African surgeons asked us to devise a solution to their funding problem.

A landmark survey had revealed that most fistula surgeons were beyond the reach of funding organizations.  This presented a big problem – not just for the women who had fistula, but for the people who treated them.  We answered the call with an innovative approach to funding.

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We gave grants to surgeons as they provided evidence of quality care

Most fistula surgeons lack administrative capacity. This means they can’t get traditional funding that requires extensive non-medical reporting.

To bridge this gap, we tied discretionary funding directly to reports on quality of care. Surgeons loved our one-page patient record. Donors loved the 71 data fields of unprecedented visibility we had into every patient’s treatment journey.

Evidence unlocked funds that flowed directly to surgeons, who had discretion to spend the funds however they wanted.

 Our Approach

Our Pilot Program had 3 Goals

Goal 1:

Activate 5 Partnerships in 3 Countries

Goal 2:

Improve Surgical Throughput by 30% in a Year

Goal 3:

Support Treatment for 200 Women with Fistula

We targeted countries with virtually no outside funding.

We wanted to build new capacity, so it was important to look at the places the rest of the fistula funding community had missed. If we could get funding there, we could address one of the major bottlenecks to eradicating fistula. To identify these target countries, we studied public information and mapped out the gaps in fistula funding (countries in orange to the right).


The Results

We Activated 21 Partnerships in 4 Countries

9 of these surgeons received direct funding while the other 12 were funded through partnerships with grassroots organizations and UNFPA Madagascar. Our pioneering partnership with UNFPA Madagascar represented the first time the UNFPA has accepted conditional funding for fistula.

We Improved Surgical Throughput by 39%

In Malawi we improved local surgical capacity by 198% in the first year (from 49 to 146). In Madagascar, we encouraged local surgeons to treat fewer patients and focus on quality improvements. Throughput decreased by 9% over the group of Malagasy surgeons (from 152 to 138). In Mauritania, we had a slight increase in volume over a small number of patients.

We Funded Treatment for 752 Women

This number so significantly exceeded our target because need demanded it. We reallocated budget to treat more patients and even mobilized additional resources to extend the pilot. At the time of writing this report, we continue to receive funding requests.

These Surgeries Had a

Massive Impact

7,956 Years

The number of disability adjusted life years, or DALYs, averted by the surgeries we funded.

In other words, every woman we treated gained back, on average, 10.6 years of healthy life that would otherwise have been lost to living with fistula.

 About DALYs

Our Pilot Program Delivered

Exceptional Value for Money

We aim to maximize the impact of money spent on fistula treatment.

In our project, we gave $142,592 in grants and spent an additional $73,909 delivering the program, bringing our total costs to $216,501. We use two indicators to evaluate our project’s value for money: efficiency and cost-effectiveness.


Efficiency refers to cost per unit of output. Our output is the 752 patients treated. To calculate efficiency, we divide our grant and total costs by the 752 patients.


Cost-effectiveness refers to the cost per unit of impact created. Our surgeries averted years of disability that the patient would have lived with had they not had the surgery. The number of years averted by our 752 surgeries totals 7,956. To calculate cost-effectiveness, we divide grant and total costs by the 7,956 DALYs averted.