Malaria Consortium and PATH—Scoping Grant to Assess Feasibility of Intermittent Preventive Treatment in Infants (IPTi) for Malaria (September 2021)


Intermittent preventive treatment in infants (IPTi) for malaria is a program that distributes preventive antimalarial medication to infants that is delivered during routine immunization services. There is strong evidence showing the program is effective at preventing malaria among the treated population.

We believe this program is potentially promising; we currently think that it may be as or more cost-effective than other programs we expect to direct funding to in 2021, but this estimate is highly uncertain and depends upon, for example, the costs of the program, the likelihood of success, and the burden and seasonality of malaria in selected geographies.

In order to learn more about some of these uncertainties, in September 2021 we recommended a grant of $120,000 from an anonymous individual donor to PATH and Malaria Consortium to work together over four to six months to scope the feasibility of implementing IPTi at national scale in suitable areas in the Democratic Republic of the Congo (DRC) and Nigeria, assess the potential cost-effectiveness of delivering the program in those places, and build a notional plan for implementation.

If, based upon this work, we think that IPTi is likely to meet our cost-effectiveness bar in these countries after the scoping period, we may recommend funding to PATH and Malaria Consortium to implement the program at national scale.

Published: January 2022

Table of Contents

The intervention

IPTi is the provision of a malaria-preventive medication, generally sulfadoxine-pyrimethamine (SP), to infants, typically during their routine immunization visits in the first year of life.1

There is strong evidence showing that IPTi is effective in substantially reducing cases of malaria in the treated population: a Cochrane meta-analysis of 12 randomized controlled trials (RCTs)2 found that IPTi reduced cases of clinical malaria by 30%.3 See here for our review of this evidence.4

The World Health Organization (WHO) has recommended IPTi since 2010,5 but it has been implemented at a national scale in only one country.6 Some reasons we think that more widespread adoption of IPTi may have been hindered include:

  • The WHO guidelines currently recommend that IPTi be conducted only where prevalence of markers of parasite resistance to SP is at or below 50%,7 which may make it more challenging for countries to take up IPTi if they no longer have routine monitoring of SP resistance or have levels of SP resistance above that threshold.8
  • Until recently, existing drug formulations of SP were not suitable for infants and needed to be cut and crushed to appropriate dosages, which made administration of the drug more challenging.9 A dispersible tablet at the appropriate dosage for infants is now available.10
  • The program requires strong coordination between national immunization and malaria programs.11

However, a previous UNICEF pilot implementation found that it was feasible to implement IPTi with high coverage levels12 in six countries in Africa (Benin, Ghana, Madagascar, Mali, Malawi, and Senegal).13 In addition, there has been increasing interest in accelerating the adoption of IPTi, as evidenced by IPTi's selection as one of the focus areas of the 2019 WHO technical consultation,14 as well as recent Unitaid15 and Bill and Melinda Gates Foundation (BMGF)16 investments in IPTi.

The organizations

Our process for identifying partners

Because we do not know of any organizations currently implementing IPTi at a substantial scale, our process for identifying partners was different from what we normally do at this stage of our research. We sent a request for information (RFI) to 18 organizations with demonstrated experience launching and scaling up malaria- or immunization-related programs in Africa. Our goal was to identify organizations that seemed well suited to designing and implementing an IPTi program at national scale.

In the RFI, we requested information related to organizational track record delivering similar interventions, as well as high-level thoughts on how each organization would approach assessing the feasibility and cost-effectiveness of bringing IPTi to national scale. We did not indicate any preference in terms of geographical focus.17

Seven organizations responded, and individual GiveWell researchers independently scored their expressions of interest. Based on those scores, we selected four organizations for further discussions. We had up to two rounds of discussions with each of these four organizations, in which we dug further into the organizations’ track records and proposed approaches to scoping and scaling up implementation of IPTi.

We ultimately selected two organizations — PATH and Malaria Consortium — to work together to conduct a study to assess the feasibility and cost-effectiveness of introducing IPTi into national policy in two countries.

Why PATH and Malaria Consortium?

After several conversations and a review of past performance, we believe that PATH and Malaria Consortium could have the organizational experience and positioning to successfully implement IPTi. It was our impression that both organizations demonstrated knowledge of scientific and practical considerations relevant to implementing malaria chemoprevention and vaccine strategies, thoughtful and transparent reasoning, and the ability to communicate effectively with us. Moreover, the two organizations have complementary strengths relevant to scaling up IPTi and have had experience working together successfully in the past.18

Based on conversations we’ve had with other organizations and experts in the malaria space, it is our impression that PATH has strong relationships with relevant stakeholders in the primary countries of interest, which we think would be important for the success of interventions implemented within government health systems.

PATH is one of the main implementation partners working on rolling out the RTS,S malaria vaccine in three African countries.19 This work has been successful so far in that it has achieved a high degree of coverage in a short period of time,20 and we think that PATH’s experience working at the intersection of immunization and malaria programs for scaling up RTS,S may be applicable to successfully implementing IPTi through immunization platforms.21

Malaria Consortium
Our impression is that Malaria Consortium is relatively strong in on-the-ground implementation and research design.22 In addition, we felt that they had a technical command of the details of IPTi.23 Moreover, Malaria Consortium is already piloting IPTi in six local government areas in Nigeria with BMGF funding,24 and it may be possible to leverage this work to support the scale-up of IPTi in Nigeria.

During our calls, Malaria Consortium appeared to be aligned with us around the importance of robust monitoring and evaluation (M&E) and cost-effectiveness as key considerations in planning for IPTi implementation.25

Planned activities


Working with PATH and Malaria Consortium, we identified Nigeria and the Democratic Republic of the Congo (DRC) as promising settings in which to implement IPTi, for several reasons:26

  • High malaria burden among infants27
  • Low levels of parasitic resistance to SP, the drug used for IPTi28
  • Large target populations, which could lead to higher cost-effectiveness if there are fixed costs to scaling up the program in each country29
  • Malaria Consortium and PATH's apparently strong positioning in these two countries (see previous section)

However, we are highly uncertain about the feasibility of and costs associated with implementing IPTi in these countries.

Scoping feasibility and cost-effectiveness

PATH and Malaria Consortium are working together for four to six months, starting from September 2021, to scope the feasibility and likely cost-effectiveness of implementing IPTi at national scale in DRC and Nigeria, build a timeline, and plan program implementation. Specifically, the scoping work will include:

  • Identifying stakeholders and assessing country interest in IPTi in conversation with those stakeholders30
  • Defining subnational target areas through epidemiological analysis (i.e., which areas are suitable for IPTi based on the patterns of transmission and the burden of malaria)31
  • Exploring existing delivery platforms that could be used for IPTi delivery (such as routine immunization platforms or community-based delivery with trained community health workers)32
  • Understanding commodity procurement and distribution channels for IPTi drugs (i.e., whether there is a viable supply chain to bring IPTi to scale)33
  • Assessing programmatic risks and developing risk mitigation strategies34
  • Assessing the quality of routine surveillance and data systems in target areas, and proposing approaches for monitoring the uptake of IPTi were it to be introduced into national policy and practice35
  • Building a timeline and plan for scale, including a costing model with an overall budget for implementation in each country36

The scoping phase will be followed by a full grant investigation to assess the promisingness of funding scale-up of IPTi in DRC and Nigeria.

It is possible that major uncertainties will remain about the feasibility and cost-effectiveness of IPTi implementation even after the scoping period.


The budget for the grant is $120,000, including the costs of labor, travel, data collection, local consultants, and meetings.37

Risks and reservations

Some uncertainties and reservations we have about recommending this scoping grant for IPTi include: