Against Malaria Foundation — Support for ITN Campaigns in DRC (June 2024)

Note: This page summarizes the rationale behind a GiveWell-recommended grant to the Against Malaria Foundation (AMF). The information below reflects our views at the time we made the grant decision and does not reflect any information we have learned or work we have done since that point. AMF staff reviewed this page prior to publication.

Published: June 2025

Summary

Background

Malaria is a disease caused by Plasmodium parasites which are transmitted to people through the bites of infected mosquitoes. Symptomatic cases involve flu-like symptoms including fever, which can progress to severe illness or death. Distribution of insecticide-treated nets (ITNs) is one of two main WHO-recommended strategies for malaria vector control. Our full research report on ITNs is available here.

In June 2024, GiveWell recommended a $41 million grant to the Against Malaria Foundation (AMF) to support the delivery of ITNs in the Democratic Republic of the Congo (DRC) in 2025 and 2026. AMF is one of GiveWell's Top Charities.

What we think this grant will do

This grant will fund AMF to procure and monitor the distribution of ITNs in the DRC. We expect this grant to result in an additional ~7.9 million ITNs being procured for DRC campaigns. AMF will lead the net selection and procurement process and oversee campaign monitoring (including a series of checks and surveys prior to, during, and after net distribution). It will also work with local and international partners on logistics, staff training, campaign planning, and community outreach. We expect these campaigns will target relatively high burden geographies which would otherwise not be served by mass distribution campaigns, although we are uncertain as to the exact geographies this grant will fund.

We think this grant will increase the number of people protected against malaria by ITNs by roughly 11 million, resulting in an estimated 6,600 deaths averted among children under the age of five. We also expected the grant to avert the deaths of approximately 2,000 older children and adults, and to increase the incomes of protected children later in life.

Why we made this grant

Our best estimate is that this grant will be approximately 11x as cost-effective as unconditional cash transfers (GiveWell’s benchmark for comparing different programs). At the time of writing this page, GiveWell’s Top Charity funding bar is to fund grants that we estimate to be 8x or more as cost-effective as cash transfers.

In simple terms, we believe this grant will be cost-effective because:

• It is relatively cheap to reach people with ITNs. ITNs are relatively inexpensive to purchase (~$2.38 each in the DRC) and deliver (~$3.102 each in the DRC).3 We estimate that 75% of delivered nets are used, that each net protects around two people on average, and that net use among children under five is 12% higher than for the overall population, resulting in a cost of $22 per child under 5 effectively reached by the intervention. (More)
• We expect that a large number of children will use nets distributed by campaigns. We estimate that this grant will enable AMF to reach approximately 1.9 million children under the age of 5 with a net. This is based on our estimate that 87% of targeted children will be reached with and make use of nets distributed by campaigns funded via this grant. (More)
• We think most people who access nets through campaigns would not otherwise have access to them. Our best guess is that ITN coverage in the absence of a mass campaign would likely be relatively low, around 15% of the under-5 population in the DRC. This translates to an estimate of 22% of reached children who would have used ITNs in the absence of a distribution, which enables us to estimate the additional children sleeping under an ITN as a result of the campaign. Because nets are routinely distributed at antenatal care and infant vaccination visits, we think nets from non-campaign sources are disproportionately likely to cover very young children (who are disproportionately likely to experience morbidity and mortality from malaria). To account for this, we apply a 15% downward adjustment to our estimate of young children covered as a result of the campaign. (More)
• We think that, on average, each ITN provides the equivalent of 1.5 years worth of full protection. We assume that the efficacy of delivered nets declines over time due to wear and tear or nets being taken down and no longer used. Our estimate of the effective protection provided by nets is informed by the rate of attrition in net use, the rate of physical decay of nets, and the rate of chemical (insecticide) decay of nets. (More)
• We believe that malaria is a significant cause of child mortality in the areas of the DRC this grant is likely to fund. We estimate that the annual malaria mortality rate among 1-59-month-olds in the DRC was 0.34% as of 2021. We make a downward adjustment to account for our expectation that this grant will fund areas of the DRC with malaria burden that is lower than the national average. We also make an upward adjustment to account for our expectation that the grant will avert additional deaths that are indirectly caused by malaria.4 Finally, because we are trying to model mortality in the absence of nets, we applied an adjustment to account for our estimate that mortality in the underlying burden data is 36% lower than it would be without ITNs. Altogether, this leads us to estimate that the under-five mortality rate attributable to malaria in the areas that this grant will likely fund is 0.55%. (More)
• ITNs provide significant protection against malaria. Our impression is that there is widespread agreement in the global health community that ITNs are an important malaria prevention tool. We think nets are effective at reducing child mortality related to malaria (~56% reduction in the DRC). For more information about the impact of ITNs on malaria, see our ITNs intervention report.
• ITNs probably provide significant benefits beyond averting under-5 mortality. In addition to the primary benefit of averting the deaths of young children, we expect this grant to avert the deaths of approximately 2,000 older children and adults. We also think that by averting malaria during a sensitive period of childhood development, ITNs could lead to income increases later in life. We estimate that around 34% of the total benefits of this grant come from increased income. (More)

A sketch of our cost-effectiveness analysis is below.

What we are estimating	Best guess (rounded)	Confidence intervals (25th-75th percentile)	Implied cost-effectiveness
Grant size	$41,000,000
Cost per person under age five reached	$21.92	$16.44 - $27.40	14x - 9x
Number of people under age five reached	~1,870,000
Proportion of reached children who would have slept under ITNs in the absence of the program	22%	15% - 30%	12x - 10x
Additional children sleeping under ITNs as a result of the program	~1,450,000
Years of coverage provided by ITNs	1.5	1.0 - 1.9	8x - 14x
Malaria-attributable mortality rate among people under age five	0.55%	0.22% - 0.88%	4x - 17x
Effect of ITN distributions on deaths related to malaria	56%	45% - 67%	9x - 13x
Number of deaths averted among people under age five	~6,500
Initial cost-effectiveness estimate
Cost per under-five death averted (before adjustments)	~$6,200
Moral weight of averting the death of a person under age five	116
Initial cost-effectiveness estimate (child mortality only)	6x
Summary of primary benefits (% of modeled benefits)
Reduced child mortality	55%
Reduced mortality among older children and adults	11%
Income increases in later life	34%
Additional adjustments
Adjustment for additional program benefits and downsides	53%	42% - 63%	10x - 11x
Adjustment for grantee-level factors	-20%	(-40%) - 0%	8x - 13x
Adjustment for diverting other actors' spending into ITNs ("leverage")	-1%
Adjustment for diverting other actors' spending away from ITNs ("funging")	-12%	(-22%) - (-2%)	9x - 12x
Overall cost-effectiveness (in multiples of cash transfers)	11x
Cost per life saved	~$6,800

You can see the simple cost-effectiveness analysis for this grant here and the full version here.

Main reservations

• We are particularly uncertain about the level of malaria burden in the parts of the DRC where this grant will fund distribution campaigns. We have concerns about the accuracy of the IHME data that we rely on to inform our estimates of the national malaria burden in the DRC. If the IHME data is inaccurate, it could lead us to overestimate or underestimate the cost-effectiveness of this grant. On the other hand, we’re also uncertain about how malaria burden in the areas this grant will fund compares to the national average, which could be leading us to either overestimate or underestimate the cost-effectiveness of the grant. Finally, we also have limited confidence in a very rough subjective adjustment that we make in our CEA to account for what malaria mortality burden might be in a hypothetical scenario where no one in the DRC used ITNs. Altogether, we think it is somewhat more likely that we are underestimating malaria burden than overestimating it. (More)
• We are uncertain how long nets will last and be effective in the DRC. We have substantial uncertainty about net durability in general, and some additional uncertainty about durability in the DRC specifically. It’s possible that we are overestimating net durability. Our uncertainty stems from the fact that a) net durability data in general is sparse and unlikely to be representative of the whole country where it is gathered; b) we are unsure how much weight to put on limited data coming directly from the DRC versus on data from other countries; and c) we are unsure how the durability of next-generation nets (which are being distributed more often as a way to address insecticide resistance) compares to other types of nets we’ve previously studied. (More)
• We are uncertain about how many children would be protected by nets in the absence of a mass-distribution campaign. We attempted to estimate the percentage of children under five that would have slept under an ITN in the absence of this program and arrived at a best guess estimate of 22%. We make an additional adjustment to account for our expectation that routine distribution channels (predominantly antenatal care and infant vaccination visits) disproportionately cover the very youngest children who are also at highest risk of malaria mortality. We estimate that this reduces child deaths averted due to this grant by 15%.
• We have some uncertainty about the effect of ITNs on mortality. We make the assumption that there is a 1:1 ratio between reduced malaria cases and reduced malaria deaths, but there is limited evidence to support this assumption. This uncertainty is not specific to the DRC. For more information about this uncertainty, see the relevant section of our ITN intervention report.
• We are somewhat concerned that there may be significant delays and unrecorded net loss during net delivery campaigns due to operational challenges in the DRC and limitations to last-mile monitoring. The DRC is a challenging operating environment; poor infrastructure can lead to delays in net distributions while issues including transportation difficulties and corruption may lead to net loss that could go unrecorded. The environmental challenges are compounded by the fact that there are meaningful methodological limitations to the system of backchecks currently used by AMF to confirm that nets marked as distributed were actually distributed. To account for this issue, we’ve added an additional net loss adjustment on top of the net loss recorded by AMF, and we are working with AMF to design an improved system of backchecks that will be introduced during this implementation period. If implemented well, we think that this new approach will meaningfully reduce our uncertainty. (More)

Basics

What is the problem?

Malaria is caused by parasites that are transmitted to people through the bites of infected mosquitoes.5 Malaria can result in life-threatening symptoms and poses a significant health risk to children under five years old and others with low immunity.6

What is the program?

An insecticide-treated net (ITN) is a net which has been treated with insecticide to kill and repel the mosquitoes that carry malaria.7 Long-lasting insecticidal nets (LLINs) are factory-treated ITNs made of material into which insecticide is incorporated or bound around the fibers.8 These nets are typically hung over beds to provide protection during sleep.

The World Health Organization (WHO) recommends ITNs, particularly LLINs, as a main strategy for malaria vector control.9 ITNs are primarily distributed via mass distribution campaigns, in which nets are delivered door-to-door to households or through central distribution sites in a community. Based on current WHO guidance,10 most countries aim to deliver these campaigns every 36 months. For more information about malaria and ITN campaigns, see our intervention report.

In the DRC, ITN campaigns occur at the province level on a rolling basis. DRC's Programme National de Lutte Contre le Paludisme (PNLP), or national malaria control program, believes that LLINs should be delivered to each province every 30 months, even more frequently than the WHO-recommended 36-month interval. This is based on evidence that ITN durability is worse in the DRC than in other locations.11 While we’re unsure exactly which locations in the DRC will receive net distribution campaigns as a result of this funding, our best guess is that the funding will largely be used to cover health zones that the government has categorized as third level priorities, which represent the most vulnerable areas that are not yet covered by currently available funding.12

Planned activities

This grant will fund AMF to procure ITNs for mass distribution campaigns in several provinces in the DRC and to conduct monitoring of the shipments and distribution. Specific activities that AMF will carry out to implement this campaign include:

• Purchase of ITNs. AMF negotiates costs directly with net manufacturers.13
• Calls with key actors involved with net shipments. AMF holds weekly calls with actors involved in the shipment of nets from the point of manufacture to delivery at the level of the health area (the smallest administrative unit in the DRC).14 Such actors include the IDA Foundation, which manages international shipment, and SANRU, which manages local transport. The purpose of these calls is to monitor progress and resolve challenges.
• Reviewing data on net shipments. AMF reviews monitoring data related to net shipment (e.g., "bills of lading" for international shipment and "waybills" for domestic transport) to identify sources of net loss.15 AMF has a particular incentive to thoroughly monitor nets through logistics and transport because nets that it procures are insured by the Global Fund against loss, damage, and theft during this process, and AMF actively submits and tracks insurance claims.16
• Reviewing net distribution data. AMF reviews and compiles digitally-collected data from household registration and net distribution.
• Contracts for additional monitoring. AMF contracts a local firm to conduct an audit of survey data by visiting a sample of households to confirm that distribution occurred as reported.17 AMF also contracts an independent monitor to attend stakeholder meetings, flag challenges to AMF, and shadow training, planning, and distributions of nets at 40 villages per province and to shadow backchecks at 10 villages per province.18
• Collaboration with key partners. AMF works with many local and international partners in supporting logistics, staff training, campaign planning, and community outreach for net campaigns. This includes the DRC’s malaria control program, which plans and implements distribution campaigns. AMF will also collaborate with the Global Fund, which will finance the distribution of the nets.19 (This grant does not cover the cost of net distribution.)

We’re unsure about some of the details of how this funding will be used (namely, which geographic areas in the DRC this grant will cover). Our best guess is that the DRC will select locations for net distributions via a mix of health zone and province-level stratification,20 and that this grant would likely cover the most vulnerable areas that are not yet covered by available funding.

We believe that AMF’s track record makes it likely that campaigns are carried out successfully, which would lead to higher coverage (and higher usage) of ITNs than would be the case without our grant.

The case for the grant

We are recommending this grant because we expect it to be a cost-effective use of funding. Our best guess is that this grant will be approximately 11 times as cost-effective as unconditional cash transfers (GiveWell’s benchmark for comparing different programs), which is above our current bar for directing funding.21 The main benefit that we expect from this grant is reduced child mortality. Our best guess is that the grant will avert ~6,500 child deaths from malaria

In our separate report on nets, we explain why we think nets are generally a cost-effective intervention. The specific factors driving high cost-effectiveness in this particular grant are discussed below.

