Unlimit Health

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 Unlimit Health.

Unlimit Health (UH) supports programs that treat schistosomiasis and soil-transmitted helminthiasis by working with governments through a combination of technical assistance, fundraising, and grantmaking. Their deworming programs treat schoolchildren with inexpensive drugs to reduce the harm caused by parasitic worms.

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

What problem are they trying to solve?

More than a billion people are at risk from parasitic worm infections. Two particularly common afflictions are schistosomiasis and soil-transmitted helminthiasis. Schistosomiasis is transmitted through water contaminated with the larvae of a parasitic worm, and affects roughly 251 million people.¹ Soil-transmitted helminthiasis is transmitted through faeces and soil, and affects 1.5 billion people worldwide.² Children living in severe poverty and without adequate access to sanitation are especially at risk, and there is evidence that worms negatively impact their development and reduce the income they earn later in life.³

The negative effects of these diseases are almost always avoidable. While effective treatments exist, many people in low- and middle-income countries are unable to access them. Poverty, inequality, and a lack of awareness in low- and middle-income countries hamper the distribution of highly effective drugs.⁴

What do they do?

UH works with governments in sub-Saharan Africa to start or scale up mass drug administrations for schistosomiasis and soil-transmitted helminthiasis. They focus mainly on treating school-age children, although they do provide treatment for other high risk groups.⁵ UH works to identify suitable government partners and regions with high prevalence of worms, fund and support government-implemented programs, and conduct monitoring and evaluation of these programs.⁶

UH currently supports government deworming mass drug administration programmes in Ethiopia, DRC, Malawi, Madagascar, Tanzania, Uganda, Côte d'Ivoire, Niger, Liberia, Zanzibar, Burundi, and Mauritania. Depending upon the requirements of the specific context, UH may employ staff for program management, technical assistance and capacity building or fund governments to carry out infection mapping and treatment programs.⁷ UH works in close partnership with ministries of health and is careful not to establish structures parallel to the existing health system.

For further information on UH’s involvement in deworming programs, including a full list of implementation partners and specific interventions/case-studies, see GiveWell’s write-up on UH.

Why do we recommend them?

• GiveWell, our research partner in global health and development, recommends UH as one of the most cost-effective global development organisations in the world.
• There is strong evidence that administration of deworming drugs reduces worm loads.
• There is some evidence that reductions in worm loads lead to improved life outcomes.
• GiveWell reports that UH is a strong, transparent, responsive, and impact-driven organisation. This impression has been confirmed during our re-evaluation communications with them.

Cost-effectiveness

Mass deworming pill distribution is an inexpensive and safe solution to parasitic worms. GiveWell estimates it costs about $1.03 to deworm a child in UH-supported programs, depending upon the location and specific program, and have no significant side effects.⁸ Due to the inexpensive nature of treatment, it is more cost-effective to distribute the medication to large groups of people, rather than testing to identify only those who are affected by the illness.⁹ GiveWell estimates that, excluding the cost of drugs (which are often donated) and in-kind government contributions, UH is able to treat one child for approximately $0.40.¹⁰

Evidence of impact

GiveWell asserts that there is strong evidence that administration of deworming medication reduces worm loads.¹¹ GiveWell has reviewed evidence that SCI’s programs have been successful in reaching a high proportion of targeted children.¹² GiveWell has reviewed coverage surveys from a majority of the countries in which UH works. Across surveys, median coverage has been 85%, exceeding the World Health Organization’s recommended threshold of 75% coverage, for both schistosomiasis and soil-transmitted helminthiasis treatments.¹³

While GiveWell believes that there is strong evidence that administration of deworming drugs reduces worm loads, the evidence for a causal relationship between reduced worm loads and improved life outcomes is less strong. For GiveWell’s full exploration of the evidence for deworming mass drug administration, see their report on deworming. Key studies discussed in GiveWell’s report include deworming experiments conducted in Kenya and Uganda by Miguel and Kremer (2004), Baird et al (2012), and Croke (2014). Each of these found improved life outcomes from deworming programs, but should not be considered entirely conclusive or representative due to the higher prevalence of worms in the regions studied than in most of the contexts in which deworming is carried out today.¹⁴ It is unclear how similar the effects of deworming programs in other contexts will be. Still, the evidence is strong enough that GiveWell considers the mass administration of deworming medication to be a highly effective intervention in expectation, even after discounting for lower worm prevalence and limitations of the evidence.

Commitment to impact evaluation and transparency

GiveWell recommends UH as one of their top charities. They assess all their recommended organisations in measures of transparency, self-improvement, and organisational strength.¹⁵

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 solely 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. Despite recent changes to GiveWell's Top Charity criteria, GiveWell continues to see UH's program as 'exceptionally strong' and to provide increasing amounts of funding to them.¹⁶

What would they do with more funding?

Funding opportunities

As of November 2022, UH had identified $46 million in opportunities to support existing and new deworming programmes, from April 2022 through to December 2025.¹⁷

Room for funding

After accounting for available funding including a $20 million dollar grant from GiveWell in January 2022, projected funding, and likelihood of worm prevalence decreasing on future surveys, we estimate that UH could use up to an additional $10.7 million to support deworming of school-aged children during the period December 2022 through December 2025.¹⁸

What are the major open questions?

As noted above, the evidence for a connection between reduced morbidity in children and higher incomes later in life has been challenged. While GiveWell believes that the evidence is strong enough to make this intervention worth funding in expectation, there is a lot of uncertainty about the size of this effect.

GiveWell believes that UH may use additional funding in order to treat adults in areas with moderate or high risk of infection. This is part of a strategy to treat schistosomiasis in all at-risk populations.¹⁹ However, there is not yet sufficient evidence to suggest that this strategy is as cost-effective as treating school-age children. While this may help to decrease infection rates in children, GiveWell has not yet found sufficient evidence to confirm cost-effectiveness, and treatment of adults may not have the same positive effects on long-term earning as treatment of children.²⁰

GiveWell has a relatively high level of uncertainty about their estimate for UH’s room for more funding. In recent years, UH has received substantial funding from the UK government for deworming, but this funding ended earlier than expected in 2021.²¹ Additionally the WHO has issued new recommendations suggesting lower prevalence thresholds for treatment, and UH expects to conduct new prevalence mapping to determine which regions it will work in going forward. These considerations mean that RFF could be revised significantly in either direction in the coming year.²²

Lastly, UH is planning on shifting their strategy to an elimination approach in coming years. The likely effectiveness of this approach will depend on UH’s ability to procure sufficient medication to treat adults and preschool aged children, as well as evaluating new evidence on the effectiveness of additional primary prevention strategies such as snail control and water, sanitation and behavior change approaches. Our recommended funding is currently restricted only to their most effective traditional programs for school aged children. However, this may change in future evaluations.²³

Message from the organization

“We aim to improve the health of the poorest and most marginalised people in the world, enabling them to reach their full potential. Working in partnership with Governments in Sub-Saharan Africa, the UH helps to deliver impactful public health programmes - working towards the elimination of preventable diseases. We work across multiple sectors to deliver effective and robust health programmes that have a lasting impact. We’re proud to consistently be named as one of the most cost-effective non-profit initiatives globally.”²⁴

More resources

• GiveWell write up on UH
• GiveWell review of the evidence for Deworming
• Founders Pledge report on Deworming
• UH’s website

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

Notes

1. World Health Organisation. (Dec 2022). Weekly epidemiological record From https://apps.who.int/iris/bitstream/handle/10665/364997/WER9748-eng-fre.pdf ↩

2. World Health Organisation. (2020).Soil-transmitted helminth infections. Who.int. Retrieved 18 February 2021 From https://www.who.int/en/news-room/fact-sheets/detail/soil-transmitted-helminth-infections ↩

3. “This systematic review and meta-analysis of the cognitive and educational impact of Schistosoma infection in school-aged children supports the hypothesis that infection is associated with reduced school-attendance, with deficits in scholastic achievement and deficits in memory and learning domains of psychometrically evaluated cognitive function.” Ezeamama, A., Bustinduy, A., Nkwata, A., Martinez, L., Pabalan, N., Boivin, M., and King, C. (2018). Cognitive deficits and educational loss in children with schistosome infection—A systematic review and meta-analysis. https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0005524 ↩

4. “It was observed that 32.0%, 19.2% and 4.1% of the respondents had correct knowledge about the causes of schistosomiasis, malaria and STHs, respectively, whilst 22.1%, 19.2% and 5.8% knew correct measures to control schistosomiasis, malaria and STHs.” Midzi, N., Mtapuri-Zinyowera, S., Mapingure, N., Paul, N., Sangweme, D., Hlerma, G., Mutsaka, M., Tongogara, F., Makware, G., Chadukur, V., Brouwer, K., Mutapi, F., Kumar, N., and Mduluza, T. Knowledge attitudes and practices of Grade three primary schoolchildren in relation to schistosomiasis, soil transmitted helminthiasis and malaria. BMC Infectious Diseases, 11, 169. (2011). https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-11-169 ↩

5. “In the selected countries: to reach at least 75% of school-aged children (which in most countries would be from 6 to 15-year-old) and other high-risk groups with chemotherapy, namely PZQ and ALB; and thereby reducing prevalence and intensity of schistosomiasis and STH infections; as well as reducing schistosomiasis-related morbidity in high risk groups; and burdens due to STH infections in the targeted populations.” Fenwick, A., Webster, J., Bosque-Oliva, E., Blair, L., Fleming, F., Zhang, Y., Garba, A., Stothard, J., Gabrielli, A., Clements, A., Kabatereine, N., Toure, S., Dembele, R., Nyandindi, Y., Mwansa, J., and Koukounari, A. (2009). The Schistosomiasis Control Initiative (UH): rationale, development and implementation from 2002–2008. Cambridge University Press. ↩

6. GiveWell. (2020). UH: What do they do?. Givewell.org. Retrieved 24 February 2021. From https://www.givewell.org/charities/UH-foundation#Whatdotheydo ↩

7. Ibid. ↩

8. GiveWell reports that - when including the cost of drugs - the total cost of treating one child in Sightsavers’ deworming programs averages approximately $1.03. ↩

9. “Is mass treatment justified? On cost-effectiveness grounds we believe that it clearly is, as the cost of treatment is cheaper than individual screening. The WHO states that the cost of screening is four to ten times that of the treatment itself. Because the drugs are very safe and has no side effects for the uninfected, the WHO does not recommend individual screening. The WHO instead recommends mass drug administration in areas where more than 20% of children are infected." Evidence Action. (2016). Our Fight Against Worms. Evidenceaction.org. Retrieved 23 February 2021. From https://www.evidenceaction.org/dewormtheworld/ ↩

10. GiveWell. (2020). UH: What do you get for your dollar?. Givewell.org. Retrieved 24 February 2023. From https://www.givewell.org/charities/sci-foundation#Whatdoyougetforyourdollar ↩

11. Deol, Arminder K., Fiona M. Fleming, Beatriz Calvo-Urbano, Martin Walker, Victor Bucumi, Issah Gnandou, Edridah M. Tukahebwa, et al. “Schistosomiasis - Assessing Progress towards the 2020 and 2025 Global Goals.” The New England Journal of Medicine 381, no. 26 (December 26, 2019): 2519–28. https://doi.org/10.1056/NEJMoa1812165. ↩

12. “We believe that there is strong evidence that administration of deworming drugs reduces worm loads...Coverage surveys from fourteen of the countries UH has worked in, including many of the countries where UH's work has been focused in the past five years. These household surveys estimate what percentage of individuals who were targeted for treatment actually received treatment. Overall, coverage of school-aged children was above 75% (the WHO-recommended minimum threshold) in most of the districts surveyed by SCI.” GiveWell. (2020). UH: Does it work?. Givewell.org. Retrieved 24 February 2021. From https://www.givewell.org/charities/sci-foundation#Doesitwork ↩

13. GiveWell. (2019). UH coverage surveys. Givewell.org. Retrieved 24 February 2021. From https://docs.google.com/spreadsheets/d/11zcUoKwltTd4FY14pyzA7yUS1w34pmYMYu6__0d01Uw/edit#gid=1487323759 ↩

14. “...one experiment (Miguel and Kremer 2004) finds that reducing worm infection loads during childhood can have a significant later impact on income. We find these studies to constitute evidence that is suggestive, though not conclusive or necessarily representative (the intensity of worm infections in this study was substantially heavier than the intensity of worm infections in most contexts where deworming is carried out today).” Givewell. (2018). Combination Deworming (Mass Drug Administration Targeting Both Schistosomiasis and Soil-Transmitted Helminths). Givewell.org. Retrieved 18 February 2021. From https://www.givewell.org/international/technical/programs/deworming ↩

15. GiveWell. (2020). Qualitative Assessments of Top Charities. Givewell.org. Retrieved 18 February 2021. From https://www.givewell.org/charities/top-charities/2020/qualitative-assessments ↩

16. Changes to our top charity criteria, and a new giving option - The GiveWell Blog ↩

17. This only includes funding opportunities categorised by UH and GiveWell as, “relatively certain to materialize...” GiveWell. (2020). UH: Is there room for more funding?. Retrieved 24 February 2021. From https://www.givewell.org/charities/sci-foundation#Isthereroomformorefunding ↩

18. “After applying SCI's available and expected funding, we estimate that UH could use up to an additional $22.9 million in funding. We estimate that UH has sufficient funding available to support its work in its 2021-22 program year, such that additional funding now would support work between April 2022 and March 2024.” GiveWell. (2020). GiveWell’s room for more funding analysis for SCI. Givewell.org. Retrieved 24 February 2021. From https://docs.google.com/spreadsheets/d/1PlS0AhOXonUPZkkaPN6FsZ_nrU0K89RqAoT8Lx7ial0/edit#gid=325558316 ↩

19. GiveWell. (2020). UH. Givewell.org. Retrieved 24 February 2021. From https://www.givewell.org/charities/sci-foundation ↩

20. “In addition to their health effects, helminth infections also impair physical and mental growth in childhood, thwart educational advancement, and hinder economic development.” Hotez, P., Bundy, D., Beegle, K., Brooker, S., Drake, L., de Silva, N., Montresor, A., Engels, D., Jukes, M., Chitsulo, L., Chow, J., Laxminarayan, R., Michaud, C., Bethony, J., Correa-Oliveira, R., Shuhua, X., Fenwick, A., and Savioli, L. (2006). Disease Control Priorities in Developing Countries. Oxford University Press. ↩

21. “We have relatively high uncertainty about our estimate of SCI's room for more funding in 2022-23. This estimate is sensitive to our best guess of how much funding will be available from the UK government for deworming in those years. It is possible that the UK government will behave differently from how we have projected, in which case SCI's room for more funding will differ from what we have projected.” GiveWell (2020). UH. Givewell.org. Retrieved 24 February 2021. From https://www.givewell.org/charities/sci-foundation ↩

22. Email exchange with Duncan Millar at UH on September 6, 2022. ↩

23. Video call with UH on November 14, 2022. ↩

24. UH. (2021). Our Work. Schistosomiasiscontrolinitiative.org. Retrieved 23 February 2021. From https://schistosomiasiscontrolinitiative.org/our-work ↩