Published: August 2014
Future distributions and room for more funding (More)
AMF currently has $6.8 million available for future distributions, having committed $8 million to distributions planned for 2014-2017. $2.7 million of its allocated funds are allocated to distributions scheduled to occur more than 2 years from now. Since 2012 (the period in which AMF has negotiated larger-scale distributions), about $8 million of the $10.3 million spent or committed has been in partnership with Concern Universal in Malawi. We continue to believe that AMF has limited room for more funding (though we believe there are ways in which AMF's actions are being affected by funding constraints) and are not planning to re-recommend it at this time.
Updates on past distributions
- AMF, with Concern Universal, completed a distribution in Balaka district, Malawi in late 2013. The distribution in Dedza, Malawi is now scheduled for late 2014. The distributions have been delayed and expanded. Total expected cost is about $1.46 million. (More)
- Two years of follow up data from Ntcheu, Malawi is now available – the first of its kind for an AMF distribution – as well as one round of follow up data from Balaka. AMF is the only organization we know of that is regularly and extensively (sampling ~5% of households that received LLINs) collecting post-distribution data on LLIN condition and use. The Ntcheu two-year survey found that 79% of individuals in households that had received LLINs were sleeping under a useable LLIN, and 77% of LLINs were in "very good" or "ok" condition. The Balaka survey suggests that LLINs may be decaying more quickly in that district. Note that we have not seen full technical details for this survey and have therefore not carefully vetted its methodology. (More)
- We have re-analyzed the total cost to distribute a LLIN funded by AMF. The cost varies considerably by country. We estimate $5.20-$5.40 in Malawi and very roughly $6.70 in DRC. (More
Table of Contents
- Distribution in Balaka and Dedza, Malawi
- Follow up surveys from Ntcheu and Balaka, Malawi
- Future distributions and room for more funding
- Re-estimation of cost per net
Distribution in Balaka and Dedza, Malawi
In our February 2013 update on AMF, we wrote that AMF planned to distribute 235,000 nets in two districts of Malawi, Balaka and Dedza, in January-July 2013. This distribution has been delayed and significantly expanded, with Balaka having taken place in October-November 2013 and Dedza scheduled for September-October 2014. AMF told us that the delay was due to the registration survey in Balaka being carried out incorrectly, following a change in leadership at Concern Universal. The survey had to be repeated.1
Concern Universal, AMF's distribution partner for this distribution, originally estimated that 80,000 nets would be needed to reach universal coverage in the district. After completing the household registration survey, the number of nets nearly doubled to about 154,000.2 It appears that the difference was due to:
- The household registration survey found fewer usable nets than expected: 123,627 nets were expected from a previous distribution in May 2012,3 but the survey found only 79,655 useable nets,4 increasing the number of nets needed by about 44,000.
- The household registration survey found a greater population than was previously assumed,5 increasing the number of nets needed by about 10,500.
- The average number of people per sleeping space was found to be about 1.7,6 rather than 1.8, as was found in the previous distribution in Ntcheu, increasing the number of nets needed by about 14,000.7
- 9,500 nets were added to the total during meetings with villages to verify the results of the household registration survey. These households and sleeping spaces were not included during the pre-distribution registration process.8
- 4,575 of the LLINs that were required, according to the pre-distribution registration, were not distributed, reducing the total from 158,805 to 154,230.9
The distribution was originally scheduled for January to April 2013,10 but did not take place until October to November 2013.11 The household registration data was somewhat outdated by the time of the distribution, which caused some logistical difficulties during the distribution.12
AMF has publicly shared the following information from the distribution:
- Sample data from the pre-distribution household registration (25 households), and totals from the registration, including number of households, people, useable nets, and sleeping spaces.13
- Weekly reports on the progress of the distribution with number of nets distributed, problems encountered, and lessons learned,14 plus a summary report describing the full distribution process.15 Based on this report, it seems that the distribution followed similar processes to those used by Concern Universal in the Ntcheu distribution, which we detail in our full review of AMF.
Concern Universal did not take photos and video during the distribution. AMF has confirmed with Concern that it will do so during the Dedza distribution.16
A 6-month follow up survey was completed in Balaka in April 2014.17 Details below.
