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    Clubfoot and cleft lip

    Clubfoot and cleft lip: Let every child walk, and smile.

    Of the babies born with clubfoot in poorer countries, only 18% start treatment. Simple casting fixes nearly every foot, for about $530 a child, by GiveWell's estimate.

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    Ryan K. Hertel · heyitskenton

    The problem

    What we're up against.

    • Born every few minutes.

      An estimated 176,476 babies are born with clubfoot every year. Left untreated, they grow up walking on the side or back of the foot.

    • Most go without.

      93% of clubfoot cases are in low- and middle-income countries, where only 18% of babies start treatment: 40,382 children in 2023. GiveWell's newest look agrees: only about a fifth of children who need treatment get it.

    • Not just a question of money.

      Low-income countries reached 31% of babies, while upper-middle-income countries reached only 10%.

    • Clefts are as common.

      In poorer countries, 1 in every 730 babies is born with a cleft lip or palate. About 4.1 million people live with a cleft, and more than 80% of the burden falls on low- and middle-income countries.

    • Distance and stigma.

      In Rwanda, little awareness, cultural beliefs and uneven knowledge among health workers delayed families seeking care.

    What works

    Proven, and ready to grow.

    • The best treatment, by the trials.

      Across 11 randomized trials covering 740 feet, the Ponseti method of gentle casting came out as the best treatment overall.

    • Casting beats surgery.

      Ponseti casting first corrects 96% to 98% of feet, and in the long run 73% have good or excellent results, against 62% after major surgery.

    • It works in Africa too.

      Across African programs, the Ponseti method succeeded for 84.8% of children. At the clinic, it cost about $167 a child, or $22.46 for each healthy year of life gained.

    • Cleft repair is good value.

      Cleft repair was cost-effective in every low- and middle-income study reviewed, though only one was high quality. In one African program, it cost about $62.80 for each healthy year of life gained.

    • Earlier surgery, clearer speech.

      In a randomized trial, repairing a cleft palate at six months instead of twelve cut problems with speech from 15% of children to 8.9%. Surgery on outreach trips is safe in the short run, with complications in 3.3% of procedures.

    What a family could fund

    Where the money goes furthest.

    • Casting through local clinics.

      MiracleFeet supports local clinics, and says treatment costs about $500 a child. It has supported care for more than 130,000 children in 38 countries, by its own count.

    • Checked from the outside.

      GiveWell's own estimate is about $530 a child, from $350 to $3,800 depending on the country. It recommended a grant of $5,210,581, judging the program 8 times as cost-effective as cash, just below its usual bar.

    • Reaching children who had nothing.

      Independent checks found that very few children with clubfoot were being treated before the program, and hundreds have since been enrolled.

    • Training local surgeons.

      Smile Train funds and trains local medical teams in more than 75 countries to give free cleft surgery, at about $400 a surgery, with 2 million surgeries sponsored, by its own count.

    • Surgery with volunteers.

      Operation Smile has treated more than 500,000 patients, by its own count.

    Honest limits

    What money can't promise.

    • Relapse is common.

      About 26.4% of children relapse after Ponseti treatment, and missing the brace is the biggest reason. Followed for ten years or more, 47% relapsed and 79% of those needed more surgery, though most feet still ended up flat and working.

    • Children drop out.

      Only 67% of children got their first brace, and 17.4% were lost to follow-up in African studies.

    • The evidence is weaker than it looks.

      Success rates run from 68% to 98%, depending on how success is measured, and GiveWell calls the evidence relatively weak.

    • A cleft isn't one operation.

      17.5% of children with a cleft palate need a second surgery for speech, and in eastern and central Africa, the typical child waited until age 5.4.

    • Money can't make surgeons overnight.

      Where there are fewer surgeons, clefts weigh more heavily, and in one Ethiopian cohort, 38% of surgeries were canceled, mostly because of infection and malnutrition.

    Hard questions

    Asked and answered.

    1. You might ask

      If a quarter of children relapse, isn't the money wasted?

      Ryan

      No. Relapse is usually treated with more casting or surgery, and most feet still end up flat and working. The answer is to fund bracing support and follow-up as part of the price.

    2. You might ask

      Why fund disability when the same money could save lives?

      Ryan

      GiveWell values sparing a child a lifetime of clubfoot at about 25% of saving a child's life, which puts the program just below its bar for top charities. It's a strong buy for a child's mobility and dignity, if not the most lives saved per dollar.

    3. You might ask

      Aren't fly-in surgical missions a poor model?

      Ryan

      Building local surgical teams gives better value than missions, so a family's initiative funds local surgeons, nurses and speech therapists, not just trips.

    In the slider

    See what your fortune could do here.

    Clubfoot and cleft lip

    The slider prices this cause with these numbers:

    • About $530 treats a child born with clubfoot, with casting and years of bracing, by GiveWell's estimate.
    • The whole need here is the babies born with clubfoot in low- and middle-income countries each year who aren't reached, about 136,000: our arithmetic from the newest global survey.
    • About 26.4% of children relapse, mostly when bracing stops, and clubfoot programs can absorb less than $20 million a year, by one estimate. Cleft surgery is in the chapter, not the slider.
    Try it in the sliderTalk to Ryan

    More of the Blueprint

    Keep reading.

    23 more chapters on the way

    Back to Keep 100

    Sources

    Every number in this chapter, and where it came from.

    1. Source 1: Global clubfoot treatment in 2023: an overview of advances and outcomes (Smythe, Owen, Aspden and others) (opens in a new tab)

      BMJ Global Health, 28 March 2025. Checked 16 October 2026.

      A survey of clubfoot programs in 70 countries.

    2. Source 2: MiracleFeet: Clubfoot Treatment (January 2023) (opens in a new tab)

      GiveWell, August 2023. Checked 16 October 2026.

      GiveWell's own model of the grant, independent of the charity.

    3. Source 3: The global birth prevalence of clubfoot: a systematic review and meta-analysis (Smythe and others) (opens in a new tab)

      eClinicalMedicine, 30 August 2023. Checked 16 October 2026.

    4. Source 4: Cost-effectiveness of club-foot treatment in low-income and middle-income countries by the Ponseti method (Grimes and others) (opens in a new tab)

      BMJ Global Health, 26 May 2016. Checked 16 October 2026.

      Costs from twelve countries in sub-Saharan Africa.

    5. Source 5: April 2026 Update (opens in a new tab)

      GiveWell, 27 April 2026. Checked 16 October 2026.

    6. Source 6: Systematic Review and Meta-Analysis of the Birth Prevalence of Orofacial Clefts in Low- and Middle-Income Countries (Kadir and others) (opens in a new tab)

      Cleft Palate-Craniofacial Journal, 19 July 2016. Checked 16 October 2026.

    7. Source 7: Burden of orofacial clefts from 1990-2021 at global, regional, and national levels (opens in a new tab)

      Frontiers in Pediatrics, 21 March 2025. Checked 16 October 2026.

    8. Source 8: Barriers and delays in access to cleft surgery among children with cleft deformities in Rwanda: a qualitative study (opens in a new tab)

      BMJ Open, 5 January 2026. Checked 16 October 2026.

    9. Source 9: Determining the Optimal Treatment for Idiopathic Clubfoot: A Network Meta-Analysis of Randomized Controlled Trials (Wang and others) (opens in a new tab)

      Journal of Bone and Joint Surgery, 28 November 2023. Checked 16 October 2026.

    10. Source 10: Management of idiopathic clubfoot: an umbrella review and CPAM-LRC consensus (Zhao and others) (opens in a new tab)

      Journal of Orthopaedic Surgery and Research, 26 November 2025. Checked 16 October 2026.

