International Rescue Committee (IRC) — Treatment of Malnutrition (May to August 2021 grants)

Note: This page summarizes the rationale behind GiveWell grants to the International Rescue Committee (IRC). This page discusses our rationale at the time we recommended the grants. Typically, GiveWell publishes cost-effectiveness analyses for the grants that we make. In this case, we are not publishing a cost-effectiveness analysis to accompany this page because that version of our model is now out of date. Numerical estimates on this page are sourced from the 2021 version of our cost-effectiveness analysis. IRC staff reviewed this page prior to publication.

Summary

What we thought these grants would do

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

Why we recommended these grants

• We thought that the IRC's programs in Chad, Niger, Burkina Faso and Somalia were highly cost-effective. We estimated that overall this set of countries was 10 times as cost-effective as unconditional cash transfers ("10x cash"), the benchmark we use for cost-effectiveness. Our cost-effectiveness bar for recommending grants was 8x cash when we recommended these grants.

  In simple terms, we thought these grants would be cost-effective because:

  • Children with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are at greatly elevated risk of dying compared to non-malnourished children. Depending on location, we estimated that the mortality rates of children with untreated SAM were 7% to 16%. In Somalia, the only location where we supported MAM treatment, we estimated mortality rates of children with untreated MAM to be around 2%. Our estimates were based on Institute for Health Metrics and Evaluation estimates of under-5 mortality rates, UNICEF data on malnutrition prevalence, and a pooled analysis of historical data that estimates the risk of excess mortality associated with untreated MAM and SAM. (More)
  • Children who are malnourished are significantly less likely to die if they receive treatment. We estimated that malnutrition treatment reduces the relative risk of mortality over the next year by about 40%, based on treatment cure rates reported by the IRC and our estimate of mortality rates for non-malnourished children. (More)
  • The IRC's support for malnutrition treatment programs in government-run health facilities leads to more children being treated for malnutrition. We estimated that the IRC's program would increase the number of children who receive malnutrition treatment by ~80,000 over three years. This was based on the IRC's historical caseload (where available) and population and incidence estimates (where historical caseload data was not available), as well as the IRC's best estimate of the percentage of children treated with IRC support who would be treated in its absence. (More)
• We expected these grants would provide information that would affect future grants, and thought the DRC program would be especially valuable in that respect. We expected the IRC's monitoring data would improve our estimate of the number of additional children treated as a result of the IRC’s work. We thought this information would be especially valuable for the Democratic Republic of the Congo (DRC), due to high uncertainty about this input, and a large funding gap in the country. (More)

Main reservations

• What effect does malnutrition treatment have on mortality? There exists very limited evidence on the effect of CMAM on mortality. Our estimate heavily relied on Olofin et al. 2013, a widely used meta-analysis of observational studies conducted in the 1980s and 1990s. Since we did not feel we had a solid understanding of the methodology employed in the paper, we hired an external consultant to reanalyze the meta-analysis. As a result, we significantly updated our model after making these grants. (More)
• How many additional children would receive malnutrition treatment as a result of the IRC's support? We were uncertain about the number of children who would be treated with IRC support, since our estimates relied on historical caseload data (which might not be representative of future caseload, due to fluctuations in malnutrition prevalence) or a formula using malnutrition incidence (for which we found very contrasting estimates). We were also uncertain about the number of children who would be treated without IRC support, since those were based on best guesses, and we did not know how calibrated the estimates were. (More)
• How much would we be able to learn from these grants? We were unsure of the extent to which we could extrapolate from program data to future years and additional geographies. (More)

Since we recommended these grants, we significantly updated our cost-effectiveness model for malnutrition treatment programs. In particular, we:

• Incorporated the result of a re-analysis of Olofin et al. 2013, which we had commissioned to an external consultant.
• Estimated a maximum plausible mortality rate of malnourished children (based on malnutrition incidence and overall mortality rates in the targeted areas), and applied it as a ceiling to our best guess.

Both updates decreased our estimate of mortality rates among malnourished children, decreasing the program's cost-effectiveness. More details about the updated model are in our malnutrition intervention report.

Using our updated cost-effectiveness model and the information we had at the time of recommending the grants, four of the five countries to which we recommended funding (Burkina Faso, Chad, DRC, and Somalia) would not meet the 8x cash funding bar we used at the time of recommending the grants. (More)

These grants were funded by Open Philanthropy.

Published: March 2024

The organization

The International Rescue Committee (IRC) is a large international NGO which works in more than 40 countries to address humanitarian crises.1 The IRC's program areas include economic well-being, education, and health.2 The IRC provides technical assistance to support acute malnutrition treatment in more than 30 countries.3

The intervention

The IRC supports the treatment of acute malnutrition in government facilities. Acute malnutrition refers to excessive thinness for one's height and/or the presence of nutritional edema, or swelling caused by excess fluid retention in tissues.4 Acute malnutrition is believed to raise the risks of developmental delays and death from infectious disease.5

Malnutrition treatment is provided by identifying children experiencing malnutrition and providing them with therapeutic food in an inpatient or outpatient setting. Children experiencing severe acute malnutrition (SAM) are also given a course of antibiotics to reduce infections.6

The IRC aims to increase the coverage and quality of malnutrition treatment by supporting the governments in the countries where it works. Our understanding was that the program activities may vary by country.7 However, activities funded by these grants fall into four major categories:

1. Supporting government-run outpatient malnutrition centers. The IRC's activities include training and mentoring government staff,8 including training community health volunteers to identify malnourished children and providing cascading training for caregivers on the Family MUAC (mid-upper arm circumference) approach,9 procuring equipment and medical supplies,10 and enhancing service provision in hard-to-reach areas by leveraging other healthcare platforms or by utilizing mobile clinics.11
2. Supporting government-run inpatient malnutrition clinics. The IRC's activities include training and mentoring government staff, providing medical supplies, refurbishing facilities, providing human resources, and setting up a referral system from outpatient centers.12
3. Supporting government planning. The IRC expects to help government partners predict changes in malnutrition caseload and plan resources accordingly by training health staff in CMAM Surge (an approach developed for this purpose) and/or by supporting government officials' review of the performance of malnutrition programs.13
4. Data collection. The IRC will conduct annual coverage surveys14 and will collect individual-level data on children treated, including data on age, status at admission and discharge.15

In Somalia, the IRC will provide a broader set of child and maternal health interventions.16 We expect that some activities supporting care for some non-malnourished children may take place in other grant locations, though to a lesser extent.17 We included benefits of treatment to non-malnourished children in our cost-effectiveness model for Somalia, but not for other locations.

The grants

We recommended a total of $19.9 million to the IRC, split between two grants. In May 2021, we recommended a bridge grant of $1.8 million to fund the IRC's coverage surveys in 2021 and the IRC's program costs for three months as we completed our investigation for a longer-term grant. In August 2021, we recommended a grant of $18.1 million. This amount covers the cost of 33 months of operations across five countries and three annual rounds of coverage surveys.

These grants support the IRC's work in the following locations:

• Burkina Faso (Centre region)18
• Chad (Guera province)19
• The Democratic Republic of the Congo (DRC) (Tanganyika province)20
• Niger (Tillabéry region)21
• Somalia (Banadir, Galgadud, Mudug and Nugal regions)22

Prior to these grants, the IRC was working in roughly 40% of these sites. For the remaining 60%, it would be expanding to new areas.23

In Somalia, it planned to support treatment for both children with severe acute malnutrition (SAM) and children with moderate acute malnutrition (MAM). In the remaining countries, it planned to support treatment for SAM cases only.24

Budget

Of the total $19.9 million, we expected $1.4 million to be spent on coverage surveys and $18.5 million to be spent on program implementation. This was based on the IRC's budget.25 We estimated that the IRC would spend an additional $1.3 million, covered by other funders, to implement the programs supported by these grants. This was based on information shared by the IRC.

The case for the grant

Cost-effectiveness in Burkina Faso, Chad, Niger, and Somalia

Our best guess was that the activities funded by these grants would be 10 times as cost-effective as unconditional cash transfers ("10x cash"), using a weighted average across locations. At the time we recommended these grants, our bar for funding grant opportunities was 8x cash.

The sections below report the key model inputs for our 2021 model, which we used to make this decision. We're not planning to publish that model, as it is out of date.

Key inputs

Mortality rates among targeted children

We estimated that the mortality rates of children with untreated SAM are 7% to 16% in the locations supported by these grants. We estimated that the mortality rates of children with untreated MAM are ~2% in Somalia, the only location where we support MAM treatment.

We calculated these mortality rates using the following:

• Estimates of under-5 mortality rates, based on data from the Institute for Health Metrics and Evaluation (IHME).
• Malnutrition prevalence, based on UNICEF data.26
• Olofin et al. 2013. This study pools observational data from ten historical cohorts of children under 5 years old in low-income settings to estimate the excess risk of mortality associated with untreated MAM and SAM.27

Malnutrition treatment effect on mortality

We estimated that malnutrition treatment reduces the relative risk of mortality over the next year by about 40% in the locations supported by these grants. This estimate was based on treatment cure rates (as reported by the IRC) and our estimate of mortality rates for non-malnourished children. We calculate these mortality rates using the information outlined above.

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

We estimated that the IRC's program will increase the number of children who receive malnutrition treatment by ~80,000 over three years.

We estimated this on the basis of our:

• Estimate of the number of children treated with the IRC's support:
  • For countries where the IRC has previously worked (Chad, Somalia, and Niger), we estimated the IRC's future caseload based on its historical caseload.
  • For countries where the IRC has not yet worked at a large scale (Burkina Faso and DRC), we relied on population, prevalence and incidence estimates to estimate future caseload.
• Estimate of the number of children treated without the IRC's support.
  • We estimated this on the basis of the IRC’s best guess of the percentage of children treated with the IRC who would be treated without IRC support.28
  • To serve as points of triangulation, we identified one study from Burkina Faso that reported coverage rates before and after NGO support. At baseline, it found coverage with government-only treatment was 20% while later coverage with NGO support was 52%.29 This estimate is broadly in line with IRC's estimates, which increased our confidence in the inputs we used in the model.

Leveraging malnutrition work to support additional pediatric care (Somalia only)

In Somalia, the IRC plans to also provide pediatric care for non-malnourished children in hard-to-reach areas through mobile clinics.30 We expected most of the benefits to come from vaccinations, based on the list of services the IRC planned to deliver, and pre-existing work we had done on the benefits of these services.

We estimated the impact of vaccinations on the basis of the IRC’s caseload estimates and our previous work on the benefit of vaccinations on mortality per child treated. We estimated that these grants would lead to approximately 20,000 additional children being vaccinated in Somalia over three years.

Variations in cost-effectiveness by country

Using our 2021 model and the information we had at the time we recommended the grant, we estimated the cost-effectiveness (in multiples of the value of unconditional cash transfers) of the IRC's programs by country as follows:

• Burkina Faso: 8.4x
• Chad: 10.0x
• Niger: 12.6x
• Somalia: 11.3x

Learning value for all countries, and especially DRC

We expected these grants would let us learn information that would affect future grants.

In particular, we expected to learn about additional children receiving malnutrition treatment as a result of the IRC's support, which was one of our key uncertainties about these grants. We expected to learn about the number of children treated by the IRC on the basis of the IRC's program data. We also expected to learn about the IRC's effect on the number of children treated, by comparing coverage at baseline to coverage across years, in locations with no NGO support at baseline.

We were especially interested in learning about DRC. This is because we were highly uncertain about the number of children that would be treated with the IRC (since we lacked historical data) and, as a result, about the program’s cost-effectiveness. Moreover, our understanding based on conversations with experts was that there may be a substantial funding gap for nutrition programs in DRC. This meant there was an opportunity to direct a significant amount of funding there in the future. We therefore recommended funding the program, even though our estimate for the program cost-effectiveness was well below the range of cost-effectiveness of programs we typically direct money to (5.5x cash).

