Disclosure: GiveWell recommended a grant in October 2024 for New Incentives to distribute ORS and zinc co-packs through our existing routine immunization (RI) platform in northern Nigeria. We subsequently refined the approach to distributing ORS only. GiveWell had not evaluated that revised approach and decided not to proceed with the grant. They provided a $1M unrestricted grant to cover costs incurred before the cancellation. We believe there is still a strong, time-sensitive opportunity for ORS to avert under-5 deaths from diarrhea at low marginal cost, leveraging NI’s established clinic presence and verification systems. We are now seeking dedicated ORS funding from other sources.

The problem
Diarrhoeal disease is a leading cause of death in children under five. In Nigeria specifically, diarrheal disease accounts for approximately 61,000 under-five deaths annually. Oral rehydration solution (ORS) is a simple and highly effective treatment for dehydration caused by diarrhea and has played a major role in reducing child mortality globally.

Across 9,000+ household coverage surveys we conducted in NE and NW Nigeria, on average, 28% of caregivers reported giving ORS to their 6-12-month-old during their last diarrhea episode. That means 7 out of 10 children in this age range aren’t getting this simple, cost-effective solution of salt and sugar when they are at the greatest risk of dehydration.

The bottleneck is not figuring out how to prevent death from dehydration; it’s breaking down the barriers of cost and hassle and getting it into the hands of caregivers. The challenge is not discovering a treatment—ORS is already well established—but ensuring caregivers have access to it when a diarrheal episode occurs.

Why New Incentives has a comparative advantage here
In 2025, New Incentives piloted the launch of ORS distribution, which is our first major program expansion since scaling CCTs for RI. Our core program is a highly cost-effective conditional cash transfer for routine immunization in northern Nigeria, currently active across 11 states, with its cost-effectiveness improving over the years.

We think there is an opportunity to increase timely access to ORS by providing it through these same touchpoints, leveraging our platform to distribute ORS to infants at a very low cost. Because the delivery platform already exists, the marginal cost of distributing ORS during routine immunization visits is approximately $1 per child. The fixed costs—field officers, clinic relationships, monitoring infrastructure, and data systems—are already covered by the immunization program.

The key evidence supporting preemptive distribution is Wagner et al. (2019), which found that free, preemptive delivery of ORS increased usage by 19 percentage points (95% CI 13–26; p < 0.001) and improved timeliness of treatment. Because our delivery model differs somewhat (we deliver at immunization visits rather than through door-to-door campaigns), we treat these results as suggestive rather than definitive and expect to learn more as the program scales. A randomized controlled trial currently underway in Bauchi (CHAI) is measuring the impact of preemptive ORS and zinc distribution in northern Nigeria. While results are not yet published, we are following this work closely and expect it to generate evidence directly relevant to our operating context.

A note on ORS without zinc
After reviewing the available evidence and consulting with implementing partners and state health authorities, we concluded that focusing on ORS alone is likely to deliver more value per dollar for the infants we serve.

Zinc supplementation is recommended in many clinical settings for the management of childhood diarrhea, particularly for children over six months of age. However, the evidence on mortality effects is uncertain enough that zinc is not typically modeled as contributing directly to mortality reduction in many cost-effectiveness analyses. Zinc also accounts for approximately one-third of the cost of ORS-zinc co-packs.

In addition to cost considerations, zinc requires a multi-day adherence regimen (typically 10–14 days), which introduces operational complexity, especially when provided pre-emptively.

Zinc remains available through routine clinical care in the areas where we operate, and we will continue monitoring zinc usage through our household surveys. Our current position is conservative: begin with the intervention that has the strongest evidence for preventing dehydration-related mortality while continuing to monitor emerging evidence. If new evidence suggests zinc distribution in this delivery model would generate additional impact, we remain open to revisiting this decision.

What we've learned from the pilot
We launched in May 2025 with a handful of clinics in Gombe State, expanded to all of Funakaye LGA in September 2025, and have distributed approximately 41,000 sachets across 43 clinics. 

Early on, we held informal caregiver focus groups to explore wording surrounding diarrhea and ORS/zinc. These focus groups yielded important insights: some caregivers believe that stool changing to a green color is a key indicator of diarrhea, and some believe that diarrhea caused by teething may not need treatment. We incorporated these learnings into our surveyor training, clarifying that color is irrelevant to the definition of diarrhea (unusually loose or watery stools at least three times in 24 hours) and that suspected diarrhea due to teething should also be reported. This informed key iterations of the language used.

We shifted ORS education from field officers to clinic staff in December 2025. Initially, New Incentives field officers provided basic informational guidance to caregivers alongside ORS distribution. As the pilot evolved, we aligned the model more closely with the existing health system by having clinic staff lead all caregiver education, while field officers focus on distribution verification and monitoring.

Clinic staff now provide guidance on ORS use, and field officers verify that education occurred before distributing sachets. This approach was enthusiastically supported by the state, which facilitated the first clinic staff training. We believe this model, where the PHC system provides clinical guidance and New Incentives provides supply chain and verification infrastructure, is more scalable and strengthens the existing health system.

We’ve worked to embed the ORS distribution into the same verification workflow as our cash transfers: evidence required per distribution, dates written on sachets to prevent reuse, off-site reviewer verification, weekly stock reports with photo confirmation. We are applying a similar level of verification and scrutiny as we do with cash transfers.

We look forward to learning more about the rate of diversion (ORS shared or used by others including adults), which is a real problem in our operating context. ORS sachets are widely consumed by adults for energy and rehydration. We are gathering data at the clinic about past usage and will continue exploring this.

Measuring impact
Our household coverage survey data tracks diarrhea incidence and ORS usage rates across areas of operation. Once we expand beyond the pilot LGA, we will have pre- and post-data. Though our household coverage surveys generate useful data quickly, they are not randomized and cannot cleanly attribute changes in ORS usage to our program versus other trends or factors. 

We are open to co-designing a more rigorous evaluation, including an RCT, with funders who want to invest in generating decision-relevant evidence, and we would welcome that conversation. That said, we are not waiting for perfect evidence to act on very good evidence. While stronger evaluation would be valuable, we believe the urgency of the problem and the low marginal cost of this intervention justify acting while continuing to learn.

GiveWell’s cost-effectiveness model for NI’s ORS and Zinc program suggests a cost per life saved in the range of $1,000 - $2,000. Because that model does not attribute mortality benefits to zinc, we view it as a rough reference point for the potential order of magnitude of impact for an ORS-only approach. We hold these estimates loosely given uncertainties around baseline ORS usage rates, diversion, and other limitations described here.

The ask
We are seeking $5.3M to expand ORS distribution to 10 states through March 2029, reaching approximately 1.6 million infants per year at $1 per child. We have already received state approval in 6 of the 10 target states in Nigeria. Expansion is conditional on state government approval, coverage survey data measuring baseline diarrhea incidence and ORS usage, and the final iterations of our pilot.

You can donate to the scale-up of the ORS addition through this giving form. Our core CCT for RI program remains our focus and is supported by strong RCT evidence and independent evaluation. We are not allocating core resources away from immunization.

Please reach out to liz.hixson@newincentives.org if this project is of particular interest. We’d welcome a conversation. You can also learn more on our website.

At $1 per child, we believe this is a highly cost-effective opportunity. We'd love your help making it happen.