Malaria Consortium — Support for LLIN Distribution Campaigns in Ondo and Anambra States, Nigeria (March 2021)

Note: This page summarizes the rationale behind a GiveWell grant recommendation to Malaria Consortium. Malaria Consortium staff reviewed this page prior to publication.

Published: August 2021

The organization

Malaria Consortium's seasonal malaria chemoprevention (SMC) program is one of GiveWell's top charities. This grant is the first time we have recommended funding to Malaria Consortium for LLIN campaigns. It follows a 2020 grant to Malaria Consortium for scoping LLIN funding gaps.

The intervention

Long-lasting insecticide-treated net (LLIN) campaigns are intended to reduce the burden of malaria by distributing free LLINs to households in areas at risk of malaria transmission. LLINs are designed to be hung over beds to prevent malaria-carrying mosquitoes from infecting people while they sleep inside the nets. There is strong evidence that LLIN campaigns reduce child mortality from malaria. They are one of the most cost-effective interventions we've identified for saving lives. See our intervention report on mass distribution of LLINs for more detail.

GiveWell has also recommended grants to the Against Malaria Foundation (AMF) for LLIN campaigns. AMF is one of GiveWell's top charities. This is the first grant we have recommended for implementing LLIN campaigns to a second organization.

Planned activities and budget

We expect that Malaria Consortium will use the $27.7 million to:

• Purchase 3.3 million PBO nets for Ondo and 3.9 million PBO nets for Anambra. PBO nets combine pyrethroid insecticide with piperonyl butoxide, which combats some types of mosquito resistance to pyrethroid insecticides.2 Current population estimates put the need at 3 and 3.5 million nets in Ondo and Anambra, respectively; however, Malaria Consortium believes the true need may be up to 10% higher. The total cost to purchase the LLINs for both states and ship them to Nigeria is $18.3 million, or 67% of the total budget.
• Register households for LLINs and distribute the LLINs door-to-door. This includes training distributors, purchasing mobile devices for data collection, publicizing the campaign through town announcers and radio jingles, and providing distributors with personal protective equipment (e.g., face masks and gloves) and hand sanitizer. Distribution costs total $6.8 million, or 25% of the total budget.
• Covering the costs of Malaria Consortium's staff time, including its management fee. These costs total $1 million, or 4% of the total budget.
• There is a contingency for unforeseen expenses of 5% ($1.3 million) of the budget.

See Malaria Consortium's full budgets for the project and our summarized version here. See a more detailed timeline of Malaria Consortium's planned activities in Ondo here.

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 these campaigns. More generally, there is evidence that LLIN campaigns have been consistently underfunded in Nigeria, and in Ondo and Anambra in particular. More below.
• We believe that Malaria Consortium is well-positioned to support these campaigns. It has extensive experience supporting large-scale health campaigns in Nigeria and has a track record of supporting large-scale LLIN campaigns. Our impression is that it has the staff capacity to both design and manage evaluation studies of the campaigns, including of LLIN durability, insecticide resistance, trends in malaria prevalence and incidence, mosquito density and biting behavior, and LLIN ownership and usage. More below.

Cost-effectiveness

Based on our cost-effectiveness analysis of LLIN campaigns in Ondo and Anambra, 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 the Ondo campaign is 19 times as cost-effective as GiveDirectly's program, which provides unconditional cash transfers to poor households in low-income countries, and the Anambra campaign is 13x as cost-effective as GiveDirectly. 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.

