A counterfactual QALY for USD 2.60–28.94?

post by brb243 · 2020-09-06T21:45:08.476Z · EA · GW · 6 comments


      October 1 update:
      September 19 update:
      September 9 update:
  Current project overview
  Current project data
    total diagnoses
    of patients have no other free health facility in their community
    % of patients are unable to pay for healthcare
    average, patients are 31.7 years old
    of patients have no other (paid) healthcare facility in their community
    Preventive care outputs
  Past cost-effectiveness calculations (counterfactual QALY for USD 2.60–28.94)
  Comparison to Against Malaria Foundation (1.72–19.15× more cost-effective)
  Cost-effectiveness updating
  Room for more funding (USD 618,750)
  Donation details (tax-deductible in USA and Germany)
      We will appreciate any donations.
      Donate via GlobalGiving from anywhere
      German bank account
      United States donation information
      Cameroonian bank account
  Feedback and questions
  Contact details

October 1 update:

The Mobile Clinics project gained USD 5,062, which enables it to run one clinic for additional 2 months. Conversations with WHO regarding 'phase 2' of the project are ongoing.

In addition, Reach Out is offering a remote community mobilizer internship. It should be a great opportunity for anyone to advance their skills in securing counterfactual funding, analyzing data, developing humanitarian projects, and institutionalizing the EA framework in aligned organizations.

Applicants should e-mail Marc marc@reachoutcameroon.org with a CV and a cover letter.

September 19 update:

The GlobalGiving 50% matching has ended. However, GlobalGiving still offers matching of up to 93% (100% net of the 7% platform fee) – of the first donation up to USD 200, if you set a monthly donation. Donations are tax-deductible in the US. More information follows in the Donation details section below.

September 9 update:

50% matching for donations up to $50 is available via GlobalGiving. GlobalGiving collects 7% total fee. Still, 43% will be matched. The campaign starts on Monday, September 14 at 9 am EDT and ends on Friday, September 18 at 11:59 pm EDT.


Reach Out Cameroon (REO) seeks up to USD 618,750 to continue its mobile clinics project in the conflict Northwest and Southwest (NWSW) regions of Cameroon for 6 months from October 1, 2020. The mobile clinics provide free primary preventive and curative healthcare in communities without other free primary care to persons of whom 95% are internally displaced and whose average daily expenses are below 1.25 USD (World Food Programme, October 2019). REO estimates that 74.7% of patients do not have other (paid) health facility in their community and 81% cannot pay for healthcare. We further estimate that during the past 5 months, the mobile clinics provided a counterfactual quality-adjusted life year (QALY) for USD 2.60–28.94. This makes them 1.72–19.15× more cost-effective than Against Malaria Foundation. The ongoing project has been financed from a WHO emergency grant that ends on September 30, 2020. If you consider this project competitive, please donate now, solicit donations, or work with us on grant writing. We will also appreciate any feedback.


In September 2017, the Anglophone Crisis, an ongoing conflict between state military and non-state armed groups, began in the NWSW regions of Cameroon. Recurrent cycles of inhabitant displacement followed. In December 2019, 466,000 internally displaced persons resided in the region (Internal Displacement Monitoring Centre, 2019). The crisis also led to closures of health facilities. In 2019, 53% of persons within the Divisions where mobile clinics operate reported inability to access healthcare (International Organization for Migration, 2019).

Current project overview

Since March 2020, Reach Out has been operating 8 mobile clinics in 5 Divisions of the NWSW regions of Cameroon. Each mobile clinic is staffed by 1 doctor, 3 nurses, 1 driver, and 1 safety officer. The clinics provide free primary healthcare to all patients. This care includes prevention, diagnosis, and treatment.

Current project data

We scaled our past data from 154 clinic-weeks (8 clinics, ~5 months) to 208 clinic-weeks (8 clinics, 6 months). A workbook version can be accessed here.

35,533 total diagnoses

100% of patients have no other free health facility in their community

Mobile clinics operate only in communities without other free government or NGO primary healthcare facility.

81 % of patients are unable to pay for healthcare

The below % of patients unable to pay for healthcare are averages of estimates of the 8 mobile clinic doctors.

