Elie Hassenfeld: [00:00:00] Hey everyone, this is Elie Hassenfeld, GiveWell's co-founder and CEO, and I'm here today with Buddy Shah, who's the CEO of Clinton Health Access Initiative, which is often referred to as CHAI. I am excited for this conversation 'cause I've known Buddy for a really long time, first via his work at IDinsight. Then he was at GiveWell for a couple of years and a few years ago he moved on to become the CEO of CHAI. And so he has a particularly good perspective on the way that aid cuts are affecting his organization, but also the sector of global health overall.

In the conversations that we've had to date, I've mostly been talking to GiveWell researchers about how GiveWell is thinking and responding to cuts in USAID. CHAI is a large leading global health nonprofit, and I think Buddy will have a really useful perspective to share on what's happened to date and what's coming in the future.

CHAI's also been one of the [00:01:00] organizations that GiveWell has provided financial support to in response to the cuts. So among others, we supported CHAI's building of small teams that support government decision making during this challenging time. Dan Brown and I talked about this grant and that program in episode four of the podcast.

So I hope Buddy's perspective, coming from an organization that's running effective programs all over the world, helps add to our collective understanding of the effects that cuts in USAID are having. Buddy, thanks for joining me in this conversation today.

Buddy Shah: Yeah, it's great to be here, Elie.

Elie Hassenfeld: Great. Well, before we dive in, I know your background, but I think it would help people to just know a little bit more about your history and what you've done before you came to CHAI.

Buddy Shah: Absolutely. You know, I've been a big fan and collaborator of GiveWell's for many years now, both as a individual donor, but also with different organizations that I've been with in the past.

So, previously I was the co-founder and CEO of an organization called IDinsight and IDinsight's core mission is [00:02:00] to make sure that key decision makers, whether those are people in national governments or funders like GiveWell, have the data and evidence that they need to make more impactful and cost-effective decisions.

And so this includes everything from rigorously testing the impact of programs with randomized trials, to other tools, including in GiveWell's own work in measuring the moral preferences of how much beneficiaries want a health program versus a program that can improve their income. So I've had a chance to work with GiveWell with my IDinsight hat on in a number of different ways.

And then of course, as you mentioned, I was at GiveWell as managing director for a couple of years and was just really formative to look inside at how GiveWell makes all these really hard prioritization decisions. And then of course I've been the CEO of CHAI for the last three years.

And my background is as a physician and a development economist, and I try to bring both of those lenses in thinking about how we can do the most good possible.

Elie Hassenfeld: And then since you've been at CHAI, we at GiveWell have [00:03:00] worked closely with you. We've supported something we've called the incubator at CHAI, where we supported several programs in addition to work that we've done in response to the aid cuts. Yeah, I I think it also would just be helpful to share if you can, a bit more about the nature of the work that CHAI does with the support of GiveWell.

Buddy Shah: It's been great to work together with GiveWell over the last couple of years, and I'd say that GiveWell's partnership with CHAI over the last few years falls into three big buckets. The first and most substantial of the buckets is the incubator that you mentioned. And the core idea of the incubator is to fund CHAI to really try to find some of the most cost effective ways to save lives, based both on our technical expertise and our relationships with national governments.

So one example of a program that's come out of that incubator is all about trying to prevent deaths of kids under five years old. So a lot of kids in the world get diarrheal disease, which in high income countries obviously usually resolves quite easily. [00:04:00] But in many parts of the world that is a huge driver of child mortality.

And so CHAI is essentially distributing simple oral rehydration salts, these little satchets door to door in northern Nigeria before the rainy season with the assumption that if families have them on hand, then when a kid gets diarrhea, they're gonna get zinc and ORS and be able to prevent these kinds of diarrheal deaths. And the initial results of that seemed really promising as a very cost effective way to save the lives of kids under five.

And then there's a number of other programs that the incubator is starting to spin out and test, including in malaria and TB. And again, all with the purposes of finding really scalable ways to save lives.

I think the second big way that we've been working together is around the foreign aid cuts. And there's both like the informal mechanism of just trying to share knowledge with one another. It's a really chaotic time of figuring out what's actually happening, where are the cuts, and what are the most cost effective things that we can do to mitigate the effects of these cuts [00:05:00] in foreign aid.

And then this also formal collaboration where GiveWell is funding CHAI to set up what we call technical support units, but they're basically these teams of CHAI technical experts sitting inside the government, providing surge support to help the Ministry of Health figure out where the gaps are, and then ultimately, mitigate the effects of the cuts and hopefully build back something better.

And then the last way that CHAI and GiveWell are collaborating is thinking about how do we make all of CHAI's portfolio beyond just the GiveWell incubator programs, more cost effective. And so bringing that cost-effectiveness lens to over 20 programs that CHAI runs in 40 countries around the world.

Elie Hassenfeld: And something that I've really appreciated in our work with CHAI, and it's something that others do to some extent and would love to see it happen even more, is first the kind of critical feedback we've gotten from CHAI. I think right when we started working together, we shared one of our cost effectness models for malaria with your team. And this was unrelated to any specific grant [00:06:00] investigation, but we got a ton of critical feedback about all the things that your team thought we were getting wrong, and that was great. Like we love that it was just you know, amazing substantive input.

And then something else we've really loved is there have been times when you all have spent a lot of time building up the case for a grant. And then when it comes to decision time, you've said, you know what, we don't think this is one of the most cost effective ways for us to help people. We do not think you should fund us for this. And you know, I really appreciated that too because that's the kind of thing we love in a partner where getting critical feedback, being told not to fund things, that's not always the way it is. So that's been really great.

So the main topic of this conversation is continuing on this project that we've been undertaking to try and better understand the effects that aid cuts have had on the sector and what that means for donors and where they can shift funds or direct funds to do the most good. How have the funding cuts affected CHAI's work to date?

Buddy Shah: Yeah. You know, in some [00:07:00] ways the funding cuts have really sharpened our focus on doing the things that CHAI has done for 20 years. And so that always starts with CHAI reaching out to the Minister of Health and the Ministries of Health and essentially asking them, where do you need support in designing and delivering better health policies?

And so as soon as the cuts came out, ministers of health across really our 37 country offices around the world reached out to CHAI staff, and they started articulating what they felt were their biggest needs.

And the three biggest things that came up from the Ministries of Health initially were number one, help us figure out where the cuts actually are hitting our health system. You know, it is remarkable and that's what we call gap identification, but basically the ministries of health, because they don't fully own the data in their own health system, they didn't often know which donors were funding, which healthcare workers, in what parts of their country.

So the US government might be funding some [00:08:00] HIV workers or some malaria workers in some parts of the country. Another funder, like the Global Fund, could be funding other healthcare workers in other parts of the country. And the same with essential drugs and diagnostics. And so the first part of what the ministries asked us was essentially, hey, help us figure out where the key gaps are in our budgets so that we know what we want to fill and which things we can deprioritize.

Elie Hassenfeld: This should be like relatively surprising to people. And tell me if this is like the right way of conceptualizing it.

You have a ministry of health in some country and it is operating its health system. And then at the same time, donors are funding large components of that health system. And in some ways, the accountability lines and the reporting lines for those parallel aspects of the health system, don't feed directly into the ministry of health's direct oversight and control.

And this is something that I saw when I was in Malawi a few weeks ago, when there are large cuts to something like the [00:09:00] HIV system, it takes some time to really figure out what's happening.

Buddy Shah: Yeah, that's exactly right and it is, I mean it's both really surprising to people who don't know the sector. But you know, to be honest, it's really infuriating to a lot of people that do work in the sector. 'Cause essentially you've got a national government that's trying to provide health services for its people. And often you have 10, 30, even 40% of the national health budget that comes from sources outside the country. They could be philanthropies, they could be the foreign aid agencies of different governments like the US, UK, or others, or multilateral organizations like the Global Fund or the World Bank.

And basically in a lot of the countries where we work, the government doesn't fully own or even know all of the data around who's funding what in which parts of their country. And this is something that, you know, when we talk to ministries of health and ministers of health, they're often [00:10:00] very frustrated by it.

And so that was the first piece, you actually had to combine all these different sources of data of what is the US government funding in HIV or malaria. And then you need to map that with the government's own data and the data of other funders in the space in order to create a whole picture of, in the country as a whole, here's who's funding what essential drugs or healthcare workers in what parts of the country.

And then you gotta figure out, okay, which parts of that have been cut? And then of the parts that have been cut, which are the most important for patient care and preventing sickness and death. So that the government can then do the next piece, which is to say, all right, how much money do we have in total and which of the most important gaps in our budget to fill? And so, you know, it sounds like a little bit shocking and it was to us to a certain extent. But the first piece was like very basic information gathering on where are these cuts actually gonna hit in any given [00:11:00] country.

And then the second part that the ministry said is, okay, once we actually understand where the gaps are in our budget, we need to figure out how to reprogram the rest of the money that we have to make sure that we're filling the gaps that are most critical to patient lives and moving it away from things that might be nice to haves, but less essential. And so there's the second component that they're really talking about, which is reprogramming or reprioritizing the existing budget that they had to make sure they're filling the most essential gaps.

And then the final one was essentially the ministries of health reaching out to CHAI and saying, you know, help us think about not just how to plug key gaps with our existing resources, but how do we crowd in more money, including from our own ministries of finance, but then from other potential funders.

And so, putting that all together, we essentially found that there are these three big asks that the government had. One was identifying where the gaps are in their budget. The second was [00:12:00] helping to reprogram their, whatever money they had, towards the most effective and important parts of the health system. And then the third was crowding in more resources and you know, that includes from a variety of sources.

Elie Hassenfeld: Tell me a little bit more about why you think ministers of health or ministries of health were coming to CHAI and as far as you know like who else were they going to with this question? Presumably they were doing some of this on their own, were going to others in addition to CHAI and just where does CHAI fit into that broader ecosystem, or like where did it slot in to helping with governments and like determining where they were and what they were gonna do next?

Buddy Shah: You know I think there are three big reasons why the ministries in a lot of our 37 country offices reached out to the CHAI team. One is that CHAI teams have been in basically all of our countries for roughly around 20 years. There's a big part of global health and change and being able to be effective, which is just [00:13:00] like, to what extent have you been around for a while and have deep relationships and understand the health sector in that particular context.

So one is that, we've been there for a long time and worked in this, what we call like an embedded way. So CHAI teams are often embedded within the ministries of health, often sit inside the ministry offices, and we usually work behind the scenes. So, you know, rather than claim credit for what the ministry is doing, really thinking about what are the ministry priorities and providing that support or surge support function from behind. And so I think that was one big contributing factor is being around for a while and being used to working really deeply in this trusted way behind the ministry priorities without an agenda of our own.

The second is that CHAI, in addition to this deep country presence in 37 countries around the world, also is very plugged in with the big global funders in global health. So the Global Fund for HIV, malaria, and TB, [00:14:00] Gavi for vaccines, US government. And so the Ministries of Health know that we both deeply understand their context and their priorities, but also understand how these global institutions work. And we often serve explicitly as a bridge between some of these big global funders and the national governments.

And then, you know, I think the last is just that we're able to provide technical expertise, whether that's budget analysis or epidemiologic analysis of diseases with the understanding of the country context, and there's something about that.

You know, I think that's why a lot of ministries reached out to CHAI. And then of course there's a lot of other people doing really important work during this time. The ministries have their own strategy team sometimes that were doing similar work. And in those countries, CHAI said, well, the ministry and the government basically has it covered. So, we don't really need to play a role. I think there are some other NGOs that sometimes play a similar role. And then organizations like the WHO that have in [00:15:00] country presence, but that tend to provide a different kind of support.

Elie Hassenfeld: So you got these ministries coming to CHAI asking for help understanding where the cuts are going to hit, and then seeking advice on how to potentially reprogram funding to address critical needs. I imagine there are some themes across the 37 countries, and so curious, like what did you find and what did you advise?

And then, would also just love to hear about any specific examples that really like draw out what you found and what you advised countries to do.

Buddy Shah: Yeah. And you know, this is still ongoing work, but I think that we're starting to see a pattern across multiple countries where there's impact opportunities first in driving more efficiency, essentially having more impact in the same area with less money. Secondly in what we call prioritization, moving money from less impactful or cost effective things to more impactful or cost effective things. And then third is on really making the case for governments to put more [00:16:00] money into the health sector. So let me just give you a sense of each one of those three.

First on efficiencies, we found across multiple countries that we can drive somewhere in the range of 20 to 40% reduction in cost of key public health programs without sacrificing coverage. And this includes in already cost effective areas like malaria.

One specific example in Benin that we worked on with GiveWell, they do seasonal malaria chemo prevention, It's a GiveWell Top Charity, essentially inoculating kids against malaria before the rainy season. Really cost-effective way to save lives. And we found that we were able to reduce the cost, both of planning, but also the delivery of those campaigns by around 30% by doing some pretty common sense things like shortening the training period for village health workers that will go village to village to deliver these pills because they've already done it usually for a couple of years. And so every [00:17:00] year, instead of having a three day retraining in person where you have to pay all the costs of that, you can often do a one day hybrid training, just as an example. And so there's some pretty common sense programmatic changes where we found that we're able to drive 30% cost reductions without sacrificing coverage. So I think that's one type of example.

Elie Hassenfeld: Let me push back a bit and see what you say, I mean, do you think that 30% efficiency gains is what you would think of as like the expected cost improvement across all programs? I mean, that might imply that if I guess like, to put it in a very stark way, if the US government were to cut aid by 30%, you know, then governments could respond by improving efficiency by 30%. If you took this line of argumentation, like the net effect would be zero because you'd lose some funds, but you gain efficiency and it'd be like very large gains in efficiency that would overcome those lost funds. And so, yeah, I don't know is that how you see it? Do you think that is what can happen?

Buddy Shah: Yeah. I, [00:18:00] ha, I definitely don't see it that way. I mean, I think that the 30% cost reduction that we've seen across multiple countries is in a particular type of delivery of drugs, so it's like a campaign mode. And that's only a subset of the overall funding.

There are some of the big costs that have been funded previously, which is just like the cost of drugs, as an example, where you just can't get any cost reduction beyond what we have now, because there's already been really intense negotiations with pharmaceutical companies to get those costs down to what's a sustainable model.

And so I don't wanna mislead by saying that across the board, in all health spending, we can get 30% efficiency gains. Instead, I think what we're starting to see is that in certain pockets for important programs and campaigns, you can get these big 30% cost reductions.

And I think what we honestly don't know, just to be transparent is how much of all implementation costs can we actually get [00:19:00] down at that level? But what we are seeing is promising initial instances or case studies where we can get pretty sizable costs. And I don't think we have a good answer to how does that all add up in terms of, you know, overall efficiency gains we can get in this system as a whole.

Elie Hassenfeld: Right, because like is that 30%, 30% on like the total cost of the program or 30% of the, I don't know, like planning, training, engagement because, basically the, I'm looking at the numbers we have in our report on seasonal malaria chemo prevention, and like all of planning, training, administration, engagement, M&E, which is monitoring and evaluation, and coverage surveys is like 38%. Yeah, is it like the total or that component?

Buddy Shah: Yeah. So in the Benin example specifically, we were able to drive down cost by 30% in that planning and logistics phase. And importantly we focused there because the US government had already bought the seasonal malaria chemo prevention pills, they were already [00:20:00] purchased and they're like, we're not gonna pay for logistics and planning. And so the country couldn't get those pills out there. And that's where GiveWell and CHAI stepped in, and CHAI basically said, okay, we can do that planning and logistics phase for 30% cheaper and then GiveWell funded that. And that allowed 500,000 kids to get access to that seasonal malaria chemo prevention in Benin.

And so that specific example, it was 30% cost reduction in that kind of 38% of the budget. We did do modeling and there's room to reduce costs in the rest of the budget, maybe not by as much. And so I think like this all goes back to the point that there's definitely big parts of the budget where it can drive efficiency. I definitely wouldn't say it's a hundred percent across the board and that we can just make up for the 30% cuts in USG funding simply with efficiency gains, but it's an important piece of the puzzle.

Elie Hassenfeld: Got it. Cool. Okay. So yeah, that makes sense. And so that was pillar number one just saying, we have less funds, let's be more efficient. Okay. So then pillar number two is prioritization.

Buddy Shah: And pillar number two on [00:21:00] prioritization is that just looking with fresh eyes at the full budget of what the government's spending on and saying like, okay, where can we move money from things that are less impactful and necessary for people's health to the most impactful things.

And so in Burkina Faso, we helped the government reprogram $7 million away from essentially non-essential trainings or non-time sensitive trainings, kinda retraining doctors in cities and moving that money immediately to buying family planning commodities and HIV and maternal health drugs and diagnostics that just were like much more urgent from both the government's point of view, as well as from a patient health and mortality point of view.

And so that's an example of reprogramming and essentially being able to rebalance what the health system spends on in a tighter fiscal space to make sure that you're funding the absolutely most critical things.

Elie Hassenfeld: Yeah, and I think that's an interesting one because changes like that were also similar to ones that [00:22:00] we've been hearing about. One way you could think about this is like improving prioritization. And then another way that I've sometimes thought about this decision to shift from non-urgent trainings to say like, urgent, time sensitive provision of medical supplies is in some ways it's borrowing against the future for the sake of the present.

And I mean, that makes a lot of sense. In a moment of crisis when people don't have the medical supplies they need, it makes sense to like reallocate towards what is urgent and time sensitive. And that means that there will be these less severe effects in the short term. But I also think it's not free, because it comes with these longer term costs that are harder to see and harder to measure.

And like, how much of this prioritization is, sort of making a necessary tough choice to borrow against the future for the sake of the present, versus something that's less costly, like just reprioritization towards better things with limited cost to the future.

Buddy Shah: Yeah I think that's [00:23:00] exactly the judgment call that we're trying to support the governments in making on a case by case basis. And it's not always straightforward, but I think in some cases, it's more straightforward than you might think. So just to give two examples in this, like borrowing against the future kinda risk.

One is we could advised the government to move money away from its digital health system and its disease surveillance system, which is like in the short term, not necessarily gonna get a pill in the hands of a mom who can save her kid. But we absolutely did not advise that because we have some theory that these digital health systems and disease surveillance systems helps the ministry say which sub regions of our country have the highest burden of a particular disease at a particular point in time. And then they can actually direct their resources to the highest need much more effectively and cost effectively and have their budget go further.

And instead distinguishing something like a [00:24:00] digital health system or disease surveillance system, which we do not wanna borrow against 'cause we think that there's very high borrowing costs and that would have real negative effects in a year or two years or three years, versus some of these non-urgent trainings where in the first place, maybe the calibration wasn't fully optimal, that like maybe you need the training every two years instead of every one year. And yeah, there's some loss of retention of what to do, but it's probably nowhere near the importance of a digital health system or disease surveillance system.

And so, you know, there's always some cost of moving money away from things. I don't think that there's a ton that's just spent on totally useless stuff. But I think you can draw some pretty bright lines between where you're really making a costly move and shooting yourself in the foot at building the system you want a couple years from now versus things that yeah, would've been a nice to have, but it's clearly much better to move that money to immediately lifesaving things.

Elie Hassenfeld: And then I guess the third part of [00:25:00] this advising and response is trying to help governments, or ministries of health, get more money from their own country assets. And so yeah, tell me more about that.

Buddy Shah: Just as like a concrete example, we did a budget analysis for the government of Nigeria that identified $480 million in health gaps driven by the foreign aid cuts. And we sent that report to the Minister of Health in Nigeria and that Minister, Minister Pate, with that input and obviously his own assessments and expert opinion, essentially was able to get the Ministry of Finance to commit $200 million in emergency funds.

And so governments are definitely taking action based on analysis and input on releasing emergency funds. And the big question's gonna be, to what extent can different governments actually increase their health budgets in more of a steady state way, adapting to this new reality? And I think we don't fully know that, there's a lot of [00:26:00] political conversation.

One of the big things that I think we can do as partners to these governments is do very thoughtful, detailed analysis on what the gaps are, what the health implications of having those gaps be unmet are. And then that better equips ministers of health to have those conversations with the ministry of finance or the president's office on how much the country as a whole should increase its health expenditure, which as you can imagine is like a very hard and often political question.

Elie Hassenfeld: Right. The cuts took place and then these are some of the areas that governments can respond to mitigate some of the effects of the cuts. And I guess the thing I'm wondering, and I'm curious if you have thoughts on it is, to what extent are improved efficiency, improved prioritization, and bringing more money into health, mitigating these effects? I presume they're not mitigating the effects completely, I mean that's something that, you know, we've observed in our work.

But I'm trying to get a better sense of the extent to which they're having a very small mitigation effect, a moderate effect. And I don't expect you to [00:27:00] have this answer at your fingertips, but is it like mitigating 10% of the effects or 70% of the effects of the aid cuts that we've seen?

Buddy Shah: Yeah, I mean, I just really don't have a good answer to that, unfortunately. I don't think anyone in the world does, in part because of, you know, what we were talking about before where okay, we're seeing that we can get 30% efficiencies in one part of a budget, in one part of a program, in one part of the overall health budget.

And so because there's so much chaos happening right now, and we're just really experimenting with where can we get the efficiencies? Where can we reprogram and reprioritize? There's not a very neat entire budget envelope look at how much can we drive through efficiencies or prioritizations.

And my hope is that like all of this on the ground work, where we're finding concrete ways to drive efficiency, concrete opportunities to reprogram, after we do that in this initial year of the cuts, we'll be able to partner with, you know, academics or research institutions [00:28:00] or governments in order to actually aggregate all that up and say, okay, based on these levers that we've been successful at pulling on efficiency, reprogramming, and getting the government to put in more money themselves, we think that that can blunt x percent of the total aid cuts.

But right now, I think the reality is that we're just much more in a execution mode and trying to find those opportunities and deliver on those opportunities, versus really having any kind of a robust sense of how it all stacks up at the entire health system level. So that's maybe one part of what I'd say.

And then I think the second is that like a lot just does depend on the politics of what any individual country government is willing to do to increase their budgets. And there's a lot of uncertainty there as well.

Elie Hassenfeld: Yeah, yeah. That makes sense. That's too bad that it's hard to come by this kind of information, of just like what concrete effect the cuts have had to date because of everything that folks are doing to respond.

Buddy Shah: I know it's been [00:29:00] covered in a previous GiveWell podcast, but there's two distinctions I'd make. One is that it's really hard to tell now in this first year of the cuts, because there's already been money in the system that had been allocated before the cuts happened. And so it was more around navigating the chaos of, is that money still good? Can we still use those drugs that have been purchased and delivered to countries? And I think as we get further out from the cuts and the chaos, hopefully in year two and beyond, we'll be able to have a much better sense of what the effects are.

And then the second thing I'd say is that in certain parts of the health sector, we are getting better data on what the effects of the cuts are. So CHAI in particular has released several, what we call market impact memos in the family planning space and in the HIV space. And so our most recent HIV market impact memo has already started to show that there are direct effects of the cuts.

You know, this is only based on 13 [00:30:00] countries, so it's not exhaustive of everywhere where there's HIV AIDS funding. But in those 13 countries that we surveyed, we're seeing around a 20% drop in new HIV treatment initiations, essentially people newly diagnosed with HIV getting on treatment. We're seeing up to a 40% drop in HIV testing and routine testing. And we're seeing much higher drops in what's called pre-exposure prophylaxis, essentially like getting preventive treatment before exposure to HIV, up to 65% reduction in pre-exposure prophylaxis. So, we're just, I think, starting to see the health effects of these cuts.

And the thing that I'm most worried about is actually like next year and beyond where the money's actually gonna be out of the system because of the budget cuts. And the chaos of this current year is gonna make it harder for planning. And so the big negative health effects, which I think could be very substantial, I suspect will start to hit maybe [00:31:00] second quarter, second half of next year, if that makes sense.

Elie Hassenfeld: Yeah. And I mean, I imagine that the decisions that governments are making that lead to those reductions in getting people on preventative HIV treatment and testing to initiate HIV treatment, you know, those are decisions that are sort of part of that calculus of, in a crisis, to borrow against the future to deal with the present and the sort of direct humanitarian effects, meaning people dying from HIV AIDS. Well, that still is like a couple years off in the future from the people who are not getting on their preventative treatment today. And so I think that's consistent with this pattern of, you know, really being very concerned about the effects that are to come in the next couple of years.

So we're talking about being worried about the future. I mean, when you look forward to next year, 2026, 2027, what do you think this will mean for CHAI? How big a change do you think this is for the, [00:32:00] you know, the whole world of global health and development?

Buddy Shah: Yeah, so first of all, I think it's a huge change for the world of global health and development. And you know, like as we were thinking about the cuts, one of the things I was doing is just looking back over the last 20 years of what the global health order has been, because I think this moment really is a shakeup and what comes next is potentially gonna be very different.

And just to linger on the last 20 years, I think it's been one of the most remarkable achievements of human collective action. You know, If you think about between all these different global health efforts, we've probably spent, I don't know, a couple hundred billion dollars, maybe $200 billion between US government and these Geneva based organizations. And that $200 billion over 20 plus years has probably saved tens of millions of lives.

You know, the official estimates of just the US government efforts are 37 million lives saved. Even if you apply GiveWell style discounts to all of that, or are very critical about it, I think, you know, even GiveWell would [00:33:00] say it's probably in the tens of millions of lives saved. And it's so hard to contextualize that, but that's 10,000 plus 9/11s that have been averted. That's, you know, World War II military casualties averted. It's a remarkable thing we've done over the last 20 years.

That having been said, I think that old model does need to be shaken up. And I think this is a once in every 25 year kind of moment that at least presents the opportunity to rethink what should come next. I hate to say, but I think sometimes you need these really sad and dramatic and chaotic shakeups to think about what should come next.

So what does that mean for CHAI at least? You know, one is that we want to keep doing what we have been doing. There's continuity of listening to ministries, what they need, and then helping them design and execute better programs. So there's a lot of continuity there. And the thing that we wanna do differently is just have this laser focus on helping the ministries find more efficiency within their health budget, and then [00:34:00] spend on the right things, that prioritization. And then keep making the case both to national governments and global donors on why this is such a good investment in terms of money in and human meaning or welfare coming out the other end of that.

I think the second is that, you know, there is just this technology boom that's happening now in AI and not to get swept away in the hype, but I think there's a few very concrete ways in which we're already seeing that AI at least has the potential to help us do more with less money.

So if we think about TB, one of the biggest infectious disease killers, something that GiveWell's funding CHAI to work on in India. We're starting to think about, at every point in the fight against TB, could you use AI to make things more cost effective? Now whether or not in TB, any of those individual interventions are actually gonna dramatically improve cost effectiveness, we need to do the research. But I do think that there's a lot there where [00:35:00] we could potentially use technology. And so, CHAI is trying to think very hard at what new opportunities does generative AI open up for doing a lot more with less. And there's plenty of other examples that we're scoping now, all very early stage.

And then the last thing I'd say about how the cuts are changing what CHAI does is just in trying to think about the politics. I just came back from Ghana where there was a head of states meeting, it was called the Africa Health Sovereignty Summit. And at the political level saying, how do African countries get more sovereignty over their health systems? They were clear that what they didn't want was isolationism. But there is a important question around, how do we support national governments in putting more of their own budget into health systems, in a way that continues some of the best and most effective parts of the old global health order.

And so I think those are probably the three big things that we're looking to change is like deep focused work with governments on finding efficiencies and reprogramming. Secondly, [00:36:00] really trying to find the most cost effective transformational AI or technology things that allow countries to do more with less. And then third, not shying away from the politics of what should come next, and supporting governments in stepping up with their own national budgets responsibly over the next several years to fund more and more of the health system where they can.

Elie Hassenfeld: Yeah, so those are some of the ways that CHAI and maybe the sector as a whole and country governments can respond to less funding and, perhaps more efficiency, improved technology, increased intentionality around raising more country funding can mitigate some of the effects. I mean, who knows how far it could go.

And then I guess the more negative take, which maybe I'll offer is, like relative to a counterfactual world where all of that happened anyways and funding maintained at the level it was, you know, many more people would have lived who, I think now, will not. And I think, I mean I know you agree with this, but I think that, you know, is [00:37:00] just incredibly sad.

Buddy Shah: Yeah, I definitely agree with that. It's incredibly sad. And I think that's one other thing that we are thinking a lot about is, there is a huge amount of money on the sidelines right now that could come in. And if you think about just large scale philanthropy, you know, there's $14 trillion in assets held by the world's richest people by people with, you know, that have over a billion dollars. That's growing at a trillion dollars a year, just the appreciation on that basis.

And I think being able to identify compelling cost-effective ways to save lives like GiveWell does that are easy to put money into is such an important piece of the puzzle because, frankly, we actually do have a lot of that money that's sitting on the sidelines that if it got off, we wouldn't live in such a sad world where it's as cheap as $5,000 to save a life.

Elie Hassenfeld: Right. Alright, well I wanna ask you a final question, which is, you know a lot about GiveWell, you know about how we work and I'm really curious if you think about what we might be getting [00:38:00] wrong, what do you think we might be getting wrong here?

I know that you'll have an answer to this because people don't know this, but after you left GiveWell, I think we met up, you know, about a month later and you had a giant document you had prepared of all the things I was doing wrong that I needed to do better and that GiveWell needed to do better. And so that was really helpful to me. What do you think, we, GiveWell could be doing differently to do a better job in just responding to the present moment.

Buddy Shah: There's a couple things that GiveWell has already started to do that I think what you might be missing is doing more of that. So one is just like obviously being very thoughtful about understanding where the cuts and what are the gaps that could be fillable and most cost effective. So continuing that.

But I think more importantly is embracing uncertainty and being willing to be more nimble. On the nimbleness piece, I think GiveWell's already started to explore that, hey, if all of a sudden there's a bunch of HIV funding that's been removed, we've never funded HIV, [00:39:00] but maybe that means that there's just really cost-effective opportunities that we hadn't evaluated before in new areas. And being willing to say, okay, we've traditionally funded malaria, and vaccines, And other things, but we really need to respond to the current moment and evaluate completely new areas, feels really important and I would keep a very open mind about that.

More fundamentally, I think there's always been this question on, do you fund the underlying health system or do you fund the marginal thing on top of that system of delivering the health commodity? And to date, I think GiveWell's had a very defensible position, which is like take the system as given and say, where does that extra bit of money go, where you can deliver something on the back of that system to save lives.

But now we're genuinely in a world in which the underlying system that delivers bed nets or vaccines is at risk. And it's a much harder investment case to make because I think it's harder to measure, but I think GiveWell [00:40:00] has to grapple with it. So like very simple example, GiveWell funds bed nets via AMF investments, but that relies on implementation delivery systems that are funded by other funders like the Global Fund. And if the Global Fund's budget is reducing 'cause the US government's not funding it as much, I think there's an important question on, well do we fund that basic underlying delivery implementation system? And I think those are pretty hard questions, but I think it's something that GiveWell should be thinking about.

Elie Hassenfeld: Yeah, I think those are great pushes and great questions, some of which we're thinking about critically ourselves, some of which perhaps we should think more about. I do think all of this from thinking about how we balance speed versus certainty and analysis. You know, all of GiveWell's history has been in an era of relatively high levels of foreign aid and those are falling. That just changes the nature of the project that we're involved in, to the other feedback you offered. I think that's great and certainly things that are on our minds and should be on our minds going forward. [00:41:00] Yeah well this was great. Thank you, Buddy.

Buddy Shah: Thanks, Elie.

Elie Hassenfeld: Hey everyone, it's Elie again. So I found that really interesting, a lot of what we've talked about to date is how GiveWell sees the world and how we are assessing the needs that are emerging for additional funding. And when you hear Buddy talk, what you see is that from the perspective of ministers of health who are leading the work and trying to respond to these cuts, they have a different perspective.

They're thinking about, how do we triage to ensure that we're giving the people in our country the best healthcare that they can possibly have at the moment. They're very nervous about what's coming in the future where, you know, they have a high degree of uncertainty about the funding that they'll have going forward.

And, this is something that, you know, I just saw recently when I was in Malawi that we talked to members of a nonprofit who are delivering HIV services and they expect to be laid off at the end of [00:42:00] September. And so they're just operating under this huge amount of uncertainty in everything they do.

And then I think, you know, Buddy's right, that there's just ways in which this represents a giant shift in the level of funding available for global health and development. And that has big implications for how we work at GiveWell. We've already done a lot to grow the team this year, expand our areas of focus into ones that we hadn't looked at previously, like HIV AIDS, and family planning, and data systems. But we have more to do to think about the ways in which the different world we're in means that we need to respond differently.

As always, thank you so much for listening and for your interest and really getting into the details of what's happening around the world and the ways in which we can help. If you have any questions, feedback, or advice, please email info@givewell.org. We'd love to hear from you.