How do you protect the privacy of households that receive nets?
Before we collect any data from a household, the householder is made aware of the information to be collected and its use and the householder’s permission is sought to collect it. No medical information is gathered as this is not required to determine the number of nets needed by the household to achieve universal coverage. The data collected are held securely in a database with password access provided to a limited number of authorised people with, in most cases, viewing (and not downloading) rights only.
How concerned are you about potential misuse of personal data on recipients?
We do not think the likely misuse of the data we collect is high. This is because 1. we are not collecting sensitive personal information; 2. access, and the type of access, to the data is appropriately restricted.
Climate change is not materially affecting AMF's work at the moment as there is a lot of malaria to bring under control. I’d like to think that with the right support we can bring malaria under control in the next 10 to 15 years before the impacts of climate change make things worse. There are some sensible comments being made about climate change increasing the risk that malaria will appear in new areas and new countries and that would not be good at all.
I am not clear on the water and temperature question. Can you clarify?
To add on to the question of mid to long term effects, do you have a theory on what role bednets play in transitioning a country to malaria under control or even be malaria free? How long after a country reaches either of these two stages would bednets become less critical (if ever?)
There is significant evidence that bednets have played a ‘majority role’ in reducing the number of deaths and cases of illness due to malaria. An article from the Oct 2015 edition of Nature suggested (or stated) that 68% of the 60% reduction in malaria deaths (over the prior 15 year period) was due to bednets.
When malaria is under control bednets are largely unnecessary, aside areas where it may persist. When a country is malaria free, bednets are unnecessary, aside small pockets potentially and with the exception of considering border areas next to countries that are not malaria free.
How different is it to have malaria under control vs formally being malaria free? Is there a significantly higher risk of malaria becoming out of control in the former and the rates increasing again?
Malaria under control means it is still present but at a low level that can largely be dealt with via case-by-case management when they do appear rather than national, regional or district-level malaria control activities. Malaria free is defined as having no native cases of malaria in a country for a three year period, something achieved by Sri Lanka in 2017.
How does the role of bednets in getting countries to either stage factor into your effectiveness estimates on shortening those timelines?
We don’t develop effectiveness estimates per se, because all our work is in medium to high malaria-affected countries so we are working in the ‘helping to bring under control’ category. Please do clarify further if I have not understood the question.
Have you considered collecting data on subjective wellbeing in order to help quantify these improvements? Could that be integrated into your program without too much expense/difficulty?
We haven’t considered this, no, but an interesting thought and we’ll keep the suggestion in mind.
Do you have any data on dietary changes resulting from bed net distribution (or similar programs)? Would it be feasible to collect that data in future?
No, we don’t have any data here. I suppose it may be possible to collect those data but I wouldn’t see it as a priority for AMF. I am comfortable that our focus on helping prevent deaths and illness is a good one and I cannot currently conceive of negative impacts of this work that would change that focus.
How do you and Andrew go about arguments?
I am not sure I understand the question so I’ll answer in several ways. In 20 years of working together (Andrew was previously the head of technology in a business I ran) we’ve certainly had (very) occasional disagreements (for example, should we develop first this functionality or that?; how to go about solving a particular problem) but we don’t ‘argue’. If you rather mean ‘How do we go about the development process?’, we have found it has worked for us that I share with Andrew what functionality I feel we should build, often in significant detail, and we discuss and refine what we should build and how, and he brilliantly builds it! This often involves some trade-offs, for example, less functionality initially but delivered quickly, and then further functionality added to arrive at the ‘all singing, all dancing’ functionality that does all the things we wish.
How much time did you work on average per month/week (what is easier to estimate) for the foundation?
I work full time for AMF. My hours per week vary from 40 to 70, on average 50, not infrequently 60. I feel very fortunate that I love what I do and really enjoy working with my colleagues. I bounce into work today in the same way I did when I first set up AMF 15 years ago, maybe more so given the opportunities we have ahead.
What else did you do with your "working" hours?
My understanding of this question is ‘How do I spend my time?’. My time is spent across a series of areas and varies from day to day and week to week, and includes: considering issues relating to strategy (thinking time important! - including how we get better), deciding with colleagues which distributions we fund, liaising with donors, liaising with many organisations (including co-funders, Ministries of Health, partner companies and groups, and net manufacturers), liaising with Malaria Advisory Group members, keeping across operational issues, steering and prompting technology development, reviewing data in any one of series of areas, managing finance related matters, sending thank you emails to donors, hiring (more in the last few years), contributing to website re-design (just in the last year), contributing to our work on a major randomised controlled trail of a new type of net (in the last few years; work led by a colleague), responding to emails across more issues than I care to mention (wonderfully varied!), taking part in brainstorming sessions with colleagues, reading around the subject (including product development, insecticide resistance, vaccine research and gene drive technology) and giving invited talks and presentations (many by video link across the world, and as many as I can manage in person – which I love doing as you meet some wonderful people and the Q&A is always interesting and fun).
How do you study further in general?
I generally read and learn around the subject when I am on the move, have short breaks of time and sometimes at the weekend when I have a clear run of time when more time is needed on a topic.
Is there a source about how you started and learned about founding and running an organisation (be it a charity or company)? otherwise: could you give me an apercu?
There is a history of AMF on the AMF website and I think there may be a brief bio of me knocking around on the internet somewhere. Various videos have been uploaded of talks I have given and there are podcast interviews, all of which an internet search will find, during which some of these questions have been asked. Hope that helps.
Our technology (databases etc) are bespoke – all built in-house. We follow a simple process: we decide what functionality we need, and we build it. A key element is thinking through what we need and how that needs to be structured (content, layout, user interface, analysis functionality etc) so there are two stages – establishing clearly what we need; building it.
I was interested and pleased to hear from GiveWell when they first contacted us (in 2009/10 I think) as it was obvious straight away that we shared a similar attitude to impact, transparency and accountability. I remember in particular reading at the time that they had two recommendations (and I paraphrase): ‘Do give money to these 3 charities. Don’t give money to these 132.’ I liked those numbers. It said to me that they really valued data and evidence and not stories. I didn’t think it was weird at all that they were evaluating charities. On the contrary, I thought ‘Hallelujah!’ as in many ways I am quite cynical when it comes to charity and feel it is very important that charities are held to account.
We have certainly improved monitoring practices since 2016 and it’s important that we continue to look to improve them.
The observations and criticisms made in 2014 were valid and it is one of the benefits of independent organisations reviewing our work in detail that we receive feedback and suggestions that can help us do a better job.
An example of a recent improvement is the change in the frequency and scale of our post-distribution monitoring. For many years, PDMs were 6 monthly and involved visiting 5% of the households that received nets. As a result of an 18 month trial in Uganda, where we carried out PDMs in 124 health sub-districts split into five randomised groups (Arm 1: 6-monthly, 5% of households; Arm 2: 9-monthly, 5% of HHs; Arm 3; 6-monthly, 1.5% of HHs; Arm 4: 9-monthly, 1.5% of HHs; Arm 5: A PDM at 18 months as a control), we generated the data to support a move to 9-monthly PDMs visiting 1.5% of HHs. This has reduced cost without any loss in the benefit of carrying out the PDMs or value of the data generated.
Another example that took place earlier, as a result of feedback from GiveWell, was for AMF itself to make the randomised selections of households to visit rather than leaving this to in-country partners. It is not clear if this changed the outcome and reliability of the PDMs, but the separation of who does the selecting and who does the visiting increased confidence in the results of the PDMs.
The increased use of electronic device data collection is another way in which monitoring is being improved with benefits including: lower cost, improved accuracy, earlier detection of problems and faster access to results.
Improving monitoring practices is a priority and we continually reflect on how we can do better.
Not close. Money. There are significant gaps in funding for nets and our current information is that for the period 2021-2023 that gap will be around US$500m to US$750m.
There is more malaria prevention happening now. When AMF started in 2004/05, 5 million LLINs were distributed globally by all contributors. It is now around 200 million nets per year.
There is a greater focus on data I am pleased to say with funders ever more focused on ensuring nationwide campaigns are well targeted and not wasteful.
More money has come into malaria prevention through a combination of greater awareness of the disease, its impact and what can be done about it, as well as, in our experience, donors having greater confidence that funds being given to a charity focused on a problem in Africa will be well directed and used with significant impact. There is still a very significant gap in funding each year for basic malaria control (covering people with nets) so there is still much work to do and support to gain.
There has been some progress on developing a vaccine but we do not yet have a highly effective vaccine that could make the sort of impact on reducing malaria that we would all like to see. My understanding is we are at least 5 and probably 10 years away, at the earliest, of having a vaccine that is ‘really interesting’ (but others will have a more informed and up to date opinion here than mine).
There has been significant progress with gene drive technology and there is growing hope that it may make a significant contribution to malaria control in the coming years. But we are not there yet. My understanding is we are at least five, and maybe more, years away from developments that could be, similarly, ‘really interesting’ (similar disclaimer as above).