Malaria Consortium — Seasonal Malaria Chemoprevention in Karamoja, Uganda in 2025-26 (September 2024)

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

Published: January 2025

The organization

Seasonal malaria chemoprevention (SMC) involves giving children monthly courses of antimalarial medicines during the high malaria season, in areas where malaria is seasonal. For more on this intervention, see our SMC intervention report.

Malaria Consortium's SMC program is one of GiveWell's top charities. We have made previous grants to Malaria Consortium, including grants supporting SMC delivery in Karamoja, Uganda. Malaria Consortium began supporting SMC delivery in the Karamoja subregion in Uganda in 2021 as part of a small-scale implementation and research pilot co-funded by GiveWell1 . After the pilot’s conclusion in 2022, we granted funds to support continued implementation of SMC programs in the subregion in 2023 and 2024.2 These funds have supported SMC delivery in five districts of Karamoja, with delivery in the four remaining districts being funded through the Global Fund.3

The grant

Grant activities

This grant will continue to fund Malaria Consortium’s delivery of SMC to children in five districts of the Karamoja subregion of Uganda during the 2025 and 2026 malaria seasons.4 We describe SMC in further detail in our intervention report, and Malaria Consortium's role in SMC programs in this section of our Malaria Consortium top charity review.

Budget for grant activities

We are recommending $2,731,480 from the Top Charities Fund for this grant, which will cover both the 2025 and 2026 malaria seasons.

Malaria Consortium’s budget for the 2025-2026 SMC program is $2,653,771, broken down as follows:5

• $687,190 for SMC delivery, including community engagement, training, administration, and supervision costs
• $569,996 for medicines and other SMC commodities, including freight and supply management costs
• $491,108 for staff and consultants
• $288,133 for monitoring and evaluation
• $284,333 for grant management
• $223,012 for operational costs, including digitalization and external relations
• $110,000 for research costs

Factoring in projected above-country costs,6 we recommended a total grant of $2,731,480.7

The case for the grant

For a general overview of why we consider SMC to be a cost-effective intervention, see our intervention report here. For further detail on why we consider SMC appropriate for Karamoja, Uganda, see our previous grant page here.

We are recommending this grant for SMC delivery during the 2025-2026 malaria seasons in Karamoja for the following reasons:

• Cost-effectiveness. Our current best estimate of the cost-effectiveness of SMC in Karamoja is approximately 8 times that of unconditional cash transfers, right around our current bar for grantmaking to top charities. We have decided to err on the side of continuing to fund the program while we do further work on several parameters that may push our updated estimate above, or further below, our bar (more).
  
• Malaria Consortium as the grantee. Malaria Consortium has a strong track record of SMC delivery programs, and we have a highly positive impression of them as an organization.8 From other SMC stakeholders, we've also heard positive, and often strongly positive, feedback about Malaria Consortium, including that Malaria Consortium is a good partner to work with and that it delivers high-quality programs.9 For our review of Malaria Consortium, see here.

Cost-effectiveness

Cost-effectiveness is a major consideration in our grantmaking decisions. Our current model projects that the costs of Malaria Consortium’s SMC program in Karamoja are likely to decrease in the next few years10 , and taking Malaria Consortium’s cost projections at face value, the program’s steady-state cost-effectiveness will be around 8 times that of unconditional cash transfers ("x cash"), just below our cost-effectiveness bar for top charities. A simple version of our cost-effectiveness model is below (see our full analysis here):

However, there are several parameters we are still investigating, which may shift this cost-effectiveness analysis substantially (more). In order to allow Malaria Consortium time to acquire SMC drugs in advance of the upcoming malaria season in Uganda, we made our grant decision while those investigations are still ongoing, and decided in favor of making this grant despite our current cost-effectiveness estimate landing below our funding bar. We did so because (a) we believe it is generally good practice not to suddenly end funding to programs we have supported without an exit grant, for reasons of reducing harm to staff, partners, and program beneficiaries, as well as allowing the organization and its partners time to explore other funding sources or manage a graceful phaseout period; and (b) there is a meaningful chance that further work in our ongoing investigations will, in the next six months, lead us to believe that the program is above our bar, and we do not want the program to be discontinued while we continue learning more.

At the time of our prior grant to this program, we estimated cost-effectiveness at 10x cash. The factors that have lowered this estimate include:

• Higher costs than projected. Our previous estimates of cost-effectiveness were benchmarked off of the costs of Malaria Consortium’s SMC programs elsewhere.11 Our current model has now switched to Uganda-specific cost projections because we think, and Malaria Consortium agrees, that costs are approaching a steady-state level.12 These costs are meaningfully higher ($2.24) than those in the larger programs in the Sahel ($1.1-$1.9). As Karamoja has less seasonality in malaria transmission than most of the Sahel, and thus receives five SMC cycles13 rather than four, this implies a cost per child fully treated of $11.21 (including government costs), as compared to $5-8 in the Sahel. This is the primary driver of our lowered cost-effectiveness estimate.

Malaria Consortium attributes this difference in cost to a number of factors, including the relatively higher wage commanded by community distributors in Uganda,14 the remoteness of Karamoja, and the smaller scale of this program, which we believe is unlikely to scale up meaningfully.15 The Karamoja sub-region is reported to have a higher malaria burden than most in Uganda, and is the only region recommended for SMC.16 Within the Karamoja sub-region, the Global Fund is funding SMC in four out of nine districts, with our grants to Malaria Consortium supporting the rest.17

• Adjustment for malaria vaccines. While we’re highly uncertain about what scale-up will look like, we do expect the rollout of the R21 malaria vaccine to lead to a decrease in malaria-attributable child mortality.18 This is a moderate reduction in our cost-effectiveness estimate.
• Greater funging risk. We slightly increased our estimate of the funging risk – the risk that in making a grant we are merely displacing funding that would come from other actors – to 40% from 30%. We think that it’s fairly plausible that the Global Fund could and would fund these districts in our absence (more). We now overall reduce our estimate of the value generated by this grant by approximately -20% to account for funging risk. This parameter change led to a small decrease in our estimate.

• Cost per child. We have based our figure for steady-state costs on Malaria Consortium's budget for the program, and Malaria Consortium may be able to reduce costs more than their or our current projections suggest.
• Malaria burden and malaria vaccine adjustment. Our model attempts to estimate sub-national malaria burden in a small portion of the country,19 which is also an area that reports suggest has an unusually high malaria burden for Uganda.20 We find it plausible that we could be off by a factor of two in either direction.

Similarly, we add an adjustment for vaccination effects on malaria burden, and we could be underestimating cost-effectiveness of the SMC program if this adjustment is overstated. This figure is sensitive to projected vaccination coverage, which is challenging to predict because malaria vaccines are in early stages of rollout globally and in Uganda.21

• SMC efficacy in Karamoja. Our current estimates for the effectiveness of SMC in Uganda are modestly lower than in the Sahel: 64% vs. 79% effective at reducing deaths during the malaria season, with 62% vs. 70% of malaria deaths occurring in that season. Though we think it is implausible that SMC would be more effective in Karamoja than in the Sahel,22 it would be a meaningful increase in our cost-effectiveness estimate if we believed SMC was approximately as effective in Karamoja as we model it in the Sahel.
• Funging risk and outside funding. We could be overestimating the likelihood of these districts receiving Global Fund support in the long term (more). If we model a 20% funging risk, rather than the 40% that we currently assume, the program would meet our funding bar.23

Risks and reservations

Our main reservation about this grant is:

• Uncertainty about the future of this program. This may be our last grant for the SMC program in Karamoja. If so, we would want to share that decision with Malaria Consortium and other stakeholders as early as possible to give them time to plan and to seek other funding sources. For more on why we may decide to exit, see (below).

Exit Decision

We intend to let Malaria Consortium know by mid-2025 whether we have decided against renewing this grant, based on factors including updated cost-effectiveness estimates (more), the funding landscape (more), and the program’s room for more funding.24 If we decide not to renew funding, this grant will serve as an exit grant for the program.

Funding landscape

In our model, we assume a 40% chance that the Global Fund, or another funder, would replace the funding we direct to SMC in Karamoja if we were to exit. This figure reflects our sense, explained further below, that the Global Fund is well-positioned to take over funding for the districts of Karamoja that we currently fund, as well as an understanding that there are many competing priorities for the limited malaria funding in Uganda.

The Global Fund is currently funding four of the nine SMC-eligible districts of Karamoja, where GiveWell is funding the remainder.25 If the Ugandan National Malaria Control Program (NMCP), in consultation with the Global Fund, decides that SMC is a high priority, it will likely have the option to allocate Global Fund funding to cover all nine districts in Karamoja in the next Global Fund allocation cycle (2027-2029). Currently, the Global Fund provides $2.4m to fund SMC programs in those four districts.26 For comparison, in the 2024-2026 cycle, the Ugandan National Malaria Control Program (NMCP) requested $136m of Global Fund funding for vector control, and $98m for case management.27 We think this makes it plausible that the NMCP could request additional funding for SMC for the next Global Fund funding cycle (2027-2029) and that the Global Fund would approve the request.

We also believe that this grant would be well timed to be an exit grant. The implementation period of the current Global Fund grant cycle runs through the end of 2026.28 Our understanding is that NMCPs will begin submitting funding applications for the next cycle, covering 2027-2029, in 2025. Because of this, we think providing two years of runway to cover 2025 and 2026, with an exit decision by mid-2025, is well-positioned to both ensure the program is stably funded through the end of the cycle, and to provide clear and early information to the NMCP and the Global Fund that these districts should be considered unfunded as of the next Global Fund cycle.

However, while the Global Fund and the Ugandan NMCP are presently supportive of SMC in Karamoja, it is not guaranteed that this will hold in the future. We’ve also heard repeatedly over the past few years that the Global Fund is increasingly funding-constrained, and we’ve seen recent evidence to that effect in the form of high-priority funding gaps across Africa.29 It’s possible that the Global Fund may become even more funding constrained in the next funding cycle, due to population growth, political outcomes in donor countries, or other factors, and it consequently may be less likely to fund SMC delivery in Karamoja in our absence than we have assumed.

Plans for follow up

• As with other grants to Malaria Consortium for SMC programs, we will have monthly (or more frequent) calls with Malaria Consortium to discuss operational updates, research questions, and future plans. Malaria Consortium provides details annually on spending, target populations, and coverage survey results.
• We will continue speaking with Malaria Consortium about target populations and economies of scale across areas where it is proposing support. Our sense from 2023 cost and coverage data is that we may have underestimated the share of campaign costs that are fixed at the country level, and thus underappreciated the importance of economies of scale. This may be leading us to overestimate the promise of SMC campaigns in regions where only small areas are eligible for coverage.
• We intend to continue investigating open questions on malaria burden, malaria vaccination coverage projections, and SMC efficacy outside the Sahel that may affect our model of the cost-effectiveness of this program.
• We plan to decide by mid-2025 whether to continue funding Malaria Consortium’s SMC delivery in Karamoja, and to communicate that plan to Malaria Consortium and other stakeholders.

Internal forecasts

For this grant, we are recording the following forecasts:

Our process

• We updated our cost per cycle analysis with 2023 cost and coverage data, and included Uganda in the analysis for the first time.
• We had two calls with Malaria Consortium to discuss previous years’ costs, projections for the future, and potential exit strategies in light of unexpectedly high costs per child.
• We updated burden estimates and added an adjustment for malaria mortality averted by the malaria vaccine in SMC geographies.
• A program associate used the above components and Malaria Consortium’s cost projections for Uganda to estimate cost-effectiveness in 2025 and 2026, and a research associate reviewed. See our cost-effectiveness analysis here.

Sources

• 1

  “GiveWell funded Malaria Consortium to pilot SMC in Karamoja in 2021 and 2022 and co-funded a similar two-year implementation study, (including an RCT), with BMGF.” GiveWell, Malaria Consortium.

• 2

  See our grant page for this grant here.

• 3
  • “In 2023, Malaria Consortium expects to implement SMC with philanthropic support in the same five districts as in 2022, but including children who lived in control or buffer communities and thus did not receive SMC in 2022. The philanthropic SMC target population will be approximately 190,000. We expect that the remaining four districts of Karamoja, with a combined target population of 100,000 children will be reached with support from the Global Fund.” Malaria Consortium, 2022 SMC Philanthropy Report, p. 63.
  • “Since 2017, Malaria Consortium has been using funding received as a result of GiveWell's recommendation (which we refer to as "GiveWell-directed funds" and Malaria Consortium refers to as “philanthropic funding”) to support SMC programs in several countries.” GiveWell, Malaria Consortium.

• 4

  “Malaria Consortium requests approval from GiveWell for the continued use of philanthropic
  SMC funding to support SMC in five districts of Karamoja in 2025 and 2026.” Malaria Consortium, Grant request: Supporting SMC in Uganda, 2025-2026, 2024.

• 5

  Malaria Consortium, Annex 1 - Detailed Budget 2025-26, 2024.

• 6

  Above-country costs are costs that are incurred on the organizational level, and not linked to any particular national program. We assume that additional above-country costs will be incurred proportionally to the size of a grant. See our calculation for 2025 above-country costs here, and for 2026 here. The total for the 2025-2026 grant is $77,709 ($40,766+$36,943 = $77,709).

• 7

  $2,653,771+$77,709 = $2,731,480.

• 8

  See our qualitative assessment of Malaria Consortium in GiveWell, Malaria Consortium, “Qualitative Assessment.”

• 9

  “When we have requested feedback on Malaria Consortium from national malaria programs and other SMC stakeholders,we have heard positive (and often very strongly expressed) comments. This includes feedback that Malaria Consortium is a good partner to work with, that it delivers high-quality programs, and that it conducts high-quality research.” GiveWell, Malaria Consortium.

• 10
  • For 2023, we estimated a cost per child of $15.3, and for 2025 and 2026, we estimate a cost per child of $10.42 and $9.43, respectively.
  • We expect costs to stabilize after 2026 (after the period this grant covers): “In general, the unit cost of SMC in Uganda is reducing substantially as the programme matures. Malaria Consortium believes that the unit cost would stabilise at approximately the level projected for 2026 should longer-term funding be available.” Malaria Consortium, Grant request: Supporting SMC in Uganda, 2025-2026, 2024, p. 4.

• 11

  “However, because we don't yet have costs and coverage from Malaria Consortium's full-scale implementation of SMC in Mozambique or Uganda, 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 achieved in Chad in 2022 ($1.81).” GiveWell, SMC Renewal in Uganda and Mozambique.

• 12

  “In general, the unit cost of SMC in Uganda is reducing substantially as the programme matures. Malaria Consortium believes that the unit cost would stabilise at approximately the level projected for 2026 should longer-term funding be available.” Malaria Consortium, Grant request: Supporting SMC in Uganda, 2025-2026, 2024, p. 4.

• 13

  “In Uganda, five cycles were delivered in all five supported districts.” Malaria Consortium, SMC Coverage Report 2023, p. 15.

• 14

  Correspondence from Malaria Consortium to GiveWell, December 18, 2024. (unpublished)

• 15

  Malaria Consortium in conversation with GiveWell, August 1, 2024. (unpublished)

• 16

  “Based on modelling by the Swiss Tropical and Public Health Institute, the Uganda Malaria
  Reduction and Elimination Strategic Plan 2021–2025 recommends the introduction of SMC in the Karamoja subregion, where malaria transmission is seasonal and the highest prevalence rates in the country are consistently reported.” Malaria Consortium, 2023 SMC Philanthropy Report, p. 36.

• 17

  "In 2023, Malaria Consortium expects to implement SMC with philanthropic support in the same five districts as in 2022 … We expect that the remaining four districts of Karamoja, with a combined target population of 100,000 children will be reached with support from the Global Fund." Malaria Consortium, 2022 SMC Philanthropy Report, p. 63.

• 18

  Details on this adjustment will be available in our forthcoming malaria vaccines intervention report, which will be linked here when published.

• 19

  See our estimates here, with subnational calculations available here.

• 20

  “Based on modelling by the Swiss Tropical and Public Health Institute, the Uganda Malaria
  Reduction and Elimination Strategic Plan 2021–2025 recommends the introduction of SMC in the Karamoja subregion, where malaria transmission is seasonal and the highest prevalence rates in the country are consistently reported.” Malaria Consortium, 2023 SMC Philanthropy Report, p. 36.

• 21
  • “Twelve countries across different regions in Africa are set to receive 18 million doses of the first-ever malaria vaccine over the next two years…In addition to Ghana, Kenya and Malawi, the initial 18 million dose allocation will enable nine more countries, including Benin, Burkina Faso, Burundi, Cameroon, the Democratic Republic of the Congo, Liberia, Niger, Sierra Leone and Uganda, to introduce the vaccine into their routine immunization programmes for the first time.” WHO, 18 million doses of first-ever malaria vaccine allocated to 12 African countries for 2023–2025: Gavi, WHO and UNICEF, 2023.
  • See our model calculating the malaria vaccine adjustment here

• 22

  For our analysis of SMC outside the Sahel, see here.

• 23

  Adjusting the funging risk to 20% would result in a cost-effectiveness figure greater than 8x.

• 24

  SMC delivery in Karamoja is a fairly small program in our chemoprevention portfolio, consisting of $1.5m in the 2024 malaria season. We may decide we can better spend our time by focusing on programs that are more promising in terms of scale.

• 25

  “For this GC7 malaria funding request, given the limited funds, we have prioritized SMC for all the 9 districts in Karamoja, and allocated funds within funds to continue SMC implementation in 4 districts leaving costs for five SMC in five districts prioritized as above allocation request. NMCD will engage with Givewell, an existing health sector partner, to mobilise resources to cover this gap. The Global Fund, Uganda 2023-2025 Malaria Funding Request, p. 37.

• 26

  “USD 2,440,738 is requested for SMC, of which USD 1,407,221 is for implementation costs within allocation and USD 1,540,646 under PAAR for this intervention.” The Global Fund, Uganda 2023-2025 Malaria Funding Request, p. 38.

• 27

  See The Global Fund, Uganda 2023-2025 Malaria Funding Request, p. 5. Note that though the allocation period is 2023-2025, the grant dates are 2024-2026 (see p. 1).

• 28

  The implementation period of the current grant cycle, the seventh replenishment, ends in 2026. See The Global Fund, Replenishment.

• 29

  See the “Funding landscape for SMC” section of GiveWell, Malaria Consortium — SMC Renewals in Nigeria, Burkina Faso, and Togo (January - March 2024)