The USAID suspension threatens the flagship malaria program, capable of preventing 100,000 deaths and 13 million cases in one year.

One of the most important US programs in the fight against malaria in Africa is hanging by a thread , and the consequences of its disappearance or weakening would be catastrophic. This is the conclusion reached by The Lancet, which published a study this Friday estimating that if the Presidential Malaria Initiative (PMI), which began in 2005 under George W. Bush, were to continue smoothly and at full budget, 13 million cases of the disease would be averted and more than 104,000 lives would be saved by 2025. However, these expectations are unlikely to be met due to the suspension of USAID , the US development agency that directed and executed most of the program's tasks. The situation could even worsen with the program's funding expected to be drastically reduced in 2026.

Peter Gething, one of the study's authors and co-director of the Malaria Atlas Project at the Kids Research Institute Australia, explains that this study used mathematical models to assess the potential of PMI to prevent malaria cases and deaths. "This work," he comments via email, "aims to provide objective evidence to support decision-makers at this time of significant reconfiguration of international aid policy."

Malaria is the world's deadliest mosquito-borne disease. In 2023, there were 263 million new cases in 83 countries—11 million more than in 2022—and 597,000 deaths, according to the World Health Organization's (WHO) latest report . Ninety-four percent of cases and 95% of deaths were concentrated in Africa.

Over the past 20 years, the US, through the PMI, has invested more than $9 billion (€7.8 billion) to support partner countries in the fight against this disease through the installation of insecticidal bed nets, spraying, diagnostics, combination therapies—a drug treatment that combines an artemisinin derivative with another drug that attacks the parasite—and seasonal chemoprevention during the rainy season. In addition to the calculations recently published by The Lancet for 2025, it is estimated that some 12 million lives have been saved and more than 2 billion cases of malaria have been averted in two decades of work.

But with the suspension of USAID , ordered by President Donald Trump in late January, the program was left in limbo. While the PMI remains active, cuts have been made, says Charles Kenny, a senior fellow at the Center for Global Development. “Our best estimates are that one-third of USAID malaria funding was cut as part of grant cancellations,” Kenny explains via email. And while the remaining contracts and grants are officially in place, there is evidence, the researcher says, that payments are slow and that some implementing partners have gone bankrupt—due to the lack or delay of payments from USAID—affecting operations.

There's a budget for 2025. In March, the US legislature approved the budget extension, allocating nearly $1 billion for PMI this year, according to KFF, a nonprofit organization that researches public health policy. The problem, as the Malaria No More campaign explains to this newspaper, is that "the White House and the Department of Government Efficiency have refused to spend these funds as directed by Congress." This has led, they say, to the cancellation of PMI contracts and staff reductions. "Although many PMI contracts remain in effect, the scope of its activities in endemic countries remains unclear," Malaria No More asserts.

However, the new and bigger fear is that the PMI's 2026 budget will be cut in half, to $424 million, as reported by Science , KFF , and CNN based on the Trump administration's budget request on May 30.

The authors of the study recently published in The Lancet state that the “immediate and long-term future of the PMI is currently uncertain.” Professor Gething further notes that “in the current political landscape, international aid budgets are under increasing pressure, and difficult decisions need to be made to protect the progress made.”

The most effective: combination therapies and mosquito nets

If the PMI were fully implemented by 2025, 104,000 lives would be saved, equivalent to 37% of the total mortality burden in the PMI target areas in Africa. In addition, 13 million cases would be averted, or 11% of the total disease burden. To reach this conclusion, the researchers pooled data on insecticidal nets, combination therapies, seasonal chemoprevention, and spraying, and created a scenario in which the PMI continued without unforeseen events and another in which the program was not implemented.

The study found that the most effective strategies would be combination therapy, which would prevent 55% of cases, followed by bed nets and chemoprevention. Furthermore, it found that PMI would save the most lives in Nigeria (20,000) and the Democratic Republic of the Congo (10,000). “These estimates are not based on simple extrapolations of lives saved per dollar, but are constructed from a detailed reconstruction of planned procurement and distribution activities for the main classes of malaria control commodities,” the authors write in the study.

The data, however, is conservative. The analysis does not take into account factors such as diagnostic testing, vaccination, staffing shortages, or even a rebound effect of the disease. Nor was the cost to African health systems of an increase in malaria cases calculated.

The problems these other shortages would cause are significant. For example, researchers say, if there is insufficient access to diagnostics, there is a risk of inefficient treatment distribution.

The eyes of multiple organizations working for global health are focused on the future of the fight against malaria. Other studies have already warned of the potential effects of cutting or suspending programs like the PMI. ISGlobal, for example, had estimated that 15 million additional cases of malaria and 107,000 additional deaths could occur .

Regina Rabinovich, director of ISGlobal's Malaria Elimination Initiative, says the situation is chaotic and uncertain. "I don't think they're going to completely eliminate the PMI, but rather transfer it to the State Department, and that will take time," she explains in a telephone interview, "but the State Department doesn't have the contractual capacity to do what USAID did." Even if there are attempts to maintain the PMI, Rabinovich believes, the problem is that there's no clear plan to do so: some of the workers who kept the program running have been laid off and are already looking for other jobs, and the teams operating in the communities have been reduced. "There was no transition. They cut funding and now they're trying to revive the programs," she comments. Furthermore, the director points out, the funding crisis will not only come from the US, but also from other countries such as the United Kingdom, Germany, and France, which have also reduced their spending on this sector.

Another difficulty, Rabinovich adds, is that the future of the fight against malaria will be affected not only by the cuts to the PMI, but also to other programs such as the Global Fund, which also receives US funding, and the Global Alliance for Vaccines and Immunization (GAVI).

The United to Beat Malaria campaign also fears for the future of other programs that rely on funding from the US and other countries. “A blanket reduction in support for the Global Fund could reverse decades of sustained progress against malaria and weaken health systems,” the campaign stated on its website in early June . “We can achieve a malaria-free world, but only if we continue to invest in and strengthen proven programs, like the PMI and the Global Fund, that have sustained progress and will help us accelerate it,” it argued.