Malaria Consortium — SMC Renewals in Nigeria, Burkina Faso, Chad and Togo (January - October 2024)

Note: This page summarizes the rationale behind GiveWell-recommended grants to Malaria Consortium to support implementation of seasonal malaria chemoprevention (SMC) programs that provide children with antimalarial medicines. Malaria Consortium staff reviewed this page prior to publication.

Instead of publishing individual grant pages, as we have done in the past, we're now maintaining a single grant page for renewals that we have recommended for more than one year. At the top of the page, we present the key case for all renewal grants to Malaria Consortium's SMC programs in Nigeria, Burkina Faso, Chad, and Togo, and include below the key considerations unique to individual renewal grants beginning in 2024. See the table at the bottom of the page for a list of all the pages we've published on grants recommended to support SMC in Nigeria, Burkina Faso, Chad, and Togo.

See our assessment of the effectiveness of SMC in our intervention report and an assessment of Malaria Consortium's program here.

Published: November 2024; Last updated: January 2025

Overview of SMC renewal grants in the Sahel

The organization

Malaria Consortium works on preventing, controlling, treating, and eliminating malaria and other communicable diseases.5 It was established in 2003 and, as of 2024, works in 14 countries across Africa and Southeast Asia.6

Malaria Consortium’s seasonal malaria chemoprevention (SMC) program is one of GiveWell’s top charities. Malaria Consortium uses GiveWell funding to (among other things) buy the medicines used in SMC, train community distributors to deliver the medicines door-to-door, and conduct monitoring to understand what proportion of children are reached. As of August 2024, GiveWell has also funded Malaria Consortium to deliver insecticide-treated net (ITN) campaigns to control malaria in two states in Nigeria (details on a separate page).

More information about our recommendation of Malaria Consortium’s SMC program, our qualitative assessment of Malaria Consortium as an organization, and a review of the monitoring and evaluation data it shares can be found in our top charity report.

The intervention

Seasonal malaria chemoprevention (SMC) involves giving children monthly courses of antimalarial medicines in locations where malaria is highly seasonal (i.e., a high proportion of cases occur in a relatively short period each year). SMC is delivered to all eligible children in a given location.7 The antimalarial medicines used are sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ).8

SMC is delivered in cycles at 28-day intervals. Each cycle involves giving children four doses of medicine over three days. Trained community distributors give children the first day’s doses (SP and AQ) directly, and give the doses for days two and three (AQ only) to the child’s caregiver to administer themselves.9 Each annual season of SMC (usually four or five cycles depending on the location) is referred to as a “round.”10 The World Health Organization (WHO) has recommended SMC for deployment since 2012.11 An estimated 2.6 million children were reached with SMC in 2014, rising to approximately 49 million in 2022.12

Our cost-effectiveness analysis models three main benefits from SMC:

• Reduced mortality for children under age five (more). The main impact of SMC is reduced malaria mortality for children under the age of five. We base our estimate of this impact on our review of a Cochrane meta-analysis, Meremikwu et al. 2012. We estimate that the reduction in malaria cases among children who received SMC in the studies in the Cochrane meta-analysis was 79%.13 We also estimate a 1:1 ratio between reduced malaria cases and reduced malaria deaths,14 implying that SMC reduces malaria deaths among children receiving SMC by 79% in the SMC season.
• Reduced mortality for older children and adults, from reduced malaria transmission in the community (more). Delivering SMC to children under five also disrupts malaria transmission, reducing malaria in the wider (untreated) population. We estimate SMC reduces malaria deaths by approximately 11% among older children and adults, accounting for a small portion of the total modeled benefits of SMC in the Sahel.15 This analysis relies on our review of Cissé et. al. 2016, which found that malaria cases in the untreated population in areas receiving SMC in a given transmission season fell by 26% compared to people in areas not receiving SMC.16
• Increased long-run income, from improved health in a sensitive developmental window of childhood (more). Our best guess is that averting childhood malaria cases leads to small income gains in adulthood. This contributes a substantial share of our estimated benefits for malaria programs.17 This analysis relies on two studies of historical malaria eradication campaigns: Bleakley 2010 and Cutler et. al. 2010. These studies are summarized in detail in our separate report on insecticide-treated nets.

A summary of the contributions of each type of benefit to our estimate of the modeled value of the program is below, using Bauchi, Nigeria as an example.18

For a full overview of how we model these benefits, as well as additional benefits and downsides to SMC that we account for in our model, see our SMC intervention report.

The case for grants to support SMC in the Sahel

We have made renewal grants to Malaria Consortium to support SMC in the Sahel on an annual basis for several years (see below). We continue to recommend grants to Malaria Consortium to deliver SMC in the Sahel because we believe it is a highly cost-effective intervention and because Malaria Consortium has a strong track record of delivering SMC in the region.

When making renewal grants for SMC in the Sahel, we aim to provide Malaria Consortium with three years of funding runway. 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.

High cost-effectiveness

The general reasons we think that SMC in the Sahel is cost-effective are:

• Malaria is a major cause of child mortality in the Sahel. We estimate that the chance that a 3-59 month old child (the main target group for SMC) will die as a result of malaria is around 0.3% to 0.7% per year in the Sahel.19 We rely primarily on malaria-specific mortality estimates from the Global Burden of Disease (GBD) Model, which we think are broadly in line with World Health Organization (WHO) estimates, another widely used source.20 We then adjust these estimates upward because we think malaria indirectly causes 0.75 deaths from other causes for every direct malaria death. This is based on evidence that malaria control programs often have larger impacts on mortality than would be expected from their impact on malaria alone.21
• SMC is effective at preventing malaria. We estimate that receiving SMC reduces malaria mortality by 79% during the period when it is delivered, and that reduced malaria cases translate 1:1 into reduced malaria deaths.22 Our impression is that SMC is widely viewed in the global health community as an effective program, strengthening our confidence in these estimates.
• SMC is a highly targeted program. It is delivered to a group at high risk of malaria (young children) in areas where malaria transmission is highly seasonal and during the period of time in which the majority of malaria deaths occur.23 We think this targeted program design contributes to its cost-effectiveness.
• It is relatively cheap to reach children with SMC. We estimate that it is relatively inexpensive to reach a child with all their recommended cycles of SMC.24 Intuitively, reasons for SMC being relatively cheap include the affordability of the drugs used and the door-to-door campaign approach used by Malaria Consortium reaching a high proportion of targeted children.25 Our estimate of the total cost to reach a child with all recommended cycles of SMC is based on 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.26
• SMC probably provides significant benefits beyond averting child mortality. In particular, we think that by averting malaria during a sensitive period of childhood development, it could improve children’s income in later life. This is based on two studies that find historical malaria eradication campaigns led to long-term increases in income. We use a combined estimate from these studies and discount this by 70% to reflect our uncertainty about the quality of this evidence. Even with this discount, we estimate that approximately 15% to 35% of the total modeled benefits of SMC come from increased income rather than averted deaths.27
• GiveWell funding increases the proportion of people protected by SMC. Without campaigns like the ones GiveWell funds, we estimate that virtually no children would get SMC from other sources. This is because campaigns are the only form of SMC delivery we have heard about, and our understanding is that WHO recommends that national governments prohibit the private sale of the SMC drugs in areas implementing SMC.28 We think it’s more likely that another funder would replace GiveWell’s funding for SMC campaigns in our absence, since we think SMC is a high priority for funders and national malaria programs. Our adjustment for diverting other actors’ spending away from SMC lowers cost-effectiveness,29 but we think SMC remains cost-effective even after attempting to account for this possibility.30

Malaria Consortium as a grantee

Malaria Consortium has used GiveWell-directed funding to support SMC programs in Burkina Faso and Nigeria since 2017 (and it previously supported SMC programs in both countries with non-GiveWell-directed funding).31 Malaria Consortium has a more limited track record in Togo, where it began supporting SMC in 2021.32

Our qualitative assessment of Malaria Consortium as an organization is highly positive. We previously rated it as "relatively strong" or higher on all seven of the dimensions for which we gave a rating in our most recent qualitative assessment.34 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.

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). 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.

