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            You are hereHome » Top Charities » Malaria Consortium Malaria Consortium – Seasonal Malaria Chemoprevention     FacebookTwitter>Print>Email                   Donate

  Malaria Consortium's seasonal malaria chemoprevention program is one of our top-rated charities and we believe that it offers donors an outstanding opportunity to accomplish good with their donations.

 More information: What is our evaluation process? 

 Published: November 2019

 Summary What do they do? Malaria Consortium (malariaconsortium.org) works on preventing, controlling, and treating malaria and other communicable diseases in Africa and Asia. We have only reviewed its seasonal malaria chemoprevention (SMC) program, which distributes preventive anti-malarial drugs to children 3 to 59 months old in order to prevent illness and death from malaria during the high transmission season; our recommendation is just for this part of Malaria Consortium's work. (More)

 Does it work? There is strong evidence that SMC substantially reduces cases of malaria. Malaria Consortium has conducted studies in the countries where it has worked to determine whether its programs have reached a large proportion of children targeted. Surveys conducted in 2017 and 2018 found that on average, 95% of children received at least one month of SMC treatment (out of four possible months), 74% received at least three months of treatment, and 60% received all four months of treatment. (More)

 What do you get for your dollar? We estimate that the total cost to achieve the equivalent of four person-months of SMC coverage is $6.80. The numbers of deaths averted and other benefits of SMC are a function of a number of difficult-to-estimate factors, which we discuss below. (More)

 Is there room for more funding? We believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities. We estimate that Malaria Consortium could absorb up to $69.5 million for work in 2020-2022. Update: In November 2019, we recommended that Open Philanthropy grant $33.9 million to Malaria Consortium, which leaves it with a funding gap of $36 million. See this page for a summary of Malaria Consortium’s expected use of additional funding. (More)

 Malaria Consortium's seasonal malaria chemoprevention program is recommended because:

 SMC is a program with a strong evidence base and strong cost-effectiveness. (More) Track record – Malaria Consortium has experience with supporting large-scale SMC programs in seven countries and has demonstrated success at reaching a large portion of targeted children. (More) Room for more funding – we believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities. (More)  Table of Contents   Summary Our review process What do they do?  Implementation of SMC programs  What are SMC programs? Malaria Consortium SMC implementation methods   Malaria Consortium-supported SMC programs Malaria Consortium's spending on SMC programs Malaria Consortium's role in SMC programs   Does it work?  Is SMC an effective intervention? Is Malaria Consortium working in areas suitable for SMC? Are targeted children being reached?  Two methods for estimating coverage Coverage surveys   Have malaria rates decreased in targeted populations? Are there any negative or offsetting impacts?   What do you get for your dollar?  Cost per SMC treatment Cost-effectiveness   Is there room for more funding?  Uncommitted and expected funds Additional spending opportunities Fungibility Global need for treatment   Malaria Consortium as an organization Sources    Our review process We began speaking to Malaria Consortium about the possibility of reviewing one of its programs in January 2016. 

 Over the next several months we tried to determine which of Malaria Consortium's programs we should prioritize evaluating for a possible recommendation, and we ultimately settled on seasonal malaria chemoprevention (SMC). The other programs that we investigated included: bed nets, dengue control, injectable artesunate for severe malaria, integrated community case management (ICCM), micronutrient powders, malnutrition management, neglected tropical diseases morbidity management, integration of nutrition with SMC, prevention of malaria in pregnancy, point of care diagnosis of malaria, and diagnosis of pneumonia.

 Our review process has consisted of: 

Extensive conversations with Malaria Consortium staff since 2016.1 A conversation with a researcher at the London School of Hygiene and Tropical Medicine who has led the work on evaluating the ACCESS-SMC project, a large-scale SMC project led by Malaria Consortium.2 Reviewing documents that Malaria Consortium shared with us. What do they do? Malaria Consortium works on preventing, controlling, and treating malaria and other communicable diseases.3 It was established in 2003 and currently has programs and projects in nine countries across Africa and Southeast Asia.4 Malaria Consortium's total spending from April 2017 to March 2018 was about $65 million, with about 91% of its spending coming from restricted funds.5

 This page focuses exclusively on its seasonal malaria chemoprevention (SMC) programs, which aim to distribute preventive anti-malarial drugs to children 3 months to 59 months old in order to prevent illness and death from malaria.6

 The remainder of this section provides more detail on: 

Implementation of SMC programs Malaria Consortium-supported SMC programs Spending on SMC programs Malaria Consortium's role in SMC programs Implementation of SMC programs What are SMC programs? As we wrote in our intervention report on SMC, seasonal malaria chemoprevention is the monthly administration of full treatment courses of an antimalarial medicine to children during the four months of the rainy season in areas of highly seasonal malaria transmission.7 It "consists of administering a maximum of four treatment courses of SP [sulfadoxine–pyrimethamine] + AQ [amodiaquine] at monthly intervals to children aged 3–59 months in areas of highly seasonal malaria transmission [during the high malaria transmission period]."8 SMC was "formerly known as ‘intermittent preventive treatment of malaria in children [IPTc].'"9

 According to the World Health Organization (WHO):

  The suitability of an area for SMC is determined by the seasonal pattern of rainfall, malaria transmission and the burden of malaria. SMC is recommended for deployment in areas: where more than 60% of the annual incidence of malaria occurs within 4 months; where there are measures of disease burden consistent with a high burden of malaria in children (incidence ≥ 10 cases of malaria among every 100 children during the transmission season); where SP and AQ retain their antimalarial efficacy.10  According to the WHO, "SMC provides protection for up to 1 month after each complete (3-day) course…. Health workers should give the dose of SP and the first dose of AQ to the children under their direct observation and should advise the children’s caregivers on how to give the second and third doses of AQ to the child at home [one dissolved tablet per day, for two days]."11 

 Malaria Consortium SMC implementation methods Malaria Consortium supports training of health facility workers and community distributors (CDs) to deliver treatments primarily by going door-to-door.12 Malaria Consortium told us that many CDs are community health workers (CHWs), who are people in the community who work year-round to support basic delivery of health interventions such as vaccines; malaria diagnosis, referral and treatment; nutrition programs, etc. Some CDs are recruited and trained to only deliver SMC and do not provide any other community health services.13 Malaria Consortium told us that CHWs are typically paid about $5 to $7 per day for programs such as SMC, though this amount varies by country.14 Malaria Consortium also supports training for supervisors for the program.15

 Malaria Consortium typically supports four treatment "cycles." Each cycle includes a four- to five-day distribution period and lasts 28 days, at which point a new cycle starts.16 For each cycle, Malaria Consortium instructs CDs to:17 

determine whether the child is eligible for SMC and give the age appropriate dose.18 refer all acutely sick children and children with fever to the health facility for evaluation and testing for malaria.19 directly observe the child swallowing the first dose of dispersible SP+AQ, and then re-dose once if the child vomits or spits out all of the medicine within 30 minutes of taking the first dose of the medication.20 give the child's caregiver 2 tablets of AQ and explain how to give the doses over the following two days.21 record all treatments provided on a tally sheet and mark the wall of the household or compound as visited.22 advise the child's caregivers to mark a card to record that they've given the other two doses,23 to give the medication again if the child vomits (and to visit the health facility to request additional treatments if this happens), and to take the child to the health facility if they get a fever or are very sick.24 provide health education and malaria prevention messages, including explaining the purpose and benefit of SMC and the importance of children and pregnant women sleeping inside a bed net each night.25 This is a diagram of the delivery schedule:26

 

 Other relevant aspects of the program are: 

Malaria Consortium instructs CDs not to give treatment to children who: are younger than 3 months or older than 59 months; have a fever or are severely ill (these children should be referred to the local health facility); are taking another sulfa-based medication such as cotrimoxazole; have received another dose of AQ or SP during the past month; or have an allergy to a sulfa-based medication, AQ, or SP.27 Malaria Consortium told us that CDs are trained to follow a checklist, which is translated into local languages, in order to check for these issues.28 We do not know how often CDs follow all of the suggested instructions in practice. Malaria Consortium notes that program supervisors oversee CDs to enforce compliance with SMC guidelines.29 Malaria Consortium instructs CDs to give a lower dose to children aged 3 to 12 months old than they give to children 12 to 59 months old.30 Drug packets are color-coded and include pictures of an infant or a child and are color-coded, and CDs are trained to ask caregivers a set of questions and look for age-related milestones to establish the age of the child.31 Malaria Consortium supports activities to promote community engagement and social and behavior change before and during SMC campaigns.32 Malaria Consortium has shared with us a detailed description of ACCESS-SMC’s processes for supervising the drug administration process, which we include in the following footnote.33

 More details on how Malaria Consortium assesses the coverage achieved by the SMC programs it supports are below. Malaria Consortium told us that there are several challenges with delivering SMC treatments, including insecurity, flooding, and road access during the rainy season, as well as conflicting community health campaigns, such as vaccination campaigns.34

 Malaria Consortium-supported SMC programs We have seen information from three major SMC projects that Malaria Consortium has supported: 

Pilot and scale-up of SMC in northern Nigeria: The Bill & Melinda Gates Foundation (BMGF) provided about $1.7 million to Malaria Consortium to do operational research on the best way to deliver SMC at scale in Katsina state in northern Nigeria, and then to implement its chosen delivery system and assess its efficiency and impact.35 Malaria Consortium told us that it trained over 3,600 CDs and nearly 200 health workers to provide about 1.6 million treatments to roughly 350,000 children who lived in 4 "local government areas" (LGAs) in northern Nigeria in 2012-2014.36 A major goal of the project was to share what it learned; we have seen a published paper that describes the use of research to inform the design of an SMC intervention in northern Nigeria but have not yet reviewed it in detail.37 ACCESS-SMC: Unitaid awarded up to $67 million to Malaria Consortium to lead a project called ACCESS-SMC to reach up to 7 million children per year in seven countries in the Sahel region of Africa in 2015-2017.38 The project, which Malaria Consortium described in 2014 as being the "largest-yet global programme" for SMC, concluded in February 2018.39 ACCESS-SMC was led by Malaria Consortium, with Catholic Relief Services as the "primary sub-grantee" and support from many other organizations, including impact evaluation from the London School of Hygiene & Tropical Medicine (LSHTM).40 Malaria Consortium told us that its role in ACCESS-SMC included leading implementation of SMC in three of the seven ACCESS-SMC countries (Burkina Faso, Chad, and Nigeria), overseeing budgets and planning for all ACCESS-SMC activities, and overseeing research (including methodology and presentation).41 Our impression is that ACCESS-SMC paid for almost all aspects of program implementation and monitoring, including medicines and supplies, per diems for CDs, training for CDs, trainers, supervisors, and health facility workers, and research.42 General SMC program funded primarily by GiveWell-directed funds: In 2017, Malaria Consortium began using funding received as a result of GiveWell's recommendation (which we refer to as "GiveWell-directed funds") to target 650,000 children with SMC in six additional LGAs in Nigeria (to restart SMC that had been supported previously by a one-off grant), eight additional districts in Burkina Faso (for which drugs but not operational costs were available from other sources for 2017), and one region in Guinea Bissau.43 GiveWell-directed funds also supported coverage surveys and enhanced supervision and monitoring for Malaria Consortium's ACCESS-SMC work.44 In 2018, Malaria Consortium used GiveWell-directed funds to target approximately 900,000 children in 18 districts in Burkina Faso, approximately 740,000 children in 14 districts in Chad, and approximately 2.3 million children in 46 LGAs in Nigeria (in three of these LGAs, distribution was co-funded by the United Kingdom government's Department for International Development).45 GiveWell-directed funds also supported supervision, monitoring, and evaluation.46 In 2019, Malaria Consortium used GiveWell-directed funds to target approximately 5.7 million children with SMC in Burkina Faso, Chad, and Nigeria.47 Malaria Consortium told us that the above programs represent the bulk of Malaria Consortium's work on SMC so far.48 

 Malaria Consortium's spending on SMC programs Between January and December 2018, Malaria Consortium spent about $15.1 million in GiveWell-directed funds:49

 $4.8 million (32%) to pay for SMC drugs and other commodities $4 million (26%) on SMC implementation (including development of training and implementation tools, training and paying health workers to deliver SMC, community engagement, and social and behavior change) $2 million (13%) on monitoring, evaluation, and advocacy (including monitoring of SMC implementation and trends in malaria, and advocacy to government to support the program) $1.5 million (10%) on staff costs $1 million (7%) on planning and procurement (including drug supply planning, logistics around procuring drugs, and detailed planning for delivery of SMC) $1.8 million (12%) on in-country and headquarters office and other indirect costs Of this $15.1 million, Malaria Consortium spent $4.3 million (49%) in Nigeria, $2.5 million (28%) in Burkina Faso, and $2 million (23%) in Chad.50 

 We have also seen a high-level account of how Malaria Consortium planned (as of May 2019) to spend the $23.3 million in GiveWell-directed funds it has available for SMC work in 2019.51 Malaria Consortium expects to target 5.7 million children in three countries, spending 51% in Nigeria, 25% in Burkina Faso, 21% in Chad, and 3% on research.52

 For prior work, we have also seen spending data from the pilot and scale-up of SMC in northern Nigeria,53 from 2016 for the ACCESS-SMC program,54 and from 2017 for programs supported by GiveWell-directed funds.55

 We also provide some information on the estimated cost-per-treatment of Malaria Consortium-supported SMC programs below.

 Malaria Consortium's role in SMC programs Malaria Consortium's SMC work varies by country, but in general includes the following activities:56

 Determining the quantity of drugs needed, procurement of drugs, and international shipping57 Procurement and distribution of other SMC commodities58 Funding distributions, including in-country storage and transportation of drugs and payments to front-line distributors to compensate them for the time they spend on the program Technical assistance and logistical support for training SMC implementers, targeted supervision, community engagement and social and behavior change, drug safety, and review of prior implementation and revisions to procedures Financial management and oversight, including disbursing funds to local organizations, Ministries of Health, and/or CDs, collecting and validating receipts, and preparing financial reports Developing training and supervision materials and training staff at various levels59 Monitoring, evaluation and research, including Malaria Consortium staff who directly observe program activities, and funding and coordinating with research firms and academic institutions to conduct coverage surveys and to track changes in malaria incidence and death, monitoring of drug resistance, and other research. Advocacy and fundraising with governments, international, multinational, and bilateral organizations, donors, SMC working groups, researchers, and civil society. Conducting operational research, writing and disseminating lessons learned and publications in peer-reviewed journals, and presenting at international global health conferences. Does it work? Malaria Consortium-supported SMC programs are focused on delivering treatments that have been independently studied in rigorous trials and found to be effective. 

 Malaria Consortium and its partners have conducted monitoring to determine what proportion of children targeted by its SMC programs receive treatments. Surveys conducted in 2017 and 2018 found that on average, 95% of children received at least one month of SMC treatment, 74% received at least three months of treatment, and 60% received all four months of treatment.60 In 2018, average coverage across countries was 78% of targeted children treated per cycle.61 These results rely on the assumption that caregivers accurately report whether their children received and took SMC. 

 Other research, monitoring, and evaluation Malaria Consortium has shared includes:

 Results from analyzing Health Management Information System (HMIS) and sentinel surveillance site data on malaria rates before and during its ACCESS-SMC programs. A study of malaria incidence before and during its SMC program in Northern Nigeria. A case-control study to measure how the protective effect of SMC in scale-up contexts compares with that found in randomized controlled trials. A baseline and a followup survey of the prevalence of genetic markers for resistance to SMC drugs among malaria parasites. Results from following up with a cohort of 10,000 SMC recipients to track the rate of adverse events. Details follow.

 Is SMC an effective intervention? SMC appears to have strong evidence of effectiveness. Seven randomized controlled trials provide strong evidence that SMC substantially reduces cases of malaria. More details are available at our intervention report on SMC.

 Is Malaria Consortium working in areas suitable for SMC? Malaria Consortium told us that before starting work in countries under the ACCESS-SMC program, it conducted an assessment of the overall burden of malaria, transmission and rainfall patterns, regional malaria incidence over time, and seasonal variations in malaria.62 We have not reviewed this evidence in detail, but it seems highly likely to us that Malaria Consortium is working in areas that are suitable for SMC because it is working in countries with high malaria burdens and where it seems that malaria is seasonal.63

 More information on our estimates of malaria burden in the countries where Malaria Consortium is working is available in our cost-effectiveness analysis.

 Are targeted children being reached? Two methods for estimating coverage Malaria Consortium uses two different methods to measure the coverage rates that it is achieving with its programs:64 

"Administrative" coverage: These coverage estimates are generated by collecting information from CDs’ records about how many treatments they directly provided.65 Coverage surveys: These coverage estimates are generated by surveying caregivers of eligible children about whether their children received SMC in the previous cycle or round of treatment.66 In order to verify these responses, data collectors may review eligible children's SMC record cards and treatment blister packs and look for household markings left by CDs.67 They also ask other questions to assess the quality of program delivery.68 More details below. There are sometimes large discrepancies in the coverage estimates generated by these two measures, usually with administrative coverage estimates finding higher levels of coverage.69 Malaria Consortium told us that possible reasons for discrepancies between administrative coverage estimates and coverage surveys include:70 

In some countries, large temporary migrant populations (such as nomadic tribes, or settled populations migrating for seasonal agricultural work or animal husbandry71) move into SMC treatment areas during the rainy season and then leave before they would be interviewed by coverage surveys.72 A sizeable number of treatments are likely going to children who are above the age of five.73 CDs may be treating some people who live outside of the target coverage areas. There could be errors in administrative data, either in the number of treatments reported (the numerator) or in the assumed target population (the denominator).74 In 2017, SMC programs supported by Malaria Consortium in Nigeria, Chad, and Burkina Faso began conducting coverage surveys after each SMC cycle, rather than a single coverage survey after all four cycles. Malaria Consortium decided to conduct more coverage surveys in order to determine whether surveys conducted closer to the time of SMC delivery would yield different coverage rates than surveys conducted at the end of the round (four or more months after the first SMC cycle of the season) and to identify and respond to program delivery issues during SMC campaigns.75 In addition to these post-cycle surveys, Malaria Consortium also conducted coverage surveys after the full round of SMC in 2017 and 2018 (post-round surveys).76

 Below, we focus on analyzing Malaria Consortium's coverage surveys because we believe that coverage surveys are likely to be more accurate than administrative data.

 Coverage surveys Methodology

 We have seen full reports on the details of how coverage surveys were carried out in 2015, 2016, 2017, and 2018.77 Malaria Consortium's coverage survey methodology has evolved over these years; most notably, in 2017, Malaria Consortium began to conduct coverage surveys after each SMC cycle (post-cycle surveys) in addition to coverage surveys after the full round of SMC (post-round surveys). In this review, we focus primarily on the methodology used in 2018 post-cycle and post-round surveys: 

 Post-cycle surveys Study team: In 2018, data collector recruitment and training and data analysis were performed by Malaria Consortium in Nigeria and by external consultants in Burkina Faso and Chad.78 Sampling procedure: In 2018, Malaria Consortium changed its post-cycle sampling method from randomly selecting geographic areas to conduct the survey in, to sampling all areas, and selecting a smaller number of households per area (a "lot quality assurance sampling" (LQAS) approach).79 Within these areas, villages were randomly selected in Burkina Faso and Chad and non-randomly selected in Nigeria and households were randomly selected in all countries (more details in the "Methodological Limitations" and "Results" sections below).80 In 2018, aggregating this data resulted in national-level sample sizes that were larger than those used in 2018 post-round surveys.81 This approach is intended to be quicker and cheaper than typical coverage surveys, as data collectors receive less training and ask fewer questions at each household. Malaria Consortium told us that it expected to use the post-cycle results to identify and respond to implementation issues.82 Malaria Consortium reports that in 2018, challenges in implementing this approach for the first time contributed to delays and low-quality data in some cases.83 It plans to continue using the LQAS approach in its post-cycle surveys in 2019, while making some changes to try to improve the process.84

 Data collection: Data collectors conduct interviews with caregivers of eligible children and ask them whether their children received SMC treatment during the previous cycle. Data collectors are also instructed to ask questions designed to identify issues that can be addressed during subsequent SMC cycles.85 Post-round surveys Study team: In 2018, post-round coverage surveys were conducted by a different local research firm in each country.86 In previous years, coverage surveys were led by the London School of Hygiene and Tropical Medicine (LSHTM).87 Sampling procedure: In general, the sampling method is designed to yield a sample that is representative of the areas where Malaria Consortium delivered SMC using GiveWell-directed funds.88 In most cases, all districts that received SMC are surveyed.89 Villages are selected randomly (usually using probability proportional to size sampling), with a few exceptions discussed below.90 Within villages, households are selected randomly (using a variety of methods), with a few exceptions discussed below.91 Data collection: Data collectors conduct interviews with caregivers of eligible children and ask them whether their children received SMC treatment during each cycle of the campaign.92 In order to verify these responses, data collectors are instructed to review eligible children's SMC record cards and treatment blister packs, if available.93 In past surveys, the greater of the number of treatments noted on the SMC card or reported by the caregiver was recorded as the number of treatments the child received;94 in 2018, Malaria Consortium only used caregiver responses to measure coverage due to low retention of SMC cards.95. Data collectors also ask other questions to assess program quality, such as questions about caregivers' understanding of the SMC program and CDs' and caregivers' adherence to program procedures:96 "Did you hear about SMC this month before being visited by CDs?" "Can you explain what you need to do with the card?" "Can you confirm if the CD did administer the first dose to the child?" "Did the CD leave you some SMC medicines in a blister pack to give to child?" "Why didn't you give this/these tablet(s)?" We have seen results from some of these survey questions but have not reviewed them in depth. 

 GPS location data: In 2017, it was expected that coverage survey data, which is entered on tablets, would be linked to GPS location data. However, survey teams in Chad and Nigeria experienced problems with the GPS functionality of the survey software.97 It is not clear whether GPS data was collected for a portion of the sample in Nigeria and Chad in 2017. The report from Burkina Faso notes that GPS data was collected for each household; the report does not discuss whether or how this data was used to monitor data quality.98 In Nigeria and Chad in 2018, data collectors were instructed to record GPS location data;99 the 2018 report from Burkina Faso does not mention GPS data. It appears that data collectors in all three countries used different survey software than was used in 2017.100 The 2018 reports do not discuss how the GPS functionality of these software tools performed, whether GPS data was collected, or whether or how this data was used to monitor data quality. Data quality control: Data quality control procedures vary between coverage surveys.101 In 2017, survey team supervisors repeated some interviews to ensure that interviewers administered the survey questionnaires properly.102 We have seen data from these repeat interviews in Nigeria in 2017. Approximately 90% of repeat interviews produced the same answers for each of “number of eligible children” and "number of children treated."103 We have not seen data from these audits from other coverage surveys. Details on the coverage survey methodology from all years can be found in this spreadsheet, in the "Methods" sheet.

 Methodological Limitations

 Of these coverage surveys, we note the following limitations:

 Non-random sample of districts/villages in some country-years due to security concerns. In the 2017 coverage survey in Nigeria, one LGA could not be visited due to security concerns. In Niger and Mali in 2015 and 2016, some districts could not be visited due to security concerns. If security concerns mean coverage is lower in the excluded districts in these three countries, estimates based on the observed districts may overestimate coverage.104 In the 2017 surveys in both Chad and Burkina Faso, one village could not be visited. In Chad, this was due to security concerns, and we are unsure of the reason in Burkina Faso.105 In the 2018 survey in Nigeria, two villages (1% of the sample) could not be visited due to security concerns.106 Challenges partnering with external research firms and delayed post-round survey in Chad in 2018. Malaria Consortium reports that the 2018 post-cycle surveys conducted by external research firms in Chad were of low quality. This may have impacted the accuracy of results, but we are uncertain about the magnitude or direction of this impact.107 Malaria Consortium may address this issue in 2019 through increased supervision of coverage surveys in Chad.108 Additionally, the 2018 post-round coverage survey in Chad was conducted in January 2019, three months after the SMC round ended in October 2018. This delay may have decreased the accuracy of caregivers' responses, as they may have had difficulty remembering details about treatments delivered three or more months prior to the interview.109 This concern is somewhat mitigated by the fact that coverage estimates from this post-round survey are not substantially different than coverage estimates generated by the 2018 post-cycle surveys, which occurred within one month after the relevant treatment cycles (more details in the "Results" section below). Data collection by implementers and non-random selection of villages in Nigeria in 2018. In Nigeria in 2018, post-cycle surveys were conducted by data collectors recruited by state-level health authorities, who also implemented SMC, and these data collectors may have selected villages to survey non-randomly. This may have biased data collection in two ways: 1) data collectors may have been influenced to report more positive results, and 2) because data collectors were knowledgeable about how SMC was delivered, they may have chosen to survey villages that were more likely to have received SMC.110 This may have biased the coverage estimates produced by these post-cycle surveys upward (more details in the "Results" section below). Challenges verifying results with record cards and blister packs. In recent coverage surveys in Nigeria, SMC record cards were available for between 23% and 36% of children in 2017 and for 37% of children in 2018. Card retention was higher in Chad (44% and 70% in 2017 and 2018, respectively) and Burkina Faso (88% and 81%).111 With no SMC card present, it is more difficult to check caregivers' responses. We note, however, that in the 2017 coverage surveys, which reported on the percentage of children for whom caregiver responses agreed with SMC cards, coverage rates measured from these sources were generally similar, with agreement ranging from 86% to 99%. In 2017, some coverage surveys also gathered data on the proportion of caregivers who had retained the blister pack that contained the SMC medicines, another possible check on caregivers' responses. However, in most of the examples we've seen, most caregivers did not retain the blister packs.112 The 2018 coverage surveys measured but did not report on the proportion of caregivers who had retained blister packs;113 we have not requested this information. Results

 We have seen coverage survey results from the three main countries in which Malaria Consortium implemented SMC in 2017 and 2018 (Burkina Faso, Chad, and Nigeria),114 as well as from all seven ACCESS-SMC countries for 2015 and 2016. A weighted average of these surveys finds that about 93% of children received at least one month of SMC treatment, about 72% received at least three months of treatment, and about 56% received all four months of treatment.115 More recent numbers, which we believe are somewhat more indicative of the likely future coverage rates of Malaria Consortium’s SMC programs, are not substantially different. Surveys conducted in 2017 and 2018 found that on average, 95% of children received at least one month of SMC treatment, 74% received at least three months of treatment, and 60% received all four months of treatment.116 In 2018, average coverage across countries was 85% in cycle 1, 81% in cycle 2, 76% in cycle 3, and 70% in cycle 4.117 Results from all years are summarized in this spreadsheet, sheet "Results." The fact that surveys identified relatively low coverage in some cases increases our confidence in their reliability.

 For 2017 and 2018, we have compared coverage estimates from post-round surveys conducted at the end of the fourth cycle with estimates obtained from post-cycle surveys. After converting the two sets of coverage estimates to a measure of total person-months of treatment for comparison, we find a difference of about 2% between them for 2017 and about 13% between them for 2018.118 The difference in 2018 is driven largely by results from Nigeria, where post-cycle results found 20% higher person-months of coverage than post-round results.119 We believe that the post-round results from Nigeria are a better indication of actual coverage in 2018, as post-cycle results may have been biased upward during data collection.120 

 In general, we are uncertain about which type of survey is more likely to be accurate. On the one hand, post-cycle surveys may be more accurate because caregivers may find it easier to recall only the most recent treatment. On the other hand, in 2018, Malaria Consortium noted several specific reasons to believe that the post-cycle results may have been biased or of more variable quality than the post-round results. The fact that, aside from the 2018 Nigeria results, coverage estimates between post-cycle and post-round surveys were not substantially different in either year gives us more confidence that accurate recall is not a major concern in the post-round coverage survey results.

 Malaria Consortium notes that, to put these results in context, "at each cycle, a child may not receive SMC, if they have malaria or are very sick at the time of the distribution, even though they are seen by the SMC health worker or community drug distributor. And at each cycle there is a chance that a child may miss SMC if they are away from the home (where SMC is delivered door-to-door) or are unable to attend at the SMC distribution point. 88% of children received an SMC card, generally issued at the first cycle. If the probability of receiving SMC at each cycle is 88%, the expected percentage who would receive at least three treatments is [67%], and the expected percentage who would receive four treatments is 60%."121 LSHTM estimated that less than 5% of children are excluded due to illness each cycle.122

 We have seen results on some of the other questions in coverage survey questionnaires, such as those about caregivers' understanding of the SMC program and CDs' and caregivers' adherence to program procedures. We have not reviewed these results in depth.

 Have malaria rates decreased in targeted populations? Sentinel surveillance site data (2013-2016)

 We have seen sentinel surveillance site data from Chad, Mali, and Niger for 2013 to 2016 and for Burkina Faso and Nigeria for 2015 to 2016.123 We have received only headline figures for the reduction in malaria cases in children under 5 years old; we have not seen additional information on the sources for or analysis of this data.124 We have therefore not vetted the results (described in the footnote).125 Malaria Consortium told us that the data collected in other ACCESS-SMC countries was of a low quality.

 Health Management Information System (HMIS) data

 In 2019, Malaria Consortium conducted an assessment of the impact of SMC on malaria rates in Burkina Faso, Chad, and Nigeria in 2013 to 2018, using national HMIS data.126 This assessment found no evidence of impact.127 Malaria Consortium attributes this result to the low quality of HMIS data used in the analysis.128 

 Because Malaria Consortium has a track record in conducting various types of research studies, we would expect that it would have anticipated this issue while designing the study. Malaria Consortium notes that it chose to analyze HMIS data, despite the fact that it is typically of low quality, because it is an inexpensive and commonly used source of impact data.129 Given our understanding that collecting high-quality health facility data is difficult, we find Malaria Consortium's explanation quite plausible. 

 Our overall assessment of the expected impact of SMC places little weight on the lack of impact found in HMIS-based impact assessments because:

 As discussed below (see "Northern Nigeria (2012-2014)" section), non-randomized comparisons between areas in which SMC is implemented and not implemented may over or understate the impact of SMC due to differences in the two groups other than presence of SMC. There is a risk that data quality limitations will be emphasized more where non-positive trends are found than where positive trends are found. Independently assessing the quality of HMIS data would be a large project for us and we have not prioritized that work. We base our expectation of the impact of Malaria Consortium's SMC programs on malaria rates on 1) evidence from randomized controlled trials on the impact of SMC and 2) the reach of Malaria Consortium's programs, measured through coverage surveys. 

 Case-control studies

 Malaria Consortium also shared case-control studies designed to measure the efficacy of SMC treatments from five ACCESS-SMC countries: Burkina Faso, Chad, The Gambia, Mali, and Nigeria. We have not yet vetted the methodology (some details in the footnote), and the dataset from Nigeria did not pass quality control.130 Malaria Consortium's conclusion from these studies is, "These results confirm that SMC treatments are providing a very high degree of personal protection from malaria for a period of 28 days after each treatment. Protection then declines rapidly emphasizing the importance of repeating treatments at monthly intervals."131 More details on those results in this footnote.132

 Northern Nigeria (2012-2014)

 We have seen three types of analyses of the impact of Malaria Consortium's northern Nigeria program on malaria indicators. These results seem to be consistent with the impacts of SMC found in randomized controlled trials of the program, but due to our remaining questions about the studies we do not yet see them as strong additional evidence for the impact of SMC programs. See our previous review of Malaria Consortium for more details on this study. 

 Are there any negative or offsetting impacts? Drug resistance: Mass delivery of SMC medicines could contribute to increased drug resistance of SP and/or AQ.133 In 2015, ACCESS-SMC funded a baseline study of the prevalence of gene mutations in malaria parasites that are markers of drug resistance for the drugs used in SMC.134 A followup survey was conducted in 2017, following two rounds of SMC.135 This survey found that between baseline and followup, the prevalence of mutations associated with AQ resistance did not increase and that the prevalence of mutations associated with SP resistance did increase.136 The survey did not collect any samples that contained both mutations associated with AQ resistance and mutations associated with SP resistance.137 While prevalence of both types of mutations remains low, Malaria Consortium believes that further monitoring is needed to track the increase in the prevalence of mutations associated with SP resistance. Malaria Consortium plans to conduct a second followup survey after the 2019 transmission season if it has the funding to do so.138 Possible "rebound" effects: There is a potential concern that SMC could reduce the natural development of immunity to malaria. After children turn five years old and are no longer eligible to receive SMC or if SMC programs are interrupted by lack of funding or other problems, children could lack immunity and be more susceptible to malaria, especially if other prevention methods, such as long-lasting insecticide-treated nets (LLINs), are not used. We have not yet investigated this concern in-depth. Side effects of SMC drugs: Our impression is that the most common reaction seen with SMC drugs in earlier programs was spitting or vomiting (AQ is bitter and hard to swallow if not crushed into a powder and mixed with water); more recently, AQ has been available as an orange-flavored dispersible.139 Malaria Consortium told us that the incidence of vomiting has decreased with the new dispersible formulation.140 If the child expels the drugs, they are supposed to be given only one more dose within 30 minutes; we are unsure whether caregivers typically request extra tablets of AQ from CDs when this happens at home to ensure their child gets a full treatment regimen. Our impression is that other side effects from these drugs are rare and include diarrhea, itching, headache, mild abdominal pain, and rash.141 A study in Nigeria that followed up with 10,000 SMC recipients one week after receiving SMC to ask about adverse events resulted in only five reports of adverse events, though Malaria Consortium believes there may have been reluctance to report issues.142 Malaria Consortium shared three resources that report very low severe adverse event rates from SMC drugs (available in the following footnote).143 We have lightly reviewed resources on severe adverse event rates from SMC drugs here. Drug quality and dosage: Malaria Consortium told us that its policy is to only procure products from suppliers that meet WHO guidelines for pre-qualification quality assurance standards.144 We have not yet asked Malaria Consortium for the details of this process. If there were issues with drug quality or dosage, it could reduce the effectiveness of the intervention and lead to more rapid development of drug resistance. What do you get for your dollar? Cost per SMC treatment In order to make program costs comparable across all of our top charities, we aim to estimate the total cost to all actors of supporting a given program. Our estimate of cost-per-treatment for SMC includes research costs, start-up costs, and costs incurred by actors such as governments. Our estimates also rely on coverage survey estimates to approximate the number of people reached rather than administrative coverage estimates. With these assumptions, we estimate that the total cost to achieve the equivalent of four person-months of SMC coverage is about $6.80. Full details in this spreadsheet.

 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").

 Cost-effectiveness SMC programs appear to be in the range of cost-effectiveness of our other priority programs. See our most recent cost-effectiveness model for estimates of the cost per life saved through Malaria Consortium-supported SMC programs and how our model compares this outcome with outcomes of other programs.

 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. It also does not include possible offsetting impacts or other harms.145

 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.

 Is there room for more funding? We believe that Malaria Consortium could productively use more funding than it expects to receive to scale up its SMC activities.

 In short: 

Estimated needs: Malaria Consortium estimates that it could spend $31-39 million per year on SMC in each of the next three years. Malaria Consortium would use funding to a) reach additional children and extend its work to 2021-2022 in three countries (Nigeria, Chad, and Burkina Faso), b) expand to a fourth country, and c) conduct research. (More) Cash on hand: As of June 2019, Malaria Consortium had $50.6 million available to fund its SMC work. It expected to spend $16.2 million in the remainder of 2019 and roughly $30 million in 2020 to maintain its scale in Nigeria, Chad, and Burkina Faso, and is considering spending $1.3 million in 2020 in a fourth country. It expected to put the remaining roughly $3.0 to $4.5 million toward maintaining its work in 2021. (More) Expected additional funding: Donors who give based on GiveWell's recommendation have been the primary source of funds for Malaria Consortium's SMC work in the past year. For this analysis, we focus on the funding gaps that Malaria Consortium expects will remain after the other major funders contribute to SMC. (More) Additional considerations: Malaria Consortium works on a wide variety of programs. We have asked Malaria Consortium to use any GiveWell-influenced donations to specifically support SMC programs. In sum, we estimate that Malaria Consortium could absorb $69.5 million for work in 2020-2022. See also this spreadsheet for details. Update: In November 2019, we recommended that Open Philanthropy grant $33.9 million to Malaria Consortium, which leaves it with a funding gap of $36 million. See this page for a summary of Malaria Consortium’s expected use of additional funding.

 Uncommitted and expected funds In this section we focus on funding from GiveWell-directed sources. Malaria Consortium has also received funding for SMC from the UK government's Department for International Development (DFID) and the US government's President's Malaria Initiative (PMI) for SMC in 2019 ($1.2 million in total);146 for simplicity, we exclude this funding and the activities it funds from our analysis. 

 Uncommitted funds

 As of June 30, 2019, Malaria Consortium held $50.6 million in funding restricted to SMC from GiveWell-directed sources. Malaria Consortium expects to spend $16.2 million to fund remaining SMC work in 2019, leaving it with $34.5 million in uncommitted funds.147

 Expected funds

 We expect that Malaria Consortium will receive some funding as a result of being on GiveWell's list of top charities. 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 the cost-effectiveness of remaining funding gaps. We estimate that Malaria Consortium will receive about $1.2 million from donors who use our top charity list but do not follow our recommendation for marginal donations.148 In our projections of future funding, we count only one year of funding that an organization receives as a result of being on our list of top charities in order to retain the flexibility to change our recommendations in future years.

 Malaria Consortium seems not to have allocated much unrestricted funding to its SMC programs in the past.149 Malaria Consortium told us in July 2019 that it did not have sufficient unrestricted funding in the prior year to allocate unrestricted funding to SMC;150 it did allocate at least $100,000 of unrestricted funding to projects other than SMC, in addition to using unrestricted funding to support its core costs.151

 Accounting for currently unallocated funds ($34.5 million), expectations of additional funding from the sources noted above ($1.2 million), and funding held by GiveWell for supporting Malaria Consortium ($0.3 million), we roughly estimate that Malaria Consortium will have $36.0 million in funding available to allocate to SMC in 2020-2021 (not including any funding that we specifically recommend that donors give to Malaria Consortium in late 2019 and 2020). This is in addition to the $16.2 million that Malaria Consortium has allocated to work on SMC in 2019.

 More detail in this spreadsheet; see the sheet "Available and expected funding."

 Additional spending opportunities Malaria Consortium estimates it could spend $75.9 million to maintain its 2019 scale in 2020-2022 in the three countries in which it supports SMC programs152 (of which it has $36.0 million already available—see previous section), $20.9 million to expand its scale in its current countries of operation in 2021-2022,153 $6.3 million to provide support for SMC to a fourth country in 2020-2022,154 and $2.9 million on research.155 If Malaria Consortium were fully funded for this work, on the margin (i.e. after accounting for available and expected funding), 32% of its spending would be in Nigeria, 31% in Chad, 29% in Burkina Faso, and 9% in a fourth country.156

 Accounting for funding that Malaria Consortium currently has available for its work in 2019, it could absorb a total of $69.5 million for additional spending opportunities.157 Malaria Consortium told us that with funding below this level it would prioritize in the following order:

 Maintain its 2019 scale through 2021 ($26.9 million with a projected funding gap of $17.6 million) Expand to cover additional areas in Chad and Nigeria in 2020-2021 (funding gap: $8.6 million) Expand to a fourth country in 2020, with sufficient funding to maintain that work in 2021 (funding gap: $3.8 million) Expand to cover areas previously funded by other funders if funding gaps emerge (rough estimate of funding gap: $4.0 million) Maintain work, including areas added in 2020-2021, in four countries in 2022 (funding gap: $35.6 million) More detail in this spreadsheet, see the sheet "Spending opportunities."

 Note that for our room for more funding analysis, we ask top charities for rough estimates of their ideal budgets for the next three years. GiveWell-directed funding can fluctuate a lot year-to-year and so our preference is for the organizations to which we direct funding to treat the funding as a multi-year grant to help smooth funding year-to-year and allow for longer-term planning.

 Fungibility Since Malaria Consortium works on a variety of programs, it is possible that receiving additional funds for its SMC work could lead it to reallocate unrestricted funds or other organizational resources (such as time spent fundraising) toward other programs, so that additional dollars donated to Malaria Consortium would not fully support additional SMC work. However, we do not see this as a major concern because we do not believe that Malaria Consortium has substantial unrestricted funding available, and it seems that Malaria Consortium has not allocated substantial unrestricted funding to SMC work in the past (see footnote for details).158 

 

Global need for treatment Malaria Consortium's estimate of its room for more funding for SMC makes certain assumptions about what funding will be available globally for SMC from other major institutional funders. Major funders of SMC have included the Global Fund to fight AIDS, Tuberculosis, and Malaria, the World Bank, and the President's Malaria Initiative (PMI). 

 In 2018, we noted that a large portion of eligible children were likely to not be reached with SMC in 2020 due to lack of funding. In 2019, the projections for 2020 changed significantly.159 Part of this change was additional GiveWell-directed funding for Malaria Consortium, but much of the change was due to additional Global Fund funding allocated to SMC. 

 Malaria Consortium shared the information it had, as of July 2019, about the expected size of funding gaps in 2020 in each of the countries that contain areas eligible for SMC. In short:160

 A total of 31 million children are eligible for SMC. Malaria Consortium did not have information on funding gaps for five of these countries.161 Its estimates cover nine countries with 21.2 million eligible children.162 In the nine countries, Malaria Consortium estimates that 9.1 million eligible children were not covered in 2019 and that this number will fall to 1.9 million in 2020, roughly equivalent to a funding gap of $8.4 million in 2020.163 This is due almost entirely to expected changes in Nigeria. In 2019, Nigeria was by far the largest part of the global funding gap, with 8.0 million out of 11.7 million eligible children not covered by SMC. Malaria Consortium estimates that the gap in Nigeria will be reduced to 1.1 million in 2020, as a result of increased funding from the World Bank, the UK government, the Global Fund, PMI, and Malaria Consortium. Two countries not included in the analysis, Mali and Niger, account for 8.2 million of the 9.6 million eligible children not included in Malaria Consortium's analysis. Malaria Consortium notes for both, "At the start of 2019, scale of SMC implementation had not yet been confirmed, but significant coverage gap is likely. World Bank funding will end in 2019 [and] 2020 funding [is] unclear." The African Leaders Malaria Alliance (ALMA), which tracks funding gaps for malaria interventions, told us that additional funding from the Global Fund for SMC in 2020 was largely a result of "portfolio optimization," i.e. reallocating of funding from countries and activities that spend less than they were allocated (more on this process in footnote).164 2020 is the last year of the current Global Fund three-year funding cycle; Malaria Consortium projects that the 2021-23 Global Fund allocations will be decided over the coming year.165

 Malaria Consortium as an organization We use qualitative assessments of our top charities to inform our funding recommendations. See this page for more information about this process and for our qualitative assessment of Malaria Consortium as an organization.

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GiveWell Proposal 2018-2020 Source Malaria Consortium, GiveWell SMC Cost-Per-Treatment Estimate (2017) Source Malaria Consortium, M&E Plan Nigeria Source Malaria Consortium, Monitoring and evaluation summary Nigeria Source Malaria Consortium, Nigeria SMC evaluation report, 2014 Source Malaria Consortium, Preliminary coverage summary 2017, Burkina Faso, cycle 1 Source Malaria Consortium, Preliminary coverage summary 2017, Burkina Faso, cycle 2 Source Malaria Consortium, Preliminary coverage summary 2017, Chad, cycle 1 (French) Source Malaria Consortium, Preliminary coverage summary 2017, Nigeria, cycle 1 Source Malaria Consortium, Prioritisation Spending Opportunities (2019) Source Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina Source (archive) Malaria Consortium, restricted and unrestricted expenditure analysis 2016 Source Malaria Consortium, sentinel data from Dutsi and Mai'adua Source Malaria Consortium, sentinel site surveillance data in Katsina Source Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation Unpublished Malaria Consortium, SMC presentation host page Source (archive) Malaria Consortium, SMC presentation, May 6, 2014 Source (archive) Malaria Consortium, SMC Report, February 2018 Source Malaria Consortium, Summary Narrative Report 2018 Source Malaria Consortium, Summary of Results for Cycle 1, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 1, Chad 2017 Source Malaria Consortium, Summary of Results for Cycle 1, Nigeria 2017 Source Malaria Consortium, Summary of Results for Cycle 2, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 2, Nigeria 2017 Source Malaria Consortium, Summary of Results for Cycle 3, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 3, Chad 2017 Source Malaria Consortium, Summary of Results for Cycle 3, Nigeria 2017 Source Malaria Consortium, Summary of Results for Cycle 4, Burkina Faso 2017 Source Malaria Consortium, Summary of Results for Cycle 4, Chad 2017 Source Malaria Consortium, Summary of Results for Cycle 4, Nigeria 2017 Source Malaria Consortium, summary of SMC donors Unpublished Malaria Consortium, Summary Update, May 2018 Source Malaria Consortium, SuNMaP Final Report Source Malaria Consortium, Trustees' report and financial statements 2015 Source (archive) Malaria Consortium, Trustees' report and financial statements 2016 Source Malaria Consortium, Trustees' report and financial statements 2017 Source (archive) Malaria Consortium, Trustees' report and financial statements 2018 Source NDiaye et al. 2016 Source (archive) SMC in Burkina Faso: Coverage surveys 2017 Source SMC in Chad: Coverage surveys 2017 Source SMC in Nigeria: Coverage surveys 2017 Source SMC Record Card Template 2016 Source Strachan et al. 2016 Source (archive) Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium Source Summary update - GiveWell/Good Ventures funding for SMC Source Timothy Rubashembusya Trip Report from Burkina Faso, August 2016 Source Wikipedia, "Cluster sampling" Source (archive) World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide" Source (archive) World Health Organization, "Seasonal Malaria Chemoprevention" Source (archive) 1. We had one conversation with Malaria Consortium staff in each of January, February, and March, 2016. GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, August 25, 2016. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, November 23, 2016. GiveWell's non-verbatim summary of a conversation with Malaria Consortium staff, January 18, 2017. GiveWell's non-verbatim summary of a conversation with Malaria Consortium staff, January 19, 2017. GiveWell's non-verbatim summary of a conversation with Malaria Consortium staff, March 24, 2017. GiveWell's non-verbatim summary of a conversation with Diego Moroso, April 25, 2017. Starting in 2017, we deprioritized publishing notes from our conversations with Malaria Consortium. We continued speaking regularly with Malaria Consortium staff in 2017-2018.  2. GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017

  3. "Established in 2003, Malaria Consortium is one of the world’s leading non-profit organisations specialising in the prevention, control and treatment of malaria and other communicable diseases among vulnerable populations.

 Our mission is to improve lives in Africa and Asia through sustainable, evidence-based programmes that combat targeted diseases and promote child and maternal health." Malaria Consortium website, "Who We Are".

  4. "We are currently operating in 9 countries." Malaria Consortium, comments on a draft of this page, October 2019.

  5. Malaria Consortium spent 46,150,000 British pounds from April 1, 2017 to March 31, 2018. See Malaria Consortium, Trustees' report and financial statements 2018, "Total expenditure" "for the year ended 31 March 2018", Pg 17. We used X-RATES to find the USD to GBP as of March 31, 2018: 1.401. Percentage of spending coming from restricted funds calculation: (2,315,000 + 39,763,000) / 46,150,000 British pounds = 0.91. See "Total expenditure" from 2018 and compare "Restricted funds" and "Total funds" columns on Pg 17.  6. "In March 2012, the World Health Organisation (WHO) issued a policy recommendation for a new intervention against Plasmodium falciparum malaria - seasonal malaria chemoprevention (SMC), previously referred to as intermittent preventive treatment in children (IPTc), in children under five years old. SMC is defined as the intermittent administration of full treatment courses of an anti-malarial treatment combination during the malaria season to prevent illness and death from the disease.

 The objective is to maintain therapeutic anti-malarial drug concentrations in the blood throughout the period of greatest risk. This will reduce the incidence of both simple and severe malaria disease and the associated anaemia and result in healthier, stronger children able to develop and grow without the interruption of disease episodes. SMC has been shown to be effective, cost effective and feasible for the prevention of malaria among children in areas where the malaria transmission season is no longer than four months." Malaria Consortium website, "Seasonal Malaria Chemoprevention".

  7. World Health Organization, "Seasonal Malaria Chemoprevention".

  8. World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide", Pg 7.

  9. World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide", Pg 7.

  10. World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide", Pg 8.

  11. World Health Organization, "Seasonal Malaria Chemoprevention: A Field Guide", Pg 9. Malaria Consortium provided the edit to the quotation in response to a draft of this page in October 2017.

  12. "How is SMC delivered? Local announcements each month will inform the community about the date of SMC, which will be delivered by community health workers at pre-arranged locations in the community, or by visiting each household. Health workers will receive appropriate training before the intervention begins and will be supervised by nurses and the district health team."ACCESS-SMC project brochure, Pg 3. Malaria Consortium noted that health workers are also sometimes trained for SMC programs (comment provided in response to a draft of this page in October 2017). For Malaria Consortium's SMC program in Nigeria: "House to house delivery method was the most used approach, as reported by 88.2 percent of the respondents. This was similar across the LGAs [local government areas] though Maiadua had slightly higher numbers receiving through the fixed point delivery approach. The duration spent in receipt of drugs in the home was 20 minutes, half the time spent in receipt of drugs from a fixed point which was 47 minutes. Knowledge of the different types of SMC drugs and dose duration was high at over 80 percent. This highlights house to house delivery of SMC as a quicker and most preferred delivery mechanism by the caregivers. There is need for costing the two delivery mechanisms to assess if home based delivery still remains a cost effective delivery channel." Malaria Consortium, Nigeria SMC evaluation report, 2014, Pg 38. For ACCESS-SMC delivery methods, see the annexes on Pgs 31-70 of ACCESS-SMC multi-country cost analysis, January 2017. Sample quote: "A combination of 6,500 trained community distributors and 355 health facility staff (e.g. nurses and midwives) administered SMC by way of two distribution methods: door-to-door (two-person teams) and at fixed points located at health centers (one-person teams) which were in place to serve primarily as referral centers for sick children and provide SMC to children who were came to the facility. It was estimated that 90% of SMC was distributed by door-to-door teams and 10% was distributed at fixed points. To ensure the acceptability of SMC and high rates of coverage within communities, 3,483 trained community mobilizers sensitized communities on the benefits of SMC prior to and during each distribution cycle." ACCESS-SMC multi-country cost analysis, January 2017, Pg 31. "[Delivery from pre-arranged locations in the community] was for ACCESS only. Now it is mostly [household to household]." Malaria Consortium, comments on a draft of this page, October 2019.  13. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. In response to this review, Malaria Consortium noted that “In most cases this is true. However, due to the number of CDDs/CHWs required to implement SMC we have had to recruit and train other community volunteers who only provide SMC services.” Malaria Consortium emails (unpublished), November 23, 2016. Malaria Consortium, comments on a draft of this page, October 2019.  14. Malaria Consortium emails (unpublished), November 23, 2016. Comments from Malaria Consortium in response to a draft of this page in October 2017.

  15. "This includes coordinating the supervision process during SMC monthly delivery to ensure quality of care by providing supervision tools and supervising the supervisors." Malaria Consortium, comments on a draft of this page, October 2019.

  16. See Figure 1, Pg 8, Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria"

 Malaria Consortium, comments on a draft of this page, October 2019.

  17. See Malaria Consortium, 2018 SMC Coverage Report, Table 1, Pg. 8 for an overview of SMC procedures.

  18. Malaria Consortium emails (unpublished), November 23, 2016.

  19. Comments from Malaria Consortium in response to a draft of this page in October 2017

  20. See Figure 1, Pg 8, Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria". "DOT" stands for "Directly Observed Treatment". "Malaria Consortium, comments on a draft of this page, October 2019.  21. See Figure 1, Pg 8, Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria". "DOT" stands for "Directly Observed Treatment". "How long should the Role Model Caregiver observe each child after giving SMC medicines? a) 10 minutes, b) 15 minutes, c) 30 minutes, d) 1 hour, [Correct answer: C]" Malaria Consortium Quiz Answer Key. "What should the Role Model Caregiver advise the child’s caregiver after giving the first dose of the SMC medicines? a) When to take the second and third dose of amodiaquine (AQ) at home, b) The importance of adherence to giving the two doses of amodiaquine (AQ) home, c) What to do if the child vomits, d) How to mark the SMC Record Card after giving each dose and to bring the card back for the next SMC cycle, e) When to go to the health facility if the child gets a fever or very sick, f) All of above, [Correct Answer: F.]" Malaria Consortium Quiz Answer Key. "The child’s SMC Record Card is very important because: a) It shows the Role Model Caregiver the name and register number of the child, b) The child’s caregiver should always take it with them if they need to go to the health facility, c) It shows how many times the child received the SMC medicines each month, d) It is made of thick paper and is in a plastic packet, e) a, b and c, f) All of the above, [Correct answer: E.]" Malaria Consortium Quiz Answer Key.  22. Malaria Consortium, comments on a draft of this page, October 2019.

  23. "The child’s SMC Record Card is very important because: a) It shows the Role Model Caregiver the name and register number of the child, b) The child’s caregiver should always take it with them if they need to go to the health facility, c) It shows how many times the child received the SMC medicines each month, d) It is made of thick paper and is in a plastic packet, e) a, b and c, f) All of the above, [Correct answer: E.]" Malaria Consortium Quiz Answer Key. We have seen a few versions of templates for "SMC Record Cards." The latest version that we have seen (from 2016) is here: SMC Record Card Template 2016.  24. See Figure 1, Pg 8, Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria". "DOT" stands for "Directly Observed Treatment". "How long should the Role Model Caregiver observe each child after giving SMC medicines? a) 10 minutes, b) 15 minutes, c) 30 minutes, d) 1 hour, [Correct answer: C]" Malaria Consortium Quiz Answer Key. "What should the Role Model Caregiver advise the child’s caregiver after giving the first dose of the SMC medicines? a) When to take the second and third dose of Amodiaquine (AQ) at home, b) The importance of adherence to giving the two doses of Amodiaquine (AQ) home, c) What to do if the child vomits, d) How to mark the SMC Record Card after giving each dose and to bring the card back for the next SMC cycle, e) When to go to the health facility if the child gets a fever or very sick, f) All of above, [Correct Answer: F.]" Malaria Consortium Quiz Answer Key. Malaria Consortium told us that caregivers are able to visit CDs to request additional treatments if their child vomits. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016.  25. Malaria Consortium, comments on a draft of this page, October 2019.

  26. See Figure 1, Pg 8, Malaria Consortium, "Seasonal Malaria Chemoprevention Programme Start-Up Guide, Nigeria".

  27. "Who should NOT get SMC medicines? a) Any child with a fever or who is severely ill, b) Any child who is currently taking a sulfa medication such as co-trimoxazole (Septrin, or Bactrim), c) A child who has received a dose of either Amodiaquine (AQ) and sulfadoxine / pyrimethamine (SP) during the past month, d) A child who is allergic to sulfa medication such as co-trimoxazole, Septrin, or Bactrim, e) A child who is allergic to either Amodiaquine (AQ) and sulfadoxine / pyrimethamine (SP), f) a,b,ande, g) All of the above. [Correct answer is G.]" Malaria Consortium Quiz Answer Key. "What important questions must the Role Model Caregiver ask about each child before giving SMC medicines? a) The child’s age, b) If the child has taken any medicines in the past 28 days, and which ones, c) If the child has any allergies, d) If the child has a fever or is sick, e) a, b, and d, f) All of the above, [Correct answer is F.]" Malaria Consortium Quiz Answer Key. "What should the Role Model Caregiver do if a child has a fever on the day SMC medicines are being given? a) Complete the SMC Referral Form, b) Refer the child to the nearest health facility for a malaria test, c) Complete the SMC Register with the reason for the referral, d) Give the child Coartem, e) Give the child the SMC medicines to treat the fever, f) a, b, and c, g) All of the above, [Correct answer is F.]" Malaria Consortium Quiz Answer Key.  28. Malaria Consortium emails (unpublished), November 23, 2016. Comments from Malaria Consortium in response to a draft of this page in October 2017.

  29. Malaria Consortium, comments on a draft of this page, October 2019.

  30. "SMC medicines come in two colour packets for different age children. What age group should get the medicines in the YELLOW packets? ... [correct answer:] b) 3 to 12 months " Malaria Consortium Quiz Answer Key. "SMC medicines come in two colour packets for different age children. What age group should get the medicines in the BLUE packets? ... [correct answer:] b) 12 to 59 months" Malaria Consortium Quiz Answer Key.  31. "Determining a child’s age 1. Ask the caregiver how old the child is. 2. Ask to see the child’s vaccination card. 3. If the caregiver does not know the child’s age or does not have a vaccination card; ask the caregiver to describe the events when the child was born. (Dry or rainy season, religious celebrations such as Eid or Ramadan, political, or social events). 4. Look for 1 or more of the following milestones for appropriate age category: Most infants younger than 3 months will not be able to: – Hold their head and neck steady when being held upright – Push down with their legs when their feet are on a hard surface – Grab an object in their hand and bring it to their mouth Most children 1 year or older should be able to: – Sit without help – Pull themselves up to standing using a chair or caregiver’s hand – Stand on their own or take a few steps Most children who are older than 5 years should be able to: – Raise their arm over their head to touch their opposite ear – Stand on one foot for 10 seconds or longer – Hop on one foot" From unpublished source, "Field Guide for Training and Service Delivery of Seasonal Malaria Chemoprevention – Nigeria."

  32. "The former includes supporting the selection of community distributors by community leaders according to suggested criteria, sensitization/coordination meeting with traditional and religious leaders, training and involvement of lead mothers in the campaign in Nigeria. The latter includes producing radio and TV spots advertising the campaign, as well as training 'town criers' who announce the passing of the campaign." Malaria Consortium, comments on a draft of this page, October 2019.

  33. "Malaria Consortium notes that there are several layers of supervision that provide spot-check control of how well the administration process is followed: 

There is in general a “proximity supervisory team” (CDs with higher education or literacy skills / experience or a junior health worker) who follow a number of distribution teams (for instance, in Burkina Faso it’s 1 for every 5 CD teams, in Nigeria, 1 for every 3 community drug distributor (CDD) teams). They work 3 to 4 days per cycle. Health workers from one health facility carry out spot-check corrective supervision over all CDs and all supervisors in their catchment area; they work 3 to 4 days per cycle. District health officials carry out supervisory visits over both distributors (to check quality of administration) and supervisors (to check on the quality / frequency of supervision). They work 3 to 4 days per cycle. Regional health officials carry supervisory spot-check visits over all the levels below, to check on the quality of administration and of supervision and provide corrective guidance. They work 2 to 4 days per cycle. National Malaria Control Program (NMCP) supervisors carry out supervisory spot-check visits over all the levels below (as above). They work 3 to 4 days per cycle. Malaria Consortium and partner’s country supervisors / teams carry out spot-check visits (independently or jointly with health authorities, as above). They work 4 days per cycle on supervision and implementation monitoring. AfRO Malaria Consortium and partner staff carry out regular country field visits including spot-check supervision to control all of the above. About 2 visits per country during the SMC round at minimum.The system is quite extensive and well-rehearsed, since it is used across several child survival, mass prevention campaigns. While it is likely that there will be some mistakes at this scale (in particular, age misclassification and eligibility are common issues for all mass campaigns, with no easy, inexpensive solutions around it), major mistakes in administration are likely to be caught. While these have not been quantified, in nearly 10,000 estimated instances of spot-check supervision across the region, anecdotal instances of reported gross negligence in administration of drugs, that could be identified in 2015, were within the hundreds, and promptly corrected: these mostly related to lack of observation of hygiene practices, excessive use of water, ignoring directly observed therapy (DOT) protocols, severe age misclassification, non-respect of observation time, and premature administration of second DOT after vomiting. Most of the other problems identified were, instead, around appropriate administration record-keeping, due to low literacy levels of volunteers in many countries. Please mind that no other mass campaign outside operational research is known to keep detailed individual records of recipients. In most mass campaigns that are known to be safe and effective (measles, polio, pneumonia, vitamin A, deworming, NTD MDAs, just to name a few), only simple tally sheets and sample in-process monitoring are used. Due to the research needs of a new intervention, SMC is being held to extremely high accountability standards as compared to other interventions. It is unlikely that individualized records and these layered levels of supervision are sustainable in the long term and/or at an increased scope, because of the implication on resources needed and costs to local budgets." Malaria Consortium emails (unpublished), November 23, 2016.

  34. Malaria Consortium, comments on a draft of this page, October 2019.

  35. "Budget: 1,694,339.00 (USD)" Malaria Consortium, "Support Scale up of Seasonal Malaria Chemoprevention (SMC)". We also searched the Gates Foundation's grant database to see whether it made any additional grants to Malaria Consortium for SMC work, but only saw this grant (grant page available at Gates Foundation, "Malaria Consortium"). "Malaria Consortium is implementing and assessing the feasibility of a community-based seasonal malaria chemoprevention (SMC) project in Katsina state, northern Nigeria, with funding from the Bill & Melinda Gates Foundation. Following new World Health Organisation policy recommendations on SMC, this project administers full antimalarial treatments during the malaria season in areas with highly seasonal malaria transmission, to prevent illness among children under five." Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. "The project’s objectives are: To design, in consultation with key local stakeholders, an appropriate community-based delivery system for SMC in Katsina state based on formative research, which will review aspects relating to feasibility, community acceptability, effectiveness and cost To launch and execute SMC delivery according to the selected delivery system and collect data on process indicators and costs To evaluate community acceptability, costs and effectiveness of the delivery system for SMC To inform future national and state plans for SMC continuation/ scale up by disseminating findings and sharing experiences with key stakeholders" Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 2. It appears that this project may have also been related to another major (£89 million) project that Malaria Consortium was working on in Nigeria called "Support to National Malaria Programme (SuNMaP)". "Support to National Malaria Programme (SuNMaP) is an £89 million UK aid funded project that works with the government and people of Nigeria to strengthen the national effort to control malaria. The programme began in April 2008 and [ended] in March 2016. Led by Malaria Consortium, SuNMaP was jointly managed by a consortium, including lead partners Health Partners International and GRID Consulting, with nine other implementing partners. SuNMaP was implemented in 10 states across Nigeria, including Anambra, Kano, Niger, Katsina, Ogun, Lagos, Jigawa, Enugu, Kaduna and Yobe.

 SuNMaP worked with the Nigerian government's National Malaria Elimination Programme (NMEP) to harmonise donor efforts and funding agencies around national policies and plans for malaria control. Project targets were aligned with the National Malaria Strategic Plan and Global Malaria Action Plan. The project aimed to improve national, state and local government level capacity for the prevention and treatment of malaria." Malaria Consortium, SuNMaP Final Report, Pg 38.

