2025.03.31 USG Funding Cuts Episode 2
Elie Hassenfeld: [00:00:00] Hey everyone. I'm Elie Hassenfeld, GiveWell's co-founder and CEO, and today, I'm joined by Natalie Crispin. She's a program officer who leads our vaccines team and currently focuses on malaria chemoprevention, which is a type of malaria prevention that we're going to talk about today. Hey, Natalie.
Natalie Crispin: Hey, Elie.
Elie Hassenfeld: In the conversation that I had with Julie about a week and a half ago, we talked about the big picture of how GiveWell's responding to the recent reductions in aid from the US government. That's both how we're thinking about the short term and filling urgent needs and also the long term effects on aid and on GiveWell's work.
So today, we are gonna dive into one specific case, and these are some grants that we recently made to support urgent needs in malaria prevention, and specifically malaria chemoprevention of the kind that Natalie focuses on.
What we're gonna talk about today is representative of the work that our research team is currently [00:01:00] doing across all the areas in which we work, where we're investigating more than a hundred million dollars of grants to potentially support some urgent needs. And this, we think, will be additional above the normal grant making we would've done in the absence of these cuts.
So, just wanna turn it over to you, Natalie, to give us some context on these gaps and how we decided to fill them.
Natalie Crispin: Great. So we're gonna talk today about seasonal malaria chemoprevention. These are door-to-door campaigns that take preventative malaria medicines to children under five in areas where malaria is highly seasonal. A lot of this work happens in the Sahel region of Africa, and it typically occurs between like June and October every year during the rainy season.
GiveWell has funded quite a bit of SMC in the past, it's been a major program area for us. Something like $80 million a year has been GiveWell's recent contributions to this particular program, and we've funded work [00:02:00] on SMC in about seven countries. All of GiveWell's funding for seasonal malaria chemo prevention to date has been to Malaria Consortium.
Where we are now, is that when there were the USAID funding pauses starting at the end of January, this included their work in SMC. And so USAID had been funding SMC in parts of 11 countries, and these campaigns are due to start around June, and so it was quite time sensitive to make sure that work continued.
The most time sensitive piece was the preparatory activities before the campaign. So we looked across this set of campaigns, and we had a established SMC cost-effectiveness model, we had to do just a little bit of adapting that to these additional locations, and across the board they looked quite highly cost-effective. And so we knew we wanted to look more into how could we help them continue going, particularly in this [00:03:00] preparatory period ahead of the launch in June.
Elie Hassenfeld: SMC is an area that like you said, we've supported heavily over the years, and when the funding pause and cuts came down at the end of January, presumably, we were in touch pretty soon after with groups implementing this program to hear about the funding needs they have. I'm curious if you can describe, some of what you were thinking and maybe you were hearing from them in the time after the initial pause was announced, until we decided to come in and provide some funding. And in particular, there was a lot of back and forth- , there was a pause and a freeze, and then waivers and then maybe funding will come through. And I'm curious how the groups that you were in touch with were navigating that lack of clarity about whether funds would come through and how that affected the research that you led here with potentially supporting the groups?
Natalie Crispin: Yeah, that was a big part of our back and forth with them, because the [00:04:00] situation kept changing every few days in some cases. Overall, there were about a handful of groups that we needed to coordinate with to try to help and see if we could cover some of these gaps. We've been having something like weekly conversations with each of them to understand what's going on, and at the same time, also try to make progress in getting the information we would need to decide whether to make a grant, for what, and over what time period. Also learn more about these organizations because for the most part, they were not organizations that we had made grants to before.
And there was a lot of changes in that period, as far as what the status of their funding from USAID was, there continues to be changes. Now we've heard of recent changes in the last week, and there's been a lot of different types of statuses. So there's been like totally stopped, no funding, not allowed to do work. If you do work, it won't be able to be paid for later. There's been times when they had the authority to do the [00:05:00] work and the idea is that they would get paid eventually for that work, but they hadn't been receiving payments. And so there was some question of whether they were going to in the future, and that gave them pause about whether they could continue.
So, we were trying to give assurance that they would have some funding for this period, while not overcommitting ourselves, given that there are a lot of urgent needs, and we wanna be careful with the limited funding that we have.
Elie Hassenfeld: You know, we've, GiveWell has, historically supported Malaria Consortium for the SMC program. And I think you said the US government has supported multiple organizations in these other countries. And so as part of this work, we were talking to how many new organizations that we were trying to learn about how they would implement activities in these countries?
Natalie Crispin: Right, so we've had some conversations that started and then there wasn't a need or we decided to go a different direction, but in all, probably five, six different organizations we hadn't worked closely with [00:06:00] before or hadn't worked closely on this type of programming with before.
Elie Hassenfeld: So now we've decided to make these grants and direct some funding, so about how much money and to how many organizations in how many countries?
Natalie Crispin: We've made an initial set of commitments, we're still working out the contracting details, but we plan to make the set of commitments totaling about $3 million for the period before the campaign actually starts. So everything from planning meetings and ordering, in some cases you need cups and spoons, or pre-positioning the drugs, moving them across the country, some of the training before campaigns. And that is across five or six countries, we're still working out some of the details.
And we'll keep in touch about whether there are emerging other gaps, but we think that will be the bulk of it for this initial period.
Elie Hassenfeld: And just to kind of make this concrete, you said one example is cups and spoons. So maybe it'd be worth just describing a little bit [00:07:00] about how the SMC program works and like when people go door-to-door, what they're using the cups and spoons for and why that's necessary now for the campaign that starts in June.
Natalie Crispin: Yes. So, the way an campaign works is that community distributors have two drugs in a co-pack- the acronym is SPAQ, SP is one of the drugs, AQ is the other drug. They're packaged together. And the community distributors go door-to-door every month for four to five months, depending on the length of the rainy season in a given place. And when they go to a household, they give them three days worth of doses. The first day is SP and AQ. Second day is AQ, third day is AQ. And the way the tablet works is you put a little water on it and it dissolves and the child drinks it. So it can be helpful to have a cup and a spoon to mix that together. Some programs just rely on households having that and others they bring it along to make sure. [00:08:00]
Elie Hassenfeld: Got it. So part of what was needed is this campaign was set to go in June. The drugs had been purchased, but among other things, there were some supplies that had to be purchased and in place for the campaign to go off on schedule. You mentioned some of the other things that had to happen in order for SMC to go on and be successful starting in June, and I think one of the things you mentioned was distribution trainings. Maybe you could just like talk a little bit about, what those are and why they're critical to the success of the program. Why it was so necessary to come in now with funding to ensure that this could take place.
Natalie Crispin: The bulk of the distribution trainings are for the community distributors who go house to house, there are also trainings for supervisors at a couple different levels who help with the quality control of the campaign. For the community distributors, some of them will have done it in past years, and this will be refresher training, some will be new to the program. And while it's a pretty straightforward activity, there are definitely details that matter [00:09:00] about asking if the child has had a recent fever and referring them to a health facility to get acute treatment for malaria rather than this preventative treatment. There's the way that it should be dispersed and the instructions that should be given to the caregiver about how to do it on day two and day three. Also data collection and transmitting that back to the higher levels. In some places, they have started using digital data collection, and so there's use of the phone-based data tool that they get training on.
Elie Hassenfeld: Right, so these are all things that have to happen before the campaign gets started to ensure that this program goes off successfully. And without the organizations knowing they'd be supported by US government funding or if the funding wasn't coming through, they just weren't able to move forward with these activities. And the pre-campaign activities is the focus of this set of grants that we recently committed to.
Natalie Crispin: Yep, that's [00:10:00] right.
Elie Hassenfeld: I don't know if people would have this question, but, one question that I could imagine folks having is, why did it take a couple months to decide to make these grants? You know I guess the alternative case might be, we've supported SMC for a long time. It's a fairly straightforward program. We knew that funding was in question going all the way back to the end of January. Why not just cut a check directly to these organizations? What kind of questions were we trying to answer to ensure that we were ready and comfortable delivering funding and being confident it would be necessary to delivering a very effective program?
Natalie Crispin: Yeah generally GiveWell's process is really quite rigorous and we are adapting our approach to this current moment. So we have moved quite a bit faster in making grants to something like five new organizations in places where we have not supported this program before. That said, there were things that we wanted to do and felt that we had the time to do them, we didn't have to cut checks right [00:11:00] away because there was a little bit of time to do some due diligence.
At first, we needed to track down who the groups were that were doing this work, there were quite a few of them. So it took a week ish to figure out who was doing what. These contracts that USAID works with are often multi-program, they have multiple organizations that are doing different pieces of them. So sorting out who we could fund took a little time. There was also a lot of back and forth on what we were talking about before with the USAID funding and times when we thought our funding would not be necessary.
And then there were some other key questions that we were trying to answer. So one was whether the drugs, the SPAQ would be available. We knew that the drugs had largely, if not entirely, been ordered before the funding freeze, and we didn't want to jump into placing any new orders when that might be available. Also, we didn't know that there would be [00:12:00] enough time, like generally you place these orders many months in advance. That was a worry at first. We're at a place now where we feel pretty confident that the drugs will be available, that will not be a bottleneck. There were some concerns with these organizations about whether they would be in a position to provide the support for the campaign. So whether they would have retained the staff, whether they would be solvent as an organization. So we were asking questions about that.
We did some refinements of our cost-effectiveness model, largely around how much cost per child reached, that we asked them for information to calculate. And then we also wanted to align with these new partners on things that matter to us as an organization around transparency, publishing detailed grant pages about why we do make grants, but also what our reservations are, and to align on the idea that we want to try to pursue coverage surveys that are gonna give us feedback on whether these campaigns are delivering at high coverage. And then there was some [00:13:00] negotiation on the size and nature of the budgets, how long they were gonna cover, and the details of the contracts that take a little bit of time.
Elie Hassenfeld: So I'm curious looking at the full scope of what we considered in this grant, and then also we made sure that we were able to maintain the commitment to transparency, we'll write about the grants, and we'll have coverage surveys so we know how the grants went, negotiating budget deals and contracts. What are the main risks and or weaknesses of these grants relative to normal seasonal malaria chemoprevention support? You know, like grants that you've led numerous times and more like normal times, how would you say these differ because we decided to move more quickly to fill this urgent gap?
Natalie Crispin: We have not nailed down the coverage survey piece. We have aligned at a high level, but we would like to have those surveys, and we do not feel confident that will happen for these campaigns. We don't know these partners that well, we do know that they have experience with SMC [00:14:00] in these locations, and that SMC is a pretty mature program model.
Plus, it's relatively straightforward, in that you go door-to-door, you deliver this treatment in a very similar way, across a large area. So we would expect generally less variation in quality than things that depend on more judgment, differing types of infrastructure perhaps.
But we did think it was valuable to try to maintain the existing ecosystem and the partners that were already working there, both because of their experience in that particular context. And the ability then for USAID funding, hopefully to come back online and plug back into that existing ecosystem.
We think that it is possible that they will have lower coverage. It's also possible they'll have higher coverage than what we've seen before. I think there's just more variation expected and more questions about whether we'll find that out. But overall, definitely think that this was the appropriate way to go, given [00:15:00] the time that we had and the possibility of US funding coming back.
Elie Hassenfeld: So I guess there's two things you said that I wanna pull out 'cause they seem important to me and just wanna make sure that I'm getting them right. So number one is that, at the moment, we've committed to fund this pre-planning activity, and we're hopeful that the funding for the campaigns themselves will still come through from government sources. And, you know, that happens then in some sense, like our leverage, our influence over the monitoring that happens is lower than it would be in a case where we're paying for the entire campaign.
And then the second point is that we, at GiveWell, are requiring a higher level of rigor in monitoring and evaluation than is standard for the program across the board. And so the standard kind of coverage survey that we ask Malaria Consortium to deliver for its SMC programming is just not the standard that these organizations are delivering for their SMC programming in other countries, 'cause the US government wasn't requiring that kind of monitoring before. [00:16:00]
Natalie Crispin: That's what we've been finding is that it was not required. It happens some places, and not others.
Elie Hassenfeld: Yeah, that makes sense. Anything else on this set of grants in particular that's worth highlighting?
Natalie Crispin: I'm really excited about this set of grants, I think we were just like in the right position at the right time to be helpful here. It was a program that we knew quite well, and we had some connections in the space and were able to move quite quickly. The partners that we worked with were really helpful and great to work with across the board. They were dealing with all of these back and forth about what their funding situation would be, and we were talking to them about relatively small amounts of funding, but funding that would enable them to keep doing these campaigns. And I think they were just really committed to wanting to do this work and willing to work with us even though it was a lot of work for a relatively small amount of money but was necessary to make it happen.
So, it's been a really interesting and at [00:17:00] times really sad experience, but also, a really great one to see the set of actors working on these malaria programs come together and keep focused on delivering.
Elie Hassenfeld: Right, because this was really a case where there was something ready to go in June. It was on track, but then at the end of January, funding just got turned off. And so activities that they had to implement in the subsequent months between, January and June, got put on pause and we were able to step in and ensure that those intervening activities could take place.
Hopefully by June, funding will be back in place to fund the full campaign. But regardless, we're able to keep these campaigns on track and it was really a case where we were able, through the work of the team to fill this emergent, urgent need for a very effective program to take place later in the year.
Natalie Crispin: Yeah. Yeah. So I think it just, all came together in a way that worked for us, and the partners were really helpful in that.
Elie Hassenfeld: I wanted to end our conversation by zooming [00:18:00] out a little bit. Normally, you have these two focuses of your work. One is on this malaria chemoprevention portfolio while we're looking to hire someone to lead the portfolio as a whole, and then separately on vaccines. And I'm just curious, like when you look forward over the next month or two in your job, what do you think you'll be focusing on next with respect to the US government cuts? Like will it still be the grants we've been talking about, will it be other things, where do you think your focus will be?
Natalie Crispin: Yeah, it's a little hard to say, things keep changing, but on the malaria chemoprevention side, we'll be following this particular set of grants, having conversations with those implementing partners and understanding whether there are any remaining funding gaps that could help move things along.
With my vaccines hat on, I think that's playing out over a longer period of time. There's Gavi, which is the major external funder in this space, and then domestic governments fund a lot of their own delivery, along with some external support. And so we [00:19:00] are likely to see some impacts on those delivery systems. There's a fundraising round called their replenishment coming up for Gavi, and that will be a big moment to see what happens for their next five years. So we're having a lot of conversations and trying to understand where the gaps are emerging, but I think it's gonna keep changing.
Another place that we're interested in is malaria vaccines, which are a new tool to fight malaria, and we think they could be similarly cost effective as SMC and malaria nets. And so trying to learn more about where the gaps on the margin are going to be. It's always challenging when something is scaling up because you don't know where things are gonna settle out and what the status quo is gonna be. But we're following that and we think there might be some great work to do there.
Elie Hassenfeld: I wanted to end by asking you a question that I've been thinking about the last couple months and I've heard from some donors, which is, we talked in this conversation about one specific [00:20:00] gap that we filled, and in total we've now committed about $15 million to support needs that were emergent because of the US government cuts. But the US government cuts are in the billions, you know, the US government is providing, I don't know, 12 to $15 billion or so in health assistance every year. And so I guess there's this question of why aren't we filling more gaps more quickly? Or, why is the total amount that we've directed so far relatively small in the scheme of what's out there.
I thought in this conversation, you did a good job just articulating, when you zoom all the way in on a need, there's a lot of questions that are worth answering before writing a check I'm curious, like, what else do you see? Why do you think it's the case that the needs are so large and the total amount of funding we've directed, so far is about $15 million, you know, not such a huge amount.
Natalie Crispin: Yeah, it's a great question. So I think part of the answer is that we will see some additional gaps that we will [00:21:00] fill in the future, there are a number of things that we're continuing to look into. There's also been some positive movement on the US government side. There's been funding for malaria, HIV, malnutrition, that was initially stopped and has returned. It's far from a hundred percent, and I think will leave big holes. The amount of total funding is so large that even a fairly small percentage of that is a big number.
Now we're only looking for the things that are very highly cost effective, given our limited resources. So we do need to be pretty choosy about what those are, and we might not want to fill gaps one-to-one. We might wanna look for more cost effective approaches to achieve the same goals.
So for an example, if USAID was paying for healthcare workers to retrieve vaccines from central stores, we might wanna look at, do we wanna just replace that system so that vaccines are getting to where they need to? And that [00:22:00] might have higher costs than a different system where you could push out vaccines and have a delivery system that brings them to those healthcare workers, and then those healthcare workers have more capacity to do other things.
So I think we also want to just be thoughtful about how we fill the gaps, and gaps are sometimes in areas that we aren't that familiar with, and we're getting up to speed. Our team's doing a lot to expand on new areas that we haven't done as much work in, but it takes a little time, and I think we'll have some more updates in the next few months.
Elie Hassenfeld: That's great. Thank you, Natalie.
Natalie Crispin: Thanks, Elie.
Elie Hassenfeld: Hey everyone, this is Elie again. Thanks for listening. We've been thinking a lot at GiveWell about how to respond to the current moment and focus on the aid cuts, both in the short term and the long term.
I hope today's conversation was helpful in zooming all the way in on one specific program that we were able to step in and support. Hope this is helpful in understanding more about how we're [00:23:00] addressing and responding to the cuts on a day-to-day basis.
We continue to hear from donors every day who want to help and direct funding to support needs that are emerging in low-income countries. Our recommendation remains to give to GiveWell's funds, either to the Top Charities Fund, which goes to our four top charities, or to our All Grants Fund, which gives us slightly more flexibility in how we respond to needs as they emerge.
Just wanna say thanks again for listening, for supporting GiveWell, and for caring about doing the most good we can together. We really appreciate it. Thank you.