We discussed our reasoning for these adjustments in detail on our 2022 and 2023 SMC Sahel renewal grant pages, and quantified them in this spreadsheet. We have continued to learn more about the SMC funding landscape; though we do not believe our current assessment warrants major changes to our 2022 estimates, we may revisit this in the future. The factors currently informing our understanding of the funding landscape are:

• Malaria funding appears to be plateauing. The Global Fund, which has historically been the largest funder of SMC, underwent its latest three-year funding “replenishment” in late 2022 (for interventions to be delivered in 2024-2026). The total value of the replenishment was $15.7 billion, compared to a target of at least $18 billion.35 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).36 The funding available for malaria was also relatively stable.37 By contrast, the funding available for malaria increased substantially between the 2018-2020 and 2021-2023 replenishments.38 We include an adjustment in our estimates for the increased level of funding between the 2018-2020 and 2021-2023 replenishments,39 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 2024-2026 grant period because of factors including population growth, inflation, and the introduction of new interventions. As a result, we think that funding gaps for SMC for the foreseeable future are likely to be similar to or larger than those in the previous 2021-2023 grant period.
• Low risk of crowding out funding in Nigeria (which represents three quarters of the total population Malaria Consortium targets with philanthropic funding across Nigeria, Burkina Faso, Chad, and Togo).40 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.41 Six of the Nigerian states we support (Bauchi, Kebbi, Nasarawa, Plateau, Oyo, and Sokoto states) are PMI-supported; the others (FCT, Kogi, and Borno) are intended to be supported by loan financing (GiveWell-directed funding does not support SMC in Global Fund-supported states in Nigeria).42 We think there is a small but non-negligible risk (20%) we are crowding out funding in PMI-supported states based on the following:
  • PMI’s budget for Nigeria has trended down between 2020 and 2024, fluctuating between $77 million (2020) and $68 million (2024) over this period.43 We interpret this as evidence that PMI is funding-constrained for malaria; for example, we know that mosquito net campaigns in PMI states have been occurring every four or five years rather than the recommended 36 months due to a lack of funding.44 However, it is possible that continued availability of GiveWell funding over the long term has led to crowding out of PMI malaria funding in Nigeria (see more on this below).
  • PMI expanded its support for SMC to a state (Benue) in 2022 where no funder had been supporting SMC, which we interpret as a demonstration of PMI’s willingness to prioritize funding SMC in PMI-supported states.45 We think this increases the risk that we are crowding out PMI funding for SMC.

  We think there is a somewhat lower chance (10%) that development loan financing, or funding from other sources, would be used to support SMC in states not receiving Global Fund or PMI support for malaria control: 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.46

• Moderate risk of crowding out funding in Burkina Faso and Togo (which represents one quarter of the total population Malaria Consortium targets with philanthropic funding across Nigeria, Burkina Faso, Chad, and Togo).47 We think there is a relatively high risk that our support could be crowding out funding that would otherwise have gone to support SMC programs in Togo (65% chance) and Burkina Faso (50%). See details on our reasoning and why we continue to think these programs are cost-effective funding opportunities in our risks and reservations below.
• Moderate risk of long-term funding availability crowding out future funds – GiveWell has been a consistent funder of SMC since 2017. It is possible that the long-term availability of GiveWell funding in increasingly larger amounts has given national malaria programs and other funders confidence to allocate funding to other programs that may have otherwise gone to SMC. We roughly assume that long-term GiveWell funding availability increases the risk that our grants are crowding out SMC funding by 20 percentage points across all countries, though we are unsure if this fully captures the dynamics of how our grantmaking interacts with other funders' behavior.48 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.

Risks and reservations

Overall, we are confident that the case for SMC is strong, and we have relatively few significant reservations (even compared to GiveWell’s other top charities). However, we still have several open questions that we outline in more detail in our intervention report. Below, we outline the biggest uncertainties we have about SMC in the Sahel.

Moderate risk of crowding out funding in Burkina Faso and Togo

We think the risk that GiveWell support crowds out funding from other sources is higher in Burkina Faso and Togo than it is in Nigeria.49 This is because SMC has been fully funded in Burkina Faso and Togo since at least the 2021-2023 Global Fund grant cycle,50 suggesting to us that if Malaria Consortium did not begin supporting the country's SMC program, the national malaria programs in these countries may have chosen to direct more of their Global Fund malaria allocation to SMC.51 Even after quantifying this risk, the programs still appear cost-effective, and we think that plateauing malaria funding and increasing malaria funding needs may result in a decreased risk of crowding out funding going forward. We plan to continue to speak with key stakeholders (from Global Fund, World Bank, PMI) to learn more about the risk that our support is crowding out other actors in both countries.

Uncertainties in our cost-effectiveness model

The sources of uncertainty that we think could most materially impact our assessment of SMC cost-effectiveness are:

• The malaria mortality rate for children not receiving SMC (more). We estimate that there is around a 0.3% to 0.7% risk that a child not receiving SMC will die from malaria or associated causes each year in the Sahel.52 Our cost-effectiveness model is highly sensitive to this input, which is based on two estimates that we think each have wide ranges of plausible values:
  • Baseline mortality estimates from the Institute for Health Metrics and Evaluation (IHME)'s 2019 Global Burden of Disease (GBD) model. Our estimates of annual malaria mortality for children under five are drawn from the Institute for Health Metrics and Evaluation (IHME) Global Burden of Disease (GBD) project.53 We use the 2019 GBD national-level estimate for malaria mortality among children under five. These estimates are a source of significant uncertainty in our analysis. Our understanding is that the GBD estimates rely on a number of modeling assumptions,54 in part because raw data on malaria from health surveillance systems is relatively unreliable in many low-income countries.55 We have not investigated all the modeling assumptions underlying these estimates in detail and we’re not sure how accurately GBD can attribute deaths to specific causes.
  • Non-malaria deaths indirectly averted by SMC: Malaria control interventions often have a larger effect on all-cause mortality than would be expected exclusively from declines in malaria-specific mortality.56 Deaths may have several causes, while only being attributed to one cause. For example, malaria may increase the likelihood of death from malnutrition or other infectious diseases.57 We account for this with an estimate that for each death directly caused by malaria, an additional 0.75 deaths are indirectly caused by malaria. We are uncertain about what the exact value for this effect should be; we think it's similarly plausible that the value for this adjustment could be as low as 0.5 or as high as 1, which implies a ~12% reduction to a ~12% increase in cost-effectiveness estimates across countries.58 Our estimate is based on triangulating results from a meta-analysis of the effects of nets on all-cause mortality, conversations with malaria experts, and the effects that other health interventions have on averting indirect deaths.59
• The impact of malaria reduction on long-run income (more). As above, our SMC cost-effectiveness model includes an estimate of the income benefits that children accrue in later life via reduced malaria exposure. We are uncertain about this estimate, which is drawn from historical quasi-experiments and for which we have no data from randomized controlled trials. We discuss our uncertainties about the long-term impact of malaria on income in more detail in our report on insecticide-treated nets.

Smaller sources of uncertainty

• The proportion of malaria mortality in the high transmission season (more). Our cost-effectiveness model uses a rough estimate that 70% of direct malaria mortality in countries in the Sahel falls within the high transmission season. 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%.60 We then adjust this modestly downwards because our best guess is that, on average, the SMC campaign locations in the Sahel that we have supported have a less seasonal pattern of malaria transmission than those included in the 2012 paper.61 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 impact of receiving SMC (more). As above, we estimate that the reduction in malaria cases among children who received SMC in the studies in the Cochrane meta-analysis was 79%. However, it’s possible that SMC provides indirect benefits to people who don’t receive SMC by reducing malaria transmission in the wider community. Our model does not fully account for these "spillover effects." It’s also possible that coverage levels found in these trials may be overestimated. We think both of these uncertainties could lead us to underestimate the effect of SMC on mortality.62
• Cost per cycle of SMC (more). We calculate the cost per cycle (CPC) of SMC delivered in each country based on the number of SMC cycles delivered by previous Malaria Consortium-supported SMC programs, costs incurred by Malaria Consortium, and costs incurred by other actors. We divide total costs by total cycles delivered to obtain the estimated cost per cycle in each country. This spreadsheet contains our full calculations. We have several uncertainties about some of the parameters that inform these calculations, which we outline in more detail in our intervention report.
• The counterfactual value of Global Fund spending (more). 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.63 This is an imperfect exercise, and we therefore have low confidence in the specific value we estimate.

Individual grant renewals since Q1 2024

SMC Renewal in Chad—Q4 2024

Published: January 2025

Background

Malaria Consortium began supporting SMC delivery in Chad as part of the Unitaid-funded ACCESS-SMC project in 2015, and has been using GiveWell-directed funding to support SMC in Chad since 2017.64 In 2023, GiveWell chose not to recommend renewing funding for Malaria Consortium's SMC program in Chad because we assessed it to be below our funding bar for cost-effectiveness. We provided $6.5 million in exit funding to support the program in 30 health districts of Chad through 2024.65
Since we announced our exit decision, Malaria Consortium has told us that the Global Fund has allocated funding to support SMC in 20 of these health districts in 2025-2027, leaving the remaining 10 districts unfunded. As a consequence, the Global Fund has not allocated funding to 29 other SMC-eligible districts that it had supported during the previous funding cycle.66 In total, 102 SMC-eligible health districts in Chad are expected to be unfunded in 2025 (92 districts once this grant has been accounted for).67

Planned activities and budget

This $3.4 million grant provides two additional years of support for SMC in ten districts of Chad within Bahr el Ghazal and Mayo-Kebbi Est regions for the 2025 and 2026 seasons. GiveWell previously provided $6.5 million in exit funding to support SMC in thirty districts of Chad, including the ten districts supported by this grant, for the 2023 and 2024 seasons.

