U.S. President’s Malaria Initiative

Despite substantial financial contributions by the United States President’s Malaria Initiative (PMI) since 2006, no studies have carefully assessed how this program may have affected important population-level health outcomes. We utilized multiple publicly available data sources to evaluate the association between introduction of PMI and child mortality rates in sub-Saharan Africa (SSA).

Methods and findings

We used difference-in-differences analyses to compare trends in the primary outcome of under-5 mortality rates and secondary outcomes reflecting population coverage of malaria interventions in 19 PMI-recipient and 13 non-recipient countries between 1995 and 2014. The analyses controlled for presence and intensity of other large funding sources, individual and household characteristics, and country and year fixed effects.

PMI program implementation was associated with a significant reduction in the annual risk of under-5 child mortality (adjusted risk ratio [RR] 0.84, 95% CI 0.74–0.96). Each dollar of per-capita PMI expenditures in a country, a measure of PMI intensity, was also associated with a reduction in child mortality (RR 0.86, 95% CI 0.78–0.93). We estimated that the under-5 mortality rate in PMI countries was reduced from 28.9 to 24.3 per 1,000 person-years. Population coverage of insecticide-treated nets increased by 8.34 percentage points (95% CI 0.86–15.83) and coverage of indoor residual spraying increased by 6.63 percentage points (95% CI 0.79–12.47) after PMI implementation. Per-capita PMI spending was also associated with a modest increase in artemisinin-based combination therapy coverage (3.56 percentage point increase, 95% CI −0.07–7.19), though this association was only marginally significant (p = 0.054). Our results were robust to several sensitivity analyses. Because our study design leaves open the possibility of unmeasured confounding, we cannot definitively interpret these results as causal.

Conclusions

PMI may have significantly contributed to reducing the burden of malaria in SSA and reducing the number of child deaths in the region. Introduction of PMI was associated with increased coverage of malaria prevention technologies, which are important mechanisms through which child mortality can be reduced. To our knowledge, this study is the first to assess the association between PMI and all-cause child mortality in SSA with the use of appropriate comparison groups and adjustments for regional trends in child mortality.

Why was this study done?

• Despite the considerable investment the US government has made in the President’s Malaria Initiative (PMI) since 2006, no studies to date have evaluated its association with population health outcomes.
• Previous evaluations have documented decreasing child mortality and increasing use of key malaria interventions in PMI-recipient countries. Our study sought to determine whether the trends in health outcomes in PMI-recipient countries differed significantly from the trends in these outcomes in PMI non-recipient countries in sub-Saharan Africa (SSA) over the past 2 decades.

What did the researchers do and find?

• We used a study design that leveraged multiple publicly available data sources from countries throughout SSA, spanning the years before and after PMI introduction, in order to estimate association between the introduction of PMI and child mortality rates.
• Our dataset included 7,752,071 child-year observations from 2,112,951 individual children who lived in 32 sub-Saharan countries, including all 19 PMI countries.
• We found that after adjusting for baseline differences between countries, overall time trends, other funding sources, and individual characteristics, PMI was associated with 16% annual risk reduction in child mortality and increased population coverage of key malaria prevention and treatment technologies.
• We tested the robustness of our results with a series of sensitivity analyses.

What do these findings mean?

• The study provides evidence that introduction of PMI was associated with significant reductions in child mortality in SSA, primarily through increased access to malaria prevention technologies.
• Evidence from this study can be used to inform policy decisions about future funding levels for malaria interventions.
• The interpretation of our study results rests on the assumption that there were no important unmeasured variables that differentially affected mortality rates in PMI and comparison countries during the study period.