Risks and reservations

What effect does malnutrition treatment have on mortality?

We describe how we calculated the effect that malnutrition treatment has on mortality above.

We were highly uncertain about our estimate. This is because we did not have any direct evidence of the effect that malnutrition treatment has on mortality. This is different from most other child health programs we support, where we have direct estimates of the program's effectiveness, usually from a number of randomized controlled studies.

Our estimate heavily relied on Olofin et al. 2013, a widely-used meta-analysis. Since we did not feel we had a solid understanding of the methodology employed in the paper, we hired an external consultant to reanalyze the meta-analysis. This led to a significant update in our model.

How many additional children would receive malnutrition treatment as a result of the IRC's support?

We describe how we calculated the number of additional children that receive malnutrition treatment as a result of the IRC's support above.

Our estimate was based on calculating the number of children treated with the IRC's support, the number of children treated without the IRC's support, and subtracting the latter from the former.

• Uncertainty about the number of children treated with the IRC's support. For estimates of children relying on historical caseload, the main limitation is that malnutrition prevalence and population can change significantly across years, so we were unsure of whether historical caseload can reliably predict future caseload. For estimates relying on population, malnutrition prevalence and incidence, we are especially uncertain about the incidence correction factor, an input used to translate prevalence into incidence.
• Uncertainty about the number of children who would be treated without the IRC's support. We estimated this on IRC staff best guesses. We triangulated these estimates with two studies reporting coverage rates before and after NGO support, but we were unsure whether those findings were generalizable.

We expected to learn more about this during the grant.

How much would we be able to learn from these grants?

We were unsure about the extent to which the number of children treated with IRC support during these grants would be a good proxy for the number of children treated by the IRC in future years. This is because the number of children treated is affected by malnutrition prevalence, and, based on conversations with experts, our understanding was that malnutrition prevalence can be highly variable along with economic, security, and climate conditions.

We were also unsure whether changes in coverage resulting from these grants would be a good indication of the effect of NGOs on coverage in other geographies and in future years. This is because non-programmatic factors (e.g., security challenges) could obfuscate the impact of programmatic factors on coverage.

Updates to our model between 2021 and 2022 grants

We did significant additional work on our cost-effectiveness model after recommending the 2021 grants.
For these 2021 grants, we relied on a widely-used meta-analysis, Olofin et al. 2013, to estimate mortality among untreated malnourished children (see above). After recommending our 2021 grant, we hired an external consultant to reanalyze the meta-analysis. His work implied less mortality from malnutrition than Olofin et al. 2013. We updated our model to incorporate his work, which is described in more detail in our malnutrition intervention report.

We also created a separate model to estimate the maximum plausible mortality rates of malnourished children, given malnutrition incidence and overall mortality rates in the targeted areas (a "ceiling analysis"). We used this analysis to adjust our cost-effectiveness estimates for malnutrition treatment programs. For more about the ceiling analysis, see our malnutrition intervention report.

The updates to our cost-effectiveness model led to the following changes in our estimate of the cost-effectiveness of the IRC's programs in the locations supported by these grants (in both cases, using the information we had at the time we recommended the grants). Our cost-effectiveness bar at the time we recommended the grants was 8x.

Plans for follow-up on these grants

We planned to have periodic conversations with the IRC throughout these grants and to receive information on coverage survey implementation and results.

Forecasts

For these grants, we are recording the following forecasts:

Questions for further investigation

We list our key questions for further investigation in our malnutrition intervention report.

Our process

GiveWell recommended these grants as part of a broad investigation into treatment of malnutrition as a potentially cost-effective intervention. Prior to recommending these grants, we:

• Had multiple conversations with the IRC
• Spoke with representatives from the IRC's country teams in Chad, Somalia, Niger, Burkina and DRC31
• Spoke with local stakeholders from Somalia, DRC, and Burkina Faso.
• Spoke with other implementers of malnutrition programs, including ALIMA;32 Concern Worldwide;33 Doctors Without Borders; Helen Keller International;34 Medair;35 Save the Children USA;36 and the Society for Nutrition Education, and Health Action37
• Spoke with representatives from ECHO, a prominent funder of nutrition interventions in Africa, about ECHO's funding priorities for treatment of malnutrition38
• Spoke with two malnutrition experts39
• Reviewed documents shared with us by the IRC, including IRC's proposal for the grant, which responded to a number of our questions and requests for data.
• Created a cost-effectiveness analysis for the activities funded by the grants and conducted sensitivity and plausibility checks on our results.40

Sources

• 1

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

• 2

  See IRC, "What we do"

• 3

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

• 4
  • "Wasting refers to a child who is too thin for his or her height. Wasting is the result of recent rapid weight loss or the failure to gain weight." UNICEF, WHO, World Bank, "Joint child malnutrition estimates — levels and trends," 2020, p. 2.
  • “Acute malnutrition is a major public health issue in low-income countries. It includes both wasting and edematous malnutrition, but the terms wasting and acute malnutrition are often used interchangeably." Frison, Checchi, and Kerac 2015, Abstract.

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

• 6

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

• 7

  This understanding came from multiple conversations with the IRC.

• 8

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

• 9

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

  • Regular and continuous malnutrition screening through Family MUAC approach, which aims to train and equip each household on malnutrition screening. For that, community health volunteers (CHVs) from each village will be trained on Family MUAC by a local partner (CORAB) and then will replicate the training at household level.
  • Mass screening by CHVs in areas with low SAM admission rate by trained CHVs." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14.

• 10
  • UNICEF procures RUTF in all targeted countries but DRC, where the IRC plans to purchase them. In Chad and Niger, the IRC plans to purchase some RUTF to keep as a buffer, to supplement UNICEF provision.
    • "DRC (...) Purchase of all RUTF needs to treat SAM cases" IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 16
    • "CHAD (...) Establishment of a RUTF buffer stock to respond to any possible stock out" IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 15
    • "NIGER (...) Establishment of a RUTF buffer stock to respond to any possible stock out." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 17
  • Example: "6.1 BURKINA FASO. At the health center level (OTP):
    • "Training of at least 2 health workers per health center by MoH and IRC agents.
    • "Continuous mentoring adapted to the specifics needs of health workers by the IRC agents. (...)
    • "Provision of materials, equipment, and medicines for the management of malnutrition according to the needs of each health facility (...) For that, community health volunteers (CHVs) from each village will be trained on Family MUAC by a local partner (CORAB) and then will replicate the training at household level.
    • "Mass screening by CHVs in areas with low SAM admission rate by trained CHVs." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14

• 11
  • In Chad, DRC and Niger, the IRC plans to support government health workers to deliver CMAM in hard-to-reach areas, leveraging vaccination campaigns and platforms for the treatments of pneumonia, diarrhea and malaria (iCCM). For example: "CHAD (...) 3. At village level – in hard-to-reach area through advanced vaccination strategy:
    • "Provision of materials, medicines and transportation means to integrate SAM treatment within the treatment the advanced vaccination strategy.
    • "Continuous mentoring adapted to the specifics needs of health workers responsible of the advanced vaccination strategy, by the IRC agents. This mentoring will be on a sliding scale throughout the project and will be linked to the empowerment of the health agents for CMAM." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021 p. 15
  • In Somalia, the IRC plans to use mobile clinics to cover children in hard-to-reach areas.
    • "The project targets 5 health facilities (2 in Banadir with one of the facilities providing SC services, 1 Galgadud, 1 Mudug and 1 Nugal) and 27 sites that will be reached through mobile teams in Galgadud, Mudug and Nugal regions." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 12.

• 12

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

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

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

• 13
  • For example: "Burkina Faso (...) Services are effectively planned, managed, and delivered in partnership with MoH and national actors including determining increased support during peak surges.
    • CMAM Surge implementation to enables programs and MoH to plan for and predict changes in malnutrition caseloads and access the capacity to manage. For that, at least 2 health workers per health center workers will be trained and monitored by IRC on CMAM Surge approach.
    • Quarterly joint supervision with MoH and IRC to evaluate the quality and coverage of nutrition treatment services at health facility and community level, with priority given to facilities with low performance indicators." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 14
  • "What is CMAM Surge? The Community-based Management of Acute Malnutrition (CMAM) Surge Approach was designed to help health systems more effectively deliver services for children with acute malnutrition. The approach is based on the observation that in many contexts the number of children seeking treatment for acute malnutrition tends to peak during certain months of the year." Concern Worldwide, "The CMAM Surge Approach," May 25, 2021

• 14
  • See IRC, Summary of Coverage Surveys for GiveWell, 2021, for a list of coverage surveys that IRC planned to conduct.
  • Coverage surveys for 2021 were funded by the bridge grant recommended by GiveWell in May 2021. Two additional rounds of annual coverage surveys will be covered by the grant recommended in August 2021.

• 15

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

• 16

  "6.5 SOMALIA (...)

  • Prevention services will include deworming for children 12-59 months and pregnant women in the 2nd and 3rd trimester, counselling and promotion on infant and young child feeding. Community mobilization and screening as well as micronutrient supplementation for PLW (multiple micronutrients and Iron folate) and children 6-59 months with Vitamin A supplements. The program will promote home-based fortification to enrich the diets of young children 6 - 23 months through the distribution of micronutrient powder.
  • Provision of routine immunization services to children and pregnant women in these project sites. Systematic defaulter tracing and follow up of absentees will be conducted at community level by community health workers."

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

• 17

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

• 18

  "2.1 BURKINA FASO … This project therefore represents a new area of operations for IRC nutrition programming;no other nutrition projects have yet been implemented by IRC in the Centre region. … FUNDING - CENTRE REGION … Health District … Bogodogo, Boulmiougou, Sig-Noghin." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 3

• 19

  "2.2 CHAD … This project will be implemented in the first year in Guera province. From the second year onwards, following a needs assessment budgeted in the first year, we plan also to begin nutrition in Wadi-Fira region in Eastern Chad allowing the IRC to offer nutrition services also to children under five outside of camps." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 3

• 20

  "5.3 DRC With this project, IRC proposes to support the Ministry of Health in the detection and management of malnutrition in 2 Health Zones of the Tanganyka province: Kalemie and Nyemba." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p.13

• 21

  "5.4 Niger With this project, IRC proposes to support the Ministry of Health in the detection and management of malnutrition in 3 Health Districts of the Tillabery region: Balleyara, Fillingue and Ouallam." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p.13

• 22

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

• 23

  Six of the 10 districts covered in Burkina, Chad, DRC and Niger are new areas for the IRC, and ~50% of sites covered in Somalia. For details, see IRC, Summary of Coverage Surveys for GiveWell, 2021, "New Introduction of IRC Services in the Whole District?" column and IRC, Target sites for Somalia, 2021, "status of the sites" column. See also IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, section 2: "IRC’s funding history in the region of interest" for more details by country.

• 24
  • See tables in IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, pp. 11-12. The table for Somalia includes projections for OTP (Outpatient Therapeutic Program), SC (Stabilization Center), and MAM admissions for the program. Tables for other countries only project admissions for OTP and SC.
  • IRC Somalia, Conversation with GiveWell, July 19th 2021 (unpublished)
  • We did not investigate why the IRC was planning to provide MAM treatment in Somalia, but not in other countries.

• 25

  For the IRC's proposed budget, see IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 1.

• 26

  We used estimates of the prevalence of severe and moderate wasting in each country from UNICEF Data Warehouse.