 "July 2013: Result of SuNMaP study on efficacy of sulphadoxine‐pyrimethamine (SP) for intermittent treatment against malaria in pregnancy published. SuNMaP commences seasonal malaria chemoprevention in Katsina State." Malaria Consortium, SuNMaP Final Report, Pg 16.  36. Malaria Consortium emails (unpublished), November 23, 2016. "Length of project: 2012-2014 (33 months)," Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. "[In 2013], Total number of children covered = 487,354"; "[In 2014], Total number of children covered = 1,112,330," Cost analysis of the seasonal malaria chemoprevention project in Katsina state, Nigeria, Pg 20. However, compare to "A total of 487,353 treatment courses were delivered in two LGAs over three treatment cycles in the first round of SMC representing an average of 115% coverage over the three cycles. In 2014, a total of 1,078,440 treatments were provided across four LGAs over four cycles with an average of 115% administrative coverage." Malaria Consortium, Monitoring and evaluation summary Nigeria, Pg 2. Our understanding is that about 4 treatments were aimed to be delivered per child, suggesting that about 350,000 to 400,000 children were targeted. (487,354 + 1,112,330) / 4 = 399,921, while (487,353 + 1,078,440) / 4 = 391,448.25. "The project also has a number of critical milestones:...85 percent of children targeted receive all courses of SMC in the second round," Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 2. [Under "Process of implementation 2"]: "Selection and training of 2,500 community caregivers (CHWs) and supervisors to deliver the intervention and complete the necessary forms," Slide 13, Malaria Consortium, SMC presentation, May 6, 2014. Note: Malaria Consortium gave us an updated figure of 3,600 CDs, which is cited above. "Intervention area 2013: In consultation with the State MOH and SMCP, four LGAs were chosen Two for implementation of SMC and two for control in 2013 Full implementation in four LGAs in 2014," Slide 9, Malaria Consortium, SMC presentation, May 6, 2014.  37. "The project’s objectives are: ...To inform future national and state plans for SMC continuation/scale up by disseminating findings and sharing experiences with key stakeholders," Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. Strachan et al. 2016 Abstract: "Background: Experience of seasonal malaria chemoprevention (SMC) is growing in the Sahel sub-region of Africa, though there remains insufficient evidence to recommend a standard deployment strategy. In 2012, a project was initiated in Katsina state, northern Nigeria, to design an appropriate and effective community-based delivery approach for SMC, in consultation with local stakeholders. Formative research (FR) was conducted locally to explore the potential feasibility and acceptability of SMC and to highlight information gaps and practical considerations to inform the intervention design. Methods: The FR adopted qualitative methods; 36 in-depth interviews and 18 focus group discussions were conducted across 13 target groups active across the health system and within the community. Analysis followed the ‘framework’ approach. The process for incorporating the FR results into the project design was iterative which was initiated by a week-long ‘intervention design’ workshop with relevant stakeholders. Results: The FR highlighted both supportive and hindering factors to be considered in the intervention design. Malaria control was identified as a community priority, the community health workers were a trusted resource and the local leadership exerted strong influence over household decisions. However, there were perceived challenges with quality of care at both community and health facility levels, referral linkage and supportive supervision were weak, literacy levels lower than anticipated and there was the potential for suspicion of ‘outside’ interventions. There was broad consensus across target groups that community-based SMC drug delivery would better enable a high coverage of beneficiaries and potentially garner wider community support. A mixed approach was recommended, including both community fixed-point and household-to-household SMC delivery. The FR findings were used to inform the overall distribution strategy, mechanisms for integration into the health system, capacity building and training approaches, supportive interventions to strengthen the health system, and the social mobilization strategy. Conclusions: Formative research played a valuable role in exploring local socio-cultural contexts and health system realities. Both opportunities and challenges for the introduction of SMC delivery were highlighted, which were appropriately considered in the design of the project."  38. "UNITAID has awarded up to $67 million to Malaria Consortium to oversee the largest-yet global programme to increase seasonal malaria chemoprevention (SMC) across the Sahel region of Africa, where malaria remains the leading cause of severe illness and mortality in young children...This grant will help increase capacity and reduce prices for SMC products in the seven target countries and is expected to supply an estimated 30 million treatments every year to protect 7.5 million children, preventing around 50,000 deaths." Malaria Consortium, ACCESS-SMC announcement, May 8, 2014. "ACCESS-SMC is a UNITAID-funded project, led by Malaria Consortium in partnership with Catholic Relief Services, which is scaling up access to seasonal malaria chemoprevention (SMC) across the Sahel to save children’s lives. This three year project is supported by London School of Hygiene & Tropical Medicine, Centre de Support de Santé International, Management Sciences for Health, Medicines for Malaria Venture, and Speak Up Africa. It will provide up to 30 million SMC treatments annually to 10 million children less than five years of age [specifically, children ages 3 to 59 months] in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia, potentially averting 49,000 deaths due to malaria." Malaria Consortium, ACCESS-SMC page. "ACCESS-SMC is working with all seven supported National Malaria Control Programs (NMCPs) to create SMC delivery pathways. We are providing support in a range of areas, including planning and management, supply chain, health worker training and communications and social mobilization. The project is also procuring almost 15m doses of SMC drugs in 2015, and up to 30m in 2016. Working together with NMCPs, we will reach 3.3m children in 2015 and up to 6.6m children by 2016 in Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia." ACCESS-SMC website, "The Project". Clarifications around number of children targeted annually from Malaria Consortium emails (unpublished), November 23, 2016. "Malaria Consortium implemented SMC with UNITAID funding under the ACCESS-SMC project between 2015 and 2017 (three SMC rounds), with an original geographical scope encompassing 7 countries (Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia). In 2017, the project focused on just three countries, Burkina Faso, Nigeria and Chad, where both Malaria Consortium and other stakeholders had more difficulties identifying alternative sources of funding (either domestic of international from sources such as the Global Fund, PMI or the World Bank) to transition out of ACCESS-SMC." Malaria Consortium, Summary Update, May 2018, Pg. 1.  39. "UNITAID has awarded up to $67 million to Malaria Consortium to oversee the largest-yet global programme to increase seasonal malaria chemoprevention (SMC) across the Sahel region of Africa, where malaria remains the leading cause of severe illness and mortality in young children." Malaria Consortium, ACCESS-SMC announcement, May 8, 2014. "The original ACCESS-SMC grant was expected to end on August 31st, but Malaria Consortium secured a cost extension up to February 28, 2018, to complete the third season in [Burkina Faso, Nigeria and Chad], and carry out an endline molecular markers’ survey in the seven ACCESS-SMC countries, to track trends in parasite resistance to SMC drugs." Malaria Consortium, Summary Update, May 2018, Pg. 1 40. "Malaria Consortium’s three year project, known as ACCESS SMC, will run across seven African countries: Burkina Faso, Chad, Guinea Conakry, Mali, Niger, Nigeria and The Gambia. ACCESS-SMC will be led by Malaria Consortium, with Catholic Relief Services as the primary sub-grantee. It will be supported by London School of Hygiene & Tropical Medicine, Management Sciences for Health, Medicines for Malaria Venture, Speak Up Africa and Centre de Support en Sante International." Malaria Consortium, ACCESS-SMC announcement, May 8, 2014. "The ACCESS-SMC partnership: Malaria Consortium is leading the ACCESS-SMC project, tracking its impact, managing the procurement of SMC drugs and supporting malaria control programmes to implement SMC in Burkina Faso, Chad and Nigeria. Catholic Relief Services is the lead-subrecipient and contributing to tracking the reach and impact of the project and supporting malaria control programmes to implement SMC in Guinea, Mali, Niger and The Gambia. London School of Hygiene & Tropical Medicine is generating evidence on drug resistance, strengthening pharmacovigilance and measuring SMC’s public health impact. Medicines for Malaria Ventures is supporting manufacturers to develop a child friendly, dispersible formulation and ensuring accurate drug forecasting. Management Sciences for Health is measuring the cost of SMC and working with countries to optimize the SMC supply chain. Speak Up Africa is creating an integrated health communications and advocacy campaign. The complementary nature of the partnership, which includes non-profit and academic institutions, allows substantial geographic reach and ensures that good evidence will guide future SMC implementation." ACCESS-SMC fact sheet, Pg 2.  41. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. "The ACCESS-SMC partnership: Malaria Consortium is leading the ACCESS-SMC project, tracking its impact, managing the procurement of SMC drugs and supporting malaria control programmes to implement SMC in Burkina Faso, Chad and Nigeria. Catholic Relief Services is the lead-subrecipient and contributing to tracking the reach and impact of the project and supporting malaria control programmes to implement SMC in Guinea, Mali, Niger and The Gambia." ACCESS-SMC fact sheet, Pg 2.  42. See Table 7, ACCESS-SMC multi-country cost analysis, January 2017, Pg 19. See "Costs" sheet, GiveWell SMC cost per treatment estimate, November 2017. Malaria Consortium shared the following source with us to help explain its staff structure: ACCESS-SMC, organizational structure.  43. Summary update - GiveWell/Good Ventures funding for SMC:

 "Overall, the comprehensive SMC implementation support in what we call internally 'GiveWell Districts' will target approximately 650,000 children, at an approximate cost estimated at 2.5M USD for 2017 (with some carryover costs in 2018 for operational close-out, data analysis and reporting)." Pg. 4. Nigeria: "Since 2013, Nigeria was supported first by Bill & Melinda Gates Foundation and then through other one-off funding to implement SMC in six Local Government Areas (LGAs) in the States of Katsina and Jigawa. Through the funding provided by GiveWell / Good Ventures, Malaria Consortium reinstated support to these 6 LGAs that did not have any confirmed funding in 2017." Pg. 2. Burkina Faso: "Thanks to large amount of drugs left over from various partners’ activities in 2016, Burkina Faso had drugs enough to cover approximately 360,000 extra children, but no operational costs to do so. Thus, Malaria Consortium through GiveWell / Good Ventures funding has started supporting three districts that had benefited from SMC in previous years, but which had no secured support for 2017, as well as five more new priority districts for SMC." Pg. 2. Guinea Bissau: "The original plan was to support two regions for a total of 80,000 children, and approximately 400,000 dispersible SP+AQ blisters were directed to Guinea Bissau. However, eventually the MoH managed to secure funding for half of this target (one region) through the UNDP, and as a consequence the support in Guinea Bissau will be limited to the region of Gabu in the East of the country, targeting approximately 40,000 children under 5. The drugs that will be left over from the current order will have expiration date beyond 2019, so they will be available for use for a new round in 2018." Pg 3. See also: Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium.

  44. "Two dimensions of support were prioritized under the funding framework provided by Good Ventures through GiveWell recommendations on SMC...Monitoring and evaluation support, specifically though the execution of multiple coverage surveys and enhanced in-process monitoring (including in ACCESS-SMC areas)." Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium, Pg. 1 "[G]aps have been identified in a number of M&E areas, due to a phasing out of support for established activities (such as coverage surveys) and/or because of quality assurance gaps identified during the 2015 and 2016 seasons." Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium, Pg. 3 "GiveWell / Good Ventures funding supported four coverage surveys in Nigeria and Burkina Faso, and three surveys in Chad (after cycles 1, 3 and at the end of the round). As mentioned above, coverage surveys were not carried [out in] Guinea Bissau." Malaria Consortium, Summary Update, May 2018, Pg. 7. "All contracts with independent research institutions were signed in July. To finalize the independent evaluation framework started under ACCESS-SMC, LSHTM was also contracted in the role of independent technical advisory organization, supporting the revision of the evaluation protocols (whose amendments required a revised ethical approval), additional technical supervision of field surveyors, and the analysis and interpretation of results in collaboration with Malaria Consortium technical team." Malaria Consortium, Summary Update, May 2018, Pg. 7. "Seven temporary staff were recruited in Chad and, 43 (one per LGA) Nigeria, in order to improve supervision and monitoring and make sure that administrative data received is reflective or the real distribution process in the field. In addition, in Nigeria, independent monitors piloted in-process monitoring during one cycle." Malaria Consortium, Summary Update, May 2018, Pg. 8. "[Chad] was support[ed] in terms of extra staff (five field officers for which there was not available budget under ACCESS-SMC) and additional budget for supervision logistics." Malaria Consortium, Summary Update, May 2018, Pg. 6. "New SMC child cards (which are normally distributed for multiple years) were printed in 2017, which included a unique identifier of 7 or 8 figures. [...] The cost of reproducing these tools was not fully represented in the UNITAID budget, and not budget expansion was agreed. … [R]esults were mixed, and only in Burkina Faso it appeared that CHWs/volunteers had enough literacy/numeracy to perform the task so that numbers were readable and, mostly, correct. As the difficulties in manual entry (writing) by CHWs became clear in Chad and Nigeria, the exercise was scrapped." Malaria Consortium, Summary Update, May 2018, Pg. 8.  45. Malaria Consortium, Summary Narrative Report 2018:

 “Two key dimensions of support were prioritized in 2018 under the GiveWell-directed funding framework for SMC:...Operational support to SMC implementation in Burkina Faso, Chad and Nigeria.” Pg. 1. Burkina Faso: “Burkina Faso is the third most populous country in terms of SMC eligibility after Nigeria and Niger. Without Malaria Consortium-led SMC implementation in 18 health districts, there would be significant gaps in geographical coverage. GiveWell-directed funding in 2018 helped Malaria Consortium cover nearly 30% of the SMC national needs, targeting just under 900,000 children.” Pg. 2. Chad: “Chad, together with Nigeria, is one of the most underserved countries in terms of SMC support relative to the size of its population. In 2018, thanks to GiveWell-directed funding, 14 health districts were supported by Malaria Consortium, with an estimated population of over 740,000 children.” Pg. 4. Nigeria: “Since 2013, Nigeria was supported first by the Bill & Melinda Gates Foundation and then through other one-off funding to implement SMC in six LGAs in the States of Katsina and Jigawa; subsequently, thanks to funding from Unitaid, the program extended to the whole States of Sokoto and Zamfara (37 LGAs). In 2018, thanks to GiveWell-directed funding, Malaria Consortium continued support to these 43 LGAs in the four states and supported the procurement of SP+AQ in three additional LGAs in Jigawa that had secured funding for distribution from DFID, bringing the total of supported LGAs to 46. The combined effort aimed to provide SMC to approximately 2.3m children.” Pgs. 5-6.  46. “Two key dimensions of support were prioritized in 2018 under the GiveWell-directed funding framework for SMC:...Supervision, monitoring and evaluation support, specifically through enhanced supervision, conducting a range of surveys to determine intervention coverage and the review of the evaluation framework for SMC with a focus on impact assessment.” Malaria Consortium, Summary Narrative Report 2018, Pgs. 1-2.

  47. See this spreadsheet, Sheet "Projected spending 2019 and 2020", Cell B13.

 "In Nigeria, SMC implementation for 1.1 million children is co-funded by the United Kingdom government's Department for International Development and an in-kind contribution from the US President’s Malaria Initiative (PMI). Malaria Consortium is also implementing SMC for an additional 340,000 children in Nigeria with Global Fund funding, bringing the total number of children targeted by Malaria Consortium’s SMC program to just over 6 million." Malaria Consortium, comments on a draft of this page, October 2019.

  48. Malaria Consortium emails (unpublished), November 23, 2016. Work not discussed above includes some work supported by a "one-off" grant "to implement SMC in six LGAs in the States of Katsina and Jigawa." Summary framework of GiveWell / Good Ventures funding toward Malaria Consortium, Pg. 1 [Under "Scale up – plans and possibilities":] "In Nigeria in 2014 (9.2 million children) Malaria Consortium will target 500,000 children in Katsina and Jigawa state (CHAI will also implement in Kano state if funding can be obtained)," Slide 22, Malaria Consortium, SMC presentation, May 6, 2014. "Malaria Consortium has already started working with the Ministry of Health to roll out SMC in Katsina through its management of SuNMaP (the DFID-funded Support for the National Malaria Programme) and with support from the Bill & Melinda Gates Foundation. SuNMaP will also support the roll out of SMC across Jigawa state and Malaria Consortium has plans to extend the activity to additional states in due course." Malaria Consortium website, "Seasonal Malaria Chemoprevention".  49. See this spreadsheet, Sheet "Past spending by category, Jan-Dec 2018."

 The ACCESS-SMC project ended in early 2018, so our understanding is that this spending includes the majority of costs to operate Malaria Consortium's SMC programs in its targeted areas for the remainder of 2018. "The original ACCESS-SMC grant was expected to end on August 31st [of 2017], but Malaria Consortium secured a cost extension up to February 28, 2018, to complete the third season in [Burkina Faso, Nigeria and Chad], and carry out an endline molecular markers’ survey in the seven ACCESS-SMC countries, to track trends in parasite resistance to SMC drugs." Malaria Consortium, Summary Update, May 2018, Pg. 1.

 In addition to GiveWell-directed funds, Malaria Consortium used funding from two other sources to operate its SMC programs in 2018:

 $502,328 from the UK government's Department for International Development (DFID) for SMC implementation targeting approximately 236,000 children in Jigawa State, Nigeria $64,776 from the International Federation of Red Cross and Red Crescent Societies (IFRC) for pre-implementation activities, including planning meetings and developing training materials, in Sokoto State and Zamfara State, Nigeria "For the 2018 SMC campaign, Malaria Consortium used the following non-GiveWell-directed funding:…GBP 385,457…from DIFID to support SMC implementation in Jigawa state (approx. 236,000 children), Nigeria. Using an average historical exchange rate of 1.3032, this converts to USD 502,328…[and] USD 64,776 from the International Federation of Red Cross and Red Crescent Societies (IFRC)…used to support pre-implementation activities such planning meetings and development of training materials in Sokoto and Zamfara states, Nigeria." Email from Christian Rassi, Malaria Consortium SMC Director, June 27, 2019

  50. See this spreadsheet, Sheet "Past spending by category, Jan-Dec 2018."

  51. See this spreadsheet, Sheet "Projected spending 2019 and 2020."

  52. See this spreadsheet, Sheet "Projected spending 2019 and 2020."

  53. Cost analysis of the seasonal malaria chemoprevention project in Katsina state, Nigeria. For example, see Tables 4 and 5, Pgs 20-21.

  54. In 2016, the breakdown of direct costs for the ACCESS-SMC program was: 37% to procuring SMC drugs, 37% to delivery of drugs, 16% to staff (including staff at partner organizations), 5% to "direct common costs" (we're not sure what this refers to), and the remaining 5% to a variety of smaller activities. ACCESS-SMC, 2016 direct costs

  55. Between May 2017 and February 2018, Malaria Consortium spent about $3.8 million of the about $5 million in GiveWell-directed funds that it had received at that time. We note that these funds complemented funding from the ACCESS-SMC grant and are not representative of the full cost breakdown of Malaria Consortium's SMC work in 2017. "The original ACCESS-SMC grant was expected to end on August 31st [2017], but Malaria Consortium secured a cost extension up to February 28, 2018, to complete the third season in [Burkina Faso, Nigeria and Chad], and carry out an endline molecular markers’ survey in the seven ACCESS-SMC countries, to track trends in parasite resistance to SMC drugs." Malaria Consortium, Summary Update, May 2018, Pg. 1.

 Of the $3.8 million, Malaria Consortium spent about $2 million (54%) on SMC delivery (excluding drug procurement and delivery), about $0.7 million (19%) on monitoring, about $0.5 million (14%) on drug procurement and delivery, and about $0.5 million (13%) on management, coordination, and overhead costs. See this spreadsheet, Sheet "Past spending by category, May 2017 - Feb 2018."

  56. Diego Moroso, Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, August 14, 2017. Malaria Consortium, comments on a draft of this page, October 2019.

  57. Some additional details on this activity: "All drugs procurement is centralized at our Kampala office for all countries. We require countries to carry out a revised quantification every year based on consumptions and stocks from previous years, consolidate orders, recruit procurement agent, negotiate pricing points with Guilin (and in the future, more pharma companies we hope), we monitor production and shipment schedules and make sure country teams are aware of when drugs come / delays, etc. Countries are responsible for providing us with all the relevant import requirements to make sure that all documentation is ready when drugs arrive. They then work out with local clearing agents the custom procedures, tax waivers, etc, and proceed with whatever logistics options / approaches are relevant in their countries (from direct delivery to peripheral health units as in Nigeria, to mixed approaches involving MoH storage and MC / CRS transport, to full contracting with MoH-mandated central pharmacy – depends on context)." Diego Moroso, Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, August 14, 2017. Malaria Consortium's head office is now located in the UK. Malaria Consortium, comments on a draft of this page, October 2019.  58. This may include "training materials, monitoring & evaluation forms, bags, t-shirts etc. used by CDs, water and cups for SMC administration." Malaria Consortium, comments on a draft of this page, October 2019.

  59. Some additional details on this activity: "Malaria Consortium developed all original training material for ACCESS-SMC [...] We could say that now the materials are pretty settled, with only minor changes / improvement happening yearly or less, based on experience from the field. We co-organize central trainings with [National Malaria Control Programs], and we then support and oversee cascade trainings (always in joint MC/NMCP teams – CRS teams in former CRS countries under ACCESS-SMC)." Diego Moroso, Regional Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, August 14, 2017. "We do continue to revise tools – mainly with a view to simplifying them, adapting to changing guidelines and harmonizing with other implementers." Malaria Consortium, comments on a draft of this page, October 2019.  60. See this spreadsheet, sheet "Results," rows 157-160. These averages include figures from Burkina Faso, Chad, and Nigeria in 2017 and Burkina Faso and Nigeria in 2018, weighted by target population. In 2018, Chad did not report on the number of cycles received per child. 

  61. See this spreadsheet, sheet "Results," cell E117.

  62. Malaria Consortium, comments on a draft of this page, October 2017

  63. For example, see: 

"Malaria is still a serious public health concern in Nigeria, with fevers presumed to be malaria accounting for 60 percent of outpatient visits to health facilities, 30 percent of childhood deaths, 25 percent of deaths in children under one year and 11 percent of maternal deaths. In northern Nigeria, where malaria transmission is highly seasonal, malaria prevalence is also comparatively higher than other areas during the rainy seasons. The implementation of SMC in Katsina is specifically intended to reduce mortality in children under five living in areas with seasonal malaria, and strengthen health systems at the state and national levels." Malaria Consortium, Project Brief: Seasonal malaria chemoprevention, Katsina, Pg 1. Under "Why Katsina State" in Malaria Consortium, SMC presentation, May 6, 2014: "Katsina State is within the Sahel Region; rainy season and peak malaria incidence from July to October 2012 estimated population of 6,916,641 1,383,328 under-5 years 600,281 cases of malaria (2008) 4,103 malaria related deathsKatsina overall under-5 mortality rate 180 per 1,000 live births Also, Malaria Consortium told us that “eligible districts are established by the National Malaria Programmes in the countries applying the WHO rainy season seasonality rules.” Malaria Consortium emails (unpublished), November 23, 2016.  64. For a discussion of these two methods, see Malaria Consortium, 2018 SMC Coverage Report, Pgs. 10-12.

  65. "Administrative data is obtained from routine monitoring forms used by drug distributors, often referred to as Tally Sheets, on which treatments administered are recorded...Coverage is calculated by dividing the total number of treatments provided in a given cycle by the target population of children between 3 and 59 months in a given implementation area." Malaria Consortium, 2018 SMC Coverage Report, Pg. 10. 2018 methodology: "In all areas where Malaria Consortium implemented SMC in 2018, Tally Sheets were completed by drug distributors, recording doses administered and fully ingested by eligible children, disaggregated by age and sex. SMC treatments administered by health workers to children who were referred to a health facility with fever and tested negative for malaria were also recorded. Supervisors and facility in-charges then compiled information from the Tally Sheets into Daily Summary Forms and SMC End-of-Cycle Reports. Information from End-of-Cycle Reports were collected and compiled, typically by dedicated monitoring and evaluation (M&E) staff at district and/or Local Government Area (LGA) level. In Burkina Faso and Chad, district-level data were obtained by Malaria Consortium and compiled into a Microsoft Excel spreadsheet. In Nigeria, LGA-level data were compiled by Malaria Consortium staff at state level and entered into Magpi, an electronic data collection platform. Treatments provided were divided by official target population figures provided by state authorities to calculate the proportion of eligible children in a given intervention area that received Day 1 treatment from a drug distributor or health worker as part of the 2018 SMC campaign for each cycle." Malaria Consortium, 2018 SMC Coverage Report, Pg. 12. An example of a tally sheet can be found here: Malaria Consortium, 2018 SMC Tally Sheet  66. "Coverage surveys...aim to retrospectively determine coverage by surveying caregivers of eligible children and asking them if their children received SMC treatment during the previous cycle or over the course of that year’s SMC round." Malaria Consortium, 2018 SMC Coverage Report, Pg. 11.

  67. "Where possible, responses regarding treatments received were verified by checking household markings left by drug distributors on the household wall or door, inspecting SMC Child Record Cards and asking to see empty SPAQ blisters." Malaria Consortium, 2018 SMC Coverage Report, Pg. 17.

  68. These may include questions about caregivers' understanding of the SMC program and CDs' and caregivers' adherence to program procedures. An example of a survey questionnaire can be found here: Malaria Consortium, 2018 example end-of-cycle questionnaire

  69. For example, in 2018, administrative coverage estimates found average coverage of above 100% in all three countries where Malaria Consortium delivered SMC. See this spreadsheet, sheet "Source: 2018 target population for SMC," cells L5-7. In contrast, 2018 coverage survey estimates found average coverage ranging from 70% in Nigeria to 89% in Burkina Faso. See this spreadsheet, sheet "Results," cells B117-E117.

 Malaria Consortium notes: "As a result of the numerous limitations of using administrative data to measure coverage, it is possible (and not uncommon) to achieve coverage of well over 100%." Malaria Consortium, 2018 SMC Coverage Report, Pg. 11.

  70. GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, November 23, 2016.

  71. Malaria Consortium, comments on a draft of this page, October 2017

  72. "Migrant populations are indeed likely to contribute to discrepancies, though this could go both ways: it is equally possible that they move into the SMC implementation area after the treatment period and are captured by the surveys." Malaria Consortium, comments on a draft of this page, October 2019

  73. "The accuracy of data recording further depends on the drug distributors’ ability to correctly determine eligibility, mainly with regard to the age range. It is possible that drug distributors administer drugs to ineligible children but record these as treatment provided to eligible children." Malaria Consortium, 2018 SMC Coverage Report, Pgs. 10-11. "This contributes to discrepancies between the 2 types of data because treatments provided to over-5s would not be recorded as such on tally sheets (so inflating the number of treatments), whereas coverage surveys would distinguish between age groups." Malaria Consortium, comments on a draft of this page, October 2019 Malaria Consortium's coverage surveys report on the percentage of ineligible children who receive SMC treatment. In 2018, the average percentage of children above the age of five who received treatment per cycle ranged from 19% in Burkina Faso to 84% in Chad. See this spreadsheet, sheet "Results," row 126. For estimates of the percentage of children of ineligible age who received SMC treatment in previous years, see this spreadsheet, sheet "Results."  74. "The accuracy of coverage figures obtained using administrative data is compromised both by the accuracy of the numerator and the denominator...With regard to the denominator used to calculate coverage from administrative data, accuracy is compromised due to the use of inaccurate target population estimates. These are based on census data that is frequently outdated, adjusted by estimated population growth factors. They also typically do not adequately reflect population movements, for example due to migration or internal displacement." Malaria Consortium, 2018 SMC Coverage Report, Pgs. 10-11.

  75. GiveWell's non-verbatim summary of a conversation with Malaria Consortium Staff, November 23, 2016 "In 2017, due to concern about methodology and especially linked to potential recall bias, we reorganized the framework as a series of 4 surveys post each cycle." Diego Moroso, Regional Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, May 8, 2018. "In previous years, only one coverage survey was conducted at the end of the annual SMC round to measure coverage achieved by Malaria Consortium’s SMC program. This meant that administrative data had to be relied on to gauge coverage while the campaign was ongoing. As gathering and compiling administrative data is a time-consuming process, this limited the program’s capacity to take evidence-based corrective action and make adaptations to the intervention during the campaign. For this reason, Malaria Consortium decided to implement coverage surveys following each of the four SMC cycles in each of the three implementation countries." Malaria Consortium, 2018 SMC Coverage Report, Pg. 12.  76. Results from both post-cycle and post-round surveys in 2017 and 2018 are in this spreadsheet, sheet "Results."

  77. The main sources for our understanding of the coverage survey methodology are: 

 ACCESS-SMC Coverage Survey Report: Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation. GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017. ACCESS-SMC monitoring and evaluation plan: Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pgs 13-14. 2017 coverage surveys: SMC in Nigeria: Coverage surveys 2017, SMC in Chad: Coverage surveys 2017, and SMC in Burkina Faso: Coverage surveys 2017 2018: coverage surveys: Malaria Consortium, 2018 SMC Coverage Report, Malaria Consortium, 2018 end-of-round survey report, Burkina Faso, Malaria Consortium, 2018 end-of-round survey report, Chad, Malaria Consortium, 2018 end-of-round survey report, Nigeria  78. “In Nigeria, EoC surveys were coordinated and supervised by Malaria Consortium, whereas in Burkina Faso and Chad, external consultants were contracted for this purpose.” Malaria Consortium, 2018 SMC Coverage Report, Pg. 13. "Data collectors were recruited and trained by Malaria Consortium staff in Nigeria and by external consultants contracted for this purpose in Burkina Faso and Chad...In Nigeria, data were analyzed by Malaria Consortium staff using STATA 14...In Burkina Faso and Chad, the consultants analyzed data and reported results independently." Malaria Consortium, 2018 SMC Coverage Report, Pg. 17.  79. "Post-cycle surveys using lot quality assurance sampling (LQAS) methods were conducted following Cycles 1, 2 and 3...LQAS surveys are a comparatively simple and operationally feasible way of collecting data from randomly selected supervision areas and are designed to assess whether or not the minimum expected coverage of 80% was achieved. Aggregating data at the national or state level results in a reasonably precise measure of coverage." Malaria Consortium, Summary Narrative Report 2018, Pg. 8. Malaria Consortium told us that it hopes this approach will deal with three issues that arose when conducting a full coverage survey after each cycle: "the amount of resources required for each cycle's evaluation is very large (large teams of surveyors, complex logistics, difficult travel conditions, high costs);" "the short interval between cycles (4 weeks), which makes for nearly 4 solid months of surveying under difficult conditions;" "the time needed to process the data has been too protracted to allow for nimble decision making in the field."  Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, May 8, 2018 

 80. See this spreadsheet, sheet "Methods," columns F and H.

  81. Burkina Faso: Post-cycle surveys used sample sizes ranging from 4,002 to 8,909 children. See this spreadsheet, sheet "Source: 2018 post-cycle coverage," cells C5-7. The post-round survey used a sample size of 1,828 children. Malaria Consortium, 2018 end-of-round survey report, Burkina Faso, Pg. 11, Table 3. Chad: Malaria Consortium reports that 1,482 households were surveyed per cycle. "This approach resulted in a total sample of 1,482 per cycle" Malaria Consortium, 2018 SMC Coverage Report, Pg. 15. The post-round survey used a sample size of 4,726 children. Malaria Consortium, 2018 end-of-round survey report, Chad, Pg. 22, Table 9a. Nigeria: Post-cycle surveys used sample sizes ranging from 24,206 to 38,450 children. See this spreadsheet, sheet "Source: 2018 post-cycle coverage," cells C35-37. The post-round survey used a sample size of 8,061 children. Malaria Consortium, 2018 end-of-round survey report, Nigeria, Pg. 18, Table 3. For coverage rates and confidence intervals generated by aggregating data from all SAs in 2018, see this spreadsheet, sheet "Source: 2018 post-cycle coverage," column D.  82. "An LQAS framework can be done quickly by personnel with basic training, using low inputs. Results from such enquiries can be generated in real­ time through less complex analysis. In other words, LQAS is a valid sampling approach for rapid surveys, which offers managers action ­oriented information on the spot...The proposed monitoring framework combines the advantages of both approaches. The plan would be to carry out a LQAS survey at the end of Cycles 1, 2 and 3...and then to deploy a full coverage survey at the end of Cycle 4. This methodology offers the advantage of 1) quick classification of defined supervision areas in real time, to address implementation issues as they arise and improve performance, and 2) the opportunity for independent surveyors to assess coverage with an acceptable margin of error." Diego Moroso, Regional Project Director for ACCESS-SMC at Malaria Consortium, email to GiveWell, May 8, 2018. Malaria Consortium told us that the biggest difference between the LQAS method it is using in 2018 and prior coverage surveys is the length of the questionnaire (~10% the number of questions as before). Diego Moroso, Malaria Consortium Global Programme Director - SMC, conversation with GiveWell, April 8, 2018.  83. Malaria Consortium, Summary Narrative Report 2018, Pg. 9:

 "Experience with this methodology was mixed in the different countries, reflecting the novelty of the approach and the fact that many members of Malaria Consortium’s SMC M&E team joined only in mid-2018 due to recruitment challenges. However, it also reflects different implementation strategies in different countries." Burkina Faso: "Data analysis was more time-consuming than anticipated, which led to delays in providing comprehensive reports. However, key results such as reach and treatment of children over-five were provided in time to inform improvements in subsequent cycles." Chad: "The quality of outputs from some of the selected research firms was unsatisfactory and required Malaria Consortium to carry out additional, time-consuming analyses. Despite outsourcing post-cycle surveys to different firms each cycle, deliverables did not meet our expectations, leading us to conclude that local research firms do not have the required capacity and expertise to conduct complex evaluations of coverage and quality."  84. "The overall approach of LQAS surveys following Cycles 1 to 3 and more comprehensive post-round coverage surveys will be maintained in 2019. However, we will continue to strengthen the methods and tools." Malaria Consortium, Summary Narrative Report 2018, Pg. 9.

  85. "The surveys were designed to meet the following objectives: To assess coverage in terms of compounds/households visited, Day 1 SPAQ treatments administered and full course of SPAQ received...To assess adherence to SMC guidelines...Provide timely insights on implementation issues requiring adaptations in subsequent cycles." Malaria Consortium, 2018 SMC Coverage Report, Pg. 14. An example of a post-cycle survey questionnaire can be found here: Malaria Consortium, 2018 example end-of-cycle questionnaire. Questions designed to identify implementation issues include questions about eligibility for treatment ("How many of these children were >5 to 10 years of age AND treated with SMC when the CHWs visited the household?" Pg. 40.) and about CDs' adherence to directly observed therapy ("Can you confirm if the CHW/distributor did administer the first dose to the child?" Pg. 43.). In 2018, post-cycle results showed high coverage of ineligible children, prompting Malaria Consortium to highlight this issue with CDs. Malaria Consortium believes that this may have contributed to the reduction in ineligible children treated over the course of the SMC campaign in Jigawa State and Sokoto State, Nigeria, where coverage of ineligible children dropped from 6.2% in cycle 1 to 0.9% in cycle 3 and from 14.7% in cycle 1 to 9.0% in cycle 3, respectively. "The issue of determining age eligibility was highlighted as a focus during the supervisor training. As a result of the trends found in EoC surveys, supervisors were also asked to emphasize the importance of adhering to the SMC guidelines in monthly interactions with drug distributors. The diminishing trend of coverage of children over five in Jigawa and Sokoto may indicate that the constant reminders were effective." Malaria Consortium, 2018 SMC Coverage Report, Pg. 28.  86. “All EoR surveys were conducted by local research firms selected by Malaria Consortium through a competitive bidding process:…Burkina Faso: Institut de Sciences & Techniques (INSTech)…Chad: Conseil en Sciences Sociales Communication Interculturelle et Marketing (COSSOCIM)...Nigeria: Oxford Policy Management (OPM).” Malaria Consortium, 2018 SMC Coverage Report, Pg. 17.

  87. Table 2, ACCESS-SMC M&E strategy, November 2015, Pg 10: "Responsible partner" for the "Project indicator" "Population coverage" is "LSHTM."

  88. "Two-stage cluster sample surveys in each of the seven countries were undertaken to provide estimates of the proportion of eligible children who received 0,1,2,3 or 4 SMC treatments, representative of the areas where SMC is implemented." Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation, Pg 10. "EoR surveys used a more comprehensive questionnaire and sampling methods designed to return results that were representative of the areas where Malaria Consortium implemented SMC in 2018 in Burkina Faso and Chad, and in the case of Nigeria, the LGAs covered by Malaria Consortium in each of the four states covered by Malaria Consortium." Malaria Consortium, 2018 SMC Coverage Report, Pg. 13.  89. See this spreadsheet, sheet "Methods," column D.

  90. See this spreadsheet, sheet "Methods," column F. In the coverage surveys conducted by LSHTM, villages are selected using probability proportional to size sampling. "Sampling for the coverage survey: From a list of all communities (villages or census enumeration areas) in the areas that received SMC, about 60 communities will be selected with PPES [Probability proportional to estimated size]. In each selected community, a sample of an approximately constant number of households will be made from village lists or using area sampling. All eligible children resident in the household at the time of the survey should be included. If any children are away or the parent is not present to interview, a call-back visit should be arranged before documenting a non-response for that child or household." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 14. Because each country's post-round survey was conducted by a different research firm in 2018, the methodology for selecting villages is more variable.  91. See this spreadsheet, sheet "Methods," column H. In the coverage surveys conducted by LSHTM, researchers make a map of the village on a computer tablet and divide it into segments. Then, the tablet automatically chooses a segment at random, and the interviewers are instructed to visit every household in that segment. "The SMC coverage surveys use area sampling to select participants within villages. In area sampling, researchers make a map of the village and divide it into segments, then the tablet automatically chooses a segment at random, and the interviewers include every household in that segment. This method, known as compact segment sampling, involves no subjectivity on the part of the researchers, an issue which can be an important source of bias in coverage surveys. GPS tracking of the tablets provides the location of each household, allowing supervisors to check exactly where the survey teams went. In most countries, villages were selected using probability proportional to size sampling with approximately 50 clusters representing the entire area where ACCESS-SMC was operating. The exception is Niger, in which the researchers performed separate surveys in four representative regions, because the country is too large for them to conduct surveys everywhere." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, pgs. 3-4. Because each country's post-round survey was conducted by a different research firm in 2018, the methodology for selecting households is more variable.  92. "Generally, interviews were conducted with caregivers of children aged 3 to 59 months...The EoR surveys aimed to assess coverage defined as the proportion of eligible children that received SMC treatment during each of the four monthly cycles of the 2018 SMC campaign." Malaria Consortium, 2018 SMC Coverage Report, Pg. 17.

  93. Our understanding is that CDs are expected to record the first dose of each cycle and the date they gave the dose on a family's record card and that the family is expected to record all other doses. We have seen a few versions of templates for SMC record cards. The latest version that we have seen (from 2016) is here: SMC Record Card Template 2016.  "Does the child have an SMC card? (Yes or No)...Ask to see blister: present? (Y or N)...Are there tablets remaining in the blister?" Malaria Consortium, 2018 end-of-round survey report, Nigeria, Pgs. 54-57.  94. "SMC record cards greatly improve accuracy. However, caregivers do not always retain the cards; in these cases caregiver recall is the only source of information. In addition, SMC record cards are not always fully completed by health workers, meaning that the cards are not necessarily reliable. To mitigate the problem of unreliability, ACCESS-SMC researchers ask the caregiver to remember the number of treatments their child had without looking at the record card, then check the caregiver's answers against the card. Agreement has been generally good but where there is a discrepancy the interviewer tries to resolve this; if this cannot be done, the number of treatments indicated on the card is used unless the caregiver states a larger number, in which case the caregiver’s report is used, as it is known that cards can be under-completed." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 5

  95. "In 2018, we only reported self-reported coverage. No adjustments/reconciliations were made. Data on SMC card retention and coverage according to SMC cards is available...but we believe that due to low retention rates, self-reported coverage is the most meaningful indicator." Malaria Consortium, comments on a draft of this page, October 2019

  96. Example questions are from: Malaria Consortium, 2018 end-of-round survey report, Nigeria, Pgs. 52-64.

  97. "During the various coverage surveys of SPC 2017, the data collection team did not encounter any major problems. But it must be remembered that the difficulty encountered by the data collection team is mainly related to the recording of GPS geographical coordinates of households visited which did not work as it should. This GPS capture difficulty is apparently dependent on the DHARMA application. In addition to this problem, the DHARMA application seems to be slow with regard to the internet connection which does not facilitate the sending of data as for the iForm application." SMC in Chad: Coverage surveys 2017, Pg. 42, translated from French. "During the training for cycle 1 the field workers were trained with i-Form builder, the training for cycles 2-4 were based on Dharma. The enumerators found this software easier to use, however there were some problems with configuring the GPS, and difficulties in uploading data." SMC in Nigeria: Coverage surveys 2017, Pg. 17  98. SMC in Burkina Faso: Coverage surveys 2017, Pg. 10

  99. "Now move outside and find a spot with clear vision of the sky (no roofs, no trees), and capture GPS coordinates." Malaria Consortium, 2018 end-of-round survey report, Nigeria, Pg. 60. "Exit the concession, make sure there is no obstacle between you and the sky, and then collect the GPS coordinates." Malaria Consortium, 2018 end-of-round survey report, Chad, Pg. 106, translated from French.  100. "In Burkina Faso, INSTech collected data using an Android app. Anonymized data were shared with Malaria Consortium. COSSOCIM in Chad and OPM in Nigeria collected and shared data with Malaria Consortium using MagPi." Malaria Consortium, 2018 SMC Coverage Report, Pg. 19.

  101. See this spreadsheet, sheet "Methods," column N.

  102. GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 4

  103. Number of eligible children: (68+31+5)/(68+1+6+31+1+1+5+2) = 90.4%, SMC in Nigeria: Coverage surveys 2017, Pg. 41 Number of children treated: (40+43+16+4)/(40+3+3+43+1+2+16+1+1+1+4) = 89.6%, SMC in Nigeria: Coverage surveys 2017, Pg. 41  104. "Security problems in parts of Mali and Niger prevented access to some districts, this may have led to coverage overall being [over]estimated as it is possible that coverage was poorer in those areas", Malaria Consortium, SMC Coverage in Seven West African Countries 2015-16: ACCESS-SMC Evaluation, Pg. 28. "In Sokoto...One LGA could not be surveyed because of security problems", Malaria Consortium, Summary of Results for Cycle 1, Nigeria 2017, Pg. 1.  105. "One village could not be visited, hence there were no interviews were attempted there", Malaria Consortium, Summary of Results for Cycle 2, Burkina Faso 2017 Pg. 1. "One village could not be visited in Mandelia district due to security concerns in the area, hence there were no interviews were attempted there", Malaria Consortium, Summary of Results for Cycle 3, Chad 2017 Pg. 1.  106. "Overall, a total sample size of 4120 was planned, in the end, a completion of 4090 interviews (99% completion rate) was achieved across the sampled compounds spread across the states: Jigawa, 598; Katsina, 796; Sokoto, 1594 and Zamfara, 1102. Based on security challenges, two communities in Zamfara were exempted." Malaria Consortium, 2018 end-of-round survey report, Nigeria, Pg. 17.

  107. "Chad: The quality of outputs from some of the selected research firms was unsatisfactory and required Malaria Consortium to carry out additional, time-consuming analyses. Despite outsourcing post-cycle surveys to different firms each cycle, deliverables did not meet our expectations, leading us to conclude that local research firms do not have the required capacity and expertise to conduct complex evaluations of coverage and quality." Malaria Consortium, Summary Narrative Report 2018, Pg. 9.

  108. "It is likely that 2019 surveys will be conducted under the direct supervision of Malaria Consortium M&E staff." Malaria Consortium, Summary Narrative Report 2018, Pg. 9.

  109. "For example, in Chad...finding an external firm to coordinate the EoR survey took much longer than expected, resulting in the survey only being conducted in January 2019, several months after the end of the 2018 SMC round. This is much later than recommended for coverage surveys and increases the risk of recall bias." Malaria Consortium, 2018 SMC Coverage Report, Pg. 20.

  110. "In 2018, post-cycle coverage was found to be consistently above 90%, often hovering very close to 100% in all states. However, post-cycle survey results should be interpreted with caution, as several methodological issues were documented and there were concerns over researchers being recruited from among state-level health authority staff. The post-round coverage survey found generally lower coverage figures, ranging from 92% in Katsina to 95% in Jigawa, which is likely a better reflection of actual coverage." Malaria Consortium, Summary Narrative Report 2018, Pgs. 7-8. "The main challenge related to researchers being selected by political LGA authorities. This increases safeguarding risk and may introduce bias because state authorities have a vested interest in reporting positive implementation results. Another limitation arises from researchers’ familiarity with implementation plans. If frontline implementers focus on “easy-to-reach” areas within a supervision area (the unit of randomization) and researchers, aware of implementers’ activities, simply follow in their footsteps, this may lead to an overestimation of coverage." Malaria Consortium, Summary Narrative Report 2018, Pg. 9. "In Nigeria, EoC surveys were carried out by data collectors recruited through state- or LGA-level health authorities, which raises concerns about the impartiality of data collectors, as their employers would have a stake in implementing a successful SMC campaign. There were also concerns that the data collectors, being familiar with the SMC campaign, may have selected villages they knew had been covered by drug distributors." Malaria Consortium, 2018 SMC Coverage Report, Pg. 20. "To note: there is no evidence that this actually happened, but we discussed this as a possible limitation in the report." Malaria Consortium, comments on a draft of this page, October 2019.  111. See this spreadsheet, sheet "Methods," column P, and sheet "Results," rows 73 and 127.

  112. In Burkina Faso in 2017, blister packs were retained in 24%, 56%, and 59% of cases in cycles 1, 2, and 3. Malaria Consortium, Summary of Results for Cycle 1, Burkina Faso 2017 Pg. 2; Malaria Consortium, Summary of Results for Cycle 2, Burkina Faso 2017 Pg. 3; Malaria Consortium, Summary of Results for Cycle 3, Burkina Faso 2017 Pg. 3. In Chad in 2017, blister packs were retained in 14% and 32% of cases in cycles 1 and 3. Malaria Consortium, Summary of Results for Cycle 1, Chad 2017 Pg. 3; Malaria Consortium, Summary of Results for Cycle 3, Chad 2017, Pg. 3. In Nigeria in 2017, blister packs were retained in 100% of cases in cycles 2 and 3, though we have not vetted these figures. Malaria Consortium, Summary of Results for Cycle 2, Nigeria 2017 Pg. 3; Malaria Consortium, Summary of Results for Cycle 3, Nigeria 2017, Pg. 3.  113. "The 2018 surveys did measure blister pack retention, but we did not report this in the summary report. We believe that given the low retention rates, self-reported coverage is more meaningful." Malaria Consortium, comments on a draft of this page, October 2019

  114. We have not seen a coverage survey from Malaria Consortium's program in Guinea-Bissau in 2017. We do not view this as a major limitation, as only a small portion of Malaria Consortium's spending in 2017 went to this program. See this spreadsheet, Sheet "Past spending by category, May 2017-Feb 2018," row 12. 

  115. See this spreadsheet, Sheet "Per-year analysis," cells F11-14.

  116. See this spreadsheet, sheet "Results," cells B157-B160.

  117. See this spreadsheet, sheet "Results," rows 113-116. The downward trend in these coverage rates is largely due to results from Nigeria, where coverage dropped from 82% in cycle 1 to 57% in cycle 4. Coverage rates were relatively consistent across cycles in Burkina Faso and Chad. 

  118. See this spreadsheet, sheet "Results," cells B99 and B147. 

  119. For 2018 post-cycle and post-round coverage estimates, we find a difference of 5.2% in Burkina Faso, 5.1% in Chad, and 19.7% in Nigeria. See this spreadsheet, sheet "Results," cells B141-D141.

  120. Malaria Consortium proposes three possible explanations for the inconsistent results from Nigeria: "Again, the EoR survey found slightly lower coverage in Nigeria...This difference could be a result of recall bias, data collectors’ bias or it could be due to questionnaire design." Malaria Consortium, 2018 SMC Coverage Report, Pgs. 22-23.

 Of these, it appears that bias during data collection may have contributed most to skewing post-cycle results upward:

 "In 2018, post-cycle coverage was found to be consistently above 90%, often hovering very close to 100% in all states. However, post-cycle survey results should be interpreted with caution, as several methodological issues were documented and there were concerns over researchers being recruited from among state-level health authority staff. The post-round coverage survey found generally lower coverage figures, ranging from 92% in Katsina to 95% in Jigawa, which is likely a better reflection of actual coverage." Malaria Consortium, Summary Narrative Report 2018, Pgs. 7-8. "The main challenge related to researchers being selected by political LGA authorities. This increases safeguarding risk and may introduce bias because state authorities have a vested interest in reporting positive implementation results. Another limitation arises from researchers’ familiarity with implementation plans. If frontline implementers focus on “easy-to-reach” areas within a supervision area (the unit of randomization) and researchers, aware of implementers’ activities, simply follow in their footsteps, this may lead to an overestimation of coverage." Malaria Consortium, Summary Narrative Report 2018, Pg. 9.  121. This quote is pulled from an unpublishable source: ACCESS-SMC, Health impact data with edits from Malaria Consortium emails (unpublished), November 23, 2016. The original source wrote that if the probability of receiving SMC at each cycle is 88%, the expected percentage who would receive at least three treatments is 93%. However, assuming that the probability of receiving each cycle is independent of whether the child received other cycles we believe that the correct figure here would be 67%. See Cells AF4 and AF9 in GiveWell summary of SMC coverage information, November 2016.

  122. "The proportion of children excluded due to illness is less than 5%." GiveWell's non-verbatim summary of a conversation with Paul Milligan and Diego Moroso, August 2, 2017, Pg. 5

  123. More detail on the methods is given as follows: "The relative reduction in the number of malaria cases and malaria deaths under five years of age, compared to older age groups, observed when SMC was introduced, was estimated from the number of confirmed cases of deaths in-hospital that were reported in the national Health Management Information Systems, supplemented by data on malaria cases collected from clinic registers in selected health facilities in each country." Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 3. 

  124. The data we have seen for Mali, Chad, and Niger is presented on Pg. 91-102 of Malaria Consortium, Annex III: ACCESS-SMC Evaluation. "As part of the Unitaid funded 2015-17 Achieving Catalytic Expansion of Seasonal Malaria Chemoprevention in the Sahel (ACCESS-SMC) program, which was led by Malaria Consortium, Milligan et altera from the London School of Hygiene and Tropical Medicine conducted an impact assessment, which explored malaria cases and deaths using reported data from national Health Management Information Systems (HMIS) and sentinel sites (Milligan, 2018). Data abstracted from sentinel sites showed that the estimated average reduction of malaria cases in 2015 and 2016 were 41% and 49% in Burkina Faso; 37% and 25% in Chad; 25% and 25% in Nigeria, respectively." Malaria Consortium, 2019 impact report, Pg. 3.  125. "In countries with consistent reporting, introduction of SMC was associated with a reduction of about 50% in the number of malaria deaths in implementation areas." Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 3. 

  126. "Data for impact indicators outlined in Table 1 were abstracted from the national HMIS over the years of 2013 to 2018 for Burkina Faso and Chad, and 2017 to 2018 for Nigeria and were retrospectively analysed." Malaria Consortium, 2019 impact report, Pg. 4. "To generate estimates of the level of impact of SMC, a Poisson regression model was fitted to the number of cases confirmed by RDT or microscopy reported to health facilities during the SMC distribution months (August, September, October, November) between 2013 and 2018 (or 2017-2018 for Nigeria)." Malaria Consortium, 2019 impact report, Pg. 6.  127. "Analysis of HMIS data at the national level for each country overall showed no evidence of impact." Malaria Consortium, 2019 impact report, Pg. 9.

  128. "A review of the quality of HMIS data for each country was conducted, which showed varied results between and within countries...Checks for data completeness were conducted for each country, as defined by the proportion of all monthly reports for each indicator available. Briefly, Burkina Faso showed high completeness of data with less than 1% of missing data points for the relevant indicators. Data coming from Chad and Nigeria showed low completeness ranging from 36- 42%. To mitigate potential bias from low completeness, any health facility or district with more than 1 month missing data during the SMC distribution period was excluded...Further checks for data accuracy revealed data entry errors as well as major health data reporting issues. First, common in all countries were obvious data entry errors most likely due to typing errors, entering data into the incorrect field, recording data in the wrong month, etc. The level of data accuracy varied across and within countries. Additionally, the analysis also revealed major data reporting issues that bring into question the overall accuracy of data that is captured in the national HMIS. For example, in Burkina Faso, approximately 30% of the data points reported more malaria cases in children under 5 than there were children seen that month." Malaria Consortium, 2019 impact report, Pg. 7. "However, as previously discussed, the quality of data, the limitations of HMIS data reporting, and the inability to adjust for major factors affecting malaria transmission contribute to noise in the analysis and result in inaccurate estimates of effect...With regards to quality of impact data, in this analysis, we sought to analyse impact indicators available through the national HMIS from Burkina Faso, Chad, and Nigeria. Overall, the analysis indicated that accurate health data reporting is still a point of improvement for health systems and limitations to the data must be considered when interpreting results from national HMIS. Inaccurate data with no means of verification contribute to noise in the analysis and result in either dampening or amplification of estimated effects." Malaria Consortium, 2019 impact report, Pg. 9.  129. "While we are aware of the limitations of HMIS data and we have started using other sources of data to determine impact, we will continue to analyse HMIS data for 2 reasons: 1) It is commonly used by governments and bilateral/multilateral organisations to track progress/impact of health programmes; 2) in the long-term, it is the most sustainable/affordable source of impact data and we aim to contribute to strengthening HMIS in the long run." Malaria Consortium, comments on a draft of this page, October 2019.

  130. "Efficacy of SMC treatments will be measured using the case control approach. Malaria cases, and controls who do not have malaria, will be recruited concurrently, and the dates of the doses of SMC they received noted. The efficacy of SMC can then be calculated as a function of the time since treatment using case-control analysis. It is essential that dates of SMC doses are accurately documented, and that malaria cases are parasitologically confirmed. Controls will be selected from the community, in the neighbourhood where the case lived at the time they had malaria. Trained fieldworkers will collect information about cases and controls, and make home visits to record bednet use and other household factors that may act as confounders. Microscopy will be used to confirm cases and to measure parasite density. Controls will be confirmed to be negative for P.falciparum, by RDT." Malaria Consortium, Annex III: evaluation of seasonal malaria chemoprevention, Pg 10. "The dataset from Nigeria did not pass quality control when compared against scanned forms, and are being independently re-entered", Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 75.  131. Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 76.

  132. "820 cases and 1,637 controls were recruited in 2015, and 1,433 cases and 2,867 controls in 2016. SMC was associated with an 89% reduction in malaria incidence for 4 weeks after treatment, and 62% from 5 to 6 weeks after treatment, compared with children who had not received SMC or whose last dose was more than 6 weeks before", Malaria Consortium, Annex III: ACCESS-SMC Evaluation, Pg. 2.

  133. "SMC at scale will exert a selection pressure for drug resistance, which is expected to lead to progressive loss of efficacy, but it is not known how quickly this will become a problem." Malaria Consortium, 2018 drug resistance surveys preliminary report, Pg. 5.

  134. "Resistance to sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) is associated with specific gene mutations in the malaria parasite. Monitoring the prevalence of these markers, in malaria cases health facilities and in P. falciparum carriers in the general population, permits early warning of emerging problems with drug resistance. This progress update is on monitoring P. falciparum resistance markers. The objective of the molecular monitoring through the ACCESS-SMC project was to establish a baseline for monitoring the prevalence of the markers across the subregion using standardised methods, and to determine if there have been any important changes in the prevalence of these markers after two years of SMC at scale. [...] The baseline surveys were done at the end of the 2015 transmission season in all seven countries. (In 6 countries, sampling was done in areas which had not started SMC but would implement the following year. In The Gambia, sampling was in an area where SMC had been implemented for two years). In each country, one locality was chosen, blood samples were collected from approximately 2000 children under 5 years of age and 2000 individuals 10-30 years of age per country, taken onto filter paper and shipped to London to the LSHTM laboratories for analysis. The older age group was included because they would not be treated with SMC drugs, assessment of trends in the prevalence of markers of resistance in this group therefore allows us to determine whether SMC is leading to changes in the circulating parasite population." ACCESS-SMC, Progress update - Resistance monitoring, Pg. 3 "The baseline surveys, before scale-up of SMC, showed very low frequencies of mutations associated with SP and AQ resistant genotypes." ACCESS-SMC, Progress update - Resistance monitoring, Pg. 3  135. "To determine whether there have been any changes in the frequency of molecular markers of resistance to SMC drugs after two years of SMC at scale, surveys were conducted in each of the 7 ACCESS-SMC countries after the 2017 transmission season, in the same locations and using the same sample size and sampling approach as the baseline survey." Malaria Consortium, 2018 drug resistance surveys preliminary report, Pg. 5.

  136. "Thus overall, mutations associated with amodiaquine resistance have not increased in prevalence and the prevalence of the combination pfmdr1-86Y with pfmdr1-184Y occurred with a prevalence of 1.6% and the combination of pfmdr1-86Y and pfmdr1-184Y with pfcrt-CVIET occurred with a prevalence of 0.89% in the 10-30 year age group. The mutations associated with resistance to SP, increased in prevalence between 2016 and 2018. In the 10-30 year age group the prevalence of the dhfr triple mutation increased from 81% to 90%, and the overall prevalence of the dhps 540E mutation increased almost 5-fold." Malaria Consortium, 2018 drug resistance surveys preliminary report, Pg. 9.

 "This is not surprising considering the time that SP has been available and used as an antimalarial in Africa." Malaria Consortium, comments on a draft of this page, October 2019.

  137. "No samples carried genotypes associated with resistance to both SP and amodiaquine." Malaria Consortium, 2018 drug resistance surveys preliminary report, Pg. 4.

  138. "The prevalence remains low, 0.86% among the 10-30 year olds and 1.1% in the under 5’s. No samples carried genotypes associated with resistance to both SP and amodiaquine. However the increase in prevalence of markers associated with resistance to SP needs to be carefully monitored. If the 540-E mutation were to continue to increase in prevalence at the same rate as from 2016-2018, (2-fold in Guinea) the prevalence would reach 9% in Guinea by 2020 and 19% by 2022. A further survey should be conducted after the 2019 transmission season to determine whether there have been further increases." Malaria Consortium, 2018 drug resistance surveys preliminary report, Pg. 9. As of July 2019, Malaria Consortium was seeking $750,000 to repeat the molecular markers study in 2020. See this spreadsheet.  139. "The most common reaction seen with SMC drugs during the pilot studies and during the first year of ACCESS-SMC was regurgitating the drug after ingestion. This was due to the unpleasant and lasting bitter taste of amodiaquine and because the hard tablets were not always crushed into a fine powder before mixing with water, which often caused children to gag and expel the medicine. Since the introduction of the orange flavored dispersible amodiaquine and SP tablets, this is no longer a common problem." Malaria Consortium, comments on a draft of this page, October 2017

  140. We have seen one estimate from Malaria Consortium that suggested that roughly 0.5%-1.5% of children who received SMC drugs vomited. See Malaria Consortium, 2013 operational data. We have not vetted this estimate. We have not seen other information about vomiting in Malaria Consortium's monitoring. Malaria Consortium, comments on a draft of this page, October 2017  141. "It is very rare that children become sick after taking SMC medicines, but some children may feel a bit sick for a short while; what are some symptoms children may have? a) diarrhoea, b) itching, c) headache, d) mild abdominal pain, e) rash, f) a,b, and c, g) d,e, and f, h) All of the above, [Correct answer: H.]" Malaria Consortium Quiz Answer Key.

  142. "In Nigeria, there was a follow-up of a cohort of 10,000 children one week after each SMC cycle to ask about side effects, and to assess the frequency of mild and moderate side effects that may not be reported to the health facility. […] The 10,000 children cohort in Nigeria produced only five PV reports, and it seems to be linked to some reluctance to report by beneficiaries." ACCESS-SMC, Progress update - Safety monitoring, pgs. 7 and 10. 

  143. ACCESS-SMC, Reported severe adverse events. NDiaye et al. 2016. ACCESS-SMC, Progress update - Safety monitoring  144. "We are only permitted to procure products from suppliers that meet WHO stringent guidelines for pre-qualification of malaria drugs to ensure high-quality and efficacy of SP and AQ." Malaria Consortium, comments on a draft of this page, October 2017 "There is not yet any other supplier who manufactures both products and packages them in a 1SP 3AQ treatment slide combination, irrespective of WHO guidelines. Unpackaged products could be used but it is significantly more inefficient with a much higher risk of error." Malaria Consortium, comments on a draft of this page, October 2019  145. See our most recent model, "SMC" and "Results" sheets.

  146. See this spreadsheet, sheet "Source: 2019-22 Budgets," cell C13 and A15.

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

  148. This is difficult to estimate directly because for some of the prior year (including the part of the year when giving to our top charities is highest), Malaria Consortium was the top charity we pointed to as our top recommendation. Our estimate is based on the amount of GiveWell-directed funding we tracked to Malaria Consortium in our 2017 metrics year. It excludes grants that we recommended Good Ventures make to Malaria Consortium. See this report, Pg 5, amount for "Other donors."

  149. In April 2014-March 2015, it appears that about 11% of Malaria Consortium's total expenditure was unrestricted. See "Resources expended" from 2015 and compare "Restricted funds" and "Total funds" columns on Malaria Consortium, Trustees' report and financial statements 2015, Pg 17. Percentage of spending coming from restricted funds calculation: 50,626,000 British pounds / 56,809,000 British pounds = 0.89. In April 2015-March 2016, it appears that about 14% of Malaria Consortium's total expenditure was unrestricted. See Malaria Consortium, Trustees' report and financial statements 2016, Pg 16. (Math: On the line "Total Expenditure", 5886/41189 = 0.143.) In April 2016-March 2017, it appears that 12% of Malaria Consortium's total expenditure was unrestricted. See Malaria Consortium, Trustees' report and financial statements 2017. (Math: On the line "Total Expenditure", 5,900/50,840 = 0.116.) Malaria Consortium told us that it often uses unrestricted funding to support overhead that is needed for some of the restricted grants it receives (sometimes funders' requirements do not allow it to spend on overhead), so these unrestricted funds are not available to support new programs and activities. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. For a more detailed breakdown of how Malaria Consortium has spent unrestricted funds in the past, see Malaria Consortium, restricted and unrestricted expenditure analysis 2016. It seems possible that some of the funds spent on "Monitoring & surveillance of malaria" and "Malaria strategy support" supported aspects of SMC programs, but we are uncertain. Malaria Consortium told us that it agrees with the U.K. Department for International Development about how it will use Programme Partnership Agreement (PPA) funds. It told us that it decides which programs to apply for PPA funds with depending on what it believes will be most impactful, and then if it receives PPA funds it is committed to spending the funds on those programs. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. Malaria Consortium told us that it does not expect to receive PPA funds beyond 2018. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. In 2018, Malaria Consortium told us that it has not allocated significant amounts of unrestricted funding to SMC or other program activities in the last year. Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, July 31, 2018.  150. Christian Rassi, Malaria Consortium SMC Programme Director, email to GiveWell, July 31, 2019

  151. Madeleine Marasciulo, Malaria Consortium US Development Lead, conversation with GiveWell, March 4, 2019. 

 This funding was from Malaria Consortium's US entity. Our guess is that a large portion of this funding was from donors who read our recommendation of Malaria Consortium SMC's program and gave to Malaria Consortium unrestricted, either intentionally or unintentionally. This is our guess based on Malaria Consortium noting (Madeleine Marasciulo, Malaria Consortium US Development Lead, email to GiveWell, February 22, 2019) that it has seen its unrestricted donations to its US entity increase from a very low level since GiveWell began recommending Malaria Consortium's SMC program as a top charity. 

  152. See this spreadsheet, sheet "Maintenance," cell H19

  153. See this spreadsheet, sheet "Maintenance," cell H30

  154. See this spreadsheet, sheet "Spending opportunities," cell J30

  155. See this spreadsheet, sheet "Spending opportunities," cell F17, which gives the total for research before overhead costs. To calculate the total with overhead, we multiply by 1.1 because Malaria Consortium charges 10% for overhead.

  156. See this spreadsheet, sheet "Spending opportunities," cells L27:L30. For this calculation, research costs are allocated proportionally across countries. 

  157. For this analysis, we have assumed that Malaria Consortium will scale up research funding in proportion with other spending. This is a simplifying assumption designed to match how we treat research funding in our cost per child treated analysis and allow us to more easily generate cost-effectiveness estimates for each of Malaria Consortium's funding gaps, as we have estimates for each country that Malaria Consortium works in, but not for research as an independent activity.

  158. In April 2014-March 2015, it appears that about 11% of Malaria Consortium's total expenditure was unrestricted. See "Resources expended" from 2015 and compare "Restricted funds" and "Total funds" columns on Malaria Consortium, Trustees' report and financial statements 2015, Pg 17. Percentage of spending coming from restricted funds calculation: 50,626,000 British pounds / 56,809,000 British pounds = 0.89. In April 2015-March 2016, it appears that about 14% of Malaria Consortium's total expenditure was unrestricted. See Malaria Consortium, Trustees' report and financial statements 2016, Pg 16. (Math: On the line "Total Expenditure", 5886/41189 = 0.143.) In April 2016-March 2017, it appears that 12% of Malaria Consortium's total expenditure was unrestricted. See Malaria Consortium, Trustees' report and financial statements 2017. (Math: On the line "Total Expenditure", 5,900/50,840 = 0.116.) Malaria Consortium told us that it often uses unrestricted funding to support overhead that is needed for some of the restricted grants it receives (sometimes funders' requirements do not allow it to spend on overhead), so these unrestricted funds are not available to support new programs and activities. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. For a more detailed breakdown of how Malaria Consortium has spent unrestricted funds in the past, see Malaria Consortium, restricted and unrestricted expenditure analysis 2016. It seems possible that some of the funds spent on "Monitoring & surveillance of malaria" and "Malaria strategy support" supported aspects of SMC programs, but we are uncertain. Malaria Consortium told us that it agrees with the U.K. Department for International Development about how it will use Programme Partnership Agreement (PPA) funds. It told us that it decides which programs to apply for PPA funds with depending on what it believes will be most impactful, and then if it receives PPA funds it is committed to spending the funds on those programs. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. Malaria Consortium told us that it does not expect to receive PPA funds beyond 2018 due to the discontinuation of this funding stream for all recipients by the UK government. GiveWell's non-verbatim summary of conversations with Malaria Consortium staff, November 7 and November 9, 2016. In 2018, Malaria Consortium told us that it has not allocated significant amount of unrestricted funding to either SMC programs or other program activities in the last year. Diego Moroso, Malaria Consortium Global Programme Director - SMC, email to GiveWell, July 31, 2018. Malaria Consortium told us in July 2019 that it did not have sufficient unrestricted funding in the prior year to allocate unrestricted funding to SMC (Christian Rassi, Malaria Consortium SMC Programme Director, email to GiveWell, July 31, 2019). It did allocate at least $100,000 of unrestricted funding to projects other than SMC (Madeleine Marasciulo, Malaria Consortium US Development Lead, conversation with GiveWell, March 4, 2019). This funding was from Malaria Consortium's US entity. Our guess is that a large portion of this funding was from donors who read our recommendation of Malaria Consortium SMC's program and gave to Malaria Consortium unrestricted, either intentionally or unintentionally. This is our guess based on Malaria Consortium noting (Madeleine Marasciulo, Malaria Consortium US Development Lead, email to GiveWell, February 22, 2019) that it has seen its unrestricted donations to its US entity increase from a very low level since GiveWell began recommending Malaria Consortium's SMC program as a top charity.  159. 2018 analysis is here

  160. Malaria Consortium, Donor landscape 2019

  161. Countries not included: Mali, Mauritania, Niger, Senegal, and Togo. Togo is listed as no funding gap in 2019 and 2020, however, Malaria Consortium told us that it expects Togo will have a funding gap in 2020. Christian Rassi, Malaria Consortium SMC Programme Director, conversation with GiveWell, August 7, 2019.

 "We have since obtained more detailed information about the funding gap in Togo. Funding is provided by the Global Fund and UNICEF to reach a target population of about 500,000 children. However, since 2016, funding gaps have led to three cycles being implemented rather than recommended four cycles. There has also been insufficient funding to cover operational costs for supervision or to carry out M&E and community engagement activities. This situation is not expected to change in 2020. We are currently in discussions with the Malaria Programme in Togo to estimate the funding required to close this gap. If we do expand to a fourth country next year, Togo is the most likely candidate." Malaria Consortium, comments on a draft of this page, October 2019

 "It should be noted that this is Malaria Consortium’s estimate based on sector intelligence and average population growth. In 2017, the most recent year for which we have global data, the gap was estimated at 29m (see 2018 World Malaria Report). The 2019 World Malaria Report (with 2018 data) is due for publication soon." Malaria Consortium, comments on a draft of this page, October 2019

  162. Countries included: Benin, Burkina Faso, Cameroon, Chad, The Gambia, Guinea-Bissau, Guinea-Conakry, and Nigeria.

  163. Malaria Consortium, Donor landscape 2019. 9.1 million is the total for 2019 in the source, less 0.7 million in Senegal, which we exclude from the analysis because we do not have an estimate of the size of the gap in Senegal in 2020. The funding gap is calculated by multiplying the number of eligible children by $4.37, Malaria Consortium's projected average cost per targeted child in 2020-2022. See this spreadsheet, sheet "Maintenance," cell B34.

  164. "The Global Fund to Fight AIDS, Tuberculosis, and Malaria (The Global Fund) allocates funding to country governments for treatment and prevention programs for HIV/AIDS, tuberculosis, and malaria every three years. If a country does not use as much funding during a three-year period as was originally allocated to it for a specific program (e.g., rapid diagnostic tests for malaria) it can re-program those resources towards a different program or disease. But if a country still has funds following reprogramming that remain unspent at the end of the grant period, those funds are returned to the Global Fund to be reallocated through 'portfolio optimization.' The Global Fund Secretariat, country teams, and disease-specific teams, working with partners, discuss the remaining prioritized above-allocation requests from across all Global Fund countries, examine major gaps in essential services, and decide how to prioritize additional funding allocations." See our notes from our conversation.

  165. Malaria Consortium, Donor landscape 2019, sheet "Nigeria." See also sheets "Burkina Faso" and "Chad." Malaria Consortium, comments on a draft of this page, October 2019

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