International Rescue Committee — Acute Malnutrition Treatment in Burkina Faso, Chad, Democratic Republic of the Congo, Niger, and Somalia (January 2024)

Note: This page summarizes the rationale behind a GiveWell grant to the International Rescue Committee (IRC). IRC staff reviewed this page prior to publication.

Published: April 2024

Summary

Background

In 2021, we recommended grants totaling approximately $20 million to support the IRC's work on the treatment of acute malnutrition in Burkina Faso, Chad, the Democratic Republic of the Congo (DRC), Niger, and Somalia for three years.

What we think this grant will do

This grant will support one additional year of programming in these locations. With these grants, we expect the IRC to support government-run outpatient malnutrition treatment centers and inpatient malnutrition clinics through activities such as providing training and mentoring to government staff and procuring medical supplies. In Somalia, we also expect the IRC to support a broader set of child and maternal health interventions. (More)

We expect to decide whether to further renew support for these activities later in 2024, after we receive additional program monitoring and survey data from the IRC. If we decide not to further renew our support, this grant will serve as exit funding to cover the cost associated with wrapping up the program or looking for alternative funders.

Why we recommended this grant

• We recommended this grant to provide the IRC with funding visibility while we decide whether to renew our support for an additional year.
  • We estimate that, overall, the IRC's programs in these countries are around eight times as cost-effective as unconditional cash transfers ("8x cash"), the benchmark we use for cost-effectiveness. This is close to 10x cash, our cost-effectiveness bar for recommending grants.1 Given the programs' proximity to the bar, we think it's plausible that one or more of these five countries will meet or exceed our cost-effectiveness bar when we update our cost-effectiveness estimate for the IRC's work later this year.

    The main reasons we think this grant is likely to be around our cost-effectiveness bar are that we think:

    • Children with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are at greatly elevated risk of dying compared to non-malnourished children. Depending on location, we estimate that the mortality rates of children with untreated malnutrition were 3% to 12%. Our estimates are based on Institutes for Health Metrics and Evaluation and Demographic and Health Surveys Program estimates of under-5 mortality rates, local malnutrition prevalence surveys, and a pooled analysis of historical data that estimates the risk of excess mortality associated with untreated MAM and SAM. (More)
    • Children who are malnourished are significantly less likely to die if they receive treatment. We estimate that MAM treatment reduces the relative risk of mortality over the next year by about 40% and SAM treatment reduces it by about 70%. This is based on the pooled analysis of historical data referenced in the previous bullet point. Together with our estimate of the mortality rates of malnourished children, this implies that malnutrition treatment reduces mortality by one to eight percentage points, depending on the program location and the severity of malnutrition. (More)
    • The IRC's support for malnutrition treatment programs in government-run health facilities leads to more children being treated for malnutrition. We estimated that the IRC's program would increase the number of children who receive malnutrition treatment by ~42,000 over one year. This is based on the IRC’s estimates of the number of cases it aims to treat over the proposed grant renewal period and the IRC’s estimate of the percent of children who would have received malnutrition treatment in the absence of the organization's program. (More)
  • We have several uncertainties about our cost effectiveness estimates. We expect to make progress on two of these uncertainties (the number of children who would have received malnutrition treatment with and without the IRC, and malnutrition treatment coverage with the IRC), through IRC program monitoring and coverage survey data we will receive later in 2024. (More)

Here is a sketch of our cost-effectiveness model, using annualized projections for a three-year grant renewal in Burkina Faso as an example.

Main reservations

• We're uncertain about the extent to which we will learn from the IRC's program monitoring and coverage survey data later in 2024. We're uncertain about whether this data will reduce our uncertainties about the cost-effectiveness of this portfolio because the data might be affected by one-off shocks (like stockouts of the therapeutic food used to treat malnutrition) that limit their generalisability across years. (More)
• We're uncertain about the risk of death among malnourished children and the effect malnutrition treatment has on mortality. We do not have any direct evidence of the mortality rates of untreated children with malnutrition and we're highly uncertain about our method for estimating the effect that malnutrition treatment has on mortality. This leads us to be particularly unsure about our cost-effectiveness estimate for malnutrition treatment programs, including the IRC's. (More)

The organization

The International Rescue Committee (IRC) is a large international NGO that works in more than 40 countries to address humanitarian crises.2 The IRC's program areas include economic well-being, education, and health.3 The IRC provides technical assistance to support acute malnutrition treatment in more than 30 countries.4

In 2021, we recommended grants of ~$20 million to support the IRC's work on the treatment of acute malnutrition in Burkina Faso, Chad, the Democratic Republic of the Congo (DRC), Niger, and Somalia for three years.

The intervention

The IRC supports the treatment of acute malnutrition in government facilities. Acute malnutrition refers to excessive thinness for one's height and/or the presence of nutritional edema, or swelling caused by excess fluid retention in tissues.5 Acute malnutrition is believed to raise the risks of developmental delays and death from infectious disease.6

Malnutrition treatment is provided by identifying children experiencing malnutrition and providing them with ready-to-use therapeutic food (RUTF) in an inpatient or outpatient setting. Children experiencing severe acute malnutrition (SAM) are also given a course of antibiotics to reduce infections.7

The IRC aims to increase the coverage and quality of malnutrition treatment by supporting the governments in the countries where it works. The IRC's work generally falls under the umbrella of "community-based management of acute malnutrition," or CMAM, which identifies and treats cases of uncomplicated malnutrition primarily on an outpatient basis (for more details, see our report on CMAM). Our understanding is that the IRC's program activities vary by country.8 However, activities funded by these grants fall into four major categories:

1. Supporting government-run outpatient malnutrition centers. The IRC's activities include training and mentoring government staff,9 including training community health volunteers to identify malnourished children and providing cascading training for caregivers on the Family MUAC (mid-upper arm circumference) approach,10 procuring equipment and medical supplies,11 and enhancing service provision in hard-to-reach areas by leveraging other healthcare platforms or by utilizing mobile clinics.12
2. Supporting government-run inpatient malnutrition clinics. The IRC's activities include training and mentoring government staff, providing medical supplies, refurbishing facilities, providing human resources, and setting up a referral system from outpatient centers.13
3. Supporting government planning. The IRC expects to help government partners predict changes in malnutrition caseload and plan resources accordingly by training health staff in CMAM Surge (an approach developed for this purpose) and/or by supporting government officials' review of the performance of malnutrition programs.14
4. Data collection. The IRC will conduct annual coverage surveys15 and will collect individual-level data on children treated, including data on age, status at admission, and discharge.16

In Somalia, the IRC will provide a broader set of child and maternal health interventions.17 We expect that some activities supporting care for some non-malnourished children may take place in other grant locations, though to a lesser extent.18 We included benefits of treatment to non-malnourished children in our cost-effectiveness model for Somalia, but not for other locations.19 In addition, Somalia is the only location supported by this grant in which the IRC plans to treat children with MAM.

Does malnutrition treatment work?

Our primary outcome of interest is the impact of CMAM on all-cause mortality in children 6-59 months old with malnutrition, relative to no treatment. We have not found direct estimates of this outcome, since it is widely considered unethical to study children with malnutrition without providing treatment.20

We use historical observational data on the mortality rate of children with untreated malnutrition, relative to children without malnutrition, to estimate the mortality rate of children with untreated malnutrition and the impact of CMAM on mortality.21 Additional inputs into our cost-effectiveness calculations include current local all-cause mortality rates and the prevalence of malnutrition, as well as several adjustments to account for key limitations of these estimates.22

This estimation method has major limitations but suggests that MAM treatment reduces all-cause mortality by about 40% over the following year, and SAM treatment reduces all-cause mortality by about 70%.23 Paired with the program’s highly plausible mechanism of action,24 we believe CMAM is very likely to avert child mortality, but we are uncertain about the size of the effect. This is discussed in greater detail in our malnutrition intervention report.

The grant

We are recommending a $7,485,323 grant from Open Philanthropy to support one year of IRC programming in Burkina Faso, Chad, the Democratic Republic of the Congo, Niger, and Somalia. The activities we expect the IRC to carry out with this funding are described above.

