# Against Malaria Foundation

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.

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.

• AMF is co-funding a "Malaria Control Unit" (MCU) in Malawi with United Purpose.20 The MCU will consist of up to 14 permanent staff members who will work on a variety of malaria control projects: conducting post-distribution surveys, improving malaria case rate data collection practices, monitoring the levels of malaria prevention and treatment supplies at local health centers, developing efficient methods to keep net coverage rates high in between mass distribution campaigns, and more.21 The MCU is also intended to assist with AMF and United Purpose's distributions in Malawi.22 AMF has committed approximately $736,000 over three years to this project.23 • Starting in 2015, AMF encouraged United Purpose staff to attend national malaria control strategy meetings in Malawi to share AMF's processes and results in other districts. AMF anticipated that this would result in some of its monitoring practices (e.g. using sleeping spaces data rather than population data to determine the number of nets needed; "105%" registration data collection; and putting summary village-level or health facility-level data into electronic form) being adopted in distributions supported by other funders.24 Our understanding as of early 2018 is that these practices have not yet been adopted.25 ### Spending breakdown The following table shows AMF's total expenditure, categorized into purchases of LLINs, spending on running the organization, and spending on other non-net costs (such as providing funding to other organizations to conduct post-distribution monitoring, which are described above). We include spending since FY 2012 (July 2011 to June 2012) because this is when AMF shifted to its current model of larger-scale distributions. AMF expenditure by category26 Category July 2011 to June 2018 spending Percentage of total spending, FY 2012 to 2018 LLIN purchases$115.1 million 90.4%
Costs of distributing nets and monitoring ("non-net costs") $9.1 million 7.2% Insecticide resistance research$1.6 million 1.3%
Salaries and other organizational costs $1.3 million 1.1% Total spending$127.3 million -

Prior to 2013, AMF asked all distribution partners to use their own funds or to find another funder for all non-net costs of the distribution.27 More recently, it has paid for some of these costs in certain distributions. AMF told us that it considers funding non-net costs in cases where (a) non-net costs are not covered by other partners, and (b) AMF feels confident that its distribution partners will manage and report on spending well.28

## Does it work?

On a separate page, we discuss the general evidence behind distributions of LLINs. We conclude that there is strong evidence that these distributions can be expected to reduce child mortality and malaria cases.

When evaluating the effectiveness of an LLIN distribution organization, we seek to answer the following questions:

• Are LLINs targeted at people who do not already have them? In general, we believe enough time has passed between LLIN distributions in the regions in which AMF operates that most previously-owned nets have worn out by the time that AMF's distributions take place. We do not have data on the extent to which households receive nets from other sources (e.g. on the private market, during clinic visits), but our impression is LLIN mass campaigns are the main source of nets in the locations AMF works.
• Do the LLINs reach the intended destinations? The main evidence that LLINs reached their intended destinations at a high rate are (a) post-distribution surveys, where surveyors visit a sample of households that registered for nets six or nine months after the distribution, and (b) data from registering households and, for some distributions, which households are reported to have received their nets. We have seen (a) and/or (b) from all of AMF's distributions prior to 2017; we have not seen this information for some of AMF's more recent distributions. We discuss some limitations of the post-distribution surveys below.
• Are LLINs targeted at areas with high rates of malaria? AMF seeks out distribution partners in countries that are known to have high rates of malaria, or where malaria rates are likely to increase significantly if LLIN distribution programs are not sustained. We note that Papua New Guinea (where AMF funded LLIN distributions beginning in 2017) has lower (but still significant) rates of malaria than other countries where AMF has worked or plans to work.
• Do those who receive the LLINs install them in their homes properly? Do they utilize them consistently over the long term? AMF requires partners to conduct follow-up surveys at 6- or 9-month intervals for a period of 2.5 years. In most cases the results from Malawi and Ghana seem consistent with moderate to high usage of nets for at least a year or two after distribution; the limited results we have seen from DRC have been somewhat less positive.29 We discuss some methodological limitations of the surveys below.
• Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF? The evidence we have seen suggests that donations to AMF increase the total number of LLINs distributed, but that a portion of the impact is offset by displacing funding from other sources.

Details follow.

