Note: This page summarizes the rationale behind a GiveWell grant to Nutrition International. Nutrition International staff reviewed this page prior to publication.
In a nutshell
In September 2024, GiveWell recommended a grant of up to $3.25 million to Nutrition International to renew support for its vitamin A supplementation (VAS) program in Chad for a fifth year. We're unsure whether VAS campaigns will be co-delivered with immunization campaigns in the third and fourth year of the program, which would reduce costs, and how this will affect the availability of rollover funds and the budget for year five. To account for this, we're planning to finalize the grant total during the fourth year of the grant, when we expect to have more information.
With this funding, Nutrition International will procure vitamin A capsules and support the government in planning, executing, and monitoring the performance of twice-yearly VAS campaigns.
We recommended this grant because:
- We think it's likely to be highly cost-effective, due to high mortality rates (1.5% for children under 5 in Chad), VAS having a moderate effect on the risk of death (10% decrease) and low costs ($0.97 per vitamin A supplement delivered).
- We think there are benefits of having multiple partners in VAS. In addition to Nutrition International, we also support Helen Keller International's VAS program.
Our main reservations are:
- We're uncertain whether VAS is still effective today, since the main studies we rely on were conducted three to four decades ago. We're also unsure what explains large differences in outcomes between VAS trials.
- In our cost-effectiveness model for Nutrition International's VAS program, we're particularly uncertain about our estimate of the cost per supplement ($0.97) and our estimate of the likelihood that other funders would step in if we didn't support the program (we estimate a very high 75%).
- Our main open questions about costs are: (i) the likelihood that VAS campaigns will be co-delivered with immunization campaigns (which we think reduces costs), (ii) the size of the population Nutrition International is targeting (which impacts our estimate of cost per child), and (iii) whether other actors are also funding VAS in Chad (which impacts our estimate of total costs of the program).
- We're uncertain about our estimate of the likelihood that other funders would step in because we base this on older coverage data (which we assume correlates to funding for the program prior to Nutrition International's support) and we're not sure how predictive it is of the current funding landscape. We also apply subjective adjustments to increase the comparability of this older coverage data to Nutrition International’s coverage data, but we are unsure about the magnitude of those adjustments.
Published: June 2025
The organization
Nutrition International is an international non-governmental organization headquartered in Canada that provides financial and technical assistance to governments in delivering nutrition-related interventions.1 Nutrition International has worked in vitamin A supplementation (VAS) since 1994.2 Nutrition International has supported VAS programs both by donating vitamin A capsules and by providing support to governments to carry out VAS distribution.3
This grant is our fifth year of support for Nutrition International's vitamin A supplementation (VAS) program in Chad and our third grant to the program. We previously recommended grants in January 2022 and May 2023.
The intervention
Vitamin A deficiency (VAD) is a common condition in low and middle income countries that can lead to blindness, increased susceptibility to infection, and death.4
Vitamin A supplementation (VAS) involves getting 6-59 month old children to swallow a small amount of fluid containing vitamin A, delivered via a single-use capsule.5 GiveWell currently funds Helen Keller International and Nutrition International, who provide funding and technical support to governments to deliver VAS via mass distribution campaigns.6 We think these campaigns increase the number of children who receive VAS and reduce child mortality. See more details about the program in our intervention report on vitamin A supplementation.
The grant
We're recommending a grant of up to $3.25 million to support the fifth year of Nutrition International's VAS program in Chad. The grant will fund Nutrition International from March 2026 to March 2027. We haven't determined the final grant amount yet, because we're unsure whether VAS campaigns will be co-delivered with immunization campaigns in years three and four of the grant (which will reduce costs) and how this will affect rollover funds available and budget for year five.7 To account for this, we're planning to finalize the grant total during the fourth year of the grant (2025), when we expect to have more information.
Nutrition International supports the government of Chad to conduct twice-yearly VAS campaigns to reach children 6-59 months old. We think these campaigns are the only opportunity for most children in Chad to receive VAS. Our understanding is based on a conversation with a government official in Chad and research conducted by Rethink Priorities.8
VAS campaigns may be standalone or conducted alongside existing immunization campaigns. During the first two years of the program, three out of the four VAS campaigns supported by Nutrition International were layered onto polio immunization campaigns.9 Our best guess is that there will continue to be significant opportunities to layer VAS onto polio immunization campaigns in Chad in the coming years, based on the first two years of the program and conversations with Nutrition International.10
With this grant, Nutrition International will provide several types of support for government VAS campaigns:
- Procuring vitamin A capsules and working to ensure the capsules meet quality standards, such as by monitoring manufacturers' adherence to those standards.11
- Providing technical and financial support for VAS campaigns.12 This includes helping set up and participating in a steering committee for each campaign. The committee develops and reviews campaign plans, budgets, and training materials.13 During campaigns, Nutrition International analyzes information about vitamin A capsule distribution and helps the government redistribute available stock across regions, among other activities.14
- Commissioning and providing technical and financial support for national post-campaign coverage surveys.15 This includes providing input on survey design and implementation and advocacy to incorporate learnings into future VAS campaigns.16 For example, Nutrition International encouraged the government to update its implementation in N'Djamena after surveys reported low coverage there in 2022, and coverage in N'Djamena subsequently improved.17
Budget for grant activities
Nutrition International submitted an approximately $4.4 million budget for the fifth year of its program. We're planning to recommend a grant of up to $3.25 million, which takes into account rollover funds from the first two years of the program, and will allow us to take into account expected rollover from years three and four. We plan to finalize the grant amount in Q1 2025, at which point we expect to have additional information about rollover funds and the expected budget for year five.
Budget submitted
Nutrition International submitted a $4,422,501 budget for the fifth year of its program:18
| Cost categories | Y5 |
|---|---|
| Program Activities | $3,073,134 |
| Campaign activities | $2,291,982 |
| Post event coverage surveys | $472,500 |
| Vitamin A capsule procurement | $308,652 |
| Program Management | $772,519 |
| Country Program and Technical Support | $428,828 |
| Regional and Global Program and Technical Support | $322,690 |
| Travel | $21,000 |
| Total direct cost | $3,845,653 |
| Indirect 15% | $576,848 |
| Interest earned as of Feb 2024 | |
| Grand Total | $4,422,501 |
Grant recommended
Below is a high-level sketch of how we calculated the maximum grant amount. Details and calculations can be found here.
- Year five budget submitted by Nutrition International: $4,422,501
- Nutrition International told us that it typically expenses its second-semester coverage surveys to the following year, so we expect half of the year-four survey costs in year five: $289,120
- Rollover funds from years one and two: $1,460,940
- ($4,422,501 + $289,120) - $1,460,941 = $3,250,681
Our best guess is that Nutrition International will have more rollover funds due to VAS campaigns being paired with polio campaigns in years three and four, which would result in a lower grant amount.
The case for the grant
Summary
We are recommending this grant because:
- We estimate that it is highly cost-effective. We estimate that this grant is ~14 times as cost-effective as unconditional cash transfers, the benchmark to which we compare programs. The high estimated cost-effectiveness is driven by high child mortality (1.53% among people under five), VAS having a moderate effect on the risk of death (10% decrease for children in Chad), and because the intervention is inexpensive ($0.97 per supplement delivered). More
- We think it's valuable to support multiple implementers of VAS. More
- We have a positive qualitative impression of Nutrition International. More
Details
Cost-effectiveness
We estimate that this grant is ~14 times as cost-effective as unconditional cash transfers, the benchmark to which we compare programs.19 A simple sketch of our cost-effectiveness model quantifies this intuition. You can see our full cost-effectiveness analysis for this grant here and a simple version here (outlined below).20
| What we are estimating | Best guess | Confidence intervals | Implied CE (multiples of cash) | ||
|---|---|---|---|---|---|
| 25th | 75th | 25th | 75th | ||
