Alliance for International Medical Action (ALIMA) — Malnutrition Treatment Programs in Ngouri and N'Djamena, Chad (February 2024)

Note: This page summarizes the rationale behind a GiveWell grant to ALIMA. ALIMA staff reviewed this page prior to publication.

Published: July 2024

Summary

Background

In May 2021, we recommended a grant of approximately $8 million over three years to ALIMA to support work on the treatment of acute malnutrition in N'Djamena and Ngouri, Chad. We recommended this grant because we modeled the program to be above our cost-effectiveness threshold (8x cash, at the time we recommended the grant) and because we expected that ALIMA's program data would increase our confidence in key inputs into our cost-effectiveness model.

What we think this grant will do

Our February 2024 grant will support ALIMA to provide an additional year of malnutrition treatment programming in N'Djamena and Ngouri. ALIMA aims to increase the coverage and quality of malnutrition treatment by supporting the governments in the countries where it works. (More)

This grant will serve as an exit grant for GiveWell in N'Djamena and may also serve as an exit grant in Ngouri. (More)

Why we recommended this grant

We recommended an exit grant for our support in N'Djamena because:

• ALIMA plans to wind down the program we supported, OptiMA, in N'Djamena. ALIMA told us that it had operational challenges and did not reach its coverage objectives. (More)

We initially recommended an exit grant for ALIMA's program in Ngouri, as well, because:

• We estimated ALIMA's program in Ngouri to be below our cost-effectiveness threshold. When we recommended this grant, we estimated that ALIMA's program in Ngouri was two times as cost-effective as unconditional cash transfers ("2x cash"), the benchmark we use for cost-effectiveness. Our current funding bar is 10x cash. Following the recommendation of this grant, we closely vetted our cost-effectiveness model and identified a calculation error. After correcting this error, we estimated the program to be 5x cash. (More)
• As of June 2024, we're taking a second look at this estimate, and are unsure whether our grant for Ngouri will be an exit grant. We realized that updated data on ALIMA's coverage, caseload, and budget was available and had the potential to significantly impact our view of the program. From a quick check, it's possible that incorporating this information will increase our estimate of the cost-effectiveness of ALIMA's program in Ngouri (from 5x to a higher number). We're planning to look into this and decide whether this grant is an exit grant. (More)

Our cost-effectiveness analysis quantifies our current understanding of the program's impact. Here is a sketch, using annualized projections for a grant renewal in Ngouri.

You can see our cost-effectiveness analysis for the program here and a simple version here.

Main reservations

• 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 ALIMA's. (More)
• Even after including more recent data, we expect to have a number of uncertainties about key inputs in our estimate of the program's cost-effectiveness in Ngouri. ALIMA shared updated information on its caseload and coverage in February 2024 that could potentially significantly increase our estimate of the cost-effectiveness of the program. We decided to take another look at the cost-effectiveness before finalizing our decision on whether to exit the program in Ngouri. Even after including more recent data, we expect to remain uncertain about key inputs in our model, including our estimate of population mortality rates and the number of children who receive malnutrition treatment as a result of ALIMA's support. (More)
  • ALIMA uses different metrics for success. ALIMA told us that it uses different metrics to assess success than GiveWell incorporates into our cost-effectiveness model. While we don't think that we should switch to these metrics, we may be failing to capture some important program impact in our model. (More)
• We didn't look into why ALIMA wants to wind down its OptiMA program in N'Djamena. However, we don't think this is decision-relevant because our estimate of the program cost-effectiveness is below our funding bar and we are unlikely to want to encourage ALIMA to continue a program it deems necessary to close. (More)

The organization

ALIMA supports inpatient and outpatient emergency care and long-term clinical care in 13 countries, mainly in the Sahel region of Africa.1 In January 2021, GiveWell recommended a grant to ALIMA to support its program providing treatment for malnutrition and pediatric emergencies in Mirriah, Niger. In May 2021, GiveWell recommended a grant of approximately $8 million to support its program providing treatment for malnutrition in N'Djamena and Ngouri, Chad, and broader pediatric care in Ngouri.

The intervention

ALIMA supports the treatment of acute malnutrition in government facilities.2 Acute malnutrition refers to excessive thinness for one's height, low mid-upper-arm circumference, and/or the presence of nutritional edema, which is swelling caused by excess fluid retention in tissues.3 Acute malnutrition is believed to raise the risks of developmental delays and death from infectious disease.4

Malnutrition treatment is provided by identifying children experiencing malnutrition and providing them with therapeutic food in an inpatient or outpatient setting. Children experiencing severe acute malnutrition (SAM) are also given a course of antibiotics to reduce infections.5

ALIMA aims to increase the coverage and quality of malnutrition treatment by supporting the governments in the countries where it works. It does this by training and mentoring government clinic staff, providing medical supplies, refurbishing facilities, providing additional staff, and providing incentives for staff.6 ALIMA also trains caregivers to recognize cases of malnutrition through measurements of mid-upper-arm circumference (MUAC).7

ALIMA'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.

In Ngouri, ALIMA also supports the broader pediatric care provided in the government-run health facilities it works in through a similar set of activities. This work includes diagnosing and treating malaria, treating diarrhea, and other pediatric care.8

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.9

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.10 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.11

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%.12 Paired with the program’s highly plausible mechanism of action,13 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 recommended a $2 million grant to ALIMA. The grant amount was based on a 12-month budget shared by ALIMA, which included $1.4 million for Ngouri and $0.6 million for the OptiMA program in N'Djamena.14

This is an exit grant for the OptiMA program in N'Djamena. ALIMA decided to wind down this program because it faced operational challenges and did not reach its coverage objectives. The decision was independent of GiveWell's decision to provide an exit grant. ALIMA told us that it may have savings from winding down its OptiMA program in N'Djamena that could apply to Ngouri for exit or continuation of the program.15 If there are savings from winding down N'Djamena and we exit Ngouri, we expect ALIMA to return some of the funds.

This grant may also serve as an exit grant for Ngouri. At the time we recommended the grant, we modeled ALIMA's program in Ngouri to be two times as cost-effective as unconditional cash transfers ("2x cash"). We had low confidence in our precise estimate, but it was far below our 10x cash funding threshold. For this reason, we recommended an exit grant. We subsequently vetted our cost-effectiveness model and identified an error that increased our estimate of the cost-effectiveness to ~5x cash, which was still below our funding bar.

However, ALIMA shared updated information on its caseload and coverage in February 2024 that, when combined with the one-year budget ALIMA shared, could potentially increase our estimate of the cost-effectiveness of the program (from 5x to a higher number). We plan to take another look at the cost-effectiveness of the program before finalizing our decision on whether to exit in Ngouri. In the meantime, ALIMA is seeking alternative funders for its program in Ngouri.16

The grant was funded by unrestricted donations that had been re-designated by the GiveWell board for granting. 17

The case for the grant

We recommended a one-year exit grant to ALIMA because:

ALIMA plans to wind down its OptiMA program in N'Djamena.

In November 2023, ALIMA told us that it had operational issues implementing its OptiMA program in N'Djamena. It was considering winding down the program.18 In January 2024, ALIMA confirmed it would wind down.19 ALIMA may rebuild its OptiMA program in N'Djamena at a later date.20

We decided to recommend a one-year exit grant to support ALIMA as it winds down the OptiMA program in N'Djamena. At the time we recommended the grant, we hadn't asked ALIMA to share details about the operational challenges there, though we expected to follow up in the future. We have since discussed this with ALIMA.

We estimated that ALIMA's program in Ngouri was below our cost-effectiveness threshold.

Why was the program in Ngouri below our funding threshold?

When we recommended our 2021 grant to ALIMA, we estimated the cost-effectiveness of the program in Ngouri to be 14x cash. In 2022, we made significant updates to our cost-effectiveness model, which resulted in our estimate for the 2021 grant in Ngouri declining to 9x cash. We describe these updates here.

The additional reduction in estimated cost-effectiveness from 9x cash to our current estimate of 5x cash was driven by an updated estimate of the number of malnutrition cases that ALIMA would treat each year. Our previous cost-effectiveness estimate assumed that ALIMA would treat 37,000 cases each year. This was based on ALIMA's best guess of its future caseload.

