Note: This page summarizes the rationale behind a GiveWell grant to the WHO Malaria Guidelines Development Group (GDG). WHO staff reviewed this page prior to publication.
In a nutshell
In February 2025, GiveWell recommended a $416,292 grant to the World Health Organization's Malaria Guidelines Development Group (GDG) to fund evidence reviews and updates of guidelines for two malaria programs: single low-dose primaquine and intermittent preventive treatment in pregnancy (IPTp) for HIV-positive women (more). The GDG is responsible for reviewing the evidence and formulating WHO recommendations that shape treatment and prevention policies across many countries. (more)
This grant will involve paying for WHO staff and external researcher time to review the latest evidence using the systematic review and the GRADE framework to come to WHO global recommendations on medicines for malaria treatment or prevention.
We recommended this grant because: (more)
- We think the WHO recommendations are very influential in informing the national malaria treatment policies of National Malaria Control Programs (NMCPs)
- Without our funding, we think it’s likely these evidence reviews wouldn’t happen. We think enabling and expediting these reviews could be very cost-effective, given the scope of national treatment guidelines that WHO guidelines influence and allowing guidelines to be updated once the latest evidence is reviewed.
Important reservations about this grant include: (more)
- We chose to fund evidence reviews in these two areas because the WHO flagged them to us as high priority, which external experts we consulted concurred. However, we didn’t do a full landscaping of all interventions we could have funded evidence reviews for, and it’s possible if we’d done this we would have recommended funding reviews for other programs
- It’s possible NMCPs don’t adopt new policies in these areas even after the guidelines are updated. For example, funding constraints could prevent the adoption of WHO-recommended programs in some countries
Published: May 2025
The organization
The World Health Organization (WHO) is responsible for establishing global guidelines for different malaria treatment and prevention strategies.1 These recommendations are published on the WHO website, and are disseminated through multiple activities (e.g. official dissemination memos through WHO country offices, MagicApp platform, hosting workshops with NMCPs to discuss the latest guidance).2
The intervention
This grant focuses on funding evidence reviews and guideline updates for two specific malaria programs:
- Single low-dose primaquine (SLD): A drug used to reduce transmissibility of P. falciparum malaria, particularly in areas at risk of drug resistance. Current guidelines recommend its use only in low transmission settings,3 but new evidence suggests potential benefits in other contexts.4
- IPTp for HIV-positive pregnant women: While sulfadoxine-pyrimethamine (SP) is the standard drug for malaria prevention in pregnancy, HIV-positive women cannot take SP due to interactions with other medications.5 Recent evidence suggests alternative treatments may be both safe and effective for this population.6
The WHO guidelines development process involves evaluating the quality, safety, and efficacy of these treatments through systematic evidence reviews.7 Many countries look to WHO guidelines when developing their national malaria policies,8 making this process an important step in expanding access to effective treatments.
The grant
Budget
The total grant amount is $416,292, allocated as follows:9
| SLD primaquine | IPTp in HIV+ women | |
|---|---|---|
| WHO staff time | 134,200 | 139,200 |
| External researcher time | 30,000 | 25,000 |
| Dissemination | 20,000 | 20,000 |
| WHO overheard (13%) | 23,946 | 23,946 |
| Sub-total | 208,146 | 208,146 |
| Total | 416,292 | |
Grant activities
This grant will enable the WHO Global Malaria Programme to:10
- Engage external expert researchers to evaluate the evidence. This will include those that have conducted the latest research on the interventions and independent experts in the specific technical area.
- Maintain salary support for members of the WHO GDG. The salary support from this grant is earmarked for people that will be working specifically on these guidelines reviews.
- Disseminate updated guidelines to national malaria control programs through multiple channels including in-country workshops.
The case for the grant
We recommended this grant based on several considerations:
- WHO guidelines substantially influence national malaria policies. Based on conversations with several malaria control experts, we believe that the majority of LMIC countries wait for WHO normative updated guidance before formulating new malaria policies. This influence extends to major funding bodies like the Global Fund and USAID/PMI, which look to WHO guidance for technical decision-making and funding disbursements.
- Current evidence suggests meaningful gaps between existing guidelines and optimal treatment approaches:
- For SLD primaquine: The 2015 guidelines recommend its use only in low transmission settings, primarily as part of elimination strategies.11 However, growing concerns about resistance to artemisinin-based combination therapies (ACTs) – the main drugs used for malaria treatment – suggest potential benefits of broader use, including in areas not close to elimination.12
- For IPTp in HIV-positive women: Current guidelines don't provide recommendations for HIV-positive women who cannot take the standard intermittent preventive treatment with SP .13 Recent evidence, including a 2025 systematic review, indicates that alternative treatments like dihydroartemisinin-piperaquine are both safe and effective for this population.14
- Expediting guidelines could plausibly be above our cost-effectiveness bar. The WHO told us that without our support, these guidelines reviews would likely not happen until 2028-2030.15 While we have some uncertainty about whether other funders would fill this gap or how much of a delay this would cause, we think it’s plausible that this grant could speed up the generation of these guidelines by ~3 years. Based on some threshold back-of-the-envelope-calculations, we think it’s plausible that expediting these guidelines reviews by 3 years could be more cost-effective than our marginal funding opportunity.16 These calculations are very rough; we haven’t interrogated the assumptions that went into these calculations in depth and don’t put a lot of weight on these specific figures.
- The WHO faces funding constraints that could delay these updates. Both the Gates Foundation and Unitaid have reduced their support for the GMP 2025-2027 work plan, leaving many planned activities unfunded.17 The US government announced it would withdraw its support for the WHO in January 2025,18 which we expect to cause general funding pressure. This increases our confidence that these guidelines reviews would be delayed in the absence of our funding.
- External experts we spoke to recommended we make this grant. We spoke to external malaria experts at the Worldwide Antimalarial Resistance Network, Malaria Consortium, Gates Foundation, and the University of Oxford. These experts generally corroborated the WHO’s claim that these programs were high priority to review, and that these reviews were unlikely to happen in 2025-27 without additional funding.
Risks and reservations
Our main reservations about this grant are:
- Potential “funging” of other donors. While we think it’s unlikely, we think it’s possible that had we not made this grant, another funder would have stepped in to fund these guideline reviews, which would decrease the counterfactual impact of this grant.
- Lack of landscaping exercise. We considered guidelines reviews for these two programs because they were recommended by the WHO19 and other experts we consulted, but we did not do a full ‘landscaping’ of whether funding other evidence reviews could be more impactful. It’s possible if we’d done this we would have recommended funding other programs.
- Uncertainty about government adoption. Even with updated WHO guidelines, countries may not implement the new recommendations. This will probably be affected by the broader funding landscape for malaria programs, which at the time of writing this grant page we feel highly uncertain about, given US funding withdrawal from malaria programming activities.
Plans for follow-up
We are planning very limited follow-up for this grant, including:
- Following whether the WHO releases updated guidelines as planned (Q1 2026)
- Whether national malaria policy changes in light of these guidelines
We plan to conduct this follow-up primarily through conversations with the WHO and malaria control experts.
Internal forecasts
| Confidence | Prediction | By time | Resolution |
|---|---|---|---|
| 80% | WHO updates guidelines for both SLD primaquine and IPTp in HIV+ pregnant women by the end of 2025 | Mar 2026 | - |
| 90% | WHO updates guidelines for at least one of SLD primaquine or IPTp in HIV+ pregnant women by the end of 2025 | Mar 2026 | - |
Our process
We conducted this as a relatively light-touch investigation, involving:
- Conversations with key stakeholders, including the WHO GDG leadership team, WHO Foundation representatives, and external experts.
- Development of a rough threshold BOTEC for both program areas, a light review of recent systematic reviews and evidence updates, and an assessment of WHO's funding situation and potential funging risks
Sources
- 1
"The GDGs - independent external experts - are responsible for the development of the evidence-based recommendations contained in the Guidelines." The World Health Organization, WHO guidelines for Malaria, 2024, p. 247
- 2
- "As the primary developer of global norms and standards for malaria, the Programme will play an important role in developing dissemination products that enable the implementation of published guidance…the Global Malaria Programme will develop and refine implementation guidance, including how-to manuals, field guides, operational guidelines and technical checklists to guide ministries of health, health practitioners, community health workers, civil society organizations and other partners in implementing malaria guidelines." The World Health Organization, Global Malaria Programme operational strategy 2024–2030, p. 30
- "The Global Malaria Programme will provide targeted training workshops on elimination strategies, surveillance and interventions to accelerate elimination." The World Health Organization, Global Malaria Programme operational strategy 2024–2030, p. 56
- 3
“WHO recommendation... In low transmission areas, give a single dose of 0.25 mg/kg primaquine with ACT to patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and breastfeeding women of infants aged < 6 months) to reduce transmission. Testing for G6PD deficiency is not required.” The World Health Organization, Policy brief on single-dose primaquine, 2015, p. 2
- 4
See, for example, this 2022 article (Taylor et al., 2022) which concludes that, “Gametocytocidal, age-dosed, single low-dose primaquine was well tolerated in children from Uganda and the Democratic Republic of the Congo who were infected with P falciparum, and the safety profile of this treatment was similar to that of the placebo. These data support the wider implementation of single low-dose primaquine in Africa.”
- 5
For more on IPTp for HIV-positive pregnant women, see this WHO systematic review summary: "SP cannot be co-administered with co-trimoxazole, a drug that is commonly used for infection prophylaxis in HIV-infected pregnant women."
- 6
See, for example, this 2025 systematic review (Tarig et al., 2025) that shows that IPTp with DP is well-tolerated in HIV+ women and is effective in combating malaria outcomes: "Intermittent preventive treatment with dihydroartemisinin-piperaquine (IPT-DP) during pregnancy significantly reduces the risk of malaria-related outcomes… it does not significantly impact adverse pregnancy outcomes such as low birth weight, foetal loss, or stillbirth. However, DP increases the risk of miscarriage."
- 7
"As well as providing expert opinion, the specific tasks of the GDGs included:...interpreting the evidence, considering different factors included in the EtD framework and judging how these factors may impact the direction and strength of a recommendation, particularly in terms of the overall balance of benefits and harms." The World Health Organization, WHO guidelines for Malaria, 2024, p. 247-248
- 8
This understanding is based on GiveWell’s previous work in the malaria space and discussions with external experts.
- 9
Andrea Bosman, the World Health Organization, email to GiveWell, January 29, 2025 (unpublished).
- 10
"The grant would fund the conduct of systematic reviews, the convening of the Guideline Development Group (GDG), the production and dissemination of the guidelines." The World Health Organization, GiveWell questions for WHO, 2024 (unpublished).
- 11
“WHO recommendation... In low transmission areas, give a single dose of 0.25 mg/kg primaquine with ACT to patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and breastfeeding women of infants aged < 6 months) to reduce transmission. Testing for G6PD deficiency is not required.” The World Health Organization, Policy brief on single-dose primaquine, 2015, p. 2
- 12
See, for example, this 2022 article (Taylor et al., 2022) which concludes that, “Gametocytocidal, age-dosed, single low-dose primaquine was well tolerated in children from Uganda and the Democratic Republic of the Congo who were infected with P falciparum, and the safety profile of this treatment was similar to that of the placebo. These data support the wider implementation of single low-dose primaquine in Africa.”
- 13
For more on IPTp for HIV-positive pregnant women, see this WHO systematic review summary: "SP cannot be co-administered with co-trimoxazole, a drug that is commonly used for infection prophylaxis in HIV-infected pregnant women."
- 14
See, for example, this 2025 systematic review (Tarig et al., 2025) that shows that IPTp with DP is well-tolerated in HIV+ women and is effective in combating malaria outcomes
- 15
The World Health Organization, GiveWell questions for WHO, 2024 (unpublished).
- 16
Our threshold back-of-the-envelope calculations can be found here. Note that these calculations are rough, and we don't put a lot of weight on these specific figures.
- 17
The World Health Organization, conversation with GiveWell, February 5, 2025 (unpublished).
- 18
"Sec. 2. Actions. (a) The United States intends to withdraw from the WHO." The White House, Withdrawing the United States from the World Health Organization, January 2025.
- 19
"If we need to rank them in terms of timeliness of the reviews and urgency, the priority may be placed on IPTp and SLD PQ." The World Health Organization, GiveWell questions for WHO, 2024 (unpublished).