Malaria Consortium — Support for SMC in FCT and Oyo States, Nigeria (October 2021)

Published: December 2021

Planned activities and budget

We expect that this $15.9 million grant will support SMC in:1

• FCT in 2022-2024, at a cost of about $14.5 million, or $4.8 million per year. The budget is based on an approximate target population of 1.02 million children2 and cost per child per SMC cycle of $0.95.
• Oyo in 2022, at a cost of about $1.4 million. Of 33 local government areas (LGAs) in Oyo, 6 are considered eligible for SMC. The budget is based on an approximate target population of 0.3 million children and cost per child per SMC cycle of $0.95.

Malaria Consortium provided a rough budget for this grant, which it plans to refine at a later stage of planning. It told us that it erred on the high side of projected costs. If Malaria Consortium does not need the full amount for these states in these years, it will roll the funds forward to future years.

We typically recommend three-year grants because grantees have told us in the past that there are often substantial benefits to knowing that funding for a program is secure for the future.3 We have recommended a three-year grant for FCT because we think it is unlikely that there will be another major source of funding for SMC in FCT in the next three years. For Oyo, we have recommended one year of funding, to allow for more time to understand the funding landscape in Oyo (see ​​below).

The case for the grant

• We consider this program to be cost-effective. More below.
• While there are several sources of large-scale malaria funding in Nigeria, there do not appear to be other likely funders of SMC in FCT or of SMC in Oyo in 2022. More below.
• We believe that Malaria Consortium is well-positioned to support these campaigns. It has extensive experience supporting large-scale SMC in Nigeria, as well as in other countries. More below.

Cost-effectiveness

Based on our cost-effectiveness analysis of SMC in FCT and Oyo,4 we believe the program is in the range of cost-effectiveness of programs we expect to direct funding to, as of 2021. Our estimate is that SMC in FCT is 8 times as cost-effective as GiveDirectly's program, which provides unconditional cash transfers to poor households in low-income countries, and that SMC in Oyo is 16x as cost-effective as GiveDirectly.5 At the time we recommended this grant, we were primarily looking to recommend grants that we estimated were more than 8x as cost-effective as GiveDirectly, and were willing to consider recommending a limited amount of funding to grants that were between 5x and 8x as cost-effective as GiveDirectly.

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes to other grants we have made or considered making, and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

Our cost-effectiveness analysis for this grant is based on the same structure as our model for other SMC grants. We highlight parameters that are particularly important for the model or that we have adjusted for this case below:

• Cost per child for five SMC cycles. SMC in FCT and Oyo will involve delivering five cycles of SMC drugs to as many children in the eligible age range as possible.6 In the SMC programs that Malaria Consortium has supported in Nigeria in the past, the average total cost to deliver five cycles has been $8.93.7 Malaria Consortium's budget for FCT and Oyo equated to a total cost of $10.65 for five cycles delivered.8 Malaria Consortium told us that this budget was more likely to overestimate than underestimate the cost.9 Based on this, we'd guess that the estimate of past costs is more predictive of future costs, but that the budgeted figure may indicate somewhat higher costs in FCT and Oyo than average. As an approximation, we've taken a weighted average of the two estimates with 65% weight on the estimate of past costs.10
• Malaria burden as of 2019. We rely on the ​​Local Burden of Disease (LBD) project (which provides state-level malaria prevalence and state-level under-5 all-cause mortality estimates) from the Institute for Health Metrics and Evaluation (IHME), as well as on the Malaria Atlas Project (MAP) (which provides state-level all-ages malaria mortality estimates). We combine data from these sources to create a rough estimate of state-level malaria mortality rates as a proportion of all-cause mortality for children aged 6-59 months. According to these sources, FCT has slightly lower malaria prevalence and moderately lower malaria mortality than Nigeria overall, and Oyo has higher malaria prevalence and mortality.11
• Change in malaria burden in FCT due to expected insecticide-treated net campaign. A campaign to distribute long-lasting insecticide-treated nets (LLINs) is scheduled in FCT in 2021. The National Malaria Elimination Program (NMEP) notes that this will be the first LLIN campaign since 2011.12 Based on this, we assume that few households were using effective LLINs in 2019, the year we have malaria burden estimates for. We have made a 30% downward adjustment to malaria rates in FCT to account for the anticipated impact of LLINs during 2022-2024. The 30% is based on our model of LLIN cost-effectiveness for Nigeria.13 Our understanding is that the campaign scheduled for 2021 may be delayed due to a delay in the disbursal of the loan financing that is funding the campaign;14 however, we have kept this adjustment because we are modeling the cost-effectiveness of SMC in FCT through 2024.
• Proportion of malaria mortality occurring in the five months when SMC is delivered. To date, our SMC cost-effectiveness analysis has assumed that 70% of malaria would have occurred during the SMC season, if SMC were not delivered.15 This assumption was largely based on the fact that SMC is recommended by the World Health Organization in areas where "more than 60% of the annual incidence of malaria occurs within 4 months" and on one study, published in 2012, that found that "in sites considered suitable for SMC, the median fraction of incidence occurring in the 4 consecutive months of peak transmission was 77% and the mean 75.7%."16 Oyo and FCT are further south than the Sahelian states in Nigeria where SMC was first rolled out, and rainfall is more dispersed over the course of the year than in the sites that were considered suitable for SMC at the time of the 2012 study.17 We estimate that 74% (FCT) and 69% (northern Oyo) of rainfall occurs in four months, compared with 80-90% in states along Nigeria's northern border,18 where SMC was first rolled out. We have adjusted the estimate for the proportion of malaria cases occurring in the SMC season to 60% (down from 70%), as a rough estimate.19 To give a sense of the bounds on this figure, we think it is a safe assumption that at least 42% (5/12) of malaria cases would occur in the five months SMC is delivered, as that would represent no seasonality. We discussed this estimate by email with one of the authors of the 2012 study.
• Crowding out other funders (or "funging"). We assume a probability of 20% that Global Fund or the President's Malaria Initiative (PMI) would replace Malaria Consortium's costs in FCT and 30% in Oyo (in contrast to a 25% probability for Nigeria overall).20 See discussion below.

Funding landscape for SMC in Nigeria

There do not appear to be other likely funders of these campaigns. Global Fund and PMI have traditionally restricted their funding to specific states that have been designated as focus states for each of those funders.21 Our understanding is that these designations were made in order to lower coordination costs among funders and government agencies. There are 13 states that are not designated to receive funding from Global Fund or PMI.22 In 2020, Nigeria's National Malaria Elimination Programme (NMEP) negotiated with the World Bank, Islamic Development Bank, and African Development Bank to secure loan financing for malaria control in 11 of these states.23

FCT is one of the 11 states that is slated to receive loan financing for malaria control. SMC was included in the loan funding for only one state, Borno. Our understanding is that the loan financing is highly restricted to specific programs and there's little possibility of it being reallocated to SMC in FCT.24

Oyo receives support from PMI for malaria control. So far, PMI has only supported SMC in one state (Zamfara), starting in 2019. It is possible that PMI will expand its support for SMC to another state (Benue) in 2022.25 Currently, five states that receive support for malaria control from PMI are receiving support for SMC from Malaria Consortium, largely funded with GiveWell-directed funding.26 Malaria Consortium told us that SMC in Oyo is not included in PMI's fiscal year 2022 budget (the fiscal year started October 1, 2021).27

Malaria Consortium's track record

We believe that Malaria Consortium is well-positioned to implement this grant based on (a) our positive qualitative assessment from following its past work on SMC28 and (b) its experience with SMC in Nigeria and several other countries. Malaria Consortium's SMC program is a GiveWell top charity, and we have followed its work on this program since 2016 in Nigeria, Burkina Faso, and Chad, and more recently in Togo.29 To give a sense of its scale in Nigeria, in 2020, Malaria Consortium implemented SMC, in partnership with state and national governments, in 176 local government areas in seven states, targeting a population of 9.8 million children.30 In 2021, this scale grew to 248 local government areas in 11 states, targeting a population of 16.3 million children.31

Risks and reservations

• Through many conversations, we've heard that there are often lower malaria rates and more access to health services in urban areas. FCT is one of Nigeria's smaller states by area, and it contains the federal capital, Abuja. A question we had when investigating this grant was whether the geospatial model results we rely on to estimate malaria burden in FCT might not fully adjust for the proportion of the population that lives in urban areas in FCT. We discussed this question by email with the Malaria Atlas Project, which created the malaria burden model we rely on. They confirmed that the model includes parameters that are proxies for urban vs. rural areas.32 We may fund additional research into this question in the future.
• PMI has been expanding its funding for SMC, and we'd welcome it extending that support to Oyo in 2023 and beyond. Our support for SMC in Oyo in 2022 may discourage it from doing so. On the other hand, the 2022 funding may put in place the processes and capacity that make it easier for PMI to fund SMC there in future years.

Plans for follow up

• We have monthly calls with Malaria Consortium to discuss its SMC program.
• In 2023, we expect to get updates from Malaria Consortium on total spending in FCT and Oyo in 2021 and results of coverage surveys. We plan to use this data to update our estimate of the cost-effectiveness of delivering SMC in FCT and Oyo in 2022. We may also have some conversations to update our understanding of the funding landscape for SMC in FCT and Oyo.

Internal forecasts

Confidence	Prediction	By time​​
70%	We calculate the cost per five SMC cycles delivered in FCT in 2022 as no more than 10% more than our current estimate for Nigeria—i.e., no more than $9.82.33	We expect to do this analysis by the end of 2023.
50%	Coverage in FCT in 2022, as measured by percentage of targeted cycles delivered according to the end of round coverage survey, is greater than 56%, which is the coverage estimate we use in the SMC cost-effectiveness model and is based on Malaria Consortium's past results in Nigeria.34	Coverage survey will take place around October/November 2022. We expect to do this analysis by the end of 2023.

Our process

Our process on this grant relied heavily on (a) our prior work on modeling the cost-effectiveness of SMC programs supported by Malaria Consortium, and (b) our relationship with Malaria Consortium and knowledge of its work that has resulted from supporting its SMC program since 2016.

Malaria Consortium told us about the funding gap for SMC in FCT and Oyo in September 2021.

In addition to discussions with Malaria Consortium, during the process of determining whether to recommend this grant we spoke with NMEP and representatives of PMI. We also emailed with one of the authors of the 2012 article "Estimating the potential public health impact of seasonal malaria chemoprevention in African children" about malaria seasonality in Nigeria, and with the Malaria Atlas Project about how its models account for differences in malaria transmission in urban and rural settings. We greatly appreciate their contributions to this grant decision. The conclusions described in this page, and any errors, are our own.

For internal review, two Program Officers and one Senior Researcher who weren't otherwise involved in the grant investigation gave feedback on the process for determining two key cost-effectiveness analysis parameter values: (1) proportion of annual malaria mortality occurring in SMC season, and (2) malaria burden in FCT. Open Philanthropy also reviewed the case for the grant and provided feedback.

Sources

Document	Source
Cairns et al. 2012	Source
GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021	Source
Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted)	Source
Malaria Consortium, SMC coverage report, 2020	Source
Malaria Consortium, Summary Narrative Report 2018	Source
Malaria Consortium's seasonal malaria chemoprevention program: Philanthropy report 2020	Source (archive)
World Health Organization, "Seasonal malaria chemoprevention with sulfadoxine–pyrimethamine plus amodiaquine in children: A field guide," 2013	Source (archive)

• 1

  See Nigeria Oyo and FCT SMC budget sense check (public), "[Source] MC budget and target pop" sheet.

• 2

  As of November 2021, the target population projection has been revised upward to 1.1 million children.

• 3

  More discussion of this principle ​​here (see Principle 6).

• 4

  See ​​2021 GiveWell cost-effectiveness analysis – version 4, "Malaria Consortium" sheet, "FCT, Nigeria" and "Oyo, Nigeria" columns.

• 5

  See 2021 GiveWell cost-effectiveness analysis – version 4, "Malaria Consortium" sheet, "FCT, Nigeria" and "Oyo, Nigeria" columns, "Cost-effectiveness in multiples of cash transfers, after all adjustments" row.

• 6

  See Nigeria Oyo and FCT SMC budget sense check (public), "[Source] MC budget and target pop" sheet

• 7

  The average total cost for four cycles of SMC in Nigeria is $7.14, for a per-cycle cost of $1.785. $1.785 x 5 cycles = $8.93. See 2021 GiveWell cost-effectiveness analysis – version 4, "Malaria Consortium" sheet, Nigeria column, "Cost per equivalent child treated with all cycles of SMC" row.

• 8

  See Nigeria Oyo and FCT SMC budget sense check (public), "Total cost per child fully covered" row.

• 9

  Christian Rassi, Programme Director, SMC and Multi-country Programmes, Malaria Consortium, email to GiveWell, September 27, 2021 (unpublished).

• 10

  See our calculations here.

• 11

  See our calculations here.

• 12

  "Region: North ​​Central, State: FCT . . . Year of last campaign: 2011, Planned year of campaign: 2021." Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), Pg. 9.

• 13

  For information about the adjustment, see the cell note in GiveWell's cost-effectiveness analysis, "Malaria Consortium" sheet, "FCT, Nigeria" column, "Under-5 mortality rate from malaria (per 100,000 child years)" row. Since making this adjustment, we had a call with the National Malaria Elimination Program (NMEP), and they said that the loan funding for campaigns such as this one had been delayed. It still seems fairly likely that a campaign will occur before 2024, thus affecting the cost-effectiveness of SMC. However, this may mean that SMC in 2022 is more cost-effective than we've modeled if the LLIN campaign has not happened by then. National Malaria Elimination Program (NMEP), call with GiveWell, September 22, 2021 (unpublished).

• 14

  We gained this understanding through multiple conversations.

• 15

  See 2021 GiveWell cost-effectiveness analysis – version 4, "Malaria Consortium" sheet, "Mortality reduction in treated population" section, "Proportion of annual direct malaria mortality occurring in high-transmission season" row.

• 16
  • World Health Organization, "Seasonal malaria chemoprevention with sulfadoxine–pyrimethamine plus amodiaquine in children: A field guide," 2013, Pg. 8.
  • Cairns et al. 2012, Pg. 9.

• 17
  • SMC was first rolled out in the states along Nigeria's northern border: "Since 2013, Nigeria was supported first by the Bill & Melinda Gates Foundation and then through other one-off funding to implement SMC in six LGAs in the States of Katsina and Jigawa; subsequently, thanks to funding from Unitaid, the program extended to the whole States of Sokoto and Zamfara (37 LGAs)." Malaria Consortium, Summary Narrative Report 2018, Pgs. 5-6.
  • FCT is located near the center of the country, and Oyo is located in the southwest of the country.

• 18
  • Among the earlier states where SMC was rolled out are Sokoto and Zamfara, where 90% and 86% of rainfall occurs in four months, respectively. See the rainfall data we have used here, "Rainfall in 4 consecutive months with highest rainfall" row.
  • "Since 2013, Nigeria was supported first by the Bill & Melinda Gates Foundation and then through other one-off funding to implement SMC in six LGAs in the States of Katsina and Jigawa; subsequently, thanks to funding from Unitaid, the program extended to the whole States of Sokoto and Zamfara (37 LGAs)." Malaria Consortium, Summary Narrative Report 2018, Pgs. 5-6.

• 19

  See 2021 GiveWell cost-effectiveness estimate – version 4, "Malaria ​​Consortium" sheet, "Proportion of annual direct malaria mortality occurring in high-transmission season" row.

• 20

  See 2021 GiveWell cost-effectiveness estimate – version 4, "Malaria Consortium" sheet, "Leverage/Funding adjustment" section, "Probability of scenarios in absence of philanthropic funding" section.

• 21

  "External funding for malaria interventions in Nigeria is structured such that funders typically support programs in separate states, and there is rarely flexibility for this funding to cross state borders. Currently, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President's Malaria Initiative (PMI) are separately funding malaria treatment and prevention interventions in 13 and 11 of Nigeria's states, respectively, leaving 13 states without external funding for these interventions in 2021." GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021, Pg. 1.

• 22

  "Currently, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President's Malaria Initiative (PMI) are separately funding malaria treatment and prevention interventions in 13 and 11 of Nigeria's states, respectively, leaving 13 states without external funding for these interventions in 2021." GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021, Pg. 1.

• 23
  • "The remaining 13 states are supposed to be supported by the Government of Nigeria (GoN) through loans from World Bank (WB), Islamic Development Bank (IsDB) and Africa Development Bank (ADB). . . . Discussions with Dr Audu Baba Mohammed, NMEP Director/National Coordinator, revealed that WB and IsDB are likely to provide support (after November 2020) to 11 of the 13 states for campaigns. The negotiations of GoN with these two banks have reached an advanced stage as the Federal Executive Council has signed the loan agreement." Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), Pg. 7.
  • "However, NMEP is yet to hear back from ADB that is expected to provide funds for ITN campaigns in Anambra and Ondo states. After several engagements with the bank, the Board of ADB has not approved the credit to cover these two states. The only option left to the NMEP at this stage is to look for funding elsewhere for ITN intervention." Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), Pg. 8.

• 24

  Christian Rassi, Programme Director, SMC and Multi-country Programmes, Malaria Consortium, call with GiveWell, July 22, 2021 (unpublished).

• 25

  Christian Rassi, Programme Director, SMC and Multi-country Programmes, Malaria Consortium, email to GiveWell, September 7, 2021 (unpublished).

• 26
  • The states receiving support for malaria control from PMI are identified in Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), Pg. 7, "Figure 5. Malaria donor-supported states."
  • Five of those states (Kebbi, Sokoto, Bauchi, Plateau, and Nasarawa) are receiving support for SMC from Malaria Consortium through philanthropic funding. Malaria Consortium's seasonal malaria chemoprevention program: Philanthropy report 2020, Pg. 20, "Figure 5: Support for SMC in 2021 by state and funding source, Nigeria."
  • The philanthropic funding was "received through donations to Malaria Consortium’s entities in the United Kingdom (UK) and the United States (US), primarily as a result of being awarded Top Charity status by GiveWell, a
    nonprofit organization dedicated to finding outstanding giving opportunities." Malaria Consortium's seasonal malaria chemoprevention program: Philanthropy report 2020, Pg. 5.

• 27

  Christian Rassi, Programme Director, SMC and Multi-country Programmes, Malaria Consortium, call with GiveWell, September 16, 2021 (unpublished).

• 28

  More on our qualitative assessments of top charities on this page.

• 29

  From our review of Malaria Consortium's SMC program:

  • "We began speaking to Malaria Consortium about the possibility of reviewing one of its programs in January 2016."
  • "Since 2017, Malaria Consortium has been using funding received as a result of GiveWell's recommendation (which we refer to as "GiveWell-directed funds") to support SMC programs in several countries…. In 2020, Malaria Consortium used GiveWell-directed funds to target approximately 1.6 million children in 23 districts in Burkina Faso, approximately 1 million children in 20 districts in Chad, approximately 4.3 million children in 81 LGAs in Nigeria, and approximately 200,000 children in seven districts in Togo."

• 30

  Malaria Consortium, SMC coverage report, 2020, Table 1, Pg. 11.

• 31
  • Malaria Consortium, comments on a draft of this page, November 2021.
  • Note that these figures include both the portion of Malaria Consortium's portfolio that is supported by philanthropic funding (primarily GiveWell-directed funding) and the portion that is supported by institutional funding (primarily from the Global Fund).

• 32

  Malaria Atlas Project, email to GiveWell, October 7, 2021 (unpublished).

• 33

  Our current estimate for five cycles is $8.93. See our calculations here. $8.93 x 1.1 = $9.82.

• 34

  See here.