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 spread to humans by mosquitoes. There are approximately 263 million malaria cases and 600,000 deaths each year; the majority of 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 has increased optimism in the potential to further strengthen global malaria control.
• U.S. malaria assistance bolsters national economies in countries and communities most heavily affected by the disease. A recent analysis found that every dollar of U.S. malaria assistance increased GDP in recipient countries nearly six-fold.
• 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. has been the top donor government to malaria efforts, through PMI and contributions to the Global Fund. The administration’s FY 2026 budget request includes $424 million for malaria, a decrease of $381 million (final appropriation levels are determined by Congress).
• 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 (now dissolved), PMI had been an interagency initiative led by USAID in partnership with CDC, 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, including those 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 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, announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: In early 2025 it was reported that the administration canceled 86% of all USAID awards. KFF analysis found 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. On August 13, the U.S. Court of Appeals for the D.C. Circuit overturned the district judge’s preliminary injunction, ruling that plaintiffs lacked legal standing to challenge the administration’s termination of funding. While a District Court subsequently found that the plaintiffs could seek relief through another legal avenue and granted a preliminary injunction ordering the government to obligate expiring funds, the Supreme Court ultimately ruled that the government could withhold these funds.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and move remaining USAID operations to the State Department, with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan and programs moved in July.
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy. Per the new strategy, the U.S. will:
  • Negotiate bilateral, multi-year agreements with countries receiving U.S. assistance, with implementation and monitoring plans in place by March 31, 2026. Agreements will include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period;
  • Provide 100% of current levels of funding for malaria control commodities ([insecticide-treated bednets, malaria diagnostic tests, anti-malarial medications and malaria vaccines) and frontline healthcare workers through FY 2026 and reduced funding thereafter;
  • Rapidly reduce funding for activities other than health commodities and frontline health personnel.

Impact on PMI Services and Outcomes

• An internal USAID memo estimated 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 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.
• In early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns were off-track or at risk of being delayed due to funding shortages, and such risks continue today. Several countries also face stock-out risks for key commodities including for rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions.
• Such disruptions pose significant risks, particularly during peak malaria seasons across Africa where seasonal malaria campaigns are needed 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

• Leadership: A U.S. Malaria Coordinator has not yet been appointed, and it is unclear, given the dissolution of USAID, what the leadership structure will be going forward.
• Reorganization: The dissolution of USAID and integration of any remaining USAID global health activities, including for malaria, into GHSD raises several questions, including whether additional capacities will be provided to allow for the management and implementation of PMI at the State Department.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $381 million reduction for malaria (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress in June, including proposed rescissions of more than $1 billion in funding for global health. Congress reduced that amount to $500 million and exempted some program areas, including malaria, from the rescission.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop bilateral agreements with countries and plans to scale down funding, including for malaria-related activities, the details of which will significantly shape the future of the global malaria response.