Summary

• Our charity recommendation for 2022 is StrongMinds, a non-profit that provides group psychotherapy for women in Uganda and Zambia who are struggling with depression.
• We compared StrongMinds to three interventions that have been recommended by GiveWell as being amongst the most cost-effective in the world: cash transfers, deworming pills, and anti-malarial bednets. We find that StrongMinds is more cost-effective (in almost all cases).
• HLI is pioneering a new and improved approach to evaluating charities. We focus directly on what really matters, how much they improve people’s happiness, rather than on health or wealth. We measure effectiveness in WELLBYs (wellbeing-adjusted life years).
• We estimate that StrongMinds is ~10x more cost-effective than GiveDirectly, which provides cash transfers. StrongMinds’ 8-10 week programme of group interpersonal therapy has a slightly larger effect than a $1,000 cash transfer but costs only $170 per person to deliver. 
• For deworming, our analysis finds it has a small but statistically non-significant effect on happiness. Even if we assume this effect is true, deworming is still half as cost-effective as StrongMinds.
• In our new report, The Elephant in the Bednet, we show that the relative value of life-extending and life-improving interventions depends very heavily on the philosophical assumptions you make. This issue is usually glossed over and there is no simple answer. 
• We conclude that the Against Malaria Foundation is less cost-effective than StrongMinds under almost all assumptions. We expect this conclusion will similarly apply to the other life-extending charities recommended by GiveWell.
• HLI’s original mission, when we started three years ago, was to take what appeared to be the world’s top charities – the ones GiveWell recommended – reevaluate them in terms of subjective wellbeing, and then try to find something better. We believe we’ve now accomplished that mission: treating depression at scale allows you to do even more good with your money. 
• We’re now moving to ‘Phase 2’, analysing a wider range of interventions and charities in WELLBYs to find even better opportunities for donors. 
• StrongMinds aims to raise $20 million over the next two years and there’s over $800,000 of matching funds available for StrongMinds this giving season.

Why does HLI exist?

The Happier Lives Institute advises donors how to maximise the impact of their donations. Our distinctive approach is to focus directly on what really matters to people, improving their subjective wellbeing, how they feel during and about their lives. The idea that we should take happiness seriously is simple:

1. Happiness matters. Although it’s common to think about impact in terms of health and wealth, those are just a means, not an end in themselves. What’s really important is that people enjoy their lives and are free from suffering.
   
2. We can measure happiness by asking people how they feel. Lots of research has shown that subjective wellbeing surveys are scientifically valid (e.g. OECD, 2013; Kaiser & Oswald, 2022). A typical question is, “Overall, how satisfied are you with your life, nowadays?” (0 – not at all satisfied, 10 – completely satisfied).
3. Our expectations about happiness are often wrong. When we try to guess what life would be like, for others or our future selves, we suffer from biases. When we put ourselves in other people’s shoes, we put ourselves in their shoes. 

Taking happiness seriously means setting priorities using the evidence on what makes people happier – not just looking at measures of health or wealth and combining that with our guesswork. 

We calculate the cost-effectiveness of charities in terms of WELLBYs (wellbeing-adjusted life years). 1 WELLBY is equivalent to a 1-point increase for 1 year on a 0-10 life satisfaction scale. A 0.5-point increase for 2 years would also be 1 WELLBY, and so on. 

We’re not the first to use this approach (e.g. HRI, 2020; UK Treasury, 2022). The WELLBY is a natural improvement on the QALY (quality-adjusted life year) metric that’s been used in health policy for three decades (Frijters et al., 2020). We are, however, the first to use WELLBYs to work out the best way to spend money to help others, wherever they are in the world. 

We thought the best place to start was by taking the existing charity recommendations made by GiveWell, a leading charity evaluator, assessing their impact in terms of subjective wellbeing, and then looking for something better. We agree with GiveWell’s thinking that your donations will do more good if they’re used to fund interventions that help people living in extreme poverty. We’ve analysed three of those recommended interventions – cash transfers, deworming pills, and anti-malarial bednets – and compared them to treating depression in low-income countries. The whole process has taken three years. We’ve strived to assess the evidence as rigorously as possible and model our uncertainties in line with academic best practice. 

We’re now in a position to confidently recommend StrongMinds as the most effective way we know of to help other people with your money. At the time of writing, StrongMinds is aiming to raise $20 million by 2025 to scale up their services and treat 150,000 people a year.

We’ll now go through the different analyses we’ve conducted to explain how we got here.

Cash transfers 

A large number of academic studies show that cash transfers are a very effective way to reduce poverty. The strength of this evidence led GiveWell to recommend GiveDirectly as one of their top charities (from 2011 to 2022), and treat them as ‘the bar’ to beat. 

But what impact do cash transfers have on subjective wellbeing? We conducted the first systematic review and meta-analysis to investigate this question, bringing together 45 studies. We found that cash transfers have a small, long-lasting, and statistically significant positive effect on subjective wellbeing and mental health. This work was published in Nature Human Behaviour earlier this year.