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 LLIN grants. We highlight parameters that are particularly important for the model or that we have adjusted for this case below:

• Cost per LLIN delivered. We base this figure on Malaria Consortium's budget for the campaigns. We generally prefer to use actual costs incurred by the implementing organization to deliver the same program in the past, but we opted to use budgeted figures in this case because we believed the budget Malaria Consortium provided was credible. Malaria Consortium was able to provide very detailed budgets that build on its past experiences of implementing large-scale health campaigns in Nigeria.
• Impact of LLINs on child mortality rates. We base this estimate on a Cochrane review meta-analysis of 23 randomized controlled trials (RCTs). More in our intervention report. We then adjust this estimate for the specific context under consideration, including the other inputs in this list.
• Durability of protection provided by an LLIN. LLIN campaigns are typically implemented every 36 months, but we expect that on average LLINs that are in use provide less than three full years of effective coverage due to damage or loss of the LLINs over time.3 Our "equivalent coverage years'' input is our estimate of an LLIN's average duration of protection, relative to the protection provided by nets tested in the RCTs included in the Cochrane review that we rely on for the initial estimate of impact (see above). Our durability estimates are based on our review of studies tracking the retention, physical integrity, and insecticide effectiveness over time of different brands of LLINs (see our separate report for full details). We start with an estimate of 2.3 effective coverage years for one of the most tested LLINs, the PermaNet 2.0.4 We adjust this downward slightly, to 2.0 years, because Malaria Consortium is planning to purchase a newer, less tested type of LLIN, the DuraNet Plus PBO net. We have not yet seen field data on survival of the DuraNet Plus PBO nets, and there is some field evidence of lower physical durability for the DuraNet (which is the same physical net but without the PBO chemical) from distributions in the Democratic Republic of the Congo and Benin.5 For more details, see our calculations in this spreadsheet.
• Malaria mortality rates. We expect that LLINs have a larger mortality-reduction impact in areas where malaria mortality rates are higher. For Ondo and Anambra, we rely on the Institute for Health Metrics and Evaluation (IHME)'s Local Burden of Disease (LBD) project (which provides state-level malaria prevalence and state-level under-5 all-cause mortality estimates), as well as 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 1-59 months. See our calculations in this spreadsheet.
• Reduced effectiveness of LLINs due to insecticide resistance among mosquitoes. We expect that insecticide resistance is a threat to the effectiveness of LLINs—see our separate report on this topic for more details. For the Ondo and Anambra distributions, we use an updated methodology for estimating the impact of insecticide resistance on cost-effectiveness. As of the publication date of this page, this update is not yet discussed in our separate report. Using our updated method, we estimate that insecticide resistance in Nigeria leads to a 15% reduction in cost-effectiveness when 100% of distributed LLINs are PBO nets. See our calculations in this spreadsheet. Our calculations rely on two data sources: the World Health Organization (WHO)'s malaria threat map and the IR mapper tool.6
• Extrapolated effect on mortality in people older than five. The RCTs of LLIN effectiveness focused on effects on under-five mortality because malaria mortality is highly concentrated in this age group.7 However, because LLINs are distributed to all members of the community, we expect there to be reductions in mortality for older age groups as well. We adjust the effect size for older groups down by 20% to account for later sleeping times and the possibility of lower net use among older children and adolescents.8 More discussion on this topic on a separate page. In Nigeria, IHME estimates that there is one malaria death among people over the age of five for every under-five death from malaria.9 This is a higher ratio than in most of the other countries in which we've supported LLIN campaigns (i.e., in most of the other locations, there are significantly more under-five deaths than over-five from malaria),10 so our cost-effectiveness analysis for Ondo and Anambra is more sensitive to our assumptions about LLIN effectiveness in older age groups.
• Likelihood of alternative funding sources. As with all of our cost-effectiveness models, we incorporate a subjective probability that, if we did not recommend the grant, another funder would fund this work. In general, the more likely another funder is to fund this work, the less cost-effective we consider the opportunity, all things considered. Both the probability that other funders would step in and the cost-effectiveness of their alternative use of funds are guesses and are based on qualitative impressions, often built up following many conversations and other research on the funding landscape for malaria control.​​
  • We estimate that for every $1 that Malaria Consortium contributes to LLIN campaigns in Ondo and Anambra, the national and state governments will contribute $0.05-0.10 less to LLIN distribution in expectation.11 This is based on having seen very few instances in other locations of large-scale government contributions to LLIN campaigns, and on the observation that government funding has not been forthcoming for these overdue campaigns. We estimate a non-zero effect because of the possibility that funding for the LLIN campaigns will crowd out some government spending on distribution of LLINs through health clinic visits.12
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US government's President's Malaria Initiative (PMI) are the two largest non-governmental funders of LLINs in Nigeria.13 We estimate that for every $1 that Malaria Consortium contributes to LLIN campaigns in Ondo and Anambra, the Global Fund and PMI will contribute $0.15 less to LLIN distributions in these states.14 This imagines a (low probability) scenario where one or both of these funders adds Ondo and/or Anambra to the set of states in which it supports malaria control in Nigeria. More on the funding landscape in the next section.

Funding landscape for LLINs in Nigeria

There do not appear to be other likely funders of these campaigns.15 The Global Fund and PMI have traditionally restricted their funding to specific states that have been designated as focus states for each of those funders.16 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.17 In 2020, Nigeria's National Malaria Elimination Programme (NMEP) negotiated with the World Bank, Islamic Development Bank, and African Development Bank to secure loan funding for malaria control in these 13 states.18 In the course of negotiations, each state was designated to receive financing from one of the banks.19 The negotiations with the World Bank and Islamic Development Bank were successful.20 At a late stage, the African Development Bank decided not to proceed. This left Ondo and Anambra states without funding for their LLIN campaigns.21

More generally, LLIN campaigns appear to have been chronically underfunded in Nigeria, and in Ondo and Anambra in particular. Prior to the loan funding from the World Bank and Islamic Development Bank, the most recent campaign in 8 out of 37 states in Nigeria was in 2011-2014.22 Those states represent a need for 30 million LLINs out of a total national need of 137 million, or 22% of the total need.23 By contrast, we have followed the history of campaigns in several other countries through our work with AMF and have not encountered any other cases of campaigns being more than six years overdue.

The last LLIN campaign in Ondo specifically was at the end of 2017, and in Anambra in 2014.24 Given a typical lifespan of 2-3 years for LLINs, few effective nets from the last campaign will likely remain in Ondo at the time of the upcoming campaign in late 2021. We have heard from multiple sources that, as in other countries and other states in Nigeria, there is some ongoing distribution of nets, such as through clinic staff providing them to pregnant women during antenatal visits, and that these LLINs are funded by state governments. However, these efforts are not intended to achieve high coverage on their own, and we've heard that stockouts of LLINs are common. Based on data from campaigns supported by AMF in countries other than Nigeria, the proportion of LLINs found in households that are from the most recent campaign is often above 95% and is above 85% in all the data we have reviewed;25 we have no particular reason to think that the proportion of households with LLINs from other sources would be higher or lower in Ondo and Anambra.

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 work on seasonal malaria chemoprevention (SMC)26 and (b) its experience with large-scale malaria prevention campaigns in Nigeria and with LLIN campaigns in several countries. It previously worked on an LLIN campaign in Anambra in 2009.27

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.28 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.29 While there are many differences in how LLINs and SMC are delivered, the broad strokes are similar: procuring health commodities, managing supply chain logistics for the commodities, and training community health workers and volunteers to visit each household, record information, and deliver the commodity and information about its use.

Malaria Consortium also has a track record of supporting LLIN campaigns in several countries. It was the "lead agency" for national campaigns in Uganda in 2013-2014 and 2016-2018. In 2019, it implemented an LLIN campaign in Yobe state, Nigeria, funded by the Global Fund.30 More on its track record in LLIN campaigns here.

Risks and reservations

• Will usage rates be low? Multiple people we spoke to about this grant (see the list below) raised the concern that LLIN usage rates might be relatively low in southern states in Nigeria, perhaps due to high nighttime temperatures, lack of messaging to encourage use, higher proportions of people living in urban areas, and perceived low rates of malaria (which is more of a concern for Anambra than Ondo). In a 2009 survey in Anambra, Malaria Consortium found that "net hanging was not very high with only 61.1% of campaign nets hanging but this was mainly due to motivational problems and nets not being needed rather than people not knowing how to hang the net as only 6.8% of households reported such difficulties in hanging."31 Usage rates may have increased since then, as LLIN use may have become more normalized since the first large-scale campaigns in the early 2000s and as campaign implementers have gotten more experience with methods for promoting usage. Usage may also vary by season; for example, if individuals choose to use nets more often during peak malaria season or less often in hotter seasons if nets are felt to trap heat. We plan to track usage rates through household surveys (more below).
• Will costs exceed the budget? The cost per LLIN for Ondo and Anambra, which is based on Malaria Consortium's budget for the campaigns, is lower than our estimate for most campaigns supported by AMF.32 This could reflect optimism in Malaria Consortium's budget, but may also reflect problems in our estimates for AMF-supported campaigns, which are based in part on AMF's past spending but also on rough estimates of spending by other contributors.
• Will the quality of implementation be impacted by the short planning period? We recommended this grant in March 2021, and the Ondo campaign is scheduled for just over six months later, in October to November 2021.33 The timeline is short in part because the goal is to deliver the LLINs before, or at least concurrent with, the annual peak in malaria in Ondo. Typically, grantees we have worked with have requested longer lead times to plan large-scale campaigns. One concrete outcome of the short time between the grant and the campaign is that we did not collect data to determine whether PBO nets were superior to standard LLINs in these states or whether another type of net would be more cost-effective, because Malaria Consortium needed to place the order for the nets immediately after the grant was made.34 The short planning period increases the risk of the campaign being delayed and could impact quality in hard-to-observe ways. It also limits the time available for us to work with Malaria Consortium on planning data collection and for Malaria Consortium to execute on pre-campaign data collection.

Plans for follow up

As of this writing, we are in ongoing discussions with Malaria Consortium about what data it will collect before, during, and after the campaigns. Our aim is to use this information to update our cost-effectiveness analysis of these campaigns, other LLIN campaigns for which we may direct funding to Malaria Consortium in the future, and LLIN campaigns more broadly. We will likely recommend an additional grant to Malaria Consortium to support the costs of data collection, and we have included an estimate of these additional costs as an input into the cost-effectiveness model discussed above.

Here is the current outline of the plan for data collection in Ondo over the course of three years (or until the next campaign, whichever comes first):35

• Net ownership before and after the campaign: the number of people per household and the number of LLINs owned by the household, before the campaign and shortly after the campaign. The number of people who have access to an LLIN as a result of a campaign, and who would not have had access otherwise, is a key parameter in our cost-effectiveness analysis. We would use data from this study to update this parameter.
• Reported usage: what percentage of people report sleeping under an LLIN the night before the survey. Our cost-effectiveness analysis includes a parameter for usage in current contexts relative to usage recorded during the RCTs of insecticide-treated nets. We would use data from this study to update this parameter.
• LLIN durability and insecticide effectiveness over three years: the condition of LLINs, in terms of number and size of holes, and effectiveness of remaining insecticide to kill mosquitoes that are known to be susceptible to the primary insecticide (pyrethroid). We plan to use this data to update the parameter in our cost-effectiveness analysis for durability of protection provided by an LLIN (see above). Malaria Consortium is purchasing the DuraNet Plus LLIN for both Ondo and Anambra. There have been studies completed on the durability of the DuraNet, the version of this net without PBO, in real-life conditions. To our knowledge, there have not yet been durability studies of this type completed for DuraNet Plus, though at least one study is planned.36 This research could contribute to general knowledge about the durability of the DuraNet Plus LLIN.
• Insecticide resistance: At baseline and two years post-campaign, tests would be performed to determine whether local mosquitoes are resistant to the pyrethroid insecticide and, if they are, what type(s) of resistance they exhibit. These tests are intended to aid in choosing the type of LLIN for subsequent campaigns in these two states and possibly in nearby states.
• Indoor vs. outdoor biting behavior: tracking the density of mosquitoes indoors and outdoors with CDC light traps, lab analysis to separate out the species of mosquito that is responsible for most of the transmission of the most deadly form of malaria, and measures of human behavior to determine how the times when people are under nets correspond to peak biting times.
• Malaria incidence, according to clinic data: Malaria Consortium would select clinics to track based in part on whether they have consistently reported malaria case data to the government health data system. At each clinic, Malaria Consortium would use patient registers, starting from three years before the campaign, to tally the number of malaria cases in each month. Incidence is likely to be more indicative of the impact of the campaign on mortality and morbidity than prevalence. We have not yet determined whether to expect that the current study design will yield a reliable measure of the impact of the LLIN campaign. Limitations may include non-representative clinics, incomplete recording of cases by clinic staff, and changes in the number of health facilities available to patients over time (which could affect the number of patients visiting the sampled health facilities).
• Costs of the campaign not paid by Malaria Consortium: To accurately estimate the cost-effectiveness of this work, we want to capture in the model not only costs paid by Malaria Consortium but also the opportunity cost of other resources used to deliver the campaign. For example, this might include time spent by government employees and community health workers who might have been delivering other services in that time. We have only a rough estimate of the amount and value of time and other resources spent on LLIN campaigns, and would like to improve this estimate.

We currently expect that Malaria Consortium will collect data on fewer indicators in Anambra than in Ondo. At a minimum, we expect to see data on ownership and usage from Anambra. Lower malaria rates in Anambra mean that detecting effects on incidence requires larger sample sizes. For some indicators (e.g., LLIN durability, costs), we do not expect large differences between the states. For other indicators, we may decide to focus on learning from the process in order to iterate on and improve what LLIN campaign monitoring we request in the future, so, for those indicators, following a similar process in a second location before the process is complete in the first may have limited benefits.

Internal forecasts

Confidence	Prediction	By time​​
80%	Conditional on us completing an assessment of the cost-effectiveness of this work, we will assess the work in Ondo as being more than 8 times as cost-effective as cash transfers after three years.	End of 2025
65%	We will assess the work in Anambra as being more than 8 times as cost-effective as cash transfers after three years.	2025
25%	Final cost per LLIN delivered >10% higher than budgeted.	2022
60%	We will recommend additional funding to Malaria Consortium for LLINs.	End of 2023
35%	We ask for tracking of malaria incidence for other LLIN campaigns we support.	2024

Our process

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

In June 2020, Malaria Consortium received a GiveWell Incubation Grant of $44,688 to explore whether there were funding gaps for LLIN campaigns in areas where Malaria Consortium has existing operations and would be well-positioned to implement LLIN campaigns. Malaria Consortium decided to focus on Uganda and Nigeria. It identified funding gaps in Uganda that we determined did not meet our criteria. Its work on scoping funding gaps in Nigeria led to the grant discussed on this page.

In addition to discussions with Malaria Consortium, we spoke with individuals at the following groups to ask for feedback on the grant: Nigeria's National Malaria Elimination Program, the African Leaders Malaria Alliance (conversation notes here), the Nigerian Institute of Medical Research, Society for Family Health Nigeria, SHI Nigeria, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. We greatly appreciate their contributions to this grant decision. The conclusions described in this page, and any errors, are our own.

Sources

Document	Source
GiveWell, Counterfactual scenarios on pre-existing nets (four-year spacing), 2021	Source
GiveWell, Insecticide Resistance (IR) Mapper synergist bioassay data for Nigeria, 2021	Source
GiveWell, Malaria Consortium LLINs supplementary information, 2021	Source
GiveWell, Malaria Consortium's Ondo and Anambra LLIN budget, March 19, 2021 (redacted)	Source
GiveWell, Nigeria LLIN campaign funding landscape, September 2020	Source
GiveWell, Ondo and Anambra LLIN distribution CEA, 2021	Source
GiveWell, Summary of AMF post-distribution monitoring results and methods, 2019	Source
GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021	Source
Malaria Consortium, Coverage report: Anambra state, 2011	Source
Malaria Consortium, LLIN campaign summary, 2021	Source
Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted)	Source
Malaria Consortium, Ondo state campaign timeline, 2021	Source
Malaria Consortium, Responses to questions from GiveWell, March 2021 (redacted)	Source
Malaria Consortium, SMC coverage report, 2020	Source

• 1$500,000 of this grant was funded by an individual donor.
• 2

  See a more detailed description of PBO nets and our assessment of the evidence for them here.

• 3

  See the "From LLIN distribution to LLIN ownership" section of our LLIN intervention report: "Mass distribution of LLINs typically occurs at three-year intervals, but we believe that LLINs degrade over time and on average provide less than three years of full protection over the distribution cycle. Our analysis indicates that during each three-year distribution cycle for most countries, an LLIN from an AMF-funded campaign confers 2.11 years of coverage equivalent to that provided by the nets used in the RCTs. We based this estimate on studies that tracked, in real-life conditions, the retention, physical survival (i.e., number and size of holes), and insecticide effectiveness at killing mosquitoes of two of the main brands of LLINs that AMF has purchased."

• 4

  See our report on estimating equivalent coverage years for LLINs: "We estimate that the PermaNet 2.0 provides 2.27 equivalent coverage years across a 3-year distribution."

• 5

  See a fuller explanation in the cell note here.

• 6

  We have not yet written in detail about the newer methodology we used in this case. We plan to in the future.

• 7

  See our report on the impact of malaria mortality in individuals over five years old: "We are aware of three organizations or projects that estimate malaria mortality rates: the World Health Organization (WHO), the Global Burden of Disease (GBD) study (published by the Institute for Health Metrics and Evaluation (IHME)), and the Malaria Atlas Project (MAP).... Regarding what portion of malaria deaths occur in children under 5 years old in sub-Saharan Africa, it appears that all three groups have similar estimates as of 2015-2016: that about 73-77% of malaria deaths in sub-Saharan Africa occur in children under 5 years old."

• 8

  See the "Relative efficacy of LLINs for reducing mortality of individuals age 5+" row in the "Malaria Consortium (LLINs)" tab of our cost-effectiveness analysis for these campaigns.

• 9

  See the "Number of under-5 malaria deaths per year (GBD 2019)" and "Number of age 5+ malaria deaths per year" rows in the "Malaria Consortium (LLINs)" tab of our cost-effectiveness analysis for these campaigns.

• 10

  See the most recent version of our cost-effectiveness analysis here, "AMF" tab.

• 11

  See the "Scenario 1: Government costs would replace philanthropic costs" row in the "Malaria Consortium (LLINs)" tab of our cost-effectiveness analysis for these campaigns.

• 12

  Malaria Consortium notes: "We were informed during the advocacy visit to Ondo that the state government recently procured some LLINs for routine distribution." Malaria Consortium, comments on a draft of this page, July 2021 (unpublished)

• 13

  We created a summary version of an LLIN campaign funding landscape analysis for Nigeria provided to us by Malaria Consortium. This analysis shows that the Global Fund and PMI are expected to fund 39% and 29%, respectively, of the LLINs that will be distributed in Nigeria by non-governmental actors in 2021-2024. See the full spreadsheet for the list of funding gaps, funding years, and funders by region.

• 14
  • See the "Scenario 2: Global Fund and/or PMI would replace philanthropic costs" row in the "Malaria Consortium (LLINs)" tab of our cost-effectiveness analysis for these campaigns.
  • Malaria Consortium notes: "There are currently no plan for GF or PMI to fund these states." Malaria Consortium, comments on a draft of this page, July 2021 (unpublished)

• 15

  "The COVID-19 pandemic and its impact on both the global and Nigerian economies have further complicated the global funding situation, and it is unlikely that an alternative funder will step forward in the immediate future to fill the funding gaps in Ondo and Anambra." GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021, Pg. 2

• 16

  "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

• 17

  "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

• 18

  "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

• 19

  "A number of partners have supported the Nigerian government to secure $300 million of funding that will cover malaria interventions in 11 of the 13 remaining states. $200 million will be provided by the World Bank and $100 million will be provided by the Islamic Development Bank. The funding will finance long-lasting insecticide-treated net (LLIN) distributions, seasonal malaria chemoprevention (SMC) administration where recommended, and routine case management. $50 million of funding for the final 2 states, Ondo and Anambra, was sought from the African Development Bank, which was ultimately unsuccessful at the final stages of the approval process." GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021, Pg. 1

• 20

  "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. The project appraisal, project implementation manual and plan and procurement plan have been all developed. The government and the two banks are in the process of finalizing the legal agreement (with Ministry of Justice taking the lead), and the financial agreement (with Ministry of Finance taking the lead), expected to be completed in the next two months." Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), Pgs. 7-8

• 21
  • "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
  • "$50 million of funding for the final 2 states, Ondo and Anambra, was sought from the African Development Bank, which was ultimately unsuccessful at the final stages of the approval process. Without external funding, Ondo and Anambra will be the only states in Nigeria where universal coverage campaigns to prevent malaria will not take place during the next three years." GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, January 12, 2021, Pg. 1

• 22

  We created a summary version of an LLIN campaign funding landscape analysis for Nigeria provided to us by Malaria Consortium. According to this analysis, eight states received their most recent LLIN campaigns in 2014 or earlier: Borno, Anambra, Enugu, Bayelsa, Rivers, Ekiti, Lagos, and the Federal Capital Territory (FCT).

• 23

  See this spreadsheet, "Campaign ITNs required (Ms)" column, for the number of nets required for each of these eight states: FCT (2.71 million), Borno (3.75 million), Anambra (3.42 million), Enugu (2.75 million), Bayelsa (1.42 million), Rivers (4.78 million), Ekiti (2.05 million), Lagos (9.41 million). Together these total roughly 30 million nets.

• 24

  See here and here in our summarized version of Malaria Consortium's LLIN campaign funding landscape analysis for Nigeria.

• 25

  See GiveWell, Summary of AMF post-distribution monitoring results and methods, 2019, "AMF vs. non-AMF nets" tab, "Proportion AMF" figures.

• 26

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

• 27

  See Malaria Consortium, Coverage report: Anambra state, 2011.

• 28

  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 2019, Malaria Consortium used GiveWell-directed funds to target approximately 1.3 million children in 23 districts in Burkina Faso, approximately 1 million children in 20 districts in Chad, and approximately 3.5 million children in 68 LGAs in Nigeria."

• 29

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

• 30

  See Malaria Consortium, LLIN campaign summary, 2021, rows 1-3.

• 31

  @Malaria Consortium, Coverage report: Anambra State, 2011@, Pg. 8

• 32

  See the most recent version of our cost-effectiveness analysis here, "AMF" tab.

• 33

  Malaria Consortium, Ondo state campaign timeline, 2021

• 34

  Malaria Consortium notes: "This decision on the type of net was in line with the national recommendation for PBO nets." Malaria Consortium, comments on a draft of this page, July 2021 (unpublished)

• 35

  We have discussed these plans with Malaria Consortium over the course of several conversations. The plans reflect our understanding as of this writing in June 2021 and may change before being finalized.

• 36

  Unpublished conversation with Malaria Consortium, March 3, 2021