Dec 6, 2023, 6:28 AM ETInterview

Fads and misaligned incentives in global development | Karen Levy

80,000 Hours Hiring Announcement: The organization is hiring an Operations Specialist in London to support a projected 50% staff increase in 2022; starting salary for candidates with one year of experience is approximately £58,000, with applications closing April 3rd.
Guest Profile: Karen Levy is a veteran of the global health and development sector who co-founded Evidence Action's beta team, served as Country Director for Innovations for Poverty Action (IPA) in Kenya (2006–2011), and currently leads the strategic advisory firm "Fit for Purpose."
Current Focus: Fit for Purpose helps evidence-based leaders and governments scale impact by bridging the gap between research, policy, and implementation, with a specific emphasis on lower-middle-income countries.

Market Alignment: The global health sector is experiencing a shift where the supply of high-quality, evidence-based interventions is finally aligning with the demand from funders willing to pay for verified impact.
Major Donors: Key players driving the "find, test, scale" model include GiveWell, Good Ventures, Open Philanthropy, USAID's Development Innovation Ventures, the Global Innovation Fund, and the Audacious Project.
Growth in Resources: There is a reported increase in available resources for high-impact interventions, creating a scenario where capital exceeds the number of proven solutions, driving further scaling efforts.
Pre-Policy Planning: A methodological innovation inspired by pre-analysis plans involves governments and researchers agreeing in advance on policy actions based on potential research outcomes (e.g., "If results are X, we scale; if Y, we halt").
- Case Study (Botswana): A pre-policy plan was used for the "No Sugar" intervention (teens avoiding HIV via information on older partners). When results showed the intervention might increase risky behavior, the plan allowed the government to halt the program without political fallout, despite initial desires to continue.
- Purpose: These plans align research and policy timelines, ensuring data is delivered when decisions are made and preventing "hindsight bias" where stakeholders rationalize continuing failed programs.

Sustainability Myth: Levy argues that demanding "sustainability" (self-funding via market mechanisms) is often counterproductive; it is frequently more cost-effective to fund interventions for a fixed period (e.g., 5–10 years) to solve a problem rather than trying to create a perpetual motion machine.
- Government Capacity: While governments are agents of scale, they are often resource-constrained and cannot absorb the recurring costs of complex programs; assuming they will "take over" often masks the reality that they simply lack the funds.
Participatory Pitfalls: "Participatory" approaches often devolve into unpaid user fees or labor contributions, which Levy argues can be patronizing; she posits that citizens should receive services as a right rather than being forced to "pay" for them with time or money to feel ownership.
Holistic Intervention Risks: Comprehensive "holistic" programs often fail to scale because they are too expensive (e.g., $500/student vs. $90 national budget) and obscure which specific components are effective, making it difficult to isolate impact or replicate success.
- Delivery-First Approach: Instead of integrating based on disease types (e.g., "neglected tropical diseases"), scaling should prioritize existing delivery platforms (e.g., school-based deworming) and layer compatible interventions only where logistics align.

Evidence Base: Longitudinal studies of the original 1990s Kenya deworming trials (Miguel/Kramer) show significant positive effects on adult income decades later, supporting the program's long-term value despite academic debate.
Scaling Metrics: The program now reaches over 800 million children annually, with Kenya's school-based program serving over 6 million children per year, funded largely by pharmaceutical donations for drugs and philanthropic support for logistics.
Cost Efficiency: The intervention costs less than 50 cents per treatment, making it an exceptionally high-impact investment even if the true effect size is on the lower end of optimistic estimates.
Logistical Innovations: Scaling required shifting from door-to-door to school-based delivery, standardizing training for one teacher per school to eliminate the need for frequent visits, and improving school enrollment lists to include private schools.
Risk Management: The program addressed quality erosion through rigorous monitoring (e.g., verifying tablet presence before distribution) and overcame cultural barriers by carefully managing terminology (e.g., using "tablets" instead of "pills" to avoid confusion with contraceptives).

NGO Business Model Flaws: Most NGOs operate on a model where overhead is funded as a flat percentage of total program spend, creating perverse incentives to maximize financial throughput rather than cost-effectiveness or impact reduction.
- Underspending Penalty: Organizations are penalized for underspending (efficiency) because it reduces their overhead budget, whereas success should ideally allow them to retain surplus.
Donor Strategy Volatility: Frequent "strategy refreshes" by donors create instability for implementers, who must scramble to adapt to new priorities, reducing the efficiency of long-term program execution.
The "Boring" Advantage: Levy advocates for funding "boring," proven interventions at scale rather than pursuing novel but unproven ideas, noting that unit costs drop dramatically as delivery becomes mundane and automated.

Program Termination: Evidence Action's "No Lean Season" (a seasonal migration program) was voluntarily shut down in 2019 after beta testing failed to prove viability, highlighting the difficulty of sustaining non-health interventions in development.
Fit for Purpose Model: Levy's advisory firm avoids the "project-organization" conflict by charging for time/value added rather than a percentage of program spend, allowing for honest, independent advice on cost-effectiveness and stopping underperforming initiatives.
Transparency with Donors: Effective partners (like GiveWell) value candor about weaknesses and failure risks, whereas traditional donors often reject proposals that openly acknowledge uncertainty or potential failure.

Long-Term Immersion: Levy has lived in Kenya for over 20 years, arguing that deep, long-term immersion allows for a better understanding of local institutional logic and culture, countering the "tourist" approach common in development.
Scout Mindset: She advises global health professionals to spend time living abroad to gain perspective on their own cultural biases and to approach foreign institutions with curiosity rather than judgment.
Future Outlook: She sees mental health and education as underinvested areas with high potential for cost-effective impact, particularly as new metrics (like LAYS for education) improve measurement capabilities.