MSI Reproductive Choices — Family Planning Mobile Outreach Programs in Nigeria & Sierra Leone (September 2025)

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

Published: August 2026

1. Summary

1.1 Background

We think that increasing access to modern contraception in low- and middle-income countries (LMICs) has a range of potential benefits including averting maternal mortality and morbidity from unintended pregnancies and improved health for women and children. For more on how GiveWell currently values increasing access to modern contraception see here.

MSI Reproductive Choices (MSI) is an international NGO that provides access to contraception in 36 countries across the world. MSI's mobile outreach program aims to bring comprehensive contraceptive services directly to remote, rural communities with limited access to family planning options. MSI Outreach teams visit remote communities 2-4 times annually, set up temporary family planning clinics, and provide family planning counseling and free access to modern contraceptive methods.

1.2 What we think this grant will do

This $6.3 million grant funds MSI Reproductive Choices to set up two new family planning Outreach teams in Enugu and Kwara states in Nigeria over 36 months, and maintain five existing Outreach teams in Sierra Leone for 30 months.

Each of these outreach teams will visit remote and rural communities, which have limited access to modern contraception, 2 to 4 times a year to provide information about family planning, deliver free family planning counselling, and provide a range of modern family planning methods, including 3- and 5-year implants, copper IUDs, injectables, pills and condoms at pop-up clinics.

This grant will support the Outreach team costs such as provider salaries, vehicles, and fuel, a portion of commodities required,1 as well as a portion of the MSI country team costs and global costs.2

We estimate that funding these Outreach teams over the grant period will result in roughly 520,000 counterfactually additional years of modern contraception per year (~276,000 in Sierra Leone and ~245,000 in Nigeria), before accounting for funging risk. We estimate this additional contraception will avert roughly 160,000 unintended pregnancies (~80,000 each in Sierra Leone and Nigeria).

1.3 Why we made this grant

We recommended this grant because:

• Learning value for future funding opportunities and family planning as a sector: MSI’s Outreach program has a clear program model and is well-positioned to serve as a reference point within the family planning service delivery sector. Through this grant, we expect to learn more about our key questions about family planning programs, including contraceptive access, use, and autonomy—including risks of unwanted contraception. We expect learnings from this grant (and the evaluation, funded separately) to inform our decisions regarding future grant opportunities with MSI and in family planning more broadly. (More)
• Cost-effectiveness: We estimate the Outreach activities supported by this grant are 10-14x as cost-effective as GiveWell's benchmark. MSI can provide access to modern contraception fairly cheaply (around $8-9 per year of protection, including leveraged costs), and we estimate that roughly 50% of the contraception provided is counterfactually additional because MSI targets communities with limited alternative access to the methods they provide, and reaches a high percentage of women who report never having used contraception or not being aware of another source providing the method they received from MSI. (More)

A summary of our quantitative cost-effectiveness analysis is below. Our full analysis is here.

Simple CEAs	Sierra Leone	Nigeria
Total cost to grantee (over grant duration)	$3,000,000	$3,307,053
Number of couple-years of modern contraception provided/administered	583,531	490,372
Cost per year of modern contraception provided	$5.14	$6.74
% of years of contraception provided that are counterfactually additional	47%	50%
Total number of counterfactually additional years of modern contraception provided	276,930	245,158
Value of counterfactually providing a year of contraception	0.68	0.86
Units of value generated	188,312	210,836
Adjustment for other benefits or offsetting effects	-10%	-15%
Units of value generated after adjustments (contraception being unwanted or unused)	169,481	179,211
Adjustment for leveraged costs	-19%	-6%
Adjustment for funging risk	-30%	-10%
Units of value generated after leverage adjustment	95,705	152,102
Units of value per dollar generated by this program	0.032	0.046
Units of value per dollar, our benchmark	0.00333	0.00333
Cost-effectiveness multiple in terms of GiveWell's benchmark	10	14

1.4 Our main reservations

Our main reservations about this grant are:

• Risk of unwanted contraception: We think there is a risk of unwanted or misinformed use of contraception in most family planning programs due to the possibility of provider-bias and the need for some long-acting methods to be administered and removed by providers. This risk may be higher in programs like MSI Outreach that aim to be cost-efficient (which could inadvertently incentivize providers to push clients to take up contraception or towards specific methods), offer a high proportion of long-acting methods (which cannot be self-removed by the client), and visit remote communities periodically rather than delivering continuous service provision (meaning that if a client's preference changes in between visits they may face greater access barriers to care). MSI was cited for coercive practices in one past case—through a court finding—and in 2016, a UK healthcare regulator flagged concerns around gaps in training and safeguarding that could impact informed consent. (However, recent clinic assessments by the same regulator found MSI clinics to be "Good" or "Outstanding"). Our uncertain best guess is that these cases were outliers that are not representative of MSI’s values or the quality of care that MSI provides through its programming today, and that MSI has reasonably robust procedures in place to reduce the risk of providers coercing clients to take up contraception. While MSI’s large scale of operations probably means it’s impossible to completely eliminate provider bias and other ways in which clients may receive unwanted contraception, MSI appears to have a range of monitoring and governance mechanisms in place to mitigate this risk. We will attempt to monitor and understand these risks further using independent M&E, but expect that the risk cannot be monitored perfectly and is difficult to eliminate. (More)
• Uncertainty about cost-effectiveness: We are very uncertain about our cost-effectiveness estimates for family planning programs, because of our uncertainty about the value of additional years of modern contraception relative to other outcomes, and challenges in estimating to what extent the contraception provided by family planning programs is counterfactually additional and the product of fully informed and free choice. We expect to refine our estimate over time as new information becomes available and as we consider future grantmaking opportunities. (More)
• Funging risk: Compared to some other NGOs, MSI appears to be relatively well-funded in recent years. They have had relatively small exposures to changes in US foreign aid, generate service revenue, and have accumulated funds that could sustain their higher impact programming for roughly 2 years without additional funding. This means we are less certain that the programming we are funding would not have been funded in the counterfactual. We’ve adjusted for this through a subjective downward adjustment to our cost-effectiveness estimate, but we’re uncertain about the size of this adjustment. (More)
• Uncertainty about the overall effect of abortions and how to value them relative to other outcomes: MSI provides abortion products and services in several programs, including through their Outreach teams that supply drugs for medical abortions. In Sierra Leone and Nigeria, MSI’s programs offer services for post-abortion care for unsafe abortions or spontaneous miscarriages. Our current uncertain guess is that MSI’s programming in low- and middle-income countries overall reduces the number of abortions that occur by increasing access to contraception and reducing unintended pregnancies. We haven’t tried to model the overall effect on abortions and have not developed an assessment of the net value of additional abortions. (More)

2. The organization

MSI Reproductive Choices (MSI) is an international NGO founded in 1976 that works across 36 countries3 to support people by providing access to reproductive healthcare, including contraception and abortion.4

3. The intervention

MSI's Outreach program aims to bring comprehensive contraceptive services directly to communities that are remote, rural, or otherwise face limited access to care.5 The program specifically targets areas with large unmet demand for contraception and high rates of severe multidimensional poverty, selected through collaboration with local government stakeholders using administrative data and community knowledge.6

Service delivery approach
MSI Outreach teams visit targeted communities 2-4 times annually,7 setting up temporary family planning clinics either within existing public health facilities (that lack supplies or trained staff) or at MSI-designed tents when suitable facilities aren't available.8 Each team consists of two MSI-trained clinical staff, a driver, and administrative support, sometimes supplemented by local providers.

Services provided
Teams offer group information sessions followed by private counseling and free provision of modern contraceptive methods, including 3- and 5-year implants, copper IUDs, injectables, pills, and condoms.9 Most clients choose long-acting methods like implants or IUDs,10 which are typically harder to access through local public facilities. In some countries, teams also provide limited safe abortion and post-abortion care services.11

Community engagement
Ahead of Outreach visits, MSI coordinates with government health officials and local stakeholders and health workers to select communities, schedule visits, and mobilize people who are interested in receiving family planning services to visit the Outreach sites. Program staff work with community mobilizers, faith-based organizations, and village leaders to spread awareness about upcoming services. While not door-to-door delivery, the program significantly reduces travel barriers—clients typically travel up to 5km (30 minutes to 1 hour) rather than much longer distances to reach traditional facilities.

Quality assurance
MSI maintains service quality through monitoring including data audits, vehicle tracking, clinical quality assessments, client exit interviews, and "mystery client" visits.12

3.1 Do family planning mobile outreach programs work?

Our full analysis of the family planning mobile outreach program model is covered in our intervention report.

In short, we think there is a reasonably strong case for this intervention. We think that mobile outreach has a straightforward theory of change for how it could genuinely expand access to modern contraception. Using client exit data collected by MSI, we estimate that close to half of the contraception provided by mobile outreach programs in these geographies is counterfactually additional, meaning it wouldn’t have occurred in the absence of the program.

However, our confidence in this intervention is limited by:

• limited rigorous evidence on the impact of mobile outreach programs on contraceptive use at the community level
• the risk of contributing to unwanted or misinformed use of contraception (more on this below)

Benefits of access to modern contraception

A central reservation we have about any family planning program is a high uncertainty about how to weigh the value of additional years of modern contraception relative to other types of program outcomes such as averting deaths and increasing income. We think that additional years of modern contraception can generate a range of benefits in low-and-middle income countries (LMICs), including improved well-being for people who want to use contraception, improved health for women and children, increased resources per existing child, and increased earnings for women.13 GiveWell's current approach to comparing the value of these outcomes to other program outcomes is covered on this page.

For this grant, we relied on our existing Valuing Contraception BOTEC, which suggests that in Nigeria and Sierra Leone, the benefits of additional years of modern contraception come from:14

• Improved health for women using contraception and newborns (those who are born even with increased use of contraception): ~40% of benefits
• Improved subjective well-being for women using contraception: ~30% of benefits
• Increased resources for existing children due to fewer unwanted births: ~20% of benefits
• Increased household income through higher earnings of women using contraception: ~10% of benefits

4. The grant

In Nigeria, this grant will allow MSI to launch a new outreach team in each Enugu and Kwara states and implement the Outreach program in these states for 36 months.15 MSI chose these states because they have low and declining levels of modern contraceptive use (used by 11.2% and 9.9% of married women and sexually active unmarried women of reproductive age, according to the 2023-24 DHS) and high "unmet need for family planning" (23.6% and 27.1% of married women and sexually active unmarried women of reproductive age).16

In Sierra Leone, the grant will allow MSI to continue Outreach programming in five districts for 30 months through five existing Outreach teams.17 MSI chose these districts because they have relatively low levels of modern contraceptive use and high unmet need for family planning.18

We estimate that funding these Outreach teams over the grant period will result in roughly 520,000 counterfactually additional years of modern contraception per year (~276,000 in Sierra Leone and ~245,000 in Nigeria), before accounting for funging risk. We estimate this additional contraception will avert roughly 160,000 unintended pregnancies (~80,000 each in Sierra Leone and Nigeria).19

4.1 Budget for grant activities

This grant will support the Outreach team costs such as provider salaries, vehicles, fuel, and a portion of commodities required,20 as well as a portion of the MSI country team costs and global costs.21 The total grant budgets are broken down as follows.22

Sierra Leone grant ($3,000,000 over 30 months)

• Country office and outreach personnel: $716,000
• Other direct costs (fuel, office expenses): $734,000
• Capital equipment (vehicles, medical equipment): $318,000
• Meetings, training, and M&E: $523,000
• Contraceptive commodities: $215,000
• Travel: $43,000
• Indirect/global costs (15%): $450,000

Nigeria Budget ($3,307,053 over 36 months)

• Country office and outreach personnel: $799,000
• Contraceptive commodities and shipping: $716,000
• Travel: $543,000
• Other direct costs (fuel, office expenses): $417,000
• Meetings, training, and M&E: $206,000
• Capital equipment (vehicles, medical equipment): $130,000
• Indirect/global costs (15%): $496,000

