Note: This page summarizes the rationale behind a GiveWell-recommended grant to Malaria Consortium. Malaria Consortium staff reviewed this page prior to publication.
Summary
In January 2023, GiveWell made or recommended grants totaling $87.5 million to Malaria Consortium's seasonal malaria chemoprevention (SMC) programs. This funding will enable Malaria Consortium to maintain the current scale (as of 2022) of its support to countries' SMC programs through 2025 in Nigeria,1 Burkina Faso and Togo. It will also provide an additional year of funding for Malaria Consortium’s support to the SMC program in Chad, intended as exit funding. This funding comes from the following sources:2
- $61.4 million is a grant made from Open Philanthropy on GiveWell’s recommendation.
- $23.6 million is from donations made to GiveWell’s Top Charities Fund between October and December 2022.
- $2.2 million is a grant made from Effektiv Spenden's German and Swiss entities on GiveWell’s recommendation.
- $193,000 is a grant made from Doneer Effectief in the Netherlands on GiveWell’s recommendation.
- $42,000 is a grant made from Effective Altruism New Zealand on GiveWell’s recommendation.
For the remainder of this page, we refer to these donations as a single grant.
We made this grant because we believe that it will be cost-effective even after incorporating the risks of crowding out other funders and that Malaria Consortium has a strong track record of delivering SMC programs.
Published: April 2023
Table of Contents
Planned activities and budget
GiveWell’s room for more funding analysis3 shows that Malaria Consortium holds sufficient funding (from previous GiveWell grants4 and other funding sources) to maintain its current scale (as of 2022) of support to SMC programs in Nigeria through 2024 and Burkina Faso, Togo and Chad through 2023. This new $87.5 million grant extends the program’s funding runway in all four countries. It consists of:5
- $53.6 million for Nigeria (61% of the grant). This includes:
- $44.9 million (51% of the grant) to maintain the current scale (as of 2022) of Malaria Consortium's support to the programs in Bauchi, Kebbi, Kogi, Nasarawa, Oyo, Plateau and Sokoto States and the Federal Capital Territory (FCT) through 2025.
- $1.9 million (2% of the grant) for two local government areas (LGAs) in Bauchi State in 2025. These LGAs are currently funded by the Korea International Cooperation Agency (KOICA), with funding that Malaria Consortium expects will not be renewed after 2024 (more below).
- $6.9 million (8% of the grant) to fund one additional year of Malaria Consortium’s support for the SMC program in Borno State (in 2023). This is the third year that Malaria Consortium will use GiveWell-directed funding to support this program, following delays to a World Bank loan that is due to support malaria services in Borno (more below).
- $23.0 million for Burkina Faso (26% of the grant). This includes two additional years of funding to maintain the current scale (as of 2022) of Malaria Consortium's support to the program in Burkina Faso through 2025.
- $4.4 million for Togo (5% of the grant). This includes two additional years of funding to maintain the current scale (as of 2022) of Malaria Consortium's support to the program in Togo through 2025.
- $6.5 million for Chad (7% of the grant). This amount, intended to be exit funding, is based on adding one additional year of funding at the current scale (as of 2022) of Malaria Consortium's support to the program in Chad.
The principles we have used for this grant are:
- To provide three years of funding runway to programs that meet our cost-effectiveness bar.6 We typically aim for three years of funding runway because grantees have told us in the past that there are often substantial benefits to knowing that funding for a program is secure for the future.7
- To provide two years of funding runway to programs that have historically been supported with GiveWell-directed funding but that no longer meet our cost-effectiveness bar,8 and therefore that we plan to discontinue funding. The intention behind this principle is to provide grantees with sufficient funding runway to either responsibly scale down their support or seek alternative sources of funding for the program. We established this principle with input from our grantees about how long it might take to achieve those aims, in general. In each case where it applies, we aim to get input from our grantees about whether there might be a case for a longer exit period.
The grant for Borno State, Nigeria (which provides one year of funding for the 2023 SMC season only) is an exception to this principle. This is because the funding for Borno is filling a time-sensitive funding gap that we think is unlikely to continue past 2023. This funding gap exists because there have been delays to a World Bank loan that will fund malaria services in the state but has not begun doing so.9 We decided to provide 2023 funding for Borno because both we and Malaria Consortium believe that malaria service provision under the World Bank loan is unlikely to begin in time for the 2023 SMC season (which begins in July). More below.
The case for the grant
- Cost-effectiveness. We expect that this grant will be cost-effective. 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. (More)
- Funding landscape for SMC. During this and previous grant investigations, we have investigated the funding landscape for SMC in these countries. We 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 (61% of the grant) and at moderate-to-high risk in the other three countries. (More)
- Malaria Consortium as a grantee. Malaria Consortium has a strong track record of delivering SMC programs in the countries included in this grant. Our qualitative assessment of Malaria Consortium as an organization is also 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. We refer to these opportunities 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 unconditional cash transfers to some of the world's lowest income communities 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 the time of writing, we plan to fill funding gaps that meet or exceed a relatively high threshold: 10x cash, or ten (or more) times as cost-effective as unconditional cash transfers.
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.
Cost-effectiveness of this grant
We believe that this grant will be cost-effective. Our cost-effectiveness estimates at the time we made the grant (January 2023), in terms of X times as cost-effective as cash transfers, were:
| Country | Cost-effectiveness10 |
|---|---|
| Nigeria | 11-24x |
| Burkina Faso | 15x |
| Togo | 9x |
| Chad | 6x |
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 parameters we updated in our model as we considered this grant were:
- Cost per cycle of SMC. One of the inputs to GiveWell’s cost-effectiveness model is the average cost per SMC cycle delivered in previous campaigns. This estimate is based on (1) previous years’ spending on the program and (2) estimates of the number of children reached from program monitoring data. For this grant, we updated our cost per SMC cycle analysis with data from 2021 (for Burkina Faso, Chad, and Nigeria) and made several methodological changes (details in footnote).11
These changes updated our estimate of the cost per SMC cycle as follows:12
- Our overall average estimate13 decreased from $1.66 to $1.50.
- Burkina Faso increased from $1.46 to $1.48.
- Chad decreased from $1.98 to $1.81.
- Nigeria decreased from $1.71 to $1.40.
- Probability that other funders would fill these funding gaps if we did not. 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 made some small updates to these adjustments for all four countries in the grant. More details below.
- Splitting out our Nigeria cost-effectiveness estimate into state-level estimates. We have previously used national-level data on malaria mortality and prevalence in our SMC cost-effectiveness model.14 For this grant investigation, we changed to using state-level estimates for all states in Nigeria.15 We also updated the number of SMC cycles per year by state (some states receive four cycles of SMC; some states receive five).16
This grant includes funding for two country programs that GiveWell has supported historically but, at the time we made the grant decision (January 2023), fell under our 10x cost-effectiveness threshold. The programs are Togo (9x) and Chad (6x). We have decided to include two additional years of funding for Togo in this grant (funding the program through 2025) and exit funding equivalent to one year (at 2022 scale) for Chad. Our reasoning is:
- Togo: When we made this grant decision in January 2023, we estimated that the SMC program in Togo was only slightly under our 10x cost-effectiveness threshold. There was also one pending change to our SMC cost-effectiveness model which was not finalized in time for this grant decision, but which would take the Togo SMC program over our cost-effectiveness threshold (details in footnote);17 we believed it was highly probable that this change would ultimately be incorporated into our model. This, and the comparatively smaller size of Togo's SMC program (5% of the grant), justified our decision to maintain funding for the program despite lower cost-effectiveness than Burkina Faso and Nigeria.
- Chad: We estimate that the SMC program in Chad is further below our cost-effectiveness threshold and do not have any reason to think our estimate will rise above the threshold in the medium term.
Funding landscape for SMC
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 the President’s Malaria Initiative (PMI).18 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 discussed our reasoning for these adjustments for these four countries in detail for a previous SMC grant. During this grant investigation, we made some small updates to these adjustments. These changes modestly lowered our estimates of the probability that this grant may crowd out funding from other sources. These adjustments now vary from 10-65% depending on the specific location. This spreadsheet contains our calculations.
The most significant updates to our thinking for these adjustments were:
- Malaria funding appears to be plateauing. The Global Fund, which has historically been the largest funder of SMC in Burkina Faso, Togo, and Chad,19 underwent its latest three-year funding “replenishment” in late 2022 (for interventions to be delivered in 2024-2026).20 The total value of the replenishment was $15.7 billion, compared to a target of at least $18 billion.21 This represents a fairly stable level of funding compared to the previous replenishment (a 3.3% nominal increase in the overall funding allocated to countries).22 The funding available for malaria was also stable.23 By contrast, the funding available for malaria increased substantially between the 2018-2020 and 2021-2023 replenishments.24 We include an adjustment in our estimates for the increased level of funding between the 2018-2020 and 2021-2023 replenishments,25 but no additional adjustment to reflect stable funding levels between the 2021-2023 and 2024-2026 replenishments.
- Malaria funding needs are likely to increase. In multiple conversations with grantees and other malaria stakeholders, we have heard that funding needs are likely to be higher in the next grant period because of factors including population growth, inflation, and the introduction of new interventions. As a result, we expect that funding gaps for SMC in the period covered by this grant are likely to be similar to or larger than those in the previous three-year period. We factor this update into our calculations here.
- PMI has recently expanded support for SMC in Nigeria. In Nigeria, most states are assigned to receive funding for malaria programs from the Global Fund, from PMI, or through loans from the World Bank and the Islamic Development Bank.26 Five of the Nigerian states supported in this grant (Bauchi, Kebbi, Nasarawa, Plateau, and Sokoto states) are PMI-supported; the others are loan-supported27 (GiveWell-directed funding does not support SMC in Global Fund-supported states in Nigeria). Although PMI’s budget for Nigeria decreased from $77 million in 2020 to $69 million in 2021 and $68 million in 2022,28 PMI expanded its support for SMC to a state (Benue) in 2022 where it was not previously supporting SMC29 (it has also supported SMC in Zamfara state since 2019).30 We interpret this to demonstrate PMI’s willingness to prioritize funding SMC in states where no other source of SMC funding is available. Conversely, we do not think there is a high chance that loan funding will be used to support SMC in most states: 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 SMC.31 Our best guess is that the probability of our funding crowding out other funders is therefore somewhat higher in PMI-supported states compared to loan-supported states. We separate out our adjustments for PMI-supported states and loan-supported states and assign a modestly higher probability of crowding out other funders in the PMI-supported states.32
Borno State, Nigeria
This grant includes one year of funding for Malaria Consortium to support delivery of SMC in Borno State in 2023 (see above). We initially filled this funding gap for the 2021 and 2022 SMC seasons because Malaria Consortium informed us that a World Bank loan that was intended to support malaria services in Borno was delayed.33
According to conversations with Malaria Consortium, our understanding is that, at the time we made this grant decision, this loan funding had been received by the Nigerian Ministry of Health, but not yet subgranted to implementing partners. Because we expect the 2023 SMC season in Borno will begin in July 2023,34 we and Malaria Consortium believed that the campaign could be delayed or canceled entirely if it were reliant on this loan funding (given the time required for planning) and that the probability of finding an alternative funder at late notice was low.35 We therefore decided to include an additional year of funding for the program in Borno in this grant,36 with the expectation that the loan funding will cover at least some costs for SMC in Borno for the 2024 season.
Bauchi State, Nigeria
This grant includes $1.9 million for SMC delivery in 2025 to two LGAs in Bauchi State which are currently funded by the Korea International Cooperation Agency (KOICA) as part of the SMC Impact Project.37 This funding expires in 2024 and Malaria Consortium does not expect that it will be renewed. Because Bauchi State receives support from PMI, we use the same adjustment for the probability that our funding is crowding out other funders that we use for other PMI-supported states in Nigeria.38
Malaria Consortium as a grantee
Malaria Consortium has a strong track record delivering SMC programs in three of the four countries 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).39 Malaria Consortium has a more limited track record in Togo, where it began supporting SMC in 2021.40
Malaria Consortium conducts coverage surveys after both individual cycles and full rounds of SMC to estimate the proportion of children reached. We have seen results from all SMC rounds that Malaria Consortium supported with GiveWell-directed funds for the four countries in this grant through 2021.41 Overall, our assessment is that these surveys are methodologically strong and provide evidence that Malaria Consortium’s programs reached a high proportion of targeted children in previous campaigns. We note some uncertainties and sources of potential bias in the survey results (details in footnote).42
Our qualitative assessment of Malaria Consortium as an organization is also highly positive. We previously rated it as "relatively strong" or higher on seven of eight dimensions included in our qualitative assessments.43 During the grant investigation for our January 2022 renewal grant, we asked several SMC stakeholders for feedback on Malaria Consortium and heard almost exclusively (and often strongly expressed) positive feedback.
Risks and reservations
- Risks of discontinuing funding in Chad. Our aim in providing exit funding for the SMC program in Chad is to minimize the potential for harm to program participants and stakeholders. However, we see some risks associated with our decision to discontinue funding Chad at Malaria Consortium's current scale of support. (More)
- Risk of future crowding out. 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)
Risks of discontinuing funding in Chad
Our decision to discontinue funding Malaria Consortium’s Chad SMC program after 2024 involves a number of risks:
- We provide exit funding to provide our grantees enough time to either responsibly scale down their support or seek alternative sources of funding for the program. This grant provides an amount equivalent to two years of funding runway (at 2022 scale)44 for Malaria Consortium's SMC program in Chad. In our preparations for this grant, we asked Malaria Consortium for feedback on the two-year exit principle described above; Malaria Consortium agreed that two years was reasonable. We continue to be unsure what the appropriate length of exit funding is and how providing more or less funding would affect Malaria Consortium's ability to achieve the aims of these funding.
- Our cost-effectiveness estimates, and the cost-effectiveness threshold that we use to inform our grant decisions, may change over time. This can be for a number of reasons. Firstly, we update our cost-effectiveness models continually in response to new information.45 Secondly, the funding threshold we use to inform grant decisions (currently 10x) can itself change over time. This threshold depends on the amount GiveWell is able to fundraise and the number of cost-effective funding opportunities we have identified across our portfolio.46 By discontinuing funding for the Chad SMC program, we risk narrowing our options to support the program in the future if our cost-effectiveness estimate for Chad rises or our funding threshold falls (because it might be difficult or costly for Malaria Consortium to restart support to the program).
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:
- The proportion of malaria mortality in the high transmission season. Our cost-effectiveness model uses a rough estimate that 70% of direct malaria mortality in the countries included in this grant falls within the high transmission season.47 This estimate is based on a single scientific paper published in 2012, which finds that the median proportion of malaria incidence in SMC eligible sites occurring in the high transmission season was 77% and the mean proportion was 75.7%.48 We then adjust this modestly downwards because our best guess is that, on average, the SMC campaign locations supported by this grant have a less seasonal pattern of malaria transmission than those included in the 2012 paper.49 We believe that our cost-effectiveness model would benefit from additional research to inform this parameter, particularly data that would enable us to use location-specific estimates.
- The likelihood that our funding may be crowding out funding that would otherwise have come from other sources. In evaluating our grants, 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.
- Target population figures. Our cost per SMC cycle administered analysis relies on estimates of the 3-59 month old target population for SMC in each area where the program is delivered, which Malaria Consortium reports to us. We are uncertain about how precise these estimates are. We are currently working with external researchers to learn more about this topic.
- The impact of malaria reduction on long-run income. Our SMC cost-effectiveness model includes an estimate of the income benefits that children accrue in later life via reduced malaria exposure. We are highly uncertain about this estimate, which is drawn from two natural experiments and for which we have no data from randomized controlled trials.50
- The counterfactual value of Global Fund spending. As part of our thinking about whether other funders would fill these funding gaps if we did not, we estimate the value of what other funders are likely to spend their money on instead. Specifically, we estimate the value of Global Fund spending that does not go towards the SMC programs we fund.51 Our cost-effectiveness model is sensitive to the specific value we use, but we are highly uncertain about this value.
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. In particular, we will monitor how the latest Global Fund replenishment is allocated in Burkina Faso, Chad and Togo, and the availability of PMI and loan funding for SMC in Nigeria (as none of the Nigeria states included in this grant receive support for SMC from the Global Fund).
Internal forecasts
| Confidence | Prediction | By time |
|---|---|---|
| 70% | Global Fund funding continues to support SMC in at least 22 health districts (at the same scale of support as 2022) in Burkina Faso and at least 12 districts (at the same scale of support as 2022) in Togo in 2024. | End of 2024 |
| 80% | The World Bank loan covers at least one year's worth of SPAQ52 for Borno, for either the 2024 or 2025 season. | End of 2025 |
| 60% | The World Bank loan covers at least one year's worth of all SMC costs for Borno, for either the 2024 or 2025 season. | End of 2025 |
Our process
This is a renewal grant for programs we have supported for several years. To set the grant size, we used information shared by Malaria Consortium about its available funding and projected budgets through 2025. To investigate the grant, we made the cost-effectiveness analysis updates described above, had multiple conversations with Malaria Consortium, and had one stakeholder conversation specifically about SMC in Nigeria (with Dr. Perpetua Uhomoibhi, head of the Nigerian national malaria program). We also had many conversations with other malaria stakeholders to understand the implications of the Global Fund replenishment size. 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
- 1
With the exception of Borno State, which is funded through 2023 only. See further discussion of our reasoning here.
- 2Figures may not sum to exactly $87.5 million because of rounding.
- 3
We conduct "room for more funding" analysis to understand what portion of Malaria Consortium's ideal future budget it will be unable to support with the funding it has or should expect to have available. We updated our room for more funding analysis for this grant. Our analysis is available here.
- 4
Our previous grant for the countries included in this grant is discussed here. Note: our previous grant did not include funding for three states in Nigeria which are included in this grant: Oyo, Borno and Federal Capital Territory (FCT). These were previously funded by separate GiveWell grants: Oyo and FCT here (through 2024 for FCT and 2022 for Oyo; we later approved a reallocation of Malaria Consortium's available funding to support Oyo in 2023-24), and Borno here (through 2021; we later approved a reallocation of Malaria Consortium's available funding to support Borno in 2022). This is the first time we have grouped these states in the same grant.
- 5Figures can be found in this room for more funding analysis. All figures represent Malaria Consortium's stated budget for each line item (with above-country, research, external relations, and management 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.
- 6
For further information on our cost-effectiveness bar and how we use cost-effectiveness estimates in our decision making, see this section of the grant page.
- 7
Further discussion of how we apply this principle in our grantmaking is available here.
- 8
Either because our bar has changed or because our estimate of the relevant program's cost-effectiveness has changed.
- 9
Details here.
- 10
See this row in our full cost-effectiveness model.
- 11
- The key changes we made were:
- Using program data from only more recent years, 2018-21 (rather than from 2015, as in our previous analysis). This is because we expect the cost per SMC cycle from more recent program years to be more indicative of the cost per SMC cycle that Malaria Consortium will achieve in future program years.
- Updating our adherence adjustment (to account for some children not swallowing all three doses of the SMC drugs) with more recently available data. See here for our updated calculations and assumptions.
- Not putting any weight on projected future budgets for two Nigerian states (Oyo State and FCT) where we had previously relied partly on data from previous SMC campaigns in other states in Nigeria and partly on Malaria Consortium’s future budgets (see details here). Following this update, all our Nigeria estimates are now based on previous campaign data rather than projections.
- Remaining uncertainties in our analysis include:
- Malaria Consortium did not conduct a nationally representative post-round coverage survey for Burkina Faso in 2021, so we estimate children covered in that year by applying coverage rates from previous campaigns to the 2021 target population (see here).
- We do not have information on the costs paid by the Global Fund and UNICEF for delivering SMC in Togo, so we continue to use our overall cost per SMC cycle estimate of $1.50 (a weighted average of Burkina Faso, Chad, and Nigeria) for Togo.
- The key changes we made were:
- 12
Cost per SMC cycle analysis available here. Note that we use the overall weighted average figure ($1.50) as a best guess of the cost of the Togo program rather than an estimate specific to Togo. This is because we do not have information on the costs paid by the Global Fund and UNICEF for delivering SMC in Togo.
- 13
Composed of the weighted average cost per SMC cycle in Nigeria, Burkina Faso and Chad.
- 14
With the exception of Oyo State and FCT, Nigeria, where we previously used state-level estimates. For more information on this change, see our changelog entry here.
- 15
We use subnational estimates on malaria mortality and prevalence from the Institute for Health Metrics and Evaluation (IHME) Global Burden of Disease (GBD) project.
- 16See this spreadsheet, sheet "Source: Country budgets (2022)," for projections for the proportion of Malaria Consortium's target populations in Nigeria that will be reached by five cycles in 2023-2025.
- 17
Specifically, at the time we made this grant decision, we were updating our approach to modeling malaria mortality for both our insecticide-treated bednet and SMC cost-effectiveness models, most notably increasing our estimate of the number of non-malaria deaths indirectly averted by malaria reductions. We do not focus on this update in this grant page because the change was not finalized at the time we made the grant. The cost-effectiveness estimates presented on this grant page do not take into account this expected change.
- 18
These are the largest funders of SMC in the countries in this grant. See Malaria Consortium, seasonal malaria chemoprevention program: Philanthropy report 2020, p. 10, table 1; p. 13, table 4, p. 16, table 7 and p. 23, table 11 for details on the funding landscape in Burkina Faso, Chad, Nigeria and Togo respectively.
- 19
See Malaria Consortium, seasonal malaria chemoprevention program: Philanthropy report 2020, p. 10, table 1; p. 13, table 4; and p. 23, table 11. Note that the Global Fund has also historically been the largest funder of SMC in Nigeria (see table 7, p. 16 of the same report), but Malaria Consortium is not using GiveWell-directed funding in Global Fund-supported states in Nigeria as of 2023.
- 20
Note: there is a discrepancy between the replenishment ‘fundraising period’ dates and ‘implementation period’ dates. The fundraising dates are always one year earlier than the implementation dates (e.g. fundraising dates of '17-'19 correspond to implementation dates of '18-'20). For consistency, we use the implementation dates across all replenishments. Further information is available here.
- 21
- "The Global Fund’s Seventh Replenishment is the world’s opportunity to rise to the challenge and take bold action to protect everyone, everywhere from the deadliest infectious diseases. Our target is to raise at least US$18 billion. This is the minimum required to get the world back on track toward ending HIV, TB and malaria, to build resilient and sustainable systems for health and strengthen pandemic preparedness, making the world more equitable and safer from future threats." The Global Fund, "Seventh Replenishment: Fight for What Counts"
- “The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria welcomed the Seventh Replenishment outcome of US$15.7 billion [ download in English ] during a 3-day meeting this week in Geneva.” The Global Fund, "Global Fund Board Hails Record-Breaking Seventh Replenishment Final Outcome of US$15.7 Billion," November 2022
- 22
- Of the $15.7 billion replenishment, $13.128 billion has been allocated to countries as country grants for HIV, tuberculosis, and malaria. This reflects a 3.3% increase compared to the previous replenishment ($12.71 billion).
- “Accordingly, the Board approves that the amount of sources of funds for country allocations for the
2023-2025 allocation period is US$ 12.503 billion, to which US$ 0.625 billion will be added prior to
determining the country allocation, for a total of US$ 13.128 billion, to be used in accordance with the
Allocation Methodology and decision point GF/B47/DP05.” Global Fund, 2023 – 2025 Allocation Period: Sources and Uses of Funds, 48th Board Meeting, 15-17 November, 2022, p. 2. - “Global disease split: Available funds for country allocations are distributed upfront for HIV, TB
and malaria according to the global disease split approved by the Board at its 46th meeting in
November 2021. The approved global disease split for the 2023-2025 allocation period is (1)
50% for HIV, 18% for TB and 32% for malaria for the first USD 12 billion available for country
allocations, and (2) 45% for HIV, 25% for TB and 30% for malaria for additional amounts over
USD 12 billion.” Global Fund, Allocation Methodology for the 2023-2025 Allocation Period 47th Board Meeting, 10-11-12 May 2022, p. 5. - “For the 2020-2022 allocation period, the Global Fund’s Board approved a total of US$12.71 billion for country allocations and US$890 million for catalytic investments.” Global Fund, Description of the 2020-2022 Allocation Methodology, December 2019, p. 1.
- 23
$4.2 billion was allocated to countries for malaria interventions, compared to $4.0 billion in the previous replenishment. See GiveWell’s summary here, row "total."
- 24
$4.0 billion was allocated to countries for malaria interventions compared to $3.2 billion in the previous replenishment. See GiveWell’s summary here, row "total."
- 25
See here.
- 26
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. 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. 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. In the course of negotiations, each state was designated to receive financing from one of the banks. The negotiations with the World Bank and Islamic Development Bank were successful. At a late stage, the African Development Bank decided not to proceed." GiveWell, "Malaria Consortium — Support for LLIN Distribution Campaigns in Ondo and Anambra States, Nigeria (March 2021)"
- 27
Malaria Consortium, Net-Target Project, Rapid Scoping to Delineate Priority Areas for ITN Distribution and Gap Analysis. Report 2: Nigeria, 2020, Table "Table 2. ITN gaps based on campaign funding landscape analysis.," p. 9.
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- U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2020, Table 1: Budget Breakdown by Mechanism.
- U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2021, Table 1: Budget Breakdown by Mechanism.
- U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2022, Table 1: Budget Breakdown by Mechanism.
- 29
Our understanding based on the following sources is that PMI’s support for SMC in Benue began in 2022:
- “Benue State Government, in collaboration with the US President’s Malaria Initiative, PMI, will July 1, 2022 flag off the Seasonal Malaria Chemoprevention, SMC, for children between the ages of three to 59 months in the state.” Vanguard, "Benue Govt, US President’s Malaria Initiative collaborate on SMC for children," June 18, 2022.
- “PMI Nigeria will support seasonal malaria chemoprevention (SMC) in two states, Benue and Zamfara, covering more than 2.2 million children aged 3-59 months with four cycles of SMC using sulphadoxine pyrimethamine amodiaquine (SPAQ).” U.S. President's Malaria Initiative, Nigeria, Malaria Operational Plan FY 2023, p. 8.
- “With FY 2022 funding, PMI will continue to support SMC in Zamfara State. Other partners cover SMC needs in six SMC eligible PMI-supported states. With the stratification exercise, Nigeria has expanded the number of eligible states. PMI has prioritized expansion into another PMI-supported state (likely Benue) if additional resources become available.” U.S. President's Malaria Initiative, Nigeria, Malaria Operational Plan FY 2022, p. 70.
- PMI was not previously supporting SMC in Benue, according to the following source: U.S. President's Malaria Initiative, Nigeria, Malaria Operational Plan FY 2022, Table 4, p. 20.
- 30
“PMI supports drug-based prevention programs, namely Malaria in Pregnancy (MIP) and Seasonal Malaria Chemoprevention (SMC) in Zamfara State…PMI began SMC support to Zamfara State in CY 2019”. U.S. President's Malaria Initiative, Nigeria, Malaria Operational Plan FY 2022, pp. 8, 59.
- 31
"FCT is one of the 11 states that is slated to receive loan financing for malaria control. SMC was included in the loan funding for only one state, Borno." GiveWell, "Malaria Consortium — Support for SMC in FCT and Oyo States, Nigeria (October 2021)"
- 32
See the separate values for PMI-supported states and other Nigerian states in our analysis here.
- 33
More detail about this situation can be found on this page about our decision to approve Malaria Consortium's reallocation of available funding to support the 2021 SMC season in Borno. We also approved Malaria Consortium's reallocation of available funding to support the 2022 SMC season in Borno, but did not publish a separate grant page about this.
- 34
Christian Rassi, Program Director - Seasonal Malaria Chemoprevention, Malaria Consortium, email to GiveWell, January 19, 2023 (unpublished).
- 35
Malaria Consortium, email to GiveWell, January 4, 2023 (unpublished).
- 36
Another factor in our decision is that we estimate the Borno State SMC program (11x as of January 2023) is above our cost-effectiveness threshold (10x).
- 37
“Through the SMC Impact project, KOICA funding is used to deliver SMC in two local government areas (LGAs) in Bauchi State, Northeast Nigeria: Ningi and Tafawa Balewa.” SMC Alliance, "SMC Impact project in Nigeria," accessed February 20, 2023.
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See this section of our Malaria Consortium charity review for details.
- 40
- Malaria 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.
- "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.
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This includes results from 2017-2021 in Burkina Faso, Chad, and Nigeria and from 2020-2021 in Togo. For full details, see our monitoring summary here.
- 42
- Sources of uncertainty and possible bias we have identified in Malaria Consortium’s surveys:
- A reliance on caregiver-reported responses. These responses are at risk of social desirability bias that could lead caregivers to overreport SMC administration, if they believe that this is the preferred response of data collectors. Post-round responses are also at high risk of recall bias, as they report on up to 12 or 15 doses, the first of which would have occurred at least three or four months prior.
The differences between results from post-cycle and post-round surveys have fluctuated over time. We find a difference of 2% between them for 2017, 13% for 2018, 24% for 2019, 9% for 2020, and 6% for 2021. We find it concerning that this difference is high in some years and do not know why these results would fluctuate to this extent over time.- In general, we have been uncertain about the quality of survey implementation due to the lack of a procedure to audit data collectors' work. Malaria Consortium introduced auditing measures into post-round and post-cycle surveys in Nigeria in 2021 (and post-round surveys in Mozambique and Uganda). Results from the auditing of post-round surveys in Nigeria suggest that in the vast majority of cases, data collection procedures were followed correctly.
- A reliance on caregiver-reported responses. These responses are at risk of social desirability bias that could lead caregivers to overreport SMC administration, if they believe that this is the preferred response of data collectors. Post-round responses are also at high risk of recall bias, as they report on up to 12 or 15 doses, the first of which would have occurred at least three or four months prior.
- We incorporate these concerns into our cost-effectiveness model via a downward adjustment for the risk of ‘False monitoring results’. As of the time of writing, this adjustment was 2%. See our grantee report for Malaria Consortium for a more detailed discussion of these coverage surveys and their results.
- Sources of uncertainty and possible bias we have identified in Malaria Consortium’s surveys:
- 43
See here.
- 44
The grant for Chad is set at a level to provide two years of funding runway for Chad. Malaria Consortium may use this funding either to continue its program in Chad for two years, or to scale down gradually over a longer period of time.
- 45
This section of the grant page discusses changes we made to our SMC cost-effectiveness model during this grant investigation, and the impact these changes had on our cost-effectiveness estimates.
- 46
This blog post summarizes one recent change: in 2022 we increased our cost-effectiveness threshold from 6x as cost-effective as cash transfers to 10x. This change was motivated by two developments: firstly, we identified more cost-effective opportunities than we previously anticipated, and secondly, we raised less funding than projected because of declines in financial markets in 2022.
- 47
We previously estimated a lower proportion of mortality (60%) in two southern states in Nigeria which have less seasonal rainfall: Oyo State and Federal Capital Territory (FCT). See our reasoning for this decision in the cost-effectiveness model here. We have since reverted to using an estimate of 70% for all states in Nigeria, including Oyo and FCT, on the basis that, while these states are likely to have less seasonal transmission, they also have a longer SMC delivery period (five months compared to four in most locations). We therefore expect a similar proportion of malaria mortality to occur in the period during which SMC is being delivered.
- 48
Cairns, M., Roca-Feltrer, A., Garske, T. et al. Estimating the potential public health impact of seasonal malaria chemoprevention in African children. 2012, Supplementary Table S1, 2.
- 49
- “SMC is recommended for deployment in areas...where more than 60% of the annual incidence of malaria occurs within 4 months.” WHO, Seasonal malaria chemoprevention with sulfadoxine-pyrimethamine plus amodiaquine in children: a field guide 2013, p. 8.
- In 2022, the WHO revised its guidance to remove these transmission intensity thresholds. Since SMC programs have expanded geographically since 2012 (with 60% of malaria incidence in the high transmission as the lower bound for most of this expansion period), we would expect average seasonality in the locations covered by this grant to be somewhat lower than those found in the 2012 paper.
- 50See the cell note here for further discussion of this evidence.
- 51The reasoning for our current estimate is discussed here.
- 52
SP (sulfadoxine–pyrimethamine) + AQ (amodiaquine) is the medication combination recommended by the World Health Organization for SMC.