Malaria Consortium – Seasonal Malaria Chemoprevention, Nampula, Mozambique (February 2022)

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

Published: April 2022

Planned activities and budget

$15.9 million will enable Malaria Consortium to deliver SMC to Nampula province in Mozambique in the 2022-2023 and 2023-2024 SMC seasons.1 This grant amount is based on the estimated target population of children 3-59 months in Nampula (1.2 million children) and Malaria Consortium's best guess of the cost per child it will achieve during scaleup.2

We conduct a "room for more funding" analysis to understand what portion of a grantee's ideal future budget it will be unable to support with the funding it has or should expect to have available. We may then choose to either make or recommend grants to support those unfunded activities. To determine the size of this grant, we updated our room for more funding analysis for Malaria Consortium's SMC program, available here.

This grant will enable an expansion of Malaria Consortium's support to Nampula province. Malaria Consortium delivered SMC in two districts in Nampula in the 2020-21 season3 and in four districts in the 2021-2022 season.4 Malaria Consortium would use this grant to deliver SMC in all 23 districts in Nampula during the next two SMC seasons.

Alongside SMC delivery, Malaria Consortium is conducting a two-year implementation study in Nampula, which was funded separately from this grant. Phase 1 of the study, conducted during the 2020-21 season, involved the components listed in this footnote,5 including:

• A non-randomized trial comparing clinical malaria incidence in a district that received SMC and a neighboring control district. This study found that SMC led to an approximately 80% reduction in clinical malaria6 in the treated district, which is comparable with the 75% reduction that was measured by RCTs conducted in the Sahel and which we use in our cost-effectiveness analysis.7 We have not reviewed this result in depth because we expect to see stronger (randomized) evidence on SMC's effectiveness in Mozambique from Phase 2 of the study, described below.
• A study of molecular resistance markers in malaria parasites. SMC programs typically administer two drugs: sulfadoxine–pyrimethamine (SP) and amodiaquine (AQ). The primary reason that SMC has not yet been expanded to regions outside of the Sahel that experience seasonal malaria is that resistance to SP is high in these regions.8 (However, while SP may have low therapeutic efficacy against malaria due to this resistance, it is possible that it retains chemopreventive efficacy.) As expected, this study found a high prevalence of mutations associated with SP resistance, which may suggest that SMC will be less effective in Mozambique than in the Sahel. More encouragingly, the study found negligible prevalence of mutations associated with AQ resistance (suggesting that we should expect malaria parasite sensitivity to at least one SMC drug to be high) and found no change in resistance genotypes across the four SMC cycles (suggesting that one round of SMC did not lead to increased resistance). We have not yet received these results in print but have heard them described by Malaria Consortium's SMC technical lead.9

Phase 2 of the study, currently underway, includes an RCT that will use household surveys to measure confirmed malaria cases in children. We expect to use results from this RCT to update the estimate of SMC's effectiveness in Mozambique in our cost-effectiveness model.

The research described above (both Phases 1 and 2) has been co-funded by GiveWell-directed funding and by the Bill & Melinda Gates Foundation (BMGF).10 The grant we describe here does not include any research components; it does include routine monitoring.

Case for the grant

• Cost-effectiveness. During this grant investigation, we added Mozambique to our existing cost-effectiveness model for SMC campaigns and updated various parameters to match the specifics of this funding gap. We estimate that the cost-effectiveness of SMC exceeds our funding bar. We are more uncertain about this cost-effectiveness estimate than we typically are for SMC grants. (More)
• Stakeholder support. Our impression is that Malaria Consortium's SMC project in Nampula has had the support of key stakeholders. The stakeholders we have asked for feedback on this potential grant have responded positively. (More)
• Considerations about grant size. We believe we are proposing the appropriate scope and length for this grant. (More)
• Malaria Consortium as a grantee. We believe that Malaria Consortium is the right partner to scale up SMC in Nampula. (More)
• Time-sensitivity. We believe that the funding need for the 2022-2023 season is time-sensitive. (More)

Cost-effectiveness

How we use cost-effectiveness estimates in our grantmaking

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

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

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes to other grants we have made or considered making, and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible. Our process for estimating cost-effectiveness focuses on determining whether a program is cost-effective enough that it is above our bar to consider funding; it isn't primarily intended to differentiate between values that are above that threshold.

Cost-effectiveness of this grant

We estimate that the cost-effectiveness of this grant is 8.4x cash. To generate this estimate, we added Mozambique to our existing cost-effectiveness analysis (CEA) model for SMC campaigns and updated various parameters to match the specifics of this funding gap.11 The key parameter updates we made during this grant investigation include:

• Proportion of annual direct malaria mortality occurring in the high-transmission season.12 In our cost-effectiveness model for SMC in the Sahel, we assume that if SMC were not delivered, 70% of malaria mortalities would have occurred during the SMC season.13 For our cost-effectiveness model for SMC in Mozambique, we have decreased this value to 52% based on an understanding that malaria is less seasonal there.14
• Rate ratio for malaria cases (intention to treat effect). We have increased this value to 50%, from 25% in our cost-effectiveness model for SMC in the Sahel.15 This change causes the corresponding reduction in clinical malaria among children targeted to decrease in the model from 75% to 50%.16 This lower value balances our assumption that SMC is likely to perform worse in Mozambique (based on high drug resistance) with the positive observational phase 1 results described above.
• Malaria burden (multiple parameters). Many of the parameters in our cost-effectiveness models use data we obtain from the Institute of Health Metrics and Evaluation's (IHME's) Global Burden of Disease (GBD) project. These include data on malaria prevalence and mortality in the locations where GiveWell-directed funding supports SMC. We updated the model to use province-level malaria data from Nampula, which has higher malaria mortality than the national average.
• Cost per SMC cycle administered. We typically calculate a cost per SMC cycle administered for each Malaria Consortium-supported country using spending and coverage data from past SMC campaigns conducted in those countries. However, because we don't expect costs and coverage from Malaria Consortium's implementation study in Nampula to provide a good indication of what we can expect at the greater scale supported by this grant, we have roughly estimated that the cost per SMC cycle administered that Malaria Consortium will achieve for this grant will be similar to the cost per SMC cycle administered that it achieves in Chad.17
• Likelihood that the Global Fund and/or the President’s Malaria Initiative (PMI)18 would replace Malaria Consortium's costs. We adjust our cost-effectiveness estimates to account for the extent to which we believe our funding may be crowding out funding that would otherwise have come from other sources (in the case of SMC, this is typically the Global Fund and/or PMI). Specifically, these adjustments represent the proportion of a grantee's funding that we believe may crowd out funding from other sources (for example, if we use an adjustment of 25%, we believe that 25 cents of every 1 dollar spent by the grantee would otherwise have come from other sources). See more details in this blog post. We have set this value at 20%,19 which is at the low end of the values we use for other SMC locations in our CEA. We think it is unlikely that these funders would support the work this grant will support, for several reasons. First, SMC is a new program in Mozambique, and its effectiveness has not yet been demonstrated in an RCT. Second, we guess that it would be difficult for Mozambique’s national malaria program, the Programa Nacional de Controlo da Malária (PNCM), to reallocate its Global Fund malaria allocation in time to support next year's SMC season.

We are more uncertain about this cost-effectiveness estimate than we typically are for SMC grants. Without the RCT results, our guess about SMC's effectiveness in Mozambique is necessarily rough. Our estimate for the cost per SMC cycle administered is also a rough best guess, rather than an estimate informed by past data. We have conducted sensitivity analyses that increase our confidence that we will ultimately conclude that this grant was at least 5x cash.20

Stakeholder support

Our understanding is that this grant would support the largest SMC campaigns outside of the Sahel to date. As discussed above, our impression is that there is concern within the malaria community that SMC will be less effective outside of the Sahel due to SP resistance. Two concerns we therefore might have about supporting SMC outside of the Sahel before RCT results are available are that this decision might not have the support of key stakeholders or that we may be ignorant of downsides to delivering SMC in Mozambique that don't apply to the Sahel.

Our impression, however, is that Malaria Consortium's SMC project in Nampula has had the support of key stakeholders. The stakeholders we have asked for feedback on this potential grant have responded positively and haven't raised unexpected downsides. We are aware of the following stakeholder perspectives and/or involvement in this project:

• Programa Nacional de Controlo da Malária (PNCM). Our impression is that Mozambique's PNCM is enthusiastic about scaling up SMC. In its Malaria Strategic Plan for the 2017-22 period, the PNCM recommended SMC as a malaria control strategy for the country's highest-burden locations.21 In early 2020, it approached Malaria Consortium about conducting an SMC implementation study.22 During this grant investigation, we spoke with the PNCM and asked for feedback on this grant.
• BMGF. BMGF is co-funding the implementation study.23 During this grant investigation, we spoke with BMGF and asked for feedback on this grant.
• Scientific advisory committee. Malaria Consortium has convened a scientific advisory committee "comprising malaria experts, the donor community, and national stakeholders" to advise on the design of Phase 2 research and the interpretation of results from Phases 1 and 2.24 GiveWell participates in this committee.
• WHO. According to Malaria Consortium, WHO was involved in selecting the location for the SMC project in Mozambique.25 We don't know the details of its involvement.
• Clinton Health Access Initiative (CHAI). According to Malaria Consortium, CHAI was also involved in selecting the location for the SMC project in Mozambique.26 We don't know the details of its involvement.

Considerations about grant size

Scope of grant. We are recommending the amount of funding that will enable Malaria Consortium to scale to one full province. Our decision to support scaleup beyond the currently-supported four districts is largely based on Malaria Consortium's preference. Malaria Consortium expects the cost-effectiveness of operating in a full province to be higher than that of operating in four districts because fixed costs will be spread over a larger target population, which we find convincing. Malaria Consortium also expects that scaling up to support a full province will enable it to start building out its operational capacity for SMC in Mozambique, which will in turn allow it to scale up more quickly in future years.

We have not considered supporting further scaleup to additional provinces in the 2022-23 season, though it seems likely that SMC will be recommended for additional provinces in Mozambique once the RCT results are available. This is again based on Malaria Consortium's recommendation, and also on a concern that to scale beyond Nampula would risk communicating to other funders that their funding isn't required to scale up SMC in Mozambique (more below).

Length of grant. We are recommending two years of funding for this work. Though we typically recommend grants that include three years of funding runway, we are choosing not to do so in this case because we prefer to wait to see results from the Phase 2 RCT before committing funding to future years, in case the RCT measures lower effectiveness than we expect. We expect to see those results in late 2022, past when a grant decision is needed for the 2022-23 season (see below), though likely in time to inform a grant decision for the 2023-24 season. Our reason to recommend funding for the 2023-24 season now, rather than waiting for the RCT results, is that Malaria Consortium prefers to have two years of funding secured if it's going to make the operational decision to scale up.27 We think this is a reasonable preference and have decided to recommend two years of funding because of expected high cost-effectiveness (i.e., we think there's a low likelihood that we will ultimately think this grant was <5x cash; see above).

Malaria Consortium as a grantee

We believe that Malaria Consortium is the right partner to scale up SMC in Nampula. This is because:

• Malaria Consortium is running the SMC project in Nampula and has previous experience supporting malaria programs in Mozambique.28
• Malaria Consortium has a strong track record of delivering SMC programs in the Sahel. See this section of our Malaria Consortium review for a description of its SMC implementation experience and this section for a discussion of the coverage surveys conducted after individual cycles and full rounds of SMC, which have demonstrated that Malaria Consortium's programs can reach a high proportion of targeted children.
• Our qualitative assessment of Malaria Consortium as an organization is highly positive. We rated it as "relatively strong" or “stands out” on seven of eight dimensions included in our qualitative assessments.29
• We have asked several SMC stakeholders for feedback on Malaria Consortium and have heard positive feedback. See lists of stakeholder conversations we have had recently here and here.

Time-sensitivity

We believe that the funding need for the 2022-23 season is time-sensitive. Our understanding from Malaria Consortium is that it needs to place the order for SMC drugs for that season as soon as possible, in order to avoid delaying the campaign. This means that for RCT results to become available before making this grant would have caused the 2022-2023 season to miss receiving SMC entirely. We don't believe that the funding need for the 2023-2024 season is time-sensitive.

