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             You are hereHome » Top Charities » Against Malaria Foundation Against Malaria Foundation     FacebookTwitter>Print>Email                   Donate

  The Against Malaria Foundation (AMF) is one of our top-rated charities and we feel that it offers donors an outstanding opportunity to accomplish good with their donations.

 More information: What is our evaluation process? 

 Published: November 2017

 Summary What do they do? AMF (againstmalaria.com) provides funding for long-lasting insecticide-treated net (LLIN) distributions (for protection against malaria) in developing countries.

 Does it work? There is strong evidence that distributing LLINs reduces child mortality and malaria cases. AMF has conducted post-distribution surveys of all completed distributions to determine whether LLINs have reached their intended destinations and how long they remain in good condition. AMF's post-distribution surveys have generally found positive results, with some exceptions, but have some methodological limitations.

 What do you get for your dollar? We estimate that the cost to purchase and distribute an AMF-funded net is $4.22, or $4.02 excluding in-kind contributions from governments. The numbers of deaths averted and other benefits of distributing LLINs are a function of a number of difficult-to-estimate factors, which we discuss in detail below.

 Is there room for more funding? We believe that AMF is very likely to be constrained by funding. There is high uncertainty in the maximum amount that AMF could use productively, though we expect the maximum to be much greater than what AMF is likely to receive. To fund all of the distributions that it is currently in detailed discussions about, AMF would need $50 million more than we project it will receive. The total funding gap for LLINs for 2018-2020 appears to be hundreds of millions of dollars.

  AMF is recommended because of its:

 Focus on a program with excellent evidence of effectiveness and cost-effectiveness. Processes for ensuring that nets reach their intended recipients and monitoring whether they remain in homes and in good condition over the long-term. Room for more funding – we believe AMF will be able to use additional funds to deliver additional nets. Transparency – AMF shares significant information about its work with us and we are able to closely follow and understand its work. Major open questions:

 We have seen detailed data from before and during distributions. AMF also collects follow-up data after distributions. These follow-up surveys are conducted by AMF's various partner organizations and there has been variation in quality across locations. GiveWell has commissioned an ongoing project with IDinsight to better understand the survey methods used in several countries and to provide suggestions for AMF for the future. The best evidence for nets was collected before they were widely used and there is some evidence that mosquitoes have since adapted to the insecticide used in nets, possibly making them less effective. It seems that insecticide resistance is a growing concern, but it remains difficult to quantify the impact of resistance. We will continue to follow several ongoing studies that may help to quantify the impact of resistance.1 We discuss this issue in more detail in our page on this topic.  Table of Contents   Summary Our review process What do they do?  The role of AMF and its partners in LLIN distributions  Selecting locations for distributions and finding distribution partners Registration and distribution Monitoring   Other activities Spending breakdown   Does it work?  Are LLINs targeted at people who do not already have them?  Malawi and the Democratic Republic of the Congo Ghana, Papua New Guinea, Uganda, and Togo   Do LLINs reach their intended destinations?  Post-distribution surveys Household-level data on nets received Distribution reports Other evidence   Are LLINs targeted at areas with high rates of malaria? Do those who receive the LLINs install them in their homes properly? Do those who receive the LLINs utilize them consistently over the long term?  Methods Results   Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF? Are there any negative or offsetting impacts?   What do you get for your dollar?  Cost per LLIN distributed  Our approach Shortcomings of our analysis   Cost per death averted   Is there room for more funding?  Available and expected funds Uses of additional funding Expected maximum Rate of funds moved Considerations around the size of AMF distributions  Efficiency and leverage Fungibility Our conclusion on distribution size   What portion of all net distributions are funded by AMF?   AMF as an organization Sources    Our review process We began reviewing AMF in 2009. Our review process has consisted of:

 Reviewing documents AMF made available on its website or shared with us directly. Extensive communication, including several meetings at AMF's London headquarters, with AMF Founder Rob Mather and board member Peter Sherratt. A visit to AMF's distribution partner organization, United Purpose (formerly Concern Universal), in Malawi in October 2011 (notes and photos from this visit). We also spoke with United Purpose by phone in April 2016. A visit to Greater Accra, Ghana in August 2016 to meet with representatives of AMF, AMF's distribution partners Episcopal Relief & Development and Anglican Diocesan Development and Relief Organization (ADDRO), Ghana's National Malaria Control Program, and other non-profit and government organizations involved in the AMF-funded LLIN distributions in Ghana in 2016. Notes and photos from our site visit are available here. Conversations with Peter Sherratt, AMF's Executive Chairman; Don de Savigny, a member of AMF's Malaria Advisory Group; and other individuals (who requested to remain anonymous) familiar with AMF's work. Conversations with Melanie Renshaw of the African Leaders Malaria Alliance, Marcy Erskine of the International Federation of the Red Cross, and Scott Filler of the Global Fund to Fight AIDS, Tuberculosis, and Malaria about funding needs for nets. All content on AMF, including past reviews, updates, blog posts and conversation notes, is available here. We have also published a page with additional, detailed information on AMF to supplement some of the sections below.

 What do they do? AMF provides long-lasting insecticide-treated nets (for protection against malaria) in bulk to other non-profit organizations or government agencies, which then distribute the nets in developing countries.

 As of October 2017, AMF has supported large-scale distributions in six countries (Malawi, DRC, Ghana, Uganda, Togo, and Papua New Guinea) for a total of 22 million LLINs distributed.2 In addition, AMF is funding 3 million LLINs for a planned distribution in Zambia that is expected to take place in late 2017.3

 A summary of AMF's distributions can be found in this spreadsheet. 

 The role of AMF and its partners in LLIN distributions AMF's role in LLIN distributions is to:4

 Identify countries with funding gaps for LLINs. Find distribution partners (in-country non-profit organizations or government agencies) to carry out LLIN distributions. AMF and its partners agree on expectations for the distribution, including who pays for costs other than the purchase price of LLINs (which are always covered by AMF), the process that will be used to carry out the distribution, and what information will be collected and shared with AMF. Purchase LLINs and have them shipped to the distribution partners. Work with distribution partners to collect reports on the distribution and conduct follow-up surveys. Distribution partners implement on-the-ground activities, including registering residents in targeted areas, distributing LLINs, monitoring the registration and distribution processes, and conducting follow-up surveys.5

 Details follow.

 Selecting locations for distributions and finding distribution partners When selecting locations for future distributions, AMF told us it consults a series of sources, as it believes there is no single reliable resource with up-to-date information about where there are funding gaps for LLINs. Sources it consults include the Alliance for Malaria Prevention's (AMP's) list of countries with significant net gaps, other malaria control funders, in-country technical advisors, the relevant National Malaria Control Program (NMCP), implementing organizations, and the African Leaders Malaria Alliance.6 AMF told us that it has been receiving more funding requests since it started funding larger distributions,7 and notes that its largest commitment so far—10.6 million LLINs in Uganda in 2017—was made in response to an in-bound request.8

 As AMF investigates countries with existing net gaps, it also looks into organizations working within those countries that could serve as distribution partners.9 AMF looks for distribution partners that have the capacity and willingness to implement registration, distribution, and monitoring processes that meet agreed-upon requirements.10 So far, AMF has worked with United Purpose (formerly Concern Universal) in Malawi, IMA World Health in the Democratic Republic of the Congo, Episcopal Relief & Development in Ghana, National Malaria Control Programs (NMCPs) in Ghana, Togo, Uganda, and Zambia, and the Rotary Club of Port Moresby in Papua New Guinea on large-scale LLIN distributions.11

 Registration and distribution Registration: During the registration process, AMF's distribution partners' staff or volunteers travel door-to-door in targeted areas to collect the information used to determine the number of LLINs to allocate to each household (e.g., the number of sleeping spaces, the number of previously-owned LLINs in usable condition, and/or the number of household members), as well as the information used to identify the household for the distribution and post-distribution surveys (e.g., the name of the head of the household, and/or household location). AMF has shared full or sample registration data from each completed large-scale distribution with us.12 The specifics of the registration process and LLIN allocation strategy have differed by country (process details and registration data sources on a separate page with additional details about AMF). Distribution: To distribute LLINs to recipients, AMF and its distribution partners have primarily used "point distribution" (LLIN recipients pick up their nets from a specified point in or near their community), but have also used "hang-up distribution" (staff or volunteers travel door-to-door to deliver and hang up LLINs) in one distribution in Kasaï-Occidental, DRC.13 Distribution partners manage the logistics of in-country shipping and storage of LLINs prior to the distribution. The specifics of distribution processes have varied in the different countries AMF has worked in (details on a separate page with additional details about AMF). Monitoring AMF's distribution partners also implement a set of monitoring activities to produce evidence on whether the registration and distribution processes operated as intended and on the long-term impact of the LLIN distribution. Monitoring activities have varied somewhat for different distributions. We describe these processes in more detail on our page with additional information on AMF. In short:

 Process monitoring (i.e., the activities used to assess whether the registration and distribution processes operated as intended): Data validation: This includes various processes, which have varied considerably in different distributions, to check the accuracy of registration and distribution data. It has generally involved looking for and following up on outliers or implausible data, and has sometimes involved re-entering a sample of data or reading registration lists out loud at community meetings and asking community members for corrections. "Embedded" monitoring: (Ghana only) Staff of AMF's local NGO partner organization attended district-level planning meetings to ensure that they were operating as intended, observed the registration of households by volunteers organized by the government, and observed selected distribution points.14 Distribution reports: Distribution reports provide narrative summaries of activities implemented and challenges encountered by distribution partners. Post-distribution validation tracing: (Ghana only) After distributions were complete, AMF's distribution partners in Ghana checked that a random sample of households (100 households per district) had actually received the number of LLINs they were allocated by calling or visiting the households.15 Impact monitoring (i.e., the activities used to assess the impact of the distribution): Post-distribution check-ups (PDCUs): Distribution partners conduct follow-up surveys (called post-distribution check-ups, or PDCUs) in 5% of households at 6-month intervals for 2.5 years after a distribution. PDCUs collect data on whether nets are present, whether they have been hung, and what condition they are in. We summarize which PDCUs have been completed in this spreadsheet (see "PDCUs" sheet), and summarize the results and methods of PDCUs we have seen in this spreadsheet. 

 Most scheduled PDCUs have been completed in Malawi and the Ghana PDCUs are on schedule. AMF has also shared data and reports from its first three PDCUs from Kasaï-Occidental, DRC.16 We believe the DRC PDCUs were poorly implemented and provide limited evidence on the proportion of AMF's LLINs that reached their intended destinations or the impact of AMF's distribution on LLIN usage over time in Kasaï-Occidental (see this blog post for details). The 6-month PDCU in Nord Ubangi, DRC was not completed due to security concerns. AMF has told us that the 12-month Nord Ubangi PDCU was completed in mid 2017; we have not yet seen these data.

 In June and July 2017, as part of its partnership with GiveWell, IDinsight conducted site visits to post-distribution surveys to learn about AMF's monitoring of its programs. The surveys were conducted by United Purpose (formerly Concern Universal) in Malawi and by Episcopal Relief and Development and the Anglican Diocesan Development and Relief Organization (ADDRO) in Ghana. IDinsight's notes from these two visits: Malawi site visit notes (June 2017) and Ghana site visit notes (July 2017). IDinsight is planning similar such visits to Uganda, Togo, and Zambia in 2018. IDinsight will compile a report on its findings, including the sources of potential bias in post-distribution surveys.

 Other activities AMF occasionally supports malaria control activities beyond the direct distribution of LLINs. For example:

 AMF has begun funding research on insecticide resistance that will be carried out in conjunction with AMF distributions. AMF plans to fund research on the effectiveness of PBO LLINs in conjunction with its Uganda 2017 distribution. PBO LLINs are a newer type of net incorporating piperonyl butoxide (PBO) alongside pyrethroid insecticide used in other LLINs. These nets may be more effective than other LLINs in areas where mosquitoes have developed insecticide resistance. The work is currently projected to cost $2.5 million.17 AMF also funded the first phase of a study (which cost around $100,000) on insecticide resistance in Nord Ubangi, DRC; in November 2016, AMF told us that it no longer planned to fund the completion of this study (which would have cost around an additional $700,000) because it was funding the PBO study in Uganda.18  

AMF is co-funding a "Malaria Control Unit" (MCU) in Malawi with United Purpose.19 The MCU will consist of up to 14 permanent staff members who will work on a variety of malaria control projects: conducting post-distribution surveys, improving malaria case rate data collection practices, monitoring the levels of malaria prevention and treatment supplies at local health centers, developing efficient methods to keep net coverage rates high in between mass distribution campaigns, and more.20 The MCU is also intended to assist with AMF and United Purpose's distributions in Malawi.21 AMF has committed approximately $636,000 over three years to this project.22 AMF has encouraged United Purpose staff to attend national malaria control strategy meetings in Malawi to share AMF's processes and results in other districts. As a result, AMF has told us that some of its monitoring practices were being adopted for a large national distribution (approximately 7 million nets) in 18 of Malawi's 28 districts in March to May 2016.23 The practices being implemented include (a) using sleeping spaces data (as opposed to population data) to calculate the number of nets needed, (b) "105%" registration data collection (described on another page), and (c) putting summary data (at the village or health center level) into electronic form.24 AMF told us in February 2015 that it expects to be able to see the data collected during this distribution.25 We have not yet followed up with AMF on whether this happened as expected. Spending breakdown The following table shows AMF's total expenditure, categorized into purchases of LLINs, spending on running the organization, and spending on other non-net costs (such as providing funding to other organizations to conduct post-distribution check-ups, which are described above). We include spending since FY 2012 (July 2011 to June 2012) because this is when AMF shifted to its current model of larger-scale distributions.

 

AMF expenditure by category26 Category July 2011 to June 2017 spending FY 2012 to 2017 ratio LLIN purchases $60.0 million 82.0% Costs of distributing nets and monitoring ("non-net costs") $11.8 million 16.1% Insecticide resistance research $0.4 million 0.5% Salaries and other organizational costs $0.9 million 1.3% Total spending $73.2 million - Prior to 2013, AMF asked all distribution partners to use their own funds or to find another funder for all non-net costs of the distribution.27 More recently, it has paid for some of these costs in certain distributions. AMF told us that it considers funding non-net costs in cases where (a) non-net costs are not covered by other partners, and (b) AMF feels confident that its distribution partners will manage and report on spending well.28 

 Does it work? On a separate page, we discuss the general evidence behind distributions of LLINs. We conclude that there is strong evidence that these distributions can be expected to reduce child mortality and malaria cases.

 When evaluating the effectiveness of an LLIN distribution organization, we seek to answer the following questions:

 Are LLINs targeted at people who do not already have them? When determining how many LLINs to allocate to each household, AMF's distribution partners in Malawi and DRC checked households for previously-owned LLINs in good condition, but AMF's partners in Ghana, Uganda, Papua New Guinea, and Togo did not. In Ghana, we don't know what the LLIN coverage rate was before the distribution, though we note that the previous mass LLIN distribution was four years prior and most nets wear out in less than four years; AMF told us that a similar amount of time had passed since previous distributions in other countries. Do the LLINs reach the intended destinations? The main evidence that LLINs reached their intended destinations at a high rate are (a) post-distribution surveys, where surveyors visit a sample of households that registered for nets six months after the distribution, and (b) data from registering households and, for some distributions, which households are reported to have received their nets. We have seen (a) and/or (b) from all of AMF's distributions; we discuss some limitations of the post-distribution surveys below. Are LLINs targeted at areas with high rates of malaria? AMF seeks out distribution partners in countries that are known to have high rates of malaria, or where malaria rates are likely to increase significantly if LLIN distribution programs are not sustained. We note that Papua New Guinea (where AMF plans to fund LLIN distributions in 2017 and 2018) has lower (but still significant) rates of malaria than other countries where AMF has worked or plans to work. Do those who receive the LLINs install them in their homes properly? Do they utilize them consistently over the long term? AMF requires partners to conduct follow-up surveys at 6-month intervals for a period of 2.5 years. We have little data to compare these results to, but in most cases the results from Malawi and Ghana seem consistent with moderate to high usage of nets for at least a year or two after distribution; we have very limited evidence past 18-months post-distribution.29 We discuss some methodological limitations of the surveys below. Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF? The evidence we have seen suggests that donations to AMF increase the total number of LLINs distributed, but that a portion of the impact is offset by displacing funding from other sources.Details follow.

 Are LLINs targeted at people who do not already have them? Malawi and the Democratic Republic of the Congo We believe that the LLIN allocation strategy used in Malawi and DRC is reasonably likely to avoid supplying more LLINs than needed to individual households.

 For AMF's past large-scale distributions in Malawi, a household's allocation of LLINs was determined by subtracting the number of LLINs in usable condition from the total number of sleeping spaces in the household.30 AMF's distribution partner in Malawi, United Purpose, told us that during registration health workers enter each household, ask about who is living in the household, and visually inspect sleeping spaces and existing nets.31 United Purpose has also conducted village meetings in which its staff read off household names and the number of LLINs that have been allocated to each household; households then indicate if any errors have been made.32 We observed one such village verification meeting during our visit to Malawi in October 2011.33 For more detail on the registration process used in Malawi, see a separate page with additional information on AMF.

 We have seen registration data (which include records of numbers of sleeping spaces and usable LLINs per household) from all six of AMF's completed large-scale distributions in Malawi: full data from its Ntcheu 2012, Balaka 2015, and Ntcheu 2015 distributions, and sample results from its Balaka 2013, Dedza 2014, and Dowa 2015 distributions.34

 For IMA's Kasaï-Occidental, DRC distribution, we discuss what we know about the process from reports IMA has shared here. The process appears to be largely similar to United Purpose's process for going house-to-house to determine net need and allocating LLINs by subtracting a household's usable LLINs from its number of sleeping spaces, though it did not include village verification meetings (in part because nets were distributed during the same visit in which net need was determined). We have seen full distribution data from Kasaï-Occidental, which includes data on numbers of usable LLINs and sleeping spaces per household.35 Due to logistical issues encountered with registering households and distributing nets during the same visit in the Kasaï-Occidental distribution,36 IMA and AMF implemented separate registration and distribution processes for the distribution in Nord Ubangi, DRC.37 We have seen a sample of household-level registration and distribution data from Nord Ubangi (as well as summaries of data for the entire distribution), which includes numbers of sleeping spaces per household, numbers of previously-owned LLINs, and numbers of LLINs distributed.38 The summary registration data indicates that ownership of LLINs in good condition before AMF's distribution was low, with around 18,000 LLINs in good condition owned for a population of around 1.3 million.39 We have not yet seen a distribution report from Nord Ubangi, so we do not have full details on how this data was collected.

 It is possible that some households may hide previously-owned LLINs during registration; cases of households hiding nets in order to receive extra LLINs have been observed in campaigns in Senegal and Nigeria.40 We have not seen any evidence that this has occurred in AMF's distributions.

 Ghana, Papua New Guinea, Uganda, and Togo We believe that the LLIN allocation strategy used in AMF's distributions in Ghana in 2016 and in Papua New Guinea, Uganda, and Togo in 2017 may have oversupplied some households with LLINs. 

 Prior to the 2016 distributions in Ghana, volunteers organized by the government collected information on the number of people in each household in targeted areas.41 Registered households were allocated one net per two people (rounding up for households with an odd number of people). Previously-owned nets in usable condition were not subtracted from households' LLIN allocations.42 It seems likely to us that some households in areas targeted by these distributions already owned some LLINs in usable condition, which may have been obtained through "continuous distributions" or by purchase, so these households may have been allocated more LLINs than necessary in AMF's distribution.43 However, since the most recent mass distribution of LLINs in the Northern, Greater Accra, and Upper West Regions was in 2012 (four years before AMF's distributions), we would guess that a large proportion of targeted households were in need of new LLINs.44 

 We have seen complete registration data from AMF's distribution in Ghana (which includes information on the number of individuals in each household and the number of LLINs allocated to each household). AMF and the government decided not to collect information on previously-owned LLINs for this distribution because they did not expect to find many.45 

 AMF's distribution partners also did not subtract out previously-owned usable LLINs from households' LLIN allocations during its 2017 distributions in Papua New Guinea, Togo, and Uganda.46 AMF told us that this decision was made because, in regions where the previous mass distribution was more than three years earlier, it is likely that the number of previously-owned nets in good condition will be low.47 

 AMF also told us that it has not yet determined whether usable LLINs will be subtracted from households' allocations during distributions in Malawi in 2018.48 

 AMF notes that it interprets the data from PDCUs as indicating that LLINs should be replaced at least every three years and that subtracting usable nets (unless they have never been used) increases the period where a household has to rely on old, ineffective nets until the next LLIN campaign.49

 Do LLINs reach their intended destinations? We have seen reasonable evidence that a large proportion of AMF's LLINs have reached their intended destinations in AMF's past distributions. The strongest evidence we have seen on this question in Malawi and Ghana is from post-distribution surveys, and the strongest evidence from DRC and Papua New Guinea is from household-level data on nets received. (We have not yet seen evidence on this for recent/ongoing distributions in Togo and Uganda, but expect this later.)

 The main sources of evidence that LLINs reached their intended destinations at a high rate are (a) post-distribution surveys, where surveyors visit a sample of households that registered for nets six months after the distribution, and (b) data on which households are reported to have received their nets. We have also seen narrative distribution reports for most of AMF's distributions, and a few other minor sources of evidence that LLINs reached their intended destinations. 

 Post-distribution surveys AMF's distribution partners conduct post-distribution surveys, discussed in detail below, about six months after each distribution (and every six months after that up to 2.5 years after the distribution) to determine whether nets are in place, being used, and in good condition.50 The first post-distribution surveys that have been completed to date for each large-scale distribution in Malawi have generally somewhat mixed results: the first four found rates above 80% (90%, 87%, 93%, and 91%) of LLINs from the recent AMF distribution hung over sleeping spaces, while the most recent distributions have had worse results (69% and 60%; the latter was followed by a rate of 77% at 12 months). Most nets that were not hung were present in the household: the highest rate of missing nets was 5% (see this summary of results for details).51 Hang up rates at 6 months post-distribution in Ghana were relatively high: 80%, 84%, and 90% in the three regions.

 We believe that the results of the first post-distribution surveys from distributions in Malawi and Ghana provide reasonable evidence that nets reached their intended locations at a high rate, though we note some methodological limitations of these surveys below.

 We believe that the 8-, 12-, and 18-month surveys in Kasaï-Occidental were poorly implemented, and that the results of the surveys provide limited evidence on the proportion of AMF's LLINs that reached intended destinations (details in this blog post).52

 Household-level data on nets received In addition to recording data on the number of LLINs allocated to each household during the registration process, AMF's distribution partners also record data on the number of LLINs actually distributed to each household during the distribution process.

 For Malawi, we have not seen household-level data on the number of nets received. Our understanding is that these data exist in paper form only. 

 For the Kasaï-Occidental distribution in DRC, households received nets at the same time they were registered, so the registration list provides some evidence that nets reached their intended destinations.53 We have seen registration and distribution data from Nord Ubangi, DRC that include numbers of LLINs actually received and hung up for each household.54 We have not yet seen a distribution report from Nord Ubangi, so we are uncertain about how data on the number of LLINs households actually received were collected.

 In Ghana, data on the number of LLINs actually distributed to each household were recorded by LLIN distributors, and later entered electronically into AMF's Data Entry System, where we have viewed the data.55 We also spot-checked some paper records during our visit to AMF's distribution partner in Ghana in 2016.

 Distribution reports Distribution reports provide narrative summaries of distribution activities and discuss challenges encountered. These reports provide some evidence that distributions generally operated as intended (or that distribution partners are aware of specific challenges and have plans to address them) and that households actually received LLINs; however, we do not think this type of evidence is as useful for the question of whether LLINs reached households as the quantitative evidence discussed above.

 United Purpose has provided distribution reports for four of the six large-scale distributions it has completed in Malawi.56 As we report in our March 2012 update, reports from the Ntcheu 2012 distribution note challenges including attempted thefts, double registrations, and logistical problems.57 United Purpose provided a similar level of detail on challenges encountered in the Balaka 201358 and Dedza 2014 distributions,59 and the first half of the Dowa 2015 distribution.60 These reports increase our confidence that United Purpose is aware of potential problems and has a system in place to address them.61 We have not seen reports for the Ntcheu 2015 or Balaka 2015 distributions in Malawi. 

 IMA World Health has provided a distribution report for the Kasaï-Occidental, DRC 2014 distribution. We have not yet seen any distribution reports from the Nord Ubangi, DRC distribution.62

 We have also seen progress reports covering periods of pre-distribution, distribution, and post-distribution activities from Episcopal Relief & Development, AMF's distribution partner in Ghana, for the 2016 distributions in Greater Accra, Northern Region, and Upper West Region, and a full report on the 2016 distribution in the Northern Region.63 These reports discuss problems encountered in each of these stages.64

 Other evidence For the Kasaï-Occidental 2014 distribution, AMF's distribution partner, IMA World Health, piloted the use of smartphones to record household data, including GPS coordinates, for registration and LLIN distribution.65 AMF has sent us detailed GPS data that show the GPS coordinates for each household visited.66 The registration and distribution data from Nord Ubangi, DRC also included GPS coordinates for each household.67

 In Ghana, it is our understanding that "post-distribution validation tracing" (i.e., checking, immediately after the distribution, by phone or in-person, that a randomly selected sample of households actually received the correct number of LLINs) was used for all three AMF-funded distributions in 2016, but we have not seen comprehensive results from this process (e.g., the proportion of selected households that received the appropriate number of LLINs).68 AMF told us that it expected to see data from post-distribution validation tracing from Episcopal Relief & Development in January 2017;69 we have not followed up with AMF for these data.

 Are LLINs targeted at areas with high rates of malaria? At the highest level, AMF appears to exclusively target countries with known malaria risk.70 Since 2012, AMF’s large-scale distributions have occurred in Malawi, DRC, Ghana, Uganda, Togo, and Papua New Guinea, and a distribution is planned for Zambia.71 Based on 2013 data, the World Health Organization estimated that Malawi, DRC, Ghana, Uganda, Togo, and Zambia had malaria death rates of between 50 and 99 deaths per 100,000 people, and that Papua New Guinea's malaria death rate was between 10 and 49 deaths per 100,000 people.72 

 Do those who receive the LLINs install them in their homes properly? Do those who receive the LLINs utilize them consistently over the long term? AMF requires partners to conduct PDCUs at 6-month intervals (plus or minus a month) for a period of 2.5 years, or until the next community-wide net distribution in the same area, to determine whether LLINs are present, whether they have been hung, and what condition they are in. The surveys do not measure usage or reported usage.73 Surveys to date have been highly comprehensive (covering all distributions) and have some methodological limitations, discussed below. Results have been fairly positive with substantial variation across distributions.

 Methods See our summary of AMF distributions spreadsheet, "PDCUs" sheet, for details of what PDCUs have been completed. In short, AMF's PDCUs are highly comprehensive: we have seen results from all distributions (where enough time has passed since the distribution), and few of the scheduled surveys (which are intended to be conducted every six months) have been skipped. 

 For a description of the methodology used in AMF's PDCUs, see this spreadsheet, sheet "Methods." In short:

 Households are now selected randomly for inclusion in the surveys. AMF generates the list of households to survey from the full list of households that were registered for the distribution.74 The list includes more households than will be surveyed, with the intention of allowing enumerators to skip some households; this may lead to bias in the results. Note that in some earlier surveys, households were not selected fully randomly.75 AMF has told us that it asks its partner organizations to revisit 5% of the households visited, as a means of data quality control.76 While the idea is that the results from the revisits can then be matched and cross-checked against the original results, our impression is that this matching process historically has not actually occurred. AMF believes it will be easier to match the data using the Data Entry System.77 We have not yet seen this analysis for any distributions. We believe that the 8-, 12-, and 18-month surveys in Kasaï-Occidental were poorly implemented, and that the results of the surveys provide only limited evidence on the proportion of AMF-funded LLINs that are used effectively over the long term (details in this blog post).78 However, we think that the combination of the three reported rates (at 8-, 12- and 18-months) of coverage tells a plausible story of a decline in coverage over time, which increases our confidence that these surveys are to some extent representative of LLIN hang-up rates, or at least of trends in hang-up rates. In 2017, GiveWell commissioned IDinsight to observe PDCUs in Malawi and Ghana. For Ghana, IDinsight noted: Though enumerators were trained to observe use and condition of nets, assessment was inconsistent and did not always involve direct observation.79 During data entry, illegible and inconsistent data were discarded, and records were not kept on what portion of data was discarded.80 Results Full results in this spreadsheet. Definitions of each indicator are on a separate page with additional information about AMF. In short:

 Malawi: The data from PDCUs from the first four of six distributions in Malawi show high rates of nets hanging and in at least "viable" condition for 18-33 months post-distribution. We have more limited follow-up so far on the two more recent distributions in Malawi. Early results indicate lower rates of nets from the distribution hanging and high rates of nets in at least "viable" condition. AMF believes that the low hang-up rates for these two more recent distributions may be due to the continued use of older LLINs from the 2012 distribution in Ntcheu and use of LLINs from other sources in Dowa (or other possible explanations, see footnote).81 DRC: We believe the data we have seen from AMF's distributions in DRC provide some limited evidence that LLINs decayed considerably quicker than expected. Ghana: The distributions in Ghana occurred in mid-to-late 2016, so the longest follow-up to date in Ghana is from 12 months post-distribution and so far shows high rates of nets hanging and nets in at least "viable" condition (i.e. not "worn out"). We note that net usage rates in the trials of bed net efficacy documented in our page on Long Lasting Insecticide Treated Nets had net usage rates generally in the 60%-80% range.82 However, these usage rates are not directly comparable to the data from AMF's PDCUs, which measure the proportion of nets hung, rather than usage.

 As another point of comparison, the "decay model" we use to estimate the lifespan of LLINs assumes that 92% of LLINs are functional and in use for the first year after a distribution, 80% of nets are functional and in use for the second year, and 50% of nets are functional and in use for the third year.83 It is not fully clear to us how to compare the net quality and net hangup rates found in AMF's post-distribution check-ups to the assumptions in the decay model, in part because it is not clear whether the definition of a "functional and in use" net in the decay model is comparable to what PDCUs measure.

 Do AMF's LLINs increase the total number of LLINs distributed, or would the recipients have received LLINs from other sources if not for AMF? On a separate page, we discuss some cases where AMF was in discussions to fund a distribution, but ultimately did not. In most of these cases, the net gap AMF was in discussions to fill persisted for six or more months after AMF's discussions closed, and, in two out of the five cases we looked at, gaps persisted for long periods (18 months and ~3 years, respectively). In most cases, the gap was eventually filled by another funder. As far as we can tell, during the time between AMF withdrawing from discussions and another funder stepping in, the populations targeted for distributions did not receive nets and likely were inadequately protected from malaria.

 We also discuss, on a separate page, what we have been told about what would have happened in the absence of AMF funding in two distributions that AMF did fund. In summary, in both cases our best guess is that there were no other funders who could have closed the gaps, and nets would have been at least partially targeted at higher-risk populations while others would have been left uncovered. 

 Across Africa, there are substantial funding gaps for LLINs (more below), and because our impression from following AMF's progress over time is that, due to AMF's more limited funding and, perhaps, greater data requirements, governments often seek funding first from larger funders (particularly the Global Fund to fight AIDS, TB, and Malaria) and then may ask AMF to fill gaps. However, we note that this dynamic may change if AMF has significant resources in the future (more below) and that countries are sometimes able to choose how they allocate Global Fund grants among malaria interventions (including LLINs, treatment, and diagnosis), so the availability of funding for LLINs from AMF could cause countries to allocate fewer Global Fund resources to LLINs.84

 Are there any negative or offsetting impacts? Will insecticide-treated nets continue to be effective? As discussed in our report on insecticide-treated nets, there is strong evidence for the effectiveness of this intervention; however, the best evidence for the intervention was collected before LLINs were widely used and there is some evidence that mosquitoes have since adapted to the insecticide used in LLINs, possibly making them less effective. We have reviewed the evidence on the state of insecticide resistance. We concluded, "Broadly, it seems that insecticide resistance is a larger concern now than it was when we last thoroughly evaluated the evidence in 2012, but it remains difficult to quantify the impact of resistance. Our very rough best guess (methodology described in more detail below) is that insecticide-treated nets (ITNs) are roughly one-third less effective on average across sub-Saharan Africa than they would be in the absence of insecticide resistance. ITNs remain a highly cost-effective intervention after incorporating this discount." Do free LLIN distributions distort incentives for recipients or distort local markets for nets? As discussed in our report on insecticide-treated nets, we feel that there is a reasonably strong case for distributing LLINs freely rather than selling them at market (or even below-market) prices. We also think that the benefits of distributing LLINs freely to a population likely outweigh the negative consequences of distortion in local net markets, though we have not factored these potentially negative consequences into our cost-effectiveness analysis of AMF. Could distribution of LLINs be inequitable and unfair, causing problems in the targeted communities? We feel that AMF's processes for determining needs for LLINs at the household level are fairly well-suited to ensuring that LLINs are distributed equitably. We have some concerns about whether AMF's process succeeds at identifying all villages or households located outside of villages. Does AMF divert skilled labor from other areas? In Malawi, net distributions have been conducted by low-level government health staff in partnership with the staff of AMF's partner NGO.85 AMF's partner in Malawi told us in 2012 that government health staff are normally involved in activities such as disseminating health-related information, reporting on levels of stunting and disease, carrying out immunization campaigns, and providing nutrition support.86 We do not know the extent to which net distribution reduces their ability to complete other duties, though we note that net distributions are generally completed within a few days in each local area, and we would guess that LLIN distributions are likely among the most cost-effective work they engage in.87 Diversion of skilled labor may be more of a concern in the DRC, where 22 senior district health staff were employed as Field Supervisors for the Kasaï-Occidental distribution.88 AMF's distributions in Ghana in 2016 were planned by high-level staff from a government health agency and implemented by local government staff and volunteers; monitoring of the distribution was largely implemented by a Ghanaian non-profit organization.89 We have not investigated what other activities the government and non-profit staff and volunteers engage in, or whether the LLIN distribution interferes with their ability to perform other duties. What do you get for your dollar? Cost per LLIN distributed We estimate that on average the total cost to purchase, distribute, and follow up on the distribution of an AMF-funded LLIN is $4.22. Excluding in-kind government contributions, we estimate the cost is $4.02. These estimates rely on a number of uncertain assumptions. Full details of our analysis are in this spreadsheet. For results, see sheet "Summary." More discussion follows.

 Below, we also discuss how we estimate the cost per death averted in AMF distributions.

 Our approach To get the total costs of the program, we attempt to include all partners such that our cost per LLIN represents everything required to deliver the nets. In particular, in our cost per treatment analysis for AMF, we have attempted to include these categories:

 The costs paid by AMF to purchase LLINs. This accounts for 47% of the total cost per LLIN. Costs of shipping and delivering nets, monitoring the distribution, and conducting PDCUs. In most cases, the Global Fund or another partner pays for most of these costs; in almost every case, AMF has paid for the PDCUs. In total, these costs account for 43% of the total. Resources contributed by governments, such as staff time, office space, etc. We roughly estimate these costs as a proportion of the total cost (excluding LLIN purchase costs) based on an analysis of a distribution in Malawi in 2012. This accounts for 5% of the total. Other AMF costs: staff salaries and other organizational costs, a rough estimate of the value of the CEO's donated time and estimated value of other pro bono support, research AMF has funded on insecticide resistance, and costs of the Malaria Unit in Malawi. This accounts for 5% of the total. We start with this total cost figure and apply adjustments in our cost-effectiveness analysis to account for cases where we believe the charity's funds have caused other actors to shift funds from a less cost-effective use to a more cost-effective use ("leverage") or from a more cost-effective use to a less cost-effective use ("funging").

 We used data and estimates from completed distributions, ongoing distributions, and distributions that AMF has committed to funding in the future. 

 Comment from AMF: AMF would like all donors reading this to know that the costs included for the CEO and pro bono services are not actually incurred. Each of them is very happy to provide their services for free. On a separate page, we triangulate our AMF estimates of cost per LLIN with a rough global average cost per LLIN.

 Shortcomings of our analysis There are several ways in which our analysis of AMF's cost per LLIN is uncertain:

 The price of an LLIN has been falling and in our estimate we have used a projected price per LLIN, rather than an average of the prices AMF has paid in the past. The average price in distributions AMF funded in 2016-2018 was $2.20. Based on what AMF told us it expects in the future, we have used an estimate of $2.00 per LLIN. For distribution costs not paid by AMF, we have generally used rough estimates. AMF told us that the Global Fund expects to pay $1.16 per net for these costs in Malawi in 2018 and $2.20 in DRC, and paid $1.26 in Ghana in 2016. For other countries, we use the average of these three figures. It is difficult to predict where AMF will fund LLINs in the future because it pursues several discussions at once. To get an overall average cost, we have taken a weighted average of past distributions, weighted by the number of LLINs in each distribution, rather than weighted by the number of LLINs projected for the future. This means that if, for example, AMF funds a larger proportion of nets in DRC, where costs are high, in the future than in the past, our cost per LLIN would be an underestimate. (Note that this does not mean that funding LLINs in DRC is necessarily less cost-effective—our cost-effectiveness analysis also takes into account factors such as malaria mortality rates in each country.) Cost per death averted See our most recent cost-effectiveness model for estimates of the cost per death averted through AMF-funded LLIN distributions.

 Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. For example, our model does not include the short-term impact of non-fatal cases of malaria prevented on health or productivity, prevention of other mosquito-borne diseases, or reductions in health care costs due to LLINs reducing the number of cases of malaria. It also does not include possible offsetting impacts or other harms. We do include possible developmental impacts on children who sleep under an LLIN.90 

 There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

 The full details of our cost-effectiveness analysis are in our report on mass distribution of LLINs.

 Is there room for more funding? We believe that AMF is very likely to be constrained by funding. There is high uncertainty in the maximum amount that AMF could use productively, but we expect the maximum to be much greater than what AMF is likely to receive. To fund all of the distributions that it is currently in detailed discussions about, AMF would need $50 million more than we project it will receive. The total funding gap for LLINs for 2018-2020 appears to be hundreds of millions of dollars.

 We calculate this from (more details in the sections below):

 Total opportunities to spend funds productively: AMF has set aside $23.9 million for distributions where it expects to sign agreements soon. Beyond that, AMF told us that it is in detailed discussions with partners about the possibility of committing an additional $93 million. Based on AMF's past experience, our guess is that some of these discussions will not result in agreements for reasons other than lack of funding. AMF would likely pursue discussions beyond these if it had sufficient funds. It is currently in some early stage conversations and it appears that the funding gap for LLINs across Africa will be hundreds of millions of dollars in 2018-2020. (More) Cash on hand: As of October 2017, AMF held $58.6 million in uncommitted funds of which it had set aside $23.9 million for distributions where it expects to sign agreements soon, leaving $34.8 million in funds not set aside. (More) Expected additional funding: We roughly estimate that AMF will receive $8 million in 2018-2020, not including funds due to GiveWell's recommendation. This could be an underestimate—AMF expects to make fundraising a larger priority in the future. (More) Below, we also discuss:

 Past spending rate: AMF has a track record of identifying opportunities to spend tens of millions of dollars per year, however, we see its limited staff capacity as a risk to its ability to increase its spending in the future. (More) Considerations around the size of AMF distributions: Funding a large portion of a national distribution has advantages in terms of efficiency and leverage, but also increases the risk of displacing funding from other donors. We discuss AMF's approach to this tradeoff. (More) Available and expected funds As of October 30, 2017, AMF held $76.5 million. Of this, $17.8 million was committed to PDCUs for previous distributions, future distributions in Uganda (2017), Malawi (2018) and Papua New Guinea (2018), central costs for two years (including hiring additional staff), the research study on PBO nets in Uganda, and the Malaria Unit in Malawi, leaving $58.6 million in uncommitted funds.91 A further $23.9 million was set aside for distributions where AMF expected to sign agreements soon, leaving $34.8 million currently available to allocate to additional future distributions.92 

 We expect that AMF will receive additional donations over the remainder of 2016 and in 2017 from:

 Donors who are not influenced by GiveWell's research: Historically, the vast majority of AMF's funding has been due to GiveWell's recommendation.93 As a rough guess, we expect AMF to receive $2 million per year from non-GiveWell sources in the next year. This may be an underestimate as AMF has told us that it expects fundraising to be a key priority in 2018.94 Donors who give based on GiveWell's top charity list, but do not follow our recommendation for marginal funding: GiveWell maintains both a list of all top charities that meet our criteria and a recommendation for which charity or charities to give to in order to maximize the impact of additional donations, given cost-effectiveness of remaining funding gaps. We estimate that AMF will receive about $2 million from donors who use our top charity list but don't follow our recommendation for marginal donations.95 In our projections of future funding, we count only one year of top charity funding in order to retain the flexibility to change our recommendations in future years. Donors who follow GiveWell's recommendation for marginal donations: Our estimate of room for more funding is used to make a recommendation to these donors. With $58.6 million in currently available funding and $4 million expected in additional funding ($2 million from each of the first two groups), we estimate that AMF will have about $62.6 million available in 2017 and an additional $2 million per year in each 2019 and 2020, for a total of $66.6 million in 2018-2020.

 Uses of additional funding As noted above, as of October 2017, AMF has set aside $23.9 million for distributions where it expects to sign agreements soon. This amount includes distributions in 2018 and 2019 in five countries, all of which AMF has funded distributions in previously (Ghana, Malawi, Papua New Guinea, Togo, and Zambia).96

 AMF told us that it is in detailed discussions about distributions that would cost an additional $93 million. All distributions in this category are expected to take place in the last quarter of 2018, 2019, and 2020 and would be in countries in which AMF has funded distributions previously (DRC, Zambia, Togo, and Uganda); our understanding is that work in DRC may involve new distribution partners, in addition to or instead of those AMF has worked with in the past. If all of the agreements that it expects to sign soon are completed, it will have $35 million (as of October 2017) available to allocate to these additional opportunities.

 AMF told us that it is also in early conversations with six countries in which it has not funded distributions previously. AMF roughly estimates that all of these distributions together would cost $80 million to fund. Updating these numbers for more recent data on country-level gaps, we estimate the total at $60 million, but note that there is a large amount of uncertainty both in the data we are using and the likelihood that these discussions will result in distribution agreements.

 Expected maximum We believe that there will be a large funding gap for mass LLIN campaigns in the next three years, but we are quite uncertain about the size of the gap. 

 The African Leaders Malaria Alliance (ALMA) estimates funding gaps for LLINs across all African countries. In 2014, 2015, March 2016, June 2016, and October 2017 we asked Melanie Renshaw of ALMA for updates on the size of the funding gap. On all occasions she told us that there remained significant gaps in funding for LLINs.97 As of late 2016, Melanie Renshaw roughly estimated there would be a funding gap for 100 million LLINs in 2018-2020.98 As of late 2017, Dr. Renshaw noted that some of the data are preliminary, but estimated that the gap would be roughly 150-180 million LLINs in 2018-2020. Nigeria is expected to make up a large portion of this gap: 74 million LLINs.99 

 Dr. Renshaw believed that less funding from the Global Fund would be available for LLINs in 2018-2020 than in the previous round because of changes in the way it is structuring its funding.100 

 At $4.12 per net (this is in variable monetary costs only—excludes in-kind costs and AMF organizational costs)—this is a funding gap of about $620-730 million over three years. For 2018 and 2019 only, the gap is roughly $230-280 million over the two years. The 2020 gap may be larger than in 2018-2019 because some donors may make commitments at a later date and/or because countries may choose to frontload Global Fund funding—the current round of Global Fund funding covers 2018-2020—with the hope of identifying additional sources of funding later.101 As a result, our preference is for AMF to use funds received in late 2017 and 2018 to fund distributions in 2018-2019. We understand that more lead time is beneficial for countries' planning processes,102 but are concerned that committing to distributions far in advance increases the uncertainty about whether funding would have been available from another source.

 The gap may be larger if countries begin using PBO or other "next generation" nets.

 The 2018 gap is estimated at 19% of the total need for that year, the 2019 gap at 13% of the annual total need, and the 2020 gap at 40%. This is in line with what the end of year gaps have been in recent years. Dr. Renshaw estimated that the unfilled gaps in 2013-2015 were 22 million (13% of the total need), 38 million (15% of the need), and 39 million (18% of the need), respectively.103

 Rate of funds moved We had previously expressed concerns about AMF's ability to scale up.104 We now believe that AMF has a track record of productively spending large amounts of funding annually. 

 In its 2016 and 2017 fiscal years, it spent $34.3 and $28.5 million, respectively, up from less than $4 million in each of the prior years.105 

 Progress at signing new agreements was slow in 2017, leaving AMF with a large amount of funds on hand. We attribute this to the fact that countries spent much of 2017 applying for Global Fund funding and decisions about how much funding would be allocated to LLIN distributions for 2018-2020 and what the funding gaps would be for LLINs were being finalized in many countries as of October 2017.106 AMF noted that it did not commit to funding distributions earlier in part because GiveWell had asked AMF not to make funding commitments until the size of funding gaps were known.107

 The main risk we see to AMF's ability to spend funds productively is its staff capacity. As of November 2017, AMF employs four staff: a CEO, a technology director, a program director, and a recently-hired operations manager. AMF's executive chairman also spends half his time involved in the management of AMF.108 Since 2016, AMF has had a goal of hiring more staff,109 but our impression is that progress on this has been slow. In the short term, we'd expect hiring staff to reduce AMF's staff capacity as it focuses on recruiting and training. AMF noted (in 2016) that it believed that staff capacity had not constrained its ability to sign agreements or manage distributions.110

 Considerations around the size of AMF distributions Efficiency and leverage AMF has told us that focusing on large distributions allows it to:111

 Be more efficient, since its staff capacity is largely limited by the number of distributions it is in discussions about and following up on. Focus on the countries that it has experience working with and where it has relationships with partners. Have more leverage to ask countries to carry out distributions and monitoring according to AMF's preferred processes. Funding a distribution requires negotiating with NMCPs, which we perceive to have some discretion in which funders they work with, and which we perceive to be choosing funders based on a variety of factors, including size and reporting requirements.112 In the past, AMF has been able to fund only a relatively small piece of countries' distributions (Uganda is an exception), but has maintained substantial reporting requirements. This dynamic may create fundamental reasons for governments to prefer partnerships with other funders. Give countries more confidence that their distributions will be fully funded and allow for easier planning and more timely distributions. For these reasons, AMF's preferred approach would be to offer to purchase all the nets needed for one or more countries' distributions, and, if additional funds were available, fill gaps in LLIN funding for other countries; it would not fund the non-net costs, so this would mean funding about half of the full cost of the distribution. 

 Fungibility AMF's approach in the past has been to look for funding gaps—countries that do not have sufficient funding from the Global Fund and other funders for nets—and offer to fill or partially fill those gaps. Given that countries and other funders have some discretion over how funds will be used, it is likely that some portion of AMF's funding has displaced other funding into other malaria interventions and into other uses. 

 We would guess that this effect would be significantly greater (i.e., there would be more displacement of other funding) if AMF were to pursue the strategy of offering to purchase all of the nets needed for one or more countries, rather than filling in gaps once the Global Fund has made its allocations. It is our understanding that once the Global Fund has told countries how much funding they have been allocated for each disease, it will be difficult to change those allocations and to shift funding to countries that have funding gaps for nets. Therefore, the result of AMF providing a large amount of funding for nets to one country would be for that country to spend more Global Fund resources on other malaria interventions (including general health systems strengthening) or (less likely) to reallocate funds from malaria to AIDS and/or tuberculosis work. 

 Our conclusion on distribution size We feel that the risk of displacing a large amount of funding using the approach where AMF purchases all of the nets for one or more countries outweighs the benefits. We have requested that AMF use GiveWell-influenced funding to seek out gaps that other funders are unlikely to fill.

 AMF has told us that, starting in 2017, it will require information for all distributions on how the country is spending its Global Fund malaria funding in the preceding and upcoming mass LLIN distributions, and what the other sources of funding are for the preceding and upcoming distributions.113 This should give AMF and GiveWell more insight into the chances that AMF's funding is displacing funding from LLINs into other uses. We have seen partially completed reports for Uganda and Ghana. See footnote for an example from Uganda (not fully complete).114 

 What portion of all net distributions are funded by AMF? In 2015, 2016, and the first three quarters of 2017, approximately 470 million nets were distributed in sub-Saharan Africa. 57% of these nets were funded by the Global Fund, 21% were funded by the President's Malaria Initiative, and 9% were funded by UNICEF.115

 AMF's contributions accounted for 14.2 million nets in 2015-2017 (this is less than the number of nets that AMF purchased; we have made an adjustment to account for the fact that AMF contributes the nets while other funders pay many of the other costs).116 Therefore, AMF's contribution is about 3% of all nets distributed.117

 AMF as an organization We believe the Against Malaria Foundation to be a strong organization: 

Track record: We feel AMF has built up a strong track record of finding distribution partners and getting partners to report information publicly at an unusually high level. Communication: AMF has communicated clearly and directly with us and given thoughtful answers to our critical questions. Self-evaluation: AMF collects a large amount of relevant data about its programs, demonstrating a commitment to self-evaluation. Transparency: AMF has consistently been strong in its commitment to transparency. It has provided the information we’ve asked for and has not hesitated to share it publicly (unless it had what we felt was a good reason). More on how we think about evaluating organizations at our 2012 blog post.

 Sources Document Source Alliance for Malaria Prevention 2015 Q4 Net Mapping Project Unpublished Alliance for Malaria Prevention 2016 Q3 Net Mapping Project Unpublished Alliance for Malaria Prevention 2017 Q3 Net Mapping Project Unpublished Alliance for Malaria Prevention Toolkit (version 2.0) - Chapter 3 Source ALMA LLIN gap analysis (April 2016) Unpublished ALMA LLIN gap analysis (June 2016) Unpublished ALMA LLIN gap analysis (November 2017) Unpublished AMF Audited financial statement (2005) Source (archive) AMF Audited financial statement (2006) Source (archive) AMF Audited financial statement (2007) Source (archive) AMF Audited financial statement (2008) Source (archive) AMF Audited financial statement (2009) Source (archive) AMF Audited financial statement (2010) Source (archive) AMF Audited financial statement (2011) Source (archive) AMF Audited financial statement (2012) Source (archive) AMF Audited financial statement (2013) Source (archive) AMF Audited financial statement (2014) Source (archive) AMF Audited financial statement (2015) Source AMF Countries involved Source (archive) AMF Country Funding Report Template Source AMF Data Entry System, Ghana 2016 Unpublished AMF Data Entry System, Ghana 2017 Unpublished AMF Data Entry System, Togo 2017 Unpublished AMF Data Entry System, Uganda 2017 Unpublished AMF distribution verification Kasaï-Occidental 2014 Source AMF Distributions Source (archive) AMF Financial information Source AMF Frequently Asked Questions Source (archive) AMF funds status (April 2016) Unpublished AMF funds status (June 2016) Source AMF funds status (March 2016) Unpublished AMF funds status (November 2016) Anonymized Source AMF funds status (October 2016) Unpublished AMF funds status (October 2017) Redacted Source AMF Future distributions Source (archive) AMF Ghana 2016 distribution agreement Unpublished AMF How we work with distribution partners Source AMF information we publish Source AMF insecticide research proposal from the London School of Tropical Medicine Unpublished (archive) AMF IT Developer hiring notice Source (archive) AMF LLIN distribution proposal form Source AMF Malaria Unit draft budget Unpublished AMF Malawi universal coverage calculations (September 26, 2011) Source AMF medium term strategy discussion document (May 2016) Unpublished AMF Ntcheu update (November 2012) Source (archive) AMF Operations Manager hiring notice Source (archive) AMF page on Balaka 2013 distribution Source (archive) AMF page on Balaka 2015 distribution Source (archive) AMF page on Balaka 2018 distribution Source (archive) AMF page on Dedza 2014 distribution Source (archive) AMF page on Dedza 2018 distribution Source (archive) AMF page on Dowa 2015 distribution Source (archive) AMF page on Dowa 2018 distribution Source (archive) AMF page on Kasaï-Occidental 2014 distribution Source (archive) AMF page on non-net costs Source (archive) AMF page on Nord Ubangi 2015 distribution Source (archive) AMF page on Ntcheu 2012 distribution Source (archive) AMF page on Ntcheu 2015 distribution Source (archive) AMF page on Ntcheu 2018 distribution Source (archive) AMF Papua New Guinea 2017 distribution agreement Redacted Source AMF Papua New Guinea blog post 2016 Source (archive) AMF People Source (archive) AMF post-distribution check-up comparison summary Source AMF Summary features of an AMF distribution Source (archive) AMF Togo 2017 distribution agreement Redacted Source AMF Uganda 2016 distribution agreement Source AMF Uganda Country funding report Unpublished AMF Upper West Region Ghana pre-validation registration data 2016 Unpublished AMF website, Kasaï-Occidental 2014 12-month post-distribution check-up data Source (archive) AMF website, Kasaï-Occidental 2014 8-month post-distribution check-up data Source (archive) AMF: "DRC, West Kasaï Province: Distribution Report and separate Technology Report" Source (archive) AMF: "Initial net distribution verification data for West Kasaï, DRC" Source (archive) AMF: "Introduction of smartphone technology to collect distribution data" Source (archive) AMF: "Mid-distribution weekly reports for Dedza distribution, Malawi" Source (archive) AMF: "Operational planning (12 months) and planning horizon (18 to 24 months)" Source (archive) AMF: "US$6m commitment to malaria control support in Malawi in 2018" Source (archive) Andrew Garner, AMF employee, email to GiveWell, February 22, 2016 Unpublished Balaka 2010-2015 MCRD Unpublished Balaka 2013 14-month post-distribution check-up data Source Balaka 2013 19-month post-distribution check-up data Source Balaka 2013 6-month post-distribution check-up data Source Balaka 2013 and Dedza 2014 non-net cost budgets Source (archive) Concern Universal Balaka 2013 6-month post-distribution check-up report Source (archive) Concern Universal Balaka 2013 distribution proposal Source (archive) Concern Universal Balaka 2013 distribution report Source (archive) Concern Universal Balaka 2013 pre-distribution registration survey data Source (archive) Concern Universal Balaka 2013 week 1 report Source (archive) Concern Universal Balaka 2013 week 5 report Source (archive) Concern Universal Balaka 2015 registration data 100% vs 5% Unpublished Concern Universal Dedza 2014 distribution proposal Source (archive) Concern Universal Dedza 2014 distribution report Source (archive) Concern Universal Dedza 2014 pre-distribution registration survey data Source Concern Universal Dedza 2014 week 1 report Source (archive) Concern Universal Dedza 2014 week 3 report Source (archive) Concern Universal Dowa 2015 pre-distribution registration survey data Source (archive) Concern Universal Dowa 2015 weeks 1-3 report Source (archive) Concern Universal Ntcheu 2012 24-month post-distribution check-up report Source (archive) Concern Universal Ntcheu 2012 33-month post-distribution check-up data Source (archive) Concern Universal Ntcheu 2012 33-month post-distribution check-up report Source (archive) Concern Universal Ntcheu 2012 distribution proposal Source (archive) Concern Universal Ntcheu 2012 distribution report Source (archive) Concern Universal Ntcheu 2012 mid-distribution reports Source (archive) Concern Universal Ntcheu 2012 pre-distribution registration survey data Source Concern Universal Ntcheu 2015 pre-distribution registration survey data Unpublished Concern Universal, Dowa 2015 planning document Source (archive) Dedza 2010-2015 MCRD Unpublished Dedza 2014 12-month post-distribution check-up data Source (archive) Dedza 2014 14-month post-distribution check-up data Source Dedza 2014 18-month post-distribution check-up data Source (archive) Dedza 2014 8-month post-distribution check-up data Source Dowa 2012-2015 MCRD Unpublished Dowa 2015 12-month post-distribution check-up data Source (archive) Dowa 2015 6-month post-distribution check-up data Source Dowa 2015 6-month post-distribution check-up report Source (archive) Dowa 2015 non-net cost budget Source (archive) DRC Kasaï-Occidental 2014 12-month post-distribution check-up data Source DRC Kasaï-Occidental 2014 18-month post-distribution check-up data (English summary) Source DRC Kasaï-Occidental 2014 18-month post-distribution check-up data (French full report) Source DRC Kasaï-Occidental 2014 8-month post-distribution check-up data Source Episcopal Relief & Development Ghana Activity Report 1 2016 Source Episcopal Relief & Development Ghana Activity Report 1 2017 Source Episcopal Relief & Development Ghana Activity Report 2 2016 Source Episcopal Relief & Development Ghana Activity Report 2 2017 Source Episcopal Relief & Development Ghana Activity Report 3 2016 Source Episcopal Relief & Development Ghana Activity Report 4 2016 Source Episcopal Relief & Development Ghana Activity Report 5 2016 Source Episcopal Relief & Development Ghana Activity Report 6 2016 Source Episcopal Relief & Development Ghana non-net costs budget 2016 Source Episcopal Relief & Development Ghana Northern Region distribution report 2016 Source Episcopal Relief & Development Planning Document 2016 Source Episcopal Relief & Development Pre-distribution Report Ghana Greater Accra Region December 2016 Source Episcopal Relief & Development Pre-distribution Report Ghana Northern Region June 2016 Source Episcopal Relief & Development Pre-distribution Report Ghana Upper West Region December 2016 Source Ghana Greater Accra Region 2016, 6-month post-distribution check-up Source Ghana net gap and schedule 2016 Source Ghana Northern Region 2016, 12-month post-distribution check-up Source Ghana Northern Region 2016, 6-month post-distribution check-up Source Ghana Upper West Region 2016, 6-month post-distribution check-up Source GiveWell 2015 metrics report Source GiveWell estimate of AMF cost per net (May 2016) Source GiveWell estimate of AMF cost per net (October 2015) Source GiveWell Notes from meeting regarding LLIN distribution in Malawi (October 21, 2011) Source GiveWell Notes from site visit with Concern Universal in Malawi (October 2011) Source GiveWell summary of AMF large-scale distributions Source GiveWell's non-verbatim summary of a conversation with Ghana's National Malaria Control Program, August 16-18, 2016 Source GiveWell's non-verbatim summary of a conversation with Melanie Renshaw and Marcy Erskine, October 11, 2016 Source GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, November 2, 2016 Source GiveWell's non-verbatim summary of a conversation with Nelson Coelho, April 15, 2016 Source GiveWell's non-verbatim summary of a conversation with Scott Filler, October 19, 2016 Source GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016 Source Global Fund introduction to the 2017-2019 funding cycle Unpublished IDinsight Trip Report, 2017 PDCU Site Visit, Ghana Source IHME Global Burden of Disease tool Source IMA World Health and AMF distribution agreement for Kasaï-Occidental 2014 Source IMA World Health and AMF distribution agreement for Nord Ubangi 2015 Source IMA World Health Kasaï-Occidental financial report (as of November 11, 2014) Source (archive) IMA World Health Nord Ubangi 2015-16 registration data Unpublished IMA World Health, Kasaï-Occidental 2014 distribution data Unpublished IMA World Health, Kasaï-Occidental 2014 distribution report Source (archive) IMA World Health, Kasaï-Occidental 2014 non-net costs final budget Unpublished IMA World Health, Kasaï-Occidental 2014 technology report Source (archive) Malaria Atlas Project Endemic countries Source (archive) Malawi Balaka 2015 12-month post-distribution check-up data Source Malawi Balaka 2015 6-month post-distribution check-up data Source Malawi Dedza 2014 24-month post-distribution check-up data Source Malawi Dowa 2015 18-month post-distribution check-up data Source Malawi Dowa 2015 24-month post-distribution check-up data Source Malawi Ntcheu 2015 12-month post-distribution check-up data Source Marcy Erskine and Melanie Renshaw, conversation with GiveWell, April 18, 2016 Unpublished Marcy Erskine, conversation with GiveWell, March 29, 2016 Unpublished Melanie Renshaw, African Leaders Malaria Alliance Chief Technical Advisor, email to Rob Mather, June 26, 2011 Unpublished Melanie Renshaw, African Leaders Malaria Alliance Chief Technical Advisor, phone conversation with GiveWell, May 23, 2014 Source (archive) Melanie Renshaw, African Leaders Malaria Alliance Chief Technical Advisor, phone conversation with GiveWell, October 20, 2015 Source Melanie Renshaw, conversation with GiveWell, March 16, 2016 Unpublished Melanie Renshaw, email to GiveWell, May 29, 2016 Unpublished Nelson Coelho, conversation with GiveWell, April 15, 2016 Unpublished Nonprofit Staffing New York Salary Survey Report 2011 Source Ntcheu 15-month post-distribution check-up data Source (archive) Ntcheu 2010-2015 MCRD Unpublished Ntcheu 2015 6-month post-distribution check-up report Source (archive) Ntcheu 2016 6-month post-distribution check-up data Source (archive) Ntcheu 24-month post-distribution check-up data Source (archive) Ntcheu 33-month post-distribution check-up data Source Ntcheu 6-month post-distribution check-up data Source (archive) Papua New Guinea Distribution Report, Enga Province, August 2017 Source Rob Mather and Peter Sherratt, conversation with GiveWell, April 25, 2016 Unpublished Rob Mather and Peter Sherratt, conversation with GiveWell, February 11, 2016 Source Rob Mather and Peter Sherratt, conversation with GiveWell, February 19, 2016 Unpublished Rob Mather and Peter Sherratt, conversation with GiveWell, February 28, 2016 Source Rob Mather and Peter Sherratt, conversation with GiveWell, February 6, 2015 Source (archive) Rob Mather and Peter Sherratt, conversation with GiveWell, June 2, 2015 Unpublished Rob Mather and Peter Sherratt, conversation with GiveWell, November 6, 2014 Unpublished Rob Mather and Peter Sherratt, conversation with GiveWell, October 13, 2016 Unpublished Rob Mather and Peter Sherratt, conversation with GiveWell, September 9, 2015 Source Rob Mather, AMF Founder, conversation with GiveWell, April 13, 2016 Unpublished Rob Mather, AMF Founder, conversation with GiveWell, August 15, 2013 Source (archive) Rob Mather, AMF Founder, conversation with GiveWell, February 24, 2015 Unpublished Rob Mather, AMF Founder, conversation with GiveWell, July 19, 2012 Unpublished Rob Mather, AMF Founder, conversation with GiveWell, May 23, 2014 Source (archive) Rob Mather, AMF Founder, conversation with GiveWell, November 10, 2015 Unpublished Rob Mather, AMF Founder, Conversation with GiveWell, September 28, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, April 17, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, April 30, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, August 8, 2012 Unpublished Rob Mather, AMF Founder, email to GiveWell, January 28, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, June 19, 2015 Unpublished Rob Mather, AMF Founder, email to GiveWell, June 30, 2014 Unpublished Rob Mather, AMF Founder, email to GiveWell, May 22, 2014 Unpublished Rob Mather, AMF Founder, email to GiveWell, November 14, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, November 20, 2012 Unpublished Rob Mather, AMF Founder, email to GiveWell, November 26, 2014 Unpublished Rob Mather, AMF Founder, email to GiveWell, November 8, 2014 Unpublished Rob Mather, AMF Founder, email to GiveWell, November 8, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, November 9, 2015 Unpublished Rob Mather, AMF Founder, email to GiveWell, October 10, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, October 12, 2015 Unpublished Rob Mather, AMF Founder, email to GiveWell, October 13, 2015 Unpublished Rob Mather, AMF founder, email to GiveWell, October 24, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, October 31, 2016 Unpublished Rob Mather, AMF Founder, email to GiveWell, September 16, 2015 Unpublished Rob Mather, AMF Founder, email to GiveWell, September 9, 2015 Unpublished Rob Mather, AMF Founder, Ghana distribution emails, October 2014 to January 2015 Unpublished Rob Mather, conversation with GiveWell, November 2, 2016 Unpublished Rob Mather, email to GiveWell, June 15, 2016 Unpublished Rob Mather, email to GiveWell, May 13, 2016 Unpublished Rob Mather, email to GiveWell, May 9, 2016 Unpublished Rob Mather, email to GiveWell, November 26, 2016 Unpublished Rob Mather, email to GiveWell, October 5, 2016 Unpublished Robin Todd, Concern Universal Malawi Director, email to GiveWell, April 27, 2012 Unpublished Robin Todd, Concern Universal Malawi Director, email to Rob Mather, November 18, 2011 Unpublished Robin Todd, Concern Universal Malawi Director, phone Conversation with GiveWell, March 20, 2012 Unpublished Roll Back Malaria gap analysis tool Source (archive) Roll Back Malaria Partnership gap analysis (December 2014) Source (archive) Roll Back Malaria Partnership gap analysis (October 2015) Source (archive) Roll Back Malaria Partnership gap analysis (September 2013) Source (archive) WHO 2014 Malaria World Report Source (archive) 1. In 2016 we wrote that we expected new studies to be available in 2017. We have continued to follow these studies, which, as far as we know, have not been released as of this writing in October 2017. 

  2. See our Summary of AMF Distributions spreadsheet. Adding up the "# LLINs" column for distributions including Togo and rows below.

  3. See our Summary of AMF Distributions spreadsheet.

  4. This understanding is based on many conversations with AMF, and from following AMF's progress over time.

  5. This understanding is based on many conversations with AMF and its distribution partners, and from following AMF's progress over time.

  6. "This is a list of the countries with known gaps and where there are significant contiguous areas without nets, or a significant percentage required, and for which the estimate of need is believed to be reasonably accurate. It does not include countries where there are gaps, typically up to 40% of what the nation needs, but they are spread more uniformly across the country and would therefore require an ‘in-fill campaign’. An in-fill campaign is different from a so-called ‘universal coverage campaign’ because the percentage installed base of nets is higher in the former case and so a pre-distribution registration survey (PDRS) is an absolute requirement to ensure an efficient allocation of nets. Our methodology would lend itself to these campaigns if the relevant National Malaria Control Programme (NMCP) were to embrace a detailed PDRS. The list does not include, in our view, other countries where the need has not yet been quantified. Given there are many countries with needs estimated, we have not chosen to seek out other countries in need of nets. Our assumption is groups like AMP will be a source of reporting on additional countries as quantified needs emerge." Rob Mather, AMF Founder, email to GiveWell, August 8, 2012. In September 2015, we checked in with AMF about its process for determining in which countries it works. Rob Mather noted that AMF continues to review malaria prevalence data (where that data exists), although maintains a level of skepticism about that data given that it can be unreliable. Even so, AMF feels comfortable drawing conclusions about which countries have high malaria mortality burdens based on the data it sees and the conversations that it engages in. AMF checks the following sources to keep up-to-date on which countries have a significant malaria burden: The Alliance for Malaria Prevention, which sends out a weekly email with malaria-related data and information. The African Leaders Malaria Alliance (ALMA), which AMF has conversations with on a quarterly basis. In-country partners, who frequently attend malaria task force meetings and have recent news Members of malaria advisory groups Other connections Before AMF decides to approach a country to offer funding for nets, it has many conversations to confirm the level of need that country has with the other actors that are working on malaria in the country. Rob Mather and Peter Sherratt, conversation with GiveWell, September 9, 2015

 In early 2016, AMF described a location-selection process similar to that described previously: "AMF learns about net gaps and receives funding requests through its network in the malaria control community, particularly through the Alliance for Malaria Prevention and the African Leaders Malaria Alliance." Rob Mather and Peter Sherratt, conversation with GiveWell, February 28, 2016  7. "As it becomes involved in larger distributions, AMF is receiving a growing number of funding requests. As its funding increases, AMF aims to make more strategic investments by engaging in the planning cycles of countries where it has strong connections and experience." Rob Mather and Peter Sherratt, conversation with GiveWell, February 28, 2016

  8. Comment provided in response to a draft version of this review in November 2016.

  9. Rob Mather, AMF Founder, conversation with GiveWell, July 19, 2012

  10. Rob Mather, AMF Founder, email to GiveWell, August 8, 2012

 Ghana's National Malaria Control Program, one of AMF's distribution partners for the June-July 2016 distribution campaign in Ghana, described negotiating and compromising with AMF on requirements for the distribution: "The NMCP has been working with AMF for a relatively short period of time. Their working relationship has proceeded relatively smoothly thus far, especially since AMF has shown willingness to negotiate and compromise on some areas to conform with the country's specific scenario." GiveWell's non-verbatim summary of a conversation with Ghana's National Malaria Control Program, August 16-18, 2016  11. See our Summary of AMF Distributions spreadsheet.

  12. AMF has provided us with access to its database where data is entered by distribution partners. Our understanding is that, as of October 2017, the data for Togo and Papua New Guinea was incomplete and that these distributions were ongoing.

  13. See our Summary of AMF Distributions spreadsheet.

  14. GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016

  15. "The validation was to establish precisely how many LLINs were distributed during the distribution campaign in all 12 districts. Apart from validating counterfoils, the validators undertook 'End-User Verification'. The end-user verification (EUV) is a rapid check-up to determine whether the beneficiaries really received the number of LLINs allocated for the households and are using the LLINs for the intended purpose. This involved randomly selecting 100 households in each district to verify LLINs received, LLIN use by household members, etc. Validators randomly sampled 100 booklets and from each booklet, randomly sampled one coupon counterfoil for the EUV visit. Validators then called the beneficiaries of the sampled coupon counterfoils and followed up to the households for the end-user verification exercise." Episcopal Relief & Development Ghana Activity Report 3 2016, Pgs 4-5.

  16. AMF page on Kasaï-Occidental 2014 distribution

  17. AMF funds status (October 2017) Redacted

  18. The original budget for this study was $800,000. Rob Mather, AMF Founder, conversation with GiveWell, February 24, 2015 AMF sent us a draft research proposal for the study in early 2015; some details are in our May 2015 update. AMF sent us what we believe was the final version of the research proposal in June 2015; we have not yet reviewed the final version. AMF insecticide research proposal from the London School of Tropical Medicine "Given the nature of the Uganda PBO study we have just last week decided to not proceed with Phase 2 of the DRC study. The total cost of Phase 1 was £75,667. Phase 1 looked at establishing where resistant mosquitoes were present in Nord Ubangi (they are) and Phase 2 was to look at the effectiveness of the PBO nets." Comment provided in response to a draft version of this review in November 2016. 1 GBP equals 1.25 USD. Google, November 21, 2016. 75,667 * 1.25 = $94,584.  19. "We are close to concluding discussion with Concern Universal for AMF and CU to co-fund a Malaria Unit (a larger team of people than currently in place dedicated to malaria control related work) in Malawi led by a senior CU Manager and employing 12 Malawians (10 additional hires)." Rob Mather, AMF Founder, email to GiveWell, September 9, 2015 AMF funds status (October 2017) Redacted  20. "The aim of this unit will be to provide more resource to allow 1. improved efficiency in managing the four contracted three-yearly distributions and associated work and 2. allow us to together innovate and develop additional malaria control support for the four districts and the NMCP, specifically: i) intended close liaising with Health Centre re malaria case data and elements related to the monitoring/recording of malaria data i.e. stock levels of RDTKs, rubber gloves and other diagnosis equipment; qualified staff able to test for malaria, presence at the clinic so diagnosis can happen; systems, capacities etc) ii) research (data), discussion and involvement in ways of ensuring 80% sleeping space coverage throughout the three year net-distribution cycle, including investigation of ‘injection strategy’ net distributions involving mini-mass distributions at two years post-distribution and in the subsequent distribution cycle at one-year post distribution." Rob Mather, AMF Founder, email to GiveWell, September 9, 2015

  21. The distributions and post-distribution check-ups occur frequently enough that having a trained, consistent staff to manage them is worthwhile. Rob Mather and Peter Sherratt, conversation with GiveWell, September 9, 2015

  22. $636,000 was allocated to the Malaria [Control] Unit in AMF funds status (June 2016), of which $100,000 was already paid. This allocation is about $200,000 higher than the amount AMF mentioned in our September 2015 conversation. "This would be an initial three year commitment from AMF of US$413k…Savings made on non-net costs (with the Malaria Unit funded, some costs included in non-net cost budgets would already be covered) we estimate to be of the order of US$70k, and perhaps as high as US$95k per distribution of which there are four in a three year cycle i.e. US$280-380k in total... If all progresses well we may be able to publish plans in the next six weeks once budgets have been agreed and assuming approval from the Malawi NMCP. We do not anticipate problems, although there is a work visa issue to resolve." Rob Mather, AMF Founder, email to GiveWell, September 9, 2015 AMF Malaria Unit draft budget  23. Over the last several years, AMF believes that its high net hang-up rates have begun to catch the attention of a number of groups in Malawi, including the NMCP, local organizations that distribute nets, and large international NGOs. AMF also told us that it encouraged United Purpose to take a more active role in a task force on malaria control in Malawi. This meant that as interest in learning from AMF and United Purpose grew, United Purpose was available to explain AMF’s methodologies at the malaria task force meetings, and it was eventually decided to implement some of AMF’s practices for the upcoming distribution. Rob Mather and Peter Sherratt, conversation with GiveWell, June 2, 2015

  24. Rob Mather, AMF Founder, email to GiveWell, October 12, 2015 

 25. "Although AMF won’t be managing this process, it is interested to observe how multiple districts will carry out distribution according to this particular data-driven approach. AMF believes that it will be allowed access to that data, either directly or via its in-country partners." Rob Mather and Peter Sherratt, conversation with GiveWell, February 6, 2015, pg. 2.

  26. For calculations, see this spreadsheet. 

 27. Rob Mather, AMF Founder, conversation with GiveWell, July 19, 2012.

  28. Rob Mather, AMF Founder, email to GiveWell, November 26, 2014. See this spreadsheet for details on what costs AMF has paid for each distribution For its 2016 Ghana distributions and its upcoming distributions in Uganda, Togo, and Papua New Guinea, AMF has agreed to pay for "non-standard" non-net costs, including PDCUs and, in Uganda, the cost of an "independent assessor [who will] determine whether nets are distributed to beneficiaries in the quantities listed." The Global Fund paid for the "standard" non-net costs for the Ghana distributions and the government is paying for these costs in Uganda. "Standard" costs include shipping to the country, clearance charges, in-country transportation, pre-distribution planning and registration, and distribution costs. Rob Mather, AMF Founder, email to GiveWell, January 28, 2016 "The Ghana distribution is now going ahead: AMF is funding the costs of the nets and AMF’s additional monitoring costs, and the Global Fund will fund other non-net costs." Rob Mather and Peter Sherratt, conversation with GiveWell, February 11, 2016, pg. 2. "The non-net costs will be funded by the Ghana Malaria Global Fund Grant. These costs include those for shipping to Ghana, clearance, in-country transport, pre-distribution, distribution." AMF Ghana 2016 distribution agreement, pg. 1. "The non-net costs will be funded by the Uganda Ministry of Health which may use funding from its Roll Back Malaria Partners. These costs include those for shipping to Uganda, clearance, in-country transport, pre-distribution, and distribution." AMF Uganda 2016 distribution agreement, pg 2. Discussion of independent assessor is from AMF Uganda 2016 distribution agreement, pg 4. "Post-Distribution Check-Ups… AMF will fund an NGO to run the process." AMF Uganda 2016 distribution agreement, pg 5. AMF Togo 2017 distribution agreement Redacted: "1) AMF will fund 2,413,250 LLINs. 2) The non-net costs will be funded by the MSPS which may use funding from The Global Fund or other sources." Pg 7. "Post-Distribution Check-Ups (PDCUs) will take place across all of the districts to monitor net use and condition. The results will be owned by Togo and shared with AMF. AMF will fund an NGO to run the process in full consultation with the MSPS. The MSPS will facilitate the check-ups." Pg 10. AMF Papua New Guinea 2017 distribution agreement Redacted: "1) AMF will fund 1,159,400 extra-large LLINs for distribution in 2017. 2) The costs, with the exception of the purchase of the LLINs, will be borne by RCPM which may use dedicated funding from The Global Fund and other sources." Pg 1. "Post-Distribution Check-Ups (PDCUs) to assess correct net distribution, net use and condition of LLINs will take place across all of the districts to monitor net use and condition. The results will be owned by PNG but will be shared with AMF. AMF will fund a yet-to-be-decided NGO to run the process in full consultation with the NDoH and RCPM. RCPM will facilitate the check-ups." Pg 4.  29. See our summary of post-distribution check-up (PDCU) results (the follow-up surveys) here.

  30. See our summary of AMF distributions spreadsheet, "Overview" sheet, "Allocation strategy" column.

  31. "HSAs introduce themselves to the head of household (or a representative thereof) and explain that they are there to assess the number of nets required in that household. After obtaining permission to enter the household, the HSA gathers the following information: Number of people over and under 5 years old in the household […] "The HSA determines the number of sleeping spaces by talking to household members and personally looking at sleeping spaces. The village head sometimes verifies whether the number of household members reported by the beneficiary is correct. […] "If a household owns nets, the HSA inspects them to determine whether they are in viable condition." GiveWell's non-verbatim summary of a conversation with Nelson Coelho, April 15, 2016, pg. 2.

  32. "Verification Concern Universal staff gather 4-5 villages in each catchment area at a central location, and use the registers to take roll call of the household names and the number of nets each household is registered to receive. People, households, or villages who claim to have been skipped during registration are added to the register if local leaders confirm these claims. Verification is conducted for all villages." GiveWell's non-verbatim summary of a conversation with Nelson Coelho, April 15, 2016, pg. 3.

  33. A representative of United Purpose told us that United Purpose performs this data verification for its distributions in Malawi. See here for detail. Nelson Coelho, conversation with GiveWell, April 15, 2016 GiveWell Notes from site visit with Concern Universal in Malawi (October 2011)  34. Concern Universal Ntcheu 2012 pre-distribution registration survey data Concern Universal Balaka 2013 pre-distribution registration survey data Concern Universal Dedza 2014 pre-distribution registration survey data Concern Universal Dowa 2015 pre-distribution registration survey data Concern Universal Balaka 2015 registration data 100% vs 5% Concern Universal Ntcheu 2015 pre-distribution registration survey data  35. IMA World Health, Kasaï-Occidental 2014 distribution data

  36. "IMA obtained population data for the year 2012 from the Ministry of Health and applied the MOH’s estimate for population growth of 3% per annum." IMA World Health, Kasaï-Occidental 2014 distribution report, pg. 6. "There were many occasions where the number of nets needed for a community was overestimated. This was discovered in the registration and hang up because of diligent work done. Lesson learned[:] Better population estimates are needed and 1.8 people per nets should be the ratio always used." IMA World Health, Kasaï-Occidental 2014 distribution report, pg. 46. In cases where too few nets are sent to a location, AMF's distribution partner typically performs a "mop up" exercise in which it orders extra nets and distributes them several months later to the households that didn't receive the nets the first time around. Rob Mather, AMF Founder, conversation with GiveWell, February 24, 2015 "If there are a significant number of nets left over – more than a few hundred for example, the nets are moved to the next distribution. An example would be the 5,770 so nets left over in Balaka (the need was assessed as 149,500 and we had moved in 160,000 nets to ensure we had enough nets to cover any additional need and the final number of nets distributed after mop-up was 154,230) which were moved up to Dedza and distributed as part of that distribution. The number of nets ordered and moved in to Dedza reflected that 5,700. If the number of nets left over is in the hundreds, they are passed to the District Health Officer (DHO) to be included a nets for routine distribution. Sometimes there has been a small, several hundred net shortfall and that gap has in the past been filled by nets in zone from other sources." Rob Mather, AMF Founder, email to GiveWell, September 16, 2015  37. "Differences [between the Nord Ubangi distribution and the Kasaï-Occidental 2014 distribution] 1. The North Ubangi distribution will be a two-phase distribution – a distinct pre-distribution phase and a subsequent distribution phase. In West Kasaï establishing net need per household and distributing of nets was contemporaneous. 2. Distribution of nets will be done from distribution points rather than at the household 3. The ODK registration form has been re-designed to better capture the required data, to eliminate some types of error and to reduce the chance of others. 4. Operational lessons learned from the West Kasaï distribution will be implemented. 5. An experienced, full time technology manager has been employed by IMA meaning there will be more extensive and easier liaising with AMF on data elements of the distribution. We have met the new technology manger and have spent a week working with him and are impressed.

 Similarities [between the Nord Ubangi distribution and the Kasaï-Occidental 2014 distribution] 1. The same smartphone-based data collection technology will be used as in West Kasaï.

 Comment IMA has agreed there are benefits to conducting a separate, earlier pre-distribution phase during which accurate household-level net need is established. IMA are less able to estimate accurately population and net need in North Ubangi compared to what they felt was possible in West Kasaï.

 IMA believes point distributions rather than at-household distribution will be more cost-effective." Rob Mather, AMF Founder, email to GiveWell, September 9, 2015

  38. IMA World Health Nord Ubangi 2015-16 registration data: Summary data reported for "Nbre de menages," "Population dans menage," "Nbre places a dormir," "Nbre bonne MILD," "Nbre MILD installees," and "Couverture." Translated to English, from Google Translate: "No. of households," "Population in household," "No. of places to sleep," "No. good MILD [LLIN]," "No. MILD [LLIN] be built [installed, or hung]," and "Coverage."  39. IMA World Health Nord Ubangi 2015-16 registration data

  40. "In 2010, Senegal and Cross River State in Nigeria worked on mop-up campaigns following earlier integrated campaigns targeting households with children under five years of age. In both countries, trained health workers or volunteers undertook a household registration to determine: 

 the total net need for each household (this was based on one LLIN for two people, rounding up in the case of odd numbers of people in the household, but Senegal also looked at the number of habitual sleeping spaces in each household) how many nets each household already had how many nets in each household were still viable (in Senegal this number was based on net condition, while in Cross River State, it was based on how long the net had been hanging) how many new nets each household would need for full coverageBoth countries had previously undertaken post-distribution surveys which showed high household coverage with LLINs, but during the mop-up exercise they experienced challenges with finding nets in households. Significantly lower numbers of nets were found (50-60 per cent) than would have been expected based on the surveys… In both countries, it seemed that families often hid nets once word spread that ownership of nets meant no new nets would be received. Despite efforts to encourage families to hang pre-existing nets prior to the household registration in Senegal, people hid nets in order to receive more." Alliance for Malaria Prevention Toolkit (version 2.0) - Chapter 3, pgs. 5-6.

  41. GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016:

 "GHS [Ghana Health Services] volunteers carry out the registration process, which takes place more than one month before the distribution. Volunteers are organized by the Ministry of Health (MoH) and participate in a number of government health programs, such as vaccination campaigns (immunization days). Many of them are long-time volunteers with considerable experience." Pg. 5. "Volunteers visit each house in their zone. The head of household, or someone else who is present, is asked how many people are in the household based on the 'people who eat from the same pot' definition. Ghana's policy is to provide one net for every two individuals in a household; as a result, in contrast to previous AMF distributions, volunteers were not required to check households' existing nets or number of sleeping spaces. The only exception to this policy is that household members aged 70 or older are not counted in the household total, and each receive their own net." Pg. 5.  42. See our summary of AMF distributions spreadsheet, "Overview" sheet, "Allocation strategy" column. GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016: "GHS [Ghana Health Services] volunteers carry out the registration process, which takes place more than one month before the distribution. Volunteers are organized by the Ministry of Health (MoH) and participate in a number of government health programs, such as vaccination campaigns (immunization days). Many of them are long-time volunteers with considerable experience." Pg. 5. "Volunteers visit each house in their zone. The head of household, or someone else who is present, is asked how many people are in the household based on the 'people who eat from the same pot' definition. Ghana's policy is to provide one net for every two individuals in a household; as a result, in contrast to previous AMF distributions, volunteers were not required to check households' existing nets or number of sleeping spaces. The only exception to this policy is that household members aged 70 or older are not counted in the household total, and each receive their own net." Pg. 5.  43. "In continuous distributions, nets are delivered through antenatal clinics, child welfare clinics, or schools." GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016, pg. 3. During GiveWell's site visit to Greater Accra, Ghana in August 2016, some residents of areas targeted for LLIN distribution that we met with told us that they had owned some LLINs prior to the recent AMF distribution, including LLINs obtained by purchasing them from a market and LLINs obtained through antenatal clinics. See our rough notes from household visits in this spreadsheet, column Q, and a description of our selection process for household visits in Greater Accra in GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016, Pgs 15-18.  44. "The last national distribution in Ghana occurred between 2010 and 2013." GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016, pg. 4. During GiveWell's site visit to Greater Accra, Ghana in August 2016, some residents of areas targeted for LLIN distribution that we met with told us that they last received LLINs from a mass distribution four years ago. See our rough notes from household visits in this spreadsheet, column Q, and a description of our selection process for household visits in Greater Accra in GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016, Pgs 15-18. LLINs are distributed to different regions of Ghana on a rolling basis (i.e., distributions occur in one region one month and in another region the next month). Ghana net gap and schedule 2016 We have not seen the schedule for the 2010 to 2013 distributions in Ghana, but we would guess that the last LLIN distribution in the Upper West Region and the Northern Region was also in 2012, since these distributions were scheduled around the same time in 2016. The most common "decay model" we have seen estimates that around 50% of LLINs are still in use in the third year after distribution.  45. AMF Data Entry System, Ghana 2017 AMF told us that it and the government decided that the collection of information on previously-owned LLINs was not necessary for this distribution. Comment provided in response to a draft version of this review in November 2016.  46. The procedure listed below for a 2017 distribution in Enga Province, Papua New Guinea does not mention accounting for existing nets. "Survey

 "The survey was carried out in the following way. 

 When arriving at a village and before starting the census process, a meeting was held with village elders explaining the process. If village elders have a list of all village occupants, the team would use this list to compile a census. Where a village is small, e.g. less than 30 families, team members may carry out the census by themselves. Where villages were large, village volunteers were identified with the assistance of the village chiefs, elders, health staff and councillors. One volunteer was chosen for each group of about 50 families with volunteers chosen by natural divisions in the village e.g. clans where one volunteer would make a list of only one clan. These volunteers were trained to carry out the survey by actually surveying houses with the team leaders supervising and assessing the recording. Once the team leader was confident that the volunteers knew the survey methodology, they were left to continue with the household survey with survey teams returning within an agreed period to verify the work of the survey volunteers, collect survey books and also to pay the survey volunteer if the work has been carried out correctly. For each household surveyed, all family members who normally resided at the household for a minimum of nine months were recorded by Name, Age, Sex and Relationship to head of household. All names and other information was recorded in the survey book with one survey form being used for each household. After surveying a house a white copy of the census form was given to the head of household or most senior person present in the household. Where a whole household was absent, information was taken from the neighbours and the white survey form left with them. In all cases, after the census/list was finished, all the information about the households and number of household members is entered into a summary sheet. This list is then hung in a public place where all villages can verify that the right number of family members for each household has been recorded and that all families have been included in the survey. After the list has been in a public place for 24 hours, then the volunteer requests for the RAM officer and or DHT to visit the village. RAM officers and DHTs must visit three households randomly from each survey book (6%) and verify that the survey has been carried out correctly. Only when this has been done, then the volunteer can be paid. If a village was surveyed by more than one volunteer, then volunteers are asked to work together so that lists can be hung together and the village volunteers can be verified at the same time. This process also ensures that households do not appear on more than one list. After this process, both the volunteers and the village elders sign a form to verify that this was done. All village volunteers received a standard payment of 20 kina a day. Experience has shown that volunteers can usually only survey about 30 families a day, so for the most part, they would receive up to two days allowance to complete a survey book. All volunteers are also given a small training manual. Contained in this training manual are key health education messages about malaria which volunteers are expected to discuss with households. This perhaps is the only project in PNG that is able to reach down to potentially every household in the country." Papua New Guinea Distribution Report, Enga Province, August 2017, Pgs 7-8.

 Household registration data for Uganda lists the name of the head of household, number of people in the household, and the number of nets distributed. The number of existing nets in the household is not recorded. AMF Data Entry System, Uganda 2017 Household registration data for Togo lists the name of the head of household, number of people in the household, the number of nets allocated, and the number of nets distributed. The number of existing nets in the household is not recorded. AMF Data Entry System, Togo 2017 See our summary of AMF distributions spreadsheet, "Overview" sheet, column M.  47. "[…} there are two reasons for this: where a previous distribution was at least three years earlier, the number of ‘perfectly usable nets’ in situ is likely to be low, given the lifetime of the nets, making the question of limited use so ‘not critical’; nets with some useful life left in them are likely to need replacing before the next distribution campaign so the additional nets will be of protective value before then." Comment provided in response to a draft version of this review in November 2016.

  48. Rob Mather, AMF Founder, email to GiveWell, October 10, 2016 See our summary of AMF distributions spreadsheet, "Overview" sheet, column M.  49. Comment provided in response to a draft of this page in November 2017

  50. "Continued use of nets is very important. Every six months, a post-distribution survey is carried out to assess net usage and net condition. Approximately 5% of the nets distributed are assessed through visits to randomly selected households. The data collected are used to determine if additional community-level malaria education activities are required. All data are published." AMF information we publish From a recent distribution agreement: "Post-Distribution Check-Ups (PDCUs) will take place across all of the districts to monitor net use and condition. […] A PDCU is carried out every 6-months for two and a half years' post-distribution therefore at 6, 12, 18, 24 and 30-months post-distribution." AMF Togo 2017 distribution agreement Redacted, Pg 4, English version (Pg 10 in PDF). In older distribution agreements it appears that AMF planned to require PDCUs for longer than 2.5 years following a distribution: "Please confirm you will carry out Post‐Distribution Surveys (PDSs) every 6 months post‐distribution for a period of up to four years to assess the level of net usage (hang‐up %), correct usage and condition of the nets and you will provide us with the findings. Each survey would cover approximately 5% of households." Concern Universal Dedza 2014 distribution proposal, pg. 2.  51. LLINs are categorized as "Hung," "Present but not hung," "Missing," or "Worn out / not usable." See, for example, Ntcheu 2016 6-month post-distribution check-up data A United Purpose representative told us that PDCU enumerators assess whether the net is an AMF net by looking at the net's label. Nets sourced from AMF distributions have AMF's logo and the month and year of the intended distribution date on the label. Nelson Coelho, conversation with GiveWell, April 15, 2016 In its report on the 6-month PDCU for the Ntcheu 2015 distribution, AMF notes that the rate of LLINs from the recent distribution hung is lower than for other distributions, and discusses a few possible explanations for the low rate: "This is the second universal coverage distribution in Ntcheu, with the first taking place in December 2012, a little over four years before." […] Initial hypotheses for data from this PDCU-06: Hypothesis 1: Timing differences between the 2012 PDCU-06 and the 2016 PDCU-06 mean there is a seasonal variation (e.g. linked to mosquito levels and average temperatures) Hypothesis 2: The previously distributed nets have lasted beyond the normal three years life and some of the new nets are being held in reserve to replace them when worn out. Hypothesis 3: Our criteria for assessing, prior to a mass distribution, which nets are ‘perfectly usable’ (have at least 18 months of life left) is too strict and materially more nets than we are judging to be so have extended life in them." Ntcheu 2015 6-month post-distribution check-up report, Pg 4.  52. The blog post discusses the first two surveys from Kasaï-Occidental. We have now seen results from the 18-month survey as well. There appear to have been similar issues with the implementation of the 18-month survey. About half of the data was thought to be unreliable: "# of HHs [households] where net presence data is reliable: 6,330 (45% of HHs visited)" DRC Kasaï-Occidental 2014 18-month post-distribution check-up data (English summary), pg. 1

  53. IMA World Health, Kasaï-Occidental 2014 distribution report:

 "1. Household registration, handing out and hanging nets (3 days)" Pg 16. "CHWs take the time to introduce themselves to the head of household and explain the reason for their visit in order to gain the householders’ permission to collect the required household information, distribute and hang the nets." Pg 17.  54. IMA World Health Nord Ubangi 2015-16 registration data: Summary data reported for "Nbre de menages," "Population dans menage," "Nbre places a dormir," "Nbre bonne MILD," "Nbre MILD installees," and "Couverture." Translated to English, from Google Translate: "No. of households," "Population in household," "No. of places to sleep," "No. good MILD [LLIN]," "No. MILD [LLIN] be built [installed, or hung]," and "Coverage." Household-level data for these categories also included.  55. "Distributors make sure the recipients' coupons (brought by recipients) match the registration copies (brought by distributors) and make a mark on each side. The recipient's coupon is returned to them. Distributors also have a tally sheet with rows of 5 bubbles, and mark off a bubble for every net they give out." GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016, pg. 9. AMF has shared all registration data collected from each of the three regions it has funded distributions in with us. AMF Data Entry System, Ghana 2017 The full registration data we have seen in AMF Data Entry System, Ghana 2017 includes data on "# LLINs allocated" and "# LLINs given."  56. AMF page on Ntcheu 2012 distribution AMF page on Balaka 2013 distribution AMF page on Dedza 2014 distribution AMF page on Dowa 2015 distribution  57. See our March 2012 update on AMF.

  58. All weekly reports at AMF page on Balaka 2013 distribution. Examples of problems reported:

 "The exercise despite the verification process and data cleaning faced some duplicates that were discovered during the distributions. The duplicate situation had not been dealt with during data cleaning as it was deemed only when both villages were asked to collect nets from the same distribution point that it became clear that there had been duplicate entries. However, different distribution points at the same time though at the same cluster makes it practically impossible for villagers to collect two nets from different sites by double registering." Concern Universal Balaka 2013 week 1 report, pg. 1. "There was a high number of absenteeism during the urban distribution, which resulted in some members receiving the nets on behalf of others. This absenteeism was explained by the unavailability of the beneficiaries due to professional reasons. There were some complaints from beneficiaries whose nets were received by representatives claiming that the nets weren’t handed over. Handing over of nets to representatives was cancelled since it was clear that, unlike in rural areas where all community members know each other and certify the representative’s identification and the nets were handed over to the legitimate beneficiaries, nets were being misappropriated... For the urban distributions we anticipate to conduct them during the weekend to assure that most of the household owners are free from their daily work related activities." Concern Universal Balaka 2013 week 5 report, pgs. 1-2. "One health worker assigned to facilitate the distribution process, in the community under his supervision, was caught by the beneficiaries trying to steal about 25 nets. He was reported to the authorities and discharged of his duties. This episode disrupted the distribution process and CU staff had to intervene to keep the population from beating the health worker." Concern Universal Balaka 2013 week 5 report, pg. 2.  59. All weekly reports at AMF page on Dedza 2014 distribution. Examples of problems reported:

 "The major challenge encountered during this week’s distributions was the misplacing of villages in clusters, which required us to the transfer the nets and distribution registers to the clusters where the villages have presented themselves. This delayed our distribution process but we still managed to reach and carry out the distributions to the affected villages." Concern Universal Dedza 2014 week 1 report, pg. 2. "There were 20 villages under Kaphuka that did not receive the nets because of poor communication as their HSAs were attending performance appraisals and failed to communicate the distribution dates to their respective villagers." Concern Universal Dedza 2014 week 3 report, pg. 1. "The major challenge during the week was duplication of registration in a way that some beneficiaries seem to have been deliberately registered in more than one village. The registration data was corrected and the affected beneficiaries only received the nets they were entitled to according their respective village data." Concern Universal Dedza 2014 week 3 report, pg. 2. AMF notes these issues and an additional issue on its blog, "An isolated incident of 300 nets missing from one storage location. This is being investigated and pursued with the police as any nets missing is taken very seriously. 300 nets represents 0.12% of the total nets being distributed." AMF: "Mid-distribution weekly reports for Dedza distribution, Malawi"

  60. "Mid-distribution Weekly Reports" at AMF page on Dowa 2015 distribution cover the first 184,554 nets distributed out of a total of 396,900 nets. Examples of problems reported:

 "The major challenge we encountered during the distribution was the breaking down of our distribution vehicles, which forced us to interrupt the distribution for almost one month to have them fixed, as some spare parts could not be sourced locally." Concern Universal Dowa 2015 weeks 1-3 report, pg. 2. "Some beneficiaries didn’t show up as they were attending a clothing items distribution on the same day. The fact that most inhabitants of the said villages are refugees from Rwanda, Burundi or Somalia caused identification challenges, preventing individuals claiming nets on behalf of the beneficiaries from receiving the nets. These beneficiaries will be considered during the mop up exercise." Concern Universal Dowa 2015 weeks 1-3 report, pg. 3. "Distributions were not conducted in ten of the planned villages under the three health facilities due to funerals hence we deferred distribution and managed to reach ... 493 of the 503 planned villages. However, arrangements will be made at a later date when we will reach them and conclude the distributions in the deferred villages hence their nets have been currently taken back to the warehouse for safe keeping. The above mentioned villages are: Msaka, Kancheri, Chimbalanga Mononga and Nkhota villages from Mtengowanthenga health facility with, respectively, 20, 100, 201, 91 and 49 nets returned; Masiya, Sintala 2, Mulode 2 and Mgoli from Dzoole health facility with a nets requirement of 42, 274, 26 and 84 nets respectively and Mphinda village under Kayembe health facility with a requirement of 140 nets." Concern Universal Dowa 2015 weeks 1-3 report, pg. 5.  61. “AMF has provided regular, public updates on the large, ongoing net distribution in the Ntcheu district of Malawi. Expected data collection has occurred and the distribution has proceeded close to schedule. AMF's distribution partner, Concern Universal, has been transparent about problems it has encountered, and seems to have a robust process to catch problems (such as attempts to steal nets) when they arise.” See our March 2012 update on AMF.

  62. IMA World Health, Kasaï-Occidental 2014 distribution report IMA World Health, Kasaï-Occidental 2014 technology report  63. Episcopal Relief & Development Pre-distribution Report Ghana Northern Region June 2016Episcopal Relief & Development Pre-distribution Report Ghana Upper West Region December 2016Episcopal Relief & Development Pre-distribution Report Ghana Greater Accra Region December 2016 Episcopal Relief & Development Ghana Activity Report 1 2016 Episcopal Relief & Development Ghana Activity Report 2 2016 Episcopal Relief & Development Ghana Activity Report 3 2016 Episcopal Relief & Development Ghana Activity Report 4 2016 Episcopal Relief & Development Ghana Activity Report 5 2016 Episcopal Relief & Development Ghana Activity Report 6 2016 Episcopal Relief & Development Ghana Activity Report 1 2017 Episcopal Relief & Development Ghana Activity Report 2 2017 Episcopal Relief & Development Ghana Northern Region distribution report 2016  64. Examples of problems encountered:

 Episcopal Relief & Development Pre-distribution Report Ghana Northern Region June 2016: "Some challenges noted [in pre-distribution activities in the Northern Region] include: Late submission of summary of sub-districts data to district for collation Large numbers of booklets to validate Poor telephone network making it difficult to reach some of the volunteers who had issues with some coupons and needed to get to the sub-district to clarify and if necessary go back to the households to make corrections to the registration or to re-register. Difficulty in reaching Mankarigu, a hard-to-reach sub-district across the White Volta River. The team had to travel across five districts to get to Mankarigu. Some actions taken to resolve some of the above challenges included:

 With the delay in the submission of sub-districts data, the team continued to move to the sub-district and start the validation of the coupons whilst still waiting for the summary of sub-districts data. The validation team (including ADDRO staff) visited the communities to ascertain the veracity of the information captured on the coupons especially household sizes ranging from 15 to 20 The households with large household sizes were re-registered to reduce the sizes of the households and the earlier coupons issued were retrieved and replaced with new coupons." Pgs 14-15. Episcopal Relief & Development Ghana Activity Report 1 2016: "The distribution activity itself has taken place in the Northern region and reportedly went well. While complete details will be presented in the September Distribution Report, some initial, key observations made during the monitoring of the LLIN point distribution exercise included the following: Some distribution points had issues with crowd control but were able to resolve them by forming and maintaining queues Some registered beneficiaries rejected nets given to them on the basis that each household member should be given one net. Although the universal coverage strategy was explained to the crowds some still rejected the LLINs given to them. Other households who missed out on the registration exercise turned up at some distribution points demanding nets but were not able to be served due to the protocols of pre-registration. A few household members discovered the distribution strategy (universal coverage formula) and changed their household sizes/numbers on the coupon ostensibly to receive more nets than originally allocated so each HH member gets a net. However, this was easily found out and corrected as the distribution point attendants checked the counterfoils with the coupons submitted by the households." Pg 7. Episcopal Relief & Development Ghana Activity Report 3 2016: "The Ashaiman and Ningo Prampram districts had significant numbers of nets not redeemed. For example, Ashaiman had 127 bales (12,700 pieces) at the District Health Directorate not distributed. The reasons given were that during the distribution in July, there was a LLIN shortage (because the districts had not received all their nets) so later when the districts finally had their nets, beneficiaries did not turn up to claim them. The GHS staff had called most of the beneficiaries per the contact numbers in the coupon counterfoils but only few came for the LLINs. This issue was reported to NMCP to take action." Pg 5.  65. "Our distribution of 676,000 nets in Kasaï-Occidental in partnership with IMA World Health (IMA) is our first one using smartphone technology for data collection. We see this as an exciting development with significant potential benefits including:

 Acts against potential theft Improved accountability Greater transparency Greater data accuracy Improved cost effectiveness Additional data can be collected Reduced operational risk The use of this technology may become a significant determinant of future net distributions that we fund. We will report publicly on our experience with the Kasaï-Occidental 2014 distribution and the data gathered… GPS information can also be gathered helping to locate households and tie the number of nets delivered to each." AMF: "Introduction of smartphone technology to collect distribution data"

  66. IMA World Health, Kasaï-Occidental 2014 distribution data

  67. IMA World Health Nord Ubangi 2015-16 registration data

  68. Episcopal Relief & Development Ghana Activity Report 3 2016: "The validation was to establish precisely how many LLINs were distributed during the distribution campaign in all 12 districts. Apart from validating counterfoils, the validators undertook 'End-User Verification'. The end-user verification (EUV) is a rapid check-up to determine whether the beneficiaries really received the number of LLINs allocated for the households and are using the LLINs for the intended purpose. This involved randomly selecting 100 households in each district to verify LLINs received, LLIN use by household members, etc. Validators randomly sampled 100 booklets and from each booklet, randomly sampled one coupon counterfoil for the EUV visit. Validators then called the beneficiaries of the sampled coupon counterfoils and followed up to the households for the end-user verification exercise." Pg 4-5. "24 NMCP validators were assigned to work in the 12 AMF supported districts (2 validators per district). Two teams from ADDRO (a team from the ADDRO HQ and a team from the ADDRO Greater Accra office) visited all the 12 AMF districts to monitor the validation process and to provide support for the packaging of coupon counterfoils for transportation to ADDRO headquarters in Bolgatanga. Key findings were as follows: It was comparatively easier for the validators/monitoring team to enter into bedrooms/sleeping places of beneficiaries in the rural areas to inspect or observe net usage (LLINs hanging and being used) than it was in the urban areas. Residents in the urban areas felt very reluctant to allow ‘strangers’ to observe their sleeping places. The Ashaiman and Ningo Prampram districts had significant numbers of nets not redeemed. For example, Ashaiman had 127 bales (12,700 pieces) at the District Health Directorate not distributed. The reasons given were that during the distribution in July, there was a LLIN shortage (because the districts had not received all their nets) so later when the districts finally had their nets, beneficiaries did not turn up to claim them. The GHS staff had called most of the beneficiaries per the contact numbers in the coupon counterfoils but only few came for the LLINs. This issue was reported to NMCP to take action."  Pgs 4-5. 

"In the Greater Accra, post-distribution validation tracing was implemented for a random sample of households. The same process is planned for the Upper West Region. The Global Fund imposed this requirement." GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016, pg. 10.  69. Comment provided in response to a draft version of this review in November 2016.

  70. AMF lists the countries it has provided nets to at AMF Countries involved. The Malaria Atlas Project has compiled data on malaria risk by location at Malaria Atlas Project Endemic countries. 

  71. AMF Distributions

  72. WHO 2014 Malaria World Report, pg. 37, Figures 8.6 and 8.7. An additional source of data on malaria deaths in these countries is the Institute for Health Metrics and Evaluation's (IHME) Global Burden of Disease tool. IHME Global Burden of Disease tool: 95.3 malaria deaths per 100,000 people in DRC in 2015 (95% confidence interval: 62.42 to 135.06). 68.61 malaria deaths per 100,000 people in Malawi in 2015 (95% confidence interval: 41.28 to 103.36). 52.81 malaria deaths per 100,000 people in Ghana in 2015 (95% confidence interval: 28.6 to 81.65) 41.5 malaria deaths per 100,000 people in Uganda in 2015 (95% confidence interval: 18.99 to 68.58). 99.27 malaria deaths per 100,000 people in Togo in 2015 (95% confidence interval: 70.93 to 132.55). 15.43 malaria deaths per 100,000 people in Papua New Guinea in 2015 (95% confidence interval: 9.44 to 24.59).  73. "Continued use of nets is very important. Every six months, a post-distribution survey is carried out to assess net usage and net condition. Approximately 5% of the nets distributed are assessed through visits to randomly selected households. The data collected are used to determine if additional community-level malaria education activities are required. All data are published." AMF information we publish Example from a distribution proposal: "Please confirm you will carry out Post‐Distribution Surveys (PDSs) every 6 months post‐distribution for a period of up to four years to assess the level of net usage (hang‐up %), correct usage and condition of the nets and you will provide us with the findings. Each survey would cover approximately 5% of households." Concern Universal Dedza 2014 distribution proposal, pg. 2. AMF has to be flexible about the timing of PDCUs because often there are delays that cannot be prevented. If a PDCU is delayed, the next PDCU will occur on schedule (e.g. even though the Dedza 2014 distribution's first PDCU was done at 8 months, the next PDCU will occur at 12 months), unless the delay was severe enough that sticking to the schedule would not make sense (as happened with the Ntcheu 2012 PDCUs). Although AMF originally planned to request PDCUs for four years after a distribution, this doesn't make sense in some contexts where it is required that a mass distribution of LLINs occur at least every 3 years (such as Malawi). Rob Mather and Peter Sherratt, conversation with GiveWell, September 9, 2015  74. We have seen examples of the random selection used for the Ntcheu 2015 18-month and the Balaka 2015 18-month PDCUs and for each of the PDCUs that have taken place in Ghana thus far.

  75. See this blog post for more details on non-random sampling in past post-distribution surveys in Malawi

  76. For example, "After the HSAs have collected data from all villages, spot-checkers independently collect the same data from 5% of households in each village... The two sets of data are entered into a Microsoft Access database separately. Reconciliation of the data is done after data entry." GiveWell's non-verbatim summary of a conversation with Nelson Coelho, April 15, 2016.

  77. Rob Mather, AMF Founder, email to GiveWell, October 31, 2016.

  78. The blog post discusses the first two surveys. More recently, AMF shared a summary of the 18-month survey that notes that about half of the data was discarded due to inconsistencies: "# of HHs [households] where net presence data is reliable: 6,330 (45% of HHs visited)", DRC Kasaï-Occidental 2014 18-month post-distribution check-up data (English summary), pg. 1

  79. Enumerators were trained to observe nets, shown what to look for with respect to the net and how the respondent hangs it. In practice, this was found to be lacking. Not all enumerators seemed to follow best practice of checking the net themselves. Of those that do check the net, they may not always ask the respondent to demonstrate how they hang the net if it is not already hung. Radhika Lokur, IDinsight, email to GiveWell, November 1, 2017.

  80. "ERD & ADDRO ask AMF for a 0.5% larger sample selection for the PDCU because they tend to discard inconsistent data during the data entry phase. For e.g. if the paper PDCU is hard to read or has been marked up badly or has numbers missing / don't add up -- the form is discarded, with no record of why or how many forms they discard. This affects the randomness of the sample selection as there could be a particular set of responses that are getting thrown out." Radhika Lokur, IDinsight, email to GiveWell, November 1, 2017.

  81. See all results compared to the predictions of the decay rate model in (see this spreadsheet, "Decay rate comparison" sheet.) "This is the second universal coverage distribution in Ntcheu, with the first taking place in December 2012, a little over four years before. […] Initial hypotheses for data from this PDCU-06: Hypothesis 1: Timing differences between the 2012 PDCU-06 and the 2016 PDCU-06 mean there is a seasonal variation (e.g. linked to mosquito levels and average temperatures) Hypothesis 2: The previously distributed nets have lasted beyond the normal three years life and some of the new nets are being held in reserve to replace them when worn out. Hypothesis 3: Our criteria for assessing, prior to a mass distribution, which nets are ‘perfectly usable’ (have at least 18 months of life left) is too strict and materially more nets than we are judging to be so have extended life in them." Ntcheu 2015 6-month post-distribution check-up report, Pg 4. "The data collected show the level of sleeping space coverage with nets that were distributed during April 2015 was 81%. We expected this figure to be about 5 to 10 percentage points higher. Data for the proportion of all sleeping spaces covered shows that 85% are covered. This suggests that some sleeping spaces may be covered with nets not distributed during the mass campaign. If so, these are likely to be nets distributed in the prior campaign (few, we estimate) and some nets distributed via routine mechanisms e.g. ante-natal clinics (most, we estimate). We do not have further information or data on a likely split. The level of nets present but not hung is 15%. Normally we see levels around 4-8%. This suggests householders may not be using new nets as they still have acceptable older nets. We will consider what further information we could gather to understand if a) newer nets are being held back due to being not needed (and what the implication, if any, that has for the assessment at the time of distribution of household net need and the presence of ‘perfectly usable nets’.); and/or b) whether all sleeping spaces that should be covered (ones being slept in) are not being covered and there is a need to encourage greater hang-up." Dowa 2015 6-month post-distribution check-up report, Pg 4.  82. "Usage does not appear to have been near-universal. Most studies report usage rates in the range of 60-80%, though some report 90%+ usage." From our page on Long Lasting Insecticide Treated Nets. Note that the World Malaria Reports that we looked at showed similar usage rates.  83. "Alliance for Malaria Prevention 2011 lays out a model for estimating the number of LLINs still in use after distributions: 'the number of LLINs already distributed over the last three years and considered to be available in households should be calculated and subtracted from the total need, working with a decay rate of 8 per cent at one year (0-12 months), 20 per cent at two years (13-24 months) and 50 per cent at three years (25-36 months).'… Bottom line: We believe that the "8%-20%-50%" model is the most widely used and most reasonable approximation available at the moment for capturing the extent to which LLINs remain in use in the years following distribution, accounting for any factors that might cause LLINs to be discarded or additional LLINs to be purchased. It implies an average of 2.22 years of use for each LLIN distributed. Data and analysis on this topic appears extremely thin; we have little sense for how long LLINs last in practice." "If we assume that an LLIN has a 92% chance of being in use at a given point in the first year after distribution, this implies that for each LLIN delivered, an average of 0.92 LLIN-years of use are obtained in the first year. Assuming 0.92 LLIN-years of use in the first year, 0.8 in the second year and 0.5 in the third year would yield an overall average of 2.22 years of use per LLIN. This is substantially less than the "official life" of an LLIN. As discussed below, we believe this makes sense because the decay function is intended to account for wastage of all kinds, including loss/failed delivery of LLINs, improper use resulting in disrepair, etc." GiveWell report on the "decay model" for LLINs.

  84. This is an understanding formed over many conversations.

  85. "Health Surveillance Assistants (HSAs) are Government extension workers- they are the lowest tier of government presence in the decentralized health system." Robin Todd, Concern Universal Malawi Director, email to GiveWell, April 27, 2012.

  86. "As such they are the first line of response to any public health issues in communities. Their job involves disseminating health related information (such as encouraging people to make use of sanitary facilities, go for immunizations, sleep under mosquito nets etc.), carrying out sanitation and hygiene campaigns and sending data on take-up of facilities to the District Council, conducting basic nutrition support, weighing children and reporting levels of stunting and wasting, detecting common communicable diseases and reporting these to clinicians and other health providers, implementing immunization campaigns etc. As you can see being involved in universal net distribution fits very well with their core public health responsibilities. HSAs need to have a primary school completion certificate as a minimum but the majority of them will have O-Levels (exams sat by pupils aged 16 if they have completed the school system at the recommended pace). Once they have been selected as HSAs they are sent on an initial 9 months intensive training course where they will be trained in many aspects of public health including how to recognize common diseases, how to administer immunizations etc." Robin Todd, Concern Universal Malawi Director, email to GiveWell, April 27, 2012.

  87. Pre-distribution registration surveys appear to be completed relatively quickly: "Approximately 480 personnel will be involved in the PDRS, with the majority, some 460, involved for 5-7 days over the data collection period." Concern Universal, Dowa 2015 planning document, pg. 4. In the Ntcheu 2012 distribution, the verification of PDRS data took several weeks: "The verification process took the verification team of 10 members 18 days to complete and in a day 20 clusters were verified with 10 verification sites in the morning and 10 verification sites in the afternoon." Concern Universal Ntcheu 2012 distribution report, pg. 7. In the Ntcheu 2012 distribution, distributions were scheduled for several weeks, but covered approximately 10 "clusters" per day: "The distributions were scheduled to have been concluded within 28 days with the team distributing at 10 clusters per day covering five weeks." Concern Universal Ntcheu 2012 distribution report, pgs. 7-8. United Purpose has recently started to use fewer staff for post-distribution check ups, which causes them to take somewhat longer: "However, in collaboration with the District Environmental Health Office (DEHO) and Malaria Coordinator (MC) and lessons lea[r]nt from 24 month Ntcheu PDCU, it was recommended to have a focused team of 10 data collectors rather than have the HSAs as data collectors from each HCA. This was based on the following reasons. First, this would reduce the number of data collectors that would need to be monitored and trained. Second, we would be able to select reliable individuals whom we could trust to do a diligent and accurate job of collecting the data. Third, it would leave the majority of HSAs to carry on with the normal health tasks and duties. Fourth, by having the same people covering the whole exercise they will get acquainted to the task and reduce errors on data collection. This meant the data collectors would spend thirty seven days collecting data rather than the one or several days if many more data collectors were to be used. This was judged the preferable way of organising and managing the data collection phase." Concern Universal Ntcheu 2012 33-month post-distribution check-up report, pg. 5. Other recent post-distribution check-up reports have similar language.  88. "i) Field Supervisors (FSs) 22 FSs were selected from permanent and senior health staff in Tshikapa Health District. ii) Community Health Workers (CHWs) – data collectors Each of the 22 FSs had the responsibility of recruiting, in each HA they were designated, enough CHWs to gather household data and hang nets. Two primary recruitment criteria were literacy and familiarity with using a mobile phone. The number of CHWs recruited depended on the size of the HA and the number of households to be visited. The aim was to recruit enough CHWs to carry out the entire registration and hang‐up, once it commenced, in a five day period. Between 20 and 40 CHWs were recruited by each FS for a total of 4,000 CHWs across the 8 HZs (8 HZs x 20 HAs x 25 CHWs per HA = 4,000 CHWs)." IMA World Health, Kasaï-Occidental 2014 distribution report, pg. 13.

  89. GiveWell's notes from a site visit to a bed net distribution program funded by the Against Malaria Foundation in Greater Accra, Ghana, August 15-18, 2016:

 "In the present distribution, core responsibilities of Episcopal Relief & Development and ADDRO include: Monitoring the NMCP-led pre-distribution and distribution activities, and providing feedback to the NMCP. NMCP also does its own monitoring. Post-distribution monitoring." Pg. 4. "Phase 1 – Planning and registration The registration phase was implemented by the government and is now complete in all three regions. Step 1 – Informative Meetings with Ghana Health Service Regional Health Directorates At these meetings, stakeholders discuss the LLIN distribution implementation model, the schedule of activities, and budgets. Stakeholders also agree on a date for the regional planning workshop. Step 2 – Regional planning workshops At these workshops, stakeholders discuss the registration and distribution processes, budgets, rules, and responsibilities for different groups. In the Greater Accra regional planning workshop, the stakeholders also discussed which households to target (in other regions, all households were targeted)." Pg. 4. "GHS volunteers carry out the registration process, which takes place more than one month before the distribution. Volunteers are organized by the Ministry of Health (MoH) and participate in a number of government health programs, such as vaccination campaigns (immunization days)." Pg. 5. " Steps in the distribution process 1. Beneficiaries walk a short distance to their distribution point. One staff member employed by GHS and at least one GHS volunteer are stationed at each distribution point; there are never just two GHS volunteers." Pg. 8.  90. See our most recent model, "Bednets" and "Results" sheets.

  91. See this spreadsheet, sheet "Funding commitments."

  92. See this spreadsheet, sheet "Spending opportunities."

  93. Over AMF's FY 2011 to 2017 (June 30, 2010 to July 1, 2017), AMF took in $128.7 million. In total, over GiveWell's 2011 to 2016 metrics years (January 1, 2011 to January 31, 2017—we changed metrics years in this period), GiveWell-directed donors gave $91.8 to AMF. We add to this figure the amount given by GiveWell-directed donors in February 1, 2017 to June 30, 2017 ($0.7 million; from internal donation records) plus "accruals" ($4.5 million; see note in sheet "Available and expected funds," cell E23 here), to get a total of $97 million. Note that the time period for these figures do not perfectly align (though it's close). In addition, we would guess that a portion of AMF's donations that we have not attributed to GiveWell's recommendation should be counted as due to GiveWell but have not been because of lack of information from the donors. For GiveWell money moved figures, see our impact page. See this blog post for metrics year 2016 data. AMF Financial information  94. Rob Mather, AMF Founder, email to GiveWell, November 3, 2017

  95. This is based on internal records of how much GiveWell-directed donors gave to AMF in 2013 when we listed AMF as a "top charity with limited room for more funding," inflated for growth in GiveWell's annual money moved since 2013.

  96. AMF funds status (October 2017) Redacted. Two of the distributions are listed as 2017, but we have assumed that, given the time needed between signing an agreement and delivering nets, these distributions will take place in 2018 (or later). 

  97. Melanie Renshaw, African Leaders Malaria Alliance Chief Technical Advisor, phone conversation with GiveWell, May 23, 2014 Melanie Renshaw, African Leaders Malaria Alliance Chief Technical Advisor, phone conversation with GiveWell, October 20, 2015 Melanie Renshaw, conversation with GiveWell, March 16, 2016 Summary of year-end gaps in Rob Mather, email to GiveWell, May 9, 2016. 2013-2015 year-end gaps were 22m, 38m, and 39m, respectively, and "does not include distributions delayed and pushed into the next year with the hope of finding funding for the subsequent year." ALMA LLIN gap analysis (June 2016) DRC Kasaï-Occidental 2014 18-month post-distribution check-up data (English summary)  98. GiveWell's non-verbatim summary of a conversation with Melanie Renshaw and Marcy Erskine, October 11, 2016 GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, November 2, 2016 It was difficult for her to estimate the size of the funding gap for 2018 because the Global Fund to fight AIDS, Tuberculosis and Malaria, the largest funder of LLINs, works on three-year cycles and had not yet determined how much funding it would allocate for LLINs for 2018-2020. In September 2016, it raised $12.9 billion of its $13 billion goal for the 2018-2020 period and expects to announce how much it will allocate to each country for work on each disease in mid-December 2016. In early 2017, countries will begin applying for funding, which will include specifying how much they would like to spend on LLINs. GiveWell's non-verbatim summary of a conversation with Melanie Renshaw and Marcy Erskine, October 11, 2016 "The target for the Global Fund replenishment for 2018-2020 was $13 billion, and $12.9 billion has been pledged." Pg. 1. "Funding for specific interventions will be determined through the following process: Allocations per country – The amount allocated to each country for 2018-2020 will be announced on December 15, 2016. Per-country allocations are unlikely to change after this time. Planning and proposals for diseases and interventions – After per-country allocations are announced, countries will begin putting together proposals for the specific diseases and interventions they plan to target with their allocations. The majority of countries will need to submit their proposals for malaria-related spending – including proposed LLIN allocations – by March 20th, 2017. The technical review panel will review the proposals prior to approval. Until this process is complete, it is difficult to estimate the size of the investment that countries will make in LLIN programs for 2018-2020. It is therefore difficult to predict what the global gap in funding for LLIN programs will be during this funding cycle." Pgs. 1-2. 

 99. ALMA LLIN gap analysis (November 2017)

  100. GiveWell's non-verbatim summary of a conversation with Melanie Renshaw, November 2, 2016.

 "The overall resources spent on malaria programs are likely to remain largely the same in 2018-2020 as in the past few years. The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and The U.S. President’s Malaria Initiative (PMI) are expected to make contributions at roughly the same scale as during the previous Global Fund funding cycle. However, even if AMF and other funders also continue to provide the same level of support for LLINs as they did in the past few years, there is still likely to be a significant gap in LLIN funding in 2018–2020. Dr. Renshaw estimates that this could translate to a global gap of approximately 100 million LLINs over the three-year period, including a 25 million LLIN gap in Nigeria alone." Pg. 1. "The Global Fund is the main factor in the size and scope of LLIN funding gaps. Country allocations have not yet been finalized for the upcoming funding cycle. They will be announced on December 15. However, there may be several key changes to how funding is allocated: Smaller allocation for countries – The total amount of funding for all countries during the upcoming Global Fund cycle is less than during the previous cycle. This alone would not necessarily be a significant enough reduction to impact LLIN funding. However, an additional $300 million in catalytic funding – which was previously used to fill funding gaps for LLINs – will not go toward LLIN programs in the upcoming funding cycle. These two factors combined are likely to decrease per-country LLIN funding. Allocations more evenly divided among countries – by reducing funding for large, high-burden countries. In the previous funding cycle, some large, high-burden countries were "over-allocated" – i.e., received substantially more funding than others. In the upcoming funding cycle, the Global Fund will work to distribute funds to countries more evenly, allocating less to some “over-allocated” countries and more to "under-allocated" countries. Most African countries have a high malaria burden, and “under-allocated” countries are not low burden countries like Swaziland, South Africa, etc. Rather, they are countries that did not receive sufficient funding to implement a wide variety of malaria control programs, e.g., expanding case management to community case management, rolling out seasonal malaria chemoprevention programs, or enhancing intermittent preventative treatment in pregnancy. They were generally only able to fund LLIN universal coverage campaigns and public sector case management in the past. Given additional funding, they would likely invest in enhancing case management and perhaps routine LLIN distribution. Less shock buffer – In the past, in the Global Fund rounds system, countries proposed the amount of funding needed. The Global Fund reviewed their proposals and either provided the funding requested or did not. With the move to the New Funding Model, the amount allocated to a country was required to be at least 75% of its previous allocation, to prevent shock to the programs. In the upcoming cycle, the Global Fund may reduce this shock buffer to 50%. This, combined with "over–allocated" countries possibly receiving less, could mean that countries will receive substantially less than needed to sustain coverage. It would be difficult for them to fully support their LLIN programs as a result." Pgs. 1-2.  101. Melanie Renshaw, African Leaders Malaria Alliance Chief Technical Advisor, conversation with GiveWell, October 13, 2017

  102. Rob Mather and Peter Sherratt, conversation with GiveWell, April 25, 2016 "The operational plan for a distribution typically covers 12 months. The planning horizon for a specific distribution is, however, typically 18 to 24 months as discussions to assess and approve a distribution start six months earlier and the funds required (we need to have funds in hand in order to have serious discussions) are aggregated in the preceding months." AMF: "Operational planning (12 months) and planning horizon (18 to 24 months)"  103. As reported to us in Rob Mather, email to GiveWell, May 9, 2016.

  104. In November 2013, we wrote in this blog post that we believed AMF did not have room for more funding because it had raised over $10.6 million due to GiveWell's recommendation since 2011 and had not spent the bulk of these funds. In 2014, AMF completed and signed agreements for several large distributions, increasing our confidence that it could productively use the donated funds it held. By the end of 2014, AMF had spent or committed a large portion of the funds it raised prior to 2014. As of November 2014, AMF held $4.9 million in uncommitted funds, of which it raised $2.65 million in 2014. Of committed funds, $1.9 million were for expenses that AMF would incur more than a year later, and AMF was considering reallocating these funds to the nearer-term with the expectation of raising enough to cover its later commitments by the time they were due. This reallocation brought AMF's total available funds to $6.8 million. Rob Mather, AMF Founder, email to GiveWell, November 26, 2014 In 2015, AMF did not sign any new distribution agreements for the near future, although it signed agreements to replace nets it had previously funded in Malawi in 2018. AMF: "US$6m commitment to malaria control support in Malawi in 2018"  105. See this spreadsheet

  106. Melanie Renshaw, conversation with GiveWell, October 13, 2017. AMF told us something similar.

  107. Comment provided in response to a draft of this review in November 2017

  108. See AMF People. AMF told us that it had hired an Operations Manager who was starting in November 2017. Rob Mather, AMF Founder, email to GiveWell, November 3, 2017  109. "AMF Medium Term Strategy… Increase AMF central staffing by four people before the end of 2016: two program directors, one operations assistant and a technology assistant." AMF medium term strategy discussion document (May 2016) AMF IT Developer hiring notice AMF Operations Manager hiring notice  110. "Staff capacity has not hindered in any way our ability to sign agreements or manage distributions. It has slowed aspects of IT development (website redesign) and reporting." Comment provided in response to a draft of this review in November 2016

  111. This understanding comes from many conversations with AMF, most recently in November 2016.

  112. "With or without a co-funding partner, our sense, is NMCPs will first try and achieve funding from: a) Organisations from whom they have received funding before and with whom they have established relationships (know how the relationship operates, reporting requirements etc) b) Organisations with high levels of funding to minimise the number of agreements reached (often 2) c) Organisations who have the least accountability requirements. We do not have hard information to support this but is a view shared by others within the malaria and wider aid community." Rob Mather, AMF Founder, email to GiveWell, September 9, 2015

  113. Rob Mather, AMF Founder, conversation with GiveWell, May 24, 2017

  114. AMF Uganda Country funding report

  115. Alliance for Malaria Prevention 2017 Q3 Net Mapping Project

  116. See this spreadsheet, sheet "Overview," column F. Though AMF purchased more than 14.2 million nets, because it does not pay for other distribution costs, in effect, it funded 14.2 million nets for distributions occurring in 2015-2017.

  117. In 2015-2017 (assuming 75% of the nets that will be delivered in 2017 were delivered in the first 3 quarters), 522 million nets were delivered. 14.2 million nets is 2.7% of this. Alliance for Malaria Prevention 2016 Q3 Net Mapping Project

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