This grant will fund the following activities (see budget for more details):

• $0.8 million to purchase and transport SMC medications and other necessary commodities
• $0.9 million to plan, execute, and supervise SMC campaigns
• $0.2 million to conduct monitoring and evaluation
• $0.7 million to pay Malaria Consortium staff and consultants
• $0.6 million to cover Malaria Consortium's overhead and other indirect costs
• $0.2 million to conduct research and to support shifting towards digitalized campaigns

The case for the grant

We set out a general case for grants to support SMC in the Sahel above, and this continues to form the basis of the case for this grant:

• High cost-effectiveness. At the time of writing this page, GiveWell's funding bar for grants to our Top Charities is grants we estimate to be 8 times ('8x') as cost-effective as unconditional cash transfers (GiveWell's benchmark for comparing different programs).68 Our cost-effectiveness estimate for the program is currently 13x, as of this page's publication. See more on the cost-effectiveness of SMC programs in general here. See more on the cost-effectiveness of this grant in particular below.
• We think it's unlikely that another funder will step in to support SMC in these districts. Given that we announced exit funding in 2023, our understanding is that the Global Fund and other funders have made their allocation decisions under the assumption that there would be no additional GiveWell funding. Our previous grant to Malaria Consortium funded SMC in 30 districts of Chad. Of these, the Global Fund has provided funding for 20 districts for the 2025 season. The remaining 10 will be supported by this grant.
• We think making this grant now could enable us to expand our support for SMC in Chad in the future. In addition to the 10 districts supported by this grant, there are another 92 districts eligible for SMC in Chad that have not received funding for the 2025 season.69 Malaria Consortium told us that expanding its support to additional districts would not be possible on such a short timeline, but we may consider supporting expansion for future years. We think supporting Malaria Consortium's presence in Chad in these 10 districts for the 2025 and 2026 seasons will make it easier to support SMC in a larger number of districts in the future.

Cost-effectiveness

We estimate that this grant will be 13x as cost-effective as unconditional cash transfers (GiveWell's benchmark for comparing different programs). When we decided to provide exit funding for SMC in Chad in 2023, we assessed the program to be below our cost-effectiveness bar. We changed our minds about funding this program for two reasons: (1) our cost-effectiveness bar for Top Charity programs is lower now than it was when we decided to exit, and (2) our cost-effectiveness estimate for the program is higher.

We've re-evaluated the cost-effectiveness of the program

Since deciding to exit in 2023, we have made a number of updates to our cost-effectiveness analysis (CEA) that have increased our estimate of the program's cost-effectiveness. At the time of our exit decision, we estimated the program to be 6x as cost-effective as unconditional cash transfers. Our estimate at the time of publishing this page is 13x.

Our updated view on the cost-effectiveness of the program in Chad is primarily based on additional research we've done into malaria mortality:

• National malaria mortality in Chad. Previously, we had based our estimate of child malaria mortality in Chad on the Institute for Health Metrics and Evaluation (IHME)'s 2019 Global Burden of Disease project (GBD) model, which estimated a malaria mortality rate of 0.14% for children under 5 in Chad.70 However, we've since discovered that an alternative burden model created by the UN Inter-agency Group for Child Mortality Estimation (UN IGME) attributes more than twice as many child deaths to malaria in Chad as IHME's GBD model. At this point, we do not understand the methodology behind either model well enough to feel confident fully relying on one or the other, so we've put some weight on each and arrived at an estimated child malaria mortality rate of 0.23%.71
• Subnational malaria mortality in targeted regions. We've also looked into subnational malaria mortality estimates modeled by UN IGME and the Malaria Atlas Project, which suggest that malaria mortality is ~10% higher on average in Bahr El Ghazal and Mayo-Kebbi Est, the regions encompassing the districts supported by this grant, than in Chad overall.72 This brings our malaria mortality estimate up to 0.25%.
• Deaths indirectly caused by malaria. We believe that malaria interventions prevent some deaths from other causes in addition to malaria deaths.73 We previously estimated that for every death directly caused by malaria, there are 0.5 deaths indirectly caused by malaria. We now estimate the number of indirect malaria deaths per malaria death to be 0.75. For more information on our reasoning, see our full report on SMC. After accounting for deaths indirectly caused by malaria, our estimated malaria mortality rate is 0.42%. With this baseline, when we adjust for malaria vaccination rates, our estimate of malaria mortality in Chad is currently 0.41%.

We've lowered our cost-effectiveness bar for Top Charity programs

When we decided to provide exit funding for SMC in Chad in 2023, we assessed the cost-effectiveness of the program to be below our funding bar (which, at the time, was 10x as cost-effective as unconditional cash transfers). We've since lowered our funding bar for Top Charity programs to 8x as cost-effective as unconditional cash transfers (our bar remains 10x for programs that are not Top Charities).

Risks and reservations

Our main reservations about this grant are:

• We're very uncertain about malaria mortality in Chad. The malaria burden sources we've looked at diverge significantly on malaria mortality in Chad, and the amount of weight we choose to put on each source significantly changes our cost-effectiveness estimate for the program. However, we estimate that the program would meet our cost-effectiveness bar even if we relied exclusively on the mortality rate from GBD 2021, the lower of the two mortality estimates we've seen.
• Malaria mortality might be lower in Bahr El Ghazal. The sources of subnational malaria burden estimates in Chad we've looked at suggest that malaria mortality may be significantly lower in the Bahr El Ghazal region than in the country overall.74 Districts in Bahr El Ghazal make up roughly one third of the total target population for this grant. It's possible it would be more cost-effective to exclude support for Bahr El Ghazal from this grant, though we are not confident this would be the case. We also expect that a smaller-scale program covering only Mayo-Kebbi Est and not Bahr El Ghazal would cost more per person reached, which would make the program less cost-effective.
• Reversing an exit decision could be seen by partners as irresponsible. Our understanding is that the announcement of our exit decision in 2023 caused Global Fund and other partners in Chad to restructure their SMC investments in the country, ultimately leading to a number of districts no longer receiving support beginning in 2025. Though we did not take lightly our initial exit grant or this subsequent decision to continue providing support, we understand there is a risk that partners could perceive GiveWell as irresponsible or indecisive. We hope to mitigate this risk somewhat by speaking directly and candidly with key stakeholders about the motivations behind our initial decision to exit and our reversal of that decision.

Plans for follow up

• We will continue to engage with the Global Fund to better understand their prioritization process for allocating SMC funding to districts within Chad and to better understand how SMC funding will be allocated during the Global Fund's next funding cycle (2027-2029).
• We will continue to have monthly calls with Malaria Consortium to discuss its work.
• We will request that Malaria Consortium submit spending reports and coverage surveys for the 2024, 2025, and 2026 campaigns in Chad, as it has for all previously funded campaigns. We will update our cost-effectiveness estimates for the program based on this reporting.
• We will have biannual calls with Malaria Consortium with the explicit goal of understanding how SMC implementation is going, including in Chad.
• We will consider the possibility of expanding Malaria Consortium's SMC program in Chad to additional districts.

Internal forecasts

For this grant, we are recording the following forecasts:

Our process

As this was a small renewal grant to one of our Top Charities, this was a relatively light-touch investigation that primarily centered around updating our cost-effectiveness analysis in light of new information from Malaria Consortium and new internal research into malaria burden in Chad.

As part of this grant investigation we:

• Initially communicated to Malaria Consortium that we were unlikely to renew funding for SMC in Chad (July, 2024), but discovered upon further internal research that we may have been underestimating malaria mortality in Chad (September, 2024).
• Conducted additional internal research on malaria mortality in Chad, updated the mortality assumptions in our cost-effectiveness analysis, and consulted with an external expert to sense-check these assumptions (September, 2024).
• Reviewed Malaria Consortium's proposed budget, updated funding proposal, and target population estimates for the program and used this information to update our estimate of the cost per SMC cycle delivered and our assessment of funging risk (October, 2024).

SMC Renewal in Nigeria, Burkina Faso, and Togo—Q1 2024

Planned activities and budget

Malaria Consortium uses GiveWell-recommended funding to support SMC delivery in Nigeria (Bauchi, Federal Capital Territory, Kebbi, Kogi, Nasarawa, Oyo, Plateau, Sokoto, and Borno states), Burkina Faso, and Togo. We think that Malaria Consortium holds sufficient funding (from previous GiveWell grants75 and other funding sources) to maintain its current scale (as of 2023) of support to SMC programs in Nigeria, Burkina Faso, and Togo through 2025.76 This new $73.5 million grant extends the program’s funding runway in all three countries through 2026.77 It consists of:78

• $59.9 million for Nigeria (81% of the grant). This includes:
  • $48.3 million (66% of the grant) to maintain the current scale (as of 2023) 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 2026.
  • $1.7 million (2% of the grant) for two additional local government areas (LGAs) in Bauchi State in 2026. These LGAs are currently funded by the Korea International Cooperation Agency (KOICA), with funding that Malaria Consortium expects will not be renewed after 2024.79
  • $9.9 million (13% of the grant) to fund two additional years of Malaria Consortium’s support for the SMC program in Borno State (2024-2025). 2024 will be the fourth 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 SMC in Borno (more below).
• $11.5 million for Burkina Faso (16% of the grant). This includes one additional year of funding to maintain the current scale (as of 2023) of Malaria Consortium's support to the program in Burkina Faso through 2026.
• $2 million for Togo (3% of the grant). This includes one additional year of funding to maintain the current scale (as of 2023) of Malaria Consortium's support to the program in Togo through 2026.

The activities that Malaria Consortium would conduct with these grants are described in this section of our review of Malaria Consortium's program.

The case for the grant

We set out a general case for grants to support SMC in the Sahel above, and this continues to form the basis of the case for the 2024 grant:

• High cost-effectiveness (more). At the time of writing this page, GiveWell’s funding bar is to support grants to our top charities that we estimate to be 8x or more as cost-effective as unconditional cash transfers (GiveWell’s benchmark for comparing different programs).80 Our cost-effectiveness estimates at the time we made the grant surpassed this bar:

To generate these estimates, we used our most recently published cost-effectiveness model for SMC campaigns. Cost-effectiveness estimates in this model have increased since we last made a grant to support SMC in these contexts, primarily due to:

• Our estimate of indirect deaths per malaria death, which we increased from 0.5 to 0.75. We remain uncertain about the exact value of this input, but we’ve spoken with malaria experts who told us that it is widely accepted there are roughly 0.5 to 1 indirect malaria deaths for every direct malaria death. We use a value of 0.75, the midpoint of this range.81
• Our supplemental intervention-level adjustment for medical treatment costs averted, which we increased from 6% to 20%. We include an adjustment for “treatment costs averted from prevention” because we think it’s likely that reduced disease morbidity and mortality resulting from SMC leads to reductions in medical costs borne by governments and recipient households. We recently created a model to estimate medical costs averted that updates our estimate of the “treatment costs averted from prevention” to 20%.

An example sketch of our cost-effectiveness model for SMC grants in the Sahel can also be found above.

• High SMC coverage rates (more). In 2022, average coverage across cycles was 87% to 92% in areas of Burkina Faso and 92% in Nigeria and Togo.82 Though finalized coverage survey data for the 2023 SMC season was not available at the time we recommended this grant, Malaria Consortium told us that there were no substantial differences in implementation between 2022 and 2023.83
• Low risk of crowding out funding in Nigeria (more). Programs in Nigeria represent over 80% of this grant's costs ($59.9 million of $73.5 million). We think that only a small portion of this $59.9 million would be funded by other sources in the absence of GiveWell funding due to what we believe are large malaria funding constraints of other major funders in Nigeria. We assume a 10% to 20% chance that another funder would replace our funding in the Nigerian states we are currently supporting.84

Funding for 2024 and 2025 SMC campaigns in Borno

The funding for Borno included in this grant ($9.9 million) is filling a time-sensitive funding gap that we think is unlikely to continue past 2025.85 We initially filled the funding gap in Borno in the 2021 SMC season because Malaria Consortium informed us that a World Bank loan that was intended to support malaria services in Borno was delayed.86 We subsequently funded Malaria Consortium to deliver SMC in Borno in 2022 and 2023 because this funding was further delayed.87 In 2024, our understanding is that the delay resulted from challenges in meeting World Bank requirements for selection of an implementing partner for SMC in Borno. As of March 2024, SMC drugs had still not been procured for the campaign set to begin in June.88 As a result, we have high confidence that SMC would not be delivered in Borno in 2024 without our support.89

We’ve also opted to include funding for the 2025 SMC campaign in Borno in this grant despite moderate risk of funging (more below). This is because Malaria Consortium told us that committing to supporting the 2025 campaign now will enable it to:90

• Have sufficient time to procure SMC drugs and plan the 2025 campaign. Drug procurement typically begins roughly 10 months in advance.
• Ensure it's not again in a situation where it winds down operations only to ramp back up if loan financing isn't able to fully support the 2025 campaign.91
• Be in a strong position to discuss/negotiate longer-term plans for SMC funding and implementation support in Borno with the state government. This might include, for example, helping to support a smooth transition of implementation support to another partner that is selected via the World Bank loan process in 2025.

Risks and reservations

We include our key risks and reservations for all grants we recommend to support SMC in the Sahel above, and this continues to form the basis of our risks and reservations for our 2024 renewal grant:

• Moderate risk of crowding out funding in Burkina Faso and Togo (more). Programs in Burkina Faso and Togo represent about 20% of this grant's costs ($13.5 million of $73.5 million).92 We think that a relatively large portion of this $13.5 million would be funded by other sources in the absence of GiveWell funding because these programs had been mostly (but not completely) funded prior to the introduction of our support.93 We assume a 50% chance that another funder would replace our funding in Burkina Faso and a 65% chance in Togo.
• Uncertainties in our cost-effectiveness model (more). We are most uncertain about our estimates for the malaria mortality rates of children not receiving SMC. This is the parameter our model is most sensitive to, and our current estimates make assumptions regarding the accuracy of available mortality data and the number of non-malaria deaths indirectly averted by SMC that we think could be wrong by a wide margin. Other model parameters in which we continue to have relatively higher uncertainty are the impact of malaria reduction on long-run income, the proportion of malaria mortality occurring during the time when SMC is administered, the effectiveness of SMC, the cost per cycle of SMC, and the value of spending opportunities that the Global Fund diverts funding away from to support SMC—though our model is less sensitive to these parameters.

We considered four additional key uncertainties for this specific grant opportunity:

• The typical timing of our renewal grants to support SMC in the Sahel, including this year's grant, come before we've received data from the previous year's SMC campaigns. It's possible this information could influence our decision. (more)
• If funding from the World Bank designated to support SMC in Borno becomes available in 2025, our grant could lead to this funding being reallocated for a different use that may be less cost-effective. (more)
• A preliminary update to cost per child reached in Togo implies the program is below our funding bar, which if true could mean we are making a mistake by continuing to support this opportunity. (more)
• Though we have accounted for malaria vaccine rollout in our preliminary modeling, we are still uncertain about the precise effect that malaria vaccines will have on reduced malaria deaths, and therefore the cost-effectiveness of the SMC programs we support. (more)

Details on these uncertainties are below.

Latest campaign data not yet available

Since we typically make renewal grants to support Malaria Consortium's SMC programs in the Sahel at the beginning of the year, and Malaria Consortium finalizes its reporting on SMC campaigns from the previous year in April, we are unable to incorporate this data into our grant decisions.

Since making the last Malaria Consortium SMC Sahel renewal grant in January 2023, we have received 2022 campaign data from Malaria Consortium. Malaria Consortium also sent us its finalized report on implementation during the 2023 season (including coverage rates and costs achieved) in April 2024, after we had made a grant decision. We could have waited until then and made a renewal decision based on more up-to-date cost and coverage estimates. However, Malaria Consortium told us there were no major implementation issues during the 2023 season that would lead to outcomes different from previous years, and we have observed very consistent performance from the program over several years (see yearly coverage rates achieved across countries in this spreadsheet), so we thought it was unlikely additional information in April would change our mind. In the future, we may explore the possibility of delaying our SMC renewal grants until we’ve had the opportunity to review the previous year’s report.

Moderate risk of crowding out funding for 2025 campaign in Borno

While we think there's a low chance that World Bank loan funding is able to support the 2024 SMC campaign in Borno, we think there’s a moderate chance loan funding will be available in time to support the 2025 SMC campaign. We think committing support for the 2025 campaign now increases the risk that we are crowding out future funding for the 2025 campaign. Several factors led us to include funding for the 2025 campaign in Borno despite this risk:

• Malaria Consortium expects only a portion of the full campaign cost would be supported by the World Bank loan in 2025. This is in part because the only campaign cost explicitly secured by the loan is SMC drug procurement (~50% of Malaria Consortium's budget for 2025 campaign costs).94
• Supporting SMC in Borno is explicitly listed as an objective of the World Bank loan, suggesting to us that should funding become available, it will be used to support the 2026 SMC campaign rather than reallocated for another use.95
• Cost-effectiveness remains above our 8x bar even under very pessimistic assumptions that we are crowding out other funding. Adjusting the assumptions in our CEA suggests that the risk of crowding out funding from the Global Fund or PMI would need to be 78% to move cost-effectiveness below our 8x bar in Borno.

Uncertainty in our cost per child reached for Togo

For this grant, we've roughly modeled an adjustment to our cost per SMC cycle estimates that lowered cost-effectiveness estimates in all locations where SMC is delivered. We did this because a) we plan on including a few new subjective adjustments in our model and b) we received new data from Malaria Consortium, and we wanted to quickly test the sensitivity of our CEA to these updates. These updates have not undergone extensive internal review and vetting and may therefore change before being included in the public version of our CEA.96 The only country for which this update suggests cost-effectiveness may be below our 8x bar is Togo. However, we think that our updated cost per child reached is likely an overestimate for Togo because it incorporates estimates of costs of the program paid by UNICEF and the Global Fund in 2021 and 2022 that may be overestimates due to differences between funders in how costs are reported.97 We also think costs are likely to decrease in Togo over the coming years, since the program is newer (Malaria Consortium began providing full support to Togo in 2021,98 and our preliminary model update only includes costs from the first and second years of the program). We plan to follow up with UNICEF, the Global Fund, and PMI about each organization’s expenditures in Togo to refine this estimate.99

Impact of malaria vaccine rollout on SMC cost-effectiveness

Our understanding is that malaria vaccines will be gradually introduced in Nigeria, Burkina Faso, and Togo over the coming years.100 We expect this to reduce baseline malaria burden (and therefore the potential impact of SMC) to some degree, but we are uncertain about the magnitude.

We have developed preliminary modeling suggesting that malaria vaccine rollout would only slightly lower the cost-effectiveness of SMC delivery in the contexts we support over the next few years. This is primarily due to a) a relatively low expected reduction in malaria mortality resulting from malaria vaccines, b) an assumption that malaria vaccine coverage will mirror the relatively low initial coverage of prior vaccines that were introduced in these contexts, and c) our expectation that only a portion of the children eligible for SMC (children under five) would likely receive malaria vaccines (mostly children under one). In practice, it's possible that the malaria vaccine rollout will be much quicker and achieve higher coverage than we assume, which we think could have a meaningful impact on SMC cost-effectiveness (e.g., 80% malaria vaccine coverage implies a ~30% reduction in SMC cost-effectiveness in our model). We plan to make significant updates to our modeling as we learn more.

See our intervention report for further discussion on the evidence for and cost-effectiveness of malaria vaccines.

Plans for follow up

• We will continue our monthly calls with Malaria Consortium to discuss its SMC 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 have biannual calls with Malaria Consortium with the explicit goal of understanding how SMC implementation is going.
• We will track how national malaria programs and funders choose to allocate the future funding available for SMC campaigns in these countries. Specifically, we will focus on better understanding the potential of loan financing for SMC in Borno State in Nigeria, the capacity of PMI to increase its support for SMC in Nigeria, and the capacity of Global Fund and PMI to increase their support for SMC in Burkina Faso and Togo. We also plan to discuss expenditure on SMC campaigns in Togo directly with UNICEF, Global Fund, and PMI.
• We may do further work to investigate several open questions as part of a broader malaria research agenda, including:
  • What is the effect of malaria vaccine rollout on the malaria burden averted by SMC and other interventions?
  • How prevalent is resistance to SMC drugs in the Sahel and what role is continued SMC implementation playing in increasing resistance?101
  • Are there opportunities to layer other interventions (e.g. VAS) on top of SMC to increase cost-effectiveness and thereby support SMC in areas we wouldn't otherwise?102

Internal forecasts

For this grant, we are recording the following forecasts:

Our process

• We reviewed information shared by Malaria Consortium annually about its available funding and projected budgets. For the spending opportunity in Borno state, we reviewed a formal funding request that outlined a specific case for supporting this opportunity.
• We used our existing cost-effectiveness model for SMC campaigns, sense-checked two preliminary updates to our model (described above) and their implications for cost-effectiveness, and reviewed monitoring data on coverage and costs from 2022.
• We had conversations with Malaria Consortium to understand how SMC implementation in 2023 compared to prior years and to better understand the funding landscape for malaria across the contexts where we support SMC.

All grants to Malaria Consortium's SMC program in the Sahel

Sources

• 1

  "Starting with an early implementation pilot in Nigeria in 2013, we then led the rapid scale-up of SMC through the Achieving Catalytic Expansion of Seasonal Malaria Chemoprevention in the Sahel (ACCESS-SMC) project in 2015–2017, reaching close to seven million children in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia." Malaria Consortium, "What is seasonal malaria chemoprevention?"

• 2

  Malaria Consortium initiated a partnership with Togo'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, 2020 SMC philanthropy report, p. 23.

• 3

  Malaria Consortium, 2023 SMC philanthropy report, p. 19

  • Burkina Faso target population: 2,180,000
  • Togo target population: 510,000
  • Chad target population: 1,360,000
  • Nigeria target population: 11,500,000
  • (11,500,000) / (2,180,000 + 510,000 + 1,360,000 + 11,500,000) = ~74%

  Note that philanthropic funding includes sources of funding beyond GiveWell support, though we understand these comprise a small portion of Malaria Consortium's total philanthropic funding. Note that we include Chad in this calculation despite making an exit grant in 2023 to withdraw our support. This is because we expect our funding to continue to support SMC in Chad through 2024.

• 4

  Malaria Consortium, 2023 SMC philanthropy report, p. 19

  • Burkina Faso target population: 2,180,000
  • Togo target population: 510,000
  • Chad target population: 1,360,000
  • Nigeria target population: 11,500,000
  • (2,180,000 + 510,000) / (2,180,000 + 510,000 + 1,360,000 + 11,500,000) = ~17%

  Note that philanthropic funding includes sources of funding beyond GiveWell support, though we understand these comprise a small portion of Malaria Consortium's total philanthropic funding. Note that we include Chad in this calculation despite making an exit grant in 2023 to withdraw our support. This is because we expect our funding to continue to support SMC in Chad through 2024.

• 5

  "Established in 2003, Malaria Consortium is one of the world’s leading non-profit organisations specialising in the prevention, control and treatment of malaria and other communicable diseases among vulnerable populations. Our mission is to save lives and improve health in Africa and Asia, through evidence-based programmes that combat targeted diseases and promote universal health coverage. Malaria Consortium’s Head Office is based in London, UK." Malaria Consortium, "About Us"

• 6

  Malaria Consortium, "Where we work"

• 7
  • “SMC is the intermittent administration of a curative dose of antimalarial medicine during the malaria season to asymptomatic children, regardless of whether the child is infected with the malaria parasite – that is, asymptomatic children are not tested for malaria before SMC administration. The objective of SMC is to establish antimalarial drug concentrations in the blood that clear existing infections and prevent new ones during the period of greatest malaria risk. SMC is recommended in areas of highly seasonal P. falciparum malaria transmission… The priority target areas for SMC implementation are those where: P. falciparum malaria transmission is highly seasonal and the majority (>60%) of clinical malaria cases occur within 4 consecutive months – where data on malaria from the health management information system are unreliable, rainfall data could be used as a proxy for seasonality in incidence (at least 60% of annual rainfall in 4 consecutive months); and the clinical attack rate of malaria (without SMC) is at least 0.1 episodes per child during the transmission season in the target group.” WHO, SMC field guide, 2nd ed., 2023, p. 2.
  • Children with confirmed malaria are not given SMC. In locations where rapid diagnostic tests (RDTs) and antimalarial treatments are available, children with danger signs for malaria (including a fever) are tested, and given SMC if the test is negative. In locations where tests and antimalarials are not available, all children with malaria danger signs (including a fever) are not given SMC and are referred to a health facility for appropriate care. Malaria Consortium, comments on a draft of GiveWell's Malaria Consortium report, November 9, 2023.

  “SMC should not be given to:

  • a child with an acute febrile illness or a severe illness – these children need to be referred to the nearest health facility for appropriate care (or tested and, if positive for malaria, treated on the spot with an antimalarial in countries where rapid diagnostic tests and ACT are available in the community as part of the SMC campaign;
  • a child taking co-trimoxazole (e.g. HIV-positive child receiving co-trimoxazole prophylaxis);
  • a child who has received a dose of either SP or AQ during the previous 4 weeks; or
  • a child who is allergic to either SP or AQ."

  WHO, SMC field guide, 2nd ed., 2023, p. 3

• 8

  “WHO recommends that medicines used as first- or second-line malaria treatment in a country not be used for chemoprevention in that country. The combination of SP+AQ is currently recommended for SMC for the following reasons.

  • In the clinical trials that provided the evidence base for WHO recommendations, SP+AQ conferred greater protection than other medicine combinations.
  • There are no indications that the chemoprevention efficacy of SP+AQ is diminishing in Africa.
  • The SP+AQ regimen is well tolerated and relatively inexpensive.
  • The SP+AQ regimen confers protection for 28 days.”

  WHO, SMC field guide, 2nd ed., 2023, p. 3.

• 9

  “The following considerations apply in areas where SMC is deployed.

  • The 28-day interval should be respected between cycles – that is, a child who is treated on day 1 of the first SMC cycle needs to be treated on day 1 of the following cycles.
  • SP and the first dose of AQ should be taken on the first day of treatment, under directly observed therapy (DOT1). The second and third doses of AQ should be given over the next 2 days by the caregiver. Caregiver adherence to the 3-day regimen can be reinforced through appropriate health communication and community engagement. The delivery of all three doses under directly observed therapy (DOT3) is an option, although cost-effectiveness data for DOT3 are lacking.”

  WHO, SMC field guide, 2nd ed., 2023, p. 6.

• 10

  “In a given area, SMC medicines are typically distributed over a period of four or five days. This is called the ‘distribution period’. SMC distribution is repeated in four or five monthly cycles over the course of the high transmission season. All SMC cycles in a given year are referred to as a ‘round’ of SMC." See Malaria Consortium, 2022 SMC philanthropy report, p. 21.
  Note the 2023 WHO recommendation allows for three cycles of SMC, but no locations with only three cycles are currently funded by GiveWell. “SMC should be implemented during the peak malaria transmission period, when the incidence of malaria is highest. SMC courses should be given at 28-day intervals, beginning at the start of the transmission season and continuing for 3–5 cycles, depending on the local context.” WHO, SMC field guide, 2nd ed., 2023, p. 2

• 11

  See WHO, Policy Recommendation: Seasonal Malaria Chemoprevention, 2012, p. 2.

• 12

  See World Health Organization, World malaria report 2023, p. 64, table 7.1.

• 13

  See this row in our cost-effectiveness analysis.

• 14

  See this row in our cost-effectiveness analysis.

• 15

  See this row in our cost-effectiveness analysis for the percentage of program impact coming from over 5 mortalities averted. See this row for our estimate of the expected reduction in malaria mortality among this group. In this page, we refer to our estimates for Burkina Faso, Togo, and various states in Nigeria, since these are the locations for the most recent renewal grant.

• 16
  • We use the 26% estimated reduction in malaria cases among this group as the starting point in our analysis. We divide this figure by the impact of SMC on the treated population in Cissé et. al. 2016 (60%) to estimate the ratio of SMC’s impact in the untreated vs the treated population (26% / 60% = 43%). See this section in our cost-effectiveness analysis.
  • “Among age groups too old to receive SMC, incidence was reduced by 26% (95% CI 18%–33%, p < 0.001) (RDT-confirmed), or 29% (95% CI 21%–35%, p < 0.001) (confirmed and unconfirmed cases) in areas where SMC was delivered to children compared to control areas (Fig 3).” Cisse et al. 2016, p. 11.

• 17

  See this row in our 2023 cost-effectiveness analysis, Burkina Faso, Togo, and Nigerian state columns.

• 18

  See this section of our 2023 cost-effectiveness analysis.

• 19

  See this row in our cost-effectiveness analysis. This range includes Burkina Faso, Togo, and various states in Nigeria. We exclude Chad, Mozambique, Uganda, and DRC from this range for the reasons discussed in this section.

• 20

  For more on these estimates, see this section of our report on SMC.

• 21

  See this section of our SMC intervention report for more details.

• 22

  See this section of our SMC intervention report for more details.

• 23

  At the time of writing, we estimate that 70% of malaria occurs in this period in countries in the Sahel. See this section of our SMC intervention report for more details.

• 24

  At the time of writing, we estimate that it costs Malaria Consortium approximately $5 to $6 per year (depending on the location) to reach a child with all their recommended cycles of SMC. This is roughly in line with the cost of other mass campaign programs we have seen (e.g., insecticide-treated net campaigns).

• 25

  See this section of our SMC intervention report for more details.

• 26

  See our 2022 Cost per SMC cycle analysis 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.

• 27

  See this section of our SMC intervention report for more details, and this row in our CEA for the percentage of modeled benefits.

• 28

  See this section of our SMC intervention report for more details.

• 29

  Additional funding for SMC may lead other organizations or governments to spend more (we refer to this as "leveraging" funding, or “crowding in”) or less (we refer to this as "funging," from “fungibility,” or “crowding out”) on SMC than they otherwise would. We include a “leverage and funging” adjustment in our cost-effectiveness analysis to account for this. As of December 2023, our leverage and funging adjustment is -8% to -51%, varying by location. See this row of our CEA.

• 30

  See this section of our SMC intervention report for more details.

• 31

  See this section of our Malaria Consortium top charity review for details of programs supported by GiveWell, and Malaria Consortium, "What is seasonal malaria chemoprevention?" for a history of Malaria Consortium's work since 2012.

• 32
  • Malaria Consortium initiated a partnership with Togo'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, 2020 SMC philanthropy, p. 23.

• 33

  For a full overview of Malaria Consortium’s monitoring and evaluation methodology, see this section of our Malaria Consortium charity report. For our most up-to-date average coverage estimate across all cycles (from 2017 to present), see here.

• 34

  See here.

• 35
  • "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." 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.” Global Fund, "Global Fund Board Hails Record-Breaking Seventh Replenishment Final Outcome of US$15.7 Billion," November 2022

• 36
  • 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, 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, May 2022, p. 5.
  • "In the current cycle, US$12.71 billion has been made available for country allocations for a three year period…For the 2020-2022 period, US$890 million is available for key priorities that are unable to be addressed through country allocations alone, yet are critical to successful program implementation." Global Fund, Description of the 2020-2022 Allocation Methodology, December 2019, pp. 1,3

• 37

  $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."

• 38

  $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."

• 39

  See this adjustment here.

• 40

  Malaria Consortium, 2023 SMC philanthropy report, p. 19.

  • Burkina Faso target population: 2,180,000
  • Togo target population: 510,000
  • Chad target population: 1,360,000
  • Nigeria target population: 11,500,000
  • (11,500,000) / (2,180,000 + 510,000 + 1,360,000 + 11,500,000) = ~74%

  Note that philanthropic funding includes sources of funding beyond GiveWell support, though we understand these comprise a small portion of Malaria Consortium's total philanthropic funding. Note that we include Chad in this calculation despite making an exit grant in 2023 to withdraw our support. This is because we expect our funding to continue to support SMC in Chad through 2024.

• 41

  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)

• 42

  Malaria Consortium, Net-Target Project, Rapid Scoping to Delineate Priority Areas for ITN Distribution and Gap Analysis. Report 2: Nigeria, 2020, "Table 2. ITN gaps based on campaign funding landscape analysis," p. 9.
  Additional details on the loan financing mechanisms intended to support malaria programs in FCT, Borno, and Kogi can be found on our 2021 grant page (FCT), 2022 grant page (Kogi), and 2023 grant page (Borno). We have learned from recent conversations that the situation with regard to loan financing for malaria control in Nigeria is evolving; we plan to keep abreast of any updates and use these to inform future grants to support malaria programs in states not receiving Global Fund or PMI funding.

• 43

  PMI’s malaria budget in Nigeria has fluctuated between $77 million (2020) and $68 million (2024) over this time. See:

  • 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
  • U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2023, Table 1: Budget Breakdown by Mechanism
  • U.S. President's Malaria Initiative, Nigeria, Planned Malaria Obligations for FY 2024, Table 1: Budget Breakdown by Mechanism

• 44

  See columns L, Q, and V of this spreadsheet.

• 45

  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.” Peter Duru, "Benue Govt, US President’s Malaria Initiative collaborate on SMC for children," 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.

• 46

  "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)

• 47

  Malaria Consortium, 2023 SMC philanthropy report, p. 19.

  • Burkina Faso target population: 2,180,000
  • Togo target population: 510,000
  • Chad target population: 1,360,000
  • Nigeria target population: 11,500,000
  • (2,180,000 + 510,000 + 1,360,000) / (2,180,000 + 510,000 + 1,360,000 + 11,500,000) = ~26%

  Note that philanthropic funding includes sources of funding beyond GiveWell support, though we understand these comprise a small portion of Malaria Consortium's total philanthropic funding. Note that we include Chad in this calculation despite making an exit grant in 2023 to withdraw our support. This is because we expect our funding to continue to support SMC in Chad through 2024.