Risks and reservations

• Not yet available RCT results. Waiting for RCT results to become available would have a number of benefits, and we are forgoing these benefits by choosing not to wait. (More)
• Potential difficulty of exiting. If the RCT measures lower effectiveness than we expect, it may be difficult to stop funding the program after two years. (More)
• Potential stakeholder opposition. We have only spoken with two non-Malaria Consortium stakeholders about this potential grant, and it's possible that we would hear opposition to this grant if we sought out more conversations. (More)
• Risk of future crowding out. We think it is possible that by making this grant and therefore demonstrating a willingness to fund SMC delivery at greater scale in Mozambique, we are setting the expectation for the PNCM, the Global Fund, and PMI that GiveWell funding will be available for future SMC scaleup there. (More)

Not yet available RCT results

We could have waited for RCT results to become available before making this grant. We will have more confidence in our cost-effectiveness estimate once relevant parameters have been updated to use RCT results. We are forgoing this benefit by choosing not to wait.

Potential difficulty of exiting

If the RCT measures lower effectiveness than we expect, it may be difficult to exit after two years, either because additional exit funding would be needed to wind down the program or because a quick exit could damage our reputation as a funder or Malaria Consortium's relationship with the PNCM. Mitigating this concern is the fact that Malaria Consortium has explicitly stated that it will be able to end the program after two years if the RCT measures low effectiveness. If this occurs, Malaria Consortium may not need exit funding because its staff in Mozambique work on a number of projects and may be able to pivot relatively easily.

Potential stakeholder opposition

There is concern within the malaria community that SMC will be less effective outside of the Sahel due to SP resistance. We have only spoken with two non-Malaria Consortium stakeholders about this potential grant (the PNCM and BMGF), and it's possible that we would hear opposition to this grant if we sought out more conversations.

Mitigating this concern are the facts that:

• As discussed above, our impression is that Malaria Consortium's SMC project in Nampula has had the support of key stakeholders. The stakeholders we have asked for feedback on this potential grant have responded positively.
• We aren't aware of any specific opposition to SMC scaleup in Mozambique.
• As discussed above, we have a highly positive qualitative assessment of Malaria Consortium, and our impression is that it is well-respected in the malaria community.

Risk of future crowding out

Our "Likelihood that the Global Fund and/or PMI would replace Malaria Consortium's costs" adjustment, described above, is primarily intended to account for the extent to which we believe our funding may be crowding out funding that would otherwise have come from these sources to fill this specific funding gap. It may not fully account for the effect that our grantmaking may have on these funders' behavior over the medium-to-long term.

We think it is possible that by making this grant and therefore demonstrating a willingness to fund SMC delivery at greater scale in Mozambique, we are setting the expectation for the PNCM, the Global Fund, and PMI that GiveWell funding will be available for future SMC scaleup there. This belief may, in turn, lead them to direct funding that they would have directed toward SMC scaleup to other programs and services. Our aim is for this grant to act as bridge funding between research and full scale, rather than as a commitment to take SMC to scale in Mozambique.

Plans for follow-up

• We will continue our monthly calls with Malaria Consortium to discuss its work.
• We will request that Malaria Consortium submit spending reports and coverage surveys from these campaigns, as it has for all previously-funded campaigns.
• We will track how the PNCM, the Global Fund, and PMI choose to allocate future funding for malaria programs, and specifically SMC, in Mozambique.
• We will review the results of the RCT when they are available and update relevant parameters in our cost-effectiveness analysis.

Internal forecasts

Confidence	Prediction	By time
70%	The RCT will measure at least a 50% reduction in clinical malaria.	End of 2022

Our process

Malaria Consortium has used GiveWell-directed funding to support the Nampula implementation study.30 Through the scientific advisory committee, GiveWell was involved in the design of Phase 2 research. In 2021, we began discussing options for SMC in Mozambique beyond Phase 2 with Malaria Consortium and jointly agreed upon the plan proposed here.

Our grant investigation relied heavily on our prior work modeling the cost-effectiveness of SMC campaigns supported by Malaria Consortium and our relationship with Malaria Consortium and knowledge of its work. We added Mozambique to our existing cost-effectiveness model for SMC campaigns and updated various parameters to match the specifics of this funding gap (discussed above). For internal review, a Program Officer who was not involved in this grant investigation reviewed and gave feedback on this grant prior to approval.

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

• Mozambique's PNCM.
• The Bill and Melinda Gates Foundation.