The distribution in Dedza was originally scheduled for April to June 2013.18 It is now scheduled for September to October 2014.19 Concern Universal estimates that 245,000 nets will be required for the distribution.20
This brings the total nets for the two districts to about 405,000, or about 170,000 more than previously expected. The total cost to AMF of the Balaka and Dedza distributions is expected to be about $1.46 million.21
Follow up surveys from Ntcheu and Balaka, Malawi
In December 2011 to February 2012, AMF, with Concern Universal, distributed about 270,000 nets in the district of Ntcheu, Malawi. Concern Universal has now completed three follow up surveys in the district: at 6, 15, and 24 months post-distribution.
6-month post-distribution data is also available from the Balaka distribution discussed above.
We have not seen technical details at the level of a high quality academic study on how the surveys were carried out,22 and we therefore have not been able to fully vet the results.
About the Ntcheu 6-month survey
While data from the 6-month report is available, there is no accompanying narrative report (AMF did not ask for narrative reports until before the Ntcheu 15-month survey23 ), so we do not have details on how the survey was carried out. AMF told us that similar methods were used in this survey as in subsequent surveys.24
About the Ntcheu 15-month survey
Concern Universal reported using the following methodology for the 15-month post-distribution survey:
- Ten villages in each of 37 health facility catchment areas were randomly selected for inclusion in the survey. Concern Universal noted, "Random sampling gave a chance to villages that were in remote areas to be visited [that] would not have been visited if random sampling was not done."25
- Within each village, 25 households were randomly selected from the pre-distribution registration list. Only households that received nets during the distribution were included in the sample.26
- Surveys were carried out by "Environmental Health Officers" (EHOs) – officials responsible for supervising Health Surveillance Assistants (HSAs), Malawi's community health workers. They were overseen by the district Malaria Coordinator and his deputy.27
In total, the survey cost about $6,800. Most of the cost was staff time, particularly for the data collectors and their supervisors. Most of the rest of the cost was for fuel.28 Concern Universal noted that it experienced some difficulty determining where the funds for the survey would come from.29
Data entry for the survey took about three times as long as planned, in part because AMF asked Concern Universal to submit data via an online system and internet connectivity at the office in Malawi was limited.30
About the Ntcheu 24-month survey
Concern Universal reported using similar methodology for this survey as with the 15-month survey. 10 villages were randomly selected in each of the 37 health facility catchment areas in Ntcheu. The pre-distribution registration list was used to randomly select 25 households in each village. If no one was home at the time of the survey, a randomly selected alternative household was surveyed.31
Unlike in the 15-month survey, the survey was carried out by HSAs (rather than HSA supervisors).32 Supervisors were asked to visit a randomly selected 5% of the households to check the accuracy of the data collectors’ work.33 We have not seen data on what portion of audits were carried out or what portion found errors in data collection.
As before, Concern Universal noted that AMF's requirement to use its web-based data entry system caused some problems due to internet connectivity outages.34 However, the web-based system improved the efficiency of the data cleaning process.35
The total cost of the survey was $7,650, or about $0.85 per household surveyed.36
For both the 15-month and 24-month surveys, we have not seen technical details at the level of a high quality academic study, and we therefore have not been able to fully vet the results.
