Against Malaria Foundation — Support for ITN campaign implementation costs in Ituri, DRC (August 2025)

Note: This page summarizes the rationale behind a GiveWell grant to the Against Malaria Foundation. Against Malaria Foundation staff reviewed this page prior to publication.

Published: July 2026

Summary

Background

We previously funded net procurement costs for the 2026 ITN distribution campaign in Ituri, Democratic Republic of the Congo (DRC) as part of a multi-country grant to the Against Malaria Foundation (AMF) in December 2024. When we made that grant, we were uncertain if another funder would support implementation costs for the Ituri campaign. Though The Global Fund to Fight AIDS, Tuberculosis and Malaria (TGF), one of the largest funders of malaria programs globally, had not committed to supporting this campaign, we thought it was possible that they could support the campaign through their portfolio optimization process.1 However, in 2025, the US government - the largest single funder of TGF - cut foreign aid funding considerably. As a result, TGF reduced funding for Grant Cycle 7 (GC7) grants (2024-26).2 Due to these funding cuts, we now believe it is very unlikely that TGF will fund implementation costs for the Ituri campaign.

What we think this grant will do

This grant will fund implementation costs—all expenses beyond net procurement and monitoring—for the 2026 mass ITN campaign in Ituri province, DRC. These costs include:

• Inspections of ITNs
• International and in-country shipping and logistics
• Microplanning and household registration
• Training for distribution teams
• Community sensitization and mobilization
• Distribution of ITNs to households

We expect that 4.4 million ITNs will be distributed during this campaign. The total budget is $9,627,247. AMF has indicated they may achieve savings on this projected budget, and if so, unused funds will be returned to GiveWell.

Why we made this grant

We're recommending this grant for three primary reasons:

High cost-effectiveness. We estimate this campaign will be 16 times as cost-effective as our benchmark ("16x"). 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	$9,600,000
Cost per person under age five reached	$24	$18 - $30	21x - 13x
Number of people under age five reached	400,000
Proportion of reached children who would have slept under ITNs in the absence of the program	24%	15% - 32%	18x - 14x
Additional children sleeping under ITNs as a result of the program	300,000
Years of coverage provided by ITNs	1.5	1.0 - 1.9	11x - 21x
Malaria-attributable mortality rate among people under age five	1.1%	0.44% - 1.8%	6x - 25x
Effect of ITN distributions on deaths related to malaria	50%	40% - 60%	13x - 19x
Number of deaths averted among people under age five	2,500
Cost per under-five death averted (before adjustments)	$3,800
Initial cost-effectiveness in multiples of our benchmark	9x
Proportion of benefits from each outcome
Mortalities averted for people under age five	63%
Mortalities averted for people age five and older	17%
Developmental benefits (long-term income increases)	21%
Adjustment for additional program benefits and downsides	53%	42% - 63%	15x - 17x
Adjustment for grantee-level factors	-25%	(-50%) - 0%	11x - 21x
Adjustment for leverage	-1%
Adjustment for funging	-4%	(-6%) - (-1%)	15x - 16x
Overall cost-effectiveness (in multiples of our benchmark)	16x
Cost per life saved	$3,700

The funding gap is real. TGF had never committed to funding Ituri for the GC7 cycle; due to funding cuts, we think they will now need to cut approximately two provinces in DRC from their existing ITN campaign portfolio. The President’s Malaria Initiative (PMI), formerly part of the U.S. Agency for International Development (USAID), has also not indicated any interest in supporting the Ituri campaign and has faced funding cuts. We estimate only a 5% chance that another funder would fund implementation costs for this campaign in GiveWell’s absence (more).

Learning opportunity. This will be the first time GiveWell funds AMF for ITN campaign implementation. AMF has expressed strong interest in managing complete campaigns to gather data on what level of spend on non-net costs is required and where there may be savings. This single-province campaign provides a good test case given that AMF has worked in DRC for many years and funded net procurement for the previous two Ituri campaigns (more).

Main reservations

• Net use uncertainty: Recent survey data and modeling from a technical assistance provider suggests that net use rates in Ituri may be substantially lower than the national average, though we're uncertain about the exact magnitude. We've adjusted our cost-effectiveness estimate downward to account for this (more).
• AMF's distribution experience: While AMF has extensive experience with net procurement and has closely monitored distribution in DRC for years, this is the first time GiveWell is funding AMF to directly manage distribution contracts and implementation for an ITN campaign (more).

Planned activities and budget

Activities supported by the grant

The grant will fund all aspects of the 2026 ITN campaign in Ituri, DRC beyond the nets themselves, which we funded through a separate grant in December 2024. We expect that activities will include:3

• Inspections: Before they are shipped to countries, nets are inspected for quality. This includes both a visual inspection and lab tests for bioefficacy.
• International shipping and logistics: Nets are shipped from the point of manufacture to the DRC.
• In-country transport and logistics: Nets are transported from their arrival point in the DRC to Ituri, where they are stored in warehouses before being transported to health zones.
• Microplanning: The national malaria program and in-country distribution partner compile data to accurately plan for net need, resource/budget needs, and likely distribution challenges/delays, then produce a list of villages where nets will be delivered.
• Training: Campaign staff are trained to conduct distributions through a training-of-trainers model, whereby national staff train provincial-level staff, who train health zone-level staff and community health workers.
• Community sensitization: Information about the upcoming campaign is disseminated to communities; sensitization mechanisms may include radio and television advertisements and local “criers”.
• Net distribution: Nets are distributed to households.

AMF will contract implementing partners who will directly conduct the above activities.4

Budget breakdown

The total budget is $9,627,247 for distributing approximately 4.4 million nets.5 This budget is based on TGF’s estimated budget for the campaign, but AMF has indicated they may be able to achieve savings of up to 20% ($1.9 million) compared to TGF’s budget.6

The case for the grant

High cost-effectiveness

We continue to think that ITN campaigns in Ituri are highly cost-effective because of the high malaria burden in Ituri7 and relatively low counterfactual coverage.8 When we made the grant to AMF for the net costs of this campaign in Ituri in December 2024, we modeled the CE of the campaign at 19x. We assume that cost-effectiveness is the same for implementation costs as for net costs because the way we model cost-effectiveness for ITN campaigns incorporates the full cost of procuring and delivering nets, even if we are only directly funding procurement.9

We have updated our cost-effectiveness model for this grant, and we now estimate this campaign will be 16 times as cost-effective as our benchmark.10 During the investigation for this grant, we made the following changes to our model:

• Funging adjustment: We think another organization funding non-net costs for this campaign is very unlikely (more). Therefore, we have reduced the funging adjustment from 15% to 5%.
• Insecurity leading to net loss: In areas of high insecurity, such as Ituri, there is often limited in-person monitoring of distributions. We think that this could lead to more nets being lost or otherwise unaccounted for at various stages of the distribution process. Before this investigation, we had set our adjustment for biased monitoring results at -10% for DRC (as compared to -2% in other geographies); as we believe Ituri is a context with heightened insecurity, even compared to the DRC average, we increased the magnitude of this adjustment to -15%.
• Net use: The net use data from recent surveys suggest that net use in Ituri may be lower than the national average, but we’re not sure by how much (more). To account for this, we adjust the net use estimate downward from the overall DRC estimate by 15%, which gives us an Ituri-specific estimate of 62%.

The funding gap is real

We believe it is very unlikely that another funder would support this campaign in GiveWell’s absence.11

Our understanding when we made the grant was that The Global Fund to Fight AIDS, Tuberculosis and Malaria (TGF) cut DRC's malaria budget by 12% ($35 million) for Grant Cycle 7 (GC7, 2024-26),12 after the US government - the largest single funder of TGF - has reduced aid funding substantially. TGF’s country team for DRC told us in July 2025 that they did not plan to cut any 2025 campaigns, but would likely need to cut 2026 campaigns in two provinces that they had previously intended to fund.13 Given that TGF is struggling to maintain their existing malaria commitments for DRC, they do not seem to be in a position to consider taking on new funding opportunities, such as the campaign in Ituri. Therefore, we believe it is very unlikely that TGF would fund distribution costs in Ituri in GiveWell’s absence.

The other major funder of global malaria programs, the President’s Malaria Initiative (PMI), has not expressed interest in Ituri. While we did not speak to PMI for this investigation, our impression is that in the short-term, PMI is generally adhering to its past commitments with respect to commodity procurement and distribution but is not taking on any new commitments. Therefore, we think it is very unlikely as well that PMI would fund these distribution costs.

We are not aware of any other funders that could step in to fill this gap.

Learning opportunity

To date, AMF has primarily focused on net procurement and campaign monitoring, with other partners funding and managing distribution. However, AMF has expressed interest in starting to manage campaigns from beginning to end in order to learn whether there is opportunity for cost savings on the distribution side.14 They've recently begun doing this work by directly funding distribution of, and managing the implementation partner for, the final two waves of the 2025 Guinea ITN campaign and one state in Nigeria.15

We think this campaign could be a good test case for GiveWell to learn more about how AMF manages the implementation costs for an ITN distribution given that the campaign is for only one province, it’s a province where AMF has funded net procurement previously,16 and it’s a country that AMF has worked in for many years and seems to have strong relationships with many relevant stakeholders.17

