Note: This page summarizes the rationale behind a GiveWell grant to Results for Development (R4D). R4D staff reviewed this page prior to publication.
In a nutshell
In April 2025, GiveWell recommended a $271,445 grant to Results for Development (R4D) to conduct a 3-month qualitative assessment of how the U.S. government funding cuts are affecting vaccine delivery in Nigeria, the Democratic Republic of the Congo (DRC), and Madagascar. This assessment will focus on learning about the impacts to vaccinators and other healthcare workers, supply chains, vaccination sessions, and data systems, as well as how the cuts have changed how local governments and health facilities are prioritizing health spending and resource allocation.
We believe this grant is likely to be a cost-effective use of funds because of:
- Learning value: We are unsure how U.S. government foreign aid funding cuts have affected the systems that support vaccine delivery at a local level. This grant is a way for GiveWell to learn about these impacts and may influence our vaccines team’s grantmaking strategy, how we prioritize future funding opportunities, and our management of existing grants. (more)
- While the primary learning value of this grant comes from insights for our vaccines team, the findings could also be informative for our other research teams focused on understanding local health systems. (more)
- Access to facility-level insights: R4D will focus on collecting data at the facility level, generating insights on how these cuts affect last-mile vaccine delivery that would be hard for GiveWell to access otherwise. (more)
Our main reservations include:
- Limited generalizability: This rapid assessment will interview facilities in each country selected based on conversations with stakeholders. While this selection aimed to represent a diverse range of facilities, the combination of non-random sampling and the reality that the impact of the cuts is likely to vary by location, will limit the generalizability of the findings. (more)
- Rapidly changing context: Due to the U.S. government cuts to funding for foreign assistance, and potential funding cuts by other nations, the funding situation for local health systems is unclear and rapidly changing. Therefore, the conditions in the areas that we are assessing may change rapidly, potentially making any findings outdated shortly after collection. (more)
- Reliance on third parties, especially in DRC and Madagascar: R4D's geographic reach is somewhat limited compared to other partners, and they will be relying on consultants and sub-awardees, who we are not familiar with, for the data collection in the DRC and Madagascar. (more)
For more on our response to these funding cuts, see our overview page here.
Published: August 2025
1. Background
In January 2025, the U.S. government froze all foreign assistance for a 90-day review period.1 Our understanding is that since then, the vast majority of U.S. government-funded foreign assistance programs have received formal terminations, including programs focused on health systems strengthening.2 Since then, we have heard that programs have since been reinstated, but our understanding is that health systems in countries that previously relied on U.S. government assistance continue to be significantly affected.
GiveWell has spoken to more than 20 researchers and subject matter experts involved in affected health systems to understand the impacts. One conclusion from these conversations has been a recommendation to collect more information on how the change in funding has been affecting health delivery at the facility and community levels. At the time of making this grant the U.S. had not announced planned changes to funding for Gavi, the Vaccine Alliance (Gavi), the primary mechanism through which the U.S. supports vaccine procurement in low- and middle-income countries.3 However, conversations with experts on vaccination programs4 highlighted several ways in which these U.S. government funding cuts could be having meaningful impacts on the vaccines sector, including supply chains, data management, logistics, technical assistance, and challenges in preparing for and executing rollout of malaria vaccines.3
2. The organization
Results for Development (R4D) is a nonprofit organization that partners with country governments, local organizations, and development partners to catalyze progress in health, education, and nutrition.They accomplish this through, “provide[ing] tailored support to country leaders as they navigate complex systems-change processes. And we help build a more supportive ecosystem that is truly responsive to country leaders’ priorities.”5
In the past, GiveWell has recommended three grants to R4D to support a program in Tanzania designed to increase the proportion of children with pneumonia who are treated with pediatric amoxicillin in health facilities: a grant of $6,400,000 in 2016 for Phase I, a grant of $5,605,398 in 2019 for Phase II, and an exit grant of $1,006,445 in 2022.
3. The grant
With this grant, R4D will conduct a qualitative assessment in specific subnational areas in Nigeria, the DRC, and Madagascar to better understand how cuts to U.S. government funding of health systems are playing out in real time, with a focus on impacts to last-mile vaccine delivery systems. R4D and their partners6 will use these funds to conduct key informant interviews at national, regional, subnational, and facility levels and then produce a memo highlighting key themes as well as country-specific takeaways.
The assessment is designed to document how these funding reductions are affecting health system functionality at the sub-national level with a focus on the facility and district levels (and national-level insights for context), with an emphasis on:
- Vaccinators and other frontline healthcare workers
- Sub-national vaccine supply chain performance
- Timing and coordination of vaccination sessions
- Management information systems (MIS) and data use
- Planning, coordination, and prioritization, and decision-making among national and subnational actors (such as resource prioritization and planning for the introduction of new vaccines)
These interviews will inform the five core learning questions for this assessment:7
- How are vaccinators and other frontline health workers affected by funding cuts (e.g., workload, staffing, incentives, remuneration)?
- What new vaccine supply chain issues are emerging at the facility and district levels (e.g., stockouts, procurement delays, cold chain)?
- How are fixed-site and outreach vaccination sessions being maintained or reduced, and which populations are at increased risk of being missed?
- What gaps have newly emerged in the collection and use of immunization data?
- How are district and national actors adjusting planning, budgeting, and coordination to respond to new financial constraints (including how plans for new vaccine introductions are being affected)?
See the concept note submitted by R4D for more on the methods that will be used in this assessment.
3.1 Grant budget
The $271,445 grant is allocated across the three countries as follows:8
| Country | Amount | Key Budget Items |
|---|---|---|
| Nigeria | $82,108 | R4D in-country staff ($14,380), Travel and other direct costs ($2,643), Consultants ($37,934), R4D Program Management ($27,151) |
| DRC | $114,669 | Travel and other direct costs ($2,517), Subaward ($85,000 for all costs related to data collection, including staffing, travel, translation, interview transcription, etc.), R4D Program Management ($27,151) |
| Madagascar | $74,669 | Travel and other direct costs ($2,517), Subaward ($45,000 for all costs related to data collection, including staffing, travel, translation, interview transcription, etc.), R4D Program Management ($27,151) |
4. Why we made this grant
- This grant is a way to learn more about the impacts of the U.S. government funding cuts on health systems, which could have implications across our vaccines portfolio. Learnings from this grant could inform our management of current grants, prioritization and grantmaking processes for future grants, and overall vaccines team strategy. As of now, there are gaps in our understanding of how U.S. government funding cuts are affecting vaccine delivery, and we think funding R4D to gather this data is an efficient way to get more information related to our key research questions. Even if we find that this period of disruption is temporary, this research will help provide some of the broader contextual information (i.e., more details on how vaccines supply chains work at the last mile and some examples of how this differs across countries) that could inform GiveWell's vaccines work into the long term.
- Focus on local-level insights, including directly from facilities: We are excited that this research will place a particular emphasis on the subnational and facility level. R4D will conduct key informant interviews with staff based at facilities to give some examples of how specific facilities have been affected, including facility-level resource cuts, prioritization, and decision-making. While GiveWell is often able to gather information from national and global stakeholders, we are generally less well-connected at the local level, so this R4D partnership helps fill an important gap in our understanding of the impacts of U.S. government funding shifts. While the sampling for this research is not intended to be representative, we have worked with R4D to develop a qualitative sampling strategy that will focus on generating insights related to several important categories9 of facilities that may be most affected by U.S. government funding cuts.
- This grant may produce learnings that could help other teams at GiveWell: While this grant is designed to focus primarily on impacts that affect immunization, we anticipate that the research will also gather information that will be relevant to other teams at GiveWell. For example, some countries might use the same information systems for reporting immunizations as they do for other health data.
- The R4D team has been highly collaborative and valuable thought partners throughout the process of developing this grant, which is hopefully an early signal of a good working relationship. We are hopeful that this initial period of high collaboration will establish strong up-front alignment on goals and norms of open communication.
5. Our main reservations
- Limited generalizability: We have intentionally focused this rapid assessment on highlighting local-level insights through qualitative methods rather than ensuring a fully representative sample. In particular, the generalizability of any findings from this assessment - especially from interviews conducted at the subnational and facility level - are likely to be limited for two reasons:
- This rapid assessment will interview facilities in each country selected through conversations between R4D, their partners, and government stakeholders. The final selection was based on a framework developed by R4D for systematically ensuring that different types of facilities are assessed10 as well as accessibility considerations. While we agree with this approach, the lack of random sampling will limit the generalizability of the assessment.
- We believe that the U.S. government funding cuts likely affect different regions and facilities differently based on factors such as the proportion of health funding that previously came from U.S. foreign assistance and how local governments choose to allocate their remaining funding. In this assessment, R4D will be focusing on areas that had a higher degree of reliance on U.S. funding to support health systems. Therefore, the locations included in this assessment will likely be experiencing larger than average disruptions.
Due to these limitations, we may not be able to use this data to make broad generalizations in a way that informs our entire vaccine grantmaking portfolio. Both the results of the assessment and any decisions we make based on this research need to keep these limitations in mind. We will mitigate against this by triangulating findings from multiple sources and ensuring that the final deliverables from R4D are appropriately cautious about these limitations.
- Rapidly changing context: Due to the U.S. government cuts to funding for foreign assistance, and potential funding cuts by other nations, the global development sector is highly volatile at the moment, and it's quite possible that disruptions to the vaccines systems are minimal or quickly resolved. New external events could emerge that shift our team's priorities or cause these findings to quickly become out of date.
- Uncertainty around the strengths and limitations of R4D’s networks, especially in DRC and Madagascar: R4D only has an office in one out of the three countries selected for this assessment (Nigeria). In DRC and Madagascar, R4D is relying on consultants and subawardees, and we haven't requested the details of their plans around vetting, managing, and ensuring quality and comparability from these partners.11 There might have been other partners we could have selected for this work that would have had stronger up-front overlap between organizational presence and countries of interest for GiveWell’s vaccines team. That being said, the R4D team has been able to draw on their networks to quickly identify partners in the DRC and Madagascar, and we are generally optimistic about their ability to gather and analyze data in these new countries.
- Potential for duplication of efforts: While we are not aware of other organizations doing similar work, there is some possibility that we would be able to learn about these local impacts on health systems without funding this project ourselves.
6. Plans for follow up
During the grant, we plan to have routine check-in conversations with the R4D team. GiveWell will review the data collection tools and data collection plans, an outline of the final synthesis memo, and the final memo and slides before they are finalized.12
During data collection in July and August, R4D will share biweekly updates summarizing progress made, challenges, and early learnings.
Results of the project will be used to inform GiveWell's strategy for vaccination program grant-making, and, as useful, shared with partners.
7. Internal forecasts
For this grant, we are recording the following forecasts:
| Confidence | Prediction | By time | Resolution |
|---|---|---|---|
| 30% | We will renew this grant for another round of rapid assessments by January 2026 | January 2026 | - |
| 35% | We will renew this grant for another round of rapid assessments by May 2026 | May 2026 | - |
| 55% | R4D will share a final report by August 31st, 2025. | August 31, 2025 | - |
| 90% | R4D will share a final report by October 31st, 2025. | October 31, 2025 | - |
| 50% | Findings from this study lead the GiveWell Vaccines team to update our strategy in at least 2 meaningful ways | September 2025 | - |
| 30% | Findings from this study lead the GiveWell Vaccines team to investigate funding a new type of intervention that we otherwise wouldn’t have | September 2025 | - |
| 35% | A major change in the U.S. government’s approach to global development in the next six months makes this study less relevant than anticipated | November 2025 | - |
8. Our process
- R4D contacted GiveWell to discuss the impact of U.S. foreign aid funding cuts on vaccine distribution. We found the call, which featured insights that R4D gained through conversations with colleagues in Nigeria, Ethiopia, and Tanzania, informative and agreed that digging deeper into questions around the impact of the funding cuts on vaccine delivery could be valuable.
- We had several calls with the R4D team where we discussed the contours of this project, including the countries involved, geographic focus, and sampling approach.
- We set up a joint brainstorming Google document and collaborated there asynchronously
- R4D shared a draft concept note which we iterated on together
9. Relationship disclosures
None
Sources
- 1
The timeline of events regarding the U.S. foreign aid freeze is detailed on the Kaiser Family Foundation website by Kates, Rouw, and Oum. They state that on January 20, 2025, an executive order was issued that, “called for a pause on funding on new obligations and disbursements and a 90-day review of all U.S. foreign assistance to assess alignment with American values.”
- 2
This Kaiser Family Foundation report states that after a recent review of foreign aid programs, 5,300 of 6,200 programs were listed as terminated. “Most recently, as part of its foreign aid review, the Trump administration notified Congress of the number of USAID awards it intends to terminate and those it will continue. The list included more than 6,200 awards, of which more than 5,300 were listed as terminated and almost 900 as remaining active. These awards total more than $36.0 billion in un-obligated funding, including $27.7 billion in terminated awards and $8.3 billion for awards remaining active. While it is unknown whether this will be the final list, it provided the first official indication of the administration’s plans for the U.S. foreign assistance portfolio, including for global health activities.”
- 3
Since this grant decision was made, the Trump administration put forward a budget request with no funding for Gavi in fiscal year 2026. A reduction from $300 million U.S. dollars in fiscal year 2025. The situation is still uncertain and the administration or Congress may still elect to allocate funding to Gavi. See this Kaiser Family Foundation report for more.
- 4
This was mentioned on multiple calls between GiveWell’s vaccines team and implementing organizations working in the vaccines sector.
- 5
R4D’s overall mission and general approach is described on their website here. R4D describes their immunization strategy further on this page.
- 6
R4D intends to partner with the following organizations and consultants to conduct primary data collection:
- DRC: University of Kinshasa, Department of Tropical Medicine
- Madagascar: TA4ID Consulting - Madagascar
- Nigeria: a consultant team led by Dr. Mariya Saleh, with support from Dr Ibrahim A Ahmad, Dr. Omololuoye Majekodunmi, and Dr. Tijjani Hussaini
- 7
See further details in R4D’s concept note.
- 8
Budget details provided in R4D’s concept note.
- 9
As discussed further in R4D’s concept note, these categories (or archetypes) of facilities include:
- Remote, rural facilities serving many communities that are almost fully dependent on outreach services for vaccine delivery
- Semi-remote facilities with closer to a 50/50 split between outreach and fixed-post, facility-based immunization services
- Facilities with stable demand for routine, facility-based immunization services in an accessible area with minimal outreach services required
- Facilities serving densely populated urban or peri-urban mobile/temporary settlements, including urban slums
- 10
For more on R4D’s proposed sampling approach and facility targeting framework, see the ‘Target Facility / Service Delivery Archetypes and Sampling Approach’ section of their concept note.
- 11
R4D is also working with a consultant in Nigeria, although this consultant is someone that their in-country team knows well and has worked with routinely in the past.
- 12
See further details in R4D’s concept note.