Getting It Right: USAID and the President’s Malaria Initiative

This is a joint post with Victoria Fan. While PEPFAR and the Global Health Initiative (GHI) have dominated the global health community’s attention over the past few years, the President’s Malaria Initiative (PMI) has largely flown under the radar. Surprisingly little had been written about the PMI; still the few available materials painted a reasonably positive picture.  But just this month, the PMI released the results of an external evaluation which confirms what we’ve long suspected: PMI is doing a remarkably good job and generating “value for money” in U.S. global health efforts. Such results are all the more impressive in light of the common criticisms of USAID past and present – that it is ineffective, incompetent, and hampered by a complex and arcane bureaucracy. The PMI is a USAID success story that helps validate its ongoing efforts to reform and rebuild into the U.S.’s premier development agency. Originally conceived in 2005 as a five-year, $1.2 billion scale-up of America’s malaria control efforts, the PMI was extended and expanded by the 2008 Lantos-Hyde Act, receiving $625 million in funding for FY2011. While its funding pales in comparison to PEPFAR, which received almost $7 billion for the same period, the PMI is among the largest global donors for malaria, aiming to halve the burden of malaria for 70 percent of at-risk populations in sub-Saharan Africa. Led by USAID under a U.S. Global Malaria Coordinator, the PMI is jointly implemented with the Centers for Disease Control (CDC).

USAID’s malaria programs have not always received “gold stars” from the development community. Indeed, just a few years back, U.S. malaria efforts were a source of scandal and controversy for the beleaguered aid agency. As Roger Bate described in a 2007 paper, a series of congressional investigations between 2004 and 2006 revealed a complete lack of monitoring and evaluation; no accountability for spending; over-reliance on expensive consultants; poor technical practices; and enormous waste; “only approximately 8% of USAID’s $80 million FY 2004 budget was used to purchase actual life-saving interventions…USAID could provide almost no evidence to show that programs actually helped save lives or even build sustainable capacity.”

Only six years later, the turnaround is remarkable. While also pointing out flaws and areas for improvement, the evaluation offers a glowing overall assessment:

“PMI is, by and large, a very successful, well-led component of the USG Global Health Initiative. Through its major contributions to the global malaria response via its collaborations with multilateral and bilateral partners, effective relationship with the Global Fund, and contributions to reinvigorating national malaria control programs, PMI has made substantial progress toward meeting its goal of reducing under-5 child mortality in most of the 15 focus countries….[PMI] has earned and deserves the task of sustaining and expanding the U.S. Government’s response to global malaria control efforts.”

Notably, the evaluation does not bill itself as a formal “impact evaluation” of the PMI. Instead, the document (1) provides a detailed process evaluation, and (2) uses survey data to report on progress toward outputs (i.e. 85% bed net coverage among vulnerable groups) and outcomes (70% reduction in malaria burden), using all-cause child mortality (ACCM) as the primary impact indicator. Accordingly, this evaluation methodology cannot isolate the PMI’s specific impact from the effects of other malaria efforts, including the Global Fund and national malaria control programs. Moreover, the evaluation methods rely on DHS data, which was limited at the time of its publication. Nonetheless, the evaluation pointed to signs of decline in the malaria disease burden for 8 of the 15 focus countries with available data (other surveys are underway or upcoming). In Tanzania, the only country where the PMI had already completed in-depth impact analysis, the evaluation found evidence to suggest that malaria control scale-up has reduced ACCM by 10 deaths per 1,000 live births. So what’s behind the PMI’s recent success? There are lots of good nuggets to choose from, but a few key decisions and design features stand out.

• Leadership: Housed within USAID, the PMI’s leadership earns high marks for its management skills and flexibility. According to the evaluation, the Global Coordinator’s office has effectively engaged its partners both domestically and on the ground, and achieved rapid scale-up through excellent program management. Management highlights include the fielding of interagency teams, use of “jump-start” funds to begin implementation before the distribution of annual central funding, a collaborative and transparent mechanism for resource allocation (annual country operational plans), and “a well-led, highly motivated technical and administrative workforce.” Some credit the PMI’s success to the military leadership style of U.S. Global Malaria Coordinator R. Tim Ziemer, a retired Rear Admiral with the United States Navy. Even if his personal leadership is responsible for  much of the initiative’s accomplishments, the PMI has showcased USAID’s ability to get out of the way for good managers.

• Interagency Collaboration: Despite the ongoing, high-profile interagency handwringing over GHI leadership, the PMI has managed to foster effective collaboration between USAID and the CDC, all under USAID’s stewardship. Generally speaking, the Global Coordinator has built and sustained interagency and bipartisan support for the initiative. While some friction and disagreements remains, particularly from senior CDC officials who desire greater institutional and financial autonomy, their differences have not hampered program implementation in-country, where different agency representatives put “debates aside and got on with the tasks of improving malaria control programs to meet the shared goal.”

• Focus and Selectivity: The PMI is selective both in the countries and interventions which it chooses to support. Rather than spreading its resources over a wide range of countries, the PMI has selected 19 focus countries to receive concentrated assistance based on their respective disease burdens, country commitment, and support from other funding partners such as the World Bank or Global Fund. On the program side, PMI only supports four life-saving, cost-effective interventions to prevent and treat malaria, focusing on concrete commodity procurement and distribution rather than USAID’s past, highly criticized approach of consultant-based technical expertise.

• Transparency: Everything is relative, but among U.S. programs the PMI stands out as unusually transparent to the public. The website provides detailed country operational plans, and even full contracts(!) for public viewing. Still, there is room for improvement: neither expenditure data nor line-item breakdowns of cost are currently available, making it difficult to assess the true distribution of costs and implementers’ cost-effectiveness.
• End Use Verification: We’ve all heard horror stories about bed nets being thrown out the windows of moving cars to meet ambitious output goals. To avoid this type of waste and monitor the success of distribution efforts, the PMI has implemented end use verification. This promising tool monitors the availability of key malaria commodities at the clinic level, helping to ensure effective supply chains and hold implementers accountable for successful distribution. If the PMI makes this data publicly available to civil society and researchers, it will become an even more powerful tool to promote accountability and efficiency.

At this point, there are still reasons to be concerned about USAID’s potential leadership of the GHI. Notably, these issues have little to do with USAID itself, and much more to do with structural power relationships and continued uncertainty about what, exactly, GHI leadership really entails. Still, as PEPFAR moves toward potential reauthorization in 2013, this story should offer food for thought to the administration and Congressional leaders. USAID’s rebuilding process remains a work in progress; still, it has turned malaria programs from an embarrassment into a remarkably successful initiative, all without great fanfare. Moving forward, the PMI could be a model for eventually bringing the Office of the Global AIDS Coordinator (OGAC) under the USAID umbrella. While some believe this move could compromise PEPFAR’s effectiveness and expertise, the PMI shows the best of what USAID can offer: thoughtful, collaborative leadership; the potential for a semi-autonomous but integrated OGAC within the greater USAID structure; and real potential to reemerge as the U.S.’s premier development agency.