The concept has apparent intuitive enchantment: If you happen to’re already sending group healthcare staff door-to-door in (say) distant elements of Sierra Leone to ship routine childhood vaccines, why not have these healthcare staff ship chlorine for disinfecting ingesting water, or oral rehydration answer for treating dehydration from diarrhea?
In any case, should you’re already spending cash on the fastened prices of supply, why not present different packages on the similar time? You’d be capable to amortize the prices throughout a number of items and supply further advantages to the group. (If you happen to’re getting groceries delivered, it’s extra environment friendly to have one driver ship your eggs and milk and greens all collectively than to have separate drivers going spherical delivering each individually.)
GiveWell may be very taken with these “layered interventions,” and we’re excited to help them wherever they cross our cost-effectiveness threshold. However we’ve found it’s tougher than you would possibly assume to search out methods to mix packages successfully.
If layered interventions are so intuitively interesting, what makes them more difficult in follow? Briefly: for a layered intervention to work, two completely different commodities should be related to the identical folks, on the similar time, on the identical schedule, with suitable supply logistics.
Usually, layering simply doesn’t work. For instance, when distributed through a mass marketing campaign, malaria nets are often distributed to all households in a group each three years. It in all probability wouldn’t make a lot sense to make use of these campaigns as alternatives for childhood vaccination as a result of most routine early childhood vaccinations are scheduled to be administered by skilled well being care staff in the course of the first 18 months of life. The timing and processes don’t line up.
It’d seem to be deworming campaigns, wherein youngsters are given medicine to kill parasitic worms, would possibly layer with seasonal malaria chemoprevention, wherein youngsters are given medicine to forestall malaria. However there are challenges there too: deworming occurs a few times a 12 months in areas with excessive worm burden; in distinction, seasonal malaria chemoprevention occurs as soon as a month for a number of months in the course of the malaria season in areas the place malaria is very seasonal. The timing and places don’t essentially line up.
Nevertheless, generally layering works nicely and is sort of cost-effective:
- Mixture deworming. We’ve supported deworming packages (for instance, right here and right here) that present two completely different varieties of medication on the similar time to kill two sorts of parasites: soil-transmitted helminths and the parasites that trigger schistosomiasis.
Within the case of deworming, the identical youngsters are being handled, on the identical schedule, for related illnesses. In different circumstances, packages overlap sufficient to supply some alternative for layering:
Seasonal malaria chemoprevention is supplied as soon as a month for 4 or 5 months in the course of the interval of biggest malaria transmission. Vitamin A supplementation is usually supplied twice per 12 months. So this system is ready to co-deliver one of many two vitamin A supplementation rounds—the one which coincides with the malaria season.
Not all layering occurs throughout mass campaigns like those described above. We’ve additionally funded packages that leverage current healthcare appointments by including further companies:
- Syphilis screening and therapy in being pregnant. HIV testing is customary follow throughout antenatal visits in lots of international locations. We’ve funded Proof Motion to help the governments of Zambia, Cameroon, and Liberia to change from HIV checks to twin HIV/syphilis checks, offering a strategy to determine and deal with syphilis as a part of an current well being screening.
This program is cost-effective, partially, as a result of it makes use of current processes: pregnant persons are going to the clinic anyway for his or her scheduled visits, and so they’re already being screened.1We’ve realized that constructing on current healthcare touchpoints, significantly for susceptible populations, is commonly cost-effective. That’s why most of the most promising layering alternatives we’ve discovered to this point are for infants: infants have significantly excessive mortality charges concentrated in a brief interval, and routine childhood immunizations present a variety of touchpoints with the healthcare system throughout that point. In consequence, proper now our vaccines workforce is targeted on layering further interventions with vaccine supply.
These are only some of the packages we’re researching. We’ve additionally not too long ago funded a program to advertise breastfeeding by utilizing an current system that may ship textual content messages to oldsters and caregivers (it was initially set as much as promote childhood vaccination), and we’re investigating the instance from the introduction: bundling supply of chlorine and oral rehydration answer with childhood vaccinations.
Moderately than taking a normal place on whether or not layered interventions are cost-effective, we’re supporting them the place they make sense and never the place they don’t. We’ll proceed to analyze potentialities as we search probably the most cost-effective interventions of each form.