Low cost of nets

ITNs are relatively inexpensive to purchase and deliver (read more in our intervention report on mass distribution of ITNs). While costs in the DRC specifically are higher than we’ve estimated for other countries in the past, they remain cheap overall.22 We estimate that in the DRC specifically, nets cost ~$2.38 each to purchase and ~$3.10 to deliver.23 We also estimate that 75% of delivered nets are used, that each net protects around two people on average, and that net use among children under five is 12% higher than for the overall population, resulting in a cost of $21.92 per child under 5 effectively reached by the intervention. We estimate that the cost per additional child under five reached (i.e., children who would not use ITNs in the absence of the campaigns funded by this grant) is approximately $28.24

High intervention coverage

We think that the coverage achieved for children under age 5 by net campaigns in the DRC tends to be higher on average than in other countries. We model coverage using three usage parameters:

1. The proportion of nets that actually get used
   
   1. Multiple data sources have suggested that net usage is much higher in the DRC than in other countries,25 but we’re unsure how much weight to put on that evidence. We regress our country-specific estimates 50% towards the cross-country mean to reflect our uncertainty. For the DRC, we estimate that 75% of ITNs distributed get used.
2. The number of people who sleep under each net
   
   1. We estimate that an average of 1.8 people sleep under each net.
3. An adjustment for net use rates being higher among young children
   
   1. We estimate that net use rates are 12% higher among children under age 5 than among the general population based on data from national surveys (Demographic and Health Surveys/Malaria Indicator Surveys [DHS/MIS] and UNICEF Multiple Indicator Cluster Surveys [MICS]).

We’ve estimated these parameters by triangulating AMF’s post-distribution monitoring (PDM) data with national survey data,26 though we have uncertainties about the reliability of AMF's PDM data and about the applicability of national survey data to the context of a future campaign. Altogether, the above parameters lead us to estimate that 87% of targeted children under 5 will sleep under ITNs distributed through the campaigns funded by this grant.

Counterfactual impact

In order to estimate the counterfactual impact of our funding, our cost-effectiveness analyses for net distribution campaigns estimate the number or percentage of children who would have used ITNs in the absence of a particular campaign as well as the likelihood that a campaign would happen in the absence of GiveWell funding.

How many children would have used ITNs in the absence of these campaigns

We attempt to estimate the proportion of children under 5 in the DRC that would be covered by ITNs in the absence of these campaigns. We do this by estimating the proportion that would be covered by nets received from antenatal care (ANC) and Expanded Programme on Immunization (EPI) visits (routine channels) as well as other sources such as the private market. Our best guess for the effective ITN coverage rate for children under 5 in the absence of an ITN campaign is 15%,27 though this is a very rough estimate. This is based on the following factors:

• The proportion of parents/infants that receive ITNs at an ANC or EPI visit. We estimate that 53% of infants in targeted areas’ mothers receive an ITN at an ANC visit while 35% of infants in targeted areas receive an ITN at an EPI visit. These estimates are based on DHS data, MIS data, WHO and UNICEF estimates of immunization coverage, as well as our subjective assumptions.
• The proportion of those nets that a child or infant will sleep under. We estimate this value at 75%, based on DHS and MICS national survey data and AMF's post-distribution monitoring.
• The amount of overlap between infants covered via ITNs distributed at ANC visits versus EPI visits. We estimate this value at 77%, based on our estimate of the percentage of children who received an ITN at an EPI visit whose mothers had also received an ITN at an ANC visit, assuming independence between ANC and EPI coverage.
• How much Global Fund and PMI funding is available to supply ITNs for routine distribution. We subjectively guess that there is enough funding to cover routine coverage for around 2.2 of the 3 years following a distribution. Therefore, we include a -26% downward adjustment for funding gaps for routine ITN distribution.
• The proportion of children under 5 who would sleep under ITNs from sources other than routine channels in the absence of a distribution. We estimate this value at 10% based on sources including administrative data, survey results in the DRC and sub-Saharan Africa more broadly, and assumptions made in academic studies.

We assume that receiving nets from ANC or EPI and receiving nets from campaigns are roughly independent, meaning we would expect some double treatment, but not very much.28 We could be underestimating double treatment if people who get routine nets are much more likely to get a campaign net as well, perhaps because they’re easier to reach, but accounting for this would have only a small effect on our cost-effectiveness estimate for the grant.

We also apply a separate 15% downward adjustment to the number of under-5 deaths averted by the grant to account for our expectation that ITNs distributed at ANC and EPI visits are disproportionately likely to protect the very youngest children in the under-five cohort, who are at highest risk of malaria mortality.29

Likelihood these campaigns would occur without GiveWell funding

Our impression is that it is very unlikely that another funder would fill this gap if we didn’t make this grant. Our sense from conversations with multiple stakeholders is that, absent this grant, the national malaria control program in the DRC would need to cut areas from its 2024-2026 net distribution plans.30

Our impression that another funder would not fill this gap is also based on the fact that we are funding a small portion of a very large apparent gap in ITN funding in the DRC which we’d expect other funders to have already filled if they were able, especially given our understanding that this funding opportunity is particularly time-sensitive.31

That said, we’re very uncertain about the long run impact of our giving on other actors’ plans in the DRC and the nets space more broadly. We think it’s highly likely that other actors are adjusting their plans over time to account for GiveWell spending on nets. We did not engage deeply with this question for this investigation.

Net retention and durability

We assume that the efficacy of delivered nets declines over time due to wear and tear or nets being taken down and no longer used. The national malaria control program in the DRC aims to conduct ITN campaigns on a rolling 30-month cycle, though in practice the interval between campaigns has often been closer to 36 months (3 years) or even longer. We think that ITNs that remain in use continue to provide considerable protection over that 2.5 to 3-year time period, but some of their efficacy is lost. We estimate that the average net provides the equivalent of 1.5 years of full protection. We have substantial uncertainties about this estimate, but believe that this grant remains above our 8x funding bar for top charities even under pessimistic assumptions. (more)

For this grant, we investigated three factors informing our estimate of how long nets provide effective protection:

• attrition (nets are lost, thrown away, or given away)
  • We pooled estimates from trials of a variety of net types that we think broadly reflect the mix of nets that are being distributed in modern ITN campaigns.32 We estimate that 93%, 71%, and 54% of distributed nets remain in use at the midpoint of the first, second, and third year after an ITN distribution.
• physical decay (nets become damaged)
  • We pooled estimates from durability trials of a variety of net types to estimate the reduction in protection provided by nets due to net damage. We estimate that remaining nets provide 84%, 66%, and 52% of their optimal physical protection at one, two, and three years following an ITN distribution, respectively. For years two and three, these are slightly lower than our estimates of the same values for other countries.33 Based on data from AMF and PMI, we expect nets to be less durable on average in the DRC than in other sub-Saharan countries, but we’re very uncertain about the magnitude of the difference. One longitudinal study in two districts of the DRC (as well as modeling data based on cross-sectional surveys) suggests lower net durability in some parts of the DRC than the average across other countries.34 However, this longitudinal study had a small sample size, is unlikely to be nationally representative of the DRC (given it was only conducted in two districts), and is fairly outdated (the study was conducted between 2016 and 2019). Therefore, we placed 50% weight on the DRC study and 50% weight on durability studies from other sub-Saharan countries to arrive at our estimate of the reduction in physical protection over time.
• chemical decay (the amount of insecticide on the nets decays)
  • AMF plans to buy a combination of chlorfenapyr-pyrethroid (CFP) and pyrethroid-piperonyl butoxide (PBO) nets for these campaigns.35 We think PBO nets experience particularly severe insecticide washout over time, and adjust their efficacy downward.