| Nutrition International spending (in expectation) | $3,316,876 | ||||
| Total program costs (all contributors) | $4,738,394 | ||||
| Cost per child receiving a year of VAS | $1.36 | $0.61 | $2.44 | 32x | 8x |
| Number of people under age five reached | 2,442,471 | ||||
| Proportion of reached children who would have received VAS in the absence of the program | 10% | 6% | 18% | 15x | 13x |
| Number of additional children receiving VAS as a result of the program | 2,198,224 | ||||
| Mortality rate among people under age five | 1.53% | 1.14% | 1.91% | 11x | 18x |
| Effect of VAS on under-five mortality | 10.4% | 2.1% | 18.1% | 3xx | 25xx |
| Number of deaths averted among people under age five | 3,473 | ||||
| Initial cost-effectiveness estimate (malnutrition-related mortality benefits only) | |||||
| Moral weight for each death averted | 119 | ||||
| Initial cost-effectiveness estimate (mortality benefits only) | 37x | ||||
| Adjustments for other benefits | |||||
| Adjustment to account for developmental benefits (long-term income increases) | 25% | 5% | 60% | 12x | 18x |
| Summary of primary benefits (% of modeled benefits) | |||||
| Mortalities averted for people under age five | 80% | ||||
| Developmental benefits (long-term income increases) | 20% | ||||
| Additional adjustments | |||||
| Adjustment for additional program benefits and downsides | 39% | 27% | 48% | 13x | 15x |
| Adjustment for grantee-level factors | -24% | -43% | -11% | 11x | 17x |
| Adjustment for leverage | 0% | ||||
| Adjustment for funging | -70% | -80% | -14% | -2x | 40x |
| Final cost-effectiveness estimate (multiples of cash transfers) | 14.5x | ||||
The key parameters in our cost-effectiveness model are:
- Baseline mortality. We estimate that the all-cause mortality rate among 6-59-month-olds in the absence of VAS is 1.53% in Chad. We rely on mortality estimates from the Institute for Health Metrics and Evaluation (IHME)'s Global Burden of Disease (GBD) 2021 model. We describe our approach to estimating all-cause mortality in the absence of VAS in detail in our VAS intervention report.21 We discuss our uncertainties about GBD 2021 mortality data below.
- Impact of VAS on mortality. We estimate that children receiving VAS leads to a 10.4% reduction in all-cause mortality in Chad. We discuss the impact of VAS on mortality in our intervention report here. This estimate incorporates several adjustments, including:
- External validity adjustment: VAD prevalence. We estimate 41% vitamin A deficiency (VAD) prevalence among children under 5 in Chad, based on an average of GBD 2017, 2019, and 2021 VAD prevalence data (75% weight), and a 2008 regional survey of VAD in Chad (25% weight). We make a downward adjustment to account for our understanding that VAD rates are declining over time. We discuss our uncertainties about this approach below.
- Cost per supplement delivered. We estimate that Nutrition International's cost per supplement delivered is $0.97. See our full cost per supplement analysis here. Our estimate is based on:
- Historical data
- Spending data from Nutrition International's first and second year of the program (see here).
- Information about target populations in the first and second year of the program from Nutrition International, adjusted downward by -30% to account for our uncertainty about potential overreporting. We discuss this in our uncertainties section below.
- Coverage data from Nutrition International's first and second year of the program (see here). We do not adjust this as part of estimating the cost per supplement, but we apply a -17% adjustment to the overall cost-effectiveness estimate to account for potential inaccuracies in coverage reports.
- Our estimate that the government covers 30% of program costs through in-kind contributions, based on a 2011 paper evaluating the costs of a deworming program in Niger.22
- We then adjust our estimate upward by approximately 30%, based on the ratio of the budget Nutrition International submitted for year five compared to its budget in years one and two. We make an uncertain assumption that the higher costs in year five will also be applicable to government costs. We discuss our uncertainty about the higher budget in year five below
- Historical data
- Baseline coverage of VAS. We estimate that 10% of people will receive VAS from non-campaign sources as a baseline. This is based on our understanding that routine coverage of VAS is generally quite low, so it's unlikely for many people to have alternative sources of VAS. Our understanding is based on a conversation with a government official in Chad and research conducted by Rethink Priorities.23
- Likelihood that other funders would support the program in our absence (funging risk). We estimate there is a 75% chance that domestic governments (10%) or other philanthropic actors (65%) would support this program if we did not. We refer to this as the risk of "funging," or crowding out funding that would otherwise be provided.
Our 75% estimate is very high, relative to other GiveWell grants. Our best guess is that this grant makes campaigns a bit more likely to happen (from 77% likely to 100%).
Our estimate is based on data on previous NGO support for VAS and VAS coverage in Chad from 2015 to 2021. These data show high coverage with NGO and/or donor support prior to Nutrition International's work in Chad. VAS coverage occurred via immunization-paired campaigns; Child Health Days, which are twice-yearly campaigns that include a variety of health programs, including VAS;24 and standalone VAS campaigns.25
- We calculate an average coverage achieved per semester prior to Nutrition International's support of 60%.
- We make a 20% downward adjustment to account for our best guess that this data, which is based on administrative data, over-reports VAS coverage. The 20% is a rough adjustment based on a comparison of administrative data and Nutrition International's Post Event Coverage Surveys (PECS) for 2022-2023. Our best guess that administrative data over-reports VAS coverage is also supported by our comparisons of Helen Keller International's PECS surveys with comparable administrative data.26
- We make an additional rough, 20% upward adjustment to account for the fact that Nutrition International shared administrative data on two-dose coverage, which describes children who received two doses of VAS that were spaced 4-6 months apart.27 We expect two-dose coverage to underestimate coverage per semester since it misses children who received a single dose of VAS in either semester. Our 20% adjustment is a subjective guess.
- We divide our estimate of coverage prior to Nutrition International's support by the average coverage achieved by Nutrition International in 2022-2023. This is approximately 78%.
- (60% x 80% x 120%) / 78% = 75% likelihood that campaigns would happen in Nutrition International's absence. We split this between government spending (10%) and other philanthropic actors (65%), based on a subjective guess.
- We're very uncertain about this estimate and discuss this in more detail in our uncertainties section below.
- We calculate an average coverage achieved per semester prior to Nutrition International's support of 60%.
Diversity of implementers for VAS
Given our interest in funding vitamin A supplementation, based on the program's high expected cost-effectiveness, it seems valuable to support more than one grantee that implements this program in case any issues arise. In the case of VAS, we've supported Helen Keller International and Nutrition International. Continuing to support Nutrition International will mean we continue to have multiple grantees in this space.
Positive qualitative impression of Nutrition International
We've found Nutrition International to be easy to communicate with. They tend to answer our questions clearly and on time, and we haven't identified many errors in the information they've shared. We're enthusiastic about our ability to learn from them.
Risks and reservations
Summary
Our main reservations about this grant are:
- Uncertainties about our cost-effectiveness estimate. Our primary uncertainties are:
- Uncertainties about the impact of VAS. We're uncertain whether VAS is still effective today, since the main studies we rely on were conducted three to four decades ago. We're also unsure what explains large differences in outcomes between VAS trials. More
- Uncertainties about our cost per supplement estimate. We're particularly uncertain about:
- Predicting Nutrition International's costs going forward because we're uncertain how likely campaigns are to be paired with immunization campaigns (which reduces costs).
- The target population estimates we use.
- Other actors' spending on VAS in Chad—particularly UNICEF's. More
- Uncertainties about the likelihood other funders would support the program in our absence (funging risk). We're uncertain whether coverage from 2015 to 2021 is predictive of the likelihood of coverage in our absence in 2026 to 2027. We apply subjective adjustments to increase the comparability of this data to Nutrition International’s coverage data, but we are unsure about the magnitude of those adjustments. More
- Uncertainties about GBD mortality and VAD prevalence data.
Details
Uncertainties about our cost-effectiveness estimate
Uncertainties about the impact of VAS
As described above, we estimate that receiving VAS reduces child mortality by 10.4% in Chad. Most of the main studies we use in our analysis of VAS were conducted three to four decades ago, and we're unsure whether VAS is still effective today.
Some studies of VAS find large effects; others find small or no effects. We're unsure what explains these large differences in outcomes.
We discuss these questions in detail in our vitamin A supplementation intervention report.
Cost per supplement
As described above, we estimate that Nutrition International's cost per supplement delivered is $0.97. However, we're highly uncertain about this estimate because:
- We're uncertain whether VAS will be layered onto polio immunization campaigns at the same rate in the future. We rely on Nutrition International's spending from the first and second years of the program to calculate the cost per supplement. During this time, three out of four VAS campaigns were layered onto polio campaigns, which significantly reduces their cost.28 We're uncertain whether VAS campaigns will be layered onto polio campaigns with the same frequency in the future.29
- There are large discrepancies in target population estimates. In 2022-2023, Nutrition International reported that its program targeted ~4.6 million children.30
In 2021, when we were first considering support for this grant, Nutrition International reported that it expected to target ~2.6 million children.31
When we calculate our own rough estimate using UNICEF and World Bank data, we arrive at an estimate of ~2.6 million.32
Nutrition International told us that the target population numbers it reported for 2022-2023 are more accurate than the estimates it shared in 2021. Its 2021 estimates were based on UN Population Division estimates and the 2022-2023 estimates were based on the number of children that were recorded as reached in previous polio campaigns.33 Nutrition International also told us that Chad's large refugee and internally displaced person populations influence these estimates,34 and it seems intuitively plausible that this could explain part of the discrepancy. However, we haven't looked into this in detail.
We currently make a -30% adjustment to the target populations Nutrition International reported for 2022-2023, but we're highly uncertain about the magnitude of this adjustment.
- Other actors' spending. We do not include any spending by other actors in our cost per supplement estimate for Chad. Our impression is that UNICEF also provides some funding for VAS in Chad. Our best guess is that there is little overlap with Nutrition International's work, based on our understanding that UNICEF only spends a limited amount of funding in the country, but we're not highly confident in this.35
- Nutrition International's budget for year five. Nutrition International's budget for year five is approximately 30% higher than its budget for the first and second years of the program. We're not sure why that’s the case and, as of the time of recommending this grant, we had not discussed this with Nutrition International.
Likelihood that other funders would support the program in our absence (funging risk)
As described above, we estimate a 75% probability that other funders (the government or philanthropic actors) would support this program in our absence, based on coverage data from the years prior to Nutrition International's support. This is much higher than we estimate for most grants we recommend. We're uncertain about this estimate because:
- We rely on administrative coverage data from 2015 to 2021 as a proxy for NGO/donor interest in and ability to support VAS campaigns. Some of this data is quite old at this point, and it may not be predictive of NGOs' and donors' interest in and ability to support VAS campaigns in Chad in 2026 to 2027 (the period covered by this grant).
- We apply subjective adjustments to past administrative coverage estimates to increase the comparability to Nutrition International's coverage data, and we're uncertain about the magnitude of these adjustments. For many past coverage estimates, Nutrition International reported two-dose coverage. We assume that the same coverage was achieved in each semester. We're using very rough adjustments to translate from two-dose coverage to semester coverage and from administrative data to our best guess of actual coverage. The former is a subjective guess, not based on data,36 and the latter is based on a very small dataset (comparison of two years of administrative data to two years of Post Event Coverage Surveys).37 Either could be off the mark.
- We're not sure how likely polio immunization campaigns are to continue at their current pace. Part of the reason why we estimate that it is very likely other funders would step in in our absence is because we think it is likely that polio immunization campaigns would be conducted in Chad and that VAS would be layered onto those. Because this reduces the cost of VAS campaigns, we think it increases the likelihood of another funder supporting them if we didn't.
We understand that polio immunization campaigns were being phased out prior to the COVID-19 pandemic, but have been increasing since then as polio cases have risen due to children missing out on vaccinations during the pandemic.38 We're uncertain for how long this will continue, or when campaigns may begin to be phased out again.
- We're not sure how likely it is that other funders would co-deliver VAS with polio immunization campaigns. At the time of this grant investigation, we hadn't spoken with other funders to assess this likelihood, nor do we have a strong empirical foundation for believing this.
GBD estimates
Mortality data
As described above, we use mortality data from the Global Burden of Disease (GBD) 2021 model to calculate the baseline mortality in Chad. For this grant, we updated from GBD 2019 to GBD 2021 mortality data. This had a small to moderate negative impact on cost-effectiveness in Chad (approximately -15%).39 However, looking across a broader range of countries where we support VAS, the switch from GBD 2019 to GBD 2021 led to a larger decrease in cost-effectiveness than expected, and we're not sure what explains this decrease.40 As a result, we're not confident in these estimates. We plan to look into this going forward.
In addition, we use country-level mortality data for Chad, rather than sub-national data, based on our impression that Nutrition International covers the majority of the country. However, this might mean we are overestimating the program’s cost-effectiveness if, for example, UNICEF covers the highest-mortality areas.
VAD prevalence data
As described above, we use an average of vitamin A deficiency (VAD) prevalence data from GBD 2017, 2019, and 2021 because there are large differences in those estimates (29%, 53%, and 61%, respectively) and we do not understand what's driving them. It's possible that in the absence of confidence about our understanding of the model, we should be biased toward the most recent estimate (GBD 2021).
We're not aware of any additional national-level survey measuring VAD prevalence in Chad with which to compare these estimates, though we have not recently done a thorough check if such a survey has become available.
Plans for follow up
- We expect to receive annual data from Nutrition International about:
- Spending
- Coverage (for two campaigns per year)
- We plan to confirm the grant amount for year five during year four of the grant, once we feel reasonably confident in how much funding Nutrition International can roll over from the first four years of our support. We expect to finalize the grant amount once Nutrition International has confirmed whether the second VAS round in year four will be layered with a vaccination campaign or delivered as a standalone VAS campaign. Our best guess is that this will happen in March/April 2025, though it could happen sooner or later.
- We plan to consider renewing this grant for a sixth year by March 2026. By then, we expect to have continued making intervention-wide refinements to our vitamin A supplementation cost-effectiveness model, such as looking into what drove the changes from GBD 2019 to GBD 2021 mortality data.
Internal forecasts
For this grant, we are recording the following forecasts:
| Confidence | Prediction | Date we expect to resolve the forecast | Resolution |
|---|---|---|---|
| 55% | We will renew this grant for year six by March 31, 2026. | April 1, 2026 | - |
| 70% | Two out of two VAS campaigns in Chad in 2024 will be paired with polio. | January 31, 2025 | - |
| 55% | Two out of two VAS campaigns in Chad in 2025 will be paired with polio. | January 31, 2026 | - |
| 45% | Two out of two VAS campaigns in Chad in 2026 will be paired with polio. | January 31, 2027 | - |
Our process
- We had two conversations with Nutrition International.41
- We had one conversation with a government official in Chad,42 to triangulate the program's theory of change and better understand the role of different funders, and the VAS landscape in Chad.
- We received written information from Nutrition International (March, May, and June 2024).
Sources
- 1
- "We are a dedicated team headquartered in Ottawa, Canada, with offices across Africa and Asia." Nutrition International, "About us"
- "Working as an expert ally to governments, we combine a deep technical expertise with a flexible approach to deliver proven nutrition interventions at scale." Nutrition International, "Our work"
- 2
"Since 1994, Nutrition International has been leading the global effort to reduce deaths of children under five by making sure that vitamin A supplements are delivered to developing countries around the world." Nutrition International, "Vitamin A supplementation"
- 3
"We assure the availability of high-quality vitamin A capsules globally and provide delivery support in our core countries. Our approach includes:
- Improving the manufacturing quality standard of vitamin A capsules
- Organizing and coordinating global procurement and distribution of donated capsules
- Improving local health system capacity to deliver vitamin A to children under five
- Innovating to improve coverage for hard-to-reach children"
- 4
- "Vitamin A deficiency (VAD) impairs body functions and may cause death. Adverse health consequences may also include xerophthalmia (dry eyes), susceptibility to infection, stunting and anaemia." Imdad et al. 2010, p. 9
- "Xerophthalmia (dry eyes), is "the leading cause of preventable childhood blindness" WHO, Global prevalence of vitamin A deficiency in populations at risk 1995–2005, 2009, p 1.
- 5
"In settings where vitamin A deficiency is a public health problem, vitamin A supplementation is recommended in infants and children 6–59 months of age as a public health intervention to reduce child morbidity and mortality (strong recommendation)." p. 1.
See p. 5 of the WHO guidelines for the 4-6 month recommended schedule.
WHO, Guideline: vitamin A supplementation in infants and children 6-59 months of age, 2011, pp. 1, 5. - 6
See a list of our previous VAS grants at the bottom of our VAS intervention report here.
- 7
See our grant size calculations and Nutritional International's year five budget here.
- 8
- Our understanding is that routine coverage of VAS in Chad is generally quite low. Source: GiveWell's conversation with Professor Mahamat Bechir, Chad Ministry of Public Health, Direction de l’Alimentation et la Nutrition Appliquée (DANA), June 2024 (unpublished)
- See column E of Rethink Priorities, VAS counterfactual coverage estimates - by country - January 2024, and Rethink Priorities' page on this research here.
- 9
Nutrition International, Progress Update with Givewell - Vitamin A to Maximize Nutrition at Scale (VITAMNS) in Chad, March 26, 2024 (unpublished)
- 10
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 11
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 12
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 13
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 14
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 15
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 16
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 17
Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, May 2024 (unpublished)
- 18
See Nutrition International's budgets for years 1-5 in this spreadsheet.
- 19
Note: The estimate of the value per dollar donated to cash transfers used here is out of date as of late 2024. We are continuing to use this outdated estimate for now to preserve our ability to compare across programs, while we reevaluate the benchmark we want to use to measure and communicate cost-effectiveness.
For more on our update on the impact of unconditional cash transfers, see this page. - 20
Note: our estimates here reflect our thinking at the time we made this grant in September 2024. Some have changed between then and the publication of this page.
- 21
Note: Because of updates we made in late 2024 to how we estimate baseline mortality, our intervention report may no longer accurately describe the methodology used in this grant investigation. In the CEA for this grant, we rely only on GBD 2021 mortality data (see this sheet). As of late 2024, we now incorporate other data sources into this estimate.
- 22
"Estimates of in-kind government contributions. The VAS campaigns that Helen Keller supports are ultimately managed by national governments’ ministries of health. We would expect Helen Keller’s funding to divert some ministry of health resources (e.g., staff time, office space etc.) towards VAS campaigns that might otherwise have gone towards other activities. We estimate that these in-kind contributions account for 30% of the total costs to deliver each supplement.33 This is based on a single 2011 paper evaluating the costs of a deworming program in Niger (Leslie et al. 2011).34 We would guess that VAS and deworming programs (which both take the form of mass public health campaigns) would require relatively similar types of government contributions, but we nonetheless think of this estimate as a rough best guess. Our cost-effectiveness analysis is not very sensitive to this estimate, and so we have not prioritized further work on this question." See this section of our intervention report on VAS.
We assume that this is the same for Nutrition International as for Helen Keller International countries. - 23
- Source: GiveWell's conversation with Professor Mahamat Bechir, Chad Ministry of Public Health, Direction de l’Alimentation et la Nutrition Appliquée (DANA), June 2024 (unpublished)
- See column E of Rethink Priorities, VAS counterfactual coverage estimates - by country - January 2024, and Rethink Priorities' page on this research here.
- 24
Source: Conversation between GiveWell and Nutrition International, March 26, 2024 (unpublished)
- 25
- Coverage information from years prior to Nutrition International's support comes from Nutrition International, Progress Update with Givewell - VITAMNS Chad, March 26, 2024 (unpublished)
- Nutrition International has told us that the high coverage rates in 2015 and 2019 were due to VAS being integrated into measles or polio campaigns with support from international partners. Nutrition International provided ad hoc support in the second semester of 2021 as part of its response to the COVID-19 pandemic. Coverage in 2017 and 2018 were Child Health Days supported by the Government of Canada and other donors. Source: Conversation between GiveWell and Nutrition International, March 26, 2024 (unpublished)
- 26
See a comparison of Helen Keller International's PECS surveys and administrative data here.
- 27
Sources:
- Nutrition International, Progress Update with Givewell - VITAMNS Chad, March 26, 2024 (unpublished)
- Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, June 2024 (unpublished)
- 28
Nutrition International, Progress Update with Givewell - VITAMNS Chad, March 26, 2024 (unpublished)
- 29
See how we factored this uncertainty into our grant size calculations here.
- 30
Nutrition International, VITAMNS in Chad, Written update, March 2024 (unpublished)
- 31
- 32
UNICEF reports a total population of 18.3 million (as of mid-2024). The World Bank says 47% of Chad's population is under 15 (as of February 2025). If we roughly assume an even distribution between 0 and 14 years, then we assume 30% of children under 15 are in the VAS age range (6-59 months, or 4.5 years divided by 15 years). That's 14% of the total population (30% x 47% = 14%). 18.3 million x 14% = 2.6 million.
- 33
"When writing the Case for Support to GiveWell in August 2021, before beginning our work in-country, we quoted the published and most conservative population numbers which are estimated by the United Nations Population Division for the purpose of not over-estimating our impact. UN population estimates are published globally and are based on census data and modeling. However, the methods of deriving these estimates can result in less precise population projections in countries where the availability and quality of population demographic data is low
"By September 2021, NI was engaging directly with the Government of Chad, to plan the support (using funds from GAC) for the integrated polio+VAS campaign, at which time the “polio program” denominator was communicated as the one being used for campaign planning in-country, and from that point on, the “polio program” denominator was the target used (and reported as such to GiveWell going forward). This is a larger number of estimated eligible children than the UN Pop estimate for, as we know, and as is well documented, the target population for the polio program is generally estimated using the number of children reached during the campaign/the previous round, plus some small inflation factor under the assumption the population has increased somewhat since prior round. The polio program has historically adopted this method due to the imperative for reaching every child to prevent disease transmission and the observation that the census-based targets tend to largely underestimate the number of eligible children." Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, June 2024 (unpublished) - 34
"In addition, as Chad is experiencing a large influx of refugees and other internally displaced populations, the campaign planning is based as much as possible on the local population estimates that is coming from microplanning efforts of MOH and partners." Nutrition International, VAS in Chad, Potential GiveWell Renewal Grant, Responses to GW Questions, June 2024 (unpublished)
- 35
- Chad is one of the 15 countries for which UNICEF receives funding from the Government of Canada (GAC). Government of Canada, "Project profile - Vitamin A Supplementation in a New Age (VINA)" (accessed June 11, 2024)
- A rough calculation suggests UNICEF only spends a limited amount of funding ($350,000/year, which would be ~8% of NI’s budget) from GAC funding in Chad, though we are unsure if they use additional funding to cover these campaigns:
- $34 million (total grant from GAC to UNICEF for vitamin A supplementation) x 0.7 (conversion from Canadian to US dollars, as of September 2024) x 0.045 (% of funding going to Chad) divided by 3 (number of years in the grant) = approximately $357,000/year
- Info on grant from: Government of Canada, "Project profile - Vitamin A Supplementation in a New Age (VINA)" (accessed June 11, 2024)
- This was also informed by a stakeholder conversation for which we did not receive permission to publish notes.
- 36
See the +20% adjustment for two-dose vs. one-dose coverage in our funging adjustment calculations here.
- 37
See our calculation of the adjustment from administrative data to actual coverage estimates here.
- 38
This was informed by a conversation for which we did not receive permission to publish notes.
- 39
The -15% figure comes from an internal unpublished changelog of our CEA.
- 40
This is based on an unpublished analysis of changes to our cost-effectiveness model.
- 41
Conversation between GiveWell and Nutrition International, March 26, 2024 (unpublished), Conversation between GiveWell and Nutrition International, August 19, 2024.
- 42
GiveWell's conversation with Professor Mahamat Bechir, Chad Ministry of Public Health, Direction de l’Alimentation et la Nutrition Appliquée (DANA), June 2024 (unpublished)