Note: This page summarizes the rationale behind a GiveWell grant to Spiro. Spiro staff reviewed this page prior to publication.
In a nutshell
In February 2025, GiveWell recommended a $247,118 grant to Spiro, an Ambitious Impact (AIM)-incubated organization focused on tuberculosis household contact management (TB HCM) in Pakistan (more). The grant will fill Spiro's funding gap for 2025, supporting their direct program costs, digital case management software, and a U.S. fiscal sponsorship fee. We expect this grant will help Spiro test different paths to scale and expand their reach to roughly 16,000 household contacts, which we estimate will mean averting over 150 cases of TB disease and preventing around 40 deaths of children under 5. (more)
We are recommending this grant primarily because:
- We believe it is an efficient way for GiveWell to learn about this promising program model in an additional country (Pakistan) that is complementary to our previous grant to the Clinton Health Access Initiative (CHAI) TB HCM program in India. (more)
- We think Spiro has the potential to be highly cost-effective at scale. While our current estimate of the cost-effectiveness of their 2025 programming is around 8x as cost-effective as our benchmark (more), we think that Spiro’s program has the potential to become more cost-effective over time if their fixed costs are spread over a larger target population. (more)
Our main reservations include:
- The elevated risk of failure given Spiro's early stage of development (Spiro is in their second year). (more)
- Our uncertainty about whether Spiro could have filled this funding gap without us. (more)
- Our uncertainty about whether a larger, longer-term grant might have been more impactful as an initial grant. (more)
Published: July 2025
The organization
Spiro launched in 2023 after participating in Ambitious Impact’s Charity Entrepreneurship program. They implement a version of community-based TB household contact management (TB HCM) in Pakistan, where they began implementation in 2024
The intervention
Spiro implements a version of TB HCM, partnering with local NGOs to increase uptake of tuberculosis preventive treatment (TPT) for people living in the same household as TB patients. Spiro works with partner NGOs1 to recruit dedicated "community health officers" who visit the households of TB patients, facilitate a doctor to perform remote symptom-based screening of under-5 household contacts, then provide TPT2 that the doctor prescribes for household contacts who screen negative for TB.
Spiro ran a pilot of their community-based TB HCM in Rawalpindi, Pakistan, in 2024 during which they partnered with the Pakistani NGO MALC. Spiro plans to start working with additional partners in districts where MALC doesn’t operate as they scale their program. (more)
Because WHO guidelines recommends over-5 contacts to undergo a more intensive screening for TB, which typically takes place at health facilities3 , Spiro also seeks to support TPT initiation for over-5 contacts through: i) reminder phone calls, ii) training for hospital-based staff to provide HCM-focused counselling to TB index patients, and iii) training hospital staff to facilitate household contact screening and TPT initiation.4
Does TB HCM work?
Household-contact management for tuberculosis is one of the most promising interventions we've come across for reducing under-5 mortality from tuberculosis. See our intervention report for more details.
However, this is still an intervention that we are trying to learn more about. By making this grant, we hope to learn about the feasibility and effectiveness of this program model in Pakistan – and hence inform future grantmaking decisions for this type of intervention – in a way that’s complementary to the grant we made to CHAI to support a similar program model in Bihar and Uttar Pradesh, India.
The grant
In February 2025, GiveWell recommended a grant of $247,118 to Spiro to fill their expected funding gap for 2025. Spiro plans to use this grant funding on direct program costs across all planned programs for the latter half of 2025, plus digital case management software and a U.S. fiscal sponsorship fee.5
Spiro will use its total 2025 budget of $470,000 to expand their reach to roughly 16,000 household contacts of TB patients, including around 9,000 children under the age of 5. They expect to substantially improve rates of TB screening and treatment initiation (particularly TPT) among these contacts.
Spiro plans to test three different approaches to scale-up in 2025, which they expect will yield information about which approach(es) – if any – are feasible and cost-effective at larger scales. These three approaches are summarized below.6
- The “foundations” program will continue the pilot program with the same implementation partner and programming expanding to areas where they expect that obtaining government permissions to operate will be easier, at the Federal Government TB Centre in Rawalpindi plus additional small districts in Khyber Pakhtunkhwa and Islamabad Capital Territory.
- The “scaling” program will test a similar model to the pilot but with a new implementation partner and potential economies of scale across larger provinces (Punjab and possibly Sindh). At the time of making this grant, Spiro was in final discussions with the Punjab government and initial conversations with the Sindh government.
- The “innovation” program will test two new implementation approaches, both providing technical support to add a discrete high-leverage intervention onto existing HCM programs, which could expand Spiro's program reach for a much lower cost. These two new approaches are:
- Stewarding the adoption of a new shorter, child-friendly TPT regimen (dispersible 3HP) for children under-5 across existing HCM programs (which currently use the longer 6H regimen) to improve TPT initiation and completion rates;
- Adding teleconsultation with a doctor (to enable TPT initiation at the household for children under-5) to existing HCM programs to improve TPT coverage rates for children under-5.
Budget for grant activities
A summary of Spiro's 2025 budget is outlined below:
| Budget line | Amount | Proportion |
|---|---|---|
| Personnel | $102,500 | 22% |
| Travel | $24,000 | 5% |
| Foundations program | $100,041 | 21% |
| Scaling program | $195,914 | 42% |
| Innovation program | $16,979 | 4% |
| Other program costs | $3,780 | 1% |
| US fiscal sponsorship | $26,593 | 6% |
| Total | $469,807 | |
| Already covered | $222,689 | |
| Funding gap | $247,118 |
The case for the grant
We are recommending this grant because:
- We think this grant has substantial learning value - This grant to Spiro is a cost-efficient way for us to learn about a program we’ve already investigated and think is promising, which will help inform future grantmaking decisions for this type of program – in a way that’s complementary to the grant we made to CHAI in India. Through this grant we expect to learn about:
- The cost-effectiveness of the program in Pakistan, another high-TB burden country, as well as about the TB context in Pakistan more broadly,
- The benefits and costs of a different HCM implementation model to what CHAI are planning,
- The benefits and costs of having a very small organization like Spiro do this program compared to a large organization like CHAI.
In addition, supporting a second organization to implement a TB HCM program helps round out GiveWell's TB portfolio, by making both our ability to fund these programs and our ability to learn about them less dependent on one organization. We plan to track our learnings with Spiro through a shared learning agenda.
- We think Spiro has the potential to be highly cost-effective at scale - This grant will help us learn more about their ability to scale-up and execute plans and hence provide GiveWell with future cost-effective funding opportunities. Our impression so far is that Spiro is transparent in their communication and motivated to maximize cost-effectiveness. Their approach this year of trying a number of different approaches (see above) to have larger-scale impact provides additional evidence for their focus on long-term cost-effectiveness. If they succeed in executing their current plans, our best guess is that they’d be around ‘8x cash’ in 2025 (see below), with potential to increase in cost-effectiveness as they scale up in future years.7
- We think GiveWell recommending a grant to Spiro now is likely to have positive effects on their organizational development - By filling their funding gap for this year, the grant will allow them to focus more on executing their programmatic plans for this year instead of on fundraising. Though we have reservations about funding an early-stage organization, as outlined below.
Cost-effectiveness
We estimate Spiro's program in 2025 to be around 8x as cost-effective as unconditional cash transfers, GiveWell's benchmark for evaluating grants. However, we think the program also has the potential to be more cost-effective in future years if Spiro can successfully implement it at a larger scale. Spiro's own model estimates the cost-effectiveness of the program at scale to be 17x when evaluating based on direct program costs alone, which indicates scope for higher cost-effectiveness in future years if Spiro can successfully expand.8 However, we have not reviewed their model closely.
Our cost-effectiveness estimate of 8x for Spiro's program is about the same as our estimate for CHAI's TB HCM program that we investigated for the $15.1M grant we made last year. However, there are some important differences in our impact estimates of these two programs. Spiro's program is more expensive per child under-5 reached ($68 per child compared to $35 in CHAI's program) because Spiro's costs include additional costs for supporting older household members and because Spiro's overhead costs are concentrated over a smaller program scale. On the other hand, two factors offset Spiro's higher cost:
- We expect Spiro's program to increase TPT coverage more significantly than CHAI's program in India because Pakistan has a lower baseline TPT coverage rate and Spiro's pilot showed high TPT initiation rates.
- Spiro's program generates additional benefits by supporting screening and treatment for household contacts over the age of 5, as well as children under 5. We have not tried to model this value, but have added a placeholder in our analysis to account for this additional benefit.