• 27
  • "Pooled analysis involving children 1 week to 59 months old in 10 prospective studies in Africa, Asia and South America. Utilizing most recent measurements, we calculated weight-for-age, height/length-for-age and weight-for-height/length Z scores, applying 2006 WHO Standards and the 1977 NCHS/WHO Reference. We estimated all-cause and cause-specific mortality hazard ratios (HR) using proportional hazards models comparing children with mild (−2≤ Z <−1), moderate (−3≤ Z <−2), or severe (Z <−3) anthropometric deficits with the reference category (Z ≥−1)." Olofin et al. 2013, Abstract.
  • "[W]e collated and analyzed data from 10 large prospective studies in low- and middle-income countries." Olofin et al. 2013, p. 2.

• 28
  • For MAM estimate (Somalia):
    • "Coverage where they work: 40%-50%
    • "Coverage where they do not work: 5%- 20%
    • "- MAM < SAM (+5-10% for SAM); depends on the season" Rough notes from a conversation with IRC Somalia team, July 19, 2021 (unpublished)
  • For SAM estimates, see IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 20.

• 29
  • SQUEAC Report: Fada, Burkina Faso, 2017 (in French)
    • Coverage in 2012: 19.9% (p. 9); coverage in 2017: 52.0% (p. 6)

• 30
  • "The project targets 5 health facilities (2 in Banadir with one of the facilities providing SC services, 1 Galgadud, 1 Mudug and 1 Nugal) and 27 sites that will be reached through mobile teams in Galgadud, Mudug and Nugal regions." IRC, Proposal: Cost-effective Malnutrition at Scale, 2021, p. 15.
  • "6.5 SOMALIA (...) Prevention services will include:
  • "deworming for children 12-59 months and pregnant women in the 2nd and 3rd trimester, counselling and promotion on infant and young child feeding.
  • "Community mobilization and screening as well as micronutrient supplementation for PLW (multiple micronutrients and Iron folate) and children 6-59 months with Vitamin A supplements.
  • "The program will promote home-based fortification to enrich the diets of young children 6 - 23 months through the distribution of micronutrient powder.
  • "Provision of routine immunization services to children and pregnant women in these project sites.
  • "Systematic defaulter tracing and follow up of absentees will be conducted at community level by community health workers."

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

• 31
  • IRC Chad, Conversation with GiveWell, July 29, 2021 (unpublished)
  • IRC Somalia, Conversation with GiveWell, July 19, 2021 (unpublished).
  • IRC Niger, Conversation with GiveWell, August 3, 2021 (unpublished).
  • IRC Burkina Faso, Conversation with GiveWell, July 27, 2021 (unpublished).
  • IRC DRC, Conversation with GiveWell, July 28, 2021 (unpublished).

• 32

  We had three conversations with ALIMA on program activities, outcomes and costs, as well as two additional conversations that focused more on logistics and GiveWell processes. We have public notes for one of these conversations: GiveWell's non-verbatim summary of a conversation with ALIMA, March 5, 2021.

• 33

  GiveWell's non-verbatim summary of a conversation with Concern Worldwide, January 14, 2020

• 34

  GiveWell's non-verbatim summary of a conversation with Helen Keller International, March 19, 2020

• 35

  GiveWell's non-verbatim summary of a conversation with Wendy Dyment, March 12, 2020

• 36

  GiveWell's non-verbatim summary of a conversation with Save the Children USA, March 13, 2020

• 37

  GiveWell's non-verbatim summary of a conversation with Dr. Anuja Jayaraman and Sangeetha Vadanan, February 19, 2020

• 38

  This included the following conversation: GiveWell's non-verbatim summary of a conversation with Patrick Andrey and Amadou Alzouma, November 16, 2020.

• 39
  • GiveWell's non-verbatim summary of a conversation with Jay Berkley, March 10, 2021
  • Conversation between GiveWell and a malnutrition expert at a major international NGO, March 17, 2021 (unpublished)

• 40
  • GiveWell, Malnutrition cost-effectiveness analysis, 2021 (unpublished)
  • GiveWell, Malnutrition Model Sensitivity and Research Agenda (unpublished)
  • GiveWell, Malnutrition CEA plausibility checks (unpublished)