Introducing Ansh: A Charity Entrepreneurship Incubated Charity

By Supriya, Sami Kassirer @ 2024-05-29T13:00 (+151)

Executive Summary

Ansh, a 1-year-old Charity Entrepreneurship incubated charity, has been delivering an evidence-based, scientifically proven intervention called Kangaroo Care to low birth weight and premature babies in 2 government hospitals in India since January 2024. Ansh estimates that their programs are saving, on average, 4 lives a month per facility and a total of 96 lives per year. The cost of one life saved is approximately $2077 (current costs, not a potential estimate). Ansh is now replicating the programs in two additional hospitals, doubling their impact before the end of this year.

According to the World Health Organization (WHO), neonatal conditions^[1] are among the top 10 causes of death worldwide^[2]. This makes neonatal mortality one of the largest-scale causes of suffering and death today. In 2022, 2.3 million babies died in the first 28 days of life (i.e. the newborn/neonatal period) (World Health Organisation, 2024). Let’s compare that number to one of EA’s other top cause areas. In 2022, 608,000 people died of malaria, which is about 26.4% lower than neonatal conditions. However, we have a cost-effective, scalable model for preventing malaria-caused death (e.g., with AMF and Malaria Consortium). Unfortunately, there has been no equivalently cost-effective and scalable model for preventing neonatal mortality. 

In this post, we will introduce Ansh, a 1-year-old Charity Entrepreneurship incubated charity that is working towards building tractable, scalable solutions to neonatal mortality in low- and middle-income countries (LMICs). 81% of neonatal deaths happen in low and Low-Middle SDI countries. The disparities in mortality rates between low and high-resource contexts suggest that most neonatal deaths are preventable. In the sections below, we will first introduce Ansh and its mission statement, share our results thus far, and then introduce some of our plans for how to increase our reach and impact over the next few years. We are very excited to share the work we’ve done so far with the EA community, and to hear your constructive feedback on how we can make our non-profit even more impactful!

I. The Problem and Solution

More than half of all neonatal deaths occur within the first three days after birth (Dol J, 2021) and over 75% in the first week of life (WHO, 2024), making it imperative to reach babies as soon after birth as possible. Moreover, low birth weight (LBW)^[3] is considered the number one mortality risk factor for children under 5. In fact, according to the Global Burden of Disease, around 89% of all newborn deaths in India (the country where about 22% of all newborn deaths in the world occur) happen to LBW and preterm newborns. Further, 81% of all newborn deaths occur in Low or Low-Middle SDI countries (Global Burden of Disease Collaborative Network, 2019). Hence, the most effective path toward reducing neonatal mortality rates globally lies in developing interventions aimed at helping LBW babies during their first week of life in LMIC contexts.

Thankfully, such an intervention exists: Kangaroo Care. Kangaroo Care (KC) needs neither fancy equipment nor expensive technology—the methods of KC are both simple and highly effective, especially for LBW newborns. KC requires early, continuous, and prolonged skin-to-skin contact between the mother (or another caregiver) and the baby for about 8 hours of contact per day–paired with exclusive breastfeeding and close monitoring of the baby. This is often assisted with a cloth binder, between the LBW newborn and caregiver (preferably the mother), to allow for mobility. Estimates from the 2016 Cochrane review suggest that KC can reduce LBW neonates' chance of (i) sepsis by 50%, (ii) hypothermia by 72%, and (iii) mortality by 33%.

II. Introducing Ansh

Ansh, a Charity Entrepreneurship incubated charity, is dedicated to saving newborn lives by building a scalable and cost-effective model that implements Kangaroo Care (KC) and other impact-focused newborn care practices^[4]. Our model includes building healthcare capacity by closely working with the hospital on making KC services long-term and sustainable.

We are starting by working with two government district hospitals in Rajasthan, India. The healthcare facilities we chose have huge delivery loads - one of the district hospitals handles around 6,600 deliveries per year and is the main government hospital for the district population of around 1.2 million people. The other district hospital handles over 10,800 deliveries a year, serving a population of around 2 million people. This makes them extremely cost-effective to work in. Further, the high rate of institutional births in Rajasthan (95% of all births in Rajasthan take place in institutions) makes institutional partnerships a reliable and tractable way to reach babies in this context.  

We include a summary of our implementation model, below:

1. Hospital partnership: Identify and secure permissions to operate in a suitable district hospital.
2. Staff onboarding: Once granted, we assemble a dedicated team consisting of (i) a program coordinator, (ii) an M&E coordinator, and (iii) a team of skilled nurses (around 11-12 per hospital).
3. Staff training: 3-day training for nurses to ensure proficiency in KC practices with regular weekly sessions for additional training and feedback.

4. Set up of the KC facility: Rather than establishing a separate KC ward, we instead help to equip existing maternity sections^[5] with necessary items like KC chairs, weighing scales, and KC wraps.

5. Registration: Register and initiate KC immediately following delivery with LBW babies and/or premature babies.
6. Counseling and Monitoring: We also support mothers by offering breastfeeding advice, monitoring their baby’s vital signs every four hours, and offering extensive counseling on over 20 common danger and distress signs in babies.
7. Referrals: Refer babies to the outpatient care department or intensive care units when and if they exhibit danger and distress signs and work with the hospitals to delay the discharge of unstable and very LBW babies.

8. 1-month follow-up: After discharge, conduct four telephonic follow-ups until the baby reaches one month of age, ensuring continued care and support^[6].

9. Monitoring and Evaluation: Our monitoring and evaluation (M&E) coordinators (one per hospital) continuously monitor the programs and survey the mothers and babies in our program.^[7] 

In addition to these 9 core procedures, our program extends its support to include:

1. Breastfeeding counseling for non-KC patients, especially when a mother and a baby are found struggling.
2. Group counseling sessions across different wards to provide comprehensive education on basic neonatal practices.
3. Building strong relationships with hospital stakeholders to leverage data-driven insights for implementing hospital-level changes. Our efforts sometimes lead to increased compliance with government policies on discharge, neonatal care, Infection Prevention and Control, and overall higher quality of care for mothers and babies.
4. Building a KC movement by identifying KC champions who would be willing to talk about KC in their villages.
5. Encouraging better community healthcare by informing mothers on how they can request a visit from a community health worker at their homes after discharge. This is done 4 times for all mothers.

III. Our Impact To Date

Ansh ran a pilot program in two district hospitals in the state of Rajasthan, India (population 68.5 million) from January to March 2024. The programs continued running after the pilot completed and, since January 2024, have delivered the KC interventions to over 900 LBW and premature babies.

Baseline Neonatal Mortality

The first step in estimating our impact is establishing a baseline of neonatal deaths in the hospitals we are operating in. This will provide us with a counterfactual and allow us to estimate the difference we can make (or marginal impact; MacAskill, 2015, pg. 70).

We estimate the baseline neonatal mortality (mortality before the implementation of the programs) in two ways:

1. District-Based Estimation: We start with the Neonatal Mortality Rate (NMR) of the district and make adjustments for the prevalence of LBW and the proportion of neonatal deaths attributed to LBW and premature newborns. While this method provides a broad estimate, it has limitations due to its reliance on generalized district-level data rather than specific hospital-level figures.
2. On-the-Ground Data Collection: We gather more specific and accurate data by contacting mothers who delivered LBW and premature newborns before the programs started at the hospitals we collaborate with. This method tends to be more reliable. However, it still faces challenges: not all mothers were reachable and not all LBW babies were contacted (we prioritized less than 2000g at this stage).

While both methods have their inherent limitations, we are fairly confident that the mortality is more than 13%, as we have ourselves confirmed that at least 13% of newborns had passed away in some of our baseline data groups (all estimates are between 13% and 27%).

All of our impact estimates in the remainder of this post use 13% neonatal mortality as our baseline, to be conservative when estimating our impact.

Lives Saved

Every month, around 100 babies per hospital, on average, are enrolled in Ansh’s KC program. Using our above estimate, 13% of LBW and premature newborns in these hospitals do not survive past 28 days. This translates to approximately 13 LBW and premature babies dying each month, if they were to receive no KC intervention.

As stated earlier, Cochrane review suggests that the mortality reduction from KC, when compared to incubator care, to be 33%. Hence, implementing KC in just these two hospitals should save at least 4 babies per month^[8].

However, these are our very conservative estimates. The predicted 33% reduction doesn’t take into account the 69% of babies in our context who would have never gotten incubator care. Although we understand the researchers’ desire to compare KC to a strong counterfactual, in LMIC contexts, the counterfactual to KC is often no care. Further, the Cochrane studies were done on stable babies. However, 31% of our babies were unstable and in intensive care units (NICU/SNCU). Following the evidence on Immediate KC (i.e. starting KC as soon as possible after birth) for newborns with a birth weight between 1.0 and 1.799 kg (i.e. meeting criteria for admission in NICU/SNCU) irrespective of clinical stability, decreases neonatal mortality by an additional 25% (WHO Immediate KC Study Group, 2021). Finally, in addition to providing the basic KC practices, Ansh (i) refers sick babies to proper medical staff, (ii) counsels mothers and families on basic neonatal practices and more than 20 danger signs, and (iii) provides each KC baby with a TempWatch^[9].

Based on these factors, we believe that Ansh’s program can reduce neonatal mortality by at least 50%^[10].

Cost-Effectiveness 

Assuming that we are saving on average 4 lives a month per facility (our most conservative guess using 13% baseline mortality and 33% mortality reduction from Cochrane Review), our most conservative estimated cost of one life saved is approximately $2077.

Below, we provide a breakdown of all of our costs of running the charity, and walk through how we arrived at our cost-per-life-saved estimate: 

• Setup Costs: Each hospital incurs a one-time setup cost of $4,500, total $9000 for two hospitals. This includes procuring KC chairs, backrests, training costs, weighing machines, nurse uniforms, IEC printing, laptops, and tablets for data collection.
• Hiring and Facility Management: Hiring, procurement of KC materials, and other facility running costs add up to $5,000 monthly, i.e. $60,000 annually per hospital and $120,000 for 2 hospitals.
• M&E Costs: Monitoring and Evaluation activities cost around $7,200 a year per hospital and $14,400 for two hospitals.
• Core Team Costs: Currently the core team and other expenses add up to $56,000 per year.

While working in just two hospitals, the total expenses of the charity adds up to $199,400, with the hospital expenses being $129,000 to provide KC to a total of about 2,400 babies per year. Given these expenditures, the cost per baby treated currently is approximately $83, which should significantly go down at scale^[11]. Further, we estimate that 13% of these 2,400 babies (312 LBW and premature newborns) would not make it past 28 days without KC, and that KC can save 33% of those 312 newborns, saving around 103 newborns per year.

Altogether, our current operating costs can save, at minimum, 103 lives per year. This equals a cost of $2077 per life saved. Returning to our opening comparison of AMF, GiveWell suggests that it costs between $3,000 and $8,000 to save a life with insecticide-treated bednets. Our most conservative estimate is nearly ⅔ of the cost of bednets' most aspirational estimate.

IV. Our Plans For The Future

Although we are very excited by our numbers–both the number of babies our program can save and the cost-effectiveness of our program–we are continuously working to maximize our impact. Currently, our two main paths towards further improving our impact and cost-effectiveness are through (1) improving KC via collaborations with behavioral scientists and (2) scale up our programs.

(1) KC Improvements 

The empirical evidence of KC’s benefits involved the practice of skin-to-skin contact–where a newborn is held bare against a parent’s chest–for 8 hours per day. However, in practice, we have found that having mothers (and other caregivers) hold one’s baby for 8+ hours can be difficult to implement. On average, right after delivery, our newborns were able to receive 4-5 hours of KC per day. However, the KC hours did increase with time, for both the unstable babies in the hospital after a few days of stay, and at home after discharge. Over 70% of mothers reported consistently doing 8 hours or more of KC during follow-ups^[12]. And our benefits speak for themselves: even this amount of KC appears to save a huge amount of newborns' lives. However, the full potential benefits of KC are likely not yet being realized. We expect that a higher adherence to KC practices could make our impact even larger.

To improve mothers’ adherence to KC practices, we sought out help from a behavior change scientist. Specifically, we have begun working with Dr. Samantha (Sami) Kassirer, a fellow effective altruist, who is an expert in behavioral science, social psychology, and global poverty and inequality. Dr. Samantha has extensive research on recipients' reactions to aid and the psychological and economic barriers to the take-up of valuable aid programs, making her an ideal expert to help us improve KC adherence. She is helping us to identify the primary barriers to mothers participating in KC, both in the hospital and once they return home with their babies. She recently conducted 9 in-person semi-structured interviews (averaging 40 minutes per interview) with mothers in our 2 hospitals and has developed testable hypotheses for how to increase mothers’ participation in KC.

Currently, she is working with us on developing randomized-controlled trials (RCTs) to test two interventions: one in the hospital setting and one in the household setting. For one of the projects, Dr. Ashley Whillans–an associate professor in Negotiations, Organizations, and Markets at Harvard Business School and a world expert on time poverty–will be joining our team and working with Dr. Samantha to develop RCTs in the household setting (i.e., targeting the barriers that prevent mothers from continuing KC once they return home). These interventions are psychological in nature and will be extremely cost-effective to implement. We expect that this EA academia-charity collaboration will help us to save even more babies' lives with a similar amount of resources.

(2) Scale Up

Currently, we are in 2 hospitals, providing our intervention to around 200 babies every month. We are scaling up to two additional hospitals in the next few months, doubling the number of babies reached while also building relationships with the state government of Rajasthan. We estimate there are approximately 16 more districts (just in the state of Rajasthan) that could be similarly (or more) cost-effective as our current districts. We plan to scale up our programs in all these high-burden districts of Rajasthan by the end of next year.

Post that, we plan to explore having our KC nurses hired by the government and the hospitals (significantly reducing our operation costs), with us providing technical expertise and doing M&E and quality assurance activities in the long run. 

At this stage, we hope to have learned from working with the state government in Rajasthan and use that to initiate rapid scale-ups in other states like Bihar and Madhya Pradesh. By the end of year 5, we want to scale up in all high-priority states of India. After year 5, we plan to move towards our endgame of complete national government funding and implementation for all the high priority districts in high priority states. If we are able to pivot towards a model of government funding and implementation, Ansh’s role would be to provide technical assistance and monitoring in existing hospitals. This would allow us to focus on actively expanding to other countries that have both high neonatal mortality rates and a similar healthcare system (such as Nigeria and Pakistan).

Please reach out to us at supriya@ansh.health if you would be interested in supporting us through research collaborations, funding for 2025 or by volunteering for us.

V. Acknowledgments and Partnerships

We are immensely grateful to our partners and supporters whose contributions have been vital to our endeavors. Dimagi, our pro-bono partner, developed our applications for digital collection of Kangaroo Care and monitoring data, enabling us to streamline and enhance our processes. Ansh is jointly implementing programs in Rajasthan in collaboration with Sahaj Sansthan. Kangaroo Mother Care India Foundation generously provided pro-bono training for our nurses, and a team of Indian pediatricians as our major advisors. We also extend our heartfelt thanks to Charity Entrepreneurship (now Ambitious Impact), Founders Pledge and our individual donors, whose generous funding supports the core of our work.

1. ^{^}

    Neonatal conditions include birth asphyxia and birth trauma, neonatal sepsis and infections, and preterm birth complications.

2. ^{^}

    Estimates come from data collected in 2019, and can be found here: https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death.

3. ^{^}

    LBW is defined as having a birth weight between 1.0 and 2.500 kg.  

4. ^{^}

    These practices include: (i) breastfeeding, (ii) monitoring of danger signs, (iii) infection prevention and control (IPC) measures, and (iv) counseling in best newborn care practices.

5. ^{^}

    These include Neonatal Intensive Care Units (NICUs), Special Newborn Care Units (SNCUs) and Postnatal Care wards (PNCs).

6. ^{^}

    From registration to follow-ups, the data is tracked and collected on our Dimagi application.

7. ^{^}

    Our full-time M&E coordinators conduct comprehensive assessments and oversight activities to enhance the quality and effectiveness of the program. Their primary duties include (i) interviewing mothers about their care experiences (170 interviews just during the pilot), (ii) reporting on Infection Prevention and Control (IPC) practices within the hospital and the KC program, and (iii) observing (a) cases, (b) follow-up calls, (c) counseling sessions, and (d) weighing procedures (iv) helping with impact evaluation by collecting baseline data and coverage data. Additionally, they have begun conducting skill assessments for mothers before and after their participation in the KC program to gauge the effectiveness of our counseling. M&E coordinators also play a critical role in identifying and reporting systemic issues that could impact program outcomes. For instance, they have reported problems such as significant rat infestations that disrupt the work environment for nurses, and discrepancies in discharge policies that may contravene government guidelines and result in the premature discharge of unstable newborns. We then try to influence hospital stakeholders to resolve these issues.

8. ^{^}

    A 33% reduction from the lower end of the mortality rate (13%) would save about 4 lives per month and a 33% reduction from the higher end (27%) would save about 9 lives per month.

9. ^{^}

    A TempWatches is a device that continuously monitors the baby's temperature for a month. One research study found a significant mortality reduction in the intervention group that received TempWatch as compared to the control group (6% vs. 14%, p = .013).

10. ^{^}

     A 50% reduction from the lower end of the mortality rate (13%) saves about 7 lives per month per hospital; a 50% reduction from the higher end of the mortality rate (27%) would save about 14 lives per month per hospital.

11. ^{^}

    We estimate that it will cost between $1100 and $1600 to save a life at a scale of 20 similar hospitals.

12. ^{^}

     We collect data points on various protocols of KC, including, but not limited to time of initiation of KC, skin-to-skin contact hours for every day the baby stayed in the hospital, exclusive breastfeeding at 28 days of age, type of support, resources and education provided and weight gain. Our Impact Evaluation Report digging deeper into all these factors will be released in the next few months.