# Malaria Consortium – Seasonal Malaria Chemoprevention

Malaria Consortium's seasonal malaria chemoprevention program 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? Malaria Consortium (malariaconsortium.org) works on preventing, controlling, and treating malaria and other communicable diseases in Africa and Asia. We have only reviewed its seasonal malaria chemoprevention (SMC) program, which distributes preventive anti-malarial drugs to children 3 to 59 months old in order to prevent illness and death from malaria; our recommendation is just for this part of Malaria Consortium's work. (More)

Does it work? There is strong evidence that SMC substantially reduces cases of malaria. Malaria Consortium has conducted studies in the countries where it has worked to determine whether its programs have reached a large proportion of children targeted. On average, these studies found that 92% of children received at least one month of SMC treatment (out of four possible months), 71% received at least three months of treatment, and 55% received all four months of treatment. (More)

What do you get for your dollar? We estimate that the the total cost to achieve the equivalent of four person-months of SMC coverage is $6.93. The numbers of deaths averted and other benefits of SMC are a function of a number of difficult-to-estimate factors, which we discuss below. (More) Is there room for more funding? We believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities. We estimate that Malaria Consortium could absorb up to$66 million for work in 2019-2021. Update: In November 2018, we recommended that Good Ventures grant $26.6 million to Malaria Consortium; our updated estimate of its room for more funding is$39.4 million. (More)

Malaria Consortium's seasonal malaria chemoprevention program is recommended because:

• SMC is a program with a strong evidence base and strong cost-effectiveness. (More)
• Track record – Malaria Consortium has experience with supporting large-scale SMC programs and has demonstrated success at reaching a large portion of targeted children. (More)
• Room for more funding – we believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities. (More)

## Our review process

We began speaking to Malaria Consortium about the possibility of reviewing one of its programs in January 2016.

Over the next several months we tried to determine which of Malaria Consortium's programs we should prioritize evaluating for a possible recommendation, and we ultimately settled on seasonal malaria chemoprevention (SMC). The other programs that we investigated included: bed nets, deworming, dengue control, injectable artesunate for severe malaria, integrated community case management (ICCM), micronutrient powders, malnutrition management, neglected tropical diseases morbidity management, integration of nutrition with SMC, diagnosis of malaria, and diagnosis of pneumonia.

Our review process has consisted of:

• Extensive conversations with Malaria Consortium staff since 2016.1
• A conversation with a researcher at the London School of Hygiene and Tropical Medicine who has led the work on evaluating the ACCESS-SMC project, a large-scale SMC project led by Malaria Consortium.2
• Reviewing documents that Malaria Consortium shared with us.

## What do they do?

• ACCESS-SMC: Unitaid awarded up to $67 million to Malaria Consortium to lead a project called ACCESS-SMC to reach up to 7 million children per year in seven countries in the Sahel region of Africa in 2015-2017.35 The project, which Malaria Consortium described in 2014 as being the "largest-yet global programme" for SMC, concluded in February 2018.36 ACCESS-SMC was led by Malaria Consortium, with Catholic Relief Services as the "primary sub-grantee" and support from many other organizations, including impact evaluation from the London School of Hygiene & Tropical Medicine (LSHTM).37 Malaria Consortium told us that its role in ACCESS-SMC included leading implementation of SMC in three of the seven ACCESS-SMC countries (Burkina Faso, Chad, and Nigeria), overseeing budgets and planning for all ACCESS-SMC activities, and overseeing research (including methodology and presentation).38 Our impression is that ACCESS-SMC paid for almost all aspects of program implementation and monitoring, including medicines and supplies, per diems for CHWs, training for CHWs, trainers, supervisors, and health facility workers, and research.39 • General SMC program funded primarily by GiveWell-directed funds: In 2017, Malaria Consortium began using funding received as a result of GiveWell's recommendation (which we refer to as "GiveWell-directed funds") to target 650,000 children with SMC in six additional LGAs in Nigeria (to restart SMC that had been supported previously by a one-off grant), eight additional districts in Burkina Faso (for which drugs but not operational costs were available from other sources for 2017), and one region in Guinea Bissau.40 GiveWell-directed funds also supported coverage surveys and enhanced supervision and monitoring for Malaria Consortium's ACCESS-SMC work.41 In 2018, Malaria Consortium plans to use GiveWell-directed funds to target 3,780,000 children with SMC in Burkina Faso, Chad, and Nigeria.42 Malaria Consortium told us that the above programs represent the bulk of Malaria Consortium's work on SMC so far.43 ### Malaria Consortium's spending on SMC programs We have seen spending data from 2016 for the ACCESS-SMC program44 and from 2017 for programs supported by GiveWell-directed funds.45 In 2016, the breakdown of direct costs for the ACCESS-SMC program was: 37% to procuring SMC drugs, 37% to delivery of drugs, 16% to staff (including staff at partner organizations), 5% to "direct common costs" (we're not sure what this refers to), and the remaining 5% to a variety of smaller activities.46 Between May 2017 and February 2018, Malaria Consortium spent about$3.8 million of the about $5 million in GiveWell-directed funds that it had received at that time. We note that these funds complemented funding from the ACCESS-SMC grant and are not representative of the full cost breakdown of Malaria Consortium's SMC work in 2017.47 Of the$3.8 million, Malaria Consortium spent about $2 million (54%) on SMC delivery (excluding drug procurement and delivery), about$0.7 million (19%) on monitoring, about $0.5 million (14%) on drug procurement and delivery, and about$0.5 million (13%) on management, coordination, and overhead costs.48

We have also seen a high-level account of how Malaria Consortium plans to spend the approximately $31.3 million in primarily GiveWell-directed funds it has available (or expects to raise) for SMC work in 2018 and 2019.49 The ACCESS-SMC project ended in early 2018, so our understanding is that this budget includes all costs to operate Malaria Consortium's SMC programs in its targeted areas.50 Malaria Consortium expects to target 3.8 million children in 2018 and 3.9 million in 2019 in three countries, spending 48% in Nigeria, 21% in Burkina Faso, 20% in Chad, and 11% on cross-cutting costs.51 For prior work, we have also seen spending data for the pilot and scale-up of SMC in northern Nigeria.52 We also provide some information on the estimated cost-per-treatment of Malaria Consortium-supported SMC programs below. ### Malaria Consortium's role in SMC programs Malaria Consortium's SMC work varies by country, but in general includes the following activities:53 • Determining the quantity of drugs needed, procurement of drugs, and international shipping54 • Funding distributions, including in-country storage and transportation of drugs and payments to front-line distributors to compensate them for the time they spend on the program • Technical assistance, such as logistical planning, design of social mobilization tools, review of prior implementation and revisions to procedures • Financial management and oversight, including disbursing funds to local organizations, Ministries of Health, and/or CHWs, collecting and validating receipts, and preparing financial reports • Developing training materials and training staff at various levels55 • Monitoring, evaluation and research, including Malaria Consortium staff who directly observe program activities, and funding and coordinating with a university to conduct coverage surveys and to track changes in malaria incidence and death, monitoring of drug resistance, and other research. • Advocacy to governments and fundraising for SMC programs ## Does it work? Malaria Consortium-supported SMC programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective. Malaria Consortium and its partners have conducted monitoring to determine what proportion of children targeted by its SMC programs receive treatments. A weighted average of the ACCESS-SMC surveys finds that about 92% of children received at least one month of SMC treatment, about 71% received at least three months of treatment, and about 55% received all four months of treatment.56 These results rely on the assumption that CHWs and caregivers accurately record SMC doses on SMC cards and/or that caregivers accurately report whether their children received and took SMC. Other monitoring and evaluation Malaria Consortium has shared includes: • A study of malaria incidence before and during its SMC program in Northern Nigeria. • A case-control study to measure how the protective effect of SMC in scale-up contexts compares with that found in randomized controlled trials. • A baseline assessment of the prevalence of genetic markers for resistance to SMC drugs among malaria parasites. A follow-up was scheduled for 2017; we have not yet seen results, which are expected in December 2018.57 • Results from following up with a cohort of 10,000 SMC recipients to track the rate of adverse events. Details follow. ### Is SMC an effective intervention? SMC appears to have strong evidence of effectiveness. Seven randomized controlled trials provide strong evidence that SMC substantially reduces cases of malaria. More details are available at our intervention report on SMC. ### Is Malaria Consortium working in areas suitable for SMC? Malaria Consortium told us that before starting work in countries under the ACCESS-SMC program, it conducted an assessment of the overall burden of malaria, transmission and rainfall patterns, regional malaria incidence over time, and seasonal variations in malaria.58 We have not reviewed this evidence in detail, but it seems highly likely to us that Malaria Consortium is working in areas that are suitable for SMC because it is working in countries with high malaria burdens and where it seems that malaria is seasonal.59 More information on our estimates of malaria burden in the countries where Malaria Consortium is working is available in our cost-effectiveness analysis. ### Are targeted children being reached? #### Two methods for estimating coverage Malaria Consortium uses two different methods to measure the coverage rate that it is achieving with its programs:60 1. "Administrative" coverage: These coverage estimates are generated by collecting information from CHWs’ records about how many treatments they directly observed.61 Malaria Consortium provided a summary of the process for collecting and verifying this information, which we have included in the following footnote.62 We have not yet tried to assess this process. 2. Coverage surveys: Data collectors visit a random sample of households in the target region, ask to review eligible children's caregivers' SMC record cards, and ask a variety of other questions to understand the quality of the program and the likely coverage of SMC. More details below. It appears that there are sometimes large discrepancies in the estimates of coverage between these two measures, usually with administrative coverage estimates finding higher levels of coverage.63 Malaria Consortium told us that possible reasons for discrepancies between administrative coverage estimates and coverage surveys include:64 • In some countries, large temporary migrant populations move into SMC treatment areas during the rainy season (such as nomadic tribes, or settled populations migrating for seasonal agricultural work or animal husbandry65) and then leave before they would be interviewed by coverage surveys. • A substantial number of treatments are likely going to children who are above the age of five.66 • CHWs may be treating some people who live outside of the target coverage areas. • There could be errors either in the number of treatments reported (the numerator) or in the assumed target population (the denominator). In 2017, SMC programs supported by Malaria Consortium in Nigeria, Chad, and Burkina Faso began conducting coverage surveys after each SMC cycle, rather than a single coverage survey after all four cycles, in part to better understand why there are discrepancies between coverage estimates.67 Below, we focus on analyzing Malaria Consortium's coverage surveys because we believe that coverage surveys are more likely to be accurate. #### Coverage surveys Methodology We have seen full reports on the details of how coverage surveys were carried out in 2015 and 2016; we have not yet seen methodological details for 2017. The process described below is based on those reports and on a conversation in 2017 with the principal investigator who has led the work on the coverage surveys. It is therefore mostly informed by the methodology for the 2015 and 2016 surveys.68 Additional details on the methodology can be found in this spreadsheet, in the "Methods" sheet. • Coverage surveys have been led by the London School of Hygiene and Tropical Medicine (LSHTM).69 • In 2015 and 2016, ACCESS-SMC conducted one coverage survey in each country,70 following the last SMC cycle for the year.71 In 2017, coverage surveys began to be conducted following each SMC cycle (of which there are four per year) in Malaria Consortium-supported areas.72 • The sampling method is designed to yield a sample that is representative of the full population receiving the program. Villages are selected randomly (using probability proportional to size sampling), with a few exceptions discussed below. Within villages, researchers make a map of the village on a computer tablet and divide it into segments, the tablet automatically chooses a segment at random, and the interviewers are instructed to visit every household in that segment.73 Each survey aims for a sample size of at least 600 children aged 3 months to 59 months old.74 • Surveyors were instructed to both ask caregivers "Did you get a blister pack in the first month, the second month, the third month, and the most recent month?" and to ask to see the child's SMC card and record what is written on it.75 Surveyors are also instructed to ask a variety of other questions to attempt to understand how many SMC treatments were received, such as:76 • "Do you know how many days should the child be given the drugs?" • "What type of drug was given out?" • "Do you know the recommended method to [administer] the tablets?"77 • "In your opinion, how many children under five in this community have taken the medicine that prevents malaria during the rainy season?" • "Did (NAME) take / swallow the drugs on day 2 and day 3 at home?" We have not seen data from these survey questions. Generally, the greater of the number of treatments noted on the SMC card or reported by the caregiver is recorded as the number of treatments the child received.78 • Starting in 2017, coverage survey data, which is entered on tablets, was expected to be linked to GPS location data.79 • Survey team supervisors are instructed to repeat some interviews to ensure that interviewers are administering the survey questionnaires properly.80 We have not seen data from these audits. • In 2018, Malaria Consortium began using a Lot Quality Assurance Sampling (LQAS) approach after each of the first three cycles in the three supported countries (Burkina Faso, Chad, and Nigeria), rather than a full coverage survey.81 This approach is intended to be quicker and cheaper, with cost savings coming primarily from asking fewer questions at each household.82 We have not vetted this approach in detail to understand its potential downsides, such as whether the quality of the data will be affected. A full coverage survey will still be done at the end of the fourth cycle in all countries.83 Methodological Limitations • Non-random sample of districts/villages in some country-years due to security concerns. In Niger, four districts were chosen purposefully with the intention of being nationally representative. In Mali, districts were chosen using probability proportional to size sampling. However, in both countries, security concerns prevented access to some districts, meaning the final sample of districts was non-random. In addition, one LGA could not be visited due to security concerns in the 2017 coverage survey in Nigeria. If security concerns mean coverage is lower in the excluded districts in these three countries, estimates based on the observed districts may overestimate coverage. 84 In the 2017 surveys in both Chad and Burkina Faso, one village could not be visited. In Chad, this was due to security concerns, and we are unsure of the reason in Burkina Faso.85 However, since only one village was affected, this is unlikely to create much bias in the final coverage estimates. • Non-random selection of households within villages in Niger. In the two urban areas in the coverage surveys in Niger, the twenty-four "nearest households" were surveyed; we are unsure how the initial location for the cluster of households was selected. We are unsure whether and in what direction this is likely to bias the coverage estimates. In the two rural areas, one segment of households was chosen at random as in the coverage surveys in every other country.86 • Challenges verifying results with record cards and blister packs. SMC Record Cards were available for 50% or fewer children in the coverage surveys in Niger (2015 and 2016), Chad 2016, Nigeria (2016 and 2017), Guinea 2016, Mali 2016, and The Gambia 2016. With no SMC card present, it is more difficult to check caregivers' responses.87 For those who received and retained the record cards, on average across the four surveys in 2017 there was agreement between caregiver responses and SMC cards in only 43% of cases in Nigeria and 66% of cases in Chad; we have not seen data on agreement between cards and verbal reports for other surveys. In both cases, this gap was largely explained by caregivers answering that a dose had been received when no dose was recorded on the card.88 In 2017, some coverage surveys also gathered data on the proportion of caregivers who had retained the blister pack that contained the SMC medicines, another possible check on caregivers' responses. However, in most of the examples we've seen, most caregivers did not retain the blister packs.89 Results We have seen coverage survey results from all seven ACCESS-SMC countries for 2015 and 2016 and for all three remaining countries in 2017 (Burkina Faso, Chad, and Nigeria). A weighted average of these surveys finds that about 92% of children received at least one month of SMC treatment, about 71% received at least three months of treatment, and about 55% received all four months of treatment. Results are summarized in this spreadsheet, sheet "Results." For 2017, we have compared these coverage estimates, which come from post-round surveys conducted at the end of the fourth cycle, with estimates obtained from surveys that are conducted at the end of each cycle and ask only about the most recent cycle. Surveys conducted at the end of each cycle may be more accurate as caregivers may find it easier to recall only the most recent treatment. After converting the two sets of coverage estimates to a measure of total person-months of treatment for comparison, we find less than a 1% difference between them. This gives us more confidence in the post-round coverage survey estimates, which are available for all three years.90 Malaria Consortium notes that, to put these results in context, "at each cycle, a child may not receive SMC, if they have malaria or are very sick at the time of the distribution, even though they are seen by the SMC health worker or community drug distributor. And at each cycle there is a chance that a child may miss SMC if they are away from the home (where SMC is delivered door-to-door) or are unable to attend at the SMC distribution point. 88% of children received an SMC card, generally issued at the first cycle. If the probability of receiving SMC at each cycle is 88%, the expected percentage who would receive at least three treatments is [67%], and the expected percentage who would receive four treatments is 60%."91 LSHTM estimated that less than 5% of children are excluded due to illness each cycle.92 The fact that surveys identified relatively low coverage in some cases increases our confidence in their reliability. We have not yet seen results on many of the other questions listed in the ACCESS-SMC, Questionnaire for SMC coverage survey, such as what type of drug was given out and whether caregivers knew the recommended method to administer the drugs. ### Have malaria rates decreased in targeted populations? ACCESS-SMC We wrote in 2017 that we were expecting to see results in 2018 from the monitoring of malaria cases and deaths at health facilities in ACCESS-SMC countries (we had previously expected those results in 2017, but they were delayed).93 We have only received headline figures for the reduction in malaria cases in children under 5 years old in three countries (Mali, Chad and Niger); we have not seen additional information on the sources for or analysis of this data.94 We have therefore not vetted the results (described in the footnote).95 Malaria Consortium told us that the data collected in other ACCESS-SMC countries was of a low quality. We believe there is a risk of bias here. More effort to collect and fully share this monitoring data may have been made if the early indications were that data would demonstrate that the program was having a positive impact. However, given our understanding that collecting high-quality health facility data is difficult, we find Malaria Consortium's explanation quite plausible and think the risk of bias is low. Malaria Consortium also shared case-control studies designed to measure the efficacy of SMC treatments from five ACCESS-SMC countries: Burkina Faso, Chad, The Gambia, Mali, and Nigeria. We have not yet vetted the methodology (some details in the footnote), and the dataset from Nigeria did not pass quality control.96 Malaria Consortium's conclusion from these studies is, "These results confirm that SMC treatments are providing a very high degree of personal protection from malaria for a period of 28 days after each treatment. Protection then declines rapidly emphasizing the importance of repeating treatments at monthly intervals."97 More details on those results in this footnote.98 Northern Nigeria (2012-2014) We have seen three types of analyses of the impact of Malaria Consortium's northern Nigeria program on malaria indicators. These results seem to be consistent with the impacts of SMC found in randomized controlled trials of the program, but due to our remaining questions about the studies we do not yet see them as strong additional evidence for the impact of SMC programs. See our previous review of Malaria Consortium for more details on this study. ### Are there any negative or offsetting impacts? • Drug resistance: Mass-delivery of SMC medicines could contribute to increased drug resistance of SP and/or AQ. In 2015, ACCESS-SMC funded a baseline study of the prevalence of gene mutations in malaria parasites that are markers of drug resistance for the drugs used in SMC.99 A second survey was scheduled for 2017, following two rounds of SMC (we have not yet seen results, which are expected in December 2018100), and Malaria Consortium would like to fund subsequent surveys, if it has the funding to do so.101 • Possible "rebound" effects: There is a potential concern that SMC could reduce the natural development of immunity to malaria. After children turn five years old and are no longer eligible to receive SMC or if SMC programs are interrupted by lack of funding or other problems, children could lack immunity and be more susceptible to malaria, especially if other prevention methods, such as long-lasting insecticide-treated nets (LLINs), are not used. We have not yet investigated this concern in-depth. • Side effects of SMC drugs: Our impression is that the most common reaction seen with SMC drugs in earlier programs was vomiting (AQ is bitter and hard to swallow if not crushed into a powder and mixed with water); more recently, AQ has been available as an orange-flavored dispersible.102 Malaria Consortium told us that vomiting is no longer a common problem with the new dispersible formulation.103 If the child expels the drugs, they are supposed to be given only one more dose within 30 minutes; we are unsure whether caregivers typically request extra tablets of AQ from CHWs when this happens at home to ensure their child gets a full treatment regimen. Our impression is that other side effects from these drugs are rare and include diarrhea, itching, headache, mild abdominal pain, and rash.104 A study in Nigeria that followed up with 10,000 SMC recipients one week after receiving SMC to ask about adverse events resulted in only five reports of adverse events, though Malaria Consortium believes there may have been reluctance to report issues.105 Malaria Consortium shared three resources that report very low severe adverse event rates from SMC drugs (available in the following footnote).106 We have not yet reviewed these. • Drug quality and dosage: Malaria Consortium told us that it is only permitted to procure products from suppliers that meet WHO guidelines for pre-qualification quality assurance standards.107 We have not yet asked Malaria Consortium for the details of this process. If there were issues with drug quality or dosage, it could reduce the effectiveness of the intervention and lead to more rapid development of drug resistance. ## What do you get for your dollar? ### Cost per SMC treatment In order to make program costs comparable across all of our top charities, we aim to estimate the total cost to all actors of supporting a given program. Our estimate of cost-per-treatment for SMC includes research costs, start-up costs, and costs incurred by actors such as governments. Our estimates also rely on coverage survey estimates to approximate the number of people reached rather than administrative coverage estimates. With these assumptions, we estimate that the total cost to achieve the equivalent of four person-months of SMC coverage is about$6.93. Full details in this spreadsheet.

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").

### Cost-effectiveness

SMC programs appear to be in the range of cost-effectiveness of our other priority programs. See our most recent cost-effectiveness model for estimates of the cost per life saved through Malaria Consortium-supported SMC programs and how our model compares this outcome with outcomes of other programs.

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. It also does not include possible offsetting impacts or other harms.108

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.

## Is there room for more funding?

We believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities.

In short:

• Estimated needs: Malaria Consortium estimates that it could spend $22-32 million per year on SMC in each of the next three years. Its ability to absorb funding could be reduced by a modest amount by constraints in drug supply in 2019 and/or additional funding becoming available from the World Bank for SMC in Burkina Faso. Malaria Consortium would use funding to reach additional children and extend its work to 2020-2021 in three countries: Nigeria, Chad, and Burkina Faso. (More) • Cash on hand: As of June 2018, Malaria Consortium had$17.3 million available to fund its SMC work in 2019 and a further $0.5 million in uncommitted funding available for SMC. (More) • Other sources of funds: Donors who gave based on GiveWell's recommendation have been the primary source of funds for Malaria Consortium's SMC work in the past year. It also received a grant from the UK government for SMC in 2018, which has not yet been renewed. Malaria Consortium has not received significant funding from other sources for SMC in the last year. (More) • Additional considerations: Malaria Consortium works on a wide variety of programs. We have asked Malaria Consortium to use any GiveWell-influenced donations to specifically support SMC programs. In sum, we estimate that Malaria Consortium could absorb$66 million for work in 2019-2021. If it faces constraints in drug supply in 2019 and room for more funding in Burkina Faso in 2020-2021, it would be able to absorb $53 million in this period. Further discussion follows. See also this spreadsheet for details. Update: In November 2018, we recommended that Good Ventures grant$26.6 million to Malaria Consortium; our updated estimate of its room for more funding is $39.4 million. ### Uncommitted and expected funds Uncommitted funds As of June 30, 2018, Malaria Consortium held$26.9 million in funding restricted to SMC from GiveWell-directed sources. Other than a grant from UK government's Department for International Development (DFID) for about $580,000 for delivering SMC in Nigeria in 2018, Malaria Consortium does not hold any significant funding for SMC from other sources.109 Of the GiveWell-directed funding: • Malaria Consortium expects to spend$9.1 million to fund SMC work in 2018. This is in addition to funds spent prior to June 30, 2018.
• Malaria Consortium expects to spend $17.3 million to fund SMC work in 2019. • Malaria Consortium has not yet committed the remaining$0.5 million to future activities.

Expected funds

With the exception of the DFID grant noted above, which has not yet been renewed for 2019, GiveWell-directed funds were the only significant source of funding for Malaria Consortium's SMC work in 2018.110 As a result, we do not expect Malaria Consortium to receive a large amount of funding from other sources in the next year.

We expect that Malaria Consortium will receive some funding as a result of being on GiveWell's list of top charities. 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 Malaria Consortium will receive about $1.1 million from donors who use our top charity list but do not follow our recommendation for marginal donations.111 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. Malaria Consortium seems not to have allocated much unrestricted funding to its SMC programs in the past.112 Accounting for currently unallocated funds ($0.5 million) and expectations of additional funding from the sources noted above ($1.1 million), we roughly estimate that Malaria Consortium will have$1.6 million in funding available to allocate to SMC over the course of the next year (before any funding that we specifically recommend that donors give to Malaria Consortium in late 2018 and 2019). This is in addition to the $17.3 million that Malaria Consortium has allocated to work on SMC in 2019. More detail in this spreadsheet; see the sheet "Funds on hand and projected revenue." ### Additional spending opportunities Malaria Consortium estimates it could spend$22.1 total in 2019 (of which it has $17.3 million already available) and$31 million per year in each 2020 and 2021 to deliver SMC. It would use this funding to continue delivering SMC in the three countries it currently works in: Nigeria, Burkina Faso, and Chad. If Malaria Consortium were fully funded for this work, approximately 71% of additional funding would fund work in Nigeria, 13% in Burkina Faso, 14% in Chad, and 1% to fund a study of drug resistance in 2020.

Accounting for funding that Malaria Consortium currently has available for its work in 2019, it could absorb a total of $65.7 million for additional spending opportunities. There is a possibility that its ability to absorb funding will be modestly limited by one or both of the following factors: • Drug supply in 2019: Of the$65.7 million total, $3.1 million would be to expand Malaria Consortium's work in 2019. There is a possibility that funds Malaria Consortium received at the end of 2018 would arrive too late to allow it to purchase more SMC drugs for the 2019 malaria season. There is currently only one WHO-approved manufacturer of SMC drugs who may not have capacity for additional orders after November 2018. A second manufacturer may be approved by WHO by early 2019; if that happens, Malaria Consortium does not expect any supply constraints in 2019.113 • Alternative funding for Burkina Faso: Of the$65.7 million total, $8.0 million would fund SMC in Burkina Faso in 2020-2021. Malaria Consortium notes that there are ongoing discussions between the government of Burkina Faso and the World Bank that could lead to a decrease or increase in the total funding gap for SMC in Burkina Faso. This would affect the amount of that Malaria Consortium could absorb for its work there.114 If Malaria Consortium faced both of the constraints above at their maximum level, which we believe is unlikely, this would reduce the amount that Malaria Consortium could absorb to$53.0 million.115

If Malaria Consortium were funded at this level, it expects to be able to support Chad in reaching all remaining eligible children and to reach about 3 million children per year in Nigeria in 2019, rising to 5 million in 2020 and 2021. Due to organizational capacity limits, Malaria Consortium is not seeking funding for growth beyond that level in Nigeria.116

More detail in this spreadsheet, see the sheet "Spending opportunities."

Note that for our room for more funding analysis we ask top charities for rough estimates of their ideal budgets for the next three years. GiveWell-directed funding can fluctuate a lot year to year and so our preference is for the organizations we direct funding to to treat the funding as a multi-year grant to help smooth funding year-to-year and allow for longer-term planning.

### Fungibility

Since Malaria Consortium works on a variety of programs, it is possible that receiving additional funds for its SMC work could lead it to reallocate unrestricted funds or other organizational resources (such as time spent fundraising) toward other programs, so that additional dollars donated to Malaria Consortium would not fully support additional SMC work. However, we do not see this as a major concern because we do not believe that Malaria Consortium has substantial unrestricted funding available, and it seems that Malaria Consortium has not allocated substantial unrestricted funding to SMC work in the past (see footnote for details).117

### Global need for treatment

Malaria Consortium's estimate of its room for more funding for SMC makes certain assumptions about what funding will be available globally for SMC from other major institutional funders. Our understanding of the funding landscape for SMC is available on this page.

In summary, as of April 2018, Malaria Consortium estimates that a gap of roughly $205 million exists for providing SMC between 2018 and 2020 to all children in eligible districts in the seven countries for which we have reasonable estimates. According to these estimates, the largest absolute funding gaps are in Nigeria ($128 million) and Niger (37 million), with smaller gaps in Mali, Burkina Faso, Chad, and Guinea. We estimate that in 2018 about 50% of eligible children will be covered, with GiveWell-directed funding covering about 13% of eligible children.118 The World Malaria Report 2017 cites lack of funding as the most important reason large gaps remain in SMC coverage. Major funders of SMC include the Global Fund, the World Bank, and the President's Malaria Initiative. Malaria Consortium told us that it is hopeful that in the longer term the Global Fund will be able to fully fund SMC in all countries that need it, but that this is unlikely to happen soon and that country governments need to be convinced of the value of SMC to prioritize using Global Fund funding to support it.119 Malaria Consortium told us that it believes an important part of its role is collecting evidence and operational knowledge that could persuade governments and other funders to support SMC in the future.120 The seven countries that were previously funded for SMC by the ACCESS-SMC program allocated Global Fund funding to SMC to cover 80 districts in 2017 and 92 in 2018, up from 5 in 2016.121 It is not yet clear how much funding the World Bank will provide for SMC in future years, which is a major source of uncertainty about the size of the funding gap in Nigeria, Burkina Faso, Niger, and Mali.122 It is possible that limited drug supply or other non-monetary bottlenecks, such as inadequate distribution system capacity or lack of government prioritization of the program, could limit the scale-up of SMC in the future.123 ## Malaria Consortium as an organization We have spent less time investigating Malaria Consortium and have somewhat less insight into its activities and track record than we do for top charities we have followed for many years. As such, we have a somewhat limited view on the qualities below. • Track record: Malaria Consortium has experience with supporting large-scale SMC programs, particularly through its work on ACCESS-SMC. • Self-evaluation: Malaria Consortium's self-evaluation is strong compared to the vast majority of organizations we have considered. • Communication: Malaria Consortium has generally communicated clearly and directly with us, given thoughtful answers to our critical questions, and shared significant, substantive information. • Transparency: Malaria Consortium has provided the information we’ve asked for and has not hesitated to share it publicly (unless it had what we felt was a good reason). More on how we think about evaluating organizations at our 2012 blog post. ## Sources Document Source ACCESS-SMC fact sheet Source (archive) ACCESS-SMC M&E strategy, November 2015 Source ACCESS-SMC multi-country cost analysis, January 2017 Source ACCESS-SMC Presentation, "Progress in scale-up of SMC in the Sahel," November 2016 Source ACCESS-SMC project brochure Source (archive) ACCESS-SMC Register Template Source ACCESS-SMC website, "The Project" Source (archive) ACCESS-SMC, 2016 direct costs Source ACCESS-SMC, 2016 presentation on safety monitoring Source ACCESS-SMC, adverse events cycle 1 in Nigeria 2015 Source ACCESS-SMC, Health impact data Unpublished ACCESS-SMC, Nigeria coverage summary report 2015 Source ACCESS-SMC, organizational structure Source ACCESS-SMC, presentation on cost and impact, June 2016 Source (archive) ACCESS-SMC, Progress update - Resistance monitoring Source ACCESS-SMC, Progress update - Safety monitoring Source ACCESS-SMC, Questionnaire for SMC coverage survey Source ACCESS-SMC, Reported severe adverse events Source ACCESS-SMC, Research progress update, April 2017 Source ACCESS-SMC, SMC donor mapping 2016 (with GiveWell calculations) Source ACCESS-SMC, summary administrative coverage spreadsheet Source ACCESS-SMC, summary of serious adverse events 2015 Source Cost analysis of the seasonal malaria chemoprevention project in Katsina state, Nigeria Source Gates Foundation, "Malaria Consortium" Source (archive) GiveWell SMC cost per treatment estimate, November 2017 Source GiveWell summary of SMC coverage information, November 2016 Source GiveWell's non-verbatim summary of a conversation with Diego Moroso, April 25, 2017 Source GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, August 25, 2016 Unpublished GiveWell's non-verbatim summary of a conversation with Malaria Consortium staff, January 18, 2017 Source GiveWell's non-verbatim summary of a conversation with Malaria Consortium staff, January 19, 2017 Source GiveWell's non-verbatim summary of a conversation with Malaria Consortium staff, March 24, 2017 Source GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, November 23, 2016 Unpublished GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017 Source GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016 Unpublished Global Fund, Executive Director statement on Nigeria, May 2016 Source (archive) Global Fund, Investigation in Nigeria, May 2016 Source (archive) Malaria cases and deaths over time, Burkina Faso and the Gambia (2011-2016) Source Malaria Consortium emails (unpublished), November 23, 2016 Unpublished Malaria Consortium Quiz Answer Key Source Malaria Consortium training, competency checklist Unpublished Malaria Consortium training, daily evaluation Unpublished Malaria Consortium training, Final evaluation Unpublished Malaria Consortium training, pre- and post- test scores Unpublished Malaria Consortium website, "Seasonal Malaria Chemoprevention" Source (archive) Malaria Consortium website, "Who We Are" Source (archive) Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria" Source (archive) Malaria Consortium, "Support Scale up of Seasonal Malaria Chemoprevention (SMC)" Source (archive) Malaria Consortium, 2013 operational data Source Malaria Consortium, ACCESS-SMC announcement, May 8, 2014 Source (archive) Malaria Consortium, ACCESS-SMC page Source (archive) Malaria Consortium, Annex II, 2017 Coverage Summary Source Malaria Consortium, Annex III: ACCESS-SMC Evaluation Source Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention Source Malaria Consortium, Annual Reviews Source (archive) Malaria Consortium, Coverage survey summary 2016, Burkina Faso Source Malaria Consortium, Coverage survey summary 2016, Chad Source Malaria Consortium, Coverage survey summary 2016, Guinea Source Malaria Consortium, Coverage survey summary 2016, Mali Source Malaria Consortium, Coverage survey summary 2016, Niger Source Malaria Consortium, Coverage survey summary 2016, Nigeria Source Malaria Consortium, Coverage survey summary 2016, The Gambia Source Malaria Consortium, drug resistance Katsina study Source Malaria Consortium, excerpts of results and analyses in Katsina Source Malaria Consortium, Financial summary, September 2017 Source Malaria Consortium, GiveWell Proposal 2018-2020 Source Malaria Consortium, GiveWell SMC Cost-Per-Treatment Estimate (2017) Source Malaria Consortium, M&E Plan Nigeria Source Malaria Consortium, Monitoring and evaluation summary Nigeria Source Malaria Consortium, Nigeria SMC evaluation report, 2014 Source Malaria Consortium, Preliminary coverage summary 2017, Burkina Faso, cycle 1 Source Malaria Consortium, Preliminary coverage summary 2017, Burkina Faso, cycle 2 Source Malaria Consortium, Preliminary coverage summary 2017, Chad, cycle 1 (French) Source Malaria Consortium, Preliminary coverage summary 2017, Nigeria, cycle 1 Source Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina Source (archive) Malaria Consortium, restricted and unrestricted expenditure analysis 2016 Source Malaria Consortium, sentinel data from Dutsi and Mai'adua Source Malaria Consortium, sentinel site surveillance data in Katsina Source Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation Unpublished Malaria Consortium, SMC presentation host page Source (archive) Malaria Consortium, SMC presentation, May 6, 2014 Source (archive) Malaria Consortium, SMC Report, February 2018 Source Malaria Consortium, Summary of Results for Cycle 1, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 1, Chad 2017 Source Malaria Consortium, Summary of Results for Cycle 1, Nigeria 2017 Source Malaria Consortium, Summary of Results for Cycle 2, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 2, Nigeria 2017 Source Malaria Consortium, Summary of Results for Cycle 3, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 3, Chad 2017 Source Malaria Consortium, Summary of Results for Cycle 3, Nigeria 2017 Source Malaria Consortium, Summary of Results for Cycle 4, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 4, Chad 2017 Source Malaria Consortium, Summary of Results for Cycle 4, Nigeria 2017 Source Malaria Consortium, summary of SMC donors Unpublished Malaria Consortium, Summary Update, May 2018 Source Malaria Consortium, SuNMaP Final Report Source Malaria Consortium, Trustees' report and financial statements 2015 Source (archive) Malaria Consortium, Trustees' report and financial statements 2016 Source Malaria Consortium, Trustees' report and financial statements 2017 Source (archive) NDiaye et al. 2016 Source (archive) SMC Record Card Template 2016 Source Strachan et al. 2016 Source (archive) Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium Source Summary update - GiveWell/Good Ventures funding for SMC Source Timothy Rubashembusya Trip Report from Burkina Faso, August 2016 Source Wikipedia, "Cluster sampling" Source (archive) World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide" Source (archive) World Health Organization, "Seasonal Malaria Chemoprevention" Source (archive) • 1. • 2. GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017 • 3. "Established in 2003, Malaria Consortium is one of the world’s leading non-profit organisations specialising in the prevention, control and treatment of malaria and other communicable diseases among vulnerable populations. Our mission is to improve lives in Africa and Asia through sustainable, evidence-based programmes that combat targeted diseases and promote child and maternal health." Malaria Consortium website, "Who We Are". • 4. "Established in 2003, Malaria Consortium is one of the world’s leading non-profit organisations specialising in the prevention, control and treatment of malaria and other communicable diseases among vulnerable populations. ...With 95 percent of our staff working in malaria endemic areas, we currently have programmes and projects in 12 countries across Africa and Southeast Asia. Our local insight, embedded technical expertise and practical skills give us the agility to respond to critical challenges quickly and effectively." Malaria Consortium website, "Who We Are". • 5. • 6. "In March 2012, the World Health Organisation (WHO) issued a policy recommendation for a new intervention against Plasmodium falciparum malaria - seasonal malaria chemoprevention (SMC), previously referred to as intermittent preventive treatment in children (IPTc), in children under five years old. SMC is defined as the intermittent administration of full treatment courses of an anti-malarial treatment combination during the malaria season to prevent illness and death from the disease. The objective is to maintain therapeutic anti-malarial drug concentrations in the blood throughout the period of greatest risk. This will reduce the incidence of both simple and severe malaria disease and the associated anaemia and result in healthier, stronger children able to develop and grow without the interruption of disease episodes. SMC has been shown to be effective, cost effective and feasible for the prevention of malaria among children in areas where the malaria transmission season is no longer than four months." Malaria Consortium website, "Seasonal Malaria Chemoprevention". • 7. • 8. • 9. • 10. • 11. World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide", Pg 9. Malaria Consortium provided the edit to the quotation in response to a draft of this page in October 2017. • 12. "How is SMC delivered? Local announcements each month will inform the community about the date of SMC, which will be delivered by community health workers at pre-arranged locations in the community, or by visiting each household. Health workers will receive appropriate training before the intervention begins and will be supervised by nurses and the district health team."ACCESS-SMC project brochure, Pg 3. Malaria Consortium noted that health workers are also sometimes trained for SMC programs (comment provided in response to a draft of this page in October 2017). • 13. • For Malaria Consortium's SMC program in Nigeria: "House to house delivery method was the most used approach, as reported by 88.2 percent of the respondents. This was similar across the LGAs [local government areas] though Maiadua had slightly higher numbers receiving through the fixed point delivery approach. The duration spent in receipt of drugs in the home was 20 minutes, half the time spent in receipt of drugs from a fixed point which was 47 minutes. Knowledge of the different types of SMC drugs and dose duration was high at over 80 percent. This highlights house to house delivery of SMC as a quicker and most preferred delivery mechanism by the caregivers. There is need for costing the two delivery mechanisms to assess if home based delivery still remains a cost effective delivery channel." Malaria Consortium, Nigeria SMC evaluation report, 2014, Pg 38. • For ACCESS-SMC delivery methods, see the annexes on Pgs 31-70 of ACCESS-SMC multi-country cost analysis, January 2017. Sample quote: "A combination of 6,500 trained community distributors and 355 health facility staff (e.g. nurses and midwives) administered SMC by way of two distribution methods: door-to-door (two-person teams) and at fixed points located at health centers (one-person teams) which were in place to serve primarily as referral centers for sick children and provide SMC to children who were came to the facility. It was estimated that 90% of SMC was distributed by door-to-door teams and 10% was distributed at fixed points. To ensure the acceptability of SMC and high rates of coverage within communities, 3,483 trained community mobilizers sensitized communities on the benefits of SMC prior to and during each distribution cycle." ACCESS-SMC multi-country cost analysis, January 2017, Pg 31. • 14. • 15. Malaria Consortium emails (unpublished), November 23, 2016. Comments from Malaria Consortium in response to a draft of this page in October 2017. • 16. Note from Malaria Consortium provided in response to a draft of this page in October 2017. • 17. • 18. • 19. Comments from Malaria Consortium in response to a draft of this page in October 2017 • 20. • 21. • See Figure 1, Pg 8, Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria". "DOT" stands for "Directly Observed Treatment". • "How long should the Role Model Caregiver observe each child after giving SMC medicines? a) 10 minutes, b) 15 minutes, c) 30 minutes, d) 1 hour, [Correct answer: C]" Malaria Consortium Quiz Answer Key. • "What should the Role Model Caregiver advise the child’s caregiver after giving the first dose of the SMC medicines? a) When to take the second and third dose of Amodiaquine (AQ) at home, b) The importance of adherence to giving the two doses of Amodiaquine (AQ) home, c) What to do if the child vomits, d) How to mark the SMC Record Card after giving each dose and to bring the card back for the next SMC cycle, e) When to go to the health facility if the child gets a fever or very sick, f) All of above, [Correct Answer: F.]" Malaria Consortium Quiz Answer Key. • "The child’s SMC Record Card is very important because: a) It shows the Role Model Caregiver the name and register number of the child, b) The child’s caregiver should always take it with them if they need to go to the health facility, c) It shows how many times the child received the SMC medicines each month, d) It is made of thick paper and is in a plastic packet, e) a, b and c, f) All of the above, [Correct answer: E.]" Malaria Consortium Quiz Answer Key. • 22. • "The child’s SMC Record Card is very important because: a) It shows the Role Model Caregiver the name and register number of the child, b) The child’s caregiver should always take it with them if they need to go to the health facility, c) It shows how many times the child received the SMC medicines each month, d) It is made of thick paper and is in a plastic packet, e) a, b and c, f) All of the above, [Correct answer: E.]" Malaria Consortium Quiz Answer Key. • We have seen a few versions of templates for "SMC Record Cards." The latest version that we have seen (from 2016) is here: SMC Record Card Template 2016. • 23. • 24. • 25. • "Who should NOT get SMC medicines? a) Any child with a fever or who is severely ill, b) Any child who is currently taking a sulfa medication such as co-trimoxazole (Septrin, or Bactrim), c) A child who has received a dose of either Amodiaquine (AQ) and sulfadoxine / pyrimethamine (SP) during the past month, d) A child who is allergic to sulfa medication such as co-trimoxazole, Septrin, or Bactrim, e) A child who is allergic to either Amodiaquine (AQ) and sulfadoxine / pyrimethamine (SP), f) a,b,ande, g) All of the above. [Correct answer is G.]" Malaria Consortium Quiz Answer Key. • "What important questions must the Role Model Caregiver ask about each child before giving SMC medicines? a) The child’s age, b) If the child has taken any medicines in the past 28 days, and which ones, c) If the child has any allergies, d) If the child has a fever or is sick, e) a, b, and d, f) All of the above, [Correct answer is F.]" Malaria Consortium Quiz Answer Key. • "What should the Role Model Caregiver do if a child has a fever on the day SMC medicines are being given? a) Complete the SMC Referral Form, b) Refer the child to the nearest health facility for a malaria test, c) Complete the SMC Register with the reason for the referral, d) Give the child Coartem, e) Give the child the SMC medicines to treat the fever, f) a, b, and c, g) All of the above, [Correct answer is F.]" Malaria Consortium Quiz Answer Key. • 26. Malaria Consortium emails (unpublished), November 23, 2016. Comments from Malaria Consortium in response to a draft of this page in October 2017. • 27. Comments from Malaria Consortium in response to a draft of this page in October 2017. • 28. • "SMC medicines come in two colour packets for different age children. What age group should get the medicines in the YELLOW packets? ... [correct answer:] b) 3 to 12 months " Malaria Consortium Quiz Answer Key. • "SMC medicines come in two colour packets for different age children. What age group should get the medicines in the BLUE packets? ... [correct answer:] b) 12 to 59 months" Malaria Consortium Quiz Answer Key. • 29. "Determining a child’s age 1. Ask the caregiver how old the child is. 2. Ask to see the child’s vaccination card. 3. If the caregiver does not know the child’s age or does not have a vaccination card; ask the caregiver to describe the events when the child was born. (Dry or rainy season, religious celebrations such as Eid or Ramadan, political, or social events). 4. Look for 1 or more of the following milestones for appropriate age category: Most infants younger than 3 months will not be able to: – Hold their head and neck steady when being held upright – Push down with their legs when their feet are on a hard surface – Grab an object in their hand and bring it to their mouth Most children 1 year or older should be able to: – Sit without help – Pull themselves up to standing using a chair or caregiver’s hand – Stand on their own or take a few steps Most children who are older than 5 years should be able to: – Raise their arm over their head to touch their opposite ear – Stand on one foot for 10 seconds or longer – Hop on one foot" From unpublished source, "Field Guide for Training and Service Delivery of Seasonal Malaria Chemoprevention – Nigeria." • 30. "Malaria Consortium notes that there are several layers of supervision that provide spot-check control of how well the administration process is followed: • There is in general a “proximity supervisory team” (CHWs with higher education or literacy skills / experience or a junior health worker) who follow a number of distribution teams (for instance, in Burkina Faso it’s 1 for every 5 CHW teams, in Nigeria, 1 for every 3 community drug distributor (CDD) teams). They work 3 to 4 days per cycle. • Health workers from one health facility carry out spot-check corrective supervision over all CDDs/CHWs and all supervisors in their catchment area; they work 3 to 4 days per cycle. • District health officials carry out supervisory visits over both distributors (to check quality of administration) and supervisors (to check on the quality / frequency of supervision). They work 3 to 4 days per cycle. • Regional health officials carry supervisory spot-check visits over all the levels below, to check on the quality of administration and of supervision and provide corrective guidance. They work 2 to 4 days per cycle. • National Malaria Control Program (NMCP) supervisors carry out supervisory spot-check visits over all the levels below (as above). They work 3 to 4 days per cycle. • Malaria Consortium and partner’s country supervisors / teams carry out spot-check visits (independently or jointly with health authorities, as above). They work 4 days per cycle on supervision and implementation monitoring. • AfRO Malaria Consortium and partner staff carry out regular country field visits including spot-check supervision to control all of the above. About 2 visits per country during the SMC round at minimum. The system is quite extensive and well-rehearsed, since it is used across several child survival, mass prevention campaigns. While it is likely that there will be some mistakes at this scale (in particular, age misclassification and eligibility are common issues for all mass campaigns, with no easy, inexpensive solutions around it), major mistakes in administration are likely to be caught. While these have not been quantified, in nearly 10,000 estimated instances of spot-check supervision across the region, anecdotal instances of reported gross negligence in administration of drugs, that could be identified in 2015, were within the hundreds, and promptly corrected: these mostly related to lack of observation of hygiene practices, excessive use of water, ignoring directly observed therapy (DOT) protocols, severe age misclassification, non-respect of observation time, and premature administration of second DOT after vomiting. Most of the other problems identified were, instead, around appropriate administration record-keeping, due to low literacy levels of volunteers in many countries. Please mind that no other mass campaign outside operational research is known to keep detailed individual records of recipients. In most mass campaigns that are known to be safe and effective (measles, polio, pneumonia, vitamin A, deworming, NTD MDAs, just to name a few), only simple tally sheets and sample in-process monitoring are used. Due to the research needs of a new intervention, SMC is being held to extremely high accountability standards as compared to other interventions. It is unlikely that individualized records and these layered levels of supervision are sustainable in the long term and/or at an increased scope, because of the implication on resources needed and costs to local budgets." Malaria Consortium emails (unpublished), November 23, 2016. • 31. • 32. • "Budget: 1,694,339.00 (USD)" Malaria Consortium, "Support Scale up of Seasonal Malaria Chemoprevention (SMC)". We also searched the Gates Foundation's grant database to see whether it made any additional grants to Malaria Consortium for SMC work, but only saw this grant (grant page available at Gates Foundation, "Malaria Consortium"). • "Malaria Consortium is implementing and assessing the feasibility of a community-based seasonal malaria chemoprevention (SMC) project in Katsina state, northern Nigeria, with funding from the Bill & Melinda Gates Foundation. Following new World Health Organisation policy recommendations on SMC, this project administers full antimalarial treatments during the malaria season in areas with highly seasonal malaria transmission, to prevent illness among children under five." Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. • "The project’s objectives are: • To design, in consultation with key local stakeholders, an appropriate community-based delivery system for SMC in Katsina state based on formative research, which will review aspects relating to feasibility, community acceptability, effectiveness and cost • To launch and execute SMC delivery according to the selected delivery system and collect data on process indicators and costs • To evaluate community acceptability, costs and effectiveness of the delivery system for SMC • To inform future national and state plans for SMC continuation/ scale up by disseminating findings and sharing experiences with key stakeholders" Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 2. • It appears that this project may have also been related to another major (£89 million) project that Malaria Consortium was working on in Nigeria called "Support to National Malaria Programme (SuNMaP)". • "Support to National Malaria Programme (SuNMaP) is an £89 million UK aid funded project that works with the government and people of Nigeria to strengthen the national effort to control malaria. The programme began in April 2008 and [ended] in March 2016. Led by Malaria Consortium, SuNMaP was jointly managed by a consortium, including lead partners Health Partners International and GRID Consulting, with nine other implementing partners. SuNMaP was implemented in 10 states across Nigeria, including Anambra, Kano, Niger, Katsina, Ogun, Lagos, Jigawa, Enugu, Kaduna and Yobe. SuNMaP worked with the Nigerian government's National Malaria Elimination Programme (NMEP) to harmonise donor efforts and funding agencies around national policies and plans for malaria control. Project targets were aligned with the National Malaria Strategic Plan and Global Malaria Action Plan. The project aimed to improve national, state and local government level capacity for the prevention and treatment of malaria." Malaria Consortium, SuNMaP Final Report, Pg 38. • "July 2013: Result of SuNMaP study on efficacy of sulphadoxine‐pyrimethamine (SP) for intermittent treatment against malaria in pregnancy published. SuNMaP commences seasonal malaria chemoprevention in Katsina State." Malaria Consortium, SuNMaP Final Report, Pg 16. • 33. • 34. • "The project’s objectives are: ...To inform future national and state plans for SMC continuation/scale up by disseminating findings and sharing experiences with key stakeholders," Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. • Strachan et al. 2016 Abstract: • "Background: Experience of seasonal malaria chemoprevention (SMC) is growing in the Sahel sub-region of Africa, though there remains insufficient evidence to recommend a standard deployment strategy. In 2012, a project was initiated in Katsina state, northern Nigeria, to design an appropriate and effective community-based delivery approach for SMC, in consultation with local stakeholders. Formative research (FR) was conducted locally to explore the potential feasibility and acceptability of SMC and to highlight information gaps and practical considerations to inform the intervention design. • Methods: The FR adopted qualitative methods; 36 in-depth interviews and 18 focus group discussions were conducted across 13 target groups active across the health system and within the community. Analysis followed the ‘framework’ approach. The process for incorporating the FR results into the project design was iterative which was initiated by a week-long ‘intervention design’ workshop with relevant stakeholders. • Results: The FR highlighted both supportive and hindering factors to be considered in the intervention design. Malaria control was identified as a community priority, the community health workers were a trusted resource and the local leadership exerted strong influence over household decisions. However, there were perceived challenges with quality of care at both community and health facility levels, referral linkage and supportive supervision were weak, literacy levels lower than anticipated and there was the potential for suspicion of ‘outside’ interventions. There was broad consensus across target groups that community-based SMC drug delivery would better enable a high coverage of beneficiaries and potentially garner wider community support. A mixed approach was recommended, including both community fixed-point and household-to-household SMC delivery. The FR findings were used to inform the overall distribution strategy, mechanisms for integration into the health system, capacity building and training approaches, supportive interventions to strengthen the health system, and the social mobilization strategy. • Conclusions: Formative research played a valuable role in exploring local socio-cultural contexts and health system realities. Both opportunities and challenges for the introduction of SMC delivery were highlighted, which were appropriately considered in the design of the project." • 35. • "UNITAID has awarded up to67 million to Malaria Consortium to oversee the largest-yet global programme to increase seasonal malaria chemoprevention (SMC) across the Sahel region of Africa, where malaria remains the leading cause of severe illness and mortality in young children...This grant will help increase capacity and reduce prices for SMC products in the seven target countries and is expected to supply an estimated 30 million treatments every year to protect 7.5 million children, preventing around 50,000 deaths." Malaria Consortium, ACCESS-SMC announcement, May 8, 2014.
• "ACCESS-SMC is a UNITAID-funded project, led by Malaria Consortium in partnership with Catholic Relief Services, which is scaling up access to seasonal malaria chemoprevention (SMC) across the Sahel to save children’s lives. This three year project is supported by London School of Hygiene & Tropical Medicine, Centre de Support de Santé International, Management Sciences for Health, Medicines for Malaria Venture, and Speak Up Africa. It will provide up to 30 million SMC treatments annually to 10 million children less than five years of age [specifically, children ages 3 to 59 months] in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia, potentially averting 49,000 deaths due to malaria." Malaria Consortium, ACCESS-SMC page.
• "ACCESS-SMC is working with all seven supported National Malaria Control Programs (NMCPs) to create SMC delivery pathways. We are providing support in a range of areas, including planning and management, supply chain, health worker training and communications and social mobilization. The project is also procuring almost 15m doses of SMC drugs in 2015, and up to 30m in 2016. Working together with NMCPs, we will reach 3.3m children in 2015 and up to 6.6m children by 2016 in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia." ACCESS-SMC website, "The Project".
• Clarifications around number of children targeted annually from Malaria Consortium emails (unpublished), November 23, 2016.
• "Malaria Consortium implemented SMC with UNITAID funding under the ACCESS-SMC project between 2015 and 2017 (three SMC rounds), with an original geographical scope encompassing 7 countries (Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia). In 2017, the project focused on just three countries, Burkina Faso, Nigeria and Chad, where both Malaria Consortium and other stakeholders had more difficulties identifying alternative sources of funding (either domestic of international from sources such as the Global Fund, PMI or the World Bank) to transition out of ACCESS-SMC." Malaria Consortium, Summary Update, May 2018, Pg. 1.
• 36.
• "UNITAID has awarded up to $67 million to Malaria Consortium to oversee the largest-yet global programme to increase seasonal malaria chemoprevention (SMC) across the Sahel region of Africa, where malaria remains the leading cause of severe illness and mortality in young children." Malaria Consortium, ACCESS-SMC announcement, May 8, 2014. • "The original ACCESS-SMC grant was expected to end on August 31st, but Malaria Consortium secured a cost extension up to February 28, 2018, to complete the third season in [Burkina Faso, Nigeria and Chad], and carry out an endline molecular markers’ survey in the seven ACCESS-SMC countries, to track trends in parasite resistance to SMC drugs." Malaria Consortium, Summary Update, May 2018, Pg. 1 • 37. • "Malaria Consortium’s three year project, known as ACCESS SMC, will run across seven African countries: Burkina Faso, Chad, Guinea Conakry, Mali, Niger, Nigeria and The Gambia. ACCESS-SMC will be led by Malaria Consortium, with Catholic Relief Services as the primary sub-grantee. It will be supported by London School of Hygiene & Tropical Medicine, Management Sciences for Health, Medicines for Malaria Venture, Speak Up Africa and Centre de Support en Sante International." Malaria Consortium, ACCESS-SMC announcement, May 8, 2014. • "The ACCESS-SMC partnership: • Malaria Consortium is leading the ACCESS-SMC project, tracking its impact, managing the procurement of SMC drugs and supporting malaria control programmes to implement SMC in Burkina Faso, Chad and Nigeria. • Catholic Relief Services is the lead-subrecipient and contributing to tracking the reach and impact of the project and supporting malaria control programmes to implement SMC in Guinea, Mali, Niger and The Gambia. • London School of Hygiene & Tropical Medicine is generating evidence on drug resistance, strengthening pharmacovigilance and measuring SMC’s public health impact. • Medicines for Malaria Ventures is supporting manufacturers to develop a child friendly, dispersible formulation and ensuring accurate drug forecasting. • Management Sciences for Health is measuring the cost of SMC and working with countries to optimize the SMC supply chain. • Speak Up Africa is creating an integrated health communications and advocacy campaign. The complementary nature of the partnership, which includes non-profit and academic institutions, allows substantial geographic reach and ensures that good evidence will guide future SMC implementation." ACCESS-SMC fact sheet, Pg 2. • 38. • 39. • 40. • "Overall, the comprehensive SMC implementation support in what we call internally 'GiveWell Districts' will target approximately 650,000 children, at an approximate cost estimated at 2.5M USD for 2017 (with some carryover costs in 2018 for operational close-out, data analysis and reporting)." Pg. 4. • Nigeria: "Since 2013, Nigeria was supported first by Bill & Melinda Gates Foundation and then through other one-off funding to implement SMC in six Local Government Areas (LGAs) in the States of Katsina and Jigawa. Through the funding provided by GiveWell / Good Ventures, Malaria Consortium reinstated support to these 6 LGAs that did not have any confirmed funding in 2017." Pg. 2. • Burkina Faso: "Thanks to large amount of drugs left over from various partners’ activities in 2016, Burkina Faso had drugs enough to cover approximately 360,000 extra children, but no operational costs to do so. Thus, Malaria Consortium through GiveWell / Good Ventures funding has started supporting three districts that had benefited from SMC in previous years, but which had no secured support for 2017, as well as five more new priority districts for SMC." Pg. 2. • Guinea Bissau: "The original plan was to support two regions for a total of 80,000 children, and approximately 400,000 dispersible SP+AQ blisters were directed to Guinea Bissau. However, eventually the MoH managed to secure funding for half of this target (one region) through the UNDP, and as a consequence the support in Guinea Bissau will be limited to the region of Gabu in the East of the country, targeting approximately 40,000 children under 5. The drugs that will be left over from the current order will have expiration date beyond 2019, so they will be available for use for a new round in 2018." Pg 3. • 41. • "Two dimensions of support were prioritized under the funding framework provided by Good Ventures through GiveWell recommendations on SMC...Monitoring and evaluation support, specifically though the execution of multiple coverage surveys and enhanced in-process monitoring (including in ACCESS-SMC areas)." Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium, Pg. 1 • "[G]aps have been identified in a number of M&E areas, due to a phasing out of support for established activities (such as coverage surveys) and/or because of quality assurance gaps identified during the 2015 and 2016 seasons." Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium, Pg. 3 • "GiveWell / Good Ventures funding supported four coverage surveys in Nigeria and Burkina Faso, and three surveys in Chad (after cycles 1, 3 and at the end of the round). As mentioned above, coverage surveys were not carried [out in] Guinea Bissau." Malaria Consortium, Summary Update, May 2018, Pg. 7. • "All contracts with independent research institutions were signed in July. To finalize the independent evaluation framework started under ACCESS-SMC, LSHTM was also contracted in the role of independent technical advisory organization, supporting the revision of the evaluation protocols (whose amendments required a revised ethical approval), additional technical supervision of field surveyors, and the analysis and interpretation of results in collaboration with Malaria Consortium technical team." Malaria Consortium, Summary Update, May 2018, Pg. 7. • "Seven temporary staff were recruited in Chad and, 43 (one per LGA) Nigeria, in order to improve supervision and monitoring and make sure that administrative data received is reflective or the real distribution process in the field. In addition, in Nigeria, independent monitors piloted in-process monitoring during one cycle." Malaria Consortium, Summary Update, May 2018, Pg. 8. • "[Chad] was support[ed] in terms of extra staff (five field officers for which there was not available budget under ACCESS-SMC) and additional budget for supervision logistics." Malaria Consortium, Summary Update, May 2018, Pg. 6. • "New SMC child cards (which are normally distributed for multiple years) were printed in 2017, which included a unique identifier of 7 or 8 figures. [...] The cost of reproducing these tools was not fully represented in the UNITAID budget, and not budget expansion was agreed. … [R]esults were mixed, and only in Burkina Faso it appeared that CHWs/volunteers had enough literacy/numeracy to perform the task so that numbers were readable and, mostly, correct. As the difficulties in manual entry (writing) by CHWs became clear in Chad and Nigeria, the exercise was scrapped." Malaria Consortium, Summary Update, May 2018, Pg. 8. • 42. See this spreadsheet, Sheet "Projected spending 2018 and 2019", Cell B11. • 43. • 44. ACCESS-SMC, 2016 direct costs • 45. See this spreadsheet, Sheet "Past spending by category" • 46. • 47. "The original ACCESS-SMC grant was expected to end on August 31st [2017], but Malaria Consortium secured a cost extension up to February 28, 2018, to complete the third season in [Burkina Faso, Nigeria and Chad], and carry out an endline molecular markers’ survey in the seven ACCESS-SMC countries, to track trends in parasite resistance to SMC drugs." Malaria Consortium, Summary Update, May 2018, Pg. 1. • 48. See this spreadsheet, Sheet "Past spending by category". • 49. See this spreadsheet, Sheet "Projected spending 2018 and 2019". • 50. "The original ACCESS-SMC grant was expected to end on August 31st [of 2017], but Malaria Consortium secured a cost extension up to February 28, 2018, to complete the third season in [Burkina Faso, Nigeria and Chad], and carry out an endline molecular markers’ survey in the seven ACCESS-SMC countries, to track trends in parasite resistance to SMC drugs." Malaria Consortium, Summary Update, May 2018, Pg. 1. • 51. See this spreadsheet, Sheet "Projected spending 2018 and 2019". • 52. Cost analysis of the seasonal malaria chemoprevention project in Katsina state, Nigeria. For example, see Tables 4 and 5, Pgs 20-21. • 53. Diego Moroso, Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, August 14, 2017. • 54. Some additional details on this activity: "All drugs procurement is centralized at our Kampala office for all countries. We require countries to carry out a revised quantification every year based on consumptions and stocks from previous years, consolidate orders, recruit procurement agent, negotiate pricing points with Guilin (and in the future, more pharma companies we hope), we monitor production and shipment schedules and make sure country teams are aware of when drugs come / delays, etc. Countries are responsible for providing us with all the relevant import requirements to make sure that all documentation is ready when drugs arrive. They then work out with local clearing agents the custom procedures, tax waivers, etc, and proceed with whatever logistics options / approaches are relevant in their countries (from direct delivery to peripheral health units as in Nigeria, to mixed approaches involving MoH storage and MC / CRS transport, to full contracting with MoH-mandated central pharmacy – depends on context)." Diego Moroso, Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, August 14, 2017. • 55. Some additional details on this activity: "Malaria Consortium developed all original training material for ACCESS-SMC [...] We could say that now the materials are pretty settled, with only minor changes / improvement happening yearly or less, based on experience from the field. We co-organize central trainings with [National Malaria Control Programs], and we then support and oversee cascade trainings (always in joint MC/NMCP teams – CRS teams in former CRS countries under ACCESS-SMC)." Diego Moroso, Regional Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, August 14, 2017. • 56. See this spreadsheet, sheet "Coverage." • 57. Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, June 13, 2018 • 58. Malaria Consortium, comments on a draft of this page, October 2017 • 59. For example, see: • "Malaria is still a serious public health concern in Nigeria, with fevers presumed to be malaria accounting for 60 percent of outpatient visits to health facilities, 30 percent of childhood deaths, 25 percent of deaths in children under one year and 11 percent of maternal deaths. In northern Nigeria, where malaria transmission is highly seasonal, malaria prevalence is also comparatively higher than other areas during the rainy seasons. The implementation of SMC in Katsina is specifically intended to reduce mortality in children under five living in areas with seasonal malaria, and strengthen health systems at the state and national levels." Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. • Under "Why Katsina State" in Malaria Consortium, SMC presentation, May 6, 2014: • "Katsina State is within the Sahel Region; rainy season and peak malaria incidence from July to October • 2012 estimated population of 6,916,641 • 1,383,328 under-5 years • 600,281 cases of malaria (2008) • 4,103 malaria related deaths • Katsina overall under-5 mortality rate 180 per 1,000 live births • Also, Malaria Consortium told us that “eligible districts are established by the National Malaria Programmes in the countries applying the WHO rainy season seasonality rules.” Malaria Consortium emails (unpublished), November 23, 2016. • 60. A few sources that seem to discuss the two different methods are: • Timothy Rubashembusya Trip Report from Burkina Faso, August 2016 includes a table that shows discrepancies in estimated coverage rates between "MC data" and "LSHTM survey". See Pg 4. • Timothy Rubashembusya Trip Report from Burkina Faso, August 2016 writes: "Propose data quality assessments for 2015 distribution data: The background of this was due to major discrepancies of coverage rates arising between the LSHTM 2015 End of Cycle survey and the administrative data submitted. Whereas these are not expected to be exactly the same, there were some major discrepancies in Cycle 4 coverage rates arising from the LSHTM survey in relation to the data reported through our routine reports. Examining further the results from the LSHTM reports presents some questions about the numbers presented which will only be ascertained by further evaluation of where the problem arose from. For example, the LSHTM reports that the rate of children who received all the 4 cycles was 86.4%. This isn’t realistic as both Cycle 4 and Cycle 3 from the same survey showed rates less than 86.4% (ie. 68.4% and 82.0%, respectively). i.e. the number of those who received all the 4 cycles would need to be less or equal to the least cycle coverage rate to be valid – which is not the case. Recommendation: These discrepancies will be assessed further in relation to other countries to enable propose a clear strategy. However in the interim, I have proposed to plan a data verification exercise for 3 randomly selected districts out of the 11 which were part of the 2015 SMC distribution. This verification exercise would only focus on the fourth cycle – given that this is where we see a major gap. Out of these 3 districts, we would need to validate the records available at 3 (also randomly selected) CSPSes by comparing these records with those submitted in the MC reports. I will collaborate directly with Damiba Jean-Dieudonne to see how this can be achieved and in what timeframe." Timothy Rubashembusya Trip Report from Burkina Faso, August 2016, Pgs 4-5. • "SMC coverage surveys: All eligible children in endemic areas are expected to receive SMC every month during the high transmission season. Although output level data will provide information on the number of children who received SMC during each distribution cycle, the real coverage at population level can only be measured through representative household surveys, similar to coverage assessment of the Expanded Programme of Immunization (EPI). Indeed, sampling households at community level will guarantee the inclusion of eligible children potentially missed by the distribution teams and the exclusion of outsiders to the targeted community." ACCESS-SMC M&E strategy, November 2015, Pg 8. • 61. • We came to this understanding through comments from Malaria Consortium emails (unpublished), November 23, 2016. • Relevant quotes include: • "Routine monitoring data included SMC distribution data, extracted from SMC registers and selected routine health facility Health Management Information System (HMIS) data obtained from selected sentinel sites. Routine SMC distribution data was extracted from community health workers (CHWs) at the end of each distribution cycle. This data was aggregated at settlement, ward and LGA levels and compared with the estimated eligible population totals to establish SMC coverage at each distribution cycle. SMC coverage, estimated from distribution data is highlighted in figure 1 below. A total of 487,353 treatment courses were delivered in two LGAs over three treatment cycles in the first round of SMC representing an average of 115% coverage over the three cycles. In 2014, a total of 1,078,440 treatments were provided across four LGAs over four cycles with an average of 115% administrative coverage." Malaria Consortium, Monitoring and evaluation summary Nigeria, Pg 2. • "Table 1: Routine data and sources...Children reached…[Routine data source:] CHWs & HF [Health Facility] SMC drug registers" See Table 1, Malaria Consortium, M&E Plan Nigeria, Pg 10. • We have seen a few versions of templates for registers that CHWs may use when distributing SMC drugs. The latest version that we have seen is here: ACCESS-SMC Register Template. • We have seen a few versions of templates for "SMC Record Cards." The latest version that we have seen (from 2016) is here: SMC Record Card Template 2016. • Regarding data management, Malaria Consortium writes: "The project will set up a data management system to track all indicators both routine and non-routine. All data collected by the project from the different data sources mentioned above will systematically be entered into a database resident at the project offices in Katsina. The system will have in built data cleaning, validation and reporting modules to allow timely extraction of performance reports based on the data submitted. Under the management of project research officer, the data management system will be routinely used for the following purposes: • Produce reports for feedback to providers of the data on project progress e.g. SMC coverage, trends in malaria presentation • Produce indicator performance statistics to aid project management and decision making regarding project implementation." Malaria Consortium, M&E Plan Nigeria, Pg 17. • We have not yet seen reports from the above data management system. • 62. • "Each CDD/CHW team fills – among other things – one tally sheet per day with one directly observed treatment per child successfully treated – among other information recorded, by age, and which they submit to their reference health facility (to the head nurse or doctor, as applicable). • The health workers consolidate tally sheets each day, and transmit information by SMC or calls or other means to district. • District data managers (or equivalent role) consolidate all tally sheet data from their facilities and submit for validation / consolidation to regions and NMCP / central administration. • This is how data for any mass campaign are managed, with slight variations in roles, tools, layers of control / validation, quality assurance elements." Malaria Consortium emails (unpublished), November 23, 2016. • 63. For example, see: • It appears that about 62% of targeted children received at least 3 cycles of SMC in 2014 according to coverage surveys. See Table 5.3, Malaria Consortium, Nigeria SMC evaluation report, 2014, Pg 31. However, it appears that administrative coverage showed coverage estimates of over 100%: "A total of 487,353 treatment courses were delivered in two LGAs over three treatment cycles in the first round of SMC representing an average of 115% coverage over the three cycles. In 2014, a total of 1,078,440 treatments were provided across four LGAs over four cycles with an average of 115% administrative coverage." Malaria Consortium, Monitoring and evaluation summary Nigeria, Pg 2. The figure 62% refers to the proportion of targeted children receiving at least 3 cycles of treatment according to coverage, while 115% refers to the average administrative rate of coverage in each cycle of treatment. While these numbers are not directly analogous, we believe they demonstrate the discrepancy between these two types of coverage estimates. • ACCESS-SMC: "Percent coverage (3-59 months) [who received four cycles]" versus "Percent of children (3-59 months) receiving four full cycles of SMC, based on LSHTM coverage survey" in Table 3, ACCESS-SMC multi-country cost analysis, January 2017, Pg 12. • Timothy Rubashembusya Trip Report from Burkina Faso, August 2016 includes a table that shows discrepancies in estimated coverage rates between "MC data" and "LSHTM survey". See Pg 4. • 64. • 65. Malaria Consortium, comments on a draft of this page, October 2017 • 66. For estimates of how many children who were six to seven years old received at least one cycle of SMC in ACCESS-SMC countries in 2015 and 2016, see this spreadsheet, sheet "Results." The estimates suggest that among children in this age group whose caregivers were interviewed, 57% (range across countries: 15%-85%) received at least one cycle of treatments. • 67. GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, November 23, 2016. Data for both the surveys conducted after all four cycles and after each cycle in 2017 are in this spreadsheet, sheet "Coverage." • 68. The main sources for our understanding of the coverage survey methodology are: • 69. Table 2, ACCESS-SMC M&E strategy, November 2015, Pg 10: "Responsible partner" for the "Project indicator" "Population coverage" is "LSHTM." • 70. Results and sources in this spreadsheet. • 71. "One month after the last SMC cycle in 2015, and after the last cycle in 2016, a household survey will be undertaken to record the dates of SMC doses received that year. The survey will be done shortly after the last CMS cycle in order to minimise the time interval for recall." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 13. • 72. Results and sources in this spreadsheet, sheet "Results." • 73. • "Two-stage cluster sample surveys in each of the seven countries were undertaken to provide estimates of the proportion of eligible children who received 0,1,2,3 or 4 SMC treatments, representative of the areas where SMC is implemented." Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation, Pg 10. • "Sampling for the coverage survey: From a list of all communities (villages or census enumeration areas) in the areas that received SMC, about 60 communities will be selected with PPES [Probability proportional to estimated size]. In each selected community, a sample of an approximately constant number of households will be made from village lists or using area sampling. All eligible children resident in the household at the time of the survey should be included. If any children are away or the parent is not present to interview, a call-back visit should be arranged before documenting a non-response for that child or household." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 14. • "The SMC coverage surveys use area sampling to select participants within villages. In area sampling, researchers make a map of the village and divide it into segments, then the tablet automatically chooses a segment at random, and the interviewers include every household in that segment. This method, known as compact segment sampling, involves no subjectivity on the part of the researchers, an issue which can be an important source of bias in coverage surveys. GPS tracking of the tablets provides the location of each household, allowing supervisors to check exactly where the survey teams went. In most countries, villages were selected using probability proportional to size sampling with approximately 50 clusters representing the entire area where ACCESS-SMC was operating. The exception is Niger, in which the researchers performed separate surveys in four representative regions, because the country is too large for them to conduct surveys everywhere." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, pgs. 3-4. • For details on the procedure to select districts for the sample in Mali (2015 and 2016), Niger (2015 and 2016) and Nigeria (2016), see this spreadsheet, "Methods" sheet. • 74. • "A sample size of 60 clusters with approximately 10 children per cluster who were aged 3-59 months at cycle 1 and hence eligible for four treatments, was estimated to be required to give good precision for the overall estimate of coverage while permitting reasonable precision of sub-regional estimates for about 3 equal sub-regions. To allow for the fact that children up to 7 yrs of age will be surveyed, the target sample size was increased to about 14 per cluster (total 60x14=840). This was then increased to a target of 1000 to allow for about 15% non-response. This calculation was based on the assumption that the rate of homogeneity (roh) would be about 0.2 (the value obtained using a similar sampling method for vaccination coverage surveys in The Gambia, for DPT3 coverage). This gives a design effect of Deff=1+(b- 1).roh=2.8 for a cluster size b=10. A survey of 600 then corresponds to a sample size of 600/2.8=214 if we were to use simple random sampling and this would give, if the coverage was 70%, a margin of error (95% confidence interval) of +/-6%, if the coverage was 50%, +/-7%. And for sub-regional estimates, if we divide the area into three with 200 sampled in each of these three areas, the precision would be 50% +/-12% or 70% +/-11%. For estimating coverage in the out-of-range children (>5yr and 7<yrs), if we have about 4 of these per cluster, a total of 60x4=240, we would have a margin of error of +/-8% if the coverage was 20%." Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation, Pg.11. • For the three coverage surveys we have seen from 2017, the sample size exceeded 600 in each. Sources in this spreadsheet, sheet "Results." • 75. • Regarding how SMC Record Cards are used: Our understanding is that CHWs are expected to record the first dose of each cycle and the date they gave the dose on a family's Record Card and that the family is expected to record all other doses. We have seen a few versions of templates for "SMC Record Cards." The latest version that we have seen (from 2016) is here: SMC Record Card Template 2016. • "Children in endemic areas should receive SMC every month for up to 4 months in the transmission season. A key indicator that should be reported is the percentage of children that receive all of their scheduled SMC treatments. Provided SMC doses are accurately recorded on a family-held record card, this can be done through household surveys using a similar methodology to that employed for vaccination coverage surveys, but will need to be supplemented by asking mothers about treatments." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 7. • "Q62: Was (Name) given a card to keep record of the drugs given?...If No or DK => Q64." "Q64: Did the child take the first dose in the presence of the caregivers for each distribution cycle? Q65: Did you continue to give the tablets at home the following days?" ACCESS-SMC, Questionnaire for SMC coverage survey, Pgs 14-15. • "SMC doses: Dates of SMC doses will be recorded from the child’s SMC card. In countries where administration of SMC doses was recorded electronically, a hand-held device will be used to read the QR code on the child’s card. The mother or carer should also be asked about receipt of SMC doses to cross-check the information on the card and to provide information about doses where the card has been lost. A short questionnaire, including reasons for missed SMC cycles, and adherence to the supervised and home doses, occurrence of fever in the child in the last 2 weeks and any treatment seeking for that fever, and the use of bednets by the child, will be completed. Where possible, a cross-check on SMC dates should be made from the SMC register." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 14. • "The researchers ask caregivers: Do you know about the SMC program? Has your child had SMC? How many times did the health worker come? How many times did you get a blister pack for this child? Did you get a blister pack in the first month, the second month, the third month, and the most recent month? Then they take the SMC record card and transcribe what is written on it. This year, researchers will photograph the card as well, to remove transcription error." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 3 • 76. Examples of questions are pulled from ACCESS-SMC, Questionnaire for SMC coverage survey and from Malaria Consortium emails (unpublished), November 23, 2016. • 77. • "Do you know the recommended method to crush the tablets?" ACCESS-SMC, Questionnaire for SMC coverage survey • In an email on October 19, 2018, Malaria Consortium staff told us that it has since switched from hard to dispersible tablets, which do not need to be crushed. • 78. "SMC record cards greatly improve accuracy. However, caregivers do not always retain the cards; in these cases caregiver recall is the only source of information. In addition, SMC record cards are not always fully completed by health workers, meaning that the cards are not necessarily reliable. To mitigate the problem of unreliability, ACCESS-SMC researchers ask the caregiver to remember the number of treatments their child had without looking at the record card, then check the caregiver's answers against the card. Agreement has been generally good but where there is a discrepancy the interviewer tries to resolve this; if this cannot be done, the number of treatments indicated on the card is used unless the caregiver states a larger number, in which case the caregiver’s report is used, as it is known that cards can be under-completed." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 5 • 79. • "All coverage survey data are collected directly into tablet computers. The tablets used in the surveys should automatically record the GPS location where the data are being captured. This feature was not working reliably last year, but is expected to work this year." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 3 • We have not seen full reports of the methodology used in 2017 and so have not verified whether this feature worked better in 2017. • 80. • 81. Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, August 8, 2018. • 82. • Malaria Consortium told us that the biggest difference between the LQAS method it is using in 2018 and prior coverage surveys is the length of the questionnaire (~10% the number of questions as before). Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, April 8, 2018. • Malaria Consortium told us that it hopes this approach will deal with three issues that arose when conducting a full coverage survey after each cycle: 1. "the amount of resources required for each cycle's evaluation is very large (large teams of surveyors, complex logistics, difficult travel conditions, high costs);" 2. "the short interval between cycles (4 weeks), which makes for nearly 4 solid months of surveying under difficult conditions;" 3. "the time needed to process the data has been too protracted to allow for nimble decision making in the field". Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, May 8, 2018 • 83. "The plan would be to carry out a LQAS survey at the end of Cycles 1, 2 and 3...and then to deploy a full coverage survey at the end of Cycle 4." Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, May 8, 2018 • 84. • 85. • 86. "In the urban areas...at each locations the 24 nearest houses were surveyed". "In the rural areas...this subunit was then segmented into S segments and one segment randomly selected", Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation, Pg. 100. • 87. See this spreadsheet, sheet "Methods" for details. • 88. • 89. • 90. See cell F60 in this spreadsheet, in the "Coverage" sheet for this calculation. We estimate that the difference in total person-months of treatment is just 0.28% between the post-round and post-cycle surveys. • 91. This quote is pulled from an unpublishable source: ACCESS-SMC, Health impact data with edits from Malaria Consortium emails (unpublished), November 23, 2016. The original source wrote that if the probability of receiving SMC at each cycle is 88%, the expected percentage who would receive at least three treatments is 93%. However, assuming that the probability of receiving each cycle is independent of whether the child received other cycles we believe that the correct figure here would be 67%. See Cells AF4 and AF9 in GiveWell summary of SMC coverage information, November 2016. • 92. "The proportion of children excluded due to illness is less than 5%." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 5 • 93. More detail on the methods is given as follows: "The relative reduction in the number of malaria cases and malaria deaths under five years of age, compared to older age groups, observed when SMC was introduced, was estimated from the number of confirmed cases of deaths in-hospital that were reported in the national Health Management Information Systems, supplemented by data on malaria cases collected from clinic registers in selected health facilities in each country", Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 3. • 94. The data we have seen is presented on Pg. 91-102 of Malaria Consortium, Annex III: ACCESS-SMC Evaluation. • 95. "In countries with consistent reporting, introduction of SMC was associated with a reduction of about 50% in the number of malaria deaths in implementation areas", Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 3. • 96. • "Efficacy of SMC treatments will be measured using the case control approach. Malaria cases, and controls who do not have malaria, will be recruited concurrently, and the dates of the doses of SMC they received noted. The efficacy of SMC can then be calculated as a function of the time since treatment using case-control analysis. It is essential that dates of SMC doses are accurately documented, and that malaria cases are parasitologically confirmed. Controls will be selected from the community, in the neighbourhood where the case lived at the time they had malaria. Trained fieldworkers will collect information about cases and controls, and make home visits to record bednet use and other household factors that may act as confounders. Microscopy will be used to confirm cases and to measure parasite density. Controls will be confirmed to be negative for P.falciparum, by RDT." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 10. • "The dataset from Nigeria did not pass quality control when compared against scanned forms, and are being independently re-entered", Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 75. • 97. • 98. "820 cases and 1,637 controls were recruited in 2015, and 1,433 cases and 2,867 controls in 2016. SMC was associated with an 89% reduction in malaria incidence for 4 weeks after treatment, and 62% from 5 to 6 weeks after treatment, compared with children who had not received SMC or whose last dose was more than 6 weeks before", Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 2. • 99. • "Resistance to sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) is associated with specific gene mutations in the malaria parasite. Monitoring the prevalence of these markers, in malaria cases health facilities and in P. falciparum carriers in the general population, permits early warning of emerging problems with drug resistance. This progress update is on monitoring P. falciparum resistance markers. The objective of the molecular monitoring through the ACCESS-SMC project was to establish a baseline for monitoring the prevalence of the markers across the subregion using standardised methods, and to determine if there have been any important changes in the prevalence of these markers after two years of SMC at scale. [...] The baseline surveys were done at the end of the 2015 transmission season in all seven countries. (In 6 countries, sampling was done in areas which had not started SMC but would implement the following year. In The Gambia, sampling was in an area where SMC had been implemented for two years). In each country, one locality was chosen, blood samples were collected from approximately 2000 children under 5 years of age and 2000 individuals 10-30 years of age per country, taken onto filter paper and shipped to London to the LSHTM laboratories for analysis. The older age group was included because they would not be treated with SMC drugs, assessment of trends in the prevalence of markers of resistance in this group therefore allows us to determine whether SMC is leading to changes in the circulating parasite population." ACCESS-SMC, Progress update - Resistance monitoring, Pg. 3 • "The baseline surveys, before scale-up of SMC, showed very low frequencies of mutations associated with SP and AQ resistant genotypes." ACCESS-SMC, Progress update - Resistance monitoring, Pg. 3 • 100. Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, June 13, 2018 • 101. • "The objective of the molecular monitoring through the ACCESS-SMC project was to establish a baseline for monitoring the prevalence of the markers across the subregion using standardised methods, and to determine if there have been any important changes in the prevalence of these markers after two years of SMC at scale [...] The baseline surveys, before scale-up of SMC, showed very low frequencies of mutations associated with SP and AQ resistant genotypes. The markers indicative of resistance to SMC drugs are shown in the following table." ACCESS-SMC, Progress update - Resistance monitoring, pg 3. • "This report presents an update on analysis of baseline survey data. A second survey is planned to be conducted in each country at the end of the 2017 transmission season. The baseline surveys were done at the end of the 2015 transmission season." ACCESS-SMC, Progress update - Resistance monitoring, pg 7. • As of July 2018, Malaria Consortium was seeking$850,000 to repeat the molecular markers study in 2020. See this spreadsheet.
• 102.

"The most common reaction seen with SMC drugs during the pilot studies and during the first year of ACCESS-SMC was regurgitating the drug after ingestion. This was due to the unpleasant and lasting bitter taste of amodiaquine and because the hard tablets were not always crushed into a fine powder before mixing with water, which often caused children to gag and expel the medicine. Since the introduction of the orange flavored dispersible amodiaquine and SP tablets, this is no longer a common problem." Malaria Consortium, comments on a draft of this page, October 2017

• 103.
• We have seen one estimate from Malaria Consortium that suggested that roughly 0.5%-1.5% of children who received SMC drugs vomited. See Malaria Consortium, 2013 operational data. We have not vetted this estimate. We have not seen other information about vomiting in Malaria Consortium's monitoring.
• 104.

"It is very rare that children become sick after taking SMC medicines, but some children may feel a bit sick for a short while; what are some symptoms children may have? a) diarrhoea, b) itching, c) headache, d) mild abdominal pain, e) rash, f) a,b, and c, g) d,e, and f, h) All of the above, [Correct answer: H.]" Malaria Consortium Quiz Answer Key.

• 105.

"In Nigeria, there was a follow-up of a cohort of 10,000 children one week after each SMC cycle to ask about side effects, and to assess the frequency of mild and moderate side effects that may not be reported to the health facility. […] The 10,000 children cohort in Nigeria produced only five PV reports, and it seems to be linked to some reluctance to report by beneficiaries." ACCESS-SMC, Progress update - Safety monitoring, pgs. 7 and 10.

• 106.
• 107.

"We are only permitted to procure products from suppliers that meet WHO stringent guidelines for pre-qualification of malaria drugs to ensure high-quality and efficacy of SP and AQ." Malaria Consortium, comments on a draft of this page, October 2017

• 108.

See our most recent model, "SMC" and "Results" sheets.

• 109.

Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, September 13, 2018

• 110.

Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, September 13, 2018

• 111.

This is based on internal records of how much GiveWell-directed donors gave to Malaria Consortium in GiveWell's 2017 "metrics year."

• 112.
• 113.

Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, September 13, 2018

• 114.
• Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, August 8, 2018.
• Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, September 13, 2018.
• 115.

This is a 'lower bound' in that it assumes that both (a) additional drug supply is not available for 2019, reducing total room for more funding by $4.7 million (which is the additional amount that Malaria Consortium may be able to spend in 2019) from$65.7 to $60.1 million; and (b) there is no funding gap in Burkina Faso for 2020-2021, further reducing total room for more funding by$8.0 million (which is the additional amount Malaria Consortium estimates it could absorb for Burkina Faso for 2020 and 2021) from $60.1 to$53.0 million. Calculations in this spreadsheet, sheet "Spending opportunities."

• 116.
• "Nigeria remains the biggest gap. However, the strategic direction for Malaria Consortium is to consolidate in 4 states only, by continuing in Sokoto and Zamfara and expanding to cover fully (ideally) Katsina and Jigawa. This is based on what we believe is an organizational capacity ceiling to serve effectively approximately 5M children max, within linguistically accessible areas. We believe we would stretch too much on SMC if we went above such threshold, which may in turn affect quality of implementation." See this spreadsheet, sheet "spending opportunities."
• Malaria Consortium noted that to expand further would likely mean expanding into the state of Kano, which includes a major urban area and Malaria Consortium has found that delivering programs like SMC is more challenging in urban areas. Other operational considerations include the costs of identifying qualified staff and incurring start up costs for a program for which it may not have adequate funding to continue in the future. Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, August 8, 2018.
• 117.
• 118.

See this spreadsheet, sheet "Coverage by country," rows 124 and below. 3.5 million funded by GiveWell/Good Ventures in 2018 out of 26.1 million total = 13.5%.

• 119.
• 120.
• 121.

See this spreadsheet, sheet "SMC donor mapping."

• 122.

Diego Moroso, Project Director for ACCESS-SMC at Malaria Consortium, conversation with GiveWell, August 8, 2018.

• 123.

"Why is SMC not more widely available?
While 23.7 million children are eligible for SMC, currently only 3.4% of them benefit from this intervention. Health ministries, donors and communities are have shown great interest in implementing SMC and scaling it up, but five critical barriers persist:

• Countries do not yet have the systems in place to distribute SMC drugs and administer them to children, including trained staff, logistics, tools, plans and communications materials.
• Global production of quality SMC drugs falls far short of demand, and current formulations of SMC drugs are complicated for community health workers to administer.
• The delivery of SMC drugs, which are themselves relatively inexpensive, is considered to be costly, while a lack of analysis and cost benchmarking means SMC’s cost effectiveness is poorly evidenced.
• Although evidence of safety and efficacy of SMC drugs has been demonstrated in trials, there is limited evidence at scale. This uncertainty prevents drug manufacturers and implementers from making large-scale investment in SMC.
• Health ministries, donors and the private sector currently dedicate insufficient financial resources to expanding SMC, meaning resources for scale-up are not available." ACCESS-SMC website, "The Project".