On average, patients are 31.7 years old

74.7% of patients have no other (paid) healthcare facility in their community

>100,000 Preventive care outputs

Past cost-effectiveness calculations (counterfactual QALY for USD 2.60–28.94)

Calculations can be reviewed in the data workbook.

Our calculations do not consider any health outcomes resulting from preventive care measures and may thus underestimate the project cost-effectiveness.

Comparison to Against Malaria Foundation (1.72–19.15× more cost-effective)

Cost-effectiveness updating

If we continue the project from October 1, 2020, we will collect baseline, midline, and endline health outputs/outcomes data in communities where mobile clinics begin to operate and in comparable non-intervention communities. Based on this data, we will update the project cost-effectiveness estimates.

Room for more funding (USD 618,750)

REO can utilize USD 618,750 to run 11 mobile clinics for additional 6 months from October 1, 2020, with the current counterfactual cost-effectiveness. The ongoing project has been financed by a WHO emergency grant that ends on September 30, 2020. So far, REO has secured USD 3,425 for this project (September 17, 2020). We will update this number when additional funding is secured. During the next 6 months, we will continue to seek further institutional funding.

Donation details (tax-deductible in USA and Germany)

We will appreciate any donations.

If you are interested in soliciting donations that would not have happened otherwise, e. g. in your company or at your school, please contact Bara [EA · GW], a trained economic diplomat. Also, please let us know if you can work with us on grant writing.

Please follow this link to donate via GlobalGiving from anywhere. Donations to GlobalGiving are tax-deductible in the US. The platform charges 7% fee but matches up to 100% (of the first donation up to USD 200, if you set a monthly donation). Donation options include Debit/Credit Card, PayPal, Gift Card, Check, Wire Transfer, Donor Advised Funds, Stock, and Charities Aid Foundation.

German bank account

Donations are tax-deductible in Germany and subject to national tax deduction laws in other European countries.

Currency: EUR

IBAN: DE43 5206 0410 0008 0074 54

Payee’s name: "Freundeskreis Reach Out Cameroon e.V."

Payee’s address: "Gleina 48, 07586 Bad Köstritz"

Bank name: "Evangelische Bank"

Bank address: "Kohlenstrasse 132, 34121 Kassel"


United States donation information

Donations to Friends of Reach Out International 501(c)(3) (EIN of 83-2978981) are tax-deductible in the US. The US bank account is currently dormant. We will update with account information. You can send the free Zelle US transfer to my US bank account (Wells Fargo, USD), using brb243{at}atlas[dot]cz as the recipient unique identifier. I am not formally associated with the Foundation.

Cameroonian bank account

Currency: Any major currency (will be automatically converted to XAF)

Recipient name: REACH OUT CAMEROON

Recipient Address: P O BOX 88, BUEA, CAMEROON

IBAN: CM2110001068423082594200417




Bank code: 10001

Agency code: 06842

Account number: 30825942004

RIB key: 17

Feedback and questions

Please comment below with any feedback or questions.

Contact details

For other general questions, please contact Marc (marc@reachoutcameroon.org, WhatsApp: +237 650 32 34 92), the Humanitarian Coordinator of REO. For technical inquiries, contact Dr. Jarman (eljarman89@gmail.com), the mobile clinics project coordinator.


GBD 2016 Diarrhoeal Disease Collaborators. (2018). Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet of Infectious Diseases, 18, 1211-28. Retrieved from https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30362-1/fulltext

Health Cluster. (2020). Immunisation 2019 in South West region, Cameroon. Health Cluster meeting. Buea: Health Cluster, Southwest.

Human Rights Watch. (2020a). Cameroon Events on 2019. Retrieved July 9, 2020, from https://www.hrw.org/world-report/2020/country-chapters/cameroon

IDMC. (2019). Global Report of Internal Displacement 2019. Geneva: Internal Displacement Monitoring Centre. Retrieved from https://www.internal-displacement.org/global-report/grid2019/

IDMC. (2020). IDMC Cameroon. Retrieved June 17, 2020, from https://www.internal-displacement.org/countries/cameroon

Internal Displacement Monitoring Centre. (2019). Global Internal Displacement Database. Retrieved February 10, 2020, from https://www.internal-displacement.org/database/displacement-data

International Organization for Migration. (2019). Multi-Sector Needs Assessment. Geneva: OCHA.

MINSANTE. (2019). Northwest Regional delegation of Public Health / Southwest Regional Delegation of Public Health. Buea / Bamenda: MINSANTE.

Norweigan Refugee Council. (2020, August 20). Africa is home to nine of ten of the world’s most neglected crises . Retrieved from Norweigan Refugee Council: https://www.nrc.no/news/2020/june/africa-is-home-to-nine-of-ten-of-the-most-neglected-crises/#:~:text=Cameroon%2C%20DR%20Congo%20and%20Burkina,and%20deprioritized%20in%20the%20world.

OCHA. (2020e). CAMEROON North-West and South-West regions - Operational Presence. Geneva: OCHA. Retrieved from https://reliefweb.int/map/cameroon/cameroon-north-west-and-south-west-regions-operational-presence-march-2020

Organisation for the Coordination of Humanitarian Affaris. (2020). Geneva: OCHA.

Regional Delegation of Public Health Southwest. (2020). Cholera Outbreak Situation Report No 28. Buea: MINSANTE.

Schwinger, C., Golden, M., Grellety, E., Roberfroid, D., & Guesdon, B. (2019). Severe acute malnutrition and mortality in children in the community: Comparison of indicators in a multi-country pooled analysis. PLOS ONE, https://doi.org/10.1371/journal.pone.0219745.

Tekelab, T., Chojenta, C., Smith, R., & Loxton , D. (2019). The impact of antenatal care on neonatal mortality in sub-Saharan Africa: A systematic review and meta-analysis. Europe PMC, 10.1371/journal.pone.0222566 .

UNICEF. (2019). MATERNAL AND NEWBORN HEALTH DISPARITIES. Geneva: UNICEF. Retrieved from https://data.unicef.org/wp-content/uploads/country_profiles/Cameroon/Maternal%20and%20newborn%20health%20country%20profiles/country%20profile_CMR.pdf

World Data Atlas. (2020, 18 August). Cameroon - Neonatal mortality rate. Retrieved from World Data Atlas: https://knoema.com/atlas/Cameroon/Neonatal-mortality-rate#:~:text=In%202018%2C%20neonatal%20mortality%20rate,1%2C000%20live%20births%20in%202018.

World Food Programme. (October 2019). Emergency Food Security Assessment.


Comments sorted by top scores.

comment by MarcSerna · 2020-10-17T08:54:16.394Z · EA(p) · GW(p)


I am Marc Serna, from Reach Out. I want to thank Barbara inmensely for writing this post.

As you can see, we think we have a good project that is giving healthcare to people who otherwise would not have it. But it seems evident we are not collecting data in a convincing enough way for EA standards. That is OK, we have a long way to go and we are committed to improving.

We would deeply appreciate any orientation on what type of data should we begin collecting right now, so that we can present more convincing numbers in the future.

Although we did not raise the hundreds of thousands of dollars we needed to keep at scale, we did raise enough money to keep one clinic running for the next two months, which gives us more time to fundraise. We have full control over this clinic, since the funds are crowdfunded and unrestricted, so it should be easy to incorporate any key questions or data collection into the daily work (unless it is really demanding of the medical team).

comment by esantorella · 2020-09-08T20:36:57.868Z · EA(p) · GW(p)

How did you arrive at the QALY/diagnosis estimates? Do you have a sense of how much REO tends to help a patient with one of these conditions? Cancer and cardiovascular disease have high QALY burdens, but won't be cured in a single visit to an outpatient clinic, so the counterfactual QALY improvement might be low.

comment by brb243 · 2020-09-08T21:43:29.485Z · EA(p) · GW(p)

The diagnosis numbers are data of the past ~5 months of the project scaled up to 6 months (×208/154 (clinic-weeks)). REO records data on all diagnoses (by week) and the provided are the sums.

For the QALY estimates, I used my best judgment, also based on the potential decrease of the Health-related Quality of Life (HRQoL) multiplied by the years lived with the (consequences of the) condition (equivalent Years Lost due to Disability) and on the potential Years of Live Lost. For example, for the mild condition treatments, deworming or vitamin A supplementation can have great long-term quality of life effect. However, treating other minor conditions may have only relatively small short-term effects. Thus, the wide ranges in estimates.

In terms of the QALY improvement, this will depend on the facility of treatment of the condition. For example, treating severe malaria, severe acute malnutrition, averting maternal deaths due to antenatal care, or deworming may be relatively easier than treating cancer, cardiovascular disease, or hypertension. This should be already factored in the ranges - for example, for life-threatening conditions, the upper QALY estimate is that the clinics save all lives and the lower estimate is that perhaps only ~1/3 of lives is saved or that all interventions save a life but its quality is decreased by 67 percentage points, or a combination of the two that results in the same increase in overall quality×quantity of life.

comment by Derek · 2020-09-10T12:30:53.982Z · EA(p) · GW(p)

I'm sure there are many giving opportunities in global health that are better than the GiveWell top charities, and I'm pleased to see promising small or medium-sized projects like this being brought to the attention of EAs. 

However, I think you should try to get better estimates of QALYs gained (or DALYs averted)—especially if you're going to feature the cost-effectiveness ratio so prominently in your write-up. This should be possible by referring to the relevant literature. The current estimates don't seem all that plausible to me, e.g. an episode of "simple malaria" (by which you presumably mean there are no other complications like anaemia) tends to last a few weeks or less, so even if it could be immediately cured at the beginning, it wouldn't reach your lower estimate of 0.1 QALYs, let alone the upper of 5 QALYs. For life-threatening conditions, I don't think you should have the theoretical maximum of "save all lives" as the upper estimate, as that wouldn't happen in any context, and certainly not this one. If you must rely on your intuitive guesstimates, perhaps you should use 90% or 95% credible intervals.

Good luck with the project!


comment by brb243 · 2020-10-08T20:57:13.317Z · EA(p) · GW(p)


I found the dataset that I thought I saw before: the Institute for Health Metrics and Evaluation (IHME) Global Burden of Disease Study 2017 (GBD 2017) Disability Weights. Disability weights are the changes of Health-related Quality of Life (HRQoL) due to a condition. I re-ran the calculations and found the cost-effectiveness of the mobile clinics project as 26.63 USD/QALY, with a low estimate of 184.14 USD/QALY and high estimate of 6.33 USD/QALY. I used the same data to estimate the cost-effectiveness of AMF and found 56.07 USD/QALY (low 112.14 and high 11.21). The Business Insider AMF number is about 49.76 USD/QALY. Thus, these updated calculations may be more accurate. Still, the calculations do not take into account the preventive care outcomes, deaths averted due to the Ebola outbreak response, and economic benefits (e. g. of deworming) that may lead to further health improvements, leave alone the positive long-term virtuous cycle of improved health and wealth - but that may apply to other health-related programs too.

comment by brb243 · 2020-09-15T18:30:12.365Z · EA(p) · GW(p)

Hello. I apologize for the late reply. I was moving over the weekend. I am looking at the IHME DALY by cause data (my calculations here) but these do not seem to take into account the long-term effects of the diseases. For example, deworming and vitamin A supplementation may have positive long-term effects in terms of schooling and economic gains that may far outweigh the direct short-term QALY losses. From there the upper estimate of 5. Simple malaria I would presume one that does not require immediate medical attention but one that still may result in severe condition if untreated (CDC). For the life-threatening conditions, my rationale was also that children treated with severe acute malnutrition are younger than average-age patients and that persons who survive 5 years live on average longer than life expectancy.

Also, the QALY estimates are not taking into account the effects of preventive measures - e. g. almost 90,000 persons informed on STIs and the response to a cholera outbreak (training and material provided) - before the intervention, 5 persons died, after no other deaths occurred.

On that note, I would actually appreciate if anyone could provide more credible estimates, taking into account the effectiveness and long-term consequences of the treatment. I am sure that REO would welcome such cooperation, also for capacity building reasons.