About the Balaka 6-month survey
While data from the 6-month report is available, AMF has not yet published an accompanying narrative report, so we do not have details on how the survey was carried out. AMF has told us that this survey used similar methods to those used in Ntechu surveys.37 AMF expects to publish the survey details by October 2014.38
Results from follow up surveys
Data sources in footnote.39
|Ntcheu: 6-month||Ntcheu: 15-month||Ntcheu: 24-month||Balaka: 6-month|
|# of households surveyed||7,689||9,250||8,939||4,536|
|# of AMF nets received by surveyed households||15,814||18,580||18,448||7,977|
|% of nets surveyed of total distributed||6%||7%||7%||5%|
|% of nets hung||90%||85%||81%||87%|
|% of nets missing||1%||3%||4%||2%|
|% nets in very good condition||99%||89%||49%||70%|
|% of nets in OK condition||1%||6%||28%||25%|
|% of nets in poor condition||0%||2%||15%||4%|
|% of nets worn out||0%||3%||8%||1%|
|% of nets used correctly||98%||98%||90%||94%|
|% of people covered by nets||90%||84%||79%||90%|
- Nets hung: We have not seen a precise definition of this term. AMF told us that interviewers are asked to observe whether nets are hung by entering interviewees' houses (rather than simply asking interviewees if they are hung).40
- Very good condition: LLIN has fewer than 2 holes of less than 2 cm in size.41
- OK condition: LLIN has fewer than 10 small holes.42
- Poor condition: LLIN has more than 10 small holes or has one or more large holes.43
- Worn out: Survey reports from Concern Universal did not provide a definition of this term. AMF told us that an LLIN is considered worn out if it has multiple large holes and the LLIN is unrepairable, such that it would not provide protection against mosquitos.44
- Used correctly: According to a survey form from 2012, interviewers are asked to "ask the householder to demonstrate how the nets are used at night" and to then select yes or no to the question "are the nets being used correctly."45 AMF told us that the procedure has not changed in more recent surveys.46
79% of individuals in households that received LLINs sleeping under a useable LLIN (at 24-month follow up in Ntcheu) is roughly in line with usage rates of the trials of bednet efficacy documented in our page on Long Lasting Insecticide Treated Nets, in which small-scale studies of bednet efficacy had net usage rates generally in the 60%-80% range.47
The "decay model" we use to anticipate the lifespan of LLINs assumes that 80% of LLINs are effective at 24 months.48 AMF found that 77% LLINs in Ntcheu were in "very good" or "OK" condition at 24 months. LLINs appear to have decayed more quickly in Balaka, where 70% of nets were in "very good" condition at 6-months (and 25% in "OK" condition), compared with 99% in "very good" condition at 6-months in Ntcheu. It is not clear to us whether these rates of decay are comparable to the assumptions in the decay model, in part because it is not clear whether the definitions of useable are similar in the model and AMF's data. We may do further analysis to more directly compare the model and AMF's data in the future.
Malaria case rate data
In early March 2014, AMF told us that additional malaria case rate data from Ntcheu would be available around the end of March.49 In May, AMF told us that it had received some of this data and expected to post an update on malaria cases in Ntcheu in June.50
Note that in August 2013 AMF and its distribution partner found that there were some problems in the quality of the malaria case rate data in Ntcheu. AMF told us that it would be assessing the credibility of this data.51
Future distributions and room for more funding
As of June 2014, AMF held about $14.8 million. Of this amount, it has committed $8 million to future distributions over the next three years. The remaining $6.8 million is uncommitted.52
Kasaï Occidental, Democratic Republic of the Congo
On March 25, 2014, AMF announced that it had agreed to fund 676,000 nets in the province of Kasaï Occidental in DRC, at a cost of about $1.94 million53 – its largest distribution to date. The UK's Department of International Development (DFID) will fund the non-net costs of the distribution and the distribution will be carried out by IMA World Health.54
AMF notes that DRC is a very difficult country to work in, but that the agreement has met its high standards for monitoring and evaluation.55
Four districts in Malawi
AMF, with Concern Universal, has distributed LLINs, or will soon do so, in three districts in Malawi: Ntcheu (early 2012), Balaka (late 2013), and Dedza (planned for late 2014). AMF has recently announced that is will add a fourth district, Dowa, where it plans to conduct a distribution in November 2014. AMF has also committed funds to replenishing LLINs in the first three districts over the next three years. In total, AMF has committed $5.6 million to distribute 1.4 million LLINs in Malawi in 2014-2017 (not including the previously planned distribution in Dedza in late 2014). Number of LLINs and expected timing by district:56
- Dowa District: 400,000 LLINs in November 2014
- Ntcheu District: 350,000 LLINs in October 2015
- Balaka District: 235,000 LLINs in October 2016
- Dedza District: 430,000 LLINs in October 2017
North Idjwi, Democratic Republic of the Congo
AMF plans to fund 60,000 LLINs for a universal coverage campaign in the northern part of Idjwi island. It will work in partnership with Amani Global Works. Once this distribution is complete, AMF expects to fund another 60,000 LLINs for the southern part of the island.57 AMF expects each portion of the distribution to cost $186,000, for a total of $372,000.58
Summary of recent and confirmed distributions
|Year||Distributions planned (# of LLINs)||Cost|
|2013||Balaka (154,230)60 and Dedza (delayed to 2014, 245,000)61||$1,210,744|
|2014||Kasaï Occidental (676,000), Dowa (400,000) and North Idjwi (60,000)||$3,726,000|
|2015||Ntcheu (350,000) and South Idjwi (60,000)||$1,586,000|
Total funding for distributions in partnership with Concern Universal: $7.98 million.