Treating depression

But how does alleviating poverty compare to treating depression? I’ve long suspected that, if we focused on wellbeing, we might see that treating depression in low-income countries could be as, or more, cost-effective than providing cash transfers to those in extreme poverty. This was one of the main reasons I founded the Happier Lives Institute. 

So, to enable an ‘apples-to-apples’ comparison to GiveWell’s recommendations, we needed to identify the most promising charities delivering mental health interventions in low-income countries. After a rigorous assessment of 76 mental health programmes, we identified StrongMinds as one of the best. It’s a non-profit that provides group interpersonal therapy for women in Uganda and Zambia who are struggling with depression.

Sean Mayberry, Founder and CEO of StrongMinds, is running an AMA (Ask Me Anything) on the Forum this week. If you have any questions about StrongMinds, please take this opportunity to ask him directly.

Cash transfers vs treating depression

To compare cash transfers to treating depression, we conducted a systematic review and meta-analysis of group or lay-delivered psychotherapy in low-income countries, similar to the one we produced for cash transfers. 

Drawing on evidence from over 80 studies and 140,000 participants, our cost-effectiveness analyses of cash transfers and psychotherapy allowed us to make a direct comparison between StrongMinds and GiveDirectly. To our knowledge, this is the first time that the cost-effectiveness of these two interventions has been compared in the same units using measures of subjective wellbeing. 

To be clear, although both interventions are delivered in low-income countries, they are delivered to different groups of people. Only those diagnosed with depression are being treated for depression, whereas cash transfers are distributed to very poor people (only some of whom will be depressed). 

We illustrate the total effect of both interventions in Figure 1. StrongMinds’s group therapy has a similar overall effect to a $1,000 dollar cash transfer: the initial effect is larger, but it fades faster. What drives the difference is that group therapy costs much less ($170 per person).

Figure 1: Effects over time for GiveDirectly and StrongMinds

A few months later, we updated our analysis to include an estimate of the ‘spillover effects’ on other household members. For cash transfers, we estimate that each household member experiences 86% of the benefit received by the recipient. For psychotherapy, we estimate the spillover ratio to be 53%.

We also estimated the uncertainty in our model using a Monte Carlo simulation, where each dot represents a simulation. This is displayed below in Figure 2. 

Figure 2: Cost-effectiveness of StrongMinds compared to GiveDirectly

Overall, we estimate that StrongMinds is ~10 times more cost-effective than GiveDirectly. This finding presents a challenge to current thinking about the best ways to improve the lives of others and suggests that treating mental health conditions should be a much higher priority for donors and decision-makers.

Deworming

From 2011 until a few months ago, GiveWell recommended several deworming charities that treat large numbers of children for intestinal worms. The case for deworming is that it is very cheap (less than $1 per year of treatment per person) and there is suggestive evidence it might have large effects on later income (by improving educational outcomes which enable recipients to earn more in later life). 

GiveWell has claimed that deworming programmes are several times more cost-effective than cash transfers. But how does deworming compare to treating depression, particularly when we look for the effects on happiness, not just income? 

In July 2022, we published a critique of GiveWell’s deworming analysis. In replicating their model, we found an error in their calculations of the long-term income effects. With this correction, the total effects would be substantially smaller. In their response, GiveWell said:

Our current best guess is that incorporating decay into our cost-effectiveness estimates would reduce the cost-effectiveness of deworming charities by 10%-30%. This adjustment would have led to $2-$8 million less out of $55 million total to deworming since late 2019…We believe HLI’s feedback is likely to change some of our funding recommendations, at least marginally, and perhaps more importantly improve our decision-making across multiple interventions.

GiveWell subsequently launched their Change Our Mind Contest for which they awarded us a prize, retroactively. (Our follow-up entry to that contest suggested a dozen other problems with GiveWell’s analyses.)

In August 2022, GiveWell announced they had removed deworming charities from their top charities list. GiveWell now stipulates that their top charities must have “a high likelihood of substantial impact” and the evidence for deworming fails to meet that requirement.

Our analysis finds that deworming has a small, non-significant effect on happiness. Even if we take this non-significant effect at face value, deworming still looks about half as cost-effective as StrongMinds, with wide uncertainty.

In light of both our analysis and the fact that GiveWell has removed deworming from their list of top charities, we do not recommend any deworming charities over StrongMinds. 

Life-extending charities

To complete our analysis of GiveWell’s top charities, we compared the relative value of life-improving and life-extending interventions. Our new report, The Elephant in the Bednet, explores this topic in detail. 

As the title suggests, this issue is important and unavoidable but it’s a question that people (understandably) find discomforting. The relative value of extending or improving life depends very heavily on your philosophical views about the badness of death and the point at which a person’s wellbeing changes from positive to negative (see Figure 3 below). Although these issues are well-known in academic philosophy, they are almost entirely glossed over by donors and decision-makers. 