• 48

  See this row in our crowding out analysis.

• 49

  See the values for Burkina Faso and Togo in our analysis here.

• 50
  • In Burkina Faso, prior to the introduction of philanthropic support in 2017, SMC funding was covered in 54 out of 70 districts. The majority of funding came from a program that was scheduled to end in 2018. Full scale coverage was achieved in 2019.
  • In Togo, though all 19 districts considered eligible at the time received some SMC prior to the introduction of philanthropic support, there was insufficient funding for the recommended number of cycles in some districts, and for campaign activities such as training and supervision, until 2020.
  • Source: Malaria Consortium, comments on a draft of this page, September 2024

• 51

  See more details in our 2022 renewal grant page.

• 52

  See this row in our cost-effectiveness analysis. This range includes Burkina Faso, Togo, and various states in Nigeria. We exclude Chad, Mozambique, Uganda, and DRC from this range for the reasons discussed in this section.

• 53

  See the GBD estimates in our CEA here. See our summary of this data for Mozambique here and for Uganda here.

• 54

  This understanding is based on multiple conversations with IHME researchers. Detailed modeling assumptions for the GBD estimates are available in the GBD 2019 methods appendix.

• 55

  "Despite its importance, current knowledge on the nature and drivers of changing endemicity in sub-Saharan Africa is remarkably weak. National health records in 32 highly endemic countries (together accounting for about 90% of the global malaria burden) are considered inadequate to assess trends in malaria cases. This stems from low care-seeking rates (many malaria cases are not seen at formal health facilities), incomplete record keeping and curation (many recorded cases are never captured in surveillance databases), and historically poor access to parasitological diagnosis (malaria cases were often diagnosed presumptively with poor specificity).” Bhatt et al. 2015, p. 2.

• 56

  "During randomized controlled intervention trials aimed at reducing the incidence of infection (but not 100 percent protective), the all-cause mortality of children is often reduced more than would be attributed by VA diagnosis of malaria. For example, in Kilifi the proportion of deaths of children under five years attributed to malaria by VA was 34 percent (R. W. Snow, unpublished data). During a randomized controlled trial of insecticide-treated bednets in the same area, the incidence of malaria infection was reduced by 50 percent (Snow et al. 1996), which was sufficient to reduce all-cause mortality by 33 percent (Nevill et al. 1996). More dramatically, in The Gambia, insecticide-treated bednets reduced all-cause mortality by over 60 percent, and yet the VA-diagnosed contribution of malaria to all-cause mortality among control populations was only 16 percent (Alonso et al. 1993). This has led some to speculate that malaria infection is a contributor to broad causes of mortality beyond the direct fatal consequences of infection (Molineaux 1997)." Jamison et al. 2006, p. 204.
  "Data on all-cause mortality of children under five from DSS studies undertaken across a broad range of malaria transmission settings in Sub-Saharan Africa were analyzed against the prevalence of P. falciparum infection at each site. Weighted least-squares regression was used to model the contiguous relationships between all-cause mortality and parasite prevalence rates, allowing for the square of parasite prevalence (for possible saturation of parasite prevalence), timing, location, and the sampling precision of each study (Snow, Korenromp, and Gouws 2004). The unadjusted median all-cause child mortality rate for low prevalence areas of childhood infection (less than 25 percent) was 10.9 per year per 1,000 children under five (IQR 7.8–17.6). This rose dramatically to 39.1 per year per 1,000 children (IQR 32.8–52.2) among populations exposed to childhood parasite prevalence risks greater than or equal to 25 percent. In the regression model, mortality increased significantly with parasite prevalence, but this effect leveled off at higher prevalence rates. The model suggested that, in rural DSS sites throughout Sub-Saharan Africa, all-cause mortality increases by more than twofold (25–30 deaths per 1,000 children under five years old) over the prevalences of malaria infection covered by the DSS sites, and parasite prevalence explained 64 percent of the variation between sites in all-cause under-five mortality. By contrast, the direct estimation of malaria-specific mortality presented earlier for children living under stable endemic conditions was only 28.2 percent." Jamison et al. 2006, p. 206.

• 57

  “Indirect consequences of P. falciparum infection include anemia (unless anemia is linked to acute high-density parasitemia as a direct cause), low birthweight, growth retardation, or undernutrition. In addition, malaria infection can increase the severity of other comorbid infectious diseases through immune suppression or enhanced invasive capacities across physical barriers to infection (for example, blood and tissue). Previous approaches to the global burden of disease have assumed that each death must be attributed to a single cause and can be fitted into the fixed disease-mix matrix of all causes (Murray and Lopez 1997).” Jamison et al. 2006, p. 206

• 58

  See cost-effectiveness comparisons for the high and low values for this input on this sheet. This copy of our CEA uses the low end estimate, and this copy uses the high end estimate for the indirect deaths averted parameter.

• 59

  See this section of our SMC intervention report for more details.

• 60

  Cairns et al. 2012, Supplementary Table S1, 2.

• 61
  • “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 season 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.

• 62

  See details in this section of our SMC intervention report.

• 63

  We estimate that each dollar that the Global Fund spends on other activities rather than SMC in the Sahel generates 0.015 units of value. Our calculations for this estimate are available in this spreadsheet.

• 64
  • "Starting with an early implementation pilot in Nigeria in 2013, we then led the rapid scale-up of SMC through the Achieving Catalytic Expansion of Seasonal Malaria Chemoprevention in the Sahel (ACCESS-SMC) project in 2015–2017, reaching close to seven million children in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia." Malaria Consortium, What is seasonal malaria chemoprevention?
  • "In total, we are recommending that Good Ventures make the following grants:...Malaria Consortium…Part of the funding gap for SMC in Burkina Faso, Nigeria, and Chad over the next three years." GiveWell, Our top charities for giving season 2017.

• 65
  • "$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." GiveWell, Malaria Consortium — SMC Renewal in Nigeria, Burkina Faso, Chad, and Togo (January 2023).
  • Due to administrative changes, the number of health districts supported by Malaria Consortium increased from 27 to 30 between 2023 and 2024, but the geographical area supported did not change. "The increase in the number of supported health districts is due to administrative changes. The geographical area supported remains unchanged compared with 2023." Malaria Consortium, 2023 Philanthropy Report, April 2024, P. 24.

• 66

  "We understand that the Global Fund will support 28 health districts 2025-27, including 20 that are currently funded by philanthropy and 8 that are currently Global Fund supported. This means SMC will be discontinued in 10 districts currently supported by philanthropy and 29 of the eligible health districts currently supported by the Global Fund. SMC will also be discontinued in the 7 districts that are not considered eligible but that do receive SMC with Global Fund support in 2024." Email from Christian Rassi, Malaria Consortium SMC Program Director, July 30, 2024 (unpublished).

• 67

  "Under the Global Fund’s Grant Cycle 7, it is now expected that 28 health districts will be supported with Global Fund funding from 2025, including 20 that have so far been supported with philanthropic funding. UNICEF and MSF are expected to maintain funding support for the 11 health districts they are supporting in 2024. There are therefore 102 eligible health districts that do not have SMC funding confirmed for 2025, including 39 that had previously received SMC. Out of those, 10 had previously received philanthropic support." Malaria Consortium, Funding request for SMC in Chad 2025-26, 2024.

• 68

  Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.

• 69

  "There are therefore 102 eligible health districts that do not have SMC funding confirmed for 2025, including 39 that had previously received SMC. Out of those, 10 had previously received philanthropic support." This grant will provide funding for those 10 districts, meaning that 92 eligible districts in chat will not receive funding. Malaria Consortium, Funding request for SMC in Chad 2025-26, 2024 (unpublished).

• 70

  IHME has since published the 2021 version of its GBD model, which estimates the mortality rate to be 0.15%. The slight increase from the 2019 version to the 2021 version of GBD played a very small role in our updated view on malaria mortality in Chad.

• 71

  We put 65% weight on the child malaria mortality estimate from IHME's GBD model and 35% weight on the child malaria mortality estimate we've imputed from the UN IGME's model. See our calculations here.

• 72

  Malaria mortality appears to be substantially higher in Mayo-Kebbi Est than in Bahr El Ghazal; for example, the Malaria Access Project finds a subnational mortality rate of 205 per 100,000 in Mayo-Kebbi Est versus 106 in Bahr El Ghazal. However, averaging the regions (and including multiple sources of data), we found a mortality rate of 251 per 100,000, versus 227 in Chad overall, an increase of about 10%. (251-227 = 24. 24/227 = 10.6%.)

• 73

  For example, a person's death could be indirectly caused by malaria if malaria weakened their immune system, leaving them more susceptible to dying of another infectious disease.

• 74

  The Malaria Atlas Project estimates that the malaria mortality rate among people of all ages in Bahr El Ghazal is ~30% lower than in Chad overall and ~50% lower than in Mayo-Kebbi Est, the other region supported by this grant. In addition, Djaskano et al. 2023, a study of malaria control interventions in Chad, found that malaria prevalence and incidence rates were drastically lower in Bahr El Ghazal than in Chad overall. See our summary of these disease burden sources here.

• 75

  Our previous grant for the countries included in this grant is discussed here. Note that this grant does not include renewal funding for Chad, as we previously discontinued funding there after 2024.

• 76

  See the Nigeria, Burkina Faso, and Togo rows in the "Maintain 2023 scale - 2025" section, "Spending opportunities" tab in our room for more funding analysis here.

• 77

  Excluding the program in Borno State, Nigeria, which will be supported through 2025. See this section of this page.

• 78

  See this table in our room for more funding analysis for the numbers in this cost breakdown.

• 79

  For more details, see this section of our page on our January 2023 renewal grant to Malaria Consortium.

• 80

  Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.

• 81

  See additional explanation for this parameter update in our intervention report.

• 82

  Since making the last Malaria Consortium SMC Sahel renewal grant in January 2023, we have received 2022 campaign data from Malaria Consortium. We have also received Malaria Consortium's finalized report on implementation during the 2023 season (including coverage rates and costs achieved), although we did not have this document at the time of making this grant. While we investigated this grant renewal, Malaria Consortium told us there were no major implementation issues during the 2023 season that would lead to coverage or quality outcomes different from previous years, and we have observed very consistent performance from the program over several years (see yearly coverage rates achieved across countries in this spreadsheet).
  Survey results can be found in Malaria Consortium's 2022 coverage report; we average results across cycles in our analysis of Malaria Consortium SMC coverage surveys.

• 83

  GiveWell's non-verbatim summary of a conversation with Malaria Consortium, February 15, 2024 (unpublished)

• 84

  See our 2022 renewal grant page for more details on the funding landscape and our adjustment for crowding out other funders in Bauchi, Kebbi, Kogi, Nasarawa, Plateau, and Sokoto state, and our 2021 grant page for more details in FCT and Oyo states.

• 85

  See Malaria Consortium, Funding Request: SMC in Borno state, Nigeria, 2024-25,Table 1, p. 3

• 86

  More detail about this situation can be found on this page. 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.

• 87

  The reasons for the delay have changed over time. See details of our support to fill this funding gap in prior years here.

• 88

  "At this point in time [March 2024], there are no plans to implement SMC in Borno in 2024 and no commodities have been procured. In the absence of Malaria Consortium’s support, it is extremely unlikely that SMC will be implemented in the state this year." Malaria Consortium, Funding Request: SMC in Borno state, Nigeria, 2024-25, p. 2

• 89

  Malaria Consortium is able to support this campaign even with insufficient lead time for SMC drug procurement because it retained leftover stock from the 2023 campaign it supported in Borno, as well as buffer stock that it procures for future campaigns in other GiveWell-supported Nigerian states. Source: Malaria Consortium, Funding Request: SMC in Borno state, Nigeria, 2024-25, p. 2 and comments on a review of this grant page, September 2024.

• 90

  GiveWell's non-verbatim summary of a conversation with Malaria Consortium, March 7, 2024 (unpublished)

• 91

  Our previous support for Malaria Consortium’s operations in Borno state lasted through 2023 in anticipation of the World Bank loan coming through for the 2024 campaign (see this section of our previous grant page). As a result, Malaria Consortium scaled down its operations there following the 2023 campaign and will now need to quickly scale back up for the 2024 campaign. If we had only committed to supporting the 2024 campaign, Malaria Consortium would have to begin winding down in-country operations at the end of the campaign this year again, likely before we have more clarity around the status of the World Bank loan in 2025. Source: GiveWell's non-verbatim summaries of conversations with Malaria Consortium, January 18, 2024 and February 15, 2024 (unpublished)

• 92

  See this table in our room for more funding analysis for the cost breakdown by country.

• 93

  Malaria Consortium, Donor Landscape, 2019 (unpublished), Malaria Consortium, Donor Landscape, June 2020 (unpublished), Malaria Consortium, Donor Landscape, June 2021 (unpublished)

• 94
  • Conversation with Malaria Consortium, March 7, 2024 (unpublished)
  • Malaria Consortium, Funding Request: SMC in Borno state, Nigeria, 2024-25
  • SMC medicines and freight: $2,973,770
  • Total budget: $6,667,797
  • $2,973,770 / $6,667,797 = 45%.

• 95
  • GiveWell's non-verbatim summary of a conversation with Malaria Consortium, March 7, 2024 (unpublished)
  • "The subcomponent will also finance procurement of preventative and curative medicines and commodities for malaria including LLINs, ACTs, RDTs, SP, SPAQSMC17 for Borno (Sahelian state), and so on." World Bank, Project appraisal document for IMPACT project, p. 34

• 96

  We've roughly modeled an increase to our cost per SMC cycle administered estimates of 48% in Togo and 14%-15% everywhere else. This update is based on:

  • The inclusion of two new downward adjustments into our calculations: an adjustment for self-report bias in SMC coverage figures and an adjustment for overestimated target population figures.
  • Data from Malaria Consortium on costs and coverage from the 2022 SMC season. Not including the two downward adjustments described above, incorporating new data on costs and coverage led to a lower estimated cost per SMC cycle administered in all countries except Togo.
  • Data on UNICEF and Global Fund expenditures in Togo over the 2021 and 2022 SMC seasons. This update significantly increased our estimated cost per SMC cycle administered for Togo, though we have significant uncertainties about this (see details above).

  This analysis is not yet finalized and remains unpublished.

• 97

  We previously pegged Togo's cost per child estimate to our overall cost per SMC cycle estimate (a weighted average of Burkina Faso, Chad, and Nigeria) because we lacked this information. The new estimates of UNICEF and Global Fund costs come via the Togolese national malaria program (unlike our model for other countries, where we receive all information on campaign expenditure directly from Malaria Consortium).
  Malaria Consortium told us that they would expect costs to be similar to Burkina Faso because it is a neighboring country with similar cost drivers, including security needs and medicine prices. Our preliminary cost per child reached estimate for Togo is ~30% higher than our estimate for Burkina Faso. GiveWell's non-verbatim summary of a conversation with Malaria Consortium, February 15, 2024 (unpublished)

• 98

  Malaria Consortium initiated a partnership with Togo'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, 2020 SMC philanthropy report, p. 23.

• 99

  As of 2024, PMI is also supporting SMC in Togo. Source: Malaria consortium, comments on a draft of this page, September 2024.

• 100
  • “Central African Republic, along with Chad, Cote d’Ivoire, Democratic Republic of Congo, Mozambique, Nigeria, South Sudan, and Uganda, are preparing to receive R21 shipments. Around 4.33 million doses of RTS,S have been delivered to 8 countries so far – Benin, Burkina Faso, Cameroon, Ghana, Kenya, Liberia, Malawi, and Sierra Leone – that are offering the vaccine in their routine child immunization programmes as part of national malaria control plans. Burundi and Niger are next on the list for RTS,S shipments.” WHO, "Shipment of newest malaria vaccine, R21, to Central African Republic marks latest milestone for child survival"
  • "[Togo] is preparing a Gavi draft application for the RTS,S vaccine targeted to protect vulnerable children from malaria." US President's Malaria Initiative, Togo Malaria Operational Plan, 2024 , p. 8

• 101

  We currently make rough adjustments in our CEA, based on limited data, to account for the impact of rising drug resistance on SMC effectiveness. These adjustments suggest only a slight reduction in cost-effectiveness due to drug resistance. We have since supported Malaria Consortium to conduct research on SMC effectiveness (i.e. ability to reduce cases of malaria), efficacy (i.e., ability to clear parasite load), and drug resistance in a variety of contexts. We have seen and analyzed results from its studies in Mozambique and Uganda, and we incorporate this into our thinking around SMC in countries outside the Sahel. We are awaiting results from studies conducted in the Sahel.
  We also plan to have additional conversations with various experts to better understand the state of knowledge around SMC drug resistance.

• 102

  We modeled the cost-effectiveness of layering VAS and SMC as part of our grant supporting Malaria Consortium to codeliver VAS and SMC in two Nigerian states. We may consider layering SMC with interventions beyond VAS, and/or layering in contexts beyond Nigeria.