Note: This page summarizes the rationale behind a GiveWell Incubation Grant to ALIMA. ALIMA staff reviewed this page prior to publication.
Summary
In January 2021, the Alliance for International Medical Action (ALIMA) received a GiveWell Incubation Grant of $1,008,450, funded by Open Philanthropy, to support its program providing treatment for malnutrition and pediatric emergencies in Mirriah, Niger. The grant will partially fund ALIMA's operations from March 2021 through April 2022.
A major goal for GiveWell in 2021 is to identify additional highly cost-effective giving opportunities. We view this grant primarily as an opportunity to learn more about a potentially promising intervention—treatment of malnutrition—and about ALIMA as an organization, which may put us in a better position to evaluate potential future grants to support malnutrition treatment.
Published: July 2021
Table of Contents
- Summary
- The intervention
- Planned activities
- Budget
- Case for the grant
- Our process
- Plans for follow-up
- Risks and reservations
- Internal forecasts
- Sources
The intervention
The Alliance for International Medical Action (ALIMA) implements inpatient and outpatient treatment for malnourished children in the Sahel region of Africa.1 The outpatient element of ALIMA's program is known as community-based management of acute malnutrition (CMAM), which involves screening children in communities for signs of malnutrition, providing outpatient treatment at health centers to those with uncomplicated cases of malnutrition, and referring complicated cases to inpatient treatment.2
Acute malnutrition refers to "wasting" (low weight-for-height caused by rapid weight loss or failure to gain weight)3 and/or the presence of nutritional edema (swelling caused by excess fluid retention)4 and is associated with heightened risks of morbidity and mortality.5 Moderate acute malnutrition (MAM) is characterized by low weight-for-height or mid-upper arm circumference.6 Severe acute malnutrition (SAM) is characterized by very low weight-for-height, very low mid-upper arm circumference, and/or the presence of nutritional edema.7 If the underlying causes are left untreated, the condition of a child with MAM may become more severe and cross the threshold into SAM.8
The national CMAM treatment protocols that we've seen include both MAM and SAM treatment but recommend different treatment strategies. Uncomplicated cases of SAM are treated with ready-to-use therapeutic food (RUTF), an all-in-one food product that is designed to provide malnourished children with the nutrients they need to recover,9 along with a course of antibiotics.10 The MAM component of CMAM protocols relies on the use of ready-to-use supplementary food (RUSF) or enriched flours.11 In practice, separate treatment for MAM is often underfunded or excluded from CMAM programs.12 However, recently developed "combined protocols" treat children with both SAM and MAM using RUTF.13 These combined protocols aim to expand coverage by reducing the complexity of implementation for healthcare practitioners, as well as reducing the dosage of RUTF given to each child, which reduces treatment costs per child.14 By expanding admission criteria to MUAC less than 125 mm rather than less than 115 mm,15 combined protocols aim to treat more children, earlier on, before they reach the severe stage of acute malnutrition.16 Multiple trials of combined protocols have been conducted and, so far, it appears that combined protocols are similar in effectiveness to the standard protocol.17 However, standard protocol CMAM remains the norm in most places.18
We are investigating both the standard protocol and the combined protocols for CMAM, and we think both versions of the program could potentially be within the range of cost-effectiveness of programs we would consider directing funding to in the future. We believe our remaining uncertainties about the intervention can be better resolved by learning about the implementation of a specific program rather than through further desk research.
Planned activities
This grant is intended to partially fund ALIMA's general operations from March 2021 through April 2022 to support its work in Mirriah, Niger. Specifically, we expect the grant to fund the following activities:19
- Training roughly 55,000 caregivers to use mid-upper arm circumference (MUAC) measurements to screen their children for acute malnutrition.
- Providing standard malnutrition treatment, including both outpatient (CMAM) and inpatient treatment, to roughly 9,000 children.
- Providing pediatric emergency services20 to roughly 5,400 children.21
- Providing treatment to patients as part of a randomized controlled trial (RCT) to test two variants of the combined protocol against the standard protocol for CMAM.22 At the time we recommended the grant, the trial was expected to begin in February 2021.23
Budget
A rough breakdown of ALIMA's budget for the activities funded by the grant can be viewed here.24
Case for the grant
Note: Unless otherwise stated, the case for the grant laid out below reflects our thinking at the time we recommended the grant.
One of GiveWell's top priorities in 2021 is to identify additional highly cost-effective giving opportunities.25 We recommended this grant primarily because we expect it to help us learn about an intervention and organization that we could potentially direct a large amount of funding to in the future.
Specifically, we decided to recommend the grant for the following reasons:
- Refining our cost-effectiveness estimates for CMAM. We have low confidence in our cost-effectiveness analysis for CMAM. We believe recommending this grant could allow us to gain valuable information that may help us resolve some of our uncertainties. (More)
- Learning about treatment of malnutrition in Niger. We believe treatment of malnutrition is a potentially cost-effective intervention and that Niger could be a promising context in which to direct funding to it. (More)
- Learning about ALIMA. Based on our initial impressions of the organizations we have spoken to, we believe ALIMA to be one of the most promising potential implementers of treatment of malnutrition. We believe this grant will help us learn more about whether we would potentially be interested in recommending a larger grant to ALIMA in the future to fund malnutrition programs in Niger or elsewhere. (More)
- Increasing the possibility of directing funding to large-scale treatment of malnutrition. What we learn about CMAM and ALIMA as a result of this grant, along with the potential that the RCT could result in increased adoption of combined protocol CMAM, may put us in a better position to evaluate and potentially recommend larger grants to support malnutrition treatment in the future. (More)
- Funding highly cost-effective activities. We think it is possible that the activities funded by the grant are similar in cost-effectiveness to our top charities. However, our cost-effectiveness estimate is highly uncertain, and we would not have recommended this grant on the basis of cost-effectiveness alone. (More)
Refining our cost-effectiveness analysis for malnutrition treatment
We believe CMAM is a potentially cost-effective program with substantial room for more funding,26 and we roughly estimate that combined protocol CMAM, which ALIMA is planning to test in its RCT, is somewhat more cost-effective than the standard protocol.27 However, we are highly uncertain about many of the inputs in our cost-effectiveness analysis for CMAM, and we believe this grant could give us an opportunity to gain information about some of these inputs, which could increase our confidence in our estimates.
The inputs we expect to learn about as a result of recommending this grant include, but are not limited to, the following:
- The impact of treating children with MAM (per the combined protocol) on the number and recovery rates of children with SAM.
- The impact of the combined protocol on the number of children with complicated versus uncomplicated SAM.
- Program costs.
- The impact of ALIMA funding malnutrition treatment on the level of funding provided by the government of Niger.28 Our cost-effectiveness analysis assumes that ALIMA's activities will not displace government funding and that the government will incur minimal additional costs as a result of ALIMA's activities.29 If these assumptions are incorrect, it could reduce our cost-effectiveness estimate for the program.
Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.
Learning about treatment of malnutrition in Niger
Niger appears to be a country with a high burden of malnutrition. According to the Nigerien National Institute of Statistics' 2020 SMART nutrition survey, 12.7% of children under five years old meet the diagnostic criteria for at least MAM, including 2.6% who meet the diagnostic criteria for SAM.30 Niger also appears to have a large unmet need for funding treatment of malnutrition,31 and our understanding is that philanthropic funding for malnutrition treatment in Niger has been declining in recent years.32 Gaining more confidence in these beliefs could make us more likely to direct funding to malnutrition treatment in Niger in the future.
Learning about ALIMA
Based on our initial impressions from speaking with its staff, ALIMA appears to be a potentially good implementer of malnutrition treatment. The organization appears to share some of GiveWell's values, including transparency and evidence-based decision-making. It also appears to be a relatively small, funding-constrained33 organization, and our impression is that it is prepared to be innovative and flexible in its approach to implementing malnutrition interventions. ALIMA also expressed readiness to implement combined protocol CMAM at a large scale, which we might be interested in directing funding to in the future.34
We view this grant as a relatively low-cost way to learn more about ALIMA's willingness to be transparent and provide us with information that will improve our understanding of CMAM. We also believe the grant will allow us to learn more about ALIMA's goals for scaling up CMAM, its program costs, and its room for more funding.
Increasing the possibility of directing funding to large-scale treatment of malnutrition
ALIMA's planned RCT is designed to compare two variants of the combined protocol with standard protocol CMAM in Mirriah, Niger.35 The RCT will test the hypothesis that the combined protocols increase coverage and maintain recovery rates without increasing program costs.36 We believe this outcome is relatively likely, given the results of other combined protocol trials we had seen.37 We also believe it is plausible that promising results from the RCT will increase the likelihood that governments and NGOs will pursue scaling up the combined protocol in Niger and elsewhere and, therefore, the likelihood that we will identify more cost-effective opportunities to direct funding to large-scale CMAM programs.
Scale-up in Niger
ALIMA told us that it believed the government of Niger would be very likely to integrate the combined protocol into its national CMAM strategy if the RCT found that the combined protocol achieved higher coverage while maintaining recovery rates and program costs.38 ALIMA also told us that two of the investigators working on the RCT are members of the Nigerien government and would be well placed to influence policy if the trial results are promising.39 In addition, ECHO, a prominent funder of malnutrition programming in the Sahel region of Africa, told us that there would likely be an opportunity to update the official malnutrition treatment protocol in Niger within the next few years.40 We believe the combination of these factors point to the plausibility of Niger adopting the combined protocol as a result of the RCT.
Scale-up in other countries
Since there is little existing evidence about the effects of the combined protocol and it has been studied in a small number of contexts,41 results from the RCT in Niger may play an important role in broadening the evidence base and could lead to the program being scaled up in other countries. The RCT will also be the first trial we are aware of that will test two variants of the combined protocol against each other, which we expect will improve research synthesis in the field and increase the applicability of the results to organizations implementing differing malnutrition programs.
ALIMA told us that it is prepared to continue implementing combined protocol CMAM programs in Burkina Faso, Chad, and Mali,42 and we think it's possible that we will be interested in directing funding to these programs in the future if the opportunities appear to be cost-effective after further examination. Our understanding is that other implementing organizations may also be watching combined protocol research closely and may be more likely to implement their own combined protocol CMAM programs if the trial results are promising, although we are highly uncertain whether this is the case.43
Standard protocol CMAM
We believe that recommending this grant could increase our likelihood of directing funding to CMAM at scale, even if the results of ALIMA's RCT find the combined protocols to be less cost-effective than we currently anticipate. The majority of the children who will be treated with CMAM under the grant will not be participants in the treatment arms of the RCT and therefore will be treated using the standard protocol,44 which we also believe to be potentially cost-effective.45 We expect that what we learn about standard protocol CMAM will put us in a better position to evaluate potential opportunities to direct funding to large-scale CMAM programs in the future.
Funding highly cost-effective activities
Our best guess is that the activities funded by the grant are close to the level of cost-effectiveness of opportunities we would consider directing funding to in the future,46 but this estimate is highly uncertain. Several inputs into our model that we are particularly uncertain about include:
- The proportion of children with MAM and uncomplicated SAM who would receive government-funded treatment in the absence of the grant and the effectiveness of the treatment they would receive.47
- The coverage and quality of treatment that children with complicated cases of SAM would receive in the absence of the grant.
- The coverage and quality of the pediatric emergency services children would receive in the absence of the grant.
This cost-effectiveness analysis does not include any of the potential informational benefits GiveWell might gain by recommending this grant, nor does it include the potential value of the RCT results to the field of malnutrition as a whole. Due to the significant uncertainty around this cost-effectiveness estimate, the true cost-effectiveness of the activities funded by the grant could be much higher or lower than we've estimated.
Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.
Our process
GiveWell recommended this grant as part of a broad investigation into treatment of malnutrition as a potentially cost-effective intervention. Prior to recommending this grant, we:
- Had multiple conversations with ALIMA.48
- Spoke with one of ALIMA's funders about its relationship with ALIMA.49
- Spoke with a prominent funder of nutrition interventions in Africa about its funding priorities for treatment of malnutrition in Niger.50
- Reviewed internal documents shared with us by ALIMA.