Total funding for distributions with other partners: $2.31 million.
Distribution discussions that did not succeed
AMF was previously involved in negotiations for two further distributions that would have cost a total of $12.85 million. It is no longer proceeding with these negotiations. The majority of the $12.85 million would have funded a distribution in DRC. There were two main partners involved in the DRC negotiations: a co-funding partner who would have funded the non-net costs of the distribution and a distribution partner who would have carried out the distribution. According to AMF, the distribution did not proceed because "after extensive discussions we did not reach agreement [with the distribution partner] on the detailed aspects of verification of the distribution or monitoring and evaluation within the timeframe necessary to secure a firm commitment from our co-funding partner. During the negotiation, significant budget cuts were also placed on our co-funding partner."
It is our understanding that AMF currently has a limited pipeline for future distributions. It previously was in discussions for several large distributions and if all discussions had succeeded, it would have had a small funding gap.62 AMF told us that it is, as of June 2014, "looking at building a distribution pipeline to replace this."63
We believe that funding constraints are affecting the actions AMF has taken recently and will take in the short-term. Examples include:
- AMF would like to be a major partner in a large distribution, which would cost perhaps $10 million or more. This would allow AMF more leverage to influence how the distribution and monitoring was carried out.
- AMF feels that it can only negotiate distributions for which it has high confidence that it will have enough funds available. This means that AMF is limited in the number of distributions it will explore at one time.
- AMF would like to have a planning horizon of at least three years. Limited funds now could affect AMF's distribution pipeline for several years into the future.
Our determination that AMF has limited room for more is based largely on our level of confidence in AMF's ability to negotiate further distributions. This determination may change as AMF's negotiations proceed.
Re-estimation of cost per net
In our most recent review of AMF, we relied on an estimate from the Roll Back Malaria Partnership's Harmonization Working Group for the cost to purchase and deliver an LLIN ($5.80). In this update we have attempted to improve on that estimate by: (a) talking to the Harmonization Working Group about its estimate; (b) comparing this estimate to AMF's financial history and plans.
We spoke to Melanie Renshaw, Co-Chair of the Harmonization Working Group. Dr. Renshaw told us that the group uses $2.50 per net for non-net costs because it has found this to be the historical average. Actual costs can vary significantly across countries.64
Using budgets and estimates provided by AMF, we estimate that the total cost to purchase, distribute and follow up on an AMF LLIN is $5.20-$5.40 in Malawi and very roughly $6.70 in DRC. We focus on these two countries because they are where AMF has completed recent distributions or is planning distributions.
The estimate for Malawi is based on:
- The purchase price per LLIN, calculated from AMF's total LLIN budget and the number of LLINs for the distributions in Dedza ($3.02 per LLIN) and Balaka ($3.06 per LLIN).
- Concern Universal's budget for non-net costs for the Dedza and Balaka distributions, which include the costs of six follow up surveys. AMF told us that that non-net budget includes all monetary costs incurred by Concern Universal and use of vehicles;65 non-monetary costs such as use of office space and managerial staff time do not appear to be included.
- An estimate of non-monetary costs incurred by Concern Universal and local governments, based on estimates provided in 2012 by Concern Universal for its distribution in Ntcheu province.
- An estimate of AMF's organizational costs per net, including an estimate of the value of donated services and volunteer time. Because these costs generally do not vary with the number of LLINs distributed and remain roughly constant on a per year basis, the per LLIN estimate is highly dependent on the time period used and the number of LLINs distributed in that period. We estimate AMF's organizational costs as $0.58 for 2013-2015. This estimate assumes that AMF will complete the distributions it currently plans for that period and does not account for any additional distributions.
We shared our analysis with AMF before publishing and AMF wrote the following in response.
The AMF view is it more relevant to its donors to look at AMF’s actual costs when calculating its cost-effectiveness, rather than adding in costs where either no cash cost exits or support is provided pro bono.
This matters as not to do so distorts cost-effectiveness figures. AMF’s overhead costs per annum are $120,000. Using this figure the cost per delivered and monitored net would be $4.50 - $4.80 (midpoint $4.65).
GiveWell uses an overhead figure of $300,000 due to adding in a CEO salary of $100,000 (AMF’s CEO does not draw a salary) and $80,000 of other overhead costs for services provided pro bono to AMF and therefore where no cash cost exists (the organisations providing pro bono support are very happy to work for no immediate financial return since they benefit in other ways from their involvement, e.g. in improved staff morale. This means they incur no net cost from providing the pro bono service).
As a result, GiveWell calculates the cost per net for AMF at between $5.20 - $5.40 (midpoint $5.30).
GiveWell has calculated the cost per net for other organisations as $5.80.
At $5.30 per net, AMF is 10% more cost-effective than other organisations. At $4.65 per net, 25% more effective. That is a material difference.
We believe our donors are more interested in a comparison derived from AMF’s actual costs rather than penalising it (reducing its assessed effectiveness) by not considering the no-cost and pro bono cost savings they may achieve. AMF as an organisation will continue to seek pro bono support believing this is more cost effective than paying for services.
For DRC, the estimate is much rougher. It is based on the assumption of $3 to purchase an LLIN, $3 in non-net costs (based on AMF's rough estimate that purchase and non-net costs for DRC are roughly equal), and the same estimates of non-monetary and AMF organizational costs used for Malawi.
Full details in this spreadsheet.
We have not yet updated our analysis of the cost per life saved with LLIN distributions. Our previous analysis used $6.13 as the total cost to distribute an LLIN and estimated that this translated to roughly $3,400 per life saved (with a number of caveats). Our revised cost per LLIN would translate into a lower cost per life saved in Malawi and perhaps a slightly higher cost per life saved in DRC. These adjustments do not take into account any differences in the effectiveness across countries and it is not straightforward how to account for such differences.
Rob Mather, email to GiveWell, May 22, 2014.
"Nets distributed: 154,230." Balaka distribution report (2013), Pg 13.
Balaka distribution proposal (2013), Pg 3. Note that AMF later told us that the official estimate of LLINs distributed in May 2012 is 129,800, but that at the time AMF and Concern Universal were planning the distribution, they believed it was 123,627. Rob Mather, email to GiveWell, June 30, 2014.
Number of people: 388,782
Number of sleeping spaces: 229,945
- Population: 388,782 (see previous footnote)
- Population divided by 1.8: 215,990
- Population divided by 1.69: 230,049
- Difference: 14,058
Nets required: 158,805
Nets distributed: 154,230
Balaka distribution report (2013), Pg 13.
“Another reason for the mismatch is the long delay between the registration process and the beginning of the distribution, which allowed for some households to migrate to other villages.” Balaka distribution weekly report (October 7-12, 2013).
Linked in "Distribution" tab at AMF page on Balaka 2013 distribution.
"[GiveWell:] Does AMF expect to post photos/videos from the Balaka distribution?
[AMF:] No, CU did not take photos of this one. They are aware of this slip and there will be photos and video footage from Dedza. Photos and videos are also included in the agreement for the DRC-Kasai distribution." Rob Mather, email to GiveWell, May 22, 2014.
See our November 2013 update on AMF.
Total funding for nets in Balaka: $457,470. AMF page on Balaka 2013 distribution.
Total funding for nets in Dedza: $630,000. AMF page on Dedza 2014 distribution.
Non-net cost budget: $369,648. (Note: this does not take into account the increase in nets in Dedza.) AMF non-net cost budget for Balaka and Dedza (October 2013).
Total: $1.46 million
The type of technical information we would ideally like to see includes:
- Results of audits on data quality.
- Analysis of the extent to which respondent selection was carried out according to the protocol.
- Analysis the extent to which selected households were replaced with pre-selected alternate households (i.e. attrition from the sample).
- Survey text used in each survey round and detailed protocols for responses that are directly observed by surveyors.
Rob Mather, email to GiveWell, August 22, 2014.
Rob Mather, email to GiveWell, August 22, 2014.
"Ntcheu district has 37 Health facilities. The standard sample size for each health facility was 250 respondents in each health facility (catchment Area). The health facility catchment area was taken as one area. Therefore Ntcheu district had a total of 9250 samples.
Ten villages in each catchment area were selected using Probability Proportional to size sampling (PPS) method. The process involved reviewing data from both Ministry of Health list of villages under each catchment area, calculating the cumulative population for each catchment area, calculating the sampling interval by dividing total cumulative population by 10 and choosing the random number using the Random Number Table to determine the first village to be interviewed. This generated a list of 10 villages to be interviewed. The number ten was chosen due to the budget and time. With this process villages with larger population had higher chances of being selected…
In the village households for interview were randomly selected using the household list from Net distribution register. Using a random number table the reference household was selected from this reference household the nearest household was taken using the nearest household 25 households were reached in each area. The household interviewed was supposed to have received the LLINs during the 2011/2012 AMF nets distribution as eligibility for being interviewed. If the household did not receive the AMF nets the next nearest household was taken until the number of twenty-five was reached.
If it happens that villages close by were selected the household interviewed were marked PDS showing that interview has already taken place." Ntcheu 12-month post-distribution check-up report, Pg 3.
"The selection of Data Collectors was based on those that were coming within the district health office mainly Environmental Health Officers (EHOs) who are the supervisors for he Health Surveillance Assistants… There were 16 EHOs that were divided into two teams each team was visiting one health facility per day guided by one team leader who was responsible to check that data collection was done as planned (random selection) and the selected villages was visited. The two team leaders were the district Malaria Coordinator and his deputy." Ntcheu 12-month post-distribution check-up report, Pgs 3-4.
"There was no budget line for the activity hence we lost time during the process of identifying where to take the resources." Ntcheu 12-month post-distribution check-up report, Pg 6.
- "The data entry and editing took over one and half months which was initially planned for fifteen days." Ntcheu 12-month post-distribution check-up report, Pg 4.
- "Internet problem let us to take long time to finish data entry as well (frustrating situation)." Ntcheu 12-month post-distribution check-up report, Pg 6.
"Ntcheu district has 37 health facilities. It was decided to collect data from 250 households in each health centre catchment area with 25 households selected at random from ten villages, also selected at random. Villages were randomly selected using the village lists generated from the pre-distribution and distribution work for the 2011/2012 AMF-funded universal coverage LLIN distribution. A random number table was used to select the villages. Households were randomly selected using the household lists produced during the same campaign. A random number table was used to select 25 villages [Note that based on the second sentence of this quote, we believe this is a typo and should say "25 households"]. Five more households were put on reserve in case no one was at home in the selected households." Ntcheu 24-month post-distribution check-up report, Pgs 5-6.
"There were 368 HSAs involved in collecting data." Ntcheu 24-month post-distribution check-up report, Pg 5.
"Data was entered into a database via a web interface created by AMF. An internet connection was required for this work. This created some problems when the internet connection was down at the data entry location." Ntcheu 24-month post-distribution check-up report, Pg 6.
"Once all data had been entered these was a period of several days in which duplicate forms were removed and data errors corrected. The online system highlighted duplicates and errors for checking which made this task relatively easy. The data entry system has now been improved to make it impossible to enter duplicates." Ntcheu 24-month post-distribution check-up report, Pgs 6-7.
"The PDCU cost US$ 7,650 equal to US$0.85 per household." Ntcheu 24-month post-distribution check-up report, Pg 3.
