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Estimating the Funding Gaps for Distribution of Antimalarial Nets and Seasonal Malaria Chemoprevention

Published: November 2018

Summary

This page estimates the funding gaps for distribution of long-lasting insecticide-treated nets (LLINs) and seasonal malaria chemoprevention (SMC) between 2018 and 2020.

The best data that we are aware of on funding gaps for these interventions comes from the RBM Partnership to End Malaria (for LLINs) and from Malaria Consortium (for SMC). We believe their estimates are reasonable given limited information, but they also rely on a number of difficult judgment calls which may lead them to overestimate or underestimate gaps. We would recommend funders using the information in this post to coordinate with actors in Ministries of Health to verify whether gaps remain, and fill them as needed.

Our analysis of the RBM and Malaria Consortium estimates leads us to conclude:

  • Delivering LLINs to all people who need them in the 35 countries for which data is available between 2018 and 2020 would cost about $2.75 billion over three years. About $2.1 billion of this is already financed, or is expected to be financed with high confidence, leaving a gap of about $640 million.
  • Delivering SMC to all children living in eligible districts in the seven countries for which we have reasonable estimates between 2018 and 2020 would cost about $392 million over three years. About $187 million of this is already financed, or is expected to be financed with high confidence, leaving a gap of about $205 million.

There are reasons to believe these gaps may shrink considerably:

  • The estimated gap for LLINs in 2017 was relatively small (about 2% of total need), although RBM has told us this is due to large contributions from a funding mechanism that is no longer available (more below).
  • RBM told us that Nigeria is currently attempting to raise $300 million from the development banks for malaria control. If successful, this would substantially reduce the size of both the LLIN and SMC funding gaps between 2018-2020.
  • Countries may have some ability to shift funds between health programs or between budget years to close urgent gaps if they are not able to raise additional funds externally.

Nevertheless, the gaps are large in absolute terms and our best guess is that they will not be fully closed, leading to suboptimally planned distributions, delays in distributions, or missed distributions. We see it as a high priority to ensure that countries with a high burden of malaria, and remaining gaps, receive sufficient funding to deliver LLINs and SMC.

Calculations for all the figures presented below can be found in the spreadsheets GiveWell's LLIN funding gaps analysis, April 2018 and GiveWell's SMC funding gaps analysis, April 2018.

Mass Distribution of Long-Lasting Insecticide-Treated Nets (LLINs)

There is strong evidence that when large numbers of people use LLINs to protect themselves while sleeping, the burden of malaria can be reduced, resulting in large reductions in child mortality, as well as potential increases in long run income from protected children.1 Our best guess of the cost-effectiveness of Against Malaria Foundation (AMF)'s LLIN distributions is roughly $3,500 per life saved.2

What would it cost to deliver nets to everyone who needed them?

Our analysis of data provided by the RBM Partnership to End Malaria suggests that delivering nets to all people who need them in the 35 countries for which data is available between 2018 and 2020 would cost about $2.75 billion over three years. About $2.1 billion of this is already financed, or is expected to be financed with high confidence, leaving a gap of about $640 million.3

The below maps show estimates of absolute and percentage funding gaps for LLINs by country between 2018 and 2020.

The largest absolute funding gaps are in Nigeria ($330 million), DRC ($95 million), Uganda ($42 million), and Kenya ($34 million).

The largest percentage funding gaps are in Nigeria (49%), Chad (46%), Kenya (37%), Sierra Leone (34%), Niger (32%), South Sudan (30%), and Benin (30%).

These estimates rely on a number of simplifying assumptions. You can see calculations in the spreadsheet below.

Key limitations and judgement calls of our analysis include:

  • Data completeness. RBM shared estimates of funding gaps in 35 countries for which it has more reliable information.4 The gap in 10 other malaria endemic countries is unclear.5 These estimates therefore represent a plausible lower bound on the funding gap in Africa. Our best guess is that these estimates cover countries comprising about 93% of malaria deaths in Africa.6
  • Cost estimates. As a simplifying assumption, we use $4.11 per LLIN delivered for every country, which is in line with our estimate of the average cost of delivering nets for AMF-funded distributions (excluding research and AMF organizational costs). Our estimates for AMF distributions range between $3.55 and $5.39.7 If countries switch to more effective (but more expensive) next generation nets before 2020, the funding gap is likely to be higher.8
  • Funding is not the only constraint to delivery of LLINs. For example, instability in Nigeria, and DRC is a risk to the successful delivery of LLINs. The gap analysis above includes those living in areas of instability. Our analysis of AMF distribution costs suggests that per net costs for hard to reach areas (DRC) are roughly 20% higher than the average AMF distribution.9
  • Extrapolation of expected future funding. We make a number of assumptions about future spending by major funders.
    • The Global Fund has allocated funding for the period 2018-20, and so no extrapolation was required.10
    • PMI has allocated funding for 2018, but not yet for 2019 or 2020. PMI allocations for 2018 have been extrapolated to 2019 and 2020.11
    • GiveWell/AMF have allocated funding for 2018 and 2019. AMF funding is extrapolated to 2019 and 2020.12
    • Expected DfID commitments have been extrapolated for DRC and Nigeria.13
    • Continued World Bank financing is uncertain, and so has not been extrapolated.14

Will the gaps be filled?

