Note: This page summarizes the rationale behind a GiveWell grant to CHAI. CHAI staff reviewed this page prior to publication.
In a nutshell
In July 2025, GiveWell recommended an $842,400 grant to the Clinton Health Access Initiative (CHAI) to purchase and ship approximately 3 million malaria rapid diagnostic tests (RDTs) to Nigeria. This grant aims to reduce stockouts of RDTs that we expect to occur between August and November 2025 due to shipments from the President’s Malaria Initiative (PMI) that are delayed relative to previous years.
We are recommending this grant because:
- We believe there is likely to be a significant RDT stockout in Nigeria. Based on quarterly forecast reviews that CHAI supports, we expect RDT stockouts across several Nigerian states for two to four months, during which time we expect the quality and effectiveness of malaria diagnosis and treatment (as well as treatment for other febrile illnesses) would be reduced. (more)
- We believe CHAI has a reasonable chance of preventing part of this stockout. We estimate a 60% chance that CHAI can successfully procure and deliver RDTs to central warehouses before a September resupply deadline, shortening the stockout by approximately two months. We also believe it is unlikely that this gap is filled without our support of CHAI. (more)
- We expect that filling this gap would be highly cost-effective. We estimate this grant is approximately 14x as cost-effective as our benchmark. This is because we think that RDTs are inexpensive ($0.25-$0.30 per person reached), they target a high-risk population (we estimate 30-40% of fever patients seeking care in these locations have malaria), and increase appropriate treatment by approximately 10 percentage points. We also expect smaller benefits from improved diagnosis and treatment of non-malarial febrile illnesses. (more)
Our main reservations are:
- Risk of crowding out other funding. We are concerned that this grant might disincentivize other funders from investing in malaria commodities, though we think this risk is low given the grant's small size and one-time nature. (more)
- Strict timelines pose a risk of failure. Given the logistical complexity of procuring and delivering these tests on a short timeline, we estimate a 40% chance that CHAI cannot deliver the RDTs in time to prevent the stockout. (more)
- Limited verification of the problem. Due to time constraints, we have not independently verified CHAI's stockout predictions with other stakeholders such as PMI, the Global Fund, or Chemonics. (more)
Our cost-effectiveness analysis for this grant can be found here.
Published: January 2026
1. The organization
The Clinton Health Access Initiative (CHAI) is a global health organization that works with governments and the private sector to strengthen health systems and expand access to care. For this grant, we are relying on CHAI's capability in forecasting commodity needs and managing procurement logistics.
Our understanding is that CHAI has been monitoring malaria commodity supplies and gaps in Nigeria and has experience with health commodity procurement, as well as relationships with relevant manufacturers, making us confident that they’re well positioned to carry out this grant.1
2. The intervention
Malaria rapid diagnostic tests (RDTs) are used to help diagnose malaria by measuring malaria parasites present in blood samples, and are especially useful in areas with limited access to high-quality microscopy.2
RDTs support accurate diagnosis of malaria, which we think likely:3
- Encourages appropriate treatment for malaria and preserves stocks of antimalarial medicines,
- Encourages treatment for other conditions that may have been presumptively treated as malaria, and
- Discourages inappropriate use of malaria treatments in individuals without malaria, potentially limiting the spread of antimalarial resistance.
3. The grant
This grant will allow CHAI to procure RDTs from manufacturers and ship them to central warehouses in Nigeria. As long as the shipments arrive on time, this restock should mean that there are RDTs available for the Chemonics-supported resupply process in September, which transports commodities from central warehouses to individual clinics.4
Without this grant, we expect that there would be an insufficient quantity of RDTs at central warehouses for the September resupply, creating stockouts at clinics until the next resupply in late November or early December.
Budget for grant activities
The budget breakdown is as follows:5
| Activity | Amount | Percentage |
|---|---|---|
| RDT procurement | ~$750,000 | ~90% |
| Shipping and customs | ~$30,000 | ~4% |
| CHAI overhead | ~$62,000 | ~7% |
| Total | $842,000 | 100% |
4. The case for the grant
We are recommending this grant because we believe that it will be a highly cost-effective use of funds, 14x as cost-effective as our benchmark (more). Contributing to our case for the grant are our beliefs that:
- There is likely to be a significant RDT stockout in Nigeria. Based on information we’ve received from CHAI, we expect stockouts across several formerly PMI-supported Nigerian states6 between August and November 2025. This gap is due to a PMI order that CHAI believes was delayed by disruptions resulting from shifts in United States foreign assistance. Our understanding is that the next confirmed PMI delivery is not scheduled until late October 2025, which will miss the September resupply cycle.7
- CHAI has a reasonable chance of preventing part of this stockout. CHAI estimates a 60% probability that they can successfully procure and deliver approximately 3 million RDTs to central warehouses before the September resupply deadline, an estimate that we think is reasonable.8 This would make RDTs available for October and November, shortening the stockout by approximately two months.
- No other actors are likely to fill this gap. CHAI reports that nearby states sometimes provide emergency support to neighboring states when RDT stocks are low and that these states have indicated they cannot help because their own RDT stocks are low.9 We think it’s unlikely that other funders or the Nigerian government will respond quickly enough to prevent this stockout.
Cost-effectiveness
Our best guess is that this grant is approximately 14x as cost-effective as our benchmark.10 We think this intervention is cost-effective because:
- RDTs are exceptionally cheap. At $0.26-$0.30 per person reached, RDTs represent a low-cost intervention that targets a population seeking care for malaria in a location with high malaria prevalence (we estimate 30-40% of fever patients seeking care in these locations have malaria).11
- RDTs improve malaria treatment among people seeking care. We estimate that RDT availability increases the proportion of people with malaria who receive artemisinin combination therapy (ACT), a drug used to treat malaria, by approximately 10 percentage points (from 70% with presumptive treatment to 80% with RDT-guided treatment).12
- RDTs also improve rates of treatment for non-malarial illnesses. RDTs help identify when patients do not have malaria but are experiencing symptoms of another illness. We think, though are highly unsure, that this leads to a 29 percentage point increase in treatment for other (non-malaria) conditions.13 We think most of this comes in the form of increased antibiotic prescription and use.
- The estimated mortality impact is meaningful. We estimate that 77% of mortality benefits from this grant come from averting malaria deaths and 23% from averting deaths from other illnesses that are better treated when malaria is ruled out.14
A simplified version of our cost-effectiveness analysis can be found here.
5. Risks and reservations
Our main reservations about this grant are:
- Risk of crowding out other funding. We have two distinct concerns about ”funging”:
- Would this grant have been funded by someone else?: We think it's unlikely that another funder would have covered this specific gap, given the urgency and timing constraints. We have done some limited investigation into this question and think that no other funder is well positioned to fill this gap prior to the September resupply cycle.
- Long-term disincentive effects: We are more concerned that covering this gap might signal to other funders that GiveWell will backstop future commodity shortfalls, potentially reducing their own investments in malaria commodities. This concern is heightened by our other recent malaria grants in Nigeria responding to foreign aid cuts (more). However, we agree with CHAI’s assessment that the risk is low given this grant's relatively small size and explicitly one-time nature—we have also asked CHAI to clearly communicate to stakeholders that this is a one-off emergency response with no guarantee of future commodity support from GiveWell.
- Strict timelines pose a risk of failure. CHAI estimates there is a 40% chance that they cannot complete procurement and delivery in time to prevent the stockout, an estimate that we think is reasonable. Even with immediate action, procurement and shipping timelines are tight.
- Limited verification of the problem. Due to time constraints, we have not independently confirmed CHAI's stockout predictions with other stakeholders such as PMI, the Global Fund, or Chemonics. We also lack detailed understanding of the procurement and shipping logistics in Nigeria.
- Uncertainty about our impact model. Our estimate that RDTs increase ACT usage by 10 percentage points is difficult to triangulate, particularly in the specific context of Nigerian states during a stockout. There may be higher-than-usual presumptive treatment that would reduce RDT impact.15
- Potential underestimation or overestimation of benefits. We have not fully modeled the value of preserving ACT stocks or reducing antimalarial resistance, by reducing unnecessary prescriptions of ACTs. We may also have overestimated benefits if people who are most likely to progress to severe malaria receive ACTs regardless of RDT availability, or if alternative diagnostics are used during stockouts. We have also not modelled second-order impacts from increased antibiotic use (e.g. increasing antibiotic-resistance).
6. Plans for follow up
To measure the outcomes of this grant:
- CHAI will report key milestones, including obtaining import/export documentation, CRIA approval,16 shipping initiation, and warehouse delivery.
- CHAI will provide data to GiveWell regarding actual stock levels to verify whether predicted stockouts occur starting in August 2025.
- We will assess lessons learned from this emergency procurement to inform future commodity gap-filling strategies.
7. Internal forecasts
For this grant, we are recording the following forecasts:
| Confidence | Prediction | By Date | Resolution |
|---|---|---|---|
| 75% | There are reports of RDT stockouts in Nigeria (in the time period immediately before CHAI delivery) | End of July 2025 | - |
| 60% | CHAI successfully delivers >2 million RDTs to Nigeria before September resupply | September 2025 | - |
8. Our process
We’ve been in conversations with CHAI around malaria commodity gaps since early June. In July, CHAI came to us with this potential gap that they had come across through their ongoing surveillance work. We then proceeded to evaluate this grant through a rapid process, owing to the time-sensitive nature of the need. Our process included:
- Three conversations with CHAI about commodity backstopping and this specific Nigeria gap
- Consultations with GiveWell’s malaria team about commodity funding and risks around the possibility of crowding out other funding
- A conversation with Cammie Lee, a former Gates Foundation market shaping expert, about backstop funding
- A conversation with a malaria expert about counterfactual ACT treatment
- A conversation with Nick Laing (CEO of OneDayHealth) about on-ground malaria treatment experience
- A conversation with Dr. Julie Gutman about RDT use and malaria case management
- Conversations with several malaria experts, including Mamadou Seriba Doumbia, Charles Chineme Nwobu, and Dr. Bilongo Plong Briot
Due to time constraints, there were several potential steps we did not take:
- We didn’t speak with organizations or governments we might be at risk of crowding out for funding (PMI, Global Fund, Chemonics)
- We didn’t investigate specific characteristics of affected Nigerian states
- We didn’t conduct detailed assessment of procurement and shipping logistics
- We didn’t thoroughly model ACT stock preservation benefits or antimalarial resistance impacts
- We didn’t triangulate CHAI’s predictions for stockouts, e.g. by speaking to Chemonics or PMI
9. Relationship disclosures
Neil Buddy Shah was hired in April 2022 as CHAI’s CEO. Previously, he was GiveWell’s Managing Director.
10. Sources
- 1
This understanding is based on our own conversations with CHAI.
- 2
From the WHO page on malaria RDTs: “WHO recommends prompt parasite-based diagnosis in all patients suspected of malaria before treatment is administered. Malaria rapid diagnostic tests (RDTs) have the potential to greatly improve the quality of management of malaria infections, especially in remote areas with limited access to good quality microscopy services.”
- 3
Our understanding of how RDTs impact treatment for malaria and similar conditions is based on our review of Bruxvoort et al., 2017, a meta-analysis on this topic and our conversations with experts within the malaria treatment space.
In Bruxvoort, figure 2, rates of presumptive ACT treatment range from 20-100%. We guess that 70-90% of febrile cases are given presumptive malaria treatment in government facilities and that the highest rates of presumptive treatment occur in rural settings with limited healthcare access and higher perceived malaria risk.
