Reallocation of Malaria Consortium SMC funding to support SMC in Borno, Nigeria in 2021

Published: September 2021

What is the source of funding?

This is not a new grant. Malaria Consortium plans to fund this work with its existing philanthropic SMC funding. It received most of this funding based on GiveWell's recommendation. We communicated to Malaria Consortium that we were supportive of it using funding in this way. It did not require our formal approval to reallocate funds within its SMC program. This page documents our reasons for our decision to tell Malaria Consortium that we were supportive of the reallocation; Malaria Consortium has told us that it would not have proceeded otherwise.1

We expect that the funding would have otherwise been used to support Malaria Consortium's SMC programs in Nigeria, Burkina Faso, and Togo in 2023. Malaria Consortium was able to reallocate this funding because (a) we have not restricted how it uses funding we've directed beyond restricting it for use on SMC, and (b) it's not yet necessary for Malaria Consortium to make concrete spending decisions for 2023.2 We believe that Malaria Consortium's SMC programs in Nigeria, Burkina Faso, and Togo in 2023 also meet our criteria for funding so it is likely that we'll make a grant, or recommend that a funder we advise make a grant, to backfill this funding. We expect to do so by the end of 2021, because Malaria Consortium will start making more concrete plans for 2023 around that time.

Planned activities and budget

Malaria Consortium estimated that it would cost $8.8 million to support the full costs of SMC implementation, including purchasing SMC drugs, in Borno state from August to November 2021. This budget was based on Malaria Consortium's experience implementing SMC in other states in Nigeria and on the implementing model used for SMC in Borno in the last few years.

SMC has been implemented in parts of Borno for the past four years, funded by WHO in 2017-19, then by the Global Fund to fight AIDS, Tuberculosis, and Malaria in 20203 using funding that had been budgeted for other activities in the 2018-2020 grant cycle and was not ultimately needed for those purposes.4 Nigeria has obtained a World Bank loan that will support malaria control in several states, including Borno, over three years. The loan funding was expected to be available to support SMC in Borno in 2020 and 2021 but, as of June 2021, was delayed.5

As of this writing, the details of how SMC will be implemented are being worked out. At the time we made this decision, Malaria Consortium's budget was based on the assumption that there will be three implementing models, similar to how SMC was delivered in Borno in recent years:6

1. Malaria Consortium's typical model for supporting SMC. More on the typical model here. About 40% of the target population was expected to be reached this way.7
2. Through other organizations providing services in internally displaced people (IDP) camps. 40% of the target population was expected to be reached this way.8 As of this writing, we don't know what organizations Malaria Consortium will fund for this work.
3. By other organizations with an established presence in what are considered the hardest-to-reach areas. Examples of such organizations include Médecins Sans Frontières (MSF, also known as Doctors Without Borders) and INTERSOS. 20% of the target population was expected to be reached this way.9

Since we made this decision, Malaria Consortium has learned more about the operating context and revised its expectations in the direction of targeting a greater proportion of children through its typical model.10 Updates include that, ​​in hard-to-reach areas, the state malaria programme will implement directly, with support from humanitarian organisations; the US President’s Malaria Initiative has agreed to donate a certain quantity of SPAQ for use in Borno; and cost estimates have been updated based on the refined plans for the implementation model.11

The case for reallocating funding

• We consider this program to be cost-effective. More below.
• We believed it was very unlikely that another funder would step in in time. By the time we learned of the funding gap, it was less than two months before SMC was usually scheduled to start. In our experience, funders (including GiveWell) only rarely make grants with as little lead time as this.
• There was an implementing partner, Malaria Consortium, who was well positioned to both work with us (based on a strong working relationship built over several years) and with the National Malaria Elimination Program (NMEP) in Nigeria. Malaria Consortium had implemented SMC in several states in northern Nigeria since 2013.12 Malaria Consortium also had flexible funding on hand,13 which cut down on time needed to administratively process a new grant.
• While the timeline was very short and Malaria Consortium would be supporting SMC in Borno for the first time, there was a blueprint for implementation because SMC had been implemented in Borno for the past five years (see above).

Cost-effectiveness

Based on our cost-effectiveness analysis of SMC in Borno in 2021, 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 work that this funding will support is 10 times as cost-effective as GiveDirectly's program, which provides unconditional cash transfers to poor households in low-income countries. At the time we recommended this grant, we were primarily looking to fund 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 SMC grants. We highlight parameters that are particularly important for the model or that we have adjusted for this case below:

• Malaria burden: 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. According to these sources, Borno has moderately lower malaria prevalence and malaria mortality than Nigeria overall. See our calculations in this spreadsheet.
• Costs: Based on Malaria Consortium's budget and estimate of the target population (see above), the cost per child targeted is $4.40. This is higher than our overall estimate for Nigeria of $4.01. A higher-than-average cost per child targeted seems plausible in this context, given that: (a) insecurity in Borno could mean that operating costs are higher, and (b) a short planning timeline could increase costs, e.g. because drugs must be transported by air instead of by sea.
• Coverage: We currently assume that Borno would have the same effective coverage rate for four person-months of treatment of 56% as we calculate for Malaria Consortium for Nigeria overall (see below).
• Crowding out other funders (or "funging"): We assume a probability of 20% that other funders would replace Malaria Consortium's costs (in contrast to a 55% probability for Nigeria overall). As we understand it, the funding for SMC this year was expected to come from a World Bank loan that has been approved in some fashion but held up for some reason.14 Given the very short time frame for this work, we guess that there is very little chance that another funder would step in and fund SMC in Borno this year. We want to account for the possibility that our stepping in now makes it less likely that another funder will step in next year, though that scenario is likely only relevant if there are continued delays with the World Bank loan.

Risks and reservations

• We did this work quickly and with less internal review than we normally would for a grant of the same size, because of the very short timeline for making a decision. We have since completed additional internal review and did not find significant errors in the calculations or reasoning.
• The budget provided by Malaria Consortium is preliminary. Malaria Consortium is continuing to work through the details of how to deliver in and monitor the different types of program areas. The budget could increase (or decrease) as they learn more.
• The target population that Malaria Consortium is using for its planning and that we have used in our cost-effectiveness model is higher than would be implied by publicly available population figures for Borno. Malaria Consortium's budget assumed a target population of 2.2 million children aged 3 to 59 months,15 which has since been revised down to 2.05 million.16 The government of Borno cites a total population of 5.9 million as of 2016,17 which would translate to 6.8 million as of 2021 assuming 3% annual population growth (a growth rate we've seen assumed in many program budgets for this region).18 In our cost-effectiveness model, we use an estimate of 15% for the proportion of the population that is under 5 years of age in Nigeria as a whole,19 suggesting that the under-5 population in Borno would be around 1 million. Malaria Consortium notes some possible explanations for the difference in these figures, including that the total population estimates tend to be inaccurate and are particularly prone to problems in areas with high rates of population movement due to insecurity (with Borno being particularly insecure for the area), and the NMEP uses an estimate of 20% of the population under the age of 5, rather than 15%.20 We opted to not resolve this uncertainty and to defer to Malaria Consortium's expertise in sourcing estimates for the target population.
• We don't know what coverage levels have been achieved in Borno in past years. In our cost-effectiveness model, we have projected that SMC coverage will be as high in Borno as in other states in Nigeria where Malaria Consortium has supported SMC. Malaria Consortium plans to employ different implementation strategies in some parts of Borno (see above), due to security concerns and it is possible that this will result in lower coverage than average for Nigeria. This projection of the coverage rate represents our best guess because our coverage estimates for Nigeria are already quite low compared to other countries that Malaria Consortium supports,21 and Malaria Consortium is budgeting a higher cost per child targeted to account for security challenges.
• We are more uncertain than we have been for other recent SMC grants about whether we will see high-quality monitoring data from this work. Malaria Consortium told us that it thinks it will be able to conduct a coverage survey after the SMC season in most areas of Borno. It may not be possible to conduct a coverage survey in the hardest-to-reach areas where 20% of the population lives due to security concerns.22 If coverage surveys are conducted that are representative of 80% of the population, we expect to be in a reasonably strong position to evaluate the impact of this funding.
• The short planning period and the fact that Malaria Consortium has not supported SMC in Borno before could reduce the quality of the program.
• Any delays in any component necessary for the program (e.g. drug shipments) will delay that program as a whole and could reduce the impact of the funding by a lot by missing the beginning of the rainy season. If one or more cycles are skipped, however, then the cost would also be reduced, offsetting the reduction in impact.
• The 20% of the population in the hardest-to-reach areas will most likely be served by humanitarian organizations such as MSF. MSF is a large organization with access to unrestricted funding. It is possible that if Malaria Consortium were to provide the SMC drugs, those organizations would cover the other costs. Given the short planning period, we haven't attempted to coordinate with those organizations in this way. In the initial budget that we based this decision on, the non-drug costs for this segment of the population were 16% of the total budget for SMC in Borno.23

Plans for follow up

• We have monthly calls with Malaria Consortium to discuss its SMC program. We plan to periodically ask for updates on Borno in upcoming calls.
• In 2022, we expect to get updates from Malaria Consortium on total spending in Borno in 2021 and results of coverage surveys (assuming it is able to conduct them). We plan to use this data to update our estimate of the cost-effectiveness of delivering SMC in Borno in 2021. We may also have some conversations to update our understanding of the funding landscape for SMC in Borno in 2021 and going forward.

Internal forecasts

Confidence	Prediction	By time
65%	Four cycles of SMC are delivered in Borno in 2021, targeting at least 70% of the population.	November 2021
85%	At least three cycles of SMC are delivered in Borno in 2021, targeting at least 70% of the population.	December 2021
80%	Conditional on at least three cycles of SMC delivered, end-of-round coverage surveys that are representative of at least 70% of the population are completed.	January 2022
70%	Conditional on us completing an assessment of the cost-effectiveness of this work, we will assess the grant as being more than 8 times as cost-effective as cash transfers.	December 2022
70%	SMC in Borno in 2022 will be supported by a loan from the World Bank.	August 2022

Our process

We learned about this funding gap from a contact at the Bill and Melinda Gates Foundation who we had spoken to previously about our grants to support SMC. She had learned about it from the SMC Alliance, a coordinating body for SMC stakeholders. (We've since joined the SMC Alliance.)

In the course of learning more about the funding gap, we spoke with the secretariat of the SMC Alliance, which is hosted by Medicines for Malaria Ventures, and several times with Malaria Consortium. We also reviewed a proposal written by the Nigerian National Malaria Elimination Program and a detailed budget for the work from Malaria Consortium.

Following the decision to tell Malaria Consortium that we were supportive of its use of available funding for SMC in Borno in 2021, we did some additional internal review of the decision. A second Program Officer provided feedback on the decision and the stated reasoning for the decision, and another member of the research team rechecked the calculations and inputs in our cost-effectiveness model.

Sources

Document	Source
Borno State Government, 2016 population projection, 2021	Source (archive)
GiveWell, 2021 CEA Version 2, 2021	Source
GiveWell, CEA for SMC in Borno, 2021	Source
GiveWell, RFMF analysis for Malaria Consortium, 2020	Source
GiveWell, SMC cost per child covered, 2020	Source
Malaria Consortium, "Our SMC programme"	Source (archive)
Malaria Consortium, Borno SMC budget, 2021 (unpublished)	Unpublished
The World Bank, "Nigeria Improved Child Survival Program for Human Capital MPA"	Source (archive)
The World Bank, Project appraisal document on a proposed credit to Nigeria, 2020	Source (archive)

• 1

  Malaria Consortium, Comments on a draft of this page, September 3, 2021 (unpublished)

• 2

  Malaria Consortium has told us in the past that it would like to have funding secured 18 months before an SMC season, e.g. end of 2021 for the summer 2023 season.

• 3

  NMEP of Nigeria, Proposal for 2021 SMC implementation in Borno state (unpublished)

• 4

  Conversation with SMC Alliance secretariat at Medicines for Malaria Ventures on June 4, 2021 (unpublished).

• 5

  Conversation with Malaria Consortium on June 15, 2021 (unpublished). See more on the World Bank loan at The World Bank, "Nigeria Improved Child Survival Program for Human Capital MPA". Page 33 of The World Bank, Project appraisal document on a proposed credit to Nigeria, 2020 notes that SMC in Borno will be funded by the loan.

• 6

  Conversation with Malaria Consortium on June 15, 2021 (unpublished).

• 7

  Malaria Consortium, Borno SMC budget, 2021 (unpublished)

• 8

  Malaria Consortium, Borno SMC budget, 2021 (unpublished)

• 9

  Malaria Consortium, Borno SMC budget, 2021 (unpublished)

• 10

  Conversation with Malaria Consortium on July 22, 2021 (unpublished).

• 11Malaria Consortium, Comments on a draft of this page, September 3, 2021 (unpublished)

• 12

  We have followed Malaria Consortium's SMC work in Nigeria, and other countries, since we began supporting it in 2016. In our first review, we focused on its work under the ACCESS-SMC project, which scaled up SMC in Nigeria and several other countries starting in 2015. See our review of Malaria Consortium's SMC program here. Malaria Consortium summarizes the timeline of its SMC work in Nigeria as follows: "Malaria Consortium has been a leading implementer of SMC since WHO issued its recommendation to scale up the intervention in 2012. Starting with an early implementation pilot in Nigeria in 2013, we then led the rapid scale-up of SMC through the Achieving Catalytic Expansion of Seasonal Malaria Chemoprevention in the Sahel (ACCESS-SMC) project in 2015–2017, reaching close to seven million children in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia. Since 2018, Malaria Consortium has continued to implement SMC, mainly using philanthropic funding received as a result of being awarded Top Charity status by GiveWell, a non-profit organisation dedicated to finding outstanding giving opportunities through in-depth analysis." Malaria Consortium, "Our SMC programme".

• 13

  Conversation with Malaria Consortium on June 15, 2021 (unpublished). See also our 2020 analysis of Malaria Consortium's funding available for SMC.

• 14

  Conversations with Malaria Consortium in June 2021 (unpublished).

• 15

  Malaria Consortium, Borno SMC budget, 2021 (unpublished)

• 16

  Malaria Consortium, Comments on a draft of this page, September 3, 2021 (unpublished)

• 17

  Borno State Government, 2016 population projection, 2021.

• 18

  5.8 million x (1.03)^5 = ~6.8 million

• 19

  See GiveWell, 2021 CEA Version 2, 2021, sheet "AMF," row "Percent of population under 5 years old (used for mortality effects and development effects)," column "Nigeria (PMI States)."

• 20

  Malaria Consortium, Comments on a draft of this page, September 3, 2021 (unpublished)

• 21

  See GiveWell, SMC cost per child covered, 2020, sheet "Per-country analysis," row "Sanity check: effective coverage rate for 4-cycles of person-months of coverage."

• 22

  Conversation with Malaria Consortium on June 15, 2021 (unpublished).

• 23

  GiveWell, CEA for SMC in Borno, 2021, sheet "Supplementary Borno calculations," row "'Hard-to-reach' segment," column "'Activity costs' in Malaria Consortium budget, excluding SPAQ" and row "Total budget."

  $1,374,688 / $8,786,033 = ~16%