- Reviewed published articles about trials conducted by ALIMA.51
- Created a cost-effectiveness analysis for the activities funded by the grant.52
Plans for follow-up
We plan to have additional conversations with ALIMA as we continue our investigation into treatment of malnutrition. We expect the information we learn from continuing to work with ALIMA will help us resolve our uncertainties and refine our cost-effectiveness analysis. We also plan to review the results of the RCT when they become available.
Risks and reservations
- We are highly uncertain about our cost-effectiveness analysis for CMAM. We think it is possible that as we continue our investigation, something independent of the grant could lead us to believe that CMAM is less cost-effective than opportunities we would consider directing funding to.
- We know relatively little about ALIMA. We think it is possible that we will turn out to be less aligned with ALIMA and its intentions to scale up malnutrition programming than we thought.
- We used data about the burden of acute malnutrition in Niger to inform our estimate of room for more funding. We think it is possible that relying on burden of disease data could have led us to overestimate room for more funding, for example, if there are not enough implementing organizations that meet our standards to fill the entire funding gap or if implementing organizations are facing non-financial expansion constraints. It is also possible that variance in cost-effectiveness across contexts could mean that there is less cost-effective room for more funding overall, for example, if implementing CMAM in some countries is so costly that it is no longer within the range of cost-effectiveness for programs we would recommend funding.
- ALIMA told us it had the capacity to expand existing malnutrition programs in Burkina Faso, Chad, and Mali.53 We have not explicitly modeled the cost-effectiveness of these other programs, and they may be less cost-effective than opportunities we would consider directing funding to. If that were the case, ALIMA may have substantially less cost-effective room for more funding for treatment of malnutrition.
Internal forecasts
For this grant, we are recording the following forecasts:
| Prediction | Confidence | Resolution Date |
|---|---|---|
| ALIMA's RCT will be implemented as planned, and the results will be published in a peer reviewed journal. | 80% | January 1, 2023 |
| Niger will update its national protocol for malnutrition treatment to include a) treatment of children with MAM and b) simplified diagnostic criteria. | 50% | December 31, 2023 |
| Our cost-effectiveness analysis for combined protocol CMAM will estimate it to be at least eight times as cost-effective as unconditional cash transfers. | 67% | April 30, 2022 (the end of the grant period) |
In the first half of 2021, we will recommend grants totaling at least the following amounts supporting treatment of malnutrition overall (i.e., across grantees):54
|
|
July 1, 2021 |
In the second half of 2021, we will recommend grants totaling at least the following amounts supporting treatment of malnutrition overall (i.e., across grantees):55
|
|
January 1, 2022 |
| We will recommend grants totaling at least $40 million to fund treatment of malnutrition work overall (i.e., across grantees) in 2022.56 | 30% | January 1, 2023 |
Sources
- 1
- In addition to directly employing staff, ALIMA provides financial support to its local implementing partner, Well-being of Women and Children in Niger (BEFEN), a medical NGO.
- "ALIMA works in Niger with its local partner BEFEN (Well-being of Women and Children in Niger) on several issues, including acute malnutrition and malaria. Thanks to this partnership, free care is provided to children suffering from acute malnutrition in Mirriah, in the Zinder region, and in Dakoro, in the Maradi region. In these districts, field teams work in intensive therapeutic feeding centers and pediatric services, but also in 31 integrated health centers." ALIMA, "Where we work: Niger"
- 2
"The community-based approach involves timely detection of severe acute malnutrition in the community and provision of treatment for those without medical complications with ready-to-use therapeutic foods or other nutrient-dense foods at home [...] Community health workers or volunteers can easily identify the children affected by severe acute malnutrition using simple coloured plastic strips that are designed to measure mid-upper arm circumference (MUAC) [...] Once children are identified as suffering from severe acute malnutrition, they need to be seen by a health worker who has the skills to fully assess them following the Integrated Management of Childhood Illness (IMCI) approach. The health worker should then determine whether they can be treated in the community with regular visits to the health centre, or whether referral to in-patient care is required." WHO, "Community-based management of severe acute malnutrition," 2007, Pgs. 2-3.
- 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, and the World Bank, "Joint child malnutrition estimates - levels and trends," 2020, Pg. 2.
- 4
"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.
- 5
- "Restricted growth as a result of inadequate nutrition and infections is an important cause of morbidity and mortality in infants and children worldwide [1]–[3]. [...] Several prospective studies have shown associations of undernutrition with increased risk of various disease outcomes, and reduced survival, in children [5]–[14]." Olofin et al. 2013, Pg. 1.
- "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.
- 6
"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
- 7
"Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or more below the median, or three SD [standard deviations] or more below the mean National Centre for Health Statistics reference values (that will likely be replaced by new WHO growth curves), which is called "wasted"; the presence of bilateral pitting oedema of nutritional origin, which is called "oedematous malnutrition" or a mid-upper-arm circumference of less than 110 mm in children age 1–5 years." Collins et al. 2006, Pg. 1.
- In 2009, WHO recommended increasing the MUAC cut-off point for defining SAM from 110 mm to 115 mm. "WHO standards for mid-upper arm circumference (MUAC)-for-age show that in a well nourished population there are very few children aged 6–60 months with a MUAC less than 115 mm. Children with a MUAC less than 115 mm have a highly elevated risk of death compared to those who are above. Thus it is recommended to increase the cut-off point from 110 to 115 mm to define SAM with MUAC." WHO and UNICEF, WHO child growth standards and the identification of severe acute malnutrition in infants and children, 2009, Pg. 2.
- 8
Our understanding is that reliable data about children who do not receive treatment is scarce.
- "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 and UNICEF, WHO child growth standards and the identification of severe acute malnutrition in infants and children, 2009, Pg. 4.
However, one study in Ethiopia tracked children identified as MAM whose home districts were ineligible for food supplementation programs and found that only slightly over half of the children recovered without experiencing an episode of SAM during the 28 week tracking period:
- “We prospectively surveyed 884 children aged 6–59 months living with MAM in a rural area of Ethiopia not eligible for a supplementary feeding programme. Weekly home visits were made for seven months (28 weeks), covering the end of peak malnutrition through to the post-harvest period (the most food secure window), collecting anthropometric, socio-demographic and food security data [...] only 54.2% of the children recovered with no episode of SAM by the end of the study.” James et al. 2016, Abstract
- 9
"Ready-to-use Therapeutic Food (RUTF) has revolutionized the treatment of severe malnutrition – providing foods that are safe to use at home and ensure rapid weight gain in severely malnourished children. The advantage of RUTF is that it is a ready-to-use paste which does not need to be mixed with water, thereby avoiding the risk of bacterial proliferation in case of accidental contamination. The product, which is based on peanut butter mixed with dried skimmed milk and vitamins and minerals, can be consumed directly by the child and provides sufficient nutrient intake for complete recovery." WHO, "Malnutrition"
- 10
- "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, Pg. 29.
- Table 1, Pg. 37 of Chad's national protocol for management of acute malnutrition displays the differences between SAM and MAM treatment:
- The "Produits [Products]" row for the "Traitement MAS [SAM treatment]" column states, "Différent produits Aliment Thérapeutique Prêt à l’Emploi (ATPE) – F75 – F100," which translates in English to "Different Ready-to-Use Therapeutic Food (RUTF) products - F75 - F100." The "Antibiothérapie systématique [Systematic antibiotic therapy]" row for the SAM column states "Oui" or "Yes" in English.
- The "Produits [Products]" row for the "Traitement MAM [MAM treatment]" column states, "Différents produits : Farines fortifiées (ex.CSB), Aliment de Supplément Prêt àl’Emploi (ASPE)," which translates in English to "Different products: Fortified flour (e.g. CSB), Ready-to-use supplementary food (RUSF)." The "Antibiothérapie systématique [Systematic antibiotic therapy]" row for the MAM column states "Non," or "No" in English.
- Mali's national CMAM protocol indicates that RUTF and systematic antibiotic therapy should be used to treat SAM:
- "L’Aliment Thérapeutique Prêt à l’Emploi (ATPE) est un composant essentiel des URENAS, permettant le traitement à domicile." Pg. 200.
- English translation from original French: "Ready-to-Use Therapeutic Food (RUTF) is an essential component of URENAS, allowing treatment at home."
- "Les antibiotiques doivent être donnés aux patients souffrant de MAS systématiquement, même si le patient ne présente pas de signes cliniques d’infections généralisées." Pg. 72.
- English translation from original French: "Antibiotics should be routinely given to patients suffering from SAM, even if the patient does not show clinical signs of general infection."
- "L’Aliment Thérapeutique Prêt à l’Emploi (ATPE) est un composant essentiel des URENAS, permettant le traitement à domicile." Pg. 200.
- 11
- Table 1, Pg. 37 of Chad's national protocol for management of acute malnutrition displays the differences between SAM and MAM treatment:
- The "Produits [Products]" row for the "Traitement MAS [SAM treatment]" column states, "Différent produits Aliment Thérapeutique Prêt à l’Emploi (ATPE) – F75 – F100," which translates in English to "Different Ready-to-Use Therapeutic Food (RUTF) products - F75 - F100." The "Antibiothérapie systématique [Systematic antibiotic therapy]" row for the SAM column states "Oui" or "Yes" in English.
- The "Produits [Products]" row for the "Traitement MAM [MAM treatment]" column states, "Différents produits : Farines fortifiées (ex.CSB), Aliment de Supplément Prêt àl’Emploi (ASPE)," which translates in English to "Different products: Fortified flour (e.g. CSB), Ready-to-use supplementary food (RUSF)." The "Antibiothérapie systématique [Systematic antibiotic therapy]" row for the MAM column states "Non," or "No" in English.
- Section IV, Pg. 118 of Mali's national CMAM protocol, which discusses management of MAM, states that the types of treatment provided for MAM include enriched flour and RUSF:
- "Les aliments de supplémentation utilisés par les URENAM sont à base de:
- Farines industrielles améliorées en complexes minéralo-vitaminiques répondant aux normes internationales (Supercerealplus, Supercereal2),
- Farines locales enrichies (Exemple: Misola)53.
- Aliments Supplémentaires prêts à l’emploi(ASPE): Pâte à base de lipides (Exemple, «Supplementary Plumpy»ou PlumpySup)."
- English translation from original French: "The supplementation foods used by URENAM are based on:
- Industrial flour improved in mineral-vitamin complexes meeting international standards (Supercerealplus, Supercereal2),
- Enriched local flours (Example: Misola) 53.
- Ready-to-use supplementary food (RUSF): Lipid-based paste (Example, "Supplementary Plumpy" or PlumpySup)."
- "Les aliments de supplémentation utilisés par les URENAM sont à base de:
- Table 1, Pg. 37 of Chad's national protocol for management of acute malnutrition displays the differences between SAM and MAM treatment:
- 12
- "SAM and MAM are managed in separate programs, using different food products and protocols. There is currently no globally accepted guidance for the treatment of MAM, and MAM is not always routinely treated [17,18]. International mandate adds an additional layer of complexity: UNICEF supports the treatment of SAM and provides ready-to-use therapeutic food (RUTF) for use in outpatient therapeutic programs (OTPs); the World Food Programme supports the treatment of MAM and provides ready-to-use supplementary food (RUSF) or fortified blended flours for use in supplementary feeding programs (SFPs) [19,20]. In humanitarian settings, providing treatment for both SAM and MAM adds to the logistical and financial burden of health systems. When resources are scarce, and in the many settings where prevalence is not high enough to reach emergency thresholds, treatment of SAM is often prioritized, and children with MAM may not be eligible to receive care unless they deteriorate." Bailey et al. 2020, Pg. 4.
- "In addition to the tangle of agencies and case definitions, SAM and MAM programmes are chronically underfunded with only 25% of SAM cases treated globally in 2016 and 16% of (9,10) MAM cases reached by the World Food Program in 2017." Daures et al. 2020, Pg. 757.
- 13
We are aware of two variants of the combined protocol (one known as ComPAS and one known as OptiMA):
- "The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6–59 months [...] Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm." Bailey et al. 2020, Abstract.
- "Although acute malnutrition is a continuum condition, it is arbitrarily divided into moderate (MAM) and severe (SAM) categories defined by mid upper arm circumference (MUAC) or weight-for-height Z-score (WHZ) [...] We piloted a new MUAC-based and oedema approach for treating acute malnutrition in Burkina Faso with a single-arm proof-of-concept trial called Optimising treatment for acute MAlnutrition (OptiMA) [...] only one product was used for treatment (RUTF) at a gradually reduced dose based on a child’s weight and MUAC status." Daures et al. 2020, Pgs. 756-757.
- 14
- "As part of the solution, practitioners and experts have recognised the need to simplify approaches to wasting treatment and have identified key research priorities, such as “reviewing appropriate entry and discharge criteria for treatment of acute malnutrition” and “investigating the safety, effectiveness and cost-effectiveness of reduced dosage ready to-use therapeutic food dosages” (No Wasted Lives, 2018). The aim is to achieve greater coverage and improved efficiency of services (including cost-effectiveness) for children at high risk of illness and death, while maintaining quality of care." Emergency Nutrition Network, "Simplified approaches to the treatment of wasting," July 2020, Pg. 1.
- "ALIMA’s Optimizing treatment for acute MAlnutrition (OptiMA) is one such strategy, proposing three main changes to current protocols:
- Earlier detection by training mothers and caregivers how to use mid-upper arm circumference (MUAC) bands to screen children regularly for malnutrition in the home (i.e., family MUAC.)
- Simplification and easier management by using only one anthropometric measure (MUAC <125 mm (and/or oedema)) for admissions and one product (RUTF) for treatment.
- More intelligent use of the costliest input (RUTF) by gradually reducing the dosage based on a child’s MUAC status and weight to increase the number of children with access to treatment at no extra or similar cost." Phelan 2019, Pg. 40.
- 15
"ALIMA’s Optimizing treatment for acute MAlnutrition (OptiMA) is one such strategy, proposing three main changes to current protocols:
- Earlier detection by training mothers and caregivers how to use mid-upper arm circumference (MUAC) bands to screen children regularly for malnutrition in the home (i.e., family MUAC.)
- Simplification and easier management by using only one anthropometric measure (MUAC <125 mm (and/or oedema)) for admissions and one product (RUTF) for treatment.
- More intelligent use of the costliest input (RUTF) by gradually reducing the dosage based on a child’s MUAC status and weight to increase the number of children with access to treatment at no extra or similar cost." Phelan 2019, Pg. 40.
WHO defines 115 mm MUAC as the cutoff point between SAM and MAM:
- "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
- “Severe acute malnutrition is when children suffer severe wasting that may or may not be accompanied by swelling of the body from fluid retention. It occurs when infants and children do not have adequate energy, protein and micronutrients in their diet, combined with other health problems such as recurrent infections. It is diagnosed when the circumference of the upper arm is less than 115 mm or when the weight for height of a child is severely reduced.” WHO, "WHO issues new guidance for treating children with severe acute malnutrition," 2013
- 16
Victoire Hubert, Research Manager, ALIMA, comments on a draft of this page, May 8, 2021 (unpublished)
- 17
- Daures et al. 2020 was an operational pilot of a simplified combined protocol (OptiMA). Although it did not compare OptiMA to the standard national protocol, it showed the feasibility and effectiveness of implementing OptiMA:
- "The Optimising treatment for acute MAlnutrition (OptiMA) strategy trains mothers to use mid upper arm circumference (MUAC) bracelets for screening and targets treatment to children with MUAC < 125 mm or oedema with one therapeutic food at a gradually reduced dose." Abstract.
- "OptiMA was successfully implemented at the scale of an entire district under ‘real-life’ conditions. Programme outcomes exceeded SPHERE standards, but further study is needed to determine if increasing therapeutic food dosages for the most severely malnourished will improve recovery.” Abstract.
- Bailey et al. 2020 compared recovery rates under a simplified combined protocol (ComPAS) using mid-upper-arm circumference (MUAC) as the primary diagnostic tool with the standard protocol in South Sudan and Kenya. The study found that rates of recovery, mortality, and non-response did not differ significantly between children treated with the simplified combined protocol and the standard protocol:
- "A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm." Abstract.
- "ComPAS compared a simplified, combined protocol for acute malnutrition to standard care, and found non-inferior nutritional recovery in the combined protocol arm relative to the standard care arm. The findings of the per-protocol and intention-to-treat analyses were similar. Clinical effectiveness was similar, with no evidence of a difference for the secondary outcomes death, non-response, defaulting, transfer to inpatient care, length of stay, program coverage, average daily weight gain, and average daily MUAC gain." Pgs. 14-15.
- We are aware of another trial comparing an alternative combined protocol (OptiMA) to the standard protocol in the Democratic Republic of the Congo. See the study description here: U.S. National Library of Medicine, ClinicalTrials.gov, "Optimizing Acute Malnutrition Management in Children Aged 6 to 59 Months in Democratic Republic of Congo (OptiMA-DRC)". The results from this trial have not yet been published and we cannot discuss them publicly, but we have factored these results into our overall view of the combined protocol.
- Daures et al. 2020 was an operational pilot of a simplified combined protocol (OptiMA). Although it did not compare OptiMA to the standard national protocol, it showed the feasibility and effectiveness of implementing OptiMA:
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"Current global outpatient treatment protocols for uncomplicated SAM and MAM, adapted by most countries for use at national level, call for SAM and MAM to be managed separately, however global-level stakeholders have recently begun evaluating simplified and/or combined protocols managing acute malnutrition." Kozuki et al. 2020, Pg. 1.
- 19
"Beneficiaries :
- 8937 children from 6-59 suffering from severe acute malnutrition, including 3330 children in the OPTIMA study cohort, i.e. 1110 children per arm in the study.)
- 31 staff trained in proper medical and nutritional care and emergency response according to the CMAM Surge approach and for the implementation of the OPTIMA study.
- 56 754 mothers trained in the MUAC approach in CRENI and CRENAS.
- 42 community health workers (CHWs) to be trained as part of the follow-up of the children included in the OPTIMA study
- 5430 children taken in charge for pediatric emergencies" ALIMA, Concept note for Niger RCT, October 2020, Pg. 4.
- 20
This refers broadly to any emergency services (both outpatient and inpatient) provided to children, not limited to malnutrition-related emergencies. Providing such services in combination with malnutrition treatment programs is standard practice in some areas where ALIMA works, including Mirriah.
- 21
The number of caregivers and children expected to receive training or treatment as a result of the grant are based on estimates given to us by ALIMA.
- 22
This grant will cover the treatment provided to trial participants; research components of the RCT are being funded separately.
- 23
Due to a disruption in RUTF supply, the trial actually began in March 2021. Victoire Hubert, Research Manager, ALIMA, comments on a draft of this page, May 8, 2021 (unpublished)
- 24
We expect another funder to provide roughly €500,000, leaving an €830,000 funding gap. At the time the grant was disbursed, €830,000 was equivalent to roughly $1,008,450.
- 25
See additional details on our recent progress and future plans to find more cost-effective giving opportunities in this document presented at an August 25, 2020 meeting of GiveWell's Board of Directors.
- 26
- A 2010 World Bank report estimated that $2.6 billion in annual additional funding (i.e., beyond what has already been allocated) would be needed to fund CMAM to treat SAM cases globally. We believe this may be an underestimate, as it is based on the assumption that preventive measures will reduce SAM cases by 50%, and it uses a target coverage rate of 80% rather than aiming for full coverage.
- "We assume that if all the other interventions are funded, that prevalence of severe acute malnutrition will fall to 50 percent of present levels (Isanaka et al. 2009, reporting on the effect of an intensive complementary feeding program). Unlike other interventions (where we aim for 100 percent coverage) we aim for 80 percent coverage, since there are no existing programs at scale achieving higher coverage, and we cost the intervention accordingly. Current coverage is approximately one million children (Stephane Doyon, Médecins Sans Frontières, personal communication). Additional annual cost =US$2.6 billion." Horton et al. 2010, Pg. 31.
- "Global rates of severe wasting remain high: in 2018, around 16.6 million children under 5 were estimated to suffer from it [...] Overall far too few children with SAM are being treated. Despite global progress in the number of children reached (from 1.1 million children in 2009 to 4.4 million in 2017), only about one in four children receives treatment." UNICEF, "Children, food and nutrition," 2019, Pgs. 41 and 43.
- A 2010 World Bank report estimated that $2.6 billion in annual additional funding (i.e., beyond what has already been allocated) would be needed to fund CMAM to treat SAM cases globally. We believe this may be an underestimate, as it is based on the assumption that preventive measures will reduce SAM cases by 50%, and it uses a target coverage rate of 80% rather than aiming for full coverage.
- 27
As of June 2021, our preliminary cost-effectiveness analysis for combined protocol CMAM estimates it to be about ten times as cost-effective as unconditional cash transfers. Our preliminary cost-effectiveness analysis for standard protocol CMAM estimates it to be about eight times as cost-effective as unconditional cash transfers. See this spreadsheet, sheets "Summary CEA- Combined Protocol CMAM" and "Summary CEA - Standard CMAM." These estimates are particularly uncertain, and we do not currently place much weight on them.
Note that while we believe treating children using combined protocols is likely to make this grant somewhat more cost-effective, the majority of the children treated for malnutrition using funds from this grant will not be participants in the treatment arms of the RCT and will be treated under the standard protocol. Our guess about the percentage of total costs that will be used to treat children using the combined protocols is uncertain, and this is a minor factor in our overall assessment of cost-effectiveness.
- 28
We refer to these considerations as "leverage and funging." For more on how we think about leverage and funging in our cost-effectiveness analyses, see this blog post.
- 29
See this spreadsheet, sheet "CEA," section "Government leverage / funging."
- 30
- "Sur le plan national, la prévalence de la Malnutrition Aigüe Globale (MAG) est de 12,7% [11,6-14,0] au cours de cette enquête. Cette prévalence est au-dessus du seuil élevé de 10% fixé par l’Organisation Mondiale de la Santé (OMS) en matière de santé publique. Elle n’est pas statistiquement différente de celle observée en 2019 (10,7% [9,5-12,0]) malgré cette hausse de 2 points de pourcentage. Quant à la prévalence de la malnutrition aigüe sévère, elle est à 2,6% [2,2-3,1], ce qui est supérieur au seuil d’urgence de 2%. Elle est quasi-identique à celle observée en 2019 qui était de 2,7% [2,1-3,4].]. La forme modérée observée (10,1% [9,1-11,2]) est à la limite comparable à celle observée en 2019 (8,0% [7,0-9,1])." National Institute of Statistics of Niger, SMART Survey, 2020, Pg. 42.
- English translation from the original French: "Nationally, the prevalence of Global Acute Malnutrition (GAM) is 12.7% [11.6-14.0] during this survey. This prevalence is above the high threshold of 10% set by the World Health Organization (WHO) for public health. It is not statistically different from that observed in 2019 (10.7% [9.5-12.0]) despite this increase of 2 percentage points. As for the prevalence of severe acute malnutrition, it is 2.6% [2.2-3.1], which is above the emergency threshold of 2%. It is almost identical to that observed in 2019 which was 2.7% [2.1-3.4].]. The moderate form observed (10.1% [9.1-11.2]) is at the limit comparable to that observed in 2019 (8.0% [7.0-9.1])."
- "Global acute malnutrition (GAM) refers to MAM and SAM together; it is used as a measurement of nutritional status at a population level and as an indicator of the severity of an emergency situation (GNC 2014)." Lenters, Wazny, and Bhutta 2016, Pg. 206.
- "Sur le plan national, la prévalence de la Malnutrition Aigüe Globale (MAG) est de 12,7% [11,6-14,0] au cours de cette enquête. Cette prévalence est au-dessus du seuil élevé de 10% fixé par l’Organisation Mondiale de la Santé (OMS) en matière de santé publique. Elle n’est pas statistiquement différente de celle observée en 2019 (10,7% [9,5-12,0]) malgré cette hausse de 2 points de pourcentage. Quant à la prévalence de la malnutrition aigüe sévère, elle est à 2,6% [2,2-3,1], ce qui est supérieur au seuil d’urgence de 2%. Elle est quasi-identique à celle observée en 2019 qui était de 2,7% [2,1-3,4].]. La forme modérée observée (10,1% [9,1-11,2]) est à la limite comparable à celle observée en 2019 (8,0% [7,0-9,1])." National Institute of Statistics of Niger, SMART Survey, 2020, Pg. 42.
- 31
- We estimate roughly $140 million per year in room for more funding for SAM treatment in Niger.
- "In 2019, according to DHIS-2 figures, 414,239 under-five children suffering from SAM were admitted for treatment." UNICEF, "Niger: Humanitarian Situation Report No. 12," 2019, Pg. 2.
- In our CMAM cost-effectiveness analysis (as of June 2021), we estimate a cost of $224 to treat a child with SAM, which implies SAM treatment costs of $93 million in 2019 ($224 per child * 414,239 children = ~$93 million).
- We reviewed two studies that estimate coverage of SAM treatment programs in Niger at less than 40%.
- "We conducted a study comparing a SQUEAC conjugate Bayesian analysis to a two-stage cluster survey estimating the coverage of a therapeutic feeding program in Niger in 2016 [...]The two-stage cluster survey yielded a final coverage estimate of 25.7% (95% CI: 17.6, 33.7%), with a total of 113 cases found, 29 of which were found to be undergoing treatment (either SAM or recovering from SAM). In the SQUEAC, prior estimates from the program staff (Scenarios 1 and 2) resulted in a conflict with the likelihood result, invalidating any interpretation of the resulting posterior estimate of coverage (for example Fig. 2). Even allowing for increased uncertainty, the conflict between the prior and likelihood data remained. The prior estimate produced by the external support team (Scenario 3) was 42% and was the only prior estimate that did not conflict with the likelihood data. The final coverage estimate from the external support team was 30.3% (95% CI: 22.5, 39.6%)." Isanaka et al. 2018, Pgs. 1 and 4.
- "Contact coverage, defined by the proportion of children with SAM in the population receiving treatment, is a key indicator of service performance and compares with international standards [23] [...] Contact coverage of SAM in Niger overall was low, indicating that three out of four children with SAM did not access treatment." Deconinck et al. 2016, Pgs. 5-6.
- Using an optimistic estimate that 40% of children with SAM actually received treatment in health centers in 2019, this implies that costs to treat all children with SAM in Niger would have been about $233 million ($93 million / 40% coverage = $233 million). Subtracting the costs of treatment administered in 2019 yields a total of $140 million in room for more funding ($233 million - $93 million = $140 million).
- This estimate is highly uncertain and doesn't include treatment of MAM, which is much more prevalent. We expect that including MAM treatment in our estimate would add substantial additional room for more funding, though we have not explicitly modeled it.
- We estimate roughly $140 million per year in room for more funding for SAM treatment in Niger.
- 32
- "The Directorate-General for European Civil Protection and Humanitarian Aid Operations (ECHO) has been funding malnutrition programming in the Sahel since roughly 2005, when it began responding to a malnutrition crisis in Niger. For many years, an outright majority of ECHO's funding was dedicated to acute malnutrition programming, amounting to more than 25 million Euros per year in some years." Pg. 1.
- "ECHO's mandate is to grant emergency funding for programs addressing acute crises. ECHO views its long-term support for malnutrition programming in the Sahel as a contradiction to its mandate, since it views malnutrition as an ongoing structural problem, rather than an emergency situation. As a result, ECHO has been working towards ensuring a transition for development donors and State services to take over an increasing part of acute malnutrition treatment and has consequently reduced its financial support from acute malnutrition treatment for several years, decreasing its total funding in the sector from 24 million Euros in 2015 down to 10 million Euros in 2020." Pg. 1.
- "ECHO is one of the largest funders in the malnutrition sector, and it doesn't expect that alternative funders will be able to provide enough support to fully absorb the caseload of acute malnutrition in the Sahel, which appears to have increased from 2019 to 2020 in some areas, according to national SMART surveys." Pg. 2.
- 33
"In 2019, 94% of our financial resources came from institutional donors and 6% from private funders (companies, foundations, major donors and individual donors)." ALIMA, Annual report, 2019, Pg. 30.
Our understanding is that institutional donors are likely to provide restricted funding, which may constrain the capacity of ALIMA to allocate funding flexibly.
- 34
ALIMA has already conducted a large-scale operational pilot of CMAM in Burkina Faso (Daures et al. 2020). ALIMA also told us that it is prepared to continue implementation of the combined protocol in Chad, Burkina Faso, and at least two districts in Mali. Conversation with ALIMA, January 29, 2021 (unpublished)
- 35
"This community-based non-inferiority trial will compare two strategies for the treatment of AM to the Niger protocol for SAM and MAM. The Optimizing treatment for acute MAlnutrition (OptiMA) strategy uses MUAC < 125 mm or nutritional oedema as admission criteria and optimizes RUTF by adapting doses to the degree of malnutrition. RUTF dose for MUAC < 115 mm or oedema is 170 kcal/kg/d and progressively reduces to 75 kcal/kg/d as MUAC increases. The Combined Protocol for Acute Malnutrition Study (ComPAS) uses the same eligibility criteria like OptiMA, but simplifies more the RUTF ration by providing 1000 kcal/d for children with oedema or MUAC < 115 mm and 500 kg/d for children with MUAC 115-124 mm. Children are considered recovered if they have 2 consecutive weekly MUAC measures ≥ 125 mm. Children will be individually randomized to treatment in one of the 3 study arms and will attend clinic visits weekly until nutritional recovery. After discharged, they will be monitored monthly via a nurse-conducted home visits until 6 months post-inclusion. The trial arms will be compared using a composite outcome indicator that includes vital status, anthropometric measures and relapse following the index AM episode." U.S. National Library of Medicine, ClinicalTrials.gov, "Optimizing Acute Malnutrition Management in Children Aged 6 to 59 Months in Niger (OptIMA Niger)"
- 36
"The hypothesis is that simplified strategies could substantially increase the number of children in care compared to current SAM programs without requiring additional RUTF or staffing while maintaining recovery rates in line with current programs." U.S. National Library of Medicine, ClinicalTrials.gov, "Optimizing Acute Malnutrition Management in Children Aged 6 to 59 Months in Niger (OptIMA Niger)"
- 37
- Daures et al. 2020 was an operational pilot of a simplified combined protocol (OptiMA). Although it did not compare OptiMA to the standard national protocol, it showed the feasibility and effectiveness of implementing OptiMA: “OptiMA was successfully implemented at the scale of an entire district under ‘real-life’ conditions. Programme outcomes exceeded SPHERE standards, but further study is needed to determine if increasing therapeutic food dosages for the most severely malnourished will improve recovery.” Abstract
- Bailey et al. 2020 compared recovery rates under a simplified combined protocol (ComPAS) using mid-upper-arm circumference (MUAC) as the primary diagnostic tool with the standard protocol in South Sudan and Kenya. The study found that rates of recovery, mortality, and non-response did not differ significantly between children treated with the simplified combined protocol and the standard protocol:
- "A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm." Abstract.
- "ComPAS compared a simplified, combined protocol for acute malnutrition to standard care, and found non-inferior nutritional recovery in the combined protocol arm relative to the standard care arm. The findings of the per-protocol and intention-to-treat analyses were similar. Clinical effectiveness was similar, with no evidence of a difference for the secondary outcomes death, non-response, defaulting, transfer to inpatient care, length of stay, program coverage, average daily weight gain, and average daily MUAC gain." Pgs. 14-15.
- We are aware of another trial comparing an alternative combined protocol (OptiMA) to the standard protocol in the Democratic Republic of the Congo. See the study description here: U.S. National Library of Medicine, ClinicalTrials.gov, "Optimizing Acute Malnutrition Management in Children Aged 6 to 59 Months in Democratic Republic of Congo (OptiMA-DRC)". The results from this trial have not yet been published and we cannot discuss them publicly, but we have factored these results into our overall view of the combined protocol.
- 38
"If the results of the Mirriah trial are positive for OptiMA and/or ComPAS, ALIMA thinks there is a 95% chance that the government will adopt one of the simplified protocols. ALIMA generally finds that when governments see that an approach is cheaper, simpler, and effective in practice, they tend to embrace it." GiveWell's non-verbatim summary of a conversation with ALIMA, November 13, 2020, Pg. 7.
- 39
Dr. Atté Sanoussi is a member of the Department of Nutrition within Niger's Ministry of Health, and Dr. Aboubacar Mahamane is a member of the High Commission for the Nigeriens Nourish Nigeriens Initiative (HC3N), a government program. Dr. Sanoussi and Dr. Mahamane are listed as National Coordinating Investigators in the protocol for ALIMA's RCT. ALIMA, Biomedical Research Protocol: OPTIMA- Niger, 2020
- 40
- "The Directorate-General for European Civil Protection and Humanitarian Aid Operations (ECHO) has been funding malnutrition programming in the Sahel since roughly 2005, when it began responding to a malnutrition crisis in Niger. For many years, an outright majority of ECHO's funding was dedicated to acute malnutrition programming, amounting to more than 25 million Euros per year in some years." Pg. 1.
- "ECHO's perception is that there is a consensus within the malnutrition sector that a combined protocol for SAM and MAM would be beneficial. ECHO also believes there is an opportunity to change the official malnutrition protocol in Niger within the next few years. The protocol is scheduled to be updated in 2021, but ALIMA may advocate for the government to revise the protocol in 2022, after results from its RCT become available." Pg. 4.
- 41
We are aware of two published studies and one forthcoming study of combined protocols:
- "The Optimising treatment for acute MAlnutrition (OptiMA) strategy trains mothers to use mid upper arm circumference (MUAC) bracelets for screening and targets treatment to children with MUAC < 125 mm or oedema with one therapeutic food at a gradually reduced dose. This study seeks to determine whether OptiMA conforms to SPHERE standards (recovery rate > 75 %). A single-arm proof-of-concept trial was conducted in 2017 in Yako district, Burkina Faso including children aged 6–59 months in outpatient health centres with MUAC < 125 mm or oedema." Daures et al. 2020, Abstract.
- "A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan." Bailey et al. 2020
- "The investigators propose to conduct a community-based non-inferiority clinical trial with individual randomization comparing the OptiMA strategy to the Democratic Republic of Congo standard nutritional protocol for SAM." U.S. National Library of Medicine, ClinicalTrials.gov, "Optimizing Acute Malnutrition Management in Children Aged 6 to 59 Months in Democratic Republic of Congo (OptiMA-DRC)".
- 42
Conversation with ALIMA, January 29, 2021 (unpublished)
- 43
- "There is an expanding evidence base on different RUTF dosage schedules that reduce the amount of product required per course of treatment. However, to draw robust conclusions about the safety and effectiveness of reduced dosage schedules, more research is needed across contexts, particularly from outside of sub-Saharan Africa, on short term and longer-term outcomes (including impact on height, body composition and other non-anthropometric outcomes) as well as on effects among different age groups and vulnerable populations." The No Wasted Lives Coalition and The Council of Research & Technical Advice on Acute Malnutrition (CORTASAM), "Research Agenda for Acute Malnutrition – Revisited," 2021, Pg. 3.
- Conversation with ELMA Philanthropies, November 10, 2020 (unpublished)
- 44
See above for details.
- 45
See this spreadsheet, sheet "Summary CEA - Standard CMAM" for our cost-effectiveness estimate for standard protocol CMAM.
- 46
See this spreadsheet, sheet "Simplified CEA."
- 47
Based on conversations we've had with ALIMA, we believe that if the funding gap filled by this grant were not filled, ALIMA's support of outpatient treatment for malnutrition in Mirriah, Niger would go unfunded, necessitating an emergency transition of these activities to the local healthcare system. We are uncertain about the level of care these children would receive in this case.
- 48
- GiveWell's non-verbatim summary of a conversation with Charlie Kunzer and Kevin Phelan, June 9, 2020
- GiveWell's non-verbatim summary of a conversation with ALIMA, November 13, 2020
- Conversation with ALIMA, January 29, 2021 (unpublished)
- 49
GiveWell's non-verbatim summary of a conversation with Peter Morrison, November 10, 2020
- 50
- GiveWell's non-verbatim summary of a conversation with Patrick Andrey and Amadou Alzouma, November 16, 2020
- Conversation with ECHO, December 16, 2020 (unpublished)
- 51
- 52
Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.
- 53
Conversation with ALIMA, January 29, 2021 (unpublished)
- 54
This forecast is about decisions made during this time period; the work funded by these grants may take place after our stated resolution date.
- 55
This forecast is about decisions made during this time period; the work funded by these grants may take place after our stated resolution date.
- 56
This forecast is about decisions made during this time period; the work funded by these grants may take place after our stated resolution date.