- 4
Our understanding, based on conversations with CHAI and other stakeholders, is that Chemonics manages the distribution of malaria commodities from central warehouses to health facilities in Nigerian states formerly supported by PMI. They run regular resupply cycles (typically in July, September, and November/December) that transport commodities from central warehouses to individual clinics. For this grant, CHAI would procure and deliver RDTs to central warehouses in Lagos, transfer custody to Nigeria's National Malaria Elimination Programme (NMEP), who would then transfer to Chemonics for distribution to health facilities during their September 2025 resupply cycle. Without RDTs arriving at the central warehouse before this September resupply, clinics would face stockouts until the next resupply cycle in late November/early December.
- 5
CHAI, Budget for malaria RDT procurement in Nigeria (unpublished)
- 6
Our understanding, based on conversations with CHAI, is that these states are
- Oyo
- Nasarawa
- Kebbi
- Akwa Ibom
- Ebonyi
- Bauchi
- Cross River
- Benue
- Plateau
- Zamfara
- 7
Source: Conversations with CHAI (unpublished)
- 8
We’ve included this chance of missing the deadline for the September resupply deadline into our CEA as a -40% adjustment here to account for this risk.
- 9
Source: Conversations with CHAI (unpublished)
- 10
For more on our benchmark and how we compare programs, see this page.
- 11
- The cost per person reached figures are based on the costs to CHAI of procuring, shipping, and storing the RDTs in a warehouse in Nigeria, as well as an adjustment that we make for potential wastage and inefficiencies. It does not include CHAI’s overhead costs for supporting the grant. You can see how we calculate these figures here.
- We estimate that malaria prevalence in the areas supported by this grant range from 20-26% and we guess that the population seeking treatment for malaria has a 50% higher prevalence than the population as a whole. You can see how we calculate these figures here.
- 12
Our understanding of how RDTs impact treatment for malaria and similar conditions is based on our review of Bruxvoort et al., 2017, a meta-analysis on this topic and our conversations with experts within the malaria treatment space.
In Bruxvoort, figure 2, rates of presumptive ACT treatment range from 20-100%. We guess that 70-90% of febrile cases are given presumptive malaria treatment in government facilities and that the highest rates of presumptive treatment occur in rural settings with limited healthcare access and higher perceived malaria risk. In this setting, our best guess is that 70% of febrile cases would receive presumptive care.
To estimate the rate of treatment for people who receive a positive RDT result, we rely on Burchett et al. 2017, where a simple average of their figure 1 based on 24 cases from 9 studies results in a rate of 81%.
- 13
To estimate rates of treatment for non-malaria illnesses, we rely on Bruxvoort et al., 2017, a meta-analysis on this topic and our conversations with experts within the malaria treatment space, and Hopkins et al. 2017 a study on the impact of RDTs on antibiotic prescriptions.
To see how we derive our estimates, see this section of our cost-effectiveness analysis.
- 14
See this section of our simplified cost-effectiveness analysis for more on how we derive this figure.
- 15
Our understanding of how RDTs impact treatment for malaria and similar conditions is based on our review of Bruxvoort et al., 2017, a meta-analysis on this topic and our conversations with experts within the malaria treatment space.
In Bruxvoort, figure 2, rates of presumptive ACT treatment range from 20-100%. We guess that 70-90% of febrile cases are given presumptive malaria treatment in government facilities and that the highest rates of presumptive treatment occur in rural settings with limited healthcare access and higher perceived malaria risk. In this setting, our best guess is that 70% of febrile cases would receive presumptive care.
To estimate the rate of treatment for people who receive a positive RDT result, we rely on Burchett et al. 2017, where a simple average of their figure 1 based on 24 cases from 9 studies results in a rate of 81%.
- 16
CRIA (Clean Report of Inspection and Analysis) approval, per a Nigerian government website is, “is a mandatory conformity assessment scheme introduced by the Federal Government of Nigeria through the National Agency for Food and Drug Administration and Control (NAFDAC) to ensure the quality and safety of all imports of regulated products into the country.”