We have now updated our estimate to 19,000 cases per year. This update is based on ALIMA's caseload data from 2022 and early 2023, which we converted into an annualized estimate. We then projected forward an increase in caseload that was proportional to our expectation of:

• A 20% increase in coverage of malnutrition treatment with ALIMA's support, relative to baseline levels, over 5 years. This was a rough guess.
• Population growth. This was based on 2021 World Bank data.

Because the program was below our 10x funding bar following these updates, we viewed our February 2024 grant as an exit grant.

Why might we be wrong?

After recommending an exit grant, we realized that updated data on coverage, caseload, and budget was available and had the potential to significantly impact our view of the program. Recommending an exit grant before reviewing this information was a mistake.21 Based on a preliminary, shallow review, we think it's possible these updates could increase our estimate of the program's cost-effectiveness because:

• SAM and MAM coverage rates were higher in 2024 than 2023.22 Higher coverage rates lead us to estimate a larger mortality burden per child among untreated malnourished children, which would increase our estimate of the program's cost-effectiveness (details in footnote).23
• We expect that the program budget will be lower as a result of reduced caseloads.

As of May 2024, we're revisiting our estimate and will decide whether this is an exit grant in Ngouri, pending the results.

If we decide to stop funding the program in Ngouri, ALIMA plans to seek other funding to continue the program. ALIMA told us that the program is functioning well on the metrics it uses to judge program success (details below) and that it is excited to continue this work.24

Risks and reservations

Our main reservations about this grant are:

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. We typically have direct estimates of a program’s effectiveness, usually from a number of randomized controlled studies. For malnutrition treatment programs, 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. We discuss this in more detail in our CMAM intervention report.

These contribute to a high level of uncertainty about our cost-effectiveness estimate for malnutrition treatment programs, including those supported by this grant.

Even after including more recent data, we expect to have a number of uncertainties about key inputs in our estimate of the program's cost-effectiveness in Ngouri.

As discussed above, we plan to update our cost-effectiveness model using more recent caseload data, coverage data, and program budget information. Our best guess is that this will lead to higher estimated cost-effectiveness, but we're unsure of the likely magnitude of this update and whether it will lead ALIMA's Ngouri program to meet our funding criteria.

Even after including more recent data, we expect to have a number of uncertainties about key inputs in our estimate of the program’s cost-effectiveness in Ngouri, specifically:

• Population mortality rates. Our estimate of mortality rates in the target population has significantly decreased from 2021, mostly as a result of updated estimates from SMART surveys.25 We're unsure about the reliability of mortality data from SMART surveys because they provide imprecise estimates of mortality, as they are not powered to estimate mortality. However, the more recent SMART estimates are closer to the estimates from the Institute for Health Metrics and Evaluation, the other data source we rely on in our estimates, which makes us more confident in them.26
• The number of additional children who receive malnutrition treatment as a result of ALIMA's support. Our estimate is based on calculating the number of children treated with ALIMA's support and the number of children treated without ALIMA's support. We base our estimate of the latter on ALIMA's best guess of the percent of children that would receive treatment without its support. We're highly uncertain about this guess, since we haven't triangulated it. You can read more about this here.
  

  ALIMA uses different metrics.

  In our cost-effectiveness model, estimated caseloads are one of the most important variables in driving our estimate of program impact.27 While ALIMA agrees caseloads are relevant, it also considers a broader range of indicators related to program quality, including the default rate and the percentage of children receiving appropriate treatment. ALIMA tells us its Ngouri program is above expectations on both dimensions.28 While we incorporate a general estimate of successful treatment by NGOs relative to government programs in our model, we do not adjust for variations across governments and NGOs, so ALIMA's data on these metrics are not incorporated into our model.29 However, we do not expect this to make a significant difference to our cost-effectiveness model, since we already assume high treatment rates for NGO programs. ALIMA also told us that the proportion of SAM children in the treatment cohort decreased during the grant period, which is another signal of program success.30 In our model, the impact of this change is captured by the benefit of treating MAM children. However, we think it’s possible that these are broader signals of program quality that could boost impact via mechanisms not captured in our cost-effectiveness model.31

  In addition, ALIMA thinks we're looking at the wrong indicator for coverage. Our cost-effectiveness model uses "point" estimates for ALIMA's coverage, which represent the number of children receiving treatment out of those who were classified as malnourished at the time of the coverage survey. We use point coverage because we think it is consistent with the rest of our modeling choices. Specifically, we use coverage in conjunction with point prevalence, or the percent of children who are classified as malnourished at one point in time, to estimate the percent of children that are both (i) malnourished and (ii) not receiving treatment at one point in time.

  ALIMA has told us that we should instead use "period" coverage rates. These represent the number of children receiving treatment who are currently malnourished or recovering, out of the total number of children with malnutrition or recovering from malnutrition and receiving treatment. ALIMA thinks that period coverage rates more accurately reflect program success since they also account for treated children whose condition has improved.32

  We didn't look into why ALIMA wants to wind down its OptiMA program in N'Djamena.

  At the time of recommending the exit grant, we hadn't asked ALIMA for details about why it wants to wind down its OptiMA program in N'Djamena. However, we don't think this is decision-relevant because our estimate of the program's cost-effectiveness is below our funding bar and because we are unlikely to want to encourage ALIMA to continue a program it deems necessary to close.

  Plans for follow up

  After recommending the grant, we spoke with ALIMA to learn more about why it is winding down its OptiMA program in N'Djamena and what explains the lower than expected caseload in Ngouri. These learnings might inform future investigations into malnutrition programs.

  Going forward, we plan to update our cost-effectiveness model for Ngouri using the most recent coverage and caseload data, as well as an updated program budget. We will decide whether this is an exit grant for Ngouri following the completion of that work.

  We also plan to learn whether ALIMA expects to be able to apply funds from winding down its OptiMA program in N'Djamena to Ngouri (if we continue funding the program) or return the funds to us (if we exit Ngouri).

  Internal forecasts

  For this grant, we are recording the following forecasts:

  Confidence	Prediction	By time
  70%	ALIMA has wrapped up the OptiMA program in N'Djamena.	End of 2025

  Our process

  • In May 2021, we recommended a three-year grant to ALIMA to support its work in N'Djamena and Ngouri, Chad.
  • In 2022, we updated our cost-effectiveness model. We describe these updates in more detail in our malnutrition intervention report.
  • As part of our investigation into potential renewal grants, we updated our cost-effectiveness model with new data from the Institute of Health Metrics and Evaluation, new SMART survey data, and additional information we received from ALIMA.
  • ALIMA provided feedback on our cost-effectiveness model updates.
  • ALIMA sent us a budget for a 12-month exit grant in Ngouri and N'Djamena.

  Relationship disclosures

  None.

  Sources

  Document	Source
  ALIMA Chad exit grant budget (Q1 2024)	Source
  ALIMA, "What we do"	Source (archive)
  ALIMA, "Where we work"	Source (archive)
  ALIMA, "Who we are"	Source (archive)
  ALIMA, Summary Coverage Surveys - Ngouri - 2022-2024	Source
  Data Commons, Timelines, Rate of population growth in Chad	Source (archive)
  David Roodman, On the association between anthropometry and mortality in children, 2022	Source
  Frison, Checchi, and Kerac 2015	Source (archive)
  GiveWell, Alliance for International Medical Action (ALIMA) — Malnutrition Treatment in Chad (May 2021) and in Niger and Nigeria (November 2022)	Source
  GiveWell, Alliance for International Medical Action (ALIMA) — Treatment of Malnutrition in Niger	Source
  GiveWell, Community-based management of acute malnutrition (CMAM)	Source
  GiveWell, Malnutrition treatment CEA (ALIMA Chad - 2024 renewal)	Source
  GiveWell, Malnutrition treatment CEA (combined protocol ALIMA)	Source
  GiveWell's non-verbatim summary of a conversation with ALIMA, March 5th, 2021	Source
  HealthDirect, "Fluid retention"	Source (archive)
  Olofin et al. 2013	Source
  UNICEF, WHO, World Bank, "Joint child malnutrition estimates — levels and trends," 2020	Source
  WHO, "Guideline: updates on the management of severe acute malnutrition in infants and children," 2013	Source
  WHO, "Supplementary foods for the management of moderate acute malnutrition in children aged 6–59 months," 2019	Source
  WHO, "WHO child growth standards and the identification of severe acute malnutrition in infants and children," 2009	Source

  Note that this grant size differs from the actual grant we recommended for the Ngouri program, which was $1.4 million.

