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Helen Keller International’s Vitamin A Supplementation Program

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▲ Photo from Helen Keller International in Côte d'Ivoire

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Children's nutrition report

This is a Founders Pledge summary and interpretation of original research published by GiveWell, our research partner focused on global health and development. For GiveWell's full research see their review of Helen Keller International's vitamin A supplementation program.

Helen Keller International supports programs focused on reducing malnutrition and blindness through a combination of technical assistance, advocacy, and funding. We recommend their vitamin A supplementation programs, through which preschool-aged children, in sub-Saharan Africa, are provided with vitamin A supplements twice yearly.

If you are interested in co-funding a portfolio of organizations like this one, please see our Global Health and Development Fund.

What problem are they trying to solve?

Around 190 million preschool-aged children worldwide suffer from Vitamin A deficiency. This has terrible consequences for their development as Vitamin A is crucial for the healthy functioning of the human immune and visual systems. Vitamin A deficiency is one of the leading causes of blindness in low- and middle-income countries, can cause chronic lung impairment and causes millions of deaths every year. It typically begins in early childhood, when infants do not receive adequate supplies of colostrum or breast milk.

What do they do?

Helen Keller International provides technical assistance and funding to governments implementing vitamin A supplementation programs for preschool-aged children. They focus on countries in sub-Saharan Africa, where vitamin A deficiency among children is most prevalent.

Helen Keller International-supported vitamin A supplementation programs include both mass distribution campaigns and routine delivery programs, in which caregivers take their children to existing health facilities to receive supplements every six months. Mass distribution campaigns can be conducted in a number of ways, including door-to-door campaigns in which community health workers travel to recipients’ homes and fixed-site campaigns in which caregivers bring preschool-aged children to health facilities or field sites. Routine delivery is usually used where existing health services are stronger. Since high-dose Vitamin A supplements can be stored in the liver for several months, Helen Keller International aims to conduct mass distributions of vitamin A supplements every six months.

Why do we recommend them?

  • GiveWell, our research partner in global health and development, recommends Helen Keller International as one of the most cost-effective global development organisations in the world.
  • GiveWell reports that vitamin A supplementation has strong evidence of effectiveness.
  • Helen Keller International has a strong track record, with experience supporting vitamin A supplementation in a large number of countries.
  • GiveWell reports that Helen Keller International is a highly transparent organisation and has shared detailed information about its program.

Cost-effectiveness

GiveWell estimates that the total cost to purchase and distribute a vitamin A supplement through Helen Keller International is $1.10. GiveWell’s full calculations are available in this spreadsheet. This suggests, according to GiveWell, that Helen Keller International’s vitamin A supplementation program is currently able to save a life for approximately every $3,000-$5,000 donated.

Evidence of impact

GiveWell bases its expectation of the impact of Helen Keller International’s vitamin A supplementation programs on three types of evidence: 1) evidence that vitamin A supplementation reduces child mortality, 2) evidence of widespread vitamin A deficiency in the regions targeted, and 3) evidence, from coverage surveys conducted after supplementation campaigns, that a high proportion of targeted children receive and ingest the supplements.

GiveWell has reviewed evidence that vitamin A supplementation reduces child mortality. Imdad et al. (2010) found that vitamin A supplementation reduces mortality of 6 to 59-month-old children by 24%. This study, GiveWell reports, covered sixteen randomised controlled trials with consistent evidence of positive impact. Similarly, an updated review by Imdad et al. (2017) combined results from previous trials with those of Fisker et al. (2014) and Deworming and Enhanced Vitamin A (2013), described below, also concluded that vitamin A supplementation significantly reduces child mortality.

Deworming and Enhanced Vitamin A (2013) conducted a trial with more than one million participants in India, and did not find significant effects on child mortality. GiveWell suggests that this may be because of improved overall health conditions in the population studied in the trial, compared to the populations studied in earlier trials. Overall, GiveWell expects that vitamin A supplementation programs continue to reduce child mortality in populations with high rates of vitamin A deficiency and child mortality, including the areas targeted by Helen Keller International.

