The President’s Malaria Initiative Reduced All-Cause Childhood Mortality Interview with:

Alexsandra Jakubowski

Aleksandra Jakubowski MPH

Aleksandra Jakubowski, MPH PhD candidate
Department of Health Policy and Management
Gillings School of Global Public Health
University of North Carolina at Chapel Hill What is the background for this study?

Response: The US President’s Malaria Initiative (PMI) provides approximately $600 million annually to fund implementation of key evidence-based malaria prevention and treatment interventions, including insecticide treated nets (ITNs), artemisinin-based combination therapy (ACT), and indoor residual spraying (IRS) to populations in 19 recipient countries in sub-Saharan Africa (SSA). Despite this considerable investment, no study to date has evaluated the impact of PMI on population health outcomes. Previous evaluations have noted improved health outcomes in PMI countries, but comparison groups are needed to establish whether these changes were beyond the declining trends in mortality observed in the rest of the region. Our study sought to generate objective evidence for policy makers about the role this US-funded malaria aid program may have played in curbing child mortality in SSA.

We used a quasi-experimental design known as difference-in-differences to compare trends in health outcomes in PMI-recipient vs. PMI non-recipient countries. We analyzed publicly-available data from 32 countries in SSA spanning a period that included about ten years before and after the introduction of the program. What are the main findings?

Response: Our main study finding is that the introduction of thePresident’s Malaria Initiative was associated with a 16% reduction in the annual risk of all-cause mortality among children aged <5 years. This finding was confirmed using a measure of PMI spending in recipient countries. Essentially, following the introduction of PMI in countries, the pace of child mortality decline accelerated significantly. Our model accounted for the overall trends in child mortality in Africa, the baseline differences in child mortality rates between study countries, availability of other funding sources including the Global Fund and PEPFAR, and various individual-level and household-level covariates.

Moreover, at the same time as child mortality was decreasing, population coverage of the key malaria prevention and treatment interventions funded by PMI was increasing. On average, ITN coverage increased by 8.3 percentage points, IRS coverage increased by 6.6 percentage points, and ACT coverage increased by 3.6 percentage points. The association between PMI and all our study outcomes grew larger in magnitude over time. Finally, our robustness checks showed that the association between PMI and child mortality was even larger in rural areas, where malaria burden is generally greater, and was larger in magnitude when we excluded deaths that occurred within first month of a child’s life, i.e. deaths that would have been avoided more likely due to prenatal or delivery care than PMI efforts. What should clinicians and patients take away from your report?

Response: ThePresident’s Malaria Initiative was associated with large and meaningful reductions in child mortality. In other words, PMI’s investment in evidence-based malaria interventions appears to have provided large positive returns in terms of reduced malaria burden and lower child mortality. At a time of increasing uncertainty about future funding levels of US foreign aid, our study provides objective evidence that programs such as PMI offer substantial returns on investment. What recommendations do you have for future research as a result of this study?

Response: Our study did not account for national government spending on malaria interventions due to lack of reliable data. Countries have taken on more pronounced roles in funding their health systems and the potential contributions of domestic spending to the improved child mortality rates should not be overlooked. Indeed, PMI works in close collaboration with recipient governments. Future studies that include data on national health spending could help us understand the synergies that might exist between foreign health aid and countries’ own investments in various components of their health systems.

PMI has been praised by some experts for being well managed, targeting specific interventions, and spending majority of its budget on procurement of goods for direct distribution to populations in countries. Disentangling which of PMI’s implementation techniques may have led to this program’s success could provide valuable insights into the design of other large-scale health interventions in the region.

While our study suggests that PMI may have significantly contributed to reducing all-cause child mortality rates in Africa, additional research is needed to assess the cost-effectiveness of PMI investments.

Finally, this study is a good example of using publicly available data to explore how policies and programs affect population health. We combined data from multiple sources in order to create a large and robust dataset that spanned a long follow-up period from 32 countries. Future research should make greater use of publicly available data to evaluate other health initiatives. Is there anything else you would like to add?

Response: Our analyses focused on PMI’s role in reducing child mortality. The study findings should not be taken to mean that other funding programs and country investments did not have a meaningful impact. Part of PMI’s success might have been due to this program’s coordination of activities with their partners and recipient governments.

This work was completed as part of my dissertation. I would like to extend thanks to my co-authors and committee members. In particular, I would like to thank my dissertation Chair, Dr. Harsha Thirumurthy, who has helped me develop the concept for this paper and provided me with guidance throughout the analysis and manuscript development. Thank you for your contribution to the community.


Jakubowski A, Stearns SC, Kruk ME, Angeles G, Thirumurthy H. The US President’s Malaria Initiative and under-5 child mortality in sub-Saharan Africa: A difference-in-differences analysis. PLoS Med, 2017 DOI: 10.1371/journal.pmed.1002319

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Last Updated on June 21, 2017 by Marie Benz MD FAAD