What have you learned about delivering this program in northern Nigeria that you don’t think would apply elsewhere? In other words, are there culturally specific features which make the program harder/​ easier to implement?
Congrats on your program’s cost effectiveness! Sometimes, the analysis updates the other way. How do you personally manage the possibility that your program might end up being less cost-effective than you hoped, and you may have to pivot?[1]
Thanks, Toby! And thank you for all you do to cultivate these conversations on the EA Forum.
In Nigeria, we work across 7,000+ public health clinics that already provide childhood immunizations. Embedding our program within existing health infrastructure is essential and wouldn’t be feasible in environments without a relatively stable vaccine supply chain and widespread clinic access. Northern Nigeria also has low vaccination coverage, high disease burden, and large birth cohorts, creating substantial room for impact. In higher-coverage contexts, marginal returns may look quite different.
We also invest heavily in addressing vaccine hesitancy: participating in village meetings, discussing questions from fathers, and engaging religious and traditional leaders to mobilize their communities. What that looks like varies considerably by setting.
What I think does generalize is the core logic: small financial incentives that offset practical barriers, such as transportation costs and lost income, can meaningfully shift caregiver behavior around routine health visits. At the same time, the importance of operational visibility and verified delivery at scale feels broadly underappreciated. How those principles are operationalized, at what cost, and through what systems would need to be worked out carefully in each new context.
Honestly, this is something I think about a lot. Our cost-effectiveness has improved significantly over time due to both operational efficiencies and favorable exchange rates, but we recognize that either can shift, and the program’s CEA could change at any time. There are three ways I think about managing this.
First, we are continually trying to simplify systems, reduce low-value operational burden, and identify where additional complexity is no longer improving program quality. We do this both to improve our cost per infant and to build the operational discipline that makes the program resilient to external changes.
Second, we’ve been investing in making our program genuinely reversible, such as developing the systems and governance to responsibly exit a geography when the evidence indicates it’s time to do so, rather than continuing out of inertia.
Third, we’re exploring how to improve cost-effectiveness by layering additional interventions onto our existing platform (such as ORS distribution) and testing lower-cost incentive models. The latter could unlock new geographies within Nigeria and beyond, and potentially serve as a graduation model for areas where our current approach is no longer sufficiently cost-effective.
Hey Svetha! Thanks for doing this AMA.
Two questions:
What have you learned about delivering this program in northern Nigeria that you don’t think would apply elsewhere? In other words, are there culturally specific features which make the program harder/​ easier to implement?
Congrats on your program’s cost effectiveness! Sometimes, the analysis updates the other way. How do you personally manage the possibility that your program might end up being less cost-effective than you hoped, and you may have to pivot?[1]
Not picking your program out in particular, this is a problem everyone trying to do good faces, including our team on the EA Forum.
Thanks, Toby! And thank you for all you do to cultivate these conversations on the EA Forum.
In Nigeria, we work across 7,000+ public health clinics that already provide childhood immunizations. Embedding our program within existing health infrastructure is essential and wouldn’t be feasible in environments without a relatively stable vaccine supply chain and widespread clinic access. Northern Nigeria also has low vaccination coverage, high disease burden, and large birth cohorts, creating substantial room for impact. In higher-coverage contexts, marginal returns may look quite different.
We also invest heavily in addressing vaccine hesitancy: participating in village meetings, discussing questions from fathers, and engaging religious and traditional leaders to mobilize their communities. What that looks like varies considerably by setting.
What I think does generalize is the core logic: small financial incentives that offset practical barriers, such as transportation costs and lost income, can meaningfully shift caregiver behavior around routine health visits. At the same time, the importance of operational visibility and verified delivery at scale feels broadly underappreciated. How those principles are operationalized, at what cost, and through what systems would need to be worked out carefully in each new context.
Honestly, this is something I think about a lot. Our cost-effectiveness has improved significantly over time due to both operational efficiencies and favorable exchange rates, but we recognize that either can shift, and the program’s CEA could change at any time. There are three ways I think about managing this.
First, we are continually trying to simplify systems, reduce low-value operational burden, and identify where additional complexity is no longer improving program quality. We do this both to improve our cost per infant and to build the operational discipline that makes the program resilient to external changes.
Second, we’ve been investing in making our program genuinely reversible, such as developing the systems and governance to responsibly exit a geography when the evidence indicates it’s time to do so, rather than continuing out of inertia.
Third, we’re exploring how to improve cost-effectiveness by layering additional interventions onto our existing platform (such as ORS distribution) and testing lower-cost incentive models. The latter could unlock new geographies within Nigeria and beyond, and potentially serve as a graduation model for areas where our current approach is no longer sufficiently cost-effective.