  The grant size in our model is the annual budget for the 3-year grant we made to ALIMA's Ngouri program in 2021. At the time we recommended the grant, we believed that this budget would be similar to the annual budget for a 2024 renewal grant to ALIMA. The actual grant we recommended is the budget that ALIMA sent to us for an exit grant.

  ($2.7m / $174)

  (15,500 x (1-48%) x 6.2% x 55%) + (15,500 x 48% x 6.5% x 4%)

  (Multiples of the value of direct cash transfers)
  (294 * 118 / $2m) / 0.00335)

  (5.1x / 97%) x (100% + 6%) x (100% - 17%)
  • 1
    • "ALIMA provides emergency medical care in conflict zones and difficult-to-reach areas that may be suffering from high mortality rates. We are also implementing longer-term clinical and operational research projects to develop new treatments and offer innovative solutions in order to transform humanitarian medicine. ALIMA, "What we do"
    • In addition to directly employing staff, ALIMA provides financial support to several local implementing partners. "ALIMA works hand-in-hand with our local partners, an integral part of our governance model. Our local partners look to their vast experience to create solutions adapted to local or regional contexts. Departing from conventional humanitarian protocols, a network of partner organizations increases the impact of our medical emergency programs, especially in areas of conflict with high mortality rates. In addition, the majority of our staff are African, representing 98% of all ALIMA employees, at all levels, from country directors to our operational headquarters in Dakar." ALIMA, "Who we are"
    • ALIMA, "Where we work"

  • 2

    "ALIMA works within existing Ministry of Health systems, which include outpatient care as well as inpatient care with pediatric, surgical, and maternity wards." GiveWell's non-verbatim summary of a conversation with ALIMA, March 5th, 2021

  • 3
    • "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"
    • "In children aged 6–59 months, moderate acute malnutrition is defined as moderate wasting (i.e. weight-for-height between –3 and –2 Z-scores of the WHO Child Growth Standards median) and/or mid-upper-arm circumference (MUAC) greater or equal to 115 mm and less than 125 mm." WHO, "Supplementary foods for the management of moderate acute malnutrition in children aged 6–59 months," 2019.

  • 4
    • "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.
    • "All degrees of underweight, stunting and wasting were associated with significantly higher mortality. The strength of association increased monotonically as Z scores decreased. Pooled mortality HR was 1.52 (95% Confidence Interval 1.28, 1.81) for mild underweight; 2.63 (2.20, 3.14) for moderate underweight; and 9.40 (8.02, 11.03) for severe underweight. Wasting was a stronger determinant of mortality than stunting or underweight." Olofin et al. 2013, Abstract.

  • 5

    "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.

  • 6

    ALIMA confirmed via review of this grant page prior to publication.

  • 7

    "Under this approach [family MUAC], [caregivers] are trained by community health workers to diagnose malnutrition and edema in their own children." GiveWell's non-verbatim summary of a conversation with ALIMA June 9, 2020 (unpublished).

  • 8

    ALIMA confirmed via review of this grant page prior to publication.

  • 9

    “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.

  • 10

    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.

  • 11

    See the additional inputs into our calculations here.

  • 12

    Percent mortality reduction can be calculated by taking the inverse of the mortality ratios in table 10 of David’s report, and subtracting them from 1.
    Using Niger 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 / 1.71) = 0.42 (0.58 relative risk of mortality with MAM treatment)
    Mortality reduction from SAM treatment: 1 - (1 / 3.23) = 0.69 (0.31 relative risk of mortality with SAM)
    David Roodman, On the association between anthropometry and mortality in children, 2022, table 10, p. 45.

  • 13

    "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)

  • 14

    ALIMA Chad exit grant budget (Q1 2024)

  • 15

    Email from ALIMA, January 25, 2024 (unpublished)

  • 16

    "Indeed, I confirm that we plan to fully wind down our current program in N'djamena and seek additional funds outside of GiveWell to continue our program in Ngouri." Email from ALIMA, January 25, 2024 (unpublished)

  • 17

    For more information, see our Excess Assets policy.

  • 18

    Conversation with ALIMA on November 6, 2023 (unpublished)

  • 19

    "Indeed, I confirm that we plan to fully wind down our current program in N'djamena and seek additional funds outside of GiveWell to continue our program in Ngouri." Email from ALIMA, January 25, 2024 (unpublished)

  • 20

    Conversation with ALIMA on November 6, 2023 (unpublished)

  • 21

    ALIMA shared its latest coverage and caseload estimates with us after we had submitted the grant recommendation to senior leadership, but prior to senior leadership signing off on the decision. It was a mistake of ours not to realize this information was forthcoming and to wait for it before submitting the grant recommendation.

  • 22

    ALIMA reported that MAM point coverage was 19.9% in 2023 and 39.6% in 2024. ALIMA reported that SAM point coverage was 28.9% in 2023 and 50.0% in 2024. ALIMA, summary coverage surveys, Ngouri 2022-2024

  • 23

    We use a "ceiling analysis" to estimate the maximum plausible mortality rates among untreated malnourished children (additional details are in our write-up on community-based management of acute malnutrition). In the ceiling analysis, we make a best guess of the maximum percent of deaths in children between 6-59 months old that occur in children who are malnourished. We then "distribute" this mortality burden over the number of untreated malnourished children. The lower the number of untreated children with malnutrition (e.g., because of high coverage rates), the higher the plausible mortality "burden" for each child. The higher the burden, the more cost-effective the program looks. This is because changing a child from untreated to treated has a larger effect on reducing their mortality risk.

  • 24

    Conversation with ALIMA on May 10, 2024 (unpublished)

  • 25

    Note: We place 25% weight on SMART surveys; the remaining weight is on estimates from the Institute for Health Metrics and Evaluation (IHME).

  • 26

    See comparison of IHME and SMART surveys in our 2021 cost-effectiveness model, compared to our current model.

  • 27

    This parameter enters our model linearly: a 50% reduction in caseloads would lead to a 50% reduction in cost-effectiveness (prior to accounting for leverage and funging) because half as many children are treated.

  • 28

    Conversation with ALIMA on March 22, 2024 (unpublished)

  • 29

    In our cost-effectiveness analysis, we estimate that malnutrition treatment performed by NGOs is generally more effective at preventing mortality than treatment performed by governments (particularly for children with SAM). For more detail, see the mortality ratios we use in our model, which quantify the relative risk of mortality from untreated malnutrition vs. malnutrition treated by governments and NGOs in Chad.

  • 30

    The number of SAM children in the treatment cohort in 2024 can be seen here: ALIMA, summary coverage surveys, Ngouri 2022-2024 (No SAM children treated previous yr and No MAM children treated previous yr): 2,575/(2,575+10,944)*100 = 19%. This is a decrease from 2022: 13,541/(13,541+15,923)*100 = 46%. ALIMA, summary coverage surveys, Ngouri 2022-2024
    We don't use the ratio of SAM to MAM children in our model directly. Instead, we calculate the number of SAM children and MAM children that are expected to be treated, based on ALIMA's reported caseload numbers.
    Source for the claim that a reduction in the proportion of SAM children during the grant period indicates program success: Conversation with ALIMA, May 10, 2024 (unpublished).

  • 31

    For example, low default rates might signal a high degree of trust between ALIMA and the communities in which it works. This may influence impact and program sustainability in ways that aren’t captured by our simple model.

  • 32

    "As point coverage only considers children under treatment who are within the specific criterion
    on the day of the survey - and does not take into consideration that a number of children who were admitted as SAM but now are either within MAM criterion or are no longer considered malnourished - this considerably under estimates the actual coverage of the program. Period coverage includes (to the extent we can identify them by ration card) children under treatment who were admitted as SAM, but are now in any one of the 3 categories, SAM, MAM or not malnourished." Email from ALIMA, December 11, 2023 (unpublished).