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

Sources

Document	Source
Candrinho 2021	Source (archive)
GiveWell, "GiveDirectly"	Source
GiveWell, "Malaria Consortium—Seasonal Malaria Chemoprevention"	Source
GiveWell, "Qualitative Assessments of Top Charities," 2020	Source
GiveWell, "Recommendation to Open Philanthropy for Grants to Top Charities," 2019	Source
GiveWell, "Revisiting leverage," 2018	Source
GiveWell, "Why we can’t take expected value estimates literally (even when they’re unbiased)," 2016	Source
GiveWell, "Why we’re excited to fund charities’ work a few years in the future," 2020	Source
GiveWell, [Mozambique copy] GiveWell's room for more funding analysis for Malaria Consortium's SMC program, 2021	Source
GiveWell, 2022 cost-effectiveness analysis - Mozambique sensitivity analysis	Source
GiveWell, Cost-effectiveness analysis — version 4, 2022	Source
IHME, "Global Burdens of Disease"	Source (archive)
Malaria Consortium, "Mozambique"	Source (archive)
Malaria Consortium, SMC in Nampula Mozambique concept note and authorship agreement	Unpublished
Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021	Unpublished
Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020	Source
PMI, "Where We Work"	Source (archive)

• 1

  Unlike SMC programs in the Sahel, the malaria transmission season in Mozambique runs across calendar years. For example, "Four monthly cycles of SMC will be implemented between November 2021 and February 2022 in four districts in Nampula province, two will be focused on research and two will have the standard SMC distribution." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 15. (unpublished)

• 2

  Malaria Consortium’s estimates of target populations and cost per child are ​​here in our room for more funding analysis.

• 3

  "Phase 1 of the pilot project involved administering four monthly cycles of SMC to a target population of around 72,000 children aged 3-59 months in two districts of Nampula province between November 2020 and February 2021." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 13. (unpublished)

• 4
  • "Four monthly cycles of SMC will be implemented between November 2021 and February 2022 in four districts in Nampula province, two will be focused on research and two will have the standard SMC distribution." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 15. (unpublished)
  • The 2021-22 season began in January 2021, after being delayed as Malaria Consortium waited for ethical approval for Phase 2 of the accompanying study. Conversation with Malaria Consortium, January 20, 2022 (unpublished).

• 5

  "A hybrid effectiveness-implementation design was adopted, which involved the following components:

  • documentation of the process of SMC implementation and adaptations compared to the model used in west and central Africa
  • a representative end-of-round household survey with more than 1,800 respondents
  • KIIs and FGDs with policy makers, SMC implementers, and beneficiaries
  • analysis of HMIS data on malaria indicators reported at the health facility and district levels
  • a non-randomized controlled trial involving around 800 children in an intervention and a control arm to determine the odds of clinically significant malaria outcomes among eligible children
  • a molecular resistance markers study to determine baseline prevalence of SP and AQ resistance and any increase in resistance prevalence after one annual round of SMC."

  Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, pg. 43.

• 6

  "The intervention appears to be highly effective: in a non-randomised controlled trial,
  children who lived in a district where SMC had been implemented had 86 percent lower
  odds of developing clinical malaria during the peak transmission season compared with
  children who lived in the control district without SMC implementation." Candrinho 2021, slide 17.

• 7

  See parameter "Corresponding reduction in clinical malaria among children targeted" in our cost-effectiveness analysis.

• 8

  "Because resistance to SP is widespread in East and Southern Africa, SMC has so far only been implemented across the Sahel region of West and Central Africa." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 8. (unpublished)

• 9

  Conversation with Malaria Consortium, October 21, 2021 (unpublished).

• 10

  "Malaria Consortium’s SMC project in Mozambique is funded through philanthropic donations, mainly received as a result of being awarded Top Charity status by GiveWell, a non-profit organisation dedicated to finding outstanding giving opportunities through in-depth analysis. Phase 1 research for this project was co-funded through a Bill & Melinda Gates Foundation grant." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 2. (unpublished) Phase 2 research is also being co-funded by BMGF.

• 11

  See this change in our cost-effectiveness analysis changelog.

• 12

  See this parameter in our cost-effectiveness analysis here.

• 13

  See the ‘Proportion of annual direct malaria mortality occurring in high-transmission season’ parameter for Burkina Faso, Nigeria, Togo, and Chad, which are all in the Sahel.

• 14

  We calculate a value of 52% by averaging 70% (the value we use for the Sahel) and 33% (a value that assumes no seasonality in malaria cases).

• 15

  See the ‘Rate ratio for malaria cases (intention to treat effect)’ parameter in our cost-effectiveness analysis here.

• 16

  See the ‘Corresponding reduction in clinical malaria among children targeted’ parameter here.

• 17

  Malaria Consortium has indicated that it expects costs to be relatively high during the scaleup period. Of the countries we support in the Sahel, we estimate that Chad has the highest cost per SMC cycle administered. We have therefore decided to use the value we calculate for Chad in our model for Mozambique.

• 18

  Mozambique receives funding from PMI. Mozambique is listed on PMI, "Where We Work".

• 19

  See the ‘Scenario 2: Global Fund and/or PMI would replace philanthropic costs’ parameter here.

• 20

  Our guess about SMC's effectiveness in Mozambique (50% reduction in clinical malaria among children targeted) could be reduced to 48% to meet an 8x cash bar and to 28% to meet a 5x cash bar. See this version of the CEA, Mozambique (minimum efficacy to meet 8x) and Mozambique (minimum efficacy to meet 5x). Given the observational phase 1 result (described above) of 80%, we guess that the probability of the RCT measuring at least 28% efficacy—and therefore the probability of this grant being at least 5x cash—is high. The value we currently use from Chad ($1.98) for the cost per SMC cycle administered parameter could be increased to $2.09 to meet an 8x cash bar and to $3.63 to meet a 5x cash bar.

• 21

  "A mid-term review of Mozambique’s Malaria Strategic Plan 2017–2022 recommended SMC as a strategy to accelerate impact in the highest-burden locations." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, pg. 25.

• 22

  "The national malaria program (Programa Nacional de Controlo da Malária, PNCM) approached Malaria Consortium about the possibility of piloting SMC in Mozambique in early 2020." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, pg. 25.

• 23

  "Malaria Consortium’s SMC project in Mozambique is funded through philanthropic donations, mainly received as a result of being awarded Top Charity status by GiveWell, a non-profit organisation dedicated to finding outstanding giving opportunities through in-depth analysis. Phase 1 research for this project was co-funded through a Bill & Melinda Gates Foundation grant." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 2. (unpublished)

• 24

  "Research activities are ongoing. Results will be published over the course of 2021 and 2022. A scientific advisory committee comprising malaria experts, the donor community, and national stakeholders has been formed to advise on the interpretation of results from year one and the research design for year two." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, pg. 44.

• 25

  "As a first step, a prioritization exercise was conducted in collaboration with the PNCM, WHO, and the Clinton Health Access Initiative. The following criteria were applied to identify suitable implementation areas for the SMC pilot." Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, pg. 25.

• 26

  "As a first step, a prioritization exercise was conducted in collaboration with the PNCM, WHO, and the Clinton Health Access Initiative. The following criteria were applied to identify suitable implementation areas for the SMC pilot."Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020, pg. 25.

• 27

  Conversation with Malaria Consortium, November 17, 2021 (unpublished).

• 28

  "We work closely with the Ministry of Health (MoH), the National Malaria Control Programme (NMCP), the National Community Health Workers Programme, provincial and district health authorities and affected communities. We provide technical assistance to our partners to strengthen existing health systems by: improving the integrated community case management (iCCM) of common illnesses, such as malaria, diarrhoea and pneumonia; deploying functional surveillance mechanisms; developing and scaling innovative community-focused platforms to facilitate data informed decision-making; addressing knowledge gaps through operational research; and through social and behaviour change approaches." Malaria Consortium, "Mozambique"

• 29

  See GiveWell, "Qualitative Assessments of Top Charities," 2020. Our latest published assessment is from 2020. Our impressions of our top charities' performance on these dimensions has not changed meaningfully since that time.

• 30

  "Malaria Consortium’s SMC project in Mozambique is funded through philanthropic donations, mainly received as a result of being awarded Top Charity status by GiveWell, a non-profit organisation dedicated to finding outstanding giving opportunities through in-depth analysis. Phase 1 research for this project was co-funded through a Bill & Melinda Gates Foundation grant." Malaria Consortium, SMC in Nampula province Mozambique study protocol, 2021, pg. 2. (unpublished)