Cover image courtesy of Against Malaria Foundation
–by Tamilore Alabi and Luke Whitney–
Malaria is a deadly issue affecting the lives of many African people and poses a serious problem for the countries they belong to, claiming over a million lives yearly with 90% of these deaths occurring in sub-Saharan Africa. Many organizations have risen to challenge the threat of this disease, with one of the most prominent being the Against Malaria Foundation (AMF). AMF’s approach to combating malaria is centered around mass distribution of long-lasting insecticide nets (LLIN) to families, delivering almost 80 million nets worldwide mostly in Africa. This article looks at the disease and its effects on the countries it plagues and evaluates the effectiveness of AMF’s approach in this context.
We first explore the disease itself to provide context to our discussion, both its direct effects and its overall economic impacts including GDP. We then look into the organization itself and its malaria prevention approach. We examine whether LLINs are an effective method of malaria prevention. We conclude by exploring some criticisms of AMF, finding the organization to have several weaknesses but providing an overall positive impact.
What is Malaria?
The Against Malaria Foundation, as the name describes, is an organisation focused of the prevention of malaria. The Centre for Disease Control describes malaria as a “serious and sometimes fatal disease caused by a parasite that commonly infects a certain type of mosquito”. People who contract this disease get high fevers, chills and flu like symptoms.[i] Malaria is known to have caused millions of deaths yearly, although exact figures are not agreed upon, the WHO estimates at least 435,000 deaths in 2017 alone. Unfortunately, 90% of these deaths occurred in Africa with 70% of the deceased being children under the age of 5.[ii]
Malaria is commonly transmitted through the Anopheles mosquito. As these mosquitos feed on human blood for survival and nurturing of their young, they pass the malaria vector by biting one infected person then biting an uninfected person. Malaria is less commonly transmitted through blood transfusions, syringes and child birth. Due to the climatic conditions necessary for the Anopheles mosquito to thrive, sub-Saharan African regions provide a fertile landscape for these insects to thrive. Collections of fresh water, especially in the rainy season, as well as the longer mosquito lifespan are reasons why sub-Saharan Africa sees nearly 90% of the world’s malaria cases.2
Beyond the death numbers, malaria is known to have effects on the economies it affects. Malaney and Sachs cite in The Economic and Social Burden of Malaria that as a rule of thumb, “when malaria prospers most, human societies have prospered least.”[iii] They note that malaria-stricken countries are not only poorer than their non-stricken counterparts, but they have a lower rate of economic growth. These stricken countries over a 25-year study have a GDP growth of 0.4% per year as opposed to the 2.3% growth in the non-stricken countries.3 Malaria has also been linked with reduction in economic linkages between stricken and non-stricken countries. This lower rate of economic growth is as a result of the effects of malaria on the activities that boost growth. One of such activities is school attendance by school-age children. Malaney reports that primary school students in Kenya miss up to 11% of school.3 This absence from school, especially in the early school years, has knock on effects which lead to students failing in school and even dropping out. In addition, chronic malaria is known to cause anaemia whose effects lower worker productivity.
Sachs notes that the failure of investments is probably the most-costly effect of malaria for long term economic growth. Potential investors are scared off by the fear of contracting the disease. This fear has been reaffirmed by incidences such as with Billiton, who faced 7,000 cases of malaria and lost 13 expatriate employees in Mozambique.3 Overall, estimates say that malaria costs Africa $12 billion yearly in terms of heath care, decreased productivity and loss of foreign investment and tourism.[iv]
William Jobin approaches this same concept from a different perspective by analysing the impact of a reduction in malaria on economic productivity in African countries. In his article, William examines the links between a US Presidential Malaria Initiative program (PMI) in African countries and the resulting increase in per capita GDP. Figure 1 below shows the resulting trend between these 2 variables:
As evident by the figure above, there is a correlation between increase in PMI per capita investment and the GDP per capita from 2007 to 2011. This supports the notion that increased investment in malaria prevention and success in that prevention can translate to economic advantages. Sachs and Pia would agree with this conclusion as their research shows the opposite effect, that increase malaria occurrences have negative effects on the affected economies. Other estimates also indicate the GDP effect of malaria prevention citing a minimum $6.75 GDP per capita increase for every $1 spent combating malaria.4
Against Malaria Foundation
Rob Mather founded the Against Malaria Foundation (AMF) in 2004 with the primary aim of helping people protect against malaria. The organization has been active in 36 countries, mainly in the sub-Saharan region of Africa. Till date, AMF has raised about $180 million and provided $81.2 million nets to the regions it serves.[vi] Figure 2 below shows an example of one of such nets, spread out over a bed.
Due to the nature of its transmission, long-lasting insecticide nets (LLINs) provide a means through which malaria can be prevented. As mosquitos usually bite during the sleeping hours between 10PM and 2AM, providing protection against mosquitoes in these hours may prove vital in combating malaria. LLINs are designed to cover the bed of individuals while they sleep and provide safety from these mosquitoes overnight. Nets function as a barrier between mosquitoes and individuals but also as a means for killing mosquitoes, seeing as they contain insecticides. LLINs have been shown to reduce mortality rates in children under 5 years of age by up to 60%. It is worth noting that these nets do not prevent mosquito bites unless one is in a bed covered by these nets. As such individuals could still contract malaria through bites as they go about their regular days. One potential danger with these nets is the increase of insecticide resistant mosquitoes. While little is known on the current landscape of the notion of insecticide resistant mosquitoes, organisations like the WHO are putting measures in place to prepare for this eventuality. Through the Global Plan for Insecticide Resistance in Management in Malaria Vectors (GPIRM), the WHO has committed to developing knowledge in this field and pre-emptively taking steps to combat resistant mosquitoes once they’ve been understood.[vii]
AMF is an incredibly transparent organisation. They keep detailed documentation of their financials including their cost and number of nets distributed in the region. According to the AMF website, 100% of any public donation goes to buying nets. AMF also does a thorough job of keeping track of their net donations and life time of these nets. They conduct post distribution surveys which assist in monitoring proper net use. These surveys show that majority of AMFs distributed nets reach their intended demographic. AMF is special in that they focus on distributing nets accountably. AMF partners directly with several organisations but most importantly with local organisations to determine where nets should be distributed. One key takeaway from a semester in Africa and the Urge to Help is the importance of interacting and relying on local input when attempting to solve a problem. With this AMF is able to reliably ensure that their distribution is incredibly effective.
Effectiveness of Long-Lasting Insecticide Net Distribution
Are long-lasting insecticide nets effective? We examine a case study in Uganda to determine whether LLINs achieve their purpose. Malaria is the leading cause of sickness and death in Uganda, causing 150 deaths each day.[viii] Uganda’s malarial burden is the third highest in Africa[ix]. Uganda has also undertaken a universal coverage campaign, resulting in mass LLIN distributions to achieve this goal.7 These factors combine to make Uganda an ideal case for examination. Important considerations in LLIN effectiveness are whether mass distribution campaigns such as those made by AMF translate into actual bed net use, whether the use of LLINs is successful in preventing malaria, and the overall impact of LLIN distributions on a country.
An important way to gauge LLIN usage is among the populations most at risk. Malaria has the highest death rates among pregnant women and children. A 2017 study by Taremwa et al. focused on the knowledge, attitude and behaviour towards the use of LLINS among pregnant women and children in rural southwestern Uganda. The study found that though most people are aware of the causes and symptoms of malaria, this knowledge does not necessarily translate into knowledge on how to prevent malaria. Though 84% of the pregnant women and children studied possessed nets due to a recent LLIN distribution, this did not translate into overwhelming usage, with only 66% of the nets being used. Some women interviewed held false beliefs about the adverse effects of the chemicals used in the LLINs, even washing them to remove the chemicals. Others complained about insufficient size of some of the LLINs, which could not effectively cover the beds.8 Even though LLIN possession was high, usage was still limited by local misconceptions and inadequate nets.
Usage among the general population is also important. A 2018 study of LLIN use before and after a mass distribution in Uganda found the mass distribution method to be highly effective in promoting net usage. Those with access to an LLIN increased from 60% to 85% thanks to the distribution. This also translated into higher net usage, with a 24% increase in people who had slept under an LLIN during the previous night.[x] If LLINs are effective at preventing malaria, mass distributions of nets would seem a good method.
Effectiveness at Malaria Prevention
Do the nets work, though? Another study in 2018 conducted in Mbarara, Uganda, examined the occurrence of parasitaemia in children under five years old, a measure of parasites in the blood that can be used to measure the prevalence of malaria. The study found only 2.9% prevalence of parasitaemia in the children in an area six months after a mass LLIN distribution, versus a 19% prevalence in Uganda nationwide.[xi] The study attributes this to the high LLIN usage in the area either preventing transmission directly or providing a level of herd immunity to the area. The strong correlation between areas with high LLIN usage and low prevalence of parasitaemia gives a strong argument for the effectiveness of LLINs in preventing Malaria among the most at-risk group of children under five.
Uganda’s own ministry of health also reports that LLINs are effective in reducing deaths due to malaria. Their 2018 report on the National Malaria Control Program states that the LLIN program has reduced child mortality rates by 20%, clinical cases of malaria by 50%, and severe malaria by 45%.7 The campaign, aided by AMF, has the goal of providing LLIN coverage to at least 85% of Uganda’s population. This has been successful already in many districts, including Uganda’s Mbarara district.
AMF clearly has found a successful way of making a positive impact. The nets it provides are generally put into use, although there are some that do not get used, do not get used properly, or become damaged. Still, the nets that are put into use have been shown to be effective at reducing malaria, especially among the most at-risk groups of children and pregnant women. The malaria reduction also has a long-term positive economic impact. The Against Malaria Foundation’s methods are effective.
Problems with AMF’s Model
While highly effective, AMF’s approach is not perfect. Though it has its advantages, there are several limitations to the approach of focusing solely on LLIN purchase. Net distribution can become a problem, and has in the past, since AMF does not perform the distribution. Post-distribution surveys, while positive for transparency and evaluation, can also pose problems. Other limitations to AMF’s solution of only providing nets also exist.
Net distribution at large scale has posed a problem for AMF in the past. In 2011, the charity rating authority GiveWell listed AMF as number one for charities to donate to. In 2013, however, it was forced to rescind this recommendation. A major reason GiveWell provided for revoking its recommendation of AMF was its failure to finalize a sufficiently large LLIN distribution following a surge in donations due to GiveWell’s recommendation. Previously, AMF had distributed nets at scales of up to ~$1 million in Malawi, but the $10.6 million it received as a result of the recommendation necessitated a much larger distribution scale than the organization was prepared for.[xii] Currently, AMF is committed to ensuring that every contribution goes directly to the purchase of a long-lasting insecticide net, and not to administrative or distribution costs.[xiii] The organization believes that this is a key part of its transparency strategy that draws donors. Because all donations go directly to nets, however, it relies on securing relationships with distribution partners to get the manufactured nets into the hands of the people who will use them.
Another factor that plays into this difficulty in obtaining distribution partners is also a key part of AMF’s strategy. To ensure the nets are being distributed and used properly, and to gain feedback on its own methods, AMF requires that distributor funders provide extensive data collection and reporting on the distribution process and follow-up surveys after distribution. These requirements, while excellent for transparency and accountability, are more strenuous on funders than requirements from other possible LLIN suppliers. AMF claims that this was a major factor in its difficulty in obtaining a suitable large-scale distribution partner.11 GiveWell has since restored AMF to its recommended charity list and AMF has addressed some of these concerns by securing several large net distribution partnerships.[xiv] The underlying issues with the strategy, however, remain a potential problem.
In addition to potentially causing problems with securing distribution partners, the reporting AMF requires can have other issues. GiveWell describes that collecting and releasing the data adds costs and administrative hassles to the net distribution process. In some countries, however, this data collection is not an option because the infrastructure necessary to collect the data is not present. These countries would require additional broad funding to their health system infrastructure to make data collection possible.11
AMF’s commitment to providing the data from the surveys conducted post-distribution to evaluate net effectiveness was made apparent in the past. These surveys, conducted when possible, found many distributions to be effective long after they had been conducted, and when they were not, the evaluations provided possible causes for low net usage or conditions and provided recommendations for solving the issues. In recent years, however, AMF has not been prompt either in conducting the surveys or providing the data from them, despite several large distributions. The most recent surveys available are from March of 2016.[xv] This leads to concerns about AMF’s current views on transparency, despite its excellent track record.
Various other factors have the ability to reduce the effectiveness of AMF’s method. A rise in populations of insecticide-resistant mosquitoes is a possibility that has been voiced by the World Health Organization.[xvi] So far resistance has not developed into an issue, but the potential is there, possibly reducing the effectiveness of the LLINs distributed by AMF. Nets as a standalone strategy are also unable to guarantee removal of malaria as malarial mosquitos will survive away from the nets. This can lead to transmission when people are away from their homes or otherwise not under the nets.15 While LLINs can prevent the majority of the ways in which malaria spreads, they cannot stop its transmission entirely.
The Against Malaria Foundation is committed to reducing Malaria in Africa through supplying long-lasting insecticide treated mosquito nets for mass distributions among malaria-stricken communities. In its approach, it emphasizes transparency and evaluation of its impacts. The use of long-lasting insecticide nets remains an effective low-cost solution to preventing malaria in Africa. Mass distribution campaigns such as those used by AMF have proven effective in providing nets that will largely be put to good use. They have reduced mortality rates especially among pregnant women and children under five years old, who are most susceptible to malaria. The GDP of countries suppressing malaria has also risen in proportion to the amount spent on anti-malarial measures.
Though AMF’s strategy is effective, it is not without its weaknesses. AMF has had to overcome large-scale distribution issues, especially difficult with the stringent reporting requirements it imposes on distributors. Sometimes post distribution is not possible due to the funding required, and surveys on recent net distributions have been absent. AMF continues to commit to using general donations only for LLIN purchases, forcing the organization to rely on other donations to fund administration and distribution. It also prevents AMF from exploring other solutions to eliminating malaria, which LLINs cannot do alone.
Overall, the Against Malaria Foundation is still a top organization in transparency and accountability, using all donations to make a measurable positive impact in Africa without any apparent unintended consequences. It remains on GiveWell’s list of top charities to donate to and is where GiveWell recommends allocating the majority of donations to maximize donation impact.[xvii] AMF could improve by also taking donations for LLIN distribution or to better support surveys used to measure net impact after distribution, rather than funneling all donations to purchase nets. Though no organization is perfect, we have found the Against Malaria Foundation to be one of the best.
This post may have been edited by admin for clarity and length.
[i] CDC. “Malaria.” Centers for Disease Control and Prevention, 5 Oct. 2018. www.cdc.gov/malaria/malaria_worldwide/reduction/itn.html
[ii] WHO. “Malaria.” World Health Organization, 2018. http://www.who.int/news-room/fact-sheets/detail/malaria
[iii] Malaney, Pia and Jeffrey Sachs. “The Economic & Social Burden of Malaria.” Nature Vol 415, 7 February 2002: 680-684. Macmillan Magazines Ltd, 2002. https://sites.hks.harvard.edu/cid/cidinthenews/articles/sachsmalariafeb02.pdf
[iv] “Against Malaria Foundation.” The Life You Can Save, Peter Singer, 2018. https://www.thelifeyoucansave.org/where-to-donate/against-malaria-foundation
[v] Jobin, William, “Suppression of malaria transmission and increases in economic productivity in African countries from 2007 to 2011.” MalariaWorld Journal, Vol. 5, No. 4, March 2014: 6. https://malariaworld.org/sites/default/files/mwjournal/article/MWJ2014_5_4.pdf
[vii] World Health Organisation “Malaria, Insecticide Resistance.” https://www.who.int/malaria/areas/vector_control/insecticide_resistance/en/
[viii] LLIN Newsletter 2018, “National Malaria Control Program.” The Republic of Uganda Ministry of Health, Mar. 2018. http://library.health.go.ug/publications/service-delivery-diseases-control-prevention-communicable-diseases/malaria/llin
[ix] Taremwa, Ivan and Scolastic Ashaba, “Knowledge, attitude and behavior towards the use of insecticide treated mosquito nets among pregnant women and children in rural Southwestern Uganda”, BMC Public Health Volume 17. October 10, 2017. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4824-4
[x] Wanzira, Humphrey, et al. “Long Lasting Insecticidal Bed Nets Ownership, Access and Use in a High Malaria Transmission Setting before and after a Mass Distribution Campaign in Uganda.” Plos One, vol. 13, no. 1, 2018, doi:10.1371/journal.pone.0191191. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191191
[xi] Nuwamanya, Simpson, Noel Kansiime, Emmanuel Aheebwe, et al., “Utilization of Long-Lasting Insecticide Treated Nets and Parasitaemia at 6 Months after a Mass Distribution Exercise among Households in Mbarara Municipality, Uganda: A Cross-Sectional Community Based Study,” Malaria Research and Treatment, vol. 2018, Article ID 4387506, 10 pages, 2018. https://doi.org/10.1155/2018/4387506
[xii] Holden. “Change in Against Malaria Foundation Recommendation Status (Room-for-More-Funding-Related).” The GiveWell Blog, 22 Feb. 2016. https://blog.givewell.org/2013/11/26/change-in-against-malaria-foundation-recommendation-status-room-for-more-funding-related/
[xiii] Against Malaria Foundation, “Guiding Principles.” Against Malaria Foundation, 2018. https://www.againstmalaria.com/GuidingPrinciples.aspx
[xiv] Crispin, Natalie. “Mid-year update to top charity recommendations.” The GiveWell Blog, 28 Jul. 2018. https://blog.givewell.org/2016/06/23/top-charities-refresh/#Sec1
[xvi] “Global Technical Strategy for Malaria, 2016-2030.” Global Malaria Programme, World Health Organization, 2015. https://books.google.com/books?hl=en&lr=&id=LV40DgAAQBAJ&oi=fnd&pg=PA1&dq=world+health+organization+malaria&ots=kerrCTByDd&sig=mfBm72qEsIPlgcpNmDrDUTjgjCM#v=onepage&q=world%20health%20organization%20malaria&f=false