Since the above estimates account for our best guesses of contributions from the largest funders, we think there is a reasonable likelihood that future funding gaps may not be filled, causing a delay in distributions or missed distributions.

Relevant considerations for thinking about the likelihood of funding gaps remaining unfilled are:

  • Remaining funding gaps were highly variable between years. In 2016, RBM estimates that roughly 59 million out of 206 million required nets (29%) in Sub-Saharan Africa were unfinanced. In 2017, only about 6 million out of 247 million nets (2%) were unfinanced.15 This difference is largely driven by a large number of unfinanced nets in Nigeria in 2016, comprising 82% of the gap in 2016.16 RBM told us that the gap in Nigeria in 2016 was due to a delay in Global Fund grant implementation. These gaps rolled over to 2017, when they were filled by Global Fund incentive funding, and reprogramming of other activities.17 RBM has told us that these financing options are no longer available.18
  • The gap is unlikely to be filled by the largest LLIN funders. Between 2015 and 2017, RBM estimates that the largest funders of LLINs were the Global Fund (57%), and the President’s Malaria Initiative (PMI) (21%).19 The Global Fund has made its spending commitments for 2018-20, and our estimates extrapolate PMI spending commitments for 2018 to 2019 and 2020.20
  • Countries may be able to shift funds to close urgent gaps. It is possible that funds earmarked for other interventions or allocated to future budget years could be reprogrammed to fill urgent gaps. RBM told us that the financing mechanisms used to do this in the past from Global Fund contributions are no longer available.21 We have not fully reviewed how likely it is that other financing mechanisms could be used to fill these gaps.
  • The largest gaps are in 2020. We estimate that roughly 65% of the gap is in 2020,22 suggesting there is still time for funders to fill those gaps. However, if those gaps persist, it seems unlikely that countries will be able to sufficiently plan for distributions to be completed on time (our understanding is that planning for a distribution often takes substantial time after funding has been secured). There are still some funding gaps for distributions in 2018 and 2019; it seems likely that gaps will cause suboptimally planned distributions, delays in distributions, or missed distributions since there is not much time remaining before these distributions would ideally happen.

Potential funders who could fill these gaps include:

  • The UK’s Department for International Development (DfID). Nigeria, DRC, Uganda and Kenya are all UK priority countries.23 DfID remains a major funder of malaria control and prevention, both through contributions to the Global Fund, and bilateral aid.24

    It has committed to spending £500 million (about $675 million) per year on malaria up to 2021.25 DfID already funds some nets in Nigeria and DRC.26

  • Domestic governments. The 2017 World Malaria Report estimated that in 2016, domestic governments contributed $800 million (31%) of funding for malaria control and elimination.27
  • Development banks. We have heard that Nigeria is currently attempting to raise $300 million from the development banks for malaria control.28 If successful, this would substantially reduce the size of both the LLIN and SMC funding gaps between 2018-2020.
  • Private philanthropy. We estimate that AMF financed about 3% of nets delivered in Africa between 2015 and 2017.29 AMF’s expected contributions are included in the estimates above (based on AMF's current funds on hand; this does not include any additional funding that AMF may receive in the future).

Seasonal Malaria Chemoprevention (SMC)

SMC involves giving children under the age of 5 full malaria treatment courses intermittently during the malaria season. Seven randomized controlled trials provide strong evidence that this program reduces cases of malaria (although the trials were insufficiently powered to detect effects on all-cause mortality.)30 Our best guess of the cost-effectiveness of Malaria Consortium's SMC distributions is roughly $2,000 per life saved.31

What would it cost to deliver SMC to every child living in an eligible district?

Our analysis of data provided by Malaria Consortium suggests that delivering SMC to all children living in eligible districts in the seven countries for which we have reasonable estimates between 2018 and 2020 would cost about $392 million over three years. About $187 million of this is already financed, or is expected to be financed with high confidence, leaving a gap of about $205 million.32

The below map shows estimates of funding gaps for SMC by country. The largest absolute funding gaps are in Nigeria ($128 million) and Niger ($37 million), and the largest percentage gaps are in Nigeria (83%), Niger (67%), and Chad (61%).

These estimates rely on a number of simplifying assumptions. You can see calculations in the spreadsheet below.

Key limitations and judgement calls of our analysis include:

  • Data completeness. Malaria Consortium shared estimates of the number of districts that are expected to be covered by current funding sources in seven countries eligible for SMC for which it has more reliable information. The gap in five other eligible countries is unclear, but Malaria Consortium believes it is unlikely to be substantial. The estimates above only include the seven countries for which we have received estimates from Malaria Consortium and therefore represent a plausible lower bound on the global funding gap. Our best guess is that these seven countries comprise about 85% of the population eligible for SMC.33
  • Cost estimates. As a simplifying assumption, we use $4.33 per child targeted in every country, which is in line with our estimate of the average cost of SMC for Malaria Consortium distributions.34
  • Funding is not the only constraint to delivery of SMC. Security concerns and logistical barriers may limit the speed of scale-up.35
  • Extrapolation of expected future funding. We make a number of assumptions about future spending by major funders.
    • The Global Fund has allocated funding for the period 2018-20, and so no extrapolation was required.36
    • PMI has allocated funding for 2018, but not yet for 2019 or 2020. PMI allocations for 2018 have been extrapolated to 2019 and 2020.37
    • PMI has allocated funding for 2018, but not yet for 2019 or 2020. PMI allocations for 2018 have been extrapolated to 2019 and 2020.38
    • GiveWell/Malaria Consortium have allocated funding for 2018 and 2019. This funding has been extrapolated to 2020.39
    • Continued World Bank financing is uncertain, and so has not been extrapolated.40

Will the gaps be filled?

SMC is a relatively new intervention, which is still being scaled up. We don’t yet have a good sense of the maximum speed at which SMC could be scaled up with additional funding.

The chart below shows historic contributions and future support to SMC (which is expected with high confidence) from each major funder.

We estimate that in 2018, roughly 60% of eligible children will be covered in the countries for which we have information.41 The World Malaria Report 2017 cites lack of funding as the most important reason large gaps remain in SMC coverage.42

Funding for SMC becomes uncertain from 2020. Malaria Consortium understands that the Global Fund and PMI are likely to maintain their 2018 support through 2020, but it is unclear whether the World Bank will do so.43

Major funders in the past include:

  • UNITAID provided an initial $68 million grant to scale up SMC between 2014 and 2017.44 Malaria Consortium told us that areas previously covered by UNITAID have been transitioned to funding from other sources.45
  • Development banks. The World Bank currently supports a significant proportion of SMC in Burkina Faso, Mali, and Niger.46 The World Bank’s support for SMC is structured as a loan rather than a grant, and renewal may depend on how well a given country has met the conditions of a loan. We have not included possible World Bank funding in 2020, as Malaria Consortium told us it is unclear whether the World Bank will renew its support.47 RBM told us and other media report that Nigeria is currently attempting to raise $300 million from the development banks for malaria control.48 If successful, this would substantially reduce the size of both the LLIN and SMC funding gaps between 2018-2020.
  • The Global Fund allocations have been extrapolated to 2020, as Malaria Consortium believes the Global Fund is likely to maintain its support.49
  • President’s Malaria Initiative (PMI) currently supports SMC activities in Senegal, Mali, and Burkina Faso. It will also be supporting activities in Benin, Cameroon, Guinea and Northern Nigeria, and is expected to start supporting SMC in Niger in 2019. We have included possible PMI funding in 2019 and 2020 in our expectations, because Malaria Consortium told us it is likely to continue.50
  • GiveWell / Good Ventures. Malaria Consortium is one of our top charities. In Giving Season 2017, GiveWell recommended Good Ventures disburse $27.9 million to Malaria Consortium to work in Burkina Faso, Nigeria and Chad in 2018 and 2019. We have not included possible GiveWell funding in 2020. Whether to grant additional funds to support additional work in 2020 will depend on our evaluation of Malaria Consortium’s SMC program relative to competing priorities.
  • Department for International Development (DfID). Malaria Consortium understands that DfID is planning to fund SMC in four (out of 227 eligible) districts in Nigeria in 2018.51 It is possible that DfID could provide additional support in the future to help close the funding gap.

Sources

Document Source
Aidspan - Global Fund provides update on incentive funding awarded to Nigeria and India, 23 October 2017 Source (archive)
Al Jazeera article, 21 February 2018 Source (archive)
Alliance for Malaria Prevention 2017 Q3 Net Mapping Project Unpublished
Country and Regional Support Partner Committee (CRSPC) Malaria Gap Analysis - Updated April 2018 Source (archive)
Devtracker - UK investment in the Global Fund, 2016-2019 Source (archive)
DfID - Nigeria country profile, 2017 Source (archive)
DfID - Where we work, 11 August 2017 Source (archive)
DfID press release, 25 January 2016 Source (archive)
GiveWell's AMF cost per net analysis, 2017 Source
GiveWell's LLIN funding gaps analysis, April 2018 Source
GiveWell's non-verbatim summary of a conversation with Diego Moroso, April 23, 2018 Source
GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, April 25, 2018 Source
GiveWell's SMC funding gaps analysis, April 2018 Source
GiveWell’s top charity cost-effectiveness analysis, May 3rd 2018 Source
Unitaid - Seasonal malaria chemoprevention for children in the Sahel Source (archive)
Vanguard article, 23 April 2018 Source (archive)
WHO - DRC country profile Source (archive)
WHO - Nigeria country profile Source (archive)
WHO - World Malaria Report 2017 Source (archive)