Note: This page summarizes the rationale behind a GiveWell grant to ALIMA. ALIMA staff reviewed this page prior to publication.
In a nutshell
In June 2025, GiveWell recommended a $1.9 million grant to the Alliance for International Medical Action (ALIMA) (more) to support primary healthcare, hospital services, and malnutrition treatment in Mokolo and Makary districts in Far North Cameroon for one year (more). This grant supports staffing and operations at approximately 16 health facilities serving a conflict-affected population, including an 80,000-person internally displaced persons (IDP) camp. (more)
We recommended this grant because:
- We think the program is likely to be cost-effective. Our best guess is that this program is 7 to 11 times as cost-effective as unconditional cash transfers (more). Factors influencing this estimate are:
- ALIMA targets a high-mortality population (pregnant women and children under 5 in a conflict-affected area) (more)
- The program delivers proven life-saving interventions at relatively low cost
- We expect limited healthcare access without ALIMA's support
- The grant addresses an urgent funding gap. ALIMA's previous USAID funding was cancelled, and without this grant, critical services would end by December 2025. (more)
- We expect to learn about multi-sectoral humanitarian health programming. This is an area where we anticipate more funding opportunities following recent aid cuts. (more)
Our main reservations:
- This was a rapid investigation (4-6 weeks vs. our typical 2-3 months) with higher uncertainty tolerance than usual due to the grant's time-sensitive nature. Our analysis relied on rougher modeling, triangulation across multiple approaches rather than deep investigation of any single approach, and greater weight on qualitative factors that suggest we may be underestimating benefits. We believe that this approach was appropriate given the time-sensitivity of the grant. (more)
- The cost-effectiveness estimate is uncertain and near our funding threshold. While multiple analyses suggest similar results, we have high uncertainty about key parameters. (more)
- We're particularly uncertain about healthcare coverage without ALIMA. We estimate roughly 30% of patients would receive treatment without ALIMA, but this could be wrong. (more)
Published: February 2026
1. The organization
ALIMA supports inpatient and outpatient emergency care and long-term clinical care in 13 countries, mainly in the Sahel region of Africa. Since 2021, GiveWell has recommended four previous grants to ALIMA totaling over $8 million, primarily supporting malnutrition treatment programs in Niger, Nigeria, and Chad.1 This is our fifth grant to ALIMA and our first supporting their multi-sectoral healthcare programming.
2. The intervention
In the Far North region of Cameroon, ALIMA provides comprehensive healthcare support to government facilities that cannot adequately serve their populations due in part to regional conflict. ALIMA's support includes:
- Staffing: Funding salaries for approximately two-thirds of healthcare workers across 16 facilities, including doctors, nurses, and community health workers2
- Medical supplies: Providing essential medications, equipment, and nutritional supplements, particularly during government stockouts3
- Specialized services: Supporting operations for the region's only neonatal care unit and inpatient malnutrition treatment services as well as providing general malnutrition care4
- Training and supervision: Building local capacity in evidence-based protocols like kangaroo mother care and malnutrition treatment
- Rapid response mechanism: Ready-to-act structure, designed to enable immediate action in emergency situations, such as disease outbreaks, natural disasters, or sudden crises.
The most common treatments provided include antimalarial medications (ACTs), oral rehydration solution (ORS) for diarrhea, antibiotics for respiratory infections, treatment for acute malnutrition (CMAM), and neonatal care.5
3. The grant
This $1.9 million grant will support ALIMA's operations in Mokolo and Makary districts from July 2025 through June 2026. The grant fills a critical gap left by cancelled USAID funding.
At the time of the investigation, ALIMA had already withdrawn some staff from facilities due to funding constraints, but stated that they would be able to quickly reinstate them if funding was secured by July 2025.6 Without new funding, we expect that ALIMA would have withdrawn staff from the region by December 2025.7
We expect this grant to support treatment for approximately 65,000 individuals over one year, including 33,000 children under five.8
3.1 Budget for grant activities
The $1.9 million budget includes:9
- $950,000 (50%) - Healthcare worker salaries and incentives
- $342,000 (18%) - Medical supplies and equipment
- $152,000 (8%) - Transportation and mobile clinic operations
- $456,000 (24%) - Program management, training, and overhead
4. The case for the grant
We recommended this grant because:
- We estimate the program is highly cost-effective, despite significant uncertainty. (More below)
- The program targets a high-mortality population in an area with limited healthcare access. (More below)
- The grant addresses an urgent need with time-sensitive impact. (More below)
- We expect to gain valuable insights about multi-sectoral humanitarian programming. (More below)
4.1 Cost-effectiveness
To evaluate this program we conducted three different analyses that all converged on similar results, estimating this program is 7-11 times as cost-effective as unconditional cash transfers.10 We think that the program costs approximately $29 per unique beneficiary treated, which is comparable to other ALIMA programs we consider cost-effective.11
These models are as follows:
- Consultation-based model: We estimated mortality effects by condition based on the types of treatments ALIMA provides (malaria, diarrhea, respiratory infections, malnutrition, neonatal care). This approach yielded an estimate of 8x (range 7-11x).
- Population-level analysis: We compared ALIMA's expected impact to similar iCCM/CHW programs we've previously evaluated, adjusting for program intensity (~$5 per person served across the population). This suggested cost-effectiveness of ~9x.
- Patient-level analysis: We adapted our existing CMAM model assumptions to this context, accounting for the higher severity of cases seen in hospital settings. This resulted in an estimate of 7-8x.
The convergence of these different approaches increased our confidence in this estimate, though significant uncertainty remains about key parameters.
However, we think there are plausible additional benefits that we didn’t spend much time investigating, and think aren’t captured in these models (e.g. support for vaccine delivery, role in disease outbreak response, training to support additional services)12 . Consideration of these unmodeled benefits pushes our best guess of the cost effectiveness of the program over our funding bar of 10x.
A summary of the results of our consultation model can be seen in the simplified cost-effectiveness analysis below.
Simplified cost-effectiveness analysis
| Best guess | 25th - 75th percentile | CE over this range | ||
|---|---|---|---|---|
| Grant | ||||
| Total cost | $1,900,000 | |||
| Cost per person reached | $29 | |||
| Benefits to children under 5 | ||||
| Mortality effects | ||||
| Number of children under 5 treated | 33,305 | 15000 - 41000 | 4x - 9x | |
| Average mortality rate, across conditions (including direct + indirect effects from conditions treated by ALIMA) | 3% | 1% - 7% | 4x - 22x | |
| Average reduction in mortality reduction from treatment | 46% | 25% - 65% | 5x - 11x | |
| Estimated deaths of children under 5 averted | 433 | |||
| Moral value of averting the death of a child under 5 | 119 | |||
| Units of value from mortality effect for children under 5 | 51,503 | |||
| Developmental effects | ||||
| Size of the developmental effect, as a proportion of the mortality effect | 19% | |||
| Units of value from under 5 mortality and developmental effects | 61,271 | |||
| Benefits to people over 5 | ||||
| Mortality effects | ||||
| People over 5 treated | 31,567 | 16000 - 43000 | 7x - 8x | |
| Average mortality rate across conditions (including direct + indirect effects from conditions treated by ALIMA) | 1% | 0.4% - 1.5% | 7x - 9x | |
| Average reduction in mortality from treatment | 42% | 20% - 65% | 7x - 8x | |
| Estimated deaths of people over 5 averted | 104 | |||
| Moral value of averting the death of a person over 5 | 73 | |||
| Units of value from mortality effect for people over 5 | 7,614 | |||
| Adjustments | ||||
| Discount: Counterfactual healthcare coverage | -30% | -55% , -20% | 5x - 9x | |
| Discount: Saving same lives each year | -10% | |||
| Discount: Risk of implementation issues | -20% | -30%, 0% | 7x - 10x | |
| Discount: Some consultations won't result in treatment | -5% | |||
| Adjustment: Some children benefit from multiple treatment | 25% | 35%, 0% | 6x - 8x | |
| Adjustment: Health sensitisation, vaccine catch up | 10% | |||
| Final cost-effectiveness estimate | ||||
| Final cost-effectiveness in terms of multiples of GiveDirectly's unconditional cash transfer program | 8 |
4.2 High-mortality population with low counterfactual coverage
We estimate that children under five in this region would have approximately a 2.7% annual mortality rate without ALIMA's services.13 While we draw on multiple data sources including SMART surveys14 , data from the Demographic and Health Surveys program, and ALIMA's data from similar contexts, we note that none of these sources are both recent and specific to this population, and all are subject to considerable statistical noise. As a result, we have significant uncertainty about the true mortality rate.
Our understanding is that ALIMA provides approximately two-thirds of trained medical staff across local facilities and runs nutrition and neonatology services for the districts served, including providing kangaroo mother care across the entire region.15 Our best assessment is that without ALIMA, the neonatal department would likely close while the hospital would attempt to maintain some level of pediatric care by shifting staff from other departments.16
4.3 Urgent need
This grant is time-sensitive. ALIMA has already withdrawn staff from some facilities but can reinstate them quickly with funding.17 Further delays would result in additional layoffs and potentially permanent closure of services.
4.4 Learning value
We expect this grant to help us understand multi-sectoral humanitarian health programming, which is important because:
- Many nutrition projects include multi-sectoral components beyond targeted nutrition interventions
- Recent U.S. government funding cuts have created more gaps in this space, potentially expanding our funding opportunities
- We need better approaches to model and assess these programs, as we generally have more experience evaluating targeted interventions
For example, this program delivers CMAM (an intervention we consider cost-effective in some settings) but also provides direct care for other conditions, trains medical staff across various topics, conducts community sensitization on health/WASH18 /nutrition topics, and improves WASH/sanitation practices at facilities.
We plan to explore options to use M&E data from this program, alongside qualitative research, to better understand how to assess program quality and counterfactual service availability..
5. Risks and reservations
Our main concerns about this grant:
- Cost-effectiveness is near our threshold and highly uncertain. While multiple analyses (described above) yield similar results (7-11x), we have significant uncertainty about key parameters. Our sensitivity analysis shows the estimate could range from 4x to 22x depending on assumptions about baseline mortality rates (1-7%) and treatment effectiveness (20-65%).19
- Limited understanding of healthcare without ALIMA. We estimate 30% of patients would receive care without ALIMA,20
but this is a rough estimate based on:
- ALIMA providing ~67% of healthcare workers across facilities
- The expectation that nutrition and neonatology services would completely cease
- Local health authorities' attempts to reallocate remaining staff from other departments
- Some access to private markets for basic medications
This was corroborated by a local stakeholder. However, we're uncertain about private sector alternatives, potential government responses, and how care-seeking behavior would change. If more patients could access care elsewhere (e.g., 50% instead of 30%), the program's cost-effectiveness would drop below our threshold.
- Rapid investigation may have missed important factors. This investigation was conducted quickly due to time constraints (completed in approximately 4-6 weeks versus our typical 2-3 month timeline). As a result:
- We had limited time to investigate potential “funging” concerns. While we believe ALIMA is filling a genuine gap (USAID funding was cancelled with no replacement), we didn't deeply investigate whether other donors might step in, whether the government might reallocate resources from other regions, or whether other NGOs might expand operations
- We couldn't conduct site visits or extensive stakeholder interviews beyond ALIMA staff and one hospital director
- We relied heavily on ALIMA's own data and estimates rather than independent verification
- We may have missed important contextual factors about the local health system's capacity to adapt
- Operational risks in a conflict-affected region. The Far North region faces ongoing security challenges.21 Additionally, Cameroon's 2025 elections could disrupt operations. We've applied a 20% discount for implementation challenges, but this may underestimate risks.
6. Plans for follow up
- Quarterly check-ins with ALIMA on program progress and challenges
- Potential qualitative evaluation to assess:
- Changes in healthcare utilization with and without ALIMA
- Quality of care provided
- Counterfactual healthcare availability
- Monitoring of the NutriVax trial implementation
- Assessment of learning from this grant to inform future multi-sectoral health funding decisions
7. Internal forecasts
For this grant, we are recording the following forecasts:
| Confidence | Prediction | By time |
|---|---|---|
| 50% | We will decide to renew this grant to ALIMA in 2026 | January 2026 |
| 50% | ALIMA will treat >12,000 unique children under 5 for malnutrition or malaria during grant period in Mokolo/ Makary | June 2026 |
| 60% | We will recommend a separate monitoring and evaluation grant to monitor this work | January 2026 |
8. Our process
Our investigation included:
- Three conversations with ALIMA leadership
- Three conversations with ALIMA's Cameroon operations team
- Conversation with the Mokolo hospital director
- Consultation with external experts on humanitarian health programming
- Review of ALIMA's program data and budgets
- Development of multiple cost-effectiveness models
- Internal review by GiveWell research staff
9. Relationship disclosures
We have no relationship disclosures related to this grant.
Sources
- 1
Our most recent grant to ALIMA is described here.
- 2
ALIMA staff list and budget, 2025 (unpublished).
- 3
ALIMA records and conversation with ALIMA, April 2025 (unpublished).
- 4
Mokolo Hospital Director, conversation with GiveWell, May 30, 2025 (unpublished).
- 5
Based on ALIMA's 2024 program data (unpublished) showing consultation breakdowns by condition.
- 6
ALIMA states that they have maintained contracts with these staff to enable rapid reinstatement.
- 7
Based on ALIMA's current funding runway and operational requirements.
- 8
- Source: GiveWell analysis of ALIMA program data and population coverage estimates (unpublished).
- Note: These figures include benefits to both mothers and children for delivery and antenatal care. We note that our estimates of individuals served differ somewhat from ALIMA's own estimates. This is because to model program benefits we need to translate from caseload seen to individuals served, meaning we have to adjust for any individual who attends the facility more than once within the program time frame. Our best guess of how many individuals are repeat attenders is higher than ALIMA's so our estimate of individuals served by the program is lower.
- 9
ALIMA, Budget for Cameroon Program 2025-2026 (unpublished).
- 10
- Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. See GiveWell's Cost-Effectiveness Analysis page for more information about how we use cost-effectiveness estimates in our grantmaking.
- To date, GiveWell has used GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding opportunities, which we describe in multiples of "cash." In 2024, we re-evaluated the cost-effectiveness of direct cash transfers as implemented by GiveDirectly and we now estimate that their cash program is 3 to 4 times more cost-effective than we'd previously estimated.
- 11
Comparison based on ALIMA programs in Kaita, Nigeria ($30/child) and Niger ($17/child).
- 12
Below is a summary of the plausible unmodeled benefits of ALIMA’s program
- Training and supervision. While we think training and oversight of staff within the facilities would show up in the caseload level mortality estimates, we have also heard that ALIMA conducts training with local NGOs, for example in the delivery of kangaroo mother care (KMC). We are not certain but think it’s likely that these NGOs cover a population beyond those covered by the facilities ALIMA is directly supported. This is corroborated by our conversation with the Mokolo hospital director who described ALIMA as having brought KMC to the entire region (i.e. not just the districts where they directly work).
- Disease outbreak monitoring. ALIMA supports efforts to coordinate and monitor for disease outbreaks (most notably cholera) in the region. Without this we expect the health system to pick up some activities, but at lower capacity which could diminish any future outbreak response.
- Community sensitization. There are various community sensitization efforts run by ALIMA’s CHWs in the region which include health promotion components. We think it’s possible that there are additional effects (probably small) of improved healthy behaviors (e.g. sanitation practices, promotion of breastfeeding, gender-based violence, and maternal health).
- Vaccine delivery. ALIMA plays two main roles in vaccine delivery: 1) identifying children who need catch-up vaccination when they attend facilities and ensuring vaccination is delivered, 2) supporting the cold chain supply. ALIMA will specifically be supporting the supply chain management of the malaria vaccine once it arrives in the region, which very speculatively, could have a substantial additional effect on malaria mortality than we’re currently estimating.
- 13Based on a weighted average of 2020 SMART survey data for Far North Cameroon, DHS 2018, IGME estimates, and ALIMA mortality data from similar contexts.
- 14SMART surveys are standardized cross-sectional field surveys that measure two key humanitarian indicators - childhood malnutrition rates (through anthropometric measurements of children under 5) and population mortality rates - to assess the severity of humanitarian crises and inform emergency response decisions.
- 15
This is our understanding based on conversations with ALIMA and the Mokolo hospital director (unpublished).
- 16
Mokolo Hospital Director, conversation with GiveWell, May 30, 2025 (unpublished).
- 17
Staff were withdrawn in early 2025 but, according to ALIMA, remain available for reinstatement.
- 18
Water, Sanitation, and Hygiene interventions (WASH)
- 19
Particularly regarding baseline mortality rates and the proportion of patients who would receive care without ALIMA.
- 20Based on facility staffing levels, available services, and expected care seeking behavior without ALIMA.
- 21
The U.S. Department of State recommends against traveling to Cameroon’s Far North region due to a risk of crime, kidnapping, and terrorism