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Against Malaria Foundation - May 2015 Update

Published: July 2015

Summary

Bottom line: We continue to recommend AMF as an excellent giving opportunity and believe it has room for more funding.

Updates on completed distributions (more)

  • The Against Malaria Foundation (AMF) has completed two recent distributions: one in Dedza, Malawi and the other in Kasaï Occidental, Democratic Republic of the Congo.

Updates on in-progress distributions (more)

  • Three of AMF’s distributions that were scheduled to take place in late 2014 or early 2015 have been delayed but are expected to go forward in the next several months.
  • AMF committed approximately 113,000 nets to a new emergency distribution in Malawi in response to severe flooding.

Updates on potential future distributions (more)

  • Malawi has asked AMF to help fund its universal coverage campaign in 2018. AMF told us that it will likely provide approximately $6 million to support this distribution.
  • AMF is working to finalize several new distribution agreements including one for approximately 2.5 million nets in Country X (AMF cannot publicly share the names of countries it is negotiating with), and one for approximately 5.5 million nets over the next three years in Country Y.

Room for more funding (more)

  • AMF currently has $14.2 million available for future distributions.
  • At this point in time, we continue to recommend AMF as an excellent giving opportunity and believe it has room for more funding, but we would be hesitant to recommend that it receive a large amount of additional funding (i.e., on the order of tens of millions of dollars) until we can evaluate results from Kasaï Occidental, its first large-scale distribution outside of Malawi.

Updates on completed distributions

Major updates on completed distributions are:

  • AMF completed two recent distributions: one in Dedza, Malawi and the other in Kasaï Occidental, Democratic Republic of the Congo (DRC).
  • We have not yet seen documentation for the Kasaï Occidental distribution (completed in November 2014), which was AMF’s largest distribution to date and its first large-scale distribution outside of Malawi.
  • AMF told us that Concern Universal has sent it long-delayed malaria case-rate data for the four districts in Malawi for which AMF has provided nets.

More details below.

Distributions in Malawi

AMF has completed three large distributions (i.e., distributions on the order of hundreds of thousands of nets) in Malawi over the last four years:1

  • Ntcheu district, 2011-2012, ~268,000 long-lasting insecticide-treated nets (LLINs): completed; post-distribution check-ups ongoing (more)
  • Balaka district, 2013, ~154,000 LLINs: completed; post-distribution check-ups ongoing (more)
  • Dedza district, 2014, ~245,000 LLINs: recently completed; 45,000 LLIN mop up distribution remaining (more)

This section provides an update on these distributions.

Dedza 2014 distribution

AMF’s Dedza 2014 distribution, which delivered ~245,000 nets in September-October 2014, has largely been completed.2 However, AMF told us that the pre-distribution survey underestimated the amount of nets needed to adequately cover all households in this region by approximately 45,000 nets.3 AMF has ordered an additional 45,000 nets, and a “mop up” distribution will be implemented in April or May of 2015.4

AMF told us that it is not unusual for the number of nets initially ordered to differ from the number of nets ultimately needed because the number of nets initially ordered is based on a pre-distribution survey, and sometimes these surveys miss households.5 However, AMF said that the difference of 45,000 nets was atypically large; it said the large size of the gap was due to a longer-than-normal delay between the pre-distribution survey and the actual distribution.6 AMF plans to compare the pre-distribution survey data to the distribution survey data to try to understand how such a large gap occurred; it received the data that will allow it to make this comparison in February, but we have not yet asked when the analysis will be completed.7

We have not yet seen a post-distribution report for this distribution; Concern Universal is waiting until after the mop up distribution to complete this report.8 We also have not yet seen photos and video from this distribution.9 AMF told us that photos and videos would be made available for this distribution, but we do not know when they will be available.10

The 6-month post-distribution check-up (PDCU) for the Dedza distribution was scheduled to begin in late March or early April.11 However, AMF told us the PDCU-6 began in late May.12 It said the delay was caused by additional work that took place in the first quarter of 2015 in response to flooding that occurred in January 2015 and that affected 15 of Malawi’s 28 districts.13

Malaria case rate data (relevant to all 3 distributions)

In the distribution agreements for Ntcheu, Balaka, and Dedza, AMF requested that Concern Universal, AMF’s partner in Malawi, provide monthly malaria case rate data from all health centers in the three districts.14 AMF previously told us to expect the results from a data audit in September 2013 and additional malaria case rate data in early 2014.15 Since then, we have seen neither data audits nor the data itself, and AMF has delayed when it expected to share these materials several times.16

In late February, AMF informed us that it had received updated malaria case rate data from Concern Universal.17 AMF told us that this data includes approximately 2 years of malaria case rates from the Ntcheu district (distribution was in 2011-2012), 12 months of rates from the Balaka district (distribution was in 2013), and a few months of rates from the Dedza district (distribution was in late 2014).18 AMF said the data also includes 2 years of case rate information from the Dowa district, where AMF is planning to carry out a distribution in 2015 (more).19

AMF has not yet had time to check the quality of the data; it expected that it would have reviewed and formatted the data by early April, after which it would have shared the results with GiveWell.20 As of writing this update in early April, we have not yet received the data. We plan to follow up on the status of this data in our next AMF update.

Post-distribution check-ups (relevant to all 3 distributions)

The post-distribution check-ups for AMF’s completed distributions in Malawi seem to be proceeding on schedule. Updates on post-distribution check-up data are:

  • Data collection for Ntcheu’s 33-month post-distribution check-up was completed in November 2014.21 As of the writing of this update (in early April 2015), the data from this check-up was still being publicly entered on AMF’s website.22
  • Data for Balaka’s 12-month post-distribution check-up (conducted in November 2014) was also being publicly entered on AMF’s website.23
  • As mentioned above, the 6-month post-distribution check-up for the Dedza 2014 distribution was scheduled to begin by early April 2015.24

Distribution in the DRC

Kasaï Occidental distribution

In November of 2014, AMF completed its distribution of 676,000 nets in the province of Kasaï Occidental in the DRC – its largest distribution to date.25

As of the writing of this update (in early April 2015), we have not yet seen documentation for this distribution, such as:

  • Distribution proposal26
  • Complete photos and video of the distribution27
  • Detailed post-distribution documentation, such as data on the number of households reached and how many nets were distributed28

AMF told us that it has been waiting to receive the distribution report from its distribution partner and that the delay is in part due to staff travel and stretched resources.29 AMF said it plans to work closely with its distribution partner to ensure that such delays are avoided in the future.30 A distribution report and a separate technology report are being produced.31

AMF originally predicted that documentation would be available in mid-March, then later predicted it would be available by the end of March.32 We have the impression that documentation from this distribution is taking longer to be made public than most documentation from AMF’s large-scale distributions in Malawi.33 AMF has told us that this is partially due to a) there being two reports and b) the additional data gathering required for the technology report.34

This distribution was the first that AMF has funded that used smartphones to collect data.35 AMF is preparing a technology report on the use of smartphones; AMF told us that it expected this report to be available by mid-April.36 AMF told us that the initial results were promising, although there were some issues with the use of smartphones.37 For example, some of the smartphones that were ordered turned out to be nonfunctional and during the distribution there were too few back-up batteries.38 AMF said that such problems are to be expected when introducing new technologies and that it plans to continue to experiment with smartphones in future distributions because of their potential benefits.39

The 6-month post-distribution check-up for the Kasaï Occidental distribution will be in May, and AMF said that data from this check-up should be available in June or July.40

Updates on in-progress distributions

Major updates on AMF’s in-progress distributions are:

  • Three of AMF’s distributions that were scheduled to take place in late 2014 or early 2015 have been delayed but are expected to go forward in the next several months. Our impression is that the justifications for these delays are broadly reasonable.
  • AMF committed approximately 113,000 nets to a new emergency distribution in Malawi in response to severe flooding. Our impression is that this was a reasonable use of AMF’s resources.
  • Malawi may ask many of the organizations that distribute nets within its borders to implement some of AMF’s distribution practices even in districts for which AMF does not fund distributions.

More details below.

Distributions in Malawi

Dowa 2015 distribution

The Dowa 2015 distribution, originally scheduled for January-February 2015, has been delayed, because some of the nets originally intended for this distribution were donated to an emergency distribution (more details below).41 AMF told us that the pre-distribution survey for the Dowa distribution is almost completed and that it expects the distribution to occur sometime during March-May.42 AMF needs to order approximately 113,000 nets to replace those used for the emergency distribution.43

Emergency distribution

In early 2015, Malawi was in a state of emergency due to severe flooding.44 AMF told us that it learned that roughly 370,000 people were left unprotected by nets and that malaria rates were beginning to rise.45 AMF had approximately 400,000 nets in a warehouse in Malawi waiting to be distributed in the Dowa district when the Malawi government approached AMF about donating some of those nets.46 AMF agreed to give approximately 113,000 nets, effectively making a new ~$315,000 commitment.47 The nets were to be distributed by 7 different partner organizations in February and March 2015.48

AMF is funding a 3-month post-distribution check-up for the distribution. Concern Universal, AMF’s historical partner in Malawi, will run the check-up.49 For the check-up, 5% of the households that received nets will be randomly visited (the visits will be unannounced) to gather information on whether or not the nets were distributed as claimed and are being used properly.50 AMF told us that monitoring for emergency distributions is rare and that it hopes that its monitoring will set a precedent for future similar situations.51

Balaka, Ntcheu, and Dedza late-2015 to late-2017 distributions

  • The pre-distribution survey for the 2015 Ntcheu distribution (scheduled for October-November 2015) was expected to take place in March and April.52
  • The pre-distribution survey for the 2015 Balaka distribution (scheduled for September-October 2015) will take place in April and May.53
  • There are no updates on the Dedza distribution planned for late 2017, as it is fairly far in the future.54

Data collection for other distributions in Malawi

AMF primarily distributes nets in 4 of Malawi’s 28 districts.55 However, AMF told us that for the second and third quarter of 2015, the National Malaria Control Program (NMCP) of Malawi is planning to implement some of AMF’s distribution practices in districts for which AMF does not fund distributions.56

AMF told us that AMF staff and Nelson Coelho, an employee of Concern Universal, have worked closely with the NMCP of Malawi to make this happen.57 Additionally, AMF is considering funding an additional staff member to further support the NMCP as it considers the development of the mechanisms it uses to distribute and follow up on nets.58

Some of the practices that will be implemented include: gathering registration data for all households and checking data quality.59 These practices will be implemented in 18 of Malawi’s districts that together will receive 7 million nets in 2015.60

DRC distributions

North Idjwi Island and South Idjwi Island

The North Idjwi Island distribution of ~62,000 LLINs, originally planned for November 2014 through April 2015, has been delayed due to issues with the pre-distribution survey.61 The pre-distribution survey is intended to only include seven questions. However, AMF told us that the North Idjwi Island officials in charge of the survey decided to add many more questions, which made the survey so long that approximately one-third of the target population refused to take or complete the survey.62 So, the pre-distribution survey has to be re-done, and AMF does not expect to be able to sign off on the distribution until September 2015.63 This means that the distribution will likely not take place until October or November 2015.64

Because the South Idjwi Island distribution (also ~62,000 LLINs) was not going to begin until the North Idjwi Island distribution was completed, the South Idjwi Island distribution, originally planned for April-May of 2015, is also delayed.65

Nord Ubangi distribution

The Nord Ubangi distribution is slightly delayed. It was originally scheduled for April through June of 2015.66 However, AMF informed us that the 730,000 nets for the distribution were expected to arrive in July.67 At the time of writing this update (in early April 2015), we have not yet asked AMF why this distribution was delayed.

Updates on potential future distributions

Major updates on potential future distributions are:

  • Malawi has asked AMF to help fund its universal coverage campaign in 2018. AMF told us that it will likely provide approximately $6 million to support this distribution.
  • AMF is attempting to finalize two new distribution agreements: one for approximately 2.5 million nets in Country X (AMF cannot publicly share the names of countries it is negotiating with), and one for approximately 5.5 million nets over the next three years in Country Y. We do not have a strong sense of how likely it is that AMF will be able to finalize these distribution agreements.
  • AMF is planning to fund a study on insecticide resistance that will be conducted with its 2015 Nord Ubangi distribution.
  • AMF is also in discussion with the NMCPs in several other countries for distributions in 2015 to 2017. AMF has indicated that it could provide at least low millions of nets in each case.

More details below.

Potential distributions in Malawi

In late 2014, AMF was interested in funding additional distributions in Malawi in 2015.68 Since then, AMF has shifted focus to funding additional distributions in Malawi in 2018 because the NMCP of Malawi has requested AMF’s assistance with mass LLIN distributions in 2018.69 AMF is planning to agree to assist Malawi in 2018 in the four districts where AMF has previously provided funding (Ntcheu, Balaka, Dedza, Dowa); AMF estimates that these distributions will cost approximately $6 million.70

Potential distributions in Country X

AMF has been working to fund a distribution in Country X.71 Originally, AMF planned to provide approximately $12 million to fund 4 million nets in Country X.72 A co-funding partner planned to provide another approximately $12 million to cover all non-net costs.73

However, AMF told us that the partner that AMF chose to distribute nets in Country X could not come to an agreement with AMF over some of AMF’s monitoring requirements and pulled out of this plan.74 This caused the co-funding partner to also withdraw its funding, because it needed to commit its funds on a specific funding schedule and could not wait for AMF to find a new distribution partner.75

After these events, the head of Country X’s NMCP was able to acquire some funding from other sources, reducing Country X’s need to between 2.5 and 2.7 million nets.76

AMF has continued to offer to fund enough nets to cover the remaining gap in Country X.77 However, AMF told us that it is not in a position to cover the non-net costs of this distribution.78 AMF is currently talking to other actors who may be able to fund the non-net costs.79 Additionally, AMF told us that it has identified another partner for this distribution and has an agreement in place with it to distribute nets if AMF ultimately funds a distribution in Country X.80

AMF has informed Country X that it would pursue other opportunities in case a distribution in Country X could not be worked out.81

Potential distributions in Country Y

Large distribution

AMF told us that there is currently a need for funding for roughly 9 million nets in Country Y for 2015-2017.82 AMF is currently discussing the possibility of funding 5.5 million nets of this gap.83 A co-funding partner is in place to cover non-net costs.84

AMF told us that it is primarily negotiating its distribution agreement with Country Y’s NMCP.85 AMF said that if they reach an agreement, an implementing distribution partner that agrees to AMF’s monitoring requirements will take responsibility for the net distribution, follow-up and associated reporting.86

Small distribution

There is also a smaller distribution of approximately 60,000 nets in Country Y that AMF is interested in funding.87 However, until AMF knows which districts the larger distribution in Country Y may fund, it cannot agree to fund this smaller distribution.88 AMF is particularly interested in this distribution because its implementing partner plans to use smartphones for data collection, and AMF would like to test the use of smartphones for data collection in other contexts.89

Other potential distributions

AMF is in discussions with several other countries regarding contributions of a few million nets.90 We do not yet have more details on these potential distributions.

Insecticide resistance studies

AMF plans to fund at least one, and possibly two, studies on insecticide resistance.91

One of these studies will be conducted by the Liverpool School of Tropical Medicine with the 2015 Nord Ubangi distribution. We have now seen a preliminary research proposal for this study.92 The study will include:

  • Measurements of species abundance, resistance prevalence and level, and the effect of PBO (an insecticide) on insects’ mortality at baseline and at a 1-year post-distribution follow-up93
  • Monthly measurements of insect pesticide resistance in households covered by different net types (some households will be covered by standard LLINs while others will be covered by standard LLINs that have also been treated with PBO).94

AMF expected to receive the full research proposal in late March, and expected to approve the research plan by mid-April.95 We have not yet followed up with AMF about whether it received the full proposal.

Room for more funding

It is difficult to assess AMF’s room for more funding because (1) AMF moves money in large chunks once it reaches a large-scale distribution agreement, so AMF would ideally have a large amount of funding ready to commit at any given time, but (2) we have some remaining uncertainty about AMF’s ability to sign new agreements and conduct high-quality large-scale distributions outside of Malawi (more), so we are cautious about directing a large amount of additional funding to AMF.

At this point in time, we continue to recommend AMF as an excellent giving opportunity and believe it has room for more funding, but we would be hesitant to recommend that it receive a large amount of additional funding (i.e., on the order of tens of millions of dollars) until we can evaluate results from Kasaï Occidental, its first large-scale distribution outside of Malawi.

AMF’s current funding situation

As of March 2015, AMF held about $19.6 million.96 Of this amount, about $5.4 million is committed to distributions through the end of 2017, leaving about $14.2 million uncommitted.97

If AMF were to fund all of the potential distributions and projects that it is currently discussing at a high level of detail that would take place in late 2015, AMF would need about $14.6 million:

  • $7.5 million for 2.5 million nets in Country X (assuming $3 per net)
  • $6.6 million for 2.2 million nets in Country Y (assuming $3 per net)
  • $500,000 (estimate) for a study on insecticide resistance during the Nord Ubangi distribution in April98

In addition, AMF may need to commit approximately $6 million within the next six months to Malawi for the 2018 national distribution that Malawi has asked AMF to help fund.99
AMF also hopes to sign an agreement with Country Y that would only hold it legally responsible for providing funds for Country Y’s 2015 distribution, with an implicit agreement that AMF would provide funding for Country Y’s distributions in 2016 and 2017 as well.100 This would give AMF more time to fundraise for those future distributions.

Because AMF has limited funding for future potential distributions, it is pursuing a strategy of engaging deeply in discussions with 1-2 countries for large distributions (currently Country X and Country Y), and engaging less deeply with a number of other countries for smaller distributions (in case the large distributions fall through).101

AMF told us that it does not feel constrained by its current staff capacity and does not have any plans to significantly increase its fundraising efforts.102

Sources

Document Source
7-partner agreement for emergency distribution (DRAFT) Unpublished
AMF All distributions page Source (archive)
AMF blog post, February 18, 2015 Source (archive)
AMF blog post, March 17, 2015 Source (archive)
AMF page on Balaka 2013 distribution Source (archive)
AMF page on Dedza 2014 distribution Source (archive)
AMF page on Dedza 2017 distribution Source (archive)
AMF page on flood affected districts distribution Source (archive)
AMF page on future distributions Source (archive)
AMF page on Kasaï Occidental 2014 distribution Source (archive)
AMF page on non-net costs Source (archive)
AMF page on Nord Ubangi 2015 distribution Source (archive)
AMF page on Ntcheu 2012 distribution Source (archive)
AMF page on the introduction of smartphone technology Source (archive)
Balaka (2013) 12-month post-distribution check-up data Source (archive)
Concern Universal Balaka 2013 distribution proposal Source (archive)
Concern Universal Dedza 2014 distribution proposal Source (archive)
Country Y - Population by region Unpublished
Country Y 2015 mass LLIN distribution schedule Unpublished
Country Y - LLINs gap Unpublished
Email attachment from AMF - Country Y 1, sent to GiveWell on February 6, 2015 Unpublished
Email attachment from AMF - Country Y 2, sent to GiveWell on February 6, 2015 Unpublished
GiveWell 2014 end-of-the-year review of AMF Source
GiveWell estimate of AMF cost per net 2014 Source
GiveWell’s non-verbatim summary of a conversation with Rob Mather and Peter Sherratt on February 6, 2015 Source
Insecticide resistance research proposal Unpublished
Malawi 4 Districts Schedule Source
Malawi NMCP invitation for 2018 distribution Unpublished
Melanie Renshaw, phone conversation with GiveWell, May 23, 2014 Source
Ntcheu (2011-12) 33-month post-distribution check-up data Source (archive)
Rob Mather, conversation with GiveWell, February 24, 2015 Unpublished
Rob Mather and Peter Sherratt, conversation with GiveWell, November 6, 2014 Unpublished
Rob Mather and Peter Sherratt, conversation with GiveWell, February 6, 2015 Unpublished
Rob Mather, email to GiveWell, February 24, 2015 Unpublished
Rob Mather, email to GiveWell, November 6, 2014 Unpublished
Rob Mather, email to GiveWell, February 6, 2015 Unpublished
Rob Mather, email to GiveWell, March 23, 2015 Unpublished
Rob Mather, email to GiveWell, June 19, 2015 Unpublished