Clinton Health Access Initiative (CHAI) Technical Support Units (TSUs) (April 2025)

Published: June 2025

The grant

GiveWell and Open Philanthropy recommended a grant of $4,657,500 to CHAI to provide technical assistance to Ministries of Health (MoHs) as they execute government-led reform agendas in response to the funding cuts from the US government (USG) and other entities. The grant supports CHAI's technical support units (TSUs) for one year in Burkina Faso, Malawi, Nigeria (across 7 states: Bauchi, FCT, Ondo, Ogun, Gombe, Akwa Ibom, Enugu; and at the national level), Uganda, and Zambia.1

The scope and staffing model of TSUs will look different in each country. In general, the grant will fund 1-4 person in-country teams in each country (with additional staff in Nigeria given the multi-state scope) as well as a small global team for cross-cutting support. These teams will provide technical assistance to support MoHs to: i) identify the impact of the cuts across programs and systems, ii) identify cost-efficiencies in programs to make remaining funds go further, iii) conduct cost-effectiveness analyses to reallocate funding to more cost-effective uses, and iv) try to crowd-in new funding for health programs either from external donors or through other parts of the domestic government budget.

CHAI will customize their support in each country based on the priorities of the MoH and the work the MoH has already done towards these objectives. Within the first month of the grant period, CHAI will solicit letters of support from the MoHs to confirm the grant activities fully align with government priorities.

GiveWell and Open Philanthropy co-investigated and co-funded this grant.

Budget for grant activities

CHAI's $4,657,500 budget is broken down as follows:

	Nigeria (7 states + National)	Burkina Faso	Malawi	Uganda	Zambia	Global	Total
CHAI personnel and consultants	$1,140,000	$350,000	$350,000	$350,000	$350,000	$452,000	$2,992,000
Travel, meetings, and other direct costs	$360,000	$150,000	$150,000	$150,000	$150,000	$98,000	$1,058,000
Sub-Total	$1,500,000	$500,000	$500,000	$500,000	$500,000	$550,000	$4,050,000
Indirect (15%)	$225,000	$75,000	$75,000	$75,000	$75,000	$82,500	$607,500
Total	$1,725,000	$575,000	$575,000	$575,000	$575,000	$632,500	$4,657,500

GiveWell is contributing $2,511,961, and Open Philanthropy is contributing $2,145,539 of this grant.

What we think this grant will do

What will the TSUs do?

CHAI will provide technical assistance through units of 1-4 staff in each country (supported by a small global team) working with the MoH on its response to the USG funding cuts.2 CHAI will work in five countries: Burkina Faso, Malawi, Nigeria (in 7 states—Bauchi, FCT, Ondo, Ogun, Gombe, Akwa Ibom, Enugu—as well as at the national level),3 Uganda, and Zambia.

These TSUs will support the MoHs on four different workstreams:

1. The TSUs will support information gathering to identify the impact of the USG funding cuts across programs and systems. Our understanding is that this will require meeting with staff from across government departments and implementing partners and aggregating existing information into one place (such as a dashboard and written reports) which can be more easily used by the MoHs’ relevant cross-sector planning departments.4 We do not believe this will require new first-hand data collection. We understand that information gathering is the first exercise most MoHs started working on immediately after the funding freeze began, so a portion of this work may already be done. CHAI plans to tailor their support in each country based on what has already been completed.5
2. The TSUs will work to identify cost-efficiencies in health programs and systems to enable remaining resources to go further. Our understanding is that this will involve meetings with government stakeholders and conducting analysis to identify ways to structure programs and health systems more efficiently, such as:
   • Transitioning activities from former USG contractors to government or local organizations. USG often hired international for-profit organizations to provide services at a high cost, and hired health workers to deliver specific services (e.g., HIV services) through parallel health systems often paid at a higher pay scale than the domestic government. CHAI believes they can work with the MoH to find ways to deliver the same services at lower cost, for instance, by hiring local organizations or paying health workers to deliver an integrated set of services in line with the domestic government pay scale.6
   • Integrating shared services: CHAI believes they can support improvements in the efficiency of health program delivery by integrating shared services–such as supply chains, last mile commodity distribution, data systems and training and supervision of health workers–across programs which address different disease or cause areas.7
3. The TSUs will conduct cost-effectiveness analyses in collaboration with the relevant MoH to advise its prioritization decisions and in order to help allocate remaining resources to the most cost-effective uses. These analyses will be an input for the MoH as they conduct prioritization decisions across remaining funding sources, which may help them to identify improvements to the cost-effectiveness of health programs such as through changes in geographic or demographic targeting or choices of intervention. We expect that any given MoH will consider these cost-effectiveness analyses as one factor among many other decision making objectives and constraints, and CHAI’s intention is to support the MoHs to make evidence-based decisions within their existing priorities, not to try to introduce new priorities.8
4. The TSUs will work to support the MoH to crowd in new funding for health programs either from external donors or through other parts of the domestic government budget. Through the work done in the workstreams outlined above, CHAI will work with governments to generate a list of funding opportunities and present them to external donors, including GiveWell.9 CHAI will also work with the MoHs to try to obtain additional funding for health from the domestic government budget, which might involve negotiating with Ministries of Finance and making the case for the impact and cost-effectiveness of the additional health spending.10 In addition, CHAI explained that they will help the MoH use its full health budget, where budget execution can be improved. CHAI raised that it is common for portions of health budgets to go unspent, in part due to a lack of real-time information on expenditure, complex requisitioning and multiple different entities managing the disbursement of multilateral funds, among other issues.11 We have not investigated whether there are unused health budgets in these five countries, but if this is the case, CHAI may work with MoHs to identify solutions. This could allow governments to more fully utilize their health budgets, and in turn strengthen their case for increased future allocations from Ministries of Finance.

We expect the relative focus of the TSUs across the four workstreams to differ across countries based on each country's specific needs, priorities, and what work has already been done.12

What will our funding do that wouldn't happen without it?

CHAI already has secured some funding for TSU work from other donors and may also receive more, since this work is addressing a timely need that other funders may also be interested in. CHAI has a longer list of 11 countries (which also includes Eswatini, Ghana, Ethiopia, Kenya, Lesotho, Cameroon) in which it believes it has government buy-in and the capacity to start providing technical support right away, and they have aspirations to scope additional locations as well.13

CHAI told us that, in the absence of this grant, they would have used some of its existing funding to work in these five countries but likely in a lighter-touch and potentially more fragmented way. Therefore, compared to the counterfactual14 (as in, compared to the world in which we do not make this grant), we believe that some of our funding will effectively be used towards TSUs in countries from CHAI's longer list, as well as to deepen and accelerate the TSU work in the five countries explicitly covered by this grant.

If our funding does indeed enable CHAI to extend TSU work to additional countries beyond the 5 we're directly supporting, this could still be highly cost-effective, though we have not investigated government buy-in or the broader case for impact in additional countries.

The case for the grant

The primary reasons we made this grant are as follows.

This grant will address a real, urgent need within a time-limited window

We think this TSU work will address a real and urgent need to help governments make difficult planning and prioritization decisions in countries that have been severely affected by the USG funding cuts (and other reductions in foreign aid) and have a high disease burden. CHAI selected this grant’s five countries (Nigeria, Malawi, Uganda, Burkina Faso, and Zambia) based on a set of criteria which included the size of the USG funding gap and the burden of preventable disease. We did a light-touch validation of this country selection which broadly confirmed CHAI’s results.15 Countries like Malawi and Uganda have previously been among the most dependent on US health funding, with over 30% of their health expenditure estimated to have come from USG sources in 2022-23.16 Meanwhile, Nigeria and Burkina Faso have particularly high burdens of preventable disease that could be exacerbated by funding reductions.17 The work of the TSUs is very time-sensitive, as our impression is that governments are already beginning this planning process and could benefit from immediate technical support.

There is indication of strong government support for this work

We spoke with senior Ministry of Health officials in each country about this grant, given that the response to the USG funding cuts is government led. Overall, governments voiced strong support and demand for the proposed TSUs and were eager to have CHAI's support on this work. They also emphasized the need to ensure that this work stays government-led and closely coordinated with existing efforts across the MoH, which is fully in line with GiveWell's and CHAI's vision for this work.

The impact of this grant will depend in large part on the governments' support and willingness to partner with CHAI. In order to confirm alignment with the MoHs, in the first month of the grant period, CHAI will obtain explicit letters of support from government decision-makers. The overall positive response we've heard from government stakeholders increases our confidence that CHAI will be able to partner effectively with the MoH.

This grant looks highly cost-effective

We are making this grant predominantly based on the qualitative case. We don't place much weight on the rough cost-effectiveness model we have created because the numbers are highly subjective. However, our model does increase our confidence that these grants could have cost-effective impact. Our rough BOTEC (“back-of-the-envelope calculation”) suggests that these grants could be around 13-28x as cost-effective as unconditional cash transfers.18 The model demonstrates that this grant looks highly cost-effective if it supports the MoHs to make even a relatively small portion of their expenditure more cost-effective. For instance, we conducted a threshold analysis which suggests that a TSU that costs around $1 million would have to find 31% cost savings and a 20% improvement in cost-effectiveness through improved program allocation across $1 million of annual government expenditure and $8 million of crowded-in funds over 1.5 years in order to meet GiveWell's 10x bar.19

CHAI has the relevant experience and government relationships to do this work well

CHAI has demonstrated their experience and capacity to provide the technical support based on their track record and existing relationships with MoHs. They currently operate malaria-specific TSUs in several countries, including Uganda and Burkina Faso. CHAI has also provided GiveWell with examples of other planning and prioritization work they've conducted with the governments of this grant’s five countries. They have cross-cutting teams with expertise in health systems and health financing, which will be important for addressing the systemic challenges created by funding cuts.20 CHAI's strong in-country presence and existing relationships with relevant decision-makers further strengthen their ability to implement this work effectively.

We also believe that CHAI is strongly aligned on cost-effectiveness with GiveWell based on their work in the Maximum Impact Incubator.

This grant may generate learning value

This grant provides several valuable learning opportunities for GiveWell. First, the TSUs will identify potentially cost-effective funding gaps through its information-gathering activities, which GiveWell may investigate and support directly. Second, we'll learn first-hand about CHAI's ability to provide high-level technical support to governments through process indicators and case studies they'll share at regular intervals. Third, we'll gain insights into how MoH make prioritization decisions in practice, including what factors they consider beyond cost-effectiveness. CHAI will report on instances where they find cost-effectiveness modelling is or is not helpful for government decision-making and why, which could inform our broader approach to government engagement. Finally, the information gathered by the TSUs could serve as a valuable public good if it can be shared more widely with other donors and implementers responding to the funding cuts, if–and only if–the governments want the information to be shared.

This grant could help attract additional funding for TSUs in additional countries and other cost-effective health programs

Our decision to fund these TSUs could encourage additional philanthropic support for similar work in other countries. GiveWell and Open Philanthropy are aware of other funders and donors who are interested in supporting this type of work. Additionally, the TSUs themselves will work to identify high-priority funding opportunities and present them to external donors, potentially mobilizing significant additional resources for effective health programs.

Our main reservations

Our main reservations about these grants are as follows.

We are highly uncertain about the impact of the TSU work

The work these TSUs will undertake is more "upstream" than many of the programs that GiveWell typically funds. There are several ways the TSUs might fail to achieve their intended impact, despite the interest expressed by government officials. First, the MoHs may have already completed some of the proposed work, particularly the information-gathering activities to identify funding gaps, which could diminish the additive impact of the TSUs. Second, despite initial expressions of support, the MoHs might not ultimately implement the recommendations TSU teams develop with the government due to political factors or competing priorities. Third, external constraints, such as World Bank loan conditionalities, might restrict the government's ability to reallocate resources as recommended. Additionally, the TSU teams might face challenges in crowding in additional funding or identifying the expected cost efficiencies. We've tried to mitigate these risks by speaking directly with senior officials and requesting letters of support to confirm government alignment on the TSUs' work plans, but uncertainties remain.

It is possible our grant could replace, rather than add to, other funding sources for this work

There's a risk that our funding might replace rather than complement support from other donors. We know that CHAI is actively seeking funding from multiple sources for TSU work and that another funder has established a financing facility with similar objectives in countries that overlap with this grant. However, given the scope of need for support in response to USG funding cuts, we think that any funding this grant may displace is likely to also go to similar cost-effective uses, such as TSU support in additional countries or health commodity supply chain strengthening.

We did not verify government support for this work in the other countries where our funding might indirectly cause TSU work to happen

Given the fungibility of our grant with other funds CHAI receives for TSU work (as outlined above), our grant may enable CHAI to extend TSU work to countries beyond the five we've directly assessed. We have not verified government interest or commitment in the additional countries from CHAI's expanded list (which includes Eswatini, Ghana, Ethiopia, Kenya, Lesotho, and Cameroon) because of the time sensitivity of this grant decision. However, CHAI reports they have government relationships and capacity to begin work in these locations if they receive funding to do so.

The TSUs may not sustainably transfer long-term capacity within domestic governments such that the MoHs continue this work beyond the end of the grant period

TSUs are intended to provide temporary analytical support to augment government capacity during a crisis period. In highly technical areas such as cost-effectiveness modeling the short-duration of the grant may not allow time to build capacity within existing long-term MoH staff that can continue these complex analyses. CHAI has committed to transferring activities to the MoH by the end of the grant, but we are uncertain what this handoff will look like, given limited time and resources.

However, since CHAI has partnered with the governments in these countries in varying capacities for many years, we think they will be able to coordinate a handoff that avoids any detrimental effects, leaving government capacity either the same level or better than it was before the TSU work. As part of the grant activities, CHAI will also develop brief work plans that outline how they will approach the eventual handover of activities to government counterparts.

We did not extensively look into alternative implementers for this work

We're aware of multiple organizations that offer similar kinds of support to what CHAI has proposed for these TSUs. It is plausible that another of these organizations could be better positioned to offer this support in some of the countries we're funding. However, we've chosen not to investigate a wider range of organizations given the urgency of the need, the fact that the MoH officials we spoke to confirmed they were happy to partner with CHAI, and because other stakeholders spoke highly of CHAI's expertise in TSU work.

GiveWell remains open to considering additional proposals from other implementers to support TSU work in additional locations.

Plans for follow up

Within the first month of the grant period, we will request the following from CHAI:

• Letters of support: We will require CHAI to provide letters of support from the relevant government decision-makers within one month of contract signing.
• Work plans: CHAI will provide brief work plans outlining the key activities agreed upon with each MoH, including eventual handoff activities.

Beyond that, GiveWell and Open Philanthropy will have regular check-ins throughout the grant period to track progress and learn about:

• Process indicators (staff hiring, government engagement, recommendations implemented);
• Case studies of how government prioritization decisions are made;
• Promising funding opportunities identified through the TSU work;
• Contexts where cost-effectiveness considerations are or aren't helpful for government decision-making.

Our process

We co-investigated this grant opportunity with Open Philanthropy. Our process included:

1. Reviewing CHAI's proposal and budget;
2. Conducting multiple meetings with CHAI's global team;
3. Meeting with CHAI's country teams where we had specific questions;
4. Consulting external stakeholders, including other funders and technical assistance providers;
5. Holding meetings with senior MoH officials from each country to gauge government interest and buy-in.

We expedited this investigation given the urgent need for support.

Relationship disclosures

Neil Buddy Shah was hired in April 2022 as CHAI's CEO. Previously, he was GiveWell's Managing Director. We consulted with Dr. Shah and other CHAI leadership during this grant investigation.

Sources

Document	Source
Center for Global Development, “26 Countries Are Most Vulnerable to US Global Health Aid Cuts. Can Other Funders Bridge the Gap?,” February 25, 2025	Source (archive)
CHAI, “From Crisis to resilience: Rapidly responding to US aid cuts and transitioning programs to domestic ownership” (original proposal), March 4, 2025 [reducted]	Source
CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025	Unpublished
GiveWell Blog, “The fungibility question: How does GiveWell’s funding affect other funders?,” June 21, 2024	Source
GiveWell, “Clinton Health Access Initiative – CHAI Incubator,” August 2022	Source
GiveWell, “Glossary of Key Terms”	Source
GiveWell, “USAID Funding Cuts: Our Response and Ways to Help,” April 25, 2025	Source
GiveWell, Simple CEA/BOTEC of CHAI TSUs, April 2025	Source
Reuters, “Nigeria makes $200 million budget provision to fill U.S. aid suspension gaps,” February 13, 2025	Source (archive)

• 1

  We simultaneously investigated and recommended a grant to PATH of $1,529,231 to fund a TSU to provide similar technical assistance to the Ministry of Health in the Democratic Republic of Congo (DRC). You can read more about this grant here.

• 2

  "In general, we estimate a TSU would comprise 3-4 people, however, this would be based on government request and country scope. In some countries where there are already strong teams on the ground or malaria TSU support, we may only need to augment the existing staff with 1-2 additional staff members." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 3

  In FCT, CHAI will be doing some work at both the state and federal level: "It makes more sense to call out FCT as a 7th state explicitly as we will be doing both state and national level work in FCT … Yes, as articulated in more detail in the concept note we will do significant work at federal level in collaboration with the SWAp office. We intend to second one of our staff to support resource mapping and coordination of TA alignment in the SWAp Coordination Office." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 4
  • "We believe this [will require] accessing data from U.S. implementing partners that are now in some cases offline and consolidating government and partner operational plans, which are often in hard copy and fragmented across multiple documents. These would need to be reviewed and aggregated to build a clear picture of budget line items and gaps. For maternal health, for example, where much of the funding is channeled directly through embassies to implementers, we would need to sit with the government to review each IP contract—mapping how funds are allocated across maternal and child health activities—before aggregating this information to calculate gaps and inefficiencies." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).
  • "Impacts can also be monitored through a dashboard made available online as we have done with resource mapping and expenditure tracking in Burkina Faso and previously in Malawi." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 5

  "Yes, we recognize in several of the countries we’re proposing, some of this work has been done—such as the initial gap analysis—often with the support of CHAI. We will pick up from the government's current stage and tailor our support to each country context." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 6

  "International entities lead systems in data, supply, workforce etc. that often run parallel to government at high cost … Many governments are prioritizing planning to absorb these health parallel workers into national initiatives and align compensation to government pay scales—thereby providing integrated rather than siloed services (e.g., HIV testing only). This will lower the overall cost of employing health workers while expanding service offerings." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 7

  "We also anticipate governments will prioritize integration and adoption of parallel data systems, removal of TA services, integration of verticalized HW trainings and supervisions, and integration of supply chain and last mile delivery systems, including involvement of the local private sector." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 8
  • GiveWell, Non-verbatim notes from meeting with CHAI, March 26, 2025 (unpublished).
  • "Other criteria include equity (weighting CEA towards certain underserved or vulnerable groups in some cases), addressing drivers of out-of-pocket spending (an economic concern rather than strictly related to health outcomes), expectations of the population, and budget impact. Again, the establishment of such processes is less about the specific criteria that the government decides upon, but the existence of an evidence-informed, systematic way to make the difficult choices driven by scarce resources." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March 2025 (unpublished).

• 9

  "CHAI is working with governments and funders to mobilize targeted resources for high-impact, cost-effective opportunities that will have an outsized impact in preventing large-scale disruptions." CHAI, “From Crisis to resilience: Rapidly responding to US aid cuts and transitioning programs to domestic ownership” (original proposal), March 4, 2025 [redacted], p. 2.

• 10

  "We will use these plans to make the case to increase health budgets while improving efficiency in health spending." CHAI, “From Crisis to resilience: Rapidly responding to US aid cuts and transitioning programs to domestic ownership” (original proposal), March 4, 2025 [redacted], p. 4.

• 11

  "Across countries, we often see some portion of health budgets go unspent, despite clear needs. Incomplete absorption of funds is due to operational bottlenecks and gaps in timely, quality data to decision makers and can be addressed by strengthening the flow of data combined with timely action to manage these bottlenecks... Monitoring concrete expenditure against budget and progress against operational plans, to ensure that re-planning and course correction was conducted." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 12

  For example, in Nigeria, we think the MoH has done a lot of the information gathering already; this formed the basis of the $200m emergency budget provision for health.

• 13

  "In addition to the 4 countries proposed to GiveWell [Nigeria, Burkina Faso, Uganda, Malawi], we believe Eswatini, Ghana, Ethiopia, Kenya, Zambia, Lesotho, Cameroon and Benin would be ready to move forward establishing TSUs quickly." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).

• 14Read more about how GiveWell thinks about counterfactual impact here.
• 15

  We have loosely validated this selection as follows:

  • We have mapped USG funding for health as a proportion of total domestic health expenditure based on Center for Global Development data available here. Malawi and Uganda are at the top of that list, with over 30% of health expenditure coming from USG, while Zambia is 7th.
  • The work of another GiveWell team mapping health systems impacts from USG cuts also suggested anecdotally that DRC and Malawi have been severely affected.
  • We have not spent time trying to model the burden of preventable disease which could be influenced by this work, but we understand from other GiveWell grant investigations that there is a particularly high disease burden in Nigeria and Burkina Faso.

• 16

  This is based on analysis of Center for Global Development data available here.

• 17

  For this grant decision, we have not spent time trying to model the burden of preventable disease which could be influenced by this work, but this is our understanding, not least judging by where previous GiveWell programs have been targeted.

• 18
  • The basic logic of the BOTEC is as follows: A relatively small grant of around $700k-$2m enables the TSU to generate a 12-14% improvement in the cost-effectiveness of $20-40m worth of government expenditure by reallocating it to more cost-effective uses, and to achieve a further 4-30% improvement by identifying cost efficiencies in those programs. In addition, the TSU crowds in a further $2-20m in funding for health programs from both other government departments and external funders. We assume that these benefits accrue for six months beyond the end of the grant period, and we make discounts to account for funging and the possibility that the government could make a portion of these improvements on its own without TSU support. Given time constraints, we do not explicitly model option value from future grant opportunities identified by the TSUs.
  • The list of countries evolved throughout this accelerated investigation, and this BOTEC was based on an earlier list that didn’t include Zambia. However, we expect Zambia would model in a similar range of cost-effectiveness.

• 19
  • To date, GiveWell has used GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding opportunities, which we describe in multiples of "cash” (more). In 2024, we re-evaluated the cost effectiveness of direct cash transfers as implemented by GiveDirectly and we now estimate that their cash program is 3 to 4 times more cost-effective than we’d previously estimated (more).
  • For the time being, we continue to use our estimate of the effectiveness of unconditional cash transfers prior to the update to preserve our ability to compare across programs, while we reevaluate the benchmark we want to use to measure and communicate cost-effectiveness.
  • 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. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.

• 20

  "CHAI’s health systems group includes workforce, financing and digital health expertise. In addition, CHAI works in the supply chain, though largely through disease specific programs and specific country reforms. The majority of staff are based in-country given the context-specific nature of this work. There is then a global team working across these different areas." CHAI, “Running document with GiveWell: CHAI Technical Support Units,” March-April 2025 (unpublished).