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Welcome to GiveWell’s podcast sharing the latest updates on our work. Tune in for conversations with GiveWell staff members discussing current priorities of our Research team and recent developments in the global health landscape.
Webinar Promo: [00:00:00] Before diving into today's episode, we want to invite you to join us for a virtual panel discussion with GiveWell researchers on Thursday, December 4th.
Major cuts to foreign aid have created deep uncertainty for global health programs and their futures. At GiveWell, we've been assessing and responding to the impacts in real time, leveraging 18 years of cost effectiveness research experience.
We expect needs to continue growing in the years ahead. As foreign aid becomes more limited, it's even more important that resources are used as effectively as possible.
To learn more, join our upcoming webinar—Growing Needs, Shrinking Aid: Cost Effective Action In a Year of Funding Cuts—on Thursday, December 4th at 12:00 PM Eastern, 9:00 AM Pacific.
Moderated by GiveWell co-founder and CEO, Ellie Hassenfeld, a panel of GiveWell researchers will answer questions selected live by the audience on the effects of recent aid cuts, how [00:01:00] GiveWell is responding, and what we're learning along the way—including our predictions and uncertainties about the future.
To attend the webinar register at givewell.org/GrowingNeedsShrinkingAid. We hope to see you there.
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Elie Hassenfeld: Hey everyone, this is Elie Hassenfeld, GiveWell's co-founder and CEO. Today we're going to be talking about GiveWell's support of a program called seasonal malaria chemoprevention, in response to USAID cuts. This program is administering anti-malarial medicines at monthly intervals during the rainy season, and that's when the risk of infection from malaria is highest. It's delivering this anti-malarial medicine to very young children, those between the ages of three months and five years.
Historically, GiveWell has primarily supported an organization called Malaria Consortium to deliver seasonal malaria chemoprevention. In this conversation, we're going to use the acronym [00:02:00] SMC when we talk about this program. We've supported Malaria Consortium to deliver SMC since 2016 when we named it a Top Charity. And all told, we've directed about $500 million to SMC since 2016. So as an organization, we know this program, SMC, fairly well.
When the news about aid cuts came down earlier this year, it was immediately clear that there could be a large need in SMC. What we'll be talking about today is how it was hard to determine who had a need and how much the need was, which organizations to support, and how to support them. These were all organizations that had previously been US government funded. So they weren't Malaria Consortium, whom we had supported, but other ones that we had to get to know.
And of course we wanted to be sure that if we were going to direct donor funding to these organizations, that we provided support where it was needed, and to the extent it was needed, but not more than it was needed.
We prioritized SMC because it's really an amazingly straightforward [00:03:00] program that in many ways is paradigmatic of the kinds of programs GiveWell supports with our Top Charities. It's delivered a few times a year, and a number of randomized controlled trials show that it leads to a really massive reduction in annual cases from malaria. When adhered to fully, it prevents about 50%, half the cases of malaria. This program is absolutely massive globally. It reaches more than 50 million children per year.
So this was a program that, you know, when it was put at risk, it was clear that it was worth our attention to see what we could do to try and address the potential risk that the program wouldn't move ahead.
Today I'm going to talk to Natalie Crispin. She's the program officer who led our work on this program. And she said that this work that we did this year was one of the most exciting things that she's been involved with at GiveWell, because it was a lot of work and a big challenge, but the money we directed ultimately led to us ensuring that many [00:04:00] millions of children would be reached with a lifesaving program. And so we're very glad for the role that we were able to play in ensuring that this program could move ahead.
Hey, Natalie.
Natalie Crispin: Hey, Elie.
Elie Hassenfeld: Before we dive in, could you just introduce yourself and your history at GiveWell?
Natalie Crispin: As you said, I'm a program officer here at GiveWell. I've been at GiveWell for 16 years, so I joined a much smaller version of GiveWell right after I graduated college. I currently lead our vaccination portfolio, however, I worked on malaria prevention grants prior to this, and that included SMC programs. So that's the reason I'm joining you here today.
Elie Hassenfeld: Thanks for having this conversation, Natalie. In this case, we followed SMC for a long time, and we knew early on this year that some SMC campaigns were at risk. Can you just tell us a little bit, maybe first, about how SMC works and why you were particularly worried about these campaigns?
Natalie Crispin: Right. So SMC, it's seasonal, that's the S in [00:05:00] SMC. And it is a series of months in which malaria is at its highest in certain areas where it peaks once a year. This tends to correspond to the rainy season, and the rainy season in much of the Sahel region of Africa, where a lot of the SMC is done, is in around June to September.
So the aid cuts happened in January, and that was just shortly before the preparations for the year of SMC were due to kick off, in the spring. And so, we were looking at what was happening in the aid cuts and seeing that if this lasted the full 90 days, which were originally announced for the aid cuts, that that was going to cut into this planning process and put these campaigns at risk.
And so what we started doing was asking around, trying to understand [00:06:00] where was the US government formally funding these programs, these SMC programs, and where were the organizations that they were funding each implementing.
And so we had a series of conversations to match up those cuts to the specific locations and implementers, and start to evaluate what might look particularly cost-effective and require some intervention to keep them on track for that June to September period.
Elie Hassenfeld: Got it. So these are campaigns that happen from June to September, and staff from organizations go literally door to door, delivering the anti-malarial medicine. And then what we were, at this point early on, thinking about supporting was the planning activities for those campaigns. What are the kinds of things that they're planning? How critical was this planning, and why was it the focus of your [00:07:00] investigations?
Natalie Crispin: It was the focus largely because of the timing and that we wanted to make sure that those activities happened before the campaign. And I do think they're critical. So those activities include planning how many packages of drugs and how many drug distributors would be sent to each local area, each sort of a point from which they would then be sent out into the communities, so that might be a local health center.
They also needed to hire and train the individuals who would be distributing the drugs during the campaign. Those individuals needed to know how to explain the benefits and potential side effects of the drugs, how to determine the children's ages—because they're supposed to give them to children who are above three months but no more than five years old. These drug distributors will administer the drugs directly to the children when they arrive at the home, but then there's also drugs that those children need to take on the second day and third day. And so they need to know how to explain that well to the [00:08:00] parents. And then in rare cases, they don't provide the drugs and instead refer sick children to health facilities, and so they need to know how to identify those children and how to provide the information about what should happen instead.
Also, the preparations need to include letting the communities know that this is going to happen and when it's going to happen so that it's not a surprise and that people know to be available for those activities.
These things do get easier each year as these programs last over many years. However, there's turnover and there's movement of populations, and they do need to happen in order to ensure a successful program.
Elie Hassenfeld: Right, so there's a few different pieces here, and I think it might help to just talk about the scale of the program. In one of the countries we support, how many households are being reached with this program?
Natalie Crispin: So to give one sense, the Malaria Consortium itself is just one of many implementers that [00:09:00] provide SMC. They reached about 22 million children in 2024 with SMC, and about 15 million of those were supported by GiveWell and other philanthropic funders. I think globally it's something like 50 million children a year are receiving SMC. But the sense that I want to share is that it's like a very massive program across tens of millions of children.
Elie Hassenfeld: One challenge that the planning activities have to address is that the sheer logistical challenge of ensuring that the right number of medicines are available to reach every child who should be reached with this program, that the staff who are going door to door know what to tell parents. You know, just imagine someone showing up at your door saying, here's preventative medicine for your children. As a parent, that's something I'd have a lot of questions about, and so I think it's important that staff are trained effectively to do that [00:10:00] well.
And so all of that was at risk in this period where we weren't sure if the funds for preparation would come through. How did we go about thinking about the nature of support? You know, in normal times when we've supported Malaria Consortium, one of our Top Charities, to implement this program, we provide them broad support to implement this program. You know, we have followed them over a long period of time.
What kind of support did we provide to the organizations that we funded as part of this short-term effort to ensure the campaigns could go ahead.
Natalie Crispin: The support did look quite different from what we normally provide to Malaria Consortium as part of a long-term support for their programs. The US government announced that this was a short-term pause in their work. And so what we wanted to do was keep the programs going during this period with a unclear end date. Because the programs were under review, it wasn't entirely clear when that funding would be [00:11:00] resumed.
And so, we went through a bunch of internal discussion, discussion with the organizations that were implementing the SMC who we were looking at supporting as to how to structure this support. Just literally like whether to make it a loan, or a guarantee, or a upfront payment, in order to enable them to do the work, without replacing [00:10:00] their existing stream of funding from the US government, which we expected to be resumed, you know, potentially any day or week during this period.
And so we ultimately landed on funding that was guaranteed to cover the planning period but was distributed as monthly disbursements. And for each additional monthly disbursement, we asked the organization who was receiving it to confirm whether or not they had resumed receiving US government funding. By the end of that period many of them had, and so not all of the funding that we guaranteed was actually paid out.
Elie Hassenfeld: And so a [00:12:00] lot of our goal here was to ensure that the planning could go ahead so the programs could operate, while also only spending the amount that we really needed to. And so we tried to come up with mechanisms that would enable us to retain funds or receive funds in return if it didn't end up being necessary. And I think that happened in some cases.
Natalie Crispin: Yeah, it did. So in the end, we made about $8 million worth of commitments to these different programs. There were six different country programs that we ultimately made commitments to. Of that 8 million, we spent about 4 million, and so much of the funding wasn't ultimately paid out, and a small amount of the funding that was paid out was returned.
Elie Hassenfeld: And so what was literally happening with these organizations that we were talking to in this period, did they, did they not have sufficient cash in the bank, and so us directing funds to them enabled it to move ahead? Or were they just running low on cash or fearful of running low on cash and unsure about [00:13:00] whether the US government would come through in the future, and so the guarantee just gave them the confidence to move ahead? How did our actions affect, you know, what they were able to do?
Natalie Crispin: So in all of these cases, the US government was saying, we are not going to be paying for the activities that happen during this period. So, some organizations across the wider space of organizations that were facing these pauses in their USAID funding were able to cover some with unrestricted funding that they had.
But most of these organizations are not sitting on large amounts of unrestricted funding. And if they have large US-funded programs, that's just not something they can do for more than maybe a couple weeks. And so, we were covering costs that they did not expect to be able to get reimbursed because the government said that they were not covering this period of activity. And, yeah, the idea that they could cover [00:14:00] that themselves was not realistic in most cases.
Elie Hassenfeld: Got it. What was challenging about deciding whether or not to direct funds in this case? We know that SMC, this malaria program, is very effective, it's very cost-effective. We knew that funds had been put on pause and maybe would be cut. What kind of questions were you trying to answer, and what was challenging about not just moving ahead immediately with funding organizations who were in need?
Natalie Crispin: I think one of the biggest questions was what was gonna happen next week with US government funding. That was often throughout this process not clear. And so we were trying to come up with grant structures that made sense for that situation.
However, we were also trying to react to different pieces of information that kept changing about, for example, announcements that life-saving work, which should include SMC, was exempted from the pauses, and maybe [00:15:00] that meant that no additional work on this was necessary. But then we were waiting to see the paperwork come through to each of the different organizations about whether their specific funding stream had been renewed. Sometimes they would receive notice of something, only to two days later, receive notice that actually that was a mistake and they were back to where they started.
So, this just took a long time to play out entirely.
Elie Hassenfeld: I guess there, like part of the challenge is we're talking about large amounts of money. You know, ultimately, we guaranteed about $8 million. And this was with organizations mostly we hadn't worked with before. You know, they were organizations working in countries that had had a different funder—the US government—previously.
And so we really wanted to be confident that the money we were spending was needed. And so I guess as you were getting these different reports of what the government might step in to do that, you know, led us to at least question whether the funding we'd provide would end up being necessary.
Natalie Crispin: That's right. There were 11 countries that the [00:16:00] US government was funding SMC in. One of those countries was one that we decided early we weren't going to pursue because there was lower malaria burden there, and we didn't think it was going to be above our cost-effectiveness threshold.
The other 10 we were talking to, at least at some point in the process, and four of them, ultimately they got their funding back sooner and didn't need any support. But just because of sort of idiosyncrasies in the system, the other six got it later. One of those got it much later, and we made a further grant to support the implementation for about half of the SMC cycle.
So, there was not sort of a single story for all of the countries, and there was just a lot of coordination and discussions to keep track of each different country situation, which was also changing quickly over that time.
Over the course of this grant investigation, we had about 60 calls in about three months. And we were building a lot of new [00:17:00] relationships. We were, as I said, reacting to good news and bad news. And there were times when we thought we needed to move very quickly because the organizations were going to lay off key staff and maybe we needed to get them funds within a couple of days. So there was a lot of sort of fits and starts where we thought we were going down one path, and ultimately that was a dead end and we needed to start again.
Elie Hassenfeld: Looking back now, like how did this go from your perspective? How do you think about this work that we did that, you know, you led during this period?
Natalie Crispin: I think it's one of the most exciting things that I've been a part of at GiveWell. It was not a huge grant. GiveWell sometimes makes large grants that have a lot of impact across a long period of time. And this was a different sort of thing, but it meant that a lot of SMC that was otherwise at risk happened.
And we can't play the tape back and know what would've happened without this funding. But I think it's some of the best funding that GiveWell [00:18:00] has spent because it enabled these programs to know that they could continue their work.
Even if most of that SMC could have happened without GiveWell's intervention, enabling even a fairly small amount of that to happen probably would make this worth it. It was a lot of work, but I think—we've gotten a lot of gratitude for it from other players in the SMC space—and I think that just reflects that this was coming at a time when there weren't a lot of other options, and GiveWell was just in the right place to be able to understand this program and make grants relatively quickly to ensure that the programs could continue.
Elie Hassenfeld: Right, it's a case where the impact, which is a little hard to know counterfactually, but the impact was disproportionate to the dollar amount. And really the dollar amounts, relative to other grants we've made, are fairly small, but the potential impact because it enabled this much larger set of work to surely go ahead with eventual US government [00:19:00] support, you know, really made a huge difference.
And so the US government support eventually came back and, you know, how did these programs play out over the course of the year? You know, now we're in November, so I guess the campaigns were completed a couple of months ago.
Natalie Crispin: Yeah. So all the campaigns happened, it was really a great success. Across all of the countries that we were speaking to folks about, the US government funding resumed, and the campaigns happened pretty much on time.
So 2025 just looked pretty similar in terms of total US government funding for SMC as 2024. And we're just really excited to have played a small part in making that happen.
Elie Hassenfeld: Right. And so I guess there was this moment, you know, between the end of January and then February, March when you were involved in this, when it seemed like this outcome wasn't guaranteed. Like there really could have been an outcome where, you know, all of these SMC campaigns didn't happen or weren't able to happen in the same way that they had in the past.
Natalie Crispin: Yeah, we definitely had many fairly doomsday [00:20:00] meetings about what was going to happen with all of this SMC and where could resources come from to make this happen. If you had told me in February that it would all be fine in the end, I would've thought that was a pretty low probability outcome. But it has, and it's really a optimistic story.
Elie Hassenfeld: So how about looking forward to 2026 and beyond? I mean, with global aid still in a somewhat precarious position, US funded aid is somewhat uncertain. Predict the future, what's gonna happen in 2026 and beyond?
Natalie Crispin: Predicting the future is tricky right now. Maybe it's always tricky, but feels particularly tricky right now, where the US government is not clearly signaling what it's going to do. It does seem that 2026 is looking pretty good on the SMC front, I'd say, where, a lot of the funding for SMC, in addition to the US government also comes from the Global Fund, which many donor governments contribute to, [00:21:00] including the US, and 2026 is part of a phase of the Global Fund that's already funded. So, we think that that will look similar to 2025.
From 2027 onward, we're less sure because the Global Fund needs to raise a large amount of additional resources. As we're recording this, the Global Fund is about to start its fundraising event, where they bring donors together and ask for pledges for that next period. So by the time this airs, there might be some more news on that. But, that will be a big piece is what the Global Fund raises and then also what the US government decides to do in direct funding of SMC.
The signs so far suggest that malaria funding will be a continued priority for the US government. That might decrease over time, but in its early stages in the next year or two we [00:22:00] should see a pretty stable picture. We'll see, I think we'll keep monitoring that. It's definitely not guaranteed.
Elie Hassenfeld: Looking back at this whole investigation and this year, you think we spent, you know, the right amount of money, or we could have spent less and got similar results, or perhaps we should have spent more to enable something else to happen? How do you look back at those decisions and what you think we should have done differently?
Natalie Crispin: It is always possible to look back and say, I wish we could have spent less time and gotten to the answer more quickly. That feels like the most costly piece was the amount of time that went into dead ends that didn't lead us anywhere.
In terms of the money, I feel really good about the amount that GiveWell spent on this work. And I think it has disproportionate value compared to the amount. So, yes, I think the amount of money spent was just really good, and I would do that piece again for sure.
Elie Hassenfeld: You mentioned, you go through these research dead [00:23:00] ends where they don't lead anywhere, and you say, I wish I could have that time back. What were some of those dead ends that we ran into in the research that maybe at the time we felt like we had to, you know, turn over the rock and look underneath, and then on reflection it didn't really lead us anywhere.
Natalie Crispin: Yeah. So some examples were, we spent a long time trying to figure out a structure for giving loans rather than grants. And as we thought about it more, we just couldn't see the value there. But we were spending time talking to our legal counsel and to the grantees and understanding how they would incorporate this into their own financial processes. So a lot of back and forth on that.
Another example was a case where someone told a government official that GiveWell had committed to funding SMC in a region of their country. And if we had communicated more clearly, we think that that would not have played out that way. It wasn't true at the time that we had made a commitment, and we found out about it through a back channel. We had to [00:24:00] then go and tell the government official that it wasn't the case. They then had to do a bunch of backtracking with their colleagues, which they did not appreciate having to do, that was messy.
In the end, the US funding came back in time for that SMC to happen, so it was okay that GiveWell hadn't committed to it. However, we definitely wish we could have that time back, and not have strained that relationship.
Elie Hassenfeld: I mean, there was a lot of challenges just dealing with the uncertainty and how quickly information was changing, which is unusual for us in the work that we do. Any lessons learned from this work? You know, things we did particularly well here that we should make sure to continue to do in the future?
Natalie Crispin: This work really brought home to me how valuable it is to be connected in the space that you're working in, and to know how to reach the right people quickly, so that when things change, you can get a read on what's going on and how your work should change too.
This [00:25:00] particular piece of work with the SMC reaction to the aid cuts, we had some connections and those were very useful in making additional connections in the space of SMC. It would've been even more valuable if we had started from an even stronger place of having those, that network. And this effort was a way to jumpstart that broader network. So if we had to do it again, we would be in a much better position because we would already have that network.
And I think that's something that GiveWell is trying to apply across many of the areas that we work in. I know in the space that I primarily work in today, vaccination, a big priority is to understand who's doing what and to talk to them regularly so that we can be learning from them, sharing what we're doing, getting feedback on that work. And I just can see the value more clearly than I had before.
Elie Hassenfeld: Was there anything that happened in the investigation that was particularly [00:26:00] surprising, where you remember thinking, you know, we just learned something and that's not at all what I would've expected to come up in this context?
Natalie Crispin: I found it surprisingly challenging to get information on how much SMC costs in these programs. Because when GiveWell funds a program, we're generally funding one specific thing. It's SMC, it's insecticide-treated nets, it's vitamin A, and the cost part is the more straightforward part. You ask, how much did you spend? And there is definitely complications around what the coverage rates were and the target population.
However, with these US government contracts, there was a lot more complication around figuring out how much SMC specifically costs, because the way these contracts worked, SMC was often bundled with a lot of other interventions, mainly malaria interventions, but there might also be some other pieces in there. That took quite a bit of back and forth with these [00:27:00] organizations, and was one of the pieces that initially I thought was going to be quite simple. They already had budgets for the US government, couldn't they just pass them along?
Elie Hassenfeld: Got it. So the way it worked is the US government was funding some organization to implement a set of activities, one component of which was SMC. We really wanted to support SMC, in contexts in which it would be cost-effective. And so to get at that, we needed to know how much it costs, what we would be paying, what the budget would be.
But that budget was wrapped up in a series of other programs that we were not necessarily interested in supporting. And so it was just very challenging to sort out how much the program we wanted to support actually costs.
Natalie Crispin: That's right. We didn't talk about quite how cost-effective these programs are. Give Well's benchmark, we try to fund programs that are at least 10 times as cost-effective as that benchmark. And many of these SMC programs that we were looking at were 15, 20, even 30 times as cost-effective as our benchmark.
So [00:28:00] one of the programs that we ultimately funded part of the implementation of, and therefore was the biggest outlay of funding as part of this work, was around 20 to 25 times our benchmark in our modeling. That was something that was playing really strongly into our thinking from the beginning, was not just that these programs were above our bar, but they were actually many times above our bar, and we thought they were among the most valuable programs that GiveWell could fund or could keep going.
And so this was just like a really high priority for us because we think about cost-effectiveness not simply as above or below the bar, but rather how cost-effective is it? And if it's well above the bar, that is a higher priority for us. And, yeah, just to also translate that, about 20 to 25 times our benchmark means that these programs are saving a life for around $2,500.
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Elie Hassenfeld: [00:29:00] Hey everyone, it's Elie again. So I hope that story provides an illustration of one way in which GiveWell responded to the aid cuts this year, showing a little bit of the, you know, the chaos and the uncertainty that we had to deal with, and how the team stepped up and was able to respond to ensure that lifesaving programs could go ahead.
A lot of the time, we think about our impact as mostly a function of the amount of money we're able to direct. But in this case, I think the particular way in which we were able to direct these funds at a moment when there was high need meant that we were able to have a really significant impact on this lifesaving program going ahead.
Thanks as always for listening. If you have any questions, if you have topics you'd like to hear us discuss, please send them in to info@givewell.org. And as always, if you'd like to support our work, there are three primary options through which you can do that. You can give to our Top Charities Fund, which enables us to support one of our four Top Charities. These are the [00:30:00] organizations that we have the highest confidence in that their programs are significantly impactful. For most people just getting to know GiveWell, we recommend the Top Charities Fund.
We have our All Grants Fund, where you can support the full range of our grantmaking work. And then finally, there's supporting GiveWell in an unrestricted fashion, giving us the ability to choose between supporting our operations directly and regranting the funds to organizations that need it. Thank you as always for your support, and thank you for listening.