If we decide not to further renew our support for the IRC, we expect this grant to serve as exit funding, with which the IRC can look for alternative funders or exit the program responsibly.

Budget for grant activities

The budget for each country is between $1.1 million and $1.6 million per year. A detailed budget breakdown is available here.

The case for the grant

We are recommending this grant because:

Funding visibility for the IRC

We expect to use information from forthcoming IRC program monitoring and coverage survey data to refine our cost-effectiveness estimate and inform whether we want to renew our support for the IRC's program in these locations for another year. We expect to receive this information in March 2024.

Our 2021 grant funding will run out in August 2024, so providing funding for one additional year of programming now will give the IRC funding visibility as we consider whether to further renew our support later in 2024.

Cost-effectiveness

We estimate this grant is close to our cost-effectiveness bar. We estimate that, overall, the IRC's programs across these five countries are approximately eight times as cost-effective as unconditional cash transfers ("8x cash"), the benchmark we use for cost-effectiveness. At the time we recommended this 2024 renewal grant, our cost-effectiveness bar for recommending grants was 10x cash. Given the programs' proximity to the bar, we think it's plausible that one or more of these five countries will meet or exceed our cost-effectiveness bar when we update it later this year.

The section below details key inputs to our most recent cost-effectiveness analysis for IRC's programs.

Key inputs

Mortality rates among targeted children

Children with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are at greatly elevated risk of dying compared to non-malnourished children. Depending on the country, our estimates of the mortality rates of children with untreated malnutrition range from 3% to 12%.

We calculated these mortality rates in two steps. First, we formulated an initial estimate based on:

• Mortality ratios that our consultant David Roodman calculated on the basis of observational data from the 1980s and 1990s. In these locations, we estimated that children with untreated MAM are ~2.5 times more likely to die than children without malnutrition over a one-year period following measurement of their weight and height.25 We estimated that children with untreated SAM are ~7 times more likely to die.26 We describe the method we use for calculating these ratios in more detail in our malnutrition intervention report.
• The local prevalence of untreated SAM and MAM. We estimate this on the basis of point-in-time estimates of the prevalence of malnutrition and malnutrition treatment coverage estimates.
• Local population-wide under-5 mortality rates. We calculate these on the basis of under-five mortality rates from Institute for Health Metrics and Evaluation (IHME) and nutrition surveys, and our estimate of the percentage of those deaths that occur in the 6-59 month age bracket.

For more details, see this section of our malnutrition intervention report.

Then, we developed a "ceiling analysis" to check whether this initial estimate passed a plausibility check. If it didn't, we applied a discount to account for that. The intuition behind the plausibility check was that there is a constrained relationship between total under-5 mortality rates, malnutrition mortality rates, and malnutrition incidence that is not reflected in our initial estimate. This meant that our model could return malnutrition mortality rates that are unrealistically high, given the amount of malnutrition in a population and its overall mortality rate. Our ceiling analysis accounted for this constrained relationship. This analysis implied that our initial estimate of mortality rates was indeed unrealistically high in the locations targeted by these grants. To address this, we discounted the initial mortality rates by 0% to 55%, depending on location. We describe the method we use for calculating this ceiling in more detail in our malnutrition intervention report.

Malnutrition treatment effect on mortality

Children who are malnourished are significantly less likely to die if they receive treatment. We estimate that IRC's MAM treatment reduces the relative risk of mortality over the next year by about 40% and SAM treatment reduces it by about 70%.27 Together with our estimate of the mortality rates of malnourished children, this implies that malnutrition treatment reduces mortality by one to eight percentage points, depending on the program and the severity of malnutrition.28

To estimate the impact of malnutrition on mortality in our CEA, we use observational studies conducted in the 1980s and 1990s to generate a mortality ratio that represents the comparison of average weight-for-height z-score (WHZ), a measure of malnutrition, before and after malnutrition treatment.29 WHZ inputs come from a literature review of the impact of malnutrition programs on WHZ, adjusted for differences in recovery rates between government-only and NGO-supported malnutrition programs. For more details, see our intervention report on community-based management of acute malnutrition (CMAM).

For the IRC's program, we also apply a 15% discount to account for internal and external validity concerns that we have not explicitly modeled.

Additional number of children treated as a result of the IRC's work

The IRC's support for malnutrition treatment programs in government-run health facilities leads to more children being treated for malnutrition. We estimate this on the basis of the number of children we estimate that the IRC will reach (around 9,000 to 14,000 children per year, depending on the country) and the percent of children we estimate would have received malnutrition treatment in the absence of the IRC's program (1% to 40%, depending on the country). In total, we estimate that the IRC's program would increase the number of children who receive malnutrition treatment by ~42,000 over one year.30

• We estimate this based on the IRC's estimate of the number of cases it will treat, which we take at face value. We take these at face value because the IRC’s estimates for year one caseload were roughly right across its portfolio.31
• As noted in the previous bullet, we sense-check these numbers by comparing them to the IRC's caseload in the first year following our 2021 grant. Our estimates for how many children the IRC will reach with this grant are 100% to 160% of their caseload in the first year. This seems reasonable to us because we expect the IRC to improve its coverage over time, as it learns more about bottlenecks to treatment.
• We adjust our estimates downward by 15% to account for our expectation that the number of children treated will be lower than caseload due to some children being treated more than once.

• We base this on estimates that the IRC provided to us in October 2023.32 We take the IRC's estimates largely at face value, since we do not have additional quantitative data on which to base our estimates in four of the five countries.
  • We do not have year one coverage surveys for Chad, the Democratic Republic of Congo, and Somalia.
  • We do have a year one coverage survey for Niger, but we don't think it's very informative of future coverage because there were widespread RUTF stockouts prior to the survey, which we think may be a one-off shock rather than a persistent issue.33

We expect to make progress on two of our uncertainties about IRC's cost-effectiveness

For the second year of the program we supported, the IRC is conducting coverage and prevalence surveys across all five countries. We expect to use this information to make progress in understanding two of our key uncertainties regarding the IRC's cost-effectiveness:

• The number of children who would have received malnutrition treatment with and without IRC
  • Number of children who would have received malnutrition treatment with the IRC. The number of malnourished children reached informs our estimate of the cost per child reached, and so our overall cost-effectiveness estimate for the program is relatively sensitive to this input.

    As described above, our current estimates rely heavily on the IRC's estimates of caseload, which we've sense-checked against data from the first year of IRC's program. We expect that having an additional year of caseload data will improve our assessment of whether IRC estimates are reliable.

  • Percent of children who would be treated without the IRC. We think the primary benefit of the IRC's program is to cause malnourished children who wouldn't otherwise be treated to receive treatment. Our cost-effectiveness model is very sensitive to our estimate of the percent of children that would have received treatment without the IRC.

    Right now, we have baseline data on coverage without the IRC in locations where the IRC was not previously working: Burkina Faso, the Democratic Republic of the Congo, and two districts across Niger and Chad. However, we only have reliable coverage data for the first year of the program in Burkina Faso (see above). Having coverage data for the second year of the program in these locations will enable us to roughly estimate the percentage of malnutrition cases that would be treated in the absence of IRC support (assuming that baseline coverage rates remain constant). We can then compare these against the IRC's estimates, which we're relying on for Chad, the Democratic Republic of the Congo, Niger, and Somalia, and refine our estimates.

• Malnutrition treatment coverage with the IRC
  • Coverage rates are an important input into our calculations for the ceiling analysis that puts a cap on annual mortality among untreated malnourished children. All else equal, higher coverage rates imply a lower cap on this mortality rate, increasing estimated cost-effectiveness.

We expected to receive this data in March 2024 and to use it to refine our cost-effectiveness estimates.

Risks and reservations

Our main reservations about this grant are:

We're uncertain of the extent to which we will learn from program monitoring and survey data

We are uncertain about whether this data will reduce our uncertainties about the cost-effectiveness of this portfolio, because the data might be affected by one-off shocks (like stockouts of RUTF, the treatment for malnutrition) that limit their generalizability across years.

When we recommended the 2021 grant, we planned to learn about the IRC's effect on coverage by measuring baseline and year-to-year coverage in targeted areas that did not have NGO support at baseline (Burkina Faso, the Democratic Republic of Congo, and one district each in Chad and Niger).34

However, we now think that coverage may fluctuate significantly each year due to external shocks. The IRC told us that it now estimates lower counterfactual coverage in Chad and the Democratic Republic of the Congo in year 1 than at baseline due to insufficient RUTF stock35 and that the coverage rate from its year one survey in Niger is unreliable due to widespread RUTF stockouts prior to the survey.36 This decreases our confidence in the learning value of this grant.

We're uncertain about the risk of death among malnourished children and the effect malnutrition treatment has on mortality

We do not have any direct evidence of the mortality rates of untreated children with malnutrition. This is different from most other child health programs we support, where we have direct estimates of the program’s effectiveness, usually from a number of randomized controlled studies. We instead rely on historical observational studies to inform our estimate. You can read more in our intervention report on community-based management of acute malnutrition (CMAM).

We're also highly uncertain about our method for estimating the effect that malnutrition treatment has on mortality. As above, we discuss this in more detail in our intervention report on community-based management of acute malnutrition (CMAM).

These contribute to a high level of uncertainty about our cost-effectiveness estimate for malnutrition treatment that we do not expect to resolve with this grant.

Plans for follow up

We're expecting to receive coverage and prevalence surveys from the second year of the IRC's program in March 2024. Using this information, we expect to make a decision later in 2024 about whether to provide additional funding to the IRC to support this work, or to wrap up our support.

Internal forecasts

For this grant, we are recording the following forecasts:

Our process

• We made an initial three-year grant to the IRC in 2021 to support its work in Burkina Faso, Chad, the Democratic Republic of the Congo, Niger, and Somalia.
• In 2022, we updated our cost-effectiveness model.
  • For our 2021 grant, we primarily relied on a widely-used meta-analysis, Olofin et al. 2013, to estimate mortality among untreated malnourished children. After making our 2021 grant, we hired an external consultant to reanalyze the meta-analysis. His work implied less mortality from malnutrition than Olofin et al. 2013. We updated our model to incorporate his work, which is described in more detail in our malnutrition intervention report.
  • We also created a separate model to estimate the maximum plausible mortality rates of malnourished children, given malnutrition incidence and overall mortality rates in the targeted areas (a "ceiling analysis"). We use this analysis to adjust our cost-effectiveness estimates for malnutrition treatment programs. For more about the ceiling analysis, see our malnutrition intervention report.
• As part of our investigation into potential renewal grants, we updated our cost-effectiveness model based on new data from IHME and additional information we received from the IRC.
• We requested the IRC's feedback to our model updates, and reviewed the feedback to confirm that it did not suggest substantive upward adjustments to our cost-effectiveness estimates.

Relationship disclosures

Justin Labeille, a former GiveWell staff member, works for the IRC.

Sources

• 1

  Our cost-effectiveness bar was 10x cash in January 2024, at the time this grant was recommended. Our cost-effectiveness bar can change over time.

• 2

  "The International Rescue Committee responds to the world's worst humanitarian crises and helps people whose lives and livelihoods are shattered by conflict and disaster to survive, recover and gain control of their future. In more than 40 countries and over 20 U.S. cities, our dedicated teams provide clean water, shelter, health care, education and empowerment support to refugees and displaced people." IRC, "The IRC's impact at a glance"

• 3

  See IRC, "What we do"

• 4

  "IRC practitioners provide technical assistance to more than 30 country programs. Technical advisors are charged with staying abreast of the best available research and practices in their respective fields and support IRC's frontline teams to implement best practice. They also lead research and advocacy strategies to encourage uptake of interventions proven to be effective." IRC, "Nutrition at the International Rescue Committee," November 12, 2018.

• 5
  • "Wasting refers to a child who is too thin for his or her height. Wasting is the result of recent rapid weight loss or the failure to gain weight." UNICEF, WHO, World Bank, "Joint child malnutrition estimates — levels and trends," 2020, p. 2.
  • "Acute malnutrition is a major public health issue in low-income countries. It includes both wasting and edematous malnutrition, but the terms wasting and acute malnutrition are often used interchangeably." Frison, Checchi, and Kerac 2015, Abstract.

  "Fluid retention is also called oedema or water retention. It occurs when parts of the body swell due to a build-up of trapped fluid. The fluid gets trapped and makes the area swollen or puffy." HealthDirect, "Fluid retention."

• 6
  • "Restricted growth as a result of inadequate nutrition and infections is an important cause of morbidity and mortality in infants and children worldwide. . . . Several prospective studies have shown associations of undernutrition with increased risk of various disease outcomes, and reduced survival, in children." Olofin et al. 2013, Introduction.
  • "Stunting is the devastating result of poor nutrition in-utero and early childhood. Children suffering from stunting may never attain their full possible height and their brains may never develop to their full cognitive potential. Globally, 144.0 million children under 5 suffer from stunting. These children begin their lives at a marked disadvantage: they face learning difficulties in school, earn less as adults, and face barriers to participation in their communities." UNICEF, WHO, World Bank, "Joint child malnutrition estimates — levels and trends," 2020, p. 2.

• 7

  "Children with uncomplicated severe acute malnutrition, not requiring to be admitted and who are managed as outpatients, should be given a course of oral antibiotic such as amoxicillin." WHO, "Guideline: updates on the management of severe acute malnutrition in infants and children," 2013, p. 29.

• 8

  This understanding came from multiple conversations with the IRC.

• 9

  For example, "CHAD … 1. At the hospital level (SC): Training of at least four (4) health workers per SC by MoH (national level) and IRC agent … 2. At the health center level (OTP): Training of at least two (2) health workers per health center by MoH and IRC agents" IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 15

• 10

  For example, "BURKINA FASO … Caregivers of children seek prompt treatment and adopt household practices for the appropriate management of acute malnutrition

  • Regular and continuous malnutrition screening through Family MUAC approach, which aims to train and equip each household on malnutrition screening. For that, community health volunteers (CHVs) from each village will be trained on Family MUAC by a local partner (CORAB) and then will replicate the training at household level.
  • Mass screening by CHVs in areas with low SAM admission rate by trained CHVs."

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14.

• 11
  • UNICEF procures ready-to-use therapeutic food (RUTF) in all targeted countries but DRC, where IRC plans to purchase them. In Chad and Niger, IRC plans to purchase some RUTF to keep as a buffer, to supplement UNICEF provision.
    • "DRC (...) Purchase of all RUTF needs to treat SAM cases" IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 16
    • "CHAD (...) Establishment of a RUTF buffer stock to respond to any possible stock out" IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 15
    • "NIGER (...) Establishment of a RUTF buffer stock to respond to any possible stock out." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 17
  • Example: "6.1 BURKINA FASO. At the health center level (OTP):
    • "Training of at least 2 health workers per health center by MoH and IRC agents.
    • "Continuous mentoring adapted to the specifics needs of health workers by the IRC agents. (...)
    • "Provision of materials, equipment, and medicines for the management of malnutrition according to the needs of each health facility (...) For that, community health volunteers (CHVs) from each village will be trained on Family MUAC by a local partner (CORAB) and then will replicate the training at household level.
    • "Mass screening by CHVs in areas with low SAM admission rate by trained CHVs"

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14

• 12
  • In Chad, DRC and Niger, IRC plans to support government health workers to deliver CMAM in hard-to-reach areas, leveraging vaccination campaigns and platforms for the treatments of pneumonia, diarrhea and malaria (iCCM). For example: "CHAD (...) 3. At village level – in hard-to-reach area through advanced vaccination strategy:
    • "Provision of materials, medicines and transportation means to integrate SAM treatment within the treatment the advanced vaccination strategy.
    • "Continuous mentoring adapted to the specifics needs of health workers responsible of the advanced vaccination strategy, by the IRC agents. This mentoring will be on a sliding scale throughout the project and will be linked to the empowerment of the health agents for CMAM."

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021 p. 15

  • In Somalia, IRC plans to use mobile clinics to cover children in hard-to-reach areas.
    • "The project targets 5 health facilities (2 in Banadir with one of the facilities providing SC services, 1 Galgadud, 1 Mudug and 1 Nugal) and 27 sites that will be reached through mobile teams in Galgadud, Mudug and Nugal regions." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 12.

• 13

  For example: "6.1 BURKINA FASO: Children under 5 have access to good quality treatment services including in hard-to-reach area. At the hospital level (SC):

  • Training of at least 10 health workers per SC by MoH (national level) and IRC agents.
  • Continuous mentoring adapted to the specifics needs of health workers by the IRC agents. This mentoring will be on a sliding scale throughout the project and will be linked to the empowerment of the health agents in the management of medical complications.
  • Provision of materials, equipment, medicines, additional human resources, referral system and rehabilitation in the 3 SC (located in the HD hospitals).
  • Rehabilitation of SC ward."

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14

• 14
  • For example: "Burkina Faso (...) Services are effectively planned, managed, and delivered in partnership with MoH and national actors including determining increased support during peak surges.
    • CMAM Surge implementation to enables programs and MoH to plan for and predict changes in malnutrition caseloads and access the capacity to manage. For that, at least 2 health workers per health center workers will be trained and monitored by IRC on CMAM Surge approach.
    • Quarterly joint supervision with MoH and IRC to evaluate the quality and coverage of nutrition treatment services at health facility and community level, with priority given to facilities with low performance indicators."

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14

  • "What is CMAM Surge? The Community-based Management of Acute Malnutrition (CMAM) Surge Approach was designed to help health systems more effectively deliver services for children with acute malnutrition. The approach is based on the observation that in many contexts the number of children seeking treatment for acute malnutrition tends to peak during certain months of the year." Concern Worldwide, "The CMAM Surge Approach," May 25, 2021

• 15
  • See IRC, Summary for GiveWell, 2021, "Coverage Surveys" sheet for a list of coverage surveys that IRC plans to conduct.
  • Coverage surveys for 2021 were funded by the bridge grant recommended by GiveWell in May 2021. Two additional rounds of annual coverage surveys will be covered by the grant recommended in August 2021.

• 16

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, pp. 23-24

• 17
  • "The project targets 5 health facilities (2 in Banadir with one of the facilities providing SC services, 1 Galgadud, 1 Mudug and 1 Nugal) and 27 sites that will be reached through mobile teams in Galgadud, Mudug and Nugal regions." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 15.
  • "6.5 SOMALIA (...)
    • Prevention services will include deworming for children 12-59 months and pregnant women in the 2nd and 3rd trimester, counselling and promotion on infant and young child feeding. Community mobilization and screening as well as micronutrient supplementation for PLW (multiple micronutrients and Iron folate) and children 6-59 months with Vitamin A supplements. The program will promote home-based fortification to enrich the diets of young children 6 - 23 months through the distribution of micronutrient powder.
    • Provision of routine immunization services to children and pregnant women in these project sites. Systematic defaulter tracing and follow up of absentees will be conducted at community level by community health workers."

  IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, pp. 18-19

• 18

  For example, the Niger team reported conducting some outreach immunization activities, helping health staff predict and plan for seasonal peaks in malaria and diarrhea, and paying salaries for doctors who also provide inpatient care for non-malnourished children. IRC Niger, Conversation with GiveWell, August 3, 2021 (unpublished).

• 19

  We include these additional benefits in Somalia in the "excluded effects" adjustment in our CEA here.

• 20

  "The assessment of the risk of death associated with different degrees of wasting can be carried out only by community based longitudinal studies with a follow up of untreated malnourished children. This can be analysed only from a limited number of existing studies. For ethical reasons, these observational studies cannot be repeated, as an effective community-based treatment of severe acute malnutrition is now possible." WHO, "WHO child growth standards and the identification of severe acute malnutrition in infants and children," 2009, p. 4, footnote 1.

• 21

  This work was conducted by GiveWell senior advisor David Roodman and is described in the following report: David Roodman, On the association between anthropometry and mortality in children, 2022.

• 22

  See the additional inputs into our calculations in our CEA here.

