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More notes on Copenhagen Consensus

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  • Holden Karnofsky
    I m going back through the Copenhagen Consensus to try to get very specific about which interventions they do and don t endorse. This is for purposes of
    Message 1 of 1 , Feb 3, 2009
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      I'm going back through the Copenhagen Consensus to try to get very specific about which interventions they do and don't endorse.  This is for purposes of completing the table linked at the top of http://www.givewell.net/wiki/index.php?title=DWDA_intervention_writeups

      For now I'm gathering info on education interventions even though I'm not sure yet whether we're going to end up really covering that.  I am skipping legislation-only and research-only stuff.

      Having gone through these, I note that the Copenhagen Consensus seems overwhelmingly concerned with cost-effectiveness calculations and not very concerned at all with rigor/track record of interventions.  Throughout their papers is an enormous amount of discussion of their assumptions, methodology, etc. for cost-effectiveness calcs, and although they cite papers in support of interventions' effectiveness they almost never discuss the rigor of these papers, potential alternative hypotheses, etc.  I think the DCP report (whose scholars overlap with Copenhagen Consensus's) has the same tendency.  

      This is good to keep in mind: an endorsement from one of these groups can be taken to mean that the intervention is one of the most cost-effective when its measured effects are taken at face value, but without an independent confirmation that it has a track record of success (rigorous micro evidence or a large-scale success story to point to) it's appropriate to be cautious.  Especially for non-medical interventions whose effectiveness is very much in question.  I think this explains why there is pretty limited overlap between the interventions that these guys recommend and the ones that Abhijit Banerjee (who is much more focused on rigor) recommends.


      Women (http://www.copenhagenconsensus.com/Default.aspx?ID=1153) - top-level recs are "Increase and improve girls' schooling" (#8), "Provide support for women's reproductive role" (#10), Microfinance (#22), 

      pg 13: discussion of "Option 1 - Increase and improve girls' schooling"
      Lots of refs on returns to education - looks like a pretty broad (not just women-specific) lit review of the matter - may want to revisit at some pt
      • 15-16: not strong on building new schools.  however, ""the supply of a close and culturally appropriate school for girls can have sizable impacts on enrollments in some contexts provided that the school is quite close (not necessitating girls to travel more than half a kilometer on their own), a female teacher is present, and there are adequate sanitary facilities for girls (e.g.  Hill and King, 1995; Alderman, Orazem and Paterno, 2001; Orazem and King, 2007; Herz and Sperling, 2004).  In these contexts, specific supply-side interventions could help."
      • Endorses vouchers (16) and conditional cash transfers (17).
      pg 21: Option 2 - reduce women's financial vulnerability through microfinance
      Refs arguing that "women who receive credit may command greater bargaining power in the household" ... "women's access to credit resources also tends to increase labor force participation.
      CC lists difft kinds of microfinance but doesn't seem to distinguish between them in its endorsement.

      pg 28: Option 3 - Provide support for women's reproductive role
      CC endorses (28):
      • Family planning programs for young women
      • Support for safe births
      • Emergency contraception and related services
      The endorsement of #2 appears fairly "blanket."  29: "Experts recommend the best way  to combat such risk is to ensure that delivery services are provided by professionals skilled in obstetrics, both in health facilities and in homes. Health centers providing primary care are needed to provide prenatal care (including managing abortion complications), postpartum care, and care of newborns (Graham et al. 2006).  Routine prenatal care includes screening and treatment of syphilis, immunization with tetanus toxoid, prevention and treatment of anemia, and prophylaxis or bed nets for preventing and treating malaria.  Basic emergency obsetric care (BEmOC) should also be available but is highly dependent on the availability of supplies, drugs, infrastructure, and skilled health care providers. In case of need,  a rapid referral communication chain is needed between district-level hospitals and the primary-care level. District hospitals must be able to provide surgical interventions and blood bank services.  Lastly, routine physical examinations of postpartum women are critical, a difference from the focus on education."  

      Nutrition supplements too (28): "Appropriate interventions could include the provision of multivitamins, minerals, or macronutrient supplements, such as protein-energy supplements as well as iron and folic acid to combat anemia. While evidence of the impacts of such policies has been limited, Graham et al. (2006) find  that interventions in addressing maternal health are more cost-effective if nutritional supplementation is included."

      More on 31-32 on what sorts of programs they picture.  I'm putting them down for general support for maternal mortality programs for now.

      Option 4 is affirmative action, outside our scope (and not in the final Copenhagen Consensus list).

      Water and sanitation (http://www.copenhagenconsensus.com/Default.aspx?ID=1150) - top-level recs are biosand filters (#15), "rural water supply" (#16), total sanitation campaign (#20), "large multipurpose dam in Africa" (#24).  

      This paper is written in a very hedgy tone.  It doesn't flat out say "X is better than Y" but it often implies that X > Y, and of course the master Copenhagen Consensus table (http://www.copenhagenconsensus.com/Default.aspx?ID=953) lists as "recommended solutions" things that the paper might call "illustrations" (more on this below).  My strategy here is to take the things that match what the master table lists and call them "recommendations," even though the paper often concedes that other things might work better under different circumstances.

      Pg 48 makes fairly clear which interventions these are.
      • Rural water supply = borehole well construction with hand pump.  Mentions that these only make sense when the water source is below-ground (57); the cost-effectiveness depends on # users (>500 gets overly crowded and inconvenient); the value of labor (since one of the main benefits of boreholes is to save people time); the incidence of diarrhea; and the availability of water from other sources.  57-58 concede that rural water supply programs have had significant failures, but claims that a new "demand-driven" approach is working.  Cites refs for both (refs for the latter are all from 2007 - so we may want to check this out).
      • Total sanitation campaign = behavior-focused campaign along the lines of Community-Led Total Sanitation Program (we discussed this prog briefly at http://blog.givewell.net/?p=261).  76-90 gives a couple arguments for the superiority of behavior focus over focus on building latrines.
      • Biosand filters: CC says We selected the biosand filter for illustrative purposes; we do not argue that it is the "best" of the available POU technologies (90).  However, it then goes on to give args for why it's good: has been demonstrated to be safe & effective, is widely in use, is convenient/simple to install (and uses easily available materials).
      • Multipurpose dam in Africa: In recent years large multipurpose dams have been among the most controversial infrastructure projects in both industrialized and developing countries (World Commission on Dams, 2000).  Proponents cite several types of direct economic benefits: hydroelectric power generation, domestic and industrial water supply, drought mitigation, recreation, irrigation, and flood control. They also claim a variety of indirect benefits (e.g., increased employment, better diplomatic relationships between riparians on international rivers, reduced risk of conflict over water resources, improved trade, and enhanced economic integration).18 On the other hand, critics believe that these benefits are overstated or nonexistent, that the high construction and resettlement costs are underestimated, and that negative side effects, especially environmental and cultural losses, are high (Duflo and Pande, 2007). Table 24 presents a list of the types of costs and benefits typically associated with dam projects.  (103)
      Education (http://www.copenhagenconsensus.com/Default.aspx?ID=1147) - top-level recs are deworming and other school nutrition programs (#6), lowering the price of schooling (#7), conditional cash transfers (#17).

      Education paper opens with review of returns to schooling literature.

      Favors primary schooling interventions (11-12) as opposed to programs targeted at later education.  Favors demand-side over supply-side interventions (discussion begins on pg 25) - this means that they want to focus on getting kids to attend rather than on improving/building schools.
      • They provide pretty much a blanket recommendation for nutrition programs aimed at school-age children, with scattered refs on why this can matter (31-34; mostly attendance effects but some cognition/performance stuff).
      • "Lowering the price of schooling" means capitation grants to school operators (36), vouchers (37-38), and after-school tutoring programs (38).
      • Conditional cash transfers: this is the first place I've seen refs for programs other than (though still including) PROGRESA (39-41).
      Diseases (http://www.copenhagenconsensus.com/Default.aspx?ID=1146) - top-level recs are "expanded immunization coverage for children" (#4), heart attack acute management (#11), malaria prevention & treatment (#12), tuberculosis case finding & treatment (#13), HIV "combination prevention" (#19), improving surgical capacity at district hospital level (#21), tobacco tax (#28).

      This paper is written by the DCP2 lead author and explicitly is aiming to identify the "best of the DCP."  Has a long discussion of why disease interventions are a good idea, including macro argument that technology is responsible for improving health and some refs (starting on 16) for the link between health/productivity.

      Pg 51 summary table gives slightly more clarity on the above listed.  When it was still unclear, I hunted down the discussion to figure out exactly what they were talking about.

      A couple confusing things:

      1. The paper lists a lot of under-5 health interventions on pgs 29-33, not all of which make the final table on pg 51.  It seems likely to me that the field was narrowed based on issues of scalability (33-35); this isn't fully spelled out, but the table on pg 51 includes a "level of capacity required" column.  I've listed the interventions that aren't in the final table, below (immediately after the ones that are in the final table).

      2. The rank-order given by the paper's authors is not the same as the one given by the Copenhagen Consensus.  For example, the authors state that "TB [tuberculosis] treatment stands out as perhaps the most important investment" (53) and, consistent with this, rank it first; but in the overall Copenhagen Consensus, TB treatment is ranked 13th, below 3 of the other interventions in the table (vaccines is #4).

      Just so we don't lose any info, what I've done is created 2 columns in our intervention summary table.  One holds the official Copenhagen Consensus rank for an intervention; the other, labeled "Jamison/Jha/Bloom", lists the ranking given in this paper, "honorable mention" for those that are listed in the paper but not in the final table.

      • Expanded immunization coverage (from pg 32) - Copenhagen Consensus #4 of 30, Jamison/Jha/Bloom #4 of 7
        • Expanding the traditional Expanded program on Immunization (diphtheria-tetanus-pertussis vaccine, BCG vaccine for tuberculosis and meningitis, polio vaccine, measles vaccine - see http://dcp2.org/pubs/DCP/20/Section/2680)
        • HiB vaccine
        • Hepatitis B vaccine
        • Rotavirus vaccine
        • Streptococcus (pneumococcal disease) vaccine
      • Heart attack acute management = acute management with low-cost drugs (I assume this is the "aspirin and beta-blockers" from DCP and conversation with Prabat Jha) (43-46).  Copenhagen Consensus #11 of 30, Jamison/Jha/Bloom #2 of 7.
      • Malaria prevention & treatment = "prevention and ACT treatment package" = (from pg 32).  Copenhagen Consensus #12 of 30, Jamison/Jha/Bloom #3 of 7.
        • Insecticide-treated bednets
        • Drug treatment specifically for pregnant women (intermittent preventive treatment for pregnant women)
        • Indoor residual spraying with DDT
      • Tuberculosis case finding & treatment = DOTS strategy (41-42).  Copenhagen Consensus #13 of 30, Jamison/Jha/Bloom #1 of 7.
      • HIV combination prevention = lists lots of things, without recommending a particular combination.  Copenhagen Consensus  #19 of 30, Jamison/Jha/Bloom #6 of 7.  "prevention efforts appear to work best when there is national leadership and simultaneous, sustained investment in multiple approaches to prevention, including efforts to reduce stigmatization of vulnerable groups" (38).  39-41 argues for caution in ART (blogged about this at http://blog.givewell.net/?p=329).  Components listed on pgs 36-38:
        • Peer interventions among sex workers (such as the one conducted in Thailand, condom distribution & promotion)
        • Treatment for sexually transmitted infections (other than HIV/AIDS; they increase risk)
        • Voluntary counseling & testing
        • Prevention of mother-to-child transmission through antiretroviral therapy
        • Needle safety & blood exchange programs   
      • Improving surgical capacity at district hospital level = specifically for difficult childbirths and injuries (52).  Copenhagen Consensus #21 of 30, Jamison/Jha/Bloom #7 of 7.
      • Tobacco tax (46-51).  Copenhagen Consensus #28 of 30, Jamison/Jha/Bloom #5 of 7.
      • Stillbirth and neonatal interventions - not in table - refers to "Newborn survival" chapter of DCP report. (30)  Checked out that chapter and there are an enormous # of interventions; for now I'm just entering a "Newborn survival" category in the table.
      • Education interventions (30-31) - listed elsewhere in Copenhagen Consensus - argues that education is associated with lower infant mortality rates.  I am skeptical that there is any causative (as opposed to correlative) linkage here.
      • Breastfeeding promotion (32) - not in table
      • Expand the use of the simple and low cost but highly effective treatments for diarrhea and child pneumonia through integrated management of childhood illness or other mechanisms (32) - not in table
      • Micronutrient distribution (esp Vitamin A, Zinc, iron) (32) - listed elsewhere in Copenhagen Consensus.
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