Elie Hassenfeld: [00:00:00] Hey everyone. I'm Elie Hassenfeld, GiveWell's co-founder and CEO, and today we're gonna talk about the current situation with malaria funding globally. We wanna talk about this because malaria is the area that GiveWell has directed the most funding to in our history. We've now directed more than a billion dollars to malaria programs over the course of GiveWell's work, and we think that funding has or will avert the deaths of approximately 200,000 people, mostly young children.

And now, malaria programming is at a crossroads because of uncertainty and potential funding cuts that could come from large government donors. And so today, what we want to do is talk through some context on malaria overall. We also wanna discuss the current funding situation, and how organizations that we're in contact with are responding. And then finally, we wanna talk about some of the programs that we're investigating, where we're trying to determine how we can [00:01:00] best support and address current needs.

Malaria deaths are a huge problem, approximately 600,000 people, mostly young children die every year. But this actually represents a lot of progress relative to where we were 25 years ago. In the year 2000, there were approximately 900,000 deaths per year, and we've seen significant progress, because of a massive increase in donor funding to malaria, and then the development and delivery of new effective tools that can prevent and treat malaria.

So back in the year 2000, donors, meaning donor governments, individual donors, and large foundations, collectively were giving about $250 million per year, that's inflation adjusted, to malaria programs. And there was a rapid increase from there. And for, let's say the last several years, very roughly, donors have been giving approximately $3 billion per year to malaria programs. So, over the course of this 25 year period, there's been this 12 fold increase in the amount of funding that's going to malaria.

And during this [00:02:00] time, we, the world, globally, we've developed new tools that can prevent and treat malaria effectively. Just a couple examples. Back in the year 2000, only 3% of people who needed them had access to malaria nets. Now more than 50% do. In the year 2000, a program that GiveWell has supported for a long time called seasonal malaria chemo prevention, which is malaria preventative medicine, didn't exist. Randomized control trials were run on this program between the years 2006 and 2011. And in 2022, more than 50 million children in Africa were reached with this program. There are also new protocols for treatment and malaria vaccines. So altogether, this increase in funding and this development of new tools led to this massive reduction in deaths from 900,000 to 600,000 per year.

But now malaria is in a fairly precarious position. Global donors led by the US may significantly reduce funding for malaria in the future. We anticipate that they will, and that these reductions could be in the range of 20 to 30% off of [00:03:00] preexisting levels. Even now, some large institutions that fund malaria programs don't expect all the pledges that donors have given them to come through, and so they're reallocating funds to deal with this moment of funding uncertainty.

And so today, I'm going to speak with two members of GiveWell's research team who've been focusing on malaria recently, Alex Bowles and Rosie Bettle. And we're gonna try to just talk through the current state of malaria funding. How the world is responding, and how organizations we talk to are dealing with this uncertainty, and some recent grants that we've considered and have made to try and address some of the problems that we're seeing and help people around the world.

Alex and Rosie, it's great to chat with you, can you just share a bit about your personal background?

Alex Bowles: Sure. Thanks Elie, nice to talk about this today. Yeah, I'm Alex Bowles, I'm a program officer. I lead our malaria vector control work at GiveWell. I've been at GiveWell for about a year and before that I worked at Open Philanthropy and at the Clinton Health Access Initiative [00:04:00] working on malaria and non-vaccines.

Rosie Bettle: Hi everyone. It's great to chat about this. My name is Rosie. I've been at GiveWell for about eight months or so now. I'm based on the crosscutting team, so more methodological work across lots of different grants, but more recently have been doing more rapid grantmaking for USAID cut items that have come up. Before that I worked at another philanthropy called Founder's Pledge. Was a grantmaker and researcher, and before that I was doing a PhD in bio-psychology.

Elie Hassenfeld: Great. Thank you both. So, the place I wanna start is just getting the lay of the land of the basic landscape. You know, some of the biggest funders globally in malaria are the US government's President's Malaria Initiative, the Global Fund. Both of these institutions account for a large proportion of malaria funding globally, but now they're facing some uncertainty about their current and future funding.

So Alex, can you just walk us through some of the numbers here, you know, what's happening, what it means [00:05:00] for the state of malaria, and how they're thinking about their funding going forward.

Alex Bowles: Yeah, absolutely. So first of all, you're completely right to say that the President's Malaria Initiative, so the US government direct support for malaria and the Global Fund are the two main funders of malaria activities in the world, really, in these high burden countries.

And something that's worth mentioning is the US is also a really important funder of the Global Fund. So the US government provides about a third of the funding for the Global Fund. And so when the US government has made decisions about shifting its priorities, that has a big effect, not just on the President's Malaria Initiative, or PMI, but on the Global Fund itself.

And so the US government before this year, was spending more than a billion dollars a year supporting these two initiatives on malaria. So about $800 million a year through the President's Malaria Initiative, and that's direct bilateral support to countries, so, helping those countries buy the kind of commodities that you need to prevent and treat malaria. And then, I [00:06:00] think about $400 million a year was going to support malaria through the Global Fund. So they provided funding more than that overall to the Global Fund, and then a proportion of that goes to malaria.

When the stop work orders and the pauses to global aid from the US government came through earlier this year, that did stop a lot of activities in malaria and has caused a lot of uncertainty in the space, in terms of commodities, in terms of understanding where these treatments that are ordered and paid for by the US government are, essentially. And it's also created some uncertainty for the Global Fund.

A few years ago, donor governments made commitments to the Global Fund to support its work. These are financial commitments. And then they come through with those pledges in terms of actually transferring the money.

And one of the challenges this year is because of these pauses in funding from the US government, the Global Fund has been uncertain about how much of its funding that the US government had previously committed would come through and be able to be transferred to countries to support their malaria programming.

We've had a bit [00:07:00] more clarity on the direct support from the US government's PMI, the President's Malaria Initiative, in that we think, at least this year, it's gone down from about $800 million to $400 million, although there's still uncertainty about that. And we can talk a bit more about the uncertainty maybe later on. Less certainty on what's happening with the Global Fund.

Now, the Global Fund has been trying to understand what the prospects of this funding coming through from the US government is. And they've been preparing countries to make adjustments in the face of funding cuts. Just a couple of weeks ago, they communicated to countries that they were expecting an 11% cut across the board from the Global Fund. Now that's across all three diseases that the Global Fund supports. So not just malaria, but HIV and TB. And countries are now going into this process of reorganizing their grants essentially from the Global Fund, reprioritizing their activities to adjust for this cut. They're about halfway through a three year grant cycle, and so they have to reorganize the activities that were funded by that to make sure that they can preserve the most effective, most lifesaving [00:08:00] activities.

Elie Hassenfeld: The first point that seems really critical to take away is the US has a disproportionate impact on malaria funding globally. Approximately a little bit more than $3 billion per year was being directed by donors to malaria control. The US government was giving more than $1 billion. So, right off the bat, a third of the funding in some sense was at risk or uncertain with the changes that happened to aid earlier this year.

So, the Global Fund raises money on a three year cycle. When it raises that money, it raises pledges. So countries say, we'll give you X dollars in the future. And then, with that funding in hand, countries are then able to plan their activities and apply to the Global Fund for funding. And so right now we're nearing the end of one of these three year cycles, and the Global Fund is telling its constituent countries that it may not be able to deliver the funding that they previously expected because it's uncertain whether pledges from the US government will come through.

And that's creating the need to change the [00:09:00] programming they had previously planned to deliver, to be consistent with having potentially less money in hand even during this current fundraising cycle.

I guess I'm curious, is that basically right? And then what does that mean in practice for these countries if they're trying to all of a sudden like shift gears, what does that look like?

Alex Bowles: Sure. So first of all, I think that's a really good summary of the situation. I would agree with all of that. And what it means practically for countries is that they are in the midst of delivering the programs that are being funded by these resources from the Global Fund. So a lot of planning goes into the campaigns that deliver nets or that deliver the kind of seasonal malaria chemo prevention medicines that you were talking about earlier.

And they're complicated operations and a lot of them are happening right now. One of the consequences is that some part of the staff of these malaria programs are having to divert their attention from implementing these programs, making these programs as effective as they can be, to reorganizing their activities and [00:10:00] replanning their activities in the face of less resources. So one of the things I worry about is just that programming being implemented this year will be lower quality because the attention of these staff is divided.

The other thing that they're having to do is think about prioritization. At GiveWell, this is our kind of bread and butter. This is what we think about all the time, is prioritization. And it's really important and there is this range of things that are supported. I think we think that basically all of what the Global Fund is supporting in malaria is good in the sense that it is saving lives. But there is a range. We think that some things are more effective than others. And we are not unique in the malaria world in thinking this. And so, these countries are having to think about what to cut.