### Are LLINs targeted at people who do not already have them?

We believe it is likely that AMF's distributions primarily result in people who would not otherwise have viable LLINs receiving them, though it may lead in some cases to households that already own nets receiving more nets than are needed. Key factors in this assessment include:

• The amount of time elapsed between distributions, as compared to our expectation of how quickly nets become worn out. Distributions are generally scheduled for every three years. Our best guess is that LLINs last, on average, between 2 and 2.5 years.30
• Whether people targeted by AMF's distributions would obtain nets from other sources in the absence of AMF's work. We do not have data on whether people targeted by AMF's distributions obtain nets from other sources; our impression is that mass distributions like those supported by AMF are the primary means by which people obtain nets.31
• AMF's process for allocating nets to households, which involves AMF's distribution partners visiting households and recording how many nets are needed, based on the number of people or number of sleeping spaces in each house.32

AMF notes that it interprets the data from PDMs as indicating that LLINs should be replaced at least every three years and that subtracting usable nets (unless they have never been used) increases the period where a household has to rely on old, ineffective nets until the next LLIN campaign.33

In past distributions in Malawi and DRC, AMF has allocated nets based on the number required per household minus the number of nets already owned by that household. Going forward, AMF will not be taking previously-owned nets into account.34

### Do LLINs reach their intended destinations?

We have seen reasonable evidence that a large proportion of AMF's LLINs have reached their intended destinations in AMF's past distributions, excluding its most recent distributions. The strongest evidence we have seen on this question in Malawi and Ghana is from post-distribution surveys, and the strongest evidence from DRC and Papua New Guinea is from household-level data on nets received. We have not yet seen evidence on this for recent distributions in Togo, Uganda, and Zambia. (We had expected to see at least some of this information from Togo, Uganda, and Zambia by this point in time.)

The main sources of evidence that LLINs reached their intended destinations at a high rate are (a) post-distribution monitoring, where monitors visit a sample of households that registered for nets generally six or nine months after the distribution, and (b) data on which households are reported to have received their nets. We have also seen narrative distribution reports for most of AMF's distributions, and a few other minor sources of evidence that LLINs reached their intended destinations.

#### Post-distribution monitoring

AMF's distribution partners conduct post-distribution monitoring, discussed in detail below, about six to nine months after each distribution (and regularly after that up to 2.5 years after the distribution) to determine whether nets are in place, being used, and in good condition.35 The first post-distribution surveys that have been completed to date for each large-scale distribution in Malawi have generally somewhat mixed results: the first four found rates above 80% (90%, 87%, 93%, and 81%) of LLINs from the recent AMF distributions hung over sleeping spaces, while the more recent distributions have had worse results (69% and 60%; the latter was followed by a rate of 77% at 12 months). Most nets that were not hung were present in the household: the highest rate of missing nets was 5% (see this summary of results for details).36 Hang-up rates at 6 months post-distribution in Ghana were relatively high: 80%, 84%, and 90% in the three regions.

We believe that the results of the first post-distribution surveys from distributions in Malawi and Ghana provide reasonable evidence that nets reached their intended locations at a high rate, though we note some methodological limitations of these surveys below.

We believe that the 8-, 12-, and 18-month surveys in Kasaï-Occidental were poorly implemented, and that the results of the surveys provide limited evidence on the proportion of AMF's LLINs that reached intended destinations (details in this blog post).37 The 6-month survey in Nord Ubangi was canceled due to violence; the 12-month survey found a hang-up rate of 64%.38

In more recent distributions, AMF plans to conduct PDMs starting at nine months rather than six months.39

Four "waves" of distributions in Uganda had been completed by July 2017.40 Our understanding is that the first PDMs have yet to occur in those regions. We believe PDMs more than a year after a distribution are less helpful for determining whether nets reached their intended destinations than PDMs six months after the distribution.

#### Household-level data on nets received

In addition to recording data on the number of LLINs allocated to each household during the registration process, AMF's distribution partners also record data on the number of LLINs actually distributed to each household during the distribution process.

For the 2014 and 2015 distributions in Malawi, we have not seen household-level data on the number of nets received. Our understanding is that these data exist in paper form only.

For the 2014 Kasaï-Occidental distribution in DRC, households received nets at the same time they were registered, so the registration list provides some evidence that nets reached their intended destinations.41 We have seen registration and distribution data from Nord Ubangi, DRC that include numbers of LLINs actually received and hung up for each household.42 We have not yet seen a distribution report from Nord Ubangi, so we are uncertain about how data on the number of LLINs households actually received were collected.

In Ghana, data on the number of LLINs actually distributed to each household were recorded by LLIN distributors, and later entered electronically into AMF's Data Entry System, where we have viewed the data.43 We also spot-checked some paper records during our visit to AMF's distribution partner in Ghana in 2016.

We have not yet seen this data for recent distributions in Togo, Uganda, Papua New Guinea, and Zambia.

#### Distribution reports

Distribution reports provide narrative summaries of distribution activities and discuss challenges encountered. These reports provide some evidence that distributions generally operated as intended (or that distribution partners are aware of specific challenges and have plans to address them) and that households actually received LLINs; however, we do not think this type of evidence is as useful for the question of whether LLINs reached households as the two types of evidence discussed above.

United Purpose has provided distribution reports for four of the six large-scale distributions it has completed in Malawi.44 As we report in our March 2012 update, reports from the Ntcheu 2012 distribution note challenges including attempted thefts, double registrations, and logistical problems.45 United Purpose provided a similar level of detail on challenges encountered in the Balaka 201346 and Dedza 2014 distributions,47 and the first half of the Dowa 2015 distribution.48 These reports increase our confidence that United Purpose is aware of potential problems and has a system in place to address them.49 We have not seen reports for the Ntcheu 2015 or Balaka 2015 distributions in Malawi.

IMA World Health has provided a distribution report for the Kasaï-Occidental, DRC 2014 distribution. We have not yet seen any distribution reports from the Nord Ubangi, DRC distribution.50

We have seen progress reports covering periods of pre-distribution, distribution, and post-distribution activities from Episcopal Relief & Development, AMF's distribution partner in Ghana, for the 2016 distributions in Greater Accra, Northern Region, and Upper West Region, and a full report on the 2016 distribution in the Northern Region.51 These reports discuss problems encountered in each of these stages.52

AMF has also shared distribution reports from each of its newer countries of operation, namely Uganda, Togo, Papua New Guinea, and Zambia.53 These reports give an overview of the distributions that occurred and discuss challenges and problems encountered during the distribution; see footnote for examples.54

#### Other evidence

For the Kasaï-Occidental 2014 distribution, AMF's distribution partner, IMA World Health, piloted the use of smartphones to record household data, including GPS coordinates, for registration and LLIN distribution.55 AMF has sent us detailed GPS data that show the GPS coordinates for each household visited.56 The registration and distribution data from Nord Ubangi, DRC also included GPS coordinates for each household.57

In Ghana, it is our understanding that "post-distribution validation tracing" (i.e., checking, immediately after the distribution, by phone or in-person, that a randomly selected sample of households actually received the correct number of LLINs) was used for all three AMF-funded distributions in 2016, but we have not seen comprehensive results from this process (e.g., the proportion of selected households that received the appropriate number of LLINs).58 AMF told us that it expected to see data from post-distribution validation tracing from Episcopal Relief & Development in January 2017;59 we have not followed up with AMF for these data.

### Are LLINs targeted at areas with high rates of malaria?

At the highest level, AMF appears to exclusively target countries with known malaria risk.60 Since 2012, AMF’s large-scale distributions have occurred in Malawi, DRC, Ghana, Uganda, Togo, Papua New Guinea, and Zambia.61 Based on 2013 data, the World Health Organization estimated that Malawi, DRC, Ghana, Uganda, Togo, and Zambia had malaria death rates of between 50 and 99 deaths per 100,000 people, and that Papua New Guinea's malaria death rate was between 10 and 49 deaths per 100,000 people.62

### Do those who receive the LLINs install them in their homes properly? Do those who receive the LLINs utilize them consistently over the long term?

AMF requires partners to conduct PDMs at regular intervals for a period of 2.5 years, or until the next community-wide net distribution in the same area, to determine whether LLINs are present, whether they have been hung, and what condition they are in. Up to this point (mid-2018), AMF has conducted PDMs every 6 months. Going forward, PDMs will occur every 9 months (for distributions for which no PDMs have already taken place).63 Surveys covering distributions prior to 2017 have been reasonably comprehensive of the distributions that AMF has funded. They have some methodological limitations, discussed below. Results have been fairly positive with substantial variation across distributions.

#### Methods

See our summary of AMF distributions spreadsheet, "PDMs" sheet, for details of what PDMs have been completed. In short, AMF's PDMs are reasonably comprehensive: we have seen highly comprehensive results from all distributions taking place prior to 2017, and few of the scheduled surveys (which were intended to be conducted every six months) have been skipped.

We have not yet seen post-distribution surveys from Uganda, Togo, Papua New Guinea, or Zambia. This gap in monitoring is broadly due to a combination of (1) distributions having been completed fairly recently, (2) the shift from surveys beginning at 6 months to beginning at 9 months, and (3) delays in surveys being conducted.

For a description of the methodology used in AMF's PDMs, see this spreadsheet, sheet "Methods." In short:

• Households are now selected randomly for inclusion in the surveys. AMF generates the list of households to survey from the full list of households that were registered for the distribution.64 The list includes more households than will be surveyed, with the intention of allowing enumerators to skip some households (for example, when members of a household are not available); this may lead to bias in the results. Note that in some earlier surveys, households were not selected fully randomly.65
• AMF has told us that it asks its partner organizations to revisit 5% of the households visited, as a means of data quality control.66 While the idea is that the results from the revisits can then be matched and cross-checked against the original results, our impression is that this matching process historically has not actually occurred. AMF believes it will be easier to match the data using the Data Entry System.67 We have not yet seen this analysis for any distributions.
• We believe that the 8-, 12-, and 18-month surveys in Kasaï-Occidental were poorly implemented, and that the results of the surveys provide only limited evidence on the proportion of AMF-funded LLINs that are used effectively over the long term (details in this blog post).68 However, we think that the combination of the three reported rates of coverage (at 8-, 12- and 18-months) tells a plausible story of a decline in coverage over time, which increases our confidence that these surveys are to some extent representative of LLIN hang-up rates, or at least of trends in hang-up rates.
• In 2017, GiveWell commissioned IDinsight to observe PDMs in Malawi and Ghana. For Ghana, IDinsight noted:
• Though enumerators were trained to observe use and condition of nets, assessment was inconsistent and did not always involve direct observation.69
• During data entry, illegible and inconsistent data were discarded, and records were not kept on what portion of data was discarded.70

