Note: This page summarizes the rationale behind a GiveWell grant to Clear Solutions. Clear Solutions staff reviewed this page prior to publication.
In a nutshell
In July 2025, GiveWell recommended that Open Philanthropy grant $81,573 to Clear Solutions to evaluate a pilot layering the delivery of oral rehydration solution (ORS) and zinc for children with diarrhea on top of Malaria Consortium's door-to-door distribution of seasonal malaria chemoprevention (SMC) in Chad.
We are recommending this grant because 1) it can help us learn about whether ORS coverage could increase if provided alongside SMC distribution and what the operational challenges are, 2) our guess is that ORS distribution in Chad is likely to be highly cost-effective, and 3) it fits with GiveWell's broader strategy of learning about layered programs (more). Our main reservations are that there might be unforeseen risks from funding early-stage organizations, and we think there is a possibility that diarrhea-attributed mortality is overestimated in Chad so this grant could be less cost-effective than anticipated (more).
GiveWell recommended this grant via our policy for small discretionary grantmaking. As a small discretionary grant, this funding opportunity did not receive the same review as larger grants we recommend. Instead, we more minimally evaluated the case for the grant and any potential risks or downsides.
Published: September 2025
Background
In July 2025, GiveWell recommended a $81,573 grant to Clear Solutions for an evaluation of a pilot to layer delivery of oral rehydration solution (ORS) and zinc on top of seasonal malaria chemoprevention (SMC) for distribution to children under five in Chad, together with Malaria Consortium.
Clear Solutions was incubated by Ambitious Impact (AIM)1 and launched in October 2023. It is focused on increasing coverage of ORS and zinc for children with diarrhea.2 We believe that delivering ORS and zinc to children under five is highly cost-effective as diarrhea is a key driver of mortality and these commodities are very inexpensive. For more, see our intervention report on ORS and zinc here.
Clear Solutions plans to support Malaria Consortium's community distribution of SMC by supplying ORS/zinc co-packs3 at the time of the 4th SMC cycle (likely October 2025).4 For more on Malaria Consortium’s SMC program, see our report here. The grant will cover costs for surveys before and after a district-wide pilot in Moulko district,5 along with surveys in a district that does not receive the intervention,6 qualitative interviews, and focus group discussions.7
The case for the grant
We are recommending this grant because:
- It can help us learn whether ORS coverage could increase if provided alongside SMC distribution, and whether there are operational challenges to layering these interventions. One of the key research questions which the pilot evaluation could help answer is whether layering ORS and zinc with SMC distribution leads to an increase in caregivers using ORS to treat cases of diarrhea.8 We also expect to learn about whether layering ORS and zinc onto Malaria Consortium's SMC program is feasible without negatively affecting SMC coverage and delivery quality, and how much the program's costs might increase. If the results suggest coverage remains high and costs do not increase significantly with layering, we see two likely next steps: either the program could be scaled with rigorous monitoring and evaluation, or we could fund a more intensive evaluation of a larger pilot.
- We think ORS distribution is likely to be highly cost-effective in Chad. We think that, in general, programs that increase ORS and zinc usage are likely to be highly cost-effective in locations with a high burden of deaths due to diarrhea (for example, we estimate that a program in Nigeria could be around 12x GiveWell’s benchmark, which is above our 10x funding bar).9 We haven't formally done a cost-effectiveness analysis for Chad, but 2021 estimates from the Institute for Health Metrics and Evaluation (IHME)'s Global Burden of Disease (GBD) project imply that child mortality attributed to diarrhea is more than twice as high in Chad as in Nigeria,10 and baseline coverage of ORS appears to be lower.11 The cost of ORS does appear to be higher in Chad than in Nigeria,12 but on net, we think that an ORS program would be more cost-effective in Chad given the higher disease burden and lower ORS coverage.
- This fits with GiveWell's broader strategy of learning about layered programs. We have been actively looking for opportunities to learn about the impact of layering programs (including co-delivery of vitamin A supplementation and SMC, testing the impact of bundling different health commodities for delivery, etc.). Malaria Consortium has also been piloting various programs to layer onto their existing platforms.13 The pilot evaluation fits squarely into these learning goals. We believe that delivering ORS on top of an SMC program could be promising given the potential for cost sharing at scale14 and the expectation that overall SMC campaign time will not be significantly longer or that significantly more distributors will be needed.15
Risks and reservations
We think this grant is low risk. However, we have two main reservations:
- GiveWell hasn’t funded many very early-stage organizations in the past, so there’s a chance that we aren’t accounting for some unforeseen risks. We don’t think this is a substantial risk in this case because this grant is to specifically fund an evaluation gap. Malaria Consortium - a well established organization - will be implementing the program, and we have been impressed with the Clear Solutions team in our engagement so far. However, we will continue to evaluate GiveWell’s approach to funding of early-stage organizations, and will be open with Clear Solutions about our thinking throughout the grant period.
- We think there’s a reasonable chance that diarrhea-attributed mortality is overestimated in Chad. IHME’s estimate of the diarrhea mortality rate is significantly higher in Chad than other countries with similarly high child mortality rates, like Nigeria.16 GiveWell has also received skeptical feedback about diarrhea mortality estimates in general.17 We plan to look into this further as one of our highest-priority questions on our ORS research agenda.
Plans for follow up
We plan to check in with Clear Solutions at key milestone points during the grant to learn about their evaluation progress and results.
Our process
GiveWell recommended this grant via our policy for small discretionary grantmaking, following a conversation with Clear Solutions. We received responses to various questions from both Clear Solutions and Malaria Consortium. As a small discretionary grant, this funding opportunity did not receive the same review as larger grants we recommend. Instead, we more minimally evaluated the case for the grant and any potential risks or downsides.
Sources
- 1
Formerly Charity Entrepreneurship. See Clear Solutions' incubation program page here.
- 2
"The treatment: ORS and Zinc.
Oral rehydration solution (ORS)- Mixture of Water, Sugar, and Salts
- Helps prevent dehydration, the primary cause of children’s deaths due to diarrhoea
- Prevents up to 93% of diarrhoea deaths
Zinc tablets
- Restore function of the intestines, boosts the immune system
- Reduces the duration of the diarrheal episode and helps prevent future episodes for 2-3 months."
- 3
"MC will coordinate the Community Relays (CRs) who perform the SMC campaign are to add an ORSZ component into each household visit, such that each primary caregiver of eligible children within the household is provided:
- a printed leaflet on ORSZ usage (to be provided digitally by Clear Solutions for print arranged by MC) with a talk-through of the main points on the leaflet,
- a verbal set of emphasis points on diarrhoea risks and effective treatment,
- one box of co-packaged ORS and Zinc (1 “co-pack”) for each eligible child that the householder is primary caregiver for."
Clear Solutions, ORSZ/SMC Layering Project Overview and Evaluation Plan, 2025
- 4
District-wide Pilot: SMC Cycle 4, provisional dates October 15-18-12, 2025. The updated provisional dates for cycle 4 distribution were provided by Malaria Consortium during review of this page, July 2025)
- 5
“District-wide Pilot: SMC Cycle 4, (provisional dates October 15-18, 2025)
The project will expand to all remaining SMC program health facility catchment areas within Moulko district in a refined and scaled-up second phase…. Training, messaging, supervision, and logistics will be adjusted in response to feedback and monitoring data collected in the first phase to ensure improved delivery and stronger community uptake.” Clear Solutions, ORSZ/SMC Layering Project Overview and Evaluation Plan, 2025 (the updated provisional dates for cycle 4 distribution were provided by Malaria Consortium during review of this page, July 2025) - 6
"We will compare the change in ORS use from baseline to endline in Moulko region, where the ORS+zinc deliveries will be implemented, to the change in ORS over the same period in a comparison region where Malaria Consortium conducts the SMC intervention but where the ORS+zinc deliveries will not be implemented. Ideally the comparison district will look identical to the treatment district on have the same underlying trend in key characteristics and outcomes, in particular, ORS use. To identify a comparison region we use a propensity score matching approach using Malaria Consortium monitoring data. We estimated propensity scores using child-level, caregiver-level, and household-level characteristics. We identified 2 health districts with very similar propensity scores to Moulko and the Malari Consortium team suggested we select one of these, Guelendeng, because this district was closer in proximity to Moulko, is more accessible than some other regions, and the MC team has a good working relationship with the local health team in this area." Clear Solutions, ORSZ/SMC Layering Project Overview and Evaluation Plan, 2025
- 7
"In addition, a qualitative component will be conducted in both intervention and control areas to explore caregivers’ understanding, perceptions, and practices regarding the use of ORS+zinc, as well as to assess the feasibility and acceptability of the intervention from the perspective of both caregivers and community distributors. This will include semi-structured interviews and focus group discussions carried out during the post-intervention phase." Clear Solutions, ORSZ/SMC Layering Project Overview and Evaluation Plan, 2025
- 8
"Primary Outcome: Was a case of diarrhea that occurred within the last 4 weeks treated with ORS?" Clear Solutions, ORSZ/SMC Layering Project Overview and Evaluation Plan, 2025
- 9
See this section of our intervention report on ORS/zinc.
- 10
Estimated direct under-five mortality rate based on GBD 2021 estimates:
Chad: 20,375.14 deaths attributed to diarrhea / 3,635,515.16 children aged under 5 = 0.56% annual mortality rate from diarrhea
Nigeria: 97,679.86 deaths attributed to diarrhea / 37,117,842.49 children aged under 5 = 0.26% annual mortality rate from diarrhea - 11
To roughly compare baseline ORS coverage in Nigeria and in Chad, we use survey data on the usage of ORS or Recommended Home Fluids (RHF) to treat diarrhea. , The 2019 Chad Multiple Indicator Cluster Survey (MICS) (see Tableau TC.3.3, p. 213) found that ORS or RHF usage for children with diarrhea was 22.2% in Chad. In Nigeria, the 2018 Demographic and Health Survey (see table 10.10, p. 248) indicated that treatment of diarrhea with either ORS or RHF was 41.9%.
- 12
On costs, Clear Solutions told us: “On the point of access to ORS - Chad does not have an internal manufacturing capacity so they have to rely on imports from other countries (unlike Nigeria with rich manufacturing capabilities). Furthermore, Chad’s landlocked status means that transport cost is substantial. During our initial RFP process, the quotes for ORSZ was significantly higher than Nigeria (more than 0.80 USD in Chad compared to less than 0.40 USD in Nigeria). Thus, price may play a particularly important role in Chad. (Note that for this pilot, we have managed to procure it at around 0.50 USD per ORSZ copack, including delivery to MC storage)” Clear Solutions, Responses to GiveWell's questions on SMC+ORS pilot, June 2025 (unpublished)
- 13
“ORSZ fits very well into Malaria Consortium’s strategy of strengthening community health systems by integrating health interventions with SMC delivery, especially as there is no established mass delivery platform for ORSZ and SMC is an opportunity to not only increase access to ORSZ but also to move from reactive to proactive provision of ORSZ. We hypothesise that both those factors will improve health outcomes, while building on SMC as an established delivery platform.” Email from Malaria Consortium to GiveWell, June 24, 2025 (unpublished)
- 14
“We are combining the training to be on the same day (i.e. not adding additional days), and the distribution will be completed within the same framework. For the pilot, the additive costs come in the community outreach and engagement element - whereby engagement with the government stakeholders and additional sensitisation of the communities are likely needed. We suspect that while these costs may be needed in the short term, these can be shared in the longer term as ORSZ distribution becomes more of a norm. At scale, our goal is that almost everything will be shared except for the procurement costs and perhaps some additional high-level staffing required to ensure high quality execution/ coordination of ORSZ components.” Clear Solutions, Responses to GiveWell's questions on SMC+ORS pilot, June 2025 (unpublished)
- 15
“We suspect that the ORSZ education will increase the household visits by a few minutes. The target of households per day may be decreased slightly (current projection is 75 households per day will be decreased to 70 households per day). Even if this number is too ‘generous’, the SMC campaign runs for 4 days each month - and the fourth day is reserved mainly for ‘mop-up’ activities (i.e. it is essentially a buffer). Thus, with this buffer day in mind, we don’t think it will lead to lengthening of the overall campaign. We also have some confidence in this conclusion given that MC team has layered on other programs in the past (Vit A, MUAC screening), and noted a similar dynamic in place.” Clear Solutions, Responses to GiveWell's questions on SMC+ORS pilot, June 2025 (unpublished)
- Malaria Consortium has informed us that layering ORS/zinc onto the SMC program will not require substantially more distributors (Malaria Consortium, review of this grant page, July 2025)
- 16
According to the World Bank, the estimated total under-5 child mortality rates in Nigeria and Chad are 103 and 101 deaths per 1,000 live births, respectively. The estimated child diarrhea mortality rate in Chad is 560 deaths per 100,000 population, while this figure is lower at 263 deaths per 100,000 population in Nigeria. See footnote 10 above.
- 17
This feedback came through our "Forecast with Givewell" page on the online forecasting platform Metaculus (see more about this effort to solicit external feedback on our forecasts in our blog post here).
See this comment from Nick Laing.