High child mortality

We believe that malaria is a significant cause of child mortality in the areas of the DRC this grant is likely to fund. Based on population and malaria-specific mortality estimates from the Institute for Health Metrics and Evaluation’s Global Burden of Disease (GBD) model, we estimate that the annual malaria mortality rate among 1-59-month-olds in the DRC was 0.34% as of 2021. We make a downward adjustment of 40% to account for our expectation that this grant will fund areas of the DRC with malaria burden that is lower than the national average. We also make an upward adjustment to account for our expectation that the grant will avert additional deaths that are indirectly caused by malaria.36 Finally, because GBD burden estimates are rooted in data from populations where some amount of ITNs were in use, we make a very rough subjective adjustment to estimate malaria mortality burden in a hypothetical scenario where no one in the DRC used ITNs. Altogether, this leads us to estimate that the under-five mortality rate attributable to malaria in the areas that this grant will likely fund is 0.55%. These estimates align with the perception of malaria as a major health issue in the DRC, but we continue to have significant uncertainty about them (more below).

Additional benefits

In addition to the primary benefit of averting the deaths of young children, we expect this grant to avert the deaths of approximately 2,000 older children and adults. These benefits account for 11% of the value of this grant.

We also think that by reducing the incidence of malaria among children under the age of 15 (a sensitive period of childhood development), ITNs could lead to income increases later in life. We estimate that around 34% of the total benefits of this grant come from increased income. This is based on two studies that find historical malaria eradication campaigns led to long-term increases in income.37 We use a combined estimate from these studies and cross reference it against other child health programs that we think lead to income effects (e.g., deworming, iron fortification).

Risks and reservations

Malaria burden

We have substantial uncertainty about the level of burden of malaria in the areas this grant would fund. The reasons for our uncertainty are as follows:

• We have concerns about the accuracy of IHME's estimate of the national malaria burden in the DRC.
  • We base our national malaria mortality estimates on modeled estimates from IHME’s GBD 2021. We are very uncertain about IHME’s estimate because a) we don't understand their model very well, b) we’ve heard from various experts and modelers that there are reasons to doubt the accuracy of these estimates, and c) a rough and uncertain analysis suggested GBD 2019 estimates of malaria mortality in the DRC may have been somewhat lower than estimates from the Malaria Atlas Project (MAP) and the United Nations Inter-agency Group for Child Mortality Estimation for those years.38
  • Our best guess (after all adjustments and accounting for subnational targeting) is that the malaria mortality rate among 1-59 month olds in the regions in the DRC we expect this grant to target is 0.55%. Our 25% and 75% confidence intervals for this value are +/-60%, corresponding to malaria mortality rates of 0.22% and 0.88%. This suggests plausible cost-effectiveness ranges for this grant of 4-17x. We think further work and communication with IHME and MAP could decrease our uncertainty about this parameter somewhat.
• We have concerns about the quality of the data on subnational malaria burden in the DRC.
  • We aren’t certain what specific geographic regions of the DRC will receive ITN distribution campaigns through this grant, but our best guess is that this funding will cover campaigns in regions of the DRC that have been designated as “lower-priority” by the government (more). We thus make adjustments in our CEA to account for the fact that we expect the burden in funded campaign areas to be lower than the national average.
  • We estimate that malaria mortality will be 40% lower than the national average in the areas funded by the grant, and that malaria incidence will be 25% lower. This is based on a pooled estimate using different data sources and accounting for different potential target areas.39
  • This adjustment is based on subnational burden data we received from AMF and triangulated against two other sources. We have significant concerns about the quality of this data, but it’s not clear to us whether the data might lead us to overestimate or underestimate cost-effectiveness for this grant. It’s possible that under-5 malaria mortality is much more similar across the country than the data suggests (transmission is high almost everywhere, which could lead to relatively even burden across the country); if that were the case, that would mean our cost-effectiveness estimate is too low. It’s also possible that there are actually large differences in malaria mortality across health zones, but these differences aren’t fully seen in the data because health zones designated as “lower-priority” (like those we expect this grant to fund) are recording deaths more accurately than high-priority health zones (possibly due to being better resourced); this would imply that our modeled cost-effectiveness estimate is too high.
• We have little confidence in the adjustments we make in our CEA to account for what malaria burden would be in the DRC if no ITNs were used.
  • GBD burden estimates are rooted in data from populations where some amount of ITNs were in use. We think IHME may even be making explicit modeling choices to account for expected net coverage, but we do not understand how this modeling works. To account for this, we make a very rough subjective adjustment to account for what malaria mortality burden might be in a hypothetical scenario where no one in the DRC used ITNs. This adjustment relies on coverage estimates from GBD that we also don't understand. We’ve made some efforts to resolve our questions via conversations with IHME and MAP, with limited success, so we remain very uncertain about this adjustment.

Altogether, we think it is somewhat more likely that we are underestimating malaria burden than overestimating it. Our learning from this grant won’t resolve our underlying uncertainties about malaria burden data, which are not specific to this grant.

Net durability in the DRC

We have substantial uncertainty about the durability of nets in the DRC. Our best guess is that the average net in the DRC provides the equivalent of 1.5 years of full protection (see above). However, our 25% and 75% confidence intervals for this value are +/-30% (which correspond to a cost-effectiveness range of 8-14x for this grant).

These large uncertainty intervals stem from our substantial uncertainty about the durability of nets in general (regardless of context),40 as well as our uncertainty about the durability of nets in the DRC specifically. The reasons for our uncertainty are as follows:

• Durability data is sparse and unlikely to be representative. Our estimates are based on longitudinal net durability studies largely carried out by PMI. These are relatively expensive to conduct, so they’re typically done with just a few hundred nets in 1-3 selected districts, and no more often than once every 5-10 years in any given country. We don’t know how representative these are for the country as a whole, nor do we know how applicable these results are across different brands of nets. Furthermore, our analysis of insecticide loss is based on a single study from Uganda, which means our estimates of insecticide durability are highly uncertain. This uncertainty could be causing us to either overestimate or underestimate net durability.
• We’re unsure how much weight to put on limited net durability data from the DRC. We have data from one longitudinal study in two districts of the DRC that suggests lower net durability in some parts of the DRC than the average across other countries. However, this study had a small sample size, is unlikely to be nationally representative of the DRC (given it was only conducted in two districts), and is fairly outdated (the study was conducted between 2016 and 2019). In our model, we place 50% weight on the DRC study and 50% weight on durability studies from other sub-Saharan countries to estimate the reduction in physical protection of nets in the DRC over time. We’re uncertain about these weights; it’s possible we should instead place full weight on the DRC study. This uncertainty could be causing us to overestimate net durability. However, even if we placed 100% weight on the DRC study, we would still estimate the cost-effectiveness of this grant to be above our bar for funding.
• We are unsure how the durability of next-generation nets compares to other types of nets. In the past, we've based our assumptions about net durability largely on durability trials of one brand of standard ITNs. However, insecticide resistance has intensified over time, causing mass-distribution campaigns to shift away from standard ITNs toward distributing more “next-generation nets” (nets that contain additives designed to mitigate insecticide resistance). As such, we've updated our net durability modeling to incorporate durability trials of a variety of net types and brands. The data suggests that next-generation nets experience physical decay at a slightly higher rate.41 If we only used data from next-generation nets to estimate durability, this would reduce our estimate of nets’ overall lifespan in the DRC by a small amount (2-3%). This uncertainty could be causing us to overestimate net durability. We have not yet conducted an in-depth investigation of insecticide durability in next-generation nets.
• We have not fully reviewed PDM data from AMF. We have not investigated AMF’s cross-sectional monitoring data to see if any of the above trends are confirmed by their survey findings. This could be causing us to either overestimate or underestimate net durability.

Overall, it seems more likely that we are overestimating net durability than underestimating it. We could learn more about this in the future by funding net durability studies.

Counterfactual coverage

We are quite uncertain about how many children would be protected by nets in the absence of a mass-distribution campaign. Most of the survey data we have on counterfactual coverage suggests that ITN coverage through non-campaign channels tends to be quite low in sub-Saharan Africa, but we have concerns about the age and validity of this data. Additionally, we are aware that approximately 32 million nets are being procured for distribution through routine channels (primarily ANC and EPI visits) in the DRC for this funding cycle.42 Given that the number of nets needed to achieve universal coverage in the DRC is 73 million,43 this implies that coverage nearly as high as 44% could be achieved by the routine distribution system alone.44

We attempted to resolve some of this uncertainty by estimating the proportion of reached children who would have slept under ITNs in the absence of the program and conducting a sensitivity analysis on this parameter. Our best guess is that 22% of children reached would have slept under an ITN in the absence of the program. Our 25% and 75% confidence intervals for this value range from 15% to 30%.

However, the routine distribution channels where people are most likely to obtain nets (antenatal care visits and infant vaccination visits) disproportionately cover the very youngest children who are also at highest risk of malaria mortality. (This would reduce the cost effectiveness of this grant because the additional children treated by the mass distribution campaign would be less likely on average to die from malaria.) Our best guess is that routine coverage skewing towards very young children reduces child deaths averted due to this grant by 15%, and we've added an adjustment to the CEA to reflect this. This is a new adjustment to our model which has not been vetted to the same degree as other aspects of our model, so it’s possible that we’ve introduced mistakes through its addition.

Effect of ITNs on mortality

We are reasonably confident that sleeping under a net reduces the rate of malaria cases by a significant amount. However, we’re less certain about our assumption that reductions in malaria incidence result in one-to-one reductions in malaria mortality. This is a longstanding uncertainty in our malaria CEAs and not something specific to this grant investigation. Our 25% and 75% confidence intervals for the effect of full ITN coverage on malaria mortality in the DRC are -20% and +20% of our best guess (56%). This suggests a potential range of cost-effectiveness for this grant of 9-13x. Read more in our intervention report on mass distribution of ITNs.

Net delays and loss

We are also concerned that contextual factors specific to the DRC could contribute to significant delays or large levels of net loss prior to and during distribution, and that these may not be fully accounted for in AMF’s coverage data. In particular, we are concerned about:

• Transportation infrastructure: We have heard from stakeholders that delays in net distributions due to poor transportation infrastructure (e.g. roads and bridges in poor condition, particularly during the rainy season) are common in the DRC. For example, during the previous net campaign in Kasaï-Oriental, there was an instance of a delay lasting roughly one year.45 Though we haven't heard of any specific instances of major net loss in the DRC, we think it’s plausible that transportation difficulties could lead to net loss and that this could go unrecorded. AMF has told us that they incorporate expected delays into their lead time for net procurement; though we don't expect this process to be perfectly calibrated, we believe it probably helps reduce the likelihood that target populations go very long stretches of time between net campaigns. We have not sought comprehensive data from AMF on delays for past DRC campaigns, which could be limiting our understanding of the problem.46
• Corruption: Corruption is widespread throughout the DRC. Based on what we've heard from stakeholders and what we know about the accountability mechanisms for net campaigns in the DRC, our best guess (with low to moderate confidence) is that corruption does not manifest in major loss of nets. We have heard from stakeholders that this may be because: 1) nets are bulkier than other health commodities and are therefore harder to steal; and, 2) there are many layers of supervision that could both act as a deterrent for engaging in fraud and as an enforcement mechanism for holding corrupt actors accountable.47 However, despite the large number of eyes on DRC campaigns, it's possible that the depth of supervision by each actor is limited, meaning that large-scale corruption could still go unnoticed.

Limitations of AMF’s monitoring to track net loss

AMF’s net loss monitoring occurs at two different stages: transport and distribution. At both stages, there are limitations to AMF’s ability to fully account for net loss.

• Transport: We believe that AMF’s monitoring system to prevent large-scale net loss during transport is fairly comprehensive. However, AMF records less than 1% of all nets that it has procured for distribution in the DRC over the past four years as lost, stolen, or damaged during transit, which intuitively seems lower than we would expect. Our best guess is that the number of nets reported as distributed is biased upwards by ~3% due to unrecorded transport loss, so we therefore include a corresponding -3% adjustment in our cost per-net calculation.48
• Distribution: AMF tracks net distribution and validates distribution data extensively; net distributions are recorded directly by distributors, and then AMF conducts surveys shortly afterwards to validate these estimates in ~5% of households ("5% backchecks"). We have some concerns about the quality of the distribution data and the methodology of the backchecks.49 We also understand that AMF's net accounting system suggests that only ~0.1% of nets it has procured for the DRC have been lost at the distribution stage, which seems intuitively low to us.50 Given these concerns, our best guess is that the number of nets reported to be distributed is biased upwards by 10%, so we include a -10% adjustment in our cost-effectiveness model.51

More information about AMF’s monitoring, including their post-distribution monitoring (PDM), is available on our top charity page for AMF.

Plans to improve AMF’s monitoring

We have discussed a couple of options with AMF to improve the quality of their monitoring. These include the following:

• Implementation of “PDM-0”: In order to verify the number of nets that were distributed during the campaign, AMF has agreed to conduct post-distribution monitoring a couple of weeks after distribution (“PDM-0”).52 We expect that successful implementation of PDM-0 will give us more confidence in parameters such as the average number of nets distributed to each household, the percentage of households that received the correct number of nets based on their household size, and the percentage of nets reported as distributed that are not found in the household shortly after distribution (net loss).
• Automated checks on distribution data: AMF has put together a document outlining a series of proposed automated checks to run on their distribution data, including geolocation checks to ensure that nets are being distributed in the areas we expect them to be and timestamp checks to ensure that distributors are not working faster than is realistic. We expect that implementing these checks will improve the quality of AMF’s distribution data, giving us more confidence that nets are being distributed where and when we expect them to be and that distribution protocols are being followed.