    11. Source 11: Treatment outcome of the Ponseti method for clubfoot in Africa: a systematic review and meta-analysis (Abdu and others) (opens in a new tab)

      Bone & Joint Open, 23 January 2026. Checked 16 October 2026.

      Forty-seven studies from fifteen African countries.

    12. Source 12: A Systematic Review of the Cost-Effectiveness of Cleft Care in Low- and Middle-Income Countries: What is Needed? (opens in a new tab)

      Cleft Palate-Craniofacial Journal, 3 July 2022. Checked 16 October 2026.

    13. Source 13: The impact and cost-effectiveness of the Amref Health Africa-Smile Train Cleft Lip and Palate Surgical Repair Programme in Eastern and Central Africa (Hamze, Mengiste and Carter) (opens in a new tab)

      Pan African Medical Journal, 14 September 2017. Checked 16 October 2026.

    14. Source 14: Timing of Primary Surgery for Cleft Palate (TOPS trial) (opens in a new tab)

      New England Journal of Medicine, 1 August 2023. Checked 16 October 2026.

      A randomized trial with 558 infants, in Europe and South America.

    15. Source 15: Outcomes and Complications of Cleft Lip and Palate Surgery During International Surgical Outreach: A Systematic Review (Abdurrob and others) (opens in a new tab)

      Facial Plastic Surgery & Aesthetic Medicine, 15 July 2026. Checked 16 October 2026.

    16. Source 16: Our Model (opens in a new tab)

      MiracleFeet. Checked 16 October 2026.

      The organization's own account.

    17. Source 17: Evaluating and Funding a New Kind of Grant (Clubfoot Treatment) (opens in a new tab)

      GiveWell, 16 April 2026. Checked 16 October 2026.

    18. Source 18: Smile Train (opens in a new tab)

      Smile Train. Checked 16 October 2026.

      The organization's own account.

    19. Source 19: Impact Report 2023 (opens in a new tab)

      Smile Train. Checked 16 October 2026.

      The organization's own figures.

    20. Source 20: Operation Smile (opens in a new tab)

      Operation Smile. Checked 16 October 2026.

      The organization's own account.

    21. Source 21: Global prevalence, patterns, and predictors of relapse following Ponseti treatment for idiopathic clubfoot: a systematic review and meta-analysis (Ogutu and others) (opens in a new tab)

      BMC Musculoskeletal Disorders, 28 May 2026. Checked 16 October 2026.

    22. Source 22: Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review (opens in a new tab)

      International Orthopaedics, 20 August 2021. Checked 16 October 2026.

    23. Source 23: Assessment of success of the Ponseti method of clubfoot management in sub-Saharan Africa: a systematic review (Smythe and others) (opens in a new tab)

      BMC Musculoskeletal Disorders, 15 November 2017. Checked 16 October 2026.

    24. Source 24: The Rate of Secondary Speech Surgery After Cleft Palate Repair: A Systematic Review (opens in a new tab)

      Plastic and Reconstructive Surgery Global Open, 24 February 2025. Checked 16 October 2026.

    25. Source 25: Global Burden of Orofacial Clefts and the World Surgical Workforce (opens in a new tab)

      Plastic and Reconstructive Surgery, 1 October 2021. Checked 16 October 2026.

    26. Source 26: The Near-Absence of Isolated Cleft Palate in a Surgical Mission Cohort in Ethiopia (Kibe and others) (opens in a new tab)

      Congenital Anomalies, 1 January 2026. Checked 16 October 2026.

      A small study of 150 patients.

    27. Source 27: Economic value of international missions and domestic initiatives to strengthen surgical care in low- and middle-income countries: systematic review (Ifeanyichi and others) (opens in a new tab)

      British Journal of Surgery, 1 December 2025. Checked 16 October 2026.

    28. Source 28: Ponseti Casting for Clubfoot (opens in a new tab)

      GiveWell, December 2022. Checked 16 October 2026.

      A short report. GiveWell says it hasn't checked the funding estimate itself.