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 and has been the largest donor to the sector. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up funding and activities to address malaria in the hardest hit African countries, helping to contribute to global success in driving down malaria cases and deaths.
• Still, in 2024, there were 282 million cases of malaria, a life-threatening disease spread to humans by mosquitoes, and 610,000 malaria deaths (the majority of which were among children under age five), a slight increase over the prior year.
• Recent decades have seen major gains in reducing the impact of malaria, and PMI is credited with having helped to save 11.7 million lives and prevent 2.1 billion malaria cases. Indeed, as of 2024, in countries where PMI worked, global efforts supported a 29% decrease in malaria case rates and 48% decline in deaths. In addition, U.S. malaria assistance has been found to bolster the national economies in countries and communities most heavily affected by the disease with an analysis finding that every dollar of U.S. malaria assistance increased GDP in recipient countries nearly six-fold. The introduction of two malaria vaccines in 2021 and 2023 has increased optimism in the potential to further strengthen global malaria control.
• Prior to the dissolution of USAID in 2025, PMI had operated as an interagency initiative led by USAID and implemented in partnership with CDC, focused in 30 countries that account for most of the world’s malaria cases and deaths. It had been 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.
• While the Trump administration has requested significantly less funding for PMI in its budget requests, prior to the start of the Trump administration U.S. funding provided to PMI and other bilateral global malaria efforts in FY 2024 was about $805 million; funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was $1.65 billion.

Current Status of PMI/Malaria Activities

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

• 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 terminate staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4, 2025, 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 remained 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 and operations have 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 did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and move any remaining USAID operations to the State Department, with global health activities, including for malaria, 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 with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. Malaria has been included in most of the agreements signed to date, although there is little information available on activities and funding. A U.S. Malaria Coordinator has yet to be appointed.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for PMI and other malaria efforts in its budget requests and canceled funding for numerous malaria-related projects and awards. Despite this, Congress has continued to appropriate level funding for PMI and other bilateral global malaria efforts, including about $805 million in FY 2026. It also appropriated $1.25 billion for the Global Fund in FY 2026.

Impact on PMI Services and Outcomes

• An internal USAID memo from 2025 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 in 2025 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 to delay the start of anti-malarial campaigns in Africa last year.
• A modeling project estimated that a full year U.S. funding cuts could result in an additional 2.4 million malaria cases among adults and an additional 7.2 million malaria cases among children.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral malaria efforts and contributions to the Global Fund
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes