Malaria Consortium — SMC Renewal in Nigeria, Burkina Faso, Chad, and Togo (January 2022)

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

Published: April 2022

Planned activities and budget

This $79.9 million grant comprises:2

• $67.5 million for Nigeria (85% of the grant). This amount will enable Malaria Consortium to maintain its current (as of 2021) scale3 of support to the country's SMC program in 2023 ($21.1 million) and in 2024 ($34.7 million).4 This grant will also enable Malaria Consortium to scale up to an additional twelve local government areas (LGAs) in Kogi state in 2022 and maintain that expanded scale in 2023-2024 ($11.8 million).5
• $7.4 million for Burkina Faso (9% of the grant). This amount will enable Malaria Consortium to maintain its current scale of support to the country's SMC program in 2023.
• $3.8 million for Chad (5% of the grant). This amount will enable Malaria Consortium to maintain its current scale of support to the country's SMC program in 2023.
• $1 million for Togo (1% of the grant). This amount will enable Malaria Consortium to maintain its current scale of support to the country's SMC program in 2023.
• $0.2 million to explore expansion opportunities in new countries (<1% of the grant).

Though we typically recommend grants that include three years of funding runway (as we are doing for Nigeria), we have decided to hold off on recommending funding for the 2024 SMC season in Burkina Faso, Chad, and Togo. The Global Fund, which has been the largest funder of SMC in each of these countries,6 raises funding on a three-year cycle. In late 2022, it will have its next "replenishment," the funding from which will be allocated to countries in the 2024-2026 grant period.7 We prefer to wait to see the size of the Global Fund's next replenishment before we make a commitment to 2024, so that we better understand what level of additional funding is needed. Our reasoning for this is that between the 2018-2020 and 2021-2023 grant periods, the Global Fund's malaria allocation to each of these countries increased substantially.8 While we don't have a well-informed expectation about how this next replenishment might compare to the previous one, historical precedent suggests to us that an increase is possible, which could, in turn, lead to more funding available for SMC. While we expect it to be difficult to predict country-level malaria allocations (which won't be determined until later) based on overall replenishment size, we think it's worth waiting for this new information. Because Malaria Consortium won't order SMC drugs for the 2024 season until late 2022 at the earliest (more below), waiting a year to make this commitment shouldn't hinder Malaria Consortium's planning significantly.

We are recommending funding for 2024 for Nigeria, rather than waiting for the Global Fund replenishment, because:

• Nigeria is relatively underfunded for malaria (more below). We expect that funding gaps are likely to remain even if the Global Fund's malaria allocation to Nigeria increases.
• GiveWell-directed funding supports Malaria Consortium to deliver SMC in states that are not assigned to the Global Fund for malaria funding support. Our impression is that it is possible but not likely that the Global Fund would fund SMC in states that are not assigned to it for support (more below).
• Part of this grant will support expansion. Unless we have a strong reason not to, we default to providing three years of funding runway for expansion opportunities, in order to give grantees the confidence in future funding necessary to pursue these opportunities.

Case for the grant

• Cost-effectiveness. During this grant investigation, we used our existing cost-effectiveness model for SMC campaigns and updated various parameters to match the specifics of these funding gaps. For the four countries this grant will support, we estimate that the cost-effectiveness of SMC exceeds our funding bar. (More)
• Funding landscape for SMC. We investigated the funding landscape for SMC in these countries and believe that these funding gaps are unlikely to be fully filled by other funders. We adjust our cost-effectiveness estimates to account for the extent to which we believe our funding may be crowding out funding that would otherwise have come from other sources. We believe that we are at relatively low risk of crowding out other funders in Nigeria (85% of the grant) and at moderate-to-high risk in the other three countries. (More)
• Time-sensitivity. Making this grant now will enable Malaria Consortium to place the order for SMC drugs for the 2023 season as soon as possible, in early 2022, in order to avoid delaying 2023 campaigns. (More)
• Malaria Consortium as a grantee. Malaria Consortium has a strong track record delivering SMC programs in three of the four countries included in this grant. Our qualitative assessment of Malaria Consortium as an organization is highly positive. (More)

Cost-effectiveness

How we use cost-effectiveness estimates in our grantmaking

After assessing a potential grantee's room for more funding, we may then choose to investigate potential grants to support the spending opportunities that we do not expect to be funded with the grantee's available and expected funding, which we refer to as "funding gaps." The principles we follow in deciding whether or not to fill a funding gap are described on this page.

The first of those principles is to put significant weight on our cost-effectiveness estimates. We use GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding gaps, which we describe in multiples of "cash." Thus, if we estimate that a funding gap is "10x cash," this means we estimate it to be ten times as cost-effective as unconditional cash transfers. As of this writing, we have typically funded opportunities that meet or exceed a relatively high bar: 8x cash, or eight (or more) times as cost-effective as GiveDirectly's unconditional cash transfers. We also consider funding opportunities that are between 5x and 8x cash.

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 process for estimating cost-effectiveness focuses on determining whether a program is cost-effective enough that it is above our bar to consider funding; it isn't primarily intended to differentiate between values that are above that threshold.

Cost-effectiveness of this grant

We estimate that the cost-effectiveness of SMC is:

• 13x cash in Nigeria (85% of the grant).
• 14x cash in Burkina Faso (9% of the grant).
• 6x cash in Chad (5% of the grant).
• 9x cash in Togo (1% of the grant).

To generate these estimates, we used our existing cost-effectiveness model for SMC campaigns and updated various parameters to match the specifics of these funding gaps. The key parameter updates we made (or considered making) during this grant investigation include:

• Malaria burden (multiple parameters)—update to use sub-national data. Many of the parameters in our cost-effectiveness models use estimates we obtain from the Institute of Health Metrics and Evaluation's (IHME's) Global Burden of Disease (GBD) project. These include estimates of malaria prevalence and mortality in the locations where GiveWell-directed funding supports SMC. Previously, our cost-effectiveness model for SMC in Nigeria used national-level malaria estimates. During this grant investigation, we updated the model to use state-level malaria estimates for the six states where we expect Malaria Consortium to use this funding to deliver SMC: Bauchi, Kebbi, Kogi, Nasarawa, Plateau, and Sokoto.9 Because malaria burden is higher in these states than the national average, this change caused our cost-effectiveness estimate to increase slightly.10
• Adjustment to account for the decline in malaria prevalence due to net distributions. Our understanding is that IHME's malaria modeling factors the expected impact of past long-lasting insecticide-treated net (LLIN) campaigns into its malaria prevalence and mortality estimates. However, the most recent GBD data available is for the year 2019, and we think it is likely that the LLIN coverage estimates being used are somewhat outdated. We therefore think that true malaria prevalence and mortality rates during the period this grant will support may be lower than GBD estimates would suggest. We decided to apply a rough downward adjustment of 5% to our cost-effectiveness estimate of SMC in Nigeria.11
• Cost per child treated with all cycles of SMC.
  • Update to incorporate a fifth cycle of SMC. Historically, countries eligible for SMC have aimed to deliver annual SMC rounds comprising four monthly cycles, as previously recommended by the WHO. Recently, some countries have revised their strategies and now aim to deliver a total of five monthly cycles to locations deemed eligible for an additional cycle because their peak malaria transmission season is longer than other SMC-eligible locations. Beginning in 2021, Malaria Consortium supported the governments of Burkina Faso12 and Nigeria13 in delivering a fifth cycle of SMC in eligible locations. It expects to continue to support five SMC cycles in some locations in these countries in 2022-2024.14 Previously, we used a supplemental adjustment15 to account for our best guess of how much less cost-effective a fifth SMC cycle is than the previous four cycles. For this grant, we changed our approach: we eliminated this adjustment, and we now calculate a "cost per SMC cycle administered" instead of the "cost per four SMC cycles administered" that we used to calculate (i.e., we now divide by four). We then multiply this by a new parameter ("Average number of SMC cycles per year"), which uses data provided by Malaria Consortium on the proportion of its target population set to receive four vs. five cycles in the period this grant will support, to calculate a cost per child treated with all cycles of SMC for each country.16 This change slightly decreased our cost-effectiveness estimates of Malaria Consortium's programs in Burkina Faso and Nigeria.17
  • Update to incorporate recent data. To calculate a cost per SMC cycle administered, we use data on Malaria Consortium's past spending and results from coverage surveys conducted after past campaigns (more details in this section of our review of Malaria Consortium). During this grant investigation, we updated our analysis to incorporate spending and coverage data from 2020 campaigns.18 Incorporating this data led to small increases in our estimates of cost per SMC cycle administered—and therefore small decreases in cost-effectiveness—for all countries except Burkina Faso.19
• Likelihood that the Global Fund and/or the President’s Malaria Initiative (PMI) would replace Malaria Consortium's costs. See details below.

Funding landscape for SMC

We investigated the funding landscape for SMC in these countries by having conversations with national malaria programs and other major SMC funders (see below) and reviewing published data on malaria funding from other major SMC funders. We have also recently joined the SMC Alliance in order to build relationships and learn more about the partner landscape for SMC. As a result of this investigation, we believe that these funding gaps are unlikely to be fully filled by other funders, but that some of our funding may be crowding out funding that would otherwise have come from other sources.

We adjust our cost-effectiveness estimates to account for the extent to which we believe our funding may be crowding out funding that would otherwise have come from other sources (in the case of SMC, this is typically the Global Fund and/or PMI). Specifically, these adjustments represent the proportion of a grantee's funding that we believe may crowd out funding from other sources (for example, if we use an adjustment of 25%, we believe that 25 cents of every dollar spent by the grantee would otherwise have come from other sources). See more details in this blog post. We have incorporated considerations about the funding landscape for SMC in Nigeria, Burkina Faso, Chad, and Togo into location-specific adjustments, which are accounted for in the cost-effectiveness estimates listed in the previous section. We describe these considerations below.

Note that in the sections below, we describe, for each location, reasons we believe that some portion of our funding may be crowding out funding that would otherwise have come from other sources. The case for the grant rests not on a belief that it will result in minimal crowding out, but rather on the belief that after thorough investigation, we are sufficiently well-informed about the funding landscapes in these countries to not be missing important considerations from our location-specific cost-effectiveness adjustments and on the fact that after incorporating these adjustments, our estimates of the cost-effectiveness of the funding opportunities exceed our bar for grantmaking.

Note that in the sections below, we use the term 'Malaria Consortium's funding' to mean Malaria Consortium's philanthropic funding, which is largely GiveWell-directed. This excludes funding it receives from institutional funders, primarily the Global Fund.

Nigeria

Prior to this grant investigation, we used a value of 55% for the proportion of Malaria Consortium's funding that we believed may crowd out funding from other SMC funders (primarily the Global Fund and PMI20 ) in Nigeria. This spreadsheet explains our reasoning for that value.

Our understanding is that malaria programs are relatively underfunded in Nigeria. In Nigeria, most states are assigned to receive funding for malaria programs from the Global Fund, from PMI, or through a loan from the World Bank and the Islamic Development Bank.21 We are aware of large funding gaps that have existed in all categories of states, including the states with dedicated malaria funding (e.g., GiveWell has now recommended grants to fill funding gaps for LLIN campaigns in both Global Fund-supported and PMI-supported states in Nigeria). Nigeria has not yet achieved full coverage of its SMC-eligible population.22

We expect Malaria Consortium to use this funding to deliver SMC in Bauchi, Kebbi, Kogi, Nasarawa, Plateau, and Sokoto states.23 Five of these states (Bauchi, Kebbi, Nasarawa, Plateau, and Sokoto states) are PMI-supported24 and one (Kogi) is slated to receive Islamic Development Bank financing for malaria control25 but not for SMC (our understanding is that of the 11 states slated to receive development bank loan financing for malaria control, Borno is the only state with funding budgeted for SMC26 ). Our impression is that it is possible but not likely that the Global Fund would fund SMC in states that are not assigned to it for malaria support27 or that additional states would be assigned to the Global Fund for support. We have therefore focused on understanding the likelihood that PMI would fund SMC in the five states; we do not believe there is a significant risk of crowding out other funders in Kogi state.

For the reasons listed below, we believe that our risk of crowding out PMI funding for SMC is relatively low:

• It appears to be the case that malaria funding is highly constrained in PMI-supported states. For example, we know from AMF that LLIN campaigns in PMI states have been occurring every four or five years28 rather than the recommended 36 months, due to a lack of funding.
• PMI's budget for Nigeria decreased from $77 million29 in 2020 to $69 million30 in 2021 and $68 million31 in 2022. PMI's malaria operational plan for FY 2022 states that it intends to maintain support for SMC in the state where it already does so (Zamfara) and would consider "expanding SMC to another PMI-supported state depending on funds availability."32 Our understanding is that the state being considered for this expansion of support is Benue (see here), which is not a Malaria-Consortium supported state.

We have consequently chosen to decrease to a value of 25% for the proportion of Malaria Consortium's funding that we believed may crowd out funding from other SMC funders in Nigeria. This spreadsheet explains our reasoning for that value.

Burkina Faso

Prior to this grant investigation, we used a value of 60% for the proportion of Malaria Consortium's funding that we believed may crowd out funding from other SMC funders (primarily the Global Fund and PMI33 ) in Burkina Faso. This document explains our reasoning for that value.

SMC has been fully funded in Burkina Faso at least since the previous Global Fund grant cycle,34 with Malaria Consortium contributing an estimated 50% of that funding in 2021.35 This suggests to us that if Malaria Consortium did not have a history of providing support to Burkina Faso's SMC program, the Burkinabé national malaria program may have chosen to direct more of its Global Fund malaria allocation to SMC.

It is not clear whether or not that funding could be reallocated to SMC at this point in the grant cycle, were Malaria Consortium to decide now to reduce its support for 2023—an option we considered and discussed with Malaria Consortium. We know that in 2020 (the final year of the previous grant cycle), the Global Fund increased the level of support it was providing to Burkina Faso's SMC program (from 20 districts to 33 districts) using reallocated funding, and then somewhat decreased the level of support in 2021.36 It seems possible that a similar reallocation could occur for 2023, the final year of the current grant cycle. However:

• Our understanding is that the first round of such reallocations will occur in early 2022. It is unclear whether funding could be reallocated in time to avoid causing delays to 2023 campaigns, given that SMC drugs for these campaigns need to be ordered soon (more below).
• Our understanding is that funding gaps for 2023 LLIN campaigns are likely to be the top priority for these reallocations,37 though this could be based on an expectation that Malaria Consortium's SMC support will continue at its current level and therefore might no longer be true if that support decreased.
• We have heard from multiple sources that less funding is expected to be available to reallocate to standard programming in this grant cycle because of the increased costs associated with the Covid-19 pandemic.

Given the time-sensitivity and high cost-effectiveness of this opportunity, we are recommending fully funding Malaria Consortium for 2023 (with the understanding that a high proportion of our funding may be crowding out the Global Fund). We have chosen to retain the value of 60% for the proportion of Malaria Consortium's funding that we believe may crowd out funding from the Global Fund and/or PMI.

Chad

Prior to this grant investigation, we used a value of 55% for the proportion of Malaria Consortium's funding that we believed may crowd out funding from other SMC funders (primarily the Global Fund;38 Chad does not receive malaria funding from PMI39 ) in Chad. This document explains our reasoning for that value.

SMC has been fully funded in Chad since 2020 (the previous Global Fund grant cycle),40 with Malaria Consortium contributing an estimated 50% of that funding in 2021.41 This suggests to us that if Malaria Consortium did not have a history of providing support to Chad's SMC program, the Chadian national malaria program may have chosen to direct more of its Global Fund malaria allocation to SMC. On the other hand, we have heard from multiple sources that the top priorities for the current malaria allocation were case management and SMC; this slightly decreases our concern that we are crowding out SMC funding.

It is not clear whether or not Global Fund funding could be reallocated to SMC at this point in the grant cycle, were Malaria Consortium to decide now to reduce its support for 2023—an option we considered and discussed with Malaria Consortium. We know that in 2020 (the final year of the previous grant cycle), the Global Fund increased the level of support it was providing to Chad's SMC program (from 17 districts to 38 districts) using reallocated funding, and then somewhat decreased the level of support in 2021.42 It seems possible that a similar reallocation could occur for 2023, the final year of the current grant cycle. However:

• Our understanding is that the first round of such reallocations will occur in early 2022. It is unclear whether funding could be reallocated in time to avoid causing delays to 2023 campaigns, given that SMC drugs for these campaigns need to be ordered soon (more below).
• Our understanding is that funding gaps for 2023 LLIN campaigns are likely to be the top priority for these reallocations,43 though this could be based on an expectation that Malaria Consortium's SMC support will continue at its current level and therefore might no longer be true if that support decreased.
• We have heard from multiple sources that less funding is expected to be available to reallocate to standard programming in this grant cycle because of the increased costs associated with the Covid-19 pandemic.

Given the time-sensitivity and moderate cost-effectiveness of this opportunity, we are recommending fully funding Malaria Consortium for 2023 (with the understanding that a high proportion of our funding may be crowding out the Global Fund). We have chosen to retain the value of 55% for the proportion of Malaria Consortium's funding that we believe may crowd out funding from the Global Fund and/or PMI.

Togo

Prior to this grant investigation, we used a value of 70% for the proportion of Malaria Consortium's funding that we believed may crowd out funding from other SMC funders (primarily the Global Fund and UNICEF;44 Togo does not receive malaria funding from PMI45 ) in Togo. This document explains our reasoning for that value. A key consideration informing that value was the fact that between the 2018-2020 and 2021-2023 grant cycles, the Global Fund's malaria allocation grew substantially.46

In investigating a grant to AMF, however, we learned that $26 million (roughly 45%) of the 2021-2023 malaria allocation is being spent on health systems strengthening,47 rather than programs specific to malaria. This is up from $7.5 million of the Global Fund malaria allocation spent on health systems strengthening in the 2018-2020 grant cycle.48 Our understanding is that this funding is being spent on projects that the Togolese government considers high-priority and that have been planned for some time, and is therefore highly unlikely to be reallocated at this point in the grant cycle.

Despite this, Togo appears to be relatively well-funded for malaria. SMC has been fully funded in Togo at least since the previous Global Fund grant cycle.49 This suggests to us that if Malaria Consortium did not begin supporting the country's SMC program in 2020, the Togolese national malaria program may have chosen to direct more of its Global Fund malaria allocation to SMC. We have chosen to retain the value of 70% for the proportion of Malaria Consortium's funding that we believe may crowd out funding from the Global Fund and/or UNICEF.

Time-sensitivity

We believe that the 2023 funding gaps are time-sensitive. Our understanding from Malaria Consortium50 is that it aims to place the order for SMC drugs for the subsequent year's SMC season by the beginning of the current year, at the latest. Making this grant now will enable Malaria Consortium to place the order for SMC drugs for the 2023 season as soon as possible, in early 2022, in order to avoid delaying 2023 campaigns.51

Malaria Consortium as a grantee

Malaria Consortium has a strong track record delivering SMC programs in three of the four countries included in this grant. Malaria Consortium has used GiveWell-directed funding to support SMC programs in Burkina Faso and Nigeria since 2017 and in Chad since 2018 (and it previously supported SMC programs in all three countries with non-GiveWell-directed funding).52 Coverage surveys conducted after individual cycles and full rounds of SMC have demonstrated that Malaria Consortium's programs can reach a high proportion of targeted children.53 As discussed above, we have incorporated these results into our analysis of the cost per SMC cycle administered.

Malaria Consortium has a more limited track record in Togo (which accounts for 1% of this grant). It began supporting SMC in Togo in 2021.54

In addition, our qualitative assessment of Malaria Consortium as an organization is highly positive. In 2020, we rated it as "relatively strong" on seven of eight dimensions included in our qualitative assessments.55 Since then, we have asked several SMC stakeholders for feedback on Malaria Consortium and have heard almost exclusively (and often strongly expressed) positive feedback.

Risks and reservations

• Other options considered. We considered other options for which opportunities to include and exclude in this grant, and we are forgoing the benefits of these options by declining to select them. (More)
• Lower cost-effectiveness in Chad. At 6x cash, our estimate of the cost-effectiveness of SMC in Chad is lower than our estimate for the other countries included in this grant. We decided to make this grant from the $100 million we budgeted to direct during our 2021 metrics year to opportunities that were 5-8x cash. (More)
• Risk of future crowding out. We think it is possible that by filling these funding gaps, we are setting the expectation that GiveWell funding will continue to be available at the same level for SMC campaigns in these countries. This may deter national malaria programs and other funders from increasing the funding they direct to those campaigns. (More)
• Uncertainties in our cost-effectiveness model. We are uncertain about the values we use for several of the parameters included in our SMC cost-effectiveness model. (More)

Other options considered

We considered other options for which opportunities to include and exclude in this grant, and we are forgoing the benefits of these options by declining to select them. These include:

• We could have decreased our scale of support to Burkina Faso and Chad in 2023. As described above, we believe that a relatively high proportion of our funding in these countries may be crowding out funding that would otherwise have come from other sources. We spoke with Malaria Consortium about possibilities for responsibly reducing its support to these countries. The benefit of this option would be the possibility that other funders would replace this support. As described above, we did not choose this option because of the time-sensitivity and cost-effectiveness of these opportunities.
• We could have waited to recommend funding for the 2024 SMC season in Nigeria, as we did for Burkina Faso, Chad, and Togo. The benefit of this option would be the possibility that other funders would replace this support. As described above, we did not choose this option because we think this outcome is unlikely.
• We could have declined to fund Malaria Consortium's proposed expansion in Nigeria. The benefit of this option would be the possibility that other funders would instead initiate this support. As described above, we did not choose this option because we think this outcome is unlikely.
• We could have included funding for the 2024 SMC season in Burkina Faso, Chad, and Togo in this grant. The benefit of this option would be that providing three years of funding runway could give Malaria Consortium more confidence in future funding and therefore have subtle positive effects on its planning for 2024. As described above, we did not choose this option because we think the benefit of waiting to see the size of the Global Fund's next replenishment before we make a commitment to 2024 outweighs this other benefit.

Lower cost-effectiveness in Chad

At 6x cash, our estimate of the cost-effectiveness of SMC in Chad is lower than our estimate for the other countries included in this grant. We could decline to extend the funding runway in Chad, in favor of saving that funding for more cost-effective opportunities. Instead, we decided to make this grant from the $100 million we budgeted to direct during our 2021 metrics year to opportunities that were 5-8x cash. (GiveWell's 2021 metrics year ran from February 2021 to January 2022.)

We have written previously (see here and here) about our past reasons to continue funding SMC in Chad despite lower cost-effectiveness. In short, these included:

• We wanted to avoid restricting how Malaria Consortium uses funding within SMC but wanted to fund opportunities that we expected Malaria Consortium would prioritize below maintaining its program in Chad. This reason continues to inform our decision to maintain funding in Chad.
• We didn't want to cause harm by reducing funding for the program too rapidly. This reason continues to inform our decision to maintain funding in Chad.
• We believed that funding SMC in Chad at a lower level of support in the future could make the program more cost-effective or that our cost-effectiveness bar would decrease to our estimate for Chad or below that estimate. We were interested in keeping this program as a funding option in case either of these possibilities came to fruition—the latter of which did, as we decided to budget up to $100 million during our 2021 metrics year to opportunities that were 5-8x cash. As described above, we spoke with Malaria Consortium about the former possibility but ultimately decided to recommend funding for full scale.

Risk of future crowding out

The adjustments we describe above are primarily intended to account for the extent to which we believe our funding may be crowding out funding that would otherwise have come from other sources to fill these specific funding gaps. They may not fully account for the effect that our grantmaking may have on other funders' behavior over the long term.

We think it is possible that by filling these funding gaps, we are setting the expectation for national malaria programs and other funders that GiveWell funding will be available at a similar level for future SMC campaigns. This belief may, in turn, lead them to direct funding that they would have directed toward these future campaigns to other programs and services. In our conversations with national malaria programs and other funders, we have communicated and will continue to communicate that, to the extent possible, our goal is for the funding we direct to SMC campaigns to add to the pool of funding available for those campaigns, rather than to replace funding that would otherwise have been in that pool.

Uncertainties in our cost-effectiveness model

We are uncertain about the values we use for several of the parameters included in our cost-effectiveness model. For this grant, the values we are particularly uncertain about include:

• Proportion of annual direct malaria mortality occurring in ​​the high-transmission season. In our cost-effectiveness model for SMC, we assume that if SMC were not delivered, 70% of malaria mortalities would have occurred during the SMC season. We have not done substantial research to inform this value. For our recent grant for the Federal Capital Territory (FCT) in Nigeria, we lowered this to 60% because rainfall is somewhat less seasonally concentrated in FCT than in states along Nigeria's northern border where SMC was first rolled out.56 While it's possible that further work would lead us to use a value of less than 70% for the states that will be supported by this grant, we think it's unlikely that this would substantially decrease our cost-effectiveness estimate because we expect malaria to be relatively less seasonal in FCT (a newly SMC-eligible state based on expanded guidelines) than in the states that will be supported by this grant, and we applied only a small reduction to the FCT value. We may do more work on this in the future.
• Likelihood that the Global Fund and/or PMI would replace philanthropic costs. In evaluating grants that we make or recommend, we routinely ask: what would happen to this program if it did not receive this grant? Would another funder step in to support it, or would it go unfunded? Through this line of questioning, we develop a best guess of what would happen in a scenario without GiveWell-directed funding, which we refer to as "the counterfactual." Our best guesses about what would happen without GiveWell-directed funding can substantially affect our estimate of a grant's cost-effectiveness, but they are necessarily based on subjective guesses because we don't have the opportunity to witness the counterfactual. This is particularly true when we try to make predictions about the counterfactual behavior of other funders, as we can only speculate about their future priorities and decisions. As such, the adjustments we make to account for our crowding out of other funders (described above) are highly uncertain.

Plans for follow up

• We will continue our monthly calls with Malaria Consortium to discuss its work.
• We will request that Malaria Consortium submit spending reports and coverage surveys from these campaigns, as it has for all previously funded campaigns.
• We will track how national malaria programs and other funders choose to allocate the future funding available for SMC campaigns in these countries.

Internal forecasts

Confidence	Prediction	By time
85%	The Global Fund's 2024-2026 malaria allocations to Burkina Faso, Chad, and Togo will be equal to or larger than its 2021-2023 malaria allocations to these countries.	End of 2023
50%	The Global Fund's scale of support to Burkina Faso's SMC program (measured by target population) will increase by at least 10% in 2024.	2024 SMC season
50%	The Global Fund's scale of support to Chad's SMC program (measured by target population) will increase by at least 10% in 2024.	2024 SMC season
50%	PMI will begin funding SMC in one additional state in Nigeria by 2023.	2023 SMC season

Our process

We learned about these funding gaps from Malaria Consortium, and we updated our room for more funding analysis using information it provided. Our grant investigation relied heavily on our prior work modeling the cost-effectiveness of SMC campaigns supported by Malaria Consortium and our relationship with Malaria Consortium and knowledge of its work. Three Program Officers and two Senior Researchers at GiveWell who were not involved in this grant investigation reviewed plans for the investigation and the case for the grant prior to approval. We used our existing cost-effectiveness model for SMC campaigns and updated various parameters to match the specifics of these funding gaps.

We aim to get feedback on our grantmaking from stakeholders other than our top charities, such as government officials, other implementers involved in delivering the program, and other organizations working in the relevant context. The goals of these conversations are to learn more about the context in which a program will be delivered, to confirm the need for additional support of the program, and to seek feedback on the activities that a potential grant to support the program would enable. The external conversations we had about this grant include:57

• Nigeria:
  • Nigeria's national malaria program (NMEP).
  • The Global Fund.
  • Catholic Relief Services (CRS). CRS is the principal recipient of the Global Fund's malaria grant to Nigeria. Malaria Consortium is a sub-recipient of CRS, delivering SMC in four Global Fund-supported states.
  • PMI, for a previous grant investigation.
• Burkina Faso:
  • The Global Fund.
• Chad:
  • Chad's national malaria program (PNLP).
  • The Global Fund.

We value the insights we gained by speaking with these organizations and appreciate the time they spent answering our questions. We note that the views expressed on this page, and any errors, are our own.

Sources

Document	Source
Against Malaria Foundation, PMI Nigeria plan	Source
GiveWell, "Qualitative Assessments of Top Charities," 2019	Source
GiveWell, "Revisiting Leverage," 2018	Source
GiveWell, 2022 Cost-Effectiveness Analysis Changelog	Source
GiveWell, Analysis of Malaria Consortium's cost per SMC cycle administered, 2022	Source
GiveWell, Cost-effectiveness analysis – version 3, 2022	Source
GiveWell, GiveWell cost-effectiveness analysis — version 3, 2021	Source
GiveWell, Likelihood of crowding out GFATM/PMI, January 2021	Source
GiveWell, Likelihood of crowding out GFATM/PMI, October 2020 [document]	Source
GiveWell, Likelihood of crowding out GFATM/PMI, October 2020 [spreadsheet]	Source
GiveWell, Likelihood of crowding out GFATM/PMI, October 2021	Source
GiveWell, Nigeria SMC state-level data, 2021	Source
GiveWell, Room for more funding analysis for Malaria Consortium's SMC program, 2021	Source
Global Fund spending in countries receiving funding from AMF, 2021 (redacted)	Source
Global Fund, "United States to Host Next Global Fund Replenishment Conference," 2021	Source (archive)
Malaria Consortium, Donor Landscape, 2019 (unpublished)	Unpublished
Malaria Consortium, Donor Landscape, June 2020 (unpublished)	Unpublished
Malaria Consortium, Donor Landscape, June 2021 (unpublished)	Unpublished
Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted)	Source
Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020	Source
SMC Alliance, Home page	Source (archive)
U.S. President's Malaria Initiative, "Where We Work"	Source (archive)
U.S. President's Malaria Initiative, Nigeria, Malaria Operational Plan FY 2022	Source (archive)
U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2020	Source (archive)
U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2021	Source (archive)
U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2022	Source (archive)

• 1

  Due to rounding, these numbers add up to slightly more than the total grant amount.

• 2Figures can be found in this room for more funding analysis. See sheet "RFMF projections" and the "High-level spending opportunities" section on sheet "Spending opportunities." All figures represent Malaria Consortium's stated budget for each line item (with above-country costs allocated proportionally), less the available and projected funding that we have allocated to this line item in our analysis. All maintenance figures assume population growth.
  
• 3We expect Malaria Consortium to use this funding to deliver SMC in Bauchi, Kebbi, Kogi, Nasarawa, Plateau, and Sokoto states. See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 20, figure 5. These states represent Malaria Consortium's 2021 scale in Nigeria, with the exception of Borno state, where Malaria Consortium reallocated funding to provide one year of support in 2021.
• 4GiveWell recommended a separate grant to Malaria Consortium to deliver SMC in Nigeria in the Federal Capital Territory (FCT) in 2022-2024 and in Oyo state in 2022.
• 5Malaria Consortium already supports some LGAs in Kogi; this grant will enable it to scale to full coverage of all SMC-eligible LGAs in the state. See this cell: "Expansion to an additional 12 LGAs (additional target population 690,000) to cover the entire state of Kogi."
• 6See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 10, table 1; p. 13, table 4; and p. 23, table 11.
• 7"The Global Fund to Fight AIDS, Tuberculosis and Malaria enthusiastically welcomes President Joe Biden's decision to host the Global Fund’s Seventh Replenishment Conference in the United States in the second half of 2022…. The Global Fund raises money on a three-year cycle…. The Seventh Replenishment, which will take place in a challenging global health landscape, will seek to secure pledges to fund grants for the three years 2024 to 2026." Global Fund, "United States to Host Next Global Fund Replenishment Conference," 2021.
• 8See the table on p. 4 of GiveWell, Likelihood of crowding out GFATM/PMI, October 2020 [document].
• 9See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 20, figure 5. These states represent Malaria Consortium's 2021 scale in Nigeria, with the exception of Borno state, where Malaria Consortium reallocated funding to provide one year of support in 2021. The state-level malaria estimates can be found on this sheet; they are used for calculations in the baseline mortality rate section for our CEA of Nigeria here.
• 10See GiveWell, 2022 Cost-effectiveness Changelog, version 2, change 3.
• 11See the adjustment here. Note that we had a similar concern for a past SMC grant but used a different method in that model. In October 2021, GiveWell recommended a grant to Malaria Consortium to deliver SMC in Nigeria in the Federal Capital Territory (FCT) in 2022-2024. In the cost-effectiveness model we created for that grant, we directly adjusted GBD data on malaria burden downward to account for the expected decline in malaria prevalence due to an LLIN campaign scheduled to occur during the time that our funding would support SMC. See details here.
• 12
  • "Under the HBHI initiative’s ‘strategic information’ response element, the PNLP conducted a stratification exercise with support from WHO, the Institute for Disease Modeling, and Northwestern University to determine the optimal mix of malaria interventions at the health district level. The exercise involved stratifying health districts based on epidemiological characteristics including prevalence, incidence, and all-cause mortality among children under five, and combining the epidemiological information with measures of seasonality, urbanization, and access to care. For SMC, the analysis also modeled the impact of varying the number of cycles depending on seasonality patterns. Based on the recommendations from this exercise, the PNLP decided to adopt five annual cycles of SMC from 2021 onwards in 19 of the country’s 70 health districts, primarily in the south (Figure 2), including 11 of the health districts that will be supported by Malaria Consortium." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 12.
  • "11 health districts (30% of the target population) implement 5 cycles." See sheet "Source: 2021-24 projections" in this spreadsheet.

• 13
  • "Malaria Consortium will use philanthropic funding to continue to support SMC in Kebbi and Sokoto. In Bauchi, where only 10 LGAs were considered eligible in 2020, we will expand to all 21 LGAs. Two of the new LGAs will be funded by the Korea International Cooperation Agency. We also plan to expand SMC to three states not previously covered: Kogi, Nasarawa, and Plateau, where five SMC cycles will be implemented due to the slightly longer rainy season." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 20.
  • "3 states (Kogi, Nasarawa, Plateau; 46% of the total target population) implement 5 cycles." See sheet "Source: 2021-24 projections" in this spreadsheet.

• 14See this spreadsheet, sheet "Source: Workings," for projections for the proportion of Malaria Consortium's target populations in Burkina Faso and Nigeria that will be reached by five cycles in these years.
• 15"Adjustment for impact relative to the counterfactual to be moving from 4 cycles to 5"—seehere in a past cost-effectiveness analysis.
• 16See the new parameters here.
• 17See the costs for SMC in Burkina Faso and Nigeria before the change here and after the change here. For more information about the change we made, see GiveWell, 2022 Cost-effectiveness Changelog, version 3, change 2.
• 18 See our calculations here.
• 19See GiveWell, 2022 Cost-effectiveness Changelog, version 3, change 3.
  
• 20These are the two other major funders of SMC in Nigeria. See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 16, table 7.
• 21For more details, see this page. The two states not covered by one of these funding sources are Ondo and Anambra.
• 22 In 2021, 1.7 million eligible children in Nigeria were not reached. Malaria Consortium, Donor Landscape, June 2021 (unpublished)
• 23 See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 20, figure 5. These states represent Malaria Consortium's 2021 scale in Nigeria, with the exception of Borno state, where Malaria Consortium reallocated funding to provide one year of support in 2021.
• 24See Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), p. 9, Table 2.
• 25See Malaria Consortium, Net-target project report: Nigeria, 2020 (redacted), p. 9, Table 2.
• 26See details here.
• 27

  We are aware of one example where this occurred, for the 2020 SMC season in Borno state. Reasons why this may be unlikely to occur again:

  • As of 2021, the Nigerian national malaria program has expanded SMC eligibility to 400 LGAs in 21 states, compared to 217 LGAs in nine states previously.
    • "The NMEP [National Malaria Elimination Programme] will consider LGAs in 21 states eligible for SMC from 2021 onwards, compared to nine states pre-stratification." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 19.
    • The 400 LGAs figure is from Malaria Consortium, comments on a draft of this page.
  • According to Malaria Consortium, 93 of these newly eligible LGAs are in Global Fund-supported states (Malaria Consortium, comments on a draft of this page). This means that more funding is now needed to fully support SMC in Global Fund-supported states.
  • We have heard from multiple sources that less funding is expected to be available to reallocate to standard programming in this grant cycle because of the increased costs associated with the Covid-19 pandemic.

• 28See column L, Q, and V of this spreadsheet.
• 29 U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2020, Table 1.
• 30U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2021, Table 1.
• 31 U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2022, Table 1
• 32"PMI supports drug-based prevention programs, namely Malaria in Pregnancy (MIP) and Seasonal Malaria Chemoprevention (SMC) in Zamfara State. Proposed investments will be maintained for MIP and SMC…. Nigeria has expanded the number of eligible states for SMC, so there is a possibility of expanding SMC to another PMI-supported state depending on funds availability." U.S. President's Malaria Initiative, Nigeria, Malaria Operational Plan FY 2022, p. 8.
• 33These are the two other major funders of SMC in Burkina Faso. See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 10, table 1.
• 34Donor landscape spreadsheets provided by Malaria Consortium show no coverage gap for eligible children since at least 2019. Malaria Consortium, Donor Landscape, 2019 (unpublished), Malaria Consortium, Donor Landscape, June 2020 (unpublished), Malaria Consortium, Donor Landscape, June 2021 (unpublished)
• 352,020,000 children (Malaria Consortium's GiveWell-funded target population in 2021) / 4,230,000 children (total target population in 2021, per Malaria Consortium, Donor Landscape, June 2021 (unpublished)) = 48%
• 36
  • Support levels described in Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 10, Table 1, shows the Global Fund covering 33 health districts in 2020.
  • "In this process, the Global Fund, PMI and Malaria Consortium also agreed to split health districts supported by the World Bank until 2019 and covered by the Global Fund in 2020. As a result of the changes, Malaria Consortium’s support will increase to 27 health districts." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 12.

• 37We learned this by attending meetings hosted by the RBM Partnership to End Malaria.
• 38This is the other major funder of SMC in Chad. See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 13, table 4.
• 39Chad is not listed on PMI's "Where We Work" page. U.S. President's Malaria Initiative, "Where We Work".
• 40Donor landscape spreadsheets provided by Malaria Consortium show no coverage gap for eligible children starting in 2020. Malaria Consortium, Donor Landscape, 2019 (unpublished), Malaria Consortium, Donor Landscape, June 2020 (unpublished), Malaria Consortium, Donor Landscape, June 2021 (unpublished).
• 41 1,080,000 children (Malaria Consortium's GiveWell-funded target population in 2021) / 2,180,000 children (total target population in 2021, per Malaria Consortium, Donor Landscape, June 2021 (unpublished)) = 50%
• 42
  • Support levels described in Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 13, Table 4 shows the Global Fund covering 38 health districts in 2020.
  • "As SMC funding from the Global Fund will decrease slightly in 2021, the PNLP has requested support from Malaria Consortium for an additional 90,000 children in five health districts in 2021." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 15.

• 43We learned this by attending meetings hosted by the RBM Partnership to End Malaria.
• 44These are the other two major funders of SMC in Togo. See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 23, table 11.
• 45Togo is not listed on PMI's "Where We Work" page. U.S. President's Malaria Initiative, "Where We Work"
• 46See here (2018-2020 malaria allocation) and here (2021-2023 malaria allocation).
• 47See this cell. This is a spreadsheet, completed by the government and shared with us by AMF, showing how Togo decided to use its malaria allocations for the 2018-2020 and 2021-2023 grant periods.
• 48See this cell. This is a spreadsheet, completed by the government and shared with us by AMF, showing how Togo decided to use its malaria allocations for the 2018-2020 and 2021-2023 grant periods.
• 49Donor landscape spreadsheets provided by Malaria Consortium show no coverage gap for eligible children since at least 2019. Malaria Consortium, Donor Landscape, 2019 (unpublished), Malaria Consortium, Donor Landscape, June 2020 (unpublished), Malaria Consortium, Donor Landscape, June 2021 (unpublished).
• 50This understanding is informed by many conversations with Malaria Consortium.
• 51While it's possible that Malaria Consortium holds sufficient funding in the bank to place the order for these drugs without receiving an additional grant, we have not asked Malaria Consortium about this. We prefer to make this grant now to give Malaria Consortium the visibility it needs to begin planning for 2023 campaigns and because we do not expect to learn new information in the near term that would substantially update our cost-effectiveness estimate for this grant.
• 52See this section of our Malaria Consortium review for details.
• 53See this section of our Malaria Consortium review for a full discussion of these coverage surveys and their results.
• 54Malaria Consortium initiated a partnership with the country's SMC program in 2020 but was prevented from providing its planned level of support to that year's SMC season by the Covid-19 pandemic. It was able to provide the level of support in 2021 that it expects to provide in future years. We have not yet seen results from that year's coverage surveys.
  • "However, days before the scheduled departure of a regional Malaria Consortium colleague who had agreed to act as temporary country director, Togo closed its borders in response to the emerging COVID-19 pandemic. It was consequently not possible to establish a presence in the country and start the NGO registration process until much later in the year, and we were unable to recruit staff or provide detailed technical and logistical support to the 2020 SMC campaign. While SMC implementation in the regions supported by the Global Fund was not compromised in principle, implementation in the region supported by UNICEF was jeopardized. To ensure the campaign could go ahead in Savanes, Malaria Consortium agreed to provide a grant to the PNLP, covering the operational costs of three SMC cycles in that region." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 23.
  • "In 2021, we plan to fully register as an NGO and expand our support for SMC in line with the funding arrangements described above." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 24.

• 55 GiveWell, "Qualitative Assessments of Top Charities," 2019.
• 56For more information about our calculations, see the "Proportion of malaria mortality occurring in the five months when SMC is delivered" bullet in the "Cost-effectiveness" section of our grant page.
• 57We did not arrange stakeholder conversations for Togo, given the small amount of funding needed there.