Elie Hassenfeld: [00:00:00] This is Elie Hassenfeld, GiveWell's co-founder and CEO. I'm here in Blantyre, Malawi with three other members of GiveWell's team, and we're here in Malawi's second largest city on the first day of a week-long site visit to see programs and people in Malawi and raise questions and assumptions that could help us better do our work.

At GiveWell, the vast majority of the work that we do is desk-based research, reviewing evidence, asking organizations questions. And site visits are a small part of what we do. I'd say that, on average, research team members spend about a week per year doing site visits to see things in person, understand context better, and raise questions. And we're here to try to do some of that.

GiveWell hasn't funded a lot of programs in Malawi over the years because even though Malawi is relatively poor, its per capita GDP is about 40% of [00:01:00] Africa's average, but it's also relatively healthy compared to Africa. Its under five mortality rate, meaning the percentage of children who are born and don't reach the age of five, is 4% as compared to a 6% average in Africa. And because so many of the programs that we support intend to reduce under-five mortality, we've funded relatively little here.

So we're visiting Malawi with two primary goals. The first one is that Malawi may be particularly hard hit by aid cuts. Malawi's health budget in the most recent year for which we have data was around $190 million a year, or I should say its government's health budget, and the US added about $150 million to that, so adding about 80% to that baseline spending.

And then we're also here because it gives us an opportunity to focus on livelihoods programs. Livelihood programs are ones that aim to increase the amount of money people have to buy the kinds of things that they need. And we've launched a more intense [00:02:00] focus on livelihoods this year, and so being here will help us gain more information and better context about that area.

So this week we'll be visiting health facilities in different parts of the country. We're going to visit two organizations, Spark and GiveDirectly, which both are in our bucket of livelihoods programs. And we're going to talk to people who are similar to the kinds of people that our programs would serve and just ask them what they want, what they see, what problems they face, and what they think about the kinds of programs we're considering.

So I expect that this week we'll see that health services have been challenged. We'll have a better understanding of exactly how they've been challenged and the problems they're facing in Malawi, and we'll be hearing that from healthcare workers and also people seeking care.

Across the board, we have beliefs and assumptions that underlie the recommendations we make, and being here is going to give us a chance to check those and see places where we might be off base.
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Elie Hassenfeld: This is Elie. I'm [00:03:00] sitting here with Teryn Mattox, our Director of Research. We're just right outside our hotel, about to set off for day one of our site visit. And today we're going to be visiting a health center right in Blantyre, Malawi, and then heading out to meet some participants in GiveDirectly's program who've received money from them.

You know, one of the main goals of this trip is to visit health facilities and get a better feel for how they've been affected by aid cuts that have happened this year. Teryn, when we visit that health facility today, what kinds of things are you expecting to see and what do you hope to learn?

Teryn Mattox: Right, so we're going to be visiting Zingwangwa Health Center, which is an urban health center, and as far as we understand, HIV viral load testing has been suspended there due to cuts. So that tests the amount of viral load in an individual that is on antiviral treatment. So when someone's on antiviral treatment, they try to monitor the amount of virus in their body to make sure that the treatment is working. And essentially what they're trying to look for is that the [00:04:00] virus is like fully suppressed and not transmittable.

So by suspending that, they don't have a way of assessing whether ARTs are working, which obviously is problematic for that individual who would then, if the ARTs are not working, progress to symptomatic HIV, and also can lead to increased resistance . . .

Elie Hassenfeld: ARTs, that's the drug that people who are HIV positive are on to prevent them from progressing to full-blown AIDS [Teryn: Right] and disease. And then what would, what would happen for them if they had viral load testing and it turned out it was high? What different health...

Teryn Mattox: I think they would progress to a different dosage of ARTs. So that's the primary, that's part of the protocol of care for somebody with HIV.

Elie Hassenfeld: Got it. So it's like you are HIV positive, you get on drugs [Teryn: And we test you regularly] that should all, that should be working, but we test you regularly. [Teryn: Right] And if it, if we have signs that it's not working it can change the treatment you're getting, which prevents you from progressing.