• 23

  Percent mortality reduction is calculated by taking the inverse of the mortality ratios in table 10 of Roodman 2022 and subtracting them from 1. Using Burkina Faso as an example, the mortality ratio for NGO-supported malnutrition treatment vs. no treatment is 1.71 for MAM and 3.23 for SAM:

  • Mortality reduction from MAM treatment: 1 - (1 / 1.69) = 0.41 (0.59 relative risk of mortality with MAM treatment)
  • Mortality reduction from SAM treatment: 1 - (1 / 3.34) = 0.70 (0.30 relative risk of mortality with SAM)
  • See all of our estimates in these rows of our CEA.

  David Roodman, On the association between anthropometry and mortality in children, 2022, table 10, p. 45.

• 24

  "Malnutrition treatment has a highly plausible mechanism of action. Low body energy stores and nutritional deficiencies increase the risk of death from infectious diseases. [Ready-to-use therapeutic food] RUTF addresses deficiencies of energy and essential nutrients, while antibiotics treat infections and may also work through less well-understood mechanisms. We also believe the standard care that is typically provided at initiation of CMAM, such as screening and treatment for malaria and administration of preventative vaccines, is likely to be beneficial. Overall, we have a strong prior that CMAM will avert deaths among malnourished children to some extent." GiveWell, "Community-Based Management of Acute Malnutrition (CMAM)"

• 25

  See this row in our CEA.

• 26

  See this row in our CEA.

• 27

  Percent mortality reduction is calculated by taking the inverse of the mortality ratios in table 10 of Roodman 2022 and subtracting them from 1. Using Burkina Faso as an example, the mortality ratio for NGO-supported malnutrition treatment vs. no treatment is 1.71 for MAM and 3.23 for SAM:

  • Mortality reduction from MAM treatment: 1 - (1 / 1.69) = 0.41 (0.59 relative risk of mortality with MAM treatment)
  • Mortality reduction from SAM treatment: 1 - (1 / 3.34) = 0.70 (0.30 relative risk of mortality with SAM)
  • See all of our estimates in these rows of our CEA.

  David Roodman, On the association between anthropometry and mortality in children, 2022, table 10, p. 45.

• 28

  See these rows in our CEA.

• 29

  See the "Treatment effect" sheet of our CEA here.

• 30

  See the country-level estimates for this parameter in this row of our CEA.

• 31

  The IRC overestimated caseload in some areas and underestimated it in other areas. Across all five locations, IRC came close to accurate. See here.

• 32

  IRC, Feedback on GiveWell Model Changes, October 2023.

• 33

  "The [Niger] EOY1 survey took place during/ after RUTF stock-outs, which likely deterred health treatment seeking. While our results are representative of coverage at the time of data collection, we do not believe they are representative of coverage year-round. We will ensure appropriate stock in place before and during EOY2 surveys." IRC, CMAM Avancé: End of Year 1 Coverage Survey Results, Filingué Health District, Niger, January 2023, p. 12.

• 34

  For these target areas which had not been receiving NGO support prior to the grant, see the areas marked "Yes" in the "New introduction of IRC services in the whole district" column in IRC, Summary of Coverage Surveys for GiveWell, 2021

• 35

  "Chad: we would estimate a counterfactual of 40%, primarily due to the insufficiency of UNICEF RUTF stock required to cover the needs in the absence of our treatment activities…DRC: We estimate that no treatment would occur without the GiveWell project, as local health ministries do not have or receive any RUTF. UNICEF only receives funding from USAID to purchase treatment supplies for the USAID project, which does not overlap with GiveWell- funded IRC activities." IRC, Feedback on GiveWell Model Changes, October 2023

• 36

  "Coverage of SAM children was 4.5% (0-14.2%) after one year of programming, compared to 2.2% at baseline. The change in SAM point coverage was not significant at a 95% confidence level…The [Niger] EOY1 survey took place during/ after RUTF stock-outs, which likely deterred health treatment seeking. While our results are representative of coverage at the time of data collection, we do not believe they are representative of coverage year-round. We will ensure appropriate stock in place before and during EOY2 surveys." IRC, CMAM Avancé: End of Year 1 Coverage Survey Results, Filingué Health District, Niger, January 2023