Figure 3: Cost-effectiveness of charities under different philosophical assumptions

The insecticide-treated nets distributed by the Against Malaria Foundation (AMF) have been considered a safe bet by the effective altruism community for many years: nets cost around $2 each and it costs, on average, a few thousand dollars to save a life. However, as you can see, the cost-effectiveness of AMF changes dramatically as we shift from one extreme of (reasonable) opinion to the other. In brief, the two crucial philosophical issues are: (a) determining the relative value of deaths at different ages, and (b) locating the neutral point on the wellbeing scale at which life is neither good nor bad for someone. 

At one end, AMF is 1.3x better than StrongMinds. At the other, StrongMinds is 12x better than AMF. Ultimately, AMF is less cost-effective than StrongMinds under almost all assumptions. 

Our general recommendation to donors is StrongMinds. We recognise that some donors will conclude that the Against Malaria Foundation does more good. It is not easy to explain the philosophical issues succinctly here so we advise interested individuals to read the full report to inform their decision-making.

We haven’t analysed them separately, but we expect effectively the same conclusions will apply to GiveWell’s other top charities which are recommended on the basis that they can prevent the deaths of very young children for between $3,500 and $5,000.These are:

• Helen Keller International (supplements to prevent vitamin A deficiency)
• Malaria Consortium (medicine to prevent malaria)
• New Incentives (cash incentives for routine childhood vaccines)

Mission accomplished

We have now completed Phase 1: we’ve (re)assessed GiveWell’s top charities using subjective wellbeing and compared their cost-effectiveness in terms of WELLBYs. We’ve shown that this can be done and found something better than the status quo: our recommended charity for 2022, StrongMinds.

Our results are summarised in Figure 4, which represents three years of work in one chart!

Figure 4: Cost-effectiveness comparison forest plot

Notes:

1. The diamonds represent the central estimate of cost-effectiveness.
2. The solid whiskers represent the 95% confidence intervals for StrongMinds, Deworm the World, and GiveDirectly.
3. The vertical dashed line represents 0 WELLBYs.
4. The vertical dotted line is the point estimate of StrongMinds’ cost-effectiveness
5. The lines for AMF are different from the others. They represent the upper and lower bound of cost-effectiveness for different philosophical views (not 95% confidence intervals). Think of them as representing moral uncertainty, rather than empirical uncertainty. The upper bound represents the assumptions most generous to extending lives and the lower bound represents those most generous to improving lives.
6. The slogan version of the philosophical views are: 
   • Deprivationism: prioritise the youngest
   • Time-relative interest account (TRIA): prioritise older children over infants. 
   • Epicureanism: prioritise living well, not living long

What’s next for HLI? On to Phase 2! 

So far, we’ve looked at four ‘micro-interventions’, those where you help one person at a time. These were all in low-income countries. However, it’s highly unlikely that we’ve found the best ways to improve happiness already. Phase 2 is to expand our search.

We already have a pipeline of promising charities and interventions to analyse next year:

Charities we want to evaluate: CorStone (resilience training), Friendship Bench (psychotherapy), Lead Exposure Elimination Project (lead paint regulation), and Usona Institute (psychedelics research).

Interventions we want to evaluate: air pollution, child development, digital mental health, and surgery for cataracts and fistula repair.

We have a long list of charities and interventions that we won’t get to in 2023 but plan to examine in future years. Eventually, we plan to consider systemic interventions and policy reforms that could affect the wellbeing of larger populations at all income levels. There’s plenty to do!

Ready to give? Here’s how

If you’re convinced by our analysis, this section explains how to maximise the impact of your donation.

If you’re still on the fence, please ask questions in the comments section below or submit your question to Sean Mayberry, Founder and CEO of StrongMinds.

Double your donation (first chance)

From Tuesday 29 November, your donations to StrongMinds will be doubled if you donate through the 2022 Double Up Drive. 

The matching starts at 8:00 am PT / 11:00 am ET / 4:00 pm GMT. We don’t know how big the matched pool will be or how long it will last so we advise you to donate as soon as it opens.

Set a calendar reminder or an alarm now!

Double your donation (second chance)

If you miss the Double Up Drive, don’t panic! The UBS Optimus Foundation will also double your donation to StrongMinds until 31 December (up to a maximum of $800,000).

Make a tax-deductible donation

Once the two matching funds have run out, you can make a tax-deductible donation in the following countries: Australia, Canada, Germany, Netherlands, New Zealand, Switzerland, United Kingdom, United States.

If your country is not listed above, you can make a direct donation at strongminds.org/donate 

Support our further research

Our progress depends on the financial support of our donors and we are continuing to fundraise for our 2023 budget. If you’d like to see this research happen, please make a donation (donations are tax-deductible in the UK, the US, and the Netherlands).