We are also working with IDinsight to review and provide input on AMF’s proposals for enhanced monitoring. For more on this engagement, see the relevant grant page.

Less important uncertainties

• Insecticide resistance: An important uncertainty in GiveWell’s research on malaria more broadly, which we plan to conduct more work on in the near future, is how increases in insecticide resistance over time are limiting the impact of ITN campaigns. We did not prioritize investigating this question for this grant because we expect around 50% of the nets purchased for the DRC to be chlorfenapyr nets,53 which we think are highly effective at combating insecticide resistance.54 We also think the work we've done so far suggests that we will make both downward and upward updates to our insecticide resistance modeling that are likely to counterbalance each other.
• Possible changes in mosquito behavior: There is some evidence suggesting that mosquitoes may be gradually evolving to bite people outdoors more often, presumably to evade indoor vector control strategies such as ITNs. GiveWell has only shallowly investigated this issue, but we expect that further work on it would not have a large enough impact on our cost-effectiveness estimates to change our mind about this grant.
• Net quality: We haven't looked into the quality of the nets AMF purchases or the quality assurance processes involved in manufacturing and/or procuring nets. If the nets AMF is purchasing are less effective or less durable than the nets used in effectiveness and durability trials, we could be overestimating the impact of campaigns.
• Misuse of nets: We've long been aware of anecdotes that people sometimes use mosquito nets from campaigns for other purposes, like fishing, that could undermine their intended impact or even cause harm. We've looked into this question somewhat, and while we think it's unlikely that this type of misuse is prevalent enough to warrant an adjustment in our model, it’s possible that misuse is more prevalent in some communities where fishing is particularly common, including some areas of the DRC. See our full write-up on this topic here.

Plans for follow up

We will continue having monthly calls with AMF to discuss its work. We plan to finalize the details of our M&E and learning agenda, a methodology for PDM-0s, and a methodology for new data validation checks with IDinsight and AMF by the end of 2024.

We will follow AMF's decision-making about how it uses its revenue from sources other than GiveWell grants, and we may estimate the cost-effectiveness of each of the funding gaps it chooses to fill with this revenue.

We will track progress on the timing of distribution campaigns to understand whether they are occurring on schedule or are delayed, and will review the full set of monitoring information that AMF collects during and after distribution campaigns. We will assess the possibility of recommending additional funding to support net campaigns in the DRC over the grant period depending on a) whether funding opportunities still exist, and b) the progress on and results of newly implemented monitoring systems.

Internal forecasts

For this grant, we are recording the following forecasts:

Confidence	Prediction	By time	Resolution
65%	Our cost-effectiveness estimate for this grant will be >10x when assessed retrospectively, using PDM-0 data.	June 2027	-
80%	DRC will ultimately receive less than $30m of funding from other sources (GF portfolio optimization, other donors, etc.) for ITN campaigns in the current cycle.	June 2026	-
45%	Distributions in provinces supported by this grant will happen, on average, within 33 months of the previous distribution.	December 2026	-
90%	AMF, GiveWell, and IDinsight will finalize a methodology for PDM-0s and new data validation checks.	December 2024	-
75%	PDM-0 data for all campaigns supported by this grant will show a total number of nets received by surveyed households within 10% of the number reported as received during distribution.	June 2027	-
60%	PDM-0 data for all campaigns supported by this grant will show a total number of household members received by surveyed households within 10% of the number reported as received during distribution.	June 2027	-
80%	PDM-0 data for all campaigns supported by this grant will exhibit a correspondence rate (the percentage of records within 1 of the value reported during distribution) of 80% or more for number of nets distributed.	June 2027	-
70%	PDM-0 data for all campaigns supported by this grant will exhibit a correspondence rate (the percentage of records within 1 of the value reported during distribution) of 80% or more for number of household members.	June 2027	-

Our process

In investigating this grant, we relied on review of AMF program documents and data, external literature, 9 calls with AMF’s leadership and operations team, and 21 conversations with third-party experts (researchers, other funders, implementers of malaria vector control initiatives) and stakeholders involved in ITN campaigns in the DRC.

Our reasoning for making the grant also received extensive internal review by GiveWell staff.

Sources

Document	Source
DHS Program, Congo Democratic Republic: Standard DHS, 2013-14	Source (archive)
GiveWell, 2020 update on GiveWell's moral weights	Source
GiveWell, Against Malaria Foundation top charity page	Source
GiveWell, Analysis of age skew in routine ITN coverage	Source
GiveWell, Analysis of Harms from Fishing with Insecticide-Treated Nets	Source
GiveWell, Analysis of ITN usage following mass campaigns	Source
GiveWell, Analysis of subnational malaria burden and stratification for DRC 2024-26 distributions	Source
GiveWell, CEA of insecticide-treated net (ITN) distributions	Source
GiveWell, DRC nets durability BOTEC	Source
GiveWell, GiveWell’s cost-effectiveness analyses	Source
GiveWell, How we produce impact estimates	Source
GiveWell, IDinsight — Review of AMF’s Monitoring (March 2024 grant page)	Source
GiveWell, Internal forecasts	Source
GiveWell, Malaria mortality benchmarking	Source
GiveWell, Mass Distribution of Insecticide-Treated Nets (ITNs)	Source
GiveWell, Our top charities	Source
Global Fund, DRC Funding Request Malaria - Allocation Period 2023-2025	Source
President's Malaria Initiative, Durability Monitoring of LLINs in Democratic Republic of Congo, 2019	Source
World Health Organization, Guidelines for Malaria Vector Control, 2019	Source
World Health Organization, Malaria factsheet	Source (archive)
World Health Organization, WHO Malaria Terminology 2021 Update	Source

• 1

  The grant was funded by Open Philanthropy ($22 million), donations to the Top Charities Fund (~$11 million), unrestricted support that has been re-designated by the GiveWell board for granting (~$6 million), and an individual donor ($2 million).

• 2

  We estimate that the total cost per distributed net in the DRC is $5.48. We estimate the average cost per net purchased in an unpublished analysis (we are unable to share this spreadsheet because we do not have permission to share all of the data contained within the analysis). We subtracted the averaged cost per net purchased ($2.38) from the total cost per distributed net ($5.48) to calculate an estimated delivery cost of $3.10.

• 3
  • We based our cost estimates for this campaign on two primary factors:
    • Net pricing information provided to us by AMF. According to AMF, chlorfenapyr nets are priced at $2.80 each, and market forces have pushed the price of a PBO net down from $2.40 to $1.96 in recent years.
    • Net distribution costs from the Global Fund's budget, provided to us by AMF. According to AMF, the Global Fund budgets $2.45 in non-net-purchase costs per net distributed.
  • For both factors, our cost estimates in the DRC are higher than the estimates we've used for other countries in the past.
    • The average net purchase price is higher because AMF plans to buy a combination of chlorfenapyr and PBO nets for these campaigns. Next-generation nets are more expensive than standard nets, but our modeling suggests that their effectiveness in combating insecticide resistance more than makes up for the increased price. See the differences in the insecticide resistance adjustments we apply for standard, PBO, and chlorfenapyr nets in the CEA.
    • We suspect that the DRC being a relatively difficult operating environment is driving the higher-than-usual net distribution costs budgeted by the Global Fund.
  • We are unable to share our full costing analysis because we do not have permission to share all of the data contained within the analysis.

• 4
  • We assume that for every malaria death, there are 0.75 additional deaths indirectly caused by malaria. This is based on evidence that malaria control programs often have larger impacts on mortality than would be expected from their impact on malaria alone. See the “Indirect Malaria Mortality” section of GiveWell’s report on mass distribution of insecticide-treated nets.
  • See GiveWell’s CEA of ITN distributions, “Main CEA” tab, row for “Indirect malaria deaths per direct malaria death.”

• 5

  World Health Organization, Malaria Factsheet, December 8th 2022. Available here.

• 6

  World Health Organization, Malaria Factsheet, December 8th 2022. Available here.

• 7

  The WHO defines an insecticide-treated net as: “A mosquito net that repels, disables or kills mosquitoes that come into contact with the insecticide on the netting material. Insecticide treated nets (ITNs) include those that require treatment and retreatment (often referred to as conventional nets) and those are “long-lasting” (see definition of long-lasting insecticidal net).” WHO, WHO Malaria Terminology 2021 Update, p. 19.

• 8

  WHO definition: “A factory-treated mosquito net made of material into which insecticide is incorporated or bound around the fibres. The net must retain its effective biological activity for at least 20 WHO standard washes under laboratory conditions and 3 years of recommended use under field conditions.” WHO, WHO Malaria Terminology 2021 Update, p. 17.

• 9

  “Core interventions for malaria vector control are applicable for all populations at risk of malaria in most epidemiological and ecological settings, namely: i) deployment of insecticide-treated nets (ITNs) that are prequalified by WHO, which in many settings are long-lasting insecticidal nets (LLINs); and ii) indoor residual spraying (IRS) with a product prequalified by WHO. Once high coverage with one core intervention has been achieved, supplementary interventions – namely the deployment of chemical or biological larvicides – can be used in addition to the core interventions in specific settings and circumstances.” World Health Organization, Guidelines for Malaria Vector Control, 2019, xiv.

• 10

  “Campaigns should also normally be repeated every three years, unless available empirical evidence justifies the use of a longer or shorter interval between campaigns.” World Health Organization, Guidelines for Malaria Vector Control, 2019, pp. 39-40

• 11

  In our cost-effectiveness model, we assume that net durability in the DRC is 17% lower than in other locations. This adjustment is based on data we have seen from Against Malaria Foundation’s post-distribution monitoring surveys, which track usage and condition over time. We also incorporate data from a durability study conducted by PMI in the DRC, which finds worse durability in the DRC compared to our analysis of durability in other locations. (PMI, Durability Monitoring of LLINs in Democratic Republic of Congo, Final report After 36 months follow-up, July 2019. Our analysis of the PMI data is available in this sheet.).This adjustment reduces our estimate of equivalent coverage-years for an ITN distribution from 2.11 in other locations to 1.75 in the DRC. See this spreadsheet for our calculations.

• 12

  Email from AMF, October 31, 2024 (unpublished)

• 13

  Information received from AMF (unpublished)

• 14

  AMF, call with GiveWell, March 14, 2024 (unpublished)

• 15

  Information received from AMF (unpublished)

• 16

  AMF, Information on theory of change and monitoring (unpublished)

• 17

  AMF, Information on theory of change and monitoring (unpublished)

• 18

  We have heard from AMF that AMF staff sometimes also directly visit campaign sites, though we're unsure how often this happens or whether it will occur for this distribution.

• 19

  Call with AMF, February 15, 2024.

• 20
  • This best guess is based on conversations with the Director of the DRC National Malaria Program (April 8, 2024) and the Global Fund’s DRC team (April 12, 2024) (unpublished).
  • Our model implicitly assumes that campaigns happen every three years, whereas the plans we’ve seen for the DRC would shorten that interval to 30 months. We’re skeptical that this can be achieved and aren’t accounting for it in the CEA, so this represents an unmodeled upside. In other words, our model already assumes some campaign delays, so we’re not worried about a massive negative effect on cost-effectiveness due to minor campaign delays.

• 21

  Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. As of mid 2024, our bar for directing funding is about 10 times as cost-effective as unconditional cash transfers for non-top charity programs and about 8 times as cost-effective as unconditional cash transfers for top charity programs. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.

• 22
  • We based our cost estimates for this campaign on two primary factors:
    • Net pricing information provided to us by AMF.
    • Net distribution costs from the Global Fund's budget, provided to us by AMF.
  • For both factors, our cost estimates in the DRC are higher than the estimates we've used for other countries in the past.
    • The average net purchase price is higher because AMF plans to buy a combination of chlorfenapyr and PBO nets for these campaigns. Next-generation nets are more expensive than standard nets, but our modeling suggests that their effectiveness in combating insecticide resistance more than makes up for the increased price. See the differences in the insecticide resistance adjustments we apply for standard, PBO, and chlorfenapyr nets in the CEA.
    • We suspect that the DRC being a relatively difficult operating environment is driving the higher-than-usual net distribution costs budgeted by the Global Fund.

• 23

  We estimate that the total cost per distributed net in the DRC is $5.48. We determined that the average cost per net purchased was $2.38 in an unpublished analysis (we are unable to share this spreadsheet because we do not have permission to share all of the data contained within the analysis). We subtracted the averaged cost per net purchased ($2.38) from the total cost per distributed net ($5.48) to calculate an estimated delivery cost of $3.10.

• 24

  To calculate this, we divide the grant amount from the simple CEA ($41,000,000) by the additional children sleeping under ITNs as a result of the program (1,451,009) and arrive at ~$28.26 per additional child reached.

• 25

  The net usage rate ranges from 2pp (when compared to usage in Guinea) to 9pp (when compared to usage in Chad and Togo) higher in the DRC. Note that we compare net usage in the DRC with net usage in a limited number of other countries.

• 26

  We compiled data from the 2007 DHS, 2013-14 DHS, and 2017-18 MICS for the DRC, as well as from AMF’s PDM, to inform our estimate of net usage. See GiveWell, Analysis of ITN usage following mass campaigns, 2024 for more details on how we calculated net usage and how net usage in the DRC compares with other countries.

• 27

  This figure incorporates both the percentage of people using nets and the percentage of full coverage provided by those nets after accounting for decreases in net durability.

• 28

  Specifically, if P(R) is the probability that someone get access to ITNs via routine nets, and P(C) is the probability that they gain access via mass campaign nets, then total coverage from either source will be P(R∪C)=P(R)+P(C)−P(R) * P(C). If P(R) ~0.15 and P(C)~0.7, then P(R∪C) = 0.745, and 10.5% (P(R∩C) = P(R) * P(C) = 0.15 * 0.7 = 0.105) will have received “double treatment”.

• 29

  See our calculations for this adjustment here.

• 30

  Conversations and emails with stakeholders (unpublished)

• 31

  We think this opportunity is particularly time-sensitive, as campaigns in the DRC need to be planned with considerable lead time. Our understanding from conversations with AMF, the Congolese government, the Global Fund, and PMI is that campaign planning has been repeatedly complicated by insufficient and delayed funding commitments. We’ve also heard from stakeholders in the nets space—including those not directly involved with the DRC—that the current funding gap in the DRC is seen as particularly dire. Our understanding is that this is due to the degree of malaria burden in the country and the number of people slated to go unprotected given current funding levels. We think these signals from others in the nets space are valuable and have factored them qualitatively into our thinking around this grant.

• 32

  In the past, we've based our assumptions about net durability largely on durability trials of one specific brand of standard pyrethroid-only ITN, the Permanet 2.0. Over time, as insecticide resistance has intensified, campaigns have shifted toward distributing more next-generation nets and fewer nets akin to the Permanet 2.0. As such, we've updated our net durability modeling to incorporate durability trials of a variety of net types and brands, which we think better reflects the mix of nets that are being distributed in campaigns today, and makes the estimate more robust.

• 33

  See our estimates of the proportion of physical protection provided by remaining nets one, two, and three years after distribution for other countries here.

• 34

  The longitudinal study on net durability was published by PMI and happened between 2016-19, while the last DHS survey in the DRC happened in 2014.

• 35

  Information provided by AMF (unpublished)

• 36
  • We assume that for every malaria death, there are 0.75 additional deaths indirectly caused by malaria. This is based on evidence that malaria control programs often have larger impacts on mortality than would be expected from their impact on malaria alone. See the “Indirect Malaria Mortality” section of GiveWell’s report on mass distribution of insecticide-treated nets.
  • See GiveWell’s CEA of ITN distributions, “Main CEA” tab, row for “Indirect malaria deaths per direct malaria death.”

• 37

  These studies and our approach for modeling the long-term income effects of ITNs are described in the “Long-term income increases” section of GiveWell’s report on mass distribution of insecticide-treated nets.

• 38

  GiveWell, Malaria mortality benchmarking (unpublished). This comparison had some significant limitations:

  • It was performed mainly on data from a different year (2019) than the year we eventually used in our final analysis (2021). The differences across sources in 2021 data may be smaller or in a different direction.
  • We were uncertain about the comparability between different estimates and worried that mortality rates may be defined differently across sources, or that different population estimates could lead to different measures of total deaths.

  We’ve since focused on a different way of comparing mortality estimates across sources than the methods used in this rough analysis, and we’re uncertain what using those newer methods would have implied when making this grant.

• 39

  These adjustments were calculated by assigning equal weight to three methodologies of calculating how much lower burden might be in currently unfunded/underfunded targeted subnational areas of the DRC: (1) using health-zone level malaria burden data shared by AMF, comparing unfunded health zones with the national average; (2) using less granular province-level malaria burden data observed in the same AMF dataset, comparing the currently least funded provinces with the national average; and (3) using province-level malaria burden data modeled by MAP, comparing the currently least funded provinces with the national average. GiveWell, Analysis of subnational malaria burden and stratification for DRC 2024-26 distributions

• 40

  More information in GiveWell’s report on Mass Distributions of Insecticide-Treated Nets.

• 41

  GiveWell, Analysis of ITN durability studies (unpublished)

• 42

  "A LLIN will be distributed to all women attending their first prenatal visit. A total of 17,054,542 pregnant women are expected to attend the antenatal consultation during the period 2024-2026, including 9,758,637 in the 16 provinces of Global Fund intervention plus Kasai…Every child who comes to the preschool consultation will receive a net, which represents a national need for 14,880,088 LLINs over the intervention period, including 634,386 in the 17 provinces of intervention of the Global Fund." Global Fund, DRC Funding Request Malaria - Allocation Period 2023-2025 (p. 3)

  • We also confirmed these numbers for routine nets via email with the Global Fund. Email from the Global Fund, June 5, 2024 (unpublished)
  • 17,054,542 + 9,758,637 = 31,934,630

• 43

  The Global Fund's population estimate for the DRC for 2025 is 130,936,878. Email from the Global Fund, June 5, 2024 (unpublished)

  • 130,936,878/1.8 = 72,742,710. This assumes an average of 1.8 people using each net per WHO recommendations.
  • "[A] ratio of 1 ITN for every 1.8 persons in the target population should be used to estimate ITN requirements, unless data to inform a different quantification ratio are available." World Health Organization, Guidelines for Malaria Vector Control, 2019.

• 44

  32,000,000 / 73,000,000 = 0.44 or 44%

• 45
• Conversations with multiple stakeholders (unpublished)

• 46

  AMF has provided us with start and end dates for the household distribution portion of these campaigns (in an unpublished spreadsheet), but we have not requested dates for other points in the logistics chain (e.g., procurement, arrival at port, arrival at health area). Note that this data could update us positively or negatively on the scope and scale of delays for net campaigns in the DRC.

• 47

  Conversations with stakeholders (unpublished)

• 48

  While we are highly uncertain about this, we intuitively think overall net loss at this stage is unlikely to be greater than ~10% and therefore unlikely to lead us to assess the cost-effectiveness of this grant as < 8x as cost-effective as unconditional cash transfers.

• 49

  We believe the distribution data is limited by a lack of automated checks on geolocations and timestamps to identify any data irregularities.

• 50

  AMF’s internal data states that 0.32% of nets procured for the DRC are lost, stolen or damaged, of which 70% is refunded, for a loss percentage of 0.09% (unpublished).

  • Since AMF has an agreement with Global Fund that nets prior to arrival at health areas are insured against loss, damage, and theft—we assume the 0.1% of non-refundable loss is the loss that AMF's accounting system counts as occurring at the distribution stage. We have not explicitly confirmed this with AMF.

• 51

  While we are highly uncertain about this, we intuitively think overall net loss at this stage is unlikely to be greater than 20% and therefore unlikely to lead us to assess the cost-effectiveness of this grant as < 8x as cost-effective as unconditional cash transfers.

• 52

  This grant includes an additional $1 million for AMF to conduct PDM-0 as part of this campaign.

• 53

  AMF, DRC LLIN Price estimate, November 2023 (unpublished)

• 54

  “In DRC (although not in other countries, reasoning in footnote), we also account for chlorfenapyr nets. Our current guess is that chlorfenapyr nets completely eliminate the reduction in effectiveness from insecticide resistance. However, our analysis of chlorfenapyr nets is still ongoing, and this conclusion could change.” GiveWell, Mass Distribution of Insecticide-Treated Nets (ITNs), 2024