Malaria Consortium — “Be In A Net” Phases 1 and 2 (February 2024)

Note: This page summarizes the rationale behind a GiveWell grant to Malaria Consortium. Staff at Malaria Consortium and the Behavioural Insights Team reviewed this page prior to publication.

Last Updated: September 2024; Published: July 2024

The organizations

Malaria Consortium's seasonal malaria chemoprevention program is one of GiveWell's top charities. In March 2021, we recommended funding for the first time to Malaria Consortium for long-lasting insecticide-treated nets (LLIN) distribution campaigns. Additional content on our view of and grants to Malaria Consortium can be found here.

The Behavioural Insights Team (BIT) is a sub-grantee for this grant and will offer behavioral science expertise to Malaria Consortium in the designing and testing of an intervention to increase net use. BIT is a for-profit company offering behavioral science consultancy services.2 BIT has conducted over 1,700 projects designing behavioral interventions, including 200 health behavior projects similar to the “Be in a Net” project, and has an established framework for developing and testing behavioral health interventions.3

Grant activities and budget

Insecticide-treated nets (ITNs) are a key malaria control intervention, and we’ve estimated their mass distribution to be between 9 and 23 times as cost-effective as spending on unconditional cash transfers (GiveWell’s benchmark for comparing different programs). However, we currently estimate that only 63% of the nets distributed in GiveWell-funded campaigns end up being used.4 Because nets only confer protection when actually used, we think increasing their use could be a promising way to further improve the effectiveness—and potentially cost-effectiveness—of this intervention.

Malaria Consortium and BIT have proposed a three-phase project, “Be In A Net,” which aims to use behavioral science to increase use of ITNs. The phases include:5

• Phase 1: Exploratory research
  • Malaria Consortium and BIT will conduct research (including desk research, semi-structured interviews, and direct observation at the household level, and focus group discussions) to identify and understand barriers to proper and lasting net use in Nigeria and Uganda.
• Phase 2: Co-creation and testing of promising interventions
  • Malaria Consortium and BIT will co-create a longlist of potential behavioral interventions to increase net use together with stakeholders in each country, then narrow this list to the most promising interventions.
  • The organizations will develop prototypes and conduct initial testing of interventions on the resulting shortlist.
  • The organizations will analyze data from initial prototype tests, develop a high-fidelity prototype(s) of the most promising intervention(s), and conduct user testing of the high-fidelity prototype(s).
  • Finally, the organizations will conduct an implementation pilot of the most promising intervention with approximately 150 households.6
• Phase 3: Randomized controlled trial (RCT)
  • Malaria Consortium and BIT will run an RCT in Nigeria and Uganda to evaluate the impact of the intervention on net use.

This grant will support only the first two phases of the project, with the possibility of a second grant to support phase three depending on the results of phases one and two. Grant activities will span a period of roughly 12 months.7 Malaria Consortium and BIT plan to share updates with GiveWell following exploratory research and initial prototyping as well as a final report detailing their process and findings following the implementation pilot.

The budget for the grant is $1,480,4378 and breaks down as follows:

• $306,366 for staff costs
• $431,878 for direct grant activities9
• $591,935 for consultancy costs
• $150,260 for travel, equipment, other direct costs, and overheads10

The case for the grant

We are recommending this grant for the following reasons:

• We believe there is potential for the behavioral intervention designed as a result of this grant to be cost-effective. A behavioral intervention to increase net use, layered on top of a net distribution campaign, could be a cost-effective use of funds if 1) implementation costs per household are considerably lower than the cost of a net, and 2) the intervention succeeds at increasing net use to an appreciable degree. We think it is likely that Malaria Consortium and BIT will be able to design an intervention that meets the first condition.11 It is also plausible that the intervention could meet the second condition,12 though we are highly uncertain about that. This grant will provide us with more information about the cost condition (which will be a key factor in our decision of whether or not to fund an RCT of the intervention) but not the effectiveness condition.
• Funding this grant provides us with the option to fund a potentially highly-valuable RCT of the designed intervention at a later date. The current grant lays the groundwork for a large-scale RCT, preserving the option of generating experimental evidence to test a new intervention’s impact on net use, but without committing us to funding the RCT until we have a better grasp of the intervention’s promisingness. Experimental evidence showing that the behavioral intervention is not just operationally feasible, but actually effective in increasing net use, could allow countries to include the intervention in future Global Fund applications13 and/or lead GiveWell to provide supplemental funding for implementation of the behavioral intervention alongside future net campaigns.
• We expect that the activities funded by this grant will give us sufficient information to decide whether to fund an RCT. In order to decide on funding the RCT, we will want to be confident that the intervention’s delivery costs are low enough for the intervention to be potentially cost-effective and that the intervention is feasible to implement. BIT indicated that prototyping and user testing would allow them to estimate the intervention’s cost per household within a range of about $0.15.14 We agreed with Malaria Consortium and BIT to add an implementation pilot of the intervention to give us additional confidence in costs and implementation feasibility.15
• We believe that Malaria Consortium and BIT are well suited for this work. We have confidence in these organizations’ ability to conduct the study and apply its findings. Malaria Consortium is well-integrated in Nigeria and Uganda, with regional offices based in Abuja and Kampala, and seems well-positioned to lead locally-grounded research and co-creation processes in the two countries. Additionally, Malaria Consortium has been a thoughtful and collaborative partner in our years of grantmaking to the organization (both for SMC and, more recently, nets), and our qualitative assessment of Malaria Consortium as an organization is highly positive. BIT has conducted over 1,700 projects designing behavior interventions across 80 countries, including 200 health behavior projects, and has an established framework for developing and testing these types of interventions.16
• This grant is an opportunity to learn about a potential new funding area for GiveWell. We’ve granted significant funding to malaria nets projects, but most of this funding has gone directly to net procurement. We think this is a good opportunity to learn more about another potential avenue to get more people sleeping under nets, even if we don’t end up funding the RCT.

Risks and reservations

Our main reservations about this grant include the following:

• If there are delays in the implementation of this grant, the Uganda arm of the eventual RCT may not be viable. It would be best to begin the RCT in each country as soon after a net distribution campaign as possible.17 Malaria Consortium has told us that baseline data collection for an RCT should begin within 18 months of an ITN campaign because declines in net retention over time would reduce statistical power of the RCT.18 Uganda’s most recent triennial ITN campaign ended in December 2023,19 which means that baseline data collection in Uganda should begin by June 2025. If there are delays in grant activities such that final results are not available within the planned timeline (approximately 12 months20 ), we may not be able to make a decision about whether to fund an RCT in time to begin data collection in Uganda. To mitigate this risk, Malaria Consortium and BIT told us they were willing to begin developing RCT study protocols and begin Institutional Review Board processes before receiving a funding decision on the RCT.21 Malaria Consortium also told us that a Nigeria-only RCT would still be valuable given the varied cultural and eco-epidemiological settings in the country.22
• It’s possible that final results of an eventual RCT may not be published before national malaria programs in Uganda and Nigeria need to submit their next round of Global Fund applications in 2026. Part of the potential value of the current grant is that if it leads to an RCT of the behavioral intervention and that RCT returns positive results, Uganda and Nigeria could then include the intervention in their upcoming applications to the Global Fund, which could result in increased net use in those countries (see above). It’s possible that final results of the RCT wouldn’t be ready in time for Uganda and Nigeria to include them in their 2026 Global Fund applications, which would reduce the value of the grant. Malaria Consortium told us that it would engage with National Malaria Programs and Global Fund partners through the study to inform them of preliminary results, so that the research uptake process could begin before the final report is published.23 Additionally, in the event that the behavioral intervention were not able to be included in the 2026 Global Fund applications, GiveWell or another funder could consider funding the intervention.
• Because the malaria space is funding-constrained, it’s possible that there would be limited availability of funding for the resulting intervention even if an RCT showed it to be effective. We’ve heard from malaria experts broadly that there is a significant amount of unmet need for malaria funding at the moment. Thus, it seems possible that even if an RCT produces positive results and the intervention is included in Nigeria and Uganda’s 2026 Global Fund applications, the Global Fund may choose not to fund the intervention. We are unsure how likely this is. However, as mentioned above, it is possible that GiveWell could fund the intervention in the absence of Global Fund funding.
• It’s possible that Malaria Consortium and BIT will be unable to design an intervention that is both inexpensive enough and effective enough to meet our funding bar. It makes intuitive sense to us that any supplemental intervention to increase net use would need to be considerably less costly than a net in order to compare favorably against a counterfactual of spending the funds on more nets. A very low cost intervention will necessarily be light-touch, and it’s possible that a light-touch intervention won’t achieve the effectiveness needed to be cost-effective. We have not explored the promisingness of light-touch behavioral interventions, but BIT has suggested that very low-cost interventions can have meaningful effects on health behaviors and would not preclude tech-based approaches like SMS nudges, which may be more promising than traditional light-touch nudges such as adding social norm messaging to leaflets.24

Plans for follow up

• We plan to have bimonthly calls with Malaria Consortium and BIT to stay updated on the research and design phases. We may have more frequent calls during the prototyping, user testing and piloting phases.
• Malaria Consortium and BIT will share intermediate outputs throughout the phases covered by this grant, including written learnings from scoping/exploratory research, co-design, and intervention testing.
• Malaria Consortium and BIT will share a final report detailing their process and findings following the implementation pilot.
• Learnings from this grant will be used by GiveWell as part of our investigation into whether to fund phase 3 of the “Be in a Net” project, i.e., an RCT of the intervention that is designed and tested in phases 1 and 2. This investigation will include modeling the cost-effectiveness of the behavioral intervention across a range of possible effectiveness estimates and modeling the value of information of an RCT in one country versus two.

Internal forecasts

For this grant, we are recording the following forecasts:

Confidence	Prediction	By time
75%	Phase 2 will have begun.	July 202425
60%	The pilot will be complete.	Dec 2024
75%	The intervention proposed at the end of prototyping and testing will have a projected per-household cost of ≤$0.50 when delivered at scale.	Sept 2024
60%	We will decide to fund phase 3 (an RCT) of the “Be in a Net” project.	Dec 2024

Our process

• Malaria Consortium and BIT sent us a proposal for their “Be in a Net” project.
• We had three calls with Malaria Consortium and BIT to discuss the project and followed up via email about additional questions.
• The case for the grant was reviewed by multiple individuals at GiveWell.
• We did not do preliminary cost-effectiveness modeling for this grant due to the time sensitivity issues discussed above and because we felt that, given the level of uncertainty about several key parameters, quantitative modeling at this stage would not be useful.

Relationship disclosures

Two GiveWell staff members worked on an early-stage proposal for this project at BIT before joining GiveWell. Neither of these staff members was involved in GiveWell’s grant investigation.

Sources

Document	Source
BIT, “The Behavioural Insights Team”	Source (archive)
BIT, "Who we are"	Source (archive)
Boulay, Lynch, and Koenker, 2014	Source
Bowen 2013	Source
GiveWell, All Content on Malaria Consortium's Seasonal Malaria Chemoprevention Program	Source
GiveWell, Malaria Consortium — Support for LLIN Distribution Campaigns in Ondo and Anambra States, Nigeria (March 2021)	Source
GiveWell, Mass Distribution of Insecticide-Treated Nets (ITNs)	Source
GiveWell, Our Top Charities	Source
GiveWell's CEA of insecticide-treated net (ITN) distributions	Source
Global Fund, "Malaria."	Source (archive)
Global Fund, "What is Replenishment?"	Source (archive)
Global Fund, Information Note: Malaria, 2022	Source
Kilian et al., 2016	Source
Malaria Consortium and Behavioral Insights Team, call with GiveWell, January 12, 2024	Unpublished
Malaria Consortium and the Behavioural Insights Team, Behavioural Insights to accelerate net use: The Be in a Net Project, 2023	Source
Malaria Consortium and the Behavioural Insights Team, call with GiveWell, January 19, 2024	Unpublished
Malaria Consortium, Revised grant budget, May 2024	Source
Malaria Consortium, Revised grant timeline, January 2024	Source

• 1

  $1,380,437 was funded by donations to the All Grants Fund and $100,000 was funded by an individual donor.

• 2
  • “Founded in 2010, the Behavioural Insights Team has grown from a seven-person unit at the heart of the UK government to a global social purpose company of over 200 professionals across many offices around the world. In December 2021 we became wholly-owned by innovation charity Nesta.” BIT, “Who we are”
  • “At BIT, we improve lives and communities by helping all levels of government, private sector and philanthropy businesses tackle their biggest challenges. We offer a selection of behavioural science consultancy and services to help clients across multiple sectors to gain an understanding of their audience and create strategies that will help them to scale their business effectively.” BIT, “The Behavioural Insights Team”

• 3

  Malaria Consortium and Behavioural Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 4
  • “We estimate that 63% of nets distributed in GiveWell-funded campaigns are used.” GiveWell, Mass Distribution of Insecticide-Treated Nets (ITNs), December 2023
  • Definitions of net use vary. We define use as the proportion of distributed nets which are hung.
  • We factor estimated use rates into our cost-effectiveness analysis of nets here.

• 5

  See the “Methodology” section of Malaria Consortium and BIT’s initial proposal, pgs 10-12. Note that some details of the “Be in a Net” project have changed since the initial proposal was developed. Malaria Consortium and the Behavioural Insights Team, Behavioural Insights to accelerate net use: The Be in a Net Project, 2023.

• 6

  The piloting step was added after the submission of Malaria Consortium and BIT’s initial proposal as a result of discussions between Malaria Consortium, BIT, and GiveWell. Malaria Consortium and the Behavioural Insights Team, call with GiveWell, January 19, 2024 (unpublished).

• 7

  Malaria Consortium, Revised grant timeline, January 2024.

• 8
  • Malaria Consortium, Revised grant budget, May 2024
  • Note that the broken down costs are rounded and, as whole numbers, do not add up to the exact grant amount.

• 9

  $20,128 for “Outcome 1” + $117,232 for “Outcome 2” + $294,518 for “Outcome 3” = $431,878. Malaria Consortium, Revised grant budget, May 2024.

• 10

  $6,459 for “Travel Costs” + $5,270 for “Equipment and Supplies” + $43,334 for “Other Direct Costs” + $95,197 for “Overheads” = $150,260. Malaria Consortium, Revised grant budget, May 2024

• 11
  • During the investigation, Malaria Consortium and BIT expressed confidence that a meaningful behavioral intervention in this context could have a delivery cost of well under $1 per household. Across the net campaigns we’ve supported, we typically estimate a cost per net of around $4-6. Malaria Consortium and Behavioural Insights Team, call with GiveWell, January 12, 2024 (unpublished).
  • Additionally, we expect future net campaigns to increasingly use next-generation pyrethroid-chlorfenapyr nets following their recommendation by the World Health Organization in 2023. These nets will likely be both more expensive and more effective than the nets currently being distributed. If that’s the case, this may increase the marginal cost-effectiveness of any intervention that increases net use because 1) the effectiveness of the nets would be higher and 2) the cost of the intervention relative to the cost of the net would be lower.

• 12
  • In their proposal, Malaria Consortium and BIT cited studies suggesting that embedding behavioral change elements into communications components of nets distribution campaigns can increase ITN use by 12-17 percentage points. We have not deeply looked into these studies or done a full review of the relevant literature. Malaria Consortium and the Behavioural Insights Team, Behavioural Insights to accelerate net use: The Be in a Net Project, 2023, pg 7.
    • “The PSM model estimated that among Cameroonians with at least one net in their household, exposure to KO Palu NightWatch activities was associated with a 6.6 percentage point increase in last-night net use among respondents (65.7% vs 59.1%, p < 0.05) and a 12.0 percentage point increase in last-night net use among respondents’ children under five (79.6% vs 67.6%, p < 0.025).” Bowen 2013, Abstract.
    • “This paper uses two analytic approaches, propensity score matching and treatment effect modelling, to examine the relationship between exposure to the BCC messages and the use of a bed net the previous night … When matched on similar propensity scores, a statistically significant 29.5 percentage point difference in ITN use is observed between exposed and unexposed respondents. … A smaller but similarly significant difference between exposed and unexposed groups, 12.7 percentage points, is observed in the treatment effect model, which also controls for the number of bed nets owned by the household and exposure to malaria information from health workers.” Boulay, Lynch, and Koenker, 2014, Abstract.
    • “All [behaviour change communication] outcomes showed a significant increase in net use, which was strongest for the confidence to take action regarding nets with an overall effect of 17 %-point increase of net use comparing poor and excellent confidence levels. Intention to use every night increased net use by 15 %-points and discussing net use in the family by 8 % points. All these effects were statistically significant (p < 0.001).” Kilian et al., 2016, Abstract.

• 13
  • The Global Fund is a large funder of malaria control programs that provides funding to country governments in three-year cycles:
    • "The Global Fund provides 65% of all international financing for malaria programs and has invested more than US$17.9 billion in malaria control programs as of June 2023." Global Fund, "Malaria."
    • The Global Fund raises and invests money in three-year cycles known as Replenishments. This three-year approach was adopted in 2005 to enable more stable and predictable financing for countries and to ensure ongoing program continuity. In September 2022, we launched our Seventh Replenishment fundraising cycle, which will run from 2023-2025. Global Fund, "What is Replenishment?"
  • Malaria Consortium told us that, in the event of positive RCT results, it plans to work with national malaria programs in Nigeria and Uganda to incorporate the intervention in their next round of applications to the Global Fund. Malaria Consortium and Behavioural Insights Team, call with GiveWell, January 12, 2024 (unpublished).
    • The Global Fund will consider funding for evidence-based behavioral interventions to accompany core programming. See Global Fund, Information Note: Malaria, 2022, pp. 12, 27: "It is expected that the ITNs program will be sub-nationally tailored, as appropriate to variations in epidemiology, vector profile (including insecticide resistance), historical ITN durability and/or attrition, population behaviors etc. Sub-national variations may include type of ITN, ITN distribution approach, frequency of ITN distribution, social and behavior change activities (SBC), or other relevant program areas… Investments in SBC need to be evidence-based, results-oriented, theory-informed and part of the national malaria SBC strategy."
  • Malaria Consortium also told us that other countries could incorporate the intervention into their Global Fund applications as well, with some tweaks for local context and piloting to confirm operational feasibility. Malaria Consortium and Behavioural Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 14

  Malaria Consortium and Behavioural Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 15

  Malaria Consortium and the Behavioural Insights Team, call with GiveWell, January 19, 2024 (unpublished).

• 16

  Malaria Consortium and Behavioural Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 17

  “The study sites and timing of the intervention will be determined by the existing schedule of ITN distributions in the study countries during round six and seven campaigns. The cRCT will be conducted as close to the distribution as possible…” Malaria Consortium and the Behavioural Insights Team, Behavioural Insights to accelerate net use: The Be in a Net Project, 2023, pg 12.

• 18
  • Malaria Consortium and Behavioral Insights Team, call with GiveWell, January 12, 2024 (unpublished).
  • We assume that the number of nets retained in homes in a given area goes down over time (for example, if nets are damaged and thus discarded), with the highest retention rates occurring directly after distribution. If an RCT were to begin more than 18 months after distribution, the number of households still owning nets may be too low to provide appropriate statistical power to an RCT attempting to increase net use among households that have a net.

• 19

  Malaria Consortium and Behavioral Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 20

  Malaria Consortium, Revised grant timeline, January 2024

• 21

  Malaria Consortium and Behavioral Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 22

  Malaria Consortium and Behavioral Insights Team, call with GiveWell, January 12, 2024 (unpublished)

• 23

  Malaria Consortium and Behavioral Insights Team, call with GiveWell, January 12, 2024 (unpublished).

• 24

  Malaria Consortium and the Behavioural Insights Team, call with GiveWell, January 19, 2024 (unpublished).

• 25

  We made this prediction in February 2024.