribbean from 21% (11–33) to 11% (4–23; PP=0·89) also occurred. In 2013, the prevalence of deficiency was highest in sub-Saharan Africa (48%; 25–75) and south Asia (44%; 13–79). 94 500 (54 200–146 800) deaths from diarrhoea and 11 200 (4300–20 500) deaths from measles were attributable to vitamin A deficiency in 2013, which accounted for 1·7% (1·0–2·6) of all deaths in children younger than 5 years in low-income and middle-income countries. More than 95% of these deaths occurred in sub-Saharan Africa and south Asia." Pg e528. 

 57. See footnote above and results for Sierra Leone, Malawi, and Kenya in this spreadsheet

 

 58. See Wirth et al. 2017, Pgs 6-7, for a list of countries in which biofortified crop programs have been implemented.

 

 59. See this spreadsheet, Sheet "VAD where HKI works (or plans to work)" for sources and details.

 

 60. See this spreadsheet, Sheet "VAD where HKI works (or plans to work)," Cells K4, K5, and K12 for sources and details.

 

 61. Engle-Stone et al. 2017:

 "We conducted representative surveys in Yaoundé and Douala, Cameroon, 2 years before and 1 year after the introduction of a mandatory national program to fortify cooking oil with VA. In each survey, 10 different households were selected within each of the same 30 clusters (n = ~300). Malaria infection and plasma indicators of inflammation and VA (retinol-binding protein, pRBP) status were assessed among women aged 15–49 years and children aged 12–59 months, and casual breast milk samples were collected for VA and fat measurements. Refined oil intake was measured by a food frequency questionnaire, and VA was measured in household oil samples post-fortification." Pg 1. Adjusted prevalence of VAD among preschool-aged children (26.6%) and unadjusted prevalence of VAD among preschool-aged children (41.2%) in 2012 reported in Engle-Stone et al. 2017, Pg 10, Table 4. Differences between 2009 and 2012 surveys of VAD prevalence and mean RBP among preschool-aged children were not statistically significant. 

 62. "There is likely a threshold of VAD prevalence below which VAS is unlikely to have much impact on mortality. If there is high-quality data showing low VAD in a region, HKI thinks it is reasonable not to expect VAS to have a mortality impact there.

 "Organizations in the Global Alliance for Vitamin A (GAVA) currently use 10% VAD as the threshold at or above which VAS programs ought to be maintained in a region. The World Health Organization (WHO) classifies VAD rates of 20% or greater among preschool-aged children as a serious public health problem. VAD rates of less than 5% are accepted as not much of a concern.

 "Despite a lack of recent micronutrient analyses in many African countries, HKI is confident that VAD is prevalent enough in many places for VAS to remain an impactful intervention. For instance, while HKI is not aware of any recent micronutrient deficiency data in Mali, it would be surprising if VAD were not prevalent there, given Mali's child mortality and malnutrition rates." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pg 2.

 

 63. "Despite the lack of data, Dr. Tanumihardjo thinks it is unlikely that oil fortification programs across sub-Saharan Africa are working well enough to render VAS programs unnecessary in most countries, given that many of the oil fortification programs are relatively new. Over the next few years, we may gain enough data on rates of VAD to make an informed decision about whether to continue or scale back VAS programs. If there were strong evidence that a country's vitamin A fortification program was effectively fortifying food and reaching target populations, it may be appropriate to scale back the programs. Dr. Tanumihardjo thinks it would be premature to start scaling back VAS programs before we have these data." GiveWell's non-verbatim summary of conversations with Sherry Tanumihardjo, October 17 and 27, 2017, Pg 2.

 

 64. See our estimates in this spreadsheet, "VAD where HKI works (or plans to work)" sheet, column N.

 

 65. GiveWell's non-verbatim summary of a conversation with the Institute for Health Metrics and Evaluation, April 5, 2019: "In its Global Burden of Disease (GBD), IHME models VAD as both a direct cause of years lived with disability (YLDs) and as a risk factor for three other diseases (diarrheal diseases, lower respiratory tract infections (LRTIs), and measles)." Pg 1. "WHO collects results from VAD surveys in its Vitamin and Mineral Nutrition Information System (VMNIS). IHME uses these results, along with additional survey results from Demographic and Health Surveys (DHS) and other sources, as inputs for its VAD prevalence estimations. "For many countries, there is either no VAD survey data available or the available data is more than 10 years old. To estimate VAD prevalence for countries and years without available survey data, IHME uses the following covariates in a predictive model (all of which are inversely related to VAD prevalence):

 VAS coverage – IHME uses UNICEF data on the proportion of targeted populations of preschool-aged children that receive vitamin A supplements. Socio-demographic Index (SDI) – IHME developed SDI as a composite of income levels, educational attainment, and fertility rates. Vitamin A availability in food – In collaboration with the Food and Agriculture Organization of the United Nations, IHME developed a global database (encompassing all 195 GBD countries) for the availability of 170 different nutrients. In its model of VAD prevalence, IHME treats vitamin A availability in national food supplies as a proxy for vitamin A consumption, but it does not account for consumption of vitamin A fortified foods—fortification data is often either unavailable or incomplete." Pg 2. 

 66. "WHO collects results from VAD surveys in its Vitamin and Mineral Nutrition Information System (VMNIS). IHME uses these results, along with additional survey results from Demographic and Health Surveys (DHS) and other sources, as inputs for its VAD prevalence estimations.

 "For many countries, there is either no VAD survey data available or the available data is more than 10 years old. To estimate VAD prevalence for countries and years without available survey data, IHME uses the following covariates in a predictive model (all of which are inversely related to VAD prevalence):

 VAS coverage – IHME uses UNICEF data on the proportion of targeted populations of preschool-aged children that receive vitamin A supplements. Socio-demographic Index (SDI) – IHME developed SDI as a composite of income levels, educational attainment, and fertility rates. Vitamin A availability in food – In collaboration with the Food and Agriculture Organization of the United Nations, IHME developed a global database (encompassing all 195 GBD countries) for the availability of 170 different nutrients. In its model of VAD prevalence, IHME treats vitamin A availability in national food supplies as a proxy for vitamin A consumption, but it does not account for consumption of vitamin A fortified foods—fortification data is often either unavailable or incomplete." GiveWell's non-verbatim summary of a conversation with the Institute for Health Metrics and Evaluation, April 5, 2019, Pg 2. 

 67. See "Weighted averages" sheet here. Note that IHME does not directly estimate VAD prevalence for children aged 6- to 59-months. It estimates VAD prevalence for "post-neonatal" (28-364 days of age) and 1- to 4-year-old children. We have used IHME's estimates to calculate a rough estimate of VAD prevalence for 6- to 59-month-old children (see this spreadsheet, sheet "External validity by country," rows 3-5). As of 2019, HKI is supporting VAS campaigns in Guinea, Mali, Burkina Faso, Côte d'Ivoire, Niger, and Kenya: "Since GiveWell recommended HKI Vitamin A Supplementation (VAS) program as a Top Charity at the end of 2017, HKI has received an additional ~USD $7.3 million from various donors, bringing the total to ~$USD 21 including the USD $13.7 million received from GiveWell over the past two years. "This funding has been used to support VAS programs in 6 countries to date: Burkina Faso, Côte d’Ivoire, Guinea, Kenya, Mali and Niger." HKI room for more funding report July 2019, Pg 2. 



 68. "In collaboration with the Food and Agriculture Organization of the United Nations, IHME developed a global database (encompassing all 195 GBD countries) for the availability of 170 different nutrients. In its model of VAD prevalence, IHME treats vitamin A availability in national food supplies as a proxy for vitamin A consumption, but it does not account for consumption of vitamin A fortified foods—fortification data is often either unavailable or incomplete." GiveWell's non-verbatim summary of a conversation with the Institute for Health Metrics and Evaluation, April 5, 2019, Pg 2.

 

 69.  "For many countries, there is either no VAD survey data available or the available data is more than 10 years old. To estimate VAD prevalence for countries and years without available survey data, IHME uses the following covariates in a predictive model (all of which are inversely related to VAD prevalence):

 VAS coverage – IHME uses UNICEF data on the proportion of targeted populations of preschool-aged children that receive vitamin A supplements. Socio-demographic Index (SDI) – IHME developed SDI as a composite of income levels, educational attainment, and fertility rates. Vitamin A availability in food – In collaboration with the Food and Agriculture Organization of the United Nations, IHME developed a global database (encompassing all 195 GBD countries) for the availability of 170 different nutrients. In its model of VAD prevalence, IHME treats vitamin A availability in national food supplies as a proxy for vitamin A consumption, but it does not account for consumption of vitamin A fortified foods—fortification data is often either unavailable or incomplete." GiveWell's non-verbatim summary of a conversation with the Institute for Health Metrics and Evaluation, April 5, 2019, Pg 2. 

 70. See GiveWell's non-verbatim summary of a conversation with the Institute for Health Metrics and Evaluation, April 5, 2019 for IHME's description of its methodology.

 

 71. See this spreadsheet, "Weighted averages" sheet for our calculations.

 

 72. See the "Improved overall health conditions" and "Interpreting the evidence in light of DEVTA" sections of our vitamin A supplementation intervention report for more information on baseline child mortality rates in VAS trials.

 

 73. See this spreadsheet, Sheet “Child mortality rates by country,” Row 20 for full details.

 

 74. Imdad et al. 2017, Pgs 111-112, Analysis 1.1.

 

 75. “Deaths per child-care centre at ages 1.0–60 years during the 5-year study (the primary trial endpoint) were 3.01 retinol versus 3.15 control (absolute reduction 0.14 [SE 0.11], mortality rate ratio [RR] 0.96, 95% CI 0.89–1.03, p=0.22), suggesting absolute risks of death between ages 1.0 and 6.0 years of approximately 2.5% retinol versus 2.6% control.” Awasthi et al. 2013, Pg 1473

 

 76. Inputs to mortality rate in DEVTA (xlsx)

 

 77. Table 2, Ross et al. 1993, Pg. 10 "The 21 906 children who entered the Survival Study were followed up for 33 287 child-years (16 508 vitamin A group, 16 779 placebo group)." Ross et al. 1993, Pg. 10 "There were 892 deaths among the children in the Survival Study, which gave an overall mean mortality rate for all clusters of 27.11 per 1,000 child-years of follow-up. 397 of the deaths were in vitamin A clusters (mean mortality rate 24.4 per 1000 child-years) and 495 in placebo clusters (29.9 per 1000 child-years)." Ross et al. 1993, Pg 10 

 78. Table III, West et al. 1991, Pg. 68

 

 79. Table III, Herrera et al. 1992, Pg. 269 "During the 18 months of follow-up, there were 120 deaths (8.4/1000) in the vitamin A group and 112 deaths (7.9/1000) in the placebo group (RR 1.06, 95% CI 0.82-1.37) (table II)." Herrera et al. 1992, Pg. 269 

 80. Table III, Daulaire et al. 1992, Pg. 208

 

 81. Table VI, Sommer et al. 1986, Pg. 1171 "Teams first visited villages between September, 1982, and August, 1983, and follow-up visits were made by the same team in the same sequence 9-13 months later." Sommer et al. 1986, Pg. 1169 

 82. "Nine trials reported mortality due to diarrhoea and showed a 12% overall reduction for VAS (RR 0.88, 95% CI 0.79 to 0.98; 1,098,538 participants; high-quality evidence). There was no significant effect for VAS on mortality due to measles, respiratory disease, and meningitis. Imdad et al. 2017, Pg 2.

 

 83. "There was no significant effect for VAS on mortality due to measles, respiratory disease, and meningitis. VAS reduced incidence of diarrhoea (RR 0.85, 95% CI 0.82 to 0.87; 15 studies; 77,946 participants; low-quality evidence) and measles (RR 0.50, 95% CI 0.37 to 0.67; 6 studies; 19,566 participants; moderate-quality evidence)." Imdad et al. 2017, Pg 2.

 

 84. See our rough analysis in this spreadsheet, "External validity by country" sheet.

 

 85. "Since 2010, Helen Keller International (HKI) has conducted post-event coverage (PEC) surveys in several African countries to estimate VAS and deworming coverage. These surveys provide a method to validate administrative figures and are important for identifying barriers to achieving high coverage." Janmohamed and Doledec 2017, Pg 822-823. "HKI helps to track national VAS coverage through the governments tally-sheet system (also referred to as 'Administrative Data'). It also assesses VAS coverage in HKI “catchment areas” which for some countries is national scale and in other countries focuses on special high-risk or hard-to-reach regions and/or districts not assisted by other partners. HKI also conducts “Post-Event Coverage Surveys” or PECS, which are population-based representative coverage surveys which provide a more valid estimate of VAS coverage relative to the tally sheet system." HKI VAS documents guide for GiveWell 2017, Pg 2. 

 86. "Stage 2: Implementation:

 Travel to survey sites; Meet with local health officials and village leaders; Map the cluster to be surveyed and divide the cluster into four quadrants; Select a starting point at random in each quadrant and identify the first house to be surveyed; Administer questionnaires to the target population (e.g., caretakers of children 6-59 months)." HKI post-event coverage survey manual 2014, Pg 4.

 

 87. Guidelines: HKI post-event coverage survey manual 2014 HKI post-event coverage survey data analysis manual 2014 Example reports: HKI post-event coverage survey report Tanzania 2015 HKI post-event coverage survey report Sierra Leone 2013 HKI post-event coverage survey report Nigeria - Ekiti and Katsina states 2014 HKI post-event coverage survey report Côte d'Ivoire (French) 2012 HKI presentation: Reaching the hard to reach with vitamin A supplementation in low-performing health zones of DR Congo  HKI post-event coverage survey report, Mali round 1 2018  HKI post-event coverage survey report, Burkina Faso round 1 2018  HKI post-event coverage survey report, Guinea round 1 2018  HKI post-event coverage survey report, Mali round 2 2018  HKI post-event coverage survey report, Côte d'Ivoire round 2 2018 Academic papers on HKI's post-event coverage surveys: Clohossey et al. 2014, on a post-event coverage survey following a child health week in Kenya in 2012 Dhillon et al. 2013, on a post-event coverage survey following a VAS campaign in Tanzania in 2010 Hodges et al. 2013, on a post-event coverage survey following a child health week in Sierra Leone in 2011 Sesay et al. 2015, on a post-event coverage survey following a child health week in Sierra Leone in 2012 

 88. It seems plausible to us that there may be an incentive for local governments to over-report the number of vitamin A supplements delivered, or for higher levels of government to over-report aggregated figures. Janmohamed and Doledec 2017, a review of post-event coverage surveys for VAS and deworming programs supported by HKI between 2010 and 2015, notes that administrative coverage estimates were higher than surveyed coverage estimates in around 90% of surveys analyzed in the review: "For VAS, administrative coverage was higher than survey estimates in 47 of 52 (90%) campaign rounds, with a mean difference of 16.1% (95% CI: 9.5–22.7; P<0.001). For deworming, administrative coverage exceeded survey estimates in 31 of 34 (91%) comparisons, with a mean difference of 29.8% (95% CI: 16.9–42.6; P<0.001)." Pg 822. 

 89. See this cell in our spreadsheet on HKI's coverage surveys, methods and results.

 90. See this spreadsheet, "Full results" sheet, Cells J8:J9, J13:J15, J23:J25 and J28:J32.

 

 91. See this spreadsheet ("Comprehensiveness" sheet).

 

 92. "Nationally-representative PECS are planned for the 1st VAS Round in Guinea, Mali and Niger for the 2nd VAS Round in Cote d’Ivoire and Burkina Faso." Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, June 5, 2019.

 

 93. "We have consulted various statisticians at Hopkins and GWU on sampling options that would potentially meet GiveWell’s information needs, provide nationally representative VAS coverage data and lower costs. One option is to select a nationally representative sample for each country but collect the data from ¼ of that sample after each round for four rounds. The aggregated result would provide an average national VAS coverage estimate for each country over a two year period (we’d average VAS coverage over the four rounds—Year 1: Round 1 and 2 + Year 2: Round 1 and 2). This estimate would still provide useful information at a country level for the VAS program, provide GiveWell with an unbiased coverage estimate for all countries over a two year period and cost about 1/4th of the amount needed for conducting nationally representative coverage surveys after each round." Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, June 5, 2019. HKI told us that it expects to begin implementing its new coverage survey methodology in 2020 if its government partners agree to its proposal. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, June 11, 2019 

 94. We have seen coverage surveys (and estimates of total vitamin A supplements delivered from administrative data for corresponding distributions) representing around 19% of the total vitamin A supplements delivered with HKI support between 2013 and 2016:

 See our summary of the results of recent coverage surveys we have seen in this spreadsheet ("Results summary" sheet). The total number of vitamin A supplements monitored through coverage surveys (for which we have also seen administrative data) in HKI's recent 2013-2016 Global Affairs Canada grant is 35,673,646. The total number of vitamin A supplements delivered in catchment areas receiving direct HKI support during HKI's recent 2013-2016 Global Affairs Canada grant is 192,281,849. Calculated from HKI VAS summary table, "VAS coverage" sheet. 35,673,646 / 192,281,849 = ~19%. Note that we are only counting "catchment areas receiving direct HKI support" in our denominator. HKI VAS summary table, "VAS coverage" sheet also reports on total vitamin A supplements delivered at a national level, but our understanding is that HKI only supports coverage surveys in regions where it directly supports VAS programs. Note that there are several coverage surveys that we have seen results from, but for which we have not seen estimates of number of VAS doses delivered according to administrative data (see spreadsheet linked above). Supplements delivered in distributions monitored by these coverage surveys are not included in our estimate of the total number of vitamin A supplements monitored through coverage surveys (35,673,646). Our understanding is that the totals included in HKI VAS summary table, "VAS coverage" sheet include vitamin A supplements delivered through routine distributions, which are not monitored through post-event coverage surveys (see here). We don't know what proportion of the totals listed were delivered through routine mechanisms. 

 95. HKI analysis of PECS data March 2017 includes a column stating the primary reason for each survey. We have copied this information into our spreadsheet on HKI's coverage surveys ("Full results" sheet). We have not seen more detailed descriptions of the reasons why these areas were chosen for surveys. We note that the stated reason for a survey in Ekiti and Katsina States reported in HKI analysis of PECS data March 2017 differs from the description in the report we have seen (see below). We have seen detailed reports on two coverage surveys from distributions conducted under HKI's most recent grant from Global Affairs Canada. See our summary of the methodologies of these surveys in this spreadsheet ("Methods" sheet). Ekiti and Katsina states in Nigeria were chosen to be surveyed in 2014-15 because they had not yet been surveyed by HKI: "Ekiti and Katsina are among the states supported by HKI for VAS implementation during MNCHW in Nigeria. According to tally sheet data the two states have recorded a considerably good VAS coverage rate over a 5 year period. However, there has not been any validation of this data before. Therefore, in order to validate VAS coverage in Ekiti and Katsina, PECS was conducted in January 2015 among caregivers of children aged 6-59 months who attended the November 2014 MNCH Week." HKI post-event coverage survey report Nigeria - Ekiti and Katsina states 2014, Pg 8. The city of Dar es Salaam in Tanzania was chosen to be surveyed in 2015 because it had a history of low VAS coverage: "In 2014, we opted to target the PECS data collection to areas which had historically performed poorly with VASD. Dar es Salaam, the countries business capital and largest city has a history of low VAS coverage, and 2014 proved to be no exception." HKI post-event coverage survey report Tanzania 2015, Pg 6. We have seen results for 31 surveys taking place under HKI's most recent grant from Global Affairs Canada (see this spreadsheet, "Results" sheet), but, with the exceptions of the Ekiti and Katsina states survey and the Dar es Salaam survey mentioned above, we do not know why HKI or its partners chose to conduct surveys in those particular areas. HKI notes: "The reasons can vary from one country to another. In some countries, PECS are undertaken to validate coverage in HKI-assisted regions. In others, the scope of a PECS depends on host country government and national working group interests or requests which might result in a survey implemented to provide a national, sub-national or area-specific (e.g.hard-to-reach) coverage estimate. PECs are NOT implemented for all VAS distribution rounds partly due to funding limitations but also because they are not warranted after each round. For example, if a PECs reveals low VAS coverage, only when demonstrable steps are taken to address the reasons for low coverage would a follow-on PECs be justified." Comment provided in response to a draft of this review in August 2017. 

 96. See this spreadsheet ("Results summary" and "Full results" sheets).

 

 97. See our summary of the results of recent coverage surveys we have seen in this spreadsheet ("Results summary" sheet).

 

 98. HKI 6-month contact point standard methodology, Pgs 2-3: "Prior to the introduction of the 6-month contact point activities, a baseline survey must be conducted. "Review the ‘6107 baseline survey’ for both caretakers of children age 9-12 months and for healthcare workers "Modify the 6107 baseline survey to include country specific factors and messaging. Indicators which should not be modified include: Age of first receipt of VAS Age of first receipt of Measles vaccine "For Methodology of the 6107 baseline survey, please refer to the cluster selection handout. The EPI cluster sampling methodology has been selected for the baseline with a minimum of 30 clusters from the targeted region randomly selected, where the probability of a cluster being selected proportional to the population size. A minimum of 10 households with children 9-12 months will be selected to complete the baseline. […] "After a minimum of 7 months, the 6107 end line survey should be conducted with caretakers of children age 9-12 months and to healthcare workers." HKI notes: "The 6-mo contact point has been a recent innovation piloted in several countries. During the pilot phase in Sierra Leone, Senegal, Cote d’Ivoire and elsewhere, HKI set up robust systems for monitoring receipt of VAS among children at 6-7 m of age. This was done to assess coverage changes as a result of this new contact point. HKI would like to assist governments to scale up the 6 m contact point and, in the process, integrate VAC receipt at 6 m into the Child Health Cards (as a means to record VAC receipt) and into the country’s routine health information system as a means to assess coverage." Comment provided in response to a draft of this review in August 2017. We have seen a presentation on the results of one of these studies (HKI 6-month contact point presentation Sierra Leone 2012), but we have not yet reviewed the results in detail. 

 99. "HKI teams work closely with national governments to support the policy, strategy and tool development mentioned above, but HKI’s major added value is its capacity to rapidly deploy technical support to the sub national level to assist local health authorities with implementing national VAS strategies. HKI focus its efforts sub-nationally because local level (at state and/or district level) health system performance is key to ensuring high VAS coverage. It also allows HKI to support other health system functions that also improve the delivery of other maternal and child health services.

 "In concrete terms, HKI, in consultation with national government counterparts, directs its support to low performing areas to help local program managers identify and solve VAS coverage barriers. This involves organizing workshops with state and district health authorities to analyze what worked and what did not. HKI teams then spend time with health managers to help them identify feasible and cost-effective solutions to improve performance of the targeted services and accompany them through the whole programming cycle (i.e. planning, budgeting, implementation, real time supervision and monitoring, and finally evaluation of the progress made). One cycle sometimes proves insufficient so the HKI teams continue working with each targeted health district until minimum thresholds of performance are met. Funds are used to support deployment of HKI teams in remote areas, to support financing workshops and joint field supervisions, to provide training for field actors, or to organize coverage surveys and review meetings at the end of the exercise. In some cases, HKI provides funds directly to the local authorities to fill financial gaps they may experience ensuring rigorous financial accountability. When conditions for a change of approach are met, HKI provides technical assistance to local authorities to design, implement and monitor with them innovative approaches such as the 6-month contact point or SMS messaging." HKI VAS documents guide for GiveWell 2017, Pg 2.

 

 100. "Many African countries are facing funding shortfalls around VAS, and some planned VAS mass campaigns have had to be cancelled. For instance, in Mali (which HKI does not currently have funds to support, but which received support from HKI for VAS programs in 2013-16), it is not clear whether VAS mass campaigns will occur at all without external technical assistance from HKI. HKI still expects vitamin A capsules to be provided to countries in sufficient numbers, but there is a risk of millions of capsules remaining undistributed if campaigns are underfunded." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pg 7.

 

 101. As evidence that its support of VAS program leads to higher coverage rates, HKI has sent us several examples of cases in which it provided support to a Child Health Day VAS mass distribution program, and in which VAS coverage rates above 80% were achieved. In Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, October 19, 2017, HKI pointed us to: A 2014 Child Health Day program in Bas Congo Province, DRC, that achieved 91.1% VAS coverage using a fixed distribution strategy, according to HKI's coverage survey: See row 12 in the "Full results" sheet in this spreadsheet. Details (in French) in HKI DRC PECS report 2014. We have not reviewed this report carefully. A 2015 Child Health Day program in Kasai Oriental, DRC, that achieved 90% coverage using a fixed strategy and 89% coverage using a door-to-door strategy, according to HKI's coverage surveys: See rows 13-14 in the "Full results" sheet in this spreadsheet. Details (in French) in HKI DRC PECS report 2015. We have not reviewed this report carefully. Increases in coverage rates in the Littoral Region in Cameroon, where HKI supported door-to-door VAS mass distributions, between 2011 and 2014. In 2011, HKI's coverage survey found 53% coverage of VAS, and its coverage survey in 2014 found 90% coverage. See HKI analysis of PECS data March 2017 for coverage survey results. These surveys are also discussed in HKI lessons learned on VAS in six urban health districts in Cameroon 2014. We have not reviewed this report carefully. HKI's national-level coverage surveys in Mozambique, which found that coverage levels were above 80% through a Child Health Day fixed distribution strategy: See rows 20-21 in the "Full results" sheet in this spreadsheet. We believe these examples are useful for showing that coverage rates above 80% can be achieved with HKI's support in Child Health Day programs using a fixed and outreach distribution strategy. But we do not find this evidence to be convincing, on its own, that HKI's support causes VAS coverage rates to increase above what they would be in HKI's absence, since we lack appropriate comparisons for these examples (e.g., coverage rates in similar districts or regions that did not have support from HKI.) 

 102. "We reanalyzed the data to explore the hypothesis that VAS reduces mortality in children who had bacille Calmette-Guerin or measles vaccine as their most recent vaccine but increased mortality when diphtheria-tetanus-pertussis vaccine (DTP) was the most recent vaccine. On the basis of previous studies, we expected the effects to be strongest in girls." Benn et al. 2009, Pg 629.

 

 103. "As hypothesized, the reanalysis suggests important interactions between VAS, sex, and vaccines. VAS was associated with a strong beneficial effect in children with no record of vaccination, whereas there was almost no effect for those who had been vaccinated. This differential effect was due to a difference in girls, in whom VAS was associated with a decrease in mortality in the unvaccinated but in whom VAS was associated with a nonsignificant increase in mortality in the vaccinated (Table 2). This was due to a differential effect of VAS according to vaccination type. Among girls who had already received MV at enrollment, VAS was associated with significantly higher mortality. This was only seen in girls who were missing doses of DTP at enrollment and were therefore likely to receive them during follow-up (Table 5)." Benn et al. 2009, Pg 635.

 

 104. Fisker et al. 2014:

 "We have hypothesized that the effect of VAS is modified by vaccines, VAS amplifying the non-specific immune-modulating effects of vaccines, thus being beneficial when provided with live vaccines but potentially harmful with inactivated vaccines." Pg e740. "As prespecified, all analyses considered interaction between VAS and gender and, in addition, previous VAS and season." Pg e741 

 105. "Between August 2007 and November 2010, 7587 children were enrolled. Within 6 months of follow-up 80 non-accident deaths occurred (VAS: 38; placebo: 42). The mortality rate ratio (MRR)comparing VAS versus placebo recipients was 0.91 (95% confidence interval 0.59–1.41) and differed significantly between boys (MRR1.92 [0.98–3.75]) and girls (MRR 0.45 [0.24–0.87]) (P= .003 for interaction between VAS and gender). At enrollment, 42% (3161/7587) received live measles vaccine, 29% (2154/7587) received inactivated diphtheria-tetanus-pertussis–containing vaccines, and 21% (1610/7587)received both live and inactivated vaccines. The effect of VAS did not differ by vaccine group." Fisker et al. 2014, Pg e739.

 

 106. See this document for our research on the biological plausibility of interactions between vitamin A supplementation and vaccine effectiveness.

 

 107. "When the correct age-specific dose of vitamin A is given with immunization, mild side-effects or adverse events may be observed. However, they are rare and transient. Occasionally, some children experience loose stools, headache, irritability, fever, nausea, and vomiting. Depending on age and the dosage given, the excess rate of occurrence of these mild symptoms of intolerance has shown be in the range of 1.5-7% (Florentino et al., 1990; West et al., 1992; Agoestina et al., 1994). These side-effects disappear in practically all children within 24-48 hours (Florentino et al., 1990; West et al., 1992; Agoestina et al., 1994)." WHO vitamin A supplements adverse events, Pgs 1-2.

 

 108.  "When the correct age-specific dose of vitamin A is given with immunization, mild side-effects or adverse events may be observed. However, they are rare and transient. Occasionally, some children experience loose stools, headache, irritability, fever, nausea, and vomiting. Depending on age and the dosage given, the excess rate of occurrence of these mild symptoms of intolerance has shown be in the range of 1.5-7% (Florentino et al., 1990; West et al., 1992; Agoestina et al., 1994). These side-effects disappear in practically all children within 24-48 hours (Florentino et al., 1990; West et al., 1992; Agoestina et al., 1994)." WHO vitamin A supplements adverse events, Pgs 1-2.

 

 109. WHO vitamin A supplements adverse events:

 "The administration of excessive amounts of vitamin A can lead to toxicity, known as hypervitaminosis A. The amount required to cause toxicity will vary among individuals." Pg 1. "Worldwide, the incidence of hypervitaminosis A is a very minor problem compared with the incidence and effects of vitamin A deficiency. An estimated 200 cases of hypervitaminosis A occurs annually…" Pg 1. "Hypervitaminosis does not result from public health intervention programs. Rather toxicity has been associated with the abuse of vitamin A supplements and with diets extremely high in preformed vitamin A (i.e., foods of animal origin). Toxic reactions provoked by large doses of vitamin A are well-known to occur following either intake of liver rich in vitamin A (e.g., polar bear, halibut or whale) or by excessive administration of vitamin A preparations (Miller & Hayes, 1982)." Pg 2. "Acute vitamin A toxicity (single ingestion of 25,000 IU per kg or more): Signs and symptoms may be delayed for 8 to 24 hours and include manifestations such as nausea, vomiting, diarrhea, changes in humour (irritability, drowsiness, dizziness, lethargy), increased intracranial pressure (headache, bulging of fontanelle, diplopia, papilloedema), skin changes (erythema, pruritus, desquamation). Peeling of skin around mouth may be observed from 1 to several days after ingestion and may spread to the rest of the body (Miller & Hayes, 1982; Bendich & Langseth, 1989; Hathcock et al., 1990; CPS, 1999; Parfit, 1999)." Pg 2. 

 110. "Hypervitaminosis does not result from public health intervention programs. Rather toxicity has been associated with the abuse of vitamin A supplements and with diets extremely high in preformed vitamin A (i.e., foods of animal origin). Toxic reactions provoked by large doses of vitamin A are well-known to occur following either intake of liver rich in vitamin A (e.g., polar bear, halibut, or whale) or by excessive administration of vitamin A preparations (Miller & Hayes, 1982)." WHO vitamin A supplements adverse events, Pg 2. HKI told us that receiving two doses of vitamin A supplements within a short time period would not meet toxicity thresholds: "[GiveWell:] In countries where six-month contact points have been initiated, is there a risk of a child receiving a 'double dose' of VAS in a short time period (one from a facility visit when the infant is six months old, and another at the next biannual Child Health Day or door-to-door campaign)? Would receiving a double-dose potentially be dangerous? (Even if they aren't dangerous, we're also concerned about double-doses because they wouldn't be an effective use of resources.) "[HKI:] This is a legitimate question and one we have had to think about carefully as we started to promote and support the 6 month contact point (6MCP). First, receiving two doses in a short time frame poses some, but minimal, risks for children as the toxicity thresholds go far beyond receiving two doses (see attached document on Adverse events following administration of VAS)."HKI responses to GiveWell's questions May 2017 



 111. For example, see discussion of GiveWell staff's observations in October 2017 Maternal and Child Health Week in Guinea, GiveWell's notes from a site visit with HKI to Conakry, Guinea, October 9-11, 2017, Pgs 11-14.

 

 112. For example, see discussion of GiveWell staff's observations in October 2017 Maternal and Child Health Week in Guinea, GiveWell's notes from a site visit with HKI to Conakry, Guinea, October 9-11, 2017, Pgs 11-14.

 113. HKI VAS expense summary 2018 redacted See "Sources for HKI's budget calculations" sheet here. 

 114. See our cost per supplement analysis spreadsheet for details.

 

 115. HKI told us the total amount of funding each of these organizations planned to grant to governments in Guinea, Mali, and Burkina Faso to support the implementation of the first (of two) Child Health Week program in 2018: David Doledec, HKI Regional VAS Program Manager, email to GiveWell, May 7, 2018: "Burkina Faso: as mentioned earlier, UNICEF is the only actor funding VAS campaigns, and they mentioned to us providing usd $367 653 for the round of campaign that will take place end of May / beginning of June. The campaign is being delayed a bit by lengthy administrative procedures at the ministry of health level. HKI direct budget should be $149,963 usd. "Mali: multiple partners as described below: Save the Children : $ 222 320 UNICEF : $ 453 526 WHO : $ 1 310 53 WORLD VISION : $47 502 HKI : $ 162 346" "...for other partners, these are just the direct payment to the MoH, and do not cover the indirect costs, staff costs and overheads. We do not have access to this information, it will take a much more rigorous study like the one we want to do for the second round, to access these details." David Doledec, HKI Regional VAS Program Manager, email to GiveWell, May 10, 2018 See our cost per supplement analysis spreadsheet for details on our calculations of rough estimates of total expected spending for these organizations in 2018. For the first supplementation round in 2019, we have seen budgets of other organizations supporting VAS campaigns for Burkina Faso, Côte d'Ivoire, Guinea, Mali, and Niger in HKI budgets round 1 2019. We have not seen budgets for other organizations supporting VAS campaigns for the second VAS campaign rounds in 2018 and 2019. 

 116. See the "Government costs" section on the "Cost per supplement" sheets for Guinea, Mali, and Burkina Faso of our cost per supplement analysis spreadsheet.

 

 117. See the "Additional inputs" section on the "Cost per supplement" sheets for Guinea, Mali, and Burkina Faso of our cost per supplement analysis spreadsheet.

 

 118. See our cost per supplement analysis spreadsheet, "HKI budgets of other organizations" sheet.

 

 119. See our cost per supplement analysis spreadsheet, "Cost per supplement" sheets for Guinea, Mali, and Burkina Faso.

 

 120. For budgets for the first round of 2018, see our cost per supplement analysis spreadsheet, "HKI 2018 budgets of other organizations" sheet. For budgets for the first round of 2019, see HKI budgets round 1 2019. 

 121. See this section of our review of the Schistosomiasis Control Initiative for details.

 

 122. See our cost per supplement analysis spreadsheet, "HKI population targets" sheet.

 

 123. "This funding has been used to support VAS programs in 6 countries to date: Burkina Faso, Côte d’Ivoire, Guinea, Kenya, Mali and Niger." HKI room for more funding report July 2019, Pg 2. See our cost per supplement analysis spreadsheet for our cost per supplement estimates for Guinea, Mali, and Burkina Faso. 

 124. We have not seen information on contributions from other organizations for: Round 1 in 2018 in Côte d'Ivoire Round 2 in 2018 in Côte d'Ivoire Round 2 in 2019 in Côte d'Ivoire Round 1 in 2019 in Kenya Round 2 in 2019 in Kenya Round 2 in 2019 in Niger We have not seen estimates of the size of targeted populations for: Round 1 in 2019 in Kenya Round 2 in 2019 in Kenya 

 125. See this spreadsheet for the list of interventions provided in Guinea, Burkina Faso, Côte d'Ivoire, and Mali in 2018.

 

 126. On the "inclusion/exclusion" sheet in our cost-effectiveness analysis, we include a rough estimation of the impact these additional interventions would have on HKI's cost-effectiveness. See our most recent cost-effectiveness analysis here.

 

 127. See our room for more funding spreadsheet, "Available and expected funding" sheet, row 27.

 

 128. Room for more funding spreadsheet: Between November 2017 (when GiveWell named HKI a top charity) and June 2019, HKI received $21.6 million in revenue for its VAS mass campaign programs. "Additional calculations" sheet, "Past revenue" section. HKI reported expenditures of $3.0 million on VAS campaign programs between January and December 2018. We have seen HKI's budgets for 2019—we assume that HKI spent $3.4 million, half of its total budget for the year, between January 1 and June 30, 2019. See "Additional calculations" sheet, "Past spending" section. $21.6 million in revenue minus $3.0 million in spending in 2018 and $3.4 million in the first half of 2019 equals $15.2 million in funding on hand. See a list of HKI's $14.8 million in funding commitments in columns D and E on the "Spending opportunities" sheet. 

 129. According to GiveWell's internal donation records, HKI received $565,920 in GiveWell-directed donations between July 2018 and the end of June 2019. HKI told us that it received $109,269 from Founders for Good last year. HKI room for more funding report July 2019, Pg 4, Table 1. We have counted funding from Founders for Good (also known as Founders Pledge) as being GiveWell-directed because Founders for Good's recommendation of HKI is based on GiveWell's research. Founders Pledge Children's Nutrition Summary and Giving Recommendation 2018. The amounts described above from July 2018 to July 2019 total to $675,189. Our best guess is that HKI will receive this same amount of funding between July 2019 and June 2020 from donors who use our top charity list but do not follow our recommendation for marginal donations. According to our donation records, we also expect HKI to receive a $100,000 grant from a foundation ("Foundation 3") between July 2019 and June 2020. See "Additional calculations" sheet in our room for more funding analysis for more details and calculations. 

 130. Between January and June 2019, HKI received $1.0 million from effect:hope. HKI told us that effect: hope was not influenced by GiveWell's recommendation of HKI. See Table 1, Pg. 4 of HKI room for more funding report July 2019 "Effect:Hope was not directly influenced by HKI’s designation as a GiveWell Top Charity" HKI room for more funding report July 2019, Pg 4. HKI told us that it believes it is unlikely that effect: hope will renew its funding to HKI next year, and that it did not expect to receive any other sources of non-GiveWell-influenced funding for its VAS campaign programs. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, August 23, 2019 

 131. Patricia Manyari, HKI Chief Financial Officer, and Sobana Prasad, HKI Controller, conversation with GiveWell, October 4, 2017 See this spreadsheet for an analysis of HKI's spending of unrestricted and restricted funds in FY2015 and FY2016. We have not updated this analysis based on HKI's spending in FY 2017 or FY 2018. HKI told us in July 2018 that it still did not expect to have unrestricted funding available to allocate to VAS mass campaign programs. Rolf Klemm, email to GiveWell, July 31, 2018 

 132. In this review, we refer to the agency with its current name, Global Affairs Canada. Documents we cite may refer to the former name of the agency, the Department of Foreign Affairs, Trade and Development of Canada (DFATD), or the Canadian International Development Agency (CIDA), which was absorbed into DFATD in 2013. "The names of several departments are being changed as follows: […] Foreign Affairs, Trade and Development Canada to Global Affairs Canada" Canada Privy Council Office Machinery of Government Changes 2015 "The agency that handles Canada's international aid is going to be brought into the Department of Foreign Affairs, the government announced Thursday in the federal budget. "It's not yet clear how the move will affect the work of the Canadian International Development Agency, which is currently the responsibility of International Co-operation Minister Julian Fantino, but the fact the minister's powers are about to be enshrined in law is seen as a positive sign for its future.

 "In the past, ministers in charge of CIDA haven't had the same enshrinement in law as other federal cabinet ministers.

 "The new department will be known as the Department of Foreign Affairs, Trade and Development." CBC News 2013 

HKI plays a range of technical assistance roles to national vitamin A supplementation programs in Africa. These have been almost exclusively supported from grants from the Canadian Government, the most recent being a grant entitled, “Scaling Up Nutrition through Integrated Life-saving Interventions Project-2013-2016.” HKI VAS documents guide for GiveWell 2017, Pg 1. "Annex 1 - History of grants devoted to VAS implemented by HKI with support from GAC [Global Affairs Canada]" lists five grants from GAC to HKI, beginning in January 2006, totaling around $80 million CAD in total funding. HKI VAS concept note, Pg 22. 

 133. "Since 2002, Helen Keller International (HKI) has partnered with UNICEF and the Department of Foreign Affairs, Trade and Development of Canada (DFATD), formerly the Canadian International Development Agency (CIDA), to work towards increasing and sustaining vitamin A supplementation (VAS) coverage in countries with a high burden of child mortality and nutrition-related disease. The partnership started in five sub-Saharan countries, and expanded during the 2005–2008 period to nine countries, where it focused primarily on shifting to twice-yearly distribution, sustainability and building national capacity. The subsequent project (Scaling up Child Health and Nutrition in Sub-Saharan Africa) ran from 2009–2013 and operated in 13 countries. "The current grant amounts to CDN$29,000,000 over a three-year period (2013–2016) and is entitled 'Scaling Up Nutrition through Integrated Life-Saving Interventions.' The two primary anticipated outcomes of the project are:

  enhanced healthy nutritional practices for children 6–59 months through maintained high coverage of child health and nutrition services; and increased national ownership of child survival activities (in transitioning countries)." HKI External Evaluation and HKI Response - Canada DFATD VAS Project 2015, Pg 1.

 "Annex 1 - History of grants devoted to VAS implemented by HKI with support from GAC [Global Affairs Canada]" lists a grant of $29 million CAD from Global Affairs Canada to HKI for 13 countries in sub-Saharan Africa implemented between February 2013 and May 2016. HKI VAS concept note, Pg 22. 

 134. "HKI requests support from Global Affairs Canada (GAC) for a five-year program (June 2016 – May 2021) focusing on the following core objectives: Provide VAS to all children 6 to 59 months in high VAD and high mortality countries in SSA through sustainable, locally managed delivery mechanisms; Continue institutionalization of VAS services within national health systems; Integrate VAS services within a comprehensive nutrition and health package for pregnant and lactating mothers and children less than five using a health systems strengthening approach ensure effective management as well as equity, quality and access to interventions that address the unacceptably high prevalence of VAD."  HKI VAS concept note, Pg 4.

 "In a three-year period between 2013 and 2016, GAC granted around $30 million (CAD) to HKI as well as provided significant funding to UNICEF and the Canadian-based Nutrition International for VAS programs in SSA. Going forward, GAC will be passing its VAS funding directly to UNICEF to ease the administration burden of managing two separate grants with the expectation that UNICEF will use some of this funding to provide grants to other organizations supporting VAS programs, including HKI." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pgs 6-7. 

 135. "In a three-year period between 2013 and 2016, GAC granted around $30 million (CAD) to HKI as well as provided significant funding to UNICEF and the Canadian-based Nutrition International for VAS programs in SSA." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pg 6.

 

 136. "In a three-year period between 2013 and 2016, GAC granted around $30 million (CAD) to HKI as well as provided significant funding to UNICEF and the Canadian-based Nutrition International for VAS programs in SSA. Going forward, GAC will be passing its VAS funding directly to UNICEF to ease the administration burden of managing two separate grants with the expectation that UNICEF will use some of this funding to provide grants to other organizations supporting VAS programs, including HKI." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pgs 6-7.

 

 137. Details of HKI's additional spending opportunities are in this spreadsheet, "Spending opportunities" sheet.

 

 138. See our room for more funding spreadsheet, "Spending opportunities" sheet for additional details.

 

 139. See our HKI country case studies spreadsheet for details.

 

 140. See our room for more funding spreadsheet, "Additional calculations" sheet, "Other calculations" section.

 

 141. See our room for more funding spreadsheet, "Additional calculations" sheet, "Other calculations" section. HKI room for more funding report July 2019: "We estimate the funding gap [in Guinea] to be $153,935 and $126,832 in 2020 and 2021, respectively, but increase to $984,796 in 2022 for a total estimated 'room for more funding' of $1,265,563 over the next three years." Pg 10. "We estimate the need [in Mali] for an additional $341,986 and $378,056 for 2020 and 2021, respectively, to support the national VAS campaign and a PECS national coverage survey and an additional $1,286,184 for 2022 for a total of $2,006,226 over the next 3 years." Pg 11. "To ensure that coverage surveys are organized annually, and funding and technical support continues for the next three years [in Burkina Faso], HKI estimates the room for more funding to be $66,950/year for 2019 to 2021 and $880,729 for 2022, totaling $1,081,579 over three years." Pg 9. 

 142. "To avoid the cancellation of the first campaign round of 2018, HKI supported its implementation with $141,825 received from GiveWell’s leveraged support. Unfortunately, the funding shortfall for the second campaign round (planned for October 2018) is significantly higher—between $500,000-$800,000--because no polio vaccination campaign will be conducted during this period. HKI plans to use existing GiveWell funds to cover a small part of the shortfall and support VAS delivery in the most vulnerable districts." HKI room for more funding report July 2018, Pg 10. HKI's finalized actual spending report for 2018 indicates that it spent $472,416 in total in Côte d'Ivoire on both VAS campaigns in 2018. HKI VAS expense summary 2018 redacted 

 143. See this cell in our HKI country case studies spreadsheet for information on VAS campaigns in Côte d'Ivoire in 2016 and 2017. "To avoid the cancellation of the first campaign round of 2018, HKI supported its implementation with $141,825 received from GiveWell’s leveraged support. Unfortunately, the funding shortfall for the second campaign round (planned for October 2018) is significantly higher—between $500,000-$800,000--because no polio vaccination campaign will be conducted during this period. HKI plans to use existing GiveWell funds to cover a small part of the shortfall and support VAS delivery in the most vulnerable districts." HKI room for more funding report July 2018, Pg 10. "UNICEF Côte d’Ivoire and the Ivorian Ministry of Health will most likely not have sufficient funding to support a full national polio immunization campaign in October. While it is possible that some funding will be available from other sources, there is a significant chance that there will be no polio campaign at all in the second half of 2018." GiveWell's non-verbatim summary of a conversation with Helen Keller International, April 9, 2018. 

 144. "In addition to the funds above, as a result of GiveWell’s Top Charity designation, HKI was contacted by and has applied for funds from the [redacted] Foundation [redacted] in the amount of $3m. HKI’s initial letter of interest to [redacted] was favorably viewed and HK was invited to submit additional documentation as part of [redacted] phase two process. A decision about the award is anticipated in September or October 2018. If HKI is successful in securing $3m from [redacted], these funds will be used to provide technical support for VAS in Cote d’Ivoire and Niger over a three-year period." HKI room for more funding report July 2018, Pgs 7-8. HKI told us that if it received the $3 million grant from the foundation, it would use $1.5 million in each Côte d'Ivoire and Niger. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018 HKI has confirmed that it will receive a $4 million grant from this foundation over four years for supporting VAS campaigns in Côte d'Ivoire and Niger. Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, October 12, 2018 We assume that HKI is planning to use $2 million of the $4 million grant in Côte d'Ivoire. $468,294 received from effect: hope and committed to Côte d'Ivoire in 2019, according to HKI budget details 2018-2021 redacted, "Effect Hope 2019" sheet. 

 145. "While the country's initial plan was to transition VAS delivery in all districts to a health systems approach by 2020, the low VAS coverage in the “transitioned” districts makes it likely that campaigns will continue until (at least) 2022. During this period, financial gaps will increase due to the cessation of polio campaigns and reduced funding from UNICEF. HKI therefore estimates a funding gap of $1,061,500 of which 50% is needed to support a second VAS campaign round in 2019 and 2020, and the other 50% to support campaigns in areas where the health systems approach is not yet effective." HKI room for more funding report July 2019, Pgs 9-10.

 

 146. "In addition to the funds above, as a result of GiveWell’s Top Charity designation, HKI was contacted by and has applied for funds from the [redacted] Foundation [redacted]in the amount of $3m. HKI’s initial letter of interest to [redacted] was favorably viewed and HK was invited to submit additional documentation as part of [redacted] phase two process. A decision about the award is anticipated in September or October 2018. If HKI is successful in securing $3m from [redacted], these funds will be used to provide technical support for VAS in Cote d’Ivoire and Niger over a three-year period." HKI room for more funding report July 2018, Pgs 7-8. HKI told us that if it received the $3 million grant from the foundation, it would use $1.5 million in each Côte d'Ivoire and Niger. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018  HKI has confirmed that it will receive a $4 million grant over four years for supporting VAS campaigns in Côte d'Ivoire and Niger. Rolf Klemm, HKI Vice President of Nutrition, email to GiveWell, October 12, 2018 We assume that HKI is planning to use $2 million of the $4 million grant in Niger. 

 147. See our 2018 room for more funding analysis, "Description of additional spending opportunities" sheet, here.

 

 148. "HKI estimates that an additional $1,244,438 is needed to cover all 31 unsupported districts over the next three years. With this additional support, we estimate that an additional 2 million children will receive a vitamin A twice per year." HKI room for more funding report July 2019, Pg 11.

 

 149. See HKI room for more funding report July 2019, Pg 5, Table 2. HKI allocated $0.4 million in funding from effect: hope and $0.3 million from Foundation 1 to VAS campaigns in Kenya in 2019. It has allocated $0.5 million from Foundation 1 to programs in Kenya in 2020 and 2021. HKI budget details 2018-2021 redacted, "Foundation 1 2019 - 2021" and "Effect Hope 2019" sheets. 

 150. "In 2018 and 2019, Nutrition International and UNICEF supported half the country, leaving 22 out of 47 counties unsupported. VAS coverage for these unsupported counties is ~20%." HKI room for more funding report July 2019, Pg 10.

 

 151. "In 2019, 15 counties were (again) missed for the first distribution round due to a funding shortfall. HKI supported eight counties with funds from the [redacted] Foundation and Global Affairs Canada, but many counties still need support. We estimate that an additional $500,000/year is needed to ensure that VAS is provided to all children in the country, or a total of $1,500,000 for the next three years." HKI room for more funding report July 2019, Pgs 10-11.

 

 152. "Before closing its office in mid-2016 due to lack of funds, HKI had supported the DRC government’s VAS program for more than a decade. It had provided VAS support to about half of the country (with UNICEF supporting the other half). In each HKI-assigned province, HKI, together with the provincial and district health authorities, defined and implemented several delivery models including (i) door to door polio campaigns, (ii) fixed + outreach Child Health Days (CHDs) campaign s with a package of services, (iii) stand - alone VAS & deworming door - to-door campaigns , and (iv) routine delivery. Whatever the approach supported by HKI, VAS coverage was consistently above 80%.

 "After HKI’s exit from DRC, funding for VAS has decreased significantly resulting in inconsistent and incomplete geographic VAS coverage. For the first round in 2017, only 88% (23 out of 26 provinces) implemented VAS distribution, and coverage was 68% based on administrative data. The situation deteriorated further for the second round of 2017 with only 19% (5 out of 16) of provinces distributing VAS and coverage of only 63% of children based on government data. For 2018, only 50% (13 of 26) of the provinces will receive support from UNICEF. Currently , UNICEF is the only partner supporting VAS financially. They provide each province with ~$ 55,000, an amount likely to be far too low to achieve high VAS coverage. This amount, if averaged over the DRC target population of preschool - age children, represent s $0. 10 per child and per round — far below the ~$0.75 - $1.00 needed." HKI room for more funding report July 2018, Pgs 10-11.

 

 153. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, August 23, 2019 "HKI proposes to support VAS campaigns in two provinces over the next three years, supplementing an estimated 2 million children per campaign round. The estimated additional budget required is $1.5 million/year or $4.5 million over 3 years." HKI room for more funding report July 2019, Pg 10. 

 154. "In Cameroon, VAD affects about 35% of children under 5 years and UFMR is ~112. In 2018, UNICEF was able to support four regions to conduct a second campaign round, but no support for the remaining 70% of the country’s population." HKI room for more funding report July 2019, Pg 9. In 2018, HKI only supported VAS campaigns in Burkina Faso, Guinea, Mali, and Côte d'Ivoire. See this spreadsheet. 

 155. "HKI estimates the support needed for two distribution rounds in these two regions to be $600,000/year or a total of $1,800,000 over three years (2020-22)." HKI room for more funding report July 2019, Pg 9.

 

 156. "HKI proposes to support VAS campaigns in Bauchi state from 2020 to 2022. Bauchi State is located in the northeast part of Nigeria and is composed of twenty local government areas and 323 political wards." HKI room for more funding report July 2019, Pg 12.

 

 157. "Its other nutritional indicators show Bauchi to be a nutritionally high-risk state with levels of severe stunting, severe underweight and severe acute malnutrition of 16.3%, 8.2% and 1.6%, respectively (NNHS, 2018). The state also suffers from low (29%) VAS coverage (NNHS, 2018)." HKI room for more funding report July 2019, Pg 12.

 

 158. "With additional funds, HKI will support bi-annual VAS campaigns in this high-priority state. We estimate the need for $789,255/year for a total of $2,367,765 over three years." HKI room for more funding report July 2019, Pg 12.

 

 159. See our room for more funding spreadsheet, "Spending opportunities" sheet.

 

 160. See our room for more funding spreadsheet, "Spending opportunities" sheet.

 

 161. In early 2018, HKI provided $141,825 to support the implementation of a VAS campaign in Côte d'Ivoire. It plans to provide $500,000 to support another campaign in Côte d'Ivoire in October 2018: "To avoid the cancellation of the first campaign round of 2018, HKI supported its implementation with $141,825 received from GiveWell’s leveraged support." HKI room for more funding report July 2018, Pg 10. HKI told us that it planned to use $500,000 to support the October 2018 Côte d'Ivoire VAS mass campaign, and that it expected that the campaign would be cancelled in HKI's absence. David Doledec, HKI Regional VAS Program Manager, and Rolf Klemm, HKI Vice President of Nutrition, conversation with GiveWell, July 18, 2018. If HKI had additional funding beyond the amount described above, we would guess that HKI would consider using it to fill in funding gaps for campaigns that would otherwise be cancelled, as it did in Côte d'Ivoire in 2018. 

 162. Global Affairs Canada Project profile: Scaling Up Nutrition - Helen Keller International Global Affairs Canada Project profile: Scaling Up Nutrition and Immunizations - UNICEF Global Affairs Canada Project profile: Enhanced Child Health Days 

 163. "In a three-year period between 2013 and 2016, Global Affairs Canada (GAC) granted around $30 million (CAD) to HKI and provided significant funding to UNICEF and the Canadian-based Nutrition International for VAS programs in sub-Saharan Africa. Going forward, GAC will be passing its VAS funding directly to UNICEF to ease the administration burden of managing two separate grants with the expectation that UNICEF will use some of this funding to provide grants to other organizations supporting VAS programs, including HKI. Under the new arrangements between GAC and UNICEF, the amount of funding to support VAS appears to be considerably lower than in previous years because it covers four rather than three years of VAS activities, supports immunization activities in addition to VAS, and because the value of the Canadian dollar relative to the US dollar has decreased ~30% since 2013. "UNICEF, as a multi-national United Nations program, works in many more countries than HKI does, and has had to prioritize certain countries over others to receive GAC funding. Many UNICEF priority countries for VAS are not countries where HKI has a presence, which has meant fewer resources to continue HKI’s VAS work in those countries not prioritized by UNICEF. There are several other global trends that cause concern for the future of funding VAS programs:

 HKI is concerned that over recent years, global attention to and funding for VAS has waned, most likely due to competition with other pressing priorities and interventions emerging to address broader maternal-newborn-child-adolescent health and nutrition needs. 'Donor fatigue' may be contributing to declining interest in supporting VAS. Due to the changing political landscapes in the U.S., Europe, and the U.K., HKI anticipates major reductions in development aid for maternal and child health programs, including for nutrition and VAS. This may further threaten the long-term funding situation for child survival interventions such as VAS in countries where the need remains high, including many of those in which HKI has a presence." GiveWell's non-verbatim summary of a conversation with Helen Keller International, June 1, 2017, Pgs 6-7.

 In 2013 to 2016, 33% of GAC's 41 million CAD grant to UNICEF was intended to cover "Basic health care" and 67% of the grant was intended to cover "Basic nutrition." Global Affairs Canada Project profile: Scaling Up Nutrition and Immunizations - UNICEF In 2013 to 2016, 100% of GAC's grant to HKI was intended to cover "Basic nutrition." Global Affairs Canada Project profile: Scaling Up Nutrition - Helen Keller International Overall, in 2013 to 2016, 19.3% ((0.33*41)/70) of GAC's grants to UNICEF and HKI were intended to cover "Basic healthcare" and the remainder (80.7%) was intended to cover "Basic nutrition" In 2016 to 2020, 33% of GAC's 70 million grant to UNICEF is intended to cover "Basic healthcare" and 67% is intended to cover "Basic nutrition." Global Affairs Canada Project profile: Enhanced Child Health Days Our understanding is that "Basic healthcare" primarily refers to immunization programs, and that "basic nutrition" primarily refers to VAS programs in this context. 

 164. "Global Affairs Canada (GAC), a department of the Canadian government, has funded vitamin A supplementation (VAS) work by HKI, UNICEF, and Nutrition International since the early 2000s. It has been the only major funder of VAS programs. GiveWell's notes from a site visit with HKI to Conakry, Guinea, October 9-11, 2017, Pg 1.

 

                    Helen Keller International (HKI) wrote the following in response to GiveWell's interim review of HKI. We have since updated our review of HKI so the below may not fully be up-to-date.

 Published: November 2017

 Helen Keller International (HKI) appreciates GiveWell’s invitation to be considered for a top charity recommendation for its vitamin A supplementation program. We have appreciated the transparency and thoroughness of GiveWell’s investigative process thus far. We also appreciate being named a standout charity based on the interim review while GiveWell undertakes additional investigation to determine if HKI qualifies as a top-rated charity. 

 We would like to offer the following statements in response to points made in GiveWell’s interim review:

 Does vitamin A supplementation (VAS) work? This is an important question and one that has received recent attention considering the shifting epidemiologic and programmatic landscape. The epidemiologic landscape has changed since the first VAS trials were published in the early 1990s. Overall, child mortality rates have declined by 49% since 1990 (Unicef 2014), but the rate of decline has been slowest in Oceania, sub-Saharan Africa and Asia. Likewise, the proportionate cause-specific mortality has also changed. In 1990, the three main killers were pneumonia (21% of under-5 mortality; U5MR), diarrhea (20%), and measles (7%) (van den Ent et al 2011), while in 2010 the main killers were pneumonia (18%), diarrhea (11%) and malaria (7%) (Liu L et al 2012). There is no question that in contexts exhibiting public health levels of vitamin A deficiency (VAD) and UFMR, VAS (and other interventions that improve the underlying vitamin A status of risk groups) is both sight- and life-saving. This conclusion stems from the results of large, rigorously conducted community trials in South Asia and Africa, which collectively provide incontrovertible evidence that vitamin A interventions, including 6-monthly VAS, reduce early childhood mortality and blindness in undernourished populations (Mayo-Wilson et al 2011). The impact is particularly striking on fatality not only from measles but also from more common diseases such as diarrhea, dysentery and other infectious illnesses. In contexts where uncertainty exists about deficiency and mortality levels (due to the lack of recent data or other reasons) stopping or modifying VAS targets potentially puts children’s lives at risk. 

 But even in countries with marked mortality declines and changes in causes of death, one cannot rule out a child survival benefit in many contexts. In all, 54 countries globally had a high U5MR (defined as ≥50 per 1000 live births) in 2012 (Unicef 2014). A large proportion of these deaths are caused by infections. Furthermore, in these high-mortality countries VAD is also likely to be high (Schultink 2002), thus reinforcing the need to maintain VAS and other vitamin A interventions. Where U5MR, VAD and infectious disease rates are low, the mortality effect of VAS will likely be reduced. Nevertheless, we must bear in mind two important facts (1) the original VAS studies observed mortality impacts in settings with a wide range of mortality and morbidity rates (Beaton et al 1993), and (2) one cannot rule out the role of VAS in helping to bring down U5MR (Bishai et al 2005; Masanja et al 2008).

 How to think about the Deworming and Enhanced Vitamin A (DEVTA) program evaluation? GiveWell’s report mentions several times the disputed and controversial DEVTA program evaluation study which suffered from important methodological limitations related to supplementation adherence and vital event monitoring systems, as acknowledged by other scientists (Mannar et al 2013; Mayo-Wilson et al 2013; Habicht et al 2013; Sommer et al 2013; Sloan et al 2013). In addition to weighing the methodological flaws of DEVTA, we feel the results of the DEVTA study should be viewed within the context of the larger body of evidence on VAS and child survival. Recently, the WHO examined evidence from all 17 trials (11 in Asia, 5 in Africa and 1 in Latin America) conducted to date for all-cause mortality. Findings revealed that VAS reduces the overall risk of death by 24% (risk ratio (RR) 0.76; 95% confidence interval (CI) 0.69–0.83). When adding the DEVTA findings to the analysis, the all-cause mortality benefit of VAS remained statistically and clinically significant at 12% (RR 0.88; 95% CI 0.84–0.94) (Mayo-Wilson et al 2011)The current best evidence indicates that VAD remains prevalent in south Asia and sub-Saharan Africa, but there is a need for more current, reliable and valid estimates of VAD prevalence. GiveWell raises the question, “How prevalent is vitamin A deficiency in areas where HKI works?”. While HKI recognizes the urgent need for updated and valid estimates of vitamin A status in the countries and sub-regions where we work, HKI relies on the best available evidence from scientific sources to ensure that its VAS programs are targeting at risk populations. The most recent global and region-specific estimates of VA deficiency prevalence come from a pooled analysis of population-based surveys from 138 low- and middle-income countries between 1991 and 2013 and published in the Lancet Global Health Journal in 2015. In this publication, the authors estimated the prevalence of deficiency in 2013 to be highest in sub-Saharan Africa (48%) and south Asia (44%) (Stevens et al 2015).  Region and country-specific VAD prevalence estimates should be updated as new data become available. Currently, many countries implementing VAS programs have no VAD data or the data do exist are >10 years old (Wirth et al 2017). Clearly, there is an urgent need to fill this data gap and for funders and host-country governments to invest in high-quality surveys to assess VA (and other micronutrient) status and program coverage in children.Achieving and sustaining high VAS coverage through HKI’s technical assistance. We provided GiveWell with evidence from two countries (Cameroon and Kenya) which demonstrated that HKI’s technical assistance contributed to significantly higher coverage rates. We appreciate GiveWell’s desire to understand HKI’s added value by assessing VAS program performance using a counterfactual paradigm. Unfortunately, due to the lack of funding in Mali and Cote d’Ivoire in 2017, HKI has been unable to provide VAS technical support to either country providing counterfactual examples. Sadly, both countries missed a VAS distribution round in the first semester of 2017 suggesting that in the absence of HKI’s support the VAS programs in both countries were negatively affected. During their planned country visit, we encourage GiveWell to look further into the added value HKI provides to VAS coverage.Cost per supplement delivered and cost-effectiveness of VAS. We feel it is important to note that VAS often serves as the driver behind Child Health Days (CHDs) and Child Health Weeks onto which other vital health and nutrition services (such as deworming, measles immunization, distribution of insecticide-treated bednets, screening for acute malnutrition, and others) are piggy-backed. For example, CHDs delivered nearly half of all global deworming treatments to preschool children in 2013, thus illustrating the strategic importance of this delivery mechanism for attaining high coverage of vital services targeting preschool-age children (Kumapley et al 2015). The design of CHDs and the package of interventions offered can be tailored to the local contexts; and in fragile health systems, CHDs serve as a major delivery platform for high-impact interventions targeted to preschool age children. Because the semi-annual delivery of VAS to preschool children is often the main driver behind CHDs, we feel it is important for cost per supplement delivered and cost-effectiveness models to consider these added benefits. The CHD delivery platform was largely propelled by the need to reach preschool-age children twice each year with a large dose of vitamin A.Questions that need more information. HKI appreciates the rigor that GiveWell applies to organizations that are being considered for “top charity” selection. GiveWell’s interim report identifies many remaining questions related to VAS and HKI that it hopes to answer or about which it wants to develop a deeper understanding. Some of these questions will require investments in new data collection. For example, the only way to assess levels of VA deficiency or U5MR in countries or sub-regions where HKI works is to measure these using reliable and valid methods. In low-resource and low-capacity settings, this will require significant investment by the global community and should be done. It is even more difficult to answer the question about the expected child survival impact of VAS given the changing epidemiologic landscape, especially since conducting placebo-controlled trials to address this question would be unethical given the weight of evidence of the benefit of VAS. HKI’s view is to trust the scientific community’s best estimates of benefit based on thoughtful and systematic meta-analyses. HKI keeps abreast of new scientific evidence as it emerges. If and when estimates of benefit are revised, HKI will revise impact expectations and program approaches. The question of HKI’s added value with respect to VAS programs is, in our view clear. HKI remains a global leader, innovator, advocate and technical support to VAS programs in countries and contexts where VAS should remain a priority intervention. We look forward to GiveWell’s site visits so they can learn more about the important role HKI has provided to VAS programs especially in Sub-Saharan Africa and the support it wishes to continue to provide until the scourge caused by VAD no longer plagues vulnerable populations. VAD will not disappear until vulnerable populations have achieved normal vitamin A status by sustained changes in dietary vitamin A intake. HKI strives to improve the diets through its fortification, nutrition education and food production programs. Until the time when the diets of vulnerable populations are replete with adequate intake of vitamin A, HKI believes periodic high-dose vitamin A has a vital public health role in protecting child health and survival, and thus remains committed to this sight- and life-saving intervention. 

References

 Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe G, Ross AC, Harvey B. Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries. Geneva, Switzerland: Administrative Committee on Coordination–Subcommittee on Nutrition (ACC/SCN); 1993.

 Bishai D, Kumar K C S, Waters H, Koenig M, Katz J, Khatry SK, West KP Jr. The impact of vitamin A supplementation on mortality inequalities among children in Nepal. Health Policy Plan. 2005 Jan;20(1):60-6.

 Habicht JP, Victora C. Vitamin A supplementation in Indian children. Lancet. 2013 Aug 17;382(9892):592.

 Kumapley RS, Kupka R, Dalmiya N. The Role of Child Health Days in the Attainment of Global Deworming Coverage Targets among Preschool-Age Children. PLoS Negl Trop Dis. 2015 Nov 6;9(11).

 Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 2012;379:2151-61.

 Mannar V, Schultink W, Spahn K. Vitamin A supplementation in Indian children. Lancet. 2013 Aug 17;382(9892):591-2. 

 Masanja H, de Savigny D, Smithson P, Schellenberg J, John T, Mbuya C, Upunda G, Boerma T, Victora C, Smith T, Mshinda H. Child survival gains in Tanzania: analysis of data from demographic and health surveys. Lancet. 2008 Apr 12;371(9620):1276-83.

 Mayo-Wilson E, Imdad A, Herzer K, Yakoob MY, Bhutta ZA. Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. BMJ 2011; 343.

 Mayo-Wilson E, Imdad A, Herzer K, Bhutta ZA. Vitamin A supplementation in Indian children. Lancet. 2013 Aug 17;382(9892):594

 Schultink W. Use of under-five mortality rate as an indicator for vitamin A deficiency in a population. J Nutr 2002;132:2881S-3S.

 Sloan NL, Mitra SN. Vitamin A supplementation in Indian children. Lancet. 2013 Aug 17;382(9892):593. .

 Sommer A, West KP Jr, Martorell R. Vitamin A supplementation in Indian children. Lancet. 2013 Aug 17;382(9892):591.

 Stevens GA, Bennett JE, Hennocq Q, et al. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. Lancet Glob Health. 2015;3:e528-e536.

 UNICEF. The State of the World’s Children 2014 In Numbers: Every Child Counts. New York 2014.

 UNICEF, WHO, Bank W, UN. Levels & Trends in Child Mortality. Report 2014. New York: UNICEF; 2014.

 van den Ent MM, Brown DW, Hoekstra EJ, Christie A, Cochi SL. Measles mortality reduction contributes substantially to reduction of all cause mortality among children less than five years of age, 1990-2008. The Journal of infectious diseases 2011;204 Suppl 1:S18-23. 

 Wirth JP, Petry N, Tanumihardjo SA, Rogers LM, McLean E, Greig A, Garrett GS, Klemm RD, Rohner F. Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency. Nutrients. 2017 Feb 24;9(3).

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