Estimating the potential malaria morbidity and mortality avertable by the President's Malaria Initiative in 2025: a geospatial modelling analysis

BackgroundSince its inception in 2005, the Presidents Malaria Initiative (PMI) has played a major role in the reductions in malaria morbidity and mortality witnessed across Africa. With the status of PMI funding and operations currently uncertain, this study aimed to quantify the impact that a fully-functioning PMI would have on malaria cases and deaths in Africa during 2025. MethodsWe combined detailed spatio-temporal information on planned 2025 PMI and non-PMI malaria commodity procurement and distribution in Africa with spatio-temporal Bayesian models of intervention coverage and Plasmodium falciparum transmission and burden in Africa. By comparing coverage scenarios with and without planned PMI contributions we estimated the number of malaria cases and deaths PMI would avert in 2025. FindingsWe estimated that business-as-usual PMI contributions to vector control, seasonal chemoprevention, and routine malaria treatment in Africa would avert in 2025 13{middle dot}6M (95% uncertainty interval 11{middle dot}4M - 16{middle dot}4M) malaria cases and 104,000 (69,000 - 161,000) deaths. This represents 11{middle dot}3% (9{middle dot}9 - 12{middle dot}9%) and 37{middle dot}5% (34{middle dot}2 - 41{middle dot}5%), respectively, of the total burden of malaria morbidity and mortality in PMIs focus geographies across 27 African countries. These estimates do not account for the additional impact of PMI-supported provision of diagnostics or severe case management commodities, nor preventive treatment for pregnant women which would add further to the averted burden. InterpretationPMI investment in supporting procurement and distribution of malaria control commodities would translate directly into millions of malaria cases averted and a hundred thousand lives saved across its focus geographies in Africa across 2025. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed on 25 February 2025 with the search term "Presidents Malaria Initiative" AND (impact OR evaluation) AND (burden OR malaria cases OR malaria deaths). 102 results were returned, of which four directly addressed the question of PMI-attributable impact on malaria burden across all its focus geographies. One focussed solely on case-management and did not provide quantitative results1. A study focussing on mortality found a strong association between PMI investment and declines in all-cause infant mortality2. Another study used a generalised estimating equation approach to assess PMIs impact, concluding a strong association between PMI spending and reductions in malaria burden3. A 2017 study used a mechanistic malaria model to estimate PMIs historic contribution to reductions in malaria morbidity and mortality, with future projections to 20204. Added value of this studyIn this study we synthesised the most up-to-date information of all-funder volumes of key malaria control interventions (ITN, IRS, ACT, SMC) with PMI data on planned volumes and spatial targeting of funding in 2025 to derive near-real-time projections of malaria control intervention coverage in Africa under two scenarios: a business-as-usual scenario in which PMI commodities procured and distributed as previously planned versus a no-PMI scenario in which PMI funding and technical assistance is absent. These scenario-based estimates of coverage were propagated through an empirical geospatial malaria model, coupled to mechanistic models of clinical incidence, in order to estimate the number of malaria infections, clinical cases, and deaths PMI activities could expect to avert in Africa in 2025. Implications of all available evidencePMI is a key contributor to malaria control efforts in Africa, and as such its impact on averting childhood mortality has been demonstrated repeatedly. Here, using empirically-derived estimates of malaria control impact, combined with detailed scenarios of intervention coverage with and without PMI support, we isolated the contemporary impact of PMI activities on malaria morbidity and mortality in Africa in 2025. Our findings suggest that PMI support is critical to maintaining suppression of malaria transmission in its focus geographies.