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The Against Malaria Foundation (AMF) is one of our top-rated charities and we believe that it offers donors an outstanding opportunity to accomplish good with their donations.

More information: What is our evaluation process?

Published: November 2018

Summary

What do they do? AMF (againstmalaria.com) provides funding for long-lasting insecticide-treated net (LLIN) distributions (for protection against malaria) in developing countries.

Does it work? There is strong evidence that distributing LLINs reduces child mortality and malaria cases. AMF conducts post-distribution surveys of completed distributions to determine whether LLINs have reached their intended destinations and how long they remain in good condition. AMF's post-distribution surveys have generally found positive results, with some exceptions, but have some methodological limitations and surveys in several recent distributions have been delayed.

What do you get for your dollar? We estimate that the cost to purchase and distribute an AMF-funded net is $4.53, or $4.29 excluding in-kind contributions from governments. The numbers of deaths averted and other benefits of distributing LLINs are a function of a number of difficult-to-estimate factors, which we discuss in detail below.

Is there room for more funding? We believe that AMF is likely to be constrained by funding. There is a high degree of uncertainty in the maximum amount that AMF could use productively, but given a) its track record of finding and filling funding gaps for LLINs (spending on the order of $20-30 million per year over the past few years), b) our expectation that it will receive approximately $10.9 million over the next three years, and c) the large size of the global funding gap (estimated to be in the hundreds of millions of dollars over three years), we expect the maximum that AMF could absorb to be significantly greater than what AMF is likely to receive. Update: In November 2018, we recommended that Good Ventures grant $2.5 million to AMF; due to the large amount of uncertainty regarding our estimate of AMF's room for more funding, this grant recommendation does not significantly impact our estimate.


AMF is recommended because of its:

  • Focus on a program with excellent evidence of effectiveness and cost-effectiveness.
  • Processes for ensuring that nets reach their intended recipients and monitoring whether they remain in homes and in good condition over the long-term.
  • Room for more funding – we believe AMF will be able to use additional funds to deliver additional nets.
  • Transparency – AMF shares significant information about its work with us and we are able to closely follow and understand its work.

Major open questions:

  • We have seen detailed data from before and during distributions. AMF also collects follow-up data after distributions. These follow-up surveys are conducted by AMF's various partner organizations and there has been variation in quality across locations. We also have not yet seen follow-up surveys from AMF's newer countries of operation. GiveWell has commissioned an ongoing project with IDinsight to better understand the survey methods used in several countries and to provide suggestions for AMF for the future. IDinsight's report with recommendations for the implementation of AMF's post-distribution monitoring is available here.
  • The best evidence for nets was collected before they were widely used and there is some evidence that mosquitoes have since adapted to the insecticide used in nets, possibly making them less effective. It seems that insecticide resistance is a growing concern, but it remains difficult to quantify the impact of resistance. We will continue to follow several ongoing studies that may help to quantify the impact of resistance. We discuss this issue in more detail in our page on this topic.

Our review process

We began reviewing AMF in 2009. Our review process has consisted of:

  • Reviewing documents AMF made available on its website or shared with us directly.
  • Extensive communication, including several meetings at AMF's London headquarters, with AMF Founder Rob Mather and board member Peter Sherratt.
  • A visit to AMF's distribution partner organization, United Purpose (formerly Concern Universal), in Malawi in October 2011 (notes and photos from this visit). We also spoke with United Purpose by phone in April 2016.
  • A visit to Greater Accra, Ghana in August 2016 to meet with representatives of AMF, AMF's distribution partners Episcopal Relief & Development and Anglican Diocesan Development and Relief Organization (ADDRO), Ghana's National Malaria Control Program, and other non-profit and government organizations involved in the AMF-funded LLIN distributions in Ghana in 2016. Notes and photos from our site visit are available here.
  • Conversations with Peter Sherratt, AMF's Executive Chairman; Don de Savigny, a member of AMF's Malaria Advisory Group; and other individuals (who requested to remain anonymous) familiar with AMF's work.
  • Conversations with Melanie Renshaw of the African Leaders Malaria Alliance, Marcy Erskine of the International Federation of the Red Cross, and Scott Filler of the Global Fund to Fight AIDS, Tuberculosis, and Malaria about funding needs for nets.


All content on AMF, including past reviews, updates, blog posts and conversation notes, is available here. We have also published a page with additional, detailed information on AMF to supplement some of the sections below.

What do they do?

AMF provides long-lasting insecticide-treated nets (for protection against malaria) in bulk to other non-profit organizations or government agencies, which then distribute the nets in developing countries.

As of September 2018, AMF has supported large-scale distributions in seven countries (Malawi, DRC, Ghana, Uganda, Togo, Papua New Guinea, and Zambia) for a total of 25 million LLINs distributed.1 AMF has also committed funding to upcoming distributions in Malawi, Papua New Guinea, Guinea, and Ghana totaling 15 million LLINs that are expected to take place in 2018-2020.2

A summary of AMF's distributions can be found in this spreadsheet.

The role of AMF and its partners in LLIN distributions

AMF's role in LLIN distributions is to:3

  1. Identify countries with funding gaps for LLINs.
  2. Find distribution partners (in-country non-profit organizations or government agencies) to carry out LLIN distributions. AMF and its partners agree on expectations for the distribution, including who pays for costs other than the purchase price of LLINs (which are always covered by AMF), the process that will be used to carry out the distribution, and what information will be collected and shared with AMF.
  3. Purchase LLINs and have them shipped to the distribution partners.
  4. Work with distribution partners to collect reports on the distribution and conduct follow-up surveys.

Distribution partners implement on-the-ground activities, including registering residents in targeted areas, distributing LLINs, monitoring the registration and distribution processes, and conducting follow-up surveys.4

Details follow.

Selecting locations for distributions and finding distribution partners

When selecting locations for future distributions, AMF told us it consults a series of sources, as it believes there is no single reliable resource with up-to-date information about where there are funding gaps for LLINs. Sources it consults include the Alliance for Malaria Prevention's (AMP's) list of countries with significant net gaps, other malaria control funders, in-country technical advisors, the relevant National Malaria Control Program (NMCP), implementing organizations, and the African Leaders Malaria Alliance.5 AMF told us that it has been receiving more funding requests since it started funding larger distributions,6 and notes that its largest commitment so far—12.8 million LLINs in Uganda in 2017—was made in response to an in-bound request.7

As AMF investigates countries with existing net gaps, it also looks into organizations working within those countries that could serve as distribution partners.8 AMF looks for distribution partners that have the capacity and willingness to implement registration, distribution, and monitoring processes that meet agreed-upon requirements.9 So far, AMF has worked with United Purpose (formerly Concern Universal) in Malawi, IMA World Health in the Democratic Republic of the Congo, Episcopal Relief & Development in Ghana, National Malaria Control Programs (NMCPs) in Ghana, Togo, Uganda, Zambia, and Malawi, and the Rotary Club of Port Moresby in Papua New Guinea on large-scale LLIN distributions.10

For an example of the process AMF went through to establish the funding gap in Guinea for its 2019 distribution, see Rob Mather, AMF CEO, email to GiveWell explaining Guinea process, October 14, 2018.

Registration and distribution

  • Registration: During the registration process, national health system staff or volunteers11 travel door-to-door in targeted areas to collect the information used to determine the number of LLINs to allocate to each household (e.g., the number of sleeping spaces and/or the number of household members), as well as the information used to identify the household for the distribution and post-distribution surveys (e.g., the name of the head of the household, and/or household location). AMF has shared full or sample registration data from each completed large-scale distribution prior to 2017 with us; we have not seen this data for some of AMF's more recent distributions. The specifics of the registration process and LLIN allocation strategy have differed by country (process details and registration data sources on a separate page with additional details about AMF).
  • Distribution: To distribute LLINs to recipients, AMF and its distribution partners have primarily used "point distribution" (LLIN recipients pick up their nets from a specified point in or near their community), but have also used "hang-up distribution" (staff or volunteers travel door-to-door to deliver and hang up LLINs) in one distribution in Kasaï-Occidental, DRC.12 Distribution partners manage the logistics of in-country shipping and storage of LLINs prior to the distribution. The specifics of distribution processes have varied in the different countries AMF has worked in (details on a separate page with additional details about AMF).

Monitoring

AMF's distribution partners also implement a set of monitoring activities to produce evidence on whether the registration and distribution processes operated as intended and on the long-term impact of the LLIN distribution. Monitoring activities have varied somewhat for different distributions. We describe these processes in more detail on our page with additional information on AMF. In short:

  • Process monitoring (i.e., the activities used to assess whether the registration and distribution processes operated as intended):
    • Data validation: This includes various processes, which have varied considerably in different distributions, to check the accuracy of registration and distribution data. It has generally involved looking for and following up on outliers or implausible data, and has sometimes involved re-entering a sample of data or reading registration lists out loud at community meetings and asking community members for corrections.
    • "Embedded" monitoring: (Ghana only) Staff of AMF's local NGO partner organization attended district-level planning meetings to ensure that they were operating as intended, observed the registration of households by volunteers organized by the government, and observed selected distribution points.13
    • Distribution reports: Distribution reports provide narrative summaries of activities implemented and challenges encountered by distribution partners.
    • Post-distribution validation tracing: (Ghana only) After distributions were complete, AMF's distribution partners in Ghana checked that a random sample of households (100 households per district) had actually received the number of LLINs they were allocated by calling or visiting the households.14
  • Impact monitoring (i.e., the activities used to assess the impact of the distribution):
    • Post-distribution monitoring (PDMs): Distribution partners conduct follow-up surveys (called post-distribution monitoring, or PDMs; formerly known as post-distribution check-ups, or PDCUs) by visiting between 1.5% and 5% of households at regular intervals (previously every 6 months, now every 6 or 9 months) for 2.5 years after a distribution.15 PDMs collect data on whether nets are present, whether they are hung, and what condition they are in.

      We summarize which PDMs have been completed in this spreadsheet (see "PDMs" sheet), and summarize the results and methods of PDMs we have seen in this spreadsheet.

      Most scheduled PDMs have been completed in Malawi and the Ghana PDMs are on schedule. AMF has also shared data and reports from its first three PDMs from Kasaï-Occidental, DRC and two PDMS in Nord Ubangi, DRC. We have not seen PDMs from AMF's newer countries of operation: Uganda, Togo, Papua New Guinea, and Zambia. We believe the Kasaï-Occidental PDMs were poorly implemented and provide limited evidence on the proportion of AMF's LLINs that reached their intended destinations or the impact of AMF's distribution on LLIN usage over time in Kasaï-Occidental (see this blog post for details). The 6-month PDM in Nord Ubangi, DRC was not completed due to security concerns. We have now seen 12- and 18-month PDMs from Nord Ubangi.

      In June and July 2017, as part of its partnership with GiveWell, IDinsight conducted site visits to post-distribution surveys to learn about AMF's monitoring of its programs. The surveys were conducted by United Purpose (formerly Concern Universal) in Malawi and by Episcopal Relief and Development and the Anglican Diocesan Development and Relief Organization (ADDRO) in Ghana. IDinsight's notes from these two visits are here: Malawi site visit notes (June 2017) and Ghana site visit notes (July 2017). IDinsight is planning similar visits to Uganda, Togo, and Zambia in 2019.16 IDinsight has compiled a report on its findings so far, including the sources of potential bias in post-distribution surveys and recommendations for improvements to AMF's monitoring processes.17

Other activities

AMF occasionally supports malaria control activities beyond the direct distribution of LLINs. For example: