Against Malaria Foundation: What we do, How we do it, and the Challenges

February 12, 2019

The Against Malaria Foundation is one of the most effective global health charities in the world, and the single most common donation target for EA Survey respondents (as of 2018). What makes this organization so special? How do they approach their work, and what challenges do they face? CEO Rob Mather answers these questions in this talk from EA Global 2018: London.

A transcript of Rob's talk is below, which we have lightly edited for clarity. You can share your thoughts about the talk on the EA Forum.

[embed src='https://www.youtube.com/watch?v=E5wr3u8Gjwg']

The Talk

I'm going to try and cover what we do and how we do it, but I use the words impact and accountability a lot in what we do. They're themes that you will see that run through what we talk about, because every charity really, our focus is to have impact. And particularly delivering that for us means focusing on accountability, because the devil is in the detail. It's not easy to raise money, but it's not where you mess up. You mess up on delivery, on operations. So that's really where our focus lies.

1100 Rob Mather

You guys can read the numbers. I hope you can see the numbers at the back more quickly than I can say them. But I think we all understand that malaria is a humanitarian issue. The numbers are pretty frightening. When I first came across malaria it was because I heard that seven jumbo jets full of children under five died from malaria every day. And that really struck me. Not only does it particularly affect children under five, but pregnant women who have a compromised immune system when they're pregnant are also particularly vulnerable.

We focus on Sub-Saharan Africa, because that's where 90% of the cases of malaria and where most of the deaths occur. But it's not just a humanitarian issue. If you're sick with malaria then you can't teach, you can't farm, you can't function. And that means you're not a constructive or productive member of society. And so malaria is a drain on the economies of all of these countries that are affected. So if the humanitarian doesn't get you like it got me, then I hope the economic component would get you instead. If we put $1 million into fighting malaria effectively and efficiently, then we will improve the GDP of the country or the continent, I should say, by $12 million. A 12 to 1 return is a pretty good offer, even if you're not persuaded by the humanitarian element.

1100 Rob Mather (1)

Unfortunately, there's no silver bullet. There is no vaccine. Lots of research going on, and we all keep our fingers crossed that they'll find something. Vaccination research and gene drives are a big hope, and we all hope fervently that something comes of them, but for now it doesn't exist. So to pick up on the under fives, if I invited you all down to Heathrow Airport and you saw this, we'd all say, "Hang on a minute. This is slaughter." And this is daily, remember, so it is a big issue that we absolutely need to do something about.

1100 Rob Mather (2)

And a big part of the solution, not the only solution, but a big part of the solution is nets. They cost $2. They protect two people each. And, therefore, given that the female mosquito that is pregnant and wants to reproduce needs a blood meal to reproduce bites between 10:00 at night and 2:00 in the morning, that is something terrific we have on our side. It means that we can cover people when they sleep, and we can protect them mechanically. We also cover these nets with insecticide. We're putting nets in very challenging environments: they're households but they're not houses. So inevitably, these nets become ripped, they become torn, they have holes in them. But fortunately, the mosquitoes don't do a red arrows maneuver through a hole. They land on the net and migrate to the hole, and when they pick up insecticide it kills them. The fact that mosquitos typically feed between 10:00 at night and 2:00 in the morning is a really good characteristic that we can exploit here.

And the impact is dramatic. We're talking about whether it's 600 nets or 1,000 nets or 400 nets, it depends on the malaria burden, but we're talking about low thousands of dollars equals one death averted, and broadly it's 1,000 cases of malaria prevented for every person that dies, the mortality to morbidity ratio. This is an extraordinary impact. And graphically that's what we see.

1100 Rob Mather (4)

We see prior to putting nets in place you have the top graph, the seasonality, rainy seasons and dry seasons, happens more or less immediately, so within weeks. It's not as easy as just handing out nets and saying, "Right, we're done." Education is involved and there's sustained effort, but broadly speaking any major health initiative where you'd have a 10% decline nationwide is dramatic. So if we can introduce 40% or 50% decline, you can see this is in the sensational category of what we can achieve.

How AMF Got Started

So just a minute or so on how I started. I shamelessly called 250,000 of my best friends and said, "Would you like to swim?" And they all said yes. In fact, the truth is that I failed because I was trying to get a million people to swim, but I'm not going to count that as true failure really. And very much the spirit behind this was, as I said to Michael Phelps, "What I'd like you to do in front of the camera is just say, 'I would like you to swim. It doesn't matter how fast I swim. When I swim I count as one person. And if you swim you count as one person as well.'"

1100 Rob Mather (5)

Very much the spirit behind what we do at AMF is that we're ordinary folks, so very grassrootsy in that I don't think this is about celebrity. It's about all of us, because it's almost the power of all the ordinary folk that can get things done. And that was very much the spirit, and it is today behind what we do at AMF. And so there were some wonderfully nutty people swimming as part of World Swim Against Malaria in 2005 in Serpentine, not far from where we are now. A whole bunch of people at PWC decided to go into the channel. And then some very sensible people in Australia and America where it was warmer.

And it was particularly important to me that there were lots of children involved, given the death toll is particularly affecting children. This was my first experience, if you like, of... actually it was the second experience after a swim for a burns victim. But I learned a lot from this experience of how people reacted to certain sorts of communication. It was a seminal period, if you like.

I was intending to go back and get a proper job because I had taken two years off to launch World Swim. And when we went to see the Global Fund, an organization based in Geneva, a big funder, they said, "Do you realize with 130,000 people swimming (which is what we had at the time), you are the largest malaria advocacy group in the world?" And I said, "Are you telling me that 20 phone calls out of the back room of my home in London has created the world's single largest advocacy group for the world's single largest killer of children." And they said, "Yes." And I said, "Well, that's shame on all of us if that's the case." I guess that meant that I didn't want to go back into a proper job. I wanted to do an improper job.

What AMF Does

What we do at AMF is we provide nets. We distribute them. We make sure they don't get stolen. That's potentially a very big issue, back to operations. We certainly want to ensure they're used. And when we get involved in funding nets we go to governments and we talk to them about data. In fact we put it a lot more politely than I'm going to put it now, but we basically say to governments, "Please don't ask us to trust you, because we won't. But we won't ask you to trust us either. Let's just focus on the data." And that is really important to making sure that we do the best job we possibly can. We don't always get it right. We're not perfect, and things do happen we have to dive in and try and solve. But in essence this is all about data for us operationally.

1100 Rob Mather (6)

When we started, again more politely than I'm about to put it, but I went to a whole bunch of people and organizations and said, "Please will you help me, but I'm not going to pay you because you don't need $5 more than a couple of kiddies in Africa need a bed net." And I'm delighted to say that everybody I spoke to, I can't think of anybody who didn't hear the question, "Who do I talk to in your industry that would be able to help me do X, Y, and Z?" and reply, "Me." And it's incredibly humbling getting a lot of people in big companies. I run this with six other people out of the back room of my house in London, and everybody works from their own homes, so we don't have any offices. But there are a lot of blue chip companies that said, "We get it. We'll support you." Because fundamentally the chief executive of big company X and big company Y, he or she have got kids, and they know kids, and they're human beings. So I guess I appeal to that sense: how do we do this together, as a lot of people coming together?

1100 Rob Mather (7)

We have five full time staff. We pay four of them. So one of the things that was a little bit different about what we do is I don't have to really go out and raise money to fund admin costs. I could, and I could certainly use the money we have to do that, but as you can imagine, we want to spend the money on nets. So I have four costs globally, centrally, and no other costs than those four people we say a commercial salary to. We have no banking, accounting, legal, website, translation. You name it, we don't have it.

When we wanted to translate the website into German, the thinking was we could go to a professional company and they'd charge us five grand to do it, or we could go to a lot of other human beings and say, "You're a professional translator. Who do we talk to in your industry such that we could get four people who would translate two and a half thousand words each?" That's 10,000 words. We can now put our website in a language and show people the courtesy in Germany of being able to read the website in their own language. So I sent out 48 e-mails, not dear all because that doesn't work, but Dear Claudia and Dear Claus and Dear Matthew and so on. And in 24 hours I had 44 positive responses out of 48. So I could've translated the website 11 times over for free. And the same thing happened in every other language. So you sort of want to jump up and kiss people when that happens because it's terrific that everybody said, "We'll help." And that in a sense is really behind what we've all built at AMF.

We have very low overheads as a result, as you'll be unsurprised to hear since we're only paying four salaries. Our overhead last year, or FY 2017 rather, was 0.6% of the money we receive, so 99.4% of what comes in goes to the front line. And that's because I am incredibly cynical about charity, which is why people say people like me set them up. And I want to keep those costs really low down, and I want to show people exactly what happens with their money because I think that's the right thing to do.

We work with co-funding partners because we can't fund everything ourselves. And in fact we often fill gaps, so somebody will say to us, "We need $11 million here. Have you got any money?" And then we can cooperate with another organization. And we work with distribution partners because I don't want to set up some massive logistical operation in a whole series of countries. That would be daft. So this is very much us contributing as one of a number of organizations because this is a big team effort. It has to be. So impact and accountability are important. Transparency and efficiency are very important to us. I guess transparency is different from, but it goes hand-in-hand with, accountability. Efficiency covers not just the money we receive but how we actually get nets out to people in the right quantities to protect them.

1100 Rob Mather (8)

I think a charity should be able to define in a sentence, or in a few words, what it is they're trying to achieve. It surprises me when some can't. In our situation, it's very simple. We want to stop people dying and stop people falling sick. So that in essence is the metric we must be judged by, although I'm going to throw something out there that we actually don't publish malaria case rate data, and there might be some questions on that later on as to why, if AMF is focusing on these metrics, aren't they publishing the metrics as to what they're achieving? It's a source of frustration, but it's something that I think is important.

1100 Rob Mather (9)

So accountability for us means holding people to account in country, so saying to our partners, "We want to see data," so we structure our relationships so that it focuses on data. And we think fundamentally what that does is it means that fewer people die and fewer people fall sick. We want to hold ourselves accountable to our donors and show, as I mentioned, where every donation goes so people can be engaged rather than, I've given them some money, it's gone into a black box, don't know what's happened to it. That, for me, would be frustrating. And we believe that leads to this virtual circle of driving donations because we cannot do anything without donations. Awareness is terrific, but awareness funds nothing. Awareness has to have an endpoint of moving on to driving donations.

1100 Rob Mather (10)

Each donor has their own individual page, as long as we have their e-mail address, and we list all their donations. I say as long as we have their e-mail address not as a cute way of saying, "Goodie, then we can market to them" because we as an organization do no marketing. We may be making mistakes in not doing marketing. In a sense other people market for us. The effective altruism community has been sensational in marketing us, and is a fundamental board member of AMF in terms of what it has helped us to achieve. We never send soliciting e-mails. We only send informational e-mails. It's really, really important to us because I think what we do should drive our support, not our ability to persuade because we write good copy.

When we go out into the field we take enough nets to cover everybody in a particular area, and the ratio is broadly two people sleep under a net. In fact its scale is 1.8. And what we focus on is making sure that our partners have visited every household, so we understand whether this household needs three, two, four, one. Whatever the number of nets they need, that's the number of nets we get to them. We make sure at the moment of distribution... and I should say there are a number of things we do to verify and ensure that that data is accurate. It's not perfect, but we can send five data collectors out after the first hundred and get them to visit 5% of the households these guys visited, and tell them beforehand, so we're putting psychology to play, to make sure they're really focusing on getting accurate data. And there are other things we do to make sure that data is good because obviously, garbage in, garbage out. And people, I'm afraid, a very small number, do want to subvert what we're trying to do and misappropriate nets.

1100 Rob Mather (11)

It's important to have independent supervision at the moment of distribution so that, again, you make sure the right things happen. We follow nets and their presence and use and condition after roughly six months. And we track malaria case rate data, albeit there are issues with the purity or reliability of that data. So when we go back in and gather data we're doing it not just because it makes us feel good, but because we do want to understand what the decline curve is, because if we're up at 95% here on day one, and we come down like this over three years, that's okay, but also that's not okay. And if we don't know, we can't do anything about it, and we do not want to bury our heads in the sand.

1100 Rob Mather (12)

So I have no problem in saying after 18 months, the coverage with our nets is down to 40%, because I'd rather know and be able to say to everybody, so we need to do something about it, because for the next 18 months we've got a significant number of people that we're telling everybody we're protecting from malaria and they're not actually protected. So let's find the data.

That bad trend is not one we see often, but we need to know whether it is there or not. And we can say to the district health officer, "You've got 37 health center catchment areas, and you've got limited resources, and we've got this data of whether sleeping spaces are covered or not, so you can focus on these 10 areas rather than the 37 and actually be more impactful, more effective with your work." So we're not just collecting data for data's sake.

We're very happy to be held to account by others, so we release all of our material. There's almost nothing we won't release, apart from people's personal salaries and things like that. And that's obviously been a terrific benefit to us, as we've been reviewed well. That has been a major driver of the donations we've received. I don't know what the current percentage is, but it's something like 70% of the donations or 60% of the donations we can tie to GiveWell and other organizations' reviews of us. So that's massive. So take 60% of $178 million, we're looking at about $100 million that has been driven by the EA community. So AMF is an EA community thing, really.

1100 Rob Mather (13)

Last year we received about 90,000 donations from 190 countries, so we're getting to lots of people. And every donation matters because every $2 buys a net. And it means that when we talk to countries that say, "Hi Rob, if you've got $11 million," we say, "We've got 8." But then the next week we've got 8.2 and 8.4. So we can literally, through the discussions come back and up the number nets we can fund. So we put money to work, in essence, as soon as it comes in, because I can't commit to nets unless I've got the money. So the three key numbers we often, if people are sort of benchmarking, what does it cost to do something in the world of malaria: it's $2 buys a net, $500 protects a village, and roughly $3,000 prevents a death, or $4,000 or $5,000. I don't know what the latest number is from GiveWell, which is where that comes from.

On top of that we have a small number of large donors that build on top of what, in essence, is the likes of most of us or all of us in the room, the many individual donors that are our life blood. These are very lumpy donations. We've had some very significant ones. When you get a $23 million donation, that's amazing because it just means we can say to a country, we can fund 12 million nets for you. And when we're funding larger quantities of nets we can hope to achieve great success in some of the things we're aspiring to.

So some fantastic big donations, but I guess if there's one thing I want to leave somebody with hearing me and looking at this slide, it's that if ever somebody were to ask, "Somebody's given $2 million. What does my $2 matter?", well, the answer is your $2 buys a net, and that matters. It just so happens that $1 million buys 500,000, but we need both. And if we didn't have all of us contributing small amounts, we wouldn't be here, because no big donations would come in on the back of a few people giving a few dollars, so these are inextricably linked.

1100 Rob Mather (14)

Over the last few years we've started to hit the tens of millions of dollars, and that means we can fund millions of nets. Everybody who's involved, all the donors, all the supporters, everybody that is involved together, we can say that we're putting ourselves in the position to stop something like 60,000 people dying, preventing 660 million cases of malaria through the number of nets funded. And while we have operated in 36 countries we focus typically on about seven in any one year. So this means that we can fund millions of nets at a time. Rather than turning up at the table and saying, "Yes, we can fund 100,000 nets," where the country would say, "Terrific-ish" because they need 10 million, we turn up and say we can fund 5 of your 10 million. That makes us get listened to, and I think rightly so.

1100 Rob Mather (15)

We don't turn up and say, "This is how you're gonna do it" because that would be insensitive, crass, and just not a good way of going about things. So we come forward and say, "Here's our draft agreement. Here's the focus on data. You let us know what's difficult, and let's work with you as to how we adjust it, but some things we're gonna be pretty difficult to move on because it's all about accountability, and we think there's sense behind them." So we're involved in a partnership in persuading. And the more money we have, the more we can do that. So things have radically changed in the last four years, really, with what we can achieve.

1100 Rob Mather (16)

But we have challenges, and most of those challenges... I'm not expecting you to read the bottom bullet point. The point is that they are many, and I could go on forever, because the devil is in the detail. But the big ones are ensuring effective planning where you've got limited resources and your span of control is limited, classic stuff. So we're improving all the time. We don't get everything right, but we think we get things more right as each day, each week, each month goes by. And we're in the business of persuading people to do things, because that's what partnerships are all about. We're also in the business of sometimes managing or doing a two step tango around the politics that suddenly can appear in certain situations in the countries we operate in.

Managing millions of household records, which is what we do, is the relatively easy bit. We put 150 lovely people in the room. We say, "Here's a laptop. Here's some data." And we provide them with our data entry system, and we get the data so we can see it, so there's no filter. Really, really important. But I won't bang on about that.

1100 Rob Mather (17)

Insecticide resistance is a second challenge. Charles Darwin told us that that would happen, and certainly it has, as it happens with all of these things. So what we have done is we've played our part in saying, "We need to put these new PBO nets"... you'll remember from your chemistry class of course that PBO stands for piperonyl butoxide. Yes, everybody knows that. It's a synergist that goes on the top of a net or on a net, and it switches off the resistance mechanism in the mosquito, which means that the pyrethroid kills it. We've stepped forward and funded six million of those, distributed in 2017, lots and lots of clusters for the statisticians in the room, so that we can actually have a very powerful study, a randomized control trial, the gold standard if you like, so that for the rest of the malaria community, the funding community, we can say, "Here's the data that tells us whether PBO nets are good, and if they are in what way and in what circumstances." And we'll have those results in about six months' time. We don't know them.

We are the funder, we are the sole funder of the study, and in a sense we were a bit surprised that others weren't going to step forward, but nobody did so we said, "We'll do it because this is important." Insecticide resistance is a challenge to be met.

1100 Rob Mather (18)

The next challenge is funding. We're allocating about $50 million at the moment, and we have $200 million worth of requests, so we have to make some nasty, nasty decisions in the next three months where we will have to say to countries, "We don't have the money." But we will do our best to try and make sure that the money we do deploy goes to optimize the impact we can have. But that challenge is also an opportunity because there are lots of countries that need help. We don't turn up in the morning and think all these challenges are weighing us down. These are opportunities for us to help. And we tend now to look at anything between 2 and 20 million nets of requests a time, so some of the numbers are quite chunky. We have to really make sure that the partnerships and the agreements we put in place are gonna deliver what we expect it to deliver. We tend to look three years out now because that matches with other funders. It means we can really plan operationally much better.

1100 Rob Mather (20)

We also have an opportunity with technology. And this is one of my favorite pictures. It shows in one of the poorest countries in the world, the Democratic Republic of Congo, the use of technology, smart phones, to demonstrate to within six meters where 250 odd thousand households are located that received nets. And when you do stuff like this you've got real time data, you've got a better accountability, you've got lower costs, etcetera. The list goes on. So, fantastic opportunity to do better, but there are challenges with deploying it because you can't just put thousands of phones into the DRC and expect it all to go well, so we have to be very careful how we do this.

1100 Rob Mather (21)

I'm going to leave you, last slide, on the note of optimism, which is if we reflect on what we've been doing in the last 15 years within the malaria community, all of us together, it's pretty dramatic in bringing down over 15 years the number of deaths and cases of malaria by about 60%. And there are countries that have moved into elimination, malaria is gone now. Sri Lanka, a very challenged country, the turmoils, war, all sorts of challenging things going on, but they are now malaria free, three years of no native cases of malaria. That's terrific. And there are now eight other countries, I think, on the cusp of that. So elimination is possible, eradication is possible. But a child still dies from malaria every minute, so while I've been talking, depending on how long I've been talking, 22 kiddiwinks have not made it, and that's pretty shocking.

As we know what we need to do, which is nets, we don't have a silver bullet with a vaccine. We don't have a silver bullet with gene drive technology yet. Nets is a big part of what we do. So certainly from our part and with others' help, we're going to continue to do as much as we can.