Evidence Action — Syphilis Screening and Treatment in Pregnancy in Zambia foreign aid gap filling grants (March 2025)

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

Published: March 2026

1. Background

In July 2022, GiveWell recommended a grant of approximately $15 million to Evidence Action to provide technical assistance to the governments of Zambia and Cameroon to support the scale up of syphilis testing and treatment in pregnancy. This grant funds Evidence Action’s efforts from 2022 to 2028 to support the governments in switching from HIV rapid tests to dual HIV/syphilis rapid tests and increasing syphilis treatment rates in routine antenatal care (ANC).

In Zambia, in partnership with the Ministry of Health, Evidence Action had been implementing a three-phase training program for healthcare providers to scale up syphilis testing and treatment during pregnancy, with some support from other US government (USG) funded organizations and the Global Fund:

• Phase 1 (more than 800 facilities serving around 50% of the ANC-attending population) was completed in 2024.1
• Phase 2 (an additional ~1,000 facilities serving around 30% of the ANC-attending population) was disrupted by the US foreign aid funding freeze in February 2025. Over 200 facilities were yet to be trained by USG-funded organizations at the time of the stop-work order.2
• Phase 3 is intended to reach a majority of remaining facilities that provide ANC services.

Additionally, PEPFAR was expected to procure a portion of Zambia's dual-tests in 2025 and it was unclear whether that order had been placed or would be fulfilled. Since tests need to be procured several months in advance, there were concerns that there would be stockouts of test kits.

2. Grant summary

In March 2025, GiveWell approved two grants totalling up to $1,046,535 to Evidence Action's Syphilis Screening and Treatment in Pregnancy program in Zambia to fill gaps left by the foreign aid funding freeze. The two grants are broken down as follows:

• $142,515 to cover additional training that was left unfunded during the foreign aid freeze period in early 2025;
• $904,020 as a contingency amount to allow Evidence Action to procure HIV/syphilis dual tests if gaps were left from delays or funding cuts since PEPFAR had supported dual test procurement.

3. What we think this grant will do

We expect these grants to enable Evidence Action to prevent major disruption to their program in two ways.

3.1 Training

The $142,515 grant allows Evidence Action to conduct additional training that was left unfunded during the foreign aid freeze period. Affected facilities had already received syphilis testing and treatment commodities but had been instructed not to use them before receiving training. By enabling training to continue as scheduled, this grant decreases the risks of either inappropriate use of commodities without training, or pregnant patients not being tested while commodities sit unused.3

The $142,515 training grant budget4 breaks down as follows:

• $68,216 for daily subsistence allowance
• $15,711 for lunch allowance for facility staff
• $19,633 for lunch allowance and transport/gas refunds for trainers
• $38,956 for regional direct shared costs and indirect costs

3.2 Procurement

The remaining $904,020 contingency amount gives Evidence Action the flexibility to procure HIV/syphilis dual tests to prevent a stockout of dual tests if gaps were left from delays or funding cuts since PEPFAR had supported dual test procurement. The procurement amount is a contingency grant, which means that GiveWell and Evidence Action agreed that if dual test orders either from PEPFAR or the government of Zambia end up coming through in time to prevent stockouts such that Evidence Action does not need to place an additional order for tests, these funds would be returned to GiveWell.

The $904,020 contingency dual test procurement amount5 breaks down as follows:

• $570,000 for the purchase of tests (600,000 tests at a cost of $0.95 per test)
• $171,000 for procurement and shipping logistics (using a rough 30% assumption based on Evidence Action’s previous procurements)
• $163,020 for Evidence Actions’s indirect costs (22%).

As of September 2025, Evidence Action told us that the government of Zambia's order for test kits was placed in time to prevent immediate stockouts, and a procurement order from PEPFAR arrived in Zambia. However, Evidence Action is monitoring the Ministry of Health's quantification exercises and commodity orders via Global Fund mechanisms which typically occur towards the end of the year, and they will keep us informed about whether they may need to place a gap-filling order in the medium term (i.e. in 2026).6

4. Why we made this grant

The case for quickly approving these grants was primarily as follows:

4.1 Cost-effectiveness

We estimate that the overall program is highly cost-effective. When we made the initial grant recommendation in 2022, we estimated that this program was around 30x as cost-effective as unconditional cash transfers. We haven’t deeply revised this CEA since then, and do have some uncertainties about whether the model used for our Zambia and Cameroon grants might overstate cost-effectiveness.7 However, even accounting for a downward adjustment, we expect this grant is still highly cost-effective. Covering additional costs to enable the program to continue as planned would still be meaningfully above our cost-effectiveness bar. A quick estimate accounting for these additional costs and an upper bound guess on future costs (including the maximum top-up anticipated at the time we made these grants, and additional commodity procurement in future years) puts the cost-effectiveness at 16x. For information about a subsequent top-up grant we made to Evidence Action’s program in Zambia, see here.

These estimates all hold the program impact unchanged from our estimate at the time we made the initial grant. We will have more insight into Evidence Action's impact when we receive the results from their next Comprehensive Facility Survey in May 2026.

4.2 Real world cost of program delay or disruption

Disruptions to this program delivery either from lack of training or lack of dual test commodities could result in some pregnant people missing screening and treatment for syphilis during pregnancy. There is strong evidence that treating syphilis with benzathine penicillin G during pregnancy prevents adverse outcomes,8 so a delay in screening and treatment could result in delayed syphilis treatment and preventable stillbirths, neonatal deaths, cases of congenital syphilis, and instances of preterm birth.

Delaying these trainings would push back Evidence Action's entire timeline, potentially disrupting screening and treatment throughout not only the remaining Phase 2 facilities, but also facilities slated for Phase 3 training. Evidence Action also noted that the delay in some Phase 2 trainings could lead to geographic inequities, and they expect that this will be a major concern to the government.9

We approved the commodity funding as a contingency amount because it was unclear whether Zambia would have a commodity gap for test kits at the time we approved this grant. There was significant uncertainty around whether PEPFAR had placed a procurement order before the stop-work order began, and if they had, whether those test kits would arrive in Zambia on time or at all. Committing this contingency funding to Evidence Action will ensure they have flexibility to respond as needed. At the time we made the grant, Evidence Action did not plan to order tests immediately, but rather planned to wait until they have a clearer sense of: (a) whether PEPFAR’s original order arrives in Zambia, (b) the extent to which PEPFAR will continue to operate in Zambia, and (c) the expected timeline of any government test order. Our contingency funding gives Evidence Action the flexibility to assess the situation as it develops and order tests, if needed.

5. Our main reservations

Our main reservation is that the global aid landscape is currently very uncertain, both for HIV programming (with which syphilis programming is integrated) and with regards to future dual test procurement.

Dual test procurement in Zambia has historically been jointly supported by PEPFAR (around 60%) and the Global Fund (around 40%).10 It currently isn’t that clear what ongoing support there may be for dual test procurement with the global aid landscape changing. If ongoing support for dual test procurement is not sustained, this could negatively affect the long term impact of Evidence Action's support once the grant period ends.

6. Sources

Document	Source
Evidence Action, "Liberia, Zambia, and Cameroon Maternal Syphilis Grants, Step-Back," November 2024. Slide 16 (unpublished).	Unpublished
Evidence Action in correspondence to Givewell, February 20, 2025. (unpublished)	Unpublished
Evidence Action, "Partner Sites Budget Breakdown," February 26, 2025.	Source
Evidence Action, "Dual Test Budget Breakdown," March 18, 2025.	Source
Evidence Action in correspondence to GiveWell, September 2025. (unpublished)	Unpublished
GiveWell, CEA for Evidence Action Syphilis Screening and Treatment in Pregnancy in Zambia foreign aid gap filling grants (March 2025)	Source
Evidence Action in correspondence to GiveWell, February 2025. (unpublished)	Unpublished
Evidence Action in conversation with GiveWell, February 2025. (unpublished).	Unpublished

• 1

  “In Phase 1 (officially concluded in early Sept), we trained 386 trainers at the national,
  provincial, and district levels who went on to train 838 health facilities and 11,500+ healthcare providers across all 10 provinces in Zambia. Together, these facilities reach approx. 50% of pregnant women in Zambia.” Evidence Action, “Liberia, Zambia, and Cameroon Maternal Syphilis Grants, Step-Back,” November 2024. Slide 16 (unpublished).

• 2
  • “We launched Phase 2 of the training cascade in January. Our goal was to reach 1,042 health facilities which serve ~30% of ANC-going pregnant women, bringing our total reach to ~79% of ANC-going pregnant women. Approx. 40% of the facilities (456) were supposed to be funded via USAID implementing partners and CDC (using PEPFAR funding). Based on trainers' reports, we estimate that ~161 were trained before the freeze, leaving 295 facilities unsupported. Recommendation: We would like to move forward and cover the costs of training the remaining facilities so that we can conclude Phase 2 by the end of March.” Evidence Action in correspondence to Givewell, February 20, 2025. (unpublished)
  • Evidence Action estimates that this grant will support 223 health facilities. See Evidence Action, “Partner Sites Budget Breakdown,” February 26, 2025.

• 3

  “Since these facilities were supposed to have been trained, they have already received test kits and benzathine penicillin and they were instructed not to use the commodities until they've been trained. We risk both untrained staff using the commodities and that the commodities languish at these facilities unused.” Evidence Action in correspondence to GiveWell, February 2025. (unpublished)

• 4

  See Evidence Action, “Partner Sites Budget Breakdown,” February 26, 2025.

• 5

  See Evidence Action, “Dual Test Budget Breakdown,” March 18, 2025.

• 6

  Evidence Action in correspondence to GiveWell, September 2025. (unpublished)

• 7

  We are working through resolving some apparent inconsistencies between our models for similar technical assistance programs, and expect to simplify these models in future.

• 8

  See our Intervention Report.

• 9

  Evidence Action in correspondence to GiveWell, February 2025. (unpublished)

• 10

  Evidence Action in conversation with GiveWell, February 2025. (unpublished).