The Trump Administration’s Foreign Aid Review: Status of the President’s Malaria Initiative (PMI)

Background on PMI

• The U.S. government has been involved in global malaria activities since the 1950s. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up efforts to address malaria in the hardest hit African countries.
• Malaria is a life-threatening disease that is spread to humans by mosquitoes. There are approximately 263 million malaria cases and 600,000 deaths each year; the majority of malaria deaths are among children under age five.
• PMI is credited with helping to save 11.7 million lives and prevent 2.1 billion malaria cases since 2000. Indeed, since 2006, in countries where PMI works, global efforts have supported a 29% decrease in malaria case rates and a 48% decline in deaths. The introduction of two malaria vaccines in 2021 and 2023, respectively, has increased optimism in the potential to further strengthen global malaria control.
• The FY 2025 Continuing Resolution that passed in March included level funding for PMI and other malaria activities at USAID and CDC of $805 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. is the top donor government to malaria efforts, through PMI and its contributions to the Global Fund.
• Overseen by a U.S. Global Malaria Coordinator, a position created by Congress in 2008 to be appointed by the President and based at USAID, PMI is an interagency initiative led by USAID in partnership with CDC. Efforts have been focused in 30 countries that account for 90% of the world’s malaria cases and deaths.

Current Status of PMI

The following administration actions have had a significant impact on PMI operations:

• Funding freeze/stop-work order: The stop-work order initially froze all PMI programming and services, halting existing PMI activities, including bed net provision, residual spraying and delivery of antimalarial medicines. Because the order halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4 allowing “life-saving services” to continue, defined as those services that “must resume within 30 days to ensure malaria diagnosis and treatment, as well as prevention through distribution of nets and indoor residual spraying targeting highest burden areas…and lifesaving malaria medicines for pregnant women and children”. Even with the waiver, services remain disrupted and implementers have faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for malaria efforts, obligating almost all bilateral malaria assistance in FY 2023 (96%). Without USAID and most of its staff, PMI’s implementation capacity has been affected. In addition, recent announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds that of the 770 global health awards identified, 157 included malaria activities, 80% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR.

Impact on PMI Services and Outcomes

• An internal USAID memo reported that an additional 12.5-17.9 million malaria cases and an additional 71,000-166,000 deaths could occur annually if PMI was halted permanently.
• A recent modeling study found that PMI could help to avert almost 15 million malaria cases and 107,000 deaths in 2025, gains that would be threatened by the foreign aid freeze, cancelations of projects, and uncertainty of funding.
• A recent rapid assessment survey of 108 WHO country offices found that of the 64 malaria-endemic countries surveyed, more than half reported moderate or severe disruptions to malaria services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• As of early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns, designed to reach 425 million people, were off-track or at risk of being delayed due to funding shortages. Countries also face limited supply of key commodities including six countries with only a 3-month supply of malaria rapid diagnostic tests (RDTs) and five countries with only a 3-month supply of artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions.
• The timing of these disruptions poses significant risks for malaria efforts given that malaria season has begun in much of Africa, requiring the need for seasonal malaria campaigns to protect millions of people. In a court filing challenging the funding freeze, for example, a major U.S. implementer reported that it had already had to delay the start of anti-malarial campaigns in Africa.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review, including for PMI. It is unknown whether it will recommend any changes to PMI (including further reductions), and how or if Congress will respond to its recommendations.
• Leadership. At this time, no U.S. Malaria Coordinator has been appointed, and it is unclear, given the dissolution of USAID, what the leadership structure will be going forward.
• Reorganization. The proposed permanent dissolution of USAID and integration of any remaining USAID global health activities into GHSD, including for malaria, raises several questions, including whether additional capacities will be provided to allow for the management and implementation of PMI and these other health programs at the State Department.
• Funding/Budget Request: The administration has signaled that it may seek rescissions of FY 2025 funding amounts, which could further affect PMI activities and funding. In addition, the President’s budget request for FY 2026, expected soon, could further signal the administration’s plans.