GiveWell has reviewed coverage surveys that show that a high proportion of children targeted by Helen Keller-supported programs are being reached. The coverage surveys GiveWell has reviewed found median coverage of 85%, with a lowest coverage rate of 74%. This, according to GiveWell, is strong evidence that Helen Keller International are not only targeting areas with high rates of vitamin A deficiency, but also successfully reaching significant numbers of children in these areas.

Why do we trust this organization?

This charity was recommended by GiveWell, our research partner for global health and development issues. GiveWell is a nonprofit dedicated to finding outstanding giving opportunities and publishing the full details of their analysis to help donors decide where to give.

Unlike charity evaluators that focus on assessing administrative or fundraising costs, GiveWell conducts in-depth research aiming to determine how much good a given program accomplishes, per dollar spent, in terms of lives saved or lives improved. Rather than try to rate as many charities as possible, they focus on the few charities that stand out according to a specific set of criteria, in order to find and confidently recommend high-impact giving opportunities. Helen Keller International's vitamin A supplementation program is on GiveWell’s list of top charities.

What would they do with more funding?

Spending opportunities and room for funding

As of June 2020, GiveWell calculates that, over the next three years, Helen Keller International could productively use $12.7 million more than its current expected funding, in order to support vitamin A supplementation programs in Cameroon ($3.8 million), Kenya ($3.5 million), and four states in Nigeria ($5.4 million).

What are the major open questions?

GiveWell notes that determining levels of vitamin A deficiency is complicated, and that they remain highly uncertain about rates of deficiency among preschool-aged children in the regions in which Helen Keller International supports supplementation programs. If rates of vitamin A deficiency are lower than estimated, this could reduce Helen Keller International’s cost-effectiveness.

Message from the organization

“Helen Keller International launched programs to deliver vitamin A supplementation to children in the 1970’s. We have pioneered this important work worldwide. Vitamin A provides young children with a critical nutrient to build healthy immune systems and strong vision. Research shows that providing doses of vitamin A supplementation twice a year to children from six months to five years of age can reduce child mortality by almost a quarter. We now deliver vitamin A to millions of vulnerable children annually in twelve countries in West, Central, and East Africa.”

More resources

Disclaimer: We do not have a reciprocal relationship with any charity, and recommendations are subject to change based on our ongoing research.

Notes

  1. US National Institute of Health. (2020). Vitamin A - Health Professional Fact Sheet. Retrieved 26 February 2021. From https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/#h5 ↩

  2. "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." World Health Organization. (2009). Global prevalence of vitamin A deficiency in populations at risk. Geneva: World Health Organization. ↩

  3. “...effects of chronic VAD in the impairment of lung physiology and pulmonary disease which represent a major global health problem...” Timoneda, J., Rodriguez-Fernandez, L., Zaragoza, R., Marin, M., Cabezuelo, M., Torres, L., Vina, J., and Barber, T. (2018). “Vitamin A Deficiency and the Lung” in Nutrients. 2018 Volume 10, Issue 9. https://www.mdpi.com/2072-6643/10/9/1132 ↩

  4. “Vitamin A deficiency is common among children in developing countries, and is responsible for one to two million deaths and half a million new cases of blindness every year. Improving vitamin A status can dramatically improve child health, vision and survival.” Sommer, A. (2001). Vitamin A Deficiency. Wiley. ↩

  5. World Health Organization. (2009). Global prevalence of vitamin A deficiency in populations at risk. Geneva: World Health Organization. ↩

  6. Night blindness is a condition often associated with vitamin A deficiency. “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…” World Health Organization. (2009). Global prevalence of vitamin A deficiency in populations at risk. Geneva: World Health Organization. ↩

  7. Guideline: Vitamin A supplementation in infants and children 6–59 months of age. Geneva: World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/44664/9789241501767_eng.pdf?sequence=1 ↩

  8. GiveWell has the highest confidence in the effectiveness of mass distribution campaigns, as opposed to routine delivery. GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#How_are_vitamin_A_supplements_distributed_and_administered_to_preschool-aged_children ↩