Risks and reservations

Uncertainty about net use rates

We spoke with an external organization that had recently modeled ITN campaign impact for each DRC province and had concluded that Ituri should be deprioritized for an ITN campaign relative to other provinces. Our understanding after speaking with this organization and investigating their models is that this conclusion was primarily based on data that suggests net use in Ituri is in the bottom quintile of DRC provinces.18

However, we are skeptical that we can conclude that net use is significantly lower than the DRC average for the following reasons:

• The model was based on overall net use, rather than net use given net access.19 We think the latter is a better indicator of net use.
• We think it’s likely that the data for the most recent DHS survey (2023-24) was collected either immediately before or during Ituri’s mass campaign. The DHS report indicates that data in the 19 provinces outside of the Kinshasa Pool20 was collected from Nov 20, 2023 to Feb 1, 202421 and Ituri's last ITN campaign happened in Dec 2023 to Jan 2024.22 Ituri’s net access rate in this survey is also quite low (60.9% vs national average of 69.4%), which corroborates this theory; it makes sense that if data was collected right before or during the early stages of a mass campaign, fewer people would have nets compared to the national average.23 We think that net use data immediately before or during a campaign is likely unrepresentative of net use in the months after a campaign because existing nets are more likely to be worn out; people are less likely to use nets that are torn compared to brand new nets.
• The 2013-14 DHS survey was conducted before the provinces of DRC were restructured in 2015. At that time, Ituri was part of Orientale province. The model used data from Orientale province for all of the new provinces that made up the former Orientale province, including Ituri.24 While this seems logical from a methodological standpoint, it also means that the data used for Ituri may not be completely representative.
• AMF’s post-distribution monitoring (PDM) data does not show nearly as large a difference. The PDM report from the 2021 campaign showed use at 72% at 18 months post-distribution versus 77% nationally, and at 53% at 27 months post-distribution versus 54% nationally.25

On the other hand, we have not dug deeply into this model or data, and we may be missing something important. While we do not think we should entirely adopt the net use estimates implied by this data, this discussion did prompt us to revisit our analysis of ITN use. To account for this uncertainty, we adjusted our net use estimate for DRC downward by 15% to produce an Ituri-specific estimate of 62%.

AMF's limited distribution experience

While AMF has extensive experience with procurement and monitoring of ITN campaigns for years, they have limited experience directly managing campaign implementation. We feel relatively confident that AMF is thinking about reasonable measures to ensure the success of the campaign26 and that their existing in-country relationships27 will be an asset, but we also think that DRC, and Ituri in particular, may be a difficult operating environment.

Plans for follow-up

We will track this grant's progress through:

• Monthly calls with AMF to discuss procurement progress, campaign planning, and implementation, including the measures discussed above, their selection of implementer, and the final campaign cost.
• Communication with TGF’s DRC country team about other potential gaps, which we may investigate filling if appropriate.
• Reviews of distribution data including coverage achieved, delays encountered, and accountability metrics.
• Analysis of post-distribution monitoring data at 9, 18, and 27 months post-campaign to assess whether net use diverges significantly from expected values.
• Some form of post-campaign assessment to evaluate whether AMF successfully implemented this campaign, which may include calls with stakeholders such as the PNLP and relevant logistics and implementation partners. We will use this to inform whether we want to make additional grants to AMF for ITN campaign logistics and distribution.

Internal forecasts

For this grant, we are recording the following forecasts:

Confidence	Prediction	By when	Resolution
35%	The final amount that AMF spends on non-net costs for this campaign is < $8.6m (~10% less than budgeted)	December 2026
30%	The campaign begins by June 2026	June 2026
80%	The campaign begins by December 2026	December 2026
70%	We will fund AMF for non-net costs again by the end of 2026	December 2026
40%	After we receive PDM data for this campaign, we will conclude that net use in Ituri is likely > 10% lower than the national average (based on PDM data and other data sources) by the end of 2028	December 2028
55%	We will investigate another grant for DRC non-net costs by the end of 2025.	December 2025
65%	We will fund a campaign in Ituri (either net costs or non-net costs) for GC8 by the end of 2028.	December 2028

Our process

Our investigation included:

• We spoke with AMF leadership and with the Global Fund DRC team about funding gaps and prioritization
• We spoke with an external organization about their prioritization modeling and methodology
• We reviewed the Global Fund reprogramming documents showing budget cuts and AMF's budgets
• We updated of our cost-effectiveness analysis and analysis of ITN use with new net use data

Sources

Document	Source
Against Malaria Foundation, Distribution Data	Unpublished
Against Malaria Foundation, Distribution Summaries	Unpublished
AMF, "Runthrough of AMF activities," 2024	Unpublished
AMF, 9-month Post-Distribution Monitoring, Ituri, Democratic Republic of Congo – 2021	Source
AMF, multiple conversations with GiveWell, 2025	Unpublished
AMF, Written responses to GiveWell questions about implementation planning, July 2025	Unpublished
DHS 2023-24 summary report, DRC, 2023-2024	Source
GiveWell, Against Malaria Foundation — Support for ITN Campaigns in Chad, DRC, Nigeria, and Zambia	Source
GiveWell’s CEA of insecticide-treated net (ITN) distributions for Ituri non-net costs	Source
GiveWell’s CEA of insecticide-treated net (ITN) distributions, Dec 2024	Source
Global Fund DRC, "Ituri campaign budget," shared by AMF, July 2025	Unpublished
Global Fund DRC, conversation with GiveWell, July 18, 2025	Unpublished
GW’s analysis of ITN usage following mass campaigns, July 2025	Source
The Global Fund, Operational Policy Note: Portfolio Optimization, 2024	Source

• 1“Portfolio Optimization is the Global Fund’s method for reallocating unused grant funds to
  areas where they can be invested to achieve greater impact.” The Global Fund.
• 2Our understanding is that TGF reduced funding for GC7 grants by approximately 11% across all diseases globally and 12% for malaria in DRC specifically. (See below.)
• 3We based this understanding of typical activities on previous information provided by AMF, and did not confirm again all components of the non-nets cost of this distribution. AMF, "Runthrough of AMF activities," 2024 (unpublished).
• 4AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).
• 5 Global Fund DRC, "Ituri campaign budget," shared by AMF, July 2025 (unpublished).
• 6AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).
• 7We estimate the malaria-attributable mortality rate among under-5s at 1.11% for Ituri, which is higher than any of the other geographies we funded as part of our December 2024 grant to AMF.
• 8We estimate that 24% of reached children would have slept under an ITN in the absence of a campaign.
• 9The intuition behind this approach is that AMF is usually “trading” ITNs with other funders for delivery costs (i.e. some of the nets that AMF procures would have been procured by other funders, which frees up these other funders to fund delivery of AMF nets). This means we think that the incremental number of nets delivered because of an AMF grant is similar to the number of nets that would be delivered if that grant was directly funding both procurement and distribution.
• 10See our full cost-effectiveness analysis here.
• 11We estimate this probability at 5% in our cost-effectiveness model.
• 12Global Fund DRC, conversation with GiveWell, July 18, 2025 (unpublished).
• 13Global Fund DRC, conversation with GiveWell, July 18, 2025 (unpublished). This was our understanding when we made the grant; we were told by the Global Fund DRC team in February 2026 that it may be possible for the Global Fund to maintain its original commitments to ITN campaigns in DRC for 2026.
• 14AMF, multiple conversations with GiveWell, 2025 (unpublished).
• 15AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).
• 16"You are correct that AMF procured nets for the last two distributions in Ituri. These were in 2021 and 2023/24." AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).
• 17"We are familiar with the organisations in DRC which would likely be best placed to deliver the Ituri campaign and have worked extensively with them previously. We would seek to work with partners and in particular key personnel that we have identified over the years as part of risk mitigation…AMF’s extensive agreement with MoH covering many operation specifics, means we have already been involved with most stages of campaign delivery in DRC, i.e. from campaign planning, microplanning, delivery tracking, distribution monitoring and closeout. While our role would change as the single funder of a provincial campaign, we would not be entering unfamiliar territory." AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).
• 18This data came from province-level DHS and MICS surveys conducted in 2023-24 (DHS), 2017-18 (MICS), and 2013-14 (DHS).
• 19Conversation with external organization, July 25, 2025 (unpublished). The external organization have said they control for net access by modeling when campaigns happened, but we’re not convinced that this overcomes the concern that the DHS data might have been gathered just before the campaign (see following bullet).
• 20The following provinces are included in the Kinshasa Pool: Kinshasa, Kasaï, Kwango, Kwilu, Kongo Central, Mai-Ndombe, and Sankuru (DHS 2023-24 summary report, pg. 6).
• 21"It was carried out in stages: first in the seven provinces of the Kinshasa Pool (from October 6 to December 8, 2023), then in the 19 other provinces (from November 20, 2023 to February 1, 2024)." DHS 2023-24 summary report, pg. ix, translated.
• 22Against Malaria Foundation, Distribution Summaries (unpublished).
• 23DHS 2023-24 summary report, pg. 38
• 24 Conversation with external organization, July 25, 2025 (unpublished).
• 25Against Malaria Foundation, Distribution Data (unpublished).
• 26When we asked AMF about this, they said they are considering measures including increasing their scope of campaign monitoring, interviewing experts to gain more insight into campaign management, and more regular partner check-ins and reviews, possibly including more frequent trips to Kinshasa. AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).
• 27AMF, Written responses to GiveWell questions about implementation planning, July 2025 (unpublished).