Teryn Mattox: Exactly. Which prevents you from progressing, prevents you from transmitting the disease, and then obviously prevents resistance from [00:05:00] developing.

So it's not clear whether the HIV clinic will be open today. We learned yesterday that they tend to try to have a day that's for HIV testing specifically. And we're not sure whether that's going to be happening today or not. But if it is happening today, I'm really interested in understanding what the situation is, whether they have any of the reagents, any of the testing materials. If they do, how they're triaging patients, how they think about mothers and children with HIV as opposed to others in the community with HIV.

Elie Hassenfeld: Yeah, I mean, and something else that we heard that I'm interested in is we have this estimate that something like 40% of Malawi's health workers were laid off due to the cuts. And, you know, this is the kind of stat that we got. It was really disturbing, but also it's just not clear today, like exactly how that, you know, is happening on the ground. And I think just having an opportunity to talk to people and gut check that kind of expectation will be really helpful to us.

Teryn Mattox: [00:06:00] Right. Not just laid off, but folks that have taken pay cuts. I think we've also heard that the data systems in Malawi have also been disrupted, so it would be interesting to hear from them what their experience has been with that.

And I think beyond the aid cuts, I'm just really interested in understanding what their primary difficulties are in the clinic, what they would do if they had a magic wand and could improve their service delivery, what's the first thing they would do?

Elie Hassenfeld: Right. A lot of the things that we've supported, you know, we talked about providing malaria treatments, rapid diagnostic tests through clinics. And so I think this today and then this week, just an opportunity to spend a lot of time in health centers and see how they operate, what challenges they're facing, will be additive to the understanding that we have so far.

Teryn Mattox: Right. Malawi is one of the three countries that piloted the malaria vaccine, and we funded the rollout of that vaccine more broadly beyond the initial pilot communities. And I'm really eager to understand in these areas, the extent to which the vaccine is available, is being used. One thing that I've heard from doctors is that [00:07:00] the number of folks coming in for malaria treatment has fallen as the introduction of the malaria vaccine has come through. And so I'm really curious to explore whether that's the case here.

Elie Hassenfeld: Got it. Cool.
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Elie Hassenfeld: Our first stop was to a primary healthcare center that seemed to have a major focus on HIV/AIDS. There was a sign out front detailing the services it offered, including counseling, testing, treatment, and more. The center itself was down a very steep set of stairs and was a few one-story, very long brick buildings that we went down to.

We saw a large number of people, it seemed like mostly mothers with young children waiting to be seen. And the GiveWell group went with our translators and some hospital staff into a small area outside where we could sit and ask questions.

After we'd asked staff questions, a few colleagues and I sat with the laboratory [00:08:00] technician. And we asked him about some of the impacts that he had seen and experienced as a result of the recent cuts in US funding. This is some of what he said.
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Lab technician: I'm Ronald Pandy, lab technician.

Elie Hassenfeld: Nice to meet you. Thanks for talking to us.

Lab technician: You are welcome.

Elie Hassenfeld: Can you just tell us what do you do as a lab technician? What's your job? What do you do day to day?

Lab technician: OK, as far as my position is concerned, we draw specimen from the patients. The clinicians refer the patients to the lab for any type of lab test, either malaria, urine, stool, TB, and the rest. Yeah. And also we do collect blood samples, especially when we have measles cases, or in the past years, we had COVID. We used to collect specimens and test as well.

Elie Hassenfeld: You know, there were cuts in funding [00:09:00] from the US this year. Did anything change in your job during that period?

Lab technician: Yes, there was a big challenge because HIV testing is done down there. So all these I've mentioned here, they're also funded by USAID. Yes. So there was cut there, there was a cut of services there. So we have to leave our operations here and also support them in testing HIV. There was no transportation of samples, so we stopped collecting viral samples, plasma samples, because they need agent attention, right? And also some of the assistance like reagents, some of the equipment also supported by our colleagues funded by USAID. Yeah.

Elie Hassenfeld: And so what happened with the equipment? The equipment and the [00:10:00] reagents? Did you have it?

Lab technician: So the equipment we have, but as far as the reagents were concerned, we stopped it because there was short of supply or totally we had nothing. Yes.

Elie Hassenfeld: And sorry, I don't, so I don't know how this works, but the reagents are something you need. Yes. In order to do the testing in order, without them, you couldn't do the testing. Now are the reagents here?

Lab technician: Partially, but not all.

Elie Hassenfeld: And so if they're not all here, they're not here, what happens? What does that mean for your ability to test?

Lab technician: So we can't do the test because we don't have the reagents.

Elie Hassenfeld: Was any other testing affected by the US cuts?

Lab technician: Yes, even the supplies for HIV, the kits, we have a shortage of the kits and even in the lab we, it's [00:11:00] like they also assist us in TB and whenever there is a new outbreak, then they are the ones who assist us and the information where to train us as far as a sample collection is concerned.

Elie Hassenfeld: Yeah, so we heard that Riders for Health was picking up samples for, I think, the viral load testing.

Lab technician: Yeah. They usually come for viral testing and for dry blood spots for the clients who, at the age of six weeks, who were born with the mothers were HIV positive to be tested for DNA. So they stopped coming.

Like I remember one time, we had a backlog of samples, viral samples, so there was nobody, we had no transport to move them to Queen Elizabeth Central Hospital to be tested. So they were just piling in our small refrigerator there. [00:12:00] Then, the clinical in charge herself, took the initiative to transport the specimens to Queen Elizabeth Central hospital. Mm-hmm. Yeah.

Elie Hassenfeld: Is Riders for Health operating now?

Lab technician: They are, but not as they used to do in the past.

Elie Hassenfeld: Oh, really? What's different now?

Lab technician: Because since we started this week, they haven't yet come. I don't know if they'll come today or, because nowadays they either come once a week . . .

Elie Hassenfeld: Oh, so like six months ago?

Lab technician: Yeah, they were coming twice or three times a week. And now it's down to once a week or sometimes the week can pass without coming.

Elie Hassenfeld: What effect does that have, if Rider for Health only comes once a week?

Lab technician: Yeah, they're delaying, they're delaying the justice for the patients to be tested first time and then get their results first. If the viral load is high, maybe he or she can be initiated to the second-line drugs, but they are being delayed.

Steven Profaizer: If you could change [00:13:00] one thing that would make your job better or easier, what is the thing that you think would be most important?

Lab technician: Yeah, for my job to be better, it's like when every necessity or supplies are in stock and the machines are working properly, we don't have power cuts, and also on top of that, if we have more equipment, it makes our job easier. Yes.

Elie Hassenfeld: And so, and how often do you have those problems where, let's say you don't have the supplies? How regularly do you feel like you don't have the supplies that you need?

Lab technician: As of now, I can't really say because even when USAID initiated that stop order. We also had some problems in even the rapid tests for malaria. Yes.

Elie Hassenfeld: When you say some problems, [00:14:00] does that mean there were days when you wanted to test people but you didn't have the tests?

Lab technician: Yes, yes. We could ask our colleagues from other facilities. They tell you we also are running out of those things. Recently, there also was a problem as far as TB is concerned? During the stop order, we had a shortage of TB supplies, like TB reagents, like the cartridges for testing TB, and also the slides for microscope, TB microscope but short supply of slides for testing those on follow-up patients.
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Elie Hassenfeld: We then split up to spend time in two villages who had recently received unconditional cash transfers from GiveDirectly. When my group arrived, we were coming down a long, fairly flat dirt road, and we arrived in a [00:15:00] village where we were met by the village chief and members of the village council. They took us aside to an area where chairs were set up in a circle, and we sat down there where they welcomed us. They explained the way in which they had worked with GiveDirectly, and we were able to express our gratitude for their hosting us, and we were able to ask them some questions.

After that we were able to walk around in the village and spent several hours speaking with recent recipients of GiveDirectly transfers to see what they had done and, you know, what they were hoping to do with the transfers they received.

Here's a little of what I heard and learned from those conversations.
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Elie Hassenfeld: Can she tell the story of how she learned about this cash transfer and I don't know, what did she think of it, and then what happened?

[Translator translating the question for recipient and recipient responding] [00:16:00]

Translator: She was just sitting at her house one of these days, and she heard a message that they're calling them at the Chief's house. That's where they got the message, and she got her name registered.

Elie Hassenfeld: How did she get the message?

Translator: Okay, so they called for a meeting in the village. That's when she was called as part of the community to converge at that village. So they were meeting at the Chief's house.

Elie Hassenfeld: And did everyone from the village come?

Translator: Everyone in the village was at that meeting.

Elie Hassenfeld: Okay, so I want to ask about the money that you received from GiveDirectly. And so some of it you bought the roof, the iron sheets for the roof, the mattress and the bedding. How have things changed? Are things the same here as they were when you were a child?

[Recipient responding]

Translator: Okay, so she's saying life is better now than it was before because now they're able to eat three times a day. That time they were eating [00:17:00] just once.

Elie Hassenfeld: So when she was a kid, they were eating just once a day?

[Recipient responding]

Translator: Yeah, so when she was a small girl, they used to be very good farmers. They were growing maize, cassava, so they were sustainable in terms of food. But things changed in between. Then they started eating just once a day because of expensive fertilizers and because she's also growing old and she's not able to grow crops. So that's how the things changed. And now, because of this help, she's able to buy food and eat three times a day.

Elie Hassenfeld: In the past month, the month since the cash came. Is that right?

[Recipient responding]

Translator: Life was very tough earlier this year before she got the help because she can't even do business, she's old, she wasn't able to fend for her household until this help came, that's when she managed to do all this.
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Elie Hassenfeld: Can you tell us about the GiveDirectly transfer. So [00:18:00] how many transfers did your household receive?

[Translator translating the question for recipient and recipient responding]

Translator: Three.

Elie Hassenfeld: Three? Because him, and his wife, and then the oldest child. And so what, did each of them, maybe just start with you, like what did you spend on, then what did your wife spend on, what did your eldest child?

[Recipient responding]

Translator: So him and his wife put the money together, which was about about 2 million kwacha. So first of all, they bought the cow here. The remaining money is using, is doing some fish business. So he sells the fish around the markets here. So he invested about 350,000 towards fish business.

Elie Hassenfeld: What did you have to buy to invest in the fish business?

Translator: So he used to order the fish from the source, so that can be saving from coming to other markets. So it's like the capital, capital for the fish business.

Elie Hassenfeld: I see. So it takes some money to buy the fish.

Translator: Yeah. So you buy and you sell, you, you order from somewhere [00:19:00] and sell here. So mostly we go to town to order from in town, and you come to sell here. So he used, for that one, he used 350,000.

Elie Hassenfeld: And so what did you use the capital for, just to buy a lot of fish or were there other things you had to pay for to create the fish business?

[Recipient responding]

Translator: So he used the money for transport to order the fish and come back and be selling in the villages around here.
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Elie Hassenfeld: What did you, when you got money from GiveDirectly, what did you use the money for?

[Translator translating the question for recipient and recipient responding]

Translator: So the first thing she did was to buy iron sheets and then about 300,000 she used to invest in her business. So she orders vegetables and also she cooks this, I think they're finished, you see the potatoes, they dip them in some colored butter. Then they fry them, so people come to buy and eat. [00:20:00]

Elie Hassenfeld: I see. So just what we're looking at. So here there's vegetables, like cabbage and tomatoes and the onions. So people buy the vegetables. Where do you get the vegetables from that people are buying?

[Recipient responding]

Translator: Mm-hmm. Okay, so she orders from other farmers, so like the Irish potatoes, she goes into town in Blantyre to order them, and then the vegetables, there's another market called Goliati that's where she goes to order that.

Elie Hassenfeld: Since GiveDirectly gave the money, does she think more people are buying?

[Recipient responding]

Translator: Okay. So she has seen a change because previously she'll make less money, but now with all the money that is circulating, she's making a little more. Previously she'll make, maybe the most would be around 30,000, but now she can go up to 50 something.

Elie Hassenfeld: She said that was a good day, 55 is a good day, so what's a bad day?

Translator: 45. Okay. So only a bad day will be about 45.

Elie Hassenfeld: Okay. How many days a week do you sit here and for what hours are you selling? [00:21:00]

[Recipient responding]

Translator: Okay, so she's here every day except when she's sick.

Elie Hassenfeld: Every day, like Monday through Sunday?

Translator: Yeah, Monday through Sunday. Every single day she's here, except if she's sick, that's when she'll not show up.

Elie Hassenfeld: What, how, when, what time of day, from when to when?

Translator: So she comes here at six in the morning and then goes home at nine in the evening.
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Elie Hassenfeld: Okay. So we're back where we started this morning. We're at our hotel sitting outside, it's nighttime, had a long day. We started out at a health facility where we got to talk to the facility leadership and just hear how things are going.

And then we were able to, in our group, each of us went individually. We were able to talk to different people there. So, I talked to a lab technician, Teryn got to talk to the HIV section. And then our colleague Julie got to talk to the outpatient department.

And then after we left that health facility, we also split up and went to two different [00:22:00] villages that GiveDirectly has served in Malawi, and, you know, got to go individually with a translator to talk to as many people as we could in those villages. And, yeah, we're just coming back today and sort of downloading how it went, what we learned, what we were surprised by, how it might inform our future work.

And so I haven't had a chance even to talk to Teryn yet and just hear how like, what she saw in this day, where we were in different places. And so I would just love to run through that and hear what you thought. So let's start at the beginning with the health facility.

Teryn Mattox: Yeah. So it was Zingwangwa Health Center and we got a fair, I thought we got a pretty clear picture of the impact of the cuts.

Elie Hassenfeld: Yeah.

Teryn Mattox: I don't know, it was very specific. Their HIV testing work had been suspended in February, and it was suspended just for a couple of months, but it sounds like nothing else, at least as far as they knew, had dropped off as a result of USAID cuts.

So what that means, again, I think we talked about that a little bit this morning, but if HIV testing is [00:23:00] suspended, it means that PrEP, so the provision of pre-exposure prophylaxis, is also suspended, or the new patients on PrEP are suspended because you can't test them for viral load, which is required before you put them on PrEP.

Elie Hassenfeld: Right. Because it is, people are coming in, and they get tested and they have to be HIV negative in order to go on that program. [Teryn: That's right.] So when testing was suspended, this had to be suspended.

Teryn Mattox: Yeah. And similarly for folks that are actually already on treatment for HIV, they can't have their viral load tested. So, they don't have any picture into whether the treatment is working.

So it sounds like they had nine people that were doing the testing, and six of those were funded by USAID via a partner organization. So USAID wasn't directly funding the health center but was funding the Elizabeth Glaser Pediatric AIDS Foundation and then one other NGO, whose name I did not catch, which were six of those nine individuals. And those people all disappeared for two [00:24:00] months. And then what that meant was that the three remaining Ministry of Health workers, who had not been extensively trained—it sounds like—on the testing protocols, had to take all of that over.

Those three workers were not just testers but had also done community outreach. So the community outreach work stopped during that time, and they came back to the facility and were spending all of their time with what sounds like a very large caseload of patients that they were testing. This is an urban health center and, you know, when I was talking to the testing provider, she said there's lots of nightclubs around, lots of sex workers, the demand for these treatments was fairly high at this place. So they were handling a fairly large load of patients by themselves. They said they were working seven days a week, there were really long lines, and were glad that those folks had come back online but were looking ahead to September when there were rumors swirling that cuts would come again.

And so interestingly, to deal with that, the Ministry of Health, it sounds like this is a national [00:25:00] move, was trying to get those government-funded workers trained up on the protocols that previously the partners had been implementing. So they're preparing now for the next wave, if it comes.

Elie Hassenfeld: And it was really interesting how the partners were so integrated in their work. It's not like, I don't know, you could kind of imagine there's the health facility and then there are these partners that are just like the next building over. And it was literally right there. And they were different but very much intertwined with the health facility.

Teryn Mattox: Yeah, exactly. They said there were lots of stockouts of family planning medications, but they didn't know if that was because of the cuts because there had been stockouts before. And that's something we've heard too, is that just because of politics in the US, family planning funding can kind of go on and off. So I was wondering if that was I mean . . .

Elie Hassenfeld: I thought that was like a wild story when you heard it. It was like there's this challenge of informing people of their options for family planning. Then someone would decide that they might want like an injectable contraceptive, but then they would show up a month later and they'd be like, well, sorry, we're out of stock from your contraceptive of choice, you have to switch to something else. And then people are bouncing around to [00:26:00] different options and having to learn about, get used to the side effects, understand what they are. And it's just like the way it is.

Teryn Mattox: Yeah, it's crazy. I mean, you know, switching birth control is like a very painful physical experience, like the hormonal changes are very intense. And just to imagine people having to do that every month as different stocks come in is a very crazy, crazy thing.

It sounds like they were out of stock of a lot of some of the most basic medications, and that's not because of USAID cuts, that's for other reasons. And I actually got some insight into that from Cedric, one of our translators. But one of the things they said they ran out of often was oxytocin, which is for hemorrhage during birth, which is really scary. And if a woman is hemorrhaging and there's no oxytocin, they need to send her to the hospital. And so then there's one centralized location where there are ambulances and so they have to go petition to get an ambulance if they need it. And there's never an ambulance. And so then these, this woman who was bleeding out, their family needs to find a way to transport them.

Elie Hassenfeld: And you sort of asked this question like, well, what do you do? Yeah. I mean their answer was fairly [00:27:00] direct. I mean, they started with the ambulance, but they were like well, not much.

Teryn Mattox: There's not much.

Elie Hassenfeld: Because there's no, if they don't have the medication.

Teryn Mattox: Right, exactly.

Elie Hassenfeld: This was like one of the takeaways for me from the whole, like that part of the health facility visit, which is there's all these basic drugs that, you know, oxytocin and they talked about magnesium sulfate and amoxicillin. Julie was talking about the blood pressure medication that they used to give out for three months now is rationed to one month. Maybe that's USAID related, maybe not.

These are the kinds of things that are always present in a facility like this in Malawi. And then there's this fact that according to us, Malawi's a pretty, is a healthy enough country that we don't direct a lot of funding to Malawi. You know what I mean, right? It's not cost-effective enough for GiveWell. And I guess we could be wrong about that, but I think it's more likely that it's just a sign that there are other places that have even bigger problems, [00:28:00] like Northern Nigeria and DRC.

And so then we come here, and it just reminds you of just how massive the need is beyond our cost-effectiveness threshold. I mean, we have to try to direct funding at the most cost-effective level, but if we had a lot more funding, there's so much good to be done. Like oxytocin, so you can treat people in childbirth who are hemorrhaging, or amoxicillin or batteries for needed measurements and all of that is just sometimes there and sometimes not there.

We went to the health facility and then after that we drove maybe for like 20 or 30 minutes to meet up with folks from GiveDirectly. And so GiveDirectly is an organization that gives what's called an unconditional cash transfer to very poor people. And that means that they give people money. [00:29:00] People are allowed to spend that money on whatever they want, no strings attached. GiveDirectly is about 15 years old now. Many years ago, GiveWell directed a lot of funding to GiveDirectly. GiveDirectly was one of our Top Charities. And I had the opportunity to visit them in 2012 in Kenya, and it's nice to be back visiting them again.

Over the years, you know, we kept finding things that we thought were even more cost-effective than that, and so GiveDirectly fell off our list and we gave less. But, you know, now we're interested in looking at them again. And, also, you know, they were able to take us to see villages and people who are very similar to the kinds of people that lots of GiveWell's programs serve. And so just nice to be out there with them.

And then in order to facilitate seeing more and questioning more—actually GiveDirectly had given us a list of six villages to choose from, and then we chose two and we split up between those two. And so then we are just going to go through and talk about what we saw, what we learned, what we were surprised by in those villages.

Teryn Mattox: So both of the villages I think were between, in the middle of their transfer scheme, right. They'd either gotten one or two, and so they'd already made some purchases. And the village you guys visited had gotten so much more, And you said primarily they'd bought . . .

Elie Hassenfeld: Iron roof. Livestock, which meant cow. [00:30:00] And the cow they were using for milk. Food. So just like bags of maize. And then seeds and fertilizer. So, one person showed us a plot of land that he owned and sort of had prepped it a little bit more, but then was able to buy all the materials necessary to have an extra plot of land to farm.

And then a lot of people talked about investing in their business. And the businesses were varied, and we never really were able to nail down exactly what the investment was and how the money was necessary. But there were people who had a fish-selling business where they would purchase fish from far away and then they could pay someone to transport it into town and then sell it in town. So that was like one business.

Another one was brewing some kind of alcohol. So there was like gin and beer and we saw the people actually coming back from having sold it in town, they were selling like 50 liters of homemade alcohol and then coming back with like bags of sugar and maize bran, which were the main ingredients, so they could make [00:31:00] more.

Teryn Mattox: Yeah. So that's exactly the composition with the exception that the livestock was goats in the village we were in, of purchases that folks were making, they were buying iron roofs.

Actually, one thing that was really interesting, we talked to several people that were going to build a house, like build a new house, and they had made themselves some bricks. They were gonna pay for labor to fire the bricks. They needed to buy cement. They wanted to buy a roof. And, you know, they were starting this process of investment and that was their whole plan. And we asked them, do you know how much it costs to build a house?

And in no case did they know what the total cost would be. And they were like, I'm just hoping that the money covers it and maybe it won't. And I was just imagining after all this cash, just a pile of bricks or like a half-built house, it seems like such a loss. And then I was talking to the GiveDirectly folks about how they approach that. Like can they counsel people and help them understand budgeting and because it's unconditional, they really [00:32:00] don't want to be in there talking, like giving people advice on how to use the money. And then also because of the inflationary environment, they can't really counsel them on prices either because it's unclear what things will cost. So, which is probably also part of the reason that they were like, I don't know if I can do a house with this. But it felt like such a sad information asymmetry or something, that feels like it must be resolvable somehow.

Elie Hassenfeld: Yeah, so we spent the afternoon with GiveDirectly recipients. You know, some of that was to ask people about their interactions with GiveDirectly and how they spent the money they received. But a lot of it was just to be able to speak with the kinds of people that GiveWell programs support in lots of different ways. And so we could ask them about how they access healthcare, what challenges they face, where their kids go to school, how far they have to walk.

I don't know. I just thought today was a really good example of why site visits are important. And also like why they can only be a small part of our work. So they're really important because we've been talking for months about aid cuts, [00:33:00] right?

And we're like, what exactly has happened? And in one hour at a health facility, we got more, I feel like I got more concrete information. [Teryn: A hundred percent. I agree.] It's two months. It's these things. It's, you know, HIV testing and this staff had to be reallocated and it's Riders for Health and viral load testing, and it was really concrete.

So yeah, it's really helpful because we get that concrete information and then, I mean, that alone is insufficient, you know? It's like, well what do you make of that? And what does it mean for what we should do differently? And we have no idea . . .

Teryn Mattox: How representative is what we're hearing?

Elie Hassenfeld: Is it representative? What's the humanitarian cost of these health workers doing testing as opposed to being in the community. And in some ways, most importantly, what can we do about it, if anything? Is it a commodity problem or is it a governance problem?

And so being on these visits just enables us to learn things that we wouldn't have learned if we were in, I don't know, at our desk back home. But also just raises questions that are going to take us even longer to try to get to the bottom of. And I think that's a [00:34:00] lot of the point. It's seeing things, asking questions, finding things that are confusing, and then going home and trying to figure them all out.

Teryn Mattox: And asking better questions when we get back to our desk.

Elie Hassenfeld: Yeah.