#### Results

Full results in this spreadsheet. Definitions of each indicator are on a separate page with additional information about AMF. In short:

• Malawi: The data from PDMs from the six distributions in Malawi show moderate-to-high rates of nets hanging and in at least "viable" condition for around 18 to 24 months post-distribution. The number of nets "worn out" appears to generally increase substantially as the time elapsed since the distribution approaches 2.5 years. Of the six distributions, the two more recent distributions seemed to have lower rates of nets from the distribution hanging. AMF believes that the low hang-up rates for these two more recent distributions may be due to the continued use of older LLINs from the 2012 distribution in Ntcheu and use of LLINs from other sources in Dowa (or other possible explanations, see footnote).71
• DRC: We believe the data we have seen from AMF's distributions in DRC provide some evidence that LLINs decayed considerably more quickly than expected.
• Ghana: The distributions in Ghana occurred in mid-to-late 2016, and follow-up reaching up to 24 months post-distribution shows high rates of nets hanging and nets in at least "viable" condition (i.e. not "worn out").

We note that net usage rates in the trials of bed net efficacy documented in our page on Long Lasting Insecticide Treated Nets were generally in the 60%-80% range.72 However, these usage rates are not directly comparable to the data from AMF's PDMs, which measure the proportion of nets hung, rather than usage.

As another point of comparison, the "decay model" we use to estimate the lifespan of LLINs assumes that 92% of LLINs are functional and in use for the first year after a distribution, 80% of nets are functional and in use for the second year, and 50% of nets are functional and in use for the third year.73 It is not fully clear to us how to compare the net quality and net hang-up rates found in AMF's post-distribution monitoring to the assumptions in the decay model, in part because it is not clear whether the definition of a "functional and in use" net in the decay model is comparable to what PDMs measure.

### Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF?

On a separate page, we discuss some cases where AMF was in discussions to fund a distribution, but ultimately did not. In most of these cases, the net gap AMF was in discussions to fill persisted for six or more months after AMF's discussions closed, and, in two out of the five cases we looked at, gaps persisted for long periods (18 months and ~3 years, respectively). In most cases, the gap was eventually filled by another funder. As far as we can tell, during the time between AMF withdrawing from discussions and another funder stepping in, the populations targeted for distributions did not receive nets and likely were inadequately protected from malaria.

We also discuss, on a separate page, what we have been told about what would have happened in the absence of AMF funding in two distributions that AMF did fund. In summary, in both cases our best guess is that there were no other funders who could have closed the gaps, and nets would have been at least partially targeted at higher-risk populations while others would have been left uncovered.

Across Africa, there are substantial funding gaps for LLINs (more below), and because our impression from following AMF's progress over time is that, due to AMF's more limited funding and, perhaps, greater data requirements, governments often seek funding first from larger funders (particularly the Global Fund to fight AIDS, TB, and Malaria) and then may ask AMF to fill gaps. However, we note that this dynamic may change if AMF has significant resources in the future (more below) and that countries are sometimes able to choose how they allocate Global Fund grants among malaria interventions (including LLINs, treatment, and diagnosis), so the availability of funding for LLINs from AMF could cause countries to allocate fewer Global Fund resources to LLINs.74

### Are there any negative or offsetting impacts?

• Will insecticide-treated nets continue to be effective? As discussed in our report on insecticide-treated nets, there is strong evidence for the effectiveness of this intervention; however, the best evidence for the intervention was collected before LLINs were widely used and there is some evidence that mosquitoes have since adapted to the insecticide used in LLINs, possibly making them less effective. We have reviewed the evidence on the state of insecticide resistance. We concluded, "Broadly, it seems that insecticide resistance is a larger concern now than it was when we last thoroughly evaluated the evidence in 2012, but it remains difficult to quantify the impact of resistance. Our very rough best guess (methodology described in more detail below) is that insecticide-treated nets (ITNs) are roughly one-third less effective on average across sub-Saharan Africa than they would be in the absence of insecticide resistance. ITNs remain a highly cost-effective intervention after incorporating this discount." We wrote here about recent evidence suggesting that piperonyl butoxide (PBO) nets give additional protection over standard LLINs in areas with insecticide resistance; we also use this recent evidence to inform our estimate of the effects of insecticide resistance in distributions of standard LLINs. AMF expects that a portion of the nets it funds in the future will be PBO nets.75
• Do free LLIN distributions distort incentives for recipients or distort local markets for nets? As discussed in our report on insecticide-treated nets, we feel that there is a reasonably strong case for distributing LLINs freely rather than selling them at market (or even below-market) prices. We also think that the benefits of distributing LLINs freely to a population likely outweigh the negative consequences of distortion in local net markets, though we have not factored these potentially negative consequences into our cost-effectiveness analysis of AMF.
• Could distribution of LLINs be inequitable and unfair, causing problems in the targeted communities? We feel that AMF's processes for determining needs for LLINs at the household level are fairly well-suited to ensuring that LLINs are distributed equitably. We have some concerns about whether AMF's process succeeds at identifying all villages or households located outside of villages.
• Does AMF divert skilled labor from other areas? In Malawi, net distributions have been conducted by low-level government health staff in partnership with the staff of AMF's partner NGO.76 AMF's partner in Malawi told us in 2012 that government health staff are normally involved in activities such as disseminating health-related information, reporting on levels of stunting and disease, carrying out immunization campaigns, and providing nutrition support.77 We do not know the extent to which net distribution reduces their ability to complete other duties, though we note that net distributions are generally completed within a few days in each local area, and we would guess that LLIN distributions are likely among the most cost-effective work they engage in.78 Diversion of skilled labor may be more of a concern in the DRC, where 22 senior district health staff were employed as Field Supervisors for the Kasaï-Occidental distribution.79 AMF's distributions in Ghana in 2016 were planned by high-level staff from a government health agency and implemented by local government staff and volunteers; monitoring of the distribution was largely implemented by a Ghanaian non-profit organization.80 We have not investigated what other activities the government and non-profit staff and volunteers engage in, or whether the LLIN distribution interferes with their ability to perform other duties.

## What do you get for your dollar?

### Cost per LLIN distributed

We estimate that on average the total cost to purchase, distribute, and follow up on the distribution of an AMF-funded LLIN is $4.53. Excluding in-kind government contributions, we estimate the cost is$4.29. These estimates rely on a number of uncertain assumptions. Full details of our analysis are in this spreadsheet. For results, see sheet "Summary." More discussion follows.

Below, we also discuss how we estimate the cost per death averted in AMF distributions.

#### Our approach

To get the total costs of the program, we attempt to include all partners such that our cost per LLIN represents everything required to deliver the nets. In particular, in our cost per treatment analysis for AMF, we have attempted to include these categories:

• The costs paid by AMF to purchase LLINs. This accounts for 46% of the total cost per LLIN.
• Costs of shipping and delivering nets, monitoring the distribution, and conducting PDMs. In most cases, the Global Fund or another partner pays for most of these costs; in almost every case, AMF has paid for the PDMs. In total, these costs account for 45% of the total.
• Resources contributed by governments, such as staff time, office space, etc. We roughly estimate these costs as a proportion of the total cost (excluding LLIN purchase costs) based on an analysis of a distribution in Malawi in 2012. This accounts for 5% of the total.
• Other AMF costs: staff salaries and other organizational costs, a rough estimate of the value of the CEO's donated time and estimated value of other pro bono support, research AMF has funded on insecticide resistance, and costs of the Malaria Unit in Malawi. This accounts for 3% of the total.

We start with this total cost figure and apply adjustments in our cost-effectiveness analysis to account for cases where we believe the charity's funds have caused other actors to shift funds from a less cost-effective use to a more cost-effective use ("leverage") or from a more cost-effective use to a less cost-effective use ("funging").

We used data and estimates from completed distributions, ongoing distributions, and distributions that AMF has committed to funding in the future.

Comment from AMF: AMF would like all donors reading this to know that the costs included for the CEO and pro bono services are not actually incurred. Each of them is very happy to provide their services for free.

On a separate page, we triangulate our AMF estimates of cost per LLIN with a rough global average cost per LLIN.

#### Shortcomings of our analysis

There are several ways in which our analysis of AMF's cost per LLIN is uncertain:

• The price of an LLIN has been falling and in our estimate we have used a projected price per LLIN, rather than an average of the prices AMF has paid in the past. The average price in distributions AMF funded in 2016-2018 was $2.20. Based on what AMF told us it expects in the future, we have used an estimate of$2.10 per LLIN.
• For distribution costs not paid by AMF, we have generally used rough estimates.81
• It is difficult to predict where AMF will fund LLINs in the future because it pursues several discussions at once. To get an overall average cost, we have taken a weighted average of past distributions, weighted by AMF's spending in each distribution, rather than weighted by AMF's expected spending in the future. This means that if, for example, AMF funds a larger proportion of nets in DRC, where costs are high, in the future than in the past, our cost per LLIN would be an underestimate. (Note that this does not mean that funding LLINs in DRC is necessarily less cost-effective—our cost-effectiveness analysis also takes into account factors such as malaria mortality rates in each country.)

