Update 29 Aug 2026: We met our $512k fundraising goal mentioned in this post! Huge thanks to everyone who made that happen. We've moving ahead with engaging implementation partners for 6 months and are planning training in September and a phased roll out from October 26 - Jan 27. Our updated fundraising two-pager is here: https://tinyurl.com/spiro-proposal this covers extending the Sindh expansion work from 6 to 12 months as well as other staff and program costs for 2027. If you are interested in supporting Spiro we're still interested in hearing from you!

Thanks Verónica!

Co-founders moving on is an interesting topic that I've changed my mind on a bit over time.

Looking at AIM-incubated organisations there were a few initially that kept the same two co-founders for a long while. But more recently there has been more diversity of routes:

1. Organisations doing really well with only one founder from the start
2. A bunch where where one founder left around the 2 year mark and it seems like the right decision for the org. (By then you've built something that exists a bit beyond the two of you and having one organisational leader building an exec team around them could make more sense. )

I think that generally has pushed me (and I think others at AIM) to think that two co-founders staying for the long haul isn't always the ideal to strive for. As I understand it, AIM's messaging in the incubation program at the moment has shifted a bit to accommodate that.

Some other things to note:

• There can certainly be cases where a co-founder leaves because of conflict, or especially early on, or it might not have been ideal timing for the organisation
• There have been organisations initially in category 1 and 2 that then did bring a second person into the exec team who is co-executive again, and
• I think more traditional wisdom in other sectors can often be that they'd love to see founders really be driven by their commitment to this project and stick it out for a long time.

I think that didn't directly answer your question but hope that helped!

Thank you Tony! These are really interesting and tough questions.

We certainly see a potential route for government as a doer and payer at scale. Re payer: we've seen examples in Pakistan where he government outsource service provision in both education and health to NGOs - so NGOs deliver but government pays. Re doer: when there is a strong community based health worker force it's more possible to layer TB into what they do. There are some alternatives to consider e.g. Commcare Connect https://labs.connect.dimagi.com/ to essentially allow government staff to pick this up as gig work. But we haven't looked into these a tonne yet. I think the routes here are most promising in Punjab province and potentially other countries.

However, with the advent of the third wave of philanthropy the time pressure to handover to government as the payer at scale I think has lessened. I'm interested in your take on this too. It does seem possible to me that providing this intervention support directly in Sindh and elsewhere funded by philanthropy could be a more viable route than it has previously been. Right now I think that actually means viability of different funding sources is probably my biggest uncertainty to shed light on the best scaling strategy.

Great questions! And thank you for the kind words.

I should also say going from incubated to getting GiveWell money is in large part a function of GiveWell being excited in 2024/early 2025 to make grants to earlier stage charities and us picking an idea that they independently looked into and approved a grant to CHAI about!

The Drug Itself

1. What is it called?

A combination of two drugs: Isoniazid plus Rifapentine. The combination is called 3HP.

2. How much does it cost?

$10 for the standard version of 3HP - both drugs are combined together into one tablet.

$7 for the brand-new child-friendly version

But note Spiro doesn't buy the drugs - the government gets them usually with money from the Global Fund

3. Roughly how does it work?

For people who have been infected with TB, these are antibiotics that fight the TB bacteria before it develops into TB disease. (Roughly Isoniazid blocks the bacteria from building their cell wall, Rifapentine blocks them from replicating)

4. What's the side-effect profile like?

Generally extremely well-tolerated especially in kids. Occasional reactions can be rash or vomiting.

Growth

5. How'd you get the government so excited so quickly as total outsiders? (asking for a friend)

Haha I don't think it was quick! Each stage has been very incremental. Some amount of being at the right place right time I think. [Can say more by DM]

6. How much do you reckon you'll benefit from economies of scale?

Hopefully it should help! But I haven't done any good modelling of this yet.

7. Are funding and target population size is the only real constraints that you see at present?

I think my personal capacity is a constraint right now as all Spiro things still go through me so I need to build that out.

Outside the box

8. At least in rural areas, where getting there is the majormost cost, why not do other things beyond TB screening / prevention too e.g. delivering under-supplied medicines / vitamins / goods (assuming you / your partners aren't already doing that)

This is an excellent question and I think usually expanding to other verticals when you've solve a "last-mile problem" is a really good idea. We haven't yet explored this seriously for our TB program - one of the awkward things is that we're only going to houses where someone has TB not going to all doors in the area which would be an odd strategy for something like vitamins / immunisation. We are more hoping to go the other direction - layer our TB program onto other health workers who are already going door to door. That's our plan for Punjab. But in the meantime we're focusing on expanding our program in Sindh and showing it works at scale.

Thanks so much for doing this and for sharing! I found his comments on the portofolio of the Global Fund's malaria work to be particularly interesting :)

What, if anything, would you do differently if you were starting AMF today?

Now you have a bigger team have you found that comes with much more overhead in people management, internal communications etc?

On what frequency do you think about organisational goals and strategy internally? (If you're happy to share) E.g. do you set quarterly goals, think about big picture strategy annually etc

Relatedly / alternatively: In the course of running AMF have you ever struggled with worries about whether you're on the right track or doubted your choices? How have you handled this?

AMF has leveraged corporate support and partnerships perhaps more than other charities do. Does that seem true to you? If so, is it something you think lean nonprofits should be doing more?