5. The case for the grant

We are recommending this grant because:

• Learning value for future funding opportunities and family planning as a sector: MSI’s Outreach program has a clear program model and is well-positioned to serve as a reference point within the family planning service delivery sector. Through this grant, we expect to learn more about our key questions about family planning programs, including contraceptive access, use, and autonomy—including risks of unwanted contraception. We expect learnings from this grant (and the evaluation funded separately) to inform our decisions regarding future grant opportunities with MSI and in family planning more broadly. (More)
• Cost-effectiveness: We estimate the Outreach activities supported by this grant are 10-14x as cost-effective as GiveWell's benchmark. MSI can provide access to modern contraception fairly cheaply (around $8-9 per year of protection, including leveraged costs), and we estimate that roughly 50% of the contraception provided is counterfactually additional because MSI targets communities with limited alternative access to the methods they provide, and reaches a high percentage of women who report never having used contraception or not being aware of another source providing the method they received from MSI. (More)

5.1 Learning value

We expect this grant to generate significant learning value that could inform future funding decisions, both for MSI specifically and for family planning programs more broadly.

Learnings through this grant will help inform our understanding of the quality and cost-effectiveness of MSI's programming, in turn informing future decision-making about future MSI grant opportunities. We think MSI could have more cost-effective opportunities across its "last mile" delivery programs (Outreach, public sector strengthening, and community health worker support programs).23

This grant may also help us learn about family planning as a cause area, which we currently think is a sector with high potential for cost-effective funding opportunities. The family planning sector appears to be disproportionately exposed to foreign aid cuts relative to most other areas that GiveWell has considered funding,24 which means there could be increasing room for more funding in the future.

MSI's mobile Outreach program provides a strong first comparison point across the sector. MSI's outreach program is a relatively straightforward service delivery model with a clear theory of change. Other stakeholders we spoke to consider MSI's programs at the high end of service quality and monitoring within the family planning sector. This means this program will be a strong entry point for us to learn about family planning program implementation and delivery, as well as contextual factors, informing our future grantmaking approach across the sector. If learnings through this grant update us negatively about the likely cost-effectiveness of this program, it may represent a negative update on family planning service delivery programs more broadly, which would meaningfully inform our grant-making in the sector.

Improving Sector Knowledge and Coordination: MSI has a large footprint in international family planning and implements multiple delivery models (outreach, public sector strengthening, community health worker programs, social marketing). Through our partnership with them, we may also learn about other program types and developments in the field. We also have the opportunity, through strengthened relationships with MSI and its partners, to learn about and better understand how other stakeholders coordinate investments in this sector and how their strategies may in turn shape implementation.

We plan to learn through several channels:

• Regular check-ins with MSI (twice per year) to understand how implementation is progressing, including any deviations from plans or unexpected challenges.
• MSI's own monitoring data, including administrative data on service delivery and costs, client exit interview results, and findings from their mystery client visits.
• A site visit to observe the Outreach program in action in either Sierra Leone or Nigeria.
• Independent monitoring and evaluation that we funded through a separate grant (page forthcoming) to Innovations for Poverty Action (IPA). IPA's M&E will include household surveys, client exit interviews conducted independently of MSI, observation of outreach sessions, and mystery client visits. They will also attempt to use data from ongoing randomized controlled trials of MSI Outreach in other locations (in Nigeria and DRC) to predict how those findings would generalize to the settings we are funding. This evaluation will help us triangulate key assumptions in our cost-effectiveness analysis, particularly:
  • The extent to which contraception provided is counterfactually additional (contraception clients would not otherwise have accessed)
  • The prevalence of unwanted or coerced contraception in MSI's programs
  • The characteristics of communities and individuals reached by the program, which would inform their demand and counterfactual access to contraception

We think MSI could be a strong learning partner because they have extensive monitoring and evaluation systems, have been highly responsive to our questions, and have expressed openness to independent evaluation of their programs.

5.2 Cost-effectiveness

We estimate that MSI's Outreach program is roughly 10-14x as cost-effective as GiveWell's cost-effectiveness benchmark.25 This estimate is uncertain, and we think the true value could plausibly range from below our cost-effectiveness bar (at the time of making the grant) to substantially above it.

Our cost-effectiveness estimate rests on three main factors:

• The cost of providing contraception through mobile outreach appears low. We estimate the program costs MSI roughly $5-7 per couple-year of protection (CYP) provided, and $8-9 per CYP when including costs covered by other actors such as government-donated commodities. We think these relatively low costs are plausible for two reasons. First, the mobile outreach model, where a small team of providers visits many communities a few times per year, may be more efficient than maintaining permanent clinic presence in each community. Second, the vast majority of CYPs provided come from long-acting reversible contraceptives (LARCs), which have lower commodity costs per year of protection than short-acting methods.26 (Note that we also think provision of LARCs can create more scope for coercion and unwanted contraception than short-term methods, discussed below.)
• A substantial fraction of contraception provided appears to be counterfactually additional. We estimate that roughly 50% of the years of contraception provided by MSI Outreach would not have occurred in the program's absence. This estimate is based on MSI's client exit interview data, which shows that only 32-46% of clients report knowing of another provider offering the same service,27 and 31-48% are first-time family planning users.28 MSI’s Outreach model may induce self-selection of clients for whom family planning provided by MSI is particularly valuable, since clients typically have to travel some distance to reach the Outreach site.29 On the other hand, it’s also possible that the need to travel selects women who have more financial resources or independence and that these women are more likely to have accessed contraception in the absence of the program. We plan to learn about clients’ motivations for getting contraception through MSI Outreach via the independent evaluation.
• We think additional voluntary contraception generates substantial benefits. Based on our existing analysis of the value of contraception in low- and middle-income countries, we estimate that a counterfactually additional year of wanted modern contraception would be above our 10x cost-effectiveness bar (at the time of making the grant) if it can be delivered for less than $26 in Nigeria or $20 in Sierra Leone. This is because we believe voluntary contraception results in improved health for women and newborns (roughly 40% of estimated benefits), improved subjective wellbeing for women (30%), increased resources for existing children (20%), and increased household income (10%).

Our cost-effectiveness estimate is intended to represent our best guess, and it relies on several judgment calls and assumptions. For a more thorough walkthrough of our reasoning and assumptions that informed this model, please see our intervention report on family planning mobile outreach.

6. Risks and reservations

Our main reservations about this grant are:

• Risk of unwanted contraception: We think there is a risk of unwanted or misinformed use of contraception in most family planning programs due to pressure (unintentional and often subtle) from providers, and that this may be higher in programs like MSI Outreach that aim to be cost-efficient, offer long-acting, provider-administered methods, and visit remote communities periodically rather than delivering continuous service provision. MSI has also been implicated in one reported case of coercion in the past,30 and in 2016, a UK healthcare regulator flagged concerns about gaps in training and safeguarding that could impact informed consent. However, recent clinic assessments by the same regulator found MSI clinics to be “Good” or “Outstanding.” MSI’s large scale of operations probably means it’s impossible to completely eliminate coercion by its providers. However, MSI appears to have a range of monitoring and governance mechanisms in place to mitigate this risk, and our impression from speaking to other funders is that they generally provide high quality client care and improve reproductive autonomy for people by expanding their contraceptive options. Still, we are unsure how large the remaining risks are. We will attempt to monitor and understand these risks further using independent M&E, but expect that the risk cannot be monitored perfectly and is difficult to eliminate. (More)
• Uncertainty about cost-effectiveness: We are very uncertain about our cost-effectiveness estimates for family planning programs, partly because of our uncertainty about the value of additional years of modern contraception relative to other outcomes, and partly because of challenges in estimating to what extent the contraception provided by family planning programs is counterfactually additional and the product of fully informed and free choice. We expect to refine our estimate over time as new information becomes available and as we consider future grantmaking opportunities. (More)
• Funging risk: MSI appears to be relatively well-funded at the moment since they are not directly exposed to changes in US foreign aid and have accumulated funds that could sustain their higher impact programming for roughly 2 years without additional funding. We think there’s a high chance that the existing Sierra Leone outreach teams in particular would have been funded using MSI’s existing funding for at least some of the next two years. We’ve attempted to adjust for this through a subjective downward adjustment to our cost-effectiveness estimate, but we’re uncertain about the size of this adjustment. We don’t think we should withhold funding for this reason since this grant has broader learning value for us and because we expect MSI’s funding situation to become weaker over time given the broader outlook for family planning funding. (More)
• Provision of abortion services and uncertainty about the overall effect of abortions and how to value them relative to other outcomes: MSI provides abortion products and services in several programs, including through their Outreach teams that supply drugs for medical abortions. In Sierra Leone and Nigeria, MSI’s programs offer services for post-abortion care for unsafe abortions or spontaneous miscarriages. Our current uncertain guess is that MSI’s programming in low- and middle-income countries overall reduces the number of abortions that occur by increasing access to contraception and reducing unintended pregnancies. We haven’t tried to model the overall effect on abortions and have not developed an assessment of the net value of additional abortions. (More)

6.1 Risk of unwanted or misinformed use of contraception

We think that family planning programs, and particularly mobile outreach programs like this one, carry a meaningful risk of unwanted contraception. This could occur through instances of inadequate informed consent or patients receiving a long-acting method then not having timely access to removal care if their preference changes between outreach visits. Additionally, MSI was implicated in one previous case of women receiving sterilizations under reportedly coercive conditions, and in 2016 a UK healthcare regulator flagged concerns about gaps in training and safeguarding that could impact informed consent. However, recent clinic assessments by the same regulator found MSI clinics to be "Good" or "Outstanding."31 This is our most significant ethical concern about this grant.

We see these risks falling into three distinct categories:

• Risks in family planning programs generally
• Risks particular to mobile outreach program models
• Risks that could be particular to MSI's policies and practices.

Below is our assessment of each of these risk categories for this grant recommendation.

The risk in family planning programs generally

While all family planning programs we've encountered aim to support voluntary contraception use, we think some amount of unwanted or misinformed use is likely to occur in practice. This could range from subtler forms of provider influence, such as biased counseling, limited information about side effects, or steering clients toward particular methods, to more overt coercion like refusing to remove a long-acting method at a woman's request or administering a method without clear consent.

We are uncertain about the prevalence of different forms of inadequate informed consent. Based on available evidence and conversations with researchers, other funders, and implementers, our rough guess is that overt coercion is uncommon in the contexts we're funding (affecting less than 10% of users across family planning programs in general). However, we think subtler forms of inadequate informed consent may be more common.

The best quantitative evidence comes from Senderowicz et al. (2023), which surveyed nearly 4,000 women in Burkina Faso including over 1,200 contraceptive users. The study found that self-reports of overt coercion were rare: only about 3% of LARC users reported being refused discontinuation, and about 2% reported using contraception against their will. However, indicators of informed choice were more mixed—while 96% of users knew an advantage of family planning, only 47-48% could name a disadvantage of family planning or their specific method. This suggests gaps in the information clients receive even when overt coercion is absent.

We spoke with researchers who study contraceptive autonomy and learned that measuring it is very challenging. Clients may not recognize when they've received biased information, respondents tend to report positively about care quality in exit interviews, and private provider-client interactions are difficult to observe. One expert we consulted indicated that true coercion rates among LARC users are uncertain but likely higher than the 1-2% captured by the most overt survey measures.

This risk may be elevated in some mobile outreach programs

We think certain structural features of mobile outreach programs, like MSI's, may increase the risk of unwanted contraception compared to other service delivery models:

• Efficiency incentives may create pressure toward uptake over counselling quality. Programs focused on cost-efficiency typically measure success using metrics which capture contraceptive uptake but not the quality of counseling or whether use is truly voluntary. This could feasibly create implicit pressure to prioritize uptake. As outlined in this document, MSI has practices in place to avoid this risk.
• Long-acting methods dominate the method mix. Over 90% of the contraception (in CYP) from MSI's mobile outreach comes from LARCs like implants and IUDs.32 These methods require a provider to insert and remove, which creates more opportunity for a method to be provided when a client is unsure. Once inserted, a client cannot discontinue use without the service of a medical provider.
• Periodic visits limit access to removal services. MSI Outreach teams visit a given community 2-4 times per year. Between visits, a woman who wants her implant or IUD removed would have to travel to another facility, which may be a substantial access barrier in the remote communities MSI targets. This structural barrier could result in periods of unwanted continued use. MSI seeks to mitigate this by providing referral information and a contact center for clients seeking removal,33 but we don't know how effective these measures are in practice.

Our assessment of MSI's current practices

We investigated MSI's approach to client-centered care and informed consent. This included reviewing their internal counseling guidelines, speaking with MSI leadership, examining their monitoring and quality assurance systems, and speaking with other funders and experts familiar with their work. We also reviewed MSI's published responses to the past allegations and spoke with MSI leadership specifically about these cases and policy improvements they have made since. Our assessment at the time of making this grant is as follows.

• MSI's counseling guidelines emphasize client choice. MSI's internal guidelines for client counseling and informed consent consistently emphasize client autonomy and explicitly address the risk of coercion, including subtler forms like biased counseling or limiting the methods presented to clients. The guidelines require informed consent for all services, with written consent required for long-acting methods, permanent methods, and abortion services.
• MSI has monitoring systems to detect quality issues. MSI conducts annual client exit interviews at a sample of sites, mystery client visits, supportive supervision visits with provider competency assessments, and clinical quality audits by both country and global teams.34 They also maintain incident reporting systems and client feedback mechanisms.35 These systems appear reasonably robust for catching overt problems, though they are unlikely to detect subtler forms of biased counseling.
• Funders familiar with MSI's work view their service quality positively. In our conversations with other organizations that fund family planning programs, we heard generally positive assessments of MSI's counseling and service quality.
• MSI's client exit interviews suggest generally positive experiences. In the most recent data from Sierra Leone and Nigeria, the large majority of respondents reported positive indicators of client-centered care, though sample sizes were modest. We think these interviews are unlikely to capture instances of biased information provision, since clients may not recognize when they've received incomplete or misleading counseling.

Our overall assessment is that MSI takes this risk seriously and has reasonable systems in place to mitigate it. However, we recognize that, at MSI's scale of operations, completely eliminating provider misconduct is likely impossible, and monitoring systems cannot identify all problems—particularly subtler forms of inadequate informed consent.

We apply a downward adjustment to our cost-effectiveness estimate to account for the negative value of any unwanted contraception. We use a larger adjustment for Nigeria than Sierra Leone because MSI provides a higher proportion of LARCs in Nigeria and visits communities less frequently, which we believe increases the risk.

These adjustments are highly uncertain. They are set higher than the point estimates from survey data to account for underreporting, subtler forms of inadequate consent, and the possibility that some counted couple-years of protection represent periods of unwanted continued use. But we acknowledge we don't have strong empirical grounding for the specific magnitudes.

Independent monitoring

We have also funded independent monitoring and evaluation alongside this grant. We expect this will include mystery client visits to observe provider behavior, observations of group information sessions, client surveys with questions about contraceptive autonomy and coercion, and qualitative interviews to better understand client experiences. We hope this will help us assess whether our current downward adjustment to our cost-effectiveness estimate is appropriate and whether there are specific practices that should change.

We will also conduct a site visit to observe the Outreach program directly, review MSI's own monitoring data, and maintain regular check-ins with MSI about implementation.

We recognize that even with these measures, we cannot perfectly monitor this risk or eliminate it. If we encounter evidence suggesting unacceptably high rates of inadequate informed consent or unwanted contraception, we will consider asking MSI to pause or modify activities under this grant.

6.2 Uncertainty about cost-effectiveness

We are highly uncertain about our cost-effectiveness estimates for this grant. Our analysis suggests the program is roughly 10-14x as cost-effective as GiveWell's cost-effectiveness benchmark, but our confidence interval is wide enough that the true value could be far above or below our funding threshold.

First, as family planning is a new area for GiveWell, we have high uncertainty about how to compare the value of an additional year of voluntary modern contraception relative to other types of program outcomes like averting deaths or increasing income. Our Valuing Contraception model estimates roughly 0.7 GiveWell units of value per year of (wanted) modern contraception use in a low-income country setting, but our 25th-75th percentile range spans 0.3 to 1.1 units—a wide confidence interval driven largely by uncertainty about how many unintended pregnancies are averted per year of contraception.36 We also have qualitative uncertainties not fully captured in our model, including how to value reproductive autonomy and whether our approach adequately captures the range of benefits and potential harms from contraception.37

Second, it is difficult to estimate what proportion of the contraception MSI provides is counterfactually additional (i.e. it would not have occurred without the program) and the product of free and informed choice. As discussed above, we estimate roughly 50% is counterfactually additive based on MSI's client exit interview data. We’re not aware of any peer-reviewed RCTs or quasi-experimental studies on the impact of MSI’s Outreach program, or similar programs, on modern contraceptive use. The Family Planning High Impact Practices brief on mobile outreach lists several impact studies, but these studies don't seem to be able to attribute changes in contraception to outreach programs specifically. We expect the independent evaluation we've funded alongside this grant will help refine our estimates, but anticipate that significant uncertainty will remain.

The uncertainty about what portion of contraceptive use is "wanted" is discussed above. We expect to learn more about this parameter through this grant.

6.3 Funging risk

Fungibility is a routine consideration of GiveWell's grant decisions, and we think this grant has a higher risk of funging than most of our grant recommendations. This is because MSI appears well-funded compared to some other NGOs, which raises questions about the counterfactual impact of our grant. Particularly for the Sierra Leone teams, MSI has been funding internally since other donors withdrew support, so it seems feasible that in the absence of our grant they may have continued to fund them. MSI told us they had funds available to sustain higher-impact programs for roughly 1.5 to 2 years without additional donor funding by drawing down reserves and cutting less impactful activities, though this would be highly conditional and context dependent.38

In practice, this means the Sierra Leone Outreach teams we would fund may have continued operating for up to two years using MSI's internal funding without our grant. Our funding may therefore be extending these teams' operations into the future rather than generating immediate counterfactual impact. We have applied a 30% funging adjustment to our Sierra Leone cost-effectiveness estimate to account for this, though we are uncertain about its magnitude. For Nigeria, where our funding would establish new teams rather than sustain existing ones, we applied a smaller 10% adjustment, as we think it unlikely MSI or other donors would have funded new teams given an increasingly scarce landscape for family planning funding.

6.4 Uncertainty about abortion services

MSI has told us that post-abortion care services, following an unsafe abortion or spontaneous miscarriage, comprise a small percentage of services in Nigeria and Sierra Leone.39

We have not attempted to model the overall effect of MSI's programming on the number of abortions that occur. Our tentative view is that by increasing access to contraception and reducing unintended pregnancies, MSI's work likely reduces the total number of abortions.40 However, in these countries, because post-abortion care services are a very small share of overall services, we have not rigorously analyzed this question, and we are uncertain about both the magnitude and direction of the effect.

We also have not developed a position on how to value abortions relative to other outcomes. We recognize that people hold a wide range of views on this question and, given our uncertainty, we have chosen not to include abortion-related value (positive or negative) in our cost-effectiveness estimate.

This grant was funded through GiveWell's board-designated funds and the contributions specifically designated for this grant from an individual donor.

7. Plans for follow up

We plan to check in with MSI approximately twice per year to discuss implementation progress, any deviations from projections, and challenges encountered. We will request MSI's administrative data on service delivery and costs at the end of each year, along with results from their client exit interviews and mystery client visits. We expect to conduct a site visit to observe the Outreach program in either Nigeria or Sierra Leone.

Separately, we will review results from the independent monitoring and evaluation through IPA to help us assess the counterfactual additionality of the contraception MSI provides and the prevalence of unwanted or coerced contraception use, the two key uncertainties in our cost-effectiveness analysis.

When available, we also plan to analyze whether findings from separate, ongoing RCTs of MSI Outreach in northern Nigeria and DRC can be used to predict impacts in the settings we are funding. These results are expected in 2027.

8. Internal forecasts

For this grant, we are recording the following forecasts:

Confidence	Prediction	By time	Resolution
45%	MSI will report having exceeded their total CYP projection (across countries) for this grant by October 2028	October 2028
55%	MSI will report having exceeded their total CYP projection (across countries) for this grant by October 2029	October 2029
50%	At the end of this grant, we will conclude that our expected cost per CYP for this grant was (counting MSI costs and commodity costs) was higher than expected
45%	After having seen the results of all the M&E we expect during this grant, we will update our CEA to increase the proportion of years of contraception that are counterfactually additional
30%	After having seen the results of all the M&E we expect during this grant, we will update our CEA to increase the negative adjustment for unwanted contraception
45%	We will conduct a site visit during this grant and update positively about MSI’s programs

9. Our process

For this grant investigation, our process included the following:

• We reviewed MSI's service delivery data, cost information, and client exit interview results from Nigeria and Sierra Leone.
• We examined MSI's internal counseling and informed consent guidelines and spoke with MSI staff including their CEO, country directors, and clinical leadership.
• We consulted external family planning experts and funders, as well as academic researchers studying family planning programs and contraceptive autonomy.
• We conducted a shallow review of evidence on family planning outreach effectiveness and reviewed public reports related to past concerns about MSI service quality.
• We solicited proposals from four organizations for independent monitoring and evaluation to accompany this grant.
• We developed our cost-effectiveness analysis of this program, and had it internal peer-reviewed and vetted.

10. Sources

Document	Source
African Gender and Media Initiative, "Robbed of Choice: Forced and Coerced Sterilization Experiences of Women Living with HIV in Kenya"	Source (archive)
Brooks et al. 2019	Source
Care Quality Commission: MSI Reproductive Choices	Source (archive)
Care Quality Commission: MSI Reproductive Choices Regional Treatment Centre - Manchester	Source (archive)
Email from MSI to GiveWell, Feb 22, 2025	Unpublished
Family Planning High Impact Practices, Family Planning Mobile Outreach Services: Expanding Equitable Access to a Full Range of Modern Contraceptives	Source (archive)
GiveWell, Family planning mobile outreach BOTEC, 2026	Source
GiveWell, The fungibility question	Source
GiveWell, Valuing Contraception	Source
GiveWell, Valuing Contraception BOTEC	Source
KFF, Donor Government Funding for Family Planning in 2024	Source (archive)
MSI Reproductive Choices	Source (archive)
MSI, "MSI’s outreach: Mobile teams delivering reproductive healthcare"	Source (archive)
MSI, "What we do"	Source (archive)
MSI, "Where we work"	Source (archive)
MSI, 2024 Annual Report and Review	Source (archive)
MSI, Abortion care	Source (archive)
MSI, Client exit interviews, 2023-2024	Unpublished
MSI, Conversation with GiveWell, April 2025 (unpublished).	Unpublished
MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria	Source
MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone	Source
MSI, Nigeria Detailed Budget, 2025	Unpublished
MSI, Responses to GiveWell Questions, 2025	Unpublished
MSI, Sierra Leone Detailed Budget, 2025	Unpublished
MSI, Summary of data, impact and cost effectiveness of outreach service delivery model in 2 MSI country programmes, 2023-2024.	Source
OECD, Development Co‑operation Profiles: Netherlands	Source (archive)
Senderowicz et al. (2023)	Source
UK Parliament House of Commons Library, "UK aid: Reducing spending to 0.3% of GNI by 2027/28"	Source (archive)
UNFPA Contraceptives Price Indicator, 2022	Source (archive)

• 1A large share of commodities for MSI Outreach are allocated by the government from public stocks, but MSI is expecting lower availability of commodity stocks than in previous years so have budgeted for some share of the commodities to be funded by GiveWell and other philanthropic donors. Source: MSI detailed budgets (unpublished)
• 2MSI global costs are covered by the indirect costs line in the budget, at 15% of total costs.
• 3"36 countries. 6 continents. 9,000 team members …Starting from a single clinic in London in 1976, we’ve grown to become one of the world’s largest providers of high-quality contraception and abortion care." MSI, "Where we work"
• 4"MSI Reproductive Choices fights for everyone to make their own decisions about their body, life, and future by expanding access to contraception and abortion.​" MSI, "What we do"
• 5"The global demand for contraception and abortion is higher than ever, as more women and girls have learned about their rights and options. But many women in rural, remote places don’t yet have access to this healthcare...We’ve built local programmes that reach remote communities who typically cannot access reproductive health services. Our 350 outreach teams across Africa, Asia and Latin America travel long distances to offer modern contraception methods – and abortion where legally permitted – directly to communities." MSI, "MSI’s outreach: Mobile teams delivering reproductive healthcare"
• 6"Outreach sites are selected in close coordination with the District Health Medical Team (DHMT) and local community leaders... MSSL holds an annual meeting during which a review of available data is done to determine areas where there are limited options for services, and communities that have been underserved." MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone, 2025, p. 4

  "Site selection is a standardized process in Nigeria and conducted annually to review each outreach teams’ planned footprint to confirm that we reach communities with limited access to FP, and to explore potential areas for expansion. The process begins with a 2-day work planning meeting in collaboration with each state government…Data sources and other information/factors considered include…the data from MSIN generated heat maps, developed from secondary data sources to understand the geographic distribution of different marginalized populations (most notably, people living in poverty), to ensure the program is driving equity in access." MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria, 2025, p. 4-5

• 7"MSIN Outreach teams will typically visit each site 3-4 times a year, however, there may be some instances where sites are visited less frequently, for example, if a site has very low turn-out after multiple visits we may decrease the visit frequency." MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria, 2025, p. 5
• 8"Each team serves an average of 1,500 clients every month and provides services out of both public sector facilities as well as outreach tents when there is limited infrastructure available. Approximately half of all service sites are set up using outreach tents." MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone, 2025, p. 4
• 9See column A of MSI, Summary of data, impact and cost effectiveness of outreach service delivery model in 2 MSI country programmes, 2023-2024.
• 10"Of the total clients served, 95% chose a long-acting reversible contraceptive method." MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria, 2025, p. 3
• 11MSI email to GiveWell, February 22, 2025 (unpublished)
• 12 “Mystery Client Visits: Data from annual mystery client visits helps MSSL understand service provider performance and quality of service from a client’s perspective and identify service quality gaps. MSSL utilizes MCS data to make real-time decisions to mitigate identified risk(s). MSSL will conduct mystery client visits annually under this grant.” MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone, 2025, p. 6
  “Under this grant each team will get at least one to two mystery client visits a year.” MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria, 2025, p. 8
• 13See our existing Valuing Contraception BOTEC, which suggests that in Nigeria and Sierra Leone, the benefits of additional years of modern contraception come from:
  • Improved health for women using contraception and newborns (those who are born even with increased use of contraception): ~40% of benefits
  • Improved subjective well-being for women using contraception: ~30% of benefits
  • Increased resources for existing children due to fewer unwanted births: ~20% of benefits
  • Increased household income through higher earnings of women using contraception: ~10% of benefits

• 14See these rows in our BOTEC for the the breakdown of the program's benefits.
• 15“MSI Reproductive Choices (MSI), is pleased to submit this proposal on behalf of MSI Nigeria (MSIN) for $3,000,000 over 36 months to support two new outreach teams to reach more than 155,440 underserved women and girls in Enugu and Kwara states in South-East and South-West regions of Nigeria with family planning (FP) services.” MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria, 2025, p. 2
• 16“Enugu and Kwara states were selected because they have low rates of modern contraceptive usage at 11.2% in Enugu and 9.9% in Kwara as well as high unmet need for FP at 23.6% and 27.1%, respectively. Additionally, the mCPR rates have declined between 2018 and 2023.7 In this period, Kwara saw a 42% decline, and Enugu a 36% decline. This significant decline in mCPR has been exacerbated by the declining funding for FP interventions in these states and has led to the two states being in the lowest 15 out of 37 states (FCT included) for mCPR in Nigeria. We also selected these states because they are not included in new programs beginning this year with support from the Children’s Investment Fund Foundation (CIFF) and the Gates Foundation, and so lack investment comparatively. Additionally, both states face high poverty levels and limited access to contraceptive options.” MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Nigeria, 2025, p. 2-3
• 17“MSI Reproductive Choices (MSI), is pleased to submit this proposal on behalf of MSI Sierra Leone (MSSL) for $3,000,000 over 30 months to support five outreach teams to reach more than 265,000 clients with family planning (FP) services focusing on underserved women and girls in Tonkolili , Port Loko, Kailahun, Kono and Bonthe Island, Sierra Leone.” MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone, 2025, p. 2
• 18“This proposal requests the support of the teams in Tonkolili, Kono, Bonthe Island, Port Loko, Kailahun. These outreach teams are currently supported through an internal MSI investment, and this proposed funding would ensure that these teams can continue reaching high-impact clients over the next two and a half years. Tonkolili, Port Loko, Kailahun, Kono and Bonthe Island are MSSL’s priority districts for outreach as they have high unmet need for FP and low mCPR. Amongst married women aged 15-49, the average mCPR is only 21% across all five districts.” MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone, 2025, p. 3
• 19MSI estimates these grants will avert a much larger number of unintended pregnancies (286,600 in Sierra Leone (see proposal) and 270,000 in Nigeria (see proposal)). We think this is because they do not model the proportion of contraception provided that is not counterfactually additional, and also assume a greater number of unintended pregnancies averted per year of modern contraception provided than we do.
• 20A large share of commodities for MSI Outreach are allocated by the government from public stocks, but MSI is expecting lower availability of commodity stocks than in previous years so have budgeted for some share of the commodities to be funded by GiveWell and other philanthropic donors. Source: MSI detailed budgets (unpublished)
• 21MSI global costs are covered by the indirect costs line in the budget, at 15% of total costs. Source: MSI detailed budgets (unpublished)
• 22Sources: MSI, Nigeria Detailed Budget, 2025 (unpublished), MSI, Sierra Leone Detailed Budget, 2025 (unpublished)
• 23MSI spends about £100m or ~$135m a year on ‘last mile’ programs in LMICs. See MSI's 2024 Annual Report and Review, page 70. We think it is reasonably likely that a portion of this would meet our cost-effectiveness bar for funding.
• 24The US has been the largest bilateral funder of family planning programs (40% of donor funding), $600m a year, and the current administration has proposed large cuts to foreign aid. Family planning appears to have been particularly targeted by the current administration.
  The UK and the Netherlands have been the second and third largest government funders (30% of donor funding) and they’ve both announced foreign aid cuts, though we don’t know to what extent their family planning funding will be cut.
  • "As in the past, the U.S. was the largest donor government to family planning in 2024, accounting for 43% (US$579.6 million) of total funding, followed by the Netherlands (US$194.7 million, 14%), the U.K. (US$190.0 million, 14%)." KFF, Donor Government Funding for Family Planning in 2024, 2025."
  • "In February 2025, the UK Government announced that UK aid spending will be “gradually reduced” from 0.5% of gross national income (GNI) to 0.3% of GNI in 2027." House of Commons Library, UK aid: Reducing spending to 0.3% of GNI by 2027/28, 2026.
  • "The new development aid policy of February 2025 announced a structural reduction in ODA spending of EUR 2.4 billion, starting in 2027. The cuts are expected to reduce the ODA/GNI ratio to 0.44% by 2029, compared to 0.66% under previous budget plans." OECD, Development Co‑operation Profiles: Netherlands, 2025

