The only downside of this softly softly approach is that few outside PMI's immediate sphere of influence are aware of its significance. PMI's design represents a complete—and badly needed—overhaul of the US Agency for International Development's (USAID's) approach to malaria. Previous programmes were castigated for their opaque funding decisions and cavalier approach to measurement of effectiveness (success used to be defined solely in terms of the amounts of money being spent). But the most serious charge levelled at USAID's malaria efforts was the huge proportion (>90%) of the funds that were spent on technical advice, mainly from US consultants, rather than on life-saving interventions, such as drugs and bednets.
Now, things have changed. Malaria has moved up the international agenda and, in reflection of this priority shift, funding has increased substantially: last June, President Bush pledged US$1·2 billion in additional funding for malaria, channelled through PMI, over the next 5 years. And, perhaps more importantly, the USA has listened to its critics. Programmes that come under the banner of PMI prioritise concrete interventions—particularly indoor residual spraying with DDT, distribution of insecticide-treated bednets, and purchase of effective drugs—over advice. They have a much greater focus on accountability, tracking results by means of household surveys, paper trails, and verbal autopsies—all of which should give PMI the means to accurately ascertain the effectiveness of its programmes. Conscious of not duplicating the efforts of other organisations, at country-level PMI negotiates with other donors and non-governmental organisations to focus its efforts on methods of malaria control that are different from those already being used. And, to ensure that a vacuum is not left if the money runs out, PMI also emphasises support for national malaria control programmes, in line with advice of the Roll Back Malaria Partnership.
By learning from the PEPFAR experience, PMI is moving away from USAID's small-but-scattered project approach in favour of focused spending in just a few countries. Angola, Tanzania, and Uganda were the first beneficiaries last year, and four more countries were added to this list on June 8. The plan is to reach 15 countries in total—the same number included in PEPFAR—but to scale up slowly. This approach is already reaping results from an administrative point of view, by giving PMI time to train staff, to learn all the lessons of PEPFAR and the first PMI projects, and to work closely with other donors. But critics say choosing countries where projects funded by the Global Fund to Fight AIDS, Tuberculosis, and Malaria have already achieved success means PMI is, in effect, simply piggybacking on the Global Fund's accomplishments. For example, PMI might decide to introduce indoor spraying to a country where the Fund has helped reduce mortality by financing drugs and bednets. But critics say this approach could mean PMI pushes ahead with interventions that might not be necessary just to be seen to be doing something.
In an arena already crowded with a multitude of programmes of dubious effectiveness, close communication and collaboration with other international malaria players is essential. Some argue that by keeping such a large amount of money separate—and not committing more to the Global Fund—President Bush is undermining the newly invigorated efforts of Roll Back Malaria. But now might in fact be a good time to be outside this unwieldy association, since it is currently undergoing a soul-searching review, encompassing discussions about the roles of each of its numerous partners, the unique aspects of the organisation's structure, and the best ways to achieve results.
For PMI, the key measure of success must be whether or not it adds value independently of other organisations' efforts. As long as its existence does not jeopardise US financial support for the Global Fund, PMI's pledges to focus on what is needed, to ensure sustainability of achievements, and to empower countries to drive anti-malaria efforts themselves should win the initiative international support to expand and move forward. What is necessary now is for Congress to see PMI's potential and meet President Bush's full funding request.
The Lancet, Volume 368, Issue 9529