Rob Mather, email to GiveWell, August 22, 2014.
Rob Mather, email to GiveWell, August 22, 2014.
Ntcheu 6-month post-distribution check-up data.
Ntcheu 15-month post-distribution check-up data.
Ntcheu 24-month post-distribution check-up data.
Balaka 6-month post-distribution check up data (April 2014).
Rob Mather, email to GiveWell, June 30, 2014.
"'very good condition' (fewer than 2 holes of up to 2cms in size)." Ntcheu 24-month post-distribution check-up report, Pg 4.
"'OK' (fewer than 10 small holes on them)" Ntcheu 24-month post-distribution check-up report, Pg 4.
"'Poor' condition with more than 10 holes or 1 hole larger than 10 cm." Ntcheu 24-month post-distribution check-up report, Pg 4.
"Worn out means not usable. Typically, holes will be 10 cms of cms in size and numerous and the net considered effectively unrepairable and/or structural integrity will have gone. If hung the net would not provide protection against mosquitoes given the extent of holes or tears or other loss of structural integrity." Rob Mather, email to GiveWell, June 30, 2014.
Rob Mather, email to GiveWell, June 30, 2014.
"Usage does not appear to have been near-universal. Most studies report usage rates in the range of 60-80%, though some report 90%+ usage." From our page on Long Lasting Insecticide Treated Nets.
"Alliance for Malaria Prevention 2011 lays out a model for estimating the number of LLINs still in use after distributions: 'the number of LLINs already distributed over the last three years and considered to be available in households should be calculated and subtracted from the total need, working with a decay rate of 8 per cent at one year (0-12 months), 20 per cent at two years (13-24 months) and 50 per cent at three years (25-36 months).'…
Bottom line: We believe that the "8%-20%-50%" model is the most widely used and most reasonable approximation available at the moment for capturing the extent to which LLINs remain in use in the years following distribution, accounting for any factors that might cause LLINs to be discarded or additional LLINs to be purchased. It implies an average of 2.22 years of use for each LLIN distributed. Data and analysis on this topic appears extremely thin; we have little sense for how long LLINs last in practice." GiveWell report on the "decay model" for LLINs.
"We have received a significant quantity of case rate data and expect to post information at the end of June." Rob Mather, email to GiveWell, May 22, 2014.
"Concern Universal conducted an audit of the malaria case rate data measuring malaria rates in the regions served by AMF's distribution there (more on this data at
The audit found that the numbers from some of the health centers are less reliable than previously thought due to staff absences, lack of qualified testing personnel, or equipment stock outs, each of which could have led to under-reporting of malaria cases. Also, at times, local health staff reported 'people receiving anti-malaria treatment' as opposed to 'people diagnosed with malaria by a rapid diagnostic test.' Health staff may have given anti-malaria treatment to patients presenting with a fever without testing them, which would have led to over-reporting of malaria cases.
AMF has requested additional data from local health centers and is in the process of reviewing it. It is planning to publish the results of this audit by the end of September." GiveWell's non-verbatim summary of a conversation with Rob Mather, August 15, 2013, Pg 2.
"At the same time, operating in DRC is challenging given the recent conflict, poor infrastructure, minimal access to health care, difficult geography and long distances between towns and villages.
The distribution of nets and follow-up will be strongly data-driven. The distribution will be accompanied by detailed monitoring and reporting. Post-distribution check-ups of net use and condition will take place on a six to nine month rolling schedule for three years. The detailed planning of the distribution and follow-up will respect the practicalities of working in such a challenging environment as that presented by DRC." AMF: "676,000 LLIN distribution agreed in the Democratic Republic of Congo (DRC)".
All information in the "Four districts in Malawi" section is from AMF: "Distributions update, June 2014".
- 59AMF page on Ntcheu 2012 distribution
- 60AMF page on Balaka 2013 distribution
- 61AMF page on Dedza 2014 distribution
Rob Mather, conversation with GiveWell, May 23, 2014.
Rob Mather, email to GiveWell, June 30, 2014.
Rob Mather, conversation with GiveWell, May 23, 2014