The Backbone of Impact: How USAID and Global Institutions Empower Top Charities
A Case Study In Philanthropy's Role in Global Health and Why Waivers Aren't Working
tl;dr
GiveWell’s top global health charities depend critically on large donors like USAID, the Global Fund, and the World Bank. These institutions provide the bulk of the financing and logistical support—enabling interventions like net distributions, malaria chemoprevention, and vitamin A supplementation to reach scale.
Charities such as AMF, Malaria Consortium, and Helen Keller International don’t operate in isolation; they “piggyback” on government-led, donor-backed public health programs. This means that while philanthropic funds often fill in gaps, the heavy lifting (procurement, distribution, training) is managed by established institutional frameworks.
The synergy between small-scale philanthropic efforts and large-scale donor investments creates a powerful multiplier effect. With robust infrastructure and established supply chains provided by DFIs, these charities can achieve far greater impact and cost-effectiveness than they would be able to on their own.
Critiques lobbed at USAID have mostly been bad faith and misinformed. Even Effective Altruism (EA) seems to misunderstand global development and critics have taken aim at organizations like USAID—arguing that the agency’s involvement often siphons off resources from direct-impact interventions. These voices claim that government bureaucracy and inefficiencies at USAID undermine the cost-effectiveness of global health and development programs, effectively arguing that philanthropic dollars could achieve more if they bypassed such institutions. For example, one popular EA forum post on the implications of the recent USAID funding freeze suggests that top charities might be even more cost effective once USAID stops “taking the lower-hanging fruit” of aid delivery.
This line of criticism can sometimes appear to overlook a crucial point: USAID isn’t just a bureaucratic hurdle—it provides the robust infrastructure and long-term logistical support that enable these effective programs to scale. While critics may focus on inefficiencies, many in the EA community are genuinely concerned with ensuring that every dollar maximizes impact. Their skepticism toward USAID is often rooted in a desire for improved transparency and accountability in foreign aid.
I believe that although many critics- including effective altruists- offer sincere and thoughtful critiques, their assessments sometimes understate the indispensable role of institutions like USAID. By building and maintaining the infrastructure—be it through supply chains, government partnerships, or operational logistics—USAID creates the enabling environment for high-impact charities to flourish. In other words, even though EA critics raise important points about efficiency and effectiveness, they may be missing how foundational USAID’s contributions are to achieving the broader goals they so passionately advocate.
In what follows, we will examine each of GiveWell’s top charities in detail, exploring how their high-impact work is deeply intertwined with the support of international institutions. From the distribution of bed nets and delivery of seasonal malaria chemoprevention to vitamin A supplementation and beyond, each case study reveals that these organizations rely on robust global funding and logistical networks—such as those provided by USAID, the Global Fund, and other development finance institutions—to amplify their effectiveness. By unpacking these relationships, we aim to demonstrate that the success of these charities is not solely the result of their own efforts, but also of a collaborative framework that leverages decades of institutional expertise and infrastructure.
Against Malaria Foundation (AMF) – Bed Net Distributions
DFI Funding Dominates Net Supply: AMF funds millions of insecticide-treated bed nets, but the vast majority of nets in malaria-endemic countries are financed by big donors. From 2015–2019, the Global Fund provided ~58% of all nets delivered globally and the U.S. President’s Malaria Initiative (PMI, a USAID program) about 20%. By contrast, AMF contributed only ~3%. This highlights that AMF’s efforts piggyback on the much larger net distributions paid for by Global Fund/USAID. Without those institutions, nationwide net campaigns (and thus AMF’s incremental nets) would not reach nearly as many people.
Logistics & Partnerships: AMF explicitly depends on national malaria programs and partners for distribution. It covers the cost of purchasing nets, while governments and other partners (often funded by Global Fund or PMI) cover the costs of delivering those nets to households. In practice, AMF’s nets are added into mass campaigns run by ministries of health with major funding and logistical support from DFIs.1
Why USAID/DFIs Are Crucial2: These institutions not only finance most nets, but also strengthen supply chains and coordination. PMI (USAID) and the Global Fund invest in forecasting, procurement systems, and training of health workers for net campaigns. This infrastructure allows AMF’s funded nets to be distributed efficiently at scale. In short, AMF’s cost-effective impact is made possible by the backbone provided by USAID and others – without the massive DFI-funded campaigns, AMF could not achieve the same reach or low cost per net delivered.
Malaria Consortium – Seasonal Malaria Chemoprevention (SMC)
Shared Financing of SMC Programs: Malaria Consortium’s SMC program in the Sahel is largely enabled by philanthropic funding (via GiveWell donors), but it operates alongside major institutional funding. In 2023, Malaria Consortium supported SMC for ~25 million children across several African countries – nearly half of all children protected by SMC globally that year. However, only about 17 million of those treatments were funded by Malaria Consortium’s philanthropic donors, while the rest were co-financed by governments and global institutions. This means roughly one-third of Malaria Consortium’s SMC reach relied on non-philanthropic funding.
Operational Integration: Malaria Consortium works within national malaria programs and health systems. Its SMC delivery leverages the existing network of community health workers and clinics often supported by DFIs3. In Chad, for instance, SMC implementation is a partnership involving the Global Fund, Malaria Consortium, UNICEF, and Médecins Sans Frontières – illustrating that SMC at scale is a team effort. Malaria Consortium provides technical assistance, training, and drugs (funded by donors), but the campaigns also rely on government personnel and distribution channels bolstered by institutional funders.
Research & Catalytic Funding: The SMC strategy itself was scaled through DFI-backed efforts. Notably, from 2015–2017 Malaria Consortium led the Unitaid-funded ACCESS-SMC project ($68 million), which supported national malaria programs in 7 countries and met ~25% of the region’s SMC needs while gathering evidence on impact. This catalytic funding from a multilateral donor proved SMC’s value and helped convince larger funders (Global Fund, World Bank, etc.) to invest in SMC. Today, many SMC programs receive Global Fund grants as part of national malaria control. USAID’s PMI has also begun supporting SMC in some countries, further expanding reach. In sum, Malaria Consortium’s ability to operate at its current scale – tens of millions of treatments annually – is built on the foundation of DFI funding (for both implementation and prior research). Major donors supply SMC medicines, fund healthcare worker networks, and integrate SMC into national malaria plans, greatly amplifying the impact of every philanthropic dollar.
Helen Keller International (HKI) – Vitamin A Supplementation
Funding and Delivery Networks: HKI’s vitamin A supplementation (VAS) programs heavily rely on government and DFI-supported infrastructure. The actual cost of vitamin A capsules and delivery is often shared among stakeholders: national governments provide health staff and in-kind support, UNICEF supplies vaccines and sometimes vitamin A (with donor funding), and GiveWell grants fill remaining gaps. A primary historical funder of VAS has been Global Affairs Canada (GAC) via UNICEF and Nutrition International. In recent years, GAC’s funding for VAS has declined, leading HKI to step in with philanthropically-funded campaigns.4 This indicates that HKI’s work is embedded in a larger donor-supported effort rather than operating alone.
Piggybacking on Immunization Infrastructure: VAS distribution is often integrated into immunization or child health days. Historically, polio vaccination campaigns (funded by global initiatives including USAID) were used as a platform to deliver vitamin A, drastically reducing costs. As polio campaigns have waned, the cost and difficulty of VAS delivery have increased, and HKI’s role (with GiveWell funds) has been to ensure VAS keeps reaching kids despite the drop in other campaigns. Still, even HKI’s independent VAS campaigns use the government health system and supply chains that donors like USAID have helped strengthen over decades.
DFI Contributions to Impact: USAID and the World Bank have long contributed to nutrition programs that HKI builds upon. The World Bank and other donors have financed child health campaigns where vitamin A is given alongside other interventions. These institutions provide technical expertise, supply logistics, and funding for outreach that ensure vitamins actually get to millions of children. HKI’s effectiveness – high vitamin A coverage in target countries – is only possible because USAID/DFI-backed networks of health workers and distribution channels exist. In short, HKI acts as a crucial piece of a bigger puzzle: it fills funding gaps and offers technical help, but relies on the “heavy lift” (procurement, cold-chain, community health infrastructure) that major aid organizations support.
Other Top Charities and Institutional Support
Deworming Programs (Schistosomiasis and Soil-Transmitted Helminths): GiveWell-recommended deworming charities (e.g. Sightsavers, SCI Foundation, Evidence Action’s Deworm the World) operate through large-scale national NTD programs largely funded by USAID, UK FCDO, and others. These NGOs partner with health and education ministries to deliver mass drug administration, but the drugs themselves are usually donated by pharmaceutical companies and logistical costs are subsidized by donors like USAID’s NTD Program. For example, Sightsavers supports countries’ deworming campaigns by procuring medicines, providing logistics, and technical assistance, in collaboration with the Ministry of Health. The USAID NTD Initiative has helped reach over 30 countries with hundreds of millions of deworming treatments, forming the backbone of efforts that Sightsavers and others implement. In D.R. Congo, Sightsavers works alongside a local NGO (UFAR) to support the government in distributing deworming pills – they fund training, monitoring, and delivery, effectively amplifying the impact of government and USAID resources. Without such DFI-funded national programs, deworming charities would lack drugs to distribute and a ready infrastructure of health workers/teachers to reach children. It’s the large donors’ contributions (drug donations, transport, coverage surveys, etc.) that enable these charities to achieve continent-scale impact at a few cents per treatment.
New Incentives (Immunization Incentives): New Incentives, which pays caregivers small cash transfers to boost infant vaccination rates in Nigeria, depends fundamentally on the vaccines and clinics provided by others. Its effectiveness is only possible because Gavi, the Vaccine Alliance (to which the U.S. contributes via USAID), and the Nigerian government supply the vaccines and maintain immunization clinics. Nigeria’s immunization program itself is heavily donor-funded – since 2001 Gavi has invested over $732 million in Nigeria’s vaccine supply, cold chain, and health system. New Incentives leverages this existing system: it coordinates with government health teams and participates in outreach events (e.g. over 106,000 mobile vaccination sessions) to identify and reward caregivers. USAID and the World Bank also support Nigeria’s primary health care, funding staff training, community mobilization, and infrastructure. In effect, New Incentives adds an incentive layer to increase utilization, but the “heavy lifting” – delivering vaccines to clinics and organizing immunization days – is enabled by Gavi/USAID funding. If those institutions pulled back, vaccine availability and outreach would shrink, undermining the gains from incentives.
GiveDirectly (Cash Transfers): GiveDirectly’s model of direct cash transfers is less tied into government programs, but even it benefits from infrastructure indirectly supported by DFIs. Mobile money networks and banking systems in Kenya, Uganda, etc., have grown partly through World Bank and USAID investments in digital finance and regulation. Additionally, some of GiveDirectly’s large-scale projects have been done in partnership with government or research funded by institutions. (For instance, the landmark basic income experiment in Kenya received backing from academic researchers and funders like USAID’s Development Innovation Ventures for evaluation.) While GiveDirectly does not rely on public distribution networks in the way health charities do, it shows how enabling environments created by aid (stable mobile payment systems, government ID registries, etc.) are important for operational effectiveness.
In summary, USAID and similar institutions are crucial force-multipliers for GiveWell’s top charities. They provide the financing, supply chains, and national infrastructure that these highly effective NGOs plug into to deliver lifesaving interventions at extraordinary scale. The charities often focus on filling gaps or extending coverage, but it’s the presence of large-scale programs and logistics funded by DFIs that makes such extension possible and cost-effective. No single NGO could single-handedly replicate the reach of a USAID or Global Fund-backed program. The current snapshot is clear: whether it’s nets, medicines, or vitamins, GiveWell’s recommended charities depend on big institutional partners for the “last mile” delivery, research backing, and economies of scale. USAID and its peers enable these top charities to achieve outsized impact – truly a collaborative effort in global health, where philanthropic donations ride on the shoulders of giant aid programs to save lives.
This effect has been critical in the recent shutdown. Many of the logistics run by USAID do not appear to be eligible for the waivers and this has broken down the supply chain.
I didn’t understand these dynamics until I read an interview with the AMF founder and saw how hyper specific the program is with only 13 employees! I saved this quote and think about it a lot.
“We've been very fortunate in having a small group of donors, three effectively, who've said, you know, we'll fund the central cost sort of in perpetuity, pretty much. … The average of the last five years is our overheads as a percentage of revenue have been about 6 or 7%. Obviously, that's really quite low partly that's because we don't pay for anything other than 11 salaries of the 13 staff, 11 draw salary. … And there are a number of large donors that provide funding that covers the monitoring costs, which are significant. For every 100 million we spent on nets. We spend about seven or eight million on monitoring because we monitor the living daylights out of things we do in the countries in which we operate. They're also covered effectively. Which means that we can say honestly to donors and potential donors, if you give us 10 dollars, we will spend 10 dollars buying nets because everything else is covered. So we fund the nets, and other co-funding partners cover the non-net costs including shipping, in country transport of nets, registration across millions of households. There are a lot of health workers visiting households and gathering data. and then the distribution of nets. These are typically the next step. We fund nets at rough 2 dollars a net. The Global Fund or American Government fund the non-net costs. There are some volunteer activities that go on in-country, but the work that's done in-country is done by people paid by PDMs and are on salaries. It's just that we don't pay for that.”
Aid dependence is problematic and beyond the scope of this essay.
Canada’s decision in 2013 to restructure its international development agency—merging the Canadian International Development Agency (CIDA) into Global Affairs Canada (GAC)—has been widely discussed as having contributed to shifts in funding priorities. While it is difficult to pinpoint a single cause, several analysts have noted that after the merger, funding for some technical and long‐term development interventions, such as vitamin A supplementation (VAS), has declined.
In the pre‐2013 era, CIDA was solely focused on development effectiveness. After the merger into GAC, the agency’s mandate broadened to include diplomatic and geopolitical priorities. This shift meant that funding decisions increasingly reflected Canada’s broader foreign policy agenda, sometimes at the expense of more narrowly defined technical interventions like VAS. As a result, the support GAC provided for VAS campaigns has noticeably decreased in recent years. This reduction in governmental support appears to be one reason why organizations such as Helen Keller International (HKI) have increasingly turned to philanthropic funding to maintain their VAS distribution efforts.
It is important to note that funding decisions are influenced by a range of factors (domestic priorities, global economic conditions, evolving donor strategies, etc.), so while the 2013 reorganization likely played a role, it is one factor among several that have contributed to the observed decline in support for VAS.