Malaria Consortium – Seasonal Malaria Chemoprevention (July and August 2022)

Published: September 2022

Background

Malaria Consortium's SMC programs distribute antimalarial drugs to children 3 to 59 months old in order to prevent illness and death from malaria.1 Distribution is done in four or five monthly cycles during the part of the year when malaria transmission is highest.2 In 2022, with GiveWell-directed funding, Malaria Consortium is delivering SMC to a target population of roughly 14.5 million children in Burkina Faso, Chad, Nigeria, and Togo.3 (It is delivering SMC to an additional target population of 8 million children with other, non-GiveWell-directed sources of funding.)4 These four countries represent the bulk of Malaria Consortium's spending of GiveWell-directed funding5 and are countries where SMC has been delivered for several years.6 In 2022, Malaria Consortium is also supporting SMC in three newer countries of operation (second-year implementation research projects in Mozambique and Uganda, and a first-year pilot in South Sudan) and will begin scaling up SMC delivery in Mozambique.7

How we use cost-effectiveness estimates in our grantmaking

We use GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding opportunities, which we describe in multiples of "cash." Thus, if we estimate that a funding opportunity is "10x cash," this means we estimate it to be ten times as cost-effective as unconditional cash transfers. At the time that we directed this funding, we were primarily looking to recommend grants that we estimated were 10x cash or higher.

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.

The case for the grant

We conduct "room for more funding" analyses to understand what portion of a grantee's ideal future budget it will be unable to support with the funding it has or should expect to have available. We may then choose to either make or recommend grants to support those unfunded activities. Before directing this funding, we updated our room for more funding analysis for Malaria Consortium's SMC programs and found that Malaria Consortium needs roughly $100 million to maintain its 2022 scale of support to its SMC programs in Burkina Faso, Chad, Nigeria, and Togo in 2024 and 2025.8 (This figure excludes funding needed to maintain or scale up programs in Malaria Consortium's newer countries of operation.)

At the time that we directed this funding, we had not yet fully investigated these opportunities. As such, we were uncertain about what portion of the $100 million in room for more funding meets our 10x cash cost-effectiveness bar, and therefore what portion we will ultimately decide to fund. Despite this uncertainty, we decided to direct this funding because we prefer to grant out Top Charities Fund funding during the subsequent quarter unless we have a strong reason to hold the funding, and because we were confident that at least $13.5 million of this room for more funding (and likely much more) meets our 10x cash cost-effectiveness bar.

Our confidence that at least $13.5 million of this room for more funding meets our 10x cash cost-effectiveness bar was based on:

• Around $58 million of this room for more funding is in Nigeria,9 where our most recent cost-effectiveness estimate (11.6x cash) exceeds our 10x cash cost-effectiveness bar.10
• While it is possible that this cost-effectiveness estimate will change during further investigation, we thought it was highly unlikely that we would make updates to the model that would cause the majority of the room for more funding in Nigeria to fall below our 10x cash cost-effectiveness bar. Because our SMC model is one of our most mature cost-effectiveness models, and because it incorporates many years of data from Malaria Consortium's program in Nigeria,11 we expect that our cost-effectiveness estimate for that country is relatively robust.
• The parameter values in our SMC model that we expect to learn the most about in the coming months—i.e., the values that could change the most during further investigation—are our estimates of the proportion of our funding that is crowding out funding from other sources.12 For Nigeria, we currently estimate that 30% of our funding is crowding out funding from other sources,13 and we think that the risk of crowding out funding from other sources with this $13.5 million is highly unlikely to be higher than that. This is because that value is the result of a relatively recent and thorough investigation involving conversations with The Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President's Malaria Initiative (PMI) (the two major funders of malaria interventions in Nigeria14 ) and Nigeria's national malaria program.15 In addition, because this grant would only fill the first ~25% of the $58 million in room for more funding that Malaria Consortium has in Nigeria, we expect that the risk of it crowding out funding from other sources is particularly low. (We expect that the more of a funding gap we fill, the higher the risk that we're crowding out whatever portion of the gap other funders might have filled in our absence. We expect the opposite to be true when we fill only a small part of a large funding gap.)

We note that we did not restrict this grant to Nigeria, so the allocation of this funding among Malaria Consortium's SMC programs is at its discretion. However, we communicated the reasoning behind this grant to Malaria Consortium, and we believe that it will take our preference into account when deciding how to allocate this funding.

Plans for follow up

• We plan to investigate grants to fill the remainder of Malaria Consortium's room for more funding in Nigeria and in its other countries of operation (including Burkina Faso, Chad, Togo, and its newer countries of operation). We will publish the findings from those investigations in future grant pages.
• We have monthly calls with Malaria Consortium to discuss its work.
• We will request that Malaria Consortium submit spending reports and coverage surveys from the SMC campaigns that it supports with this grant, as it has for all previously funded campaigns.

Sources

Document	Source
Malaria Consortium, "Exploring the use of seasonal malaria chemoprevention in South Sudan," August 2022	Source (archive)
Malaria Consortium, "Seasonal malaria chemoprevention: Protecting children under five from malaria during peak transmission season," May 2021	Source (archive)
Malaria Consortium, "SMC in 2022: Maintaining scale and looking to the future," January 2022	Source (archive)
Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020	Source
GiveWell, Cost-effectiveness analysis, 2022, Version 5	Source
GiveWell, "Malaria Consortium – Seasonal Malaria Chemoprevention"	Source
GiveWell, "Malaria Consortium — SMC Renewal in Nigeria, Burkina Faso, Chad, and Togo (January 2022)," 2021	Source
GiveWell, "Revisiting Leverage," 2018	Source
GiveWell, Room for more funding analysis for Malaria Consortium's SMC Program, 2022	Source

• 1

  "[S]easonal malaria chemoprevention (SMC) programs [...] aim to distribute anti-malarial drugs to children 3 months to 59 months old in order to prevent illness and death from malaria. GiveWell, "Malaria Consortium – Seasonal Malaria Chemoprevention", "What do they do?"

• 2

  "[S]easonal malaria chemoprevention is the monthly administration of full courses of antimalarial medicines to children during the malaria season in areas of highly seasonal malaria transmission. [...] According to WHO policy recommendation, it "consists of administering a maximum of four treatment courses of SP [sulfadoxine–pyrimethamine] + AQ [amodiaquine] at monthly intervals to children aged 3–59 months in areas of highly seasonal malaria transmission." Historically, countries eligible for SMC have aimed to deliver annual SMC rounds comprising four monthly cycles prescribed by this policy recommendation. 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." GiveWell, "Malaria Consortium – Seasonal Malaria Chemoprevention", "What are SMC programs?"

• 3

  See 2022 figures for "Target population 4 cycles" and "Target population 5 cycles" for Burkina Faso, Chad, Nigeria, and Togo in this spreadsheet, sheet "Source: Country budgets (2022)."

  Target population 4 cycles Target population 5 cycles
  Burkina Faso 1,470,989 636,993
  Chad 1,200,706 0
  Nigeria 4,691,897 6,070,236
  Togo 501,623 0

  1,470,989 + 1,200,706 + 4,691,897 + 501,623 + 636,993 + 6,070,236 = 14,572,444

• 4Malaria Consortium, comments on a draft of this page.
• 5

  Between January and December 2020, for example, Malaria Consortium spent $31.4 million in GiveWell-directed funds, of which $17.1 million (54%) was spent in Nigeria, $7.6 million (24%) in Burkina Faso, $6.0 million (19%) in Chad, $0.6 million (2%) in Mozambique, and $0.1 million (less than 1%) in Togo. See "Malaria Consortium's spending on SMC programs" in our write-up on Malaria Consortium here.

• 6

  Malaria Consortium has been a leading implementer since the World Health Organization (WHO) issued its recommendation to scale up SMC in 2012. With our partners, we led the rapid scale-up 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. This project demonstrated that SMC is cost-effective, safe and that high coverage can be achieved at scale. Since 2018, we have continued to support national malaria programmes in Burkina Faso, Chad, Nigeria and Togo, reaching over 12 million children in 2020." Malaria Consortium, "Seasonal malaria chemoprevention: Protecting children under five from malaria during peak transmission season," 2021.

• 7
  • "In the coming months, our research teams in Uganda and Mozambique will conclude phase two of implementation studies to assess the effectiveness of the intervention in their respective countries – where SMC had not previously been implemented. The phase one results from those studies already found that SMC works there and is feasible and acceptable." Malaria Consortium, "SMC in 2022: Maintaining scale and looking to the future," January 2022.
  • "In South Sudan, malaria accounts for 33 percent of all hospital admissions and is the leading cause of mortality in children under five. We recently conducted implementation research in Uganda and Mozambique, demonstrating that malaria cases were significantly less likely to occur in areas that received SMC compared to those that did not, and that SMC is feasible, acceptable and safe. The study seeks to understand the feasibility, acceptability and impact of implementing SMC in Aweil South Country, to determine the chemoprevention efficacy of SMC medicines, and to explore the scalability of SMC in other states in South Sudan." Malaria Consortium, "Exploring the use of seasonal malaria chemoprevention in South Sudan," August 2022.
  • Regarding scaling up SMC delivery in Mozambique, Malaria Consortium's 2022 budget includes "[approximately] 70% of costs relating to the 2022/23 campaign [in Mozambique], which will involve scale up to all 23 districts in Nampula province (1.23m children; SMC distribution expected to start in December 2022)." See this cell in GiveWell, Room for more funding analysis for Malaria Consortium's SMC Program, 2022.

• 8

  See this cell. This total is primarily made up of room for more funding in 2024 and 2025 in Burkina Faso, Chad, and Togo and in 2025 in Nigeria. In January 2022, we recommended a grant to Malaria Consortium to maintain its 2021 scale of support to Burkina Faso, Chad, and Togo through 2023 and to Nigeria through 2024. (The $100 million in room for more funding is what remains after accounting for that grant.)

• 9

  See this cell in our room for more funding analysis.

• 10

  See this cell in our cost-effectiveness analysis.

• 11

  We've been funding Malaria Consortium's SMC program and receiving data from campaigns we've supported since 2017.

• 12

  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 to Fight AIDS, Tuberculosis and Malaria and/or the U.S. President's Malaria Initiative (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 1 dollar spent by the grantee would otherwise have come from other sources). See more details in this blog post. We incorporate considerations about the funding landscapes for SMC in the countries we are considering for grants into location-specific adjustments, which are accounted for in our cost-effectiveness estimates.

• 13

  See these cells in our cost-effectiveness analysis.

• 14See Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, p. 16, table 7.
• 15

  See here for a discussion of the reasoning behind the value.