  9. GiveWell. (2020). Helen Keller distribution methods for VAS mass distribution campaigns. Retrieved 26 February 2021. From https://docs.google.com/spreadsheets/d/1RaQvinJik4f9J7AwmWlPHbr8o5sTHA5qEoaaisx7OlM/edit#gid=0 ↩

  10. “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.” Helen Keller International. HKI Vitamin A Supplementation Overview Brochure. https://files.givewell.org/files/DWDA%202009/Helen_Keller_International/HKI_VAS_Overview_Brochure.pdf ↩

  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." World Health Organization. (2011). Guideline: Vitamin A supplementation in infants and children 6–59 months of age. Geneva: World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/44664/9789241501767_eng.pdf?sequence=1 ↩

  12. “Mass distribution campaigns are the main delivery mechanism for VAS. These campaigns are organized at least every 6 months…” Helen Keller International. HKI Vitamin A Supplementation Overview Brochure. https://files.givewell.org/files/DWDA%202009/Helen_Keller_International/HKI_VAS_Overview_Brochure.pdf ↩

  13. “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.” GiveWell. (2020). 2020 GiveWell cost-effectiveness analysis - version 2. Givewell.org Retrieved 26 February 2021. From https://docs.google.com/spreadsheets/d/16XOOB1oWse1ICbF0OVXUYtwWwpvG3mxAAQ6LYAAndQU/edit#gid=1070538669 ↩

  14. GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program: Does it work?. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#Does_it_work ↩

  15. “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.” Imad, A., Herzer, K., Mayo-Wilson, E., Yakoob, MY., and Bhutta, ZA. (2010). Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age (Review). Cochrane. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008524.pub2/pdf/full ↩

  16. GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program: Does it work?. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#Does_it_work ↩

  17. Imdad A, Mayo‐Wilson E, Herzer K, and Bhutta ZA. “Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age.” Cochrane Database of Systematic Reviews 2017, Issue 3. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008524.pub3/full ↩

  18. Awasthi S, Peto R, Read S, Clark S, Pande V, Bundy D; DEVTA (Deworming and Enhanced Vitamin A) team. “Vitamin A supplementation every 6 months with retinol in 1 million pre-school children in north India: DEVTA, a cluster-randomised trial.” Lancet. 2013 Apr 27;381(9876):1469-77. ↩

  19. GiveWell. (2018). Vitamin A Supplementation: Why did DEVTA’s results differ from previous trials?. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/international/technical/programs/vitamin-A#Why_did_DEVTAs_results_differ_from_previous_trials ↩

  20. GiveWell. (2020). Helen Keller International's Vitamin A Supplementation Program: Are programs targeted at areas where they are likely to be effective?. Givewell.org. Retrieved 20 April 2021. From https://www.givewell.org/charities/helen-keller-international#Are_programs_targeted_at_areas_where_they_are_likely_to_be_effective ↩

  21. GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#Results ↩

  22. GiveWell. (2020). Helen Keller’s coverage surveys, methods and results. Givewell.org. Retrieved 26 February 2021. From https://docs.google.com/spreadsheets/d/137nu-MF0hAhPhalAvMJmDx-3Z2xU41eHsZKz3apnmGE/edit#gid=1606491595 ↩

  23. “We believe that results from Helen Keller's coverage surveys provide relatively strong evidence that a high proportion of the target population has been reached with VAS in past campaigns.” GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#Results ↩

  24. GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program: Is there room for more funding?. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#Is_there_room_for_more_funding ↩

  25. GiveWell. (2020). Helen Keller International’s Vitamin A Supplementation Program. Givewell.org. Retrieved 26 February 2021. From https://www.givewell.org/charities/helen-keller-international#Summary ↩

  26. Helen Keller International. (2020). Looking Bravely: Ensuring Safe Delivery of Lifesaving Vitamin A. hki.org. Retrieved 26 February 2021. From https://www.hki.org/our-stories/safe-delivery-of-lifesaving-vitamin-a-supplementation/ ↩

  1. What problem are they trying to solve?
  2. What do they do?
  3. Why do we recommend them?
  4. Why do we trust this organization?
  5. What would they do with more funding?
  6. What are the major open questions?
  7. Message from the organization
  8. More resources
  9. Notes