Todd Summers
Senior Adviser, CSIS Global Health Policy Center

While the giant PEPFAR program to fight HIV/AIDS in developing countries gets a lot of attention in U.S. foreign policy discussions, a lesser known initiative to address malaria is achieving sustained, impressive results. The President’s Malaria Initiative (PMI), launched in 2005 by former President Bush, helps a range of countries prevent and treat malaria by providing them with technical guidance, programmatic support, and funding.  Its model and achievements over almost a decade offer important lessons.PMITable

PMI has been advantaged in certain important respects:

  • Malaria is a concentrated epidemic, with most of its burden in countries banded around the equator where climates support the malaria parasites and the mosquitoes essential to their spread to humans. The bulk of that burden is in sub-Saharan African countries and a few in the Mekong region of Southeast Asia2 and in Latin America.  Just two countries, Nigeria and Democratic Republic of Congo, account for over 40% of global malaria deaths.3
  • The fight with malaria revolves around only four tools: insecticide-treated bed nets, indoor spraying of insecticides, diagnosis and treatment of those with malaria, and preventive therapy in pregnant women (contrast that with six key interventions for TB and over twenty for HIV/AIDS).
  • Results show up quickly, with effective coverage of these interventions translating into reduced death rates, especially among children.

Even with these attributes, PMI deserves great credit for doing its work very well.  An independent evaluation of its first five years noted strong programmatic achievement and “excellent and creative program management.”  Admiral Tim Ziemer, who runs PMI, and Dr. Bernard Nahlen, the deputy coordinator, are a formidable team: they’re smart, seasoned, tough, and disciplined, which allows them to utilize a budget now at $650 million per annum to drive a global effort on malaria. In the six years since PMI was started, they’ve achieved:

  • More than 82 million insecticide-treated bed nets distributed;
  • Nearly 140 million anti-malarial treatments provided; and
  • Over 60 million rapid diagnostic kits for malaria procured.4

Challenges remain, however, and while positive results can be seen quickly, so too can resurgent malaria wipe away years of hard-fought gains in just one or two rainy seasons. Key issues with which PMI will need to grapple include:

  • Resistance to malaria drugs is here, and its spread is accelerating across the Mekong sub-region. That triggered the assignment of a senior PMI staff person in 2011 to the US embassy in Bangkok and another in 2012, along with rising commitments from PMI for Mekong control efforts, including in Burma. The Global Fund at the same time has announced a three-year $100m Mekong program to be introduced in close cooperation with PMI.  If, or really when, drug-resistant malaria arrives in Africa, it will have very serious consequences for the major ongoing PMI programs there.   It could come from Asia to Africa, the same route taken by malaria resistant to chloroquine, the predecessor to the Artemisinin-based combination treatments (ACTs) currently recommended to treat most malaria cases, or it could arrive de novo if the effectiveness of Artemisinin is undermined by improper drug use or substandard ACTs that are showing up more widely.  New drugs aren’t coming anytime soon, so PMI will have to work assiduously with others to slow the spread of the resistant parasites.
  • Malaria vaccines, critical to eradication, are years away; significant technical challenges remain, and those first approved vaccines are likely to be only partially effective – meaning that buying and distributing them will only add to already strained budgets.
  • Mosquitoes that carry malaria are also adapting, with reports of changing feeding patterns, biting during the day when bed nets aren’t used.  There are also reports of resistance to the long-lasting insecticides used to treat bed nets.  PMI has studies underway to understand the potential impact on bed net effectiveness.
  • Success may breed complacency, with declining death rates and near universal coverage of bed nets leading to a false sense of security about sustainable progress on elimination and eradication.
  • Political attention may be unsustainable.  Congressional support has been critical to keeping PMI’s budget and authorities intact, and it’s always a struggle in Washington to maintain attention and support over the long term.

Fortunately, funding continues to increase.  PMI is slated to receive about $20 million in additional funding in the FY2014 budget proposal recently submitted by President Obama to Congress.  The budget also proposes significant funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria of $1.65 billion — about one-third of which goes for malaria.

At the CSIS Global Health Policy Center, we’re looking to spend some more time understanding these challenges and recommending responses by the US government, the drug and bed net industry, and others.  Our recent publication on Global Health Policy in the Second Obama Term includes a chapter on U.S. Priorities for Malaria, and we’ve got a really interesting video interview with Sir Richard Feachem with his views on opportunities and challenges in fighting malaria.

We’d love to hear from you about where we should concentrate our efforts, so leave a comment below!

[1] World Health Organization, Global Health Observatory Data Repository

[2] The Greater Mekong Sub-Region focus area for PMI includes Burma, Cambodia, China (Yunnan Province), Lao People’s Democratic Republic, Thailand, and Vietnam.

[3] World Health Organization, World Malaria Report 2012, Executive Summary, December, 2012.

[4] Fast Facts: The President’s Malaria Initiative (PMI), April, 2013 (pre-publication copy).