• 25For more on GiveWell's cost-effectiveness benchmark, see here.
• 26See UNFPA Contraceptives Price Indicator Year 2022
• 2746% (Sierra Leone) and 32% (Nigeria) of clients report knowing of another provider offering the method/service they received at the MSI Outreach clinic.
• 2831% (Sierra Leone) and 48% (Nigeria) of clients say they’ve never used a family planning method before, with a further 16% and 29% respectively saying they haven’t used a method in the past three months.
• 29The average travel time is 52 minutes in Sierra Leone and 35 minutes in Nigeria, according to client exit interviews in 2024 (unpublished).
• 30See information about unwanted sterilizations of women living with HIV in Kenya prior to 2010 here, and UK Care Quality Commission assessments of MSI England abortion clinics between 2016 and 2018 here.
• 31See information about unwanted sterilizations of women living with HIV in Kenya prior to 2010 here, and UK Care Quality Commission assessments of MSI England abortion clinics between 2016 and 2018 here. See here for the more recent clinic assessments with positive findings.
• 32This is based on our internal analysis of MSI’s service data, which suggests that 99.8% of CYPs in MSI’s Nigeria Outreach are from provider-administered methods, and 96.7% in Sierra Leone. Source: unpublished analysis of MSI, Summary of data, impact and cost effectiveness of outreach service delivery model in 2 MSI country programmes, 2023-2024.
• 33"All service delivery channels including Outreach are supported by MSSL's toll-free free '3535' contact centre hotline for clients, which provides information on voluntary FP services, follow up care for clients and referrals for voluntary FP." MSI, Delivering Cost Effective Impact: An Investment in Reproductive Health in Sierra Leone, 2025, p. 4
• 34
  • "We have a range of measures exploring coercion and autonomy integrated into our annual client exit interviews."
  • "We also triangulate clinical supervision, training, and quality audits with other data including client feedback, client exit interviews which include questions on client experience including counselling, and mystery clients."

  MSI, Responses to GiveWell Questions, 2025 (unpublished).

• 35"Additional monitoring methods include:
  • Clinical record audits (CRA) are done each month. 10 records are randomly selected each month for each site. Completion of informed consent is part of this review
  • Incident reviews: any incident includes a thorough review of the client record, including checking completion of informed consent.
  • Clinical audits (internal and external): we not only check the service provision and provision of informed consent but again do a random client record audit as well.
  • Mystery clients also report back on consent experience/process."

  MSI, Responses to GiveWell Questions, 2025 (unpublished).

• 36“We have relatively high uncertainty around our estimate of the units of value per year of modern contraception (25th percentile: 0.3 units of value; 75th percentile: 1.1). Our largest source of uncertainty is our estimate of unintended pregnancies averted per year of modern contraception, because many of the benefits flow through averted unintended pregnancies and we have imperfect evidence for this estimate. Otherwise, the uncertainty is relatively evenly distributed across the benefits, though we have relatively more uncertainty on the economic benefits for women and the benefits for existing children, due to the lower-quality evidence for these benefits.” GiveWell, Valuing Contraception
• 37See this section of our report on valuing contraception.
• 38MSI, Conversation with GiveWell, April 2025 (unpublished).
• 39Email from MSI to GiveWell, Feb 22, 2025 (unpublished)
• 40At least one observational study suggests the Mexico City Policy increased abortions in affected countries by reducing funding to organizations that provide both contraception and abortion services. See Brooks et al. 2019:
  “We found that when the Mexico City Policy was in effect (2001–08), abortion rates rose among women in countries highly exposed to the policy by 4·8 abortions per 10 000 woman-years (95% CI 1·5 to 8·1, p=0·0041) relative to women in low-exposure countries and relative to periods when the policy was rescinded in 1995–2000 and 2009–14, a rise of approximately 40%. We found a symmetric reduction in use of modern contraception by 3·15 percentage points (relative decrease of 13·5%; 95% CI −4·9 to −1·4; p=0·0006) and increase in pregnancies by 3·2 percentage points (relative increase of 12%; 95% CI 1·6 to 4·8; p<0·0001) while the policy was enacted.”