Below is a summary of our cost-effectiveness analysis for Spiro's 2025 programming. More details can be found here. We built this model based on GiveWell's model for CHAI's TB HCM program.
| What we are estimating | Best guess (rounded) | Confidence intervals (25-75th percentile) | Implied cost-effectiveness |
|---|---|---|---|
| Number of under-5 household contacts reached in 2025 | 6,900 | ||
| Cost per under-5 child reached | $68 | $50-90 | 6x - 11x |
| Spiro's costs in 2025 | $469,807 | ||
| Among under-5 contacts reached, increase in TPT initiation rate (percentage points) | 75% | 40-95% | 4x - 10x |
| Prevalence of TB infection | 30% | ||
| Risk of progression from infection to disease in absence of TPT | 19% | ||
| Effectiveness of TPT in preventing progression from infection to disease | 56% | 35-75% | 5x - 11x |
| Cases of TB disease averted | 164 | ||
| Case fatality ratio for TB disease in absence of TB treatment | 34.8% | 25-50% | 6x - 11x |
| Overall case fatality ratio, accounting for TB treatment rate | 24% | ||
| Deaths averted via prevention of disease progression | 39 | ||
| Adjustment for deaths averted via increased treatment of TB disease | 12% | ||
| Initial cost-effectiveness estimate | |||
| Total number of under-5 deaths directly averted | 44 | ||
| Moral weight for averted deaths | 114 | ||
| Initial cost-effectiveness estimate (multiples of cash) | 3 | ||
| Benefit streams (% of total) | |||
| Direct mortality benefits | 38% | ||
| Morbidity benefits from averted TB disease | 1% | ||
| Benefits from averted post-TB sequelae | 14% | 3-30% | 3x - 14x |
| Long-term increases in income | 12% | 4-23% | 7x - 11x |
| Cost of illness averted | 10% | ||
| Benefits for under-5 household contacts receiving dispersible 3HP instead of 6H | 3% | ||
| Benefits for over-5 household contacts | 21% | 10-35% | 6x - 12x |
| Additional adjustments | |||
| Adjustment for downstream costs to others and risk of replacing funding from other funders | -4% | -2 - -22% | 6x - 8x |
| Overall cost-effectiveness (in multiples of cash transfers) | 8 |
Risks and reservations
Our main reservations about this grant are:
- Risks to funding an early stage organization - There’s an elevated risk of failure given Spiro is very early in their organizational development (in Year 2) and has less of a track record than organizations we typically fund. For instance, it is possible that the success of their pilot might be due to having an exceptional local NGO partner. In order to scale, Spiro will have to partner with several other local NGOs, which might not be as effective. Other failure modes could include failing to secure approvals or buy-in from governments and local partners, meaning implementation cannot go ahead at all.
- Risk of diverting other actors’ spending (“funging”) - Spiro may be able to fill their 2025 funding gap without us,9 meaning the direct impact of our funding is uncertain as we may be funging other donors. However, it seems like the most likely alternative funder(s) would be individuals in the Effective Giving ecosystem,10 who may have otherwise donated to other impactful/cost-effective programs and organizations.
- Tradeoffs of a shorter-term grant - It’s possible that Spiro would achieve greater impact if we encouraged them to plan over a longer horizon and provided a larger grant to enable them to execute on these plans (instead of just supporting their 2025 plans). If we had chosen to make a bigger, longer term initial grant, it might encourage and enable Spiro to plan their longer-term strategy, and also potentially allow us to bolster their M&E, which is important for their own and our learning. However, we ultimately decided a grant focused on this year will enable them to learn as much as possible from their experience in the near term and figure out their longer term plans as they gain more information.
- It is possible we could learn more without funding Spiro - A large part of the case for this grant is the learning opportunity it provides for GiveWell. However, it is possible we could learn a lot of what we plan to learn through this grant by just staying in touch with Spiro and following their work, without actually funding them until we have higher confidence in their track record and cost-effectiveness. However, we think that by partnering with them as a funder, we will be able to follow their progress more closely. Additionally, if we are taking up time from the founders of a promising early-stage organization, providing them with some funding at least offsets that time that they might otherwise spend fundraising.
Plans for follow up
We plan to have two check-ins with Spiro (e.g. August 2025 and December 2025/January 2026). We will ask them about progress on their activities and other information that will help answer the questions on our learning agenda.
Internal forecasts
For this grant, we are recording the following forecasts:
| Confidence | Prediction | By time | Resolution |
|---|---|---|---|
| 40% | Spiro will screen at least 6,900 (their current expectation) under-5 children by the end of 2025 | Dec 2025 | - |
| 25% | We estimate the cost-effectiveness of Spiro’s programming in 2025 was at least ‘10x cash’ | Feb 2026 | - |
Our process
This funding opportunity came to our attention through an AIM newsletter in December 2024. To investigate the funding opportunity, we:
- Contacted Spiro to learn more about their pilot, their plans for 2025, and their interest in being considered for a grant.
- Spoke to AIM to get their advice on i) making good decisions about whether/how much to fund AIM-incubated organizations, and ii) how to best support organizations we decide to fund.
- Spoke briefly with Sarah Eustis-Guthrie, who was an advisor to Spiro, to get her take on benefits/risks to Spiro of receiving a grant from GiveWell
- Spoke with Mulago Foundation to get their advice on funding early-stage organizations; we incorporated this advice into our assessment and plans above
- Requested more information from Spiro about their budget, activities, monitoring and evaluation, expectations, and goals for 2025.
- Developed a learning agenda for the grant.
- Had another call with Spiro to clarify some of their answers to our questions, ask about the possibility of doing more work in Sindh in light of potential cuts to USAID-funded programming in Sindh province, and to get feedback on our learning agenda.
- Adapted the CHAI TB CEA to reflect Spiro-specific costs and reach expectations, as well as additional benefits from Spiro’s support for older household contacts and for facilitating procurement of child-friendly 3HP for existing household contact management programs run by other NGOs.
Relationship disclosures
Sarah Eustis-Guthrie, a GiveWell employee who co-founded another AIM-incubated organization, was an advisor to Spiro during their AIM incubator process.
Sources
- 1
Spiro leads the design of its programs in Pakistan and monitors their implementation, while local NGOs deliver them on the ground.
- 2
In the pilot program, Spiro staff provided an intensive regimen of TPT called 6H (which includes 6 months of daily isoniazid), for children under the age of 2, because 3HP, the newer, shorter regimen (3 months of weekly isoniazid and rifapentine) that CHAI plans to use (weekly for 3 months) wasn’t yet approved in Pakistan for very young children. For contacts aged 2 and over, they are providing 3HP. The national guidelines will change this year to permit 3HP for all ages.
6H is described in WHO Recommendations for investigating contacts of persons with infectious tuberculosis in low-and middle-income countries (2012): “HIV-positive household or close contacts who are adults or adolescents and whose clinical evaluation suggests that they are unlikely to have active TB should receive preventive treatment with isoniazid at 300 mg/day for at least 6 months (4). It is conditionally recommended that the duration of isoniazid preventive treatment of PLHIV with no active TB be prolonged to 36 months (4).” Chapter 5 Recommendation 7
We discuss 3HP further in this footnote of our page on our 2024 grant to CHAI supporting TB HCM. - 3
Source: 2024 WHO operational handbook on tuberculosis p. 39 Figure 6
- 4
See slide 5 of Spiro’s public slides on their program.
- 5
“Spiro has a $247,000 funding gap to fulfill these proposed activities through the end of 2025. This additional amount would cover direct program costs for all of our programs for the second half of the year (July to December 2025). Specifically, it amounts to the costs of our Foundations, Scaling, and Innovation programs, digital case management software, and the associated U.S. fiscal sponsorship fee.” Spiro, Proposal for GiveWell, February 13, 2025.
We understand the fiscal sponsorship fee to be a fee paid by Spiro to Players Philanthropy Fund, the 501(c)(3) that provides legal and financial oversight to Spiro and several other AIM-incubated organizations. - 6
See slide 16 of Spiro pilot results and expansion, dated December 2024.
- 7
- To date, GiveWell has used GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding opportunities, which we describe in multiples of "cash” (more). In 2024, we re-evaluated the cost-effectiveness of direct cash transfers as implemented by GiveDirectly and we now estimate that their cash program is 3 to 4 times more cost-effective than we’d previously estimated. (more)
- For the time being, we continue to use our estimate of the cost-effectiveness of unconditional cash transfers prior to the update to preserve our ability to compare across programs, while we reevaluate the benchmark we want to use to measure and communicate cost-effectiveness.
- Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.
- 8
Spiro estimated cost-effectiveness at scale by estimating the benefits generated during their pilot and comparing this to the costs of the pilot excluding co-founder salaries and expenses. Our understanding is that they exclude co-founder salaries and expenses (which are currently a large share of their costs) since they expect these to be a small share of costs if they were to operate at a larger scale.
- 9
In our conversations with them, Spiro stated that they believed that they were moderately likely to raise the funds necessary to fill their funding gap without GiveWell’s support.
- 10
This is an assumption based on the fact that AIM (formerly Charity Entrepreneurship) is aligned with the effective altruist community, and other AIM-incubated early stage organizations are often funded by effective giving aligned donors.