Bluntly, they're going to have to lose some activities and try and maintain the most cost effective things that they can. And at the core of that is treatment, making sure that people who are sick with malaria can access the diagnosis and the treatment that they need.

But they're also going to have to try and work out how they can preserve the ITN, so the mosquito [00:11:00] net campaigns that they have coming. And a lot of those, and this one's quite important in malaria, those campaigns tend to cluster at the end of a Global Fund funding cycle, the three year cycle that Elie was talking about. That means a lot of countries haven't done their campaigns for their cycle, and it's really important that they do them because mosquito nets only last so long, they'll be wearing out, and increasingly people and children will be unprotected. So getting those out is gonna be really important.

And so that takes a lot of work. The Global Fund has asked countries to come back with their plans by September. So that's really fast, usually it takes a whole year to plan these activities. But they're having to do this in two months, so they're gonna have to do it really fast. I anticipate it's gonna be a little rough and ready. But that's what they're having to do now, trying to preserve the most important activities.

Elie Hassenfeld: It's really interesting you said that sort of the number one priority is treatment, and then programs like mass distribution of malaria nets and seasonal malaria chemo prevention are more at risk. And I'm curious, why is that the case? And what do you think about that prioritization? You know, is that driven by the fact that that treatment is more cost [00:12:00] effective or they believe it's more cost effective or something else?

Alex Bowles: Yeah. I think it's driven by a combination of things.

So one is, treatment probably is pretty cost effective. I think we have a less well developed view at GiveWell on that than we do on chemo prevention and on mosquito nets, which are areas that we have supported for a long time. And there are various reasons we haven't supported treatment, but one of them, I think, is that the US government and the Global Fund have to some extent had it covered. I'm oversimplifying a bit here, but there has been a lot of support for those areas in the past. But it is likely that it's pretty cost effective to do treatment because you are selecting, essentially the group that is already sick, and their outcomes are likely pretty bad, especially when you're thinking about children. Malaria is a very severe disease. It can progress very quickly, and the drugs to treat it are not that expensive. So I think it is likely to be pretty cost effective.

But I think there's also just a sense that it is really important to treat people who are sick. And it's tangible, and it's in front of you, and it's something that is really important to do. And prevention is just less tangible [00:13:00] in that way. We obviously think prevention is really important, others do as well. But I think there is that element, in addition to the fact that treatment is likely to be very cost effective, which drives some of the decision making here.

Elie Hassenfeld: That makes sense to me. I think that on one hand it's you can model the cost-effectiveness, on the other hand, as a country, it's important and logical, that you'd want it to be the case that people could show up at a health system and receive treatment for a deadly disease when they need it.

So, we're sort of trying to like go through right now just the current state of play in the malaria funding landscape. And so one issue is, we have this major funder, the Global Fund, they operate on these three year cycles. They and, more importantly, the countries that the Global Fund funding supports plans on these three year cycles.

And all of a sudden there's material uncertainty about whether pledges will be fulfilled, especially from the US government. So Global Fund is instructing countries to do a fairly quick, like two month turnaround on reorganizing their programming. This means that they're gonna have to make prioritization decisions relatively quickly.

That will be challenging. It means that attention will be diverted from [00:14:00] delivery to planning. So that means that programs will be lower quality. And so these are like some of the challenges that are coming up.

The next thing I wanted to ask about in sort of the current landscape are these stop work orders. You know, right at the beginning of the year, the US government issued stop work orders that put a pause on funding going out. Are those still affecting what's going on with malaria programming? I know there've been court decisions and programs that have been canceled and turned back on, but is that like played out all the way or is that still having effects on what's going on right now?

Alex Bowles: So I think, where we are now is that a lot of the core programs in malaria, the largest programs that the US government was supporting, and now I'm talking about their direct support, not their support to the Global Fund but the President's Malaria Initiative, a lot of that is no longer subject to a stop work order.

In particular, I'm thinking about a really large chunk of the US support was to procure commodities, so treatment, mosquito nets, and so on. And that's all done through one contractor, Chemonics. That work is [00:15:00] now no longer subject to the stop work order, we understand that it is moving forward. A lot of the orders that this contractor would have placed with US funds were really substantially delayed. So that's been a major effect across all parts of malaria. And we'll hear more about the diagnostics part of that, I think from Rosie, and that will continue to play out.

So there are several steps. There's the lifting the stop work order so that they're allowed to do work, but then there's the committing the funds, and then there's actually releasing those funds. And each of those steps, I think, has proved quite challenging. And we have moved quite far along on that. I think there's still some uncertainty and it's not fully transparent, I would say, from the outside, but my expectation is that the funding that was to support the procurement of these malaria commodities will be released. And so those will be ordered, but they're obviously delayed, and that creates knock on problems for countries ensuring the continuity of their supply chain, ensuring that their campaigns can go ahead on time.

And that matters a lot because malaria in many places is a very seasonal disease. [00:16:00] And so it matters when you do these campaigns. You're trying to hit the malaria season, which in some parts of, particularly the Sahel is, very seasonal, so it really matters. And there are also rains, which makes it logistically difficult to deliver campaigns at certain times and things like that.

Elie Hassenfeld: So there were these stop work orders at the beginning of the year, but then lifting the stop work order is not sufficient for organizations to go ahead, because the funds then need to be committed and released. And it sounds like, in many cases, those funds haven't been released yet. So how are organizations dealing with this? Are they just waiting for the funds to be released, and that means that programming that ideally would be happening now, isn't happening now, or, what's happening?

Alex Bowles: Yeah, so, I think a mix of approaches. One thing that I wanna be clear on, maybe a clarification from my previous response is, there are a lot of contracts and grants from the US government for malaria that were canceled. So those are not coming back, as we understand it. Those activities are not continuing, and so those organizations have had to withdraw or stop that work, let people go, et cetera.

But this [00:17:00] core commodities procurement work, essentially, yeah, I think the contractor had to stop working on it and had to reassign a lot of staff or let a lot of staff go. That work just didn't move forward. Manufacturers, in many cases were left, either they had produced stuff but weren't being paid for it, so it was sitting on their lots. Or, in some cases, it was on ships and no one really knew what to do with it when it got to the port. Just disruption throughout the supply chain.

And so, as authorization has come back online to work on this, and some funding has come through, at least enough to fund the staff that are working on it and so on, a lot of the work has been unpicking those blockages that occurred because of that sudden stop and understanding, in some cases, literally where certain commodities are in the world.

But also just now waiting, and I think this is particularly important for commodity procurement, cause in some programs, most of the money is to pay staff. And if you don't have the money, you can't do any of it. But in this case, most of the money is to buy these medicines, to buy these mosquito nets, and so on. And so you can do some of the work to prepare for it, even if you don't [00:18:00] have the authorization and the funds to actually procure whatever it is you're procuring.

Elie Hassenfeld: Right now, in multiple ways, organizations and people who are trying to deliver programs are you know, struggling because they have less money than they had in the past, they have less money than they expected to have, and they're unsure if money will come through to enable them to deliver programming. That's happening right now, literally trying to work it through like, we're talking about this on July 16th, and you said that countries have until September to come back to the Global Fund. So it's a very live issue in figuring out how they'll respond. And then beyond that, there's a lot of uncertainty for what the future will bring. You know, what kind of funding will be available for malaria programming in 2026, 2027, and beyond.

We've been talking a lot about the basic landscape and this uncertainty and some of the problems. What I think I wanna shift to now is how we at GiveWell have responded to these challenges among the global malaria community, among the organizations that we support and work with, and how we've tried to direct funds, how we're thinking about [00:19:00] directing funds in the future to address some of these needs that are now emerging.

One of the investigations that I think you've been working on, you know, relates to delivery of malaria nets. And just curious if you could tell me a little bit more about the investigation you're focused on and how it relates to some of the uncertainty that we've been talking about thus far.

Alex Bowles: Absolutely. I think this investigation that we're doing right now highlights, in some sense, the continuity actually, from the gaps that existed before to the gaps that exist now. And what I mean by that is, we made a grant last year to support the procurement of nets for a campaign in Democratic Republic of the Congo, DRC. And the way we usually support procurement of mosquito nets is grants to the Against Malaria Foundation, which buys nets and then works with partners like the Global Fund and country governments to ensure those nets are delivered. Generally speaking, they are just procuring the nets and then other partners are paying for the delivery of those nets.

Elie Hassenfeld: There's the cost to [00:20:00] like literally purchase the net itself, but then there's the cost of shipping the net to the country needs to go to, getting the nets on trucks and reaching the specific locations where those nets are distributed, and then monitoring and evaluation after the fact to ensure and understand how that program went. AMF largely pays for the nets themselves, the commodity, and then there's other partners paying for those other costs.

Alex Bowles: That's exactly right. And in a number of cases, in order to make those funds available from those other partners, AMF will discuss with them how potentially AMF might be able to procure more nets in order to free up that funding for all those costs you described , which vary depending on the context, but can cost a dollar or $2 or $3 per net to deliver, to do all that. And if you think in some of these cases we're funding the delivery of nets to really remote places and logistically difficult places, there's a lot of work and effort that go in those nets there.

And so the grant that we are investigating right now is to support that second category of cost. So not the buying [00:21:00] of the net itself, but all those costs that you described, Elie. So paying for the net to be shipped from the manufacturer to the country. And then everything that's involved in terms of getting it to the people who need it in whatever place they might be in the country. And then making sure that we have the information that the net was received, and understanding to the extent to which nets are being used afterwards and so on.

Most of the time in our past grant making, we haven't supported that directly because of this available funding from the Global Fund principally, but also often from the President's Malaria Initiative. And there is this shift now that we are having to consider of, if there is less funding overall available outside of GiveWell for malaria vector control for mosquito nets, we may have to make some shift towards being able to support that more generally.

I think that's an open question, we have to see how that pans out and what the actual funding landscape looks like in the next year or two. But that is something that we are thinking about and having to learn more about as we do these investigations.

Elie Hassenfeld: Very roughly, on average, how [00:22:00] much of the cost comes from the net itself versus those other costs?

Alex Bowles: Yeah, it varies. So the net costs can vary because of the different types of nets that are used, different chemicals and so on. And then the delivery costs can vary depending on the country context, how much logistics costs, and so on.

But I think a really rough rule of thumb could be something like two thirds for the net, one third for the cost of delivery. With a lot of variance on that.

Elie Hassenfeld: So it sounds like when we made this grant last year, 'cause it was before everything happened in the world of aid, we expected these non net costs to be paid by one of these other actors.

And so I'm kind of curious like what's the main questions of this grant investigation? Is it just, is there someone else who might end up paying for it? Or is it like, maybe we should ask for our money back, because these nets won't be delivered?

Alex Bowles: So I think a couple of things. One is in this case actually, we weren't completely sure that non net costs would come through because there's a big funding gap in this country. That was an open question for us at the end of the last grant investigation. And so we anticipated that we might [00:23:00] have to do this investigation this year anyway. And then the change in global circumstances made it certain that we would have to do this investigation.

I agree with the sort of premise of your question, which I think is that if we're funding the nets anyway, we believe that the non net costs, as we call them, are sort of part of the overall delivery of it, and we build that into our model, which we do. Then why would we not just pay for it?

And I think it's less about should we pay for those costs? 'Cause we think those costs are essential, and I think we agree with that. It's more making sure that we fully understand the overall funding landscape in that country, and that we're still up to date on who is funding what, and making sure that the kind of marginal effect of this extra money is doing what we think it will do.

Elie Hassenfeld: I wanted to shift over to talk about this other recent grant that we approved, which focused on rapid diagnostic tests for malaria. And just for some context, rapid diagnostic tests are a really quick, really easy way for people who show up at a health clinic to determine whether or not they have malaria. People could show up at a health [00:24:00] clinic for many reasons. You could show up with pneumonia or with fever, and if you don't have malaria, it would not be a good idea to get malaria treatment. On the other hand, if you do have malaria, you really want to get malaria treatment.

We recently made this grant, and Rosie, would just love for you to talk us through what led to this grant, and how did it come out of the current situation in US government cuts and, yeah, tell us a little bit about it.

Rosie Bettle: Yeah, sure. So the purpose of this grant is to try and reduce stockouts that we think is gonna happen with RDTs starting probably around August of this year in certain states of Nigeria. So concretely what we're doing is we're giving this funding so that an organization called CHAI, that's Clinton Health Access Initiative, can buy 3 million RDTs and quickly ship them out to these states in Nigeria. Even with them going quickly, we don't think unfortunately that they can cover the whole stock out, but at least reduce it, hopefully by about [00:25:00] two months.

And the reason that this has happened, we think it's come out of USAID cuts. It's difficult to pull the strings of causality right, because this is such kind of diffuse effects. But our best understanding is that amidst chaos, layoffs, reduced money, there's been fewer planning meetings, fewer shipments going into Lagos, and therefore reduce stock availability for these resupplies that take the stock from the central warehouses, you know, in Lagos and different states directly to the clinics. So now we're rushing, essentially, to try and make sure there are RDTs on hand for the next resupply to the clinics in September.

Elie Hassenfeld: The thing that we're trying to alleviate to the extent we can is the possibility that there aren't any tests available in clinics when people show up and present with symptoms that could be consistent with malaria. If the tests are there, either they have it or they don't and can get treatment. On the other hand, if they're not there, then you know that's not possible. And so we're doing this [00:26:00] because we expect that there could be stockouts, meaning like the test would not be in supply. How do we know that? What's the data we're looking at that gives us the indication that there are or could be stockouts?

Rosie Bettle: Yeah, so we've been talking a lot with CHAI, who have been doing this kind of monitoring work for quite a long time now. So we've been pulling from their data, and then checking with other data sources like Roll Back Malaria, which is a kind of dashboard for this kind of information.

What that's ultimately pulling from is organizations like CHAI are monitoring stock levels in these warehouses. So they're saying, okay, there's about this many boxes left. They also have data on the typical monthly consumption of those tests. And they're trying to get information about when incoming stock is coming in through these different shipments, you know, whether that's PMI, Global Fund, alongside information about when those resupply points taking stuff out of the warehouses is [00:27:00] gonna happen.

Elie Hassenfeld: So an organization like CHAI, can literally go to a warehouse, know how many tests are in the warehouse, and see that that level of supply is falling, they have a sense of how much is utilized on an ongoing basis. They also can say like, well, this is where the next resupply is coming in. And with that, be in a position to say like, we're not gonna have enough tests, the tests that we need in the near future. And so then, the funding we're providing is trying to alleviate that.

So we're directing funding to CHAI, and then, what exactly is CHAI doing? Are they like going out and buying these tests directly? You know, what else are they doing to ensure that the tests go where they need to?

Rosie Bettle: You are totally correct, they are directly procuring these commodities. So they're working with the manufacturers. They're saying, hey, we wanna go ahead get these 3 million RDTs ready to ship out. And then they're also doing the shipping logistics, which is actually super complex. They need to ship them over, trying to do it super quick, probably by air. You have to go through various [00:28:00] approval, regulatory steps, go through customs, et cetera, et cetera. So then they're gonna get it all the way from the manufacturers to the central warehouses, and at that point, it will then transition over. So then it should go into the normal resupply process, which is managed by Chemonics, that contractor.

Elie Hassenfeld: On some level, this sounds very straightforward. You know, there's this big introduction of chaos and uncertainty to the funding system earlier in the year. Because of that, we as a team have been watching very closely and talking with partners where we want them to come and tell us like, here are problems we're observing, money can help. Then, we get this information about stocks of tests falling, so we want to be in a position to then provide money to go buy the tests, and then CHAI is going to buy them and get them to the warehouse where they can enter the sort of standard system that delivers these tests around the country.

Is it that simple? Like what could go wrong, if anything, in that series of steps? And how would we know if this [00:29:00] didn't work out the way we expected?

Rosie Bettle: Yeah, so one thing that we are pretty uncertain about is whether CHAI, even with their best efforts and competence, whether they can successfully get these commodities there in time before this September resupply. We think there's like a 60% chance that they can. So 40% chance it's just a bit too slow. And that's baked into our modeling cost-effectiveness.

Elie Hassenfeld: Let's say that happens, we think it's slightly more likely than not that they can pull this off, but let's say they can't and the resupply comes late. Then, what effect did our funding have in that case? I mean, presumably, we wouldn't be able to alleviate the stock out. But then I don't know, how do you think about the outcome in that situation?

Rosie Bettle: Yeah, I think that's such a important question and it's one thing that makes me feel better about this, I feel pretty good about this grant, but makes me feel a little bit better about this grant, is that even if we don't manage to meet the stockout timing, my best understanding is that then there's just more [00:30:00] RDTs in Nigeria. Our understanding is, even before USAID cuts and problems, there are just frequently stockouts, depressingly, of malaria commodities, including RDTs.

So while in our modeling, which we've done quite rapidly right, we've had to move very fast for the situation, we're essentially assuming zero impact if we don't get it there in time. In reality, my opinion is that's still a very good thing, right? You don't meet the stock out, but you just have more RDTs in a high burden country.

Elie Hassenfeld: That makes a lot of sense. And then RDTs, the tests, they just tell someone if they have malaria or not, and for them to have an impact, the treatment needs to be there as well. Do you have reason to believe that treatment will consistently be in stock? To what extent is that a concern for you?

Rosie Bettle: Yeah, so we've also been trying to monitor if there are similar stockouts and what we might consider there. For Nigeria, at least at the moment, we are not too worried based on the data and so on that we've seen for this immediate period, which we're trying to cover with the [00:31:00] RDTs.

And then the benefit that we think is coming through the RDTs is through, as you're saying, basically through slightly increasing the number of people with malaria who are getting access to treatment, . So if you present at a clinic, malaria has these kind of nondescript symptoms at first, fever, fatigue, et cetera, et cetera. Most places will give you presumptive treatment, right? If you come in with those symptoms, even without an RDT. But you're not gonna be accurate a hundred percent of the time. Our best guess is you present with malaria without an RDT, maybe 70% of the time you're gonna get an ACT. With an RDT, we think that increases to about 80%. ACTs are very effective, malaria is pretty dangerous, RDTs are extremely cheap. So we think that saves lives.

Elie Hassenfeld: Yeah, just to close, I'd love to ask each of you just, what's on your mind right now with respect to the work you're doing, either in malaria or outside of it. What are you thinking about as we're going forward in the next stage of this moment of [00:32:00] uncertainty in global aid?

Rosie Bettle: I'm pretty stressed about just the sheer like uncertainty. You know, beyond the just direct depressing impacts of funding cuts, whether you are a charity, whether you are, big international NGO, whether you're a funder, just trying to suss out what's gonna happen next and appropriately plan for these hugely important interventions, I think is difficult right now. And I think it's really difficult to quantify that beyond just the sheer, oh my God, funding cuts.

What gives me a little bit of hope is how, from my sense as a researcher, is how donors seem to be responding, to this and are interested, and that inspires me like as a researcher.

Alex Bowles: I, first of all, I'd echo that sort of ongoing uncertainty is definitely something that I worry about, and the range of potential outcomes, it still seems quite wide, and so that's hard to plan for. But the second thing is that, I worry that as we try and prioritize, as we try to [00:33:00] preserve the most cost effective things, that we end up losing some things that are important but not easy to model as cost-effective. And what I'm particularly thinking about is data systems, understanding the burden of malaria, in particular, being able to track epidemics. Those are things that the US government was providing a lot of funding for. Don't fall under the sort of lifesaving criterion that they're using to prioritize.

And so I do worry that we end up having to sort of fly in the dark a bit more with malaria, and we lose a lot of the progress we've made in being able to understand what the burden really is. And that makes all of our work harder if the data gets worse. So that is definitely something on my mind.

Elie Hassenfeld: Thank you both, appreciate you know, your work on these important problems and enabling us to get money where it needs to go to help people. And thanks for spending some time with me.

Hey everyone, it's Elie again. I think this conversation was really interesting because a lot of what GiveWell spends our time on and perhaps is known for, is these really deep assessments of [00:34:00] programs on a very micro level. You know, we'll look at the delivery of malaria nets in a given location and ask questions like, how high is insecticide resistance there? How much does it cost to deliver a net? In total, what's the cost per person reached for the program as a whole? How effective should we expect these nets to be, given the underlying levels of malaria?

But right now, so much is changing in the broader landscape that in order for us to do the job of zooming in, in very particular places, we need to have a better understanding of what's happening more broadly. How the US government is going to respond, how the Global Fund is going to reallocate funding because of reduced funding and emerging needs.

And so a lot of what we were focused on in this conversation was the way in which we're trying to understand that broader landscape to inform where we should focus our detailed research energy, because we know that there are likely to be huge gaps in the future. And it's really critical that we focus our energy, and our time, and then our funding where money can go the [00:35:00] furthest and help people most.

You know, these are really major problems and we as a team are motivated to be in a position to try and help, and we're grateful for the support of donors like you, and organizations who are working on the ground, who are working together to try and deliver improved outcomes during a challenging time.

If you want to support the work we're doing, you can donate to our Top Charities Fund or our All Grants Fund, where we have more flexibility. And thank you again for your engagement and your support. And as always, if you have any feedback or questions, please email us directly at info@givewell.org. Thank you so much.