The President’s Malaria Initiative (PMI)
Malaria, one of the world’s most serious and common tropical diseases, is endemic in more than 100 countries and although preventable and treatable, it causes significant morbidity and mortality, particularly in resource-poor regions.1 While the U.S. government has been involved in malaria activities since the 1950s, the passage of the President’s Malaria Initiative (PMI) in 2005 marked a major expansion of U.S. malaria control efforts. PMI, originally a five-year (FY 2006-FY 2010), $1.2 billion effort, targeted 15 hard hit “focus countries” in Africa, with the goal of reducing malaria-related deaths by 50% through expanded coverage of four highly-effective malaria prevention and treatment interventions.2, 3
U.S. engagement in and funding for malaria, in particular through PMI, has substantially increased over time, in large part due to the 2008 Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act, which, among other things, authorized up to $5 billion for malaria over the five-year (FY 2009-FY 2013) period. The Act also continues support for PMI’s focus countries, expands assistance to other endemic countries, and calls for the development of a strategic plan to combat global malaria.4 In addition, the Act codified the position of U.S. Malaria Coordinator and called for the development of a strategic plan to combat global malaria, which the Administration released in April 2010 as the Lantos-Hyde U.S. Government Malaria Strategy (USG Malaria Strategy).3, 5, 6 The USG Malaria Strategy is integrated with the U.S. Global Health Initiative—the USG’s effort to develop a comprehensive strategy for global health announced in May 2009 by President Obama—and aims to reduce the impact of malaria by focusing on Africa, incorporating a woman-centered approach, limiting the spread of drug resistant malaria, integrating with other health interventions, strengthening health systems, and building national capacities.5, 7
PMI is an interagency initiative run by the U.S. Agency for International Development (USAID) and implemented together with the Centers for Disease Control and Prevention (CDC). Much of the USG’s activities and resources for global malaria are consolidated under PMI, which coordinates U.S. efforts across multiple agencies and programs including USAID, CDC, the Department of Defense (DoD), and the National Institutes of Health (NIH).
U.S. Global Malaria Coordinator
U.S. malaria efforts are overseen by a U.S. Global Malaria Coordinator, based at USAID, a position first created by the USAID Administrator in 2005 to oversee all USAID PMI and non-PMI malaria efforts. The 2008 reauthorization of PEPFAR codified this position as a Presidential appointment and authorized the Coordinator to oversee and coordinate “all resources and international activities of the United States Government relating to efforts to combat malaria” including the efforts of all relevant executive branch agencies, multilateral institutions, and private sector partners.
PMI Interagency Steering Group
An Interagency Steering Group, with representatives from USAID, CDC, Department of State, DoD, the National Security Council, and the Office of Management and Budget, oversees the PMI with the Coordinator.
PMI Strategy & Approach
Four operating principles guide PMI’s approach:
- Use of a comprehensive, integrated package of four proven prevention and treatment interventions: indoor residual spraying with insecticides (IRS); insecticide-treated mosquito nets (ITNs); intermittent preventive treatment for pregnant women (IPTp); and diagnosis of malaria and treatment with artemisinin-based combination therapy (ACT);
- Strengthening of health systems and integrating maternal and child health services;
- Commitment to strengthen national malaria control programs (NMCPs) and build capacity for country ownership of malaria control efforts; and
- Close coordination with international and in-country partners.
Two other key components of the PMI are:
- The Malaria Communities Program (MCP), an initiative to support communities and indigenous organizations in Africa with the goal of identifying new partners and building community-level networks to expand the reach of malaria control efforts.
- The PMI Central Emergency Procurement Fund, created to prevent stockouts of critical malaria commodities (ACTs, bed nets, IRS), which could result in adverse health consequences. The Central Fund works to rapidly procure and transport commodities to countries with shortages, due to lack of funds or other barriers.
PMI concentrates U.S. efforts in 19 focus countries in Africa and one region in Asia, using a scaled up approach. In FY 2006, PMI supported three countries (Angola, Tanzania, and Uganda), adding four countries in FY 2007 (Malawi, Mozambique, Rwanda, and Senegal), eight in FY 2008 (Benin, Ethiopia’s Oromia Region, Ghana, Kenya, Liberia, Madagascar, Mali, and Zambia), two in FY 2011 (the Democratic Republic of the Congo and Nigeria), and two in FY 2012 (Guinea and Zimbabwe). The USG Malaria Strategy calls for the expansion of PMI control efforts in additional high-burden countries by 2014.6
The focus countries are selected based on 5 criteria: high malaria burden; alignment of NMCP with internationally accepted World Health Organization (WHO) standards; country capacity to implement national control policies; willingness to partner with the U.S. in fighting malaria; and involvement of other international donors (e.g., the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Bank, etc.). Both USAID and CDC station staff in each PMI focus country.10, 11, 12
The U.S. also provides malaria assistance to three additional African countries (Burkina Faso, Burundi, and South Sudan) and reaches other countries through regional programs. In these countries and regions, the U.S. provides smaller scale support for the prevention and treatment of malaria, including technical assistance, monitoring and evaluation, research, and some commodity support.
Building on the previous successes of the PMI, the USG Malaria Strategy includes a six year horizon (FY 2009-FY 2014), and expands U.S. malaria control efforts with the goal of halving malaria morbidity and mortality in 70% of at-risk populations in sub-Saharan Africa. The USG Malaria Strategy also set a target of reducing preventable malaria-related deaths to near zero by 2015, with the ultimate goal of eradication.
The PMI & The Global Fund
In addition to bilateral assistance for malaria, the USG provides multilateral assistance to the Global Fund, an independent international financing institution which pools funding from donors to provide grants to low- and middle-income countries to combat malaria (as well as HIV and tuberculosis). The Global Fund acts as an additional mechanism for U.S. malaria support by financing programs developed by recipient countries and by reaching many countries beyond the PMI focus and non-focus countries. To date, 80 countries have received Global Fund grants for malaria, and about 30% of Global Fund commitments are for malaria programs.14 The U.S. is the largest donor to the Global Fund, even though Congress has set limits on U.S. Global Fund contributions generally and for malaria specifically.
- PEPFAR’s original authorization in 2003 limited U.S. contributions to the Global Fund to not exceed 33% of contributions from all other sources, a condition retained in the 2008 reauthorization.
- The 2008 reauthorization also restricted U.S. contributions from supporting any activities involving the Affordable Medicines Facility-Malaria (AMFm), pending evidence from pilot programs.15 AMFm is an innovative financing mechanism, first proposed in concept by the U.S. Institute of Medicine and hosted by the Global Fund since April 2009, to expand access to ACTs by negotiating lower prices directly with drug manufactures and subsidizing the lower cost for public, private, and not-for-profit buyers in eligible countries. The U.S. has raised concerns about whether the mechanism can work as intended and has deferred support until more evidence of its effectiveness is available.16
U.S. funding for malaria has increased over time, rising from $198 million in FY 2004 to $806 million in FY 2012, with $775 million requested for FY 2013—a 4% decrease from the FY 2012 level (see Figure 2). Most of this funding is provided to PMI focus countries—in FY 2012, these countries accounted for 62% of U.S. malaria funding (see Figure 3).13
In FY 2012, $650 million, or 81%, was channeled to USAID, primarily for programs in PMI focus countries; $147 went toward research at NIH, and $9.3 million was provided to CDC.13
Support for commodities, such as ITNs, insecticides, and antimalarial drugs, like ACTs, has increased since the start of PMI. Funding also supports activities such as technical assistance, monitoring and evaluation, staffing, administration, and management of programs.2, 17
Since PMI’s launch in 2005, the larger global context for addressing malaria has evolved, with renewed calls for malaria eradication and a growing emphasis on the role of malaria elimination, in addition to malaria control. At the same time, many challenges remain. As the USG continues to implement the Malaria Strategy, several issues arise, including:
- The continued need to strengthen health systems in affected countries to sustain and enhance the ability to deliver interventions and monitor and evaluate progress;2, 6
- The challenge of drug and insecticide resistance, resulting in the need for affected countries to invest in newer, costlier, first-line therapies;2
- PMI’s geographic focus, given concerns that its ability to reduce malaria burden in the 19 focus countries may be difficult without also addressing high malaria transmission rates in bordering nations; growing attention to other regions of the world, such as Asia, where high proportions of the population are at risk for malaria; and the more recent focus on malaria elimination efforts in countries where the U.S. is currently not working but which border its efforts.3
WHO. World Malaria Report 2011; December 2011.
PMI. The President’s Malaria Initiative: Sixth Annual Report to Congress; April 2012.
Moss, K. “The President’s Malaria Initiative and Other U.S. Global Efforts to Combat Malaria: Background, Issues for Congress, and Resources.” CRS. Report No. 7-5700; April 2009.
U.S. Congress, Public Law No: 110-293; July 30, 2008.
USAID. Lantos-Hyde United States Government Malaria Strategy; April 2010.
White House, Statement by the President on Global Health Initiative; May 5, 2009.
GHI, Implementation of the Global Health Initiative: Strategy Document; February 2010: http://www.pepfar.gov/ghi/index.htm.
External Evaluation of the President’s Malaria Initiative, Final Report; February 2012.
CDC, CDC’s Global Malaria Activities: http://www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html.
CDC, President’s Malaria Initiative (PMI): http://www.cdc.gov/malaria/malaria_worldwide/cdc_activities/pmi.html.
KFF Analysis of data from: FY 2012 Budget of the United States; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.
The Global Fund: http://portfolio.theglobalfund.org/en/DataDownloads/CustomizeReportDownload; accessed November 2012.
The Global Fund: http://www.theglobalfund.org/en/amfm/?lang=en.
PEPFAR, U.S. Government Positions on Decision Points for the Eighteenth Board Meeting of the Global Fund; November 2008.
PMI. Malaria Operational Plans: http://fightingmalaria.gov/countries/mops/index.html.