### Cost per death averted

See our most recent cost-effectiveness model for estimates of the cost per death averted through AMF-funded LLIN distributions.

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. For example, our model does not include the short-term impact of non-fatal cases of malaria prevented on health or productivity, prevention of other mosquito-borne diseases, or reductions in health care costs due to LLINs reducing the number of cases of malaria. It also does not include possible offsetting impacts or other harms. We do include possible developmental impacts on children who sleep under an LLIN.82

There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

The full details of our cost-effectiveness analysis are in our report on mass distribution of LLINs.

## Is there room for more funding?

Note: All content in this section reflects AMF's funding situation as of August 2018 except where otherwise noted.

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. 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 AMF's track record of finding and filling funding gaps for LLINs and the large size of the global funding gap (estimated to be in the hundreds of millions of dollars for 2018-2020), we expect the maximum to be significantly greater than what AMF is likely to receive. We expect that most new distributions that AMF signs agreements for in 2019 would not take place until 2020 or 2021. November 2018 update: AMF told us that it expects that these distributions would take place in 2019 and 2020. In short (more details in the sections below): • Total opportunities to spend funds productively: By the end of 2018, AMF expects to have signed agreements to use the full amount of funding it has on hand to fund LLIN distributions in 2019-2020, though, based on AMF's past experience, our guess is that some of the specific discussions that AMF is pursuing will not result in agreements for reasons other than lack of funding. As of August 2018, AMF had not yet identified which countries it would most likely sign distribution agreements with using funding it receives in late 2018 and early 2019. (November 2018 update: AMF told us that it has identified three to four countries where it is most likely to commit funding that it receives in late 2018 and in 2019.83) Based on AMF's track record of finding and filling gaps in LLIN distributions and on its level of spending over the past few years (in the range of$20-30 million per year), we expect it to have opportunities to commit to distributions costing in the low tens of millions of dollars with funding it receives over the next year. We roughly estimate the total global funding gap for LLINs in 2019 and 2020 at approximately $550 million. (More) • Cash on hand: As of August 2018, AMF held$84.1 million, $65 million of which was uncommitted to future activities. Update: As of October 2018, AMF held$90 million, of which $47 million was uncommitted to future activities.84 (More) • Expected additional funding: We roughly estimate that AMF will receive$10.9 million in 2019-2021, not including funds due to GiveWell's recommendation. This could be an underestimate—AMF expects to make fundraising a larger priority in the future. (More)

Below, we also discuss:

• Past spending rate: AMF has a track record of spending tens of millions of dollars per year; however, we see its limited staff capacity as a risk to its ability to increase its spending in the future. (More)
• Considerations around the size of AMF distributions: Funding a large portion of a national distribution may have advantages in terms of efficiency and leverage, but also increases the risk of displacing funding from other donors. We discuss AMF's approach to this tradeoff. (More)

### Uncommitted and expected funds

As of August 2018, AMF held $84.1 million. Of this,$19.1 million was committed to PDMs for previous distributions, future distributions in several countries, central costs, the research study on PBO nets in Uganda, and the Malaria Unit in Malawi, leaving $65 million in uncommitted funds.85 Update: As of October 2018, AMF held$90 million, of which $47 million was uncommitted to future activities.86 We expect that AMF will receive additional donations over the remainder of 2018 and in 2019 from: • Donors who are not influenced by GiveWell's research: Historically, the vast majority of AMF's funding has been due to GiveWell's recommendation.87 As a rough guess, we expect AMF to receive about$1.5 million from non-GiveWell sources in the next year. This may be an underestimate as AMF has told us that it expects fundraising to be a key priority in late 2018 and 2019.88
• Donors who give based on GiveWell's top charity list, but do not follow our recommendation for marginal funding: GiveWell maintains both a list of all top charities that meet our criteria and a recommendation for which charity or charities to give to in order to maximize the impact of additional donations, given the cost-effectiveness of remaining funding gaps. We estimate that AMF will receive about $2 million from donors who use our top charity list but don't follow our recommendation for marginal donations.89 In our projections of future funding, we count only one year of funding that an organization receives as a result of being on our list of top charities in order to retain the flexibility to change our recommendations in future years. • Funding held by GiveWell: As of mid-2018, GiveWell held$4.4 million in funding to be regranted to AMF. This includes donations made to GiveWell for regranting to AMF as well as a portion of donations to GiveWell that were restricted to regranting to top charities at our discretion. We also include in this amount a planned grant from the Global Health and Development EA Fund, which is not formally affiliated with GiveWell, but is managed by Elie Hassenfeld, Co-Founder and Executive Director of GiveWell.90

With $65 million in currently uncommitted funding and$7.9 million in expected additional funding over the next year ($1.5 million from the first source in the list above,$2 million from the second, and $4.4 million from the third), as well as an additional$1.5 million per year for the following two years from donors who are not influenced by GiveWell's research, we estimate that AMF will have about $75.9 million available over the next three years. Update: As of October 2018, AMF held$90 million, of which $47 million was uncommitted to future activities.91 Our updated best guess is that AMF will have$57.9 million available over the next three years.

Finally, AMF told us that it has a stretch goal of raising at least $100 million by the middle of 2019 with a goal of negotiating an arrangement with a major co-funding partner in which AMF funds all nets needed in one or more countries during the partner's next funding cycle, and the partner re-allocates funding it would have provided to those countries to fund LLINs to instead fund LLINs in different countries.95 We have substantial reservations about this plan (more details below), but think it is very unlikely that AMF will raise this amount of funding. #### Expected maximum We believe that there will be a large global funding gap for mass LLIN campaigns over the next few years. Our best guess is that the funding gap for the period 2018-2020 was approximately$640 million for the 35 countries for which information was available as of early 2018.96 This includes gaps of $140 million in 2019 and$410 million in 2020.97 However, these estimates rely on a number of difficult judgment calls and may therefore substantially over- or underestimate the true gaps.

Ways in which the global funding gap for LLINs in 2018-2020 may be significantly overestimated include:

• Nigeria, which accounts for about half of the global gap ($332 million), is attempting to raise$300 million for malaria control; we expect that if it is successful, this will significantly reduce the gap, though not all of the funding raised would be spent on LLINs.
• Countries may decide to reallocate funding from other health programs or budget years in order to fill urgent gaps.
• The majority of the gap for this period is in 2020, which may be due to countries choosing to frontload Global Fund funding with the hope of identifying additional sources of funding later (the current round of Global Fund funding covers 2018-2020).98 There may still be enough time for other funders to fill gaps in that year.

Despite these considerations, we expect the funding gap for 2018-2020 to remain in the range of several hundred million dollars. The projected gaps for 2018-2020 (13% of total need in 2018, 13% of total need in 2019, and 40% of total need in 2020)99 are roughly in line with the end-of-year gaps in recent years. According to the RBM Partnership to End Malaria, the unfilled LLIN gaps in 2013-2015 were 22 million (13% of total need), 38 million (15% of total need), and 39 million (18% of total need), respectively.100 We estimate that the net gap in 2016 was 29% of total need, and that the gap in 2017 was 2% of total need.101 The RBM Partnership to End Malaria told us that the gap in 2017 was particularly low due to funding mechanisms that are no longer available.102

For more detail on our analysis of the global funding gap for LLINs, see our report on global funding gaps for LLINs and seasonal malaria chemoprevention and the spreadsheet with the calculations we used in that report.

#### Rate of funds moved

We had previously expressed concerns about AMF's ability to scale up.103 We now believe that AMF has a track record of productively spending large amounts of funding annually. It spent $34.3 million in its 2016 fiscal year,$28.5 million in 2017, and $26 million in 2018, up from less than$4 million in each of the prior years.104

Progress at signing new agreements was slow compared with AMF's available funding in 2017 and 2018, leaving AMF with a large amount of funds on hand. We attribute this to the facts that countries spent much of 2017 applying for Global Fund funding; decisions about how much funding would be allocated to LLIN distributions for 2018-2020 (and therefore what the funding gaps would be for LLINs) were still being finalized in many countries as of late 2017;105 and details of specific distributions, such as decisions about how funding would be allocated between 2018, 2019, and 2020, were still being finalized in many countries as of August 2018.

With the possible exception of one country AMF is currently in discussions with, any new distributions it signs with funds received at the end of 2018 or in 2019 would be in countries where it has not funded major distributions in the past. We expect that discussions with new countries require more time than discussions with countries where AMF has funded distributions previously. Taking into account this longer timeline for discussions as well as AMF's preference for committing funding at least 18 months in advance of a distribution to give its partners time to plan a high-quality distribution, funding that AMF receives at the end of 2018 and beginning of 2019 would likely fund distributions in 2020 at the earliest.

While we understand that having more lead time is beneficial for countries' planning processes,106 we are concerned that committing to distributions far in advance increases the uncertainty about whether funding would have been available from another source. Specifically, we are mildly concerned that committing to distributions that will take place in 2021 could lead the Global Fund to allocate less funding to these areas for its 2021-2023 funding cycle.

November 2018 update: AMF told us that it is in discussions with three countries where it has funded major distributions in the past and that if these discussions are successful, it expects the majority of these distributions to take place in 2019 and 2020.

#### Staff capacity

We see AMF's staff capacity as one of the main risks to its ability to spend funds efficiently. Since November 2017, AMF has grown from four to seven staff.107 Our impression is that it continues to be severely capacity constrained, possibly due in part to the delay between hiring new staff and seeing meaningful increases in capacity. AMF noted (in 2016) that it believed that staff capacity had not constrained its ability to sign agreements or manage distributions.108

### Considerations around the size of AMF distributions

#### Efficiency and leverage

AMF has told us that focusing on large distributions allows it to:109

• Be more efficient, since its staff capacity is largely limited by the number of distributions it is in discussions about and following up on.
• Focus on the countries that it has experience working with and where it has relationships with partners.
• Have more leverage to ask countries to carry out distributions and monitoring according to AMF's preferred processes. Funding a distribution requires negotiating with NMCPs, which we perceive to have some discretion in which funders they work with, and which we perceive to be choosing funders based on a variety of factors, including size and reporting requirements.110 In the past, AMF has been able to fund only a relatively small piece of countries' distributions (Uganda is an exception), but has maintained substantial reporting requirements. This dynamic may create fundamental reasons for governments to prefer partnerships with other funders.
• Give countries more confidence that their distributions will be fully funded and allow for easier planning and more timely distributions.

For these reasons, AMF's preferred approach would be to offer to purchase all the nets needed for one or more countries' distributions, and, if additional funds were available, fill gaps in LLIN funding for other countries; it would not fund the non-net costs, so this would mean funding about half of the full cost of the distribution.

#### Fungibility

AMF's approach in the past has been to look for funding gaps—countries that do not have sufficient funding from the Global Fund and other funders for nets—and offer to fill or partially fill those gaps. Given that countries and other funders have some discretion over how funds will be used, it is likely that some portion of AMF's funding has displaced other funding into other malaria interventions and into other uses.

We would guess that this effect would be significantly greater (i.e., there would be more displacement of other funding) if AMF were to pursue the strategy of offering to purchase all of the nets needed for one or more countries, rather than filling in gaps once the Global Fund has made its allocations. It is our understanding that once the Global Fund has told countries how much funding they have been allocated for each disease, it is difficult to change those allocations and to shift funding to countries that have funding gaps for nets. Therefore, we think that the most likely result of AMF providing a large amount of funding for nets to one country would be for that country to spend more Global Fund resources on other malaria interventions (including general health systems strengthening) or (less likely) to reallocate funds from malaria to AIDS and/or tuberculosis work (the other two diseases that the Global Fund provides funding for).

AMF has told us that it has a stretch goal of raising at least \$100 million by the middle of 2019 with a goal of negotiating an arrangement with a major co-funding partner in which AMF funds all nets needed in one or more countries during the partner's next funding cycle, and the partner re-allocates funding it would have provided to those countries to fund LLINs to instead fund LLINs in different countries.111 We are concerned about this plan because we think it would be difficult to gain convincing evidence that the partner's total funding for LLINs had not been reduced. However, we think it is very unlikely that AMF will raise sufficient funding to move forward with this plan.

In 2017, AMF began requiring information for all distributions on how the country is spending its Global Fund malaria funding in the preceding and upcoming mass LLIN distributions, and what the other sources of funding are for the preceding and upcoming distributions.112 So far, we have seen reports from Uganda, Ghana, Guinea, and Papua New Guinea; we are waiting to receive a report from Malawi.113 The data we have seen so far, while incomplete, is consistent with the idea that AMF is not displacing Global Fund funding. We have summarized this information in this spreadsheet. In Uganda, Ghana, and Papua New Guinea, the portion of the total Global Fund grant (which is generally split between HIV/AIDS, malaria, tuberculosis, and health systems strengthening) that was allocated to work on malaria remained about the same in the period before and after AMF began funding LLINs in the country. The portion of total Global Fund malaria spending that was allocated to LLINs remained the same in Ghana and increased substantially in Uganda (27% to 40%) and Papua New Guinea (42% to 62%) in the period before and after AMF's involvement. In Guinea, there has not been a significant change in the proportion of total Global Fund funding allocated to malaria work or the proportion of malaria funding allocated to LLINs, but given that AMF's first large distribution in Guinea is scheduled to take place in 2019, we do not take this as very strong evidence about whether or not AMF will displace Global Fund funding in Guinea in the future.

#### Our conclusion on distribution size

We feel that the risk of displacing a large amount of funding using the approach where AMF purchases all of the nets for one or more countries outweighs the benefits. We have requested that AMF use GiveWell-influenced funding to seek out gaps that other funders are unlikely to fill.

### What portion of all net distributions are funded by AMF?

In 2015, 2016, and the first three quarters of 2017, approximately 470 million nets were distributed in sub-Saharan Africa. 57% of these nets were funded by the Global Fund, 21% were funded by the President's Malaria Initiative, and 9% were funded by UNICEF.114

AMF's contributions accounted for 14.2 million nets in 2015-2017 (this is less than the number of nets that AMF purchased; we have made an adjustment to account for the fact that AMF contributes the nets while other funders pay many of the other costs).115 Therefore, AMF's contribution during this period was about 3% of all nets distributed.116

## AMF as an organization

We believe the Against Malaria Foundation to be a strong organization: