AMA: Rob Mather, founder and CEO of the Against Malaria Foundation

I’d be interested to read more about that.

If other projects, including projects to promote economic growth, can be demonstrated to be very or more-cost effective at saving lives (than funding and distributing long-lasting insecticidal nets) I would be interested in supporting them.

The problem we have today is people falling ill with, and dying from, malaria. Currently, the bednet is the most effective way of preventing that so it seems good and sensible to put funds into distributing nets.

My over-riding thought is that protecting people from malaria is a humanitarian issue first, and then an economic one, and whilst I would be interested in actions that drive economic growth, I would also want to support actions and interventions that improve health outcomes (saves lives, reduce illness) in the near and medium-term.

Perhaps I should have written 20 minute ‘approach’ rather than rule.

Sometimes when I wish to achieve an objective, I think about how I might do so with 20 minutes of effort.

It doesn’t apply to all circumstances, but the idea is to focus thinking on how best to go about getting something done and come up with suitable actions.

Actions compatible with the objective.

For me, the 20 minutes begins once you start ‘doing’ something i.e. picking up the phone or writing an email to someone. You can have as much thinking time before that as you like.

There has to be some poetic licence here as many ‘big things’ are unlikely to be achieved in 20 minutes but I don’t let that get in the way of the thinking.

An example might help.

When I was considering trying to get a million people to swim ‘against malaria’ back in 2004/05, my answer to the 20 minute question was ‘I am going to call 20 people, spend a minute on the phone with each, and ask them to each give me 5,000 people to swim. If I achieve that, we’ll be on the way to having 100,000 committed to swim and that is a credible platform from which to launch World Swim Against Malaria and to see if we can achieve a million swimming.’

And, pretty much, that’s what I did.

I phoned 20 people and they all agreed to commit to ‘contributing’ 5,000 people to swim. Admittedly some phone calls were longer than a minute and I went to meet about half of those I spoke with, but the '20 minute limit' allowed me to focus on actions that were at the right scale. It meant I didn’t start by going to the local swimming club and gaining 50 participants and then the local school and gaining 100 etc which would never have got us to a very large number of people swimming.

Relatedly, could you explain a case where the 20 minute rule failed to produce a good outcome?

Yes, I try and respond quickly (meetings, calls, other commitments etc notwithstanding) out of courtesy and a desire to allow others to keep going with their projects and work, without me holding them up. The speed with which I am able to respond to an email will also depend on whether the response is clear and simple, meaning a quick response is possible, or requires more thought, data collection, liaising with others etc, which leads to a longer response time.

Yes, based on a) if AMF no longer adds value, we’ll stop (I think of that as Plan B for the charity, and I’d love for AMF to close if its work is no longer needed. Sadly, it looks as though malaria will be here for the next 10 years at least and within that time frame, currently, the distribution of nets is the most effective thing we can do to prevent malaria); and b) those of us involved in AMF care very much about what we do and I suspect others might also like to focus on another area where we can make a difference.

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.

1. What do you think are the main positive and negative indirect impacts of the program, both long- and short-term? (E.g. increasing productivity and economic growth, increasing/decreasing total population, strengthening health systems, greenhouse gas emissions, consumption of factory-farmed meat...) Do you have any data on these? Are you planning to gather data on any of them?

The main positive indirect impact of distributing nets is to improve the economy in the areas in which the nets are distributed. If people are sick, they cannot teach, they cannot drive, they cannot farm, they cannot function. They cannot be productive members of the community, and they may in addition draw on the heath service. It has been estimated that there is a 12:1 multiplier i.e. that for every $1m we spend effectively fighting malaria we improve the GDP (Gross Domestic Product, a measure of economic performance) by $12m. A pretty good return, aside the humanitarian benefits of such funding. Similar calculations and analysis can be found in: The economic burden of malaria – Gallup & Sachs, 2001, The American Journal of Tropical Medicine and Hygiene; The economic and social burden of malaria, Sachs & Malaney, Feb 2002, Nature.

The main negative indirect impact of distributing nets is millions of pieces of plastic being brought into the environment. A net is ultimately a piece of plastic. However, this is an OK price to pay for the impact the nets have on health outcomes. FYI, over the last few years we have moved to not providing individual packaging for nets but provide nets loose in bales (typically 40, 50 or 100 nets per bale) and that avoided 4.8 million pieces of plastic going to Guinea in the recent distribution, so we are making progress in this area.

2. What proportion of the long-term benefit from the program is due to short-term direct effects such as saving lives and averting unpleasant episodes of malaria, relative to indirect benefits?

I guess you’d have to say a high proportion of the long-term benefits from our work (people living healthy lives, being productive members of society and reducing the funds spent avoidably on health care) are due to the short-term direct effects (saving lives and avoiding illness) rather than any indirect benefits.

(I may not have fully understand the question as an indirect benefit of our work is improved economic performance but that is also a long-term benefit. If I have not understood correctly, please do feel free to explain further.)

3. Do you hold a particular view of population ethics (totalism, averagism, person-affecting, etc)?

My population ethics could best be summed up by saying that my four children go to sleep at night with the consequence of a mosquito bite being an annoying itch and not severe illness or worse and I wish to do all I can to make sure it is the same for children, and others, in currently malarious areas.

4. What is your response to critics who claim we are ultimately "clueless" about the long-run magnitude or even sign of interventions like this? (I think the basic argument is that e.g. averting deaths has a wide range of knock-on effects, both good and bad, and that we may not be justified in being confident that ultimately – say, over the next few hundred years - the impact will be net positive. See e.g. here, here, and here for a better explanation)

My response would be that the short and medium term consequences of distributing bednets – saving lives, avoiding illness and improving economic circumstances, are very persuasive for me and I could not imagine any unknown long term consequences could persuade me that the actions we take now are not worthwhile.

Nothing particularly insightful, I’m afraid. I have always been a fan of the portfolio approach to supporting charities given there are many good charities doing important work so if there are a variety of views and interests within the EA movement, that seems like a good thing to me. At AMF, we have a significant gap in funding and of course we would like as many as possible to support what we do so that means we have to continue to make the case that we are worthy of support whilst understanding donors will wish to put their support, financial or otherwise, in many different areas.

Unfortunately, I don’t think we will run out of areas in which to distribute nets. We don’t just distribute nets in easily accessible areas but also in hard and very hard to get to areas as it is important to protect everybody and achieve ‘universal coverage’ i.e. all sleeping spaces covered. Often the hardest to reach areas are those that most need nets as they have more challenging access to health care. There are many examples of hard to reach areas in DRC, one of the two countries in the world most affected by malaria, and in Papua New Guinea where geography is particularly challenging, but most countries, regions and districts have areas that are tough to get to and require extra effort.

The insecticide lasts for more than three years, the typical mechanical lifetime of the net. BTW, the long-lasting in ‘long-lasting insecticidal net’ (LLIN) refers to the insecticide. In some of the next generation nets we are looking at and working with, that typically have a second (safe for humans) chemical on them to enable the net to be more effective at dealing those mosquitoes species that may be developing a resistance to the (pyrethroid) insecticide on the net, we are monitoring carefully how long the ‘active ingredients’ as they called, last.

You may be interested to know that a net remains effective not just because of the longevity of the insecticide, but also because the insecticide is ‘bio-available’ i.e. it is on the surface of the nets and is available for the mosquitoes to pick it up via their feet. The insecticide is held on the net by a binding agent and the agent has to achieve the balance of keeping the insecticide from evaporating (too quickly) but also allowing it to be released. In some net manufacturing processes, the insecticide actually ‘sweats out’ of the filaments that make up the net. As a result, the humble $2 bednet is in fact quite an amazingly well engineered and chemically engineered product.

We do already go back to the same areas and distribute nets because of the three year lifetime of the net. The global approach to bednet distributions is that they take place in an area every three years. In fact, we would suggest the lifetime (on average, for a large cohort of nets) is closer to two and a half years and we are looking at repeat distributions with this frequency in some areas in order to ensure the populations in these malarious areas are continually covered. How long a net lasts depends on its environment (a net in a thatched dwelling is not likely to last as long as one in a brick house) and how it is treated.

Yes to the former and no to the latter! We have been able to do more things and some of the same things more quickly - and better.

With a bigger team we have, amongst other things:

greater depth in management talent allowing us to manage more projects, more effectively

greater depth in data analysis talent allowing us to carry out deeper analysis of (larger quantities of) data

been able to invest time in putting together templates to allow us to more quickly assess projects. For example, standardised proposal templates (both word documents and excel spreadsheets) make multiple proposals much easier to compare and lead to better and quicker decisions (a further step will be to move to receiving some proposal materials online, so we are still seeking to improve in this area)

been able to help partners be more efficient and quicker with their reporting to us by moving away from word and pdf documents, and the inevitable receiving of emails, to online reporting. This has also allowed us to be better and quicker at assessing reports for implications and actions.

French language fluency in the team which has led to better, more effective interactions in Francophone countries (currently Guinea, Togo and DRC)

been able to take on, through 2017 to 2019, the world’s largest ever study of a new type of long-lasting insecticidal net, the PBO net (explainer, 18 month report)

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.

Focus on the data and make sure they are as accurate as possible.

That underpins what we do at AMF as it gives us the best chance of understanding well what is needed (e.g. how many nets are needed and where) and reaching our objective as best we can (i.e. all sleeping spaces covered). An example would be structuring our work to: a) maximise the proportion of households that are visited during the registration phase of a distribution during which we establish how many nets are needed by each household (we aim for 100%); and b) ensure the data are accurate. We seek to maximise accuracy via two techniques. First, we carry out ‘105% registration’ which involves visiting a random selection of 5% of the households with the 5% data collectors having no knowledge of the data previously collected for the households and, most importantly, by making sure the 100% data collectors know in advance of doing their work that their work will be checked in this way and the 5% overlap compared.

Keep things simple and design things out.

I think that has helped us at AMF. An example of keeping things simple is to focus just on nets. An example of designing things out is taking our annual accounts preparation and reporting process, that used to require three people working for four weeks, to requiring essentially no one, We did this by building a system that allows us to track all relevant financial numbers on a daily basis (including, last year, more than 112,000 donations in a myriad of currencies) with all reporting material and documents either automatically generated at the end of the financial year or able to be generated within minutes. As a result, we are able to produce all our annual accounts' materials across 12 countries, including material for three separate audits, within nine hours of the end of our financial year.

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?

Why not, assuming it can be agreed what is the definition of high impact for animal charities. For human-focused charities, measures include deaths averted and health outcomes improved and I don’t see why the same should not be achievable for animal charities. It is then a case of charities focused on these causes providing data and other information to allow independent assessment of their level of impact.

I don’t feel I know enough to suggest what may be missing in current animal charities’ activities, including advocacy.

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).

I guess the probability I would have ended up doing something like [founding and running AMF] before I did is zero, given I didn’t! 😊 Would I have ended up doing something like I am now had the ‘chance event’ (me being useless with a remote control and not succeeding in turning off the tv news one evening and instead switching to a channel showing a programme about a burns victim that led me to organise a swim for the little girl that then led to World Swim Against Malaria…), yes I think I would have. That is based on me feeling (through my 20s and 30s and beyond) that I have been fortunate in many ways in my life (education opportunities, work experiences, family, friends, health etc) and that I wished helping others in some way to be an important part of my life.

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.

You are very kind – our website is hopelessly out of date! We are currently working with a web design company who is helping us pro bono and we have made very good progress on the new design. We expect the new website design to be better in a number of important ways including: clearer in explaining what we do, easier to navigate (the aim is 'intuitively navigable'), easier to access content and responsive to different devices used to view the site.

We are hiring a technology developer and that person will increase our overall technology capability that is primarily focused on managing and developing database-related functionality.

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.

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.